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de Fijter J, Dreyer G, Mallat M, Budde K, Pratschke J, Klempnauer J, Zeier M, Arns W, Hugo C, Rump LC, Hauser I, Schenker P, Schiffer M, Grimm MO, Kliem V, Olbricht CJ, Pisarski P, Banas B, Suwelack B, Hakenberg O, Berlakovich G, Schneeberger S, van de Wetering J, Berger S, Bemelman F, Kuypers D, Heidt S, Rahmel A, Claas F, Peeters P, Oberbauer R, Heemann U, Krämer BK. A paired-kidney allocation study found superior survival with HLA-DR compatible kidney transplants in the Eurotransplant Senior Program. Kidney Int 2023; 104:552-561. [PMID: 37343659 DOI: 10.1016/j.kint.2023.05.025] [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: 08/18/2022] [Revised: 03/27/2023] [Accepted: 05/04/2023] [Indexed: 06/23/2023]
Abstract
The Eurotransplant Senior Program (ESP) has expedited the chance for elderly patients with kidney failure to receive a timely transplant. This current study evaluated survival parameters of kidneys donated after brain death with or without matching for HLA-DR antigens. This cohort study evaluated the period within ESP with paired allocation of 675 kidneys from donors 65 years and older to transplant candidates 65 years and older, the first kidney to 341 patients within the Eurotransplant Senior DR-compatible Program and 334 contralateral kidneys without (ESP) HLA-DR antigen matching. We used Kaplan-Meier estimates and competing risk analysis to assess all cause mortality and kidney graft failure, respectively. The log-rank test and Cox proportional hazards regression were used for comparisons. Within ESP, matching for HLA-DR antigens was associated with a significantly lower five-year risk of mortality (hazard ratio 0.71; 95% confidence interval 0.53-0.95) and significantly lower cause-specific hazards for kidney graft failure and return to dialysis at one year (0.55; 0.35-0.87) and five years (0.73; 0.53-0.99) post-transplant. Allocation based on HLA-DR matching resulted in longer cold ischemia (mean difference 1.00 hours; 95% confidence interval: 0.32-1.68) and kidney offers with a significantly shorter median dialysis vintage of 2.4 versus 4.1 yrs. in ESP without matching. Thus, our allocation based on HLA-DR matching improved five-year patient and kidney allograft survival. Hence, our paired allocation study suggests a superior outcome of HLA-DR matching in the context of old-for-old kidney transplantation.
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Affiliation(s)
- Johan de Fijter
- Department of Nephrology, Leiden University Medical Center, Leiden, Netherlands.
| | - Geertje Dreyer
- Department of Nephrology, Leiden University Medical Center, Leiden, Netherlands
| | - Marko Mallat
- Department of Nephrology, Leiden University Medical Center, Leiden, Netherlands
| | - Klemens Budde
- Department of Nephrology, Internal Intensive Care Medicine, Campus Charité Mitte, Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, Campus Charité Mitte and Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jürgen Klempnauer
- Integrated Research and Treatment Centre Transplantation, Hannover Medical School, Hannover, Germany
| | - Martin Zeier
- Department of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Wolfgang Arns
- Department of Nephrology and Transplantation, Cologne Merheim Medical Center, Cologne, Germany
| | - Christian Hugo
- Clinic for Internal Medicine III, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Lars-Christian Rump
- Department of Internal Medicine/Nephrology, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Ingeborg Hauser
- Department of Nephrology, Goethe University Hospital Frankfurt, Frankfurt/Main, Germany
| | - Peter Schenker
- Department of Surgery, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, Bochum, Germany
| | - Mario Schiffer
- Department of Nephrology, Erlangen University Hospital, Erlangen, Germany
| | | | - Volker Kliem
- Department of Internal Medicine and Nephrology, Kidney Transplant Center, Nephrological Center of Lower Saxony, Klinikum Hann, Münden, Germany
| | | | - Przemyslaw Pisarski
- Department of Surgery, Section of Transplant Surgery, Medical Center-University of Freiburg, Freiburg, Germany
| | - Bernhard Banas
- Department of Nephrology, University Hospital Regensburg, Regensburg, Germany
| | - Barbara Suwelack
- Department of Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster, Münster, Germany
| | | | - Gabriela Berlakovich
- Division of Transplantation, Department of Surgery, Medical University of Vienna, Wien, Austria
| | - Stefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Stefan Berger
- Department of Nephrology, University Medical Center Groningen, Groningen, Netherlands
| | - Frederike Bemelman
- Department of Nephrology, Division of Internal Medicine, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Dirk Kuypers
- Department of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Sebastiaan Heidt
- Eurotransplant Reference Laboratory, Leiden University Medical Center, Leiden, Netherlands
| | - Axel Rahmel
- Eurotransplant International Foundation, Leiden, Netherlands
| | - Frans Claas
- Eurotransplant Reference Laboratory, Leiden University Medical Center, Leiden, Netherlands
| | - Patrick Peeters
- Department of Nephrology, Ghent University Hospital, Ghent, Belgium
| | - Rainer Oberbauer
- Department of Nephrology, Medical University of Vienna, Vienna, Austria
| | - Uwe Heemann
- Department of Nephrology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Bernhard K Krämer
- V-th Department of Medicine (Nephrology), University Medical Center Mannheim/University of Heidelberg, Mannheim, Germany
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Emmanouilidis N, Hashem AAB, Stiegler P, Ringe BP, Alten TA, Klempnauer J, Schrem H. Transplanting a left or right donor kidney into the left or right iliac fossa: importance of laterality and site of venous anastomosis. Updates Surg 2023:10.1007/s13304-023-01512-9. [PMID: 37171776 DOI: 10.1007/s13304-023-01512-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 04/17/2023] [Indexed: 05/13/2023]
Abstract
Data on the impact of donor-to-recipient laterality on kidney transplantation are lacking. This study evaluated the impact of donor-to-iliac fossa laterality and the site of venous anastomosis on operating time and surgical outcome. This retrospective single-center study analyzed 1262 deceased donor adult kidney transplants into pristine iliac fossa. Multivariable linear and logistic regression analyses were used to identify variables with an impact on operating time and surgical complications. Operating time was shorter by 11 min in median for transplantations into the right iliac fossa compared to the left iliac fossa (p < 0.001). Operating time in left-to-right donor-to-recipient combination was shorter by 17 min in median if venous anastomoses were performed on the caval vein or common iliac vein as compared to anastomoses to the external iliac vein (p < 0.001). Overall, the shortest operating times (median 112.5 min) were achieved in left-to-right donor-to-recipient combinations with venous anastomosis to the caval or common iliac vein, without an increase in surgical complications. Kidney transplantation into the right iliac fossa with anastomosis to the caval vein or the common iliac vein saves operating time and reduces thrombotic complications. Acceptance of a left donor kidney is likely to further reduce operating time.
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Affiliation(s)
- Nikos Emmanouilidis
- General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany.
- General, Visceral, Thoracic and Minimalinvasive Surgery, St. Elisabeth Hospital, Stadtring Kattenstroth 130, 33332, Gütersloh, Germany.
| | | | - Philipp Stiegler
- Department of Transplant Surgery, Medizinische Universität Graz, Graz, Austria
| | - Bastian Paul Ringe
- General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Tim Alexander Alten
- Department of Radiology, Hannover Medical School, Hannover, Germany
- Department of Radiology, St. Vincenz Hospital Paderborn, Paderborn, Germany
| | - Jürgen Klempnauer
- General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Harald Schrem
- General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
- Department of Transplant Surgery, Medizinische Universität Graz, Graz, Austria
- Core Facility Quality Management & Health Technology Assessment in Transplantation, Hannover Medical School, Hannover, Germany
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Schmelzle M, Benzing C, Fischer L, Herden U, Sterneck M, Settmacher U, Bauschke A, Neumann U, Pelzer U, Müller T, Strassburg C, Lang H, Becker T, Königsrainer A, Nadalin S, Quante M, Paul A, Friess H, Klempnauer J, Richter N, Vondran F, Pascher A, Rösch T, Schöning W, Krenzien F, Öllinger R, Seehofer D, Neuhaus P, Pratschke J. Feasibility and Efficacy of Adjuvant Chemotherapy With Gemcitabine After Liver Transplantation for Perihilar Cholangiocarcinoma - A Multi-Center, Randomized, Controlled Trial (pro-duct001). Front Oncol 2022; 12:910871. [PMID: 36330499 PMCID: PMC9624225 DOI: 10.3389/fonc.2022.910871] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 05/19/2022] [Indexed: 11/14/2022] Open
Abstract
Background Liver transplantation (LT) is considered a therapeutic option for unresectable perihilar cholangiocarcinoma (PHC) within defined criteria. It remains uncertain whether patients can safely receive adjuvant chemotherapy after LT. Methods We performed a prospective, multi-center, randomized, non-blinded two-arm trial (pro-duct001). Patients after LT for unresectable PHC within defined criteria were randomized to adjuvant gemcitabine (LT-Gem group) and LT alone (LT alone group). The primary objective was to investigate if adjuvant chemotherapy is feasible in ≥ 85% of patients after LT. The primary endpoint was the percentage of patients completing the 24 weeks course of adjuvant chemotherapy. Secondary endpoints included overall survival (OS) and disease-free (DFS), and complication rates. Results Twelve patients underwent LT for PHC, of which six (50%) were eligible for randomization (LT-Gem: three patients, LT alone: three patients). Two out of three patients discontinued adjuvant chemotherapy after LT due to intolerance. The study was prematurely terminated due to slow enrollment. One patient with PHC had underlying primary sclerosing cholangitis (PSC). Tumor-free margins could be achieved in all patients. In both the LT-Gem and the LT alone group, the cumulative 1-, 3-, and 5-year OS and DFS rates were 100%, 100%, 67%, and 100%, 67% and 67%, respectively. Conclusions This prospective, multi-center study was prematurely terminated due to slow enrollment and a statement on the defined endpoints cannot be made. Nevertheless, long-term survival data are consistent with available retrospective data and confirm defined criteria for LT. Since more evidence of LT per se in unresectable PHC is urgently needed, a prospective, non-randomized follow-up study (pro-duct002) has since been launched.
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Affiliation(s)
- Moritz Schmelzle
- Department of Surgery, Charité – Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of General, Visceral and Transplant Surgery, Medizinische Hochschule Hannover, Hannover, Germany
| | - Christian Benzing
- Department of Surgery, Charité – Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Lutz Fischer
- Department of Visceral Transplant Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Herden
- Department of Visceral Transplant Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Martina Sterneck
- Department of Medicine I, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Utz Settmacher
- Department of General, Visceral and Vascular Surgery, University Hospital Jena, Jena, Germany
| | - Astrid Bauschke
- Department of General, Visceral and Vascular Surgery, University Hospital Jena, Jena, Germany
| | - Ulf Neumann
- Department of General, Visceral and Transplant Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Uwe Pelzer
- Department of Medicine - Hematology, Oncology and Tumour Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Tobias Müller
- Department of Medicine - Hepatology and Gastroenterology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Hauke Lang
- Department of General, Visceral and Transplant Surgery, University Hospital Mainz, Mainz, Germany
| | - Thomas Becker
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Alfred Königsrainer
- Department of General, Visceral and Transplant, University Hospital Tübingen, Tübingen, Germany
| | - Silvio Nadalin
- Department of General, Visceral and Transplant, University Hospital Tübingen, Tübingen, Germany
| | - Markus Quante
- Department of General, Visceral and Transplant, University Hospital Tübingen, Tübingen, Germany
| | - Andreas Paul
- Department of General, Visceral and Transplant, University Hospital Essen, Essen, Germany
| | - Helmut Friess
- Department of General, Visceral, Thoracic and Transplant, University Hospital rechts der Isar, München, Germany
| | - Jürgen Klempnauer
- Department of General, Visceral and Transplant Surgery, Medizinische Hochschule Hannover, Hannover, Germany
| | - Nicolas Richter
- Department of General, Visceral and Transplant, University Hospital Tübingen, Tübingen, Germany
| | - Florian Vondran
- Department of General, Visceral and Transplant, University Hospital Tübingen, Tübingen, Germany
| | - Andreas Pascher
- Department of General, Visceral and Transplant, University Hospital Münster, Münster, Germany
| | - Thomas Rösch
- University Hospital Hamburg-Eppendorf, Klinik und Poliklinik für Interdisziplinäre Endoskopie, Hamburg, Germany
| | - Wenzel Schöning
- Department of Surgery, Charité – Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Felix Krenzien
- Department of Surgery, Charité – Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Robert Öllinger
- Department of Surgery, Charité – Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Daniel Seehofer
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Peter Neuhaus
- Department of Surgery, Charité – Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, Charité – Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- *Correspondence: Johann Pratschke,
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Schnitzler LJ, Oldhafer F, Kulik U, Klempnauer J, Reese T, Oldhafer KJ, Beetz O. Preoperative leukocytosis is an independent risk factor for morbidity and survival after resection of colorectal liver metastases. ANZ J Surg 2022; 92:2551-2559. [PMID: 35723493 DOI: 10.1111/ans.17845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 05/21/2022] [Accepted: 05/24/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Although surgical resection of colorectal liver metastases (CRLM) remains to be the only option for long term survival, traditional surgical concepts have been challenged by the introduction of the liver first approach or neoadjuvant chemotherapy in resectable CRLM and interventional therapies. The aim of this study was to identify prognostic factors for postoperative morbidity and survival and to externally evaluate the recently introduced resection severity index (RSI), in order to optimize patient selection and treatment strategies. METHODS This is a retrospective single centre analysis of 213 patients undergoing surgery for CRLM in curative intent between January 2010 and December 2018. RESULTS Median follow up after liver resection was 28.56 (0.01-111.46) months. Severe postoperative complications (Clavien-Dindo ≥ IIIa) were observed in 46 (21.6%) cases. Preoperative leukocytosis (OR: 3.114, CI-95%: 1.089-8.901; p = 0.034) and operation time in minutes (OR: 1.007, CI-95%: 1.002-1.011; p = 0.002) were determined as independent risk factors. Overall survival (OS) was 46.68 months with a 5-year survival rate of 40.5%. Independent prognostic factors were preoperative leukocytosis (HR: 2.358, CI-95%: 1.170-4.752; p = 0.016), major hepatectomy (HR: 1.741, CI-95%: 1.098-2.759; p = 0.018) and low grading of the primary intestinal tumour (HR: 0.392, CI-95%: 0.231-0.667; p < 0.001). The RSI (ASAT (U/l) divided by Quick (%) multiplied by the extent of liver resection in points) was identified as independent risk factor for OS only in patients without neoadjuvant chemotherapy. CONCLUSIONS Detection of leukocytosis in patients prior resection of CRLM was associated with increased postoperative morbidity and decreased OS and could therefore prove valuable for perioperative risk stratification.
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Affiliation(s)
- Laura Julie Schnitzler
- Department of Surgery, Division of Hepato-biliary and Pancreatic (HBP) Surgery, Asklepios Hospital Barmbek, Hamburg, Germany.,Faculty of Medicine, Semmelweis University Budapest, Asklepios Campus Hamburg, Hamburg, Germany
| | - Felix Oldhafer
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Ulf Kulik
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Jürgen Klempnauer
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Tim Reese
- Department of Surgery, Division of Hepato-biliary and Pancreatic (HBP) Surgery, Asklepios Hospital Barmbek, Hamburg, Germany.,Faculty of Medicine, Semmelweis University Budapest, Asklepios Campus Hamburg, Hamburg, Germany
| | - Karl J Oldhafer
- Department of Surgery, Division of Hepato-biliary and Pancreatic (HBP) Surgery, Asklepios Hospital Barmbek, Hamburg, Germany.,Faculty of Medicine, Semmelweis University Budapest, Asklepios Campus Hamburg, Hamburg, Germany
| | - Oliver Beetz
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
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Cammann S, Karabulut S, DeTemple DE, Oldhafer F, Kulik U, Schroeter A, Vondran FWR, Klempnauer J, Kleine M, Timrott K, Beetz O. Antibiotic-Resistant Bacteria Colonizing the Bile Duct Are Associated with Increased Morbidity and Mortality after Resection of Extrahepatic Cholangiocarcinoma. Surg Infect (Larchmt) 2022; 23:270-279. [PMID: 35172114 DOI: 10.1089/sur.2021.117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: Patients with extrahepatic cholangiocarcinoma (CCA) face considerable morbidity including septic complications after surgery. The aim of this study was to characterize the bacterial spectrum of the common hepatic duct (CHD) and its clinical relevance regarding morbidity and mortality after resection of extrahepatic CCA. Methods: We retrospectively analyzed data from 205 patients undergoing surgery for extrahepatic CCA in our department between January 2000 and March 2015. Patients were reviewed for pre-operative medical conditions, biliary bacterial flora obtained from intra-operative swabs, different septic complications, and post-operative outcome. Results: Bacterial colonization of the CHD was observed in 84.9% of the patients, with Enterococcus faecalis being detected most frequently (28.3%). Wound infections occurred in 30.7% of patients. Bacterial flora of the CHD and of the post-operatively colonized wounds coincided in 51.5% and of intra-abdominal swabs obtained during surgical revisions in 40.0%. Ciprofloxacin-resistant bacteria in the CHD were identified as independent risk factor for wound infections (odds ratio [OR], 3.330; 95% confidence interval [CI], 1.771-6.263; p < 0.001) and for complications requiring surgical revision (OR, 2.417; 95% CI, 1.288-4.539; p = 0.006). Most important independent risk factors for intra-hospital mortality were ampicillin-sulbactam-resistant bacteria in the CHD (OR, 3.969; 95% CI, 1.515-10.399; p = 0.005) and American Society of Anesthesiologists (ASA) grading >2 (OR, 2.936; 95% CI, 1.337-6.451; p = 0.007). Conclusions: Antibiotic-resistant bacteria from the CHD are associated with increased morbidity and mortality in patients undergoing resection for extrahepatic CCA.
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Affiliation(s)
- Sebastian Cammann
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Sultan Karabulut
- Department of General and Visceral Surgery, Diakovere Henriettenstift and Friederikenstift, Hannover, Germany
| | - Daphne E DeTemple
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Felix Oldhafer
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Ulf Kulik
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Andreas Schroeter
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Florian W R Vondran
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Jürgen Klempnauer
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Moritz Kleine
- Department of General, Visceral and Vascular Surgery and Coloproctology, Vinzenzkrankenhaus Hannover, Hannover, Germany
| | - Kai Timrott
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Oliver Beetz
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
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Blossey RD, Kleine-Döpke D, Ringe KI, Pöhnert D, Ringe B, Klempnauer J, Beetz O. Recurrent Hurthle cell thyroid carcinoma does not preclude long-term survival: a case report and review of the literature. J Med Case Rep 2021; 15:399. [PMID: 34376229 PMCID: PMC8356425 DOI: 10.1186/s13256-021-02987-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 06/28/2021] [Indexed: 11/22/2022] Open
Abstract
Background Follicular thyroid carcinoma is the second most common malignancy of the thyroid gland. In 2016, the so-called Hurthle cell thyroid carcinoma, formerly known as the oxyphilic variant of the follicular thyroid carcinoma, was reclassified by the World Health Organization as a separate pathological entity, which accounts for approximately 3% of all thyroid cancers. Although Hurthle cell thyroid carcinomas are known for their more aggressive tumor biology, metastases are observed in a minority of cases, and long-term survival can be expected. However, disseminated disease is often associated with poor outcome. Case presentation In the presented case, a 63-year-old Caucasian female was incidentally diagnosed with Hurthle cell thyroid carcinoma after undergoing hemithyroidectomy for a nodular goiter. Following completion thyroidectomy, two courses of radioactive iodine therapy were administered. After 4 years of uneventful follow-up, the patient gradually developed metastases in five different organs, with the majority representing unusual sites, such as heart, kidney, and pancreas over a course of 14 years. The lesions were either treated with radioactive iodine therapy or removed surgically, depending on iodine avidity. Conclusion Follicular and Hurthle cell thyroid carcinoma are known to potentially spread hematogenously to typical sites, such as lung or bones, however; unusual metastatic sites as presented in our case can also be observed. A search of the literature revealed only scattered reports on patients with multiple metastases in unusual locations. Furthermore, the observed long-term survival of our patient is contradictory to the existing data. As demonstrated, recurrent disease may appear years after the initial diagnosis, emphasizing the importance of consistent aftercare. Radioactive iodine therapy, extracorporeal radiation therapy, and surgical metastasectomy are central therapeutic components. In summary, our case exemplifies that thorough aftercare and aggressive treatment enables long-term survival even in recurrent Hurthle cell thyroid carcinoma displaying unusual multisite metastases.
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Affiliation(s)
- Richard David Blossey
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Lower Saxony, Germany.
| | - Dennis Kleine-Döpke
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Lower Saxony, Germany
| | - Kristina Imeen Ringe
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Daniel Pöhnert
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Lower Saxony, Germany
| | - Bastian Ringe
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Lower Saxony, Germany
| | - Jürgen Klempnauer
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Lower Saxony, Germany
| | - Oliver Beetz
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Lower Saxony, Germany
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Beetz O, Thies J, Weigle CA, Ius F, Winkler M, Bara C, Richter N, Klempnauer J, Warnecke G, Haverich A, Avsar M, Grannas G. 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. BMC Nephrol 2021; 22:258. [PMID: 34243724 PMCID: PMC8268408 DOI: 10.1186/s12882-021-02430-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 05/31/2021] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Oliver Beetz
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30626, Hannover, Germany
| | - Juliane Thies
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30626, Hannover, Germany
| | - Clara A Weigle
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30626, Hannover, Germany
| | - Fabio Ius
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Michael Winkler
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30626, Hannover, Germany
| | - Christoph Bara
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Nicolas Richter
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30626, Hannover, Germany
| | - Jürgen Klempnauer
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30626, Hannover, Germany
| | - Gregor Warnecke
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Murat Avsar
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Gerrit Grannas
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30626, Hannover, Germany.
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8
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Dirks M, Buchert R, Wirries AK, Pflugrad H, Grosse GM, Petrusch C, Schütze C, Wilke F, Mamach M, Hamann L, Langer LBN, Ding XQ, Barg-Hock H, Klempnauer J, Wetzel CH, Lukacevic M, Janssen E, Kessler M, Bengel FM, Geworski L, Rupprecht R, Ross TL, Berding G, Weissenborn K. Reduced microglia activity in patients with long-term immunosuppressive therapy after liver transplantation. Eur J Nucl Med Mol Imaging 2021; 49:234-245. [PMID: 33978829 PMCID: PMC8712291 DOI: 10.1007/s00259-021-05398-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 05/02/2021] [Indexed: 12/12/2022]
Abstract
Purpose Calcineurin inhibitors (CNI) can cause long-term impairment of brain function. Possible pathomechanisms include alterations of the cerebral immune system. This study used positron emission tomography (PET) imaging with the translocator protein (TSPO) ligand 18F-GE-180 to evaluate microglial activation in liver-transplanted patients under different regimens of immunosuppression. Methods PET was performed in 22 liver-transplanted patients (3 CNI free, 9 with low-dose CNI, 10 with standard-dose CNI immunosuppression) and 9 healthy controls. The total distribution volume (VT) estimated in 12 volumes-of-interest was analyzed regarding TSPO genotype, CNI therapy, and cognitive performance. Results In controls, VT was about 80% higher in high affinity binders (n = 5) compared to mixed affinity binders (n = 3). Mean VT corrected for TSPO genotype was significantly lower in patients compared to controls, especially in patients in whom CNI dose had been reduced because of nephrotoxic side effect. Conclusion Our results provide evidence of chronic suppression of microglial activity in liver-transplanted patients under CNI therapy especially in patients with high sensitivity to CNI toxicity. Supplementary Information The online version contains supplementary material available at 10.1007/s00259-021-05398-w.
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Affiliation(s)
- Meike Dirks
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
- Integrated Research and Treatment Centre Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany.
| | - Ralph Buchert
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ann-Katrin Wirries
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Henning Pflugrad
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
- Integrated Research and Treatment Centre Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Gerrit M Grosse
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Carlotta Petrusch
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Christian Schütze
- Department of Medical Physics and Radiation Protection, Hannover Medical School, Hannover, Germany
| | - Florian Wilke
- Department of Medical Physics and Radiation Protection, Hannover Medical School, Hannover, Germany
| | - Martin Mamach
- Department of Medical Physics and Radiation Protection, Hannover Medical School, Hannover, Germany
| | - Linda Hamann
- Department of Medical Physics and Radiation Protection, Hannover Medical School, Hannover, Germany
| | - Laura B N Langer
- Department of Nuclear Medicine, Hannover Medical School, Hannover, Germany
| | - Xiao-Qi Ding
- Institute of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany
| | - Hannelore Barg-Hock
- General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Jürgen Klempnauer
- General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Christian H Wetzel
- Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany
| | - Mario Lukacevic
- Department of Nuclear Medicine, Hannover Medical School, Hannover, Germany
| | - Eike Janssen
- Department of Nuclear Medicine, Hannover Medical School, Hannover, Germany
| | - Mariella Kessler
- Department of Nuclear Medicine, Hannover Medical School, Hannover, Germany
| | - Frank M Bengel
- Department of Nuclear Medicine, Hannover Medical School, Hannover, Germany
| | - Lilli Geworski
- Department of Medical Physics and Radiation Protection, Hannover Medical School, Hannover, Germany
| | - Rainer Rupprecht
- Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany
| | - Tobias L Ross
- Department of Nuclear Medicine, Hannover Medical School, Hannover, Germany
| | - Georg Berding
- Department of Nuclear Medicine, Hannover Medical School, Hannover, Germany
| | - Karin Weissenborn
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
- Integrated Research and Treatment Centre Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
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9
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Beetz O, Weigle CA, Nogly R, Klempnauer J, Pape L, Richter N, Vondran FWR. Surgical complications in pediatric kidney transplantation-Incidence, risk factors, and effects on graft survival: A retrospective single-center study. Pediatr Transplant 2021; 25:e13871. [PMID: 33053269 DOI: 10.1111/petr.13871] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/12/2020] [Accepted: 09/08/2020] [Indexed: 12/26/2022]
Abstract
The field of pediatric kidney transplantation remains challenging due to an ongoing lack of size-matched grafts and anatomical peculiarities. In the current study, we investigated the incidence of surgical complications in pediatric recipients, with a focus on risk factors and effects on graft outcome. We retrospectively reviewed all 2386 kidney transplantations at our institution from January 2005 until December 2018. Of these, 221 transplants were performed in pediatric recipients, defined as under the age of 18 years. Donor-recipient body surface area ratios were calculated to evaluate the effects of size mismatching. Regression analyses were performed to identify independent risk factors for surgical complications and graft survival, respectively. Perioperative surgical complications requiring revision were observed in 34 (15.4%) cases. Leading cause for revision were vascular complications such as thrombosis or stenosis (n = 15 [6.8%]), which were significantly more frequent in case of young donors, (ie, donor age <6 years; OR: 4.281; CI-95%:1.385-13.226; P = .012), previous nephrectomy (OR: 3.407; CI-95%:1.019-11.387; P = .046), and en-bloc grafts (OR: 4.923; CI-95%:1.355-17.884; P = .015), followed by postoperative hemorrhage (n = 10 [4.5%]), ureteral complications (n = 8 [3.6%]), and lymphoceles (n = 7 [3.2%]). Median follow-up was 84.13 (0.92-175.72) months. One-, 5-, and 10-year graft survival rates were 97.1%, 88.9%, and 65.1%, respectively. Except for vascular complications (HR: 4.727; CI-95%:1.363-16.394; P = .014), none of the analyzed surgical morbidities significantly influenced graft survival. In conclusion, pediatric kidney transplantation achieves excellent long-term results. However, meticulous surgical technique and continuous postoperative monitoring are imperative for early detection and treatment of imminent vascular complications, especially in case of young donors and en-bloc grafts.
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Affiliation(s)
- Oliver Beetz
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Clara A Weigle
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Rabea Nogly
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Jürgen Klempnauer
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Lars Pape
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Nicolas Richter
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Florian W R Vondran
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
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10
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Falz R, Thieme R, Tegtbur U, Bischoff C, Leps C, Hillemanns P, Kohlhaw K, Klempnauer J, Lordick F, Stolzenburg JU, Aktas B, Weitz J, Bork U, Wimberger P, Thomas C, Biemann R, Jansen-Winkeln B, Schulze A, Gockel I, Busse M. CRBP-TS - evaluation of a home-based training and health care program for colorectal, breast, and prostate cancer using telemonitoring and self-management: study protocol for a randomized controlled trial. BMC Sports Sci Med Rehabil 2021; 13:15. [PMID: 33622370 PMCID: PMC7901214 DOI: 10.1186/s13102-021-00244-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 02/07/2021] [Indexed: 01/19/2023]
Abstract
Background Physical training is recommended in various national and international guidelines for patients with cancer. Observational studies have shown that physical activity leads to reduced recurrence and mortality rates by 20–40% in colorectal, breast, and prostate cancer. Despite existing evidence, a systematic care structure is still lacking. The primary aim of this study is to implement and evaluate an online training platform to strengthen physical performance and patient empowerment after cancer surgery. Methods The evaluation will be conducted as a prospective multicenter randomized controlled trial with three subgroups (colorectal-, breast-, and prostate cancer). Each group will include 100 patients (total 300 patients including dropouts; clinical stages T1–3 and/or N+; M0 after surgery intervention) and the primary endpoint (13% increase in the maximal oxygen consumption during exercise) will be examined. The intervention group will receive a 6-month home-based online training (2–3 times per week strength-endurance training using video presentations), bidirectional activity feedback information, online communication, and online counseling. The control group (usual care) will be advised lifestyle improvement. In-hospital testing will be performed before, during, and after the intervention. In addition to cardiopulmonary capacity, tumor specific diagnostics (liquid biopsy, depression and fatigue assessment, metabolic and endothelial screening) will be applied. Discussion Due to the increasing incidence of cancer, associated with considerable mortality, morbidity and impaired quality of life, there is an imperative requirement for improved cancer care, of which structured physical training may become an integral component. Trial registration DRKS-ID: DRKS00020499; Registered 17 March 2020.
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Affiliation(s)
- Roberto Falz
- Institute of Sport Medicine and Prevention, University Leipzig, Marschnerstraße 29a, 04109, Leipzig, Germany.
| | - René Thieme
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Uwe Tegtbur
- Institute of Sport Medicine, Hannover Medical School, Hannover, Germany
| | - Christian Bischoff
- Institute of Sport Medicine and Prevention, University Leipzig, Marschnerstraße 29a, 04109, Leipzig, Germany
| | - Christian Leps
- Institute of Sport Medicine and Prevention, University Leipzig, Marschnerstraße 29a, 04109, Leipzig, Germany
| | - Peter Hillemanns
- Department of Gynecology and Obstetrics, Hannover Medical School, Hannover, Germany
| | - Kay Kohlhaw
- Department of Surgery, Sana Hospitals "Leipziger Land", Borna, Germany
| | - Jürgen Klempnauer
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Florian Lordick
- Department of Oncology, Gastroenterology, Hepatology, Pulmonology and Infectious Diseases, University Hospital Leipzig, Leipzig, Germany.,University Cancer Center Leipzig, University Hospital Leipzig, Leipzig, Germany
| | | | - Bahriye Aktas
- Department of Gynaecology, University Hospital Leipzig, Leipzig, Germany
| | - Jürgen Weitz
- Department of Visceral-, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,National Center for Tumor Diseases (NCT), Partner site Dresden, Dresden, Germany
| | - Ulrich Bork
- Department of Visceral-, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,National Center for Tumor Diseases (NCT), Partner site Dresden, Dresden, Germany
| | - Pauline Wimberger
- National Center for Tumor Diseases (NCT), Partner site Dresden, Dresden, Germany.,Department of Gynecology and Obstetrics, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Christian Thomas
- National Center for Tumor Diseases (NCT), Partner site Dresden, Dresden, Germany.,Department of Urology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Ronald Biemann
- Institute of Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University Hospital Leipzig, Leipzig, Germany
| | - Boris Jansen-Winkeln
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Antina Schulze
- Institute of Sport Medicine and Prevention, University Leipzig, Marschnerstraße 29a, 04109, Leipzig, Germany
| | - Ines Gockel
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Martin Busse
- Institute of Sport Medicine and Prevention, University Leipzig, Marschnerstraße 29a, 04109, Leipzig, Germany
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11
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Schnitzbauer AA, Filmann N, Adam R, Bachellier P, Bechstein WO, Becker T, Bhoori S, Bilbao I, Brockmann J, Burra P, Chazoullières O, Cillo U, Colledan M, Duvoux C, Ganten TM, Gugenheim J, Heise M, van Hoek B, Jamieson N, de Jong KP, Klein CG, Klempnauer J, Kneteman N, Lerut J, Mäkisalo H, Mazzaferro V, Mirza DF, Nadalin S, Neuhaus P, Pageaux GP, Pinna AD, Pirenne J, Pratschke J, Powel J, Rentsch M, Rizell M, Rossi G, Rostaing L, Roy A, Scholz T, Settmacher U, Soliman T, Strasser S, Söderdahl G, Troisi RI, Turrión VS, Schlitt HJ, Geissler EK. mTOR Inhibition Is Most Beneficial After Liver Transplantation for Hepatocellular Carcinoma in Patients With Active Tumors. Ann Surg 2020; 272:855-862. [PMID: 32889867 DOI: 10.1097/sla.0000000000004280] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the survival benefit of sirolimus in patients undergoing liver transplantation (LT) for hepatocellular carcinoma (HCC) (exploratory analysis of the SiLVER-trial). SUMMARY AND BACKGROUND DATA Patients receiving LT) for HCC are at a high risk for tumor recurrence. Calcineurin inhibitors have shown evidence to promote cancer growth, whereas mammalian target of rapamycin (mTOR) inhibitors like sirolimus have anticancer effects. In the SiLVER-trial (Clinicaltrials.gov: NCT00355862), the effect of sirolimus on the recurrence of HCC after LT was investigated in a prospective randomized trial. Although the primary endpoint of improved disease-free survival (DFS) with sirolimus was not met, outcomes were improved for patients in the sirolimus-treatment arm in the first 3 to 5 years. To learn more about the key variables, a multivariate analysis was performed on the SiLVER-trial data. PATIENTS AND METHODS Data from 508 patients of the intention-to-treat analysis were included in exploratory univariate and multivariate models for overall survival (OS), DFS and a competing risk analysis for HCC recurrence. RESULTS Sirolimus use for ≥3 months after LT for HCC independently reduced the hazard for death in the multivariate analysis [hazard ratio (HR): 0.7 (95% confidence interval, CI: 0.52-0.96, P = 0.02). Most strikingly, patients with an alpha-fetoprotein (AFP) ≥10 ng/mL and having used sirolimus for ≥3 months, benefited most with regard to OS, DFS, and HCC-recurrence (HR: 0.49-0.59, P = 0.0079-0.0245). CONCLUSIONS mTOR-inhibitor treatment with sirolimus for ≥3 months improves outcomes in LT for HCC, especially in patients with AFP-evidence of higher tumor activity, advocating particularly for mTOR inhibitor use in this subgroup of patients. CLINICAL TRIAL REGISTRATION EudraCT: 2005-005362-36 CLINICALTRIALS.GOV:: NCT00355862.
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Affiliation(s)
- Andreas A Schnitzbauer
- Universitätsklinikum Frankfurt, Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Frankfurt am Main, Germany
| | - Natalie Filmann
- Universitätsklinikum Frankfurt, Institut für Biostatistik und Mathematisches Modellierung, Frankfurt am Main, Germany
| | - René Adam
- Hôpital Paul Brousse, Centre Hépato Biliaire, Paris, France
| | - Philippe Bachellier
- Les Hôpitaux Universitaires de Strasbourg, Hôpital de Hautepierre, Service de Chirurgie Générale, Hépatique, Endocrinienne, et Transplantation, Strasbourg, France
| | - Wolf O Bechstein
- Universitätsklinikum Frankfurt, Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Frankfurt am Main, Germany
| | - Thomas Becker
- Universitätsklinikum Schleswig-Holstein - Campus Kiel, Klinik für Allgemeine Chirurgie, Viszeral-, Thorax, Transplantations- und Kinderchirurgie, Kiel, Germany
| | - Sherrie Bhoori
- Fondazione IRCCS Istituto Nazionale dei Tumori, National Cancer Institute Milan, Department of Surgery, Transplantation and Hepatobiliary Cancer Unit, Milano, Italy
| | - Itxarone Bilbao
- Hospital Universitari Vall d'Hebron, Servicio de Cirugía General, Unidad de Trasplante Hepatico, Barcelona, Spain
| | - Jens Brockmann
- Universitätsklinikum Münster, Klinik für Allgemein- und ViszeralchirurgieMünster, Germany
| | - Patrizia Burra
- Università degli Studi di Padova, Dipartimento di Scienze Chirurgiche, Oncologiche e Gastroenterologiche (DiSCOG), Padova, Italy
| | - Olivier Chazoullières
- Hôpital Saint Antoine, Federation d'Hepato-Gastro-Enterologie, Service d'Hepatologie, Paris, France
| | - Umberto Cillo
- Università di Padova, Azienda Ospedaliera di Padova, Chirurgia Epatobiliare e Trapianto Epatico, Padova, Italy
| | - Michele Colledan
- Azienda Ospedaliera Papa Giovanni XXIII, Chirurgia terza e Chirurgia Toracica, Bergamo (BG), Italy
| | - Christoph Duvoux
- Université Paris-Est Créteil Val-de-Marne, Centre Hospitalier Universitaire Henri-Mondor, Service d'Hepatologie et de Gastroenterologie, Unite d'Hepatologie et de Transplantation Hepatique, Paris, France
| | - Tom M Ganten
- Universitätsklinikum Heidelberg, Fürst Stirum Klinik Bruchsal, Bruchsal, Germany
| | - Jean Gugenheim
- Centre Hospitalier Universitaire de Nice, Hôpital ARCHET 2, Service de Chirurgie Digestive, Centre de Transplantation Hépatique, Nice Cedex, France
| | - Michael Heise
- Universitätsklinikum Frankfurt, Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Frankfurt am Main, Germany
| | - Bart van Hoek
- Leiden University Medical Center (LUMC), Dept. of Gastroenterology and Hepatology, Leiden, Netherlands
| | - Neville Jamieson
- Cambridge University Hospitals, NHS Foundation Trust, Addenbrooke's Hospital, Department of Surgery, Hills Road, Cambridge, United Kingdom
| | - Koert P de Jong
- University Medical Center Groningen, University of Groningen, Department of Surgery, Div. of Hepato-Pancreatico-Biliary Surgery & Liver Transplantation, Groningen, Netherlands
| | - Christian G Klein
- Universitätsklinikum Essen, Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Essen, Germany
| | - Jürgen Klempnauer
- Medizinische Hochschule Hannover, Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Hannover, Germany
| | - Norman Kneteman
- University of Alberta, Alberta Health Services Liver Transplant Program, Alberta, Canada
| | - Jan Lerut
- Institute for Experimental and Clinical Research (IREC), Université catholique Louvain(UCL), Brussels, Belgium
| | - Heikki Mäkisalo
- Helsinki University Central Hospital, Division of Transplantation and Liver Surgery, Helsinki, Finland
| | - Vincenzo Mazzaferro
- Fondazione IRCCS Istituto Nazionale dei Tumori, National Cancer Institute Milan, Department of Surgery, Transplantation and Hepatobiliary Cancer Unit, Milano, Italy
| | - Darius F Mirza
- University Hospitals Birmingham, NHS Foundation Trust, The Queen Elizabeth Hospital, Liver and Hepato-Pancreato-Biliary (HPB) Unit, Edgbaston, Birmingham, United Kingdom
| | - Silvio Nadalin
- Klinikum der Universität Tübingen, Klinik für Allgemeine, Viszeral- und Transplantationschirurgie, Tübingen, Germany
| | - Peter Neuhaus
- Charité Campus Virchow Klinikum, Universitätsmedizin Berlin, Klinik für Allgemein-, Visceral- und Transplantationschirurgie, Berlin, Germany
| | - George-Philippe Pageaux
- CHRU de Montpellier, APEMAD, Hôpital Saint-Eloi, Service d'Hepato-Gastroentérologie et Transplantation Hepatique, Cedex 5, France
| | - Antonio D Pinna
- Universita di Bologna, Policlinico S. Orsola-Malpighi, Chirurgia Generale e dei Trapianti, Bologna, Italy
| | - Jaques Pirenne
- UZ Leuven, Campus Gasthuisberg, Abdominale Transplantatiechirurgie, Leuven, Belgium
| | - Johann Pratschke
- Charité - Universitätsmedizin Berlin Augustenburger Platz 1, 13353 Berlin
| | - James Powel
- Royal Infirmary of Edinburgh, NHS Lothian, Hepatic-Pancreatico-Biliary Surgical Services and Edinburgh Transplant Unit, 51 Little France Crescent, Edinburgh, Scotland, United Kingdom
| | - Markus Rentsch
- Klinikum der Ludwig-Maximillians-Universität München-Großhadern, current affiliation: Klinikum Ingolstadt, Klinik für Allgemein-, Viszeral- und Thoraxchirurgie, Ingolstadt, Germany
| | - Magnus Rizell
- Sahlgrenska University Hospital, Department of Surgery and Transplantation, Göteborg, Sweden
| | - Giorgio Rossi
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico IRCCS di Milano, Centro Trapianti Fegato, Pad Zonda I piano, Milano, Italy
| | - Lionel Rostaing
- Department of Nephrology, Hemodialysis, Apheresis and Transplantation, Grenoble-Alpes University Hospital Center, Avenue du Maquis du Grésivaudan, La Tronche, France
| | - André Roy
- Hopital St Luc, Centre Hospitalier de l'Université Montréal (CHUM), Hepatobiliary and Pancreatic Surgery Unit, Principal Pavillion, 1058 Rue St Denis Montreal, Quebec, Canada
| | - Tim Scholz
- Uppsala University Hospital, Deptartment for Transplant Surgery, Uppsala, Sweden
| | - Utz Settmacher
- Universitätsklinikum Jena, Klinik für Allgemein-, Viszeral- und Gefässchirurgie, Jena, Germany
| | - Thomas Soliman
- Medizinische Universität Wien, AKH- Wien, Universitätsklinik für Chirurgie, Abteilung für Transplantation, Vienna, Austria
| | - Simone Strasser
- Royal Prince Alfred Hospital, AW Morrow Gastroenterology, and Liver Centre and Liver Transplant Unit, Camperdown, Sydney, Australia
| | - Gunnar Söderdahl
- Karolinska University Hospital, Department of Transplantation Surgery, Stockholm, Sweden
| | - Roberto I Troisi
- Ghent University Hospital and Medical School, Hepato- Biliary and Pancreatic Surgery, Ghent, Belgium
| | - Victor Sánchez Turrión
- Hospital Universitario Puerta de Hierro-Majadahonda, Departamento de Cirugía, Unidad de Trasplante Hepático, Calle Manuel de Falla 1, Madrid, Spain
| | - Hans J Schlitt
- University Hospital Regensburg, Department of Surgery, Franz-Josef-Strauss-Allee 11, Regensburg, Germany
| | - Edward K Geissler
- University Hospital Regensburg, Department of Surgery and Section of Experimental Surgery, Franz-Josef-Strauss-Allee 11, Regensburg, Germany.,Division of Tumor Therapy, Fraunhofer Institute of Experimental Medicine and Toxicology, Regensburg, Germany
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12
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Mahlmann JC, Wirth TC, Hartleben B, Schrem H, Mahlmann JF, Kaltenborn A, Klempnauer J, Kulik U. Chemotherapy and Hepatic Steatosis: Impact on Postoperative Morbidity and Survival after Liver Resection for Colorectal Liver Metastases. Visc Med 2020; 37:198-205. [PMID: 34250077 DOI: 10.1159/000510661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 08/03/2020] [Indexed: 01/22/2023] Open
Abstract
Background Hepatic steatosis and chemotherapy in the treatment of colorectal liver metastases (CLM) are often linked to increased mortality and morbidity after liver resection. This study evaluates the influence of macrovesicular hepatic steatosis and chemotherapeutic regimes on graded morbidity and mortality after liver resection for CLM. Methods A total of 323 cases of liver resection for CLM were retrospectively analysed using univariable and multivariable linear, ordinal and Cox regression analyses. The resected liver tissue was re-evaluated by a single observer to determine the grade and type of hepatic steatosis. Results Macrovesicular steatosis did not influence postoperative morbidity and survival, as evidenced by risk-adjusted multivariable Cox regression analysis (p = 0.521). Conversion chemotherapy containing oxaliplatin was an independent and significant risk factor for mortality in risk-adjusted multivariable Cox regression analysis (p = 0.005). Identified independently, significant risk factors for postoperative morbidity were neoadjuvant treatment of metastases of the primary tumour with irinotecan (p = 0.003), the duration of surgery in minutes (p = 0.001) and the number of intraoperatively transfused packed red blood cells (p ≤ 0.001). Surprisingly, macrovesicular hepatic steatosis was not a risk factor for postoperative morbidity and was even associated with lower rates of complications (p = 0.006). Conclusion The results emphasize the multifactorial influence of preoperative liver damage and chemotherapy on the severity of postoperative morbidity, as well as the significant impact of conversion chemotherapy containing oxaliplatin on survival.
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Affiliation(s)
- Jan C Mahlmann
- General, Visceral and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - Thomas C Wirth
- Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | | | - Harald Schrem
- Division of Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Jens F Mahlmann
- Departament d'Astronomia i Astrofísica, Universitat de València, Valencia, Spain
| | - Alexander Kaltenborn
- General, Visceral and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - Jürgen Klempnauer
- General, Visceral and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - Ulf Kulik
- General, Visceral and Transplantation Surgery, Hannover Medical School, Hannover, Germany
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13
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Beetz O, Sarisin A, Kaltenborn A, Klempnauer J, Winkler M, Grannas G. Multivisceral resection for adenocarcinoma of the pancreatic body and tail-a retrospective single-center analysis. World J Surg Oncol 2020; 18:218. [PMID: 32819373 PMCID: PMC7441692 DOI: 10.1186/s12957-020-01973-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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] [Received: 04/01/2020] [Accepted: 07/28/2020] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Oliver Beetz
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Akin Sarisin
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Alexander Kaltenborn
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Jürgen Klempnauer
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Michael Winkler
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Gerrit Grannas
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany.
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14
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Beetz O, Weigle CA, Cammann S, Vondran FWR, Timrott K, Kulik U, Bektas H, Klempnauer J, Kleine M, Oldhafer F. Preoperative leukocytosis and the resection severity index are independent risk factors for survival in patients with intrahepatic cholangiocarcinoma. Langenbecks Arch Surg 2020; 405:977-988. [PMID: 32815017 PMCID: PMC7541380 DOI: 10.1007/s00423-020-01962-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 08/09/2020] [Indexed: 02/08/2023]
Abstract
PURPOSE The incidence of intrahepatic cholangiocarcinoma is increasing worldwide. Despite advances in surgical and non-surgical treatment, reported outcomes are still poor and surgical resection remains to be the only chance for long-term survival of affected patients. The identification and validation of prognostic factors and scores, such as the recently introduced resection severity index, for postoperative morbidity and mortality are essential to facilitate optimal therapeutic regimens. METHODS This is a retrospective analysis of 269 patients undergoing resection of histologically confirmed intrahepatic cholangiocarcinoma between February 1996 and September 2018 at a tertiary referral center for hepatobiliary surgery. Regression analyses were performed to evaluate potential prognostic factors, including the resection severity index. RESULTS Median postoperative follow-up time was 22.93 (0.10-234.39) months. Severe postoperative complications (≥ Clavien-Dindo grade III) were observed in 94 (34.9%) patients. The body mass index (p = 0.035), the resection severity index (ASAT in U/l divided by Quick in % multiplied by the extent of liver resection graded in points; p = 0.006), additional hilar bile duct resection (p = 0.005), and number of packed red blood cells transfused during operation (p = 0.036) were independent risk factors for the onset of severe postoperative complications. Median Kaplan-Meier survival after resection was 27.63 months. Preoperative leukocytosis (p = 0.003), the resection severity index (p = 0.005), multivisceral resection (p = 0.001), and T stage ≥ 3 (p = 0.013) were identified as independent risk factors for survival. CONCLUSION Preoperative leukocytosis and the resection severity index are useful variables for preoperative risk stratification since they were identified as significant predictors for postoperative morbidity and mortality, respectively.
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Affiliation(s)
- Oliver Beetz
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany.
| | - Clara A Weigle
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Sebastian Cammann
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Florian W R Vondran
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Kai Timrott
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Ulf Kulik
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Hüseyin Bektas
- Department of General, Visceral and Oncological Surgery, Hospital Group Gesundheit Nord, Bremen, Germany
| | - Jürgen Klempnauer
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Moritz Kleine
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Felix Oldhafer
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
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15
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Beetz O, Bajunaid A, Meißler L, Vondran FWR, Kleine M, Cammann S, Hanke JS, Schmitto JD, Haverich A, Klempnauer J, Ringe KI, Oldhafer F, Timrott K. Abdominal Surgery in Patients with Ventricular Assist Devices: a Single-Center Report. ASAIO J 2020; 66:890-898. [PMID: 32740349 DOI: 10.1097/mat.0000000000001085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
This study was performed to evaluate the incidence and outcome of patients with ventricular assist devices (VADs) undergoing abdominal surgery at our institution. A total of 604 adult patients who underwent VAD implantation between February 2004 and February 2018 were analyzed retrospectively with a median follow-up time of 66 (6-174) months. Thirty-nine patients (6.5%) underwent abdominal surgery. Elective surgical procedures were performed in 22 patients (56.4%), mainly for abdominal wall hernia repairs, partial colectomies, and cholecystectomies. Early after elective abdominal surgery no patient died, resulting in a median survival of 23 (1-78) months. Emergency surgery was performed in 17 patients (43.6%). The most common emergency indications were intestinal ischemia and/or perforation. Eight patients undergoing emergent surgery (44.4%) died within the first 30 days after primary abdominal operation, mainly due to sepsis and consecutive multiple organ failure, resulting in a dismal median survival of one month (0-52). Patients undergoing abdominal surgery had significantly lower rates of realized heart-transplantation (p = 0.031) and a significantly higher rate of VAD exchange, before or after abdominal surgery, due to thromboses or infections (p = 0.037). Nonetheless, overall survival after primary VAD implantation in these patients (median 38 months; 0-107) was not significantly impaired when compared to all other patients undergoing VAD implantation (median 30 months; 0-171). In summary, elective abdominal surgery can be performed safely when well planned by an experienced multidisciplinary team. Abdominal complications in VAD patients requiring emergent surgery, however, lead to a significant increase in short-term morbidity and a high 30-day mortality rate.
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Affiliation(s)
- Oliver Beetz
- From the Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Anwar Bajunaid
- From the Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Luise Meißler
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Florian W R Vondran
- From the Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Moritz Kleine
- From the Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Sebastian Cammann
- From the Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Jasmin S Hanke
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jan D Schmitto
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jürgen Klempnauer
- From the Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Kristina I Ringe
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Felix Oldhafer
- From the Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Kai Timrott
- From the Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
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16
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Weigle CA, Lieke T, Vondran FWR, Timrott K, Klempnauer J, Beetz O. An Immunological Model for Heterotopic Heart and Cardiac Muscle Cell Transplantation in Rats. J Vis Exp 2020. [PMID: 32449721 DOI: 10.3791/60956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Heterotopic heart transplantation in rats has been a commonly used model for diverse immunological studies for more than 50 years. Several modifications have been reported since the first description in 1964. After 30 years of performing heterotopic heart transplantation in rats, we have developed a simplified surgical approach, which can be easily taught and performed without further surgical training or background. After dissection of the ascending aorta and the pulmonary artery and ligation of superior and inferior caval and pulmonary veins, the donor heart is harvested and subsequently perfused with ice-cold saline solution supplemented with heparin. After clamping and incising the recipient abdominal vessels, the donor ascending aorta and pulmonary artery are anastomosed to the recipient abdominal aorta and inferior vena cava, respectively, using continuous running sutures. Depending on different donor-recipient combinations, this model allows analyses of either acute or chronic rejection of allografts. The immunological significance of this model is further enhanced by a novel approach of in-ear injection of vital cardiac muscle cells and subsequent analysis of draining cervical lymphatic tissue.
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Affiliation(s)
- Clara A Weigle
- Regenerative Medicine and Experimental Surgery, Department of General, Visceral and Transplant Surgery, Hannover Medical School
| | - Thorsten Lieke
- Regenerative Medicine and Experimental Surgery, Department of General, Visceral and Transplant Surgery, Hannover Medical School
| | - Florian W R Vondran
- Regenerative Medicine and Experimental Surgery, Department of General, Visceral and Transplant Surgery, Hannover Medical School
| | - Kai Timrott
- Regenerative Medicine and Experimental Surgery, Department of General, Visceral and Transplant Surgery, Hannover Medical School
| | - Jürgen Klempnauer
- Regenerative Medicine and Experimental Surgery, Department of General, Visceral and Transplant Surgery, Hannover Medical School
| | - Oliver Beetz
- Regenerative Medicine and Experimental Surgery, Department of General, Visceral and Transplant Surgery, Hannover Medical School;
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17
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Mehrabi A, Kulu Y, Sabagh M, Khajeh E, Mohammadi S, Ghamarnejad O, Golriz M, Morath C, Bechstein WO, Berlakovich GA, Demartines N, Duran M, Fischer L, Gürke L, Klempnauer J, Königsrainer A, Lang H, Neumann UP, Pascher A, Paul A, Pisarski P, Pratschke J, Schneeberger S, Settmacher U, Viebahn R, Wirth M, Wullich B, Zeier M, Büchler MW. Consensus on definition and severity grading of lymphatic complications after kidney transplantation. Br J Surg 2020; 107:801-811. [PMID: 32227483 DOI: 10.1002/bjs.11587] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 01/23/2020] [Accepted: 02/14/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND The incidence of lymphatic complications after kidney transplantation varies considerably in the literature. This is partly because a universally accepted definition has not been established. This study aimed to propose an acceptable definition and severity grading system for lymphatic complications based on their management strategy. METHODS Relevant literature published in MEDLINE and Web of Science was searched systematically. A consensus for definition and a severity grading was then sought between 20 high-volume transplant centres. RESULTS Lymphorrhoea/lymphocele was defined in 32 of 87 included studies. Sixty-three articles explained how lymphatic complications were managed, but none graded their severity. The proposed definition of lymphorrhoea was leakage of more than 50 ml fluid (not urine, blood or pus) per day from the drain, or the drain site after removal of the drain, for more than 1 week after kidney transplantation. The proposed definition of lymphocele was a fluid collection of any size near to the transplanted kidney, after urinoma, haematoma and abscess have been excluded. Grade A lymphatic complications have a minor and/or non-invasive impact on the clinical management of the patient; grade B complications require non-surgical intervention; and grade C complications require invasive surgical intervention. CONCLUSION A clear definition and severity grading for lymphatic complications after kidney transplantation was agreed. The proposed definitions should allow better comparisons between studies.
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Affiliation(s)
- A Mehrabi
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - Y Kulu
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - M Sabagh
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - E Khajeh
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - S Mohammadi
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - O Ghamarnejad
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - M Golriz
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - C Morath
- Division of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - W O Bechstein
- Department of General and Visceral Surgery, Frankfurt University Hospital, Goethe University, Frankfurt am Main, Germany
| | - G A Berlakovich
- Division of Transplantation, Department of Surgery, Vienna Medical University, Vienna, Austria
| | - N Demartines
- Department of Visceral Surgery, CHUV University Hospital, Lausanne, Switzerland
| | - M Duran
- Department of Vascular and Endovascular Surgery, Düsseldorf University Hospital, Heinrich-Heine-University, Düsseldorf, Germany
| | - L Fischer
- Department of Visceral and Transplantation Surgery, Hamburg-Eppendorf University Hospital, Hamburg, Germany
| | - L Gürke
- Department of Vascular and Transplantation Surgery, Basel University Hospital, Basel, Switzerland
| | - J Klempnauer
- Department of General, Visceral, and Transplantation Surgery, Hannover Medical University, Hannover, Germany
| | - A Königsrainer
- Department of General, Visceral and Transplantation Surgery, Eberhard-Karls-University Hospital, Tübingen, Germany
| | - H Lang
- Department of General, Visceral and Transplantation Surgery, Johannes Gutenberg Medical University, Mainz, Germany
| | - U P Neumann
- Department of General, Visceral and Transplantation Surgery, RWTH University Hospital, Aachen, Germany
| | - A Pascher
- Department of General, Visceral and Transplantation Surgery, Münster University Hospital, Münster, Germany
| | - A Paul
- Department of General, Visceral and Transplantation Surgery, Essen University Hospital, Essen, Germany
| | - P Pisarski
- Department of General, Visceral and Surgery, Freiburg University Hospital, Freiburg, Germany
| | - J Pratschke
- Department of Surgery, Charité University Hospital, Berlin, Germany
| | - S Schneeberger
- Department of Visceral, Transplantation and Thoracic Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - U Settmacher
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Jena, Germany
| | - R Viebahn
- Department of Surgery, Knappschaftskrankenhaus University Hospital of Bochum, Ruhr University of Bochum, Bochum, Germany
| | - M Wirth
- Department of Urology, Carl Gustav Carus University Hospital, Dresden, Germany
| | - B Wullich
- Department of Urology and Pediatric Urology, University Hospital Erlangen, Erlangen, Germany
| | - M Zeier
- Division of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - M W Büchler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
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18
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Pflugrad H, Nösel P, Ding X, Schmitz B, Lanfermann H, Barg-Hock H, Klempnauer J, Schiffer M, Weissenborn K. Brain function and metabolism in patients with long-term tacrolimus therapy after kidney transplantation in comparison to patients after liver transplantation. PLoS One 2020; 15:e0229759. [PMID: 32155172 PMCID: PMC7064204 DOI: 10.1371/journal.pone.0229759] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 02/13/2020] [Indexed: 12/21/2022] Open
Abstract
Background About 50% of the patients 5–7 years after kidney transplantation show impairment of memory, attention and executive function. Tacrolimus frequently induces neurological complications in the first few weeks after transplantation. Furthermore, tacrolimus treatment is associated with impaired cognitive function in the long-term in patients after liver transplantation. We hypothesize that long-term tacrolimus therapy is associated with cognitive dysfunction and alterations of brain structure and metabolism in patients after kidney transplantation. Methods Twenty-one patients 10 years after kidney transplantation underwent cognitive testing, magnetic resonance imaging and whole brain 31-phosphor magnetic resonance spectroscopy for the assessment of brain function, structure and energy metabolism. Using a cross-sectional study design the results were compared to those of patients 1 (n = 11) and 5 years (n = 10) after kidney transplantation, and healthy controls (n = 17). To further analyze the share of transplantation, tacrolimus therapy and kidney dysfunction on the results patients after liver transplantation (n = 9) were selected as a patient control group. Results Patients 1 and 10 years after kidney transplantation (p = 0.02) similar to patients 10 years after liver transplantation (p<0.01) showed significantly worse cognitive function than healthy controls. In contrast to patients after liver transplantation patients after kidney transplantation showed significantly reduced adenosine triphosphate levels in the brain compared to healthy controls (p≤0.01). Patients 1 and 5 years after kidney transplantation had significantly increased periventricular hyperintensities compared to healthy controls (p<0.05). Conclusions Our data indicate that cognitive impairment in the long-term after liver and kidney transplantation cannot exclusively be explained by CNI neurotoxicity.
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Affiliation(s)
- Henning Pflugrad
- Department of Neurology, Hannover Medical School, Hannover, Germany
- Integrated Research and Treatment Centre Transplantation, Hannover Medical School, Hannover, Germany
- * E-mail:
| | - Patrick Nösel
- Institute of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany
| | - Xiaoqi Ding
- Institute of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany
| | - Birte Schmitz
- Institute of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany
| | - Heinrich Lanfermann
- Institute of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany
| | - Hannelore Barg-Hock
- Clinic for Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Jürgen Klempnauer
- Integrated Research and Treatment Centre Transplantation, Hannover Medical School, Hannover, Germany
- Clinic for Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Mario Schiffer
- Integrated Research and Treatment Centre Transplantation, Hannover Medical School, Hannover, Germany
- Clinic for Nephrology, Hannover Medical School, Hannover, Germany
| | - Karin Weissenborn
- Department of Neurology, Hannover Medical School, Hannover, Germany
- Integrated Research and Treatment Centre Transplantation, Hannover Medical School, Hannover, Germany
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19
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Hopp AE, Dirks M, Petrusch C, Goldbecker A, Tryc AB, Barg-Hock H, Strassburg C, Klempnauer J, Weissenborn K, Pflugrad H. Hepatic Encephalopathy Is Reversible in the Long Term After Liver Transplantation. Liver Transpl 2019; 25:1661-1672. [PMID: 31437344 DOI: 10.1002/lt.25626] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 08/10/2019] [Indexed: 12/14/2022]
Abstract
Cognitive dysfunction caused by hepatic encephalopathy (HE) improves within the first year after liver transplantation (LT). However, cognitive restitution seems to be incomplete in a subset of patients and after LT a new-onset cognitive decline was described. Data about the longterm development of cognitive function after liver transplantation (LT) are sparse. This prospective study analyzed whether a history of hepatic encephalopathy (HE) before LT had an impact on the longterm outcome of cognitive function after LT and if patients who underwent LT 5 years earlier showed worse cognitive function than healthy controls. The cognitive function of 34 patients was assessed before LT and at 1 year and 5 years after LT by psychometric tests, including the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) and the portosystemic encephalopathy syndrome test, which provides the psychometric hepatic encephalopathy score (PHES). Furthermore, patients completed surveys to assess health-related quality of life (HRQOL). An 22 additional patients were included after LT. Patients were subdivided by having a history of HE before LT. The control group consisted of 55 healthy patients adjusted for age and education. Before LT, patients performed significantly worse than controls in the psychometric tests: RBANS Total Scale (TS), mean ± standard deviation (SD), 92.6 ± 13.3 versus 99.9 ± 12.0, P = 0.01; and PHES, median (interquartile range [IQR]), 0 (-3 to 1) versus 1 (0-2), P < 0.001. At 1 year after LT, patients with a history of HE still showed cognitive impairment compared with controls: RBANS TS, mean ± SD, 89.8 ± 15.1 versus 99.9 ± 12.0, P < 0.01; and PHES, median (IQR), 0 (-2 to 1.25) versus 1 (0-2), P = 0.03. At 5 years after LT, patients with and without a history of HE showed normal cognitive function and improved HRQOL. In conclusion, HE-associated cognitive impairment seems to be reversible within 5 years after LT.
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Affiliation(s)
| | - Meike Dirks
- Department of Neurology, Hannover Medical School, Hannover, Germany.,Integrated Research and Treatment Centre Transplantation, Hannover Medical School, Hannover, Germany
| | | | - Annemarie Goldbecker
- Department of Neurology, Hannover Medical School, Hannover, Germany.,Integrated Research and Treatment Centre Transplantation, Hannover Medical School, Hannover, Germany
| | - Anita Blanka Tryc
- Department of Neurology, Hannover Medical School, Hannover, Germany.,Integrated Research and Treatment Centre Transplantation, Hannover Medical School, Hannover, Germany
| | - Hannelore Barg-Hock
- Clinic for Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Christian Strassburg
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Jürgen Klempnauer
- Integrated Research and Treatment Centre Transplantation, Hannover Medical School, Hannover, Germany.,Clinic for Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Karin Weissenborn
- Department of Neurology, Hannover Medical School, Hannover, Germany.,Integrated Research and Treatment Centre Transplantation, Hannover Medical School, Hannover, Germany
| | - Henning Pflugrad
- Department of Neurology, Hannover Medical School, Hannover, Germany.,Integrated Research and Treatment Centre Transplantation, Hannover Medical School, Hannover, Germany
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20
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Rummo O, Carmellini M, Kamar N, Durrbach A, Mousson C, Caputo F, Mathe Z, Christiaans MHL, Kuypers DRJ, Klempnauer J, Anaokar S, Hurst M, Kazeem G, Undre N, Lehner F. Long-term, prolonged-release tacrolimus-based immunosuppression in de novo kidney transplant recipients: 5-year prospective follow-up of the ADHERE study patients. Transpl Int 2019; 33:161-173. [PMID: 31536654 DOI: 10.1111/tri.13527] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 04/10/2019] [Accepted: 09/17/2019] [Indexed: 12/29/2022]
Abstract
The objectives of this study were to assess long-term graft survival, patient survival, renal function, and acute rejections in de novo kidney transplant recipients, treated with once-daily prolonged-release tacrolimus-based therapy. The study was a 5-year non-interventional prospective follow-up of patients from the ADHERE study, a Phase IV 12-month open-label assessment of patients randomized to receive prolonged-release tacrolimus in combination with mycophenolate mofetil (MMF) (Arm 1) or sirolimus (Arm 2). From 838 patients in the randomized study, 587 were included in the long-term follow-up, of whom 510 completed the study at year 5. At 1 year post-transplant, graft and patient survival rates were 93.0% and 97.8%, respectively, and at 5 years were 84.0% and 90.8%, respectively. Cox proportional hazards analysis showed no association between graft loss, initial randomized treatment arm, donor age, donor type, or sex. The 5-year acute rejection-free survival rate was 77.4%, and biopsy-confirmed acute rejection-free survival rate was 86.0%. Renal function remained stable over the follow-up period: mean ± SD eGFR 4-variable modification diet in renal disease formula (MDRD4) was 52.3 ± 21.6 ml/min/1.73 m2 at 6 months and 52.5 ± 23.0 ml/min/1.73 m2 at 5 years post-transplant. These findings support the role of long-term once-daily prolonged-release tacrolimus-based immunosuppression, in combination with sirolimus or MMF, for renal transplant recipients in routine clinical practice.
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Affiliation(s)
- Oleg Rummo
- Republican Scientific and Practical Center (RSPC) for Organ and Tissue Transplantation, Minsk, Belarus
| | - Mario Carmellini
- Department of Medical, Surgical and Neuroscience, Policlinico Santa Maria alle Scotte, University of Siena, Siena, Italy
| | - Nassim Kamar
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Université Paul Sabatier Toulouse, Toulouse Cedex 9, France
| | - Antoine Durrbach
- Nephrology Service, Centre Hospitalier de Bicetre, Le Kremlin Bicetre, France.,UMRS1197, INSERM, Villejuif, France.,University Paris Sud, Orsay, France
| | - Christiane Mousson
- Department of Nephrology-Transplantation, University Hospital Dijon, Dijon, France
| | - Flavia Caputo
- UOC Nephrology 2, Dialysis and Transplantation, ARNAS Civico Palermo, Palermo, Italy
| | - Zoltan Mathe
- Transplantation and Surgery Clinic, Semmelweis University, Budapest, Hungary
| | - Maarten H L Christiaans
- Department of Internal Medicine/Division of Nephrology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Dirk R J Kuypers
- Department of Nephrology, and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Jürgen Klempnauer
- General, Visceral and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | | | | | - Gbenga Kazeem
- Astellas Pharma Europe Ltd, Chertsey, UK.,BENKAZ Consulting Ltd, Cambridge, UK
| | | | - Frank Lehner
- General, Visceral and Transplantation Surgery, Hannover Medical School, Hannover, Germany
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21
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Goede LL, Pflugrad H, Schmitz B, Lanfermann H, Tryc AB, Barg-Hock H, Klempnauer J, Weissenborn K, Ding XQ. Quantitative magnetic resonance imaging indicates brain tissue alterations in patients after liver transplantation. PLoS One 2019; 14:e0222934. [PMID: 31553760 PMCID: PMC6760889 DOI: 10.1371/journal.pone.0222934] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 09/10/2019] [Indexed: 12/28/2022] Open
Abstract
PURPOSE To investigate cerebral microstructural alterations in patients treated with calcineurin inhibitors (CNI) after orthotopic liver transplantation (OLT) using quantitative magnetic resonance imaging (qMRI) and a cross-sectional study design. METHODS Cerebral qMRI was performed in 85 patients in a median 10 years after OLT compared to 31 healthy controls. Patients were treated with different dosages of CNI or with a CNI-free immunosuppression (CNI-free: n = 19; CNI-low: n = 36; CNI-standard: n = 30). T2-, T2*- and T2'- relaxation times, as well as apparent diffusion coefficient (ADC) and fractional anisotropy (FA) were measured in brain gray and white matter by using the regions of interest method. RESULTS In comparison to controls, patients revealed significantly increased T2, T2*, T2', ADC and reduced FA, predominantly in the frontal white matter, indicating microstructural brain alterations represented by increased free water (increased T2), reduced neuronal metabolism (increased T2') and a lower degree of spatial organization of the nervous fibers (reduced FA). CNI-low and CNI-free patients showed more alterations than CNI-standard patients. Analysis of their history revealed impairment of kidney function while under standard CNI dose suggesting that these patients may be more vulnerable to toxic CNI side-effects. CONCLUSION Our findings suggest that the individual sensitivity to toxic side effects should be considered when choosing an appropriate immunosuppressive regimen in patients after liver transplantation.
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Affiliation(s)
- Lukas Laurids Goede
- Department of Neurology, Hannover Medical School, Hannover, Germany
- Institute of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany
- Integrated Research and Treatment Centre Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Henning Pflugrad
- Department of Neurology, Hannover Medical School, Hannover, Germany
- Integrated Research and Treatment Centre Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Birte Schmitz
- Institute of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany
| | - Heinrich Lanfermann
- Institute of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany
| | - Anita Blanka Tryc
- Department of Neurology, Hannover Medical School, Hannover, Germany
- Integrated Research and Treatment Centre Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Hannelore Barg-Hock
- Clinic for Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Jürgen Klempnauer
- Clinic for Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Karin Weissenborn
- Department of Neurology, Hannover Medical School, Hannover, Germany
- Integrated Research and Treatment Centre Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Xiao-Qi Ding
- Institute of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany
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22
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Kettler B, Scheffner I, Bräsen JH, Hallensleben M, Richter N, Heiringhoff KH, Lehner F, Klempnauer J, Gwinner W. Reply to Sabah et al. Transpl Int 2019; 32:1341-1342. [PMID: 31519055 DOI: 10.1111/tri.13522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Bastian Kettler
- Clinic for General-, Abdominal- and Transplant-Surgery, Medical School Hannover, Hannover, Germany
| | - Irena Scheffner
- Clinic for Nephrology, Medical School Hannover, Hannover, Germany
| | - Jan-Hinrich Bräsen
- Nephropathology Unit, Institute for Pathology, Medical School Hannover, Hannover, Germany
| | | | - Nicolas Richter
- Clinic for General-, Abdominal- and Transplant-Surgery, Medical School Hannover, Hannover, Germany
| | - Karl-Heinz Heiringhoff
- Clinic for General-, Abdominal- and Transplant-Surgery, Medical School Hannover, Hannover, Germany
| | - Frank Lehner
- Clinic for General-, Abdominal- and Transplant-Surgery, Medical School Hannover, Hannover, Germany
| | - Jürgen Klempnauer
- Clinic for General-, Abdominal- and Transplant-Surgery, Medical School Hannover, Hannover, Germany
| | - Wilfried Gwinner
- Clinic for Nephrology, Medical School Hannover, Hannover, Germany
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23
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Pflugrad H, Tryc AB, Goldbecker A, Barg-Hock H, Strassburg C, Klempnauer J, Lanfermann H, Weissenborn K, Raab P. Cerebral metabolite alterations in patients with posttransplant encephalopathy after liver transplantation. PLoS One 2019; 14:e0221626. [PMID: 31442276 PMCID: PMC6707570 DOI: 10.1371/journal.pone.0221626] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 08/12/2019] [Indexed: 12/13/2022] Open
Abstract
Background In the first weeks after liver transplantation about 30% of the patients develop a posttransplant encephalopathy. A posttransplant encephalopathy comprises metabolic-toxic caused symptoms such as disorientation, confusion, hallucinations, cognitive dysfunction and seizures. We hypothesize that alterations of cerebral metabolites before liver transplantation predispose posttransplant encephalopathy development after liver transplantation. Methods 31 patients with chronic liver disease underwent magnetic resonance spectroscopy (MRS) before liver transplantation to assess glutamine/glutamate (Glx), myo-Inositol (mI), choline (Cho), creatine/phosphocreatine- and N-acetyl-aspartate/N-acetyl-aspartate-glutamate concentrations in the thalamus, lentiform nucleus and white matter. Of these, 14 patients underwent MRS additionally after liver transplantation. Furthermore, 15 patients received MRS only after liver transplantation. Patients’ data were compared to 20 healthy age adjusted controls. Results Patients showed significantly increased Glx and decreased mI and Cho concentrations compared to controls before liver transplantation (p≤0.01). The MRS values before liver transplantation of patients with posttransplant encephalopathy showed no significant difference compared to patients without posttransplant encephalopathy. Patients after liver transplantation showed increased Glx concentrations (p≤0.01) compared to controls, however, patients with and without posttransplant encephalopathy did not differ. Patients with posttransplant encephalopathy who underwent MRS before and after liver transplantation showed a significant mI increase in all three brain regions (p<0.04) and Glx decrease in the lentiform nucleus after liver transplantation (p = 0.04) while patients without posttransplant encephalopathy only showed a mI increase in the thalamus (p = 0.04). Conclusion Patients with and without posttransplant encephalopathy showed no significant difference in cerebral metabolites before liver transplantation. However, the paired sub-analysis indicates that the extent of cerebral metabolite alterations in patients with liver cirrhosis might be critical for the development of posttransplant encephalopathy after liver transplantation.
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Affiliation(s)
- Henning Pflugrad
- Department of Neurology, Hannover Medical School, Hannover, Germany
- Integrated Research and Treatment Centre Transplantation, Hannover, Germany
- * E-mail:
| | - Anita Blanka Tryc
- Department of Neurology, Hannover Medical School, Hannover, Germany
- Integrated Research and Treatment Centre Transplantation, Hannover, Germany
| | - Annemarie Goldbecker
- Department of Neurology, Hannover Medical School, Hannover, Germany
- Integrated Research and Treatment Centre Transplantation, Hannover, Germany
| | - Hannelore Barg-Hock
- Clinic for Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Christian Strassburg
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Jürgen Klempnauer
- Integrated Research and Treatment Centre Transplantation, Hannover, Germany
- Clinic for Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Heinrich Lanfermann
- Institute of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany
| | - Karin Weissenborn
- Department of Neurology, Hannover Medical School, Hannover, Germany
- Integrated Research and Treatment Centre Transplantation, Hannover, Germany
| | - Peter Raab
- Institute of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany
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24
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Beetz O, Kolb J, Buck B, Trautewig B, Timrott K, Vondran FWR, Meder I, Löbbert C, Hundrieser J, Klempnauer J, Bektaş H, Lieke T. Recipient natural killer cells alter the course of rejection of allogeneic heart grafts in rats. PLoS One 2019; 14:e0220546. [PMID: 31437165 PMCID: PMC6705777 DOI: 10.1371/journal.pone.0220546] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 07/04/2019] [Indexed: 12/11/2022] Open
Abstract
Rejection of solid organ grafts is regarded to be dependent on T cell responses. Nonetheless, numerous studies have focused on the contribution of NK cells in this process, resulting in contradictory theories. While some conclude that there is no participation of NK cells, others found an inflammatory or regulative role of NK cells. However, the experimental settings are rarely comparable with regard to challenged species, strain combinations or the nature of the graft. Thus, clear definition of NK cell contribution might be impeded by these circumstances. In this study we performed heterotopic heart transplantation (HTx) in rats, choosing one donor-recipient-combination leading to a fast and a second leading to a prolonged course of graft rejection. We intervened in the rejection process, by depletion of recipient NK cells on the one hand and by injection of activated NK cells syngeneic to the recipients on the other. The fast course of rejection could not be influenced by any of the NK cell manipulative treatments. However, the more prolonged course of rejection was highly susceptible to depletion of NK cells, resulting in significant acceleration of rejection, while injection of NK cells induced acceptance of the grafts. We suggest that, depending on the specific setting, NK cells can attenuate the first trigger of immune response, which allows establishing the regulatory activity leading to tolerance of the graft.
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Affiliation(s)
- Oliver Beetz
- Regenerative Medicine and Experimental Surgery, Department of General-, Visceral- and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - Joline Kolb
- Regenerative Medicine and Experimental Surgery, Department of General-, Visceral- and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - Benjamin Buck
- Regenerative Medicine and Experimental Surgery, Department of General-, Visceral- and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - Britta Trautewig
- Regenerative Medicine and Experimental Surgery, Department of General-, Visceral- and Transplantation Surgery, Hannover Medical School, Hannover, Germany
- Transplant Laboratory, Department of General-, Visceral- and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - Kai Timrott
- Regenerative Medicine and Experimental Surgery, Department of General-, Visceral- and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - Florian W. R. Vondran
- Regenerative Medicine and Experimental Surgery, Department of General-, Visceral- and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - Ingrid Meder
- Regenerative Medicine and Experimental Surgery, Department of General-, Visceral- and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - Corinna Löbbert
- Regenerative Medicine and Experimental Surgery, Department of General-, Visceral- and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - Joachim Hundrieser
- Transplant Laboratory, Department of General-, Visceral- and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - Jürgen Klempnauer
- Transplant Laboratory, Department of General-, Visceral- and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - Hüseyin Bektaş
- Regenerative Medicine and Experimental Surgery, Department of General-, Visceral- and Transplantation Surgery, Hannover Medical School, Hannover, Germany
- Department of General-, Visceral- and Oncological Surgery, Hospital Group Gesundheit Nord, Bremen, Germany
| | - Thorsten Lieke
- Regenerative Medicine and Experimental Surgery, Department of General-, Visceral- and Transplantation Surgery, Hannover Medical School, Hannover, Germany
- * E-mail:
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25
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Homeyer RS, Roberts KJ, Sutcliffe RP, Kaltenborn A, Mirza D, Qu Z, Klempnauer J, Schrem H. Ventilation after pancreaticoduodenectomy increases perioperative mortality: Identification of risk factors and their relevance in Germany that do not apply in England. Hepatobiliary Pancreat Dis Int 2019; 18:379-388. [PMID: 31122750 DOI: 10.1016/j.hbpd.2019.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 04/23/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Pre-operative risk factors for post-operative ventilation and their influence on survival after pancreaticoduodenectomy for malignancy are unknown. METHODS Totally 391 patients operated in Hannover, Germany were investigated with multivariable logistic regression and Cox regression modeling to identify independent risk factors for post-operative ventilation ≥6 h, patient survival and 90-day mortality. And 84 patients operated in Birmingham, United Kingdom were analyzed to assess the external relevance of findings. RESULTS Longer operations, history of thrombosis, intra-operative blood transfusion, lower estimated glomerular filtration rates (eGFR) and higher values of the age at operation divided by the Horovitz Quotient independently increased the risk of post-operative ventilation ≥ 6 h in German patients (n = 108; 27.6%) (P<0.050). Blood transfusion and lower pre-operative eGFR levels increased the risk of early death in German patients significantly and independently of established prognostic factors. A history of thrombosis and lower eGFR levels were also independent significant risk factors for 90-day mortality in German patients but not in English patients. None of the English patients received post-operative ventilation. Significantly more German patients were >75 years, had a history of thrombosis, received blood transfusions, and had significantly worse lung function parameters. pT4 tumors were detected in 18 German patients (4.6%), but not in the English patients. CONCLUSIONS Identified risk factors for post-operative ventilation are clinically relevant in Germany but not in England and may be used to lower mortality risk. The German and the English cohorts displayed significant differences in the approach to patient selection and early post-operative extubation.
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Affiliation(s)
- Rieke-Sophie Homeyer
- Core Facility Quality Management Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany; General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Keith J Roberts
- Department of HPB Surgery, Queen Elizabeth Hospital Birmingham, Mindelsohn Way Edgbaston, Birmingham B15 2GW, United Kingdom
| | - Robert P Sutcliffe
- Department of HPB Surgery, Queen Elizabeth Hospital Birmingham, Mindelsohn Way Edgbaston, Birmingham B15 2GW, United Kingdom
| | - Alexander Kaltenborn
- Core Facility Quality Management Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Darius Mirza
- Department of HPB Surgery, Queen Elizabeth Hospital Birmingham, Mindelsohn Way Edgbaston, Birmingham B15 2GW, United Kingdom
| | - Zhi Qu
- Core Facility Quality Management Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Jürgen Klempnauer
- General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Harald Schrem
- Core Facility Quality Management Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany; General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany; Department of General, Visceral and Transplant Surgery, Medical University Graz, Auenbrugger Platz 5, 8036 Graz, Austria.
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26
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Oldhafer F, Ringe KI, Timrott K, Kleine M, Beetz O, Ramackers W, Cammann S, Klempnauer J, Bektas H, Vondran FWR. Response to "Critical appraisal of the modified ante situm liver resection-is the original method the better choice?". Langenbecks Arch Surg 2019; 404:649-651. [PMID: 31256253 DOI: 10.1007/s00423-019-01795-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 05/28/2019] [Indexed: 11/30/2022]
Affiliation(s)
- F Oldhafer
- ReMediES, Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - K I Ringe
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, 30625, Hannover, Germany
| | - K Timrott
- ReMediES, Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - M Kleine
- ReMediES, Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - O Beetz
- ReMediES, Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - W Ramackers
- ReMediES, Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - S Cammann
- ReMediES, Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - J Klempnauer
- ReMediES, Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - H Bektas
- ReMediES, Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.,General, Visceral and Oncologic Surgery, Klinikum Bremen-Mitte/Bremen-Ost, Bremen, Germany
| | - Florian W R Vondran
- ReMediES, Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
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27
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Kettler B, Scheffner I, Bräsen JH, Hallensleben M, Richter N, Heiringhoff KH, Lehner F, Klempnauer J, Gwinner W. Kidney graft survival of >25 years: a single center report including associated graft biopsy results. Transpl Int 2019; 32:1277-1285. [PMID: 31188498 DOI: 10.1111/tri.13469] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Revised: 10/29/2018] [Accepted: 06/07/2019] [Indexed: 11/28/2022]
Abstract
Only few centers have reported their observations on patients with very long-term kidney graft survival of more than 25 years. Eighty-six subjects were identified in our center with graft survival of >25 years. Donor age was 31.3 ± 18.5 years. Mean duration of transplantation was 30.3 ± 3.6 years. At last follow-up, the cystatin C clearance was 47 ± 23 ml/min. Transplant biopsies for cause were performed in 30 subjects at a median of 28.4 years (19.1-40.3) after transplantation. Acute or chronic active T cell-mediated rejection was present in five cases and histological characteristics of acute or chronic active humoral rejection in eight cases. More than 80% of biopsies had inflammatory infiltrates in nonatrophic or atrophic cortical areas. The number of HLA mismatches were higher in biopsied subjects (3.0 ± 1.8 vs. 2.2 ± 1.7 without biopsy). Immunosuppressive therapy was adapted in most biopsied subjects; impaired graft function and proteinuria was unchanged at last follow-up. Sixty percent of all subjects had hyperparathyroidism (iPTH of the whole group: 132 ± 157 pg/ml), which was predominantly secondary, as judged by serum calcium and graft function. Young donor age was certainly a prerequisite of longterm graft survival. Nonetheless, inflammation or rejection in most biopsied patients suggests an important role of alloreactivity even in this late course.
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Affiliation(s)
- Bastian Kettler
- Clinic for General-, Abdominal- and Transplant-Surgery, Medical School Hannover, Hannover, Germany
| | - Irina Scheffner
- Clinic for Nephrology, Medical School Hannover, Hannover, Germany
| | - Jan H Bräsen
- Institute for Transfusion Medicine, Medical School Hannover, Hannover, Germany
| | - Michael Hallensleben
- Nephropathology Unit, Institute for Pathology, Medical School Hannover, Hannover, Germany
| | - Nicolas Richter
- Clinic for General-, Abdominal- and Transplant-Surgery, Medical School Hannover, Hannover, Germany
| | - Karl-Heinz Heiringhoff
- Clinic for General-, Abdominal- and Transplant-Surgery, Medical School Hannover, Hannover, Germany
| | - Frank Lehner
- Clinic for General-, Abdominal- and Transplant-Surgery, Medical School Hannover, Hannover, Germany
| | - Jürgen Klempnauer
- Clinic for General-, Abdominal- and Transplant-Surgery, Medical School Hannover, Hannover, Germany
| | - Wilfried Gwinner
- Clinic for Nephrology, Medical School Hannover, Hannover, Germany
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28
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Trunečka P, Klempnauer J, Bechstein WO, Pirenne J, Bennet W, Zhao A, Isoniemi H, Rostaing L, Settmacher U, Mönch C, Brown M, Undre N, Kazeem G, Tisone G. The Effect of Donor Age and Recipient Characteristics on Renal Outcomes in Patients Receiving Prolonged-Release Tacrolimus After Liver Transplantation: Post-Hoc Analyses of the DIAMOND Study. Ann Transplant 2019; 24:319-327. [PMID: 31160549 PMCID: PMC6568030 DOI: 10.12659/aot.913103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background The DIAMOND study of de novo liver transplant patients showed that prolonged-release tacrolimus exposure in the acute post-transplant period maintained renal function over 24 weeks of treatment. To assess these findings further, we performed a post-hoc analysis in patients according to baseline kidney function, Model for End-stage Liver Disease [MELD] scores, and donor age. Material/Methods Patients received prolonged-release tacrolimus (initial-dose, Arm 1: 0.2 mg/kg/day, Arm 2: 0.15–0.175 mg/kg/day, Arm 3: 0.2 mg/kg/day delayed until Day 5), mycophenolate mofetil and 1 steroid bolus. Arms 2 and 3 also received basiliximab. The recommended tacrolimus target trough levels to Day 42 post-transplantation were 5–15 ng/mL in all arms. In this post-hoc analysis, change in renal outcome, based on estimated glomerular filtration rate (eGFR), Modified Diet in Renal Disease-4 (MDRD4), values from baseline to Week 24 post-transplantation, were assessed according to baseline patient factors: eGFR (≥60 and <60 mL/min/1.73 m2), MELD score (<25 and ≥25) and donor age (<50 and ≥50 years). Results Baseline characteristics were comparable (Arms 1–3: n=283, n=287, n=274, respectively). Patients with baseline renal function, eGFR ≥60 mL/min/1.73 m2, experienced a decrease in eGFR in all tacrolimus treatment arms. In patients with lower baseline renal function (eGFR <60 mL/min/1.73 m2), an advantage for renal function was observed with both the early lower-dose and delayed higher-dose tacrolimus regimens compared with the early introduction of higher-dose tacrolimus. At Week 24, renal function was higher in the early-lower tacrolimus arm with older donors, and the delayed higher-dose tacrolimus arm with younger donors, both compared with early higher-dose tacrolimus. Conclusions Pre-transplantation factors, such as renal function and donor age, could guide the choice of prolonged-release tacrolimus regimen following liver transplantation.
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Affiliation(s)
- Pavel Trunečka
- Transplantcenter, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Jürgen Klempnauer
- Department of General-, Visceral- and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - Wolf Otto Bechstein
- Department of Surgery, Goethe University Hospital and Clinics, Frankfurt, Germany
| | - Jacques Pirenne
- Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium
| | - William Bennet
- The Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Alexey Zhao
- Department of Abdominal Surgery, A.V. Vishnevsky Institute of Surgery, Moscow, Russian Federation
| | - Helena Isoniemi
- Department of Transplantation and Liver Surgery Clinic, Helsinki University Hospital, Helsinki, Finland
| | - Lionel Rostaing
- Department of Nephrology and Organ Transplantation, Toulouse University Hospital, Toulouse, France
| | - Utz Settmacher
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Jena, Germany
| | - Christian Mönch
- Department of Surgery, Goethe University Hospital and Clinics, Frankfurt, Germany.,Department of General, Visceral and Transplantation Surgery, Westpfalz-Klinikum Hospital, Kaiserslautern, Germany
| | - Malcolm Brown
- Astellas Pharma, Medical Affairs - Global, Northbrook, IL, USA
| | | | - Gbenga Kazeem
- Astellas Pharma Europe Ltd., Chertsey, United Kingdom.,BENKAZ Consulting Ltd., Cambridge, United Kingdom
| | - Giuseppe Tisone
- Transplant and Hepatobiliary Unit, Department of Surgery, University of Rome Tor Vergata, Rome, Italy
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29
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Schmitz B, Pflugrad H, Tryc AB, Lanfermann H, Jäckel E, Schrem H, Beneke J, Barg-Hock H, Klempnauer J, Weissenborn K, Ding XQ. Brain metabolic alterations in patients with long-term calcineurin inhibitor therapy after liver transplantation. Aliment Pharmacol Ther 2019; 49:1431-1441. [PMID: 31006881 DOI: 10.1111/apt.15256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 12/24/2018] [Accepted: 03/20/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Calcineurin inhibitor (CNI) neurotoxicity after liver transplantation might be due to impairment of the cerebral metabolism. AIMS To investigate CNI-related alterations of brain metabolite distributions and associations between cognitive function and brain metabolism in patients with long-term CNI treatment after liver transplantation. METHODS Eighty-two patients (19 CNI free, 34 CNI low-dose and 29 standard-dose CNI immunosuppression) 10 years after liver transplantation and 32 adjusted healthy controls underwent nonlocalised brain phosphorus magnetic resonance spectroscopy (MRS) and single voxel proton MRS in the parietal white matter to estimate brain metabolite contents. The MRS results were correlated with psychometric data assessing cognitive function. RESULTS Phosphorus metabolite concentrations with the exception of phosphocreatine (PCr) were reduced in patients compared to controls. Particularly, patients with low-dose CNI therapy showed a significant decrease in adenosine triphosphate (0.209 ± 0.012 vs 0.222 ± 0.010; P < 0.001) and a significant increase in PCr (0.344 ± 0.026 vs 0.321 ± 0.017; P < 0.001) compared to controls. Myo-Inositol in the CNI free group (2.719 ± 0.549 institutional unit [iu]) was significantly lower compared to controls (3.181 ± 0.425 iu; P = 0.02), patients on low-dose (3.130 ± 0.513 iu; P < 0.05) and standard-dose CNI therapy (3.207 ± 0.632 iu; P < 0.02). Glutamate and glutamine levels correlated negatively with cognitive function (Repeatable Battery for the Assessment of Neuropsychological Status Total Scale: R = -0.362, P = 0.029). CONCLUSION Long-term CNI therapy after liver transplantation might be associated with alterations of brain metabolites.
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Affiliation(s)
- Birte Schmitz
- Department of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany
| | - Henning Pflugrad
- Department of Neurology, Hannover Medical School, Hannover, Germany.,Integrated Research and Treatment Centre Transplantation, Hannover Medical School, Hannover, Germany
| | - Anita B Tryc
- Department of Neurology, Hannover Medical School, Hannover, Germany.,Integrated Research and Treatment Centre Transplantation, Hannover Medical School, Hannover, Germany
| | - Heinrich Lanfermann
- Department of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany
| | - Elmar Jäckel
- Integrated Research and Treatment Centre Transplantation, Hannover Medical School, Hannover, Germany.,Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Harald Schrem
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Hannover Medical School, Hannover, Germany.,Clinic for Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Jan Beneke
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Hannover Medical School, Hannover, Germany
| | - Hannelore Barg-Hock
- Clinic for Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Jürgen Klempnauer
- Integrated Research and Treatment Centre Transplantation, Hannover Medical School, Hannover, Germany.,Clinic for Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Karin Weissenborn
- Department of Neurology, Hannover Medical School, Hannover, Germany.,Integrated Research and Treatment Centre Transplantation, Hannover Medical School, Hannover, Germany
| | - Xiao-Qi Ding
- Department of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany
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Schwager Y, Littbarski SA, Nolte A, Kaltenborn A, Emmanouilidis N, Kleine-Döpke D, Klempnauer J, Schrem H. Prediction of Three-Year Mortality After Deceased Donor Kidney Transplantation in Adults with Pre-Transplant Donor and Recipient Variables. Ann Transplant 2019; 24:273-290. [PMID: 31097680 PMCID: PMC6540619 DOI: 10.12659/aot.913217] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background Prognostic models for 3-year mortality after kidney transplantation based on pre-transplant donor and recipient variables may avoid futility and thus improve donor organ allocation. Material/Methods There were 1546 consecutive deceased-donor kidney transplants in adults (January 1, 2000 to December 31, 2012) used to identify pre-transplant donor and recipient variables with significant independent influence on long-term survival (Cox regression modelling). Detected factors were used to develop a prognostic model for 3-year mortality in 1289 patients with follow-up of >3 years (multivariable logistic regression). The sensitivity and specificity of this model’s prognostic ability was assessed with the area under the receiver operating characteristic curve (AUROC). Results Highly immunized recipients [hazard ratio (HR: 2.579, 95% CI: 1.272–4.631], high urgency recipients (HR: 3.062, 95% CI: 1.294–6.082), recipients with diabetic nephropathy (HR: 3.471, 95% CI: 2.476–4.751), as well as 0, 1, or 2 HLA DR mismatches (HR: 1.349, 95% CI: 1.160–1.569) were independent and significant risk factors for patient survival. Younger recipient age ≤42.1 years (HR: 0.137, 95% CI: 0.090–0.203), recipient age 42.2–52.8 years (HR: 0.374, 95% CI: 0.278–0.498), recipient age 52.9–62.8 years (HR: 0.553, 95% CI: 0.421–0.723), short cold ischemic times ≤11.8 hours (HR: 0.602, 95% CI: 0.438–0.814) and cold ischemic times 11.9–15.3 hours (HR: 0.736, 95% CI: 0.557–0.962) reduced this risk independently and significantly. The AUROC of the derived model for 3-year post-transplant mortality with these variables was 0.748 (95% CI: 0.689–0.788). Conclusions Older, highly immunized or high urgency transplant candidates with anticipated longer cold ischemic times, who were transplanted with the indication of diabetic nephropathy should receive donor organs with no HLA DR mismatches to improve their mortality risk.
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Affiliation(s)
- Ysabell Schwager
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Facility Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Simon Alexander Littbarski
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Facility Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Almut Nolte
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Facility Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Alexander Kaltenborn
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Facility Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Nikos Emmanouilidis
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Dennis Kleine-Döpke
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Jürgen Klempnauer
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Harald Schrem
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Facility Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany.,Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany.,Department of General, Visceral and Transplant Surgery, Medical University of Graz, Graz, Austria
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31
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Thude H, Rother S, Sterneck M, Klempnauer J, Nashan B, Schwinzer R, Koch M. The killer cell lectin-like receptor B1 (KLRB1) 503T>C polymorphism (rs1135816) and acute rejection after liver transplantation. HLA 2019; 91:52-55. [PMID: 29111570 DOI: 10.1111/tan.13172] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 11/02/2017] [Accepted: 11/03/2017] [Indexed: 12/27/2022]
Abstract
The killer cell lectin-like receptor B1 (KLRB1) gene encodes for CD161 expressed by different subsets of leukocytes involved in the development of acute liver transplant rejection. The single nucleotide polymorphism (SNP) 503T>C (rs1135816) in the KLRB1 gene represents a missense mutation modifying functional properties of CD161. The aim of our study is to determine whether the SNP 503T>C is associated with acute liver transplant rejection. We genotyped the SNP for 163 liver recipients without acute rejection, 125 recipients with a single acute rejection, and 53 recipients with multiple acute rejections. The genotype frequencies within the groups did not show any significant difference. Our data suggest that the SNP 503T>C has no impact on the susceptibility of acute liver transplant rejection.
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Affiliation(s)
- H Thude
- Department of Hepatobiliary and Transplant Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - S Rother
- Department of General, Visceral and Transplantation Surgery, Transplant Laboratory, Hannover Medical School, Hannover, Germany
| | - M Sterneck
- Department of Hepatobiliary and Transplant Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - J Klempnauer
- Department of General, Visceral and Transplantation Surgery, Transplant Laboratory, Hannover Medical School, Hannover, Germany
| | - B Nashan
- Department of Hepatobiliary and Transplant Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - R Schwinzer
- Department of General, Visceral and Transplantation Surgery, Transplant Laboratory, Hannover Medical School, Hannover, Germany
| | - M Koch
- Department of Hepatobiliary and Transplant Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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32
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Beetz O, Kleine M, Vondran FWR, Cammann S, Klempnauer J, Kettler B. A Case of Recurrent Pneumoperitoneum and Pneumatosis Intestinalis After Bilateral Lung Transplant. EXP CLIN TRANSPLANT 2019; 17:124-127. [DOI: 10.6002/ect.2016.0249] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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33
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Ramackers W, Werwitzke S, Klose J, Friedrich L, Johanning K, Bergmann S, Klempnauer J, Winkler M, Tiede A. Investigation of the influence of xenoreactive antibodies on activation of complement and coagulation in an ex vivo perfusion animal study using porcine kidneys. Transpl Int 2019; 32:546-556. [PMID: 30597634 DOI: 10.1111/tri.13396] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 06/10/2018] [Accepted: 12/23/2018] [Indexed: 12/30/2022]
Abstract
During pig-to-primate xenotransplantation or perfusion of porcine organs with human blood, a xenogeneic coagulopathy with consecutive development of thrombotic microangiopathy (TMA) can be observed. The aim of this study was to elucidate the influence of the reduction of xenoreactive natural antibodies on the coagulopathy using an ex vivo perfusion system. Thirteen perfusion experiments using landrace wild-type porcine kidneys were performed in three different experimental groups: autologous, xenogeneic, and immunoadsorption. During and after perfusion, blood and tissue samples were collected to assess markers of coagulation, complement, inflammation, and endothelial activation. Immunoadsorption prior to perfusion did not prolong perfusion time (174 min ±28) compared to xenogeneic (182 min ±22) experiments, whereas autologous perfusion was possible for maximum of 240 min in all experiments. Activation of coagulation was similar comparing perfusions after immunoadsorption (D-Dimer 24 186 μg/l ±5813; TAT 566 μg/l ±34) to xenogeneic (D-Dimer 22 175 μg/l ±7826, TAT 600 μg/l ±0) experiments. But antibody-mediated complement activation was reduced in the immunoadsorption group. TNF-alpha and markers of endothelial cell activation were lower in the immunoadsorption group compared to the xenogeneic experiments. In this ex vivo perfusion model, we observed that marked removal of xenogeneic antibodies can reduce complement activation via the classical pathway as well as endothelial cell activation and inflammation. Immunoadsorption cannot prevent the activation of the terminal complement cascade and coagulation.
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Affiliation(s)
- Wolf Ramackers
- Department of General and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - Sonja Werwitzke
- Department of Hematology Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Johannes Klose
- Department of Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Lars Friedrich
- Department of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - Kai Johanning
- Department of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - Sabine Bergmann
- Department of General and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - Jürgen Klempnauer
- Department of General and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - Michael Winkler
- Department of General and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - Andreas Tiede
- Department of Hematology Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
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34
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Junge N, Dingemann J, Petersen C, Manns MP, Richter N, Klempnauer J, Baumann U, Schneider A. [Biliary atresia and congenital cholestatic syndromes : Characteristics before, after and during transition]. Internist (Berl) 2018; 59:1146-1156. [PMID: 30264190 DOI: 10.1007/s00108-018-0506-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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: 01/14/2023]
Abstract
BACKGROUND A growing number of patients with biliary atresia and congenital cholestatic syndromes are reaching adulthood. These patients often have a number of typical medical features, including specific characteristics of liver transplantation medicine. OBJECTIVE What are the special features in the care of adults suffering from liver diseases with manifestation in childhood and adolescence, both before and after liver transplantation (LTX). How does the progression of individual diseases differ depending on age at manifestation? What are specific aspects following pediatric LTX? PATIENTS AND METHODS Evaluation and discussion of existing guidelines and recommendations of the individual disciplines and professional societies as well as the current literature. Joint discussion of the recommendations between disciplines (gastroenterology, pediatric gastroenterology, surgery). Inclusion of center-specific experiences with transition from existing transition outpatient departments and training. RESULTS The recommendations are presented specifically for each disease. Special features in individual diseases after LTX are also discussed. Diagnosis-independent general treatment concepts for cholestasis and chronic liver disease are presented. CONCLUSION Patients with biliary atresia and congenital cholestatic syndromes have a life-long chronic liver disease with and without LTX and require specific medical care. The patients benefit from the pooling of expertise in the individual disciplines.
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Affiliation(s)
- N Junge
- Klinik für Pädiatrische Nieren‑, Leber- und Stoffwechselerkrankungen, Schwerpunkt Pädiatrische Gastroenterologie und Hepatologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
| | - J Dingemann
- Klinik für Kinderchirurgie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - C Petersen
- Klinik für Kinderchirurgie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - M P Manns
- Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - N Richter
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - J Klempnauer
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - U Baumann
- Klinik für Pädiatrische Nieren‑, Leber- und Stoffwechselerkrankungen, Schwerpunkt Pädiatrische Gastroenterologie und Hepatologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - A Schneider
- Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover, Hannover, Deutschland
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35
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Gerken K, Roberts KJ, Reichert B, Sutcliffe RP, Marcon F, Kamarajah SK, Kaltenborn A, Becker T, Heits NG, Mirza DF, Klempnauer J, Schrem H. Development and multicentre validation of a prognostic model to predict resectability of pancreatic head malignancy. BJS Open 2018; 2:319-327. [PMID: 30263983 PMCID: PMC6156170 DOI: 10.1002/bjs5.79] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 04/11/2018] [Indexed: 11/09/2022] Open
Abstract
Background At the time of planned pancreatoduodenectomy patients frequently undergo exploratory laparotomy without resection, leading to delayed systemic therapy. This study aimed to develop and validate a prognostic model for the preoperative prediction of resectability of pancreatic head tumours. Methods This was a retrospective study of patients undergoing attempted resection for confirmed malignant tumours of the pancreatic head in a university hospital in Hannover, Germany. The prognostic value of patient and tumour characteristics was investigated in a multivariable logistic regression model. External validation was performed using data from two other centres. Results Some 109 patients were included in the development cohort, with 51 and 175 patients in the two validation cohorts. Eighty patients (73·4 per cent) in the development cohort underwent resection, and 37 (73 per cent) and 141 (80·6 per cent) in the validation cohorts. The main reasons for performing no resection in the development cohort were: local invasion of vasculature or arterial abutment (15 patients, 52 per cent), and liver (12, 41 per cent), peritoneal (8, 28 per cent) and aortocaval lymph node (6, 21 per cent) metastases. The final model contained the following variables: time to surgery (odds ratio (OR) 0·99, 95 per cent c.i. 0·98 to 0·99), carbohydrate antigen 19-9 concentration (OR 0·99, 0·99 to 0·99), jaundice (OR 4·45, 1·21 to 16·36) and back pain (OR 0·02, 0·00 to 0·22), with an area under the receiver operating characteristic (ROC) curve (AUROC) of 0·918 in the development cohort. AUROC values were 0·813 and 0·761 in the validation cohorts. The positive predictive value of the final model for prediction of resectability was 98·0 per cent in the development cohort, and 91·7 and 94·7 per cent in the two external validation cohorts. [Corrections added on 18 July 2018, after first online publication: The figures for OR of the variables time to surgery and CA19-9 in the abstract and in Table 3 and Table 4 were amended from 1·00 to 0·99]. Conclusion For preoperative prediction of the likelihood of resectability of pancreatic head tumours, this validated model is a valuable addition to CT findings.
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Affiliation(s)
- K Gerken
- Department of General, Visceral and Transplant Surgery, Hannover Medical School Hannover Germany.,Core Facility for Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Centre Transplantation (IFB-Tx), Hannover Medical School Hannover Germany
| | - K J Roberts
- Liver and Hepato-Pancreato-Biliary Unit, Queen Elizabeth Hospital Birmingham UK
| | - B Reichert
- Department of General, Visceral, Thoracic, Transplant and Paediatric Surgery University Medical Centre Schleswig-Holstein Kiel Germany
| | - R P Sutcliffe
- Liver and Hepato-Pancreato-Biliary Unit, Queen Elizabeth Hospital Birmingham UK
| | - F Marcon
- Liver and Hepato-Pancreato-Biliary Unit, Queen Elizabeth Hospital Birmingham UK
| | - S K Kamarajah
- Liver and Hepato-Pancreato-Biliary Unit, Queen Elizabeth Hospital Birmingham UK
| | - A Kaltenborn
- Core Facility for Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Centre Transplantation (IFB-Tx), Hannover Medical School Hannover Germany
| | - T Becker
- Department of General, Visceral, Thoracic, Transplant and Paediatric Surgery University Medical Centre Schleswig-Holstein Kiel Germany
| | - N G Heits
- Department of General, Visceral, Thoracic, Transplant and Paediatric Surgery University Medical Centre Schleswig-Holstein Kiel Germany
| | - D F Mirza
- Liver and Hepato-Pancreato-Biliary Unit, Queen Elizabeth Hospital Birmingham UK
| | - J Klempnauer
- Department of General, Visceral and Transplant Surgery, Hannover Medical School Hannover Germany
| | - H Schrem
- Department of General, Visceral and Transplant Surgery, Hannover Medical School Hannover Germany.,Core Facility for Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Centre Transplantation (IFB-Tx), Hannover Medical School Hannover Germany
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36
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Pfister ED, Karch A, Adam R, Polak WG, Karam V, Mirza D, O'Grady J, Klempnauer J, Reding R, Kalicinski P, Coker A, Trunecka P, Astarcioglu I, Jacquemin E, Pratschke J, Paul A, Popescu I, Schneeberger S, Boillot O, Fischer L, Mikolajczyk RT, Baumann U, Duvoux C. Predictive Factors for Survival in Children Receiving Liver Transplants for Wilson's Disease: A Cohort Study Using European Liver Transplant Registry Data. Liver Transpl 2018; 24:1186-1198. [PMID: 30021057 DOI: 10.1002/lt.25308] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 04/25/2018] [Indexed: 02/07/2023]
Abstract
Liver transplantation (LT) is a rescue therapy for life-threatening complications of Wilson's disease (WD). However, data on the outcome of WD patients after LT are scarce. The aim of our study was to analyze a large pediatric WD cohort with the aim of investigating the longterm outcome of pediatric WD patients after LT and to identify predictive factors for patient and transplant survival. This is a retrospective cohort study using data of all children (<18 years) transplanted for WD enrolled in the European Liver Transplant Registry from January 1968 until December 2013. In total, 338 patients (57.6% female) transplanted at 80 different European centers (1-26 patients per center) were included in this study. The median age at transplantation was 14.0 years (interquartile range [IQR], 11.2-16.1 years); patients were followed up for a median of 5.4 years (IQR, 1.0-10.9 years) after LT. Overall patient survival rates were high with 87% (1-year survival), 84% (5-year survival), and 81% (10-year survival); survival rates increased considerably with the calendar year (P < 0.001). Early age at LT, living donation, and histidine tryptophan ketoglutarate preservation liquid were identified as risk factors for poor patient survival in the multivariate analysis. LT is an excellent treatment option for pediatric patients with WD and associated end-stage liver disease. Longterm outcome in these patients is similar to other pediatric causes for LT. Overall patient and graft survival rates improved considerably over the last decades. To improve future research in the field, the vast variability of allocation strategies should be harmonized and a generally accepted definition or discrimination of acute versus chronic WD needs to be found.
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Affiliation(s)
- Eva-Doreen Pfister
- Division of Pediatric Gastroenterology and Hepatology, Departments of Pediatric Kidney, Liver, and Metabolic Diseases, Hannover, Germany
| | - André Karch
- Research Group Epidemiological and Statistical Methods, Helmholtz Center for Infection Research, Braunschweig, Germany.,German Center for Infection Research, Hannover-Braunschweig, Germany
| | - René Adam
- European Liver Transplant Registry.,AP-HP Hôpital Paul Brousse, Université Paris-Sud, Center Hépato-Biliaire, INSERM U 935, Villejuif, France
| | | | - Vincent Karam
- European Liver Transplant Registry.,AP-HP Hôpital Paul Brousse, Université Paris-Sud, Center Hépato-Biliaire, INSERM U 935, Villejuif, France
| | - Darius Mirza
- Liver Unit, Elizabeth Hospital Birmingham, University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, United Kingdom
| | - John O'Grady
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Jürgen Klempnauer
- General, Visceral and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | | | - Piotr Kalicinski
- Department of Pediatric and Transplant Surgery, Children's Memorial Health Institute, Warsaw, Poland
| | - Ahmet Coker
- Department of Gastroenterology, Bozyaka Training and Research Hospital, Izmir, Turkey
| | - Pavel Trunecka
- Transplant Center, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Ibrahim Astarcioglu
- HPB Surgery and Liver Transplantation Unit, Department of General Surgery, School of Medicine, Dokuz Eylul University, Inciralti, İzmir, Turkey
| | - Emmanual Jacquemin
- AP-HP Hôpital Paul Brousse, Université Paris-Sud, Center Hépato-Biliaire, INSERM U 935, Villejuif, France
| | | | - Andreas Paul
- Department of General and Transplant Surgery, University Hospital Essen, Essen, Germany
| | - Irinel Popescu
- Department of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Stefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Innsbruck Medical University, Innsbruck, Austria
| | - Oliver Boillot
- Liver Transplant Unit, Edouard Herriot Hospital, Lyon, France
| | - Lutz Fischer
- Department of Hepatobiliary Surgery and Visceral Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rafael T Mikolajczyk
- Research Group Epidemiological and Statistical Methods, Helmholtz Center for Infection Research, Braunschweig, Germany.,German Center for Infection Research, Hannover-Braunschweig, Germany
| | - Ulrich Baumann
- Division of Pediatric Gastroenterology and Hepatology, Departments of Pediatric Kidney, Liver, and Metabolic Diseases, Hannover, Germany
| | - Christophe Duvoux
- Department of Hepatology and Liver Transplant Unit, AP-HP Henri Mondor Hospital, Paris Est University, Créteil, France
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Qu Z, Ling Q, Gwiasda J, Xu X, Schrem H, Beneke J, Kaltenborn A, Krauth C, Mix H, Klempnauer J, Emmanouilidis N. Hangzhou criteria are more accurate than Milan criteria in predicting long-term survival after liver transplantation for HCC in Germany. Langenbecks Arch Surg 2018; 403:643-654. [PMID: 30120543 DOI: 10.1007/s00423-018-1696-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 07/10/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Milan criteria are used for patient selection in liver transplantation for hepatocellular carcinoma (HCC). Hangzhou criteria have been shown in China to enable access to liver transplantation for more patients when compared to Milan criteria without negative effects on long-term survival. The purpose of this study was to evaluate the Hangzhou criteria in a German cohort. METHODS One hundred fifty-nine patients transplanted for HCC between 1975 and 2010 were investigated. Patients were categorized into four groups depending on the fulfillment of Milan and Hangzhou criteria. General and tumor baseline characteristics were compared. Overall and tumor-free survival rates were investigated with the Kaplan-Meier analysis. RESULTS One-, 3-, 5-, and 10-year survival rates for patients fulfilling Milan criteria (n = 68) were 89.7, 83.7, 75.8, and 62.1%, respectively, versus 89.8, 82.2, 75.2, and 62.6% for patients fulfilling Hangzhou criteria (n = 109) (p = 0.833). When comparing patients exceeding Milan or Hangzhou criteria, survival rates were 75.3, 53.2, 48.1, and 41.1% versus 63.3, 31.4, 26.9, and 22.1%, respectively (p = 0.019). The comparison of tumor-free survival rates in patients fulfilling Milan or Hangzhou criteria was statistically not significant (p = 0.785), whereas the comparison of the groups exceeding the criteria showed significantly worse survival for patients outside Hangzhou criteria (p = 0.007). The proportion of patients fulfilling Hangzhou criteria (68.6%) was significantly larger as compared to the proportion fulfilling Milan criteria (42.8%) (p < 0.001). CONCLUSION Hangzhou criteria are more accurate in predicting long-term survival after liver transplantation for HCC in Germany. Deployment of the Hangzhou criteria for patient selection could enlarge the pool of transplantable patients.
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Affiliation(s)
- Zhi Qu
- Institute for Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School, Hannover, Germany.,Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Facility Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Qi Ling
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79, Qingchun Road, Hangzhou, 310003, Zhejiang Province, China
| | - Jill Gwiasda
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Facility Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Xiao Xu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79, Qingchun Road, Hangzhou, 310003, Zhejiang Province, China.
| | - Harald Schrem
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Facility Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany. .,General, Visceral and Transplantation Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Jan Beneke
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Facility Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Alexander Kaltenborn
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Facility Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Christian Krauth
- Institute for Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School, Hannover, Germany.,Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Facility Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Heiko Mix
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Facility Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Jürgen Klempnauer
- General, Visceral and Transplantation Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Nikos Emmanouilidis
- General, Visceral and Transplantation Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
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Beetz O, Klein M, Schrem H, Gwiasda J, Vondran FWR, Oldhafer F, Cammann S, Klempnauer J, Oldhafer KJ, Kleine M. Relevant prognostic factors influencing outcome of patients after surgical resection of distal cholangiocarcinoma. BMC Surg 2018; 18:56. [PMID: 30103720 PMCID: PMC6090737 DOI: 10.1186/s12893-018-0384-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 07/26/2018] [Indexed: 12/11/2022] Open
Abstract
Background Distal cholangiocarcinoma (DCC) is a rare but over the last decade increasing malignancy and is associated with poor prognosis. According to the present knowledge curative surgery is the only chance for long term survival. This study was performed to evaluate prognostic factors for the outcome of patients undergoing curative surgery for distal cholangiocarcinoma. Methods 75 patients who underwent surgery between January 2000 and December 2014 for DCC in curative intention were analysed retrospectively. Potential prognostic factors for survival were investigated including the extent of surgery using purposeful selection of covariates in multivariable Cox regression modeling. Results Preoperative biliary stenting (Hazard ratio (HR): 2.530; 95%-CI: 1.146–6.464, p = 0.020), the extent of surgery in case of positive histological venous invasion (HR: 1.209; 95%-CI: 1.017–1.410, p = 0.032), lymph node staging (HR: 2.183; 95%-CI: 1.250–3.841, p = 0.006), perineural invasion (HR: 2.118; 95%-CI: 1.147–4.054, p = 0.016) and postoperative complications graded in points according to Clavien-Dindo (HR: 1.395; 95%-CI: 1.148–1.699, p = 0.001) were indentified as independent significant risk factors for survival. Patients receiving preoperative biliary stenting showed prolonged duration between onset of symptoms and date of operation (p = 0.048). Conclusions Preoperative biliary stenting reduces survival possibly due to delayed surgery. The extent of surgery is not an independent risk factor for survival except for patients with concomitant histological venous invasion. Oncological factors and postoperative surgical complications are independent prognostic factors for survival.
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Affiliation(s)
- Oliver Beetz
- Department of General, Visceral and Transplant Surgery, Medizinische Hochschule Hannover, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Michael Klein
- Department of General, Visceral and Transplant Surgery, Medizinische Hochschule Hannover, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Harald Schrem
- Department of General, Visceral and Transplant Surgery, Medizinische Hochschule Hannover, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany.,Core Facility Quality Management Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Jill Gwiasda
- Core Facility Quality Management Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Florian W R Vondran
- Department of General, Visceral and Transplant Surgery, Medizinische Hochschule Hannover, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Felix Oldhafer
- Department of General, Visceral and Transplant Surgery, Medizinische Hochschule Hannover, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Sebastian Cammann
- Department of General, Visceral and Transplant Surgery, Medizinische Hochschule Hannover, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Jürgen Klempnauer
- Department of General, Visceral and Transplant Surgery, Medizinische Hochschule Hannover, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Karl J Oldhafer
- Department of General, Visceral and Oncological Surgery, Asklepios Klinik Barmbek, Hamburg, Germany
| | - Moritz Kleine
- Department of General, Visceral and Transplant Surgery, Medizinische Hochschule Hannover, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany.
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39
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Kleine-Döpke D, Oelke M, Schwarz A, Schwager Y, Lehner F, Klempnauer J, Schrem H. Renal cell cancer after kidney transplantation. Langenbecks Arch Surg 2018; 403:631-641. [DOI: 10.1007/s00423-018-1694-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Accepted: 07/06/2018] [Indexed: 01/20/2023]
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40
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Filali Bouami S, Gwiasda J, Beneke J, Kaltenborn A, Liersch S, Suero EM, Koch HF, Krauth C, Klempnauer J, Schrem H. Prognostic factors for long-term survival after adult liver transplantation. Langenbecks Arch Surg 2018; 403:495-508. [DOI: 10.1007/s00423-018-1670-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 03/21/2018] [Indexed: 12/31/2022]
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41
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Oldhafer F, Ringe KI, Timrott K, Kleine M, Beetz O, Ramackers W, Cammann S, Klempnauer J, Vondran FWR, Bektas H. Modified ante situm liver resection without use of cold perfusion nor veno-venous bypass for treatment of hepatic lesions infiltrating the hepatocaval confluence. Langenbecks Arch Surg 2018; 403:379-386. [PMID: 29470630 DOI: 10.1007/s00423-018-1658-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Accepted: 02/01/2018] [Indexed: 12/15/2022]
Abstract
PURPOSE Treatment of malignancies invading the hepatic veins/inferior vena cava is a surgical challenge. An ante situm technique allows luxation of the liver in front of the situs to perform tumor resection. Usually, cold perfusion and veno-venous bypass are applied. Our experience with modified ante situm resection relying only on total vascular occlusion is reported. METHODS Retrospective analysis on an almost 15-year experience with ante situm resection without application of cold perfusion or veno-venous bypass RESULTS: The ante situm technique was applied on eight patients. Five individuals were treated due to intrahepatic cholangiocellular cancer and one case each for mixed cholangio-/hepatocellular carcinoma, colorectal liver metastasis, and pheochromocytoma. Trisectorectomy (n = 4), left hemihepatectomy, right hepatectomy, atypical resection, or mesohepatectomy (each n = 1) were performed, combined with dissection of suprahepatic/retrohepatic vena cava/hepatic veins. Venous reconstruction was achieved by reimplantation of hepatic veins with/without vascular replacement using allogeneic donor veins or PTFE grafts. Median total vascular occlusion of the liver was 23 min. Severe morbidity occurred in three patients (Dindo-Clavien > 3A). R0 status was achieved in six cases with a median overall survival of 33.5 months. CONCLUSIONS Ante situm liver resection can be applied without cold perfusion nor veno-venous bypass with acceptable morbidity and mortality. However, this procedure remains challenging even for the experienced hepato-pancreato-biliary surgeon.
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Affiliation(s)
- F Oldhafer
- ReMediES, Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - K I Ringe
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, 30625, Hannover, Germany
| | - K Timrott
- ReMediES, Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - M Kleine
- ReMediES, Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - O Beetz
- ReMediES, Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - W Ramackers
- ReMediES, Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - S Cammann
- ReMediES, Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - J Klempnauer
- ReMediES, Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - F W R Vondran
- ReMediES, Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - H Bektas
- ReMediES, Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.,General, Visceral and Oncologic Surgery, Klinikum Bremen-Mitte/Bremen-Ost, Bremen, Germany
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Oldhafer F, Alten T, Klempnauer J, Emmanouilidis N. Pubic and inguinal venous collaterals mimic inguinal hernia. J Surg Case Rep 2018; 2017:rjx113. [PMID: 29423159 PMCID: PMC5798014 DOI: 10.1093/jscr/rjx113] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 08/14/2017] [Indexed: 11/13/2022] Open
Abstract
Herein we report a case of a 38-year-old men who presented with acute suprapubic pain caused by a tubular, hypoechoic, non-compressible, inguinal mass with no flow evident on color Doppler sonography. The history of the patient, the clinical signs of local inflammation and tenderness on palpation as well as the results of the Doppler ultrasound examination led to the diagnose of an inguinal hernia with bowl incarceration. However, due to a remaining uncertainty whether a bilateral or unilateral hernia was immanent and whether the bowl incarceration was caused by a right or left sided hernia the on-call surgeon initiated a computed tomography (CT) scan. Surprisingly, this CT scan revealed extensive suprapubic venous collaterals with thrombophlebitis that mimicked a bilateral inguinal hernia secondary to an acute unilateral femoral vein thrombosis. Instead of undergoing surgery the patient was treated with antibiotics, pain killer and heparin and was discharged from hospital after 8 days.
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Affiliation(s)
- F Oldhafer
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - T Alten
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - J Klempnauer
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - N Emmanouilidis
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
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Salman J, Grannas G, Ius F, Sommer W, Siemeni T, Avsar M, Kuehn C, Boethig D, Richter N, Gottlieb J, Klempnauer J, Welte T, Haverich A, Tudorache I, Warnecke G, Lehner F. The “Liver First'' Approach for Combined Lung and Liver Transplantation in Patients with Cystic Fibrosis. Thorac Cardiovasc Surg 2018. [DOI: 10.1055/s-0038-1628098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Pflugrad H, Schrader AK, Tryc AB, Ding X, Lanfermann H, Jäckel E, Schrem H, Beneke J, Barg-Hock H, Klempnauer J, Weissenborn K. Longterm calcineurin inhibitor therapy and brain function in patients after liver transplantation. Liver Transpl 2018; 24:56-66. [PMID: 29156491 DOI: 10.1002/lt.24984] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 10/05/2017] [Accepted: 10/19/2017] [Indexed: 02/07/2023]
Abstract
Calcineurin inhibitors (CNIs) frequently induce neurological complications early after orthotopic liver transplantation (OLT). We hypothesize that longterm CNI therapy after OLT causes dose-dependent cognitive dysfunction and alteration of brain structure. In this study, 85 OLT patients (20 with CNI-free, 35 with CNI low-dose, and 30 with standard-dose CNI immunosuppression) underwent psychometric testing and cerebral magnetic resonance imaging approximately 10 years after OLT to assess brain function and structural brain alterations. A total of 33 healthy patients adjusted for age, sex, and education served as controls. Patients receiving CNI showed a significantly worse visuospatial/constructional ability compared with controls (P ≤ 0.04). Furthermore, patients on low-dose CNI therapy had an overall impaired cognitive function compared with controls (P = 0.01). The tacrolimus total dose and mean trough level were negatively correlated to cognitive function. CNI doses had been adjusted in 91% of the patients in the low-dose and CNI-free groups in the past due to CNI-induced kidney damage. Patients treated with CNI showed significantly more white matter hyperintensities (WMH) than patients on CNI-free immunosuppression and controls (P < 0.05). Both the mean cyclosporine A and tacrolimus trough levels correlated significantly with WMH. In conclusion, longterm CNI therapy carries a risk of cognitive dysfunction especially in patients who already showed nephrotoxic side effects indicating an increased susceptibility of these patients against toxic CNI effects. This subgroup of patients might benefit from a change to CNI-free immunosuppression. Liver Transplantation 24 56-66 2018 AASLD.
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Affiliation(s)
- Henning Pflugrad
- Departments of Neurology.,Integrated Research and Treatment Centre Transplantation
| | | | - Anita Blanka Tryc
- Departments of Neurology.,Integrated Research and Treatment Centre Transplantation
| | - Xiaoqi Ding
- Diagnostic and Interventional Neuroradiology
| | | | - Elmar Jäckel
- Gastroenterology, Hepatology and Endocrinology.,Integrated Research and Treatment Centre Transplantation
| | - Harald Schrem
- Core Facility Quality Management Transplantation.,Clinic for Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Jan Beneke
- Core Facility Quality Management Transplantation
| | - Hannelore Barg-Hock
- Clinic for Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Jürgen Klempnauer
- Integrated Research and Treatment Centre Transplantation.,Clinic for Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Karin Weissenborn
- Departments of Neurology.,Integrated Research and Treatment Centre Transplantation
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Littbarski SA, Kaltenborn A, Gwiasda J, Beneke J, Arelin V, Schwager Y, Stupak JV, Marcheel IL, Emmanouilidis N, Jäger MD, Scheumann GFW, Klempnauer J, Schrem H. Timing of parathyroidectomy in kidney transplant candidates with secondary hyperparathryroidism: effect of pretransplant versus early or late post-transplant parathyroidectomy. Surgery 2017; 163:373-380. [PMID: 29284591 DOI: 10.1016/j.surg.2017.10.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Revised: 08/28/2017] [Accepted: 10/11/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND The timing of parathyroidectomy in kidney transplant candidates suffering from secondary hyperparathyroidism before versus early or late after transplantation remains controversial. METHODS The short-term follow-up cohort comprised 66 patients with 1-year post-transplant follow-up, while the long-term follow-up cohort contained 123 patients. Risk-adjusted identification of independent risk factors for compromised renal graft function (KDIGO stage ≥ IV) was performed using multivariable regression analysis adjusted for propensity score logits for parathyroidectomy before versus after renal transplantation. Intra-individual matched-pairs analyses were used to identify significant effects of post-transplant parathyroidectomy on graft function as assessed by estimated glomerular filtration rate (eGFR) and paired t tests. RESULTS Donor kidney function KDIGO stage III (P = .030; OR = 5.191, 95% CI: 1.100-24.508), donor blood group 0 (P = .005; OR = 0.176, 95% CI: 0.048-0.642), and post-transplant parathyroidectomy (P = .032; OR = 17.849, 95% CI: 1.086-293.268) were revealed as independent significant risk factors for compromised renal graft function in the short-term follow-up cohort using propensity score risk adjustment while post-transplant parathyroidectomy had no independent influence in the long-term follow-up cohort (P = .651). Parathyroidectomy after renal transplantation compromised graft function early after parathyroidectomy and at last follow-up in all post-transplant parathyroidectomy cases (P ≤ .004). Parathyroidectomy within the first post-transplant year was associated with compromised renal graft function until last follow-up (P = .004), while parathyroidectomy late post-transplant was not. CONCLUSION Parathyroidectomy should be conducted before transplantation or, if this is not possible, preferably after the first post-transplant year.
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Affiliation(s)
- Simon A Littbarski
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Facility Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Alexander Kaltenborn
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Facility Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Jill Gwiasda
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Facility Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Jan Beneke
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Facility Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Viktor Arelin
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Facility Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany; Department of Nephrology, Hannover Medical School, Hannover, Germany
| | - Ysabell Schwager
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Facility Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Julia V Stupak
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Facility Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Indra L Marcheel
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Facility Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Nikos Emmanouilidis
- General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Mark D Jäger
- General, Visceral and Minimally Invasive Surgery, Municipal Hospital Wolfenbüttel, Hannover, Germany
| | | | - Jürgen Klempnauer
- General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Harald Schrem
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Facility Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany; General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany.
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Cammann S, Timrott K, Vondran FWR, Schrem H, Lehner F, Klempnauer J, Knitsch W, Kleine M. Early Tracheostomy Reduces Time of Mechanical Ventilation in Respiratory High-Risk Patients After Liver Transplant. EXP CLIN TRANSPLANT 2017; 16:631-634. [PMID: 29025380 DOI: 10.6002/ect.2017.0113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Weaning from mechanical ventilation after liver transplant can be demanding. In selected cases, tracheostomy is helpful. The optimal timing for tracheostomy in ventilator-dependent liver transplant recipients is not well known. MATERIALS AND METHODS We retrospectively analyzed data of 447 patients who had undergone liver transplant in our hospital. Thirty-nine patients who had high risk of prolonged mechanical ventilation according to the Respiratory Risk Score were identified from 95 patients who received tracheostomy after liver transplant. RESULTS When compared with tracheostomy performed > 3 days after transplant, early tracheostomy (≤ 3 days) had a higher likelihood of a brief duration of mechanical ventilation (62.5% vs 9.7%; P = .001). Accordingly, time spent in an intensive care unit was shorter with early tracheostomy. CONCLUSIONS This study provides a retrospective analysis of a small study cohort; therefore, validation of our findings requires a prospective randomized multicenter study on early tracheostomy in respiratory high-risk liver transplant recipients.
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Affiliation(s)
- Sebastian Cammann
- From the General, Visceral, and Transplant Surgery, Hannover Medical School, Hannover, Germany
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47
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Schrem H, Volz S, Koch HF, Gwiasda J, Kürsch P, Goldis A, Pöhnert D, Winny M, Klempnauer J, Kaltenborn A. Statistical approach to quality assessment in liver transplantation. Langenbecks Arch Surg 2017; 403:61-71. [DOI: 10.1007/s00423-017-1612-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 07/24/2017] [Indexed: 01/07/2023]
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48
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Cammann S, Oldhafer F, Ringe KI, Ramackers W, Timrott K, Kleine M, Klempnauer J, Lehner F, Bektas H, Vondran FWR. Use of the liver maximum function capacity test (LiMAx) for the management of liver resection in cirrhosis - A case of hypopharyngeal cancer liver metastasis. Int J Surg Case Rep 2017; 39:140-144. [PMID: 28841541 PMCID: PMC5568863 DOI: 10.1016/j.ijscr.2017.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 08/04/2017] [Accepted: 08/08/2017] [Indexed: 02/06/2023] Open
Abstract
A patient with a liver metastasis of pharyngeal cancer and aspect of severe cirrhosis is presented. Conventional laboratory tests are surrogate parameters and might underestimate cirrhosis. The LiMAx test provides a direct measurement of the liver function capacity even in cirrhosis. Safe resection was performed after LiMAx test proved operability.
Introduction The presence of liver cirrhosis goes along with a higher chance for the need of liver resection. As established laboratory parameters often underestimate the degree of cirrhosis this is associated with an increased risk for postoperative liver failure due to the preoperatively impaired liver function. Known liver function tests are unlikely to be performed in daily use because of high cost or expenditure of time. Liver maximum function capacity test (LiMAx) provides a novel tool for measurement of liver function and references for the safety of liver resection. Presentation of case A 63-year old patient presented at our hospital with a large, solitary liver metastasis from hypopharyngeal cancer in segments VII/VIII with infiltration of the diaphragm. Liver resection was unsuccessful in a peripheral hospital 10 months before due to considerable macroscopic liver cirrhosis (CHILD B). Upon presentation conventional laboratory parameters revealed sufficient liver function. LiMAx was performed and showed regular liver function (354 μg/kg/h; at norm >315 μg/kg/h). Consequently, atypical liver resection (R0) was performed resulting in a postoperative LiMAx value of 281 μg/h/kg (>150 μg/kg/h). The patient was discharged from hospital 37 days after surgery without any signs of postoperative liver failure. Conclusion The LiMAx-test enables determination of liver function at a so far unavailable level (metabolism via cytochrome P450 1A2) and hence might provide crucial additional diagnostic information to allow for safe liver resection even in cirrhotic patients.
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Affiliation(s)
- S Cammann
- Regenerative Medicine & Experimental Surgery (ReMediES), Department of General, Visceral and Transplant Surgery, Hannover Medical School, Germany.
| | - F Oldhafer
- Regenerative Medicine & Experimental Surgery (ReMediES), Department of General, Visceral and Transplant Surgery, Hannover Medical School, Germany
| | - K I Ringe
- Regenerative Medicine & Experimental Surgery (ReMediES), Department of General, Visceral and Transplant Surgery, Hannover Medical School, Germany
| | - W Ramackers
- Regenerative Medicine & Experimental Surgery (ReMediES), Department of General, Visceral and Transplant Surgery, Hannover Medical School, Germany
| | - K Timrott
- Regenerative Medicine & Experimental Surgery (ReMediES), Department of General, Visceral and Transplant Surgery, Hannover Medical School, Germany
| | - M Kleine
- Regenerative Medicine & Experimental Surgery (ReMediES), Department of General, Visceral and Transplant Surgery, Hannover Medical School, Germany
| | - J Klempnauer
- Regenerative Medicine & Experimental Surgery (ReMediES), Department of General, Visceral and Transplant Surgery, Hannover Medical School, Germany
| | - F Lehner
- Regenerative Medicine & Experimental Surgery (ReMediES), Department of General, Visceral and Transplant Surgery, Hannover Medical School, Germany
| | - H Bektas
- Regenerative Medicine & Experimental Surgery (ReMediES), Department of General, Visceral and Transplant Surgery, Hannover Medical School, Germany
| | - F W R Vondran
- Regenerative Medicine & Experimental Surgery (ReMediES), Department of General, Visceral and Transplant Surgery, Hannover Medical School, Germany
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Gwiasda J, Schrem H, Kaltenborn A, Mahlmann J, Mix H, Lehner F, Kayser N, Klempnauer J, Kulik U. Introduction of the resection severity index as independent risk factor limiting survival after resection of colorectal liver metastases. Surg Oncol 2017; 26:382-388. [PMID: 29113656 DOI: 10.1016/j.suronc.2017.08.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Indexed: 01/24/2023]
Abstract
BACKGROUND The purpose of this study is to evaluate the influence of the recently introduced resection severity index (RSI) in patients with liver resection for hepatocellular carcinoma on survival after resection of colorectal liver metastases. The RSI quantifies pre-operatively the liver cellular damage, liver synthetic function and loss of organ parenchyma. METHODS All consecutive patients who underwent liver resection for metastases of colorectal cancer (CLM) between 2000 and 2015 were included in this study. Risk factors limiting survival were analyzed using univariable and multivariable Cox regression analyses. RESULTS The median survival after liver resection for CLM was 3.0 years. Significant independent risk factors for mortality were the RSI (p = 0.029; hazard ratio (HR): 1.088, 95%-confidence interval (95%-CI): 1.009-1.174), age at resection in years (p = 0.001; HR: 1.017, 95%-CI: 1.007-1.027), pre-operative hemoglobin level (p = 0.041; HR: 0.932, 95%-CI: 0.891-0.997), the cecum as location of primary CRC (p < 0.001; HR: 2.023, 95%-CI: 1.403-2.833), adjuvant chemotherapy (p < 0.001; HR: 1.506, 95%-CI: 1.212-1.878), local relapse of the primary tumor (p = 0.027; HR: 1.591, 95%-CI: 1.057-2.297), the units of intra-operatively transfused packed red blood cells (p < 0.001; HR: 1.068, 95%-CI: 1.033-1.104), the size of the largest metastasis (p = 0.002; HR: 1.005, 95%-CI: 1.002-1.008) and the metastasis' distance to the resection margin (p = 0.014; HR: 0.984, 95%-CI: 0.972-0.997). CONCLUSION The RSI is an independent prognostic factor for survival after liver resection for CLM. Besides the extent of liver resection certain primary tumor characteristics have to be taken into account to ensure long-term survival.
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Affiliation(s)
- Jill Gwiasda
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Center-Transplantation (IFB-Tx), Hannover Medical School, Germany.
| | - Harald Schrem
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Center-Transplantation (IFB-Tx), Hannover Medical School, Germany; Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Alexander Kaltenborn
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Center-Transplantation (IFB-Tx), Hannover Medical School, Germany
| | - Jan Mahlmann
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Center-Transplantation (IFB-Tx), Hannover Medical School, Germany
| | - Heiko Mix
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Center-Transplantation (IFB-Tx), Hannover Medical School, Germany
| | - Frank Lehner
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Nicolas Kayser
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Center-Transplantation (IFB-Tx), Hannover Medical School, Germany
| | - Jürgen Klempnauer
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Ulf Kulik
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
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Kulik U, Lehner F, Klempnauer J, Borlak J. Primary non-function is frequently associated with fatty liver allografts and high mortality after re-transplantation. Liver Int 2017; 37:1219-1228. [PMID: 28267886 DOI: 10.1111/liv.13404] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [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: 12/28/2016] [Accepted: 02/27/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS The shortage of liver donations demands the use of suboptimal grafts with steatosis being a frequent finding. Although ≤30% macrovesicular steatosis is considered to be safe the risk for primary non-function (PNF) and outcome after re-transplantation (re-OLT) is unknown. METHODS Among 1205 orthotopic liver transplantations performed at our institution the frequency, survival and reason of re-OLT were evaluated. PNF (group A) cases and those with initial transplant function but subsequent need for re-OLT (group B) were analysed. Histopathology and clinical judgement determined the cause of PNF and included an assessment of hepatic steatosis. Additionally, survival of fatty liver allografts (group C) not requiring re-OLT was considered in Kaplan-Meier and multivariate regression analysis. RESULTS A total of 77 high urgency re-OLTs were identified and included 39 PNF cases. Nearly 70% of PNF cases were due to primary fatty liver allografts. The 3-month in-hospital mortality for PNF cases after re-OLT was 46% and the mean survival after re-OLT was 0.5 years as compared to 5.2 and 5.1 years for group B, C, respectively, (P<.008). In multivariate Cox regression analysis only hepatic steatosis was associated with an inferior survival (HR 4.272, P=.002). The MELD score, donor BMI, age, cold ischaemic time, ICU stay, serum sodium and transaminases did not influence overall survival. CONCLUSIONS Our study highlights fatty liver allografts to be a major cause for PNF with excessive mortality after re-transplantation. The findings demand the development of new methods to predict risk for PNF of fatty liver allografts.
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Affiliation(s)
- Ulf Kulik
- Department of General-, Visceral- and Transplantation Surgery, Hannover, Germany
| | - Frank Lehner
- Department of General-, Visceral- and Transplantation Surgery, Hannover, Germany
| | - Jürgen Klempnauer
- Department of General-, Visceral- and Transplantation Surgery, Hannover, Germany
| | - Jürgen Borlak
- Centre for Pharmacology and Toxicology, Hannover Medical School, Hannover, Germany
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