Announcing the best of 2018
The editors of the American Journal of Transplantation wish to thank all authors who have contributed to the journal over the past year and congratulate those who have published their work with us in 2018. We offer a top ten list for the year as a way to recognize the outstanding research that moves the field of transplantation forward, but realize that this influence extends far beyond these articles, and that the number “ten” is quite arbitrary. These are presented below by month of publication.
John Gill, Deputy Editor, Kenneth Newell, and Alexander Wiseman
In January, Takahashi et al described a novel mechanism of costimulation blockade–induced tolerance induction following lung transplantation, in which PD-1 expression by CD8+ T cells regulates the immune synapse with graft-infiltrating antigen-presenting cells with reduced effector memory cell differentiation. In the same issue, Hayanga and colleagues reported that bridging strategies in lung transplantation with extracorporeal circulatory support and/or ventilatory support offers substantial opportunity for successful transplantation, providing reassurance that exacerbation of underlying pulmonary disease should not automatically disqualify candidates from transplant.
In March, Bowring et al clarified the value of accepting kidneys from PHS-defined increased infectious risk deceased donors in the United States, demonstrating superior long-term survival for those kidney transplant candidates who accept these organs compared to those who decline these kidneys. In the same issue, a greater understanding of the evolution of renal function following living donation was provided by Matas et al, who noted that eGFR continues to rise for more than ten years postdonation. Despite slope differences between related and unrelated donors, postdonation eGFR trajectory did not explain the increase in end-stage renal disease after donation noted in previous reports. This finding is of particular importance when combined with the findings of Wainright et al (below).
In May, Axelrod et al confirmed the ongoing cost-effectiveness of kidney transplantation, a finding historically appreciated but not revisited in the current era of higher-risk donors and higher-risk candidates. Kidney transplantation using high-KDPI deceased donor, ABO-incompatible, or HLA-incompatible living donors were all cost-effective compared with dialysis. In the same issue, Wainright et al used data from the OPTN and CMS to assess the risk of ESRD in prior living kidney donors. They confirm and extend the findings of other groups demonstrating that the risk of ESRD in former living kidney donors is not uniform. Living donors with African ancestry, male sex, a higher BMI, or a lower predonation eGFR, or who were related to the recipient or lived in lower socioeconomic status neighborhoods at the time of donation had an increased risk of developing ESRD.
In the August issue, Stewart et al described a novel method to assess equity in the access of waitlisted kidney transplant recipients to transplantation with a kidney from a deceased donor organ. They noted that the introduction of KAS substantially improved equity in access to deceased donor kidney transplantation. However, while the implementation of KAS was associated with a significant reduction in the impact of a high cPRA on access to kidney transplantation, the donor service area in which the recipient was listed, the recipient’s blood type and the etiology of the recipient’s ESRD all contributed to persisting disparities in the access to deceased donor kidney transplantation.
Also in the August issue, Lai et al used a recently developed Liver Frailty Index (LFI) to assess the prevalence of frailty prior to and at three time points following liver transplantation. They observed that frailty before transplantation was closely associated with frailty following transplantation. They also reported that compared to pretransplant values, the LFI worsened at 3 months, was similar at 6 months, and improved at 12 months. However, despite the modest improvement in the LFI noted at one year, only a minority of liver transplant recipients who were frail prior to transplantation attained a state of robustness following transplantation. As liver transplantation often fails to reverse a pre-existing state of frailty, the authors call for aggressive interventions to reduce frailty in patients awaiting liver transplantation.
In September, Zuckerman et al reported the results of a multi-center, NIH-sponsored study conducted by the CTOTC consortium to determine the incidence, pattern and clinical impact of de novo DSA in pediatric heart transplant recipients. The authors report that one third of recipients developed de novo DSA. This occurred primarily at early time points following transplantation and was associated with an increased incidence of ACR but not ABMR. The development of de novo DSA had no impact on the incidence of graft or patient survival at one year.
In December, McCaughan et al reported the effect of epitope mismatches on the development of de novo DSA following heart or lung transplantation. High-risk epitope mismatches were associated with an increased risk of developing de novo DSA. The authors describe the generation of a theoretical allocation algorithm that avoids high-risk epitope mismatches thereby reducing the risk of de novo DSA without additional testing, eplet analysis, or cost.
Takahashi et al
Hayanga et al
Turn down for what? Patient outcomes associated with declining increased infectious risk kidneys
Bowring et al
Matas et al
Risk of ESRD in prior living kidney donors
Wainwright et al
An economic assessment of contemporary kidney transplant practice
Axelrod et al
Measuring and monitoring equity in access to deceased donor kidney transplantation
Stewart et al
Physical frailty after liver transplantation
Lai et al
Zuckerman et al
McCaughan et al