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PubMed1999

Hematopoietic progenitor cells from allogeneic bone marrow transplant donors circulate in the very early post-transplant period.

Despite the therapeutic efficacy of allogeneic bone marrow transplantation (allo-BMT), circulating hematopoietic progenitor cells after bone marrow transplantation have not been well characterized. In the present study, we focused on these 'post-transplant circulating progenitor cells (PTCPC)' which may be on their way to bone marrow. We analyzed the number of myeloid progenitor cells (CFU-GM) per 10 ml of peripheral blood (PB) on days 0 (just before transplantation), 1 (8-15 h after the completion of transplantation), 2, 3, 5, 7, 10, 14, 17, 21, 28 and 35 after allo-BMT in five transplant patients using a standard methylcellulose assay. In addition, high proliferative potential colony-forming cells (HPP-CFC) of the harvested donor bone marrow (BM) and day 1 PB of recipients were assayed in five patients. The origin of HPP-CFC from day 1 PB was analyzed by polymerase chain reaction of a DNA region containing a variable number of tandem repeats. The replating potential of these HPP-CFC was evaluated by a secondary colony assay. The proportion of CD38negative cells among CD34+ cells in the harvested BM and day 1 PB was evaluated by two-color flow cytometric analysis. The number of CFU-GM on day 1 ranged from 6 to 73/10 ml PB, and became undetectable on day 5. The reappearance of PTCPC was observed on day 14, along with hematopoietic recovery. The proportion of HPP-CFC among myeloid colonies from day 1 PB was significantly higher than that from harvested BM (44.3+/-10.4% vs 11.3+/-2.1%, respectively, n=5, P=0.0030). These HPP-CFC from day 1 PB were confirmed to be of donor origin. More than 90% of these HPP-CFC had replating potential. Two-color flow cytometric analysis revealed that the proportion of CD34+CD38negative cells was significantly higher in day 1 PB than in the harvested BM (61.0+/-16.5% vs 9.3+/-3.5%, respectively, n=7, P=0.0002). These observations suggest that both primitive and committed transplanted myeloid progenitor cells may circulate in the very early period following allo-BMT.

ADP-ribosyl Cyclase↗
PubMed2006

Cardiovascular events following renal transplantation: role of traditional and transplant-specific risk factors.

Cardiovascular mortality is increased in transplant recipients. However, studies including non-fatal events are critical to assess the burden of disease and to identify novel risk factors. We described the incidence of fatal and non-fatal events, and explored associations and interactions among traditional and transplant-specific risk factors and cardiovascular events (CVE) in a cohort of 922 patients transplanted between 1993 and 1998. One hundred and seventy-six patients experienced 201 CVE (111 cardiac, 48 cerebrovascular, 42 peripheral-vascular). Most CVE were non-fatal. Factors associated with cardiac events were (adjusted hazard ratios) tobacco (3.53; P<0.001), obesity (2.92; P<0.001), diabetes (2.63; P<0.001), multiple rejections (2.19; P=0.008), prior CVE (2.0; P=0.004), dialysis >1 year (1.91; P=0.007), and overweight status (1.68; P=0.04); with cerebrovascular events: diabetes and peritoneal dialysis (11.95; P<0.001), age >45 (6.77; P<0.001), diabetes (4.87; P<0.001), prior CVE (3.73; P<0.001), creatinine >141 micromol/l (3.16; P=0.001), peritoneal dialysis (3.06; P=0.027), and obesity (0.32; P=0.046); with peripheral-vascular events: diabetes (8.48; P<0.001), tobacco and cytomegalovirus (3.88; P<0.001), age >45 (2.31; P=0.019), and prior CVE (2.25; P=0.016); with mortality: tobacco and deceased-donor (3.52; P<0.001), age >45 (1.81; P=0.002), diabetes (1.76; P=0.002), pulse pressure (1.64; P=0.029), prior CVE (1.52; P=0.04), and dialysis >1 year (1.47; P=0.04). The majority of CVE post-transplant were non-fatal. Previous CVE was strongly associated with CVE post-transplant. Interactions among transplant-specific and traditional risks impacted significantly the incidence of CVE. Modifiable factors such as duration of dialysis, deceased-donor transplantation, and acute rejection should be viewed as cardiovascular risks.

Adolescent↗
PubMed2003

Cost of organ procurement and transplantation network data collection for a large transplant center.

Collection of data on transplant candidates and recipients for the Organ Procurement and Transplantation Network (OPTN) and the Scientific Registry of Transplant Recipients (SRTR) is a burden that falls primarily on the transplant centers. We examined the cost of data collection at one large transplant center. The average number of forms per year submitted more than 3 years was 5245. For the 3 years, 2.46 full time equivalents (FTEs) were committed to this data collection. Annual salaries in addition to benefits (calculated at 22% of salary) for these FTEs were US dollars 143026.22. The calculated annual cost per form submitted amounted to US dollars 27.27. Collection of data on transplant candidates and recipients is expensive and the cost of data collection should be understood before the institution of new data collection requirements for the transplant centers.

Costs and Cost Analysis↗
PubMed2001

A comparison between office and ambulatory blood pressure measurements in renal transplant patients with chronic transplant nephropathy.

Hypertension is an important risk factor for chronic transplant nephropathy. Therapy is usually based on casual office blood pressure (BP) measurements. However, it is not well known how casual BP predicts 24-hour BP in this population. The main focus of this study is to compare casual office BP with 24-hour ambulatory BP monitoring in renal transplant recipients with signs of chronic transplant nephropathy. Moreover, in this group, the day-night BP profile was assessed. In 36 renal transplant recipients with incipient or progressive proteinuria or an increase in serum creatinine level greater than 20%, 24-hour ambulatory BP was performed. Patients were defined as a nondipper if the mean BP decreased by less than 10% during the nighttime period. The correlation between single office and 24-hour ambulatory BPs was 0.61 for systolic BP and 0.55 for diastolic BP (P < 0.001). The mean difference between 24-hour ambulatory and single office BPs was -4.2 +/- 18.6 mm Hg (range, -44 to 36 mm Hg) for systolic BP and -1.1 +/- 10.7 mm Hg (range, -34 to 27 mm Hg) for diastolic BP; 94.5% of patients were classified as nondippers. There was a significant relation between the nightly decline in mean arterial pressure and calculated creatinine clearance (r = 0.34; P < 0.05). In conclusion, in renal transplant recipients with chronic transplant nephropathy, a large difference between office and ambulatory BPs is present, with both overestimation and underestimation of 24-hour BP by office BP measurements. Moreover, a severely disturbed day-night BP rhythm was observed. In transplant recipients with compromised graft function, office BP may not reflect 24-hour BP adequately, and ambulatory BP measurements should be considered.

Adult↗
PubMed2001

Long-term management of the renal transplant recipient: optimizing the relationship between the transplant center and the community nephrologist.

Rapid growth in the number of kidney transplant recipients along with improved viability of transplanted organs and increased patient survival have all led to the need for effective long-term management of these patients. The increasing numbers of transplants and the duration of posttransplant medical care can overwhelm the resources of a transplant center. These factors highlight the need for optimizing the relationship between the transplant center and the community nephrologist. There are several factors that affect the timing for transitioning patients from the transplant center to the community nephrologist and no standard timing has yet been established. Continued management of pretransplant comorbid conditions is important as are monitoring for adverse effects of failure of immunosuppressive therapy and the development of posttransplant complications. An array of testing that can be useful in monitoring these patients as well as the suggested frequency for their use are reviewed. Guidelines for the optimal interaction between the transplant center and the community nephrologist are provided to include circumstances concerning adjustment or conversion of immunosuppressive medications, evidence of allograft dysfunction, and the development of malignancy.

Adult↗
PubMed2000

Predicting clinical and economic outcomes after liver transplantation using the Mayo primary sclerosing cholangitis model and Child-Pugh score. National Institutes of Diabetes and Digestive and Kidney Diseases Liver Transplantation Database Group.

Issues in the selection and timing of liver transplantation for primary sclerosing cholangitis (PSC) remain controversial. Although the Child-Pugh classification (CP) score and Mayo PSC model have similar abilities to estimate pretransplantation survival, a comparison of these 2 scores in predicting survival after liver transplantation has not been conducted. The aim of this study is to compare the Mayo PSC model and CP score in predicting patient survival and related economic outcomes after liver transplantation. Data from 128 patients with PSC, identified from the NIDDK database, were used to calculate patient-specific Mayo PSC and CP scores before transplantation. Levels reflecting a poor outcome were defined a priori. Receiver operating characteristic (ROC) curves and regression methods (Cox proportional hazards and linear regression models) were used to assess the relationship between these 2 scores and 5 post liver transplantation outcome measures. CP score was found to be a significantly (P <.05) better predictor of death 4 months or less after liver transplantation than: (a) length of hospital stay >21 days (or death before discharge) and (b) resource utilization >200,000 units (measured by area under the ROC curve). The Cox model identified statistically significant (P <.05) associations between CP score and each outcome after adjusting for the Mayo PSC risk score. Similar results were not observed for the Mayo PSC model when adjusted for CP score. Among patients with PSC undergoing liver transplantation, CP score was a better overall predictor of both survival and economic resource utilization compared with the Mayo PSC model.

Adolescent↗
PubMed2001

[Acute or chronic transplant rejection - high resolution CT of the chest in lung transplant recipients].

PURPOSE: Aim of the study was to evaluate the postoperative changes in patients with single (SLTX) or double lung transplantation (DLTX) with HRCT and to correlate those findings with the clinical diagnosis. MATERIAL AND METHODS: 29 patients with SLTX (n = 14) or DLTX (n = 15) were observed for more than 6 years after transplantation by HRCT (n = 82). CT examinations were performed in inspiration and expiration (n = 70) with a slice thickness of 1 mm and a feed of 10 mm. The image material was evaluated by 2 experienced radiologists in consensus. Criteria for acute rejection at HRCT were: ground glass opacities and focal air trapping in expiration. Criteria for chronic transplant rejection were: bronchial dilatation, bronchial wall thickening and thickening of interlobar septae. The clinical evaluation consisted of laboratory tests, lung function tests, and bronchoscopy including bronchial lavage in special cases. RESULTS: 20/29 patients are still alive (mean 21 months). 5/9 patients died because of chronic transplantant rejection, 1 patient suffered from a non-Hodgkin's lymphoma localised at the right hilus. Severe threatening pneumonia occurred in 13 cases. 10/29 patients showed symptoms of acute rejection. Expiratory HRCT found a focal air trapping in all cases and extended ground glass opacities in 11/14 cases. Also a bronchial dilatation was observed in more than 50 % (9/14). 12/29 patients suffered from chronic transplant rejection. HRCT showed bronchial dilatation in 26/27 investigations and severe ground glass opacities in 21/27 investigations. Thickening of the interlobal septa as well as centrilobular opacities were found in more than 50 % of the examinations. CONCLUSION: High resolution CT of the chest in patients after lung transplantation is able to show numerous pathological alterations. Without clinical information a confident differentiation in acute or chronic transplant rejection or pneumonia can be difficult or impossible.

Acute Disease↗
PubMed2006

The issue of "facial appearance and identity transfer" after mock transplantation: a cadaver study in preparation for facial allograft transplantation in humans.

The authors have assessed the facial "appearance" of recipient cadavers after mock facial transplantation, the "appearance" of donor facial flaps following transfer to artificial head models, and the "appearance" of donor flaps after replantation back to the same cadavers. Based on the results of different types of facial flap transplantation, the issue of "identity transfer" is discussed. Ten fresh human cadavers were dissected. In eight cadavers, the entire facial/scalp flap was harvested. Two cadavers served as recipients of the donor facial flaps. Two different types of artificial head models were used as the "recipients" for the harvested facial flaps. The facial appearance of the recipient cadavers after mock transplantation was a mixture of features of both the recipient and the donor. The appearance of the facial flaps mounted on the head models was close to the framework of the head models. When harvested facial flaps were transferred back to the original cadavers, the facial appearance was nearly the same as before transplant. Based on this study, the authors will be able to discuss the variation in post-transplant appearance with potential candidates for facial transplant. The issue of correlating facial appearance with "identity transfer" will be difficult to assess until the authors' first facial transplantation is performed.

Cadaver↗
PubMed1999

Effects of modification of the allocation system on ischemia duration and costs of heart transplantation. Transplantation Cooperation UNI-NRW.

BACKGROUND: In order to optimize regional utilization of transplantable thoracic organs, the seven university hospitals in North-Rhine-Westfalia have formed a transplant cooperation meanwhile approved by Eurotransplant. METHODS: Heart transplant and organ donation activities of the cooperating hospitals in the year before the foundation of the cooperation (period A, 7/95 - 6/96) and in the year thereafter (period B, 7/96 - 6/97) were retrospectively analysed. RESULTS: In period A, a total of 39 heart transplants and 74 heart donations were performed, whereas in period B 67 heart transplantations and 78 heart donations could be achieved. The regional utilization of the donor organs increased from 4% to 30% with a significantly shorter ischemia time of regionally or locally allocated donor hearts than of nationally or internationally allocated ones. CONCLUSIONS: A high rate of regional or local heart transplant procedures with short ischemia times clearly demonstrate the benefits of a regionalization of heart transplant medicine for medical as well as economical reasons.

Cost-Benefit Analysis↗
PubMed1997

Evolution of hyperparathyroidism after renal transplantation in children--effect of pre-emptive transplantation and duration of dialysis.

BACKGROUND: The main causes of secondary hyperparathyroidism in end-stage renal disease are supposed to disappear after renal transplantation thanks to good graft function, but the regression of the glandular hyperfunction often takes a long time. The aim of the present work was to evaluate the possible role of the duration of dialysis in the outcome of parathyroid function after renal transplantation in children. METHODS AND RESULTS: The study was based on data from calcium-phosphate metabolism before and over a 90-day period after renal transplantation in 41 children. Patients were divided into: group I, pre-emptive transplantation (n = 17), and group II, dialysis prior to transplant (n = 24). Groups were matched for age, sex, causes of chronic renal failure, duration of ischaemia time and immunosuppressive treatment. No significant difference was noted with respect to all assessments of serum Ca, P, 25OHD and Mg between the two groups. On the other hand, PTH was statistically different both before and after renal transplantation, while glomerular filtration rate and tubular function tests were identical. CONCLUSION: It is therefore suggested that children submitted to pre-emptive transplantation achieve normal PTH levels sooner than dialysed children, which might denote an 'inappropriate PTH secretion' in the latter group. Skeletal resistance to PTH, low density of calcitriol receptor in parathyroid and/or nodular rather than diffuse hyperplasia of the gland could be speculated to explain such conclusions.

Adolescent↗
PubMed1999

Living donor kidney transplants: a biopsy study 1 year after transplantation, compared with baseline changes and correlation to kidney function at 1 and 3 years.

INTRODUCTION: Chronic changes in biopsies from long-term stable kidney allografts have been reported to correlate with graft prognosis. Morphological changes in baseline ('zero-hour') biopsies have been described as well, but their importance for long-term prognosis have been less clear. The aim of the present study was to evaluate biopsy changes from baseline to 1 year after transplantation in patients receiving kidneys from living donors, and to assess the possible prognostic implications of these findings. METHODS: Light microscopical changes in 18 gauge full-core biopsies were scored semi-quantitatively in 33 patients 1 year after transplantation, and compared to baseline changes previously reported [1]. All cases were also examined with transmission electron microscopy. The semi-quantitative data from baseline and at 1 year were correlated with kidney function 1 and 3 years after transplantation. The reproducibility of baseline findings regarding arteriosclerosis and arteriolar hyalinosis was tested by comparison with biopsies 1 week after transplantation (n = 43). RESULTS: We found a significant increase in mesangial glomerular sclerosis (P<0.001), interstitial fibrosis/tubular atrophy (if/ta) (P = 0.002), and mononuclear cell interstitial infiltration (P = 0.003) after 1 year, compared to baseline changes. There was an increase of arteriosclerosis (P = 0.028) and arteriolar hyalinosis (P = 0.006) when compared to biopsies taken 1 week after transplantation, but not when compared to the 'zero-hour' findings. Electron microscopy revealed one case of recurrent immune-complex glomerulonephritis and another case of recurrent light chain deposition kidney disease. Comparing 1-week vascular findings with baseline gave a low level of reproducibility, probably due to sampling error. Baseline biopsy findings could not predict long-term kidney function. In the 1-year biopsy, if/ta was significantly correlated with serum creatinine (P = 0.007) and glomerular filtration rate (GFR) (P<0.001) at 1 year, with serum creatinine at 3 years (P = 0.011), and with the first-year cumulative dose of methylprednisolone (P = 0.004). Serum creatinine at 1 year, however, was found to be the most accurate predictor of 3-year kidney function (P<0.001). Donor age was correlated to kidney function at 3 years (P = 0.013) but not at 1 year after transplantation. CONCLUSION: Morphological changes in baseline biopsies of living donor kidneys tend to become more pronounced in well-functioning allografts during the first year after transplantation. In the 1 year biopsy, if/ta seems to be the most reliable variate for grading of chronic changes. However, 1-year serum creatinine predicted long-term kidney function more precisely than did the biopsy scores. Based on the results of the present study, a protocol 1-year biopsy does not seem warranted in the management of the graft recipient with a stable kidney function.

Adult↗
PubMed2004

The role of bridge to transplantation: should LVAD patients be transplanted?

PURPOSE OF REVIEW: The decrease in useable donor organs means an increasing number of patients are requiring support with a left ventricular assist device (LVAD) for survival when their clinical status deteriorates before transplantation. We address whether these patients should be transplanted, if so, with what priority, and when and if they are not transplanted, what are the alternatives? RECENT FINDINGS: The perioperative mortality and morbidity of LVAD insertion remains high. Infection and device failure still limit the safety of long periods of bridging and might necessitate earlier transplantation. Early results suggest that the smaller impeller pumps may be associated with a lower incidence of device failure and infection, but with more thromboembolic and hemorrhagic complications. Transplantation of LVAD patients results in survival rates as good as those with conventional transplantation, and the survival benefit is better than for non-LVAD-supported patients. A small number of LVAD patients have shown a significant improvement in myocardial function, sufficient enough to allow explantation of the device. The proportion of these patients has previously been reported to be as low as 5%, but a strategy to maximize recovery has allowed pump removal in approximately two thirds of dilated cardiomyopathy patients. In a recent destination therapy trial, survival in LVAD patients was superior to those on medical therapy, but the frequency of infection, bleeding, and malfunction of the device was higher. SUMMARY: LVAD technology is continuing to evolve quickly, while transplantation is here to stay. The interaction between these two powerful modalities requires continued thoughtful evaluation for maximal benefit to patients.

Contraindications↗
PubMed1999

Human herpesvirus 6 seronegativity before transplantation predicts the occurrence of fungal infection in liver transplant recipients.

BACKGROUND: Invasive fungal infection has a major impact on the morbidity and mortality of liver transplant recipients. Human herpesvirus (HHV)-6 infection after transplantation is associated with an immunosuppressive state and the development of cytomegalovirus disease. Because cytomegalovirus infection is a risk factor for invasive fungal infection after transplantation, we have examined whether HHV-6 and fungal infection are associated after transplantation. METHODS: Pretransplantation sera from 247 consecutive liver transplant recipients were analyzed for IgG to HHV-6. Thirty-three (13%) HHV-6-seronegative recipients were identified. Six of 33 (18%) seronegative recipients experienced fungal infection as compared with 15 of 214 (7%) seropositive recipients (P=0.034). RESULTS: In a univariate analysis of risk factors for fungal infection, pretransplantation seronegativity to HHV-6 (P=0.034), intraoperative cryoprecipitate requirements greater than the 75th percentile (P=0.035), reoperation (P=0.005), biliary stricturing postoperatively (P=0.046), and gastrointestinal or vascular complications postoperatively (P=0.030) were identified as significant risk factors. Moreover, in pairwise multivariate analysis, pretransplantation HHV-6 seronegativity remained a significant variable even in the presence of each of the other variables. CONCLUSIONS: These results suggest that HHV-6 seronegativity before transplantation is a valuable clinical marker that identifies patients at risk for developing fungal infection after transplantation.

Disease-Free Survival↗
PubMed1999

Safety of kidney biopsy in pediatric transplantation: a report of the Controlled Clinical Trials in Pediatric Transplantation Trial of Induction Therapy Study Group.

BACKGROUND: Historically, young children undergoing renal transplantation have lower allograft survival than adults, and potential causes of this are being addressed by the North American Pediatric Renal Transplant Cooperative Study through the National Institutes of Health-sponsored study Cooperative Clinical Trials in Pediatric Transplantation. Included in this study is evaluation of surveillance renal biopsies (SB) and clinically indicated biopsies (CB). Few data exist in children to identify the risk involved with renal transplant biopsies. METHODS: Questionnaires were mailed to 21 participating centers asking for descriptions of adverse events associated with kidney biopsies, with choices limited to none, gross hematuria, perinephric hematoma, and other. Further clinical details were obtained from review of medical records of all patients with reported adverse events. Data were collected from 19 centers on 126 patients. RESULTS: Eighty-six patients had undergone 212 biopsies (75 SB and 137 CB). Nine biopsy-related adverse events were reported (4.2%): three SB (4.0%) and six CB (4.4%). Gross hematuria was reported in six patients (2.8%): two SB (2.7%) and four CB (2.9%). A perinephric hematoma was reported in one patient. Two patients with intraperitoneal kidneys developed significant bleeding after biopsy and required transfusions and surgical exploration. No patient lost kidney function or required nephrectomy after biopsy. No difference was noted in adverse events between SB at day 5 or 12 versus CB. CONCLUSION: Evaluation of transplanted kidney tissue may provide important information for the care of the transplantation patient. This analysis suggests that transplanted kidney biopsies can be performed with minimal risks in pediatric patients.

Adolescent↗
PubMed2002

Trends in invasive fungal infections in liver transplant recipients: correlation with evolution in transplantation practices.

BACKGROUND: The incidence of invasive fungal infections, particularly invasive candidiasis, after liver transplantation is strongly influenced by surgical factors and technical complexity of the surgery. We assessed the temporal trends in invasive fungal infections in the context of evolution in liver transplantation practices, technical developments, and other risk factors. METHODS: Demographic and clinical characteristics of the patients, transplantation-related variables, and rates of infection were longitudinally analyzed over the last 10 years in 190 consecutive liver transplant recipients at our institution. Trends for categorical data were evaluated using the Cochran-Armitage trend test and for continuous variables using analysis of variance with linear contrast. RESULTS: A decrease in the length of operation (P=0.03), intraoperative transfusion requirements (P=0.0001), cold ischemic time (P<0.0001), use of roux-en-Y biliary anastomosis (P=0.0015), rate of biopsy proven rejection (P<0.0001), and retransplantation (P=0.056) was documented over the successive years. A significant decline in Child-Pugh score (P=0.02) and in the proportion of patients transplanted as UNOS 2a occurred (P=0.0001). Although the incidence of cytomegalovirus infection remained unchanged, a significant increase in the frequency of primary cytomegalovirus infection (P=0.045), and a decrease in cytomegalovirus disease (P=0.0006) was documented. Over the same time period, a significant decrease in the incidence of invasive candidiasis (P=0.015), and an insignificant increase in the rate of invasive aspergillosis (P=0.20) occurred. CONCLUSION: Notable technical developments in liver transplantation practices and risk profiles of patients have occurred over the decade. These variables may have a role in influencing the evolving trends in invasive fungal infections in liver transplant recipients.

Adult↗
PubMed2002

Living kidney donors in need of kidney transplants: a report from the organ procurement and transplantation network.

BACKGROUND: Our aim was to use the Organ Procurement and Transplantation Network (OPTN) database to determine the number of renal waitlist candidates who previously had been living donors. METHODS: All living renal donors in the OPTN database were cross-checked against the renal waitlist history files. Additionally, renal transplant programs were contacted that had listed candidates as qualified for four additional allocation points available to patients who previously had donated an organ. Confirmatory phone calls to transplant programs yielded additional cases previously unreported to the United Network for Organ Sharing. RESULTS: A total of 56 previous living donors were identified as having been subsequently listed for cadaveric kidney transplantation. Forty-three have received transplants; 36 currently have functioning grafts. One died after transplantation. Two candidates died while waiting. CONCLUSIONS: Living renal donation has long-term risks that may not be apparent in the short term. The numbers here reported underestimate the actual number of living donors with renal failure, because they include only patients listed for a kidney transplant. To determine risk factors for postdonation renal failure, long-term living-donor follow-up data are needed.

Databases as Topic↗
PubMed2004

Experience with 274 cardiac transplant recipients with posttransplant lymphoproliferative disorder: a report from the Israel Penn International Transplant Tumor Registry.

BACKGROUND: Posttransplant lymphoproliferative disorder (PTLD) is a life-threatening complication that occurs in a small but significant minority of solid organ transplant recipients. Published experiences with PTLD in cardiac transplant recipients are limited to relatively small single-center reports. METHODS: This report presents experience with 274 cases of PTLD in cardiac transplant recipients reported to the Israel Penn International Transplant Tumor Registry (IPITTR). RESULTS: PTLD carried an ominous prognosis: Kaplan Meier survival after PTLD diagnosis was 45%, 33%, 30%, and 13%, respectively, at 1, 3, 5, and 10 years. Common causes of death included: PTLD, cardiovascular collapse, and infection; all occurred at a median of less than 6 months. Risk of death from cardiovascular collapse secondary to immunosuppression withdrawal was substantial (28%), indicating that a fine balance exists between death from PTLD and from sudden cardiac death due to acute rejection. PTLD therapy in the majority of patients consisted of combination therapy (49%). Survival in patients receiving immunosuppression minimization (ISM) alone was 32%, with ISM plus other therapy was 27%, and with other therapies not containing ISM was 11% (P < 0.01). CONCLUSION: PTLD in cardiac transplant recipients is associated with low long-term survival rates. Analysis of PTLD therapies and outcomes suggest that immunosuppression minimization, when applied, improves survival. However, risk of sudden death may mitigate the positive effect of ISM. This observation has important implications for ISM in PTLD therapy in cardiac transplant recipients. Carefully designed prospective studies are needed to evaluate the positive and negative effects of ISM in cardiac transplant recipients with PTLD.

Adult↗
PubMed2006

Impact of donor age and year of transplantation on graft and patient survival following liver transplantation for hepatitis C virus.

BACKGROUND: Hepatitis C virus (HCV) infection has become the most common indication for liver transplantation (LT). Graft and patient survival are adversely affected by recurrent infection of the graft. Recent publications have described an inferior outcome for recently transplanted HCV patients and have highlighted the impact of advancing donor age on severity of recurrent HCV. The donor age at which a measurable impact on graft and patient outcome can be observed has not clearly been defined. In addition, the impact of donor age on graft and patient survival for non-HCV patients needs to be examined. METHODS: We have examined a large European liver transplant database to define the impact of transplantation date and donor age on graft and patient survival for HCV patients (n = 4,736) and the impact for a comparison group of transplanted alcoholic liver disease patients (ALD, n = 5,406). RESULTS: For the entire cohorts, graft and patient survival of HCV patients was inferior to ALD patients. Since 1987, there has been a steady and ongoing improvement in the outcome of transplanted ALD patients, an improvement not observed for HCV patients. Every year since 1989, there has been an increase in liver donor age. Graft and patient survival for both ALD and HCV cohorts was adversely affected by advancing donor age. Comparison of graft and patient survival for HCV and ALD cohorts was made according to donor age (donor age subgrouped <20, 20-30, 30-40, 40-50, 50-60 and >60 years of age). For donors younger than 40 years of age, HCV and ALD recipient graft and patient survival are not significantly different. For donors older than 40, HCV recipient graft survival is inferior to ALD graft survival, an inferiority that increases for each advancing decade of donor age. For donors older than 50 years, HCV recipient patient survival is inferior to ALD patient survival, an inferiority that increases when the donor age is greater than 60 years. CONCLUSION: The results of liver transplantation for European HCV patients is inferior to a comparison group of ALD patients, and have not improved during the past 15 years. Liver donor age has increased significantly during that period. Advancing donor age has an adverse influence on graft and patient survival for ALD and HCV patients, but a significantly greater impact is observed for HCV patients when the donor is older than 40 years.

Adolescent↗