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• W2313306527 abstract "The World Transplant Congress presented a wide array of clinical and translational studies involving all organs and many different approaches to immunosuppression, monitoring, outcomes, diagnosis, donors, and recipients in addition to relevant social sciences. Studies relating to kidney transplantation dominated the presentations, however, the entire field remains vibrant with significant breadth and depth in many different domains. DONATION Donor safety and comfort, new operative techniques, organ allocation, and improved utility and outcomes were among the themes that were presented. Segev and colleagues1 from Johns Hopkins Hospital in Baltimore, MD, investigated approaches to optimize living and deceased donor renal allografts for young pediatric recipients who may be expected to undergo several transplants over the course of a lifetime. Their Markov decision process model showed that in the most highly sensitized patients, a deceased-donor-first strategy was advantageous, but for all other patients, a living-donor-first strategy was recommended. This approach illustrates how patients, families, and providers can be given predictions to plan for deceased versus living donor transplantation for pediatric recipients. Sood et al2 from Henry Ford Hospital in Detroit, MI, presented a large series of 67 robotic living donor kidney transplants. From a technical standpoint, they described a regional hypothermia apparatus to permit safe in situ cooling, rapid implantation with short anastomotic times, and routine reperitonealization to prevent vascular kinking or torsion. Excellent results for patient management, graft survival, and patient survival were obtained, demonstrating that in selected candidates, this may become an important technique for recipient implantation. The Organ Procurement and Transportation Network (OPTN) Disease Transmission Advisory Committee (DTAC) reported on their assessments of potential donor-derived transmission events.3 Using algorithms, they screened a large number of reports to identify those with high likelihoods of transmission of infection, malignancy and other entities to one or more recipients, and these represented only 11.3% of the total original reports. Among proven/probable cases, rates of transmission to donors varied by category of disease, with malignancies, viruses, bacteria, fungi, and parasites leading to transmission in 67%, 46%, 34%, 29%, and 17% of exposed donors, respectively. The use of the new standard algorithm and triaging process enhanced the reproducibility of DTAC assessments and allowed analysis of our aggregate DTAC experience. Englum et al4 from Duke University in Durham, NC, conducted a study of the SRTR registry, focusing on patient and graft survival after living kidney donation from donors older than 60 years. The results show that these donor kidneys provide outcomes comparable to standard criteria deceased donor and better than extended criteria deceased donor kidneys. Careful selection of living donors and proper matching of donors and recipients with regard to age and recipient comorbidities is now widely accepted and produces excellent results. These observations suggest that this practice can likely be extended and enlarged. OUTCOMES Although tried and true studies of immunosuppression, rejection, and pathology continued to resonate among the presenters, additional studies on resource utilization, complications, and long-term benefits were equally represented. Taber et al5 from the Medical University of South Carolina in Charleston performed a retrospective review to investigate factors associated with the risk for 30-day readmission after renal transplantation. Using parsimonious risk models and focusing on immutable versus dynamic data, they identified that dynamically evolving clinical data outperformed the model using only static variables. The final model included 6 static variables (education, history of CVA, retransplant, delayed graft function, history of CAD, induction therapy) and 3 dynamic variables (change in systolic blood pressure, change in diastolic blood pressure, initial transplant costs). Identification of important variables may allow specific focus to improve outcomes and decrease readmissions. Jordan et al6 from Cedars-Sinai Medical Center in Los Angeles, CA, continue their studies into prevention and treatment of antibody-mediated renal allograft rejection. In this early phase I/II study of a C1 inhibitor (C1-INH), the results showed that the inhibitor was well tolerated; might reduce ischemia-reperfusion injury; caused significant elevations of C1-INH, C3, and C4; and reduced C1q+ HLA antibodies. In combination with the modalities of plasmapheresis, IVIG, and anti-CD20 antibodies, C1-INH may prove useful in preventing antibody-mediated rejection. Nabokow et al7 performed a multicenter, retrospective analysis on the effect of isolated glomerulitis combined with T cell– or B cell–mediated rejection on renal allograft outcomes. Glomerulitis carried a particularly negative effect on survival and was equivalent to B cell–mediated rejection in the negative consequences for graft survival. These observations suggest that B cell–mediated rejection must be diligently searched in patients whose biopsies present with isolated glomerulitis lesions. Ildstad et al8 at the University of Kentucky in Louisville and Northwestern University, Chicago, IL, provided an important update on the longer-term follow -up of immunosuppression withdrawal and tolerance in their recipients treated with reduced intensity conditioning, bone marrow transplantation, facilitating cells, and HLA mismatched living donor renal allografts. The results showed complete hematopoietic chimerism, excellent allograft function without rejection, reconstitution of immune competence to vaccination and viral pathogens, and de novo production of thymic derived CD4 and CD8 T cells. These observations have important implications for understanding chimerism and tolerance. Massey et al9 from Erasmus Medical Center in Rotterdam, the Netherlands, studied the interaction of patient beliefs, sense of well-being, and adherence to medication regimens after kidney transplantation. The results demonstrated that although the vast majority of patients understood and intended to adhere to medications, actual adherence was significantly less. Adherence was inversely associated with a sense of health and well-being, so that as patients recovered from transplant and felt well with good organ function, adherence actually declined. The results have important implications for education and reinforcement of appropriate habits in recipients well after the initial transplant events. Pihlstrøm et al10 from Oslo University Hospital in Norway reported on the effects of postrenal transplant hyperparathyroidism on long-term outcomes. This was a post hoc investigation using data from The Assessment of LEscol in Renal Transplantation trial, a randomized, double-blind, placebo-controlled study examined the effect of fluvastatin on cardiac and renal outcomes. The results showed that increased PTH was associated with all-cause mortality and graft loss, but not with major cardiovascular events. The results suggest that constant vigilance after transplantation for primary, secondary, and tertiary hyperparathyroidism remains an important component of long-term care. Dunn and colleagues11 from the University of Minnesota reviewed their extensive experience in pancreas retransplantation. The results showed that over time, technical failures and patient deaths decreased, whereas rejection and immunologic loss remained significant and in comparison increased as a percentage cause of allograft loss. Those results demonstrated that pancreas retransplantation can be very safe and effective, and that attention to anatomic detail in patient selection and attention to immunologic risk and treatment will contribute to improving outcomes. Bunnipradist et al12 from University of California in Los Angeles investigated the effect of pretransplant on posttransplant malignancies in cardiac allograft recipients using the Organ Procurement and Transportation Network /UNOS database. The results showed an overall risk of posttransplant malignancy of 11.5%, whereas pretransplant malignancy increased the hazard ratio by about 1.5-fold to 2.8-fold. The median time to presentation was between 2.5 to 3.5 years, considering separate groups for skin cancers, solid cancers, and posttransplant lymphoproliferative disorder (PTLD). The results suggest that given the high prevalence of posttransplant cancers, attentive screening, particularly to those with a prior history, will have a positive impact on diagnosis, treatment and survival. Sonnenday and colleagues13 from the University of Michigan studied measurements and consequences of frailty in liver transplant candidates. The results demonstrated that frailty was far more associated with measures of quality of life (QoL) in comparison to MELD scores, which had poor association with QoL measures. Thus, diminished QoL appears to be significantly negatively associated with frailty and not with severity of liver disease. This finding has strong implications for pretransplant selection and management, particularly rehabilitative interventions. Altogether, these reports demonstrate the many opportunities not only for significant and novel research, but also opportunities to increase both organ utilization and all aspects of outcomes in a financially advantageous manner. Jonathan S. Bromberg University of Maryland Baltimore, USA" @default.
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• W2313306527 date "2015-02-01" @default.
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• W2313306527 title "WTC Clinical Papers" @default.
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