Impact of parenteral nutrition-associated liver disease on intestinal transplant waitlist dynamics.

BACKGROUND: United Network for Organ Sharing (UNOS) reports indicate that waiting list mortality for intestinal transplant candidates greatly exceeds that for all other organ transplant candidates. But United Network for Organ Sharing outcomes reports have not routinely distinguished between the intestine candidate subgroups that are listed only for an intestine and those that are also listed for a liver. STUDY DESIGN: Data were obtained by request from the collaborative Organ Procurement and Transplantation Network (United Network for Organ Sharing)/Scientific Registry of Transplant Recipients (University Research and Education Association) database. Waiting list data for intestinal transplant recipients from 1995 to 2004 were divided into those candidates listed for only an intestine and those listed for both an intestine and a liver. Additional data concerning overall waiting list outcomes and posttransplant survival rates stratified into pediatric and adult subsets were also obtained and analyzed. RESULTS: The overall number of candidates on the intestinal transplant waiting list has increased steadily since 1995 and, consistently, the majority of candidates have also been listed for a liver. This subset was found to have both a higher relative risk of dying while awaiting transplantation and lower relative odds of receiving transplants. In addition, parenteral nutrition-associated liver disease is a major problem across all age groups, as evidenced by the combined liver and intestine listings that compose the majority of both adult and pediatric waiting list populations. Posttransplant survival data were found to be superior for isolated intestine recipients compared with liver-intestine recipients. CONCLUSIONS: The preponderance of dual listings and their associated inferior outcomes, before and after transplantation, has skewed overall intestinal transplant outcomes. Because progression of parenteral nutrition-associated liver disease can be insidious, and recognition of irreversibility is often difficult, intestine-only transplants should be considered early for high-risk patients before parenteral nutrition-associated liver disease progression mandates inclusion of a liver graft also.

Radiotherapy for rejection of renal transplant allografts refractory to medical immunosuppression.

OBJECTIVE: To evaluate the outcome and prognostic factors of patients who underwent local graft irradiation for acute renal allograft rejection refractory to modern immunosuppressive medications. METHODS: From 1996 to 2005, 33 patients received local graft irradiation (LGI), with 3 patients receiving 2 courses of radiation. Graft rejection was diagnosed when a rise in creatinine prompted a renal biopsy that demonstrated acute allograft rejection. Upon failure of medical immunosuppresion to resolve rejection, patients were then referred by the organ transplant team for LGI. The median dose was 800 cGy (range, 600-800 cGy), and was given in 200 cGy fractions generally using AP/PA fields. A retrospective review was conducted to determine dialysis-free survival, defined as the date from initiation of radiation therapy to date of hemodialysis placement, and to analyze potential factors that may predict dialysis free survival. RESULTS: Median follow-up from date of radiation therapy to date of last follow-up was 25 months (range, 0.9-99.4 months). The median time between allograft transplantation and radiation therapy was 17.8 months. For the entire group of patients, 20.6% were alive with a functioning graft. The median dialysis-free survival for the entire group was 3.8 months. The median dialysis-free survival for those patients not on dialysis at time of irradiation versus those patients on dialysis was significantly different (5.6 versus 0 months, P = 0.02). CONCLUSION: In renal allograft transplant recipients who experienced acute rejection episodes refractory to modern chemical immunosuppression, LGI was well tolerated and remains a viable salvage treatment option.

The economic impact of MELD on liver transplant centers.

Adoption of the model for end stage liver disease (MELD) system prioritized patients awaiting liver transplant (LT) by severity of illness including progressive renal dysfunction. Unfortunately, current reimbursement for LT is not adjusted by severity of illness or need for simultaneous liver-kidney transplantation (LKT). This study examines hospital cost and reimbursement for LT and LKT to determine the effect of MELD on transplant center (TC) financial outcomes given current reimbursement practices as well as DRG outlier threshold limits. LT was performed for 86 adults prior to and 127 following the implementation of MELD. Between the eras, there was a substantial increase in the average laboratory MELD score (17.1 to 20.7 p=0.004) and percentage of LKTs performed (5.8% to 17.3% p=0.01). Increasing MELD score was associated with higher costs ($4309 per MELD point p<0.001) and decreasing TC net income ($1512 per MELD point p<0.001). In patients not achieving the Medicare outlier status, predicted net loss was $17,700 for high-MELD patients and $19,133 for those needing LKT. In conclusion, contractual reimbursement agreements that are not indexed by severity of disease may not reflect the increased costs resulting from the MELD system. Even with outlier thresholds, Medicare reimbursement is inadequate resulting in a net loss for the TC.