Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 42
Filtrar
1.
J Am Soc Nephrol ; 2021 Mar 12.
Artigo em Inglês | MEDLINE | ID: mdl-33712528

RESUMO

BACKGROUND: Transplant candidates may gain an advantage by traveling to receive care at a transplant center that may have more favorable characteristics than their local center. Factors associated with longer travel distance for transplant care and whether the excess travel distance (ETD) is associated with access to transplantation or with graft failure are unknown. METHODS: This study of adults in the United States wait-listed for kidney transplantation in 1995-2015 used ETD, defined as distance a patient traveled beyond the nearest transplant center for initial waiting list registration. We used linear regression to examine patient and center characteristics associated with ETD and Fine-Gray models to examine the association between ETD (modeled as a spline) and time to deceased or living donor transplantation or graft failure. RESULTS: Of 373,365 patients, 11% had an ETD≥50 miles. Traveling excess distance was more likely among patients who were of non-Black race or those whose nearest transplant center had lower annual living donor transplant volume. At an ETD of 50 miles, we observed a lower likelihood of deceased donor transplantation (subhazard ratio [SHR], 0.85; 95% confidence interval [95% CI], 0.84 to 0.87) but higher likelihood of living donor transplantation (SHR, 1.14; 95% CI, 1.12 to 1.16) compared with those who received care at their nearest center. ETD was weakly associated with higher risk of graft failure. CONCLUSIONS: Patients who travel excess distances for transplant care have better access to living donor but not deceased donor transplantation and slightly higher risk of graft failure. Traveling excess distances is not clearly associated with better outcomes, especially if living donors are unavailable.

2.
Liver Transpl ; 2021 Feb 09.
Artigo em Inglês | MEDLINE | ID: mdl-33561897

RESUMO

The authors of Outcomes in living donor compared to deceased donor primary liver transplant in lower acuity MELD score < 30 present an analysis comparing outcomes based on graft type (1) . This type of analysis is challenging for a number of reasons, so the authors should be commended for their efforts. The finding of suboptimal outcome after left lobe LDLT in recipients with ascites is an important finding.

3.
Transplantation ; 2020 Jun 22.
Artigo em Inglês | MEDLINE | ID: mdl-33347261

RESUMO

BACKGROUND: The use of living donor liver transplantation (LDLT) for primary liver transplant (LT) may quell concerns about allocating deceased donor organs if the need for re-transplantation (re-LT) arises because the primary LT did not draw from the limited organ pool. However, outcomes of re-LT after LDLT are poorly studied. The purpose of this study was to analyze the Adult to Adult Living Donor Liver Transplantation Study (A2ALL) data to report outcomes of re-LT after LDLT, with a focus on long-term survival after re-LT. METHODS: A retrospective review of A2ALL data collected between 1998-2014 was performed. Patients were excluded if they received a deceased donor liver transplant. Demographic data, post-operative outcomes and complications, graft and patient survival, and predictors of re-LT and patient survival were assessed. RESULTS: Of the 1065 patients who underwent LDLT during the study time period, 110 recipients (10.3%) required re-LT. In multivariable analyses, HCV, longer LOS at LDLT, HAT, biliary stricture, infection, and disease recurrence were associated with an increased risk of re-LT. Patient survival among re-LT patients was significantly inferior to those who underwent primary transplant only at 1 (86 vs. 92%), 5 (64 vs. 82%), and 10 years (44 vs. 68%). CONCLUSIONS: Approximately 10% of A2ALL patients who underwent primary LDLT required re-LT. Compared with patients who underwent primary LT, survival among re-LT recipients was worse at 1, 5, and 10 years after LT, and re-LT was associated with a significantly increased risk of death in MV modeling (HR 2.29, p<0.001).

4.
PLoS One ; 15(11): e0242784, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33253253

RESUMO

High body mass index is a known barrier to access to kidney transplantation in patients with end-stage kidney disease. The extent to which weight and weight changes affect access to transplantation among obese candidates differentially by race/ethnicity has received little attention. We included 10 221 obese patients waitlisted for kidney transplantation prior to end-stage kidney disease onset between 1995-2015. We used multinomial logistic regression models to examine the association between race/ethnicity and annualized change in body mass index (defined as stable [-2 to 2 kg/m2/year], loss [>2 kg/m2/year] or gain [>2 kg/m2/year]). We then used Fine-Gray models to examine the association between weight changes and access to living or deceased donor transplantation by race/ethnicity, accounting for the competing risk of death. Overall, 29% of the cohort lost weight and 7% gained weight; 46% received a transplant. Non-Hispanic blacks had a 24% (95% CI 1.12-1.38) higher odds of weight loss and 22% lower odds of weight gain (95% CI 0.64-0.95) compared with non-Hispanic whites. Hispanics did not differ from whites in their odds of weight loss or weight gain. Overall, weight gain was associated with lower access to transplantation (HR 0.88 [95% CI 0.79-0.99]) compared with maintenance of stable weight, but weight loss was not associated with better access to transplantation (HR 0.96 [95% CI 0.90-1.02]), although this relation differed by baseline body mass index and for recipients of living versus deceased donor organs. For example, weight loss was associated with improved access to living donor transplantation (HR 1.24 [95% CI 1.07-1.44]) in whites but not in blacks or Hispanics. In a cohort of obese patients waitlisted before dialysis, blacks were more likely to lose weight and less likely to gain weight compared with whites. Weight loss was only associated with improved access to living donor transplantation among whites. Further studies are needed to understand the reasons for the observed associations.

5.
Transplant Direct ; 6(10): e602, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-33134482

RESUMO

Rates of kidney transplantation vary substantially across dialysis facilities in the United States. Whether distance between the dialysis facility and transplant center associates with variations in transplantation rates has not been examined. Methods: We performed a retrospective study of adults treated with dialysis between 2005 and 2015, according to the US Renal Data System. We examined the association between distance from dialysis facility to transplant center and time to kidney transplantation (primary outcome) and waitlist registration (secondary outcome) using Fine-Gray models. We also performed sensitivity analyses using the distance from each patient's dialysis facility to the nearest transplant center as the predictor so that patients who were never registered on the waitlist (and therefore would not have a transplant center) could be included. Results: In total, 178 885 waitlisted patients were included for our primary analysis. As distance between dialysis facility and transplant center increased, lower hazard of transplantation (subhazard ratio [HR], 0.92; 95% confidence interval [CI], 0.91-0.94, if distance was 10 to <50 miles; sub-HR, 0.90; 95% CI, 0.88-0.92, if distance ≥50 miles compared with <10 miles) was noted. We also found a weak association between longer distance and hazard of waitlist registration (sub-HR, 0.96; 95% CI, 0.94-0.97, if distance was ≥50 miles versus <10 miles). Findings were similar in sensitivity analyses using distance between dialysis facility and the nearest transplant center (N = 1 149 721). Conclusions: Patients receiving dialysis in facilities located further away from transplant centers have lower hazard of kidney transplantation. Developing strategies to address barriers to transplantation in patients receiving dialysis at facilities located far away from a transplant center may help improve disparities in transplantation rates.

6.
Liver Transpl ; 2020 May 17.
Artigo em Inglês | MEDLINE | ID: mdl-32419266

RESUMO

Declining a liver offer during organ procurement likely increases the risk of discard, but specifics around late reallocation remain obscure. This voluntarily submitted, prospectively collected data describes late declines and the ultimate disposition of 893 livers. Once a liver suffered an intraoperative decline, only 49% of recovered livers were transplanted. Livers declined ≥80 minutes prior to cross clamp were transplanted 80% of the time, versus livers declined ≥80 minutes after cross clamp that were transplanted 45% of the time. The final disposition of these livers was into a pre-determined backup patient (51%) or required an out of sequence expedited allocation (42%). Pre-recovery imaging and pre-recovery biopsy did not influence the ability to reallocate a liver, and livers from donors after circulatory death are rarely successfully reallocated. CONCLUSION: this study begins to shed light on this seemingly common practice. Eighty-five percent of centers had an intraoperative decline, but 4% of centers accounted for 25% of the declines. Organ procurement organizations (OPO) often enter expedited liver allocation, and instituting a cross clamp delay to allow for reallocation may influence the disposition of these liver grafts. Expedited allocation was more time consuming than allocation into a pre-determined back up. Although a certain number of intraoperative declines probably suggests a healthy amount of donor selection aggressiveness at the time of the initial organ offer, the 47% risk of discard of livers declined intraoperatively suggests UNOS should consider systematically collecting data about intraoperative declines so we can learn more about this event which influences organ utilization.

7.
Int J Surg ; 82S: 36-43, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32389812

RESUMO

The utilization of donation after circulatory death (DCD) livers has been growing over the last decade. In large-volume centers, survival outcomes have improved and are comparable to outcomes with brain death donor (DBD) liver transplantation (LT). The relatively concentrated success with DCD LT demonstrated by high-volume transplant centers has rekindled international enthusiasm. The combination of increasing expertise in DCD LT and ongoing shortage in transplantable organs has promoted expansion of the DCD donor pool with regards to donor age, body mass index and donor warm ischemia time. In this review, we focused on the practice patterns in DCD liver graft utilization in the last decade, along with the possibilities for further expansion of DCD liver graft utilization and new technologies, such as machine perfusion.

8.
Transplantation ; 104(11): e308-e316, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32467477

RESUMO

BACKGROUND: Acute kidney injury (AKI) after liver transplantation is associated with increased morbidity and mortality. It remains controversial whether the choice of vena cava reconstruction technique impacts AKI. METHODS: This is a single-center retrospective cohort of 897 liver transplants performed between June 2009 and September 2018 using either the vena cava preserving piggyback technique or caval replacement technique without veno-venous bypass or shunts. The association between vena cava reconstruction technique and stage of postoperative AKI was assessed using multivariable ordinal logistic regression. Causal mediation analysis was used to evaluate warm ischemia time as a potential mediator of this association. RESULTS: The incidence of AKI (AKI stage ≥2) within 48 h after transplant was lower in the piggyback group (40.3%) compared to the caval replacement group (51.8%, P < 0.001). Piggyback technique was associated with a reduced risk of developing a higher stage of postoperative AKI (odds ratio, 0.49; 95% confidence interval, 0.37-0.65, P < 0.001). Warm ischemia time was shorter in the piggyback group and identified as potential mediator of this effect. There was no difference in renal function (estimated glomerular filtration rate and the number of patients alive without dialysis) 1 y after transplant. CONCLUSIONS: Piggyback technique, compared with caval replacement, was associated with a reduced incidence of AKI after liver transplantation. There was no difference in long-term renal outcomes between the 2 groups.

9.
Am J Transplant ; 20(8): 2091-2100, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-31994295

RESUMO

The approach to transplantation in human immunodeficiency virus (HIV)-positive patients has been conservative due to fear of exacerbating an immunocompromised condition. As a result, HIV-positive patients with diabetes were initially excluded from beta cell replacement therapy. Early reports of pancreas transplant in patients with HIV described high rates of early graft loss with limited follow-up. We report long-term follow-up of islet or pancreas transplantation in HIV-positive type 1 diabetic patients who received a kidney transplant concurrently or had previously undergone kidney transplantation. Although 4 patients developed polyoma viremia, highly active antiretroviral therapy and adequate infectious prophylaxis were successful in providing protection until CD4+ counts recovered. Coordination with HIV providers is critical to reduce the risk of rejection by minimizing drug-drug interactions. Also, protocols for prophylaxis of opportunistic infections and strategies for monitoring and treating BK viremia are important given the degree of immunosuppression required. This series demonstrates that type 1 diabetic patients with well-controlled HIV and renal failure can be appropriate candidates for beta cell replacement, with a low rate of infectious complications, early graft loss, and rejection, so excellent long-term graft survival is possible. Additionally, patients with HIV and cardiovascular contraindications can undergo islet infusion.

10.
Transplantation ; 104(7): 1437-1444, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-31568216

RESUMO

BACKGROUND: Non-Hispanic black (NHB) and Hispanic patients have lower access to kidney transplantation compared to non-Hispanic whites (NHWs). We examined whether differences in the prevalence of comorbidities that affect eligibility for transplant contribute to disparities in receipt of transplantation. METHODS: We performed a retrospective study of 986 019 adults who started dialysis between 2005 and 2014, according to the United States Renal Data System. We compared prevalence of comorbidities that could influence transplant eligibility by race/ethnicity. We examined time to first transplant by race/ethnicity in this overall cohort and in a very healthy sub-cohort without conditions that could be contraindications to transplantation. RESULTS: During 2.3 years of mean follow-up, 64 892 transplants occurred. NHBs and Hispanics had a lower prevalence of medical barriers to transplantation at the time of dialysis initiation than NHWs, including age >70 years (26% in NHB versus 47% in NHW) and malignancy (4% in Hispanics versus 10% in NHWs). Access to transplant was 65% lower (95% CI, 0.33-0.37) in NHBs and 43% lower (95% CI, 0.54-0.62) in Hispanics (versus NHWs) in the first year after end-stage renal disease, but by Year 4, access to transplantation was not statistically significantly different between Hispanics or NHBs (versus NHWs). In our very healthy cohort, racial and ethnic disparities in access to transplantation persisted up to Year 5 in NHBs and Year 4 in Hispanics after end-stage renal disease onset. CONCLUSIONS: Differences in medical eligibility do not appear to explain racial/ethnic disparities in receipt of kidney transplantation and may mask the actual magnitude of the inequities that are present.


Assuntos
Definição da Elegibilidade/estatística & dados numéricos , Acesso aos Serviços de Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/estatística & dados numéricos , Falência Renal Crônica/terapia , Transplante de Rim/estatística & dados numéricos , Adulto , Afro-Americanos/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Definição da Elegibilidade/normas , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Feminino , Seguimentos , Acesso aos Serviços de Saúde/normas , Hispano-Americanos/estatística & dados numéricos , Humanos , Falência Renal Crônica/epidemiologia , Transplante de Rim/normas , Masculino , Pessoa de Meia-Idade , Prevalência , Diálise Renal/estatística & dados numéricos , Estudos Retrospectivos , Tempo para o Tratamento/estatística & dados numéricos , Estados Unidos/epidemiologia
11.
Transplantation ; 104(6): 1239-1245, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-31449187

RESUMO

BACKGROUND: It is estimated that 19.2% of kidneys exported for candidates with >98% calculated panel reactive antibodies are transplanted into unintended recipients, most commonly due to positive physical crossmatch (PXM). We describe the application of a virtual crossmatch (VXM) that has resulted in a very low rate of transplantation into unintended recipients. METHODS: We performed a retrospective review of kidneys imported to our center to assess the reasons driving late reallocation based on the type of pretransplant crossmatch used for the intended recipient. RESULTS: From December 2014 to October 2017, 254 kidneys were imported based on our assessment of a VXM. Of these, 215 (84.6%) were transplanted without a pretransplant PXM. The remaining 39 (15.4%) recipients required a PXM on admission using a new sample because they did not have an HLA antibody test within the preceding 3 months or because they had a recent blood transfusion. A total of 93% of the imported kidneys were transplanted into intended recipients. There were 18 late reallocations: 9 (3.5%) due to identification of a new recipient medical problem upon admission, 5 (2%) due to suboptimal organ quality on arrival, and only 4 (1.6%) due to a positive PXM or HLA antibody concern. A total of 42% of the recipients of imported kidneys had a 100% calculated panel reactive antibodies. There were no hyperacute rejections and very infrequent acute rejection in the first year suggesting no evidence for immunologic memory response. CONCLUSIONS: Seamless sharing is within reach, even when kidneys are shipped long distances for highly sensitized recipients. Late reallocations can be almost entirely avoided with a strategy that relies heavily on VXM.


Assuntos
Seleção do Doador/métodos , Rejeição de Enxerto/prevenção & controle , Teste de Histocompatibilidade/métodos , Transplante de Rim/métodos , Aloenxertos/imunologia , Aloenxertos/provisão & distribução , Seleção do Doador/organização & administração , Feminino , Citometria de Fluxo/métodos , Citometria de Fluxo/estatística & dados numéricos , Rejeição de Enxerto/imunologia , Antígenos HLA/imunologia , Teste de Histocompatibilidade/estatística & dados numéricos , Humanos , Memória Imunológica , Isoanticorpos/imunologia , Rim/imunologia , Transplante de Rim/efeitos adversos , Masculino , Estudos Retrospectivos , Doadores de Tecidos , Transplantados/estatística & dados numéricos
12.
Transplantation ; 104(2): 285-292, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31107823

RESUMO

BACKGROUND: Alcoholic liver disease (ALD) accounts for 15%-30% of transplants performed in the United States and Europe; however, the data on living donor liver transplantation (LDLT) for ALD remain sparse. The purpose of this study was to examine the outcomes following LDLT for ALD using data from the adult-to-adult living donor liver transplantation (A2ALL) study, which represents the largest Western experience with adult-to-adult LDLT. METHODS: A retrospective review of A2ALL data collected between 1998 and 2014 was performed. Patients were excluded if they received a deceased donor liver transplant. Demographic data, postoperative outcomes and complications, graft and patient survival, and predictors of graft and patient survival were assessed. RESULTS: Of the 1065 patients who underwent LDLT during the study time period, 168 (15.8%) were transplanted for a diagnosis of ALD. Comparing patients who underwent transplant for ALD with those who were transplanted for other etiologies of liver disease, there was no significant difference in graft survival at 1 (88% versus 84%), 5 (76% versus 74%), or 10 years following transplant (55% versus 61%, P = 0.29). Similarly, there was no difference in patient survival at 1 (94% versus 91%), 5 (83% versus 79%), or 10 years following transplant (61% versus 66%, P = 0.32). CONCLUSIONS: LDLT for ALD results in excellent 1-, 5-, and 10-year graft and patient survival. Patients with ALD and impaired renal function have a higher risk of graft loss and death. These findings support the notion that early LDLT for patients with ALD may help optimize outcomes.


Assuntos
Hepatopatias Alcoólicas/complicações , Falência Hepática/cirurgia , Transplante de Fígado/métodos , Doadores Vivos/estatística & dados numéricos , Medição de Risco/métodos , Adulto , Seguimentos , Sobrevivência de Enxerto , Humanos , Incidência , Hepatopatias Alcoólicas/cirurgia , Falência Hepática/epidemiologia , Falência Hepática/etiologia , Pessoa de Meia-Idade , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Fatores de Tempo , Estados Unidos/epidemiologia
13.
Clin Liver Dis (Hoboken) ; 14(5): 180-182, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31879560
14.
Clin Transplant ; 33(4): e13505, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30791137

RESUMO

Transplant surgery is a predominantly male specialty with high burnout rates. There are currently limited data regarding how programs can attract a diverse applicant pool to the field of transplant surgery. This study evaluated the effect of an Organ Procurement Experience elective on preclinical medical students' perceptions of transplant surgery in a prospective, longitudinal study. Preclinical medical students were anonymously surveyed before and after attending a deceased donor organ procurement. Questions focused on the following themes: Personal Beliefs, Personal/Professional Life, Diversity, and Gender Equality. Responses were rated on a five-point Likert scale. Ninety-nine and 45 students completed pre/post-procurement survey, respectively. Post-procurement responses demonstrated increased education about the field (2.1/5 vs 3.89/5, P < 0.001) and perceptions of the personalities and collegiality between surgeons (3.06/5 vs 3.73/5, P = 0.005). Post-procurement, women were less likely to feel that female transplant surgeons are treated differently (3.98/5 vs. 3.45/5, P < 0.017). Post-procurement, 19% agreed that transplant surgeons have a high quality of life. One percent of respondents felt the current gender distribution in transplant surgery is satisfactory. The Organ Procurement Experience significantly improved preclinical students' perceptions of the field. However, there remains a strong concern about quality of life and gender diversity within the field.


Assuntos
Atitude do Pessoal de Saúde , Cirurgia Geral/educação , Conhecimentos, Atitudes e Prática em Saúde , Transplante de Órgãos/métodos , Qualidade de Vida , Estudantes de Medicina/psicologia , Obtenção de Tecidos e Órgãos/organização & administração , Adulto , Educação de Graduação em Medicina/métodos , Feminino , Seguimentos , Humanos , Estudos Longitudinais , Masculino , Estudos Prospectivos , Inquéritos e Questionários , Doadores de Tecidos , Adulto Jovem
15.
JAMA Dermatol ; 155(3): 307-314, 2019 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-30673077

RESUMO

Importance: Risk factors for the development of skin cancer after solid-organ transplant can inform clinical care, but data on these risk factors are limited. Objective: To study the association between HLA antigen mismatch and skin cancer incidence after solid-organ transplant. Design, Setting, and Participants: This retrospective cohort study is a secondary analysis of the multicenter Transplant Skin Cancer Network study of 10 649 adults who underwent a primary solid-organ transplant between January 1, 2003, and December 31, 2003, or between January 1, 2008, and December 31, 2008. These participants were identified through the Scientific Registry of Transplant Recipients standard analysis files, which contain data collected mostly by the Organ Procurement and Transplantation Network. Participants were matched to skin cancer outcomes by medical record review. This study was conducted from August 1, 2016, to July 31, 2017. Main Outcomes and Measures: The primary outcome was time to diagnosis of posttransplant skin cancer, including squamous cell carcinoma, melanoma, and Merkel cell carcinoma. The HLA antigen mismatch was calculated based on the 2016 Organ Procurement and Transplantation Network guidelines. Risk of skin cancer was analyzed using a multivariate Cox proportional hazards regression model. Results: In total, 10 649 organ transplant recipients (6776 men [63.6%], with a mean [SD] age of 51 [12] years) contributed 59 923 years of follow-up. For each additional mismatched allele, a 7% to 8% reduction in skin cancer risk was found (adjusted hazard ratio [HR], 0.93; 95% CI, 0.87-0.99; P = .01). Subgroup analysis found the protective effect of HLA antigen mismatch to be statistically significant in lung (adjusted HR, 0.70; 95% CI, 0.56-0.87; P = .001) and heart (adjusted HR, 0.75; 95% CI, 0.60-0.93; P = .008) transplant recipients but not for recipients of liver, kidney, or pancreas. The degree of HLA-DR mismatch, but not HLA-A or HLA-B mismatch, was the most statistically significant for skin cancer risk (adjusted HR, 0.85; 95% CI, 0.74-0.97; P = .01). Conclusions and Relevance: The HLA antigen mismatch appears to be associated with reductions in the risk of skin cancer after solid-organ transplant among heart and lung transplant recipients; this finding suggests that HLA antigen mismatch activates the tumor surveillance mechanisms that protect against skin cancer in transplant recipients and that skin cancer risk may be higher in patients who received a well-matched organ.


Assuntos
Antígenos HLA/imunologia , Histocompatibilidade/imunologia , Transplante de Órgãos/efeitos adversos , Neoplasias Cutâneas/etiologia , Adulto , Distribuição por Idade , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Transplante de Órgãos/métodos , Valor Preditivo dos Testes , Prevalência , Prognóstico , Modelos de Riscos Proporcionais , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Distribuição por Sexo , Neoplasias Cutâneas/epidemiologia , Neoplasias Cutâneas/patologia , Transplantados , Imunologia de Transplantes
17.
Transplantation ; 102(11): e466-e471, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30048397

RESUMO

BACKGROUND: In liver transplantation, both cold and warm ischemia times are known to impact early graft function. The extraction time is a period during the initial phase of organ cooling which occurs during deceased donor procurement. During this time, the organ is at risk of suboptimal cooling. Whether donor extraction time, the time from donor aortic cross-clamp to removal of the donor organ from the body cavity has an effect on early graft function is not known. METHODS: We investigated the effect of donor extraction time on early graft function in 292 recipients of liver grafts procured locally and transplanted at our center between June 2012 and December 2016. Early graft function was assessed using the model of early allograft function score in a multivariable regression model including donor extraction time, cold ischemia time, warm ischemia time, donor risk index, and terminal donor sodium. RESULTS: Donor extraction time had an independent effect on early graft function measured by the model of early allograft function score (coefficient, 0.021; 95% confidence interval, 0.007-0.035; P < 0.01; for each minute increase of donor extraction time). Besides donor extraction time, cold ischemia time, warm ischemia time, and donor risk index had a significant effect on early graft function. CONCLUSIONS: We demonstrate an independent effect of donor extraction time on graft function after liver transplantation. Efforts to minimize donor extraction time could improve early graft function in liver transplantation.


Assuntos
Isquemia Fria , Hepatectomia , Transplante de Fígado/métodos , Duração da Cirurgia , Doadores de Tecidos , Coleta de Tecidos e Órgãos/métodos , Isquemia Quente , Adulto , Isquemia Fria/efeitos adversos , Técnicas de Apoio para a Decisão , Feminino , Sobrevivência de Enxerto , Hepatectomia/efeitos adversos , Humanos , Testes de Função Hepática , Transplante de Fígado/efeitos adversos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Disfunção Primária do Enxerto/diagnóstico , Disfunção Primária do Enxerto/etiologia , Medição de Risco , Fatores de Risco , Fatores de Tempo , Coleta de Tecidos e Órgãos/efeitos adversos , Resultado do Tratamento , Isquemia Quente/efeitos adversos
18.
Clin Transplant ; 32(5): e13238, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29526051

RESUMO

BACKGROUND: During kidney transplantation, intraoperative fluid management can affect post-transplant graft function. It is unclear whether or not central venous pressure (CVP) monitoring is required to guide fluid therapy during kidney transplantation. METHODS: We compared post-transplant graft function in recipients of living donor kidney transplants between August 2006 and March 2009 based on the use or absence of intraoperative CVP monitoring. Graft function, assessed using the creatinine reduction ratio on postoperative day 2 (CCR2), was evaluated by multivariable linear regression analysis and in a propensity-matched cohort. RESULTS: Two hundred and ninety patients were included in the analysis. Central venous pressure was monitored in 84 patients (29%). There was no difference in post-transplant graft function, as measured by CCR2, between patients with and without CVP monitoring in both unadjusted and multivariable-adjusted analyses. There were also no statistically significant differences in CCR2, delayed graft function, or 3-month renal function between those monitored with CVP and those without, in the propensity-matched cohort. CONCLUSIONS: In this single-center analysis, immediate post-transplant renal function was not associated with the use of intraoperative CVP monitoring.


Assuntos
Pressão Venosa Central/fisiologia , Função Retardada do Enxerto/diagnóstico , Sobrevivência de Enxerto , Falência Renal Crônica/cirurgia , Transplante de Rim/métodos , Doadores Vivos , Monitorização Fisiológica , Estudos de Coortes , Feminino , Seguimentos , Taxa de Filtração Glomerular , Humanos , Rim/fisiologia , Testes de Função Renal , Masculino , Pessoa de Meia-Idade , Assistência Perioperatória , Prognóstico , Pontuação de Propensão , Fatores de Risco , Transplantados
19.
Transplantation ; 102(5): e229-e235, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29470352

RESUMO

BACKGROUND: Renal failure is common among patients undergoing liver transplantation. Liver allocation based on the model for end-stage liver disease score has increased the number of recipients who require perioperative renal replacement therapy (RRT). Although RRT can be continued intraoperatively, the risks and benefits of intraoperative RRT are not well defined. The aim of this study is to report the intraoperative management of patients with pretransplant renal failure at a transplant center with extremely infrequent utilization of intraoperative RRT. MATERIALS AND METHODS: We performed a retrospective analysis of all adult patients undergoing orthotopic liver or simultaneous liver-kidney (SLK) transplantation between June 2009 and December 2015. Patients were divided into 2 groups based on their need for pretransplant RRT. RESULTS: A total of 785 patients underwent liver or SLK transplant during the study period. One hundred and seventy-four patients (22.2%) required preoperative dialysis. Only 2 patients required intraoperative RRT. There was no difference in the incidence of acidosis or hyperkalemia between patients who required preoperative dialysis and those who did not. CONCLUSIONS: We describe the successful management of patients undergoing liver or SLK transplantation almost entirely without the need for intraoperative RRT.


Assuntos
Doença Hepática Terminal/cirurgia , Cuidados Intraoperatórios/métodos , Transplante de Rim/métodos , Transplante de Fígado/métodos , Diálise Renal , Insuficiência Renal/terapia , Acidose/etiologia , Doença Hepática Terminal/complicações , Doença Hepática Terminal/diagnóstico , Doença Hepática Terminal/fisiopatologia , Feminino , Humanos , Hiperpotassemia/etiologia , Cuidados Intraoperatórios/efeitos adversos , Transplante de Rim/efeitos adversos , Transplante de Fígado/efeitos adversos , Masculino , Pessoa de Meia-Idade , Diálise Renal/efeitos adversos , Insuficiência Renal/complicações , Insuficiência Renal/diagnóstico , Insuficiência Renal/fisiopatologia , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento
20.
Ann Surg ; 265(5): 1009-1015, 2017 05.
Artigo em Inglês | MEDLINE | ID: mdl-27257738

RESUMO

OBJECTIVE: The primary aim of this study is to evaluate the role of split liver transplantation (SLT) in a combined pediatric and adult liver transplant center. The secondary aim is to reflect on our clinical practice and discuss strategies to build a successful split program using an "intention to split policy." BACKGROUND: SLT is an established procedure to expand the organ pool and reduce wait list mortality; however, technical and logistic issues are limiting factors. METHODS: Prospectively collected data and outcomes of SLT procedures performed between November 1992 and March 2014 were analyzed retrospectively. To assess the effect of standardization and learning curve, the experience was divided into 2 time periods. RESULTS: Out of 3449 liver transplant procedures performed, 516(15%) were SLT. The recipients included 266 children (290 grafts; 56%) and 212 adults (226 grafts; 44%). The median donor age was 25(7-63 years) and the median weight was 70(22-111 kg). The cold and warm ischemic times improved significantly during the second period (SP) (2001-2014). With experience, there was a significant reduction in the biliary complications for both grafts. The introduction of "intention to split policy" resulted in a significantly increased usage of SLT. There was no mortality on the pediatric wait list for last 4 years. Over the last decade 65% of our pediatric transplants were SLT. The overall 1-, 5-, 10-year patient and graft survival of left graft recipients was 91%, 90%, and 89% and 90%, 87%, and 86%. For right grafts it was 87%, 82%, and 81% and 82%, 81%, and 79%, respectively. CONCLUSIONS: SLT is an effective surgical strategy to meet the demands in a combined adult and pediatric transplant center. Good outcomes can be achieved with a standardized technique.


Assuntos
Centros Médicos Acadêmicos , Transplante de Fígado/métodos , Formulação de Políticas , Obtenção de Tecidos e Órgãos/organização & administração , Listas de Espera , Adulto , Fatores Etários , Criança , Pré-Escolar , Estudos de Coortes , Bases de Dados Factuais , Rejeição de Enxerto , Sobrevivência de Enxerto , Política de Saúde , Humanos , Estimativa de Kaplan-Meier , Transplante de Fígado/mortalidade , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Taxa de Sobrevida , Doadores de Tecidos , Resultado do Tratamento , Reino Unido
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA
...