Would a 6-Month Wait Time for Patients With Hepatocellular Carcinoma Improve Organ Allocation in Centers With Active Living Related Liver Transplant Activity?

OBJECTIVES: The Model for End-Stage Liver Disease score is used to prioritize patients awaiting liver transplant. Since hepatocellular carcinoma does not affect the score, patients with hepatocellular carcinoma are given exception points to promote fairness. In the United States,this practice has resulted in overcorrection; hence, a 6-month delay to grant exceptions was implemented. A similar flaw may exist in Saudi Arabia. MATERIALS AND METHODS: We retrospectively reviewed data for 214 adults listed for liver transplant from January 2016 to July 2020 at King Abdulaziz Medical City, Riyadh. Data included diagnoses, Model for End-Stage Liver Disease scores, wait times, and outcomes. Comparative analyses were performed to contrast patients with hepatocellular carcinoma versus patients without hepatocellular carcinoma. RESULTS: Mean age was 55.2 ± 11.6 years, and 61% were male patients. Outcomes were that the patient received a transplant(77%; n = 165/214), dropped out (18%; n = 38/214), or remained on the wait (5%; n = 11/214). Of the hepatocellular carcinoma group, 84% (n = 56/68) received transplant versus 74% (n = 108/146) in the control group (P = .11). There was no significant difference in dropout rates (P = .33). Patients with hepatocellular carcinoma constituted 32% (n = 68/214) ofthe waitlist, yetthey received 40% of deceased organ offers (P = .015). Most patients in the hepatocellular carcinoma group received pretransplant bridging therapy for a median of 166 days (101-329.5 days). Median time from listing to transplant was shorter for the control group, 57 days versus 148 days (P < .001). Long-term outcomes were comparable between both groups. CONCLUSIONS: This study suggests that implementation of the 6-month wait time for patients with hepatocellular carcinoma before granting exception points may not be necessary for active living related liver transplant programs. Nevertheless, this remains a sound strategy to follow.

Urinary Tract Infections in the First 6 Months after Renal Transplantation.

PURPOSE: Urinary tract infections (UTIs) are common in the first 6 months after renal transplantation, and there are only limited data about UTIs after transplantation in Saudi Arabia in general. METHODS: A retrospective study from January 2017 to May 2020 with 6-month follow-up. RESULTS: 279 renal transplant recipients were included. Mean age was 43.4 ± 16.0 years, and114 (40.9%) were women. Urinary stents were inserted routinely during transplantation and were removed 35.3 ± 28 days postoperatively. Ninety-seven patients (35%) developed urinary tract infections (UTIs) in the first six months after renal transplantation. Of those who developed the first episode of UTI, the recurrence rates were 57%, 27%, and 14% for having one, two, or three recurrences, respectively. Late urinary stent removals, defined as more than 21 days postoperatively, tended to have more UTIs (OR: 1.43, P: 0.259, CI: 0.76-2.66). Age >40, female gender, history of neurogenic bladder, and transplantation abroad were statistically significant factors associated with UTIs and recurrence. Diabetes, level of immunosuppression, deceased donor renal transplantation, pretransplant residual urine volume, or history of vesicoureteral reflux (VUR) was not associated with a higher incidence of UTIs. UTIs were asymptomatic in 60% but complicated with bacteremia in 6% of the cases. Multidrug resistant organisms (MDROs) were the causative organisms in 42% of cases, and in-hospital treatment was required in about 50% of cases. Norfloxacin + Bactrim DD (160/800 mg) every other day was not associated with the lower risk of developing UTIs compared to the standard prophylaxis daily Bactrim SS (80/400 mg). CONCLUSION: UTIs and recurrence are common in the first 6 months after renal transplantation. Age >40, female gender, neurogenic bladder, and transplantation abroad are associated with the increased risk of UTIs and recurrence. MDROs are common causative organisms, and hospitalization is frequently required. Dual prophylactic antibiotics did not seem to be advantageous over the standard daily Bactrim.

Clinical Practice Guidelines for Liver Transplantation in Saudi Arabia.

The demand for liver transplantation in the Kingdom of Saudi Arabia (KSA) is associated with the country's high burden of liver disease. Trends in the epidemiology of liver transplantation indications among recipients in KSA have changed over 20 years. Non-alcoholic steatohepatitis has eclipsed the hepatitis C virus in the country due to the effective treatment strategies for HCV. Risk factors for NASH, like type 2 diabetes mellitus, obesity, and hyperlipidemia, are becoming a major concern and a leading indication for liver transplantation in the KSA. There is also a significantly increased prevalence and incidence of genetic adult familial liver diseases in KSA. New immunosuppressive agents and preservation solutions, improved surgical capabilities, and early disease recognition and management have increased the success rate of liver transplant outcome but concerns about the side effects of immunosuppressive therapy can jeopardise long-term survival outcomes. Despite this, indications for liver transplantation continue to increase, resulting in ongoing challenges to maximize the number of potential donors and reduce patient mortality rate while expecting to get transplanted. The Saudi Center of Organ Transplant is the recognized National Organ Donation Agency for transplantation, which renders important support for procurement and allocation of organs. This guidance document aims to help healthcare providers in managing patients in the liver transplant setting.

The Impact of Timing of Stent Removal on the Incidence of UTI, Recurrence, Symptomatology, Resistance, and Hospitalization in Renal Transplant Recipients.

PURPOSE: To evaluate the impact of early (<3 weeks) versus late (>3 weeks) urinary stent removal on urinary tract infections (UTIs) post renal transplantation. METHODS: A retrospective study was performed including all adult renal transplants who were transplanted between January 2017 and May 2020 with a minimum of 6-month follow-up at King Abdulaziz Medical City, Riyadh, Saudi Arabia. RESULTS: A total of 279 kidney recipients included in the study were stratified into 114 in the early stent removal group (ESR) and 165 in the late stent removal group (LSR). Mean age was 43.4 ± 15.8; women: n: 114, 40.90%; and deceased donor transplant: n: 55, 19.70%. Mean stent removal time was 35.3 ± 28.0 days posttransplant (14.1 ± 4.6 days in the ESR versus 49.9 ± 28.1 days in LSR, p < 0.001). Seventy-four UTIs were diagnosed while the stents were in vivo or up to two weeks after the stent removal "UTIs related to the stent" (n = 20, 17.5% in ESR versus n = 54, 32.7% in LSR; p=0.006). By six months after transplantation, there were 97 UTIs (n = 36, 31.6% UTIs in ESR versus n = 61, 37% in LSR; p=0.373). Compared with UTIs diagnosed after stent removal, UTIs diagnosed while the stent was still in vivo tended to be complicated (17.9% versus 4.9%, p: 0.019), recurrent (66.1% versus 46.3%; p: 0.063), associated with bacteremia (10.7% versus 0%; p: 0.019), and requiring hospitalization (61% versus 24%, p: 0.024). Early stent removal decreased the need for expedited stent removal due to UTI reasons (rate of UTIs before stent removal) (n = 11, 9% in the early group versus n = 45, 27% in the late group; p=0.001). The effect on the rate of multidrug-resistant organisms (MDRO) was less clear (33% versus 47%, p: 0.205). Early stent removal was associated with a statistically significant reduction in the incidence of UTIs related to the stent (HR = 0.505, 95% CI: 0.302-0.844, p=0.009) without increasing the incidence of urological complications. Removing the stent before 21 days posttransplantation decreased UTIs related to stent (aOR: 0.403, CI: 0.218-0.744). Removing the stent before 14 days may even further decrease the risk of UTIs (aOR: 0.311, CI: 0.035- 2.726). CONCLUSION: Early ureteric stent removal defined as less than 21 days post renal transplantation reduced the incidence of UTIs related to stent without increasing the incidence of urological complications. UTIs occurring while the ureteric stent still in vivo were notably associated with bacteremia and hospitalization. A randomized trial will be required to further determine the best timing for stent removal.

Quality of life in living kidney donors: A single-center experience at the king abdulaziz medical city.

Chronic kidney disease (CKD) results in irreversible decline in renal function, which ultimately progresses to end-stage renal disease (ESRD). Transplantation is the treatment of choice for ESRD, and this is possible only if donor kidneys are available. Several doubts can appear in the minds of donors and among general public regarding the quality of life (QOL) after donation which can affect the willingness to donate. Therefore, we aimed to assess the QOL in living kidney donors in King Abdulaziz Medical City, Riyadh, Saudi Arabia using the kidney disease QOL instrument short form (KDQOL-SF). This was a cross-sectional survey of living kidney donors between 18 and 65 years of age who donated their kidneys between 2008 and 2014 and was conducted in the hepatobiliary and transplantation department of our hospital. The study measured 17 domains in KDQOL-SF. Each domain score is up to 100; the higher the score in each domain, the better the QOL. Data will be entered and analyzed using Statistical Package for the Social Sciences version 21.0. The descriptive statistics will be presented as frequency and percentage for the categorical variables (e.g., gender and income) and the mean ± SD for numerical variables (e.g., QOL score). The study included 60 donors who donated during the study period between 2008 and 2014. Males were 49 (82%) with the age (mean ± standard deviation) as 32 ± 6.5 years. The donors reported an "overall-mean-score" of 86.7 ± 14.6. Four domains had lower scores between 60 and 80: "sleep" (61.8 ± 13.8), "emotional-well-being" (71.6 ± 11.1), "quality-of-social-interaction," and "energy/fatigue." The other 13 domains had scores >80. The two highest domains: "role-physical" (97.9 ± 13.3) and "effect-of-kidney-disease" (97.4 ± 8). Comparing males and females scores, work status was higher in males with P = 0.03. Our findings suggest that donors have a good QOL which may result in more donations. It is important to improve the standard of care for donors to enable them to live their life to the fullest.

Long-term outcome after liver transplantation for hepatic schistosomiasis: a single-center experience over 15 years.

Our objective was to study the long-term outcomes of patients who had undergone liver transplantation because of schistosomiasis at our institute over the last 15 years. Four hundred forty-one patients underwent liver transplantation at our institute, and 14 did so for schistosomiasis. The survival of patients who underwent transplantation for schistosomiasis was compared with that of patients who underwent transplantation for other liver diseases. Survival curves were drawn via the Kaplan-Meier method and were compared with the log-rank test. P < 0.05 was considered significant. All 14 patients were male, and the average age was 56.8 ± 8.4 years. The average Model for End-Stage Liver Disease score was 18.2 ± 5.6, and the average Child-Pugh score was 10.6 ± 1.2. All patients had splenomegaly; pretransplant variceal bleeding occurred in 7 patients (50%), and portal vein thrombosis was diagnosed in 5 patients (36%). Patient survival was 75% 1 year after transplantation and 75% at the end of follow-up because no patients were lost after the first year. Patients who underwent transplantation for other causes achieved survival rates of 86% and 76% 1 and 10 years after transplantation, respectively. There was no significant survival difference between the 2 groups (P = 0.66). All patients who survived the early posttransplant period had functioning liver grafts with no reported diagnoses of schistosomiasis in the new grafts. In conclusion, liver transplantation for patients with schistosomiasis has a favorable outcome with no risk of reactivation.

Outcome of duct-to-duct vs. Roux-en-Y hepaticojejunostomy biliary anastomoses in below 15-kg pediatric liver transplant recipients.

The best type of biliary anastomosis to use in lower weight pediatric liver transplant recipients is debatable. In this study, we share a single center's experience comparing the rate of anastomotic biliary complications based on the type of biliary anastomosis performed in this population of patients. A retrospective review of pediatric liver transplants for recipients weighing <15 kg from 11/2003 till 12/2011 was performed. Patients were grouped based on the type of biliary anastomosis into two groups: duct-to-duct (d-d) and Roux-en-Y hepaticojejunostomy (h-j) anastomoses. A total of 24 patients (12 males, 12 females) with a mean age of 26 ± 20 months and a mean weight of 9.27 ± 2.63 kg (range = 5.3-13.9 kg) were studied. All anastomotic complications occurred in patients who received left lateral segments. No statistical differences were found in the post-operative biliary (p = 0.86) or vascular (p = 0.99) complications between the two groups. Acknowledging the limited sample size, our data suggest that duct-to-duct anastomosis can be performed safely in pediatric liver transplantation recipients weighing below 15 kg.

Endoscopic extraction of vascular embolization coils that have migrated into the biliary tract in a liver transplant recipient.

Hepatic artery pseudoaneurysm (HAA) is a rare vascular complication of liver transplantation. Minimally invasive radiological interventions are generally considered before seeking surgical treatment of HAA. Coil embolization of the aneurysmal sac and or exclusion of pseudoaneurysm by deploying a stent over the aneurysm are effective interventions to control hemobilia arising from the HAA. Migration of coils inside the bile duct is a rarely reported complication in post-hepatic transplantation. Treatment options remain largely unexplored due to the rarity of its occurrence. Endoscopic retrograde cholangiographic removal of migrated vascular coils in the common bile duct following embolization of HAA has not been described in a liver transplant setting. We report a liver transplant recipient who underwent uneventful and successful endoscopic removal of migrated coils into the bile duct.

Outcomes in esophageal atresia and tracheoesophageal fistula.

BACKGROUND/PURPOSE: The purpose of this analysis was to investigate outcomes in newborns with esophageal atresia (EA) or tracheoesophageal fistula (TEF) with respect to prognostic classifications and complications. METHODS: Charts of all 144 infants with EA/TEF treated at British Columbia Children's Hospital (BCCH) from 1984 to 2000 were reviewed. Patient demographics, frequency of associated anomalies, and details of management and outcomes were examined. RESULTS: Applying the Waterston prognostic classification to our patient population, survival rate was 100% for class A, 100% for class B, and 80% for class C. The Montreal classification survival rate was 92% for class I and 71% for class II (P =.08). Using the Spitz classification, survival rate was 99% for type I, 84% for type II, and 43% for type III (P <.05). The Bremen classification survival rate was 95% "without complications" and 71% "with complications." Complications included stricture (52%), gastroesophageal reflux (31%), anastomotic leakage (8%), recurrent fistula (8%), and pneumonia (6%). Seventeen patients underwent fundoplication for gastroesophageal reflux, 16 pre-1992 and one post-1992. CONCLUSIONS: Comparing the major prognostic classifications, the Spitz classification scheme was found to be most applicable. In our institution, the trend in management of gastroesophageal reflux after repair of EA/TEF has moved away from fundoplication toward medical management.