Can reporting more lead to less? The role of metrics in assessing liver transplant program performance.

Appropriate metrics for performance analysis is an active topic of debate within the transplant community. This study explores current proposals on metric expansion as well as potential metrics and prospective collaborations that have not received widespread discussion within the transplant community. The premature introduction of additional, nonvalidated metrics risks behaviors that may undermine donor utilization and patient access to transplantation.

Accepting Hearts From Hepatitis C-Positive Donor: Can We Expand the Donor Pool?

BACKGROUND: Until recently, transplantation from hepatitis C-positive donors was relatively contraindicated as eradication of active hepatitis C previously required an interferon-based regimen that has been associated with rejection in solid organ transplantation. New interferon-free treatment regimens for hepatitis C have fewer adverse events and higher cure rates than interferon-based regimens. Interferon-free regimens have been shown to be safe in the liver transplantation literature, but little is known about the safety and efficacy of treatment in heart transplantation. CASE DESCRIPTION AND DISCUSSION: Here we report a case of successful eradication of hepatitis C with a non-interferon-based regimen using ledipasvir-sofosbuvir following combined orthotopic heart and liver transplantation. Based on the prevalence of hepatitis C in the general population, inclusion of hepatitis C-positive donors for heart transplantation can expand this component of the donor pool 3- to 6-fold. CONCLUSIONS: In carefully selected patients and recipients, inclusion of hepatitis C-positive donors may allow for expansion of the donor pool.

The impact of adult-to-adult living donor liver transplantation on transplant center outcomes reporting.

BACKGROUND: The Scientific Registry of Transplant Recipients (SRTR) has released a 5-tier performance ranking system based upon results of deceased-donor and living-donor liver transplantation. MATERIALS AND METHODS: An analysis of Spring 2017 SRTR Program Specific Reports for outcomes of adult living-donor and deceased-donor liver transplantation. RESULTS: Utilizing the current SRTR performance algorithm, living-donor liver transplant results may disproportionately affect transplant center performance ranking. CONCLUSION: Improvements in SRTR performance ranking including transparency in outcomes calculation, a calculating tool for transplant centers, and the potential reporting of living-donor outcomes as a separate report are necessary.

Systematic Sampling of the Female Reproductive System for Molecular Characterization.

As part of the National Institutes of Health Human BioMolecular Atlas Program to develop a global platform to map the 37 trillion cells in the adult human body, we are generating a comprehensive molecular characterization of the female reproductive system. Data gathered from multiple single-cell/single-nucleus and spatial molecular assays will be used to build a 3D molecular atlas. Herein, we describe our multistep protocol, beginning with an optimized organ procurement workflow that maintains functional characteristics of the uterus, ovaries, and fallopian tubes by perfusing these organs with preservation solution. We have also developed a structured tissue sampling procedure that retains information on individual-level anatomic, physiologic, and individual diversity of the female reproductive system, toward full exploration of the function and structure of female reproductive cells. © 2023 Wiley Periodicals LLC. Basic Protocol 1: Preparation and preservation of the female reproductive system (ovaries, fallopian tubes, and uterus) prior to procurement Basic Protocol 2: Removal of the female reproductive system en bloc Basic Protocol 3: Postsurgical dissection of ovaries Basic Protocol 4: Postsurgical dissection of fallopian tubes Basic Protocol 5: Postsurgical dissection of cervix Basic Protocol 6: Postsurgical dissection of uterine body Support Protocol 1: OCT-embedded tissue protocol Support Protocol 2: Tissue fixation protocol Support Protocol 3: Snap-frozen tissue protocol Basic Protocol 7: Tissue slice preparation for Visium analysis Support Protocol 4: Hematoxylin and eosin staining for 10X Visium imaging Basic Protocol 8: Manual tissue dissociation for Multiome analysis Basic Protocol 9: Tissue dissociation for Multiome analysis using S2 Singulator.

Coconut power: a sustainable approach for the removal of Cr6+ ions using a new coconut-based polyurethane foam/activated carbon composite in a fixed-bed column.

To attain efficient removal of hexavalent chromium (Cr6+) from aqueous solutions, a novel polyurethane foam-activated carbon (PUAC) adsorbent composite was developed. The composite material was synthesized by the binding of coconut shell-based activated carbon (AC) onto a coconut oil-based polyurethane matrix. To thoroughly characterize the physicochemical properties of the newly developed material, various analytical techniques including FTIR spectroscopy, SEM, XRD, BET, and TGA analyses were conducted. The removal efficiency of the PUAC composite in removing Cr6+ ions from aqueous solutions was evaluated through column experiments with the highest adsorption capacity of 28.41 mg g-1 while taking into account variables such as bed height, flow rate, initial Cr6+ ion concentration, and pH. Experimental data were fitted using Thomas, Yoon-Nelson, and Adams-Bohart models to predict the column profiles and the results demonstrate high breakthrough and exhaustion time dependence on these variables. Among the obtained R2 values of the models, a better fit was observed using the Thomas and Yoon-Nelson models, indicating their ability to effectively predict the adsorption of Cr6+ ions in a fixed bed column. Significantly, the exhausted adsorbent can be conveniently regenerated without any noteworthy loss of adsorption capability. Based on these findings, it can be concluded that this new PUAC composite material holds significant promise as a potent sorbent for wastewater treatment backed by its excellent performance, cost-effectiveness, biodegradability, and outstanding reusability.

Digital imaging of extended criteria donor livers to facilitate placement and utilization.

The disparity between organ supply and demand has necessitated more aggressive use of livers from extended criteria donors. Organ sharing between donor service areas and transplant centers in other regions is common. Confidence in the graft quality is greatly improved with a digital image taken in conjunction with the recovery surgeon's report and biopsy data. Three cases in which digital images of various levels of quality allowed the recipient's surgery to proceed, minimized the cold ischemia time, and yielded excellent outcomes are described. Another case in which a picture was not available and the liver was discarded after importation is also presented for comparison.

Hospital-Acquired Conditions after Liver Transplantation.

Hospital-acquired conditions (HACs) are used to define hospital performance measures. Patient comorbidity may influence HAC development. The National Inpatient Sample database was used to investigate HACs for the patients who underwent liver transplantation. Multivariate analysis was used to identify HAC risk factors. We found a total of 13,816 patients who underwent liver transplantation during 2002-2014. Of these, 330 (2.4%) had a report of HACs. Most frequent HACs were vascular catheter-associated infection [220 (1.6%)], falls and trauma [66 (0.5%), catheter-associated UTI [24 (0.2%)], and pressure ulcer stage III/IV [22 (0.2%)]. Factors correlating with HACs included extreme loss function (AOR: 52.13, P < 0.01) and major loss function (AOR: 8.11, P = 0.04), hepatopulmonary syndrome (AOR: 3.39, P = 0.02), portal hypertension (AOR: 1.49, P = 0.02), and hospitalization length of stay before transplant (AOR: 1.01, P < 0.01). The rate of HACs for liver transplantation is three times higher than the reported overall rate of HACs for GI procedures. Multiple patient factors are associated with HACs, and HACs may not be a reliable measure to evaluate hospital performance. Vascular catheter-associated infection is the most common HAC after liver transplantation.

Survival of Clostridium perfringens sepsis in a liver transplant recipient.

Clostridium perfringens sepsis following orthotopic liver transplantation (OLT) is a rare but reported complication that historically results in mortality or emergent retransplantation (ReTx). Complications from C. perfringens emphysematous gastritis have contributed to the death of a healthy live liver donor as well. Herein, we describe the first documented survivor of C. perfringens sepsis following OLT managed without laparotomy or emergent ReTx.

HCV infection and cryptogenic cirrhosis are risk factors for hepatocellular carcinoma among Latinos in New York City.

Latinos in the US experience a 60% higher death rate from primary hepatocellular carcinoma (HCC) when compared to Non-Latinos. The goal of this study was to examine risk factors that are associated with ethnic disparities among HCC patients seen at the transplant center of a metropolitan medical center in New York City. We compared HCC risk factors in 140 Non-Latino and 55 Latino patients that presented with HCC from 1995 to 2003. Surnames were used to define Latino and Non-Latino HCC patients in a retrospective analysis. Latino and Non-Latino HCC patients did not vary by gender or age at presentation (mean Latino age 60.8). Latino HCC patients had a higher frequency of presentation with advanced disease, defined as patients with unresectable HCC, than non Latino HCC patients (Latino 52.7%; 95% CI 39.1-66.3 vs. Non-Latino vs. 36.4%; 95% CI 28.3-44.4). Latinos were more likely than Non Latinos to have underlying HCV (34.5 vs. 22.1%, P < .0001; adjusted odds ratio [Siegel, 2008 #564], 3.69; 95% CI, 1.16-11.7) and cryptogenic liver diseases (7.2 vs. 3.5%, P < .0001; OR 8.86; 95% CI, 1.21-65.0) after adjusting for age, gender and alfa-fetoprotein levels. Although more advanced disease may signal delay in access to care or more aggressive disease, HCV infection and cryptogenic cirrhosis at presentation are likely key factors for the greater burden of HCC among Latinos in New York City.

Kidney After Intestinal Transplantation Using Two Different Living Donors: A First Case Report.

We describe a unique case of a 53-year-old woman who underwent a nonrelated living donor kidney transplant 9 years after a previous small bowel transplant from her sister. The patient had suffered from short bowel syndrome secondary to volvulus after undergoing bariatric surgery for morbid obesity. Her entire small bowel had to be resected emergently, but she also developed acute kidney failure at the time. This initial kidney injury associated with long-term exposure to calcineurin-inhibitor medication eventually led to end-stage renal disease. A successful kidney transplant from a different, nonrelated adult donor was performed. Of note, the unrelated kidney donor matched exactly the 2 HLA-A and HLA-B antigens that the recipient had not matched with her sister. We discuss the unique HLA configuration between the patient and her 2 living donors, the absence of posttransplant rejection and posttransplant immunosuppressive therapy. To our knowledge this is the first published report of a successful kidney after a previous bowel transplant using (2 different) living donors.

Donor-to-recipient transmission of factor XII deficiency by orthotopic liver transplantation.

Transmission of congenital clotting factor deficiencies following orthotopic liver transplantation is rare. There has been one reported case of donor-to-recipient transmission of factor XII deficiency in a transplant, and we report the second case.

Real-Time, Intraoperative Doppler/Ultrasound Monitoring of Islet Infusion During Total Pancreatectomy With Islet Autotransplant: A First Report.

Chronic pancreatitis (CP), secondary to a wide variety of etiologies, is a progressive and irreversible disease. Initially, CP is managed with endoscopic interventions, long-term analgesia for its associated chronic abdominal pain syndrome and pancreatic enzyme replacement for exocrine dysfunction. As the disease advances, pancreatic drainage procedures and partial resections are considered, but they leave diseased tissue behind and usually result in short-term relief only. Total pancreatectomy alone is widely viewed as a last resort treatment option because it causes brittle diabetes mellitus. However, total pancreatectomy with islet autotransplantation (TPIAT) can prevent the development of diabetes and cure the chronic pain syndrome. One serious, albeit rare, complication of TPIAT is (partial) portal vein thrombosis. Its incidence is probably about 5%. To prevent the occurrence of portal vein thrombosis, we propose herein, and have successfully performed, continuous real-time Doppler ultrasonography during the islet infusion to study portal vein and intrahepatic flow patterns, as well as changes in Doppler signals. Flow and signal changes may allow for timely adjustment of the infusion rate, before a marked increase in portal vein pressure is noted and decrease the risk of portal vein thrombosis.

Utilization, outcomes, and retransplantation of liver allografts from donation after cardiac death: implications for further expansion of the deceased-donor pool.

OBJECTIVE: Utilization, outcomes, and retransplantation (ReTx) of liver allografts obtained by donation after cardiac death (DCD) are examined to identify mechanisms to optimize donation. SUMMARY AND BACKGROUND DATA: DCD for liver transplantation (LTX) has immediate potential to expand the donor pool but application is limited. METHODS: Retrospective analysis of the Scientific Registry of Transplant Recipients (SRTR) from January 2002 to April 2007 identified 855 DCD and 21,089 donation after brain death (DBD) adult, initial, whole-organ, liver-only LTX. Donor, recipient, and transplant characteristics were compared. Outcome measures were listing for ReTx within 1 year and graft survival determined as death or ReTx. RESULTS: DCD donors were younger (P < 0.001), with fewer African American and non-white race (P < 0.001), and fewer deaths secondary to stroke (P < 0.001). DCD recipients were older (P < 0.001), with lower Model for End-Stage Liver Disease (MELD) scores (P < 0.001), and less likely in intensive care (P = 0.02) or high-urgency status (P < 0.001). DCD allografts were more frequently imported from another allocation region (12% vs. 7%; P < 0.001). Cox regression analysis of time to DCD graft failure demonstrates higher DCD graft failure within the first 180 days (20.5% DCD vs. 11.5% DBD; P < 0.001) with convergence thereafter. DCD listing for ReTx and graft failure progressed continuously over 180 days versus 20 days in DBD. At ReTx, DCD recipients waited longer and received higher risk allografts (P = 0.039) more often from another region. More DCD recipients remain waiting for ReTx with fewer removed for death, clinical deterioration, or improvement. CONCLUSIONS: DCD utilization is impeded by early outcomes and a temporally different failure pattern that limits access to ReTx. Allocation policy that recognizes these limitations and increases access to ReTx is necessary for expansion of this donor population.

Utility of liver allograft biopsy obtained at procurement.

Extended-donor criteria (EDC) liver allografts potentiate the role of procurement biopsy in organ utilization. To expedite allocation, histologic evaluation is routinely performed upon frozen-section (FS) specimens by local pathologists. This descriptive study compares FS reports by local pathologists with permanent-section (PS) evaluation by dedicated hepatopathologists, identifies histologic characteristics underrepresented by FS evaluation, and evaluates the efficacy of a biopsy decision analysis based on organ visualization. Fifty-two liver transplants using EDC allografts evaluated by FS with PS were studied. Pathologic worksheets created by an organ procurement organization were applied in 34 FS. PS analysis included 7 staining procedures for 8 histologic criteria. PS from 56 additional allografts determined not to require donor biopsy were also analyzed. A high correlation was observed between FS and PS. Underestimation of steatosis by FS was associated with allograft dysfunction. Surgical assessment of cholestasis, congestion, and steatosis was accurate whereas inflammation, necrosis, and fibrosis were underestimated in allografts suffering parenchymal injury. In conclusion, the correlation between FS and PS is high, and significant discrepancies are rare. Biopsy is not a prerequisite for EDC utilization but is suggested in hepatitis C, hypernatremia, donation after cardiac death, or multiple EDC indications. Implementation of a universal FS worksheet could standardize histologic reporting and facilitate data collection, allocation, and research.

Transplantation-mediated alloimmune thrombocytopenia: Guidelines for utilization of thrombocytopenic donors.

Transplantation-mediated alloimmune thrombocytopenia (TMAT) is donor-derived thrombocytopenia following solid-organ transplantation. To date, no clear consensus on the appropriateness of organ utilization from cadaver donors with a history of idiopathic thrombocytopenia purpura (ITP) has emerged. Herein is reported a devastating case of TMAT following liver transplantation utilizing an allograft from a donor with ITP that resulted in allograft failure. The literature is reviewed in this context to propose preliminary guidelines regarding utilization of allografts from cadaver donors with a history of ITP.

Report of the Paris consensus meeting on expanded criteria donors in liver transplantation.

Because of organ shortage and a constant imbalance between available organs and candidates for liver transplantation, expanded criteria donors are needed. Experience shows that there are wide variations in the definitions, selection criteria, and use of expanded criteria donors according to different geographic areas and different centers. Overall, selection criteria for donors have tended to be relaxed in recent years. Consensus recommendations are needed. This article reports the conclusions of a consensus meeting held in Paris in March 2007 with the contribution of experts from Europe, the United States, and Asia. Definitions of expanded criteria donors with respect to donor variables (including age, liver function tests, steatosis, infections, malignancies, and heart-beating versus non-heart-beating, among others) are proposed. It is emphasized that donor quality represents a continuum of risk rather than "good or bad." A distinction is made between donor factors that generate increased risk of graft failure and factors independent of graft function, such as transmissible infectious disease or donor-derived malignancy, that may preclude a good outcome. Updated data concerning the risks associated with different donor variables in different recipient populations are given. Recommendations on how to safely expand donor selection criteria are proposed.

Vasopressin decreases portal vein pressure and flow in the native liver during liver transplantation.

Vasodilation due to impaired vascular tone is common in liver failure. Vasoconstrictor drugs are almost always required during the anhepatic phase of a liver transplant to maintain blood pressure unless venovenous bypass is employed. Arginine-vasopressin can be used as a vasoconstrictor instead of or in addition to norepinephrine for this purpose, but the effect of vasopressin on the portal vein pressure and flow in this setting is unknown. Portal vein pressure, portal vein blood flow, hemodynamic variables, and plasma vasopressin levels were measured in 16 patients during liver transplantation after ligation of the hepatic artery before and after a vasopressin infusion of 3.8 +/- 1.1 units/hour. Measurements were performed on the native liver prior to caval clamping. After vasopressin infusion, the portal vein pressure decreased significantly from 24.0 +/- 6.5 to 21.5 +/- 7.4 mm Hg [mean +/- standard deviation (SD), P = 0.006]. The portal vein blood flow also decreased (from 1.01 +/- 0.53 to 0.76 +/- 0.53 L/minute, mean +/- SD, P < 0.0001), as did the portal vein blood flow to cardiac output ratio (from 0.14 +/- 0.06 to 0.10 +/- 0.07, mean +/- SD, P < 0.0001). In conclusion, vasopressin significantly decreased portal vein pressure and flow of the native liver without decreasing cardiac output or intestinal perfusion in patients undergoing liver transplantations.