Faculty Bibliography

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.

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.

OBJECTIVE:Peripheral artery disease (PAD) is a common comorbidity among patients waitlisted for deceased donor kidney transplant (DDKT). However, some centers consider PAD a contraindication for transplant given the higher risk of post-operative complications. We aimed to examine the survival benefit of DDKT among patients with and without PAD. METHODS:We used data from the Scientific Registry of Transplant Recipients (SRTR) from January 2003 to December 2022 to identify all DDK waitlist candidates. Kaplan-Meier survival estimates and multivariable Cox proportional hazards models were used to compare patient mortality for those who received a DDKT versus those remaining on the waitlist, stratified by PAD status. RESULTS:506,785 candidates were listed for adult kidney-only transplant during the study period, of which 8.7% had PAD and 36.0% received a DDKT. After a median follow-up time of 3.21 years from waitlist activation [interquartile range 1.11-7.03 years], mortality varied significantly according to DDKT and PAD status. After adjusting for baseline differences, DDKT was associated with a significantly lower hazard of death compared to remaining on the waitlist, regardless of PAD status [adjusted hazards ratio (aHR) 0.45-0.60, P<0.001]. Further stratifying by sex, race and ethnicity, and diabetes status did not substantially alter these results. CONCLUSION/CONCLUSIONS:PAD includes a spectrum of diseases with varying mortality risks. As captured and dichotomized in the SRTR database, DDKT conferred a similar long-term benefit relative to remaining on the waitlist for candidates with and without PAD. Therefore, PAD should not be an absolute contraindication to DDKT.

[This corrects the article DOI: 10.1016/j.lana.2024.100895.].

Transplantation of kidneys from donors with HIV to recipients with HIV (HIV D+/R+) has been shown to be safe and effective, but there is a unique risk of donor-derived HIV-superinfection (HIV-SI) in these recipients. Recipients from a multicenter observational HIV D+/R+ study were examined for HIV-SI using site-directed next-generation sequencing (Illumina). Eighteen HIV D+/R+ kidney transplant recipients had both baseline and follow-up samples that successfully amplified. One recipient was confirmed to have experienced donor-derived HIV-SI at week 26, but did not experience any clinically significant changes. HIV-SI in HIV D+/R+ transplant recipients is rare, and the clinical ramifications appear negligible.

The benefits of bilateral lung transplantation (BLT) versus single lung transplantation (SLT) are still debated. One impediment to clinical recommendations is that BLT vs. SLT advantages may vary based on underlying disease. Since both options are clinically tenable in patients with emphysema, we conducted a comprehensive assessment of lung allograft survival in this population. Using U.S. registry data, we studied time to all-cause allograft failure in 8,092 patients 12 years or older transplanted from 2006 to 2022, adjusting for recipient, donor, and transplant factors by inverse propensity weighting. Median allograft survival was 6.6 years in BLT compared to 5.3 years in SLT, a 25% risk-adjusted survival advantage of _0.81.3_1.8 years. Risk-adjusted bilateral survival advantages varied between 0.9 and 2.4 years across eleven subgroups. Median allograft survival in BLT was 1.2 years greater than right SLT and 2.0 years greater than left SLT. During the 16-year study period, allograft survival steadily improved for BLT but not for SLT. Although the 25% BLT survival advantage pre-dated the pandemic, COVID-19 may have contributed to an apparent SLT survival decline. Recognizing the possible influence of residual confounding due to selection biases, these findings may aid offer decision-making when both donor lungs are available.