Predictors of Systolic Heart Failure and Mortality Following Orthotopic Liver Transplantation: a Single-Center Cohort.

OBJECTIVES: The purpose of this study was to identify risk factors that may predict heart failure with reduced ejection fraction (HFrEF) following orthotopic liver transplantation (OLT) and associated mortality. BACKGROUND: HFrEF following OLT is a poorly understood phenomenon, reported in 3% to 7% of transplanted patients. METHODS: This is a retrospective analysis of 176 consecutive patients who underwent OLT from 2010 to 2017. Multivariate logistic regression was used to identify associations between cardiovascular risk factors and perioperative variables with post-OLT HFrEF, defined as reduction in left ventricular ejection fraction of at least 10% and left ventricular ejection fraction less than or equal to 40% with acute heart failure symptoms. Multivariate cox proportional hazards regression (with inverse probability weighting by propensity scores) was used to evaluate effects of HFrEF on 1-year mortality. RESULTS: Of the176 patients, 14% developed HFrEF with a median of 5 days. History of heart failure (OR 10.99, 2.15-56.09; P = .04) and intraoperative transfusion of greater than 11 units of packed red blood cells (OR 3.377, 1.025-11.13; P = .045) were associated with increased incidence of HFrEF. Pre-transplant hemoglobin greater than 8.5 g/dL (OR 0.252, CI 0.0954- 0.665; P = .05) was protective against HFrEF. Thirty-three percent of HFrEF group died within 1 year (HR 7.36, 2.57-21.12; P < .001). CONCLUSIONS: The incidence of acute HFrEF post-OLT is 14% and is associated with a 7-fold increase in 1-year mortality. Cirrhotic cardiomyopathy and stress-induced cardiomyopathy maybe the underlying mechanisms. Our study identified risk factors associated with post-OLT HFrEF and should provide additional guidance for risk stratification of patients undergoing OLT.

Post-Transplant Diabetes Mellitus After Kidney Transplant in Hispanics and Caucasians Treated with Tacrolimus-Based Immunosuppression.

BACKGROUND Development of post-transplant diabetes mellitus after kidney transplant (PTDM) significantly increases kidney graft loss and mortality. Several risk factors for PTDM have been reported, including Hispanic ethnicity and the use of calcineurin inhibitors and corticosteroids. The incidence and impact of PTDM in the Hispanic kidney transplant population is unknown. MATERIAL AND METHODS We retrospectively reviewed the medical records of 155 Hispanic and 124 Caucasian patients, who were not diabetics and underwent kidney transplant between January 2006 and December 2011. We analyzed their clinical outcomes at 12 months post-transplant, including the incidence of PTDM, acute rejection rates, and patient and graft survival. RESULTS Hispanics who developed PTDM (n=22) were more than 10 years older and had higher body mass index (BMI) than Hispanics without PTDM (p<0.001 and p=0.001, respectively). Caucasians with PTDM (n=13) were non-significantly older (2.5 years) and had higher BMI than Caucasians without PTDM (p=0.526, p=0.043, respectively). The incidence of PTDM was not significantly different between Hispanics and Caucasians treated with tacrolimus-based immunosuppression (14.2% and 10.5%, respectively). CONCLUSIONS PTDM did not cause significant difference in short-term outcomes after kidney transplant in Hispanics or Caucasians. Larger multicenter prospective and long-term clinical trials are needed to validate these findings.

Diffuse hepatic epithelioid hemangioendothelioma developed in a patient with hepatitis C cirrhosis.

Hepatic epithelioid hemangioendothelioma (HEHE) is an infrequent vascular tumor of endothelial origin that primarily occurs in women in the mid-fifth decade of life without underlying chronic liver disease or cirrhosis. Liver transplant should be the first-line of therapy in patients with large or diffuse unresectable tumors even in the presence of metastatic disease due to the favorable long-term outcome. We report the case of a 48-year-old female who complained of abdominal pain and weight loss. She has a history of cirrhosis secondary to chronic hepatitis C (HCV) and was treated with interferon and ribavirin with sustained virological response. Her work-up revealed multiple confluent infiltrating bilobar liver masses diagnosed as HEHE. She underwent a successful liver transplant without evidence of recurrent HCV infection. She developed cervical spine (C4-C6) HEHE metastases 4 years after transplant. She underwent surgical resection and local radiotherapy after resection with good clinical response. To the best of our knowledge, this is the first report of HEHE that developed in a patient with HCV cirrhosis successfully treated with antiviral therapy before transplant and liver transplant with good allograft function without evidence of recurrent liver tumor or HCV infection but developed metastases to the cervical spine 4 years after transplant.

Comparison of outcomes of hand-assisted laparoscopic to open donor nephrectomy for pediatric recipients.

The purpose of this study is to compare the outcome of pediatric recipients of kidneys procured using a hand-assisted laparoscopic (HALDN group) to an open technique (ODN group). Twenty-eight patients ≤18 yr old (HALDN group) were compared with 17 patients (ODN group). The serum creatinine for HALDN and ODN groups at discharge were 0.93 ± 0.48 and 0.94 ± 0.54 mg/dL (p = 0.917), respectively. The serum creatinine for HALDN and ODN groups at six and 12 months was 1.01 ± 0.44 and 1.11 ± 0.55, and 1.04 ± 0.52 and 1.14 ± 0.46 mg/dL (p = 0.516, p = 0.554), respectively. The eGFR for HALDN and ODN groups at discharge was 108.66 ± 37.23 and 106.1 ± 50.55 mL/min/1.73 m(2) (p = 0.845), respectively. The eGFR for HALDN and ODN groups at six and 12 months was 97.77 ± 28.25 and 81.73 ± 27.46, and 94.56 ± 28.3 and 85.74 ± 30.1 mL/min/1.73 m2 (p = 0.085, p = 0.344), respectively. The patient and graft survival for both groups were 100% at 12 months post-transplant. In conclusion, the short-term outcome of recipients of kidneys procured via HALDN is comparable to that of kidneys procured via ODN in pediatric patients.

Morbidity of 200 consecutive cases of hand-assisted laparoscopic living donor nephrectomies: a single-center experience.

Background. Recipients of laparoscopically procured kidneys have been reported to have delayed graft function, a slower creatinine nadir, and potential significant complications. As the technique has evolved laparoscopic donor nephrectomy technique is becoming the gold standard for living donation. Study Design. We retrospectively reviewed the data of the first 200 hand-assisted laparoscopic living donor nephrectomies performed between January 2003 and February 2009. The initial 41 donors and their recipients (Group 1) were compared to the next 159 donors and their recipients (Group 2). The estimated blood loss, serum creatinine at discharge and 6 months, and the incidence of delayed graft function and perioperative complications were analyzed. Results. The median donor serum creatinine at discharge and 6 months was 1.2 mg/dL in each group. None of the laparoscopic procedures required conversion to an open procedure, and none of the donors required perioperative blood transfusion. The median recipient serum creatinine at 6 months after transplant was 1.2 mg/dL for each group. No ischemic ureteral complications related to the laparoscopic technique were seen. Conclusions. HALDN with meticulous surgical technique allows kidney procurement with very low morbidity and no mortality. This improved safety and decreased invasiveness from laparoscopic approach may further decrease morbidity of the procedure and increase organ donation.

The impact of intercurrent EBV infection on ATP levels in CD4+ T cells of pediatric kidney transplant recipients.

ImmuKnow measures ATP (ng/mL) in PHA-activated CD4+ T cells from patient's whole blood. According to published reports, median ImmuKnow is 258 ng/mL in stable pediatric kidney transplant (PKT) recipients > or =12 yr, and 165 ng/mL in those <12 yr. However, data on the effect of infection or AR on ImmuKnow are scarce. We studied the effect of Epstein-Barr virus (EBV) viremia on ImmuKnow in PKT with GD. Twenty-eight PKT with GD were reviewed. Group 1 has 19 PKT > or =12 yr, and group 2 has nine PKT <12 yr. Mean follow-up was 19.4 +/- 12 months. All ImmuKnow values discussed in this study were measured during GD +/- fever. None had ImmuKnow pretransplant. EBV DNA was isolated from patient blood by real-time PCR. Group 1 has eight boys and 11 girls (mean age = 16.6 +/- 2.4 yr). Group 2 has two boys and seven girls (mean age = 6 +/- 3.1 yr). Median ImmuKnow was 292 ng/mL in group 1, and 370 ng/mL in group 2. Nine children developed EBV viremia: two in group 1 (median ImmuKnow = 273 ng/mL), and seven in group 2 (median ImmuKnow = 475 ng/mL). Overall mean ImmuKnow in the nine EBV viremic patients was higher than that in the 19 non-viremic ones (422 +/- 176 ng/mL, and 302 +/- 113 ng/mL, respectively, unequal variance t-test, p = 0.08). Eight children developed AR (all in G1, median ImmuKnow = 272 ng/mL). In group 1, one patient developed concurrent EBV viremia and rejection, while another patient developed EBV viremia six months following a rejection episode. In group 2, none developed simultaneous AR, CMV, or BK virus infection with EBV viremia. None developed post-transplant lymphoproliferative disease. In summary, EBV viremia was paradoxically associated with high ImmuKnow in PKT <12 yr. This suggests strong co-stimulation of PHA-activated CD4+ T cells by EBV-transformed B cells.

Laparoscopic donor nephrectomy: effect of perirenal fat upon donor operative time.

PURPOSE: Previous attempts to correlate preoperative patient characteristics with operative complexity and operative time prior to laparoscopic donor nephrectomy have found few consistent relationships. The purpose of this study is to determine the effect of abdominal and perirenal fat measured with preoperative computerized tomography (CT) upon subsequent operative time and complexity during hand-assisted laparoscopic donor nephrectomy. MATERIALS AND METHODS: A retrospective chart, database, and CT angiogram review was conducted on 103 consecutive patients who underwent a hand-assisted laparoscopic donor nephrectomy. Perirenal fat and abdominal wall fat were correlated with a variety of parameters including operative time. Univariate and multivariate regression analysis was performed and p values<0.05 were considered significant. RESULTS: There was no correlation between operative time and body mass index (BMI), abdominal fat measurements, or spleno-renal distance. There was a significant positive correlation between operative time and anterior perirenal fat (r=0.28, p=0.005), posterior perirenal fat (r=0.20, p=0.05), and donor CPK levels (r=0.53, p<0.001). Men had greater perirenal fat, while women had greater abdominal fat. A multivariate model including anterior perirenal fat measurement accounted for 20% of the variance in operative time. CONCLUSION: This is the first study to demonstrate that increased perirenal fat increases operative complexity as measured by operative time. This information may potentially be used to help predict operative complexity based upon measurable preoperative variables and help improve operating room efficiency and donor and recipient outcomes.

Comparison of outcomes with low-dose anti-thymocyte globulin, basiliximab or no induction therapy in pediatric kidney transplant recipients: a retrospective study.

It is unclear which induction therapy yields the best outcomes in pediatric kidney transplantation. Retrospective data of 88 children receiving a renal allograft between November 1996 and October 2003 were analyzed. Patients received ATGI (n = 12), BI (n = 29), or NAI (n = 47). The mean ATG dose was 5.1 +/- 2.1 mg/kg. At 12 months, graft survival rates were 91.7%, 100%, and 97.9% for ATGI, BI, and NAI groups, respectively. Acute rejection rates at 12 months were 0 (ATGI), 20.6% (BI), and 10.7% (NAI). The mean GFR for ATGI (42.4 +/- 25.9 mL/min) was lower than for BI (78.3 +/- 27.2 mL/min), and NAI (66 +/- 28.3 mL/min) at 12 months (p < 0.05). One ATGI patient developed CMV pneumonia but none developed post-transplant lymphoproliferative disorder. Although there was no renal allograft survival benefit with either ATGI or BI, relative to NAI, the absence of acute rejection and equivalent rates of viral infections in the higher-risk ATGI recipient group suggests that the treatment strategy is promising. A large prospective study is needed to better define the role of ATGI in pediatric kidney transplantation.

Incidence of increased creatine kinase and its effect on kidney function in hand assisted laparoscopic kidney donors and their recipients.

PURPOSE: Rhabdomyolysis is a rare cause of acute renal failure following laparoscopic donor nephrectomy. The incidence of rhabdomyolysis is not well known and to our knowledge the amount of creatine kinase elevation resulting in renal damage is unknown. We evaluated the incidence of increased creatine kinase, risk factors for increased creatine kinase and its effect on renal function in a series of patients undergoing hand assisted laparoscopic donor nephrectomy. MATERIALS AND METHODS: Serum creatine kinase was prospectively measured in 74 consecutive patients who underwent hand assisted laparoscopic donor nephrectomy. These values were measured daily beginning in the recovery room. Demographic and laboratory data, and surgical parameters were analyzed to determine predictors of increased creatine kinase. RESULTS: Eight of 74 patients (10.8%) had a creatine kinase of 2,500 IU/l or greater and 17 (23%) had a creatine kinase of 1,000 IU/l or greater. Factors associated with a creatine kinase of 2,500 IU/l or greater were operative time (320 vs 275 minutes, p = 0.01) and warm ischemia time (192 vs 138 seconds, p <0.01). Operative time remained an independent risk factor on multivariate analysis (p <0.05). There was no difference in preoperative or postoperative donor creatinine between patients with or without increased creatine kinase, although there was an increased percent change in creatinine in the increased creatine kinase group (80% vs 59%, p = 0.04). CONCLUSIONS: Creatine kinase elevation occurs in a small but significant number of patients. Operative time was an independent risk factor for increased creatine kinase. Although creatine kinase had no significant effect on short-term creatinine, there was an increase in the percent change in donor creatinine. Finally, the long-term significance of increased creatine kinase without clinical symptoms is unknown.

Undifferentiated embryonal sarcoma of the liver successfully treated with chemotherapy and liver resection.

Undifferentiated embryonal sarcoma is the third most common malignant tumor of the liver in children, accounting for 13% of hepatic malignancies in this age group. It has been considered an aggressive neoplasm with very poor prognosis until the late 1980s, when long-term survivors were reported after multiagent chemotherapy followed by resection. We, herein, report two pediatric cases of undifferentiated embryonal sarcoma treated successfully with surgical resection after neoadjuvant chemotherapy based on therapy used in childhood soft tissue sarcomas and in childhood hepatic malignancies. The first patient also had a concurrent cerebellar tumor (pilocytic astrocytoma), for which he first underwent craniotomy and resection, delaying the liver tumor resection by 10 weeks. They are alive and tumor free at 48 months (case no. 1) and 18 months (case no. 2) following neoadjuvant chemotherapy and liver resection.

Improved detection of renal vascular anatomy using multidetector CT angiography: Is 100% detection possible?

BACKGROUND AND PURPOSE: Multidetector CT angiography (MDCTA) is being used increasingly to evaluate vascular anatomy prior to donor nephrectomy. To improve the ability of MDCTA to predict donor renal anatomy, a novel protocol including four-phase imaging with three-dimensional reconstruction and maximum intensity projections (MIPs) was incorporated into the standard donor evaluation. The purpose of this study was to determine the results of this protocol. PATIENTS AND METHODS: Seventy consecutive patients who underwent hand-assisted laparoscopic donor nephrectomy between January 2003 and September 2004 were reviewed. All MDCTA studies were examined initially by a radiologist alone, after which, a second preoperative reading was performed by a radiologist and the operating surgeon together. The two reviews were compared with the operative findings. RESULTS: Using this protocol to detect the total number of renal arteries, veins, and ureters, the sensitivity of the initial radiologist was 97%, 100%, and 96%, respectively. These values increased to 100%, 100%, and 99% when the films were reviewed by a radiologist together with the surgeon who would operate on the donor. The sensitivity, specificity, and accuracy in predicting supernumerary arteries, including early (< or =1-cm) arterial branching was 89%, 100%, and 97%, respectively after the single reading but increased to 100%, 100%, and 100% with the combined reading. CONCLUSIONS: An MDCTA study with this protocol provides excellent anatomic detail prior to donor nephrectomy. Its ability to predict renal-arterial and ureteral anatomy is enhanced when the films are reviewed simultaneously by a radiologist and the operating surgeon.

Gadodiamide-associated nephrogenic systemic fibrosis: why radiologists should be concerned.

OBJECTIVE: Nephrogenic systemic fibrosis (NSF) is a rare multisystemic fibrosing disorder that principally affects the skin but may affect other organs of patients with renal insufficiency. The purpose of our study was to identify any common risk factors and determine whether i.v. gadodiamide is associated with the development of NSF. MATERIALS AND METHODS: A retrospective chart review was performed for all 12 patients diagnosed with NSF at our institution between 2000 and 2006 to identify the clinical manifestations, timing, and dose of gadodiamide administration; dialysis records; concurrent medications; comorbid conditions and surgeries; laboratory findings; imaging findings; and clinical outcome. A review of the dialysis and MR records between 2000 and 2006 showed 559 MRI examinations on 168 dialysis patients (including 301 contrast-enhanced examinations). RESULTS: NSF was diagnosed by clinical findings and tissue diagnosis. All 12 patients had renal insufficiency--eight with dialysis-dependent chronic renal insufficiency and four with acute hepatorenal syndrome. All 12 patients developed skin fibrosis within 2-11 weeks after gadodiamide administration. The odds ratio for development of NSF after gadodiamide exposure was 22.3. No other common event or exposure could be found. Four patients had abnormal scintigraphic bone scans with skin and muscle uptake and lower-extremity MRI finding of edema in the muscles, intermuscular fascia, and skin. Despite the fact that 10 patients were dialyzed within 2 days of gadodiamide administration, this did not prevent the development of NSF. CONCLUSION: Development of NSF was strongly associated with gadodiamide administration in the setting of either acute hepatorenal syndrome or dialysis-dependent chronic renal insufficiency.

Multidetector computerized tomography angiography to predict lumbar venous anatomy before donor nephrectomy.

PURPOSE: Multidetector computerized tomography angiography has been used to predict renal anatomy before donor nephrectomy. Unrecognized lumbar veins represent a significant risk during laparoscopic surgery but to our knowledge no previous group has attempted to predict lumbar veins with multidetector computerized tomography angiography before laparoscopic donor nephrectomy. We evaluated the ability of multidetector computerized tomography angiography to preoperatively predict the size and location of anomalous left lumbar veins. MATERIALS AND METHODS: A prospective study was performed in patients undergoing left hand assisted laparoscopic donor nephrectomy from January 2003 to September 2004. All patients were imaged using 4-phase computerized tomography, including computerized tomography angiography with 1.25 mm collimation of the arterial and venous phases. Each multidetector computerized tomography angiogram was prospectively reviewed by a radiologist and operating surgeon, and retrospectively reviewed by a second blinded radiologist. RESULTS: A total of 70 patients underwent left hand assisted laparoscopic donor nephrectomy between January 2003 and September 2004. Five patients underwent imaging elsewhere and were excluded from study. Of the remaining 65 patients 54 (83%) had at least 1 anomalous lumbar vein of any size recognized at surgery. Additionally, 33 of these 65 patients (51%) had an anomalous lumbar vein that was 3 mm or greater. These 3 mm or greater vessels carry a significant risk of bleeding and they were used in further calculations. As read by a radiologist and surgeon, the sensitivity and specificity of multidetector computerized tomography angiography compared to surgical identification were 97% and 91%, respectively. Positive and negative predictive values, and accuracy were 91.4%, 97% and 94%, respectively. CONCLUSIONS: Multidetector computerized tomography angiography accurately predicts lumbar venous anatomy before donor nephrectomy with high sensitivity, specificity and accuracy.

Control of the renal artery and vein with the nonabsorbable polymer ligating clip in hand-assisted laparoscopic donor nephrectomy.

BACKGROUND: The large and variable size of the renal vein has prompted most surgeons to select linear stapling devices to secure the vein during laparoscopic donor nephrectomy. Although effective, these stapling devices have a potential for misfire. Use of the nonabsorbable polymer ligating (NPL) clip during laparoscopic donor nephrectomy provides increased graft vessel length compared with the stapling device, and the NPL clip has a locking mechanism which may increase security compared with standard titanium clips. The objective of this study was to evaluate the safety and efficacy of the NPL clip for control of the renal artery and vein during hand-assisted laparoscopic donor nephrectomy (HALDN). METHODS: A retrospective chart review of 50 consecutive HALDN patients was conducted where two parallel NPL clips were used to control both the renal artery and vein. Information collected included demographic data, operative and postoperative data, and complications. RESULTS: Mean donor age was 33.4 years and body mass index was 25.8 kg/m2. Mean operative time was 266.0 min, mean hospital stay was 3.2 days, and mean warm ischemia time was 123.3 seconds. There were no transfusions, open conversions, or complications related to use of the NPL clip. A US 16,300 dollars disposable cost savings was seen during this 1-year period alone. CONCLUSIONS: The NPL clip was 100% safe and effective in controlling the renal artery and vein during HALDN, allowed for additional vessel length, and resulted in a disposable cost savings of US 362 dollars per patient.

Hand-assisted laparoscopic donor nephrectomy is safe and results in increased kidney donation.

The impact of hand-assisted laparoscopic donor nephrectomy on kidney allograft function, perioperative complications, and organ supply was evaluated by retrospective analysis of 41 hand-assisted laparoscopic donor nephrectomy patients and their recipients between January and October 2003. Serum creatinine at discharge, length of stay, estimated blood loss, operative time, and perioperative complications were analyzed. The mean values for laparoscopic donors and their recipients were 1.2 +/- 0.3 and 1.3 +/- 0.8 mg/dL for creatinine, 3.3 +/- 0.8 and 6.7 +/- 3 days for length of stay, and 110.4 +/- 76.9 and 111.6 +/- 56 mL for estimated blood loss, respectively. No major complications occurred in the laparoscopic donors. The number of living kidney donors increased by 94% compared to the mean of the previous 4 years following implementation of the laparoscopic program. Hand-assisted laparoscopic donor nephrectomy is safe, results in excellent allograft function, and significantly increases donation.

Nephrogenic fibrosing dermopathy after liver transplantation successfully treated with plasmapheresis.

Nephrogenic fibrosing dermopathy (NFD) is a recently described cutaneous fibrosing disorder associated with renal dysfunction. It appears similar to scleromyxedema but with some notable exceptions, including the lack of involvement of the face and absence of plasma cells on histology, systemic involvement, and paraproteinemia. Patients can present with thickened or edematous skin with indurated papules and plaques involving the extremities and the trunk. We report the first three cases of NFD after liver transplantation successfully treated with plasmapheresis. Two patients underwent liver transplantation for hepatitis C virus-induced cirrhosis and one for hepatitis B virus-induced cirrhosis. All the patients had encephalopathy, refractory ascites, and malnutrition prior to transplantation. Like those patients with NFD, all three of our patients had renal dysfunction and required hemodialysis before and after transplantation. Two were not dependent on dialysis at the time of diagnosis, however. These patients had excellent liver allograft function, but the other patient had allograft failure secondary to recurrent hepatitis C. Immunosuppression therapy consisted of basiliximab, mycophenolate mofetil, calcineurin inhibitor, and prednisone. The patients developed "woody" skin induration of the distal extremities, erythematous papules, and contractures at 1, 2, and 120 months after transplantation. Skin biopsies resembled NFD. No paraproteinemia was evident. One to three 5-day courses of plasmapheresis resulted in moderate to marked clinical improvement. The improvement of the kidney function in two of our patients did not appear to correlate with that of the skin disorder, because the kidney function was improving at the time the diagnosis of NFD was made. In conclusion, we report the first three cases of NFD after liver transplantation. Plasmapheresis was moderately successful in resolving the skin-indurated papules, severe skin induration, and associated joint contractures. Preliminary studies (unpublished data) show that decreasing plasma levels of transforming growth factor-beta1 after plasmapheresis appear to correlate with the amelioration of this clinical condition.