Jorge Ortiz

Long-term outcome of controlled, non-heart-beating donor liver transplantation.

Background. Previous reports have established the feasibility of using livers from controlled, non–heart-beating donors (CNHBD) with good immediate graft function. This has been largely borne out of necessity because of the donor shortage. Methods. Retrospective database review for the last 7 years (1995–2002), encompassing 19 patients receiving CNHBD, with follow-up period of 1,000±694 days, median 762 days. Detailed review of recipient characteristics, operative and clinical course, immunosuppression, complications, survival rates, and comparison with the results obtained in patients receiving transplants of allografts procured in standard fashion, from heart-beating donors Results. Kaplan-Meier patient survival rates were 100%, 89.5%, and 83.5% at 30 days, 1, and 2 years, respectively, which is not different from recipients of livers procured from heart-beating cadaveric donors (P=0.74, log-rank test). Five patients died at a mean follow-up time of 492 (range 46–1,103) days. The causes of death were related to secondary sclerosing cholangitis (n=1), cardiac failure (n=1), and sepsis (n=3). Two (10.5%) recipients underwent retransplantation, one for primary graft nonfunction and one because of biliary cast syndrome with cholangitis. Significant preservation damage (ALT>2,000) developed in five patients, but this did not affect survival. The incidence of vascular (15.6% vs. 9.6%, P=0.34) and biliary complications (10.55 vs. 13.8%, P=0.68) was no different than for those recipients receiving standard cadaveric donors. Conclusions. CNHBD safely expands the donor pool with similar long-term results as those obtained in patients receiving organs from brain-dead donors under standard procurement techniques.

Fungal Infections in Solid Organ Transplant Patients

BACKGROUNDnSolid organ transplantation is becoming increasingly more common in the treatment of end-stage organ failure. Opportunistic fungal infections are a frequent life-threatening complication of transplantation.nnnMATERIALS AND METHODSnIn this article, a review of the infections in the different organ transplant recipients is presented.nnnRESULTSnThe incidence of fungal infections in organ transplant patients ranges from 2% to 50% depending on the type of organ transplanted, kidney recipients being the least frequent and liver recipients having the highest rate of infection. New antifungal medications and immunosuppressants have changed the spectrum of fungal treatment and prevention.nnnCONCLUSIONnPrompt recognition and treatment of infection is imperative for successful therapy. Further advancements in early detection and the development of less toxic medications will lead to refinements in the treatment of fungal infections.

Operative Start Times and Complications After Liver Transplantation

The recent national focus on patient safety has led to a re‐examination of the risks and benefits of nighttime surgery. In liver transplantation, the hypothetical risks of nighttime operation must be weighed against either the well‐established risks of prolonging cold ischemia or the potential risks of strategies to manipulate operative start times. A retrospective review was conducted of 578 liver transplants performed at a single institution between 1995 and 2008 to determine whether the incidence of postoperative complications correlated with operative start times. We hypothesized that no correlation would be observed between complication rates and operative start times. No consistent trends in relative risk of postoperative wound, vascular, biliary, or other complications were observed when eight 3‐h time strata were compared. When two 12‐h time strata (night, 3 p.m.–3 a.m., and day, 3 a.m.–3 p.m.) were compared, complications were not significantly different, but nighttime operations were longer in duration, and were associated a twofold greater risk of early death compared to daytime operations (adjusted OR 2.9, 95% CI 1.16–7.00, p = 0.023), though long‐term survival did not differ significantly between the subgroups. This observation warrants further evaluation and underscores the need to explore and identify institution‐specific practices that ensure safe operations regardless of time of day.

MELD score less than 15 predicts prolonged survival after transjugular intrahepatic portosystemic shunt for refractory ascites after liver transplantation.

Background. Transjugular intrahepatic portosystemic shunt (TIPS) is used in the management of refractory ascites (RA) and variceal bleeds. Little data exist on TIPS safety, efficacy, and survival after liver transplantation (LT). Methods. We conducted a retrospective analysis of patients who underwent TIPS placement after LT for RA. Clinical success was defined as a reduction of portosystemic gradient (PSG) and resolution of RA. Results. Twenty-six patients underwent TIPS. The most common indication for LT was hepatitis C virus (88%). Median time from LT to TIPS was 17 months (1–89 months). Median pre-TIPS model for end-stage liver disease (MELD) score was 15 (7–33). The median pre-TIPS PSG was 18 mm Hg (7–38 mm Hg). Median change in the PSG after TIPS was 11 mm Hg (1–27 mm Hg). Fifty-eight percent (15/26) of TIPS were considered clinically successful. Median post-TIPS patient survival was 15 months (1–109 months). Cumulative 1-year post-TIPS patient survival was 50%. On multivariate analysis, pre-TIPS MELD was a significant and independent predictor of patient survival (P<0.01). The 3- and 6-month patient mortality and graft loss for patients with a pre-TIPS MELD of more than or equal to 15 were significantly higher than those with a pre-TIPS MELD score of less than 15 (P<0.01). The overall median survival for patients with a pre-TIPS MELD score of more than or equal to 15 was 3 months (1–59 months) compared with 45 months (2–109 months) for patients with pre-TIPS MELD score of less than 15. Conclusions. TIPS after LT can be clinically effective in patients with RA with a MELD score less than 15. This suggests that TIPS could be used as a means to extend posttransplant survival but should be carefully individualized in patients with a MELD score more than or equal to 15.

Pancreas transplantation from donors after cardiac death: an update of the UNOS database.

Objective There is reluctance to use donation after cardiac death (DCD) organs for fear of worse outcomes due to increased warm ischemia time. Extensive evidence to confirm the quality of DCD pancreas transplants is not manifest. Methods A united network for organ sharing database review of pancreas transplants performed between 1996 and 2012 was conducted. We compared outcomes and all demographic variables between donors after cardiac death and donors after brain death in pancreas transplantation. Results There were 320 DCD pancreas transplants and 20,448 donation after brain death pancreas transplants performed in the United States between 1996 and 2012. There was no statistically significant difference in graft survival or patient survival in pancreas transplantation in DCD versus donation after brain death donors measured at 1-year, 3-year, 5-year, 10-year, and 15-year intervals. There was no significant difference between donor and recipient age, race, sex, and body mass index (BMI) between the groups. There was no significant difference between the recipient ethnicity or time on wait list between the groups. Conclusions Pancreata procured by DCD have comparable outcomes to those procured after brain death. Donation after cardiac death pancreas transplant is a viable method of increasing the donor pool, decreasing wait list mortality, and improving the quality of life for type 1 diabetic patients.

Successful Re‐Use of Liver Allografts: Three Case Reports and a Review of the UNOS Database

The donor organ shortage has compelled transplant centers to use organs from non‐traditional sources. One example is the re‐use of a previously transplanted organ, such as a kidney or liver. We report three cases detailing the successful re‐use of liver allografts. In all three cases, the index recipient was declared brain‐dead very soon post‐transplant, but was felt to have a well‐functioning liver graft. Important points in these cases were to ensure that the liver graft was functioning well in the index recipient, that it appeared normal per biopsy examination, and that ischemic time was kept very short at the time of the second transplant. We queried the United Network for Organ Sharing (UNOS) database for similar cases, and found 11 such cases, which we briefly describe herein.

Perioperative management of spontaneous splenorenal shunts in orthotopic liver transplant patients.

OBJECTIVESnSpontaneous splenorenal shunts cause significant vascular steal from the liver. There is no accepted algorithm for treating spontaneous splenorenal shunts before, during, or after liver transplant, and evidence for efficacy of treatments remains limited.nnnMATERIALS AND METHODSnWe reviewed the literature, and our institutions experience regarding spontaneous splenorenal shunts, including a case series of 6 patients with spontaneous splenorenal shunts undergoing transjugular intrahepatic porto-systemic shunts, a case of intraoperative ligation of a large spontaneous splenorenal shunts during transplant, and 1 patient requiring multiple endovascular interventions to embolize recurrent spontaneous splenorenal shunts after orthotopic liver transplant.nnnRESULTSnSmall spontaneous splenorenal shunts may not need intervention, as involution after liver transplant is well known. Transjugular intrahepatic porto-systemic shunts may decrease the porto-systemic gradient in patients with large spontaneous splenorenal shunts, as shown in our review of 6 patients with large spontaneous splenorenal shunts undergoing transjugular intrahepatic porto-systemic shunts. We have demonstrated re-establishment of physiologic flow after ligation of a large spontaneous splenorenal shunt at the time of transplant, supporting operative ligation may be justified if intraoperative compression of the spontaneous splenorenal shunts demonstrates significant improvement of allograft portal venous flow. Ligation of the left renal vein for large spontaneous splenorenal shunts is a safe and effective method of preventing portal venous steal. For concomitant spontaneous splenorenal shunts and portal vein thrombosis, renoportal anastomosis can be performed. We report transient success with endovascular embolization of large spontaneous splenorenal shunts in a patient posttransplant who required multiple interventions.nnnCONCLUSIONSnExperience in the approach to and treatment of spontaneous splenorenal shunts in liver transplant recipients is limited. Further investigation into the best approach to treat spontaneous splenorenal shunts is warranted as the presence and persistence of spontaneous splenorenal shunts can lead to allograft dysfunction and possible allograft loss.

Fate of Abstracts Presented at the 2009 American Transplant Congress

INTRODUCTIONnOral and poster presentations at major meetings serve to rapidly present and share study results with the scientific community. On the other hand, full-text publication of abstracts in peer-reviewed journals provides dissemination of knowledge. The purpose of this study was to evaluate the publication rate of abstracts presented at the 2009 American Transplant Congress (ATC), to assess the factors influencing publication and determine the impact factor of these journals.nnnMETHODSnAll abstracts presented at the 2009 ATC were included in the study. A Pubmed-Medline search was performed to identify a matching journal article. Topics, country of origin, study type, study center and publication year were tabulated. Journals and impact factors of publication were noted.nnnRESULTSnOut of 1938 oral and posters abstracts presented, 103 (16.6%) of oral abstracts and 141 poster abstracts (10.9%) were published as full-text articles. Publication rates according to topics of the meeting and country of origin did demonstrate statistical significant differences (p < 0.05). Single-centered studies had higher publication rates 70.87% (73/103) than multi-centered studies among oral abstracts. Abstracts from multi-centered studies had higher publication rates among poster abstracts (68.09% vs. 31.91%), and the journals they were published in had higher impact factors than single center studies (4.578 vs. 3.897). The median impact factor of the journals was 4.2 (4.8 for oral presentations and 3.627 for poster presentations) that went on to be published as full text manuscripts. When comparing multi-center and single institutions, the difference between 12 month and 24 month publication rates was not statistically significant (p = 0.5443 and 0.1134). However, oral and poster abstracts published by study center (multi/single) did demonstrate a statistically significant difference (p < 0.0001); comparing the type of study, there was also a statistically significant difference between the oral and poster abstract (p < 0.0001).nnnCONCLUSIONnThe publication rate for abstracts of this 2009 ATC was lower than rates from other fields of medicine. Factors leading to failure require elucidation. Encouraging authors to submit their presentations for full-text publication might improve the rate of publication. Authors should be wary of accepting oral and poster abstracts as dogma; authors should refrain from citing them in publications especially if they are from outside United States and are about liver and kidney transplantation.

An analysis of pancreas transplantation outcomes based on age groupings--an update of the UNOS database.

Previously, increasing age has been a part of the exclusion criteria used when determining eligibility for a pancreas transplant. However, the analysis of pancreas transplantation outcomes based on age groupings has largely been based on single‐center reports.

Is Bariatric Surgery Safe in Cirrhotics

Obesity is associated with an increase in mortality and primary graft nonfunction after liver transplantation (LT) (1). Weight loss is recommended for obese patients in need of LT. Diet, exercise, or medications are rarely successful. Conversely, bariatric surgery can allow patients to achieve significant and sustained weight loss, leading to improvement of obesity-associated comorbidities such as hyperlipidemia and diabetes (2-4). n nBariatric surgery may be useful in cirrhotics needing LT who were denied evaluation primarily because of weight. We examined the medical literature concerning the safety and efficacy of bariatric surgery in cirrhotics by conducting a literature search using MD Consult, Cochrane, Ovid, and Medline with keywords “cirrhosis,” “bariatric,” and “obesity surgery.” Studies in English through January 2012 were included. We recorded information about demographics, type of bariatric surgery, and surgical outcome. n nThree articles were identified, giving a combined total of 44 patients with cirrhosis undergoing bariatric surgery (5-7). Laparoscopic surgery was performed in two studies (Dallal et al., Takata et al.). The third (Brolin et al) employed open approaches (Table). The mean age at surgery was 49.5 years. The average BMI before surgery was 52.5 kg/m2. Where reported, all patients were Child class A or B. Most of the patients (32, 73%) were found to have cirrhosis unexpectedly during surgery. n n n nTable n nDemographics, Surgical Information, and Complications n n n n27 patients underwent laparoscopic Roux-en-Y gastric bypass (RYGB), seven patients underwent open RYGB, 9 patients underwent laparoscopic sleeve gastrectomy, and 1 patient underwent jejunoileal bypass. 3 patients who underwent laparoscopic banding were excluded from one of the studies. 21 patients (48%) were followed at least 9 months with an average percentage of excess weight loss (EWL) of 54.2%. n nDallal et al. reported that the mean operative time was 4 hours, while Takata et al. reported a mean operative time of 2.4 hours. Operative time was not mentioned in Brolin et al. There were no intraoperative deaths; one patient died during the perioperative period from acute hepatic decompensation with hepatorenal syndrome. Postoperative complications occurred in 14 patients (32%) (Table). n nDallal et al. noted that the average estimated blood loss was over twice that of patients without cirrhosis. However, a mean estimated blood loss of 58 mL was reported for the 6 patients in Takata et al. Estimated blood loss in the open approach (Brolin et al.) was generally 150-300 mL. n nThere was considerable heterogeneity in terms of type of surgery performed and the reporting of demographics and outcomes. However, the data suggest that bariatric surgery can be successfully performed in carefully selected patients with cirrhosis, resulting in substantial weight loss, although the risk of certain complications such as renal failure and blood loss may be somewhat higher. Blood loss appears to be less with a laparoscopic approach. n nRecently published guidelines on the management of nonalcoholic fatty liver disease (NAFLD) do not make any recommendations regarding the utility of bariatric surgery on obese patients with cirrhosis due to NAFLD (8). Currently, there is no consensus on what bariatric modality is best for a patient with cirrhosis. It does appear that less invasive, laparoscopic procedures are safer to perform. Currently, the three most widely used laparoscopic modalities are RYGB, sleeve gastrectomy, and gastric banding, each having distinct advantages and disadvantages. RYGB presents unique challenges for a patient with cirrhosis, as endoscopic access to the stomach remnant is rendered impossible; this is of particular concern in the setting of a GI bleed or biliary obstruction. In addition, RYGB is often complicated by malabsorption and vitamin deficiencies. Gastric banding appears to be the least invasive of the three laparoscopic modalities. It allows for an effective degree of weight loss, but there is a significant potential risk of infection with the implementation of a foreign device, particularly in the setting of ascites. The FDA currently lists cirrhosis, portal hypertension, and other conditions predisposing to upper gastrointestinal bleeding, such as varices, as contraindications to placement of a gastric band (9). Finally, laparoscopic sleeve gastrectomy, which results in a significant reduction in stomach volume, does not cause malabsorption and does not require implantation of a foreign body. However, there is the risk for significant bleeding in a patient with gastric varices as a portion of the stomach is removed. n nIt remains unknown whether certain bariatric surgery modalities may complicate future orthotopic liver transplantation. Of the three modalities, RYGB has the most potential to affect future LT. Given the lack of literature comparing the safety and long-term outcomes, the decision of what modality to undergo should be individualized to the patient’s known medical comorbidities. Although there are significant risks with any of these surgical procedures in a cirrhotic, the potential benefits of weight loss and transplant candidacy may outweigh the risks, and it may be reasonable to proceed with bariatric surgery after careful discussion with the patient. While successful bariatric procedures have been demonstrated in patients with relatively preserved hepatic function, as implied from the Child class, it remains unknown whether such surgery may be performed successfully in patients with a higher Child class or MELD score. n nWe do not know how many patients with cirrhosis were excluded from surgery because of advanced, decompensated cirrhosis. Additionally, the decision was made to abort surgery in some patients who were found to have cirrhosis intraoperatively. There are insufficient data to assess whether complications are higher when a certain surgical modality is used. MELD scores and portal pressures were not calculated in any of the studies. Post-operative weight loss was only reported for 21 of the 44 patients in this study. Child class was reported in only 2 of the 3 papers. Long-term outcomes are not available. It is unknown whether any of these patients underwent LT after surgery. n nGiven the paucity of data available, we suggest that a registry be created, perhaps under the United Network for Organ Sharing (UNOS). This registry would record the outcomes, complications, and transplant status of obese cirrhotics undergoing bariatric surgery. Such a database would significantly improve our knowledge of the relationship between bariatric surgery and cirrhosis and help establish guidelines where such a surgery may be safely performed and beneficial.