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Cannon RM, Goldberg DS, Sheikh SS, Anderson DJ, Pozo M, Rabbani U, Locke JE. Regional Social Vulnerability is Associated With Geographic Disparity in Waitlist Outcomes for Patients With Non-Hepatocellular Carcinoma Model for End-stage Liver Disease Exceptions in the United States. Ann Surg 2024; 279:825-831. [PMID: 37753656 PMCID: PMC10965505 DOI: 10.1097/sla.0000000000006097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
OBJECTIVE This study was undertaken to evaluate the role of regional social vulnerability in geographic disparity for patients listed for liver transplantation with non-hepatocellular carcinoma (HCC) model for end-stage liver disease (MELD) exceptions. SUMMARY AND BACKGROUND Prior work has demonstrated regional variability in the appropriateness of MELD exceptions for diagnoses other than HCC. METHODS Adults listed at a single center for first-time liver-only transplantation without HCC after June 18, 2013 in the Scientific Registry of Transplant Recipients database as of March 2021 were examined. Candidates were mapped to hospital referral regions (HRRs). Adjusted likelihood of mortality and liver transplantation were modeled. Advantaged HRRs were defined as those where exception patients were more likely to be transplanted, yet no more likely to die in adjusted analysis. The Centers for Disease Control's Social Vulnerability Index (SVI) was used as the measure for community health. Higher SVIs indicate poorer community health. RESULTS There were 49,494 candidates in the cohort, of whom 4337 (8.8%) had MELD exceptions. Among continental US HRRs, 27.3% (n = 78) were identified as advantaged. The mean SVI of advantaged HRRs was 0.42 versus 0.53 in nonadvantaged HRRs ( P = 0.002), indicating better community health in these areas. Only 25.3% of advantaged HRRs were in spatial clusters of high SVI versus 40.7% of nonadvantaged HRRs, whereas 44.6% of advantaged HRRs were in spatial clusters of low SVI versus 38.0% of nonadvantaged HRRs ( P = 0.037). CONCLUSIONS An advantage for non-HCC MELD exception patients is associated with lower social vulnerability on a population level. These findings suggest assigning similar waitlist priority to all non-HCC exception candidates without considering geographic differences in social determinants of health may actually exacerbate rather than ameliorate disparity.
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Affiliation(s)
- Robert M. Cannon
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation, Birmingham, Alabama
| | - David S. Goldberg
- University of Miami, Department of Medicine, Division of Digestive Health and Liver Disease, Miami, Florida
| | - Saulat S. Sheikh
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation, Birmingham, Alabama
| | - Douglas J. Anderson
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation, Birmingham, Alabama
| | - Marcos Pozo
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation, Birmingham, Alabama
| | - Umaid Rabbani
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation, Birmingham, Alabama
| | - Jayme E. Locke
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation, Birmingham, Alabama
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Brubaker AL, Sellers MT, Abt PL, Croome KP, Merani S, Wall A, Abreu P, Alebrahim M, Baskin R, Bohorquez H, Cannon RM, Cederquist K, Edwards J, Huerter BG, Hobeika MJ, Kautzman L, Langnas AN, Lee DD, Manzi J, Nassar A, Neidlinger N, Nydam TL, Schnickel GT, Siddiqui F, Suah A, Taj R, Taner CB, Testa G, Vianna R, Vyas F, Montenovo MI. US Liver Transplant Outcomes After Normothermic Regional Perfusion vs Standard Super Rapid Recovery. JAMA Surg 2024:2817111. [PMID: 38568597 PMCID: PMC10993160 DOI: 10.1001/jamasurg.2024.0520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 01/06/2024] [Indexed: 04/06/2024]
Abstract
Importance Normothermic regional perfusion (NRP) is an emerging recovery modality for transplantable allografts from controlled donation after circulatory death (cDCD) donors. In the US, only 11.4% of liver recipients who are transplanted from a deceased donor receive a cDCD liver. NRP has the potential to safely expand the US donor pool with improved transplant outcomes as compared with standard super rapid recovery (SRR). Objective To assess outcomes of US liver transplants using controlled donation after circulatory death livers recovered with normothermic regional perfusion vs standard super rapid recovery. Design, Setting, and Participants This was a retrospective, observational cohort study comparing liver transplant outcomes from cDCD donors recovered by NRP vs SRR. Outcomes of cDCD liver transplant from January 2017 to May 2023 were collated from 17 US transplant centers and included livers recovered by SRR and NRP (thoracoabdominal NRP [TA-NRP] and abdominal NRP [A-NRP]). Seven transplant centers used NRP, allowing for liver allografts to be transplanted at 17 centers; 10 centers imported livers recovered via NRP from other centers. Exposures cDCD livers were recovered by either NRP or SRR. Main Outcomes and Measures The primary outcome was ischemic cholangiopathy (IC). Secondary end points included primary nonfunction (PNF), early allograft dysfunction (EAD), biliary anastomotic strictures, posttransplant length of stay (LOS), and patient and graft survival. Results A total of 242 cDCD livers were included in this study: 136 recovered by SRR and 106 recovered by NRP (TA-NRP, 79 and A-NRP, 27). Median (IQR) NRP and SRR donor age was 30.5 (22-44) years and 36 (27-49) years, respectively. Median (IQR) posttransplant LOS was significantly shorter in the NRP cohort (7 [5-11] days vs 10 [7-16] days; P < .001). PNF occurred only in the SRR allografts group (n = 2). EAD was more common in the SRR cohort (123 of 136 [56.1%] vs 77 of 106 [36.4%]; P = .007). Biliary anastomotic strictures were increased 2.8-fold in SRR recipients (7 of 105 [6.7%] vs 30 of 134 [22.4%]; P = .001). Only SRR recipients had IC (0 vs 12 of 133 [9.0%]; P = .002); IC-free survival by Kaplan-Meier was significantly improved in NRP recipients. Patient and graft survival were comparable between cohorts. Conclusion and Relevance There was comparable patient and graft survival in liver transplant recipients of cDCD donors recovered by NRP vs SRR, with reduced rates of IC, biliary complications, and EAD in NRP recipients. The feasibility of A-NRP and TA-NRP implementation across multiple US transplant centers supports increasing adoption of NRP to improve organ use, access to transplant, and risk of wait-list mortality.
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Affiliation(s)
- Aleah L. Brubaker
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, University of California San Diego, La Jolla, California
- CONCORD: Consortium for Donation after Circulatory Death and Normothermic Regional Perfusion Outcomes Research and Development
| | - Marty T. Sellers
- CONCORD: Consortium for Donation after Circulatory Death and Normothermic Regional Perfusion Outcomes Research and Development
- Tennessee Donor Services, Nashville
| | - Peter L. Abt
- CONCORD: Consortium for Donation after Circulatory Death and Normothermic Regional Perfusion Outcomes Research and Development
- Department of Surgery, Transplant Division, University of Pennsylvania, Philadelphia
| | - Kristopher P. Croome
- CONCORD: Consortium for Donation after Circulatory Death and Normothermic Regional Perfusion Outcomes Research and Development
- Department of Transplant, Mayo Clinic Florida, Jacksonville
| | - Shaheed Merani
- CONCORD: Consortium for Donation after Circulatory Death and Normothermic Regional Perfusion Outcomes Research and Development
- Department of Surgery, University of Nebraska Medical Center, Omaha
| | - Anji Wall
- CONCORD: Consortium for Donation after Circulatory Death and Normothermic Regional Perfusion Outcomes Research and Development
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Phillipe Abreu
- Miami Transplant Institute, Jackson Memorial Hospital, University of Miami, Miami, Florida
| | | | - Roy Baskin
- Methodist Transplant Specialists, Dallas, Texas
| | - Humberto Bohorquez
- Department of Surgery, Ochsner School of Medicine, New Orleans, Louisiana
| | - Robert M. Cannon
- Department of Surgery, University of Alabama at Birmingham, Birmingham
| | - Kelly Cederquist
- Department of Surgery, Transplant Division, University of Pennsylvania, Philadelphia
| | - John Edwards
- Gift of Life Donor Program, Philadelphia, Pennsylvania
| | | | - Mark J. Hobeika
- J.C. Walter Jr Transplant Center, Houston Methodist Hospital, Houston, Texas
| | | | - Alan N. Langnas
- Department of Surgery, University of Nebraska Medical Center, Omaha
| | - David D. Lee
- Department of Surgery, Loyola University, Chicago, Illinois
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Joao Manzi
- Miami Transplant Institute, Jackson Memorial Hospital, University of Miami, Miami, Florida
| | - Ahmed Nassar
- Department of Surgery, Emory University, Atlanta, Georgia
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, Michigan
| | | | - Trevor L. Nydam
- CONCORD: Consortium for Donation after Circulatory Death and Normothermic Regional Perfusion Outcomes Research and Development
- Department of Surgery, Division of Transplant Surgery, University of Colorado, Aurora
| | - Gabriel T. Schnickel
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, University of California San Diego, La Jolla, California
| | - Farjad Siddiqui
- Department of Surgery, The Ohio State University, Columbus
- Department of Surgery, Emory University, Atlanta, Georgia
| | - Ashley Suah
- Department of Surgery, Emory University, Atlanta, Georgia
- Department of Surgery, University of Chicago, Chicago, Illinois
| | - Raeda Taj
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, University of California San Diego, La Jolla, California
- Department of Surgery, Transplant Division, University of Pennsylvania, Philadelphia
| | | | - Giuliano Testa
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Rodrigo Vianna
- Miami Transplant Institute, Jackson Memorial Hospital, University of Miami, Miami, Florida
| | - Frederick Vyas
- Department of Surgery, Transplant Division, University of Pennsylvania, Philadelphia
| | - Martin I. Montenovo
- CONCORD: Consortium for Donation after Circulatory Death and Normothermic Regional Perfusion Outcomes Research and Development
- Department of Surgery, Vanderbilt University, Nashville, Tennessee
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Frey KL, McLeod MC, Cannon RM, Sheikh SS, Purvis JW, Locke JE, Orandi BJ. Non-invasive evaluation of hepatic macrosteatosis in deceased donors. Am J Surg 2023; 226:692-696. [PMID: 37558520 DOI: 10.1016/j.amjsurg.2023.07.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 07/24/2023] [Accepted: 07/26/2023] [Indexed: 08/11/2023]
Abstract
INTRODUCTION Liver allocation changes have led to increased travel and expenditures, highlighting the need to efficiently identify marginal livers suitable for transplant. We evaluated the validity of existing non-invasive liver quality tests and a novel machine learning-based model at predicting deceased donor macrosteatosis >30%. METHODS We compared previously-validated non-invasive tests and a novel machine learning-based model to biopsies in predicting macrosteatosis >30%. We also tested them in populations enriched for macrosteatosis. RESULTS The Hepatic Steatosis Index area-under-the-curve (AUC) was 0.56. At the threshold identified by Youden's J statistic, sensitivity, specificity, positive, and negative predictive values were 49.6%, 58.9%, 14.0%, and 89.7%. Other tests demonstrated comparable results. Machine learning produced the highest AUC (0.71). Even in populations enriched for macrosteatosis, no test was sufficiently predictive. CONCLUSION Commonly used clinical scoring systems and a novel machine learning-based model were not clinically useful, highlighting the importance of pre-procurement biopsies to facilitate allocation.
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Affiliation(s)
- Kayla L Frey
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation, Birmingham, AL, USA
| | - M Chandler McLeod
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation, Birmingham, AL, USA
| | - Robert M Cannon
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation, Birmingham, AL, USA
| | - Saulat S Sheikh
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation, Birmingham, AL, USA
| | - Joshua W Purvis
- University of Alabama at Birmingham, Department of Anesthesia, Birmingham, AL, USA
| | - Jayme E Locke
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation, Birmingham, AL, USA
| | - Babak J Orandi
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation, Birmingham, AL, USA; Weill Cornell Medicine, Department of Medicine, New York, NY, USA.
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Cannon RM, Locke JE. It Is Time for the Light to Shine on Organ Procurement Organizations. JAMA Surg 2023; 158:409. [PMID: 36753286 DOI: 10.1001/jamasurg.2022.7857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Affiliation(s)
- Robert M Cannon
- University of Alabama at Birmingham Heersink School of Medicine, Birmingham
| | - Jayme E Locke
- University of Alabama at Birmingham Heersink School of Medicine, Birmingham
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Cannon RM, Anderson DJ, MacLennan P, Orandi BJ, Sheikh S, Kumar V, Hanaway MJ, Locke JE. Perpetuating Disparity: Failure of the Kidney Transplant System to Provide the Most Kidney Transplants to Communities With the Greatest Need. Ann Surg 2022; 276:597-604. [PMID: 35837899 PMCID: PMC9463094 DOI: 10.1097/sla.0000000000005585] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The burden of end-stage kidney disease (ESKD) and kidney transplant rates vary significantly across the United States. This study aims to examine the mismatch between ESKD burden and kidney transplant rates from a perspective of spatial epidemiology. METHODS US Renal Data System data from 2015 to 2017 on incident ESKD and kidney transplants per 1000 incident ESKD cases was analyzed. Clustering of ESKD burden and kidney transplant rates at the county level was determined using local Moran's I and correlated to county health scores. Higher percentile county health scores indicated worse overall community health. RESULTS Significant clusters of high-ESKD burden tended to coincide with clusters of low kidney transplant rates, and vice versa. The most common cluster type had high incident ESKD with low transplant rates (377 counties). Counties in these clusters had the lowest overall mean transplant rate (61.1), highest overall mean ESKD incidence (61.3), and highest mean county health scores percentile (80.9%, P <0.001 vs all other cluster types). By comparison, counties in clusters with low ESKD incidence and high transplant rates (n=359) had the highest mean transplant rate (110.6), the lowest mean ESKD incidence (28.9), and the lowest county health scores (20.2%). All comparisons to high-ESKD/low-transplant clusters were significant at P value <0.001. CONCLUSION There was a significant mismatch between kidney transplant rates and ESKD burden, where areas with the greatest need had the lowest transplant rates. This pattern exacerbates pre-existing disparities, as disadvantaged high-ESKD regions already suffer from worse access to care and overall community health, as evidenced by the highest county health scores in the study.
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Affiliation(s)
- Robert M Cannon
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Douglas J Anderson
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Paul MacLennan
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Babak J Orandi
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Saulat Sheikh
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Vineeta Kumar
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Michael J Hanaway
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Jayme E Locke
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
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Killian AC, Carter AJ, Reed RD, Shelton BA, Qu H, McLeod MC, Orandi BJ, Cannon RM, Anderson D, MacLennan PA, Kumar V, Hanaway M, Locke JE. Greater community vulnerability is associated with poor living donor navigator program fidelity. Surgery 2022; 172:997-1004. [PMID: 35831221 PMCID: PMC9633042 DOI: 10.1016/j.surg.2022.04.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 04/19/2022] [Accepted: 04/20/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Community-level factors contribute to living donor kidney transplantation disparities but may also influence the interventions aimed to mitigate these disparities. The Living Donor Navigator Program was designed to separate the advocacy role from the patient in need of transplantation-friends/family are encouraged to participate as the patients' advocates to identify living donors, though some of the patients participate alone as self-advocates. Self-advocates have a lower living donor kidney transplantation likelihood compared to the patients with an advocate. We sought to evaluate the relationship between the patients' community-level vulnerability and living donor navigator self-advocacy as a surrogate for program fidelity. METHODS This single-center, retrospective study included 110 Living Donor Navigator participants (April 2017-June 2019). Program fidelity was assessed using the participants' advocacy status. Measures of community vulnerability were obtained from the Centers for Disease Control and Prevention Social Vulnerability Index. Modified Poisson regression was used to evaluate the association between community-level vulnerability and living donor navigator self-advocacy. RESULTS Of the 110 participants, 19% (n = 21) were self-advocates. For every 10% increase in community-level vulnerability, patients had 17% higher risk of self-advocacy (adjusted relative risk 1.17, 95% confidence interval: 1.03-1.32, P = .01). Living in areas with greater unemployment (adjusted relative risk: 1.18, 95% confidence interval: 1.04-1.33, P = .01), single-parent households (adjusted relative risk: 1.23, 95% confidence interval: 1.06-1.42, P = .006), minority population (adjusted relative risk: 1.30, 95% confidence interval: 1.04-1.55, P = .02), or no-vehicle households (adjusted relative risk: 1.17, 95% confidence interval: 1.02-1.35, P = .02) were associated with increased risk of self-advocacy. CONCLUSION Having a greater community-level vulnerability was associated with poor Living Donor Navigator Program fidelity. The potential barriers identified using the Social Vulnerability Index may direct resource allocation and program refinement to optimize program fidelity and efficacy for all participants.
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Affiliation(s)
- A Cozette Killian
- University of Alabama Comprehensive Transplant Institute, Birmingham, AL. https://twitter.com/CozetteKale
| | - Alexis J Carter
- University of Alabama Comprehensive Transplant Institute, Birmingham, AL. https://twitter.com/carteraj21
| | - Rhiannon D Reed
- University of Alabama Comprehensive Transplant Institute, Birmingham, AL. https://twitter.com/rhiruns
| | - Brittany A Shelton
- University of Alabama Comprehensive Transplant Institute, Birmingham, AL
| | - Haiyan Qu
- University of Alabama Comprehensive Transplant Institute, Birmingham, AL
| | - M Chandler McLeod
- University of Alabama Comprehensive Transplant Institute, Birmingham, AL
| | - Babak J Orandi
- University of Alabama Comprehensive Transplant Institute, Birmingham, AL
| | - Robert M Cannon
- University of Alabama Comprehensive Transplant Institute, Birmingham, AL
| | - Douglas Anderson
- University of Alabama Comprehensive Transplant Institute, Birmingham, AL
| | - Paul A MacLennan
- University of Alabama Comprehensive Transplant Institute, Birmingham, AL
| | - Vineeta Kumar
- University of Alabama Comprehensive Transplant Institute, Birmingham, AL
| | - Michael Hanaway
- University of Alabama Comprehensive Transplant Institute, Birmingham, AL
| | - Jayme E Locke
- University of Alabama Comprehensive Transplant Institute, Birmingham, AL.
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Cannon RM, Nassel A, Walker JT, Sheikh SS, Orandi BJ, Shah MB, Lynch RJ, Goldberg DS, Locke JE. County-level Differences in Liver-related Mortality, Waitlisting, and Liver Transplantation in the United States. Transplantation 2022; 106:1799-1806. [PMID: 35609185 PMCID: PMC9420757 DOI: 10.1097/tp.0000000000004171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Much of our understanding regarding geographic issues in transplantation is based on statistical techniques that do not formally account for geography and is based on obsolete boundaries such as donation service area. METHODS We applied spatial epidemiological techniques to analyze liver-related mortality and access to liver transplant services at the county level using data from the Centers for Disease Control and Prevention and Scientific Registry of Transplant Recipients from 2010 to 2018. RESULTS There was a significant negative spatial correlation between transplant rates and liver-related mortality at the county level (Moran's I, -0.319; P = 0.001). Significant clusters were identified with high transplant rates and low liver-related mortality. Counties in geographic clusters with high ratios of liver transplants to liver-related deaths had more liver transplant centers within 150 nautical miles (6.7 versus 3.6 centers; P < 0.001) compared with all other counties, as did counties in geographic clusters with high ratios of waitlist additions to liver-related deaths (8.5 versus 2.5 centers; P < 0.001). The spatial correlation between waitlist mortality and overall liver-related mortality was positive (Moran's I, 0.060; P = 0.001) but weaker. Several areas with high waitlist mortality had some of the lowest overall liver-related mortality in the country. CONCLUSIONS These data suggest that high waitlist mortality and allocation model for end-stage liver disease do not necessarily correlate with decreased access to transplant, whereas local transplant center density is associated with better access to waitlisting and transplant.
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Affiliation(s)
- Robert M. Cannon
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation, Birmingham, Alabama
| | - Ariann Nassel
- University of Alabama at Birmingham, Lister Hill Center for Health Policy, Birmingham, Alabama
| | - Jeffery T. Walker
- University of Alabama at Birmingham, Center for the Study of Community Health, Birmingham, Alabama
| | - Saulat S. Sheikh
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation, Birmingham, Alabama
| | - Babak J. Orandi
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation, Birmingham, Alabama
| | - Malay B. Shah
- University of Kentucky, Department of Surgery, Division of Transplantation, Lexington, Kentucky
| | - Raymond J. Lynch
- Emory University, Department of Surgery, Division of Transplantation, Atlanta, Georgia
| | - David S. Goldberg
- University of Miami, Department of Medicine, Division of Digestive Health and Liver Disease, Miami, Florida
| | - Jayme E. Locke
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation, Birmingham, Alabama
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Cannon RM, Nassel AF, Walker JT, Sheikh SS, Orandi BJ, Lynch RJ, Shah MB, Goldberg DS, Locke JE. Lost potential and missed opportunities for DCD liver transplantation in the United States. Am J Surg 2022; 224:990-998. [PMID: 35589438 PMCID: PMC9940905 DOI: 10.1016/j.amjsurg.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 04/20/2022] [Accepted: 05/03/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Donation after cardiac death(DCD) has been proposed as an avenue to expand the liver donor pool. METHODS We examined factors associated with nonrecovery of DCD livers using UNOS data from 2015 to 2019. RESULTS There 265 non-recovered potential(NRP) DCD livers. Blood type AB (7.8% vs. 1.1%) and B (16.9% vs. 9.8%) were more frequent in the NRP versus actual donors (p < 0.001). The median driving time between donor hospital and transplant center was similar for NRP and actual donors (30.1 min vs. 30.0 min; p = 0.689), as was the percentage located within a transplant hospital (20.8% vs. 20.9%; p = 0.984).The donation service area(DSA) of a donor hospital explained 27.9% (p = 0.001) of the variability in whether a DCD liver was recovered. CONCLUSION A number of potentially high quality DCD donor livers go unrecovered each year, which may be partially explained by donor blood type and variation in regional and DSA level practice patterns.
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Affiliation(s)
- Robert M Cannon
- Department of Surgery, Division of Transplantation, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Ariann F Nassel
- Lister Hill Center for Health Policy, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jeffery T Walker
- Center for the Study of Community Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Saulat S Sheikh
- Department of Surgery, Division of Transplantation, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Babak J Orandi
- Department of Surgery, Division of Transplantation, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Raymond J Lynch
- Department of Surgery, Division of Transplantation, Emory University, Atlanta, GA, USA
| | - Malay B Shah
- Department of Surgery, Division of Transplantation, University of Kentucky, Lexington, KY, USA
| | - David S Goldberg
- Department of Medicine, Division of Digestive Health and Liver Diseases, University of Miami, Miami, FL, USA
| | - Jayme E Locke
- Department of Surgery, Division of Transplantation, University of Alabama at Birmingham, Birmingham, AL, USA
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Shah MB, Villagomez Rubio DA, Orozco G, Desai S, Ancheta A, Gupta M, Mei X, Evers BM, Gedaly R, Cannon RM. Outcomes in Elderly Patients Undergoing Liver Transplantation Compared with Liver-Directed Ablative Therapy in Early-Stage Hepatocellular Carcinoma. J Am Coll Surg 2022; 234:892-899. [PMID: 35426403 DOI: 10.1097/xcs.0000000000000135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Orthotopic liver transplantation (OLT) is the accepted treatment in patients with unresectable, early-stage hepatocellular carcinoma (HCC) in the setting of cirrhosis. Due to increasing waitlist demand for OLT, determining optimal groups for transplant is critical. Elderly patients are known to have poorer postoperative outcomes. Considering the effectiveness of liver-directed therapies for HCC, we sought to determine whether elderly patients received survival benefit from OLT over liver-directed therapy alone. STUDY DESIGN The National Cancer Database participant use file was used to analyze data between 2004 and 2017. Only patients ≥70 years of age who received OLT or liver-directed therapy alone were included. Patients with alpha-fetoprotein >500 ng/mL or missing alpha-fetoprotein values were excluded. Baseline demographic variables, model for end-stage liver disease score, and overall survival from time of diagnosis were collected. Descriptive statistics, Kaplan-Meier survival, Cox proportional hazards model, and propensity score matching were used. RESULTS A total of 2,377 patients received ablative therapy alone, and 214 patients received OLT. Multivariable analysis and Kaplan-Meier showed that OLT conferred a significant survival benefit compared to liver-directed therapy alone. Age was also associated with a yearly 3% increase in risk of mortality. Propensity-matched analysis adjusting also demonstrated a significant survival benefit for elderly patients receiving OLT compared to liver-directed therapy alone. CONCLUSION Despite increased age and associated comorbidities being factors associated with poor outcomes, OLT confers a survival advantage compared to liver-directed ablative therapies alone in selected elderly patients with HCC. OLT should be offered in medically appropriate elderly patients with HCC.
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Affiliation(s)
- Malay B Shah
- From the Department of Surgery, Division of Transplantation (Shah, Rubio, Orozco, Desai, Ancheta, Gupta, Mei, Gedaly), University of Kentucky, Lexington, KY
| | - Diego A Villagomez Rubio
- From the Department of Surgery, Division of Transplantation (Shah, Rubio, Orozco, Desai, Ancheta, Gupta, Mei, Gedaly), University of Kentucky, Lexington, KY
| | - Gabriel Orozco
- From the Department of Surgery, Division of Transplantation (Shah, Rubio, Orozco, Desai, Ancheta, Gupta, Mei, Gedaly), University of Kentucky, Lexington, KY
| | - Siddharth Desai
- From the Department of Surgery, Division of Transplantation (Shah, Rubio, Orozco, Desai, Ancheta, Gupta, Mei, Gedaly), University of Kentucky, Lexington, KY
| | - Alexandre Ancheta
- From the Department of Surgery, Division of Transplantation (Shah, Rubio, Orozco, Desai, Ancheta, Gupta, Mei, Gedaly), University of Kentucky, Lexington, KY
| | - Meera Gupta
- From the Department of Surgery, Division of Transplantation (Shah, Rubio, Orozco, Desai, Ancheta, Gupta, Mei, Gedaly), University of Kentucky, Lexington, KY
| | - Xiaonan Mei
- From the Department of Surgery, Division of Transplantation (Shah, Rubio, Orozco, Desai, Ancheta, Gupta, Mei, Gedaly), University of Kentucky, Lexington, KY
| | - B Mark Evers
- Department of Surgery, Markey Cancer Center (Evers), University of Kentucky, Lexington, KY
| | - Roberto Gedaly
- From the Department of Surgery, Division of Transplantation (Shah, Rubio, Orozco, Desai, Ancheta, Gupta, Mei, Gedaly), University of Kentucky, Lexington, KY
| | - Robert M Cannon
- Department of Surgery, Division of Transplantation, University of Alabama at Birmingham, Birmingham, AL (Cannon)
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Sellers MT, Nassar A, Alebrahim M, Sasaki K, Lee DD, Bohorquez H, Cannon RM, Selvaggi G, Neidlinger N, McMaster WG, Hoffman JRH, Shah AS, Montenovo MI. Early United States experience with liver donation after circulatory determination of death using thoraco-abdominal normothermic regional perfusion: A multi-institutional observational study. Clin Transplant 2022; 36:e14659. [PMID: 35362152 DOI: 10.1111/ctr.14659] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/07/2022] [Accepted: 03/25/2022] [Indexed: 11/28/2022]
Abstract
Mortality on the liver waitlist remains unacceptably high. Donation after circulatory determination of death (DCD) donors are considered marginal but are a potentially underutilized resource. Thoraco-abdominal normothermic perfusion (TA-NRP) in DCD donors might result in higher quality livers and offset waitlist mortality. We retrospectively reviewed outcomes of the first 13 livers transplanted from TA-NRP donors in the US. Nine centers transplanted livers from 8 organ procurement organizations. Median donor age was 25 years; median agonal phase was 13 minutes. Median recipient age was 60 years; median lab MELD score was 21. Three patients (23%) met early allograft dysfunction (EAD) criteria. Three received simultaneous liver-kidney transplants; neither had EAD nor delayed renal allograft function. One recipient died 186 days post-transplant from sepsis but had normal pre-sepsis liver function. One patient developed a biliary anastomotic stricture, managed endoscopically; no recipient developed clinical evidence of ischemic cholangiopathy (IC). Twelve of 13 (92%) patients are alive with good liver function at 439 days median follow-up; 1 patient has extrahepatic recurrent HCC. TA-NRP DCD livers in these recipients all functioned well, particularly with respect to IC, and provide a valuable option to decrease deaths on the waiting list. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Marty T Sellers
- Department of Surgery, Emory University, Atlanta, Georgia.,Tennessee Donor Services, Nashville, Tennessee
| | - Ahmed Nassar
- Department of Surgery, Emory University, Atlanta, Georgia
| | - Musab Alebrahim
- Department of Surgery, The Ohio State University, Columbus, Ohio
| | - Kazunari Sasaki
- Department of General Surgery, Cleveland Clinic, Cleveland, Ohio.,Department of Surgery, Stanford University
| | - David D Lee
- Department of Surgery, Loyola University, Chicago, Illinois
| | - Humberto Bohorquez
- Department of Surgery, Ochsner School of Medicine, New Orleans, Louisiana
| | - Robert M Cannon
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - William G McMaster
- Department of Cardiac Surgery, Vanderbilt University, Nashville, Tennessee
| | - Jordan R H Hoffman
- Department of Cardiac Surgery, Vanderbilt University, Nashville, Tennessee
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University, Nashville, Tennessee
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11
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Cannon RM. Double Standards and Double Jeopardy: The Unintended Consequence of Policy Regarding Substance Use in Potential Kidney Transplant Candidates. Transplantation 2022; 106:e200-e201. [PMID: 35135971 DOI: 10.1097/tp.0000000000004055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Robert M Cannon
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
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Orandi BJ, Reed RD, Qu H, Owens G, Brooks S, Killian AC, Kumar V, Sheikh SS, Cannon RM, Anderson DJ, Lewis CE, Locke JE. Donor‐reported barriers to living kidney donor follow‐up. Clin Transplant 2022; 36:e14621. [PMID: 35184328 PMCID: PMC9098679 DOI: 10.1111/ctr.14621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 02/08/2022] [Accepted: 02/09/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Despite regulations mandating follow-up laboratory testing for living kidney donors, less than half of transplant centers are in compliance. We sought to understand barriers to follow-up testing from the donors' perspective. METHODS We surveyed our center's living kidney donors. Binary logistic regression was used to assess factors associated with follow-up testing completion. RESULTS Of 185 living kidney donors, 110 (59.4%) participated. Among them, 82 (74.5%) completed 6-month laboratory testing, 76 (69.1%) completed 12-month testing, 68 (61.8%) completed both, and 21 (19.0%) completed neither. Six-month testing completion was strongly associated with 12-month testing completion (OR 9.74, 95%CI: 2.23-42.50; p = .002). Those who disagreed with the statements, "Getting labs checked wasn't a priority for me," (OR for completing 6-month testing: 15.05, 95%CI: 3.70-61.18; p < .001; OR for completing 12-month testing: 5.85, 95%CI: 1.94-17.63; p = .002); and, "I forgot to get labs drawn [until I was reminded]" (OR for completing 6-month testing: 6.93, 95%CI: 1.59-30.08; p = .01; OR for completing 12-month testing: 6.55, 95%CI: 1.98-21.63; p = .002) were more likely to complete testing. CONCLUSIONS To our knowledge, this is the only study providing perspective on donor insights regarding the need for follow-up testing post donation. Interventions to influence living donor attitudes toward follow-up testing may improve follow-up.
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Affiliation(s)
- Babak J. Orandi
- University of Alabama at Birmingham Department of Surgery Division of Transplantation Birmingham AL United States
| | - Rhiannon D. Reed
- University of Alabama at Birmingham Department of Surgery Division of Transplantation Birmingham AL United States
| | - Haiyan Qu
- University of Alabama at Birmingham Department of Surgery Division of Transplantation Birmingham AL United States
| | - Grace Owens
- University of Alabama at Birmingham Department of Surgery Division of Transplantation Birmingham AL United States
| | - Sydney Brooks
- University of Alabama at Birmingham Department of Surgery Division of Transplantation Birmingham AL United States
| | - A. Cozette Killian
- University of Alabama at Birmingham Department of Surgery Division of Transplantation Birmingham AL United States
| | - Vineeta Kumar
- University of Alabama at Birmingham Department of Medicine Division of Nephrology Birmingham AL United States
| | - Saulat S. Sheikh
- University of Alabama at Birmingham Department of Surgery Division of Transplantation Birmingham AL United States
| | - Robert M. Cannon
- University of Alabama at Birmingham Department of Surgery Division of Transplantation Birmingham AL United States
| | - Douglas J. Anderson
- University of Alabama at Birmingham Department of Surgery Division of Transplantation Birmingham AL United States
| | - Cora E. Lewis
- University of Alabama at Birmingham School of Public Health Department of Epidemiology Birmingham AL United States
| | - Jayme E. Locke
- University of Alabama at Birmingham Department of Surgery Division of Transplantation Birmingham AL United States
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13
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Purvis JW, Orandi BJ, Dhall D, McLeod C, Sanchez LHG, Gray M, Frey K, Sheikh SS, Cannon RM, Terrault NA, Lewis CE, Locke JE. Hepatic macrosteatosis in the US pediatric deceased liver donor population. Pediatr Transplant 2022; 26:e14155. [PMID: 34590386 PMCID: PMC8752486 DOI: 10.1111/petr.14155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 08/04/2021] [Accepted: 09/19/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION The pediatric obesity epidemic is associated with early development of hepatic macrosteatosis, a hallmark of non-alcoholic fatty LI disease, which is thought to be more rapidly progressive in children than adults. Macrosteatosis in adult allografts is associated with allograft loss, but this has not been examined in pediatric donors. METHODS We studied all pediatric potential whole LI donors (2005-2018) who had a LI biopsy in the SRTR (n = 862) and whose LI was transplanted (n = 862). Macrosteatosis was abstracted from biopsy reports and compared to values in the SRTR standard analytic file. Recipients of macrosteatotic pediatric allografts were matched 1:1 to recipients of non-macrosteatotic pediatric allografts by propensity score matching on donor/recipient variables. All-cause allograft loss was estimated via Kaplan-Meier analysis and Cox proportional hazards model. RESULTS From 2005 to 2018, the proportion of pediatric donors (age ≥2 years) with obesity increased (14.8% to 21.7%; p < .001), as did the proportion of pediatric deceased whole LI-only donor allografts with macrosteatosis (n = 10 648; 1.8% to 3.9%; p < .001). The median degree of macrosteatosis among macrosteatotic donors was 10% (IQR 5-30). There were no significant differences in all-cause allograft loss between recipients of pediatric LI allografts with and without macrosteatosis at 90 days (p = .11) or 1 year (p = .14) post-transplant in Kaplan-Meier analysis or a Cox proportional hazards model (p > .05). CONCLUSION Obese pediatric LI donors have increased over time and were more likely to have hepatic macrosteatosis; however, pediatric macrosteatosis did not appear to adversely affect recipient outcomes.
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Affiliation(s)
- Joshua W. Purvis
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation; Birmingham, AL
| | - Babak J. Orandi
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation; Birmingham, AL
| | - Deepti Dhall
- University of Alabama at Birmingham, Department of Pathology; Birmingham, AL
| | - Chandler McLeod
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation; Birmingham, AL
| | - Luz Helena Gutierrez Sanchez
- University of Alabama at Birmingham, Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Birmingham, Alabama
| | - Meagan Gray
- University of Alabama at Birmingham, Department of Medicine, Division of Gastroenterology and Hepatology
| | - Kayla Frey
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation; Birmingham, AL
| | - Saulat S. Sheikh
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation; Birmingham, AL
| | - Robert M. Cannon
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation; Birmingham, AL
| | - Norah A. Terrault
- University of Southern California Keck School of Medicine, Department of Medicine, Division of Gastrointestinal and Liver Diseases
| | - Cora E. Lewis
- University of Alabama at Birmingham, School of Public Health, Department of Epidemiology
| | - Jayme E. Locke
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation; Birmingham, AL
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14
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He K, Sheikh SS, Orandi BJ, Smith B, Locke JE, Cannon RM. Patient survival following third time liver transplant in the United States in the MELD era. Am J Surg 2021; 223:1206-1211. [PMID: 34809906 DOI: 10.1016/j.amjsurg.2021.10.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 10/11/2021] [Accepted: 10/31/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Third time liver transplantation is a technically demanding exercise with variable outcomes in single center series. There has been no national level description of survival following third time liver transplant in the US in the MELD era. METHODS Third time liver transplants between March 1, 2002 and January 1, 2018 in the UNOS dataset were analyzed. RESULTS Patient survival among the 240 third time liver transplant recipients in the study at 1, 3, 5, and 10 years (71.8%, 62.4%, 59.1%, 49.5%) was significantly worse compared to primary liver transplant (90.6%, 83.9%, 78.8%, 67.6%; p < 0.001) and retransplant (77.1%, 70.3%, 65.6%, 54.9%; p = 0.014). Recipients who were under 43 years old, not on dialysis, without diabetes, and over 1 month out from their second transplant had acceptable survival at 1, 3, 5, and 10 years (88.5%, 78.4%, 73.6%, 69.7%). CONCLUSIONS While redo-redo transplant remains a challenging endeavor, appropriate patient selection can yield acceptable results.
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Affiliation(s)
- Kai He
- Department of Surgery, Division of Transplantation, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Saulat S Sheikh
- Department of Surgery, Division of Transplantation, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Babak J Orandi
- Department of Surgery, Division of Transplantation, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Blair Smith
- Department of Anesthesia, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jayme E Locke
- Department of Surgery, Division of Transplantation, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Robert M Cannon
- Department of Surgery, Division of Transplantation, University of Alabama at Birmingham, Birmingham, AL, USA
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15
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Carter AJ, Reed RD, Kale AC, Qu H, Kumar V, Hanaway MJ, Cannon RM, Locke JE. Impact of Social Vulnerability on Access to Educational Programming Designed to Enhance Living Donation. Prog Transplant 2021; 31:305-313. [PMID: 34713750 DOI: 10.1177/15269248211046014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Transplant candidate participation in the Living Donor Navigator Program is associated with an increased likelihood of achieving living donor kidney transplantation; yet not every transplant candidate participates in navigator programming. RESEARCH QUESTION We sought to assess interest and ability to participate in the Living Donor Navigator Program by the degree of social vulnerability. DESIGN Eighty-two adult kidney-only candidates initiating evaluation at our center provided Likert-scaled responses to survey questions on interest and ability to participate in the Living Donor Navigator Program. Surveys were linked at the participant-level to the Centers for Disease Control and Prevention Social Vulnerability Index and county health rankings and overall social vulnerability and subthemes, individual barriers, telehealth capabilities/ knowledge, interest, and ability to participate were assessed utilizing nonparametric Wilcoxon ranks sums tests, chi-square, and Fisher's exact tests. RESULTS Participants indicating distance as a barrier to participation in navigator programming lived approximately 82 miles farther from our center. Disinterested participants lived in areas with the highest social vulnerability, higher physical inactivity rates, lower college education rates, and higher uninsurance (lack of insurance) and unemployment rates. Similarly, participants without a computer, who never heard of telehealth, and who were not encouraged to participate in telehealth resided in areas of highest social vulnerability. CONCLUSION These data suggest geography combined with being from under-resourced areas with high social vulnerability was negatively associated with health care engagement. Geography and poverty may be surrogates for lower health literacy and fewer health care interactions.
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Affiliation(s)
- Alexis J Carter
- 9968University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL, USA
| | - Rhiannon D Reed
- 9968University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL, USA
| | - A Cozette Kale
- 9968University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL, USA
| | - Haiyan Qu
- 9968University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL, USA
| | - Vineeta Kumar
- 9968University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL, USA
| | - Michael J Hanaway
- 9968University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL, USA
| | - Robert M Cannon
- 9968University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL, USA
| | - Jayme E Locke
- 9968University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL, USA
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16
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Turgeon MK, Shah SA, Delman AM, Tran BV, Agopian VG, Wedd JP, Magliocca JF, Kim A, Cameron A, Olyaei A, Orloff SL, Anderson MP, Kubal CA, Cannon RM, Locke JE, Simpson MA, Akoad ME, Wongjirad CP, Emamaullee J, Moro A, Aucejo F, Feizpour CA, Vagefi PA, Nguyen MH, Esquivel CO, Dhanireddy K, Subramanian V, Chavarriaga A, Kazimi MM, Anderson MS, Sonnenday CJ, Kim SC, Foley DP, Abdouljoud M, Salgia RJ, Moris D, Sudan DL, Ganesh SR, Humar A, Doyle M, Chapman WC, Maithel SK. Optimal Timing of Administration of Direct-acting Antivirals for Patients With Hepatitis C-associated Hepatocellular Carcinoma Undergoing Liver Transplantation. Ann Surg 2021; 274:613-620. [PMID: 34506316 PMCID: PMC8559662 DOI: 10.1097/sla.0000000000005070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To investigate the optimal timing of direct acting antiviral (DAA) administration in patients with hepatitis C-associated hepatocellular carcinoma (HCC) undergoing liver transplantation (LT). SUMMARY OF BACKGROUND DATA In patients with hepatitis C (HCV) associated HCC undergoing LT, the optimal timing of direct-acting antivirals (DAA) administration to achieve sustained virologic response (SVR) and improved oncologic outcomes remains a topic of much debate. METHODS The United States HCC LT Consortium (2015-2019) was reviewed for patients with primary HCV-associated HCC who underwent LT and received DAA therapy at 20 institutions. Primary outcomes were SVR and HCC recurrence-free survival (RFS). RESULTS Of 857 patients, 725 were within Milan criteria. SVR was associated with improved 5-year RFS (92% vs 77%, P < 0.01). Patients who received DAAs pre-LT, 0-3 months post-LT, and ≥3 months post-LT had SVR rates of 91%, 92%, and 82%, and 5-year RFS of 93%, 94%, and 87%, respectively. Among 427 HCV treatment-naïve patients (no previous interferon therapy), patients who achieved SVR with DAAs had improved 5-year RFS (93% vs 76%, P < 0.01). Patients who received DAAs pre-LT, 0-3 months post-LT, and ≥3 months post-LT had SVR rates of 91%, 93%, and 78% (P < 0.01) and 5-year RFS of 93%, 100%, and 83% (P = 0.01). CONCLUSIONS The optimal timing of DAA therapy appears to be 0 to 3 months after LT for HCV-associated HCC, given increased rates of SVR and improved RFS. Delayed administration after transplant should be avoided. A prospective randomized controlled trial is warranted to validate these results.
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Affiliation(s)
| | - Shimul A. Shah
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Aaron M. Delman
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Benjamin V. Tran
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | | | | | | | | | | | - Ali Olyaei
- Oregon Health and Science University, Portland, Oregon
| | | | | | | | | | - Jayme E. Locke
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | | | - Juliet Emamaullee
- Keck Hospital of University of Southern California, Los Angeles, California
| | | | | | | | | | | | | | | | | | | | | | | | | | - Steven C. Kim
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - David P. Foley
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | | | | | | | | | | | - Abhinav Humar
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Majella Doyle
- Washington University School of Medicine at St. Louis, St. Louis, Missouri
| | - William C. Chapman
- Washington University School of Medicine at St. Louis, St. Louis, Missouri
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Orandi BJ, Lewis CE, MacLennan PA, Qu H, Mehta S, Kumar V, Sheikh SS, Cannon RM, Anderson DJ, Hanaway MJ, Reed RD, Killian AC, Purvis JW, Terrault NA, Locke JE. Obesity as an isolated contraindication to kidney transplantation in the end-stage renal disease population: A cohort study. Obesity (Silver Spring) 2021; 29:1538-1546. [PMID: 34338423 PMCID: PMC8547159 DOI: 10.1002/oby.23195] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 03/31/2021] [Accepted: 04/11/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The aim of this study was to characterize end-stage renal disease (ESRD) patients with obesity as their only contraindication to listing and to quantify wait-list and transplant access. METHODS Using the US Renal Data System, a retrospective cohort study of incident dialysis cases (2012 to 2014) was performed. The primary outcomes were time to wait-listing and time to transplantation. RESULTS Of 157,572 dialysis patients not already listed, 39,844 had BMI as their only demonstrable transplant contraindication. They tended to be younger, female, and Black. Compared with patients with BMI < 35, those with BMI 35 to 39.9, 40 to 44.9, and ≥45 were, respectively, 15% (adjusted hazard ratio [aHR] 0.85; 95% CI: 0.83-0.88; p < 0.001), 45% (aHR 0.55; 95% CI: 0.52-0.57; p < 0.001), and 71% (aHR 0.29; 95% CI: 0.27-0.31; p < 0.001) less likely to be wait-listed. Wait-listed patients with BMI 35 to 39.9 were 24% less likely to achieve transplant (aHR 0.76; 95% CI: 0.72-0.80; p < 0.0001), BMI 40 to 44.9 were 21% less likely (aHR 0.79; 95% CI: 0.72-0.86; p < 0.0001), and BMI ≥ 45 were 15% less likely (aHR 0.85; 95% CI: 0.75-0.95; p = 0.004) compared with patients with BMI < 35. CONCLUSIONS Obesity was the sole contraindication to wait-listing for 40,000 dialysis patients. They were less likely to be wait-listed. For those who were, they had a lower likelihood of transplant. Aggressive weight-loss interventions may help this population achieve wait-listing and transplant.
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Affiliation(s)
- Babak J. Orandi
- University of Alabama at Birmingham, Department of Surgery; Birmingham, AL
| | - Cora E. Lewis
- University of Alabama at Birmingham, School of Public Health, Department of Epidemiology; Birmingham, AL
| | - Paul A. MacLennan
- University of Alabama at Birmingham, Department of Surgery; Birmingham, AL
| | - Haiyan Qu
- University of Alabama at Birmingham, Department of Surgery; Birmingham, AL
| | - Shikha Mehta
- University of Alabama at Birmingham, Department of Medicine
| | - Vineeta Kumar
- University of Alabama at Birmingham, Department of Medicine
| | - Saulat S. Sheikh
- University of Alabama at Birmingham, Department of Surgery; Birmingham, AL
| | - Robert M. Cannon
- University of Alabama at Birmingham, Department of Surgery; Birmingham, AL
| | | | - Michael J. Hanaway
- University of Alabama at Birmingham, Department of Surgery; Birmingham, AL
| | - Rhiannon D. Reed
- University of Alabama at Birmingham, Department of Surgery; Birmingham, AL
| | - A. Cozette Killian
- University of Alabama at Birmingham, Department of Surgery; Birmingham, AL
| | - Joshua W. Purvis
- University of Alabama at Birmingham, Department of Surgery; Birmingham, AL
| | - Norah A. Terrault
- University of Southern California Keck School of Medicine, Department of Medicine; Los Angeles, CA
| | - Jayme E. Locke
- University of Alabama at Birmingham, Department of Surgery; Birmingham, AL
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Abstract
BACKGROUND A safety net policy was implemented in August 2017 giving liver transplant alone (LTA) recipients with significant renal dysfunction posttransplant priority for subsequent kidney transplantation (KT). This study was undertaken to evaluate early outcomes under this policy. METHODS Adults undergoing LTA after implementation of the safety net policy and were subsequently listed for KT between 60 and 365 days after liver transplantation contained in United Network for Organ Sharing data were examined. Outcomes of interest were receipt of a kidney transplant and postliver transplant survival. Safety net patients were compared with LTA recipients not subsequently listed for KT as well as to patients listed for simultaneous liver-kidney (SLK) transplant yet underwent LTA and were not subsequently listed for KT. RESULTS There were 100 patients listed for safety net KT versus 9458 patients undergoing LTA without subsequent KT listing. The cumulative incidence of KT following listing was 32.5% at 180 days. The safety net patients had similar 1-year unadjusted patient survival (96.4% versus 93.4%; P = 0.234) but superior adjusted survival (hazard ratio0.133, 0.3570.960; P = 0.041) versus LTA recipients not subsequently listed for KT. Safety net patients had superior 1-year unadjusted (96.4% versus 75.0%; P < 0.001) and adjusted (hazard ratio0.039, 0.1260.406; P < 0.001) survival versus SLK listed patients undergoing LTA without subsequent KT listing. CONCLUSIONS The safety net appears to provide rapid access to KT with good early survival for those able to take advantage of it. Survival of patients unable to qualify for KT listing after LTA needs to be better understood before further limitation of SLK, however.
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Affiliation(s)
- Robert M Cannon
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - David S Goldberg
- Division of Hepatology, Department of Medicine, University of Miami, Coral Gables, FL
| | - Devin E Eckhoff
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Douglas J Anderson
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Babak J Orandi
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Jayme E Locke
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
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19
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Purvis J, McLeod C, Smith B, Orandi BJ, Kale C, Goldberg DS, Eckhoff DE, Locke JE, Cannon RM. Survival following simultaneous liver-lung versus liver alone transplantation: Results of the US National experience. Am J Surg 2021; 222:813-818. [PMID: 33589242 DOI: 10.1016/j.amjsurg.2021.01.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 01/24/2021] [Accepted: 01/31/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND There are little data to compare the post-transplant survival between lung-liver transplant (LLT) and liver-alone recipients. This study was undertaken to compare survival between LLT and liver-alone transplant. METHODS UNOS data for patients undergoing LLT from 2002 to 2017 was analyzed. LLT recipients (n = 81) were matched 1:4 to liver-alone recipients (n = 324) by propensity score and patient survival was compared in the matched cohorts. RESULTS Unadjusted 1, 3, and 5-year patient survival in the matched cohort was significantly worse in the LLT (82.5%, 72.2%, and 62.2%) versus liver-alone (92.2%, 82.8%, and 80.9%; p = 0.005). This difference persisted after adjusting for covariates with residual imbalance (HR 2.05, 95% CI 1.37-3.08; p = 0.001). CONCLUSION LLT has significantly worse survival than liver-alone transplant. With an increasing organ shortage, medical necessity criteria such as those developed for simultaneous liver-kidney transplantation should be developed for simultaneous lung-liver transplants to assure liver allografts are only allocated when truly needed.
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Affiliation(s)
- Joshua Purvis
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation, Birmingham, AL, USA
| | - Chandler McLeod
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation, Birmingham, AL, USA
| | - Blair Smith
- University of Alabama at Birmingham, Department of Anesthesia, Birmingham, AL, USA
| | - Babak J Orandi
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation, Birmingham, AL, USA
| | - Cozette Kale
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation, Birmingham, AL, USA
| | - David S Goldberg
- University of Miami Miller School of Medicine, Department of Medicine, Miami, FL, USA
| | - Devin E Eckhoff
- Beth Israel Deaconess Medical Center, Department of Surgery, Boston, MA, USA
| | - Jayme E Locke
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation, Birmingham, AL, USA
| | - Robert M Cannon
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation, Birmingham, AL, USA.
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Killian AC, Reed RD, Carter A, McLeod MC, Shelton BA, Kumar V, Qu H, MacLennan PA, Orandi BJ, Cannon RM, Anderson D, Hanaway MJ, Locke JE. Self-advocacy is associated with lower likelihood of living donor kidney transplantation. Am J Surg 2020; 222:36-41. [PMID: 33413873 DOI: 10.1016/j.amjsurg.2020.12.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 12/08/2020] [Accepted: 12/20/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND The Living Donor Navigator (LDN) Program pairs kidney transplant candidates (TC) with a friend or family member for advocacy training to help identify donors and achieve living donor kidney transplantation (LDKT). However, some TCs participate alone as self-advocates. METHODS In this retrospective cohort study of TCs in the LDN program (04/2017-06/2019), we evaluated the likelihood of LDKT using Cox proportional hazards regression and rate of donor screenings using ordered events conditional models by advocate type. RESULTS Self-advocates (25/127) had lower likelihood of LDKT compared to patients with an advocate (adjusted hazard ratio (aHR): 0.22, 95% confidence interval (CI): 0.03-1.66, p = 0.14). After LDN enrollment, rate of donor screenings increased 2.5-fold for self-advocates (aHR: 2.48, 95%CI: 1.26-4.90, p = 0.009) and 3.4-fold for TCs with an advocate (aHR: 3.39, 95%CI: 2.20-5.24, p < 0.0001). CONCLUSIONS Advocacy training was beneficial for self-advocates, but having an independent advocate may increase the likelihood of LDKT.
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Affiliation(s)
- A Cozette Killian
- University of Alabama at Birmingham Comprehensive Transplant Institute, 701 19th Street South, LHRB 790, Birmingham, AL, 35233, USA.
| | - Rhiannon D Reed
- University of Alabama at Birmingham Comprehensive Transplant Institute, 701 19th Street South, LHRB 790, Birmingham, AL, 35233, USA.
| | - Alexis Carter
- University of Alabama at Birmingham Comprehensive Transplant Institute, 701 19th Street South, LHRB 790, Birmingham, AL, 35233, USA.
| | - M Chandler McLeod
- University of Alabama at Birmingham Comprehensive Transplant Institute, 701 19th Street South, LHRB 790, Birmingham, AL, 35233, USA.
| | - Brittany A Shelton
- University of Alabama at Birmingham Comprehensive Transplant Institute, 701 19th Street South, LHRB 790, Birmingham, AL, 35233, USA.
| | - Vineeta Kumar
- University of Alabama at Birmingham Comprehensive Transplant Institute, 701 19th Street South, LHRB 790, Birmingham, AL, 35233, USA.
| | - Haiyan Qu
- University of Alabama at Birmingham Comprehensive Transplant Institute, 701 19th Street South, LHRB 790, Birmingham, AL, 35233, USA.
| | - Paul A MacLennan
- University of Alabama at Birmingham Comprehensive Transplant Institute, 701 19th Street South, LHRB 790, Birmingham, AL, 35233, USA.
| | - Babak J Orandi
- University of Alabama at Birmingham Comprehensive Transplant Institute, 701 19th Street South, LHRB 790, Birmingham, AL, 35233, USA.
| | - Robert M Cannon
- University of Alabama at Birmingham Comprehensive Transplant Institute, 701 19th Street South, LHRB 790, Birmingham, AL, 35233, USA.
| | - Douglas Anderson
- University of Alabama at Birmingham Comprehensive Transplant Institute, 701 19th Street South, LHRB 790, Birmingham, AL, 35233, USA.
| | - Michael J Hanaway
- University of Alabama at Birmingham Comprehensive Transplant Institute, 701 19th Street South, LHRB 790, Birmingham, AL, 35233, USA.
| | - Jayme E Locke
- University of Alabama at Birmingham Comprehensive Transplant Institute, 701 19th Street South, LHRB 790, Birmingham, AL, 35233, USA.
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Orandi BJ, Purvis JW, Cannon RM, Smith AB, Lewis CE, Terrault NA, Locke JE. Bariatric surgery to achieve transplant in end-stage organ disease patients: A systematic review and meta-analysis. Am J Surg 2020; 220:566-579. [PMID: 32600846 PMCID: PMC7484004 DOI: 10.1016/j.amjsurg.2020.04.041] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 04/29/2020] [Accepted: 04/30/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND As obesity prevalence grows, more end-stage organ disease patients will be precluded from transplant. Numerous reports suggest bariatric surgery in end-stage organ disease may help patients achieve weight loss sufficient for transplant listing. METHODS We performed a systematic review/meta-analysis of studies of bariatric surgery to achieve solid organ transplant listing. RESULTS Among 82 heart failure patients, 40.2% lost sufficient weight for listing, 29.3% were transplanted, and 8.5% had sufficient improvement with weight loss they no longer required transplantation. Among 28 end-stage lung disease patients, 28.6% lost sufficient weight for listing, 7.1% were transplanted, and 14.3% had sufficient improvement following weight loss they no longer required transplant. Among 41 cirrhosis patients, 58.5% lost sufficient weight for listing, 41.5% were transplanted, and 21.9% had sufficient improvement following weight loss they no longer required transplant. Among 288 end-stage/chronic kidney disease patients, 50.3% lost sufficient weight for listing and 29.5% were transplanted. CONCLUSIONS Small sample size and publication bias are limitations; however, bariatric surgery may benefit select end-stage organ disease patients with obesity that precludes transplant candidacy.
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Affiliation(s)
- Babak J Orandi
- University of Alabama at Birmingham Schools of Medicine, Department of Surgery, United States.
| | - Joshua W Purvis
- University of Alabama at Birmingham Schools of Medicine, Department of Surgery, United States
| | - Robert M Cannon
- University of Alabama at Birmingham Schools of Medicine, Department of Surgery, United States
| | - A Blair Smith
- University of Alabama at Birmingham Schools of Medicine, Department of Anesthesia, United States
| | - Cora E Lewis
- University of Alabama at Birmingham Schools of Medicine, Department of Medicine, United States; University of Alabama at Birmingham Schools of Medicine, Public Health, United States
| | - Norah A Terrault
- University of Southern California Keck School of Medicine, Department of Medicine, United States
| | - Jayme E Locke
- University of Alabama at Birmingham Schools of Medicine, Department of Surgery, United States
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Abstract
Many transplant recipients travel long distances to their transplant center with challenging access to their transplant team. As such, many centers keep recipients near to the center for a period immediately after discharge from the transplant admission. Thus far, the correlation between distance to the transplant center, readmission, and outcomes has not been described. The aim of this study was to examine this relationship. Patients undergoing deceased donor kidney transplant at a single center over a three-year period were analyzed via retrospective chart review for factors associated with distance to the transplant center and readmission. P values < 0.05 were considered significant. Of 141 patients, the overall 90-day readmission rate was 38.3 per cent, and rates were similar between nonlocal and local recipients. Nonlocal were more likely whites (66.1% vs 45.6%; P = 0.032) and from rural areas (56.5% vs 13.9%; P < 0.001). Length of stay was similar between groups, as were rates of delayed graft function. Non–death-censored graft survival was higher at one and three years for nonlocal patients (96.8% and 96.8% vs 89.7% and 78.4%; P = 0.016). This remained significant after adjusting for baseline differences between the groups (hazard ratio (HR) for graft failure = 0.195, 95%, P = 0.046). Patients who live remotely from the transplant center do not experience higher rates of readmission or worsened outcomes, and thus may be managed safely at home. Interestingly, graft survival is improved in nonlocal patients. This may reflect the urban nature of the area surrounding our transplant center, but warrants further study for conclusions to be reached.
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Affiliation(s)
- Jessica Schucht
- From the Hiram C. Polk Jr. MD Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Eric G. Davis
- From the Hiram C. Polk Jr. MD Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Christopher M. Jones
- From the Hiram C. Polk Jr. MD Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Robert M. Cannon
- From the Hiram C. Polk Jr. MD Department of Surgery, University of Louisville, Louisville, Kentucky
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Cannon RM, Brown RE, Hill CR, Dunki-Jacobs E, Martin RCG, McMasters KM, Scoggins CR. Negative Effects of Transfused Blood Components after Hepatectomy for Metastatic Colorectal Cancer. Am Surg 2020. [DOI: 10.1177/000313481307900120] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
There has been conflicting evidence regarding negative effects of blood transfusion in oncology patients. This study was undertaken to determine any negative effects of specific blood product transfusion after resection of hepatic colorectal metastases (CRM). Retrospective review of patients undergoing hepatectomy for CRM from 1995 to 2009 at a single institution was performed. Specific attention was paid to the effect of blood transfusion within 30 days of operation on overall survival, disease-free survival (DFS), and complications. To mitigate the bias introduced by complications that require blood transfusion to treat, only nonbleeding complications were considered. Complications were analyzed with univariate and multivariate logistic regression. Survival was analyzed according to Kaplan-Meier and Cox proportional hazards. There were 239 patients included in the study. There were 64 (26.8%) receiving a transfusion of any kind with 25.5 per cent getting red cells (PRBCs), 7.11 per cent getting fresh-frozen plasma, and 3.77 per cent getting platelets. Multivariate analysis revealed only PRBC transfusion to be independently associated with nonbleeding complications (odds ratio, 1.980; 95% confidence interval, 1.094 to 3.582; P = 0.0239). There was no significant adverse effect of transfusion with any product on overall or DFS. PRBC transfusion appears to increase the risk of postoperative complications; thus, strategies to minimize blood use may be warranted.
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Affiliation(s)
- Robert M. Cannon
- From the Department of Surgery, Division of Surgical Oncology, University of Louisville, Louisville, Kentucky
| | - Russell E. Brown
- From the Department of Surgery, Division of Surgical Oncology, University of Louisville, Louisville, Kentucky
| | - Charles R. Hill
- From the Department of Surgery, Division of Surgical Oncology, University of Louisville, Louisville, Kentucky
| | - Eric Dunki-Jacobs
- From the Department of Surgery, Division of Surgical Oncology, University of Louisville, Louisville, Kentucky
| | - Robert C. G. Martin
- From the Department of Surgery, Division of Surgical Oncology, University of Louisville, Louisville, Kentucky
| | - Kelly M. McMasters
- From the Department of Surgery, Division of Surgical Oncology, University of Louisville, Louisville, Kentucky
| | - Charles R. Scoggins
- From the Department of Surgery, Division of Surgical Oncology, University of Louisville, Louisville, Kentucky
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Cannon RM, Davis EG, Goldberg DS, Lynch RJ, Shah MB, Locke JE, McMasters KM, Jones CM. Regional Variation in Appropriateness of Non-Hepatocellular Carcinoma Model for End-Stage Liver Disease Exception. J Am Coll Surg 2020; 230:503-512.e8. [DOI: 10.1016/j.jamcollsurg.2019.12.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 12/16/2019] [Indexed: 12/18/2022]
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25
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Schucht J, Davis EG, Jones CM, Cannon RM. Incidence of and Risk Factors for Multiple Readmissions after Kidney Transplantation. Am Surg 2020; 86:116-120. [PMID: 32167042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Unplanned readmission is often used as a surgical quality metric. A subset of kidney transplant recipients undergos multiple readmissions (MRs), although the incidence and risk factors are not well described. The aim of this study was to evaluate risk factors for MR after deceased donor kidney transplantation. All patients undergoing deceased donor kidney transplantation at a single center over a three-year period were analyzed via retrospective chart review for factors associated with MR. P values <0.05 were considered significant. Of 141 patients, the 30-day readmission rate was 26.2 per cent. MR occurred in 43 (30.5%) patients. Age, race, gender, initial organ function, and dialysis vintage were not associated with MR. Diabetic recipients, those who received basiliximab induction, those with acute rejection, and those with unplanned reoperations were at increased risk for MR. Infection was the most common reason for initial readmission in patients with MR (23.3%). One-year patient survival and death-censored graft survival were reduced for patients with MR. MRs are required for 30 per cent of kidney transplant recipients, primarily because of infection and immunologic causes. Recipients with diabetes and those who have acute rejection are at greatest risk.
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26
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Abstract
Unplanned readmission is often used as a surgical quality metric. A subset of kidney transplant recipients undergos multiple readmissions (MRs), although the incidence and risk factors are not well described. The aim of this study was to evaluate risk factors for MR after deceased donor kidney transplantation. All patients undergoing deceased donor kidney transplantation at a single center over a three-year period were analyzed via retrospective chart review for factors associated with MR. P values <0.05 were considered significant. Of 141 patients, the 30-day readmission rate was 26.2 per cent. MR occurred in 43 (30.5%) patients. Age, race, gender, initial organ function, and dialysis vintage were not associated with MR. Diabetic recipients, those who received basiliximab induction, those with acute rejection, and those with unplanned reoperations were at increased risk for MR. Infection was the most common reason for initial readmission in patients with MR (23.3%). One-year patient survival and death-censored graft survival were reduced for patients with MR. MRs are required for 30 per cent of kidney transplant recipients, primarily because of infection and immunologic causes. Recipients with diabetes and those who have acute rejection are at greatest risk.
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Affiliation(s)
- Jessica Schucht
- From the Division of Transplantation, Hiram C. Polk Jr. MD Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Eric G. Davis
- From the Division of Transplantation, Hiram C. Polk Jr. MD Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Christopher M. Jones
- From the Division of Transplantation, Hiram C. Polk Jr. MD Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Robert M. Cannon
- From the Division of Transplantation, Hiram C. Polk Jr. MD Department of Surgery, University of Louisville, Louisville, Kentucky
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Cannon RM, Jones CM, Davis EG, Franklin GA, Gupta M, Shah MB. Patterns of geographic variability in mortality and eligible deaths between organ procurement organizations. Am J Transplant 2019; 19:2756-2763. [PMID: 30980456 DOI: 10.1111/ajt.15390] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 03/15/2019] [Accepted: 03/26/2019] [Indexed: 01/25/2023]
Abstract
Eligible deaths are currently used as the denominator of the donor conversion ratio to mitigate the effect of varying mortality patterns in the populations served by different organ procurement organizations (OPOs). Eligible death is an OPO-reported metric rather than a product of formal epidemiological analysis, however, and may be confounded with OPO performance. Using Scientific Registry of Transplant Recipients and Centers for Disease Control and Prevention data, patterns of mortality and eligible deaths within each OPO were analyzed with the use of formal geostatistical analysis to determine whether eligible deaths truly reflect the geographic patterns they are intended to mitigate. There was a 2.1-fold difference in mortality between the OPOs with the highest and lowest rates, with significant positive spatial autocorrelation evident in mortality rates (Moran I = .110; P < .001), meaning geographically proximate OPOs tended to have similar mortality rates. The eligible death ratio demonstrated greater variability, with a 4.5-fold difference between the OPOs with the highest and lowest rates. Contrary to the pattern of mortality rates, the geographic distribution of eligible deaths among OPOs was random (Moran I = -.002; P = .410). This finding suggests geographic patterns do not play a significant role in eligible deaths, thus questioning its continuing use in OPO performance comparisons.
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Affiliation(s)
- Robert M Cannon
- Hiram C. Polk Jr. MD Department of Surgery, Division of Transplantation, University of Louisville, Louisville, Kentucky
| | - Christopher M Jones
- Hiram C. Polk Jr. MD Department of Surgery, Division of Transplantation, University of Louisville, Louisville, Kentucky
| | - Eric G Davis
- Hiram C. Polk Jr. MD Department of Surgery, Division of Transplantation, University of Louisville, Louisville, Kentucky
| | - Glen A Franklin
- Hiram C. Polk Jr. MD Department of Surgery, Division of Transplantation, University of Louisville, Louisville, Kentucky.,Kentucky Organ Donor Affiliates, Louisville, Kentucky
| | - Meera Gupta
- Department of Surgery, Division of Transplantation, University of Kentucky, Lexington, Kentucky
| | - Malay B Shah
- Department of Surgery, Division of Transplantation, University of Kentucky, Lexington, Kentucky
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28
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Katsaros GD, Schucht J, Jones CM, Cannon RM. Nationwide Outcomes after Renal Transplantation from Kidney-Only versus Multiple-Organ Deceased Donors. Am Surg 2019; 85:1066-1072. [PMID: 31638526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
To assess renal transplant outcomes after donation by kidney-only (KO) versus multiple-organ (MO) donors on a national scale. The United Network for Organ Sharing database was examined for patients undergoing isolated kidney transplant from a deceased donor from 2000 through 2016. Comparison was made between recipients of grafts from KO versus MO donors at baseline and in a cohort of KO and MO recipients matched via propensity scoring. Outcomes of interest included delayed graft function (DGF), patient survival, and the cumulative incidence of graft loss. There were 33,326 recipients in the KO cohort versus 144,690 in the MO cohort. Donation after cardiac death donors were more prevalent in the KO group (43.8% vs 5.3%; P < 0.001). DGF occurred in 36.1 per cent of the KO versus 22.7 per cent of the MO recipients (P < 0.001). Five-year survival was 79.5 per cent versus 83.4 per cent (P < 0.001) in the KO versus MO group. After propensity matching, DGF was still more common in the KO group (33.1% vs 30.1%; P < 0.001). Patient survival was similar (79.5% KO vs 80.1% MO; P = 0.117). Cumulative incidence of graft loss was higher in the KO group (17.8% vs 16.8%). Survival outcomes from KO donors are actually quite good and should not be considered as inferior to MO donors.
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29
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Abstract
To assess renal transplant outcomes after donation by kidney-only (KO) versus multiple-organ (MO) donors on a national scale. The United Network for Organ Sharing database was examined for patients undergoing isolated kidney transplant from a deceased donor from 2000 through 2016. Comparison was made between recipients of grafts from KO versus MO donors at baseline and in a cohort of KO and MO recipients matched via propensity scoring. Outcomes of interest included delayed graft function (DGF), patient survival, and the cumulative incidence of graft loss. There were 33,326 recipients in the KO cohort versus 144,690 in the MO cohort. Donation after cardiac death donors were more prevalent in the KO group (43.8% vs 5.3%; P < 0.001). DGF occurred in 36.1 per cent of the KO versus 22.7 per cent of the MO recipients ( P < 0.001). Five-year survival was 79.5 per cent versus 83.4 per cent ( P < 0.001) in the KO versus MO group. After propensity matching, DGF was still more common in the KO group (33.1% vs 30.1%; P < 0.001). Patient survival was similar (79.5% KO vs 80.1% MO; P = 0.117). Cumulative incidence of graft loss was higher in the KO group (17.8% vs 16.8%). Survival outcomes from KO donors are actually quite good and should not be considered as inferior to MO donors.
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30
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Schucht J, Davis EG, Jones CM, Cannon RM. Does Distance to Transplant Center Affect Post Kidney Transplant Readmission Rates? Am Surg 2019; 85:834-839. [PMID: 32051063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Many transplant recipients travel long distances to their transplant center with challenging access to their transplant team. As such, many centers keep recipients near to the center for a period immediately after discharge from the transplant admission. Thus far, the correlation between distance to the transplant center, readmission, and outcomes has not been described. The aim of this study was to examine this relationship. Patients undergoing deceased donor kidney transplant at a single center over a three-year period were analyzed via retrospective chart review for factors associated with distance to the transplant center and readmission. P values < 0.05 were considered significant. Of 141 patients, the overall 90-day readmission rate was 38.3 per cent, and rates were similar between nonlocal and local recipients. Nonlocal were more likely whites (66.1% vs 45.6%; P = 0.032) and from rural areas (56.5% vs 13.9%; P < 0.001). Length of stay was similar between groups, as were rates of delayed graft function. Non-death-censored graft survival was higher at one and three years for nonlocal patients (96.8% and 96.8% vs 89.7% and 78.4%; P = 0.016). This remained significant after adjusting for baseline differences between the groups (hazard ratio (HR) for graft failure = 0.195, 95%, P = 0.046). Patients who live remotely from the transplant center do not experience higher rates of readmission or worsened outcomes, and thus may be managed safely at home. Interestingly, graft survival is improved in nonlocal patients. This may reflect the urban nature of the area surrounding our transplant center, but warrants further study for conclusions to be reached.
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Cannon RM, Davis EG, Jones CM. A Tale of Two Kidneys: Differences in Graft Survival for Kidneys Allocated to Simultaneous Liver Kidney Transplant Compared with Contralateral Kidney from the Same Donor. J Am Coll Surg 2019; 229:7-17. [DOI: 10.1016/j.jamcollsurg.2019.04.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 02/28/2019] [Accepted: 04/15/2019] [Indexed: 12/21/2022]
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Watson AM, Jones CM, Cannon RM. An analysis of unplanned return to the operating room following deceased donor kidney transplantation. Am J Surg 2019; 218:27-31. [PMID: 30691674 DOI: 10.1016/j.amjsurg.2019.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 11/20/2018] [Accepted: 01/21/2019] [Indexed: 10/27/2022]
Abstract
INTRODUCTION This study was undertaken to characterize unplanned return to the OR following kidney transplantation(KT). METHODS All patients undergoing KT at a single center from 1/2015 through 11/2017 were evaluated. The primary endpoint was unplanned return to the OR within 90 days. Perioperative and one year patient and graft outcomes were also determined. RESULTS Of 190 patients, 14(7.4%) of patients had unplanned reoperation. The most common individual indications were bleeding from biopsy sites(n = 2), poor vascular flow on postop ultrasound(n = 4), and perforated diverticulitis(n = 2). Forty Three percent of all reoperations were unrelated to the technical conduct of the transplant operation. Reoperated patients had significantly worse survival at one year(78.6% vs. 96.6%), although graft function in survivors was similar to those who did not return to the OR. CONCLUSION Reoperation following KT is frequently unrelated to the technical conduct of the transplant procedure, thus it may not be useful as a quality metric.
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Affiliation(s)
- Ashley M Watson
- Division of Transplantation, Hiram C. Polk Jr. MD Department of Surgery, University of Louisville, Louisville, KY. 550 South Jackson Street, Department of Surgery, Louisville, KY, 40202, USA
| | - Christopher M Jones
- Division of Transplantation, Hiram C. Polk Jr. MD Department of Surgery, University of Louisville, Louisville, KY. 550 South Jackson Street, Department of Surgery, Louisville, KY, 40202, USA
| | - Robert M Cannon
- Division of Transplantation, Hiram C. Polk Jr. MD Department of Surgery, University of Louisville, Louisville, KY. 550 South Jackson Street, Department of Surgery, Louisville, KY, 40202, USA.
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Cannon RM, Bolus DN, White JA. Irreversible Electroporation as a Bridge to Liver Transplantation. Am Surg 2019; 85:103-110. [PMID: 30760354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Hepatocellular carcinoma (HCC) in proximity to major hepatic vasculature poses a risk for invasion, which would contraindicate liver transplantation, yet, is difficult to treat with thermal ablation. This study was undertaken to evaluate the feasibility of irreversible electroporation (IRE) as a bridge to transplantation for high-risk tumors. All patients with HCC in proximity to major hepatic vasculature treated with laparoscopic IRE as bridge to transplantation were studied. Patient and tumor characteristics, length of stay, and treatment-related complications were recorded. Tumor response was assessed with CT and explant pathology. Five patients with a median Model for End Stage Liver Disease (MELD) of 13 (7-21) underwent IRE. The median tumor size was 2.7 cm (1.5-3.7 cm). Adjacent structures included the right portal vein, hepatic veins/inferior vena cava (IVC) and left portal vein. Length of stay was one day for all patients. One patient suffered portal vein thrombosis. The transplant occurred at a median of 142 days (47-264) after IRE. Pathologic necrosis ranged from 30 to 100 per cent, without any vascular invasion. Four patients remain alive with no evidence of disease with median follow-up of 403 (227-623) days. The remaining patients died because of transplant-related complications on post IRE day 297. IRE shows promise as a bridge to liver transplant for high risk HCC in a preliminary series, justifying further prospective evaluation.
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Abstract
Hepatocellular carcinoma (HCC) in proximity to major hepatic vasculature poses a risk for invasion, which would contraindicate liver transplantation, yet, is difficult to treat with thermal ablation. This study was undertaken to evaluate the feasibility of irreversible electroporation (IRE) as a bridge to transplantation for high-risk tumors. All patients with HCC in proximity to major hepatic vasculature treated with laparoscopic IRE as bridge to transplantation were studied. Patient and tumor characteristics, length of stay, and treatment-related complications were recorded. Tumor response was assessed with CT and explant pathology. Five patients with a median Model for End Stage Liver Disease (MELD) of 13 (7–21) underwent IRE. The median tumor size was 2.7 cm (1.5–3.7 cm). Adjacent structures included the right portal vein, hepatic veins/inferior vena cava (IVC) and left portal vein. Length of stay was one day for all patients. One patient suffered portal vein thrombosis. The transplant occurred at a median of 142 days (47–264) after IRE. Pathologic necrosis ranged from 30 to 100 per cent, without any vascular invasion. Four patients remain alive with no evidence of disease with median follow-up of 403 (227–623) days. The remaining patients died because of transplant-related complications onpost IRE day 297. IRE shows promise as a bridge to liver transplant for high risk HCC in a preliminary series, justifying further prospective evaluation.
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Affiliation(s)
- Robert M. Cannon
- Hiram C. Polk Jr., M.D. Department of Surgery, University of Louisville, Louisville, Kentucky; Departments of
| | | | - Jared A. White
- Surgery, University of Alabama at Birmingham, Birmingham, Alabama
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35
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Cannon RM, Jones CM, Davis EG, Eckhoff DE. Effect of Renal Diagnosis on Survival in Simultaneous Liver-Kidney Transplantation. J Am Coll Surg 2018; 228:536-544.e3. [PMID: 30586642 DOI: 10.1016/j.jamcollsurg.2018.12.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 12/10/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Simultaneous liver-kidney transplantation is lifesaving, however, the utility of allocating 2 organs to a single recipient remains controversial, particularly in the face of potentially inferior survival. This study aims to determine the effect of renal indication for transplantation on simultaneous liver-kidney transplantation outcomes. METHODS All adult recipients of combined whole liver-kidney transplants in the United Network for Organ Sharing database from 2003 to 2016 with a renal diagnosis of hypertension (HTN), diabetes mellitus (DM), acute tubular necrosis (ATN), or hepatorenal syndrome (HRS) were examined. Comparisons were made between the HTN/DM group and the ATN/HRS group using standard statistical methods. RESULTS There were 1,204 patients in the HRS/ATN group vs 1,272 patients in the HTN/DM group. The HTN/DM patients were slightly older (58.1 vs 56.4 years; p < 0.001), more likely to have liver disease due to chronic viral hepatitis (33.2% vs 21.5%; p < 0.001), and less acutely ill (mean Model for End-Stage Liver Disease score of 27.2 vs 33.1; p < 0.001) than their HRS/ATN counterparts. The prevalence of nonalcoholic steatohepatitis was 16.8% in both groups. Donor demographics were similar in both groups, although HTN/DM patients were more likely to have a local (81.6% vs 67.7%; p < 0.001) rather than regional donor. Patient survival rates at 1, 3, and 5 years were significantly lower in the HTN/DM group (87.4%, 78.2%, and 71.2% vs 90.7%, 84.1%, and 76.6%, respectively). Median survival was 118 months for the HTN/DM group vs 139.7 months for the HRS/ATN (p < 0.001). The HTN/DM patients were at significantly higher risk of death (hazard ratio 1.533; p < 0.001), liver graft loss (hazard ratio 1.611; p < 0.001), and renal graft loss (hazard ratio 1.592; p < 0.001) than ATN/HRS patients on multivariable analysis. CONCLUSIONS Despite a lower acuity of illness, HTN/DM patients have inferior survival after simultaneous liver-kidney transplantation than those with ATN/HRS. This should be considered in risk adjustment and allocation schemes.
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Affiliation(s)
- Robert M Cannon
- Hiram C Polk Jr, MD Department of Surgery, Division of Transplantation, University of Louisville, Louisville, KY.
| | - Christopher M Jones
- Hiram C Polk Jr, MD Department of Surgery, Division of Transplantation, University of Louisville, Louisville, KY
| | - Eric G Davis
- Hiram C Polk Jr, MD Department of Surgery, Division of Transplantation, University of Louisville, Louisville, KY
| | - Devin E Eckhoff
- Department of Surgery, Division of Abdominal Transplantation, University of Alabama at Birmingham, Birmingham, AL
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Trivedi JR, Ising M, Fox MP, Cannon RM, Van Berkel VH, Slaughter MS. Solid-Organ Transplantation and the Affordable Care Act: Accessibility and Outcomes. Am Surg 2018. [DOI: 10.1177/000313481808401234] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The objective of the study is to evaluate the impact of the Affordable Care Act (ACA) on accessibility to solid organ transplant and outcomes. Data source registry: United Network of Organ Sharing database. Patients aged ≥18 years listed for kidney, liver, heart, and lung transplant between years 2010 and 2016 were classified by insurance and status of Medicaid adoption under ACA to evaluate insurance distribution. Between 2010 and 2016, states that adopted Medicaid had 2 to 4 per cent point increase in the proportion of patients listed with Medicaid across all organs. One-year waiting list survival of Medicaid patients was better in the ACA era. States that expanded Medicaid under the ACA had a significant increase in the proportion of patients listed with Medicaid and better one-year waiting list survival.
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Affiliation(s)
- Jaimin R. Trivedi
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Mickey Ising
- Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Matthew P. Fox
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Robert M. Cannon
- Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Victor H. Van Berkel
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Mark S. Slaughter
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Louisville, Kentucky
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Trivedi JR, Ising M, Fox MP, Cannon RM, van Berkel VH, Slaughter MS. Solid-Organ Transplantation and the Affordable Care Act: Accessibility and Outcomes. Am Surg 2018; 84:1894-1899. [PMID: 30606345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The objective of the study is to evaluate the impact of the Affordable Care Act (ACA) on accessibility to solid organ transplant and outcomes. Data source registry: United Network of Organ Sharing database. Patients aged ≥18 years listed for kidney, liver, heart, and lung transplant between years 2010 and 2016 were classified by insurance and status of Medicaid adoption under ACA to evaluate insurance distribution. Between 2010 and 2016, states that adopted Medicaid had 2 to 4 per cent point increase in the proportion of patients listed with Medicaid across all organs. One-year waiting list survival of Medicaid patients was better in the ACA era. States that expanded Medicaid under the ACA had a significant increase in the proportion of patients listed with Medicaid and better one-year waiting list survival.
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Schucht J, Davis EG, Jones CM, Cannon RM. Incidence of and Risk Factors for Multiple Readmissions after Kidney Transplantation. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.08.601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Bhutiani N, Jones JM, Wei D, Goldstein LJ, Martin RCG, Jones CM, Cannon RM. A cost analysis of early biliary strictures following orthotopic liver transplantation in the United States. Clin Transplant 2018; 32:e13396. [PMID: 30160322 DOI: 10.1111/ctr.13396] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 08/20/2018] [Accepted: 08/25/2018] [Indexed: 12/17/2022]
Abstract
INTRODUCTION To date, the financial burden of biliary strictures (BS) after orthotopic liver transplantation (OLT) has remained largely unassessed. This study sought to approximate perioperative costs associated with early BS and delineate where in the hospital these costs are incurred. METHODS The Premier Healthcare Database was queried for patients undergoing OLT between 2010 and 2016. Patients who did and did not develop early BS were compared with respect to perioperative costs and outcome variables. Multivariable regression models were used to estimate differences between groups. RESULTS Patients who developed early BS had a longer length of stay (LOS) (35.3 days vs 17.8 days, P < 0.001) and were less likely to be discharged home (odds ratio = 0.45, P = 0.003). Development of early BS was associated with an incremental cost increase of $81 881 (45.8%, P < 0.001). The greatest relative cost increases were in radiology (+163.5%) and respiratory therapy (+157.1%), while the greatest absolute increase was in room and board (+$27 589). CONCLUSIONS Early BS after OLT result in higher costs stemming from longer LOS and increased need for various diagnostic studies and therapies. In addition to incentivizing measures that may prevent early BS, hospitals should account for these factors when developing payment schemes for OLT with payors.
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Affiliation(s)
- Neal Bhutiani
- Division of Transplantation, Hiram C. Polk Jr, MD Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Jordan M Jones
- Division of Transplantation, Hiram C. Polk Jr, MD Department of Surgery, University of Louisville, Louisville, Kentucky
| | - David Wei
- Epidemiology, Medical Devices, Johnson & Johnson, New Brunswick, New Jersey
| | - Laura J Goldstein
- Franchise Health Economics and Market Access, Ethicon, Somerville, New Jersey
| | - Robert C G Martin
- Division of Transplantation, Hiram C. Polk Jr, MD Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Christopher M Jones
- Division of Transplantation, Hiram C. Polk Jr, MD Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Robert M Cannon
- Division of Transplantation, Hiram C. Polk Jr, MD Department of Surgery, University of Louisville, Louisville, Kentucky
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Watson AM, Bhutiani N, Philips P, Davis EG, Eng M, Cannon RM, Jones CM. The role of FDG-PET in detecting rejection after liver transplantation. Surgery 2018; 164:257-261. [DOI: 10.1016/j.surg.2018.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 03/20/2018] [Accepted: 04/03/2018] [Indexed: 01/20/2023]
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Mustian MN, Cannon RM, MacLennan PA, Reed RD, Shelton BA, McWilliams DM, Deierhoi MH, Locke JE. Landscape of ABO-Incompatible Live Donor Kidney Transplantation in the US. J Am Coll Surg 2018; 226:615-621. [PMID: 29309944 PMCID: PMC5869103 DOI: 10.1016/j.jamcollsurg.2017.12.026] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 12/13/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND Widespread implementation of ABO-incompatible (ABOi) living donor kidney transplantation (LDKT) has been proposed as a means to partially ameliorate the national shortage of deceased donor kidneys. Acceptance of this practice has been encouraged by reports from experienced centers demonstrating acute rejection (AR) rates similar to those obtained with ABO-compatible (ABOc) LDKT. Acute rejection rate and graft survival after ABOi LDKT on a national level have yet to be fully determined. STUDY DESIGN We studied adult (>18 years) LDKT recipients, from 2000 to 2015, reported to the Scientific Registry of Transplant Recipients. Acute rejection rates in the first post-transplant year (modified Poisson regression) and graft survival (Cox proportional hazards) were assessed by ABO compatibility status (ABOi: 930; ABOc: 89,713). RESULTS Patients undergoing ABOi LDKT had an AR rate of 19.4% compared with 10.5% for ABOc recipients (p < 0.0001). After adjusting for recipient- and donor-related risk factors, patients undergoing ABOi LDKT were found to have a 1.76-fold greater risk for AR within 1 year of transplantation compared with ABOc LDKT recipients (adjusted relative risk [aRR] 1.76; 95% CI 1.54 to 2.01). Moreover, there was a 2.34-fold greater risk of death-censored graft loss at 1-year post-transplant among ABOi vs ABOc LDKT recipients (adjusted hazard ratio [aHR] 2.34; 95% CI 1.85 to 2.96). CONCLUSIONS Based on these findings, the low rates of AR and excellent short-term graft survival presented in single center series may not be sustainable on a national level. These findings highlight the potential utility for identification of centers of excellence and regionalization of ABOi LDKT.
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Affiliation(s)
- Margaux N Mustian
- Department of Surgery, Division of Transplantation, University of Alabama at Birmingham, Birmingham, AL
| | - Robert M Cannon
- Department of Surgery, Division of Transplantation, University of Louisville, Louisville, KY
| | - Paul A MacLennan
- Department of Surgery, Division of Transplantation, University of Alabama at Birmingham, Birmingham, AL
| | - Rhiannon D Reed
- Department of Surgery, Division of Transplantation, University of Alabama at Birmingham, Birmingham, AL
| | - Brittany A Shelton
- Department of Surgery, Division of Transplantation, University of Alabama at Birmingham, Birmingham, AL
| | - Deanna M McWilliams
- Department of Surgery, Division of Transplantation, University of Alabama at Birmingham, Birmingham, AL
| | - Mark H Deierhoi
- Department of Surgery, Division of Transplantation, University of Alabama at Birmingham, Birmingham, AL
| | - Jayme E Locke
- Department of Surgery, Division of Transplantation, University of Alabama at Birmingham, Birmingham, AL.
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Bhutiani N, Jones CM, Cannon RM, Wei D, Goldstein L, Roy S, Philips P, Scoggins CR, McMasters KM, Martin RCG. Assessing relative cost of complications following orthotopic liver transplant. Clin Transplant 2018; 32:e13209. [PMID: 29364553 DOI: 10.1111/ctr.13209] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2018] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Perioperative complications impose both a clinical and financial burden on patients and the healthcare system. This study sought to identify the frequency and economic impact of complications following orthotopic liver transplantation (OLT). METHODS The Premier Perspective® Hospital Database was queried for patients undergoing OLT between 2008 and 2015. Complications were identified by ICD-9 code and grouped by complication type. Complication frequency as well as impact on clinical and economic outcomes was calculated. Complication frequency and effect on cost were combined to determine the annual impact of each complication type on perioperative OLT cost. RESULTS Among 2747 OLT patients, the most common groups of complications following OLT were pulmonary, bleeding, and infectious. The complications with the greatest average effect on treatment-related costs were infectious, neurologic, deep vein thrombosis/pulmonary embolus, and hepatic arterial thrombosis. Infectious, pulmonary, and bleeding complications had the greatest annual effect on perioperative OLT cost. CONCLUSIONS Efforts focused on preventing coagulopathic bleeding, improving post-operative pulmonary toilet, and minimizing sources of infection can help improve the cost-effectiveness of OLT. Additionally, the combination of these cost data and systematized protocols can help insurers construct bundled payments for OLT that more accurately reflect the cost of perioperative transplant care.
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Affiliation(s)
- Neal Bhutiani
- Department of Surgery, University of Louisville, Louisville, KY, USA
| | | | - Robert M Cannon
- Department of Surgery, University of Louisville, Louisville, KY, USA
| | - David Wei
- Epidemiology, Medical Devices, Johnson & Johnson, New Brunswick, NJ, USA
| | - Laura Goldstein
- Health Economics and Market Access, Ethicon, Somerville, NJ, USA
| | - Sanjoy Roy
- Health Economics and Market Access, Ethicon, Somerville, NJ, USA
| | - Prejesh Philips
- Department of Surgery, University of Louisville, Louisville, KY, USA
| | | | - Kelly M McMasters
- Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Robert C G Martin
- Department of Surgery, University of Louisville, Louisville, KY, USA
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Hill CJ, Courtney AE, Cardwell CR, Maxwell AP, Lucarelli G, Veroux M, Furriel F, Cannon RM, Hoogeveen EK, Doshi M, McCaughan JA. Recipient obesity and outcomes after kidney transplantation: a systematic review and meta-analysis. Nephrol Dial Transplant 2015; 30:1403-11. [PMID: 26044837 DOI: 10.1093/ndt/gfv214] [Citation(s) in RCA: 122] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 04/15/2015] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The prevalence of obesity is increasing globally and is associated with chronic kidney disease and premature mortality. However, the impact of recipient obesity on kidney transplant outcomes remains unclear. This study aimed to investigate the association between recipient obesity and mortality, death-censored graft loss and delayed graft function (DGF) following kidney transplantation. METHODS A systematic review and meta-analysis was conducted using Medline, Embase and the Cochrane Library. Observational studies or randomized controlled trials investigating the association between recipient obesity at transplantation and mortality, death-censored graft loss and DGF were included. Obesity was defined as a body mass index (BMI) of ≥30 kg/m(2). Obese recipients were compared with those with a normal BMI (18.5-24.9 kg/m(2)). Pooled estimates of hazard ratios (HRs) for patient mortality or death-censored graft loss and odds ratios (ORs) for DGF were calculated. RESULTS Seventeen studies including 138 081 patients were analysed. After adjustment, there was no significant difference in mortality risk in obese recipients [HR = 1.24, 95% confidence interval (CI) = 0.90-1.70, studies = 5, n = 83 416]. However, obesity was associated with an increased risk of death-censored graft loss (HR = 1.06, 95% CI = 1.01-1.12, studies = 5, n = 83 416) and an increased likelihood of DGF (OR = 1.68, 95% CI = 1.39-2.03, studies = 4, n = 28 847). CONCLUSIONS Despite having a much higher likelihood of DGF, obese transplant recipients have only a slightly increased risk of graft loss and experience similar survival to recipients with normal BMI.
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Affiliation(s)
| | | | | | | | - Giuseppe Lucarelli
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Massimiliano Veroux
- Vascular Surgery and Organ Transplant Unit, University of Catania, Catania, Italy
| | - Frederico Furriel
- Department of Urology and Renal Transplantation, University Hospital, Coimbra, Portugal
| | - Robert M Cannon
- Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Ellen K Hoogeveen
- Department of Nephrology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Mona Doshi
- Department of Internal Medicine, Wayne State University, Detroit, MI, USA
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Cannon RM, Brock GN, Garrison RN, Marvin MR, Franklin GA, Davis EG. Machine perfusion: not just for marginal kidney donors. Am Surg 2015; 81:550-556. [PMID: 26031265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Interest in machine perfusion (MP) for donated kidneys has markedly increased in the past decade as a means to improve graft function, although the donor populations in which it should be applied have not yet been resolved. All adults undergoing de-novo isolated kidney transplantation from standard-criteria donors in the UNOS database 2005 to 2011 were reviewed with the primary endpoint of delayed graft function (DGF), defined as dialysis within seven days of transplantation, in those who received kidneys that underwent MP versus cold storage (CS) alone. Three methods were used to control for differences between groups. Multivariable logistic regression was performed, adjusting for donor and recipient characteristics significantly associated with DGF. Rates were also compared in a cohort of propensity-matched MP vs CS recipients. Finally, a paired-kidney study was performed, where one kidney underwent MP and the contralateral underwent CS. There were 36,323 patients, with unadjusted DGF rates of 18.6 per cent (n = 1830/9882) and 22.4 per cent (n = 5931/26,441; P < 0.001) in the MP vs CS groups, respectively. After multivariable analysis, the odds ratio for DGF in the MP group was 0.59 (P < 0.001) versus CS. In the propensity-matched cohort, there were 8929 patients each in the MP and CS groups. DGF occurred in 16.8 per cent of the MP group vs 25.3 per cent with CS (P < 0.001, OR 0.59). In the paired-kidney study, rates of DGF were 16.7 per cent vs 24.3 per cent (P < 0.001) in the 1665 recipients each in the MP versus CS groups (OR 0.6). In conclusion, machine perfusion is beneficial in reducing DGF even when standard donors are utilized, and thus should not be limited to marginal kidneys.
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Affiliation(s)
- Robert M Cannon
- Department of Surgery, University of Louisville School of Medicine, Hiram C Polk Jr. Louisville, Kentucky, USA
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Abstract
Interest in machine perfusion (MP) for donated kidneys has markedly increased in the past decade as a means to improve graft function, although the donor populations in which it should be applied have not yet been resolved. All adults undergoing de-novo isolated kidney transplantation from standard-criteria donors in the UNOS database 2005 to 2011 were reviewed with the primary endpoint of delayed graft function (DGF), defined as dialysis within seven days of transplantation, in those who received kidneys that underwent MP versus cold storage (CS) alone. Three methods were used to control for differences between groups. Multivariable logistic regression was performed, adjusting for donor and recipient characteristics significantly associated with DGF. Rates were also compared in a cohort of propensity-matched MP vs CS recipients. Finally, a paired-kidney study was performed, where one kidney underwent MP and the contralateral underwent CS. There were 36,323 patients, with unadjusted DGF rates of 18.6 per cent (n = 1830/9882) and 22.4 per cent (n = 5931/26,441; P < 0.001) in the MP vs CS groups, respectively. After multivariable analysis, the odds ratio for DGF in the MP group was 0.59 ( P < 0.001) versus CS. In the propensity-matched cohort, there were 8929 patients each in the MP and CS groups. DGF occurred in 16.8 per cent of the MP group vs 25.3 per cent with CS ( P < 0.001, OR 0.59). In the paired-kidney study, rates of DGF were 16.7 per cent vs 24.3 per cent ( P < 0.001) in the 1665 recipients each in the MP versus CS groups (OR 0.6). In conclusion, machine perfusion is beneficial in reducing DGF even when standard donors are utilized, and thus should not be limited to marginal kidneys.
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Affiliation(s)
- Robert M. Cannon
- Department of Surgery, University of Louisville School of Medicine, Hiram C Polk Jr. Louisville, Kentucky and
| | - Guy N. Brock
- Department of Biostatistics and Bioinformatics, University of Louisville School of Public Health and Information Sciences, Louisville, Kentucky
| | - R. Neal Garrison
- Department of Surgery, University of Louisville School of Medicine, Hiram C Polk Jr. Louisville, Kentucky and
| | - Michael R. Marvin
- Department of Surgery, University of Louisville School of Medicine, Hiram C Polk Jr. Louisville, Kentucky and
| | - Glen A. Franklin
- Department of Surgery, University of Louisville School of Medicine, Hiram C Polk Jr. Louisville, Kentucky and
| | - Eric G. Davis
- Department of Surgery, University of Louisville School of Medicine, Hiram C Polk Jr. Louisville, Kentucky and
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Marvin MR, Ferguson N, Cannon RM, Jones CM, Brock GN. MELDEQ : An alternative Model for End-Stage Liver Disease score for patients with hepatocellular carcinoma. Liver Transpl 2015; 21:612-22. [PMID: 25694099 DOI: 10.1002/lt.24098] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 12/20/2014] [Accepted: 01/22/2015] [Indexed: 12/14/2022]
Abstract
Multiple studies have demonstrated an advantage for hepatocellular carcinoma (HCC) patients under the current liver allocation system, such that the United Network for Organ Sharing (UNOS) recently voted in support of a proposal to delay granting Model for End-Stage Liver Disease (MELD) exception points to all HCC patients for 6 months, independently of a candidate's native MELD score or alpha-fetoprotein (AFP) level. We obtained UNOS data on adult patients who were added to the wait list between January 22, 2005 and September 30, 2009, and we explored the relationship between HCC, MELD, AFP, and other factors that contribute to not only dropout on the wait list but posttransplant survival as well. The aim was to establish an equivalent Model for End-Stage Liver Disease (MELDEQ ) score for HCC patients that would reduce the disparity in access to transplantation between HCC and non-HCC patients. We determined risk groups for HCC patients with dropout hazards equivalent to those of non-HCC patients, and we evaluated projections for HCC wait-list dropout/transplantation probabilities on the basis of the MELDEQ prioritization scheme. Projections indicate that lower risk HCC patients (MELDEQ ≤ 18) would have dropout probabilities similar to those of non-HCC patients in the same MELD score range, whereas dropout probabilities for higher risk HCC patients would actually be improved. The posttransplant survival of all HCC risk groups is lower than that of their non-HCC counterparts, with 1-year survival of 0.77 (95% CI, 0.70-0.85) for MELDEQ scores ≥ 31. These results suggest that HCC patients with a combination of a low biochemical MELD score and a low AFP level (MELDEQ ≤ 15) would receive a marked advantage in comparison with patients with chemical MELD scores in a similar range and that a delay of 6 months for listing may be appropriate. In contrast, patients with MELDEQ scores > 15 would likely be adversely affected by a universal 6-month delay in listing.
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Affiliation(s)
- Michael R Marvin
- Division of Transplantation, Hiram C. Polk Jr., M.D. Department of Surgery, University of Louisville, Louisville, KY
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Martin RCG, Cannon RM, Brown RE, Ellis SF, Williams S, Scoggins CR, Abbas AE. Evaluation of quality of life following placement of self-expanding plastic stents as a bridge to surgery in patients receiving neoadjuvant therapy for esophageal cancer. Oncologist 2014; 19:259-65. [PMID: 24567281 DOI: 10.1634/theoncologist.2013-0344] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
PURPOSE To determine whether self-expanding plastic stent (SEPS) placement significantly improves quality of life and maintains optimal nutrition while allowing full-dose neoadjuvant therapy (NAT) in patients with esophageal cancer. PATIENTS AND METHODS A prospective, dual-institution, single-arm, phase II (http://ClinicalTrials.gov: NCT00727376) evaluation of esophageal cancer patients undergoing NAT prior to resection. All patients had a self-expanding polymer stent placed prior to NAT. The European Organisation for Research and Treatment of Cancer QLQ-C30 and QLQ-OG25, Functional Assessment of Cancer Therapy-Anorexia, and Functional Assessment of Cancer Therapy-General surveys were administered prior to stenting, within 1 week post-stent placement, and at the completion of neoadjuvant therapy. RESULTS Fifty-two patients were enrolled; 3 (5.8%) had stent migrations requiring replacement. There were no instances of esophageal erosion or perforation. All patients received some form of neoadjuvant therapy. Thirty-six (69%) received chemoradiation; 34 (93%) of these patients received the planned dose of chemotherapy, and 27 (75%) received the full planned dose of radiotherapy. There were 16 (31%) patients receiving chemotherapy alone; 12 (74%) of patients in the chemotherapy-alone group completed the planned dose of therapy. CONCLUSION Placement of SEPS appears to provide significant improvement in quality of life related to dysphagia and eating restriction in patients with esophageal cancer undergoing neoadjuvant therapy. Consideration of SEPS instead of percutaneous feeding tube should be initiated as a first line in dysphagia palliation and NAT nutritional support.
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Affiliation(s)
- Robert C G Martin
- University of Louisville, Department of Surgery, Division of Surgical Oncology, Louisville, Kentucky, USA; Department of Surgery, Ochsner Medical Center, Ochsner Health Systems, New Orleans, Louisiana, USA
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Abstract
INTRODUCTION Patients presenting with cirrhosis and hepatic tumours represent a fragile group that have typically been avoided in early series of laparoscopic liver resection. This study was undertaken to evaluate the results of a laparoscopic hepatectomy in the setting of cirrhosis. METHODS Subgroup analysis of patients with cirrhosis within a series of 327 patients undergoing a laparoscopic resection was performed. Comparisons were made with patients without cirrhosis where appropriate to highlight differences in patient selection and outcomes. Specific variables assessed included operative details and short-term outcomes including length of stay (LOS), morbidity and mortality. Outcomes specific to hepatocellular carcinoma (HCC) were also assessed. RESULTS There were 52 patients with cirrhosis undergoing a laparoscopic hepatic resection. Ninety per cent of patients were Childs class A, with a median model for end-stage liver disease (MELD) score of 8. Hepatitis C was the most common cause of cirrhosis (88.5%), whereas the most common indication for an operation was HCC (71.2%). Resections were generally limited, with the median number of segments resected being 2 (range: 1-4). Complications occurred in 13 (25%) patients, with a 90-day mortality of 5.8%. The median LOS was 3 days. CONCLUSIONS A laparoscopic hepatectomy is safe in the setting of cirrhosis, provided the application of appropriate selection criteria and sufficient experience with the procedure.
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Affiliation(s)
- Robert M Cannon
- Deparment of Surgery, University of LouisvilleLouisville, KY, USA
| | - Bob Saggi
- Tulane Abdominal Transplant Institute, Tulane UniversityNew Orleans, LA, USA
| | - Joseph F Buell
- Tulane Abdominal Transplant Institute, Tulane UniversityNew Orleans, LA, USA,Joseph F. Buell, Department of Surgery, Tulane University, 1415 Tulane Avenue TW35, New Orleans, LA 70112, USA. Tel: +1 504 988 7615. Fax: +1 504 988 7510. E-mail:
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Fox M, Cannon RM, Egger M, Spate K, Kehdy FJ. Laparoscopic component separation reduces postoperative wound complications but does not alter recurrence rates in complex hernia repairs. Am J Surg 2013; 206:869-74; discussion 874-5. [PMID: 24112668 DOI: 10.1016/j.amjsurg.2013.08.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Revised: 08/06/2013] [Accepted: 08/07/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate and compare the incidence of wound complications after laparoscopic component separation (LCS) vs open component separation (OCS) in patients with complex abdominal wall hernias. METHODS A retrospective review was performed of all patients who underwent LCS or OCS for repair of a complex abdominal wall hernia at a single institution between 2009 and 2011. Charts were reviewed to identify postoperative wound complications. A computed tomographic scan or physical examination was used for the determination of hernia recurrence. Categoric variables were compared using the Fisher exact test. Univariate and multivariate analyses were performed using linear and Cox regression. Recurrence rates were compared using log-rank tests (Kaplan-Meier method). RESULTS A total of 44 patients underwent LCS (n = 18) or OCS (n = 26). There was no statistically significant difference between categoric variables. Multivariate analysis using wound complications as the dependent variable showed a statistically significantly lower rate of wound complications in the LCS group. CONCLUSIONS LCS is associated with a lower rate of wound complications when compared with OCS but yields comparable recurrence rates.
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Affiliation(s)
- Mathew Fox
- Department of Surgery, University of Louisville, 550 S Jackson Street, 2nd Floor ACB, Louisville, KY 40202, USA
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Walker SK, Maki AC, Cannon RM, Foley DS, Wilson KM, Galganski LA, Wiesenauer CA, Bond SJ. Etiology and incidence of pediatric gallbladder disease. Surgery 2013; 154:927-31; discussion 931-3. [DOI: 10.1016/j.surg.2013.04.040] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Accepted: 04/19/2013] [Indexed: 12/29/2022]
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