Is left lobe adult-to-adult living donor liver transplantation ready for widespread use? The US experience (1998–2010)

Objectives

Living donor liver transplantation (LDLT) is an accepted treatment for patients with end-stage liver disease. To minimize risk to the donor, left lobe (LL) LDLT may be an ideal option in adult LDLT.

Methods

This study assessed the outcomes of LL-LDLT compared with right lobe (RL) LDLT in adults (1998–2010) as reported to the United Network for Organ Sharing (UNOS) Organ Procurement and Transplantation Network (OPTN).

Results

A total of 2844 recipients of LDLT were identified. Of these, 2690 (94.6%) underwent RL-LDLT and 154 (5.4%) underwent LL-LDLT. A recent increase in the number of LL-LDLTs was noted: average numbers of LL-LDLTs per year were 5.2 during 1998–2003 and 19.4 during 2004–2010. Compared with RL-LDLT recipients, LL-LDLT recipients were younger (mean age: 50.5 years vs. 47.0 years), had a lower body mass index (BMI) (mean BMI: 24.5 kg/m² vs. 26.8 kg/m²), and were more likely to be female (64.6% vs. 41.9%). Donors in LL-LDLT had a higher BMI (mean BMI: 29.4 kg/m² vs. 26.5 kg/m²) and were less likely to be female (30.9% vs. 48.1%). Recipients of LL-LDLT had a longer mean length of stay (24.9 days vs. 18.2 days) and higher retransplantation rates (20.3% vs. 10.9%). Allograft survival in LL-LDLT was significantly lower than in RL-LDLT and there was a trend towards inferior patient survival. In Cox regression analysis, LL-LDLT was found to be associated with an increased risk for allograft failure [hazard ratio (HR): 2.39)] and inferior patient survival (HR: 1.86).

Conclusions

The number of LL-LDLTs has increased in recent years.     

Beneficial effects of direct call to Emergency Medical Services on time delays and management of patients with acute myocardial infarction. The RICO (obseRvatoire des Infarctus de Côte-d'Or) data

The influence of direct calls to specialized Emergency Medical Services in case of suspected myocardial infarction has not been extensively studied. The RICO registry is an exhaustive registry implemented in all six institutions participating in primary care of patients with acute myocardial infarction in one French administrative department (C?te-d'Or). From January 2001 to October 2001, 322 patients were admitted for acute myocardial infarction, among whom only 57 (18%) had directly called emergency medical services after the onset of symptoms. The baseline characteristics of patients who had directly called the emergency services were not different from those of the patients who had not. However, the time from symptom onset to first medical intervention (48 versus 105 minutes, p = 0.02) and from first medical intervention to hospital admission (60 versus 103 minutes, p = 0.02) were markedly shorter in patients who had directly called the emergency medical services. This resulted in a significant increase in the use of reperfusion therapy (70% versus 38%, p = 0.003), including a higher proportion of primary angioplasty (33% versus 20%, p = 0.04). This study documents the beneficial effect of a direct call to the Emergency Medical Services by the patients themselves. Too few patients, however use this opportunity and actions should be taken for informing the lay public of the benefits of this medical service.     

Is intravenous recombinant tissue plasminogen activator (rt-PA) safe for use in patients over 80 years old with acute ischaemic stroke? - The Calgary experience

BACKGROUND: Acute ischaemic stroke is common in older people. There is one licensed acute treatment, intravenous recombinant tissue plasminogen activator, but little information is available on its safety in over 80 year olds. DESIGN: Review of prospectively collected data on 62 consecutive patients, aged 80 years and over, treated with recombinant tissue plasminogen activator in a tertiary centre. METHODS: Admission demographic data, clinical and CT stroke severity, symptomatic haemorrhage rate and other complications were compared between patients who were dead at 3 months and those who survived. Discharge location and functional scores outcome were reviewed. The results were compared to those of other studies. RESULTS: The in-hospital death rate was 24.2% and 3 month mortality 32.8%. Patients that died had higher stroke severity scores at presentation (NIHSS 20 versus 16, P = 0.04). Six patients (9.7%) suffered symptomatic intracranial haemorrhage (SICH), three were classified as fatal (4.8%). SICH was significantly associated with death by 3 months (P = 0.02). There were no other serious bleeding complications. The SICH rate is similar to that from other thrombolytic studies and the mortality rate is similar to the natural history of stroke in older populations. CONCLUSION: Older patients have high mortality and morbidity from stroke. Older patients should not be excluded from recombinant tissue plasminogen activator treatment on the basis of age alone.     

The XMN I Site (-158, C→T) 5′ to ttle Gγ GENE: Correlation with the Senegalese Haplotype and Gγ Globin Expression

There are three major African haplotypes associated with the sickle mutation: Benin (#19), Senegalese (#3), and Central African Repblic (#20). Previous studies have suggested that the Xmn I site (-158 bp 5′ to the ^G_γ gene) is associated with elevated levels of ^G_γ andwiththe Senegalesehaplotype, while other investigators questioned this association. In order to clarify theissue.we have determined βhalotypes, tested fortlie presenceof theXninI site, and measured HbF and ^G_γ expressionlevels in 143 AmericanBlackpatients with sickle cell anemia. Haplotypes were determined using eight polvmorphic sites in the β-like globin gene cluster: Hinc II 5′ to ?, Hind III in IVS-II ^G_γ and ^A_γ, Hinc II within and 3′ to φ β, Ava II in IVS-II of β, and Hpa I and Bani HI 3′ to β. The ^G_γ/^A_γ ratio was analyzed by high performance liquid chromatography using a C₁₈ column. The Xmn I site was present in all 31chromosomes with the Sengalese haplotype. Of the remaining 255 chromosomes with other haplotypes, only 2 (0.8%) had the Xmn I site present. Therewas significant correlation between the presence of the Xmn I site and increased ^G_γ/^A_γ ratio in a dose-dependent manner.The Hb F level was not significantly, increased in thepresence of the Xmn I site.The data indicate that the Xmn I site maintains a ^G_γ/^A_γ ratio typical of fetal life but does not necessarily cause elevation of Hb F. The latter seems to depend on factors other than the Xmn I site.     

Letter to the editor: “The association of CD40 polymorphism (rs1883832C/T) and soluble CD40 with the risk of systemic lupus erythematosus among Egyptian patients”

Clinical Rheumatology -