Richard B Freeman

Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, United States

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Publications (57)313.89 Total impact

  • Richard B Freeman
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    ABSTRACT: As the pressure for providing liver transplantation to more and more candidates increases, transplant programs have begun to consider deceased donor characteristics that were previously considered unacceptable. With this trend, attention has focused on better defining those donor factors that can impact the outcome of liver transplantation. This review examines deceased donor factors that have been associated with patient or graft survival as well as delayed graft function and other liver transplant results.
    Transplant International 02/2013; DOI:10.1111/tri.12071 · 3.16 Impact Factor
  • Richard B Freeman, James L Bernat
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    ABSTRACT: We discuss ethical issues of organ transplantation including the stewardship tension between physicians' duty to do everything possible for their patients and their duty to serve society by encouraging organ donation. We emphasize consideration of the role of the principles of justice, utility and equity in the just distribution of transplantable organ as scarce resources. We then consider ethical issues of determining death of the organ donor including the remaining controversies in brain death determination and the new controversies raised by circulatory death determination. We need uniformity in standards of death determination, agreement on the duration of asystole before death is declared, and consensus on the allowable circulatory interventions on the newly declared organ donor that are intended to improve organ function. We discuss the importance of maintaining the dead donor rule, despite the argument of some scholars to abandon it.
    Progress in cardiovascular diseases 11/2012; 55(3):282-289. DOI:10.1016/j.pcad.2012.08.005 · 4.25 Impact Factor
  • Richard B Freeman
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    ABSTRACT: The model for end-stage liver disease (MELD) driven liver allocation system has been in place for 10 years now. Understanding what the driving forces were, what principles were developed and employed, and assessing how these have stood the test of time will help future policy makers further refine the system. Prior to development of the MELD system, policymakers had limited data and organ allocation policy development was rarely systematic or evidence-based and was not necessarily centered on the patient. The MELD process focused on patient-specific variables and validation of the risk prediction models to be sure the system would function reasonably well across the spectrum of potential candidates and that it did not impose artificial categorizations of patients. In addition, the transplant community focused on assessing the effects of this policy change which was also something new. Numerous publications since have reported outcomes for MELD-based liver allocation here in the United States and in many other areas around the world. Some of these reports have suggested changes to the MELD equation or other ways to adapt the system to more accurately reflect the need for transplant. The transparency that this type of system brings allows for much more rigorous assessment of results and for highlighting areas for improvement toward a more fair, equitable, and utilitarian system.
    Current opinion in organ transplantation 04/2012; 17(3):211-5. DOI:10.1097/MOT.0b013e3283534dde · 2.38 Impact Factor
  • Richard B Freeman
    Nature Reviews Gastroenterology &#38 Hepatology 04/2012; 9(5):248-9. DOI:10.1038/nrgastro.2012.69 · 10.81 Impact Factor
  • Richard B Freeman
    01/2012; 14(3):272-7. DOI:10.1001/virtualmentor.2012.14.3.oped1-1203
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    ABSTRACT: Liver transplantation is accepted as the standard treatment for selected patients with hepatocellular carcinoma and chronic liver disease. Liver transplantation achieves oncological clearance whilst treating the underlying chronic liver disease. The gap between the demand and supply of cadaveric organs necessitates the use of selection criteria that optimise utilisation of cadaveric grafts for patients with hepatocellular carcinoma. This must be carefully offset against the potential detriment to existing patients without hepatocellular carcinoma also awaiting these scarce organs. With the introduction and subsequent validation of the Milan criteria in 1996, 5 year survival in excess of 70% in patients satisfying the criteria has been achieved in units internationally. They are now widely accepted and used as standard selection criteria for cadaveric liver transplantation. Analysis of the outcomes of liver transplantation for hepatocellular carcinoma has however identified a subgroup of patients not satisfying the Milan criteria, but in whom excellent results were achieved. This prompted a call for expansion or revision of the selection criteria to optimize resource allocation. This review summarizes the main issues and offers the authors' recommendations presented to the 2010 International Consensus Conference on Liver Transplantation for Hepatocellular Carcinoma. Liver Transpl, 2011. © 2011 AASLD.
    Liver Transplantation 10/2011; 17 Suppl 2(S2):S81-9. DOI:10.1002/lt.22380 · 3.79 Impact Factor
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    Richard B Freeman
    Liver Transplantation 06/2011; 17(6):631-2. DOI:10.1002/lt.22253 · 3.79 Impact Factor
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    Richard B Freeman
    Liver Transplantation 01/2011; 17(9):991-2. DOI:10.1002/lt.22376 · 3.79 Impact Factor
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    ABSTRACT: Proponents of orthotopic liver transplantation (TXP) for the treatment of hepatocellular carcinoma (HCC) advocate expanding the Milan criteria. We performed a matched analysis comparing patients treated with TXP to patients treated with partial hepatectomy (PHX) for HCC exceeding the Milan criteria. From the United Network for Organ Sharing registry, we identified 92 US patients with HCC exceeding the Milan criteria who underwent TXP between 2002 and 2005. During the same period, 94 patients with similar tumor size criteria underwent PHX at a single center. Data were analyzed using χ(2), parametric, nonparametric, and Kaplan-Meier methods. TXP patients were more commonly male (82% vs. 65%, P=0.01) and had a higher Model for End Stage Liver Disease score (median 11 vs. 7, P<0.001). Pathologic cirrhosis (79% TXP vs. 38% PHX, P<0.001), particularly secondary to hepatitis C virus (29% TXP vs. 5% PHX, P<0.001), was more common among TXP patients. Mean cumulative tumor size was 10.0 cm (63% exceeding University of California at San Francisco criteria) among PHX patients compared with 6.4 cm (20% exceeding University of California at San Francisco criteria) for TXP patients (P<0.001). With a median follow-up of 34 months (range, 1-86), 3-year survival was similar between the cohorts (66%±10% for TXP vs. 66%±10% for PHX, P=0.97). Cancer deaths (26/37, 70%) were more prevalent among PHX patients, whereas noncancer deaths (25/37, 68%) were common in TXP patients (P<0.001). Among heterogeneous patients with HCC who exceed the Milan criteria, TXP and PHX achieve similar overall survival. Further study is needed to ensure appropriate patient selection for these disparate therapies.
    American journal of clinical oncology 10/2010; 34(5):466-71. DOI:10.1097/COC.0b013e3181ec63dd · 2.61 Impact Factor
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    ABSTRACT: Pulmonary arterial hypertension (PAH) associated with portal hypertension [portopulmonary hypertension (PPHTN)] occurs in 2% to 10% of patients with advanced liver disease and carries a very poor prognosis without treatment. Most hepatic transplantation centers consider moderate to severe PPHTN to be a contraindication to liver transplantation because of the high rate of perioperative complications. We present 3 patients with PPHTN who were managed with intravenous prostacyclin therapy followed by living donor liver transplantation (LDLT). These individuals demonstrated subsequent resolution of their pulmonary hypertension and were weaned off all PAH-specific medical therapy. We present their demographics, clinical courses, and hemodynamics. We discuss the potential indications for LDLT and risks with respect to this patient population. Limitations of the Model for End-Stage Liver Disease scoring system and outcome data for this patient population are reviewed. Future studies should be directed toward better defining indications for LDLT in patients with PPHTN, improving medicosurgical management, and assessing long-term outcomes.
    Liver Transplantation 08/2010; 16(8):983-9. DOI:10.1002/lt.22107 · 3.79 Impact Factor
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    Richard B Freeman
    Liver Transplantation 08/2009; 15(8):831-3. DOI:10.1002/lt.21752 · 3.79 Impact Factor
  • Jeffrey T Cooper, Richard B Freeman
    American Journal of Kidney Diseases 07/2009; 54(3):410-2. DOI:10.1053/j.ajkd.2009.05.004 · 5.76 Impact Factor
  • Richard B. Freeman
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    ABSTRACT: The equitable allocation of deceased donor livers for transplantation is an important and contentious issue. The institution of liver allocation based on the Model for End-Stage Liver Disease (MELD) score has allowed prioritization to be based on an objective measure of illness. In addition, after institution of the MELD system, policy makers were now able to measure differences among patients, institutions, and geographical areas that are much less influenced by the artificial biases that waiting time introduced. A careful analysis of MELD scores <15 showed that patients face a greater mortality risk from the transplant procedure than from their liver disease without surgery. As a result, the organ allocation policy was changed such that regional sharing is now based on offering organs to candidates with MELD score ≥ 15 before local allocation to patients with MELD scores <15. Since the institution of the “Share 15” policy, the number of transplants performed in patients with high MELD score has increased, while the number of deaths on the transplant list has decreased. Key WordsLiver transplantation–Organ allocation–Liver allocation–Model for End-Stage Liver Disease
    04/2009: pages 91-102;
  • Jason Rhee, Barbara Kern, Jeffery Cooper, Richard B Freeman
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    ABSTRACT: Liver transplantation expertise has expanded throughout the world to the point where liver transplants are available in most developed countries. In many cases, however, legislation and regulations have not kept pace with the advances in healthcare technology. In a few cases, these regulatory voids have lead to exploitation and profit making around transplantation activities. The growing patient demand has motivated governments to develop numerous national efforts to improve the standards by which organ donation and transplantation are practiced and programs to increase the number organ of donors, most notably in Spain. Although these efforts have helped, the worldwide demand for lifesaving transplantation exerts extreme pressures such that financial incentives, profit making, and overt exploitation have compelled the World Health Organization to issue guiding principles. Other efforts to increase the number of available organs have centered on expanding the medical criteria for acceptable organ donors and using donation after cardiac death protocols. Implicit in these efforts is the need to understand, both on the part of the practitioner and the recipient, the higher risks involved in using these donors, the circumstances in which taking such risks are justified, and that all parties-including those responsible for paying the higher healthcare costs associated with using these organs-are willing to assume these risks. Also important is recognizing that the risks of transmission of donor disease to recipients are very low but not zero, even though these events receive enormous media attention. As the demand for organs rises relentlessly, more research must be devoted to understanding how to make the marginal donor organs function better.
    Seminars in Liver Disease 03/2009; 29(1):19-39. DOI:10.1055/s-0029-1192053 · 5.12 Impact Factor
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    Journal of Hepatology 03/2009; 50(4):664-73. DOI:10.1016/j.jhep.2009.01.013 · 10.40 Impact Factor
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    ABSTRACT: Because of organ shortage and a constant imbalance between available organs and candidates for liver transplantation, expanded criteria donors are needed. Experience shows that there are wide variations in the definitions, selection criteria, and use of expanded criteria donors according to different geographic areas and different centers. Overall, selection criteria for donors have tended to be relaxed in recent years. Consensus recommendations are needed. This article reports the conclusions of a consensus meeting held in Paris in March 2007 with the contribution of experts from Europe, the United States, and Asia. Definitions of expanded criteria donors with respect to donor variables (including age, liver function tests, steatosis, infections, malignancies, and heart-beating versus non-heart-beating, among others) are proposed. It is emphasized that donor quality represents a continuum of risk rather than "good or bad." A distinction is made between donor factors that generate increased risk of graft failure and factors independent of graft function, such as transmissible infectious disease or donor-derived malignancy, that may preclude a good outcome. Updated data concerning the risks associated with different donor variables in different recipient populations are given. Recommendations on how to safely expand donor selection criteria are proposed.
    Liver Transplantation 12/2008; 14(12):1694-707. DOI:10.1002/lt.21668 · 3.79 Impact Factor
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    ABSTRACT: Compared with standard donors, kidneys recovered from donors after cardiac death (DCD) exhibit higher rates of delayed graft function (DGF), and DCD livers demonstrate higher rates of biliary ischemia, graft loss, and worse patient survival. Current practice limits the use of these organs based on time from donor extubation to asystole, but data to support this is incomplete. We hypothesized that donor postextubation parameters, including duration and severity of hemodynamic instability or hypoxia might be a better predictor of subsequent graft function. We performed a retrospective examination of the New England Organ Bank DCD database, concentrating on donor factors including vital signs after withdrawal of support. Prolonged, severe hypotension in the postextubation period was a better predictor of subsequent organ function that time from extubation to asystole. For DCD kidneys, this manifested as a trend toward increased DGF. For DCD livers, this manifested as increased rates of poor outcomes. Maximizing the predictive value of this test in the liver cohort suggested that greater than 15 min between the time when the donor systolic blood pressure drops below 50 mm Hg and flush correlates with increased rates of diffuse biliary ischemia, graft loss, or death. Donor age also correlated with worse outcome. Time between profound instability and cold perfusion is a better predictor of outcome than time from extubation to asystole. If validated, this information could be used to predict DGF after DCD renal transplant and improve outcomes after DCD liver transplant.
    Transplantation 07/2008; 85(11):1588-94. DOI:10.1097/TP.0b013e318170b6bb · 3.78 Impact Factor
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    Richard B Freeman
    Hepatology 03/2008; 47(3):1052-7. DOI:10.1002/hep.22135 · 11.19 Impact Factor
  • Richard B Freeman
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    ABSTRACT: Liver transplantation for patients with early-stage hepatocellular cancer evidently represents an extremely effective treatment as compared to other modalities, at least by one analysis of a cancer database. However, less than one-fourth of the apparently acceptable candidates receive this treatment and African Americans are underrepresented in this group. The cause of these results, however, remains obscure with the need for a more in-depth confirmation of these findings readily apparent.
    The American Journal of Gastroenterology 02/2008; 103(1):128-30. DOI:10.1111/j.1572-0241.2007.01630.x · 9.21 Impact Factor
  • Richard B Freeman
    Transplantation 01/2008; 84(12):1559-60. DOI:10.1097/01.tp.0000296818.13150.aa · 3.78 Impact Factor

Publication Stats

1k Citations
313.89 Total Impact Points

Institutions

  • 2012–2013
    • Geisel School of Medicine at Dartmouth
      • Department of Surgery
      Hanover, New Hampshire, United States
  • 2011–2012
    • Dartmouth–Hitchcock Medical Center
      • Department of Surgery
      Lebanon, New Hampshire, United States
  • 2010
    • Beverly Hospital, Boston MA
      Beverly, Massachusetts, United States
  • 2001–2010
    • Tufts Medical Center
      • • Department of Surgery
      • • Division of Nephrology
      Boston, Massachusetts, United States
  • 1994–2008
    • Tufts University
      • • Department of Surgery
      • • Division of Gastroenterology
      Бостон, Georgia, United States
  • 2004
    • New England Baptist Hospital
      Boston, Massachusetts, United States
  • 1999
    • Boston Medical Center
      Boston, Massachusetts, United States
  • 1991
    • University of California, Davis
      • School of Medicine
      Davis, California, United States