Amy D. Lu

Evaluation of the older cadaveric kidney donor: the impact of donor hypertension and creatinine clearance on graft performance and survival.

Background. The use of older donors for cadaveric renal transplantation (CRT) remains controversial because older donors are associated with decreased graft survival, yet offer the opportunity for donor pool expansion.We investigated the impact of two age-related donor factors, hypertension and calculated creatinine clearance (C Cr), as predictors of graft outcome in recipients of CRTs from donors ≥55 years of age. Methods. We reviewed 33,595 recipients of CRTs reported to UNOS since 4/1/94, of which 4,732 were from donors aged ≥55 years. Outcome measures were graft survival, serum creatinine, and incidence of delayed graft function with 3 years of follow-up. We first analyzed the effect of hypertension on outcome from donors ≥55 years: 2679 donors had no hypertension, 1058 had hypertension ≤10 years, and 557 had hypertension >10 years. Next, the effect of donor C Cr as a risk predictor was investigated. Based on this analysis, recipients of older donors were grouped into two cohorts for comparison: 2570 donors with C Cr <80 ml/min and 2162 donors with C Cr ≥80 ml/min. Results. Actuarial graft survival from donors aged <55 years was 88.0, 83.4, and 78.5% at 1, 2, and 3 years, vs. 80.6, 73.5, and 65.3% from donors ≥55 years (P <0.0001). When stratified by hypertension, older donors hypertensive >10 years had survivals of 77, 66, and 57% vs. 81, 73, and 65% from donors without hypertension (P <0.017) and 80, 74, and 66% from donors hypertensive <10 years (P <0.017). When stratified by C Cr, older donors with C Cr <80 ml/min had survivals of 77, 69, and 62% vs. 83, 76, and 66% from donors with C Cr ≥80 (P <0.0001). Finally, older donors with both hypertension >10 years and C Cr <80 ml/min had survivals of 77, 61, and 53%. Conclusions. Long-standing hypertension and low calculated creatinine clearance are risk factors for decreased graft survival of CRTs from older donors. When both factors are present, graft survival is significantly decreased.

Outcome in recipients of dual kidney transplants: An analysis of the dual registry patients

BACKGROUND A novel but controversial method to increase the utilization of aged donor kidneys is the transplantation of both kidneys as a dual transplant. Initial single-center reports demonstrated outcomes similar to single kidneys from younger donors. In this report, we compare outcome in recipients of kidneys from donors > or =54 years of age who received a single kidney transplant reported to the United Network for Organ Sharing Scientific Registry versus a dual kidney transplant reported to the Dual Kidney Registry. METHODS A retrospective analysis was performed, comparing four donor and nine recipient and outcome variables between recipients of a single versus a dual transplant between March 1993 and March 1999. RESULTS Dual versus single transplants from donors > or =54 years of age have a significantly decreased incidence of delayed graft function, and lower serum creatinines up to 2 years after transplant despite having kidneys from significantly older donors with poorer HLA matching. CONCLUSIONS Dual kidney transplants improve graft performance and outcome in recipients of kidneys from donors > or =54 years of age.

Severe glomerular sclerosis is not associated with poor outcome after kidney transplantation

BACKGROUND The increased utilization of expanded criteria kidney donors has necessitated the reevaluation of multiple donor risk factors to insure the best outcome from this valuable resource. Reports of decreased graft survival in recipients of kidneys from donors with > or =20% glomerular sclerosis (GS) have led many transplant centers to refuse these donor kidneys. The purpose of this study is to compare outcome in recipients of cadaveric donor kidneys with > or =20% GS versus those with <20% or no GS at our center. METHODS We retrospectively reviewed 18 donor and 19 recipient and outcome variables in 89 recipients of kidneys, which were biopsied at the time of transplantation, between February 1995 and November 1998. We evaluated outcome based upon the percent of GS and the degree of vasculopathy. RESULTS Donors with > or =20% GS were older and had more hypertension. Recipients of kidneys with > or =20% GS were older, had higher serum creatinine values at 1 and 2 years, but similar rates of delayed graft function and 2-year graft survival. Vasculopathy did not correlate to any important donor criteria except the percent GS. However, serum creatinine was significantly higher in recipients of kidneys with moderate vasculopathy versus none, up to 2 years after transplantation. There was no significant difference in graft loss based upon vasculopathy. CONCLUSION Kidneys from donors with > or =20% GS provide excellent outcome similar to kidneys from donors with no GS.

Candida fasciitis following renal transplantation.

Background. We describe a rare case of necrotizing fasciitis involving Candida albicans, an organism that has been reported to have a minimal potential for invasive soft tissue infection. In this case, immunosuppression, chronic renal failure, and a history of diabetes mellitus were predisposing factors. Methods. The medical record and histopathologic material were examined. The clinical literature was reviewed for previous cases of C albicans necrotizing fasciitis. Results. A review of the literature showed that in solid organ transplant recipients, localized fungal soft tissue infection is infrequent, with only 35 cases reported between 1974 and 1992. Necrotizing fasciitis caused by C albicans is extremely rare in the modern era of solid organ transplantation. Conclusions. The management of transplant patients at risk for invasive fungal infection warrants a high index of suspicion for fungal necrotizing fasciitis in the setting of wound infection and merits a thorough investigation for atypical pathogens.

Outcome of extra-anatomic vascular reconstruction in orthotopic liver transplantation

BACKGROUND Portal venous and hepatic arterial reconstruction are critical to successful outcomes in orthotopic liver transplantation (OLT). With portal vein thrombosis or inadequate hepatic arterial inflow, extra-anatomic vascular reconstruction is required. However, the clinical outcomes following extra-anatomic vascular reconstruction are largely unknown. METHODS To determine the outcomes associated with extra-anatomic vascular reconstruction, we performed a retrospective review of 205 OLT recipients transplanted between 1995 and 2000. RESULTS Extra-anatomic portal venous inflow was based upon the recipient superior mesenteric vein using donor iliac vein graft in a retrogastric position (n = 12). Extra-anatomic arterial inflow was based on recipient infrarenal aorta using donor iliac artery graft through the transverse mesocolon (n = 25). OLT with routine anatomic vascular construction served as control (n = 168). Extra-anatomic vascular reconstruction was not associated with increased morbidity, mortality, operating room time, length of stay, or thrombosis. CONCLUSION We conclude that extra-anatomic vascular conduits are associated with excellent long-term outcomes and provide acceptable alternatives for vascular reconstruction in OLT.

Nonischemic cardiomyopathy after orthotopic liver transplantation: A report of three cases and a review of the literature

In 2002 there were more than 5,000 liver transplantations performed in the United States. As of February 2004 there were more than 17,000 registrations for liver transplantation. As more organs are transplanted and surgical techniques improve, unique causes of morbidity and mortality will become apparent. We describe three cases of postoperative nonischemic dilated cardiomyopathy in patients who underwent orthotopic liver transplantation (OLT), one of whom underwent diagnostic myocardial biopsy. This paper will discuss the three patients, including biopsy results, and briefly review the relevant literature. (Liver Transpl 2005;11:573–578.)

The dual kidney transplant registry.

There has been a steady increase in the utilization of aged donor kidneys for dual transplantation during the past several years. As the follow-up of these dual kidney recipients accrues, it is clear that the long-term graft survival rate approaches that seen in recipients of single kidneys transplanted from younger donors. Because the kidneys used for dual kidney transplants would have otherwise been discarded, it is imperative to recognize that kidneys from cadaver donors that fall outside the normal acceptance criteria are a valuable resource and can provide excellent long-term function when properly placed. Reducing cold storage time may be the single most important aspect to insuring long-term graft survival in recipients of aged dual kidney transplants.

Liver transplantation for fulminant hepatitis at Stanford University

Background. To review the clinical characteristics and outcomes of 26 patients evaluated for liver transplantation for fulminant hepatic failure at Stanford University and Lucile Packard Children’s Hospital in an attempt to identify risk factors and prognostic predictors of survival.Methods. A retrospective review of the records of 26 consecutive patients who were evaluated for possible liver transplantation for acute liver failure from May 1, 1995, to January 1, 2000. Pretransplant patient demographics and clinical characteristics were collected, and the data were analyzed by univariate and multivariate analysis.Results. Clinical assessment of encephalopathy did not predict outcome. Patients with abnormal computed tomography (CT) of the brain had a twofold increase in mortality compared with those patients with normal studies (p = 0.03). Patients requiring mechanical ventilation and continuous venovenous hemofiltration (CVVH) also had a poor prognosis.Conclusion. Predictors of poor outcome after fulminant hepatic failure include abnormal CT scan, mechanical ventilation, and requirement for hemofiltration.

Case Series of 10 Patients with Cirrhosis Undergoing Emergent Repair of Ruptured Umbilical Hernias: Natural History and Predictors of Outcomes

OBJECTIVES Ascites represents an important event in the natural history of cirrhosis, portending increased 1-year mortality. Umbilical herniation with rupture is an uncommon complication of large-volume ascites that is associated with significant morbidity and mortality. The aim of this study was to describe predictors of outcomes in patients undergoing emergent repair for spontaneous umbilical hernia rupture. MATERIALS AND METHODS We report a case series of 10 patients with decompensated cirrhosis (mean age 66 ± 9 years, mean Model for End-Stage Liver Disease score of 21 ± 7) who presented with a ruptured umbilical hernia and had emergent repair. RESULTS Thirty percent (3/10) of patients died or required liver transplant. Factors associated with death or transplant included the development of bacterial peritonitis (P = .03) and the presurgical 30-day Mayo Clinic Postoperative Mortality Risk in Patient with Cirrhosis Score (P = .03). CONCLUSIONS Emergent repair after umbilical hernia rupture in patients with decompensated cirrhosis carries a poor prognosis with 30% of patients developing poor postsurgical outcomes.