1
|
Wang BK, Chen AY, Prasadh J, Desai D, Shubin AD, Raschzok N, MacConmara M, Ivanics T, Cotter T, Hwang C, Shah JA, Mufti A, Vagefi PA, Hanish SI, Patel MS. A contemporary analysis of 20,086 deceased donor liver biopsies. World J Surg 2024; 48:437-445. [PMID: 38310313 DOI: 10.1002/wjs.12034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 11/14/2023] [Indexed: 02/05/2024]
Abstract
BACKGROUND Pre-transplant deceased donor liver biopsy may impact decision making; however, interpretation of the results remains variable and depends on accepting center practice patterns. METHODS In this cohort study, adult recipients from 04/01/2015-12/31/2020 were identified using the UNOS STARfile data. The deceased donor liver biopsies were stratified by risk based on degree of fibrosis, macrovesicular fat content, and level of portal infiltration (low-risk: no fibrosis, no portal infiltrates, and <30% macrosteatosis; moderate-risk: some fibrosis or mild infiltrates and <30% macrosteatosis; high-risk: most fibrosis, moderate/marked infiltrates, or ≥30% macrosteatosis). Graft utilization, donor risk profile, and recipient outcomes were compared across groups. RESULTS Of the 51,094 donor livers available, 20,086 (39.3%) were biopsied, and 34,606 (67.7%) were transplanted. Of the transplanted livers, 14,908 (43.1%) were biopsied. The transplanted grafts had lower mean macrovesicular fat content (9.3% transplanted vs. 26.9% non-transplanted, P < 0.001) and less often had any degree of fibrosis (20.9% vs. 39.9%, P < 0.001) or portal infiltration (51.3% vs. 58.2%, P < 0.001) versus non-transplanted grafts. Post-transplant recipient LOS (14.2 days high-risk vs. 15.2 days low-risk, P = 0.170) and 1-year graft survival (90.5% vs. 91.7%, P = 0.137) did not differ significantly between high- versus low-risk groups. Kaplan-Meier survival estimates further revealed no differences in the 5-year graft survival across risk strata (P = 0.833). Of the 5178 grafts biopsied and turned down, PSM revealed 1338 (26.0%) were potentially useable based on biopsy results and donor characteristics. CONCLUSION Carefully matched deceased donor livers with some fibrosis, inflammation, or steatosis ≥30% may be suitable for transplantation. Further study of this group of grafts may decrease turndowns of potentially useable organs.
Collapse
Affiliation(s)
- Benjamin K Wang
- Department of Surgery, Division of Surgical Transplantation, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Alyssa Y Chen
- Department of Surgery, Division of Surgical Transplantation, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jai Prasadh
- Department of Surgery, Division of Surgical Transplantation, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Drewv Desai
- Department of Surgery, Division of Surgical Transplantation, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Andrew D Shubin
- Department of Surgery, Division of Surgical Transplantation, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Nathanael Raschzok
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Tommy Ivanics
- Department of Surgery, Henry Ford Medical Center, Detroit, Michigan, USA
| | - Thomas Cotter
- Department of Surgery, Division of Surgical Transplantation, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Christine Hwang
- Department of Surgery, Division of Surgical Transplantation, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jigesh A Shah
- Department of Surgery, Division of Surgical Transplantation, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Arjmand Mufti
- Department of Surgery, Division of Surgical Transplantation, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Parsia A Vagefi
- Department of Surgery, Division of Surgical Transplantation, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Steven I Hanish
- Department of Surgery, Division of Surgical Transplantation, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Madhukar S Patel
- Department of Surgery, Division of Surgical Transplantation, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| |
Collapse
|
2
|
Cotter TG, Mitchell MC, Patel MJ, Anouti A, Lieber SR, Rich NE, Arab JP, Díaz LA, Louissaint J, Kerr T, Mufti AR, Hanish SI, Vagefi PA, Patel MS, VanWagner LB, Lee WM, O'Leary JG, Singal AG. Racial and Ethnic Disparities in Liver Transplantation for Alcohol-associated Liver Diseases in the United States. Transplantation 2024; 108:225-234. [PMID: 37340542 DOI: 10.1097/tp.0000000000004701] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
BACKGROUND Emerging data suggest disparities exist in liver transplantation (LT) for alcohol-associated liver disease (ALD). As the incidence of ALD increases, we aimed to characterize recent trends in ALD LT frequency and outcomes, including racial and ethnic disparities. METHODS Using United Network for Organ Sharing/Organ Procurement and Transplantation Network data (2015 through 2021), we evaluated LT frequency, waitlist mortality, and graft survival among US adults with ALD (alcohol-associated hepatitis [AH] and alcohol-associated cirrhosis [AAC]) stratified by race and ethnicity. We used adjusted competing-risk regression analysis to evaluate waitlist outcomes, Kaplan-Meier analysis to illustrate graft survival, and Cox proportional hazards modeling to identify factors associated with graft survival. RESULTS There were 1211 AH and 26 526 AAC new LT waitlist additions, with 970 AH and 15 522 AAC LTs performed. Compared with non-Hispanic White patients (NHWs) with AAC, higher hazards of waitlist death were observed for Hispanic (subdistribution hazard ratio [SHR] = 1.23, 95% confidence interval [CI]: 1.16-1.32), Asian (SHR = 1.22, 95% CI:1. 01-1.47), and American Indian/Alaskan Native (SHR = 1.42, 95% CI: 1.15-1.76) candidates. Similarly, significantly higher graft failures were observed in non-Hispanic Black (HR = 1.32, 95% CI: 1.09-1.61) and American Indian/Alaskan Native (HR = 1.65, 95% CI: 1.15-2.38) patients with AAC than NHWs. We did not observe differences in waitlist or post-LT outcomes by race or ethnicity in AH, although analyses were limited by small subgroups. CONCLUSIONS Significant racial and ethnic disparities exist for ALD LT frequency and outcomes in the United States. Compared with NHWs, racial and ethnic minorities with AAC experience increased risk of waitlist mortality and graft failure. Efforts are needed to identify determinants for LT disparities in ALD that can inform intervention strategies.
Collapse
Affiliation(s)
- Thomas G Cotter
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Mack C Mitchell
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Mausam J Patel
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Ahmad Anouti
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Sarah R Lieber
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Nicole E Rich
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Juan Pablo Arab
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, ON, Canada
| | - Luis Antonio Díaz
- Departmento de Gastroenterología, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Jeremy Louissaint
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Thomas Kerr
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Arjmand R Mufti
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Steven I Hanish
- Department of Surgery, UT Southwestern Medical Center, Dallas, TX
| | - Parsia A Vagefi
- Department of Surgery, UT Southwestern Medical Center, Dallas, TX
| | - Madhukar S Patel
- Department of Surgery, UT Southwestern Medical Center, Dallas, TX
| | - Lisa B VanWagner
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - William M Lee
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Jacqueline G O'Leary
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Amit G Singal
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| |
Collapse
|
3
|
Kurian J, Matevish LE, Feizpour C, Shah JA, Hwang C, Hanish SI, Mufti AR, Neill-Fogus S, Vagefi PA, Patel MS. Liver Transplantation in Elderly Recipients: Is Age Just a Number? Am Surg 2023; 89:5737-5743. [PMID: 37142265 DOI: 10.1177/00031348231173998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
BACKGROUND The proportion of older patients on the liver transplant waitlist continues to increase. With limited existing data to guide liver transplant evaluation of elderly patients, we aimed to study selection practices and outcomes of patients ≥70 years old. We hypothesized that 1-year patient and graft survival would not differ between appropriately selected elderly patients and those who are younger. METHODS All patients referred for liver transplantation between 2018 and 2020 were stratified into elderly (age ≥70) and young (age <70) cohorts. Evaluation data pertaining to medical, surgical, and psychosocial risk assessment were reviewed. Recipient characteristics and post-operative outcomes, primarily 1-year graft and patient survival, were compared, with a median follow-up of 16.4 months. RESULTS 322 patients underwent transplant out of 2331 referred. Elderly patients represented 230 of these referrals and 20 underwent transplant. The most common reasons for denial of elderly patients were multiple medical comorbidities (49%), cardiac risk (15%) and psychosocial barriers (13%). The median MELD of elderly recipients was lower (19 vs 24, P = .02), and proportion of hepatocellular carcinoma was higher (60% vs 23%, P < .001). There was no difference in 1-year graft (elderly 90.9% vs young 93.3%, P = .72) or patient survival (elderly 90.9% vs young 94.7%, P = .88). DISCUSSION Liver transplant outcomes and survival are not affected by advanced age in carefully evaluated and selected recipients. Age should not be considered an absolute contraindication for liver transplant referral. Efforts should be made to develop guidelines for risk stratification and donor-recipient matching that optimize outcomes in elderly patients.
Collapse
Affiliation(s)
- Joshua Kurian
- Division of Surgical Transplantation, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Lauren E Matevish
- Division of Surgical Transplantation, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Cyrus Feizpour
- Division of Surgical Transplantation, The University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jigesh A Shah
- Division of Surgical Transplantation, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Christine Hwang
- Division of Surgical Transplantation, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Steven I Hanish
- Division of Surgical Transplantation, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Arjmand R Mufti
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Susan Neill-Fogus
- Division of Surgical Transplantation, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Parsia A Vagefi
- Division of Surgical Transplantation, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Madhukar S Patel
- Division of Surgical Transplantation, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| |
Collapse
|
4
|
Shah J, Mufti A, Dumas R, Porembka M, Minei J, Hanish SI, Vagefi PA. Multidisciplinary Management of Severe Traumatic Hepatic Injury Involving Interventional Radiology Embolization, Trauma Laparotomy, and Liver Transplantation. Am Surg 2023; 89:2105-2107. [PMID: 34233503 DOI: 10.1177/00031348211031852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This report describes liver transplantation as a successful strategy in the management of a young man who presented to a local emergency room following catastrophic traumatic hepatic vascular injuries. Expeditious multidisciplinary management, including interventional radiology, trauma surgery, and ultimately transplant surgery, provided the patient with definitive therapy following his injuries and early return to normal activity. Our experience highlights the importance of prompt referral of select hepatic trauma patients for liver transplant evaluation as part of their complex trauma management.
Collapse
Affiliation(s)
- Jigesh Shah
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Arjmand Mufti
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ryan Dumas
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Matthew Porembka
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Joseph Minei
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Steven I Hanish
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Parsia A Vagefi
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| |
Collapse
|
5
|
Shubin AD, Feizpour C, Hwang CS, Hanish SI, Raschzok N, Wang BK, Desai DM, Shah JA, Vagefi PA, MacConmara MP, Patel MS. Normothermic Machine Perfusion for Older Transplant Recipients. Artif Organs 2023. [PMID: 36906889 DOI: 10.1111/aor.14519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 01/23/2023] [Accepted: 02/22/2023] [Indexed: 03/13/2023]
Abstract
INTRODUCTION Elderly patients (≥ 65 years old) are increasingly undergoing liver transplantation and are more likely to be removed from the waitlist. Normothermic machine perfusion (NMP) holds promise in expanding the number of livers available for transplant and improving outcomes for marginal donors and recipients. We aimed to determine the impact of NMP on outcomes in elderly recipients at our institution and nationally using the UNOS database. METHODS The use of NMP on outcomes in elderly recipients was reviewed using both the UNOS/SRTR database (2016-2022) and institutional data (2018-2020). Characteristics and clinical outcomes were compared between the NMP and static cold (control) groups within both populations. RESULTS Nationally, using the UNOS/SRTR database, we identified 165 elderly recipients from 28 centers who received a liver allograft undergoing NMP and 4,270 that underwent traditional cold static storage. NMP donors were older (48.3 vs. 43.4 years, p<0.01), had similar rates of steatosis (8.5% vs 8.5%, p = 0.58), were more likely to be from a DCD (41.8% vs 12.3% p < 0.01) and had a higher donor risk index (DRI; 1.70 vs. 1.60, p <0 .02). NMP recipients had similar age but had a lower MELD score at transplant (17.9 vs. 20.7, p=0.01). Despite increased marginality of the donor graft, NMP recipients had similar allograft survival and decreased length of stay, even after accounting for recipient characteristics including MELD. Institutional data showed that 10 elderly recipients underwent NMP and 68 underwent cold static storage. At our institution NMP recipients had a similar length of stay, rates of complications, and readmissions. CONCLUSIONS NMP may mitigate donor risk factors that are relative contraindications for transplantation in elderly liver recipients, increasing the donor pool. The application of NMP in older recipients should be considered.
Collapse
Affiliation(s)
- Andrew D Shubin
- Department of Surgery, Transplant Division, University of Texas Southwestern Medical Center
| | - Cyrus Feizpour
- Department of Surgery, Transplant Division, University of Texas Southwestern Medical Center
| | - Christine S Hwang
- Department of Surgery, Transplant Division, University of Texas Southwestern Medical Center
| | - Steven I Hanish
- Department of Surgery, Transplant Division, University of Texas Southwestern Medical Center
| | - Nathanael Raschzok
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Surgery, Experimental Surgery, Berlin, Germany
| | - Benjamin K Wang
- Department of Surgery, Transplant Division, University of Texas Southwestern Medical Center
| | - Dev M Desai
- Department of Surgery, Transplant Division, University of Texas Southwestern Medical Center
| | - Jigesh A Shah
- Department of Surgery, Transplant Division, University of Texas Southwestern Medical Center
| | - Parsia A Vagefi
- Department of Surgery, Transplant Division, University of Texas Southwestern Medical Center
| | | | - Madhukar S Patel
- Department of Surgery, Transplant Division, University of Texas Southwestern Medical Center
| |
Collapse
|
6
|
Shubin AD, MacConmara MP, Patel MS, Wang BK, Feizpour CA, Reese J, Niles PA, Shah JA, Desai DM, De Gregorio L, Hanish SI, Vagefi PA, Hwang CS. No Stone Left Unturned: Utilization of an Organ Procurement Organization Donor Surgeon at Procurement Reduces Discards of Marginal Liver Allografts. Transplantation 2023; 107:648-653. [PMID: 36253907 DOI: 10.1097/tp.0000000000004367] [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: 11/25/2022]
Abstract
BACKGROUND The recent trend of organ procurement organizations (OPOs) employing independent surgeons for organ procurement has been developed with the goal of improving the supply of suitable organs for transplantation. We investigated the effects that the addition of an OPO-employed, organ-procurement specialist has on liver allograft discard rate, marginal organ utilization, and graft survival. METHODS Organ Procurement and Transplant Network and OPO data were retrospectively studied between April 1, 2014' and July 31, 2019' within the Southwest Transplant Alliance donor service area. Liver procurements with an OPO-surgeon present (OPO-Present) were compared to those without the involvement of an OPO surgeon (OPO-Absent). Donor and recipient characteristics as well as outcomes were analyzed across groups using propensity score matching. RESULTS In total 869 OPO-Present liver allografts had similar rates of discard (5.2%) compared to 771 OPO-Absent livers (5.8%). However, after adjusting for donor risk, OPO-Present livers had a lower propensity of discard compared to OPO-Absent (3.4% versus 7.6%, P < 0.05). OPO-Present livers were more likely to be shared nationally (11.0% versus 4.8%, P < 0.001). Outcome analysis showed allograft survival of OPO-Present livers at 5 y was comparable to OPO-Absent livers (79.5% versus 80%, P = 0.34). CONCLUSIONS The presence of an OPO surgeon was associated with decreased liver allograft discard and increased utilization of marginal donor organs. The OPO surgeon's presence represents a potential strategy to increase organ utilization nationally.
Collapse
Affiliation(s)
- Andrew D Shubin
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Madhukar S Patel
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Benjamin K Wang
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Cyrus A Feizpour
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | | | | | - Jigesh A Shah
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Dev M Desai
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Lucia De Gregorio
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Steven I Hanish
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Parsia A Vagefi
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Christine S Hwang
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| |
Collapse
|
7
|
Patel MS, Wang BK, MacConmara M, Hwang C, Shah JA, De Gregorio L, Hanish SI, Desai DM, Zhang S, Zeh HJ, Vagefi PA. Is there value in volume? An assessment of liver transplant practices in the United States since the inception of MELD. Surgery 2022; 172:1257-1262. [PMID: 35871852 DOI: 10.1016/j.surg.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 04/26/2022] [Accepted: 05/02/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Liver transplantation has increased in volume and provides substantial survival benefit. However, there remains a need for value-based assessment of this costly procedure. METHODS Model for end stage liver disease era adult recipients were identified using United Network for Organ Sharing Standard Transplant Analysis file data (n = 75,988) and compared across time periods (period A: February 2002 to January 2007; B: February 2007 to January 2013; C: February 2013 to January 2019). Liver centers were divided into volume tertiles for each period (small, medium, large). Value for the index transplant episode was defined as percentage graft survival ≥1 year divided by mean posttransplant duration of stay. RESULTS All centers increased value over time due to ubiquitous improvement in 1-year graft survival. However, large centers demonstrated the most significant value change (large +17% vs small +7.0%, P < .001) due to a -8.5% reduction in large centers duration of stay from period A to C, while small centers duration of stay remained unchanged (-0.1%). Large centers delivered higher value despite more complex care: older recipients (54.8 ± 10.3 vs 53.0 ± 11.4 years P < .001), fewer model for end stage liver disease exceptions (34.0% vs 38.2%, P < .001), higher rates of candidate portal vein thrombosis (10.1% vs 8.5%, P < .001) and prior abdominal surgery (43.4% vs 37.4%, P < .001), and more marginal donor utilization (donor risk index 1.45 ± 0.38 vs 1.36 ± 0.33, P < .001). Mahalanobis metric matching demonstrated that compared with small centers, large centers progressively shortened recipient duration of stay per transplant in each period (A: -0.36 days, P = .437; B: -2.14 days, P < .001; C: -2.49 days, P < .001). CONCLUSION There is value in liver transplant volume. Adoption of value-based practices from large centers may allow optimization of health care delivery for this costly procedure.
Collapse
Affiliation(s)
- Madhukar S Patel
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Benjamin K Wang
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Christine Hwang
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Jigesh A Shah
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Lucia De Gregorio
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Dev M Desai
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Song Zhang
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX
| | - Herbert J Zeh
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Parsia A Vagefi
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX.
| |
Collapse
|
8
|
Feizpour CA, Hoffman J, Patel MS, Wang B, Hwang C, Balsara K, Shah A, Shah JA, Hanish SI, Vagefi PA, MacConmara M. Simultaneous ex vivo normothermic preservation of liver and heart grafts from a donation after circulatory death donor. J Card Surg 2022; 37:1076-1079. [DOI: 10.1111/jocs.16269] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 12/29/2021] [Accepted: 01/13/2022] [Indexed: 01/03/2023]
Affiliation(s)
- Cyrus A. Feizpour
- Department of Surgery UT Southwestern Medical Center, Division of Surgical Transplantation Dallas Texas USA
| | - Jordan Hoffman
- Department of Cardiac Surgery Vanderbilt University Medical Center Nashville Tennessee USA
| | - Madhukar S. Patel
- Department of Surgery UT Southwestern Medical Center, Division of Surgical Transplantation Dallas Texas USA
| | - Benjamin Wang
- Department of Surgery UT Southwestern Medical Center, Division of Surgical Transplantation Dallas Texas USA
| | - Christine Hwang
- Department of Surgery UT Southwestern Medical Center, Division of Surgical Transplantation Dallas Texas USA
| | - Keki Balsara
- Department of Cardiac Surgery Vanderbilt University Medical Center Nashville Tennessee USA
| | - Ashish Shah
- Department of Cardiac Surgery Vanderbilt University Medical Center Nashville Tennessee USA
| | - Jigesh A. Shah
- Department of Surgery UT Southwestern Medical Center, Division of Surgical Transplantation Dallas Texas USA
| | - Steven I. Hanish
- Department of Surgery UT Southwestern Medical Center, Division of Surgical Transplantation Dallas Texas USA
| | - Parsia A. Vagefi
- Department of Surgery UT Southwestern Medical Center, Division of Surgical Transplantation Dallas Texas USA
| | | |
Collapse
|
9
|
MacConmara M, Wang B, Patel MS, Hwang CS, DeGregorio L, Shah J, Hanish SI, Desai D, Lynch R, Tanriover B, Zeh H, Vagefi PA. Liver Transplantation in the Time of a Pandemic: A Widening of the Racial and Socioeconomic Health Care Gap During COVID-19. Ann Surg 2021; 274:427-433. [PMID: 34183513 PMCID: PMC8354487 DOI: 10.1097/sla.0000000000004994] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE During the initial wave of the COVID-19 pandemic, organ transplantation was classified a CMS Tier 3b procedure which should not be postponed. The differential impact of the pandemic on access to liver transplantation was assessed. SUMMARY BACKGROUND DATA Disparities in organ access and transplant outcomes among vulnerable populations have served as obstacles in liver transplantation. METHODS Using UNOS STARfile data, adult waitlisted candidates were identified from March 1, 2020 to November 30, 2020 (n = 21,702 pandemic) and March 1, 2019 to November 30, 2019 (n = 22,797 pre-pandemic), and further categorized and analyzed by time periods: March to May (Period 1), June to August (Period 2), and September to November (Period 3). Comparisons between pandemic and pre-pandemic groups included: Minority status, demographics, diagnosis, MELD, insurance type, and transplant center characteristics. Liver transplant centers (n = 113) were divided into tertiles by volume (small, medium, large) for further analyses. Multivariable logistic regression was fitted to assess odds of transplant. Competing risk regression was used to predict probability of removal from the waitlist due to transplantation or death and sickness. Additional temporal analyses were performed to assess changes in outcomes over the course of the pandemic. RESULTS During Period 1 of the pandemic, Minorities showed greater reduction in both listing (-14% vs -12% Whites), and transplant (-15% vs -7% Whites), despite a higher median MELD at transplant (23 vs 20 Whites, P < 0.001). Of candidates with public insurance, Minorities demonstrated an 18.5% decrease in transplants during Period 1 (vs -8% Whites). Although large programs increased transplants during Period 1, accounting for 61.5% of liver transplants versus 53.4% pre-pandemic (P < 0.001), Minorities constituted significantly fewer transplants at these programs during this time period (27.7% pandemic vs 31.7% pre-pandemic, P = 0.04). Although improvements in disparities in candidate listings, removals, and transplants were observed during Periods 2 and 3, the adjusted odds ratio of transplant for Minorities was 0.89 (95% CI 0.83-0.96, P = 0.001) over the entire pandemic period. CONCLUSIONS COVID-19's effect on access to liver transplantation has been ubiquitous. However, Minorities, especially those with public insurance, have been disproportionately affected. Importantly, despite the uncertainty and challenges, our systems have remarkable resiliency, as demonstrated by the temporal improvements observed during Periods 2 and 3. As the pandemic persists, and the aftermath ensues, health care systems must consciously strive to identify and equitably serve vulnerable populations.
Collapse
Affiliation(s)
- Malcolm MacConmara
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Benjamin Wang
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Madhukar S Patel
- Department of Transplantation, University of Toronto, Toronto, ON, Canada
| | - Christine S Hwang
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Lucia DeGregorio
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Jigesh Shah
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Steven I Hanish
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Dev Desai
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Raymond Lynch
- Division of Transplantation, Department of Surgery, Emory University, Atlanta, GA
| | - Bekir Tanriover
- Division of Nephrology, Department of Medicine, University of Arizona, Tuscon, AZ
| | - Herbert Zeh
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Parsia A Vagefi
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| |
Collapse
|
10
|
Goussous N, Akbar H, LaMattina JC, Hanish SI, Barth RN, Bruno DA. Extracorporeal membrane oxygenation support following liver transplantation—A case series. Clin Transplant 2019; 33:e13628. [DOI: 10.1111/ctr.13628] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Revised: 05/13/2019] [Accepted: 06/04/2019] [Indexed: 12/18/2022]
Affiliation(s)
- Naeem Goussous
- University of Maryland School of Medicine Baltimore Maryland
| | - Hashem Akbar
- University of Maryland School of Medicine Baltimore Maryland
| | | | | | - Rolf N. Barth
- University of Maryland School of Medicine Baltimore Maryland
| | - David A. Bruno
- University of Maryland School of Medicine Baltimore Maryland
| |
Collapse
|
11
|
LaMattina JC, Akbar H, Sultan S, Hanish SI, Bruno DA, Hutson WR, Stein DM, Bartlett ST, Scalea TM, Barth RN. Molecular Adsorbent Recirculating System Support Followed by Liver Transplantation for Multiorgan Failure From Heatstroke. Transplant Proc 2018; 50:3516-3520. [PMID: 30577229 DOI: 10.1016/j.transproceed.2018.07.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 07/09/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Exertional heatstroke is an extremely rare cause of fulminant hepatic failure. Maximal supportive care has failed to provide adequate survival in earlier studies. This is particularly true in cases accompanied by multiorgan failure. METHODS AND MATERIALS Our prospectively collected transplant database was retrospectively reviewed to identify patients undergoing liver transplantation for heatstroke between January 1, 2012, and December 31, 2016. We report 3 consecutive cases of male patients with fulminant hepatic failure from exertional heatstroke. RESULTS All patients developed multiorgan failure and required intubation, vasopressor support, and renal replacement therapy. All patients were listed urgently for liver transplantation and were supported with the molecular adsorbent recirculating system while awaiting transplantation. All patients underwent liver transplantation alone and are alive and well, with recovered renal function, normal liver allograft function, and no chronic sequelae of their multiorgan failure at more than one year. CONCLUSION Extreme heatstroke leading to whole-body organ dysfunction and fulminant liver failure is a complex entity that may benefit from therapy using the Molecular Adsorbent Recirculating System while waiting for liver transplantation as a component of a multidisciplinary, multiorgan system approach.
Collapse
Affiliation(s)
- J C LaMattina
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland.
| | - H Akbar
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - S Sultan
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - S I Hanish
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - D A Bruno
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - W R Hutson
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - D M Stein
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - S T Bartlett
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - T M Scalea
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - R N Barth
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| |
Collapse
|
12
|
LaMattina JC, Sultan S, Hanish SI, Bruno DA, Thuluvath PJ, Maheshwari A, Barth RN. Previous living donor hemihepatectomy as cadaveric donor of remnant liver. Liver Transpl 2017. [PMID: 28650115 DOI: 10.1002/lt.24804] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- John C LaMattina
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Samuel Sultan
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Steven I Hanish
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - David A Bruno
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | | | | | - Rolf N Barth
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| |
Collapse
|
13
|
Posner AD, Sultan ST, Zaghloul NA, Twaddell WS, Bruno DA, Hanish SI, Hutson WR, Hebert L, Barth RN, LaMattina JC. Resolution of donor non-alcoholic fatty liver disease following liver transplantation. Clin Transplant 2017. [PMID: 28636211 DOI: 10.1111/ctr.13032] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Transplant surgeons conventionally select against livers displaying high degrees (>30%) of macrosteatosis (MaS), out of concern for primary non-function or severe graft dysfunction. As such, there is relatively limited experience with such livers, and the natural history remains incompletely characterized. We present our experience of transplanted livers with high degrees of MaS and microsteatosis (MiS), with a focus on the histopathologic and clinical outcomes. METHODS Twenty-nine cases were identified with liver biopsies available from both the donor and the corresponding liver transplant recipient. Donor liver biopsies displayed either MaS or MiS ≥15%, while all recipients received postoperative liver biopsies for cause. RESULTS The mean donor MaS and MiS were 15.6% (range 0%-60%) and 41.3% (7.5%-97.5%), respectively. MaS decreased significantly from donor (M=15.6%) to recipient postoperative biopsies (M=0.86%), P<.001. Similarly, MiS decreased significantly from donor biopsies (M=41.3%) to recipient postoperative biopsies (M=1.8%), P<.001. At a median of 68 days postoperatively (range 4-384), full resolution of MaS and MiS was observed in 27 of 29 recipients. CONCLUSIONS High degrees of MaS and MiS in donor livers resolve in recipients following liver transplantation. Further insight into the mechanisms responsible for treating fatty liver diseases could translate into therapeutic targets.
Collapse
Affiliation(s)
- Andrew D Posner
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Samuel T Sultan
- Division of Transplantation, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | | | - David A Bruno
- Division of Transplantation, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Steven I Hanish
- Division of Transplantation, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Laci Hebert
- Division of Transplantation, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Rolf N Barth
- Division of Transplantation, University of Maryland School of Medicine, Baltimore, MD, USA
| | - John C LaMattina
- Division of Transplantation, University of Maryland School of Medicine, Baltimore, MD, USA
| |
Collapse
|
14
|
Siskind EJ, Vandermeer F, Siskind TR, Bruno DA, Sultan S, Alvarez-Casas J, Stafford A, Lane B, Lamattina JC, Barth RN, Hanish SI. Postoperative Elevated Resistive Indices Do Not Predict Hepatic Artery Thrombosis in Extended Criteria Donor Livers. Int J Angiol 2017; 26:238-240. [PMID: 29142490 DOI: 10.1055/s-0037-1598623] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Postoperative transplant liver ultrasounds were analyzed in standard criteria donor (SCD), extended criteria donor (ECD), and donation after cardiac death (DCD) liver allografts to determine if elevated resistive indices (RIs) are consistently present and if they are pathological. Postoperative transplant liver ultrasounds were reviewed from 115 consecutive patients. Hepatic arterial RIs were stratified based on the type of donor: DCD, macrosteatosis (>30%), or standard criteria. In all patients with elevated RI, subsequent ultrasounds were reviewed to demonstrate RI normalization. The mean RI for all 115 patients was 0.64, DCD was 0.67, macrosteatosis was 0.81, and SCD was 0.61 ( p = 0.033). The RI on subsequent liver ultrasounds for DCD and macrosteatosis normalized without any intervention. There were no incidences of early hepatic artery thrombosis (HAT) observed in the cohort. Hepatic arterial RI in ECDs and DCDs are elevated in the immediate postoperative period but are not predictive of HAT. It represents interparenchymal graft stiffness and overall graft edema rather than an impending technical complication. The results of our study do not support the routine use of anticoagulation or routine investigation with computed tomography angiography for elevated RIs as these findings are self-limiting and normalize over a short period of time. We hope that this information helps guide the clinical management of liver transplant patients from expanded criteria donors.
Collapse
Affiliation(s)
- Eric J Siskind
- Division of Transplantation, University of Maryland Medical Center, Baltimore, Maryland
| | - Fauzia Vandermeer
- Division of Transplantation, University of Maryland Medical Center, Baltimore, Maryland
| | - Tamar R Siskind
- Division of Transplantation, University of Maryland Medical Center, Baltimore, Maryland
| | - David A Bruno
- Division of Transplantation, University of Maryland Medical Center, Baltimore, Maryland
| | - Samuel Sultan
- Division of Transplantation, University of Maryland Medical Center, Baltimore, Maryland
| | - Josue Alvarez-Casas
- Division of Transplantation, University of Maryland Medical Center, Baltimore, Maryland
| | - Arielle Stafford
- Division of Transplantation, University of Maryland Medical Center, Baltimore, Maryland
| | - Barton Lane
- Division of Transplantation, University of Maryland Medical Center, Baltimore, Maryland
| | - John C Lamattina
- Division of Transplantation, University of Maryland Medical Center, Baltimore, Maryland
| | - Rolf N Barth
- Division of Transplantation, University of Maryland Medical Center, Baltimore, Maryland
| | - Steven I Hanish
- Division of Transplantation, University of Maryland Medical Center, Baltimore, Maryland
| |
Collapse
|
15
|
Mindikoglu AL, Dowling TC, Schaub DJ, Hutson WR, Potosky DR, Christenson RH, Barth RN, LaMattina JC, Hanish SI, Weir MR, Raufman JP. Pharmacokinetics and Tolerability of Intravenous Sildenafil in Two Subjects with Child-Turcotte-Pugh Class C Cirrhosis and Renal Dysfunction. Dig Dis Sci 2015; 60:3491-4. [PMID: 26143343 PMCID: PMC4623880 DOI: 10.1007/s10620-015-3771-0] [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: 05/05/2015] [Accepted: 06/15/2015] [Indexed: 12/09/2022]
Abstract
Phosphodiesterase-5 (PDE-5) inhibitors have been used successfully in patients with cirrhosis to treat porto-pulmonary hypertension. Additionally, in cirrhosis, PDE-5 inhibitors can potentially improve portal hypertension and renal hemodynamics. No pharmacokinetics and tolerability studies of intravenous (IV) sildenafil have been conducted in Child-Turcotte-Pugh (CTP) class C cirrhosis and renal dysfunction. We report two subjects with CTP class C cirrhosis and estimated glomerular filtration rate of 25.8 and 22.4 ml/min/1.73m2 treated with a single-dose, IV bolus injection of 2.5 mg sildenafil. Both subjects had diuretic-refractory ascites with model for end-stage liver disease scores of 25 and 35. Both subjects tolerated IV Sildenafil without side effects. The observed maximum concentrations of plasma sildenafil were 35 and 20.6 ng/ml, with modeled pharmacokinetic estimates for clearance (11.9 and 14.9 L/hr), volumes of distribution (72.8 and 77.3 L) and half-life (4.2 and 3.6 hrs). N-desmethyl sildenafil concentrations ranged from 3 to 40% of the parent concentrations. Our results showed that in CTP class C cirrhosis and renal dysfunction, IV bolus injection of 2.5 mg sildenafil is safe and tolerable.
Collapse
Affiliation(s)
- Ayse L. Mindikoglu
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine
| | | | - David J. Schaub
- Department of Neurology, University of Maryland School of Medicine
| | - William R. Hutson
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine
| | - Darryn R. Potosky
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine
| | | | - Rolf N. Barth
- Department of Surgery, University of Maryland School of Medicine
| | | | - Steven I. Hanish
- Department of Surgery, University of Maryland School of Medicine
| | - Matthew R. Weir
- Department of Medicine, Division of Nephrology, University of Maryland School of Medicine
| | - Jean-Pierre Raufman
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine
| |
Collapse
|
16
|
Squires MH, Hanish SI, Fisher SB, Garrett C, Kooby DA, Sarmiento JM, Cardona K, Adams AB, Russell MC, Magliocca JF, Knechtle SJ, Staley CA, Maithel SK. Transplant versus resection for the management of hepatocellular carcinoma meeting Milan Criteria in the MELD exception era at a single institution in a UNOS region with short wait times. J Surg Oncol 2013; 109:533-41. [PMID: 24347475 DOI: 10.1002/jso.23531] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [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: 10/03/2013] [Accepted: 11/22/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Management of hepatocellular carcinoma (HCC) in the Model for End-Stage Liver Disease (MELD) exception era remains regionally variable. Outcomes were compared for patients undergoing transplant versus resection at a single institution in a UNOS region with short wait times for organ availability. METHODS All patients who underwent resection of HCC from January 2000 to August 2012 and patients who underwent transplant post-January 2006, during the Milan Criteria (MC)-based MELD exception policy for HCC, were identified. Primary outcomes were overall survival (OS) and recurrence-free survival (RFS). RESULTS Two hundred fifty-seven patients were analyzed, of whom 131 underwent transplant and 126 underwent resection. All transplant patients met MC; 45 (36%) resection patients met MC. Median follow-up time was 30 months. Median wait time to transplant was 55 days; no patients dropped off the waitlist while awaiting an organ. Among patients meeting MC, transplant demonstrated significantly greater 5-year OS (65.7% vs. 43.8%; P = 0.005) and RFS (85.3% vs. 22.7%; P < 0.001) versus resection. For patients with hepatitis C, transplant (n = 87) demonstrated significantly improved 5-year outcomes compared to patients meeting MC who underwent resection (n = 21; OS: 63.5% vs. 23.3%; P = 0.001; RFS: 83.5% vs. 23.7%; P < 0.001). CONCLUSION In a region with short waitlist times for organ availability, liver transplant is associated with improved survival compared to resection for HCC within MC and should be considered for all patients meeting MC, particularly those with hepatitis C.
Collapse
Affiliation(s)
- Malcolm H Squires
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Onor IO, Todd SB, Meredith E, Perez SD, Mehta AK, Marshall Lyon G, Knechtle SJ, Hanish SI. Evaluation of clinical outcomes of prophylactic versus preemptive cytomegalovirus strategy in liver transplant recipients. Transpl Int 2013; 26:592-600. [PMID: 23590709 DOI: 10.1111/tri.12101] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Revised: 10/30/2012] [Accepted: 03/18/2013] [Indexed: 12/17/2022]
Abstract
Cytomegalovirus (CMV) is a major cause of morbidity and mortality following solid organ transplantation (SOT). Two strategies, prophylactic, and preemptive have emerged for the prevention of CMV infection and disease after SOT. This retrospective chart review of two liver transplant cohorts: prophylactic and preemptive, compares the clinical impact of transitioning from prophylactic to preemptive strategy. The primary outcome is the incidence of CMV viremia at 3-and 6-months post-transplant. Secondary outcomes include: incidence of CMV tissue-invasive disease, acute cellular rejection, leukopenia and neutropenia, opportunistic infection rates, hospital readmission rates, and mortality at 3-and 6-months post-transplant. A total of 109 patients were included in the analysis. The incidence of CMV viremia was 4.9% and 50.0% (P < 0.001) in the prophylactic versus preemptive cohort, respectively, at 3 months post-transplant. The incidence of CMV viremia was 24.6% and 8.3% (P = 0.026) in the prophylactic versus preemptive cohort, respectively, at 6 months post-transplant. There were no statistical significant differences in the secondary outcomes between both cohorts. In conclusion, there is a statistical significant difference in time to onset of CMV viremia; however, the use of either prophylactic or preemptive strategy was not associated with significant negative clinical outcomes of CMV.
Collapse
Affiliation(s)
- Ifeanyichukwu O Onor
- Department of Pharmaceutical Services, Emory University Hospital, Atlanta, GA, USA
| | | | | | | | | | | | | | | |
Collapse
|
18
|
Prajapati HJ, Spivey JR, Hanish SI, El-Rayes BF, Kauh JS, Chen Z, Kim HS. mRECIST and EASL responses at early time point by contrast-enhanced dynamic MRI predict survival in patients with unresectable hepatocellular carcinoma (HCC) treated by doxorubicin drug-eluting beads transarterial chemoembolization (DEB TACE). Ann Oncol 2012; 24:965-73. [PMID: 23223331 DOI: 10.1093/annonc/mds605] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND We analyzed the magnetic resonance imaging (MRI) responses by world health organization (WHO), response evaluation criteria in solid tumor (RECIST), European Association for the Study of Liver (EASL), and modified RECIST (mRECIST) guidelines and correlated with survival after doxorubicin (Adriamycin; Pharmacia & Upjohn, Peapac, NJ). drug-eluting beads transarterial chemoembolization (DEB TACE) in patients with unresectable hepatocellular carcinoma (HCC). PATIENTS AND METHODS The early target and overall imaging responses were studied in 120 consecutive patients treated with DEB TACE for unresectable HCC, using RECIST, WHO, EASL, and mRECIST guidelines on contrast-enhanced dynamic liver MRI. The median period between the DEB TACE and assessment scan was 33.50 days. Survival analyses were carried out with the Kaplan-Meier method and the Cox proportional model. RESULTS WHO and RECIST1.1 had poor correlation with survival. mRECIST and EASL had significant correlation with survival with target lesion response rates of 63.3% and 48.3% and with overall response rates of 52.5% and 39.2%, respectively. The responders of EASL and mRECIST had significant median survival (P ≤ 0.0001). Moreover, mRECIST was better than EASL in predicting survival, because the survival difference between responders and non-responders of overall response was statistically significant (P = 0.013) for mRECIST, but not for EASL (P = 0.064). CONCLUSIONS EASL and mRECIST responses measured on MRI at an early time point after DEB TACE predicted survival. mRECIST response demonstrated higher survival correlation than EASL.
Collapse
Affiliation(s)
- H J Prajapati
- Departments of Interventional Radiology and Image Guided Medicine, Winship Cancer Institute, Emory University School of Medicine, 1364 Clifton Road NE, Suite AG-05, Atlanta, GA 30322, USA
| | | | | | | | | | | | | |
Collapse
|
19
|
Badell IR, Hanish SI, Hughes CB, Hewitt WR, Chung RT, Spivey JR, Knechtle SJ. Domino liver transplantation in maple syrup urine disease: a case report and review of the literature. Transplant Proc 2012; 45:806-9. [PMID: 23267808 DOI: 10.1016/j.transproceed.2012.04.031] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Accepted: 04/27/2012] [Indexed: 12/31/2022]
Abstract
BACKGROUND Improved outcomes have expanded the indications for liver transplantation, thus aggravating the already limited supply of donor organs. Domino liver transplantation (DLT) has been one strategy to augment the supply of donor organs in cases of inborn errors of metabolism. One such disease is maple syrup urine disease (MSUD), an inherited disorder of branched-chain amino acid (BCAA) metabolism. METHODS We report on the transplantation of a deceased donor liver into a patient with MSUD, and the sequential transplantation of the explanted liver into a patient with hemophilia A, HIV, hepatitis C, and a low priority on the transplant waiting list. RESULTS At 30 months, the MSUD recipient has had significant correction of BCAA metabolism on a protein-unrestricted diet and no progression of neuropsychiatric symptoms. The DLT recipient has been cured of hemophilia and has normal BCAA homeostasis. This case provides further evidence that elective orthotopic liver transplantation for MSUD attenuates the disease with restoration of BCAA metabolism, and that DLT in this setting can achieve excellent results in ESLD patients. CONCLUSION It is possible that domino grafts from patients with MSUD could be used in more conventional recipients, but additional studies and longer-term outcomes are needed to determine the validity of DLT in MSUD.
Collapse
Affiliation(s)
- I R Badell
- Emory Transplant Center, Emory University, Atlanta, Georgia 30322, USA
| | | | | | | | | | | | | |
Collapse
|
20
|
Becker-Weidman DJS, Kalb B, Sharma P, Kitajima HD, Lurie CR, Chen Z, Spivey JR, Knechtle SJ, Hanish SI, Adsay NV, Farris AB, Martin DR. Hepatocellular carcinoma lesion characterization: single-institution clinical performance review of multiphase gadolinium-enhanced MR imaging--comparison to prior same-center results after MR systems improvements. Radiology 2011; 261:824-33. [PMID: 21969663 DOI: 10.1148/radiol.11110157] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE To measure diagnostic performance in the detection of hepatocellular carcinoma (HCC) by using the most recent technology and multiphase gadolinium-enhanced magnetic resonance (MR) imaging and to compare with earlier results at the same institution. MATERIALS AND METHODS This retrospective study was institutional review board approved and HIPAA compliant. Informed consent was obtained. Between January 2008 and April 2010, 101 patients underwent liver transplantation and pretransplantation abdominal MR imaging within 90 days. Prospective image interpretations from the clinical record were reviewed for documentation of HCC, including size, number, and location. Liver explant histologic examination provided the reference standard for lesion analysis and was performed in axial gross slices in conjunction with the MR imaging report for direct comparison. Tumors were categorized according to size (≥ 2 cm or <2 cm), and MR imaging detection sensitivity, specificity, predictive values, and accuracy were calculated according to category. The Fisher exact test was used to compare results from this study against prior reported results. RESULTS Thirty-five (34.7%) of 101 patients had HCC at explant analysis. Patient-based analysis of all lesions showed a sensitivity and specificity of 97.1% (34 of 35) and 100% (66 of 66), respectively. For lesions 2 cm or larger, MR imaging had a sensitivity and specificity of 100% (23 of 23) and 100% (78 of 78), respectively. For lesions smaller than 2 cm, MR imaging had a sensitivity and specificity of 82.6% (19 of 23) and 100% (78 of 78), respectively. Lesion-based sensitivity for all tumors was 91.4% (53 of 58) in the current study, compared with 77.8% in 2007 (P = .07). For lesions smaller than 2 cm, the sensitivity was 87.5% (28 of 32) in the current study, compared with 55.6% previously (P = .02). CONCLUSION MR imaging remains a highly accurate diagnostic method for the preoperative evaluation of HCC, and detection of small (<2 cm) tumors has been significantly improved compared with that of earlier studies.
Collapse
|
21
|
Hanish SI, Knechtle SJ. Liver transplantation for the treatment of hepatocellular carcinoma. Oncology (Williston Park) 2011; 25:752-757. [PMID: 21874838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
The rise of infection with hepatitis C virus worldwide and the lack of effective treatment for this infection has led to a rise in the incidence of hepatocellular carcinoma (HCC). Moreover, it is now accepted that the cirrhotic liver, regardless of etiology, is a nidus for tumor formation. A landmark study of 60 patients by Mazzaferro et al, published in 1996, forever changed the way in which surgeons approach this disease. The Milan criteria (one lesion <5 cm or three lesions < 3 cm each) were adopted by the United Network for Organ Sharing in 2002 as the criteria by which patients would be given exception points for liver transplantation for HCC. Resection for HCC in the cirrhotic patient has poor outcomes, and many patients' livers cannot be resected due to underlying portal hypertension and thrombocytopenia. Results of transplantation are excellent, with an 80% 5-year survival. Finally, it has been demonstrated that the use of sirolimus for immunosuppression management in these patients may improve long-term disease-free survival; however, no consensus has been reached across the transplant community.
Collapse
Affiliation(s)
- Steven I Hanish
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia 30322, USA.
| | | |
Collapse
|
22
|
Affiliation(s)
- Steven I Hanish
- Department of Surgery, Division of General Surgery, Duke University Medical Center, Durham, North Carolina 27710, USA
| | | |
Collapse
|
23
|
Petersen RP, Pham D, Burfeind WR, Hanish SI, Toloza EM, Harpole DH, D'Amico TA. Thoracoscopic lobectomy facilitates the delivery of chemotherapy after resection for lung cancer. Ann Thorac Surg 2007; 83:1245-9; discussion 1250. [PMID: 17383320 DOI: 10.1016/j.athoracsur.2006.12.029] [Citation(s) in RCA: 235] [Impact Index Per Article: 13.8] [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] [Received: 11/09/2006] [Revised: 12/13/2006] [Accepted: 12/18/2006] [Indexed: 12/13/2022]
Abstract
BACKGROUND We conducted a study of patients who underwent anatomic resection with adjuvant chemotherapy to determine if thoracoscopic lobectomy enables more effective administration of adjuvant chemotherapy than lobectomy by thoracotomy. METHODS We reviewed the outcomes of 100 consecutive patients with non-small cell lung cancer (NSCLC) who underwent lobectomy and received adjuvant chemotherapy (1999 to 2004). The variables analyzed were time to initiation of chemotherapy, percentage of planned regimen received, number of delayed or reduced chemotherapy doses, toxicity grade, length of hospitalization, chest tube duration, 30-day mortality, and major complications (pneumonia, respiratory failure, atrial fibrillation). The chi2 test and Student t test were used to compare dichotomous and continuous variables, respectively. RESULTS Complete resection was performed by thoracotomy in 43 patients and by thoracoscopy in 57 (no conversions). All patients received adjuvant chemotherapy, and 20 (20%) received adjuvant radiation therapy: 13 (30%) of 43 in the thoracotomy group and 7 (12%) of 57 in the thoracoscopy group (p = 0.04). Patients undergoing thoracoscopic lobectomy had significantly fewer delayed (18% versus 58%, p < 0.001) and reduced (26% versus 49%, p = 0.02) chemotherapy doses. A higher percentage of patients undergoing thoracoscopic resection received 75% or more of their planned adjuvant regimen without delayed or reduced doses (61% versus 40%, p = 0.03). There were no significant differences in time to initiation of chemotherapy or toxicity. Patients undergoing a thoracoscopic lobectomy had a shorter median length of hospitalization (4 days versus 5 days, p = 0.02). CONCLUSIONS Thoracoscopy was associated with an overall higher compliance rate and fewer delayed or reduced doses of chemotherapy in patients receiving adjuvant chemotherapy.
Collapse
Affiliation(s)
- Rebecca P Petersen
- Department of Surgery, Division of Thoracic Surgery, Duke University Medical Center, Durham, North Carolina 27710, USA
| | | | | | | | | | | | | |
Collapse
|
24
|
Petersen RP, Hanish SI, Haney JC, Miller CC, Burfeind WR, Tyler DS, Seigler HF, Wolfe W, D'Amico TA, Harpole DH. Improved survival with pulmonary metastasectomy: an analysis of 1720 patients with pulmonary metastatic melanoma. J Thorac Cardiovasc Surg 2007; 133:104-10. [PMID: 17198792 DOI: 10.1016/j.jtcvs.2006.08.065] [Citation(s) in RCA: 124] [Impact Index Per Article: 7.3] [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] [Received: 04/28/2006] [Revised: 07/18/2006] [Accepted: 08/07/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVES The outcomes of patients with metastatic melanoma are poor. Although prognostic models have been developed to predict the occurrence of pulmonary metastasis from cutaneous melanoma, few data exist to define the outcomes of these patients once metastasis has occurred. The objective of this study was to discriminate predictors of survival for patients with pulmonary metastatic melanoma. METHODS We found 1720 patients with pulmonary metastasis listed in a prospective comprehensive cancer center database of 14,057 consecutive patients with melanoma (Jan 1, 1970-June 1, 2004). Demographic and histopathologic data, time and location of recurrences, number of pulmonary nodules, and subsequent therapies were collected. Univariate and multivariate Cox proportional hazards models were used to identify predictors of survival for patients with pulmonary metastatic melanoma. RESULTS The median survival was 7.3 months after development of pulmonary metastasis. Significant predictors of survival from the multivariate model included nodular histologic type (P = .033), disease-free interval (P < .001), number of pulmonary metastases (P = .012), presence of extrathoracic metastasis (P < .001), and performance of pulmonary metastasectomy (P < .001). Interactions were identified between metastasectomy and disease-free interval and presence of extrathoracic metastasis. Surgery was associated with a survival advantage of 12 months for patients with a disease-free interval longer than 5 years (19 vs 7 months, P < .01) and of 10 months for patients without extrathoracic metastasis (18 vs 8 months, P < .01). CONCLUSIONS When all other identified risk factors were controlled for mathematically, metastasectomy maintained a significant survival advantage for patients with pulmonary metastatic melanoma. These data support the role of surgery for a select subset of patients with pulmonary metastasis.
Collapse
Affiliation(s)
- Rebecca P Petersen
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Petersen RP, Pham D, Toloza EM, Burfeind WR, Harpole DH, Hanish SI, D'Amico TA. Thoracoscopic lobectomy: a safe and effective strategy for patients receiving induction therapy for non-small cell lung cancer. Ann Thorac Surg 2006; 82:214-8; discussion 219. [PMID: 16798217 DOI: 10.1016/j.athoracsur.2006.02.051] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2005] [Revised: 02/13/2006] [Accepted: 02/22/2006] [Indexed: 11/24/2022]
Abstract
BACKGROUND Thoracoscopic lobectomy is an accepted oncologic approach for early stage non-small cell lung cancer (NSCLC). We conducted a retrospective study of patients who underwent lobectomy after induction therapy to determine the feasibility of thoracoscopic lobectomy compared with conventional thoracotomy lobectomy. METHODS The outcomes of 97 consecutive patients with NSCLC who received induction therapy followed by lobectomy from 1996 to 2005 were reviewed. Outcome variables analyzed included complete resection, chest tube duration, length of hospitalization, 30-day mortality, hemorrhage, pneumonia, respiratory failure, and other major complications. The Student t test and chi2 or RxC contingency tables were used to compare continuous and categoric variables, respectively. RESULTS Lobectomy was performed by thoracotomy in 85 patients and thoracoscopically in 12 patients (1 conversion), with complete resection in all patients. All patients received induction chemotherapy, and 74 (76%) received induction radiotherapy as well: 66 of 85 (78%) in the thoracotomy group and 8 of 12 (67%) in the thoracoscopy group. The overall median survival was 2.3 years, with no difference between the groups. Patients undergoing a thoracoscopic lobectomy had a shorter median hospital stay (3.5 vs 5 days, p = 0.0024) and chest tube duration (2 vs 4 days, p < 0.001). There were no significant differences in 30-day mortality, hemorrhage, pneumonia, or respiratory failure. CONCLUSIONS Thoracoscopic lobectomy is a feasible approach for selected patients undergoing resection after induction therapy, and is associated with shorter hospital stay and chest tube duration. Long-term follow-up of survival will determine the role of thoracoscopic lobectomy in the management of patients after induction therapy.
Collapse
Affiliation(s)
- Rebecca P Petersen
- Department of Surgery, Duke University Medical Center, Durham, North Carolina 27710, USA
| | | | | | | | | | | | | |
Collapse
|
26
|
Hanish SI, Petersen RP, Collins BH, Tuttle-Newhall J, Marroquin CE, Kuo PC, Butterly DW, Smith SR, Desai DM. Obesity predicts increased overall complications following pancreas transplantation. Transplant Proc 2006; 37:3564-6. [PMID: 16298662 DOI: 10.1016/j.transproceed.2005.09.068] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE We sought to evaluate the role of recipient body mass index (BMI) on postoperative complications in patients receiving pancreas transplants. METHODS A single-institution retrospective study of 145 consecutive patients undergoing either simultaneous kidney pancreas (SPK) or pancreas after kidney (PAK) transplantation from January 1997 through December 2003. Variables analyzed included: age, sex, BMI, number of prior transplants, cytomegalovirus status of donor and recipient, postoperative insulin resistance, complications, and overall patient and graft survival. Differences in continuous variables and dichotomous variables were evaluated using two-tailed t test and Fisher exact test, respectively. Univariate and multivariate logistic regression analyses were employed to identify predictors of overall complications following surgery. RESULTS Obesity was defined by a BMI > or = 30. Of the 145 patients, 33 (23%) had a BMI > or = 30 and 112 (77%) had a BMI < 30. There was no significant difference in age or sex between obese and nonobese patients (P = .98 and P = .56, respectively). The type of transplantation, SPK or PAK, did not affect the complication rate (P = .36). Overall complications (infection, dehiscence, evisceration, ventral hernia, allograft failure, gangrene, necrotizing fasciitis, postoperative bleeding, or death) were significantly higher in the obese group (81% vs 40%, P < .001). Obesity was specifically associated with increased frequency of dehiscence, ventral hernia, intra-abdominal infection, gangrene, necrotizing fasciitis, and repeat laparotomy. Obese patients also had a threefold higher rate of graft pancreatitis/enteric leak. Multivariate logistic regression analysis identified age > or = 50 and BMI > or = 30 as independent predictors of overall complications following surgery (odds ratio 4.0, P = .014 and OR 6.8, P < .001, respectively). There was no difference identified between groups with regards to allograft failure, posttransplant insulin resistance, and death. CONCLUSION Obese patients are at increased risk of overall complications following pancreas transplantation. Specifically, obese patients experience higher frequency of dehiscence, ventral hernia, intra-abdominal infection, gangrene, and necrotizing fasciitis. This study demonstrates the need for careful postoperative monitoring in the obese patient.
Collapse
Affiliation(s)
- S I Hanish
- Duke University Medical Center, Box 3443, Durham, NC 27710, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Petrofski JA, Hata JA, Williams ML, Parsa CJ, Thompson RB, Hanish SI, Gehrig TR, Koch WJ, Milano CA. A Gβγ inhibitor reduces intimal hyperplasia in aortocoronary saphenous vein grafts. J Thorac Cardiovasc Surg 2005; 130:1683-90. [PMID: 16308016 DOI: 10.1016/j.jtcvs.2005.01.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2004] [Revised: 12/12/2004] [Accepted: 01/10/2005] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Approximately 50% of aortocoronary saphenous vein grafts are occluded 10 years after coronary revascularization surgery. Intimal hyperplasia, a critical component in saphenous vein graft failure, is defined by vascular smooth muscle cell proliferation, which is mediated in part by betagamma subunits of heterotrimeric G proteins (G(betagamma)) and downstream effectors such as mitogen-activated protein kinases. A peptide consisting of the carboxyl-terminus of the beta-adrenergic receptor kinase (betaARKct) binds G(betagamma), thereby inhibiting G(betagamma) signaling. Utilizing a recombinant adenovirus containing the coding sequence for the betaARKct peptide (AdbetaARKct), this study investigates whether treatment of the vein graft with AdbetaARKct reduces intimal hyperplasia in a large animal model of aortocoronary saphenous vein graft intimal hyperplasia. METHODS Twenty-seven dogs (27-32 kg) underwent aortocoronary bypass grafting to the left anterior descending artery using autologous saphenous vein. Vein grafts were treated with saline (n = 8), an empty adenovirus (n = 8), or AdbetaARKct (n = 8). A subset of dogs (n = 3) were sacrificed on postoperative day 7 and betaARKct expression confirmed by Northern blotting. RESULTS Arteriograms performed on postoperative day 90 confirmed that saphenous vein grafts were patent. At postoperative day 90, AdbetaARKct-treated grafts demonstrated reduced intimal area compared to empty virus and saline treated animals (P < .05). Additionally, AdbetaARKct treatment of isolated vascular smooth muscle cells in vitro inhibited mitogen-activated protein kinase activation and decreased overall vascular smooth muscle cell proliferation. CONCLUSION This study demonstrates that betaARKct expression in aortocoronary saphenous vein grafts reduces intimal hyperplasia and decreases vascular smooth muscle cell proliferation in vitro via inhibition of G(betagamma)-mediated mitogen-activated protein kinase activation. Modulation of G(betagamma) via betaARKct may represent a novel therapy to reduce intimal hyperplasia and saphenous vein graft failure.
Collapse
|
28
|
|
29
|
Petrofski JA, Hata JA, Gehrig TR, Hanish SI, Williams ML, Thompson RB, Parsa CJ, Koch WJ, Milano CA. Gene delivery to aortocoronary saphenous vein grafts in a large animal model of intimal hyperplasia. J Thorac Cardiovasc Surg 2004; 127:27-33. [PMID: 14752409 DOI: 10.1016/j.jtcvs.2003.07.032] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE More than 50% of aortocoronary saphenous vein grafts are occluded 10 years after surgery. Intimal hyperplasia is an initial, critical step in the progression toward occlusion. To date, no clinically relevant large animal models of aortocoronary saphenous vein graft intimal hyperplasia have been fully characterized. Gene therapy holds promise as a novel treatment for aortocoronary saphenous vein graft intimal hyperplasia. The 2 objectives of this study are to characterize a canine model of aortocoronary saphenous vein graft intimal hyperplasia and to demonstrate that ex vivo gene delivery is possible in these grafts using adenoviral vectors. METHODS Ten dogs underwent aortocoronary bypass grafting using saphenous veins. Six dogs underwent serial arteriograms to monitor graft patency. On postoperative day 90, the dogs were killed and their grafted and nongrafted saphenous veins were studied histologically. Four dogs underwent the same procedure, but their saphenous veins were treated with 1 x 10(12) total viral particles of a replication-deficient, recombinant adenovirus containing beta-galactosidase (n = 2) or the beta-adrenergic receptor kinase carboxyl terminus (n = 2). These animals were killed on postoperative day 7 for determination of transgene expression. RESULTS All grafts were demonstrated patent by arteriogram before the animals were killed. The mean intimal area of the saphenous vein grafts was increased when compared with that of the nongrafted saphenous veins (2.83 mm(2) vs 0.09 mm(2), P <.0008). Adenoviral-treated saphenous vein grafts demonstrated positive transgene expression either by X-gal staining (beta-galactosidase) or Northern analysis (beta-adrenergic receptor kinase carboxyl terminus). CONCLUSION This study characterizes a clinically relevant canine model of aortocoronary saphenous vein graft intimal hyperplasia. In addition, it demonstrates that adenoviral vectors can be delivered ex vivo to the saphenous vein graft vessel wall at subphysiologic distension pressures. This model may be used in future studies to manipulate molecular targets critical in aortocoronary saphenous vein graft intimal hyperplasia.
Collapse
Affiliation(s)
- Jason A Petrofski
- Department of Surgery, Duke University Medical Center, Durham, NC 27703, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Petrofski JA, Hata JA, Parsa CJ, Williams ML, Hanish SI, Thompson RB, Matthew JP, Milano CA. Elevated donor serum troponin levels are not associated with increased recipient morbidity and mortality after heart transplantation. J Card Fail 2003. [DOI: 10.1016/s1071-9164(03)00519-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|