Citations

AbstractBackgroundPrevious studies indicate there may be psychological consequences of being unable to serve as a living donor, but these have not been explored in a large national cohort of low‐income individuals who initiated living donor evaluation in US transplant centers.MethodsUsing data from 6574 National Living Donor Assistance Center (NLDAC) participants (November 1, 2007‐December 31, 2018), we utilized a cross‐sectional study design to evaluate short‐term depressive symptoms and satisfaction with life in living donors and non‐donors (those who were declined or withdrew from evaluation) using the Satisfaction with Life Scale (SWLS) and the PHQ‐8, with and without risk adjustment using linear regression.ResultsNational Living Donor Assistance Center participants originated from 207 US transplant centers. 52% of NLDAC participants responded to the survey (n = 3423; donors = 2848 (58.6% of all donors), non‐donors = 575 (33.5% of all non‐donors); ncenters = 201)). Respondents were significantly older, more likely to be female, white, non‐Hispanic, married, more educated, more full‐time employed, and more likely to be unrelated to the recipient vs non‐respondents (all, P < .001). Among survey respondents, donors were significantly younger, more likely to be non‐Hispanic, employed, and related to the recipient compared to non‐donors (all, P < .05). Higher PHQ‐8 scores were correlated with lower SWL scores (r = −.32, P < .001). Both groups displayed high SWLS (donors vs non‐donors: 27.1 vs 26.3, P = .002). Both groups had low levels of depressive symptoms overall, but donors had more symptoms than non‐donors (3.5 vs 2.4, P < .001). After risk adjustment, non‐donors had significantly less depressive symptoms by PHQ‐8 (28% lower, P < .001), but had lower life satisfaction (1.2 points lower, P < .001).ConclusionsDonors and non‐donors have high global levels of overall life satisfaction and low levels of depressive symptoms at 8 weeks after donation or denial. While small effect sizes were observed between groups in these outcomes, being a non‐donor was an independent risk factor for lower life satisfaction, which warrants further evaluation.

Intraoperative Transesophageal Echocardiography (TEE) during orthotopic liver transplant (OLT) is used to gather real-time information on cardiovascular function and intravascular volume status. We report a case where nonstandard TEE views were used to inspect the hepatic vasculature after allograft implantation. A 29-year-old male with secondary biliary cirrhosis with a MELD score of 20 underwent OLT using a liver from a 21-year-old brain-dead donor. Postreperfusion TEE, using the modified hepatic vein views, confirmed the presence of an inferior vena cava (IVC) suprahepatic anastomotic stenosis and hepatic vein and IVC thrombus resulting in hepatic venous outflow obstruction, allograft congestion, and hemodynamic instability. These nonstandard TEE images established the extent of suprahepatic caval outflow obstruction, in which intraoperative ultrasound was unable to definitively demonstrate. This guided real-time surgical decision-making in the postimplantation phase of the operation—ultimately leading to hepatic vein and IVC thrombectomy and revision of suprahepatic caval anastomosis.

Background. Kidneys from deceased donors with acute kidney injury (AKI) are more likely to be discarded because of concerns for poor outcomes after transplantation. The aim of this study was to determine the long-term outcomes of a large cohort of patients transplanted utilizing kidneys from deceased donors with AKI. Methods. All patients receiving a deceased donor kidney transplant during a recent 10-year period were included. Acute Kidney Injury Network (AKIN) criteria were used to classify the donors. Donor kidneys with >10% cortical necrosis or more than mild chronic changes were discarded. The primary outcome is the combined endpoint of death or graft loss. Results. The cohort included 1313 kidneys from 974 donors, AKIN stage 0 (no AKI) in 319 (24.3%), stage 1 in 370 (28.2%), stage 2 in 177 (13.5), and stage 3 in 447 (34.0%). Estimated 5-year graft survival (95% confidence interval) was 78.5% (72.5-84.5), 77.8% (72.8-82.1), 83.8% (76.8-88.9), and 84.6% (79.5-88.7) for AKIN donor stage 0 to 3, respectively (log-rank P = 0.10). After adjusting for baseline differences, the hazard ratio (95% confidence interval) for the combined endpoint for the AKIN stage 3 group (relative to AKIN 0 group) was 0.70 (0.45-1.10). Delayed graft function occurred in 44.6% and 75.4% of AKIN 2 and 3 groups, as compared to 33.9% and 33.5% in AKIN 0 and 1 ( P < 0.001). Conclusion. We conclude that transplanting selected kidneys from deceased donors with AKI with preimplantation biopsy showing <10% cortical necrosis and no more than mild chronic changes have excellent long-term graft survival.

355 Background: In this study, we sought to determine the prognostic factors impacting survival of patients with NELM who underwent LT at Mayo Clinic. Methods: We performed a three-site retrospective analysis of patients with unresectable NELM treated with LT from 1990 -2017. Cases were identified from clinical databases at Mayo Clinic. Data on demographics, timing of diagnosis and transplant, extent of liver involvement, and tumor grade, were extracted. Extent of liver involvement was calculated using previously validated standardized volumetry with high defined as > 25% increase in the weight of the extracted liver at the time of the transplant as compared to the standard liver volume. Survival was calculated using the Kaplan–Meier method. Results: We identified 37 patients. Median age at LT was 47 (range 17.0-64.0), male: female (73% vs. 27%, respectively). Primary tumor site was in the pancreas in 51.3% and in the small bowels in 43.2%; 78.4% had NELM at presentation. While primary tumor resection was done at the time of LT in 5 (13.9%) cases, most patients (80.6%) had ˃6-months interval between primary tumor resection and LT surgery. Prior to LT, 25 (74.3%) patients received somatostatin analogues and 18 (61.3%) had liver-directed therapy. Median time from diagnosis to transplant was 33.6 months (0-246). High extent of liver involvement was identified in 12 patients (33.3%). Disease-Free Survival (DFS) at 3, 5, and 10 years was 56.8%, 43.1%, and 22.4% respectively. Overall-survival (OS) at 3, 5, and 10 years was 86.9%, 79.6%, and 52.6% respectively. High extent of liver involvement at the time of transplantation was associated with inferior DFS and OS and patients˃45 years-old at the time of transplantation had worse DFS. Patients whose disease met the OPTN (Organ Procurement and Transplantation Network) criteria for NELM transplantation had significantly better DFS and OS with median 10-year OS of 80.7 % vs. 17%. Conclusions: LT is a reasonable therapeutic option for selected patients with unresectable NELM with 10-year OS of 52.6%. High extent of liver involvement was associated with worse long-term outcomes while meeting OPTN criteria resulted in best outcomes.

Background. The present multicenter study investigated whether equivalent outcomes to primary liver transplant (LT) could be achieved with liver retransplant (reLT) and whether improvements in outcomes have taken place over time, particularly in the direct-acting antiviral era. Methods. All reLT performed at Mayo Clinic Florida, Mayo Clinic Rochester, and Mayo Clinic Arizona were divided into era 1 (2002–2007), era 2 (2008–2012), and era 3 (2013–2017) based on the date of reLT. Results. Improvement in graft survival (GS) after reLT was seen over the 3 eras (P < 0.001). In era 1, GS after reLT was inferior to primary LT (P < 0.001), whereas no difference was seen between reLT and primary LT in era 2 (P = 0.68) or era 3 (P = 0.36). A significantly higher proportion of patients achieved sustained viral response (SVR) within the first year after reLT in each subsequent era (era 1: 10.3%, era 2: 22.5%, and era 3: 100%) (P < 0.001). Graft survival was superior in patients undergoing reLT for recurrent hepatitis C virus who achieved SVR after reLT compared with those who did not (P = 0.03). Conclusions. Results similar to primary LT were achieved in era 3. These improvements coincide with the availability of direct-acting antivirals, which resulted in a 100% SVR rate in era 3 and a decrease in the number of patients undergoing reLT for recurrent hepatitis C virus. The historic dogma that reLT results in inferior outcomes should be revisited.

Introduction: The population of patients with cirrhosis is growing and shifting toward a more elderly demographic and thus are at risk of developing orthopedic complications. There is lack of data on safety of orthopedic procedures in this population. Methods: We performed an analysis of the Nationwide Inpatient Sample from 2005 to 2011 for patients undergoing hip arthroplasty, knee arthroplasty, and spinal laminectomy/fusion, stratified by presence of cirrhosis. The primary endpoint was in-hospital mortality and secondary endpoints included length of stay (LOS) and costs. Results: There were 693,610 inpatient stays for orthopedic procedures conducted during the study period, with 3014 (0.43%) patients coded as having cirrhosis. Patients with cirrhosis had a lower median age (62 vs. 66 y; P<0.001) and were more likely to be male (52.3% vs. 41.1%; P<0.001). The inpatient mortality rate was significantly higher in patients with cirrhosis (2.4% vs. 0.4%; P<0.001) as was median LOS (4 vs. 3 d; P<0.001) and mean costs ($19,321 vs. $18,833; P<0.001). Patients with decompensated cirrhosis (vs. compensated cirrhosis) had significantly higher inpatient mortality rates (5.8% vs. 1.1%; P<0.001) with higher LOS and costs (P<0.001). On multivariable analysis, cirrhosis was associated with an increased risk of mortality (odds ratio, 4.22; 95% confidence interval, 2.92-6.10). Hospital cirrhosis volume was inversely associated with mortality, while hospital orthopedic procedure volumes had an inconsistent impact on outcomes. Conclusions: Inpatient orthopedic procedures in patients with cirrhosis result in high postoperative mortality, LOS, and costs. Careful patient selection is warranted to optimize cirrhosis patient postoperative outcomes.

Background Significant heterogeneity exists in practice patterns and algorithms used for cardiac screening before kidney transplant. Cardiorespiratory fitness, as measured by peak oxygen uptake (VO 2peak ), is an established validated predictor of future cardiovascular morbidity and mortality in both healthy and diseased populations. The literature supports its use among asymptomatic patients in abrogating the need for further cardiac testing. Methods and Results We outlined a pre–renal transplant screening algorithm to incorporate VO 2peak testing among a population of asymptomatic high‐risk patients (with diabetes mellitus and/or >50 years of age). Only those with VO 2peak <17 mL/kg per minute (equivalent to <5 metabolic equivalents) underwent further noninvasive cardiac screening tests. We conducted a retrospective study of the a priori dichotomization of the VO 2peak <17 versus ≥17 mL/kg per minute to determine negative and positive predictive value of future cardiac events and all‐cause mortality. We report a high (>90%) negative predictive value, indicating that VO 2peak ≥17 mL/kg per minute is effective to rule out future cardiac events and all‐cause mortality. However, lower VO 2peak had low positive predictive value and should not be used as a reliable metric to predict future cardiac events and/or mortality. In addition, a simple mathematical calculation documented a cost savings of ≈$272 600 in the cardiac screening among our study cohort of 637 patients undergoing evaluation for kidney and/or pancreas transplant. Conclusions We conclude that incorporating an objective measure of cardiorespiratory fitness with VO 2peak is safe and allows for a cost savings in the cardiovascular screening protocol among higher‐risk phenotype (with diabetes mellitus and >50 years of age) being evaluated for kidney transplant.

AbstractBackgroundThe National Living Donor Assistance Center (NLDAC) enables living donor kidney transplants through financial assistance of living donors, but its return on investment (ROI) through savings on dialysis costs remains unknown.MethodsWe retrospectively reviewed 2012‐2015 data from NLDAC, the United States Renal Data System, and the Scientific Registry of Transplant Recipients to construct 1‐, 3‐, and 5‐year ROI models based on NLDAC applications and national dialysis and transplant cost data. ROI was defined as state‐specific federal dialysis cost minus (NLDAC program costs plus state‐specific transplant cost), adjusted for median waiting time (WT).ResultsA total of 2425 NLDAC applications were approved, and NLDAC costs were USD $6.76 million. Median donor age was 41 years, 66.1% were female, and median income was $33 759; 43.6% were evaluated at centers with WT >72 months. Median dialysis cost/patient‐year was $81 485 (IQR $74 489‐$89 802). Median kidney transplant cost/patient‐year was $30 101 (IQR $26 832‐$33 916). Overall, ROI varied from 5.1‐fold (1‐year) to 28.2‐fold (5‐year), resulting in $256 million in savings. Higher ROI was significantly associated with high WT, larger dialysis and transplant costs differences, and more NLDAC applicants completing the donation process.ConclusionsFinancial support for donor out‐of‐pocket expenses produces dramatic federal savings through incremental living donor kidney transplants.