High MELD score does not adversely affect outcome of living donor liver transplantation: Experience in 1000 recipients

In countries where deceased organ donation is scarce, there is a big gap between demand and supply of organs and living donor liver transplantation (LDLT) plays an important role in meeting this unmet need. This study was conducted to analyze the effect of pretransplant Model for End‐stage Liver Disease (MELD) score on outcomes following LDLT. The outcome of 1000 patients who underwent LDLT from July 2010 to March 2015 was analyzed retrospectively. Patients were grouped into low MELD<25 and high MELD ≥25 score to compare short‐term outcomes. Cumulative overall survival rates were calculated using Kaplan‐Meier methods. A total of 849 recipients were in low MELD group (Mean MELD=16.90±9.2) and 151 were in high MELD group (Mean MELD=28.77±7.2). No significant difference in etiology of CLD was observed between groups except for a higher prevalence of hepatitis C virus (29.6% vs 19.9%, P=.01) in low MELD patients. No significant difference was observed in 1‐year survival (88.5% vs 84.1%, P=.12) between the groups. The multivariate analysis showed that pretransplant MELD score does not predict survival of recipients. Pretransplant high MELD score does not adversely affect outcomes after LDLT. In view of shortage of deceased organs, LDLT can be a good option in high MELD recipients.     

Obesity does not adversely affect the outcome of laparoscopic antireflux surgery (LARS)

Background: Because it has been suggested that obesity adversely affects the outcome of LARS, it is unclear how surgeons should counsel obese patients referred for antireflux surgery. Methods: A prospective database of patients undergoing LARS from 1992 to 2001 was used to compare obese and nonobese patients. Patients were surveyed preoperatively and annually thereafter. Questionnaires were completed regarding global symptoms and overall satisfaction. Results: Of the 505 patients, the body mass index (BMI) was <25 (normal) in 16%, 25–29 (overweight) in 42%, and >30 (obese) in 42%. Although the operative time was longer in the obese group than in the normal weight group (137 ± 55 min vs 115 ± 42 min, p = 0.003), the time to discharge and rate of complications did not differ. At a mean follow-up of 35 ± 25 months, there were no differences in symptoms, overall improvement, or patient satisfaction. Further, the rates of anatomic failure were similar among the obese, overweight, and normal weight groups. Conclusions: Although the operative time is longer in the obese, complication and anatomic failure rates are similar to those in the nonobese at long-term follow-up. Obese patients have equivalent symptom relief and are equally satisfied postoperatively. Therefore, obesity should not be a contraindication to LARS. Presented at the annual meeting of the Association of Academic Surgeons, Boston, MA, USA, November 2002     

Socioeconomic status does not affect the outcome of liver transplantation

The outcome of liver transplantation is dependent on many factors. It was suggested that racial disparities in outcome may be related to differences in socioeconomic status (SES). In this retrospective study, we analyzed the effect of SES on graft and patient survival. Two hundred seventy-six adult patients who underwent liver transplantation at our institution from July 1988 to June 2001 were included in the analysis. Educational and occupation statuses were coded using established criteria (Hollingshead Index of Social Status [HI]). SES then was calculated using the HI formula: SES = education level × 3 + occupation × 5, and categorized into four groups: group 1, score less than 29 (n = 71); group 2, score of 29 to 42 (n = 82); group 3, score of 42 to 53 (n = 69); and group 4, score greater than 53 (n = 54). Kaplan-Meier analysis was used for graft and patient survival, and Cox regression analysis was used to determine the effect of confounding factors. Demographics of all four groups were similar. One-, 2-, and 5-year graft and patient survival did not differ significantly across groups by Kaplan-Meier and Cox regression survival analysis. In conclusion, SES did not predict graft and patient survival after liver transplantation. (Liver Transpl 2002;8:1133-1137.)     

Prior dialysis does not affect the outcome of pediatric renal transplantation

The effect of pretransplantation dialysis treatment was examined retrospectively in 70 children less than 6 years old receiving a primary renal transplant at the University of Minnesota. Patient and graft survivals were compared at 1, 2 and 3 years and there were no significant differences between patients who received only hemodialysis (group 1), only peritoneal dialysis (group 2), or no prior dialysis (group 3). All patients received deliberate blood transfusions before transplantation and children at risk for recurrent diseases were excluded from the analyses. No grafts were lost due to perioperative thrombosis. Also, treatment with cyclosporine A did not significantly influence the outcomes. In this series, the choice to proceed directly to renal transplantation without an interposed interval of dialysis imposes no penalty in terms of patient or graft survival. Likewise, when dialysis was required, the dialysis mode selected exerted no clear effect on the outcome of transplantation.     

Microscopic intrarenal particles after pulsatile machine preservation do not adversely affect outcomes after renal transplantation

INTRODUCTION: Our center has recently observed foreign carbohydrate-appearing particles (FP) on transplant postreperfusion biopsy specimens: (PRBx). METHODS: To further characterize FPs, we reviewed all renal transplant RBx (30-45 minutes) performed between September 1, 2004 and December 3, 2005. Donor, preservation, and outcome variables were collected among patients with FP. RESULTS: A total of 135 PRBx were performed (45 deceased donors [DD] and 90 live donors [LD]). Fifteen PRBx demonstrated FP. All 15 cases were DD kidneys that underwent machine perfusion (MP) on the Waters RM3 (Waters Medical Systems, Rochester, Minn, United States) with Belzer MP solution (Trans Med, Elk River, Minn, United States). Donor age was 39.8 +/- 15.7 years. Terminal creatinine level was 1.45 +/- 0.8 mg/dL. Two of 15 were flushed in situ with HTK solution (no starch). Cold ischemia time was 28.8 +/- 9.1 hours with 14.3 +/- 5.1 hours of MP. In 13 of 15 patients, perfusion parameters were excellent (flow > 100 mL; resistance < .35). CHARACTERISTICS OF FP: Particles were 10-30 mu and globular in shape. FP were not visible on hematoxylin and eosin stain, but stained strongly periodic acid-Schiff-(PAS) positive and were refractile under polarized light. FP were seen segmentally within glomerular capillaries in all cases and in peritubular capillaries in 3. In 11 of the 15 cases with FP, focal glomerular fibrin thrombi or intracapillary neutrophil margination was seen. Ten of 15 patients with FP had a biopsy within the first week with no identifiable FP. OUTCOMES: Recipient age was 45.3 +/- 11.6 years. Eight patients (53.3%) had delayed graft function. Biopsy-proven rejection occurred in 3 patients (20%). Three-month creatinine level was 1.59 +/- 0.35 mg/dL. One graft was lost to early thrombosis in a patient with a hypercoagulable state and 1 patient died of sepsis at 2 months. All remaining 13 patients are alive with excellent graft function at a median follow-up of 6.7 months (range, 3-17 months). CONCLUSIONS: Microscopic intrarenal particles may be seen on DD kidney PRBx after MP. These FPs likely originate from surgical gloves. FPs are too small to be captured by standard filters but clear spontaneously and do not have deleterious effects on renal function or outcomes.     

Prolonged donor ischemic time does not adversely affect long-term survival in adult patients undergoing cardiac transplantation

OBJECTIVE: With liberalization of donor eligibility criteria, organs are being harvested from remote locations, increasing donor ischemic times. Although several studies have evaluated the effects of prolonged donor ischemic times on short-term survival and graft function, few have addressed concerns regarding long-term survival. METHODS: Over the last 11 years, 819 consecutive adults underwent cardiac transplantation at Columbia Presbyterian Medical Center. Recipients were separated into the following 4 groups based on donor ischemic time: <150 minutes, 150 to 200 minutes, 200 to 250 minutes, and >250 minutes. Statistical analysis included Kaplan-Meier survival and Cox proportional hazard models to identify predictors of long-term survival. RESULTS: Donor ischemic time was 120.1 +/- 21.1 minutes for group 1 (n = 321), 174.1 +/- 14.7 minutes for group 2 (n = 264), 221.7 +/- 14.6 minutes for group 3 (n = 154), and 295.5 +/- 37.1 minutes for group 4 (n = 80) (P <.001). There were no significant differences in recipient age, donor age, etiology of heart failure, United Network for Organ Sharing status, or history of previous cardiac surgery among the groups (P = NS). Prolonged donor ischemic time did not adversely affect long-term survival, with actuarial survival at 1, 5, and 10 years of 86.9%, 75.2%, and 56.4% for group 1; 86.2%, 76.9%, and 50.9% for group 2; 86.4%, 71.0%, and 43.7% for group 3; and 86.7%, 70.1%, and 50.9% for group 4 (P =.867). There was no significant difference in freedom from transplant coronary artery disease among the 4 groups (P =.474). CONCLUSIONS: Prolonged donor ischemic time is not a risk factor for decreased long-term survival. Procurement of hearts with prolonged donor ischemic time is justified in the setting of an increasing recipient pool with a fixed donor population.     

Pulmonary artery stenosis 5 years after single lung transplantation in primary pulmonary hypertension

This is a case report about a 56-year-old female patient with primary pulmonary hypertension who underwent single, right lung transplantation. Five years postoperatively she developed signs of right heart failure. History and physical examination suggested pulmonary artery stenosis. Diagnosis was confirmed by pulmonary angiography. Percutaneous placement of a balloon expandable stent normalized pulmonary artery pressure.     

Pregnancy after treatment of breast cancer in young women does not adversely affect the prognosis

We assessed whether pregnancy after breast cancer in patients younger than 36 years of age affects the prognosis. Of 115 women with breast cancer followed for a mean of 6 years, 18 became pregnant (median time between diagnosis and the first pregnancy 44.5 months). Voluntary interruption of pregnancy was decided by 8 (44.4%) women. Significant differences in prognostic factors between pregnant and non-pregnant women were not observed. Pregnant women showed a lower frequency of positive estrogen receptors (41%) than non-pregnant (64%) (P=0.06). At 5 years of follow-up, 100% of women in the pregnant group and 80% in the non-pregnant group were alive. The percentages of disease-free women were 94% and 64%, respectively (P=0.009). Breast cancer patients presented a high number of unwanted pregnancies. Pregnancy after breast cancer not only did not adversely affect prognosis of the neoplasm but also may have a protective effect.     

Increasing age does not affect good outcome after lumbar disc replacement

From 1992 to 1998 fifteen Link-Charite SB III disc prostheses were implanted into 14 patients. The main indication was degenerative lumbar disc disease with segmental instability. With a mean follow-up of 48 months (18–68 months); 12 patients had a good (10) or fair (2) outcome regarding pain relief, return to employment and level of general physical activity. In contrast to previous publications we felt that age over 45 years did not appear to adversely affect the outcome.

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Résumé  De 1992 a 1998 quinze prothe`ses discales LINK-CHARITE III ont été posées chez quatorze patients avec une dégéneration lombaire. Avec un suivi post-operatoire de 48 mois (18 – 68 mois); douze patients ont bien récupéré en ce qui concerne l’analgesie ainsi que la retour au travail et aux activites physiques générales. Nous ne trouvont pas que l’age plus de 45 ans affectait les resultats.

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Accepted: 21 November 1999     

On-site coagulation monitoring does not affect hemostatic outcome after cardiac surgery

BACKGROUND: Rapid coagulation tests are now available for monitoring of bleeding patients after cardiac surgery. As inappropriate blood use in these patients may be due to lack of timely coagulation data, we studied the effect of an algorithm with on-line coagulation monitoring on transfusions in these patients. METHODS: Prospectively, patients bleeding (>1.5 ml kg(-1) 15 min(-1)) after cardiac surgery were randomly assigned to two groups: in group A (n=28), hemostatic treatment during the immediate recovery period (1 h after surgery) was based on an algorithm with on-site hemostasis monitoring, whereas during the same period group B patients (n=30) were managed solely according to the clinician's judgement; laboratory tests other than activated clotting time after heparin neutralization were prohibited. RESULTS: Cumulative chest tube drainage up to 16 h and total transfusion requirements did not differ between the groups. Using a platelet transfusion trigger of 100x10(9)/l, significantly more patients received platelets during the immediate recovery period in the algorithm group than in the control group (14 vs. 3 patients, P=0.001). Desmopressin acetate was administered more often in group A than in group B (8 vs. 2 patients, P=0.04). CONCLUSIONS: Algorithm-based therapy increased utilization of hemostatic interventions during the immediate recovery period without any obvious benefit to the hemostatic outcome. Re-evaluation of the platelet transfusion trigger seems warranted.     

Graft damage after a single lung transplantation for pulmonary hypertension in a rat model

The hemodynamic effect and degree of damage in grafts of single lung transplants for pulmonary hypertension were studied in rats with monocrotaline-induced pulmonary hypertension. Inbred male Lewis rats (weight 200–230 g) were divided into two groups. Group 1 (control group,n = 16) underwent isogenic left lung transplantation, while group 2 (n = 15) received an intravenous administration of monocrotaline (80 mg/kg i.v.) and underwent isogenic left single lung transplantation 3 weeks later. Hemodynamic evaluations were performed prior to transplantation, at 1h postoperatively, and on days 3 and 7 after transplantation. Mean pulmonary arterial pressure (mPAP) rapidly declined after transplantation in group 2, from 39.3 ± 8.7 mmHg to 18.5 ±3.0 mmHg 1h after transplantation, and remained stable on day 7 after tranaplantation. No significant difference in the mPAP between the two groups was observed after tranaplantation. The extravascular lung water volume (ELWV: dry/wet ratio) in the right lung of group 2 significantly increased on day 3 (0.86 ± 0.02) (P < 0.01), and subsequently decreased to control levels on day 7 (0.83 ± 0.02). There was no significant difference in the ELWV in the grafted lungs between the two groups (0.84 ± 0.03 vs 0.86 ± 0.04), but there was tendency toward an increase in ELWV in group 2 on days 3 and 7. These data thus demonstrated that a hemodynamic improvement was obtained by single lung transplantation; however the degree of graft damage was remarkable in the pulmonary hypertension group.