Eighteen‐year experience with femoro‐femoral bypass

Background : The role of femoro‐femoral bypass in the management of aorto‐iliac occlusive disease has evolved during the past two decades. The aim of the present study was to evaluate the early and long‐term outcomes of femoro‐femoral bypass grafts performed at the University of Hong Kong Medical Centre during an 18‐year period. Methods : From 1981 to 1998, a retrospective analysis of 61 patients who underwent femoro‐femoral bypass at the University of Hong Kong Medical Centre was undertaken. Data on demographic features and results of surgical intervention were reviewed. Early outcomes (morbidity, mortality and improvement of clinical category) and long‐term outcomes (graft patency, patient survival and limb salvage rates) were analysed. Results : The postoperative morbidity and mortality rates were 16% and 7%, respectively. Clinical success was achieved in 48 patients (79%) after operation. The primary patency of femoro‐femoral bypass was 86%, 79% and 71% at 1, 3 and 5 years, respectively. The limb salvage rate was 85% at 3 years. The cumulative survival rate of the study population was 89%, 82% and 73% at 1, 3 and 5 years, respectively. Conclusions : Femoro‐femoral bypass was successful in relieving ischaemic pain and limb salvage in ~ 80% of patients. A 5‐year patency rate of 71% was achieved. Femoro‐femoral bypass remains a valuable surgical procedure for limb salvage in poor‐risk patients with unilateral iliac artery occlusion.     

Survival of patients with bladder cancer from a UK hospital: a 10‐year follow‐up study

Study Type – Prognosis (case series)
Level of Evidence 4

OBJECTIVE

To compare 10‐year overall (OS) and cancer‐specific survival (CSS) of a cohort of consecutively presenting patients with bladder cancer of all pT categories from one UK institution.

PATIENTS AND METHODS

Data were collected on 144 patients with newly diagnosed bladder tumours presenting from 1983 to 1985 followed up for 10 years. Histological variables were reviewed by one pathologist who had no knowledge of the clinical details. Bladder muscle was present in 95% of the transurethral resection specimens. Date and causes of death were ascertained through death certificates, primary care physicians and/or hospital case notes. Data were analysed using the Kaplan–Meier method and Cox model.

RESULTS

There were 69 patients (48%) with pTa, 32 (22%) with pT1 and 43 (30%) with pT2/3/4 tumours. The 10‐year OS was 54%, 34% and 16% and the CSS was 97%, 50% and 29%, respectively. There were only two cancer‐related deaths in the pTa category whereas half the pT1 cases and half the muscle‐invasive cases died within 5 and 2 years of diagnosis, respectively.

CONCLUSIONS

This study compared the 10‐year OS and CSS of a cohort of patients with bladder cancer from the UK, where such data are lacking, and showed marked differences. The CSS was higher in all pT categories compared with OS, especially within pTa cancers in which almost all patients died of competing causes. It is important to be aware of such a significant difference between the two survival measures and to use them appropriately in the right context.     

Eurotransplant donor‐risk‐index and recipient factors: influence on long‐term outcome after liver transplantation – A large single‐center experience

The organ shortage has led to increased use of marginal organs. The Eurotransplant Donor‐Risk‐Index (ET‐DRI) was established to estimate outcome after Liver Transplantation (LT). Currently, data on impact of ET‐DRI on long‐term outcome for different indications and recipient conditions are missing. Retrospective, single‐center analysis of long‐term graft survival (GS) of 1767 adult primary LTs according to indication, labMELDcategory (1: ≤18; 2: >18–25; 3: >25–35; 4: >35), and ET‐DRI. Mean ET‐DRI in our cohort was 1.63 (±0.43). One‐, 10, and 15‐yr GS was 83.5%, 63.3%, and 54.8%. Long‐term GS was significantly influenced by ET‐DRI. Accordingly, four ET‐DRI categories were defined and analyzed with respect to underlying disease. Significant impact of these categories was observed for: Alcohol, cholestatic/autoimmune diseases (CD/AIH), and HCV, but not for HCC, HBV, cryptogenic cirrhosis, and acute liver failure. labMELD categories showed no significant influence on graft, but on patient survival. Matching ET‐DRI categories with labMELD revealed significant differences in long‐term GS for labMELDcategories 1, 2, and 3, but not 4. In multivariate analysis, HCV combined with ET‐DRI > 2 and labMELDcategory 3 combined with ET‐DRI > 2 emerged as negative predictors. To achieve excellent long‐term graft survival, higher risk organs (ET‐DRI > 1.4) should be used restrictively for patients with CD/AIH or HCV. Organs with ET‐DRI > 2 should be avoided in patients with a labMELD of >25–35.     

A mathematical model provides new insights into solid organ transplant‐associated acute graft‐versus‐host disease

Solid organ transplantation‐associated acute graft‐versus‐host disease (SOT‐aGvHD) is a rare but highly fatal condition. Our poor understanding of this entity in addition to its rarity has hampered treatment progress and most patients succumb to the disease. A mechanistic mathematical model is developed to replicate and explain the complex pathogenesis of SOT‐aGvHD. The model captures a number of important features of SOT‐aGvHD including (i) the occurrence of stable and persistent mixed chimerism in some, but not all, cases, (ii) fluctuation in chimerism in some persistently mixed chimeric cases, (iii) rare occurrence of full donor chimerism, and (iv) beneficial effect of escalating immunosuppression in some cases of SOT‐aGvHD and detrimental effect in others. In addition, the model predicts the conditions under which escalation or de‐escalation of immunosuppression would be the preferred treatment strategy. In an exceedingly rare condition such as SOT‐aGvHD, where prospective trials are not feasible, mathematical modeling can provide useful insights into pathogenesis and treatment.     

Model for end‐stage liver disease‐sodium and survival benefit in liver transplantation

There are currently no studies calculating the survival benefit of liver transplantation (LT) according to model for end‐stage liver disease‐sodium (MELD‐Na) and based on the competing risk (CR) method. We enrolled consecutive adult patients with chronic end‐stage liver disease entering the waiting list (WL) for primary LT (WL group = 337) and undergoing LT (LT group = 220) in the period 2006–2009. Two independent multivariable regressions (WL and LT models) were created to measure the prognostic power of MELD‐Na with respect to MELD. For the WL model, both Cox and CR multivariable analyses were performed. Estimates were finally included in a Markov model to calculate 3‐year survival benefit. WL Cox model: MELD‐Na (P < 0.0001) and MELD (P < 0.0001) significantly predicted survival. WL CR model: MELD‐Na (P = 0.0045) and MELD (P = 0.0109) significantly predicted survival. LT Cox model: MELD‐Na (P = 0.7608) and MELD score (P = 0.9413) had not correlation with survival. Benefit model: MELD and MELD‐Na had an overlapping significant impact on 3‐year survival benefit; CR method determined a significant decrease in 3‐year life expectancy (LE) estimations. MELD‐Na and MELD scores similarly predicted 3‐year LT survival benefit, but the gain in LE is significantly lower when a CR method is adopted.     

Donor‐specific anti‐HLA antibodies detected by Luminex: predictive for short‐term but not long‐term survival after heart transplantation

In heart transplantation, the clinical significance of pretransplant donor‐specific antibodies (DSA) detected by solid phase assay (SPA), which is more sensitive than the conventional complement‐dependent cytotoxicity (CDC) assays, is unclear. The aim was to evaluate SPA performed on pretransplant sera for survival after heart transplantation. Pretransplant sera of 272 heart transplant recipients were screened for anti‐HLA antibodies using CDC and SPA. For determination of pretransplant DSA, a single‐antigen bead assay was performed. The presence of anti‐HLA antibodies was correlated with survival. Secondary outcome parameters were acute cellular rejection, graft coronary vasculopathy and ejection fraction. In Kaplan–Meier analysis, SPA‐screening did not predict survival (P = 0.494), this in contrast to CDC screening (P = 0.002). However, the presence of pretransplant DSA against HLA class I was associated with decreased short‐term survival compared to non‐DSA (P = 0.038). ROC curve analysis showed a sensitivity of 76% and specificity of 73% at a cutoff of 2000 MFI. In contrast, the presence of anti‐HLA antibodies had no influence on long‐term survival, rejection incidence, and graft function. Thus, detection of DSA class I in pretransplant serum is a strong predictor of short‐term, but not long‐term survival and may help in the early management of heart transplant patients.     

Preformed donor‐specific HLA antibodies are associated with increased risk of early mortality after liver transplantation

There is limited evidence for a negative impact of preformed, donor‐specific HLA antibodies (DSA) identified by cross‐matching on outcomes after liver transplantation. Three recent studies have suggested an association between preformed DSA detected by Luminex and reduced graft or recipient survival in liver transplant cohorts with a high prevalence of hepatitis C. This study investigated the impact of preformed DSA identified by Luminex in the Scottish liver transplant population. All recipients of liver transplants in Scotland between 2007 and 2015 with samples available for day of transplant antibody testing and donor HLA typing were included (n=459); 96% of the cohort were white and 19% had a primary diagnosis of hepatitis C. The median follow‐up time was 36 months. Preformed DSA were detected in 88 recipients. In multivariate analysis, preformed DSA with a median fluorescent intensity ≥10 000 were associated with recipient mortality at 1 year. There was no association between DSA and overall graft or recipient survival. This study adds to the growing body of evidence supporting a detrimental impact of preformed, high‐level DSA in a subset of liver transplant recipients by identifying an association in an ethnically and demographically distinct liver transplant population.