Liver Transplantation for Severe Hepatic Trauma: a multicenter analysis from the UNOS dataset.

BACKGROUND: Orthotopic liver transplantation (OLT) is rarely indicated after hepatic trauma but it can be the only therapeutic option in some patients. There are scarce data analyzing the surgical outcomes of OLT after trauma. METHODS: We used the UNOS dataset to identify patients who underwent OLT for trauma from 1987 to 2022, and compared them to a cohort of patients transplanted for other indications. Cox proportional hazard and multivariable logistic regression analyses were performed to assess predictors of graft and patient survival. RESULTS: 72 patients underwent OLT for trauma during the study period. Patients with trauma were more frequently on mechanical ventilation at the time of transplantation (26.4% vs. 7.6%, p < 0.001) and had a greater incidence of pre-transplant portal vein thrombosis (PVT) (12.5% vs. 4%, p = 0.002). Our 4:1 matched analysis showed that trauma patients had significantly shorter wait times, higher incidence of pre-transplant PVT and prolonged length of stay (LOS). Trauma was associated with decreased overall graft survival (HR = 1.42, 95% CI = 1.01-1.98), and increased LOS (p = 0.048). There were no significant differences in long term patient survival. CONCLUSION: Unique physiological and vascular challenges after severe hepatic trauma might be associated with decreased graft survival in patients requiring liver transplantation. LEVEL OF EVIDENCE: Retrospective cohort study, III.

Liver transplantation for biliary cysts: perioperative and long-term outcomes.

BACKGROUND: Biliary cysts (BC) is a rare indication for orthotopic liver transplantation (OLT). METHODS: We queried the UNOS dataset to identify patients who underwent OLT for Caroli's disease (CD) and choledochal cysts (CC). All patients with BC (CD + CC) were compared to a cohort of patients transplanted for other indications. Patients with CC were also compared to those with CD. Cox proportional hazard model was performed to assess predictors of graft and patient survival. RESULTS: 261 patients underwent OLT for BC. Patients with BC had better pre-operative liver function compared to those transplanted for other indications. 5-year graft and patient survival were 72% and 81%, respectively, similar to those transplanted for other indications after matching. Patients with CC were younger and had increased preoperative cholestasis compared to those with CD. Donor age, race, and gender were predictors of poor graft and patient survival in patients transplanted for CC. CONCLUSIONS: Patients with BC have similar outcomes to those transplanted for other indications and more frequently require MELD score exception. In patients transplanted for choledochal cysts, female gender, donor age, and African-American race were independent predictors of poor survival. Pediatric patients transplanted for Caroli's disease had better survival compared to adults.

Anti-neoplastic sulfonamides alter the metabolic homeostasis and disrupt the suppressor activity of regulatory T cells.

Regulatory T cells (Tregs) are essential to maintain self-tolerance and immune homeostasis but, as components of the tumor microenvironment (TME), are also a major barrier to effective cancer immunosurveillance and immunotherapy. FH535 and its derivative Y3 are two N-aryl-benzene-sulfonamides (NABs) that inhibit HCC cell proliferation and tumor progression. However, the impact of NABs on the immune cells in the TME is not yet known. Analyses of explanted livers from patients with hepatocellular carcinoma (HCC) showed that high levels of tumor-infiltrating Tregs were associated with poor tumor differentiation. These results lead us to investigate the immunomodulatory effects of NABs in regulatory and effector T cells. Exposure of primary human Tregs to NABs induced a rapid but temporary increase of cell expansion, a gradual disruption of suppressor activity, and concomitant bioenergetics and autophagic flux dysregulations. In contrast to Tregs, no gross effects were observed in effector T cells. Addition of Rapamycin prevented the functional decay of Tregs and restored their metabolic profile, suggesting that NAB effects require the integrity of the mTOR pathway. This study revealed the immunomodulatory properties of NABs with a preferential impact on Treg activity and provided novel insights into the anti-tumor potential of sulfonamides.

Predictors of Liver Failure in Non-Cirrhotic Patients Undergoing Hepatectomy.

BACKGROUND: Post-hepatectomy liver failure (PHLF) is associated with high mortality following liver resection. There have been limited studies evaluating predictors of PHLF and clinically significant PHLF in non-cirrhotic patients. METHODS: This was a retrospective cohort study using the National Surgical Quality Improvement Program database (NSQIP) to evaluate 8,093 non-cirrhotic patients undergoing hepatectomy from 2014 to 2018. Primary endpoints were PHLF and clinically significant PHLF (PHLF grade B or C). RESULTS: Among all patients, 4.74% (n = 383) developed PHLF and 2.5% clinically significant PHLF (n = 203). The overall 30-day mortality was 1.35% (n = 109), 11.5% (n = 44) in patients with PHLF, and 19.2% in those with clinically significant PHLF. Factors associated with PHLF were: metastatic liver disease (OR = 1.84, CI = 1.14-2.98), trisectionectomy (OR = 3.71, CI = 2.59-5.32), right total lobectomy (OR = 4.17, CI = 3.06-5.68), transfusions (OR = 1.99, CI = 1.52-2.62), organ/space SSI (OR = 2.84, CI = 2.02-3.98), post-operative pneumonia (OR = 2.43, CI = 1.57-3.76), sepsis (OR = 2.27, CI = 1.47-3.51), and septic shock (OR = 5.67, CI = 3.43-9.36). Patients who developed PHLF or clinically significant PHLF had 2-threefold increased risk of perioperative mortality. Post-hepatectomy renal failure (OR = 8.47, CI = 3.96-18.1), older age (OR = 1.04, CI = 1.014-1.063), male sex (OR = 1.83, CI = 1.07-3.14), sepsis (OR = 2.96, CI = 1.22-7.2), and septic shock (OR = 3.92, CI = 1.61-9.58) were independently associated with 30-mortality in patients with clinically significant PHLF. CONCLUSION: PHLF in non-cirrhotic patients increased the risk of perioperative mortality and is associated with the extent of hepatectomy and infectious complications. Careful evaluation of the liver remnant, antibiotic prophylaxis, nutritional assessment, and timely management of post-operative infections could decrease major morbidity and mortality following hepatectomy.

Outcomes in Elderly Patients Undergoing Liver Transplantation Compared with Liver-Directed Ablative Therapy in Early-Stage Hepatocellular Carcinoma.

BACKGROUND: Orthotopic liver transplantation (OLT) is the accepted treatment in patients with unresectable, early-stage hepatocellular carcinoma (HCC) in the setting of cirrhosis. Due to increasing waitlist demand for OLT, determining optimal groups for transplant is critical. Elderly patients are known to have poorer postoperative outcomes. Considering the effectiveness of liver-directed therapies for HCC, we sought to determine whether elderly patients received survival benefit from OLT over liver-directed therapy alone. STUDY DESIGN: The National Cancer Database participant use file was used to analyze data between 2004 and 2017. Only patients ≥70 years of age who received OLT or liver-directed therapy alone were included. Patients with alpha-fetoprotein >500 ng/mL or missing alpha-fetoprotein values were excluded. Baseline demographic variables, model for end-stage liver disease score, and overall survival from time of diagnosis were collected. Descriptive statistics, Kaplan-Meier survival, Cox proportional hazards model, and propensity score matching were used. RESULTS: A total of 2,377 patients received ablative therapy alone, and 214 patients received OLT. Multivariable analysis and Kaplan-Meier showed that OLT conferred a significant survival benefit compared to liver-directed therapy alone. Age was also associated with a yearly 3% increase in risk of mortality. Propensity-matched analysis adjusting also demonstrated a significant survival benefit for elderly patients receiving OLT compared to liver-directed therapy alone. CONCLUSION: Despite increased age and associated comorbidities being factors associated with poor outcomes, OLT confers a survival advantage compared to liver-directed ablative therapies alone in selected elderly patients with HCC. OLT should be offered in medically appropriate elderly patients with HCC.

Perioperative Challenges in Patients Transplanted with Livers from Extreme Obese Donors.

The combination of rising rates of obesity and the shortage of deceased donor livers have forced the consideration of marginal liver donors in terms of body mass index (BMI) for liver transplantation (LT). To date, there are still conflicting data on the impact of donor obesity on post-LT outcomes. We analyzed all patients undergoing LT alone in the United States (US) from October 2005 through December 2019 using the United Network of Organ Sharing (UNOS) data set. We categorized donor BMI >40 kg/m2 as extremely obese (EO). Primary endpoints included 30-day perioperative mortality and early graft loss (EGL) within 7 days. A subgroup analysis was performed for the EO donor group to assess how macrovesicular steatosis (MaS) >30% affects 30-day mortality and EGL within 7 days. A total of 72,616 patients underwent LT during the study period. The 30-day perioperative mortality was significantly higher in the EO donor group (P = 0.02). On multivariate analysis, recipients undergoing LT with EO donors had a 38% higher 30-day mortality risk (odds ratio [OR], 1.38; 95% confidence interval [CI], 1.21-1.69) and 53% increased risk of EGL (OR, 1.53; 95% CI, 1.22-1.90). MaS >30% was independently associated with a 2-fold increased risk of 30-day mortality (P = 0.003) and 3.5-fold increased risk of EGL within 7 days (P < 0.001). The impact of MaS >30% in EGL was 2-fold for all patients transplanted during the study period compared with 3.5-fold in the EO donor group. There is an increased risk of EGL and 30-day perioperative mortality in recipients transplanted with EO donors. Future studies are warranted in morbid and super obese donors to assess the possible effect of obesity-related proinflammatory factors in EGL.

Alcohol-related cirrhosis is associated with high coronary artery calcium scores in patients undergoing evaluation for orthotopic liver transplantation.

BACKGROUND AND AIMS: Coronary artery disease is a major cause of morbidity and mortality in liver transplant patients. Coronary artery calcium (CAC) score has been used to evaluate the risk of CAD in non-cirrhotic patients. However, its significance in cirrhotic patients is unknown. This study aimed to identify factors associated with elevated CAC scores in patients with end-stage liver disease undergoing liver transplant evaluation. METHODS: We retrospectively reviewed all patients who underwent liver transplantation evaluation and had coronary CT scan between January 2015 and December 2018. Patients with prior history of CAD were excluded. CAC score was calculated based on the method described by Agatston. RESULTS: Sixty-two patients were included. 37.1% had alcohol-related liver disease and 27.4% had NASH cirrhosis. Mean CAC score was 261.1 ± SD, 463.84. Alcohol-related liver disease, male gender, and hypertension were significantly associated with CAC score >100 and only alcohol-related liver disease was associated with CAC score >300. In logistic regression, patients with alcohol-related liver disease had more than sixfold increase in risk of having CAC scores >100 and 300 (OR 6.14, and 6.70, respectively). CONCLUSION: Alcohol-related liver disease, male gender, and hypertension were significantly associated with an increased CAC score >100. However, alcohol-related liver disease was the only factor associated with CAC score >300.

Younger Age Is Associated with Improved Survival in Patients Undergoing Liver Transplantation Alone for Metastatic Neuroendocrine Tumors.

BACKGROUND: Neuroendocrine tumor (NET) metastases are a major cause of morbidity and mortality. The role of liver transplantation to treat unresectable metastases from NET is controversial. METHODS: We evaluated outcomes of all patients undergoing "isolated" liver transplantation (LT) for metastatic NETs in the USA, from October 1988 through June 2018 using the UNOS dataset. RESULTS: During the study period, 160,360 LTs were performed. Two hundred six adult patients underwent "isolated" LT for metastatic NETs. The mean (SD) age was 48.2 (11.7) years, ranging from 19 to 75 years; 117 (56.8%) patients were male. Overall 1-, 3-, 5-, and 10-year patient survival rates were 89.1%, 75.3%, 64.9%, and 46.1%, respectively. Tumor recurrence was seen in 70 of 206 patients who underwent LT (34%). The median time to recurrence was 28 months (range, 1 to 192 months) and median wait time for LT was 112 days. Tumor recurrence was significantly higher in transplanted patients waiting less than 6 months compared with those waiting more than 6 months (74.3% vs. 25.7%). Patients' age ≤ 45 years had significantly better survival compared with those > 45 years (p = 0.03). Younger patients with carcinoid tumors had better survival but this trend was not observed in the non-carcinoid group. On multivariable analysis, recipient age, donor age, cold ischemic time MELD score, and tumor recurrence were significant predictors of poor patient survival. CONCLUSIONS: Waiting time longer than 6 months is associated to lower rates of tumor recurrence. Younger patients ≤ 45 years had significantly improved survival after LT for NET metastases.

Continuous renal replacement therapy in critically ill patients with acute on chronic liver failure and acute kidney injury: A retrospective cohort study
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BACKGROUND: Incident acute kidney injury (AKI) in critically ill patients with acute on chronic liver failure (ACLF) is associated with poor prognosis. The role of continuous renal replacement therapy (CRRT) is not well established for patients with ACLF and AKI. MATERIALS AND METHODS: We conducted a retrospective cohort study to examine clinical outcomes in 66 patients with ACLF and AKI requiring CRRT. RESULTS: All-cause hospital mortality was 89.4%. Five (7.6%) patients were listed for liver transplantation, of whom 1 (1.5%) was eventually subjected to transplantation. Etiology of AKI included type 1 hepatorenal syndrome (HRS) with or without some degree of acute tubular necrosis (ATN) in 20 (30.3%) patients, and primarily ATN in 46 (69.7%) patients. When evaluated at the time of CRRT initiation, Child-Pugh-Turcotte (CPT) and Model for End-stage Liver Disease (MELD) (area under the receiver operating characteristics curve (AUROC) 0.67 for both) had fair performance for prediction of mortality, whereas Sequential Organ Failure Assessment (SOFA) and Chronic Liver Failure (CLIF)-SOFA performed better for the prediction of mortality (AUROC 0.87 for both). SOFA and CLIF-SOFA also performed well when determined at the time of ICU admission (AUROC 0.86 and 0.85, respectively). Etiology of liver disease or AKI did not influence prognosis. CONCLUSION: Critically ill patients with ACLF and AKI requiring CRRT have poor hospital survival, even with provision of extracorporeal support therapy. SOFA and CLIF-SOFA are good prognostic tools of mortality in this susceptible population.

Prevalence, Risk Factors, Treatment, and Overall Impact of BK Viremia on Kidney Transplantation.

BK viremia (BKV) is a recognized and potentially serious problem in renal transplantation. The risk factors and the impact of BKV on renal allograft and patient survival are controversial. This study reports an 8-year, single-center experience on the prevalence, risk factors, and outcomes of BKV in kidney transplant recipients. This is a retrospective analysis of all patients who received a kidney transplant at the University of Kentucky and had BK viral titers available from 2009 to 2017. BKV was defined by a polymerase chain reaction viral load of ≥ 10,000 copies per mL. Demographic, clinical, and laboratory data generated during routine outpatient follow up and inpatients records were collected. Independent risk factors for BKV were determined using uni- and multivariate analysis. Graft and patient survival was compared using Kaplan-Meier analysis, and the severity of polyomavirus nephropathy on biopsy was scored using the Banff 2017 classification. We identified 122 BK positive (19%) and 527 BK negative (81%) patients. BKV developed after a median of 115 days (range, 80-249 days) following kidney transplantation. The 1-, 5-, and 10-year graft survival was 97%, 75%, and 33% in the BKV group and 96%, 85%, and 71% in the BK negative group, respectively. Likewise, the 1-, 5-, and 10-year patient survival was 98%, 84%, and 52% in the BKV group and 98%, 92%, and 84% in the BK negative group. Male sex, age at transplantation, maintenance steroids, and alemtuzumab induction were associated with developing BKV in the multivariate analysis. We concluded that BKV is not uncommon after renal transplantation. The determinants for BKV are male sex, older transplant recipients, and maintenance steroids. BKV adversely affected graft and patient survival. A unified approach for BKV and polyomavirus nephropathy treatment is needed.

Impact of human leukocyte antigen and calculated panel reactive antibody on BK viremia in kidney transplant recipients: A single-center experience and literature review.

BACKGROUND: The aim of this retrospective analysis was to investigate the effect of human leukocyte antigen (HLA) and calculated panel reactive antibody (cPRA) on BK virus activation as evidenced by BK viremia (BKV). PATIENTS AND METHODS: At our institution, 649 kidney transplant patients were screened for BKV from 2009 to 2017. Patients were considered to have BKV if they had >10 000 copies/mL of BK DNA in their blood. Donor and recipient HLA and cPRA, demographic, clinical and laboratory data, as well as immunosuppressive medications were collected. RESULTS: We identified 122 BK positive and 527 BK negative patients. Only 25% of the patients had cPRA of 20% or more, and 64% had more than three HLA-A, -B, and -DR mismatches. In both univariate and multivariate analyses, male gender, age, and maintenance of steroid therapy significantly increased the risk of BKV (P = 0.005, 0.005 and <0.001, respectively). The degree of cPRA and the individual HLA allele and HLA allele matching did not significantly affect BKV. CONCLUSION: Neither the degree of HLA mismatching nor cPRA appears to affect BKV. Moreover, no specific HLA allele, HLA allele matching, or cPRA were associated with BKV.

Long term outcomes of patients transplanted for hepatocellular carcinoma with human immunodeficiency virus infection.

BACKGROUND: We aimed to study outcomes in HIV + patients with HCC in the US following Liver Transplantation (LT) using the UNOS dataset. METHODS: The database was queried from 2003 to 2016 for patients undergoing LT with HCC, HIV+, and HCC/HIV+. RESULTS: Out of 17,397 LT performed for HCC during the study period, 113 were transplanted for HCC with HIV infection (91 isolated livers). Patients transplanted for HCC/HIV+ were younger (55.54 ± 5.89 vs 58.80 ± 7.37, p < 0.001), had lower total bilirubin (1.20 vs 1.60, p = 0.042) significantly lower BMI (25.35 ± 4.43 vs 28.39 ± 5.17, p < 0.001) and were more likely to be co-infected with HBV (25.3% vs 8.2% p < 0.001) than those transplanted for HCC alone. HCC/HIV + patients were found to have a 3.8 fold increased risk of peri-operative mortality at 90 days after matching. HCC/HIV + recipients had 54% decreased long-term survival within the HCC cohort. Our initial analysis of overall graft and patient survival found significant differences between HCC/HIV and HCC/HIV + recipients. However, these variances were lost after case-matching. Recurrence and disease free survival were similar in HCC alone vs HCC/HIV + recipients. CONCLUSIONS: Our analysis suggests that excellent outcomes can be achieved in selected patients with HCC/HIV+.

Outcome of Patients With Small Vessel Vasculitis After Renal Transplantation: National Database Analysis.

BACKGROUND: Small vessel vasculitis commonly affects the kidney and can progress to end-stage renal disease. The goal of this study is to compare outcomes of patients who received a renal transplant as a result of small vessel vasculitis (group A) with those who received kidney transplants because of other causes (group B). METHODS: This is a retrospective analysis of United Network for Organ Sharing registry data for adult primary kidney transplants from January 2000 to December 2014. Group A patients (N = 2196) were compared with a group B (N = 6588); groups were case matched for age, race, sex, donor type, and year of transplant in a 1:3 ratio. RESULTS: Renal and patient survivals were better in the group A (P < 0.001). New-onset diabetes after transplant developed in 8.3% of the group A and 11.3% of group B (P < 0.001). Seventeen (0.8%) patients in group A developed recurrent disease. Of these, 7 patients had graft failure, 3 of which were due to disease recurrence. Group A patients had significantly higher risk of developing posttransplant solid organ malignancies (11.3% vs 9.3%, P = 0.006) and lymphoproliferative disorder (1.3% vs 0.8%, P = 0.026). Independent predictors of graft failure and patient mortality were recipients' morbid obesity, diabetes, age, and dialysis duration (hazard ratio of 1.7, 1.4, 1.1/10 years, and 1.1/year for graft failure, and 1.7, 1.7, 1.6/10 years and 1.1/year for patient mortality, respectively). CONCLUSIONS: Renal transplantation in patients with has favorable long-term graft and patient outcomes with a low disease recurrence rate. However, they may have a higher risk of developing posttransplant malignancies.

Re-transplantation for Hepatic Artery Thrombosis: A National Perspective.

BACKGROUND: Hepatic artery thrombosis (HAT) is a major complication after liver transplantation that commonly requires re-transplantation. METHODS: We queried the UNOS dataset for all patients transplanted between 1995 and 2015 for HAT. RESULTS: We identified 623 patients who underwent re-transplantation for HAT with a mean age of 51.25 + 10.4 years. The mean BMI was 26.72 kg/m2, and mean MELD score was 19.62 + 9.09. There was a higher proportion of male patients, with higher prevalence of pre-transplant portal vein thrombosis (7.4 vs. 5.4%, p = 0.04), lower incidence of hepatitis C virus infection (29.5 vs. 35.8%, p = 0.002), and shorter waiting time (61 vs. 111 days, p = 0.001) in the HAT group compared to those re-transplanted for other indications. The perioperative 90-day mortality was lower in patients re-transplanted for HAT (16 vs. 20%, p = 0.02). Patients undergoing re-transplantation for HAT had 13% decreased graft survival and 13% increased long-term survival. After case-control matched analysis, graft survival and patient survival were significantly better in the HAT group. Late re-transplantation (>30 days) for HAT was linked to decreased graft and patient survival when compared to those undergoing early re-transplantation (within 30 days). CONCLUSIONS: Improved outcomes were seen in patients undergoing re-transplantation for HAT compared to patients who underwent re-transplantation for other indications. Those re-transplanted late after HAT (>30 days) were associated with worse outcomes when compared to early re-transplantation.

Liver Transplantation for the Treatment of Complicated Iatrogenic Biliary Injuries: A National Review from the UNOS Data Set.

BACKGROUND: Liver transplantation (LT) is rarely indicated in the management of iatrogenic bile duct injuries (IBDI), but occasionally, it becomes the only remaining therapy. The purpose of this study is to evaluate potential complications of IBDI and their impact on perioperative mortality, graft, and patient survival after LT. METHODS: The United Network for Organ Sharing database was queried for all LT performed in the United States between 1994 and 2014. Of the 101 238 liver transplants performed, 61 were related to IBDI. We performed a case matched analysis in a 5:1 ratio. RESULTS: The median age for patients with IBDI was 50.16 ± 11.7 years with a mean Model End-Stage Liver Disease score of 22.6 ± 9.8. Patients receiving LT for IBDI were more likely women (54.1%, P = 0.001), had lower incidence of hepatitis C virus infection (4.9%, P = 0.001) and longer cold ischemic time (P = 0.001). The mean body mass index was 25.5 ± 5.2 in patients transplanted for IBDI. IBDI was recognized as the strongest independent predictor associated with eightfold increased risk of early graft loss (P = 0.001; odds ratio, 8.4) and a 2.9-fold increased risk of 30-day mortality after LT in a case matched analysis (P = 0.03). CONCLUSIONS: IBDI is an uncommon but challenging indication for LT. These patients have significantly increased rates of early graft loss. IBDI is an independent factor related to increased risk of perioperative death after LT. Further studies are needed to determine the causes of perioperative complications and identify potential modifiable factors to improve outcomes in patients undergoing transplantation for IBDI.

Perioperative and long-term outcomes in octogenarians after kidney transplantation: the US perspective
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BACKGROUND: We aimed to study outcomes on octogenarian patients undergoing kidney transplantation in the US. METHODS: We queried the UNOS dataset from 1988 through 2013 and found 471 octogenarians transplanted during the study period. RESULTS: 86 (18.3%) were female and 385 (81.7%) were male with a mean age of 81.58 years. The octogenarians had a significantly higher incidence of diabetes, at 17.2% compared to 13.7% in the non-octogenarian group (p < 0.001). The mean donor age was 50.32 years in the octogenarian group vs. 38.02 years in the younger group (p < 0.001). The cold ischemic time of the octogenarian group was 16.72 hours vs. 14.29 hours in non-octogenarians (p < 0.001). Length of stay (LOS) was increased by 1 day in the octogenarians. We demonstrated that patients with age ≥ 80 have a 2.2-fold increased risk of perioperative death. The Cox analysis demonstrated that octogenarians have a 3.2-fold and 84% increased risk of graft failure and decreased survival, respectively. CONCLUSION: Octogenarians have significantly increased LOS, perioperative mortality, and rates of graft loss. Age older than 80 was an independent risk factor associated with decreased patient survival. Future studies should address differences in outcomes and quality of life of octogenarians on dialysis compared to those after kidney transplantation.
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Decreased graft survival in liver transplant recipients of donors with positive blood cultures: a review of the United Network for Organ Sharing dataset.

Liver transplantation using blood culture positive donors (BCPD) has allowed a significant expansion of the donor pool. We aimed to characterize BCPD and assess the outcomes of BCPD liver transplant recipients. We retrieved data from the United Network for Organ Sharing (UNOS) registry on all adults who underwent primary, single-organ deceased-donor liver transplantation in the USA between 2008 and 2013. Patients were classified into two cohorts: the BCPD cohort and the non-BCPD cohort. One-year graft and patient survival were compared between cohorts using Kaplan-Meier estimates and Cox models. A total of 28 961 patients were included. There were 2316 (8.0%) recipients of BCPD. BCPD were more likely to be older, female, black, diabetic, hypertensive, and obese compared to non-BCPD. Graft survival was significantly lower in BCPD recipients compared to non-BCPD recipients (Kaplan-Meier, 0.85 vs. 0.87; P = 0.009). Results remained significant in propensity-matched analysis (P = 0.038). BCPD was independently associated with decreased graft survival (adjusted HR; 1.10, 95% CI 1.01-1.20; P = 0.04). There were no significant differences in patient survival between study groups. BCPD was associated with decreased graft survival in liver transplant recipients. Studies are needed to identify subgroups of BCPD with the highest risk of graft failure and characterize the underlying pathogenic mechanisms.

Liver transplantation for fibrolamellar hepatocellular carcinoma: A national perspective.

BACKGROUND: Fibrolamellar Hepatocellular Carcinoma (FL-HCC) is a rare primary liver tumor that usually presents in younger patients without underlying liver disease. METHODS: We queried the United Network of Organ Sharing (UNOS) database between October 1988 and January 2013 to evaluate outcomes in patients with FL-HCC undergoing liver transplantation in the United States compared to patients with conventional Hepatocellular Carcinoma (HCC). RESULTS: Sixty-three patients were identified (57% female, mean age 30 years). Only one patient (2%) had an associated Hepatitis C Virus. Mean Model for End-Stage Liver Disease (MELD) score at the time of transplantation was 11.3. Mean waiting time was 325 days and mean cold ischemic time was 6 hr. Overall survival of FL-HCC patients at 1, 3, and 5 years was 96%, 80%, and 48% as compared to HCC patients whose rates were 89%, 77%, and 68%. Six patients had tumor recurrence (10%). The Cox Model demonstrated that MELD and cold ischemic time are the strongest predictors of overall survival in FL-HCC patients. Age and wait time were not associated with poor patient survival in this series. CONCLUSIONS: Good results can be obtained in selected patients transplanted for FL-HCC. FL-HCC patients had similar survival compared to those transplanted for HCC. J. Surg. Oncol. 2017;115:319-323. © 2016 Wiley Periodicals, Inc.

Kidney Transplant Outcomes in the Super Obese: A National Study From the UNOS Dataset.

BACKGROUND: We evaluated outcomes of super-obese patients (BMI > 50) undergoing kidney transplantation in the US. METHODS: We performed a review of 190 super-obese patients undergoing kidney transplantation from 1988 through 2013 using the UNOS dataset. RESULTS: Super-obese patients had a mean age of 45.7 years (21-75 years) and 111 (58.4 %) were female. The mean BMI of the super-obese group was 56 (range 50.0-74.2). A subgroup analysis demonstrated that patients with BMI > 50 had worse survival compared to any other BMI class. The 30-day perioperative mortality and length of stay was 3.7 % and 10.09 days compared to 0.8 % and 7.34 days in nonsuper-obese group. On multivariable analysis, BMI > 50 was an independent predictor of 30-day mortality, with a 4.6-fold increased risk of perioperative death. BMI > 50 increased the risk of delayed graft function and the length of stay by twofold. The multivariable analysis of survival showed a 78 % increased risk of death in this group. Overall patient survival for super-obese transplant recipients at 1, 3, and 5 years was 88, 82, and 76 %, compared to 96, 91, 86 % on patients transplanted with BMI < 50. A propensity score adjusted analysis further demonstrates significant worse survival rates in super-obese patients undergoing kidney transplantation. CONCLUSION: Super-obese patients had prolonged LOS and worse DGF rates. Perioperative mortality was increased 4.6-fold compared to patients with BMI < 50. In a subgroup analysis, super-obese patients who underwent kidney transplantation had significantly worse graft and patient survival compared to underweight, normal weight, and obesity class I, II, and III (BMI 40-50) patients.

Donor positive blood culture is associated with delayed graft function in kidney transplant recipients: a propensity score analysis of the UNOS database.

BACKGROUND: The effect of blood culture positive donor (BCPD) on delayed graft function (DGF) in kidney transplant recipients has not been well established. METHODS: We retrieved data from the United Network for Organ Sharing (UNOS) registry on all adults who underwent primary, single organ deceased-donor kidney transplantation in US between 2008 and 2013. Patients were classified in two cohorts: the BCPD cohort and the non-BCPD cohort. We used propensity scores for 1:1 matching of BCPD and non-BCPD cohorts. DGF, graft and patient survival at one yr were compared between cohorts using multivariable logistic and Cox regression models. DGF was defined as requiring dialysis within the first week post-transplant. RESULTS: There were 4126 (8.1%) recipients of BCPD during the study period. DGF was associated with BCPD (aOR; 1.15, 95% CI 1.07-1.24). This association was maintained in the propensity-score matched analysis (p < 0.01). No association was found between BCPD and graft survival (aHR; 1.01, 95% CI, 0.92-1.09) or patient survival (aHR; 0.92, 95% CI, 0.82-1.04). CONCLUSION: Blood culture positive donor was associated with DGF but did not impact graft or patient survival in deceased-donor kidney transplants. This suggests a transient negative effect of BCPD that does not appear to translate into a more persistent deleterious outcome.