IntroductionIn pediatric solid organ transplant and bone marrow transplant recipients, there is minimal data describing coronavirus disease 2019 (COVID-19) vaccine uptake and effectiveness.Research QuestionsWhat is the real-world experience of COVID-19 vaccination, subsequent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, and vaccine efficacy in pediatric heart, liver, kidney and bone marrow transplant recipients?DesignThis observational cohort study assessed COVID-19 vaccination rates and outcomes between March 2020 and January 2024 among pediatric heart, liver, kidney, and bone marrow transplant recipients. This study was approved by the local institutional review board as exempt.ResultsOne hundred and thirty-three pediatric solid organ transplant or bone marrow recipients were included; 33 of 133 (24.8%) were unvaccinated, 100 and 133 (75.2%) had at least 1 dose, and 72 of 133 (54.1%) completed at least 3 doses of COVID-19 vaccination. Ninety-two SARS-CoV-2 infection episodes in 74 of 133 (55.6%) patients. Fifty-eight (63%) episodes were in those who were never vaccinated or before completion of 3 doses and 34 (36.9%) episodes were after completion of the primary series ( = 0.09). Hospitalization was required in 2 of 34 (5.9%) and 7 of 59 (11.9%) of the infections among vaccinated and unvaccinated patients. No severe cases occurred among vaccinated patients while severe infection was seen among those unvaccinated. Adjusted COVID-19 vaccine effectiveness against SARS-CoV-2 infection was estimated as 52.6% (95% CI 7.0% -72%).ConclusionCOVID-19 vaccine uptake remains suboptimal among pediatric transplant recipients and completion of primary series is low. Further studies to understand dynamics of vaccine acceptance and vaccine effectiveness among pediatric transplant patients are needed.

IntroductionWhile most transplant recipients remain sedentary posttransplant, some transplant recipients are able to meet and even exceed recommended physical activity levels.Research QuestionThe objective of this study was (1) to explore what physical activity levels 25 recipient athletes could sustain over a 7-month period while preparing for and participating in the World Transplant Games in cycling and/or triathlon, and (2) what intensity levels recipients sustained in competitive conditions.DesignThe study adopted an observational descriptive research design and used physical activity self-reported data of 25 recipient athletes and self-tracked data from online social fitness network apps such as Strava. It also examined World Transplant Games performance metrics to evaluate transplant athletes' capabilities in competitive settings.ResultsFindings revealed that transplant athletes exceeded the current physical activity level guidelines by 300% over a 7-month period, with an average of 8.33 h per week of self-reported activities and 4.67 h per week of self-tracked moderate to intense physical activity.ConclusionThe findings highlighted the need to consider the capabilities of transplant athletes in reassessing the current physical activity guidelines since the results demonstrated that enhanced performance in competition settings was attainable through physical activity and support. There is a need for more personalised physical activity metrics and recommendations for transplant recipients.

IntroductionLiving donor liver transplantation is expanding worldwide as a treatment for end-stage liver disease, especially in high-risk recipients. No standardized information is provided to donors during the informed consent process. Consequently, variable information may be provided to the donor about the recipient, which may undermine donor-informed consent.Research QuestionsIn high-risk donation scenarios, it is uncertain whether information disclosed about the recipient is sufficient for donor-informed decision-making. Would information about the recipient's potential adverse and beneficial short- and long-term outcomes help donors make a decision about donating?DesignAn online survey was conducted of previous living liver donors' likelihood of donating and information needs regarding their recipients in 3 hypothetical high-risk clinical scenarios: alcoholic liver disease (ALD) with high relapse risk, acute liver failure (ALF), and hepatocellular carcinoma (HCC) with high recurrence risk.ResultsA total of 98 living liver donors participated in this study. Most living liver donors expressed willingness to donate to a patient in each scenario: ALD (51%), ALF (56%), and HCC (85%). Most living liver donors (56% to 93%) reported desiring information about the recipient's diagnosis, clinical condition, and projected outcomes in their donation decision-making process. Most living liver donors (82%) considered an acute consultation service to be useful in deciding whether to donate to a patient with ALF.ConclusionsThe findings suggested that transplant programs should incorporate recipient health information with recipient consent into the informed consent process and offer consultation services to support living liver donors' decision-making.

IntroductionWomen comprise 55% to 65% of living kidney donors. Most studies focus on individuals who underwent donor nephrectomies, rather than potential living donors prior to engagement with the healthcare system. Therefore, the underlying reasons for gender discrepancy are unclear.Research questionAmong relatives of patients with renal disease, do men and women differ in willingness to be evaluated for living kidney donation, regardless of prior donation behavior?DesignAn online survey administered in 2019 to US adult members of the Qualtrics Survey Panel whose relatives had weak or failing kidneys. The survey was designed to examine perspectives of living kidney donation from realistic potential donors. Self-reported willingness was compared between men and women for statistically significant differences. Average marginal effects of male gender on willingness and interaction effects estimated with multivariable logistic regression, adjusted for respondent/patient demographics and relationship.ResultsA total of 1647 responses showed 7.1% higher willingness among men ( = .016). Among those whose relatives ( = 808) were seeking transplants [subgroup], men had 13.1% higher willingness ( = .002). Interaction effect analysis showed men aged 70 to 79 years, with insurance, self-reported very good health, and self-reported medical contraindications, had significantly higher willingness than corresponding women. In the transplant subgroup, men aged 18 to 39 years and with full-time employment also had higher willingness.ConclusionMen showed 7.1% higher willingness to be evaluated for living kidney donation. Rather than reflecting a fixed difference, the existence and degree of gender difference were context-dependent. Identifying strategic interventions to facilitate male donation in contexts where they reported high willingness could improve access to transplantation.

IntroductionPostoperative atrial fibrillation is an arrhythmia that may complicate postsurgical care in kidney transplant recipients and is associated with longer hospitalizations, postsurgical complications, and increased in-hospital mortality. Pathophysiology is not well understood but is thought to be multifactorial. Iatrogenic hypervolemia may contribute to the incidence of postoperative atrial fibrillation. Project AimsThe program evaluation aim was to evaluate the effects of furosemide concentration on reducing volume overload, and subsequently postoperative atrial fibrillation incidence. DesignThis was a single-center, retrospective, cohort study that analyzed kidney transplant recipients during index hospitalization. Recipients receiving furosemide infusions of 500 mg/50 mL between June 2022 and May 2023 were considered the concentrated group and recipients receiving infusions of 500 mg/250 mL between January 2013 and December 2017 were the dilute group. ResultsThere was no difference identified in atrial fibrillation rates when using concentrated versus dilute furosemide infusions (7.7% vs 12.4%; = .101). When excluding those with immediate graft function, there was a lower incidence in the concentrated group (9.3% vs 22.0%, = .031) compared to slow/delayed graft function. Recipients in the concentrated infusion group had higher rates of high (11.7% vs 35.1%) and very high (3.0% vs 14.9%) cardiovascular risk (< .001). Recipients receiving concentrated infusions had improvement in net fluid balance (0.4 L vs 1.4 L; < .001) with higher furosemide exposure (2.3 g vs 1.4 g; < .001). ConclusionsPostoperative atrial fibrillation rates were similar between groups, Recipients with slow/delayed graft function had lower rates of postoperative atrial fibrillation with concentrated furosemide.

Rising discrepancies between supply and demand of lifesaving organs necessitates considering advancements to improve the health outcomes of Canadians. There is an increased use of organs after death by circulatory criteria, however the evolution of this treatment should be explored to continue to advance practices and save lives. To summarize the literature on the evolution and use of organ donation after death by circulatory criteria in Canada, to highlight how this donation modality may support future advancements. A search of electronic databases for any date until June 1st, 2024, was performed. Additional searches of grey literature using Google Scholar and the snowball technique were performed. Applicable documents underwent a multi-phase screening process, and data were extracted, analyzed, and evaluated. There were 793 documents located, and 50 were included in this review. Three main categories emerged among the documents that described the evolution of guidelines for death by circulatory criteria organ donation, experiences with program development and delivery for death by circulatory criteria organ donation and Canadian perspectives of this donation modality. Canada has made strides in circulatory criteria organ donation practices through consensus meetings and discussions on key topics, yet variations in practice exist across the country that warrant further investigation when considering future advancements. While national efforts have advanced practices, ongoing variations across programs highlighted the need for continued evaluation, education and harmonization to maximize the life-saving potential of organ donation practices.

Posttransplant sleep disturbances may influence recovery, immunosuppressive adherence, and graft outcomes. This study examined sleep disruption in acute renal transplant recipients and its relationship with medication comprehension and hospital stressors. A mixed-methods, pilot prospective cohort study was conducted at a metropolitan hospital in Australia. Consecutive renal transplant patients were recruited. Perioperative sleep patterns were assessed using the American Academy of Sleep Medicine's sleep diary. The Kidney Transplant Understanding Tool evaluated medication comprehension. Qualitative data from semistructured interviews were analysed using inductive content analysis. Univariate linear regression assessed associations between sleep and perioperative outcomes ( ≤ .05). Ten recipients were recruited. Recipients averaged 5.2 hours of sleep per night with frequent disruptions. Sleep ranged from 0 to 10 hours per night, with the longest sleepless period being 41 hours. An inverse correlation was observed between sleep duration and medication comprehension scores(β=-8.736, = .0232), suggesting recipients with less sleep had better medication comprehension. Qualitative analysis identified sleep disruptions due to hospital practices, environmental factors, transplant-related stress, and medication side effects. Perioperative sleep disturbances were multifactorial, influenced by hospital and procedural factors. The paradoxical association between reduced sleep and increased medication comprehension highlights a complex interplay between stress, sleep, and cognitive engagement. This pilot study suggested that addressing sleep disturbances and incorporating culturally sensitive education may enhance perioperative care. However, further research is needed to validate these findings in larger cohorts.

IntroductionIntrapatient variability (IPV) of tacrolimus and its predictors post-lung transplant are unclear. Project AimsThis program evaluation aimed to characterize the IPV of immediate-release versus LCP-tacrolimus and predictors of variability ≥30% in lung transplant recipients. DesignAdult lung transplant recipients who received immediate-release- or LCP-tacrolimus from January 2016 through August 2023 were included in this single-center retrospective evaluation. Immediate-release- and LCP-tacrolimus groups were matched 2:1 by time from transplant, presence of azole antifungal, and ethnicity. Three previously published equations calculated IPV. Outcomes to determine clinical impact of tacrolimus variability included de novo donor-specific antibody (DSA) development, rejection, graft loss/mortality, eGFR <60 mL/min, infection. Time in therapeutic range was assessed. Data were analyzed to determine predictors of variability ≥30%. ResultsThere were no significant differences in the variability of immediate-release- versus LCP-tacrolimus among 3 equations used. There was no difference in de novo DSA development, rejection, graft loss, mortality, eGFR <60 mL/min, or infection between groups. Recipients with rejection during follow-up had higher variability compared to those who did not ( = .04). Presence of CYP34A inhibition predicted variability >30% in multivariate analysis. Immediate-release tacrolimus had higher time in therapeutic range versus LCP-tacrolimus, 67% versus 33%, ( = .15). ConclusionThe IPV and associated clinical outcomes of immediate-release versus LCP-tacrolimus in lung transplant recipients did not significantly differ. Development of acute cellular rejection within 1 year follow-up was associated with higher tacrolimus variability regardless of formulation.

Sleep quality after lung transplant is important for recovery, overall health, and performance of healthy behaviors, such as exercise. The purpose of this study was to explore the associations between sleep quality and factors likely to influence and/or be influenced by sleep. This was a secondary analysis of data from a randomized controlled trial of a tele-rehab exercise intervention for lung transplant recipients. Baseline demographic and clinical characteristics, sleep quality, physical activity, symptom burden, and psychological distress data were collected. Multivariate logistic regression model was used to identify factors associated with poor sleep quality. Participants (N=88) were aged 56.4 (13.0) years and male (54.5%). Seventy-four percent of the patients met the established cut-off for poor sleep quality and the mean Pittsburgh Sleep Quality Index total score was 7.1 (3.7). Recipients reported anxiety (n=21, 23.9%) and depression (n=27, 30.7%). When lung-specific items of the sleep questionnaire were explored, the reported presence of cough or snoring loudly was associated with poor sleep ( = .010). Patients reporting any psychological distress (n=33, 37.5%) had increased odds of experiencing poor sleep (odds ratio [OR]=13.72; 95% confidence interval [CI] =2.33, 264.7.01; =.017). In a model examining respiratory symptoms concurrently, wheezing increased the odds of reporting poor sleep quality (OR=10.88, 95% CI=1.65, 222.02; =.037). Clinical attention is needed to detect and manage symptom burden and psychological distress to improve sleep quality and optimize posttransplant recovery among lung recipients. Future studies examining these variables are needed to help guide screening and treatment protocols.

Due to increased risk of myalgia and rhabdomyolysis associated with the use of simvastatin with cyclosporine, use of high-intensity 3-hydroxy-3-methylglutaryl Coenzyme A reductase inhibitors (statins) is often avoided in transplant recipients. This program evaluation aimed to determine the safety of high-intensity statins in liver and kidney transplant recipients taking tacrolimus. All liver and kidney transplant recipients who filled prescriptions for tacrolimus and any statin except for simvastatin between June 15, 2020 and July 22, 2022 were screened for inclusion. High-intensity was defined as atorvastatin 40 or 80 mg, or rosuvastatin 20 or 40 mg. The primary outcome was a composite of statin-related myalgia, statin-related rhabdomyolysis, and creatine kinase above the upper limit of normal. Secondary outcomes included liver function tests above 3 times the upper limit of normal, statin discontinuation, and statin dose decrease and associated reason. A total of 178 recipients were included, with 100 receiving low-to-moderate-intensity statins and 78 receiving high-intensity statins. There were no differences between groups for statin-related myalgia, and no reported cases of statin-related rhabdomyolysis in either group. Low to moderate intensity statin use was associated with an increased rate of liver function test elevation (26% vs 11.5%, = .014) occurring a median of 306 days (interquartile range [IQR] 134-725) post-statin initiation. In liver and kidney transplant recipients receiving tacrolimus, the use of high-intensity statins was not associated with an increased risk of myalgia, rhabdomyolysis, or elevated creatinine kinase when compared with low-to-moderate-intensity statin use.

The transplant selection process for solid organ recipients relies on committee review and is susceptible to human nature and bias. The current model of selection committees has been under-examined and untested. Few studies exist on transplant selection committees. Barriers to quality decision-making have been studied in other industries. Lessons learned in other industries were explored and how they may be applied to a transplant selection committee. These include appointing an ethical representative or an advocate (pro) and dissenter (against) for discussion, adopting an ideal committee size/composition, and reviewing previous committee decisions (post-mortem). The transplant selection committee can function beyond a singular decision and be an opportunity to identify gaps in patients' treatment plans and available resources. Looking forward, a transplant selection committee that is more consistent, equitable, and protocolized can reduce bias, moral burden, and missed listings for our patients.

Sleep is essential for maintaining optimal physical and mental health as it supports crucial functions such as cognition, immune system regulation, and overall well-being. A growing emphasis on the importance of sleep warrants an investigation of sleep quality after lung transplantation. What is the overall prevalence, nature, and severity of patient-reported disrupted sleep quality after lung transplantation using the Pittsburgh Sleep Quality Index (PSQI)? This study employed a single-site, exploratory, cross-sectional descriptive design involving lung transplant recipients who completed an anonymous survey. Sleep quality was assessed using the PSQI scale. Additionally, participants provided self-reported data on demographic and transplant-related variables. The response rate was 38.4% (61/158) and 64% of the respondents (39/61) demonstrated PSQI >5 with a mean PSQI score of 8.07 (SD = 4.5), suggestive of poor sleep quality. Lung transplant recipients reported difficulties across all components of sleep quality with more challenges in the categories of sleep duration, sleep latency, sleep efficiency, and the use of sleep medications. The prevalence of poor subjective sleep quality among lung transplant recipients highlighted the importance of continued investigation into this phenomenon. Further research employing standardized measures, larger sample sizes, and longitudinal study designs is warranted to enhance understanding of poor sleep post-lung transplant. Such endeavors are crucial for informing the development of effective assessment strategies and interventions aimed at improving sleep outcomes in patients after lung transplantation.

IntroductionCharacteristics and the impact of frailty on adult solid organ transplant recipients have not been clearly described. The purpose of this integrative review was to identify characteristics of frailty and associations between frailty and patient mortality and graft failure in adult solid organ transplant recipients.MethodsAn integrative literature review was performed using Cooper's integrative methodology. PubMed, Excerpta Medica, and the Cumulative Index of Nursing and Allied Health Literature databases were searched using the terms frailty and transplant. Inclusion criteria were primary research reports, written in English, focusing on adult solid organ transplant recipients, and including graft or patient survival outcomes.ResultsThe review included 35 articles, were largely retrospective, and published between 2015 and 2023 in 11 different countries. Most studies were single-center studies that were not theory-based, and liver transplant recipients were highly represented. Males outnumbered females in the majority of studies and White race was represented in half of the studies. Most studies used one strategy to measure frailty, and modified versions of the Physical Frailty Phenotype were the measurement used most often. Of the 35 articles that investigated the association of frailty with patient mortality, 44 measures were used, and of those, 32 showed a significant association. For graft failure, of the 10 studies included, half showed a significant association between frailty and graft failure.ConclusionThis integrative review offers insights into the characteristics and the association between frailty, patient mortality, and graft failure.

Adverse effects from antimetabolites often lead to therapy adjustments; older patients may be more susceptible to these effects. Compare the intolerance of antimetabolites between older and younger lung transplant recipients. A single-center, retrospective analysis of adult lung transplant recipients transplanted between January 1, 2019 and October 31, 2021 was conducted. Patients were stratified by age at the time of transplant (≥60 or <60 years) and assessed for the first year posttransplant. The primary outcome was the incidence of antimetabolite intolerance (defined as dose adjustment, agent/formulation change, or holding/discontinuation of agent). Secondary outcomes included reason for intolerance, safety (infection and leukopenia), and efficacy (rejection and patient/graft survival). One hundred and nine recipients were included; 54 in the older (≥60 years) and 55 in the younger (<60 years) cohort. Most were initiated on azathioprine (74%) posttransplant. Antimetabolite intolerance occurred in 61% of older and 53% of younger recipients ( = 0.377). The most common reasons for intolerance were leukopenia followed by gastrointestinal side effects. Biopsy-proven acute rejection occurred more often in the older cohort (39% vs 18%,  = 0.017); this no longer remained significant when controlling for induction, indication, transplant type, gender, and antimetabolite intolerance (OR 0.36, 95% CI 0.11 to 1.15). There was no difference in the incidence of leukopenia, bacterial infection, or graft/patient survival within 1 year posttransplant. Antimetabolite intolerance between older and younger lung transplant recipients was similar. Most required modification to the initial antimetabolite regimen due to leukopenia and gastrointestinal side effects.

Dialysis social workers are integral in the transplant evaluation process; however, research on dialysis social workers' perspectives on access to kidney transplantation is limited. A mixed methods study examining dialysis social workers' perspectives on transplant barriers and facilitators. Dialysis social workers completed online surveys and participated in virtual, semi-structured interviews. Qualitative data were recorded, transcribed, and analyzed using thematic analysis. Quantitative data were analyzed descriptively. Twenty-seven dialysis social workers completed surveys, and 15 participated in qualitative interviews. Participants were predominantly female (93%) and White (89%). While the majority (67%) had practiced as a social worker for 6+ years, most had ≤5 years of dialysis experience (52%). The majority described the transplant referral process as somewhat easy (67%) and rated their relationship with transplant programs as either fair or good (78%). Both survey and interview data identified similar patient-level barriers, such as lack of social support and obesity. Interviews further elucidated organizational and system level barriers including tensions between dialysis and transplant centers, transplant center accessibility, and systemic discrimination. Identified facilitators included patient motivation, transplant center communication, and transplant resources. Dialysis social workers provided a unique perspective on barriers and facilitators to kidney transplantation. While barriers to transplant were often considered at the patient level, organizational and system level factors were crucial to understanding transplant access. These findings could inform future efforts between dialysis and transplant centers to improve access to kidney transplantation.

IntroductionEntertainment portrayals of organ donation continue to inform viewers' beliefs. Research showed many of the belief's individuals have about organ donation rose from exposure to popular entertainment programs such as Grey's Anatomy. Grey's Anatomy routinely portrays medical doctors in a realistic way as altruistic and heroic medical care providers.Research QuestionThe central question asked was whether favorable portrayals resulted in audience's perceiving real world doctors as altruistic and in turn, favorable organ donation registration attitudes.DesignThe current study employed a cross-sectional survey to adults.ResultsThe current study found a positive association between show exposure and show realism among adults ( = 211). Moreover, show realism was positively associated with a belief in doctor altruism. In turn, altruism was positively associated with favorable perceptions toward registering as an organ donor.ConclusionThe results showed that realism influenced beliefs about medical provider altruism, which in turn can affect attitudes toward organ donation. The next step in this research is to employ rigorous experimental designs to identify the specific contexts and narratives in which these medical portrayals have the greatest impact.

Research shows that donor families report feeling abandoned, lacking social support, and receiving insufficient aftercare services. To meet the needs of these families, Taylor's Gift Foundation developed a free, virtual grief support program that pairs participating donor family members with Caring Guides trained in assertive community engagement and offers peer-facilitated support groups. The aim was to assess participant experiences with Taylor's Gift Foundation grief support program to understand its impact on grief symptoms, donor family access to grief support, and perceived social support. Researchers conducted a qualitative evaluation using semi-structured interviews with 21 program participants. Results were analyzed using rapid qualitative analysis and descriptive statistics. Eighteen (86%) participants worked with Caring Guides, 12 (57%) attended an average of 7 support groups, and 8 (39%) worked with Caring Guides and attended support groups. Eleven (52%) program participants reported difficulties accessing mental health services. Most program participants (86%) reported a decrease in grief intensity since enrolling in the program. Effective aftercare services were critical in helping donor families cope with, and adapt to, their loss. The Taylor's Gift Foundation grief support program helped donor family members access otherwise inaccessible grief support services and provided a valuable means of social support.

Durable left ventricular assist devices serve as a critical bridge to heart transplantation for patients with advanced heart failure. Yet the demands placed on care partners (CPs) are often underestimated, and their well-being in supporting postimplant recovery is frequently overlooked. This qualitative single-site study explored the struggles and support needs of 13 CPs who participated in audio-recorded interviews following device placement. Data analysis, using inductive content analysis, revealed 6 major themes: feeling unprepared, being hypervigilant, feeling overwhelmed, the vanishing CP, lacking self-care, and needing connection with other CPs. Findings revealed that CPs often felt overlooked by healthcare teams, contributing to emotional distress and isolation, while inadequate education on perioperative complications and minimal peer support reinforced their sense of being unprepared. These results underscored the integral role that CP well-being played in sustaining successful device management and ensuring patients remained eligible for heart transplantation. Psychosocial services, peer support, and structured educational programs may help mitigate the strain experienced by CPs and improve transplantation outcomes. Embedding CP needs into the transplant pathway, beginning at implantation, was essential to preventing burnout, maintaining candidacy, and improving overall posttransplant success. Refinements in CP-centered interventions may help reduce hospital readmissions, enhance device adherence, and support emotional resilience. By prioritizing CP support within advanced heart failure management, transplant programs can optimize both patient and CP well-being and foster positive outcomes. Such focus ensures bridging to transplantation and hope for families.

IntroductionThe utility of routine monitoring of apixaban anti-Xa levels in lung transplant recipients remains uncertain due to insufficient data. This population presents unique characteristics including altered renal function and medication interactions that may affect serum apixaban concentrations. Project Aims: This study evaluated the correlation between apixaban anti-Xa levels and specific covariates in lung transplant recipients to identify influential variables.DesignData from adult inpatient lung transplant recipients who had received apixaban between August 8, 2021, and December 12, 2023, at a single transplant center was analyzed. Multiple linear regression analysis was conducted, adjusting for gender, age, serum creatinine, weight, azole antifungal use, package insert deviation, dose, and level timing. Safety was assessed based on thrombotic events and major bleeding incidents during hospital admission.ResultsSeventy-eight unique apixaban anti-Xa levels were analyzed. Higher age, serum creatinine, and apixaban dose, as well as closer level timing to administration and female gender correlated with elevated anti-Xa levels. Thrombotic events occurred in 27% of cases, with one major bleeding incident.ConclusionApixaban anti-Xa levels correlated with age, serum creatinine, dose, and timing of administration in lung transplant patients. This questions the utility and necessity of obtaining apixaban anti-Xa levels despite the unique patient cohort. Larger trials are needed to assess the absolute correlation of anti-Xa levels with bleeding and thromboembolic outcomes in this population.