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ABSTRACT: OBJECTIVES: The optimal immunosuppression regimen for elderly kidney transplant recipients is poorly defined. We sought to evaluate the short-term efficacy and safety of thymoglobulin in geriatric recipients of deceased-donor kidneys. MATERIALS AND METHODS: A single-center, retrospective analysis was undertaken between elderly (≥ 65 years) (n=137) and nonelderly (n=276) kidney transplant recipients who received rabbit antithymocyte globulin induction and calcineurin inhibitor, mycophenolic acid, and prednisone maintenance. RESULTS: The mean age was 70 versus 52 years. Fewer elderly patients had an earlier transplant or panel reactive antibodies > 20%, but had more machine perfused, older, and extended criteria donor kidneys. Elderly patients received lower rabbit antithymocyte globulin (5.4 vs 5.6 mg/kg; P = .04) and initial mycophenolic acid doses (1620 vs 1774 mg; P = .002), and experienced less delayed graft function (31.1% vs 50.0%; P < .001). Death-censored graft survival and graft function at 3 years and biopsy-proven acute rejection at 1 year were comparable; however, there was lower 3-year patient survival in elderly patients. Donor age was the only factor associated with reduced patient survival. Rates of malignancy, infection, or thrombocytopenia were similar; however, leukopenia occurred less frequently in elderly patients (11.7% vs 19.9%; P = .038). CONCLUSIONS: Elderly kidney transplant recipients receiving rabbit antithymocyte globulin did not experience different short-term graft survival, graft function or rates of infection, malignancy or hematologic adverse reactions than did nonelderly patients; they experienced fewer episodes of delayed graft function, but had lower 3-year patient survival.
Experimental and clinical transplantation : official journal of the Middle East Society for Organ Transplantation. 02/2013;
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ABSTRACT: Background: A recent review reported that recipient HCV infection had no significant impact on acute rejection rates or patient survival in SPKT but the utilization of HCV(+) organs was negligible. Using the UNOS database, we sought to determine utilization rates for HCV(+) allografts in Simultaneous Pancreas-Kidney Transplantation (SPKT. Material/Methods: The Organ Procurement and Transplant Network / United Network for Organ Sharing database was employed to obtain information regarding HCV(+) and HCV-negative (HCV(-)) SPKT recipients and the disposition of donor pancreata. Results: Between 2000 and January 2011, 702 of 25,904 donors (2.7%) were HCV(+) and met otherwise ideal criteria. We identified 16 patients who received HCV(+) organs for SPKT between 1995 and 2010. Four had kidney allograft losses secondary to chronic rejection. Six had pancreatic allograft losses: one due to pancreatitis, one to infection, one to chronic rejection, one to acute rejection and two to graft thrombosis. None of the sixteen patients were subsequently listed for liver transplantation. Meanwhile, 702 HCV(+) donors between the age of 14 and 40 with a BMI less than 30 were identified. During that time period, only 8 simultaneous pancreas-kidney transplants using HCV(+) donor organs occurred. Therefore, 694 HCV(+) pancreata were not utilized for SPKT in that time span. Conclusions: 16 patients have undergone SPKT with HCV(+) organs. Aggressive use of HCV(+) organs for SPKT could potentially lead to earlier transplantation for HCV(+) recipients and allow HCV(-) organs to be available more quickly for HCV(-) recipients additional research of this topic is warranted.
Annals of transplantation: quarterly of the Polish Transplantation Society 12/2012; 17(4):39-44. · 2.02 Impact Factor
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Transplantation 12/2012; 94(11):e65-e66. · 4.00 Impact Factor
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ABSTRACT: Soft tissue sarcomas typically present as soft, painless masses on an extremity. Here, we present a patient with metastatic soft tissue sarcomas at his dialysis access site. This association with dialysis access has not been documented previously. A 62-year-old man presented with a nonhealing wound on his left upper extremity after excision of a pseudoaneurysmal arteriovenous fistula. The patient had received a second kidney transplant that was functioning well. Immunosuppression included tacrolimus, mycophenolate mofetil, and prednisone. He was induced with thymoglobulin twice. A biopsy was performed showing a high-grade pleomorphic sarcoma. A magnetic resonance image of his left upper extremity showed an 11 × 5.5 × 3 cm mass abutting the biceps and brachialis muscles. Also, we discovered several lesions in the axilla and the left side of the neck, which were suspicious for metastases. A positron emission tomography-computed tomography scan confirmed a left upper extremity soft tissue mass, with marked fluorodeoxyglucose uptake, in abnormally enlarged axillary, and supraclavicular lymph nodes of the left thorax, consistent with metastases. The patient underwent chemotherapy and radiation therapy. Soft tissue sarcomas are rare. A high index of suspicion is needed to make a diagnosis. This is the first reported case of a soft tissue sarcoma discovered at a dialysis access site. As with all malignancies, early diagnosis is key to patient survival. Thorough physical examinations and increased vigilance by physicians caring for immunosuppressed patients is invaluable.
Experimental and clinical transplantation : official journal of the Middle East Society for Organ Transplantation. 08/2012; 10(4):410-5.
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ABSTRACT: Delayed graft function affects up to 50% of kidney transplant recipients. Some guidelines recommend surveillance biopsies beginning 7 days after engraftment. This may be unnecessary with anti-thymocyte globulin induction.
We conducted a retrospective study of deceased-donor renal transplant recipients with delayed graft function.
One hundred eleven patients met the inclusion criteria. The incidence of rejections during delayed graft function was 2.7%. They were diagnosed between 9 and 11 days after transplant. The subsequent incidence of rejection at 12-month follow-up was 13.5% (n=15). The median time to rejection after transplant was 10 weeks. Fourteen of 15 patients had subtherapeutic immunosuppression. The only risk factor associated with later rejection after delayed graft function was use of donors after cardiac death.
Early rejection during delayed graft function with anti-thymocyte globulin induction and maintenance immunosuppression with tacrolimus, mycophenolate mofetil, and steroids is rare. When later rejection occurs, it is at a median of 10 weeks after a transplant. Two of the 3 early rejections were antibody mediated. Later rejections were associated with subtherapeutic immunosuppression and donors after cardiac death. Biopsies need not be performed during the early postoperative period when anti-thymocyte globulin is used with tacrolimus, mycophenolate mofetil, and steroids.
Experimental and clinical transplantation : official journal of the Middle East Society for Organ Transplantation. 06/2012; 10(3):232-8.
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ABSTRACT: The worldwide focus on work hour regulations and patient safety has led to the re-examination of the merits of night-time surgery, including kidney transplantation. The risks of operating during nontraditional work hours with potentially fatigued surgeons and staff must be weighed against the negative effects of prolonged cold ischemic time with resultant graft compromise. The aim of this study was to evaluate the impact of performing renal transplantation procedures during evening versus day time hours. The main outcome measures assessed between the day and night cohorts included comparisons of the postoperative complication rates and survival outcomes for both the renal allograft and the patient. A retrospective review of 633 deceased donor renal transplants performed at a single institution was analyzed. Three statistically significant results were noted, namely, a decrease in vascular complications in the nighttime cohort, an increase in urologic complications on subgroup analysis in the 3 AM to 6 AM cohort, and the 12 AM to 3 AM subgroup had the greatest odds of any complication. There was no statistical difference in either patient or graft survival over a twelve month period following transplantation. We conclude that although the complication rate varied among cohorts this was clinically insignificant and there was no overall clinically relevant impact on patient or graft survival.
Clinical Transplantation 05/2012; 26(3):E177-83. · 1.67 Impact Factor
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Liver Transplantation 08/2011; 17(12):1485; author reply 1486. · 3.39 Impact Factor
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ABSTRACT: Tc-99m-BrIDA hepatobiliary scans are noninvasive tests for detecting biliary leaks and obstructions. However, there is low sensitivity and specificity in patients with hyperbilirubinemia. Biliary complications (BC) are the Achilles heel of orthotopic liver transplantation (OLT). We questioned whether hyperbilirubinemia in liver transplant recipients rendered HIDA scanning less dependable.
HIDA findings were compared to endoscopic retrograde cholangiopancreatography, laparotomy, and clinical course. Results were categorized as follows: true positive (TP), true negative (TN), false positive (FP), false negative (FN), or nondiagnostic/inconclusive. We searched for variables associated with erroneous or nondiagnostic tests which we defined as all examinations determined to be FP, FN and/or nondiagnostic/inconclusive.
Thirty-four patients underwent a HIDA scan. The sensitivity and specificity were 70 and 100%. The sensitivity of HIDA improved to 100% in patients with a total bilirubin (TB) <5 mg/dl. Inconclusive and FN patients had a total bilirubin >5 mg/dl. One FN had a TB <5 mg/dl, but was determined inconclusive due to the roux-en-Y.
HIDA scans performed when the total bilirubin was <5 mg/dl had a high sensitivity and specificity for detecting biliary complications after OLT. However, when the total bilirubin exceeded 5 mg/dl, the specificity was still 100% but the numbers of nondiagnostic/inconclusive and FN exams were increased.
Annals of Nuclear Medicine 08/2011; 25(10):762-7. · 1.50 Impact Factor
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ABSTRACT: The rate of hepatitis C virus recurrence after donation after cardiac death liver transplant is not clearly defined.
This is a retrospective review of 39 donations after cardiac death-liver transplant recipients. Biopsies were performed at 6, 12, 24, and 36 months for all hepatitis C virus positive donation after cardiac death recipients.
The 6-, 12-, 24-, and 36-month severe hepatitis C virus recurrence rates were 60%, 73%, 87%, and 94%. A histologic comparison group of 26 long-surviving hepatitis C virus positive donation after neurologic death recipients had severe hepatitis C virus recurrence 27%, 31%, 42%, and 52% of the time. Six of the 19 hepatitis C virus donation after cardiac death patients developed cirrhosis at a median of 56 months (range, 14-119 months). There was no significant 3-year allograft and patient survival difference between hepatitis C virus and nonhepatitis C virus donation after cardiac death recipients. The factors most associated with decreased survival in the entire cohort included biliary and vascular complications. Organs procured by our institution's attending surgeons were associated with a better 3-year allograft survival.
Severe hepatitis C virus recurrence was nearly universal but did not lead to increased graft loss when compared with nonhepatitis C virus donation after cardiac death at 3 years. These data may justify early interferon treatment in these at-risk patients.
Experimental and clinical transplantation : official journal of the Middle East Society for Organ Transplantation. 04/2011; 9(2):105-12.
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The American surgeon 09/2010; 76(9):E156-7. · 1.28 Impact Factor
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ABSTRACT: The "July effect" is a widely discussed phenomenon of worse patient outcomes at teaching hospitals in July due to inexperienced house staff.
We conducted a retrospective review of Organ Procurement and Transplantation Network data from Oct 1, 1987 to June 30, 2011, including longitudinal censored data of 360,330 transplantations. Demographic and comorbid variables for donors and recipients were collected. Primary outcomes were graft loss, patient death, and delayed graft function. Secondary outcomes were surgical complications, length of stay, and graft rejection. We compared survival indicators (1-month, 1-, 3-, and 5-year survival and median survival times) for both grafts and patients. We also analyzed death-censored graft survival.
There were fewer July donors with diabetes (p = 0.003), hypertension (p = 0.000), and extended criteria (p<0.0001). Graft survival (p = 0.000), death-censored graft survival (p = 0.001), and patient survival (p = 0.002) were statistically higher in July. After adjusting the Cox model for extended criteria donors, there was no difference in outcomes (p>0.05 for graft, death-censored graft survival, and patient survival).
We conclude that there is no July effect. Initially identified, superior outcomes in July may be attributed to more conservative allografts selection in the beginning of the academic year.
70(3):357-67. · 1.07 Impact Factor
