Robot-assisted Transplant Ureteral Repair after Robot-assisted Kidney Transplant

Objective: To use a video to describe steps of robotic-assisted transplant ureteral repair (RATUR) for treating transplant ureteral stricture (TUS) in a patient who had undergone robot assisted kidney transplant (RAKT). Method: We recorded and edited the operation of a patient who experienced TUS by distal obstruction due to a calcification after RAKT and underwent RATUR in 2020. Results: We present a case of a 65-year-old male who developed graft dysfunction. He was found to have a short intrinsic obstruction of the distal transplant ureter due to a calcification that formed around the suture line at the ureteroneocystostomy. The video covers the steps of the operation which include positioning, placement of the ports, orientation, dissection of the paravesicle space, identification and dissection of the ureter, stent placement, reconstruction and post-operative course. We try to include tips and tricks that could be useful in other similar robotic cases. Conclusion: Open surgical repair of the transplant ureter is the standard of care for transplant ureteral stenosis. However, it requires the morbidity of a large surgical incision. Robotic assisted transplant ureteral repair can be done successfully while limiting convalescence from an open reoperation

Improved Survival With Higher-risk Donor Grafts in Liver Transplant With Acute-on-chronic Liver Failure

Use of higher-risk grafts in liver transplantation for patients with acute-on-chronic liver failure (ACLF) has been associated with poor outcomes. This study analyzes trends in liver transplantation outcomes for ACLF over time based on the donor risk index (DRI). Methods: Using the Organ Procurement and Transplantation Network and the United Network for Organ Sharing registry, 17 300 ACLF patients who underwent liver transplantation between 2002 and 2019 were evaluated. Based on DRI, adjusted hazard ratios for 1-y patient death were analyzed in 3 eras: Era 1 (2002-2007, n = 4032), Era 2 (2008-2013, n = 6130), and Era 3 (2014-2019, n = 7138). DRI groups were defined by DRI2.0. Results: ACLF patients had significantly lower risks of patient death within 1 y in Era 2 (adjusted hazard ratio, 0.69; 95% confidence interval, 0.61-0.78; P \u3c 0.001) and Era 3 (adjusted hazard ratio, 0.48; 95% confidence interval, 0.42-0.55; P \u3c 0.001) than in Era 1. All DRI groups showed lower hazards in Era 3 than in Era 1. Improvement of posttransplant outcomes were found both in ACLF-1/2 and ACLF-3 patients. In ACLF-1/2, DRI 1.2 to 1.6 and \u3e2.0 had lower adjusted risk in Era 3 than in Era 1. In ACLF-3, DRI 1.2 to 2.0 had lower risk in Era 3. In the overall ACLF cohort, the 2 categories with DRI \u3e1.6 had significantly higher adjusted risks of 1-y patient death than DRI \u3c1.2. When analyzing hazards in each era, DRI \u3e 2.0 carried significantly higher adjusted risks in Eras 1 and 3\u27 whereas DRI 1.2 to 2.0 had similar adjusted risks throughout eras. Similar tendency was found in ACLF-1/2. In the non-ACLF cohort, steady improvement of posttransplant outcomes was obtained in all DRI categories. Similar results were obtained when only hepatitis C virus-uninfected ACLF patients were evaluated. Conclusions: In ACLF patients, posttransplant outcomes have significantly improved, and outcomes with higher-risk organs have improved in all ACLF grades. These results might encourage the use of higher-risk donors in ACLF patients and provide improved access to transplant

Improvements in liver transplant outcomes in patients with HCV/HIV coinfection after the introduction of direct-acting antiviral therapies

BACKGROUND: In recipients with HCV/HIV coinfection, the impact that the wider use of direct-acting antivirals (DAAs) has had on post-liver transplant (LT) outcomes has not been evaluated. We investigated the impact of DAAs introduction on post-LT outcome in patients with HCV/HIV coinfection. METHODS: Using Organ Procurement and Transplant Network/United Network for Organ Sharing data, we compared post-LT outcomes in patients with HCV and/or HIV pre- and post-DAAs introduction. We categorized these patients into two eras: pre-DAA (2008-2012 [pre-DAA era]) and post-DAA (2014-2019 [post-DAA era]). To study the impact of DAAs introduction, inverse probability of treatment weighting was used to adjust patient characteristics. RESULTS: A total of 17 215 LT recipients were eligible for this study (HCV/HIV [n = 160]; HIV mono-infection [n = 188]; HCV mono-infection [n = 16 867]). HCV/HIV coinfection and HCV mono-infection had a significantly lower hazard of 1- and 3-year graft loss post-DAA, compared pre-DAA (1-year: adjusted hazard ratio [aHR] 0.29, 95% confidence interval (CI) 0.16-0.53 in HIV/HCV, aHR 0.58, 95% CI 0.54-0.63, respectively; 3-year: aHR 0.30, 95% CI 0.14-0.61, aHR 0.64, 95% CI 0.58-0.70, respectively). The hazards of 1- and 3-year graft loss post-DAA in HIV mono-infection were comparable to those in pre-DAA. HCV/HIV coinfection had significantly lower patient mortality post-DAA, compared to pre-DAA (1-year: aHR 0.30, 95% CI 0.17-0.55; 3-year: aHR 0.31, 95% CI 0.15-0.63). CONCLUSIONS: Post-LT outcomes in patients with coinfection significantly improved and became comparable to those with HCV mono-infection after introducing DAA therapy. The introduction of DAAs supports the use of LT in the setting of HCV/HIV coinfection

Takotsubo Cardiomyopathy Following Liver Transplantation: A Report of 2 Cases

Purpose: Takotsubo cardiomyopathy, also called apical ballooning syndrome, is characterized by regional left ventricular systolic dysfunction that resembles myocardial infarction in its initial presentation; however, it lacks angiographic evidence of coronary artery disease. We evaluated the incidence of takotsubo cardiomyopathy following liver transplant at a diverse urban transplant program. Methods: This is a retrospective review of patients transplanted at a single center between 2017 and 2019. Here we report 2 cases of takotsubo cardiomyopathy that developed after liver transplantation. Results: A 65-year-old woman diagnosed with alcoholic cirrhosis underwent a brain-dead donor liver transplant. The postoperative course was complicated by stroke, pulmonary hypertension, and a left internal jugular thrombus. Six months following transplant, the patient developed takotsubo cardiomyopathy with congestive hepatopathy and died of heart failure complications despite maximal medical care. The second case was a 65-year-old woman with alcoholic cirrhosis admitted for a living donor liver transplant. The postoperative period involved recurrent seizures and elevated troponins with markedly reduced ejection fraction, which were appropriately managed. The patient recovered well with supportive care and was discharged to a rehabilitation facility shortly after. Conclusion: We present a series of patients with takotsubo cardiomyopathy after liver transplantation. The diagnosis depends on the clinical presentation and findings on electrocardiography, echocardiography, and cardiac enzymes. Our patients met the Mayo Clinic diagnostic criteria and were appropriately managed according to guidelines. Our report highlights the possibility of pulmonary hypertension contributing to the development of takotsubo cardiomyopathy. Additional studies are needed to establish a definite correlation

The Impact of Thromboelastography on Decreasing Blood Product Usage in Liver Transplantation

Introduction: Thromboelastography (TEG) has emerged as a tool to guide resuscitation in Liver Transplantation (LT). We aim to identify effects of TEG utilization on product use and blood loss in LT. Methods: Adult patients (age \u3e18-years-old) who received LT between 2014 and 2020 were retrospectively reviewed. Living donor, simultaneous/multi-organ transplants, re-transplants, and pediatric transplants were excluded. Impact of TEG on blood products and intraoperative blood loss was analyzed. A subgroup analysis was done based on INR. The median, 75th and 90th percentile of INR at transplant were used as cut-off values. Patients were classified into four categories: no, mild, moderate, and severe coagulopathy groups. Results: Four-hundred-fifty-one patients met inclusion criteria and were separated into TEG(n=144) vs non-TEG(n=307). Background characteristics between these groups were comparable. Median blood products used were similar between TEG and non-TEG groups. In the subgroup analysis, there was a significant decrease in product use in the TEG-group with moderate coagulopathy, compared to the non-TEG group: pRBC (4.5vs7.0 units, p=0.002); FFP (6.0vs9.0 units, p=0.005); Cryoprecipitate (1.0vs2.0 units, p=0.005). Tranexamic acid (TXA) use was significantly higher in the TEG-group with median values of 1000vs0 mg (p\u3c0.001). There was no difference in median blood loss. In the no, mild, and severe coagulopathy groups, there was no difference in blood product use, blood loss, or TXA use between groups. Conclusion: TEG guided resuscitation in LT resulted in a decrease in product usage, and more utilization of TXA in patients with moderate coagulopathy defined as INR between 2.2 and 2.8

Combined liver and lung transplantation with extended normothermic liver preservation using TransmedicsOrgan Care System (OCS)™ liver: A single center experience

Combined liver-lung transplantation (CLLT) is indicated in patients who cannot survive single-organ transplantation alone. Ex-situ normothermic machine perfusion (NMP) has been used to increase the pool of suboptimal donors and has been previously used for extended normothermic lung preservation in CLLT. We aim to describe our single-center experience using the \u27Transmedics Organ Care System (OCS) ™ liver for extended normothermic liver preservation in CLLT. Results [Values shown as mean (standard deviation)]: Four CLLTs were performed from 2015 to 2020 including 3 male and 1 female recipients, age 50 (±13.7) years (Table 1). Indications for lung transplantation: (1) cystic fibrosis (CF), (1) severe bronchiectasis, and (2) interstitial pulmonary fibrosis. Indications for liver transplantation: (1) biliary cirrhosis secondary to CF, (1) autoimmune hepatitis, (1) alcoholic cirrhosis, and (1) cryptogenic cirrhosis. The lung was transplanted first for all patients. Recipient characteristics at transplant: Mean forced expiratory volume in 1 second (FEV1) was 51% (±22), and Model for End- Stage Liver Disease was 12 (±3.7). The livers were donated after brain death with donor age of 34 (±9.4) years and cold ischemia time 566 (±38) minutes. Ex-vivo pump time for the livers was 411 (±38) minutes (Table 2). Mean hospital stay was 34 days (±18). Over a median follow-up of 201 days, all patients were alive and doing well, while 50% had biopsy-proven acute cellular rejection of the liver. Conclusion: Normothermic extended liver preservation is a safe method to prolong perfusion time and preserve the liver during combined organ transplantation

Measurement of physical activity and frailty in the early post-operative period after kidney transplant: Single-center prospective pilot study using Fitbit watch

Background: Physical activity monitors (PAMs) allow patients to track multiple health parameters and may be helpful tools to assess patient’s physical recovery after kidney transplant (KT). We performed a pilot study to quantify early postoperative physical activity after KT. Methods: Adult KT candidates were screened prospectively for inclusion and provided with a PAM (Fitbit® Inspire 2) for the first 30 days after KT. Patients who did not speak English and had undergone multi-organ transplants were excluded. Several frailty tests were performed prior to KT and on post-operative day 30: Fried Frailty Phenotype and 6-minute walk test. Results: 14 patients were enrolled since February 2021 with baseline characteristics described in Table 1. There was a significant difference in the average daily steps during the 1st week compared to the 4th week after KT (Week 1: 3200 steps vs. Week 4: 6978 steps, p\u3c0.001). The number of steps during the first 30 days after KT correlated negatively with hospital length of stay (r -0.53,p=0.02). There was no difference in the average daily steps between pre-frail and non-frail patients [Figure 1A]. Having a post-operative complication (Clavien grade 1-3: n=5) significantly dropped the average daily steps for the first 30 days after KT (complication 6811 steps [SD 2810] vs. no-complication 2275 steps [SD 740];p=0.009) [Figure 1B]. Conclusion: PAM effectively captures post-operative biophysical parameters and can be successfully implemented to monitor patient’s recovery after KT

The use of normothermic liver preservation in combined liver and lung transplantation: A single-center experience

Combined liver and lung transplantation (CLLT) is indicated in patients with both end-stage liver and lung disease. Ex-situ normothermic machine perfusion (NMP) has been previously used for extended normothermic lung preservation in CLLT. We aim to describe our single-center experience using ex-situ NMP for extended normothermic liver preservation in CLLT. Four CLLTs were performed from 2019 to 2020 with the lung transplanted first for all patients. Median ex-situ pump time for the liver was 413 min (IQR 400-424). Over a median follow-up of 15 months (IQR 14-19), all patients were alive and doing well. Normothermic extended liver preservation is a safe method to allow prolonged cold ischemia using normothermic perfusion of the liver during CLLT

Favorable waitlist and transplant outcomes in transplant centers with a rapid increase in center volume

Background: It is unclear if centers can rapidly increase liver transplant (LT) volume without compromising their post-LT outcomes. This study aims to investigate the eff ects of a rapid increase in center volume on waitlist and post-LT outcomes. Patients and methods: This study uses data from UNOS registry and evaluated adult patients listed for LT or underwent LT between 2014 and 2019. Patients listed as multi-organ transplant and re-LT were excluded. The “change in LT center volume” was defined by the “volume in 2017-19 (late era) minus volume in 2014-16 (early era)” per center with categorization into three groups: Centers with increased volume (Group A:\u3e60 cases [20 cases/year]), those with equivalent volume (Group B:0-60 cases), and those with decline in volume (Group C:\u3c0 case). Ninety-day waitlist mortality (WLM), LT probability and one-year graft survival were compared between eras in each group. Results: Of 67,046 patients eligible for waitlist outcome analysis, the late era was associated with a lower risk of 90-day WLM than the early era in all groups. The late era was associated with a higher 90-day LT probability than the early era in Group A and B but not in Group C (Figure 1A and B). Among 39,579 patients, the late era was associated with a lower risk of one-year GL in Group A and C (Figure 1C). Conclusion: A rapid increase in LT center volume was associated with signifi cant improvements in waitlist outcomes, especially increased transplant probability

Improvements in Liver Transplantation Outcomes in Patients with Hepatitis C Virus/HIV Coinfection after the Introduction of Direct-Acting Antiviral Therapies

Introduction: Although liver transplantation (LT) outcomes in patients with hepatitis C virus (HCV) infection have improved after the introduction of direct-acting antivirals (DAAs), their impact on patients with HCV/HIV coinfection has not been evaluated. We aimed to assess the effects of DAAs on post-LT outcomes in patients with HCV/HIV compared with those with HIV or HCV mono-infection. Methods: Using the Organ Procurement and Transplantation Network/United Network for Organ Sharing data, we compared post-LT graft survival in patients with HCV and/or HIV before and after DAAs introduction. Patients were classified into the following eras: era 1 (2008-2012 [pre-DAAs]) and era 2 (2014-2019 [post-DAAs]). Patients who received transplants in 2013 were excluded to allow a washout period of the effect of DAAs. Inverse probability weighting was used to adjust characteristic differences between eras. Analyses considered possible infection by era interactions. Results: A total of 18,053 LT recipients were identified (HCV/HIV [n = 160]; HCV mono-infection [n = 17,705]; HIV mono-infection [n = 188]). In era 1, the 1-year graft survival rate in the coinfection group was significantly worse than in HCV and HIV mono-infection groups, but no difference was detected in era 2 (Fig. 1). Both HCV/HIV and HCV mono-infection had significant reduction on year-1 graft loss, compared with era 1; hazard ratio 0.25 (95% CI, 0.14 to 0.43) for HIV/HCV and hazard ratio 0.61 (95% CI, 0.57 to 0.65) for HCV (Table 1). Improvement was more prominent in the coinfection group. There was no significant change in patients with HIV mono-infection. Conclusion: After the introduction of DAAs, more significant improvements in post-LT outcomes were observed in patients with coinfection compared with those with HIV or HCV mono-infection