Nitin Katariya

Pretransplant risk score for new-onset diabetes after kidney transplantation

OBJECTIVE New-onset diabetes after kidney transplantation (NODAT) has adverse clinical and economic implications. A risk score for NODAT could help identify research subjects for intervention studies. RESEARCH DESIGN AND METHODS We conducted a single-center retrospective cohort study using pretransplant clinical and laboratory measurements to construct a risk score for NODAT. NODAT was defined by hemoglobin A1c (HbA1c) ≥6.5%, fasting serum glucose ≥126 mg/dL, or prescribed therapy for diabetes within 1 year posttransplant. Three multivariate logistic regression models were constructed: 1) standard model, with both continuous and discrete variables; 2) dichotomous model, with continuous variables dichotomized at clinically relevant cut points; and 3) summary score defined as the sum of the points accrued using the terms from the dichotomous model. RESULTS A total of 316 subjects had seven pretransplant variables with P < 0.10 in univariate logistic regression analyses (age, planned corticosteroid therapy posttransplant, prescription for gout medicine, BMI, fasting glucose and triglycerides, and family history of type 2 diabetes) that were selected for multivariate models. Areas under receiver operating curves for all three models were similar (0.72, 0.71, and 0.70). A simple risk score calculated as the sum of points from the seven variables performed as well as the other two models in identifying risk of NODAT. CONCLUSIONS A risk score computed from seven simple pretransplant variables can identify risk of NODAT.

Transplanting Kidneys from Deceased Donors With Severe Acute Kidney Injury

Our aim was to determine outcomes with transplanting kidneys from deceased donors with acute kidney injury, defined as a donor with terminal serum creatinine ≥2.0 mg/dL, or a donor requiring acute renal replacement therapy. We included all patients who received deceased donor kidney transplant from June 2004 to October 2013. There were 162 AKI donor transplant recipients (21% of deceased donor transplants): 139 in the standard criteria donor (SCD) and 23 in the expanded criteria donor (ECD) cohort. 71% of the AKI donors had stage 3 (severe AKI), based on acute kidney injury network (AKIN) staging. Protocol biopsies were done at 1, 4, and 12 months posttransplant. One and four month formalin‐fixed paraffin embedded (FFPE) biopsies from 48 patients (24 AKI donors, 24 non‐AKI) underwent global gene expression profiling using DNA microarrays (96 arrays). DGF was more common in the AKI group but eGFR, graft survival at 1 year and proportion with IF/TA>2 at 1 year were similar for the two groups. At 1 month, there were 898 differentially expressed genes in the AKI group (p‐value <0.005; FDR <10%), but by 4 months there were no differences. Transplanting selected kidneys from deceased donors with AKI is safe and has excellent outcomes.

Genetic Differences in Native Americans and Tacrolimus Dosing After Kidney Transplantation

Tacrolimus pharmacokinetics vary due to single nucleotide polymorphisms (SNPs) in metabolizing enzymes and membrane transporters that alter drug elimination. Clinically we observed that Native Americans require lower dosages of tacrolimus to attain trough levels similar to Caucasians. We previously demonstrated that Native Americans have decreased oral clearance of tacrolimus, suggesting that Native Americans may have more variant SNPs and, therefore, altered tacrolimus pharmacokinetic parameters. We conducted 12-hour pharmacokinetic studies on 24 adult Native American kidney transplant recipients on stable doses of tacrolimus for at least 1 month posttransplantation. Twenty-four Caucasian kidney transplant recipients were compared as controls. SNPs encoding the genes for the enzymes (CYP3A4, CYP3A5) and transporters (ABCB1, BCRP, and MRP1) were typed using TaqMan. The mean daily tacrolimus dose in the Native Americans was 0.03 ± 0.02 compared with the Caucasians 0.5 ± 0.3 (mg/kg/d; P = .002), with no significant differences in trough levels, (6.7 ± 3.1 vs 7.4 ± 2.1 ng/dL; P = .4). Many Native Americans, but not Caucasians, demonstrated the 3/*3 - C3435T CC and the *3/*3 -G2677T GG genotype combination previously associated with low tacrolimus dosing. Native Americans required significantly lower tacrolimus doses than Caucasians to achieve similar tacrolimus trough levels, in part due to lower tacrolimus clearance from decreased drug metabolism and excretion.

Rapid Resolution of Donor-Derived Glomerular Fibrin Thrombi after Deceased Donor Kidney Transplantation

The aim of this study was to determine the clinical and histologic outcomes related to transplanting kidneys from deceased donors with glomerular fibrin thrombi (GFT). We included all cases transplanted between October 2003 and October 2014 that had either a preimplantation biopsy or an immediate postreperfusion biopsy showing GFT. The study cohort included 61 recipients (9.9%) with GFT and 557 in the control group without GFT. Delayed graft function occurred in 49% of the GFT group and 39% in the control group (p = 0.14). Serum creatinine at 1, 4, and 12 months and estimated GFR at 12 months were similar in the two groups. Estimated 1‐year graft survival was 93.2% in the GFT group and 95.1% in the control group (p = 0.22 by log‐rank). Fifty‐two of the 61 patients in the GFT group (85%) had a 1‐month protocol biopsy, and only two biopsies (4%) showed residual focal glomerular thrombi. At the 1‐year protocol biopsy, the prevalence of moderate to severe interstitial fibrosis and tubular atrophy was 24% in the GFT group and 30% in the control group (p = 0.42). We concluded that GFT resolves rapidly after transplantation and that transplanting selected kidneys from deceased donors with GFT is a safe practice.

Hepatoid Carcinoma of the Pancreas: Case Report, Next-Generation Tumor Profiling, and Literature Review

Fewer than 25 cases of hepatoid carcinoma of the pancreas have been reported in the literature. We present a case in a 61-year-old male with a remote history of Hodgkin’s lymphoma and gastric neuroendocrine cell hyperplasia. On surveillance endoscopic ultrasound, an 8 × 5 mm cystic lesion was seen in the tail of the pancreas. MRI showed a focal pancreatic duct cut-off with mild ductal dilation. Fine needle aspiration was performed, which was concerning for acinar cell carcinoma. The patient underwent distal pancreatectomy and recovered uneventfully. Final pathology demonstrated a 1.3-cm hepatoid carcinoma of the pancreas, with a final clinicopathological stage of T1N0M0. Next-generation nucleic acid sequencing of the tumor did not suggest a viable adjuvant chemotherapeutic agent, and no adjuvant therapy was administered. The patient has no evidence of disease 6 months following resection. A further characterization and description of the outcomes of these rare tumors is warranted to help guide providers and counsel patients.

Metastatic Fibrolamellar Hepatocellular Carcinoma to the Pancreas.

Fibrolamellar hepatocellular carcinoma (FL-HCC) is a rare variant of hepatocellular carcinoma, usually presenting in the younger population (<40 years) without underlying liver disease. Although it has a better prognosis than hepatocellular carcinoma, it has a high rate of recurrence months to years after primary resection. While sites of recurrence usually involve the liver, regional lymph nodes, peritoneum, and lung, metastasis to the pancreas is extremely rare, with only 2 other cases reported in the literature. We present the case of a 46-year-old patient with metastatic FL-HCC to the pancreas 30 years after diagnosis and 26 years since his last resected liver recurrence.

MP06-03 ROBOT ASSISTED TRANSPLANT ALLOGRAFT NEPHRECTOMY SERIES: A NOVEL APPROACH FOR A CHALLENGING OPERATION

INTRODUCTION AND OBJECTIVES: Despite improvements in medical care, surgical removal of failed transplant renal allografts may be mandated by sepsis, bleeding, pain, or erythropoietin resistance. Transplant nephrectomy has historically been performed in an open fashion by transplant surgeons and carries morbidity up to 50% with mortality up to 7%. To date, there is a single reported case of robot assisted transplant allograft nephrectomy from a deceased donor kidney. We herein present our series of robotic assisted transplant nephrectomy (RTN). METHODS: All patients who underwent robotic allograft nephrectomy at Mayo Clinic Arizona were included. Patients were not excluded for undergoing a concurrent procedure. All RTN were performed by a single Urologist (EPC) in conjunction with a single Transplant surgeon (NNK) via a transperitoneal approach utilizing a dual console Da Vinci Robotic Si/Xi surgical system. Study design was retrospective and observational. Variables analyzed included: demographics (age, BMI, ASA), comorbidities, transplant related (time from transplant to transplant nephrectomy, living related or deceased donor transplants), operative variables (operative time, estimated blood loss and additional procedures performed) peri-operative variables (length of stay (LOS), drain duration, Foley catheter duration, and hemoglobin change), and 30-day Clavien-Dindo complications. All variables were analyzed by non-parametric tests with commercially available software (SPSS vs, 21, Chicago, Illinois RESULTS: Six patients underwent RTN between 10/31/2014 until 4/31/2016. The time from transplant to transplant nephrectomy was a median of 5.9 years (range: 0.3 40). The majority of transplants were from deceased donors (66%). The median operating time was 306 minutes (range: 178 e 532). Of note, in two of the six RTN cases bilateral laparoscopic native nephrectomies were performed and in a third case a robotic nephrectomy and a lymph node biopsy by plastic surgery was performed. There were no intraoperative complications or conversions to open nephrectomy. Estimated median blood loss was 150 mL (range: 100 e 400), with a transfusion rate of 16%. Drains were utilized in 84% of patients and for a median of 2 days. There were three minor complications. CONCLUSIONS: In this first reported series of robotic transabdominal allograft nephrectomy we demonstrate the safety and feasibility of the use of robotic technology for transplant nephrectomy. This is a small series that includes our learning curve.

Interventional radiology in the management of the liver transplant patient

Liver transplantation (LT) is commonly used to treat patients with end‐stage liver disease. The evolution of surgical techniques, endovascular methods, and medical care has led to a progressive decrease in posttransplant morbidity and mortality. Despite these improvements, a multidisciplinary approach to each patient remains essential as the early diagnosis and treatment of the complications of transplantation influence graft and patient survival. The critical role of interventional radiology in the collaborative approach to the care of the LT patient will be reviewed. Liver Transplantation 23 1328–1341 2017 AASLD.

Glucose homeostasis after simultaneous pancreas and kidney transplantation: a comparison of subjects with C-peptide-positive non-type 1 diabetes mellitus and type 1 diabetes mellitus.

While simultaneous pancreas kidney transplant (SPKTx) is a therapeutic option for patients with type 1 diabetes (T1DM) and renal failure, few centers offer SPKTx to “select” non‐T1DM patients. To address concerns that existing insulin resistance may limit the benefits of the pancreas allograft among non‐T1DM, we compared several indices of glucose homeostasis, in “select” non‐T1DM and T1DM patients who received SPKTx.

Dialysis Access Flow Phenomenon Demonstrated via an Internal Jugular Central Venous Catheter Uniquely Positioned within a Superior Vena Cava Stenosis

R IGHT internal jugular vein central venous catheter placement is routine for cadaveric renal transplantation to assist intraoperative assessment of cardiac preload and intravascular volume status. The presence of a surgical upper extremity arteriovenous fistula for hemodialysis can significantly alter flow patterns in regional vessels and both the arterial and venous circulation. This can be compounded by variations in venous anatomy. Many patients with end-stage renal failure who advance to hemodialysis via an arteriovenous fistula have a period of dialysis via a tunneled central venous catheter often in the internal jugular vein. Central venous stenosis and thromboses are frequent complications of prolonged and repeated central venous access in hemodialysis patients. The authors report a case of concomitant arterial and venous pressure waveforms with correlating blood gas analysis measured via adjacent ports of a double lumen internal jugular venous catheter placed for cadaveric renal transplantation that was uniquely positioned within a superior vena cava stenosis. CASE REPORT