Bile Spillage as a Prognostic Factor for Gall Bladder Cancer: A Systematic Review and Meta-analysis.

INTRODUCTION: Biliary spillage (BS) is a common complication following initial cholecystectomy for gall bladder cancer (GBC). Few studies have explored the importance of BS as a long-term prognostic factor. We perform a meta-analysis of the association between BS and survival in GBC. METHODS: A systematic literature search was performed in February 2023. Studies evaluating the incidence of BS and its association with long-term outcomes in patients undergoing initial laparoscopic or open cholecystectomy for either incidental or resectable GBC were included. Overall survival (OS), disease-free survival (DFS), and rate of peritoneal carcinomatosis (RPC) were the primary end points. Forest plot analyses were used to calculate the pooled hazard ratios (HRs) of OS, DFS, and RPC. Metaregression was used to evaluate study-level association between BS and perioperative risk factors. RESULTS: Of 181 published articles, 11 met inclusion criteria with a sample size of 1116 patients. The rate of BS ranged between 9% and 67%. On pooled analysis, BS was associated with worse OS (HR = 1.68, 95% confidence interval [CI] = 1.32-2.14), DFS (pooled HR= 2.19, 95% CI = 1.30-3.68), and higher RPC (odds ratio = 9.37, 95% CI = 3.49-25.2). The rate of BS was not associated with higher T stage, lymph node metastasis, higher grade, positive margin status, reresection, or conversion rates. CONCLUSIONS: Our meta-analysis shows that BS is a predictor of higher peritoneal recurrence and poor survival in GBC. BS was not associated with tumor characteristics or conversion rates. Further research is needed to identify other potential risk factors for BS and investigate the ideal treatment schedule to improve survival.

Collaborative Approach Toward Transplant Candidacy for Obese Patients with End-Stage Renal Disease.

BACKGROUND: An elevated BMI is a major cause of transplant preclusion for patients with end-stage renal disease (ESRD). This phenomenon exacerbates existing socioeconomic and racial disparities and increases the economic burden of maintaining patients on dialysis. Metabolic bariatric surgery (MBS) in such patients is not widely available. Our center created a collaborative program to undergo weight loss surgery before obtaining a kidney transplant. STUDY DESIGN: We studied the outcomes of these patients after MBS and transplant surgery. One hundred eighty-three patients with ESRD were referred to the bariatric team by the transplant team between January 2019 and June 2023. Of these, 36 patients underwent MBS (20 underwent Roux-en-Y gastric bypass and 16 underwent sleeve gastrectomy), and 10 underwent subsequent transplantation, with another 15 currently waitlisted. Both surgical teams shared resources, including dieticians, social workers, and a common database, for easy transition between teams. RESULTS: The mean starting BMI for all referrals was 46.4 kg/m 2 and was 33.9 kg/m 2 at the time of transplant. The average number of hypertension medications decreased from 2 (range 2 to 4) presurgery to 1 (range 1 to 3) postsurgery. Similarly, hemoglobin A1C levels improved, with preoperative averages at 6.2 (range 5.4 to 7.6) and postoperative levels at 5.2 (range 4.6 to 5.8) All transplants are currently functioning, with a median creatinine of 1.5 (1.2 to 1.6) mg/dL (glomerular filtration rate 46 [36.3 to 71]). CONCLUSIONS: A collaborative approach between bariatric and transplant surgery teams offers a pathway toward transplant for obese ESRD patients and potentially alleviates existing healthcare disparities. ESRD patients who undergo MBS have unique complications to be aware of. The improvement in comorbidities may lead to superior posttransplant outcomes.

Balancing Waitlist Dropout in Pancreas Transplantation.

BACKGROUND: The time a patient spends on the waiting list for a Simultaneous Pancreas-Kidney (SPK) transplant depends on several donor and recipient-specific factors. The average wait-list time for SPK in the United States has been about 1 to 3 years, significantly shorter than the average wait time for kidney-only transplantation. A single-center retrospective analysis of SPK waitlisted candidates was performed to determine the implication of wait-list time on dropout from the wait-list due to death or poor health. METHODS: We analyzed all deceased donor Simultaneous Pancreas-Kidney wait-listed candidates between Jan 1994 and June 2021. Waitlisted candidates who got transplanted (TG) were compared to those who dropped out from the wait list due to death or poor health (DPHG). RESULTS: In the study period, 297 candidates were waitlisted for SPK transplants. Eight candidates were removed, as transplantation was not needed due to improvement in health while on the waiting list. Fourteen wait-listed candidates transferred to another center were also excluded from the study group. Two hundred and thirty wait-listed candidates were transplanted (TG). Forty-five patients were delisted due to death or poor health (DPHG). The mean body mass index of candidates in TG and DPHG were 25.1 and 24.9, respectively. The mean age at dropout in DPHG was 40.7, similar to the mean age at transplant in TG (39.4). The mean age of diabetes onset was slightly lower in TG (17.4) compared to 20.02 in DPHG. The mean days spent by the candidates on the waitlist in DPHG were significantly higher than those in TG (821 days vs 252 days). Eight of the 45 patients (17.7%) in DPHG had 1 or more organ transplants before listing compared to 1 of 230 patients (0.43%) in TG. Despite low wait times for SPK transplants, increased wait times can account for a dropout from the waitlist due to death or poor health. Centers should exercise caution in wait listing SPK candidates with prior organ transplants.

Laparoscopic Living Donor Nephrectomy: A Single Center Comparison of Three Different Techniques.

Background and Objectives: In this study, we compare three different surgical approaches at a single institution. Pure laparoscopic donor nephrectomy with Pfannenstiel incision (PLDN) was compared with hand-assisted laparoscopic donor nephrectomy via midline hand port (HALDNM) and hand-assisted laparoscopic donor nephrectomy via left iliac hand port (HALDNL). Methods: This study included all laparoscopic left donor nephrectomies performed at our institution between January 1, 2020 and December 31, 2021. Donor characteristics including age, sex, body mass index, number of renal arteries, duration of surgical procedure, warm ischemia time (WIT), and length of hospital stay were compared. Cosmetic scores were calculated by totaling the length of all incisions placed. Postoperative complications within 90 days were compared. Results: During the study period 71 laparoscopic donor nephrectomies were performed of which 26 were HALDNM, 24 were HALDNL, and 21 were PLDN. Donor characteristics were similar in all three groups. Total operative time was significantly lower in HALDNM (181 minutes) than PLDN (233 minutes) and HALDNL (242 minutes) (p < 0.001). The WIT was comparable in all three groups: HALDNL (7.2 minutes), PLDN (4.1 minutes), and HALDM (4.9 minutes) (p = 0.913). Median cosmetic score was significantly better in the PLDN group (8.2 cm) when compared to HALDNM (11.1 cm) and HALDNL (9.9 cm) (p < 0.001). Conclusion: Our results show that all three technical modifications of laparoscopic donor nephrectomy are safe and feasible with good postoperative outcomes. HALDNM has the added benefit of decreased operative time while PLDN has a cosmetic advantage.

Kidney Transplant Outcomes in Recipients Over the Age of 70.

BACKGROUND: Patients older than 70 years are the fastest-growing age group of patients requiring renal replacement therapy. This has resulted in a corresponding increase in the number of elderly transplant recipients. We hypothesized that graft survival in this population would be comparable to that seen in the literature on kidney transplant recipients under 70 years of age. METHODS: This was a retrospective, single-center review of outcomes of kidney transplant recipients aged ≥70 years. Patients were dichotomized based on whether their allograft originated from a living or deceased donor. RESULTS: A total of 59 recipients aged ≥70 years underwent kidney transplantation. Of these, five (8.5%) were lost to follow-up within the first year post transplant and excluded from the analysis. History of cerebrovascular accident (p = 0.003), coronary artery disease (p = 0.03), postoperative return to the operating room (p = 0.03), and readmission within one year of transplant were predictive of graft loss (p = 0.003). Overall graft survival in our cohort declined from 92.6% at one year to 53.8% at five years. Death-censored graft survival was 100% at one year and decreased to 80.8% at five years. There were no differences seen in patient, graft, or death-censored graft survival based on donor type. CONCLUSIONS: Kidney transplant patients over 70 years, as seen in our cohort, had good short-term outcomes. Graft survival is similar to rates seen in younger cohorts but the decline in this rate over time is steeper in the older age group, possibly due to decreased patient survival. These findings could be validated further in larger multi-center studies.

Littoral cell angiomas: Benign lesion with a penchant for visceral malignancies.

Littoral cell angiomas are rare vascular tumors of the spleen. Because of their rarity, unclear etiopathogenesis, and association with other malignancies, these tumors can pose diagnostic and therapeutic challenges. Due to paucity of published literature on this entity often limited to case reports, relevant data on this topic were procured and synthesized with the aid of a comprehensive Medline search in addition to oncologic, pathologic, radiologic, and surgical literature review on littoral cell angiomas. This article provides an in-depth review into postulated etiopathogenesis, pathology, clinical manifestations, associated malignancies, and prognostic features of littoral cell angiomas.

Short and Long-Term Outcomes of Kidney Transplant Recipients Diagnosed With COVID-19 Infection: A Single-Center Observational Study.

PURPOSE: Kidney transplant recipients (KTRs) are at an increased risk of severe disease and death caused by coronavirus disease 2019 (COVID-19) infection. There is a paucity of information on the evolution of graft function among hospitalized KTRs who overcome the infection. METHODS: The study included adult KTRs at a single transplant institute who were diagnosed with COVID-19 and needed hospitalization between March 15, 2020, and January 15, 2021. We analyzed patient demographics, comorbid risk factors, and inpatient clinical courses for patients who were able to recover from the infection. Kidney function was analyzed pre-infection, during initial hospitalization, and up to 12 months post-infection. RESULTS: We identified 48 KTRs who were diagnosed with COVID-19 infection during the study period. Eighteen KTRs among these needed hospitalization for symptoms of fever and respiratory distress. Four patients died of COVID-19 infection-related complications and were excluded from the study. The 14 remaining patients in the study were predominantly of the Black race (85.7%), with a median time since transplant of four years. Of the patients, 64.3% developed acute kidney injury (AKI), with an average peak serum creatinine (sCr) of 2.6 mg/dl and a glomerular filtration rate (GFR) of 35. The mean sCr and GFR of the group were 2 mg/dl and 44 at baseline (prior to infection). This represented an increase in their sCr and GFR of 34% and 29%, respectively. The median follow-up post-infection was 14.5 months. sCr and GFR were 1.87 mg/dl and 47 at three to six months, and 1.89 mg/dl and 48 at nine to 12 months post-infection. New onset proteinuria was noted in five out of 14 patients (36%), with complete resolution of the same in all at three to six months follow-up. Of patients with AKI, 78% had complete recovery at three to six months follow-up. The mean baseline sCr and GFR of patients who had incomplete recovery was 2.35 and 31.5 with pre-existing proteinuria. Of our entire cohort, there was only one patient who experienced graft loss. This patient had a baseline sCr and GFR of 3.8 mg/dl and 22, existing proteinuria on urinalysis, and a history of biopsy-proven rejection. CONCLUSION: AKI is common among KTRs who are hospitalized with COVID-19 infection. Most of these recovered, although we noted that patients with baseline lower kidney function and existing proteinuria had a lower recovery rate.

Resolution of Disseminated Angiosarcoma in a Kidney Transplant Recipient After Treatment With Sirolimus: A Case Report.

Angiosarcoma is a rare, almost universally fatal malignant neoplasm in kidney transplant recipients. No evidence-based guidelines are available for disseminated disease. Here, we report a case of a 66-year-old woman who developed disseminated angiosarcoma 4 months after living nonrelated kidney transplant. She underwent only 2 rounds of chemotherapy because of intolerable adverse effects. Her mycophenolic acid and tacrolimus were withdrawn and sirolimus use was started. In addition to its immunosuppressant effects, sirolimus has been shown to have antineoplastic properties. Remarkably, at almost 2 years post-transplant, the patient has had complete resolution of all gross metastatic disease with only immunosuppressant medication changes. This case highlights the interesting possibility that sirolimus is an effective adjunct treatment for disseminated angiosarcoma in kidney transplant recipients.

Robotic Assisted Living Donor Nephrectomies: A Safe Alternative to Laparoscopic Technique for Kidney Transplant Donation.

OBJECTIVE: To review outcomes after laparoscopic, robotic-assisted living donor nephrectomy (RLDN) in the first, and largest series reported to date. SUMMARY OF BACKGROUND DATA: Introduction of minimal invasive, laparoscopic donor nephrectomy has increased live kidney donation, paving the way for further innovation to expand the donor pool with RLDN. METHODS: Retrospective chart review of 1084 consecutive RLDNs performed between 2000 and 2017. Patient demographics, surgical data, and complications were collected. RESULTS: Six patients underwent conversion to open procedures between 2002 and 2005, whereas the remainder were successfully completed robotically. Median donor age was 35.7 (17.4) years, with a median BMI of 28.6 (7.7) kg/m2. Nephrectomies were preferentially performed on the left side (95.2%). Multiple renal arteries were present in 24.1%. Median operative time was 159 (54) minutes, warm ischemia time 180 (90) seconds, estimated blood loss 50 (32) mL, and length of stay 3 (1) days. The median follow-up was 15 (28) months. Complications were reported in 216 patients (19.9%), of which 176 patients (81.5%) were minor (Clavien-Dindo class I and II). Duration of surgery, warm ischemia time, operative blood loss, conversion, and complication rates were not associated with increase in body mass index. CONCLUSION: RLDN is a safe technique and offers a reasonable alternative to conventional laparoscopic surgery, in particular in donors with higher body mass index and multiple arteries. It offers transplant surgeons a platform to develop skills in robotic-assisted surgery needed in the more advanced setting of minimal invasive recipient operations.

Real-Time Intraoperative Assessment of Microcirculation in Living-Donor Small Bowel Transplant: A Case Report.

Living-donor small bowel transplant has emerged as a modality to transplant patients with short bowel syndrome without prolonged wait time, albeit at the cost of technical challenges associated with vascular anastomosis due to the small size of vessels. Suboptimal perfusion in a transplanted bowel can lead to a devastating outcome, and clinical judgment alone is not completely reliable for assessment of bowel microcirculation. Here, we report a 55-year-old female patient who underwent flow cytometric cross-match-positive living-donor bowel transplant from her daughter. Initial suboptimal perfusion prompted a revision of the arterial anastomoses. Despite normal Doppler signals over the mesenteric vessels, the bowel had a variegated appearance. The microcirculation of the bowel wall was subsequently assessed in a real-time fashion by indocyanine green fluorescence angiography, which showed improved perfusion indices with time. Hence, this simple test helped us to avoid another unnecessary exploration and revision of the anastomoses. At present, the patient is thriving on an enteral diet. This case underpins the importance of real-time intraoperative assessment of bowel per-fusion and microcirculation in difficult cases. These assessments are needed to help surgeons identify tissues at risk for ischemia and necrosis, thereby allowing for maneuvers to improve intestinal viability.

Observational Study of the Clinical Characteristics and Short-Term Outcomes of Kidney Transplant Recipients Diagnosed With COVID-19 Infection (SARS-CoV-2) Requiring Hospitalization in New Orleans.

Background: Kidney transplant recipients are at increased risk of severe disease and death caused by coronavirus disease 2019 (COVID-19) infection. The role of immunosuppressive medications in the clinical presentation, disease course, and outcomes is not well understood. Methods: We analyzed kidney transplant recipients diagnosed with COVID-19 and requiring hospitalization during the initial infection surge at 2 large transplant centers in New Orleans, Louisiana, between February 1, 2020 and April 30, 2020. Patient presentation, clinical course, kidney transplant function, and postdischarge details are included in this analysis. Results: Twenty-three kidney transplant recipients hospitalized with COVID-19 were included in the study. The majority of patients were Black (95.7%). Diabetes, hypertension, and obesity were present in more than 50% of the patients. The most common presenting symptom was fever, present in 52.2% of patients. All patients were managed with reduction in immunosuppression. Patients received azithromycin (60.9%), hydroxychloroquine (47.8%), remdesivir (8.7%), and intravenous methylprednisolone pulse (8.7%). The average length of stay was 4.5 days (range, 2-18 days). In this study population, 73.9% of the patients sustained acute kidney injury, with an average peak serum creatinine of 3.81 mg/dL. Twenty-six percent of the patients required renal replacement therapy. Seventy-seven percent of patients developed proteinuria (at least 1+ proteinuria on urinalysis). Of the patients in this population who required mechanical ventilation (39.1%), 77.8% died. Overall, 30.4% of patients died of COVID-19-related complications during admission. Of the 16 patients discharged, the average serum creatinine at discharge was 2.09 mg/dL compared with an average preadmission serum creatinine of 1.8 mg/dL. Conclusion: During the initial COVID-19 infection surge in New Orleans, we noted that kidney transplant recipients had initial symptoms similar to the general population. However, we recorded a higher incidence of acute kidney injury and death compared to nontransplant patients. Patients who required mechanical ventilation had a high mortality rate. Black patients are overrepresented in our study.

Recipient risk factors for acute cellular rejection after orthotopic liver transplant - a single-center, retrospective study.

The use of model for end-stage liver disease (MELD) score for liver allocation has resulted in transplanting sicker patients. As such, it is unclear whether the risk factors and severity of acute cellular rejection (ACR) have changed. To identify ACR characteristics where average MELD score at transplant is higher than previously published studies. This is a single-center, retrospective study designed to assess risk factors associated with ACR after adult orthotopic liver transplant (OLT) using a steroid sparing regimen. This study included 174 OLT patients transplanted from 2008 to 2013 at a single tertiary care center. Recipient demographics, preoperative clinical, and laboratory data were recorded for each transplant. Univariate and multivariate regression analyses were performed to identify variables that are significant predictors for ACR. The median MELD at transplantation was 29.5. The average time from transplant to ACR diagnosis was 283.9 days and a majority of ACR episodes were mild to moderate. Serum creatinine, primary sclerosing cholangitis etiology, and tacrolimus use were significant predictors for ACR (P < 0.05). This study confirmed a change in timing and severity of ACR in the MELD era. Recipient characteristics may affect the risk for developing ACR and should be considered when managing immunosuppression.

Robotic kidney transplantation in the obese patient: 10-year experience from a single center.

Despite increasing obesity rates in the dialysis population, obese kidney transplant candidates are still denied transplantation by many centers. We performed a single-center retrospective analysis of a robotic-assisted kidney transplant (RAKT) cohort from January 2009 to December 2018. A total of 239 patients were included in this analysis. The median BMI was 41.4 kg/m2 , with the majority (53.1%) of patients being African American and 69.4% of organs sourced from living donors. The median surgery duration and warm ischemia times were 4.8 hours and 45 minutes respectively. Wound complications (mostly seromas and hematomas) occurred in 3.8% of patients, with 1 patient developing a surgical site infection (SSI). Seventeen (7.1%) graft failures, mostly due to acute rejection, were reported during follow-up. Patient survival was 98% and 95%, whereas graft survival was 98% and 93%, at 1 and 3 years respectively. Similar survival statistics were obtained from patients undergoing open transplant over the same time period from the UNOS database. In conclusion, RAKT can be safely performed in obese patients with minimal SSI risk, excellent graft function, and patient outcomes comparable to national data. RAKT could improve access to kidney transplantation in obese patients due to the low surgical complication rate.

Living Donor Liver Transplantation: Technical Innovations.

Living donor liver transplantation (LDLT) has found a place to serve the end-stage liver disease community as the donor safety and recipient suitability has been elucidated. Donor safety is of paramount importance and transplant programs must continue endeavors to maintain the highest possible standards. At the same time, adequacy of grafts based on recipient clinical status via their model for end-stage liver disease (MELD) score and volumetric studies to achieve a GRBWR >0.8, along with special attention to anatomic tailoring and portal venous flow optimization are necessary for successful transplantation. Technical innovations have improved sequentially the utility and availability of LDLT.

Pancreas Transplantation From Pediatric Donors: A United Network for Organ Sharing Registry Analysis.

BACKGROUND: Pancreas grafts from pediatric donors are still considered "not ideal." Perceived concerns are related to low islet mass and potential for graft thrombosis. METHODS: The study evaluated all pancreas transplants from January 2000 to May 2015 using the Organ Procurement and Transplant Network database. Comparative analysis of recipient and graft survival was performed between pediatric (≤18 years) and adult donors. In the pediatric group, the outcomes were stratified based on donor age (≤6, 7-12, and 13-18 years) and weight (<30, 30-95, and >95 kg). RESULTS: In the selected era, 18 430 pancreas transplants were performed from 4915 pediatric donors (27%). Short-term graft and patient survivals were comparable between pediatric and adult donors. Ten-year patient and graft survivals were higher in the pediatric donor group: (70% and 54% vs 68% and 51%, P = 0.001). However, very-low-weight pediatric donors (<30 kg) resulted in worse graft survival in the long term (44% at 10 years, P = 0.006). CONCLUSIONS: Pediatric donor pancreas transplants had comparable patient and graft survival to the adult donor transplants. However, the islet mass of very small donors could influence long-term graft survival if the weights of donors and recipients are not properly matched. Usage of "very small" pediatric donors was not associated with higher incidence of technical complications or early graft loss.

Long-term outcomes of living-related small intestinal transplantation in children: A single-center experience.

Pediatric patients with irreversible intestinal failure present a significant challenge to meet the nutritional needs that promote growth. From 2002 to 2013, 13 living-related small intestinal transplantations were performed in 10 children, with a median age of 18 months. Grafts included isolated living-related intestinal transplantation (n=7), and living-related liver and small intestine (n=6). The immunosuppression protocol consisted of induction with thymoglobulin and maintenance therapy with tacrolimus and steroids. Seven of 10 children are currently alive with a functioning graft and good quality of life. Six of the seven children who are alive have a follow-up longer than 10 years. The average time to initiation of oral diet was 32 days (range, 13-202 days). The median day for ileostomy takedown was 77 (range, 18-224 days). Seven children are on an oral diet, and one of them is on supplements at night through a g-tube. We observed an improvement in growth during the first 3 years post-transplant and progressive weight gain throughout the first year post-transplantation. Growth catch-up and weight gain plateaued after these time periods. We concluded that living donor intestinal transplantation potentially offers a feasible, alternative strategy for long-term treatment of irreversible intestinal failure in children.

The use of bovine pericardial patch for vascular reconstruction in infected fields for transplant recipients.

Infectious vascular complications affecting transplant recipients may lead to severe morbidity and graft loss. This is a retrospective review of vascular repair with bovine pericardial patch (BPP) in infected fields for immunosuppressed patients. BPP was used as either a patch or an interposition graft. Five cases of arterial reconstruction in infected fields using BPP were performed. There were no complications related to bleeding, thrombosis, or recurrent infection. In our limited experience, the use of BPP as a vascular patch is successful, and it represents an alternative when vascular reconstruction is needed in the context of infected fields.

Single Center Experience With Robotic Kidney Transplantation for Recipients With BMI of 40 kg/m2 Or Greater: A Comparison With the UNOS Registry.

BACKGROUND: Obesity represents a barrier to kidney transplantation, but the increasing prevalence among renal failure patients has forced some centers to carefully consider such candidates. Morbidly obese patients may be at increased risk of delayed graft function, higher postoperative complications, and inferior graft outcomes. Nevertheless, mortality on the waiting list remains significantly higher than after transplant. We have applied minimally invasive surgery to perform kidney transplant in individuals with body mass index (BMI) of 40 kg/m or greater. We compared our results to the national United Network of Organ Sharing database. METHODS: The United Network of Organ Sharing registry was reviewed for adult living donor kidney transplant recipients with BMI of 40 kg/m or greater performed from September 2009 to December 2014. We compared transplants performed with robotic technique (RKT) versus patients performed with open surgery at all US centers including our own (open kidney transplant). Subgroup analysis in patients with BMI of 45 kg/m or greater was conducted. We compared outcomes including patient and graft survival, renal function, and technical complications. RESULTS: Robotic kidney transplantation group had a significantly higher mean BMI overall. The 1-year patient and graft survival rates were similar between groups. Renal function was also similar at 6, 12, and 36 months. Thrombosis caused 1.3% of the graft losses in open kidney transplant and 0% in the RKT group. Interestingly, 52.8% of the overall experience in patients with BMI of 45 kg/m or greater was performed with the robotic technique. CONCLUSIONS: Robotic surgery offers similar patient and graft survivals with comparable renal function to open technique. Robotic kidney transplantation permits transplantation in extreme BMI categories without additional technical complications. Further studies are required to establish the role of RKT for obese candidates but preliminary data are encouraging.

Obesity Increases the Risk of Primary Nonfunction and Early Access Loss, and Decreases Overall Patency in Patients Who Underwent Hemodialysis Reliable Outflow Device Placement.

BACKGROUND: Hemodialysis reliable outflow (HeRO) catheters were introduced in 2008, and have been since providing a reliable alternative for hemodialysis patients who are deemed "access challenged." However, its outcomes have not been extensively investigated due to its relatively young age. Here, we report our 6-year single institution experience, and demonstrate the significant impact of obesity on HeRO graft outcomes, an aspect not previously studied in the literature. METHODS: Patients who underwent HeRO graft placement at the University of Illinois Hospital between April 2009 and August 2015 were included retrospectively. Data were collected from patients' electronic medical records and analyzed using SPSS software. RESULTS: Thirty-three patients who underwent 34 HeRO catheter placements were included. Mean age was 47 ± 12 years, and mean body mass index (BMI) was 30.75 ± 10.22. Median follow-up was 635 days. Overall catheter-related complications were thrombosis (70.59%), infection (20.59%), arterial steal (8.82%), and pseudoaneurysms requiring intervention (8.82%). Overall primary and secondary patency rates after 6 and 12 months were 31.25%, 25%, 78.13%, and 71.86%, respectively. Primary nonfunction rate was 14.7%. Obese patients had significantly higher rate of primary nonfunction (38.46% vs. 0%, P = 0.0046), and relative risk 3.62 (95% confidence interval [CI] 2.01-6.52). They also had a significantly decreased rate of graft patency after 12 months (10.53% vs. 53.85%, P = 0.0227), leading to a relative risk of "early" graft loss within 1 year of 5.12 (95% CI 1.26-20.83). Overall median graft patency in obese patients was significantly shorter than that of nonobese patients (311 vs. 1295 days, P = 0.014). BMI, as a continuous variable, was a significant predictor of primary nonfunction (P = 0.046) and early graft loss (0.020) when tested against age, sex, race, and diabetes in a multivariate logistic regression analysis. CONCLUSIONS: HeRO catheters offer a reliable, and possibly the last, alternative in hemodialysis access-challenged patients. In our population, obesity was a significant risk factor for primary nonfunction, early graft loss, and a shorter overall graft patency. BMI, as a continuous variable, can serve as a predictor of primary nonfunction and early graft loss after adjustment for age, race, sex, and diabetes. Obesity's effect on HeRO catheters has not been amply addressed; therefore further prospective studies are warranted.