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Kourounis G, Tingle SJ, Hoather TJ, Thompson ER, Rogers A, Page T, Sanni A, Rix DA, Soomro NA, Wilson C. Robotic versus laparoscopic versus open nephrectomy for live kidney donors. Cochrane Database Syst Rev 2024; 5:CD006124. [PMID: 38721875 PMCID: PMC11079970 DOI: 10.1002/14651858.cd006124.pub3] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Abstract
BACKGROUND Waiting lists for kidney transplantation continue to grow. Live kidney donation significantly reduces waiting times and improves long-term outcomes for recipients. Major disincentives to potential kidney donors are the pain and morbidity associated with surgery. This is an update of a review published in 2011. OBJECTIVES To assess the benefits and harms of open donor nephrectomy (ODN), laparoscopic donor nephrectomy (LDN), hand-assisted LDN (HALDN) and robotic donor nephrectomy (RDN) as appropriate surgical techniques for live kidney donors. SEARCH METHODS We contacted the Information Specialist and searched the Cochrane Kidney and Transplant Register of Studies up to 31 March 2024 using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing LDN with ODN, HALDN, or RDN were included. DATA COLLECTION AND ANALYSIS Two review authors independently screened titles and abstracts for eligibility, assessed study quality, and extracted data. We contacted study authors for additional information where necessary. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) or standardised mean difference (SMD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS Thirteen studies randomising 1280 live kidney donors to ODN, LDN, HALDN, or RDN were included. All studies were assessed as having a low or unclear risk of bias for selection bias. Five studies had a high risk of bias for blinding. Seven studies randomised 815 live kidney donors to LDN or ODN. LDN was associated with reduced analgesia use (high certainty evidence) and shorter hospital stay, a longer procedure and longer warm ischaemia time (moderate certainty evidence). There were no overall differences in blood loss, perioperative complications, or need for operations (low or very low certainty evidence). Three studies randomised 270 live kidney donors to LDN or HALDN. There were no differences between HALDN and LDN for analgesia requirement, hospital stay (high certainty evidence), duration of procedure (moderate certainty evidence), blood loss, perioperative complications, or reoperations (low certainty evidence). The evidence for warm ischaemia time was very uncertain due to high heterogeneity. One study randomised 50 live kidney donors to retroperitoneal ODN or HALDN and reported less pain and analgesia requirements with ODN. It found decreased blood loss and duration of the procedure with HALDN. No differences were found in perioperative complications, reoperations, hospital stay, or primary warm ischaemia time. One study randomised 45 live kidney donors to LDN or RDN and reported a longer warm ischaemia time with RDN but no differences in analgesia requirement, duration of procedure, blood loss, perioperative complications, reoperations, or hospital stay. One study randomised 100 live kidney donors to two variations of LDN and reported no differences in hospital stay, duration of procedure, conversion rates, primary warm ischaemia times, or complications (not meta-analysed). The conversion rates to ODN were 6/587 (1.02%) in LDN, 1/160 (0.63%) in HALDN, and 0/15 in RDN. Graft outcomes were rarely or selectively reported across the studies. There were no differences between LDN and ODN for early graft loss, delayed graft function, acute rejection, ureteric complications, kidney function or one-year graft loss. In a meta-regression analysis between LDN and ODN, moderate certainty evidence on procedure duration changed significantly in favour of LDN over time (yearly reduction = 7.12 min, 95% CI 2.56 to 11.67; P = 0.0022). Differences in very low certainty evidence on perioperative complications also changed significantly in favour of LDN over time (yearly change in LnRR = 0.107, 95% CI 0.022 to 0.192; P = 0.014). Various different combinations of techniques were used in each study, resulting in heterogeneity among the results. AUTHORS' CONCLUSIONS LDN is associated with less pain compared to ODN and has comparable pain to HALDN and RDN. HALDN is comparable to LDN in all outcomes except warm ischaemia time, which may be associated with a reduction. One study reported kidneys obtained during RDN had greater warm ischaemia times. Complications and occurrences of perioperative events needing further intervention were equivalent between all methods.
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Affiliation(s)
- Georgios Kourounis
- NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, UK
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
| | - Samuel J Tingle
- NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, UK
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
| | - Thomas J Hoather
- Department of Education, Newcastle University, Newcastle Upon Tyne, UK
| | - Emily R Thompson
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
| | - Alistair Rogers
- Department of Urology, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Tobias Page
- Department of Urology, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Aliu Sanni
- Department of Surgery, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - David A Rix
- Department of Urology, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Naeem A Soomro
- Department of Urology, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Colin Wilson
- NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, UK
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
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Malik AK, Tingle SJ, Chung N, Owen R, Mahendran B, Counter C, Sinha S, Muthasamy A, Sutherland A, Casey J, Drage M, van Dellen D, Callaghan CJ, Elker D, Manas DM, Pettigrew GJ, Wilson CH, White SA. The impact of time to death in donors after circulatory death on recipient outcome in simultaneous pancreas-kidney transplantation. Am J Transplant 2024:S1600-6135(24)00134-5. [PMID: 38360185 DOI: 10.1016/j.ajt.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 01/27/2024] [Accepted: 02/07/2024] [Indexed: 02/17/2024]
Abstract
The time to arrest donors after circulatory death is unpredictable and can vary. This leads to variable periods of warm ischemic damage prior to pancreas transplantation. There is little evidence supporting procurement team stand-down times based on donor time to death (TTD). We examined what impact TTD had on pancreas graft outcomes following donors after circulatory death (DCD) simultaneous pancreas-kidney transplantation. Data were extracted from the UK transplant registry from 2014 to 2022. Predictors of graft loss were evaluated using a Cox proportional hazards model. Adjusted restricted cubic spline models were generated to further delineate the relationship between TTD and outcome. Three-hundred-and-seventy-five DCD simultaneous kidney-pancreas transplant recipients were included. Increasing TTD was not associated with graft survival (adjusted hazard ratio HR 0.98, 95% confidence interval 0.68-1.41, P = .901). Increasing asystolic time worsened graft survival (adjusted hazard ratio 2.51, 95% confidence interval 1.16-5.43, P = .020). Restricted cubic spline modeling revealed a nonlinear relationship between asystolic time and graft survival and no relationship between TTD and graft survival. We found no evidence that TTD impacts pancreas graft survival after DCD simultaneous pancreas-kidney transplantation; however, increasing asystolic time was a significant predictor of graft loss. Procurement teams should attempt to minimize asystolic time to optimize pancreas graft survival rather than focus on the duration of TTD.
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Affiliation(s)
- Abdullah K Malik
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK; NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, Cambridge, UK.
| | - Samuel J Tingle
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK; NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, Cambridge, UK
| | - Nicholas Chung
- Northumbria Healthcare NHS Foundation Trust, Cramlington, UK
| | - Ruth Owen
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Balaji Mahendran
- NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, Cambridge, UK
| | | | - Sanjay Sinha
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | | | - John Casey
- Edinburgh Royal Infirmary, Edinburgh, UK
| | - Martin Drage
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Chris J Callaghan
- NHS Blood and Transplant, Bristol, UK; Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Doruk Elker
- Cardiff and Vale University Health Board, Cardiff, UK
| | - Derek M Manas
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK; NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, Cambridge, UK; NHS Blood and Transplant, Bristol, UK
| | - Gavin J Pettigrew
- NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, Cambridge, UK; Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Colin H Wilson
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK; NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, Cambridge, UK
| | - Steven A White
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK; NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, Cambridge, UK; NHS Blood and Transplant, Bristol, UK
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Owen RV, Carr HJ, Counter C, Tingle SJ, Thompson ER, Manas DM, Shaw JA, Wilson CH, White SA. Multi-Centre UK Analysis of Simultaneous Pancreas and Kidney (SPK) Transplant in Recipients With Type 2 Diabetes Mellitus. Transpl Int 2024; 36:11792. [PMID: 38370534 PMCID: PMC10869449 DOI: 10.3389/ti.2023.11792] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 10/27/2023] [Indexed: 02/20/2024]
Abstract
90% of the UK diabetic population are classified as T2DM. This study aims to compare outcomes after SPK transplant between recipients with T1DM or T2DM. Data on all UK SPK transplants from 2003-2019 were obtained from the NHSBT Registry (n = 2,236). Current SPK transplant selection criteria for T2DM requires insulin treatment and recipient BMI < 30 kg/m2. After exclusions (re-transplants/ambiguous type of diabetes) we had a cohort of n = 2,154. Graft (GS) and patient (PS) survival analyses were conducted using Kaplan-Meier plots and Cox-regression models. Complications were compared using chi-squared analyses. 95.6% of SPK transplants were performed in recipients with T1DM (n = 2,060). Univariate analysis showed comparable outcomes for pancreas GS at 1 year (p = 0.120), 3 years (p = 0.237), and 10 years (p = 0.196) and kidney GS at 1 year (p = 0.438), 3 years (p = 0.548), and 10 years (p = 0.947). PS was comparable at 1 year (p = 0.886) and 3 years (p = 0.237) and at 10 years (p = 0.161). Multi-variate analysis showed comparable outcomes in pancreas GS (p = 0.564, HR 1.221, 95% CI 0.619, 2.406) and PS(p = 0.556, HR 1.280, 95% CI 0.563, 2.911). Comparable rates of common complications were demonstrated. This is the largest series outside of the US evaluating outcomes after SPK transplants and shows similar outcomes between T1DM and T2DM recipients. It is hoped dissemination of this data will lead to increased referral rates and assessment of T2DM patients who could benefit from SPK transplantation.
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Affiliation(s)
- Ruth V. Owen
- Institute of Transplantation, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
| | | | - Claire Counter
- Statistics and Clinical Research, NHS Blood and Transplant, Bristol, United Kingdom
| | - Samuel J. Tingle
- Institute of Transplantation, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
- Blood and Transplant Unit, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Emily R. Thompson
- Institute of Transplantation, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
| | - Derek M. Manas
- Institute of Transplantation, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
| | - James A. Shaw
- Institute of Transplantation, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
- Blood and Transplant Unit, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Colin H. Wilson
- Institute of Transplantation, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
- Blood and Transplant Unit, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Steve A. White
- Institute of Transplantation, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
- Blood and Transplant Unit, Newcastle University, Newcastle Upon Tyne, United Kingdom
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Mahendran B, Tingle SJ, Malik AK, Figueiredo R, Hammond JS, Sen G, Amer A, Talbot D, Manas DM, Sharp L, Exley C, White S, Wilson CH. Racial disparities in outcomes after liver transplantation in the UK: registry analysis. Br J Surg 2024; 111:znae020. [PMID: 38364060 DOI: 10.1093/bjs/znae020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 12/20/2023] [Accepted: 01/06/2024] [Indexed: 02/18/2024]
Affiliation(s)
- Balaji Mahendran
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
- NIHR Blood and Transplant Research Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Samuel J Tingle
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
- NIHR Blood and Transplant Research Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Abdullah K Malik
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
- NIHR Blood and Transplant Research Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Rodrigo Figueiredo
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - John S Hammond
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Gourab Sen
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Aimen Amer
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - David Talbot
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Derek M Manas
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
- NIHR Blood and Transplant Research Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Linda Sharp
- NIHR Blood and Transplant Research Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Catherine Exley
- NIHR Blood and Transplant Research Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Steven White
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
- NIHR Blood and Transplant Research Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Colin H Wilson
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
- NIHR Blood and Transplant Research Unit, Newcastle University, Newcastle upon Tyne, UK
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Tingle SJ, Bramley R, Goodfellow M, Thompson ER, McPherson S, White SA, Wilson CH. Donor Liver Blood Tests and Liver Transplant Outcomes: UK Registry Cohort Study. Transplantation 2023; 107:2533-2544. [PMID: 37069657 DOI: 10.1097/tp.0000000000004610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2023]
Abstract
BACKGROUND Safely increasing organ utilization is a global priority. Donor serum transaminase levels are often used to decline livers, despite minimal evidence to support such decisions. This study aimed to investigate the impact of donor "liver blood tests" on transplant outcomes. METHODS This retrospective cohort study used the National Health Service registry on adult liver transplantation (2016-2019); adjusted regressions models were used to assess the effect of donor "liver blood tests" on outcomes. RESULTS A total of 3299 adult liver transplant recipients were included (2530 following brain stem death, 769 following circulatory death). Peak alanine transaminase (ALT) ranged from 6 to 5927 U/L (median = 45). Donor cause of death significantly predicted donor ALT; 4.2-fold increase in peak ALT with hypoxic brain injury versus intracranial hemorrhage (adjusted P < 0.001). On multivariable analysis, adjusting for a wide range of factors, transaminase level (ALT or aspartate aminotransferase) failed to predict graft survival, primary nonfunction, 90-d graft loss, or mortality. This held true in all examined subgroups, that is, steatotic grafts, donation following circulatory death, hypoxic brain injury donors, and donors, in which ALT was still rising at the time of retrieval. Even grafts from donors with extremely deranged ALT (>1000 U/L) displayed excellent posttransplant outcomes. In contrast, donor peak alkaline phosphatase was a significant predictor of graft loss (adjusted hazard ratio = 1.808; 1.016-3.216; P = 0.044). CONCLUSIONS Donor transaminases do not predict posttransplant outcomes. When other factors are favorable, livers from donors with raised transaminases can be accepted and transplanted with confidence. Such knowledge should improve organ utilization decision-making and prevent future unnecessary organ discard. This provides a safe, simple, and immediate option to expand the donor pool.
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Affiliation(s)
- Samuel J Tingle
- National Institute for Health Research Blood and Transplant Research Unit (NIHR BTRU) in Organ Donation and Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Rebecca Bramley
- National Institute for Health Research Blood and Transplant Research Unit (NIHR BTRU) in Organ Donation and Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Michael Goodfellow
- National Institute for Health Research Blood and Transplant Research Unit (NIHR BTRU) in Organ Donation and Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Emily R Thompson
- National Institute for Health Research Blood and Transplant Research Unit (NIHR BTRU) in Organ Donation and Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Stuart McPherson
- Department of Hepatology, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Steve A White
- National Institute for Health Research Blood and Transplant Research Unit (NIHR BTRU) in Organ Donation and Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Colin H Wilson
- National Institute for Health Research Blood and Transplant Research Unit (NIHR BTRU) in Organ Donation and Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
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McGovern J, Tingle SJ, Robinson S, Moir J. Is aggressive intravenous fluid prescription the answer to reduce mortality in severe pancreatitis? The FLIP study: Fluid resuscitation in pancreatitis. Ann Hepatobiliary Pancreat Surg 2023; 27:394-402. [PMID: 37827531 DOI: 10.14701/ahbps.23-044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 06/01/2023] [Accepted: 06/06/2023] [Indexed: 10/14/2023] Open
Abstract
Backgrounds/Aims Acute pancreatitis is an emergency presentation, which can range from mild to life threatening. Intravenous fluids are the cornerstone of management. Although the WATERFALL trial described the optimal fluid rate in mild/moderate pancreatitis, this trial excluded patients with moderate-severe/severe pancreatitis. The aim of this study was to establish clinical practice regarding intravenous fluid administration in acute pancreatitis and assess its effect on mortality. Methods Prospective multi-centre audit of patients with acute pancreatitis was conducted. Data were collected regarding intravenous fluid administration within 72 hours of admission. The primary outcome was 30-day mortality. Multivariable logistic regression was used to identify predictors of 30-day mortality. Results Those with severe pancreatitis received more fluid; median 5.7 L versus 4 L in 72 hours (p = 0.003). Participants with severe pancreatitis who died within 30 days received a median of 2,750 mL in the first 24 hours, compared to 4,000 mL in those who survived. The following factors were significant predictors of 30-day mortality: age, Glasgow score, C-reactive protein, ischaemic heart disease, and pancreatitis aetiology. Overall, volume of intravenous fluid was not associated with mortality. However, the effect of intravenous fluid volume on mortality differed significantly depending on pancreatitis severity. In severe pancreatitis, increased volume of intravenous fluid was associated with significant reductions in mortality (odds ratio = 0.655; 0.459-0.936; p = 0.020). Conclusions In severe pancreatitis, more aggressive fluid prescription was associated with decreased mortality; however, this was not the case in milder disease. Further prospective trials guiding fluid resuscitation in severe pancreatitis are needed, as the impact of fluid on this population appears to differ from that in those with milder disease.
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Affiliation(s)
- Julia McGovern
- Health Education England North East, Newcastle upon Tyne, UK
| | - Samuel J Tingle
- Health Education England North East, Newcastle upon Tyne, UK
| | - Stuart Robinson
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - John Moir
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
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Tingle SJ, Dobbins JJ, Thompson ER, Figueiredo RS, Mahendran B, Pandanaboyana S, Wilson C. Machine perfusion in liver transplantation. Cochrane Database Syst Rev 2023; 9:CD014685. [PMID: 37698189 PMCID: PMC10496129 DOI: 10.1002/14651858.cd014685.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
BACKGROUND Liver transplantation is the only chance of cure for people with end-stage liver disease and some people with advanced liver cancers or acute liver failure. The increasing prevalence of these conditions drives demand and necessitates the increasing use of donated livers which have traditionally been considered suboptimal. Several novel machine perfusion preservation technologies have been developed, which attempt to ameliorate some of the deleterious effects of ischaemia reperfusion injury. Machine perfusion technology aims to improve organ quality, thereby improving outcomes in recipients of suboptimal livers when compared to traditional static cold storage (SCS; ice box). OBJECTIVES To evaluate the effects of different methods of machine perfusion (including hypothermic oxygenated machine perfusion (HOPE), normothermic machine perfusion (NMP), controlled oxygenated rewarming, and normothermic regional perfusion) versus each other or versus static cold storage (SCS) in people undergoing liver transplantation. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 10 January 2023. SELECTION CRITERIA We included randomised clinical trials which compared different methods of machine perfusion, either with each other or with SCS. Studies comparing HOPE via both hepatic artery and portal vein, or via portal vein only, were grouped. The protocol detailed that we also planned to include quasi-randomised studies to assess treatment harms. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were 1. overall participant survival, 2. quality of life, and 3. serious adverse events. Secondary outcomes were 4. graft survival, 5. ischaemic biliary complications, 6. primary non-function of the graft, 7. early allograft function, 8. non-serious adverse events, 9. transplant utilisation, and 10. transaminase release during the first week post-transplant. We assessed bias using Cochrane's RoB 2 tool and used GRADE to assess certainty of evidence. MAIN RESULTS We included seven randomised trials (1024 transplant recipients from 1301 randomised/included livers). All trials were parallel two-group trials; four compared HOPE versus SCS, and three compared NMP versus SCS. No trials used normothermic regional perfusion. When compared with SCS, it was uncertain whether overall participant survival was improved with either HOPE (hazard ratio (HR) 0.91, 95% confidence interval (CI) 0.42 to 1.98; P = 0.81, I2 = 0%; 4 trials, 482 recipients; low-certainty evidence due to imprecision because of low number of events) or NMP (HR 1.08, 95% CI 0.31 to 3.80; P = 0.90; 1 trial, 222 recipients; very low-certainty evidence due to imprecision and risk of bias). No trials reported quality of life. When compared with SCS alone, HOPE was associated with improvement in the following clinically relevant outcomes: graft survival (HR 0.45, 95% CI 0.23 to 0.87; P = 0.02, I2 = 0%; 4 trials, 482 recipients; high-certainty evidence), serious adverse events in extended criteria DBD liver transplants (OR 0.45, 95% CI 0.22 to 0.91; P = 0.03, I2 = 0%; 2 trials, 156 participants; moderate-certainty evidence) and clinically significant ischaemic cholangiopathy in recipients of DCD livers (OR 0.31, 95% CI 0.11 to 0.92; P = 0.03; 1 trial, 156 recipients; high-certainty evidence). In contrast, NMP was not associated with improvement in any of these clinically relevant outcomes. NMP was associated with improved utilisation compared with SCS (one trial found a 50% lower rate of organ discard; P = 0.008), but the reasons underlying this effect are unknown. We identified 11 ongoing studies investigating machine perfusion technologies. AUTHORS' CONCLUSIONS In situations where the decision has been made to transplant a liver donated after circulatory death or donated following brain death, end-ischaemic HOPE will provide superior clinically relevant outcomes compared with SCS alone. Specifically, graft survival is improved (high-certainty evidence), serious adverse events are reduced (moderate-certainty evidence), and in donors after circulatory death, clinically relevant ischaemic biliary complications are reduced (high-certainty evidence). There is no good evidence that NMP has the same benefits over SCS in terms of these clinically relevant outcomes. NMP does appear to improve utilisation of grafts that would otherwise be discarded with SCS; however, the reasons for this, and whether this effect is specific to NMP, is not clear. Further studies into NMP viability criteria and utilisation, as well as head-to-head trials with other perfusion technologies are needed. In the setting of donation following circulatory death transplantation, further trials are needed to assess the effect of these ex situ machine perfusion methods against, or in combination with, normothermic regional perfusion.
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Affiliation(s)
- Samuel J Tingle
- NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, UK
| | | | - Emily R Thompson
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
| | | | | | - Sanjay Pandanaboyana
- HPB and Liver Transplant Surgery, Freeman Hospital, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Colin Wilson
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
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Malik AK, Amer AO, Tingle SJ, Thompson ER, White SA, Manas DM, Wilson C. Fibrin-based haemostatic agents for reducing blood loss in adult liver resection. Cochrane Database Syst Rev 2023; 8:CD010872. [PMID: 37551841 PMCID: PMC10411946 DOI: 10.1002/14651858.cd010872.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
BACKGROUND Liver resection is the optimal treatment for selected benign and malignant liver tumours, but it can be associated with significant blood loss. Numerous anaesthetic and surgical techniques have been developed to reduce blood loss and improve perioperative outcomes. One such technique is the application of topical fibrin-based haemostatic agents (FBHAs) to the resection surface. There is no standard practice for FBHA use, and a variety of commercial agents and devices are available, as well as non-FBHAs (e.g. collagen-based agents). The literature is inconclusive on the effectiveness of these methods and on the clinical benefits of their routine use. OBJECTIVES To evaluate the benefits and harms of fibrin-based haemostatic agents in reducing intraoperative blood loss in adults undergoing liver resection. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group (CHBG) Controlled Trials Register, CENTRAL, MEDLINE, Embase, LILACS, Science Citation Index Expanded, and Conference Proceedings Citation Index-Science up to 20 January 2023. We also searched online trial registries, checked the reference lists of all primary studies, and contacted the authors of included trials for additional published or unpublished trials. SELECTION CRITERIA We considered for inclusion all randomised clinical trials evaluating FBHAs versus no topical intervention or non-FBHAs, irrespective of publication type, publication status, language of publication, and outcomes reported. Eligible participants could have any liver pathology and be undergoing major or minor liver resections through open or laparoscopic surgery. DATA COLLECTION AND ANALYSIS Two review authors independently screened the results of the literature search and used data extraction forms to collate the results. We expressed dichotomous outcome results as risk ratios (RRs) and continuous outcome results as mean differences (MDs), each with their corresponding 95% confidence interval (CI). We used a random-effects model for the main analyses. Our primary outcomes were perioperative mortality, serious adverse events, haemostatic efficacy, and health-related quality of life. Our secondary outcomes were efficacy as sealant, adverse events considered non-serious, operating time, and length of hospital stay. We assessed the certainty of the evidence with GRADE and presented results in two summary of findings tables. MAIN RESULTS We included 22 trials (2945 participants) evaluating FBHAs versus no intervention or non-FBHAs; 19 trials with 2642 participants provided data for the meta-analyses. Twelve trials reported commercial funding, one trial reported no financial support, and nine trials provided no information on funding. Below we present the most clinically relevant outcome results, also displayed in our summary of findings table. Fibrin-based haemostatic agents versus no intervention Six trials (1001 participants) compared FBHAs with no intervention. One trial was at low risk of bias in all five domains, and all other trials were at high or unclear risk of bias in at least one domain. Two trials were at high risk of bias related to blinding. It is unclear if FBHAs compared with no intervention have an effect on perioperative mortality (RR 2.58, 95% CI 0.89 to 7.44; 4 trials, 782 participants), serious adverse events (RR 0.96, 95% CI 0.88 to 1.05; 4 trials, 782 participants), postoperative transfusion (RR 1.04, 95% CI 0.77 to 1.40; 5 trials, 864 participants), reoperation (RR 2.92, 95% CI 0.58 to 14.61; 2 trials, 612 participants), or postoperative bile leak (RR 1.00, 95% CI 0.67 to 1.48; 4 trials, 782 participants), as the certainty of evidence was very low for all these outcomes. Fibrin-based haemostatic agents versus non-fibrin-based haemostatic agents Sixteen trials (1944 participants) compared FBHAs with non-FBHAs. All trials had at least one domain at high or unclear risk of bias. Twelve trials were at high risk of bias related to blinding. It is unclear if FBHAs compared with non-FBHAs have an effect on perioperative mortality (RR 1.03, 95% CI 0.62 to 1.72; 11 trials, 1436 participants), postoperative transfusion (RR 0.92, 95% CI 0.68 to 1.25; 7 trials, 599 participants), reoperation (RR 0.48, 95% CI 0.25 to 0.90; 3 trials, 358 participants), or postoperative bile leak (RR 1.15, 95% CI 0.60 to 2.21; 9 trials, 1115 participants), as the certainty of evidence was very low for all these outcomes. FBHAs compared with non-FBHAs may have little or no effect on the risk of serious adverse events (RR 0.99, 95% CI 0.95 to 1.03; 9 trials, 1176 participants; low-certainty evidence). AUTHORS' CONCLUSIONS The evidence for the outcomes in both comparisons (FBHAs versus no intervention and FBHAs versus non-FBHAs) was of very low certainty (or low certainty in one instance) and cannot justify the routine use of FBHAs to reduce blood loss in adult liver resection. While the meta-analysis showed a reduced risk of reoperation with FBHAs compared with non-FBHAs, the analysis was confounded by the small number of trials reporting the event and the risk of bias in all these trials. Future trials should focus on the use of FBHAs in people undergoing liver resection who are at particularly high risk of bleeding. Investigators should evaluate clinically meaningful and patient-important outcomes and follow the SPIRIT and CONSORT statements.
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Affiliation(s)
- Abdullah K Malik
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
- NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, UK
| | - Aimen O Amer
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
| | - Samuel J Tingle
- NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, UK
| | - Emily R Thompson
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
- NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, UK
| | - Steven A White
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
| | - Derek M Manas
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
| | - Colin Wilson
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
- NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, UK
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9
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Goodfellow M, Thompson ER, Tingle SJ, Wilson C. Early versus late removal of urinary catheter after kidney transplantation. Cochrane Database Syst Rev 2023; 7:CD013788. [PMID: 37449968 PMCID: PMC10347544 DOI: 10.1002/14651858.cd013788.pub2] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
BACKGROUND The optimal treatment for end-stage kidney disease is kidney transplantation. During the operation, a catheter is introduced into the bladder and remains in place postoperatively to allow the bladder to drain. This decreases tension from the cysto-ureteric anastomosis and promotes healing. Unfortunately, urinary catheters can pose an infection risk to patients as they allow bacteria into the bladder, potentially resulting in a urinary tract infection (UTI). The longer the catheter remains in place, the greater the risk of developing a UTI. There is no consensus approach to the time a catheter should remain in place post-transplant. Furthermore, the different timings of catheter removal are thought to be associated with different incidences of UTI and postoperative complications, such as anastomotic breakdown. OBJECTIVES This review aimed to compare patients who had their catheter removed < 5 days post-transplant surgery to those patients who had their catheter removed ≥ 5 days following their kidney transplant. Primary outcome measures between the two groups included: the incidence of symptomatic UTIs, the incidence of asymptomatic bacteriuria and the incidence of major urological complications requiring intervention and treatment. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 13 April 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA All randomised controlled trials (RCTs) and quasi-RCTs comparing timing of catheter removal post-transplantation were eligible for inclusion. All donor types were included, and all recipients were included regardless of age, demographics or type of urinary catheter used. DATA COLLECTION AND ANALYSIS Results from the literature search were screened by two authors to identify if they met our inclusion criteria. We designated removal of a urinary catheter before five days (120 hours) as an 'early removal' and anything later than this as a 'late removal.' The studies were assessed for quality using the risk of bias tool. The primary outcome of interest was the incidence of asymptomatic bacteriuria. Statistical analyses were performed using the random effects model, and results were expressed as relative risk (RR) with 95% confidence intervals (CI). Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS Two studies (197 patients) were included in our analysis. One study comprised a full-text article, and the other was a conference abstract with very limited information. The risk of bias in the included studies was generally either high or unclear. It is uncertain whether early versus late removal of the urinary catheter made any difference to the incidence of asymptomatic bacteriuria (RR 0.89, 95% Cl 0.17 to 4.57; participants = 197; I2 = 88%; very low certainty evidence). Data on other outcomes, such as the incidence of UTI and the incidence of major urological complications, were lacking. Furthermore, the follow-up of patients across the studies was short, with no patients being followed beyond one month. AUTHORS' CONCLUSIONS A high-quality, well-designed RCT is required to compare the effectiveness of early catheter removal versus late catheter removal in patients following a kidney transplant. At the present time, there is insufficient evidence to suggest any difference between early and late catheter removal post-transplant, and the studies investigating this were generally of poor quality.
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Affiliation(s)
- Michael Goodfellow
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
| | - Emily R Thompson
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
| | - Samuel J Tingle
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
| | - Colin Wilson
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
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Tingle SJ, Hoather TJ, Thompson ER, Wilson C. Therapeutic donor hypothermia following brain death to improve the quality of transplanted organs. Cochrane Database Syst Rev 2023; 2023:CD015190. [PMCID: PMC9878618 DOI: 10.1002/14651858.cd015190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
This is a protocol for a Cochrane Review (intervention). The objectives are as follows: This review aims to examine the benefits and harms of therapeutic donor hypothermia in recipients or organs donated after brain death.
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Affiliation(s)
| | - Samuel J Tingle
- NIHR Blood and Transplant Research UnitNewcastle University and Cambridge UniversityNewcastle upon TyneUK
| | - Thomas J Hoather
- Department of EducationNewcastle UniversityNewcastle Upon TyneUK
| | - Emily R Thompson
- Institute of TransplantationThe Freeman HospitalNewcastle upon TyneUK
| | - Colin Wilson
- Institute of TransplantationThe Freeman HospitalNewcastle upon TyneUK
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11
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Tingle SJ, Thompson ER, Bates L, Ibrahim IK, Govaere O, Shuttleworth V, Wang L, Figueiredo R, Palmer J, Bury Y, Anstee QM, Wilson C. Pharmacological testing of therapeutics using normothermic machine perfusion: A pilot study of 2,4-dinitrophenol delivery to steatotic human livers. Artif Organs 2022; 46:2201-2214. [PMID: 35546070 DOI: 10.1111/aor.14309] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/19/2022] [Accepted: 04/29/2022] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Normothermic machine perfusion (NMP) provides a platform for drug-delivery. However, pharmacological considerations for therapeutics delivered during NMP are scarcely reported. We aimed to demonstrate the ability of NMP as a platform for pharmacological testing, using a drug which increases metabolism (2,4-dinitrophenol; DNP) as an example therapeutic. METHODS We performed 25 h of NMP on human livers which had been declined for transplant due to steatosis (n = 7). Three livers received a DNP bolus, three were controls, and one received a DNP infusion. RESULTS Toxicity studies revealed DNP delivery was safe, without hepatotoxic effects. The liver surface temperature was increased in the DNP group (p = 0.046), but no livers suffered hyperthermia-the mechanism of DNP toxicity in vivo. Pharmacokinetic studies revealed DNP elimination with first-order kinetics and 7.7 h half-life (95% CI = 5.1-15.9 hrs). The clearance of DNP in bile was negligible. As expected, DNP significantly increased oxygen consumption (p = 0.023); this increase was closely correlated with perfusate DNP concentration (r2 = 0.975; p = 0.002) and the effect was lost as DNP was eliminated by the liver. A DNP infusion rate, calculated using our pharmacokinetic data, successfully maintained perfusate DNP concentration. DISCUSSION Detailed pharmacological testing can be performed during NMP. Our therapeutic (DNP) is rapidly eliminated by the ex vivo liver, meaning the drug effect of increased metabolism is only transient. This demonstrates the importance of assessing pharmacokinetics when delivering therapeutics during NMP, especially for prolonged perfusion of organs with established roles in drug elimination. Rigorous pharmacological testing is needed to unlock the potential of NMP as a clinical drug-delivery platform.
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Affiliation(s)
- Samuel J Tingle
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
- Blood and Transplant Research Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Emily R Thompson
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
- Blood and Transplant Research Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Lucy Bates
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Blood and Transplant Research Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Ibrahim K Ibrahim
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - Olivier Govaere
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Victoria Shuttleworth
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Lu Wang
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Blood and Transplant Research Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Rodrigo Figueiredo
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - Jeremy Palmer
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Yvonne Bury
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Department of Cellular Pathology, Victoria Infirmary, Newcastle upon Tyne, UK
| | - Quentin M Anstee
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Newcastle NIHR Biomedical Research Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Colin Wilson
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
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12
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Tingle SJ, Thompson ER, Bates L, Connelly C, Colenutt S, Turner M, Ugail H, Hodgetts R, Thomson BM, Sheerin N, Wilson C. O030 Image-analysis algorithm to determine quality of cold perfusion in kidney transplantation. Br J Surg 2022. [DOI: 10.1093/bjs/znac242.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
Introduction
Surgeon assessment of visual ‘quality of perfusion’ (QOP) influences kidney discard and predicts transplant outcome. However, this assessment is subjective and bias-prone.
We aimed to design an application utilising a smartphone camera to make this assessment objective and enhance decision making.
Methods
The QOP in photographs of backbench kidneys was graded from 1 (ideal) to 5 (very poor) by three independent surgeons. A training cohort was used to develop an image-analysis algorithm, which was validated in a separate cohort.
Results
Analysing surgeon scores of 174 kidney images revealed that inter-rater agreement was good for kidneys displaying the best (rated 1) and worst (rated 4 or 5) QOP. However, for intermediate scores inter-rater agreement was poor. Inter-rater agreement between surgeons decreased as they graded more images; as surgeons fatigued, their ability to classify images worsened. A training cohort (n=174 kidneys) was used for algorithm development. First, small regions within each image were mapped within the CEILAB colour-space, where well-perfused and poorly perfused areas show clear separation. To generate a score for each kidney these regions are compared with ideally flushed kidney tissue. Testing our algorithm (validation cohort - n=29 kidneys) revealed strong correlation between image-analysis QOP score and surgeon assessment, r=0.789 (0.587–0.899), P<0.001.
Conclusion
Surgeon inter-rater agreement on kidney QOP is low for kidneys with borderline QOP and worsens with fatigue. We provide a QOP score utilising an image-analysis algorithm, which correlates with surgeon scoring. With additional images and training this could provide an objective, numerical, point-of-care assessment of organ quality.
Take-home message
Current visual assessment of transplant organ quality is subjective and bias-prone. This body of work attempts to create a point-of-care image-analysis application to provide an objective numeric organ quality score.
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Affiliation(s)
- SJ Tingle
- NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation at Cambridge and Newcastle Universities , Newcastle upon Tyne, NE1 7RU
- Translational and Clinical Research Institute, Newcastle University , NE2 4HH
| | - ER Thompson
- NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation at Cambridge and Newcastle Universities , Newcastle upon Tyne, NE1 7RU
- Translational and Clinical Research Institute, Newcastle University , NE2 4HH
| | - L Bates
- NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation at Cambridge and Newcastle Universities , Newcastle upon Tyne, NE1 7RU
- Translational and Clinical Research Institute, Newcastle University , NE2 4HH
| | - C Connelly
- NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation at Cambridge and Newcastle Universities , Newcastle upon Tyne, NE1 7RU
- Translational and Clinical Research Institute, Newcastle University , NE2 4HH
| | - S Colenutt
- NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation at Cambridge and Newcastle Universities , Newcastle upon Tyne, NE1 7RU
- Translational and Clinical Research Institute, Newcastle University , NE2 4HH
| | - M Turner
- Translational and Clinical Research Institute, Newcastle University , NE2 4HH
| | - H Ugail
- Department of Engineering and Informatics IRC, University of Bradford , BD7 1DP
- Aedstem Ltd , Yorkshire, Yorkshire, YO42 2QE
| | - R Hodgetts
- Department of Engineering and Informatics IRC, University of Bradford , BD7 1DP
- Aedstem Ltd , Yorkshire, Yorkshire, YO42 2QE
| | - BM Thomson
- Department of Engineering and Informatics IRC, University of Bradford , BD7 1DP
- Aedstem Ltd , Yorkshire, Yorkshire, YO42 2QE
| | - N Sheerin
- Translational and Clinical Research Institute, Newcastle University , NE2 4HH
| | - C Wilson
- NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation at Cambridge and Newcastle Universities , Newcastle upon Tyne, NE1 7RU
- Translational and Clinical Research Institute, Newcastle University , NE2 4HH
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13
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Thompson ER, Sewpaul A, Figuereido R, Bates L, Tingle SJ, Ferdinand JR, Situmorang GR, Ladak SS, Connelly CM, Hosgood SA, Nicholson ML, Clatworthy MR, Ali S, Wilson CH, Sheerin NS. MicroRNA antagonist therapy during normothermic machine perfusion of donor kidneys. Am J Transplant 2022; 22:1088-1100. [PMID: 34932895 DOI: 10.1111/ajt.16929] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [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: 05/02/2021] [Revised: 12/12/2021] [Accepted: 12/14/2021] [Indexed: 01/25/2023]
Abstract
Normothermic machine perfusion (NMP) is a novel clinical approach to overcome the limitations of traditional hypothermic organ preservation. NMP can be used to assess and recondition organs prior to transplant and is the subject of clinical trials in solid organ transplantation. In addition, NMP provides an opportunity to deliver therapeutic agents directly to the organ, thus avoiding many limitations associated with systemic treatment of the recipient. We report the delivery of oligonucleotide-based therapy to human kidneys during NMP, in this case to target microRNA function (antagomir). An antagomir targeting mir-24-3p localized to the endothelium and proximal tubular epithelium. Endosomal uptake during NMP conditions facilitated antagomir co-localization with proteins involved in the RNA-induced silencing complex (RISC) and demonstrated engagement of the miRNA target. This pattern of uptake was not seen during cold perfusion. Targeting mir-24-3p action increased expression of genes controlled by this microRNA, including heme oxygenase-1 and sphingosine-1-phosphate receptor 1. The expression of genes not under the control of mir-24-3p was unchanged, indicating specificity of the antagomir effect. In summary, this is the first report of ex vivo gymnotic delivery of oligonucleotide to the human kidney and demonstrates that NMP provides the platform to bind and block detrimental microRNAs in donor kidneys prior to transplantation.
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Affiliation(s)
- Emily R Thompson
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK.,NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Newcastle upon Tyne, UK
| | - Avinash Sewpaul
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK.,NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Newcastle upon Tyne, UK
| | - Rodrigo Figuereido
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK.,NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Newcastle upon Tyne, UK
| | - Lucy Bates
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Newcastle upon Tyne, UK
| | - Samuel J Tingle
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK.,NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Newcastle upon Tyne, UK
| | - John R Ferdinand
- NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Newcastle upon Tyne, UK.,Department of Medicine, University of Cambridge, Cambridge, UK
| | - Gerhard R Situmorang
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Shameem S Ladak
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Chloe M Connelly
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Sarah A Hosgood
- NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Newcastle upon Tyne, UK.,Department of Surgery, University of Cambridge, Cambridge, UK
| | - Michael L Nicholson
- NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Newcastle upon Tyne, UK.,Department of Surgery, University of Cambridge, Cambridge, UK
| | - Menna R Clatworthy
- NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Newcastle upon Tyne, UK.,Department of Medicine, University of Cambridge, Cambridge, UK
| | - Simi Ali
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Newcastle upon Tyne, UK
| | - Colin H Wilson
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK.,NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Newcastle upon Tyne, UK
| | - Neil S Sheerin
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK.,NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Newcastle upon Tyne, UK
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14
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Carolan C, Tingle SJ, Thompson ER, Sen G, Wilson CH. Comparing outcomes in right versus left kidney transplantation: A systematic review and meta-analysis. Clin Transplant 2021; 35:e14475. [PMID: 34496090 DOI: 10.1111/ctr.14475] [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: 06/13/2021] [Revised: 08/29/2021] [Accepted: 09/02/2021] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Transplantation of right kidneys can pose technical challenges due to the short right renal vein. Whether this results in inferior outcomes remains controversial. METHOD Healthcare Database Advanced Search (HDAS) was used to identify relevant studies. Two authors independently reviewed each study. Statistical analyses were performed using random effects models and results expressed as HR or relative risk (RR) with 95% confidence intervals. Subgroup analyses were performed in kidneys from deceased donors (DD) and living donors (LD). RESULTS A total of 35 studies (257,429 participants) were identified. Both deceased and living donor right kidneys were at increased risk of delayed graft function (DGF; RR = 1.12[1.06-1.18] and RR = 1.33[1.21-1.46] respectively; both p < .0001). In absolute terms, for each 100 kidney pairs of DD kidneys transplanted there are 2.72 (1.67-3.78, p < .00001) excess episodes of DGF in right kidneys. Graft thromboses and graft loss due to technical failure was also significantly more likely in right kidneys, in both DD and LD settings. There was no evidence that laterality alters long term graft survival in LD or DD. CONCLUSION Right kidneys have inferior early outcomes, with higher rates of DGF, technical failure and graft thrombosis. However, these differences are small in absolute terms, and long-term graft survival is equivalent.
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Affiliation(s)
- Caitlin Carolan
- Northumbria Healthcare NHS Foundation Trust, Cramlington, UK
| | - Samuel J Tingle
- Department of HPB and Transplant Surgery, Freeman Hospital, Freeman Rd, High Heaton, Newcastle upon Tyne, UK.,Faculty of Medical Sciences, Newcastle University, Framlington Place, Newcastle upon Tyne, UK
| | - Emily R Thompson
- Department of HPB and Transplant Surgery, Freeman Hospital, Freeman Rd, High Heaton, Newcastle upon Tyne, UK.,Faculty of Medical Sciences, Newcastle University, Framlington Place, Newcastle upon Tyne, UK
| | - Gourab Sen
- Department of HPB and Transplant Surgery, Freeman Hospital, Freeman Rd, High Heaton, Newcastle upon Tyne, UK
| | - Colin H Wilson
- Department of HPB and Transplant Surgery, Freeman Hospital, Freeman Rd, High Heaton, Newcastle upon Tyne, UK.,Faculty of Medical Sciences, Newcastle University, Framlington Place, Newcastle upon Tyne, UK
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Jordan NP, Tingle SJ, Shuttleworth VG, Cooke K, Redgrave RE, Singh E, Glover EK, Ahmad Tajuddin HB, Kirby JA, Arthur HM, Ward C, Sheerin NS, Ali S. MiR-126-3p Is Dynamically Regulated in Endothelial-to-Mesenchymal Transition during Fibrosis. Int J Mol Sci 2021; 22:ijms22168629. [PMID: 34445337 PMCID: PMC8395326 DOI: 10.3390/ijms22168629] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [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: 07/07/2021] [Revised: 07/30/2021] [Accepted: 08/04/2021] [Indexed: 02/06/2023] Open
Abstract
In fibrotic diseases, myofibroblasts derive from a range of cell types including endothelial-to-mesenchymal transition (EndMT). Increasing evidence suggests that miRNAs are key regulators in biological processes but their profile is relatively understudied in EndMT. In human umbilical vein endothelial cells (HUVEC), EndMT was induced by treatment with TGFβ2 and IL1β. A significant decrease in endothelial markers such as VE-cadherin, CD31 and an increase in mesenchymal markers such as fibronectin were observed. In parallel, miRNA profiling showed that miR-126-3p was down-regulated in HUVECs undergoing EndMT and over-expression of miR-126-3p prevented EndMT, maintaining CD31 and repressing fibronectin expression. EndMT was investigated using lineage tracing with transgenic Cdh5-Cre-ERT2; Rosa26R-stop-YFP mice in two established models of fibrosis: cardiac ischaemic injury and kidney ureteric occlusion. In both cardiac and kidney fibrosis, lineage tracing showed a significant subpopulation of endothelial-derived cells expressed mesenchymal markers, indicating they had undergone EndMT. In addition, miR-126-3p was restricted to endothelial cells and down-regulated in murine fibrotic kidney and heart tissue. These findings were confirmed in patient kidney biopsies. MiR-126-3p expression is restricted to endothelial cells and is down-regulated during EndMT. Over-expression of miR-126-3p reduces EndMT, therefore, it could be considered for miRNA-based therapeutics in fibrotic organs.
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Affiliation(s)
- Nina P. Jordan
- Theme-Immunity and Inflammation, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE2 4HH, UK; (N.P.J.); (S.J.T.); (V.G.S.); (K.C.); (E.K.G.); (H.B.A.T.); (J.A.K.); (C.W.); (N.S.S.)
- Inserm U1082, F-86000 Poitiers, France
| | - Samuel J. Tingle
- Theme-Immunity and Inflammation, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE2 4HH, UK; (N.P.J.); (S.J.T.); (V.G.S.); (K.C.); (E.K.G.); (H.B.A.T.); (J.A.K.); (C.W.); (N.S.S.)
| | - Victoria G. Shuttleworth
- Theme-Immunity and Inflammation, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE2 4HH, UK; (N.P.J.); (S.J.T.); (V.G.S.); (K.C.); (E.K.G.); (H.B.A.T.); (J.A.K.); (C.W.); (N.S.S.)
| | - Katie Cooke
- Theme-Immunity and Inflammation, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE2 4HH, UK; (N.P.J.); (S.J.T.); (V.G.S.); (K.C.); (E.K.G.); (H.B.A.T.); (J.A.K.); (C.W.); (N.S.S.)
| | - Rachael E. Redgrave
- Biosciences Institute, Newcastle University, Newcastle upon Tyne NE1 3BZ, UK; (R.E.R.); (E.S.); (H.M.A.)
| | - Esha Singh
- Biosciences Institute, Newcastle University, Newcastle upon Tyne NE1 3BZ, UK; (R.E.R.); (E.S.); (H.M.A.)
| | - Emily K. Glover
- Theme-Immunity and Inflammation, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE2 4HH, UK; (N.P.J.); (S.J.T.); (V.G.S.); (K.C.); (E.K.G.); (H.B.A.T.); (J.A.K.); (C.W.); (N.S.S.)
| | - Hafiza B. Ahmad Tajuddin
- Theme-Immunity and Inflammation, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE2 4HH, UK; (N.P.J.); (S.J.T.); (V.G.S.); (K.C.); (E.K.G.); (H.B.A.T.); (J.A.K.); (C.W.); (N.S.S.)
| | - John A. Kirby
- Theme-Immunity and Inflammation, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE2 4HH, UK; (N.P.J.); (S.J.T.); (V.G.S.); (K.C.); (E.K.G.); (H.B.A.T.); (J.A.K.); (C.W.); (N.S.S.)
| | - Helen M. Arthur
- Biosciences Institute, Newcastle University, Newcastle upon Tyne NE1 3BZ, UK; (R.E.R.); (E.S.); (H.M.A.)
| | - Chris Ward
- Theme-Immunity and Inflammation, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE2 4HH, UK; (N.P.J.); (S.J.T.); (V.G.S.); (K.C.); (E.K.G.); (H.B.A.T.); (J.A.K.); (C.W.); (N.S.S.)
| | - Neil S. Sheerin
- Theme-Immunity and Inflammation, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE2 4HH, UK; (N.P.J.); (S.J.T.); (V.G.S.); (K.C.); (E.K.G.); (H.B.A.T.); (J.A.K.); (C.W.); (N.S.S.)
| | - Simi Ali
- Theme-Immunity and Inflammation, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE2 4HH, UK; (N.P.J.); (S.J.T.); (V.G.S.); (K.C.); (E.K.G.); (H.B.A.T.); (J.A.K.); (C.W.); (N.S.S.)
- Correspondence: ; Tel.: +44-(0)191-208-7158
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Tingle SJ, Thompson ER, Figueiredo RS, Mahendran B, Pandanaboyana S, Wilson CH. Machine perfusion in liver transplantation: a network meta-analysis. Hippokratia 2021. [DOI: 10.1002/14651858.cd014685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Samuel J Tingle
- NIHR Blood and Transplant Research Unit; Newcastle University and Cambridge University; Newcastle upon Tyne UK
| | - Emily R Thompson
- Institute of Transplantation; The Freeman Hospital; Newcastle upon Tyne UK
| | | | | | - Sanjay Pandanaboyana
- HPB and Liver Transplant Surgery; Freeman Hospital, The Newcastle upon Tyne Hospitals NHS Foundation Trust; Newcastle upon Tyne UK
| | - Colin H Wilson
- Institute of Transplantation; The Freeman Hospital; Newcastle upon Tyne UK
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17
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Barker CJ, Marriot A, Khan M, Oswald T, Tingle SJ, Partington PF, Carluke I, Reed MR. Hip aspiration culture: analysing data from a single operator series investigating periprosthetic joint infection. J Bone Jt Infect 2021; 6:165-170. [PMID: 34084706 PMCID: PMC8137858 DOI: 10.5194/jbji-6-165-2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 04/09/2021] [Indexed: 01/29/2023] Open
Abstract
Introduction:
We undertook this study to know the sensitivity, specificity and post-test
probabilities of hip aspiration when diagnosing periprosthetic hip infections. We also examined “dry tap” (injection with saline and
aspiration) results and aspiration volumes.
Methods:
This is a retrospective cohort study of patients aspirated for suspected
periprosthetic joint infection between July 2012 and October 2016. All aspirations were carried out by one trained surgical care practitioner
(SCP). All aspirations followed an aseptic technique and fluoroscopic guidance. Aspiration was compared to tissue biopsy taken at revision.
Aspiration volumes were analysed for comparison.
Results:
Between January 2012 and September 2016, 461 hip aspirations were performed
by our SCP. Of these 125 progressed to revision. We calculated sensitivity
59 % (confidence interval (CI) 35 %–82 %) and specificity 94 % (CI
89 %–98 %). Pre-test probability for our cohort was 0.14. Positive post-test
probability was 0.59 and negative post-test probability 0.06. Aspiration
volume for infected (n=17) and non-infected (n=108) joints was compared
and showed no significant difference. Dry taps were experienced five times; in each instance the dry tap agreed with the biopsy result.
Conclusions:
Our data show that hip aspiration culture is a highly specific investigation
for diagnosing infection but that it is not sensitive. Aspiration volume
showed no significant difference between infected and non-infected groups.
Each time a joint was infiltrated with saline to achieve a result, the result matched tissue sampling.
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Affiliation(s)
| | - Alan Marriot
- Northumbria Healthcare NHS Foundation Trust, Cramlington, NE23 6NZ, UK
| | - Munir Khan
- Northumbria Healthcare NHS Foundation trust, Cramlington, NE23 6NZ, UK
| | - Tamsin Oswald
- Northumbria Healthcare NHS Foundation Trust, Cramlington, NE23 6NZ, UK
| | - Samuel J Tingle
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, Newcastle upon Tyne, NE7 7DN, UK
| | - Paul F Partington
- Northumbria Healthcare NHS Foundation Trust, Cramlington, NE23 6NZ, UK
| | - Ian Carluke
- Northumbria Healthcare NHS Foundation Trust, Cramlington, NE23 6NZ, UK
| | - Mike R Reed
- Northumbria Healthcare NHS Foundation Trust, Cramlington, NE23 6NZ, UK
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18
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Innes AH, Tingle SJ, Ibrahim I, Thompson E, Bates L, Manas D, White S, Wilson C. O59: USE OF DEXTRAN 40 FOLLOWING PANCREAS TRANSPLANT MAY REDUCE EARLY INFLAMMATION AND SIGNIFICANT BLEEDING COMPARED TO A HEPARIN-BASED PROTOCOL. Br J Surg 2021. [DOI: 10.1093/bjs/znab117.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Introduction
Dextran 40 (D40) is a synthetic colloid with anticoagulant properties, which is commonly used instead of heparin following pancreas transplantation, however there is a lack of evidence over which is more effective. Graft thrombosis and pancreatitis, which may be mediated through micro or macrothrombosis within the graft, remain significant complications following pancreas transplantation. We hypothesised that D40 reduces inflammation through its antithrombotic pro-microcirculatory effects. We aimed to evaluate D40 compared to a heparin-based protocol by comparing post-operative complications and post-transplant levels of inflammation.
Method
Data were collected retrospectively for pancreas transplant patients between December 2009 and August 2018 – 26 patients had been treated with the pre-Dextran protocol and 37 had received D40. Post-operative complications and inflammatory markers (WCC, CRP and amylase) on post-operative days 1, 2, 3 and 7 were compared between the two groups. Potential confounders were also recorded.
Result
Patients in the D40 group had similar thrombosis rates but were less likely to have had substantial post-operative bleeding compared to the heparin-based protocol. The group who received D40 had significantly lower CRP and WCC on days 2, 3 and 7. The differences on days 3 and 7 remained when the results were adjusted for the significant confounders - cold ischaemic time and donor age.
Conclusion
D40 appears to be as effective as IV heparin at preventing graft thrombosis following pancreas transplant, and to confer a reduced risk of bleeding. It may also reduce post-operative inflammatory processes, leading to reduced graft pancreatitis.
Take-home message
Using Dextran 40 as an anticoagulant after pancreas transplantation is as effective as IV heparin at preventing graft thromboses and has a reduced risk of bleeding.
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Affiliation(s)
- AH Innes
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne
| | - SJ Tingle
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne
| | - I Ibrahim
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne
| | - E Thompson
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne
| | - L Bates
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne
| | - D Manas
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne
| | - S White
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne
| | - C Wilson
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne
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19
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Tingle SJ, Ramsingh JK, Bliss RD, Truran PP. O73: IMPROVING CONSENT WITH A VISUAL TOOL FOR COMMUNICATING SURGICAL RISKS. Br J Surg 2021. [DOI: 10.1093/bjs/znab117.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Introduction
Patients must understand the risks of a procedure to provide valid consent. Guidance from the General Medical Council and Royal College of Surgeons of England highlights that surgeons need to communicate risks in a way that patients can understand, and both institutions specifically mention the use of written information. We aimed to improve communication of surgical risks to patients undergoing thyroid surgery.
Method
Over 3 months, all patients undergoing thyroid surgery in a tertiary referral centre were included (n=51). Participants were given a 10 point questionnaire after the consent process. Each question had 4 options (very common, common, uncommon and rare) and tested participant understanding of surgical risks. Our intervention was a single page annotated graphic, which used a traffic-light system to explain surgical risks.
Result
When consented prior to our intervention (n=28), patient understanding of the magnitude of surgical risks was poor; median questionnaire score was 4.5 out of 10, and for some questions <15% of participants selected the correct answer. Following introduction of our surgical risk tool (n=23) median overall participant score increased from 4.5 (range 2-7) to 8.0 (4-10) out of 10 (P<0.0001; Mann-Whitney U test).
Conclusion
Patients must understand the risks of an operation, and the magnitude of those risks, in order to provide valid consent. Addition of a visual surgical risk tool enabled us to increase patient understanding of surgical risks, improving the consent process. This has implications not just for thyroid surgery, but for any procedure requiring consent.
Take-home message
Clear communication of surgical risks is essential to obtain valid consent. The use of a visual surgical risk tool increases patient understanding of risks, and therefore improves the consent process.
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Affiliation(s)
- SJ Tingle
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne
| | - JK Ramsingh
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne
| | - RD Bliss
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne
| | - PP Truran
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne
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20
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Tingle SJ, Thompson ER, Ali SS, Ibrahim IK, Irwin E, Sen G, White SA, Manas DM, Wilson CH. O6: EARLY ANASTOMOTIC BILIARY COMPLICATIONS AFTER LIVER TRANSPLANTATION. Br J Surg 2021. [DOI: 10.1093/bjs/znab117.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Introduction
Biliary leaks and anastomotic strictures are common early biliary complications (EBC) following liver transplantation. However, their impact on outcomes remains controversial and poorly described.
Method
The NHS registry on adult liver transplantation between 2006 and 2017 was retrospectively reviewed (n=8304). Multiple imputations were performed to account for missing data. Adjusted regression models were used to assess predictors of EBC, and their impact on outcomes. 35 potential variables were included, and backwards stepwise selection enabled unbiased selection of variables for inclusion in final models.
Result
EBC occurred in 9.6% of patients. Adjusted cox regression revealed that EBCs have a significant and independent impact on graft survival (Leak HR=1.325; P=0.021, Stricture HR=1.514; P=0.002, Leak plus stricture HR=1.533; P=0.034) and patient survival (Leak HR=1.218; P=0.131, Stricture HR=1.578; P<0.001, Leak plus stricture HR=1.507; P=0.044). Patients with EBC had longer median hospital stay (23 versus 15 days; P<0.001) and increased chance for readmission within the first year (56% versus 32%; P<0.001). On adjusted logistic regression the following were identified as independent risk factors for development of EBC: donation following circulatory death (OR=1.280; P=0.009), accessory hepatic artery (OR=1.324; P=0.005), vascular anastomosis time in minutes (OR=1.005; P=0.032) and ethnicity ‘other’ (OR=1.838; P=0.011).
Conclusion
EBCs prolong hospital stay, increase readmission rates and are independent risk factors for diminished graft survival and increased mortality in liver transplantation. We have identified factors that increase the likelihood of EBC occurrence; further research into interventions to prevent EBCs in these at-risk groups is vital to improve liver transplantation outcomes.
Take-home message
Using a large registry database we have shown that early anastomotic biliary complications are independent risk factors for decreased graft survival and increased mortality after liver transplantation. Research into interventions to prevent biliary complications in high risk groups are essential to improve liver transplant outcomes.
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Affiliation(s)
- SJ Tingle
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - ER Thompson
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - SS Ali
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - IK Ibrahim
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - E Irwin
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - G Sen
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - SA White
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - DM Manas
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - CH Wilson
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
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21
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Tingle SJ, Thompson ER, Ali SS, Figueiredo R, Hudson M, Sen G, White SA, Manas DM, Wilson CH. Risk factors and impact of early anastomotic biliary complications after liver transplantation: UK registry analysis. BJS Open 2021; 5:6226008. [PMID: 33855363 PMCID: PMC8047096 DOI: 10.1093/bjsopen/zrab019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 02/15/2021] [Indexed: 12/15/2022] Open
Abstract
Background Biliary leaks and anastomotic strictures are common early anastomotic biliary complications (EABCs) following liver transplantation. However, there are no large multicentre studies investigating their clinical impact or risk factors. This study aimed to define the incidence, risk factors and impact of EABC. Methods The NHS registry on adult liver transplantation between 2006 and 2017 was reviewed retrospectively. Adjusted regression models were used to assess predictors of EABC, and their impact on outcomes. Results Analyses included 8304 liver transplant recipients. Patients with EABC (9·6 per cent) had prolonged hospitalization (23 versus 15 days; P < 0·001) and increased chance for readmission within the first year (56 versus 32 per cent; P < 0·001). Patients with EABC had decreased estimated 5-year graft survival of 75·1 versus 84·5 per cent in those without EABC, and decreased 5-year patient survival of 76·9 versus 83·3 per cent; both P < 0.001. Adjusted Cox regression revealed that EABCs have a significant and independent impact on graft survival (leak hazard ratio (HR) 1·344, P = 0·015; stricture HR 1·513, P = 0·002; leak plus stricture HR 1·526, P = 0·036) and patient survival (leak HR 1·215, P = 0·136, stricture HR 1·526, P = 0·001; leak plus stricture HR 1·509; P = 0·043). On adjusted logistic regression, risk factors for EABC included donation after circulatory death grafts, graft aberrant arterial anatomy, biliary anastomosis type, vascular anastomosis time and recipient model of end-stage liver disease. Conclusion EABCs prolong hospital stay, increase readmission rates and are independent risk factors for graft loss and increased mortality. This study has identified factors that increase the likelihood of EABC occurrence; research into interventions to prevent EABCs in these at-risk groups is vital to improve liver transplantation outcomes.
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Affiliation(s)
- S J Tingle
- National Institute for Health Research Blood and Transplant Research Unit (NIHR BTRU) in Organ Donation and Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne UK
| | - E R Thompson
- National Institute for Health Research Blood and Transplant Research Unit (NIHR BTRU) in Organ Donation and Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne UK
| | - S S Ali
- Faculty of Medical Sciences, Imperial College London, South Kensington, London, UK
| | - R Figueiredo
- National Institute for Health Research Blood and Transplant Research Unit (NIHR BTRU) in Organ Donation and Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne UK
| | - M Hudson
- Department of Hepatology, Freeman Hospital, Newcastle upon Tyne, UK
| | - G Sen
- National Institute for Health Research Blood and Transplant Research Unit (NIHR BTRU) in Organ Donation and Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne UK
| | - S A White
- National Institute for Health Research Blood and Transplant Research Unit (NIHR BTRU) in Organ Donation and Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne UK
| | - D M Manas
- National Institute for Health Research Blood and Transplant Research Unit (NIHR BTRU) in Organ Donation and Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne UK
| | - C H Wilson
- National Institute for Health Research Blood and Transplant Research Unit (NIHR BTRU) in Organ Donation and Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne UK
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22
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Tingle SJ, Thompson ER, Bates L, Ibrahim IK, Figueiredo R, Bury Y, Wilson CH. Microvascular obstructions in portal bile duct capillaries and hepatic sinusoids during normothermic machine perfusion of marginal human livers. Am J Transplant 2021; 21:1662-1664. [PMID: 33037747 DOI: 10.1111/ajt.16337] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Samuel J Tingle
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - Emily R Thompson
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - Lucy Bates
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - Ibrahim K Ibrahim
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | | | - Yvonne Bury
- Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Colin H Wilson
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
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23
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Thompson ER, Bates L, Ibrahim IK, Sewpaul A, Stenberg B, McNeill A, Figueiredo R, Girdlestone T, Wilkins GC, Wang L, Tingle SJ, Scott WE, de Paula Lemos H, Mellor AL, Roobrouck VD, Ting AE, Hosgood SA, Nicholson ML, Fisher AJ, Ali S, Sheerin NS, Wilson CH. Novel delivery of cellular therapy to reduce ischemia reperfusion injury in kidney transplantation. Am J Transplant 2021; 21:1402-1414. [PMID: 32506663 DOI: 10.1111/ajt.16100] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/15/2020] [Accepted: 05/21/2020] [Indexed: 02/06/2023]
Abstract
Ex vivo normothermic machine perfusion (NMP) of donor kidneys prior to transplantation provides a platform for direct delivery of cellular therapeutics to optimize organ quality prior to transplantation. Multipotent Adult Progenitor Cells (MAPC® ) possess potent immunomodulatory properties that could minimize ischemia reperfusion injury. We investigated the potential capability of MAPC cells in kidney NMP. Pairs (5) of human kidneys, from the same donor, were simultaneously perfused for 7 hours. Kidneys were randomly allocated to receive MAPC treatment or control. Serial samples of perfusate, urine, and tissue biopsies were taken for comparison. MAPC-treated kidneys demonstrated improved urine output (P = .009), decreased expression of injury biomarker NGAL (P = .012), improved microvascular perfusion on contrast-enhanced ultrasound (cortex P = .019, medulla P = .001), downregulation of interleukin (IL)-1β (P = .050), and upregulation of IL-10 (P < .047) and Indolamine-2, 3-dioxygenase (P = .050). A chemotaxis model demonstrated decreased neutrophil recruitment when stimulated with perfusate from MAPC-treated kidneys (P < .001). Immunofluorescence revealed prelabeled MAPC cells in the perivascular space of kidneys during NMP. We report the first successful delivery of cellular therapy to a human kidney during NMP. Kidneys treated with MAPC cells demonstrate improvement in clinically relevant parameters and injury biomarkers. This novel method of cell therapy delivery provides an exciting opportunity to recondition organs prior to transplantation.
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Affiliation(s)
- Emily R Thompson
- NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK.,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Lucy Bates
- NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK.,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Ibrahim K Ibrahim
- NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - Avinash Sewpaul
- NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - Ben Stenberg
- Department of Radiology, Freeman Hospital, Newcastle upon Tyne, UK
| | - Andrew McNeill
- Department of Radiology, Freeman Hospital, Newcastle upon Tyne, UK
| | - Rodrigo Figueiredo
- NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - Tom Girdlestone
- NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK.,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Georgina C Wilkins
- NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK.,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Lu Wang
- NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK.,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Samuel J Tingle
- NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - William E Scott
- NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK.,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Henrique de Paula Lemos
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Andrew L Mellor
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | | | - Sarah A Hosgood
- NIHR Blood and Transplant Research Unit, Department of Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Michael L Nicholson
- NIHR Blood and Transplant Research Unit, Department of Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Andrew J Fisher
- NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK.,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Simi Ali
- NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK.,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Neil S Sheerin
- NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK.,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Colin H Wilson
- NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK.,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
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Abstract
BACKGROUND Graft thrombosis is a well-recognised complication of solid organ transplantation and is one of the leading causes of graft failure. Currently there are no standardised protocols for thromboprophylaxis. Many transplant units use unfractionated heparin (UFH) and fractionated heparins (low molecular weight heparin; LMWH) as prophylaxis for thrombosis. Antiplatelet agents such as aspirin are routinely used as prophylaxis of other thrombotic conditions and may have a role in preventing graft thrombosis. However, any pharmacological thromboprophylaxis comes with the theoretical risk of increasing the risk of major blood loss following transplant. This review looks at benefits and harms of thromboprophylaxis in patients undergoing solid organ transplantation. OBJECTIVES To assess the benefits and harms of instituting thromboprophylaxis to patients undergoing solid organ transplantation. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 10 November 2020 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA We included all randomised controlled trials (RCTs) and quasi-RCTs designed to examine interventions to prevent thrombosis in solid organ transplant recipients. All donor types were included (donor after circulatory (DCD) and brainstem death (DBD) and live transplantation). There was no upper age limit for recipients in our search. DATA COLLECTION AND ANALYSIS The results of the literature search were screened and data collected by two independent authors. Dichotomous outcome results were expressed as risk ratio (RR) with 95% confidence intervals (CI). Random effects models were used for data analysis. Risk of bias was independently assessed by two authors using the risk of bias assessment tool. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS We identified nine studies (712 participants). Seven studies (544 participants) included kidney transplant recipients, and studies included liver transplant recipients. We did not identify any study enrolling heart, lung, pancreas, bowel, or any other solid organ transplant recipient. Selection bias was high or unclear in eight of the nine studies; five studies were at high risk of bias for performance and/or detection bias; while attrition and reporting biases were in general low or unclear. Three studies (180 participants) primarily investigated heparinisation in kidney transplantation. Only two studies reported on graft vessel thrombosis in kidney transplantation (144 participants). These small studies were at high risk of bias in several domains and reported only two graft thromboses between them; it therefore remains unclear whether heparin decreases the risk of early graft thrombosis or non-graft thrombosis (very low certainty). UFH may make little or no difference versus placebo to the rate of major bleeding events in kidney transplantation (3 studies, 155 participants: RR 2.92, 95% CI 0.89 to 9.56; I² = 0%; low certainty evidence). Sensitivity analysis using a fixed-effect model suggested that UFH may increase the risk of haemorrhagic events compared to placebo (RR 3.33, 95% CI 1.04 to 10.67, P = 0.04). Compared to control, any heparin (including LMWH) may make little or no difference to the number of major bleeding events (3 studies, 180 participants: RR 2.70, 95% CI 0.89 to 8.19; I² = 0%; low certainty evidence) and had an unclear effect on risk of readmission to intensive care (3 studies, 180 participants: RR 0.68, 95% CI 0.12 to 3.90, I² = 45%; very low certainty evidence). The effect of heparin on our other outcomes (including death, patient and graft survival, transfusion requirements) remains unclear (very low certainty evidence). Three studies (144 participants) investigated antiplatelet interventions in kidney transplantation: aspirin versus dipyridamole (1), and Lipo-PGE1 plus low-dose heparin to "control" in patients who had a diagnosis of acute rejection (2). None of these reported on early graft thromboses. The effect of aspirin, dipyridamole and Lipo PGE1 plus low-dose heparin on any outcomes is unclear (very low certainty evidence). Two studies (168 participants) assessed interventions in liver transplants. One compared warfarin versus aspirin in patients with pre-existing portal vein thrombosis and the other investigated plasmapheresis plus anticoagulation. Both studies were abstract-only publications, had high risk of bias in several domains, and no outcomes could be meta-analysed. Overall, the effect of any of these interventions on any of our outcomes remains unclear with no evidence to guide anti-thrombotic therapy in standard liver transplant recipients (very low certainty evidence). AUTHORS' CONCLUSIONS Overall, there is a paucity of research in the field of graft thrombosis prevention. Due to a lack of high quality evidence, it remains unclear whether any therapy is able to reduce the rate of early graft thrombosis in any type of solid organ transplant. UFH may increase the risk of major bleeding in kidney transplant recipients, however this is based on low certainty evidence. There is no evidence from RCTs to guide anti-thrombotic strategies in liver, heart, lung, or other solid organ transplants. Further studies are required in comparing anticoagulants, antiplatelets to placebo in solid organ transplantation. These should focus on outcomes such as early graft thrombosis, major haemorrhagic complications, return to theatre, and patient/graft survival.
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Affiliation(s)
| | - Thomas J Hoather
- Department of Education, Newcastle University, Newcastle Upon Tyne, UK
| | - Samuel J Tingle
- NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, UK
| | - Emily R Thompson
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
| | - John Hanley
- Department of Haematology, Newcastle upon Tyne Acute Hospitals, Newcastle upon Tyne, UK
| | - Colin H Wilson
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
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Tingle SJ, Ibrahim I, Thompson ER, Bates L, Sivaharan A, Bury Y, Figuereido R, Wilson C. Methaemoglobinaemia Can Complicate Normothermic Machine Perfusion of Human Livers. Front Surg 2021; 8:634777. [PMID: 33598479 PMCID: PMC7882904 DOI: 10.3389/fsurg.2021.634777] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 01/04/2021] [Indexed: 01/14/2023] Open
Abstract
Background: Although liver normothermic machine perfusion is increasingly used clinically, there are few reports of complications or adverse events. Many centers perform liver NMP to viability test suboptimal grafts, often for prolonged periods. In addition, several researchers are investigating NMP as a drug delivery platform, which usually necessitates prolonged perfusion of otherwise non-viable liver grafts. We describe two instances of methaemoglobinaemia during NMP of suboptimal livers. Methods: The NMP of eight human livers rejected for transplantation is described. Methaemoglobinaeima developed in two; one perfused using generic Medtronic™ perfusion equipment and one using the OrganOx Metra®. Results: The first liver (53 years DBD) developed methaemoglobinaemia (metHb = 2.4%) after 13 h of NMP, increasing to metHb = 19% at 16 h. Another liver (45 years DBD) developed methaemoglobinaemia at 25 h (metHb = 2.8%), which increased to metHb = 28.2% at 38 h. Development of methaemoglobinaemia was associated with large reductions in oxygen delivery and oxygen extraction. Both livers were steatotic and showed several suboptimal features on viability testing. Delivery of methylene blue failed to reverse the methaemoglobinaemia. Compared to a matched cohort of steatotic organs, livers which developed methaemoglobinaemia showed significantly higher levels of hemolysis at 12 h (prior to development of methaemoglobinaemia). Conclusions: Methaemglobinaemia is a complication of NMP of suboptimal liver grafts, not limited to a single machine or perfusion protocol. It can occur within 13 h (a timepoint frequently surpassed when NMP is used clinically) and renders further perfusion futile. Therefore, metHb should be monitored during NMP visually and using blood gas analysis.
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Affiliation(s)
- Samuel J Tingle
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom.,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Ibrahim Ibrahim
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom.,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Emily R Thompson
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom.,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Lucy Bates
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom.,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Ashwin Sivaharan
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Yvonne Bury
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom.,Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Rodrigo Figuereido
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom.,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Colin Wilson
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom
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Goodfellow M, Thompson ER, Tingle SJ, Wilson CH. Early versus late removal of urinary catheter after kidney transplantation. Hippokratia 2020. [DOI: 10.1002/14651858.cd013788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Michael Goodfellow
- Institute of Transplantation; The Freeman Hospital; Newcastle upon Tyne UK
| | - Emily R Thompson
- Institute of Transplantation; The Freeman Hospital; Newcastle upon Tyne UK
| | - Samuel J Tingle
- Institute of Transplantation; The Freeman Hospital; Newcastle upon Tyne UK
| | - Colin H Wilson
- Institute of Transplantation; The Freeman Hospital; Newcastle upon Tyne UK
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Abdelghany TM, Leitch AC, Nevjestić I, Ibrahim I, Tingle SJ, Miwa S, Sandrine H, Wilson C, Wright MC. Investigating the Structure‐Toxicity Relationship of Methylimidazolium Ionic Liquids in Isolated Primary Human Hepatocytes. FASEB J 2020. [DOI: 10.1096/fasebj.2020.34.s1.00697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Tarek M. Abdelghany
- Institute Cellular Medicine Newcastle University
- Faculty of Pharmacy Cairo University
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Tingle SJ, Figueiredo RS, Moir JA, Goodfellow M, Thompson ER, Ibrahim IK, Bates L, Talbot D, Wilson CH. Hypothermic machine perfusion is superior to static cold storage in deceased donor kidney transplantation: A meta-analysis. Clin Transplant 2020; 34:e13814. [PMID: 32031711 DOI: 10.1111/ctr.13814] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [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: 07/17/2019] [Revised: 12/27/2019] [Accepted: 02/03/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND There remains a lack of consensus on the optimal storage method for deceased donor kidneys. This meta-analysis compares storage with hypothermic machine perfusion (HMP) vs traditional static cold storage (SCS). METHODS The Cochrane Kidney and Transplant Specialised Register was searched to identify (quasi-) randomized controlled trials (RCTs) to include in our meta-analysis. PRISMA guidelines were used to perform and write this review. RESULTS There is high-certainty evidence that HMP reduces the risk of delayed graft function (DGF) when compared to SCS (2138 participants from 14 studies, RR = 0.77; 0.67-0.90, P = .0006). This benefit is significant in both donation following circulatory death (DCD; 772 patients from seven studies, RR = 0.75; 0.64-0.87, P = .0002) and donation following brainstem death (DBD) grafts (971 patients from four studies, RR = 0.78; 0.65-0.93, P = .006). The number of perfusions required to prevent one episode of DGF was 7.26 and 13.60 in DCD and DBD grafts, respectively. There is strong evidence that HMP also improves graft survival in both DBD and DCD grafts, at both 1 and 3 years. Economic analyses suggest HMP is cost-saving at 1 year compared with SCS. CONCLUSION Hypothermic machine perfusion is superior to SCS in deceased donor renal transplantation. Direct comparisons with normothermic machine perfusion in RCTs are essential to identify optimal preservation methods in kidney transplantation.
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Affiliation(s)
- Samuel J Tingle
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, United Kingdom.,Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Rodrigo S Figueiredo
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - John Ag Moir
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Michael Goodfellow
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, United Kingdom.,Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Emily R Thompson
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, United Kingdom.,Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Ibrahim K Ibrahim
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, United Kingdom.,Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Lucy Bates
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, United Kingdom.,Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - David Talbot
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Colin H Wilson
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, United Kingdom.,Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
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Tingle SJ, Sewpaul A, Bates L, Thompson ER, Shuttleworth V, Figueiredo R, Ibrahim IK, Ali S, Wilson C, Sheerin NS. Dual MicroRNA Blockade Increases Expression of Antioxidant Protective Proteins: Implications for Ischemia-Reperfusion Injury. Transplantation 2020; 104:1853-1861. [DOI: 10.1097/tp.0000000000003215] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Tingle SJ, Figueiredo RS, Moir JAG, Goodfellow M, Talbot D, Wilson CH. Machine perfusion preservation versus static cold storage for deceased donor kidney transplantation. Cochrane Database Syst Rev 2019; 3:CD011671. [PMID: 30875082 PMCID: PMC6419919 DOI: 10.1002/14651858.cd011671.pub2] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Kidney transplantation is the optimal treatment for end-stage kidney disease. Retrieval, transport and transplant of kidney grafts causes ischaemia reperfusion injury. The current accepted standard is static cold storage (SCS) whereby the kidney is stored on ice after removal from the donor and then removed from the ice box at the time of implantation. However, technology is now available to perfuse or "pump" the kidney during the transport phase or at the recipient centre. This can be done at a variety of temperatures and using different perfusates. The effectiveness of treatment is manifest clinically as delayed graft function (DGF), whereby the kidney fails to produce urine immediately after transplant. OBJECTIVES To compare hypothermic machine perfusion (HMP) and (sub)normothermic machine perfusion (NMP) with standard SCS. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies to 18 October 2018 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA All randomised controlled trials (RCTs) and quasi-RCTs comparing HMP/NMP versus SCS for deceased donor kidney transplantation were eligible for inclusion. All donor types were included (donor after circulatory (DCD) and brainstem death (DBD), standard and extended/expanded criteria donors). Both paired and unpaired studies were eligible for inclusion. DATA COLLECTION AND ANALYSIS The results of the literature search were screened and a standard data extraction form was used to collect data. Both of these steps were performed by two independent authors. Dichotomous outcome results were expressed as risk ratio (RR) with 95% confidence intervals (CI). Continuous scales of measurement were expressed as a mean difference (MD). Random effects models were used for data analysis. The primary outcome was incidence of DGF. Secondary outcomes included: one-year graft survival, incidence of primary non-function (PNF), DGF duration, long term graft survival, economic implications, graft function, patient survival and incidence of acute rejection. MAIN RESULTS No studies reported on NMP, however one ongoing study was identified.Sixteen studies (2266 participants) comparing HMP with SCS were included; 15 studies could be meta-analysed. Fourteen studies reported on requirement for dialysis in the first week post-transplant (DGF incidence); there is high-certainty evidence that HMP reduces the risk of DGF when compared to SCS (RR 0.77; 95% CI 0.67 to 0.90; P = 0.0006). HMP reduces the risk of DGF in kidneys from DCD donors (7 studies, 772 participants: RR 0.75; 95% CI 0.64 to 0.87; P = 0.0002; high certainty evidence), as well as kidneys from DBD donors (4 studies, 971 participants: RR 0.78, 95% CI 0.65 to 0.93; P = 0.006; high certainty evidence). The number of perfusions required to prevent one episode of DGF (number needed to treat, NNT) was 7.26 and 13.60 in DCD and DBD kidneys respectively. Studies performed in the last decade all used the LifePort machine and confirmed that HMP reduces the incidence of DGF in the modern era (5 studies, 1355 participants: RR 0.77, 95% CI 0.66 to 0.91; P = 0.002; high certainty evidence). Reports of economic analysis suggest that HMP can lead to cost savings in both the North American and European settings.Two studies reported HMP also improves graft survival however we were not able to meta-analyse these results. A reduction in incidence of PNF could not be demonstrated. The effect of HMP on our other outcomes (incidence of acute rejection, patient survival, hospital stay, long-term graft function, duration of DGF) remains uncertain. AUTHORS' CONCLUSIONS HMP is superior to SCS in deceased donor kidney transplantation. This is true for both DBD and DCD kidneys, and remains true in the modern era (studies performed in the last decade). As kidneys from DCD donors have a higher overall DGF rate, fewer perfusions are needed to prevent one episode of DGF (7.26 versus 13.60 in DBD kidneys).Further studies looking solely at the impact of HMP on DGF incidence are not required. Follow-up reports detailing long-term graft survival from participants of the studies already included in this review would be an efficient way to generate further long-term graft survival data.Economic analysis, based on the results of this review, would help cement HMP as the standard preservation method in deceased donor kidney transplantation.RCTs investigating (sub)NMP are required.
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Affiliation(s)
- Samuel J Tingle
- Newcastle University Medical SchoolFaculty of Medical SciencesFramlington PlaceNewcastle upon TyneUKNE2 4HH
| | | | - John AG Moir
- The Freeman HospitalFreeman RdNewcastle upon TyneUKNE7 7DN
| | - Michael Goodfellow
- Newcastle UniversityNewcastle Medical SchoolFramlington PlaceNewcastle upon TyneUKNE2 4HH
| | - David Talbot
- The Freeman HospitalThe Liver/Renal UnitHigh HeatonNewcastle upon TyneUKNE7 7DN
| | - Colin H Wilson
- The Freeman HospitalInstitute of TransplantationFreeman RoadHigh HeatonNewcastle upon TyneUKNE7 7DN
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Tingle SJ, Severs GR, Goodfellow M, Moir JA, White SA. NARCA: A novel prognostic scoring system using neutrophil-albumin ratio and Ca19-9 to predict overall survival in palliative pancreatic cancer. J Surg Oncol 2018; 118:680-686. [PMID: 30196571 DOI: 10.1002/jso.25209] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 07/26/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND AND OBJECTIVES Several serum based-markers and ratios have been investigated for their prognostic value in pancreatic ductal adenocarcinoma (PDAC). This cohort study aimed to combine these into a novel prognostic scoring system. METHODS A retrospective cohort study was performed on 145 patients with unresectable histologically-confirmed PDAC. Based on the existing literature the following markers were investigated: neutrophil-lymphocyte ratio (NLR), neutrophil-albumin ratio (NAR), platelet-lymphocyte ratio (PLR), fibrinogen, and Ca19-9. These values were dichotomized about their medians for Kaplan-Meier and Cox regression analysis. RESULTS Univariate Cox regression revealed statistically significant prognostic value for: NLR, NAR, PLR, fibrinogen, and Ca19-9. When combining these using Cox regression analysis adjusting for other prognostic indicators, only NAR (hazard ratios [HR] = 3.174, P = 0.022) and Ca19-9 (HR = 2.697, P = 0.031) were independent predictors of survival. Combining NAR and Ca19-9 we split the cohort into three "NARCA" groups: NARCA0 = NAR ≤ 0.13 and Ca19-9 ≤ 770, NARCA1 = either NAR > 0.13 or Ca19-9 >770, NARCA2 = NAR > 0.13 and Ca19-9 > 770. Median survival was 20.5, 9.7 and 4.1 months in NARCA0, 1, and 2 respectively ( P < 0.0005, log-rank test). A separate validation cohort confirmed the prognostic significance of the score ( P = 0.048). CONCLUSIONS Combining NAR and Ca19-9 into a prognostic score allows stratification of unresectable PDAC patients into groups with significantly different overall survival.
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Affiliation(s)
- Samuel J Tingle
- Department of HPB Surgery, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
| | - George R Severs
- Department of HPB Surgery, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
| | - Michael Goodfellow
- Department of HPB Surgery, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
| | - John A Moir
- Department of HPB Surgery, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
| | - Steven A White
- Department of HPB Surgery, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
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Tingle SJ, Marriott A, Partington PF, Carluke I, Reed MR. Performance and learning curve of a surgical care practitioner in completing hip aspirations. Ann R Coll Surg Engl 2017; 98:543-546. [PMID: 27791410 DOI: 10.1308/rcsann.2016.0315] [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] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The roles of non-medically trained practitioners within the NHS are expanding; they are now being employed by many specialties, including surgery, to relieve pressures on healthcare teams. AIMS To investigate the learning curve and competence of an orthopaedic surgical care practitioner (SCP) in performing hip aspirations. METHODS Data were retrospectively collected on 510 orthopaedic hip aspirations, of which 360 were completed by a single SCP and 150 were completed by surgeons before the SCP took over routine aspiration. The 360 aspirations completed by an SCP were separated into groups of 30 by date, so any trend in failure rate could be analysed. Ordinal χ2 analysis was used to analyse this trend and Pearson χ2 analysis was used to analyse differences in failure rates between professionals. RESULTS The hip aspiration failure rate for the SCP was significantly lower than for the surgeons; 8.6% vs 20.7% (P<0.001). With the experience gained in completing the first 210 procedures, the failure rate of the SCP dropped to 3.3% for the remaining 150 procedures. This downward trend in hip aspiration failure rate, with advancing experience of the SCP, was shown to be statistically significant (P=0.006). DISCUSSION SCPs who complete hip aspirations on a regular basis have significantly lower failure rates than surgeons, probably as a result of the learning curve, which this study demonstrated. Other trusts should consider delegating routine hip aspiration work to a designated SCP to lower failure rates.
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Affiliation(s)
- S J Tingle
- Faculty of Medical Sciences, Newcastle University, Newcastle , Tyne and Wear , UK
| | - A Marriott
- Trauma and Orthopaedics, Northumbria Healthcare, Ashington , Tyne and Wear , UK
| | - P F Partington
- Trauma and Orthopaedics, Northumbria Healthcare, Ashington , Tyne and Wear , UK
| | - I Carluke
- Trauma and Orthopaedics, Northumbria Healthcare, Ashington , Tyne and Wear , UK
| | - M R Reed
- Trauma and Orthopaedics, Northumbria Healthcare, Ashington , Tyne and Wear , UK
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Tingle SJ, Moir JA, White SA. Role of anti-stromal polypharmacy in increasing survival after pancreaticoduodenectomy for pancreatic ductal adenocarcinoma. World J Gastrointest Pathophysiol 2015; 6:235-242. [PMID: 26600982 PMCID: PMC4644888 DOI: 10.4291/wjgp.v6.i4.235] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 07/30/2015] [Accepted: 10/19/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the survival impact of common pharmaceuticals, which target stromal interactions, following a pancreaticoduodenectomy for pancreatic ductal adenocarcinoma.
METHODS: Data was collected retrospectively for 164 patients who underwent a pancreaticoduodenectomy for pancreatic ductal adenocarcinoma (PDAC). Survival analysis was performed on patients receiving the following medications: angiotensin-converting enzyme inhibitors (ACEI)/angiotensin II receptor blockers (ARB), calcium channel blockers (CCB), aspirin, and statins. Statistical analysis included Kaplan-meier survival estimates and cox multivariate regression; the latter of which allowed for any differences in a range of prognostic indicators between groups. Medications showing a significant survival benefit were investigated in combination with other medications to evaluate synergistic effects.
RESULTS: No survival benefit was observed with respect to ACEI/ARB (n = 41), aspirin or statins on individual drug analysis (n = 39). However, the entire CCB group (n = 26) showed a significant survival benefit on multivariate cox regression; hazard ratio (HR) of 0.475 (CI = 0.250-0.902, P = 0.023). Further analysis revealed that this was influenced by a group of patients who were taking aspirin in combination with CCB; median survival was significantly higher in the CCB + aspirin group (n = 15) compared with the group taking neither drug (n = 98); 1414 d vs 601 d (P = 0.029, log-rank test). Multivariate cox regression revealed neither aspirin nor CCB had a statistically significant impact on survival when given alone, however in combination the survival benefit was significant; HR = 0.332 (CI = 0.126-0.870, P = 0.025). None of the other medications showed a survival benefit in any combination.
CONCLUSION: Aspirin + CCB in combination appears to increase survival in patients with PDAC, highlighting the potential clinical use of combination therapy to target stromal interactions in pancreatic cancer.
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