Nguyen, Justin H.

AbstractBackgroundHepatic artery stenosis (HAS) after liver transplant (LT) is a source of significant morbidity. Some reports have suggested higher arterial complications in patients who receive donation after cardiac death (DCD) livers.MethodsA total of 2860 consecutive LT were reviewed from a prospectively collected database. All angiograms performed in LT recipients were reviewed and primary patency rates determined by need for further intervention or graft loss due to HAT.ResultsHepatic artery stenosis was seen in 4.6% of DCD and donation after brain death (DBD) recipients. Recipient male gender, age at transplant, complex donor hepatic artery anatomy, and prolonged operative time were all associated with HAS, but not DCD status. While HAS in recipients of DCD grafts required more stents (1.7% vs 0.6%, P = 0.04) and had worse primary patency rates (logrank, P = 0.02), outcomes as defined by HAT, patient and graft survival were not significantly different between the recipients of DCD or DBD grafts.ConclusionWe observed no significant difference in the incidence of hepatic artery complications, patient survival, or graft survival in recipients of DCD or DBD grafts. However, HAS in DCD recipients had worse primary patency and a higher need for stent placement.

Although hepatocellular carcinoma (HCC) has become a common indication for liver transplantation (LT), intrahepatic cholangiocarcinoma (ICC) and combined hepatocellular carcinoma–cholangiocarcinoma (cHCC‐CCA) are historically contraindicated due to their aggressive behavior. On the basis of recent experiences, some groups have proposed a clinical trial investigating the role of LT for patients with early cholangiocarcinoma (CCA), defined as a single lesion ≤ 2 cm. The purpose of this study is to assess the clinicopathologic features and outcomes following LT for patients who were initially diagnosed with HCC and subsequently found to have either ICC or cHCC‐CCA on explant. Patients with the diagnosis of primary liver cancer (PLC) after LT from a single center were retrospectively reviewed. Outcomes for patients with early CCA were compared with patients with HCC within Milan criteria (MC). Out of 618 patients transplanted with PLC, 44 patients were found to have CCA on explant. On the basis of preoperative imaging, 12 patients met criteria for early CCA and were compared with 319 patients who had HCC within MC. The 1‐ and 5‐year overall survival for early CCA versus HCC was 63.6% versus 90.0% and 63.6% versus 70.3% (log‐rank, P = 0.25), respectively. Overall recurrence was 33.3% for early CCA versus 11% for HCC. On explant the patients with CCA were more likely understaged with higher tumor grade and vascular invasion. In conclusion, patients with CCA present a diagnostic challenge, which often leads to the finding of more aggressive lesions on explant after LT, higher recurrence rates, and worse post‐LT survival. Careful consideration of this diagnostic conundrum needs to be made before a clinical trial is undertaken. Liver Transplantation 24 634–644 2018 AASLD.

INTRODUCTION: Female patients being evaluated for liver transplantation (LT) routinely undergo a gynecologic exam including cervical cancer screening. The prevalence of cervical cytologic abnormalities in this high risk population is unknown. Our study determines prevalence of cervical cytologic abnormalities, HPV positive status, and risk factors for abnormal cervical screening for this population. METHODS: With Institutional review board approval, we reviewed 375 charts of women undergoing evaluation for LT from 2008‒2013 at Mayo Clinic Florida. We recorded demographics, Pap smear results, High risk HPV positive results, and co-morbid conditions. Univariate analysis was done to determine risk factors. We compared the result of the LT group to the general female population getting cervical cancer screening during the same time period. RESULTS: 37 of 375 (9.86%) LT patients had abnormal Pap smear, compared to 1784 of 26118 (6.83%) of the general population patients (p < 0.01). Among LT patients with cervical cytologic abnormalities, 40.5% were ASCUS, HPV positive (64.8% for non-LT patients), 29.7% were LSIL (28.1% for non-LT patients), 5.4% were HSIL (6.7% for non-LT patients) and 24.3% were cytology negative with HPV positive (0.2% for non-LT patients, p < 0.05). Younger age and presence of hypertension were associated with higher risk of having an abnormal cervical cytology or positive HPV status among LT patients. CONCLUSION: Patients undergoing evaluation for LT have increased prevalence of abnormal cervical cytology, or a positive High risk HPV test. Gynecologic surveillance for this high risk population is recommended.

238 Background: To compare post-transplant recurrence rates of hepatocellular carcinoma (HCC) and differences in percent tumor necrosis in patients with pre-operative superselective chemoembolization (CE) vs. non-superselective CE. Methods: Retrospective review of 147 patients with liver transplant (LT) for HCC treated with pre-operative CE. Those transplanted less than 24 hours after CE and those who had other concomitant treatments were excluded. The angiographic studies and written reports were reviewed to categorize patients into superselective and non-superselective groups. CE was done with an emulsion of lipiodol, cisplatin, doxorubicin, mitomycin C, and contrast, with or without embolization particles. Superselective CE was defined as treatment directly into the vessel(s) feeding the tumor. Treatment from more proximal vessels was considered non-superselective. Data gathered included age, gender, date of CE, date of LT, tumor size and number, tumor stage, MELD score, Child-Pugh class, alpha fetoprotein, percent tumor necrosis at explant, date of recurrence, date and cause of death, and date of last follow-up. Patient and disease characteristics and percent tumor necrosis were analyzed with a Wilcoxon rank sum test or Fisher’s exact test. The Kaplan-Meier method was used to estimate the cumulative incidences of death due to recurrent disease after LT. Results: 99 patients were included, 53 had superselective CE and 46 non-superselective. HCC recurrence rates at 1, 3, 5, and 8 years were all significantly less for superselective CE compared to non-superselective CE (p = 0.039 single, p = 0.011 multivariable). Using multivariable analysis, superselective CE had a lower risk of death due to recurrent HCC at 1, 3, 5, and 8 years (p = 0.046). There was a trend toward more percent tumor necrosis after superselective CE, but it did not reach significance (p = 0.057). Conclusions: This study provides evidence that HCC recurrence after LT and death due to recurrent HCC is lower after pre-LT superselective CE versus non-superselective CE. The strong trend for greater percent tumor necrosis with superselective CE may explain the differences in recurrence rate.

Background: Nurse practitioners (NPs) and physician assistants (PAs) are increasingly utilized in health care. However, their roles in liver transplantation (LT) have not been investigated. Materials and Methods: In this study, we reviewed the employment and development of NPs and PAs and their impact on our deceased-donor LT (DDLT) program. Results: We found a safe and efficient way to utilize NPs and PAs in a DDLT program. Since the beginning of our program, Model of End-Stage Liver Disease (MELD) scores have increased significantly, suggesting patients are sicker at the time of transplant, and wait times of patients have become longer. With the incorporation of NPs and PAs, we found that length of stay (LOS) was not affected. The overall median warm ischemic time did not increase. Outcomes of LT for both patient and graft survival actually improved and remain at or above the expected values. These results collectively support the usefulness and validity of NPs and PAs in a DDLT program. Conclusion: We have determined that surgical and medical NPs and PAs are essential for optimal patient outcomes. They facilitate a better learning experience for residents and fellows on their transplant rotations. Further investigations to assess the roles of these providers and their impact on the education of residents and fellows in transplantation are warranted. Further transplant hepatology education programs and/or fellowships are recommended to assist in the education and professional development of transplant NPs and PAs.

The use of liver grafts from donation after cardiac death (DCD) has been limited due to the increased rate of graft failure, mostly related to ischemic cholangiopathy (IC). It is our hypothesis that longterm outcomes and quality of life (QOL) similar to patients undergoing liver transplantation (LT) with donation after brain death (DBD) can be achieved. Clinical outcomes of all patients undergoing DCD LT (n = 300) between 1998 and 2015 were compared with a propensity score–matched cohort of patients undergoing DBD LT (n = 300). Patients were contacted for a follow‐up questionnaire and short‐form (SF)–12 QOL Survey administration. Median follow‐up was >5 years. Graft survival at 1‐, 3‐, and 5‐years was 83.8%, 75.5%, and 70.1% in the DCD LT group and 88.4%, 80.3%, and 73.9% in the DBD LT group ( P = 0.27). Patient survival at 1‐, 3‐, and 5‐years was 92.3%, 86.1%, and 80.3% in the DCD LT group and 92.3%, 85.1%, and 79.5% in the DBD LT group ( P = 0.81). IC developed in 11.7% and 2% of patients in the DCD LT group and DBD LT group, respectively ( P < 0.001). DCD LT recipients who developed IC had inferior graft survival compared with both the DCD non‐IC group ( P < 0.001) and the DBD LT group ( P < 0.001); no difference in graft survival was observed between the DCD non‐IC group and the DBD LT group ( P = 0.50). Physical and Mental Composite Scores on the SF‐12 QOL questionnaire were similar between the DCD LT and DBD LT groups (44.0 versus 45.4; P = 0.34 and 51.9 versus 52.2; P = 0.83), respectively. Similar longterm survival and QOL scores can be achieved between DCD LT and DBD LT. Prevention of IC in DCD LT yields excellent graft and patient survival with virtually no difference compared with DBD LT. Liver Transplantation 23 342–351 2017 AASLD .

Although there is an agreement that liver grafts from pediatric donors (PDs) should ideally be used for pediatric patients, there remain situations when these grafts are turned down for pediatric recipients and are then offered to adult recipients. The present study aimed to investigate the outcomes of using these grafts for liver transplantation (LT) in adult patients. Data from all patients undergoing LT between 2002 and 2014 were obtained from the United Network for Organ Sharing Standard Analysis and Research file. Adult recipients undergoing LT were divided into 2 groups: those receiving a pediatric liver graft (pediatric‐to‐adult group) and those receiving a liver graft from adult donors (adult‐to‐adult group). A separate subgroup analysis comparing the PDs used for adult recipients and those used for pediatric recipients was also performed. Patient and graft survival were not significantly different between pediatric‐to‐adult and adult‐to‐adult groups (P = 0.08 andP = 0.21, respectively). Hepatic artery thrombosis as the cause for graft loss was higher in the pediatric‐to‐adult group (3.6%) than the adult‐to‐adult group (1.9%;P < 0.001). A subanalysis looking at the pediatric‐to‐adult group found that patients with a predicted graft‐to‐recipient weight ratio (GRWR) < 0.8 had a higher 90‐day graft loss rate than those with a GRWR ≥ 0.8 (39% versus 9%;P < 0.001). PDs used for adult recipients had a higher proportion of donors with elevated aspartate aminotransferase/alanine aminotransferase (20% vs. 12%;P < 0.001), elevated creatinine (11% vs. 4%;P < 0.001), donation after cardiac death donors (12% vs. 0.9%;P < 0.001), and were hepatitis B virus core positive (1% vs. 0.3%;P = 0.002) than PDs used for pediatric recipients. In conclusion, acceptable patient and graft survival can be achieved with the use of pediatric liver grafts in adult recipients, when these grafts have been determined to be inappropriate for usage in the pediatric population.Liver Transplantation 22 1099–1106 2016 AASLD

Although the consequences of implantation of a large whole liver graft into a small recipient such as compression and compromise of graft perfusion are well known, no accepted measure to aid in donor‐to‐recipient size matching exists. Donor liver graft and recipient native liver weights as well as donor and recipient size and amount of ascites were investigated in 1953 patients who underwent liver transplantation using deceased donor grafts between January 2002 and July 2013. We used a previously described formula for liver resections (standardized total liver volume [sTLV] = –794.41 + 1267.28 × body surface area [m2]) for calculating sTLV, in the current cohort of deceased liver donors. Early allograft dysfunction (EAD) and graft survival were the primary outcome measures. The formula for calculating sTLV for liver resections was validated as an accurate predictor of liver volume in the current cohort of deceased liver donors (r2 = 0.45;P < 0.001). A cutoff point of sTLV ratio ≥ 1.25 was determined through receiver operating characteristic curves, and patients were dichotomized into 2 groups. In the sTLV ratio ≥ 1.25 group, 50% of patients developed EAD compared to 25% of patients in the sTLV ratio < 1.25 group (P < 0.001). The proportion of patients developing graft failure within 90 days was 9.6% in the sTLV ratio ≥ 1.25 group and 5.4% in the sTLV ratio < 1.25 group (P = 0.045). This study validates the use of the sTLV for prediction of actual donor liver weight in the transplant setting. Using this formula, donors with a calculated sTLV size ratio ≥ 1.25 have an increased risk of EAD and therefore caution should be used when that value is exceeded. This adjusted size ratio can be used as a decision aid when considering donor and recipient matching with potential liver organ offers.Liver Transpl 21:1471‐1477, 2015. © 2015 AASLD.