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Superior survival using living donors and donor-recipient matching using a novel living donor risk index.

ABSTRACT: The deceased-donor organ supply in the U.S. has not been able to keep pace with the increasing demand for liver transplantation. We examined national Organ Procurement and Transplantation Network/United Network for Organ Sharing (OPTN/UNOS) data from 2002-2012 to assess whether living donor liver transplantation (LDLT) has surpassed deceased donor liver transplantation (DDLT) as a superior method of transplantation, and used donor and recipient characteristics to develop a risk score to optimize donor and recipient selection for LDLT. From 2002-2012, there were 2,103 LDLTs and 46,674 DDLTs that met the inclusion criteria. The unadjusted 3-year graft survival for DDLTs was 75.5% (95% confidence interval [CI]: 75.1-76.0%) compared with 78.9% (95% CI: 76.9-80.8%; P<0.001) for LDLTs that were performed at experienced centers (>15 LDLTs), with substantial improvement in LDLT graft survival over time. In multivariate models, LDLT recipients transplanted at experienced centers with either autoimmune hepatitis or cholestatic liver disease had significantly lower risks of graft failure (hazard ratio [HR]: 0.56, 95% CI: 0.37-0.84 and HR: 0.76, 95% CI: 0.63-0.92, respectively). An LDLT risk score that included both donor and recipient variables facilitated stratification of LDLT recipients into high, intermediate, and low-risk groups, with predicted 3-year graft survival ranging from >87% in the lowest risk group to <74% in the highest risk group.Current posttransplant outcomes for LDLT are equivalent, if not superior, to DDLT when performed at experienced centers. An LDLT risk score can be used to optimize LDLT outcomes and provides objective selection criteria for donor selection in LDLT.

SUBMITTER: Goldberg DS

PROVIDER: S-EPMC4211952 | biostudies-literature | 2014 Nov

REPOSITORIES: biostudies-literature

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Superior survival using living donors and donor-recipient matching using a novel living donor risk index.

Goldberg David S DS French Benjamin B Abt Peter L PL Olthoff Kim K Shaked Abraham A

Hepatology (Baltimore, Md.) 20141002 5

<h4>Unlabelled</h4>The deceased-donor organ supply in the U.S. has not been able to keep pace with the increasing demand for liver transplantation. We examined national Organ Procurement and Transplantation Network/United Network for Organ Sharing (OPTN/UNOS) data from 2002-2012 to assess whether living donor liver transplantation (LDLT) has surpassed deceased donor liver transplantation (DDLT) as a superior method of transplantation, and used donor and recipient characteristics to develop a ris ...[more]

PMID: 25042283

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Project description:ObjectiveOne of the main problems of lung transplantation is the shortage of organs as well as reduced survival rates. In the absence of an international standardized model for lung donor-recipient allocation, we set out to develop such a model based on the characteristics of past experiences with lung donors and recipients with the aim of improving the outcomes of the entire transplantation process.MethodsThis was a retrospective analysis of 404 lung transplants carried out at the Reina Sofía University Hospital (Córdoba, Spain) over 23 years. We analyzed various clinical variables obtained via our experience of clinical practice in the donation and transplantation process. These were used to create various classification models, including classical statistical methods and also incorporating newer machine-learning approaches.ResultsThe proposed model represents a powerful tool for donor-recipient matching, which in this current work, exceeded the capacity of classical statistical methods. The variables that predicted an increase in the probability of survival were: higher pre-transplant and post-transplant functional vital capacity (FVC), lower pre-transplant carbon dioxide (PCO2) pressure, lower donor mechanical ventilation, and shorter ischemia time. The variables that negatively influenced transplant survival were low forced expiratory volume in the first second (FEV1) pre-transplant, lower arterial oxygen pressure (PaO2)/fraction of inspired oxygen (FiO2) ratio, bilobar transplant, elderly recipient and donor, donor-recipient graft disproportion requiring a surgical reduction (Tailor), type of combined transplant, need for cardiopulmonary bypass during the surgery, death of the donor due to head trauma, hospitalization status before surgery, and female and male recipient donor sex.ConclusionsThese results show the difficulty of the problem which required the introduction of other variables into the analysis. The combination of classical statistical methods and machine learning can support decision-making about the compatibility between donors and recipients. This helps to facilitate reliable prediction and to optimize the grafts for transplantation, thereby improving the transplanted patient survival rate.

Project description:Rationale & objectiveRisk factors for kidney failure are the basis of live kidney donor candidate evaluation. We quantified risk for end-stage kidney disease (ESKD) by the biological relationship of the donor to the recipient, a risk factor that is not addressed by current clinical practice guidelines.Study designRetrospective cohort study.Setting & participantsA cohort of 143,750 US kidney donors between 1987 and 2017.ExposureBiological relationship of donor and recipient.OutcomeESKD. Donors' records were linked to national dialysis and transplantation registries to ascertain development of the outcome.Analytic approachDonors were observed over a median of 12 (interquartile range, 6-18; maximum, 30) years. Survival analysis methods that account for the competing risk for death were used.ResultsRisk for ESKD varied by orders of magnitude across donor-recipient relationship categories. For Asian donors, risks compared with unrelated donors were 259.4-fold greater for identical twins (95% CI, 19.5-3445.6), 4.7-fold greater for full siblings (95% CI, 0.5-41.0), 3.5-fold greater for offspring (95% CI, 0.6-39.5), 1.0 for parents, and 1.0 for half-sibling or other biological relatives. For black donors, risks were 22.5-fold greater for identical twin donors (95% CI, 4.7-107.0), 4.1-fold for full siblings (95% CI, 2.1-7.8), 2.7-fold for offspring (95% CI, 1.4-5.4), 3.1-fold for parents (95% CI, 1.4-6.8), and 1.3-fold for half-sibling or other biological relatives (95% CI, 0.5-3.3). For white donors, risks were 3.5-fold greater for identical twin donors (95% CI, 0.5-25.3), 2.0-fold for full siblings (95% CI, 1.4-2.8), 1.4-fold for offspring (95% CI, 0.9-2.3), 2.9-fold for parents (95% CI, 2.0-4.1), and 0.8-fold for half-sibling or other biological relatives (95% CI, 0.3-1.6).LimitationsInsufficient sample size in some race and relationship groups. Absence of data for family history of kidney disease for donors biologically unrelated to their recipients.ConclusionsMarked differences in risk for ESKD across types of donor-recipient relationship were observed for Asian, black, and white donors. These findings warrant further validation with more robust data to better inform clinical practice guidelines.

Project description:Background and objectivesSmall donor and/or kidney sizes relative to recipient size are associated with a higher risk of kidney allograft failure. Donor and recipient ages are associated with graft survival and may modulate the relationship between size mismatch and the latter. The aim of this study was to determine whether the association between donor-recipient size mismatch and graft survival differs by donor and recipient age.Design, setting, participants, & measurementWe performed a retrospective cohort study of first adult deceased donor kidney transplantations performed between 2000 and 2018 recorded in the Scientific Registry of Transplant Recipients. We used multivariable Cox proportional hazards models to assess the association between donor-recipient body surface area ratio and death-censored graft survival, defined as return to dialysis or retransplantation. We considered interactions between donor-recipient body surface area ratio and each of recipient and donor age.ResultsAmong the 136,321 kidney transplant recipients included in this study, 23,614 (17%) experienced death-censored graft loss over a median follow-up of 4.3 years (interquartile range, 1.9-7.8 years). The three-way donor-recipient body surface area ratio by donor age by recipient age interaction was statistically significant (P=0.04). The magnitude of the association between severe size mismatch (donor-recipient body surface area ratio <0.80 versus ≥1.00) and death-censored graft survival was stronger with older donor age and recipient age. In all recipient age categories except the youngest (18-30 years), 5- and 10-year graft survival rates were similar or better with a size-mismatched donor aged <40 years than a nonsize-mismatched donor aged 40 years or older.ConclusionsThe association of donor-recipient size mismatch on long-term graft survival is modulated by recipient and donor age. Size-mismatched kidneys yield excellent graft survival when the donor is young. Donor age was more strongly associated with graft survival than size mismatch.

Project description:BackgroundThe Living Kidney Donor Profile Index (LKDPI) was derived in a cohort of kidney transplant recipients (KTR) from the United States to predict the risk of total graft failure. There are important differences in patient demographics, listing practices, access to transplantation, delivery of care, and posttransplant mortality in Canada as compared with the United States, and the generalizability of the LKDPI in the Canadian context is unknown.ObjectiveThe purpose of this study was to externally validate the LKDPI in a large contemporary cohort of Canadian KTR.DesignRetrospective cohort validation study.SettingToronto General Hospital, University Health Network, Toronto, Ontario, Canada.PatientsA total of 645 adult (≥18 years old) living donor KTR between January 1, 2006 and December 31, 2016 with follow-up until December 31, 2017 were included in the study.MeasurementsThe predictive performance of the LKDPI was evaluated. The outcome of interest was total graft failure, defined as the need for chronic dialysis, retransplantation, or death with graft function.MethodsThe Cox proportional hazards model was used to examine the relation between the LKDPI and total graft failure. The Cox proportional hazards model was also used for external validation and performance assessment of the model. Discrimination and calibration were used to assess model performance. Discrimination was assessed using Harrell's C statistic and calibration was assessed graphically, comparing observed versus predicted probabilities of total graft failure.ResultsA total of 645 living donor KTR were included in the study. The median LKDPI score was 13 (interquartile range [IQR] = 1.1, 29.9). Higher LKDPI scores were associated with an increased risk of total graft failure (hazard ratio = 1.01; 95% confidence interval [CI] = 1.0-1.02; P = .02). Discrimination was poor (C statistic = 0.55; 95% CI = 0.48-0.61). Calibration was as good at 1-year posttransplant but suboptimal at 3- and 5-years posttransplant.LimitationsLimitations include a relatively small sample size, predicted probabilities for assessment of calibration only available for scores of 0 to 100, and some missing data handled by imputation.ConclusionsIn this external validation study, the predictive ability of the LKDPI was modest in a cohort of Canadian KTR. Validation of prediction models is an important step to assess performance in external populations. Potential recalibration of the LKDPI may be useful prior to clinical use in external cohorts.

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Superior survival using living donors and donor-recipient matching using a novel living donor risk index.

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Superior survival using living donors and donor-recipient matching using a novel living donor risk index.

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