Improving living renal transplant: lessons from a multi-ethnic transplant program.

Living-renal transplant (LRT) is the most effective treatment for endstage renal disease (ESRD), and innovative strategies to increase donation are needed. We reviewed our ethnically/culturally diverse program to identify factors that contribute to donors' decision to participate. Records of 110 LRT (related:unrelated = 66:44) and respective donors (1999-2005) were reviewed for demographics, outcome, education, employment, language, religion, and motivation. One and 5-year graft survival were 98.2% and 92% respectively. Mean donor age was 41.1 yrs with Men:Women = 62:48 and similar ethnicity to recipients. Donors tended to be married (65.5%), educated (31.8% -- high school, 58.1% -- additional education/degree), employed (84.4%), religious (55.9%) and English-speaking (73.8%). Successful donors were motivated: 54% traveled from off-island, and 10.9% had prior acts of altruism. Proper referral, identification & education of donors, and individual motivation of potential donors are key factors required for LRT. Continued efforts to overcome educational/language/cultural barriers are necessary to assist patients in finding donors and increasing LRT.

Liver transplant in Hawai'i: over a hundred cases.

One hundred and two liver transplants have been performed since the program's inception in Hawai'i in 1993. Viral hepatitis continues to be the primary indication for liver transplant, though hepatocellular cancer is involved in 23.5% of cases. One, 3 and 5-year patient survival rates have been 88%, 79%, and 74% respectively which is comparable to mainland centers and national data.

Hepatitis B and alcohol affect survival of hepatocellular carcinoma patients.

AIM: In the USA, Hawaii has the highest incidence of hepatocellular carcinoma (HCC) and a diverse population. It is an ideal place to characterize HCC in the context of ethnicity/risk factors. METHODS: A total of 262 cases of HCC (1992-2003) were retrospectively reviewed for demographics, ethnicity, birthplace, viral hepatitis, alcohol use, diabetes, smoking and risk factors for viral hepatitis such as intravenous drug abuse (IVDA), transfusions, tattoos and vertical transmission. Tumor stage, Child's class, Cancer of the Liver Italian Program (CLIP) score, alpha-fetoprotein level, treatment and survival were recorded. RESULTS: Gender, age, viral hepatitis, alcohol, IVDA, and diabetes differed significantly in Asians, non-Asians and Pacific Islanders. There were also specific differences within Asian subgroups. Alpha-fetoprotein, smoking, transfusions, stage and resectability did not differ between groups. Asians were more likely to have hepatitis B, while non-Asians were more likely to have hepatitis C. Factors that decreased survival included hepatitis B, alcohol, elevated alpha-fetoprotein, CLIP>2 and increased Child's class. When Asians were combined with Pacific Islanders, median survival (1.52 years vs 3.54 years), 1- and 3-year survival was significantly worse than those for non-Asians. After Cox regression analysis for hepatitis B and alcohol, there was no difference in survival by ethnicity. CONCLUSION: Various ethnicities have different risk factors for HCC. Hepatitis B, alcohol, and alpha-fetoprotein are more important factors for survival than ethnicity.

Factors affecting outcome in liver resection.

BACKGROUND: Studies demonstrate an inverse relationship between institution/surgeon procedural volumes and patient outcomes. Similar studies exist for liver resections, which recommend referral of patients for liver resections to 'high-volume' centers. These studies did not elucidate the factors that underlie such outcomes. We believe there exists a complex interaction of patient-related and perioperative factors that determine patient outcomes after liver resection. We sought to delineate these factors. METHODS: Retrospective review of 114 liver resections by a single surgeon from 1993-2003: Records were reviewed for demographics; diagnosis; type/year of surgery; American Society of Anesthesiologists (ASA) score; preoperative albumin, creatinine, and bilirubin; operative time; intraoperative blood transfusions; epidural use; and intraoperative hypotension. Main outcome measurements were postoperative morbidities, mortalities and length of stay (LOS). Data were analyzed using a multivariate linear regression model (SPSS v10.1 statistical analysis program). RESULTS: Primary indications for resections were hepatocellular carcinoma (HCC) (N=57), metastatic colorectal cancer (N=25), and benign disease (N=18). There were no intraoperative mortalities and 4 perioperative (30-day) mortalities (3.5%). Mortality occurred in patients with malignancies who were older than 50 years. Morbidity was higher in malignant (15.6%) versus benign (5.5%) disease. Complications included bile leak/stricture (N=6), liver insufficiency (N=3), postoperative bleeding (N=2), myocardial infarction (N=2), aspiration pneumonia (N=1), renal insufficiency (N=1), and cancer implantation into the wound (N=1). Average LOS for all resections was 8.6 days. Longer operative time (p=0.04), lower albumin (p<0.001), higher ASA score (p<0.001), no epidural use (p=0.04), and higher creatinine (p<0.001) all correlated positively with longer LOS. ASA score and creatinine were the strongest predictors of LOS. LOS was not affected by patient age, sex, diagnosis, presence of malignancy, intraoperative transfusion requirements, intraoperative hypotension, preoperative bilirubin, case volume per year or year of surgery. CONCLUSIONS: Liver resections can be performed with low mortality/morbidity and with acceptable LOS by an experienced liver surgeon. Outcome as measured by LOS is most influenced by patient comorbidities entering into surgery. Annual case volume did not influence LOS and had no impact on patient safety. Length of stay may not reflect surgeon/institution performance, as LOS is multifactorial and likely related to patient population, patient selection and increased high-risk cases with a surgeon's experience.

Splenorenal shunt: an ideal procedure in the Pacific.

HYPOTHESIS: Splenorenal shunt, an accepted treatment to prevent recurrent variceal bleeding, is an ideal procedure for patients with psychosocial issues or limited access to tertiary medical centers. METHODS: We retrospectively reviewed the medical records of 34 patients (32 distal splenorenal shunts and 2 central splenorenal shunts) treated from January 1, 1995, through December 31, 2001, for demographic data, substance abuse status, psychosocial factors, previous treatments, Child class, length of hospital stay, operative transfusions, complications, and outcome. RESULTS: Of the 34 patients, 17 were from surrounding Pacific islands (as many as 3800 miles away from Honolulu, Hawaii). Sixteen patients were Child class A, and 18 were Child class B. Twenty-four patients were either homeless, actively involved in substance abuse, or being treated for psychiatric problems, and 20 patients were either uninsured or insured by third-party payers that did not cover liver transplantation. Four patients underwent distal splenorenal shunt for a failed transjugular intrahepatic portosystemic shunt. Patients received a mean of 1.3 U of packed red blood cells (range, 0-5 U), and 15 received no blood transfusions. Mean length of hospital stay was 12.7 days (9 days postoperatively). Perioperative mortality was 8.8%. Three patients rebled postoperatively, 2 because of gastric ulcers and 1 because of an inadequate shunt. The 1-year survival rate was 95% in the 20 patients for whom data were available. CONCLUSIONS: Splenorenal shunt is an important treatment for noncompliant patients or patients living in remote areas where access to specialized treatments, such as endoscopy, transjugular intrahepatic portosystemic shunt, ultrasonography, and liver transplantation, is limited. We can achieve acceptable morbidity and mortality in this group of patients, although follow-up can be difficult.