No abstract

Rising expenditures threaten healthcare sustainability. While transplant programs are typically considered profitable, transplant medications are expensive and frequently targeted for cost savings. This review aims to summarize available literature supporting cost-containment strategies used in solid organ transplant. Despite widespread use of these tactics, we found the available evidence to be fairly low quality. Strategies mainly focus on induction, particularly rabbit antithymocyte globulin (rATG), given its significant cost and the lack of consensus surrounding dosing. While there is higherquality evidence for high single-dose rATG, and dose-rounding protocols to reduce waste are likely low risk, more aggressive strategies, such as dosing rATG by CD3+ target-attainment or on ideal-body-weight, have less robust support and did not always attain similar efficacy outcomes. Extrapolation of induction dosing strategies to rejection treatment is not supported by any currently available literature. Cost-saving strategies for supportive therapies, such as IVIG and rituximab also have minimal literature support. Deferral of high-cost agents to the outpatient arena is associated with minimal risk and increases reimbursement, although may increase complexity and cost-burden for patients and infusion centers. The available evidence highlights the need for evaluation of unique patient-specific clinical scenarios and optimization of therapies, rather than simple blanket application of cost-saving initiatives in the transplant population.

Purpose Direct-acting antivirals (DAAs) allow for successful transplantation of livers from hepatitis C nucleic acid test (NAT)–positive donors to negative recipients. However, limited data exist to support crushing DAAs in patients with multiple absorption concerns or significant drug interactions. Summary Crushed sofosbuvir/velpatasvir has been successfully used in nontransplant patients with dysphagia, but data in transplant patients with absorption concerns are limited. A 31-year-old hepatitis C–negative female underwent liver transplantation from a hepatitis C NAT–positive donor. Her postoperative course was complicated by a mucormycosis infection, gastrointestinal bleed, and necrotizing pancreatitis requiring treatment with liposomal amphotericin B and pantoprazole 80 mg twice daily. Surgical interventions included an above-the-knee amputation and ileostomy. Hepatitis C treatment was initially delayed because of concern for reduced absorption with crushed DAA administration through the nasogastric (NG) tube, high ileostomy output, gastrointestinal bleed, pancreatitis, and a known drug interaction with pantoprazole. One month after transplantation, the patient’s bilirubin level remained elevated and hepatitis C treatment was initiated with sofosbuvir/velpatasvir. Crushed sofosbuvir/velpatasvir was mixed with 30 mL of water and administered through the NG tube daily. Hepatitis C viral loads were obtained weekly during treatment to monitor efficacy. Although the patient died before evaluation of sustained virological response at 12 weeks, hepatitis C viral clearance was observed within 4 weeks of initiating treatment. Conclusion A liver transplant patient exhibited viral clearance of hepatitis C following administration of crushed sofosbuvir/velpatasvir in the setting of multiple absorption concerns.

Lung transplant recipients (LRs) have a reduced median 5-year survival of approximately 55% primarily due to chronic lung allograft dysfunction (CLAD). Statins have anti-inflammatory and immunomodulatory effects that may facilitate CLAD prevention. This study sought to evaluate statin effect on CLAD development. Adult bilateralLRs from January 2004 to October 2013 were included. Statin group included recipients with early statin use and continued for minimum 6 months. Propensity score matching was performed for age, gender, and native lung disease to select matched nonstatin group. Competing risk approach was used to evaluate statin effect on CLAD development at 3 years while controlling for acute rejection and CMV pneumonitis. A total of 130 patients were included in each group. CLAD cumulative incidence at 3 years for statin and nonstatin groups was 20.6% (CI: 11.8%-33.5%) and 22.4%

Introduction: The variability of clinical research experiences for solid organ transplant (SOT) trainees is complex and involves close inspection of program personnel, values, and expectations. It is unknown how these variables impact early career publication (ECP) success and continued participation in research. Objectives: The purpose of this study was to assess the incidence of ECPs among SOT clinical pharmacists, to describe training and early career research experiences, and to describe factors associated with ECPs. Methods: A 53-question electronic survey was distributed through three SOT pharmacy listservs from 11/1/202 to 12/3/2021. Eligible respondents were SOT pharmacists who completed specialty training from 2015 to 2021. The survey captured data on publication success, perception of training received, and early career research endeavors. Multivariate analysis assessed factors associated with ECP.Results: A total of 92 individuals were included in the analysis (36.9% response rate).A majority of respondents were female (73.9%), completed postgraduate year 2 (PGY2) residency training only (93.5%), and currently serve in hybrid clinical specialist positions (having inpatient and outpatient roles) (67.4%). The incidence ECP among respondents was 42.3% (33/78). Within their jobs, research and/or quality assurance and performance improvement (QAPI) participation was common (83.3%, 65/78). Protected time for research (21.8%, 17/78) and formal research mentorship (7.7%, 6/78) were not frequent and did not alter ECP success. Multiple publications during training (odds ratio [OR] 13.9, 95% confidence interval [CI] 1.90-101.37, P = 0.01) was associated with ECP. SOT pharmacists with hybrid clinical specialist positions had lower ECP obtainment (OR 0.06, 95% CI 0.004-0.89, P = 0.04). Conclusions:The incidence of ECP was 42.3%. Research and QAPI are common components of SOT training and SOT pharmacists' jobs, yet experiences are diverse with great variability for support and structure guiding these endeavors and influencing their eventual success.