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Patients undergoing complex surgery at safety net hospitals have been shown to suffer inferior short-term outcomes. Liver transplantation, one of the most complex surgical interventions, is offered at certain safety net hospitals. We sought to identify whether patients undergoing liver transplantation at safety net hospitals have inferior outcomes compared with lower burden centers.Using a link between the University HealthSystem Consortium and Scientific Registry of Transplant Recipient databases, we identified 11,047 patients undergoing liver transplantation at 63 centers between 2009 and 2012. Hospitals were grouped by safety net burden, defined as the proportion of Medicaid or uninsured patient encounters during that time. The highest quartile (safety net hospitals) was compared to medium- and low-burden hospitals regarding recipient and donor characteristics, perioperative outcomes, and long-term survival.Liver transplantation recipients at safety net hospitals were more often black and of lower socioeconomic status (P.01), but had similar model for end-stage liver disease scores (20 vs 20 vs 18) compared with median-burden hospitals and low burden hospitals. Length of stay and readmission rates were similar; however, safety net hospitals demonstrated higher in-hospital mortality (5.2% vs 4.5% vs 2.9%, P.01). Despite this, there was no significant difference in overall patient or graft survivals in patients who underwent liver transplantation at safety net hospitals and survived the perioperative setting at a median follow-up of 2 years (P.05).Despite differences in perioperative outcomes at safety net hospitals, these centers achieve noninferior long-term patient and graft survival for potentially vulnerable patients requiring liver transplantation. Strict care standardization, as achieved in liver transplantation, may be a mechanism by which outcomes can be improved at safety net hospitals after other complex surgical procedures.

OBJECTIVES Machine perfusionfor kidney preservation is a common practice. There is no consensus on the best formula for perfusion solutions. We aimed to discern the additives that organ procurement organizations in the United States include in their perfusate and the impact of these additives on transplant outcomes. MATERIALS AND METHODS A telephone survey of all 58 organ procurement organizations in the United States regarding additives to their perfusion solutions was conducted. The survey data were merged with transplant recipient outcome data from the United Network for Organ Sharing database.The final analysis included perfused kidneys between January 2014 and March 2019. Logistic regressions were performed to investigate whether a particular perfusion formula was associated with delayed graft function, primary nonfunction, or early graft failure. RESULTS Additives correlated with decreased rates of graft failure were mannitol in all kidneys and kidneys of lower quality (P < .01) and penicillin/ampicillin in all kidneys (P < .05). Additives associated with increased graft failure regardless of type included verapamil in all kidneys (P < .05) and kidneys of lower quality (P < .01) and arginine with glutathione in all kidneys and low-quality kidneys alone (P < .01). CONCLUSIONS Further outcomes research and standardized guidelines for additives in machine perfusion of kidneys across all organ procurement organizations are needed.

Post-transplant diabetes mellitus (PTDM) is a complication which reduces allograft and recipient life-span. Polygenic risk scores (PRS) robustly show association with greater type 2 diabetes (T2D) development risk. We examined T2D-PRS in transplant recipients and donors using genome-wide genotyping in 1581 liver recipients, and 1555 donors and 2062 kidney recipients and 533 donors from four centers. Liver and kidney recipient T2D-PRS was associated with pre-transplant T2D and PTDM development. Liver donor, but not kidney donor, T2D-PRS was an independent risk factor for PTDM development. Inclusion of a combined liver recipient and donor T2D-PRS significantly improved PTDM prediction vs clinical characteristics-only models: AUC (95%CI): 67.6% (64.1% − 71.1%) vs. 62.3% (58.8% − 65.8%), p = 0.0001. Liver recipients in the highest quintile of recipient-donor combined T2D-PRS had the greatest PTDM risk: OR (95%CI) = 3.22 (2.07–5.00), p = 1.92E-07, compared to the lowest quintile. T2D-PRS allows identification of transplant candidates with high PTDM risk, for whom early preemptive diabetes management is warranted. Pre-transplant knowledge of donor T2D-PRS in the setting of living liver donation should optimized selection of donors to reduce PTDM.

The question of whether transplant clinicians should mandate COVID‐19 vaccination as a condition of transplant candidacy is complex. A vaccine mandate may be defensible on the grounds that transplant clinicians are obligated to ensure transplantation is conducted safely, and in a manner that entails the best use of a scarce public good. However, mandate proponents will inexorably predicate their arguments on contingent clinical judgments that meliorate rather than resolve core value disagreements. Vaccine mandates are conceivably defensible on narrow grounds, but may prove to be purchased at the expense of an attenuation of shared decision‐making, proffering claims of risk reduction from a vaccine mandate beyond what the current evidence base supports, and unintentionally exacerbating durable inequities in access to transplantation.

Summary In response to the COVID‐19 pandemic, SARS‐CoV‐2 vaccines have been developed at an unparalleled speed, with 14 SARS‐CoV‐2 vaccines currently authorized. Solid‐organ transplant (SOT) recipients are at risk for developing a higher rate of COVID‐19‐related complications and therefore they are at priority for immunization against SARS‐CoV‐2. Preliminary data suggest that although SARS‐CoV‐2 vaccines are safe in SOT recipients (with similar rate of adverse events than in the general population), the antibody responses are decreased in this population. Risk factors for poor vaccine immunogenicity include older age, shorter time from transplantation, use of mycophenolate and belatacept, and worse allograft function. SOT recipients should continue to be advised to maintain hand hygiene, use of facemasks, and social distancing after SARS‐CoV‐2 vaccine. Vaccination of household contacts should be also prioritized. Although highly encouraged for research purposes, systematic assessment in clinical practice of humoral and cellular immune responses after SARS‐CoV‐2 vaccination is controversial, since correlation between immunological findings and clinical protection from severe COVID‐19, and cutoffs for protection are currently unknown in SOT recipients. Alternative immunization schemes, including a booster dose, higher doses, and modulation of immunosuppression during vaccination, need to be assessed in the context of well‐designed clinical trials., In this review, we summarize the existent literature of the low immunogenicity of SARS‐CoV‐2 vaccines in SOT recipients. We discuss the clinical relevance of this observation, the strategies that may potentially increase the immune response of the vaccine, and the information that we should convey to transplant physicians and patients.