Simultaneous Liver–Kidney Allocation Policy: A Proposal to Optimize Appropriate Utilization of Scarce Resources

The introduction of the Mayo End‐Stage Liver Disease score into the Organ Procurement and Transplantation Network (OPTN) deceased donor liver allocation policy in 2002 has led to a significant increase in the number of simultaneous liver–kidney transplants in the United States. Despite multiple attempts, clinical science has not been able to reliably predict which liver candidates with renal insufficiency will recover renal function or need a concurrent kidney transplant. The problem facing the transplant community is that currently there are almost no medical criteria for candidacy for simultaneous liver–kidney allocation in the United States, and this lack of standardized rules and medical eligibility criteria for kidney allocation with a liver is counter to OPTN's Final Rule. Moreover, almost 50% of simultaneous liver–kidney organs come from a donor with a kidney donor profile index of ≤0.35. The kidneys from these donors could otherwise be allocated to pediatric recipients, young adults or prior organ donors. This paper presents the new OPTN and United Network of Organ Sharing simultaneous liver–kidney allocation policy, provides the supporting evidence and explains the rationale on which the policy was based.     

Legionnaires' disease outbreak: Victoria's largest identified outbreak

This paper describes and analyses some aspects of an outbreak of Legionnaires' disease in Victoria, commencing in late October 1998. In all, 18 cases caused by Legionella pneumophila serogroup 1 were notified within 10 days making this the largest outbreak in Victoria reported to that date. All cases had epidemiological links to an industrial estate in a northern Melbourne suburb. Extensive environmental sampling revealed Legionella bacteria in five cooling towers. Molecular sub-typing techniques were used to compare clinical and environmental isolates. Isolates from one tower had a pulsed-field gel electrophoresis pattern that was indistinguishable from clinical isolates from eight cases. Control of outbreaks caused by Legionella bacteria requires rapid, coordinated responses to linked cases of disease. The Legionella urinary antigen test facilitated a rapid public health response, and culture and molecular sub-typing of clinical specimens assisted in developing epidemiological links.     

ECMO support for the treatment of cardiogenic shock due to left ventricular free wall rupture

Left ventricular free wall rupture (LVFWR) is still an uncommon catastrophic complication after acute myocardial infarction (MI), and it is one of the most frequent causes of sudden cardiac death. Immediate surgical repair is the treatment of choice. When LVFWR presents acutely with tamponade and cardiogenic shock in emergency department, salvage with a good outcome is still possible by timely pericardiocentesis and extracorporeal membrane oxygenation (ECMO) support. We report a case of cardiac rupture with tamponade and cardiogenic shock in which cardiopulmonary support with portable ECMO was used to rescue the patient before the operation.     

Hemoglobin level and XRCC1 polymorphisms to select patients with locally advanced rectal cancer candidate for neoadjuvant chemoradiotherapy with concurrent capecitabine and a platinum salt

A platinum salt (oxaliplatin or cisplatin) is widely used to enhance chemoradation (CRT) response. The potential of cisplatin in neoadjuvant CRT for locally advanced rectal cancer (LARC) has not been fully investigated. Consecutive patients with histologically confirmed LARC were treated with standard pelvic radiotherapy and concurrent cisplatin plus capecitabine (CisCape CRT). Surgery and eight cycles of adjuvant FOLFOX4 were offered to all patients after CRT. Common biochemical variables and key germline genetic polymorphisms were analyzed as predictors of pathological complete response (pCR). Fifty-one patients were enrolled. pCR (regression AJCC grade 0) was documented in 7 patients (14%), nearly complete response (AJCC grade 1) in 10 pts. There was a strong association between disease-free survival and AJCC grade (p 0.0047). Grade 3–4 toxicities (mainly diarrhea) was observed in 41% of patients. Among all analyzed variables, baseline hemoglobin (Hb) was significantly associated with AJCC grade 0–1 response (p 0.027). As for the pharmacogenetic analysis, XRCC1 rs25487 polymorphism was significantly associated with AJCC grade 0–1, Odds Ratio 25.8, p 0.049. AJCC grade 0–1 response rate for patients with high Hb and/or XRCC1 rs25487 G/G genotype was as high as 57%. Baseline Hb and XRCC1 polymorphisms are valuable selection criteria for the CisCape CRT regimen, given its otherwise meaningful toxicity.