The utilization of multidisciplinary tumor boards (MDT) in clinical routine: results of a health care research study focusing on patients with metastasized colorectal cancer.

PURPOSE: Multidisciplinary tumor boards (MDT) have been advocated as standard of care in modern oncology. German guidelines for metastasized colorectal cancer (mCRC) recommend MDT discussion of colon cancer patients after completion of primary tumor therapy but stage IV colon cancer as well as rectal cancer patients prior to any therapy. In this health care research study, we evaluated application and decisional consequences of this approach in clinical routine. METHODS: All major institutions providing oncological care in southern Lower Saxony and Northern Hesse (N = 11) were invited. Patients with mCRC diagnosed between 01/2011 and 12/2013 were eligible. Data were collected using a standardized patient report form and stored in a GCP-conform EDC-system (secuTrial®). RESULTS: A university medical center, four teaching hospitals, one communal hospital, and three oncological focus practices participated in the study. In total, 470 patients with a median age of 70 years were enrolled. Guideline conform MDT discussion was performed in 63% of operated colon cancer patients, 38% of stage IV colon cancer patients and 47% of rectal cancer patients, respectively. Resection of metastases was performed in 41% of cases. Patients ≥70 years (n = 250) received significantly more often treatment following MDT discussion (86 versus 64%, p = 0.0002). Not the resection rate (48 versus 57%, p = 0.1574) but indication for preoperative chemotherapy (57 versus 33%, p = 0.0056) significantly differed when patients with single organ metastases experienced MDT discussion. CONCLUSIONS: MDT discussion is not as established as advocated by national guidelines. Treatment decisions differ especially in older patients and those with single organ metastases.

Basiliximab induction therapy in kidney transplantation: benefits for long term allograft function after 10 years?

The interleukin-2 receptor antagonist basiliximab has proven in large clinical trials to be safe and effective to reduce acute rejections in the first year after renal transplantation. Since acute rejections are a risk factor for chronic graft loss, their effective reduction might have a positive effect on long term allograft survival. So far data is spares to prove this hypothesis and 10-year follow up on basiliximab induction therapy is not available. In our center, 41 patients were enrolled in the multicenter trial CHIB201 in 1995/96 comparing basiliximab vs no induction therapy after renal transplantation. We retrospectively analyzed the outcome of these patients after 10 years. The main reason for patient death with functioning graft were infectious complications (basiliximab: 3/20, placebo 1/19), 21% of all patients developed cancer without an obvious correlation to specific immunosuppression. Death censored 10-year graft survival was equivalent in both groups: 65% in the basiliximab and 68% in the placebo group with a mean s-creatinine-clearance of 60 and 44 ml/min. In this small study patient and graft survival was equivalent 10 years after transplantation comparing basiliximab induction therapy and placebo.

Living kidney donors >60 years of age: is it acceptable for the donor and the recipient?

Donors >60 years are now frequently accepted for living kidney transplantation (LKT). We asked whether a donor age >60 years may result in a higher risk for donor and recipient. All adult LKT from May 1996 to June 2005 were included. Long-term outcome was analysed, and results were compared for donors >60 and 60 (group A) and 158 from donors 60 years, we suggest that age should no longer be considered as a contra-indication for living donation.

Surgical experience in splitting donor liver into left lateral and right extended lobes.

AIM: To outline the surgical experience with donor liver splitting in split liver transplantation. METHODS: From March 1 to September 1 in 2004, 10 donor livers were split ex situ into a left lateral lobe (segments II and III) and a right extended lobe (segments I, IV-VIII) in Medical School of Hannover, and thereafter split liver transplantation was performed successfully in 19 cases. The average age, weight and ICU staying period of the donors were 32.7 years (15-51 years), 64.5 kg (45-75 kg) and 2.4 d (1-8 d) respectively. RESULTS: The average weight of the whole graft and the left lateral lobe was 1,322.6 g (956-1,665 g) and 281.8 g (198-373 g) respectively, and the average ratio of left lateral lobe to the whole graft was 0.215 (0.178-0.274). The average graft to recipient weight ratio (GRWR) of the left lateral lobe and the right extended lobe reached 2.44% (1.22-5.41%) and 1.73% (1.31-2.30%) respectively. On average it took approximately 105 min (85-135 min) to split the donor liver. Five donor organs showed anatomic variation including the left hepatic vein variation in two cases, the left hepatic artery variation in two cases and the bile duct variation in one case. CONCLUSION: Split liver transplantation has become a mature surgical technique to expand the donor pool with promising results. In the process of graft splitting, close attention needs to be paid to potential anatomic variations, especially to variations of the left hepatic vein, the left hepatic artery, and the bile duct.

Blood transfers infectious immunologic tolerance in MHC-incompatible heart transplantation in rats.

"Infectious tolerance" or inducing immunologic tolerance of infection in allografts is still poorly understood. We investigated whether transfusing blood from LEW.1A rats tolerant of LEW.1W hearts could transmit tolerance to naive LEW.1A rats. In 4 of 6 cases, transfusing blood from tolerant animals was followed by immunologic tolerance of heart transplants from LEW.1W donor rats in LEW.1A recipient animals, whereas transplanting heart grafts that were tolerated in previous transplantations across MHC barriers did not transfer tolerance in major histocompatibility complex (MHC)-incompatible animals. We conclude that in rat heart transplantation, the transfer of immunologic tolerance can be enhanced by transfusing blood from tolerant animals to naive animals before transplantation across MHC barriers.

Living donor nephrectomy: flank incision versus anterior vertical mini-incision.

BACKGROUND: Currently, many centers perform laparoscopic donor nephrectomy (DN). We studied the outcome of donors and recipients following open DN using either flank incision (ODN) or mini-incision (MIDN). METHODS: Data of 196 living kidney donors were recorded prospectively. In 127 cases ODN and 69 cases MIDN were performed. RESULTS: Demographic details of donors were comparable for both groups. The left kidney was procured in 58% for ODN and in 64% for MIDN. Multiple arteries were more frequently present when MIDN (11% vs. 28%) was performed. The mean operating time was 129 min for ODN and 133 min for MIDN. Early complications occurred in 7% following ODN and in 4% following MIDN. Late complications were observed in 21% after ODN and 1% after MIDN. The mean hospital stay was significantly longer following ODN compared with MIDN (7.5 vs. 6.4 days). The primary graft function rate was 97% in both groups. One-year graft survival was 97% after ODN and 100% after MIDN. CONCLUSIONS: Results following MIDN are superior to those following ODN. Even in case of multiple renal vessels MIDN can be safely applied. In comparison with laparoscopic DN advantages of MIDN may be reduced costs, shorter operating time, and comparable cosmetic results.

Liver transplantation using organs from donors older than 60 years.

At present, it is frequently accepted to expand the organ pool for liver transplantation (LTx) by including livers from critical donors. From 1990 to June 2002 a total of 1,208 LTx were performed. Of those, 67 livers from donors older than 60 years were transplanted to 66 patients, including re-LTx in eight patients. Fourteen patients had malignant diseases (21%). Ten patients had a high urgency status (15%). Median donor age was 65 years (range 61-80 years). Primary graft function was observed in 84%. Patient survival rate at 1 and 5 years was 79% and 62%, and graft survival was 68% and 53%, respectively. No difference was observed in LTx with livers from donors younger than 60 years. Fifteen graft losses occurred during the study. Surgical complications were observed in 23 patients (34%). The outcome of LTx with livers from donors older than 60 years is satisfactory and is comparable to results of LTx with livers from donors younger than 60 years. The frequency of vascular complications and cholestasis syndrome is not increased.

Results of combined and sequential liver-kidney transplantation.

Experience with combined liver-kidney transplantation (L-KTx) has increased, but controversy regarding this procedure continues because the indications are not clearly defined yet. Between 1984 and 2000, 38 patients underwent simultaneous L-KTx and 9 patients underwent sequential transplantation, receiving either a liver before a kidney or a kidney before a liver. Main indications for a simultaneous procedure were polycystic liver-kidney disease with cirrhosis and coincidental renal failure. The main indications for sequential procedure were cirrhosis caused by viral infection for the liver and glomerulonephritis for the kidneys. Outcomes in these patients were evaluated retrospectively. Regarding simultaneous transplantation, 28 (73.7%) long-term survivors were followed up for 0.7 to 12.5 years. Currently, 24 (63.2%) patients are alive with good liver function. Fourteen patients died; 10 patients died in the early postoperative phase because of septic complications, and most of them were cirrhotic with a poor preoperative clinical status. Currently, 2 of the surviving patients (8%) have returned to dialysis, 4 (17%) have reduced renal function, and 18 (75%) have good renal function. Five liver and 2 kidney retransplantations were performed during the follow-up. In cases of sequential grafting, patients undergoing kidney transplantation in the presence of a previously transplanted stable liver did better than those who underwent liver transplantation after kidney transplantation. When liver transplantation was performed early and electively before substantial worsening, combined L-KTx is a safe procedure offering excellent long-term palliation.