Regional Social Vulnerability is Associated with Geographic Disparity in Waitlist Outcomes for Patients with Non-HCC MELD Exceptions in the United States.

BACKGROUND: This study was undertaken to evaluate the role of regional social vulnerability in geographic disparity for patients listed for liver transplant with non-HCC MELD exceptions. METHODS: Adults listed at a single center for a first time liver only transplant without HCC after June 18, 2013 in the SRTR database as of March 2021 were examined. Candidates were mapped to hospital referral regions (HRRs). Adjusted likelihood of mortality and liver transplant were modeled. Advantaged HRRs were defined as those where exception patients were more likely to be transplanted, yet no more likely to die in adjusted analysis. The Centers for Disease Control's Social Vulnerability Index (SVI) was used as the measure for community health. Higher SVIs indicate poorer community health. RESULTS: There were 49,494 candidates in the cohort, of whom 4,337 (8.8%) had MELD exceptions. Among continental US HRRs, 27.3% (n=78) were identified as advantaged. The mean SVI of advantaged HRRs was 0.42 vs. 0.53 in non-advantaged HRRs (P=0.002), indicating better community health in these areas. Only 25.3% of advantaged HRRs were in spatial clusters of high SVI vs. 40.7% of non-advantaged HRRs, while 44.6% of advantaged HRRs were in spatial clusters of low SVI vs.38.0% of non-advantaged HRRs (P=0.037). CONCLUSION: Advantage for non-HCC MELD exception patients is associated with lower social vulnerability on a population level. These findings suggest assigning similar waitlist priority to all non-HCC exception candidates without considering geographic differences in social determinants of health may actually exacerbate rather than ameliorate disparity.

Overview of pediatric kidney transplantation.

Kidney transplantation is the treatment of choice for pediatric patients with end-stage kidney disease. Unlike adult recipients undergoing transplantation, special considerations must be taken when transplanting children based on the underlying etiology of kidney disease, previous surgical procedures, anatomical limitations and necessary technical adjustments. Additionally, the choice of donor must be measured to ensure optimal graft survival given a longer post-transplant life expectancy. Those topics as well as frequently encountered postoperative complications are also discussed in this publication.

Practice patterns in arteriovenous fistula ligation among kidney transplant recipients in the United States Renal Data Systems.

BACKGROUND: Arteriovenous fistulas (AVF) and grafts (AVG) have been associated with significant cardiac morbidity that often improves after ligation. However, AV access ligation after kidney transplant (KT) is controversial due to concern for potential long-term allograft failure. We investigated US trends in AV access ligation after KT and the association between ligation and allograft failure. METHODS: All adult Medicare patients on pretransplant hemodialysis with a functioning AVF or AVG who underwent first-time KT were studied using the United States Renal Data Systems (January 2011 to December 2013). Post-transplant AV access ligation was determined using current procedural terminology codes. The incidence of post-transplant AV access ligation was described, and characteristics for patients undergoing ligation vs no ligation were compared. Kaplan-Meier curves and Cox proportional hazard models were then used to determine the association of AV access ligation with long-term allograft failure and all-cause mortality after accounting for patient characteristics, donor characteristics, and variation in transplant center practices. RESULTS: A total of 16,845 patients with functioning AVF/AVG received a KT during the study period. Of these, 779 (4.6%) underwent post-transplant AV access ligation. The proportion of patients who underwent ligation varied substantially between transplant centers, ranging from 0% (43.0% of centers) to >10% (11.0% of centers). Transplant recipients who underwent access ligation were more likely to be female (40.4% vs 36.6%), had lower median body mass index (27.6 vs 28.4 kg/m2), spent longer on dialysis pretransplant (4.2 vs 4.0 years), and were less likely to have renal failure secondary to diabetes compared with other etiologies (25.0% vs 34.9%) (all, P ≤ .03). Patients who underwent ligation were also more likely to have steal syndrome (77.2% vs 4.1%) and AV access infectious or aneurysmal complications (2.7% vs 0.7%) (both, P < .001). After adjusting for donor and recipient characteristics, increasing age (adjusted hazards ratio [aHR], 1.01; 95% confidence interval [CI], 1.00-1.01), increasing years on dialysis (aHR, 1.06; 95% CI, 1.00-1.13), zero human leukocyte antigen mismatch (aHR, 1.82; [95% CI, 1.09-3.05), and steal syndrome (aHR, 41.00; 95% CI, 34.56-48.64) were associated with post-transplant AV access ligation. Black race (aHR, 0.82; 95% CI, 0.69-0.98) and congestive heart failure (aHR, 0.66; 95% CI, 0.54-0.82) were negatively associated with ligation. Three-year allograft failure occurred in 4.9% ± 1.3% transplant recipients who underwent access ligation vs 9.5% ± 0.5% transplant recipients with functioning access (log-rank, P = .30), and was not significantly different between groups after risk adjustment (aHR, 0.81; 95% CI, 0.47-1.40). There was also no significant association between AV access and all-cause mortality after risk adjustment (aHR, 0.84; 95% CI, 0.46-1.54). CONCLUSIONS: Post-transplant AV access ligation is uncommon and generally reserved for patients with steal syndrome. Importantly, ligation is not associated with post-transplant allograft failure, which occurs in less than 10% of patients at 3 years. There also appears to be no reduction in all-cause mortality with AV access ligation. These data suggest that AV access ligation after KT can likely be reserved for access-related complications because the systemic benefits appear to be minimal.

National Trends in Liver Transplantation in Older Adults.

OBJECTIVES: To explore trends in liver transplantation (LT) and outcomes for older recipients for evaluation, counseling, and appropriate referral of this vulnerable group of older adults. DESIGN: Prospective national cohort study. SETTING: Scientific Registry of Transplant Recipients (January 1, 2003-December 31, 2016). PARTICIPANTS: Older (aged ≥ 65) deceased donor liver-only transplant recipients (n=8,627). MEASUREMENTS: We evaluated temporal changes in recipient, donor, and transplant characteristics and post-LT length of stay (LOS), acute rejection, graft loss, and mortality using logistic regression and Cox proportional hazards. RESULTS: LT in older adults almost quadrupled, from 263 in 2003 (9.5% of total LTs that year) to 1,144 in 2016 (20.7% of total LTs). Recent recipients were more likely to be female and African American and have a higher body mass index and Model for End-Stage Liver Disease score. Hepatitis C, nonalcoholic steatohepatitis, and hepatocellular carcinoma were the most common indications for LT in recent recipients. Odds of LOS longer than 2 weeks decreased 34% from 2003-06 to 2013-16 (adjusted odds ratio (aOR)=0.66, 95% confidence interval (CI)=0.57-0.76, P < .001), 1-year acute rejection decreased 30% (aOR=0.70, 95% CI=0.56-0.88, P = .002), all-cause graft loss decreased 54% (adjusted hazard ratio (aHR)=0.46, 95% CI=0.40-0.52, P < .001), and mortality decreased 57% (aHR=0.43, 95% CI=0.38-0.49, P < .001). CONCLUSION: Despite the substantial increase in the number of older adults undergoing LT and the severity of their condition, LOS, rejection, graft loss, and mortality have significantly decreased over time. These trends can help guide appropriate LT referral and counseling in older adults with end-stage liver disease. J Am Geriatr Soc 66:2321-2326, 2018.

Watch and wait approach to rectal cancer: A review.

In 2014, there were an estimated 136800 new cases of colorectal cancer, making it the most common gastrointestinal malignancy. It is the second leading cause of cancer death in both men and women in the United States and over one-third of newly diagnosed patients have stage III (node-positive) disease. For stage II and III colorectal cancer patients, the mainstay of curative therapy is neoadjuvant therapy, followed by radical surgical resection of the rectum. However, the consequences of a proctectomy, either by low anterior resection or abdominoperineal resection, can lead to very extensive comorbidities, such as the need for a permanent colostomy, fecal incontinence, sexual and urinary dysfunction, and even mortality. Recently, trends of complete regression of the rectal cancer after neoadjuvant chemoradiation therapy have been confirmed by clinical and radiographic evaluation-this is known as complete clinical response (cCR). The "watch and wait" approach was first proposed by Dr. Angelita Habr-Gama in Brazil in 2009. Those patients with cCR are followed with close surveillance physical examinations, endoscopy, and imaging. Here, we review management of rectal cancer, the development of the "watch and wait" approach and its outcomes.

Well differentiated neuroendocrine tumor of the appendix and low-grade appendiceal mucinous neoplasm presenting as a collision tumor

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Safety and quality outcomes in peritoneal surface malignancy patients: developing a national center for excellence in Colombia.

BACKGROUND: Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS + HIPEC) is being used more frequently for the treatment of peritoneal surface malignancies. There are a paucity of data regarding safety and quality outcomes in this group of patients. The aim of this study was to evaluate safety events and quality measures in a group of patients who underwent CRS + HIPEC. METHODS: All patients who underwent CRS + HIPEC procedures between December 2007 and March 2014 were included. All safety-related events and quality outcomes were reviewed. Major events were defined as occurrences in which there was harm to patient or healthcare personnel. Minor events were defined as quality or safety events in which there was potential for damage. RESULTS: A total of 72 patients were included. The mean Peritoneal Cancer Index for the study group was 20.5. One hundred percent compliance for informed consent, patient identification and surgical site marking, and antibiotic and venous thromboembolism prophylaxis guidelines was identified. The incidence of major safety events was 37.5 %. Minor events occurred in 47.2 % of patients. There was a 2.78 % 30-day mortality in the study group. CONCLUSIONS: One in three patients undergoing CRS + HIPEC procedures experienced a major safety or quality event before, during, or after surgery. Adequate surgical care alone is not sufficient to prevent these occurrences. Active surveillance of safety events and quality leads to early detection and development of improvement plans. New CRS + HIPEC centers need to adhere to strict safety and quality guidelines to ensure excellent patient outcomes.

An overview of renal replacement therapy and health care personnel deficiencies in sub-Saharan Africa.

Chronic kidney disease (CKD) is a public health problem in sub-Saharan Africa (SSA) but there is limited data to guide programs or plan interventions. To help set priorities and understand the needs for renal replacement therapy a baseline assessment is required. World Health Organization (WHO) databases and Medline were searched to determine the number of physicians, nephrologists, and dialysis centers and patients in SSA. Data on renal transplant (RTx) programs were collected from the WHO Global Observatory on Donation & Transplantation database for deceased-donor and living-donor RTx. Of the 47 countries in SSA only 15 had recent data with most rates of physicians per 10,000 population under 2.0. Nigeria and South Africa had the greatest absolute numbers of physicians and nephrologists but Mauritius had the greatest proportion to population. South Africa had the most dialysis patients. Kenya, Nigeria and South Africa were the only countries with RTx programs and reported rates per million population of 0.60, 0.23 and 5.12, respectively. Treatment for patients with CKD in SSA is limited by a lack of physicians, nephrologists, and dialysis centers. Few countries are performing RTx. Resources are needed to increase the health workforce and increase RTx programs in SSA.

Aneurisma de la aorta abdominal: controversias y tendencias en su diagnóstico y manejo / Abdominal aortic aneurysms: trends and controversies in management

Los aneurismas de aorta abdominal son una alteración frecuente en poblaciones con edad mayor de 65 años. Si se tiene en cuenta que la mayoría de los casos son asintomáticos, esta condición debería ser tamizada en todo paciente con factores de riesgo. Su tratamiento se fundamenta en el riesgo de ruptura y la mortalidad asociada. El abordaje quirúrgico está indicado siempre que el paciente presente síntomas o complicaciones asociadas (embolia distal, efecto compresivo en estructuras adyacentes) o cuando el diámetro del aneurisma supere los 5,5 cm. Las opciones de manejo consisten en un abordaje convencional (vía abierta) o en un abordaje intravascular. La decisión debe basarse en un proceso individualizado en el que se consideren las enfermedades concomitantes, las preferencias del paciente y la experiencia del equipo médico. Con este objetivo, se revisará el conocimiento actual respecto al manejo de aneurismas menores de 5,5 cm de diámetro, y las nuevas tendencias en cuanto a terapias farmacológicas y a modificaciones del estilo de vida, que han probado ser protectoras. El artículo incluye una revisión de la literatura y la presentación de un caso clínico.

The prevalence of abdominal aortic aneurysms (AAA) increases with age, especially after 65 years. Screening for this pathology should be performed in every patient with known risk factors, considering that most cases are asymptomatic. Surgical treatment is the mainstay therapy, based upon the risk of rupture and the associated high mortality rates. Surgical repair is indicated as long as the patient presents with symptoms or complications derived from the AAA (distal embolization, compressive effect on adjacent structures) or when aneurysm diameter is greater than 5.5cm. Surgical options are conventional open aneurysm repair or endovascular aneurysm repair (EVAR). Treatment decisions should be individually considered according to comorbidities, experience of the medical team and the patient’s preferences. Current recommendations regarding small aneurysms (<5.5cm diameter) and new medical treatments to slow progression of the disease are discussed. The article includes a literature review and a case presentation.