Nyberg, Scott

ABSTRACT Background Ureteral stents are commonly placed during kidney transplantation (KT) to mitigate urologic complications. The objective of this study was to compare clinical outcomes in KT recipients with either early stent removal when attached to the Foley catheter or late removal via cystoscopy when unattached. Methods We conducted a multi‐center retrospective analysis of consecutive living donor KT patients (8/18/21‐4/21/23) stratified into Foley‐attached and unattached stent groups. Outcomes assessed were ureteral stricture, urine leaks, UTIs at 90 days and allograft failure and BKV DNAemia (BK virus DNAemia) at 1 year. Data are reported as mean and standard deviation. Results Among 247 patients with attached and 260 with unattached stents, baseline demographics (age, sex, diabetes) were similar between groups. There was a difference in race (87.9% vs. 77.8% Caucasian; p = 0.004). Foley catheters remained longer in the attached group (3.7 ± 1.8 vs. 3.0 ± 2.0 days; p < 0.001), but stents were removed earlier (3.7 ± 1.8 vs. 21.9 ± 4.7 days; p < 0.001). Comparing attached versus unattached, there were no differences in ureteral stricture (0.4% vs. 1.5%; p = 0.197), urine leak (0.8% vs. 0.4%; p = 0.533), BKV DNAemia (17.7% vs. 16.9%; p = 0.616), or allograft failure (0% vs. 0.8%; p = 0.167). However, UTI incidence by 90 days was lower in the attached group (5.7% vs. 11.9% p = 0.013). Induction therapy differed significantly between groups, with Alemtuzumab more common in the unattached group (58.1% vs. 19.4%, p < 0.001), Basiliximab more common in the attached group (43.3% vs. 35.0%, p < 0.001), and Thymoglobulin more common in the attached group (36.0% vs. 6.9%, p < 0.001). Baseline steroid use was higher in the unattached group (81.9% vs. 57.9%, p < 0.001). Conclusion Early stent removal via connection to the Foley catheter had similarly low rates of ureteral complications while reducing urinary tract infections and avoiding cystoscopic removal.

Background. Portopulmonary hypertension (POPH) is the presence of pulmonary arterial (PA) hypertension in patients with portal hypertension and is associated with significant morbidity and mortality. In a cohort of POPH patients, we describe the clinical outcomes of POPH patients who underwent liver transplantation (LT). Methods. Retrospectively collected data from a prospectively assembled cohort of all consecutive POPH adults evaluated in 3 transplant centers from 1996 to 2019. Results. From a cohort of 228 POPH patients, 50 patients underwent LT. Significant hemodynamic improvement after PA-targeted therapy was observed, with 58% receiving only monotherapy pretransplant. After LT, 21 (42%) patients were able to discontinue and remained off PA-targeted therapy. The 1-, 3-, and 5-y unadjusted survival rates after LT were 72%, 63%, and 60%, respectively. An elevated pulmonary vascular resistance (PVR) before LT was associated with worse survival rate (HR, 1.91; 95% CI, 1.07-3.74, P = 0.04). No survival difference was observed in those granted MELD exception or transplants performed before or after the year 2010. Conclusions. Significant number of POPH patients discontinued PA-targeted therapy after LT. Higher PVR before LT was associated with worse survival, as was monotherapy use. Despite effective PA-targeted therapies, POPH survival outcomes after LT in our cohort were modest and may reflect the need for more aggressive therapy.

Background. The role of MZ phenotype of α 1 antitrypsin (α1AT) deficiency as a potential cofactor in advanced liver disease arising from other primary causes is not widely understood. In the general population, MZ phenotype accounts for 2%–4% in Europe and 2%–7.1% in North America. The aim of this study was to determine the prevalence of the MZ phenotype among various causes of cirrhosis in the United States in the modern era and its impact on pulmonary function before and after liver transplantation. Methods. This retrospective study included adult patients with cirrhosis who underwent liver transplantation at Mayo Clinic. Participants’ data including pathogenesis of cirrhosis, model for end-stage liver disease-Na score, α1AT phenotype, liver decompensation events, and pulmonary outcomes was determined by retrospective review of the liver transplantation database. Results. One hundred thirty of 1341 adult patients with cirrhosis (9.7%) were α1AT MZ carriers. When comparing the distribution of protease inhibitor (PI) MZ among different pathogenesis, the prevalence of MZ was significantly increased in nonalcoholic steatohepatitis (NASH), alcoholic liver disease (ALD), and cryptogenic cirrhosis compared with other causes. Thirty-seven of 171 with NASH (22%), 37 of 187 with ALD (20%), and 9 of 39 with cryptogenic cirrhosis (23.1%) were identified as PI MZ, while in other subgroups; we detected 18 of 320 with viral hepatitis, and 11 of 339 with primary biliary cholangitis/primary sclerosing cholangitis. Also, MZ patients were more likely to develop preoperative chronic obstructive lung disease, and postoperative pulmonary hypertension and pulmonary embolism than MM patients. Conclusions. The rates of preoperative and postoperative pulmonary complications were found to be higher in PI MZ patients than in PI MM patients. The MZ phenotype was significantly enriched in NASH, ALD, and cryptogenic cirrhosis.