Research Spotlight

Wall, A. E., G. Testa, D. Axelrod and L. Johannesson (2021). “Uterus transplantation-questions and answers about the procedure that is expanding the field of solid organ transplantation.” Proc (Bayl Univ Med Cent) 34(5): 581-585.

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Uterus transplant is a new and rapidly evolving field of solid organ transplantation designed to help women with absolute uterine-factor infertility who desire to carry their own pregnancies. The advent of this procedure and human clinical trials of uterus transplantation have raised technical, clinical, and ethical questions. We address several questions about uterus transplantation based on available literature and the clinical experience at Baylor University Medical Center, which has the largest uterus transplant program in the United States.

Kasiske, B. L., Y. S. Ahn, M. Conboy, M. A. Dew, C. Folken, M. L. Levan, A. Humar, A. K. Israni, D. L. Rudow, J. F. Trotter, A. B. Massie and D. Musgrove (2021). “Outcomes of living liver donor candidate evaluations in the Living Donor Collective pilot registry.” Clin Transplant Aug 3. [Epub ahead of print].

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BACKGROUND: To gather information on long-term outcomes after living donation, the Scientific Registry of Transplant Recipients (SRTR) conducted a pilot on the feasibility of establishing a comprehensive donor candidate registry. METHODS: A convenience sample of 6 US living liver donor programs evaluated 398 consecutive donor candidates in 2018, ending with the March 12, 2020, COVID-19 emergency. RESULTS: For 333/398 (83.7%), the donor or program decided whether to donate; 166/333 (49.8%) were approved, and 167/333 (50.2%) were not or opted out. Approval rates varied by program, from 27.0% to 63.3% (median, 46%; intraquartile range, 37.3-51.1%). Of those approved, 90.4% were white, 57.2% were women, 83.1% were < 50 years, and 85.5% had more than a high school education. Of 167 candidates, 131 (78.4%) were not approved or opted out because of: medical risk (10.7%); chronic liver disease risk (11.5%); psychosocial reasons (5.3%); candidate declined (6.1%); anatomical reasons increasing recipient risk (26.0%); recipient-related reasons (33.6%); finances (1.5%); or other (5.3%). CONCLUSIONS: A comprehensive national registry is feasible and necessary to better understand candidate selection and long-term outcomes. As a result, the US Health Resources and Services Administration asked SRTR to expand the pilot to include all US living donor programs.

Wey, A., S. Noreen, S. Gentry, M. Cafarella, J. Trotter, N. Salkowski, D. Segev, A. Israni, B. Kasiske, R. Hirose and J. Snyder (2021). “The effect of acuity circles on deceased donor transplant and offer rates across MELD and exception statuses.” Liver Transpl Sep 5. [Epub ahead of print].

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Acuity circles (AC), the new liver allocation system, was implemented on February 4, 2020. Difference-in-differences analyses estimated the effect of AC on adjusted deceased donor transplant and offer rates across pediatric and adult models for end-stage liver disease (P/MELD) categories and types of exception statuses. The offer rates were the number of first offers, top 5 offers, and top 10 offers on the match run per person-year. Each analysis adjusted for candidate characteristics, and only used active candidate time on the waiting list. The before-AC period was February 4, 2019, to February 3, 2020, and the after-AC period was February 4, 2020, to February 3, 2021. P/MELD 29-32 and P/MELD 33-36 candidates had higher transplant rates than P/MELD 15-28 candidates after AC compared to before (transplant rate ratios: P/MELD 29-32, (2.34) 3.32(4.71) ; P/MELD 33-36, (1.70) 2.51(3.71) ). P/MELD 29 or higher candidates had higher offer rates than P/MELD 15-28 candidates, and P/MELD 29-32 candidates had the largest difference (offer rate ratios [ORR]: 1(st) offers, (2.77) 3.95(5.63) ; top 5 offers, (3.90) 4.39(4.95) ; top 10 offers, (4.85) 5.30(5.80) ). Candidates with exceptions had lower offer rates than candidates without exceptions for offers in the top 5 (ORR: hepatocellular carcinoma [HCC], (0.68) 0.77(0.88) ; non-HCC, (0.73) 0.81(0.89) ) and top 10 (ORR: HCC, (0.59) 0.65(0.71) ; non-HCC, (0.69) 0.75(0.81) ). P/MELD 15-28 and HCC exception recipients received a larger proportion of donation after circulatory death (DCD) donors after AC than before, although the differences in the liver donor risk index was comparatively small. Thus, P/MELD 29-34 and non-exception candidates had better access to transplant after AC, and donor quality did not notably change beyond the proportion of DCD donors.

Tolia, V. N., R. Hunter Clark, Jr., B. Perelmuter, J. A. Frankfurt, K. A. Ahmad, M. E. Abrams, J. L. Cohen and R. H. Clark (2021). “Hydrops fetalis-trends in associated diagnoses and mortality from 1997-2018.” J Perinatol Aug 12. [Epub ahead of print].

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OBJECTIVES: To describe and evaluate trends in the etiology and mortality risk in neonates admitted for neonatal intensive care with hydrops fetalis. STUDY DESIGN: A retrospective review of de-identified patient data in the Pediatrix Clinical Data Warehouse from 1997 to 2018. RESULTS: We identified 2144 infants diagnosed with hydrops fetalis. The most common diagnoses were congenital heart disease (n = 325, 15.2%), genetic diagnoses (n = 269, 12.5%) and cardiac arrhythmia (n = 176, 8.2%). Of 2144 neonates, 988 (46%) survived to hospital discharge and 775 (36%) died prior to discharge. Mortality rate was highly variable across diagnoses, ranging from 90% in infants with congenital diaphragmatic hernia to 0% in infants with atrial flutter. Over the study period, more infants were diagnosed with trisomies and fewer with twin-to-twin transfusion. Mortality decreased by 5% from 1997-2007 to 2008-2018. CONCLUSIONS: The risk of death among neonates with hydrops fetalis is highly dependent on the underlying cause, with increasing risk of mortality at lower gestational ages.

Hagadorn, J. I., M. L. Shaffer, V. N. Tolia and R. G. Greenberg (2021). “Covariation of changing patent ductus arteriosus management and preterm infant outcomes in Pediatrix neonatal intensive care units.” J Perinatol Aug 5. [Epub ahead of print].

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OBJECTIVE: To test the hypothesis that NICU-specific preterm infant outcomes co-vary with changes in local patent ductus arteriosus (PDA) management. STUDY DESIGN: This retrospective multicenter study examined NICU-specific aggregated data for infants born 400-1499 g (VLBW) in the Pediatrix Clinical Data Warehouse. For each NICU and each year 2006-2016 we calculated proportion of infants receiving cyclooxygenase inhibitor (COXI) and/or PDA ligation and determined NICU-specific changes in these therapies between consecutive years. We examined relationships between NICU-specific changes in COXI/ligation and concurrent changes in local adjusted in-hospital outcomes. RESULTS: In 5678 observations of change at 259 NICUs summarizing 78,105 infants, between-year decreases in NICU-specific proportion treated with COXI/ligation were associated with concurrent increases in local mortality and decreases in BPD among infants 400-749 g, and with decreased pulmonary hemorrhage in larger infants. CONCLUSIONS: NICU-specific adjusted mortality, BPD, and pulmonary hemorrhage rates co-vary with changes in local COXI/ligation rates in some VLBW infant subgroups.