Faculty Bibliography

BACKGROUND:Organ Procurement and Transplantation Network (OPTN) policy requires 2 years of follow-up for living kidney donors (LKDs); however, many transplant hospitals struggle to meet this requirement. We developed and tested a mobile health (mHealth) system for LKD follow-up in a pilot randomized-controlled trial (RCT). METHODS:LKDs were randomly assigned to either the intervention (mHealth + standard of care) or control arm (standard of care). We assessed OPTN policy-defined completeness and timeliness of 6-month, 1-year, and 2-year follow-ups. Four hundred LKDs were enrolled in the study (June 2018 to February 2021). RESULTS:At 6-month follow-up, a higher proportion of the intervention arm participants completed composite visits (97.5% vs. 91.5%, p = 0.01). Both arms had similar compliance rates at 1- and 2-year follow-up (92.0% vs. 89.5%, p = 0.49, and 66.5% vs. 65.0%, p = 0.83). Intervention arm participants completed 6-month follow-up 11 days earlier than their counterparts (p = 0.009). CONCLUSION/CONCLUSIONS:mHealth technologies improved 6-month follow-up, but did not impact 1- and 2-year LKD follow-up in this single-center RCT. Other strategies, such as providing services beyond data collection, may be necessary to improve donor engagement and support LDK's long-term follow-up.

INTRODUCTION/BACKGROUND:Predicting graft failure risk in pediatric liver transplantation (LT) recipients could identify areas for improving management. Persistent cognitive, motor, academic, and functional deficits are common in recipients and their impact on graft survival following LT helps inform risk prediction. METHODS:Using SRTR data 2008-2023, we evaluated the cognitive, motor, academic, and functional deficits of LT recipients at time of transplant to 14 years post-LT. We compared all cause graft failure (ACGF) among patients with versus without pre-LT and 1-year post-LT deficits using Cox regression, adjusting for recipient characteristics. We calculated an individual risk score for ACGF. RESULTS:In 8062 pediatric LT recipients median age 3 (IQR: 1, 10), 28.0%, 29.5%, 35.0%, and 79.8% of recipients had pre-LT deficits in cognition, motor, academic activity, and functional status respectively. This decreased to 23.0%, 18.1%, 14.2%, and 38.7% 1-year post-LT. Increased hazard of ACGF was noted in recipients with pre-LT decreased functional status (aHR = 1.13 (per 10% decrease), 95% CI: 1.10-1.15, p < 0.001), definite motor delay (aHR = 1.60, 95% CI: 1.21-2.10, p < 0.001), and inability to participate in academics (aHR = 1.49, 95% CI: 1.08-1.89, p = 0.01), but not delays in cognition (aHR = 0.91, 95% CI: 0.69-1.21, p = 0.19). Our risk score predicting ACGF demonstrated improved predictive performance compared to clinical parameters alone (C-statistic = 0.70 (0.67, 0.72) vs. 0.66 (0.64, 0.69), p < 0.001). CONCLUSIONS:Pediatric LT recipients with pre- or post-LT motor, academic, and functional deficits are at higher risk for ACGF. Care should be taken to assess deficits to identify patients who may benefit from functional intervention to potentially reduce ACGF risk.

BACKGROUND/UNASSIGNED:) and long-term premature cognitive aging. We tested whether CMV was associated with post-KT cognitive impairment. METHODS/UNASSIGNED:In a 2-center prospective cohort study of 574 KTRs (mean age: 54.7 y), we obtained CMV donor/recipient (D/R) serostatus and measured pre- and post-KT cognitive function using the Modified Mini-Mental State Examination. We estimated post-KT global cognitive function trajectories by CMV serostatus using adjusted mixed effect models with linear spline terms. RESULTS/UNASSIGNED:(slope = 0.01 points/year; 95% CI, -1.87 to 1.89). CONCLUSIONS/UNASSIGNED:KTRs may be at elevated risk for post-KT cognitive impairment; clinicians may prioritize early interventions in this population.

BACKGROUND:People with human immunodeficiency virus (HIV) are at an increased risk for end-stage lung disease, for which lung transplantation (LT) may be necessary. METHODS:We aimed to characterize the national practice patterns of LT in recipients with HIV (HIV R+) and post-LT outcomes, including rejection in the US over time. Using the Scientific Registry of Transplant Recipients data (from January 1, 2004, to December 1, 2024, for practice patterns and from January 1, 2016, to December 1, 2024, for outcomes), we compared 96 adult HIV R+ to 42 341 LT recipients without HIV (HIV R-). We examined the association between HIV and outcomes using Gini coefficients, Cox regression, and modified Poisson regression before and after 2020. RESULTS:HIV R+ LTs increased from 0.1% in 2004 to 0.4% of LTs in 2024 (p = 0.07). Pre-2020, 18 centers performed 80% of HIV R+ LTs (Gini = 0.78); post-2020, 14 centers performed 80% of HIV R+ LTs (Gini = 0.76), indicating no expansion of the practice across centers. HIV R+ did not have an increased risk of mortality (adjusted hazard ratio pre-2020: 0.91 [95% confidence interval 0.41-1.62], p = 0.7 and post-2020: 1.05 [0.49-3.25], p = 0.8), or increased risk of 1-year rejection rate (adjusted relative risk pre-2020: 0.60 [0.20-1.77], p = 0.3, and post-2020: 0.77 [0.26-2.2], p = 0.6). CONCLUSIONS:Increasing numbers of HIV R+ LTs and comparable outcomes to those without HIV are encouraging, yet few centers perform these transplants.

Impaired cognition in liver recipients has been studied in the immediate posttransplant period but is poorly understood in the long term, despite its importance to quality of life. In a single-center cohort of liver recipients transplanted in 2010-2022 and >1 year after transplant, we assessed cognitive performance using a telephone-based battery. We compared depression, anxiety, and self-reported function by cognitive performance using descriptive statistics. Among 120 participants (median age 65, median 7.3 y after transplant), 25% had below-expectation cognition, 53% at-expectation cognition, and 22% above-expectation. Baseline characteristics were similar between groups. Below-expectation performance was most commonly observed in verbal learning (28%) and verbal memory (22%). Overall, 46% had symptoms of depression (38%) and/or anxiety (28%); anxiety was less common among those with above-expectation cognition (0%) versus below-expectation (34%) or at-expectation cognition (38%, p=0.01). The impaired global daily function was reported by 36% of recipients but was not associated with objective cognitive performance. Below-expectation cognition was prevalent among 25% of liver recipients at least 1 year after transplant and was associated with a higher likelihood of reporting psychiatric distress. These findings underscore the need for longitudinal assessment of cognitive and mental health outcomes among recipients of liver transplants.

INTRODUCTION/BACKGROUND:Early post-kidney transplant (KT) changes likely impact body composition, resulting in adverse post-KT outcomes. We estimated post-KT trajectories of computed tomography (CT)-based muscle quantity/quality and tested whether they were associated with mortality and death-censored graft loss (DCGL) among frail and nonfrail recipients. METHODS:We leveraged a cohort of 294 adult KT recipients (December 2008-February 2020) with CT measurements (muscle quantity: skeletal muscle index; muscle quality: skeletal muscle radiation attenuation). We used mixed linear regression models to estimate 3-year post-KT muscle quantity/quality trajectories. Cox proportional hazard models quantified the association between time-varying pre-/post-KT muscle mass measurements and post-KT mortality and DCGL. RESULTS:) was associated with elevated mortality risk (aHR: 2.00, 95% CI: 1.08-3.70), but not among nonfrail recipients. Among older (≥65 years) recipients, lower muscle quantity was associated with increased DCGL risk (aHR: 2.70, 95% CI: 1.04-7.04), but not among younger recipients. Lower muscle quality (per 10 HU) was associated with elevated mortality (aHR: 2.23, 95% CI: 1.61-3.08) and DCGL (aHR: 1.90, 95% CI: 1.16-3.12) risk. CONCLUSION/CONCLUSIONS:Lower pre-/post-KT muscle quantity/quality were associated with higher risks of post-KT adverse outcomes. Pre-/post-KT rehabilitation to improve muscle quantity/quality may be an effective clinical intervention to minimize risks of adverse post-KT outcomes.

Given the unique risk profile of kidney transplant recipients (KTRs), characterizing their cardiovascular disease (CVD) risk after COVID-19 remains critical for targeted management. We performed a retrospective analysis of 809 clinically diagnosed symptomatic COVID-19 events among 778 KTRs from one Maryland health system (3/2020-1/2024) to characterize incidence and risk factors of post-COVID-19 CVD. We followed KTRs until composite CVD (acute coronary syndrome (ACS), stroke, heart failure (HF), CVD death), non-CVD death, or one year after COVID-19 and identified risk factors using LASSO-based sub-distribution hazards regression. Incidence of post-COVID CVD was 8.7% at one-year (2.7% ACS, 1.4% stroke, 3.6% HF, and 1.0% CVD death). KTRs with CVD history had higher incidence than those without (19.1% vs 5.0%). Older age, Black race, Hispanic ethnicity, prior CVD, and COVID-19 hospitalization increased post-COVID CVD risk; BMI>30 and treatment with remdesivir decreased post-COVID CVD risk. COVID-19 hospitalization conferred equivalent risk to prior CVD: incidence was 11.2% among KTRs with prior CVD but no hospitalization, 12.0% among KTRs with hospitalization but no prior CVD, 25.2% among KTRs with both, and 1.8% among KTRs with neither. Post-COVID-19 CVD risk was high among KTRs and hospitalization for COVID-19 was as important as having had a prior cardiovascular event.

BACKGROUND:Transplant waitlist registrants in the United States may be delisted because of receipt of a transplant abroad. Although not universally unethical, "travel for transplantation" poses risks to posttransplant care. To better understand this phenomenon, this study identifies temporal trends, geographic patterns, and demographic factors associated with cross-border transplantation. METHODS:Using Scientific Registry of Transplant Recipients data, we identified 818 US waitlist candidates who were removed because of transplantation abroad between 2010 and 2023. We described recipient characteristics overall, by organ, and by top transplant destinations. We used a Cox regression framework to identify characteristics associated with waitlist removal due to transplantation abroad. RESULTS:Transplants abroad averaged 58.4 per year. Incidence peaked at 80 transplants in 2017, with an upward trend after 2021. Kidney transplants made up 92.1% of cases. The most common destinations were the Philippines (19.8%), India (16.5%), Mexico (9.4%), China (8.4%), and Iran (4.4%). India and Mexico experienced the smallest drop-off during the height of the COVID-19 pandemic 2020-2021. Most recipients were US citizens (65.0%) or residents (23.5%). Female (adjusted hazard ratio [aHR], 0.520.610.71; P < 0.001) and Black candidates (aHR, 0.120.180.26; P < 0.001) were less likely to travel abroad compared with Asian candidates (aHR, 5.927.108.52; P < 0.001). Nonresidents (aHR, 6.708.6911.26; P < 0.001) and, among registrations in 2012 or later, nonresidents who traveled to the United States for transplantation (aHR, 27.2738.9155.50; P < 0.001) had a greater chance of undergoing transplantation abroad. CONCLUSIONS:Understanding patterns of international travel for transplantation is key not only for preventing resource drains from destination countries but also for providing adequate posttransplant care for recipients.

Kidney transplantation from donors with HIV has recently become standard clinical practice, but the plasma inflammatory profile is not well characterized. Thirty-two cytokines and chemokines were evaluated among donors with HIV (n = 63) and without HIV (n = 41). Wilcoxon rank sum test was used to compare cytokines between groups. Donors with and without HIV were generally similar in terms of characteristics, except those with HIV had a non-significantly lower kidney donor profile index, reflecting better graft survival, creatinine, and body mass index. Most cytokine and chemokine levels were similar between groups. However, median IL-8 levels were higher (p < 0.0015) in donors without HIV (32.6 pg/mL, IQR = 13.8-394.9) compared to donors with HIV (15.1 pg/mL, IQR = 8.4-35.5). There were no significant correlations between cytokine and chemokine concentrations and CD4 counts or HIV viral load. In summary, inflammatory profiles were similar or lower among donors with HIV compared to donors without HIV supporting the safety of this emerging kidney transplantation practice.