DERMATOLOGIC SURGERY, Issue 10 2005
Matt Leavitt DO
Background. The improved scalp coverage achieved by hair transplant for men with androgenetic alopecia can be diminished by continued miniaturization and loss of preexisting, nontransplanted hairs. Objectives. To evaluate whether finasteride 1 mg, administered daily from 4 weeks before until 48 weeks after hair transplant, improves scalp hair and growth of nontransplanted hair in areas surrounding the transplant and to evaluate the safety and tolerability of finasteride for men undergoing hair transplant. Methods. In this randomized, double-blind, placebo-controlled study, 79 men with androgenetic alopecia (20,45 years of age) were assigned to treatment with finasteride 1 mg (n = 40) or placebo (n = 39) once daily from 4 weeks before until 48 weeks after hair transplant. Efficacy was evaluated by review of global photographs by an expert dermatologist and by macrophotography for scalp hair counts. Results. Treatment with finasteride resulted in significant improvements from baseline, compared with placebo, in scalp hair based on global photographic assessment (p < .01) and hair counts (p < .01) at week 48. Visible increases in superior/frontal scalp hair post-transplant were recorded for 94% and 67% of patients in the finasteride and placebo groups, respectively. Finasteride treatment was generally well tolerated. Conclusion. For men with androgenetic alopecia, therapy with finasteride 1 mg daily from 4 weeks before until 48 weeks after hair transplant improves scalp hair surrounding the hair transplant and increases hair density. [source]

Effect of Graft Size, Angle, and Intergraft Distance on Dense Packing in Hair Transplant

DERMATOLOGIC SURGERY, Issue 6 2005
Mohammed Alhaddab MD
Background. The maximum number of hair grafts that can be safely implanted in 1 cm2 is still debatable. To our knowledge, no previous report has addressed this issue in three dimensions, taking into account the size, the angle of the graft, and the intergraft distance. Objectives. To study the effect of the size and angle of the graft and the intergraft distance on dense packing. Methods. Using a mathematical formula (the maximum number of hair grafts in 1 cm2 = 33 * cosine), the volume of the recipient area and the volume of the hair graft are calculated, assuming that the surface area of the recipient area is 1 cm2, the diameter of the hair graft is 1 mm, and the intergraft distance is 1.5 mm laterally and 1 mm anteriorly and posteriorly. Results. The maximum number of hair grafts that could be implanted in 1 cm2 at a 90 angle in relation to the skin surface is 33 grafts, at a 60 angle is 28 grafts, and at a 30 angle is 16 grafts. Conclusion. The maximum number of hair grafts that can be implanted in any given recipient area depends on the graft size, the angle or direction of these grafts, and the intergraft distance. Where more space is allowed between the grafts, and the more acute the angle, the fewer hair grafts that can be implanted. [source]

Guidelines for the Management of Squamous Cell Carcinoma in Organ Transplant Recipients

DERMATOLOGIC SURGERY, Issue 4p2 2004
Thomas Stasko MD
Background. Solid-organ transplant recipients have a high incidence of cutaneous squamous cell carcinoma (SCC) and often develop multiple and aggressive tumors. There are few published studies or reviews, which provide guidance to the clinician in the treatment of these patients. Objective. The objective was to develop useful clinical guidelines for the treatment of skin cancer in organ transplant recipients (OTRs). Methods. The members of the Guidelines Committee of the International Transplant,Skin Cancer Collaborative (ITSCC) carried out a computerized search utilizing the databases of the National Library of Medicine for reports in the literature on SCC in OTRs. These reports were collectively examined by the group and combined with experiences from the members' clinical practices in the development of the guidelines. Results. More than 300 articles relating to SCC in OTRs were reviewed. In general, reports concerning the prevention and treatment of SCC in OTRs are of individual cases or small case series. They are retrospective in nature, statistically nonrigorous, and lack the complete epidemiologic data necessary to derive definitive conclusions. Combining these studies and collective clinical experience, however, is at present the best available method for devising guidelines for the treatment of SCC in OTRs. Conclusion. Guidelines developed for the treatment of skin cancer in OTRs, supported by the best available data and collective clinical experience, may assist in the management of OTRs with SCC. The development of clinical pathways and complete documentation with rigorous prospective study is necessary to improve and refine future guideline development. [source]

Skeletal Myoblast Transplant in Heart Failure

JOURNAL OF CARDIAC SURGERY, Issue 4 2003
Eugene K.W. Sim F.R.C.S.
Heart transplantation has emerged as a viable option but is fraught with problems of supply. Mechanical assist devices are extremely expensive and dynamic cardiomyoplasty has shown only limited success in the clinical setting. Recent insights into the pathogenesis of myocardial diseases and the progress made in the field of molecular biology have resulted in the development of new strategies at molecular as well as cellular levels for cardiac muscle repair. One such strategy is to augment ventricular function by means of cellular cardiomyoplasty through intracardiac cell grafting using adult and fetal cardiomyocytes, stem cells, and autologous skeletal myoblasts. (J Card Surg 2003; 18:319-327) [source]

,-Endorphin Neuronal Cell Transplant Reduces Corticotropin Releasing Hormone Hyperresponse to Lipopolysaccharide and Eliminates Natural Killer Cell Functional Deficiencies in Fetal Alcohol Exposed Rats

ALCOHOLISM, Issue 5 2009
Nadka I. Boyadjieva
Background:, Natural killer (NK) cell dysfunction is associated with hyperresponse of corticotropin releasing hormone (CRH) to immune challenge and with a loss of ,-endorphin (BEP) neurons in fetal alcohol exposed animals. Recently, we established a method to differentiate neural stem cells into BEP neurons using cyclic adenosine monophosphate (cAMP)-elevating agents in cultures. Hence, we determined whether in vitro differentiated BEP neurons could be used for reversing the compromised stress response and immune function in fetal alcohol exposed rats. Methods:, To determine the effect of BEP neuron transplants on NK cell function, we implanted in vitro differentiated BEP neurons into the paraventricular nucleus of pubertal and adult male rats exposed to ethanol or control in utero. The functionality of transplanted BEP neurons was determined by measuring proopiomelanocortin (POMC) gene expression in these cells and their effects on CRH gene expression under basal and after lipopolysaccaride (LPS) challenge. In addition, the effectiveness of BEP neurons in activating NK cell functions is determined by measuring NK cell cytolytic activity and interferon-, (IFN-,) production in the spleen and in the peripheral blood mononuclear cell (PBMC) following cell transplantation. Results:, We showed here that when these in vitro differentiated BEP neurons were transplanted into the hypothalamus, they maintain biological functions by producing POMC and reducing the CRH neuronal response to the LPS challenge. BEP neuronal transplants significantly increased NK cell cytolytic activity in the spleen and in the PBMC and increased plasma levels of IFN-, in control and fetal alcohol exposed rats. Conclusions:, These data further establish the BEP neuronal regulatory role in the control of CRH and NK cell cytolytic function and identify a possible novel therapy to treat stress hyperresponse and immune deficiency in fetal alcohol exposed subjects. [source]

Outcomes of critically ill patients with cirrhosis admitted to intensive care: an important perspective from the non-transplant setting

ALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 2 2010
S. J. Thomson
Aliment Pharmacol Ther 2010; 32: 233,243 Summary Background, Hospital admissions for cirrhosis have been increasing in the United Kingdom, leading to increased pressure on intensive care (ICU) services. Outcome data for patients admitted to ICU are currently limited to transplant centre reports, with mortality rates exceeding 70%. These tertiary reports could fuel a negative bias when patients with cirrhosis are reviewed for ICU admission in secondary care. Aims, To determine whether disease severity and mortality rates in non-transplant general ICU are less severe than those reported by tertiary datasets. Methods, A prospective dual-centre non-transplant ICU study. Admissions were screened for cirrhosis and physiological and biochemical data were collected. Disease-specific and critical illness scoring systems were evaluated. Results, Cirrhosis was present in 137/4198 (3.3%) of ICU admissions. ICU and hospital mortality were 38% and 47%, respectively; median age 50 [43,59] years, 68% men, 72% alcoholic cirrhosis, median Child Pugh Score (CPS) 10 [8,11], Model for End-Stage Liver Disease (MELD) 18 [12,24], Acute Physiology and Chronic Health Evaluation II score (APACHE II) 16 [13,22]. Conclusions, Mortality rates and disease staging were notably lower than in the published literature, suggesting that patients have a more favourable outlook than previously considered. Transplant centre data should therefore be interpreted with caution when evaluating the merits of intensive care admission for patients in general secondary care ICUs. [source]

Interpreting incidence trends for treated end-stage renal disease: Implications for evaluating disease control in Australia

NEPHROLOGY, Issue 4 2004
JOHN H STEWART
SUMMARY: Background: Five sources of change modify trends in incidence of treated end-stage renal disease (ESRD): (i) demography; (ii) disease control, comprising prevention and treatment of progressive kidney disease; (iii) competing risks, which encompass dying from untreated uraemia or non-renal comorbidity; (iv) lead-time bias; and (v) classification bias. Thus, rising crude incidence of treated ESRD may conceal effective disease control when there has been demographic change, lessening competing risks, or the introduction of bias. Methods: Age-specific incidences of treated ESRD in Australia were calculated from Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry data by indigenous/non-indigenous status (all causes) and by primary renal disease (non-indigenous only) for two successive decades, 1982,1991 and 1992,2001. Results: We postulate that less competing risks explained much of the increase in treated ESRD in the elderly and Indigenous Australians. The increase in glomerulonephritic ESRD in non-indigenous Australians could be ascribed mainly to immigration from non-European countries. There was no significant change in incidence of treated ESRD in Indigenous or non-indigenous persons aged less than 25 years, in non-indigenous persons aged 25,64 years for ESRD caused by hereditary polycystic disease or hypertension, or in type 1 diabetics aged over 55 years. End-stage renal disease from analgesic nephropathy had declined. The increase in treated ESRD caused by type 2 diabetic nephropathy appeared to be multifactorial. Lead-time/length bias and less competing risks may have concealed a small favourable trend in other primary renal diseases. Conclusion: Whether recent disease control measures have had an impact on incidence of treated ESRD is not yet certain, but seems more likely than implied by previous reports. [source]

Globalization and Indigenization: Legal Transplant of a Universal TRIPS Regime in a Multicultural World

AMERICAN BUSINESS LAW JOURNAL, Issue 3 2010
Wei Shi
First page of article [source]

Long-term outcome following pediatric liver transplantation for metabolic disorders

PEDIATRIC TRANSPLANTATION, Issue 2 2010
Terrell Stevenson
Stevenson T, Millan MT, Wayman K, Berquist WE, Sarwal M, Johnston EE, Esquivel CO, Enns GM. Long-term outcome following pediatric liver transplantation for metabolic disorders. Pediatr Transplant 2010:14:268,275. © 2009 John Wiley & Sons, A/S. Abstract:, In order to determine long-term outcome, including survival, growth and development, following liver transplantation in children with metabolic disorders, we retrospectively reviewed charts of 54 children with metabolic disorders evaluated from 1989,2005 for presenting symptoms, transplantation timing and indications, survival, metabolic parameters, growth, and development. Thirty-three patients underwent liver transplantation (12 received combined liver,kidney transplants) at a median age of 21 months. At a median follow-up of 3.6 yr, patient survival was 100%, and liver and kidney allograft survival was 92%, and 100%, respectively. For the group as a whole, weight Z scores improved and body mass index at follow-up was in the normal range. Two yr post-transplantation, psychomotor development improved significantly (p < 0.01), but mental skills did not; however, both indices were in the low-normal range of development. When compared to patients with biliary atresia, children with metabolic disorders showed significantly lower mental developmental scores at one and two yr post-transplantation (p < 0.05), but psychomotor developmental scores were not significantly different. We conclude that, in patients with metabolic disorders meeting indications for transplantation, liver transplantation or combined liver,kidney transplantation (for those with accompanying renal failure) is associated with excellent long-term survival, improved growth, and improved psychomotor development. [source]

Comments on ,Skin transplantation to monitor clinical donor-related tolerance in mixed hematopoietic chimerism' by Mache et al. (Pediatr Transplant 2006;10:128,131)

PEDIATRIC TRANSPLANTATION, Issue 6 2006
Christian Urban
No abstract is available for this article. [source]

Face Transplant: Real and Imagined Ethical Challenges

THE JOURNAL OF LAW, MEDICINE & ETHICS, Issue 1 2006
Tia Powell
Ethical lapses associated with the first facial transplant included breaches of confidentiality, bending of research rules, and film deals. However, discussions of the risk-benefit ratio for face transplantation are often deficient in that they ignore the needs, experience, and decision-making capability of potential recipients. [source]

Comparison of the Incidence of Malignancy in Recipients of Different Types of Organ: A UK Registry Audit

AMERICAN JOURNAL OF TRANSPLANTATION, Issue 8 2010
D. Collett
An increased incidence of malignancy is an established complication of organ transplantation and the associated immunosuppression. In this study on cancer incidence in solid organ transplant recipients in Britain, we describe the incidence of de novo cancers in the allograft recipient, and compare these incidences following the transplantation of different organs. Data in the UK Transplant Registry held by NHS Blood and Transplant (NHSBT) were linked with data made available by the cancer registries in England, Scotland and Wales. Incidence rates in the transplanted population were then compared with the general population, using standardized incidence ratios matched for age, gender and time period. The 10-year incidence of de novo cancer in transplant recipients is twice that of the general population, with the incidence of nonmelanoma skin cancer being 13 times greater. Nonmelanoma skin cancer, cancer of the lip, posttransplant lymphoproliferative disease and anal cancer have the largest standardized incidence ratios, but the incidence of different types of malignancy differs according to the organ transplanted. Patterns in standardized incidence ratios over time since transplantation are different for different types of transplant recipient, as well as for different malignancies. These results have implications for a national screening program. [source]

Evolution of Causes and Risk Factors for Mortality Post-Liver Transplant: Results of the NIDDK Long-Term Follow-Up Study

AMERICAN JOURNAL OF TRANSPLANTATION, Issue 6 2010
K. D. S. Watt
Although mortality rates following liver transplantation (LT) are well described, there is a lack of detailed, prospective studies determining patterns of and risk factors for long-term mortality. We analyzed the multicenter, prospectively obtained The National Institute of Diabetes and Digestive and Kidney Diseases LT Database of 798 transplant recipients from 1990 to 1994 (follow-up 2003). Overall, 327 recipients died. Causes of death >1 year: 28% hepatic, 22% malignancy, 11% cardiovascular, 9% infection, 6% renal failure. Renal-related death increased dramatically over time. Risk factors for death >1 year (univariate): male gender, age/decade, pre-LT diabetes, post-LT diabetes, post-LT hypertension, post-LT renal insufficiency, retransplantation >1 year, pre-LT malignancy, alcoholic disease (ALD) and metabolic liver disease, with similar risks noted for death >5 years. Hepatitis C, retransplantation, post-LT diabetes, hypertension and renal insufficiency were significant risk factors for liver-related death. Cardiac deaths associated with age, male gender, ALD, cryptogenic disease, pre-LT hypertension and post-LT renal insufficiency. In summary, the leading causes of late deaths after transplant were graft failure, malignancy, cardiovascular disease and renal failure. Older age, diabetes and renal insufficiency identified patients at highest risk of poor survival overall. Diligent management of modifiable post-LT factors including diabetes, hypertension and renal insufficiency may impact long-term mortality. [source]

Retransplantation After BK Virus Nephropathy in Prior Kidney Transplant: An OPTN Database Analysis

AMERICAN JOURNAL OF TRANSPLANTATION, Issue 5 2010
V. R. Dharnidharka
BK virus (BKV) has emerged as a major complication of kidney transplantation. Since June 30, 2004, the OPTN in the USA collects BKV as a primary or secondary cause of graft loss and also if treatment for BK virus (TBKV) is administered. In this study, we determined characteristics of those recipients of repeat kidney transplants from the OPTN database, where either (a) a graft loss occurred between June 30, 2004 and December 31, 2008 and database recorded prior TBKV in that allograft or (b) a graft loss between June 30, 2004 and December 31, 2008 was attributed primarily or secondarily due to BKV. In the study time period, 823 graft losses have occurred where TBKV or graft failure attributable to BKV was reported in prior transplant; of these, 126 have received a retransplant as of June 5, 2009. Induction and maintenance immunosuppression usage mirrored current trends. As of June 5, 2009, 118/126 grafts are still functioning, one graft failure attributed to BKV. TBKV was reported in 17.5% of the retransplants. In the retransplants performed through December 31, 2007, 1-year acute rejection rate was 7%, 1-year and 3-year Kaplan,Meier graft survival rates and median GFR were 98.5%, 93.6%, 65.5 and 68.4 mL/min, respectively. Retransplantation after BKV appears to be associated with good results. [source]

,Normal for Now' or ,At Future Risk': A Double Standard for Selecting Young and Older Living Kidney Donors

AMERICAN JOURNAL OF TRANSPLANTATION, Issue 4 2010
R. W. Steiner
Transplant centers medically evaluate potential living kidney donors in part to determine their baseline remaining lifetime risk for end stage renal disease (ESRD). If baseline risk is increased by the presence of a risk factor for ESRD, donation is often refused. However, as only about 13% of ESRD occurs in the general population by age 44, a normal medical evaluation cannot be expected to significantly reduce the 7% lifetime risk for a ,normal' 25-year-old black donor or the 2,3% risk for a similar white donor. About half of newly diagnosed ESRD in the United States occurs by age 65, and about half of that is from diabetic nephropathy, which takes about 25 years to develop. Therefore, the remaining baseline lifetime risk for ESRD is significantly lower in the normal, nondiabetic 55-year-old donor candidate. Some older donors with an isolated medical abnormality such as mild hypertension will be at lower or about the same overall baseline lifetime risk for ESRD as are young ,normal' donor candidates. Transplant centers use a ,normal for now' standard for accepting young donors, in place of the long-term risk estimates that must guide selection of all donors. [source]

Medium-Term Outcome of an ABO Incompatible Lung Transplant

AMERICAN JOURNAL OF TRANSPLANTATION, Issue 3 2010
M. Patel
No abstract is available for this article. [source]

Racial and Ethnic Differences in Mortality in Children Awaiting Heart Transplant in the United States

AMERICAN JOURNAL OF TRANSPLANTATION, Issue 12 2009
T. P. Singh
Racial differences in outcomes are well known in children after heart transplant (HT) but not in children awaiting HT. We assessed racial and ethnic differences in wait-list mortality in children <18 years old listed for primary HT in the United States during 1999,2006 using multivariable Cox models. Of 3299 listed children, 58% were listed as white, 20% as black, 16% as Hispanic, 3% as Asian and 3% were defined as ,Other'. Mortality on the wait-list was 14%, 19%, 21%, 17% and 27% for white, black, Hispanic, Asian and Other children, respectively. Black (hazard ratio [HR] 1.6, 95% confidence interval [CI] 1.3, 1.9), Hispanic (HR 1.5, CI 1.2, 1.9), Asian (HR, 2.0, CI 1.3, 3.3) and Other children (HR 2.3, CI 1.5, 3.4) were all at higher risk of wait-list death compared to white children after controlling for age, listing status, cardiac diagnosis, hemodyamic support, renal function and blood group. After adjusting additionally for medical insurance and area household income, the risk remained higher for all minorities. We conclude that minority children listed for HT have significantly higher wait-list mortality compared to white children. Socioeconomic variables appear to explain a small fraction of this increased risk. [source]

Differential Dose Adjustments of Immunosuppressants after Resuming Boosted versus Unboosted HIV-Protease Inhibitors Postliver Transplant

AMERICAN JOURNAL OF TRANSPLANTATION, Issue 10 2009
G. Guaraldi
Pharmacokinetic (PK) interactions between protease inhibitors (PIs) and immunosuppressive agents (IS) are critical elements in the management of HIV-infected patients who undergo liver transplantation (LTx). The primary objective of this study was to evaluate the decreases in IS dosages necessary to maintain an appropriate therapeutic window (TW) after initiating PI-based antiretroviral therapy regimens post-LTx. Single-center, PK cross-sectional study of consecutive HIV-infected adult patients who underwent LTx was done. Blood trough concentrations (Ct) of IS were obtained using a commercial MEIA test; plasma Ct of PIs were measured using HPLC. Twelve consecutive HIV-infected adult patients (11 males, 1 female) were enrolled. More rapid increases in IS plasma Ct were observed 48 h after initiating ritonavir (RTV)-boosted PI therapy post-LTx than when using unboosted PIs. Seven patients developed acute renal failure. The median fold decrease in IS dosages required to regain IS concentrations that were in the TW was 7.5 (range 6,14) after resuming boosted PIs and 2.9 (range 2,4) after unboosted PIs. The overall median time necessary to reach IS TW after dose adjustment was 3.5 days (range 0,15). Unboosted PIs exhibited lesser PK interactions with IS than did RTV-boosted PIs and were thus more amenable to use in the post-LTx setting. [source]

Acute Humoral Rejection in an ABO Compatible Combined Liver,Kidney Transplant,The Kidney Is Not Always Protected

AMERICAN JOURNAL OF TRANSPLANTATION, Issue 8 2009
T. W. Reichman
Combined liver,kidney transplantation has become a common practice for the treatment of patients with concurrent end-stage renal disease and end-stage liver disease. Liver transplantation in the setting of multiorgan transplantation is thought to have a protective effect against humoral rejection even when a positive crossmatch is obtained prior to surgery. In most centers, a pre liver,kidney transplant crossmatch is rarely performed because of the known immunoprotective effect of the liver allograft. In this report, a case of acute humoral rejection in the kidney allograft after a combined liver,kidney transplant is described. Although humoral rejection was treated using plasmapheresis, intravenous immunoglobulin and rituximab, the kidney required 3 months to recover function and finally progressed to chronic allograft nephropathy. A heightened index of suspicion for acute humoral rejection of the renal allograft is necessary when performing combined liver,kidney transplants to highly sensitized patients due to previous organ transplants. [source]

Heavy LYFTing: KASting Pearls Before Swine

AMERICAN JOURNAL OF TRANSPLANTATION, Issue 7 2009
J. Bromberg
The use of "Life Years from Transplant" (LYFT) to allocate kidneys is controversial. Several articles in this issue of AJT present critiques and analysis of KAS and LYFT and provide a road map for future progress. See Special Feature on pages 1500,1532. [source]

Evaluating Options for Utility-Based Kidney Allocation

AMERICAN JOURNAL OF TRANSPLANTATION, Issue 7 2009
D. L. Segev
Over the last 5 years, a number of utility-based allocation systems have been proposed in an effort to increase the life-prolonging potential of deceased donor kidneys in the United States. These have included various adaptations of age-matching and net benefit, including the Eurotransplant Senior Program, Life Years From Transplant, and several systems for avoiding extreme donor/recipient mismatch. However, utility-based allocation is complex and raises issues regarding choice of metric, appropriateness of certain factors for use in allocation, accuracy of prediction models, transparency and perception, and possible effects on donation rates. Changing the role of utility in kidney allocation will likely cause changes to efficiency, equity, predictability, autonomy, controversy, trust and live donation. In this manuscript, various allocation systems are discussed, and a framework is proposed for quantifying the goals of the transplant community and evaluating options for utility-based kidney allocation in this context. [source]

Developing a New Kidney Allocation Policy: The Rationale for Including Life Years from Transplant

AMERICAN JOURNAL OF TRANSPLANTATION, Issue 7 2009
M. D. Stegall
The viewpoint outlines the rationale for using LYFT as the major utility metric in kidney allocation and describes a compromise proposal in which recent public feedback is incorporated into the OPTN draft proposal. [source]

Reassessing the Impact of Donor HLA-C Genotype on Long-Term Liver Transplant Survival

AMERICAN JOURNAL OF TRANSPLANTATION, Issue 7 2009
T. H. Tran
HLA-C is the major inhibitory ligand for killer immunoglobulin-like receptors (KIRs) that are expressed on natural killer (NK) cells. Based on their KIR specificity, HLA-C alleles can be divided into two groups, termed HLA-C1 and HLA-C2. Donor HLA-C group has recently been identified by Hanvesakul et al. (Am J Transplant 2008) as a critical determinant of clinical outcome following liver transplantation: Possession of at least one HLA-C group 2 allele by the donor was associated with significantly improved long-term graft and patient survival, presumably due to an inhibition of host NK cell function. To verify this study, we performed genotyping of 913 deceased liver donors for the relevant KIR epitopes of HLA-C and correlated the presence or absence of donor HLA-C2 genotype with graft and patient survival. In our study, donor HLA-C2 genotype had no impact on 10-year graft or patient survival. We cannot confirm a major role of donor HLA-C2 genotype on long-term allograft survival after liver transplantation. [source]

Outcomes of Simultaneous Heart,Kidney Transplant in the US: A Retrospective Analysis Using OPTN/UNOS Data

AMERICAN JOURNAL OF TRANSPLANTATION, Issue 4 2009
J. Gill
Simultaneous heart,kidney transplantation (SHK) remains uncommon in the US. We examined outcomes of SHK compared to heart transplant alone (HTA) and deceased donor kidney transplant (DDKT). Data from OPTN/UNOS heart and kidney data bases were used to identify 16 710 HTA, 263 SHK transplants and 68 833 DDK transplants between 1998 and 2007. Outcomes included patient survival (PS), acute cardiac and renal rejection and renal graft survival (rGS). The adjusted risk of death was 44% lower with SHK compared to HTA. Over half of SHK were performed in cases where pretransplant dialysis was not initiated. In these cases, there was no significant difference in the risk of death between SHK and HTA (HR 1.01; 95% CI 0.67,1.50). Recipients of SHK had worse 1-year rGS and PS and had a higher relative risk of overall renal graft loss compared to DDKT recipients. One-year rates of cardiac (14.5%) and renal (6.5%) rejection were lower in SHK compared to HTA and DDKT, respectively. Recipients of SHK had a lower adjusted risk of death compared to HTA recipients, particularly in patients who required pretransplant dialysis. These data suggest that SHK should be considered in heart transplant candidates with renal failure requiring dialysis, whereas the utility of SHK in cases of renal failure not requiring dialysis warrants further study. [source]

Assessment of Psychoeducational Outcomes After Pediatric Liver Transplant

AMERICAN JOURNAL OF TRANSPLANTATION, Issue 2 2009
S. Gilmour
Outcomes research in pediatric liver transplant (LT) has focused on mortality and morbidity but there is a need to also evaluate functional outcomes. Standardized cognitive testing was administered to a cohort of children with infantile chronic liver disease who were transplanted at the University of Alberta during their preschool years. Thirty children had comprehensive assessments with the Bayley Scales of Infant Development or Wechsler testing. Patient variables potentially associated with cognitive delay were analyzed with multiple regression analysis. The mean DQ/IQ score (developmental quotient/intelligence quotient) was 81 ± 17. Delay (DQ/IQ score < 70), and borderline delay (DQ/IQ 70,84) were each present in 27% of the cohort, with only 46% demonstrating normal cognition. Regression analysis demonstrated that the decreased IQ was associated with pretransplant growth retardation and elevated calcineurin inhibitor levels. Performance IQ had strong correlation with pretransplant growth retardation and elevated serum ammonia, R2= 45%, compared to verbal IQ that was associated was elevated calcineurin inhibitor levels, R2= 23%. Children post-LT are at high risk for cognitive delay or borderline delay. This is the first study to demonstrate the association calcineurin inhibitors with impaired IQ and also the unique finding of different variables predictive of impaired verbal intelligence quotient (VIQ) versus performance intelligence quotient (PIQ). [source]

Successful Long-Term Outcome of the First Combined Heart and Kidney Transplant in a Patient with Systemic AL Amyloidosis

AMERICAN JOURNAL OF TRANSPLANTATION, Issue 1 2009
V. Audard
Simultaneous cardiac and renal involvement is associated with a particularly poor prognosis in patients with AL amyloidosis (AL-A). We report the first case of a successful long-term outcome of combined heart and kidney transplantation not followed by autologous stem cell transplantation in a patient with systemic AL-A. The recipient was a 46-year-old man with end-stage renal failure associated with serious cardiac involvement in the context of AL-A. Before transplantation, two courses of oral melphalan plus prednisone induced partial hematologic remission, as shown by the decrease in circulating free light chain with no improvement of renal or heart function. The patient underwent combined heart and kidney transplantation as a rescue treatment. During the follow-up period (36 months), plasma cell dyscrasia remains in complete remission, with normal free lambda light chain levels and no recurrence of amyloid deposition on heart and kidney grafts. This case report demonstrates that combined heart and kidney transplantation not systematically associated with stem cell transplantation may be considered an additional therapeutic option in AL-A patients with severe organ dysfunction and partial hematologic remission. [source]

Survival Outcomes Following Liver Transplantation (SOFT) Score: A Novel Method to Predict Patient Survival Following Liver Transplantation

AMERICAN JOURNAL OF TRANSPLANTATION, Issue 12 2008
A. Rana
It is critical to balance waitlist mortality against posttransplant mortality. Our objective was to devise a scoring system that predicts recipient survival at 3 months following liver transplantation to complement MELD-predicted waitlist mortality. Univariate and multivariate analysis on 21 673 liver transplant recipients identified independent recipient and donor risk factors for posttransplant mortality. A retrospective analysis conducted on 30 321 waitlisted candidates reevaluated the predictive ability of the Model for End-Stage Liver Disease (MELD) score. We identified 13 recipient factors, 4 donor factors and 2 operative factors (warm and cold ischemia) as significant predictors of recipient mortality following liver transplantation at 3 months. The Survival Outcomes Following Liver Transplant (SOFT) Score utilized 18 risk factors (excluding warm ischemia) to successfully predict 3-month recipient survival following liver transplantation. This analysis represents a study of waitlisted candidates and transplant recipients of liver allografts after the MELD score was implemented. Unlike MELD, the SOFT score can accurately predict 3-month survival following liver transplantation. The most significant risk factors were previous transplantation and life support pretransplant. The SOFT score can help clinicians determine in real time which candidates should be transplanted with which allografts. Combined with MELD, SOFT can better quantify survival benefit for individual transplant procedures. [source]

Survival Advantage of Pediatric Recipients of a First Kidney Transplant Among Children Awaiting Kidney Transplantation

AMERICAN JOURNAL OF TRANSPLANTATION, Issue 12 2008
D. L. Gillen
The mortality rate in children with ESRD is substantially lower than the rate experienced by adults. However, the risk of death while awaiting kidney transplantation and the impact of transplantation on long-term survival has not been well characterized in the pediatric population. We performed a longitudinal study of 5961 patients under age 19 who were placed on the kidney transplant waiting list in the United States. Of these, 5270 received their first kidney transplant between 1990 and 2003. Survival was assessed via a time-varying nonproportional hazards model adjusted for potential confounders. Transplanted children had a lower mortality rate (13.1 deaths/1000 patient-years) compared to patients on the waiting list (17.6 deaths/1000 patient-years). Within the first 6 months of transplant, there was no significant excess in mortality compared to patients remaining on the waiting list (adjusted Relative Risk (aRR) = 1.01; p = 0.93). After 6 months, the risk of death was significantly lower: at 6,12 months (aRR = 0.37; p < 0.001) and at 30 months (aRR 0.26; p < 0.001). Compared to children who remain on the kidney transplant waiting list, those who receive a transplant have a long-term survival advantage. With the potential for unmeasured bias in this observational data, the results of the analysis should be interpreted conservatively. [source]

FOXP3 Expression in Human Kidney Transplant Biopsies Is Associated with Rejection and Time Post Transplant but Not with Favorable Outcomes

AMERICAN JOURNAL OF TRANSPLANTATION, Issue 7 2008
S. Bunnag
Expression of the transcription factor forkhead box P3 (FOXP3) in transplant biopsies is of interest due to its role in a population of regulatory T cells. We analyzed FOXP3 mRNA expression using RT-PCR in 83 renal transplant biopsies for cause in relationship to histopathology, clinical findings and expression of pathogenesis-based transcript sets assessed by microarrays. FOXP3 mRNA was higher in rejection (T-cell and antibody-mediated) than nonrejection. Surprisingly, some native kidney controls also expressed FOXP3 mRNA. Immunostaining for FOXP3 was consistent with RT-PCR, showing interstitial FOXP3+ lymphocytes, even in some native kidney controls. FOXP3 expression correlated with interstitial inflammation, tubulitis, interstitial fibrosis, tubular atrophy, C4d positivity, longer time posttransplant, younger donors, class II panel reactive antibody >20% and transcript sets reflecting inflammation and injury, but unlike these features was time dependent. In multivariate analysis, higher FOXP3 mRNA was independently associated with rejection, T-cell-associated transcripts, younger donor age and longer time posttransplant. FOXP3 expression did not correlate with favorable graft outcomes, even when the analysis was restricted to biopsies with rejection. Thus FOXP3 mRNA expression is a time-dependent feature of inflammatory infiltrates in renal tissue. We hypothesize that time-dependent entry of FOXP3-positive cells represents a mechanism for stabilizing inflammatory sites. [source]