Abdominal Organ Transplant Center Tobacco Use Policies Vary by Organ Program Type.

BACKGROUND: Smoking is a modifiable risk factor for cardiovascular disease, malignancy, and surgical complications. Transplant center practices toward smokers vary widely and evoke the classic tension between the ethical principles of justice and utility. We sought to assess current smoking policy variation in U.S. kidney, liver, and pancreas transplant centers. METHODS: An online survey was sent to program directors of all United Network for Organ Sharing-approved solid abdominal organ transplant programs regarding their policies toward prior and current tobacco use. RESULTS: Responses were received from 26% of kidney, 31% of liver, and 37% of pancreas transplant centers. Across organ programs, virtually all centers (97% to 100%) reported transplantations for former smokers, whereas 59% of kidney, 62% of liver, and 33% of pancreas programs reported transplantations for current smokers. Organ programs reported similar rates of having smoking cessation programs (74% to 77%) and performing serum cotinine testing (31% to 38%). Smoking was an absolute contraindication to transplantation at 38% of kidney, 15% of liver, and 50% of pancreas programs. Programs with absolute contraindication policies were less likely to perform transplantations in current smokers and more likely to check serum cotinine levels, but no more likely to have smoking cessation programs. CONCLUSIONS: There is variation in tobacco use policies among abdominal organ transplant programs and centers. Balancing equity and justice when deciding which patients to waitlist requires an individualized approach to the tobacco-using patient, consideration of organ-specific factors, tobacco-related disease burden, and overall patient health. Such multifaceted assessments might be favorable to inflexible tobacco use policies.

MELD scores do not predict patient morbidity while on the liver transplant waiting list.

The goals of this study were to assess waitlist morbidity in terms of the frequency of health care services utilized by patients while on the liver transplant (LTX) waiting list and to determine whether that utilization can be predicted by the Model for End-Stage Liver Disease (MELD). Sixty-three noncomatose subjects were followed from waitlist placement until death, change in status, LTX, or study discontinuance. Health care events included doctor/clinic visits, labs, outpatient/inpatient tests and procedures, and hospital/intensive care unit days. Listing MELD scores and LTX MELD scores were examined against the number of health care event occurrences within 60 days of listing and 60 days of LTX, respectively, as were changes in MELD scores between listing and LTX and differences in the number of occurrences between the two time points. The only significant correlations noted were between LTX MELD scores and number of hospital days near LTX (r = .360, P = .046) and between LTX MELD scores and the sum total number of occurrences near LTX (r = .370, P = .044). These results suggest that MELD scores do not appear to predict morbidity in terms of health care utilization in patients awaiting LTX. Developing a system capable of predicting waitlist morbidity may lead to the implementation of medical interventions aimed at circumventing foreseeable complications and/or crises in patients awaiting LTX.

Sirolimus conversion after liver transplantation: improvement in measured glomerular filtration rate after 2 years.

METHODS: We reviewed our prospectively maintained database of 2005 liver transplantations. Therapy was either started de novo or converted from calcineurin inhibitors (CNIs) to sirolimus as the main immunosuppressive agent for nephrotoxicity or rejection. Glomerular filtration rate (GFR) was determined with iodine 125-labeled sodium isthalamate (Glofil-125), and serum creatinine concentration was obtained before and 3 months after transplantation, and yearly in both groups. Sirolimus levels were 10 to 15 ng/mL in patients at less than 3 months after transplantations and 5 to 10 ng/mL in the remaining patients. All patients received mycophenolate mofetil as maintenance therapy. RESULTS: Data for 29 patients in the de novo group and 35 in the conversion group were reviewed. Patients in the de novo group demonstrated an acute cellular rejection rate of 17.2%, 40% of which were steroid resistant. In this group, 48.2% discontinuation of sirolimus was necessary because of adverse effects. Patients in the conversion group demonstrated an acute cellular rejection rate of 2.8% and a 34.3% rate of sirolimus discontinuation. Seventeen (56.7%) patients at 1 year and 8 (44.4%) patients at 2 years demonstrated continued improvement in GFR. In the conversion group, case-control analysis did not demonstrate a significant difference in GFR and serum creatinine concentration (P > .05) at 1 and 2 years after conversion. At the time of review, no patients in the conversion group required hemodialysis. CONCLUSIONS: Conversion to sirolimus therapy is an effective strategy in improving renal function in patients with CNI-induced nephrotoxicity and can be done without increased rejection. Most of our patients (65.7%) tolerated sirolimus conversion. Of these, 56.7% and 44.4% demonstrated continued increase in GFR with the CNI-free regimen at 1 and 2 years, respectively. Long-term, large-population, prospective, randomized, controlled studies should further validate these results.

Cannulation of the aorta in organ donors with infrarenal aortic pathologies.

Retrograde embolization of atherosclerotic arterial plaque remains a threat at the time of organ perfusion in elderly donors. In order to circumvent this potential procurement complication, we describe a technique with two variations. This technique allows for perfusion with UW solution without having to cannulate through severely atherosclerotic distal aortic walls.

Cannulation of the aorta in organ donors with aortic and caval injuries at the time of procurement.

Injuries sustained by major vessels during procurement pose a major threat to organ viability. Aortic and inferior vena cava lacerations produce rapid hemorrhage associated with hypoperfusion and ischemic damage. We describe a technique that will prevent such damage in the event of vascular mishaps.

Post-transplant lymphoproliferative syndrome in the pediatric liver transplant population.

Post-transplant lymphoproliferative disease remains a complication with a high morbidity and mortality. The present study examined 291 pediatric liver transplants performed in 263 children from October 1984 to December 1999. Post-transplant lymphoproliferative disease has an overall incidence of 12%. Tacrolimus and cyclosporine had a similar incidence of post-transplant lymphoproliferative disease. Fifty-six per cent of patients who developed post-transplant lymphoproliferative disease were Epstein-Barr virus negative at the time of transplantation. Mean time of conversion to Epstein-Barr virus positivity was 1.1 years after liver transplantation. Ten per cent of those who developed post-transplant lymphoproliferative disease never had Epstein-Barr virus detected. Mean time from Epstein-Barr virus positivity to detection of post-transplant lymphoproliferative disease was 2.68 years, and 3.13 years from liver transplantation (OLTx) to post-transplant lymphoproliferative disease. There was a 35% incidence of mortality. Deaths occurred a mean of 0.76 years after diagnosis of post-transplant lymphoproliferative disease. Most cases of post-transplant lymphoproliferative disease had extranodal location. There was one recurrence in 10% of patients, and two in 3%. All recurrent cases were seen in recipients who became Epstein-Barr virus positive after transplantation. There has been a decrease in the incidence of post-transplant lymphoproliferative disease from 15% to 9% to 4%. Post-transplant lymphoproliferative disease should be diagnosed promptly and treated aggressively. The best treatment, however, seems to be prevention, starting in the immediate postoperative period. Survivors should be monitored for both recurrence of post-transplant lymphoproliferative disease and acute cellular rejection.

Experimental studies of thermal therapy for severe nonvariceal bleeding in dogs.

BACKGROUND: There are several methods of achieving endoscopic hemostasis for nonvariceal hemorrhage, including use of a heater probe, bipolar electrocoagulation, use of a Gold probe, and injection therapy with epinephrine or ethyl alcohol. However, due to clinical variations, clinical studies comparing thermal with injection therapy have yielded conflicting results. Therefore, we used a canine model of acute bleeding from gastric serosal vessels to examine the efficacy of the heater probe and the Gold probe in achieving hemostasis and to compare the injurious effects of these methods with injection therapy. METHODS: Seven mongrel dogs were used in the study. Four were assigned to acute experiments in which transected blood vessels were allowed to bleed profusely. Two dogs of this group were treated with either a large or small Gold probe, while the other two were treated with either a large or small heater probe. In the other three dogs, we tested the chronic effects of the heater probe, the Gold probe, and injection therapy with dilute epinephrine. RESULTS: Complete hemostasis was achieved for all four dogs in the acute experiments. Dogs treated with either a large or small heater probe had coagulation necrosis that extended to the serosa and muscularis but not to the mucosa. The large Gold probe had similar results, but the small Gold probe caused tissue damage to the serosa, muscularis, submucosa, and mucosa at several of the application sites. Both probes caused scarring of the gastric wall. In the chronic experiments, we found that the Gold probe caused larger mucosal ulcers than the heater probe. All ulcers healed in 3 weeks. The epinephrine injection caused localized swelling and discoloration, but after 1 week the tissue returned to normal. CONCLUSIONS: Both the heater probe and the Gold probe are effective in achieving hemostasis in a canine model of nonvariceal hemorrhage, and both methods are superior to injection therapy. For active bleeding ulcers, we currently recommend a combination therapy, using first injection therapy and then a heater or Gold probe. However, clinicians should be aware of the potential for tissue damage.