The disparity between the number of patients waiting for kidney transplantation and the limited supply of kidney allografts has renewed interest in the benefit from kidney transplantation experienced by different groups. This study evaluated kidney transplant survival benefit in prior nonrenal transplant recipients (kidney after liver, KALi; lung, KALu; heart, KAH) compared to primary isolated (KA1) or repeat isolated kidney (KA2) transplant. Multivariable Cox regression models were fit using UNOS data for patients wait listed and transplanted from 1995 to 2008. Compared to KA1, the risk of death on the wait list was lower for KA2 (p < 0.001;HR = 0.84;CI = 0.81–0.88), but substantially higher for KALu (p < 0.001; HR = 3.80;CI = 3.08–4.69), KAH (p < 0.001; HR = 1.92; CI = 1.66–2.22), and KALi (p < 0.001; HR = 2.69; CI = 2.46–2.95). Following kidney transplant, patient survival was greatest for KA1, similar among KA2, KALi, KAH, and inferior for KALu. Compared to the entire wait list, renal transplantation was associated with a survival benefit among all groups except KALu (p = 0.017; HR = 1.61; CI = 1.09–2.38), where posttransplant survival was inferior to the wait list population. Recipients of KA1 kidney transplantation have the greatest posttransplant survival and compared to the overall kidney wait list, the greatest survival benefit.

Donor safety has been scrutinized by both the medical community and the media. Variability exists in reported donor complications and associated risk factors are ill defined. Use of administrative data can overcome the bias of single-center studies and explore variables associated with untoward events. A retrospective cohort study identifying living liver donors in two large healthcare registries yielded 433 right and left lobe donors from 13 centers between 2001 and 2005. Perioperative complications were identified using International Classification of Diseases, 9th Revision (ICD-9) coding data and classified according to the Clavien system. Logistic regression models identified factors associated with complications. There was one perioperative death (0.23%). The overall complication rate was 29.1% and major complication rate defined by a Clavien grade ≥3 was 3.5%. Center living-donor volume (OR = 0.97, 95% CI = 0.95–0.99) and the ratio of living-donors to all donors (living and deceased) (OR = 0.94, 95% CI = 0.92–0.96) were associated with a lower risk of all complications. Donor age >50 years (OR = 4.25, 95% CI = 1.22–14.87) was associated with a higher risk of major complications. Living liver donation is currently performed with a low risk of major morbidity. Use of administrative data represents an important tool to facilitate a better understanding of donor risk factors.

Background. Expansion of living kidney donation through liberalizing acceptance criteria invites a renewed focus on safety and outcomes. Wide variability exists in reported donor complications, and associated risk factors are ill defined. Use of administrative data can overcome the bias of single-center studies and identify variables associated with untoward events. Methods. The study population consisted of 3074 living kidney donors from 28 centers during 2004 and 2005. Data from a large healthcare registry were used to retrospectively identify the study cohort. Perioperative complications were identified using ICD-9-CM coding and classified according to the Clavien system. Logistic regression models were constructed to identify donor and center factors associated with complications. Results. There were no perioperative deaths. The overall complication rate was 10.6% and major complications defined by Clavien grade ≥3 was 4.2%. The prevalence of tobacco use, obesity, and hypertension, was 7.8%, 2.4%, and 2.3%, respectively. Age >50 (odds ratio [OR]=1.81, 95% confidence interval [95% CI]=1.25–2.61), tobacco use (OR=1.41, 95% CI=1.02–1.94), obesity (OR=1.92, 95% CI=1.06–3.46), and annual center volume ≤50 (OR=2.28, 95% CI=1.68–3.09), were significantly associated with overall morbidity, however only annual center volume ≤50 (OR=2.07, 95% CI=1.27–3.37) was significantly associated with a risk of major complications. Conclusions. The inclusion of donors with tobacco abuse, obesity, and age >50 increases complications; however, the risk of major morbidity is small. Use of administrative data represents an important tool to facilitate the reconciliation of an increased need for organ donors with the concern for donor safety.

Simultaneous thoracic and abdominal (STA) transplantation is controversial because two organs are allocated to a single individual. We studied wait-list urgency, and whether transplantation led to successful outcomes. Candidates and recipients for heart-kidney (SHK), heart-liver (SHLi), lung-liver (SLuLi) and lung-kidney (SLuK) were identified through the United Network for Organ Sharing (UNOS) and outcomes were compared to single-organ transplantation. Since 1987, there were 1801 STA candidates and 836 recipients. Wait-list survival at 1- and 3 years for SHK (67.4%, 40.8%; N = 1420), SHLi (65.7%, 43.6%; N = 218) and SLuLi (65.7%, 41.0%; N = 122), was lower than controls (p < 0.001), whereas for SLuK (65.0%, 51.6%; N = 41) it was comparable (p = 0.34). All STA groups demonstrated similar 1- and 5 years posttransplant survival to thoracic controls. Compared to abdominal controls, 1- and 5 years posttransplant survival in SHK (85.3%, 74.0%; N = 684), SLuLi (75.5%, 59.0%; N= 42) and SLuK (66.7%, 55.6%; N = 18) was decreased (p < 0.01), but SHLi (85.9%, 74.3%; N = 92) was comparable (p = 0.81). In summary, STA candidates had greater risk of wait-list mortality compared to single-organ candidates. STA outcomes were similar to thoracic transplantation; however, outcomes were similar to abdominal transplantation for SHLi only. Although select patients benefit from STA, risk-exposure variables for decreased survival should be identified, aiming to eliminate futile transplantation.

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. Conclusion : 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. (Hepatology 2014;60:1717–1726)

Donation after cardiac death is an important source of transplantable organs, but evidence suggests donor warm ischemia contributes to inferior outcomes. Attempts to predict recipient outcome using donor hemodynamic measurements have not yielded statistically significant results. We evaluated novel measures of donor hemodynamics as predictors of delayed graft function and graft failure in a cohort of 1050 kidneys from 566 donors. Hemodynamics were described using regression line slopes, areas under the curve, and time beyond thresholds for systolic blood pressure, oxygen saturation, and shock index (heart rate divided by systolic blood pressure). A logistic generalized estimation equation model showed that area under the curve for systolic blood pressure was predictive of delayed graft function (above median: odds ratio 1.42, 95% confidence interval [CI] 1.06-1.90). Multivariable Cox regression demonstrated that slope of oxygen saturation during the first 10 minutes after extubation was associated with graft failure (below median: hazard ratio 1.30, 95% CI 1.03-1.64), with 5-year graft survival of 70.0% (95%CI 64.5%-74.8%) for donors above the median versus 61.4% (95%CI 55.5%-66.7%) for those below the median. Among older donors, increased shock index slope was associated with increased hazard of graft failure. Validation of these findings is necessary to determine the utility of characterizing donor warm ischemia to predict recipient outcome.