How can we utilize livers from advanced aged donors for liver transplantation for hepatitis C?

Advanced age donors have inferior outcomes of liver transplantation for Hepatitis C (HCV). Aged donors grafts may be transplanted into young or low model for end stage liver disease (MELD) patients in order to offset the effect of donor age. However, it is not well understood how to utilize liver grafts from advanced aged donors for HCV patients. Using the UNOS database, we retrospectively studied 7508 HCV patients who underwent primary liver transplantation. Risk factors for graft failure and graft survival using advanced aged grafts (donor age ≥ 60 years) were analyzed by Cox hazards models, donor risk index (DRI) and organ patient index (OPI). Recipient's age did not affect on graft survival regardless of donor age. Advanced aged grafts had significant inferior survival compared to younger aged grafts regardless of MELD score (P < 0.0001). Risk factors of HCV patients receiving advanced aged grafts included donation after cardiac death (DCD, HR: 1.69) and recent hospitalization (HR: 1.43). Advanced aged grafts showed significant difference in graft survival of HCV patients with stratification of DRI and OPI. In conclusion, there was no offsetting effect by use of advanced aged grafts into younger or low MELD patients. Advanced aged grafts, especially DCD, should be judiciously used for HCV patients with low MELD score.

Single dose of alemtuzumab induction with steroid-free maintenance immunosuppression in pancreas transplantation.

BACKGROUND: The use of alemtuzumab (humanized anti-CD52 monoclonal antibody) has been primarily studied in renal transplantation, and the experience of alemtuzumab induction in pancreas transplantation is still limited. The objective of this study is to analyze the outcome of pancreas transplantation by using a single dose of 30 mg alemtuzumab induction with steroid-free maintenance immunosuppression. METHODS: We performed a total 28 pancreas transplants (17 simultaneous kidney-pancreas transplantation [SPK], 5 pancreas after kidney transplantation [PAK], and 6 pancreas transplant alone [PTA]) between November 2006 and April 2010. Median follow-up was 25 months (range, 8-49 months). Maintenance immunosuppression consists of tacrolimus and mycophenolate. We analyzed patient/graft survival, graft function, and complications. RESULTS: One-year actuarial patient/graft survival was 100%/100% in SPK, PAK, and PTA. Three-year actuarial patient/pancreas graft survival rates for SPK, PAK, and PTA were 100%/100%, 100%/100%, and 100%/83%, respectively. Excellent pancreas and kidney graft functions were observed. Acute cellular rejection occurred in 42% of patients. Most of the rejection episode occurred approximately 1 or 6 months after transplant. Absolute lymphocyte count remained below preoperative level for 1 year posttransplant and WBC counts were significantly lower for 3 years after transplant compared with pretransplant level. Cytomegalovirus infection and bacterial infection occurred in 28% and 36% of patients, respectively. Eleven percent of patients developed donor-specific antibodies and 7% of patients experienced antibody-mediated rejection. CONCLUSION: A single dose of 30 mg alemtuzumab induction with steroid-free maintenance immunosuppression achieved excellent mid-term patient and graft survival for pancreas transplantation with acceptable complication rate.