Early Assessment of Cardiac Allograft Vasculopathy Risk Among Recipients of Hepatitis C Virus-infected Donors in the Current Era.

BACKGROUND: Transplantation of hearts from hepatitis C virus (HCV)-positive donors has increased substantially in recent years following development of highly effective direct-acting antiviral therapies for treatment and cure of HCV. Although historical data from the pre-direct-acting antiviral era demonstrated an association between HCV-positive donors and accelerated cardiac allograft vasculopathy (CAV) in recipients, the relationship between the use of HCV nucleic acid test-positive (NAT+) donors and the development of CAV in the direct-acting antiviral era remains unclear. METHODS AND RESULTS: We performed a retrospective, single-center observational study comparing coronary angiographic CAV outcomes during the first year after transplant in 84 heart transplant recipients of HCV NAT+ donors and 231 recipients of HCV NAT- donors. Additionally, in a subsample of 149 patients (including 55 in the NAT+ cohort and 94 in the NAT- cohort) who had serial adjunctive intravascular ultrasound examination performed, we compared development of rapidly progressive CAV, defined as an increase in maximal intimal thickening of ≥0.5 mm in matched vessel segments during the first year post-transplant. In an unadjusted analysis, recipients of HCV NAT+ hearts had reduced survival free of CAV ≥1 over the first year after heart transplant compared with recipients of HCV NAT- hearts. After adjustment for known CAV risk factors, however, there was no significant difference between cohorts in the likelihood of the primary outcome, nor was there a difference in development of rapidly progressive CAV. CONCLUSIONS: These findings support larger, longer-term follow-up studies to better elucidate CAV outcomes in recipients of HCV NAT+ hearts and to inform post-transplant management strategies.

Associations between social determinants of health and abdominal solid organ transplant wait-lists in the United States.

BACKGROUND: Societal factors that influence wait-listing for transplantation are complex and poorly understood. Social determinants of health (SDOH) affect rates of and outcomes after transplantation. METHODS: This cross-sectional study investigated the impact of SDOH on additions to state-level, 2017-2018 kidney and liver wait-lists. Principal components analysis, starting with 127 variables among 3142 counties, was used to derive novel, comprehensive state-level composites, designated (1) health/economics and (2) community capital/urbanicity. Stepwise multivariate linear regression with backwards elimination (n = 51; 50 states and DC) tested the effects of these composites, Medicaid expansion, and center density on adult disease burden-adjusted wait-list additions. RESULTS: SDOH related to increased community capital/urbanicity were independently associated with wait-listing (starting models: B = .40, P = .010 Kidney; B = .36, P = .038 Liver) (final models: B = .31, P = .027 Kidney, B = .34, P = .015 Liver). In contrast and surprisingly, no other covariates were associated with wait-listing (P ≥ .122). CONCLUSIONS: These results suggest that deficits in community resources are important contributors to disparities in wait-list access. Our composite SDOH metrics may help identify at-risk communities, which can be the focus of local and national policy initiatives to improve access to organ transplantation.

Sex and Gender Disparities in Pretransplant Characteristics and Relationships with Postoperative Outcomes in Liver Transplant Recipients with Alcoholic Liver Disease.

OBJECTIVES: Previous studies of liver transplant recipients have reported discrepancies with regard to gender and/or sex differences but have focused on pretransplant outcomes. Female candidates are less likely to receive liver transplant and more likely to die or be delisted than their male counterparts. Here, we examined differences in men versus women with alcoholic liver disease before liver transplant and the effects of these differences on posttransplant survival. MATERIALS AND METHODS: We analyzed the Scientific Registry of Transplant Recipients records of adult, deceased-donor, whole liver transplant recipients with decompensated alcoholic liver disease from 2002 to 2017 to evaluate the effects of gender on survival in 2 alcoholic liver disease cohorts: (a) including and (b) excluding recipients with additional diagnoses. Pretransplant characteristics were compared using chi-square or t tests. Kaplan-Meier and multivariable proportional hazards regression models were used to evaluate the main and covariable-adjusted effects of gender on survival. RESULTS: Of 13781 transplant recipients with decompensated end-stage liver disease, as defined by Model for End-Stage Liver Disease score ≥ 15, 10924 (79%) were men and 2857 (21%) were women. Women had higher Model for End-Stage Liver Disease scores, higher rates of stage 4 and 5 chronic kidney disease, and were more likely to be on dialysis or ventilator support at time of transplant (all P < .05). Among all recipients, and after adjusting for risk factors, men were approximately 9% more likely than women to experience long-term graft loss (hazard ratio = 1.093; 95% confidence interval, 1.00-1.19; P = .043). However, sex difference was not associated with risk of graft loss among those without additional diagnoses (hazard ratio = 1.09; 95% confidence interval, 0.99-1.21; P = .095). CONCLUSIONS: Although women with alcoholic liver disease who undergo liver transplant have higher severity of illness than their male counterparts, long-term outcomes are comparable.

Geographic Disparities in Access to Simultaneous Pancreas and Kidney Transplant in the Pre- and Post-Pancreas Allocation System Eras.

BACKGROUND: The 2014 pancreas allocation system (PAS) intended to decrease geographic variability in listing practices for simultaneous pancreas and kidney (SPK) transplant and define eligibility criteria for those with type 2 diabetes mellitus (T2DM). Our primary aims were to evaluate geographic disparities in access to SPK and assess T2DM SPK listings in the pre- and post-PAS eras. METHODS: Adult listings for SPK and kidney transplant (pre-PAS, January 2010 to October 29, 2014; post-PAS, October 30, 2014, to June 2, 2017) were identified in the Scientific Registry of Transplant Recipients. Multivariable logistic regression models tested associations of geography and/or diabetes mellitus type on the likelihood of SPK versus kidney transplant listing pre- and post-PAS. Competing risk models tested the likelihood of SPK transplantation within 2 years of listing for SPK. RESULTS: Among 41 205 listings (27 393 pre-PAS; 24 439 T2DM), univariate analysis showed reduced percentages for SPK post-PAS (22.1%-20.8%; P = 0.003). After adjusting for patient and center characteristics, geographic disparities declined slightly but persisted post-PAS (era by region interaction P < 0.001). The era by type of diabetes mellitus interaction effect was statistically significant (P = 0.039), reflecting that the proportions of SPK listings for T2DM increased in the post-PAS era (3.4%-3.9%; univariate P = 0.038), while those for type 1 diabetes mellitus remained statistically stable (47.9%-48.4%; univariate P = 0.571). Among people listed for SPK, geographic disparities in the cumulative incidence of transplantation within 2 years declined and the overall likelihood of transplantation increased in the post-PAS era (both P < 0.001). CONCLUSIONS: Geographic disparities in access to SPK declined slightly but persisted post-PAS. With new allocation change proposals and elimination of listing criteria for T2DM, further monitoring is warranted.

A2 to B Kidney Transplantation in the Post-Kidney Allocation System Era: A 3-year Experience with Anti-A Titers, Outcomes, and Cost.

BACKGROUND: The new kidney allocation systems (KAS) instituted December 2014 permitted A2 to B deceased donor kidney transplantation (DDKTx) to improve access and reduce disparities in wait time for minorities. A recent United Network for Organ Sharing (UNOS) analysis, however, indicated only 4.5% of B candidates were registered for A2 kidneys. Cited barriers to A2 to B DDKTx include titer thresholds, patient eligibility, and increased costs. There are little published data on post-transplantation anti-A titers or outcomes of A2 to B DDKTx since this allocation change. STUDY DESIGN: We conducted a retrospective, single center, cohort analysis of 29 consecutive A2 to B and 50 B to B DDKTx from December 2014 to December 2017. Pre- and postoperative anti-A titers were monitored prospectively. Outcomes included post-transplant anti-A titers, patient and graft survival, renal function, and hospital costs. RESULTS: African Americans comprised 72% of the A2 to B and 60% of the B to B group. There was no difference in mean wait time (58.8 vs 70.8 months). Paired tests indicated that anti-A IgG titers in A2 to B DDKTx were increased at discharge (p = 0.001) and at 4 weeks (p = 0.037). There were no significant differences in patient or graft survival, serum creatinine (SCr), or estimated glomerular filtration rate (eGFR), but the trajectories of SCr and eGFR differed between groups over the follow-up period. A2 to B had significantly higher mean transplant total hospital costs ($114,638 vs $91,697, p < 0.001) and hospital costs net organ acquisition costs ($42,356 vs $20,983, p < 0.001). CONCLUSIONS: Initial experience under KAS shows comparable outcomes for A2 to B vs B to B DDKTx. Anti-A titers increased significantly post-transplantation, but did not adversely affect outcomes. Hospital costs were significantly higher with A2 to B DDKTx. Transplant programs, regulators, and payors will need to weigh improved access for minorities with increased costs.

Directed solutions to address differences in access to liver transplantation.

The United Network for Organ Sharing recently altered current liver allocation with the goal of decreasing Model for End-Stage Liver Disease (MELD) variance at transplant. Concerns over these and further planned revisions to policy include predicted decrease in total transplants, increased flying and logistical complexity, adverse impact on areas with poor quality health care, and minimal effect on high MELD donor service areas. To address these issues, we describe general approaches to equalize critical transplant metrics among regions and determine how they alter MELD variance at transplant and organ supply to underserved communities. We show an allocation system that increases minimum MELD for local allocation or preferentially directs organs into areas of need decreases MELD variance. Both models have minimal adverse effects on flying and total transplants, and do not disproportionately disadvantage already underserved communities. When combined together, these approaches decrease MELD variance by 28%, more than the recently adopted proposal. These models can be adapted for any measure of variance, can be combined with other proposals, and can be configured to automatically adjust to changes in disease incidence as is occurring with hepatitis C and nonalcoholic fatty liver disease.