Impact of sex on the outcomes of deceased donor liver transplantation.

BACKGROUND: Data examining the impact of sex on liver transplant (LT) outcomes are limited. It is clear that further research into sex-related differences in transplant patients is necessary to identify areas for improvement. Elucidation of these differences may help to identify specific areas of focus to improve on the organ matching process, as well as the peri- and post-operative care of these patients. AIM: To utilize data from a high-volume Eurotransplant center to compare characteristics of male and female patients undergoing liver transplant and assess asso ciation between sex-specific variables with short- and long-term post-transplant outcomes. METHODS: A retrospective review of the University of Essen's transplant database was performed with collection of baseline patient characteristics, transplant-related data, and short-term outcomes. Comparisons of these data were made with Shapiro-Wilk, Mann-Whitney U, χ2 and Bonferroni tests applied where app ropriate. A P value of < 0.05 was accepted as statistically significant. RESULTS: Of the total 779 LT recipients, 261 (33.5%) were female. Female patients suffered higher incidences of acute liver failure and lower incidences of alcohol-related or viremic liver disease (P = 0.001). Female patients were more likely to have received an organ from a female donor with a higher donor risk index score, and as a high urgency offer (all P < 0.05). Baseline characteristics of male and female recipients were also significantly different. In multivariate hazard regression analysis, recipient lab-Model for End-Stage Liver Disease score and donor cause of death were associated with long-term outcomes in females. Pre-operative diagnosis of hepatocellular carcinoma, age at time of listing, duration of surgery, and units transfused during surgery, were associated with long-term outcomes in males. Severity of complications was associated with long-term outcomes in both groups. Overall survival was similar in both males and females; however, when stratified by age, females < 50 years of age had the best survival. CONCLUSION: Female and male LT recipients have different baseline and transplant-related characteristics, with sex-specific variables which are associated with long-term outcomes. Female recipients < 50 years of age demonstrated the best long-term outcomes. Pre- and post-transplant practices should be individualized based on sex-specific variables to optimize long-term outcomes.

Factors Associated With Growth After Deceased and Live Donor Pediatric Liver Transplantation.

BACKGROUND: There are limited data on predictors of growth after pediatric liver transplantation. METHODS: We reviewed the impact of graft type, ethnicity, and biliary complications (BC) on growth after pediatric liver transplantation (LT). We compared preoperative and 6-, 12-, and 24-month weight, height, and body mass index (BMI) percentiles between living donor (LD), deceased donor full-size (DD-full), and deceased donor split (DD-split) graft recipients. We also compared length of stay (LOS) between groups. RESULTS: We had 98 patients (DD-split: 32; DD-full: 43, LD: 23). The Median Pediatric End-stage Liver Disease (PELD) scores, exception points, albumin, bilirubin, failure to thrive, and presence of ascites were similar among groups. The DD-full group had the lowest preoperative percentiles in all categories and exceeded these at 24 months. The DD-split group was at preoperative percentiles at 24 months. The LD group had parallel weight curves compared to the DD-full group and exceeded only the preoperative weight percentile at 24 months. Black patients had the lowest percentiles in all categories (P < .01). The BC group caught up weight and BMI percentile at 24 months but had persistent decrease in height percentiles. Patients without BC exceeded preoperative height percentiles. The longer LOS group had lower height and BMI percentiles at 24 months; however, there was no statistical difference. CONCLUSION: DD-full and black patients seem to benefit the most from LT in terms of growth. BC seems to affect height percentiles. Patients with longer LOS had lower height and BMI percentiles (P>.05). Longer follow up and larger cohorts are necessary to improve the power of these findings.

Comparison of glycemic control after pancreas transplantation for Type 1 and Type 2 diabetic recipients at a high volume center.

INTRODUCTION: The number of pancreas transplants (PTX) in patients with Type 2 diabetes (T2DM) has increased in response to excellent outcomes in appropriately selected patients. Not all pancreas transplant centers share an enthusiasm for performing PTX for T2DM out of concern for increased complication rates. This study aims to clarify the characteristics of T2DM recipients with successful outcomes to clarify which candidates are more suitable for PTX as means of maximizing access to this highly effective therapy for Type 2 patients. METHODS & RESULTS: At MedStar Georgetown Transplant Institute, 50 patients underwent pancreas transplant between 2013 and 2016. Based on patient characteristics, 38 (78%) were categorized as T1DM, and 11 (22%) were considered T2DM. One case was excluded due to early graft loss. The estimated age of diabetes onset was significantly different between T1DM and T2DM cohorts (13 years vs. 29 years, P < .001). T2DM patients had significantly higher preoperative C-peptide levels (4.11 vs. 0.05, P < .001). Preoperative HbA1c, preoperative Body Mass Index (BMI), number of diabetic complications, and hemodialysis status were similar between both groups. At 2-year follow-up, there was no statistical difference in glycemic control between the two groups (T1DM vs. T2DM). Infectious complications and readmission rates were similar. Other trends that did not meet statistical significance included T1DM group with a slightly higher mortality and re-intervention rate. The T2DM group demonstrated higher BMI, higher rejection rates, and higher short-term postoperative insulin requirements. Graft survival was 95% and 82% for T1 and T2DM at 2 years post-transplant, respectively. CONCLUSION: Successful PTX in T1DM and T2DM recipient groups resulted in comparable glycemic control at 2-year post-transplant follow-up. T2DM group had a trend toward higher BMI as well as higher rates of rejection, temporary insulin requirement and graft failure, although none of these trends reached statistical significance. These results suggest that strict classification of T1 and T2DM by itself may not be relevant to achieving excellent outcomes in pancreas transplantation and, therefore, patient selection for PTX should not be based primarily on this classification.

Transplant nephrectomy with peritoneal window: Georgetown University experience.

OBJECTIVES: Transplant nephrectomy is a technically challenging procedure with high complication rates. Morbidity and mortality are mostly due to hemorrhage or infection and are reported to be 17-60% and 1-39%, respectively. The most common surgical technique for transplant nephrectomy is sub-capsular, extraperitoneal approach which may result in fluid accumulation and subsequent super-infection. We report that intraperitoneal approach, after assuring hemostasis of the transplant pedicle, allows for passive drainage, decreases hematoma formation and minimizes the subsequent infection risk in the nephrectomy bed. MATERIAL AND METHODS: From July 2009 to July 2014 a total of 38 transplant nephrectomies were performed using the intraperitoneal window technique at Georgetown University MedStar Transplant Institute (MGTI). Data was collected retrospectively. RESULTS: Average age at the time of transplant nephrectomy was 43.9 ± 14.3, and the majority were male (55.3%). Mean time to nephrectomy was 71.7 ± 67.4 months following transplantation. Indications for nephrectomy included pain, hematuria, fever, and recalcitrant rejection. Average operative time was 97.1 ± 28.9 minutes, average blood loss was 172.5 ± 213.6 mL. A total of 9 (24%) complications occurred. Postoperative blood transfusion was the most common complication (15.7%) followed by 2 (5.3%) re-interventions; one take back for hematoma and one percutaneous drain placement for symptomatic fluid collection. We had no infection, postoperative sepsis, ICU admissions, or mortality. CONCLUSION: Transplant nephrectomy with peritoneal window is a technique with better results compared to the literature. An opening between the transplant cavity and the peritoneum allows for passive drainage of fluid and minimizes the risk of hematoma and abscess formation. This approach does not add significant time to the operation, furthermore it may decrease morbidity and mortality by reducing overall complications, namely hematoma formation and infection, which overall decreases rates of re-interventions and length of hospital stay.