Transplant waitlist management, CMS, UNOS, and more

Audio/video recording of Aurora St. Luke\u27s Transplant Grand Rounds on September 5, 2017 presented by Ajay Sahajpal. 55 minutes

Liver transplant using donation after circulatory death donors: A low-volume single-center experience

OBJECTIVES: Although donor shortages have prompted increased use of livers from donors after circulatory death, data are limited on their outcomes in low-volume centers and their applicability in this setting. MATERIALS AND METHODS: We retrospectively reviewed liver transplants from donors after circulatory death performed at our low-volume center over a 7-year period and identified predictors of outcomes. RESULTS: Between 2007 and 2014, of 196 liver transplants (mean 28/year), donations after circulatory death accounted for 31%. Patient/liver graft survival rates were similar in recipients of brain dead donor versus circulatory death donor allografts (P = .47 and P = .87 respectively): 88.4% versus 85.7%/87.7 versus 86.3% at 1 year, 78.5 versus 74.2%/76.5% versus 75.4% at 3 years, and 70.8% versus 62.0%/65.1% versus 63.7% at 5 years. Multivariable analysis identified recipients with hepatitis C virus from donors \u3e50 years old as an independent predictor of graft and patient survival (P \u3c .01). Biliary complications trended higher in recipients of circulatory death donor livers. Among solitary liver transplant recipients, although biliary complications adversely affected graft survival in both groups (circulatory death vs brain dead donor cohorts, P = .02 vs P = .03), patient survival was only affected in the circulatory death donor cohort (P = .01). However, when all transplants were included in graft loss modeling, presence of biliary complications significantly impacted graft survival only in recipients of livers from circulatory death donors (P \u3c .01). Among biliary complications, ischemic cholangiopathy had the greatest impact on graft loss (P ≤ .01). CONCLUSIONS: Donation after circulatory death allografts could be safely used to expand the donor pool even in low-volume liver transplant centers. Outcomes were comparable to grafts from donors after brain death, although biliary complications, mainly because of ischemic cholangiopathy, had a greater effect on liver transplants from circulatory death donors. Efforts to minimize ischemic cholangiopathy could enable their greater utilization, regardless of center volume, without compromising outcomes

Impact of donation after circulatory death allografts on outcomes following simultaneous liver-kidney transplant: A single-center experience and review of the literature

Objectives:Limited data exist on outcomes after simultaneous liver-kidney transplants with extended criteria donor grafts. We compared outcomes in recipients of simultaneous liver-kidney transplants with donation after circulatory death versus donation after brain death grafts. Materials and methods:This retrospective analysis included all liver transplants performed over a 7-year period at a single center. We compared categorical variables using the chi-square test and continuous variables using the t test. We compared survival using the Kaplan-Meier method and performed a univariate analysis of predictors of outcomes using Cox regression method. Results:Over the study period, 196 patients underwent liver transplant, with 33 (16.8%) undergoing simultaneous liver-kidney transplant. In this cohort, 23 and 10 patients, respectively, received grafts from donors after brain death versus circulatory death. Both groups were comparable with respect to age, sex, hepatitis C virus status, and presence of hepatocellular carcinoma. Median (range) Model for End-Stage Liver Disease score was higher in recipients of donation after brain death grafts (37 [26-40] vs 23 [21-24]; P \u3c .01). Liver allograft survival was comparable in donation after brain death versus donation after circulatory death recipients (P = .82) at 1 year (64.0% vs 66.7%), 3 years (57.6% vs 55.6%), and 5 years (57.6% vs 55.6%). Patient survival was also comparable (P = .89) at 1 year (70.1% vs 77.8%), 3 years (63.1% vs 55.6%), and 5 years (63.1% vs 55.6%). Graft outcomes remained similar even after adjustment for Model for End-Stage Liver Disease score at transplant (hazard ratio 0.58; 95% CI, 0.14-2.44; P = .45). Univariate analysis of predictors of patient survival after simultaneous liver- kidney transplant showed a trend toward statistical significance with recipient age and donor male sex. Conclusions:Grafts from donors after circulatory death could help safely expand the donor pool in patients undergoing simultaneous liver-kidney transplant without compromising outcomes

Impact of donation aftercirculatory death allografts on outcomes after liver transplant for hepatitis C: A single-center experience and review of the literature

Objectives: We investigated the impact of liver transplant from donors after circulatory death on incidence and severity of recurrent hepatitis C virus infection, graft and patient survival and aimed to identify predictors of outcomes. Materials and methods: We retrospectively reviewed all liver transplants performed at a single center (July 2007-February 2014). Patients with hepatitis C who underwent liver transplant from donors after circulatory death (group 1) were compared with hepatitis C patients who received grafts from donors after brain death (group 2) and patients without hepatitis C who received grafts from donors after circulatory death (group 3).We used the Kaplan-Meier method for survival analysis and performed a multivariable analysis for predictors of outcomes using Cox regression. Competing risk was used to analyze hepatitis C recurrence. Results: Of 196 patients, 107 were included: 25 in group 1, 46 in group 2, and 36 in group 3. All 3 groups were comparable, except for longer cold ischemia time (P \u3c .01) in group 1, lower Model for End-Stage Liver Disease score at transplant in groups 1 and 3 (P \u3c .01), and greater proportion of recipients with hepatocellular carcinoma in groups 1 and 2 (P = .02). Hepatitis C recurrence and severe recurrence at 1 and 3 years were higher in group 1 (but not statistically significant). Severe recurrence was noted in 17% versus 8% at 1 year (P = .12) and 30% versus 14% at 3 years (P = .08). Graft and patient survival rates at 1, 3, and 5 years were comparable in all 3 study groups. Conclusions: Recurrent hepatitis C, including severe recurrence, was greater following donation after circulatory death compared with donation after brain death liver transplant. However, graft survival and patient survival were comparable, including in recipients of donation after circulatory death grafts without hepatitis C

Transplant selection process: Ethics in transplantation, a panel discussion

Audio/video recording of Aurora St. Luke\u27s Transplant Grand Rounds on September 28, 2016. A panel including Ajay Sahajpal, MD, Vinay Thohan, MD, Jeff Lauzon, Betsy Blair, and Michelle Roberts. Moderators are Ann Wade, RN and Christina Hutchins, RN. 57 minutes

Cardiac Metastasis After Curative Treatment of Hepatocellular Carcinoma: Risk Factors, Treatment Options, and Prognosis

Hepatocellular carcinoma (HCC) is primary hepatic malignancy with a high incidence of recurrence. The risk of recurrence directly correlates to patient’s overall prognosis. Management of advanced HCC involves a combination of surgical resection, locoregional therapy, and systemic treatment. Distant metastases are rare, and intraventricular cardiac metastases are even more infrequent. This brief review details an illustrative case of cardiac metastasis after curative treatment of primary HCC and then summarizes the literature on risk factors, treatment options, and patient prognosis in the setting of distant metastases from HCC. Prognosis of metastasis to the heart is generally poor, and available evidence emphasizes the importance of maintaining regular posttreatment screening for metastases in patients with HCC. Given the variable presentation and high risk of recurrence, it is critical to have individualized multimodality treatment plans

Evaluation of the effects of n-acetylcysteine treatment in adult liver transplant recipients

Background: N-acetylcysteine (NAC) has been used in post-orthotopic liver transplant (OLT) patients for the proposed mechanism of preventing tissue damage of the newly transplanted organ from reactive oxygen species. This in turn may reduce cytokines and inflammation making oxygen delivery to the newly transplanted organ easier, which can lead to decreased reperfusion injury. Objective: To evaluate the efficacy and safety of NAC use in patients post-OLT. Graft survival was examined as the primary outcome with post-operative bleeding requiring an exploratory laparotomy, biliary complications, and length of hospitalization. Methods: The study is a retrospective review of the impact of NAC on solitary livers transplanted between January 2010 and June 2014. Student\u27s t-test was used to compare continuous variables and Chi-Square test was used to compare categorical variables. Kaplan-Meier Method and Cox Proportional Hazards model were used to analyze outcomes post-OLT. Results:118 solitary livers were included with 50 (42%) receiving NAC post-OLT and 68 (58%) not receiving NAC. Those who received NAC had similar MELD at transplant, weight, age, and gender compared to those who did not. The average length of hospitalization post-OLT in the NAC group was 19.5 +/- 26.4 days vs. 14.1 +/- 11.0 days in the no NAC group (p=0.13.) Post-operative bleeding was similar between groups. A higher percent of those who received NAC had a DCD organ (32% vs. 15%, p=0.02). NAC patients had higher initial post-OLT AST and ALT compared to those who did not receive NAC (2604 +/- 1761 vs. 1192 +/- 1026, p Conclusion: Further examination of association between biliary outcomes and NAC in a multivariable model also did not reach statistical significance. This could be due to our limited sample size, or overshadowed by more important variables like year of transplant or donor status. These results support the further need for research to fully understand the role of NAC use in post-operative liver transplant patients

Evalation of the Impact of the Implementation of a Specialty Pharmacy Program in the Treatment of Hepatitis C (HCV)

Conclusion: SVR (sustained virologic response) rates are comparable to clinical trials in this real-life clinical setting using a specialty pharmacy program. Those with HCV Genotype 1A had lower SVR rates post-medication completion, though it did not reach statistical significance. There was no difference in SVR rates between previously treated and treatment-naive patients

Evaluation of socioeconomic factors and achievement of sustained virologic response (SVR) in the treatment of hepatitis C virus (HCV)

Poster presented at: Aurora Scientific Day; May 24, 2017; Milwaukee, WI