2019年 夏季 期刊文獻精選
2019-05-08 14:57
Peripheral Blood versus Bone Marrow from Unrelated Donors: Bone Marrow Allografts Have Improved Long-Term Overall and Graft-versus-Host Disease-Free, Relapse-Free Survival.
Amin Alousi, Tao Wang, Michael T. Hemmer, Stephen R. Spellman, Mukta Arora, Daniel R. Couriel, Joseph Pidala, Paolo Anderlini, Michael Boyiadzis, Christopher N. Bredeson, Jean-Yves Cahn, Mitchell S. Cairo, Shahinaz M. Gadalla, Shahrukh K. Hashmi, Robert Peter Gale, Junya Kanda, Rammurti T. Kamble, Mohamed A. Kharfan-Dabaja, Mark R. Litzow, Olle Ringden, Ayman A. Saad, Kirk R. Schultz, Leo F. Verdonck, Edmund K. Waller, Jean A. Yared, Shernan G. Holtan 及 Daniel J. Weisdorf
Biology of Blood and Marrow Transplantation, 2019-02-01, 卷 25, 期 2, 頁面 270-278, Copyright © 2018 Elsevier Ltd
Abstract
Peripheral blood (PB) and bone marrow (BM) from unrelated donors can serve as a graft source for hematopoietic cell transplantation (HCT). Currently, PB is most commonly used in roughly 80% of adult recipients. Determining the long-term impact of graft source on outcomes would inform this decision. Data collected by the Center for International Blood and Marrow Transplant Research from 5200 adult recipients of a first HCT from an 8/8 or 7/8 HLA antigen-matched unrelated donor for treatment of acute leukemia, chronic myelogenous leukemia, or myelodysplastic syndrome between 2001 and 2011 were analyzed to determine the impact of graft source on graft-versus-host disease (GVHD) relapse-free survival (GRFS), defined as freedom from grade III/IV acute GVHD, chronic GVHD requiring immunosuppressive therapy, relapse, and death, and overall survival. GRFS at 2 years was superior in BM recipients compared with PB recipients (16%; 95% confidence interval [CI], 14% to 18% versus 10%; 95% CI, 8% to 11%; P <.0001) in the 8/8 HLA-matched cohort and 7/8 HLA-matched cohort (11%; 95% CI, 8% to 14% versus 5%; 95% CI, 4% to 7%; P = .001). With 8/8 HLA-matched unrelated donors, overall survival at 5 years was superior in recipients of BM (43%; 95% CI, 40% to 46% versus 38%; 95% CI, 36% to 40%; P = .014). The inferior 5-year survival in the PB cohort was attributable to a higher frequency of deaths while in remission compared with the BM cohort. For recipients of 7/8 HLA-matched grafts, survival at 5 years was similar in BM recipients and PB recipients (32% versus 29%; P = .329). BM grafts are associated with improved long-term GRFS and overall survival in recipients of matched unrelated donor HCT and should be considered the unrelated allograft of choice, when available, for adults with acute leukemia, chronic myelogenous leukemia, and myelodysplastic syndrome.
Validation of the International Society for Heart and Lung Transplantation primary graft dysfunction instrument in heart transplantation.
Farid Foroutan HBSc, PhD(c), Ana Carolina Alba MD, PhD, Madeleine Stein BSc, John Krakovsky MD(c), Kevin Gar Wai Chien BSc, Sharon Chih MD, PhD, Gordon Guyatt MD, MSc 及 Heather Ross MD, MHSc
Journal of Heart and Lung Transplantation, 2019-03-01, 卷 38, 期 3, 頁面 260-266, Copyright © 2019 Elsevier Ltd
Abstract
Background
In 2014, the International Society for Heart and Lung Transplantation (ISHLT) developed a classification instrument for left ventricular (LV) and isolated right ventricular (RV) primary graft dysfunction post‒heart transplant. The instrument classifies LV-PGD as mild, moderate, or severe. In this study, we evaluated the predictive validity of this instrument.
Methods
We conducted a cohort study of 412 consecutive patients transplanted between 2004 and 2015 at the Toronto General Hospital and Ottawa Heart Institute (Canada). We classified LV-PGD as mild, moderate, or severe, using the ISHLT instrument. To assess predictive validity, we evaluated the association between LV-PGD severity and 1-year post-transplant mortality using a Cox regression model adjusted for recipient age.
Results
The cohort was predominantly male (71%), mean age 50 ± 13 years, mean donor age 38 ± 14 years, with 25% female donors. Mean ischemic time was 3.7 ± 1.1 hours. LV-PGD was mild in 3.6% of patients, moderate in 9.5%, and severe in 3.9%. All levels of LV-PGD were associated with increased 1-year mortality, with a gradient in the association between mild, moderate, and severe. We only observed a statistically significant association for moderate and severe forms of LV-PGD (mild: hazard ratio [HR] 2.4, 95% confidence interval [CI] 0.6 to 10.2; moderate: HR 7.0, 95% CI 3.4 to 14.6; severe: HR 15.9, 95% CI 7.2 to 35.0).
Conclusions
The ISHLT LV-PGD classification convincingly identifies a substantial increase in the risk of death at 1 year, and an increased gradient of risk, in those with moderate or severe LV-PGD.
Bronchiolitis obliterans syndrome–free survival after lung transplantation: An International Society for Heart and Lung Transplantation Thoracic Transplant Registry analysis.
Hrishikesh S. Kulkarni MD, MSCI, Wida S. Cherikh PhD, Daniel C. Chambers MD, MRCP, Victoria C. Garcia MPH, Ramsey R. Hachem MD, Daniel Kreisel MD, PhD, Varun Puri MD, MSCI, Benjamin D. Kozower MD, MPH, Derek E. Byers MD, PhD, Chad A. Witt MD, Jennifer Alexander-Brett MD, PhD, Patrick R. Aguilar MD, Laneshia K. Tague MD, MSCI, Yuka Furuya MD, G. Alec Patterson MD, Elbert P. Trulock MD 及 Roger D. Yusen MD, MPH
Journal of Heart and Lung Transplantation, 2019-01-01, 卷 38, 期 1, 頁面 5-16, Copyright © 2018 Elsevier Ltd
Abstract
Background
Lung transplant (LTx) recipients have low long-term survival and a high incidence of bronchiolitis obliterans syndrome (BOS). However, few long-term, multicenter, and precise estimates of BOS-free survival (a composite outcome of death or BOS) incidence exist.
Methods
This retrospective cohort study of primary LTx recipients (1994–2011) reported to the International Society of Heart and Lung Transplantation Thoracic Transplant Registry assessed outcomes through 2012. For the composite primary outcome of BOS-free survival, we used Kaplan-Meier survival and Cox proportional hazards regression, censoring for loss to follow-up, end of study, and re-LTx. Although standard Thoracic Transplant Registry analyses censor at the last consecutive annual complete BOS status report, our analyses allowed for partially missing BOS data.
Results
Due to BOS reporting standards, 99.1% of the cohort received LTx in North America. During 79,896 person-years of follow-up, single LTx (6,599 of 15,268 [43%]) and bilateral LTx (8,699 of 15,268 [57%]) recipients had a median BOS-free survival of 3.16 years (95% confidence interval [CI], 2.99–3.30 years) and 3.58 years (95% CI, 3.53–3.72 years), respectively. Almost 90% of the single and bilateral LTx recipients developed the composite outcome within 10 years of transplantation. Standard Registry analyses “overestimated” median BOS-free survival by 0.42 years and “underestimated” the median survival after BOS by about a half-year for both single and bilateral LTx ( p < 0.05).
Conclusion
Most LTx recipients die or develop BOS within 4 years, and very few remain alive and free from BOS at 10 years post-LTx. Less inclusive Thoracic Transplant Registry analytic methods tend to overestimate BOS-free survival. The Registry would benefit from improved international reporting of BOS and other chronic lung allograft dysfunction (CLAD) events.
Donation After Cardiac Death in Liver Transplantation: An Additional Source of Organs With Similar Results to Donation After Brain Death.
M. Pitarch Martínez, B. Sánchez Pérez, F.J. León Díaz, J.L. Fernández Aguilar, J.A. Pérez Daga, M.C. Montiel Casado, J.M. Aranda Narváez, M.Á. Suárez Muñoz 及 J. Santoyo Santoyo
Transplantation Proceedings, 2019-01-01, 卷 51, 期 1, 頁面 4-8, Copyright © 2018 Elsevier Inc.
Abstract
Background
As new sources of organs are needed, liver transplantation using donors after cardiac death (DCD) is progressively increasing, but outcomes with this method are still questioned. This study was accomplished to verify that DCD outcomes are comparable to those seen in donation after brain death (DBD).
Methods
This was a prospective cohort study including 100 liver transplantation performed between 2014 and 2017, divided according to donor type in 75 DBD and 25 DCD.
Results
DCD donors were younger (mean age: DCD 56 years, DBD 59 years; P = .009). Mean Modified End-stage Liver Disease (MELD) score was lower for DCD (DCD 16, DBD 19; P < .001). No differences were found regarding ischemia times and development of postreperfusion syndrome or coagulopathy. Primary graft dysfunction was more frequent in DCD (60%, DCD 29.3%; P = .006). Rates of primary graft nonfunction (DCD 0%, DBD 1.3%; P = .562) and acute rejection (DCD 20%, DBD 16.4%; P = .685) were similar. Acute kidney injury occurred more often in DBD (DCD 32%, DBD 12%; P = .051). Length of stay was comparable. Rates of biliary complications (DCD 20%, DBD 26.7%; P = .505) were similar, unlike ischemic cholangiopathy (DCD 12%, DBD 1.3%; P = .018). Retransplantation rates were also similar (DCD 8%, DBD 4%; P = .427) as was survival rate after 3 years (DCD 84%, DBD 86.7%; P = .739).
Conclusion
DCD represents an additional graft source with results that are encouraging and may be comparable to DBD with a careful donor and recipient selection.
Fungal infections in solid organ transplantation: An update on diagnosis and treatment.
Vincent Kabir, Johan Maertens 及 Dirk Kuypers
Transplantation Reviews, 2019-04-01, 卷 33, 期 2, 頁面 77-86, Copyright © 2018 Elsevier Inc.
Abstract
Invasive fungal infections constitute an important cause of morbidity and mortality in solid organ transplantation recipients. Since solid organ transplantation is an effective therapy for many patients with end-stage organ failure, prevention and treatment of fungal infections are of vital importance. Diagnosis and management of these infections, however, remain difficult due to the variety of clinical symptoms in addition to the lack of accurate diagnostic methods. The use of fungal biomarkers can lead to an increased diagnostic accuracy, resulting in improved clinical outcomes. The evidence for optimal prophylactic approaches remains inconclusive, which results in considerable variation in the administration of prophylaxis. The implementation of a standard protocol for prophylaxis remains difficult as previous treatment regimens, which can alter the distribution of different pathogens, affect the outcome of antifungal susceptibility testing. Furthermore, the increasing use of antifungals also contributes to incremental costs and the risk of development of drug resistance. This review will highlight risk factors, clinical manifestations and timing of fungal infections and will focus predominately on the current evidence for diagnosis and management of fungal infections.
The clinical impact of donor-specific antibodies in heart transplantation.
Markus J. Barten, Uwe Schulz, Andres Beiras-Fernandez, Michael Berchtold-Herz, Udo Boeken, Jens Garbade, Stephan Hirt, Manfred Richter, Arjang Ruhpawar, Tim Sandhaus, Jan Dieter Schmitto, Felix Schönrath, Rene Schramm, Martin Schweiger, Markus Wilhelm 及 Andreas Zuckermann
Transplantation Reviews, 2018-10-01, 卷 32, 期 4, 頁面 207-217, Copyright © 2018 Elsevier Inc.
Abstract
Donor-specific antibodies (DSA) are integral to the development of antibody-mediated rejection (AMR). Chronic AMR is associated with high mortality and an increased risk for cardiac allograft vasculopathy (CAV). Anti-donor HLA antibodies are present in 3–11% of patients at the time of heart transplantation (HTx), with de novo DSA (predominantly anti-HLA class II) developing post-transplant in 10–30% of patients. DSA are associated with lower graft and patient survival after HTx, with one study suggesting a three-fold increase in mortality in patients who develop de novo DSA (dnDSA). DSA against anti-HLA class II, notably DQ, are at particularly high risk for graft loss. Although detection of DSA is not a criterion for pathologic diagnosis of AMR, circulating DSA are found in almost all cases of AMR. MFI thresholds of ~5000 for DSA against class I antibodies, 2000 against class II antibodies, or an overall cut-off of 5−6000 for any DSA, have been suggested as being predictive for AMR. There is no firm consensus on pre-transplant strategies to treat HLA antibodies, or for the elimination of antibodies after diagnosis of AMR. Minimizing the risk of dnDSA is rational but data on risk factors in HTx are limited. The effect of different immunosuppressive regimens is largely unexplored in HTx, but studies in kidney transplantation emphasize the importance of adherence and maintaining adequate immunosuppression. One study has suggested a reduced risk for dnDSA with rabbit antithymocyte globulin induction. Management of DSA pre- and post-HTx varies but typically most centers rely on a plasmapheresis or immunoadsorption, with or without rituximab and/or intravenous immunoglobulin. Based on the literature and a multi-center survey, an algorithm for a suggested surveillance and therapeutic strategy is provided.
The immunology of organ transplantation.
Benedict L. Phillips 及 Chris Callaghan
Surgery, 2017-07-01, 卷 35, 期 7, 頁面 333-340, Copyright © 2017 Elsevier Ltd
Abstract
Transplantation is the gold standard treatment for many patients with end-stage organ failure. In addition to the medical and surgical challenges in organ transplantation, the major biological barrier is immunological. This barrier may lead to graft rejection and loss. An understanding of transplant immunology is essential in order to care for transplant recipients. The aims of this article are to describe commonly used immunological terms, the immunology of graft rejection the different types of rejection, and how this process may be prevented with immunosuppressive therapy. Finally, the article will review the practical translations of transplant immunology. This article aims to afford the reader an overall view of basic transplant immunology that will be of use in the clinical setting or in preparation for examinations.
The surgical challenges of salvage living donor liver transplantation for Hepatocellular carcinoma; The cumulative experience of 100 cases - A retrospective cohort study and a propensity score analysis.
Chee-Chien Yong, Ahmed M. Elsarawy, Shih-Ho Wang, Tsan-Shiun Lin, Chih-Chi Wang, Wei-Feng Li, Ting-Lung Lin, Fang-Ying Kuo, Yu-Fan Cheng, Chao-Long Chen 及 Chih-Che Lin
International Journal of Surgery, 2018-06-01, 卷 54, 頁面 187-192, Copyright © 2018 IJS Publishing Group Ltd
Abstract
Background
Hepatocellular carcinoma (HCC) is increasingly managed by liver resection first then salvage liver transplantation in case of recurrence within accepted criteria. Many reports compared the safety of the salvage against the primary surgery in the setting of deceased donation but the difference in case of living donation is not sufficiently defined. Salvage living donor liver transplantation (SLDLT) is believed to be a more challenging surgery than primary living donor liver transplantation (PLDLT) due to operative field adhesions, in addition to the inherent difficulties particularly short vasculobiliary stumps. In this report, we compared both pathways from a surgical perspective in a homogenous LDLT-only cohort.
Materials and methods
Over 15 years, 448 LDLTs for HCC were performed in a single liver transplant institution in Taiwan, including PLDLT (n = 348) and SLDLT (n = 100). A retrospective comparative review of the surgical outcomes of both pathways using a propensity score matching model (1–1, 100 pairs) was performed with adjustment for age, Child score and MELD score. The surgical outcome and survival were compared across 2 time eras.
Results
The operative data showed that SLDLT surgery encountered more extensive adhesions (57% vs. 0%, p < 0.001), longer operative duration (650 vs. 618 min, p = 0.04 ), and was followed by more incidence of re-exploration (16% vs. 5%, p = 0.01 ), than the PLDLT surgery. There was no significant difference regarding the incidence of in-hospital mortality, vascular and biliary complications, or overall survival (OS). The 1-year OS of SLDLT was inferior to PLDLT in the first 50 cases (90% vs. 98%, p = 0.03 ), then the same OS was found in the 2nd 50 cases (96% vs. 96%, p = 0.9 ).
Conclusions
The SLDLT surgery is a demanding lengthy procedure with extensive adhesions and possibility of frequent re-explorations. Significant case load and high centre volume are important factors for safe practice of SLDLT and better cumulative OS.
Kidney Transplantation With and Without Native Nephrectomy for Polycystic Kidney Disease: Results of the National Inpatient Sample and the Rationale for a 2-Staged Procedure.
Raymond A. Jean MD, MA, Mehida Alexandre BA 及 Peter S. Yoo MD, FACS
Journal of the American College of Surgeons, 2018-06-01, 卷 226, 期 6, 頁面 1079-1084, Copyright © 2017 American College of Surgeons
Abstract
Background
Polycystic kidney disease (PKD) is one of the most common causes of end-stage renal disease requiring hemodialysis or transplantation. In patients requiring transplantation, there are several indications for native nephrectomy, including recurrent cyst infection, bleeding, or to provide room for the graft. There is disagreement about whether it is advisable to perform kidney transplantation alone (KT), or to perform KT with simultaneous native nephrectomy (KTN). We compared postoperative outcomes of KTN and KT in a large national cohort.
Study Design
The Nationwide Inpatient Sample (NIS) between 2000 and 2014 was examined for a diagnosis of PKD with evidence for KT or KTN. Logistic regression, adjusting for age, sex, comorbidity, and hospital region, was used to compare groups for the need for blood transfusion, need for critical care interventions, and development of postoperative complications.
Results
A total of 4,003 hospitalizations were identified, which was representative of 19,302 weighted discharges nationally. In adjusted logistic regression models, KTN demonstrated significantly higher risk for blood transfusion (odds ratio [OR] 2.06; 95% CI 1.44 to 2.96; p < 0.0001), postoperative complications (OR 1.44; 95% CI 1.05 to 1.96; p = 0.02), and critical care interventions (OR 1.44; 95% CI 1.07 to 1.95; p = 0.02). Other significant predictors for blood transfusion included female sex (OR 1.76; 95% CI 1.45 to 2.13; p < 0.0001), age older than 61 years (OR 1.60; 95% CI 1.21 to 2.10; p = 0.001), and Charlson comorbidity score ≥2 (OR 1.52; 95% CI 1.10 to 2.09; p = 0.01).
Conclusion
Among patients with PKD, in comparison with KTN, KT alone represents a decreased risk for negative postoperative outcomes. A 2-staged procedure should be considered, when feasible, to minimize adverse patient outcomes.
Single Versus Bilateral Lung Transplantation for Idiopathic Pulmonary Fibrosis in the Lung Allocation Score Era.
John R. Spratt MD, MA, Rade Tomic MD, Roland Z. Brown BS, Kyle Rudser PhD, Gabriel Loor MD, Marshall Hertz MD, Sara Shumway MD 及 Rosemary F. Kelly MD
Journal of Surgical Research, 2019-02-01, 卷 234, 頁面 84-95, Copyright © 2018 Elsevier Inc.
Abstract
Background
Idiopathic pulmonary fibrosis (IPF) is a progressive and fatal disease. Lung transplantation is the only therapy associated with prolonged survival. The ideal transplant procedure for IPF is unclear. Outcomes after single transplantation (SLTx) versus bilateral lung transplantation (BLTx) in IPF patients after introduction of the Lung Allocation Score were examined.
Methods
Records of patients undergoing lung transplantation for IPF at our institution between May 2005 and March 2017 were reviewed to examine the effect of transplant laterality. Primary outcomes were overall, rejection-free, and bronchiolitis obliterans (BOS)-free survival at 1 and 5 years post-transplant.
Results
Lung transplantation was performed in 151 IPF patients post-Lung Allocation Score. Most recipients were male with average age 59 ± 8 years. SLTx was performed in 94 patients (62%). In the overall cohort, comparative survival between SLTx and BLTx was similar at 1 and 5 years before and after adjusting for age and pulmonary hypertension (PH). SLTx was associated with shorter ventilator time and intensive care unit stay and trended toward improved survival over BLTx in patients without PH.
Conclusions
The use of SLTx versus BLTx in IPF did not correspond to significantly different survival adjusting for age and PH. BLTx was associated with prolonged postoperative ventilation and length of stay compared with SLTx. Patients without PH, all older patients, and patients with PH and advanced disease should be considered for SLTx for IPF.
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