Clinical Impact of Antecedent Bariatric Surgery on Liver Transplant Outcomes: A Retrospective Matched Case-control Study.

BACKGROUND: Bariatric surgery (BS) may be associated with significant malabsorption and nutritional deficiencies. METHODS: Between March 1987 and January 2017, we performed 922 liver transplants (LT) at our institution; 33 had antecedent BS. We matched the BS cohort to LT recipients without BS (1:3 matching) based on exact matching for gender and cancer and inverse variance matching for age, LT body mass index, MELD score, and transplant date. RESULTS: We analyzed outcomes in 132 LT recipients (33 BS; 99 non-BS). The BS cohort comprised 26 (79%) women with a mean age of 52.4 years. The BS procedures included 20 Roux-en-Y gastric bypass (61%), 6 jejunoileal bypass (18%), 3 gastric band (9%), 2 sleeve gastrectomy (6%), and 1 duodenal switch (3%). The primary indications for LT listing were alcoholic cirrhosis (9; 27%), nonalcoholic steatohepatitis (7; 21%), hepatitis C (8; 24%), and hepatocellular carcinoma (3; 9%). At LT, body mass index for the BS cohort was 29.6, and MELD was 24. Compared with matched controls, BS recipients did not have longer LT length of hospital stay (17.8 versus 15.7 d, P = 0.71), longer intensive care unit length of stay (5.3 versus 4.1 d, P = 0.16), or higher 30-day complication rate (76% versus 85%, P = 0.43). Overall patient survival was similar (1- and 3-y survival was 90.1% and 75.9% for BS; 90.9% and 76.4% for non-BS, P = 0.34). CONCLUSIONS: A history of BS does not portend a deleterious effect on LT outcomes.

Long-Term Infectious and Noninfectious Outcomes of Monthly Alemtuzumab as a Calcineurin Inhibitor- and Steroid-Free Regimen for Pancreas Transplant Recipients.

Multiple doses of alemtuzumab for immunosuppressive therapy of patients with hematologic malignancies and hematopoietic stem cell transplant have been associated with a high rate of infection. In transplantation, limited alemtuzumab dosing has been successfully used as induction immunosuppression. The effect of multiple doses of alemtuzumab, used as maintenance therapy to minimize steroid and/or calcineurin inhibitor toxicity in solid organ transplant recipients, is unknown. We evaluated the infectious and noninfectious outcomes of 179 pancreas transplant recipients treated with alemtuzumab for induction and maintenance therapy (extended alemtuzumab exposure (EAE)) from 2/28/2003 through 8/31/2005, compared with 159 pancreas transplant recipients with standard induction and maintenance (SIM) therapy performed before (1/1/2002 until 12/31/2002) and after (1/1/2006 until 12/31/2006) the implementation of EAE. EAE was associated with higher risk of overall infections (hazard ratio (HR) 1.33 (1.06-1.66), P=0.01), bacterial infections (HR 1.33 (1.05-1.67), P=0.02), fungal infections (HR 1.86 (1.28-2.71), P < 0.01), and cytomegalovirus infections (HR 2.29 (1.39-3.77), P < 0.01). In addition, EAE was associated with higher risk of acute cellular rejection (HR 2.09 (1.46-2.99), P < 0.01). In conclusion, while a limited alemtuzumab dosing is safe and effective for induction therapy in pancreas transplantation, EAE combined with steroid and calcineurin minimization is associated with a high risk of infectious complications and acute cellular rejection.

Long-term outcomes of pediatric kidney transplant recipients with a pretransplant malignancy.

A childhood malignancy can rarely progress to ESRD requiring a KT. To date, few reports describe long-term outcomes of pediatric KT recipients with a pretransplant malignancy. Between 1963 and 2015, 884 pediatric (age: 0-17 years old) recipients received 1055 KTs at our institution. KT outcomes were analyzed in children with a pretransplant malignancy. We identified 14 patients who had a pretransplant malignancy prior to KT; the majority were <10 years old at the time of KT. Ten (71%) patients received their grafts from living donors, the majority of which were related to the recipient. Wilms' tumor was the dominant type of pretransplant malignancy, seen in 50% of patients. The other pretransplant malignancy types were EBV-positive lymphoproliferative disorders, non-EBV-positive lymphoma, leukemia, neuroblastoma, soft-tissue sarcoma, and ovarian cancer. Ten of the 14 patients received chemotherapy as part of their pretransplant malignancy treatment. Graft survival at 1, 3, and 5 years was 93%, 83%, and 72%, respectively. Patient survival at 1, 5, and 10 years was 100%, 91%, and 83%, respectively. Six (40%) patients suffered AR following KT; half of them had their first episode of AR within 1 month of KT. Our single-center experience demonstrates that pediatric KT recipients with a previously treated pretransplant malignancy did not exhibit worse outcomes than other pediatric KT patients.

Kidney donor outcomes ≥ 50 years after donation.

Many living kidney donors (LDs) are young at donation; yet there are little data on long-term LD follow-up. We report on 66 LDs who donated ≥50 years ago: 22 (33.3%) are still alive (current age, 78.5 ± 7.25 years); 39 (59%) died (mean age at death, 74.2 ± 12.3 years); and 5 are lost to follow-up (mean age at last contact, 68.7 ± 4.6 years). Those who died were older at donation (P < .001). Causes of death included 12 (30.8% of deaths) cardiovascular diseases, 9 (23.0%) respiratory failures, 5 (12.8%) malignancies and 4 (10.3%) infections, and 9 (23%) were unknown or miscellaneous. Forty-nine living donors (74%) developed hypertension at a mean age of 59.9 ± 14.0 years; 12 (18%) developed diabetes at a mean age of 62 ± 19.4 years; and 11 (16.7%) developed proteinuria at a mean age of 60.6 ± 18.2 years-each at a similar incidence as seen in the age-matched general population. At last follow-up, the eGFR by CKD-EPI (mean ± SD) for donors currently alive was 60.2 ± 13.4 mL/min/1.73 m2 ; for those that died, 54.0 ± 21.5 mL/min/1.73 m2 ; for those lost to follow-up, 55.6 ± 7.5 mL/min/1.73 m2 . ESRD developed in 2 (3.3%). SF-36 quality of life health survey scores (n = 21) were similar to the age-matched general population.

Clinical utility of postoperative phosphate recovery profiles to predict liver insufficiency after living donor hepatectomy.

BACKGROUND: Living donor hepatectomy (LDH) is associated with significant postoperative hypophosphatemia. METHODS: From January 1997 through July 2017, we performed 176 LDH and compared donors who developed liver insufficiency (LI) to those that did not within 30 days of LDH. Using smoothing splines, we constructed a mixed-effects model and assessed receiver operating characteristic curves. RESULTS: Of the 176 donors, 161 were included in our study and 10 (6.2%) developed LI. The cohorts differed in minimum observed phosphate levels (1.77 mg/dL, LI cohort; 2.01 mg/dL No LI cohort) at a median nadir of 1.6 days (38 h) postoperatively (p = 0.003). In the ROC analysis, intraoperative time and postoperative phosphate levels best predicted LI (sensitivity, 90%; specificity, 55.6%). CONCLUSION: Mean postoperative phosphate profiles differ significantly between those patients who develop LI and those who do not in the first 38 h after LDH.

Weight gain after kidney donation: Association with increased risks of type 2 diabetes and hypertension.

In the general population, obesity is associated with an increased risk of developing hypertension (HTN), type 2 diabetes mellitus (DM), and end-stage renal disease (ESRD). Therefore, most transplant centers have a body mass index (BMI) threshold for accepting living kidney donors. But there have been no studies of postdonation weight gain trends and any associated risks. We tracked serial BMIs in 940 donors for a median (IQ range) follow-up of 22.3 (15.4-35.8) years. We studied the impact of postdonation weight gain in a model adjusted for family history of HTN or DM. Donor characteristics included age, sex, smoking, fasting blood glucose, eGFR, systolic and diastolic BP, and BMI at time of donation and time postdonation. Postdonation weight gain was associated with a significant increase in the relative risk of developing HTN RR 1.93 (95% CI 1.51-2.46) (P < 0.001) and/or DM RR 4.18 (95% CI 2.05-8.5) (P < 0.0001), but not (to date) cardiovascular disease (CVD), reduced eGFR or death. Like the general population, donors gained weight as they aged; a higher BMI was associated with higher incidence of DM and HTN. Postdonation care should include ongoing counseling on the risks of substantial weight gain.

Causes and timing of end-stage renal disease after living kidney donation.

End-stage renal disease (ESRD) is a risk after kidney donation. We sought, in a large cohort of kidney donors, to determine the causes of donor ESRD, the interval from donation to ESRD, the role of the donor/recipient relationship, and the trajectory of the estimated GFR (eGFR) from donation to ESRD. From 1/1/1963 thru 12/31/2015, 4030 individuals underwent living donor nephrectomy at our center, as well as ascertainment of ESRD status. Of these, 39 developed ESRD (mean age ± standard deviation [SD] at ESRD, 62.4 ± 14.1 years; mean interval between donation and ESRD, 27.1 ± 9.8 years). Donors developing ESRD were more likely to be male, as well as smokers, and younger at donation, and to have donated to a first-degree relative. Of donors with a known cause of ESRD (n = 25), 48% was due to diabetes and/or hypertension; only 2 from a disease that would have affected 1 kidney (cancer). Of those 25 with an ascertainable ESRD cause, 4 shared a similar etiology of ESRD with their recipient. Almost universally, thechange of eGFR over time was stable, until new-onset disease (kidney or systemic). Knowledge of factors contributing to ESRD after living kidney donation can improve donor selection and counseling, as well as long-term postdonation care.

Financial Burden Borne by Laparoscopic Living Kidney Donors.

BACKGROUND: Living kidney donors have donation-related out-of-pocket costs (direct costs) and/or ongoing daily expenses while losing income (indirect costs). Yet there is little information about how much of a subjective burden these constitute for the donors. METHODS: From December 2003 through December 2014, we surveyed donors 6 months postdonation to determine their financial burden related to donation (on a scale of 1 to 10) and what resources were used to cover expenses. RESULTS: Of 1136 surveyed, 796 (70%) responded. Among respondents, mean age at donation was 43.6 ± 10.6 years, 64% were women, 96% were white, and 53% were related by blood to their recipient. Overall, 26% scored their financial burden as 5 or higher; 8% scored it as 8 or higher. Increased expenses were associated with a higher reported burden; however, significant burden was reported by some with no out-of-pocket expenses (presumably due to lost wages and continuing expenses). The burden was scored as 5 or higher by 27% of those employed outside the home (n = 660), 15% homemakers, 13% retirees, 40% students; 28% unemployed; and 26% whose occupation was unknown. Over half (51%) of those receiving a local or (means-tested) national grant still reported moderate to severe burden. Besides grants, donors used a variety of sources to help offset expenses: dipped into savings, borrowed from friends or family, took out a loan, and/or had a fundraiser. Those with the highest burden reported using the most additional sources. CONCLUSIONS: Donors should not have to incur costs or a financial burden to donate; the transplant community should strive to make donation financially neutral.

Return to normal activities and work after living donor laparoscopic nephrectomy.

Transplant programs inform potential donors that they should be able to return to normal activities within ~2 weeks and to work by 6 weeks after laparoscopic nephrectomy. We studied actual time. Between 10/2004 and 9/2014, 911 donors having laparoscopic nephrectomy were surveyed 6 months post-donation. Surveys asked questions specific to their recovery experience, including time to return to normal activities and work and a description of their recovery time relative to pre-donation expectations. Of the 911, 646 (71%) responded: mean age at donation was 43.5±10.6 years; 65% were female, 95% were white, 51% were biologically related to their recipient, and 83% reported education beyond high school. Of the 646 respondents, a total of 35% returned to normal activities by 2 weeks post-donation; 79% by 4 weeks post-donation; 94% by 5-6 weeks; however, 6% took >6 weeks. Of the 646, 551 (85%) were working for pay; of these, mean time to return to work was 5.3±2.8 weeks; median, 5 weeks. Of the 551, a total of 14% returned to work in 1-2 weeks, 46% by 3-4 weeks, and 76% by 5-6 weeks. Importantly, 24% required >6 weeks before returning to work with the highest rates for donors in manual labor or a skilled trade. Significantly longer return to work was reported by females (vs males; P=.01), those without (vs those with) post-high school education (P=.010, those with longer hospital stay (P=.01), and those with a postoperative complication (P=.02). Of respondents, 37% described their recovery time as longer than expected. During the donor informed consent process, additional emphasis on realistic expectations around recovery to baseline activities and return to work is warranted.

Quality of life in elderly kidney transplant recipients.

OBJECTIVES: To evaluate quality of life (QOL) in kidney transplant recipients aged 65 and older, identify predictors of impaired physical and mental QOL cross-sectionally and compare QOL over time with that of younger transplant recipients and general population controls. DESIGN: Comparison of serial Medical Outcomes Study 36-item Short-Form Survey (SF-36) QOL scores in transplant recipients aged 65 and older with those of transplant recipients younger than 65 and with those of general population controls from the National Health Measurement Study (NHMS). SETTING: University of Minnesota. PARTICIPANTS: Individuals aged 65 and older (n = 150) and younger than 65 (n = 1,544) who received a primary kidney transplant between 1963 and 2009. MEASUREMENTS: Two-sample t-tests and logistic regression were used to assess the risk of significant impairment in physical and mental QOL, defined as 1 standard deviation below the general population norms (<40 points) for the SF-36 Physical (PCS) and Mental Component Subscale (MCS) scores. RESULTS: PCS scores were 39.3 for transplant recipients aged 65 and older, 43.5 for recipients younger than 65, and 49.2 for NHMS controls (P < .005 for each pairwise comparison). MCS scores were 54.6 for transplant recipients aged 65 and older, 51.0 for recipients younger than 65, and 53.8 for NHMS controls (P < .005 for ≥ 65 vs <65 and NHMS vs <65). These scores did not change significantly from the first (3.6 years after transplant) to the last (6.2 years after transplant) survey. Longer time since transplantation in elderly participants was associated with having significantly impaired physical QOL, but no predictors were associated with significantly impaired mental QOL. In younger recipients, rejection, diabetes mellitus, delayed graft function, coronary artery disease, and longer time on dialysis were associated with impaired physical QOL. Rejection, smoking, diabetes mellitus, and longer time on dialysis were predictors of impaired mental QOL. CONCLUSION: Physical QOL is lower in elderly recipients but mental QOL is maintained and is higher than in younger recipients.

Medical outcomes of adolescent live kidney donors.

Living kidney donation from donors <18 yr of age is uncommon. The majority of donations from adolescents took place several decades ago providing a unique opportunity to study true long-term consequences of donation. We compared survival, renal outcomes, and rates of hypertension and diabetes among 42 adolescent donors and matched older controls. Adolescent donors were matched with donors 18-30 yr on the following: gender, relation to the recipient, BMI at donation, eGFR at donation, and year of donation. After a mean follow-up of 31.8 ± 8.0 yr, 94.9% of adolescent donors were alive vs. 93.8% of controls. There was no significant difference in having eGFR (MDRD) <60 mL/min/1.73 m(2) (26.1% vs. 40.9%), hypertension (35.9% vs. 39.4%), diabetes (5.1% vs. 12.5%), or proteinuria (15.4% vs. 14.1%): adolescent donors vs. controls for all comparisons. These data suggest that adolescent donors are not at a higher risk of shortened survival, hypertension, diabetes, or proteinuria. Nevertheless, they probably should donate only when other options are exhausted as they have to live with a single kidney for decades and longer follow-up is needed.