Misdiagnosis of hepatocellular carcinoma in patients receiving no local‐regional therapy prior to liver transplant: An analysis of the Organ Procurement and Transplantation Network explant pathology form

Patients with T1 hepatocellular carcinoma (HCC) are not eligible for Model for End Stage Liver Disease (MELD) exception for liver transplant (LT) in part due to a high rate of misdiagnosis (no HCC on explant). The likelihood of misdiagnosis for T2 HCC and factors associated with misdiagnosis are unknown. We analyzed the Organ Procurement and Transplantation Network database including 5664 adults who underwent LT from 2012 to 2015 with MELD exception for T2 HCC, and searched for no evidence of HCC in the explant pathology file. We focused on those (n = 324) receiving no local‐regional therapy (LRT) to evaluate the probability of no HCC found in explant. Median waiting time was short at 1.7 months, and 35 (11%) had no HCC on explant. On multivariable logistic regression, factors associated with no HCC on explant were age <50 (OR: 17.3, P < .001), non‐HCV (OR: 5.4, P = .001), and alpha‐fetoprotein <10 (OR: 2.9, P = .04). Tumor size and number were not different between groups. The proportion of misdiagnosis did not change significantly after implementation of Liver Imaging Reporting and Data System (LI‐RADS) for HCC diagnosis. Conclusion: The rate of misdiagnosis was 11% among T2 HCC patients who underwent LT without receiving LRT prior to LT and did not change significantly after implementation of LI‐RADS. More efforts are needed to eliminate unnecessary LT for patients without HCC.     

我国人体器官获取组织建设与规范化管理的探讨

器官获取组织（OPO）是随着器官移植事业发展而产生的新生组织,其建立和管理尚无统一的标准或模式.通过分析我国建立OPO的必要性以及OPO建设和发展中存在的问题,提示应采取加大宣传教育力度、规范OPO的运行流程、建立规范化OPO经济管理措施、加强OPO成员专业化培训、采取适当的激励措施、加强器官捐献移植系统信息化建设等对策,旨在推动OPO的发展,规范器官移植工作.     

医疗设备采购管理改进对策探讨与研究

各类医疗设备用于临床诊治、科研、教学等活动中,需通过科学的方法对大量的医疗设备进行管理,提高设备的使用价值。本研究以医疗设备采购为研究对象,探究医疗设备采购特点,并深入分析医疗设备采购管理现状,从成本控制、制定合理地采购计划等方面改进医疗设备采购管理方法,推动医院可持续发展战略顺利实施。     

Clinical Practice of Steroid Avoidance in Pediatric Kidney Transplantation

Steroid‐avoidance protocols have recently gained popularity in pediatric kidney transplantation. We investigated the clinical practice of steroid avoidance among 9494 kidney transplant recipients at 124 transplant centers between 2000 and 2012 in the Organ Procurement and Transplantation Network database. The practice of steroid avoidance increased during the study period and demonstrated significant variability among transplant centers. From 2008 to 2012, 39% of transplant centers used steroid avoidance in <10% of all discharged transplant recipients. Twenty‐one percent of transplant centers practiced steroid avoidance in 10–40% of transplant recipients, and 40% of transplant centers used steroid avoidance in >40% of discharged patients. Children receiving steroid avoidance more frequently received induction with lymphocyte‐depleting agents. Repeat kidney transplants were the least likely to receive steroid avoidance. Children who received a deceased donor kidney, underwent pretransplant dialysis, were highly sensitized, or had glomerular kidney disease or delayed graft function were also less likely to receive steroid avoidance. The variation in practice between centers remained highly significant (p < 0.0001) after adjustment for all patient‐ and center‐level factors in multivariate analysis. We conclude that significant differences in the practice of steroid avoidance among transplant centers remain unexplained and may reflect uncertainty about the safety and efficacy of steroid‐avoidance protocols.     

福建省单中心器官捐献转化率和器官产出率及其影响因素研究

目的探讨福建省单中心器官捐献转化率和器官产出率及其影响因素。方法回顾性分析2018年11月至2021年6月福建医科大学附属协和医院182例潜在器官捐献者的基本信息,分析器官捐献转化率、器官捐献成功者的基本情况及器官捐献失败者捐献失败的原因。分析器官捐献产出情况及器官捐献数量的影响因素。结果182例潜在器官捐献者中,捐献成功46例,捐献转化率为25.3%;失败136例,失败原因包括家属不同意(58.1%)、无充足时间评估(24.3%)和未达到捐献状态标准(17.6%)。46例器官捐献者共捐献大器官和组织212个,包括肾脏88个、肝脏42个、肺脏15个、心脏19个和角膜48个,人均捐献大器官和组织4.6个,人均捐献大器官3.6个。年龄、性别、籍贯、捐献辖区和血型是大器官捐献数量的影响因素;捐献辖区是组织捐献数量的影响因素。结论福建省单中心器官捐献转化率偏低,家属不同意是最主要的原因。应针对性地选择合适的潜在器官捐献者开展器官捐献工作,提升器官捐献转化率和器官产出率。     

The Collaborative Innovation and Improvement Network (COIIN): Effect on donor yield,waitlist mortality,transplant rates,and offer acceptance

The Organ Procurement and Transplantation Network implemented the Collaborative Improvement and Innovation Network (COIIN) to improve the use of donors with kidney donor profile index >50%. COIIN recruited 2 separate cohorts of kidney transplant programs. Cohort A included 19 programs of 44 applicants (January 1, 2017, to September 30, 2017), and cohort B included 39 programs of 47 applicants (October 1, 2017, to June 30, 2018). We investigated the effect of COIIN on kidney yield (number of kidneys transplanted from donors from whom any organ was recovered), offer acceptance, deceased donor transplant rates, and waitlist mortality rates for January 1, 2016, to March 31, 2019. COIIN did not notably affect kidney yield or waitlist mortality rates. Cohort A, but not cohort B, had significantly higher deceased donor transplant and offer acceptance rates during its intervention period than programs not in COIIN (adjusted transplant rate ratio: cohort A, _1.081.17_1.27, cohort B, _0.941.01_1.08; adjusted offer acceptance ratio: cohort A, _1.081.18_1.29, cohort B, _0.931.00_1.08). Thus, COIIN improved the use of kidneys at programs in cohort A but not at those in cohort B. Further research is necessary to understand the different effects for cohorts A and B, and further monitoring of posttransplant outcomes is required.     

A change of heart: Preliminary results of the US 2018 adult heart allocation revision

In 2018, the Organ Procurement and Transplantation Network (OPTN) modified adult heart allocation to better stratify candidates and provide broader access to the most medically urgent candidates. We analyzed OPTN data that included waiting list and transplant characteristics, geographical distribution, and early outcomes 1 year before (pre: October 18, 2017‐October 17, 2018) and following (post: October 18, 2018‐October 17, 2019) implementation. The number of adult heart transplants increased from 2954 pre‐ to 3032 postimplementation. Seventy‐eight percent of transplants in the post era were for the most medically urgent (statuses 1‐3) compared to 68% for status 1A in the pre era. The median distance between the donor hospital and transplant center increased from 83 to 216 nautical miles, with an increase in total ischemic time from 3 to 3.4 hours (all P < .001). Waiting list mortality was not different across eras (14.8 vs 14.9 deaths per 100 patient‐years pre vs post respectively). Posttransplant patient survival was not different, 93.6% pre and 92.8% post. There is early evidence that the heart allocation policy has enhanced stratification of candidates by their medical urgency and broader distribution for the most medically urgent candidates with minimal impact on overall waiting list mortality and posttransplant outcomes.     

No country for old livers? Examining and optimizing the utilization of elderly liver grafts

Of the 1.6 million patients >70 years of age who died of stroke since 2002, donor livers were retrieved from only 2402 (0.15% yield rate). Despite reports of successful liver transplantation (LT) with elderly grafts (EG), advanced donor age is considered a risk for poor outcomes. Centers for Medicare and Medicaid Services definitions of an “eligible death” for donation excludes patients >70 years of age, creating disincentives to donation. We investigated utilization and outcomes of recipients of donors >70 through analysis of a United Network for Organ Sharing Standard Transplant Analysis and Research‐file of adult LTs from 2002 to 2014. Survival analysis was conducted using Kaplan‐Meier curves, and Cox regression was used to identify factors influencing outcomes of EG recipients. Three thousand one hundred four livers from donors >70, ≈40% of which were used in 2 regions: 2 (520/3104) and 9 (666/3104). Unadjusted survival was significantly worse among recipients of EG compared to recipients of younger grafts (P < .0001). Eight independent negative predictors of survival in recipients of EG were identified on multivariable analysis. Survival of low‐risk recipients who received EG was significantly better than survival of recipients of younger grafts (P = .04). Outcomes of recipients of EG can therefore be optimized to equal outcomes of younger grafts. Given the large number of stroke deaths in patients >70 years of age, the yield rate of EGs can be maximized and disincentives removed to help resolve the organ shortage crisis.