Kidney transplant candidates’ views of the transplant allocation system

Objectives

The point system used to distribute scarce transplantable kidneys places great emphasis on antigen matching. This contributes to increased waiting times for African Americans, who have a disporoportionate share of rare antigens. We conducted a pilot study to explore the understanding and attitudes of kidney transplant candidates toward the way the transplant allocation system trades off between antigen matching and waiting time.

Measurements and main Results

We performed semistructured interviews of a convenience sample of 33 patients awaiting transplants in Philadelphia and its surrounding suburbs. Patients had a number of misconceptions about the transplant allocation system. Many incorrectly thought, for example, that quality of life and finacial status influence which patients on the walting list receive available organs. Despite these and other misconceptions, the majority of patients thought the allocation system was fair. However, many African Americans thought the system was biased against them because of their race. After hearing about how the transplant system factors antigen matching and waiting time into organ allocation, the majority of subjects still felt the system was fair. After hearing that the emphasis on antigen matching causes African Americans to wait twice as long as whites, a larger number of subjects thought the system was unfair. Nevertheless, few thought the system should be changed. Even African American patients who felt the system was unfair still approved of the emphasis on antigen matching out of a desire to have a successful kidney transplant.

Conclusions

We found that most of the interviewed patients awaiting kidney transplant thought the system should continue to emphasize antigen matching. Although attitudes toward the allocation system differed by race, with African American patients more suspicious of the system, the importance patients placed on antigen matching did not appear to differ by race.     

Hereditary haemorrhagic telangiectasia: to transplant or not to transplant?

The Association of hereditary hemorrhagic telangiectasia (HHT) and type I hereditary angioedema is a very rare condition in medicine. The case reported by Muller et al., describes the coexistence of the two diseases and emphasizes the need for listing HHT patients for liver transplantation in case indications occurs, such as the presence of HCC, abnormally increased cardiac output, and gastrointestinal bleeding as reported for this case. The case described by Mueller et al. is anecdotal for the usefulness of liver transplantation in HHT patients and shows that liver transplantation may be the best supportive care and, sometimes, the unique and final therapeutic option for these patients.     

Hereditary hemorrhagic telangiectasia: to transplant or not to transplant?

This report comments the case reported by Muller et al. which describes a combination of at least two different indications for orthotopic liver transplant (OLT) in a same patient: hepatocarcinoma and HHT complicated with severe liver involvement and high output cardiac failure. This case report highlighted that the clear time for OLT in HHT can be difficult to determine. In HHT, if intensive medical approach is not efficient, OLT, has to be considered. In the case of Muller et al., the patient was correctly listed for OLT for a single hepatocellular carcinoma, however, he did not receive a sufficient priority so as to avoid worsening of liver vascular malformations complications. Bevacizumab may be a therapeutic option in the treatment of complicated liver VMs in HHT, However, the recurrence of symptoms after withdrawal of the drug make it unsuitable as a replacement for OLT in the cure of complicated liver VMs in HHT. In the case reported by Muller et al. the right “OLT window” after bevacizumab was lost. The right time for OLT in severe complicated liver VMs in HHT does exist but, as this case illustrates, it can be very difficult to determine. As OLT is a radical cure for liver VMs, with excellent outcomes, it should be the therapeutic choice in patients under the age of 65 years. Bevacizumab may be an interesting option, either for patients over the age of 65 years, or those who are poor candidates for surgery; if these latter respond to bevacizumab they should be re‐ evaluated for OLT (with a “fast‐ track”) as the prognosis of severe complicated liver VMs is very poor.     

Is transplant operation important in determining posttransplant risk of bronchiolitis obliterans syndrome in lung transplant recipients?

STUDY OBJECTIVES: Lung transplantation continues to be limited by the development of chronic allograft dysfunction in the form of bronchiolitis obliterans syndrome (BOS). The effect of a transplant operation on patients with BOS has not been well-studied, but patients who undergo double-lung transplantation have better long-term survival. We hypothesized that double-lung transplantation leads to decreased rates of BOS. METHODS: A retrospective review of all lung transplant recipients at our institution, surviving for > 6 months after undergoing their transplant operation. Demographic data, information on other factors leading to the development of BOS, survival information, and data on the presence and timing of BOS were collected. RESULTS: BOS occurred in 41.3% of the recipients (93 of 225 patients) at a median time of 4.2 years. Single-lung transplantation was associated with increased rates of BOS compared to double-lung transplantation (49.3% vs 31.7%, respectively; p = 0.007), at the time of the analysis. Single-lung and double-lung transplant recipients had different baseline characteristics, but after controlling for these factors the type of transplant remained a significant predictor of the length of time to the onset of BOS in a multivariable proportional hazard model. CONCLUSIONS: Double-lung transplantation is associated with a reduced risk for BOS in our study population. A multicenter study with complete BOS information on all patients with a single pretransplant diagnosis would be useful to confirm the above findings. Further research is needed to determine how the type of transplant contributes to the risk for BOS.     

《Upfront haploidentical transplant for acquired severe aplastic anemia:registry-based comparison with matched related transplant》解读

=本文最初发表于2017年《J Hematol Oncol》杂志上,文章题录为:Xu LP,Jin S,Wang SQ,et al.Uptransplant[J].J Hematol Oncol,2017,10:25。本研究在世界范围内首次报道了对多中心的连续病例进行一线单倍体移植与同期一线同胞全相合移植的疗效比较。共纳入11个移植中心的158例患者,所有进行单倍体移植的患者采用相同的移植方案,结果显示单倍型相合移植作为一线治疗与同期一线同胞全相合移植相比,3年总生存率和无失败生存率相似;多因素分析显示移植前输血量以及移植前患者的一般情况(PS评分)是影响生存的独立危险因素;所以对于具备移植条件的重型再生障碍性贫血患者,尽早采取单倍型相合移植作为一线治疗选择值得进一步研究。     

How old is too old for a transplant?

Allogeneic transplantation remains the most definitive curative option for patients with acute myeloid leukemia (AML). However, given the median age of diagnosis of AML in the late 60s, patients and clinicians have been reluctant to offer transplant to many in the older population. In this age group, AML presents with higher risk molecular and cytogenetic phenotype and patients' comorbidities, performance status, frailty and life views all impact the decision-making about whether to proceed with transplantation. Recent analyses suggest promising outcomes and thus acknowledgement of chronological age should be tempered with assessments of performance status, frailty, donor availability and careful balancing of a patient's wishes, life goals and understanding of the risks before restricting access of older patients to the curative potential of allotransplantation.     

Liver transplant for 70 patients with end-stage liver diseases

Introduction Progress in immunosuppression, surgical techniques, and perioperative care has promoted orthotopic liver transplantation from an experimental procedure to an accepted clinical treatment. Liver transplantation is considered the standard therapeutic approach for end-stage liver disease[1-4] with a postoperative survival rate increasing to 80% in 5 5] years.[1, However, there are a wide range of possible postoperative complications of technical and medical origin.[6-9] Based on ortho…     

Regulations governing clinical application of human organ transplant in China

To regulate human organ transplant, guarantee the quality and safety of the operation, protect the health of the people, the Health Ministry of China issued Regulations governing Clinical Application of Human Organ Transplant on March 27, 2006, which is to be put into effect on the coming July 1. The regulations contain 5 chapters and 47 articles including general principles, registration of diagnosis and treatment, clinical management, supervision, and supplementary items.