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Cooper M, Wiseman AC, Doshi MD, Hall IE, Parsons RF, Pastan S, Reddy KS, Schold JD, Mohan S, Hippen BE. Understanding Delayed Graft Function to Improve Organ Utilization and Patient Outcomes: Report of a Scientific Workshop Sponsored by the National Kidney Foundation. Am J Kidney Dis 2024; 83:360-369. [PMID: 37844725 DOI: 10.1053/j.ajkd.2023.08.018] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/22/2023] [Accepted: 08/26/2023] [Indexed: 10/18/2023]
Abstract
Delayed graft function (DGF) is a common complication after kidney transplant. Despite extensive literature on the topic, the extant definition of DGF has not been conducive to advancing the scientific understanding of the influences and mechanisms contributing to its onset, duration, resolution, or long-term prognostic implications. In 2022, the National Kidney Foundation sponsored a multidisciplinary scientific workshop to comprehensively review the current state of knowledge about the diagnosis, therapy, and management of DGF and conducted a survey of relevant stakeholders on topics of clinical and regulatory interest. In this Special Report, we propose and defend a novel taxonomy for the clinical and research definitions of DGF, address key regulatory and clinical practice issues surrounding DGF, review the current state of therapies to reduce and/or attenuate DGF, offer considerations for clinical practice related to the outpatient management of DGF, and outline a prospective research and policy agenda.
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Affiliation(s)
- Matthew Cooper
- Department of Surgery, Division of Transplantation, Medical College of Wisconsin, Milwaukee, WI.
| | | | - Mona D Doshi
- Department of Medicine, Division of Nephrology, University of Michigan, Ann Arbor, Michigan
| | - Isaac E Hall
- Division of Nephrology & Hypertension, Department of Internal Medicine, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, Utah
| | | | - Stephen Pastan
- Department of Medicine, Renal Division, Emory University School of Medicine, Atlanta, Georgia
| | - Kunam S Reddy
- Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Jesse D Schold
- Departments of Surgery and Epidemiology, University of Colorado Anschutz Medical College, Aurora, Colorado
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Benjamin E Hippen
- Global Medical Office, Fresenius Medical Care, Charlotte, North Carolina
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Zhang C, Calderon E, Chang YH, Lu P, Durant AM, Villa EL, Katariya NN, Jadlowiec C, Reddy KS, Moss A, Mathur AK. Portal vein thrombosis and donation after cardiac death liver transplantation: Pre-perfusion data implications for the perfusion era. Am J Surg 2024; 228:301-304. [PMID: 37777377 DOI: 10.1016/j.amjsurg.2023.09.026] [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: 07/23/2023] [Revised: 09/14/2023] [Accepted: 09/19/2023] [Indexed: 10/02/2023]
Affiliation(s)
- Chi Zhang
- Transplant Center, Mayo Clinic Arizona, Phoenix, AZ, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic Rochester, MN, USA
| | | | - Yu-Hui Chang
- Quantitative Health Sciences, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Patricia Lu
- Transplant Center, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Adri M Durant
- Transplant Center, Mayo Clinic Arizona, Phoenix, AZ, USA
| | | | | | | | - Kunam S Reddy
- Transplant Center, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Adyr Moss
- Transplant Center, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Amit K Mathur
- Transplant Center, Mayo Clinic Arizona, Phoenix, AZ, USA.
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Punukollu R, Ohara SY, Budhiraja P, Smith ML, Kumm K, Ruch B, Misra S, Reddy KS, Heilman RL, Jadlowiec CC. Duration of Dialysis in Acute Kidney Injury Donors and Transplant Outcomes. J Am Coll Surg 2024; 238:61-69. [PMID: 37870238 DOI: 10.1097/xcs.0000000000000870] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) kidneys, including those from donors on dialysis, are often underutilized, although there is increasing data available demonstrating good transplant outcomes. To date, data on the duration of donor dialysis and transplant outcomes are limited. STUDY DESIGN This was a single-center study of deceased donor kidney transplants from 2010 to 2022. The study cohort consisted of recipients of deceased donor kidney transplants from donors with AKI and on dialysis. Three groups were identified based on the predetermined interquartile range of donor dialysis duration: 1 to 2 dialysis days, 3 to 4 dialysis days, and 5 or more dialysis days. RESULTS During this period, 765 AKI deceased donor transplants were performed, of which 230 were from donors on dialysis. The median dialysis duration was 2 days with a maximum of 13 days. Across the 3 groups, there were no differences in recipient age (p = 0.23) or dialysis vintage (p = 0.70). Donor age (p = 0.86) and kidney donor profile index (p = 0.57) were comparable between the groups. Recipients of deceased donor kidney transplants from donors on dialysis 5 or more days had lower terminal creatinine levels (p = 0.003) and longer cold ischemia times (p = 0.04). Posttransplant, the median length of hospital stay was 3 days for all groups (p = 0.75). There were no differences in delayed graft function occurrence (94.4% vs 86.8% vs 92.1%, p = 0.19), duration of delayed graft function (p = 0.56), or readmissions (p = 0.99). At 1 year posttransplant, the estimated glomerular filtration rate (p = 0.76), patient survival (p = 0.82), or death-censored graft survival (p = 0.28) were comparable. CONCLUSIONS Excellent outcomes have been observed in AKI deceased donor kidney transplants, including those coming from donors on dialysis. In this small cohort, the duration of donor dialysis did not adversely affect outcomes. Cautious expansion of the donor pool, including donors on dialysis, should be considered given the ongoing organ shortage.
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Affiliation(s)
- Rachana Punukollu
- From the Division of Transplant Surgery, Department of Surgery (Punukollu, Kumm, Ruch, Reddy, Jadlowiec) Mayo Clinic, Phoenix, AZ
| | - Stephanie Y Ohara
- Division of Surgery, Valleywise Health Medical Center, Creighton University (Ohara), Phoenix, AZ
| | - Pooja Budhiraja
- Division of Nephrology (Budhiraja, Misra, Heilman) Mayo Clinic, Phoenix, AZ
| | - Maxwell L Smith
- Division of Anatomic Pathology (Smith) Mayo Clinic, Phoenix, AZ
| | - Kayla Kumm
- From the Division of Transplant Surgery, Department of Surgery (Punukollu, Kumm, Ruch, Reddy, Jadlowiec) Mayo Clinic, Phoenix, AZ
| | - Brianna Ruch
- From the Division of Transplant Surgery, Department of Surgery (Punukollu, Kumm, Ruch, Reddy, Jadlowiec) Mayo Clinic, Phoenix, AZ
| | - Suman Misra
- Division of Nephrology (Budhiraja, Misra, Heilman) Mayo Clinic, Phoenix, AZ
| | - Kunam S Reddy
- From the Division of Transplant Surgery, Department of Surgery (Punukollu, Kumm, Ruch, Reddy, Jadlowiec) Mayo Clinic, Phoenix, AZ
| | - Raymond L Heilman
- Division of Nephrology (Budhiraja, Misra, Heilman) Mayo Clinic, Phoenix, AZ
| | - Caroline C Jadlowiec
- From the Division of Transplant Surgery, Department of Surgery (Punukollu, Kumm, Ruch, Reddy, Jadlowiec) Mayo Clinic, Phoenix, AZ
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Me HM, Budhiraja P, Nair S, Kodali L, Ryan M, Khamash H, Heilman R, Wagler J, Ruch B, Jadlowiec CC, Moss A, Reddy KS. Utilizing kidneys from a donor with bile-cast nephropathy. Am J Transplant 2024; 24:141-144. [PMID: 37633448 DOI: 10.1016/j.ajt.2023.08.018] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 08/18/2023] [Accepted: 08/21/2023] [Indexed: 08/28/2023]
Abstract
Here we discuss the successful utilization of a pair of deceased donor kidneys with bile-cast nephropathy. The donor had a kidney donor profile index of 48% and an acute kidney injury requiring continuous renal replacement therapy. Peak donor bilirubin was 40.5 mg/dL, and renal wedge biopsies showed bile-cast nephropathy. Both recipients had delayed graft function lasting up to 4 weeks. The 4-month biopsies showed mild interstitial fibrosis, tubular atrophy, and a resolution of bile casts. These kidney allografts showed the reversible course of cholemic nephropathy and the potential for increasing the utilization of previously discarded kidneys.
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Affiliation(s)
- Hay Me Me
- Division of Nephrology, Mayo Clinic, Phoenix, Arizona, USA.
| | | | - Sumi Nair
- Division of Nephrology, Mayo Clinic, Phoenix, Arizona, USA
| | - Lavanya Kodali
- Division of Nephrology, Mayo Clinic, Phoenix, Arizona, USA
| | - Margaret Ryan
- Division of Laboratory Medicine and Pathology, Mayo Clinic, Phoenix, Arizona, USA
| | - Hasan Khamash
- Division of Nephrology, Mayo Clinic, Phoenix, Arizona, USA
| | | | - Josiah Wagler
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Brianna Ruch
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Caroline C Jadlowiec
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Adyr Moss
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Kunam S Reddy
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, Arizona, USA
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Jadlowiec CC, Brooks A, Pont K, Macdonough E, Buckner Petty S, Valenti K, Lizaola-Mayo B, Frasco P, Aqel B, Mathur AK, Moss A, Reddy KS. Liver transplant outcomes using late allocation grafts. Liver Transpl 2023; 29:1323-1329. [PMID: 37432903 DOI: 10.1097/lvt.0000000000000208] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 06/14/2023] [Indexed: 07/13/2023]
Abstract
Post-cross clamp late allocation (LA) liver allografts are at increased risk for discard for many reasons including logistical complexity. Nearest neighbor propensity score matching was used to match 2 standard allocation (SA) offers to every 1 LA liver offer performed at our center between 2015 and 2021. Propensity scores were based on a logistic regression model including recipient age, recipient sex, graft type (donation after circulatory death vs. donation after brain death), Model for End-stage Liver Disease (MELD), and DRI score. During this time, 101 liver transplants (LT) were performed at our center using LA offers. In comparing LA and SA offers, there were no differences in recipient characteristics including indication for transplant ( p = 0.29), presence of PVT ( p = 0.19), TIPS ( p = 0.83), and HCC status ( p = 0.24). LA grafts came from younger donors (mean age 43.6 vs. 48.9 y, p = 0.009) and were more likely to come from regional or national Organ Procurement Organizations (OPOs) ( p < 0.001). Cold ischemia time was longer for LA grafts (median 8.5 vs 6.3 h, p < 0.001). Following LT, there were no differences between the 2 groups in intensive care unit ( p = 0.22) and hospital ( p = 0.49) lengths of stay, need for endoscopic interventions ( p = 0.55), or biliary strictures ( p = 0.21). Patient (HR 1.0, 95% CI, 0.47-2.15, p = 0.99) and graft (HR 1.23, 95% CI, 0.43-3.50, p = 0.70) survival did not vary between the LA and SA cohorts. One-year LA and SA patient survival was 95.1% and 95.0%; 1-year graft survival was 93.1% and 92.1%, respectively. Despite the additional logistical complexity and longer cold ischemia time, LT outcomes utilizing LA grafts are similar to those allocated by means of SA. Improving allocation policies specific to LA offers, as well as the sharing of best practices between transplant centers and OPOs, are opportunities to further help minimize unnecessary discards.
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Affiliation(s)
- Caroline C Jadlowiec
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Abigail Brooks
- Department of Surgery, Division of Surgery, Montefiore Medical Center, New York City, New York, USA
| | - Kylie Pont
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Elizabeth Macdonough
- Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, Arizona, USA
| | - Skye Buckner Petty
- Department of Research and Biostatistics, Division of Research Biostatistics, Mayo Clinic, Phoenix, Arizona, USA
| | - Kristi Valenti
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Blanca Lizaola-Mayo
- Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, Arizona, USA
| | - Peter Frasco
- Department of Anesthesiology, Division of Anesthesiology, Mayo Clinic, Phoenix, Arizona, USA
| | - Bashar Aqel
- Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, Arizona, USA
| | - Amit K Mathur
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Adyr Moss
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Kunam S Reddy
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, Arizona, USA
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Jadlowiec CC, Ohara SY, Punukollu R, Wagler J, Ruch B, Kumm K, Budhiraja P, Me HM, Mathur AK, Reddy KS, Khamash H, Heilman R. Outcomes with transplanting kidneys offered through expedited allocation. Clin Transplant 2023; 37:e15094. [PMID: 37563488 DOI: 10.1111/ctr.15094] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 07/26/2023] [Accepted: 07/27/2023] [Indexed: 08/12/2023]
Abstract
INTRODUCTION Expedited out-of-sequence deceased donor kidney allocation is a strategy to avoid discards after early placement attempts have been unsuccessful. Our study aimed to assess outcomes and characteristics of these transplanted kidneys. METHODS KDPI matching was performed between expedited allocation (EA) and standard allocation (SA) deceased donor kidney transplants performed at our center. RESULTS Between 2018 and 2021, there were 225 EA offers, and 189 (84%) were transplanted. EA recipients were older (p = .007) and had shorter dialysis vintage (p < .0001). EA kidneys were likely to be nationally allocated (p < .001), have AKI (p < .0001) and longer CIT (p < .0001). There were no differences in EA and SA time-zero kidney biopsies (ci, p = .07; ct, p = .89; cv, p = .95; ah, p = .79). EA kidneys had more DGF (p = .0006), but there were no differences in DGF duration (p = .83), hospital length of stay (p = .43), 1- and 2-year eGFR (p = .16, p = .99), patient (p = .34), or death-censored graft (p = .66) survival. CONCLUSION During this study period, our center transplanted 189 kidneys through EA following local-regional declines. These kidneys often came from AKI donors and had more DGF but had similar outcomes to KDPI-matched SA kidneys. Although it has been suggested that EA has the potential to worsen transplant disparities, transplant center level decisions on organ acceptance contribute to these variations.
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Affiliation(s)
- Caroline C Jadlowiec
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Stephanie Y Ohara
- Division of Surgery, Valleywise Health Medical Center, Creighton University, Phoenix, Arizona, USA
| | - Rachana Punukollu
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Josiah Wagler
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Brianna Ruch
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Kayla Kumm
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | | | - Hay Me Me
- Division of Nephrology, Mayo Clinic, Phoenix, Arizona, USA
| | - Amit K Mathur
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Kunam S Reddy
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Hasan Khamash
- Division of Nephrology, Mayo Clinic, Phoenix, Arizona, USA
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Ruch B, Kumm K, Kirk WV, Geraghty PJ, Harbell JW, Aqel BA, Reddy KS, Katariya NN, Mathur AK. P2.3: Rapid Maastricht type 3 donors and normothermic perfusion: Relieving time constraints in non-renal organ recovery. Transplantation 2023; 107:82. [PMID: 37845975 DOI: 10.1097/01.tp.0000993480.41080.40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2023]
Affiliation(s)
- Brianna Ruch
- Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Kayla Kumm
- Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ, United States
| | | | - P J Geraghty
- Donor Network of Arizona, Tempe, AZ, United States
| | - Jack W Harbell
- Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Bashar A Aqel
- Transplant Hepatology, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Kunam S Reddy
- Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Nitin N Katariya
- Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Amit K Mathur
- Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ, United States
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Budhiraja P, Reddy KS, Heilman RL, Jadlowiec CC, Khamash H, Reddy S, Katariya N, Chakkera HA. Favorable outcomes in Hispanic recipients receiving simultaneous pancreas kidney transplantation. Clin Transplant 2023; 37:e15062. [PMID: 37378620 DOI: 10.1111/ctr.15062] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 06/08/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023]
Abstract
The objective of this study was to compare the long-term outcomes of Hispanic versus white recipients who underwent simultaneous pancreas kidney transplantation (SPKT). This single-center study, conducted from 2003 to 2022, had a median follow-up of 7.5 years. The study included 91 Hispanic and 202 white SPKT recipients. The mean age (44 vs. 46 years), percentage of males (67% vs. 58%), and body mass index (BMI) (25.6 vs. 25.3 kg/m2 ) were similar between the Hispanic and white groups. The Hispanic group had more recipients with type 2 diabetes (38%) compared to the white group (5%, p < .001). The duration of dialysis was longer in Hispanics (640 vs. 473 days, p = .02), and fewer patients received preemptive transplants (10% vs. 29%, p < .01) compared to whites. Hospital length of stay, rates of BK Viremia, and acute rejection episodes within 1 year were similar between the groups. The estimated 5-year kidney, pancreas, and patient survival rates were also similar between the groups, 94%, 81%, and 95% in Hispanics, compared to 90%, 79%, and 90% in whites. Increasing age and longer duration of dialysis were risk factors for death. Although Hispanic recipients had a longer duration on dialysis and fewer preemptive transplants, the survival rates were similar to those of white recipients. However, referring providers and many transplant centers continue to overlook pancreas transplants for appropriately selected patients with type 2 diabetes, particularly among minority populations. As a transplant community, it is crucial that we make efforts to comprehend and tackle these obstacles to transplantation.
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Affiliation(s)
- Pooja Budhiraja
- Division of Medicine, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Kunam S Reddy
- Department of Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | | | | | - Hassan Khamash
- Division of Medicine, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Swetha Reddy
- Department of Medicine, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Nitin Katariya
- Department of Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
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Punukollu R, Ryan M, Misra S, Budhiraja P, Ohara S, Kumm K, Guerra G, Reddy KS, Heilman R, Jadlowiec CC. Past, Current, and Future Perspectives on Transplanting Acute Kidney Injury Kidneys. Clin Pract 2023; 13:944-958. [PMID: 37623267 PMCID: PMC10453697 DOI: 10.3390/clinpract13040086] [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: 05/10/2023] [Revised: 07/24/2023] [Accepted: 08/08/2023] [Indexed: 08/26/2023] Open
Abstract
(1) Background: Acute kidney injury (AKI) kidneys have high non-utilization rates due to concerns regarding unfavorable outcomes. In this paper, we aimed to review the past, present, and future opinions on AKI kidneys. (2) Methods: A PubMed search was conducted for topics relevant to AKI kidney transplantation. (3) Results: Current short- and long-term data on AKI kidneys have demonstrated good outcomes including favorable graft function and survival. The role of procurement biopsies is controversial, but they have been shown to be beneficial in AKI kidneys by allowing clinicians to differentiate between reversible tubular injury and irreversible cortical necrosis. Machine perfusion has also been applied to AKI kidneys and has been shown to reduce delayed graft function (DGF). The incidence of DGF increases with AKI severity and its management can be challenging. Strategies employed to counteract this have included early initiation of dialysis after kidney transplantation, early targeting of adequate immunosuppression levels to minimize rejection risk, and establishment of outpatient dialysis. (4) Conclusions: Despite good outcomes, there continue to be barriers that impact AKI kidney utilization. Successful strategies have included use of procurement biopsies or machine perfusion and expectant management of DGF. With increasing experience, better use of AKI kidneys can result in additional opportunities to expand the donor pool.
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Affiliation(s)
- Rachana Punukollu
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Margaret Ryan
- Division of Anatomic Pathology, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Suman Misra
- Division of Nephrology, Mayo Clinic, Phoenix, AZ 85054, USA
| | | | - Stephanie Ohara
- Division of Surgery, Valleywise Health Medical Center, Creighton University, Phoenix, AZ 85008, USA
| | - Kayla Kumm
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Giselle Guerra
- Division of Nephrology, Miami Transplant Institute, Miami, FL 33136, USA
| | - Kunam S. Reddy
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ 85054, USA
| | | | - Caroline C. Jadlowiec
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ 85054, USA
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Egbert LK, Ohara SY, Das D, Brooks A, Mahdi G, Aqel B, Buckner Petty SA, Mathur AK, Moss A, Reddy KS, Jadlowiec CC. Expanding Liver Transplant Opportunities in Older Patients With Nonconventional Grafts. J Surg Res 2023; 288:140-147. [PMID: 36966594 DOI: 10.1016/j.jss.2023.01.017] [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: 09/28/2022] [Revised: 01/06/2023] [Accepted: 01/30/2023] [Indexed: 05/15/2023]
Abstract
INTRODUCTION Broader use of donation after circulatory death (DCD) and nonconventional grafts for liver transplant helps reduce disparities in organ availability. Limited data, however, exists on outcomes specific to nonconventional graft utilization in older patients. As such, this study aimed to investigate outcomes specific to conventional and nonconventional graft utilization in recipients > 70 y of age. METHODS 1-to-3 matching based on recipient sex, Model for End-Stage Liver Disease score, and donor type was performed on patients ≥70 and <70 y of age who underwent liver transplant alone at Mayo Clinic Arizona between 2015 and 2020. Primary outcomes were posttransplant patient and liver allograft survival for recipients greater than or less than 70 y of age. Secondary outcomes included grafts utilization patterns, hospital length of stay, need for reoperation, biliary complications and disposition at time of hospital discharge. RESULTS In this cohort, 36.1% of grafts came from DCD donors, 17.4% were postcross clamp offers, and 20.8% were nationally allocated. Median recipient ages were 59 and 71 y (P < 0.01). Recipients had similar Intensive care unit (P = 0.82) and hospital (P = 0.14) lengths of stay, and there were no differences in patient (P = 0.68) or graft (P = 0.38) survival. When comparing donation after brain death and DCD grafts in those >70 y, there were no differences in patient (P = 0.89) or graft (P = 0.71) survival. CONCLUSIONS Excellent outcomes can be achieved in older recipients, even with use of nonconventional grafts. Expanded use of nonconventional grafts can help facilitate transplant opportunities in older patients.
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Affiliation(s)
- Lena K Egbert
- Department of Surgery, Mayo Clinic, Phoenix, Arizona
| | - Stephanie Y Ohara
- Division of Surgery, Valleywise Health Medical Center, Creighton University, Phoenix, Arizona
| | - Devika Das
- Division of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Abigail Brooks
- Division of Surgery, Montefiore Medical Center, New York City, New York
| | - Giyth Mahdi
- Mayo Clinic Alix School of Medicine, Scottsdale, Arizona
| | - Bashar Aqel
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, Arizona
| | | | - Amit K Mathur
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, Arizona
| | - Adyr Moss
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, Arizona
| | - Kunam S Reddy
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, Arizona
| | - Caroline C Jadlowiec
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, Arizona.
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Yetmar ZA, McCord M, Lahr BD, Kudva YC, Seville MT, Bosch W, Lemke A, Katariya NN, Reddy KS, Perry DK, Huskey JL, Jarmi T, Kukla A, Dean PG, Bernard SA, Beam E. Impact of Perioperative Prophylaxis With Enterococcus Activity on Risk of Surgical-Site Infection After Pancreas Transplantation. Transplant Direct 2023; 9:e1496. [PMID: 37305653 PMCID: PMC10256365 DOI: 10.1097/txd.0000000000001496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 04/13/2023] [Accepted: 04/16/2023] [Indexed: 06/13/2023] Open
Abstract
Surgical-site infection (SSI) is the most common early infectious complication after pancreas transplantation (PT). Although SSI has been shown to worsen outcomes, little data exist to guide optimal choices in perioperative prophylaxis. Methods We performed a retrospective cohort study of PT recipients from 2010-2020 to examine the effect of perioperative antibiotic prophylaxis with Enterococcus coverage. Enterococcus coverage included antibiotics that would be active for penicillin-susceptible Enterococcus isolates. The primary outcome was SSI within 30 d of transplantation, and secondary outcomes were Clostridioides difficile infection (CDI) and a composite of pancreas allograft failure or death. Outcomes were analyzed by multivariable Cox regression. Results Of 477 PT recipients, 217 (45.5%) received perioperative prophylaxis with Enterococcus coverage. Eighty-seven recipients (18.2%) developed an SSI after a median of 15 d from transplantation. In multivariable Cox regression analysis, perioperative Enterococcus prophylaxis was associated with reduced risk of SSI (hazard ratio [HR] 0.58; 95% confidence interval [CI], 0.35-0.96; P = 0.034). Anastomotic leak was also significantly associated with elevated risk of SSI (HR 13.95; 95% CI, 8.72-22.32; P < 0.001). Overall, 90-d CDI was 7.4%, with no difference between prophylaxis groups (P = 0.680). SSI was associated with pancreas allograft failure or death, even after adjusting for clinical factors (HR 1.94; 95% CI, 1.16-3.23; P = 0.011). Conclusions Perioperative prophylaxis with Enterococcus coverage was associated with reduced risk of 30-d SSI but did not seem to influence risk of 90-d CDI after PT. This difference may be because of the use of beta-lactam/beta-lactamase inhibitor combinations, which provide better activity against enteric organisms such as Enterococcus and anaerobes compared with cephalosporin. Risk of SSI was also related to anastomotic leak from surgery, and SSI itself was associated with subsequent risk of a poor outcome. Measures to mitigate or prevent early complications are warranted.
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Affiliation(s)
- Zachary A. Yetmar
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Molly McCord
- Department of Pharmacy, Mayo Clinic, Rochester, MN
| | - Brian D. Lahr
- Division of Biomedical Statistics and Informatics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | - Yogish C. Kudva
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Maria Teresa Seville
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Phoenix, AZ
| | - Wendelyn Bosch
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Jacksonville, FL
| | - Adley Lemke
- Department of Pharmacy, Mayo Clinic, Rochester, MN
| | - Nitin N. Katariya
- Division of Transplantation Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ
| | - Kunam S. Reddy
- Division of Transplantation Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ
| | - Dana K. Perry
- Division of Transplantation Surgery, Department of Transplantation, Mayo Clinic, Jacksonville, FL
| | - Janna L. Huskey
- Division of Nephrology, Department of Medicine, Mayo Clinic, Phoenix, AZ
| | - Tambi Jarmi
- Division of Nephrology, Department of Medicine, Mayo Clinic, Jacksonville, FL
| | - Aleksandra Kukla
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Patrick G. Dean
- Division of Transplantation Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | | | - Elena Beam
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
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Ohara S, Lizaola-Mayo B, Macdonough E, Morgan P, Das D, Egbert L, Brooks A, Mathur AK, Aqel B, Reddy KS, Jadlowiec CC. Reassessing Geographic, Logistical, and Cold Ischemia Cutoffs in Liver Transplantation. Prog Transplant 2023; 33:168-174. [PMID: 37013356 DOI: 10.1177/15269248231164169] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
INTRODUCTION Liver acceptance patterns vary significantly between transplant centers. Data pertaining to outcomes of livers declined by local and regional centers and allocated nationally remains limited. PROJECT AIM The objective was to compare post-liver transplant outcomes between liver allografts transplanted as a result of national and local-regional allocation. DESIGN This was a retrospective evaluation of 109 nationally allocated liver allografts used for transplant by a single center. Outcomes of nationally allocated grafts were compared to standard allocation grafts (N = 505) during the same period. RESULTS Recipients of nationally allocated grafts had lower model for end stage liver disease scores (17 vs 22, P = .001). Nationally allocated grafts were more likely to be post-cross clamp offers (29.4% vs 13.4%, P = .001) and have longer cold ischemia times (median hours 7.8 vs 5.5, P = .001). Early allograft dysfunction was common (54.1% vs 52.5%, P = .75) and did not impact hospital length of stay (median 5 vs 6 days, P = .89). There were no differences in biliary complications (P = .11). There were no differences in patient (P = .88) or graft survival (P = .35). In a multivariate model, after accounting for differences in cold ischemia time and posttransplant biliary complications, nationally allocated grafts were not associated with increased risk for graft loss (HR 0.9, 95% CI 0.4-1.8). Abnormal liver biopsy findings (33.0%) followed by donor donation after circulatory death status (22.9%) were the most common reasons for decline by local-regional centers. CONCLUSION Despite longer cold ischemia times, patient and graft survival outcomes remain excellent and comparable to those seen from standard allocation grafts.
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Affiliation(s)
- Stephanie Ohara
- Division of Surgery, Valleywise Health Medical Center, Creighton University, Phoenix, AZ, USA
| | | | | | - Paige Morgan
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Devika Das
- Division of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Lena Egbert
- Department of Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Abigail Brooks
- Division of Surgery, Montefiore Medical Center, New York City, NY, USA
| | - Amit K Mathur
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Bashar Aqel
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
| | - Kunam S Reddy
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Caroline C Jadlowiec
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ, USA
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13
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Hydrick TC, Zhang C, Ruch B, Wagler J, Kumm K, Harbell JW, Hewitt WR, Jadlowiec CC, Katariya NN, Moss AA, Nguyen MC, Reddy KS, Singer AL, Mathur AK. Declining Medicare reimbursement in abdominal transplantation from 2000 to 2021. Surgery 2023; 173:1484-1490. [PMID: 36894411 DOI: 10.1016/j.surg.2023.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 01/20/2023] [Accepted: 01/24/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND The Centers for Medicare and Medicaid Services is a major payer for abdominal transplant services. Reimbursement reductions could have a major impact on the transplant surgical workforce and hospitals. Yet government reimbursement trends in abdominal transplantation have not been fully characterized. METHODS We performed an economic analysis to characterize changes in inflation-adjusted trends in Medicare surgical reimbursement for abdominal transplant procedures. Using the Medicare Fee Schedule Look-Up Tool, we performed a procedure code-based surgical reimbursement rate analysis. Reimbursement rates were adjusted for inflation to calculate overall changes in reimbursement, overall year-over-year, 5-year year-over-year, and compound annual growth rate from 2000 to 2021. RESULTS We observed declines in adjusted reimbursement of common abdominal transplant procedures, including liver (-32.4%), kidney with and without nephrectomy (-24.2% and -24.1%, respectively), and pancreas transplant (-15.2%) (all, P < .05). Overall, the yearly average change for liver, kidney with and without nephrectomy, and pancreas transplant were -1.54%, -1.15%, -1.15%, and -0.72%. Five-year annual change averaged -2.69%, -2.35%, -2.64%, and -2.43%, respectively. The overall average compound annual growth rate was -1.27%. CONCLUSION This analysis depicts a worrisome reimbursement pattern for abdominal transplant procedures. Transplant surgeons, centers, and professional organizations should note these trends to advocate sustainable reimbursement policy and to preserve continued access to transplant services.
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Affiliation(s)
| | - Chi Zhang
- Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic, Rochester, MN. https://twitter.com/ChiZhang_MD
| | - Brianna Ruch
- Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ. https://twitter.com/BriannaCRuch
| | - Josiah Wagler
- Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ
| | - Kayla Kumm
- Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ
| | - Jack W Harbell
- Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ
| | - Winston R Hewitt
- Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ
| | - Caroline C Jadlowiec
- Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ. https://twitter.com/CarrieJadlowiec
| | - Nitin N Katariya
- Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ
| | - Adyr A Moss
- Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ
| | | | - Kunam S Reddy
- Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ
| | - Andrew L Singer
- Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ
| | - Amit K Mathur
- Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic, Rochester, MN.
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14
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Jadlowiec CC, Hippen B, Gill J, Heilman R, Stewart D, Reddy KS, Mohan S, Wiseman A, Cooper M. Current opinions on DGF management practices: A survey of the United States and Canada. Clin Transplant 2023; 37:e14949. [PMID: 36849704 DOI: 10.1111/ctr.14949] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [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: 08/29/2022] [Revised: 10/24/2022] [Accepted: 02/18/2023] [Indexed: 03/01/2023]
Abstract
INTRODUCTION Significant center-to-center variation in attitudes and management of delayed graft function (DGF) remains common. METHODS A survey to describe current DGF practices was developed by workgroup members sponsored by the National Kidney Foundation (NKF) and was distributed to both the NKF DGF workgroup members, kidney transplant program directors and the transplant community within the United States and Canada. Seventy-one percent of NKF workgroup members completed the survey along with 70 unique the United States and three Canadian kidney transplant programs. All Organ Procurement and Transplantation Network (OPTN) regions were represented. RESULTS DGF was reported to occur at rate of 20%-40% for most centers with 3.9% indicating their incidence to be >60%. Most centers reported longer hospital lengths of stay and more frequent outpatient visits. Despite the commonality of DGF, only half of centers reported having an established protocol to manage DGF. Kidney allograft biopsies were the only consistent DGF management strategy observed, although use of machine perfusion was also heavily favored. Other DGF management strategies voiced by a minority included having established outpatient practices to care for DGF patients and administering outpatient community-based hemodialysis. CONCLUSION Although approximately a third of survey responders indicated that risk of DGF played a role in their willingness to accept organs, most did not feel that increased cost or clinical impact on outcomes was a deterrent. Future strategies, including broader sharing of best practices, redefining terminology specific to DGF, the establishment of DGF dialysis guidelines and improving access to machine perfusion across OPOs may help reduce discard and improve utilization of kidneys at risk for DGF.
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Affiliation(s)
- Caroline C Jadlowiec
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Benjamin Hippen
- Global Medical Office, Fresenius Medical Care, Charlotte, North Carolina, USA
| | - John Gill
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Darren Stewart
- United Network for Organ Sharing, Richmond, Virginia, USA
| | - Kunam S Reddy
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians & Surgeons, New York, New York, USA
| | - Alex Wiseman
- Division of Nephrology, University of Colorado, Denver, Colorado, USA
| | - Matthew Cooper
- Division of Transplant Surgery, MedStar Georgetown Transplant Institute, Washington, District of Columbia, USA
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15
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Jadlowiec CC, Macdonough E, Pont K, Valenti K, Lizaola‐Mayo B, Brooks A, Das D, Heilman R, Mathur AK, Hewitt W, Moss A, Aqel B, Reddy KS. Donation after circulatory death transplant outcomes using livers recovered by local surgeons. Liver Transpl 2022; 28:1726-1734. [PMID: 35332655 PMCID: PMC9790574 DOI: 10.1002/lt.26461] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 02/26/2022] [Accepted: 03/19/2022] [Indexed: 12/30/2022]
Abstract
Donation after circulatory death (DCD) liver transplantation (LT) outcomes have been attributed to multiple variables, including procurement surgeon recovery techniques. Outcomes of 196 DCD LTs at Mayo Clinic Arizona were analyzed based on graft recovery by a surgeon from our center (transplant procurement team [TPT]) versus a local procurement surgeon (non-TPT [NTPT]). A standard recovery technique was used for all TPT livers. The recovery technique used by the NTPT was left to the discretion of that surgeon. A total of 129 (65.8%) grafts were recovered by our TPT, 67 (34.2%) by the NTPT. Recipient age (p = 0.43), Model for End-Stage Liver Disease score (median 17 vs. 18; p = 0.22), and donor warm ischemia time (median 21.0 vs. 21.5; p = 0.86) were similar between the TPT and NTPT groups. NTPT livers had longer cold ischemia times (6.5 vs. 5.0 median hours; p < 0.001). Early allograft dysfunction (80.6% vs. 76.1%; p = 0.42) and primary nonfunction (0.8% vs. 0.0%; p = 0.47) were similar. Ischemic cholangiopathy (IC) treated with endoscopy occurred in 18.6% and 11.9% of TPT and NTPT grafts (p = 0.23). At last follow-up, approximately half of those requiring endoscopy were undergoing a stent-free trial (58.3% TPT; 50.0% NTPT; p = 0.68). IC requiring re-LT in the first year occurred in 0.8% (n = 1) of TPT and 3.0% (n = 2) of NTPT grafts (p = 0.23). There were no differences in patient (hazard ratio [HR], 1.95; 95% confidence interval [CI], 0.76-5.03; p = 0.23) or graft (HR, 1.99; 95% CI, 0.98-4.09; p = 0.10) survival rates. Graft survival at 1 year was 91.5% for TPT grafts and 95.5% for NTPT grafts. Excellent outcomes can be achieved using NTPT for the recovery of DCD livers. There may be an opportunity to expand the use of DCD livers in the United States by increasing the use of NTPT.
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Affiliation(s)
| | | | - Kylie Pont
- Division of Transplant SurgeryDepartment of SurgeryMayo ClinicPhoenixArizonaUSA
| | - Kristi Valenti
- Division of Transplant SurgeryDepartment of SurgeryMayo ClinicPhoenixArizonaUSA
| | | | - Abigail Brooks
- Tel Aviv University School of MedicineTel Aviv‐YafoIsrael
| | - Devika Das
- Division of Internal MedicineMayo ClinicRochesterMinnesotaUSA
| | | | - Amit K. Mathur
- Division of Transplant SurgeryDepartment of SurgeryMayo ClinicPhoenixArizonaUSA
| | - Winston Hewitt
- Division of Transplant SurgeryDepartment of SurgeryMayo ClinicPhoenixArizonaUSA
| | - Adyr Moss
- Division of Transplant SurgeryDepartment of SurgeryMayo ClinicPhoenixArizonaUSA
| | - Bashar Aqel
- Division of Gastroenterology and HepatologyMayo ClinicPhoenixArizonaUSA
| | - Kunam S. Reddy
- Division of Transplant SurgeryDepartment of SurgeryMayo ClinicPhoenixArizonaUSA
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16
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Ohara S, Macdonough E, Egbert L, Brooks A, Lizaola-Mayo B, Mathur AK, Aqel B, Reddy KS, Jadlowiec CC. Decreasing Significance of Early Allograft Dysfunction with Rising Use of Nonconventional Donors. Medicina (Kaunas) 2022; 58:medicina58060821. [PMID: 35744084 PMCID: PMC9227373 DOI: 10.3390/medicina58060821] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 06/07/2022] [Accepted: 06/13/2022] [Indexed: 11/27/2022]
Abstract
Background and Objectives: Early allograft dysfunction (EAD) is considered a surrogate marker for adverse post-liver transplant (LT) outcomes. With the increasing use of nonconventional donors, EAD has become a more frequent occurrence. Given this background, we aimed to assess the prevalence and impact of EAD in an updated cohort inclusive of both conventional and nonconventional liver allografts. Materials and Methods: Perioperative and one-year outcomes were assessed for a total of 611 LT recipients with and without EAD from Mayo Clinic Arizona. EAD was defined as the presence of one or more of the following: bilirubin > 10 mg/dL on day 7, INR > 1.6 on day 7, or ALT and/or AST > 2000 IU/L within the first 7 days of LT. Results: Within this cohort, 31.8% of grafts (n = 194) came from donation after circulatory death (DCD) donors, 17.7% (n = 108) were nationally shared, 16.4% (n = 100) were allocated as post-cross clamp, and 8.7% contained moderate steatosis. EAD was observed in 52.2% (n = 321) of grafts in the study cohort (79% in DCD grafts and 40% in DBD grafts). EAD grafts had higher donor risk index (DRI) scores (1.9 vs. 1.6, p < 0.0001), were more likely to come from DCD donors (48% vs. 13.8%, p < 0.0001), were regionally allocated (p = 0.003), and had higher cold ischemia times (median 6.0 vs. 5.5 h, p = 0.001). Primary nonfunction events were rare in both groups (1.3% vs. 0.3%, p = 0.22). Post-LT acute kidney injury occurred at a similar frequency in recipients with and without EAD (43.6% vs. 30.3%, p = 0.41), and there were no differences in ICU (median 2 vs. 1 day, p = 0.60) or hospital (6 vs. 5 days, p = 0.24) length of stay. For DCD grafts, the rate of ischemic cholangiopathy was similar in the two groups (14.9% EAD vs. 17.5% no EAD, p = 0.69). One-year patient survival for grafts with and without EAD was 96.0% and 94.1% (HR 1.2, 95% CI 0.7−1.8; p = 0.54); one-year graft survival was 92.5% and 92.1% (HR 1.0, 95% CI 0.7−1.5; p = 0.88). Conclusions: In this cohort, EAD occurred in 52% of grafts. The occurrence of EAD, however, did not portend inferior outcomes. Compared to those without EAD, recipients with EAD had similar post-operative outcomes, as well as one-year patient and graft survival. EAD should be managed supportively and should not be viewed as a deterrent to utilization of non-ideal grafts.
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Affiliation(s)
- Stephanie Ohara
- Division of Surgery, Valleywise Health Medical Center, Creighton University, Phoenix, AZ 85008, USA;
| | - Elizabeth Macdonough
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ 85054, USA; (E.M.); (B.L.-M.); (B.A.)
| | - Lena Egbert
- Mayo Clinic Alix School of Medicine, Scottsdale, AZ 85259, USA;
| | - Abigail Brooks
- School of Medicine, Tel Aviv University, Tel Aviv-Yafo 6997801, Israel;
| | - Blanca Lizaola-Mayo
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ 85054, USA; (E.M.); (B.L.-M.); (B.A.)
| | - Amit K. Mathur
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ 85054, USA; (A.K.M.); (K.S.R.)
| | - Bashar Aqel
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ 85054, USA; (E.M.); (B.L.-M.); (B.A.)
| | - Kunam S. Reddy
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ 85054, USA; (A.K.M.); (K.S.R.)
| | - Caroline C. Jadlowiec
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ 85054, USA; (A.K.M.); (K.S.R.)
- Correspondence: ; Tel.: +1-480-342-0437
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17
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Mour GK, Chang YH, Calderon E, Chang JM, Velazco CS, Jadlowiec CC, Reddy KS, Heilman RL, Mathur AK. Kidney donor profile index and post-transplant health care utilization: Implications for value of transplant care delivery. Clin Transplant 2022; 36:e14618. [PMID: 35182437 DOI: 10.1111/ctr.14618] [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: 09/17/2021] [Revised: 01/17/2022] [Accepted: 02/10/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Centers discard high kidney donor profile index (KDPI) allografts, potentially related to delayed graft function and prolonged hospital use by kidney transplant recipients (KTR). We sought to determine whether high KDPI KTRs have excess health care utilization. METHODS We conducted a retrospective cohort study from a high-volume center analyzing KTRs from January 3, 2011 to April 12, 2015 (n = 652). We measured differences in hospital use, emergency visits, and outpatient visits within the first 90 days between low (≤85%) versus high KDPI (>85%) KTRs, as well as long-term graft function and patient survival. RESULTS High (n = 107) and low KDPI (n = 545) KTRs had similar length of stay (median = 3 days, P = .66), and readmission rates at 7, 30, and 90 days after surgery (all, P > .05). High KDPI kidneys were not associated with excess utilization of the hospital, emergency services, outpatient transplant clinics, or ambulatory infusion visits on univariate or multivariate analysis (all, P > .05). Low KDPI KTRs had significantly better eGFR at 2 years (Low vs. High KDPI: 60.35 vs. 41.54 ml/min, P < .001), but similar 3-year patient and graft survival (both, P > .09). CONCLUSIONS High and low KDPI KTRs demonstrated similar 90-day risk-adjusted health care utilization, which should encourage use of high KDPI kidneys.
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Affiliation(s)
- Girish K Mour
- Division of Nephrology, Mayo Clinic, Phoenix, Arizona, USA
| | - Yu-Hui Chang
- Robert D. and Patricia E. Kern Center for the Center for the Science of Healthcare Delivery, Mayo Clinic, Phoenix, Arizona, USA
| | - Esteban Calderon
- Division of Transplant Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - James M Chang
- Division of Vascular Surgery, Emory University, Atlanta, Georgia, USA
| | | | | | - Kunam S Reddy
- Division of Transplant Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | | | - Amit K Mathur
- Robert D. and Patricia E. Kern Center for the Center for the Science of Healthcare Delivery, Mayo Clinic, Phoenix, Arizona, USA.,Division of Transplant Surgery, Mayo Clinic, Phoenix, Arizona, USA
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18
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Budhiraja P, Reddy KS, Butterfield RJ, Jadlowiec CC, Moss AA, Khamash HA, Kodali L, Misra SS, Heilman RL. Duration of delayed graft function and its impact on graft outcomes in deceased donor kidney transplantation. BMC Nephrol 2022; 23:154. [PMID: 35440023 PMCID: PMC9017045 DOI: 10.1186/s12882-022-02777-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 03/30/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is controversy regarding the impact of delayed graft function (DGF) on kidney transplant outcomes. We hypothesize that the duration of DGF, rather than DGF itself, is associated with long-term kidney graft function. METHODS We analyzed all deceased donor kidney transplants (DDKT) done at our center between 2008 to 2020. We determined factors associated with DGF duration. DGF duration was assessed at three 14-day intervals: < 14 DGF days, 14-27 DGF days, > 28 DGF days. We studied the impact of DGF duration on survival and graft function and resource utilization, including hospital length of stay and readmissions. RESULTS 1714 DDKT recipients were included, 59.4% (n = 1018) had DGF. The median DGF duration was 10 days IQR (6,15). The majority of recipients (95%) had resolution of DGF within 28 days. Donor factors associated with DGF days were longer cold ischemia time, donor on inotropes, older age, donation after circulatory death, higher terminal creatinine, and hypertension. Recipient factors associated with increased DGF duration included male sex, length on dialysis before transplant, and higher body mass index. There were no differences in acute rejection events or interstitial fibrosis progression by 4 months when comparing DGF days. The median length of stay was 3 days. However, readmissions increased with increasing DGF duration. Death-censored graft survival was not associated with the length of DGF except when DGF lasted > 28 days. CONCLUSIONS Inferior graft survival was observed only in recipients of DDKT with DGF lasting beyond 28 days. DGF lasting < 28 days had no impact on graft survival. Duration of DGF, rather than DGF itself, is associated with graft survival. TRIAL REGISTRATION Retrospective study approved by Mayo Clinic IRB number ID: 20-011561.
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Affiliation(s)
- Pooja Budhiraja
- Division of Nephrology, Mayo Clinic Hospital, 5777 East Mayo Blvd, Phoenix, AZ, 85054, USA.
| | - Kunam S Reddy
- Department of Surgery, Mayo Clinic, 5777 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | | | - Caroline C Jadlowiec
- Department of Surgery, Mayo Clinic, 5777 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Adyr A Moss
- Department of Surgery, Mayo Clinic, 5777 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Hassan A Khamash
- Division of Nephrology, Mayo Clinic Hospital, 5777 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Lavanya Kodali
- Division of Nephrology, Mayo Clinic Hospital, 5777 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Suman S Misra
- Division of Nephrology, Mayo Clinic Hospital, 5777 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Raymond L Heilman
- Division of Nephrology, Mayo Clinic Hospital, 5777 East Mayo Blvd, Phoenix, AZ, 85054, USA
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19
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Calderon E, Chang YH, Chang JM, Velazco CS, Giorgakis E, Srinivasan A, Moss AA, Khamash H, Heilman R, Reddy KS, Mathur AK. Outcomes and Health Care Utilization After Early Hospital Dismissal in Kidney Transplantation: An Analysis of 1001 Consecutive Cases. Ann Surg 2022; 275:e511-e519. [PMID: 32516231 DOI: 10.1097/sla.0000000000003948] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [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: 11/26/2022]
Abstract
OBJECTIVE To understand whether reduced lengths of stay after kidney transplantation were associated with excess health care utilization in the first 90 days or long-term graft and patient survival outcomes. BACKGROUND Reducing length of stay after kidney transplant has an unknown effect on post-transplant health care utilization. We studied this association in a cohort of 1001 consecutive kidney transplants. METHODS We retrospectively reviewed 2011-2015 data from a prospectively-maintained kidney transplant database from a single center. RESULTS A total of 1001 patients underwent kidney transplant, and were dismissed from the hospital in 3 groups: Early [≤2 days] (19.8%), Normal [3-7 days] (79.4%) and Late [>7 days] (3.8%). 34.8% of patients had living donor transplants (Early 51%, Normal 31.4%, Late 18.4%, P < 0.001). Early patients had lower delayed graft function rates (Early 19.2%, Normal 32%, Late73.7%, P = 0.001). By the hospital dismissal group, there were no differences in readmissions or emergency room visits at 30 or 90 days. Glomerular filtration rate at 12 months and rates of biopsy-proven acute rejection were also similar between groups. The timing of hospital dismissal was not associated with the risk-adjusted likelihood of readmission. Early and Normal patients had similar graft and patient survival. Late dismissal patients, who had higher rates of cardiovascular complications, had significantly higher late mortality versus Normal dismissal patients in unadjusted and risk-adjusted models. CONCLUSION Dismissing patients from the hospital 2 days after kidney transplant is safe, feasible, and improves value. It is not associated with excess health care utilization or worse short or long-term transplant outcomes.
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Affiliation(s)
| | - Yu-Hui Chang
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Phoenix, Arizona
| | - James M Chang
- Department of Surgery, Mayo Clinic, Phoenix, Arizona
| | | | | | | | - Adyr A Moss
- Department of Surgery, Mayo Clinic, Phoenix, Arizona
| | - Hasan Khamash
- Department of Nephrology, Mayo Clinic, Phoenix, Arizona
| | | | - Kunam S Reddy
- Department of Surgery, Mayo Clinic, Phoenix, Arizona
| | - Amit K Mathur
- Department of Surgery, Mayo Clinic, Phoenix, Arizona
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Phoenix, Arizona
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Affiliation(s)
- K S Reddy
- Policy and Research Urban Health 360 Glenn Dale, MD,USA, Investigator, Bruyere Research Institute, University of Ottawa, 85 Primrose Ave, Ottawa, ON K1R 6M1, Canada WHO Collaborating Centre for Knowledge Translation and Health Technology Assessment in Health Equity, Ottawa, Canada
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21
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Egbert LK, Das DM, Ohara SY, Brooks A, Wagler JD, Mahdi GM, Aqel B, Moss AA, Reddy KS, Jadlowiec CC. Liver Transplantation in the Elderly: Balancing Outcomes and Resources. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.200] [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: 12/01/2022]
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22
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Park WD, Kim DY, Mai ML, Reddy KS, Gonwa T, Ryan MS, Herrera Hernandez LP, Smith ML, Geiger XJ, Turkevi-Nagy S, Cornell LD, Smith BH, Kremers WK, Stegall MD. Progressive decline of function in renal allografts with normal 1-year biopsies: Gene expression studies fail to identify a classifier. Clin Transplant 2021; 35:e14456. [PMID: 34717009 DOI: 10.1111/ctr.14456] [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: 04/30/2021] [Revised: 07/23/2021] [Accepted: 08/04/2021] [Indexed: 11/29/2022]
Abstract
Histologic findings on 1-year biopsies such as inflammation with fibrosis and transplant glomerulopathy predict renal allograft loss by 5 years. However, almost half of the patients with graft loss have a 1-year biopsy that is either normal or has only interstitial fibrosis. The goal of this study was to determine if there was a gene expression profile in these relatively normal 1-year biopsies that predicted subsequent decline in renal function. Using transcriptome microarrays we measured intragraft mRNA levels in a retrospective Discovery cohort (170 patients with a normal/minimal fibrosis 1-year biopsy, 54 with progressive decline in function/graft loss and 116 with stable function) and developed a nested 10-fold cross-validated gene classifier that predicted progressive decline in renal function (positive predictive value = 38 ± 34%%; negative predictive value = 73 ± 30%, c-statistic = .59). In a prospective, multicenter Validation cohort (270 patients with Normal/Interstitial Fibrosis [IF]), the classifier had a 20% positive predictive value, 85% negative predictive value and .58 c-statistic. Importantly, the majority of patients with graft loss in the prospective study had 1-year biopsies scored as Normal or IF. We conclude predicting graft loss in many renal allograft recipients (i.e., those with a relatively normal 1-year biopsy and eGFR > 40) remains difficult.
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Affiliation(s)
| | - Dean Y Kim
- Henry Ford Hospital, Detroit, Michigan, USA
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23
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Reddy NC, Reddy AC, Reddy KS. Assessment of Comprehensive Mutational Profiling in T-lymphoblastic leukemia/lymphoma (T-ALL/LBL): A Single Center Experience. Am J Clin Pathol 2021. [DOI: 10.1093/ajcp/aqab191.308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction/Objective
T-lymphoblastic leukemia/lymphoma (T-ALL/LBL) is a malignancy arising from immature precursor T cells with T-ALL involving bone marrow/blood and T-LBL occurring in the thymus and nodal/extranodal sites. Studies have now revealed >100 recurrently altered genes that are not necessarily disease initiating but can provide diagnostic, prognostic, and predictive information which can then be utilized in personalized therapy.
Methods/Case Report
Next-generation sequencing was performed on DNA and/or RNA extracted from blood/marrow aspirates or tissue at an external CLIA-certified, CAP-accredited laboratory. The hematology panel sequenced DNA of 406 genes, introns of 31 gene rearrangements, and RNA of 265 genes.
This retrospective single-center study highlights salient findings noted in genomic profiles of 15 T-ALL/LBL cases out of 83 total patients with ALL from 2018-2021. While the majority were B-ALL cases, T-ALL accounted for 18%, and all but 1 case were pediatric patients (ages 9-21 years).
Results (if a Case Study enter NA)
In our pediatric cohort (14 patients; 9 males, 5 females), as in literature, NOTCH signaling was most frequently involved with NOTCH1 (50%) and FBXW7 (36%) mutations, followed by those in cell cycle process CDKN2A/2B (36%) and PTEN (28%) mutations. Other mutations: PHF6 (21%), BCOR and TAL1 (14%) each. The prognostic effect of mutations: NOTCH1 favorable, FBXW7 no effect but trend toward favorable when FBXW7 co-occurs with NOTCH1 while PTEN is unfavorable (3 patients had relapses). Some unusual or useful findings: a patient diagnosed initially as AML with aberrant CD3 was re-classified as early T-cell precursor ALL, supported by RELN mutation (occurs in 4% ETP-ALL). The adult with NOTCH1 and BCOR mutations in addition to BCR-ABL1 fusion was diagnosed as having T-ALL blasts with CML. We could not study detailed nuances in mutational profiles of T-ALL vs T-LBL with only 1 case of T-LBL showing FBXW7, PTEN, NF1, RB1, BCOR and NRAS mutations (latter is typically noted in pediatric T-LBL cases).
Conclusion
Clinical molecular testing in our pediatric T-ALL patients revealed gene alterations that provide refinement of diagnosis, prognosis, and risk stratification. It also contributes a useful data set for further analysis and potential use of clinically actionable therapeutic targets in some cases. Longer term follow-up incorporating therapy and outcomes information would be valuable.
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Affiliation(s)
- N C Reddy
- Pathology and Laboratory Medicine, Northwell Health, Evanston, Illinois, UNITED STATES
| | - A C Reddy
- Pathology and Laboratory Medicine, Northwell Health, Evanston, Illinois, UNITED STATES
| | - K S Reddy
- Pathology and Laboratory Medicine, Northwell Health, Evanston, Illinois, UNITED STATES
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Reddy AC, Reddy KS. A case of NTRK-rearranged Spindle cell tumor in a Pediatric patient. Am J Clin Pathol 2021. [DOI: 10.1093/ajcp/aqab191.306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction/Objective
Recent studies continue to demonstrate that NTRK fusions occur more frequently in pediatric than in adult patients involving a broader panel of fusion partners as well as a wider range of pediatric tumors than previously recognized. The identification of these NTRK fusions has facilitated precision cancer diagnosis and TRK inhibitor targeted therapy. With the recent FDA approval of larotrectinib and entrectinib for the treatment of adult and pediatric NTRK-positive, unresectable solid tumors, identification of these fusions directly impacts patient care.
Methods/Case Report
Our patient, a 10 year old female presented with a large right sided buttock mass and pressure effects from the tumor. An incisional biopsy showed a moderately moderately cellular tumor with a collagenous and partially myxoid stroma. The atypical cells had ovoid nuclei with vesicular chromatin, minimal to no atypia, and rare mitotic activity (<2/30 high-power fields), as well as fibrous tissue that appeared as ropy collagen. Some of the blood vessels were rimmed by a hyalinized cuff. A mild inflammatory component, namely scattered lymphocytes and fewer plasma cells were noted. Immunohistochemistry showed: SMA(faint+), S100(+), CD34(+), CD31(+), FLI1(+), NTRK(+). Negative for ALK1, desmin, SOX10, EMA, keratin AE1/3, CAM5.2, D2-40, myogenin, MUC4, TLE1, STAT6, BCOR, ERG. Both INI1 and H3K27me3 were retained. Proliferative rate by Ki-67 was low, showing <2% positivity.
Next generation sequencing revealed the following: LMNA-NTRK1 fusion; CD36 N53fs*24 and CDKN2A/B CDKN2A loss exon 1. Thus, the histologic, immunophenotypic, and molecular findings together supported a diagnosis of NTRK-rearranged spindle cell tumor. This entity has alternately been termed lipofibromatosis-like tumor. Following confirmation of NTRK fusion, she was treated with oral TRK inhibitor with near total response. With this NTRK-rearranged spindle cell tumor’s minimal mitotic activity, absence of necrosis, and low cellularity, the behavior of this tumor was expected to be indolent rather than aggressive. However, the patient was presented for assessment and management at a recent tumor board about 8 months after her initial diagnosis as she had residual/recurrent tumor.
Results (if a Case Study enter NA)
NA
Conclusion
Our case highlights the clinical utility of screening for NTRK fusions in all pediatric tumors.
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Affiliation(s)
- A C Reddy
- Pathology and Laboratory Medicine, Northwell Health, Evanston, Illinois, UNITED STATES
| | - K S Reddy
- Pathology and Laboratory Medicine, Northwell Health, Evanston, Illinois, UNITED STATES
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Budhiraja P, Heilman RL, Jadlowiec CC, Smith ML, Ryan MS, Khamash HA, Kodali L, Moss AA, Mathur AK, Reddy KS. Successful outcomes with transplanting kidneys from deceased donors with acute kidney injuryon temporary renal replacement therapy. Clin Transplant 2021; 35:e14465. [PMID: 34514643 DOI: 10.1111/ctr.14465] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 05/27/2021] [Revised: 08/11/2021] [Accepted: 08/13/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND OBJECTIVES We aimed to determine outcomes with transplanting kidneys from deceased donors with severe acute kidney injury requiring acute renal replacement therapy (RRT). MATERIALS AND METHODS A total of 172 recipients received a kidney from donors with acute kidney injury stage 3 (AKIN3) requiring RRT. We compared the study group to 528 recipients who received a kidney from donors with AKIN stage 3 not on RRT and 463 recipients who received < 85% Kidney Donor Profile Index (KDPI) AKIN stage 0 kidney. RESULTS The study group donors were younger compared to the 2 control groups. Despite higher DGF in the study group, the length of hospital stay and acute rejection were similar. Death censored graft survival (96% AKIN3-RRT vs. 97%AKIN3 no RRT vs. 96% KDPI < 85% AKIN0, P = 0.26) and patient survival with functioning graft at 1 year (95% across all groups, P = 0.402) were similar. The estimated glomerular filtration rate were similar across the 3 groups after first month. Interstitial fibrosis and tubular atrophy score ≥ 2 on protocol biopsy at time 0, 4 and 12 months were similar. Primary nonfunction was rare and associated with high KDPI. CONCLUSIONS Transplanting selected kidneys from deceased donors with AKIN3 requiring RRT is safe and has good outcomes.
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Affiliation(s)
- Pooja Budhiraja
- Division of Nephrology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | | | | | - Maxwell L Smith
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Phoenix, Arizona, USA
| | - Margaret S Ryan
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Phoenix, Arizona, USA
| | - Hasan A Khamash
- Division of Nephrology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Lavanya Kodali
- Division of Nephrology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Adyr A Moss
- Department of Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Amit K Mathur
- Department of Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Kunam S Reddy
- Department of Surgery, Mayo Clinic, Phoenix, Arizona, USA
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Ninan J, Smith ML, Mathur AK, Harbell JW, Jadlowiec CC, Nair SS, Moss A, Reddy KS, Heilman RL. Correlation of Chronic Histologic Changes on Preimplantation Frozen Section Biopsy With Transplant Outcomes After Deceased Donor Kidney Transplantation. Arch Pathol Lab Med 2021; 146:205-212. [PMID: 34086859 DOI: 10.5858/arpa.2020-0675-oa] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2021] [Indexed: 11/06/2022]
Abstract
CONTEXT.— It is unclear if preimplantation frozen section biopsy correlates with outcomes after deceased donor kidney transplantation. OBJECTIVE.— To assess if chronic histologic changes on the preimplant frozen section correlates with graft loss and estimated glomerular filtration rate independently of kidney donor profile index (KDPI). DESIGN.— Seven hundred three preimplantation biopsies were reviewed and a Banff sum score was calculated using glomerular sclerosis, interstitial fibrosis, vascular intimal thickening, and arteriolar hyalinosis. The posttransplant outcomes were compared for preimplantation biopsy Banff sum 0-1, 2-3, and 4-9. The cohort was also stratified by KDPI 85 or less versus more than 85. RESULTS.— For the entire biopsy cohort, graft survival, estimated glomerular filtration rate at 1 year and chronic changes on a 1-year posttransplant biopsy were superior in the group with preimplantation Banff sum 0-1. After stratifying by KDPI, the Banff sum no longer correlated with graft survival. In a univariate mode, using the Banff sum score as a continuous variable, a higher Banff sum score was significantly associated with graft failure (P = .03); however, after adjusting the KDPI, the Banff sum score no longer correlated with graft failure (P = .45). The 1-year estimated glomerular filtration rate and 1 year biopsy changes were superior in the group with Banff sum 0-1 only in the cohort with KDPI 85 or less. CONCLUSIONS.— In donor kidneys used for transplant, preimplantation biopsy chronic changes correlate with estimated glomerular filtration rate and biopsy findings at 1 year, but biopsies with mostly mild chronicity and sum scores less than or equal to 5 did not impact graft survival beyond KDPI.
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Affiliation(s)
- Jacob Ninan
- From the Department of Medicine (Ninan, Nair, Heilman), Mayo Clinic Arizona Phoenix, Arizona
| | - Maxwell L Smith
- Department of Laboratory Medicine and Pathology (Smith), Mayo Clinic Arizona Phoenix, Arizona
| | - Amit K Mathur
- the Department of Surgery (Mathur, Harbell, Jadlowiec, Moss, Reddy), Mayo Clinic Arizona Phoenix, Arizona
| | - Jack W Harbell
- the Department of Surgery (Mathur, Harbell, Jadlowiec, Moss, Reddy), Mayo Clinic Arizona Phoenix, Arizona
| | - Caroline C Jadlowiec
- the Department of Surgery (Mathur, Harbell, Jadlowiec, Moss, Reddy), Mayo Clinic Arizona Phoenix, Arizona
| | - Sumi Sukumaran Nair
- From the Department of Medicine (Ninan, Nair, Heilman), Mayo Clinic Arizona Phoenix, Arizona
| | - Adyr Moss
- the Department of Surgery (Mathur, Harbell, Jadlowiec, Moss, Reddy), Mayo Clinic Arizona Phoenix, Arizona
| | - Kunam S Reddy
- the Department of Surgery (Mathur, Harbell, Jadlowiec, Moss, Reddy), Mayo Clinic Arizona Phoenix, Arizona
| | - Raymond L Heilman
- From the Department of Medicine (Ninan, Nair, Heilman), Mayo Clinic Arizona Phoenix, Arizona
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Das DM, Heilman RL, Khamash HA, Mathur AK, Singer AL, Reddy KS, Jadlowiec CC. Overcoming Mismatch Concerns for Adult Recipients of Small Pediatric Deceased Donor Kidneys. Transplant Proc 2021; 53:1509-1513. [PMID: 33892934 DOI: 10.1016/j.transproceed.2021.03.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 02/11/2021] [Accepted: 03/10/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Kidneys from very young pediatric donors continue to be underutilized. To reduce discard, the Organ Procurement and Transplantation Network (OPTN) policy was recently updated to allow kidneys from donors weighing <18 kg to be recovered en bloc. METHODS We reviewed our center's experience with kidney transplantation in adult recipients of <18 kg pediatric donor kidneys to assess renal function outcomes specific to solitary vs en bloc usage. RESULTS The majority of <18 kg donors were used en bloc (n = 39, 72.2% vs n = 15, 27.8%). Donor weight (kg) was similar between the 2 groups (12.3 ± 3.2 vs 14.1 ± 2.5, P = .05). Recipient weight was lower in the solitary kidney group (P = .01). Both groups had a similar donor-to-recipient body weight ratio (0.24 ± 0.3 vs 0.18 ± 0.3, P = .51). The solitary kidney group had a lower estimated glomerular filtration rate at 1 (56.9 ± 24.3 vs 81.8 ± 24.8, P = .01) and 2 years (72 ± 18.6 vs 93.7 ± 21.6, P = .03). By 2 years, both groups had an average estimated glomerular filtration rate >60 mL/min. Kidney allograft growth occurred in both groups, with the largest increase occurring the first month posttransplant (11.9%, 18.6%, P < .0001). CONCLUSION For pediatric donors weighing <18 kg, improvements in renal function continue beyond the first posttransplant year. Risk for hyperfiltration injury appears low and renal mass-recipient mass matching is useful in guiding decision-making for solitary vs en bloc utilization.
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Affiliation(s)
- Devika M Das
- Mayo Clinic Alix School of Medicine, Scottsdale, Arizona
| | | | | | - Amit K Mathur
- Division of Transplant Surgery, Mayo Clinic, Phoenix, Arizona
| | - Andrew L Singer
- Division of Transplant Surgery, Mayo Clinic, Phoenix, Arizona
| | - Kunam S Reddy
- Division of Transplant Surgery, Mayo Clinic, Phoenix, Arizona
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Jadlowiec CC, Hanna WA, Ninan J, Ryan MS, Das DM, Smith M, Khamash H, Mathur AK, Singer A, Moss A, Reddy KS, Heilman RL. Transplant outcomes using kidneys from high KDPI acute kidney injury donors. Clin Transplant 2021; 35:e14279. [PMID: 33690907 DOI: 10.1111/ctr.14279] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [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: 01/04/2021] [Revised: 02/11/2021] [Accepted: 02/27/2021] [Indexed: 11/28/2022]
Abstract
Kidney transplant (KT) outcomes from high kidney donor profile index (KDPI ≥85%) donors with acute kidney injury (AKI) remain underreported. KT from 172 high KDPI Acute Kidney Injury Network (AKIN) stage 0-1 donors and 76 high KDPI AKIN stage 2-3 donors from a single center were retrospectively assessed. The AKIN 2-3 cohort had more delayed graft function (71% vs. 37%, p < .001). At one year, there were no differences in the estimated glomerular filtration rate (44 ± 17 vs. 46 ± 18, p = .42) or fibrosis on protocol biopsy (ci, p = .85). Donor terminal creatinine (p = .59) and length of delayed graft function (p = .39) did not impact one-year eGFR. There were more primary nonfunction (PNF) events in the high KDPI AKIN 2-3 group (5.3% vs. 0.6%, p = .02). With a median follow-up of 3.8 years, one-year death-censored graft failure was 3.5% for AKIN 0-1 and 14.5% for AKIN 2-3 (HR 2.40, 95% CI 1.24-4.63, p = .01). Although AKIN stage 2-3 high KDPI kidneys had comparable one-year eGFR to AKIN stage 0-1 high KDPI kidneys, there were more PNF occurrences and one-year death-censored graft survival was reduced. Given these findings, additional precautions should be undertaken when assessing and utilizing kidneys from severe AKI high KDPI donors.
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Affiliation(s)
| | - Wael A Hanna
- Division of Nephrology, Mayo Clinic, Phoenix, AZ, USA
| | - Jacob Ninan
- Division of Nephrology, Mayo Clinic, Phoenix, AZ, USA
| | - Margaret S Ryan
- Division of Anatomic Pathology, Mayo Clinic, Phoenix, AZ, USA
| | - Devika M Das
- Alix School of Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Maxwell Smith
- Division of Anatomic Pathology, Mayo Clinic, Phoenix, AZ, USA
| | - Hasan Khamash
- Division of Nephrology, Mayo Clinic, Phoenix, AZ, USA
| | - Amit K Mathur
- Division of Transplant Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Andrew Singer
- Division of Transplant Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Adyr Moss
- Division of Transplant Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Kunam S Reddy
- Division of Transplant Surgery, Mayo Clinic, Phoenix, AZ, USA
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Ravi K, Pushpa NB, Kishore S, Kaur S, Mehta V, Reddy KS. Taxation of micronuclei frequency as a prognostic marker in oral and oropharyngeal carcinoma: A cytogenetic study. Natl J Clin Anat 2021. [DOI: 10.4103/njca.njca_8_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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30
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Nunez-Nateras R, Reddy KS, Aqel BA, Heilman R, Morgan P, Mathur AK, Hewitt W, Heimbach J, Rosen C, Moss AA, Taner T, Jadlowiec CC. Simultaneous liver-kidney transplantation from donation after cardiac death donors: an updated perspective. Am J Transplant 2020; 20:3582-3589. [PMID: 32654322 DOI: 10.1111/ajt.16191] [Citation(s) in RCA: 9] [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] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 06/24/2020] [Accepted: 06/28/2020] [Indexed: 01/25/2023]
Abstract
Outcomes of both donation after cardiac death (DCD) liver and kidney transplants are improving. Experience in simultaneous liver-kidney transplant (SLK) using DCD donors, however, remains limited. In an updated cohort (2010-2018), outcomes of 30 DCD SLK and 131 donation after brain death (DBD) SLK from Mayo Clinic Arizona and Mayo Clinic Minnesota were reviewed. The Model for End-Stage Liver Disease score was lower in the DCD SLK group (23 vs 29, P = .01). Kidney delayed graft function (DGF) rates were similar between the 2 groups (P = .11), although the duration of DGF was longer for DCD SLK recipients (20 vs 4 days, P = .01). Liver allograft (93.3% vs 93.1%, P = .29), kidney allograft (93.3% vs 93.1%, P = .91), and patient (96.7% vs 95.4%, P = .70) 1-year survival rates were similar. At 1 year, there were no differences in the estimated glomerular filtration rate (57.7 ± 18.2 vs 56.3 ± 17.7, P = .75) or progression of fibrosis (ci) on protocol kidney biopsy (P = .67). A higher incidence of biliary complications was observed in the DCD SLK group, with ischemic cholangiopathy being the most common (10.0% vs 0.0%, P = .03). The majority of biliary complications resolved with endoscopic management. With appropriate selection, DCD SLK recipients can have results equivalent to those of DBD SLK recipients.
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Affiliation(s)
- Rafael Nunez-Nateras
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Kunam S Reddy
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Bashar A Aqel
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, Arizona, USA
| | | | - Paige Morgan
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Amit K Mathur
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Winston Hewitt
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Julie Heimbach
- William J. Von Liebig Center for Transplantation, Mayo Clinic, Rochester, Minnesota, USA
| | - Charles Rosen
- William J. Von Liebig Center for Transplantation, Mayo Clinic, Rochester, Minnesota, USA
| | - Adyr A Moss
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Timucin Taner
- William J. Von Liebig Center for Transplantation, Mayo Clinic, Rochester, Minnesota, USA
| | - Caroline C Jadlowiec
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, Arizona, USA
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Madurai Elavarasan R, Shafiullah GM, Raju K, Mudgal V, Arif MT, Jamal T, Subramanian S, Sriraja Balaguru VS, Reddy KS, Subramaniam U. COVID-19: Impact analysis and recommendations for power sector operation. Appl Energy 2020; 279:115739. [PMID: 32904736 PMCID: PMC7458120 DOI: 10.1016/j.apenergy.2020.115739] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 08/01/2020] [Accepted: 08/18/2020] [Indexed: 05/03/2023]
Abstract
The demand of electricity has been reduced significantly due to the recent COVID-19 pandemic. Governments around the world were compelled to reduce the business activity in response to minimize the threat of coronavirus. This on-going situation due to COVID-19 has changed the lifestyle globally as people are mostly staying home and working from home if possible. Hence, there is a significant increase in residential load demand while there is a substantial decrease in commercial and industrial loads. This devastating situation creates new challenges in the technical and financial activities of the power sector and hence most of the utilities around the world initiated a disaster management plan to tackle this ongoing challenges/threats. Therefore, this study aims to investigate the global scenarios of power systems during COVID-19 along with the socio-economic and technical issues faced by the utilities. Then, this study further scrutinized the Indian power system as a case study and explored scenarios, issues and challenges currently being faced to manage the consumer load demand, including the actions taken by the utilities/power sector for the smooth operation of the power system. Finally, a set of recommendations are presented to support the government/policymakers/utilities around the world not only to overcome the current crisis but also to overcome future unforeseeable pandemic alike scenario.
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Key Words
- ACT, Actual
- CEEW, Council of Energy Environment and Water
- CERC, Central Electricity Regulatory Commission
- COVID-19
- DISCOMs, Distribution Companies
- DSM, Deviation Settlement Mechanism
- ER, Eastern Region
- ERLDC, Eastern Regional Load Dispatch Centre
- FVI, Frequency Variation Index
- FY, Financial Year
- Global power systems
- IEGC, Indian Electricity Grid Code
- IEX, Indian Energy Exchange
- IISD, Institute for Sustainable Development
- IR, Indian Rupee
- Indian power system
- Load demand
- MCP, Market Clearing Price
- MCV, Market Clearing Volume
- NER, North Eastern Region
- NERLDC, North Eastern Regional Load Dispatch Centre
- NHPC, National Hydroelectric Power Corporation
- NLDC, National Load Dispatch Centre
- NR, Northern Region
- NREL, National Renewable Energy Laboratory
- NRLDC, Northern Regional Load Dispatch Centre
- NTPC, National Thermal Power Corporation
- PGCIL, Power Grid Corporation of India Ltd
- POSOCO, Power System Operation Corporation
- PXI, Power Energy Exchange
- Power systems
- RES, Renewable Energy sources
- RLDC, Regional Load Dispatch Centre
- Recommendations for sustainable power systems
- SCH, Schedule
- SLDC, State Load Dispatch Centre
- SR, Southern Region
- SRLDC, Southern Regional Load Dispatch Centre
- STATCOM, Static Var Compensator
- UFLS, Under Frequency based Load Shedding
- USAID, United States Agency for International Development
- VAR, Volt Ampere Reactive
- VDI, Voltage Deviation Index
- WR, Western Region
- WRLDC, Western Regional Load Dispatch Centre
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Affiliation(s)
| | - G M Shafiullah
- Discipline of Engineering and Energy, Murdoch University, Perth, WA 6150, Australia
| | - Kannadasan Raju
- Department of Electrical and Electronics Engineering, Sri Venkateswara College of Engineering, Chennai 602117, India
| | - Vijay Mudgal
- Heat Transfer and Thermal Power Laboratory, Department of Mechanical Engineering, Indian Institute of Technology Madras, Chennai 600036, India
| | - M T Arif
- School of Engineering, Deakin University, Waurn Ponds, Geelong, VIC 3216, Australia
| | - Taskin Jamal
- Department of Electrical and Electronic Engineering, Ahsanullah University of Science and Technology, Dhaka, Bangladesh
| | - Senthilkumar Subramanian
- State Load Despatch Centre, Grid Operation, TANTRANSCO, Chennai 600002, India
- Department of Electrical and Electronics Engineering, College of Engineering, Anna University, Chennai 600025, India
| | - V S Sriraja Balaguru
- Non Conventional Energy Sources, TANGEDCO, Chennai 600002, India
- Department of Electrical and Electronics Engineering, College of Engineering, Anna University, Chennai 600025, India
| | - K S Reddy
- Heat Transfer and Thermal Power Laboratory, Department of Mechanical Engineering, Indian Institute of Technology Madras, Chennai 600036, India
| | - Umashankar Subramaniam
- Department of Communications and Networks, Renewable Energy Laboratory, College of Engineering, Prince Sultan University, Riyadh 12435, Saudi Arabia
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Das DM, Huskey JL, Harbell JW, Heilman RL, Singer AL, Mathur A, Neville MR, Morgan P, Reddy KS, Jadlowiec CC. Early technical pancreas failure in Simultaneous Pancreas-Kidney Recipients does not impact renal allograft outcomes. Clin Transplant 2020; 35:e14138. [PMID: 33131111 DOI: 10.1111/ctr.14138] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 06/18/2020] [Revised: 10/12/2020] [Accepted: 10/19/2020] [Indexed: 01/08/2023]
Abstract
Early pancreas loss in simultaneous pancreas-kidney (SPK) transplants has been associated with longer perioperative recovery and reduced kidney allograft function. We assessed the impact of early pancreas allograft failure on transplant outcomes in a contemporary cohort of SPK patients (n = 218). Early pancreas allograft loss occurred in 12.8% (n = 28) of recipients. Delayed graft function (DGF) was more common (21.4% vs. 7.4%, p = 0.03) in the early pancreas loss group, but there were no differences in hospital length of stay (median 6.5 vs. 7.0, p = 0.22), surgical wound complications (p = 0.12), or rejection episodes occurring in the first year (p = 0.87). Despite differences in DGF, both groups had excellent renal function at 1 year post-transplant (eGFR 64.1 ± 20.8 vs. 65.8 ± 22.9, p = 0.75). There were no differences in patient (HR 0.58, 95% CI 0.18-1.87, p = 0.26) or kidney allograft survival (HR 0.84, 95% CI 0.23-3.06, p = 0.77). One- and 2-year protocol kidney biopsies were comparable between the groups and showed minimal chronic changes; the early pancreas loss group showed more cv changes at 2 years (p = 0.04). Current data demonstrate good outcomes and excellent kidney allograft function following early pancreas loss.
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Affiliation(s)
- Devika M Das
- Mayo Clinic Alix School of Medicine, Scottsdale, AZ, USA
| | | | - Jack W Harbell
- Division of Transplant Surgery, Mayo Clinic, Phoenix, AZ, USA
| | | | - Andrew L Singer
- Division of Transplant Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Amit Mathur
- Division of Transplant Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Matthew R Neville
- Instructor in Biostatistics, Mayo Clinic College of Medicine, Phoenix, AZ, USA
| | - Paige Morgan
- Division of Transplant Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Kunam S Reddy
- Division of Transplant Surgery, Mayo Clinic, Phoenix, AZ, USA
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Reddy KS. Utility of Discordant Mismatch Repair-Deficiency (MMR)/Microsatellite Instability (MSI) Testing in Screening Uterine Leiomyosarcoma Patient for Lynch/Other Familial Cancer Syndromes. Am J Clin Pathol 2020. [DOI: 10.1093/ajcp/aqaa161.326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Casestudy
Lynch Syndrome (LS) is primarily linked to colorectal and endometrial cancers. Occasional sarcomas, including leiomyosarcoma, have been recognized within the spectrum of LS demonstrating mismatch repair-deficiency (MMR)/microsatellite instability (MSI) in this context.
Results
A 67-year-old female of bilineal Ashkenazi Jewish descent was recently diagnosed with uterine leiomyosarcoma in addition to metastatic papillary thyroid carcinoma at age 58. She met NCCN criteria for LS and BRCA1/2 (brother with renal cancer at age 64, father with colon cancer at age 60, paternal half-sister with rectal cancer at age 50 and maternal aunt with breast cancer).
Studies have shown that immunohistochemistry (IHC) for MMR proteins and PCR-based MSI have comparable sensitivity and specificity with high concordance, but neither test alone is sufficient to capture all defective MMR tumors. Screening strategies vary depending on the level of clinical suspicion for LS. When high, a normal result by one method warrants testing via a second method or concurrent IHC plus PCR testing to minimize the impact of rare false normal results. Rarely, this strategy can yield discordant results, as in our case wherein MSI by PCR was stable (MSS) but IHC for MLH-1 and PMS-2 showed heterogeneous (patchy/focal) nuclear loss of protein expression. The latter is not always due to artefact but can correspond to MMR status differences within the tumor, requiring recognition to prevent false-positive/false-negative evaluations. Heterogenous MLH1 and/or PMS2 expression, may be suggestive of variable MLH1 methylation/second hit mutations, variable epitope expression or expression related to variable differentiation.
Conclusion
The clinical significance of this pattern was unclear in our patient whose initial genetic screen (including MLH1, PMS2, MSH2, MSH6, EPCAM) was negative. However, as studies have indicated that patients with indeterminate IHC findings can have MLH1 hypermethylation or germline mutations, she had justification to undergo extended genetic screening. A heterozygous pathogenic variant in BLM 2207_2212delinsTAGATTC (p.Tyr736Leufs*5) associated with autosomal recessive Bloom Syndrome (BS) was identified. Carriers of BS do not show symptoms of the disease, but they are at a greater than average risk of developing cancers.
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Affiliation(s)
- K S Reddy
- Pathology and Laboratory Medicine, NorthShore University Hospital System, Evanston, Illinois, UNITED STATES
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Reddy AC, Reddy KS. Pediatric Patient With Neurological And Leukemic Peripheral Blood Involvement By Small Cell Variant Of ALK- Positive Anaplastic Large Cell Lymphoma (ALCL): Case Study. Am J Clin Pathol 2020. [DOI: 10.1093/ajcp/aqaa161.248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Casestudy
Anaplastic large cell lymphoma (ALCL), is a T-cell lymphoma typically consisting of large lymphoid cells including characteristic horseshoe- shaped hallmark cells. The rare small cell morphological variant of ALCL may pose a challenge in diagnosis, especially when the initial presentation is unusual.
Results
Our patient, a 7-year-old girl presented with a headache. A complete blood count showed leukocytosis and anemia. The smear was reported to have segmented neutrophils, reactive lymphocytes, and monocytes. A spinal tap was performed and flow analysis identified a minute aberrant T cell population (0.3% of total), positive for CD3, CD4, bright CD7; negative CD5, CD8 in the CSF sample. The peripheral blood sample was reviewed again; some small- medium atypical lymphocytes, with irregular nuclear contours and cytoplasmic azurophilic granules were noted. Flow immunophenotyping displayed an aberrant T cell population positive for CD45, CD2, CD3, bright CD7, CD4, CD13; negative CD30, TdT CD5, CD8, CD117, CD34; consistent with T cell lymphoma/leukemia. A cell block prepared from peripheral blood sample showed blood with numerous atypical cells with irregular nuclei positive for ALK, CD30, CD3, CD4, CD7; negative CD5 and CD8. A diagnosis of leukemic ALK(+) ALCL was rendered, though classic hallmark cells were difficult to see. A marrow biopsy showed interstitial and sinusoidal pattern of mainly small to medium-sized cells with irregular nuclei. Molecular study revealed ALK gene alteration showing characteristic NPM1-ALK fusion. The patient underwent a bone bone marrow transplantation but recently relapsed with a submandibular lymph hode biopsy showing the presence of many larger ALCL cells.
Conclusion
Correct clinical diagnosis of the small-cell variant of ALCL is often challenging as the scarce “hallmark cells” are scattered and difficult to recognize. While leukemic peripheral blood involvement is rare in ALCL, an association has been reported with small-cell variants, which may be a potential explanation for the poor prognosis and aggressive nature of small-cell variant ALCL. A meticulous examination of peripheral blood smears, comprehensive immunophenotypic studies, and early bone marrow and lymph node/tissue biopsy are needed to facilitate diagnosis.
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Affiliation(s)
- A C Reddy
- Pathology and Laboratory Medicine, Northwell Health, Evanston, Illinois, UNITED STATES
| | - K S Reddy
- Pathology and Laboratory Medicine, Northwell Health, Evanston, Illinois, UNITED STATES
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Abdul-Muhsin HM, McAdams SB, Syal A, Nuñez-Nateras R, Navaratnam A, Moss AA, Hewitt WR, Singer AL, Jadlowiec CC, Harbell JW, Mathur AK, Reddy KS, Castle EP. Robot Assisted Renal Allograft Nephrectomy: Initial Case Series and Description of Technique. Urology 2020; 146:118-124. [PMID: 33091385 DOI: 10.1016/j.urology.2020.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 09/27/2020] [Accepted: 10/06/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the outcomes and perioperative complication rates following robot- assisted transplant nephrectomy ((RATN). METHODS All patients who underwent RATN at our institution were included. No exclusion criteria were applied. Clinical records were retrospectively reviewed and reported. This included preoperative, intraoperative, and postoperative outcomes. Complications were reported utilizing the Clavien-Dindo classification system. Descriptive statistics were reported using frequencies and percentages for categorical variables, means and standard deviation for continuous variables. RESULTS Between July 2014 and April 2018, 15 patients underwent RATN. Most patients had the transplant in the right iliac fossa (13/15). Ten patients underwent a concomitant procedure. The total operative time for the entire cohort was 336 (±102) minutes (including cases who had concomitant procedures) and 259 (±46 minutes) when cases with concomitant procedures were excluded. Mean estimated blood loss was 383 (±444) mL. Postoperatively, 3 patients required blood transfusion. Average hospital stay was 4 (±2.7) days. Most patients had finding consistent with graft rejection on final pathology. There were 5 complications; 3 of which were minor (grade 2 = 2 and grade 3 = 1); one patient had a wound infection requiring dressing (3A) and one patient died due to pulmonary embolism following discharge. Limitations include small series and retrospective nature of the study. CONCLUSION This case series demonstrate that RATN is technically feasible. With continued experience and larger case series, the robotic approach may provide a minimally invasive alternative to open allograft nephrectomy.
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Affiliation(s)
| | | | - Amit Syal
- Mayo Clinic Arizona, Department of Urology, Phoenix, AZ
| | | | | | - Adyr A Moss
- Mayo Clinic Arizona, Department of Transplantation, Phoenix, AZ
| | | | - Andrew L Singer
- Mayo Clinic Arizona, Department of Transplantation, Phoenix, AZ
| | | | - Jack W Harbell
- Mayo Clinic Arizona, Department of Transplantation, Phoenix, AZ
| | - Amit K Mathur
- Mayo Clinic Arizona, Department of Transplantation, Phoenix, AZ
| | - Kunam S Reddy
- Mayo Clinic Arizona, Department of Transplantation, Phoenix, AZ
| | - Erik P Castle
- Mayo Clinic Arizona, Department of Urology, Phoenix, AZ
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Breite MD, Breite CN, Money SR, Moss AA, Huskey JL, Reddy KS, Davila VJ. Renal transplantation in the setting of aortic atresia: Utilizing hepatic artery inflow with donor vessel jump graft. Am J Transplant 2020; 20:2602-2605. [PMID: 32277581 DOI: 10.1111/ajt.15908] [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: 11/30/2019] [Revised: 03/26/2020] [Accepted: 03/27/2020] [Indexed: 01/25/2023]
Abstract
Both congenital and acquired recipient anatomy can present a significant challenge to renal transplantation. A patient with congenital aortic atresia and limited dialysis access options presented to our institution for consideration of transplant. Through multidisciplinary planning, a strategy to accommodate the patient's variant anatomy was devised and successfully performed. A deceased donor vessel graft was used as conduit in combination with the recipient hepatic artery for renal graft inflow.
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Affiliation(s)
- Matthew D Breite
- Department of General Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Christine N Breite
- Department of General Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Samuel R Money
- Department of Vascular Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Adyr A Moss
- Department of Transplant Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Janna L Huskey
- Department of Nephrology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Kunam S Reddy
- Department of Transplant Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Victor J Davila
- Department of Vascular Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
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Sheckley M, Calderon E, Patel BM, Sen A, Giorgakis E, Hewitt WR, Singer AL, Reddy KS, Moss AA, Mathur AK. Utilization of Veno-Arterial Extracorporeal Life Support for Acute Respiratory Distress Syndrome After Liver Transplant. EXP CLIN TRANSPLANT 2020; 20:616-620. [PMID: 32778014 DOI: 10.6002/ect.2020.0068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In this report, we present a case of successful long-term salvage of a patient with transfusion-related acute lung injury associated with acute respiratory distress syndrome immediately after a liver transplant. The patient was a 29-year-old man with end-stage liver disease due to sclerosing cholangitis who underwent liver transplant. After organ reperfusion, there was evidence of liver congestion, acidosis, coagulopathy, and acute kidney injury. He received 61 units of blood products. Continuous renal replacement therapy was initiated intraoperatively. On arrival to the intensive care unit, the patient was on high-dose pressors, and the patient developed respiratory failure and was immediately placed on veno-arterial extracorporeal membrane oxygenation via open femoral exposure. The patient presented with severe coagulopathy and early allograft dysfunction; therefore, no systemic heparin was administered and no thrombotic events occurred. He required extracorporeal membrane oxygenation support until posttransplant day 4, when resolution of the respiratory and cardiac dysfunction was noted. At 2 years after liver transplant, the patient has normal liver function, normal cognitive function, and stage V chronic kidney disease. We conclude that extracorporeal membrane oxygenation is a valuable therapeutic approach in patients with cardiorespiratory failure after liver transplant.
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Affiliation(s)
- Marwan Sheckley
- From the Division of Transplant Surgery, Department of Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
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Jadlowiec CC, Heilman RL, Smith ML, Khamash HA, Huskey JL, Harbell J, Reddy KS, Moss AA. Transplanting kidneys from donation after cardiac death donors with acute kidney injury. Am J Transplant 2020; 20:864-869. [PMID: 31612611 DOI: 10.1111/ajt.15653] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [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: 06/12/2019] [Revised: 09/10/2019] [Accepted: 10/03/2019] [Indexed: 02/06/2023]
Abstract
Donation after cardiac death (DCD) and acute kidney injury (AKI) donors have historically been considered independent risk factors for delayed graft function (DGF), allograft failure, and inferior outcomes. With growing experience, updated analyses have shown good outcomes. There continues to be limited data, however, on outcomes specific to DCD donors who have AKI. Primary outcomes for this study were post-kidney transplant patient and allograft survival comparing two donor groups: DCD AKIN stage 2-3 and DBD AKIN stage 2-3. In comparing these groups, there were no short- or long-term differences in patient (hazard ratio [HR] 1.07, 95% confidence interval [CI] 0.54-1.93, P = .83) or allograft survival (HR 1.47, 95% CI 0.64-2.97, P = .32). In multivariate models, the DCD/DBD status had no significant impact on the estimated GFR (eGFR) at 1 (P = .38), 2 (P = .60), and 3 years (P = .52). DGF (57.9% vs 67.9%, P = .09), rejection (12.1% vs 13.9%, P = .12), and progression of interstitial fibrosis/tubular atrophy (IFTA) on protocol biopsy (P = .16) were similar between the two groups. With careful selection, good outcomes can be achieved utilizing severe AKI DCD kidneys. Historic concerns regarding primary nonfunction, DGF resulting in interstitial fibrosis and rejection, and inferior outcomes were not observed. Given the ongoing organ shortage, increased effort should be undertaken to further utilize these donors.
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Affiliation(s)
| | | | - Maxwell L Smith
- Division of Anatomic Pathology, Mayo Clinic, Phoenix, Arizona
| | - Hasan A Khamash
- Division of Transplant Nephrology, Mayo Clinic, Phoenix, Arizona
| | - Janna L Huskey
- Division of Transplant Nephrology, Mayo Clinic, Phoenix, Arizona
| | - Jack Harbell
- Division of Transplant Surgery, Mayo Clinic, Phoenix, Arizona
| | - Kunam S Reddy
- Division of Transplant Surgery, Mayo Clinic, Phoenix, Arizona
| | - Adyr A Moss
- Division of Transplant Surgery, Mayo Clinic, Phoenix, Arizona
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Smestad GP, Germer TA, Alrashidi H, Fernández EF, Dey S, Brahma H, Sarmah N, Ghosh A, Sellami N, Hassan IAI, Desouky M, Kasry A, Pesala B, Sundaram S, Almonacid F, Reddy KS, Mallick TK, Micheli L. Modelling photovoltaic soiling losses through optical characterization. Sci Rep 2020; 10:58. [PMID: 31919401 PMCID: PMC6952442 DOI: 10.1038/s41598-019-56868-z] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 10/30/2019] [Indexed: 11/30/2022] Open
Abstract
The accumulation of soiling on photovoltaic (PV) modules affects PV systems worldwide. Soiling consists of mineral dust, soot particles, aerosols, pollen, fungi and/or other contaminants that deposit on the surface of PV modules. Soiling absorbs, scatters, and reflects a fraction of the incoming sunlight, reducing the intensity that reaches the active part of the solar cell. Here, we report on the comparison of naturally accumulated soiling on coupons of PV glass soiled at seven locations worldwide. The spectral hemispherical transmittance was measured. It was found that natural soiling disproportionately impacts the blue and ultraviolet (UV) portions of the spectrum compared to the visible and infrared (IR). Also, the general shape of the transmittance spectra was similar at all the studied sites and could adequately be described by a modified form of the Ångström turbidity equation. In addition, the distribution of particles sizes was found to follow the IEST-STD-CC 1246E cleanliness standard. The fractional coverage of the glass surface by particles could be determined directly or indirectly and, as expected, has a linear correlation with the transmittance. It thus becomes feasible to estimate the optical consequences of the soiling of PV modules from the particle size distribution and the cleanliness value.
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Affiliation(s)
- Greg P Smestad
- Sol Ideas Technology Development, P.O. Box 5729, San José, California, 95150, USA.
| | - Thomas A Germer
- National Institute of Standards and Technology, 100 Bureau Drive, Gaithersburg, MD, USA
| | | | - Eduardo F Fernández
- Centro de Estudios Avanzados en Energía y Medio Ambiente (CEAEMA), Universidad de Jaén, 23071, Jaén, Spain
| | - Sumon Dey
- Academy of Scientific and Innovative Research, Chennai, 600113, India
| | | | | | | | - Nazmi Sellami
- Heriot-Watt University, Dubai, UAE.,Robert Gordon University, Aberdeen, UK
| | - Ibrahim A I Hassan
- Department of Chemistry, South Valley University, 83523, Qena, Egypt.,Faculty of Environmental Studies, University of York, Toronto, M3J 1P3, ON, Canada
| | - Mai Desouky
- Nanotechnology Research Centre, The British University in Egypt, 11837, El Sherouk City, Cairo, Egypt
| | - Amal Kasry
- Nanotechnology Research Centre, The British University in Egypt, 11837, El Sherouk City, Cairo, Egypt
| | - Bala Pesala
- CSIR-Central Electronics Engineering Research Institute & Academy of Scientific and Innovative Research, Chennai, 600113, India
| | | | - Florencia Almonacid
- Centro de Estudios Avanzados en Energía y Medio Ambiente (CEAEMA), Universidad de Jaén, 23071, Jaén, Spain
| | - K S Reddy
- Indian Institute of Technology Madras, Chennai, India
| | | | - Leonardo Micheli
- Centro de Estudios Avanzados en Energía y Medio Ambiente (CEAEMA), Universidad de Jaén, 23071, Jaén, Spain. .,National Renewable Energy Laboratory, Golden, CO, USA.
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Mohan S, Jarhyan P, Ganesh S, Nikhil SV, Khatkar R, Rao BM, Reddy KS, Tandon N, Prabhakaran D. P1945High levels of unawareness and suboptimal management of hypertension in India: data from a large community based study. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0692] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Hypertension is the most common cause of the rising cardiovascular disease (CVD) epidemic in India. However, despite availability of proven therapies management remains sub-optimal.
Purpose
To determine the hypertension control rates and associated factors among adults with known hypertension in urban and rural India.
Methods
We conducted a representative population based cross-sectional survey among 12243 participants aged ≥30 years residing in rural and urban North and South India. Participants were selected using a multistage cluster random sampling technique. Trained personnel collected the data using an interviewer administered questionnaire, measured blood pressure, conducted anthropometry and collected bio-samples. Hypertension was defined as known hypertension (self-report of physician diagnosis) or systolic blood pressure (SBP) ≥140 mmHg or diastolic blood pressure (DBP) ≥90 mmHg. Control was defined as SBP <140 mmHg and DBP <90 mmHg among those with known hypertension. The associations were measured using logistic regression.
Results
The mean (±SD) age of participants was 47.7 (±12.5) years, women comprised 54%. The age-standardized prevalence of hypertension was 29.0% (95% CI: 28.2- 29.8) and known hypertension was 14.0% (13.4- 14.6). Among all hypertensives 38.6% (37.0–40.2) were on treatment and 26.2% (24.6–28.0) had their blood pressure controlled, while among known hypertensives 79.8% (77.8–81.7) were on treatment and 55.7% (53.3–58.1) had their blood pressure controlled. In multivariate analysis, participants from North Indian site [OR: 1.9 (1.6–2.3)], urban residents [1.3 (1.1–1.6)], younger participants [1.5 (1.2–1.8)], men [2.0 (1.5–2.6)], those with low socio-economic status [1.6 (1.1–2.3)], without comorbidities and those without a family history hypertension were more likely to be unaware about their hypertensive status and less likely to take treatment. Hypertension control was significantly higher in participants from South Indian site [1.5 (1.2–1.0)], the highly educated [1.6 (1.1–2.4)], those without heart diseases [1.8 (1.1–3.1)], those without central obesity [1.4 (1.1–1.9)], physically active individuals [1.5 (1.1–2.0)] and current non-alcohol users [1.9 (1.3–2.6)].
Conclusions
Many individuals with hypertension remain unaware and sub-optimally managed. This warrants the implementation of tailored public education to raise awareness, complemented by active screening for the early detection and effective management of hypertension, in order to stem the rising tide of preventable CVD in India.
Acknowledgement/Funding
Unrestricted educational grant from Eli Lilly under the Lilly NCD Partnership
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Affiliation(s)
- S Mohan
- Public Health Foundation of India, Gurgaon, India
| | - P Jarhyan
- Public Health Foundation of India, Gurgaon, India
| | - S Ganesh
- Public Health Foundation of India, Gurgaon, India
| | - S V Nikhil
- Public Health Foundation of India, Gurgaon, India
| | - R Khatkar
- Public Health Foundation of India, Gurgaon, India
| | - B M Rao
- KIMS ICON, Cardiology, Visakhapatnam, India
| | - K S Reddy
- Public Health Foundation of India, Gurgaon, India
| | - N Tandon
- All India Institute of Medical Sciences (AIIMS), New Delhi, India
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Rosenfeld DM, Smith ML, Seamans DP, Giorgakis E, Gaitan BD, Khurmi N, Aqel BA, Reddy KS. Fatal diffuse pulmonary fat microemboli following reperfusion in liver transplantation with the use of marginal steatotic allografts. Am J Transplant 2019; 19:2640-2645. [PMID: 31012531 DOI: 10.1111/ajt.15399] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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: 11/28/2018] [Revised: 03/29/2019] [Accepted: 04/18/2019] [Indexed: 01/25/2023]
Abstract
Organ shortage is a major cause of delayed liver transplantation and increased waitlist time. The level of donor steatosis is a significant determinant in organ selection. Scarcity of organs has led some programs to expand their acceptable criteria for the percentage of steatosis. We report two cases of liver transplantation of steatotic donor organs that resulted in mortality within hours from transplantation. Postmortem analysis showed evidence of diffuse pulmonary fat microemboli likely originating from the donor organ, with marked preservation reperfusion injury. The mechanism of diffuse fat microemboli in this setting and possible relationship to other perioperative syndromes (transfusion-related lung injury, acute kidney injury, and postreperfusion syndrome) is discussed.
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Affiliation(s)
- David M Rosenfeld
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Arizona, Phoenix, Arizona
| | - Maxwell L Smith
- Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona, Phoenix, Arizona
| | - David P Seamans
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Arizona, Phoenix, Arizona
| | - Emmanouil Giorgakis
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Brantley D Gaitan
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Arizona, Phoenix, Arizona
| | - Narjeet Khurmi
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Arizona, Phoenix, Arizona
| | - Bashar A Aqel
- Department of Medicine, Division of Transplant Hepatology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Kunam S Reddy
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, Arizona
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Gupta R, Abraham RA, Kondal D, Dhatwalia S, Jeemon P, Reddy KS, Prabhakaran D, Ramakrishnan L. Association of trans fatty acids with lipids and other cardiovascular risk factors in an Indian industrial population. BMC Res Notes 2019; 12:342. [PMID: 31208468 PMCID: PMC6580624 DOI: 10.1186/s13104-019-4352-7] [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: 12/27/2018] [Accepted: 05/31/2019] [Indexed: 11/20/2022] Open
Abstract
Objective Trans-fat, an invariable component of industrial fat is considered as one of the major dietary factors associated with CVD. Although the use of trans-fat is completely banned in some of the high-income countries where the CVD epidemic is declining, it is widely used in LMIC. We aimed to investigate the association of trans fatty acid in serum with risk markers of CVD in an industrial population in India. Participants were randomly selected from a study conducted in an industrial setting among employees and their family members. Information related to their demographic profile, anthropometric measurements, oil intake were recorded. Fasting samples were collected and stored at − 80 °C for analysis. Their lipid profile and hs CRP were measured and fatty acids analyzed using gas chromatography (GC) with flame ionization detector (FID). Results Complete data was available for 176 participants. Among trans fatty acids, mono trans fatty acid was significant predictor of serum triglycerides [Unadjusted β (95% CI) 22.9 (2.6, 43.2); Adjusted β (95% CI) 20.4 (3.5, 37.3)]. None of the other trans fatty acids either individually or in group correlated with any of the biochemical markers studied. Electronic supplementary material The online version of this article (10.1186/s13104-019-4352-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ruby Gupta
- Public Health Foundation of India, Gurgaon, India.
| | - Ransi Ann Abraham
- Department of Cardiac Biochemistry, Cardio-thoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | | | | | - Panniyammakal Jeemon
- Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - K S Reddy
- Public Health Foundation of India, Gurgaon, India
| | | | - Lakshmy Ramakrishnan
- Department of Cardiac Biochemistry, Cardio-thoracic Centre, All India Institute of Medical Sciences, New Delhi, India
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Mathur AK, Chang YH, Steidley DE, Heilman RL, Wasif N, Etzioni D, Reddy KS, Moss AA. Factors associated with adverse outcomes from cardiovascular events in the kidney transplant population: an analysis of national discharge data, hospital characteristics, and process measures. BMC Nephrol 2019; 20:190. [PMID: 31138156 PMCID: PMC6540439 DOI: 10.1186/s12882-019-1390-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 05/17/2019] [Indexed: 11/10/2022] Open
Abstract
Background Kidney transplant (KT) patients presenting with cardiovascular (CVD) events are being managed increasingly in non-transplant facilities. We aimed to identify drivers of mortality and costs, including transplant hospital status. Methods Data from the 2009–2011 Nationwide Inpatient Sample, the American Hospital Association, and Hospital Compare were used to evaluate post-KT patients hospitalized for MI, CHF, stroke, cardiac arrest, dysrhythmia, and malignant hypertension. We used generalized estimating equations to identify clinical, structural, and process factors associated with risk-adjusted mortality and high cost hospitalization (HCH). Results Data on 7803 admissions were abstracted from 275 hospitals. Transplant hospitals had lower crude mortality (3.0% vs. 3.8%, p = 0.06), and higher un-adjusted total episodic costs (Median $33,271 vs. $28,022, p < 0.0001). After risk-adjusting for clinical, structural, and process factors, mortality predictors included: age, CVD burden, CV destination hospital, diagnostic cardiac catheterization without intervention (all, p < 0.001). Female sex, race, documented co-morbidities, and hospital teaching status were protective (all, p < 0.05). Transplant and non-transplant hospitals had similar risk-adjusted mortality. HCH was associated with: age, CVD burden, CV procedures, and staffing patterns. Hospitalizations at transplant facilities had 37% lower risk-adjusted odds of HCH. Cardiovascular process measures were not associated with adverse outcomes. Conclusion KT patients presenting with CVD events had similar risk-adjusted mortality at transplant and non-transplant hospitals, but high cost care was less likely in transplant hospitals. Transplant hospitals may provide better value in cardiovascular care for transplant patients. These data have significant implications for patients, transplant and non-transplant providers, and payers.
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Affiliation(s)
- Amit K Mathur
- Division of Transplant Surgery, Department of Surgeyr, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ, 85054, USA. .,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Phoenix, AZ, USA.
| | - Yu-Hui Chang
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Phoenix, AZ, USA
| | - D Eric Steidley
- Division of Cardiovascular Medicine, Mayo Clinic Arizona, Phoenix, AZ, USA
| | | | - Nabil Wasif
- Division of Transplant Surgery, Department of Surgeyr, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ, 85054, USA.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Phoenix, AZ, USA
| | - David Etzioni
- Division of Transplant Surgery, Department of Surgeyr, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ, 85054, USA.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Phoenix, AZ, USA
| | - Kunam S Reddy
- Division of Transplant Surgery, Department of Surgeyr, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ, 85054, USA
| | - Adyr A Moss
- Division of Transplant Surgery, Department of Surgeyr, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ, 85054, USA
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Giorgakis E, Mathur AK, Chakkera HA, Reddy KS, Moss AA, Singer AL. Solid pancreas transplant: Pushing forward. World J Transplant 2018; 8:237-251. [PMID: 30596031 PMCID: PMC6304337 DOI: 10.5500/wjt.v8.i7.237] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Revised: 11/10/2018] [Accepted: 11/15/2018] [Indexed: 02/05/2023] Open
Abstract
Pancreas transplant has evolved significantly in recent years. It has now become a viable treatment option on type 1 diabetic patients with poorly controlled diabetes on conventional treatment, insulin intolerance, hypoglycaemia unawareness, brittle diabetes and/ or end-stage kidney disease. The purpose of this review is to provide an overview of pancreas transplant historical origins and current barriers to broader utilization of pancreata for transplant, with a focus on areas for future improvement to better pancreas transplant care. Donor pancreata remain underutilized; pancreatic allograft discard rates remain close to 30% in the United States. Donations after cardiac death (DCD) pancreata are seldom procured. Study groups from Europe and the United Kingdom showed that procurement professionalization and standardization of technique, as well as development of independent regional procurement teams might increase organ procurement efficiency, decrease discards and increase pancreatic allograft utilization. Pancreas transplant programs should consider exploring pancreas procurement opportunities on DCD and obese donors. Selected type 2 diabetics should be considered for pancreas transplant. Longer follow-up studies need to be performed in order to ascertain the long-term cardiovascular and quality of life benefits following pancreas transplant; the outcomes of which might eventually spearhead advocacy towards broader application of pancreas transplant among diabetics.
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Affiliation(s)
- Emmanouil Giorgakis
- Division of Transplant, Department of Surgery, Mayo Clinic, Phoenix, AZ 85054, United States
- Department of Transplant, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
| | - Amit K Mathur
- Division of Transplant, Department of Surgery, Mayo Clinic, Phoenix, AZ 85054, United States
| | - Harini A Chakkera
- Division of Nephrology, Department of Internal Medicine, Mayo Clinic, Phoenix, AZ 85054, United States
| | - Kunam S Reddy
- Division of Transplant, Department of Surgery, Mayo Clinic, Phoenix, AZ 85054, United States
| | - Adyr A Moss
- Division of Transplant, Department of Surgery, Mayo Clinic, Phoenix, AZ 85054, United States
| | - Andrew L Singer
- Division of Transplant, Department of Surgery, Mayo Clinic, Phoenix, AZ 85054, United States
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Chascsa DM, Mousa OY, Pungpapong S, Zhang N, Chervenak A, Nidamanuri S, Rodriguez E, Franco D, Ryland K, Keaveny AP, Huskey JL, Smith M, Reddy KS, Taner CB, Vargas HE, Aqel BA. Clinical outcomes of hepatitis C treatment before and after kidney transplantation and its impact on time to transplant: A multicenter study. Am J Transplant 2018; 18:2559-2565. [PMID: 29758123 DOI: 10.1111/ajt.14931] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [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: 01/14/2018] [Revised: 05/04/2018] [Accepted: 05/06/2018] [Indexed: 01/25/2023]
Abstract
Waitlist time for kidney transplantation is long but may be shortened with the utilization of hepatitis C positive allografts. We retrospectively reviewed the course of 36 hepatitis C positive patients awaiting kidney transplantation at 2 large centers within the same health system, with near-identical care delivery models with the exception of timing of hepatitis C treatment, to determine the impact of timing of hepatitis C treatment on access to transplant, waitlist time, and treatment efficacy and tolerability. The majority of patients had hepatitis C genotype 1a or 1b, and all received direct acting antiviral therapy with 100% treatment response. One patient underwent transplantation in the pretransplant treatment group. The 1-year transplantation rate was 12.5% vs 67.9% (P = .0013) in those treated posttransplantation. The median waitlist time in the posttransplant group was 122 (interquartile range [IQR] 21.5, 531.0) days, which was significantly shorter than the center's regional and national wait time. Pathologic review revealed no difference in allograft quality. Overall treatment related adverse events were not different between the 2 groups. A strategy of posttransplant hepatitis C treatment increased access to transplant and reduced waitlist time. Delaying treatment until after transplant did not appear to adversely affect recipients' kidney allograft or overall survival.
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Affiliation(s)
- D M Chascsa
- Transplant Center, Mayo Clinic, Phoenix, AZ, USA.,Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
| | - O Y Mousa
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - S Pungpapong
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA.,Transplant Center, Mayo Clinic, Jacksonville, FL, USA
| | - N Zhang
- Department of Biostatistics, Mayo Clinic, Phoenix, AZ, USA
| | - A Chervenak
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
| | - S Nidamanuri
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
| | - E Rodriguez
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
| | - D Franco
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
| | - K Ryland
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - A P Keaveny
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA.,Transplant Center, Mayo Clinic, Jacksonville, FL, USA
| | - J L Huskey
- Transplant Center, Mayo Clinic, Phoenix, AZ, USA.,Department of Nephrology, Mayo Clinic, Phoenix, AZ, USA
| | - M Smith
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Phoenix, AZ, USA
| | - K S Reddy
- Transplant Center, Mayo Clinic, Phoenix, AZ, USA.,Department of Transplantation Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - C B Taner
- Transplant Center, Mayo Clinic, Jacksonville, FL, USA.,Department of Transplantation Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - H E Vargas
- Transplant Center, Mayo Clinic, Phoenix, AZ, USA.,Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
| | - B A Aqel
- Transplant Center, Mayo Clinic, Phoenix, AZ, USA.,Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
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Khurmi NS, Chang YH, Eric Steidley D, Singer AL, Hewitt WR, Reddy KS, Moss AA, Mathur AK. Hospitalizations for Cardiovascular Disease After Liver Transplantation in the United States. Liver Transpl 2018; 24:1398-1410. [PMID: 29544033 DOI: 10.1002/lt.25055] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [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: 11/02/2017] [Revised: 04/30/2018] [Accepted: 03/10/2018] [Indexed: 02/07/2023]
Abstract
Cardiovascular disease (CVD) is a leading cause of post-liver transplant death, and variable care patterns may affect outcomes. We aimed to describe epidemiology and outcomes of inpatient CVD care across US hospitals. Using a merged data set from the 2002-2011 Nationwide Inpatient Sample and the American Hospital Association Annual Survey, we evaluated liver transplant patients admitted primarily with myocardial infarction (MI), stroke (cerebrovascular accident [CVA]), congestive heart failure (CHF), dysrhythmias, cardiac arrest (CA), or malignant hypertension. Patient-level data include demographics, Charlson comorbidity index, and CVD diagnoses. Facility-level variables included ownership status, payer-mix, hospital resources, teaching status, and physician/nursing-to-bed ratios. We used generalized estimating equations to evaluate patient- and hospital-level factors associated with mortality. There were 4763 hospitalizations that occurred in 153 facilities (transplant hospitals, n = 80). CVD hospitalizations increased overall by 115% over the decade (P < 0.01). CVA and MI declined over time (both P < 0.05), but CHF and dysrhythmia grew significantly (both P < 0.03); a total of 19% of hospitalizations were for multiple CVD diagnoses. Transplant hospitals had lower comorbidity patients (P < 0.001) and greater resource intensity including presence of cardiac intensive care unit, interventional radiology, operating rooms, teaching status, and nursing density (all P < 0.01). Transplant and nontransplant hospitals had similar unadjusted mortality (overall, 3.9%, P = 0.55; by diagnosis, all P > 0.07). Transplant hospitals had significantly longer overall length of stay, higher total costs, and more high-cost hospitalizations (all P < 0.05). After risk adjustment, transplant hospitals were associated with higher mortality and high-cost hospitalizations. In conclusion, CVD after liver transplant is evolving and responsible for growing rates of inpatient care. Transplant hospitals are associated with poor outcomes, even after risk adjustment for patient and hospital characteristics, which may be attributable to selective referral of certain patient phenotypes but could also be related to differences in quality of care. Further study is warranted.
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Affiliation(s)
| | - Yu-Hui Chang
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery
| | | | - Andrew L Singer
- Transplant Surgery, Department of Surgery, Mayo Clinic School of Medicine, Mayo Clinic Arizona, Phoenix, AZ
| | - Winston R Hewitt
- Transplant Surgery, Department of Surgery, Mayo Clinic School of Medicine, Mayo Clinic Arizona, Phoenix, AZ
| | - Kunam S Reddy
- Transplant Surgery, Department of Surgery, Mayo Clinic School of Medicine, Mayo Clinic Arizona, Phoenix, AZ
| | - Adyr A Moss
- Transplant Surgery, Department of Surgery, Mayo Clinic School of Medicine, Mayo Clinic Arizona, Phoenix, AZ
| | - Amit K Mathur
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery.,Transplant Surgery, Department of Surgery, Mayo Clinic School of Medicine, Mayo Clinic Arizona, Phoenix, AZ
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Chakkera HA, Angadi SS, Heilman RL, Kaplan B, Scott RL, Bollempalli H, Cha SS, Khamash HA, Huskey JL, Mour GK, Sukumaran Nair S, Singer AL, Reddy KS, Mathur AK, Moss AA, Hewitt WR, Qaqish I, Behmen S, Keddis MT, Unzek S, Steidley DE. Cardiorespiratory Fitness (Peak Oxygen Uptake): Safe and Effective Measure for Cardiovascular Screening Before Kidney Transplant. J Am Heart Assoc 2018; 7:JAHA.118.008662. [PMID: 29853444 PMCID: PMC6015378 DOI: 10.1161/jaha.118.008662] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Significant heterogeneity exists in practice patterns and algorithms used for cardiac screening before kidney transplant. Cardiorespiratory fitness, as measured by peak oxygen uptake (VO2peak), is an established validated predictor of future cardiovascular morbidity and mortality in both healthy and diseased populations. The literature supports its use among asymptomatic patients in abrogating the need for further cardiac testing. METHODS AND RESULTS We outlined a pre-renal transplant screening algorithm to incorporate VO2peak testing among a population of asymptomatic high-risk patients (with diabetes mellitus and/or >50 years of age). Only those with VO2peak <17 mL/kg per minute (equivalent to <5 metabolic equivalents) underwent further noninvasive cardiac screening tests. We conducted a retrospective study of the a priori dichotomization of the VO2peak <17 versus ≥17 mL/kg per minute to determine negative and positive predictive value of future cardiac events and all-cause mortality. We report a high (>90%) negative predictive value, indicating that VO2peak ≥17 mL/kg per minute is effective to rule out future cardiac events and all-cause mortality. However, lower VO2peak had low positive predictive value and should not be used as a reliable metric to predict future cardiac events and/or mortality. In addition, a simple mathematical calculation documented a cost savings of ≈$272 600 in the cardiac screening among our study cohort of 637 patients undergoing evaluation for kidney and/or pancreas transplant. CONCLUSIONS We conclude that incorporating an objective measure of cardiorespiratory fitness with VO2peak is safe and allows for a cost savings in the cardiovascular screening protocol among higher-risk phenotype (with diabetes mellitus and >50 years of age) being evaluated for kidney transplant.
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Balakrishna K, Lakshmi DV, Mustafa S, Reddy KS, Ghorpade TK. Synthesis, UV/Vis and Fluorescence studies of Naphthoquinone Pyridyl Tetrazole-based Chemical Probe. Indian J Pharm Sci 2018. [DOI: 10.4172/pharmaceutical-sciences.1000420] [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: 11/09/2022] Open
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Heilman RL, Green EP, Reddy KS, Moss A, Kaplan B. Potential Impact of Risk and Loss Aversion on the Process of Accepting Kidneys for Transplantation. Transplantation 2017. [DOI: 10.1097/tp.0000000000001715] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Mathur AK, Chakrabarti AK, Mellinger JL, Volk ML, Day R, Singer AL, Hewitt WR, Reddy KS, Moss AA. Hospital resource intensity and cirrhosis mortality in United States. World J Gastroenterol 2017; 23:1857-1865. [PMID: 28348492 PMCID: PMC5352927 DOI: 10.3748/wjg.v23.i10.1857] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Revised: 01/04/2017] [Accepted: 02/08/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To determine whether hospital characteristics predict cirrhosis mortality and how much variation in mortality is attributable to hospital differences.
METHODS We used data from the 2005-2011 Nationwide Inpatient Sample and the American Hospital Association Annual survey to identify hospitalizations for decompensated cirrhosis and corresponding facility characteristics. We created hospital-specific risk and reliability-adjusted odds ratios for cirrhosis mortality, and evaluated patient and facility differences based on hospital performance quintiles. We used hierarchical regression models to determine the effect of these factors on mortality.
RESULTS Seventy-two thousand seven hundred and thirty-three cirrhosis admissions were evaluated in 805 hospitals. Hospital mean cirrhosis annual case volume was 90.4 (range 25-828). Overall hospital cirrhosis mortality rate was 8.00%. Hospital-adjusted odds ratios (aOR) for mortality ranged from 0.48 to 1.89. Patient characteristics varied significantly by hospital aOR for mortality. Length of stay averaged 6.0 ± 1.6 days, and varied significantly by hospital performance (P < 0.001). Facility level predictors of risk-adjusted mortality were higher Medicaid case-mix (OR = 1.00, P = 0.029) and LPN staffing (OR = 1.02, P = 0.015). Higher cirrhosis volume (OR = 0.99, P = 0.025) and liver transplant program status (OR = 0.83, P = 0.026) were significantly associated with survival. After adjusting for patient differences, era, and clustering effects, 15.3% of variation between hospitals was attributable to differences in facility characteristics.
CONCLUSION Hospital characteristics account for a significant proportion of variation in cirrhosis mortality. These findings have several implications for patients, providers, and health care delivery in liver disease care and inpatient health care design.
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