Mary Eng

A review of the United States experience with combined heart-liver transplantation

Since first described by Starzl, combined heart and liver transplantation (CHLT) has been a relatively rare event, although utilization has increased in the past decade. This study was undertaken to review the United States experience with this procedure; UNOS data on CHLT was reviewed. CHLT was compared with liver transplantation alone and heart transplantation alone in terms of acute rejection within 12 months, graft survival, and patient survival. Survival was calculated according to Kaplan–Meier and Cox proportional hazards. Continuous variables were compared using Student’s t‐test and categorical variables with chi‐squared. Between 1987 and 2010, there were 97 reported cases of CHLT in the United States. Amyloidosis was the most common indication for both heart (n = 26, 26.8%) and liver (n = 27, 27.8%) transplantation in this cohort. Liver graft survival in the CHLT cohort at 1, 5, and 10 years was 83.4%, 72.8%, and 71.0%, whereas survival of the cardiac allograft was 83.5%, 73.2%, and 71.5%. This was similar to graft survival in liver alone transplantation (79.4%, 71.0%, 65.1%; P = 0.894) and heart transplantation alone (82.6%, 71.9%, 63.2%; P = 0.341). CHLT is a safe and effective procedure, with graft survival rates similar to isolated heart and isolated liver transplantation.

The impact of recipient obesity on outcomes after renal transplantation.

Background:The benefit of renal transplantation in obese patients is controversial, with many centers setting upper limits on body mass index (BMI) in consideration for listing patients for transplant. This study was undertaken to determine the effect of recipient obesity on delayed graft function (DGF) and graft survival after renal transplantation. Methods:Retrospective review of all renal transplant recipients in the United Network for Organ Sharing database from January 1, 2004, through December 31, 2009, was performed. Primary endpoints were DGF and non–death-censored graft survival. Comparisons were made on the basis of the following weight classes: nonobese (BMI < 30), class I obese (30 ⩽ BMI < 35), class II obese (35 ⩽ BMI < 40), and class III obese (BMI ≥ 40). Results:Multivariable logistic regression indicated a significantly increased risk for DGF in obese patients. The odds ratios for DGF compared with nonobese patients were 1.34 [95% confidence interval (CI) 1.27–1.42; P < 0.001], 1.68 (95% CI 1.56–1.82; P < 0.001), and 2.68 (95% CI 2.34–3.07; P < 0.001) for the class I obese, class II obese, and class III obese groups, respectively. Class I obesity was not a significant risk for non–death-censored graft failure [hazard ratio (HR) 1.00, 95% CI 0.95–1.05; P = 0.901] compared with nonobese patients. Patients in the class II obese (HR 1.15, 95% CI 1.07–1.24; P < 0.001) and class III obese (HR 1.26, 95% CI 1.11–1.43; P < 0.001) groups were at a significantly increased risk for graft failure than their nonobese counterparts. Conclusions:Obese patients in all weight classes are at an increased risk for DGF after renal transplantation, although differences in non–death-censored graft survival are such that transplantation should not be denied on the basis of BMI criteria alone.

Review of the use of hepatitis B core antibody-positive kidney donors.

This article reviews the risks of transplanting hepatitis B core antibody (anti-HBc)-positive (+) kidneys and strategies to minimize the risks to the recipient. In the United States, there is a shortage of kidneys available for transplantation. Presently, 4% of kidneys transplanted are anti-HBc (+). In published retrospective studies, the serologic conversion rate for recipients of anti-HBc (+) kidneys varied between 0% and 27%; and the development of elevated hepatic transaminases varied between 0% and 26%. Only one published article had a trend toward increased risk of graft loss. Other published studies had no significant difference in graft or patient survival. Factors that influence the risk of transmission include hepatitis B viral load, vaccination, and antiviral therapy. If the donor is anti-HBc (+) and hepatitis B DNA negative, the risk of transmission is negligible; unfortunately, this information may not be available at the time of transplant. Vaccinated recipients with a protective hepatitis B surface antibody of at least 10 mIU/mL had a 4% conversion rate compared with 10% in recipients with antibody levels not exceeding 10 mIU/mL. Both hepatitis B immunoglobulin and lamivudine have been used in recipients of anti-HBc (+) kidneys to decrease seroconversion with success. The data do support the use of anti-HBc (+) kidneys if precautions are taken. The recipients should be informed of the risk, should be vaccinated with an adequate response, and should have surveillance serologies performed.

Perioperative anticoagulation and antiplatelet therapy in renal transplant: is there an increase in bleeding complication?

Eng M, Brock G, Li X, Chen Y, Ravindra KV, Buell JF, Marvin MR. Perioperative anticoagulation and antiplatelet therapy in renal transplant: is there an increase in bleeding complication? 
Clin Transplant 2011: 25: 292–296.

Bk viral disease in renal transplantation

Purpose of reviewBK virus is one of the most frequent causes of graft loss after renal transplantation, with BK virus-associated nephropathy occurring in roughly 8% of patients, and graft loss rates reported as high as 50%. This review is meant to highlight the literature on BK viral disease following renal transplantation published in the most recent year. Recent findingsPrevention of BK virus-associated graft loss requires early diagnosis of BK viral replication, which is best achieved by screening for BK viral DNA in the blood. Screening intervals more frequently than the currently recommended 3 months appear to offer increased efficacy. Reduction in immunosuppression remains the mainstay for treatment of BK viral disease, with consideration given to antiviral drug therapy with leflunomide. Acute rejection may be minimized by a short course of intravenous immunoglobulin. Sirolimus appears to be a promising addition to the therapeutic armamentarium. For patients requiring re-transplantation after BK virus-associated graft loss, viral clearance from the bloodstream prior to re-transplantation should be achieved to attain optimal results. SummaryBK virus is a major pathogen affecting renal allografts, although intensive surveillance and targeted dose reduction in immunosuppression with the consideration of additional antiviral drug therapy can minimize graft loss resulting from infection.

Increasing Utilization of Human T-Cell Lymphotropic Virus () Donors in Liver Transplantation: Is it Safe?

Background. Liver transplantation is the best treatment option for endstage liver disease. The human T-cell lymphotrophic virus (HTLV) has been associated with leukemia/lymphoma and progressive neurologic disease. There has, however, been an increased utilization of HTLV (+) grafts with little data available to support or discourage their use. Methods. We performed univariate and multivariate analyses related to graft and patient survival for recipients of HTLV (+) donors and compared them with recipients of HTLV (−) donors using the United Network for Organ Sharing database. Complete analysis of recipient and donor clinical and demographic factors was performed. Results. There were 81 adult recipients of HTLV (+) donors and 29,747 HTLV (−) donor recipients. HTLV (+) donors were more likely to be older, women, and black, with a higher average donor risk index and creatinine, and were more likely to be shared nationally. Recipients of HTLV (+) organs were at slightly elevated risk of graft failure (HR=1.39, 95% CI 0.91–2.11) and death (HR=1.20, CI 0.71–2.02) relative to HTLV (−) donor recipients (P=0.12 and 0.5, respectively). The risk decreased after multivariate analysis - graft survival (HR=1.20, CI 0.79–1.83) and patient survival (HR=1.06, CI 0.63–1.79). Conclusion. Our analysis reveals no statistically significant difference in graft or patient survival between recipients of HTLV (+) and (−) donors. Serious limitations of these data are that serologic testing for HTLV has a high false positive rate and that there was a short follow-up period. Until these issues are addressed, extreme caution should be exercised when using these organs.

Hand-assisted laparoscopic nephrectomy for polycystic kidney disease.

Hand-assisted laparoscopic nephrectomy for polycystic kidney disease seemed to result in shorter length of hospital stay and reduced need for transfusion compared with patients undergoing the same procedure with an open technique.

Analysis of BK viral infection after alemtuzumab induction for renal transplant

Induction immunosuppression has provided great advances in reducing the incidence of acute rejection (AR) following kidney transplantation. Despite this success, there has been recent concern over possible increased rates of viral complications when such powerful immunosuppressive therapy is used. This study was undertaken to determine the incidence of BK viral infection following kidney transplantation under alemtuzumab induction therapy.

Prophylaxis against de novo hepatitis B for liver transplantation utilizing hep B core (+) donors: does hepatitis B immunoglobulin provide a survival advantage?

Donor liver allografts with positive serology for hepatitis B core antibody [HBc (+)] have been increasingly used for liver transplantation. However, the optimal prophylactic regimen to prevent development of de novo hepatitis B has not been determined. To evaluate this, we screened United Network for Organ Sharing (UNOS) Standard Transplant Analysis and Research (STAR) registry data for adult recipients of HBc (+) organs who were HBsAg (−), and evaluated the effects of using prophylactic anti‐viral therapies (HBIG and lamivudine) on patient and graft survival. Out of a total cohort of 958 patients transplanted since 2004, 61 received HBIG alone, 116 received lamivudine alone, 66 both, 509 neither and 206 were missing this information. Based on several multivariable Cox regression models, patients receiving HBIG therapy‐only were observed to have a statistically significant (approximately 70%) reduction in risk of mortality compared with patients receiving lamivudine‐only therapy [HR = 0.29, 95% CI (0.10, 0.86), P = 0.026], and a nonstatistically significant reduction in risk of graft failure. However, no graft failures were attributed to de novo hepatitis B, suggesting that any improved graft/patient survival possibly associated with HBIG therapy occurs independently of de novo hepatitis B virus (HBV) reduction. While this study cannot prove that HBIG therapy is protective for graft and patient survival after liver transplantation, these findings do highlight the need to further examine and study prophylactic use in recipients of HBc (+) donors.

Cecal volvulus following laparoscopic nephrectomy and renal transplantation.

Cecal volvulus is a rare cause of bowel obstruction that carries significant mortality. A high index of suspicion is needed to avoid delay in definitive treatment.