Search

Because of the continued demand in kidney transplantation, organs from donors with risk criteria for blood-borne viruses, high Kidney Donor Profile Index (KDPI) kidneys, and hepatitis C virus (HCV)-positive kidneys are being considered. There continues to be reluctance on the part of the providers and the candidates to accept HCV-positive kidneys.We conducted a retrospective analysis of the Organ Procurement and Transplantation Network database of all adult (≥18 y old) recipients undergoing kidney transplant from May 10, 2013, to June 30, 2021. We compared patient and graft survival in candidates who received HCV-positive kidneys versus non-hepatitis C (Hep C) high KDPI kidneys by estimated posttransplant survival (EPTS) groups.HCV-viremic kidneys were transplanted in 5.6% of patients in the EPTS61% group compared with 5.1% of patients in the 21%-60% EPTS group and 1.9% of 0%-20% EPTS group ( P0.001). Of all transplants performed in the EPTS 61%-100% group, 11.9% were KDPI85% compared with 5.2% in the EPTS 21%-60%, and 0.5% in the EPTS 0%-20%. Patient survival was significantly longer at 1, 3, and 5 y in the EPTS61% group who received Hep C-viremic or -nonviremic allografts compared with non-Hep C kidneys with KDPI85%. When it comes to listing, only 25% of candidates in the EPTS61% group were listed for Hep C nucleic acid testing-positive kidneys in 2021.Our findings could be used for counseling candidates on the types of kidneys they should consider for transplantation. Also, listing practices for viremic Hep C kidneys need continued re-evaluation.

To review and summarize the evolution of the Public Health Service (PHS) guidelines and Organ Procurement and Transplantation Network (OPTN) regulations for the prevention of blood borne virus transmission in solid organ transplant through the lens of popular culture, scientific evolution, patient and practitioner bias and outcomes research.The most recent set of guidelines and regulations were released in 2020 and represent a culmination of decades of opinion, research and debate within the scientific and lay communities.The guidelines were created to address public concern, and the risk of undiagnosed disease transmission in the context of the novel public health crisis of AIDS. We reviewed milestone publications from the scientific and lay press from the first description of AIDS in 1981 to the present to help illustrate the context in which the guidelines were created, the way they changed with subsequent editions, and offer critical consideration of issues with the current set of guidelines and a potential way forward. Further consideration should be given to the way in which the current guidelines identify donors with risk criteria for infectious disease transmission and mandate explanation of donor-specific risk factors to potential recipients, in our era of universal donor screening and recipient surveillance.

Simultaneous liver-kidney transplant is a treatment option for patients with end-stage liver disease and concomitant irreversible kidney injury. We developed a decision toolto aid transplant programs to advise their candidates for simultaneous liver-kidney transplant on accepting high-risk grafts versus waiting for lower-risk grafts.To find the critical decision factors, we used the prescriptive analytic technique of microsimulation.All probabilities used in the simulation model were calculated from Organ Procurement and Transplantation Network data collected from February 27, 2002 to June 30, 2018.The simulated patient population results revealed, on average, that high-risk candidates for simultaneous liver-kidney transplant who accept highrisk organs have 254.8 ± 225.4 weeks of life compared with 285.6 ± 232.4 weeks if they waited for better organs. However, critical decision factors included the specific organ offer rates within individual transplant programs and the rank of the candidate in each program's waitlist. Thus, for programs with lower organ offer rates or for candidates with a rare blood type, a high-risk simultaneous liver-kidney transplant candidate might accept a high-risk organ for longer survival.Our model can be utilized to determine when acceptance of high-risk organs for patients being considered for simultaneous liver-kidney transplant would lead to survival benefit, based on probabilities specific for their program.

Objectives Kidney transplant is the optimal treatment for patients with end-stage renal disease. The effects of using machine perfusion for donor kidneys with varying Kidney Donor Profile Index scores are unknown. We sought to assess the impact of machine perfusion on the incidence of delayed graft function in different score groups of kidney grafts classified with the Kidney Donor Profile Index. Materials and methods We conducted a retrospective analysis from January 2008 through September 2017 of adult recipients (≥ 18 years old) undergoing kidney-only transplant from deceased donors. All transplant recipients were followed until December 2017. Recipients who received multiorgan transplants or kidneys from living donors were excluded from our analyses. Recipients were divided according to 5 donor categories of Kidney Donor Profile Index scores (0-20, 21-40, 41-60, 61-80, and 81-100). Logistic regression analysis was performed for each score group to determine the effects of machine perfusion on development of delayed graft function within each score group. Results Our study included 101222 recipients who met the inclusion criteria. Multivariate analysis revealed that machine perfusion was associated with significantly decreased development of delayed graft function only in donors with high-risk profiles: the 61 to 80 score group (odds ratio = 0.83; confidence interval, 0.78-0.89) and the 81 to 100 score group (odds ratio = 0.72; confidence interval, 0.67-0.78). Conclusions Machine perfusion is beneficial in reducing delayed graft function only in donor kidneys with a higher risk profile.

US deceased donor solid organ transplantation (dd-SOT) depends upon an individual's/family's altruistic willingness to donate organs after death; however, there is a shortage of deceased organ donors in the United States. Informing individuals of their own lifetime risk of needing dd-SOT could reframe the decision-making around organ donation after death. Using United Network for Organ Sharing (UNOS) data (2007-2016), this cross-sectional study identified (1) deceased organ donors, (2) individuals waitlisted for dd-SOT (liver, kidney, pancreas, heart, lung, intestine), and (3) dd-SOT recipients. Using US population projections, life tables, and mortality estimates, we quantified probabilities (Pr) of (1) becoming deceased organ donors, (2) needing dd-SOT, and (3) receiving dd-SOT. Lifetime Pr (per 100 000 US population) for males and females of becoming deceased organ donors were 212 and 146, respectively, and of needing dd-SOT were 1323 and 803, respectively. Lifetime Pr of receiving dd-SOT was 50% for males, 48% for females. Over a lifetime, males were 6.2 and females 5.5 times more likely to need dd-SOT than to become deceased organ donors. Organ donation is traditionally contextualized in terms of charity toward others. Our analyses yield a new tool, in the form of quantifying an individual's own likelihood of needing dd-SOT, which may assist with reframing motivations toward deceased donor organ donation.

We sought to evaluate the association between de novo donor-specific antibodies (dnDSAs) class and their mean fluorescence intensity (MFI) with donor-derived cell-free DNA (dd-cfDNA), aiming to further clarify the biomarker utility of these noninvasive tests in relation to renal allograft function and histology.The study included kidney transplant recipients (n = 171) who underwent surveillance testing with DSA and dd-cfDNA as part of their clinical care between September 2017 and December 2019 at our center.We identified dnDSA in 43 patients (25%) at a median of 4.63 y (IQR, 1.5-7) posttransplant. The presence of DSA with MFI2500 was associated with a median dd-cfDNA of 0.96% (IQR, 0.26-2.95) significantly higher than in patients with DSA MFI2500 (0.28%; IQR, 0.19-0.39) or without detectable DSA (0.22%; IQR, 0.17-0.37;Our study identifies class II dnDSA as being strongly associated with late alloimmune injury post kidney transplant independent of allograft dysfunction and shows that dd-cfDNA may complement the clinical significance of dnDSAs.

Transplant tourism, the practice of traveling to other countries for transplantation, continues to be a major problem worldwide. We describe a patient who traveled to Pakistan and underwent commercial kidney transplantation. He developed life-threatening infections from New Delhi metallo-beta-lactamase-1-producing Enterobacter cloacae and Rhizopus oryzae resulting in a necrotizing kidney allograft infection and subsequent external iliac artery rupture. He survived after a prolonged course of non-standardized antimicrobial therapy, including a combination of aztreonam and ceftazidime/avibactam, and aggressive surgical debridement with allograft nephrectomy. The early timing of infection with these unusual organisms localized to the allograft suggests contamination and substandard care at the time of transplant. This case highlights the challenges of caring for these infections and serves as a cautionary tale for the potential complications of commercial transplant tourism.

Antibodies against angiotensin II type-1 receptors (AT1R) have been increasingly recognized in association with rejection and poor allograft outcomes. Our goal was to define the prevalence of preformed antibodies against AT1R and evaluate the association with renal allograft outcomes in a consecutive cohort of 150 transplant recipients. IgG antibodies against AT1R were measured by enzyme-linked immunosorbent assay using cryopreserved serum samples obtained for HLA testing at the time of transplantation. Results were categorized as negative if 10 U/mL (44%), intermediate from 10 to 17 U/mL (38%), or strongly positive if17 U/mL (18%). The presence of AT1R antibodies was inversely associated with age, dialysis status, and diabetes. We found a strong association between the presence of AT1R antibodies and acute cellular rejection using multivariate analyses, odds ratio 3.86 (95% CI, 1.03-14.47) for intermediate titers and 9.99 (95% CI, 2.6-38.4) for strongly positive titers. There was no association with HLA sensitization or C4d-positive antibody-mediated rejection. We did not observe a significant association with graft failure, allograft function, or proteinuria. Preformed AT1R antibodies are prevalent and highly associated with acute cellular rejection early after transplant, independent of anti-HLA antibodies. The presence of AT1R antibodies correlates with recipient characteristics that may denote stronger immune responses. Future studies are needed to evaluate the mechanism and causative effect of AT1R antibodies.

Hyperammonemia syndrome, with high levels of ammonia and neurologic dysfunction, is a syndrome with historically high mortality that may occur after solid organ transplantation. Recently, this has been associated with infection due to Ureaplasma, mostly following lung transplantation. We describe the first case of hyperammonemia syndrome due to Ureaplasma infection after liver-kidney transplantation. Our patient rapidly recovered after specific antibiotic treatment. It is important to consider these infections in the differential diagnosis for encephalopathy post-transplant, as these organisms often do not grow using routine culture methods and polymerase chain reaction testing is typically required for their detection. This is particularly critical after liver transplantation, where a number of other etiologies may be considered as a cause of hyperammonemia syndrome.

Background Kidney transplants from donors after circulatory death (DCD) make up an increasing proportion of all deceased donor kidney transplants in the United States (US). However, DCD grafts are considered to be of lower quality than kidneys from donors after brain death (DBD). It is unclear whether graft survival is different for these two types of donor kidneys. Materials and methods We conducted a retrospective cohort study of US deceased donor kidney recipients using data from the United Network of Organ Sharing from 12/4/2014 to 6/30/2018. We employed a Cox proportional hazard model with mixed effects to compare all-cause graft loss and death-censored graft loss for DCD versus DBD deceased donor kidney transplant recipients. We used transplant center as the random effects term to account for cluster-specific random effects. In the multivariable analysis, we adjusted for recipient characteristics, donor factors, and transplant logistics. Results Our cohort included 27,494 DBD and 7,770 DCD graft recipients transplanted from 2014 to 2018 who were followed over a median of 1.92 years (IQR 1.08–2.83). For DCD compared with DBD recipients, we did not find a significant difference in all-cause graft loss (hazard ratio [HR] 0.96, 95% confidence interval [CI] 0.87–1.05 in univariable and HR 1.03 [95% CI 0.95–1.13] in multivariable analysis) or for death-censored graft loss (HR 0.97 (95% CI 0.91–1.06) in univariable and 1.05 (95% CI 0.99–1.11) in multivariable analysis). Conclusions For a contemporary cohort of deceased donor kidney transplant recipients, we did not find a difference in the likelihood of graft loss for DCD compared with DBD grafts. These findings signal a need for additional investigation into whether DCD status independently contributes to other important outcomes for current kidney transplant recipients and indices of graft quality.

Kidney Donor Risk Index (KDRI) introduced in 2009 included hepatitis C serologic but not viremic status of the donors. With nucleic acid amplification testing (NAT) now being mandatory, further evaluation of these donors is possible. We conducted a retrospective matched case-control analysis of adult deceased donor kidney transplants performed between December 5, 2014 to December 31, 2016 with the KDRI score and hepatitis C virus antibody (HCV Ab) and NAT testing status obtained from the United Network for Organ Sharing database. The 205 aviremic HCV Ab+ NAT - kidney transplants were compared to KDRI matched control kidneys that were HCV Ab-NAT-. The aviremic HCV kidneys were recovered from donors who were significantly younger, more likely to be white, and less likely to have hypertension and diabetes. The majority of the recipients of the aviremic HCV kidneys when compared to matched controls were HCV positive: 90.2% vs 4.3%. The recipients were significantly older, were on dialysis for a shorter time, and were transplanted sooner. The graft survival of aviremic HCV kidneys was similar (P .08). If the HCV status of the aviremic kidneys was assumed to be negative, 122 more kidneys could have been allocated to patients with estimated posttransplant survival20. Seven kidneys would no longer have Kidney Donor Profile Index85%. Further policies might consider these findings to appropriately allocate these kidneys.

Young adult and adolescent kidney transplant recipients have shorter graft survival than older and younger recipients. Although multifactorial, the tendency toward premature graft loss in young kidney transplant recipients has often been attributed to medication nonadherence and the transition from pediatric to adult care. Multiple interventions for medication nonadherence in kidney transplant recipients have been studied. Potential preventative interventions include pre-transplant screening, transition and young adult clinics, technologies such as reminders or mobile applications, and simplification of the post-transplant medication regimen. There are also recent advances in monitoring interventions for nonadherence in transplant recipients, including electronic monitoring devices such as wireless pill bottles and the Ingestible Sensor System, which incorporates ingestible microsensors into medications. Treatment interventions for medication nonadherence include cognitive behavioral programs, behavioral contracts, and screening and treatment for depression. Several of the interventions reviewed are currently available to providers caring for young kidney transplant recipients, without any complex programmatic changes. Further research in all of these areas would be of great value.

BACKGROUND The number of Public Health Service increased-risk organ donors (PHS IRD) is growing, largely from an increase in intravenous drug use overdoses due to the current opioid epidemic. MATERIAL AND METHODS We conducted a retrospective case series review using our single-center data. We reviewed 82 PHS IRD kidney transplant offers between 2015 and 2017, 20 of which were declined. We reviewed outcomes of patients who declined vs. accepted PHS IRD offers. We studied the effect of education on these patients' willingness to consider another PHS IRD. RESULTS Twenty patients declined PHS IRD over a 2-year period. They waited on average 9 months for another transplant, and tended to be transplanted with a higher-KDPI kidney than the one originally offered. Patients who declined PHS IRD were more likely to be predialysis, women, and Asian American, and to require an interpreter. Ninety-two percent of patients who received education on PHS IRD after declining an offer stated that they would consider another PHS IRD offer in the future. Four of these patients received a PHS IRD transplant. CONCLUSIONS Our results suggest that education of patients may have a positive impact on patient attitudes toward PHS IRD.

A case of stress (takotsubo) cardiomyopathy (TC) that occurred intraoperatively during liver transplantation surgery was identified by transesophageal echocardiography. Only a few cases of TC occurring during liver transplantation have been reported to date. Unlike other cases reported, TC occurred during the anhepatic stage of the liver transplantation, with subsequent complete recovery. Notwithstanding the large number of cases of TC in the perioperative settings reported worldwide, the exact reasons of this syndrome occurring intraoperatively as well as precipitating factors and conditions remain mostly unknown.

Aim To examine temporal changes in the indications for liver transplantation (LT) and characteristics of patients transplanted for alcoholic liver disease (ALD). Methods We performed a retrospective cohort analysis of trends in the indication for LT using the United Network for Organ Sharing (UNOS) database between 2002 and 2015. Patients were grouped by etiology of the liver disease and characteristics were compared using χ2 and t-tests. Time series analysis was used identifying any year with a significant change in the number of transplants per year for ALD, and before and after eras were modeled using a general linear model. Subgroup analysis of recipients with ALD was performed by age group, gender, UNOS region and etiology (alcoholic cirrhosis, alcoholic hepatitis and hepatitis C - alcoholic cirrhosis dual listing). Results Of 74216 liver transplant recipients, ALD (n = 9400, 12.7%) was the third leading indication for transplant after hepatitis C and hepatocellular carcinoma. Transplants for ALD, increased from 12.8% (553) in 2002 to 16.5% (1020) in 2015. Time series analysis indicated a significant increase in the number of transplants per year for ALD in 2013 (P = 0.03). There were a stable number of transplants per year between 2002 and 2012 (linear coefficient 3, 95%CI: -4.6, 11.2) an increase of 177 per year between 2013 and 2015 (95%CI: 119, 234). This increase was significant for all age groups except those 71-83 years old, was observed for both genders, and was incompletely explained by a decrease in transplants for hepatitis C and ALD dual listing. All UNOS regions except region 9 saw an increase in the mean number of transplants per year when comparing eras, and this increase was significant in regions 2, 3, 4, 5, 6, 8, 10 and 11. Conclusion There has been a dramatic increase in the number of transplants for ALD starting in 2013.

Previous studies have grouped all donors positive for hepatitis C virus (HCV) antibody (Ab). Only recently has donor HCV nucleic acid testing (NAT) become routine, and the impact of Ab and NAT status on organ utilization is unknown. Using the United Network for Organ Sharing database, we identified 9290 donors from 2015 to 2016 for whom both HCV Ab and NAT data were available and compared organ utilization by HCV status. Overall, 93.8% of donors were Ab negative and NAT negative (Ab-NAT-), 0.15% were Ab negative and NAT positive, 1.8% were Ab positive and NAT negative (Ab+NAT-), and 4.2% were both Ab and NAT positive (Ab+NAT+). Ab-NAT- donors donated at the highest rate for all organs except livers, of which Ab+NAT- donors donated at a higher rate (81.2% vs 73.2%, p = 0.03). Livers were discarded for reasons related to abnormal biopsies in Ab+NAT+ donors, whereas kidneys from Ab- or NAT-positive donors were discarded for reasons related to HCV status. Using a propensity score-matched model, we estimated that using Ab+NAT- donors at the same rate as Ab-NAT- donors could result in 48 more kidney donors, 37 more heart donors, and 15 more lung donors annually. We urge the use of HCV Ab+NAT- donors for appropriately selected and consenting recipients.

The therapeutic options that provide the best long-term outcome for patients who have a combination of end-stage renal disease and compensated cirrhosis are unknown.Given the paucity of data and the lack of clinical guidance in this area, a national survey was conducted in the form of an e-mail-based questionnaire addressed to the transplantation surgeons registered with the American Society of Transplant Surgeons.Of the 818 surgeons invited to participate in the survey, 167 (20%) responded. Twenty-one (12.6%) respondents indicated that their program performed 50 kidney transplantations per year, 49 (29.3%) reported performing 50 to 100 kidney transplantations per year, and the majority, 97 (58.1%) of respondents, performed100 kidney transplantations per year. The majority, 116 (69.5%), believed that compensated cirrhotic patients with end-stage renal disease could be considered for renal transplantation alone, 45 (26.9%) respondents believed that compensated cirrhotic patients on dialysis could only be considered for simultaneous liver-kidney transplantation, and 6 (3.6%) believed that this population of patients was not suitable for kidney transplantation alone.Our findings suggest that there is a substantial heterogeneity of opinion among transplantation surgeons towards transplantation options for compensated cirrhotic patients. Further data is needed to define best practices and clinical guidelines.

BACKGROUND Young children and small-statured candidates are dying on liver candidate waitlists. The Organ Procurement and Transplantation Network and United Network for Organ Sharing have proposed a split liver (SL) variance encouraging transplant programs to split more livers to aid these smaller statured candidates. METHODS We evaluated the US experience of splitting donor livers during 2002-2016. The results of our analysis provide new evidence to support this variance. RESULTS During 2002-2016, SL grafts from 935 donors were transplanted into 1870 recipients. Controlling for recipient factors and using time period and program identification as random variables, a multivariable mixed Cox proportional hazards model for graft failure revealed that donor aged 3-10 years had a relative risk (RR) of 3.94 (2.86-5.44), and donor aged >30 years had a RR of 1.94 (1.59-2.35) for graft failure. Donor-to-recipient body surface area ratio

The opioid epidemic has resulted in increasing the incidence of hepatitis C virus in the general population and more deceased organ donors with hepatitis C in the United States. We aim to describe how the changing donor landscape affects patterns of liver and kidney transplantation among donors, waitlist candidates, and transplanted recipients.Using data supplied by the United Network for Organ Sharing, we examined donor hepatitis C virus antibody (Ab) and nucleic acid testing (NAT) status, center waitlist patterns, and liver and kidney transplants and discards between 2015 and 2017 by 6-month periods.We observed an increase in donors with any marker of the hepatitis C virus (n = 283 [6.2%] in period 1 to n = 384 [7.4%] in period 5, P = .008) and antibody positive nucleic acid testing negative donors (n = 81 [1.8%] in period 1 to n = 131 [2.5%] in period 5, P.001). We observed a significant increase in aviremic recipients of liver transplants from antibody positive nucleic acid testing negative donors (n = 1 [1.7%] in period 1, to n = 27 [31.0%] in period 5, P = .005) and a significant decrease in the antibody positive nucleic acid testing positive liver discard rate (P = .01). By the end of the study, 75.8% (n = 97) of recipients of antibody positive nucleic acid testing negative kidneys were hepatitis C virus negative, an increase from 10.6% (n = 5) in period 1.The number of donors with the hepatitis C virus is increasing. We observed a concomitant increase in the transplantation of kidneys and livers from aviremic donors, and the recipient population of these organs is increasingly hepatitis C virus negative.

Significant geographic disparities exist in access to liver transplantation and consequently the current liver allocation system is being challenged. We sought to describe our unique experience with using organs with long cold ischemia times from the largest donation service area.From 2009-2014 we performed 350 liver transplants. 167 (48%) had a cold ischemia time8 hours, 134 (38%) between 8 and 12 hours, and 49 (14%) greater than 12 hours.Early allograft dysfunction was observed more commonly with increasing cold ischemia times. 53% of the recipients in the12 h group had early allograft dysfunction compared to 28% in the 8-12 h group, and 18% in the8 h group (P0.001). We found no correlation between early allograft dysfunction and allograft or patient survival. One-year liver allograft survival was 92%, 94%, 87%, three-year graft survival was 82%, 89%, and 87%, and five-year graft survival was 82%, 89%, and 79% in the8 h, 8-12 h, and12 h cold ischemia time groups, respectively. One-year patient survival was 95%, 94%, and 92% and five-year patient survival was 90%, 89%, and 83% in the8 h, 8-12 h, and12 h cold ischemia time groups, respectively. Both unadjusted and multivariate Cox regression analyses indicated no statistically significant associations between cold ischemia time and graft or patient survival.In conclusion, the prolonged cold ischemia time led to early allograft dysfunction but did not have a deleterious association with graft or patient survival.

Background Complicated diverticulitis after transplantation occurs in as many as 3.5% of cases and carries a 25% mortality rate. Diagnosis of complicated diverticulitis in this population can be challenging because of abnormal presentations caused by immunosuppression. Only 4 cases of fistulization after kidney transplantation are described in the literature; none occurred after simultaneous pancreas-kidney transplant. Methods We present a first case of a coloduodenovesical fistula in a patient 9 years after simultaneous pancreas-kidney transplant. The patient presented with intermittent episodes of elevated creatinine and recurrent urinary tract infection. The presence of fistula was strongly suspected in cystoscopy, but, despite extensive investigation, a fistula tract could not be identified. Results The patient ultimately underwent surgical exploration for positive cystoscopy examination, continuation of urinary complaints, and presence of multiple colonic diverticula in computed tomography scan. At surgical exploration, a fistula track was identified between the sigmoid colon and duodenal stump of the pancreas allograft. Subsequently, sigmoidectomy, bladder repair, and enteric conversion of the pancreas transplant were performed. Conclusions Complications of diverticulitis should be considered in organ transplant recipients presenting with recurrent urinary infection and elevated creatinine, and surgical exploration might be indicated even if unable to well-define the fistula tract.

Under the new kidney allocation system (KAS), implemented in 2014, the distribution of the best quality donor kidney grafts shifted between age groups, but it is unclear whether this change translates to meaningful differences in post-transplant outcomes. We conducted a retrospective cohort study of 20,345 deceased donor kidney transplant recipients before and 4,605 recipients after implementation of the KAS using data from the United Network of Organ Sharing. Overall, two-year mortality was greater among recipients in the post-KAS era compared with the pre-KAS era (6.31% vs 5.91% respectively, [p = 0.01]), and two-year graft loss was not significantly different between eras (9.95% and 9.65%, respectively [p = 0.13]). In analysis stratified by age group (18-45, 46-55, 56-65, and ≥66 years), relative risk of mortality was 1.48 (95% confidence interval [CI] 1.09-1.98) among recipients 46-55 years old and 1.47 (95% CI 1.18-1.81) among recipients 56-65 years old. Relative risk of all-cause graft loss was 1.43 (95% CI 1.20-1.70) among recipients 56-65 years old. There were no significant differences in relative risk of mortality or graft loss associated with the KAS era among other age groups. After adjustment for recipient characteristics and characteristics of the changing donor pool, relative risk of two-year mortality and graft loss associated with the post-KAS era was attenuated for recipients aged 46-55 and 56-65 years, but remained statistically significant. In this early analysis after implementation of the KAS, there is suggestion that increased risk of mortality and graft loss may be disproportionately borne by middle-aged recipients, which is only partially accounted for by changes in recipient and donor characteristics. These findings signal a need to continue to monitor the effects of the KAS to ensure that allocation practices both maximize utility of the kidney graft pool and respect fairness between age groups.

BACKGROUND Implementation of the Kidney Allocation System (KAS) changed how kidneys are allocated and the information on which organ utilization decisions are based. We aimed to evaluate how KAS implementation changed kidney utilization and recipient outcomes. MATERIAL AND METHODS Using the United Network for Organ Sharing database, we identified recipients of kidney transplants from donors with kidney donor profile index (KDPI) of 61-90% in the 5-years pre- and 18-months post-KAS implementation and examined patient and graft survival and donor kidney discard rates based on standard criteria donor (SCD) or expanded criteria donor (ECD) status. RESULTS The proportion of ECD kidneys was unchanged pre- versus post-KAS. Post-KAS, SCD kidneys were less likely to be transplanted into young recipients while ECD kidneys were more likely to be transplanted. SCD kidneys in the post-KAS period conferred a 1.42 (95% CI: 1.18-1.73) times higher adjusted mortality and 2% lower 1-year survival (94.2% vs. 96.2%, P

Approximately 8-11% of all organ donors are classified by Public Health Service (PHS) as increased-risk. The proportion of PHS increased-risk donors is on the rise. At the University of Washington Medical Center, in 2014, the proportion of transplants from PHS increased-risk donors was 28% of liver transplants and 23% of kidney transplants. Nationally, transplant providers have been reluctant to use organs from PHS increased-risk donors because of concern for transmission of HIV, HCV, or HBV. There is also patient apprehension when these organs are being offered, and thus the discard rate of these otherwise good quality organs is high. Because of the organ shortage, preventing underutilization of such organs is essential. We provide data and considerations that should be used to guide the use of organs from PHS increased-risk donors.

The new kidney allocation system (KAS) intends to allocate the top 20% of kidneys to younger recipients with longer life expectancy. We hypothesized that the new KAS would lead to greater allocation of Public Health Service (PHS) increased-risk donor organs to younger recipients.Analyses of the Organ Procurement and Transplantation Network data of patients who underwent primary deceased kidney transplantation were performed in pre- and post-KAS periods.The allocation of PHS increased-risk kidney allografts in various age groups changed significantly after implementation of the new KAS, with an increased proportion of younger individuals receiving increased-risk kidneys (7% vs 10% in age group 20-29 y and 13% vs 18% in age group 30-39 y before and after KAS, respectively; P .0001). This trend was reversed in recipients 50-59 years old, with 31% in the pre-KAS period compared with 26% after KAS (P .0001).The new KAS resulted in a substantial increase in allocation of PHS increased-risk kidneys to candidates in younger age groups. Because increased-risk kidneys are generally underutilized, future efforts to optimize the utilization of these organs should target younger recipients and their providers.

With the introduction of the new highly effective antiviral therapies, there has been a dramatic increase in the use of the hepatitis C virus (HCV)-positive livers in HCV-positive recipients. In the majority of studies, HCV positivity was defined as a donor testing HCV Ab positive. In 2015, all Organ Procurement Organizations were mandated to perform and report HCV Nucleic Acid Amplification Testing (NAT) results on all deceased and living donors. Studies are not yet available on how organs are being utilized based on NAT status and whether NAT status affects recipient outcomes. Further studies are needed to maximize the use of these organs.

Acute kidney injury (AKI) is a frequent postoperative complication after liver transplantation. The etiology is multifactorial, including perioperative renal status, surgery related events, and postoperative immunosuppression therapy. The role of renal hypoperfusion and hepatic ischemia-reperfusion injury as causes of early AKI are now being increasingly recognized. Further studies should focus on therapies that would attenuate this injury.

With the need for organs far exceeding supply, donors previously exposed to hepatitis B (HBV) and hepatitis C (HCV) viral infections should be considered for transplantation. Although many centers have protocols for transplanting organs from HBV core antibody-positive (HBcAb+) donors into select recipients, in the era of direct-acting antivirals (DAAs), a new focus should be placed on HCV-positive donors. The transmission rate from HCV antibody-positive (HCVAb+) nucleic acid testing negative (HCV NAT-) donors is expected to be very low, and we encourage use of such organs in HCV recipients provided a normal biopsy, appropriate counseling, and careful post-transplant monitoring. While transmission of HCV from HCV NAT+ donors is universal, the success of DAA in obtaining a sustained viral response in post-transplant recipients should make the use of these organs more appealing. We herein provide information to help guide the use of organs from HCV donors.

The important first step to a successful kidney transplant is a timely referral for transplant evaluation. There are a number of barriers to early referral for kidney transplant evaluation. These include a lack of complete understanding of the process and the advantages and disadvantages of kidney transplantation as a therapy for chronic kidney disease and end-stage renal disease by both patients and physicians. The aim of this chapter is to provide an understanding of the referral process for kidney transplantation.

Patients with end stage liver disease may become critically ill prior to LT requiring admission to the intensive care unit (ICU). The high acuity patients may be thought too ill to transplant; however, often LT is the only therapeutic option. Choosing the correct liver allograft for these patients is often difficult and it is imperative that the allograft work immediately. Donation after cardiac death (DCD) donors provide an important source of livers, however, DCD graft allocation remains a controversial topic, in critically ill patients. Between January 2003-December 2008, 1215 LTs were performed: 85 patients at the time of LT were in the ICU. Twelve patients received DCD grafts and 73 received donation after brain dead (DBD) grafts. After retransplant cases and multiorgan transplants were excluded, 8 recipients of DCD grafts and 42 recipients of DBD grafts were included in this study. Post-transplant outcomes of DCD and DBD liver grafts were compared. While there were differences in graft and survival between DCD and DBD groups at 4 month and 1 year time points, the differences did not reach statistical significance. The graft and patient survival rates were similar among the groups at 3-year time point. There is need for other large liver transplant programs to report their outcomes using liver grafts from DCD and DBD donors. We believe that the experience of the surgical, medical and critical care team is important for successfully using DCD grafts for critically ill patients.

Summary This study sought to determine the procurement factors that lead to development of intrahepatic bile duct strictures (ITBS) and overall biliary complications in recipients of donation after cardiac death (DCD) liver grafts. Detailed information for different time points during procurement (withdrawal of support; SBP

The Kidney Donor Risk Index (KDRI) and Kidney Donor Profile Index (KDPI) assist clinicians with the selection of deceased donor kidneys. This scoring system is based on 10 donor factors including Hepatitis C virus (HCV) status from serological or NAT testing. The donor HCV status (i.e., having either a positive hepatitis C antibody (Ab) or nucleic acid testing (NAT) result) increases the hazard ratio for graft failure by 1.27 and the KDPI by approximately 20%. Whether this increase in KDPI is a true reflection of graft quality for HCV seropositive but not viremic donors is unknown. Further investigations are needed to maximize the use of these organs.

The use of donation after cardiac death (DCD) liver grafts is controversial because of the overall increased rates of graft loss and morbidity, which are mostly related to the consequences of ischemic cholangiopathy (IC). In this study, we sought to determine the factors leading to graft loss and the development of IC and to compare patient and graft survival rates for recipients of DCD liver grafts and recipients of donation after brain death (DBD) liver grafts in a large series at a single transplant center. Two hundred liver transplants with DCD donors were performed between 1998 and 2010 at Mayo Clinic Florida. Logistic regression models were used in the univariate and multivariate analyses of predictors for the development of IC. Additional analyses using Cox regression models were performed to identify predictors of graft survival and to compare outcomes for DCD and DBD graft recipients. In our series, the patient survival rates for the DCD and DBD groups at 1, 3, and 5 years was 92.6%, 85%, and 80.9% and 89.8%, 83.0%, and 76.6%, respectively (P = not significant). The graft survival rates for the DCD and DBD groups at 1, 3, and 5 years were 80.9%, 72.7%, and 68.9% and 83.3%, 75.1%, and 68.6%, respectively (P = not significant). In the DCD group, 5 patients (2.5%) had primary nonfunction, 7 patients (3.5%) had hepatic artery thrombosis, and 3 patients (1.5%) experienced hepatic necrosis. IC was diagnosed in 24 patients (12%), and 11 of these patients (5.5%) required retransplantation. In the multivariate analysis, the asystole-to-cross clamp duration [odds ratio = 1.161, 95% confidence interval (CI) = 1.021-1.321] and African American recipient race (odds ratio = 5.374, 95% CI = 1.368-21.103) were identified as significant factors for predicting the development of IC (P < 0.05). This study has established a link between the development of IC and the asystole-to-cross clamp duration. Procurement techniques that prolong the nonperfusion period increase the risk for the development of IC in DCD liver grafts.

Introduction. Donation after cardiac death (DCD) donors provide an important source of livers that has been used to expand the donor pool. As a consequence of increased numbers of OLT, allograft failure due to early and late complications and disease recurrence are more commonly encountered. The only life saving treatment for patients with liver allograft failure is liver re-transplantation (LR). The use of DCD liver grafts for LR is controversial. Material and methods. Between February 1998 and June 2008, 10 patients underwent LR with DCD allografts. Five (50%) patients had no post operative complications. The 30 day, 1 year, and 3 year patient survival are 80, 60, and 60%, respectively. When DCD grafts are used for sick patients with high MELD scores for LR, the patient and graft survivals are prohibitively low. Conclusion. We do not recommend utilization of DCD liver grafts for LR if a candidate recipient has moderate to high MELD score.