Response to “Dynamic Challenges Inhibiting Optimal Adoption of Kidney Paired Donation: Findings of a Consensus Conference” by Melcher et al.

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/99040/1/ajt12345.pd

Liver and Intestine Transplantation in the United States, 1996–2005

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/72937/1/j.1600-6143.2007.01782.x.pd

Kidney transplant graft outcomes in 379 257 recipients on 3 continents

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/145422/1/ajt14694_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/145422/2/ajt14694.pd

Longitudinal assessment of mortality risk among candidates for liver transplantation

Liver allocation policy recently was modified to use the Model for End-Stage Liver Disease (MELD) for patients with chronic liver disease to stratify potential recipients according to risk for waitlist death. In this study, a retrospective cohort of 760 adult patients with chronic liver disease placed on the liver transplant waitlist between January 1995 and March 2001 and followed up for up to 74 months was studied to assess the ability of the MELD to predict mortality among waitlisted candidates and evaluate the prognostic importance of changes in MELD score over time. Serial MELD scores predicted waitlist mortality significantly better than baseline MELD scores or medical urgency status. Each unit of the 40-point MELD score was associated with a 22% increased risk for waitlist death ( P < .001), whereas medical urgency status was not a significant independent predictor. For any given MELD score, the magnitude and direction of change in MELD score during the previous 30 days (ΔMELD) was a significant independent mortality predictor. Patients with MELD score increases greater than 5 points over 30 days had a threefold greater waitlist mortality risk than those for whom MELD scores increased more gradually ( P < .0001). We conclude that mortality risk on the liver transplant waitlist is predicted more accurately by serial MELD score determinations than by medical urgency status or single MELD measurements. ΔMELD score over time reflects progression of liver disease and conveys important additional prognostic information that should be considered in the further evolution of national liver allocation policy.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/35282/1/500090102_ftp.pd

Improving Organ Procurement Travel Practices in the United States: Proceedings from the Michigan Donor Travel Forum

There are significant risks and inefficiencies associated with organ procurement travel. In an effort to identify, quantify, and define opportunities to mitigate these risks and inefficiencies, 25 experts from the transplantation, transportation and insurance fields were convened. The forum concluded that: on procurement travel practices are inadequate, there is wide variation in the quality of aero-medical transportation, current travel practices for organ procurement are inefficient and there is a lack of standards for organ procurement travel liability coverage. The forum concluded that the transplant community should require that air-craft vendors adhere to industry quality standards compatible with the degree of risk in their mission profiles. Within this context, a purchasing collaborative within the transplant community may offer opportunities for improved service and safety with lower costs. In addition, changes in travel practices should be considered with broader sharing of procurement duties across centers. Finally, best practice standards should be instituted for life insurance for transplant personnel and liability insurance for providers. Overall, the aims of these proposals are to raise procurement travel standards and in doing so, to improve the transplantation as a whole.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/79257/1/j.1600-6143.2009.02964.x.pd

Health‐Related Quality of Life in Kidney Donors From the Last Five Decades: Results From the RELIVE Study

Live donation benefits recipients, but the long‐term consequences for donors remain uncertain. Renal and Lung Living Donors Evaluation Study surveyed kidney donors (N = 2455; 61% women; mean age 58, aged 24–94; mean time from donation 17 years, range 5–48 years) using the Short Form‐36 Health Survey (SF‐36). The 95% confidence intervals for White and African‐American donors included or exceeded SF‐36 norms. Over 80% of donors reported average or above average health for their age and sex (p 1 SD below norm). Obesity, history of psychiatric difficulties and non‐White race were risk factors for impaired physical health; history of psychiatric difficulties was a risk factor for impaired mental health. Education, older donation age and a first‐degree relation to the recipient were protective factors. One percent reported that donation affected their health very negatively. Enhanced predonation evaluation and counseling may be warranted, along with ongoing monitoring for overweight donors. Questionnaires completed by 2544 living donors 5 to 48 years postnephrectomy show that 80% have average or better health‐related quality of life for their age and sex based on SF‐36 norms and that obesity, history of psychiatric difficulties and nonwhite race are risk factors for poor health‐related quality of life outcomes, whereas being older, having more education and/or being a first‐degree relation to the recipient predict better outcomes.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/100300/1/ajt12434.pd

Estimating the effect of a rare time‐dependent treatment on the recurrent event rate

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/143592/1/sim7626_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/143592/2/sim7626.pd

Limitations of the MELD score in predicting mortality or need for removal from waiting list in patients awaiting liver transplantation

<p>Abstract</p> <p>Background</p> <p>Decompensated cirrhosis is associated with a poor prognosis and liver transplantation provides the only curative treatment option with excellent long-term results. The relative shortage of organ donors renders the allocation algorithms of organs essential. The optimal strategy based on scoring systems and/or waiting time is still under debate.</p> <p>Methods</p> <p>Data sets of 268 consecutive patients listed for single-organ liver transplantation for nonfulminant liver disease between 2003 and 2005 were included into the study. The Model for End-Stage Liver Disease (MELD) and Child-Turcotte-Pugh (CTP) scores of all patients at the time of listing were used for calculation. The predictive ability not only for mortality on the waiting list but also for the need for withdrawal from the waiting list was calculated for both scores. The Mann-Whitney-U Test was used for the univariate analysis and the AUC-Model for discrimination of the scores.</p> <p>Results</p> <p>In the univariate analysis comparing patients who are still on the waiting list and patients who died or were removed from the waiting list due to poor conditions, the serum albumin, bilirubin INR, and CTP and MELD scores as well as the presence of ascites and encephalopathy were significantly different between the groups (p < 0.05), whereas serum creatinine and urea showed no difference.</p> <p>Comparing the predictive abilities of CTP and MELD scores, the best discrimination between patients still alive on the waiting list and patients who died on or were removed from the waiting list was achieved at a CTP score of ≥9 and a MELD score of ≥14.4. The sensitivity and specificity to identify mortality or severe deterioration for CTP was 69.0% and 70.5%, respectively; for MELD, it was 62.1% and 72.7%, respectively. This result was supported by the AUC analysis showing a strong trend for superiority of CTP over MELD scores (AUROC 0.73 and 0.68, resp.; p = 0.091).</p> <p>Conclusion</p> <p>The long term prediction of mortality or removal from waiting list in patients awaiting liver transplantation might be better assessed by the CTP score than the MELD score. This might have implications for the development of new improved scoring systems.</p

Cyclosporin toxicity at therapeutic blood levels and cytochrome P-450 IIIA

A 40-year-old male liver allograft recipient had neurological dysfunction and renal failure while his cyclosporin blood levels were in the therapeutic range; these features recurred on rechallenge. The hypothesis that this toxic effect might have resulted from abnormal metabolism of cyclosporin by liver cytochrome P-450 IIIA was investigated with the [14C]erythromycin breath test, which is a measure of this enzyme's activity. P-450 IIIA activity was decreased compared with that in controls, including other liver transplant recipients. Pretreatment with rifampicin, an inducer of P-450 IIIA, increased enzyme activity. After treatment with rifampicin the patient could be rechallenged with cyclosporin at a dose almost twice that which had previously been toxic. The patient died during a second transplantation and the microsomal content of P-450 IIIA was found to be low in the first transplant.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/28757/1/0000587.pd

Are three‐day voiding diaries feasible and reliable? Results from the Symptoms of Lower Urinary Tract Dysfunction Research Network (LURN) cohort

AimsThe aims of this study were to assess the completeness of voiding diaries in a research context and to correlate diary data with patient‐reported questionnaires.MethodsMen and women enrolled in the Symptoms of Lower Urinary Tract Dysfunction Research Network (LURN) were given a 3‐day voiding and fluid‐intake diary to fill‐out. Diaries were assessed for completeness and intake‐output imbalances. They were assigned to one of four categories based on a percentage of missing data and fluid imbalance: no diary submitted, unusable (>40% missing void or intake volumes, or unphysiological fluid imbalance), usable but not complete, and complete.ResultsA total of 1064 participants were enrolled and 85% (n = 902) returned the bladder diary. Of the diaries returned, 94% (n = 845) had data on three separate days, 87% (n = 786) had no missing intake volumes, 61% (n = 547) had no missing voided volumes, and 70% (n = 635) had a fluid imbalance within 3 L across the 3‐day time period, resulting in 50% (n = 448) of participants with 100% complete diaries. Younger age was associated with a higher likelihood of not submitting a diary, or submitting an unusable diary. Women had a higher likelihood of submitting an unusable diary or a usable but incomplete diary.ConclusionOverall, 50% of LURN participants returned voiding diaries with perfectly complete data. Incomplete data for voided volumes was the most common deficiency. There was only a moderate correlation between diary data and questionnaire responses, indicating that diaries are a source of unique information.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/152022/1/nau24113.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/152022/2/nau24113_am.pd