Neoadjuvant versus definitive radiochemotherapy of locoregionally advanced oesophageal cancer-who benefits?

PURPOSE

For years, there have been discussions on whether neoadjuvant radiochemotherapy followed by surgery (nRCT-S) is superior to definitive radiochemotherapy (dRCT) as the standard of care for locoregionally advanced oesophageal cancer (OC). This retrospective study aimed to evaluate our patient cohort regarding differences in survival and recurrence between nRCT‑S and dRCT.

METHODS

Data from 68 patients with dRCT and 33 patients with nRCT‑S treated from 2010 to 2018 were analysed. Comorbidities were recorded using the Charlson Comorbidity Index (CCI). Recurrence patterns were recorded as in-field or out-field. Kaplan-Meier analyses were used to compare survival data (overall survival [OS], progression-free survival [PFS], and locoregional control [LRC]).

RESULTS

Patients with nRCT‑S showed significantly lower CCI values than those with dRCT (p = 0.001). The median follow-up was 47 months. The median OS times were 31 months for nRCT‑S and 12 months for dRCT (p = 0.009), the median PFS times were 11 and 9 months, respectively (p = 0.057), and the median LRC times were not reached and 23 months, respectively (p = 0.037). The only further factor with a significant impact on OS was the CCI (p = 0.016). In subgroup analyses for comorbidities regarding differences in OS, the superiority of the nRCT‑S remained almost significant for CCI values 2-6 (p = 0.061).

CONCLUSION

Our study showed significantly longer OS and LRC for patients with nRCT‑S than for those with dRCT. Due to different comorbidities in the groups, it can be deduced from the subgroup analysis that patients with few comorbidities seem to especially profit from nRCT‑S.

Impact of perioperative blood transfusions on postoperative renal function and survival after resection of colorectal liver metastases

Background and aims

Recent studies focusing on thoracic surgery suggest postoperative kidney injury depending on the amount of perioperative blood transfusions. Data investigating similar effects after resection of colorectal liver metastases (CRLM) are not available. Aim of this study was therefore to evaluate the influence of perioperative blood transfusions on postoperative renal function and survival after resection of CRLM.

Methods

Seven hundred twenty-seven cases of liver resection for CRLM were retrospectively analyzed. Renal function was measured via estimated glomerular filtration rate (eGFR) and a postoperative decline of ≥ 10% was considered substantial. Potential influences on postoperative kidney function were assessed using univariable and multivariable logistic regression analyses. Cox-regression analyses were performed to estimate the impact on overall survival (OS).

Results

Preoperative impaired kidney function (p = 0.001, OR 2.477) and transfusion of > 2 units of packed red blood cells (PRBC) (p = 0.046; OR 1.638) were independently associated with an increased risk for ≥ 10% loss of renal function. Neither a pre-existing renal impairment, nor the additional loss of renal function were associated with reduced survival. Chemotherapies in the context of primary colorectal cancer treatment (p = 0.002), age > 70 years at liver resection (p = 0.005), number (p = 0.001), and size of metastases > 50 mm (p = 0.018), duration of resection > 120 min (p = 0.006) and transfusions of > 2 units of PRBC (p = 0.039) showed a negative independent influence on OS.

Conclusion

The results demonstrate a negative impact of perioperative blood transfusions on the postoperative renal function and OS. Hence, efforts to reduce blood transfusions should be intensified.

Simultaneous heart-kidney transplantation results in respectable long-term outcome but a high rate of early kidney graft loss in high-risk recipients - a European single center analysis

BACKGROUND

In spite of renal graft shortage and increasing waiting times for transplant candidates, simultaneous heart and kidney transplantation (HKTx) is an increasingly performed procedure established for patients with combined end-stage cardiac and renal failure. Although data on renal graft outcome in this setting is limited, reports on reduced graft survival in comparison to solitary kidney transplantation (KTx) have led to an ongoing discussion of adequate organ utilization.

METHODS

This retrospective study was conducted to evaluate prognostic factors and outcomes of 27 patients undergoing HKTx in comparison to a matched cohort of 27 patients undergoing solitary KTx between September 1987 and October 2019 in one of Europe's largest transplant centers.

RESULTS

Median follow-up was 100.33 (0.46-362.09) months. Despite lower five-year kidney graft survival (62.6% versus 92.1%; 111.73 versus 183.08 months; p = 0.189), graft function and patient survival (138.90 versus 192.71 months; p = 0.128) were not significantly inferior after HKTx in general. However, in case of prior cardiac surgery requiring sternotomy we observed significantly reduced early graft and patient survival (57.00 and 94.09 months, respectively) when compared to patients undergoing solitary KTx (183.08 and 192.71 months; p < 0.001, respectively) or HKTx without prior cardiac surgery (203.22 and 203.22 months; p = 0.016 and p = 0.019, respectively), most probably explained by the significantly increased rate of primary nonfunction (33.3%) and in-hospital mortality (25.0%).

CONCLUSIONS

Our data demonstrates the increased rate of early kidney graft loss and thus significantly inferior graft survival in high-risk patients undergoing HKTx. Thus, we advocate for a "kidney-after-heart" program in such patients to ensure responsible and reasonable utilization of scarce resources in times of ongoing organ shortage crisis.

Liver-first strategy for a combined lung and liver transplant in patients with cystic fibrosis

OBJECTIVES

A combined lung and liver transplant in patients with cystic fibrosis (CF) is an uncommon procedure. The goal of this study was to compare long-term outcomes between patients with CF who underwent either a combined lung-liver or a lung-only transplant.

METHODS

This is a retrospective single-centre study of patients with CF who underwent a lung transplant between January 2005 and May 2020. Since 2006, our preference for a combined lung-liver transplant was to transplant the liver first and then the lung. Outcomes were compared using the Kaplan-Meier analysis and the log-rank test. Median follow-up was 53 (23-97) months.

RESULTS

During the study period, among 357 patients with CF who underwent a lung transplant, 14 (4%) required a lung-liver transplant whereas 343 (96%) had a lung-only transplant. Lung cold ischaemic time was longer in the lung-liver transplant group, but no patient in this group showed primary graft dysfunction at 72 h after the transplant. Prevalence of anti-human leucocyte antigen donor-specific antibodies was 7.1% vs 13.7% in the lung-liver versus the lung-only transplant group (P = 0.42). At 5 years, lung graft survival (78% vs 69%) and freedom from chronic lung allograft dysfunction (79% vs 62%) did not differ between the lung-liver versus the lung-only groups (P = 0.45 and P = 0.55, respectively). Freedom from lung biopsy-confirmed rejection was significantly higher in patients undergoing a lung-liver transplant (91% vs 50%; P = 0.027).

CONCLUSIONS

A lung-liver transplant did not impair lung graft function. The lower prevalence of donor-specific antibodies and the better freedom from lung biopsy-confirmed rejection suggest tolerogenic effects of the liver graft.

Multivisceral resection for adenocarcinoma of the pancreatic body and tail-a retrospective single-center analysis

BACKGROUND

Adenocarcinoma of the pancreatic body and tail is associated with a dismal prognosis. As patients frequently present themselves with locally advanced tumors, extended surgery including multivisceral resection is often necessary in order to achieve tumor-free resection margins. The aim of this study was to identify prognostic factors for postoperative morbidity and mortality and to evaluate the influence of multivisceral resections on patient outcome.

METHODS

This is a retrospective analysis of 94 patients undergoing resection of adenocarcinoma located in the pancreatic body and/or tail between April 1995 and December 2016 at our institution. Uni- and multivariable Cox regression analysis was conducted to identify independent prognostic factors for postoperative survival.

RESULTS

Multivisceral resections, including partial resections of the liver, the large and small intestines, the stomach, the left kidney and adrenal gland, and major vessels, were carried out in 47 patients (50.0%). The median postoperative follow-up time was 12.90 (0.16-220.92) months. Median Kaplan-Meier survival after resection was 12.78 months with 1-, 3-, and 5-year survival rates of 53.2%, 15.8%, and 9.0%. Multivariable Cox regression identified coeliac trunk resection (p = 0.027), portal vein resection (p = 0.010), intraoperative blood transfusions (p = 0.005), and lymph node ratio in percentage (p = 0.001) as independent risk factors for survival. Although postoperative complications requiring surgical revision were observed more frequently after multivisceral resections (14.9 versus 2.1%; p = 0.029), postoperative survival was not significantly inferior when compared to patients undergoing standard distal or subtotal pancreatectomy (12.35 versus 13.87 months; p = 0.377).

CONCLUSIONS

Our data indicates that multivisceral resection in cases of locally advanced pancreatic carcinoma of the body and/or tail is justified, as it is not associated with increased mortality and can even facilitate long-term survival, albeit with an increase in postoperative morbidity. Simultaneous resections of major vessels, however, should be considered carefully, as they are associated with inferior survival.

Ten-year outcomes in a randomized phase II study of kidney transplant recipients administered belatacept 4-weekly or 8-weekly

In the phase II IM103-100 study, kidney transplant recipients were first randomized to belatacept more-intensive-based (n = 74), belatacept less-intensive-based (n = 71), or cyclosporine-based (n = 73) immunosuppression. At 3-6 months posttransplant, belatacept-treated patients were re-randomized to receive belatacept every 4 weeks (4-weekly, n = 62) or every 8 weeks (8-weekly, n = 60). Patients initially randomized to cyclosporine continued to receive cyclosporine-based immunosuppression. Cumulative rates of biopsy-proven acute rejection (BPAR) from first randomization to year 10 were 22.8%, 37.0%, and 25.8% for belatacept more-intensive, belatacept less-intensive, and cyclosporine, respectively (belatacept more-intensive vs cyclosporine: hazard ratio [HR] = 0.95; 95% confidence interval [CI] 0.47-1.92; P = .89; belatacept less-intensive vs cyclosporine: HR = 1.61; 95% CI 0.85-3.05; P = .15). Cumulative BPAR rates from second randomization to year 10 for belatacept 4-weekly, belatacept 8-weekly, and cyclosporine were 11.1%, 21.9%, and 13.9%, respectively (belatacept 4-weekly vs cyclosporine: HR = 1.06, 95% CI 0.35-3.17, P = .92; belatacept 8-weekly vs cyclosporine: HR = 2.00, 95% CI 0.75-5.35, P = .17). Renal function trends were estimated using a repeated-measures model. Estimated mean GFR values at year 10 for belatacept 4-weekly, belatacept 8-weekly, and cyclosporine were 67.0, 68.7, and 42.7 mL/min per 1.73 m² , respectively (P<.001 for overall treatment effect). Although not statistically significant, rates of BPAR were 2-fold higher in patients administered belatacept every 8 weeks vs every 4 weeks.

Efficacy and Safety Outcomes of Extended Criteria Donor Kidneys by Subtype: Subgroup Analysis of BENEFIT-EXT at 7 Years After Transplant

The phase III Belatacept Evaluation of Nephroprotection and Efficacy as First-Line Immunosuppression Trial-Extended Criteria Donors Trial (BENEFIT-EXT) study compared more or less intensive belatacept-based immunosuppression with cyclosporine (CsA)-based immunosuppression in recipients of extended criteria donor kidneys. In this post hoc analysis, patient outcomes were assessed according to donor kidney subtype. In total, 68.9% of patients received an expanded criteria donor kidney (United Network for Organ Sharing definition), 10.1% received a donation after cardiac death kidney, and 21.0% received a kidney with an anticipated cold ischemic time ≥24 h. Over 7 years, time to death or graft loss was similar between belatacept- and CsA-based immunosuppression, regardless of donor kidney subtype. In all three donor kidney cohorts, estimated mean GFR increased over months 1-84 for belatacept-based treatment but declined for CsA-based treatment. The estimated differences in GFR significantly favored each belatacept-based regimen versus the CsA-based regimen in the three subgroups (p < 0.0001 for overall treatment effect). No differences in the safety profile of belatacept were observed by donor kidney subtype.

Ten years experience with belatacept-based immunosuppression after kidney transplantation

Background

Belatacept was approved for prevention of acute rejection in adult kidney transplantation in 2011 based on two randomized, controlled, multicenter phase 3 studies. Long-term experience over 10 years with belatacept-based immunosuppression after kidney transplantation has not been reported before.

Patients and Methods

Analyzed were 20 patients who had been included into a randomized multicenter phase 2 study by our institution between March 2001 and November 2002. For 10-year follow-up, three different groups could be analyzed: 1) patients with primary calcineurin inhibitor-based (CNI-based) immunosuppression (n = 5), 2) patients with early switch from a belatacept-based to a CNI-based regimen within the first 14 months (n = 8) and 3) patients with completely CNI-free belatacept immunosuppression (n = 7).

Results

Fifteen patients received primary belatacept-based immunosuppression and five patients primary cyclosporine A (CyA). Five patients are still on belatacept. Kidney function measured by serum creatinine levels worsened in the CNI group and the belatacept to CNI switch group during long-term follow-up whereas all patients receiving belatacept throughout follow-up showed stable creatinine values. Acute rejections occurred predominantly in the first 12 months after transplantation and were responsible for four of seven switches from belatacept- to CNI-based immunosuppression within the first 14 months. Five of the 20 patients died.

Conclusions

Belatacept is effective and safe in renal transplant patients and was not associated with graft loss due to chronic allograft nephropathy. Belatacept was well tolerated in all patients and caused less nephrotoxic side effects and was well accepted in most patients.

Ascites drainage leading to intestinal adhesions at the mesentery of the small intestine with fatal outcome

A common problem in patients with chronic liver diseases and liver cirrhosis is the development of ascites. First line therapy for ascites is the restriction of sodium intake and a diuretic treatment. Paracentesis is indicated in patients with large compromising volumes of ascites. In selected cases, permanent drainage of ascites over prolonged periods of time may be indicated. In the case presented here, a 66-year-old male patient, who was hospitalized with liver cirrhosis caused by alcoholic abuse, required permanent drainage of ascites. After three weeks of continuous ascites drainage, he developed bacterial peritonitis. Conventional attempts to remove the catheter by transcutaneous pulling failed and we thus decided to perform a median laparotomy to remove the catheter surgically. Intraoperatively an adhesion of the ascites drain (a so called ‘basket catheter’) to the mesentery very close to the small intestine was found, approximately 50 mm distal of the ligament suspensorium duodeni (ligament of Treitz). The basket catheter used for this patient was especially designed to drain infections, not fluids. We solved the adhesion, removed the basket catheter, placed a new surgical drain and finished the operation. The patient developed a rupture of his abdominal fascia suture 12 days later, which was caused by massive ascites and complicated by hepatorenal syndrome type I. The patient was taken to the operating theater again. After the second operation, the chronic liver failure decompensated and the patient died. Ascites caused by liver cirrhosis is still a medical challenge. The indication for the use of the correct percutaneous catheter for permanent paracentesis should be carefully considered. Some catheters are obviously not suited to drain ascites and may lead to fatal outcomes.

Effects of mycophenolate mofetil introduction in liver transplant patients: results from an observational, non-interventional, multicenter study (LOBSTER)

The benefits of calcineurin inhibitor (CNI)-sparing regimens on renal function following liver transplantation (LT) have been demonstrated in clinical studies. This observational study assessed the real-life effects of mycophenolate mofetil (MMF) introduction in LT patients. Four hundred and ninety-seven patients in whom MMF was introduced according to local standards or clinical considerations were entered. Patients were grouped by time between transplantation and start of MMF (start of study): Group A (n = 263): ≤6 d; Group B (n = 64): >6 d to ≤1 month; Group C (n = 74): >1 month to ≤1 yr; and Group D (n = 96): >1 yr. CNI sparing occurred in all groups, particularly in Groups C and D. Mean MMF doses at 12 months were 1202.7, 1363.5, 1504.7, and 1578.1 mg/d, respectively, in Groups A-D. At introduction of MMF, median glomerular filtration rate was 73.3, 81.7, 62.7, and 53.7 mL/min/1.73 m(2) in Groups A-D. At 12 months, this decreased to 66 mL/min/1.73 m(2) in Groups A and B, remained stable in Group C, and increased in Group D (64.8 mL/min/1.73 m(2) ). Serious adverse drug reactions were lowest in Group D. In conclusion, MMF with a subsequent decrease in CNI was well tolerated and improved renal function even years after transplantation. A more forceful MMF dosing strategy with greater CNI sparing may further improve renal function.

Resource use and treatment costs after kidney transplantation: impact of demographic factors, comorbidities, and complications

BACKGROUND

Our goal was to quantify outcomes, resource use, and treatment costs for the first 2 years after renal transplantation in a "real-life" European setting and to assess the impact of preoperative risk factors and postoperative complications on treatment costs.

METHODS

Inpatient and outpatient records of all patients who received a renal transplant at Medizinische Hochschule Hannover, Germany, between January 1998 and July 2000, were evaluated. Key clinical events were recorded. Direct costs were calculated for primary hospitalization, the remainder of year 1, and year 2 after transplantation. Cost of organ procurement, pretransplant care, and transplant surgery were excluded. Cost consequences for key clinical events were determined.

RESULTS

Of 204 patients undergoing transplantation, 195 and 149 completed 1 year and 2 years of follow-up, respectively. The outcomes of years 1 and 2, respectively, were as follows: graft failure, 5.4%, 0.7%; acute rejection, 35.9%, 5.4%; cytomegalovirus (CMV) infection, 29.2%, 2.0%; and delayed graft function, 30.9%. Costs for primary hospitalization, the remainder of year 1, and year 2 averaged Euro 15,380, Euro 18,636, and Euro 14,484, respectively. Cost-driving events included graft failure Euro 36,228), acute rejection (Euro 9,638), delayed graft function (Euro7,359), and CMV infection (Euro 4,149). Graft failure and acute rejection for year 1 also added significantly to the costs for year 2.

CONCLUSIONS

These results show that posttransplant clinical outcomes result in a significant increase in treatment costs. Because the economic impact of primary causes of chronic rejection (acute rejection and CMV) and delayed graft function is substantial, careful selection of the most appropriate immunosuppressive regimen is essential.

Expansion of the donor pool in liver transplantation: the Hannover experience 1996-2002

In the past decade liver transplantation has become the standard therapy for terminal liver failure. An increasing organ shortage, specific regional allocation systems within the Eurotransplant area and the lack of an efficient system to identify donors have resulted in decreasing numbers of liver transplants. Approximately 20% of patients are dying on the waiting list, a list that has exploded in numbers and waiting time in the past 3 years. In particular children and small adults are put at a disadvantage since standard donors have standard size livers. Two options to solve this dilemma are the expanded use of split-liver and living-donor liver transplantation. The specific experiences applying these techniques at the Medizinische Hochschule Hannover are discussed and compared with the results given in the European Liver Transplant Registry. The retrospective analysis demonstrates a shift in the use of resources, with decreasing numbers of full-size cadaver liver transplants and an increase in split- and living-donor liver transplantation. Both techniques are limited to specific patient populations, a notion that has to be considered in the comparison of results and outcome. According to our experience the full-size cadaver liver is still the standard option, while other techniques require careful attention to the chosen recipient population, advanced surgical skills and, for living donors, as a sine qua non the prerequisite of nihil nocere.