Peritoneal cooling may provide improved protection for uncontrolled donors after cardiac death: an exploratory porcine study

Uncontrolled donation after cardiac death (DCD) renal transplantation relies on rapid establishment of organ preservation interventions. We have developed a model of the uncontrolled DCD, comparing current in situ perfusion (ISP) techniques with additional peritoneal cooling (PC). Ten pigs were killed and subjected to a 2 h ischemia period. The ISP group modeled current DCD protocols. The PC group (PC) modeled current protocols plus PC. Two animals were used as controls and subjected to 2 h of warm ischemia. Core renal temperature and microdialysis markers of ischemia were measured. Preservation interventions began at 30 min, with rapid laparotomy and kidney recovery performed at 2 h, prior to machine perfusion viability testing. The final mean renal temperature achieved in the ISP group was 26.3 degrees C versus 16.9 degrees C in the PC group (p = 0.0001). A significant cryopreservation benefit was suggested by lower peak microdialysate lactate and glycerol levels (ISP vs. PC, p = 0.0003 and 0.0008), and the superiority of the PC group viability criteria (p = 0.0147). This pilot study has demonstrated significant temperature, ischemia protection and viability assessment benefits with the use of supplementary PC. The data suggests a need for further research to determine the potential for reductions in the rates of ischemia-related clinical phenomena for uncontrolled DCDs.

Exploration of basal diurnal salivary cortisol profiles in middle-aged adults: associations with sleep quality and metabolic parameters

The use of saliva samples is a practical and feasible method to explore basal diurnal cortisol profiles in free-living research. This study explores a number of psychological and physiological characteristics in relation to the observed pattern of salivary cortisol activity over a 12-h period with particular emphasis on sleep. Basal diurnal cortisol profiles were examined in a sample of 147 volunteers (mean age 46.21+/-7.18 years). Profiles were constructed for each volunteer and explored in terms of the area under the curve (AUC) of the cortisol-awakening response with samples obtained immediately upon waking (0, 15, 30 and 45 min post waking) and at 3, 6, 9 and 12h post waking to assess diurnal decline. Diurnal mean of cortisol was based on the mean of cortisol at time points 3, 6, 9 and 12h post waking. Psychological measures of perceived stress and sleep were collected with concurrent biological assessment of fasting plasma glucose, insulin, blood lipids and inflammatory markers. Blunted cortisol profiles, characterised by a reduced AUC, were observed in the majority (78%) of a middle-aged sample and were associated with significantly poorer sleep quality and significantly greater waist-hip ratio (WHR). Blunted cortisol profiles were further associated with a tendency to exhibit a less favourable metabolic profile. These findings suggest that reduced cortisol secretion post waking may serve as an additional marker of psychological and biological vulnerability to adverse health outcomes in middle-aged adults.

Ischemic cholangiopathy after liver transplantation from controlled non-heart-beating donors-a single-center experience

BACKGROUND

Previous reports have shown that livers from controlled non-heart-beating-donors (NHBD) are associated with higher rates of primary failure and ischemic cholangiopathy of orthotopic liver transplantation (OLT) as a complication of the prolonged warm ischemia.

METHODS

This retrospective review of activities from 1999 to 2006 examined donor characteristics of age, liver function tests, warm ischemic time before (1WITa) and after cardiac arrest (1WITb), cold ischemic time (CIT) and transplant results.

RESULTS

Eleven NHBD retrieved livers were transplanted from "ideal" donors except for one elderly donor (73 years). Of the 11 recipients, 3 developed biliary cholangiopathy (27%). There were no episodes of primary graft nonfunction, but one recipient displayed primary graft dysfunction. Two recipients died: one due to biliary complications with sepsis (long CIT >10 hours, fatty liver), and the other due to aspiration pneumonia and hypoxic brain damage with normal liver function. One recipient required retransplantation owing to ischemic cholangiopathy (1WITb 45 min) at 6 months after OLT with a good result. The other eight recipients are alive (observation period 72 to 14 months) including six with normal liver function, one with biopsy-proven biliary ischemia and one with recurrent primary sclerosing cholangitis without biliary ischemic changes on biopsy. Among 164 heart-beating donors recipients transplanted in the same period, biliary complications occurred in 27 patients (16%), of whom 12 were leaks and 15 anastomotic strictures.

CONCLUSION

NHBD were a good source for livers with reasonable early results. To avoid late complications especially ischemic cholangiopathy, caution is urged with the use of these organs as well as strict donor and ischemic time criteria.

Primary prevention of type-2 diabetes and heart disease: action research in secondary schools serving an ethnically diverse UK population

BACKGROUND

Escalating rates of childhood obesity are likely to have an impact on the prevalence of coronary heart disease and type-2 diabetes. We aimed to identify barriers to healthy lifestyles and evaluate the effectiveness of an action research approach to lifestyle modification in secondary schools.

METHODS

An action research partnership between schools and university researchers involved pupils aged 11-15 in five inner-city secondary schools serving a predominantly South Asian population in Leicester, UK. Data collection included baseline and follow-up diet and physical activity questionnaires. Focus groups and observational visits were used to identify barriers, assist with developing tailored interventions and review the impact of the study.

RESULTS

Working with secondary schools presented challenges but a useful partnership was sustained. Qualitative feedback suggested that this had raised awareness of healthy lifestyle issues in participating schools. Barriers in pupils included low prioritization of health when making lifestyle choices. Sub-optimal diet and activity habits were identified at baseline. Overall, these persisted at follow-up, although some limited positive changes were identified.

CONCLUSIONS

Using action research methods in this context is challenging but can facilitate useful data collection and may have a modest impact on lifestyle behaviours.

Survival of arteriovenous fistula for dialysis at different centers in the North of England

BACKGROUND

Renal failure patients rely on their vascular access for hemodialysis. Surgery for construction of arteriovenous fistulae is provided by a range of specialists. The aim of this review was to assess the survival of arteriovenous fistulae for hemodialysis patients in different centers of Northern England.

METHODS

Data was collected on 473 hemodialysis patients in the North of England. Risk factors for failure were determined for each patient (age, sex, diabetes), together with their current mode of dialysis and history of surgical access procedures. This was expressed against their duration of dialysis. The dialysis units were then compared for fistula survival using the Kaplan Meier method.

RESULTS

68.3% (323) patients were dialysed through via arteriovenous fistulae and 31.7% (150) via neck line. Overall fistula survival rates were 85.1% at 1 year, 82.5% at 2 years and 72.7% at 3 years. The best 1 year survival was 91.6% and worst 76.1%. These were 74.4% and 53.1% at 5 years and 74.4% and 29.5% at 10 years; these differences were highly statistically significant (p = 0.0033).

CONCLUSION

Though graft survival is affected by many things, surgical training in access surgery is not mandatory and a review of surgical practice is urgently needed.

Venae comitantes fistulae: an option in patients with difficult hemodialysis access

OBJECTIVES

To evaluate the outcome of use of venae comitantes vessels in the formation of arterio-venous fistulae as vascular access for hemodialysis, in patients with limited venous anatomy.

METHODS

Twenty patients who underwent arterio-venous anastomosis between brachial artery and venae comitantes were identified (2002 - 2005) and the notes reviewed.

RESULTS

There was early failure in two (10%) patients (immediate postoperative period) and a further four (20%) failed late (mean 26 weeks, range 7-60). One patient developed a steal syndrome with radial nerve dysfunction requiring ligation of the fistula. Six (30%) patients utilised their fistulae for dialysis successfully without additional surgery and a further 6(30%) required surgical intervention to exteriorise the fistulae by the use of interposition grafts to allow successful use.

CONCLUSION

Venae Comitantes arterial fistulae offer an option in patients with limited venous anatomy for standard reconstruction. If access surgery utilizes such veins second stage procedures are often required with overall 70% use.

Do laparoscopy and intraoperative ultrasound have a role in the assessment of patients with end-stage liver disease and hepatocellular carcinoma for liver transplantation?

BACKGROUND

Liver transplantation is the treatment of choice for patients with end-stage liver disease (ESLD) and early hepatocellular carcinoma (HCC), Routine laparoscopy with intraoperative ultrasound was employed in an attempt to improve patient selection for transplantation. Our aim was to assess whether laparoscopy improved the patient selection with ESLD and HCC being considered for transplantation.

METHODS

We retrospectively reviewed the clinical notes and transplant database of all patients with ESLD complicated by HCC, being assessed for liver transplantation, from January 2000 to April 2005.

RESULTS

Twenty-five patients with ESLD and HCC underwent assessment for liver transplantation. Eight were deemed untransplantable on cross-sectional imaging alone. Sixteen patients underwent laparoscopy and intraoperative ultrasound. One patient had undergone a previous segmental hepatectomy and laparoscopy was not technically feasible. At laparoscopy, all 16 patients were found to be free from extrahepatic disease and major vascular involvement. All 16 patients were listed for transplantation. At transplantation, one patient was found to have extrahepatic disease; the procedure was abandoned. One patient was found to have lesser curvature lymphadenopathy, Two patients had major vascular involvement noted in the explanted liver. All these findings were missed on pretransplant imaging and at laparoscopy.

CONCLUSIONS

As an additional investigation, laparoscopy did not improve staging or alter the management of patients with HCC being assessed for liver transplantation. Since July 2005, we have ceased routine laparoscopic assessment of patients prior to listing. The decision use laparoscopy on patients is now being taken on a more selective basis.

Rapid onset intratubular calcification following renal transplantation requiring urgent parathyroidectomy

BACKGROUND

Secondary hyperparathyroidism is a common complication of end-stage renal disease often requiring parathyroidectomy. Renal transplant with the restoration of normal renal function often allows resolution of hyperparathyroidism, avoiding the need for parathyroid surgery. However, a proportion of patients with hyperparathyroidism become overtly hypercalcemic after renal transplantation which poses management dilemmas between medical and surgical treatment.

CASE

We present the case of a 48-yearold man with end-stage renal failure known to have secondary hyperparathyroidism who received a living related renal transplant. Postoperatively he developed prompt hypercalcemia, polyuria, polydipsia and rapid onset intratubular calcification, leading to acute tubular necrosis diagnosed on renal biopsy on Day 7 post transplantation. He underwent surgical parathyroidectomy with resolution of his hypercalcemia and improved renal transplant function.

DISCUSSION

This case emphasizes the need for good management of secondary hyperparathyroidism together with close surveillance of PTH in patients awaiting renal transplantation. With good renal transplant function hyperparathyroidism usually resolves. Posttransplant surgical parathyroidectomy should be reserved for severe progressive end organ damage.

The use of pharmacokinetic and pharmacodynamic end points to determine the dose of AQ4N, a novel hypoxic cell cytotoxin, given with fractionated radiotherapy in a phase I study

BACKGROUND

AQ4N (1,4-bis[[2-(dimethylamino)ethyl] amino]-5,8-dihydroxyanthracene-9, 10-dione bis-N-oxide dihydrochloride) is a prodrug which is selectively activated within hypoxic tissues to AQ4, a topoisomerase II inhibitor and DNA intercalator.

PATIENTS AND METHODS

In the phase I study, 22 patients with oesophageal carcinoma received an i.v. infusion of AQ4N (22.5-447 mg/m(2)) followed, 2 weeks later, by further infusion and radiotherapy. Pharmacokinetics and lymphocyte AQ4N and AQ4 levels were measured after the first dose. At 447 mg/m(2), biopsies of tumour and normal tissue were taken after AQ4N administration.

RESULTS

Drug-related adverse events were blue discolouration of skin and urine, grade 2-3 lymphopenia, grade 1-3 fatigue, grade 1-2 anaemia, leucopenia and nausea. There were no drug-related serious adverse events (SAEs). Three patients had reductions in tumour volume >50%, nine had stable disease. Pharmacokinetics indicated predictable clearance. Plasma area under the curve (AUC) at 447 mg/m(2) exceeded AQ4N concentrations in mice at therapeutic doses and tumour biopsies contained concentrations of AQ4 greater than those in normal tissue. Tumour concentrations of AQ4 exceeded in vitro IC(50) values for most cell lines investigated.

CONCLUSIONS

No dose-limiting toxic effects were observed and a maximum tolerated dose was not established. Tumour AQ4 concentrations and plasma AUC at 447 mg/m(2) exceeded active levels in preclinical models. This dose was chosen for future studies with radiotherapy.

Comparison of HTK and hypertonic citrate to intraarterial cooling in human non-heart-beating kidney donors

Intraarterial cooling (IAC) of non-heart-beating donors (NHBD) for renal donation requires a cheap, low-viscosity solution. HTK contains a high hydrogen ion buffer level that theoretically should reduce the observable acidosis associated with ongoing anaerobic metabolism. A retrospective comparison of all retrieved NHBD kidneys as well as of viability on the Organ Recovery Systems Lifeporter machine perfusion circuit was performed with respect to the preservation solution HTK or Marshall's HOC. Forty-two NHBD kidneys (19 HTK and 23 HOC) were machine perfused between February 2004 and May 2005. Most of the HTK kidneys were obtained from uncontrolled donors (12 vs 5; Fisher exact test, P = .01). As a consequence, the glutathione-s-transferase viability assay (411 vs 292 IU/L, P = .12) and the lactate concentrations (2.33 vs 1.94 mmol/L, P = .13) were higher among the HTK cohort. There was evidence of greater buffering capacity in HTK, since the lactate:hydrogen ion ratios were consistently lower during the first 2 perfusion hours (1 hour P = .03, 2 hour P = .02). A linear regression analysis confirmed that this was related to the IAC solution (ANCOVA, P < .001). All controlled donor kidneys passed viability testing and were transplanted. In contrast, 83% (10/12) of the uncontrolled donor kidneys preserved with HTK passed the viability test and were transplanted, compared with only 20% (1/5) of the HOC-treated comparators (Fisher exact test, P = .03). It may be concluded that the postulated advantages of improved pH buffering with HTK appear to have clinical relevance.

Non-heart-beating kidney transplantation: 6-year outcomes

Non-heart-beating donor kidneys (NHBD) are being used to increase the donor pool due to the scarcity of cadaveric heart beating donors (HBD). We evaluated the long-term outcomes of renal transplantation using NHBD kidneys, comparing the first 100 NHBD kidneys transplanted at our facility to the next consecutive cadaveric HBD kidneys for graft survival, recipient survival, and quality of graft function. Recipient survival (P = .22) and graft survival (P = .19) at 6 years did not differ between recipients of NHBD (83%, 80%) and HBD (89%, 87%) kidneys. Quality of graft function using the mean glomular filtration rates were significantly lower in the NHBD group up to 3 months following discharge (41 +/- 2 vs 47 +/- 2, P = .007) but were then comparable up to 6 years following transplantation (43 +/- 5 vs 46 +/- 4, P = .55).

Diabetic donors as a source of non-heart-beating renal transplants

Due to the organ shortage, many renal transplantation centers attempt to increase the donor pool by using non-heart-beating donors (NHBDs). These kidneys are generally regarded as "marginal" grafts. Many centers do not consider transplantation from an NHBD with a history of diabetes as it is a more suboptimal donor. We began our NHBD program in 1998 and have performed 5 renal transplants from diabetic NHBDs. Viability testing identified kidneys suitable for single or dual transplantation. Although kidneys from brain stem dead donors with diabetes have been used successfully, our data suggested that kidneys from diabetic NHBDs can also be used although we still need long-term results.

Anatomic and functional imaging of metastatic carcinoid tumors

Carcinoid tumors are a fascinating group of neuroendocrine neoplasms that develop either sporadically or as part of an inheritable syndrome. Many tumors arise in the bronchopulmonary or gastrointestinal tract, but a neuroendocrine tumor can arise in almost any organ. The tumors have varied malignant potential depending on the site of their origin, and the clinical manifestations often are nonspecific. Metastases may be present at the time of diagnosis, which often occurs at a late stage of the disease. Imaging plays a pivotal role in the localization and staging of neuroendocrine tumors and in monitoring the treatment response. Imaging is often challenging, and a combination of anatomic and functional techniques is usually required, depending on the tumor type and location. Techniques include ultrasonography, barium studies, endoscopy, computed tomography, magnetic resonance imaging, somatostatin receptor scintigraphy, iobenguane scintigraphy, and, in select cases, positron emission tomography. Coregistration of structural and functional images is often of incremental value for accurate localization of the primary tumor and any meta-static disease. Radiologists must understand the contribution of each imaging modality in the assessment of different neuroendocrine tumors. In addition, knowledge of the optimal technique for each radiologic and radionuclide imaging examination is essential. Familiarity with the protean imaging appearances of both primary and metastatic disease is essential for accurate staging, treatment monitoring, and surveillance. Finally, an understanding of the wide variety of treatment options for patients with carcinoid tumors is vital for optimal management.

Donor risk factors for renal graft thrombosis

Graft thrombosis is one of the most devastating complications of transplantation. In obtaining consent prior to transplant, it is useful to share potential risk factors with the recipient. In order to do this, we explored the impact of different risk factors that could contribute to this complication. Using multivariate analysis we found that neither multiple vessels nor vascular injury had a bearing on the risk of graft thrombosis but atheroma did (P < .02).

Donation after cardiac death kidneys with low severity pre-arrest acute renal failure

The widening gap between supply and demand for renal transplantation has prompted many centers to use donors after cardiac death. Some of these donors exhibit signs of acute renal failure (ARF) prior to cardiac arrest. Concern has been expressed about poor quality of graft function from such donors. In response to this perception, we reviewed 49 single renal transplant recipients from category III donors after cardiac death between 1998 and 2005, at our center. All kidneys but one had hypothermic machine perfusion and viability testing prior to transplantation. According to the RIFLE criteria, nine recipients had kidneys from donors with "low severity pre-arrest ARF". The remainder of the recipients were used as control group. There was no statistical significant difference in delayed graft function and rejection rates between these two groups. Recipients GFR at 12 months was 44.4 +/- 17.1 and 45.2 +/- 14.7 (mL/min/1.73m(2)) from donors with ARF and without ARF, respectively (p = 0.96). In conclusion, low severity ARF in kidneys from controlled after cardiac death donors can be a reversible condition after transplantation. Short-term results are comparable to the kidneys from same category donors without renal failure, providing that some form of viability assessment is implemented prior to transplantation.

Renal transplants from category III non-heart-beating donors with evidence of pre-arrest acute renal failure

Kidneys transplanted from non-heart-beating donors (NHBDs) have been exposed to varying degrees of ischemic damage after death. Category III donors have invariably been managed, treated, and investigated in a hospital setting prior to arrest and death. Some therefore exhibit evidence of renal dysfunction and even acute renal failure (ARF) before death. Many surgeons would regard a NHBD with pre-arrest evidence of ARF as too marginal for renal transplantation. This retrospective study examines five Maastricht category III NHBD donors with evidence of pre-arrest ARF. We compare 3- and 12-month GFR outcome data from the nine resulting transplants with 40 category III NHBD transplants with normal pre-arrest renal function. The mean GFR at 3 months was 45.4 and 43.8 for the ARF and normal group, respectively. At 12 months the GFR was 42.2 and 44.7 in the ARF and normal groups, respectively. Thus evidence of ARF pre-arrest does not preclude successful category III NHBD renal transplantation.

Dual renal transplantation for kidneys from marginal non-heart-beating donors

Kidneys transplanted from non-heart-beating donors (NHBD) are generally regarded as marginal or extended criteria grafts due to the associated period of warm ischemia. The most prolonged periods occurring in the category II (uncontrolled) donor. This potential for injury can adversely affect the glomular filtration rate (GFR), which in severe cases results in primary nonfunction. Viability testing can identify a group of kidneys that, although unsuitable for solitary transplantation, may be considered for dual transplant. This retrospective study examined a series of 11 dual renal transplants, comparing 3- and 12-month GFR outcome data with 81 single NHBD transplants. The mean GFR at 3 months in the dual group was 47.6 and at 12 months was 48.6. In the single group the GFR at 3 months was 40.6 and at 12 months was 41.9. Thus using viability testing to identify NHBD kidneys suitable for dual transplant appears reliable and predictable.

Agonal period in potential non-heart-beating donors

The shortage of donor kidneys for renal transplantation is becoming more severe as the gap between the number of patients waiting for renal transplantation and the number of cadaveric organs available continues to widen. Therefore, many centres have started using non-heart-beating (NHB) donors. There was no clear plan for maximal duration of agonal period in Maastricht category NHB donors after withdrawal of treatment in Newcastle. This withdrawal has been audited in retrospect. Our current wait time is now a maximum of 5 hours; however, previously there have been some considerably longer periods. Concern has always been expressed about poor quality with protracted periods. Nonuse in this review of 58 kidneys can be expressed against time: 0 to 2 hours 13%, 2 to 5 hours 33%, and >5 hours 45%. Therefore, though the nonuse rate was significantly different between 0 to 2 hours and >5 hours (P < .05, chi-square), there were 16 transplants performed with kidneys >2 hours and 12 transplanted >5 hours. In conclusion, although good usable kidneys can still be used with protracted withdrawal, there are considerable logistical difficulties with our 5-hour cut-off, which means that one third of potential kidneys will not be utilized.

Perioperative Erythropoietin Efficacy in Renal Transplantation

BACKGROUND

There is no consensus on the usage of erythropoietin in the immediate postoperative period to prevent anemia and delayed graft function.

METHODS

A retrospective case note audit of renal transplants included hemoglobin (Hb) and serum creatinine (Scr) values preoperatively as well as at days 7, 14, 30, 60, and 90. Patients were categorized as those receiving erythropoietin during the first 6 months posttransplant (Epo+ve) and those not receiving any erythropoietin (Epo-ve).

RESULTS

Hb decreased from 12.4 +/- 1.6 g/L preoperatively to 9.5 +/- 1.5 g/L at day 14 and then rose to 10.5 +/- 1.6 g/L at 1 month and 12.4 +/- 1.7 g/L at 3 months. There was no difference in absolute Hb values in three transplant groups. Scr decreased from 597.0 +/- 200.1 mmol/L preoperatively to 254.1 +/- 196.9 mmol/L at day 14 and continued to fall to 163.8 +/- 98.9 mmol/L at 1 month and 147.8 +/- 66.9 mmol/L at 3 months. There was no difference in absolute Hb values and delayed graft function in the three transplant groups.

CONCLUSION

With respect to anemia and delayed graft function, the use of erythropoietin in the first 3 months had little impact. We suggest that such an expensive medication may be safely omitted in the immediate postoperative period.

Renal Graft Function After Prolonged Agonal Time in Non–Heart-Beating Donors

To deal with the increasing gap between organ demand and supply for kidney transplantation, many centers have started to use non-heart-beating (NHB) donors. When we initiated our program to utilize kidneys from such donors in 1998, we had no protocol for the maximal agonal period. This however was audited in retrospect. Our current wait time is now a maximum of 5 hours. Concern has been expressed in the past about possible deterioration in the quality of the organs with a protracted agonal time. We aimed in this study to examine the effect of prolonging agonal period on the quality of kidneys retrieved from Maastricht category III donors: A total of 40 kidneys were transplanted from 29 category III donors between 1998 and 2004. Eleven kidneys had donor agonal times of >5 hours; the remainder, agonal times <5 hours. Both groups were matched for donor and recipient factors. The mean glomerular filtration rates at 12 months for <5 hours versus >5 hours agonal time were 43.8 +/- 4.4 versus 49.8 +/- 5.8, respectively (P = .24) and at 24 months, 46.83 +/- 8.99 versus 37.67 +/- 3.85, respectively (P = .24). In conclusion, intermediate graft function is comparable to ones with shorter agonal time, although we await long-term results.

Preservation solutions for solid organ transplantation

Solid organ transplantation was one of the greatest medical advances of the 20th century. Current preservation technology falls short of maintaining organs ex vivo in perpetuity. This review examines the biochemical basis of organ degradation in response to ischaemia, preservation solution composition and potential future organ preservation technology.

DHA-paclitaxel (Taxoprexin) as first-line treatment in patients with stage IIIB or IV non-small cell lung cancer: report of a phase II open-label multicenter trial

INTRODUCTION

This prospective, open-label, non-randomized, multi-institutional phase II study was undertaken to assess the antitumor activity and safety of docosahexaenoic acid-paclitaxel (Taxoprexin) as first-line treatment of patients with advanced non-small cell lung cancer.

PATIENTS AND METHODS

Chemotherapy-naive patients were eligible if they had measurable stage IIIB or IV non-small cell lung cancer. Forty-four patients received docosahexaenoic acid-paclitaxel by intravenous infusion every 21 days. Two doses were evaluated: 1100 mg/m and 900 mg/m. Patients were monitored for toxicity and tumor response.

RESULTS

Patients received between one and seven (median, two) cycles of treatment. Twenty-eight courses were administered in the cohort starting at 1100 mg/m and 109 courses at 900 mg/m. The starting dose was reduced to 900 mg/m because of toxicity in the first 13 patients. Subsequently, the most severe toxicity was neutropenia (grade III/IV in 68% of patients treated with 900 mg/m). Forty patients were eligible for assessment of tumor response. Two partial responses (4.5%) were documented, and a further 16 patients (36.4%) had stable disease based on an intent-to-treat analysis. The median duration of survival for all patients was 243 days (range, 154-359) and the 1-year survival rate was 35%.

CONCLUSION

As a single-agent, docosahexaenoic acid-paclitaxel has little activity in patients with advanced non-small cell lung cancer, with 18 patients (40.1%) achieving either stable disease or a partial response after treatment. Despite the low objective response rate, treatment was associated with survival comparable to that seen with standard platinum-based combination chemotherapy. The dose-limiting toxicity was myelosuppression.

Predisposing Factors for Biliary Complications Following Liver Transplantation

INTRODUCTION

Biliary complications remain a major cause of morbidity and mortality in patients following liver transplantation. We sought to identify possible risk factors predisposing to biliary complications after OLT using duct-to-duct biliary reconstruction.

MATERIALS AND METHODS

We retrospectively reviewed 5 years of prospectively collected donor and recipient data between April 1999 and April 2004. We evaluated the presence of biliary complications, donor and recipient age, cold ischemia time, hepatic artery thrombosis, non-heart-beating donor (NHBD), and graft steatosis (>30%). The results were compared with a control group of OLT patients without biliary complications.

RESULTS

Among 173 OLT recipients, biliary complications occurred in 28 patients (16.2%), of whom 12 were leaks, 15 strictures, and 1 a nonanastomotic intrahepatic stricture. The mortality following biliary complications was 11%, compared to 6% in the control group.

CONCLUSION

Biliary complications remain a persistent problem in OLT. Analysis of risk factors identified hepatic artery thrombosis and steatosis as predisposing factors. With greater experience, NHBD livers may also prove to be at greater risk of biliary complications.