Generating strategies for a national comeback in pancreas transplantation: A Delphi survey and US conference report.

In the United States, potential transplant candidates with insulin-dependent diabetes mellitus are inconsistently offered pancreas transplantation (PTx), contributing to a dramatic decline in pancreas allograft utilization over the past 2 decades. The American Society of Transplantation organized a workshop to identify barriers inhibiting PTx and to develop strategies for a national comeback. The 2-day workshop focused on 4 main topics: (1) referral/candidate selection, (2) organ recovery/utilization, (3) program performance/patient outcomes, and (4) enhanced education/research. Topics were explored through expert presentations, patient testimonials, breakout sessions, and strategic planning, including the identification of tasks for immediate focus. Additionally, a modified-Delphi survey was conducted among workshop members to develop and rate the importance of barriers, and the impact and feasibility of workgroup-identified improvement strategies. The panelists identified 16 barriers to progress and 44 strategies for consideration. The steps for a national comeback in PTx involve greater emphasis on efficient referral and candidate selection, better donor pancreas utilization practices, eliminating financial barriers to procurement and transplant, improving collaboration between transplant and diabetes societies and professionals, and increasing focus on PTx training, education, and research. Partnership between national societies, patient advocacy groups, and professionals will be essential to realizing this critical agenda.

Disparities in Referrals to End-of-Life Care in Eligible Hepatocellular Carcinoma Patients.

BACKGROUND: Hepatocellular Carcinoma (HCC) is a malignancy with increasing incidence and morbidity. For patients with a poor prognosis, engagement with advanced care planning and end-of life (EOL) services (I.e., palliative care, hospice) can address physical, financial, and social complications of a terminal diagnosis. Minimal data exist on the demographics of the patients being referred to and enrolling in EOL services for HCC. AIMS: We aim to report the relationship between demographics and EOL service referral. METHODS: Retrospective review of a prospectively maintained high-volume liver center registry of patients diagnosed with HCC from 2004 to 2022. EOL services eligible patients were defined as BCLC stage C or D, evidence of metastases, and/or transplant ineligible. RESULTS: Black patients were more likely to be referred than white patients (OR 1.47 (1.03, 2.11)). Once referred, patients were significantly more likely to be enrolled if they had insurance coverage, though no other factors in models were significant. There were no significant differences in survival among those referred who did or did not enroll, after controlling for other factors. CONCLUSION: Black patients were more likely to be referred compared to white patients and patients who were insured were more likely to be enrolled. Whether this is indicative of black patients being appropriately referred at a higher rate, being offered EOL care instead of aggressive treatment, or other unknown factors warrants further study.

Advances and innovations in living donor liver transplant techniques, matching and surgical training: Meeting report from the living donor liver transplant consensus conference.

The practice of LDLT currently delivers limited impact in western transplant centers. The American Society of Transplantation organized a virtual consensus conference in October 2021 to identify barriers and gaps to LDLT growth, and to provide evidence-based recommendations to foster safe expansion of LDLT in the United States. This article reports the findings and recommendations regarding innovations and advances in approaches to donor-recipient matching challenges, the technical aspects of the donor and recipient operations, and surgical training. Among these themes, the barriers deemed most influential/detrimental to LDLT expansion in the United States included: (1) prohibitive issues related to donor age, graft size, insufficient donor remnant, and ABO incompatibility; (2) lack of acknowledgment and awareness of the excellent outcomes and benefits of LDLT; (3) ambiguous messaging regarding LDLT to patients and hospital leadership; and (4) a limited number of proficient LDLT surgeons across the United States. Donor-recipient mismatching may be circumvented by way of liver paired exchange. The creation of a national registry to generate granular data on donor-recipient matching will guide the practice of liver paired exchange. The surgical challenges to LDLT are addressed herein and focuses on the development of robust training pathways resulting in proficiency in donor and recipient surgery. Utilizing strong mentorship/collaboration programs with novel training practices under the auspices of established training and certification bodies will add to the breadth and depth of training.

Living donor liver transplantation: A multi-disciplinary collaboration towards growth, consensus, and a change in culture.

INTRODUCTION: Living donor liver transplantation (LDLT) reduces liver transplant waitlist mortality and provides excellent long-term outcomes for persons with end stage liver disease. Yet, utilization of LDLT has been limited in the United States (US). METHODS: In October 2021, the American Society of Transplantation held a consensus conference to identify important barriers to broader expansion of LDLT in the US, including data gaps, and make recommendations for impactful and feasible mitigation strategies to overcome these barriers. Domains addressed encompassed the entirety of the LDLT process. Representation from international centers and living donor kidney transplantation were included for their perspective/experience in addition to members across disciplines within the US liver transplantation community. A modified Delphi approach was employed as the consensus methodology. RESULTS: The predominant theme permeating discussion and polling results centered on culture; the beliefs and behaviors of a group of people perpetuated over time. CONCLUSIONS: Creating a culture of support for LDLT in the US is key for expansion and includes engagement and education of stakeholders across the spectrum of the process of LDLT. A shift from awareness of LDLT to acknowledgement of benefit of LDLT is the primary goal. Propagation of the maxim "LDLT is the best option" is pivotal.

A survey of transplant providers regarding attitudes, barriers, and facilitators to living donor liver transplantation in the United States.

INTRODUCTION: A successful living donor liver transplant (LDLT) is the culmination of a multifaceted process coordinated among key stakeholders. METHODS: We conducted an electronic survey of US liver transplant (LT) centers (August 26, 2021-October 10, 2021) regarding attitudes, barriers, and facilitators of LDLT to learn how to expand LDLT safely and effectively in preparation for the American Society of Transplantation Living Donor Liver Transplant Consensus Conference. RESULTS: Responses were received from staff at 58 programs (40.1% of US LT centers). There is interest in broadening LDLT (100% of LDLT centers, 66.7% of non-LDLT centers) with high level of agreement that LDLT mitigates donor shortage (93.3% of respondents) and that it should be offered to all suitable candidates (87.5% of respondents), though LDLT was less often endorsed as the best first option (29.5% of respondents). Key barriers at non-LDLT centers were institutional factors and surgical expertise, whereas those at LDLT centers focused on waitlist candidate and donor factors. Heterogeneity in candidate selection for LDLT, candidate reluctance to pursue LDLT, high donor exclusion rate, and disparities in access were important barriers. CONCLUSION: Findings from this study may help guide current and future expansion of LDLT more efficiently in the US. These efforts require clear and cohesive messaging regarding LDLT benefits, engagement of the public community, and dedicated resources to equitably increase LDLT access.

Living donor liver transplant candidate and donor selection and engagement: Meeting report from the living donor liver transplant consensus conference.

INTRODUCTION: Living donor liver transplantation (LDLT) is a promising option for mitigating the deceased donor organ shortage and reducing waitlist mortality. Despite excellent outcomes and data supporting expanding candidate indications for LDLT, broader uptake throughout the United States has yet to occur. METHODS: In response to this, the American Society of Transplantation hosted a virtual consensus conference (October 18-19, 2021), bringing together relevant experts with the aim of identifying barriers to broader implementation and making recommendations regarding strategies to address these barriers. In this report, we summarize the findings relevant to the selection and engagement of both the LDLT candidate and living donor. Utilizing a modified Delphi approach, barrier and strategy statements were developed, refined, and voted on for overall barrier importance and potential impact and feasibility of the strategy to address said barrier. RESULTS: Barriers identified fell into three general categories: 1) awareness, acceptance, and engagement across patients (potential candidates and donors), providers, and institutions, 2) data gaps and lack of standardization in candidate and donor selection, and 3) data gaps regarding post-living liver donation outcomes and resource needs. CONCLUSIONS: Strategies to address barriers included efforts toward education and engagement across populations, rigorous and collaborative research, and institutional commitment and resources.

Disparities in Use of Virtual Primary Care During the Early COVID-19 Pandemic.

Background: The COVID-19 pandemic increased the use of virtual health care. However, certain factors may disparately affect some patients' utilization of virtual care. Associations between age, racial categories (White or Black), and socioeconomic disadvantage were evaluated during the early COVID-19 pandemic. Methods: This cross-sectional retrospective study included adult patients with virtual or in-person primary care encounters at a large, midwestern hospital system with widespread urban and suburban offices between March 1, 2020, and June 30, 2020. Virtual visits included synchronous video and telephone visits and asynchronous patient portal E-visits. Chi-squared tests and multivariable logistic analysis assessed the associations between ages and racial categories, and area deprivation index with the use of virtual versus in-person primary care. Results: Of 72,153 patient encounters, 43.0% were virtual visits, 54.6% were White patients, and 45.4% were Black. Across equivalent age ranges, black patients were slightly less likely to utilize virtual care than similarly aged White patients, but not consistently across virtual modalities. Women were more likely to use virtual care across all modalities, and individuals >65 years were more likely to use telephone visits and less likely to use video and E-visits, regardless of race. Patients residing in areas with the greatest socioeconomic advantage were more likely to utilize video and E-visits. Conclusions: Differential patterns of utilization emerged across racial categories and age ranges, suggesting that racial disparities are exacerbated depending upon patient age and mode of utilization.

A viewpoint describing the American Society of Transplantation rationale to conduct a comprehensive patient survey assessing unmet immunosuppressive therapy needs.

This viewpoint aims to "set the stage" and provide the rationale for the proposed development of a large-scale, comprehensive survey assessing transplant patients' perceived unmet immunosuppressive therapy needs. Research in organ transplantation has historically focused on reducing the incidence and impact of rejection on allograft survival and minimizing or eliminating the need for chronic immunosuppressive therapies. There has been less emphasis and investment in therapies to improve patient-reported outcomes including health-related quality of life and side-effects. Patient-focused drug development (PFDD) is a new and important emphasis of the Food and Drug Administration (FDA) that provides a guiding philosophy for incorporating the patient experience into drug development and evaluation. The American Society of Transplantation (AST) Board of Directors commissioned this working group to prepare for the conduct of a comprehensive patient survey assessing unmet immunosuppressive therapy needs. This paper aims to describe the basis for why it is important to conduct this survey and briefly outline the plan for broad stakeholder engagement to ensure the information gained is diverse, inclusive, and relevant for advancing PFDD in organ transplant recipients.

Current recommendations regarding evaluation of cognitive functioning in organ transplant candidates.

PURPOSE OF REVIEW: Cognitive impairment is associated with negative effects on solid organ transplant candidates, recipients, and their care partners. However, because of the heterogeneity of mechanisms, presentations, and assessment measures, research suggests a wide array of impairments, patterns of impairments, and unclear trajectories posttransplant. This review provides an abbreviated synthesis of recent research on cognitive impairments observed in organ-eligible candidates and potential trajectories through posttransplant, current clinical recommendations regarding integration of assessment into routine clinical transplant practice, as well as recommendations for future research. RECENT FINDINGS: Transplantation may resolve certain disease-contributing factors to cognitive impairments but also introduces new potential neurocognitive assaults. Recent studies in kidney and lung recipients document continued impairments in subsets of patients, particularly those identified as frail. For liver candidates, new assessment measures of hepatic encephalopathy have been developed and preliminarily tested with potential for translation into routine clinical care. Clinical implications, as well as ethical considerations are discussed. SUMMARY: Although guidelines agree that cognitive assessment is an important part of the organ transplantation process, many questions remain of how to best assess cognition and intervene when cognitive impairment is identified in transplant populations. Further research should focus on prospective, longitudinal assessments in transplant-eligible populations through posttransplant.

Heterogeneity in Center Practices in Liver Transplantation for Alcohol-Associated Liver Disease in the United States.

INTRODUCTION: Alcohol-related liver disease (ALD) is now the leading indication for liver transplantation (LT) in the United States (US). It remains unclear how centers are managing the medical and psychosocial issues associated with these patients. METHODS: We conducted a web-based survey of LT centers in the United States to identify center-level details on peri-LT management of ALD and related issues. RESULTS: Of the 117 adult LT centers, 100 responses (85.5%) were collected, representing all Organ Procurement and Transplantation Network regions. For alcohol-associated cirrhosis, 70.0% of the centers reported no minimum sobriety requirement while 21.0% required 6 months of sobriety. LT for severe alcohol-associated hepatitis was performed at 85.0% of the centers. Monitoring protocols for pre-LT and post-LT alcohol use varied among centers. DISCUSSION: Our findings highlight a change in center attitudes toward LT for ALD, particularly for severe alcohol-associated hepatitis.

Substance use screening in transplant populations: Recommendations from a consensus workgroup.

Transplant patients are frequently treated with substances that have dependence potential and/or they may have a history of substance use disorders. The Psychosocial and Ethics Community of Practice of the American Society of Transplantation formed a Drug Testing Workgroup with participation from members of the Pharmacy Community of Practice and members of the Academy of Consultation-Liaison Psychiatry. The workgroup reviewed the literature regarding the following issues: the role of drug testing in patients with substance use disorders, for patients prescribed controlled substances, legal, ethical and prescription drug monitoring issues, financial and insurance issues, and which patients should be tested. We also reviewed current laboratory testing for substances. Group discussions to develop a consensus occurred, and summaries of each topic were reviewed. The workgroup recommends that transplant patients be informed of drug testing and be screened for substances prior to transplant to ensure optimal care and implement ongoing testing if warranted by clinical history. While use of certain substances may not result in the exclusion for transplantation, an awareness of the patient's practices and possible risk from substances is necessary, allowing transplant teams to screen for substance use disorders and ensure the patient is able to manage and minimize risks post-transplant.

Non-pharmacological interventions engaging organ transplant caregivers: A systematic review.

INTRODUCTION: Lay-caregivers in organ transplantation (to candidates, recipients, and donors) are essential to pre- and postoperative care, but report significant caregiving-related stressors. This review aims to summarize studies testing nonpharmacological interventions aimed at improving organ transplant caregiver-reported outcomes. METHODS: In accordance with PRISMA, we conducted a systematic review (searched PubMed, Embase, Cochrane Central, PsycInfo, and CINAHL, no start-date restriction through 7/1/2021). Quality of comparative studies assessed by ROBS-2 or ROBINS. RESULTS: Twelve studies met inclusion. Study designs, interventions, and outcomes varied. Sample sizes were small across caregivers to adults (nine studies, five with caregiver samples ns≤50) and pediatric patients (three studies, caregiver samples ns≤16). Study designs included seven single-arm interventions, two prepost with comparison cohorts, and three randomized-controlled trials. Eight studies included transplant-specific education as the intervention, an interventional component, or as the comparison group. Outcomes included transplant specific knowledge, mental health, and intervention acceptability. Of the nine prepost caregiver assessments and/or comparison groups, four studies demonstrated no statistically significant intervention effects. CONCLUSION: Few interventions addressing the needs of organ transplant caregivers have been empirically evaluated. Existing interventions were well-received by caregivers. Given complexities of care in transplantation, research is needed evaluating interventions using rigorous trial methodology with adequate samples.

Prerenal Transplant Education and Evaluation Positively Impacts Outcomes.

Introduction: An outstanding question in kidney transplantation is how to prepare candidates and their social supports for optimal posttransplant outcomes. Project Aims: This program evaluation assessed whether a pretransplant quality improvement clinic improved clinical outcomes in the year posttransplant compared to recipients receiving standard of care. Design: The Countdown to Transplant Clinic was implemented with kidney transplant candidates expected to receive a transplant within the next few months. The clinic included an enhanced education session on posttransplant lifestyle management, confirmation of support (≥2 adults), and evaluations by transplant social work, psychology, and nephrology. Results: Seventy-five patients participated in the clinic and underwent a transplant. A retrospective chart review of posttransplant laboratory values, rehospitalizations (within 3-months posttransplant), biopsy-confirmed graft failure, and mortality (within 1-year posttransplant) were collected from both groups. Univariate and multivariate propensity score-weighted linear or logistic regression models were used to evaluate the association between clinic participation and outcomes. In models adjusting for relevant covariates, participation in The Countdown to Transplant Clinic (vs standard care) was associated with a lower coefficient of variation of serum tacrolimus (all values collected 3-12 months posttransplant), 30-day posttransplant white blood cell counts (but not 90-day), 90-day posttransplant potassium, and 30 and 31 to 90 days rehospitalizations. Clinic participation did not predict serum glucose levels at 30- or 90-days posttransplant. Due to low rates of rejection and mortality, meaningful comparisons were not possible. Conclusion: Participation in a pretransplant, multicomponent clinic may improve certain outcomes of interest posttransplantation. Pilot testing for feasibility for randomized controlled trials is a necessary next step.

Findings and recommendations from the organ transplant caregiver initiative: Moving clinical care and research forward.

Lay-caregivers are essential to the continuum of care in adult organ transplantation. However, we have a limited understanding of the experiences, exigencies, and outcomes associated with lay-caregiving for organ transplant patients. While much discussion and debate has focused on caregiver requirements in relation to transplant candidate selection, little focus has been given to understanding the needs of caregivers themselves. In response to this, the Organ Transplant Caregiver Initiative was created, and a meeting was held during October 6-7, 2019. Transplant healthcare professionals, researchers, and lay-caregivers discussed the experiences, educational needs, existing research, and research recommendations to improve the experience of lay-caregivers for adult organ transplant patients. In this report, we summarize the Organ Transplant Caregiver Initiative and meeting findings, providing a preliminary action plan to improve education, research, and advocacy for organ transplant caregivers.

Burnout in Certified Anesthesiologist Assistants.

Certified anesthesiologist assistants (CAAs) are Advanced Practice Providers (APPs) within the anesthesia care team. This research evaluated their burnout. CAAs were surveyed nationally about their professional/work characteristics, perceived fairness of salary/benefits compared to certified registered nurse anesthetists/CAAs, the Maslach Burnout Inventory-Human Services Survey (MBI-HSS), the Conditions for Work Effectiveness Questionnaire II, and questions regarding wellness resources at their place of employment. The survey was completed by 457 respondents (19.7%). Of them, 110 (24.1%) scored high on the Emotional Exhaustion subscale of the MBI-HSS. Factors associated with greater emotional exhaustion included younger age, full-time status, perception that salary/benefits were unfair/inadequate compared to other CAAs, more information about the state of their employer and related values/goals of administration, but fewer resources (i.e., time), lower job-related empowerment, and lower formal power. Forty-seven (10.3%) scored high on the Depersonalization subscale. Factors associated with greater depersonalization include younger age, full-time status, more information about state of employer and related values/goals, but less global empowerment, which predicted greater depersonalization. CAAs may report lower levels of burnout compared to other professionals in the anesthesia team but are, nonetheless, susceptible to effects of burnout. Both leaders of organizations and the APPs themselves hold responsibility in protecting against burnout.

Psychiatric Profile of Patients Currently Listed for Kidney Transplantation: Evidence of the Need for More Thorough Pretransplant Psychiatric Evaluations.

BACKGROUND: Patients with end-stage renal disease are at increased risk for psychiatric and cognitive pathologies. Despite this, there is little standardization of the psychosocial and/or psychiatric evaluation of renal transplant candidates. The purpose of this study is to report the frequency of psychiatric and cognitive pathologies and corresponding psychiatric recommendations in a sample of patients actively listed for kidney transplant. METHODS: We performed a retrospective chart review of 104 patients listed for kidney transplant who underwent semistructured psychiatric assessments as part of a novel clinical protocol. Transplant psychiatry routinely administers brief screeners of cognitive functioning and health literacy, also collected from patients' charts. RESULTS: There were a number of primary psychiatric disorders, including active substance abuse. Even using a conservative cutoff, 52.4% of patients' charts indicated evidence of cognitive impairment, and 28.9% indicated limited health literacy. In addition, there were numerous additional recommendations made within every category (educational, psychotherapeutic/psychiatric, cognitive, cessation of substance use, substance abuse treatment, and mobilizing support for transplant). With the exclusion of the recommendation for more education regarding the transplant process, most patients had at least 1 to 3 recommendations (n = 72, 69.2%). CONCLUSIONS: We have identified a number of concerning psychosocial and psychiatric factors in patients who were evaluated and listed for kidney transplantation that can adversely impact transplant outcomes. The findings provide support for more in-depth and ongoing psychiatric assessments as standard clinical protocol for kidney transplant candidates.

Racial disparities in patient selection for liver transplantation: An ongoing challenge.

Ample evidence suggests continued racial disparities once listed for liver transplantation, though few studies examine disparities in the selection process for listing. The objective of this study, via retrospective chart review, was to determine whether listing for liver transplantation was influenced by socioeconomic status and race/ethnicity. We identified 1968 patients with end-stage liver disease who underwent evaluation at a large, Midwestern center from January 1, 2004 through December 31, 2012 (72.9% white, 19.6% black, and 7.5% other). Over half (54.6%) of evaluated patients were listed; the three most common reasons for not listing were medical contraindications (11.9%), patient expired during evaluation (7.0%), and psychosocial contraindications (5.9%). In multivariable logistic regressions (listed vs not listed), across the three racial categories, the odds of being listed were lower for alcohol-induced hepatitis (±hepatitis C), unmarried, more than one insurance, inadequate insurance, and lower annual household income quartile. Similar factors predicted time to transplant listing, including being identified as black race. Black race, even when adjusting for the above mentioned medical and socioeconomic factors, was associated with 26% lower odds of being listed and a longer time to listing decision compared to all other patients.

Acupuncture in living liver and kidney donors: a feasibility study.

OBJECTIVE: The purpose of this study was to test the feasibility of integrating acupuncture into the routine care of living liver and kidney donors during the process of donation and recovery. METHODS: This is a pilot study on the feasibility of a brief acupuncture intervention for living liver and kidney donors. Participants received acupuncture immediately prior to organ donation surgery, every day as inpatients, while recovering from donation, and at a 2-week follow-up. Prior to surgery, questionnaires were completed on acupuncture outcome expectations and the State-Trait Anxiety Inventory. After participating, those who received acupuncture provided feedback. Following the active intervention, a retrospective chart review was conducted, using donors who did not receive acupuncture as a comparison cohort. RESULTS: Forty donor candidates were approached and recruited, 32 consented and ultimately 25 donors participated in the acupuncture intervention (15 of kidney, 10 of liver), 68% female, and 88% Caucasian; only one had prior experience with acupuncture. Participants received an average of 4 sessions while inpatient (range 2-8). Those who expected acupuncture to be more helpful prior to the intervention reported lower inpatient pain scores (P = 0.04). Qualitative feedback from patients was predominantly positive, indicating acupuncture was helpful for relaxation and pain. However, a few patients reported feeling overburdened during postdonation recovery, and that the study was viewed as additional obligation. CONCLUSION: Preliminary findings suggest it is feasible to integrate acupuncture into inpatient recovery for living organ donation. Tailoring interventions to the specific needs of patients is important to address ongoing concerns. Larger studies are needed to further ascertain benefits of peri-operative acupuncture.