John B. Sorensen

Transplantation of ABO group A2 kidneys from living donors into group O and B recipients.

Fifteen blood group O and B recipients have been transplanted with kidneys from subtype A2 living donors since April 1992. ABO red cell grouping was performed by local licensed blood banks with A2 subtype determined using an anti‐A1 lectin and, retrospectively, by a polymerase chain reaction (PCR)‐based molecular method. All grafts functioned immediately and no patient has required dialysis. Three patients each experienced one reversible rejection episode. With the exception of one cardiac death at 9 months and one patient with profound toxicity to calcineurin inhibitors, all allografts continue to function normally. One donor, mistyped as a group A2 using lectin, was by PCR typing an A1O1 nonsecretor; the graft continues to function normally at 30 months. Transplantation of living donor A2 renal allografts into non‐A recipients produces excellent long‐term allograft survival and expands the potential living donor pool for nonblood group A recipients.

Liver transplantation in septuagenarians receiving model for end-stage liver disease exception points for hepatocellular carcinoma: the national experience.

Current liver allocation policy in the United States grants liver transplant candidates with stage T2 hepatocellular carcinoma (HCC) a priority Model for End‐Stage Liver Disease (MELD) score of 22, regardless of age. Because advanced age may portend an increase in all‐cause mortality after transplantation for any diagnosis, the aim of this study was to examine overall posttransplant survival in elderly patients with HCC versus younger cohorts. Based on Organ Procurement and Transplantation Network data, Kaplan‐Meier 5‐year survival rates were compared. Recipients undergoing primary liver transplantation were stratified into cohorts based on age (<70 or ≥70 years) and the receipt of MELD exception points for HCC. Log‐rank and Wilcoxon tests were used for statistical comparisons. In 2009, 143 transplants were performed for patients who were 70 years old or older. Forty‐two percent of these patients received a MELD exception for HCC. Regardless of the diagnosis, the overall survival rate was significantly attenuated for the septuagenarians versus the younger cohort. After 5 years of follow‐up, this disparity exceeded 10% to 15% depending on the populations being compared. The 1‐, 2‐, 3‐, 4‐, and 5‐year actuarial survival rates were 88.4%, 83.2%, 79.6%, 76.1%, and 72.7%, respectively, for the patients who were younger than 70 years and 81.1%, 73.8%, 67.1%, 61.9%, and 55.2%, respectively, for the patients who were 70 years old or older. Five‐year survival was negatively affected for patients with HCC who were younger than 70 years; this disparity was not observed for patients with HCC who were 70 years old or older. In conclusion, although patients who are 70 years old or older compose a small fraction of transplant recipients in the United States, patients in this group undergoing transplantation for HCC form an even smaller subset. Overall, transplantation in this age group yields outcomes inferior to those for younger cohorts. However, unlike patients who are less than 70 years old and receive MELD exception points, overall liver transplant survival is not affected by HCC at an advanced age. Liver Transpl 18:423–433, 2012.

Liver transplantation for cholangiocarcinoma.

Liver transplantation for cholangiocarcinoma (CCA) remains a controversial subject. More than 15 years after, a novel protocol combining neoadjuvant chemoradiation and orthotopic liver transplantation was first used in patients with unresectable hilar CCAs, these methods have yet to reach broad application. Results have confirmed that this approach leads to significantly lower recurrence rates and higher long-term survival rates than other existing treatment modalities. Despite this, protocols to treat patients with CCA are not widespread, and are available at only a handful of transplant programs. At these centers, treatment success may ultimately hinge on regional model for end-stage liver disease scores and waiting time for transplant. While acknowledging these factors as well as a severe organ shortage, it is important that the transplant community not overlook a potentially effective form of therapy for a previously untreatable disease.

Experience with an organ procurement organization-based non-directed living kidney donation programme

Abstract:  The organ procurement organization (OPO)‐based non‐directed living kidney donation programme was developed to decrease wait times for kidney transplants, and to meet the communitys desire for altruistic living donation. Community awareness was encouraged through information about non‐directed living kidney donation on the state donor registry Web site, and through the media. The OPO received all inquiries and responded with phone calls, e‐mails, printed information, medical/social history questionnaires, interviews, and referrals to the transplant centres. Kidneys were allocated according to the United Network for Organ Sharing (UNOS) wait list for the evaluating transplant centre. Between March 2002 and 23 September 2005, there were 608 inquiries to the OPO about non‐directed living kidney donation. In 41 months, 20 transplants occurred with kidneys from non‐directed donors. The donor registry and OPO‐sponsored publicity led to 578 of the 608 inquiries and 15 of the 20 transplants. OPO screening saved transplant centre resources by ruling out 523 inquiries, referring 76 to transplant centres for complete evaluations. Optional donor/recipient meetings appeared to be beneficial to those participating. OPO‐based non‐directed living donor programmes can be effective and efficient. Standardization of evaluation, allocation, and follow‐up will allow for better data collection and more widespread implementation.

A Case for Manual Entry of Structured, Coded Laboratory Data from Multiple Sources into an Ambulatory Electronic Health Record

Laboratory results provide necessary information for the management of ambulatory patients. To realize the benefits of an electronic health record (EHR) and coded laboratory data (e.g., decision support and improved data access and display), results from laboratories that are external to the health care enterprise need to be integrated with internal results. We describe the development and clinical impact of integrating external results into the EHR at Intermountain Health Care (IHC). During 2004, over 14,000 external laboratory results for 128 liver transplant patients were added to the EHR. The results were used to generate computerized alerts that assisted clinicians with managing laboratory tests in the ambulatory setting. The external results were sent from 85 different facilities and can now be viewed in the EHR integrated with IHC results. We encountered regulatory, logistic, economic, and data quality issues that should be of interest to others developing similar applications.

Cholangiocarcinoma in a 17-year-old boy with primary sclerosing cholangitis and inflammatory bowel disease.

JPGN Volume 52, N C holangiocarcinoma (CCA) is a known complication of primary sclerosing cholangitis (PSC) in adults. We describe a young patient who developed CCA 3 years after diagnosis of inflammatory bowel disease (IBD) and PSC. We describe the use of molecular marker techniques for diagnosis, and neoadjuvant cytoreductive therapy and orthotopic liver transplantation for therapy. The patient first presented at age 14 with 2 days of jaundice, fever, dyspnea, and chest and abdominal pain. He also complained of several months of nonbloody, watery diarrhea up to 9 times per day and fecal urgency both day and night, often waking him from sleep. This was unrelieved by daily loperamide and a prescribed course of empiric metronidazole. Medical and family histories were unremarkable. He was febrile, tachycardic, tachypneic, and mildly hypoxemic. Physical examination demonstrated jaundice with scleral icterus. He had a soft but tender abdomen with prominent splenomegaly. Breathing was labored with retractions, but the lungs were clear to auscultation. Initial laboratory studies revealed cholestasis, elevated transaminases, low albumin, leukocytosis, and a normal coagulation profile (Table 1). C-reactive protein and erythrocyte sedimentation rate were elevated and stool was positive for occult blood. Magnetic resonance cholangiopancreatography demonstrated an irregular and narrowed common hepatic duct, without biliary dilatation, cystic lesions, and intrahepatic mass. Liver biopsy revealed bile duct proliferation and periductular fibrosis consistent with PSC and without findings of overlap (Fig. 1). Anti-nuclear antibody and smooth muscle antibody were negative. Anti-nuclear cytoplasmic antibody was present in a 1:512 titer with peripheral staining pattern. Endoscopic retrograde cholangiopancreatography (ERCP) was not obtained at this time because clinical, radiographic, and histological findings were consistent with PSC and there was no biliary ductal dilatation on magnetic resonance imaging. Stool culture and Clostridium difficile cytotoxins were negative. Colonoscopy revealed regionally distributed inflammation and friable mucosa throughout the colon, with rectal sparing. A biopsy showed transmucosal chronic inflammatory cells, moderate crypt

Minimally invasive aortic valve replacement with orthotopic liver transplantation: report of a case

Cardiac surgery and liver transplantation (LT) are rarely performed at the same time, because of the potential risks of coupling two such complex surgical procedures [1–3]. This combined surgery is typically reserved for patients with structural heart disease, including multivessel obstructive coronary artery disease and severe valvular disease with heart failure and end-stage liver disease, in whom the untreated organ may decompensate if only one organ is addressed [4]. Combined aortic valve replacement (AVR) and LT is the rarest of such combined surgery, with only ten cases published previously. We present the first reported case of combined minimally invasive AVR and LT and review the literature on similar combined surgery.

Perceived Benefits of a Transplant Surgery Experience to General Surgery Residency Training

OBJECTIVES The benefit of a solid-organ transplant experience during general surgical training has been questioned recently. In 2008, in response to an American Board of Surgery (ABS) directive, a survey was conducted by the Association of Program Directors in Surgery (APDS) in coordination with the American Society of Transplant Surgeons (ASTS) to determine the perceived value of a transplant surgery rotation to program directors and residents. With the aim of providing additional insight, we conducted a separate study, independent of the ABS and ASTS, to ascertain resident perceptions regarding the specific skill sets that they acquire during their transplant surgery rotations and their applicability to other surgical subspecialties. METHODS A preliminary, 51-item, web-based questionnaire was completed by 69.6% of residents in nationally accredited general surgery programs who accessed the survey. The results were examined using appropriate statistical methods to determine associations between answers. RESULTS Although only 16.6% of participants responded that they were considering a career in transplantation, 63.4% answered that the skill sets acquired during this rotation would assist them in their surgical careers regardless of their chosen specialty. Most (65.5%) respondents answered that the techniques learned were directly applicable to other specialties, such as vascular, urologic, trauma, and hepatobiliary surgery. Free response questions indicated that the most common criticisms of this rotation were the limited amount of operative participation, lack of teaching by attendings, and lifestyle limitations. CONCLUSIONS The results of this study indicate that surgery residents are conflicted regarding their transplant surgery experience but regard it as a beneficial addition to their training. Most respondents indicated also that these skills were transferable directly to other surgical specialties.

Adult post-transplant lymphoproliferative disease in the liver graft in patients with recurrent hepatitis C

Aim The aim of this study is to clarify the association between hepatitis C virus (HCV) infection and post-transplant lymphoproliferative disease (PTLD) in the liver allograft. Methods Of the 933 adults who underwent liver transplantation (LT) between 1990 and 2005, 10 patients developed PTLD. Seven of the 10 patients that were HCV(+) (group 1) were compared with three HCV-negative recipients (group 2). Results The mean time between LT and PTLD was 24.5 months. There were no differences between in Epstein–Barr virus antibody status or tumor lymphocyte subsets. In five of the seven HCV-positive recipients who developed PTLD, PTLD recurred preferentially in the liver allograft, whereas none of the three HCV-negative patients who developed PTLD did so in the liver (71.4 vs. 0%, respectively, P=0.038). In all five patients with graft PTLD, HCV recurred within 12 months followed by PTLD. There were significant differences between groups 1 and 2 in mean lymphocyte infiltrate scores (6.0±2.1 vs. 2.0±0.7, P=0.037), fibrosis stage (2.4±0.5 vs. 0.7±0.5, P=0.029), and frequency of lymphoid follicles in portal areas (33.6±14.8% vs. 1.1±2.3%, P=0.0002). Conclusion When PTLD occurs in patients with HCV recurrence after LT, it does so preferentially in the liver allograft.

Liver transplantation in a 7-month-old girl with Caroli's disease.

Carolis disease (including Carolis syndrome) is a rare autosomal recessive disorder of the liver characterized by diffuse cystic dilatation of the intrahepatic bile ducts. The disease may present at any age and is characterized by recurrent episodes of biliary obstruction, cholangitis, hepaticolithiasis, and liver abscesses. Carolis syndrome is further associated with congenital hepatic fibrosis and portal hypertension. Patients with recurrent complications or cirrhosis may die because of recurrent infection, portal hypertension, liver failure, or cholangiocarcinoma. Liver transplantation is the treatment of choice for these complicated patients. Here we describe the youngest reported patient with Carolis syndrome treated successfully using liver transplantation and review the recent literature.