Estimated Cost of Transcarotid Arterial Revascularization Compared With Carotid Endarterectomy and Transfemoral Carotid Stenting.

Objectives Transcarotid arterial revascularization (TCAR) is associated with a lower risk of stroke or death than transfemoral carotid artery stenting (TF-CAS). TCAR infers a lower risk of cranial nerve injury and a similar risk of myocardial infarction (MI) than carotid endarterectomy (CEA). There have been no comparative studies on the cost of TCAR, TF-CAS, and CEA, which may have important implications for institutional support for the new modality to address carotid artery stenosis. Our aim was to compare the estimated cost profiles of TCAR, TF-CAS, and CEA. Methods A review was performed on Medicare patients who underwent TCAR, TF-CAS, or CEA between January 1, 2020, and December 31, 2020. Demographics, comorbidities, operative details, and postoperative complications were reviewed. Acute stroke presentations and elective procedures were included. Cost data were obtained from the hospital's finance department. Quantitative variables were compared using analysis of variance, and categorical variables were compared using the chi-square analysis. Results In total, 21 TCAR, 97 TF-CAS, and 26 CEA patients were initially identified. After removing the non-Medicare patients, 17 TCAR, 57 TF-CAS, and 13 CEA patients were included in the analysis. In-hospital stroke, MI, and mortality included three deaths in TF-CAS patients. At 30 days, the stroke rates for TCAR, TF-CAS, and CEA groups were 0%, 1.8%, and 0%, respectively. The payments for TCAR, TF-CAS, and CEA were $15,400 ± 2,100, $23,400 ± 11,800 and $14,300 ± 5,700 (p=0.001), respectively. The estimated costs for TCAR, TF-CAS, and CEA were $10,500 ± 3,300, $13,800 ± 14,300, and $12,400 ± 6,000 (p=0.575), respectively. The profit margins for TCAR, TF-CAS, and CEA were $5,100 ± 3,100, $9,600 ± 12,100, and $1,900 ± 6,400 (p=0.032), respectively. There was no significant difference in American Society of Anesthesiologists (ASA) scores (p=0.635) or age (p=0.485) among the three groups. The length of hospital stay was not significantly different (p=0.107). The TF-CAS maintained the highest profit margin (p<0.001) when matched for the same diagnosis-related code (without complications or comorbidities). Urgency classification within the TF-CAS group included 45 elective, four urgent, and eight emergent cases. The profit margin was significantly higher for the elective group than for the emergent group (p=0.002) but not different for elective versus urgent (p=0.503) or urgent versus emergent (p=0.102). All patients who underwent TCAR and CEA were elective. Conclusion The hospital reimbursement and profit margins are higher for TF-CAS than for TCAR. With the increasing data now demonstrating similar outcomes with TF-CAS and CEA, further research is required to examine the long-term cost-effectiveness of TCAR and how this will compare to TF-CAS.

Current organ allocation disadvantages kidney alone recipients over combined organ recipients.

BACKGROUND: The United Network for Organ Sharing began including the Kidney Donor Profile Index (KDPI) March 26, 2012 and began a new allocation scheme December 1, 2014. METHODS: Kidney donors from our organ procurement organization from March 2012 to December 2014 were reviewed. The KDPIs of all 919 kidney only transplants were compared with all 102 kidney/extrarenal transplants. RESULTS: The average KDPI for kidney alone allografts was 47 (range 1 to 100) (standard deviation = 25.83) vs 27 for kidney/extrarenal kidneys (range 1 to 82) (standard deviation = 20.16) (P < .001, t test). Multivariate analysis including in- vs out-of-state recipient, donor body mass index, and donation after cardiac death vs brain-dead donor showed significantly lower KDPI for kidney/extrarenal transplants. CONCLUSIONS: Kidney/extrarenal organs have decreased graft survival compared with kidneys transplanted alone. In this sample, 21% of lower KDPI kidneys were allocated as kidney/extrarenal organs. This disadvantages those waiting for a kidney alone. Attention to the outcomes of kidneys transplanted with extrarenal organs is needed.

Early pancreas transplant outcomes with histidine-tryptophan-ketoglutarate preservation: a multicenter study.

Little is known about the use of histidine-tryptophan-ketoglutarate (HTK) preservation solution for pancreas preservation. We compared early pancreas graft outcomes at four pancreas transplant programs within the state of Michigan in 2002 and 2003 (University of Wisconsin [UW] era) with those in 2004 (HTK era). The primary endpoint was early graft loss. The UW group (n=41) and the HTK group (n=36) had similar outcomes with respect to: technical graft loss (9.8% vs. 8.3%, P=NS), 90-day graft function (90.2% vs. 86.1%, P=NS), and rate of pancreatic leak/abscess (12.2% vs. 11.1%, P=NS). There were also no significant differences in postoperative amylase and lipase levels between the two groups. The HTK group did have significantly more acute rejection within the first 180 days (25.0% vs. 9.8%, P<0.05). HTK is a suitable substitute for UW in the preservation of pancreas allografts.

Induction therapy with basiliximab versus Thymoglobulin in African-American kidney transplant recipients.

BACKGROUND: It has been suggested that the use of antilymphocyte induction therapy in African-American (AA) renal transplant recipients reduces the risk of acute rejection (AR) and improves graft survival. It is not clear whether the efficacy of basiliximab (BSX) is different from that of Thymoglobulin (ATG) in this regard. METHODS: We retrospectively assessed the effect of induction therapy with BSX versus ATG in 88 AA renal allograft recipients receiving transplants at our center between July 2001 and June 2003 and followed for 19+/-7 months. All patients were maintained on mycophenolate mofetil, prednisone, and either tacrolimus or sirolimus. Study endpoints included patient and graft survival, graft function, and incidence of AR and cytomegalovirus infection. Regression models were used to evaluate the independent effect of each induction agent on these endpoints. RESULTS: Thirty-six patients received ATG, and 52 received BSX. The groups were comparable with regard to donor race and age, and recipient sex, body mass index, human leukocyte antigen (HLA) matching, and hepatitis C virus serostatus. The ATG group was younger, more likely to receive retransplant, had longer duration of end-stage renal disease and higher panel reactive antibody, and was less likely to receive live-donor organs. However, after adjusting for all these variables, graft outcomes, as well as renal function, were comparable between the two induction groups. We found that the degree of HLA mismatch, delayed graft function, and AR were the only significant predictors of graft loss. CONCLUSION: The results of our study suggest that the choice of induction agent may not have a major impact on graft outcomes in AA renal-allograft recipients.

Cytomegalovirus prophylaxis with valganciclovir in African-American renal allograft recipients based on donor/recipient serostatus.

There is a paucity of data examining the efficacy of valganciclovir (VGC) for cytomegalovirus (CMV) prophylaxis in kidney transplant patients, particularly with regard to utilization of a risk-stratified dosing regimen. Eighty adult African-American (AA) renal allograft recipients transplanted from November 3, 2001 to May 28, 2003 and followed for 22 +/- 8 months received VGC once daily for 90 d post-transplant dosed according to donor/recipient (D/R) serostatus: high risk (D+/R-) received 900 mg (n = 12); moderate risk (D+/R+, D-/R+) received 450 mg (n = 60); and low risk (D-/R-) received no prophylaxis (n = 8). Thymoglobulin or basiliximab was used for induction, and mycophenolate mofetil, prednisone, and either tacrolimus or sirolimus for maintenance immunosuppression. Only six patients (7.5%) developed symptomatic CMV infection diagnosed by pp65 antigenemia, three in the high-risk (25%) and three in the moderate-risk (5%) group (p = 0.02). All patients were on tacrolimus for at least 3 months prior to diagnosis. There were no cases of tissue-invasive disease, resistance to treatment, or recurrence. D+/R- serostatus was the only significant independent predictor for CMV infection using multivariate analysis (odds ratio 10.5; p = 0.04). Thymoglobulin induction was not associated with CMV infection. None of 43 patients who were exposed to sirolimus for >30 d developed CMV infection, vs. six of 37 who were not (p = 0.006). We conclude that VGC dosed according to D/R serostatus provides safe and effective CMV prophylaxis in AA renal allograft recipients.

West Nile virus encephalitis: an emerging disease in renal transplant recipients.

West Nile virus (WNV) has emerged as an important cause of several outbreaks of febrile illness and encephalitis in North America over the past few years. The most common manifestation in symptomatic patients is a transient febrile illness. Neuroinvasive disease, that can be fatal, occurs most often in elderly and immunocompromised hosts. The role of this virus as a cause of meninoencephalitis in organ transplant recipients is becoming better recognized. We describe herein the clinical course of two renal allograft recipients who developed WNV encephalitis. One patient developed status epilepticus and eventually died, while the other had a full recovery. In both cases, the diagnosis was confirmed by detection of WNV-specific IgM in CSF or serum, with a delayed antibody response in one patient. This viral infection should be considered in all renal transplant recipients who present with a febrile illness associated with neurological symptoms.

Sirolimus-induced angioedema.

Sirolimus (SRL) is a macrolide immunosuppressant that has gained widespread use in organ transplantation. Its full spectrum of side-effects is yet to be defined. We describe herein three cases of SRL-induced angioedema (AE) in African-American (AA) primary renal allograft recipients who received SRL in combination with mycophenolate mofetil and steroids. In two cases, AE manifested after SRL was restarted after a period of discontinuation. The third case presented upon initial exposure to the drug. None of the patients was receiving any drug that has been previously associated with AE. Complete resolution occurred only after SRL was withdrawn. AE has not recurred in any of the patients during a follow-up period of up to 21 months. We conclude that AE is a previously unrecognized adverse event associated with SRL use. Close monitoring for this side-effect, especially in AA patients, is warranted.

Lack of donor hyporesponsiveness and donor chimerism after clinical transplantation of the hand.

BACKGROUND: Composite tissue allografts offer great potential in reconstructive surgery. However, the risks of immunosuppression and graft-versus-host disease (GVHD) after transplantation of vascularized bone in these grafts are significant. Transplantation of vascularized bone also may confer donor hematopoietic chimerism and, potentially, tolerance. We have followed two hand transplant recipients for more than 1 year to determine the level of chimerism and possible donor-specific tolerance, in addition to possible GVHD. METHODS: We performed kinetic studies on peripheral blood of two subjects after hand transplantation that included portions of the radius and ulna. We evaluated donor-specific reactivity, chimerism, and antibody production. RESULTS: Donor-specific tolerance did not develop clinically or in mixed lymphocyte reaction. The first subject recovered an excellent in vitro response to phytohemagglutinin, donor and third-party alloantigen, and by month 4 and at month 12 also recovered the ability to respond to Epstein-Barr virus. The second subject also demonstrated good in vitro proliferative responses, which were attenuated by immunosuppression. No phenotypic changes in mature hematopoietic lineages were detected by four-color flow cytometry other than those expected in response to immunosuppression. Donor chimerism was not detectable using four-color flow cytometry. Microchimerism (approximately 1:75,000 cells) was observed at the level of detection in some of the early posttransplantation specimens and was undetectable thereafter. CONCLUSIONS: In this particular transplantation and immunosuppressive regimen, the composite tissue allograft with vascularized bone marrow did not provide the immunologic benefit of tolerance induction nor cause GVHD.

A position statement in support of hand transplantation.

The scientific basis for human trials of hand transplantation was both experimental and clinical. Prolonged survival of limb transplants was achieved in small and large animals by using novel immunosuppressive drugs. Further, all tissue components of the hand (skin, muscle, tendon, nerve, bone, and joint) were individually transplanted with success in humans. After appropriate institutional review of the ethics, experimental data, treatment protocol, and informed consent, clinical trials were approved. Thirteen hands have been transplanted onto 10 recipients, with resultant low morbidity and no mortality. With the exception of one recipient who requested amputation after the second year, results of hand transplantation have been highly successful. Functional return mirrored that seen after hand replantation. The limbs were progressively integrated into activities of daily living and professional tasks. The hand and patient survival rate exceeds the initial results of any previously transplanted organ. This success strongly supports continuation of these human trials.