Walking Ability and Brain Natriuretic Peptide Are Highly Predictive of Kidney Transplant Waiting List Removal.

Kidney transplant waitlist management is complex because waiting time is long, and the patients have significant comorbidities. Identification of patients at highest risk for waiting list removal for death and medical complications could allow better outcomes and allocation of resources. Methods: Demographics, functional and frailty assessment' and biochemical data were retrospectively analyzed on 313 consecutive patients listed for kidney transplant. Troponin, brain natriuretic peptide, components of the Fried frailty metrics, pedometer activity, and treadmill ability were measured at the time of transplant evaluation and at subsequent re-evaluations. Cox proportional hazards models were used to identify factors associated with death or waiting list removal for medical reasons. Multivariate models were created to identify significant predictor sets. Results: Among 249 patients removed while waitlisted, 19 (6.1%) died and 51 (16.3%) were removed for medical reasons. Mean follow-up duration was 2.3 y (±1.5 y). 417 sets of measurements were collected. Significant (P < 0.05) non-time-dependent variables associated with the composite outcome identified on univariate analysis included N-terminal probrain natriuretic peptide (BNP), treadmill ability, pedometer activity, diagnosis of diabetes and the Center of Epidemiological Studies Depression Scale question asking how many days per week could you not get going. Significant time-dependent factors included BNP, treadmill ability, Up and Go, pedometer activity, handgrip, 30 s chair sit-stand test, and age. The optimal time-dependent predictor set included BNP, treadmill ability, and patient age. Conclusions: Changes in functional and biochemical markers are predictive of kidney waitlist removal for death and medical reasons. BNP and measures of walking ability were of particular importance.

Biliary Complications After Liver Transplantation in the United States: Changing Trends and Economic Implications.

BACKGROUND: Biliary complications (BCs) continue to impact patient and graft survival after liver transplant (LT), despite improvements in organ preservation, surgical technique, and posttransplant care. Real-world evidence provides a national estimate of the incidence of BC after LT, implications for patient and graft outcomes, and attributable cost not available in transplant registry data. METHODS: An administrative health claims-based BC identification algorithm was validated using electronic health records (N = 128) and then applied to nationally linked Medicare and transplant registry claims. RESULTS: The real-world evidence algorithm identified 97% of BCs in the electronic health record review. Nationally, the incidence of BCs within 1 y of LT appears to have improved from 22.2% in 2002 to 20.8% in 2018. Factors associated with BCs include donor type (living versus deceased), recipient age, diagnosis, prior transplant, donor age, and donor cause of death. BCs increased the risk-adjusted hazard ratio (aHR) for posttransplant death (aHR, 1.43; P < 0.0001) and graft loss (aHR, 1.48; P < 0.0001). Nationally, BCs requiring intervention increased risk-adjusted first-year Medicare spending by $39 710 ( P < 0.0001). CONCLUSIONS: BCs remain an important cause of morbidity and expense after LT and would benefit from a systematic quality-improvement program.

Psychosocial characteristics of patients evaluated for kidney transplant and associations with functional and frailty metrics at a veterans affairs hospital.

BACKGROUND: The effect of psychosocial problems on listing outcomes and potential interactions with functional metrics is not well-characterized among Veteran transplant candidates. METHODS: The results from psychosocial evaluations, frailty metrics, and biochemical markers were collected on 375 consecutive Veteran kidney transplant candidates. Psychosocial diagnoses were compared between patients listed or denied for transplant. Functional abilities were compared among patients with or without psychosocial diagnoses and then evaluated based on reason for denial. RESULTS: Eighty-four percent of patients had a psychosocial diagnosis. Common issues included substance or alcohol abuse (62%), psychiatric diagnoses (50%), and poor adherence (25%). Patients with psychiatric diagnoses, cognitive impairments, and poor adherence were more likely to be denied for transplant (P < .05). Patients with depression, PTSD, and anxiety did not have worse functional ability, but experienced more exhaustion than patients without these problems. Patients denied for medical but not purely psychosocial reasons had worse troponin and functional metrics compared with listed patients. CONCLUSION: Over 80% of patients with a psychosocial diagnosis were listed; however, poor adherence was a particularly important reason for denial for purely psychosocial reasons. Patients with psychosocial diagnoses generally were not more functionally limited than their counterparts without psychosocial diagnoses or those listed for transplant.

Acute pancreatitis: predictors of mortality, pancreatic necrosis and intervention.

OBJECTIVES: Several predictive scoring systems are used in the prognostication of acute pancreatitis (AP). However, the quantity of evidence of these prognostic systems in the Indian population remains sparse. The aim of our study was to evaluate the usefulness of such prognostic scores to predict mortality, incidence of pancreatic necrosis and intervention in AP. MATERIAL AND METHODS: This was an observational study of patients diagnosed with AP between June 2012 and November 2013 in a tertiary referral center in India. Vital signs, biochemical tests and CT-findings were recorded to identify SIRS, Ranson's score and CT-severity index at diagnosis. Chi square test was used to compare incidence of mortality, pancreatic necrosis, and intervention between mild versus severe acute pancreatitis groups. RESULTS: A total of 100 patients with AP were treated during out study period. Ranson's score more than 7 and presence of pancreatic necrosis were significantly associated with increased mortality (p <0.05). SIRS, CTSI score more than 7, inotropic support, and complications were more frequently associated with patients with necrosis. Prophylactic antibiotics did not decrease mortality, but decreased intervention rate (p <0.05). Presence of systemic inflammatory response syndrome (SIRS), Ranson's score > 7, necrosis, inotropic support and presence of complications were associated with a greater rate of interventions including surgery and percutaneous procedures (p <0.05). CONCLUSION: We validate SIRS, Ranson's, and CTSI score as prognostic markers for AP in the Indian population. These predictors, when used in combination, can direct early monitoring and aggressive management in order to decrease mortality associated with severe AP.

Frailty measures can be used to predict the outcome of kidney transplant evaluation.

BACKGROUND: Experience incorporating frailty and functional metrics in the transplant evaluation process is limited. We hypothesized that simple tests correlate with kidney transplant listing outcomes. METHODS: Frailty metrics, treadmill ability, pedometer data, troponin T, and brain natriuretic peptide were collected on 375 consecutive kidney transplant evaluations between July 2015 and December 2018. Patients initially denied were compared with those listed or deferred. Frailty metrics included handgrip, chair sit-stand, up-and-go, chair sit-reach, and questions related to exhaustion. RESULTS: A total of 95 (25%) patients were initially denied. Those denied were older, diabetic, or had higher body mass indexes. Frailty metrics including chair sit-stand, up-and-go, chair sit-reach, grip strength, and exhaustion; biochemical markers troponin and brain natriuretic peptide; and pedometer and treadmill ability were all significantly associated with denial (P < .001). The best order three model combining parsimony and predictiveness included treadmill ability, exhaustion, and troponin. The most predictive pedometer model also included exhaustion and up-and-go. The best order three model excluding biochemical markers, pedometer, and treadmill results included up-and-go, exhaustion, and chair sit-reach. CONCLUSION: Outcomes after on-site kidney transplant evaluation strongly correlated with the results of common clinical and functional frailty metrics.

Studying Morbidity and Predicting Mortality in Patients with Blunt Chest Trauma using a Novel Clinical Score.

BACKGROUND: A departmental audit in March 2015 revealed significant mortality rate of 40% in blunt chest trauma patients (much greater than the global 25%). A study was thus planned to study morbidity and predictors of mortality in blunt chest trauma patients admitted to our hospital. METHODS: This study was a prospective observational study of 139 patients with a history of blunt chest trauma between June 2015 and November 2015 after the Institutional Ethics Committee approval in April 2015. The sample size was calculated from the prevalence rate in our institute from the past medical records. RESULTS: The morbidity factors following blunt chest injuries apart from pain were need for Intensive Care Unit stay, mechanical ventilation, and pneumonia/acute respiratory distress syndrome. Significant predictors of mortality in our study were SpO2 <80 at the time of presentation, Glasgow coma scale ≤ 8, patients with four or more rib fractures, presence of associated head injury, Injury Severity Score >16, and need for mechanical ventilation. By calculating the likelihood ratios of each respiratory sign, a clinical score was devised. CONCLUSION: The modifiable factors affecting morbidity and mortality were identified. Mild to moderate chest injury due to blunt trauma is difficult to diagnose. The restoration of respiratory physiology has not only significant implications on recovery from chest injury but also all other injuries. It is our sincere hope that the score we have formulated will help reduce mortality and morbidity after further trials.

Pedicled omental and split skin graft in the reconstruction of the anterior abdominal wall.

INTRODUCTION: The POSSG is a pedicled graft based on either the right or left gastro-epiploic arteries. It is used with a dual mesh in reconstruction of full thickness defects of anterior abdominal wall and covered by skin grafts. PRESENTATION OF CASE: A recurrent malignant peripheral nerve sheath tumor (MPNST) of the anterior abdominal wall was excised leaving a large defect. The POSSG was used for reconstruction. A large dual mesh was placed to close the defect in the abdominal wall by suturing it to the remnant rim of abdominal muscles. The omental pedicle was brought through a keyhole in the mesh, spread out over the mesh, sutured and covered by split skin grafts. The final graft take was 90 percent. DISCUSSION: The POSSG can be used to reconstruct any size of anterior abdominal wall defects due to the malleable nature of omentum. Its prerequisite however is a dual mesh like PROCEED. The POSSG helps keep the more complex musculofasciocutaneous flaps as lifeboats. It can be used singly where multiple musculofasciocutaneous flaps would otherwise have been required. It can be used in patients with poor prognosis of underlying malignancy. It may be used by general surgeons due to familiarity with anatomy of the relevant structures and lack of need for microsurgical skill. CONCLUSION: The POSSG can be used in reconstruction of abdominal wall defects of any size by general surgeons.