Transplant tourism - a missed opportunity.

PURPOSE OF REVIEW: To explore the resurgence of transplant tourism (TT) despite the recent reiteration of the Declaration of Istanbul (DoI) in 2018. As demand grows exponentially and supply remains static, novel approaches to bridging the gap should be explored. RECENT FINDINGS: TT is estimated to comprise up to 10% of transplants worldwide. Prosecuting patients seeking organs through TT has been unsuccessful. Extra jurisdictional prosecution of brokers, vendors and institutions participating in illicit TT has been difficult. Resurgence of TT has occurred in both "traditional" and new countries. The public attitude towards TT and paid donation is largely positive. The Iranian experience with state regulated paid donors merits attention and perhaps emulation. Numerous philosophers, ethicists and transplant professionals find it acceptable to promote financial consideration for organ donors. SUMMARY: Acknowledging the autonomy of persons, including poor and vulnerable ones, to receive financial consideration for their sacrifice should not be considered morally reprehensible. Strict international regulation, oversight and legislation should be implemented to assure adequate compensation, donor wellbeing, elimination of brokers and excellent medical care. Implementing such a system internationally may eliminate kidney waiting lists, provide great benefits to vendors, improve transplant facilities in developing countries and provide substantial savings to insurers.

The Effect of a 26-Hour Fast in Living Kidney Donors.

BACKGROUND: Living kidney donation is widely practiced, and short- and long-term outcomes are acceptable. Within the living kidney donor population there are unique ethnic groups who practice customs that affect kidney function. In Judaism, Yom Kippur (Day of Atonement) is a 25- to 26-hour fast practiced yearly. There are no studies describing the effect of this fast on LKDs. METHODS: Living kidney donors were approached via e-mail. Exclusion criteria were conditions considered prohibitive of fasting. Control participants were potential living kidney donors approved by the standard medical evaluation but that had not yet donated. Blood and urine samples were obtained at 3 time points: baseline: 3 months before fast; fasting: 1 hour after fast; and follow-up: 14 days after fast. RESULTS: In total, 85 living kidney donors and 27 control participants were included. Donors were older (42.8 vs 38.8 years) and had a higher baseline creatinine (103 vs 72 umol/L). All other parameters were the same. The percent change between fasting and nonfasting creatinine was smaller in living kidney donors than in control participants (0.12% vs 0.21% change, P = .04). Values of sodium, albumin, and osmolarity were not different between groups. Time from donation did not influence results. CONCLUSIONS: Living kidney donors practicing a day fast showed a different pattern regarding the change in creatinine levels. This pattern cannot be considered hazardous for living kidney donors. The emotional wellbeing of living kidney donors is of utmost importance, and this first report of the safety of a 24-hour fast is reassuring. These findings may be of interest to other religious groups, for example, the Muslim community which observes Ramadan.

Prognosis and Treatment of Liver Transplant Recipients in the COVID-19 Era: A Literature Review.

Liver transplantation during the COVID-19 pandemic is challenging. Both donor and recipient issues can be influenced by the risks attributed to the pandemic. Allocation policy may need to be modified and criteria may be influenced by local infection rates and availability of medical facilities. Modifying immunosuppression (IS) protocols is controversial and is not evidence-based. In this study, we review the published literature on liver transplant recipients who were infected with COVID-19. A literature review was performed using PubMed, ScienceDirect, and WHO databases to identify relevant English-language articles published up to May 20, 2020. Fifteen articles reported 120 liver transplant recipients who were infected with COVID-19. Only 10 papers with 22 patients reported full encounter characteristics. Four papers reported 23, 17, 13, and 6 patients, respectively, but with minimal data. One paper reported the authors' own 39 patients' characteristics and demographics. The mean age was 58.2 years with 66% males. The most commonly reported presentations in descending order were fever (91%), cough (36.7%), shortness of breath (SOB) (31.8%), and diarrhea (31.8%). Liver transplant patients infected with COVID-19 were maintained on Tac (79%), mycophenolate (MMF) (48.4%), and Prednisone (29.6%) and were managed by reducing MMF in 14.3% of patients and reducing Tac in 14.3% of patients; 28.6% of patients needed ICU admission, 13.6% of patients had died, and the reported general population COVID-19 mortality rate was 3.4%. The clinical presentation of COVID-19 in liver transplant recipients may be different from the general population, with higher rates of severe disease, complications, and mortality.

Practical recommendations for kidney transplantation in the COVID-19 pandemic.

Kidney transplantation at the time of a global viral pandemic has become challenging in many aspects. Firstly, we must reassess deceased donor safety (for the recipient) especially in communities with a relatively high incidence of coronavirus disease 19 (COVID-19). With respect to elective live donors, if one decides to do them at all, similar considerations must be made that may impose undue hardship on the donor. Recipient selection is also problematic since there is clear evidence of a much higher morbidity and mortality from COVID-19 for patients older than 60 and those with comorbidities such as hypertension, diabetes, obesity and lung disease. Unfortunately, many, if not most of dialysis patients fit that mold. We may and indeed must reassess our allocation policies, but this must be done based on data rather than conjecture. Follow-up routines must be re-engineered to minimize patient travel and exposure. Reliance on technology and telemedicine is paramount. Making this technology available to patients is extremely important. Modifying or changing immunosuppression protocols is controversial and not based on clinical studies. Nevertheless, we should reassess the need for induction therapy across the board for ordinary patients and the more liberal use of mammalian target of rapamycin inhibitors in transplant patients with proven infection.

Kidney Transplantation in the Times of COVID-19 - A Literature Review.

Kidney transplantation at the time of the COVID-19 pandemic is challenging. Modifying the immunosuppression protocols is controversial and not evidence based. In this study, we aim to review the published literature of kidney transplant recipients who encountered COVID-19. A literature review was performed using PubMed, ScienceDirect, and World Health Organization databases to identify relevant English-language articles published up to May 7, 2020. There were 24 articles that reported 129 kidney transplant recipients who encountered COVID-19. The age mean was 54.2 years with 73.7% as males. The most commonly reported presentations in order were fever (82.3%), cough (58%), shortness of breath (33.2%), and fatigue (30.7%). Acute kidney injury was observed in 34.1% of patients. Kidney transplant patients encountered COVID-19 were maintained on tacrolimus (Tac, 92%), mycophenolate mofetil (MMF, 78.8%), and prednisone (Pred, 77%) and were manage by holding MMF in 79.1% of patients and holding Tac in 34.4% of patients. In all, 20% of patients needed Intensive Care Unit (ICU) admission and 24.6% of patients required mechanical ventilation. In all, 18.8% of patients had died compared to the reported general population COVID-19 mortality of 3.4%. The clinical presentation of COVID-19 in kidney transplant recipients may be different from the general population with a higher rate of severe disease, complications including renal failure, and mortality.

Repeat Kidney Transplant in a Patient With a Double Inferior Vena Cava and Difficult Venous Access: A Case Report.

Many obstacles may complicate renal transplant, the preferred treatment for end-stage renal disease. Anatomic anomalies are of special importance during surgery. Double inferior vena cava is a rare anomaly reported in 0.2% to 3% of the population and may complicate renal transplant in certain cases. We present a case of a 29-year-old man with end-stage renal disease who was scheduled for repeat kidney renal transplant from a living related donor. His transplant posed many challenges to the transplant team. These included (1) difficult access for dialysis, which required transhepatic insertion of a dialysis catheter, (2) anomalous inferior vena cava anatomy with a double inferior vena cava, (3) a blocked right inferior vena cava, and (4) a small blocked bridging vein connecting the right inferior vena cava to an additional left inferior vena cava. A stent was inserted into the bridging vein to allow venous drainage from the graft. During the transplant procedure, the donated kidney was transplanted into the left iliac fossa and anastomosed to the left external iliac vein. The surgery was successful, without major operative or postoperative complications. The patient was discharged with normal renal function and enjoys normal renal function 6 months after surgery. This case emphasizes the importance of pretransplant evaluation and preparation and the need for high index of suspicion for anatomic variants in donors and recipients.

Multiplication product of Model for End-stage Liver Disease and Donor Risk Index as predictive models of survival after liver transplantation.

BACKGROUND: Liver transplantation (LT) is the treatment of choice for most end-stage liver diseases. This treatment increases survival rates and improves quality of life. Because of the shortage of organ donors, as opposed to waiting patients, the need to optimize the matching of donors to recipients for maximum utility is crucial. AIM: The aim of this study was to examine a predictive model based on the combination of donor and recipient risk factors using the liver Donor Risk Index (DRI) and recipient Model of End-stage Liver Disease (MELD) to predict patients' survival following LT. PATIENTS AND METHODS: The charts of 289 adult primary LT patients, who had undergone transplantation in Israel between 2010 and 2015, were studied retrospectively using prospectively gathered data. RESULTS: Two variables, DRI and MELD, were found to significantly affect post-transplant patient survival. DRI negatively affected survival in a continuous fashion, whereas MELD had a significantly negative effect only at MELD more than 30. Both female sex and the presence of hepatocellular carcinoma were associated with increased patient survival. CONCLUSION: According to our findings, the model described here is a novel prediction tool for the success of orthotopic LT and can thus be considered in liver allocation.

Successful Embolization of Hemorrhagic Hepatic Hydatid Cyst Followed by Surgical Resection: Report of Two Cases and Review of the Literature.

Hepatic hydatid cysts (HHCs) are common in endemic areas. Mostly they are asymptomatic, but some cause serious complications. We report 2 cases of HHC complicated arterial bleeding. Owing to signs of active bleeding, the patients were treated with selective embolization of the hepatic artery to stop the bleeding and stabilize the patients' condition. Subsequently, partial hepatectomy of the involved liver lobe was performed in an elective setting and without postoperative complications. We recommend bridging therapy by selective angiography and embolization for hemorrhagic hepatic hydatid cyst before definitive surgical treatment.

Operative treatment of hepatic hydatid cysts: A single center experience.

BACKGROUND: Hydatid cyst is a zoonotic disease caused by Echinococcus genera. Surgery is needed in most cases. We aimed to describe our center's experience in the surgical management of hepatic hydated cysts (HHC). METHODS: Data was retrospectively collected for patients who underwent operative management for HHC between the years 1994-2014. RESULTS: Sixty-nine underwent surgical treatment for HHC. Group A included 34 treated with an unroofing procedure, group B included 24 patients who underwent hepatectomy and group C included 11 patients who underwent peri-cystectomy. The median ± (range) age for groups A, B and C were 39.5 (6.5-69), 40 (17-74) and 32 (20-62), respectively (P > 0.1). Post-operative complications occurred in 16, 11 and 5 patients in group A, B and C, respectively, as assessed by clavien-dindo classification (CDC). The average CDC was significantly higher in the hepatectomy group as compared to the unroofing group (2.3 vs.1.5, P = 0.04). Recurrence was significantly higher after the unroofing procedure as compared to the hepatectomy group (P = 0.05). CONCLUSION: Surgery remains the mainstay of treatment for HHC, once surgery is pursued, the results are satisfactory.

Pre-liver transplant psychosocial evaluation predicts post-transplantation outcomes.

Psychosocial factors greatly impact the course of patients throughout the liver transplantation process. A retrospective chart review was performed of patients who underwent liver transplantation at Hadassah-Hebrew University Medical Center between 2002 and 2012. A composite psychosocial score was computed based on the patient's pre-transplant evaluation. Patients were divided into two groups based on compliance, support and insight: Optimal psychosocial score and Non-optimal psychosocial score. Post-liver transplantation survival and complication rates were evaluated. Out of 100 patients who underwent liver transplantation at the Hadassah-Hebrew University Medical Center between 2002 and 2012, 93% had a complete pre-liver transplant psychosocial evaluation in the medical record performed by professional psychologists and social workers. Post-liver transplantation survival was significantly higher in the Optimal group (85%) as compared to the Non-optimal group (56%, p = .002). Post-liver transplantation rate of renal failure was significantly lower in the Optimal group. No significant differences were observed between the groups in other post-transplant complications. A patient's psychosocial status may impact outcomes following transplantation as inferior psychosocial grades were associated with lower overall survival and increased rates of complications. Pre-liver transplant psychosocial evaluations are an important tool to help predict survival following transplantation.

Ocular melanoma metastasizing to intra-abdominal lymph nodes.

Background. Visceral metastatic spread of ocular melanoma most commonly occurs via hematogenous route to the liver. Lymphatic spread of ocular melanoma into abdominal lymph nodes has not been reported previously. Case Presentation. A 47-year-old man with a history of ocular melanoma presented with a soft tissue mass on CT scan. The mass encased the portal structures of the hepaticoduodenal ligament. Image-guided biopsy revealed it to be a metastatic melanoma to lymph nodes. The patient underwent surgery with the intent to prolong disease-free survival. On final pathological examination, two lymph nodes were found harboring metastatic melanoma. Conclusion. Extrahepatic lymphatic intra-abdominal spread of ocular melanoma is not impossible. Since this mode of spread is rare, the oncologic significance of surgical resection of isolated intra-abdominal nodal with metastatic ocular melanoma is difficult to determine at the present time.

Revascularization of the celiac and superior mesenteric arteries after operative injury using both splenic artery and saphenous graft.

We report a case of iatrogenic resection of both the superior mesenteric artery (SMA) and celiac artery during left nephrectomy and adrenalectomy. A 47-year-old woman was diagnosed with a large adrenal tumor and underwent a laparoscopic left adrenalectomy that was converted to open adrenalectomy and nephrectomy as a result of a bulky tumor. Both the SMA and celiac artery were inadvertently cut at their origin because of adherence of the tumor to the aorta. Both arteries were revascularized by anastomosing the distal splenic artery to the aorta after performing splenectomy to revascularize the celiac circulation and using an autologous saphenous vein graft to revascularize the SMA. The patient had no postoperative complications. To our knowledge, this is the first description of use of the splenic artery for celiac revascularization.

Graft survival and its determinants: a 3 year national experience with liver transplantation in Israel.

BACKGROUND: There is a dearth of organs for liver transplantation in Israel. Enhancing our understanding of factors affecting graft survival in this country could help optimize the results of the transplant operation. OBJECTIVES: To report 3 years national experience with orthotopic liver transplantation, and to evaluate patient and perioperative risk factors that could affect 1 year graft survival. METHODS: The study related to all 124 isolated adult liver transplantations performed in Israel between October 1997 and October 2000. Data were abstracted from the medical records. One-year graft survival was described using the Kaplan-Meier survival curve and three multivariate logistic regression models were performed: one with preoperative case-mix factors alone, and the other two with the addition of donor and operative factors respectively. RESULTS: Of the 124 liver transplantations performed, 32 failed (25.8%). The 1 year survival was lower than rates reported from both the United States and Europe but the difference was not significant. Of the preoperative risk factors, recipient age > 60 years, critical condition prior to surgery, high serum bilirubin and serum hemoglobin < or = 10 g/dl were independently associated with graft failure, adjusting for all the other factors that entered the logistic regression equation. Extending the model to include donor and operative factors raised the C-statistic from 0.79 to 0.87. Donor age > or = 40, cold ischemic time > 10 hours and a prolonged operation (> 10 hours) were the additional predictors for graft survival. A MELD score of over 18 was associated with a sixfold increased risk for graft failure (odds ratio = 6.5, P = 0.001). CONCLUSIONS: Graft survival in Israel is slightly lower than that reported from the U.S. and Europe. Adding donor and operative factors to recipient characteristics significantly increased our understanding of 1 year survival of liver grafts.

Minimally invasive techniques in the treatment of liver tumors.

BACKGROUND: Despite advances in cancer therapy the treatment of liver tumors remains a challenge. Most patients are poor candidates for surgical resection; both chemotherapy and irradiation have a low success rate and neither is without complications. New minimally invasive techniques for ablation of unresectable tumors have gained attention as effective treatment alternatives. Among these are percutaneous ethanol injection and radiofrequency ablation; both are effective for primary liver tumors and RFA is also effective for hepatic metastases. OBJECTIVE: To report our experience with PEI and RFA in the treatment of hepatic lesions. METHODS: The study included 49 lesions in 27 patients: 23 primary lesions in 13 patents treated with PEI and 26 lesions (22 secondary and 4 primary) in 14 patients treated with RFA. PEI was performed on an outpatient basis in the ultrasound suite; RFA was done in hospitalized patents (9 in the ultrasound suite and 4 in the operating room). Patients were followed with triphasic spiral computerized tomography 1 month after treatment and every 3-6 months thereafter. RESULTS: Complete necrosis was achieved with PEI on the first attempt in 11 of 23 primary lesions (91.3%). In 8.7% (2/23) a second series of treatments was required. Using RFA, complete necrosis was achieved in 85% of lesions (22/26) and partial necrosis in 15% (4/26). Complications included low fever (3 patients), high fever and abscess formation (1 patient), peri-tumoral necrosis (1 patient) and portal vein thrombosis (1 patient). CONCLUSIONS: Our preliminary results confirm that PEI and RFA are an effective and safe option for treating hepatic tumors in patients unfit for surgery.