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Background: We examined the combined effects of donor age and graft type on pediatric liver transplantation outcomes with an aim to offer insights into the strategic utilization of these donor and graft options. Methods: A retrospective analysis was conducted using a national database on 0–2‐year‐old (N = 2714) and 3–17‐year‐old (N = 2263) pediatric recipients. These recipients were categorized based on donor age (≥40 vs <40 years) and graft type. Survival outcomes were analyzed using the Kaplan–Meier and Cox proportional hazards models, followed by an intention‐to‐treat (ITT) analysis to examine overall patient survival. Results: Living and younger donors generally resulted in better outcomes compared to deceased and older donors, respectively. This difference was more significant among younger recipients (0–2 years compared to 3–17 years). Despite this finding, ITT survival analysis showed that donor age and graft type did not impact survival with the exception of 0–2‐year‐old recipients who had an improved survival with a younger living donor graft. Conclusions: Timely transplantation has the largest impact on survival in pediatric recipients. Improving waitlist mortality requires uniform surgical expertise at many transplant centers to provide technical variant graft (TVG) options and shed the conservative mindset of seeking only the "best" graft for pediatric recipients. [ABSTRACT FROM AUTHOR]

Heart transplantation has become the standard of care for pediatric patients with end‐stage heart disease throughout the world. Since the first transplant was performed in 1967, the number of transplants has grown dramatically with 13 449 pediatric heart transplants being reported to The International Society of Heart and Lung Transplant (ISHLT) between January 1992 and June 30, 2018. Outcomes have consistently improved over the last few decades, specifically short‐term outcomes. Most recent survival data demonstrate that recipients who survive to 1‐year post‐transplant have excellent long‐term survival with more than 60% of those who were transplanted as infants being alive 25 years later. Nonetheless, the rates of graft loss beyond the first year have remained relatively constant over time; driven primarily by our poor understanding and lack of treatments for chronic allograft vasculopathy (CAV). Acute rejection, CAV, graft failure, and infection continue to be the major causes of death within the first 5 years post‐transplant. In addition, renal dysfunction, malignancy, and the need for re‐transplantation remain as significant issues that require close follow‐up. Looking forward, key challenges include improving donor utilization rates (including donation after cardiac death (DCD) and the use of ex vivo perfusion devices), the development of non‐invasive biomarkers for rejection, efforts to mitigate the long‐term effects of immunosuppression, and prevention of CAV. It is not possible to cover the entire evolution of pediatric heart transplantation over the last five decades, but in this review, we hope to touch on key observations, lessons learned, and practice changes that have advanced the field, as well as glance ahead to the next decade. [ABSTRACT FROM AUTHOR]

Background & Aims: Patients with acute liver failure (ALF) awaiting liver transplantation (LT) may develop multiorgan failure, but organ failure does not impact waitlist prioritization. The aim of this study was to examine the impact of organ failure on waitlist mortality risk and post LT outcomes in patients with ALF. Methods: We studied adults waitlisted for ALF in the United Network for Organ Sharing (UNOS) database (2002–2019). Organ failures were defined using a previously described Chronic Liver Failure modified sequential organ failure score assessment adapted to UNOS data. Regression analyses of the primary endpoints, 30‐day waitlist mortality (Competing risk), and post‐LT mortality (Cox‐proportional hazards), were performed. Latent class analysis (LCA) was used to determine the organ failures most closely associated with 30‐day waitlist mortality. Results: About 3212 adults with ALF were waitlisted, for hepatotoxicity (41%), viral (12%) and unspecified (36%) etiologies. The median number of organ failures was three (interquartile range 1–3). Having ≥3 organ failures (vs. ≤2) was associated with a sub hazard ratio (HR) of 2.7 (95%CI 2.2–3.4)) and a HR of 1.5 (95%CI 1.1–2.5)) for waitlist and post‐LT mortality, respectively. LCA identified neurologic and respiratory failure as most impactful on 30‐day waitlist mortality. The odds ratios for both organ failures (vs. neither) were higher for mortality 4.5 (95% CI 3.4–5.9) and lower for delisting for spontaneous survival.5 (95%CI.4–.7) and LT.6 (95%CI.5–.7). Conclusion: Cumulative organ failure, especially neurologic and respiratory failure, significantly impacts waitlist and post‐LT mortality in patients with ALF and may inform risk‐prioritized allocation of organs. [ABSTRACT FROM AUTHOR]

Background: Donation after circulatory death (DCD) liver transplantation (LT) has become an effective mechanism for expanding the donor pool and decreasing waitlist mortality. However, it is unclear if low‐volume DCD centers can achieve comparable outcomes to high‐volume centers. Methods: From 2011 to 2019 utilizing the United Network for Organ Sharing (UNOS) database, liver transplant centers were categorized into tertiles based on their annual volume of DCD LTs. Donor selection, recipient selection, and survival outcomes were compared between very‐low volume (VLV, n = 1–2 DCD LTs per year), low‐volume (LV, n = 3–5), and high‐volume (HV, n > 5) centers. Results: One hundred and ten centers performed 3273 DCD LTs. VLV‐centers performed 339 (10.4%), LV‐centers performed 627 (19.2%), and HV‐centers performed 2307 (70.4%) LTs. 30‐day, 90‐day, and 1‐year patient and graft survival were significantly increased at HV‐centers (all P <.05). Recipients at HV‐centers had shorter waitlist durations (P <.01) and shorter hospital lengths of stay (P <.01). On multivariable regression, undergoing DCD LT at a VLV‐center or LV‐center was associated with increased 1‐year patient mortality (VLV‐OR:1.73, 1.12–2.69) (LV‐OR: 1.42, 1.01–2.00) and 1‐year graft failure (VLV‐OR: 1.79, 1.24–2.58) (LV‐OR: 1.28,.95–1.72). Discussion: Increased annual DCD liver transplant volume is associated with improved patient and graft survival. [ABSTRACT FROM AUTHOR]

Background: Data are sparse on etiology specific outcomes on waitlist (WL) and post‐transplant outcomes among patients with acute on chronic liver failure (ACLF). Methods and results: In a retrospective cohort of 14,774 adults from United network for organ sharing (UNOS) database listed for Liver transplantation (LT) with cirrhosis and ACLF (January 2013–June 2019), 40% were due to alcohol‐associated liver disease (ALD), followed by hepatitis C virus (HCV) at 20%, non‐alcoholic steatohepatitis (19%), cryptogenic cirrhosis (7%), autoimmune hepatitis (5%), primary sclerosing cholangitis (PSC) at 3%, and 2% each for hepatitis B, primary biliary cholangitis (PBC), and metabolic etiology. Using competing risk analysis, cumulative risk of WL mortality was highest for PBC at 20.5% and lowest for PSC at 13.3%, P <.001. Compared with ALD as reference, WL mortality was higher for PBC (1.45 [1.16–1.82]), and similar for other etiologies, P <.001. Of this cohort, 9650 (65.3%) patients received LT, with 1‐year. patient survival of 91.6% for PBC, worst for cryptogenic cirrhosis (89.5%) and best for PSC and ALD (93.4%), P <.001. Conclusion: Among listed candidates with ACLF, those with PBC have highest WL mortality 1‐year. post‐transplant survival was excellent among recipients for PBC. If these findings are validated in prospective studies, liver disease etiology should be considered for LT selection among patients in ACLF. [ABSTRACT FROM AUTHOR]

Sarcopenia is common in cirrhotic adults and associated with waitlist mortality and worse outcome after liver transplantation. Psoas muscle mass has been used to define sarcopenia. Therefore, we aimed to determine the association between psoas muscle mass and waitlist mortality as well as post‐transplant outcome in children with end‐stage liver disease. Medical records and abdominal imaging of pediatric liver transplant candidates during 2010–2019 were reviewed. A subset of images was measured by two radiologists to determine inter‐rater reliability. Psoas muscle surface area was determined at intervertebral lumbar disk 3–4 (L3‐4) and 4–5 (L4‐5) levels. PMI was calculated by psoas muscle surface area divided by height squared. We included 105 children, most with biliary atresia (84%). Patients with waitlist mortality had lower PMI compared to the ones who survived to transplantation (PMI at L3‐4 levels 352.8 ± 162.5 vs. 416.8 ± 136.2 mm2/m2 and at L4‐5 levels 497.3 ± 167.8 vs. 571.4 ± 163.4 mm2/m2, both p =.04), but not in the multivariate analyses. For transplanted patients (n = 75), a higher rate of re‐operation (39% vs. 15%, p =.03) and longer hospital stay (53 vs. 45 days, p =.02) were found in patients with lower PMI. Lower PMI is associated with higher re‐operation rate and longer hospital stay following transplantation, but not waitlist mortality. PMI may be taken into consideration with other biomarkers to predict post‐transplant complications. [ABSTRACT FROM AUTHOR]

Canadian lung transplant centers currently use a subjective and dichotomous "Status" ranking to prioritize waitlisted patients for lung transplantation. The lung allocation score (LAS) is an objective composite score derived from clinical parameters associated with both waitlist and post‐transplant survival. We performed a retrospective cohort study to determine whether clinical judgment (Status) or LAS better predicted waitlist mortality. All adult patients listed for lung transplantation between 2007 and 2012 at three Canadian lung transplant programs were included. Status and LAS were compared in their ability to predict waitlist mortality using Cox proportional hazards models and C‐statistics. Status and LAS were available for 1122 patients. Status 2 patients had a higher LAS compared to Status 1 patients (mean 40.8 (4.4) vs 34.6 (12.5), P =.0001). Higher LAS was associated with higher risk of waitlist mortality (HR 1.06 per unit LAS, 95% CI 1.05, 1.07, P <.001). LAS predicted waitlist mortality better than Status (C‐statistic 0.689 vs 0.674). Patients classified as Status 2 and LAS ≥ 37 had the worst survival awaiting transplant, HR of 8.94 (95% CI 5.97, 13.37). LAS predicted waitlist mortality better than Status; however, the best predictor of waitlist mortality may be a combination of both LAS and clinical judgment. [ABSTRACT FROM AUTHOR]

Aim: To clarify the risk–benefit point of the Model for End‐stage Liver Disease (MELD) score in patients waiting for deceased‐donor liver transplantation (DDLT). Methods: The present study retrospectively investigated 213 patients registered on the waiting list at Kyoto University (Kyoto, Japan) between 2005 and 2016. Patients were stratified by MELD score (6–9/10–14/15–20/21–30/31–40) and classified into two groups: the DDLT group (30 patients) and the waiting group (183 patients). Their post‐registration mortality risk and long‐term survival were compared. Results: For all MELD categories, the mortality risk was lower in the DDLT group than in the waiting group. The hazard ratio of post‐registration mortality decreased in the DDLT group compared to the waiting group as the MELD score increased (0.36/0.12/0.06/0.042/0.004). Survival was significantly better among patients in the DDLT group with a MELD score of 15 or more than among patients in the waiting group. Conclusion: For all MELD categories, DDLT reduced the mortality risk of patients on the waiting list. [ABSTRACT FROM AUTHOR]

Abstract: Background: HCV‐infected (HCV+) ESRD patients derive significant survival benefit from kidney transplantation (KT) over remaining on dialysis. Given high mortality rates on dialysis and the unique ability to accept HCV+ and HCV‐ donor kidneys, understanding their access to KT is essential. Methods: Three thousand nine hundred and sixty‐three adult kidney‐only candidates reported as willing to accept an HCV+ kidney from 2008 to 2014 were identified and assumed to be HCV+. Time‐at‐risk began at date of listing. Cumulative incidence of transplant and waitlist mortality were assessed using competing risks, and separate mixed effects Cox proportional hazards models were used to examine waitlist mortality and transplantation rates. All models were adjusted for candidate demographic and clinical characteristics with a random effect for listing organ procurement organization with nested listing center. Results: HCV+ candidates were commonly older (>50 years: 82.6%), African American (52.8%), and male (73.6%). Five years after listing, 35.5% of candidates were transplanted with an HCV+ donor kidney, 9.7% transplanted with an HCV‐ donor kidney, and 23.6% died on the waitlist. Overall transplant rates exceeded waitlist mortality rates (22.69 vs 11.45 per 100 person‐years [PY]), largely driven by transplantation with HCV+ donor kidneys. Utilization of HCV+ donor kidneys was associated with increased transplantation rate (17.72 per 100 PY), while rate of transplant with HCV‐ donor kidneys was much lower (4.97 per 100 PY) than waitlist mortality (11.45 per 100 PY). Conclusion: In light of effective HCV therapies, it may be prudent to institute strategies to decrease waiting time and waitlist mortality for HCV+ candidates by increasing utilization of HCV+ donor kidneys. [ABSTRACT FROM AUTHOR]

Aim: Geographic disparities persist in the USA despite locoregional organ sharing policies. The impact of national organ sharing policies on waiting‐list mortality on a regional basis remains unknown. Methods: Data on all adult liver transplants between 1 February 2002 and 31 March 2015 were obtained from the United Network for Organ Sharing/Organ and Transplantation Network. Multivariable Cox proportional hazards models were constructed in a time‐to‐event analysis to estimate waiting‐list mortality for the pre‐ and post‐Share35 eras. Results: In the analyzed time period, 134 247 patients were listed for transplantation and 54 510 received organs (42.8%). Listing volume increased following the introduction of the Share35 organ sharing policy (15 976 candidates pre‐ vs. 18 375 post) without significant regional changes as did the number of transplants (7210 pre‐ vs. 8224 post). Waiting‐list mortality improved from 12.2% to 8.1% (P < 0.001). Adjusted waiting‐list mortality ratios remained geographically disparate. Region 10 and region 11 had lower hazard ratios (HR) but still had increased mortality (1.46, 95% confidence interval [CI] 1.34–1.60, P < 0.001; and HR 1.49, 95% CI 1.37–1.62, P < 0.001, respectively). Regions 3 and 6 had increased HR with persistently elevated waiting‐list mortality (1.79, 95% CI 1.66–1.93, P < 0.001; and HR 1.29, 95% CI 1.16–1.45, P < 0.001, respectively). Model for End‐state Liver Disease (MELD) exception continued to propagate a survival benefit (HR 0.65, 95% CI 0.63–0.68, P < 0.001). Conclusions: Although overall waiting‐list mortality has decreased, geographic disparities persist, but appear reduced despite broader sharing policies enacted by Share35. The advantage afforded by MELD exception, while still present, was diminished by Share35 as organs are being shifted to MELD >35 candidates. The disparities highlighted by our findings imply a need to review current allocation policies to best balance local, regional, and national transplant environments. [ABSTRACT FROM AUTHOR]

Morphometric assessments, such as muscle density and body fat distribution, have emerged as strong predictors of cardiovascular risk and postoperative morbidity and mortality. To date, no study has examined morphometric mortality risk prediction among kidney transplant ( KT) candidates. KT candidates, waitlisted 2008-2009, were identified (n=96) and followed to the earliest of transplant, death, or administrative end of study. Morphometric measures, including abdominal adipose tissue, paraspinous and psoas muscle composition, and aortic calcification, were measured from CTs. Risk of waitlist mortality was examined using Cox proportional hazard regression. On adjusted analyses, radiologic measures remained independently and significantly associated with lower waitlist mortality; the addition of radiologic measures significantly improved model predictive ability over models containing traditional risk factors alone (net reclassification index: 0.56, 95% CI: 0.31-0.75). Higher psoas muscle attenuation (indicative of leaner muscle) was associated with decreased risk of death ( aHR: 0.93, 95% CI: 0.91-0.96, P<.001), and for each unit increase in lean paraspinous volume, there was an associated 2% decreased risk for death ( aHR: 0.98, 95% CI: 0.96-0.99, P=.03). Radiologic measures of lean muscle mass, such as psoas muscle attenuation and paraspinous lean volume, may improve waitlist mortality risk prediction and candidate selection. [ABSTRACT FROM AUTHOR]

Multiple listing is associated with shorter waitlist durations and increased likelihood of transplantation for renal candidates. Little is known about multiple listing in pediatric heart transplantation. We examined the prevalence and outcomes of multiple listing using OPTN data from 1995 through 2009. Characteristics and waitlist outcomes of propensity-score-matched single- and multiple-listed patients were compared. Multiple listing occurred in 23 of 6290 listings (0.4%). Median days between listings was 35 (0-1015) and median duration of multiple listings was 32 days (3-363). Among multiple-listed patients, there were trends toward less ECMO use (0% vs. 11%, p = 0.1) and more frequent requirement for a prospective cross-match (17% vs. 8%, p = 0.08). Multiple-listed patients more commonly had private insurance (78% vs. 56%; p = 0.03). Urgency status at listing was similar between groups (1/1A: 61% vs. 64%, 1B/2: 39 vs. 36%; p = 0.45) as were weight, age, diagnosis, ventilator/inotrope use, and median income (each p ≥ 0.17). There was a trend toward increased incidence of heart transplantation for multiple-listed patients at three, six, and 24 months (50%, 65%, 80%) vs. single-listed patients (40%, 54%, 64%; p = 0.11). Multiple listing for pediatric heart transplantation in the USA occurs infrequently and is more common in patients with private insurance. [ABSTRACT FROM AUTHOR]