Management of early hepatocellular carcinoma: results of the Delphi consensus process of the Americas Hepato-Pancreato-Biliary Association.

BACKGROUND: There are many potential treatment options for patients with early stage hepatocellular carcinoma (HCC) and practice patterns vary widely. This project aimed to use a Delphi conference to generate consensus regarding the management of small resectable HCC. METHODS: A base case was established with review by members of AHPBA Research Committee. The Delphi panel of experts reviewed the literature and scored clinical case statements to identify areas of agreement and disagreement. Following initial scoring, discussion was undertaken, questions were amended, and scoring was repeated. This cycle was repeated until no further likelihood of reaching consensus existed. RESULTS: The panel achieved agreement or disagreement consensus regarding 27 statements. The overarching themes included that resection, ablation, transplantation, or any locoregional therapy as a bridge to transplant were all appropriate modalities for early or recurrent HCC. For larger lesions, consensus was reached that radiofrequency ablation and microwave ablation were not appropriate treatments. CONCLUSION: Using a validated system for identifying consensus, an expert panel agreed that multiple treatment modalities are appropriate for early stage HCC. These consensus guidelines are intended to help guide physicians through treatment modalities for early HCC; however, clinical decisions should continue to be made on a patient-specific basis.

The Kidney Transplant Morbidity Index (KTMI): a simple prognostic tool to help determine outcome risk in kidney transplant candidates.

BACKGROUND: The Kidney Transplant Morbidity Index (KTMI) is a novel prognostic morbidity index to help determine the impact that pretransplant comorbid conditions have on transplant outcome. OBJECTIVE: To use national data to validate the KTMI. DESIGN: Retrospective analysis of the Organ Procurement and Transplant Network/United Network for Organ Sharing database. SETTING AND PARTICIPANTS: The study sample consisted of 100 261 adult patients who received a kidney transplant between 2000 and 2008. MAIN OUTCOME MEASURE: Kaplan-Meier survival curves were used to demonstrate 3-year graft and patient survival for each KTMI score. Cox proportional hazards regression models were created to determine hazards for 3-year graft failure and patient mortality for each KTMI score. RESULTS: A sequential decrease in graft survival (0 = 91.2%, 1 = 88.2%, 2 = 85.4%, 3 = 81.7%, 4 = 77.8%, 5 = 74.0%, 6 = 69.8%, and ≥ 7 = 68.7) and patient survival (0 = 98.2%, 1 = 96.6%, 2 = 93.7%, 3 = 89.7%, 4 = 84.8%, 5 = 80.8%, 6 = 76.0%, and ≥ 7 = 74.7%) is seen as KTMI scores increase. The differences in graft and patient survival between KTMI scores are all significant (P< .001) except between 6 and ≥ 7. Multivariate regression analysis reveals that KTMI is an independent predictor of higher graft failure and patient mortality rates and that risk increases as KTMI scores increase. CONCLUSION: The KTMI strongly predicts graft and patient survival by using pretransplant comorbid conditions; therefore, this easy-to-use tool can aid in determining outcome risk and transplant candidacy before listing, particularly in candidates with multiple comorbid conditions.

The impact of morbid obesity on hospital length of stay in kidney transplant recipients.

OBJECTIVES: Obesity is often associated with higher hospital costs because of longer length of stay (LOS) but this has not been well studied in the kidney transplant population. Therefore, we used national data to compare LOS in select groups of morbidly obese and normal weight recipients after kidney transplant. DESIGN: This study was a retrospective analysis of the Organ Procurement and Transplant Network/United Network for Organ Sharing database. SUBJECTS: The study sample consisted of 42,787 morbidly obese (body mass index 35-40 kg/m(2)) and normal weight (body mass index 18.5-24.9 kg/m(2)) who underwent primary kidney-only transplantation between 2000 and 2008. MAIN OUTCOME MEASURES: Morbidly obese and normal-weight subgroups were crudely evaluated for prolonged LOS (>7 days). Logistic regression modeling compared LOS in morbidly obese and normal-weight subgroups with varying characteristics and determined predictors of prolonged LOS. RESULTS: All morbidly obese subgroups had significantly higher crude rates of prolonged LOS (P < .05). However, no significant differences in prolonged LOS were seen between any of the morbidly obese or normal-weight subgroups in multivariate analysis. Morbid obesity was an independent predictor of prolonged LOS (P < .001) but not a stronger predictor than that of being African American, having coronary artery disease, diabetes mellitus, or peripheral vascular disease, being 50 to 80 years of age, having a previous transplant or poor functional status. Receiving a deceased-donor transplant and being dialysis dependent >4 years were significantly better predictors of prolonged LOS compared with morbid obesity (P < .05). CONCLUSIONS: Some morbidly obese populations have LOS rates that are not significantly different than many commonly transplanted normal weight populations, and the impact morbid obesity has on LOS is not different than many other factors often seen in kidney transplant recipients; therefore, morbid obesity alone should not be a financial consideration in kidney transplant.

Role of Coronary Angiography in the Assessment of Cardiovascular Risk in Kidney Transplant Candidates.

Cardiovascular disease is the leading cause of death among those with renal insufficiency, those requiring dialysis, and in recipients of kidney transplants reflecting the greatly increased cardiovascular burden that these patients carry. The best method by which to assess cardiovascular risk in such patients is not well established. In the present study, 1,225 patients seeking a kidney transplant, over a 30-month period, underwent cardiovascular evaluation. Two hundred twenty-five patients, who met selected criteria, underwent coronary angiography that revealed significant coronary artery disease (CAD) in 47%. Those found to have significant disease underwent revascularization. Among the patients found to have significant CAD, 74% had undergone a nuclear stress test before angiography and 65% of these stress tests were negative for ischemia. The positive predictive value of a nuclear stress test in this patient population was 0.43 and the negative predictive value was 0.47. During a 30-month period, 28 patients who underwent coronary angiography received an allograft. None of these patients died, experienced a myocardial infarction, or lost their allograft. The annual mortality rate of those who remained on the waiting list was well below the national average. In conclusion, our results indicate that, in renal failure patients, noninvasive testing fails to detect the majority of significant CAD, that selected criteria may identify patients with a high likelihood of CAD, and that revascularization reduces mortality both for those on the waiting list and for those who receive an allograft.

Kidney transplantation from organ donors following cardiopulmonary death using extracorporeal membrane oxygenation support.

Extracorporeal membrane oxygenation (ECMO) has the ability to provide normal organ perfusion and oxygenation in the absence of cardiac function and thus has the potential to improve viability of subsequently transplanted kidneys. In addition, ECMO support allows the donation following cardiopulmonary death (DCD) process to occur in a controlled manner that is acceptable to staff unfamiliar with DCD. In 1999 our center implemented a controlled DCD program that incorporates post-mortem ECMO support of the organs. Arterial and venous cannulae are placed following consent to donate, but prior to withdrawal of support. ECMO circulation is initiated immediately following declaration of death. Following a brief period where the donor family is allowed to grieve, the donor is moved to the operating room where organ recovery occurs. We reviewed the results of 20 kidney transplants from 13 ECMO supported donors that occurred between October 2000 and August 2003. One renal allograft was lost due to surgical complications, all 19 remaining grafts functioned. An 11% (2/19) delayed graft function rate was observed. Kidneys donated from "controlled" ECMO supported CPD donors are a viable source of organs for renal transplantation. This recovery method warrants further investigation.

Successful renal transplantation following prior bone marrow transplantation in pediatric patients.

Improving survival rates following pediatric bone marrow transplantation (BMT) will likely result in greater numbers of children progressing to end-stage renal disease (ESRD) because of prior chemotherapy, irradiation, sepsis, and exposure to nephrotoxic agents. Renal transplantation remains the treatment of choice for ESRD; however, the safety of renal transplantation in this unique population is not well established. We report our experience with living related renal transplantation in three pediatric patients with ESRD following prior BMT. Two patients with neuroblastoma and ESRD because of BMT nephropathy, and one patient with Schimke immuno-osseous dysplasia and ESRD because of immune complex mediated glomerulonephritis and nephrotic syndrome. Age at time of BMT ranged from 2 to 7 yr. All patients had stable bone marrow function prior to renal transplantation. Age at renal transplant ranged from 8 to 14 yr. All three patients have been managed with conventional immunosuppression, as no patient received a kidney and BMT from the same donor source. These patients are currently 7 months to 6 yr status post-living related transplant. All have functioning bone marrow and kidney transplants, with serum creatinine levels ranging 0.6-1.2 mg/dL. There have been no episodes of rejection. One patient with a history of grade III skin and grade IV gastrointestinal-graft-vs.-host disease (GI-GVHD) prior to transplantation, had a mild flare of GI-GVHD (grade I) post-renal transplant and is currently asymptomatic. The incidence of opportunistic infection has been comparable with our pediatric renal transplant population without prior BMT. One patient was treated for basal cell carcinoma via wide local excision. Renal transplantation is an excellent option for the treatment of pediatric patients with ESRD following BMT. Short-term results in this small population show promising patient and graft survival, however long-term follow-up is needed. Pre-existing immune system impairment and bone marrow function should be taken into consideration when weighing different immunosuppressive agents for renal transplantation. Patients who have undergone renal transplantation following BMT are at high risk for opportunistic infections and malignancy, and need life-long medical surveillance.