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Pancreas Transplantation from Hepatitis C Viremic Donors to Uninfected Recipients

Lonze, Bonnie E; Baptiste, Gillian; Ali, Nicole M; Dagher, Nabil N; Gelb, Bruce E; Mattoo, Aprajita; Soomro, Irfana; Tatapudi, Vashista S; Montgomery, Robert A; Stewart, Zoe A
Despite utilization of hepatitis C viremic organs for hepatitis C naïve recipients (HCV D+/R-) in other solid organ transplants, HCV viremic pancreata remain an unexplored source of donor organs. This study reports the first series of HCV D+/R- pancreas transplants. HCV D+/R- had shorter wait list times compared to HCV D-/R-, waiting a mean of 16 days from listing for HCV positive organs. HCV D+/R- had a lower match allocation sequence than HCV D-/R-, and this correlated to receipt of organs with a lower Pancreas Donor Risk Index (PDRI) score. All HCV D+R- had excellent graft function with a mean follow up of 438 days and had undetectable HCV RNA levels by a mean of 23 days after initiation of HCV-directed therapy. The rates of infectious complications, re-operation, readmission, rejection, and length of stay were not impacted by donor HCV status. A national review of potential ideal pancreas donors found that 37% of ideal HCV negative pancreas allografts were transplanted, compared to only 5% of ideal HCV positive pancreas allografts. The results of the current study demonstrate the safety of accepting HCV positive pancreata for HCV naïve recipients and advocates for increased utilization of ideal HCV positive pancreas allografts.
PMID: 33346951
ISSN: 1600-6143
CID: 4726692

Measles Outbreak Risk Assessment for Transplant Candidates and Recipients

Kreiger-Benson, Elana; Gelb, Bruce; Neumann, Henry J; Hochman, Sarah; Lighter, Jennifer; Mehta, Sapna A
Solid organ transplant (SOT) candidates and recipients are at risk of significant morbidity and mortality from infection, including those circulating in the community from unexpected outbreaks. In late 2018-summer of 2019, a measles outbreak occurred in the New York City area, with a total of 649 cases reported. We developed a systematic three-part approach to address measles risk in our adult SOT program through: 1) identification of non-immune adults living in outbreak ZIP codes, 2) education focused on risk reduction for patients from outbreak ZIP codes and 3) risk reduction for non-immune patients. All waitlisted or previously transplanted patients residing in outbreak areas received a measles patient education handout. The electronic medical record of patients born in or after 1957 was reviewed for serologic evidence of measles immunity. Measles immunity testing was performed in patients without documentation of immunity. Patients who tested non-immune were offered MMR vaccination or intravenous immunoglobulin depending on their transplant phase and risk profile. Thus, we demonstrate successful implementation of a systematic risk assessment during a large measles outbreak to identify and protect at-risk SOT patients. As vaccine hesitancy persists, our strategies may be increasingly relevant to transplant centers and those caring for immunocompromised patients.
PMID: 32808470
ISSN: 1600-6143
CID: 4583752

Acute Peritoneal Dialysis During the COVID-19 Pandemic at Bellevue Hospital in New York City

Caplin, Nina J; Zhadanova, Olga; Tandon, Manish; Thompson, Nathan; Patel, Dhwanil; Soomro, Qandeel; Ranjeeta, Fnu; Joseph, Leian; Scherer, Jennifer; Joshi, Shivam; Dyal, Betty; Chawla, Harminder; Iyer, Sitalakshmi; Bails, Douglas; Benstein, Judith; Goldfarb, David S; Gelb, Bruce; Amerling, Richard; Charytan, David M
ORIGINAL:0015108
ISSN: n/a
CID: 4874982

Acute Peritoneal Dialysis During the COVID-19 Pandemic at Bellevue Hospital in New York City

Caplin, Nina J; Zhdanova, Olga; Tandon, Manish; Thompson, Nathan; Patel, Dhwanil; Soomro, Qandeel; Ranjeeta, Fnu; Joseph, Leian; Scherer, Jennifer; Joshi, Shivam; Dyal, Betty; Chawla, Harminder; Iyer, Sitalakshmi; Bails, Douglas; Benstein, Judith; Goldfarb, David S; Gelb, Bruce; Amerling, Richard; Charytan, David M
Background:The COVID-19 pandemic strained hospital resources in New York City, including those for providing dialysis. New York University Medical Center and affiliations, including New York City Health and Hospitals/Bellevue, developed a plan to offset the increased needs for KRT. We established acute peritoneal dialysis (PD) capability, as usual dialysis modalities were overwhelmed by COVID-19 AKI. Methods:Observational study of patients requiring KRT admitted to Bellevue Hospital during the COVID surge. Bellevue Hospital is one of the largest public hospitals in the United States, providing medical care to an underserved population. There were substantial staff, supplies, and equipment shortages. Adult patients admitted with AKI who required KRT were considered for PD. We rapidly established an acute PD program. A surgery team placed catheters at the bedside in the intensive care unit; a nephrology team delivered treatment. We provided an alternative to hemodialysis and continuous venovenous hemofiltration for treating patients in the intensive-care unit, demonstrating efficacy with outcomes comparable to standard care. Results:From April 8, 2020 to May 8, 2020, 39 catheters were placed into ten women and 29 men. By June 10, 39% of the patients started on PD recovered kidney function (average ages 56 years for men and 59.5 years for women); men and women who expired were an average 71.8 and 66.2 years old. No episodes of peritonitis were observed; there were nine incidents of minor leaking. Some patients were treated while ventilated in the prone position. Conclusions:Demand compelled us to utilize acute PD during the COVID-19 pandemic. Our experience is one of the largest recently reported in the United States of which we are aware. Acute PD provided lifesaving care to acutely ill patients when expanding current resources was impossible. Our experience may help other programs to avoid rationing dialysis treatments in health crises.
PMCID:8815539
PMID: 35372895
ISSN: 2641-7650
CID: 5219412

A Comparison of Immunosuppression Regimens in Hand, Face, and Kidney Transplantation

Rifkin, William J; Manjunath, Amit K; Kantar, Rami S; Jacoby, Adam; Kimberly, Laura L; Gelb, Bruce E; Diaz-Siso, J Rodrigo; Rodriguez, Eduardo D
BACKGROUND:Authors have speculated that vascularized composite allotransplantation (VCA) recipients may require greater maintenance immunosuppression than solid organ transplant (SOT) recipients due to the higher antigenicity of skin. However, detailed comparisons of VCA and SOT immunosuppression regimens have been limited. METHODS:Hand and face VCA recipient immunosuppression data were collected through a systematic literature review. Kidney recipient data were obtained through a retrospective chart review of the authors' institution. Prednisone and mycophenolate mofetil (MMF) doses were compared between VCA and kidney recipients at predefined follow-up intervals (<1, 1-5, and >5 y). Tacrolimus target trough levels (TTTL) were compared at follow-up intervals of 1-5 and >5 y, and stratified into our institution's kidney transplant risk-based target ranges (4-6 ng/mL, 6-8 ng/mL) or higher (>8 ng/mL). RESULTS:Immunosuppression data were available for 57 VCA and 98 kidney recipients. There were no significant differences in prednisone doses between groups at all follow-up intervals. VCA recipient mean MMF dose was significantly greater at <1-y (1.71 ± 0.58 versus 1.16 ± 0.55 gm/d; P = 0.01). For VCA recipients, there was a significant difference (P = 0.02) in TTTL distribution over the three predefined therapeutic ranges (4-6 ng/mL, 6-8 ng/mL, and >8 ng/mL) between 1 and 5 y (24.0%, 20.0%, 56.0%, respectively) and >5 y (28.6%, 42.9%, 28.6%). CONCLUSIONS:At longer follow-up, VCA and kidney recipients receive comparable MMF/prednisone doses, and most VCA recipients are treated with TTTL similar to kidney recipients. Further research may improve our understanding of VCA's complex risk/benefit ratio, and enhance informed consent.
PMID: 32977237
ISSN: 1095-8673
CID: 4609112

A case of facial composite tissue allograft rejection [Case Report]

Yan, Di; Stokar, Evan; Jacoby, Adam; Gelb, Bruce E; Rodriguez, Eduardo D; Meehan, Shane A
PMCID:7452299
PMID: 32875035
ISSN: 2352-5126
CID: 4615392

Vascularized Composite Allotransplantation 2.0: The Future Is Now

Ramly, Elie P; Berman, Zoe P; Diep, Gustave K; Alfonso, Allyson R; Kimberly, Laura L; Gelb, Bruce E; Rodriguez, Eduardo D
PMID: 32842130
ISSN: 1529-4242
CID: 4614452

Lung-derived HMGB1 is detrimental for vascular remodeling of metabolically imbalanced arterial macrophages

Boytard, Ludovic; Hadi, Tarik; Silvestro, Michele; Qu, Hengdong; Kumpfbeck, Andrew; Sleiman, Rayan; Fils, Kissinger Hyppolite; Alebrahim, Dornazsadat; Boccalatte, Francesco; Kugler, Matthias; Corsica, Annanina; Gelb, Bruce E; Jacobowitz, Glenn; Miller, George; Bellini, Chiara; Oakes, Jessica; Silvestre, Jean-Sébastien; Zangi, Lior; Ramkhelawon, Bhama
Pulmonary disease increases the risk of developing abdominal aortic aneurysms (AAA). However, the mechanism underlying the pathological dialogue between the lungs and aorta is undefined. Here, we find that inflicting acute lung injury (ALI) to mice doubles their incidence of AAA and accelerates macrophage-driven proteolytic damage of the aortic wall. ALI-induced HMGB1 leaks and is captured by arterial macrophages thereby altering their mitochondrial metabolism through RIPK3. RIPK3 promotes mitochondrial fission leading to elevated oxidative stress via DRP1. This triggers MMP12 to lyse arterial matrix, thereby stimulating AAA. Administration of recombinant HMGB1 to WT, but not Ripk3-/- mice, recapitulates ALI-induced proteolytic collapse of arterial architecture. Deletion of RIPK3 in myeloid cells, DRP1 or MMP12 suppression in ALI-inflicted mice repress arterial stress and brake MMP12 release by transmural macrophages thereby maintaining a strengthened arterial framework refractory to AAA. Our results establish an inter-organ circuitry that alerts arterial macrophages to regulate vascular remodeling.
PMID: 32855420
ISSN: 2041-1723
CID: 4575922

Anesthetic Considerations in Facial Transplantation: Experience at NYU Langone Health and Systematic Review

Alfonso, Allyson R; Ramly, Elie P; Kantar, Rami S; Rifkin, William J; Diaz-Siso, J Rodrigo; Gelb, Bruce E; Yeh, Joseph S; Espina, Mark F; Jain, Sudheer K; Piper, Greta L; Rodriguez, Eduardo D
Anesthetic considerations are integral to the success of facial transplantation (FT), yet limited evidence exists to guide quality improvement. This study presents an institutional anesthesia protocol, defines reported anesthetic considerations, and provides a comprehensive update to inform future directions of the field.
PMCID:7489595
PMID: 32983760
ISSN: 2169-7574
CID: 4616462

The ethics of testing and research of manufactured organs on brain-dead/recently deceased subjects

Parent, Brendan; Gelb, Bruce; Latham, Stephen; Lewis, Ariane; Kimberly, Laura L; Caplan, Arthur L
Over 115 000 people are waiting for life-saving organ transplants, of whom a small fraction will receive transplants and many others will die while waiting. Existing efforts to expand the number of available organs, including increasing the number of registered donors and procuring organs in uncontrolled environments, are crucial but unlikely to address the shortage in the near future and will not improve donor/recipient compatibility or organ quality. If successful, organ bioengineering can solve the shortage and improve functional outcomes. Studying manufactured organs in animal models has produced valuable data, but is not sufficient to understand viability in humans. Before risking manufactured organ experimentation in living humans, study of bioengineered organs in recently deceased humans would facilitate evaluation of the function of engineered tissues and the complex interactions between the host and the transplanted tissue. Although such studies do not pose risk to human subjects, they pose unique ethical challenges concerning the previous wishes of the deceased, rights of surviving family members, effective operation and fair distribution of medical services, and public transparency. This article investigates the ethical, legal and social considerations in performing engineered organ research on the recently deceased.
PMID: 31563872
ISSN: 1473-4257
CID: 4115892