OPTN/SRTR 2022 Annual Data Report: Vascularized Composite Allograft.

This year's chapter on vascularized composite allograft (VCA) encompasses reviews of data collected from 2014 (when VCA was included in the Final Rule) through 2022. The present Annual Data Report shows that the number of VCA recipients in the United States continues to be small and has remained consistent from the prior report. The data continue to be limited by sample size, with trends persistently demonstrating a predominance of White males in the young/middle-aged population as both donors and recipients for nonuterus VCA transplants, and White women younger than 35 years as the predominant recipients of uterus transplant. Similar to the 2021 report, there were only eight failed uterus grafts and one failed nonuterus VCA graft reported from 2014 through 2022. Standardization of definitions of success and failure as well as outcome measures for the different VCA types remain unmet needs in VCA transplantation.

Simultaneous Heart and Kidney Transplantation: A Systematic Review and Proportional Meta-Analysis of Its Characteristics and Long-Term Variables.

Patients with end-stage heart disease who undergo a heart transplant frequently have simultaneous kidney insufficiency, therefore simultaneous heart and kidney transplantation is an option and it is necessary to understand its characteristics and long-term variables. The recipient characteristics and operative and long-term variables were assessed in a meta-analysis. A total of 781 studies were screened, and 33 were thoroughly reviewed. 15 retrospective cohort studies and 376 patients were included. The recipient's mean age was 51.1 years (95% CI 48.52-53.67) and 84% (95% CI 80-87) were male. 71% (95% CI 59-83) of the recipients were dialysis dependent. The most common indication was ischemic cardiomyopathy [47% (95% CI 41-53)] and cardiorenal syndrome [22% (95% CI 9-35)]. Also, 33% (95% CI 20-46) of the patients presented with delayed graft function. During the mean follow-up period of 67.49 months (95% CI 45.64-89.33), simultaneous rejection episodes of both organ allografts were described in 5 cases only. Overall survival was 95% (95% CI 88-100) at 30 days, 81% (95% CI 76-86) at 1 year, 79% (95% CI 71-87) at 3, and 71% (95% CI 59-83) at 5 years. Simultaneous heart and kidney transplantation is an important option for concurrent cardiac and renal dysfunction and has acceptable rejection and survival rates.

OPTN/SRTR 2021 Annual Data Report: Vascularized Composite Allograft.

Year 2020 marked the first OPTN/SRTR Annual Data Report that included a chapter on vascularized composite allograft (VCA), which encompassed reviews of data collected between 2014 (when VCA was included in the Final Rule) and 2020. The present Annual Data Report shows that the number of VCA recipients in the United States continues to be small and trended downward in 2021. While data continue to be limited by sample size, trends continue to show a predominance in White, young/middle-aged, male recipients. Similar to the 2020 report, eight uterus and one non-uterus VCA graft failures were reported from 2014 through 2021. Critical to advancement of VCA transplantation will be the standardization of definitions, protocols, and outcome measures for the different VCA types. Like intestinal transplants, it is likely that VCA transplants will be concentrated and performed at referral transplant centers.

Pediatric impacts of multiorgan transplant allocation policy in the United States.

BACKGROUND: Multiorgan transplantation is increasingly common, driving recent increased attention to multiorgan allocation policies. METHODS: In this review, we summarize current multiorgan transplant allocation policies in the United States, with attention to recent and proposed changes and their impact on pediatric candidates. RESULTS: Existing multiorgan transplant policies attempt to balance equity and utility. Currently, there are clear allocation policies for some, but not all, multiorgan transplant combinations, and there are no mandatory outcomes reporting. Multiorgan candidates are prioritized above all kidney-alone transplant candidates, which negatively affect pediatric kidney transplant wait times. Pediatric candidates are typically exempt from multiorgan listing criteria. CONCLUSION: Multiorgan transplant allocation presents unique challenges for policy development. As the United States Network for Organ Sharing begins exploring continuous distribution allocation, multiorgan allocation will require special consideration and the development of clear and equitable policies.

Impact of multiorgan and kidney-pancreas allocation policies on pediatric kidney-alone transplant candidates in the United States.

BACKGROUND: The United States organ allocation policies prioritize kidney-pancreas and other multiorgan candidates above pediatric kidney-alone candidates, but the effects of these policies are unclear. METHODS: We used OPTN data to describe trends in multiorgan and kidney-pancreas transplantation and identify 377 next-sequential pediatric kidney-alone candidates between 4/1/2015 and 10/31/2019 for individual-level analysis. RESULTS: Eleven percent of all kidneys were allocated as part of a multiorgan or kidney-pancreas transplant and 6% of pediatric kidney candidates were impacted. Pediatric next-sequential candidates accrued a median of 118 days (IQR 97-135 days) of additional wait time, and this was significantly longer for children who were Hispanic (p = .02), blood type B or O (p = .01), or had a cPRA ≥20% (p < .01). Eight pediatric next-sequential candidates (2%) were removed from the waitlist due to death or "too sick to transplant." 63% were transplanted with a kidney with a higher KDPI than the original multiorgan match (p < .01). Donor service areas with higher volumes of kidney-pancreas transplants had significantly longer additional wait times for pediatric next-sequential candidates (p = .01). CONCLUSIONS: Current allocation policy results in longer waiting times and higher KDPI kidneys for pediatric kidney candidates. As multiorgan transplant volume is increasing, further consideration of allocation policy is necessary to maximize equality and utility.

Outcomes following concomitant multiorgan heart transplantation from circulatory death donors: The United States experience.

BACKGROUND: Donation after circulatory death (DCD) has reemerged as a method of expanding the donor heart pool. Given the high waitlist mortality of multiorgan heart candidates, we evaluated waitlist outcomes associated with willingness to consider DCD offers and post-transplant outcomes following DCD transplant for these candidates. METHODS: We identified adult multiorgan heart candidates and recipients between January 1, 2020 and March 31, 2023 nationally. Among candidates that met inclusion criteria, we compared the cumulative incidence of transplant, with waitlist death/deterioration as a competing risk, by willingness to consider DCD offers. Among recipients of DCD versus brain death (DBD) transplants, we compared perioperative outcomes and post-transplant survival. RESULTS: Of 1,802 heart-kidney, 266 heart-liver, and 440 heart-lung candidates, 15.8%, 12.4%, and 31.1%, respectively, were willing to consider DCD offers. On adjusted analysis, willingness to consider DCD offers was associated with higher likelihood of transplant for all multiorgan heart candidates and decreased likelihood of waitlist deterioration for heart-lung candidates. Of 1,100 heart-kidney, 173 heart-liver, and 159 heart-lung recipients, 5.4%, 2.3%, and 2.5%, respectively, received DCD organs. Recipients of DCD and DBD heart-kidney transplants had a similar likelihood of perioperative outcomes and 1-year survival. All other DCD multiorgan heart recipients have survived to the last follow-up. CONCLUSIONS: Multiorgan heart candidates who were willing to consider DCD offers had favorable waitlist outcomes, and heart-kidney recipients of DCD transplants had similar post-transplant outcomes to recipients of DBD transplants. We recommend the use of DCD organs to increase the donor pool for these high-risk candidates.

Do age and functional dependence affect outcomes of simultaneous heart-kidney transplantation?

Objective: This study assessed characteristics and outcomes of younger (18-65) versus older (>65) recipients of simultaneous heart-kidney (SHK) transplantation with varying functional dependence. Methods: This study retrospectively analyzed 1398 patients from the United Network for Organ Sharing database who received SHK between 2010 and 2021. Patients who were <18 year old, underwent transplant of additional organs simultaneously, or had previous heart transplant were excluded. The primary end point was all-cause mortality, and secondary end points included adverse events and cause of death. Outcomes were also evaluated by propensity score-matched comparison. Results: The number of annual SHK transplantation in the United States has significantly increased among both age groups over the past 2 decades (P < .0001). After propensity score matching of recipients aged 18 to 65 years (n = 1162) versus age >65 years (n = 236), baseline characteristics were similar and well-balanced between the 2 cohorts. Between matched cohorts, older recipients did not have increased posttransplant mortality compared with younger recipients (90-day survival, P = .85; 7-year survival, P = .61). Multivariable Cox regression analysis found that age (hazard ratio [HR], 1.039 [0.975-1.106], P = .2415) and pretransplant functional status with interaction term for age (some assistance, HR, 0.965 [0.902-1.033], P = .3079; total assistance, HR, 0.976 [0.914-1.041], P = .4610) were not significant risk factors for 7-year post-SHK transplantation mortality. Conclusions: Older and more functionally dependent recipients in this study did not have increased post-SHK transplantation mortality. These findings have important implications for organ allocation among elderly patients, as they support the need for thorough assessment of SHK candidates in terms of comorbidities, rather than exclusion solely based on age and functional dependence.

National outcomes of bridge to multiorgan cardiac transplantation using mechanical circulatory support.

BACKGROUND: Little is known regarding the profile of patients with multiorgan failure listed for simultaneous cardiac transplantation and secondary organ. In addition, few studies have reported how these patients are bridged with mechanical circulatory support (MCS). In this study, we examined national data of patients listed for multiorgan transplantation and their outcomes after bridging with or without MCS. METHODS: United Network for Organ Sharing data were reviewed for adult multiorgan transplantations from 1986 to 2019. Post-transplant patients and total waitlist listings were examined and stratified according to MCS status. Survival was assessed via Cox regression in the post-transplant cohort and Fine-Gray competing risk regression with transplantation as a competing risk in the waitlist cohort. RESULTS: There were 4534 waitlist patients for multiorgan transplant during the study period, of whom 2117 received multiorgan transplants. There was no significant difference in post-transplant survival between the MCS types and those without MCS in the whole cohort and heart-kidney subgroup. Fine-Gray competing risk regression showed that patients bridged with extracorporeal membrane oxygenation had significantly greater waitlist mortality compared with those without MCS when controlling for preoperative characteristics (subdistribution hazard ratio, 2.27; 95% confidence interval, 1.48-3.47; P < .001), whereas those bridged with a ventricular assist device had a decreased incidence of death compared with those without MCS (subdistribution hazard ratio, 0.78; 95% confidence interval, 0.63-0.96; P = .017). CONCLUSIONS: MCS, as currently applied, does not appear to compromise the survival of multiorgan heart transplant patients. Waitlist data show that extracorporeal membrane oxygenation patients have profoundly worse survival irrespective of preoperative factors including organ type listed. Survival on the waitlist for multiorgan transplant has improved across device eras.

Outcomes of Multi-Organ Transplant in Adult Patients With Congenital Heart Disease.

Background The prevalence of adult congenital heart disease (ACHD) is increasing in the United States because of improved survival into adulthood. The unique physiology of ACHD commonly leads to multiorgan dysfunction, prompting interest in outcomes after multiorgan (heart+X) transplantation. Methods and Results We queried the SRTR (Scientific Registry of Transplant Recipients) database to examine 5-year outcomes in ACHD patients (aged ≥18 years) who underwent dual organ (heart+kidney/liver/lung) transplantation between 2000 and 2016. Cox proportional hazards models were constructed to look at survival of dual organ transplant recipients versus heart-only recipients in the ACHD population and heart+lung recipients versus heart-only recipients in the ACHD populations and versus non-ACHD recipients of heart+lung transplant. We then constructed a multivariable model to investigate independent risk factors for 5-year mortality after multiorgan transplant. Overall, 5-year mortality was greater for multiorgan (heart+kidney/liver/lung) transplant compared with heart-only transplant. On further analysis, only heart+lung transplant was associated with increased mortality. Outcomes after heart+lung transplant were no different between the ACHD and non-ACHD population. Risk factors for increased risk of 5-year mortality in ACHD patients after multiorgan transplant included heart+lung transplant, previous cardiac surgery, and severe functional limitation. Conclusions The mortality risk associated with multiorgan heart transplant in ACHD patients is attributable primarily to heart+lung transplants. Multiorgan transplant in ACHD does not convey increased risk compared with the non-ACHD population. Need for multiorgan transplant should not be an impediment to listing ACHD patients needing a heart transplant.

Trasplante intestinal en pediatría: análisis de la primera serie de receptores en la Argentina / Intestinal transplantation in pediatrics: analysis of the first recipient series in Argentina

El presente trabajo comunica la evolución posoperatoria inmediata y alejada de los pacientes pediátricos trasplantados en un único centro enla Argentina, desde marzo de 2006 hasta marzo de 2010, en variables demográficas, indicaciones, contraindicaciones, evolución y supervivencia de pacientes e injerto. Basándose en los resultados se puede concluir que el trasplante intestinal debe ser considerado como un tratamiento válido para todos aquellos pacientes que presenten insuficiencia intestinal,con complicaciones del soporte parenteral. Los resultados adquiridos en nuestro programa son similares a los comunicados internacionalmentey abren una nueva perspectiva para un grupo especial de niños que carecían de solución en nuestro medio.

The present is a retrospective analysis of all pediatric patients that underwent intestinal transplant from march 2006 to march 2010, describing demographics, indications, contraindications, clinical follow up and survival in a single center in Argentina. Based on the results shown one can conclude that intestinal transplant should be considered as a valid treatment for patients with intestinal insufficiency and complications related to parenteral nutrition. The results of our program are similar to those reported in the international Intestinal Transplant Registry. This opens a new perspective to a special population that otherwise would not have any other therapeutic option.

El centro de trasplante de clínica las condes: después de 15 años ¿cuál ha sido el aporte a la medicina chilena? / The Transplantation center of clínica las condes 15 years after: it contribution to chilean medicine development

El Centro de Trasplante de Clínica Las Condes se formó en 1994, doce años después de fundada la institución, con el objetivo de aplicar las técnicas de los trasplantes de órganos sólidos a receptores con insuficiencia de variados órganos abdominales y torácicos. Quince años después se pueden mostrar resultados que considerados en sus conjuntos son inéditos en el país: 212 trasplantes hepáticos, 179 trasplantes renales, 60 trasplantes de pulmón, 20 trasplantes cardiacos, 13 trasplantes combinados de páncreas y riñón, 2 de intestino y uno de islotes de páncreas. Los resultados clínicos son comparables a los de centros especializados de países desarrollados. Además, se han procurado órganos dentro y fuera de la institución, se ha realizado docencia de post grado en Trasplante para médicos y enfermeras, se ha hecho investigación básica y clínica en alianza con la Universidad de Chile, se ha innovado tecnológicamente para ofrecer una terapia actualizada y segura. Todo ello ha sido posible por la constitución de un sólido equipo de trabajo asentado en una institución eficiente que estimula el progreso y el perfeccionamiento.

The Transplantation Center of Clínica Las Condes was created in 1994, 12 years after the initiation of the based institution, with the purpose of offering to Chilean patients who suffer end stage solid organ disease a modern therapy. Fifteen years after the numbers of multiorgan transplants speak by themselves: 212 liver transplants, 179 renal transplants, 60 pulmonary transplants, 20 cardiac transplants, 13 combined pancreas and renal transplants, 2 intestine grafts, and one pancreatic islet transplant. Clinical resulst are comparable to those shown by centres of more developped countries. In addition, an active organ procurement system have been installed locally providing organs to the organ distribution Chilean system. Also, associated to the University of Chile, post graduate teaching in the Transplantation area have been started dedicated to medical doctors and nurses and Basic and Clinical investigation have been performed with significant scientific production. All this was possible thanks to being installed in a solid health care institution that stimulate progress and improvement.