Matthew Ambrosio

This study evaluates whether contrast-enhanced ultrasound (CEUS) serves as an effective next-step imaging modality for patients with end-stage renal disease (ESRD) who have indeterminate renal lesions on computed tomography (CT), assessing its diagnostic performance and potential impact on surgical decision-making. A retrospective chart review was conducted on patients with ESRD who underwent both CEUS and CT between 2021 and 2024 within the VCU Health System. The primary lesion analyzed in each case was the one most concerning for malignancy per the radiology report. If no malignancy was suspected, the largest lesion was selected. Imaging findings from CEUS and CT were assessed based on radiology reports and compared against histopathological results and clinical follow-up. A total of 76 patients met the inclusion criteria. There was no significant difference in lesion characterization accuracy between CEUS and CT ( P =0.51), lesion diameter ( P =0.70), or location ( P =0.87). Among the 12 patients who underwent surgery due to suspected lesion malignancy, 11 (91.7%) were referred for surgery based on CEUS findings, with 100% confirmed malignancy on histopathology. CEUS demonstrates diagnostic performance comparable to CT for characterizing indeterminate renal lesions in patients with ESRD. When used as the next step after noncontrast CT, CEUS can reliably guide surgical decision-making while minimizing contrast and radiation exposure. Early integration of CEUS into structured clinical pathways may streamline evaluation, reduce delays to definitive management, and support timely progression toward transplant eligibility. Its safety, accessibility, and cost-effectiveness make CEUS a valuable tool for guiding care in this complex population.

BACKGROUND: Heart transplantation in the United States is increasingly performed amid expanding Medicare and Medicaid coverage. We analyzed the impact of recipient insurance trajectories on long-term graft and recipient survival following the 2018 United Network for Organ Sharing heart allocation change. METHODS: Adults aged 18 to 64 years undergoing first-time heart transplantation between October 2018 and March 2024 were identified from the national United Network for Organ Sharing solid-organ transplant registry. Recipients surviving ≥1 year were stratified by insurance trajectory across waitlisting, transplantation, and 1-year follow-up into 5 groups: continuous private, continuous public (Medicaid, Medicare, or Veterans Affairs), private-to-public transition, public-to-private transition, and multiple transitions. All-cause mortality and graft failure through 5 years posttransplant were assessed using Kaplan-Meier and multivariable Cox proportional hazards models with continuous private insurance as the referent. RESULTS: Among 15 864 recipients (mean age, 50.9±11.4 years; 31% female), 42.5% had continuous private insurance, 33.9% continuous public, 12.6% private-to-public, 4.8% public-to-private, and 6.3% multiple transitions. Five-year mortality was higher with continuous public insurance (15.1%) and multiple transitions (14.6%) than with continuous private (11.9%), and 5-year graft failure followed the same pattern (4.3% and 3.6% versus 3.2%). Continuous public insurance (hazard ratio [HR], 1.27 [95% CI, 1.15–1.40]) and multiple transitions (HR, 1.19 [95% CI, 1.12–1.43]) were independently associated with increased mortality. Continuous public insurance (HR, 1.29 [95% CI, 1.06–1.56]), private-to-public transition (HR, 1.32 [95% CI, 1.03–1.71]), and multiple transitions (HR, 1.09 [95% CI, 1.07–1.55]) elevated graft failure risk; public-to-private transition was associated with lowered risk (HR, 0.73 [95% CI, 0.45–0.92]). Residence in distressed communities was independently associated with increased mortality (HR, 1.21 [95% CI, 1.12–1.57]) and graft failure (HR, 1.31 [95% CI, 1.20–1.41]). CONCLUSIONS: Public insurance and insurance instability are associated with worse heart transplantation outcomes, while gaining private insurance was associated with improved outcomes, highlighting disparities in posttransplant care.

Background: Direct-acting antivirals (DAAs) achieve high sustained virologic response (SVR) in hepatitis C virus (HCV) patients with cirrhosis, yet the risk of hepatic decompensation or hepatocellular carcinoma (HCC) persists. Fibrosis-4 (FIB-4), a pre-treatment index that predicts advanced fibrosis, is linked to HCC risk post SVR. We compared post-SVR outcomes and care engagement, and determined the optimal pre-treatment FIB-4 index to predict the risk of HCC or decompensation in HCV patients with cirrhosis treated at the Department of Corrections (DOC) and non-DOC clinics. Methods: HCV patients with cirrhosis treated with DAAs since 2014 in the HCV Treatment Registry were included. Cirrhosis was defined by elastography, imaging, or clinical criteria. Patients with prior decompensation or HCC were excluded. Outcomes (HCC, decompensation) were collected from records. The FIB-4 index was compared between DOC and non-DOC groups. Results: Among 2104 cirrhotic patients (mean age 54; 76% male), 53% were treated in DOC via telemedicine and 47% in non-DOC clinics. HCC developed in 4.8% and decompensation in 8.1%. DOC patients had lower FIB-4 scores and SVR, partly from higher loss to follow-up (9% vs. 1%). Of 1581 with follow-up, surveillance was more common in non-DOC, which also had higher HCC and decompensation. A higher baseline FIB-4 index independently predicted HCC and decompensation (cutoffs: 3.24, 3.7; AUROC 0.79, 0.75, respectively). Conclusions: Despite SVR, cirrhotic patients—especially with a high FIB-4 index—remain at risk for HCC and decompensation. Outcomes differ by care setting, highlighting the need for continued AASLD-recommended surveillance post-SVR.

Background: As COVID‐19 becomes endemic, evaluating COVID‐19+ donors for heart transplantation (HT) remains important. We assessed long‐term outcomes using national data and propensity‐matched analysis. Methods: All adults (>18 years) undergoing HT between 4/2020 and 9/2024 were identified in the UNOS database. They were stratified into COVID‐19+ versus –, defined by either a positive nucleic acid or antigen test within 7 days of HT. Groups were then 3:1 nearest propensity score matched. Survival was estimated by the Kaplan–Meier method. Mortality risk was assessed using Cox regression models. Results: A total of 879 recipients of COVID‐19– hearts were matched with 293 recipients of COVID‐19+ hearts. We found no significant differences in 3‐year landmark survival between cohorts ( p  = 0.23). Rates of acute rejection ( p  = 0.15), length of hospital stay (LOS) ( p  > 0.9), and postoperative stroke ( p  = 0.53) did not differ significantly between groups. However, dialysis (17% vs. 12%, p  = 0.04) and primary graft dysfunction rates at 24‐h post‐HT were significantly higher in COVID‐19+ heart recipients (5.5% vs. 1.8%, p  = 0.01). Donor COVID‐19+ status was not significantly associated with mortality risk (HR 1.01, p  = 0.66). COVID‐19+ donor HTs in recent years (2022–2024) were associated with decreased mortality risk (HR 0.82, p  = 0.02), rates of acute rejection ( p  < 0.001), LOS ( p  = 0.01), and dialysis (18% vs. 8.9%, p  = 0.03). Conclusions: COVID‐19+ hearts demonstrate adequate long‐term outcomes, particularly in recent years. Future studies should assess the impact of donor vaccination to optimize survival benefits.

Background: In donation after circulatory death (DCD) heart transplants, choosing an optimal procurement method between normothermic regional perfusion (NRP) and direct procurement and preservation on the TransMedics Organ Care System (OCS) remains an important consideration. Thus, we aimed to evaluate long-term outcomes between NRP and OCS in DCD heart transplants. Methods: Using the UNOS registry, we queried all adults (≥18 years old) undergoing DCD and donation after brain death (DBD) heart transplantation between December 2019 and September 2023. TransMedics OCS donors were defined by time from death to clamp ≤30 minutes. Comparatively, NRP donors were defined by time from death to clamp >30 minutes. Kaplan–Meier recipient and graft survival analyses were conducted. Multivariate Cox proportional hazard models were used to identify independent predictors of mortality. Results: We identified 11,767 DBD transplants, 507 OCS, and 265 NRP recipients. Acute rejection rates were not significantly different between groups (p = 0.42). However, significant differences in overall survival were identified between DBD, OCS, and NRP (p = 0.019). Nonetheless, this difference may be attributed to a significant decline in survival for OCS recipients at 3 years (60.7% vs. 78.8% for DBD vs. 83.3% for NRP). Moreover, there were significant differences in graft survival (p = 0.02), with NRP demonstrating superior outcomes at 3 years (83.3%) compared to 60.7% for OCS and 80.0% for DBD. Conclusion: Both procurement methods demonstrate comparable short-term survival and graft function. However, long-term outcomes are more favorable among NRP recipients than OCS and conventional DBD methods. Nevertheless, continued investigation is needed to understand why this mortality difference exists.