Abnormal Liver Biopsies of Donor Grafts in Pediatric Liver Transplantation: How Do They Fare?

BACKGROUND Little is known about outcomes of pediatric patients transplanted using donor liver grafts with abnormal biopsy results. We assessed donor liver biopsy data to report characteristics and outcomes of abnormal livers transplanted in pediatric patients. MATERIAL AND METHODS We identified pediatric patients who received a liver transplant from a biopsied deceased donor between 2015 and 2022 using the national database UNOS Standard Transplant Analysis and Research files. Recipients were excluded if they received multi-organ transplants or were lost to follow-up. Livers with ≤5% macrosteatosis, no fibrosis, and no inflammation were classified as normal livers (NL). Allografts with >5% macrosteatosis, any fibrosis, or any inflammation were considered abnormal livers (AL). Donor and recipient demographic data and outcomes were examined. RESULTS Of the 3808 total pediatric liver transplants in the study period, there were 213 biopsied donor liver allografts transplanted into pediatric recipients. Of those, 114 were NL and 99 were AL. 35.4% (35/99) of the AL had >5% macrosteatosis with a mean of 7.6±11.4%, 64.6% (64/99) had any inflammation, and 18.2% (18/99) had any fibrosis. AL donors were significantly older than NL donors. AL recipients had higher PELD scores. There were no significant differences in length of stay, rejection rates and causes, or allograft survival between AL and NL. Multivariable analysis revealed that inflammation was independently associated with a significantly greater risk for graft failure. CONCLUSIONS Outcomes of abnormal livers are excellent. Inflammation was an independent risk factor for poor graft prognosis. Donor biopsies in pediatric liver transplantation can be a useful adjunct to assess outcomes.

Liver Transplantation in the Time of a Pandemic: A Widening of the Racial and Socioeconomic Health Care Gap During COVID-19.

OBJECTIVE: During the initial wave of the COVID-19 pandemic, organ transplantation was classified a CMS Tier 3b procedure which should not be postponed. The differential impact of the pandemic on access to liver transplantation was assessed. SUMMARY BACKGROUND DATA: Disparities in organ access and transplant outcomes among vulnerable populations have served as obstacles in liver transplantation. METHODS: Using UNOS STARfile data, adult waitlisted candidates were identified from March 1, 2020 to November 30, 2020 (n = 21,702 pandemic) and March 1, 2019 to November 30, 2019 (n = 22,797 pre-pandemic), and further categorized and analyzed by time periods: March to May (Period 1), June to August (Period 2), and September to November (Period 3). Comparisons between pandemic and pre-pandemic groups included: Minority status, demographics, diagnosis, MELD, insurance type, and transplant center characteristics. Liver transplant centers (n = 113) were divided into tertiles by volume (small, medium, large) for further analyses. Multivariable logistic regression was fitted to assess odds of transplant. Competing risk regression was used to predict probability of removal from the waitlist due to transplantation or death and sickness. Additional temporal analyses were performed to assess changes in outcomes over the course of the pandemic. RESULTS: During Period 1 of the pandemic, Minorities showed greater reduction in both listing (-14% vs -12% Whites), and transplant (-15% vs -7% Whites), despite a higher median MELD at transplant (23 vs 20 Whites, P < 0.001). Of candidates with public insurance, Minorities demonstrated an 18.5% decrease in transplants during Period 1 (vs -8% Whites). Although large programs increased transplants during Period 1, accounting for 61.5% of liver transplants versus 53.4% pre-pandemic (P < 0.001), Minorities constituted significantly fewer transplants at these programs during this time period (27.7% pandemic vs 31.7% pre-pandemic, P = 0.04). Although improvements in disparities in candidate listings, removals, and transplants were observed during Periods 2 and 3, the adjusted odds ratio of transplant for Minorities was 0.89 (95% CI 0.83-0.96, P = 0.001) over the entire pandemic period. CONCLUSIONS: COVID-19's effect on access to liver transplantation has been ubiquitous. However, Minorities, especially those with public insurance, have been disproportionately affected. Importantly, despite the uncertainty and challenges, our systems have remarkable resiliency, as demonstrated by the temporal improvements observed during Periods 2 and 3. As the pandemic persists, and the aftermath ensues, health care systems must consciously strive to identify and equitably serve vulnerable populations.

Making Every Liver Count: Increased Transplant Yield of Donor Livers Through Normothermic Machine Perfusion.

OBJECTIVE: Normothermic machine perfusion (NMP) enables optimized ex-vivo preservation of a donor liver in a normal physiologic state. The impact of this emerging technology on donor liver utilization has yet to be assessed. SUMMARY BACKGROUND DATA: NMP of the donor liver and ex-vivo enhancement of its function has been envisioned for decades, however only with recent technological advances have devices been suitable for transition to clinical practice. The present study examines the effect NMP on liver utilization in the United States. METHODS: The United Network for Organ Sharing database was queried to identify deceased donor livers procured from 2016 to 2019 (n = 30596). Donor livers were divided by preservation method: standard cold-static preservation (COLD, n = 30,368) versus NMP (n = 228). Donor and recipient risk factors, liver disposition, and discard reasons were analyzed. The primary outcome was liver discard rate between 2 groups. RESULTS: A total of 4037 livers were discarded. The NMP group had a 3.5% discard rate versus 13.3% in the COLD group (P < 0.001), and this was despite NMP donors being older (47.7 vs 39.5 years, P < 0.0001), more frequently donation after cardiac death (DCD) (18% vs 7%, P < 0.001), and having a greater donor risk index (1.6 vs 1.5, P < 0.05). The most common reasons for liver discard in the COLD group were biopsy findings (38%), DCD warm ischemic time (11%), and prolonged preservation time (10%). Survival analysis, following propensity score matching, found no significant difference in 1-year overall survival between recipients of NMP versus COLD livers. CONCLUSIONS: NMP reduces the discard rate of procured livers despite its use in donors traditionally considered of more marginal quality. NMP maintains excellent graft and patient survival. Broader application of NMP technology holds the potential to generate a significant number of additional liver grafts for transplantation every year, thus greatly reducing the nationwide disparity between supply and demand.

Utilizing increased risk for disease transmission (IRD) kidneys for pediatric renal transplant recipients.

BACKGROUND: Strategies to expand numbers of deceased donor kidneys suitable for pediatric recipients are urgently needed to prevent long-term dialysis-associated morbidity and mortality. Donors designated as increased risk of disease transmission (IRD) are infrequently used in pediatric recipients. We examined outcomes of these kidneys in pediatric patients and the potential to increase the donor pool. METHODS: The United Network for Organ Sharing (UNOS) database records presence of IRD in all deceased donors since 2004. All pediatric kidney transplant recipients from 2004 to 2017 were identified and stratified by IRD status, and outcomes were examined. RESULTS: Four hundred seventy-three pediatric kidney transplant recipients received an IRD allograft. IRD donors had lower kidney donor profile index (KDPI); were more likely to be younger, male, and Caucasian; and were more likely to have used drugs. IRD kidneys were more likely to have been biopsied and placed on pulsatile perfusion. Other than an older recipient age, demographic data were not different between groups. Allograft and patient survivals were similar, as were rejection and delayed graft function rates. Compared with adult recipients and adult IRD recipients, pediatric recipients were more likely to have a younger donor, receive a kidney with a lower creatinine, and were less likely to have delayed graft function (p < 0.05). There were no recorded disease transmissions in IRD group. CONCLUSIONS: Patient and allograft survivals are similar in IRD and non-IRD kidneys. High-quality IRD organs used in adults represent a large number of donors with excellent outcomes. IRD allografts have a potential to increase transplant volume and should be considered for pediatric patients.

Two-stage liver transplant for ruptured hepatic adenoma: A case report.

BACKGROUND: Only one case of liver transplantation for hepatic adenoma has previously been reported for patients with rupture and uncontrolled hemorrhage. We present the case of a massive ruptured hepatic adenoma with persistent hemorrhagic shock and toxic liver syndrome which resulted in a two-stage liver transplantation. This is the first case of a two-stage liver transplantation performed for a ruptured hepatic adenoma. CASE SUMMARY: A 23 years old African American female with a history of pre-diabetes and oral contraceptive presented to an outside facility complaining of right-sided chest pain and emesis for one day. She was found to be in hemorrhagic shock due to a massive ruptured hepatic hepatic adenoma. She underwent repeated embolizations with interventional radiology with ongoing hemorrhage and the development of renal failure, hepatic failure, and hemodynamic instability, known as toxic liver syndrome. In the setting of uncontrolled hemorrhage and toxic liver syndrome, a hepatectomy with porto-caval anastomosis was performed with liver transplantation 15 h later. She tolerated the anhepatic stage well, and has done well over one year later. CONCLUSION: When toxic liver syndrome is recognized, liver transplantation with or without hepatectomy should be considered before the patient becomes unstable.

Novel Application of Extracorporeal Photopheresis as Treatment of Graft-versus-Host Disease Following Liver Transplantation.

A 48-year-old man with hepatitis C virus (HCV) cirrhosis complicated by hepatocellular carcinoma underwent liver transplantation. His course was complicated by fever, diarrhea, abdominal pain, and pancytopenia. He developed a diffuse erythematous rash, which progressed to erythroderma. Biopsies of the colon and skin were consistent with acute graft-versus-host disease. Donor-derived lymphocytes were present in the peripheral blood. The patient was treated with corticosteroids and cyclosporine; however, he had minimal response to intensive immunosuppressive therapy. Extracorporeal photopheresis was initiated as a salvage therapy. He had a dramatic response, and his rash, diarrhea, and pancytopenia resolved. He is maintained on minimal immunosuppression 24 months later.

The cost of resident education.

BACKGROUND: Patients cared for by surgeons with resident coverage have an increase in cost versus those patients cared for by surgeons without resident coverage, despite no significant difference in complications. We evaluated the reasons for the disparate cost. METHODS: In a single institutional analysis, patients received their care from a group of eight surgeons, four with and four without resident coverage. We analyzed ancillary costs, including pharmacy, radiology, laboratory, and central supply costs, and length of stay, total cost, and hospital margin for these patients. In a separate analysis, we compared data that contributes to cost from the National Surgical Quality Improvement Program (NSQIP) database, including age in years, ASA class I-IV, total operating room time in minutes (min), length of hospital stay in days (d), number of patients with a return to OR in 30 d, and complications. RESULTS: There were no significant differences in ancillary costs in patients cared for by residents. The length of stay was longer in patients cared for by residents (3.3 versus 4.6 d, no resident versus resident, respectively, P = 0.0001). When adjusted for the length of stay, the difference between total costs was $1949/d versus $2103/d (P = NS) for the no resident versus resident groups, respectively. There were 32,685 patients evaluated in the NSQIP database. In all comparisons, operating room time was significantly longer in patients with procedures involving residents. CONCLUSION: The increase in cost in patients cared for by surgeons with residents is not from significant differences in ancillary costs, and may be from length of stay. Surgical procedures are significantly longer with resident involvement.

Laparoscopic ventral hernia repair is safer than open repair: analysis of the NSQIP data.

INTRODUCTION: Previous single institutional studies have demonstrated fewer complications in laparoscopic ventral hernia repair (LVHR) compared to open ventral hernia repair (OVHR). We questioned whether or not these data were supported in large cross-sectional studies. MATERIALS AND METHODS: We evaluated the National Surgical Quality Improvement Program (NSQIP) database comparing all LVHR versus primary OVHR for patients from 2005 to 2006. We compared demographic data, ASA class, wound classification, and outcome data. We also evaluated recurrent open repair (R-OVHR) data. Differences were considered significant for P < or = 0.05. No statistical comparisons were made with the R-OVHR group. RESULTS: There were no differences in demographic data, except older age, between the LVHR and OVHR groups. Wound and ASA classifications were not different. There were fewer total complications (5.7% versus 9.8%, P<0.001), and fewer superficial (1.5% versus 4.1%, P<0.001) and deep (0.5% versus 1.6%, P=0.001) infections in the laparoscopic group. There were more total and infectious complications in the R-OVHR group. CONCLUSION: Despite no differences in ASA class or wound classification, there were more total and infectious complications in the OVHR group. This large cross-sectional study supports single institutional studies that demonstrate fewer complications and infections in patients with laparoscopic versus open ventral hernia repair.

Resident versus no resident: a single institutional study on operative complications, mortality, and cost.

BACKGROUND: Previous studies have demonstrated an increase in surgical morbidity, mortality, duration of stay, and costs in teaching hospitals. These studies are confounded by many variables. Controlling for these variables, we studied the effect of surgical residents on these outcomes during rotations with non-academic-based teaching faculty at a teaching hospital. METHODS: Patients received care at a single teaching hospital from a group of 8 surgeons. Four surgeons did not have resident coverage (group 1) and the other 4 had coverage (group 2). Continuous severity adjusted complications, mortality, length of stay, cost, and hospital margin data were collected and compared. RESULTS: Five common procedures were examined: bowel resection, laparoscopic cholecystectomy, hernia, mastectomy, and appendectomy. Comparing all procedures together, there were no differences in complications between the groups, although there was greater mortality, a greater duration of stay, and higher costs in group 2. When comparing the 5 most common procedures individually, there was no difference in complications or mortality, although a greater length of stay and higher costs in group 2. CONCLUSIONS: Comparing the most common procedures performed individually, patients cared for by surgeons with surgical residents at a teaching hospital have an increase in duration of stay and cost, although no difference in complications or mortality compared to surgeons without residents.