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This paper responds to the position statement released by the American College of Physicians (ACP) entitled "Ethics, Determination of Death, and Organ Transplantation in Normothermic Regional Perfusion (NRP) with Controlled Donation after Circulatory Determination of Death (cDCD): American College of Physicians Statement of Concern." The ACP's statement engages with critical ethical issues surrounding cDCD NRP, but several of their conclusions are flawed. Contrary to the statement, the practice respects the dead donor rule and the legal definition of death while honoring the wishes of the deceased and their loved ones to help save the lives of those in need of organ transplants. cDCD NRP is well established in many countries, it can enhance trust in medical practice and organ donation, and will increase the availability of optimal organs for life-saving transplants.

OBJECTIVE:This pilot study sought to evaluate the feasibility of our donation after circulatory death (DCD) heart transplantation protocol using cardiopulmonary bypass (CPB) for normothermic regional reperfusion (NRP). METHODS:Suitable local DCD candidates were transferred to our institution. Life support was withdrawn in the operating room (OR). On declaration of circulatory death, sternotomy was performed, and the aortic arch vessels were ligated. CPB was initiated with left ventricular venting. The heart was reperfused, with correction of any metabolic abnormalities. CPB was weaned, and cardiac function was assessed at 30-minute intervals. If accepted, the heart was procured with cold preservation and transplanted into recipients in a nearby OR. RESULTS:Between January 2020 and January 2021, a total of 8 DCD heart transplants were performed: 6 isolated hearts, 1 heart-lung, and 1 combined heart and kidney. All donor hearts were successfully resuscitated and weaned from CPB without inotropic support. Average lactate and potassium levels decreased from 9.39 ± 1.47 mmol/L to 7.20 ± 0.13 mmol/L and 7.49 ± 1.32 mmol/L to 4.36 ± 0.67 mmol/L, respectively. Post-transplantation, the heart-lung transplant recipient required venoarterial extracorporeal membrane oxygenation for primary lung graft dysfunction but was decannulated on postoperative day 3 and recovered uneventfully. All other recipients required minimal inotropic support without mechanical circulatory support. Survival was 100% with a median follow-up of 304 days (interquartile range, 105-371 days). CONCLUSIONS:DCD heart transplantation outcomes have been excellent. Our DCD protocol is adoptable for more widespread use and will increase donor heart availability in the United States.

Purpose: Utilization of HCV viremic donor kidneys for transplant into HCV naive recipients has become more widespread, yet best practices governing the initiation, timing or duration of direct acting antiviral (DAA) therapy are lacking. Most published series describe DAA initiation weeks to months after transplant. However, fibrosing cholestatic hepatitis has been reported with delayed DAA initiation. Herein we report our center practice utilizing donor blood for HCV genotyping to expedite DAA insurance approval and minimize the duration of recipient viremia.
Method(s): Patients received education and DAA insurance benefits were ensured prior to listing for HCV+ organs. At the time of transplant, donor blood accompanying the kidney was used for HCV genotyping. Results were received within one week of transplant. Recipients were screened for HCV RNA by POD#4, and weekly for 12 weeks. Insurance authorization for DAA coverage was sought after both recipient viremia and donor HCV genotyping resulted. In 3 cases, donor viral load was insufficient for genotyping, and these recipients were genotyped once viremic.
Result(s): 80 hepatitis C naive patients received hepatitis C positive donor kidneys between July, 2018 and October, 2020. 17 donors were HCV Ab+/NAT-and 63 donors were HCV Ab+/NAT+. All recipients of NAT+ donor organs became viremic; 89% were genotype 1a or 3. The median time to DAA initiation was 10 days for cases with donor genotyping (IQR 8-13). In contrast, the median time to DAA initiation was 20 days for the 3 cases with recipient genotyping (IQR 18-24). Median time from transplant to clearance of HCV viremia was 38 days (IQR 30-47) (Table 1). SVR12 was achieved in all patients, and no cases of fibrosing cholestatic hepatitis have been observed. There were 2 needlestick exposures of patient family members, though no HCV transmission occurred.
Conclusion(s): Early HCV genotyping using donor blood results in expedited initiation of DAA therapy for recipients of HCV+ kidneys. Compared to published reports, our patients are clearing viremia at the time that most other centers' patients are initiating DAA therapy. Whether duration of viremia or peak viral load are associated with adverse allograft events such as acute rejection is not known. The advantages to a shortened duration of HCV viremia remain to be characterized, but may include a lower risk of fibrosing cholestatic hepatitis and lower risk of HCV exposure to family members and caregivers. Our practice of expedited genotyping using donor blood is immediately implementable at all centers performing these transplants. (Table Presented)

Purpose: Blood type B candidates on the deceased donor kidney waitlist have a lower transplantation rate and longer wait time than candidates of other blood types. The new national kidney allocation system (KAS), implemented in December 2014, prioritizes the allocation of kidneys from blood type A2 and A2B deceased donors to blood type B candidates to mitigate this disparity in access to transplantation. We analyzed our center's data to determine whether blood type A2/A2B to B transplantation is clinically feasible without the need for additional immunosuppression.
Method(s): We conducted a single-center retrospective cohort study to analyze the utilization and outcomes in A2/A2B to B deceased donor renal transplants. Data on adult, kidney-only recipients were extracted with custom reports from the United Network for Organ transplantation (UNOS) portal. We used multivariable Coxproportional hazards models to compare graft and patient survival in blood type A2/A2B to B deceased donor renal transplants to survival in blood type B to B transplants. We estimated Kaplan-Meier (KM) graft and patient survival functions.
Result(s): Since 2015, our center has performed 44 A2/A2B to B and 65 B to B kidney transplants. We followed the patients for a median of 712 days (IQR 343-1143). Recipients of A2/A2B to B and B to B kidney transplants were similar with respect to age, gender, estimated post-transplant survival (EPTS), calculated panel reactive antibody (CPRA), HLA ABDR mismatch, kidney donor profile index (KDPI), and the incidence of delayed graft function (DGF). A higher percentage of A2/A2B to B transplant recipients were Black/African American (22/44, 50%) than B to B transplant recipients (14/65, 21.5%). Blood type A2/A2B to B and B to B transplant recipients had similar 1-year graft (97.7% vs. 93.8%, p=0.34) and 1-year patient survival (97.7% vs. 98.5%, p=0.78) rates. Multivariable models adjusted for race/ ethnicity showed that death censored graft survival (adjusted HR=1.45, p=0.70, 95% CI=0.21 to 9.82) and patient survival (4.22, p=0.14, 95% CI=0.64 to 27.92) in A2/A2B to B transplant recipients were similar to the traditionally ABO blood type compatible B to B transplants.
Conclusion(s): The NYU Langone blood type A2/A2B to B transplantation adds to the body of evidence suggesting that blood type A2/A2B to B transplantation is clinically feasible. This provision of the KAS appears to be having its intended effect of increasing access to transplantation in blood type B candidates with no attendant compromise in overall patient or death censored graft survival

BACKGROUND:Hepatitis E virus (HEV) infection has been associated with immune-mediated kidney diseases in developing countries. However, its relationship with kidney transplant outcomes has never been studied. We investigated the association between HEV infection and kidney graft rejection among kidney transplant recipients (KTRs). METHODS:We conducted a matched cohort and longitudinal study utilizing banked sera following kidney transplantation during 1988-2012. Studies with evidence of post-transplantation HEV infection were identified by positive ELISA tests (anti-HEV IgM or anti-HEV IgG seroconversion) or positive HEV PCR and matched to KTR controls with negative HEV ELISA and PCR tests in a 1:5 ratio by age, sex, crossmatch status, immunosuppression era, and time of HEV testing. Outcome data collected included time to first kidney graft rejection, transaminases, and glomerular filtration rates. Log-ranked test was used to analyze survival. RESULTS:) but did not reach significance (p = 0.24). CONCLUSION/CONCLUSIONS:Subjects with evidence of post-transplantation HEV infection demonstrated earlier kidney graft rejection compared to controls.

Transplanting hepatitis C viremic donor organs into hepatitis C virus (HCV)-negative recipients is becoming increasingly common; however, practices for posttransplant direct-acting antiviral (DAA) treatment vary widely. Protracted insurance authorization processes for DAA therapy often lead to treatment delays.