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Guo H, Zions VS, Law BA, Hewitt KC. Potential of Raman-Reflectance Combination in Quantifying Liver Steatosis and Fat Droplet Size: Evidence From Monte Carlo Simulations and Phantom Studies. JOURNAL OF BIOPHOTONICS 2024:e202400156. [PMID: 39223068 DOI: 10.1002/jbio.202400156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 08/07/2024] [Accepted: 08/08/2024] [Indexed: 09/04/2024]
Abstract
This study explores a combined strategy of Raman and reflectance spectroscopy for quantifying liver fat content and fat droplet size, crucial in assessing donor livers. By using Monte Carlo simulations and experimental setups with oil-in-water phantoms, our findings indicate that Raman scattering can solely differentiate between varying fat contents. At the same time, reflectance intensity is influenced by both fat content and oil droplet size, with a more pronounced sensitivity to fat droplet size. This study demonstrates the efficacy of combined Raman and reflectance spectroscopy in assessing liver steatosis and fat droplet size, potentially aiding in assessing donor livers for transplantation.
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Affiliation(s)
- Hao Guo
- Department of Physics and Atmospheric Science, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Medical Physics, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Vanessa S Zions
- Fisheries and Oceans Canada, Bedford Institute of Oceanography, Dartmouth, Nova Scotia, Canada
| | - Brent A Law
- Fisheries and Oceans Canada, Bedford Institute of Oceanography, Dartmouth, Nova Scotia, Canada
| | - Kevin C Hewitt
- Department of Physics and Atmospheric Science, Dalhousie University, Halifax, Nova Scotia, Canada
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2
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Liu Z, Zhu H, Zhao J, Yu L, Que S, Xu J, Geng L, Zhou L, Valenti L, Zheng S. Multi-omics analysis reveals a crosstalk between ferroptosis and peroxisomes on steatotic graft failure after liver transplantation. MedComm (Beijing) 2024; 5:e588. [PMID: 38868330 PMCID: PMC11167151 DOI: 10.1002/mco2.588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 04/17/2024] [Accepted: 04/25/2024] [Indexed: 06/14/2024] Open
Abstract
To identify the mechanism underlying macrosteatosis (MaS)-related graft failure (GF) in liver transplantation (LT) by multi-omics network analysis. The transcriptome and metabolome were assayed in graft and recipient plasma in discovery (n = 68) and validation (n = 89) cohorts. Differentially expressed molecules were identified by MaS and GF status. Transcriptional regulatory networks were generated to explore the mechanism for MaS-related inferior post-transplant prognosis. The differentially expressed molecules associated with MaS and GF were enriched in ferroptosis and peroxisome-related pathways. Core features of MaS-related GF were presented on decreased transferrin and impaired anti-oxidative capacity dependent upon dysregulation of transcription factors hepatocyte nuclear factor 4A (HNF4A) and hypoxia-inducible factor 1A (HIF1A). Furthermore, miR-362-3p and miR-299-5p inhibited transferrin and HIF1A expression, respectively. Lower M2 macrophages but higher memory CD4 T cells were observed in MaS-related GF cases. These results were validated in clinical specimens and cellular models. Systemic analysis of multi-omics data depicted a panorama of biological pathways deregulated in MaS-related GF. Transcriptional regulatory networks centered on transferrin and anti-oxidant responses were associated with poor MaS graft quality, qualifying as potential targets to improve prognosis of patients after LT.
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Affiliation(s)
- Zhengtao Liu
- Shulan International Medical CollegeZhejiang Shuren UniversityHangzhouChina
- Key Laboratory of Artificial Organs and Computational Medicine in Zhejiang ProvinceShulan International Medical CollegeZhejiang Shuren UniversityHangzhouChina
- NHC Key Laboratory of Combined Multi‐Organ TransplantationKey Laboratory of the Diagnosis and Treatment of Organ TransplantationCAMS, First Affiliated HospitalSchool of MedicineZhejiang UniversityHangzhouChina
- Key Laboratory of Organ TransplantationFirst Affiliated HospitalSchool of MedicineZhejiang UniversityHangzhouChina
- Shulan Hospital (Hangzhou)HangzhouChina
| | - Hai Zhu
- NHC Key Laboratory of Combined Multi‐Organ TransplantationKey Laboratory of the Diagnosis and Treatment of Organ TransplantationCAMS, First Affiliated HospitalSchool of MedicineZhejiang UniversityHangzhouChina
- Key Laboratory of Organ TransplantationFirst Affiliated HospitalSchool of MedicineZhejiang UniversityHangzhouChina
- Department of Hepatobiliary SurgeryFirst Affiliated Hospital of Guangxi Medical UniversityNanningChina
| | - Junsheng Zhao
- Shulan International Medical CollegeZhejiang Shuren UniversityHangzhouChina
- Key Laboratory of Artificial Organs and Computational Medicine in Zhejiang ProvinceShulan International Medical CollegeZhejiang Shuren UniversityHangzhouChina
| | - Lu Yu
- Shulan International Medical CollegeZhejiang Shuren UniversityHangzhouChina
- Shulan Hospital (Hangzhou)HangzhouChina
- School of MedicineZhejiang Chinese Medical UniversityHangzhouChina
| | | | - Jun Xu
- Division of Hepatobiliary and Pancreatic SurgeryDepartment of SurgeryFirst Affiliated HospitalSchool of MedicineZhejiang UniversityHangzhouChina
| | - Lei Geng
- Division of Hepatobiliary and Pancreatic SurgeryDepartment of SurgeryFirst Affiliated HospitalSchool of MedicineZhejiang UniversityHangzhouChina
| | - Lin Zhou
- NHC Key Laboratory of Combined Multi‐Organ TransplantationKey Laboratory of the Diagnosis and Treatment of Organ TransplantationCAMS, First Affiliated HospitalSchool of MedicineZhejiang UniversityHangzhouChina
- Key Laboratory of Organ TransplantationFirst Affiliated HospitalSchool of MedicineZhejiang UniversityHangzhouChina
- Division of Hepatobiliary and Pancreatic SurgeryDepartment of SurgeryFirst Affiliated HospitalSchool of MedicineZhejiang UniversityHangzhouChina
| | - Luca Valenti
- Department of Pathophysiology and TransplantationUniversità degli Studi di MilanoMilanItaly
- Transfusion Medicine UnitFondazione IRCCS Ca’ Granda Ospedale Maggiore PoliclinicoMilanItaly
- Biological Resource Center UnitFondazione IRCCS Ca’ Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Shusen Zheng
- Shulan International Medical CollegeZhejiang Shuren UniversityHangzhouChina
- Key Laboratory of Artificial Organs and Computational Medicine in Zhejiang ProvinceShulan International Medical CollegeZhejiang Shuren UniversityHangzhouChina
- NHC Key Laboratory of Combined Multi‐Organ TransplantationKey Laboratory of the Diagnosis and Treatment of Organ TransplantationCAMS, First Affiliated HospitalSchool of MedicineZhejiang UniversityHangzhouChina
- Key Laboratory of Organ TransplantationFirst Affiliated HospitalSchool of MedicineZhejiang UniversityHangzhouChina
- Shulan Hospital (Hangzhou)HangzhouChina
- Division of Hepatobiliary and Pancreatic SurgeryDepartment of SurgeryFirst Affiliated HospitalSchool of MedicineZhejiang UniversityHangzhouChina
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3
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Acun A, Fan L, Oganesyan R, Uygun KM, Yeh H, Yarmush ML, Uygun BE. Effect of Donor Age and Liver Steatosis on Potential of Decellularized Liver Matrices to be used as a Platform for iPSC-Hepatocyte Culture. Adv Healthc Mater 2024; 13:e2302943. [PMID: 38266310 PMCID: PMC11102338 DOI: 10.1002/adhm.202302943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 11/13/2023] [Indexed: 01/26/2024]
Abstract
Decellularization of discarded whole livers and their recellularization with patient-specific induced pluripotent stem cells (iPSCs) to develop a functional organ is a promising approach to increasing the donor pool. The effect of extracellular matrix (ECM) of marginal livers on iPSC-hepatocyte differentiation and function has not been shown. To test the effect of donor liver ECM age and steatosis, young and old, as well as no, low, and high steatosis livers, are decellularized. All livers are decellularized successfully. High steatosis livers have fat remaining on the ECM after decellularization. Old donor liver ECM induces lower marker expression in early differentiation stages, compared to young liver ECM, while this difference is closed at later stages and do not affect iPSC-hepatocyte function significantly. High steatosis levels of liver ECM lead to higher albumin mRNA expression and secretion while at later stages of differentiation expression of major cytochrome (CYP) 450 enzymes is highest in low steatosis liver ECM. Both primary human hepatocytes and iPSC-hepatocytes show an increase in fat metabolism marker expression with increasing steatosis levels most likely induced by excess fat remaining on the ECM. Overall, removal of excess fat from liver ECM may be needed for inducing proper hepatic function after recellularization.
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Affiliation(s)
- Aylin Acun
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
- Shriners Children’s, Boston, Boston, MA, 02114, USA
- Department of Biomedical Engineering, Widener University, Chester, PA, 19013, USA
| | - Letao Fan
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
- Shriners Children’s, Boston, Boston, MA, 02114, USA
| | - Ruben Oganesyan
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
- Shriners Children’s, Boston, Boston, MA, 02114, USA
| | - Korkut M. Uygun
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
- Shriners Children’s, Boston, Boston, MA, 02114, USA
| | - Heidi Yeh
- Shriners Children’s, Boston, Boston, MA, 02114, USA
| | - Martin L. Yarmush
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
- Shriners Children’s, Boston, Boston, MA, 02114, USA
- Department of Biomedical Engineering, Rutgers University, Piscataway, NJ, 08854, USA
| | - Basak E. Uygun
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
- Shriners Children’s, Boston, Boston, MA, 02114, USA
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4
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Mazur RD, Cron DC, Chang DC, Yeh H, Dageforde LAD. Impact of Median MELD at Transplant Minus 3 National Policy on Quality of Transplanted Livers for Patients With and Without Hepatocellular Carcinoma. Transplantation 2024; 108:204-214. [PMID: 37189232 PMCID: PMC10651798 DOI: 10.1097/tp.0000000000004621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
BACKGROUND Patients with hepatocellular carcinoma (HCC) have been overprioritized in the deceased donor liver allocation system. The United Network for Organ Sharing adopted a policy in May 2019 that limited HCC exception points to the median Model for End-Stage Liver Disease at transplant in the listing region minus 3. We hypothesized this policy change would increase the likelihood to transplant marginal quality livers into HCC patients. METHODS This was a retrospective cohort study of a national transplant registry, including adult deceased donor liver transplant recipients with and without HCC from May 18, 2017, to May 18, 2019 (prepolicy) to May 19, 2019, to March 1, 2021 (postpolicy). Transplanted livers were considered of marginal quality if they met ≥1 of the following: (1) donation after circulatory death, (2) donor age ≥70, (3) macrosteatosis ≥30% and (4) donor risk index ≥95th percentile. We compared characteristics across policy periods and by HCC status. RESULTS A total of 23 164 patients were included (11 339 prepolicy and 11 825 postpolicy), 22.7% of whom received HCC exception points (prepolicy versus postpolicy: 26.1% versus 19.4%; P = 0.03). The percentage of transplanted donor livers meeting marginal quality criteria decreased for non-HCC (17.3% versus 16.0%; P < 0.001) but increased for HCC (17.7% versus 19.4%; P < 0.001) prepolicy versus postpolicy. After adjusting for recipient characteristics, HCC recipients had 28% higher odds of being transplanted with marginal quality liver independent of policy period (odds ratio: 1.28; confidence interval, 1.09-1.50; P < 0.01). CONCLUSIONS The median Model for End-Stage Liver Disease at transplant in the listing region minus 3 policy limited exception points and decreased the quality of livers received by HCC patients.
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Affiliation(s)
| | - David C Cron
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Heidi Yeh
- Division of Transplantation, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Leigh Anne D Dageforde
- Division of Transplantation, Department of Surgery, Massachusetts General Hospital, Boston, MA
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5
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Stewart D, Hasz R, Lonze B. Beyond donation to organ utilization in the USA. Curr Opin Organ Transplant 2023; 28:197-206. [PMID: 36912063 DOI: 10.1097/mot.0000000000001060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
PURPOSE OF REVIEW The deceased donor organ pool has broadened beyond young, otherwise healthy head trauma victims. But an abundance of donated organs only benefits patients if they are accepted, expeditiously transported and actually transplanted. This review focuses on postdonation challenges and opportunities to increase the number of transplants through improved organ utilization. RECENT FINDINGS We build upon recently proposed changes in terminology for measuring organ utilization. Among organs recovered for transplant, the nonuse rate (NUR REC ) has risen above 25% for kidneys and pancreata. Among donors, the nonuse rate (NUR DON ) has risen to 40% for livers and exceeds 70% for thoracic organs. Programme-level variation in offer acceptance rates vastly exceeds variation in the traditional, 1-year survival benchmark. Key opportunities to boost utilization include donation after circulatory death and hepatitis C virus (HCV)+ organs; acute kidney injury and suboptimal biopsy kidneys; older and steatotic livers. SUMMARY Underutilization of less-than-ideal, yet transplant-worthy organs remains an obstacle to maximizing the impact of the U.S. transplant system. The increased risk of inferior posttransplant outcomes must always be weighed against the risks of remaining on the waitlist. Advanced perfusion technologies; tuning allocation systems for placement efficiency; and data-driven clinical decision support have the potential to increase utilization of medically complex organs.
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Affiliation(s)
- Darren Stewart
- Department of Surgery, NYU Langone Health, New York, New York
| | - Richard Hasz
- Gift of Life Donor Program, Philadelphia, Pennsylvania, USA
| | - Bonnie Lonze
- Department of Surgery, NYU Langone Health, New York, New York
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6
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Kwong AJ, Kim WR, Lake J, Stock PG, Wang CJ, Wetmore JB, Melcher ML, Wey A, Salkowski N, Snyder JJ, Israni AK. Impact of Donor Liver Macrovesicular Steatosis on Deceased Donor Yield and Posttransplant Outcome. Transplantation 2023; 107:405-409. [PMID: 36042548 PMCID: PMC9877102 DOI: 10.1097/tp.0000000000004291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND The Scientific Registry of Transplant Recipients (SRTR) had not traditionally considered biopsy results in risk-adjustment models, yet biopsy results may influence outcomes and thus decisions regarding organ acceptance. METHODS Using SRTR data, which includes data on all donors, waitlisted candidates, and transplant recipients in the United States, we assessed (1) the impact of macrovesicular steatosis on deceased donor yield (defined as number of livers transplanted per donor) and 1-y posttransplant graft failure and (2) the effect of incorporating this variable into existing SRTR risk-adjustment models. RESULTS There were 21 559 donors with any recovered organ and 17 801 liver transplant recipients included for analysis. Increasing levels of macrovesicular steatosis on donor liver biopsy predicted lower organ yield: ≥31% macrovesicular steatosis on liver biopsy was associated with 87% to 95% lower odds of utilization, with 55% of these livers being discarded. The hazard ratio for graft failure with these livers was 1.53, compared with those with no pretransplant liver biopsy and 0% to 10% steatosis. There was minimal change on organ procurement organization-specific deceased donor yield or program-specific posttransplant outcome assessments when macrovesicular steatosis was added to the risk-adjustment models. CONCLUSIONS Donor livers with macrovesicular steatosis are disproportionately not transplanted relative to their risk for graft failure. To avoid undue risk aversion, SRTR now accounts for macrovesicular steatosis in the SRTR risk-adjustment models to help facilitate use of these higher-risk organs. Increased recognition of this variable may also encourage further efforts to standardize the reporting of liver biopsy results.
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Affiliation(s)
- Allison J. Kwong
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, CA
| | - W. Ray Kim
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, CA
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - John Lake
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, MN, USA
| | - Peter G. Stock
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
- Division of Transplantation, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Connie J. Wang
- Division of Nephrology, Hennepin County Medical Center, and University of Minnesota, Minneapolis, MN, USA
| | - James B. Wetmore
- Division of Nephrology, Hennepin County Medical Center, and University of Minnesota, Minneapolis, MN, USA
| | - Marc L. Melcher
- Department of Surgery, Stanford University, Palo Alto, CA, USA
| | - Andrew Wey
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Nicholas Salkowski
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Jon J. Snyder
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
- Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Ajay K. Israni
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
- Division of Nephrology, Hennepin County Medical Center, and University of Minnesota, Minneapolis, MN, USA
- Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, USA
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7
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Jiang Y, Da BL, Satiya J, Heda RP, Lau LF, Fahmy A, Winnick A, Roth N, Grodstein E, Thuluvath PJ, Singal AK, Schiano TD, Teperman LW, Satapathy SK. Outcomes after Liver Transplantation with Steatotic Grafts: Redefining Acceptable Cutoffs for Steatotic Grafts. Euroasian J Hepatogastroenterol 2022; 12:S5-S14. [DOI: 10.5005/jp-journals-10018-1361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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8
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Yuan M, Lin L, Cao H, Zheng W, Wu L, Zuo H, Tian X, Song H. Intestinal Microbiota Participates in the Protective Effect of HO-1/BMMSCs on Liver Transplantation With Steatotic Liver Grafts in Rats. Front Microbiol 2022; 13:905567. [PMID: 35756057 PMCID: PMC9226684 DOI: 10.3389/fmicb.2022.905567] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 05/03/2022] [Indexed: 11/13/2022] Open
Abstract
The present study aimed to explore whether heme oxygenase-1 (HO-1)-modified bone marrow mesenchymal stem cells (BMMSCs) have a protective effect on liver transplantation with steatotic liver grafts in rats, and to determine the role of the intestinal microbiota in such protection. HO-1/BMMSCs were obtained by transduction of Hmox1 gene [encoding heme oxygenase (HO-1)]-encoding adenoviruses into primary rat BMMSCs. Steatotic livers were obtained by feeding rats a high-fat diet, and a model of liver transplantation with steatotic liver grafts was established. The recipients were treated with BMMSCs, HO-1/BMMSCs, or neither, via the portal vein. Two time points were used: postoperative day 1 (POD 1) and POD 7. The results showed that under the effect of HO-1/BMMSCs, the degree of steatosis in the liver grafts was significantly reduced, and the level of liver enzymes and the levels of pro-inflammatory cytokines in plasma were reduced. The effect of HO-1/BMMSCs was better than that of pure BMMSCs in the prolongation of the rats' postoperative time. In addition, HO-1/BMMSCs promoted the recovery of recipients' intestinal structure and function, especially on POD 7. The intestinal villi returned to normal, the expression of tight junction proteins was restored, and intestinal permeability was reduced on POD 7. The intestinal bacterial of the LT group showed significantly weakened energy metabolism and overgrowth. On POD 1, the abundance of Akkermansiaceae was higher. On POD 7, the abundance of Clostridiaceae increased, the level of lipopolysaccharide increased, the intestinal mucosal barrier function was destroyed, and the levels of several invasive bacteria increased. When treated with HO-1/BMMSCs, the energy metabolism of intestinal bacteria was enhanced, and on POD 1, levels bacteria that protect the intestinal mucosa, such as Desulfovibrionaceae, increased significantly. On POD 7, the changed intestinal microbiota improved lipid metabolism and increased the levels of butyrate-producing bacteria, such as Lachnospiraceae. In conclusion, HO-1/BMMSCs have protective effects on steatotic liver grafts and the intestinal barrier function of the recipients. By improving lipid metabolism and increasing the abundance of butyrate-producing bacteria, the changed intestinal microbiota has a protective effect and prolongs the recipients' survival time.
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Affiliation(s)
- Mengshu Yuan
- Tianjin First Central Hospital Clinic Institute, Tianjin Medical University, Tianjin, China
| | - Ling Lin
- Tianjin First Central Hospital Clinic Institute, Tianjin Medical University, Tianjin, China
| | - Huan Cao
- Tianjin First Central Hospital Clinic Institute, Tianjin Medical University, Tianjin, China
| | - Weiping Zheng
- Department of Organ Transplantation, Tianjin First Central Hospital, Tianjin, China.,National Health Commission (NHC) Key Laboratory of Critical Care Medicine, Tianjin, China
| | - Longlong Wu
- School of Medicine, Nankai University, Tianjin, China
| | - Huaiwen Zuo
- Tianjin First Central Hospital Clinic Institute, Tianjin Medical University, Tianjin, China
| | - Xiaorong Tian
- Tianjin First Central Hospital Clinic Institute, Tianjin Medical University, Tianjin, China
| | - Hongli Song
- Department of Organ Transplantation, Tianjin First Central Hospital, Tianjin, China.,Tianjin Key Laboratory of Organ Transplantation, Tianjin, China
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9
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Altshuler PJ, Dang H, Frank AM, Shah AP, Glorioso J, Zhan T, Rios Diaz A, Shaheen O, Ramirez CB, Maley WR, Bodzin AS. Evaluating Outcomes Related to Donor and Recipient Metabolic Environment: Macrosteatotic Allografts and Nonalcoholic Steatohepatitis. Liver Transpl 2022; 28:623-635. [PMID: 34564931 PMCID: PMC10152802 DOI: 10.1002/lt.26313] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 09/13/2021] [Accepted: 09/17/2021] [Indexed: 12/19/2022]
Abstract
The increasing prevalence of nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) affects both recipient and donor populations in liver transplantation. Presently, it is unclear whether transplantation of macrosteatotic allografts is affected by the metabolic milieu of liver transplant recipients. This study investigates fatty liver disease at the intersection of donor and recipient. A retrospective review of the Organ Procurement and Transplantation database identified 5167 NASH and 26,289 non-NASH transplant recipients who received transplants from January 1, 2004, to June 12, 2020. A total of 12,569 donors had allografts with no macrosteatosis (<5%), 16,140 had mild macrosteatosis (5%-29%), and 2747 had moderate to severe macrosteatosis (≥30%). Comparing recipients with NASH to propensity score-matched (PSM) recipients without NASH demonstrated noninferior graft and patient survival up to 10 years in patients with NASH. Similar trends were observed in subgroup analyses of transplants within each strata of allograft macrosteatosis. Assessing allograft macrosteatosis specifically in the NASH population demonstrated that allografts with ≥30% macrosteatosis were associated with reduced early graft survival (30 days, 93.32% versus 96.54% [P = 0.02]; 1 year, 84.53% versus 88.99% [P = 0.05]) compared with PSM grafts with <30% macrosteatosis. Long-term graft survival at 5 and 10 years, however, was similar. The use of carefully selected macrosteatotic allografts can be successful in both recipients with NASH and recipients without NASH. The metabolic environment of patients with NASH does not appear to adversely affect outcomes with regard to the allograft when controlled for numerous confounders. It is, however, important to remain cognizant of the potential for high-risk macrosteatotic allografts to negatively affect outcomes.
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Affiliation(s)
- Peter J Altshuler
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Hien Dang
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Adam M Frank
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Ashesh P Shah
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Jaime Glorioso
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Tingting Zhan
- Division of Biostatistics, Department of Pharmacology & Experimental Therapeutics, Thomas Jefferson University, Philadelphia, PA
| | - Arturo Rios Diaz
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Osama Shaheen
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Carlo B Ramirez
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Warren R Maley
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Adam S Bodzin
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA
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10
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Ruck JM, Jackson KR, Motter JD, Massie AB, Philosophe B, Cameron AM, Ottmann SE, Wesson R, Gurakar AO, Segev DL, Garonzik-Wang J. Temporal Trends in Utilization and Outcomes of DCD Livers in the United States. Transplantation 2022; 106:543-551. [PMID: 34259435 DOI: 10.1097/tp.0000000000003878] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Historically, donation after circulatory death (DCD) livers were frequently discarded because of higher mortality and graft loss after liver transplantation (LT). However, the demand for LT continues to outstrip the supply of "acceptable" organs. Additionally, changes in the donor pool, organ allocation, and clinical management of donors and recipients, and improved clinical protocols might have altered post-DCD-LT outcomes. METHODS We studied 5975 recovered DCD livers using US Scientific Registry of Transplant Recipients data from 2005 to 2017, with a comparison group of 78 235 adult donation after brain death (DBD) livers recovered during the same time period. We quantified temporal trends in discard using adjusted multilevel logistic regression and temporal trends in post-LT mortality and graft loss for DCD LT recipients using adjusted Cox regression. RESULTS DCD livers were more likely to be discarded than DBD livers across the entire study period, and the relative likelihood of discard increased over time (adjusted odds ratio [aOR] of discard DCD versus DBD 3.854.455.14 2005-2007, 5.225.876.59 2015-2017) despite improving outcomes after DCD LT. Mortality risk for DCD LTs decreased in each time period (compared with 2005-2007, aHR 2008-2011 0.720.840.97, aHR 2012-2014 0.480.580.70, aHR 2015-2017 0.340.430.55), as did risk of graft loss (compared with 2005-2007, aHR 2008-2011 0.690.810.94, aHR 2012-2014 0.450.550.67, aHR 2015-2017 0.360.450.56). CONCLUSIONS Despite dramatic improvements in outcomes of DCD LT recipients, DCD livers remain substantially more likely to be discarded than DBD livers, and this discrepancy has actually increased over time. DCD livers are underutilized and have the potential to expand the donor pool.
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Affiliation(s)
- Jessica M Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kyle R Jackson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jennifer D Motter
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Allan B Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Benjamin Philosophe
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andrew M Cameron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Shane E Ottmann
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Russell Wesson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ahmet O Gurakar
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.,Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD.,Scientific Registry of Transplant Recipients, Minneapolis, MN
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Purvis JW, Orandi BJ, Dhall D, McLeod C, Sanchez LHG, Gray M, Frey K, Sheikh SS, Cannon RM, Terrault NA, Lewis CE, Locke JE. Hepatic macrosteatosis in the US pediatric deceased liver donor population. Pediatr Transplant 2022; 26:e14155. [PMID: 34590386 PMCID: PMC8752486 DOI: 10.1111/petr.14155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 08/04/2021] [Accepted: 09/19/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION The pediatric obesity epidemic is associated with early development of hepatic macrosteatosis, a hallmark of non-alcoholic fatty LI disease, which is thought to be more rapidly progressive in children than adults. Macrosteatosis in adult allografts is associated with allograft loss, but this has not been examined in pediatric donors. METHODS We studied all pediatric potential whole LI donors (2005-2018) who had a LI biopsy in the SRTR (n = 862) and whose LI was transplanted (n = 862). Macrosteatosis was abstracted from biopsy reports and compared to values in the SRTR standard analytic file. Recipients of macrosteatotic pediatric allografts were matched 1:1 to recipients of non-macrosteatotic pediatric allografts by propensity score matching on donor/recipient variables. All-cause allograft loss was estimated via Kaplan-Meier analysis and Cox proportional hazards model. RESULTS From 2005 to 2018, the proportion of pediatric donors (age ≥2 years) with obesity increased (14.8% to 21.7%; p < .001), as did the proportion of pediatric deceased whole LI-only donor allografts with macrosteatosis (n = 10 648; 1.8% to 3.9%; p < .001). The median degree of macrosteatosis among macrosteatotic donors was 10% (IQR 5-30). There were no significant differences in all-cause allograft loss between recipients of pediatric LI allografts with and without macrosteatosis at 90 days (p = .11) or 1 year (p = .14) post-transplant in Kaplan-Meier analysis or a Cox proportional hazards model (p > .05). CONCLUSION Obese pediatric LI donors have increased over time and were more likely to have hepatic macrosteatosis; however, pediatric macrosteatosis did not appear to adversely affect recipient outcomes.
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Affiliation(s)
- Joshua W. Purvis
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation; Birmingham, AL
| | - Babak J. Orandi
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation; Birmingham, AL
| | - Deepti Dhall
- University of Alabama at Birmingham, Department of Pathology; Birmingham, AL
| | - Chandler McLeod
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation; Birmingham, AL
| | - Luz Helena Gutierrez Sanchez
- University of Alabama at Birmingham, Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Birmingham, Alabama
| | - Meagan Gray
- University of Alabama at Birmingham, Department of Medicine, Division of Gastroenterology and Hepatology
| | - Kayla Frey
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation; Birmingham, AL
| | - Saulat S. Sheikh
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation; Birmingham, AL
| | - Robert M. Cannon
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation; Birmingham, AL
| | - Norah A. Terrault
- University of Southern California Keck School of Medicine, Department of Medicine, Division of Gastrointestinal and Liver Diseases
| | - Cora E. Lewis
- University of Alabama at Birmingham, School of Public Health, Department of Epidemiology
| | - Jayme E. Locke
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation; Birmingham, AL
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A Clinical Tool to Guide Selection and Utilization of Marginal Donor Livers With Graft Steatosis in Liver Transplantation. Transplant Direct 2022; 8:e1280. [PMID: 35047662 PMCID: PMC8759620 DOI: 10.1097/txd.0000000000001280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 11/03/2021] [Accepted: 11/19/2021] [Indexed: 11/26/2022] Open
Abstract
Supplemental Digital Content is available in the text. Background. Donor liver biopsy (DLBx) in liver transplantation provides information on allograft quality; however, predicting outcomes from these allografts remains difficult. Methods. Between 2006 and 2015, 16 691 transplants with DLBx were identified from the Standard Transplant Analysis and Research database. Cox proportional hazard regression analyses identified donor and recipient characteristics associated with 30-d, 90-d, 1-y, and 3-y graft survival. A composite model, the Liver Transplant After Biopsy (LTAB) score, was created. The Mini-LTAB was then derived consisting of only donor age, macrosteatosis on DLBx, recipient model for end-stage liver disease score, and cold ischemic time. Risk groups were identified for each score and graft survival was evaluated. P values <0.05 were considered significant. Results. The LTAB model used 14 variables and 5 risk groups and identified low-, mild-, moderate-, high-, and severe-risk groups. Compared with moderate-risk recipients, severe-risk recipients had increased risk of graft loss at 30 d (hazard ratio, 3.270; 95% confidence interval, 2.568-4.120) and at 1 y (2.258; 1.928-2.544). The Mini-LTAB model identified low-, moderate-, and high-risk groups. Graft survival in Mini-LTAB high-risk transplants was significantly lower than moderate- or low-risk transplants at all time points. Conclusions. The LTAB and Mini-LTAB scores represent guiding principles and provide clinically useful tools for the successful selection and utilization of marginal allografts in liver transplantation.
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13
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Reexamining Risk Aversion: Willingness to Pursue and Utilize Nonideal Donor Livers Among US Donation Service Areas. Transplant Direct 2021; 7:e742. [PMID: 34386579 PMCID: PMC8352624 DOI: 10.1097/txd.0000000000001173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 04/15/2021] [Accepted: 04/17/2021] [Indexed: 01/10/2023] Open
Abstract
Background Livers from "nonideal" but acceptable donors are underutilized; however, organ procurement organization (OPO) metrics do not assess how OPO-specific practices contribute to these trends. In this analysis, we evaluated nonideal liver donor avoidance or risk aversion among OPOs and within US donation service areas (DSAs). Methods Adult donors in the United Network for Organ Sharing registry who donated ≥1 organ for transplantation between 2007 and 2019 were included. Nonideal donors were defined by any of the following: age > 70, hepatitis C seropositive, body mass index > 40, donation after circulatory death, or history of malignancy. OPO-specific performance was evaluated based on rates of nonideal donor pursuit and consent attainment. DSA performance (OPO + transplant centers) was evaluated based on rates of nonideal donor pursuit, consent attainment, liver recovery, and transplantation. Lower rates were considered to represent increased donor avoidance or increased risk aversion. Results Of 97 911 donors, 31 799 (32.5%) were nonideal. Unadjusted OPO-level rates of nonideal donor pursuit ranged from 88% to 100%. In a 5-tier system of overall risk aversion, tier 5 DSAs (least risk-averse) and tier 1 DSAs (most risk-averse) had the highest and lowest respective rates of non-ideal donor pursuit, consent attainment, liver recovery, and transplantation. On average, recovery rates were over 25% higher among tier 5 versus tier 1 DSAs. If tier 1 DSAs had achieved the same average liver recovery rate as tier 5 DSAs, approximately 2100 additional livers could have been recovered during the study period. Conclusion Most OPOs aggressively pursue nonideal liver donors; however, recovery practices vary widely among DSAs. Fair OPO evaluations should consider early donation process stages to best disentangle OPO and center-level practices.
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Ritschl PV, Günther J, Hofhansel L, Ernst S, Ebner S, Sattler A, Weiß S, Weissenbacher A, Oberhuber R, Cardini B, Öllinger R, Biebl M, Denecke C, Margreiter C, Resch T, Schneeberger S, Maglione M, Kotsch K, Pratschke J. Perioperative Perfusion of Allografts with Anti-Human T-lymphocyte Globulin Does Not Improve Outcome Post Liver Transplantation-A Randomized Placebo-Controlled Trial. J Clin Med 2021; 10:jcm10132816. [PMID: 34202355 PMCID: PMC8267618 DOI: 10.3390/jcm10132816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 06/05/2021] [Accepted: 06/17/2021] [Indexed: 11/16/2022] Open
Abstract
Due to the lack of suitable organs transplant surgeons have to accept unfavorable extended criteria donor (ECD) organs. Recently, we demonstrated that the perfusion of kidney organs with anti-human T-lymphocyte globulin (ATLG) prior to transplantation ameliorates ischemia-reperfusion injury (IRI). Here, we report on the results of perioperative ATLG perfusion in a randomized, single-blinded, placebo-controlled, feasibility trial (RCT) involving 30 liver recipients (LTx). Organs were randomly assigned for perfusion with ATLG/Grafalon® (AP) (n = 16) or saline only (control perfusion = CP) (n = 14) prior to implantation. The primary endpoint was defined as graft function reflected by aspartate transaminase (AST) values at day 7 post-transplantation (post-tx). With respect to the primary endpoint, no significant differences in AST levels were shown in the intervention group at day 7 (AP: 53.0 ± 21.3 mg/dL, CP: 59.7 ± 59.2 mg/dL, p = 0.686). Similarly, exploratory analysis of secondary clinical outcomes (e.g., patient survival) and treatment-specific adverse events revealed no differences between the study groups. Among liver transplant recipients, pre-operative organ perfusion with ATLG did not improve short-term outcomes, compared to those who received placebo perfusion. However, ATLG perfusion of liver grafts was proven to be a safe procedure without the occurrence of relevant adverse events.
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Affiliation(s)
- Paul Viktor Ritschl
- Department of Surgery, Campus Charité-Mitte and Campus Virchow-Klinikum, Charité—Universitätsmedizin Berlin, 13353 Berlin, Germany; (P.V.R.); (S.W.); (R.Ö.); (M.B.); (C.D.); (J.P.)
- Clinician Scientist Program, Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Str. 2, 10178 Berlin, Germany
| | - Julia Günther
- Center for Operative Medicine, Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, 5020 Innsbruck, Austria; (J.G.); (L.H.); (S.E.); (A.W.); (R.O.); (B.C.); (C.M.); (T.R.); (S.S.); (M.M.)
| | - Lena Hofhansel
- Center for Operative Medicine, Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, 5020 Innsbruck, Austria; (J.G.); (L.H.); (S.E.); (A.W.); (R.O.); (B.C.); (C.M.); (T.R.); (S.S.); (M.M.)
- Department of Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, RWTH Aachen, 52074 Aachen, Germany
| | - Stefanie Ernst
- Biostatistics Unit, Clinical Research Unit, Berlin Institute of Health, Charité—Universitätsmedizin Berlin, 10117 Berlin, Germany;
| | - Susanne Ebner
- Center for Operative Medicine, Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, 5020 Innsbruck, Austria; (J.G.); (L.H.); (S.E.); (A.W.); (R.O.); (B.C.); (C.M.); (T.R.); (S.S.); (M.M.)
| | - Arne Sattler
- Department of General, Visceral- and Vascular Surgery, Campus Benjamin Franklin, Charité—Universitätsmedizin Berlin, 12203 Berlin, Germany;
| | - Sascha Weiß
- Department of Surgery, Campus Charité-Mitte and Campus Virchow-Klinikum, Charité—Universitätsmedizin Berlin, 13353 Berlin, Germany; (P.V.R.); (S.W.); (R.Ö.); (M.B.); (C.D.); (J.P.)
| | - Annemarie Weissenbacher
- Center for Operative Medicine, Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, 5020 Innsbruck, Austria; (J.G.); (L.H.); (S.E.); (A.W.); (R.O.); (B.C.); (C.M.); (T.R.); (S.S.); (M.M.)
| | - Rupert Oberhuber
- Center for Operative Medicine, Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, 5020 Innsbruck, Austria; (J.G.); (L.H.); (S.E.); (A.W.); (R.O.); (B.C.); (C.M.); (T.R.); (S.S.); (M.M.)
| | - Benno Cardini
- Center for Operative Medicine, Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, 5020 Innsbruck, Austria; (J.G.); (L.H.); (S.E.); (A.W.); (R.O.); (B.C.); (C.M.); (T.R.); (S.S.); (M.M.)
| | - Robert Öllinger
- Department of Surgery, Campus Charité-Mitte and Campus Virchow-Klinikum, Charité—Universitätsmedizin Berlin, 13353 Berlin, Germany; (P.V.R.); (S.W.); (R.Ö.); (M.B.); (C.D.); (J.P.)
| | - Matthias Biebl
- Department of Surgery, Campus Charité-Mitte and Campus Virchow-Klinikum, Charité—Universitätsmedizin Berlin, 13353 Berlin, Germany; (P.V.R.); (S.W.); (R.Ö.); (M.B.); (C.D.); (J.P.)
| | - Christian Denecke
- Department of Surgery, Campus Charité-Mitte and Campus Virchow-Klinikum, Charité—Universitätsmedizin Berlin, 13353 Berlin, Germany; (P.V.R.); (S.W.); (R.Ö.); (M.B.); (C.D.); (J.P.)
| | - Christian Margreiter
- Center for Operative Medicine, Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, 5020 Innsbruck, Austria; (J.G.); (L.H.); (S.E.); (A.W.); (R.O.); (B.C.); (C.M.); (T.R.); (S.S.); (M.M.)
| | - Thomas Resch
- Center for Operative Medicine, Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, 5020 Innsbruck, Austria; (J.G.); (L.H.); (S.E.); (A.W.); (R.O.); (B.C.); (C.M.); (T.R.); (S.S.); (M.M.)
| | - Stefan Schneeberger
- Center for Operative Medicine, Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, 5020 Innsbruck, Austria; (J.G.); (L.H.); (S.E.); (A.W.); (R.O.); (B.C.); (C.M.); (T.R.); (S.S.); (M.M.)
| | - Manuel Maglione
- Center for Operative Medicine, Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, 5020 Innsbruck, Austria; (J.G.); (L.H.); (S.E.); (A.W.); (R.O.); (B.C.); (C.M.); (T.R.); (S.S.); (M.M.)
| | - Katja Kotsch
- Department of General, Visceral- and Vascular Surgery, Campus Benjamin Franklin, Charité—Universitätsmedizin Berlin, 12203 Berlin, Germany;
- Correspondence: ; Tel.: +49-30-450-552247
| | - Johann Pratschke
- Department of Surgery, Campus Charité-Mitte and Campus Virchow-Klinikum, Charité—Universitätsmedizin Berlin, 13353 Berlin, Germany; (P.V.R.); (S.W.); (R.Ö.); (M.B.); (C.D.); (J.P.)
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15
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Moosburner S, Sauer IM, Förster F, Winklmann T, Gassner JMGV, Ritschl PV, Öllinger R, Pratschke J, Raschzok N. Early Allograft Dysfunction Increases Hospital Associated Costs After Liver Transplantation-A Propensity Score-Matched Analysis. Hepatol Commun 2021; 5:526-537. [PMID: 33681684 PMCID: PMC7917275 DOI: 10.1002/hep4.1651] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 10/07/2020] [Accepted: 11/05/2020] [Indexed: 12/16/2022] Open
Abstract
Concepts to ameliorate the continued mismatch between demand for liver allografts and supply include the acceptance of allografts that meet extended donor criteria (ECD). ECD grafts are generally associated with an increased rate of complications such as early allograft dysfunction (EAD). The costs of liver transplantation for the health care system with respect to specific risk factors remain unclear and are subject to change. We analyzed 317 liver transplant recipients from 2013 to 2018 for outcome after liver transplantation and hospital costs in a German transplant center. In our study period, 1-year survival after transplantation was 80.1% (95% confidence interval: 75.8%-84.6%) and median hospital stay was 33 days (interquartile rage: 24), with mean hospital costs of €115,924 (SD €113,347). There was a positive correlation between costs and laboratory Model for End-Stage Liver Disease score (rs = 0.48, P < 0.001), and the development of EAD increased hospital costs by €26,229. ECD grafts were not associated with a higher risk of EAD in our cohort. When adjusting for recipient-associated risk factors such as laboratory Model for End-Stage Liver Disease score, recipient age, and split liver transplantation with propensity score matching, only EAD and cold ischemia increased total costs. Conclusion: Our data show that EAD leads to significantly higher hospital costs for liver transplantation, which are primarily attributed to recipient health status. Strategies to reduce the incidence of EAD are needed to control costs in liver transplantation.
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Affiliation(s)
- Simon Moosburner
- Department of SurgeryCharité-Universitätsmedizin BerlinCampus Charité MitteCampus Virchow-KlinikumCorporate Member of Freie Universität BerlinHumboldt-Universität zu Berlin and Berlin Institute of HealthBerlinGermany
| | - Igor M Sauer
- Department of SurgeryCharité-Universitätsmedizin BerlinCampus Charité MitteCampus Virchow-KlinikumCorporate Member of Freie Universität BerlinHumboldt-Universität zu Berlin and Berlin Institute of HealthBerlinGermany
| | - Frank Förster
- Corporate ControllingCharité-Universitätsmedizin BerlinCorporate Member of Freie Universität BerlinHumboldt-Universität zu Berlin and Berlin Institute of HealthBerlinGermany
| | - Thomas Winklmann
- Department of SurgeryCharité-Universitätsmedizin BerlinCampus Charité MitteCampus Virchow-KlinikumCorporate Member of Freie Universität BerlinHumboldt-Universität zu Berlin and Berlin Institute of HealthBerlinGermany
| | - Joseph Maria George Vernon Gassner
- Department of SurgeryCharité-Universitätsmedizin BerlinCampus Charité MitteCampus Virchow-KlinikumCorporate Member of Freie Universität BerlinHumboldt-Universität zu Berlin and Berlin Institute of HealthBerlinGermany
| | - Paul V Ritschl
- Department of SurgeryCharité-Universitätsmedizin BerlinCampus Charité MitteCampus Virchow-KlinikumCorporate Member of Freie Universität BerlinHumboldt-Universität zu Berlin and Berlin Institute of HealthBerlinGermany
| | - Robert Öllinger
- Department of SurgeryCharité-Universitätsmedizin BerlinCampus Charité MitteCampus Virchow-KlinikumCorporate Member of Freie Universität BerlinHumboldt-Universität zu Berlin and Berlin Institute of HealthBerlinGermany
| | - Johann Pratschke
- Department of SurgeryCharité-Universitätsmedizin BerlinCampus Charité MitteCampus Virchow-KlinikumCorporate Member of Freie Universität BerlinHumboldt-Universität zu Berlin and Berlin Institute of HealthBerlinGermany
| | - Nathanael Raschzok
- Department of SurgeryCharité-Universitätsmedizin BerlinCampus Charité MitteCampus Virchow-KlinikumCorporate Member of Freie Universität BerlinHumboldt-Universität zu Berlin and Berlin Institute of HealthBerlinGermany
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16
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Usefulness of Controlled Attenuation Parameter and Liver Stiffness Measurement for the Identification of Extended-criteria Donors and Risk-assessment in Liver Transplantation. Transplantation 2021; 106:318-327. [PMID: 33675319 DOI: 10.1097/tp.0000000000003720] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Controlled attenuation parameter (CAP) and liver stiffness measurement (LSM) are noninvasive surrogates for hepatic steatosis and fibrosis, respectively, and could help identify extended criteria donors in liver transplantation (LT). We aimed to determine the accuracy of CAP/LSM in deceased donors along with post-LT changes. METHODS Accuracy of preprocurement CAP/LSM to grade/stage steatosis/fibrosis was determined using liver biopsy as reference. Transplant outcomes, including primary nonfunction (PNF) and early allograft dysfunction (EAD), were recorded. Recipients underwent CAP/LSM as outpatients. Areas under the receiver operating characteristic curve (AUROC) and regression models were constructed to analyze data. RESULTS We prospectively evaluated 160 allografts (138 transplanted). Same-probe paired baseline/post-LT CAP was 231 dB/m (181-277) / 225 (187-261) (p=0.61), and LSM 7.6 kPa (6.3-10.8) / 5.9 (4.6-8.7) (p=0.002), respectively. CAP reading was affected by BMI and LSM by ALT, race and bilirubin. Although CAP did not correlate with steatosis from frozen sections (rho=0.08; p=0.47), it correlated with steatosis from permanent sections (rho=0.32; p<0.001) and with oil red O histomorphometry (rho=0.35, p=0.001). CAP identified moderate-to-severe steatosis with an AUROC curve of 0.79 (0.66-0.91), for a negative predictive value of 100% at a cutoff value of 230 dB/m. LSM correlated with fibrosis staging (rho=0.22, p=0.007) and it identified discarded allografts with advanced fibrosis/cirrhosis. Patients with no to minimal fibrosis had an LSM of 7.6 (6-10.1) kPa. CONCLUSIONS Our results are proof-of-concept of the utility of CAP/LSM during organ procurement. Establishing the precise role of these noninvasive tools in the organ allocation process mandates confirmatory studies.
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Fagenson AM, Pitt HA, Moten AS, Karhadkar SS, Di Carlo A, Lau KN. Fatty liver: The metabolic syndrome increases major hepatectomy mortality. Surgery 2020; 169:1054-1060. [PMID: 33358472 DOI: 10.1016/j.surg.2020.11.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 11/01/2020] [Accepted: 11/17/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND As the obesity epidemic worsens, the prevalence of fatty liver disease has increased. However, minimal data exist on the impact of combined fatty liver and metabolic syndrome on hepatectomy outcomes. Therefore, the aim of this analysis is to measure the outcomes of patients who do and do not have a fatty liver undergoing hepatectomy in the presence and absence of the metabolic syndrome. METHODS Patients with fatty and normal livers undergoing major hepatectomy (≥3 segments) were identified in the 2014 to 2018 American College of Surgeon National Surgical Quality Improvement Program database. Patients undergoing partial hepatectomy and those with missing liver texture data were excluded. Propensity matching was used and adjusted for multiple variables. A subgroup analysis stratified by the metabolic syndrome (body mass index ≥30 kg/m2, hypertension and diabetes) was performed. Demographics and outcomes were compared by χ2 and Mann-Whitney tests. RESULTS Of 2,927 hepatectomies, 30% of patients (N = 863) had a fatty liver. The median body mass index was 28.6, and the metabolic syndrome was present in 6.3% of patients (N = 184). After propensity matching, 863 patients with fatty and 863 with normal livers were compared. Multiple outcomes were significantly worse in patients with fatty livers (P <.05), including serious morbidity (32% vs 24%), postoperative invasive biliary procedures (15% vs 10%), organ space infections (11% vs 7.8%), and pulmonary complications. Patients with fatty livers and the metabolic syndrome had significantly increased postoperative cardiac arrests, pulmonary embolisms, and mortality (P < .05). CONCLUSION Fatty liver disease is associated with significantly worse outcomes after major hepatectomy. The metabolic syndrome confers an increased risk of postoperative mortality.
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Affiliation(s)
| | - Henry A Pitt
- Department of Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Ambria S Moten
- Department of Surgery, Temple University Hospital, Philadelphia, PA
| | | | - Antonio Di Carlo
- Department of Surgery, Temple University Hospital, Philadelphia, PA
| | - Kwan N Lau
- Department of Surgery, Temple University Hospital, Philadelphia, PA.
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Goldaracena N, Cullen JM, Kim DS, Ekser B, Halazun KJ. Expanding the donor pool for liver transplantation with marginal donors. Int J Surg 2020; 82S:30-35. [PMID: 32422385 DOI: 10.1016/j.ijsu.2020.05.024] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 05/06/2020] [Accepted: 05/12/2020] [Indexed: 12/16/2022]
Abstract
The current supply of acceptable donor livers is not sufficient to meet the demands of listed patients awaiting transplantation resulting in thousands of deaths each year. Increased utilization of marginal livers may help alleviate this supply/demand mismatch by expanding the donor liver pool. The current status of liver transplantation using marginal donor grafts and efforts to optimize usage are discussed with attention to elderly donors, steatotic livers, donors after circulatory death, and split liver grafts.
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Affiliation(s)
- Nicolas Goldaracena
- Department of Surgery, Division of Transplant Surgery, University of Virginia, Charlottesville, VA, USA.
| | - J Michael Cullen
- Department of Surgery, Division of Transplant Surgery, University of Virginia, Charlottesville, VA, USA.
| | - Dong-Sik Kim
- Division of HBP Surgery & Liver Transplantation, Department of Surgery, Korea University College of Medicine, Seoul, South Korea.
| | - Burcin Ekser
- Division of Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Karim J Halazun
- Department of Surgery, Division of Liver Transplantation and Hepatobiliary Surgery, Weill Cornell Medical College, New York, NY, USA.
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