The Immune Tolerance Network ITN030ST A‐WISH assessed immunosuppression withdrawal in liver transplant recipients with hepatitis C or nonimmune nonviral liver disease. Of 275 recipients enrolled ...before transplantation, 95 were randomly assigned 4:1 to withdrawal (n = 77) or maintenance (n = 18) 1‐ to 2‐years posttransplant. Randomization eligibility criteria included stable immunosuppression monotherapy; adequate liver and kidney function; ≤Stage 2 Ishak fibrosis; and absence of rejection on biopsy. Immunosuppression withdrawal followed an 8‐step reduction algorithm with ≥8 weeks per level. Fifty‐two of 77 subjects (67.5%) reduced to ≤50% of baseline dose, and 10 of 77 (13.0%) discontinued all immunosuppression for ≥1 year. Acute rejection and/or abnormal liver tests were treated with increased immunosuppression; 5 of 32 rejection episodes required a methylprednisolone bolus. The composite end point (death or graft loss; grade 4 secondary malignancy or opportunistic infection; Ishak stage ≥3; or >25% decrease in glomerular filtration rate within 24 months of randomization) occurred in 12 of 66 (18%) and 4 of 13 (31%) subjects in the withdrawal and maintenance groups. Early immunosuppression minimization is feasible in selected liver recipients, while complete withdrawal is successful in only a small proportion. The composite end point comparison was inconclusive for noninferiority of the withdrawal to the maintenance group.
The ITN030ST A‐WISH immunosuppression withdrawal study demonstrates that early posttransplantation immunosuppressant minimization is feasible but complete withdrawal is rarely successful.
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BACKGROUNDExtracorporeal support (ECS) during organ procurement from donors after circulatory determination of death (DCDD) could increase the number of donor organs and decrease posttransplant ...complications. This study reports the experience of a large transplant center with controlled DCDD.
METHODSA retrospective review of all potential controlled-DCDD cases between October 1, 2000 and July 31, 2013 was performed. We focused on methods, ethical and practical issues, and recipient outcome data of organs procured and transplanted in our institution using ECS-assisted DCDD (E-DCDD).
RESULTSECS was used for organ procurement in 37 controlled DCDD. The number of organs procured per donor was 2.59, and the number of organs transplanted per donor was 1.68. Delayed graft function occurred in 31% of renal grafts. In three donors (8%), organ donation was not completed because of surgeon judgment. Forty-eight renal grafts (65.8%), thirteen livers (61.9%), and one pancreas (50%) were successfully transplanted.
CONCLUSIONSECS can be routinely implemented in controlled DCDD. In our experience, the organs provided per donor was 2.59. Widely applied, EDCDD could result in more donor organs, especially when applied to DCDD in uncontrolled conditions.
Organ Transplantation in Ethiopia Ahmed, Momina M; Tedla, Fasika M; Leichtman, Alan B ...
Transplantation,
2019-March, 2019-03-00, 20190301, Volume:
103, Issue:
3
Journal Article
At transplant centers, nephrologists and transplant surgeons work together to provide kidney transplant care to patients with chronic kidney disease (CKD). Many transplant centers also provide ...dialysis access placement services to their own and external CKD patients. While such dialysis access management is often integrated and multidisciplinary, patients are typically drawn from a smaller area clustered around the transplant center, rather than the larger area serviced by the transplant center’s kidney transplant program. However, there is a national need for complex dialysis access placement services that isn’t always available in smaller communities. Given this shortage, an integrated CKD outreach program may, by providing potential referring nephrologists with additional options for patients having difficulty establishing dialysis access that are not amenable to local resources, increase the likelihood of later transplant referral.
METHODSAs part of the Leadership Development Series program of the Transplantation Society (TTS), a project expanding and integrating outreach from the Multidisciplinary Dialysis Access Clinic (MDAC), a joint effort of Transplant Surgery and Interventional Nephrology, into the existing Transplant Center Kidney Program (TCKP) efforts was instituted.
RESULTS & DISCUSSIONA medical assistant was hired to support the additional efforts of the MDAC. A stand-alone website was designed for the MDAC that emphasized the multidisciplinary services offered by the MDAC, as a component of the Transplant Center. Links to the faculty websites for the surgeons and interventional nephrologists are included. Linkage from the Transplant Center website, as well as from Interventional Nephrology, are in progress. A brochure with similar content is under production.Additional information about the MDAC was added to the TCKP outreach slides set, which is presented to referring nephrologists and dialysis units. For outreach talks within an hour’s drive, one of the dialysis access coordinators will accompany the kidney transplant outreach coordinators. For the longer distances, follow-up calls will be arranged for those interested. Similarly, information about the TCKP is included in the MDAC outreach information.Aspects of the MDAC morbidity and mortality conference, as well as its quality assurance program, were integrated into, and supported by, the Transplant Center as well, to emphasize the integrated nature of CKD care provided by the TCKP program. Changes in referral patterns following outreach effort will be analyzed once the program has been active for a year.
CONCLUSIONDialysis access affords an opportunity to engender good will from potential referring nephrologists. While any increase in access volume will likely have a high proportion of complex resource intensive patients, the potential to increase kidney transplant evaluation referrals may be significant.
Background. Vancomycin-resistant enterococcal (VRE) infections cause significant morbidity and mortality among patients undergoing liver transplantation. We performed a prospective study among ...patients awaiting transplantation to assess rates, risk factors, and outcomes associated with VRE colonization before and after transplantation. Methods. All adults on the transplantation waiting list from 2000–2003 were eligible. Demographic, historical, and laboratory data, as well as stool samples to be analyzed for VRE, were collected at enrollment and every 4–6 months thereafter until transplantation. After transplantation, samples were obtained every 3 days during hospitalization and were analyzed for VRE; outcomes were assessed at 90 days. Results. Overall, 375 patients were enrolled in our study, and 142 received transplants. VRE colonization occurred in 50 (13%) of 375 patients before transplantation and was independently associated with treatment with antianaerobic antimicrobials, third-generation cephalosporins, proton pump inhibitors, or neomycin; having a recent endoscopic retrograde cholangiopancreatogram or paracentesis procedure; and admission to the liver unit. Of these 50 patients, 22 (44%) received a transplant, and 7 (32%) of 22 developed a VRE infection after transplantation. An additional 22 patients (18%) who were not colonized before transplantation acquired VRE after transplantation; VRE infection developed in 5 (23%) of these patients. Patients colonized with VRE either before or after transplantation had longer stays in the intensive care unit and the hospital. Mortality at 90 days was significantly greater among those who acquired VRE after transplantation (5 23% of 22), compared with those who had VRE colonization before transplantation (2 9% of 22). Conclusions. Liver transplantation candidates with VRE colonization before transplantation experience greater morbidity but not greater mortality, compared with noncolonized candidates. Transplant recipients who acquire VRE after transplantation have a higher mortality rate than noncolonized recipients. Strategies should be implemented to reduce nosocomial VRE acquisition after transplantation among this vulnerable group.
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