A consensus conference on frailty in kidney, liver, heart and lung transplantation, sponsored by the American Society of Transplantation (AST) and endorsed by the American Society of Nephrology (ASN), the American Society of Transplant Surgeons (ASTS) and the Canadian Society of Transplantation (CST), took place on February 11, 2018 in Phoenix, Arizona. Input from the transplant community through scheduled conference calls enabled wide discussion of current concepts in frailty, exploration of best practices for frailty risk assessment of transplant candidates and for management after transplant, and development of ideas for future research. A current understanding of frailty was compiled by each of the solid organ groups and is presented in this paper. Frailty is a common entity in patients with end‐stage organ disease who are awaiting organ transplantation, and affects mortality on the wait‐list and in the post‐transplant period. The optimal methods by which frailty should be measured in each organ group are yet to be determined, but studies are underway. Interventions to reverse frailty vary among organ groups and appear promising. This conference achieved its intent to highlight the importance of frailty in organ transplantation and to plant the seeds for further discussion and research in this field.

Allosensitization represents a major barrier to heart transplantation (HTx). We assessed the efficacy and safety of complement inhibition at transplant in highly sensitized heart transplant recipients. We performed a single‐center, single‐arm, open‐label trial (NCT02013037). Patients with panel reactive antibodies (PRA) ≥70% and pre‐formed donor‐specific antibodies (DSA) were eligible. In addition to standard of care, patients received 9 infusions of eculizumab during the first two months post‐transplant. The primary composite endpoint was antibody‐mediated rejection (AMR) ≥ pAMR2 and/or left ventricular dysfunction during the first year. Secondary endpoints included hemodynamic compromise, allograft rejection and patient survival. Twenty patients were included. Median cPRA and mean fluorescence intensity of immunodominant DSA were 95% (90‐97%) and 6,250 (5,000‐10,000), respectively. Retrospective B‐cell and T‐cell flow crossmatches were positive in 14 and 11 patients, respectively. The primary endpoint occurred in 4 patients (20%). Survival at 1‐year was 90% with no deaths resulting from AMR. In a pre‐specified analysis comparing treated patients to matched control patients, we observed a dramatic reduction in the risk of biopsy‐proven AMR in patients treated with eculizumab (HR=0.36, 95%CI=0.14‐0.95, p=0.032). Our findings support the prophylactic use of complement inhibition for heart transplantation at high immunological risk.

A consensus conference on frailty in solid‐organ transplantation took place on February 11, 2018 to discuss the latest developments in frailty, adopt a standardized approach to assessment and generate ideas for future research. The findings and consensus of the Frailty Heart Workgroup (American Society of Transplantation’s Thoracic and Critical Care Community of Practice) are presented here. Frailty is defined as a clinically recognizable state of increased vulnerability resulting from aging‐associated decline in reserve and function across multiple physiologic systems such that the ability to cope with every day or acute stressors is compromised. Frailty is increasingly recognized as a distinct biologic entity that can adversely affect outcomes before and after heart transplantation. A greater proportion of patients referred for heart transplantation are older and have more complex co‐morbidities. However, outcomes data in the pre‐transplant setting, particularly for younger patients, is limited. Therefore, there is a need to develop objective frailty assessment tools for risk stratification in patients with advanced heart disease. These tools will help to determine appropriate recipient selection for advanced heart disease therapies including heart transplantation and mechanical circulatory support, improve overall outcomes and help distinguish frailty phenotypes amenable to intervention.