BACKGROUND: Despite improvements in access to transplantation, there remains disparities in all aspects of transplant among minority patients. We sought to examine referral practices and long-term outcomes of kidney transplantation across racial identities at our center. STUDY DESIGN: We conducted a retrospective review of kidney transplantation recipients from January 2010 to May 2024. Data were obtained from United Network for Organ Sharing and confirmed with the electronic medical record. Patients were categorized as White, Black, Asian, Hispanic, Hawaiian/Pacific Islander, and American Indian/Alaska Native. RESULTS: A total of 1,369 patients met criteria with 67% White, 6.9% Black, 7.9% Asian, 14.1% Hispanic, 2.6% Hawaiian/Pacific Islander, and 1.5% American Indian/Alaska Native. There were no significant between group differences in kidney donor profile index, expected posttransplant survival, recipient or donor age or cytomegalovirus status, cold ischemia time, and time from referral to evaluation or listing. There was a significant difference in waiting time for Black compared with White patients (733.6 vs 595.4 days, p = 0.026). Black patients had higher mean creatinine at 6 months and 1 year compared with all others (1.6 vs 1.3 mg/dL at both time points, p < 0.001). After adjusting for baseline characteristics, Black patients had an increased risk of allograft loss at 15 years compared with White patients (p < 0.001) and were to receive a living donor transplant (10.5% vs 25.3%, p < 0.01) or a preemptive kidney transplantation (10.5% vs 27.0%, p < 0.01). CONCLUSIONS: Despite disproportionate representation among patients with chronic kidney disease, compared with age-matched White patients, Black patients at our center are referred for transplant later and have a higher rate of 10-year allograft loss. It is up to us to focus on education and close the gap and improve outcomes for all of our transplant recipients.

Posttransplant lymphoproliferative disorder (PTLD) is a life-threatening complication of organ transplantation, commonly diagnosed after patients present with nonspecific constitutional symptoms and/or transplant organ dysfunction. In this article, we report a case of a kidney transplant recipient who was found to have highly elevated circulating donor-derived cell-free DNA (dd-cfDNA) levels on routine serum surveillance for allograft rejection, initially without organ dysfunction or evidence of allograft rejection on biopsy. Later, for cause imaging revealed retroperitoneal lymphadenopathy and an allograft hilar mass, which was biopsied to show PTLD/diffuse large B cell lymphoma. The elevated circulating dd-cfDNA levels in this patient prompted targeted next-generation sequencing of the same 266 single-nucleotide polymorphisms used to detect dd-cfDNA on the diffuse large B cell lymphoma, which identified it as derived from the donor. The patient achieved complete remission with retained allograft kidney function after reduced immunosuppression and 6 cycles of immunochemotherapy. This case suggests that dd-cfDNA may be an early detection tool in rare but potentially life-threatening cases of donor-derived malignancy, such as donor-derived PTLD.

Study Purpose Cytomegalovirus (CMV) is a common opportunistic viral infection among liver transplant (LT) recipients. This study evaluated the status of current CMV prophylaxis, treatment and associated antiviral side effects in LT patients. Procedures This single-center, retrospective study of 570 adult LT recipients from January 1, 2013, to December 31, 2023 compared CMV infection, disease, antiviral side effects and survival among high- (D+/R-, n = 157), intermediate- (D-/R+, D+/R+, n = 341), and low-CMV risk patients (D-/R-, n = 72). Maintenance immunosuppression was tacrolimus, mycophenolate or azathioprine (Imuran), and prednisone. High-risk patients received valganciclovir 900 mg daily for 6 months, and intermediate-risk patients received valganciclovir 450 mg daily for 3 months. Low-risk recipients received acyclovir 400 mg BID for 3 months. Findings Overall, 92 (16 %) patients developed CMV infection, and 64 (11 %) developed CMV disease. The high-risk group had the highest rates of CMV infection (50.3 % vs. 3.2 % vs. 2.8 %; p < 0.001) and disease (37.6 % vs. 1.2 % vs. 1.4 %; p < 0.001) compared to intermediate- and low-risk groups. Of those with CMV disease, 90.6 % received antiviral treatment, while 9.4 % resolved their disease without treatment. During prophylaxis, the high-risk group experienced higher rates of leukopenia (65.6 % vs. 45.7 % vs. 18.1 %; p < 0.001), antiviral-associated neutropenia (AAN; 48.4 % vs. 16.1 % vs. 8.3 %; p < 0.001), and uptrend in AAN requiring G-CSF (28.0 % vs. 8.7 % vs. 2.8 %; p = 0.802). Notably, more intermediate-risk recipients developed AAN requiring G-CSF during prophylaxis than developed CMV disease (8.7 % vs. 1.2 %). Conclusion This study demonstrates the need for revised antiviral prophylactic and treatment algorithms that effectively manage CMV disease while minimizing antiviral side effects such as AAN.

697 Background: Pre-operative therapy for resectable pancreatic ductal adenocarcinoma (PDAC) may eliminate micro-metastatic disease early and help achieve negative surgical margins. The present study is based on the hypothesis that gemcitabine/nab-paclitaxel chemotherapy followed by chemo-radiation with fluoropyrimidine is a feasible and efficacious pre-operative treatment for borderline resectable or node-positive PDAC. Methods: This is a single-arm phase II trial to evaluate pre-operative treatment with 2 cycles of gemcitabine 1000 mg/m2 and nab-paclitaxel 125 mg/m2 on days 1, 8, 15 every 28 days followed by 50.4 Gy of intensity-modulated radiation therapy over 28 fractions with concurrent 5-fluorouracil or capecitabine prior to pancreatic resection. Patients were eligible if they met borderline resectable criteria or had abnormal regional nodes visible on contrast CT. After surgery, they were eligible to receive up to 4 additional cycles of gemcitabine/nab-paclitaxel. The primary endpoint was the R0 resection rate. Secondary endpoints included response to pre-operative therapy, overall toxicities, relapse-free survival, and overall survival. Results: Nineteen of 24 screened patients have been enrolled. Median age was 68, 10 (53%) were female, and 4 (21%) were non-Caucasian. Eleven (78%) had head of pancreas cancers, 13 (68%) exhibited both arterial and venous involvement, and 12 (63%) had positive clinical nodes. All 19 patients received 2 months of gemcitabine/nab-paclitaxel, of which 17 patients continued to chemo-radiation (1 developed metastatic disease and 1 moved out of state). In the interval between chemo-radiation and surgery, 3 developed metastatic disease, 1 became unresectable, 1 withdrew from study, and 1 was deemed too frail for surgery. Nine have undergone successful pancreatic resection, and 2 are pending resection. Conclusions: Pre-operative gemcitabine/nab-paclitaxel followed by chemo-radiation with fluoropyrimidine is feasible in patients with borderline resectable PDAC and represents another strategy to FOLFIRINOX-based therapy. A planned interim analysis is ongoing. Clinical trial information: NCT02427841.

BACKGROUND:Portal venous reconstruction (PVR) is often needed during resection of hepatopancreato-biliary (HPB) malignancies. Primary repair (PR), autologous vein (AV), or cryopreserved cadaveric vein (CCV) are frequently utilized, however relative patency is not well studied. METHODS:All patients undergoing PVR between 2007-2019 at our center were identified. 3-year primary patency (PP), overall survival (OS), and survival-adjusted patency (SAP) were evaluated with Kaplan-Meier and Cox proportional hazards modeling. RESULTS:One-hundred-twenty patients were identified with a median follow-up of 11 months. PR, AV, and CCV reconstruction were used in 28 (23%), 35 (29%), and 57 (48%) patients, respectively, with two (7%), four (11%), and 29 (51%) thromboses, respectively. 3-year PP was greater for both primary repair (90%) and AV (83%) compared to CCV (33%, both p<0.001). On multivariable analysis, CCV had worse 3-year PP (HR 7.89, p=0.005) and SAP (HR 2.09, p=0.02) compared to PR; AV reconstruction had equivalent oncologic and patency-related outcomes to PR (p>0.4 for both comparisons). CONCLUSIONS:Primary patency for PR and AV reconstruction is superior to CCV for PVR during resection of HPB malignancies. AV conduit should be the preferred choice of reconstruction when PR is not achievable. Surgeons should only use CCV when factors preclude PR/AV reconstruction.

Surgical fellowships eligible for an Americas Hepato-pancreato–biliary Association (AHPBA) certificate have non-centralized curricula offering widely varied clinical experiences and thus disparate preparedness for independent practice. This variability obscures general understanding of what AHPBA-trained surgeons are prepared to do in practice. The impact of this educational variation is compounded by a surplus of surgeons wishing to perform hepatopancreatobiliary (HPB) cases in North America. Challenged by a desire to maintain consistent quality in HPB surgical care in North America, AHPBA sought to critically appraise and then strengthen the value of the AHPBA certificate. Thus, the AHPBA commissioned a taskforce to analyze perceived Strengths, Weaknesses, Opportunities, and Threats (SWOT) facing HPB fellowship programs and stakeholders surrounding them.

Background: Intraoperative autologous transfusion (IAT) of salvaged blood is a common method of resuscitation during liver transplantation (LT), however concern for recurrence in recipients with hepatocellular carcinoma (HCC) has limited widespread adoption. Methods: A review of patients undergoing LT for HCC between 2008 and 2018 was performed. Clinicopathologic and intraoperative characteristics associated with inferior recurrence-free (RFS) and overall survival (OS) were identified using Kaplan-Meier analysis and uni-/multi-variable Cox proportional hazards modeling. Propensity matching was utilized to derive clinicopathologically similar groups for subgroup analysis. Results: One-hundred-eighty-six patients were identified with a median follow up of 65 months. Transplant recipients receiving IAT (n = 131, 70%) also had higher allogenic transfusions (median 5 versus 0 units, P < 0.001). There were 14 recurrences and 46 deaths, yielding an estimated 10-year RFS and OS of 89% and 67%, respectively. IAT was not associated with RFS (HR 0.89/liter, P = 0.60), or OS (HR 0.98/liter, P = 0.83) pre-matching, or with RFS (HR 0.97/liter, P = 0.92) or OS (HR 1.04/liter, P = 0.77) in the matched cohort (n = 49 per group). Conclusion: IAT during LT for HCC is not associated with adverse oncologic outcomes. Use of IAT should be encouraged to minimize the volume of allogenic transfusion in patients undergoing LT for HCC.