Psychosocial Outcomes in Nondirected Uterus Donors 1 Y After Donation

BACKGROUND

As uterus transplantation transitions to a clinical procedure for women with absolute uterine-factor infertility, transplant centers performing uterus transplantation need information about the experience of living donors. This study examined the psychosocial impact on 17 nondirected uterus donors in the Dallas UtErus Transplant Study 1 y following donation.

METHODS

A prospective longitudinal study was conducted to measure psychosocial outcomes of depression, anxiety, posttraumatic stress, quality of life, and resilience [measured using the Hospital Anxiety and Depression Scale or Patient Health Questionnaire 9-Item, Generalized Anxiety Disorder 7-Item, Posttraumatic Stress Disorder Checklist for the DSM-5, health-related quality of life Short Form-36, and Connor-Davidson Resilience Scale 10-Item, respectively) assessed at baseline, at 6-mo and 1-y follow-up. Differences among baseline, 6-mo, and 1-y postdonation were analyzed.

RESULTS

The median age was 38.0 y, 16 were married, 15 were of non-Hispanic/Latino ethnicity. Most donors did not report psychosocial distress; however, 1 donor reported decline on the role limitations because of Emotional Problems Scale and also showed an increase in depression symptoms at the 6 mo, but at 1 y was below the clinical cutoff for depression. A second donor showed modest decline in emotional well-being. Improvements were seen in other donors on the Physical Functioning Scale and posttraumatic stress symptoms.

CONCLUSIONS

Although most nondirected donors appeared to remain stable, both positive and negative changes were observed over the first year. Larger studies are needed to determine psychosocial risks and benefit and what additional resources might be needed to ensure optimal psychosocial outcomes.

Clinical and biological significance of circulating miRNAs in chronic pancreatitis patients undergoing total pancreatectomy with islet autotransplantation

BACKGROUND

Specific microRNAs (miRNAs) were elevated in chronic pancreatitis (CP) patients during islet infusion after total pancreatectomy (TPIAT). We aimed to identify circulating miRNA signatures of pancreatic damage, predict miRNA-mRNA networks to identify potential links to CP pathogenesis and identify islet isolation and transplantation functional outcomes.

METHODS

Small RNA sequencing was performed to identify distinct circulating miRNA signatures in CP. Plasma miRNAs were measured using miRCURY LNA SYBR green quantitative real-time polymerase chain reaction assays. Correlation analyses were performed using R software. The miRNA target and disease interactions were determined using miRNet and the miRNA enrichment and annotation tool.

RESULTS

Alterations were found in circulating miRNAs in CP patients compared to healthy controls. Further studies were conducted on 12 circulating miRNAs enriched in the pancreas, other tissues and other diseases including cancer and fibrosis. Approximately 2888 mRNAs in the pancreas were their targets, demonstrating interactions with 76 small molecules. Three miRNAs exhibited interactions with morphine and five exhibited interactions with glucose. The miRNA panel targeted 22 genes associated with pancreatitis. The islet-specific, acinar cell-specific and liver-specific miRNAs were elevated at 6 h after islet infusion and returned to baseline levels 3 months after TPIAT. Circulating levels of miRNAs returned to pre-transplant levels 1-year post-transplant. Circulating miRNAs measured before and 6 h after islet infusion were directly or inversely associated with metabolic outcomes at 3 and 6 months post-transplant.

CONCLUSIONS

miRNAs may contribute to CP pathogenesis, and elevated circulating levels may be specific to pancreatic inflammation and fibrosis, warranting further investigation.

Improved Quality of Life Among Chronic Pancreatitis Patients Undergoing Total Pancreatectomy With Islet Autotransplantation-Single Center Experience With Large Cohort of Patients

Total pancreatectomy with islet autotransplantation (TPIAT) is the treatment of choice to preserve pancreatic endocrine function, alleviate pain, and improve quality of life (QoL) when other strategies are ineffective for chronic pancreatitis (CP) patients. This study utilized pancreatic disease-specific surveys developed by the European Organisation for Research and Treatment of Cancer (EORTC) to conduct a comprehensive, single-center examination of a large cohort of patients to gain understanding of QoL post-TPIAT. Two validated QoL surveys of the EORTC-QLQ-C30 and QLQ-PAN26-were administered in a prospective cohort of CP patients during pre-and post-operative scheduled visits. A total of 116 patients responded to the preoperative survey and were included in this study. The global health scale of QLQ-C30 was significantly improved after TPIAT when compared to baseline with delta scores of 24.26, 20.54, and 26.7 at 1, 2, and 3 years post-TPIAT (p < 0.001). The EORTC-PAN26 revealed significant improvements in symptom scales for pancreatic pain, bloating, digestive symptoms, taste, indigestion, weight loss, body image, and future worries. The comprehensive surveys in such a large cohort expands the QoL criterion in CP patients and indicates significant improvement in QoL post-TPIAT, further validating TPIAT as a treatment option for refractory CP.

Predicting the outcome of liver transplantation in patients with non-alcoholic steatohepatitis cirrhosis: The NASH LT risk-benefit calculator

BACKGROUND

Non-alcoholic Steatohepatitis (NASH) cirrhosis is the second most common indication for liver transplantation (LT) in the US and often is associated with significant co-morbidities. We validated a model and risk prediction score that reflects the benefit derived from LT for NASH cirrhosis by predicting 5-year survival post-LT.

METHODS

We developed a prediction score utilizing 6515 NASH deceased donor LT (DDLT) recipients from 2002 to 2019 from the Scientific Registry of Transplant Recipients (SRTR) database to identify a parsimonious set of independent predictors of survival. Coefficients of relevant recipient factors were converted to weighted points to construct a risk scoring system that was then externally validated.

RESULTS

The final risk score includes the following independent recipient predictors and corresponding points: recipient age (5 points for age ≥70 years), functional status (3 points for total assistance), presence of TIPSS (2 points), hepatic encephalopathy (1 point), serum creatinine (5 points if >1.45 mg/dl), need for mechanical ventilation (3 points), and dialysis within 1 week prior to LT (7 points). Diabetes is a stratifying variable for baseline risk. Scores range from 0 to 20 with scores above 13 having an overall survival of <65% at 5 years post-LT. Internal and external validation indicated good predictive ability.

CONCLUSION

Our practically useable and validated risk score helps to identify and stratify candidates who will derive the most long-term benefit from LT for NASH cirrhosis.

Assessment of donor quality and risk of graft failure after liver transplantation: The ID2 EAL score

Accurate assessment of donor quality at the time of organ offer for liver transplantation candidates may be inadequately captured by the donor risk index (DRI). We sought to develop and validate a novel objective and simple model to assess donor risk using donor level variables available at the time of organ offer. We utilized national data from candidates undergoing primary LT (2013-2019) and assessed the prediction of graft failure 1 year after LT. The final components were donor Insulin-dependent diabetes mellitus, Donor type (DCD or DBD), cause of Death = CVA, serum creatinine, Age, height, and weight (length). The ID² EAL score had better discrimination than DRI using bootstrap corrected concordant index over time, especially in the current era. We explored donor-recipient matching. Relative risk of graft failure ranged from 1.15 to 3.5 based on relevant donor-recipient matching by the ID² EAL score. As an example, for certain recipients, a young DCD donor offer was preferable to an older DBD with relevant comorbidities. The ID² EAL score may serve as an important tool for patient discussion about donor risk and decisions regarding offer acceptance. In addition, the score may be preferable to succinctly capture donor risk in future organ allocation that considers continuous distribution (www.iddealscore.com).

Prediction of long-term morbidity and mortality after liver transplantation using two-dimensional shear wave elastography compared with liver biopsy

The role of noninvasive liver disease assessment by two-dimensional shear wave elastography (2D-SWE) to diagnose fibrosis is well described in patients with chronic liver disease. However, its role in prognosis, especially after liver transplantation (LT) has not been adequately examined. We hypothesized that elevated liver stiffness measurement (LSM) as measured by 2D-SWE after LT predicts future morbidity and mortality independent of fibrosis by liver biopsy. In a prospective cohort study, consecutive LT recipients underwent concomitant protocol 2D-SWE and protocol liver biopsy (2012-2014), with the assessor blinded to biopsy findings. We examined the baseline correlation of LSM with fibrosis stage and the association between elevated LSM and the development of subsequent clinical outcomes and all-cause mortality. A total of 187 LT recipients (median age 58 years, 38.5% women, median body mass index 26.5 kg/m² , 55.1% hepatitis C virus, 17.6% nonalcoholic steatohepatitis/cryptogenic) were examined. Median time between LT and biopsy/2D-SWE assessment was 4.0 years, and the median follow-up time after LSM determination was 3.5 years. Median LSM was 9 kPa (8 kPa [F0/F1], 11.5 kPa [F2], 12 kPa [F3/F4]). There was a positive correlation between LSM and fibrosis stage (r_s  = 0.41; p < 0.001). LSM ≥11 kPa was associated with lower survival within 3 years (84.8 vs. 93.7%; p = 0.04). After adjusting for age, sex, and fibrosis stage, LSM ≥11 kPa was independently associated with mortality (hazard ratio, 2.45; 95% confidence interval, 1.08-5.60). Elevated LSM by 2D-SWE is associated with increased mortality after LT independent of hepatic fibrosis. Given the overall decrease in the use of liver biopsy in the current era, 2D-SWE may serve as a novel noninvasive prognostic tool to predict relevant outcomes late after LT.

Nonselective beta-blocker use is associated with increased hepatic encephalopathy-related readmissions in cirrhosis

BACKGROUND

Hepatic encephalopathy (HE) is a neurocognitive condition in cirrhosis leading to frequent hospitalizations. Nonselective beta-blockers (NSBBs) are the mainstay of pharmacologic treatment in cirrhotic patients. We hypothesized that since NSBBs decrease cardiac output and portal flow, the decreased metabolic filtering process of liver parenchyma may lead to increased HE-related hospitalizations.

AIM

To evaluate the impact of NSBB administration on HE-related readmissions in cirrhotic patients.

METHODS

In this retrospective cohort study, we included 393 patients admitted to Baylor University Medical Center for liver-related portal hypertension indications between January 2013 and July 2018. Independent predictors of the first HE-related readmissions were identified using Cox proportional hazards analysis. The cumulative incidence of the first HE-related readmissions between patients receiving NSBBs and not receiving NSBBs was examined using Fine-Gray modeling to account for the competing risk of death or liver transplantation.

RESULTS

The mean age was 58.1 ± 10.2 years and most patients fell into Child class C (49.1%) or B (43.8%). The median Model for End-Stage Liver Disease-Sodium score was 22 (IQR: 11). The cumulative incidence of the first HE-related readmissions was significantly higher in patients taking NSBBs compared to patients not receiving NSBBs (71.8% vs 41.8%, P < 0.0001). In multivariate analysis, after adjusting for demographics, markers of liver disease severity, selective beta-blocker, lactulose and rifaximin use, NSBB use [Hazard ratio: 1.74 (95%CI: 1.29-2.34)] was independently associated with the first HE-related readmissions over a median follow-up of 3.8 years.

CONCLUSION

NSBB use is independently associated with increased HE-related readmissions in patients with cirrhosis, regardless of liver disease severity.

Spleen-preserving total pancreatectomy and islet autotransplantation with complete preservation of the splenic arterial and venous supply does not impact islet yield and function

BACKGROUND

Standard total pancreatectomy and islet autotransplantation (TPIAT) for chronic pancreatitis includes splenectomy, but TPIAT can be performed without splenectomy by full preservation of the blood supply to the spleen.

METHODS

We compared the metabolic and clinical outcomes of patients who underwent TPIAT at our center between 2015 and 2021 with or without splenectomy. A total of 89 patients were included in the study, and 17 of them underwent spleen-preserving total pancreatectomy (SPTP).

RESULTS

The two study groups had similar demographic and metabolic parameters. Short-term morbidity and long-term outcomes were similar. The operative time was significantly shorter with splenectomy: a median of 9.91 h (interquartile range [IQR] 8.89-10.83) compared to 10.78 h (IQR 10.2-11.6) for SPTP (P = 0.021). There was no difference between the groups in postoperative morbidity. Metabolic outcomes at 1 year were better in the SPTP group compared to the splenectomy group, with a median daily insulin requirement of 7 units (IQR 4-12) vs 15 units (IQR 7-26; P = 0.049) and a median C-peptide at 1 year of 0.65 (IQR 0.40-1.26) vs 1.00 (IQR 0.80-1.90; P = 0.63). The reduction in morphine milligram equivalents per day over time was significantly better in the SPTP group (P < 0.001), as was the decrease in pain score (P < 0.001).

CONCLUSION

TPIAT with full arterial and venous preservation of the spleen had no adverse impact on islet yield or function. TPIAT can be safely and effectively performed with preservation of the spleen and the entire splenic artery and vein. The spleen should be preserved when feasible in every TPIAT surgery.

Predicting Long-term Survival After Liver Transplantation in Patients With NASH Cirrhosis

Nonalcoholic steatohepatitis (NASH) cirrhosis is the second most common indication for liver transplantation (LT) in the United States.¹ Patients are increasingly older at presentation, with higher rates of metabolic syndrome, obesity, hyperlipidemia, diabetes mellitus, and renal failure.² They are also at higher risk of cardiovascular events and mortality while on the waiting list¹ and in the post-transplant period.^3,4 We sought to identify predictors of long-term benefit based on 5-year survival post-LT in NASH cirrhosis, thereby delineating those patients that derive a clear benefit from LT versus those in whom LT may be futile.

Estimating Glomerular Filtration Rate in Cirrhosis Using Creatinine-Based and Cystatin C-Based Equations: Systematic Review and Meta-Analysis

Accurate estimation of kidney function in cirrhosis is crucial for prognosis and decisions regarding dual-organ transplantation. We performed a systematic review/meta-analysis to assess the performance of creatinine-based and cystatin C (CysC)-based eGFR equations compared with measured GFR (mGFR) in patients with cirrhosis. A total of 25 studies (n = 4565, 52.0 years, 37.0% women) comprising 18 equations met the inclusion criteria. In all GFR equations, the creatinine-based equations overestimated GFR (standardized mean difference, SMD, 0.51; 95% confidence interval [CI], 0.31-0.71) and CysC-based equations underestimated GFR (SMD, -0.3; 95% CI, -0.60 to -0.02). Equations based on both creatinine and CysC were the least biased (SMD, -0.14; 95% CI, -0.46 to 0.18). Chronic kidney disease-Epi-serum creatinine-CysC (CESC) was the least biased but had low precision and underestimated GFR by -3.6 mL/minute/1.73 m² (95% CI, -17.4 to 10.3). All equations significantly overestimated GFR (+21.7 mL/minute/1.73 m² ; 95% CI, 17.7-25.7) at GFR <60 mL/minute/1.73 m² ; of these, chronic kidney disease-Epi-CysC (10.3 mL/minute/1.73 m² ; 95% CI, 2.1-18.4) and GFR Assessment in Liver Disease (12.6 mL/minute/1.73 m² ; 95% CI, 7.2-18.0) were the least biased followed by Royal Free Hospital (15 mL/minute/1.73 m² ; 95% CI, 5.5-24.6) and Modification of Diet in Renal Disease 6 (15.7 mL/minute/1.73 m² ; 95% CI, 10.6-20.8); however, there was an overlap in the precision of estimates, and the studies were limited. In ascites, overestimation of GFR was common (+8.3 mL/minute/1.73 m² ; 95% CI, -3.1 to 19.7). However, overestimation of GFR by 10 to 20 mL/minute/1.73m² is common in patients with cirrhosis with most equations in ascites and/or kidney dysfunction. A tailored approach is required especially for decisions regarding dual-organ transplantation.

Motivations and Psychological Characteristics of Nondirected Uterus Donors From The Dallas UtErus Transplant Study

INTRODUCTION

Uterus transplantation has demonstrated success in clinical trials. Questions regarding how it should transition to a clinical procedure must be addressed. A critical element is an evidence regarding the psychological experiences of living uterus donors, especially donors who are nondirected (altruistic).

PROJECT AIMS

To describe the motivations for donation, psychological characteristics, and mental health history of nondirected living uterus donors in the Dallas UtErus Transplant Study (NCT02656550).

DESIGN

An observational design was used to evaluate 44 self-referred nondirected uterus donors for the uterus transplant program. The donors participated in a clinical interview with a licensed psychologist and completed assessment instruments for depression, anxiety, posttraumatic stress, health-related quality of life, and resilience at the time of evaluation.

RESULTS

Among the 11 donors, the median age was 36 years, 10 were married, 10 were of non-Hispanic/Latino ethnicity, and all had given birth (median of 2 children). The most frequent motivations for the donation were to provide another woman with the opportunity to carry her own child and to contribute to science. No participants met clinical criteria for depression, anxiety or posttraumatic stress but 4 reported current mental health conditions and 7 reported past or present treatment. Quality of life and resilience scores were above population norms.

CONCLUSION

Women selected as nondirected uterus donors were motivated to help other women experience carrying their own child and to contribute to science. A minority of women reported mental health conditions and/or treatment, and this was determined not to exclude participation with uterus donation.

Psychological Characteristics of Recipients Pretransplantation in the Dallas UtErus Transplant Study (DUETS)

INTRODUCTION

Uterus transplantation is now a viable option for fertility treatment for women with absolute uterine factor infertility. Psychological assessment is recommended as a part of the perioperative evaluation process.

RESEARCH OBJECTIVE

The purpose of this study was to examine the psychological characteristics and mental health history of the 20 women who participated in the Dallas UtErus Transplant Study (DUETS) trial.

DESIGN

This retrospective observational descriptive study was part of a prospective clinical trial. Prior to transplant, 20 women completed a clinical psychological interview, 19 of whom also completed psychological assessment measures including the Hospital Anxiety and Depression Scale, Patient Health Questionnaire 9 item, Generalized Anxiety Disorder 7 item, PTSD Checklist for DSM-5, 36-Item Short Form, Connor-Davidson Resilience Scale 10 item, and Dyadic Adjustment Scale.

RESULTS

Women who participated in the trial had high health-related quality of life and minimal psychological history, with most reporting psychological distress associated with their initial infertility diagnosis (N = 13). None of the participants endorsed psychological distress to meet clinical concerns on the psychological measures used. Satisfaction with relationship adjustment with their partners was also high.

CONCLUSIONS

Women with absolute uterine factor infertility who underwent uterus transplant demonstrated low psychological distress on assessment measures, were resilient, had high health related quality of life, and strong satisfaction with the quality of relationships with their partners. Although some women reported either current or past psychological diagnosis, most reported psychological distress that occurred at the time of the infertility diagnosis and appeared to resolve over time.

Search for Lepton Number and Flavor Violation in K^{+} and π^{0} Decays

Searches for the lepton number violating K^{+}→π^{-}μ^{+}e^{+} decay and the lepton flavor violating K^{+}→π^{+}μ^{-}e^{+} and π^{0}→μ^{-}e^{+} decays are reported using data collected by the NA62 experiment at CERN in 2017-2018. No evidence for these decays is found and upper limits of the branching ratios are obtained at 90% confidence level: B(K^{+}→π^{-}μ^{+}e^{+})<4.2×10^{-11}, B(K^{+}→π^{+}μ^{-}e^{+})<6.6×10^{-11} and B(π^{0}→μ^{-}e^{+})<3.2×10^{-10}. These results improve by 1 order of magnitude over previous results for these decay modes.

A new cylindrical borehole detector for radiographic imaging with muons

Muon radiography is a methodology which enables measuring the mass distribution within large objects. It exploits the abundant flux of cosmic muons and uses detectors with different technologies depending on the application. As the sensitive surface and geometric acceptance are two fundamental parameters for increasing the collection of muons, the optimization of the detectors is very significant. Here we show a potentially innovative detector of size and shape suitable to be inserted inside a borehole, that optimizes the sensitive area and maximizes the angular acceptance thanks to its cylindrical geometry obtained using plastic arc-shaped scintillators. Good spatial resolution is obtained with a reasonable number of channels. The dimensions of the detector make it ideal for use in 25 cm diameter wells. Detailed simulations based on Monte Carlo methods show great cavity detection capability. The detector has been tested in the laboratory, achieving overall excellent performance.

Effects of Initial Hepatic Artery Followed by Portal Reperfusion Technique on Deceased Donor Liver Transplant Outcomes

OBJECTIVES

Although initial portal vein reperfusion of a liver allograft is nearly standardized, limited data suggest initial hepatic artery reperfusion may improve hemodynamics and posttransplant outcomes.

MATERIALS AND METHODS

We retrospectively reviewed orthotopic liver transplants performed between January 2013 and February 2018. Parameters of liver recipients with initial hepatic artery reperfusion were compared with those with initial portal vein reperfusion.

RESULTS

Of 204 recipients, 53 (26%) were initially perfused from the hepatic artery and 151 (74%) were initially perfused from the portal vein. Demographics between groups did not differ. There were no significant differences in the incidence of acute rejection between recipients with initial hepatic artery reperfusion versus portal vein reperfusion at 3 months and 1 year (1.9% vs 7.9% and 7.5% vs 10.6%; not significant), hepatic artery thrombosis (1.9% vs 4.0% and 1.9% vs 7.3%; not significant), biliary leakage (7.5% vs 4.0% and 9.4 vs 6.6; not significant), biliary strictures (7.5% vs 5.3% and 11.3% vs 7.9%; not significant), or portal or hepatic venous thrombosis/stenosis (5.7% vs 5.3% and 7.5% vs 7.9%; not significant). Furthermore, recipients with initial hepatic artery reperfusion and portal vein reperfusion were both hospitalized for a median of 8.5 days (interquartile range, 6.5-15.5 vs 7.0-14.0 days, respectively), and both groups were in the intensive care unit for a median of 3 days (interquartile range, 2-7 vs 2-4 days, respectively). Initial hepatic artery reperfusion was associated with significantly less intraoperative packet red blood cell transfusion (median, 11.9 U [interquartile range, 11.1-13.1 U] vs 15.5 U [interquartile range, 12.9-17.9 U]; P < .001). The 2 groups did not differ in terms of patient and graft survival.

CONCLUSIONS

Initial reperfusion of liver allografts with arterial, rather than portal, blood has benefits to hemodynamic stability, did not have deleterious effects on outcomes, and resulted in less intraoperative blood utilization.

Predicting clinical decompensation in patients with cirrhosis using the Hepquant-SHUNT test

BACKGROUND

Early identification of risk for decompensation in clinically stable cirrhotic patients helps specialists target early interventions and supports effective referrals from primary care providers to specialty centres.

AIMS

To examine whether the HepQuant-SHUNT test (HepQuant LLC, Greenwood Village, Colorado, USA) predicts decompensation and the need for liver transplantation, hospitalisation or liver-related death.

METHODS

Thirty-five compensated and 35 subjects with a previous episode of decompensation underwent the SHUNT Test and were followed for a median of 4.2 years. The disease severity index (DSI) (range 0-50) was examined for association with decompensation in compensated patients; and liver transplantation, liver-related death, and the number and days of liver related hospitalisations in all. DSI prediction of decompensation was also evaluated in 84 subjects with compensated cirrhosis from the Hepatitis C Antiviral Long-Term Treatment against Cirrhosis Trial (HALT-C) followed for a median of 5.8 years.

RESULTS

At baseline, subjects with prior decompensation had significantly higher DSI than compensated subjects (32.6 vs 20.9, P < 0.001). DSI ≥24 distinguished the decompensated from the compensated patients and independently predicted adverse clinical outcomes (hazard ratio: 4.92, 95% confidence interval: 1.42-17.06). In the HALT-C cohort, 65% with baseline DSI ≥24 vs 19% with DSI <24 experienced adverse clinical outcomes (relative risk 3.45, P < 0.0001).

CONCLUSIONS

The SHUNT test is a novel, noninvasive test that predicts risk of decompensation in previously compensated patients. DSI ≥24 is independently associated with risk for clinical decompensation, liver transplantation, death and hospitalisation.

Multicenter validation of the liver graft assessment following transplantation (L-GrAFT) score for assessment of early allograft dysfunction

BACKGROUND & AIMS

Early allograft dysfunction (EAD) following liver transplantation (LT) negatively impacts graft and patient outcomes. Previously we reported that the liver graft assessment following transplantation (L-GrAFT₇) risk score was superior to binary EAD or the model for early allograft function (MEAF) score for estimating 3-month graft failure-free survival in a single-center derivation cohort. Herein, we sought to externally validate L-GrAFT₇, and compare its prognostic performance to EAD and MEAF.

METHODS

Accuracies of L-GrAFT₇, EAD, and MEAF were compared in a 3-center US validation cohort (n = 3,201), and a Consortium for Organ Preservation in Europe (COPE) normothermic machine perfusion (NMP) trial cohort (n = 222); characteristics were compared to assess generalizability.

RESULTS

Compared to the derivation cohort, patients in the validation and NMP trial cohort had lower recipient median MELD scores; were less likely to require pretransplant hospitalization, renal replacement therapy or mechanical ventilation; and had superior 1-year overall (90% and 95% vs. 84%) and graft failure-free (88% and 93% vs. 81%) survival, with a lower incidence of 3-month graft failure (7.4% and 4.0% vs. 11.1%; p <0.001 for all comparisons). Despite significant differences in cohort characteristics, L-GrAFT₇ maintained an excellent validation AUROC of 0.78, significantly superior to binary EAD (AUROC 0.68, p = 0.001) and MEAF scores (AUROC 0.72, p <0.001). In post hoc analysis of the COPE NMP trial, the highest tertile of L-GrAFT₇ was significantly associated with time to liver allograft (hazard ratio [HR] 2.17, p = 0.016), Clavien ≥IIIB (HR 2.60, p = 0.034) and ≥IVa (HR 4.99, p = 0.011) complications; post-LT length of hospitalization (p = 0.002); and renal replacement therapy (odds ratio 3.62, p = 0.016).

CONCLUSIONS

We have validated the L-GrAFT₇ risk score as a generalizable, highly accurate, individualized risk assessment of 3-month liver allograft failure that is superior to existing scores. L-GrAFT₇ may standardize grading of early hepatic allograft function and serve as a clinical endpoint in translational studies (www.lgraft.com).

LAY SUMMARY

Early allograft dysfunction negatively affects outcomes following liver transplantation. In independent multicenter US and European cohorts totaling 3,423 patients undergoing liver transplantation, the liver graft assessment following transplantation (L-GrAFT) risk score is validated as a superior measure of early allograft function that accurately discriminates 3-month graft failure-free survival and post-liver transplantation complications.

Center Variation in Intention-to-Treat Survival Among Patients Listed for Liver Transplant

In the United States, centers performing liver transplant (LT) are primarily evaluated by patient survival within 1 year after LT, but tight clustering of outcomes allows only a narrow window for evaluation of center variation for quality improvement. Alternate measures more relevant to patients and the transplant community are needed. We examined adults listed for LT in the United States, using data submitted to the Scientific Registry of Transplant Recipients. Intention-to-treat (ITT) survival was defined as survival within 1 year from listing, regardless of transplant. Mixed effects/frailty models were used to assess center variation in ITT survival. Between January 2010 and December 2016, there were 66,428 new listings at 113 centers. Overall, median 1-year ITT survival was 79.8% (interquartile range [IQR], 76.1%-83.4%), whereas 1-year waiting-list (WL) survival was 75.8% (IQR, 71.2%-79.4%), and 1-year post-LT survival was 90.0% (IQR, 87.9%-91.8%). Higher rates of ITT mortality were correlated with increased WL mortality (correlation, r = 0.76), increased post-LT mortality (r = 0.31), lower volume centers (r = -0.34), and lower transplant rate ratio (r = -0.25). Similar patterns were observed in the subgroup of WL candidates listed with Model for End-Stage Liver Disease (MELD) ≥25: median 1-year ITT survival was 65.2% (IQR, 60.2%-72.6%), whereas 1-year post-LT survival was 87.5% (IQR, 84.0%-90.9%), and 1-year WL survival was 36.6% (IQR, 27.9%-47.0%). In mixed effects modeling, the transplant center was an independent predictor of ITT survival even after adjustment for age, sex, MELD, and sociodemographic variables. Center variation for ITT survival was larger compared with post-LT survival. The measurement of ITT outcome offers a complementary method to assess center performance. This is a first step toward understanding differences in program quality beyond patient and graft survival after LT.

Laparoscopic Versus Finger-Assisted Open Donor Nephrectomy Technique: A Possible Safe Alternative

OBJECTIVES

Despite the present use ofthe laparoscopic technique for living-donor kidney nephrectomy, a search for alternative techniques continues.The aim of this study was to compare finger-assisted open donor nephrectomy versus laparoscopic donor nephrectomy.

MATERIALS AND METHODS

This study included retrospective data of 95 consecutive donors in a transplant center who were under going donor nephrectomy RESULTS: Donor demographics and clinical characteristics were generally similar between treatment groups. There were fewer female donors in the finger-assisted open donor nephrectomy treatment group (70.5% vs 29.5%; P = .003), but median body mass index was similar between groups (28 vs 26 kg/m²; P = .032). Patients who received laparoscopic donor nephrectomy had longer operative duration (3.5 vs 1.2 h; P < .001), longer combined length of incision (6 vs 5 cm; P = .001), andshorter median hospital length of stay (3 vs 4 days; P < .001). A left nephrectomy was preferred in both groups. Minor postoperative complications occurred less often in the finger-assisted open donor nephrectomy group (14.7% vs 31.6%; P = .0094). Donors who received laparoscopic nephrectomy had lower glomerular filtration rate at 1 year after donation (60 vs 89 mL/min/1.73 m²; P < .001) than donors who received finger-assisted nephrectomy. However, recipients of donors of both procedures had similar glomerular filtration rate at 1 year after transplant (65 vs 69 mL/min/1.73 m²; P = .5).

CONCLUSIONS

Our study demonstrated that finger-assisted open donor nephrectomy is a successful and safe alternative versus laparoscopic donor nephrectomy, providing favorable results for patients in terms of complications and outcomes.

Impact of Prior Bariatric Surgery on Perioperative Liver Transplant Outcomes

Bariatric surgery (BS) is effective in treating morbid obesity, but the impact of prior BS on candidacy for liver transplantation (LT) is unclear. We examined 78 patients with cirrhosis with prior BS compared with a concurrent cohort of 156 patients matched by age, Model for End-Stage Liver Disease score, and underlying liver disease. We compared rates of transplant denial after evaluation, delisting on the waiting list, and survival after LT. The median time from BS to LT evaluation was 7 years. Roux-en-Y gastric bypass was the most common BS procedure performed (63% of cohort). Nonalcoholic fatty liver disease was the leading etiology for liver cirrhosis (47%). Delisting/death on the waiting list was higher among patients with BS (33.3% versus 10.1%; P = 0.002), and the transplantation rate was lower (48.9% versus 65.2%; P = 0.03). Intention-to-treat (ITT) survival from listing to 1 year after LT was lower in the BS cohort versus concurrent cohort (1-year survival, 84% versus 90%; P = 0.05). On adjusted analysis, a history of BS was associated with an increased risk of death on the waiting list (hazard ratio [HR], 5.7; 95% confidence interval [CI], 2.2-15.1), but this impact was attenuated (HR, 4.9; 95% CI, 1.8-13.4) by the presence of malnutrition. When limited to matched controls by sex, mortality attributed to BS was no longer significant for females (P = 0.37) but was significant for males (P = 0.046). Sarcopenia, as captured by skeletal muscle index, was calculated in a subset of patients (n = 49). The total skeletal surface area was lower in the BS group (127 [105-141] cm² versus 153 [131-191] cm² ; P = 0.005). Rates of sarcopenia were higher among patients delisted after listing (71.4% versus 16.7%; P = 0.04). In conclusion, a history of BS was associated with higher rates of delisting on the waiting list as well as lower survival from the time of listing on ITT analysis. Presence of malnutrition and sarcopenia among patients with BS may contribute to worse outcomes.

Applications of muon absorption radiography to the fields of archaeology and civil engineering

Muon radiography, also known as muography, is an imaging technique that provides information on the mass density distribution inside large objects. Muons are naturally produced in the interactions of cosmic rays in the Earth's atmosphere. The physical process exploited by muography is the attenuation of the muon flux, that depends on the thickness and density of matter that muons cross in the course of their trajectory. A particle detector with tracking capability allows the measurement of the muons flux as a function of the muon direction. The comparison of the measured muon flux with the expected one gives information on the distribution of the density of matter, in particular, on the presence of cavities. In this article, the measurement performed at Mt. Echia in Naples (Saracino 2017 Sci. Rep. 7, 1181. (doi:10.1038/s41598-017-01277-3)), will be discussed as a practical example of the possible application of muography in archaeology and civil engineering.This article is part of the Theo Murphy meeting issue 'Cosmic-ray muography'.

Volcanoes in Italy and the role of muon radiography

Cosmic-ray muon radiography (muography), an imaging technique that can provide measurements of rock densities within the top few 100 m of a volcanic cone, has now achieved a spatial resolution of the order of 10 m in optimal detection conditions. Muography provides images of the top region of a volcano edifice with a resolution that is considerably better than that typically achieved with other conventional methods (i.e. gravimetric). We expect such precise measurements, to provide us with information on anomalies in the rock density distribution, which can be affected by dense lava conduits, low-density magma supply paths or the compression with the depth of the overlying soil. The MUon RAdiography of VESuvius (MURAVES) project is now in its final phase of construction and deployment. Up to four muon hodoscopes, each with a surface of roughly 1 m², will be installed on the slope of Vesuvius and take data for at least 12 months. We will use the muographic profiles, combined with data from gravimetric and seismic measurement campaigns, to determine the stratigraphy of the lava plug at the bottom of the Vesuvius crater, in order to infer potential eruption pathways. While the MURAVES project unfolds, others are using emulsion detectors on Stromboli to study the lava conduits at the top of the volcano. These measurements are ongoing: they have completed two measurement campaigns and are now performing the first data analysis.This article is part of the Theo Murphy meeting issue 'Cosmic-ray muography'.

Tests of a novel imaging algorithm to localize hidden objects or cavities with muon radiography

A novel algorithm developed within muon radiography to localize objects or cavities hidden inside large material volumes was recently proposed by some of the authors (Bonechi et al. 2015 J. Instrum. 10, P02003 (doi:10.1088/1748-0221/10/02/P02003)). The algorithm, based on muon back projection, helps to estimate the three-dimensional position and the transverse extension of detected objects without the need for measurements from different points of view, which would be required to make a triangulation. This algorithm can now be tested owing to the availability of real data collected both in laboratory tests and from real-world measurements. The methodology and some test results are presented in this paper.This article is part of the Theo Murphy meeting issue 'Cosmic-ray muography'.

The MURAVES project and other parallel activities on muon absorption radiography

The MURAVES (MUon RAdiography of VESuvius) project is a joint activity participated by INGV, INFN and the Universities of Naples “Federico II” and Florence. The collaboration, following the experience gained within the previous INFN R&D project Mu-Ray, is currently completing the production of a robust four square meter low power consumption detector to be installed on the flank of Mount Vesuvius, an active volcano located on the western coast of Italy. The detector is supposed to collect data for at least one year, thus allowing performing a scan of the structure of the Vesuvius volcanic cone. In this work the status of the project and some parallel activities on muon radiography are presented.

Eversion Bile Duct Anastomosis: A Safe Alternative for Bile Duct Size Discrepancy in Deceased Donor Liver Transplantation

Bile duct size discrepancy in liver transplantation may increase the risk of biliary complications (BCs). The aim of this study was to evaluate the safety and outcomes of the eversion bile duct anastomosis technique in deceased donor liver transplantation (DDLT) with duct-to-duct anastomosis. A total of 210 patients who received a DDLT with duct-to-duct anastomosis from 2012 to 2017 were divided into 2 groups: those who had eversion bile duct anastomosis (n = 70) and those who had standard bile duct anastomosis (n = 140). BC rates were compared between the 2 groups. There was no difference in the cumulative incidence of biliary strictures (P = 0.20) and leaks (P = 0.17) between the 2 groups. The BC rate in the eversion group was 14.3% and 11.4% in the standard anastomosis group. All the BCs in the eversion group were managed with endoscopic stenting. A severe size mismatch (≥3:1 ratio) was associated with a significantly higher incidence of biliary strictures (44.4%) compared with a 2:1 ratio (8.2%; P = 0.002). In conclusion, the use of the eversion technique is a safe alternative for bile duct discrepancy in DDLT. However, severe bile duct size mismatch may be a risk factor for biliary strictures with such a technique.

Recipient characteristics and morbidity and mortality after liver transplantation

BACKGROUND AND AIMS

Over the last decade, liver transplantation of sicker, older non-hepatitis C cirrhotics with multiple co-morbidities has increased in the United States. We sought to identify an easily applicable set of recipient factors among HCV negative adult transplant recipients associated with significant morbidity and mortality within five years after liver transplantation.

METHODS

We collected national (n = 31,829, 2002-2015) and center-specific data. Coefficients of relevant recipient factors were converted to weighted points and scaled from 0-5. Recipient factors associated with graft failure included: ventilator support (five patients; hazard ratio [HR] 1.59; 95% CI 1.48-1.72); recipient age >60 years (three patients; HR 1.29; 95% CI 1.23-1.36); hemodialysis (three patients; HR 1.26; 95% CI 1.16-1.37); diabetes (two patients; HR 1.20; 95% CI 1.14-1.27); or serum creatinine ≥1.5 mg/dl without hemodialysis (two patients; HR 1.15; 95% CI 1.09-1.22).

RESULTS

Graft survival within five years based on points (any combination) was 77.2% (0-4), 69.1% (5-8) and 57.9% (>8). In recipients with >8 points, graft survival was 42% (model for end-stage liver disease [MELD] score <25) and 50% (MELD score 25-35) in recipients receiving grafts from donors with a donor risk index >1.7. In center-specific data within the first year, subjects with ≥5 points (vs. 0-4) had longer hospitalization (11 vs. 8 days, p <0.01), higher admissions for rehabilitation (12.3% vs. 2.7%, p <0.01), and higher incidence of cardiac disease (14.2% vs. 5.3%, p <0.01) and stage 3 chronic kidney disease (78.6% vs. 39.5%, p = 0.03) within five years.

CONCLUSION

The impact of co-morbidities in an MELD-based organ allocation system need to be reassessed. The proposed clinical tool may be helpful for center-specific assessment of risk of graft failure in non-HCV patients and for discussion regarding relevant morbidity in selected subsets.

LAY SUMMARY

Over the last decade, liver transplantation of sicker, older patient with multiple co-morbidities has increased. In this study, we show that a set of recipient factors (recipient age >60 years, ventilator status, diabetes, hemodialysis and creatinine >1.5 mg/dl) can help identify patients that may not do well after transplant. Transplanting sicker organs in patients with certain combinations of these characteristics leads to lower survival.

Risk factors for early readmission after total pancreatectomy and islet auto transplantation

BACKGROUND

Little published data exist examining causes of hospital readmission following total pancreatectomy with islet autotransplantation (TPIAT).

METHODS

A retrospective analysis was performed of a prospectively collected institutional TPIAT database. Primary outcome was unplanned readmission to the hospital within 30 days from discharge. Reasons and risk factors for readmission as well as islet function were evaluated and compared by univariate and multivariate analysis.

RESULTS

83 patients underwent TPIAT from 2006 to 2014. 21 patients (25.3%) were readmitted within 30 days. Gastrointestinal problems (52.4%) and surgical site infection (42.8%) were the most common reasons for readmission. Initial LOS and reoperation were risk factors for early readmission. Patients with delayed gastric emptying (DGE) were three times more likely to get readmitted. In multivariate analysis, patients undergoing pylorus preservation surgery were nine times more likely to be readmitted than the antrectomy group.

CONCLUSION

Early readmission after TPIAT is common (one in four patients), underscoring the complexity of this procedure. Early readmission is not detrimental to islet graft function. Patients undergoing pylorus preservation are more likely to get readmitted, perhaps due to increased incidence of delayed gastric emptying. Decision for antrectomy vs. pylorus preservation needs to be individualized.

NA62 and NA48/2 results on search for Heavy Neutral Leptons

In this paper we present new results on upper limits for the search of Heavy Neutral Leptons (HNL) with data collected by NA48/2 (2003-2004), NA62-RK (2007) and NA62 (2015) CERN experiments. The data collected with different trigger configuration allow to search for both long and short living heavy neutrinos in the mass range below the kaon mass. In addition the status of the search for K+ → π+vv with the NA62 detector will be briefly presented.

Comparison of Clinical Characteristics, Complications, and Outcomes in Recipients Having Heart Transplants <65 Years of Age Versus ≥65 Years of Age

Advanced recipient age remains a limiting factor for heart transplant candidacy, with many centers reluctant to transplant older patients. Here, we report our experience with recipients aged ≥65 years compared with younger recipients in terms of baseline characteristics, intraoperative and immediate postoperative experiences, and post-transplant morbidity and survival. The main study outcome was primary graft dysfunction (PGD), which has not been widely studied in this population. Donor and recipient data from 255 heart transplantations performed between 2012 and 2016 were reviewed. Seventy (27%) recipients were ≥65 years and 185 were younger. The older group had a higher frequency of ischemic cardiomyopathy and more frequently had a previous sternotomy than the younger recipients (all p <0.007). We found no significant differences in post-transplant morbidity (intensive care unit and hospital stay, pneumonia, infections, reoperation for bleeding, stroke, renal failure, or in-hospital mortality; all p >0.12). One-year survival was also similar in the 2 groups (p = 0.88). The incidence of moderate or severe PGD was lower in the older group (6%) than in the younger group (16%; p = 0.037). Multivariate logistic regression found pretransplant creatinine and donor undersizing by predicted heart mass to be predictors of moderate to severe PGD, whereas recipient age ≥65 years was identified as protective against PGD in this cohort. In conclusion, our study showed comparable survival and outcomes in recipients ≥65 years of age with otherwise similar nutritional status and body mass composition.

Application of the International Society for Heart and Lung Transplantation (ISHLT) criteria for primary graft dysfunction after cardiac transplantation: outcomes from a high-volume centre†

OBJECTIVES

A standardized definition for primary graft dysfunction (PGD) after cardiac transplantation was recently proposed by the International Society of Heart and Lung Transplantation (ISHLT). We sought to characterize the outcomes associated with and identify risk factors for PGD following cardiac transplantation using these criteria at a high volume centre.

METHODS

Donor and recipient medical records of 201 consecutive adult cardiac transplantations performed between November 2012 and March 2015 were retrospectively reviewed. Patients undergoing isolated heart transplantation were diagnosed with none, mild, moderate, or severe PGD using ISHLT criteria. Cumulative survival was calculated according to the Kaplan–Meier method. Associations of risk factors for combined moderate/severe PGD were assessed with univariate and multivariate analyses.

RESULTS

A total of 191 consecutive patients underwent isolated heart transplantation, and 59 (30%) met ISHLT criteria for PGD: 35 (18%) mild, 8 (4%) moderate and 16 (8%) severe. Thirty-day/in-hospital mortality occurred in six (3%) patients, all of whom were diagnosed with severe PGD. Patients with moderate/severe PGD also had significantly increased intensive care unit length of stay (LOS), total LOS, reoperations for bleeding and postoperative infections. Survival at 1-year was diminished with increasing severity of PGD (none 93%, mild 94%, moderate 75% and severe 44%; log-rank P < 0.001). Elevated preoperative creatinine, pretransplantation hospitalized recipient and undersized donor were independently predictive of moderate/severe PGD.

CONCLUSIONS

A diagnosis of PGD portends worse outcomes including increased 30-day and 1-year mortality. The ISHLT diagnostic criteria for moderate and severe PGD identify and discriminate patients with PGD in a clinically relevant manner.

Significance of measured intraoperative portal vein flows after thrombendvenectomy in deceased donor liver transplantations with portal vein thrombosis

Adequate portal vein (PV) flow in liver transplantation is essential for a good outcome, and it may be compromised in patients with portal vein thrombosis (PVT). This study evaluated the impact of intraoperatively measured PV flow after PV thrombendvenectomy on outcomes after deceased donor liver transplantation (DDLT). The study included 77 patients over a 16-year period who underwent PV thrombendvenectomy with complete flow data. Patients were classified into 2 groups: high PV flow (>1300 mL/minute; n = 55) and low PV flow (≤1300 mL/minute; n = 22). Postoperative complications and graft survival were analyzed according to the PV flow. The 2 groups were similar in demographic characteristics. Low PV flow was associated with higher cumulative rates of biliary strictures (P = 0.02) and lower 1-, 2-, and 5-year graft survival (89%, 85%, and 68% versus 64%, 55%, and 38%, respectively; P = 0.002). There was no difference in the incidence of postoperative PVT between the groups (1.8% versus 9.1%; P = 0.19). No biliary leaks or hepatic artery thromboses were reported in either group. By multivariate analyses, age >60 years (hazard ratio [HR], 3.04, 95% confidence interval [CI], 1.36-6.82; P = 0.007) and low portal flow (HR, 2.31; 95% CI, 1.15-4.65; P = 0.02) were associated with worse survival. In conclusion, PV flow <1300 mL/minute after PV thrombendvenectomy for PVT during DDLT was associated with higher rates of biliary strictures and worse graft survival. Consideration should be given to identifying reasons for low flow and performing maneuvers to increase PV flow when intraoperative PV flows are <1300 mL/minute. Liver Transplantation 23 1032-1039 2017 AASLD.

Imaging of underground cavities with cosmic-ray muons from observations at Mt. Echia (Naples)

Muography is an imaging technique based on the measurement of absorption profiles for muons as they pass through rocks and earth. Muons are produced in the interactions of high-energy cosmic rays in the Earth’s atmosphere. The technique is conceptually similar to usual X-ray radiography, but with extended capabilities of investigating over much larger thicknesses of matter thanks to the penetrating power of high-energy muons. Over the centuries a complex system of cavities has been excavated in the yellow tuff of Mt. Echia, the site of the earliest settlement of the city of Naples in the 8th century BC. A new generation muon detector designed by us, was installed under a total rock overburden of about 40 metres. A 26 days pilot run provided about 14 millions of muon events. A comparison of the measured and expected muon fluxes improved the knowledge of the average rock density. The observation of known cavities proved the validity of the muographic technique. Hints on the existence of a so far unknown cavity was obtained. The success of the investigation reported here demonstrates the substantial progress of muography in underground imaging and is likely to open new avenues for its widespread utilisation.

Probability of Accurate Heart Failure Diagnosis and the Implications for Hospital Readmissions

Heart failure (HF) is a complex syndrome with inherent diagnostic challenges. We studied the scope of possibly inaccurately documented HF in a large health care system among patients assigned a primary diagnosis of HF at discharge. Through a retrospective record review and a classification schema developed from published guidelines, we assessed the probability of the documented HF diagnosis being accurate and determined factors associated with HF-related and non-HF-related hospital readmissions. An arbitration committee of 3 experts reviewed a subset of records to corroborate the results. We assigned a low probability of accurate diagnosis to 133 (19%) of the 712 patients. A subset of patients were also reviewed by an expert panel, which concluded that 13% to 35% of patients probably did not have HF (inter-rater agreement, kappa = 0.35). Low-probability HF was predictive of being readmitted more frequently for non-HF causes (p = 0.018), as well as documented arrhythmias (p = 0.023), and age >60 years (p = 0.006). Documented sleep apnea (p = 0.035), percutaneous coronary intervention (p = 0.006), non-white race (p = 0.047), and B-type natriuretic peptide >400 pg/ml (p = 0.007) were determined to be predictive of HF readmissions in this cohort. In conclusion, approximately 1 in 5 patients documented to have HF were found to have a low probability of actually having it. Moreover, the determination of low-probability HF was twice as likely to result in readmission for non-HF causes and, thus, should be considered a determinant for all-cause readmissions in this population.

Clinical effectiveness of a pylorus-preserving procedure on total pancreatectomy with islet autotransplantation

BACKGROUND

The impact of pylorus preserving procedures (PP) on total pancreatectomy with islet autotransplantation (TPIAT) has not been examined. This study aimed to investigate the clinical impact of the PP on TPIAT.

METHODS

The Baylor Simmons Transplant Institute database was queried to identify seventy-three patients who underwent TPIAT from 2006 to 2014. All patients were investigated in postoperative complications, long-term nutritional status, and graft function.

RESULTS

Patients with PP did not face worse outcomes in terms of delayed gastric emptying and length of hospital stay. Also, nutritional status and metabolic outcome, such as body weight, serum albumin level, serum vitamin level, HbA1c level, graft survival rate and insulin independent rate, were similar between both groups.

CONCLUSIONS

Clinical results including the graft function indicated that patients undergoing TPIAT with PP did not amplify surgical complications such as delayed gastric emptying and showed no significant advantage of nutrition and metabolic outcome.

Impact of donor age on cardiac transplantation outcomes and on cardiac function

OBJECTIVES

Although the impact of older donors on heart transplant outcomes has been previously published, the survival results are conflicting. We herein analyse the impact of older donors on transplant survival and myocardial function.

METHODS

The records of the patients who underwent heart transplant at Baylor University Medical Center at Dallas from November 2012 until March 2015 were reviewed and the data were extracted. The heart recipients were divided into two groups based on donors age; 50 years of age was the division point. The two groups were compared with regard to the following transplant outcomes: in-hospital and 1-year survival, severe (3R) rejection, primary graft dysfunction, myocardial performance as reflected by the inotropic score, left ventricular ejection fraction, intensive care unit and overall length of stay.

RESULTS

Anoxia was more common cause of death in younger donors (43.9%), whereas intracranial bleeding was more frequent in older donors (48.1%, P = 0.016). The in-hospital survival and 1-year survival were the same between the two groups. Additionally, cardiac transplantation from older donors was not associated with higher incidence of graft dysfunction, higher inotropic support score, longer intensive care unit and total hospital length of stay or more frequent severe rejection episodes. The left ventricular ejection fraction was similar between the two groups.

CONCLUSIONS

Heart transplant from older donors is not associated with lower in-hospital and mid-term survival if donors are carefully selected; furthermore, the graft function is comparable. The use of hearts from donors older than 50 years of age can be expanded beyond critically ill recipients in carefully selected recipients.

Ratio of hepatic arterial flow to recipient body weight predicts biliary complications after deceased donor liver transplantation

OBJECTIVES

Adequate hepatic arterial (HA) flow to the bile duct is essential in liver transplantation. This study was conducted to determine if the ratio of directly measured HA flow to weight is related to the occurrence of biliary complications after deceased donor liver transplantation.

METHODS

A retrospective review of 2684 liver transplants carried out over a 25-year period was performed using data sourced from a prospectively maintained database. Rates of biliary complications (biliary leaks, anastomotic and non-anastomotic strictures) were compared between two groups of patients with HA flow by body weight of, respectively, <5 ml/min/kg (n = 884) and ≥5 ml/min/kg (n = 1800).

RESULTS

Patients with a lower ratio of HA flow to weight had higher body weight (92 kg versus 76 kg; P < 0.001) and lower HA flow (350 ml/min versus 550 ml/min; P < 0.001). A lower ratio of HA flow to weight was associated with higher rates of biliary complications at 2 months, 6 months and 12 months (19.8%, 28.2% and 31.9% versus 14.8%, 22.4% and 25.8%, respectively; P < 0.001).

CONCLUSIONS

A ratio of HA flow to weight of < 5 ml/min/kg is associated with higher rates of biliary complications. This ratio may be a useful parameter for application in the prevention and early detection of biliary complications.

Role of magnetic resonance elastography in compensated and decompensated liver disease

BACKGROUND & AIMS

Non-invasive predictors identifying subjects with compensated liver disease at highest risk for transitioning to a decompensated state are lacking. We hypothesized that liver shear stiffness as measured by magnetic resonance elastography is an important non-invasive predictor of hepatic decompensation.

METHODS

Among patients with advanced fibrosis undergoing magnetic resonance elastography (2007-2011), a baseline cohort and follow up cohort (compensated liver disease) were established. Cause specific cox proportional hazards analysis adjusting for competing risks was utilized to determine the association between elevated liver shear stiffness and development of decompensation (hepatic encephalopathy, ascites, variceal bleeding).

RESULTS

In the baseline cohort (n=430), subjects with decompensated liver disease had a significantly higher mean liver shear stiffness (6.8kPa, IQR 4.9-8.5) as compared to subjects with compensated liver disease (5.2kPa, IQR 4.1-6.8). After adjustment for Model for End Stage Liver Disease score, hepatitis C, age, gender, albumin, and platelet count, the mean liver shear stiffness (OR=1.13, 95% CI 1.03-1.27) was independently associated with decompensated cirrhosis at baseline. Over a median follow up of 27months (n=167), 7.2% of subjects with compensated disease experienced hepatic decompensation. In the follow up cohort, the hazard of hepatic decompensation was 1.42 (95% CI 1.16-1.75) per unit increase in liver shear stiffness over time. The hazard of hepatic decompensation was 4.96 (95% CI 1.4-17.0, p=0.019) for a subject with compensated disease and mean LSS value ⩾5.8kPa as compared to an individual with compensated disease and lower mean LSS values.

CONCLUSION

Baseline liver shear stiffness assessed by magnetic resonance elastography is independently associated with decompensated liver disease.

Sirolimus and cardiovascular disease risk in liver transplantation

BACKGROUND

Two adverse effects of sirolimus are hypertriglyceridemia and hypercholesterolemia. These elevated levels often lead clinicians to discontinue the sirolimus from concerns of an increased cardiovascular disease (CVD) risk; however, evidence suggests that sirolimus might be cardioprotective. There are no published reports of sirolimus CVD in liver transplantation.

METHODS

We reviewed all 1812 liver recipients who underwent transplantation from 1998 to 2010, identifying a cohort using sirolimus as part of the initial immunosuppression (SRL Cohort) and a control group of the remaining patients from this period where SRL was never given (Non-SRL Control). A prospectively maintained database identified all episodes of myocardial infarction (MI), congestive heart failure (CHF), abdominal aortic aneurysm (AAA), and cerebrovascular accident and tracked triglyceride, high-density and low-density lipoproteins, and total cholesterol levels. A Framingham Risk Model calculated the predicted 10-year risk of CVD for both groups.

RESULTS

The SRL Cohort (n=406) is older, more predominantly male, with more pretransplantation hypertension and diabetes and posttransplantation hypertension compared to Non-SRL Controls (n=1005). The SRL Cohort has significantly higher triglyceride, low-density lipoprotein, and cholesterol levels at 6 months and 1 year. There is no difference in MI incidence in the SRL Cohort (1.0% vs. 1.2%) and no difference in AAA, cerebrovascular accident, and CHF. The Framingham Risk Model predicts that the SRL Cohort should have almost double the 10-year risk of CVD compared to the Non-SRL Control (11% vs. 6%).

CONCLUSIONS

Sirolimus causes hypertriglyceridemia and hypercholesterolemia, but it does not increase the incidence of MI or other CVDs. Considering the SRL Cohort has more cardiac risk factors and nearly double 10-year predicted CVD risk, the fact that the CVD incidence is similar suggests that sirolimus is in fact cardioprotective.