Transplant versus resection for the management of hepatocellular carcinoma meeting Milan Criteria in the MELD exception era at a single institution in a UNOS region with short wait times.

BACKGROUND: Management of hepatocellular carcinoma (HCC) in the Model for End-Stage Liver Disease (MELD) exception era remains regionally variable. Outcomes were compared for patients undergoing transplant versus resection at a single institution in a UNOS region with short wait times for organ availability. METHODS: All patients who underwent resection of HCC from January 2000 to August 2012 and patients who underwent transplant post-January 2006, during the Milan Criteria (MC)-based MELD exception policy for HCC, were identified. Primary outcomes were overall survival (OS) and recurrence-free survival (RFS). RESULTS: Two hundred fifty-seven patients were analyzed, of whom 131 underwent transplant and 126 underwent resection. All transplant patients met MC; 45 (36%) resection patients met MC. Median follow-up time was 30 months. Median wait time to transplant was 55 days; no patients dropped off the waitlist while awaiting an organ. Among patients meeting MC, transplant demonstrated significantly greater 5-year OS (65.7% vs. 43.8%; P = 0.005) and RFS (85.3% vs. 22.7%; P < 0.001) versus resection. For patients with hepatitis C, transplant (n = 87) demonstrated significantly improved 5-year outcomes compared to patients meeting MC who underwent resection (n = 21; OS: 63.5% vs. 23.3%; P = 0.001; RFS: 83.5% vs. 23.7%; P < 0.001). CONCLUSION: In a region with short waitlist times for organ availability, liver transplant is associated with improved survival compared to resection for HCC within MC and should be considered for all patients meeting MC, particularly those with hepatitis C.

The deleterious effect of red blood cell storage on microvascular response to transfusion.

BACKGROUND: The transfusion of relatively older red blood cells (RBCs) has been associated with both morbidity and mortality in trauma patients in observational studies. Although the mechanisms responsible for this phenomenon remain unclear, alterations in the microcirculation as a result of the transfusion of relatively older blood may be a causative factor. To assess this hypothesis, we evaluated microvascular perfusion in trauma patients during RBC transfusion. METHODS: Anemic but otherwise stable trauma intensive care unit patients with orders for transfusion were identified. Thenar muscle tissue oxygen saturation (StO(2)) was measured continuously by near-infrared spectroscopy during the course of transfusion of one RBC unit. Sublingual microcirculation was observed by sidestream dark-field illumination microscopy before and after transfusion of one RBC unit. Thenar muscle StO(2) was recorded during the course of transfusion. Pretransfusion and posttransfusion perfused capillary vascular density (PCD) was determined by semiquantitative image analysis. Changes in StO(2) and PCD relative to age of RBC unit were evaluated using mixed models that adjusted for baseline StO(2) and Spearman correlation, respectively. RESULTS: Overall, 93 patients were recruited for study participation, 69% were male, and average Injury Severity Score (ISS) was 26.4. The average pretransfusion hemoglobin was 7.5 mg/dL, and the average age of RBC unit transfused was 29.4 days. The average peritransfusion StO(2) was negatively associated with increasing RBC age (slope, -0.11; p = 0.0014). Change in PCD from pretransfusion to posttransfusion period was found to correlate negatively with RBC storage age (Spearman correlation, -0.27; p = 0.037). CONCLUSION: The transfusion of relatively older RBC units was associated with a decline in both StO(2) and PCD. Collectively, these observations demonstrate that transfusions of older RBC units are associated with the inhibition of regional microvascular perfusion. In patients requiring multiple units of RBCs, alteration of the microcirculation by relatively older units could potentially contribute to adverse outcomes. LEVEL OF EVIDENCE: Prognostic study, level III.