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Arteriovenous fistula (AVF) aneurysms are a chronic complication which can be disfiguring, painful, and can rupture. Here, we compare the outcomes between three different methods of AVF aneurysm repair.One-way ANOVA, Chi-square, and Fisher Exact analyses were used to compare demographics. Multivariate logistic regression compared outcomes. Kaplan-Meier estimate illustrated long-term fistula patency.There were no differences between demographics in the aneurysmorrhaphy, end-to-end anastomosis, and synthetic graft groups. The odds of patients who received graft repair losing primary patency within one year compared to the aneurysmorrhaphy group was 3.5 (p = 0.025). Graft repair patients were 6.7 times more likely to develop an infection compared to aneurysmorrhaphy (p = 0.014). Synthetic grafts also exhibited accelerated rates of complete access loss compared to autogenous methods (p = 0.034).Graft repair of AVF aneurysms results in higher rates of infection and decreased primary and ultimate patency compared to autogenous repair techniques. Therefore, synthetic grafts should be avoided whenever possible.

Uterine transplant (UTx) is performed to address absolute uterine infertility in the presence of uterine agenesis, a non-functional uterus, or following a prior hysterectomy. Following the initial success of UTx resulting in a livebirth (2014) in Sweden, there are over 70 reported UTx surgeries resulting in more than 40 livebirths worldwide. Currently, UTx has been performed in over 10 countries. As UTx is transitioning from an "experimental procedure" to a clinical option, an increasing number of centers may contemplate a UTx program. This article discusses essential steps for establishment of a successful UTx program. These principles may be implemented in cis- and transgender UTx candidates.

To repurpose therapeutics for fibrolamellar carcinoma (FLC), we developed and validated patient-derived xenografts (PDX) from surgical resections. Most agents used clinically and inhibitors of oncogenes overexpressed in FLC showed little efficacy on PDX. A high-throughput functional drug screen found primary and metastatic FLC were vulnerable to clinically available inhibitors of TOPO1 and HDAC and to napabucasin. Napabucasin's efficacy was mediated through reactive oxygen species and inhibition of translation initiation, and specific inhibition of eIF4A was effective. The sensitivity of each PDX line inversely correlated with expression of the antiapoptotic protein Bcl-xL, and inhibition of Bcl-xL synergized with other drugs. Screening directly on cells dissociated from patient resections validated these results. This demonstrates that a direct functional screen on patient tumors provides therapeutically informative data within a clinically useful time frame. Identifying these novel therapeutic targets and combination therapies is an urgent need, as effective therapeutics for FLC are currently unavailable. Significance: Therapeutics informed by genomics have not yielded effective therapies for FLC. A functional screen identified TOPO1, HDAC inhibitors, and napabucasin as efficacious and synergistic with inhibition of Bcl-xL. Validation on cells dissociated directly from patient tumors demonstrates the ability for functional precision medicine in a solid tumor. This article is highlighted in the In This Issue feature, p. 2355

Positive resection margins are associated with worse survival after surgery for adrenocortical carcinoma (ACC). We aimed to identify risk factors for positive margins post-resection.The NCDB was queried for ACC patients from 2006 to 2015. Patients with positive versus negative resection margins post-surgery were compared using Chi-square tests. Survival based on adjuvant treatment was assessed using Kaplan-Meier curves.1,973 patients with ACC were identified, 217 (11.0%) with positive margins. Multivariable analysis identified extra-adrenal extension (HR 4.92, p 0.001), lymph node metastases (HR 2.64, p = 0.001), and distant metastases (HR 1.53, p = 0.03) as risk factors for positive margins. No significant difference in margin status existed between patients who had an open versus minimally invasive procedure (p = 0.6). Positive margin patients receiving adjuvant radiation (p = 0.007) or combined chemo-radiation (p = 0.001) had the longest survival.No modifiable risk factors were identified, but patients with positive margins receiving adjuvant radiation or chemo-radiation had the longest survival.

A national study analyzing the association between preoperative steroid use and outcomes after pancreatic resections is lacking. The purpose of this study is to evaluate the association between preoperative steroids and outcomes after pancreaticoduodenectomy using a national database.A retrospective analysis of patients undergoing pancreaticoduodenectomy was performed using the National Surgical Quality Improvement Program (NSQIP) database (2014-2019). In addition, we utilized propensity score matching to compare patients on preoperative steroids to those who were not. Outcomes measured included 30-day complications and mortality, need for readmission, a prolonged hospital length of stay, delayed gastric emptying, and pancreatic fistula.After propensity score matching, there were 438 patients in the steroid group and 876 patients in the no steroid group. There was no difference in pancreatic fistula (23.8% vs. 21.7%; p-0.3), delayed gastric emptying (21.1% vs.20.1%; p-0.06), major complications (31.8% vs. 30.1%; p-0.1), and mortality (3.5% vs. 3.2%; p-0.6) between the two groups.Glucocorticoids did not reduce the incidence of overall complications, postoperative fistula, and delayed gastric emptying following pancreaticoduodenectomy.

Many current guidelines recommend nonoperative management for pancreatic neuroendocrine tumors2 cm. The objective of this study was to evaluate the utilization and outcomes of resection for these pancreatic neuroendocrine tumors in the United States.Using the National Cancer Database (2004-2014), 3,243 cases of T1 (≤2.0 cm) pancreatic neuroendocrine tumors were identified. Additional patient and tumor characteristics were examined. Multivariate models were used to identify factors that predicted resection and to assess patient survival after resection.75% of pancreatic neuroendocrine tumors measuring 0 to 1.0 cm and 80% of pancreatic neuroendocrine tumors measuring1.0 and ≤2.0 cm were resected. Eighty-four pancreatic neuroendocrine tumors were functional, of which 82% were resected. Variables influencing resection included positive lymph nodes, tumor in body or tail of pancreas, well or moderately differentiated tumors, and resection at academic medical centers (odds ratio 1.5-4.9). When controlling for other variables, patients with pancreatic neuroendocrine tumors 1 to 2 cm who underwent resection had a prolonged 5-year survival rate (hazard ratio 0.51, confidence interval 0.34-0.75) when compared with those who did not undergo resection. This survival benefit of resection was not found for pancreatic neuroendocrine tumors 0 to 1 cm (hazard ratio = 0.63, confidence interval 0.36-1.11).Contrary to many current recommendations, most patients with pancreatic neuroendocrine tumors ≤2.0 cm undergo surgical resection in the United States. A survival benefit was found for resection of pancreatic neuroendocrine tumors 1 to 2 cm, suggesting that current recommendations should perhaps be revised.

Background Adrenocortical carcinoma (ACC) is a rare malignancy with a dismal prognosis. Two landmark trials published in 2007 and 2012 showed efficacy for adjuvant mitotane in resectable ACC and etoposide/doxorubicin/cisplatin plus mitotane for unresectable ACC, respectively. In this study, we used the National Cancer Database to examine whether treatment patterns and outcomes changed after these trials. Methods The National Cancer Database was used to examine treatment patterns and survival in patients diagnosed with ACC from 2006 to 2015. Treatment modalities were compared within that group and with a historical cohort (1985 to 2005). χ2 tests were performed, and Cox proportional hazards models were created. Results From 2006 to 2015, 2752 patients were included; 38% of patients (1042) underwent surgery alone, and 31% (859) underwent surgery with adjuvant therapy. Overall 5-year survival rates for all stages after resection were 43% (median, 41 months) in the contemporary cohort and 39% (median, 32 months) in the historical cohort. After 2007, patients who underwent surgery were more likely to receive adjuvant chemotherapy (P = 0.005), and 5-year survival with adjuvant chemotherapy improved (41% vs 25%; P = 0.02). However, survival did not improve in patients with unresectable tumors after 2011 compared with 2006 to 2011 (P = 0.79). Older age, tumor size ≥10 cm, distant metastases, and positive margins were associated with lower survival after resection (hazard ratio range: 1.39 to 3.09; P < 0.03). Conclusions Since 2007, adjuvant therapy has been used more frequently in patients with resected ACC, and survival for these patients has improved but remains low. More effective systemic therapies for patients with ACC, especially those in advanced stages, are desperately needed.

Background COVID‐19 epidemiologic studies comparing immunosuppressed and immunocompetent patients may provide insight into the impact of immunosuppressants on outcomes. Methods In this retrospective cohort study, we assembled kidney or kidney‐pancreas transplant recipients who underwent transplant from January 1, 2010, to June 30, 2020, and kidney or kidney‐pancreas waitlisted patients who were ever on the waitlist from January 1, 2019, to June 30, 2020. We identified laboratory‐confirmed COVID‐19 until January 31, 2021, and tracked its outcomes by leveraging informatics infrastructure developed for an outcomes research network. Results COVID‐19 was identified in 62 of 887 kidney or kidney‐pancreas transplant recipients and 20 of 434 kidney or kidney‐pancreas waitlisted patients (7.0% vs. 4.6%, p = .092). Of these patients with COVID‐19, hospitalization occurred in 48 of 62 transplant recipients and 8 of 20 waitlisted patients (77% vs. 40%, p = .002); intensive care unit admission occurred in 18 of 62 transplant recipients and 2 of 20 waitlisted patients (29% vs. 10%, p = .085); and 7 transplant recipients were mechanically ventilated and died, whereas no waitlisted patients were mechanically ventilated or died (11% vs. 0%, p = .116). Conclusions Our study provides single‐center data and an informatics approach that can be used to inform the design of multicenter studies.

Background The extent of liver resection for tumours is limited by the expected functional reserve of the future liver remnant (FRL), so hypertrophy may be induced by portal vein embolization (PVE), taking 6 weeks or longer for growth. This study assessed the hypothesis that simultaneous embolization of portal and hepatic veins (PVE/HVE) accelerates hypertrophy and improves resectability. Methods All centres of the international DRAGON trials study collaborative were asked to provide data on patients who had PVE/HVE or PVE on 2016–2019 (more than 5 PVE/HVE procedures was a requirement). Liver volumetry was performed using OsiriX MD software. Multivariable analysis was performed for the endpoints of resectability rate, FLR hypertrophy and major complications using receiver operating characteristic (ROC) statistics, regression, and Kaplan–Meier analysis. Results In total, 39 patients had undergone PVE/HVE and 160 had PVE alone. The PVE/HVE group had better hypertrophy than the PVE group (59 versus 48 per cent respectively; P = 0.020) and resectability (90 versus 68 per cent; P = 0.007). Major complications (26 versus 34 per cent; P = 0.550) and 90-day mortality (3 versus 16 per cent respectively, P = 0.065) were comparable. Multivariable analysis confirmed that these effects were independent of confounders. Conclusion PVE/HVE achieved better FLR hypertrophy and resectability than PVE in this collaborative experience.

BACKGROUND Patient compliance with immunosuppressive therapy after transplant has impacts on both graft and patient outcomes. For diabetic end-stage renal disease (ESRD) patients who are undergoing evaluation for kidney transplantation in our program, hemoglobin A1c (HbA1c) level of >10% is used as a flag that the patient may be at risk for noncompliance and that more comprehensive psychosocial screening is needed prior to transplant. We evaluated the association between pre-transplant HbA1c level and post-transplant compliance, as no study to date has looked at this in the transplant population. MATERIAL AND METHODS The charts of 392 patients who received a kidney transplant at a single institution between July 2008 and June 2012 were retrospectively reviewed. One hundred and sixty-five diabetic patients who received a kidney transplant alone were included in the final analysis. Our predictive variable was HbA1c level greater than 7.7% based on previous reports in the diabetic population. Outcome measures were graft survival, rejection episodes, unexplained low immunosuppressant levels, and documented noncompliance. RESULTS There were no statistically significant differences between the HbA1c groups of ≤7.7% and >7.7% in outcomes of failed grafts (22.0% and 17.8%, p=0.2), rejection episodes (15.0% and 6.7%, p=0.3), unexplained low immunosuppressant level (46.6% and 37.9%, p=0.3), and documented noncompliance (25.0% and 16.7%, p=0.4). CONCLUSIONS In diabetic ESRD patients selected for renal transplantation, elevated pre-transplant HbA1c levels, defined as HbA1c >7.7%, are not predictive of post-transplant medication compliance. We advocate that this group of patients should not be denied transplant solely on their elevated pre-transplant HbA1c.

Techniques such as the use of nonpenetrating vascular clips for arteriovenous fistula (AVF) anastomotic creation have been developed in an effort to reduce fistula-related complications. However, the outcomes data for the use of clips have remained equivocal, and the cost evaluations to support their use have been largely theoretical. Therefore, the present study aimed to determine both the clinical and the cost outcomes of AVFs created with nonpenetrating vascular clips compared with the continuous suture technique during a 10-year period at a single institution.All patients undergoing AVF creation in the upper extremity from 2009 through 2018 were retrospectively analyzed. The patient demographics and AVF outcomes were collected and compared stratified by the surgical technique used. A cost analysis was performed of a subgroup of patients from 2013 to 2018.During the 10-year study period, 916 AVFs were created (79% using the continuous suture technique and 21% using nonpenetrating vascular clips). Patient demographics and comorbid conditions did not differ between the two groups, and no differences were present in maturation, primary patency, assisted primary patency, or complication rates between the two groups at 1 year. The suture group had a shorter time to maturation (4.3 months vs 5.5 months; P .01) and improved secondary patency compared with the clip group (77.13% vs 69.59%; P = .03) The cost analysis of the procedures revealed a significant difference in direct costs (suture, $1389.26 vs clip, $1716.51; P .01) and contribution margin (suture, $1770.19 vs clip, $1128.36; P .01) for the two groups.Both suture and clip techniques in AVF creation demonstrated equivalent rates of maturation, primary patency, assisted primary patency, and complications at 1 year with higher expense associated with the use of clips. Thus, in an effort to reduce the economic burden of healthcare in the United States, the findings from the present study support the preferential use of the standard polypropylene suture technique when creating upper extremity AVFs.

Venous thromboembolism (VTE) occurs at high incidence in abdominal cancer surgery; therefore, a 4-week postoperative VTE prophylaxis is advocated. However, most patients with neuroendocrine tumors (NETs) have more favorable prognoses. This study aimed to determine the incidence of VTE in patients with abdominal NETs, compare these rates to other abdominal malignancies, and identify VTE risk factors. The ACS-NSQIP database was queried to identify patients with abdominal NETs and other abdominal malignancies who underwent surgery from 2008 to 2015. A 30-day postoperative VTE incidence for each group was compared. Univariable and multivariable analyses were used to identify VTE risk factors. Of the 7226 operations for patients with benign (2154) and malignant (5072) abdominal NETs, 144 patients experienced a VTE without significant differences between groups. Subgroup analysis revealed a spectrum of VTE rates. Compared to VTE rates of other abdominal malignancies, patients with benign (1.1% vs. 2.4%, p

The objective of the study was to determine the long-term stricture rate of hepaticojejunostiomy (HJ) performed for benign disease, to compare stricture rates for transplant patients and nontransplant patients, and to compare the success rates of procedural and surgical treatment options. Hospital charts of 135 consecutive patients undergoing HJ between 1998 and 2016 were analyzed retrospectively. The primary outcome was stricture formation. Secondary outcomes were time to stricture diagnosis and success rates of various interventions. The anastomotic stricture rate was 13.3 per cent (18). The mean follow-up period was 4.3 years. The mean time to stricture diagnosis was 2.3 years. Stricture rates were similar between the transplant (19.2%) and nontransplant, non-Whipple group (13%). Strictures were treated with radiological intervention with a 44.4 per cent success rate; each required multiple interventions. Mortality from liver disease after failure of nonoperative management of HJ strictures reached 30 per cent (3). Five of ten patients who failed radiological intervention underwent HJ revision; the success rate was 80 per cent. Anastomotic strictures of HJ performed for benign disease occur in 13 per cent of patients and typically develop within 2.5 years postoperatively. Yet, given the dangerous sequelae of chronic biliary obstruction and potential delay in presentation, a follow-up is recommended for up to 10 years. When strictures occur, HJ revision should be considered early, after two failed radiological interventions.

Heat stroke is a multiple organ dysfunction syndrome of poorly understood pathogenesis. Exertional heat stroke with acute liver failure is a rarely reported condition. Liver transplant has been recommended as treatment in cases of severe liver dysfunction; however, there are only 5 described cases of long-term survival after this procedure in patients with heat stroke. Here, we present 2 cases of young athletes who developed heat stroke. Both patients developed acute liver failure and were listed for liver transplant. Liver function tests of one patient improved, and he was discharged on postoperative day 13. The other patient showed no signs of improvement and liver biopsy showed massive necrosis. The patient underwent combined kidney-liver transplant and was discharged on postoperative day 17. After a follow-up of longer than 6 years, both patients are doing well with normal liver function and no neurologic sequelae. We also reviewed all published cases of hepatic failure associated with heat stroke and found 9 published cases of liver transplant for heat stroke in the English literature. Conservative management appears to be justified in heat stroke-associated liver failure, even in the presence of accepted criteria for emergency liver transplant. If the liver does not show signs of recovery and hepatic decompensation progresses, liver transplant should be performed.

Patients with gastroenteropancreatic neuroendocrine tumors often present with stage IV disease. Primary tumor resection in these patients remains controversial. Herein, we studied the impact of primary tumor removal, identified variables associated with prolonged survival for each neuroendocrine tumor subtype, and determined factors that influence surgeons to perform primary tumor resection.Patients with metastatic gastroenteropancreatic neuroendocrine tumors diagnosed from 2004 to 2014 were identified from the National Cancer Database. Nested Cox proportional hazards and logistic regression models were used to assess variables associated with survival and primary resection.A total of 14,510 patients met inclusion criteria. On multivariable analysis, resection of the primary tumor and grade 1 or 2 tumors was associated with prolonged survival in all subtypes (P.001). Organ-specific variables associated with prolonged survival in patients undergoing primary tumor resection included the following: low grade for all organs; young age for pancreatic, small intestinal, colonic, and rectal neuroendocrine tumor; tumor size for colonic and rectal neuroendocrine tumor; and tumor location for colonic neuroendocrine tumor. Low tumor grade was found to be significantly associated with removal of the primary tumor across all organs.This study is the first suggesting that primary tumor resection is associated with prolonged survival for all gastro-entero-pancreatic NETs. Additional variables related to survival for each NET subtype were identified and might help select patients who benefit from primary tumor removal.

Statin use in patients listed for in kidney transplant is believed to be beneficial. However, the optimum statin dose for improved survival in this high-risk population is unknown. Our study aimed to determine the impact of prekidney transplant statin dosage on survival postkidney transplant. In this retrospective cohort study, we enrolled patients who underwent kidney transplant from January 2005 to September 2015 at Rush University Medical. Data on the statin use and intensity used before kidney transplant were obtained. The patient population was stratified into 2 groups based on prekidney transplant use of statins. Patients using any form of statin, without regard to the type and dose, were placed in the statin groups, whereas the rest were categorized as the no statin group. The statin group was further classified into low-intensity, moderate-intensity, and high-intensity statin subgroups based on the present atherosclerotic cardiovascular disease definition of statin intensity. The primary outcome was patient survival after kidney transplant. A total of 687 patients had data on statin use before kidney transplant were followed. Median follow-up time was 3.4 years (interquartile range 1.2 to 5.6 years). Multivariate analysis showed that the use of statins prekidney transplant was associated with improved survival postkidney transplant compared with prestatin group (Hazard ratio 0.56, confidence intervals 0.32 to 1.00, p = 0.05). When patients on statins were stratified by statin intensity, Kaplan-Meier survival analysis revealed a significant dose-dependent improvement in survival. Multivariate analysis showed that the relation between statin intensity and survival was maintained even after adjusting for confounder (hazard ratio 0.30, confidence intervals 0.18 to 0.51, p0.001). In conclusion, our data indicate statistically significant survival benefit in patients receiving high-intensity statin before kidney transplant.

Introduction The decision for isolated kidney transplant (KT) vs. combined liver–kidney transplant (CLKT) in patients with end-stage renal disease (ESRD) with compensated cirrhosis remains controversial. We sought to determine outcomes of patients requiring listing for a liver transplant (LT) following either a cadaveric or living donor KT and compare these outcomes to similar patients receiving a CLKT. Methods Our dataset included the United Network for Organ Sharing (UNOS)/Standard Transplant and Analysis and Research (STAR) kidney files from 1987 to 2012 after being joined with the liver files from 2002 to 2012. Outcomes of patients who received a CLKT with an international normalized ratio (INR) ≤1 and total bilirubin ≤1 were compared to patients who received a primary KT and subsequently required listing for LT between zero and five yr or after five yr. Results For the three groups, 244 patients had a CLKT, 216 were wait-listed for LT between zero and five yr after KT (0–5 WL), and 320 were wait-listed five yr after KT (+5 WL). From the time of KT, the 0–5 WL group had significantly worse survival than the CLKT group and the +5 WL group. The +5 WL had the best survival of all groups. For the 0–5 WL group, 45% underwent LT and 40% died while waiting compared to the +5 WL group with 53% having LT and 26% died while waiting. At the time of LT, the 0–5 WL group had a higher model for end-stage liver disease (MELD) score, higher incidence of being in the ICU at the time of transplant, and higher incidence of requiring life support. From the time of LT, the CLKT trended toward better survival (p = 0.0549) than both the 0–5 WL and +5 WL groups, which had equivalent survival. Conclusion The 0–5 WL group is a higher risk group with poorer survival due to a higher incidence of dying on the waitlist. Better identification of patients with a high risk for hepatic decompensation following KT and agreement for regional exception for LT in the event of decompensation may improve utilization of organs and better survival for those patients.

Type 1 primary hyperoxaluria (PH1) causes renal failure, for which isolated kidney transplantation (KT) is usually unsuccessful treatment due to early oxalate stone recurrence. Although hepatectomy and liver transplantation (LT) corrects PH1 enzymatic defect, simultaneous auxiliary partial liver transplantation (APLT) and KT have been suggested as an alternative approach. APLT advantages include preservation of the donor pool and retention of native liver function in the event of liver graft loss. However, APLT relative mass may be inadequate to correct the defect. We here report the first case of native portal vein embolization (PVE) to increase APLT to native liver mass ratio (APLT/NLM-R). Following initial combined APLT-KT, both allografts functioned well, but oxalate plasma levels did not normalize. We postulated the inadequate APLT/NLM-R could be corrected by trans-hepatic native PVE. The resulting increased APLT/NLM-R decreased serum oxalate to normal levels within 1 month following PVE. We conclude that persistently elevated oxalate levels after combined APLT-KT for PH1 treatment, results from inadequate relative functional capacity. This can be reversed by partial native PVE to decrease portal flow to the native liver. This approach might be applicable to other scenarios where partial grafts have been transplanted to replace native liver function.

Purpose: Ureteroneocystostomy (UCN) is the most widely used urinary reconstruction technique during kidney transplantation. Disadvantages of this technique include a high incidence of hematuria and reflux, plus the potential for obstruction resulting from distal ureteral fibrosis. Pyeloureterostomy (PU) avoids these complications but increases the technical complexity. Methods: Between January 1990 and December 2005, 1066 adults patients underwent kidney transplantations; 768 patients (72.1%) had urinary reconstruction by PU and 298 (27.9%) underwent UNC. Results: Patients in the PU group underwent simultaneous ipsilateral native nephrectomy. The operative time was longer in the PU group compared with the UNC group: 210 � 36 min versus 182 � 24 min (P < 0.001). Overall surgical complications in the PU group were comparable to those in the UNC group (9.5% versus 12.3%). The urinary complication rate was also comparable in both groups: 3.2% (25 of 768) in the PU group and 5% (15 of 298) in the UNC group. However, urinary obstruction comprised 60% of urinary complications in the UNC group, compared with 32% in the PU group (P < 0.01). We treated most urinary complications non-operatively. However, 24% of patients (six of 25) in the PU group needed operative intervention or revision for ureteral reconstruction, compared with 46.6% (seven of 15) in the UNC group (P < 0.01). Conclusions: Pyeloureterostomy is a safe and effective method for urinary tract reconstruction in renal transplantation. Pyeloureterostomy should be part of every transplant surgeon’s armamentarium.

As patients with end-stage renal disease are receiving renal allografts at older ages, the number of male renal transplant recipients (RTRs) being diagnosed with prostate cancer (CaP) is increasing. Historically, the literature regarding the management of CaP in RTR's is limited to case reports and small case series. To date, there are no standardized guidelines for screening or management of CaP in these complex patients. To better understand the unique characteristics of CaP in the renal transplant population, we performed a literature review of PubMed, without date limitations, using a combination of search terms including prostate cancer, end stage renal disease, renal transplantation, prostate cancer screening, prostate specific antigen kinetics, immuno-suppression, prostatectomy, and radiation therapy. Of special note, teams facilitating the care of these complex patients must carefully and meticulously consider the altered anatomy for surgical and radiotherapeutic planning. Active surveillance, though gaining popularity in the general low risk prostate cancer population, needs further study in this group, as does the management of advance disease. This review provides a comprehensive and contemporary understanding of the incidence, screening measures, risk stratification, and treatment options for CaP in RTRs.

Cytomegalovirus (CMV)-seronegative kidney transplant (KTx) recipients of organs from CMV-seropositive donors (D+/R-) are at increased risk for CMV infection. Despite valganciclovir (VGCV) prophylaxis (900 mg daily for 200 days), late-onset CMV (LO-CMV) occurs at excessive rates. VGCV-associated cost and toxicities remain problematic.We retrospectively evaluated 50 D+/R- adult KTx recipients from August 2008 to August 2014 who received low-dose VGCV (450 mg daily) prophylaxis for an extended duration. The primary outcome was occurrence of CMV disease.All patients received depletion induction and underwent ABO-compatible KTx. Mean prophylaxis and follow-up durations were 22.8 and 40.7 months, respectively. Eight patients developed CMV: 5 breakthrough cases (1 case of colitis [2%] and 4 cases of infection [8%]) and 3 cases of LO-CMV (1 syndrome [2.9%] and 2 cases of infection [5.7%]). On logistic regression, longer duration of VGCV prophylaxis was protective against CMV infection or disease (P = .044; odds ratio, 1.12 [95% confidence interval, 1.03-1.29]). None of 19 recipients with prophylaxis for ≥12 months developed LO-CMV compared with 3 of 16 recipients with prophylaxis for 12 months (18.8%) (P = .086). Four patients had recurrence of CMV, and 1 patient developed resistance. CMV was not responsible for graft or patient loss and did not affect survival.Low-dose VGCV is an effective prophylaxis for D+/R- KTx recipients despite depleting induction. Longer prophylaxis is more protective, and receiving VGCV for ≥12 months nearly eradicated LO-CMV without increasing antiviral resistance.

BackgroundMany patients on hemodialysis do not have adequate anatomy for native arteriovenous fistulas. In these patients, synthetic conduits remain an alternative option for permanent hemodialysis access. We sought to compare the standard cuffed expanded polytetrafluoroethylene (ePTFE) graft with the bovine carotid artery (BCA) graft.MethodsThis was a prospective, randomized controlled trial that was set in an academic medical center. We enrolled 26 patients in the BCA group and 27 patients in the ePTFE group. Primary, assisted primary, and secondary patency were calculated using the Kaplan-Meier method. Complications were monitored and are reported.ResultsAlthough there was no significant difference in secondary patency rates, primary and assisted primary patency rates were significantly higher in BCA than in the ePTFE grafts (60.5% vs 10.1% and 60.5% vs 20.8% at 1 year, respectively). The BCA graft survival advantage was most profound in the upper arm grafts with significantly higher primary and assisted patency rates (P < .0001 and .0005, respectively). The total number of interventions (upper arm grafts) and total number of angioplasties (overall and upper arm) required to maintain patency were significantly fewer in the BCA group. The most common complication was graft thrombosis which occurred 0.34 ± 0.09 times per patient year in the BCA group compared to 0.77 ± 0.16 times per patient year in the ePTFE group, P = .01.ConclusionThe BCA graft is an excellent option for patients on hemodialysis that are not suitable for native arteriovenous fistulas, as these grafts required fewer interventions than the ePTFE grafts to maintain patency.

The effect of the model for end-stage liver disease (MELD) system on the post-transplant survival of patients with hepatocellular carcinoma (HCC) has not been fully elucidated. Our objective is to review the results of liver transplantation (LT) for HCC at the Massachusetts General Hospital over a period of 12 years, with special emphasis on the effect of the MELD system. A retrospective review of 73 patients who underwent liver transplantation for HCC between 1995 and 2007. Outcome measures included demographics, tumor stage at explant, patient survival, and tumor recurrence. On pathologic review of the explanted liver, 12.3% of patients were classified as stage I; 42.5% as stage II, 21.9% as stage III, and 23.3% as stage IV. The overall actual survival rate was 85% at 1 year, 82% at 3 years, 73% at 5 years, and 66% at 10 years. Overall tumor recurrence was 11%. Survival rates were higher after the MELD system (5 year survival 60% before MELD vs. 85% after MELD). Recurrence decreased from 21% to 7.5%. We showed improved survival for HCC after LT over the last 12 years, and especially improved survival and decreased recurrence in the time since the implementation of the MELD system.

Orthotopic liver transplantation is the only available treatment for severe liver failure, but it is currently limited by organ shortage. One technical challenge that has thus far limited the development of a tissue-engineered liver graft is oxygen and nutrient transport. Here we demonstrate a novel approach to generate transplantable liver grafts using decellularized liver matrix. The decellularization process preserves the structural and functional characteristics of the native microvascular network, allowing efficient recellularization of the liver matrix with adult hepatocytes and subsequent perfusion for in vitro culture. The recellularized graft supports liver-specific function including albumin secretion, urea synthesis and cytochrome P450 expression at comparable levels to normal liver in vitro. The recellularized liver grafts can be transplanted into rats, supporting hepatocyte survival and function with minimal ischemic damage. These results provide a proof of principle for the generation of a transplantable liver graft as a potential treatment for liver disease.

Elimination of galactose-α( 1 , 3 )galactose (Gal) expression in pig organs has been previously shown to prevent hyperacute xenograft rejection. However, naturally present antibodies to non-Gal epitopes activate endothelial cells, leading to acute humoral xenograft rejection. Still, it is unknown whether xenogeneic pig liver sinusoidal endothelial cells (LSECs) from α( 1 , 3 )galactosyltransferase (GalT)-deficient pigs are damaged by antibody and complement-mediated mechanisms. The present study examined the xeno-antibody response of LSECs from GalT-deficient and wild pigs. Isolated LSEC from wild-type and GalT pigs were expose to human and baboon sera; IgM and IgG binding was analyzed by flow cytometry. Complement activation (C3a and CH50) was quantified in vitro from serum-exposed LSEC cultures using Enzyme-Linked ImmunoSorbent assay (ELISA). Levels of complement-activated cytotoxicity (CAC) were also determined by a fluorescent Live-Dead Assay and by the quantification of LDH release. IgM binding to GalT knockout (KO) LSECs was significantly lower (80% human and 87% baboon) compare to wild-type pig LSEC. IgG binding was low in all groups. Moreover, complement activation (C3a and CH50) levels released following exposure to human or baboon sera were importantly reduced (42% human and 52% baboon), CAC in GalT KO LSECs was reduced by 60% in human serum and by 72% in baboon serum when compared to wild-type LSECs, and LDH release levels were reduced by 37% and 57%, respectively. LSECs from GalT KO pigs exhibit a significant protection to humoral-induced cell damage compared to LSECs from wild pigs when exposed to human serum. Although insufficient to inhibit xenogeneic reactivity completely, transgenic GalT KO expression on pig livers might contribute to a successful application of clinical xenotransplantation in combination with other protective strategies.

There is a paucity of data on long-term outcomes of older kidney recipients. Our aim was to compare the early and long-term outcomes of deceased donor kidney transplantation in patients agedor=60 years with outcomes in younger recipients.From 1998 to 2005, we performed 271 deceased donor kidney transplants. There were 76 recipients (28.1%)60 years old. Older candidates were carefully selected based on their physiologic, cardiac, and performance status. Demographic data, including clinical characteristics, early complications, mortality, and patient and graft survival rates, were collected and analyzed.Older patients had comparable perioperative mortality and morbidity, incidence of delayed graft function (DGF), length of stay, and readmissions compared with younger patients. The rates of acute rejection and major infections were also comparable between the 2 study groups. Among older recipients, 25/76 (32.1%) patients received extended criteria donor kidneys compared with only 35/195 (17.9%) of younger patients (P.001). Nevertheless, equivalent 1-, 3-, and 5-year allograft survival rates were observed in elderly and young patients; 91.5% versus, 92.5%, 78.5% versus 81.9%, and 75.6% versus 78.5%, respectively. Overall patient survival was also comparable in both groups.Kidney transplantation in appropriately selected elderly recipients provides equivalent outcomes compared with those observed in younger patients. These observations support the notion that older recipients should not lose access to deceased donor kidney transplantation in the effort to achieve a perceived gain in social utility.

Background Development of venous outflow stenosis has been a major obstacle in maintaining the patency of dialysis vascular grafts. In the present study, we retrospectively analyzed the long-term results of cuffed expanded polytetrafluoroethylene (ePTFE) and non-cuffed (standard) ePTFE grafts placed for hemodialysis access. Materials and methods A total of 67 patients who underwent placement of either cuffed (n = 41) or standard (n = 26) ePTFE grafts were retrospectively analyzed. There were no significant differences between the two groups with regard to age, gender, cause of end-stage renal disease, and anatomic placement of the graft. Endpoints consisted of primary (without any intervention) and secondary (with radiological or surgical intervention) graft patency rates at 1-3 years. Results There was a trend toward better primary graft patency rates in the cuffed versus the standard ePTFE: 37.7% vs. 25.7% at 1 year, 35% vs. 10.3% at 2 years, 28% vs. 5.1% at 3 years, respectively (p = 0.086, Kaplan-Meier). Secondary patency rates in the cuffed group were significantly superior (p = 0.047) to those in the standard group (81.8% vs. 56.1% at 1 year, 61.8% vs. 46.3% at 2 years, 51.5% vs. 33.1% at 3 years, respectively). Thrombosis as a cause of complete graft failure was significantly higher (34%) in the standard group than in the cuffed group (9%) (p = 0.0125). Conclusions Compared to the standard ePTFE, the cuffed ePTFE graft provided better long-term outcome, especially in terms of secondary patency rates after radiological intervention.

We sought to determine the effects of exogenous administration of human coagulation factors following pig-to-baboon liver xenotransplantation (LXT) using GalT-KO swine donors. After LXT, baboons received no coagulation factors (historical control, n = 1), bolus administration of a human prothrombin concentrate complex (hPCC; 2.5 mL/kg, n = 2), continuous infusion of hPCC (1.0 mL/h, n = 1) or continuous infusion of human recombinant factor VIIa (1 µg/kg per hour, n = 3). The historical control recipient demonstrated persistent thrombocytopenia despite platelet administration after transplant, along with widespread thrombotic microangiopathy (TMA). In contrast, platelet levels were maintained in bolus hPCC recipients; however, these animals quickly developed large-vessel thrombosis and TMA, leading to graft failure with shortened survival. Recipients of continuous coagulation factor administration experienced either stabilization or an increase in their circulating platelets with escalating doses. Furthermore, transfusion requirements were decreased, and hepatic TMA was noticeably absent in recipients of continuous coagulation factor infusions compared with the historical control and bolus hPCC recipients. This effect was most profound with a continuous, escalating dose of factor VIIa. Further studies are warranted because this regimen may allow for prolonged survival following LXT.

Awareness of smoking complications in liver transplantation patients is increasing. No study in the past 15 years has addressed attitudes toward offering transplantation to smokers. Our aim was to determine smoking policies nationwide. We conducted a survey of liver transplantation centers. The seven-question survey was sent to medical and surgical directors of liver transplantation. Results were analyzed in R 3.1.1 using two-tailed t testing and ANOVA. Fifty one of 110 centers (46 %) responded. Volume transplanted annually ranged from 10 to 190. Most respondents acknowledged a policy on smoking (38/51, 75 %). Most centers with policies required cessation (32/38, 84 %). All other centers did encourage attempts at cessation (19/19, 100 %). Whether smoking cessation was required differed by region (p = 0.02). Southern programs more commonly required smoking cessation (87.5 vs. 38.4 %, p

Bile duct adenomas are uncommon lesions that can cause obstructive jaundice. We report the unusual case of a 54-year-old man who developed Mirizzi syndrome secondary to a bile duct papillary adenoma located in the cystic duct remnant. A case report is presented, together with a review of extrahepatic bile duct adenomas published in the English-language literature, with special attention directed toward the clinical manifestations, locations, and prognosis of these tumors. Bile duct adenomas are very rare tumors. Although cholangiography can detect many of these lesions, few cases were correctly diagnosed preoperatively. Most lesions were located in the distal common bile duct or at the ampulla of Vater. Pathologic examination often revealed foci of carcinoma in situ, dysplasia, or atypia. Local resection was performed in most cases. There were no previous case reports of extrinsic common bile duct obstruction caused by tumors within the cystic duct. We describe here a very rare, acalculous variant of Mirizzi syndrome secondary to a solitary papillary adenoma of the cystic duct. In general, bile duct adenomas are uncommon lesions that are difficult to diagnoses preoperatively. These tumors usually present with jaundice secondary to intraluminal biliary obstruction. These lesions are premalignant and should be managed by complete surgical resection.

Organ transplantation is increasingly available to the thousands of patients who suffer from end-organ failure. There has been an attendant increase in demand for living donor participation. This combined with a bioethical focus on autonomy increases the burden of decision on donor candidates. The authors review the history of living donor participation in organ transplantation and explore the psychological dynamics of the clinical encounter between donor and transplant surgeon. The field of communication psychology lends to the understanding of coercion and to the importance of donors possessing a status of patient-hood in the classical Hippocratic condition.

The incidence of hepatocellular carcinoma (HCC), a frequent and incurable complication of cirrhosis, continues to rise. Orthotopic liver transplantation (OLT) has been proposed as a treatment for unresectable, intrahepatic HCC limited in extent to the Milan criteria adopted by the United Network of Organ Sharing (UNOS) in 1998. More recently, somewhat less restrictive University of California, San Francisco (UCSF)10, criteria were proposed. To examine the long-term outcomes of OLT for HCC patients and to assess the UNOS policy of assigning weighted allocation points to patients with HCC, we retrospectively analyzed 144 patients (113 after 1998) with HCC who underwent OLT over an 11-year period at 3 institutions from UNOS Region 1. We compared their outcomes with 525 patients (272 after 1998) who underwent OLT for nonmalignant liver disease. The 1- and 5-year survival rates were 80.3% and 46.7%, respectively, for patients with HCC and 81.5% and 70.6%, respectively, for patients without HCC (P = .020). However, there was no difference in survival between HCC and non-HCC patients after implementation of disease-specific allocation for HCC in 1998. A higher proportion of the HCC cohort was older and male and had chronic HCV infection and alcoholic liver disease. In univariate analysis, having alpha-fetoprotein (AFP) levels of 10 ng/mL or less and meeting clinical and pathologic UCSF criteria were each significant predictors of improved survival (P = .005, P = .02, and P = .03, respectively). AFP greater than 10 ng/mL and exceeding pathologic UCSF criteria were also significant predictors of recurrence (P = .003 and P = .02, respectively). In conclusion, taken together, our data suggest that OLT is an acceptable option for patients with early HCC and that UCSF criteria predict outcome better than Milan or UNOS criteria. Regardless of which criteria are adopted to define eligibility, strict adherence to the criteria is important to achieve acceptable outcomes.

Liver transplantation from a living donor involves removal of part of the donor liver in a fashion that does not endanger its vascular supply or metabolic function. The radiologist plays an important role in evaluation of the living donor to define the conditions under which graft donation is contraindicated and to identify anatomic variations that may alter the surgical approach. In the past, diagnostic work-up of the donor involved costly and invasive tests. Currently, dynamic contrast material–enhanced computed tomography and magnetic resonance (MR) imaging are the imaging tests performed, each of which has advantages and limitations. MR imaging performed with liver-specific and extravascular contrast agents may be used as a single imaging test for comprehensive noninvasive evaluation of living liver transplant donors. MR imaging provides valuable information about variations in the vascular and biliary anatomy and allows evaluation of the hepatic parenchyma for diffuse or focal abnormalities. © RSNA, 2004

Background and aims: Bile duct complications are the modern Achilles' heel of adult-to-adult living donor liver transplantation. A duct-to-duct anastomosis is currently performed in the presence of single graft ducts, while cholangiojejunostomy is used to drain multiple ducts. Our aim is to describe the feasibility of duct-to-duct anastomoses independent of the presence of one or multiple graft bile ducts. Methods: The probe technique for right bile duct dissection in donors and a proximal hilar bile duct division in recipients are illustrated. The BARIGA LDLT (biliary anastomosis in right graft for adult living donor liver transplantation recipients) with end-to-side or end-to-end hepatico-hepaticostomy was used in five recipients of right grafts (segments 5–8). Results: All donors and recipients are doing well; all grafts are functional at 13 months. Duct-to-duct anastomoses to single, double, or triple graft ducts have been performed. Two early anastomotic stenoses at 5 and 10 weeks were successfully treated endoscopically. Conclusion: The duct-to-duct anastomosis represents a valid alternative to the standard hepaticojejunostomy for right living donor liver grafts. Using this method, biliary complications can be treated endoscopically. End-to-side or end-to-end BARIGA LDLT has the potential to become a standard method in segmental transplantation, including split liver.

The main obstacle to a expansion of human liver transplantation is the lack of donor organs. At present mortality reported for pediatric and adult patients on the waiting list is 10%to 20%. This article focuses on several techniques to alleviate this problem. Several years ago, application of reduced-size liver transplantation overcame the donor shortage among small infants through the use of grafts shaped to almost any size needed. Today reduced-size grafts are only rarely used, most commonly with traumatized donor livers or particularly small pediatric donor livers. Split liver transplantation also yields a net gain of organs, in that it uses one organ to save either an adult and a child or, recently, two adults. The technique of ex situ splitting is progressively being replaced by the in situ splitting technique, which yields better preserved grafts,optimization of graft/donor matching by pretransplant manipulation(preconditioning), avoidance of early rejection in the recipient,portal decompression, temporary liver support, if necessary, and induction of fast regeneration. In acute hepatic failure, auxiliary heterotopic liver transplantation might be sufficient to support liver function until regeneration of the native liver has begun. Domino transplantation in some patients with inborn errors of metabolism or storage disease should be considered. This article focuses on increasing the organ supply by using split liver transplantation techniques and living-donor liver transplantation.

La transplantation des organes comme le coeur, le poumon, le foie, le pancreas, l'intestin grele et le rein, est la seule facon de traiter radicalement certaines maladies qui menacent le pronostic vital. La transplantation necessite un equipement specifique non seulement pour realiser le procede mais aussi pour assurer les soins pre et postoperatoires, ainsi que des connaissances specifiques d'une equipe experimentee de chirurgiens ou de medecins d'autres specialites pouvant intervenir aupres d'un transplante potentiel (cardiologues, nephrologues, hepatologues, pour n'en citer que quelques-uns). La transplantation est un effort d'equipe, seul garant pour obtenir les bons resultats que nous connaissons aujourd'hui. Il arrive que quelques individus essaient de monter, pratiquement tout seul un centre de transplantation. Aucun ne peut reussir sans une aide institutionnelle, financiere avec un soutien continu, et en particulier on ne peut y arriver sans une structure organisationnelle efficace. Cet article resume ce qui est necessaire pour creer un centre de transplantation du foie; il traite egalement des considerations ethiques.

Background Prophylaxis against hepatitis B virus (HBV) recurrence after orthotopic liver transplantation (OLT) includes lifelong hepatitis B immunoglobulin (HBIG) and oral antiviral agent(s). In the presence of high-genetic-barrier nucleos(t)ide analogues, the need for lifelong HBIG is questioned. We evaluated the safety and cost-effectiveness of a limited HBIG course. Methods OLT from 2006 to 2013 were reviewed. Patients with pre-OLT hepatitis B virus surface antigen who received HBV prophylaxis with 2 HBIG doses (anhepatic and first post-operative day; 10,000 units/dose) and potent nucleos(t)ide analogues were included. The primary end point was HBV recurrence (HBV-DNA detection). Results Thirteen patients (primary transplants) were included, median Model for End-Stage Liver Disease score was 18, and there was no fulminant failure; HBV-DNA was detected in 4 patients at OLT. After OLT, 10 patients received entecavir and/or tenofovir. Median follow-up was 23 months. One recurrence occurred (7.7%) at month 13 (HBV-DNA: 14 IU/mL); the graft maintained excellent function. This minimal viremic expression is related to hepatocellular carcinoma recurrence with neoplastic replication carrying integrated HBV-DNA; thus, there is no defined HBV viral recurrence. No graft loss or patient death was related to HBV recurrence. The 1-year patient and graft survival rate was 84.6%. Cost-savings in the first year was $178,100 per patient when compared with Food and Drug Administration–approved HBIG dosing. Conclusions In the era of potent oral nucleos(t)ide analogues, a limited HBIG course appears to be cost-effective in preventing HBV recurrence.

A 45-year-old male with a history of right-sided congestive heart failure associated with cirrhosis presented for combined heart-liver transplantation. At age 28 he was diagnosed with a right-sided cardiac mass. At that time he underwent a massive debulking of the mass associated with excision of the tricuspid valve. Pathology showed thrombus and a benign fibroproliferative process. After his operation he lived with severe tricuspid regurgitation, eventually leading to cardiac cirrhosis associated with recurrent ascites, pleural effusions, a chronic cough, and decreased exercise tolerance. He presented for consideration for combined heart and liver transplantation. Echocardiography performed during his transplant evaluation revealed normal left ventricular size and function, an ejection fraction of 64%, trace mitral regurgitation, and a small and hypokinetic right ventricle with only a small remnant of the tricuspid valve. There was dilation of the right ventricle and inferior vena cava with associated hepatic vein dilation. The interatrial septum was shifted toward the left, consistent with right atrial volume overload. There was evidence of a patent foramen ovale. Right and left cardiac catheterization at the time of initial evaluation demonstrated no evidence of coronary artery disease. Superior vena cava pressure was 24 mmHg, mean right atrial pressure was 26 mmHg, mean pulmonary artery pressure (PA) was 26 mmHg, and pulmonary capillary wedge pressure was 15 mmHg with spontaneous ventilation. Cardiac output was 2.45 L/min and cardiac index 1.3 L/min/m 2 by thermodilution. Pulmonary vascular resistance (PVR) was reported as 359.2 dynes·sec·cm -5 (4.49 Woods units). Liver biopsy was consistent with cirrhosis. Several attempts at radiofrequency ablation for atrial fibrillation were unsuccessful. His condition progressed such that he required intensive care management with sildenafil, intravenous milrinone (0.1 µg/kg/min), dobutamine (70 µg/min), and phenylephrine (10 µg/min) before surgery and was thus admitted to the intensive care unit and listed as status 1A for combined heart-liver transplantation. Sixty-three days after his admission, a suitable 25-year-old brain

Rapid allograft infection complicates liver transplantation (LT) in patients with hepatitis C virus (HCV). Pegylated interferon-α and ribavirin therapy after LT has significant toxicity and limited efficacy. The effect of a human monoclonal antibody targeting the HCV E2 glycoprotein (MBL-HCV1) on viral clearance was examined in a randomized, double-blind, placebo-controlled pilot study in patients infected with HCV genotype 1a undergoing LT. Subjects received 11 infusions of 50 mg/kg MBL-HCV1 (n = 6) or placebo (n = 5) intravenously with three infusions on day of transplant, a single infusion on days 1 through 7 and one infusion on day 14 after LT. MBL-HCV1 was well-tolerated and reduced viral load for a period ranging from 7 to 28 days. Median change in viral load (log10 IU/mL) from baseline was significantly greater (p = 0.02) for the antibody-treated group (range −3.07 to −3.34) compared to placebo group (range −0.331 to −1.01) on days 3 through 6 posttransplant. MBL-HCV1 treatment significantly delayed median time to viral rebound compared to placebo treatment (18.7 days vs. 2.4 days, p < 0.001). As with other HCV monotherapies, antibody-treated subjects had resistance-associated variants at the time of viral rebound. A combination study of MBL-HCV1 with a direct-acting antiviral is underway.

Background The goal of this study was to review the results of 279 laparoscopic living donor nephrectomies (LLDN) regarding outcomes of using the left or the right kidney. Methods Among 279 patients who underwent LLDN between August 1998 and April 2009, 260 underwent a left (group L) and 19, a right (group R) nephrectomy. The two groups were compared regarding intra- and postoperative parameters, including pre- and postoperative renal function, length of surgery, conversion to an open approach, delayed graft function, and complications. Results There were no significant differences between the two groups regarding preoperative glomerular filtration rate (L = 129.5 ± 32 mL/min versus group R = 127.3 ± 26 mL/min), length of surgery (group L = 228 ± 58 minutes versus group R = 226 ± 62 minutes group), postoperative donor creatinine (group L = 1.36 ± 0.9 mg/dL versus group R = 1.48 ± 0.8 mg/dL), conversion to open (group L = 6.6% versus group R = 5.3%), delayed graft function (group L = 7.2% versus group R = 6.3%) and recipient postoperative creatinine at 1 month (group L = 1.54 ± 1.4 mg/dL versus group R = 1.32 ± 1.1 mg/dL). There were three intraoperative donor complications in group L (bleeding in one donor required transfusion), and none in group R. Similarly, there was a great albeit not a significant difference in the number of major postoperative donor complications among group L ( n = 16) versus group R ( n = 2). The right kidney was chosen because of the number of vessels ( n = 5), presence of cysts ( n = 5), size and renal function ( n = 6), presence of renal stones ( n = 2), and tortuous ureter ( n = 1). The reasons for conversion to open included bleeding, anatomic issues, and presence of adhesions. It should be noted that during the last 3 years there were no conversions to open, whereas the only conversion among group R was the first case. Conclusions Intra- and postoperative parameters were comparable between the groups. Considering the limitations of the small sample size of right LLDNs in this study, it appears that it is as safe and effective as a left procedure. The learning curve is extremely important, as can be seen by the lack of conversion in the last 3 years.

With standard miniature swine donors, survivals of only 3 days have been achieved in primate liver-transplant recipients. The recent production of alpha1,3-galactosyl transferase knockout (GalT-KO) miniature swine has made it possible to evaluate xenotransplantation of pig organs in clinically relevant pig-to-non-human primate models in the absence of the effects of natural anti-Gal antibodies. We are reporting our results using GalT-KO liver grafts.We performed GalT-KO liver transplants in baboons using an immunosuppressive regimen previously used by our group in xeno heart and kidney transplantation. Post-operative liver function was assessed by laboratory function tests, coagulation parameters and histology.In two hepatectomized recipients of GalT-KO grafts, post-transplant liver function returned rapidly to normal. Over the first few days, the synthetic products of the donor swine graft appeared to replace those of the baboon. The first recipient survived for 6 days and showed no histopathological evidence of rejection at the time of death from uncontrolled bleeding, probably caused by transfusion-refractory thrombocytopenia. Amicar treatment of the second and third recipients led to maintenance of platelet counts of over 40 000 per μl throughout their 9- and 8-day survivals, which represents the longest reported survival of pig-to-primate liver transplants to date. Both of the last two animals nevertheless succumbed to bleeding and enterococcal infection, without evidence of rejection.These observations suggest that thrombocytopenia after liver xenotransplantation may be overcome by Amicar therapy. The coagulopathy and sepsis that nevertheless occurred suggest that additional causes of coagulation disturbance must be addressed, along with better prevention of infection, to achieve long-term survival.

Protein S deficiency is a thrombophilia associated with increased risk of thromboembolic episodes in affected patients. Traditionally, protein S deficiency in a potential donor was considered an absolute contraindication to living donor liver transplantation, both due to the increased risk incurred by the thrombophilic donor as well as the risk of transmitting the thrombophilia to the liver recipient, as protein S is predominantly produced by the liver. We present the first successful case of living donor liver transplantation using a donor with asymptomatic protein S deficiency. Interestingly, whereas the donor continued to have protein S levels approximately 50% of normal, the recipient maintained normal levels of protein S post-transplant, potentially due to compensation by extra-hepatic protein S production. We discuss the prior literature of protein S deficiency acquired via liver transplantation, and we evaluate potential criteria by which the safety of transplants utilizing this pool of donors may be enhanced.

Donation after cardiac death (DCD) has proven effective at increasing the availability of organs for transplantation. We performed a retrospective examination of Massachusetts General Hospital (MGH) records of all 201 donors from 1/1/98 to the 11/2008, including 54 DCD, 115 DBD and 32 DCD candidates that did not progress to donation (DCD-dnp). Comparing three time periods, era 1 (01/98–12/02), era 2 (01/03–12/05) and era 3 (01/06–11/08), DCD's comprised 14.8, 48.4% and 60% of donors, respectively (p = 0.002). A significant increase in the incidence of cardiovascular/cerebrovascular as cause of death was evident in era 3 versus eras 1 and 2; 74% versus 57.1% (p < 0.001), as was a corresponding decrease in the incidence of traumatic death. Interestingly, we noted an increase in utilization of aggressive neurological management over time, especially in the DCD group. We detected significant changes in the make-up of the donor pool over the past decade. That the changes in diagnosis over time did not differ between DCD and DBD groups suggests this difference is not responsible for the increase in DCD rates. Instead, we suggest that changes in clinical practice, especially in management of patients with severe brain injury may account for the increased proportion of DCD.

Objective To review the use of computed tomography (CT) and radiography in managing hepatic portal venous gas (HPVG) at a university-affiliated tertiary care center and in the literature. Hepatic portal venous gas is frequently associated with acute mesenteric ischemia, accounting for most of the HPVG-associated mortality. While early studies were necessarily dependent on plain abdominal radiography, modern high-resolution CT has revealed a host of benign conditions in which HPVG has been reported that do not require emergent surgery. Data Sources Patient records from our institution over the last 10 years and relevant studies from BioMed Central, CENTRAL, PubMed, and PubMed Central. In addition, references cited in selected works were also used as source data. Study Selection Patient records were selected if the CT or radiograph findings matched the term hepatic portal venous gas . Studies were selected based on the search terms hepatic portal venous gas or portal venous gas . Data Extraction Quantitative and qualitative data were quoted directly from cited work. Data Synthesis Early studies of HPVG were based on plain abdominal radiography and a literature survey in 1978 found an associated mortality rate of 75%, primarily due to ischemic bowel disease. Modern abdominal CT has resulted in the detection of HPVG in more benign conditions, and a second literature survey in 2001 found a total mortality of only 39%. While the pathophysiology of HPVG is, as yet, unclear, changing abdominal imaging technology has altered the significance of this radiologic finding. Hepatic portal venous gas therefore predicts high risk of mortality (>50%) if detected by plain radiography or by CT in a patient with additional evidence of necrotic bowel. If detected by CT in patients after surgical or endoscopic manipulation, the clinician is advised that there is no evidence of increased risk. If HPVG is detected by CT in patients with active peptic ulcer disease, intestinal obstruction and/or dilatation, or mucosal diseases such as Crohn disease or ulcerative colitis, caution is warranted, as risk of death may approach 20% to 30%. Conclusion The finding of HPVG alone cannot be an indication for emergency exploration, and we have developed an evidence-based algorithm to guide the clinician in management of patients with HPVG.

To compare the outcome of living donor kidney transplantation using allografts with a single artery with that observed in recipients of allografts with multiple arteries.Retrospective analysis.Tertiary center.Three hundred fifty patients who underwent living donor kidney transplantation from January 2000 to March 2007.Living donor kidney transplantation.Surgical complications and allograft survival.Three hundred nineteen allografts (91.1%) had a single artery (group 1) and 31 (8.9%) had multiple arteries (group 2), including 2 arteries in 21 grafts (67.8%), 3 arteries in 6 (19.3%), and 4 arteries in 4 grafts (12.9%). The operative time was shorter in group 1 compared with group 2 (mean [SD], 173 [35] vs 259 [48] minutes; P.001). The overall surgical complication rate in groups 1 and 2 was comparable (9.6% vs 9.7%; vascular, 2.8% vs 3.2%; urological, 1.6% vs 3.2%; symptomatic lymphocele, 2.8% vs 3.2%; and wound infections, 2.8% vs 3.2%). The actuarial 1- and 5-year allograft survival rates were comparable in both groups (98.4% and 91.5% in group 1 and 96.8% and 87.1% in group 2). A significant increased use of allografts with multiple arteries has been observed in recent years: 7.8% (n = 10) in grafts that were procured by open technique (n = 127), 4.1% (n = 5) during our initial experience with laparoscopic nephrectomy (n = 123), and 16% (n = 16) in the most recent 100 cases (P.01).Living donor kidney transplantation in the presence of multiple renal arteries is feasible and safe. Additionally, graft survival and graft function are not adversely affected by the presence of multiple renal arteries in grafts procured laparoscopically. Recently, there has been an increased use of kidneys with multiple arteries with excellent results.