Impact of COVID-19 on liver transplant recipients: A nationwide cohort study evaluating hospitalization, transplant rejection, and inpatient mortality

BACKGROUND The coronavirus disease 2019(COVID-19)pandemic has posed a major public health concern worldwide.Patients with comorbid conditions are at risk of adverse outcomes following COVID-19.Solid organ transplant recipients with concurrent immunosuppression and comorbidities are more susceptible to a severe COVID-19 infection.It could lead to higher rates of inpatient complications and mortality in this patient population.However,studies on COVID-19 outcomes in liver transplant(LT)recipients have yielded inconsistent findings.AIM To evaluate the impact of the COVID-19 pandemic on hospital-related outcomes among LT recipients in the United States.METHODS We conducted a retrospective cohort study using the 2019–2020 National Inpatient Sample database.Patients with primary LT hospitalizations and a secondary COVID-19 diagnosis were identified using the International Classi-fication of Diseases,Tenth Revision coding system.The primary outcomes included trends in LT hospitalizations before and during the COVID-19 pandemic.Secondary outcomes included comparative trends in inpatient mortality and transplant rejection in LT recipients.RESULTS A total of 15720 hospitalized LT recipients were included.Approximately 0.8% of patients had a secondary diagnosis of COVID-19 infection.In both cohorts,the median admission age was 57 years.The linear trends for LT hospitalizations did not differ significantly before and during the pandemic(P=0.84).The frequency of in-hospital mortality for LT recipients increased from 1.7% to 4.4% between January 2019 and December 2020.Compared to the pre-pandemic period,a higher association was noted between LT recipients and in-hospital mortality during the pandemic,with an odds ratio(OR)of 1.69[95% confidence interval(CI):1.55-1.84),P<0.001].The frequency of transplant rejections among hospitalized LT recipients increased from 0.2%to 3.6% between January 2019 and December 2020.LT hospitalizations during the COVID-19 pandemic had a higher association with transplant rejection than before the pandemic[OR:1.53(95%CI:1.26-1.85),P<0.001].CONCLUSION The hospitalization rates for LT recipients were comparable before and during the pandemic.Inpatient mortality and transplant rejection rates for hospitalized LT recipients were increased during the COVID-19 pandemic.

Optimizing growth in pediatric renal transplant recipients: An update

Growth retardation is a significant complication observed in pediatric renal transplant recipients,originating from a multifactorial etiology.Factors contributing to growth impairment encompass pre-transplant conditions such as primary kidney disease,malnutrition,quality of care,growth deficits at the time of transplantation,dialysis adequacy,and the use of recombinant human growth hormone.Additionally,elements related to the renal transplant itself,such as living donors,corticosteroid usage,and graft functioning,further compound the challenge.Although renal transplantation is the preferred renal replacement therapy,its impact on achieving final height and normal growth in children remains uncertain.The consequences of growth delay extend beyond the physi-ological realm,negatively influencing the quality of life and social conditions of pediatric renal transplant recipients,and ultimately affecting their educational and employment outcomes.Despite advancements in graft survival rates,growth retardation remains a formidable clinical concern among children undergoing renal transplantation.Major risk factors for delayed final adult height include young age at transplantation,pre-existing short stature,and the use of specific immunosuppressive drugs,particularly steroids.Effective management of growth retardation necessitates early intervention,commencing even before transplantation.Strategies involving the administration of recombinant growth hormone both pre-and post-transplant,along with protocols aimed at minimizing steroid usage,are important for achieving catch-up growth.This review provides a comprehensive outline of the multifaceted nature of growth retardation in pediatric renal transplant recipients,emphasizing the importance of early and targeted interventions to mitigate its impact on the long-term well-being of these children from birth to adolescence.INTRODUCTION Children with chronic kidney disease(CKD)endure frequent hospitalizations and ongoing treatment,which significantly affect their quality of life.One of the most noticeable effects of CKD in children is poor growth,with stunted height being a common sign of chronic malnutrition.Growth assessment involves regularly measuring weight and height/length and comparing these against z-score charts,along with other anthropometric indicators like head circumference and mid-upper arm circumference.Data from the North American Pediatric Renal Trials and Collaborative Studies(NAPRTCS)registry shows that over 35%of children enrolled had stunted growth at the time of admission,with growth impairment being more severe in younger children(58%in those aged under 1 year,compared to 22%in those aged over 12 years).Additionally,the same data revealed that growth impairment worsens as the severity of the disease increases.Although recent advances in science have enabled better outcomes for children with CKD,in resource-limited settings,numerous children are still deprived of achieving optimal growth owing to the disease and its related factors.Stunting is a key indicator of chronic growth impairment in children.A study by Wong et al[1]in the United States Renal Data System found that each SD decrease in height among children with stage V CKD is linked to a 14%increase in the risk of death[1].Similarly,research by Furth et al[2]using data from the NAPRTCS indicated that children with a height standard deviation score(SDS)of-2.5 face a relative hazard of death of 2.07.Stunting also correlates with increased hospitalizations.A study in the United States followed 1112 pediatric patients with end-stage renal disease from 1990 to 1995.It showed that children with severe or moderate growth failure had higher hospitalization rates compared to those with normal growth.Specifically,the relative risk for hospitalization was 1.14(95%CI:1.1-1.2)for those with moderate growth failure and 1.24(95%CI:1.2-1.3)for those with severe growth failure,even after adjusting for age,sex,race,cause,and duration of end-stage renal disease,and treatment type[2](dialysis or transplant).The growth of a child significantly affects his/her psychological and overall well-being as an adult.Short children are often embarrassed by peers,and it has been observed that height influences employment status,with unemployment being more prevalent among stunted individuals.Further,marital opportunities can be fewer among stunted individuals[3].Hence,all measures to achieve adequate growth should be attempted in children with CKD,regardless of whether they undergo transplantation.

Cryptococcosis in kidney transplant recipients:Current understanding and practices

Cryptococcosis is the third most commonly occurring invasive fungal disease in solid organ transplant recipients(SOT).It is caused by encapsulated yeast,Cryptococcus species,predominantly Cryptococcus neoformans and Cryptococcus gattii.Though kidney transplant recipients are at the lowest risk of cryptococcosis when compared to other solid organ transplant recipients such as lung,liver or heart,still this opportunistic infection causes significant morbidity and mortality in this subset of patients.Mortality rates with cryptococcosis range from 10%-25%,while it can be as high as 50%in SOT recipients with central nervous system involvement.The main aim of diagnosis is to find out if there is any involvement of the central nervous system in disseminated disease or whether there is only localized pulmonary involvement as it has implications for both prognostication and treatment.Detection of cryptococcal antigen(CrAg)in cerebrospinal fluid or plasma is a highly recommended test as it is more sensitive and specific than India ink and fungal cultures.The CrAg lateral flow assay is the single point of care test that can rapidly detect cryptococcal polysaccharide capsule.Treatment of cryptococcosis is challenging in kidney transplant recipients.Apart from the reduction or optimization of immunosuppression,lipid formulations of amphotericin B are preferred as induction antifungal agents.Consolidation and maintenance are done with fluconazole;carefully monitoring its interactions with calcineurin inhibitors.This review further discusses in depth the evolving developments in the epidemiology,pathogenesis,diagnostic assays,and management approach of cryptococcosis in kidney transplant recipients.

Risk stratification of renal transplant recipients using routine parameters: Implication of learning from SARS-CoV-2 into transplant follow-up program

BACKGROUND Severe acute respiratory syndrome coronavirus-2(SARS-CoV-2)infection is a global pandemic that is associated with a high risk of morbidity and mortality among recipients of solid organ transplantation.In the course of acute SARS-CoV-2 infection,various laboratory markers have been identified as predictors for high risk of mortality.AIM To risk stratify renal transplant recipients(RTxR)using general demographic parameters,comorbidities and routine laboratory markers for the severity of the disease and its outcomes.We believe that learning about these routinely monitored parameters can help us plan better strategies for the RTxR follow-up program.METHODS This present study includes RTxR who acquired SARS-CoV-2 infection from March 2020 to February 2021.We recorded the basic demographics,comorbidities and routine laboratory markers.We investigated the impact of SARS-CoV-2 infection on RTxRs and risk-stratified the progression of disease severity and outcomes in terms of recovery or mortality.RESULTS From 505 RTxRs in our renal transplant follow-up program,29(7.75%)RTxRs had PCR-positive SARS-CoV-2 infection.We recorded 8 deaths from SARS-CoV-2 infection giving an overall mortality rate of 1.6%but a significant 27.6%mortality in SARS-CoV-2 positive recipients.Age more than 68 years,non-Caucasian ethnicity and male gender were associated with a significant drop in survival probability;P≤0.001.<0.001 and<0.0001 respectively.87.5%of the deceased were diabetic;P≤0.0.0001.Estimated glomerular filtration rate of less than 26 mL/min/1.73 m2,serum albumin less than 20 g/L,Hemoglobin less than 9.6 g/L and serum calcium less than 1.70 mmol/L were all associated with significantly increased risk of mortality;P=0.0128,<0.001,<0.0001 and 0.0061 respectively.CONCLUSION This study has identified some routinely used modifiable parameters in predicting a higher risk of mortality and morbidity.This knowledge can be used in RTxR follow-up programs by addressing these parameters early to help reduce the morbidity and mortality in RTxRs.

Clinical outcomes of coronavirus disease 2019 in liver transplant recipients

BACKGROUND Liver transplant patients are at higher risk of infection due to immunosuppression.Whether liver transplant recipients are also more susceptible to severe acute respiratory syndrome coronavirus 2(SARS-CoV-2)and will have worse outcomes than the general population if they develop coronavirus disease 2019(COVID-19)due to SARS-CoV-2 is a topic of ongoing studies,including ours.AIM To assess the clinical outcomes of COVID-19 in liver transplant recipients.METHODS This was a case-control study,with a database search performed(at the study site)from March 1,2020 through February 28,2021.Patients 18 years or older who tested positive for SARS-CoV-2 via polymerase chain reaction(PCR)were included in the study.Patients with infection other than pneumonia at the time of admission were excluded.After selection,patients who had been the recipient of liver transplant were considered cases and those without as controls.After being matched by age,sex,and obesity,two controls were randomly selected for each case.Death and hospitalization due to COVID-19 infection were the primary outcomes.Secondary outcomes were pertinent only to patients who were hospitalized,and they included duration of hospital stay,need for supplemental oxygen,presence of at least one type of end-organ damage,effects on liver enzymes,incidence of acute liver failure,effect on d-dimer levels,and incidence of venous thromboembolism(VTE).Chi-square or Fisher’s exact test was used to compare all primary and secondary outcomes with the exception of duration of hospital stay and d-dimer levels,which were compared using the Wilcoxon signed-rank test.Alpha criterion was set at 0.05.Logistic regression was performed for each primary outcome(as the dependent variable).Statistical analyses were performed using R software.RESULTS Of the 470 Liver transplant recipients who were tested for COVID-19 via the PCR test,39 patients tested positive(8.3%).There was no significant difference between cases and controls regarding death[odds ratio(OR):2.04,95%confidence interval(CI):0.14–29.17;P=0.60]and hospitalization rates(OR:1.38,95%CI:0.59–3.24;P=0.46).There also was no significant difference between cases and controls with respect to all secondary outcomes.Among all patients who had elevated liver enzymes,their levels were either normalized,improving,or remained stable at the time of discharge.No patient developed acute liver failure.Of the 31 hospitalized patients,27 received a prophylactic anticoagulation dose and no patient developed VTE in either group.Among cases who were hospitalized,immunosuppression was decreased in 5 patients and there was no change in immunosuppression among the remaining 7 patients.One patient died in each of these two subgroups.Logistic regression analysis was done,but all of the models had poor model predictions as well as insignificant predictors(independent variables).Therefore,they could not be used for either prediction or inference.CONCLUSION Clinical outcomes of COVID-19 in liver transplant recipients are not different than those without transplantation.COVID-19 should not impact timely health care access and immunosuppression continuation among these patients.

Metabolic and functional effects of exercise training in diabetic kidney transplant recipients

BACKGROUND Physical activity levels are significantly lower in kidney transplant(KT)recipients compared to the general population.The effects of exercise training in KT recipients with diabetes mellitus remain unclear,and so little is known about the role of increased exercise on cardiovascular risk and metabolic profile of KT patients.AIM To investigate the effects of a 6-mo home-based exercise training program on functional capacity,glucose levels and lipid profile of diabetic KT patients.METHODS In total,21 type II diabetic KT recipients were randomly assigned into two groups:Exercise(n=11,aged 52.9±10.1 years)and control(n=10,aged 53.01±9.5 years).All participants at baseline and the end of the study underwent biochemical tests for fasting plasma glucose levels,glycated hemoglobin and lipid profile and cardiopulmonary exercise testing for maximum oxygen uptake[(VO2)peak]estimation.The exercise group followed a 6-mo supervised home-based aerobic and progressive resistance exercise program of moderate intensity 3 times per week,while the control group continued to receive usual care.RESULTS At the end of the 6-mo study,the exercise group had significantly lower values in fasting plasma glucose by 13.4%(from 120.6±28.9 mg/dL to 104.8±21.9 mg/dL,P=0.01),glycated hemoglobin by 1.5%(from 6.7%±0.4 to 6.6%±0.4,P=0.01)and triglycerides by 8.5%(from 164.7±14.8 mg/dL to 150.8±11.6 mg/dL,P<0.05)and higher values in high-density lipoprotein by 10.2%(from 51.4±8.8 mg/dL to 57.2±8.7 mg/dL,P<0.05)and(VO_(2))_(peak)by 4.7%(from 22.7±3.3 to 23.8±4.2,P=0.02)than the control group.There were statistically significant differences between the two groups at the end of the study for fasting plasma glucose(decreased by 9.6%,P<0.05),triglycerides(decreased by 4.5%,P=0.04)and(VO_(2))_(peak)(increased by 4.4%,P=0.01).Finally,after training,there was a moderate,positive linear relationship between(VO_(2))_(peak)and glycated hemoglobin in the exercise group(r=0.408,P=0.03).CONCLUSION The results demonstrated that a 6-mo home-based mixed type exercise training program can improve the functional capacity,levels of glucose and lipid profile of diabetic KT recipients.

An Evaluation of the Benefit of Cytomegalovirus Prophylaxis with Acyclovir on Post-Transplant Cytomegalovirus Infection Prevention in a Population of Renal Transplant Recipients in Nigeria

Background: Cytomegalovirus (CMV) is an important infection in renal transplant recipients and may significantly impact recipients’ long-term outcome and graft survival. Objective: This study aimed to evaluate the benefit of prophylaxis with acyclovir on post-transplant CMV infection prevention in a population of renal transplant recipients in Lagos, Nigeria. Subjects and Methods: The study was a cross-sectional design involving renal transplant recipients attending post-transplant follow-up clinics in Lagos, Nigeria between October 2004 and July 2005. Data on the use of CMV prophylaxis were obtained from the hospital case records of the study subjects. Enzyme-Linked Immunosorbent Assay (ELISA) was employed to detect CMV IgM antibodies for the diagnosis of post-transplant CMV infection and Microsoft Excel and EPI-Info 2002 statistical software were used for data entry and analysis. Results: Forty (40) renal transplant recipients were studied, 32 recipients were males and 8 were females with M:F ratio of 4:1. The mean age of the recipients was 39 ± 11.6 years old. The recipients’ post-transplant duration ranged from 2 to 80 months (Mean 17.6 ± 18.6 months). Fifteen (37.5%) of the transplant recipients received acyclovir prophylaxis for six months, one recipient (2.5%) received ganciclovir prophylaxis for three weeks while 24 recipients (60%) received no prophylactic therapy. There was no significant difference in the prevalence of seropositive CMV-IgM between transplant recipients who used CMV prophylaxis and those who did not (Fisher exact p = 0.45). Conclusion: Prophylaxis with acyclovir for six months showed no significant benefit on post-transplant CMV infection prevention in renal transplant recipients.

Awareness of Cytomegalovirus Infection among a Population of Nigerian Kidney Transplant Recipients

Background: Cytomegalovirus (CMV) is the most important infection in kidney transplant recipients and has significant impact on long term recipient and graft survival. Objective: The aim of this study is to assess the level of awareness of CMV infection among a population of kidney transplant recipients in Lagos, Nigeria. Subjects and Methods: The assessment of the level of awareness of CMV infection among kidney transplant recipients attending post-transplant follow-up clinics in Lagos, Nigeria was done by means of a structured pre-tested self-administered questionnaire from October 2004 to July 2005. Results: A total of 40 kidney transplant recipients were studied. Thirty-two recipients were males and eight were females with M:F ratio of 4:1. The mean age of the recipients was 39 ± 11.6 years old. The recipients’ post-transplant duration ranged from 2 to 80 months (Mean 17.6 ± 18.6 months). Only four (10%) of kidney transplant recipients studied had ever heard of CMV infection and only one recipient (2.5%) was aware that CMV infection could affect a transplanted kidney, and that CMV infection could be transmitted from the donor kidney graft to the recipient. One recipient (2.5%) was aware that blood transfusion could be a mode of transmission of CMV infection. None of the recipients was aware that CMV infection could be sexually transmitted. All the four recipients who were aware of CMV infection obtained the information from their doctors. Conclusion: Despite its significant impact on kidney transplant recipient and graft survival, the level of awareness of CMV infection and its relevance to kidney transplantation was very low among kidney transplant recipients. Transplant units in the study environment should include information and education about CMV infection and its impact on the transplant recipient and graft survival in their counseling programme for transplant recipients.

The application of the necessity-concerns framework in investigating adherence and beliefs about immunosuppressive medication among Chinese liver transplant recipients

Objective： This study aimed to explore adherence to and beliefs about immunosuppressive medication using the Necessity-Concerns Framework（NCF） in liver transplant recipients.Methods： A cross-sectional study performed in recipients who were at least 3 months post liver transplantation. A convenience sample of 243 recipients was recruited. Self-reported medication adherence was measured by the Basel Assessment of Adherence with Immunosuppressive Medication Scale（BAASIS）. The NCF was operationalized using the Beliefs about Medication Questionnaire（BMQ） to assess the beliefs about necessity and concerns with taking immunosuppressive medication.Results： One-hundred-forty-five liver transplant recipients were non-adherent（59.67%）. Compared to adherers, non-adherers had lower beliefs regarding the necessity of taking immunosuppressive medication and lower scores on the necessity-concerns different from adherers.Conclusions： Non-adherence is common in liver transplant recipients. Non-adherers hold beliefs that are different from adherers. Efforts to increase adherence should be made by targeting medication beliefs.

Rapamycin increased development of CD4^+ CD25~h ighFoxp3^+ T cells of peripheral blood in liver transplant recipients

Objective To investigate the possible influence of immunosuppressive therapy,including sirolimus ( SRL) and calcineurin inhibitors ( CNI,tacrolimus) ,on level of Treg in liver allo - graft recipients. Methods Forty - seven liver transplant recipients with stable liver function were assessed for at least 2 years,and divided into

Clinical study of sirolimus-associated interstitial pneumonitis in kidney transplant recipients

Objective To studt the sirolimus ( SRL) - associated interstitial pneumonitis,which is a severe side effect of sirolimus therapy. Methods In 7 renal grafts treated with SRL,interstitial pneumonitis ( 8 times) was diagnosed. One patient suffered a relapse after

Risk factors for standard Tac-related nephrotoxicity in renal transplant recipients

Objective To investigate the factors for standard TAC - related nephrotoxicity in Tac - related nephrotoxicity in renal transplant recipients. Methods Clinical data of 132 patients in TAC - based regiment with a dose of 0. 15 - 0. 3 mg.kg -1.day -1and a trough level of 8 - 11 ug /L during the first 2 years post renal transplanta-

Supportive care in transplantation: A patient-centered care model to better support kidney transplant candidates and recipients

Kidney transplantation(KT),although the best treatment option for eligible patients,entails maintaining and adhering to a life-long treatment regimen of medications,lifestyle changes,self-care,and appointments.Many patients experience uncertain outcome trajectories increasing their vulnerability and symptom burden and generating complex care needs.Even when transplants are successful,for some patients the adjustment to life post-transplant can be challenging and psychological difficulties,economic challenges and social isola-tion have been reported.About 50%of patients lose their transplant within 10 years and must return to dialysis or pursue another transplant or conservative care.This paper documents the complicated journey patients undertake before and after KT and outlines some initiatives aimed at improving patient-centered care in transplantation.A more cohesive approach to care that borrows its philosophical approach from the established field of supportive oncology may improve patient experiences and outcomes.We propose the"supportive care in transplantation"care model to operationalize a patient-centered approach in transplantation.This model can build on other ongoing initiatives of other scholars and researchers and can help advance patient-centered care through the entire care continuum of kidney transplant recipients and candidates.Multi-dimensionality,multi-disciplinarity and evidence-based approaches are proposed as other key tenets of this care model.We conclude by proposing the potential advantages of this approach to patients and healthcare systems.Core Tip:Kidney transplant recipients and candidates face several uncertainties in their care journey and have several expressed unmet healthcare needs.We recommend a structured and comprehensive approach to transplant care across the entire continuum of a transplant patient’s journey similar to what has been developed in the field of oncology.The supportive care in transplantation model can operationalize patient-centered care and build on the efforts of other researchers in the field.We postulate that such a model would significantly improve care delivery and patients’experiences and outcomes and potentially decrease healthcare utilization and cost.INTRODUCTION Patients with kidney failure benefit from(KT)[1,2],and experience improved survival rates when compared with dialysis[3-6].KT studies,using validated instruments,have also consistently demonstrated that kidney transplant recipients(KTRs)experience better health-related quality of life and several improvements in other disease-specific domains when compared with dialysis[7].In countries where dialysis is out of reach for many,the diagnosis of kidney failure would be futile without KT[8].Thus,increasing KT has been a priority for the nephrology and transplant communities.This priority has been reflected in recent global trends:Of the 79 countries where data were available,the International Society of Nephrology’s Global Kidney Atlas reported that the prevalence of KTRs in 2023 was 279 per million population which represented an increase of 9.4%from the data published four years prior[8].Despite this growth,KT can be a challenging journey for many patients and it is sometimes regarded as a‘cure’,which does not conform with the reality that many patients experience[9-13].KTRs must maintain a life-long treatment regimen of medications,lifestyle changes,self-care and medical appointments[14-17].As poignantly stated by a young female transplant recipient,“I thought everything would change once I got my kidney.I thought I would be healthy again”but after experiencing multiple side effects of immunosuppressive medications and graft loss,she stated,“I am just a different kind of patient now”[18].Indeed,a significant proportion of patients experience graft failure and return to dialysis;it is estimated that over 50%return to dialysis within 10 years of KT[19-23].Patients are often not prepared for this outcome and report several psychosocial and physical ramifications of graft failure[24,25].Overall,high symptom burden,adverse effects of immunosuppressants,risk of graft rejection or failure and mortality,contribute to complex needs,vulnerability and uncertainties for patients,increasing their care needs and treatment burden[26-30].In this paper,we highlight the complex journey that KTRs and candidates undertake that can generate varied outcome trajectories and complex healthcare needs.We highlight the need for a comprehensive patient-centered approach to care and conclude with a proposal for a“supportive care in transplantation”care model.

Impact of bisphosphonate treatment on bone mineral density after kidney transplant

BACKGROUND Mineral bone disease is associated with chronic kidney disease and persists after kidney transplantation.Immunosuppressive treatment contributes to the patho-genesis of this disease.Bisphosphonate treatments have shown positive but inde-finite results.AIM To evaluate the effectiveness and safety of bisphosphonate treatment on post kidney transplantation bone mineral density(BMD).METHODS We included kidney transplant recipients(KTRs)whose BMD was measured after the operation but before the initiation of treatment and their BMD was measured at least one year later.We also evaluated the BMD of KTRs using two valid mea-surements after transplantation who received no treatment(control group).RESULTS Out of 254 KTRs,62(39 men)were included in the study.Bisphosphonates were initiated in 35 KTRs in total(20 men),1.1±2.4 years after operation and for a period of 3.9±2.3 years while 27(19 men)received no treatment.BMD improved significantly in KTRs who received bisphosphonate treatments(from-2.29±1.07 to-1.66±1.09,P<0.0001).The control group showed a non-significant decrease in BMD after 4.2±1.4 years of follow-up after surgery.Kidney function was not affected by bisphosphonate treatment.In KTRs with established osteoporosis,active treatment had a similar and significant effect on those with osteopenia or normal bone mass.CONCLUSION In this retrospective study of KTRs receiving bisphosphonate treatment,we showed that active treatment is effective in preventing bone loss irrespective of baseline BMD.

Translation and cross-cultural adaptation of the Kidney Transplant Questionnaire 25 to Greek

BACKGROUND Kidney transplantation leads to continuous improvement in the survival rates of kidney transplant recipients(KTRs)and has been established as the treatment of choice for patients with end-stage kidney disease.Health-related quality of life(HRQoL)has become an important outcome measure.It is highly important to develop reliable methods to evaluate HRQoL with disease-specific questionnaires.AIM To translate the disease-specific instrument Kidney Transplant Questionnaire 25(KTQ-25)to the Greek language and perform a cross-cultural adaptation.METHODS The translation and adaptation of the original English version of the KTQ-25 to the Greek language were performed based on the International Quality of Life RESULTS Eighty-four KTRs(59 males;mean age 53.5±10.7 years;mean estimated glomerular filtration rate 47.7±15.1 mL/min/1.73 m2;mean transplant vintage 100.5±83.2 months)completed the Greek version of the KTQ-25 and the 36-item Short-Form Health Survey,and the results were used to evaluate the reliability of the Greek KTQ-25.The Cronbach alpha coefficients for all the KTQ-25 dimensions were satisfactory(physical symptoms=0.639,fatigue=0.856,uncertainty/fear=0.661,appearance=0.593,emotions=0.718,total score=0.708).The statistically significant correlation coefficients among the KTQ-25 dimensions ranged from 0.226 to 0.644.The correlation coeffi-cients of the KTQ-25 dimensions with the SF-36 physical component summary(PCS)ranged from 0.196 to 0.550;the correlation coefficients of the KTQ-25 with the SF-36 mental component summary(MCS)ranged from 0.260 to 0.655;and the correlation coefficients of the KTQ-25 with the total scores with the SF-36 PCS and MCS were 0.455 and 0.613,respectively.CONCLUSION According to the findings,the Greek version of the KTQ-25 is valid and reliable for administration among kidney transplant patients in Greece.

Efficacy and Safety of Different Bisphosphonates for Bone Loss Prevention in Kidney Transplant Recipients： A Network Meta-Analysis of Randomized Controlled Trials

Background： Mineral and bone disorder is one of the severe complications in kidney transplant recipients （KTRs）. Previous studies showed that bisphosphonates had favorable effects on bone mineral density （BMD）. We sought to compare different bisphosphonate regimens and rank their strategies. Methods： We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials （CENTRAL） up to April 01, 2017,for randomized controlled trials （RCTs） comparing bisphosphonate treatments in adult KTRs. The primary outcome was BMD change. We executed the tool recommended by the Cochrane Collaboration to evaluate the risk of bias. We performed pairwise meta-analyses using random effects models and network meta-analysis （NMA） using Bayesian models and assessed the quality of evidence. Results： A total of 21 RCTs （1332 participants） comparing 6 bisphosphonate regimens were included. All bisphosphonates showed a significantly increased percentage change in BMD at the lumbar spine compared to calcium except clodronate. Pamidronate with calcium and Vitamin D analogs showed improved BMD in comparison to clodronate with calcium （mean difference [MD], 9.84; 95% credibility interval [CrI], 1.06-19.70）. The combination of calcium and Vitamin D analogs had a significantly lower influence than adding either pamidronate or alendronate （MD, 6.34; 95% CrI, 2.59-11.01 and MD, 6.16; 95% CrI, 0.54-13.24, respectively）. In temas of percentage BMD change at the femoral neck, both pamidronate and ibandronate combined with calcium demonstrated a remarkable gain compared with calcium （MD, 7.02; 95% CrI, 0.30-13.29 and MD, 7.30; 95% CrI, 0.32-14.22, respectively）. The combination of ibandronate with calcium displayed a significant increase in absolute BMD compared to any other treatments and was ranked best. Conclusions： Our NMA suggested that new-generation bisphosphonates such as ibandronate were more favorable in KTRs to improve BMD. However, the conclusion should be treated with caution due to indirect comparisons.

Pathologic analysis of donor grafts in 482 cases of renal transplantation recipients

Objective To evaluate the correlation between the pathologic findings of donor renal grafts and the post-transplantative diseases throuth the biopsies of donor grafts in 482 cases. Methods The renal structures of biopsies of the donor grafts in 482 cases were observed under microscope, and the pathologic findings combined with the post-transplantative conditions were analysed. Results After transplantation, acute rejection occurred in 71 cases,of when 16(22.5%) had adverse changes in donor grafts; chronic allograft nephropahty developed in 17 cases, of whom 7 (41.2% ) had adverse changes in donor grafts; elevated sera creatinine levels with unknown causes occurred in 39 cases, of whon 7(18.0% ) had adverse changes in donor grafts. The lesion of donor renal grafts had nothing to do with the acute rejection or other abnormalities after operation ( r≤ 0.3) but some kind of lesion had certain correlation with chronic allograft nephropathy(CAN, r 】0.3). Conclusion Routine biopsy of donor renal graft is

Clinical analysis of recipients with survival over ten years after cardiac transplantation:a report of 13 cases

Objective To retrospectively analyze clinical management and follow - up of 13 recipients with survival over ten years after cardiac transplantation. Methods Thirteen male recipients underwent orthotopic heart transplantation between August 1995 and June 2001 in our center and received standard immunosuppressive

Relationship of Transforming Growth Factor-β1 and Arginase-1 Levels with Long-term Survival after Kidney Transplantation

In this study, we compared the serum levels of transforming growth factor-β1 （TGF-β1）, interleukin-10 （IL-10）, and arginase-1 in long-term survival kidney transplant recipients （LTSKTRs） with those in short-term survival kidney transplant recipients （STSKTRs）. We then evaluated the relationship between these levels and graft function. Blood samples were collected from 50 adult LTSKTRs and 20 STSKTRs （graft survival approximately 1-3 years post-transplantation）. All patients had stable kidney function. The samples were collected at our institution during the patients＇ follow-up examinations between March 2017 and September 2017. The plasma levels of TGF-β1, IL- 10, and arginase- 1 were analyzed using enzyme-linked immunosorbent assays （ELISA）. The levels of TGF-β1 and arginase-1 were significantly higher in the LTSKTRs than in the STSKTRs. The time elapsed since transplantation was positively correlated with the levels of TGF-β1 and arginase-1 in the LTSKTRs. The estimated glomerular filtration rate was positively correlated with the TGF-β1 level, and the serum creatinine level was negatively correlated with the TGF-β1 level. Higher serum levels of TGF-β1 and arginase-1 were found in LTSKTRs than in STSKTRs, and we found that TGF-β1 was positively correlated with long-term graft survival and function. Additionally, TGF-β1 and arginase-1 levels were positively correlated with the time elapsed since transplantation. On the basis of these findings, TGF-β1 and arginase- 1 may play important roles in determining long-term graft survival. Thus, we propose that TGF-β1 and arginase-1 may potentially be used as predictive markers for evaluating long-term graft survival.

Adult-to-adult living donor liver transplantation for acute liver failure in China

AIM:To investigate the long-term outcome of recipients and donors of adult-to-adult living-donor liver transplantation(AALDLT) for acute liver failure(ALF).METHODS:Between January 2005 and March 2010,170 living donor liver transplantations were performed at West China Hospital of Sichuan University.All living liver donor was voluntary and provided informed consent.Twenty ALF patients underwent AALDLT for rapid deterioration of liver function.ALF was defined based on the criteria of the American Association for the Study of Liver Diseases,including evidence of coagulation abnormality [international normalized ratio(INR) ≥ 1.5] and degree of mental alteration without pre-ex-isting cirrhosis and with an illness of < 26 wk duration.We reviewed the clinical indications,operative procedure and prognosis of AALDTL performed on patients with ALF and corresponding living donors.The potential factors of recipient with ALF and corresponding donor outcome were respectively investigated using multivariate analysis.Survival rates after operation were analyzed using the Kaplan-Meier method.Receiver operator characteristic(ROC) curve analysis was undertaken to identify the threshold of potential risk factors.RESULTS:The causes of ALF were hepatitis B(n = 18),drug-induced(n = 1) and indeterminate(n = 1).The score of the model for end-stage liver disease was 37.1 ± 8.6,and the waiting duration of recipients was 5 ± 4 d.The graft types included right lobe(n = 17) and dual graft(n = 3).The mean graft weight was 623.3 ± 111.3 g,which corresponded to graft-torecipient weight ratio of 0.95% ± 0.14%.The segment Ⅴor Ⅷ hepatic vein was reconstructed in 11 right-lobe grafts.The 1-year and 3-year recipient's survival and graft survival rates were 65%(13 of 20).Postoperative results of total bilirubin,INR and creatinine showed obvious improvements in the survived patients.However,the creatinine level of the deaths was increased postoperatively and became more aggravated compared with the level of the survived recipients.Multivariate analysis showed that waiting duration was independently correlated with increased mortality(P = 0.014).Furthermore,ROC curve revealed the cut-off value of waiting time was 5 d(P = 0.011,area under the curve = 0.791) for determining the mortality.The short-term creatinine level with different recipient's waiting duration was described.The recipients with waiting duration ≥ 5 d showed the worse renal function and higher mortality than those with waiting duration < 5 d(66.7% vs 9.1%,P = 0.017).In addition,all donors had no residual morbidity.Furthermore,univariate analysis did not show that short assessment time induced the high morbidity(P = 0.573).CONCLUSION:Timely AALDLT for patients with ALF greatly improves the recipient survival.However,further systemic review is needed to investigate the optimal treatment strategy for ALF.