Collaborative Approach Toward Transplant Candidacy for Obese Patients with End-Stage Renal Disease

BACKGROUND

An elevated BMI is a major cause of transplant preclusion for patients with end-stage renal disease (ESRD). This phenomenon exacerbates existing socioeconomic and racial disparities and increases the economic burden of maintaining patients on dialysis. Metabolic bariatric surgery (MBS) in such patients is not widely available. Our center created a collaborative program to undergo weight loss surgery before obtaining a kidney transplant.

STUDY DESIGN

We studied the outcomes of these patients after MBS and transplant surgery. One hundred eighty-three patients with ESRD were referred to the bariatric team by the transplant team between January 2019 and June 2023. Of these, 36 patients underwent MBS (20 underwent Roux-en-Y gastric bypass and 16 underwent sleeve gastrectomy), and 10 underwent subsequent transplantation, with another 15 currently waitlisted. Both surgical teams shared resources, including dieticians, social workers, and a common database, for easy transition between teams.

RESULTS

The mean starting BMI for all referrals was 46.4 kg/m 2 and was 33.9 kg/m 2 at the time of transplant. The average number of hypertension medications decreased from 2 (range 2 to 4) presurgery to 1 (range 1 to 3) postsurgery. Similarly, hemoglobin A1C levels improved, with preoperative averages at 6.2 (range 5.4 to 7.6) and postoperative levels at 5.2 (range 4.6 to 5.8) All transplants are currently functioning, with a median creatinine of 1.5 (1.2 to 1.6) mg/dL (glomerular filtration rate 46 [36.3 to 71]).

CONCLUSIONS

A collaborative approach between bariatric and transplant surgery teams offers a pathway toward transplant for obese ESRD patients and potentially alleviates existing healthcare disparities. ESRD patients who undergo MBS have unique complications to be aware of. The improvement in comorbidities may lead to superior posttransplant outcomes.

Nutritional Considerations for Patients With Renal Failure Undergoing Sleeve Gastrectomy

Obesity is highly prevalent in patients with renal disease, as it contributes to or accelerates the progression of kidney disease and is frequently a barrier to kidney transplantation. Patients with renal disease have unique dietary needs due to various metabolic disturbances resulting from altered processing and clearance of nutrients. They also frequently present with physical disability, resulting in difficulty achieving adequate weight loss through lifestyle modifications. Therefore, kidney transplant candidates may benefit from bariatric surgery, particularly sleeve gastrectomy (SG), as the safest, most effective, and long-lasting weight loss option to improve comorbidities and access to transplantation. However, concerns regarding nutritional risks prevent broader dissemination of SG in this population. No specific guidelines tailored to the nutritional needs of patients with renal disease undergoing SG have been developed. Moreover, appropriate monitoring strategies and interventions for muscle loss and functional status preservation, a major concern in this at-risk population, are unknown. We aimed to summarize the available literature on the nutritional requirements of patients with renal disease seeking SG as a bridge to transplantation. We also provide insight and guidance into the nutritional management pre and post-SG.

De novo malignancy in recipients of solid organ transplant from donors with intracranial cancer

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Background: In 2016, 33,610 organ transplants were performed in the US. Nevertheless, there is a critical deficiency of available organs. Currently, malignant neoplasms in the donor preclude organ donation, with some exceptions, such as certain CNS tumors without metastatic disease. The literature illustrates the risk of CNS tumor transmission with organ transplantation as 0-3% in the absence of additional risk factors, but organs from fewer than 0.5% of the 13,000 patients that die of glioma annually are procured. Given the critical need, we sought to reaffirm the safety of organs from donors with intracranial cancer by examining de novo malignancy outcomes in a large dataset. Methods: We examined the UNOS database to determine whether recipients of solid organ transplant from donors with intracranial cancer were at increased risk of de novo malignancy. Included were 119,430 subjects ages 18 to 65 who underwent heart, heart and lung, intestine, kidney, kidney and pancreas, liver, lung, or pancreas transplant from 1987 to 2012 and for whom there was complete data on donor history of intracranial cancer. 2-by-2 contingency tables were used to calculate odds ratios of exposure to donors with intracranial cancer. Outcomes included five-year survival, composite development of any malignancy, and development of specific malignancies including melanoma, esophageal, stomach, small intestine, pancreas, larynx, mouth, colorectal, primary liver tumor, and metastasis to liver. A p value of ≤ 0.05 was statistically significant. Results: 718 (0.60%) organs came from donors with intracranial cancer. 437 (79.02%) recipients of organs from donors with intracranial cancer survived 5 years, versus 71,055 (77.64%) recipients of organs from donors without intracranial cancer (p = 0.47). 113 (15.74%) recipients of organs from donors with intracranial cancer developed de novo malignancy, versus 17,963 (15.13%) recipients of organs from donors without intracranial cancer (p = 0.60). Of 17 contingency analyses of development of specific malignancies, we detected only 1 statistically significant positive association, de novo colorectal cancer in recipients of solid organ transplant from donors with intracranial cancer (p = 0.048, OR = 2.56). Given the large number of analyses and marginal significance of this in a very large dataset, it is likely type I error. Conclusions: Metastasis of primary CNS tumors beyond the CNS is a rare occurrence without additional risk factors. With the current organ shortage, donors with primary CNS malignancy are ideal candidates for organ donation.

Organ Donor Management: Part 1. Toward a Consensus to Guide Anesthesia Services During Donation After Brain Death

Worldwide 715 482 patients have received a lifesaving organ transplant since 1988. During this time, there have been advances in donor management and in the perioperative care of the organ transplant recipient, resulting in marked improvements in long-term survival. Although the number of organs recovered has increased year after year, a greater demand has produced a critical organ shortage. The majority of organs are from deceased donors; however, some are not suitable for transplantation. Some of this loss is due to management of the donor. Improved donor care may increase the number of available organs and help close the existing gap in supply and demand. In order to address this concern, The Organ Donation and Transplantation Alliance, the Association of Organ Procurement Organizations, and the Transplant and Critical Care Committees of the American Society of Anesthesiologists have formulated evidence-based guidelines, which include a call for greater involvement and oversight by anesthesiologists and critical care specialists, as well as uniform reporting of data during organ procurement and recovery.

Liver transplantation in New Orleans: parity in a world of disparity?

BACKGROUND

Racial disparity in access to liver transplantation among African Americans (AA) compared to Caucasians (CA) has been well described. The aim of this investigation was to examine the presentation of AA liver transplant recipients in a socioeconomically challenged region.

METHODS

680 adult liver transplant candidates and 233 resultant recipients between 2007 and 2015 were analyzed using univariate and multivariate analyses to evaluate factors significant for transplantation.

RESULTS

Percentages of wait list patients transplanted were similar between CA and AA (34.9% vs. 32.2%, p = 0.5205). AA were younger (50.4 ± 1.8 vs. 56.3 ± 0.7 yrs, p = 0.0003) with higher average MELD scores (22.9 ± 1.6 vs. 19.4 ± 0.7, p = 0.0230). Overall patient mortality was similar (AA 22.7% vs. CA 26.3%, p = 0.5931). A multiple linear regression showed that male gender was strongly associated with transplantation.

CONCLUSIONS

Equal access to liver transplantation remains challenging for racial minorities. At our institution, AA were accepted and transplanted at an equivalent rate as CA despite a higher AA population, HCV rate and diagnosed HCC. AA were younger and sicker at the time of transplant, but overall had similar outcomes compared to CA. Our study highlights the need for studies to delineate the underpinnings of disparity in transplantation access.

OPO Strategies to Prevent Unintended Use of Kidneys Exported for High PRA (>98% cPRA) Recipients

Since the advent of the Kidney Allocation System (KAS), matched candidates with high (>98%) panel reactive antibody (hPRA) are given priority over local candidates with lower PRA. This often leads to exporting of kidneys. Data for these kidneys are not detailed on routine reports. Twenty-two organ procurement organizations prospectively submitted data from August 2015 to July 2016, describing allocation practices of kidneys to hPRA patients and outcomes of these kidneys. Five hundred twenty out of 6924 procured kidneys were exported for hPRA recipients. Of these, 402 (77.3%) were transplanted into the intended recipient (IR); 100 (19.2%) were transplanted into unintended recipients (UR), and 18 (3.5%) were discarded. The most common reason for use in an UR was a positive crossmatch (XM) (63%). The most common reasons for discard were donor quality (44%) and ischemic time (39%). Prior to kidney export, when tissue crossmatching was done, 96.2% of the kidneys went to the IR, versus 80.7% following virtual CM, versus 56.7% when no crossmatching was performed (p < 0.0001). A significant number of kidneys exported for hPRA patients are not being used in the IR or are being discarded. The most common reason for this is positive tissue XM. We report that unintended use of the kidney was minimized when tissue was shipped and XM results were known prior to exporting the kidney.

Retroperitoneal Hematoma Causing Peritoneal Dialysis Catheter Malfunction

BACKGROUND

We present the unusual complication of peritoneal dialysis catheter dysfunction in a patient who developed a retroperitoneal hematoma following an endoscopic procedure and review the existing literature regarding this rare complication.

CASE REPORT

A 60-year-old male with end stage renal disease presented with PD catheter dysfunction. A computerized tomography scan of his abdomen showed a large left retroperitoneal hematoma. He underwent a diagnostic laparoscopy and PD catheter revision. The retroperitoneal hematoma had ruptured into the peritoneum with clots clogging the catheter. Clots were evacuated and the catheter was flushed. He restarted on low--volume PD three days after surgery and increased to full-volume within a week with no further issues.

CONCLUSIONS

This case summarizes the unusual complication of a retroperitoneal bleed from an endoscopic procedure which manifested as PD catheter dysfunction. The increasing utilization of PD catheters requires surgeons remain aware of potential complications.

Deceased donor organ procurement injuries in the United States

AIM: To determine the incidence of surgical injury during deceased donor organ procurements.

METHODS: Organ damage was classified into three tiers, from 1-3, with the latter rendering the organ non-transplantable. For 12 consecutive months starting in January of 2014, 36 of 58 organ procurement organization’s (OPO)’s prospectively submitted quality data regarding organ damage (as reported by the transplanting surgeon and confirmed by the OPO medical director) seen on the procured organ.

RESULTS: These 36 OPOs recovered 5401 of the nations’s 8504 deceased donors for calendar year 2014. A total of 19043 organs procured were prospectively analyzed. Of this total, 59 organs sustained damage making them non-transplantable (0 intestines; 4 pancreata; 5 lungs; 6 livers; 43 kidneys). The class 3 damage was spread over 22 (of 36) reporting OPO’s.

CONCLUSION: While damage to the procured organ is rare with organ loss being approximately 0.3% of procured organs, loss of potential transplantable organs does occur during procurement.

Laparoscopic techniques enable peritoneal dialysis in the difficult abdomen

Background and Objectives:

Continuous ambulatory peritoneal dialysis has become an increasingly popular modality of renal replacement therapy. Laparoscopic placement of peritoneal dialysis catheters may help overcome previous barriers to peritoneal dialysis, such as previous abdominal surgical procedures or the presence of hernias, without incurring substantially greater risks.

Methods:

We performed a retrospective review of 120 consecutive patients who underwent attempted laparoscopic peritoneal dialysis catheter placement between July 2009 and June 2014 by a single surgeon. Patient and catheter characteristics and outcomes were compared between patients with and without complications, as well as between patients with a history of major abdominal surgery and those without such a history.

Results:

Laparoscopic peritoneal dialysis catheter placement was aborted in 4 patients because of an inability to safely achieve sufficient access to the abdominal cavity through dissection; these patients were excluded from subsequent analysis. The mean follow-up period was 18.8 ± 12.9 months. Fifty-five patients had a history of major abdominal surgery compared with 61 without such a history. No significant difference was observed with respect to age, race, sex, or body mass index between groups. Notably, more adjunctive procedures were required in patients with previous abdominal surgery, including adhesiolysis (60.0% vs 4.9%, P < .0001) and hernia repair (12.7% vs 1.6%, P = .026). Postoperative catheter complications were not significantly different between patients with and patients without a history of abdominal surgery (29.1% vs 32.8%, P = .667). Both unassisted (56.8% vs 65.0%, P = .397) and overall (72.7% vs 76.7%, P = .647) 1-year catheter survival rates were similar between patients with and patients without previous surgery, and the overall 1-year survival rate improved to 83.9% on exclusion of patients who stopped peritoneal dialysis for nonsurgical reasons.

Conclusions:

Laparoscopic peritoneal dialysis catheter placement offers a chance to establish peritoneal dialysis access in patients traditionally viewed as noncandidates for this modality. Despite the potential risks incurred because of additional procedures at the time of catheter placement in these complicated cases, these patients can achieve good long-term peritoneal dialysis access with an aggressive surgical approach.

Retroperitoneal Hematoma Causing Peritoneal Dialysis Catheter Malfunction

BACKGROUND

We present the unusual complication of peritoneal dialysis (PD) catheter dysfunction in a patient who developed a retroperitoneal hematoma following an endoscopic procedure and review the existing literature regarding this rare complication.

CASE REPORT

A 60-year-old man with end stage renal disease presented with PD catheter dysfunction. Computed tomography scan of his abdomen showed a large left retroperitoneal hematoma. He underwent a diagnostic laparoscopy and PD catheter revision. The retroperitoneal hematoma had ruptured into the peritoneum with clots clogging the catheter. Clots were evacuated and the catheter was flushed. He restarted on low volume PD three days after surgery and increased to full volume within a week with no further issues.

CONCLUSIONS

This case summarizes the very unusual complication of a retroperitoneal bleed from an endoscopic procedure that manifested as PD catheter dysfunction. The increasing utilization of PD catheters requires that surgeons remain aware of potential complications.

Incidence and management of leukopenia/neutropenia in 233 kidney transplant patients following single dose alemtuzumab induction

BACKGROUND

The purpose of this study was to determine the incidence and management strategies for post-transplant leukopenia/neutropenia in kidney recipients receiving alemtuzumab induction during the first year following transplantation.

METHODS

We prospectively identified 233 adult patients who underwent kidney transplantation with alemtuzumab induction at a single institution. The incidence and severity of leukopenia (white blood cell count [WBC] ≤2500/mm(3)) and neutropenia (absolute neutrophil count [ANC] ≤500/mm(3)) were evaluated at 1, 3, 6, and 12 months post-transplantation. We determined any association with cytomegalovirus (CMV) infection, graft rejection, and infections requiring hospitalization. We also reviewed interventions performed, including medication adjustments, treatment with granulocyte stimulating factor, and hospitalization.

RESULTS

The combined incidence of either leukopenia or neutropenia was 47.5% (n = 114/233) with an average WBC nadir of 1700 ± 50/mm(3) at 131.0 ± 8.5 days and an average ANC nadir of 1500 ± 100/mm(3) at 130.4 ± 9.6 days. No significant difference in graft rejection, CMV infection, or infections requiring hospitalization was found in the leukopenia/neutropenia group vs the normal WBC group (P = .3). The most common intervention performed for leukopenia/neutropenia group was prophylactic medication adjustment. Six patients (5.2%) required a change in >1 medication. The majority of these patients also required granulocyte stimulating factor (61.5%; 32/52), with an average of 2.5 doses given. A total of 25 patients (21.9%) required hospitalization due to leukopenia/neutropenia with an average length of stay of 6 days.

CONCLUSIONS

Kidney transplant patients receiving alemtuzumab induction required significant interventions due to leukopenia/neutropenia in the first year post-transplantation. These results suggest the need for additional studies aimed at defining the optimum management strategies of leukopenia/neutropenia in this population.

Who's your donor? Bringing about Louisiana's first domino paired exchange transplants

Although living donation is the preferred method of kidney transplant, many donors are not a match with their intended recipient. One unique way of overcoming this is by performing a donor paired exchange. By swapping donors, transplant centers may be able to bring about multiple transplants that would not have otherwise been possible. This manuscript describes the first three way domino paired donor exchange transplant in Louisiana. Because of a single altruistic donor, we were able to facilitate three recipients getting transplanted. We discuss the formulation of this unique program, the choosing of potential donor/recipient pairs and outcomes. A review of the controversies of paired kidney donation is also presented.

Interstitial pneumonitis in the transplant patient: consider sirolimus-associated pulmonary toxicity

Interstitial pneumonia in a transplant patient can have a varied etiology. Sirolimus (Rapamycin; Rapamune) is a popularly used immunosuppressant in solid organ transplantation that has anecdotally been associated with pulmonary toxicity. Sirolimus-induced pulmonary toxicity consists of a range of syndromes that is characterized by the presence of organizing pneumonia, interstitial pneumonitis, pulmonary alveolar proteinosis, focal fibrosis, or by the presence of alveolar hemorrhage. Diagnosis can be challenging and is usually made by exclusion of other etiologies. In this report we present two cases of sirolimus-associated pulmonary toxicity with a review of the literature.

Effect of ischemia-reperfusion on the incidence of acute cellular rejection and timing of histologic hepatitis C virus recurrence after liver transplantation

BACKGROUND

Because of a critical shortage of deceased donor (DD) livers, more extended criteria allografts are being utilized; these allografts are at increased risk for ischemia-reperfusion injury (IRI). We assessed whether, in a large cohort of patients transplanted for hepatitis C virus (HCV) either via a DD or live donor (LD), there was a relationship between the degree of IRI and the frequency and timing of acute cellular rejection (ACR) and histologic HCV recurrence.

METHODS

During an 8-year study, patients were separated into four groups based on peak alanine aminotransferase (ALT) levels and three groups based on severity of IRI on postreperfusion liver biopsy.

RESULTS

The mean follow-up time of 433 DD and 44 LD recipients was 1212 days. We noted a strong correlation in DD between peak ALT and the histologic degree of IRI (P = .01). There was no difference in the incidence or grade of ACR among the four groups. There was no correlation between the severity of IRI and the incidence or time to histologic recurrence of HCV.

CONCLUSIONS

The magnitude of peak ALT correlated with the severity of IRI on postreperfusion liver biopsy. Among this large HCV cohort, there was no correlation between the severity of IRI and the incidence or timing of histologic HCV recurrence or incidence of ACR.

Pancreas transplantation--a controversy in evolution

Pancreas transplantation has been mired in controversy throughout its existence. Arguments have erupted regarding its actual indications, the way the surgical procedure should be performed, its benefits, and today, the concept of pancreas islet cell transplantation remains controversial as well. If diabetic patients had a choice between life long insulin therapy and a major operation with immunosuppression afterward, what would they choose? The answer may not be as easy as one thinks. Pancreas transplantation has come a long way. This manuscript discusses the history of pancreas transplantation, how the indications are starting to be defined, evolution of the surgical procedure, current success rates of this procedure, the current scenario of pancreas islet transplantation, and newer developing technologies.

Retroperitoneal varices presenting as an adrenal pseudotumor in a cirrhotic patient

Herein is reported a case of a putative tumor of the left adrenal gland found incidentally during the workup of a cirrhotic patient with portal hypertension. This mass manifested vascular enhancement and other features of an adenoma both on computed tomography (CT) and magnetic resonance imaging (MRI) scans. Additional workup revealed elevated salivary cortisol and plasma aldosterone levels. A proposed biopsy of this mass was deferred because of an episode of variceal bleeding that required placement of a transjugular intrahepatic portosystemic shunt (TIPS). Post TIPS placement, repeat CT and MRI scans showed that the mass had disappeared, indicating that this pseudotumor was, in fact, a knot of peri-adrenal varices, which was now decompressed. In this report, the anatomic and pathologic basis of peri-adrenal varices in a patient with portal hypertension is discussed, as well as the ability of current imaging studies at establishing this diagnosis. Liver disease may cause abnormalities in endocrine function, which make this diagnosis difficult.

Amelioration of hypertrophic cardiomyopathy using nonsurgical septal ablation in a cirrhotic patient prior to liver transplantation

A 53-year-old male with hepatitis C cirrhosis, who had been refused liver transplantation because of hypertrophic cardiomyopathy (HC), underwent nonsurgical septal ablation using alcohol with resolution of his ventricular outflow obstruction. This patient was able to subsequently undergo a successful deceased donor liver transplantation. This is the first reported case of alcohol induced septal ablation being performed in a cirrhotic patient with HC. Such nonsurgical procedures may be attractive in cirrhotic patients who are refused access to liver transplantation because of high surgical risk.

Post-liver transplant acute renal failure: factors predicting development of end-stage renal disease

BACKGROUND

Acute renal failure (ARF) occurs in 5-50% of patients undergoing orthotopic liver transplantation (OLT). The aim of this study was to determine factors that might predict the development of end stage renal disease (ESRD) in patients who had ARF after OLT.

METHODS

We studied all OLT recipients between 9/1/1988 through 12/31/2000.

RESULTS

A total of 1602 patients underwent OLT during the study period. About 350 patients (22%) developed ARF requiring dialysis post-operatively. One hundred and twenty-three (39.8%) died within a year after OLT. Median follow up was 5.8 yr (range 1-12 yr). Forty-three patients (23%) developed ESRD over median of 3.79 yr (range 1-8 yr). Multivariate logistic regression analysis revealed creatinine levels > 1.7 mg/dL at 1 yr (p < 0.001), cyclosporine as immunosuppression (p = 0.026), and the presence of diabetes pre-OLT (p < 0.001) to be associated with the development of ESRD. The development of ESRD did not decrease patient survival (p = 0.111). ESRD patients who received subsequent kidney transplantation had significantly improved survival rates (p = 0.005).

CONCLUSIONS

Serum creatinine levels at 1 yr, cyclosporine as immunosuppression, and the presence of diabetes pre-OLT are independent predictive factors for the development of ESRD. ESRD patients who received kidney transplantation had higher 10-yr survival rates when compared with patients maintained on dialysis.

Thrombotic microangiopathy associated with combined sirolimus and tacrolimus immunosuppression after intestinal transplantation

Calcineurin inhibitor-induced thrombotic microangiopathy (TMA) has been described in up to 14% of solid-organ transplant recipients. Sirolimus has recently been described in two reports in association with TMA. Sirolimus is known to potentiate cyclosporine-induced nephrotoxicity, but such effect has not been shown with tacrolimus. We report two intestinal transplant patients who developed TMA while on a tacrolimus and sirolimus immunosuppressive regimen. This syndrome appeared soon after institution of or increase in sirolimus dosage and improved only after this medication was discontinued.

Improvement of hepatopulmonary syndrome after transjugular intrahepatic portasystemic shunting: case report and review of literature

The hepatopulmonary syndrome has been described in as many as 5-29% of patients with liver disease. Patients with this syndrome may suffer from chronic hypoxemia, and mortality rates of liver patients with this syndrome are as high as 41%. Early diagnosis of such patients is essential. Currently, liver transplantation is the only effective therapy for such patients, and reversal of this syndrome is seen in up to 80% of patients post-transplant. Transjugular intrahepatic portasystemic shunting (TIPS) as a therapeutic maneuver for this syndrome has been described in five patients to date with mixed results. Reduction in portal hypertension with consequent redistribution of blood flow and altered synthesis of vasodilatory chemicals have been postulated to help resolve this disease. In this report, we describe an 11-yr-old female with biliary atresia and hepatopulmonary syndrome. Her disease was complicated with recurrent variceal bleeding. TIPS achieved a therapeutic response of both her bleeding and respiratory complications.