Hewitt, Winston R.

Abstract We present the unique case of a 15‐month‐old male born with biliary atresia and situs inversus totalis and disrupted inferior vena cava who underwent a successful liver transplantation. The patient had previously undergone a failed Kasai procedure and presented with persistent hyperbilirubinemia. The patient was transplanted with a left lateral segment donor having standard arterial anatomy. Technical considerations included identifying completely replaced arterial anatomy in the recipient from the superior mesenteric artery and creating a branch patch between the gastroduodenal artery and HA, anastomosing the donor left hepatic vein to confluences of the donor left, middle, and right hepatic veins, using a “lazy‐S” configuration of portal vein anastomosis, and suspending the allograft to the abdominal wall. Post‐operatively, his liver function tests and total bilirubin normalized and he progressed to tolerating an oral diet with tube‐feed supplementation.

Cardiovascular disease (CVD) is a leading cause of post–liver transplant death, and variable care patterns may affect outcomes. We aimed to describe epidemiology and outcomes of inpatient CVD care across US hospitals. Using a merged data set from the 2002‐2011 Nationwide Inpatient Sample and the American Hospital Association Annual Survey, we evaluated liver transplant patients admitted primarily with myocardial infarction (MI), stroke (cerebrovascular accident [CVA]), congestive heart failure (CHF), dysrhythmias, cardiac arrest (CA), or malignant hypertension. Patient‐level data include demographics, Charlson comorbidity index, and CVD diagnoses. Facility‐level variables included ownership status, payer‐mix, hospital resources, teaching status, and physician/nursing‐to‐bed ratios. We used generalized estimating equations to evaluate patient‐ and hospital‐level factors associated with mortality. There were 4763 hospitalizations that occurred in 153 facilities (transplant hospitals, n = 80). CVD hospitalizations increased overall by 115% over the decade (P < 0.01). CVA and MI declined over time (both P < 0.05), but CHF and dysrhythmia grew significantly (both P < 0.03); a total of 19% of hospitalizations were for multiple CVD diagnoses. Transplant hospitals had lower comorbidity patients (P < 0.001) and greater resource intensity including presence of cardiac intensive care unit, interventional radiology, operating rooms, teaching status, and nursing density (all P < 0.01). Transplant and nontransplant hospitals had similar unadjusted mortality (overall, 3.9%, P = 0.55; by diagnosis, all P > 0.07). Transplant hospitals had significantly longer overall length of stay, higher total costs, and more high‐cost hospitalizations (all P < 0.05). After risk adjustment, transplant hospitals were associated with higher mortality and high‐cost hospitalizations. In conclusion, CVD after liver transplant is evolving and responsible for growing rates of inpatient care. Transplant hospitals are associated with poor outcomes, even after risk adjustment for patient and hospital characteristics, which may be attributable to selective referral of certain patient phenotypes but could also be related to differences in quality of care. Further study is warranted.

AbstractBackgroundWhile simultaneous pancreas kidney transplant (SPKTx) is a therapeutic option for patients with type 1 diabetes (T1DM) and renal failure, few centers offer SPKTx to “select” non‐T1DM patients. To address concerns that existing insulin resistance may limit the benefits of the pancreas allograft among non‐T1DM, we compared several indices of glucose homeostasis, in “select” non‐T1DM and T1DM patients who received SPKTx.MethodsCriteria for “select” non‐T1DM included the following: positive C‐peptide, BMI <30 kg/m2, treatment with oral agents before insulin initiation, and insulin at <1 unit/kg/d. We compared several indices of glucose homeostasis within 1 yr post‐SPKTx among seven “select” patients with non‐T1DM and nine patients with T1DM with similar age, BMI, and immunosuppression. Measurements of insulin resistance included the following: homeostatic model, insulin sensitivity index, and insulin–glucose ratio; insulin secretion measures included the following: corrected insulin response.ResultsNon‐T1DM had similar pre‐transplant metabolic (fasting glucose, HbA1c, blood pressure, and lipid) parameters to the T1DM cohort. There were no significant differences in the various measures of insulin resistance and secretion between T1DM and “select” non‐T1DM patients.ConclusionOur results suggest SPKTx should be considered in the therapeutic armamentarium among carefully select non‐T1DM with features of minimal insulin resistance; however, a larger cohort with longer follow‐up is needed to confirm our results.