1
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Diaz S, VanWinkle C, Roney E, Kumar SS, Douville NJ, Englesbe M, Sonnenday CJ, Waits S, Schaefer SL. Universal intraoperative systemic heparin administration during liver transplantation: A case series. Liver Transpl 2024; 30:661-667. [PMID: 38190234 DOI: 10.1097/lvt.0000000000000329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 12/27/2023] [Indexed: 01/09/2024]
Affiliation(s)
- Sarah Diaz
- University of Michigan Medical School, Ann Arbor, Michigan, USA
| | | | - Emily Roney
- University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Sathish S Kumar
- Department of Anesthesia, University of Michigan, Ann Arbor, Michigan, USA
| | - Nicholas J Douville
- Department of Anesthesia, University of Michigan, Ann Arbor, Michigan, USA
- Department of Surgery, Section of Transplantation, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Michael Englesbe
- Department of Surgery, Section of Transplantation, Michigan Medicine, Ann Arbor, Michigan, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan, USA
| | - Christopher J Sonnenday
- Department of Surgery, Section of Transplantation, Michigan Medicine, Ann Arbor, Michigan, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan, USA
| | - Seth Waits
- Department of Surgery, Section of Transplantation, Michigan Medicine, Ann Arbor, Michigan, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan, USA
| | - Sara L Schaefer
- Department of Surgery, Section of Transplantation, Michigan Medicine, Ann Arbor, Michigan, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan, USA
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2
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Sonnenday CJ. Liver Transplantation for Hilar Cholangiocarcinoma. Surg Clin North Am 2024; 104:183-196. [PMID: 37953035 DOI: 10.1016/j.suc.2023.09.004] [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] [Indexed: 11/14/2023]
Abstract
Hilar cholangiocarcinoma (hCCA) is an infiltrative disease that often presents with locally advanced and/or metastatic disease, with a minority of patients eligible for surgical resection. Select patients with unresectable hCCA, or patients with hCCA in the setting of primary sclerosing cholangitis, with tumors less than 3 cm and no evidence of extrahepatic disease, can be effectively treated with neoadjuvant chemoradiation followed by liver transplantation. Staging laparotomy documenting lack of occult metastatic disease, including a portal lymphadenectomy documenting no nodal metastases, is essential to achieve optimal outcomes. Overall 5 year survival among treated patients is approximately 60%.
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Affiliation(s)
- Christopher J Sonnenday
- Department of Surgery, University of Michigan Health, F6686 UH-South, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5296, USA.
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3
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Barrett M, Sonnenday CJ. CAQ Corner: Deceased donor selection and management. Liver Transpl 2023; 29:1234-1241. [PMID: 37560989 DOI: 10.1097/lvt.0000000000000242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 07/31/2023] [Indexed: 08/11/2023]
Affiliation(s)
- Meredith Barrett
- University of Michigan, Department of Surgery, Section of Transplantation
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4
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Hughes DL, Pan J, Answine AR, Sonnenday CJ, Waits SA, Kumar SS, Menees DS, Wanamaker B, Bhave NM, Tincopa MA, Fontana RJ, Sharma P. Positron emission tomography myocardial perfusion imaging (PET MPI) findings predictive of post-liver transplant major adverse cardiac events. Liver Transpl 2023; 29:970-978. [PMID: 36879556 DOI: 10.1097/lvt.0000000000000118] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 01/24/2023] [Indexed: 03/08/2023]
Abstract
Positron emission tomography myocardial perfusion imaging (PET MPI) is a noninvasive diagnostic test capable of detecting coronary artery disease, structural heart disease, and myocardial flow reserve (MFR). We aimed to determine the prognostic utility of PET MPI to predict post-liver transplant (LT) major adverse cardiac events (MACE). Among the 215 LT candidates that completed PET MPI between 2015 and 2020, 84 underwent LT and had 4 biomarker variables of clinical interest on pre-LT PET MPI (summed stress and difference scores, resting left ventricular ejection fraction, global MFR). Post-LT MACE were defined as acute coronary syndrome, heart failure, sustained arrhythmia, or cardiac arrest within the first 12 months post-LT. Cox regression models were constructed to determine associations between PET MPI variable/s and post-LT MACE. The median LT recipient age was 58 years, 71% were male, 49% had NAFLD, 63% reported prior smoking, 51% had hypertension, and 38% had diabetes mellitus. A total of 20 MACE occurred in 16 patients (19%) at a median of 61.5 days post-LT. One-year survival of MACE patients was significantly lower than those without MACE (54% vs. 98%, p =0.001). On multivariate analysis, reduced global MFR ≤1.38 was associated with a higher risk of MACE [HR=3.42 (1.23-9.47), p =0.019], and every % reduction in left ventricular ejection fraction was associated with an 8.6% higher risk of MACE [HR=0.92 (0.86-0.98), p =0.012]. Nearly 20% of LT recipients experienced MACE within the first 12 months of LT. Reduced global MFR and reduced resting left ventricular ejection fraction on PET MPI among LT candidates were associated with increased risk of post-LT MACE. Awareness of these PET-MPI parameters may help improve cardiac risk stratification of LT candidates if confirmed in future studies.
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Affiliation(s)
- Dempsey L Hughes
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, USA
| | - Jason Pan
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Adeline R Answine
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Seth A Waits
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Sathish S Kumar
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Daniel S Menees
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Brett Wanamaker
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Nicole M Bhave
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Monica A Tincopa
- Division of Gastroenterology and Hepatology, University of California San Diego, San Diego, California
| | - Robert J Fontana
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Pratima Sharma
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
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5
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Carpenter ES, Elhossiny AM, Kadiyala P, Li J, McGue J, Griffith BD, Zhang Y, Edwards J, Nelson S, Lima F, Donahue KL, Du W, Bischoff AC, Alomari D, Watkoske HR, Mattea M, The S, Espinoza CE, Barrett M, Sonnenday CJ, Olden N, Chen CT, Peterson N, Gunchick V, Sahai V, Rao A, Bednar F, Shi J, Frankel TL, Pasca di Magliano M. Analysis of Donor Pancreata Defines the Transcriptomic Signature and Microenvironment of Early Neoplastic Lesions. Cancer Discov 2023; 13:1324-1345. [PMID: 37021392 PMCID: PMC10236159 DOI: 10.1158/2159-8290.cd-23-0013] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [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] [Received: 01/13/2023] [Revised: 03/03/2023] [Accepted: 03/15/2023] [Indexed: 04/07/2023]
Abstract
The adult healthy human pancreas has been poorly studied given the lack of indication to obtain tissue from the pancreas in the absence of disease and rapid postmortem degradation. We obtained pancreata from brain dead donors, thus avoiding any warm ischemia time. The 30 donors were diverse in age and race and had no known pancreas disease. Histopathologic analysis of the samples revealed pancreatic intraepithelial neoplasia (PanIN) lesions in most individuals irrespective of age. Using a combination of multiplex IHC, single-cell RNA sequencing, and spatial transcriptomics, we provide the first-ever characterization of the unique microenvironment of the adult human pancreas and of sporadic PanIN lesions. We compared healthy pancreata to pancreatic cancer and peritumoral tissue and observed distinct transcriptomic signatures in fibroblasts and, to a lesser extent, macrophages. PanIN epithelial cells from healthy pancreata were remarkably transcriptionally similar to cancer cells, suggesting that neoplastic pathways are initiated early in tumorigenesis. SIGNIFICANCE Precursor lesions to pancreatic cancer are poorly characterized. We analyzed donor pancreata and discovered that precursor lesions are detected at a much higher rate than the incidence of pancreatic cancer, setting the stage for efforts to elucidate the microenvironmental and cell-intrinsic factors that restrain or, conversely, promote malignant progression. See related commentary by Hoffman and Dougan, p. 1288. This article is highlighted in the In This Issue feature, p. 1275.
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Affiliation(s)
- Eileen S. Carpenter
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Ahmed M. Elhossiny
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan
| | - Padma Kadiyala
- Immunology Graduate Program, University of Michigan, Ann Arbor, Michigan
| | - Jay Li
- Medical Scientist Training Program, University of Michigan, Ann Arbor, Michigan
| | - Jake McGue
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | | | - Yaqing Zhang
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Jacob Edwards
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Sarah Nelson
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Fatima Lima
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | | | - Wenting Du
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | | | - Danyah Alomari
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | | | - Michael Mattea
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan
| | - Stephanie The
- Cancer Data Science Resource, University of Michigan, Ann Arbor, Michigan
| | | | - Meredith Barrett
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | | | | | - Chin-Tung Chen
- Colorectal Cancer Research Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nicole Peterson
- Department of Internal Medicine, Division of Hematology and Oncology, University of Michigan, Ann Arbor, Michigan
| | - Valerie Gunchick
- Department of Internal Medicine, Division of Hematology and Oncology, University of Michigan, Ann Arbor, Michigan
| | - Vaibhav Sahai
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
- Department of Internal Medicine, Division of Hematology and Oncology, University of Michigan, Ann Arbor, Michigan
| | - Arvind Rao
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan
- Cancer Data Science Resource, University of Michigan, Ann Arbor, Michigan
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Filip Bednar
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Jiaqi Shi
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
- Department of Pathology, University of Michigan, Ann Arbor, Michigan
| | - Timothy L. Frankel
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
- Immunology Graduate Program, University of Michigan, Ann Arbor, Michigan
| | - Marina Pasca di Magliano
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
- Department of Cell and Developmental Biology, University of Michigan, Ann Arbor, Michigan
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6
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Bloom PP, Gilbert T, Santos-Parker K, Memel Z, Przybyszewski E, Bethea E, Sonnenday CJ, Tapper EB, Waits S. The incidence and natural history of ascites after liver transplantation. Hepatol Commun 2023; 7:02009842-202306010-00017. [PMID: 37219847 PMCID: PMC10208690 DOI: 10.1097/hc9.0000000000000158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 03/28/2023] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND Ascites is common in cirrhosis but uncommon after liver transplant. We aimed to characterize the incidence, natural history, and current management strategies of post-transplant ascites. METHODS We performed a retrospective cohort study of patients who underwent liver transplantation at 2 centers. We included patients who underwent deceased donor whole graft liver transplants between 2002 and 2019. Chart review identified patients with post-transplant ascites, requiring a paracentesis between 1 and 6-month post-transplants. Detailed chart review identified clinical and transplant characteristics, evaluation of ascites etiology, and treatments. RESULTS Of 1591 patients who successfully underwent a first-time orthotopic liver transplant for chronic liver disease, 101 (6.3%) developed post-transplant ascites. Only 62% of these patients required large volume paracentesis for ascites before transplant. 36% of patients with post-transplant ascites had early allograft dysfunction. Most patients with post-transplant ascites (73%) required a paracentesis within 2 months of transplant, but 27% had delayed ascites onset. From 2002 to 2019, ascites studies were obtained less often, and hepatic vein pressure measurement was performed more often. Diuretics were the mainstay of treatment (58%). The use of albumin infusion and splenic artery embolization to treat post-transplant ascites increased over time. Larger pre-transplant spleen size was associated with a greater number of post-transplant paracenteses (r=0.32 and p=0.003). For patients who underwent splenic intervention, paracentesis frequency was significantly reduced (1.6-0.4 paracenteses/month, p=0.0001). The majority (72%) of patients had clinical resolution of their ascites at 6-month post-transplant. CONCLUSIONS Persistent or recurrent ascites continues to be a clinical issue in the modern era of liver transplantation. Most had clinical resolution within 6 months, some requiring intervention.
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Affiliation(s)
- Patricia P Bloom
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Timothy Gilbert
- University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Keli Santos-Parker
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Zoe Memel
- Division of Gastroenterology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Eric Przybyszewski
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Emily Bethea
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Seth Waits
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
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7
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Schaefer SL, Jabour SM, Englesbe M, Sonnenday CJ, Anderson MS. Incidence and outcomes of liver retransplantation using living donor allografts in the US. Liver Transpl 2023; 29:555-558. [PMID: 36747347 PMCID: PMC10134743 DOI: 10.1097/lvt.0000000000000085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 12/09/2022] [Indexed: 02/08/2023]
Affiliation(s)
- Sara L. Schaefer
- Section of Transplantation, Department of Surgery, Michigan Medicine, Ann Arbor, MI
| | - Sarah M. Jabour
- Department of Surgery, Johns Hopkins Medicine, Baltimore, MD
| | - Michael Englesbe
- Section of Transplantation, Department of Surgery, Michigan Medicine, Ann Arbor, MI
| | | | - Maia S. Anderson
- Section of Transplantation, Department of Surgery, Michigan Medicine, Ann Arbor, MI
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8
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Kamyszek RW, Sood SL, Sonnenday CJ, Parikh ND, Westman A, Englesbe MJ, Waits SA, Barrett M, Fontana RJ, Kumar SS. Successful living donor liver transplantation in a patient with hemophilia A and factor VIII inhibitor: a case report with perioperative recommendations. Am J Transplant 2023:S1600-6135(23)00311-8. [PMID: 36898636 DOI: 10.1016/j.ajt.2023.02.026] [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: 11/21/2022] [Revised: 01/27/2023] [Accepted: 02/27/2023] [Indexed: 03/11/2023]
Abstract
Liver transplantation in patients with end-stage liver disease and coexisting hemophilia A has been described. Controversy exists over perioperative management of patients with factor VIII inhibitor predisposing patients to hemorrhage. We describe the case of a 58-year-old man with a history of hemophilia A and factor VIII inhibitor, eradicated with rituximab prior to living donor liver transplantation without recurrence of inhibitor. We also provide perioperative management recommendations from our successful multidisciplinary approach.
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Affiliation(s)
- Reed W Kamyszek
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Suman L Sood
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | | | - Neehar D Parikh
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Amanda Westman
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, Michigan, USA; Anesthesia Practice Consultants, P.C. Grand Rapids, Michigan, USA
| | | | - Seth A Waits
- Department of Surgery, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Meredith Barrett
- Department of Surgery, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Robert J Fontana
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Sathish S Kumar
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, Michigan, USA.
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9
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Carpenter ES, Elhossiny AM, Kadiyala P, Li J, McGue J, Griffith B, Zhang Y, Edwards J, Nelson S, Lima F, Donahue KL, Du W, Bischoff AC, Alomari D, Watkoske H, Mattea M, The S, Espinoza C, Barrett M, Sonnenday CJ, Olden N, Peterson N, Gunchick V, Sahai V, Rao A, Bednar F, Shi J, Frankel TL, Di Magliano MP. Analysis of donor pancreata defines the transcriptomic signature and microenvironment of early pre-neoplastic pancreatic lesions. bioRxiv 2023:2023.01.13.523300. [PMID: 36712058 PMCID: PMC9882230 DOI: 10.1101/2023.01.13.523300] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
The adult healthy human pancreas has been poorly studied given lack of indication to obtain tissue from the pancreas in the absence of disease and rapid postmortem degradation. We obtained pancreata from brain dead donors thus avoiding any warm ischemia time. The 30 donors were diverse in age and race and had no known pancreas disease. Histopathological analysis of the samples revealed PanIN lesions in most individuals irrespective of age. Using a combination of multiplex immunohistochemistry, single cell RNA sequencing, and spatial transcriptomics, we provide the first ever characterization of the unique microenvironment of the adult human pancreas and of sporadic PanIN lesions. We compared healthy pancreata to pancreatic cancer and peritumoral tissue and observed distinct transcriptomic signatures in fibroblasts, and, to a lesser extent, macrophages. PanIN epithelial cells from healthy pancreata were remarkably transcriptionally similar to cancer cells, suggesting that neoplastic pathways are initiated early in tumorigenesis. Statement of significance The causes underlying the onset of pancreatic cancer remain largely unknown, hampering early detection and prevention strategies. Here, we show that PanIN are abundant in healthy individuals and present at a much higher rate than the incidence of pancreatic cancer, setting the stage for efforts to elucidate the microenvironmental and cell intrinsic factors that restrain, or, conversely, promote, malignant progression.
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Affiliation(s)
- Eileen S Carpenter
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI
| | - Ahmed M Elhossiny
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, MI
| | - Padma Kadiyala
- Immunology Graduate Program, University of Michigan, Ann Arbor, MI
| | - Jay Li
- Medical Scientist Training Program, University of Michigan, Ann Arbor, MI
| | - Jake McGue
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Brian Griffith
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Yaqing Zhang
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Jacob Edwards
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Sarah Nelson
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Fatima Lima
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | | | - Wenting Du
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | | | - Danyah Alomari
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - Hannah Watkoske
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Michael Mattea
- Department of Molecular & Integrative Physiology, University of Michigan, Ann Arbor, MI
| | - Stephanie The
- Cancer Data Science Resource, University of Michigan, Ann Arbor, MI
| | - Carlos Espinoza
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | | | | | | | - Nicole Peterson
- Department of Internal Medicine, Division of Hematology and Oncology, University of Michigan, Ann Arbor, MI
| | - Valerie Gunchick
- Department of Internal Medicine, Division of Hematology and Oncology, University of Michigan, Ann Arbor, MI
| | - Vaibhav Sahai
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI
- Department of Internal Medicine, Division of Hematology and Oncology, University of Michigan, Ann Arbor, MI
| | - Arvind Rao
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, MI
- Cancer Data Science Resource, University of Michigan, Ann Arbor, MI
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
- Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | - Filip Bednar
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Jiaqi Shi
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI
- Department of Pathology, University of Michigan, Ann Arbor, MI
| | - Timothy L Frankel
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI
- Immunology Graduate Program, University of Michigan, Ann Arbor, MI
| | - Marina Pasca Di Magliano
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Department of Cell and Developmental Biology, University of Michigan, Ann Arbor, MI
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10
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Berkowitz RJ, Engoren MC, Mentz G, Sharma P, Kumar SS, Davis R, Kheterpal S, Sonnenday CJ, Douville NJ. Intraoperative risk factors of acute kidney injury following liver transplantation. Liver Transpl 2022; 28:1399-1400. [PMID: 35434880 DOI: 10.1002/lt.26477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 03/24/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Rachel J Berkowitz
- Surgical Analytics and Population Health, Data Analytics and Reporting, Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Milo C Engoren
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Graciela Mentz
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Pratima Sharma
- Division of Gastroenterology, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Sathish S Kumar
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Ryan Davis
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Sachin Kheterpal
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Christopher J Sonnenday
- Section of Transplantation, Department of Surgery, Michigan Medicine, Ann Arbor, Michigan, USA.,Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA.,Institute of Healthcare Policy & Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Nicholas J Douville
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, Michigan, USA.,Institute of Healthcare Policy & Innovation, University of Michigan, Ann Arbor, Michigan, USA
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11
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Berkowitz RJ, Engoren MC, Mentz G, Sharma P, Kumar SS, Davis R, Kheterpal S, Sonnenday CJ, Douville NJ. Intraoperative risk factors of acute kidney injury after liver transplantation. Liver Transpl 2022; 28:1207-1223. [PMID: 35100664 PMCID: PMC9321139 DOI: 10.1002/lt.26417] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 01/06/2022] [Accepted: 01/10/2022] [Indexed: 01/13/2023]
Abstract
Acute kidney injury (AKI) is one of the most common complications of liver transplantation (LT). We examined the impact of intraoperative management on risk for AKI following LT. In this retrospective observational study, we linked data from the electronic health record with standardized transplant outcomes. Our primary outcome was stage 2 or 3 AKI as defined by Kidney Disease Improving Global Outcomes guidelines within the first 7 days of LT. We used logistic regression models to test the hypothesis that the addition of intraoperative variables, including inotropic/vasopressor administration, transfusion requirements, and hemodynamic markers improves our ability to predict AKI following LT. We also examined the impact of postoperative AKI on mortality. Of the 598 adult primary LT recipients included in our study, 43% (n = 255) were diagnosed with AKI within the first 7 postoperative days. Several preoperative and intraoperative variables including (1) electrolyte/acid-base balance disorder (International Classification of Diseases, Ninth Revision codes 253.6 or 276.x and International Classification of Diseases, Tenth Revision codes E22.2 or E87.x, where x is any digit; adjusted odds ratio [aOR], 1.917, 95% confidence interval [CI], 1.280-2.869; p = 0.002); (2) preoperative anemia (aOR, 2.612; 95% CI, 1.405-4.854; p = 0.002); (3) low serum albumin (aOR, 0.576; 95% CI, 0.410-0.808; p = 0.001), increased potassium value during reperfusion (aOR, 1.513; 95% CI, 1.103-2.077; p = 0.01), and lactate during reperfusion (aOR, 1.081; 95% CI, 1.003-1.166; p = 0.04) were associated with posttransplant AKI. New dialysis requirement within the first 7 days postoperatively predicted the posttransplant mortality. Our study identified significant association between several potentially modifiable variables with posttransplant AKI. The addition of intraoperative data did not improve overall model discrimination.
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Affiliation(s)
- Rachel J. Berkowitz
- Surgical Analytics and Population HealthData Analytics and ReportingLurie Children’s Hospital of ChicagoChicagoIllinoisUSA
| | - Milo C. Engoren
- Department of AnesthesiologyMichigan MedicineAnn ArborMichiganUSA
| | - Graciela Mentz
- Department of AnesthesiologyMichigan MedicineAnn ArborMichiganUSA
| | - Pratima Sharma
- Division of GastroenterologyDepartment of Internal MedicineMichigan MedicineAnn ArborMichiganUSA
| | - Sathish S. Kumar
- Department of AnesthesiologyMichigan MedicineAnn ArborMichiganUSA
| | - Ryan Davis
- Department of AnesthesiologyMichigan MedicineAnn ArborMichiganUSA
| | - Sachin Kheterpal
- Department of AnesthesiologyMichigan MedicineAnn ArborMichiganUSA
| | - Christopher J. Sonnenday
- Division of Transplantation SurgeryDepartment of SurgeryMichigan MedicineAnn ArborMichiganUSA,School of Public HealthUniversity of MichiganAnn ArborMichiganUSA
| | - Nicholas J. Douville
- Department of AnesthesiologyMichigan MedicineAnn ArborMichiganUSA,Institute of Healthcare Policy & InnovationUniversity of MichiganAnn ArborMichiganUSA
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12
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Wakam GK, Palmon I, Kulick AA, Lark M, Sonnenday CJ, Waits SA. Adapting to the Times: Combining Microlearning Videos and Twitter to Teach Surgical Technique. J Surg Educ 2022; 79:850-854. [PMID: 35227624 DOI: 10.1016/j.jsurg.2022.02.001] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 01/29/2022] [Accepted: 02/05/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVE Surgical videos are commonly utilized by trainees to prepare for surgical cases. However, currently available videos tend to be of excessive length, variable quality, and exist behind paywalls or in other exclusive formats. Our objective was to create a series of videos that would address these shortcomings, and further allow for dynamic engagement between learners and experts. DESIGN Our group created surgical videos using principles of microlearning, an educational strategy which deconstructs content into small units and uses social media platforms where learners and educators may actively engage. We published a library of short (<3 min) videos covering various steps of abdominal transplantation operations on a YouTube channel. We leveraged Twitter to disseminate the content and engage with experts and learners from around the world. SETTING Multi-institutional. RESULTS Over the period from July 2020 to January 2021, 24 microlearning videos were created, stored on a YouTube channel, and posted to Twitter weekly using a newly created account. During that time period, the videos, averaging 124 seconds in length, were viewed 4393 times and watched for a total of 127 hours. The account gained 611 followers in 37 countries and 37 US states with 312,400 impressions (defined as tweet views). Twitter users who engaged with our microlearning content (favorite, retweet, or reply) included faculty (27%), residents (21%), fellows (8%), and medical students (11%). CONCLUSIONS Broad participation with the educational material and discussion on Twitter demonstrated the potential for the microlearning technique to provide educational benefit for learners internationally. The spread of the tweets shows an opportunity to augment traditional surgical education, and the willingness of faculty to discuss alternative techniques with their peers. Our group will continue to develop a library of microlearning videos for surgical operations and engage with other institutions for collaboration and expansion.
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Affiliation(s)
- Glenn K Wakam
- Department of Surgery, University of Michigan, Ann Arbor, Michigan.
| | - Itai Palmon
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | | | - Meghan Lark
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | | | - Seth A Waits
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
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13
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Mendiratta-Lala M, Aslam A, Maturen KE, Westerhoff M, Sun Y, Maurino C, Parikh ND, Sonnenday CJ, Stein EB, Shampain KL, Kaza RK, Cuneo K, Masch W, Do RKG, Lawrence TS, Owen D. LI-RADS Treatment Response Algorithm: Performance and Diagnostic Accuracy With Radiologic-Pathologic Explant Correlation in Patients With SBRT-Treated Hepatocellular Carcinoma. Int J Radiat Oncol Biol Phys 2022; 112:704-714. [PMID: 34644607 PMCID: PMC9400832 DOI: 10.1016/j.ijrobp.2021.10.006] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 09/30/2021] [Accepted: 10/05/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE Our purpose was to evaluate the accuracy of LI-RADS Treatment Response Algorithm (LR-TRA) for assessing the viability of hepatocellular carcinoma (HCC) treated with stereotactic body radiation therapy (SBRT), using explant pathology as the gold standard. METHODS AND MATERIALS This retrospective study included patients who underwent SBRT for locoregional treatment of HCC between 2008 and 2019 with subsequent liver transplantation. Five radiologists independently assessed all treated lesions by using the LR-TRA. Imaging and posttransplant histopathology were compared. Lesions were categorized as either completely (100%) or incompletely (<100%) necrotic, and performance characteristics and predictive values for the LR-TR viable and nonviable categories were calculated for each reader. Interreader reliability was calculated using the Fleiss kappa test. RESULTS A total of 40 treated lesions in 26 patients (median age, 63 years [interquartile range, 59.4-65.5]; 23 men) were included. For lesions treated with SBRT, sensitivity for incomplete tumor necrosis across readers ranged between 71% and 86%, specificity between 85% and 96%, and positive predictive value between 86% and 92%, when the LR-TR equivocal category was treated as nonviable, accounting for subject clustering. When the LR-TR equivocal category was treated as viable, sensitivity of complete tumor necrosis for lesions treated with SBRT ranged from 88% to 96%, specificity from 71% to 93%, and negative predictive value from 85% to 96%. Interreader reliability was fair (k = 0.22; 95% confidence interval, 0.13-0.33). Although a loss of arterial phase hyperenhancement (APHE) was highly correlated with pathologically nonviable tumor on explant, almost half of the patients with APHE had pathologically nonviable tumor on explant. CONCLUSIONS LR-TRA v2018 performs well for predicting complete and incomplete necrosis in HCC treated with SBRT. In contrast to other locoregional therapies, the presence of APHE after SBRT does not always indicate viable tumor and suggests that observation may be an appropriate strategy for these patients.
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Affiliation(s)
| | | | | | - Maria Westerhoff
- Department of Pathology and clinical labs, University of Michigan Health System, NCRC building 35 2800 Plymouth Road Ann Arbor, MI 48109
| | | | | | - Neehar D. Parikh
- Division of Gastroenterology and Hepatology, University of Michigan School of Medicine
| | | | | | | | | | - Kyle Cuneo
- Department of Radiation Oncology, University of Michigan School of Medicine
| | | | | | | | - Dawn Owen
- Department of Radiation Oncology, Mayo Clinic Rochester, 200 First St SW, Rochester, MN 55905
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14
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Montgomery JR, Highet A, Brown CS, Waits SA, Englesbe MJ, Sonnenday CJ. Graft Survival and Segment Discards Among Split-Liver and Reduced-Size Transplantations in the United States From 2008 to 2018. Liver Transpl 2022; 28:247-256. [PMID: 34407278 DOI: 10.1002/lt.26271] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 08/08/2021] [Accepted: 08/14/2021] [Indexed: 01/13/2023]
Abstract
Split-liver transplantation has allocation advantages over reduced-size transplantation because of its ability to benefit 2 recipients. However, prioritization of split-liver transplantation relies on the following 3 major assumptions that have never been tested in the United States: similar long-term transplant recipient outcomes, lower incidence of segment discard among split-liver procurements, and discard of segments among reduced-size procurements that would be otherwise "transplantable." We used United Network for Organ Sharing Standard Transplant Analysis and Research data to identify all split-liver (n = 1831) and reduced-size (n = 578) transplantation episodes in the United States between 2008 and 2018. Multivariable Cox proportional hazards modeling was used to compare 7-year all-cause graft loss between cohorts. Secondary analyses included etiology of 30-day all-cause graft loss events as well as the incidence and anatomy of discarded segments. We found no difference in 7-year all-cause graft loss (adjusted hazard ratio [aHR], 1.1; 95% confidence interval [CI], 0.8-1.5) or 30-day all-cause graft loss (aHR, 1.1; 95% CI, 0.7-1.8) between split-liver and reduced-size cohorts. Vascular thrombosis was the most common etiology of 30-day all-cause graft loss for both cohorts (56.4% versus 61.8% of 30-day graft losses; P = 0.85). Finally, reduced-size transplantation was associated with a significantly higher incidence of segment discard (50.0% versus 8.7%) that were overwhelmingly right-sided liver segments (93.6% versus 30.3%). Our results support the prioritization of split-liver over reduced-size transplantation whenever technically feasible.
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Affiliation(s)
- John R Montgomery
- Department of Surgery, Michigan Medicine, Ann Arbor, MI.,Center for Healthcare Outcomes & Policy, Michigan Medicine, Ann Arbor, MI
| | | | - Craig S Brown
- Department of Surgery, Michigan Medicine, Ann Arbor, MI.,Center for Healthcare Outcomes & Policy, Michigan Medicine, Ann Arbor, MI
| | - Seth A Waits
- Center for Healthcare Outcomes & Policy, Michigan Medicine, Ann Arbor, MI.,Department of Surgery, Section of Transplantation, Michigan Medicine, Ann Arbor, MI
| | - Michael J Englesbe
- Center for Healthcare Outcomes & Policy, Michigan Medicine, Ann Arbor, MI.,Department of Surgery, Section of Transplantation, Michigan Medicine, Ann Arbor, MI
| | - Christopher J Sonnenday
- Center for Healthcare Outcomes & Policy, Michigan Medicine, Ann Arbor, MI.,Department of Surgery, Section of Transplantation, Michigan Medicine, Ann Arbor, MI
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15
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Lark ME, Anderson M, Jabour S, Schaefer SL, Englesbe M, Sonnenday CJ. Post-Transplantation Frailty Is Associated with Diminished Quality of Life in Liver Transplant Recipients. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.564] [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: 11/25/2022]
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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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17
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Louissaint J, Murphy SL, Sonnenday CJ, Lok AS, Tapper EB. Applying Administrative Data-Based Coding Algorithms for Frailty in Patients With Cirrhosis. Liver Transpl 2021; 27:1401-1411. [PMID: 33871175 PMCID: PMC8994168 DOI: 10.1002/lt.26078] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 02/04/2021] [Revised: 03/23/2021] [Accepted: 04/12/2021] [Indexed: 12/23/2022]
Abstract
Frailty is a powerful prognostic tool in cirrhosis. Claims-based frailty scores estimate the presence of frailty without the need for in-person evaluation. These algorithms have not been validated in cirrhosis. Whether they measure true frailty or perform as well as frailty in outcome prediction is unknown. We evaluated 2 claims-based frailty scores-Hospital Frailty Risk Score (HFRS) and Claims-Based Frailty Index (CFI)-in 3 prospective cohorts comprising 1100 patients with cirrhosis. We assessed differences in neuromuscular/neurocognitive capabilities in those classified as frail or nonfrail based on each score. We assessed the ability of the indexes to discriminate frailty based on the Fried Frailty Index (FFI), chair stands, activities of daily living (ADL), and falls. Finally, we compared the performance of claims-based frailty measures and physical frailty measures to predict transplant-free survival using competing risk regression and patient-reported outcomes. The CFI identified neuromuscular deficits (balance, chair stands, hip strength), whereas the HFRS only identified poor chair-stand performance. The CFI had areas under the receiver operating characteristic curve (AUROCs) for identifying frailty as measured by the FFI, ADL, and falls of 0.57, 0.60, and 0.68, respectively; similarly, the AUROCs were 0.66, 0.63, and 0.67, respectively, for the HFRS. Claims-based frailty scores were associated with poor quality of life and sleep but were outperformed by the FFI and chair stands. The HFRS, per 10-point increase (but not the CFI) predicted survival of patients in the liver transplantation (subdistribution hazard ratio [SHR], 1.08; 95% confidence interval [CI], 1.03-1.12) and non-liver transplantation cohorts (SHR, 1.13; 95% CI, 1.05-1.22). Claims-based frailty scores do not adequately associate with physical frailty but are associated with important cirrhosis-related outcomes.
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Affiliation(s)
- Jeremy Louissaint
- Division of Gastroenterology and Hepatology and University of Michigan, Ann Arbor, MI
| | - Susan L. Murphy
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI,Geriatric Research Education and Clinical Center, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | | | - Anna S. Lok
- Division of Gastroenterology and Hepatology and University of Michigan, Ann Arbor, MI
| | - Elliot B. Tapper
- Division of Gastroenterology and Hepatology and University of Michigan, Ann Arbor, MI,Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI,Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, MI
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18
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Anderson MS, Valbuena VSM, Brown CS, Waits SA, Sonnenday CJ, Englesbe M, Mellinger JL. Association of COVID-19 With New Waiting List Registrations and Liver Transplantation for Alcoholic Hepatitis in the United States. JAMA Netw Open 2021; 4:e2131132. [PMID: 34698851 PMCID: PMC8548949 DOI: 10.1001/jamanetworkopen.2021.31132] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
This cross-sectional study examines trends in new waiting list registrations and liver transplantation for alcoholic hepatitis before and during the COVID-19 pandemic in the US.
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Affiliation(s)
- Maia S. Anderson
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Valeria S. M. Valbuena
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
- National Clinician Scholars Program, University of Michigan, Ann Arbor, Michigan
| | - Craig S. Brown
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Seth A. Waits
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Christopher J. Sonnenday
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Michael Englesbe
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Jessica L. Mellinger
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
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19
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Brown CS, Waits SA, Englesbe MJ, Sonnenday CJ, Sheetz KH. Associations Among Different Domains of Quality Among US Liver Transplant Programs. JAMA Netw Open 2021; 4:e2118502. [PMID: 34369991 PMCID: PMC8353538 DOI: 10.1001/jamanetworkopen.2021.18502] [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] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 05/21/2021] [Indexed: 12/20/2022] Open
Abstract
Importance US liver transplant programs have traditionally been evaluated on 1-year patient and graft survival. However, there is concern that a narrow focus on recipient outcomes may not incentivize programs to improve in other ways that would benefit patients with end-stage liver disease. Objective To determine the correlation among different potential domains of quality for adult liver transplant programs. Design, Setting, and Participants This retrospective cohort study was conducted from 2014 to 2019 among adult liver transplant programs included in the United Network for Organ Sharing and Scientific Registry of Transplant Recipients program-specific reports. Liver transplant programs in the United States completing at least 10 liver transplants per year were included. Data were analyzed from March 2 to August 13, 2020. Main Outcomes and Measures The potential domains of quality examined included recipient outcomes (1-year graft and patient survival), aggressiveness (ie, marginal graft use, defined as the rate of use of donors with body mass index [calculated as weight in kilograms divided by height in meters squared] greater than 40, age older than 65 years, or deceased by cardiac death), and waiting list management (ie, waiting list mortality). The correlation among measures, aggregated at the center level, was evaluated using linear regression to control for mean Model for End Stage Liver Disease-Sodium score at organ allocation. The extent to which programs were able to achieve high quality across multiple domains was also evaluated. Results Among 114 transplant programs that performed a total of 44 554 transplants, the mean (SD) 1-year graft and patient survival was 90.3% (3.0%) with a total range of 75.9% to 96.6%. The mean (SD) waiting list mortality rate was 16.7 (6.1) deaths per 100 person-years, with a total range of 6.3 to 53.0 deaths per 100 person years. The mean (SD) marginal graft use rate was 15.8 (8.8) donors per 100 transplants, with a total range of 0 to 49.3 donors. There was no correlation between 1-year graft and patient survival and waiting list mortality (β = -0.053; P = .19) or marginal graft use (β = -0.007; P = .84) after correcting for mean allocation Model for End Stage Liver Disease-Sodium scores. There were 2 transplant programs (1.8%) that performed in the top quartile on all 3 measures, while 4 transplant programs (3.6%) performed in the bottom quartile on all 3 measures. Conclusions and Relevance This cohort study found that among US liver transplant programs, there were no correlations among 1-year recipient outcomes, measures of program aggressiveness, or waiting list management. These findings suggest that a program's performance in one domain may be independent and unrelated to its performance on others and that the understanding of factors contributing to these domains is incomplete.
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Affiliation(s)
- Craig S. Brown
- Department of Surgery, University of Michigan, Ann Arbor
| | - Seth A. Waits
- Department of Surgery, University of Michigan, Ann Arbor
| | | | | | - Kyle H. Sheetz
- Department of Surgery, University of Michigan, Ann Arbor
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20
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Likhitsup A, Saeed N, Winder GS, Hassan A, Sonnenday CJ, Fontana RJ. Marijuana use among adult liver transplant candidates and recipients. Clin Transplant 2021; 35:e14312. [PMID: 33829569 DOI: 10.1111/ctr.14312] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 11/27/2020] [Revised: 03/22/2021] [Accepted: 04/02/2021] [Indexed: 01/25/2023]
Abstract
BACKGROUND Data regarding marijuana (MJ) use among liver transplant (LT) candidates are limited. We set out to determine the incidence and pre- and post-LT outcomes of adult LT candidates with a self-reported history of MJ use. METHODS Baseline clinical characteristics, waitlist, and post-LT outcomes of adult LT candidates from January 2010 to March 2017 were compared. RESULTS Among 2690 LT candidates, 630(23%) and 298(11%) reported a history of MJ use and use within the past 12 months, respectively. Although the proportion of MJ users increased over time(β = .76, p = .03), the proportion listed and transplanted did not change. Listing for LT increased with male (OR 1.24, 95% CI 11.01-1.52), MELD score (OR 1.08, 95% CI 1.01-1.15), HCC (OR 1.83, 95% CI 1.39-2.41) but decreased among MJ users (OR 0.67, 95% CI 0.50-0.91, p = .01). The median time to listing was longer among MJ users compared to non-users (115 vs. 87 days, p < .0005). Post-LT survival was similar in 83 MJ users and 306 non-users. CONCLUSION The proportion of MJ users among LT candidates is increasing. MJ users have a greater burden of psychosocial issues which may contribute to longer evaluations and lower rate of LT listing. Post-LT survival was not impacted by self-reported MJ use history.
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Affiliation(s)
- Alisa Likhitsup
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
| | - Naba Saeed
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
| | - Gerald Scott Winder
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA.,Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Ammar Hassan
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
| | | | - Robert J Fontana
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
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21
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DeRoos LJ, Zhou Y, Marrero WJ, Tapper EB, Sonnenday CJ, Lavieri MS, Hutton DW, Parikh ND. Assessment of National Organ Donation Rates and Organ Procurement Organization Metrics. JAMA Surg 2021; 156:173-180. [PMID: 33263743 DOI: 10.1001/jamasurg.2020.5395] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Importance Organ transplant is a life-saving procedure for patients with end-stage organ failure. In the US, organ procurement organizations (OPOs) are responsible for the evaluation and procurement of organs from donors who have died; however, there is controversy regarding what measures should be used to evaluate their performance. Objective To evaluate OPO performance metrics using combined mortality and donation data and quantify the associations of population demographics with donation metrics. Design, Setting, and Participants This national cohort study includes data from the US organ transplantation system from January 2008 through December 2017. All individuals who died within the US, as reported by the National Death index, were included. Exposures Death, organ donation, and donation eligibility. Main Outcomes and Measures Evaluation of the variation in donation metrics and the use of ineligible donors by OPO and demographic subgroup. Results This study included 17 501 742 deaths and 75 769 deceased organ donors (45 040 men [59.4%]; 51 908 White individuals [68.5%]). Of these donors, 15 857 (20.9%) were not eligible, as defined by the OPOs. The median donation metrics by OPO were 0.004 (range, 0.002-0.012) donors per death, 0.89 (range, 0.68-1.30) donors per eligible death, and 0.72 (range, 0.57-0.86) eligible donors per eligible death. The OPOs in the upper quartile of the overall eligible donors per eligible death metric were in the upper quartile of annual rankings on 90 of 140 occasions (64.3%). There was little overlap in top-performing OPOs between metrics; an OPO in the upper quartile for 1 metric was also in the upper quartile for the other metrics on 37 of 570 occasions (6.5% of the time). The median donor eligibility rate, defined as the number of eligible donors per donor, was 0.79 (range, 0.61-0.95) across OPOs. Age (eg, 65 to 84 years, coefficient, -0.55 [SE, 0.03]; P < .001; vs those aged 18 to 34 years), sex (male individuals, -0.09 [SE, 0.02]; P < .001; vs female individuals), race (eg, Black individuals, 0.35 [SE, 0.02]; P < .001; vs White individuals), cause of death (eg, central nervous system tumor, 0.48 [SE, 0.08]; P < .001; vs anoxia), year (eg, 2016-2017: -0.10 [SE, 0.03]; P < .001; vs 2008-2009), and OPO were associated with the use of ineligible donors; OPO was a significant factor associated with performance in all metrics (χ256, 500.5; P < .001; coefficient range across individual OPOs, -0.15 [SE, 0.09] to 0.75 [SE, 0.09]), even after accounting for population differences. Female and non-White individuals were significantly less likely to be used as ineligible donors. Conclusions and Relevance We demonstrate significant variability in OPO performance rankings, depending on which donation metric is used. There were significant differences in OPO performance, even after accounting for differences in potential donor populations. Our data suggest significant variation in use of ineligible donors among OPOs, a source for increased donors. The performance of OPOs should be evaluated using a range of donation metrics.
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Affiliation(s)
- Luke J DeRoos
- Industrial and Operations Engineering, University of Michigan, Ann Arbor
| | - Yuhang Zhou
- Electrical Engineering and Computer Science, University of Michigan, Ann Arbor
| | - Wesley J Marrero
- Industrial and Operations Engineering, University of Michigan, Ann Arbor
| | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor
| | - Christopher J Sonnenday
- Department of Surgery, University of Michigan, Ann Arbor.,School of Public Health, University of Michigan, Ann Arbor
| | - Mariel S Lavieri
- Industrial and Operations Engineering, University of Michigan, Ann Arbor
| | - David W Hutton
- Industrial and Operations Engineering, University of Michigan, Ann Arbor.,School of Public Health, University of Michigan, Ann Arbor
| | - Neehar D Parikh
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor
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22
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Cron DC, Tincopa MA, Lee JS, Waljee AK, Hammoud A, Brummett CM, Waljee JF, Englesbe MJ, Sonnenday CJ. Prevalence and Patterns of Opioid Use Before and After Liver Transplantation. Transplantation 2021; 105:100-107. [PMID: 32022738 PMCID: PMC7398834 DOI: 10.1097/tp.0000000000003155] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [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] [Indexed: 12/31/2022]
Abstract
BACKGROUND Opioid use in liver transplantation is poorly understood and has potential associated morbidity. METHODS Using a national data set of employer-based insurance claims, we identified 1257 adults who underwent liver transplantation between December 2009 and February 2015. We categorized patients based on their duration of opioid fills over the year before and after transplant admission as opioid-naive/no fills, chronic opioid use (≥120 d supply), and intermittent use (all other use). We calculated risk-adjusted prevalence of peritransplant opioid fills, assessed changes in opioid use after transplant, and identified correlates of persistent or increased opioid use posttransplant. RESULTS Overall, 45% of patients filled ≥1 opioid prescription in the year before transplant (35% intermittent use, 10% chronic). Posttransplant, 61% of patients filled an opioid prescription 0-2 months after discharge, and 21% filled an opioid between 10-12 months after discharge. Among previously opioid-naive patients, 4% developed chronic use posttransplant. Among patients with pretransplant opioid use, 84% remained intermittent or increased to chronic use, and 73% of chronic users remained chronic users after transplant. Pretransplant opioid use (risk factor) and hepatobiliary malignancy (protective) were the only factors independently associated with risk of persistent or increased posttransplant opioid use. CONCLUSIONS Prescription opioid use is common before and after liver transplant, with intermittent and chronic use largely persisting, and a small development of new chronic use posttransplant. To minimize the morbidity of long-term opioid use, it is critical to improve pain management and optimize opioid use before and after liver transplant.
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Affiliation(s)
- David C Cron
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Monica A Tincopa
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Jay S Lee
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Akbar K Waljee
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
- Veteran's Affairs Center for Clinical Management Research, Ann Arbor, MI
| | - Ali Hammoud
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Chad M Brummett
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Division of Pain Research, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI
| | - Jennifer F Waljee
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Michael J Englesbe
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Christopher J Sonnenday
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
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23
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Sharma P, Chen V, Fung CM, Troost JP, Patel VN, Combs M, Norman S, Garg P, Colvin M, Aaronson K, Sonnenday CJ, Golob JL, Somers EC, Doshi MM. COVID-19 Outcomes Among Solid Organ Transplant Recipients: A Case-control Study. Transplantation 2021; 105:128-137. [PMID: 32890139 PMCID: PMC7853506 DOI: 10.1097/tp.0000000000003447] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [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: 02/06/2023]
Abstract
BACKGROUND Solid organ transplant (SOT) recipients are considered to be "vulnerable" to COVID-19 infection due to immunosuppression. To date, there are no studies that compared the disease severity of COVID-19 in SOT recipients with nontransplant patients. METHODS In this case-control study, we compared the outcomes of COVID-19 between SOT recipients and their matched nontransplant controls. The cases were all adult SOT recipients (N = 41) from our academic health center who were diagnosed with COVID-19 between March 10, 2020 and May 15, 2020 using positive reverse transcriptase polymerase chain reaction for SARS-CoV2. The controls (N = 121) were matched on age (±5 y), race, and admission status (hospital or outpatient). The primary outcome was death and secondary outcomes were severe disease, intubation and renal replacement therapy (RRT). RESULTS Median age of SOT recipients (9 heart, 3 lung, 16 kidney, 8 liver, and 5 dual organ) was 60 y, 80% were male and 67% were Black. Severe disease adjusted risk of death was similar in both the groups (hazard ratio = 0.84 [0.32-2.20]). Severity of COVID-19 and intubation were similar, but the RRT use was higher in SOT (odds ratio = 5.32 [1.26, 22.42]) compared to non-SOT COVID-19 patients. Among SOT recipients, COVID-19-related treatment with hydroxychloroquine (HCQ) was associated with 10-fold higher hazard of death compared to without HCQ (hazard ratio = 10.62 [1.24-91.09]). CONCLUSIONS Although African Americans constituted one-tenth of all SOT in our center, they represented two-thirds of COVID-19 cases. Despite high RRT use in SOT recipients, the severe disease and short-term death were similar in both groups. HCQ for the treatment of COVID-19 among SOT recipients was associated with high mortality and therefore, its role as a treatment modality requires further scrutiny.
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Affiliation(s)
- Pratima Sharma
- Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Vincent Chen
- Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Christopher M. Fung
- Department of Emergency Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Jonathan P. Troost
- Michigan Institute for Clinical and Health Research, University of Michigan, Ann Arbor, MI 48109
| | - Vaiibhav N. Patel
- Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Michael Combs
- Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Silas Norman
- Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Puneet Garg
- Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Monica Colvin
- Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Keith Aaronson
- Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Christopher J. Sonnenday
- Department of Surgery, School of Public Health Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Jonathan L. Golob
- Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Emily C. Somers
- Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
- Environmental Health Sciences, School of Public Health Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Mona M. Doshi
- Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
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24
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Kassam AF, Cortez AR, Winer LK, Conzen KD, El-Hinnawi A, Jones CM, Matsuoka L, Watkins AC, Collins KM, Bhati C, Selzner M, Sonnenday CJ, Englesbe MJ, Diwan TS, Dick AAS, Quillin RC. Extinguishing burnout: National analysis of predictors and effects of burnout in abdominal transplant surgery fellows. Am J Transplant 2021; 21:307-313. [PMID: 32463950 DOI: 10.1111/ajt.16075] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [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: 04/07/2020] [Revised: 05/13/2020] [Accepted: 05/15/2020] [Indexed: 01/25/2023]
Abstract
Burnout among surgeons has been attributed to increased workload and decreased autonomy. Although prior studies have examined burnout among transplant surgeons, no studies have evaluated burnout in abdominal transplant surgery fellows. The objective of our study was to identify predictors of burnout and understand its impact on personal and patient care during fellowship. A survey was sent to all abdominal transplant surgery fellows in an American Society of Transplant Surgeons-accredited fellowship. The response rate was 59.2% (n = 77) and 22.7% (n = 17) of fellows met criteria for burnout. Fellows with lower grit scores were more likely to exhibit burnout compared with fellows with higher scores (3.6 vs 4.0, P = .026). Those with burnout were more likely to work >100 hours per week (58.8% vs 27.6%, P = .023), have severe work-related stress (58.8% vs 22.4%, P = .010), consider quitting fellowship (94.1% vs 20.7%, P < .001), or make a medical error (35.3% vs 5.2%, P = .003). This national analysis of abdominal transplant fellows found that burnout rates are relatively low, but few fellows engage in self-care. Personal and program-related factors attribute to burnout and it has unacceptable effects on patient care. Transplant societies and fellowship programs should develop interventions to give fellows tools to prevent and combat burnout.
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Affiliation(s)
- Al-Faraaz Kassam
- Cincinnati Research on Education in Surgical Training (CREST), Cincinnati, Ohio, USA.,Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Alexander R Cortez
- Cincinnati Research on Education in Surgical Training (CREST), Cincinnati, Ohio, USA.,Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Leah K Winer
- Cincinnati Research on Education in Surgical Training (CREST), Cincinnati, Ohio, USA.,Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Kendra D Conzen
- Department of Surgery, University of Colorado, Aurora, Colorado, USA
| | - Ashraf El-Hinnawi
- Department of Surgery, The Ohio State University, Columbus, Ohio, USA
| | | | - Lea Matsuoka
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Anthony C Watkins
- Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Kelly M Collins
- Department of Transplantation and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Chandra Bhati
- Department of Surgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Markus Selzner
- Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | | | | | - Tayyab S Diwan
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - André A S Dick
- Department of Surgery, University of Washington, Seattle, Washington, USA.,Seattle Children's Hospital, Seattle, Washington, USA
| | - Ralph C Quillin
- Cincinnati Research on Education in Surgical Training (CREST), Cincinnati, Ohio, USA.,Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
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25
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Sondhi AR, Sonnenday CJ, Parikh ND, Law R. EUS-guided gastrojejunal anastomosis to facilitate endoscopic retrograde cholangiography in a patient with a right lobe liver transplant and Roux-en-Y anatomy. VideoGIE 2020; 5:473-475. [PMID: 33103001 PMCID: PMC7572321 DOI: 10.1016/j.vgie.2020.05.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Affiliation(s)
- Arjun R Sondhi
- Department of Internal Medicine, Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan
| | - Christopher J Sonnenday
- Department of Surgery, Section of Transplantation, University of Michigan, Ann Arbor, Michigan
| | - Neehar D Parikh
- Department of Internal Medicine, Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan
| | - Ryan Law
- Department of Internal Medicine, Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan
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26
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Santos-Parker KS, Santos-Parker JR, Highet A, Montgomery JR, Wakam GK, Sonnenday CJ, Waits SA. Practice change amidst the COVID-19 pandemic: Harnessing the momentum for expanding telehealth in transplant. Clin Transplant 2020; 34:e13897. [PMID: 32396979 DOI: 10.1111/ctr.13897] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 04/30/2020] [Indexed: 11/27/2022]
Affiliation(s)
| | | | | | - John Richard Montgomery
- Section of Transplantation, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Glenn Kham Wakam
- Section of Transplantation, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Christopher J Sonnenday
- Section of Transplantation, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Seth A Waits
- Section of Transplantation, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
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27
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Sheetz KH, Nuliyalu U, Nathan H, Sonnenday CJ. Association of Surgeon Case Numbers of Pancreaticoduodenectomies vs Related Procedures With Patient Outcomes to Inform Volume-Based Credentialing. JAMA Netw Open 2020; 3:e203850. [PMID: 32347950 PMCID: PMC7191322 DOI: 10.1001/jamanetworkopen.2020.3850] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Despite growing interest from various surgical societies and patient safety organizations, concerns remain that volume-based credentialing standards are arbitrary and may fail to recognize a surgeon's full scope of practice. OBJECTIVE To evaluate whether surgeon experience with related procedures was associated with better outcomes for pancreaticoduodenectomy compared with procedure-specific experience alone. DESIGN, SETTING, AND PARTICIPANTS This proof-of-concept cohort study used the all-payer State Inpatient Databases from 6 geographically diverse states to identify all operations for surgeons who performed at least 1 pancreaticoduodenectomy from January 1, 2012, to December 31, 2014. Each surgeon's mean annual volume for pancreaticoduodenectomies and related complex hepatopancreatobiliary (HPB) procedures was calculated. Outcomes for surgeons above and below a threshold of 12 pancreaticoduodenectomies per year were evaluated. Whether related HPB procedure volume was also associated with better outcomes for surgeons not meeting the procedure-specific threshold was also evaluated. Data were analyzed from March 2 through 20, 2019. MAIN OUTCOMES AND MEASURES Thirty-day mortality and complications. RESULTS The study cohort included 176 043 patients, of whom 92 064 were female (52.3%), with a mean (SD) age of 59 (17) years. Within 270 hospitals, only 54 of 1028 surgeons (5.3%) met the mean pancreaticoduodenectomy volume threshold from 2012 to 2014. In-hospital mortality after pancreaticoduodenectomy was lower for surgeons who performed 12 or more procedures per year (1.8% [95% CI, 1.1%- 2.4%] vs 4.7% [95% CI, 4.0%-5.4%]; odds ratio, 0.32; 95% CI, 0.21-0.50). However, in-hospital mortality varied 7-fold among surgeons who did not meet the threshold (1.2% [95% CI, 0.8%-1.6%] to 8.4% [95% CI, 7.9%-8.9%]). Increasing HPB case volume was associated with better outcomes for pancreaticoduodenectomy in this group. For example, surgeons performing 2 or fewer pancreaticoduodenectomies annually would need to perform an additional 27 related HPB procedures to match the in-hospital mortality rate of surgeons performing 12 or more pancreaticoduodenectomies. CONCLUSIONS AND RELEVANCE In this proof-of-concept cohort study, few surgeons met even modest annual volume thresholds for pancreaticoduodenectomy. The findings suggest that inclusion of related procedure volumes may safely expand the cohort of surgeons credentialed to perform certain procedures under volume-based standards.
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Affiliation(s)
- Kyle H. Sheetz
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, School of Medicine, University of Michigan, Ann Arbor
| | - Usha Nuliyalu
- Center for Healthcare Outcomes and Policy, School of Medicine, University of Michigan, Ann Arbor
| | - Hari Nathan
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, School of Medicine, University of Michigan, Ann Arbor
| | - Christopher J. Sonnenday
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, School of Medicine, University of Michigan, Ann Arbor
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28
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Kumar SS, Pelletier SJ, Shanks A, Thompson A, Sonnenday CJ, Picton P. Intraoperative glycemic control in patients undergoing Orthotopic liver transplant: a single center prospective randomized study. BMC Anesthesiol 2020; 20:3. [PMID: 31901245 PMCID: PMC6942664 DOI: 10.1186/s12871-019-0918-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Accepted: 12/23/2019] [Indexed: 01/04/2023] Open
Abstract
Background Perioperative hyperglycemia is associated with poor outcomes yet evidence to guide intraoperative goals and treatment modalities during non-cardiac surgery are lacking. End-stage liver disease is associated with altered glucose homeostasis; patients undergoing liver transplantation display huge fluctuations in blood glucose (BG) and represent a population of great interest. Here, we conduct a randomized trial to compare the effects of strict versus conventional glycemic control during orthotopic liver transplant (OLT). Methods Following approval by the Institutional Review Board of the University of Michigan Medical School and informed consent, 100 adult patients undergoing OLT were recruited. Patients were randomized to either strict (target BG 80–120 mg/dL) or conventional (target BG 180–200 mg/dL) BG control with block randomization for diabetic and nondiabetic patients. The primary outcomes measured were 1-year patient and graft survival assessed on an intention to treat basis. Graft survival is defined as death or needing re-transplant (www.unos.org). Three and 5-year patient and graft survival, infectious and biliary complications were measured as secondary outcomes. Data were examined using univariate methods and Kaplan-Meir survival analysis. A sensitivity analysis was performed to compare patients with a mean BG of ≤120 mg/dL and those > 120 mg/dL regardless of treatment group. Results There was no statistically significant difference in patient survival between conventional and strict control respectively;1 year, 88% vs 88% (p-0.99), 3 years, 86% vs 84% (p- 0.77), 5 years, 82% vs 78. % (p-0.36). Graft survival was not different between conventional and strict control groups at 1 year, 88% vs 84% (p-0.56), 3 years 82% vs 76% (p-0.46), 5 years 78% vs 70% (p-0.362). Conclusion There was no difference in patient or graft survival between intraoperative strict and conventional glycemic control during OLT. Trial registration Clinical trial number and registry: www.clinicaltrials.gov NCT00780026. This trial was retrospectively registered on 10/22/2008.
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Affiliation(s)
- Sathish S Kumar
- Department of Anesthesiology, Michigan Medicine, 1H247 UH, 1500 East Medical Center Drive, SPC 5048, Ann Arbor, MI, 48109-5048, USA.
| | - Shawn J Pelletier
- University of Virginia, 1215 Lee st, Charlottesville, VA, 22908, USA
| | - Amy Shanks
- Department of Anesthesiology, Michigan Medicine, 1H247 UH, 1500 East Medical Center Drive, SPC 5048, Ann Arbor, MI, 48109-5048, USA
| | - Aleda Thompson
- Department of Anesthesiology, Michigan Medicine, 1H247 UH, 1500 East Medical Center Drive, SPC 5048, Ann Arbor, MI, 48109-5048, USA
| | | | - Paul Picton
- Department of Anesthesiology, Michigan Medicine, 1H247 UH, 1500 East Medical Center Drive, SPC 5048, Ann Arbor, MI, 48109-5048, USA
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29
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Tran NH, Sahai V, Griffith KA, Nathan H, Kaza R, Cuneo KC, Shi J, Kim E, Sonnenday CJ, Cho CS, Lawrence TS, Zalupski MM. Phase 2 Trial of Neoadjuvant FOLFIRINOX and Intensity Modulated Radiation Therapy Concurrent With Fixed-Dose Rate-Gemcitabine in Patients With Borderline Resectable Pancreatic Cancer. Int J Radiat Oncol Biol Phys 2020; 106:124-133. [PMID: 31494181 PMCID: PMC7245020 DOI: 10.1016/j.ijrobp.2019.08.057] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [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: 02/26/2019] [Revised: 08/11/2019] [Accepted: 08/26/2019] [Indexed: 01/05/2023]
Abstract
PURPOSE Preoperative therapy in borderline resectable pancreatic cancer (BRPC) is intended to increase R0 resection rates. An optimal approach in BRPC is yet to be defined. METHODS AND MATERIALS Patients with BRPC, confirmed adenocarcinoma, performance status ≤1, and adequate organ function enrolled in a single-institution, phase 2 trial. Patients received FOLFIRINOX × 6 cycles, then radiation therapy (50 Gy in 25 fractions) concurrent with fixed-dose rate gemcitabine (1 g/m2 over 100 minutes) followed by 2 additional gemcitabine infusions. Computed tomography scans were performed at 2-month intervals during treatment. Patients without distant disease were offered surgical exploration. The primary objective was R0 resection rate with an alternate hypothesis of 55%. Secondary objectives included median progression-free survival (PFS), median overall survival (OS), response rate, and safety. The trial registration number is NCT01661088. RESULTS Twenty-five patients with median age of 60 years (range, 47-77 years) enrolled from November 2011 through January 2017. Twenty-one (84%) completed FOLFIRINOX and 19 (76%) completed all protocol therapy. Treatment-related grade 3 to 4 toxicities included neutropenia (40%), nausea and vomiting (28%), diarrhea (16%), and fatigue (12%). Eighteen patients (72%) underwent laparotomy, 13 (52%) were resected (all R0). The median PFS and OS in 25 patients were 13.1 months (95% confidence interval [CI], 7.3-24.7) and 24.4 months (95% CI, 12.6-40.0), respectively. For resected patients, median PFS was 21.6 months (95% CI, 8.2-37.1) and OS was 37.1 months (95% CI, 15.4-not reached). CONCLUSIONS Neoadjuvant therapy with FOLFIRINOX, followed by intensity modulated radiation therapy concurrent with fixed-dose-rate gemcitabine in BRPC is feasible and tolerated. Although the alternate hypothesis was not met, the OS of the resected cohort was favorable.
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Affiliation(s)
| | | | | | | | - Ravi Kaza
- University of Michigan, Ann Arbor, Michigan
| | | | - Jiaqi Shi
- University of Michigan, Ann Arbor, Michigan
| | - Edward Kim
- Work completed at University of Michigan. Currently at University of California, Davis, California
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30
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Patel A, Sonnenday CJ, Schulman AR. Recurrent extrahepatic cholangiocarcinoma after bile duct resection for intraductal papillary mucinous neoplasm of the bile duct. VideoGIE 2019; 4:519-521. [PMID: 31709347 PMCID: PMC6835014 DOI: 10.1016/j.vgie.2019.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Arpan Patel
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Allison R Schulman
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
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31
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DeRoos LJ, Marrero WJ, Tapper EB, Sonnenday CJ, Lavieri MS, Hutton DW, Parikh ND. Estimated Association Between Organ Availability and Presumed Consent in Solid Organ Transplant. JAMA Netw Open 2019; 2:e1912431. [PMID: 31577360 PMCID: PMC6777259 DOI: 10.1001/jamanetworkopen.2019.12431] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Presumed consent, or an opt-out organ transplant policy, has been adopted by many countries worldwide to increase organ donation. The implication of such a policy for transplants in the United States is uncertain, however. OBJECTIVE To simulate the potential implications of a presumed consent policy in the United States. DESIGN, SETTING, AND PARTICIPANTS In a decision analytical model, a simulation model was developed using cohort data from January 1, 2004, to December 31, 2014, in the Organ Procurement and Transplantation Network Standard Transplant Analysis and Research files. All US patients (n = 524 359) who were on the waiting list for at least 1 solid organ and all deceased organ donors during the study period were included in the analyses. All data and statistical analyses were performed from January 30, 2019, to July 31, 2019. MAIN OUTCOMES AND MEASURES Increase in the organs available for donation and life-years gained associated with a 5%, 15%, or 25% increase in deceased donors, based on the published changes from a presumed consent policy. RESULTS This study considered 524 359 unique candidates (aged ≥18 years; 320 908 [61.2%] male) for a solid organ transplant from January 1, 2004, to December 31, 2014. With a base case scenario of a 5% presumed consent-associated increase in donors, the removals (owing to death or illness) from the waiting list for all organs would have an associated 3.2% to 10.4% mean reduction, depending on the random or ideal allocation of new organs to patients on the waiting list. Sensitivity analyses showed that waiting list removals could be decreased up to 52%; however, this reduction was not enough to completely eliminate waiting list removals during the study period. The biggest estimated increases in annual life-years gained associated with a presumed consent policy were in kidney transplant candidates (95% CIs by deceased donor increase: 5% increase, 3440-3466 years; 15% increase, 10 321-10 399 years; 25% increase, 17 201-17 332 years) and liver transplant candidates (95% CIs by deceased donor increase: 5% increase, 898-905 years; 15% increase, 2693-2714 years; 25% increase, 4448-4523 years). Adoption of a presumed consent policy could result in a 4295-year (95% CI, 4277-4313 years) to 11 387-year (95% CI, 11 339-11 435 years) increase in life-years, accounting for the survival advantages associated with a transplant. CONCLUSIONS AND RELEVANCE In this study, presumed consent was estimated to be associated with modest but important improvement in the number of organ transplants and increases in life-years gained for patients awaiting an organ transplant. Further consideration and even debate about the ethical and public policy implications of a presumed consent policy are warranted.
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Affiliation(s)
- Luke J. DeRoos
- Industrial and Operations Engineering, University of Michigan, Ann Arbor
| | - Wesley J. Marrero
- Industrial and Operations Engineering, University of Michigan, Ann Arbor
| | - Elliot B. Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor
| | | | - Mariel S. Lavieri
- Industrial and Operations Engineering, University of Michigan, Ann Arbor
| | - David W. Hutton
- Industrial and Operations Engineering, University of Michigan, Ann Arbor
- School of Public Health, University of Michigan, Ann Arbor
| | - Neehar D. Parikh
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor
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32
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Sheetz KH, Nuliyalu U, Nathan H, Sonnenday CJ. Use of Comprehensive Practice Experience to Improve Surgeon-Specific Credentialing Standards. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.411] [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: 10/25/2022]
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Sharma P, Sun Y, Neal J, Erley J, Shen J, Tischer S, Sonnenday CJ, Park JM. Renal Outcomes of Liver Transplantation Recipients Receiving Standard Immunosuppression and Early Renal Sparing Immunosuppression: A Retrospective Single Center Study. Transplant Direct 2019; 5:e480. [PMID: 31579808 PMCID: PMC6739043 DOI: 10.1097/txd.0000000000000917] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 05/24/2019] [Accepted: 06/03/2019] [Indexed: 12/26/2022] Open
Abstract
New-onset stage 4-5 chronic kidney disease (CKD) after liver transplantation (LT) is associated with high morbidity, mortality, and economic burden. In 2010, we instituted an early renal sparing immunosuppression (RSI) protocol for LT recipients with severe renal dysfunction (pre-LT dialysis/estimated glomerular filtration rate (eGFR)<30mL/min/1.73 m2 or post-LT acute kidney injury) consisting of 2 doses of basiliximab for induction and delaying tacrolimus to post-LT day 4-7. We examined the effect of early RSI on post-LT renal outcomes. METHODS Data on all adults who had LT between January 1, 2010, and December 12, 2014 were collected. We calculated the renal risk index (RRI) score for each LT recipient (https://rri.med.umich.edu). Primary outcome was new-onset post-LT stage 4-5 CKD. RESULTS Of 214 LT recipients, 121 (57%) received early RSI and 93 (43%) received standard immunosuppression. Cumulative incidence of new-onset stage 4-5 CKD was higher in early RSI compared with standard immunosuppression (P = 0.03). Female sex and RRI score were the significant risk factors for development of post-LT stage CKD in the entire study cohort as well as the LT recipients with RRI ≥ sixth decile (high-risk group). CONCLUSIONS Delaying tacrolimus initiation combined with basiliximab induction did not have a durable effect on long-term renal outcomes in high-risk LT recipients. Further studies are needed to identify the effective strategies to preserve renal function by targeting patients at high risk for CKD progression.
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Affiliation(s)
- Pratima Sharma
- Division of Gastroenterology and Hepatology, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Yihan Sun
- College of Pharmacy, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Joslyn Neal
- College of Pharmacy, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Jennifer Erley
- College of Pharmacy, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - James Shen
- College of Pharmacy, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Sarah Tischer
- College of Pharmacy, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Christopher J. Sonnenday
- Department of Surgery, Section of Transplantation, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Jeong M. Park
- College of Pharmacy, Michigan Medicine, University of Michigan, Ann Arbor, MI
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Likhitsup A, Hassan A, Mellinger J, Askari F, Winder GS, Saeed N, Sonnenday CJ, Sharma P, Fontana RJ. Impact of a Prohibitive Versus Restrictive Tobacco Policy on Liver Transplant Candidate Outcomes. Liver Transpl 2019; 25:1165-1176. [PMID: 31116906 DOI: 10.1002/lt.25497] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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: 01/10/2019] [Accepted: 04/23/2019] [Indexed: 02/07/2023]
Abstract
Tobacco use has been associated with poorer outcomes after liver transplantation (LT). Our study examined the effect on LT listing outcomes of a newly implemented policy prohibiting the use of all tobacco products compared with a prior restrictive policy. Medical records of consecutive adult patients evaluated for LT from January 2010 to July 2013 (era 1, n = 1344) and August 2013 to March 2017 (era 2, n = 1350) were reviewed. The proportion of LT candidates listed was the primary outcome. The mean age of the 2694 LT candidates was 54 ± 11 years, 60% were male, and the mean Model for End-Stage Liver Disease (MELD) score was 15 ± 7. Although the proportion of LT candidates who were smokers was significantly higher in era 2 (33% versus 23%; P < 0.005), the proportion of smokers listed for LT remained stable (13% versus 17%; P = 0.25). However, there were more smokers excluded for ongoing tobacco use in era 2 compared with era 1 (9.6% versus 4.4%; P = 0.001). Factors independently associated with LT listing included a diagnosis of hepatocellular carcinoma, being married, private insurance, absence of psychiatry comorbidity, and absence of tobacco, marijuana, or opiate use but evaluation during era 2 was not associated with LT listing. However, the median time to listing significantly increased over time, especially in smokers (from 65 to 122 days; P = 0.001), and this trend was independently associated with evaluation during era 2, a lower MELD score, not having children, and a lower level of education (P < 0.05). In conclusion, despite an increasing incidence of active smokers being referred for LT evaluation, the proportion of smoker candidates listed for LT was unchanged after instituting our prohibitive tobacco use policy. However, the time to get on the waiting list for smokers who were eventually listed was significantly longer due to the need to achieve complete tobacco cessation.
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Affiliation(s)
- Alisa Likhitsup
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - Ammar Hassan
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - Jessica Mellinger
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - Frederick Askari
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - Gerald S Winder
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
| | - Naba Saeed
- Department of Internal Medicine, Beaumont Hospital, Dearborn, MI
| | | | - Pratima Sharma
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - Robert J Fontana
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
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35
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Leek RB, Park JM, Koerschner C, Mawby J, Sonnenday CJ, Wright Nunes JA, Sharma P. Novel educational and goal-setting tool to improve knowledge of chronic kidney disease among liver transplant recipients: A pilot study. PLoS One 2019; 14:e0219856. [PMID: 31344043 PMCID: PMC6658055 DOI: 10.1371/journal.pone.0219856] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 07/02/2019] [Indexed: 11/25/2022] Open
Abstract
Introduction Liver transplant (LT) recipients have limited understanding of post-transplant chronic kidney disease (CKD) despite an excellent pre-existing framework of transplant care. This pilot study examined the efficacy and feasibility of a tailored educational and goal-setting tool in improving CKD knowledge among LT recipients with early-stage CKD. Methods In this prospective cohort study, we administered the CKD educational and goal-setting tool to 81 LT recipients between 7/1/2016 and 12/31/2017. We excluded patients with simultaneous liver-kidney transplantation, eGFR<30 ml/min, non-English speaking, on hemodialysis or listed for kidney transplantation. The pre- and post-education knowledge scores were compared using a paired t-test. Linear regression was used to assess the independent predictors of change in knowledge score. Results Mean age was 56.3 years, 69.1% were males, 85.2% were Caucasians and mean eGFR was 61.2 ± 20.0 ml/min. The CKD educational and goal-setting tool improved the CKD knowledge scores among LT recipients (pre: 71.8 ± 16.6%, post: 83.3 ± 10.4%; p<0.001). In an adjusted model (r2 = 0.75), those with lower pre-education knowledge scores had the most improvement in their post-education knowledge scores (β = -83.2; p<0.001). Two-thirds stated their most important self-management goal and reported motivation to follow this goal. Time spent for the CKD education was approximately 15 minutes. Conclusions A simple LT-specific patient educational and goal-setting tool effectively improved CKD knowledge. Implementation of this tailored intervention will improve CKD awareness and may promote goal-setting in the target population.
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Affiliation(s)
- Rachael B. Leek
- Department of Pharmacy and College of Pharmacy, Michigan Medicine, University of Michigan Ann Arbor, Michigan, United States of America
| | - Jeong M. Park
- Department of Pharmacy and College of Pharmacy, Michigan Medicine, University of Michigan Ann Arbor, Michigan, United States of America
| | - Claire Koerschner
- Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Jennifer Mawby
- Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Christopher J. Sonnenday
- Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Julie A. Wright Nunes
- Division of Nephrology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Pratima Sharma
- Division of Gastroenterology and Hepatology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, United States of America
- * E-mail:
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36
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Lai JC, Sonnenday CJ, Tapper EB, Duarte-Rojo A, Dunn MA, Bernal W, Carey EJ, Dasarathy S, Kamath BM, Kappus MR, Montano-Loza AJ, Nagai S, Tandon P. Frailty in liver transplantation: An expert opinion statement from the American Society of Transplantation Liver and Intestinal Community of Practice. Am J Transplant 2019; 19:1896-1906. [PMID: 30980701 PMCID: PMC6814290 DOI: 10.1111/ajt.15392] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 03/18/2019] [Accepted: 03/28/2019] [Indexed: 01/25/2023]
Abstract
Frailty has emerged as a powerful predictor of outcomes in patients with cirrhosis and has inevitably made its way into decision making within liver transplantation. In an effort to harmonize integration of the concept of frailty among transplant centers, the AST and ASTS supported the efforts of our working group to develop this statement from experts in the field. Frailty is a multidimensional construct that represents the end-manifestation of derangements of multiple physiologic systems leading to decreased physiologic reserve and increased vulnerability to health stressors. In hepatology/liver transplantation, investigation of frailty has largely focused on physical frailty, which subsumes the concepts of functional performance, functional capacity, and disability. There was consensus that every liver transplant candidate should be assessed at baseline and longitudinally using a standardized frailty tool, which should guide the intensity and type of nutritional and physical therapy in individual liver transplant candidates. The working group agreed that frailty should not be used as the sole criterion for delisting a patient for liver transplantation, but rather should be considered one of many criteria when evaluating transplant candidacy and suitability. A road map to advance frailty in the clinical and research settings of liver transplantation is presented here.
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Affiliation(s)
- Jennifer C. Lai
- Division of Gastroenterology and Hepatology, University of California-San Francisco, San Francisco, California
| | | | - Elliot B. Tapper
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan
| | - Andres Duarte-Rojo
- Division of Gastroenterology & Hepatology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Michael A. Dunn
- Center for Liver Diseases, Thomas E. Starzl Transplantation Institute, and Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - William Bernal
- Institute of Liver Studies, Kings College Hospital, London, UK
| | - Elizabeth J. Carey
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona
| | | | - Binita M. Kamath
- Division of Gastroenterology, Hepatology, and Nutrition, University of Toronto, Toronto, Canada
| | - Matthew R. Kappus
- Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina
| | - Aldo J. Montano-Loza
- Division of Gastroenterology & Liver Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Shunji Nagai
- Division of Transplant Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Puneeta Tandon
- Cirrhosis Care Clinic, Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
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37
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Barrett M, Holt K, Haley A, Leininger L, Sonnenday CJ, Sandhu G, Gauger PG. Needs assessment can guide creation of a "resident-optimized clinic" in surgery. Am J Surg 2019; 218:648-652. [PMID: 30826007 DOI: 10.1016/j.amjsurg.2019.02.005] [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: 11/03/2018] [Revised: 01/21/2019] [Accepted: 02/02/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND There is limited data on deliberate teaching of residents in the clinic setting; we sought to investigate the clinic experience at our institution and improve education through creation of a novel "Resident-Optimized Clinic" (ROC). METHODS An online survey was sent separately to residents and faculty. Based on the results of this survey a modified ROC was developed to try to improve the obstacles to learning in clinic. RESULTS Qualitative analysis revealed the barriers in clinic were inconsistencies in expectations, lack of autonomy, time, and facility limitations. The modified ROC was rated positively with 100% of participants expressing they had sufficient time and autonomy; and 90% felt the environment was optimized for teaching. CONCLUSIONS Multiple themes have been identified as problematic for the clinic education experience. The ROC was rated positively by trainees suggesting thoughtful intervention to improve clinic results in a better clinic experience and more educational gain from the clinic environment.
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Affiliation(s)
- M Barrett
- Department of Surgery, Ann Arbor, MI, 48109, USA.
| | - K Holt
- Department of Surgery, Ann Arbor, MI, 48109, USA.
| | - A Haley
- Department of Surgery, Ann Arbor, MI, 48109, USA.
| | - L Leininger
- Department of Surgery, Ann Arbor, MI, 48109, USA.
| | | | - G Sandhu
- Department of Surgery, Ann Arbor, MI, 48109, USA; Department of Learning Health Sciences, Ann Arbor, MI, 48109, USA.
| | - P G Gauger
- Department of Surgery, Ann Arbor, MI, 48109, USA.
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38
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Kamarajah SK, Sonnenday CJ, Cho CS, Frankel TL, Bednar F, Nathan H. Association of Adjuvant Radiotherapy with Survival after Margin-Negative (R0) Resection of Pancreatic Ductal Adenocarcinoma: A Propensity Score-Matched National Cancer Database Analysis. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.07.360] [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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39
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Tapper EB, Konerman M, Murphy S, Sonnenday CJ. Hepatic encephalopathy impacts the predictive value of the Fried Frailty Index. Am J Transplant 2018; 18:2566-2570. [PMID: 30019835 PMCID: PMC6166663 DOI: 10.1111/ajt.15020] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [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: 03/25/2018] [Revised: 06/10/2018] [Accepted: 06/28/2018] [Indexed: 01/25/2023]
Abstract
Frailty is increasingly recognized as a predictor of poor outcomes in solid organ transplantation. The most widely utilized frailty tool, the Fried Frailty Index (FFI), includes patient-reported exhaustion, weight loss, and physical activity as well as measured walk speed and handgrip. Although hepatic encephalopathy (HE) is common among liver transplant candidates, data are lacking regarding its impact on the interpretation of frailty. We prospectively enrolled 685 patients with cirrhosis during their transplant evaluation, following them until death or transplantation. Our cohort was aged 54.5 ± 10.3 years, 60% male, with an average MELD score of 14.7 ± 6.3. A history of HE was present in 39%. Frailty was present in 41%, associated with higher MELD, low albumin, ascites, and HE. HE was associated with frail performance on three components of the FFI-grip (odds ratio 1.41 95% CI, 1.03-1.92), walk speed (1.56 95% CI, 1.14-2.15), and decreased energy (1.44 95% CI, 1.05-1.99). These three components were associated with transplant free survival in the whole cohort: energy (hazard ratio 1.67 95% CI, 1.25-2.28), grip (1.63 95% CI, 1.24-2.16), and walk speed (1.56 95% CI, 1.19-2.04). However, among patients with HE, the FFI was not associated with survival. HE plays a critical role in the frailty phenotype and the implications of frailty among patients with cirrhosis evaluated for liver transplantation.
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Affiliation(s)
- Elliot B. Tapper
- Division of Gastroenterology and Hepatology, University of
Michigan
- Gastroenterology Section, VA Ann Arbor Healthcare System,
Ann Arbor
| | - Monica Konerman
- Division of Gastroenterology and Hepatology, University of
Michigan
| | - Susan Murphy
- Department of Physical Medicine and Rehabilitation,
University of Michigan
- VA Ann Arbor Healthcare System, GRECC
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40
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Park JM, Koerschner C, Mawby J, Selman S, Kwon HK, Sonnenday CJ, Wright Nunes JA, Sharma P. Knowledge of Chronic Kidney Disease Among Liver Transplant Recipients. Liver Transpl 2018; 24:1288-1292. [PMID: 30080951 DOI: 10.1002/lt.25302] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 06/21/2018] [Indexed: 02/07/2023]
Affiliation(s)
- Jeong M Park
- College of Pharmacy, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Claire Koerschner
- Division of Transplantation Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Jennifer Mawby
- Division of Transplantation Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Sara Selman
- College of Pharmacy, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Hellan K Kwon
- Division of Gastroenterology and Hepatology, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Christopher J Sonnenday
- Division of Transplantation Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Julie A Wright Nunes
- Division of Nephrology, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Pratima Sharma
- Division of Gastroenterology and Hepatology, Michigan Medicine, University of Michigan, Ann Arbor, MI
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41
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Tran NH, Sahai V, Griffith KA, Nathan H, Kaza R, Cuneo KC, Sonnenday CJ, Cho C, Lawrence TS, Zalupski M. Neoadjuvant FOLFIRINOX and IMRT concurrent with FDR-gemcitabine in patients with borderline resectable pancreatic cancer (BRPC). J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.4_suppl.381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
381 Background: Preoperative therapy in BRPC is intended to increase the likelihood of R0 resection although an optimal regimen is yet to be defined. Methods: Patients (pts) with BRPC (NCCNv.2.2010 guidelines) and ECOG PS 0-1 were enrolled in a single-institution, phase II trial (NCT01661088). Pts received FOLFIRINOX x 6, followed by IMRT (50 Gy in 25 fractions) concurrent with FDR-gemcitabine 1 g/m2 on days 1, 8, 22, 29. Two additional FDR-gemcitabine infusions completed pre-operative treatment. Pancreatic protocol CT scans (dual phase, 0.65 mm slices) were performed after 4 infusions of FOLFIRINOX, 3 weeks after IMRT, and at treatment completion. Pts without distant disease were offered surgical exploration. The primary objective was to determine R0 resection rate. Secondary objectives included progression free survival (PFS), overall survival (OS), response rate and safety. Results: A total of 25 pts (64% men) median age 60 years (range 47-77) were enrolled from 11/2011 through 01/2017. Twenty-one (84%) pts completed FOLFIRINOX and 19 (76%) all protocol therapy. Treatment-related grade 3-4 adverse events ( > 10%) included neutropenia (40%), nausea/vomiting (28%), diarrhea (16%) and fatigue (12%). One early death and 1 discontinuation due to toxicity occurred during FOLFIRINOX. Response to pre-op therapy included 11 PR, 9 SD, 3 PD and 2 NE. Of 25 treated pts, 18 (72%) had laparotomy and 13 (52%) underwent resection (all R0). The median PFS and OS were 18.1 (95% CI, 10.6 to 25.1) and 24.2 (95% CI, 12.6 to 40.0) months, respectively. The median OS for R0 resected pts was 37.1 (95% CI, 15.4 – not reached) months. Conclusions: Neoadjuvant therapy with FOLFIRINOX, followed by IMRT with concurrent FDR-gemcitabine in BRPC is feasible and tolerated. While R0 resection rate was not obviously improved, OS of the entire cohort and especially in R0 resected pts was favorable. Clinical trial information: NCT01661088.
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Affiliation(s)
| | | | | | | | - Ravi Kaza
- University of Michigan, Ann Arbor, MI
| | | | | | | | | | - Mark Zalupski
- University of Massachusetts Memorial Medical Center, Ann Arbor, MI
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42
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Sharma P, Parikh ND, Yu J, Barman P, Derstine BA, Sonnenday CJ, Wang SC, Su GL. Bone mineral density predicts posttransplant survival among hepatocellular carcinoma liver transplant recipients. Liver Transpl 2016; 22:1092-8. [PMID: 27064263 PMCID: PMC4961525 DOI: 10.1002/lt.24458] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [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: 11/30/2015] [Revised: 03/18/2016] [Accepted: 03/21/2016] [Indexed: 01/07/2023]
Abstract
Hepatocellular carcinoma (HCC) is a common indication for liver transplantation (LT). Recent data suggest that body composition features strongly affect post-LT mortality. We examined the impact of body composition on post-LT mortality in patients with HCC. Data on adult LT recipients who received Model for End-Stage Liver Disease exception for HCC between February 29, 2002, and December 31, 2013, and who had a computed tomography (CT) scan any time 6 months prior to LT were reviewed (n = 118). All available CT scan Digital Imaging and Communication in Medicine files were analyzed using a semiautomated high throughput methodology with algorithms programmed in MATLAB. Analytic morphomics measurements including dorsal muscle group (DMG) area, visceral and subcutaneous fat, and bone mineral density (BMD) were taken at the bottom of the eleventh thoracic vertebral level. Thirty-two (27%) patients died during the median follow-up of 4.4 years. The number of HCC lesions (hazard ratio [HR], 2.81; P < 0.001), BMD (HR = 0.90/Hounsfield units [HU]; P = 0.03), pre-LT locoregional therapy (HR = 0.14; P < 0.001), and donor age (HR = 1.05; P < 0.001) were the independent predictors of post-LT mortality. DMG area did not affect post-LT survival. In conclusion, in addition to number of HCC lesions and pre-LT locoregional therapy, low BMD, a surrogate for bone loss rather than DMG area, was independently associated with post-LT mortality in HCC patients. Bone loss may be an early marker of deconditioning that precedes sarcopenia and may affect transplant outcomes. Liver Transplantation 22 1092-1098 2016 AASLD.
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Affiliation(s)
- Pratima Sharma
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Neehar D Parikh
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI,Gastroenterology, Veteran Affairs Ann Arbor Healthcare System, Ann Arbor, MI
| | | | | | - Brian A Derstine
- Morphomics Analysis Group, University of Michigan, Ann Arbor, MI
| | | | - Stewart C Wang
- Department of Surgery, University of Michigan, Ann Arbor, MI,Morphomics Analysis Group, University of Michigan, Ann Arbor, MI
| | - Grace L Su
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI,Morphomics Analysis Group, University of Michigan, Ann Arbor, MI,Gastroenterology, Veteran Affairs Ann Arbor Healthcare System, Ann Arbor, MI
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43
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Cron DC, Friedman JF, Winder GS, Thelen AE, Derck JE, Fakhoury JW, Gerebics AD, Englesbe MJ, Sonnenday CJ. Depression and Frailty in Patients With End-Stage Liver Disease Referred for Transplant Evaluation. Am J Transplant 2016; 16:1805-11. [PMID: 26613640 DOI: 10.1111/ajt.13639] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 11/19/2015] [Accepted: 11/22/2015] [Indexed: 02/06/2023]
Abstract
End-stage liver disease (ESLD) patients are believed to have a high prevalence of depression, although mental health in ESLD has not been studied comprehensively. Further, the relationship between depression and severity of liver disease is unclear. Using baseline data from a large prospective cohort study (N = 500) of frailty in ESLD patients, we studied the association of frailty with depression. Frailty was assessed with the five-component Fried Frailty Index. Patients were assigned a composite score of 0 to 5, with scores ≥3 considered frail. Depression was assessed using the 15-question Geriatric Depression Scale, with a threshold of ≥6 indicating depression; 43.2% of patients were frail and 39.4% of patients were depressed (median score 4, range 0-15). In multivariate analysis, frailty was significantly associated with depression (odds ratio 2.78, 95% confidence interval 1.87-4.15, p < 0.001), whereas model for ESLD score was not associated with depression. After covariate adjustment, depression prevalence was 3.6 times higher in the most-frail patients than the least-frail patients. In conclusion, depression is common in ESLD patients and is strongly associated with frailty but not with severity of liver disease. Transplant centers should address mental health issues and frailty; targeted interventions may lower the burden of mental illness in this population.
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Affiliation(s)
- D C Cron
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - J F Friedman
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - G S Winder
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI.,Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI
| | - A E Thelen
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - J E Derck
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - J W Fakhoury
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - A D Gerebics
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - M J Englesbe
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - C J Sonnenday
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
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44
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Terjimanian MN, Harbaugh CM, Hussain A, Olugbade KO, Waits SA, Wang SC, Sonnenday CJ, Englesbe MJ. Abdominal adiposity, body composition and survival after liver transplantation. Clin Transplant 2016; 30:289-94. [PMID: 26717257 DOI: 10.1111/ctr.12688] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [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: 12/20/2015] [Indexed: 12/27/2022]
Abstract
BACKGROUND Current measures of obesity do not accurately describe body composition. Using cross-sectional imaging, objective measures of musculature and adiposity are possible and may inform efforts to optimize liver transplantation outcomes. METHODS Abdominal visceral fat area and psoas muscle cross-sectional area were measured on CT scans for 348 liver transplant recipients. After controlling for donor and recipient characteristics, survival analysis was performed using Cox regression. RESULTS Visceral fat area was significantly associated with post-transplant mortality (p < 0.001; HR = 1.06 per 10 cm(2) , 95% CI: 1.04-1.09), as were positive hepatitis C status (p = 0.004; HR = 1.78, 95% CI: 1.21-2.61) and total psoas area (TPA) (p < 0.001; HR = 0.91 per cm(2) , 95% CI: 0.88-0.94). Among patients with smaller TPA, the patients with high visceral fat area had 71.8% one-yr survival compared to 81.8% for those with low visceral fat area (p = 0.15). At five yr, the smaller muscle patients with high visceral fat area had 36.9% survival compared to 58.2% for those with low visceral fat area (p = 0.023). CONCLUSIONS Abdominal adiposity is associated with survival after liver transplantation, especially in patients with small trunk muscle size. When coupled with trunk musculature, abdominal adiposity offers direct characterization of body composition that can aid preoperative risk evaluation and inform transplant decision-making.
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Affiliation(s)
- Michael N Terjimanian
- Morphomics Analysis Group (MAG), Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Calista M Harbaugh
- Morphomics Analysis Group (MAG), Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Adnan Hussain
- Morphomics Analysis Group (MAG), Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Kola O Olugbade
- Morphomics Analysis Group (MAG), Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Seth A Waits
- Morphomics Analysis Group (MAG), Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Stewart C Wang
- Morphomics Analysis Group (MAG), Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Christopher J Sonnenday
- Morphomics Analysis Group (MAG), Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Michael J Englesbe
- Morphomics Analysis Group (MAG), Department of Surgery, University of Michigan, Ann Arbor, MI, USA
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Mathur AK, Nadig SN, Kingman S, Lee D, Kinkade K, Sonnenday CJ, Welling TH. Internal biliary stenting during orthotopic liver transplantation: anastomotic complications, post-transplant biliary interventions, and survival. Clin Transplant 2015; 29:327-35. [PMID: 25604635 DOI: 10.1111/ctr.12518] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Biliary complications are a leading source of surgical morbidity following orthotopic liver transplantation (OLT). METHODS We examined how prophylactic internal biliary stent placement during OLT affected post-transplant morbidity and mortality in a single-center retrospective cohort study of 513 recipients (2006-2012). Recipient and donor covariates were collected. Biliary complications included major and minor anastomotic leaks, strictures, or stenoses. Multivariate regression models were created to estimate how operative biliary stents affected outcomes. RESULTS About 87.3% (n = 448) of recipients had a duct-to-duct biliary anastomosis, and 43.1% (n = 221) had biliary stents placed. The biliary complication rate was <15% at five yr, and 44.8% (n = 230) overall. Stenting was not protective from anastomotic biliary complications (p = 0.06). Stenting was associated with a 74% higher adjusted risk of needing multiple endoscopic retrograde cholangiographies (ERCs; odds ratio [OR] 1.74, p = 0.011), and trended toward a lower adjusted risk for repetitive percutaneous transhepatic cholangiography (PTCs; OR 0.56, p = 0.063). Stenting had no effect on the cumulative freedom from biliary complications (p = 0.94). Biliary complications were associated with mortality (HR 1.86, p = 0.014) and was unaffected by stenting (aHR = 0.72, p = 0.246). CONCLUSIONS Biliary stenting during OLT does not deter biliary complications and is associated with higher risk of multiple invasive biliary interventions, particularly ERCs. Surgeons should evaluate the utility of biliary stents at OLT within this context.
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Affiliation(s)
- Amit K Mathur
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA; Mayo Clinic Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Charleston, SC, USA
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Lee CS, Cron DC, Terjimanian MN, Canvasser LD, Mazurek AA, Vonfoerster E, Tishberg LM, Underwood PW, Chang ET, Wang SC, Sonnenday CJ, Englesbe MJ. Dorsal muscle group area and surgical outcomes in liver transplantation. Clin Transplant 2014; 28:1092-8. [PMID: 25040933 DOI: 10.1111/ctr.12422] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [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: 07/13/2014] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Better measures of liver transplant risk stratification are needed. Our previous work noted a strong relationship between psoas muscle area and survival following liver transplantation. The dorsal muscle group is easier to measure, but it is unclear if they are also correlated with surgical outcomes. METHODS Our study population included liver transplant recipients with a preoperative CT scan. Cross-sectional areas of the dorsal muscle group at the T12 vertebral level were measured. The primary outcomes for this study were one- and five-yr mortality and one-yr complications. The relationship between dorsal muscle group area and post-transplantation outcome was assessed using univariate and multivariate techniques. RESULTS Dorsal muscle group area measurements were strongly associated with psoas area (r = 0.72; p < 0.001). Postoperative outcome was observed from 325 patients. Multivariate logistic regression revealed dorsal muscle group area to be a significant predictor of one-yr mortality (odds ratio [OR] = 0.53, p = 0.001), five-yr mortality (OR = 0.53, p < 0.001), and one-yr complications (OR = 0.67, p = 0.007). CONCLUSION Larger dorsal muscle group muscle size is associated with improved post-transplantation outcomes. The muscle is easier to measure and may represent a clinically relevant postoperative risk factor.
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Affiliation(s)
- Christopher S Lee
- Morphomic Analysis Group, University of Michigan, Ann Arbor, MI, USA; Department of Surgery, University of Michigan, Ann Arbor, MI, USA
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Waits SA, Kim EK, Terjimanian MN, Tishberg LM, Harbaugh CM, Sheetz KH, Sonnenday CJ, Sullivan J, Wang SC, Englesbe MJ. Morphometric age and mortality after liver transplant. JAMA Surg 2014; 149:335-40. [PMID: 24500820 DOI: 10.1001/jamasurg.2013.4823] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Morphometric assessment has emerged as a strong predictor of postoperative morbidity and mortality. However, a gap exists in translating this knowledge to bedside decision making. We introduced a novel measure of patient-centered surgical risk assessment: morphometric age. OBJECTIVE To investigate the relationship between morphometric age and posttransplant survival. DATA SOURCES Medical records of recipients of deceased-donor liver transplants (study population) and kidney donors/trauma patients (morphometric age control population). STUDY SELECTION A retrospective cohort study of 348 liver transplant patients and 3313 control patients. We assessed medical records for validated morphometric characteristics of aging (psoas area, psoas density, and abdominal aortic calcification). We created a model (stratified by sex) for a morphometric age equation, which we then calculated for the control population using multivariate linear regression modeling (covariates). These models were then applied to the study population to determine each patient's morphometric age. DATA EXTRACTION AND SYNTHESIS All analytic steps related to measuring morphometric characteristics were obtained via custom algorithms programmed into commercially available software. An independent observer confirmed all algorithm outputs. Trained assistants performed medical record review to obtain patient characteristics. RESULTS Cox proportional hazards regression model showed that morphometric age was a significant independent predictor of overall mortality (hazard ratio, 1.03 per morphometric year [95% CI, 1.02-1.04; P < .001]) after liver transplant. Chronologic age was not a significant covariate for survival (hazard ratio, 1.02 per year [95% CI, 0.99-1.04; P = .21]). Morphometric age stratified patients at high and low risk for mortality. For example, patients in the middle chronologic age tertile who jumped to the oldest morphometric tertile have worse outcomes than those who jumped to the youngest morphometric tertile (74.4% vs 93.2% survival at 1 year [P = .03]; 45.2% vs 75.0% at 5 years [P = .03]). CONCLUSIONS AND RELEVANCE Morphometric age correlated with mortality after liver transplant with better discrimination than chronologic age. Assigning a morphometric age to potential liver transplant recipients could improve prediction of postoperative mortality risk.
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Affiliation(s)
- Seth A Waits
- Morphomics Analysis Group, Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Edward K Kim
- Morphomics Analysis Group, Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Michael N Terjimanian
- Morphomics Analysis Group, Department of Surgery, University of Michigan Medical School, Ann Arbor
| | | | - Calista M Harbaugh
- Morphomics Analysis Group, Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Kyle H Sheetz
- Morphomics Analysis Group, Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Christopher J Sonnenday
- Morphomics Analysis Group, Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - June Sullivan
- Morphomics Analysis Group, Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Stewart C Wang
- Morphomics Analysis Group, Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Michael J Englesbe
- Morphomics Analysis Group, Department of Surgery, University of Michigan Medical School, Ann Arbor
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Welling TH, Feng M, Wan S, Hwang SY, Volk ML, Lawrence TS, Zalupski MM, Sonnenday CJ. Neoadjuvant stereotactic body radiation therapy, capecitabine, and liver transplantation for unresectable hilar cholangiocarcinoma. Liver Transpl 2014; 20:81-8. [PMID: 24115315 PMCID: PMC4185427 DOI: 10.1002/lt.23757] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [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: 07/11/2013] [Accepted: 09/13/2013] [Indexed: 12/17/2022]
Abstract
Hilar cholangiocarcinoma (CCA) is a difficult malignancy to treat surgically because of its anatomical location and its frequent association with primary sclerosing cholangitis. Neoadjuvant chemoradiotherapy followed by liver transplantation in lymph node-negative patients has been advanced by select liver transplant centers for the treatment of patients with unresectable disease. This approach has most commonly used external-beam radiotherapy in combination with biliary brachytherapy and 5-fluorouracil-based chemotherapy. Our center recently embarked on a protocol using stereotactic body radiation therapy (SBRT) followed by capecitabine in lymph node-negative patients until liver transplantation. We, therefore, retrospectively determined the tolerability and pathological response in this pilot study. During a 3-year period, 17 patients with unresectable hilar CCA were evaluated for treatment under this protocol. In all, 12 patients qualified for neoadjuvant therapy and were treated with SBRT (50-60 Gy in 3-5 fractions over the course of 2 weeks). After 1 week of rest, capecitabine was initiated at 1330 mg/m(2) /day, and it was continued until liver transplantation. During neoadjuvant therapy, there were 35 adverse events in all, with cholangitis and palmar-plantar erythrodysesthesia being the most common. Capecitabine dose reductions were required on 5 occasions. Ultimately, 9 patients were listed for transplantation, and 6 patients received a liver transplant. The explant pathology of hilar tumors showed at least a partial treatment response in 5 patients, with extensive tumor necrosis and fibrosis noted. Additionally, high apoptotic indices and low proliferative indices were measured during histological examinations. Eleven transplant-related complications occurred, and the 1-year survival rate after transplantation was 83%. In this pilot study, neoadjuvant therapy with SBRT, capecitabine, and liver transplantation for unresectable CCA demonstrated acceptable tolerability. Further studies will determine the overall future efficacy of this therapy.
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Affiliation(s)
- Theodore H Welling
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
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Krell RW, Kaul DR, Martin AR, Englesbe MJ, Sonnenday CJ, Cai S, Malani PN. Association between sarcopenia and the risk of serious infection among adults undergoing liver transplantation. Liver Transpl 2013; 19:1396-402. [PMID: 24151041 PMCID: PMC3870151 DOI: 10.1002/lt.23752] [Citation(s) in RCA: 189] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Accepted: 08/30/2013] [Indexed: 12/16/2022]
Abstract
Although sarcopenia (muscle loss) is associated with increased mortality after liver transplantation, its influence on other complications is less well understood. We examined the association between sarcopenia and the risk of severe posttransplant infections among adult liver transplant recipients. By calculating the total psoas area (TPA) on preoperative computed tomography scans, we assessed sarcopenia among 207 liver transplant recipients. The presence or absence of a severe posttransplant infection was determined by a review of the medical chart. The influence of posttransplant infections on overall survival was also assessed. We identified 196 episodes of severe infections among 111 patients. Fifty-six patients had more than 1 infection. The median time to the development of an infection was 27 days (interquartile range = 13-62 days). When the patients were grouped by TPA tertiles, patients in the lowest tertile had a greater than 4-fold higher chance of developing a severe infection in comparison with patients in the highest tertile (odds ratio = 4.6, 95% confidence interval = 2.25-9.53). In a multivariate analysis, recipient age (hazard ratio = 1.04, P = 0.02), pretransplant TPA (hazard ratio = 0.38, P < 0.01), and pretransplant total bilirubin level (hazard ratio = 1.05, P = 0.02) were independently associated with the risk of developing severe infections. Patients with severe posttransplant infections had worse 1-year survival than patients without infections (76% versus 92%, P = 0.003). In conclusion, among patients undergoing liver transplantation, a lower TPA was associated with a heightened risk for posttransplant infectious complications and mortality. Future efforts should focus on approaches for assessing and mitigating vulnerability in patients undergoing transplantation.
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Affiliation(s)
- Robert W. Krell
- Department of Surgery, University of Michigan Health System, Ann Arbor, MI
| | - Daniel R. Kaul
- Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI,Division of Infectious Diseases, University of Michigan Health System, Ann Arbor, MI
| | - Andrew R. Martin
- Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI,Division of Infectious Diseases, University of Michigan Health System, Ann Arbor, MI
| | - Michael J. Englesbe
- Department of Surgery, University of Michigan Health System, Ann Arbor, MI,Section of Transplantation Surgery, University of Michigan Health System, Ann Arbor, MI
| | - Christopher J. Sonnenday
- Department of Surgery, University of Michigan Health System, Ann Arbor, MI,Section of Transplantation Surgery, University of Michigan Health System, Ann Arbor, MI
| | - Shijie Cai
- Department of Surgery, University of Michigan Health System, Ann Arbor, MI,Section of Transplantation Surgery, University of Michigan Health System, Ann Arbor, MI,Department of Biostatistics, University of Michigan Health System, Ann Arbor, MI
| | - Preeti N. Malani
- Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI,Division of Infectious Diseases, University of Michigan Health System, Ann Arbor, MI,Division of Geriatric and Palliative Medicine, University of Michigan Health System, Ann Arbor, MI,Veterans Affairs Ann Arbor Healthcare System, Geriatrics Research Education and Clinical Center (GRECC)
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50
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Elmunzer BJ, DeBenedet AT, Volk ML, Sonnenday CJ, Waljee AK, Fontana RJ, Oza AB, Singal A, Englesbe MJ, Scheiman JM. Clinical yield of diagnostic endoscopic retrograde cholangiopancreatography in orthotopic liver transplant recipients with suspected biliary complications. Liver Transpl 2012; 18:1479-84. [PMID: 22888069 PMCID: PMC3900243 DOI: 10.1002/lt.23535] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Accepted: 07/15/2012] [Indexed: 12/26/2022]
Abstract
Diagnostic endoscopic retrograde cholangiopancreatography (D-ERCP) is commonly performed for the evaluation of biliary complications after orthotopic liver transplantation (OLT). This practice is contrary to the national trend of reserving endoscopic retrograde cholangiopancreatography (ERCP) for therapeutic purposes. Our aim was to evaluate the clinical yield and complications of D-ERCP in OLT recipients. In this retrospective study, 165 OLT recipients who underwent ERCP between January 2006 and December 2010 at the University of Michigan were divided into 2 groups: (1) a therapeutic endoscopic retrograde cholangiopancreatography (T-ERCP) group (if they met prespecified criteria that suggested a high likelihood of endoscopic intervention) and (2) a D-ERCP group (if there was clinical suspicion of biliary disease but they did not meet any criteria). The 2 groups were compared with respect to the proportion of subjects undergoing high-yield ERCP, which was defined as a procedure resulting in a clinically important intervention that modified the disease course. 66.3% of the D-ERCP procedures were classified as high-yield, whereas 90.1% of the T-ERCP procedures were (P < 0.001). Serious complications were infrequent in both groups. A survey of practitioners caring for OLT recipients suggested that the rate of high-yield D-ERCP seen in this study is congruent with what is considered acceptable in clinical practice. In conclusion, although T-ERCP is more likely to reveal a pathological process requiring an intervention, D-ERCP appears to be an acceptable clinical strategy for OLT recipients because of the high likelihood of a high-yield study and the low rate of serious complications.
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Affiliation(s)
- B. Joseph Elmunzer
- Division of Gastroenterology and Hepatology, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Anthony T. DeBenedet
- Division of Gastroenterology and Hepatology, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Michael L. Volk
- Division of Gastroenterology and Hepatology, University of Michigan Medical Center, Ann Arbor, MI, USA
| | | | - Akbar K. Waljee
- Division of Gastroenterology and Hepatology, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Robert J. Fontana
- Division of Gastroenterology and Hepatology, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Aarti B. Oza
- Division of Gastroenterology and Hepatology, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Amit Singal
- Division of Gastroenterology and Hepatology, University of Texas-Southwestern Medical Center, Dallas, TX, USA
| | - Michael J. Englesbe
- Department of Surgery, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - James M. Scheiman
- Division of Gastroenterology and Hepatology, University of Michigan Medical Center, Ann Arbor, MI, USA
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