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Ryan JC, Haight C, Niemi EC, Grab JD, Dodge JL, Lanier LL, Monto A. Hepatocellular carcinoma after direct-acting antivirals for hepatitis C is associated with KIR-HLA types predicting weak NK cell-mediated immunity. Eur J Immunol 2024:e2350678. [PMID: 38700055 DOI: 10.1002/eji.202350678] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 04/13/2024] [Accepted: 04/18/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND AND AIMS Second-generation direct-acting antivirals (2G DAA) to cure HCV have led to dramatic clinical improvements. HCV-associated hepatocellular carcinoma (HCC), however, remains common. Impaired immune tumor surveillance may play a role in HCC development. Our cohort evaluated the effects of innate immune types and clinical variables on outcomes including HCC. METHODS Participants underwent full HLA class I/KIR typing and long-term HCV follow-up. RESULTS A total of 353 HCV+ participants were followed for a mean of 7 years. Cirrhosis: 25% at baseline, developed in 12% during follow-up. 158 participants received 2G DAA therapy. HCC developed without HCV therapy in 20 subjects, 24 HCC after HCV therapy, and 10 of these after 2G DAA. Two predictors of HCC among 2G DAA-treated patients: cirrhosis (OR, 10.0, p = 0.002) and HLA/KIR profiles predicting weak natural killer (NK) cell-mediated immunity (NK cell complementation groups 6, 9, 11, 12, OR of 5.1, p = 0.02). Without 2G DAA therapy: cirrhosis was the main clinical predictor of HCC (OR, 30.8, p < 0.0001), and weak NK-cell-mediated immunity did not predict HCC. CONCLUSION Cirrhosis is the main risk state predisposing to HCC, but weak NK-cell-mediated immunity may predispose to post-2G DAA HCC more than intermediate or strong NK-cell-mediated immunity.
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Affiliation(s)
- James C Ryan
- Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
- Division of Gastroenterology, University of California, San Francisco, California, USA
| | - Christina Haight
- Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Erene C Niemi
- Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Joshua D Grab
- Department of Medicine, University of California, San Francisco, California, USA
| | - Jennifer L Dodge
- Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Lewis L Lanier
- Department of Microbiology and Immunology, University of California, San Francisco, California, USA
| | - Alexander Monto
- Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
- Division of Gastroenterology, University of California, San Francisco, California, USA
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Nguyen VV, Wang S, Whitlock R, Xu C, Taneja S, Singh S, Abraldes JG, Burak K, Bailey RJ, Grab JD, Lai JC, Tandon P. A chair-stand time of greater than 15 seconds is associated with an increased risk of death and hospitalization in cirrhosis. Can Liver J 2023; 6:358-362. [PMID: 38020188 PMCID: PMC10652985 DOI: 10.3138/canlivj-2022-0021] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 08/09/2022] [Indexed: 12/01/2023]
Abstract
Background Frailty is a clinical state of increased vulnerability and is common in patients with cirrhosis. The liver frailty index (LFI) is a validated tool to evaluate frailty in cirrhosis, comprising of grip strength, chair stands, and balance tests. The chair-stand test is an easy to conduct frailty subcomponent that does not require specialized equipment and may be valuable to predict adverse clinical outcomes in cirrhosis. The objective of this study was to determine if the chair-stand test is an independent predictor of mortality and hospitalization in cirrhosis. Methods A retrospective review of 787 patients with cirrhosis was conducted. Chair-stand times were collected at baseline in person and divided into three groups: <10 seconds (n = 276), 10-15 seconds (n = 290), and >15 seconds (n = 221). Fine-Gray proportional hazards regression models were used to evaluate the association between chair-stand times and the outcomes of mortality and non-elective hospitalization. Results The hazard of mortality (HR 3.21, 95% CI 2.16%-4.78%, p <0.001) and non-elective hospitalization (HR 2.24, 95% CI 1.73%-2.91%, p <0.001) was increased in group 3 in comparison to group 1. A chair-stand test time >15 seconds had increased all-cause mortality (HR 2.78, 95% CI 2.01%-3.83%, p <0.001) and non-elective hospitalizations (HR 1.84, 95% CI 1.48%-2.29%, p <0.001) compared to <15 seconds. Conclusions A chair-stand test time of >15 seconds is independently associated with mortality and non-elective hospitalizations. This test holds promise as a rapid prognostication tool in cirrhosis. Future work will include external validation and virtual assessment in this population.
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Affiliation(s)
- Vivian V Nguyen
- Department of Medicine, University of Alberta Faculty of Medicine, Edmonton, Alberta, Canada
| | - Sarah Wang
- Division of Gastroen terology and Liver Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Reid Whitlock
- Chronic Disease Innovation Centre, Win- nipeg, Manitoba, Canada
| | - Chelsea Xu
- Department of Medicine, University of California, San Francisco, California, United States
| | - Sunil Taneja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Surender Singh
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Juan G Abraldes
- Division of Gastroen terology and Liver Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Kelly Burak
- Liver Unit, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Robert J Bailey
- Division of Gastroenterol ogy, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Joshua D Grab
- Division of Gastroenterology and Hepatology, University of California, San Francisco, California, United States
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, University of California, San Francisco, California, United States
| | - Puneeta Tandon
- Division of Gastroen terology and Liver Unit, University of Alberta, Edmonton, Alberta, Canada
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Silverstein J, Yao FY, Grab JD, Braun HJ, Roberts J, Dodge JL, Mehta N. National experience with living donor liver transplantation for hepatocellular carcinoma. Liver Transpl 2022; 28:1144-1157. [PMID: 35226793 DOI: 10.1002/lt.26439] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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: 07/30/2021] [Revised: 01/10/2022] [Accepted: 01/20/2022] [Indexed: 01/13/2023]
Abstract
Living donor liver transplantation (LDLT) is an attractive option to decrease waitlist dropout, particularly for patients with hepatocellular carcinoma (HCC) who face lengthening waiting times. Using the United Network for Organ Sharing (UNOS) national database, trends in LDLT utilization for patients with HCC were evaluated, and post-LT outcomes for LDLT versus deceased donor liver transplantation (DDLT) were compared. From 1998 to 2018, LT was performed in 20,161 patients with HCC including 726 (3.6%) who received LDLT. The highest LDLT utilization was prior to the 2002 HCC Model for End-Stage Liver Disease (MELD) exception policy (17.5%) and dropped thereafter (3.1%) with a slight increase following the 6-month wait policy in 2015 (3.8%). LDLT was more common in patients from long-wait UNOS regions with blood type O, in those with larger total tumor diameter (2.3 vs. 2.1 cm, p = 0.02), and higher alpha-fetoprotein at LT (11.5 vs. 9.0 ng/ml, p = 0.04). The 5-year post-LT survival (LDLT 77% vs. DDLT 75%), graft survival (72% vs. 72%), and HCC recurrence (11% vs. 13%) were similar between groups (all p > 0.20). In conclusion, LDLT utilization for HCC has remained low since 2002 with only a slight increase after the 6-month wait policy introduction in 2015. Given the excellent post-LT survival, LDLT appears to be an underutilized but valuable option for patients with HCC, especially those at high risk for waitlist dropout.
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Affiliation(s)
- Jordyn Silverstein
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Francis Y Yao
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA.,Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Joshua D Grab
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Hillary J Braun
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| | - John Roberts
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Jennifer L Dodge
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, California, USA.,Department of Gastroenterology and Liver Diseases, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Neil Mehta
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
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4
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Berry K, Asken BM, Grab JD, Chan B, Lario Lago A, Wong R, Seetharaman S, LaHue SC, Possin KL, Rojas JC, Kramer JH, Boxer AL, Lai JC, VandeVrede L. Hepatic and renal function impact concentrations of plasma biomarkers of neuropathology. Alzheimers Dement (Amst) 2022; 14:e12321. [PMID: 35845260 PMCID: PMC9274803 DOI: 10.1002/dad2.12321] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 04/14/2022] [Accepted: 04/18/2022] [Indexed: 11/11/2022]
Abstract
Introduction The impact of hepatorenal function on plasma biomarkers of neuropathology is unknown. Herein, we measured several plasma biomarkers in patients with cirrhosis. Methods Plasma phosphorylated tau (p-tau181), neurofilament light chain (NfL), glial fibrillary acidic protein (GFAP), total tau (t-tau), and ubiquitin carboxyl-terminal hydrolase L1 (UCHL1) were measured in 135 adults with cirrhosis and 22 healthy controls using Simoa. Within cirrhosis, associations between biomarkers and hepatorenal function were explored using linear regression. Results p-tau181, NfL, t-tau, and UCHL1 were increased 2- to 4-fold in cirrhosis, whereas GFAP was not increased. Within cirrhosis, creatinine moderately correlated with p-tau181 (β = 0.75, P < .01), NfL (β = 0.32, P < .01), and t-tau (β = 0.31, P < .01), but not GFAP (β = -0.01, P = .88) or UCHL1 (β = -0.05, P = .60), whereas albumin showed weak, inverse correlations: p-tau181 (β = -0.18, P < .01), NfL (β = -0.22, P < .01), GFAP (β = -0.17, P < .05), t-tau (β = -0.20, P = .02), and UCHL1 (β = -0.15, P = .09). Conclusions Elevated p-tau181, NfL, and t-tau in cirrhosis were associated with renal impairment and hypoalbuminemia, suggesting that hepatorenal function may be important when interpreting plasma biomarkers of neuropathology.
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Affiliation(s)
- Kacey Berry
- Department of MedicineDivision of GastroenterologyUniversity of California San FranciscoCaliforniaUSA
| | - Breton M. Asken
- Weill Institute for NeurosciencesDepartment of NeurologyMemory and Aging CenterUniversity of California San FranciscoCaliforniaUSA
| | - Joshua D. Grab
- Department of MedicineDivision of GastroenterologyUniversity of California San FranciscoCaliforniaUSA
| | - Brandon Chan
- Weill Institute for NeurosciencesDepartment of NeurologyMemory and Aging CenterUniversity of California San FranciscoCaliforniaUSA
| | - Argentina Lario Lago
- Weill Institute for NeurosciencesDepartment of NeurologyMemory and Aging CenterUniversity of California San FranciscoCaliforniaUSA
| | - Randi Wong
- Department of MedicineDivision of GastroenterologyUniversity of California San FranciscoCaliforniaUSA
| | - Srilakshmi Seetharaman
- Department of MedicineDivision of GastroenterologyUniversity of California San FranciscoCaliforniaUSA
| | - Sara C. LaHue
- Weill Institute for NeurosciencesDepartment of NeurologyMemory and Aging CenterUniversity of California San FranciscoCaliforniaUSA
| | - Katherine L. Possin
- Weill Institute for NeurosciencesDepartment of NeurologyMemory and Aging CenterUniversity of California San FranciscoCaliforniaUSA
| | - Julio C. Rojas
- Weill Institute for NeurosciencesDepartment of NeurologyMemory and Aging CenterUniversity of California San FranciscoCaliforniaUSA
| | - Joel H. Kramer
- Weill Institute for NeurosciencesDepartment of NeurologyMemory and Aging CenterUniversity of California San FranciscoCaliforniaUSA
| | - Adam L. Boxer
- Weill Institute for NeurosciencesDepartment of NeurologyMemory and Aging CenterUniversity of California San FranciscoCaliforniaUSA
| | - Jennifer C. Lai
- Department of MedicineDivision of GastroenterologyUniversity of California San FranciscoCaliforniaUSA
| | - Lawren VandeVrede
- Weill Institute for NeurosciencesDepartment of NeurologyMemory and Aging CenterUniversity of California San FranciscoCaliforniaUSA
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5
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Berry K, Duarte-Rojo A, Grab JD, Dunn MA, Boyarsky BJ, Verna EC, Kappus MR, Volk ML, McAdams-DeMarco M, Segev DL, Ganger DR, Ladner DP, Shui A, Tincopa MA, Rahimi RS, Lai JC. Cognitive Impairment and Physical Frailty in Patients With Cirrhosis. Hepatol Commun 2021; 6:237-246. [PMID: 34558844 PMCID: PMC8710786 DOI: 10.1002/hep4.1796] [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] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 06/04/2021] [Accepted: 06/25/2021] [Indexed: 01/10/2023] Open
Abstract
Physical frailty and impaired cognition are common in patients with cirrhosis. Physical frailty can be assessed using performance-based tests, but the extent to which impaired cognition may impact performance is not well characterized. We assessed the relationship between impaired cognition and physical frailty in patients with cirrhosis. We enrolled 1,623 ambulatory adult patients with cirrhosis waiting for liver transplantation at 10 sites. Frailty was assessed with the liver frailty index (LFI; "frail," LFI ≥ 4.4). Cognition was assessed at the same visit with the number connection test (NCT); continuous "impaired cognition" was examined in primary analysis, with longer NCT (more seconds) indicating worse impaired cognition. For descriptive statistics, "impaired cognition" was NCT ≥ 45 seconds. Linear regression associated frailty and impaired cognition; competing risk regression estimated subhazard ratios (sHRs) of wait-list mortality (i.e., death/delisting for sickness). Median NCT was 41 seconds, and 42% had impaired cognition. Median LFI (4.2 vs. 3.8) and rates of frailty (38% vs. 20%) differed between those with and without impaired cognition. In adjusted analysis, every 10-second NCT increase associated with a 0.08-LFI increase (95% confidence interval [CI], 0.07-0.10). In univariable analysis, both frailty (sHR, 1.63; 95% CI, 1.43-1.87) and impaired cognition (sHR, 1.07; 95% CI, 1.04-1.10) associated with wait-list mortality. After adjustment, frailty but not impaired cognition remained significantly associated with wait-list mortality (sHR, 1.55; 95% CI, 1.33-1.79). Impaired cognition mediated 7.4% (95% CI, 2.0%-16.4%) of the total effect of frailty on 1-year wait-list mortality. Conclusion: Patients with cirrhosis with higher impaired cognition displayed higher rates of physical frailty, yet frailty independently associated with wait-list mortality while impaired cognition did not. Our data provide evidence for using the LFI to understand mortality risk in patients with cirrhosis, even when concurrent impaired cognition varies.
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Affiliation(s)
- Kacey Berry
- Division of Gastroenterology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Andres Duarte-Rojo
- Center for Liver Diseases, Thomas A. Starzl Transplantation Institute and Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Joshua D Grab
- Division of Gastroenterology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Michael A Dunn
- Center for Liver Diseases, Thomas A. Starzl Transplantation Institute and Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Brian J Boyarsky
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Elizabeth C Verna
- Center for Liver Disease and Transplantation, Columbia University Irving Medical Center, New York, NY, USA
| | - Matthew R Kappus
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Michael L Volk
- Division of Gastroenterology and Hepatology, and Transplantation Institute, Loma Linda University Health, Loma Linda, CA, USA
| | - Mara McAdams-DeMarco
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Daniel R Ganger
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Daniela P Ladner
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University Transplant Outcomes Research Collaborative, Northwestern University, Chicago, IL, USA
| | - Amy Shui
- Division of Gastroenterology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Monica A Tincopa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | - Robert S Rahimi
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Baylor Scott and White, Dallas, TX, USA
| | - Jennifer C Lai
- Division of Gastroenterology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
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6
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Braun HJ, Grab JD, Dodge JL, Syed SM, Roll GR, Schwab MP, Liu IH, Glencer AC, Freise CE, Roberts JP, Ascher NL. Retransplantation After Living Donor Liver Transplantation: Data from the Adult to Adult Living Donor Liver Transplantation Study. Transplantation 2021; 105:1297-1302. [PMID: 33347261 PMCID: PMC7942712 DOI: 10.1097/tp.0000000000003361] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND The use of living donor liver transplantation (LDLT) for primary liver transplantation (LT) may quell concerns about allocating deceased donor organs if the need for retransplantation (re-LT) arises because the primary LT did not draw from the limited organ pool. However, outcomes of re-LT after LDLT are poorly studied. The purpose of this study was to analyze the Adult to Adult Living Donor Liver Transplantation Study (A2ALL) data to report outcomes of re-LT after LDLT, with a focus on long-term survival after re-LT. METHODS A retrospective review of A2ALL data collected between 1998 and 2014 was performed. Patients were excluded if they received a deceased donor LT. Demographic data, postoperative outcomes and complications, graft and patient survival, and predictors of re-LT and patient survival were assessed. RESULTS Of the 1065 patients who underwent LDLT during the study time period, 110 recipients (10.3%) required re-LT. In multivariable analyses, hepatitis C virus, longer length of stay at LDLT, hepatic artery thrombosis, biliary stricture, infection, and disease recurrence were associated with an increased risk of re-LT. Patient survival among re-LT patients was significantly inferior to those who underwent primary transplant only at 1 (86% versus 92%), 5 (64% versus 82%), and 10 years (44% versus 68%). CONCLUSIONS Approximately 10% of A2ALL patients who underwent primary LDLT required re-LT. Compared with patients who underwent primary LT, survival among re-LT recipients was worse at 1, 5, and 10 years after LT, and re-LT was associated with a significantly increased risk of death in multivariable modeling (hazard ratios, 2.29; P < 0.001).
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Affiliation(s)
- Hillary J. Braun
- Department of Surgery University of California, San Francisco San Francisco, CA, USA
| | - Joshua D. Grab
- Department of Surgery University of California, San Francisco San Francisco, CA, USA
| | - Jennifer L. Dodge
- Department of Surgery University of California, San Francisco San Francisco, CA, USA
| | - Shareef M. Syed
- Department of Surgery University of California, San Francisco San Francisco, CA, USA
| | - Garrett R. Roll
- Department of Surgery University of California, San Francisco San Francisco, CA, USA
| | - Marisa P. Schwab
- Department of Surgery University of California, San Francisco San Francisco, CA, USA
| | - Iris H. Liu
- Department of Surgery University of California, San Francisco San Francisco, CA, USA
| | - Alexa C. Glencer
- Department of Surgery University of California, San Francisco San Francisco, CA, USA
| | - Chris E. Freise
- Department of Surgery University of California, San Francisco San Francisco, CA, USA
| | - John P. Roberts
- Department of Surgery University of California, San Francisco San Francisco, CA, USA
| | - Nancy L. Ascher
- Department of Surgery University of California, San Francisco San Francisco, CA, USA
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Braun HJ, Dodge JL, Grab JD, Glencer AC, Schwab ME, Stock PG, Hirose R, Roberts JP, Ascher NL. Live Donor Liver Transplantation in the United States: Impact of Share 35 on Live Donor Utilization. Transplantation 2021; 105:824-831. [PMID: 32433235 PMCID: PMC7980785 DOI: 10.1097/tp.0000000000003318] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 01/19/2023]
Abstract
BACKGROUND Share 35 was a policy implemented in 2013 to increase regional sharing of deceased donor livers to patients with model for end-stage liver disease ≥ 35 to decrease waitlist mortality for the sickest patients awaiting liver transplantation (LT). The purpose of this study was to determine whether live donor liver transplantation (LDLT) volume was impacted by the shift in allocation of deceased donor livers to patients with higher model for end-stage liver disease scores. METHODS Using Network for Organ Sharing/Organ Procurement and Transplantation Network Standard Transplant Analysis and Research files, we identified all adults who received a primary LT between October 1, 2008, and March 31, 2018. LT from October 1, 2008, through June 30, 2013, was designated as the pre-Share 35 era and July 1, 2013, through March 31, 2018, as the post-Share 35 era. Primary outcomes included transplant volumes, graft survival, and patient survival in both eras. RESULTS In total, 48 779 primary adult single-organ LT occurred during the study period (22 255 pre-Share 35, 26 524 post). LDLT increased significantly (6.8% post versus 5.7% pre, P < 0.001). LDLT volume varied significantly by region (P < 0.001) with regions 2, 4, 5, and 8 demonstrating significant increases in LDLT volume post-Share 35. The number of centers performing LDLT increased only in regions 4, 6, and 11. Throughout the 2 eras, there was no difference in graft or patient survival for LDLT recipients. CONCLUSIONS Overall, LDLT volume increased following the implementation of Share 35, which was largely due to increased LDLT volume at centers with experience in LDLT, and corresponded to significant geographic variation in LDLT utilization.
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Affiliation(s)
- Hillary J. Braun
- Department of Surgery, Division of Transplantation, University of California, San Francisco, San Francisco, CA, USA
| | - Jennifer L. Dodge
- Department of Surgery, Division of Transplantation, University of California, San Francisco, San Francisco, CA, USA
| | - Joshua D. Grab
- Department of Surgery, Division of Transplantation, University of California, San Francisco, San Francisco, CA, USA
| | - Alexa C. Glencer
- Department of Surgery, Division of Transplantation, University of California, San Francisco, San Francisco, CA, USA
| | - Marisa E. Schwab
- Department of Surgery, Division of Transplantation, University of California, San Francisco, San Francisco, CA, USA
| | - Peter G. Stock
- Department of Surgery, Division of Transplantation, University of California, San Francisco, San Francisco, CA, USA
| | - Ryutaro Hirose
- Department of Surgery, Division of Transplantation, University of California, San Francisco, San Francisco, CA, USA
| | - John P. Roberts
- Department of Surgery, Division of Transplantation, University of California, San Francisco, San Francisco, CA, USA
| | - Nancy L. Ascher
- Department of Surgery, Division of Transplantation, University of California, San Francisco, San Francisco, CA, USA
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8
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Silverstein J, Roll G, Dodge JL, Grab JD, Yao FY, Mehta N. Donation After Circulatory Death Is Associated With Similar Posttransplant Survival in All but the Highest-Risk Hepatocellular Carcinoma Patients. Liver Transpl 2020; 26:1100-1111. [PMID: 32531867 PMCID: PMC8722407 DOI: 10.1002/lt.25819] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [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: 03/04/2020] [Revised: 04/28/2020] [Accepted: 05/13/2020] [Indexed: 12/15/2022]
Abstract
Liver transplantation (LT) recipients with hepatocellular carcinoma (HCC) receive a higher proportion of livers from donation after circulatory death (DCD) donors compared with non-HCC etiologies. Nevertheless, data on outcomes in patients with HCC receiving DCD grafts are limited. We evaluated the influence of DCD livers on post-LT outcome among HCC patients. We identified 7563 patients in the United Network for Organ Sharing (UNOS) database who underwent LT with Model for End-Stage Liver Disease score exceptions from 2012 to 2016, including 567 (7.5%) who received a DCD donor organ and 6996 (92.5%) who received a donation after brain death (DBD) donor organ. Kaplan-Meier probabilities of post-LT HCC recurrence at 3 years were 7.6% for DCD and 6.4% for DBD recipients (P = 0.67) and post-LT survival at 3 years was 81.1% versus 85.5%, respectively (P = 0.008). On multivariate analysis, DCD donor (hazard ratio, 1.38; P = 0.005) was an independent predictor of post-LT mortality. However, a survival difference after LT was only observed in subgroups at higher risk for HCC recurrence including Risk Estimation of Tumor Recurrence After Transplant (RETREAT) score ≥4 (DCD 57.0% versus DBD 72.6%; P = 0.02), alpha-fetoprotein (AFP) ≥100 (60.1% versus 76.9%; P = 0.049), and multiple viable tumors on last imaging before LT (69.9% versus 83.1%; P = 0.002). In this analysis of HCC patients receiving DCD versus DBD livers in the UNOS database, we found that patients with a low-to-moderate risk of HCC recurrence (80%-90% of the DCD cohort) had equivalent survival regardless of donor type. It appears that DCD donation can best be used to increase the donor pool for HCC patients with decompensated cirrhosis or partial response/stable disease after locoregional therapy with AFP at LT <100 ng/mL.
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Affiliation(s)
- Jordyn Silverstein
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Garrett Roll
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Jennifer L. Dodge
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Joshua D. Grab
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Francis Y. Yao
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, San Francisco, CA,Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Neil Mehta
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, San Francisco, CA
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9
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Mehta N, Dodge JL, Grab JD, Yao FY. National Experience on Down-Staging of Hepatocellular Carcinoma Before Liver Transplant: Influence of Tumor Burden, Alpha-Fetoprotein, and Wait Time. Hepatology 2020; 71:943-954. [PMID: 31344273 PMCID: PMC8722406 DOI: 10.1002/hep.30879] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 07/18/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND AND AIMS United Network for Organ Sharing (UNOS) recently implemented a national policy granting priority listing for liver transplantation (LT) in patients who achieved down-staging of hepatocellular carcinoma (HCC) to Milan criteria. We aimed to evaluate the national experience on down-staging by comparing two down-staging groups with (1) tumor burden meeting UNOS down-staging (UNOS-DS) inclusion criteria and (2) "all-comers" (AC-DS) with initial tumor burden beyond UNOS-DS criteria versus patients always within Milan. APPROACH AND RESULTS This is a retrospective analysis of the UNOS database of 3,819 patients who underwent LT from 2012 to 2015, classified as always within Milan (n = 3,276), UNOS-DS (n = 422), and AC-DS (n = 121). Median time to LT was 12.8 months in long wait regions, 6.5 months in mid wait regions (MWR), and 2.6 months in short wait regions (SWR). On explant, vascular invasion was found in 23.7% of AC-DS versus 16.9% of UNOS-DS and 14.4% of Milan (P = 0.002). Kaplan-Meier 3-year post-LT survival was 83.2% for Milan, 79.1% for UNOS-DS (P = 0.17 vs. Milan), and 71.4% for AC-DS (P = 0.04 vs. Milan). Within down-staging groups, risk of post-LT death in multivariable analysis was increased in SWR or MWR (hazard ratio [HR], 3.1; P = 0.005) and with alpha-fetoprotein (AFP) ≥ 100 ng/mL at LT (HR, 2.4; P = 0.009). The 3-year HCC recurrence probability was 6.9% for Milan, 12.8% for UNOS-DS, and 16.7% for AC-DS (P < 0.001). In down-staging groups, AFP ≥ 100 (HR, 2.6; P = 0.02) was the only independent predictor of HCC recurrence. CONCLUSIONS Our results validated UNOS-DS criteria based on comparable 3-year survival between UNOS-DS and Milan groups. Additional refinements based on AFP and wait time may further improve post-LT outcomes in down-staging groups, especially given that reported 3-year recurrence was higher than in those always within Milan criteria.
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Affiliation(s)
- Neil Mehta
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Jennifer L. Dodge
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Joshua D. Grab
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Francis Y. Yao
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, San Francisco, CA
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
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10
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Ferguson MK, Gaissert HA, Grab JD, Sheng S. Pulmonary complications after lung resection in the absence of chronic obstructive pulmonary disease: The predictive role of diffusing capacity. J Thorac Cardiovasc Surg 2009; 138:1297-302. [DOI: 10.1016/j.jtcvs.2009.05.045] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2008] [Revised: 04/16/2009] [Accepted: 05/05/2009] [Indexed: 11/25/2022]
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11
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Tabata M, Grab JD, Khalpey Z, Edwards FH, O'Brien SM, Cohn LH, Bolman RM. Prevalence and Variability of Internal Mammary Artery Graft Use in Contemporary Multivessel Coronary Artery Bypass Graft Surgery. Circulation 2009; 120:935-40. [PMID: 19720938 DOI: 10.1161/circulationaha.108.832444] [Citation(s) in RCA: 151] [Impact Index Per Article: 10.1] [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] [Indexed: 11/16/2022]
Abstract
Background—
Use of an internal mammary artery (IMA) is a well-recognized, nationally endorsed quality indicator for evaluating the process of operative care for coronary artery bypass graft surgery. An objective assessment of the current status of IMA use has not been systematically performed.
Methods and Results—
This cross-sectional observational study analyzed data on 541 368 coronary artery bypass graft surgery procedures reported by 745 hospitals in the Society of Thoracic Surgeons National Cardiac Database from 2002 through 2005. We assessed the current status of IMA use, the association of hospital volume and IMA use, and disparities in IMA use by patient gender and race and by region of hospital location. Rates of using at least 1 IMA and bilateral IMA were 92.4% and 4.0%, with increasing trends over the years. Hospital volume was not significantly associated with IMA use. IMAs were used less frequently in women than men (for at least 1 IMA: odds ratio, 0.62; 95% confidence interval, 0.61 to 0.63; for bilateral IMA: odds ratio, 0.65; 95% confidence interval, 0.63 to 0.68) and less frequently in nonwhite patients than white patients (for at least 1 IMA: odds ratio, 0.84; 95% confidence interval, 0.81 to 0.87; for bilateral IMA: odds ratio, 0.79; 95% confidence interval, 0.75 to 0.83). There were significant differences in frequency of IMA use by hospital region.
Conclusions—
Frequency of IMA use in coronary artery bypass graft surgery is increasing; however, many patients still do not receive the benefits of IMA grafts, and some hospitals have a very low IMA use rate. Hospital volume is not associated with IMA use in coronary artery bypass graft surgery. Analysis of this critical performance measure reveals significant gender and race disparities.
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Affiliation(s)
- Minoru Tabata
- From the Division of Cardiac Surgery, Brigham and Women’s Hospital, Boston, Mass (M.T., Z.K., L.H.C., R.M.B.); Duke Clinical Research Institute, Durham, NC (J.D.G., S.M.O.); and Division of Cardiothoracic Surgery, University of Florida, Shands Jacksonville Medical Center, Jacksonville (F.H.E.)
| | - Joshua D. Grab
- From the Division of Cardiac Surgery, Brigham and Women’s Hospital, Boston, Mass (M.T., Z.K., L.H.C., R.M.B.); Duke Clinical Research Institute, Durham, NC (J.D.G., S.M.O.); and Division of Cardiothoracic Surgery, University of Florida, Shands Jacksonville Medical Center, Jacksonville (F.H.E.)
| | - Zain Khalpey
- From the Division of Cardiac Surgery, Brigham and Women’s Hospital, Boston, Mass (M.T., Z.K., L.H.C., R.M.B.); Duke Clinical Research Institute, Durham, NC (J.D.G., S.M.O.); and Division of Cardiothoracic Surgery, University of Florida, Shands Jacksonville Medical Center, Jacksonville (F.H.E.)
| | - Fred H. Edwards
- From the Division of Cardiac Surgery, Brigham and Women’s Hospital, Boston, Mass (M.T., Z.K., L.H.C., R.M.B.); Duke Clinical Research Institute, Durham, NC (J.D.G., S.M.O.); and Division of Cardiothoracic Surgery, University of Florida, Shands Jacksonville Medical Center, Jacksonville (F.H.E.)
| | - Sean M. O'Brien
- From the Division of Cardiac Surgery, Brigham and Women’s Hospital, Boston, Mass (M.T., Z.K., L.H.C., R.M.B.); Duke Clinical Research Institute, Durham, NC (J.D.G., S.M.O.); and Division of Cardiothoracic Surgery, University of Florida, Shands Jacksonville Medical Center, Jacksonville (F.H.E.)
| | - Lawrence H. Cohn
- From the Division of Cardiac Surgery, Brigham and Women’s Hospital, Boston, Mass (M.T., Z.K., L.H.C., R.M.B.); Duke Clinical Research Institute, Durham, NC (J.D.G., S.M.O.); and Division of Cardiothoracic Surgery, University of Florida, Shands Jacksonville Medical Center, Jacksonville (F.H.E.)
| | - R. Morton Bolman
- From the Division of Cardiac Surgery, Brigham and Women’s Hospital, Boston, Mass (M.T., Z.K., L.H.C., R.M.B.); Duke Clinical Research Institute, Durham, NC (J.D.G., S.M.O.); and Division of Cardiothoracic Surgery, University of Florida, Shands Jacksonville Medical Center, Jacksonville (F.H.E.)
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12
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Mason DP, Subramanian S, Nowicki ER, Grab JD, Murthy SC, Rice TW, Blackstone EH. Impact of smoking cessation before resection of lung cancer: a Society of Thoracic Surgeons General Thoracic Surgery Database study. Ann Thorac Surg 2009; 88:362-70; discussion 370-1. [PMID: 19632374 DOI: 10.1016/j.athoracsur.2009.04.035] [Citation(s) in RCA: 142] [Impact Index Per Article: 9.5] [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: 01/23/2009] [Revised: 03/30/2009] [Accepted: 04/01/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Smoking cessation is presumed to be beneficial before resection of lung cancer. The effect of smoking cessation on outcome was investigated. METHODS From January 1999 to July 2007, in-hospital outcomes for 7990 primary resections for lung cancer in adults were reported to the Society of Thoracic Surgeons General Thoracic Surgery Database. Risk of hospital death and respiratory complications was assessed according to timing of smoking cessation, adjusted for clinical confounders. RESULTS Hospital mortality was 1.4% (n = 109), but 1.5% in patients who had smoked (105 of 6965) vs 0.39% in those who had not (4 of 1025). Compared with the latter, risk-adjusted odds ratios were 3.5 (p = 0.03), 4.6 (p = 0.03), 2.6 (p = 0.7), and 2.5 (p = 0.11) for those whose timing of smoking cessation was categorized as current smoker, quit from 14 days to 1 month, 1 to 12 months, or more than 12 months preoperatively, respectively. Prevalence of major pulmonary complications was 5.7% (456 of 7965) overall, but 6.2% in patients who had smoked (429 of 6941) vs 2.5%% in those who had not (27 of 1024). Compared with the latter, risk-adjusted odds ratios were 1.80 (p = 0.03), 1.62 (p = 0.14), 1.51 (p = 0.20), and 1.29 (p = 0.3) for those whose timing of smoking cessation was categorized as above. CONCLUSIONS Risks of hospital death and pulmonary complications after lung cancer resection were increased by smoking and mitigated slowly by preoperative cessation. No optimal interval of smoking cessation was identifiable. Patients should be counseled to stop smoking irrespective of surgical timing.
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Affiliation(s)
- David P Mason
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA.
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13
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Wright CD, Gaissert HA, Grab JD, O'Brien SM, Peterson ED, Allen MS. Predictors of Prolonged Length of Stay after Lobectomy for Lung Cancer: A Society of Thoracic Surgeons General Thoracic Surgery Database Risk-Adjustment Model. Ann Thorac Surg 2008; 85:1857-65; discussion 1865. [DOI: 10.1016/j.athoracsur.2008.03.024] [Citation(s) in RCA: 136] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2008] [Revised: 03/06/2008] [Accepted: 03/10/2008] [Indexed: 10/22/2022]
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14
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Mehta RH, Grab JD, O’Brien SM, Glower DD, Haan CK, Gammie JS, Peterson ED. Clinical Characteristics and In-Hospital Outcomes of Patients With Cardiogenic Shock Undergoing Coronary Artery Bypass Surgery. Circulation 2008; 117:876-85. [DOI: 10.1161/circulationaha.107.728147] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [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] [Indexed: 11/16/2022]
Abstract
Background—
There exist few studies that characterize contemporary clinical features and outcomes or risk factors for operative mortality in cardiogenic shock (CS) patients undergoing coronary artery bypass grafting (CABG).
Methods and Results—
We evaluated data of 708 593 patients with and without CS undergoing CABG enrolled in the Society of Thoracic Surgeons National Cardiac Database (2002–2005). Clinical, angiographic, and operative features and in-hospital outcomes were evaluated in patients with and without CS. Logistic regression was used to identify predictors of operative mortality and to estimate weights for an additive risk score. Patients with preoperative CS constituted 14 956 (2.1%) of patients undergoing CABG yet accounted for 14% of all CABG deaths. Operative mortality in CS patients was high and surgery specific, rising from 20% for isolated CABG to 33% for CABG plus valve surgery and 58% for CABG plus ventricular septal repair. Although mortality for CABG surgery overall declined significantly over time (
P
for trend <0.0001), mortality for CS patients undergoing CABG did not change significantly during the 4-year study period (
P
=0.07). Factors associated with higher death risk for CS patients undergoing CABG were identified by multivariable analysis and summarized into a simple bedside risk score (c statistic=0.74) that accurately stratified those with low (<10%) to very high (>60%) mortality risk.
Conclusions—
Patients with CS represent a minority of those undergoing CABG yet have persistently high operative risks, accounting for 14% of deaths in CABG patients. Estimation of patient-specific risk of mortality is feasible with the simplified additive risk tool developed in our study with the use of routinely available preprocedural data.
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Affiliation(s)
- Rajendra H. Mehta
- From the Duke Clinical Research Institute (R.H.M., J.D.G., S.M.O., E.D.P.) and Duke University Medical Center (R.H.M., D.D.G., E.D.P.), Durham, NC; University of Florida (C.K.H.), Jacksonville; and University of Maryland (J.S.G.), Baltimore
| | - Joshua D. Grab
- From the Duke Clinical Research Institute (R.H.M., J.D.G., S.M.O., E.D.P.) and Duke University Medical Center (R.H.M., D.D.G., E.D.P.), Durham, NC; University of Florida (C.K.H.), Jacksonville; and University of Maryland (J.S.G.), Baltimore
| | - Sean M. O’Brien
- From the Duke Clinical Research Institute (R.H.M., J.D.G., S.M.O., E.D.P.) and Duke University Medical Center (R.H.M., D.D.G., E.D.P.), Durham, NC; University of Florida (C.K.H.), Jacksonville; and University of Maryland (J.S.G.), Baltimore
| | - Donald D. Glower
- From the Duke Clinical Research Institute (R.H.M., J.D.G., S.M.O., E.D.P.) and Duke University Medical Center (R.H.M., D.D.G., E.D.P.), Durham, NC; University of Florida (C.K.H.), Jacksonville; and University of Maryland (J.S.G.), Baltimore
| | - Constance K. Haan
- From the Duke Clinical Research Institute (R.H.M., J.D.G., S.M.O., E.D.P.) and Duke University Medical Center (R.H.M., D.D.G., E.D.P.), Durham, NC; University of Florida (C.K.H.), Jacksonville; and University of Maryland (J.S.G.), Baltimore
| | - James S. Gammie
- From the Duke Clinical Research Institute (R.H.M., J.D.G., S.M.O., E.D.P.) and Duke University Medical Center (R.H.M., D.D.G., E.D.P.), Durham, NC; University of Florida (C.K.H.), Jacksonville; and University of Maryland (J.S.G.), Baltimore
| | - Eric D. Peterson
- From the Duke Clinical Research Institute (R.H.M., J.D.G., S.M.O., E.D.P.) and Duke University Medical Center (R.H.M., D.D.G., E.D.P.), Durham, NC; University of Florida (C.K.H.), Jacksonville; and University of Maryland (J.S.G.), Baltimore
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15
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Boffa DJ, Allen MS, Grab JD, Gaissert HA, Harpole DH, Wright CD. Data from The Society of Thoracic Surgeons General Thoracic Surgery database: The surgical management of primary lung tumors. J Thorac Cardiovasc Surg 2008; 135:247-54. [DOI: 10.1016/j.jtcvs.2007.07.060] [Citation(s) in RCA: 327] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2007] [Revised: 07/20/2007] [Accepted: 07/26/2007] [Indexed: 10/22/2022]
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16
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Hernandez AF, Grab JD, Gammie JS, O'Brien SM, Hammill BG, Rogers JG, Camacho MT, Dullum MK, Ferguson TB, Peterson ED. A Decade of Short-Term Outcomes in Post–Cardiac Surgery Ventricular Assist Device Implantation. Circulation 2007; 116:606-12. [PMID: 17646586 DOI: 10.1161/circulationaha.106.666289] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.8] [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] [Indexed: 11/16/2022]
Abstract
Background—
Previous studies showed 75% mortality before hospital discharge in patients with a ventricular assist device (VAD) placed for post–cardiac surgery shock. We examined a large national clinical database to assess trends in the incidence of post–cardiac surgery shock requiring VAD implantation, survival rates, and risk factors for mortality.
Methods and Results—
We identified patients undergoing a VAD procedure after cardiac surgery at US hospitals participating in the Society of Thoracic Surgeons’ National Cardiac Database during the years 1995 to 2004. Baseline characteristics and operative outcomes were analyzed in 2.5-year increments. Logistic regression modeling was performed to provide risk-adjusted operative mortality and morbidity odds ratios. A total of 5735 patients had a VAD placed during the 10-year period (0.3% cardiac surgeries). Overall survival rate to discharge after VAD placement was 54.1%. With the earliest period (January 1995 through June 1997) used as reference, the mortality odds ratio declined to 0.72 (July 1997 through December 1999) and eventually to 0.41 (July 2002 through December 2004;
P
<0.0001). The combined mortality/morbidity odds ratio also declined, to 0.84 and 0.48 over identical periods (
P
<0.0001). Preoperative characteristics associated with increased mortality were urgency of procedure, reoperation, renal failure, myocardial infarction, aortic stenosis, female sex, race, peripheral vascular disease, New York Heart Association class IV, cardiogenic shock, left main coronary stenosis, and valve procedure (c index=0.755).
Conclusions—
After adjustment for clinical characteristics of patients requiring mechanical circulatory support, rates of survival to hospital discharge have improved dramatically. Insertion of a VAD for post–cardiac surgery shock is an important therapeutic intervention that can salvage most of these patients.
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Savage EB, Grab JD, O'Brien SM, Ali A, Okum EJ, Perez-Tamayo RA, Eiferman DS, Peterson ED, Edwards FH, Higgins RSD. Use of both internal thoracic arteries in diabetic patients increases deep sternal wound infection. Ann Thorac Surg 2007; 83:1002-6. [PMID: 17307448 DOI: 10.1016/j.athoracsur.2006.09.094] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2006] [Revised: 09/27/2006] [Accepted: 09/28/2006] [Indexed: 01/04/2023]
Abstract
BACKGROUND Use of both internal thoracic arteries has been limited in diabetic patients fearing an increased incidence of deep sternal wound infection. We analyzed this concern by querying The Society of Thoracic Surgeons Database. METHODS Diabetic patients who had isolated coronary artery bypass graft surgery during 2002 to 2004 were included if they had no prior bypass surgery, two or more distal bypasses, and a left internal thoracic artery bypass. Group B (both internal thoracic arteries) was compared with group L (left internal thoracic artery only). RESULTS The incidence of deep sternal wound infection for all patients undergoing isolated first-time bypass surgery was less than 1%. Of these, 120,793 patients met criteria for inclusion: group B, 1.4% (1732); and group L, 98.6% (119,061). Group B had a higher crude (unadjusted) deep sternal wound infection rate of 2.8% (49) versus 1.7% (1969; p = 0.0005) in group L, with an estimated odds ratio of 2.23 (95% confidence interval, 1.69 to 2.96). Group B had a similar crude mortality rate of 1.7% (30) versus 2.3% (2785; p = NS) in group L, with an estimated odds ratio of 1.110 (95% CI, 0.78 to 1.59; p = NS). Patients in group B were younger, mostly male, had a lower serum creatinine level, and were more often current smokers; less commonly, they were insulin dependent, diagnosed with pulmonary or vascular disease, or on dialysis. Other risk factors for deep sternal would infection included female gender, insulin dependence, peripheral vascular disease, recent infarction, body mass index exceeding 35 kg/m2, and use of blood products. CONCLUSIONS There is a significant increase in the incidence of deep sternal would infection in diabetic patients. This is further increased with the use of both internal thoracic arteries with no apparent short-term mortality difference.
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Affiliation(s)
- Edward B Savage
- Department of Surgery, St. John's Mercy Medical Center, St. Louis, Missouri, USA.
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Mehta RH, Grab JD, O'Brien SM, Bridges CR, Gammie JS, Haan CK, Ferguson TB, Peterson ED. Bedside tool for predicting the risk of postoperative dialysis in patients undergoing cardiac surgery. Circulation 2006; 114:2208-16; quiz 2208. [PMID: 17088458 DOI: 10.1161/circulationaha.106.635573] [Citation(s) in RCA: 370] [Impact Index Per Article: 20.6] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND Estimation of an individual patient's risk for postoperative dialysis can support informed clinical decision making and patient counseling. METHODS AND RESULTS To develop a simple bedside risk algorithm for estimating patients' probability for dialysis after cardiac surgery, we evaluated data of 449,524 patients undergoing coronary artery bypass grafting (CABG) and/or valve surgery and enrolled in >600 hospitals participating in the Society of Thoracic Surgeons National Database (2002-2004). Logistic regression was used to identify major predictors of postoperative dialysis. Model coefficients were then converted into an additive risk score and internally validated. The model also was validated in a second sample of 86,009 patients undergoing cardiac surgery from January to June 2005. Postoperative dialysis was needed in 6451 patients after cardiac surgery (1.4%), ranging from 1.1% for isolated CABG procedures to 5.1% for CABG plus mitral valve surgery. Multivariable analysis identified preoperative serum creatinine, age, race, type of surgery (CABG plus valve or valve only versus CABG only), diabetes, shock, New York Heart Association class, lung disease, recent myocardial infarction, and prior cardiovascular surgery to be associated with need for postoperative dialysis (c statistic=0.83). The risk score accurately differentiated patients' need for postoperative dialysis across a broad risk spectrum and performed well in patients undergoing isolated CABG, off-pump CABG, isolated aortic valve surgery, aortic valve surgery plus CABG, isolated mitral valve surgery, and mitral valve surgery plus CABG (c statistic=0.83, 0.85, 0.81, 0.75, 0.80, and 0.75, respectively). CONCLUSIONS Our study identifies the major patient risk factors for postoperative dialysis after cardiac surgery. These risk factors have been converted into a simple, accurate bedside risk tool. This tool should facilitate improved clinician-patient discussions about risks of postoperative dialysis.
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