David N. Ranney

Obesity, Surgical Site Infection, and Outcome Following Renal Transplantation

Objective:We sought to understand whether obesity imparts detriment in outcome beyond risk of developing surgical site infection (SSI). Summary Background Data:Obesity is a risk factor for SSI following renal transplantation, and has been implicated in inferior patient and graft survival postoperatively. Methods:We conducted a retrospective review of all adult kidney-only transplants performed at the University of Michigan between September 2003 and April 2008. The primary exposure variable was recipient body mass index (BMI). Cox multivariable regression and Kaplan-Meier analysis were used to identify factors associated with SSI, graft loss, and patient death. Results:In total, 869 recipients were studied, including 351 with BMI >30. Multivariate analysis revealed recipient age, delayed graft function, and BMI >30 to be independent risk factors for SSI. SSI was a significant risk factor for graft loss (HR: 2.194, 95% CI: 1.357–3.546) and approached significance as a risk factor for patient death (HR: 1.689, 95% CI: 0.941–3.028). Obesity had no independent effect on graft or patient outcome. Conclusions:SSI is associated with detriment to patient and graft survival following renal transplantation. The prevalence of SSI is higher among obese recipients, but those who avoid SSI have comparable outcomes to nonobese recipients. These findings redemonstrate the importance of SSI prevention following renal transplantation.

Marijuana Use in Potential Liver Transplant Candidates

Concern exists that liver transplant center substance abuse policies may have an inappropriate and disproportionate impact on marijuana users. Our hypothesis is that patients with chronic liver disease who were marijuana users will have inferior survival. This is a retrospective (1999–2007) cohort study. The primary outcome measure is time‐dependent, adjusted patient survival from the time of liver transplant evaluation. The primary exposure variable is a positive cannabinoid toxicology screen during the liver transplant evaluation period. Overall, 155 patients qualified as marijuana users while 1334 patients were marijuana non‐users. Marijuana users were significantly (p < 0.05) younger (48.3 vs. 52.1), more likely to be male (78.1% vs. 63.0%), have hepatitis C (63.9% vs. 40.6%) and were less likely to receive a transplant (21.8% vs. 14.8%). Marijuana users were more likely to use tobacco, narcotics, benzodiazepines, amphetamines, cocaine or barbiturates (p < 0.05). Unadjusted survival rates were similar between cohorts. Upon multivariate analysis, MELD score, hepatitis C and transplantation were significantly associated with survival, while marijuana use was not (HR 1.09, 95% CI 0.78–1.54). We conclude that patients who did and did not use marijuana had similar survival rates. Current substance abuse policies do not seen to systematically expose marijuana users to additional risk of mortality.

The effect of smoking on biliary complications following liver transplantation

We sought to estimate the effect of smoking on the biliary complication rate following orthotopic liver transplantation. We retrospectively evaluated the records of liver transplant recipients at our center from July 1, 1999 to October 26, 2007. Using Cox proportional hazards models, we estimated the time to the earliest biliary complication (leak or stricture) based on smoking exposure, as active, former, or lifetime nonsmoker, adjusting for other clinical factors. Overall, 409 liver transplant recipients were evaluated. The overall biliary complication rate was 37.7% (n = 154). Biliary complications included 66 anastomotic leaks, 60 anastomotic strictures, and 28 nonanastomotic lesions. ERCP was the primary diagnostic modality (n = 112). 18.1% of liver transplant recipients were active smokers (n = 74) and 42.8% were former smokers (n = 175). Active smokers were at greatest risk for biliary complications on unadjusted analysis (P = 0.022). After multivariable adjustment, active smokers had a 92% higher rate of biliary complication rates compared with lifetime nonsmokers (HR 1.92, 95% CI 1.07–3.43), but no difference was noted in the rate of complication resolution. Smoking clearly portends a significant risk of biliary complications following liver transplantation. Smoking status should be clearly defined when evaluating transplant candidacy and in counseling patients with cirrhosis.

Effects of Smoking on Survival for Patients with End-Stage Liver Disease

BACKGROUND Smokers with chronic liver disease can become eligible for transplantation, but some insurers refuse reimbursement pending smoking cessation. STUDY DESIGN Our hypothesis is that liver transplantation candidates and recipients who smoke have inferior survival compared with nonsmokers. Using a retrospective cohort study design, three Cox proportional hazards models were constructed to determine covariate-adjusted mortality from transplantation evaluation and transplantation based on smoking status at evaluation, transplantation, and posttransplantation followup. RESULTS From 1999 to 2007, 2,260 patients were evaluated. Seven hundred sixty were active smokers, and 1,500 were nonsmokers. Smokers at evaluation were younger (49.3 versus 51.7 years), were more likely to be men (65.9% versus 58.7%), have hepatitis C (54.2% versus 30.1%), have a lower Model for End-Stage Liver Disease score (10.5 versus 12.3), and less likely to receive transplant (12.2% versus 18.6%) (all p < 0.05). The postevaluation multivariate model indicated that substance use, higher Model for End-Stage Liver Disease score, hepatitis C, and older age increased mortality risk (all p < 0.05), and liver transplantation (hazards ratio = 0.986; 95% CI, 0.977 to 0.994) was associated with lower mortality. Smoking was not associated with increased mortality risk at any time point in those evaluated or receiving transplants. CONCLUSIONS Providers should continue encouraging potential liver transplantation candidates to stop smoking, but insurer-driven mandated smoking cessation might not improve survival.

Financial Impact of Surgical Site Infection after Kidney Transplantation: Implications for Quality Improvement Initiative Design

BACKGROUND Surgical site infection (SSI) after kidney transplantation has been associated with worse graft and patient survival. Although there are clinical incentives to reduce the incidence of SSI, it is unknown whether these are aligned with financial incentives for payers and providers. We use post-kidney transplant surgical site infection (SSI) to quantify the financial implications of surgical complications. The goal of this study was to quantify the financial costs of SSI after kidney transplantation and to determine the party bearing the brunt of these costs. STUDY DESIGN This was a retrospective cohort study of all adult, first-time kidney-only transplant recipients at the University of Michigan Health System from September 2003 to April 2008 (n = 869). The primary exposure variable was SSI. SSI was defined as skin dehiscence, fascial dehiscence, or bowel evisceration. Primary outcomes measures were hospital revenue (payer costs), hospital inpatient costs, and hospital margin. We used simple univariate (t-test) analysis and multivariate (generalized linear regression) models to control for donor, recipient, and insurer characteristics. RESULTS Eighteen percent of patients had documented SSIs. In cases with an SSI hospital revenue increased by

Portrayal of organ donation and transplantation on American primetime television

20,176, hospital margin decreased by

Survival among children with portal vein thrombosis and end‐stage liver disease

4,278, and hospital costs increased by

Surgical resection after neoadjuvant chemoradiation for oesophageal adenocarcinoma: what is the optimal timing?

24,454. When adjusted for donor and recipient characteristics, SSI was independently associated with an

Extracorporeal membrane oxygenation following lung transplantation: indications and survival

11,132 increase in hospital revenue. CONCLUSIONS Although SSIs have negative financial effects on both hospitals and payers, the impact is greater on payers. Payers have the primary financial incentive to reduce SSI, and broad-based, quality improvement initiatives can be prudent investments for payers. Quantification of the costs associated with SSI can be used to define financial parameters for such initiatives that might prove beneficial to multiple stakeholders.

Central Cannulation as a Viable Alternative to Peripheral Cannulation in Extracorporeal Membrane Oxygenation

Harbaugh C, Afana M, Burdick S, East J, Kodali S, Lee J, Patel S, Rangrass G, Ranney D, Sood V, Lynch R, Sonnenday CJ, Englesbe MJ, Mathur AK. Portrayal of organ donation and transplantation on American primetime television.
Clin Transplant 2011: 25: E375–E380.