Objective: To compare the effectiveness in US practice of normothermic regional perfusion (NRP) and normothermic machine perfusion (NMP) for donation after circulatory death (DCD) liver transplantation (LT). Background: DCD livers historically conferred inferior outcomes to donation after brain death donors, primarily due to ischemic biliary injury. NRP and NMP have emerged as promising strategies to mitigate this risk. Methods: Using UNOS data (2022-2024), we stratified DCD donors by procurement [super-rapid recovery (SRR) or NRP] and preservation [static cold storage (SCS) or NMP] method. NMP cases were further stratified into on-site versus back-to-base initiation of perfusion. On-site NMP was directly captured in the UNOS dataset. NRP and back-to-base NMP were identified with surrogate markers. We then compared graft (GS) and overall (OS) survival in propensity-matched cohorts. Results: We identified 4632 DCD LTs. The most common procurement-preservation strategy was SRR-NMP (2637; 56.9%), followed by SRR-SCS (937; 20.2%), NRP-SCS (560; 12.1%), and NRP-NMP (498; 10.8%). SRR-NMP demonstrated superior GS (HR: 0.54, 95% CI: 0.32–0.92) versus SRR-SCS. NRP-SCS similarly reduced the risk of graft loss (HR: 0.42, 95% CI: 0.29–0.61) versus SRR-SCS. NRP-SCS and SRR-NMP had similar GS. Similarly, adding NMP to livers procured with NRP did not lead to improved outcomes compared with NRP followed by SCS. Conclusions: This study provides the most comprehensive US comparison of modern procurement and preservation strategies in DCD LT. Both NRP and NMP were associated with improved GS versus the historical standard (SRR-SCS). No significant survival differences were observed between NRP and NMP, confirming that these strategies serve complementary roles in DCD LT. These findings support the adoption of both NRP and NMP as the new standard of care in DCD LT.

OBJECTIVE:To compare the effectiveness in US practice of normothermic regional perfusion (NRP) and normothermic machine perfusion (NMP) for donation after circulatory death (DCD) liver transplantation (LT). BACKGROUND:DCD livers historically conferred inferior outcomes to donation after brain death donors, primarily due to ischemic biliary injury. NRP and NMP have emerged as promising strategies to mitigate this risk. METHODS:Using UNOS data (2022-2024), we stratified DCD donors by procurement [super-rapid recovery (SRR) or NRP] and preservation [static cold storage (SCS) or NMP] method. NMP cases were further stratified into on-site versus back-to-base initiation of perfusion. On-site NMP was directly captured in the UNOS dataset. NRP and back-to-base NMP were identified with surrogate markers. We then compared graft (GS) and overall (OS) survival in propensity-matched cohorts. RESULTS:We identified 4632 DCD LTs. The most common procurement-preservation strategy was SRR-NMP (2637; 56.9%), followed by SRR-SCS (937; 20.2%), NRP-SCS (560; 12.1%), and NRP-NMP (498; 10.8%). SRR-NMP demonstrated superior GS (HR: 0.54, 95% CI: 0.32-0.92) versus SRR-SCS. NRP-SCS similarly reduced the risk of graft loss (HR: 0.42, 95% CI: 0.29-0.61) versus SRR-SCS. NRP-SCS and SRR-NMP had similar GS. Similarly, adding NMP to livers procured with NRP did not lead to improved outcomes compared with NRP followed by SCS. CONCLUSIONS:This study provides the most comprehensive US comparison of modern procurement and preservation strategies in DCD LT. Both NRP and NMP were associated with improved GS versus the historical standard (SRR-SCS). No significant survival differences were observed between NRP and NMP, confirming that these strategies serve complementary roles in DCD LT. These findings support the adoption of both NRP and NMP as the new standard of care in DCD LT.

Background. The utilization of kidneys donated after circulatory death (DCD) is an important strategy to address the ongoing shortage of organs suitable for transplantation in the United States. However, the nonuse rate of DCD kidneys remains high compared with kidneys donated after brain death (DBD) because of concerns regarding the injury incurred during donor warm ischemia time (DWIT). Therefore, we investigated the impact of DWIT on the risk of death-censored graft failure after DCD kidney transplantation (KT). Methods. Retrospective analysis was conducted on DCD KTs using the Standard Transplant Analysis and Research data set. The association of DWIT with death-censored graft failure was evaluated using multivariable Cox proportional hazard regression, with reference to DCD KTs with Kidney Donor Risk Index (KDRI) of ≤0.78 and the median DWIT of 26 min. Results. A total of 28 032 DCD kidney-alone transplants between January 2010 and December 2021 were studied. When stratified by KDRI, increasing DWIT was associated with a clinically significant increased risk for death-censored graft failure only in the subset of kidneys with KDRI >1.14 but not in those with KDRI >0.78–≤0.94 and >0.94–≤1.14, compared with the reference group. Conclusions. We suggest that clinicians should not decline kidneys on the basis of DWIT in favor of potential offers of DBD or other DCD kidneys with shorter DWIT, provided that their KDRI scores are within an acceptable limit. Our study highlights opportunities for more efficient usage of DCD kidneys and improving the shortage of transplantable organs.

ABSTRACTCalcineurin inhibitors have been the choice for maintenance immunosuppression (IS) in kidney transplant recipients (KTR), but they are associated with nephrotoxicity and metabolic side effects. We aim to compare the long‐term outcomes of KTR on belatacept (bela) versus tacrolimus (tac) IS, in all KTRs and various subgroups. Using the UNOS‐STAR files, we identified adult first‐KTR from 2010 to 2022. Patients were categorized based on maintenance‐IS at index transplant admission by creating a propensity score matched cohort at 1:5 rate using several clinical characteristics. Primary outcomes included patient death, graft failure (GF), and death‐censored graft failure (DCGF). Secondary outcomes included delayed graft function (DGF), acute‐rejections (AR) within a year, and serum creatinine (Cr) at 1‐year. The propensity‐matched cohort included KTRs on bela (N = 2612) and tac (N = 12760). There was no significant difference in the hazard ratio of death (1.03 [0.92, 1.14]), GF (1.07 [0.97, 1.17]), or DCGF (1.11 [0.98, 1.25]). A sensitivity analysis comparing a propensity‐matched cohort of bela + tac (n = 2033) versus tac (n = 9004); demonstrated significantly reduced risks of death (0.87 [0.76–1.00], p = 0.043) and GF (0.73 [0.64–0.83] p < 0.001) compared to those on Tac alone. In conclusion, bela + tac seems to be a nephron‐sparing and rejection‐lowering IS regimen with overall improved graft and patient outcomes when compared to the current standard of tacrolimus. Larger Randomized Controlled studies are needed.

BACKGROUND:Choosing a transplant program impacts a patient's likelihood of receiving a kidney transplant. Most patients are unaware of the factors influencing their candidacy. As patients increasingly rely on online resources for health care decisions, this study quantifies the available online patient-level information on kidney transplant recipient (KTR) selection criteria across US kidney transplant centers. OBJECTIVE:We aimed to use natural language processing and a large language model to quantify the available online patient-level information regarding the guideline-recommended KTR selection criteria reported by US transplant centers. METHODS:A cross-sectional study using natural language processing and a large language model was conducted to review the websites of US kidney transplant centers from June to August 2024. Links were explored up to 3 levels deep, and information on 31 guideline-recommended KTR selection criteria was collected from each transplant center. RESULTS:A total of 255 US kidney transplant centers were analyzed, comprising 10,508 web pages and 9,113,753 words. Among the kidney transplant guideline-recommended KTR selection criteria, only 2.6% (206/7905) of the information was present on the transplant center web pages. Socioeconomic and behavioral criteria were mentioned more than those related to the patient's medical conditions and comorbidities. Of the 31 criteria, finances and health insurance was the most frequently mentioned, appearing in 25.5% (65/255) of the transplant centers. Other socioeconomic and behavioral criteria, such as family and social support systems, adherence, and psychosocial assessment, were addressed in less than 4% (9/255) of the transplant centers. No information was found on any web page for 45.2% (14/31) of the KTR selection criteria. Geographically, disparities in reporting were observed, with the South Atlantic division showing the highest number of distinct criteria, while New England had the fewest. CONCLUSIONS:Most transplant center websites do not disclose patient-level KTR selection criteria online. The lack of transparency in the evaluation and listing process for kidney transplantation may limit patients in choosing their most suitable transplant center and successfully receiving a kidney transplant.

While donation after circulatory death (DCD) has contributed significantly to growth in liver transplantation volume, 70%-80% of DCD liver allografts remain nonutilized. We suspected that neurologic exam documentation fuels concerns that potential donors would not expire within an acceptable time frame, thus discouraging the pursuit of organs. We hypothesized that the neurologic exam is an unreliable predictor of donor warm ischemia time (DWIT), but nevertheless influences clinicians' behavior with respect to organ acceptance. We conducted a retrospective study of 11,967 adult potential DCD donors in the Standard Transplant Analysis and Research file (2011-2020). Multivariable logistic regression was performed to evaluate the association between neurologic exam documentation and acceptance of liver allografts. To assess the value of neurologic exam parameters in predicting successful donations, we calculated test characteristics of positive brainstem reflexes (BSRs) for DWIT >30/60 minutes. We constructed ROC curves for the number of positive BSRs in predicting DWIT >30/60 minutes. Neurologic exam documentation was available for 6,088/11,967 (50.87%) potential DCD donors. There was no association between documentation of neurologic exam (vs. nondocumentation) and acceptance. However, documentation of positive BSRs was associated with decreased odds of acceptance. Individual BSRs were imperfect predictors of DWIT >30/60 minutes, with sensitivities in the 50%-80% range and specificities in the 30%-60% range. ROC curves for predicting DWIT by number of positive BSRs had areas under the curve of 0.58 and 0.66 for DWIT >30 and 60 minutes. Therefore, we concluded that documentation of positive BSRs is associated with nonutilization of DCD liver allografts, despite having limited ability to predict donor expiration within the appropriate time frame for a successful DCD donation.

Background. The field of transplant research has long been recognized for its innovative approaches and international collaborations. This study aims to dissect the landscape of global collaborations within transplant research during a past decade. Methods. Through a comprehensive bibliometric and network analysis of 5 high-impact factor transplantation journals from 2012 to 2021, we evaluated scientific production and collaboration patterns in 9 250 articles. International, national, and single-institution collaboration types were analyzed, using coauthorship as a measure of scientific collaboration. Results. The data set revealed 40 622 authors from 2 094 institutions across 94 countries, with a marked increase in international collaborations during the past decade. The United States and Western European countries emerged as central nodes in the global network, facilitating the majority of collaborative efforts. Only 2.2% of potential institutional collaborations were explored during the decade. We found a lower chance of citations for single-institution research over time. Low- and middle-income countries were underrepresented in high-impact transplant research. Conclusions. The findings underscore the necessity of fostering inclusive, equitable research collaborations that bridge the gap between high-income countries and low- and middle-income countries, limiting their contributions to advancing global patient care. Practical recommendations for enhancing global collaboration in transplant research include facilitating academic exchanges, equitable collaboration practices, and increased funding opportunities. This study calls for a strategic shift toward a more inclusive and integrated global research landscape, aiming to advance transplant research and patient care universally. Addressing these disparities could lead to a more integrated global research landscape, benefiting transplant research and patient care universally.

INTRODUCTION:Normothermic machine perfusion (NMP) is a promising technology for expanding the donor liver pool. This study aims to evaluate the association between the implementation of NMP on liver transplant waitlist times at a single center. METHODS:We conducted a retrospective cohort study of patients who underwent liver transplant at Beth Israel Deaconess Medical Center from 2014 to 2024. Waitlist times were compared between pre-NMP and post-NMP implementation periods. Matched cohorts based on sex, age, and the model for end-stage liver disease score were used to compare patients who received machine-perfused livers (NMP group) and those who did not (non-NMP group). Waitlist duration, donor type, hospital stay, overall survival, and graft failure were measured. A subgroup of patients diagnosed with hepatocellular carcinoma (HCC) was analyzed. RESULTS:Of 429 patients, median waitlist times were significantly reduced from 309 d pre-NMP to 48 d post-NMP (P < 0.001). In the matched analysis, the NMP group had a median waitlist time of 71 d, compared to 345 d for non-NMP group (P < 0.001). The NMP group had a 2-d shorter hospital stay than the non-NMP group (P < 0.001). For HCC patients, waitlist times decreased from 472 d pre-NMP to 83 d post-NMP (P < 0.001), and in the matched HCC cohorts, waitlist times decreased from 492 d to 121 d in the non-NMP and NMP groups, respectively (P < 0.001). CONCLUSIONS:NMP implementation was associated with significantly shorter liver transplant waitlist times and reduced hospital stays, without compromising short-term survival outcomes. NMP may address the liver transplant shortage and improve access for patients, particularly those with HCC.

Background: For many surgeons, retirement is an emotionally evocative subject, tied to a sense of loss. With minimal guidelines to facilitate a smooth transition, physicians tend to be inadequately prepared. There are few qualitative studies exploring surgeons’ perspectives and none focused on transplant surgeons, a population with arguably unique challenges. We set out to define an “ideal” retirement for transplant surgeons, and identify behavioral and cognitive patterns associated with optimism towards retirement. Study Design: We conducted 60-minute semi-structured interviews with 30 division chiefs of transplant surgery to explore their perceptions of retirement. Thematic analysis using a framework approach was performed to identify key themes. Results: The cohort was predominantly male (80.0%) and White (76.7%), with 24.8 years in practice on average (range 12-40 years). Participants expressed desires to retire at the peak of their career trajectory and maintain autonomy in this transition. However, when naming signs of impending retirement, they often cited indicators of burnout. Attributes separating those who were optimistic from others included 1) well-rounded sense of identity, 2) holistic attitude towards one’s health and well-being, 3) belief in the ability to exert autonomy over retirement process through long-range planning, 4) community centered mindset, and 5) multifaceted and evolving view of career identity. Conclusion: While surgeons aspire to “go out on top,” many envision working until they can no longer endure it. This discrepancy highlights the need for normalizing discussions around retirement. With their unique insights, we have the opportunity to develop supportive interventions, such that transplant surgeons retire in a manner which preserves dignity and celebrates their legacy.

PURPOSE:To report outcomes in hepatocellular carcinoma (HCC) patients with lobar and segmental vascular invasion treated with resin Yttrium-90 transarterial radioembolization (Y90-TARE) with single-compartment MIRD (Medical Internal Radiation Dose) model. MATERIALS AND METHODS:This was a retrospective IRB approved study of patients with a diagnosis of HCC with vascular invasion undergoing resin Y90-TARE from 2014 to 2022 (n = 61). Patients with Body Surface Area dosimetry (n = 20), main portal vein invasion (n = 6) and patients with an ECOG of > 2 were excluded (n = 1) with a final cohort of 34 patients. RESULTS:Study population consisted of 34 patients, median age 62 years [60-71], tumor size 4.2 (2.8-7.4) cm, and 82% male. The median prescribed dose was 170 (126-200) Gy. The objective response rate at 6 months was 67% and disease control rate was 72%. The median survival was 18 months, median progression-free survival was 9.8 months. The 1- and 3-year survival rates were 76% and 57% in patients prescribed > 180 Gy, compared to 29% and 15% in patients with < 180 Gy (p = 0.01). Five of 15 Childs-Pugh A, ECOG < 1 patients (33%) were downstaged to resection, with complete pathologic necrosis in 40%, and 1 and 3-year survival rates of 100%. Grade-3 adverse events were seen in only 5/34 (15%), with no grade-4 or 5 adverse events. CONCLUSION:Resin Y90-TARE using single compartment MIRD model for HCC with segmental and lobar vascular invasion can result in downstaging to resection in 33% of patients and higher prescribed doses (> 180 Gy) result in improved survival.

IntroductionWomen comprise 55% to 65% of living kidney donors. Most studies focus on individuals who underwent donor nephrectomies, rather than potential living donors prior to engagement with the healthcare system. Therefore, the underlying reasons for gender discrepancy are unclear.Research questionAmong relatives of patients with renal disease, do men and women differ in willingness to be evaluated for living kidney donation, regardless of prior donation behavior?DesignAn online survey administered in 2019 to US adult members of the Qualtrics Survey Panel whose relatives had weak or failing kidneys. The survey was designed to examine perspectives of living kidney donation from realistic potential donors. Self-reported willingness was compared between men and women for statistically significant differences. Average marginal effects of male gender on willingness and interaction effects estimated with multivariable logistic regression, adjusted for respondent/patient demographics and relationship.ResultsA total of 1647 responses showed 7.1% higher willingness among men (P = .016). Among those whose relatives (N = 808) were seeking transplants [subgroup], men had 13.1% higher willingness (P = .002). Interaction effect analysis showed men aged 70 to 79 years, with insurance, self-reported very good health, and self-reported medical contraindications, had significantly higher willingness than corresponding women. In the transplant subgroup, men aged 18 to 39 years and with full-time employment also had higher willingness.ConclusionMen showed 7.1% higher willingness to be evaluated for living kidney donation. Rather than reflecting a fixed difference, the existence and degree of gender difference were context-dependent. Identifying strategic interventions to facilitate male donation in contexts where they reported high willingness could improve access to transplantation.