Usefulness of Controlled Attenuation Parameter and Liver Stiffness Measurement for the Identification of Extended-criteria Donors and Risk-assessment in Liver Transplantation.

BACKGROUND: Controlled attenuation parameter (CAP) and liver stiffness measurement (LSM) are noninvasive surrogates for hepatic steatosis and fibrosis, respectively, and could help identify extended criteria donors in liver transplantation (LT). We aimed to determine the accuracy of CAP/LSM in deceased donors along with post-LT changes. METHODS: Accuracy of preprocurement CAP/LSM to grade/stage steatosis/fibrosis was determined using liver biopsy as reference. Transplant outcomes, including primary nonfunction (PNF) and early allograft dysfunction, were recorded. Recipients underwent CAP/LSM as outpatients. Areas under the receiver operating characteristic curve and regression models were constructed to analyze data. RESULTS: We prospectively evaluated 160 allografts (138 transplanted). Same-probe paired baseline/post-LT CAP was 231 dB/m (181-277)/225 (187-261) (P = 0.61), and LSM 7.6 kPa (6.3-10.8)/5.9 (4.6-8.7) (P = 0.002), respectively. CAP reading was affected by BMI and LSM by ALT, race and bilirubin. Although CAP did not correlate with steatosis from frozen sections (ρ = 0.08, P = 0.47), it correlated with steatosis from permanent sections (ρ = 0.32, P < 0.001) and with oil red O histomorphometry (ρ = 0.35, P = 0.001). CAP identified moderate-to-severe steatosis with an areas under the receiver operating characteristic curve curve of 0.79 (0.66-0.91), for a negative predictive value of 100% at a cutoff value of 230 dB/m. LSM correlated with fibrosis staging (ρ = 0.22, P = 0.007) and it identified discarded allografts with advanced fibrosis/cirrhosis. Patients with no to minimal fibrosis had an LSM of 7.6 (6-10.1) kPa. CONCLUSIONS: Our results are proof-of-concept of the utility of CAP/LSM during organ procurement. Establishing the precise role of these noninvasive tools in the organ allocation process mandates confirmatory studies.

Complementing Human Behavior Assessment by Leveraging Personal Ubiquitous Devices and Social Links: An Evaluation of the Peer-Ceived Momentary Assessment Method.

BACKGROUND: Ecological momentary assessment (EMA) enables individuals to self-report their subjective momentary physical and emotional states. However, certain conditions, including routine observable behaviors (eg, moods, medication adherence) as well as behaviors that may suggest declines in physical or mental health (eg, memory losses, compulsive disorders) cannot be easily and reliably measured via self-reports. OBJECTIVE: This study aims to examine a method complementary to EMA, denoted as peer-ceived momentary assessment (PeerMA), which enables the involvement of peers (eg, family members, friends) to report their perception of the individual's subjective physical and emotional states. In this paper, we aim to report the feasibility results and identified human factors influencing the acceptance and reliability of the PeerMA. METHODS: We conducted two studies of 4 weeks each, collecting self-reports from 20 participants about their stress, fatigue, anxiety, and well-being, in addition to collecting peer-reported perceptions from 27 of their peers. RESULTS: Preliminary results showed that some of the peers reported daily assessments for stress, fatigue, anxiety, and well-being statistically equal to those reported by the participant. We also showed how pairing assessments of participants and peers in time enables a qualitative and quantitative exploration of unique research questions not possible with EMA-only based assessments. We reported on the usability and implementation aspects based on the participants' experience to guide the use of the PeerMA to complement the information obtained via self-reports for observable behaviors and physical and emotional states among healthy individuals. CONCLUSIONS: It is possible to leverage the PeerMA method as a complement to EMA to assess constructs that fall in the realm of observable behaviors and states in healthy individuals.

Understanding Health Care Utilization and Mortality After Emergency General Surgery in Patients With Underlying Liver Disease.

BACKGROUND: Mortality and complications are not well defined nationally for emergency general surgery (EGS) patients presenting with underlying all-cause liver disease (LD). STUDY DESIGN: We analyzed the 2012-2014 National Inpatient Sample for adults (aged ≥ 18 years) with a primary EGS diagnosis. Underlying LD included International Classification of Diseases, Ninth Revision, Clinical Modification codes for alcoholic and viral hepatitis, malignancy, congenital etiologies, and cirrhosis. The primary outcome was mortality; secondary outcomes included complications, operative intervention, and costs. RESULTS: Of the 6.8 million EGS patients, 358 766 (5.3%) had underlying LD. 59.1% had cirrhosis, 6.7% had portal hypertension, and 13.7% had ascites. Compared with other EGS patients, EGS-LD patients had higher mean costs ($12 847 vs $10 234, P < .001). EGS-LD patients were less likely to have surgery (26.1% vs 37.0%, P < .001) but for those who did, mortality was higher (4.8% vs 1.8%, P < .001). Risk factors for mortality included ascites (adjusted odds ratio [aOR] = 2.68, P < .001), dialysis (aOR = 3.44, P < .001), sepsis (aOR = 8.97, P < .001), and respiratory failure requiring intubation (aOR = 10.40, P < .001). Odds of death increased in both surgical (aOR = 4.93, P < .001) and non-surgical EGS-LD patients (aOR = 2.56, P < .001). CONCLUSIONS: Underlying all-cause LD among EGS patients is associated with increased in-hospital mortality, even in the absence of surgical intervention.

Renal transplantation in children with thrombosis of the inferior vena cava requires careful assessment and planning.

Children with end-stage renal disease and inferior vena cava (IVC) thrombosis are rare, and their condition is complex and high risk for renal transplantation. Detailed imaging studies of the recipient's abdominal vasculature should be carried out prior to transplantation, followed by careful pre-operative joint planning by the pediatric transplant surgeon and nephrologist. Critical decisions need to be made as to whether a deceased child's kidney or an adult-sized kidney is to be used, and if the latter, whether it should be from a deceased or living donor. In addition, the contemplated site of the donor's renal vein anastomosis needs to be determined with a consideration of the possible consequences of the various choices. Sixteen cases of renal transplantation in children with pre-existing IVC thrombosis are reviewed, including the three reported by Shenoy et al. in this journal. With a full understanding of the difficulties noted, renal transplantation in a small child with IVC thrombosis can be successful. However, it requires thorough recipient assessment, coupled with a careful and thoughtful examination of options, to determine the best possible approach to the transplantation.

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.