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Heisler CA, Godecker AL, Verran D, Sinha MS, Byam J, Miller P. Workplace Microaggressions: Results of a Survey of the American College of Surgeons Members. Am J Obstet Gynecol 2024:S0002-9378(24)00570-2. [PMID: 38710272 DOI: 10.1016/j.ajog.2024.04.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 04/11/2024] [Accepted: 04/30/2024] [Indexed: 05/08/2024]
Abstract
BACKGROUND Workplace microaggressions are a longstanding but understudied problem in the surgical specialties. Microaggressions in healthcare are linked to negative emotional and physical health outcomes and can contribute to burnout and suboptimal delivery of patient care. They also negatively impact recruitment, retention and promotion, which often results in attrition. Further attrition at the time of an impending surgical workforce shortage risks compromising delivery of health care to the diverse US population and may jeopardize the financial stability of health care organizations. To date, studies on microaggressions have consisted of small focus groups comprised of women faculty or trainees at a single institution. There are no large, multi-organizational, gender-inclusive studies on microaggressions experienced by practicing surgeons. OBJECTIVE(S) To examine the demographic and occupational characteristics of surgeons who do and do not report experiencing workplace microaggressions and whether these experiences would influence a decision to pursue a career in surgery again. STUDY DESIGN We developed and internally validated a web-based survey to assess surgeon experiences with microaggressions and associated sequelae. The survey was distributed through a convenience sample of nine American College of Surgeons (ACS) online Communities from November 2022 to January 2023. All ACS Communities comprised members who had completed residency or fellowship training and had experience in the surgical workforce. The survey contained demographic, occupational, and validated microaggression items. Analyses include descriptive and chi-squared statistics, t-tests, and bivariable and multivariable logistic regression. RESULTS The survey was completed by 377 ACS members with the following characteristics: working as a surgeon (80.9%), non-Hispanic white (71.8%), general surgeons (71.0%), age ≥ 50 years (67.4%), fellowship-trained (61.0%), and women (58.4%). A total of 254 (67.4%) respondents reported experiencing microaggressions. Younger surgeons (p=0.002), women (p<0.001) and fellowship-trained surgeons (p=0.001) were more likely to report experiencing microaggressions than their counterparts. Surgeons working in academic medical centers or healthcare systems with teaching responsibilities were more likely to experience microaggressions than those in private practice (p<0.01). Surgeons currently working as a surgeon or those who are unable to work reported more experience with microaggressions (p=0.003). There was no difference in microaggressions experienced among respondents by surgical specialties, race/ethnicity, or for surgeons with a self-reported disability. In multivariable logistic regression, women had higher odds of experiencing microaggressions than men [aOR 15.9; 95% C.I.: 7.7-32.8] and surgeons in private practice had significantly lower odds of experiencing microaggressions compared to surgeons in academic medicine (aOR 0.3; 95% C.I. 0.1-0.8) or in healthcare systems with teaching responsibilities (aOR 0.2; 95% C.I. 0.1-0.6). Among surgeons responding to an online survey, respondents reporting microaggressions were less likely to say they would choose a career in surgery again (p<0.001). CONCLUSIONS Surgeons reporting experience with microaggressions reflect the diversification of surgical specialties and subspecialties. With continued expansion of surgeon gender and race/ethnicity representation, deliberate efforts to address and eliminate workplace microaggressions could have broad implications for improving recruitment and retention of surgeons.
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Affiliation(s)
- Christine A Heisler
- Departments of Obstetrics & Gynecology and Urology, University of Wisconsin, Madison, WI.
| | - Amy L Godecker
- Department of Obstetrics & Gynecology, University of Wisconsin, Madison, WI
| | | | - Michael S Sinha
- Center for Health Law Studies, Saint Louis University School of Law, Saint Louis, MO
| | - Jerome Byam
- Division of Acute Care Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Pringl Miller
- Founder & Executive Director, Physician Just Equity, Bodega Bay, CA
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Barghouth U, Gianakos A, Verran D, Klein SE, Butler KL, Miller P. Peer Support Helps Physicians Navigate Workplace Conflict. J Gen Intern Med 2023; 38:1768-1770. [PMID: 36917432 PMCID: PMC10212899 DOI: 10.1007/s11606-023-08092-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 02/08/2023] [Indexed: 03/16/2023]
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Verran D, Weissenbacher A, Paredes-Zapata D, Ortiz F. Reply To—Gender Distribution Among Transplant Journal Editorial Members. Transpl Int 2022; 35:10262. [PMID: 35368642 PMCID: PMC8967945 DOI: 10.3389/ti.2022.10262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 01/18/2022] [Indexed: 11/13/2022]
Affiliation(s)
- Deborah Verran
- Ramsay Health Care, Sydney, NSW, Australia
- *Correspondence: Deborah Verran,
| | - Annemarie Weissenbacher
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - David Paredes-Zapata
- Donation and Coordination Section, Hospital Clinic, Department of Surgery and Surgical Specializations, Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - Fernanda Ortiz
- Abdominal Center Unit, Nephrology, Helsinki University Hospital, Helsinki, Finland
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Au S, Bellato V, Carvas JM, Córdoba CD, Daudu D, Dziakova J, Eltarhoni K, El Feituri N, Fung ACH, Fysaraki C, Gallo G, Gultekin FA, Harbjerg JL, Hatem F, Ioannidis A, Jakobsen L, Clinch D, Kristensen HØ, Kuiper SZ, Kwok AMF, Kwok W, Millan M, Milto KM, Ng HJ, Pellino G, Picciariello A, Pronin S, van Ramshorst GH, Ramser M, Jiménez-Rodríguez RM, Sainz Hernandez JC, Samadov E, Sohrabi S, Uchiyama M, Wang JHS, Younis MU, Fleming S, Alhomoud S, Mayol J, Moeslein G, Smart NJ, Soreide K, Teh C, Verran D, Maeda Y. Global parental leave in surgical careers: differences according to gender, geographical regions and surgical career stages. Br J Surg 2021; 108:1315-1322. [PMID: 34467970 DOI: 10.1093/bjs/znab275] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 03/24/2021] [Accepted: 07/01/2021] [Indexed: 11/12/2022]
Abstract
BACKGROUND There is a lack of information regarding the provision of parental leave for surgical careers. This survey study aims to evaluate the experience of maternity/paternity leave and views on work-life balance globally. METHODS A 55-item online survey in 24 languages was distributed via social media as per CHERRIES guideline from February to March 2020. It explored parental leave entitlements, attitude towards leave taking, financial impact, time spent with children and compatibility of parenthood with surgical career. RESULTS Of the 1393 (male : female, 514 : 829) respondents from 65 countries, there were 479 medical students, 349 surgical trainees and 513 consultants. Consultants had less than the recommended duration of maternity leave (43.8 versus 29.1 per cent), no paid maternity (8.3 versus 3.2 per cent) or paternity leave (19.3 versus 11.0 per cent) compared with trainees. Females were less likely to have children than males (36.8 versus 45.6 per cent, P = 0.010) and were more often told surgery is incompatible with parenthood (80.2 versus 59.5 per cent, P < 0.001). Males spent less than 20 per cent of their salary on childcare and fewer than 30 hours/week with their children. More than half (59.2 per cent) of medical students did not believe a surgical career allowed work-life balance. CONCLUSION Surgeons across the globe had inadequate parental leave. Significant gender disparity was seen in multiple aspects.
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Affiliation(s)
- S Au
- NHS Education for Scotland, Edinburgh, UK
| | | | | | - C D Córdoba
- University of Lausanne, Lausanne, Switzerland
| | - D Daudu
- Faculty of Health and Medical Sciences, University of Western Australia, Australia
| | - J Dziakova
- Hospital Clinico San Carlos, IDISSC, Madrid, Spain
| | | | | | - A C H Fung
- Department of Surgery, The University of Hong Kong, Hong Kong SAR, China
| | - C Fysaraki
- Urology Department, Mid Yorkshire Hospitals NHS Trust, UK
| | - G Gallo
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - F Ayca Gultekin
- General Surgery Department, Zonguldak Bulent, Ecevit University School of Medicine, Zonguldak, Turkey
| | - J L Harbjerg
- Department of Surgery, Research Unit C119, Aarhus University Hospital, Palle Juul-Jensens, Aarhus N, Denmark
| | - F Hatem
- Glasgow Royal Infirmary, Glasgow, UK
| | | | - L Jakobsen
- UiT, The Arctic University of Norway, University Hospital of North Norway, Tromso, Norway
| | - D Clinch
- Department of General Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - H Ø Kristensen
- Department of Surgery, Research Unit C119, Aarhus University Hospital, Palle Juul-Jensens, Aarhus N, Denmark
| | - S Z Kuiper
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands
| | | | - W Kwok
- Royal Infirmary of Edinburgh, Edinburgh, UK
| | - M Millan
- Coloproctology Unit, Department of Surgery, La Fe University Hospital, Valencia, Spain
| | - K M Milto
- NHS Education for Scotland, Edinburgh, UK
| | - H J Ng
- Royal Alexandra Hospital, NHS Greater Glasgow and Clyde, UK
| | - G Pellino
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania 'Luigi Vanvitelli', Naples, Italy
| | - A Picciariello
- Department of Emergency and Organ Transplantation, University 'Aldo Moro' of Bari, Italy
| | - S Pronin
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | | | - M Ramser
- Department of Surgery, Solothurner Spitäler SoH, Bürgerspital Solothurn, Solothurn, Switzerland
| | | | - J C Sainz Hernandez
- Instituto Nacional de Ciencias Médicas y Nutrición 'Salvador Zubirán', Mexico City, Mexico
| | - E Samadov
- Surgical Department, LEYLA Medical Centre, Baku, Azerbaijan
| | | | - M Uchiyama
- Showa University School of Medicine, Tokyo, Japan
| | - J H-S Wang
- Australasian Students' Surgical Association, New Zealand
| | - M U Younis
- Mediclinic City Hospital, Dubai, United Arab Emirates
| | - S Fleming
- Barts and the London School of Medicine and Dentistry, London, UK
| | - S Alhomoud
- King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - J Mayol
- Hospital Clinico San Carlos, Instituto de Investigación Sanitaria San Carlos, Universidad Complutense, Madrid, Spain
| | - G Moeslein
- Ev. Bethesda Khs Duisburg, University of Witten, Herdecke, Germany
| | - N J Smart
- Royal Devon & Exeter Hospital & University of Exeter Medical School, Exeter, UK
| | - K Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - C Teh
- Department of Surgery, Makati Medical Centre, Makati, Philippines.,Department of General Surgery, National Kidney & Transplant Institute, Quezon City, Philippines
| | - D Verran
- Ramsey Health Care, Sydney, Australia
| | - Y Maeda
- Department of Colorectal Surgery, Western General Hospital and University of Edinburgh, Edinburgh, UK
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Cohn A, Cubitt M, Goh A, Hempenstall A, Hoffman R, Lai C, Munro J, Silvester C, Skinner C, Verran D, Walter J. Gender Equity in Australian Health Leadership. APJHM 2021. [DOI: 10.24083/apjhm.v16i1.519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective: To ascertain the gender distribution across public health boards in Australia.
Design & Setting: Analysis of data and information obtained from a cross sectional audit of online publicly listed health boards within Australia from October to December 2019.
Results: The majority of public health boards have close to equal representation of women as board members however women are underrepresented in Chair roles. Victoria has significantly more women on health boards, whereas New South Wales has significantly less women on health boards and in Chair positions.
Conclusions: Further efforts are required to drive gender equity in senior leadership roles in public health boards across Australia
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Ly M, Crawford M, Verran D. Biliary complications in donation after circulatory death liver transplantation: the Australian National Liver Transplantation Unit's experience. ANZ J Surg 2020; 91:445-450. [PMID: 32985774 DOI: 10.1111/ans.16304] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 08/19/2020] [Accepted: 08/24/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Biliary complications are the most common complications of donation after circulatory death (DCD) liver transplantation and the international experience with DCD transplants suggests increased rates of biliary complications compared to donation after brain death transplants. Therefore, it is important to understand factors that are associated with the development of biliary complications within the Australian DCD context in order to inform future practice. The aim of this study is to determine the incidence of biliary complications after DCD liver transplantation at the Australian National Liver Transplantation Unit and identify factors associated with this outcome. METHODS A retrospective analysis of all adult DCD liver transplants at the Australian National Liver Transplantation Unit from 2007 to 2015 was undertaken. The primary outcome measure was the incidence of biliary complications and was censored on 31 December 2016. Recipients were then stratified into groups based on the development of biliary complications and risk factor analysis was performed. RESULTS Biliary complications occurred in 35% of DCD transplants, including seven anastomotic strictures and 10 non-anastomotic strictures. Higher donor risk index scores (P = 0.03), post-transplant portal vein complications (P = 0.042) and peak gamma-glutamyl transferase levels within 7 days post-transplant (P = 0.047) were associated with biliary complications. CONCLUSION Findings from this study demonstrate that biliary complications remain common in DCD liver recipients. Recipients who developed a biliary complication tended to have higher donor risk index, elevated peak gamma-glutamyl transferase levels within 7 days post-transplant or a portal vein complication. The presence of any of these factors should prompt close monitoring for post-transplant biliary complications.
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Affiliation(s)
- Mark Ly
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Michael Crawford
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Department of Upper Gastrointestinal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Deborah Verran
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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Verran D, Templeton K, Sampron N, Braman J, Miller P. Untangling the Reasons Surgeons Choose to Leave Clinical Practice, including Retirement. J Am Coll Surg 2020; 231:608-609. [PMID: 32951979 DOI: 10.1016/j.jamcollsurg.2020.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 07/14/2020] [Indexed: 11/19/2022]
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Verran D, Dwyer K, Hardstaff R, Lawton P, Schultz H. Gender Parity Remains To Be Achieved for the Range of Editorial Roles Associated with Current Australasian Medical Journals. Cureus 2020; 12:e7879. [PMID: 32489733 PMCID: PMC7255541 DOI: 10.7759/cureus.7879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 04/28/2020] [Indexed: 11/25/2022] Open
Abstract
With gender parity of medical school graduates having been achieved for well over two decades, it is timely to assess whether this has translated into gender parity for all of the editorial type roles of Australasian medical journals, reflecting a move toward gender equity. Data analysis was undertaken of the gender ratios of the current editorial roles of Australasian medical journals as compared to available Australian Health Workforce data. This reveals some variation in the gender ratios for all of the current range of editorial type positions and, hence, an absence of parity. There are no women holding formal editorial positions at all for 27.7% of these journals, whilst 77.7% of the chief editors' roles are occupied by men. For five out of 18 (27.7%) of the journals, gender parity has been or is close to having been achieved for these particular roles. These gender ratios do not mirror the gender ratios of the wider community of practice for at least 50% of the journals. Hence, it can be seen that gender parity is yet to be achieved for the range of editorial roles of Australasian medical journals, which carries implications for gender equity initiatives.
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Affiliation(s)
- Deborah Verran
- Surgery, Ramsey Healthcare, Sydney, AUS
- Medicolegal Services, Avant Mutual Group, Sydney, AUS
| | | | | | - Paul Lawton
- Nephrology, Menzies School of Health Research, Darwin, AUS
- Renal Services, Top End Health Services, Darwin, AUS
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Crammond MBiostat BR, Janakiramanan N, Ganau M, Verran D, Lippa L, Braman J, Rabiei K. Letter to the Editor. Academic rank achievement by gender. J Neurosurg 2020; 133:1973-1976. [PMID: 32217796 DOI: 10.3171/2020.1.jns2052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | | | - Mario Ganau
- 3Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | | | | | - Jonathan Braman
- 6University of Minnesota Medical School, Minneapolis, MN; and
| | - Katrin Rabiei
- 7Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
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Temkin SM, Burgess NL, Butler K, Verran D, Barnett M, Wandel A, Emami C, Chopra P, Wall A, Ganai S. Full Collection of Personal Narratives. Narrat Inq Bioeth 2019; 9:184-214. [PMID: 31956112 DOI: 10.1353/nib.2019.0078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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Verran D. A Woman Surgeon's Determination Despite the Barriers to Career Progression. Narrat Inq Bioeth 2019; 9:194-196. [PMID: 31956117 DOI: 10.1353/nib.2019.0051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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12
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Pulitano C, Ho P, Verran D, Sandroussi C, Joseph D, Bowen DG, McCaughan GW, Crawford M, Shackel N. Molecular profiling of postreperfusion milieu determines acute kidney injury after liver transplantation: A prospective study. Liver Transpl 2018; 24:922-931. [PMID: 29684255 DOI: 10.1002/lt.25178] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 03/20/2018] [Accepted: 04/12/2018] [Indexed: 02/07/2023]
Abstract
Acute kidney injury (AKI) after liver transplantation (LT) is a common event, but its pathogenesis remains unclear. The aim of this prospective study is to investigate the potential relationship between postreperfusion gene expression, serum mediators, and the onset of AKI after LT. Sixty-five consecutive patients undergoing LT were included in the study. Reverse transcription polymerase chain reaction (PCR) was performed on liver biopsies. Gene expression of 23 genes involved in ischemia/reperfusion injury (IRI) was evaluated. The serum concentrations of endothelin (ET)-1 and inflammatory cytokines were analyzed. AKI after LT developed in 21 (32%) recipients (AKI group). Reverse transcription PCR of reperfusion biopsy in the AKI group showed higher expression of several genes involved in IRI compared with the non-AKI group. Fold changes in the gene expression of ET-1, interleukin (IL) 18, and tumor necrosis factor α (TNF-α) were associated with creatinine peak value. AKI patients also had significantly higher ET-1, IL18, and TNF-α postoperative serum levels. Multivariate analysis showed that ET-1 (odds ratio [OR], 16.7; 95% confidence interval [CI], 3.34-83.42; P = 0.001) and IL18 (OR, 5.27; 95% CI, 0.99-27.82, P = 0.048) serum levels on postoperative day 1 were independently predictive of AKI. Receiver operating characteristic analysis demonstrated that the combination of biomarkers ET-1+IL18 was highly predictive of AKI (area under the receiver operating characteristic curve, 0.91; 95% CI, 0.83-0.99). Early allograft dysfunction and chronic kidney disease stage ≥ 2 occurred more frequently in AKI patients. These results suggest that the graft itself, rather than intraoperative hemodynamic instability, plays a main role in AKI after LT. These data may have mechanistic and diagnostic implications for AKI after LT. Liver Transplantation 24 922-931 2018 AASLD.
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Affiliation(s)
- Carlo Pulitano
- Centenary Research Institute, University of Sydney, Sydney, New South Wales, Australia.,Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Center for Advanced Research in Liver Pancreas Biliary Surgery, Sydney, New South Wales, Australia
| | - Phong Ho
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Deborah Verran
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Charbel Sandroussi
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Center for Advanced Research in Liver Pancreas Biliary Surgery, Sydney, New South Wales, Australia
| | - David Joseph
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Center for Advanced Research in Liver Pancreas Biliary Surgery, Sydney, New South Wales, Australia
| | - David G Bowen
- Centenary Research Institute, University of Sydney, Sydney, New South Wales, Australia.,Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Geoffrey W McCaughan
- Centenary Research Institute, University of Sydney, Sydney, New South Wales, Australia.,Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Michael Crawford
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Center for Advanced Research in Liver Pancreas Biliary Surgery, Sydney, New South Wales, Australia
| | - Nicholas Shackel
- Centenary Research Institute, University of Sydney, Sydney, New South Wales, Australia.,Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
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Pulitano C, Joseph D, Sandroussi C, Verran D, Ho P, Debiasio A, Luongo A, McCaughan GW, Shackel NA, Crawford M. Postreperfusion microcirculatory derangements after liver transplantation: Relationship to hemodynamics, serum mediators, and outcome. Liver Transpl 2017; 23:527-536. [PMID: 28073175 DOI: 10.1002/lt.24721] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 11/22/2016] [Accepted: 12/08/2016] [Indexed: 02/06/2023]
Abstract
Despite the growing data supporting the role of microcirculation in regulating liver function, little of this knowledge has been translated into clinical practice. The aim of this study is to quantify hepatic microcirculation in vivo using sidestream dark field (SDF) imaging and correlate these findings with hepatic blood flow, hemodynamic parameters, and soluble mediators. Postreperfusion hepatic microcirculation was assessed using SDF imaging. Hepatic microcirculation measurements included functional sinusoidal density (cm/cm2 ), sinusoidal diameter (μm), red blood cell velocity (μm/second), volumetric blood flow (pl/second), and flow heterogeneity (FH) index. The serum concentrations of endothelin 1 (ET-1) and other inflammatory markers were analyzed with Luminex technology. Portal venous and hepatic artery flows were measured using a flowmeter. Twenty-eight patients undergoing cadaveric liver transplantations have been included in this study. Early allograft dysfunction (EAD) occurred in 7 (25%) patients and was associated with microcirculatory dysfunction. Low arterial and portal flow, high dose of inotropes, cold ischemia time, steatosis, and high ET-1 levels were all associated with impaired microcirculation. The time interval between portal venous and hepatic arterial reperfusion significantly correlated with the changes of the liver grafts' microcirculation. EAD patients tended to have higher serum levels of ET-1 on postoperative days 1, 2, 5, and 7 (all P < 0.01). Serum levels of ET-1 correlated significantly with microcirculation parameters. In conclusion, postreperfusion hepatic microcirculation is a determinant of organ dysfunction after liver reperfusion and could be used to identify very early patients at risk of EAD. Liver Transplantation 23 527-536 2017 AASLD.
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Affiliation(s)
- Carlo Pulitano
- Centenary Research Institute, University of Sydney, Sydney, NSW, Australia.,Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Center for Advanced Research in Liver Pancreas Biliary Surgery, Sydney, NSW, Australia
| | - David Joseph
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Center for Advanced Research in Liver Pancreas Biliary Surgery, Sydney, NSW, Australia
| | - Charbel Sandroussi
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Center for Advanced Research in Liver Pancreas Biliary Surgery, Sydney, NSW, Australia
| | - Deborah Verran
- Center for Advanced Research in Liver Pancreas Biliary Surgery, Sydney, NSW, Australia
| | - Phong Ho
- Center for Advanced Research in Liver Pancreas Biliary Surgery, Sydney, NSW, Australia
| | - Ashe Debiasio
- Center for Advanced Research in Liver Pancreas Biliary Surgery, Sydney, NSW, Australia
| | - Adriano Luongo
- Centenary Research Institute, University of Sydney, Sydney, NSW, Australia
| | - Geoffrey W McCaughan
- Centenary Research Institute, University of Sydney, Sydney, NSW, Australia.,Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Nicholas A Shackel
- Centenary Research Institute, University of Sydney, Sydney, NSW, Australia.,Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Michael Crawford
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Center for Advanced Research in Liver Pancreas Biliary Surgery, Sydney, NSW, Australia
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Pulitano C, Rogan C, Sandroussi C, Verran D, McCaughan GW, Waugh R, Crawford M. Percutaneous Retroperitoneal Splenorenal Shunt for Symptomatic Portal Vein Thrombosis After Liver Transplantation. Am J Transplant 2015; 15:2261-4. [PMID: 25980940 DOI: 10.1111/ajt.13243] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 01/25/2015] [Accepted: 01/25/2015] [Indexed: 01/25/2023]
Abstract
Acute or recurrent bleeding from ectopic varices is a potentially life-threatening condition in rare patients with extrahepatic complete portal vein thrombosis (PVT) after liver transplantation (LT). In this setting, the role of interventional radiology is very limited and surgical shunts, in particular splenorenal shunts are usually used, despite the high associated mortality. We present the first reports of the clinical use of a new minimally invasive technique, percutaneous retroperitoneal splenorenal shunt (PRESS), in two LT recipients with life-threatening variceal hemorrhage secondary to PVT. Both patients had a successful PRESS using a transplenic approach with resolution of bleeding, avoiding the need for a potentially complicated laparotomy. The PRESS procedure is a useful addition to the interventional armamentarium that can be used in cases unsuitable for surgical shunt, and refractory to endoscopic management. In the future, this technique may be an alternative to surgical shunts as the standard procedure in patients with extra-hepatic PVT, just as the transjugular intrahepatic portosystemic shunt (TIPS) procedure has become for the management of portal hypertension in the absence of PVT. Longer-term follow-up will be needed to establish the long-term success of this procedure.
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Affiliation(s)
- C Pulitano
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Centenary Research Institute, University of Sydney, Camperdown, New South Wales, Australia
| | - C Rogan
- Radiology Department, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - C Sandroussi
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - D Verran
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - G W McCaughan
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Centenary Research Institute, University of Sydney, Camperdown, New South Wales, Australia
| | - R Waugh
- Radiology Department, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - M Crawford
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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15
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Pulitano C, Joseph D, Sandroussi C, Verran D, Strasser SI, Shackel NA, McCaughan GW, Crawford M. Hepatic artery stenosis after liver transplantation: is endovascular treatment always necessary? Liver Transpl 2015; 21:162-8. [PMID: 25378262 DOI: 10.1002/lt.24043] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 09/15/2014] [Accepted: 10/12/2014] [Indexed: 12/12/2022]
Abstract
Hepatic artery stenosis (HAS) is thought to predispose patients to biliary complications secondary to ischemic injury. Despite this, the clinical significance of HAS remains poorly defined. The aims of this study were to determine the prevalence and outcomes of HAS and to define which patients might benefit from endovascular treatment. From a prospective database of 662 adult patients undergoing liver transplantation between 2000 and 2011, we identified 54 patients who developed HAS. HAS was defined as any stenosis > 70% that was seen during multidetector computed tomographic angiography (MDCTA) or digital subtraction angiography. The benefit of endovascular therapy was evaluated with propensity score matching. New biliary complications occurred in 17 patients (31.4%), and 23 of the 54 study patients with HAS received endovascular treatment. Among the propensity score-matched patients, the biliary stricture-free survival time was significantly longer for those who received endovascular therapy (P = 0.03). An incidental diagnosis (P = 0.07) and a time from transplantation > 6 months (P = 0.021) were associated with a reduced risk of developing biliary stricture. Patients with symptomatic HAS who received treatment had better biliary stricture-free survival than patients who were treated conservatively, although no significant difference was recorded (P = 0.11). No patient with asymptomatic HAS and normal liver function tests developed biliary strictures. In conclusion, HAS intervention was associated with improved biliary stricture-free survival. In patients with late-onset HAS (≥6 months) and asymptomatic patients, endovascular treatment is not warranted.
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Affiliation(s)
- Carlo Pulitano
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Sydney, Australia; Centenary Research Institute, University of Sydney, Sydney, Australia
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16
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Sud R, Garry L, Spicer ST, Allen RDM, Eris JM, Wyburn K, Verran D, Cooper CL, Chadban S. A role for everolimus in post-transplant encapsulating peritoneal sclerosis: first case report. Nephrology (Carlton) 2014; 19 Suppl 1:27-30. [PMID: 24460661 DOI: 10.1111/nep.12196] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2013] [Indexed: 12/14/2022]
Abstract
Encapsulating peritoneal sclerosis (EPS) is a rare complication of peritoneal dialysis (PD) that carries a high morbidity and mortality. The 'two hit theory' suggests that long term deterioration of the peritoneum combined with intraperitoneal inflammation is needed in the pathogenesis of EPS. For unclear reasons, post transplantation EPS is being increasingly reported in patients previously on PD. To date, there is no proven effective therapy with an absence of randomised controlled trials. Individual case reports and small case series have reported on the use of tamoxifen and corticosteroids for medical management of EPS. The use of everolimus has been reported in a single case, and never in the setting of renal transplantation. Here, we present the first case of post-transplant encapsulating peritoneal sclerosis treated successfully with a combination of everolimus, tamoxifen, low dose corticosteroid and surgery.
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Affiliation(s)
- Rahul Sud
- Renal Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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17
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Prakoso E, Verran D, Dilworth P, Kyd G, Tang P, Tse C, Koorey DJ, Strasser SI, Stormon M, Shun A, Thomas G, Joseph D, Pleass H, Gallagher J, Allen R, Crawford M, McCaughan GW, Shackel NA. Increasing liver transplantation waiting list mortality: a report from the Australian National Liver Transplantation Unit, Sydney. Intern Med J 2011; 40:619-25. [PMID: 20840212 DOI: 10.1111/j.1445-5994.2010.02277.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND We aimed to describe the demand for liver transplantation (LTx) and patient outcomes on the waiting list at the Australian National Liver Transplantation Unit, Sydney over the last 20 years. METHODS We performed a retrospective analysis with the data divided into three eras: 1985-1993, 1994-2000 and 2001-2008. RESULTS The number of patients accepted for LTx increased from 320 to 372 and 548 (P < 0.001) with the number of LTx being performed increasing from 262 to 312 and 452 respectively (P < 0.001). The median adult recipient age increased from 45 to 48 and 52 years (P < 0.001) while it decreased in children from 4 to 2 and 1 years respectively (P = 0.001). In parallel, the deceased donor offers decreased from 1003 to 720 and 717 (P < 0.001). Methods to improve access to donor livers have been used with the use of split livers, extended criteria and non-heart beating donors, resulting in increased acceptance of deceased donor offers by 65% and 115% in the second and third eras when compared with the first era (P < 0.001). However, the adult median waiting time has increased from 23 to 41 and 120 days respectively (P < 0.001). This was associated with increased adult mortality on the waiting list from 23 to 40 and 122 respectively (P < 0.001). CONCLUSIONS Despite the increasing proportion of donor offers being used, the waiting list mortality is increasing. A solution to this problem is an increase in organ donation to keep pace with the escalating demand for LTx.
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Affiliation(s)
- E Prakoso
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, New South Wales, Australia
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18
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Abstract
In small infants and babies who receive split or living-related adult left lateral segmental liver grafts, further reduction (hyper-reduction) of the graft may be necessary to optimize the size of the graft for the child. We report our experience with hyper-reduction of adult left lateral segment grafts in nine children. A retrospective review of the medical records of children who received hyper-reduced grafts at the Children's Hospital at Westmead, Australia was performed. Of 215 liver transplants performed on 186 children between 1986 and May 2009, 147 were reduced grafts. Nine grafts were further reduced (hyper-reduced) after an on-table assessment of graft size relative to the available abdominal space was made. Mean graft size reduction was by 30%. The pledgetted technique of resection was used in four patients. All required delayed closure of the abdomen, and in three patients, fascial closure was not possible and a Surgisis patch (Cook Surgical International, West Lafayette, IN, USA) was placed to augment the abdominal capacity. Two children had hepatic artery thrombosis. One was successfully thrombectomized. In the other, technical problems with the donor liver contributed to death 10 days post-transplant. Two bile leaks, one from the cut surface and the other at the anastomotic site, were oversewn at the time of abdominal closure. On follow-up (median 33 months), two developed biliary strictures requiring dilatation. Hyper-reduction of segmental grafts can be safely performed when needed. In view of its versatility, it may be preferable to hyper-reduce a graft rather than use a monosegment graft. Comparable long-term results are possible. The pledgetted technique of resection is easy, quick, and safe. The fact that it can be performed after revascularization with minimal blood loss adds great flexibility to this technically challenging procedure.
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Affiliation(s)
- Naveen Thomas
- Departments of Surgery, Childrens Hospital at Westmead, Westmead, Sydney, NSW, Australia.
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19
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Abstract
The aim of this study was to examine the role of HA flow abnormalities in the development of biliary strictures following split liver transplants. Data was obtained from a prospective data base of all patients undergoing split liver transplants from 2000-2008 with a follow up time of at least six months. Forty-six transplants were performed in 44 patients. Fourteen of 46 developed strictures of whom four were intrahepatic and 10 anastomotic. Nine of 14 with strictures had either hepatic artery thromobosis (HAT, four) or abnormalities of HA flow identified by routine Doppler ultrasound (5) compared with two of 32 without strictures (p < 0.02, (one temporary loss of flow and one HA aneurysm). There were no differences between the stricture and non stricture group with regard to age or weight at transplant, donor age, cold and warm ischemia times or intraoperative portal vein flow though there was a significant decrease in intraoperative HA flow in the stricture group. In conclusion, both HAT and hepatic artery flow abnormalities are associated with biliary strictures in the majority of split liver transplants. However, unrecognised abnormalities in HA flow and or other factors are likely to contribute.
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Affiliation(s)
- Edward V O'Loughlin
- Department of Gastroenterology, The Children's Hospital at Westmead, Westmead, NSW, Australia.
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20
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Allen RD, Azanza M, Wills T, Crawford M, Pleass H, Verran D. TN05�QUALITY ASSESSMENT OF THE ORGAN DONOR RETRIEVAL PROCESS. ANZ J Surg 2009. [DOI: 10.1111/j.1445-2197.2009.04933_5.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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21
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Alexander SI, Smith N, Hu M, Verran D, Shun A, Dorney S, Smith A, Webster B, Shaw PJ, Lammi A, Stormon MO. Chimerism and tolerance in a recipient of a deceased-donor liver transplant. N Engl J Med 2008; 358:369-74. [PMID: 18216357 DOI: 10.1056/nejmoa0707255] [Citation(s) in RCA: 127] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Complete hematopoietic chimerism and tolerance of a liver allograft from a deceased male donor developed in a 9-year-old girl, with no evidence of graft-versus-host disease 17 months after transplantation. The tolerance was preceded by a period of severe hemolysis, reflecting partial chimerism that was refractory to standard therapies. The hemolysis resolved after the gradual withdrawal of all immunosuppressive therapy.
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Affiliation(s)
- Stephen I Alexander
- Centre for Kidney Research, Children's Hospital at Westmead and the Department of Paediatrics and Child Health, University of Sydney, Sydney, Australia
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Prakoso E, Strasser SI, Koorey DJ, Verran D, McCaughan GW. Long-term lamivudine monotherapy prevents development of hepatitis B virus infection in hepatitis B surface-antigen negative liver transplant recipients from hepatitis B core-antibody-positive donors. Clin Transplant 2006; 20:369-73. [PMID: 16824156 DOI: 10.1111/j.1399-0012.2006.00495.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Liver transplantation from hepatitis B core-antibody (HBcAb)-positive donors to hepatitis B surface-antigen (HBsAg)-negative recipients has been associated with a risk of hepatitis B virus (HBV) infection in the absence of antiviral prophylaxis. The aim of this study is to assess the efficacy of long-term lamivudine monotherapy to prevent development of HBV infection in HBsAg-negative recipients of liver allografts from HBcAb-positive donors. METHODS From 315 cadaveric adult liver transplantations performed at our unit between July 1999 and March 2005, 18 recipients (5.7%) received liver allografts from HBcAb-positive donors, 13 of whom were HBsAg-negative pre-transplantation. The recipients consisted of four females and 14 males, age range 28-65 yr (median 49.5 yr). Post-transplantation, HBsAg-negative recipients were administered lamivudine 100 mg daily long term. HBsAg-positive recipients were administered low-dose hepatitis B immunoglobulin (HBIg) and lamivudine according to our usual protocol. Standard post-transplantation immunosuppression was given. Recipients were followed up regularly (range 2-69 months, median 21 months) for development of de novo HBV infection. RESULTS Ten HBsAg-negative recipients received long-term lamivudine. One patient (HBcAb and HBsAb positive pre-transplant) did not receive lamivudine and, in two patients, lamivudine was discontinued following urgent re-transplantation for primary graft non-function. All 13 of the HBsAg-negative recipients were still alive, with no evidence of HBV infection at the end of follow-up. CONCLUSION Long-term lamivudine monotherapy was effective in preventing development of HBV infection in HBsAg-negative liver transplant recipients from HBcAb-positive donors.
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Affiliation(s)
- Emilia Prakoso
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia
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23
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Middleton PF, Duffield M, Lynch SV, Padbury RTA, House T, Stanton P, Verran D, Maddern G. Living donor liver transplantation--adult donor outcomes: a systematic review. Liver Transpl 2006; 12:24-30. [PMID: 16498709 DOI: 10.1002/lt.20663] [Citation(s) in RCA: 183] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The objective of this study was to evaluate the safety and efficacy of adult-to-adult living donor liver transplantation, specifically donor outcomes. A systematic review, with searches of the literature up to January 2004, was undertaken. Two hundred and fourteen studies provided information on donor outcomes. The majority of these were case series studies, although there were also studies comparing living donor liver transplantation with deceased donor liver transplantation. Both underreporting and duplicate reporting is likely to have occurred, and so caution is required in interpretation of these results. Overall reported donor mortality was 12 to 13 in about 6,000 procedures (0.2%) (117 studies). Mortality for right lobe donors to adult recipients is estimated to be 2 to 8 out of 3,800 (0.23 to 0.5%). The donor morbidity rate ranged from 0% to 100% with a median of 16% (131 studies). Biliary complications and infections were the most commonly reported donor morbidities. Nearly all donors had returned to normal function by 3 to 6 months (18 studies). In conclusion, there are small, but real, risks for living liver donors. Due to the short history of adult-to-adult living donor liver transplantation, the long-term risks for donors are unknown.
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Affiliation(s)
- Philippa F Middleton
- Australian Safety and Efficacy Register of New Interventional Procedures-Surgical (ASERNIP-S), Royal Australasian College of Surgeons, SA
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24
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Abstract
BACKGROUND Vascular conduits may be required to gain arterial inflow to the donor hepatic artery in orthotopic liver transplantation. METHODS From January 1986 to December 2003, arterial conduits were required in 31/582 (5.3%) adult liver transplant procedures. RESULTS Indications for the conduit included recipient hepatic artery problems (20); hepatic artery thrombosis previous allograft (7) and other (4). The conduits used in 28/31 cases (90%) were deceased donor iliac arteries and the remainder prosthetic grafts. Patients requiring conduits were more likely to be already hospitalized (P = 0.038) or undergoing a retransplant procedure (P = 0.001) than patients not requiring conduits. Both sepsis and haemorrhage caused death in 8/31 (26%) patients requiring conduits versus 42/551 (7.6%) patients not requiring conduits. Death from thrombosis of the iliac artery conduit occurred in two cases and from bacterial infection of a prosthetic conduit in one case. For retransplant procedures, allograft loss was seen in 11/13 (84%) conduit cases versus 11/28 (39%) non-conduit cases (P = 0.016). Overall allograft survival was significantly lower in the conduit cases than in the non-conduit cases (P = 0.0001), with 12/31 (39%) allografts being lost within the first 3 months post-transplantation for the conduit cases. CONCLUSION Arterial vascular conduits are more commonly required in adult liver transplant recipients who are hospitalized or undergoing retransplant procedures. Allograft survival is poorer in the conduit cases and is associated with complications, particularly sepsis and haemorrhage, following retransplantation procedures.
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Affiliation(s)
- Tianqi Liu
- Transplant Services, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW 2050, Australia
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25
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Abstract
UNLABELLED Biopsy of cadaver renal allografts may aid in the assessment of marginal allografts. However, the use of this approach is not clear. This study presents the outcome of institution of a protocol for back table biopsy of renal allografts during organ procurement. METHODS Data from Lifelink Organ Donation Network records and the ANZDATA registry were analysed. RESULTS The biopsy rate of renal allografts increased from 0.8% to 15.6% (P=0.01). The discardment rate of potential renal allografts increased slightly with 1.9% being discarded based on the biopsy result and 3.8% being discarded for other reasons. Under the biopsy protocol, 28/40 (70%) of donors with renal allograft biopsies had <20% glomerulosclerosis. The incidence of both delayed graft function and non-function was higher (P=0.014 and P=0.033, respectively) for the protocol biopsied allografts compared with the other non-biopsied allografts. One-year renal allograft survival was not significantly different between the protocol biopsied allografts versus the other non-biopsied allografts. CONCLUSIONS A biopsy protocol for marginal potential renal allografts leads to acceptable allograft outcomes without significantly increasing allograft discardment.
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Affiliation(s)
- Deborah Verran
- Royal Prince Alfred Hospital and Lifelink Organ Donation Network, Sydney, New South Wales, Australia.
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27
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Kusyk T, Verran D, Stewart G, Ryan B, Fisher J, Tsacalos K, Chadban S, Eris J. Increased Risk of Hemorrhagic Complications in Renal Allograft Recipients Receiving Systemic Heparin Early Posttransplantation. Transplant Proc 2005; 37:1026-8. [PMID: 15848612 DOI: 10.1016/j.transproceed.2005.02.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
UNLABELLED The aim of this paper is to document the risk of hemorrhagic complications in renal allograft recipients requiring systemic heparinisation within the first 2 weeks posttransplantation. METHODS A retrospective chart review of 326 RA recipients from January 1998 to July 2003 was subjected to statistics by SPIDA with P values <.05 considered significant. RESULTS 16/326 (4.9%) recipients were initiated on intravenous (IV) heparin within the study period. Enoxaparin was subsequently used in 10/16 (62.5%) of these recipients. Intravenous heparin was instituted at a median 8 (1-14) days posttransplantation. Hemorrhagic complications occurred in 10/16 (62.5%) recipients on IV heparin versus 11/310 (3.5%) nonanticoagulated RA recipients (P = .0001). Hemorrhage occurred at a mean 9.75 (2-43) days into the course of IV heparin. The median peak APTT 24 hours prior to hemorrhage in RA recipients on heparin was 68.5 (58-180) versus a median peak APTT of 70 (50-140) among recipients on heparin who did not sustain a hemorrhagic complication (P = .30). A major intervention (predominantly surgery) was required in 6/16 (37%) recipients on IV heparin versus 7/310 (2.2%) nonheparinised RA recipients (P < .0001). Enoxaparin was instituted at a mean 22.5 (4-55) days posttransplantation. Delayed hemorrhage subsequently occurred in 4/10 (40%) recipients on enoxaparin. In conclusion, major and minor hemorrhagic complications occur more commonly among recipients requiring early post transplant IV heparin. Hemorrhage occurred despite APTT monitoring with APTT levels tending to be similar in RA recipients with versus without complications. Delayed hemorrhage was also seen with the subsequent use of enoxaparin.
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Affiliation(s)
- T Kusyk
- Transplant Services, Royal Prince Alfred Hospital, Camperdown, Australia
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28
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Abstract
This is a review of a unit's experience with the use of pediatric (up to 15 yr of age), cadaver donor livers for orthotopic liver transplantation (OLTx). The records of 86 patients who underwent 90 OLTx with pediatric donor allografts from January 1986 to September 2002 were reviewed. A total of 69 of 90 (77%) allografts from pediatric donors were used for pediatric (P) recipients, and 21 of 90 (23%) for adult (A) recipients. Donor demographics were: mean donor age 8.5 (0-15) yr; donor sex 53 males/37 females; cause of death head injury 55/90 (61%), cerebral ischaemia 14 of 90 (15%), cerebrovascular 13 of 90 (15%), other eight of 90 (9%). Whole OLTx were performed in 44 of 69 (64%) P group and 20 of 21 (95%) A group. Reduced-size OLTx (13 left lateral lobe, 10 left lobe, one right lobe, one split left lateral lobe) were performed in 25 of 69 (36%) P group vs. in one of 21 (5%) A group, (right lobe split) (p < 0.005). The median follow up was 8.8 yr. The graft loss in the P recipients was 19 of 69 (27.5%) vs. eight of 21 (38.1%) in A recipients. Graft loss for reduced size P OLTx was nine of 25 (36%) vs. 10/44 (22.7%) for whole allograft P OLTx (p = NS). Underlying cause of P graft loss were: chronic rejection six (32%); patient mortality six (32%); vascular four (21%); other three (15%). Underlying cause of A graft loss were: patient mortality four (50%), acute rejection two (25%) and vascular two (25%). OLTx-utilizing pediatric cadaver donor allografts provides acceptable outcomes, including use of reduced-size grafts in pediatric recipients. Vascular complications and chronic rejection tend to be more common in pediatric recipients, whilst patient mortality and graft loss from acute rejection are more common in adult recipients.
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Affiliation(s)
- Hideaki Tanaka
- Liver Transplantation Unit, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
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29
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Abstract
Historically inability to achieve portal inflow to the liver allograft operatively was felt to be a contraindication to orthotopic liver transplantation (OLTx). Cavoportal hemi transposition has been utilized more recently in adult OLTx recipients but rarely in pediatric recipients. Here we report the case of a 10-month-old male with biliary atresia, who required urgent retransplantation with an in situ split cadaver donor allograft for failure of his first liver allograft from portal vein thrombosis. At the time of retransplantation, cavoportal hemi transposition was required to effect portal vein inflow to the allograft because of extensive thrombosis of the recipients portomesenteric venous system.
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Affiliation(s)
- Deborah Verran
- Liver Transplantation Unit, 9E, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia.
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30
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Verran D, Kusyk T, Painter D, Fisher J, Koorey D, Strasser S, Stewart G, McCaughan G. Clinical experience gained from the use of 120 steatotic donor livers for orthotopic liver transplantation. Liver Transpl 2003; 9:500-5. [PMID: 12740794 DOI: 10.1053/jlts.2003.50099] [Citation(s) in RCA: 187] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Steatosis of the donor liver is known to impact on patient and allograft outcome after orthotopic liver transplantation (OLT). The aim of this study is to evaluate the effect of increasing grades of cadaveric donor liver steatosis on recipient outcome. Between January, 1986 and December, 2000, 120 OLTs were performed with 72 mild, 25 moderate, and 23 severe steatotic donor livers. Donors of steatotic livers were more likely to be older (P =.001) and have died of intracerebral haemorrhage than donors of nonsteatotic livers. Initial poor graft function (IPF) was more common in donor livers with either moderate or severe steatosis than in donor livers with mild steatosis (P =.03). Primary graft nonfunction (PNF) occurred in only 1 donor liver with severe steatosis. PGE1 (PGE1) usage was higher in recipients of donor livers with moderate or severe steatosis versus donor livers with mild steatosis (P =.001). Allograft loss was greater at 1 year both in the moderate and severe (P =.03) steatotic liver groups. Patient survival at 3 months and overall allograft survival both were impacted negatively by increasing grades of donor liver steatosis (P =.02, P =.03). Three-month allograft survival was reduced in the steatotic donor livers if the donor was 50+ years old (P =.033). Recipient status at OLT (P =.001) and donor steatosis (P =.046) impacted on 30 day allograft survival (multivariate analysis). In conclusion, increasing grades of donor liver steatosis were associated with worse IPF and increased PGE1 usage. There was a negative impact of steatosis on both recipient and early allograft survival.
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Affiliation(s)
- Deborah Verran
- Australian Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, Australia.
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31
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Shi LW, Verran D, Chang D, Drenckhahn C, Fisher J, Stewart G, McCaughan G. Primary liver transplantation with preexisting portal vein thrombosis. Transplant Proc 2003; 35:354-5. [PMID: 12591437 DOI: 10.1016/s0041-1345(02)04020-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- L W Shi
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, NSW 2050, Camperdown, Australia.
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32
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Shi LW, Stewart GJ, Verran D, Maley M, McCaughan G. Cytomegalovirus serology status and early hepatic artery thrombosis following adult liver transplantation. Transplant Proc 2003; 35:421-2. [PMID: 12591469 DOI: 10.1016/s0041-1345(02)03929-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- L W Shi
- Australian National Liver Transplant Unit, Department of Microbiology, Royal Prince Alfred Hospital, Camperdown, Australia
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33
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Affiliation(s)
- L W Shi
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Camperdown, Australia
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Lin M, Crawford M, Fisher J, Hitos K, Verran D. Hepatic artery thrombosis and intraoperative hepatic artery flow rates in adult orthotopic liver transplantation. ANZ J Surg 2002; 72:798-800. [PMID: 12437690 DOI: 10.1046/j.1445-2197.2002.02552.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Thrombosis of the hepatic artery following orthotopic liver transplantation (OLT) can be a devastating com-plication impacting on recipient outcome. The utility of routine intraoperative flow measurements of the hepatic artery in predicting subsequent hepatic artery thrombosis (HAT) is presented in this study. METHODS Data on all adult OLT recipients between July 1995 and May 2000 were analysed. This included the routine intra-operative flow measurements of both the hepatic artery and portal vein using a Doppler flow meter. RESULTS Thirteen out of 198 (6.6%) instances of OLT were complicated by HAT. The mean and median flow rates of the hepatic artery in the OLT with HAT were 262 mL/min and 220 mL/min, respectively. These were significantly lower than the respective values of 436 mL/min and 400 mL/min in the OLT without HAT (P = 0.0036). This was independent of recipient age, sex, weight and intraoperative portal flow rates. However there was extensive overlap for the intraoperative hepatic artery flow rates obtained between the HAT and non-HAT groups. The risk of HAT was increased by a factor of 6 if the intraoperative hepatic artery flow rate was less than 200 mL/min. The average allograft survival was significantly lower in the HAT group at 373 days vs the non-HAT group at 763 days (P = 0.026). CONCLUSION The routine use of intraoperative flow measurements of the hepatic artery may be a useful adjunct in identifying the hepatic artery reconstruction, which is at risk of subsequent HAT.
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Affiliation(s)
- Martin Lin
- Liver Transplant Unit, Royal Prince Alfred Hospital, Missenden Road, Camperdown, New South Wales, Australia
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Abstract
Macroregenerative nodules (MRN) have been detected with increased incidence in explanted livers since orthotopic liver transplantation (OLTx) has become a routine treatment for end-stage liver disease. Autopsy series suggest that MRN may be more common than once thought, and several studies point to the malignant potential of these lesions. With increasing waiting times for OLTx, the propensity for these premalignant lesions to arise in cirrhotic livers has important implications for the supervision of patients on OLTx waiting lists. We present here a striking example of a MRN and review a topic that is generating considerable interest.
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Affiliation(s)
- A Gurkan
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, Australia
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Ren B, Sun J, Hu C, Cong L, Zhang L, King N, Verran D, Sheil AG. Immunosuppressive effects of Tripterygium wilfordii hook F in a rat liver transplant model. Transplant Proc 2001; 33:520-1. [PMID: 11266935 DOI: 10.1016/s0041-1345(00)02119-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- B Ren
- Department of Surgery, University of Sydney and Royal Prince Alfred Hospital, Sydney, Australia
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Affiliation(s)
- A K Chui
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, University of Sydney, NSW, Camperdown, Australia
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He X, Verran D, Hu C, Wang C, Li L, Wang L, Huang J, Sun J, Sheil AG. Synergistic effect of Tripterygium wilfordii Hook.F (TWHF) and cyclosporin A in rat liver transplantation. Transplant Proc 2000; 32:2054. [PMID: 11120063 DOI: 10.1016/s0041-1345(00)01555-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- X He
- Department of Transplantation Surgery, First Affiliated Hospital of Sun Yat-sen University of Medical Sciences, Guangzhou, People's Republic of China
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McCaughan GW, Spencer J, Koorey D, Bowden S, Bartholomeusz A, Littlejohn M, Verran D, Chui AK, Sheil AG, Jones RM, Locarnini SA, Angus PW. Lamivudine therapy in patients undergoing liver transplantation for hepatitis B virus precore mutant-associated infection: high resistance rates in treatment of recurrence but universal prevention if used as prophylaxis with very low dose hepatitis B immune globulin. Liver Transpl Surg 1999; 5:512-9. [PMID: 10545540 DOI: 10.1002/lt.500050601] [Citation(s) in RCA: 90] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Recurrent hepatitis B virus (HBV) infection remains a major cause of morbidity and mortality after liver transplantation. Recently, antiviral therapy, such as lamivudine, has become available for prophylaxis against HBV reactivation posttransplantation and for the treatment of HBV recurrent disease. We report our initial experience with lamivudine therapy in patients with precore mutant-associated HBV infection undergoing liver transplantation (n = 29). Outcomes were compared in three patient groups: group 1, precore mutant HBV infection not receiving lamivudine (n = 10); group 2, recurrent precore mutant HBV infection posttransplantation subsequently treated with lamivudine (n = 10); and group 3, HBV precore mutant patients undergoing liver transplantation and receiving lamivudine and low-dose hepatitis B immune globulin (HBIG) from the time of transplantation (n = 9). In group 1, HBV recurred in 9 of 10 patients, with subsequent graft loss in all 9 patients. In group 2, all patients developed HBV recurrence at a mean of 7.3 months posttransplantation and started lamivudine therapy at a median of 16 months posttransplantation. Follow-up on lamivudine therapy was for a median of 11 months. Six of these 10 patients developed mutations in the HBV polymerase gene associated with lamivudine resistance. There were two liver failure-related deaths in this group. In group 3 patients, there was one death from graft-versus-host disease. The remaining 8 patients have been followed up for a mean of 15.6 months posttransplantation, and all remain hepatitis B surface antigen negative and HBV DNA negative. In conclusion, lamivudine therapy in association with low-dose HBIG is effective in preventing HBV reactivation posttransplantation. Rescue therapy with lamivudine in patients with HBV recurrence is only moderately effective, with a 60% lamivudine resistance rate in patients treated for longer than 6 months.
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Affiliation(s)
- G W McCaughan
- A.W. Morrow Gastroenterology and Liver Centre, Australia
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Verran D, Hawken L, Chui A. Comparative experience of a simple technique for laparoscopic chronic ambulatory peritoneal dialysis catheter placement: comment. Aust N Z J Surg 1999; 69:398. [PMID: 10353563 DOI: 10.1046/j.1440-1622.1999.01584.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
Carbon monoxide (CO) inhalation leads to cerebral, cardiac, and, more rarely, liver damage. The use of liver allografts from CO poisoned donors with evidence of liver damage has not previously been reported. In this report we describe two recipients, both in fulminant hepatic failure, who received liver grafts from such donors. One donor had markedly abnormal liver function tests (LFTS), and in the other LFTS were mildly abnormal. In both, the liver appeared normal at procurement. There was satisfactory early function of both allografts, although marked patchy necrosis was seen on the postreperfusion biopsy (case 1), and on a 10 day postoperative biopsy (case 2). In both cases the changes were considered to be related to damage sustained from CO inhalation. Both allografts soon achieved normal function and both recipients are well. We conclude that CO poisoning can cause liver damage that can recover completely following liver transplantation.
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Affiliation(s)
- D Verran
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Camperdown, New South Wales
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Mackie F, Verran D, Horvath J, Tiller D. Severe thrombocytopenia with OKT3 use for steroid-resistant rejection in a cadaveric renal transplant recipient. Nephrol Dial Transplant 1996; 11:2378. [PMID: 8941629 DOI: 10.1093/oxfordjournals.ndt.a027192] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
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Abstract
Late deaths (after more than 1 year) after liver transplantation were analyzed in a series of 464 consecutive patients who received liver grafts between 1982 and 1993. Recipients who survived the first posttransplant year (n = 365) had actuarial 5- and 10-year survival rates of 92% and 84%, respectively. Thirty-five patients died between 1.1 and 7.6 years after transplantation (mean, 3.2 +/- 1.9 years). The most common causes of death were related to immunosuppression (40%), namely, chronic rejection, opportunistic infection, and lymphoma. The second most common causes of death were related to the primary disease for which liver transplantation was performed (34.3%), mainly recurrence of hepatobiliary malignancy and hepatitis B. Eight patients (22.9%) died of unrelated and unpredicted causes, most commonly of cardiovascular disease. Although the survival of liver recipients who live beyond the first posttransplant year is excellent, control of rejection and the consequences of chronic immunosuppression are continual threats. Modification of immunosuppression may help in decreasing the mortality of long-term survivors. In addition, better selection of recipients and effective adjuvant therapies (antiviral and antineoplastic) are needed in patients in whom the primary liver disease is notorious for recurrence.
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Affiliation(s)
- S Asfar
- Department of Surgery, University Hospital, London, Ontario, Canada
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Lee WT, Antoszewska H, Powell KF, Collins J, Doak PB, Williams LC, Munn S, Verran D, Croxson MC. Polymerase chain reaction in detection of CMV DNA in renal allograft recipients. Aust N Z J Med 1992; 22:249-55. [PMID: 1323255 DOI: 10.1111/j.1445-5994.1992.tb02120.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
This study investigates the use of polymerase chain reaction (PCR) in comparison with viral culture and serology for monitoring of cytomegalovirus (CMV) infection in 21 consecutive renal allograft recipients treated with a quadruple immunosuppression protocol. In addition, an attempt is made to explore the significance of quantitation of CMV signals obtained from peripheral blood leucocytes. CMV infection developed in 16 patients with seven of these patients having organ involvement. All of these 16 patients had a fourfold rise in antibody titres as well as positive identification of CMV DNA in peripheral blood leucocytes by PCR. Blood viral cultures were negative in two of these patients. All five patients who remained PCR negative also remained culture negative with no antibody change. PCR detected CMV infection on average 15 days and 20 days earlier than viral culture and serology respectively. All except one of the patients with CMV organ involvement had an initial peak of CMV DNA followed by prolonged carriage of detectable CMV. The majority of patients with fever only or asymptomatic CMV infection had a transient peak of CMV DNA. A high incidence of CMV disease with organ involvement occurred in seronegative recipients of kidneys from seropositive donors (3/5) and in seropositive recipients of kidneys from seronegative donors (3/7). OKT3 was associated with a higher incidence of CMV organ involvement compared to Antilymphocytic globulin (3/5 v 4/16) but there was a higher incidence of CMV mismatched patients in the OKT3 treated group.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- W T Lee
- Department of Medicine, Auckland Hospital, New Zealand
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Verran D, Munn S, Collins J, Hill G. Impact of renal allograft implantation and immunosuppression on body composition using in vivo neutron activation analysis. Transplant Proc 1992; 24:173-4. [PMID: 1539229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- D Verran
- Department of Surgery, Auckland Hospital, New Zealand
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Verran D, Munn S, Doak P, Williams L, Collins J, Lee W. Quadruple immunosuppression in renal allografts--the Auckland experience. N Z Med J 1991; 104:517-8. [PMID: 1758662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Recipients of live related and first cadaveric renal allografts were retrospectively reviewed before and after institution of a standardized regimen incorporating greater immunosuppression, (by the addition of antilymphocyte preparations). The two review groups were comparable with 11 live related and 27 first cadaver grafts in each. Despite a small advantage in terms of graft survival and diminished rejection, this was at the expense of septic morbidity. The implications of this are discussed.
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Affiliation(s)
- D Verran
- Department of Surgery, Auckland Hospital
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Abstract
Blunt injury causing laceration of the intrahepatic bile-ducts is fortunately rare. Two cases are presented: neither was diagnosed until 48 h after initial presentation. Both were managed by laparotomy, placement of drains in the liver lacerations, and intravenous nutrition until the leaks had stopped spontaneously. The literature is reviewed and two other cases discussed. Such injuries, once diagnosed, should be treated by surgical placement of drains right at the site of leak.
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Affiliation(s)
- D Verran
- Department of Surgery, Auckland Hospital, New Zealand
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