Perioperative Challenges in Patients Transplanted with Livers from Extreme Obese Donors.

The combination of rising rates of obesity and the shortage of deceased donor livers have forced the consideration of marginal liver donors in terms of body mass index (BMI) for liver transplantation (LT). To date, there are still conflicting data on the impact of donor obesity on post-LT outcomes. We analyzed all patients undergoing LT alone in the United States (US) from October 2005 through December 2019 using the United Network of Organ Sharing (UNOS) data set. We categorized donor BMI >40 kg/m2 as extremely obese (EO). Primary endpoints included 30-day perioperative mortality and early graft loss (EGL) within 7 days. A subgroup analysis was performed for the EO donor group to assess how macrovesicular steatosis (MaS) >30% affects 30-day mortality and EGL within 7 days. A total of 72,616 patients underwent LT during the study period. The 30-day perioperative mortality was significantly higher in the EO donor group (P = 0.02). On multivariate analysis, recipients undergoing LT with EO donors had a 38% higher 30-day mortality risk (odds ratio [OR], 1.38; 95% confidence interval [CI], 1.21-1.69) and 53% increased risk of EGL (OR, 1.53; 95% CI, 1.22-1.90). MaS >30% was independently associated with a 2-fold increased risk of 30-day mortality (P = 0.003) and 3.5-fold increased risk of EGL within 7 days (P < 0.001). The impact of MaS >30% in EGL was 2-fold for all patients transplanted during the study period compared with 3.5-fold in the EO donor group. There is an increased risk of EGL and 30-day perioperative mortality in recipients transplanted with EO donors. Future studies are warranted in morbid and super obese donors to assess the possible effect of obesity-related proinflammatory factors in EGL.

Younger Age Is Associated with Improved Survival in Patients Undergoing Liver Transplantation Alone for Metastatic Neuroendocrine Tumors.

BACKGROUND: Neuroendocrine tumor (NET) metastases are a major cause of morbidity and mortality. The role of liver transplantation to treat unresectable metastases from NET is controversial. METHODS: We evaluated outcomes of all patients undergoing "isolated" liver transplantation (LT) for metastatic NETs in the USA, from October 1988 through June 2018 using the UNOS dataset. RESULTS: During the study period, 160,360 LTs were performed. Two hundred six adult patients underwent "isolated" LT for metastatic NETs. The mean (SD) age was 48.2 (11.7) years, ranging from 19 to 75 years; 117 (56.8%) patients were male. Overall 1-, 3-, 5-, and 10-year patient survival rates were 89.1%, 75.3%, 64.9%, and 46.1%, respectively. Tumor recurrence was seen in 70 of 206 patients who underwent LT (34%). The median time to recurrence was 28 months (range, 1 to 192 months) and median wait time for LT was 112 days. Tumor recurrence was significantly higher in transplanted patients waiting less than 6 months compared with those waiting more than 6 months (74.3% vs. 25.7%). Patients' age ≤ 45 years had significantly better survival compared with those > 45 years (p = 0.03). Younger patients with carcinoid tumors had better survival but this trend was not observed in the non-carcinoid group. On multivariable analysis, recipient age, donor age, cold ischemic time MELD score, and tumor recurrence were significant predictors of poor patient survival. CONCLUSIONS: Waiting time longer than 6 months is associated to lower rates of tumor recurrence. Younger patients ≤ 45 years had significantly improved survival after LT for NET metastases.

Fibrinogen, COPD and mortality in a nationally representative U.S. cohort.

BACKGROUND: Fibrinogen is a marker of systemic inflammation and may represent an important biomarker for the progression of chronic obstructive pulmonary disease (COPD). METHODS: We used baseline data from the Third National Health and Nutrition Examination Survey (NHANES III) and follow-up mortality data to determine the relation between fibrinogen levels and COPD and to examine how fibrinogen levels at baseline affected long-term outcomes. Elevated fibrinogen was defined as the upper 10% of the fibrinogen level distribution. RESULTS: Our study sample included 8,507 subjects, including 245 with Stage 3 or 4 COPD and 826 with Stage 2 COPD. Then, 3,290 of the 8,507 subjects died during the follow-up period. The mean fibrinogen level was 303.6 g/dL and 10% of the sample had levels higher than 403.0 mg/dL. Subjects with Stage 3 or 4 COPD were more likely to have a fibrinogen level > 403.0 mg/dL (odds ratio 3.4, 95% confidence interval [CI], 2.1, 5.6) than were people with normal lung function, after adjusting for covariates. An elevated fibrinogen level increased the risk of mortality (hazards ratio [HR] 1.36, 95% CI 1.13, 1.63) in the entire study sample and in subjects with Stage 3 or 4 (HR 2.11, 95% CI 1.27, 3.50) or Stage 2 (HR 1.45, 95% CI 1.08, 1.96) COPD. CONCLUSION: In the nationally representative NHANES III data, impaired lung function is a correlate of fibrinogen levels and the presence of higher fibrinogen levels increases the risk of mortality both in the overall population and among subjects with COPD.

Fibrinogen, chronic obstructive pulmonary disease (COPD) and outcomes in two United States cohorts.

BACKGROUND: Fibrinogen is a marker of systemic inflammation and may be important in the pathogenesis and progression of chronic obstructive pulmonary disease (COPD). METHODS: We used baseline data from Atherosclerosis Risk in Communities and Cardiovascular Health Studies to determine the relation between fibrinogen levels and COPD and to examine how fibrinogen levels at baseline affected outcomes of death, development of COPD, lung function decline, and COPD-hospitalizations. RESULTS: Our study sample included 20,192 subjects, of whom 2995 died during the follow-up period. The mean fibrinogen level was 307.6 mg/dL and 10% of the sample had levels >393.0 mg/dL. Subjects with Stage 3 or 4 COPD were more likely to have a fibrinogen level >393.0 mg/dL (odds ratio 2.28, 95% confidence interval [CI]: 1.79-2.95). In the longitudinal adjusted models, fibrinogen levels >393 mg/dL predicted mortality (hazards ratio 1.54, 95% CI: 1.39-1.70), COPD-related hospitalization (hazards ratio 1.45, 95% CI: 1.27-1.67), and incident Stage 2 COPD (odds ratio 1.36, 95% CI: 1.07-1.74). Similar findings were seen with continuous fibrinogen levels. CONCLUSION: In the Atherosclerosis Risk in Communities/Cardiovascular Health Studies cohort data, higher fibrinogen levels are predictors of mortality, COPD-related hospitalizations, and incident Stage 2 COPD.