Comparison of survival for haemodialysis patients vs renal transplant recipients treated in Uruguay.

BACKGROUND: Our aim was to compare survival among renal transplant recipients and haemodialysis patients treated in Uruguay. METHODS: All the patients transplanted in Uruguay (n=460) and all the patients who started haemodialysis (HD) in three centres in Uruguay (n=695) from 01 January 1981 to 31 December 1998 were included. Overall survival, adjusted survival and survival of the patients in the low-risk group were compared for HD patients and renal transplant recipients. Diabetic and non-diabetic patients were considered independently. The low-risk group was defined by the absence of any significant risk factor related to mortality on the Cox proportional hazard regression model (age more than 55 years at start of HD, previous history of diabetes, heart disease, cancer, and smoking habit). The significant variables were also used to adjust the survival curve. RESULTS: Overall survival was significantly greater in renal transplant recipients (P<0.0001). One-, five- and ten-year survival rates were 95.2, 88.0 and 78.8% for renal transplant recipients and 90.6, 62.7 and 39.8% for HD patients. In non-diabetic patients, adjusted survival rates (for age, heart disease, cancer, and smoking habit) were similar in renal transplant recipients and HD patients (P=0.8713). In the low-risk group as well, significant differences in survival between renal transplant recipients (n=289) and HD patients (n=134) were not observed (P=0.2312). Ten-year survival rates were 82.6 and 87.9% respectively. In diabetic patients 5-year survival rates adjusted for heart disease, smoking habit, and chronic pulmonary disease were 89.2% for renal transplant recipients and 40.9% for HD patients (P=0. 0168) The relative risk of haemodialysis patients related to renal graft recipients was 2.85 (1.21-6.75). CONCLUSIONS: We conclude that when the outcome is adjusted to co-morbid factors there is no difference between renal transplant recipients and haemodialysis patients survival in non-diabetic patients, while renal transplantation gives better survival rates than haemodialysis in diabetic patients.     

Relationship of hepatitis B or C virus prevalences, risk factors, and outcomes in renal transplant recipients: analysis of German data

BACKGROUND: Chronic liver disease resulting from hepatitis B (HBV) and hepatitis C (HCV) virus infections is still a major concern in kidney recipients. Our aim was to evaluate the prevalences, risk factors, and impact of HBV and HCV infections in adult renal transplant recipients in Germany. MATERIALS AND METHODS: Data were collected on 1633 kidney recipients transplanted between 1989 and 2002 at the 21 German renal transplant centers participating in MOST, the prospective Multinational Observational Study in Transplantation. Subgroup analyses compared HBV- and HCV-positive patients vs those with HBV/HCV-negative serology at the time of transplantation. RESULTS: The prevalences of 4.4% (n = 72) for HBV and 5.8% (n = 94) for HCV showed a marked decline over the last 15 years. Retransplantations were significantly more common among HBV+ (29%) and HCV+ (36%) than HBV-/HCV- patients (12%). HCV+ patients experienced significantly longer dialysis times and received significantly more pretransplantation blood transfusions. Between all groups, no significant differences were observed in acute rejection rate at 12 months or in renal graft function up to 5 years posttransplantation (mean glomerular filtration rate: HBV+, 57.3 mL/min; HCV+, 58.5 mL/min; HBV-/HCV-, 59 mL/min). No progressive elevations in liver enzymes and bilirubin were noted during the 5-year observation period. CONCLUSIONS: HBV and HCV infections currently have a low prevalence among German kidney graft recipients. Long dialysis times, blood transfusions, and retransplantations were identified as risk factors for hepatitis infections. At 5 years posttransplantation, kidney and liver functions did not differ significantly between HBV+ and HCV+ vs HBV-/HCV- renal transplant recipients.     

Chain Transplantation: Initial Experience of a Large Multicenter Program

We report the results of a large series of chain transplantations that were facilitated by a multicenter US database in which 57 centers pooled incompatible donor/recipient pairs. Chains, initiated by nondirected donors, were identified using a computer algorithm incorporating virtual cross‐matches and potential to extend chains. The first 54 chains facilitated 272 kidney transplants (mean chain length = 5.0). Seven chains ended because potential donors became unavailable to donate after their recipient received a kidney; however, every recipient whose intended donor donated was transplanted. The remaining 47 chains were eventually closed by having the last donor donate to the waiting list. Of the 272 chain recipients 46% were ethnic minorities and 63% of grafts were shipped from other centers. The number of blood type O‐patients receiving a transplant (n = 90) was greater than the number of blood type O‐non‐directed donors (n = 32) initiating chains. We have 1‐year follow up on the first 100 transplants. The mean 1‐year creatinine of the first 100 transplants from this series was 1.3 mg/dL. Chain transplantation enables many recipients with immunologically incompatible donors to be transplanted with high quality grafts.     

Pregnancy Outcomes in Female Renal Recipients: A Comparison of Systemic Lupus Erythematosus With Other Diagnoses

This study compares pregnancy outcomes in systemic lupus erythematosus (SLE) patients post renal transplant with recipients with other primary diagnoses, utilizing data from the National Transplantation Pregnancy Registry, Philadelphia, PA. Recipients were referred from transplant centers nationwide. A retrospective analysis was performed using data from questionnaires, hospital records and telephone interviews. Outcomes of pregnancies post renal transplant secondary to lupus nephritis (SLE: n = 38; 60 pregnancies) were compared with the pregnancy outcomes of renal recipients with other diagnoses (non-SLE: n = 247; 374 pregnancies). Drug-treated hypertension during pregnancy was less common in the SLE group than in the non-SLE group (45.0% vs. 62.5%, p = 0.015). There were fewer cesarean sections in the SLE group (30.2 vs. 53.2%, p = 0.008). There was no primary or gestational diabetes in the SLE group. There were no other statistical differences in maternal conditions or pregnancy outcomes between the SLE and non-SLE groups, or in the incidence of post pregnancy graft loss. Female recipients transplanted for renal failure secondary to lupus nephritis can successfully maintain pregnancy. Outcomes are comparable to renal recipients with other diagnoses. Newborns in both groups were often premature and had low birthweight. Overall childhood health was reported to be good; there were no apparent predominant structural malformations among the children.     

Anti-HCMV IgG positivity rate among renal transplant recipients in Baghdad

In developing countries, the majority of infection by human cytomegalovirus (HCMV) occurs during childhood and continues as a latent infection. By adulthood, almost all the population may show anti-HCMV IgG as positive. This study was undertaken to determine the correlation between the prevalence of HCMV antibodies and HCMV infection during post transplant period among renal transplant patients in Baghdad. 43 renal transplant patients attending three renal transplantation centers, and 40 healthy individuals who served as controls were enrolled in this study. 18 (41.9%) were transplanted recently and they were under post-operative follow-up and 25 (58.1%) were transplanted more than one year ago. Detection of anti-HCMV IgG was carried out using enzyme-linked immunosorbant assay (ELISA). The results revealed that anti-HCMV IgG was significantly higher among renal transplant recipients compared to healthy controls (97.7% vs 85%, P = 0.04). The anti-HCMV IgG positivity rate was not affected by patients' age, sex, and duration after transplantation or immunosuppressive therapy. We conclude that the high anti-HCMV IgG positivity rate among Iraqi renal transplant recipients make them prone to considerable risk of reactivation of HCMV infection.     

Impact of lung transplantation on site of death in cystic fibrosis

BACKGROUND: Cystic fibrosis (CF) remains a lethal condition where a palliative approach is often taken at the end of life. We wanted to evaluate how lung transplantation impacts end of life care in adult CF patients. METHODS: Data were abstracted using a standardized data collection instrument from all outpatient and inpatient records of adult CF patients with an FEV1< or =30% or prior lung transplantation followed at our Center. Comparisons were made between those who were listed/received lung transplant and those who were not listed. RESULTS: A total of 41 patients met the entry criteria. Of these, 63% (n=26) were referred for lung transplant evaluation and 39% (n=16) had undergone lung transplantation. Of these 41, 59% (n=24) are deceased. The majority of deceased patients expired in an acute care hospital (63%, n=15). There was no difference in site of death between the two groups (hospital versus home). However, listed/transplanted patients were more likely to die in an intensive care unit setting compared to patients not listed/transplanted (p=.013). CONCLUSIONS: Most of our CF patients' deaths occurred in an acute care hospital. Lung transplant significantly alters site of death and shifts it from medical floors to the intensive care unit.     

Infection frequency and profile in different age groups of kidney transplant recipients

BACKGROUND: Older transplant recipients have been shown to be at greater risk for infectious death than younger adults, but no study to date has looked at relative risk of infection and infection profile differences for children versus adults, which may be very different from one another. METHODS: Data from primary Medicare renal transplant recipients between 1991 and 1998 (n=64,751), as reported in the United States Renal Data System (USRDS), were analyzed for Medicare claims (both inpatient and outpatient) for infection and type of infection in the first year posttransplant. Cox regression was used to model adjusted hazard ratios (AHR) for infection. RESULTS: Total infections among renal transplant recipients increased significantly in more recent years. Patients transplanted in or after 1995 had a significantly higher adjusted risk for infection compared to those transplanted earlier (AHR 1.34, 95% CI=1.29-1.39). Older adults > or = 51 years of age had the highest percentage of experiencing infection, as compared to adults between 18-50 years and children < or = 17 years (P<0.001). Children were at highest risk of viral infection prior to 1995 but at lowest risk of viral infection after 1995, whereas elderly adults were at highest risk of bacterial infection throughout the study. Children experienced more claims for viral infections, whereas older transplant recipients experienced more claims for bacterial infections. CONCLUSIONS: The two extremes of transplant recipient age display very different risks for infection claim frequency and profile.     

The Prognostic Value of Kidney Transplant Center Report Cards

SRTR report cards provide the basis for quality measurement of US transplant centers. There is limited data evaluating the prognostic value of report cards, informing whether they are predictive of prospective patient outcomes. Using national SRTR data, we simulated report cards and calculated standardized mortality ratios (SMR) for kidney transplant centers over five distinct eras. We ranked centers based on SMR and evaluated outcomes for patients transplanted the year following reports. Recipients transplanted at the 50th, 100th and 200th ranked centers had 18% (AHR = 1.18, 1.13?1.22), 38% (AHR = 1.38, 1.28?1.49) and 91% (AHR = 1.91, 1.64?2.21) increased hazard for 1‐year mortality relative to recipients at the top‐ranked center. Risks were attenuated but remained significant for long‐term outcomes. Patients transplanted at centers meeting low‐performance criteria in the prior period had 40% (AHR = 1.40, 1.22?1.68) elevated hazard for 1‐year mortality in the prospective period. Centers' SMR from the report card was highly predictive (c‐statistics > 0.77) for prospective center SMRs and there was significant correlation between centers' SMR from the report card period and the year following (ρ = 0.57, p < 0.001). Although results do not mitigate potential biases of report cards for measuring quality, they do indicate strong prognostic value for future outcomes. Findings also highlight that outcomes are associated with center ranking across a continuum rather than solely at performance margins.

     

Cyclosporine-based immunosuppressive strategies for kidney recipients: interim analysis of German data from the Multinational Observational Study (MOST)

INTRODUCTION: We collected data from kidney recipients with a functioning graft at German kidney transplant centers in order to analyze the efficacy of various cyclosporine (CsA)-based immunosuppressive strategies, the effects of different perioperative and maintenance regimens, and the impact of donor source on clinical outcome. METHODS: As part of the ongoing prospective Multinational Observational Study in Transplantation (MOST), data for both prospective and retrospective analysis were collected from kidney recipients over 18 years bearing a functioning graft that was transplanted at 21 German kidney transplant centers between 1987 and 2002. RESULTS: Data from 1223 renal graft recipients, including their CsA-based immunosuppressive regimens, were stratified as: 402 de novo patients (median 6.8 months posttransplant) and 821 patients on maintenance therapy (median 71 months posttransplant). Triple regimens with CsA + mycophenolate mofetil (MMF) + steroids (Ste) currently comprise the major perioperative immunosuppressive strategies in Germany (de novo 65%). IL-2 receptor antagonist (IL-2Ra) use is increasing (de novo 18%, maintenance 4%), while mono and dual regimen use de novo is declining (de novo 4%, maintenance 20%). Among 689 patients transplanted between 1987 and 2002 with outcome data, the mean incidence of acute rejection during the first posttransplant year was 21.6%. Rejection rates on initial therapy with CsA + MMF + Ste +/- antibodies (n = 517) averaged 17.8%. CONCLUSIONS: Between 1987 and 2002, CsA-based immunosuppression combined with MMF and Ste became the most commonly used strategy for both initial and maintenance therapy after kidney transplantation in Germany, yielding the low acute rejection rates particularly when combined with IL-2Ra.     

Morbid obesity is not a contraindication to kidney transplantation

BACKGROUND: Concern that morbidly obese (body mass index [BMI] 35) kidney transplant recipients have worse outcomes than non-morbidly obese recipients leads many transplant centers to deny them the benefit of kidney transplantation. These concerns are supported by guidelines recently published by the American Society of Transplantation. However, successfully transplanted morbidly obese persons have a survival advantage over those that remain on dialysis. It is our practice to evaluate morbidly obese transplant candidates for transplantation under the same criteria used for nonobese candidates. This report reviews our experience with morbidly obese kidney transplant recipients having a three year follow-up. METHODS: Outcomes for 23 morbidly obese (BMI 35, range 37 to 56) kidney transplant recipients transplanted between January 1995 and February 2000 were compared with 224 nonobese (BMI 25) kidney recipients transplanted during the same period. RESULTS: Patient and graft survivals were similar between both groups. Although 3-year graft survival for morbidly obese recipients of cadaver organs was 75% compared with 90% for the nonobese group, this finding was not statistically significant, and 3-year graft survival was 100% for morbidly obese recipients of living donor organs compared with 91% for nonobese recipients. Morbidly obese recipients had significantly longer hospital stays, higher readmission rates, and a higher wound infection rate than nonobese recipients. CONCLUSIONS: We found that morbidly obese persons have 3-year graft and patient survivals similar to nonobese persons. Although they also have greater complications and greater numbers of days in the hospital, we believe these reasons are not sufficient to deny morbidly obese persons the survival and quality-of-life advantages of kidney transplantation.     

Bronchogenic carcinoma after solid organ transplantation

BACKGROUND: This study assesses the risk of bronchogenic carcinoma after solid organ transplantation. Although the overall incidence of malignancy is increased after solid organ transplantation, the risk of bronchogenic carcinoma in the transplant population has not been systematically studied. METHODS: Among a cohort of 3,374 patients transplanted in our institution between 1985 and 2000 (1,735 kidney recipients, 930 liver, 313 heart, and 396 lung recipients), 9 patients (0.3%) had a bronchogenic carcinoma develop. Lung carcinoma occurred in 3 kidney recipients, 3 liver recipients, 2 heart recipients, and 1 lung recipient. RESULTS: Time to diagnosis after the transplant procedure ranged from 9 to 126 months (mean, 63 months). Aside from the lung transplant candidate, all recipients had a smoking history. Seven patients underwent thoracotomy and 6 had a complete resection. Tumors were classified as stage IA (n = 1), IB (n = 2), IIB (n = 2), IIIA (n = 2), IIIB (n = 1), and IV (n = 1). Genotyping demonstrated that the carcinoma arising in the lung transplant recipient originated from the donor and may have been transmitted at the time of transplantation. Two patients were alive without recurrence 21 and 42 months after the operation. CONCLUSIONS: The risk of bronchogenic carcinoma is low and occurs mainly in recipients with a smoking history. However, bronchogenic carcinoma can also be transmitted from donor lungs at the time of transplantation. Hence careful examination of chest roentgenograms, and computed tomographic chest scan if available, as well as meticulous assessment of the lung, and biopsy of any suspicious lesions, are important to limit the risk of lung cancer transmission, especially with the liberalization of donor criteria.     

Influenza Virus Infection in Adult Solid Organ Transplant Recipients

BACKGROUND: Solid organ transplant (SOT) recipients have been reported to be more susceptible to influenza virus. However, little is known about the clinical epidemiology and the implications of influenza viral infection among SOT recipients. METHODS: Cohort study of influenza viral infection in SOT recipients at the University of Pittsburgh Medical Center. RESULTS: Between November 1990 and April 2000, 30 cases of influenza were diagnosed in SOT recipients at our center, including influenza A (n = 22) and influenza B (n = 8). These included recipients of lung (n = 19), liver (n = 5) and kidney (n = 6) transplants. The incidence of influenza viral infection was 41.8 cases/1,000 person years (PYs), 2.8 cases/1000 PYs and 4.3 cases/ 1,000 PYs among lung, liver and renal transplant patients, respectively (p <0.0001). Symptoms were reported in all patients and included malaise, myalgia/ arthralgia, fever, cough, and shortness of breath. Secondary bacterial pneumonia occurred in five patients (17%). Other complications were seen in three SOT recipients (2 liver and 1 kidney) and included: myocarditis, myositis, and bronchiolitis obliterans. Biopsy of the transplanted organ was performed in 21 SOT recipients (18 lung, 1 liver and 2 kidney) at the time of influenza viral infection. Overall, 62% (13/21) showed variable degrees of acute allograft rejection, and included 61% (11/18) of lung, and 100% (2/2) of kidney transplant recipients. CONCLUSIONS: Influenza infection is associated with significant morbidity in different groups of SOT recipients. Studies are needed to determine if yearly chemoprophylaxis with antiviral drugs might benefit this patient population.     

Model for End-Stage Liver Disease (MELD) system to allocate and to share livers: experience of two Italian centers

BACKGROUND: The use of the Model for End-stage Liver Disease (MELD) score to prioritize patients on liver waiting lists and to share organs among centers was effective according to US data, but few reports are available in Europe. MATERIALS AND METHODS: We evaluated the outcome of 887 patients listed between April 2004 and July 2006 in a common list by two transplant centers (University of Bologna [BO] and University of Modena [MO] ordered according to the MELD system. Patients with hepatocellular carcinoma had a score calculated according to their real MELD, tumor stage, and waiting time. RESULTS: Five hundred eighty-six (67%) patients were listed from BO and 291 (33%) from MO. The clinical features of recipients (sex, age, blood group, and real MELD) were comparable between centers. The number of liver transplantations performed was 307, and 273 (89%) recipients had a calculated MELD >or=20. Liver transplantations were equally distributed according to the number of patients listed: 215 out of 586 (36.7%) for BO and 92 out of 291 (31.6%) for MO. The median real MELD of patients transplanted was 20, and 246 out of 307 (80.1%) grafts transplanted were functioning. The dropouts from the list were 124 (14%), and 87 (70%) of these patients had a calculated MELD >or=20. CONCLUSION: The MELD system was effective to share livers among the two Italian centers. According to this policy, livers were allocated to the recipients with the highest probability of dropout and who had a satisfactory survival after liver transplantation.     

Induction immunotherapy in pediatric heart transplant recipients: a multicenter study.

BACKGROUND: The efficacy and safety of induction immunotherapy with antithymocyte antibody preparations (IND) in pediatric heart transplantation is controversial. Experimentally, recipient age is an important determinant of immune responses. The effects on induction immunotherapy were determined by an analysis of outcomes of 465 pediatric (age <18 years) heart recipients that either did or did not receive IND in the first week post-transplant. METHODS: The outcomes of 2 groups who received either OKT3 (n = 101) or rabbit polyclonal antithymocyte serum (N/R-ATS, n = 105) were compared with 255 recipients who did not receive antithymocyte antibodies. The study population were all heart recipients enrolled in the Pediatric Heart Transplant Study Group (PHTS) between January 1993 and December 1995 and followed up to 36 months. RESULTS: Overall mortality and death due to rejection were lowest with N/R-ATS IND (8/105 and 1/105, respectively) compared with the no-induction group (58/255 and 8/ 255, respectively) or the OKT3 group (22/101 and 7/101, respectively) with significance of p = 0.001 and 0.06 respectively. Late mortality beyond 30 days after transplant was lowest with N/R-ATS IND compared with the OKT3 and no IND (p = 0.01). Induction did not affect cumulative infections, deaths due to infection, or the frequency of malignancies. Patients excluded from N/R-ATS induction had the highest mortality (18/ 43), suggesting that the protocol's exclusion criteria identified a high-risk group. To minimize potential effect(s) of exclusion bias, patients transplanted at centers participating in the N/R-ATS induction trial were reanalyzed with a post hoc intent-to-treat analysis assigning patients by center (IND or no IND) irrespective of actual treatment. With this analysis overall mortality was 18% for N/R-ATS centers, 21% for OKT3 centers, and 26% for centers not using IND (p = 0.3). The mortalities of recipients <6 months old at transplant were lowest at centers using N/R-ATS and OKT3 IND compared to centers not using IND (p = 0.04). Cumulative rejection (0.8 vs 1.2 rejection/pt/year, p = 0.01) and freedom from rejection death (99% vs. 93% at year 1, p = 0.02) of the N/R-ATS centers were lower compared to OKT3 centers but were not different from centers not using IND. CONCLUSION: Following orthotopic transplantation, induction immunotherapy can exert the enduring benefit of reducing late deaths, a possible surrogate for rejection severity, in recipients less than 6 months of age, while not being associated with higher rates of infectious or malignant complications. Since polyclonal anti-T cell antibody preparations appears superior to OKT3 induction in pediatric recipients, the efficacy of ATS induction should be further evaluated in a randomized prospective study in pediatric heart recipients.     

Vitamin D Status in Renal Transplant Recipients

Vitamin D plays an important role in calcium homeostasis. Renal transplant recipients may be more susceptible to reduced levels because of decreased sun exposure and steroid therapy. This study aimed to determine vitamin D status after renal transplantation and its effect on parathyroid hormone (PTH) and bone mineral density (BMD). We measured serum 25-hydroxyvitamin D levels (25-OHD) in 244 renal transplant recipients, divided into two groups, 104 recently transplanted (less than 1 year) and 140 long-term. Vitamin D status was defined according to NKF/KDOQI guidelines. Mean 25-OHD levels were 33 +/- 19 nmol/L and 42 +/- 20 nmol/L, respectively, for the recent and long-term transplant recipients. Vitamin D insufficiency was present in 29% and 43%, deficiency in 56% and 46% and severe deficiency in 12% and 5%, respectively. An inverse correlation was found between logPTH and 25-OHD (r=-0.2, p= 0.019) in long-term but not in recently transplanted patients. No correlation was found between 25-OHD levels and BMD. Hypercalcaemia was present in 40% of the recently transplanted recipients and 25% of the long-term. In conclusion 25-OHD was low in virtually all of our renal transplant recipients and may aggravate secondary hyperparathyroidism, but its correction may be difficult in patients with hypercalcaemia.     

Outcomes of liver transplantation for hepatitis B: a single-center study of 35 patients

BACKGROUND: Results of liver transplantation (LT) for hepatitis B (HBV) have improved in the past decade but recently drug resistance has been described, the clinical significance of which is unclear. The aims of this study were to evaluate outcomes of LT for HBV and describe the prevalence of drug resistance. METHODS: A retrospective chart analysis and review of the organ transplant database was performed to identify all patients transplanted for HBV between December 1982 and April 2004 who survived more than 3 months. RESULTS: Thirty-five patients were transplanted for HBV during this period: 27 men and 8 women. Median age at LT was 48.8 years (range 18.9 to 74.3). Four patients were transplanted for fulminant liver failure and 31 for decompensated cirrhosis. Intramuscular HBIG was administered to 8 patients and intravenous HBIG to 32 patients, data were unavailable for three patients. Lamivudine was prescribed for 18 patients (58%) pre-OLT and for 31 patients (88.6%) post-LT. Drug-resistant HBV developed in two patients (5.71%) receiving lamivudine and HBIG. Adefovir substitution resulted in improvement in liver function tests, in HBV DNA and in histology in both patients. Twenty-five patients are currently alive with and 1-year survival of 95% and a 5-year survival of 75%. Causes of death were respiratory failure (n = 3), metastatic cancer of unknown primary (n = 2), renal failure (n = 2), sepsis (n = 1), cerebrovascular accident (n = 1), and cerebral edema (n = 1). CONCLUSIONS: LT for HBV shows survival rates comparable to other liver transplant recipients. Lamivudine resistance was rare in this series but responded to adefovir substitution.     

Pediatric Organ Transplantation and Risk of Premalignant and Malignant Tumors in Sweden

Increased cancer risks are well documented in adult organ transplant recipients. However, the spectrum of malignancies and risk in the pediatric organ transplant population are less well described. We identified all solid organ transplanted patients aged <18 in Sweden between 1970–2007 (n = 536) in the National Patient Register and linked to the Cancer Register. Nationwide rates were used to calculate standardized incidence rate ratios and 95% CI estimating the association between transplant and cancer during maximum 36 years of follow‐up. Nearly 7% of pediatric solid organ transplant recipients developed a premalignant or malignant tumor during follow‐up. Transplantation was associated with an increased risk of any cancer (n = 24, SIR = 12.5, 95% CI: 8.0–18.6): non‐Hodgkin lymphoma (NHL) (n = 13, SIR = 127, 95% CI: 68–217), renal cell (n = 3, SIR = 105, 95% CI: 22–307), vulva/vagina (n = 3, SIR = 665, 95% CI: 137–1934) and nonmelanoma skin cancers (n = 2, SIR = 64.7, 95% CI: 7.8–233.8). NHL typically appeared during childhood, while other tumors were diagnosed during adulthood. Apart from short‐term attention toward the potential occurrence of NHL, our results suggest cancer surveillance into adulthood with special attention to skin, kidneys and the female genitalia.     

Death after rejection with severe hemodynamic compromise in pediatric heart transplant recipients: a multi-institutional study.

BACKGROUND: Rejection with severe hemodynamic compromise results in high mortality in adult transplant patients. This study determines the incidence, outcome and risk factors for rejection with severe hemodynamic compromise in a multi-institutional study of pediatric heart transplant recipients. METHODS: Data from 847 patients transplanted between 1/1/93 and 12/31/98 at 18 centers in the Pediatric Heart Transplant Study were analyzed. Rejection with severe hemodynamic compromise was defined as a clinical event occurring beyond 1 week postoperatively, which led to augmentation of immunosuppression and use of inotropic therapy. Actuarial freedom from such rejection and death after rejection were determined and risk factors sought. RESULTS: Among 1,033 rejection episodes in 532 patients, 113 (11%) episodes were associated with severe hemodynamic compromise in 95 patients. The highest risk for severe rejection was in the first year. Risk factors were older recipient age (p >.05) and non-white race (p >.001). Survival after an episode was poor (60%), and biopsy score did not affect outcome. Deaths were due to rejection (n = 14), other cardiac causes (n = 17), infection (n = 5), lymphoma (n = 2), pulmonary causes (n = 2), and thrombosis (n = 1). CONCLUSIONS: Rejection with severe hemodynamic compromise occurs in 11% of pediatric patients, irrespective of age, sex or biopsy score, and mortality is high. Non-white race and older recipient age are independent risk factors for rejection with severe hemodynamic compromise. Aggressive treatment and close surveillance should be crucial components of protocols aimed at reducing the high mortality.     

Effect of donor-specific transfusions on the outcome of renal allografts in the cyclosporine era

Despite the introduction of new immunosuppressive agents, a steady decline of functioning renal allografts after living donation is observed. Thus nonpharmacological strategies to prevent graft loss have to be reconsidered, including donor-specific transfusions (DST). We introduced a cyclosporine-based DST protocol for renal allograft recipients from living-related/unrelated donation. From 1993 to 2003, 200 ml of whole blood, or the respective mononuclear cells from the potential living donor were administered twice to all of our 61 recipient candidates. The transplanted subjects were compared with three groups of patients without DST from the Collaborative Transplant Study (Heidelberg, Germany) during a 6-year period. Six patients were sensitized without delay for a subsequent cadaveric kidney. DST patients had less often treatment for rejection and graft survival was superior compared with subjects from the other Swiss transplant centers (n = 513) or from Western Europe (n = 7024). To diminish the probability that superior results reflect patient selection rather than effects of DST, a 'matched-pair' analysis controlling for relevant factors of transplant outcome was performed. Again, this analysis indicated that recipients with DST had better outcome. Thus, our observation suggests that DST improve the outcome of living kidney transplants even when modern immunosuppressive drugs are prescribed.     

Ethical Issues of Organ Transplantation in Chinese Community: Perspectives of Health Professionals, Legal Professionals, and Religious Experts in Taiwan and Mainland China

Objective

This study aimed to compare the perspectives of leading ethical issues related to organ transplantation as perceived by health professionals (HP), legal professionals (LP), and religious experts (RE) from Taiwan (TW) and Mainland China (MC).

Materials and Methods

A purposive sample including TW's organ transplant health professionals (OTHP), LP, and RE and MC's HP was obtained in this qualitative research. Data were analyzed by content analysis.

Results

A total of 127 subjects participated in this project (n = 119 in TW, 8 in MC). They were HP (n = 92), RE (n = 25 TW), and LP (n = 10 TW). Seven ethical dilemmas were reported: (1) difficulties in touching the hearts of the public (HP 100%, LP 100%, RE 100%); (2) challenges in helping donors and their families (HP 96%, RE 80%, LP 50%); (3) competence and availability of HP (HP 93%, RE 72%, LP 50%); (4) questionable social farewell (HP 92%, RE 20%, LP 100%); (5) questionable legitimacy of prisoners' motivations (LP 90%, RE 64%, HP 60%); (6) worry about public discrimination (LP 90%, HP 50%, RE 20%); and (7) challenges to families in taking care of the recipients (HP 87%, LP 70%, RE 52%).

Conclusions

To provide holistic care, HP need to invite RE to provide spiritual support for the donors of cadaveric organs, recipients, and their families. Reliable LP can help them to complete the sophisticated legal procedures. With help from this triangulated collaborative team, the value of organ transplantation will be appreciated by the public.