RESUMEN
Appropriate metrics for performance analysis is an active topic of debate within the transplant community. This study explores current proposals on metric expansion as well as potential metrics and prospective collaborations that have not received widespread discussion within the transplant community. The premature introduction of additional, nonvalidated metrics risks behaviors that may undermine donor utilization and patient access to transplantation.
Asunto(s)
Benchmarking , Supervivencia de Injerto , Trasplante de Hígado/métodos , Donadores Vivos , Mejoramiento de la Calidad/normas , Obtención de Tejidos y Órganos/normas , Listas de Espera , Humanos , Evaluación de Programas y Proyectos de SaludRESUMEN
BACKGROUND: Until recently, transplantation from hepatitis C-positive donors was relatively contraindicated as eradication of active hepatitis C previously required an interferon-based regimen that has been associated with rejection in solid organ transplantation. New interferon-free treatment regimens for hepatitis C have fewer adverse events and higher cure rates than interferon-based regimens. Interferon-free regimens have been shown to be safe in the liver transplantation literature, but little is known about the safety and efficacy of treatment in heart transplantation. CASE DESCRIPTION AND DISCUSSION: Here we report a case of successful eradication of hepatitis C with a non-interferon-based regimen using ledipasvir-sofosbuvir following combined orthotopic heart and liver transplantation. Based on the prevalence of hepatitis C in the general population, inclusion of hepatitis C-positive donors for heart transplantation can expand this component of the donor pool 3- to 6-fold. CONCLUSIONS: In carefully selected patients and recipients, inclusion of hepatitis C-positive donors may allow for expansion of the donor pool.
Asunto(s)
Insuficiencia Cardíaca/cirugía , Trasplante de Corazón/métodos , Hepatitis C Crónica/cirugía , Trasplante de Hígado/métodos , Donantes de Tejidos/provisión & distribución , Insuficiencia Cardíaca/complicaciones , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/tratamiento farmacológico , Hepatitis C Crónica/complicaciones , Hepatitis C Crónica/diagnóstico , Hepatitis C Crónica/tratamiento farmacológico , Humanos , Inmunosupresores/uso terapéutico , Masculino , Persona de Mediana EdadRESUMEN
BACKGROUND: The Scientific Registry of Transplant Recipients (SRTR) has released a 5-tier performance ranking system based upon results of deceased-donor and living-donor liver transplantation. MATERIALS AND METHODS: An analysis of Spring 2017 SRTR Program Specific Reports for outcomes of adult living-donor and deceased-donor liver transplantation. RESULTS: Utilizing the current SRTR performance algorithm, living-donor liver transplant results may disproportionately affect transplant center performance ranking. CONCLUSION: Improvements in SRTR performance ranking including transparency in outcomes calculation, a calculating tool for transplant centers, and the potential reporting of living-donor outcomes as a separate report are necessary.
Asunto(s)
Trasplante de Hígado , Donadores Vivos , Evaluación de Resultado en la Atención de Salud , Adulto , Humanos , Sistema de Registros , Obtención de Tejidos y ÓrganosRESUMEN
The disparity between organ supply and demand has necessitated more aggressive use of livers from extended criteria donors. Organ sharing between donor service areas and transplant centers in other regions is common. Confidence in the graft quality is greatly improved with a digital image taken in conjunction with the recovery surgeon's report and biopsy data. Three cases in which digital images of various levels of quality allowed the recipient's surgery to proceed, minimized the cold ischemia time, and yielded excellent outcomes are described. Another case in which a picture was not available and the liver was discarded after importation is also presented for comparison.
Asunto(s)
Selección de Donante/métodos , Trasplante de Hígado , Fotograbar/métodos , Procesamiento de Señales Asistido por Computador , Obtención de Tejidos y Órganos/métodos , Adulto , Anciano , Anciano de 80 o más Años , Biopsia , Teléfono Celular , Computadoras de Mano , Humanos , Masculino , Persona de Mediana Edad , Preservación de Órganos , Procesamiento de Señales Asistido por Computador/instrumentación , Factores de TiempoRESUMEN
Hospital-acquired conditions (HACs) are used to define hospital performance measures. Patient comorbidity may influence HAC development. The National Inpatient Sample database was used to investigate HACs for the patients who underwent liver transplantation. Multivariate analysis was used to identify HAC risk factors. We found a total of 13,816 patients who underwent liver transplantation during 2002-2014. Of these, 330 (2.4%) had a report of HACs. Most frequent HACs were vascular catheter-associated infection [220 (1.6%)], falls and trauma [66 (0.5%), catheter-associated UTI [24 (0.2%)], and pressure ulcer stage III/IV [22 (0.2%)]. Factors correlating with HACs included extreme loss function (AOR: 52.13, P < 0.01) and major loss function (AOR: 8.11, P = 0.04), hepatopulmonary syndrome (AOR: 3.39, P = 0.02), portal hypertension (AOR: 1.49, P = 0.02), and hospitalization length of stay before transplant (AOR: 1.01, P < 0.01). The rate of HACs for liver transplantation is three times higher than the reported overall rate of HACs for GI procedures. Multiple patient factors are associated with HACs, and HACs may not be a reliable measure to evaluate hospital performance. Vascular catheter-associated infection is the most common HAC after liver transplantation.
Asunto(s)
Enfermedad Iatrogénica/epidemiología , Trasplante de Hígado , Complicaciones Posoperatorias/epidemiología , Adulto , Anciano , Comorbilidad , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/mortalidad , Factores de Riesgo , Estados Unidos/epidemiologíaRESUMEN
Clostridium perfringens sepsis following orthotopic liver transplantation (OLT) is a rare but reported complication that historically results in mortality or emergent retransplantation (ReTx). Complications from C. perfringens emphysematous gastritis have contributed to the death of a healthy live liver donor as well. Herein, we describe the first documented survivor of C. perfringens sepsis following OLT managed without laparotomy or emergent ReTx.
Asunto(s)
Infecciones por Clostridium/transmisión , Clostridium perfringens/aislamiento & purificación , Trasplante de Hígado/efectos adversos , Complicaciones Posoperatorias/microbiología , Sepsis/microbiología , Femenino , Humanos , Persona de Mediana Edad , Complicaciones Posoperatorias/terapia , Sepsis/terapia , SobrevivientesRESUMEN
Chronic pancreatitis (CP), secondary to a wide variety of etiologies, is a progressive and irreversible disease. Initially, CP is managed with endoscopic interventions, long-term analgesia for its associated chronic abdominal pain syndrome and pancreatic enzyme replacement for exocrine dysfunction. As the disease advances, pancreatic drainage procedures and partial resections are considered, but they leave diseased tissue behind and usually result in short-term relief only. Total pancreatectomy alone is widely viewed as a last resort treatment option because it causes brittle diabetes mellitus. However, total pancreatectomy with islet autotransplantation (TPIAT) can prevent the development of diabetes and cure the chronic pain syndrome. One serious, albeit rare, complication of TPIAT is (partial) portal vein thrombosis. Its incidence is probably about 5%. To prevent the occurrence of portal vein thrombosis, we propose herein, and have successfully performed, continuous real-time Doppler ultrasonography during the islet infusion to study portal vein and intrahepatic flow patterns, as well as changes in Doppler signals. Flow and signal changes may allow for timely adjustment of the infusion rate, before a marked increase in portal vein pressure is noted and decrease the risk of portal vein thrombosis.
Asunto(s)
Trasplante de Islotes Pancreáticos/métodos , Monitoreo Intraoperatorio/métodos , Pancreatectomía/métodos , Vena Porta/diagnóstico por imagen , Ultrasonografía Doppler/métodos , Drenaje/efectos adversos , Humanos , Pancreatitis Crónica/cirugía , Trasplante Autólogo/métodosRESUMEN
We describe a unique case of a 53-year-old woman who underwent a nonrelated living donor kidney transplant 9 years after a previous small bowel transplant from her sister. The patient had suffered from short bowel syndrome secondary to volvulus after undergoing bariatric surgery for morbid obesity. Her entire small bowel had to be resected emergently, but she also developed acute kidney failure at the time. This initial kidney injury associated with long-term exposure to calcineurin-inhibitor medication eventually led to end-stage renal disease. A successful kidney transplant from a different, nonrelated adult donor was performed. Of note, the unrelated kidney donor matched exactly the 2 HLA-A and HLA-B antigens that the recipient had not matched with her sister. We discuss the unique HLA configuration between the patient and her 2 living donors, the absence of posttransplant rejection and posttransplant immunosuppressive therapy. To our knowledge this is the first published report of a successful kidney after a previous bowel transplant using (2 different) living donors.
Asunto(s)
Intestino Delgado/trasplante , Fallo Renal Crónico/cirugía , Trasplante de Riñón/métodos , Donadores Vivos , Cirugía Bariátrica/efectos adversos , Femenino , Rechazo de Injerto , Supervivencia de Injerto , Humanos , Terapia de Inmunosupresión/métodos , Vólvulo Intestinal/etiología , Vólvulo Intestinal/cirugía , Fallo Renal Crónico/complicaciones , Persona de Mediana Edad , Obesidad Mórbida/cirugía , Síndrome del Intestino Corto/etiología , Síndrome del Intestino Corto/cirugíaRESUMEN
OBJECTIVE: Utilization, outcomes, and retransplantation (ReTx) of liver allografts obtained by donation after cardiac death (DCD) are examined to identify mechanisms to optimize donation. SUMMARY AND BACKGROUND DATA: DCD for liver transplantation (LTX) has immediate potential to expand the donor pool but application is limited. METHODS: Retrospective analysis of the Scientific Registry of Transplant Recipients (SRTR) from January 2002 to April 2007 identified 855 DCD and 21,089 donation after brain death (DBD) adult, initial, whole-organ, liver-only LTX. Donor, recipient, and transplant characteristics were compared. Outcome measures were listing for ReTx within 1 year and graft survival determined as death or ReTx. RESULTS: DCD donors were younger (P < 0.001), with fewer African American and non-white race (P < 0.001), and fewer deaths secondary to stroke (P < 0.001). DCD recipients were older (P < 0.001), with lower Model for End-Stage Liver Disease (MELD) scores (P < 0.001), and less likely in intensive care (P = 0.02) or high-urgency status (P < 0.001). DCD allografts were more frequently imported from another allocation region (12% vs. 7%; P < 0.001). Cox regression analysis of time to DCD graft failure demonstrates higher DCD graft failure within the first 180 days (20.5% DCD vs. 11.5% DBD; P < 0.001) with convergence thereafter. DCD listing for ReTx and graft failure progressed continuously over 180 days versus 20 days in DBD. At ReTx, DCD recipients waited longer and received higher risk allografts (P = 0.039) more often from another region. More DCD recipients remain waiting for ReTx with fewer removed for death, clinical deterioration, or improvement. CONCLUSIONS: DCD utilization is impeded by early outcomes and a temporally different failure pattern that limits access to ReTx. Allocation policy that recognizes these limitations and increases access to ReTx is necessary for expansion of this donor population.
Asunto(s)
Muerte , Trasplante de Hígado/estadística & datos numéricos , Donantes de Tejidos/estadística & datos numéricos , Obtención de Tejidos y Órganos/estadística & datos numéricos , Listas de Espera , Adulto , Femenino , Supervivencia de Injerto , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Reoperación/estadística & datos numéricos , Estudios Retrospectivos , Conservación de Tejido , Trasplante HomólogoRESUMEN
Extended-donor criteria (EDC) liver allografts potentiate the role of procurement biopsy in organ utilization. To expedite allocation, histologic evaluation is routinely performed upon frozen-section (FS) specimens by local pathologists. This descriptive study compares FS reports by local pathologists with permanent-section (PS) evaluation by dedicated hepatopathologists, identifies histologic characteristics underrepresented by FS evaluation, and evaluates the efficacy of a biopsy decision analysis based on organ visualization. Fifty-two liver transplants using EDC allografts evaluated by FS with PS were studied. Pathologic worksheets created by an organ procurement organization were applied in 34 FS. PS analysis included 7 staining procedures for 8 histologic criteria. PS from 56 additional allografts determined not to require donor biopsy were also analyzed. A high correlation was observed between FS and PS. Underestimation of steatosis by FS was associated with allograft dysfunction. Surgical assessment of cholestasis, congestion, and steatosis was accurate whereas inflammation, necrosis, and fibrosis were underestimated in allografts suffering parenchymal injury. In conclusion, the correlation between FS and PS is high, and significant discrepancies are rare. Biopsy is not a prerequisite for EDC utilization but is suggested in hepatitis C, hypernatremia, donation after cardiac death, or multiple EDC indications. Implementation of a universal FS worksheet could standardize histologic reporting and facilitate data collection, allocation, and research.
Asunto(s)
Asignación de Recursos para la Atención de Salud/organización & administración , Hepatopatías/patología , Trasplante de Hígado , Hígado/patología , Patología Clínica/organización & administración , Donantes de Tejidos , Obtención de Tejidos y Órganos/organización & administración , Adulto , Biopsia , Secciones por Congelación , Humanos , Registros Médicos , Selección de Paciente , Valor Predictivo de las Pruebas , Reproducibilidad de los Resultados , Estudios Retrospectivos , Coloración y Etiquetado , Trasplante Homólogo , Estados UnidosRESUMEN
Transplantation-mediated alloimmune thrombocytopenia (TMAT) is donor-derived thrombocytopenia following solid-organ transplantation. To date, no clear consensus on the appropriateness of organ utilization from cadaver donors with a history of idiopathic thrombocytopenia purpura (ITP) has emerged. Herein is reported a devastating case of TMAT following liver transplantation utilizing an allograft from a donor with ITP that resulted in allograft failure. The literature is reviewed in this context to propose preliminary guidelines regarding utilization of allografts from cadaver donors with a history of ITP.
Asunto(s)
Cirrosis Hepática/cirugía , Trasplante de Hígado/efectos adversos , Complicaciones Posoperatorias/etiología , Guías de Práctica Clínica como Asunto , Púrpura Trombocitopénica Idiopática/inmunología , Trombocitopenia/etiología , Donantes de Tejidos , Anciano , Cadáver , Hematoma/diagnóstico por imagen , Hepatitis C Crónica/complicaciones , Humanos , Hígado/diagnóstico por imagen , Cirrosis Hepática/etiología , Cirrosis Hepática/virología , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/inmunología , Púrpura Trombocitopénica Idiopática/diagnóstico , Púrpura Trombocitopénica Idiopática/terapia , Radiografía , Trombocitopenia/inmunologíaRESUMEN
Because of organ shortage and a constant imbalance between available organs and candidates for liver transplantation, expanded criteria donors are needed. Experience shows that there are wide variations in the definitions, selection criteria, and use of expanded criteria donors according to different geographic areas and different centers. Overall, selection criteria for donors have tended to be relaxed in recent years. Consensus recommendations are needed. This article reports the conclusions of a consensus meeting held in Paris in March 2007 with the contribution of experts from Europe, the United States, and Asia. Definitions of expanded criteria donors with respect to donor variables (including age, liver function tests, steatosis, infections, malignancies, and heart-beating versus non-heart-beating, among others) are proposed. It is emphasized that donor quality represents a continuum of risk rather than "good or bad." A distinction is made between donor factors that generate increased risk of graft failure and factors independent of graft function, such as transmissible infectious disease or donor-derived malignancy, that may preclude a good outcome. Updated data concerning the risks associated with different donor variables in different recipient populations are given. Recommendations on how to safely expand donor selection criteria are proposed.
Asunto(s)
Selección de Donante/métodos , Selección de Donante/normas , Trasplante de Hígado , Guías de Práctica Clínica como Asunto , Donantes de Tejidos/provisión & distribución , Isquemia Fría/normas , Consenso , Selección de Donante/ética , Humanos , Trasplante de Hígado/ética , Soluciones Preservantes de Órganos/normas , Paris , Donantes de Tejidos/éticaRESUMEN
The 2016 Annual Congress of the International Liver Transplantation Society was held in Seoul, South Korea in May. The 22nd Congress marked the largest multidisciplinary liver transplantation meeting in Asia since 2010. The principal themes were living donation, allocation, immunosuppression, machine preservation, novel treatment of hepatitis C, and expansion of the deceased-donor allograft pool. This report presents select abstracts from the scientific sessions within the context of the published literature to serve as a quick reference.
Asunto(s)
Investigación Biomédica/métodos , Trasplante de Hígado/métodos , Animales , Conducta Cooperativa , Humanos , Comunicación Interdisciplinaria , Trasplante de Hígado/efectos adversosRESUMEN
Hepatic function and pulmonary function are interrelated with failure of one organ system affecting the other. With improved therapies, patients with concomitant hepatic and pulmonary failure increasingly enjoy a good quality of life and life expectancy. Therefore, the prevalence of such patients is increasing with more presenting for both emergent and elective surgical procedures. Hypoxemia requires a thorough evaluation in patients with end-stage liver disease. The most common etiologies respond to appropriate therapy. Portopulmonary hypertension and hepatopulmonary syndrome are associated with increased perioperative morbidity and mortality. It is incumbent on the anesthesiologist to understand the physiology of liver failure and its early effect on pulmonary function to ensure a successful outcome.
Asunto(s)
Anestesia/métodos , Cardiopatías/complicaciones , Enfermedades Pulmonares/complicaciones , Fibrosis Quística/complicaciones , Cardiopatías/fisiopatología , Cardiopatías/terapia , Síndrome Hepatopulmonar/complicaciones , Humanos , Hipertensión Pulmonar/complicaciones , Hipoxia/terapia , Enfermedades Pulmonares/fisiopatología , Enfermedades Pulmonares/terapia , Deficiencia de alfa 1-Antitripsina/complicacionesRESUMEN
BACKGROUND: The study reviews the incidence, timing, and outcome of infectious enteritis (IE) after intestinal transplantation (ITx). METHODS: A retrospective review of all patients who underwent ITx at a single institution between 1991 and 2003 was undertaken using database and medical records. Standard statistical analyses were performed. RESULTS: Of 33 ITx recipients, 13 (39%) developed 20 culture- or biopsy-proven episodes of IE. Recipient demographics included the following: 10 males, median age 34 (10-585) months, 11 liver + intestine grafts, and two isolated intestine grafts. Infections were diagnosed a median of 76 days (32-1,800 days) after ITx. There were 14 viral (one cytomegalovirus, eight rotavirus, four adenovirus, one Epstein-Barr virus), three bacterial (Clostridium difficile), and three protozoal (one Giardia lamblia, two Cryptosporidium) infections. The bacterial infections tended to present earlier than the viral infections, and the most frequent presenting symptom was diarrhea. Complete resolution was achieved in 17 (94%) incidences with the appropriate antimicrobial or conservative therapy. It was interesting that there were seven rejection episodes documented by biopsy at the approximate time of diagnosis of IE. There were two graft losses: one because of adenoviral enteritis and one because of rejection after rotavirus enteritis. Three-year patient survival is 74% with no deaths directly attributable to IE. CONCLUSIONS: IE can occur in 39% of recipients after ITx. Viral agents are the cause in two thirds of the cases. With supportive care and appropriate treatment, resolution is possible in the majority of cases. Differentiating rejection and infection on histopathology can be difficult and relies on cultures and immunostaining.
Asunto(s)
Enteritis/microbiología , Enteritis/parasitología , Intestinos/trasplante , Trasplante de Tejidos/efectos adversos , Adulto , Enteritis/patología , Enteritis/virología , Estudios de Seguimiento , Humanos , Intestinos/microbiología , Intestinos/parasitología , Intestinos/virología , Masculino , Estudios Retrospectivos , Tasa de Supervivencia , Factores de Tiempo , Trasplante Homólogo/efectos adversos , Resultado del TratamientoRESUMEN
Critical care of the general surgical patient requires synthesis of the patient's physiology, intraoperative events, and preexisting comorbidities. Evaluating an abdominal solid-organ transplant recipient after surgery adds a new dimension to clinical decisions because the transplanted allograft has undergone its own physiologic challenges and now must adapt to a new environment. This donor-recipient interaction forms the foundation for assessment of early allograft function (EAF). The intensivist must accurately assess and support EAF within the context of the recipient's current physiology and preexisting comorbidities. Optimizing EAF is essential because allograft failure is a significant predictor of recipient morbidity and mortality.