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Sir Roy Calne, a pioneer in the field of transplantation, passed away on January 6th, leaving behind a significant legacy. Throughout his career, Calne focused on innovation and improving the outcomes of transplantation through surgical techniques and immunosuppressive therapies. He recognized the importance of collaboration and education in the field and played a key role in the formation of the European Society for Organ Transplantation (ESOT) in 1982. Calne's philosophy of multidisciplinarity continues to shape ESOT today. His passing marks the end of an era, but his influence lives on through the generations he inspired and the visionary society he helped nurture. [Extracted from the article]

The clinical practice guideline Management of Obesity in Kidney Transplant Candidates and Recipients was developed to guide decision-making in caring for people with end-stage kidney disease (ESKD) living with obesity. The document considers the challenges in defining obesity, weighs interventions for treating obesity in kidney transplant candidates as well as recipients and reflects on the impact of obesity on the likelihood of wait-listing as well as its effect on transplant outcomes. It was designed to inform management decisions related to this topic and provide the backdrop for shared decision-making. This guideline was developed by the European Renal Association's Developing Education Science and Care for Renal Transplantation in European States working group. The group was supplemented with selected methodologists to supervise the project and provide methodological expertise in guideline development throughout the process. The guideline targets any healthcare professional treating or caring for people with ESKD being considered for kidney transplantation or having received a donor kidney. This includes nephrologists, transplant physicians, transplant surgeons, general practitioners, dialysis and transplant nurses. Development of this guideline followed an explicit process of evidence review. Treatment approaches and guideline recommendations are based on systematic reviews of relevant studies and appraisal of the quality of the evidence and the strength of recommendations followed the Grading of Recommendations Assessment, Development and Evaluation approach. Limitations of the evidence are discussed and areas of future research are presented. [ABSTRACT FROM AUTHOR]

The article discusses about proposed liver transplantation criteria for hepatocellular carcinoma (HCC) patients to help them access transplantation. The criteria involved Japanese HCC patients undergoing living donor liver transplantation (LDLT). The criteria established thresholds for size of tumour, number of HCC nodules, and concentration of alpha-fetoprotein (AFP). The previously established Milan criteria is also noted.

Introduction: Acute kidney injury is associated with a poor prognosis in acute liver failure but little is known of outcomes in patients undergoing transplantation for acute liver failure who require renal replacement therapy. Methods: A retrospective analysis of the United Kingdom Transplant Registry was performed (1 January 2001–31 December 2011) with patient and graft survival determined using Kaplan-Meier methods. Cox proportional hazards models were used together with propensity-score based full matching on renal replacement therapy use. Results: Three-year patient and graft survival for patients receiving renal replacement therapy were 77.7% and 72.6% compared with 85.1% and 79.4% for those not requiring renal replacement therapy (P<0.001 and P = 0.009 respectively, n = 725). In a Cox proportional hazards model, renal replacement therapy was a predictor of both patient death (hazard ratio (HR) 1.59, 95% CI 1.01–2.50, P = 0.044) but not graft loss (HR 1.39, 95% CI 0.92–2.10, P = 0.114). In groups fully matched on baseline covariates, those not receiving renal replacement therapy with a serum creatinine greater than 175μmol/L had a significantly worse risk of graft failure than those receiving renal replacement therapy. Conclusion: In patients being transplanted for acute liver failure, use of renal replacement therapy is a strong predictor of patient death and graft loss. Those not receiving renal replacement therapy with an elevated serum creatinine may be at greater risk of early graft failure than those receiving renal replacement therapy. A low threshold for instituting renal replacement therapy may therefore be beneficial. [ABSTRACT FROM AUTHOR]

In recent years, there has been a shift in the donor demographics with an increase in donation after circulatory death (DCD). Livers obtained from DCD donors are known to have poorer outcomes when compared to donors after brainstem death and currently only a small proportion of DCD livers are used. This review outlines the recent technological developments in liver DCD donation, including clinical studies using normothermic regional perfusion and extracorporal machine perfusion of livers from DCD donors. [ABSTRACT FROM AUTHOR]

Paracetamol overdose (POD) is a major cause of acute liver failure (ALF) requiring liver transplantation in the United Kingdom. To characterize the early and late outcome after orthotopic liver transplantation (OLT) for POD in the Scottish Liver Transplant Unit over a 14-year period (1992–2006). Data were obtained from a prospective database combined with case-note review. Of 127 liver transplants performed for ALF, 44 were for POD. The median age was 30 (range 18–51). In 18 patients (63.7%), POD was associated with alcohol/other drugs, nine (20.5%) had a staggered overdose and four patients (9.1%) accidentally overdosed. Nineteen patients (43.2%) had a history of previous overdose/psychiatric illness. Post-transplant mortality during the index admission was 30% (13 patients), whilst five patients died during follow-up. The actuarial 5-year patient survival was 54.5%, whilst graft survival was 49.5%. Some 23% of the patients were re-transplanted: primary nonfunction (1), hepatic artery thrombosis (3) and chronic rejection (2). Three patients had a subsequent transplant; three patients had two further transplants. Nine patients (35%) continue to have social/psychiatric issues. OLT for POD is associated with significant early and late morbidity and mortality. A multidisciplinary approach is required to identify the suitable candidates, in whom transplantation should be pursued promptly. [ABSTRACT FROM AUTHOR]

Background: Despite the increasing use of laparoscopic techniques, the optimal surgical approach for cystic liver disease has not been well defined. This study aims to determine the optimum operative approach for these patients. Methods: Data were identified from the Lothian Surgical Audit, case note review and general practitioner contact. Patients were contacted and asked to complete the SF-36 questionnaire on quality of life. Results: A total of 102 patients (67 with simple cysts, 31 with polycystic liver disease [PCLD], four with cystic tumours) underwent 62 laparoscopic deroofings, 15 open deroofings, 36 resections and one liver transplant between June 1985 and April 2006. The median follow-up was 77 months (range 3-250 months). Morbidity and recurrent symptom rates after laparoscopic surgery were greater in PCLD patients compared with simple cyst patients, at 31%(four patients) vs. 15%(seven patients) and 85%(11 patients) vs. 29% (24 patients), respectively. Four patients with simple cysts and eight with PCLD required further surgery. All patients with simple cysts had comparable quality of life after surgery. Patients with recurrent symptoms after surgery for PCLD had a significantly better quality of life following laparoscopic deroofing than after resection. Conclusions: Most simple cysts can be managed laparoscopically, but there is a definite role for open resection in some patients. Open deroofing is the preferred approach for a dominant cyst pattern in PCLD, whereas resection is necessary for diffuse cystic disease. [ABSTRACT FROM AUTHOR]

The liver is the most frequently injured intra-abdominal organ and associated injury to other organs increases the risk of complications and death. This has highlighted the critical need for an accurate classification system as a basis for the clinical decision-making process. Several classification systems have been proposed in an attempt to incorporate the aetiology, anatomy and extent of injury and correlate it with subsequent clinical management and outcome. The widely accepted Organ Injury Scale is based on anatomical criteria that quantify the disruption of the liver parenchyma and defines six groups which may influence management strategies and relate to outcome. The less common pancreatic injury remains a major source of morbidity and mortality due to the likelihood of associated solid or hollow-organ injuries. The implication of a delay in diagnosis and management emphasizes the need for an accurate classification system. The Organ Injury Scale is widely used for pancreas trauma and recognizes the importance of progressive parenchymal injury and in particular ductal injury. Advances in imaging techniques have led to the development of newer radiological classification systems; however, validation of their accuracy remains to be proven. An accurate classification of liver and pancreatic trauma is fundamental for the development of treatment protocols in which clinical decisions are based on the severity of injury. [ABSTRACT FROM AUTHOR]

The 21st Congress of the European Society of Organ Transplantation (ESOT), held on September 17–20th, 2023, in Athens, Greece, was a pivotal event in transplantation, focusing on the theme "Disruptive Innovation, Trusted Care." The congress attracted a global audience of 2 826 participants from 82 countries, emphasizing its international significance. Machine perfusion, as a groundbreaking technology in organ transplantation, was one of the central focuses of the conference. This year's meeting had a remarkable increase in accepted abstracts on machine perfusion, evidencing its growing prominence in the field. The collective findings from these abstracts highlighted the efficacy of machine perfusion in improving organ viability and transplant outcomes. Studies demonstrated improvements in graft survival and reduction in complications, as well as novel uses and techniques. Furthermore, the integration of machine perfusion with regenerative medicine and its application across multiple organ types were significant discussion points. The congress also highlighted the challenges and solutions in implementing machine perfusion in clinical settings, emphasizing the importance of practical training and international collaboration for advancing this technology. ESOT 2023 served as a crucial platform for disseminating scientific advancements, fostering practical learning, and facilitating international collaborations in organ transplantation. The congress underscored the evolution and importance of machine perfusion technology, marking a significant step forward in enhancing patient outcomes in the field of organ transplantation. [ABSTRACT FROM AUTHOR]

Abstract Objective: To examine the access to the renal transplant waiting list and renal transplantation in Scotland. Design: Cohort study. Setting: Renal and transplant units in Scotland. Participants: 4523 adults starting renal replacement therapy in Scotland between 1 January 1989 and 31 December 1999. Main outcome measures: Impact of age, sex, social deprivation, primary renal disease, renal or transplant unit, and geography on access to the waiting list and renal transplantation. Results: 1736 of 4523 (38.4%) patients were placed on the waiting list for renal transplantation and 1095 (24.2%) underwent transplantation up to 31 December 2000, the end of the study period. Patients were less likely to be placed on the list if they were female, older, had diabetes, were in a high deprivation category, and were treated in a renal unit in a hospital with no transplant unit. Patients living furthest away from the transplant centre were listed more quickly. The only factors governing access to transplantation once on the list were age, primary renal disease, and year of listing. A significant centre effect was found in access to the waiting list and renal transplantation. Conclusions: A major disparity exists in access to the renal transplant waiting list and renal transplantation in Scotland. Comorbidity may be an important factor. [ABSTRACT FROM AUTHOR]

Liver transplantation is a highly complex, life-saving, treatment for many patients with advanced liver disease. Liver transplantation requires multidisciplinary teams, system-wide adaptations and significant investment, as well as being an expensive treatment. Several metrics have been proposed to monitor processes and outcomes, however these lack patient focus and do not capture all aspects of the process. Most of the reported outcomes do not capture those outcomes that matter to the patients. Adopting the principles of Value-Based Health Care (VBHC), may provide an opportunity to develop those metrics that matter to patients. In this article, we present a Consensus Statement on Outcome Measures in Liver Transplantation following the principles of VBHC, developed by a dedicated panel of experts under the auspices of the European Society of Organ Transplantation (ESOT) Guidelines’ Taskforce. The overarching goal is to provide a framework to facilitate the development of outcome measures as an initial step to apply the VMC paradigm to liver transplantation. [ABSTRACT FROM AUTHOR]

Summary: Altruistic donation (unspecified donation) is an important aspect of living donor kidney transplantation. Although donation to a stranger is lawful and supported in many countries, it remains uncommon and not actively promoted. Herein, we ask the question if we have reached the limit in altruistic donation. In doing so, we examine important ethical questions that define the limits of unspecified donation, such as the appropriate balance between autonomous decision‐making and paternalistic protection of the donor, the extent of outcome uncertainty and risk‐benefit analyses that donors should be allowed to accept. We also consider the scrutiny and acceptance of donor motives, the potential for commercialization, donation to particular categories of recipients (including those encountered through social media) and the ethical boundaries of active promotion of unspecified kidney donation. We conclude that there is scope to increase the number of living donation kidney transplants further by optimizing existing practices to support and promote unspecified donation. A number of strategies including optimization of the assessment process, innovative approaches to reach potential donors together with reimbursement of expenses and a more specific recognition of unspecified donation are likely to lead to a meaningful increase in this type of donation. [ABSTRACT FROM AUTHOR]

Summary: Allocation policies are necessary to ensure a fair distribution of a scarce resource. The goal of any liver transplant allocation policy is to achieve the best possible outcomes for the waiting list population, irrespective of the indication for transplant, whilst maximizing organ utilization. Organ allocation for liver transplantation has evolved from simple centre‐based approaches driven by local issues, to complex, evidence‐based algorithm prioritizing according to need. Despite the rapid evolution of allocation policies, there remain a number of challenges and new approaches are required to ensure transparency and equity on the decision‐making process and the best possible outcomes for patients on the waiting list. New ways of modelling, together with novel outcome criteria, will be required to enable a dynamic adaptability of the allocation policies to the ever changing demographics of the donor population and the changing landscape of indications for transplantation. [ABSTRACT FROM AUTHOR]

The advent of Machine Perfusion (MP) as a superior form of preservation and assessment for cold storage of both high-risk kidney's and the liver presents opportunities in the field of beta-cell replacement. It is yet unknown whether such techniques, when applied to the pancreas, can increase the pool of suitable donor organs as well as ameliorating the effects of ischemia incurred during the retrieval process. Recent experimental models of pancreatic MP appear promising. Applications of MP to the pancreas, needs refinement regarding perfusion protocols and organ viability assessment criteria. To address the "Role of pancreas machine perfusion to increase the donor pool for beta cell replacement," the European Society for Organ Transplantation (ESOT) assembled a dedicated working group comprising of experts to review literature pertaining to the role of MP as a method of improving donor pancreas quality as well as quantity available for transplant, and to develop guidelines founded on evidence-based reviews in experimental and clinical settings. These were subsequently refined during the Consensus Conference when this took place in Prague. [ABSTRACT FROM AUTHOR]

In this article, the authors discuss the increase of body weight of potential living liver donors to avoid the risk of small-for size syndrome in donor liver transplantation. They emphasize the evidence that excessive increase in body weight causes an increase in fat content of liver leading to metabolic syndrome development. The authors also say that it is more ethically acceptable when the approach will focus on recipient measures with inflow modulation compared to donor weight regulation.

Living donation challenges the ethical principle of non-maleficence in that it exposes healthy persons to risks for the benefit of someone else. This makes safety, informed consent (IC) and education a priority. Living kidney donation has multiple benefits for the potential donor, but there are also several known short- and long-term risks. Although complete standardization of IC is likely to be unattainable, studies have emphasized the need for a standardized IC process to enable equitable educational and decision-making prospects for the prevention of inequities across transplant centers. Based on the Three-Talk Model of shared decision-making by Elwyn et al. we propose a model, named 3-Step (S) Model, where each step coincides with the three ideal timings of the process leading the living donor to the decision to pursue living donation: prior to the need for kidney replacement therapy (team talk); at the local nephrology unit or transplant center, with transplant clinicians and surgeons prior to evaluations start (option talk); and throughout evaluation, after having learned about the different aspects of donation, especially if there are second thoughts or doubts (decision talk). Based on the 3-S Model, to deliver conceptual and practical guidance to nephrologists and transplant clinicians, we provide recommendations for standardization of the timing, content, modalities for communicating risks and assessment of understanding prior to donation. The 3-S Model successfully allows an integration between standardization and individualization of IC, enabling a person-centered approach to potential donors. Studies will assess the effectiveness of the 3-S Model in kidney transplant clinical practice. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to a retrospective study which examined the influence of anastomosis time (AT) on outcomes after deceased donor kidney transplant.

The Omicron variant, which has become the dominant strain of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) worldwide, brings new challenges to preventing and controlling the infection. Moreover, the widespread implementation of vaccination policies before and after transplantation, and the development of new prophylactic and treatment strategies for coronavirus disease 2019 (COVID-19) over the past 12–18 months, has raised several new issues concerning kidney transplant recipients. In this special report, the ERA DESCARTES (Developing Education Science and Care for Renal Transplantation in European States) Working Group addresses several questions related to everyday clinical practice concerning kidney transplant recipients and to the assessment of deceased and live kidney donors: what is the current risk of severe disease and of breakthrough infection, the optimal management of immunosuppression in kidney transplant recipients with COVID-19, the role of passive immunization and the efficacy of antiviral drugs in ambulatory patients, the management of drug-to-drug interactions, safety criteria for the use of SARS-CoV-2-positive donors, issues related to the use of T cell depleting agents as induction treatment, and current recommendations for shielding practices. [ABSTRACT FROM AUTHOR]

The 2017 version of the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines is the most recent international framework for the evaluation and care of living kidneys donors. Along with the call for an integrative approach evaluating the long-term end-stage kidney disease risk for the future potential donor, several recommendations are formulated regarding the pre-donation glomerular filtration rate (GFR) adequacy with no or little consideration for the donor candidate's age or for the importance of using reference methods of GFR measurements. Herein, we question the position of the KDIGO guidelines and discuss the rationale and modalities for a more basic, but no less demanding GFR evaluation enabling a more efficient selection of potential kidney donors. [ABSTRACT FROM AUTHOR]

Summary: Innovative research in deceased donation and transplantation often presents ethical challenges for researchers and those responsible for ethical governance of research. These challenges have been recognized as potential barriers to the conduct of research. We review the literature to identify and describe ethical considerations that may cause confusion or uncertainty in the context of research involving potential deceased donors or deceased donor transplantation. We normatively examine these considerations and discuss their implications for the ethical conduct of research. In addition to the complexities of research involving critically ill, dying or recently deceased individuals, uncertainty may arise regarding the ethical status of various individuals who may be involved in research aimed at improving availability and outcomes of organ transplantation. Consequently, routine ethical guidelines for clinical research may fail to provide clear guidance with regards to the design, conduct and governance of some deceased donation or transplantation studies. Ethical uncertainty may result in delays or barriers to research, or neglect of important ethical considerations. Specific ethical guidance is needed to support research in deceased donation and transplantation as the ethical considerations that arise in the design and conduct of such research may not be addressed in the existing guidelines for human research. [ABSTRACT FROM AUTHOR]

Although overall donation and transplantation activity is higher in Europe than on other continents, differences between European countries in almost every aspect of transplantation activity (for example, in the number of transplantations, the number of people with a functioning graft, in rates of living versus deceased donation, and in the use of expanded criteria donors) suggest that there is ample room for improvement. Herein we review the policy and clinical measures that should be considered to increase access to transplantation and improve post-transplantation outcomes. This Roadmap, generated by a group of major European stakeholders collaborating within a Thematic Network, presents an outline of the challenges to increasing transplantation rates and proposes 12 key areas along with specific measures that should be considered to promote transplantation. This framework can be adopted by countries and institutions that are interested in advancing transplantation, both within and outside the European Union. Within this framework, a priority ranking of initiatives is suggested that could serve as the basis for a new European Union Action Plan on Organ Donation and Transplantation. [ABSTRACT FROM AUTHOR]

Summary: Utilization of pancreases for transplantation remains inferior to that of other organs. Herein, we analysed UK pancreas discards to identify the reasons for the low utilization rates. Data on all pancreases offered first for solid organ transplantation between 1st January 2005 and 31st December 2015 were extracted from the UK Transplant Registry. The number of organs discarded, reasons and the time point of discard were analysed. A centre specific comparison was also undertaken. 7367 pancreases were offered first for solid organ transplantation. 35% were donors after circulatory death (DCD). 3668 (49.7%) organs were not retrieved. Of the 3699 pancreases retrieved, 38% were initially accepted but subsequently discarded. 2145 (29%) grafts offered were transplanted as simultaneous pancreas‐kidney or solitary pancreas. 1177 (55%) were transplanted on the first offer whilst the remaining 968 were transplanted after a median of three offers. 52% DBD pancreases were accepted and transplanted on the first offer compared with 68% DCD grafts. There were significant differences in discard rates between centres (30–80% for DBD and 3–78% for DCD, P < 0.001). A significant number of solid pancreases are discarded. Better graft assessment at retrieval could minimize unnecessary organ travel and discards. Closer links with islet programmes may allow for better utilization of discarded grafts. [ABSTRACT FROM AUTHOR]

We examined quality of life (QoL) and other patient‐reported outcome measures (PROMs) in 95 simultaneous pancreas and kidney transplant (SPKT) recipients and 41 patients wait‐listed for SPKT recruited to the UK Access to Transplantation and Transplant Outcome Measures (ATTOM) programme. Wait‐listed patients transplanted within 12 months of recruitment (n = 22) were followed 12 months post‐transplant and compared with those still wait‐listed (n = 19) to examine pre‐ to post‐transplant changes. Qualitative interviews with ten SPKT recipients 12 months post‐transplant were analysed thematically. Cross‐sectional analyses showed several better 12‐month outcomes for SPKT recipients compared with those still wait‐listed, a trend to better health utilities but no difference in diabetes‐specific QoL or diabetes treatment satisfaction. Pre‐ to post‐transplant, SPKT recipients showed improved treatment satisfaction, well‐being, self‐reported health, generic QoL and less negative impact on renal‐specific QoL (ps < 0.05). Health utility values were better overall in transplant recipients and neither these nor diabetes‐specific QoL changed significantly in either group. Pre‐emptive transplant advantages seen in 12‐month cross‐sectional analyses disappeared when controlling for baseline values. Qualitative findings indicated diabetes complications, self‐imposed blood glucose monitoring and dietary restrictions continued to impact QoL negatively post‐transplant. Unrealistic expectations of SPKT caused some disappointment. Measuring condition‐specific PROMs over time will help in demonstrating the benefits and limitations of SPKT. [ABSTRACT FROM AUTHOR]

Donation after circulatory death (DCD) liver transplantation is associated with higher rates of graft loss. In this paper, we explored whether the Model for Early Allograft Function (MEAF) predicted outcome in DCD liver transplantation. We performed a retrospective analysis of prospectively collected data from all adult DCD (Maastricht 3) livers transplanted in Cambridge and Edinburgh between 1 January 2011 and 30 June 2017, excluding those undergoing any form of machine perfusion. 187 DCD liver transplants were performed during the study period. DCD liver transplants with a lower MEAF score had a significantly better survival compared to those with a high MEAF score (Mantel‐Cox P <.0001); this was largely due to early graft loss. Beyond 28 days post‐transplant, there were no significant long‐term graft or patient survival differences irrespective of the grade of MEAF (Mantel‐Cox P =.64 and P =.43, respectively). The MEAF score correlated with the length of ICU (P =.0011) and hospital stay (P =.0007), but did not predict the requirement for retransplantation for ischemic cholangiopathy (P =.37) or readmission (P =.74). In this study, a high MEAF score predicted early graft loss, but not the subsequent need for re‐transplantation or late graft failure as a result of intrahepatic ischemic bile duct pathology. [ABSTRACT FROM AUTHOR]

Background Existing guidelines on the evaluation and preparation of recipients for kidney transplantation target the entire spectrum of patients with end-stage renal disease. Within the ERA-EDTA Developing Education Science and Care for Renal Transplantation in European States (DESCARTES) Working Group, it was proposed that in a subset of relatively young patients (<40 years) without significant comorbidities (such as diabetes or cardiovascular disease), the work-up for transplantation could be restricted to a small set of tests. Methods Aiming for agreement between transplant centres across Europe, we surveyed the opinion of 80 transplant professionals from 11 European states on the composition of a minimal work-up. Results We show that there is a wide agreement among European experts that the work-up for kidney transplantation of the low-risk candidate, as opposed to the standard risk candidate, could include a limited number of investigations. However, there is some disagreement regarding the small number of diagnostic procedures, which is related to geographical location within Europe and the professional background of respondents. Conclusions Based on the results of the survey, published guidelines and expert meetings by the DESCARTES Working Group, we have formulated a proposal for the work-up of low-risk kidney transplant candidates. [ABSTRACT FROM AUTHOR]

Current proposals for waiting times for a renal transplant after malignant disease may not be appropriate. New data on malignancies in end-stage renal disease and recent diagnostic and therapeutic options should lead us to reconsider our current practice. [ABSTRACT FROM AUTHOR]

Transplantation medicine is a rapidly evolving field. Keeping afloat of the published literature to offer the best clinical care to our patients is a daunting task. As part of its educational mission, the Descartes advisory board identified seven topics in kidney transplantation where there has been substantial progresses over the last years: kidney allocation within Eurotransplant; kidney exchange strategies; kidney machine perfusion strategies; the changing landscape of anti-human leukocyte antigen (HLA) antibodies; the new immunosuppressive drugs in the pipeline; strategies for immunosuppression minimization; and the continuous enigma of focal segmental glomerular sclerosis recurrence after transplantation. Here, we have summarized the main knowledge and the main challenges of these seven topics with the aim to provide transplant professionals at large with key bullet points to successfully understand these new concepts. [ABSTRACT FROM AUTHOR]

Background Limited health literacy affects 25% of people with chronic kidney disease (CKD), and may reduce self-management skills resulting in poorer clinical outcomes. By disproportionately affecting people with low socio-economic status and non-white ethnicity, limited health literacy may promote health inequity. Methods We performed a systematic review of quantitative studies of health literacy and clinical outcomes among adults with CKD. Results A total of 29 studies (13 articles; 16 conference abstracts) were included. One included non-USA patients. Of the 29 studies, 5 were cohort studies and 24 were cross-sectional. In all, 18 300 patients were studied: 4367 non-dialysis CKD; 13 202 dialysis; 390 transplant; 341 unspecified. Median study size was 127 [interquartile range (IQR) 92–238)], but 480 (IQR 260–2392) for cohort studies. Median proportion of non-white participants was 48% (IQR 17–70%). Six health literacy measures were used. Outcomes included patient attributes, care processes, clinical/laboratory parameters and ‘hard’ clinical outcomes. Limited health literacy was significantly, independently associated with hospitalizations, emergency department use, missed dialysis sessions, cardiovascular events and mortality (in cohort studies). Study quality was high (1 study), moderate (3 studies) and poor (25 studies), limited by sampling methods, variable adjustment for confounders and reduced methodological detail given in conference abstracts. Conclusions There is limited robust evidence of the causal effects of health literacy on patient outcomes in CKD. Available evidence suggests associations with adverse clinical events, increased healthcare use and mortality. Prospective studies are required to determine the causal effects of health literacy on outcomes in CKD patients, and examine the relationships between socio-economic status, comorbidity, health literacy and CKD outcomes. Intervention development and evaluation will determine whether health literacy is a modifiable determinant of poor outcomes in CKD. [ABSTRACT FROM AUTHOR]

Background This study evaluates long-term outcomes and body mass index (BMI) following liver transplantation (LT) for non-alcoholic fatty liver disease (NAFLD) in comparison with alcoholic liver disease (ALD). Methods Patient and graft survival were compared using Kaplan Meier curves and log rank test. Multivariable analysis of recipient and donor characteristics was performed as determinants of patient survival. BMI at listing was compared with BMI post-LT. Results Patient survival at 1-, 3-, 5- and 10 years post-LT was similar in the ALD group (n = 195) compared with the NAFLD group (n = 84) (93% vs. 93%, 91% vs. 89%, 86% vs. 77%, 64% vs. 66% respectively, p = 0.21). One patient in the NAFLD group was re-transplanted and none in the ALD group therefore graft survival was also similar (p = 0.20). Multivariable analysis didn't identify any significant predictors of reduced survival. In comparison with the ALD group, BMI was significantly higher in the NAFLD group at listing (31 vs. 27, p < 0.001), 3-months post-LT (28 vs. 26, p < 0.05) and 6-months post-LT (29 vs. 27, p < 0.05) but was equivalent by 5-years post-LT (29 vs. 30, p = 0.80). Conclusions NAFLD patients had similar patient and graft survival post-LT compared to ALD. NAFLD patients returned to listing BMI by one-year post-LT but by 5-years post-LT there was no difference in BMI between the groups. [ABSTRACT FROM AUTHOR]

Objectives: To report health-state utility values measured using the five-level EuroQol five-dimensional questionnaire (EQ-5D-5L) in a large sample of patients with end-stage renal disease and to explore how these values vary in relation to patient characteristics and treatment factors.Methods: As part of the prospective observational study entitled "Access to Transplantation and Transplant Outcome Measures," we captured information on patient characteristics and treatment factors in a cohort of incident kidney transplant recipients and a cohort of prevalent patients on the transplant waiting list in the United Kingdom. We assessed patients' health status using the EQ-5D-5L and conducted multivariable regression analyses of index scores.Results: EQ-5D-5L responses were available for 512 transplant recipients and 1704 waiting-list patients. Mean index scores were higher in transplant recipients at 6 months after transplant surgery (0.83) compared with patients on the waiting list (0.77). In combined regression analyses, a primary renal diagnosis of diabetes was associated with the largest decrement in utility scores. When separate regression models were fitted to each cohort, female gender and Asian ethnicity were associated with lower utility scores among waiting-list patients but not among transplant recipients. Among waiting-list patients, longer time spent on dialysis was also associated with poorer utility scores. When comorbidities were included, the presence of mental illness resulted in a utility decrement of 0.12 in both cohorts.Conclusions: This study provides new insights into variations in health-state utility values from a single source that can be used to inform cost-effectiveness evaluations in patients with end-stage renal disease. [ABSTRACT FROM AUTHOR]

Background. Living donor kidney transplantation (LDKT) provides more timely access to transplantation and better clinical outcomes than deceased donor kidney transplantation (DDKT). This study investigated disparities in the utilization of LDKT in the UK. Methods. A total of 2055 adults undergoing kidney transplantation between November 2011 and March 2013 were prospectively recruited from all 23 UK transplant centres as part of the Access to Transplantation and Transplant Outcome Measures (ATTOM) study. Recipient variables independently associated with receipt of LDKT versus DDKT were identified. Results. Of the 2055 patients, 807 (39.3%) received LDKT and 1248 (60.7%) received DDKT. Multivariable modelling demonstrated a significant reduction in the likelihood of LDKT for older age {odds ratio [OR] 0.11 [95% confidence interval (CI) 0.08-0.17], P<0.0001 for 65-75 years versus 18-34 years}; Asian ethnicity [OR 0.55 (95% CI 0.39-0.77), P=0.0006 versus White]; Black ethnicity [OR 0.64 (95% CI 0.42-0.99), P=0.047 versus White]; divorced, separated or widowed [OR 0.63 (95% CI 0.46-0.88), P=0.030 versus married]; no qualifications [OR 0.55 (95% CI 0.42-0.74), P<0.0001 versus higher education qualifications]; no car ownership [OR 0.51 (95% CI 0.37-0.72), P=0.0001] and no home ownership [OR 0.65 (95% CI 0.85-0.79), P=0.002]. The odds of LDKT varied significantly between countries in the UK. Conclusions. Among patients undergoing kidney transplantation in the UK, there are significant age, ethnic, socio-economic and geographic disparities in the utilization of LDKT. Further work is needed to explore the potential for targeted interventions to improve equity in living donor transplantation. [ABSTRACT FROM AUTHOR]

Two recent matched cohort studies from the USA and Norway published in 2014 have raised some concerns related to the long-term safety of kidney living donation. Further studies on the long-term risks of living donation have since been published. In this position paper, Developing Education Science and Care for Renal Transplantation in European States (DESCARTES) board members critically review the literature in an effort to summarize the current knowledge concerning longterm risks of kidney living donation to help physicians for decision-making purposes and for providing information to the prospective live donors. Long-term risk of end-stage renal disease (ESRD) can be partially foreseen by trying to identify donors at risk of developing 'de novo' kidney diseases during life post-donation and by predicting lifetime ESRD risk. However, lifetime risk may be difficult to assess in young donors, especially in those having first-degree relatives with ESRD. The study from Norway also found an increased risk of death after living donor nephrectomy, which became visible only after >15 years of post-donation follow-up. However, these findings are likely to be largely the result of an overestimation due to the confounding effect related to a family history of renal disease. DESCARTES board members emphasize the importance of optimal risk-benefit assessment and proper information to the prospective donor, which should also include recommendations on health-promoting behaviour post-donation. [ABSTRACT FROM AUTHOR]

There is limited evidence for a negative impact of preformed, donor-specific HLA antibodies ( DSA) identified by cross-matching on outcomes after liver transplantation. Three recent studies have suggested an association between preformed DSA detected by Luminex and reduced graft or recipient survival in liver transplant cohorts with a high prevalence of hepatitis C. This study investigated the impact of preformed DSA identified by Luminex in the Scottish liver transplant population. All recipients of liver transplants in Scotland between 2007 and 2015 with samples available for day of transplant antibody testing and donor HLA typing were included (n=459); 96% of the cohort were white and 19% had a primary diagnosis of hepatitis C. The median follow-up time was 36 months. Preformed DSA were detected in 88 recipients. In multivariate analysis, preformed DSA with a median fluorescent intensity ≥10 000 were associated with recipient mortality at 1 year. There was no association between DSA and overall graft or recipient survival. This study adds to the growing body of evidence supporting a detrimental impact of preformed, high-level DSA in a subset of liver transplant recipients by identifying an association in an ethnically and demographically distinct liver transplant population. [ABSTRACT FROM AUTHOR]

Background. In a number of countries, reimbursement to hospitals providing renal dialysis services is set according to a fixed tariff. While the cost of maintenance dialysis and transplant surgery are amenable to a system of fixed tariffs, patients with established renal failure commonly present with comorbid conditions that can lead to variations in the need for hospitalization beyond the provision of renal replacement therapy. Methods. Patient-level cost data for incident renal replacement therapy patients in England were obtained as a result of linkage of the Hospital Episodes Statistics dataset to UK Renal Registry data. Regression models were developed to explore variations in hospital costs in relation to treatment modality, number of years on treatment and factors such as age and comorbidities. The final models were then used to predict annual costs for patients with different sets of characteristics. Results. Excluding the cost of renal replacement therapy itself, inpatient costs generally decreased with number of years on treatment for haemodialysis and transplant patients, whereas costs for patients receiving peritoneal dialysis remained constant. Diabetes was associated with higher mean annual costs for all patients irrespective of treatment modality and hospital setting. Age did not have a consistent effect on costs. Conclusions. Combining predicted hospital costs with the fixed costs of renal replacement therapy showed that the total cost differential for a patient continuing on dialysis rather than receiving a transplant is considerable following the first year of renal replacement therapy, thus reinforcing the longer- term economic advantage of transplantation over dialysis for the health service. [ABSTRACT FROM AUTHOR]

Background There is variation in time to listing and rates of listing for transplantation between renal units in the UK. While research has mainly focused on healthcare organization, little is known about patient perspectives of entry onto the transplant waiting list. This qualitative study aimed to explore patients' views and experiences of kidney transplant listing. Methods Semi-structured interviews were conducted with patients aged under 75, who were on dialysis and on the transplant waiting list, not on the waiting list, undergoing assessment for listing or who had received a transplant. Patients were recruited from a purposive sample of nine UK renal units, which included transplanting and non-transplanting units and units with high and low wait-listing patterns. Interviews were transcribed verbatim and analysed using thematic analysis. Results Fifty-three patients (5–7 per renal unit) were interviewed. Patients reported that they had received little information about the listing process. Some patients did not know if they were listed or had found they were not listed when they had thought they were on the list. Others expressed distress when they felt they had been excluded from potential listing based on age and/or comorbidity and felt the process was unfair. Many patients were not aware of pre-emptive transplantation and believed they had to be on dialysis before being able to be listed. There was some indication that pre-emptive transplantation was discussed more often in transplant than non-transplant units. Lastly, some patients were reluctant to consider family members as potential donors as they reported they would feel ‘guilty’ if the donor suffered subsequent negative effects. Conclusions Findings suggest a need to review current practice to further understand individual and organizational reasons for the renal unit variation identified in patient understanding of transplant listing. The communication of information warrants attention to ensure patients are fully informed about the listing process and opportunity for pre-emptive transplantation in a way that is meaningful and understandable to them. [ABSTRACT FROM PUBLISHER]