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Miller JM, Zaun D, Wood NL, Lyden GR, McKinney WT, Hirose R, Snyder JJ. Adjusting for race in metrics of organ procurement organization performance. Am J Transplant 2024:S1600-6135(24)00122-9. [PMID: 38331046 DOI: 10.1016/j.ajt.2024.01.032] [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: 10/24/2023] [Revised: 01/09/2024] [Accepted: 01/27/2024] [Indexed: 02/10/2024]
Abstract
The Scientific Registry of Transplant Recipients has previously reported the effects of adjusting for demographic variables, including race, in the Centers for Medicare & Medicaid Services (CMS) organ procurement organization (OPO) performance metrics: donation rate and transplant rate. CMS chose not to adjust for most demographic variables other than age (for the transplant rate), arguing that there is no biological reason that these variables would affect the organ donation/utilization decision. However, organ donation is a process based on altruism and trust, not a simple biological phenomenon. Focusing only on biological impacts on health ignores other pathways through which demographic factors can influence OPO outcomes. In this study, we update analyses of demographic adjustment on the OPO metrics for 2020 with a specific focus on adjusting for race. We find that adjusting for race would lead to 8 OPOs changing their CMS tier rankings, including 2 OPOs that actually overperform the national rate among non-White donors improving from a tier 3 ranking (facing decertification without possibility of recompeting) to a tier 2 ranking (allowing the possibility of recompeting). Incorporation of stratified and risk-adjusted metrics in public reporting of OPO performance could help OPOs identify areas for improvement within specific demographic categories.
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Affiliation(s)
- Jonathan M Miller
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA.
| | - David Zaun
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - Nicholas L Wood
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
| | - Grace R Lyden
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
| | - Warren T McKinney
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ryutaro Hirose
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Jon J Snyder
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA; Department of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
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2
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Meier RPH, Nunez M, Syed SM, Feng S, Tavakol M, Freise CE, Roberts JP, Ascher NL, Hirose R, Roll GR. DCD liver transplant in patients with a MELD over 35. Front Immunol 2023; 14:1246867. [PMID: 37731493 PMCID: PMC10507358 DOI: 10.3389/fimmu.2023.1246867] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 08/17/2023] [Indexed: 09/22/2023] Open
Abstract
Introduction Donation after circulatory death (DCD) liver transplantation (LT) makes up well less than 1% of all LTs with a Model for End-Stage Liver Disease (MELD)≥35 in the United States. We hypothesized DCD-LT yields acceptable ischemia-reperfusion and reasonable outcomes for recipients with MELD≥35. Methods We analyzed recipients with lab-MELD≥35 at transplant within the UCSF (n=41) and the UNOS (n=375) cohorts using multivariate Cox regression and propensity score matching. Results In the UCSF cohort, five-year patient survival was 85% for DCD-LTs and 86% for matched-Donation after Brain Death donors-(DBD) LTs (p=0.843). Multivariate analyses showed that younger donor/recipient age and more recent transplants (2011-2021 versus 1999-2010) were associated with better survival. DCD vs. DBD graft use did not significantly impact survival (HR: 1.2, 95%CI 0.6-2.7). The transaminase peak was approximately doubled, indicating suggesting an increased ischemia-reperfusion hit. DCD-LTs had a median post-LT length of stay of 11 days, and 34% (14/41) were on dialysis at discharge versus 12 days and 22% (9/41) for DBD-LTs. 27% (11/41) DCD-LTs versus 12% (5/41) DBD-LTs developed a biliary complication (p=0.095). UNOS cohort analysis confirmed patient survival predictors, but DCD graft emerged as a risk factor (HR: 1.5, 95%CI 1.3-1.9) with five-year patient survival of 65% versus 75% for DBD-LTs (p=0.016). This difference became non-significant in a sub-analysis focusing on MELD 35-36 recipients. Analysis of MELD≥35 DCD recipients showed that donor age of <30yo independently reduced the risk of graft loss by 30% (HR, 95%CI: 0.7 (0.9-0.5), p=0.019). Retransplant status was associated with a doubled risk of adverse event (HR, 95%CI: 2.1 (1.4-3.3), p=0.001). The rejection rates at 1y were similar between DCD- and DBD-LTs, (9.3% (35/375) versus 1,541 (8.7% (1,541/17,677), respectively). Discussion In highly selected recipient/donor pair, DCD transplantation is feasible and can achieve comparable survival to DBD transplantation. Biliary complications occurred at the expected rates. In the absence of selection, DCD-LTs outcomes remain worse than those of DBD-LTs.
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Affiliation(s)
- Raphael P. H. Meier
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Miguel Nunez
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Shareef M. Syed
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Sandy Feng
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Mehdi Tavakol
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Chris E. Freise
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - John P. Roberts
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Nancy L. Ascher
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Ryutaro Hirose
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Garrett R. Roll
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
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3
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Yilma M, Dalal N, Wadhwani SI, Hirose R, Mehta N. Geographic disparities in access to liver transplantation. Liver Transpl 2023; 29:987-997. [PMID: 37232214 PMCID: PMC10914246 DOI: 10.1097/lvt.0000000000000182] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 04/08/2023] [Indexed: 05/27/2023]
Abstract
Since the Final Rule regarding transplantation was published in 1999, organ distribution policies have been implemented to reduce geographic disparity. While a recent change in liver allocation, termed acuity circles, eliminated the donor service area as a unit of distribution to decrease the geographic disparity of waitlisted patients to liver transplantation, recently published results highlight the complexity of addressing geographic disparity. From geographic variation in donor supply, as well as liver disease burden and differing model for end-stage liver disease (MELD) scores of candidates and MELD scores necessary to receive liver transplantation, to the urban-rural disparity in specialty care access, and to neighborhood deprivation (community measure of socioeconomic status) in liver transplant access, addressing disparities of access will require a multipronged approach at the patient, transplant center, and national level. Herein, we review the current knowledge of these disparities-from variation in larger (regional) to smaller (census tract or zip code) levels to the common etiologies of liver disease, which are particularly affected by these geographic boundaries. The geographic disparity in liver transplant access must balance the limited organ supply with the growing demand. We must identify patient-level factors that contribute to their geographic disparity and incorporate these findings at the transplant center level to develop targeted interventions. We must simultaneously work at the national level to standardize and share patient data (including socioeconomic status and geographic social deprivation indices) to better understand the factors that contribute to the geographic disparity. The complex interplay between organ distribution policy, referral patterns, and variable waitlisting practices with the proportion of high MELD patients and differences in potential donor supply must all be considered to create a national policy strategy to address the inequities in the system.
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Affiliation(s)
- Mignote Yilma
- Department of Surgery, University of California San Francisco
- National Clinician Scholars Program, University of California San Francisco
| | - Nicole Dalal
- Department of Medicine, University of California San Francisco
| | | | - Ryutaro Hirose
- Department of Transplant, University of California San Francisco
| | - Neil Mehta
- Department of Medicine, University of California San Francisco
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4
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Yilma M, Cogan R, Shui AM, Neuhaus JM, Light C, Braun H, Mehta N, Hirose R. Community-level social vulnerability and individual socioeconomic status on liver transplant referral outcome. Hepatol Commun 2023; 7:e00196. [PMID: 37378636 DOI: 10.1097/hc9.0000000000000196] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 12/13/2022] [Accepted: 05/06/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Recent endeavors emphasize the importance of understanding early barriers to liver transplantation (LT) by consistently collecting data on patient demographics, socioeconomic factors, and geographic social deprivation indices. METHODS In this retrospective single-center cohort study of 1657 adults referred for LT evaluation, we assessed the association between community-level vulnerability and individual socioeconomic status measures on the rate of waitlisting and transplantation. Patients' addresses were linked to Social Vulnerability Index (SVI) at the census tract-level to characterize community-level vulnerability. Descriptive statistics were used to describe patient characteristics. Multivariable cause-specific HRs were used to assess the association between community-level vulnerability, individual measures of the socioeconomic status, and LT evaluation outcomes (waitlist and transplantation). RESULTS Among the 1657 patients referred for LT during the study period, 54% were waitlisted and 26% underwent LT. A 0.1 increase in overall SVI correlated with an 8% lower rate of waitlisting (HR 0.92, 95% CI 0.87-0.96, p < 0.001), with socioeconomic status, household characteristics, housing type and transportation, and racial and ethnic minority status domains contributing significantly to this association. Patients residing in more vulnerable communities experienced a 6% lower rate of transplantation (HR 0.94, 95% CI 0.91- 0.98, p = 0.007), with socioeconomic status and household characteristic domain of SVI significantly contributing to this association. At the individual level, both government insurance and employment status were associated with lower rates of waitlisting and transplantation. There was no association with mortality prior to waitlisting or mortality while on the waitlist. CONCLUSION Our findings indicate that both individual and community measures of the socioeconomic status (overall SVI) are associated with LT evaluation outcomes. Furthermore, we identified individual measures of neighborhood deprivation associated with both waitlisting and transplantation.
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Affiliation(s)
- Mignote Yilma
- General Surgery, University of California, San Francisco, California, USA
- National Clinician Scholars Program at the University of California, San Francisco, California, USA
| | - Raymond Cogan
- University of California, San Francisco Transplant Program, California, USA
| | - Amy M Shui
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - John M Neuhaus
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - Carolyn Light
- University of California, San Francisco Transplant Program, California, USA
| | - Hillary Braun
- General Surgery, University of California, San Francisco, California, USA
| | - Neil Mehta
- Division of Gastroenterology, University of California, San Francisco, California, USA
| | - Ryutaro Hirose
- Division of Transplant Surgery, University of California, San Francisco, California, USA
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Snyder JJ, Schaffhausen CR, Hart A, Axelrod DA, Dils D, Formica RN, Gaber AO, Hunt HF, Jones J, Mohan S, Patzer RE, Pinney SP, Ratner LE, Slaker D, Stewart D, Stewart ZA, Van Slyck S, Kasiske BL, Hirose R, Israni AK. Stakeholders' Perspectives on Transplant Metrics: The 2022 Scientific Registry of Transplant Recipients' Consensus Conference. Am J Transplant 2023:S1600-6135(23)00355-6. [PMID: 36958628 DOI: 10.1016/j.ajt.2023.03.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 03/10/2023] [Accepted: 03/14/2023] [Indexed: 03/25/2023]
Abstract
In July 2022, the Scientific Registry of Transplant Recipients (SRTR) hosted an innovative, multistakeholder consensus conference to identify information and metrics desired by stakeholders in the transplantation system, including patients, living donors, caregivers, deceased donor family members, transplant professionals, organ procurement organization professionals, payers, and regulators. Crucially, patients, caregivers, living donors, and deceased donor family members were included in all aspects of this conference, including serving on the planning committee, participating in preconference focus groups and learning sessions, speaking at the conference, moderating conference sessions and breakout groups, and shaping the conclusions. Patients constituted 24% of the meeting participants. In this report, we document the proceedings and enumerate 160 recommendations, 10 of which have been highly prioritized. SRTR will use the recommendations to develop new presentations of information and metrics requested by stakeholders to support informed decision-making.
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Affiliation(s)
- Jon J Snyder
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA; Department of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA.
| | - Cory R Schaffhausen
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
| | - Allyson Hart
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
| | - David A Axelrod
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; University of Iowa Transplant Institute, Iowa City, Iowa, USA
| | - Dorrie Dils
- Gift of Life Michigan, Ann Arbor, Michigan, USA
| | | | - A Osama Gaber
- Department of Surgery, Houston Methodist Hospital, J.C. Walter Jr. Transplant Center, Houston, Texas, USA
| | | | - Jennifer Jones
- American Association of Kidney Patients, Kidney Transplant Recipient
| | - Sumit Mohan
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Rachel E Patzer
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA; Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Sean P Pinney
- Department of Medicine, The University of Chicago, Chicago, IL, USA
| | - Lloyd E Ratner
- Department of Surgery, Columbia University, New York, New York
| | - Dirk Slaker
- Optum Health Solutions, Eden Prairie, Minnesota, USA
| | - Darren Stewart
- Department of Surgery, NYU Langone Health, New York, New York, USA
| | - Zoe A Stewart
- Department of Surgery, NYU Langone Health, New York, New York, USA
| | | | - Bertram L Kasiske
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ryutaro Hirose
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Ajay K Israni
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA; Department of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
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6
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Hart A, Patzer RE, Spear J, Hirose R, Tabatabai A, Wood NL, Schaffhausen CR, Axelrod DA, Israni AK, Snyder JJ. Time to discard the term "discard". Am J Transplant 2023; 23:608-610. [PMID: 36740191 DOI: 10.1016/j.ajt.2023.01.018] [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: 09/22/2022] [Revised: 11/10/2022] [Accepted: 01/25/2023] [Indexed: 02/05/2023]
Abstract
The 2022 Scientific Registry of Transplant Recipients Consensus Conference "People Driven Transplant Metrics" offered an opportunity for a diverse group of stakeholders in the solid organ transplant community to exchange ideas about what information and metrics are important to different stakeholders. Participating patients and family members called on the transplant community to cease using the term "discards" to refer to donated organs that are not transplanted.
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Affiliation(s)
- Allyson Hart
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA.
| | - Rachel E Patzer
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Julie Spear
- Deceased Donor Family Member, Region 8 Representative, Patient Affairs Committee, Organ Procurement and Transplantation Network, Boulder, CO, USA
| | - Ryutaro Hirose
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Ameen Tabatabai
- Patient representative, Patient and Family Advisory Subcommittee, Scientific Registry of Transplant Recipients, Los Angeles, CA, USA
| | - Nicholas L Wood
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - Cory R Schaffhausen
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - David A Axelrod
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Department of Surgery, University of Iowa, Iowa City, Iowa, USA
| | - Ajay K Israni
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA; Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jon J Snyder
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA; Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota, USA
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7
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Miller JM, Ahn YS, Hart A, Lindblad K, Jett C, Fox C, Hirose R, Israni AK, Snyder JJ. OPTN/SRTR 2021 Annual Data Report: COVID-19. Am J Transplant 2023; 23:S475-S522. [PMID: 37132343 PMCID: PMC9970342 DOI: 10.1016/j.ajt.2023.02.011] [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] [Indexed: 03/02/2023]
Abstract
This chapter updates the COVID-19 chapter from the 2020 Annual Data Report with trends through February 12, 2022, and introduces trends in COVID-19–specific cause of death on the waiting list and posttransplant. Transplant rates remain at or above prepandemic levels for all organs, indicating a sustained transplantation system recovery following the initial 3-month disruption due to the onset of the pandemic. Posttransplant mortality and graft failure remain a concern in all organs, with rates surging corresponding to waves of the pandemic. Waitlist mortality due to COVID-19 is also a concern, particularly among kidney candidates. While the recovery of the transplantation system has been sustained in the second year of the pandemic, ongoing efforts should focus on reducing posttransplant and waitlist mortality due to COVID-19, and graft failure.
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Affiliation(s)
- Jonathan M. Miller
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN,Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, MN
| | - Yoon Son Ahn
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN
| | - Allyson Hart
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN,Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, MN
| | - Kelsi Lindblad
- Organ Procurement and Transplantation Network, United Network for Organ Sharing, Richmond, VA
| | - Courtney Jett
- Organ Procurement and Transplantation Network, United Network for Organ Sharing, Richmond, VA
| | - Cole Fox
- Organ Procurement and Transplantation Network, United Network for Organ Sharing, Richmond, VA
| | - Ryutaro Hirose
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN,Department of Surgery, University of California San Francisco, San Francisco, CA
| | - Ajay K. Israni
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN,Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, MN,Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN
| | - Jon J. Snyder
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN,Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, MN,Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN
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Miller J, Lyden GR, Zaun D, Kasiske BL, Hirose R, Israni AK, Snyder JJ. Transplant program evaluations in the middle of the COVID-19 pandemic. Am J Transplant 2022; 22:2616-2626. [PMID: 35727854 PMCID: PMC9350340 DOI: 10.1111/ajt.17123] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 05/26/2022] [Accepted: 06/19/2022] [Indexed: 01/25/2023]
Abstract
Potential regional variations in effects of COVID-19 on federally mandated, program-specific evaluations by the Scientific Registry of Transplant Recipients (SRTR) have been controversial. SRTR January 2022 program evaluations ended transplant follow-up on March 12, 2020, and excluded transplants performed from March 13, 2020 to June 12, 2020 (the "carve-out"). This study examined the carve-out's impact, and the effect of additionally censoring COVID-19 deaths, on first-year posttransplant outcomes for transplants from July 2018 through December 2020. Program-specific hazard ratios (HRs) for graft failure and death estimated under two alternative scenarios were compared with published HRs: (1) the carve-out was removed; (2) the carve-out was retained, but deaths due to COVID-19 were additionally censored. The HRs estimated by censoring COVID-19 deaths were highly correlated with those estimated with the carve-out alone (r2 = .96). Removal of the carve-out resulted in greater variation in HRs while remaining highly correlated (r2 = .82); however, little geographic impact of the carve-out was observed. The carve-out increased average HR in the Northwest by 0.049; carve-out plus censoring reduced average HR in the Midwest by 0.009. Other regions of the country were not significantly affected. Thus, the current COVID-19 carve-out does not appear to impart substantial bias based on the region of the country.
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Affiliation(s)
- Jonathan Miller
- Scientific Registry of Transplant Recipients Hennepin Healthcare Research Institute Minneapolis, Minnesota USA
| | - Grace R. Lyden
- Scientific Registry of Transplant Recipients Hennepin Healthcare Research Institute Minneapolis, Minnesota USA
| | - David Zaun
- Scientific Registry of Transplant Recipients Hennepin Healthcare Research Institute Minneapolis, Minnesota USA
| | - Bertram L. Kasiske
- Scientific Registry of Transplant Recipients Hennepin Healthcare Research Institute Minneapolis, Minnesota USA
| | - Ryutaro Hirose
- Scientific Registry of Transplant Recipients Hennepin Healthcare Research Institute Minneapolis, Minnesota USA
- Department of Surgery University of California San Francisco San Francisco, California USA
| | - Ajay K. Israni
- Scientific Registry of Transplant Recipients Hennepin Healthcare Research Institute Minneapolis, Minnesota USA
- Department of Medicine, Hennepin Healthcare University of Minnesota Minneapolis, Minnesota USA
- Department of Epidemiology and Community Health University of Minnesota Minneapolis, Minnesota USA
| | - Jon J. Snyder
- Scientific Registry of Transplant Recipients Hennepin Healthcare Research Institute Minneapolis, Minnesota USA
- Department of Medicine, Hennepin Healthcare University of Minnesota Minneapolis, Minnesota USA
- Department of Epidemiology and Community Health University of Minnesota Minneapolis, Minnesota USA
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9
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Greenberg AL, Karimzada MM, Brian R, Yap A, Luu HY, Ahmed S, Huang CY, Waits SA, Hirose R, Alseidi A, Rapp JH, O’Sullivan PS, Chern H, Syed SM. Assessment of Surgeon Performance of Advanced Open Surgical Skills Using a Microskills-Based Novel Curriculum. JAMA Netw Open 2022; 5:e2229787. [PMID: 36053533 PMCID: PMC9440404 DOI: 10.1001/jamanetworkopen.2022.29787] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE The increase in minimally invasive surgical procedures has eroded exposure of general surgery residents to open operations. High-fidelity simulation, together with deliberate instruction, is needed for advanced open surgical skill (AOSS) development. OBJECTIVE To collect validity evidence for AOSS tools to support a shared model for instruction. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study included postresidency surgeons (PRSs) and second-year general surgery residents (R2s) at a single academic medical center who completed simulated tasks taught within the AOSS curriculum between June 1 and October 31, 2021. EXPOSURES The AOSS curriculum includes 6 fine-suture and needle handling tasks, including deep suture tying (with and without needles) and continuous suturing using the pitch-and-catch and push-push-pull techniques (both superficial and deep). Teaching and assessment are based on specific microskills using a 3-dimensional printed iliac fossa model. MAIN OUTCOMES AND MEASURES The PRS group was timed and scored (5-point Likert scale) on 10 repetitions of each task. Six months after receiving instruction on the AOSS tasks, the R2 group was similarly timed and scored. RESULTS The PRS group included 14 surgeons (11 male [79%]; 8 [57%] attending surgeons) who completed the simulation; the R2 group, 9 surgeons (5 female [55%]) who completed the simulation. Score and time variability were greater for the R2s compared with the PRSs for all tasks. The R2s scored lower and took longer on (1) deep pitch-and-catch suturing (69% of maximum points for a mean [SD] of 142.0 [31.7] seconds vs 77% for a mean [SD] of 95.9 [29.4] seconds) and deep push-push-pull suturing (63% of maximum points for a mean [SD] of 284.0 [72.9] seconds vs 85% for a mean [SD] of 141.4 [29.1] seconds) relative to the corresponding superficial tasks; (2) suture tying with a needle vs suture tying without a needle (74% of maximum points for a mean [SD] of 64.6 [19.8] seconds vs 90% for a mean [SD] of 54.4 [15.6] seconds); and (3) the deep push-push-pull vs pitch-and-catch techniques (63% of maximum points for a mean [SD] of 284.0 [72.9] seconds vs 69% of maximum points for a mean [SD] of 142.0 [31.7] seconds). For the PRS group, time was negatively associated with score for the 3 hardest tasks: superficial push-push-pull (ρ = 0.60; P = .02), deep pitch-and-catch (ρ = 0.73; P = .003), and deep push-push-pull (ρ = 0.81; P < .001). For the R2 group, time was negatively associated with score for the 2 easiest tasks: suture tying without a needle (ρ = 0.78; P = .01) and superficial pitch-and-catch (ρ = 0.79; P = .01). CONCLUSIONS AND RELEVANCE The findings of this cohort study offer validity evidence for a novel AOSS curriculum; reveal differential difficulty of tasks that can be attributed to specific microskills; and suggest that position on the surgical learning curve may dictate the association between competency and speed. Together these findings suggest specific, actionable opportunities to guide instruction of AOSS, including which microskills to focus on, when individual rehearsal vs guided instruction is more appropriate, and when to focus on speed.
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Affiliation(s)
| | | | - Riley Brian
- Department of Surgery, University of California, San Francisco
| | - Ava Yap
- Department of Surgery, University of California, San Francisco
| | - Hubert Y. Luu
- Department of Surgery, University of California, San Francisco
| | - Saira Ahmed
- Department of Surgery, University of Illinois at Chicago
| | - Chiung-Yu Huang
- Department of Surgery, University of California, San Francisco
| | - Seth A. Waits
- Department of Surgery, University of Michigan, Ann Arbor
| | - Ryutaro Hirose
- Department of Surgery, University of California, San Francisco
| | - Adnan Alseidi
- Department of Surgery, University of California, San Francisco
| | - Joseph H. Rapp
- Department of Surgery, University of California, San Francisco
| | | | - Hueylan Chern
- Department of Surgery, University of California, San Francisco
| | - Shareef M. Syed
- Department of Surgery, University of California, San Francisco
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10
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Roll GR, Hirose R. Toward a more efficient organ placement system (and defeating FOMO). Am J Transplant 2022; 22:1511-1512. [PMID: 35182002 DOI: 10.1111/ajt.17004] [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] [Received: 02/02/2022] [Accepted: 02/14/2022] [Indexed: 01/25/2023]
Affiliation(s)
- Garrett R Roll
- Department of Surgery, Division of Transplant, University of California, San Francisco, California, USA
| | - Ryutaro Hirose
- Department of Surgery, Division of Transplant, University of California, San Francisco, California, USA
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11
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Israni AK, Hirose R, Segev DL, Hart A, Schaffhausen CR, Axelrod DA, Kasiske BL, Snyder JJ. Toward continuous improvement of Scientific Registry of Transplant Recipients performance reporting: Advances following 2012 consensus conference and future consensus building for 2022 consensus conference. Clin Transplant 2022; 36:e14716. [PMID: 35598080 DOI: 10.1111/ctr.14716] [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: 03/10/2022] [Revised: 04/27/2022] [Accepted: 05/16/2022] [Indexed: 11/29/2022]
Abstract
The Scientific Registry of Transplant Recipients (SRTR) held a consensus conference in 2012 that examined methods used by SRTR for constructing performance metrics and made recommendations on how to improve program-specific reports. That consensus conference provided 25 recommendations categorized as follows: statistical methods, risk adjustment, and outcomes and data. During the subsequent decade, SRTR has implemented most of these recommendations; these are described in this article along with plans for another consensus conference in 2022. With the present article, SRTR aims to create transparency in the field of transplant metrics and guide discussion in the planning of the next consensus conference in 2022. The new conference will revisit the previous topics and have a broader focus to improve the metrics and information that SRTR provides. Readers can provide feedback on topics to be discussed at the next consensus conference as early as possible, by emailing srtr@srtr.org with the subject line "Task 5 Public Comment." This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Ajay K Israni
- Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA.,Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA.,Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ryutaro Hirose
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA.,Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Dorry L Segev
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA.,Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Allyson Hart
- Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA.,Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - Cory R Schaffhausen
- Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA.,Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - David A Axelrod
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA.,Department of Surgery, University of Iowa, Iowa City, Iowa, USA
| | - Bertram L Kasiske
- Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA.,Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - Jon J Snyder
- Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA.,Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA.,Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota, USA
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12
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Affiliation(s)
- J. Miller
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN
| | - A. Wey
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN
| | - Y.S. Ahn
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN
| | - D. Musgrove
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN
| | - A. Hart
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN,Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, MN
| | - A. Wilk
- Organ Procurement and Transplantation Network, United Network for Organ Sharing, Richmond, VA
| | - K. Lindblad
- Organ Procurement and Transplantation Network, United Network for Organ Sharing, Richmond, VA
| | - R. Hirose
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN,Department of Surgery, University of California San Francisco, San Francisco, CA
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13
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Zarinsefat A, Gulati A, Shui A, Braun H, Rogers R, Hirose R, Ascher N, Stock P. Long-term Outcomes Following Kidney and Liver Transplant in Recipients With HIV. JAMA Surg 2022; 157:240-247. [PMID: 34985513 PMCID: PMC8733865 DOI: 10.1001/jamasurg.2021.6798] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Importance Kidney transplant (KT) and liver transplant (LT) in HIV-positive patients have become more widely adopted. Data looking at long-term outcomes of patient and graft survival are lacking. Objective To compare the long-term outcomes of KT and LT in HIV-positive recipients with matched HIV-negative recipients. Design, Setting, and Participants Retrospective, single-center, cohort, study using data from 2000 to 2019. Patients were observed until death, or graft failure requiring retransplant. All HIV-positive patients who underwent KT and/or LT between 2000 and 2019 were included. Propensity matching was performed to the corresponding HIV-negative cohort, which was obtained from the University of California, San Francisco's transplant recipient registry. The data were analyzed from 2020 to 2021. Exposures HIV infection. Main Outcomes and Measures Patient and graft survival for KT and patient survival for LT. Incidence of acute rejection and its association with KT graft survival. Results For KT, 655 HIV-negative recipients (mean [SD] age, 52.3 [13.6] years; 450 [68.7%] were men) and 119 HIV-positive recipients (mean [SD] age, 51.7 [9.4] years; 86 [72.3%] were men) were included. Patient survival was 79.6% (95% CI, 73.6%-86.1%) and 53.6% (95% CI, 38.9%-74.0%) at 15 years posttransplant, respectively. Graft survival was 57.0% (95% CI, 47.8%-68.0%) and 75.0% (95% CI, 65.3%-86.2%) at 15 years posttransplant, respectively. Diagnosis of HIV was not associated with worse graft survival (hazard ratio, 1.09; 95% CI, 0.61-1.97; P = .77). For LT, 80 HIV-positive recipients (mean [SD] age, 52.6 [8.2] years; 53 [66.3%] were men) and 440 HIV-negative recipients (mean [SD] age, 54.6 [12.8] years; 291 [66.1%] were men) were included. Patient survival was 75.7% (95% CI, 71.8%-79.8%) for HIV-negative LT recipients and 70.0% (95% CI, 60.6%-80.8%) for HIV-positive LT recipients at 15 years posttransplant. Diagnosis of HIV was not a statistically significant predictor of patient survival (hazard ratio, 1.36; 95% CI, 0.83-2.24; P = .22). In KT, HIV-positive patients with at least 1 episode of acute rejection had a graft survival of 52.8% (95% CI, 38.4%-72.5%; P < .001) at 15 years posttransplant, compared with 91.8% in those without AR. Conclusions and Relevance In this single-center cohort study, KT and LT in HIV-positive patients had comparable long-term outcomes with those in matched HIV-negative patients. The high incidence of acute rejection was associated with reduced graft survival. The findings support providing transplant to HIV-positive patients, which may be an appropriate use of transplant resources and provides equitable access for HIV-positive patients.
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Affiliation(s)
- Arya Zarinsefat
- Department of Surgery, University of California, San Francisco
| | - Arushi Gulati
- School of Medicine, University of California, San Francisco
| | - Amy Shui
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Hillary Braun
- Department of Surgery, University of California, San Francisco
| | - Rodney Rogers
- Department of Surgery, University of California, San Francisco
| | - Ryutaro Hirose
- Department of Surgery, University of California, San Francisco
| | - Nancy Ascher
- Department of Surgery, University of California, San Francisco
| | - Peter Stock
- Department of Surgery, University of California, San Francisco
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14
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Wey A, Noreen S, Gentry S, Cafarella M, Trotter J, Salkowski N, Segev D, Israni A, Kasiske B, Hirose R, Snyder J. The Effect of Acuity Circles on Deceased Donor Transplant and Offer Rates Across Model for End-Stage Liver Disease Scores and Exception Statuses. Liver Transpl 2022; 28:363-375. [PMID: 34482614 DOI: 10.1002/lt.26286] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 08/25/2021] [Accepted: 08/29/2021] [Indexed: 01/05/2023]
Abstract
Acuity circles (AC), the new liver allocation system, was implemented on February 4, 2020. Difference-in-differences analyses estimated the effect of AC on adjusted deceased donor transplant and offer rates across Pediatric End-Stage Liver Disease (PELD) and Model for End-Stage Liver Disease (MELD) categories and types of exception statuses. The offer rates were the number of first offers, top 5 offers, and top 10 offers on the match run per person-year. Each analysis adjusted for candidate characteristics and only used active candidate time on the waiting list. The before-AC period was February 4, 2019, to February 3, 2020, and the after-AC period was February 4, 2020, to February 3, 2021. Candidates with PELD/MELD scores 29 to 32 and PELD/MELD scores 33 to 36 had higher transplant rates than candidates with PELD/MELD scores 15 to 28 after AC compared with before AC (transplant rate ratios: PELD/MELD scores 29-32, 2.34 3.324.71 ; PELD/MELD scores 33-36, 1.70 2.513.71 ). Candidates with PELD/MELD scores 29 or higher had higher offer rates than candidates with PELD/MELD scores 15 to 28, and candidates with PELD/MELD scores 29 to 32 had the largest difference (offer rate ratios [ORR]: first offers, 2.77 3.955.63 ; top 5 offers, 3.90 4.394.95 ; top 10 offers, 4.85 5.305.80 ). Candidates with exceptions had lower offer rates than candidates without exceptions for offers in the top 5 (ORR: hepatocellular carcinoma [HCC], 0.68 0.770.88 ; non-HCC, 0.73 0.810.89 ) and top 10 (ORR: HCC, 0.59 0.650.71 ; non-HCC, 0.69 0.750.81 ). Recipients with PELD/MELD scores 15 to 28 and an HCC exception received a larger proportion of donation after circulatory death (DCD) donors after AC than before AC, although the differences in the liver donor risk index were comparatively small. Thus, candidates with PELD/MELD scores 29 to 34 and no exceptions had better access to transplant after AC, and donor quality did not notably change beyond the proportion of DCD donors.
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Affiliation(s)
- Andrew Wey
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN
| | - Samantha Noreen
- Organ Procurement and Transplantation Network, United Network for Organ Sharing, Richmond, VA
| | - Sommer Gentry
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN.,Department of Mathematics, United States Naval Academy, Annapolis, MD
| | - Matt Cafarella
- Organ Procurement and Transplantation Network, United Network for Organ Sharing, Richmond, VA
| | - James Trotter
- Division of Transplant Hepatology, Baylor University Medical Center, Dallas, TX
| | - Nicholas Salkowski
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN
| | - Dorry Segev
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN.,Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Ajay Israni
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN.,Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN.,Department of Medicine, Hennepin Healthcare, Minneapolis, MN
| | - Bertram Kasiske
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN.,Department of Medicine, Hennepin Healthcare, Minneapolis, MN
| | - Ryutaro Hirose
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN.,Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Jon Snyder
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN.,Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN
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15
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Bernards S, Hirose R, Yao FY, Jin C, Dodge JL, Huang CY, Mehta N. The Impact of Median Model for End-Stage Liver Disease at Transplant Minus 3 National Policy on Waitlist Outcomes in Patients With and Without Hepatocellular Carcinoma. Liver Transpl 2022; 28:376-385. [PMID: 34761847 PMCID: PMC8857020 DOI: 10.1002/lt.26368] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 09/20/2021] [Accepted: 10/21/2021] [Indexed: 01/13/2023]
Abstract
As a result of ongoing regional disparities, the United Network for Organ Sharing (UNOS) implemented policy in May 2019 limiting exception points for waitlisted patients with hepatocellular carcinoma (HCC) to median Model for End-Stage Liver Disease at transplant in the area surrounding a transplant center minus 3 points (MMAT-3). The impact of this policy change remains unknown. We included adult patients with HCC (n = 4567) and without HCC (n = 19,773) in the UNOS database added to the waiting list before this policy change (May 7, 2017-May 18, 2019) and after (May 19, 2019-March 7, 2020). Cumulative incidence analysis estimated the probability of dropout within 1 year of listing decreased from 12.9% before the policy to 11.1% after the policy in candidates without HCC and from 14% to 10.7% in candidates with HCC. Incidence rates of liver transplantation (LT) and waitlist dropout varied significantly before the policy in patients with HCC and without HCC but nearly equalized in the postpolicy era. These effects were observed in both shorter and longer wait regions. With policy change being modeled as a time-dependent covariate, competing risk regression analyses estimated a decreased risk of dropout after policy change in the non-HCC group (cause-specific hazard ratio, 0.91; P = 0.02) after adjusting for demographic variables. These results suggest that the MMAT-3 policy has successfully reduced disparities in access to LT including across UNOS wait regions, although certain patients with HCC are now disadvantaged.
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Affiliation(s)
- Sarah Bernards
- Department of Medicine, University of California, San Francisco; San Francisco, CA
| | - Ryutaro Hirose
- Department of Surgery, University of California, San Francisco; San Francisco, CA
| | - Francis Y. Yao
- Department of Medicine, University of California, San Francisco; San Francisco, CA,Department of Surgery, University of California, San Francisco; San Francisco, CA
| | - Chengshi Jin
- Department of Surgery, University of California, San Francisco; San Francisco, CA
| | - Jennifer L. Dodge
- Department of Medicine, University of Southern California; Los Angeles, CA
| | - Chiung-Yu Huang
- Department of Surgery, University of California, San Francisco; San Francisco, CA
| | - Neil Mehta
- Department of Medicine, University of California, San Francisco; San Francisco, CA
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16
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Lentine KL, Smith JM, Hart A, Miller J, Skeans MA, Larkin L, Robinson A, Gauntt K, Israni AK, Hirose R, Snyder JJ. OPTN/SRTR 2020 Annual Data Report: Kidney. Am J Transplant 2022; 22 Suppl 2:21-136. [PMID: 35266618 DOI: 10.1111/ajt.16982] [Citation(s) in RCA: 162] [Impact Index Per Article: 81.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The year 2020 presented significant challenges to the field of kidney transplantation. After increasing each year since 2015 and reaching the highest annual count to date in 2019, the total number of kidney trans- plants decreased slightly, to 23642, in 2020. The decrease in total kidney transplants was due to a decrease in living donor transplants; the number of deceased donor transplants rose in 2020. The number of patients waiting for a kidney transplant in the United States declined slightly in 2020, driven by a slight drop in the number of new candidates added in 2020 and an increase in patients removed from the waiting list owing to death-important patterns that correlated with the COVID-19 pandemic. The complexities of the pandemic were accompanied by other ongoing challenges. Nationwide, only about a quarter of waitlisted patients receive a deceased donor kidney transplant within 5 years, a proportion that varies dramatically by donation service area, from 14.8% to 73.0%. The nonutilization (discard) rate of recovered organs rose to its highest value, at 21.3%, despite a dramatic decline in the discard of organs from hepatitis C-positive donors. Nonutilization rates remain particularly high for Kidney Donor Profile Index ≥85% kidneys and kidneys from which a biopsy specimen was obtained. Due to pandemic-related disruption of living donation in spring 2020, the number of living donor transplants in 2020 declined below annual counts over the last decade. In this context, only a small proportion of the waiting list receives living donor transplants each year, and racial disparities in living donor transplant access persist. As both graft and patient survival continue to improve incrementally, the total number of living kidney transplant recipients with a functioning graft exceeded 250,000 in 2020. Pediatric transplant numbers seem to have been impacted by the COVID-19 pandemic. The total number of pediatric kidney transplants performed decreased to 715 in 2020, from a peak of 872 in 2009. Despite numerous efforts, living donor kidney transplant remains low among pediatric recipients, with continued racial disparities among recipients. Of concern, the rate of deceased donor transplant among pediatric waitlisted candidates continued to decrease, reaching its lowest point in 2020. While this may be partly explained by the COVID-19 pandemic, close attention to this trend is critically important. Congenital anomalies of the kidney and urinary tract remain the leading cause of kidney disease in the pediatric population. While most pediatric de- ceased donor recipients receive a kidney from a donor with KDPI less than 35%, most pediatric deceased donor recipients had four or more HLA mis- matches. Graft survival continues to improve, with superior survival for living donor recipients versus deceased donor recipients.
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Affiliation(s)
- K L Lentine
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN.,Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, MO
| | - J M Smith
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN.,Department of Pediatrics, University of Washington, Seattle, WA
| | - A Hart
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN.,Department of Medicine, Hennepin Healthcare, Minneapolis, MN
| | - J Miller
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN
| | - M A Skeans
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN
| | - L Larkin
- Organ Procurement and Transplantation Network, United Network for Organ Sharing, Richmond, VA
| | - A Robinson
- Organ Procurement and Transplantation Network, United Network for Organ Sharing, Richmond, VA
| | - K Gauntt
- Organ Procurement and Transplantation Network, United Network for Organ Sharing, Richmond, VA
| | - A K Israni
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN.,Department of Medicine, Hennepin Healthcare, Minneapolis, MN.,Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN
| | - R Hirose
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN.,Department of Surgery, University of California San Francisco, San Fran- cisco, CA
| | - J J Snyder
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN.,Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN
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17
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Amara D, Parekh J, Sudan D, Elias N, Foley DP, Conzen K, Grieco A, Braun HJ, Greenstein S, Byrd C, Ko C, Hirose R. Surgical complications after living and deceased donor liver transplant: The NSQIP transplant experience. Clin Transplant 2022; 36:e14610. [PMID: 35143698 DOI: 10.1111/ctr.14610] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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: 08/12/2021] [Revised: 01/14/2022] [Accepted: 01/31/2022] [Indexed: 12/01/2022]
Abstract
This study used the prospective National Surgical Quality Improvement Program (NSQIP) Transplant pilot database to analyze surgical complications after liver transplantation (LT) in LT recipients from 2017-2019. The primary outcome was surgical complication requiring intervention (Clavien-Dindo grade II or greater) within 90 days of transplant. Of the 1684 deceased donor and 109 living donor LT cases included from 29 centers, 38% of deceased donor liver recipients and 47% of living donor liver recipients experienced a complication. The most common complications included biliary complications (19% DDLT; 31% LDLT), hemorrhage requiring reoperation (14% DDLT; 9% LDLT) and vascular complications (6% DDLT; 9% LDLT). Management of biliary leaks (35.3% ERCP, 38.0% percutaneous drainage, 26.3% reoperation) and vascular complications (36.2% angioplasty/stenting, 31.2% medication, 29.8% reoperation) was variable. Biliary (aHR 5.14, 95% CI 2.69-9.8, p<0.001), hemorrhage (aHR 2.54, 95% CI 1.13-5.7, p = 0.024) and vascular (aHR 2.88, 95% CI 0.85-9.7, p = 0.089) complication status at 30-days post-transplant were associated with lower 1-year patient survival. We conclude that biliary, hemorrhagic and vascular complications continue to be significant sources of morbidity and mortality for LT recipients. Understanding the different risk factors for complications between deceased and living donor liver recipients and standardizing complication management represent avenues for continued improvement. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Dominic Amara
- School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Justin Parekh
- Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Debra Sudan
- Department of Surgery, Duke University, Durham, NC, USA
| | - Nahel Elias
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - David P Foley
- Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Kendra Conzen
- Department of Surgery, University of Colorado, Aurora, CO, USA
| | | | - Hillary J Braun
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | | | | | - Clifford Ko
- American College of Surgeons, Chicago, IL, USA.,Department of Surgery, University of California Los Angeles, Los Angeles, CA, USA.,The Healthcare Improvement Studies Institute (THIS Institute), University of Cambridge, Cambridge, UK
| | - Ryutaro Hirose
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
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18
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Braun HJ, Amara D, Shui AM, Stock PG, Hirose R, Delmonico FL, Ascher NL. International Travel for Liver Transplantation: A Comprehensive Assessment of the Impact on the United States Transplant System. Transplantation 2022; 106:e141-e152. [PMID: 34608102 DOI: 10.1097/tp.0000000000003970] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND International travel for transplantation remains a global issue as countries continue to struggle in establishing self-sufficiency. In the United States, the United Network for Organ Sharing (UNOS) requires citizenship classification at time of waitlisting to remain transparent and understand to whom our organs are allocated. This study provides an assessment of patients who travel internationally for liver transplantation and their outcomes using the current citizenship classification used by UNOS. METHODS Adult liver UNOS data from 2003 to 2019 were used. Patients were identified as citizens, noncitizen, nonresidents (NCNR), or noncitizen residents (NC-R) according to citizenship status. Descriptive statistics compared demographics among the waitlisted patients and demographics and donor characteristics among transplant recipients. A competing risks model was used to examine waitlist outcomes. The Kaplan-Meier method and Cox proportional hazards were used for posttransplant outcomes. RESULTS There were significant demographic differences according to citizenship group among waitlisted (n = 125 652) and transplanted (n = 71 536) patients. Compared with US citizens, NCNR was associated with a 9% increase in transplant (subdistribution hazard ratio [SHR], 1.09; 95% confidence interval [CI], 1.00-1.18; P = 0.04), and NC-R was associated with a 24% decrease in transplant (SHR, 0.76; 95% CI, 0.72-0.79; P < 0.0001) and a 23% increase in death or removal for being too sick (SHR, 1.23; 95% CI, 1.14-1.33; P < 0.0001). US citizens had significantly inferior graft and patient survival (P < 0.001). CONCLUSIONS Though the purpose of the citizenship classification system is transparency, the results of this study highlight significant disparities in the access to and outcomes following liver transplantation according to citizenship status.
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Affiliation(s)
- Hillary J Braun
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Dominic Amara
- School of Medicine, University of California, San Francisco, San Francisco, CA
| | - Amy M Shui
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Peter G Stock
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Ryutaro Hirose
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | | | - Nancy L Ascher
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
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19
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Miller J, Wey A, Valapour M, Hart A, Musgrove D, Hirose R, Ahn YS, Israni AK, Snyder JJ. Impact of COVID-19 pandemic on the size of US transplant waiting lists. Clin Transplant 2022; 36:e14596. [PMID: 35037301 DOI: 10.1111/ctr.14596] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [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: 10/13/2021] [Revised: 01/07/2022] [Accepted: 01/10/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND More patients are waitlisted for solid organs than transplants are performed each year. The COVID-19 pandemic immediately increased waitlist mortality and decreased transplants and listings. METHODS To calculate the number of candidate listings after the pandemic began and short-term changes that may affect waiting time, we conducted a Scientific Registry of Transplant Recipients surveillance study from January 1, 2012, to February 28, 2021. RESULTS The number of candidates on the liver waitlist continued a steady decline that began before the pandemic. Numbers of candidates on the kidney, heart, and lung waitlists decreased dramatically. More than 3000 fewer candidates were awaiting a kidney transplant on March 7, 2021, than on March 8, 2020. Listings and removals decreased for each solid organ beginning in March 2020. The number of heart and lung listings returned to equal or above that of removals. Listings for kidney transplant, which is often less urgent than heart and lung transplant, remain below numbers of removals. Removals due to transplant decreased for all organs, while removals due to death increased for only kidneys. CONCLUSIONS We found no evidence of the predicted surge in listings for solid organ transplant with a plateau or control of the pandemic. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Jonathan Miller
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute
| | - Andrew Wey
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute
| | - Maryam Valapour
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute.,Department of Pulmonary Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Allyson Hart
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute.,Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota
| | - Donald Musgrove
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute
| | - Ryutaro Hirose
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute.,Department of Surgery, University of California San Francisco, San Francisco, California
| | - Yoon Son Ahn
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute
| | - Ajay K Israni
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute.,Department of Pulmonary Medicine, Cleveland Clinic, Cleveland, Ohio.,Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota
| | - Jon J Snyder
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute.,Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota
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20
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Meier RPH, Kelly Y, Yamaguchi S, Braun HJ, Lunow-Luke T, Adelmann D, Niemann C, Maluf DG, Dietch ZC, Stock PG, Kang SM, Feng S, Posselt AM, Gardner JM, Syed SM, Hirose R, Freise CE, Ascher NL, Roberts JP, Roll GR. Advantages and Limitations of Clinical Scores for Donation After Circulatory Death Liver Transplantation. Front Surg 2022; 8:808733. [PMID: 35071316 PMCID: PMC8766343 DOI: 10.3389/fsurg.2021.808733] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/09/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Scoring systems have been proposed to select donation after circulatory death (DCD) donors and recipients for liver transplantation (LT). We hypothesized that complex scoring systems derived in large datasets might not predict outcomes locally. Methods: Based on 1-year DCD-LT graft survival predictors in multivariate logistic regression models, we designed, validated, and compared a simple index using the University of California, San Francisco (UCSF) cohort (n = 136) and a universal-comprehensive (UC)-DCD score using the United Network for Organ Sharing (UNOS) cohort (n = 5,792) to previously published DCD scoring systems. Results: The total warm ischemia time (WIT)-index included donor WIT (dWIT) and hepatectomy time (dHep). The UC-DCD score included dWIT, dHep, recipient on mechanical ventilation, transjugular-intrahepatic-portosystemic-shunt, cause of liver disease, model for end-stage liver disease, body mass index, donor/recipient age, and cold ischemia time. In the UNOS cohort, the UC-score outperformed all previously published scores in predicting DCD-LT graft survival (AUC: 0.635 vs. ≤0.562). In the UCSF cohort, the total WIT index successfully stratified survival and biliary complications, whereas other scores did not. Conclusion: DCD risk scores generated in large cohorts provide general guidance for safe recipient/donor selection, but they must be tailored based on non-/partially-modifiable local circumstances to expand DCD utilization.
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Affiliation(s)
- Raphael P. H. Meier
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
- Department of Surgery, University of Maryland, Baltimore, MD, United States
| | - Yvonne Kelly
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Seiji Yamaguchi
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Hillary J. Braun
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Tyler Lunow-Luke
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Dieter Adelmann
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
- Department of Anesthesia, University of California, San Francisco, San Francisco, CA, United States
| | - Claus Niemann
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
- Department of Anesthesia, University of California, San Francisco, San Francisco, CA, United States
| | - Daniel G. Maluf
- Department of Surgery, University of Maryland, Baltimore, MD, United States
| | - Zachary C. Dietch
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Peter G. Stock
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Sang-Mo Kang
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Sandy Feng
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Andrew M. Posselt
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - James M. Gardner
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Shareef M. Syed
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Ryutaro Hirose
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Chris E. Freise
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Nancy L. Ascher
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - John P. Roberts
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Garrett R. Roll
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
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21
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Abstract
PURPOSE OF REVIEW Seven years have passed since the implementation of the kidney allocation policy by the Organ Procurement and Transplantation Network in the United States, the purpose of this article is to review the impact of these policy changes in addressing disparity and inequities in access to transplantation as well as to assess future directions needed in achieving equity in kidney transplantation. RECENT FINDINGS The 2014 kidney allocation system policy aimed to improve access to transplantation through various approaches by reducing organ/recipient longevity mismatches, prioritizing highly sensitized patients, and backdating waitlist time to start of dialysis. The policy however did not improve utilization of high-kidney donor profile index kidneys or decrease kidney discard rate. SUMMARY Although the supply-to-demand gap for waitlisted patients has decreased there are several areas that need further investigation, including geographic disparity, barriers in referral for transplantation, evaluating the impact of transplant education, and transplant center waitlist practices on inequities that exist in the prewaitlist stage that impact access to transplantation.
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Affiliation(s)
- Mignote Yilma
- Department of Surgery, University of California, San Francisco, California, USA
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22
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Miller J, Wey A, Musgrove D, Son Ahn Y, Hart A, Kasiske BL, Hirose R, Israni AK, Snyder JJ. Mortality among solid organ waitlist candidates during COVID-19 in the United States. Am J Transplant 2021; 21:2262-2268. [PMID: 33621421 PMCID: PMC8014331 DOI: 10.1111/ajt.16550] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [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: 11/10/2020] [Revised: 02/12/2021] [Accepted: 02/15/2021] [Indexed: 02/06/2023]
Abstract
We examined the effects of COVID-19 on solid organ waiting list mortality in the United States and compared effects across patient demographics (e.g., race, age, and sex) and donation service areas. Three separate piecewise exponential survival models estimated for each solid organ the overall, demographic-specific, and donation service area-specific differences in the hazard of waitlist mortality before and after the national emergency declaration on March 13, 2020. Kidney waiting list mortality was higher after than before the national emergency (adjusted hazard ratio [aHR], 1.37; 95% CI, 1.23-1.52). The hazard of waitlist mortality was not significantly different before and after COVID-19 for liver (aHR, 0.94), pancreas (aHR, 1.01), lung (aHR, 1.00), and heart (aHR, 0.94). Kidney candidates had notable variability in differences across donation service areas (aHRs, New York City, 2.52; New Jersey, 1.84; and Michigan, 1.56). The only demographic group with increased waiting list mortality were Blacks versus Whites (aHR, 1.41; 95% CI, 1.07-1.86) for kidney candidates. The first 10 weeks after the declaration of a national emergency had a heterogeneous effect on waitlist mortality rate, varying by geography and ethnicity. This heterogeneity will complicate comparisons of transplant program performance during COVID-19.
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Affiliation(s)
- Jonathan Miller
- Scientific Registry of Transplant RecipientsHennepin Healthcare Research InstituteMinneapolisMinnesotaUSA
| | - Andrew Wey
- Scientific Registry of Transplant RecipientsHennepin Healthcare Research InstituteMinneapolisMinnesotaUSA
| | - Donald Musgrove
- Scientific Registry of Transplant RecipientsHennepin Healthcare Research InstituteMinneapolisMinnesotaUSA
| | - Yoon Son Ahn
- Scientific Registry of Transplant RecipientsHennepin Healthcare Research InstituteMinneapolisMinnesotaUSA
| | - Allyson Hart
- Scientific Registry of Transplant RecipientsHennepin Healthcare Research InstituteMinneapolisMinnesotaUSA,Department of MedicineHennepin HealthcareUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Bertram L. Kasiske
- Scientific Registry of Transplant RecipientsHennepin Healthcare Research InstituteMinneapolisMinnesotaUSA,Department of MedicineHennepin HealthcareUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Ryutaro Hirose
- Department of SurgeryUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Ajay K. Israni
- Scientific Registry of Transplant RecipientsHennepin Healthcare Research InstituteMinneapolisMinnesotaUSA,Department of MedicineHennepin HealthcareUniversity of MinnesotaMinneapolisMinnesotaUSA,Department of Epidemiology and Community HealthUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Jon J. Snyder
- Scientific Registry of Transplant RecipientsHennepin Healthcare Research InstituteMinneapolisMinnesotaUSA,Department of Epidemiology and Community HealthUniversity of MinnesotaMinneapolisMinnesotaUSA
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23
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Wisel SA, Thiessen C, Day R, Belin LJ, Syed SM, Hirose R, Ascher N, Roberts JP, Freise CE. Setting rules for the sandbox: A response to "Successfully sharing the sandbox: A perspective on combined DCD liver and heart donor procurement". Am J Transplant 2021; 21:1981-1982. [PMID: 33277813 DOI: 10.1111/ajt.16426] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/11/2020] [Accepted: 11/27/2020] [Indexed: 01/25/2023]
Affiliation(s)
- Steven A Wisel
- University of California at San Francisco, San Francisco, California
| | - Carrie Thiessen
- University of California at San Francisco, San Francisco, California
| | - Ryan Day
- University of California at San Francisco, San Francisco, California
| | - L Justin Belin
- University of California at San Francisco, San Francisco, California
| | - Shareef M Syed
- University of California at San Francisco, San Francisco, California
| | - Ryutaro Hirose
- University of California at San Francisco, San Francisco, California
| | - Nancy Ascher
- University of California at San Francisco, San Francisco, California
| | - John P Roberts
- University of California at San Francisco, San Francisco, California
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24
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Schwab ME, Braun HJ, Quan D, Roll GR, Budanova N, Ascher NL, Hirose R. Standardizing Discharge Opioid Prescriptions in Kidney Transplant Patients Decreases Opioid Usage. J Surg Res 2021; 265:153-158. [PMID: 33940238 DOI: 10.1016/j.jss.2021.03.038] [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: 11/10/2020] [Revised: 03/02/2021] [Accepted: 03/23/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Kidney transplant recipients are frequently prescribed excess opioids at discharge relative to their inpatient requirements. Recipients who fill prescriptions after transplant have an increased risk of death and graft loss. This study examined the impact of standardized prescriptions on discharge amount and number of outpatient refills. MATERIALS AND METHODS A historical cohort (Group 1) was compared to a cohort without patient-controlled analgesia (Group 2) and a cohort in which providers prescribed no opioids to patients who required none on the day prior to discharge, and 10 pills to those who required opioids on the day prior (Group 3). Demographics, oral morphine equivalents (OMEs) prescribed on the day prior to and at discharge, and outpatient refills were collected. RESULTS 270 recipients were included. There was a nonsignificant trend towards lower OMEs on the day prior to discharge in Groups 2 and 3. Nonopioid adjunct use increased (P < 0.001). Discharge OMEs significantly decreased (mean 87.2 in Group 1, 62.8 in Group 2, 26.6 in Group 3, P< 0.001). The number of patients discharged without opioids increased (23.8% of Group 1, 37.5% of Group 2, 60.6% of Group 3, P < 0.001). Group 3, Asian descent, and lower OMEs on the day prior were factors significantly associated with decreased discharge OMEs on multivariable linear regression. Twelve percent of Group 2 and 2% of Group 3 patients received an outpatient refill (P = 0.02). CONCLUSIONS A protocol targeting discharge opioids significantly reduced the amount of opioids prescribed in kidney transplant recipients; most patients subsequently received no opioids at discharge.
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Affiliation(s)
- Marisa Eve Schwab
- Department of Surgery, Division of Transplantation, University of California San Francisco, CA
| | - Hillary J Braun
- Department of Surgery, Division of Transplantation, University of California San Francisco, CA
| | - David Quan
- Department of Surgery, Division of Transplantation, University of California San Francisco, CA
| | - Garrett R Roll
- Department of Surgery, Division of Transplantation, University of California San Francisco, CA
| | - Nataliya Budanova
- Department of Surgery, Division of Transplantation, University of California San Francisco, CA
| | - Nancy L Ascher
- Department of Surgery, Division of Transplantation, University of California San Francisco, CA
| | - Ryutaro Hirose
- Department of Surgery, Division of Transplantation, University of California San Francisco, CA.
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25
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Braun HJ, Dodge JL, Grab JD, Glencer AC, Schwab ME, Stock PG, Hirose R, Roberts JP, Ascher NL. Live Donor Liver Transplantation in the United States: Impact of Share 35 on Live Donor Utilization. Transplantation 2021; 105:824-831. [PMID: 32433235 PMCID: PMC7980785 DOI: 10.1097/tp.0000000000003318] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Share 35 was a policy implemented in 2013 to increase regional sharing of deceased donor livers to patients with model for end-stage liver disease ≥ 35 to decrease waitlist mortality for the sickest patients awaiting liver transplantation (LT). The purpose of this study was to determine whether live donor liver transplantation (LDLT) volume was impacted by the shift in allocation of deceased donor livers to patients with higher model for end-stage liver disease scores. METHODS Using Network for Organ Sharing/Organ Procurement and Transplantation Network Standard Transplant Analysis and Research files, we identified all adults who received a primary LT between October 1, 2008, and March 31, 2018. LT from October 1, 2008, through June 30, 2013, was designated as the pre-Share 35 era and July 1, 2013, through March 31, 2018, as the post-Share 35 era. Primary outcomes included transplant volumes, graft survival, and patient survival in both eras. RESULTS In total, 48 779 primary adult single-organ LT occurred during the study period (22 255 pre-Share 35, 26 524 post). LDLT increased significantly (6.8% post versus 5.7% pre, P < 0.001). LDLT volume varied significantly by region (P < 0.001) with regions 2, 4, 5, and 8 demonstrating significant increases in LDLT volume post-Share 35. The number of centers performing LDLT increased only in regions 4, 6, and 11. Throughout the 2 eras, there was no difference in graft or patient survival for LDLT recipients. CONCLUSIONS Overall, LDLT volume increased following the implementation of Share 35, which was largely due to increased LDLT volume at centers with experience in LDLT, and corresponded to significant geographic variation in LDLT utilization.
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Affiliation(s)
- Hillary J. Braun
- Department of Surgery, Division of Transplantation, University of California, San Francisco, San Francisco, CA, USA
| | - Jennifer L. Dodge
- Department of Surgery, Division of Transplantation, University of California, San Francisco, San Francisco, CA, USA
| | - Joshua D. Grab
- Department of Surgery, Division of Transplantation, University of California, San Francisco, San Francisco, CA, USA
| | - Alexa C. Glencer
- Department of Surgery, Division of Transplantation, University of California, San Francisco, San Francisco, CA, USA
| | - Marisa E. Schwab
- Department of Surgery, Division of Transplantation, University of California, San Francisco, San Francisco, CA, USA
| | - Peter G. Stock
- Department of Surgery, Division of Transplantation, University of California, San Francisco, San Francisco, CA, USA
| | - Ryutaro Hirose
- Department of Surgery, Division of Transplantation, University of California, San Francisco, San Francisco, CA, USA
| | - John P. Roberts
- Department of Surgery, Division of Transplantation, University of California, San Francisco, San Francisco, CA, USA
| | - Nancy L. Ascher
- Department of Surgery, Division of Transplantation, University of California, San Francisco, San Francisco, CA, USA
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26
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Hart A, Lentine KL, Smith JM, Miller JM, Skeans MA, Prentice M, Robinson A, Foutz J, Booker SE, Israni AK, Hirose R, Snyder JJ. OPTN/SRTR 2019 Annual Data Report: Kidney. Am J Transplant 2021; 21 Suppl 2:21-137. [PMID: 33595191 DOI: 10.1111/ajt.16502] [Citation(s) in RCA: 238] [Impact Index Per Article: 79.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Despite the ongoing severe shortage of available kidney grafts relative to candidates in need, data from 2019 reveal some promising trends. After remaining relatively stagnant for many years, the number of kidney transplants has increased each year since 2015, reaching the highest annual count to date of 24,273 in 2019. The number of patients waiting for a kidney transplant in the United States was relatively stable, despite an increase in the number of new candidates added in 2019 and a decrease in patients removed from the waiting list owing to death or deteriorating medical condition. However, these encouraging trends are tempered by ongoing challenges. Nationwide, only a quarter of waitlisted patients receive a deceased-donor kidney transplant within 5 years, and this proportion varies dramatically by donation service area, from 15.5% to 67.8%. The non-utilization (discard) rate of recovered organs remains at 20.1%, despite adramatic decline in the discard of organs from hepatitis C-positive donors. Non-utilization rates remain particularly high for Kidney Donor Profile Index ≥85% kidneys and kidneys from which a biopsy specimen was obtained. While the number of living-donor transplants increased again in 2019, only a small proportion of the waiting list receives living-donor transplants each year, and racial disparities in living-donor transplant access persist. As both graft and patient survival continue to improve incrementally, the total number of living kidney transplant recipients with a functioning graft is anticipated to exceed 250,000 in the next 1-2 years. Over the past decade, the total number of pediatric kidney transplants performed has remained stable. Despite numerous efforts, living donor kidney transplant remains low among pediatric recipients with continued racial disparities among recipients. Congenital anomalies of the kidney and urinary tract remain the leading cause of kidney disease. While most deceased donor recipients receive a kidney from a donor with KDPI less than 35%, the majority of pediatric recipients had four or more HLA mismatches. Graft survival continues to improve with superior outcomes for living donor recipients.
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Affiliation(s)
- A Hart
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN.,Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, MN
| | - K L Lentine
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN.,Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, MO
| | - J M Smith
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN.,Department of Pediatrics, University of Washington, Seattle, WA
| | - J M Miller
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN
| | - M A Skeans
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN
| | - M Prentice
- Organ Procurement and Transplantation Network, United Network for Organ Sharing, Richmond, VA
| | - A Robinson
- Organ Procurement and Transplantation Network, United Network for Organ Sharing, Richmond, VA
| | - J Foutz
- Organ Procurement and Transplantation Network, United Network for Organ Sharing, Richmond, VA
| | - S E Booker
- Organ Procurement and Transplantation Network, United Network for Organ Sharing, Richmond, VA
| | - A K Israni
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN.,Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, MN.,Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN
| | - R Hirose
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN.,Department Surgery, University of California San Francisco, San Francisco, CA
| | - J J Snyder
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN.,Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN
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27
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Gomez A, Wisneski AD, Luu HY, Hirose K, Roberts JP, Hirose R, Freise CE, Nakakura EK, Corvera CU. Contemporary Management of Hepatic Cyst Disease: Techniques and Outcomes at a Tertiary Hepatobiliary Center. J Gastrointest Surg 2021; 25:77-84. [PMID: 33083858 PMCID: PMC7850990 DOI: 10.1007/s11605-020-04821-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 10/01/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Hepatic cyst disease is often asymptomatic, but treatment is warranted if patients experience symptoms. We describe our management approach to these patients and review the technical nuances of the laparoscopic approach. METHODS Medical records were reviewed for operative management of hepatic cysts from 2012 to 2019 at a single, tertiary academic medical center. RESULTS Fifty-three patients (39 female) met the inclusion criteria with median age at presentation of 65 years. Fifty cases (94.3%) were performed laparoscopically. Fourteen patients carried diagnosis of polycystic liver disease. Dominant cyst diameter was median 129 mm and located within the right lobe (30), left lobe (17), caudate (2), or was bilobar (4). Pre-operative concern for biliary cystadenoma/cystadenocarcinoma existed for 7 patients. Operative techniques included fenestration (40), fenestration with decapitation (7), decapitation alone (3), and excision (2). Partial hepatectomy was performed in conjunction with fenestration/decapitation for 15 cases: right sided (7), left sided (7), and central (1). One formal left hepatectomy was performed in a polycystic liver disease patient. Final pathology yielded simple cyst (52) and one biliary cystadenoma. Post-operative complications included bile leak (2), perihepatic fluid collection (1), pleural effusion (1), and ascites (1). At median 7.1-month follow-up, complete resolution of symptoms occurred for 34/49 patients (69.4%) who had symptoms preoperatively. Reintervention for cyst recurrence occurred for 5 cases (9.4%). CONCLUSIONS Outcomes for hepatic cyst disease are described with predominantly laparoscopic approach, approach with minimal morbidity, and excellent clinical results.
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Affiliation(s)
- Axel Gomez
- Department of Surgery, University of California San Francisco, 533 Parnassus Avenue, Room 370, San Francisco, CA, USA
| | - Andrew D Wisneski
- Department of Surgery, University of California San Francisco, 533 Parnassus Avenue, Room 370, San Francisco, CA, USA
| | - Hubert Y Luu
- Department of Surgery, University of California San Francisco, 533 Parnassus Avenue, Room 370, San Francisco, CA, USA
| | - Kenzo Hirose
- Department of Surgery, University of California San Francisco, 533 Parnassus Avenue, Room 370, San Francisco, CA, USA
| | - John P Roberts
- Department of Surgery, University of California San Francisco, 533 Parnassus Avenue, Room 370, San Francisco, CA, USA
| | - Ryutaro Hirose
- Department of Surgery, University of California San Francisco, 533 Parnassus Avenue, Room 370, San Francisco, CA, USA
| | - Christopher E Freise
- Department of Surgery, University of California San Francisco, 533 Parnassus Avenue, Room 370, San Francisco, CA, USA
| | - Eric K Nakakura
- Department of Surgery, University of California San Francisco, 533 Parnassus Avenue, Room 370, San Francisco, CA, USA
| | - Carlos U Corvera
- Department of Surgery, University of California San Francisco, 533 Parnassus Avenue, Room 370, San Francisco, CA, USA.
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28
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Braun HJ, Schwab MP, Jin C, Amara D, Mehta NJ, Grace TR, Croci R, Freise CE, Roberts JP, Hirose R, Ascher NL. Opioid use prior to liver transplant is associated with increased risk of death after transplant. Am J Surg 2020; 222:234-240. [PMID: 33384155 DOI: 10.1016/j.amjsurg.2020.11.039] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 11/12/2020] [Accepted: 11/16/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Opioids are generally discouraged and used sparingly in liver transplant (LT) candidates prior to LT. This study examined the relationship between opioid use at the time of LT and graft and patient survival following transplantation. METHODS A retrospective single center cohort study of LT recipients from June 2012 to December 2019 was performed. Primary outcomes were graft and patient survival, analyzed with the Kaplan-Meier method and Cox proportional hazards models; primary predictor was active opioid prescription at LT. RESULTS 751 LT recipients were included; 16% had an opioid prescription at LT. Post-transplant death was significantly greater in opioid users (pvalue<0.001). In a multivariable Cox model examining predictors of death, opioid use remained associated with a significant increase in the risk of death (HR 2.4 CI 1.5-4.0, p < 0.001) even after controlling for other factors. CONCLUSION Opioid use at LT is associated with a markedly increased risk of death following transplant.
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Affiliation(s)
- Hillary J Braun
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Marisa P Schwab
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Chengshi Jin
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Dominic Amara
- School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Neil J Mehta
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Trevor R Grace
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Rhiannon Croci
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Chris E Freise
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - John P Roberts
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Ryutaro Hirose
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Nancy L Ascher
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA.
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29
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Boyarsky BJ, Werbel WA, Durand CM, Avery RK, Jackson KR, Kernodle AB, Snyder J, Hirose R, Massie IM, Garonzik-Wang JM, Segev DL, Massie AB. Early national and center-level changes to kidney transplantation in the United States during the COVID-19 epidemic. Am J Transplant 2020; 20:3131-3139. [PMID: 32594606 PMCID: PMC7361931 DOI: 10.1111/ajt.16167] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 06/01/2020] [Accepted: 06/18/2020] [Indexed: 01/25/2023]
Abstract
In March 2020, coronavirus disease 2019 (COVID-19) spread rapidly nationally, causing widespread emergent changes to the health system. Our goal was to understand the impact of the epidemic on kidney transplantation (KT), at both the national and center levels, accounting statistically for waitlist composition. Using Scientific Registry of Transplant Recipients data, we compared data on observed waitlist registrations, waitlist mortality, and living-donor and deceased-donor kidney transplants (LDKT/DDKT) March 15-April 30, 2020 to expected events calculated from preepidemic data January 2016-February 2020. There were few changes before March 15, at which point the number of new listings/DDKT/LDKT dropped to 18%/24%/87% below the expected value (all P < .001). Only 12 centers performed LDKT March 15-31; by April 30, 40 centers had resumed LDKT. The decline in new listings and DDKT was greater among states with higher per capita confirmed COVID-19 cases. The number of waitlist deaths was 2.2-fold higher than expected in the 5 states with highest COVID-19 burden (P < .001). DCD DDKT and regional/national imports declined nationwide but most steeply in states with the highest COVID-19 burden. The COVID-19 epidemic has resulted in substantial changes to KT; we must adapt and learn rapidly to continue to provide safe access to transplantation and limit the growing indirect toll of an already deadly disease.
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Affiliation(s)
- Brian J. Boyarsky
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - William A. Werbel
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christine M. Durand
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Robin K. Avery
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kyle R. Jackson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Amber B. Kernodle
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jon Snyder
- Scientific Registry of Transplant Recipients, Minneapolis, Minnesota, USA
| | - Ryutaro Hirose
- Department of Surgery, University of California, San Francisco, California, USA
| | | | | | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
- Scientific Registry of Transplant Recipients, Minneapolis, Minnesota, USA
| | - Allan B. Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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30
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Amara D, Braun HJ, Jin C, Parekh J, Paul Foley D, Mark Greenstein S, Stock PG, Hirose R. Beyond Death and Graft Survival: Understanding 30-Day Readmission Rates from Kidney Transplantation. Results from the NSQIP Transplant Beta Phase. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.07.406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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31
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Zarinsefat A, Gulati A, Hirose R, Ascher NL, Tavakol M, Rogers R, Stock PG. Successful Long-Term Outcomes in HIV-Infected Transplant Recipients: Overcoming Hepatitis C. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.07.415] [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: 10/23/2022]
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32
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Snyder JJ, Musgrove D, Zaun D, Wey A, Salkowski N, Rosendale J, Israni AK, Hirose R, Kasiske BL. The Centers for Medicare and Medicaid Services' proposed metrics for recertification of organ procurement organizations: Evaluation by the Scientific Registry of Transplant Recipients. Am J Transplant 2020; 20:2466-2480. [PMID: 32157810 DOI: 10.1111/ajt.15842] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [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: 01/30/2020] [Revised: 01/30/2020] [Accepted: 02/23/2020] [Indexed: 01/25/2023]
Abstract
On December 23, 2019, the US Centers for Medicare and Medicaid Services proposed 2 new standards that organ procurement organizations (OPOs) must meet for recertification. An OPO's organ donation rate (deceased donors/potential donors) and organ transplant rate (organs transplanted/potential donors) must not fall significantly below the 75th percentile for rates among all OPOs. We examined how OPOs would have fared under the proposed performance standards in 2016-2017. Data on donors and transplants were from the Organ Procurement and Transplantation Network; donor potential was estimated from Detailed Multiple Cause of Death data collected by the Centers for Disease Control and Prevention. In 2017, 31 (53%) OPOs failed to meet the proposed donation rate standard, 36 (62%) failed to meet the proposed organ transplant rate standard, and 37 (64%) failed at least 1 standard. We found that adjusting for age, race, and Hispanic ethnicity altered the evaluation: 8 OPOs changed their pass/fail status for the donation rate and 5 for the proposed organ transplant rate standard. We conclude that the proposed new standards may result in over half of OPOs facing decertification, and risk adjustment suggests that underlying characteristics of deaths vary regionally such that decertification decisions may be affected.
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Affiliation(s)
- Jon J Snyder
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA.,Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Donald Musgrove
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - David Zaun
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - Andrew Wey
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - Nicholas Salkowski
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - John Rosendale
- Organ Procurement and Transplantation Network, United Network for Organ Sharing, Richmond, Virginia, USA
| | - Ajay K Israni
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA.,Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ryutaro Hirose
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA.,Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Bertram L Kasiske
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA.,Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
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33
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Roll GR, Posselt AM, Freise J, Baird J, Syed S, Mo Kang S, Hirose R, Szot GL, Zarinsefat A, Feng S, Worner G, Sarwal M, Stock PG. Long-term follow-up of beta cell replacement therapy in 10 HIV-infected patients with renal failure secondary to type 1 diabetes mellitus. Am J Transplant 2020; 20:2091-2100. [PMID: 31994295 PMCID: PMC7650842 DOI: 10.1111/ajt.15796] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 01/16/2020] [Accepted: 01/17/2020] [Indexed: 01/25/2023]
Abstract
The approach to transplantation in human immunodeficiency virus (HIV)-positive patients has been conservative due to fear of exacerbating an immunocompromised condition. As a result, HIV-positive patients with diabetes were initially excluded from beta cell replacement therapy. Early reports of pancreas transplant in patients with HIV described high rates of early graft loss with limited follow-up. We report long-term follow-up of islet or pancreas transplantation in HIV-positive type 1 diabetic patients who received a kidney transplant concurrently or had previously undergone kidney transplantation. Although 4 patients developed polyoma viremia, highly active antiretroviral therapy and adequate infectious prophylaxis were successful in providing protection until CD4+ counts recovered. Coordination with HIV providers is critical to reduce the risk of rejection by minimizing drug-drug interactions. Also, protocols for prophylaxis of opportunistic infections and strategies for monitoring and treating BK viremia are important given the degree of immunosuppression required. This series demonstrates that type 1 diabetic patients with well-controlled HIV and renal failure can be appropriate candidates for beta cell replacement, with a low rate of infectious complications, early graft loss, and rejection, so excellent long-term graft survival is possible. Additionally, patients with HIV and cardiovascular contraindications can undergo islet infusion.
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Affiliation(s)
- Garrett R Roll
- Department of Surgery, Division of Transplantation, University of California San Francisco, San Francisco, California
| | - Andrew M Posselt
- Department of Surgery, Division of Transplantation, University of California San Francisco, San Francisco, California
| | - Jonathan Freise
- School of Medicine, University of California San Francisco, San Francisco, California
| | - Julia Baird
- Department of Surgery, Division of Transplantation, University of California San Francisco, San Francisco, California
| | - Shareef Syed
- Department of Surgery, Division of Transplantation, University of California San Francisco, San Francisco, California
| | - Sang Mo Kang
- Department of Surgery, Division of Transplantation, University of California San Francisco, San Francisco, California
| | - Ryutaro Hirose
- Department of Surgery, Division of Transplantation, University of California San Francisco, San Francisco, California
| | - Gregory L Szot
- Department of Surgery, Division of Transplantation, University of California San Francisco, San Francisco, California
| | - Arya Zarinsefat
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Sandy Feng
- Department of Surgery, Division of Transplantation, University of California San Francisco, San Francisco, California
| | - Giulia Worner
- Department of Surgery, Division of Transplantation, University of California San Francisco, San Francisco, California
| | - Minnie Sarwal
- Department of Surgery, Division of Transplantation, University of California San Francisco, San Francisco, California
| | - Peter G Stock
- Department of Surgery, Division of Transplantation, University of California San Francisco, San Francisco, California
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34
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Brondfield MN, Dodge JL, Hirose R, Heimbach J, Yao FY, Mehta N. Unfair Advantages for Hepatocellular Carcinoma Patients Listed for Liver Transplant in Short-Wait Regions Following 2015 Hepatocellular Carcinoma Policy Change. Liver Transpl 2020; 26:662-672. [PMID: 31833634 PMCID: PMC8751234 DOI: 10.1002/lt.25701] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 12/05/2019] [Indexed: 02/07/2023]
Abstract
For patients with hepatocellular carcinoma (HCC) listed for liver transplantation (LT), United Network for Organ Sharing (UNOS) enacted policy changes in 2015 to improve equity between HCC and non-HCC patients. We evaluated the impact of these changes on regional disparities in wait-list dropout and LT. We included patients in the UNOS database listed with Model for End-Stage Liver Disease HCC exceptions in long-wait regions (LWRs), mid-wait regions (MWRs), and short-wait regions (SWRs) before these policy changes (era 1, January 1 to December 31, 2013) and after (era 2, October 7, 2015, to October 7, 2016). Cumulative incidence of wait-list dropout and LT were evaluated using competing risk regression. Median time to LT increased by 3.6 months (3.1 to 6.7 months) in SWRs and 1.3 months (6.9 to 8.2 months) in MWRs (P < 0.001), with a slight decrease in LWRs (13.4 to 12.9 months; P = 0.02). The 2-year cumulative incidence of dropout increased from 9.7% to 14.8% in SWRs (P = 0.03) and from 18.9% to 22.6% in MWRs (P = 0.18) but decreased in LWRs from 26.7% to 24.8% (P = 0.31). Factors predicting wait-list dropout included listing in era 2 (hazard ratio [HR], 1.17), in LWRs (HR, 2.56), and in MWRs (HR, 1.91). Regional differences in wait-list outcomes decreased with policy changes, but HCC patients in SWRs remain advantaged. Recent policy change may narrow these disparities.
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Affiliation(s)
| | - Jennifer L. Dodge
- Division of Transplant Surgery, Department of Surgery University of California, San Francisco, CA
| | - Ryutaro Hirose
- Division of Transplant Surgery, Department of Surgery University of California, San Francisco, CA
| | - Julie Heimbach
- Division of Transplantation, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Francis Y. Yao
- Division of Transplant Surgery, Department of Surgery University of California, San Francisco, CA;,Division of Gastroenterology, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Neil Mehta
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, San Francisco, CA
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35
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Gao Y, Twigg AR, Hirose R, Roll GR, Nowacki AS, Maytin EV, Vidimos AT, Rajalingam R, Arron ST. Association of HLA Antigen Mismatch With Risk of Developing Skin Cancer After Solid-Organ Transplant. JAMA Dermatol 2020; 155:307-314. [PMID: 30673077 DOI: 10.1001/jamadermatol.2018.4983] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Importance Risk factors for the development of skin cancer after solid-organ transplant can inform clinical care, but data on these risk factors are limited. Objective To study the association between HLA antigen mismatch and skin cancer incidence after solid-organ transplant. Design, Setting, and Participants This retrospective cohort study is a secondary analysis of the multicenter Transplant Skin Cancer Network study of 10 649 adults who underwent a primary solid-organ transplant between January 1, 2003, and December 31, 2003, or between January 1, 2008, and December 31, 2008. These participants were identified through the Scientific Registry of Transplant Recipients standard analysis files, which contain data collected mostly by the Organ Procurement and Transplantation Network. Participants were matched to skin cancer outcomes by medical record review. This study was conducted from August 1, 2016, to July 31, 2017. Main Outcomes and Measures The primary outcome was time to diagnosis of posttransplant skin cancer, including squamous cell carcinoma, melanoma, and Merkel cell carcinoma. The HLA antigen mismatch was calculated based on the 2016 Organ Procurement and Transplantation Network guidelines. Risk of skin cancer was analyzed using a multivariate Cox proportional hazards regression model. Results In total, 10 649 organ transplant recipients (6776 men [63.6%], with a mean [SD] age of 51 [12] years) contributed 59 923 years of follow-up. For each additional mismatched allele, a 7% to 8% reduction in skin cancer risk was found (adjusted hazard ratio [HR], 0.93; 95% CI, 0.87-0.99; P = .01). Subgroup analysis found the protective effect of HLA antigen mismatch to be statistically significant in lung (adjusted HR, 0.70; 95% CI, 0.56-0.87; P = .001) and heart (adjusted HR, 0.75; 95% CI, 0.60-0.93; P = .008) transplant recipients but not for recipients of liver, kidney, or pancreas. The degree of HLA-DR mismatch, but not HLA-A or HLA-B mismatch, was the most statistically significant for skin cancer risk (adjusted HR, 0.85; 95% CI, 0.74-0.97; P = .01). Conclusions and Relevance The HLA antigen mismatch appears to be associated with reductions in the risk of skin cancer after solid-organ transplant among heart and lung transplant recipients; this finding suggests that HLA antigen mismatch activates the tumor surveillance mechanisms that protect against skin cancer in transplant recipients and that skin cancer risk may be higher in patients who received a well-matched organ.
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Affiliation(s)
- Yi Gao
- Department of Medicine, Banner University Medical Center, Phoenix, Arizona
| | - Amanda R Twigg
- Department of Dermatology, University of California, San Francisco, San Francisco
| | - Ryutaro Hirose
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco
| | - Garrett R Roll
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco
| | - Amy S Nowacki
- Department of Quantitative Health Sciences, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Edward V Maytin
- Department of Dermatology, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Allison T Vidimos
- Department of Dermatology, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Raja Rajalingam
- Immunogenetics and Transplantation Laboratory, Department of Surgery, University of California, San Francisco, San Francisco
| | - Sarah T Arron
- Department of Dermatology, University of California, San Francisco, San Francisco
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36
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Parekh JR, Hirose R, Foley DP, Grieco A, Cohen ME, Hall BL, Ko CY, Greenstein S. Beyond death and graft survival-Variation in outcomes after kidney transplantation. Results from the NSQIP Transplant beta phase. Am J Transplant 2019; 19:2622-2630. [PMID: 30980484 DOI: 10.1111/ajt.15391] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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: 11/11/2018] [Revised: 03/12/2019] [Accepted: 03/28/2019] [Indexed: 01/25/2023]
Abstract
The National Surgical Quality Program (NSQIP) Transplant was designed by transplant surgeons from the ground up to track posttransplant outcomes beyond basic recipient and graft survival. After an initial pilot phase, the program has expanded to 29 participating sites and enrolled more than 4300 recipient-donor pairs into the database, including 2876 complete kidney transplant cases. In this analysis, surgical site infection (SSI), urinary tract infection (UTI), and reoperation/intervention were evaluated for kidney transplant recipients. We observed impressive variation in the crude incidence between sites for SSI (0%-17%), UTI (0%-14%), and reoperation/intervention (0%-25%). After adjustment for donor and recipient factors, 2 sites were outliers with respect to their incidence of UTI. For the first time, the field of transplantation has data that demonstrate variation in kidney recipient surgical outcomes between sites. More importantly, NSQIP Transplant provides a powerful platform to improve care beyond basic patient and graft survival.
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Affiliation(s)
- Justin R Parekh
- Department of Surgery, University of California San Diego, San Diego, California
| | - Ryutaro Hirose
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - David P Foley
- School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | | | | | - Bruce L Hall
- American College of Surgeons, Chicago, Illinois.,Washington University in St. Louis, Saint Louis Veterans Affairs Medical Center, St. Louis, Missouri.,Center for Health Policy and the Olin Business School, Washington University in St. Louis, St. Louis, Missouri
| | - Clifford Y Ko
- American College of Surgeons, Chicago, Illinois.,Department of Surgery, University of California Los Angeles David Geffen School of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Stuart Greenstein
- Montefiore Einstein Center for Transplantation, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
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37
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Mehta N, Dodge JL, Hirose R, Roberts JP, Yao FY. Predictors of low risk for dropout from the liver transplant waiting list for hepatocellular carcinoma in long wait time regions: Implications for organ allocation. Am J Transplant 2019; 19:2210-2218. [PMID: 30861298 PMCID: PMC7072024 DOI: 10.1111/ajt.15353] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 02/24/2019] [Accepted: 02/28/2019] [Indexed: 01/25/2023]
Abstract
All patients with hepatocellular carcinoma meeting United Network for Organ Sharing T2 criteria currently receive the same listing priority for liver transplant (LT). A previous study from our center identified a subgroup with a very low risk of waitlist dropout who may not derive immediate LT benefit. To evaluate this issue at a national level, we analyzed within the United Network for Organ Sharing database 2052 patients with T2 hepatocellular carcinoma receiving priority listing from 2011 to 2014 in long wait time regions 1, 5, and 9. Probabilities of waitlist dropout were 18.3% at 1 year and 27% at 2 years. In multivariate analysis, factors associated with a lower risk of waitlist dropout included Model for End-Stage Liver Disease-Na < 15, Child's class A, single 2- to 3-cm lesion, and α-fetoprotein ≤20 ng/mL. The subgroup of 245 (11.9%) patients meeting these 4 criteria at LT listing had a 1-year probability of dropout of 5.5% vs 20% for all others (P < .001). On explant, the low dropout risk group was more likely to have complete tumor necrosis (35.5% vs 24.9%, P = .01) and less likely to exceed Milan criteria (9.9% vs 17.7%, P = .03). We identified a subgroup with a low risk of waitlist dropout who should not receive the same LT listing priority.
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Affiliation(s)
- Neil Mehta
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Jennifer L. Dodge
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, California
| | - Ryutaro Hirose
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, California
| | - John P. Roberts
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, California
| | - Francis Y. Yao
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, San Francisco, California
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, California
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38
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Parekh JR, Greenstein S, Sudan DL, Grieco A, Cohen ME, Hall BL, Ko CY, Hirose R. Beyond death and graft survival-Variation in outcomes after liver transplant. Results from the NSQIP transplant beta phase. Am J Transplant 2019; 19:2108-2115. [PMID: 30887634 DOI: 10.1111/ajt.15357] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 03/10/2019] [Accepted: 03/11/2019] [Indexed: 01/25/2023]
Abstract
The National Surgical Quality Program (NSQIP) Transplant program was designed by transplant surgeons from the ground up to track posttransplant outcomes beyond basic recipient and graft survival. After an initial pilot phase, the program has expanded to 29 participating sites and enrolled more than 4300 recipient-donor pairs into the database, including 1444 completed liver transplant cases. In this analysis, surgical site infection (SSI), urinary tract infection (UTI), and unplanned reoperation/intervention after liver transplantation were evaluated. We observed impressive variation in the crude incidence between sites for SSI (0%-29%), UTI (0%-10%), and reoperation/intervention (0%-57%). After adjustment for donor and recipient factors, at least 1 site was identified as an outlier for each of the analyzed outcomes. For the first time, the field of transplantation has data that demonstrate variation in liver recipient outcomes beyond death and graft survival between sites. More importantly, NSQIP Transplant provides a powerful platform to improve care beyond basic patient and graft survival.
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Affiliation(s)
- Justin R Parekh
- Department of Surgery, University of California San Diego, San Diego, California
| | - Stuart Greenstein
- Montefiore Einstein Center for Transplantation, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Debra L Sudan
- Division of Abdominal Transplant Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | | | | | - Bruce L Hall
- American College of Surgeons, Chicago, Illinois.,Department of Surgery, Washington University in St. Louis, Saint Louis Veterans Affairs Medical Center, St. Louis, Missouri.,Center for Health Policy and the Olin Business School, Washington University in St. Louis, St. Louis, Missouri
| | - Clifford Y Ko
- American College of Surgeons, Chicago, Illinois.,Department of Surgery, University of California Los Angeles David Geffen School of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Ryutaro Hirose
- Department of Surgery, University of California San Francisco, San Francisco, California
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39
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Affiliation(s)
- Ryutaro Hirose
- Department of Surgery, University of California, San Francisco, San Francisco, CA
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40
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Bertsimas D, Kung J, Trichakis N, Wang Y, Hirose R, Vagefi PA. Development and validation of an optimized prediction of mortality for candidates awaiting liver transplantation. Am J Transplant 2019; 19:1109-1118. [PMID: 30411495 DOI: 10.1111/ajt.15172] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [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: 06/18/2018] [Revised: 10/04/2018] [Accepted: 10/22/2018] [Indexed: 01/25/2023]
Abstract
Since 2002, the Model for End-Stage Liver Disease (MELD) has been used to rank liver transplant candidates. However, despite numerous revisions, MELD allocation still does not allow for equitable access to all waitlisted candidates. An optimized prediction of mortality (OPOM) was developed (http://www.opom.online) utilizing machine-learning optimal classification tree models trained to predict a candidate's 3-month waitlist mortality or removal utilizing the Standard Transplant Analysis and Research (STAR) dataset. The Liver Simulated Allocation Model (LSAM) was then used to compare OPOM to MELD-based allocation. Out-of-sample area under the curve (AUC) was also calculated for candidate groups of increasing disease severity. OPOM allocation, when compared to MELD, reduced mortality on average by 417.96 (406.8-428.4) deaths every year in LSAM analysis. Improved survival was noted across all candidate demographics, diagnoses, and geographic regions. OPOM delivered a substantially higher AUC across all disease severity groups. OPOM more accurately and objectively prioritizes candidates for liver transplantation based on disease severity, allowing for more equitable allocation of livers with a resultant significant number of additional lives saved every year. These data demonstrate the potential of machine learning technology to help guide clinical practice, and potentially guide national policy.
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Affiliation(s)
- Dimitris Bertsimas
- Operations Research Center, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Jerry Kung
- Operations Research Center, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Nikolaos Trichakis
- Operations Research Center, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Yuchen Wang
- Operations Research Center, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Ryutaro Hirose
- Department of Surgery, University of California, San Francisco, California
| | - Parsia A Vagefi
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
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41
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Mehta N, Dodge JL, Roberts JP, Hirose R, Yao FY. Alpha-Fetoprotein Decrease from > 1,000 to < 500 ng/mL in Patients with Hepatocellular Carcinoma Leads to Improved Posttransplant Outcomes. Hepatology 2019; 69:1193-1205. [PMID: 30548884 PMCID: PMC7087461 DOI: 10.1002/hep.30413] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 09/23/2018] [Indexed: 12/13/2022]
Abstract
High alpha-fetoprotein (AFP) > 1,000 ng/mL is associated with poor outcomes after liver transplantation (LT) for hepatocellular carcinoma (HCC). A new national policy has been implemented for AFP > 1,000 ng/mL requiring a decrease to < 500 ng/mL before LT, but there is a paucity of data on the optimal AFP threshold before LT. We aimed to evaluate the effects of a reduction in AFP from > 1,000 ng/mL to different AFP thresholds before LT on survival and HCC recurrence after LT using the United Network for Organ Sharing database. We identified 407 patients who underwent transplant between January 2005 and September 2015 and who had AFP > 1,000 ng/mL at least once before LT. The last AFP measurement before LT was > 1,000 ng/mL in 72.0%, decreased from > 1,000 to 101-499 ng/mL in 9.6%, and decreased to ≤ 100 ng/mL in 14.3%. Local-regional therapy was not performed in 45.4% of patients with AFP > 1,000 ng/mL at LT versus 12.8% of those with AFP of 101-499 ng/mL and 10.3% of those with AFP ≤ 100 ng/mL at LT (P < 0.001). Kaplan-Meier 5-year post-LT survival for those with AFP > 1,000 ng/mL at LT was 48.8% versus 67.0% for those with a decrease in AFP to 101-499 ng/mL (P < 0.001) and 88.4% for those with AFP ≤ 100 ng/mL at LT (P < 0.001). HCC recurrence probability at 5 years was 35.0% for patients with AFP > 1,000 ng/mL versus 13.3% for patients with AFP of 101-499 ng/mL and 7.2% for patients with AFP ≤ 100 ng/mL at LT (P < 0.001). In multivariable analysis, a decrease in the AFP to 101-499 ng/mL was associated with a > 2-fold reduction in posttransplant mortality (P = 0.01) and a nearly 3-fold reduction in HCC recurrence (P = 0.02) compared with AFP > 1,000 ng/mL at LT. Conclusion: Our results demonstrated significantly improved post-LT outcomes when restricting LT to patients with a reduction in AFP from > 1,000 to < 500 ng/mL, validating the recently implemented national policy.
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Affiliation(s)
- Neil Mehta
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Jennifer L. Dodge
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - John P. Roberts
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Ryutaro Hirose
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Francis Y. Yao
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, San Francisco, CA,Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
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Cooper M, Formica R, Friedewald J, Hirose R, O’Connor K, Mohan S, Schold J, Axelrod D, Pastan S. Report of National Kidney Foundation Consensus Conference to Decrease Kidney Discards. Clin Transplant 2018; 33:e13419. [DOI: 10.1111/ctr.13419] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 09/29/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Matthew Cooper
- Medstar Georgetown Transplant Institute; Georgetown University; Washington District of Columbia
| | - Richard Formica
- Department of Medicine, Section of Nephrology; Yale School of Medicine; New Haven Connecticut
| | - John Friedewald
- Northwestern University Comprehensive Transplant Center; Chicago Illinois
| | - Ryutaro Hirose
- Department of Surgery; University of California San Francisco; San Francisco California
| | | | - Sumit Mohan
- Division of Nephrology, Department of Medicine; Vagelos College of Physicians & Surgeons, Columbia University; New York New York
- Department of Epidemiology, Mailman School of Public Health; Columbia University; New York New York
| | - Jesse Schold
- Department of Quantitative Health Sciences; Cleveland Clinic; Cleveland Ohio
| | - David Axelrod
- Department of Surgery; Lahey Hospital and Medical Center; Burlington Massachusetts
| | - Stephen Pastan
- Renal Division, Department of Medicine; Emory University School of Medicine; Atlanta Georgia
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43
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Mehta N, Dodge JL, Hirose R, Roberts JP, Yao FY. Increasing Liver Transplantation Wait-List Dropout for Hepatocellular Carcinoma With Widening Geographical Disparities: Implications for Organ Allocation. Liver Transpl 2018; 24:1346-1356. [PMID: 30067889 PMCID: PMC6445639 DOI: 10.1002/lt.25317] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 06/25/2018] [Accepted: 07/24/2018] [Indexed: 12/22/2022]
Abstract
Given the increasing incidence of hepatocellular carcinoma (HCC) and regional variation in liver transplantation (LT) rates for HCC, we investigated temporal and geographic disparities in LT and wait-list dropout. LT candidates receiving Model for End-Stage Liver Disease (MELD) exception from 2005 to 2014 were identified from the United Network for Organ Sharing database (n = 14,320). Temporal differences were compared across 2 eras (2005-2009 and 2010-2014). Regional groups were defined based on median wait time as long-wait region (LWR; regions 1, 5, and 9), mid-wait region (MWR; regions 2, 4, 6, 7, and 8), and short-wait region (SWR; regions 3, 10, and 11). Fine and Gray competing risk regression estimated risk of wait-list dropout as hazard ratios (HRs). The cumulative probability of LT within 3 years was 70% in the LWR versus 81% in the MWR and 91% in the SWR (P < 0.001). From 2005-2009 to 2010-2014, median time to LT increased by 6.0 months (5.6 to 11.6 months) in the LWR compared with 3.8 months (2.6 to 6.4 months) in the MWR and 1.3 months (1.0 to 2.3 months) in the SWR. The cumulative probability of dropout within 3 years was 24% in the LWR versus 16% in the MWR and 8% in the SWR (P < 0.001). From 2005-2009 to 2010-2014, the LWR also had the greatest increase in probability of dropout. Risk of dropout was increased in the LWR (HR, 3.5; P < 0.001) and the MWR (HR, 2.2; P < 0.001) compared with the SWR, and year of MELD exception 2010-2014 (HR, 1.9; P < 0.001) compared with 2005-2009. From 2005-2009 to 2010-2014, intention-to-treat 3-year survival decreased from 69% to 63% in the LWR (P < 0.001), 72% to 69% in the MWR (P = 0.008), and remained at 74% in the SWR (P = 0.48). In conclusion, we observed a significant increase in wait-list dropout in HCC patients in recent years that disproportionately impacted LWR patients. Widening geographical disparities call for changes in allocation policy as well as enhanced efforts at increasing organ donation and utilization.
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Affiliation(s)
- Neil Mehta
- Divisions of Gastroenterology, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Jennifer L. Dodge
- Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Ryutaro Hirose
- Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - John P. Roberts
- Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Francis Y. Yao
- Divisions of Gastroenterology, Department of Medicine, University of California, San Francisco, San Francisco, CA,Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
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44
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Harbell JW, Morgan T, Feldstein VA, Roll GR, Posselt A, Kang SM, Feng S, Hirose R, Freise CE, Stock P. Splenic Vein Thrombosis Following Pancreas Transplantation: Identification of Factors That Support Conservative Management. Am J Transplant 2017; 17:2955-2962. [PMID: 28707821 DOI: 10.1111/ajt.14428] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 06/14/2017] [Accepted: 07/03/2017] [Indexed: 01/25/2023]
Abstract
Prophylaxis for graft portal/splenic venous thrombosis following pancreas transplant varies between institutions. Similarly, treatment of venous thrombosis ranges from early re-exploration to conservative management with anticoagulation. We wished to determine the prevalence of graft splenic vein (SV) thrombosis, as well as the clinical significance of non-occlusive thrombus observed on routine imaging. Records of 112 pancreas transplant recipients over a 5-year period at a single center were reviewed. Venous thrombosis was defined as absence of flow or presence of thrombus identified in any part of the graft SV on ultrasound. Thirty patients (27%) had some degree of thrombus or absence of flow in the SV on postoperative ultrasound. There were 5 graft losses in this group. Four were due to venous thrombosis, and occurred within 20 days of transplant. All patients with non-occlusive partial SV thrombus but normal arterial signal on Doppler ultrasound were successfully treated with IV heparin followed by warfarin for 3-6 months, and remained insulin independent. Findings of arterial signal abnormalities, such as absence or reversal of diastolic flow within the graft, require urgent operative intervention since this finding can be associated with more extensive thrombus that may lead to graft loss.
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Affiliation(s)
- J W Harbell
- Division of Transplantation, Department of Surgery, University of California San Francisco, San Francisco, CA
| | - T Morgan
- Department of Radiology, University of California San Francisco, San Francisco, CA
| | - V A Feldstein
- Department of Radiology, University of California San Francisco, San Francisco, CA
| | - G R Roll
- Division of Transplantation, Department of Surgery, University of California San Francisco, San Francisco, CA
| | - A Posselt
- Division of Transplantation, Department of Surgery, University of California San Francisco, San Francisco, CA
| | - S-M Kang
- Division of Transplantation, Department of Surgery, University of California San Francisco, San Francisco, CA
| | - S Feng
- Division of Transplantation, Department of Surgery, University of California San Francisco, San Francisco, CA
| | - R Hirose
- Division of Transplantation, Department of Surgery, University of California San Francisco, San Francisco, CA
| | - C E Freise
- Division of Transplantation, Department of Surgery, University of California San Francisco, San Francisco, CA
| | - P Stock
- Division of Transplantation, Department of Surgery, University of California San Francisco, San Francisco, CA
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45
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Mehta N, Dodge JL, Roberts JP, Hirose R, Yao FY. Misdiagnosis of hepatocellular carcinoma in patients receiving no local-regional therapy prior to liver transplant: An analysis of the Organ Procurement and Transplantation Network explant pathology form. Clin Transplant 2017; 31. [PMID: 28881064 DOI: 10.1111/ctr.13107] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2017] [Indexed: 12/13/2022]
Abstract
Patients with T1 hepatocellular carcinoma (HCC) are not eligible for Model for End Stage Liver Disease (MELD) exception for liver transplant (LT) in part due to a high rate of misdiagnosis (no HCC on explant). The likelihood of misdiagnosis for T2 HCC and factors associated with misdiagnosis are unknown. We analyzed the Organ Procurement and Transplantation Network database including 5664 adults who underwent LT from 2012 to 2015 with MELD exception for T2 HCC, and searched for no evidence of HCC in the explant pathology file. We focused on those (n = 324) receiving no local-regional therapy (LRT) to evaluate the probability of no HCC found in explant. Median waiting time was short at 1.7 months, and 35 (11%) had no HCC on explant. On multivariable logistic regression, factors associated with no HCC on explant were age <50 (OR: 17.3, P < .001), non-HCV (OR: 5.4, P = .001), and alpha-fetoprotein <10 (OR: 2.9, P = .04). Tumor size and number were not different between groups. The proportion of misdiagnosis did not change significantly after implementation of Liver Imaging Reporting and Data System (LI-RADS) for HCC diagnosis. CONCLUSION The rate of misdiagnosis was 11% among T2 HCC patients who underwent LT without receiving LRT prior to LT and did not change significantly after implementation of LI-RADS. More efforts are needed to eliminate unnecessary LT for patients without HCC.
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Affiliation(s)
- Neil Mehta
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, CA, USA
| | - Jennifer L Dodge
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, CA, USA
| | - John P Roberts
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, CA, USA
| | - Ryutaro Hirose
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, CA, USA
| | - Francis Y Yao
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, CA, USA.,Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, CA, USA
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46
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Wisel SA, Gardner JM, Roll GR, Harbell J, Freise CE, Feng S, Kang SM, Hirose R, Kaufman DB, Posselt A, Stock PG. Pancreas-After-Islet Transplantation in Nonuremic Type 1 Diabetes: A Strategy for Restoring Durable Insulin Independence. Am J Transplant 2017; 17:2444-2450. [PMID: 28489277 PMCID: PMC5573612 DOI: 10.1111/ajt.14344] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Revised: 04/21/2017] [Accepted: 04/22/2017] [Indexed: 01/25/2023]
Abstract
Islet transplantation offers a minimally invasive approach for β cell replacement in diabetic patients with hypoglycemic unawareness. Attempts at insulin independence may require multiple islet reinfusions from distinct donors, increasing the risk of allogeneic sensitization. Currently, solid organ pancreas transplant is the only remaining surgical option following failed islet transplantation in the United States; however, the immunologic impact of repeated exposure to donor antigens on subsequent pancreas transplantation is unclear. We describe a case series of seven patients undergoing solid organ pancreas transplant following islet graft failure with long-term follow-up of pancreatic graft survival and renal function. Despite highly variable panel reactive antibody levels prior to pancreas transplant (mean 27 ± 35%), all seven patients achieved stable and durable insulin independence with a mean follow-up of 6.7 years. Mean hemoglobin A1c values improved significantly from postislet, prepancreas levels (mean 8.1 ± 1.5%) to postpancreas levels (mean 5.3 ± 0.1%; p = 0.0022). Three patients experienced acute rejection episodes that were successfully managed with thymoglobulin and methylprednisolone, and none of these preuremic type 1 diabetic recipients developed stage 4 or 5 chronic kidney disease postoperatively. These results support pancreas-after-islet transplantation with aggressive immunosuppression and protocol biopsies as a viable strategy to restore insulin independence after islet graft failure.
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Affiliation(s)
- SA Wisel
- Department of Surgery, University of California, San Francisco; San Francisco, CA, United States
| | - JM Gardner
- Department of Surgery, University of California, San Francisco; San Francisco, CA, United States
| | - GR Roll
- Department of Surgery, University of California, San Francisco; San Francisco, CA, United States
| | - J Harbell
- Department of Surgery, University of California, San Francisco; San Francisco, CA, United States
| | - CE Freise
- Department of Surgery, University of California, San Francisco; San Francisco, CA, United States
| | - S Feng
- Department of Surgery, University of California, San Francisco; San Francisco, CA, United States
| | - SM Kang
- Department of Surgery, University of California, San Francisco; San Francisco, CA, United States
| | - R Hirose
- Department of Surgery, University of California, San Francisco; San Francisco, CA, United States
| | - DB Kaufman
- Department of Surgery, University of Wisconsin; Madison, WI, United States
| | - A Posselt
- Department of Surgery, University of California, San Francisco; San Francisco, CA, United States
| | - PG Stock
- Department of Surgery, University of California, San Francisco; San Francisco, CA, United States
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Parekh J, Ko C, Lappin J, Greenstein S, Hirose R. A Transplant-Specific Quality Initiative-Introducing TransQIP: A Joint Effort of the ASTS and ACS. Am J Transplant 2017; 17:1719-1722. [PMID: 28421672 DOI: 10.1111/ajt.14315] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 03/13/2017] [Accepted: 03/19/2017] [Indexed: 01/25/2023]
Abstract
In an attempt to improve surgical quality in the field of transplantation, the American College of Surgeons (ACS) and American Society of Transplant Surgeons have initiated a national quality improvement program in transplantation. This transplant-specific quality improvement program, called TransQIP, has been built from the ground up by transplant surgeons and captures detailed information on donor and recipient factors as well as transplant-specific outcomes. It is built upon the existing ACS/National Surgical Quality Improvement Program infrastructure and is designed to capture 100% of liver and kidney transplants performed at participating sites. TransQIP has completed its alpha pilot and will embark upon its beta phase at approximately 30 centers in the spring of 2017. Going forward, we anticipate TransQIP will help satisfy Centers for Medicare and Medicaid Services requirements for a quality improvement program, surgeon requirements for maintenance of certification, and qualify as a clinical practice improvement activity under the Merit-Based Incentive Payment System. Most importantly, we believe TransQIP will provide insight into surgical outcomes in transplantation that will allow the field to provide better care to our patients.
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Affiliation(s)
- J Parekh
- Department of Surgery, Division of Transplantation, UT Southwestern Medical Center, Dallas, TX
| | - C Ko
- Department of Surgery, University of California Los Angeles Medical Center and Director National Surgical Quality Improvement Program, Los Angeles, CA
| | - J Lappin
- Baylor Scott & White Health, Temple, TX
| | - S Greenstein
- Department of Surgery, Division of Transplantation, Montefiore Medical Center, Bronx, NY
| | - R Hirose
- Department of Surgery, Division of Transplantation, University of California San Francisco, San Francisco, CA
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48
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Hirose R, Heimbach J. Defining disparities in liver transplantation: The devil is in the details. Liver Transpl 2017; 23:557-558. [PMID: 28160412 DOI: 10.1002/lt.24740] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 01/10/2017] [Indexed: 01/13/2023]
Affiliation(s)
- Ryutaro Hirose
- Connie Frank Transplantation Center, University of California, San Francisco, CA
| | - Julie Heimbach
- Department of Transplantation Surgery, Mayo Clinic, Rochester, MN
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49
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Hirose R, Nakaya T, Daidoji T. Long term detection of seasonal influenza RNA in faeces and intestine – Author's Reply. Clin Microbiol Infect 2017; 23:273-274. [DOI: 10.1016/j.cmi.2016.09.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 09/17/2016] [Indexed: 11/17/2022]
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50
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Affiliation(s)
- Sommer E. Gentry
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland2Department of Mathematics, US Naval Academy, Annapolis, Maryland3Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Ryutaro Hirose
- Department of Surgery, University of California, San Francisco
| | - David Mulligan
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
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