Development of the Eurotransplant Discard Risk Index to Predict Acceptance of Livers for Transplantation: A Retrospective Database Analysis.

OBJECTIVES: The utilization of liver allografts could be optimized if nonacceptance is predicted. This study aimed to evaluate the prognostic ability of an updated Discard Risk Index in Eurotransplant. MATERIALS AND METHODS: Potential deceased donors from January 2010 to December 2015 who had been reported to Eurotransplant were included in our analyses. Liver utilization was defined by transplant status as the primary outcome to evaluate the performance of the Eurotransplant-developed Discard Risk Index. RESULTS: Of 11670 potential livers, 9565 (81%) were actually transplanted. Donor sex, age, history of diabetes, drug abuse, use of vasopressors, body mass index category, serum sodium, cause of death, donor type, and levels of C-reactive protein, bilirubin, aspartate and alanine aminotransferases, international normalized ratio, and gamma-glutamyltranspeptidase were associated with discard and combined in the Eurotransplant-developed Discard Risk Index. Correlation between the two Discard Risk Indexes was high (r = 0.86), and both achieved high C statistics of 0.72 and 0.75 (P < .001), respectively. Despite strong calibration, discard rates of 0.8% for overall donors and 6% of donors after circulatory death could be predicted with 80% accuracy. CONCLUSIONS: The Eurotransplant-developed Discard Risk Index showed a high prognostic ability to predict liver utilization in a European setting. The model could therefore be valuable for identifying livers at high risk of not being transplanted in an early stage. These organs might profit the most from modified allocation strategies or advanced preservation techniques.

Peri-operative Monitoring of an Asystolic Cardiac Arrest Requiring Cardiopulmonary Resuscitation During Carotid Endarterectomy for Symptomatic Carotid Artery Stenosis.

INTRODUCTION: A carotid endarterectomy (CEA) has certain risks, of which peri-operative cardiovascular risk is one. Peri-operative neurological monitoring can be done with electroencephalography (EEG) and transcranial Doppler (TCD). No previous reports have been published demonstrating the actual changes in cerebral and cardiac activity during a peri-operative asystole. REPORT: The case of a 70 year old man with a symptomatic (bilateral) carotid stenosis is described. The patient complained of amaurosis fugax in both eyes. Duplex ultrasound showed a stenosis of >70% in both carotid arteries. The most severe symptoms were on the right side, so a staged approach was chosen, starting with a right sided eversion CEA (eCEA). Peri-operatively, the patient experienced an asystolic cardiac arrest after external carotid artery revascularisation, requiring brief cardiopulmonary resuscitation, which was recorded on the EEG. Post-operatively, the patient recovered fully, with no post-operative neurological or cardiac sequelae. The (symptomatic) contralateral stenosis was treated conservatively with best medical therapy (BMT; dual antiplatelets and statin). The patient is currently in good clinical condition, 1.5 years later. CONCLUSION: This case shows the unique EEG recording of a cardiological event during eCEA. The cause of asystole was most likely a vasovagal syncope as a result of the surgical procedure by iatrogenic damage to the carotid sinus fibres, causing impairment of the baroreflex and chemoreflex mechanisms, which is greater during eCEA. The unilateral eCEA and contralateral BMT in this symptomatic (bilateral) stenosis seemed appropriate when cardiological risk was increased but follow up ruled out any cardiological cause.

A 'Final Destination injury': Penetrating trauma of the neck and a pneumomediastinum by a metal part shot from a lawnmower.

INTRODUCTION: Outside of war regions, penetrating neck injury is rare. Penetrating neck injury due to a lawnmower has never been described, despite the annual 74.000 injuries caused by lawnmowers in the United States. In this report, the case of a 65-year old women, admitted after a penetrating neck injury due to a metal piece shot from a lawnmower, is described. REPORT: A 65-year old women, with no relevant medical history, presented at the Emergency Department after she was hit in the neck by an iron projectile shot from a professional lawnmower. On site, the projectile, a metal part from the lawnmower blade, was removed by her husband. CT scan showed a pneumomediastinum, without signs of vascular injury. Surgical exploration was immediately performed in the operation room (OR). No vascular or esophageal injuries werefound, only lacerated neck muscles. Perioperatively, the ENT surgeon performed an endoscopy, which showed a small injury of the hypopharynx. Postoperatively, the patient was prophylactically treated with antibiotics for 7 days. Patient was discharged in good clinical condition after 7 days, without complications. CONCLUSION: In this report we present a case with a sharp traumatic injury of the neck, caused by a metal projectile shot from a lawnmower. The laceration of the pharynx was explored in the OR by the ENT- and vascular surgeon. The pneumomediastinum was treated with prophylactic antibiotics. Currently the patient is doing fine without any complications of the injury. Traumatic injury of the neck requires direct direct surgical exploration, however, when patients present hemodynamically stable, a neck CTA will add to the diagnosis (e.g. a pneumomediastium).

Predictive Capacity of Risk Models in Liver Transplantation.

BACKGROUND: Several risk models to predict outcome after liver transplantation (LT) have been developed in the last decade. This study compares the predictive performance of 7 risk models. METHODS: Data on 62 294 deceased donor LTs performed in recipients ≥18 years old between January 2005 and December 2015 in the United Network for Organ Sharing region were used for this study. The balance of risk, donor risk index (DRI), Eurotransplant-DRI, donor-to-recipient model (DRM), simplified recipient risk index, Survival Outcomes Following Liver Transplantation (SOFT), and donor Model for End-stage Liver Disease scores were calculated, and calibration and discrimination were evaluated for patient, overall graft, and death-censored graft survival. Calibration was evaluated by outcome of high-risk transplantations (>80th percentile of the respective risk score) and discrimination by concordance index (c-index). RESULTS: Patient survival at 3 months was best predicted by the SOFT (c-index: 0.68) and Balance of Risk score (c-index: 0.64), while the DRM and SOFT score had the highest predictive capacity at 60 months (c-index: 0.59). Overall, graft survival was best predicted by the SOFT score at 3-month follow-up (c-index: 0.65) and by the SOFT and DRM at 60-month follow-up (c-index: 0.58). Death-censored graft survival at 60-month follow-up is best predicted by the DRI (c-index: 0.59) and Eurotransplant-DRI (c-index: 0.58). For patient and overall graft survival, high-risk transplantations were best defined by the DRM. For death-censored graft survival, this was best defined by the DRI. CONCLUSIONS: This study shows that models dominated by recipient factors have the best performance for short-term patient survival. Models that also include sufficient donor factors have better performance for long-term graft survival. Death-censored graft survival is best predicted by models that predominantly included donor factors.

Successful Endovascular Treatment of a Giant Intraparenchymal Renal Artery Pseudoaneurysm in a Young Female Patient.

INTRODUCTION: Pseudoaneurysms of the renal artery are fairly uncommon and mostly asymptomatic. They develop mostly in the right renal artery and in female patients. REPORT: In this report, a female patient with an intraparenchymal renal artery pseudoaneurysm with one year follow up is described. She presented with non-specific abdominal pain. A computed tomography scan revealed hydronephrosis of the right kidney and a giant, intracapsular, contained rupture of a pseudoaneurysm of the right renal artery. The patient was admitted to hospital and underwent a successful selective embolisation of the pseudoaneurysm. Follow up at one year showed normal renal function and an excluded aneurysm. DISCUSSION: Although relatively uncommon, renal artery pseudoaneurysms should be considered in the work up of patients with colicky flank pain. As a treatment option, endovascular approaches are appealing because they are less invasive. Successful treatment can prevent resection of the affected kidney.

Optimizing the Use of Geriatric Livers for Transplantation in the Eurotransplant Region.

Acceptance criteria for liver allografts are ever more expanding because of a persisting wait-list mortality. Older livers are therefore offered and used more frequently for transplantation. This study aims to analyze the use and longterm outcome of these transplantations. Data were included on 17,811 first liver transplantations (LTs) and information on livers that were reported for allocation but not transplanted from 2000 to 2015 in the Eurotransplant (ET) region. Graft survival was defined as the period between transplantation and date of retransplantation or date of recipient death. In the study period, 2394 (13%) transplantations were performed with livers ≥70 years old. Graft survival was 74%, 57%, and 41% at 1-, 5-, and 10-year follow-up, respectively. A history of diabetes mellitus in the donor (hazard ratio [HR], 1.3; P = 0.01) and positive hepatitis C virus antibody in the recipient (HR, 1.5; P < 0.001) are specific risk factors for transplantations with livers ≥70 years old. Although donor age is associated with a linearly increasing risk of graft loss between 25 and 80 years old, no difference in graft survival could be observed when "preferred" recipients were transplanted with a liver <70 or ≥70 years old (HR 1.1; CI 0.92-1.23, P = 0.40) or with a donor <40 or ≥70 years old (HR 1.2; CI 0.96-1.37, P = 0.13). Utilization of reported livers ≥70 years old increased from 42% in 2000-2003 to 76% in 2013-2015 without a decrease in graft survival (P = 0.45). In conclusion, an important proportion of LTs in the ET region are performed with livers ≥70 years old. The risk of donor age on graft loss increases linearly between 25 and 80 years old. Livers ≥70 years old can, however, be transplanted safely in preferred patients and are to be used more frequently to further reduce wait-list mortality.

Identification and Validation of the Predictive Capacity of Risk Factors and Models in Liver Transplantation Over Time.

BACKGROUND: Outcome after liver transplantation (LT) is determined by donor, transplant and recipient risk factors. These factors may have different impact on either patient or graft survival (outcome type). In the literature, there is wide variation in the use of outcome types and points in time (short term or long term). Objective of this study is to analyze the predictive capacity of risk factors and risk models in LT and how they vary over time and per outcome type. METHODS: All LTs performed in the Netherlands from January 1, 2002, to December 31, 2011, were analyzed with multivariate analyses at 3-month, 1-year, and 5-year for patient and (non-)death-censored graft survival. The predictive capacity of the investigated risk models was compared with concordance indices. RESULTS: Recipient age, model for end-stage liver disease sodium, ventilatory support, diabetes mellitus, hepatocellular carcinoma, previous malignancy, hepatitis C virus antibody, hepatitis B virus antibody, perfusion fluid, and Eurotransplant donor risk index (ET-DRI) had significant impact on outcome (graft or patient survival) at 1 or multiple points in time. Significant factors at 3-month patient survival (recipient age, model for end-stage liver disease sodium, ventilatory support) were used to compose a concept model. This model, had a higher c-index than the balance-of-risk score, DRI, ET-DRI, donor-recipient model and simplified recipient risk index for long-term patient and non-death-censored graft survival. CONCLUSIONS: In this study, the effects of recipient risk factors and models on different outcome types and time points were shown. Short-term patient survival mainly depends on recipient risk factors, long-term graft survival on donor risk factors and is more difficult to predict. Next to the concept model, the donor-recipient model has a higher predictive capacity to other risk models for (long-term) patient and non-death-censored graft survival. The DRI and ET-DRI best predicted death-censored graft survival. Knowledge about risk factors and models is critical when using these for waitlist management and/or help in organ allocation and decision-making.

The center effect in liver transplantation in the Eurotransplant region: a retrospective database analysis.

Apart from donor and recipient risk factors, the effect of center-related factors has significant impact on graft survival after liver transplantation (LT). To investigate this effect in Eurotransplant, a retrospective database analysis was performed, including all LT's in adult recipients (≥18 years) in the Eurotransplant region from 1.1.2007 until 31.12.2013. Additionally, a survey was sent out to all transplant centers requesting information on surgeons' experience and exposure. In total, 10 265 LT's were included (median follow-up 3.3 years), performed in 39 transplant centers. Funnel plots showed significant differences in graft survival between the transplant centers. After correction for donor and recipient risk, with the Eurotransplant donor risk index (ET-DRI) and the simplified recipient risk index (sRRI) and random effects, these differences diminished. Mean historical volume (in the preceding 5 years) was a significant (P < 0.001), nonlinear marker for graft survival in the multivariate analysis. This study demonstrates that funnel plots can be used for benchmarking purposes in LT. Case-mix correction can be performed with the use of the ET-DRI and sRRI. The center effect encompasses the entire complex process of preoperative workup, operation to follow-up.

Longterm results of liver transplantation from donation after circulatory death.

Donation after circulatory death (DCD) liver transplantation (LT) may imply a risk for decreased graft survival, caused by posttransplantation complications such as primary nonfunction or ischemic-type biliary lesions. However, similar survival rates for DCD and donation after brain death (DBD) LT have been reported. The objective of this study is to determine the longterm outcome of DCD LT in the Eurotransplant region corrected for the Eurotransplant donor risk index (ET-DRI). Transplants performed in Belgium and the Netherlands (January 1, 2003 to December 31, 2007) in adult recipients were included. Graft failure was defined as either the date of recipient death or retransplantation whichever occurred first (death-uncensored graft survival). Mean follow-up was 7.2 years. In total, 126 DCD and 1264 DBD LTs were performed. Kaplan-Meier survival analyses showed different graft survival for DBD and DCD at 1 year (77.7% versus 74.8%, respectively; P = 0.71), 5 years (65.6% versus 54.4%, respectively; P = 0.02), and 10 years (47.3% versus 44.2%, respectively; P = 0.55; log-rank P = 0.038). Although there was an overall significant difference, the survival curves almost reach each other after 10 years, which is most likely caused by other risk factors being less in DCD livers. Patient survival was not significantly different (P = 0.59). Multivariate Cox regression analysis showed a hazard ratio of 1.7 (P < 0.001) for DCD (corrected for ET-DRI and recipient factors). First warm ischemia time (WIT), which is the time from the end of circulation until aortic cold perfusion, over 25 minutes was associated with a lower graft survival in univariate analysis of all DCD transplants (P = 0.002). In conclusion, DCD LT has an increased risk for diminished graft survival compared to DBD. There was no significant difference in patient survival. DCD allografts with a first WIT > 25 minutes have an increased risk for a decrease in graft survival. Liver Transplantation 22 1107-1114 2016 AASLD.

The Value of PDRI and P-PASS as Predictors of Outcome After Pancreas Transplantation in a Large European Pancreas Transplantation Center.

OBJECTIVE: In 2008, the preprocurement pancreas suitability score (P-PASS) was introduced within Eurotransplant to predict suitability of pancreas donors. A P-PASS of 17 or higher would have lower graft survival compared with pancreatic grafts from donors with a P-PASS lower than 17. In 2010, a continuous model, the pancreas donor risk index (PDRI), was designed. Before using this model in the European donor population, it has to be validated in the European setting. METHODS: In this study, P-PASS and PDRI were validated using the results of all pancreas transplants performed at our center. The P-PASS and PDRI were compared as both continuous and dichotomous values. The original cutoff point of 17 divided P-PASS groups. Median PDRI (1.24) divided PDRI groups. RESULTS: In total, 349 pancreas transplantations were performed. The P-PASS of 17 or higher was not associated with graft survival (P = 0.448). The PDRI of 1.24 or higher was associated with reduced graft survival in univariate analysis (P = 0.007) and multivariate analysis (P = 0.002). The PDRI concordance index was 0.69. CONCLUSIONS: The P-PASS has no predictive value for pancreas graft survival and should not be used in clinical decision making. The PDRI is a significant predictor of pancreas graft survival but should be used carefully, because good results can be achieved with grafts from high-PDRI donors.

Combined effect of donor and recipient risk on outcome after liver transplantation: Research of the Eurotransplant database.

Recently the Eurotransplant donor risk index (ET-DRI) was published, a model based on data from the Eurotransplant database that can be used for risk indication of liver donors within the Eurotransplant region. Because outcome after liver transplantation (LT) depends both on donor and recipient risk factors, a combined donor-recipient model (DRM) would give a more complete picture of the overall risk involved. All liver transplants in adult recipients from January 1, 2008 to December 31, 2010 in the Eurotransplant region were included. Risk factors in donors and recipients for failure-free (retransplant free) survival were analyzed in univariate and multivariate analyses. A simplified recipient risk index (sRRI) was constructed using all available recipient factors. A total of 4466 liver transplants were analyzed. Median donor risk index and ET-DRI were 1.78 and 1.91, respectively. The ET-DRI was validated in this new cohort (P < 0.001; concordance index [c-index], 0.59). After construction of a simplified recipient risk index of significant recipient factors, Cox regression analysis showed that the combination ET-DRI and sRRI into a new DRM gave the highest predictive value (P < 0.001; c-index, 0.62). The combined model of ET-DRI and sRRI gave a significant prediction of outcome after orthotopic LT in the Eurotransplant region, better than the ET-DRI alone. This DRM has potential in comparing data in the literature and correcting for sickness/physical condition of transplant recipients. It is a first step toward benchmarking of graft survival in the Eurotransplant region.