Incidence of and Risk Factors for Multiple Readmissions after Kidney Transplantation.

Unplanned readmission is often used as a surgical quality metric. A subset of kidney transplant recipients undergos multiple readmissions (MRs), although the incidence and risk factors are not well described. The aim of this study was to evaluate risk factors for MR after deceased donor kidney transplantation. All patients undergoing deceased donor kidney transplantation at a single center over a three-year period were analyzed via retrospective chart review for factors associated with MR. P values <0.05 were considered significant. Of 141 patients, the 30-day readmission rate was 26.2 per cent. MR occurred in 43 (30.5%) patients. Age, race, gender, initial organ function, and dialysis vintage were not associated with MR. Diabetic recipients, those who received basiliximab induction, those with acute rejection, and those with unplanned reoperations were at increased risk for MR. Infection was the most common reason for initial readmission in patients with MR (23.3%). One-year patient survival and death-censored graft survival were reduced for patients with MR. MRs are required for 30 per cent of kidney transplant recipients, primarily because of infection and immunologic causes. Recipients with diabetes and those who have acute rejection are at greatest risk.

Regional Variation in Appropriateness of Non-Hepatocellular Carcinoma Model for End-Stage Liver Disease Exception.

BACKGROUND: Patients thought to be at greater risk of liver waitlist dropout than their laboratory Model for End-Stage Liver Disease (lMELD) score reflects are commonly given MELD exceptions, where a higher allocation MELD (aMELD) score is assigned that is thought to reflect the patient's risk. This study was undertaken to determine whether exceptions for reasons other than hepatocellular carcinoma (HCC) are justified, and whether exception aMELD scores appropriately estimate risk. METHODS: Adult primary liver transplantation candidates listed in the current era of liver allocation in the United Network for Organ Sharing database were analyzed. Patients granted non-HCC-related MELD exceptions and those without MELD exceptions were compared. Rates of waitlist dropout and liver transplantation were analyzed using cause-specific hazards regression, with separate models fitted to adjust for lMELD and aMELD. RESULTS: There were 29,243 patients, with 2,555 in the exception group. Nationally, exception patients were more likely to dropout (hazard ratio [HR] 1.60; 95% CI, 1.45 to 1.76; p < 0.001) or undergo liver transplantation (HR 3.49; 95% CI, 3.32 to 3.67; p < 0.001) than their lMELD-adjusted counterparts. Adjusting for aMELD, exception patients were less likely to dropout (HR 0.77; 95% CI, 0.70 to 0.85; p < 0.001) and less likely to undergo liver transplantation (HR 0.76; 95% CI, 0.72 to 0.80; p < 0.001). Exception patients were not at significantly increased risk of waitlist dropout when adjusted for lMELD in 4 of 11 United Network for Organ Sharing regions. CONCLUSIONS: Despite appropriate use of non-HCC MELD exceptions on a national level, patients with non-HCC MELD exceptions were awarded inappropriately high priority for transplantation in many regions. This highlights the need to consider local conditions faced by transplantation candidates when estimating waitlist mortality and determining priority for transplantation.

Impact of Donor Hepatitis C Virus on Kidney Transplant Outcomes for Hepatitis C-positive Recipients in the Direct-acting Antiviral Era: Time to Revise the Kidney Donor Risk Index?

BACKGROUND: Kidneys from donors with hepatitis C virus (HCV) infection are traditionally considered to be at risk for poorer survival outcomes, as reflected in the kidney donor profile index (KDPI). Modern direct-acting antivirals may modify this risk. METHODS: Using United Network for Organ Sharing data, HCV-infected adult first-time kidney transplant recipients from 2014 to 2017 were examined. Graft and patient survival were compared in a propensity-matched cohort of recipients of HCV antibody (Ab)(+) kidneys versus Ab(-) kidneys. Subsequent analysis was performed in a propensity-matched cohort of recipients of HCV-viremic (RNA positive) versus HCV-naïve kidneys. RESULTS: There were 379 recipients each in the matched cohort of recipients of HCV Ab(+) versus HCV Ab(-) kidneys. Despite a higher KDPI (58.2% for HCV Ab[+] versus 38.8% for HCV Ab[-]), 1-year patient and graft survival were similar in the HCV(+) and HCV(-) groups (95.4% and 94.9% versus 97.9% and 96.0%, P = 0.543 and P = 0.834, respectively). There were 200 recipients each in the cohort of recipients of HCV-viremic versus HCV-naïve kidneys, with the KDPI again higher in the HCV-viremic group (56.8% versus 35.2%). Baseline hazard ratios (HRs) for graft failure (HR, 4.69; P = 0.009) and death (HR, 7.60; P = 0.003) were significantly elevated in the viremic group, but crossed 1 at 21 and 24 months, respectively. CONCLUSIONS: In the modern direct-acting antiviral era, calculated likely KDPI overestimates risk kidneys from HCV (+) donors. Donor viremia conveys an early risk which appears to subside over time. These results suggest that it may be time to revise the kidney donor risk index.

Patterns of geographic variability in mortality and eligible deaths between organ procurement organizations.

Eligible deaths are currently used as the denominator of the donor conversion ratio to mitigate the effect of varying mortality patterns in the populations served by different organ procurement organizations (OPOs). Eligible death is an OPO-reported metric rather than a product of formal epidemiological analysis, however, and may be confounded with OPO performance. Using Scientific Registry of Transplant Recipients and Centers for Disease Control and Prevention data, patterns of mortality and eligible deaths within each OPO were analyzed with the use of formal geostatistical analysis to determine whether eligible deaths truly reflect the geographic patterns they are intended to mitigate. There was a 2.1-fold difference in mortality between the OPOs with the highest and lowest rates, with significant positive spatial autocorrelation evident in mortality rates (Moran I = .110; P < .001), meaning geographically proximate OPOs tended to have similar mortality rates. The eligible death ratio demonstrated greater variability, with a 4.5-fold difference between the OPOs with the highest and lowest rates. Contrary to the pattern of mortality rates, the geographic distribution of eligible deaths among OPOs was random (Moran I = -.002; P = .410). This finding suggests geographic patterns do not play a significant role in eligible deaths, thus questioning its continuing use in OPO performance comparisons.

A Tale of Two Kidneys: Differences in Graft Survival for Kidneys Allocated to Simultaneous Liver Kidney Transplant Compared with Contralateral Kidney from the Same Donor.

BACKGROUND: Renal graft lifespan in simultaneous liver kidney transplant (SLK) is generally thought to be shorter than in kidney transplant (KT) alone, raising questions about the utility of SLK. This study aims to estimate what the outcomes would be for a kidney allocated to SLK if it were allocated to KT instead. METHODS: Using United Network for Organ Sharing data, recipients of SLK from 2003 to 2012 were paired with the recipient who received the partner kidney from the same donor in a kidney or kidney pancreas transplant for analysis. The primary outcomes were long-term patient and renal graft survival. This was investigated using modified multivariable Cox regression, which allowed for changes in the hazard ratio (HR) associated with SLK over time (non-proportional hazards), accounted for the paired nature of the study, and adjusted for differences in recipient characteristics. RESULTS: There were 3,721 recipients in each group. Ninety-day mortality was 8.0% for SLK vs 1.9% for KT recipients (p < 0.001). Median unadjusted renal graft survival was 11 years for the SLK group vs 10.5 years for KT (p < 0.001). The baseline adjusted HRs for death and renal graft loss associated with SLK were 3.03 and 2.05. These HRs became equal to 1 at 6.5 years for death and 5 years for renal graft loss. The HRs for death and renal graft loss associated with SLK at 10 years were 0.55 and 0.50. CONCLUSIONS: Although kidneys allocated to SLK vs KT demonstrate worse short-term survival, this risk appears to be reversed when follow-up is extended long-term.

Operative Considerations for the General Surgeon in Patients with Chronic Liver Disease.

Chronic liver disease remains a prevalent and challenging comorbidity in the American population at large. Scarring and fibrosis cause physical and physiological changes that may prove challenging in both medical and surgical management. However, because there has been relevant improvements in preoperative diagnostic, perioperative hepatologic, and intensive care management, as well as in surgical techniques, patients with cirrhosis can safely be operated on but patient selection remains vital. Patients with chronic liver disease may present to a general surgeon for evaluation of a number of elective or emergent surgical conditions. Here, we review current literature on the perioperative management and operative strategies of seemingly routine general surgery issues and provide a review of the pathophysiology associated with chronic liver disease.

Does Distance to Transplant Center Affect Post Kidney Transplant Readmission Rates?

Many transplant recipients travel long distances to their transplant center with challenging access to their transplant team. As such, many centers keep recipients near to the center for a period immediately after discharge from the transplant admission. Thus far, the correlation between distance to the transplant center, readmission, and outcomes has not been described. The aim of this study was to examine this relationship. Patients undergoing deceased donor kidney transplant at a single center over a three-year period were analyzed via retrospective chart review for factors associated with distance to the transplant center and readmission. P values < 0.05 were considered significant. Of 141 patients, the overall 90-day readmission rate was 38.3 per cent, and rates were similar between nonlocal and local recipients. Nonlocal were more likely whites (66.1% vs 45.6%; P = 0.032) and from rural areas (56.5% vs 13.9%; P < 0.001). Length of stay was similar between groups, as were rates of delayed graft function. Non-death-censored graft survival was higher at one and three years for nonlocal patients (96.8% and 96.8% vs 89.7% and 78.4%; P = 0.016). This remained significant after adjusting for baseline differences between the groups (hazard ratio (HR) for graft failure = 0.195, 95%, P = 0.046). Patients who live remotely from the transplant center do not experience higher rates of readmission or worsened outcomes, and thus may be managed safely at home. Interestingly, graft survival is improved in nonlocal patients. This may reflect the urban nature of the area surrounding our transplant center, but warrants further study for conclusions to be reached.

Effect of Renal Diagnosis on Survival in Simultaneous Liver-Kidney Transplantation.

BACKGROUND: Simultaneous liver-kidney transplantation is lifesaving, however, the utility of allocating 2 organs to a single recipient remains controversial, particularly in the face of potentially inferior survival. This study aims to determine the effect of renal indication for transplantation on simultaneous liver-kidney transplantation outcomes. METHODS: All adult recipients of combined whole liver-kidney transplants in the United Network for Organ Sharing database from 2003 to 2016 with a renal diagnosis of hypertension (HTN), diabetes mellitus (DM), acute tubular necrosis (ATN), or hepatorenal syndrome (HRS) were examined. Comparisons were made between the HTN/DM group and the ATN/HRS group using standard statistical methods. RESULTS: There were 1,204 patients in the HRS/ATN group vs 1,272 patients in the HTN/DM group. The HTN/DM patients were slightly older (58.1 vs 56.4 years; p < 0.001), more likely to have liver disease due to chronic viral hepatitis (33.2% vs 21.5%; p < 0.001), and less acutely ill (mean Model for End-Stage Liver Disease score of 27.2 vs 33.1; p < 0.001) than their HRS/ATN counterparts. The prevalence of nonalcoholic steatohepatitis was 16.8% in both groups. Donor demographics were similar in both groups, although HTN/DM patients were more likely to have a local (81.6% vs 67.7%; p < 0.001) rather than regional donor. Patient survival rates at 1, 3, and 5 years were significantly lower in the HTN/DM group (87.4%, 78.2%, and 71.2% vs 90.7%, 84.1%, and 76.6%, respectively). Median survival was 118 months for the HTN/DM group vs 139.7 months for the HRS/ATN (p < 0.001). The HTN/DM patients were at significantly higher risk of death (hazard ratio 1.533; p < 0.001), liver graft loss (hazard ratio 1.611; p < 0.001), and renal graft loss (hazard ratio 1.592; p < 0.001) than ATN/HRS patients on multivariable analysis. CONCLUSIONS: Despite a lower acuity of illness, HTN/DM patients have inferior survival after simultaneous liver-kidney transplantation than those with ATN/HRS. This should be considered in risk adjustment and allocation schemes.

Correlation of Biliary Colic in the Absence of Cholelithiasis with Pancreaticobiliary Obstruction.

A small fraction of patients undergoing cholecystectomy for biliary colic are subsequently diagnosed with an obstructive pancreatic head mass. We review our experience with such patients to provide insight into improving evaluation before cholecystectomy. Retrospective chart review of patients undergoing cholecystectomy from 2004 to 2015 identified six patients who underwent laparoscopic cholecystectomy for biliary colic before being diagnosed with a pancreatic head neoplasm within six months after cholecystectomy. Charts were analyzed for presenting symptoms, evaluation before and after cholecystectomy, and operative findings. Patients ranged from 50 to 72 years of age and included five males and one female. None had evidence of cholelithiasis or acute cholecystitis on initial evaluation. Median time from cholecystectomy to diagnosis of pancreatic head mass was two months (range 1-5 months). Two patients eventually underwent pancreaticoduodenectomy. Patients with symptoms of biliary colic in the absence of evidence of cholecystitis or choledochal abnormality should undergo intraoperative cholangiogram at the time of cholecystectomy as well as close clinical follow-up to ensure resolution of symptoms. Abnormalities of either should prompt radiographic evaluation focused on identification of a pancreatic mass causing extrinsic compression of the bile duct.

The role of FDG-PET in detecting rejection after liver transplantation.

BACKGROUND: The activation and increased metabolic activity of T cells in acute cellular rejection could allow fluoro-2-deoxyglucose positron emission tomography to be utilized for detection of acute cellular rejection. The objective of this study was to evaluate the effectiveness of fluoro-2-deoxyglucose positron emission tomography in detecting acute cellular rejection in the clinical setting. METHODS: Fluoro-2-deoxyglucose positron emission tomography studies were performed on 88 orthotopic liver transplant patients at 7 and 17 days postoperatively (first positron emission tomography and second positron emission tomography, respectively). Additional studies were performed if patients had suspicion of rejection and at resolution of rejection (third positron emission tomography and fourth positron emission tomography, respectively). A circular region of interest was placed over the liver for semiquantitative evaluation of fluoro-2-deoxyglucose positron emission tomography images by means of standard uptake values. RESULTS: Eighteen of 88 patients in our study (20.5%) had histologically proven acute cellular rejection during a 16 ± 11 day follow-up. There was no significant difference between the standard uptake values of first positron emission tomography among non-rejecters versus rejecters (2.05 ±0.46 non-rejecters versus 1.82 ± 0.40 rejecters, P = .127). Within the rejection cohort, the standard uptake values from the third positron emission tomography (rejection) were higher compared to the first positron emission tomography (baseline) (2.41 ± 0.48 third positron emission tomography versus 1.82 ± 0.41 first positron emission tomography, P < .001). CONCLUSION: Increased signal on fluoro-2-deoxyglucose positron emission tomography over baseline is associated with acute cellular rejection in liver transplant recipients. Additional prospective validation studies are essential to define the role of fluoro-2-deoxyglucose positron emission tomography scan as an early marker for acute cellular rejection.

Simeprevir and sofosbuvir with or without ribavirin to treat recurrent genotype 1 hepatitis C virus infection after orthotopic liver transplantation.

Although combination simeprevir (SIM) plus sofosbuvir (SOF) is an approved regimen for genotype 1 chronic hepatitis C virus (HCV), data regarding its safety and efficacy in liver transplant recipients remain limited. A multicenter retrospective study was performed to determine the efficacy and tolerability of a 12-week regimen of SIM/SOF with or without ribavirin (RBV) in 56 consecutive liver transplant recipients in 2014; 79% of patients had genotype 1a, 14% had cirrhosis, and 73% were treatment experienced. Sustained virological response at 12 weeks (SVR12) was 88% by intention to treat analysis (95% confidence interval, 84%-90%). Four patients relapsed, but no on-treatment virological failures occurred. The Q80K polymorphism did not impact SVR12, but there was a trend toward decreased sustained virological response with advanced fibrosis (P = 0.18). HCV RNA was detectable at treatment week 4 in 21% of patients, and those who had detectable levels were less likely to achieve SVR12 (58% versus 95%; P = 0.003). Five patients had baseline Child-Pugh class B cirrhosis, and 2 of them died (1 following early discontinuation of therapy). An additional discontinuation resulted from a severe photosensitivity reaction in a patient on concomitant cyclosporine. Seven patients receiving RBV developed progressive anemia requiring intervention. Immunosuppression dose modifications were minimal. SIM/SOF for 12 weeks was effective and well tolerated by compensated liver transplant recipients especially when administered without concomitant RBV or cyclosporine. SIM/SOF appears to have a niche as the only 12-week RBV-free treatment regimen currently recommended by guidelines for compensated transplant recipients. However, 12 weeks may not be the optimal duration of therapy for those with detectable virus at week 4 or possibly for those with cirrhosis. These data require confirmation by prospective randomized clinical trials. Liver Transplantation 22 635-643 2016 AASLD.

Machine perfusion: not just for marginal kidney donors.

Interest in machine perfusion (MP) for donated kidneys has markedly increased in the past decade as a means to improve graft function, although the donor populations in which it should be applied have not yet been resolved. All adults undergoing de-novo isolated kidney transplantation from standard-criteria donors in the UNOS database 2005 to 2011 were reviewed with the primary endpoint of delayed graft function (DGF), defined as dialysis within seven days of transplantation, in those who received kidneys that underwent MP versus cold storage (CS) alone. Three methods were used to control for differences between groups. Multivariable logistic regression was performed, adjusting for donor and recipient characteristics significantly associated with DGF. Rates were also compared in a cohort of propensity-matched MP vs CS recipients. Finally, a paired-kidney study was performed, where one kidney underwent MP and the contralateral underwent CS. There were 36,323 patients, with unadjusted DGF rates of 18.6 per cent (n = 1830/9882) and 22.4 per cent (n = 5931/26,441; P < 0.001) in the MP vs CS groups, respectively. After multivariable analysis, the odds ratio for DGF in the MP group was 0.59 (P < 0.001) versus CS. In the propensity-matched cohort, there were 8929 patients each in the MP and CS groups. DGF occurred in 16.8 per cent of the MP group vs 25.3 per cent with CS (P < 0.001, OR 0.59). In the paired-kidney study, rates of DGF were 16.7 per cent vs 24.3 per cent (P < 0.001) in the 1665 recipients each in the MP versus CS groups (OR 0.6). In conclusion, machine perfusion is beneficial in reducing DGF even when standard donors are utilized, and thus should not be limited to marginal kidneys.

Principles of surgical treatment of malignant melanoma.

Although melanoma represents less than 5% of all skin cancers, it is responsible for the bulk of skin cancer-related deaths. Nevertheless, despite this aggressive reputation, most patients with cutaneous melanoma will be surgically cured of their disease. Early detection allows for curative resection, and 5-year survival for all stages of melanoma is 91%. This review outlines the surgical treatment of melanoma, including principles of wide local excision and management of the regional lymph nodes.

Factors predictive of readmission after hepatic resection for hepatocellular carcinoma.

BACKGROUND: Hepatic resection is associated with substantial morbidity and resource use. To contain costs and improve outcomes, recent health care regulations focus on reducing hospital readmissions while using readmission rates as a quality measure. The goal of this investigation was to characterize the incidence, patterns, and risk factors for readmission after resection for hepatocellular carcinoma. STUDY DESIGN: Patient demographics, operative factors, and perioperative outcomes of 245 patients undergoing hepatic resection at an academic center from 2000 to 2012 were reviewed retrospectively. Factors associated for readmission within 90 days of operation were identified through univariate and multivariate logistic regression analysis. RESULTS: Forty-six patients (18.7%) required hospital readmission. Univariate analysis identified American Society of Anesthesiologists class, preoperative Model for End-stage Liver Disease score and total bilirubin, preexisting vascular disease, acute renal failure, bile leak, peak postoperative total bilirubin, and intraabdominal infection as factors associated with readmission. Intraabdominal infection, postoperative renal failure, and a history of vascular disease were found to be significant on multivariate analysis. Overall, intraabdominal infection was the strongest predictor for readmission. CONCLUSION: Early readmission after hepatectomy remains relatively common. Postoperative complications and patient comorbidities are the dominant factors in readmission, and we must be mindful of those patients at increased risk for readmission.

Catastrophic gastrointestinal injury due to battery acid ingestion.

BACKGROUND: Acids account for 20% of all chemical exposures through various routes. Caustic acids such as hydrochloric and sulfuric acid are common ingredients in many household and industrial products. Due to the corrosive properties of these substances, tissue injury caused by oral exposure can lead to severe esophageal and gastrointestinal burns. CASE REPORT: We report a case of a patient presenting with severe acidosis, who required multiple laparoscopic evaluations to assess various gastrointestinal tract injuries and who ultimately underwent total gastrectomy. The diagnosis was made primarily based on the arterial blood gas and esophagogastroduodenoscopy findings, as well as the pathological examinations of various biopsied and resected tissues showing hemorrhagic necrosis of the esophagus, stomach, and small bowel. This patient eventually admitted to having ingested an unspecified amount of battery acid. CONCLUSIONS: Collaborative efforts by Emergency Medicine, Pathology, and General Surgery services are required for timely diagnosis, treatment, and management of patients after caustic acid exposures.

Aggressive operative treatment for emetogenic rupture yields superior results.

The treatment of emetogenic rupture remained controversial and was particularly so when the patient arrived for definitive care greater than 24 hours postrupture. We treated patients with continued extravasation of contrast from the esophagus by early operation regardless of the timing of their presentation. All primary repairs received a reinforced closure and many delayed repairs had an onlay flap for closure of the leak. We treated 31 patients with emetogenic rupture; 24 of 25 patients with extravasation had operative repair, whereas six with small, contained ruptures were treated medically. Twelve were operated on within 24 hours, whereas 24 presented from 36 to 796 hours postrupture. We were able to achieve closure of the defect by primary suture repair or with a tissue flap in all patients. There were no postoperative leaks. One patient each died in the operated group and observed group. There were minimal complications and a relatively short hospital stay. Our results support the use of aggressive operative treatment for emetogenic rupture regardless of the timing of patient presentation. Such treatment preserved esophageal function and was accomplished with relatively low morbidity and mortality.