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ABSTRACT: BACKGROUND: Blood loss during liver transplantation is not incorporated into the dominant models for post-transplant survival. Our objective was to investigate blood transfusion requirement as a risk factor for mortality after liver transplantation, and to further analyze risk factors for intraoperative blood transfusion requirement and hepatectomy time. STUDY DESIGN: We conducted a retrospective analysis of 233 consecutive liver transplant recipients over a span of 3 years by a single experienced surgeon. Mean follow-up was 2.5 years. Independent risk factors for patient survival after liver transplantation were identified using Cox proportion hazard regression. Independent risk factors for intraoperative blood transfusion requirement and hepatectomy time were identified using logistic regression. RESULTS: Two factors were identified as significant predictors in multivariate analysis for survival after liver transplantation: hepatocellular carcinoma (hazard ratio [HR] 1.9, 95% CI 1.1 to 3.2) and intraoperative blood transfusion requirement per unit (HR 1.01, 95% CI 1.0 to 1.02). Threshold analysis revealed that intraoperative blood transfusion volume ≥28 units or 85th percentile (HR 2.5, 95% CI 1.3 to 4.7) was a significant risk factor for patient survival. Four covariates were identified as significant risk factors for intraoperative blood requirement: warm ischemia time (odds ratio [OR] 1.12, 95% CI 1.06 to 1.18), bilirubin (OR 1.04, 95% CI 1.02 to 1.08), previous surgery (OR 1.7, 95% CI 1.02 to 2.9), and hepatectomy time (OR 1.01, 95% CI 1.00 to 1.02). The only risk factor for prolonged hepatectomy time was previous major abdominal surgery (OR 4.0, 95% CI 1.7 to 9.5). CONCLUSIONS: Intraoperative blood transfusion requirement is an important risk factor for mortality after liver transplantation. The strongest risk factors for intraoperative blood transfusion requirement are warm ischemia time and bilirubin levels. Intraoperative blood loss and its risk factors should be incorporated into models to predict survival after liver transplantation.
Journal of the American College of Surgeons 03/2013; · 4.55 Impact Factor
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Hasan Yersiz,
Coney Lee,
Fady M Kaldas,
Johnny C Hong, Abbas Rana,
Gabriel T Schnickel,
Jason A Wertheim,
Ali Zarrinpar,
Vatche G Agopian,
Jeffrey Gornbein,
Bita V Naini,
Charles R Lassman,
Ronald W Busuttil,
Henrik Petrowsky
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ABSTRACT: Accurate clinical assessment of hepatic steatosis before transplantation is critical for successful outcomes after liver transplantation especially if a pathologist is not available at time of procurement. The present prospective study investigated the surgeon's accuracy in predicting hepatic steatosis and organ quality in 201 adult donor livers. Steatosis assessment by a blinded expert pathologist served as the reference "gold standard". The surgeon's steatosis estimate was more strongly correlated with large droplet macrovesicular (ld-MaS) (r(S) =0.504) rather than small droplet macrovesicular stetaosis (sd-MaS) (r(S) =0.398). True microvesicular steatosis was present in only 2 donors (1%). Liver texture criteria (yellowness, absence of scratch marks, round edges) were mainly associated with ld-MaS (variance 0.62) and less with sd-MaS (variance 0.26). Prediction for ld-MaS?30% vs. <30% was excellent when liver texture criteria were used (accuracy 86%) but was less accurate for the surgeon's direct estimation of steatosis percentage (accuracy 75%). The surgeon's quality grading correlated with the degree of ld-MaS and surgeon's steatosis estimate as well as with the incidence of initial poor and primary non-function. In conclusion, the precise estimation of steatosis remains challenging even in experienced hands. Liver texture characteristics were more helpful in identifying macrosteatotic organs than the actual steatosis perception of the surgeon. These findings are especially important when the histological assessment in the donor hospital is not available. © 2013 American Association for the Study of Liver Diseases.
Liver Transplantation 02/2013; · 3.39 Impact Factor
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Vatche G Agopian,
Fady M Kaldas,
Johnny C Hong,
Meredith Whittaker,
Curtis Holt, Abbas Rana,
Ali Zarrinpar,
Henrik Petrowsky,
Douglas Farmer,
Hasan Yersiz,
Victor Xia,
Jonathan R Hiatt,
Ronald W Busuttil
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ABSTRACT: : To analyze incidence, outcomes, and utilization of health care resources in liver transplantation (LT) for nonalcoholic steatohepatitis (NASH).
: With the epidemic of obesity and metabolic syndrome in nearly 33% of the US population, NASH is projected to become the leading indication for LT in the next several years. Data on predictors of outcome and utilization of health care resources after LT in NASH is limited.
: We conducted an analysis from our prospective database of 144 adult NASH patients who underwent LT between December 1993 and August 2011. Outcomes and resource utilization were compared with other common indications for LT. Independent predictors of graft and patient survival were identified.
: The average Model for End-Stage Liver Disease score was 33. The frequency of NASH as the primary indication for LT increased from 3% in 2002 to 19% in 2011 to become the second most common indication for LT at our center behind hepatitis C. NASH patients had significantly longer operative times (402 vs 322 minutes; P < 0.001), operative blood loss (18 vs 14 packed red blood cell units; P = 0.001), and posttransplant length of stay (35 vs 29 days; P = 0.032), but 1-, 3-, and 5-year graft (81%, 71%, 63%) and patient (84%, 75%, 70%) survival were comparable with other diagnoses. Age greater than 55 years, pretransplant intubation, dialysis, hospitalization, presence of hepatocellular carcinoma on explant, donor age greater than 55 years, and cold ischemia time greater than 550 minutes were significant independent predictors of survival for all patients, whereas body mass index greater than 35 was a predictor in NASH patients only.
: We report the largest single institution experience of LT for NASH. Over a 10-year period, the frequency of LT for NASH has increased 5-fold. Although outcomes are comparable with LT for other indications, health care resources are stressed significantly by this new and increasing group of transplant candidates.
Annals of surgery 09/2012; 256(4):624-33. · 7.90 Impact Factor
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ABSTRACT: Surgical resection is the primary modality of treatment for hilar and intrahepatic cholangiocarcinoma (HCCA-ICCA). For unresectable early-stage HCCA, excellent long-term tumor recurrence-free patient survival has been achieved using a strict regimen of preoperative staging and neoadjuvant chemoradiation treatment followed by orthotopic liver transplantation (OLT). However, in the case of unresectable ICCA, data on outcomes after OLT are limited. The present article reviews the current literature on the surgical treatment of ICCA focusing on the role of OLT in combination with neoadjuvant therapy and risk stratification of patients being considered for transplantation for unresectable ICCA.
Numerous studies reported poor survival outcomes after OLT for ICCA. Recent data using a combination of neoadjuvant therapy followed by OLT in appropriately selected patients with unresectable ICCA demonstrated promising disease recurrence-free survival.
Risk stratification for patient selection is crucial to optimize survival outcomes. Excellent long-term disease recurrence-free survival can be achieved in selected patients with unresectable ICCA using a combination of OLT and neoadjuvant therapy. Current data support the expansion of liver transplant criteria for treatment of unresectable ICCA.
Current opinion in gastroenterology 02/2012; 28(3):258-65. · 4.33 Impact Factor
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Archives of surgery (Chicago, Ill.: 1960) 09/2011; 146(9):1059-60. · 4.32 Impact Factor
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ABSTRACT: Altruistic unbalanced paired kidney exchanges (AUPKE) use compatible live donor/recipient pairs to facilitate transplants for individuals with incompatible live donors. We report a three donor/recipient pair complex AUPKE. Little is known of the circumstances under which individuals are likely to trade away a compatible live donor or the overall impact that AUPKE could have on the organ supply.
(1) A retrospective analysis of live donor renal transplants was performed using United Network for Organ Sharing data and our own center experience to determine the potential impact of AUPKE. (2) At initial evaluation, potential donors and recipients were administered a survey regarding attitudes toward AUPKE using a 5-point Likert Scale.
(1) One thousand three hundred ninety-six (22.8%) ABO compatible but nonidentical live donor transplants were performed in the United States in 2005. Ninety-one percent of donors were blood group O. (2) Recipient survey respondents were more likely than donors (P=0.002) to favor participation in AUPKE with no advantage to themselves. A number of circumstances increased the propensity to view AUPKE favorably (P<0.05).
(1) AUPKE can have a profound impact on the kidney supply. (2) By using ABO compatible but nonidentical donors, AUPKE can be performed at individual centers without requiring large sharing networks. (3) O recipients with incompatible donors are likely to be the primary beneficiary of AUPKE. (4) Attitudes are not static and can be influenced in favor of participation if there is a perceived benefit to the recipient. (5) Both donors and recipients are more willing to participate if their intended recipient or donor is enthusiastic about participating. (6) AUPKE reflects a paradigm shift for live donation, converting a private resource (the donor) to a shared one.
Transplantation 01/2010; 89(1):15-22. · 4.00 Impact Factor
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Piotr Witkowski,
Hugo Sondermeijer,
Mark A Hardy,
David C Woodland,
Keagan Lee,
Govind Bhagat,
Kajetan Witkowski,
Fiona See, Abbas Rana,
Antonella Maffei,
Silviu Itescu,
Paul E Harris
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ABSTRACT: Because the hepatic portal system may not be the optimal site for islet transplantation, several extrahepatic sites have been studied. Here, we examine an intramuscular transplantation site, bioengineered to better support islet neovascularization, engraftment, and survival, and we demonstrate that at this novel site, grafted beta cell mass may be quantitated in a real-time noninvasive manner by positron emission tomography (PET) imaging.
Streptozotocin-induced rats were pretreated intramuscularly with a biocompatible angiogenic scaffold received syngeneic islet transplants 2 weeks later. The recipients were monitored serially by blood glucose and glucose tolerance measurements and by PET imaging of the transplant site with [11C] dihydrotetrabenazine. Parallel histopathologic evaluation of the grafts was performed using insulin staining and evaluation of microvasularity.
Reversal of hyperglycemia by islet transplantation was most successful in recipients pretreated with bioscaffolds containing angiogenic factors when compared with those who received no bioscaffolds or bioscaffolds not treated with angiogenic factors. PET imaging with [11C] dihydrotetrabenazine, insulin staining, and microvascular density patterns were consistent with islet survival, increased levels of angiogenesis, and with reversal of hyperglycemia.
Induction of increased neovascularization at an intramuscular site significantly improves islet transplant engraftment and survival compared with controls. The use of a nonhepatic transplant site may avoid intrahepatic complications and permit the use of PET imaging to measure and follow transplanted beta cell mass in real time. These findings have important implications for effective islet implantation outside of the liver and offer promising possibilities for improving islet survival, monitoring, and even prevention of islet loss.
Transplantation 11/2009; 88(9):1065-74. · 4.00 Impact Factor
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ABSTRACT: The Milan criteria have been adopted by United Network for Organ Sharing (UNOS) to preoperatively assess outcome in patients with hepatocellular carcinoma (HCC) who receive orthotopic liver transplantation (OLT). These criteria rely solely on radiographic appearances of the tumor, providing no measure of tumor biology. Recurrence rates, therefore, remain around 20% for patients within the criteria. The neutrophil-lymphocyte ratio (NLR) is an indicator of inflammatory status previously established as a prognostic indicator in colorectal liver metastases. We aimed to determine whether NLR predicts outcome in patients undergoing OLT for HCC.
Analysis of patients undergoing OLT for HCC between 2001 and 2007 at our institution. A NLR > or =5 was considered to be elevated.
: A total of 150 patients were identified, with 13 patients having an elevated NLR. Of these, 62% developed recurrence compared with 14% with normal NLR (P < 0.0001). The disease-free survival for patients with high NLR was significantly worse than that for patients with normal NLR (1-, 3-, and 5-year survivals of 38%, 25%, and 25% vs. 92%, 85%, and 75%, P < 0.0001). Patients with high NLR also had poorer overall survival (5-year survival, 28% vs. 64%, P = 0.001). Patients within Milan with an elevated NLR had significantly poorer disease-free survival than those with normal NLR within Milan (5-year survival, 30% vs. 81%, P < 0.0001). On univariate analysis, 9 factors including an NLR > or =5 were significant predictors of poor disease-free survival. However, only a raised NLR remained significant on multivariate analysis (P = 0.005, HR: 19.98).
Elevated NLR significantly increases the risk for tumor recurrence and recipient death. Preoperative NLR measurement may provide a simple method of identifying patients with poorer prognosis and act as an adjunct to Milan in determining, which patients benefit most from OLT.
Annals of surgery 07/2009; 250(1):141-51. · 7.90 Impact Factor
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ABSTRACT: Pretransplantation patient characteristics determine survival following combined heart and kidney transplantation (HKT).
Time-to-event analysis.
Academic research.
The United Network for Organ Sharing provided deidentified patient-level data. Analysis included 19,373 heart transplant recipients from January 1, 1995, to December 31, 2005.
Multivariate Cox proportional hazards regression analysis was performed to identify pretransplantation recipient characteristics associated with improved long-term survival following HKT. Kaplan-Meier survival functions and Cox proportional hazards regression were used for time-to-event analysis. Using the relative risks calculated in regression analysis, weights were assigned for each risk factor, allowing for the construction of a risk score.
Among heart transplant recipients, 264 (1.4%) underwent HKT. Factors associated with diminished survival included peripheral vascular disease, recipient age older than 65 years, nonischemic etiology of heart failure, dialysis dependence at the time of transplantation, and bridge to transplantation using a ventricular assist device. After stratification by risk score, 1-year survival was 93.2% and 61.9% in the lowest- and highest-risk HKT groups, respectively. Further stratification by estimated glomerular filtration rate (eGFR) was performed based on a previous study showing decreased survival of patients undergoing orthotopic heart transplantation with a preoperative eGFR of less than 33 mL/min. Low-risk patients with an eGFR of less than 33 mL/min undergoing HKT constituted the only group that had significantly better survival compared with isolated patients undergoing orthotopic heart transplantation with eGFRs and risk scores in the same range (P = .006).
When patients were stratified by risk score and by diminished eGFR (<33 mL/min), low-risk HKT recipients with a diminished eGFR had improved survival following HKT over isolated heart transplant recipients. Only low-risk patients with combined kidney failure (eGFR, <33 mL/min) and heart failure seem to gain a survival benefit from HKT.
Archives of surgery (Chicago, Ill.: 1960) 04/2009; 144(3):241-6. · 4.32 Impact Factor
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ABSTRACT: To further our understanding of the potential protective effects of one organ allograft for another in combined organ transplants by comparing rejection-free survival and the 1-year rejection rate of each type of combined organ transplant.
Liver allografts have been thought to be immunoprotective of other donor-specific allografts. Recent observations have extended this property to other organs.
Analysis of data from the United Network of Organ Sharing included recipients 18 years or older (except those receiving intestinal transplants) transplanted between January 1, 1994, and October 6, 2005, and excluded those with a previous transplant (n = 45,306), live-donor transplant (n = 80,850), or insufficient follow-up (n = 4304). Patients were followed from transplant until death (n = 41,524), retransplantation (n = 4649), or last follow-up (n = 87,243).
A total of 133,416 patients were analyzed. Rejection rates for allografts co-transplanted with donor-specific primary liver, kidney, and heart allografts are significantly lower than rejection rates for allografts transplanted alone. Allografts accompanying primary intestinal or pancreatic allografts did not have reduced rejection rates. A decreased rate of rejection was seen in interval kidney-heart transplants when allografts shared partial antigenic identity. Decreased rates of rejection were also seen in transplants of 2 donor-specific organs of the same type.
In combined simultaneous transplants, heart, liver, and kidney allografts are themselves protected and protect the other organ from rejection. Analysis of interval heart-kidney allografts suggests the need for partial antigenic identity between organs for the immunoprotection to take effect. This was not demonstrated in interval liver-kidney transplants. Increased antigen load of identical antigens, as seen in double-lung and double-kidney transplants, also offers immunologic protection against rejection.
Annals of surgery 12/2008; 248(5):871-9. · 7.90 Impact Factor
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ABSTRACT: Paired kidney exchanges are being used with increasing frequency to overcome humoral immunologic incompatibilities between patients in need of renal transplantation and their potential live donors. Altruistic unbalanced exchanges utilize compatible donor/recipient pairs in order to facilitate the transplantation of a patient with an incompatible donor. We have now performed several altruistic unbalanced paired kidney exchanges at our institution. Also, we have surveyed potential donors and recipients regarding their attitudes toward participating in altruistic unbalanced paired kidney exchanges. Patients are most amenable to participation if they perceive a benefit from trading away a compatible donor. Given the number of compatible live donor transplants performed annually, if practiced on a broad scale, altruistic unbalancedpaired kidney exchanges can have a profound impact upon the supply of kidneys for transplantation. These exchanges can be performed at individual centers without the requirement for largesharing pools or complex computer algorithms. However, there are a number of ethical and logistical considerations that must be addressed. Altruistic unbalanced paired kidney exchanges represent a major paradigm shift in renal transplantation, in that a private resource (i.e. the live kidney donor) is converted to a shared or public one.
Clinical transplants 02/2008;
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ABSTRACT: It has been 6 years since the Edmonton group published their outstanding results with pancreatic islet transplantation patients, demonstrating one-year insulin independence of 100% with type I diabetics. In order to assess what has been achieved for past six years we analyzed the actual state of islet transplantation, based on the updated summary of results from Edmonton and compare this experience with combined results from 19 institutions in North America as reported to the Collaborative Islet Transplant Registry (CITR). CITR data have largely substantiated the reproducibility of the Edmonton procedure. Complete insulin-independence was achieved in more then 55% of patients 1 year after transplant, but this state has not been sustained permanently. Although only 10% of patients remained insulin-free after 5 years, more then 80% of them had still detectable levels of C peptide and substantially improved glycemic control without episodes of hypoglycemia. Even though currently, the islet graft is still not a remedy for every brittle diabetic, islet transplantation has already obtained "nonresearch" status in Canada and is close to having a biological license status approved by the FDA in the United States that would further stimulate progress in the field.
Annals of transplantation: quarterly of the Polish Transplantation Society 02/2006; 11(2):5-13; discussion 32-43. · 2.02 Impact Factor
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Journal of the American College of Surgeons 08/2005; 201(1):143-8. · 4.55 Impact Factor
