Pretransplant Candidates Research Articles

Development of a checklist framework for kidney transplantation.

Kidney transplantation is the therapy of choice for end-stage kidney disease, and a fast-growing transplant procedure worldwide. Diverse clinical practices for recipients and donors' selection and management between transplant centers hinder the creation and dissemination of an anesthesia-surgical checklist. Components of the anesthesia-surgical checklist were selected after a review of the English literature using PubMed search for donor, recipient and graft protocols and outcomes of existing practices in the field of kidney transplantation. Key elements of the most relevant articles were combined with our own center's experience and formulated into the proposed checklist. The checklist is intended to be used perioperatively, once patient receives an offer. The perioperative checklist centers primarily on the following donor and recipient's factors: (i) Review of the pretransplant candidate workup; (ii) Assessment of donor/graft status; (iii) Hypothermic machine perfusion parameters; (iv) Operating room management; (v) Sign out. The proposed kidney transplant checklist was designed to ensure consistency and completeness of diverse tasks and facilitates team communication and coordination. We present a novel standardized combined anesthesia-surgical checklist framework for kidney transplant aimed at increasing perioperative safety and streamline the perioperative care of recipients. Future validation studies will determine its clinical feasibility and post-implementation efficacy.

Wits Transplant Unit Annual Report 2022: Adult and paediatric liver transplantation.

In 2022, the Wits Transplant Unit performed 57 liver transplants: 33/57 adult (58%) and 24/57 paediatric (42%) recipients. At the beginning of 2022, 28 candidates were on the adult waitlist. Forty-six candidates were added to the waitlist during the year. Sixty-five percent of waitlisted candidate were transplanted. Adult candidates remained on the waitlist for longer than previous years, with 52% of them waitlisted for less than one year before undergoing liver transplantation. There was a decrease in adult pretransplant mortality to 9% in 2021 from 25% in 2020. The most common aetiology in waitlist candidates was alcoholic steatohepatitis (ASH)/non-alcoholic steatohepatitis (NASH) (36%) and in recipients cholestatic (primary sclerosing cholangitis (PSC) and primary biliary sclerosis (PBC)) (40%). Most adult recipients received a deceased donor graft (79%). Unadjusted recipient one- and three-year survivals were 75% (95% confidence interval (CI) 65 - 83) and 74% (95% CI 65 - 81), respectively. In the paediatric population, the most common aetiologies for both pretransplant candidates and transplant recipients remained cholestatic disease and acute liver failure. There was a decrease in paediatric pretransplant mortality from 27% in 2017 to 6% in 2021. Unlike the adult cohort, most paediatric recipients received a living donor graft (79%). Unadjusted one-year and three-year survival rates were 85% (95% CI 75 - 92) and 68% (95% CI 56 - 77), respectively.

Identifying gaps in the cascade of care for latent TB infection in a low-incidence setting.

BACKGROUND: The End TB Strategy calls for the global scale-up of treatment for latent TB infection (LTBI). We aimed to evaluate a nurse-led care programme for LTBI by identifying gaps in the care cascade in a low-incidence TB setting.METHODS: We included people at risk of TB over a 15-year period. We define three main outcomes in the LTBI care cascade: 1) attendance at the first appointment, 2) completion of the evaluation process, and 3) completion of treatment.RESULTS: We identified 6,126 individuals (2,369 TB contacts, 1,749 biological therapy candidates, and 2,008 transplant candidates). Overall, 5,938 (96.9%) attended, 5,872/5,938 (98.9%) completed the evaluation and 1,624/1,847 (87.9%) completed treatment. Pre-biological (aOR 2.32, 95% CI 1.54-3.49) and pre-transplant (aOR 1.82, 95% CI 1.20-2.76) candidates were more likely to attend the first appointment, while age was associated with completing the evaluation process (aOR 1.02, 95% CI 1.003-1.04). Female sex (aOR 1.47, 95% CI 1.08-1.99) was associated with completing the treatment.CONCLUSION: Successful assessment and treatment of LTBI is achievable when delivered as a part of a comprehensive, nurse-led, patient-centred programme in specialist TB clinics.

Many a Slip Twixt the Intake Form and the Living Donation.

Many a Slip Twixt the Intake Form and the Living Donation.

Outcomes of malignant melanoma in kidney transplant recipients .

Kidney transplant recipients (KTRs) have an increased risk of skin cancer. We analyzed the outcomes of KTRs transplanted at our center between January 1, 1994, and December 31, 2015, who reported pretransplant melanoma or had post-transplant de novo melanoma. Of 6,522 kidney or kidney with pancreas transplant recipients, 37 had pretransplant melanoma. After adjustment of multiple variables, pretransplant melanoma was associated with overall increased risk of death (HR: 1.75, 95% CI 1.02 - 3.03, p=0.04) but not for death-censored graft failure (DCGF). A total of 46 patients developed post-transplant de novo melanoma. After adjustment of multiple variables, post-transplant de novo melanoma was associated with significant risk for death within the first year of the diagnosis of melanoma (HR: 4.40, 95% CI 2.21 - 8.74, p < 0.001), and DCGF after the first year (HR: 1.93, 95% CI 1.13 - 3.64, p=0.04). Similarly, among all pretransplant candidates (including those with history of melanoma) in Cox regression multivariate analysis, older age (HR: 1.32, 95% CI 0.31 - 1.14, p=0.04) and a history of pretransplant melanoma (HR: 9.27, 95% CI 2.81 - 30.53, p < 0.001) were significantly associated with the risk for development of post-transplant melanoma. Proper risk stratification and early diagnosis may improve patient and graft survival.

Exploration of the Stanford Integrated Psychosocial Assessment for Transplantation With Psychosocial and Medical Outcomes in Kidney and Kidney-Pancreas Transplant Recipients.

The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) is a psychometric instrument designed to assess patient risk for transplant. We investigated the association between SIPAT scores and demographic data with psychosocial and medical outcomes within a diverse kidney/kidney-pancreas transplant population. The SIPAT was administered to all pretransplant candidates. A retrospective review of transplanted patients who had at least 6 months of follow-up was completed. The sample included 136 patients: male (n = 77 [57%]) with a mean age of 47 years old. Thirty-eight percent were black (n = 51), 55% had less than a high school education (n = 74), and 65% had low socioeconomic status (n = 89). Statistical difference was found among SIPAT scores and substance use and support system instability (P = .035, P = .012). Females (P = .012) and patients with a history of psychopathology (P = .002) developed or had a relapse of psychopathology following transplant. Patients with more than a high school education (P = .025) and who were less than 30 years (P = .026) had higher rejection incidence rates. Risk factors for rehospitalizations included Hispanic race, diabetes, and low socioeconomic status (P = .036, P = .038, P = .014). African American/Black and male patients had higher incidence of infection events (P = .032, P = .049). Mortality and treatment nonadherence were not significantly associated with SIPAT scores or demographic variables. The SIPAT was associated with posttransplant substance use and support system instability, while demographic variables were associated with the development and/or relapse of psychopathology, graft loss, rejection, infection events, and medical rehospitalizations. Revision of the SIPAT to include additional demographic components may lend to improved prediction of transplant outcomes.

Psychosocial Assessment of Candidates for Transplantation (PACT) Score Identifies High Risk Patients in Pediatric Renal Transplantation.

Background: Currently, there is no standardized approach for determining psychosocial readiness in pediatric transplantation. We examined the utility of the Psychosocial Assessment of Candidates for Transplantation (PACT) to identify pediatric kidney transplant recipients at risk for adverse clinical outcomes.Methods: Kidney transplant patients <21-years-old transplanted at Duke University Medical Center between 2005 and 2015 underwent psychosocial assessment by a social worker with either PACT or unstructured interview, which were used to determine transplant candidacy. PACT assessed candidates on a scale of 0 (poor candidate) to 4 (excellent candidate) in areas of social support, psychological health, lifestyle factors, and understanding. Demographics and clinical outcomes were analyzed by presence or absence of PACT and further characterized by high (≥3) and low (≤2) scores.Results: Of 54 pediatric patients, 25 (46.3%) patients underwent pre-transplant evaluation utilizing PACT, while 29 (53.7%) were not evaluated with PACT. Patients assessed with PACT had a significantly lower percentage of acute rejection (16.0 vs. 55.2%, p = 0.007). After adjusting for HLA mismatch, a pre-transplant PACT score was persistently associated with lower odds of acute rejection (Odds Ratio 0.119, 95% Confidence Interval 0.027–0.52, p = 0.005). In PACT subsection analysis, the lack of family availability (OR 0.08, 95% CI 0.01–0.97, p = 0.047) and risk for psychopathology (OR 0.34, 95% CI 0.13–0.87, p = 0.025) were associated with a low PACT score and post-transplant non-adherence.Conclusions: Our study highlights the importance of standardized psychosocial assessments and the potential use of PACT in risk stratifying pre-transplant candidates.

The Effects of Religious and Cultural Beliefs on Muslim Transplant Candidates During the Pretransplant Waiting Period

Background:Awaiting organ transplantation can be stressful, and pretransplant candidates’ religious and cultural beliefs can influence how they adapt to the stress. While little is known about the effect religious and cultural beliefs have on the pretransplant waiting period, virtually nothing is known regarding whether and how Shia Muslim patients’ religious and cultural beliefs facilitate more positive patient outcomes while they await transplantation. Therefore, it is important for nurses and other health care providers to understand transplant candidates’ experiences dealing with the stressors that present themselves during the pretransplant waiting period, especially how their religious and cultural beliefs affect their adaptation to the stressors.Aim:The purpose of this study was to explore the lived experience of Shia Muslim organ transplant candidates regarding how their religious and cultural beliefs affect their adaptation to the pretransplant waiting period.Sample:A purposeful sample of 11 Shia Muslim organ transplant candidates who were on an organ transplant waiting list in Iran (kidney,n= 4; heart,n= 4; liver,n= 3) was recruited.Method:A qualitative research design using the hermeneutical phenomenological approach was utilized in this study. In-depth unstructured interviews were conducted by one of the authors (ZS) in different locations across Iran.Results:Data analysis led to the development of six themes: “the misty road of organ transplantation,” “to accede to organ transplantation despite religious conflict,” “one step away from death,” “the master key of liberation,” “fear of the unknown,” and “reliance on God.”Nursing Implications:The findings of this study will help nurses understand the religious and cultural meaning associated with stressors experienced by Shia Muslim patients awaiting organ transplant. This information can assist nurses to develop plans of care that include patient-specific interventions that take into consideration the patients’ religious and cultural beliefs.Conclusion:Shia Muslim patients awaiting organ transplantation experience feelings that are often in conflict with their religious and cultural beliefs. However, the patients’ reliance on God during the pretransplant waiting period facilitated healthier attitudes regarding transplantation.

The Effects of Religious and Cultural Beliefs on Muslim Transplant Candidates During the Pretransplant Waiting Period.

Awaiting organ transplantation can be stressful, and pretransplant candidates' religious and cultural beliefs can influence how they adapt to the stress. While little is known about the effect religious and cultural beliefs have on the pretransplant waiting period, virtually nothing is known regarding whether and how Shia Muslim patients' religious and cultural beliefs facilitate more positive patient outcomes while they await transplantation. Therefore, it is important for nurses and other health care providers to understand transplant candidates' experiences dealing with the stressors that present themselves during the pretransplant waiting period, especially how their religious and cultural beliefs affect their adaptation to the stressors. The purpose of this study was to explore the lived experience of Shia Muslim organ transplant candidates regarding how their religious and cultural beliefs affect their adaptation to the pretransplant waiting period. A purposeful sample of 11 Shia Muslim organ transplant candidates who were on an organ transplant waiting list in Iran (kidney, n = 4; heart, n = 4; liver, n = 3) was recruited. A qualitative research design using the hermeneutical phenomenological approach was utilized in this study. In-depth unstructured interviews were conducted by one of the authors (ZS) in different locations across Iran. Data analysis led to the development of six themes: "the misty road of organ transplantation," "to accede to organ transplantation despite religious conflict," "one step away from death," "the master key of liberation," "fear of the unknown," and "reliance on God." The findings of this study will help nurses understand the religious and cultural meaning associated with stressors experienced by Shia Muslim patients awaiting organ transplant. This information can assist nurses to develop plans of care that include patient-specific interventions that take into consideration the patients' religious and cultural beliefs. Shia Muslim patients awaiting organ transplantation experience feelings that are often in conflict with their religious and cultural beliefs. However, the patients' reliance on God during the pretransplant waiting period facilitated healthier attitudes regarding transplantation.

Evaluation of Carotid Ultrasonography Screening Among Kidney Transplant Candidates: A Single-Center, Retrospective Study.

BackgroundKidney transplant candidates undergo rigorous testing prior to clearance for transplantation. Because kidney transplant candidates may be at increased risk for carotid artery stenosis because of arteriosclerosis and atherosclerosis secondary to hypertension, vascular calcification, and diabetes, carotid ultrasound is often performed with the intent of preventing a cerebrovascular accident in the perioperative or posttransplant period. To our knowledge, there has not been a study investigating the utility of screening carotid ultrasonography in pretransplant candidates. The purpose of the present study was to investigate the yield of carotid ultrasonography in end-stage renal disease patients, at high risk for having clinically significant vascular disease evaluated at our center for kidney transplantation during the years 2009 to 2014.MethodsData for carotid ultrasound findings and risk factors for carotid artery disease were extracted from the medical records.ResultsA total of 882 patients were included in our study of which only 13 patients (1.47% of the cohort) had significant carotid artery stenosis (>70%) on ultrasound testing. Using multiple logistic regression on the outcome of carotid stenosis, congestive heart failure (adjusted odds ratio, 5.2), and peripheral vascular disease (adjusted odds ratio, 4.4) were positively associated with carotid stenosis.ConclusionsThe prevalence of significant carotid artery stenosis was only 1.47% in our cohort of kidney transplant candidates, and the routine use of carotid ultrasound testing in this population may not be an efficient use of clinical resources. Use of risk factors, such as congestive heart failure or peripheral vascular disease, may identify patients who are more likely to benefit from carotid ultrasonography screening.

Understanding the lung allocation score for the non-transplant pulmonologist

In order to better allocate scarce donor lung organs, the lung allocation score (LAS) was implemented in May 2005. The goals of the LAS were to reduce waiting list mortality of lung transplant candidates, to prioritize candidates based on medical urgency, and to maximize overall lung transplant benefit. Pre-transplant candidate variables are used to calculate waiting list survival, post-transplant survival, and transplant benefit measures. These measures produce a numerical lung allocation score between 0 and 100 with a higher score recipient receiving a greater priority ranking for donor lungs. LAS implementation improved candidate waiting list time and prioritized patients with the greatest medical urgency. However, waiting list mortality has not improved and further revisions to predicting variables have been implemented to better reflect the current transplant candidate population. One-year post-transplant survival in the post-LAS era has not changed compared to that in the pre-LAS era.

Section 3. Current status of downstaging of hepatocellular carcinoma before liver transplantation.

Liver transplantation (LT) is a well-established option of cure for hepatocellular carcinoma (HCC). Milan criteria is recognized as standard for selection of patients and set the baseline of survival to be achieved. It has been shown that tumor biology including differentiation, vascular invasion, and serum α-fetoprotein (AFP) predict posttransplant recurrence and survival better than morphology. Downstaging by locoregional therapies of HCC before LT, with the response to treatments and progression within observation period, serves as a selection tool rather than modulation of tumor biology. It selects those patients outside standard criteria at presentation but good tumor biology and high chance of good outcome to receive transplantation. The definition of downstaging should be differentiated from neo-adjuvant therapy, and the objectives in surgical and pretransplant candidates also differ.Published studies in this area showed variation in inclusion criteria, downstaging protocol and assessment of successful downstaging. Tumor biology predownstaging and postdownstaging was not incorporated. Posttransplant outcome were not clearly stated with regard to intention-to-treat survival, disease-free survival, and comparison against those originally within criteria. Meta-analysis of these results was impossible. Nevertheless, majority had reasonable protocol and were able to select patients whom likely to have good outcome. At present, there is no evidence that downstaged patients have a poorer prognosis than those presenting within the Milan criteria. Patients with tumors outside Milan criteria should be offered downstaging therapies. Those who are successfully downstaged to within Milan criteria should be eligible to liver transplant as same as those initially fit the criteria. In the last decade, various extended criteria of HCC for LT have been proposed and reported satisfactory survival. That makes downstaging technically unnecessary.To refine and validate the role of downstaging, it needs collaborative and prospective study with significant sample size, adequate preoperative staging, standardized protocol of selection of patients, and approaches to downstaging. Selection criteria should include histopathological data on tumor biology and serum AFP. There should be standardized definition of successful downstaging. Posttransplant disease-free survival should be reported in detail and compared with those who fit the standard criteria initially. A consistent immunosuppressant protocol is important to avoid bias.

How to manage malignant tumors surgery in patients supported with long term implantable left ventricular assist device?

Background Left ventricular assist devices are increasingly used as bridges to transplantation. Malignant tumors can be discovered on the pre-implantation or pre-transplantation screening and surgeons may be required to perform tumors resection in those patients. We reported our experience on this challenge given the hemodynamic, hematologic and outcome considerations. Methods 34 patients underwent implantation of Heartmate II (HMII); we performed 4 resections of malignant tumors: 2 partial nephrectomies for renal tumors (8 months after implantation), a left segmentectomy for lung cancer (2 years later) under videothoracoscopy and a tumorectomy with lymphadenectomy for breast cancer (9 months later). Renal tumors were diagnosed during the pre-implantation screening; while the others were diagnosed after the device’s implantation. Results Invasive surgical approach can be difficult in patients with heart failure; therefore we decided to support them with HMII before the renal tumor’ sr esection. Surgery in patients supported with HMII device expose to bleeding as well as hemostasis revealed an acquired Von Willebrand disease in 2 patients. 5 days prior to the surgery, we substituted Vitamin K antagonist with heparin (PTT1,5- 2). None of them experienced bleeding. During surgery, the use of the right lateral decubitus in 3 patients resulted in decreased cardiac output, which was resolved with vasopressor, hydration and decrease of the pump speed. Length of stay in intensive care unit was 1-4 days and reoperation was necessary for evacuation of post nephrectomy hematoma. After discussion with cardiologists and oncologists, 1 patient received heart transplant 2 years after partial nephrectomy and complete remission;3 are on the waiting list. Conclusion Our results suggest that, in the setting of cancer in a pretransplant candidate, tumors resection can be safely achieved even for high-risk HMII patients and regaining candidacy for heart transplant is conceivable.

Laparoscopic sleeve gastrectomy is safe and efficacious for pretransplant candidates

BackgroundMorbid obesity is a relative contraindication for organ transplant because it is associated with higher postoperative morbidity and mortality. The safety and efficacy of laparoscopic sleeve gastrectomy (LSG) as a weight loss method for patients awaiting transplant has not been examined. MethodsA retrospective review was performed on morbidly obese patients awaiting liver or kidney transplant who underwent LSG from 2006 to 2012. Data included patient demographic characteristics, operative details, 30-day complications, percentage of excess weight loss, postoperative laboratory data, and status of transplant candidacy. ResultsTwenty-six pretransplant patients underwent LSG. The mean age was 57 years, and 17 (65%) were women. Six patients had end-stage renal disease, and 20 patients had end-stage liver disease. The preoperative mean body mass index was 48.3kg/m2 (range 38–60.4kg/m2). There were no deaths, and there were 6 postoperative complications: 2 superficial wound infections, 1 staple line leak, 1 postoperative bleed requiring blood transfusion, 1 transient encephalopathy, and 1 temporary renal insufficiency. The mean percentage of excess weight loss at 1, 3, and 12 months was 17% (n = 24/26), 26% (n = 23/26), and 50% (n = 18/20), respectively. All patients met our institution’s body mass index cutoffs for transplantation by 12 months after the procedure. One patient’s renal function stabilized, and he was taken off the transplant list. Eight patients eventually underwent solid organ transplant. Six received liver transplants, 1 patient received a combined liver and kidney transplant, and 1 received a kidney transplant. The mean time between LSG and transplant was 16.6 months. ConclusionsThis is the largest case series involving LSG in patients awaiting solid organ transplantation. LSG is well tolerated, is technically feasible, and improves candidacy for transplantation.

Infection Prevention in Transplant Recipients

Opportunistic infections are major causes of morbidity and mortality in hematopoietic stem-cell transplant and solid organ transplant recipients. The epidemiology and incidence of opportunistic infections in those patients have been dramatically changed with use of potent immunosuppressive agents as well as routine prophylaxis against various microorganisms such as common bacterial pathogens, fungi, cytomegalovirus, Pneumocystis jirovecii, and so on. Because transplant recipients are at the greatest risk for infection during early phase (1-3 months) after transplant, safe and effective prevention strategies should be implemented in this period. Moreover, beyond early phase, recipients are often susceptible to infections due to prolonged immunosuppressive therapy for graft rejection or chronic graft-versus-host diseases. Therefore, clinicians should assess a recipient`s risk of infection on the basis of concomitant graft function, intensity of immunosuppression, and other factors that may contribute to susceptibility to infections. We discussed infection prevention strategies among recipients of hematopoietic stem-cell and solid organ transplantation against various opportunistic pathogens. Vaccinations should also be recommended for pre-transplant candidates and post-transplant recipients for the best prevention of infections. (Korean J Med 2013;84:168-178)

Laparoscopic Sleeve Gastrectomy (LSG) Is Safe, Well Tolerated and Improves Candidacy in Morbidly Obese Patients Awaiting Liver Transplantation

Introduction: Morbid obesity is a relative contraindication to liver transplantation due to higher risks of perioperative morbidity and worse long-term outcomes. We evaluated the safety and efficacy of laparoscopic sleeve gastrectomy (LSG) as a strategy for achieving long-lasting weight loss and improving transplant candidacy in morbidly obese patients with end stage liver disease (ESLD) awaiting liver transplantation. Methods: We collected data on patients with ESLD who were not eligible for transplantation due to morbid obesity and underwent LSG at our institution between 2006 -2011. Parameters included demographics, operative details, complications, percent excess weight loss (EWL), laboratory data, and transplant candidacy. Results: 20 patients with ESLD (8 NASH, 8 HCV, 2 Alcohol, and 2 autoimmune hepatitis) underwent LSG (Table 1). Mean age was 56 6y, 60% of the cohort was female, and mean follow-up was 2.5 1.7y. Mean preop body mass index (BMI) was 46 5 kg/m2 (range 38-55). There were 5 postop complications: 2 superficial wound infections, 1 staple line leak, 1 with transient encephalopathy, 1 temporary renal insufficiency, but no mortalities. Serum albumin and other nutritional parameters 12 months or later after surgery were similar to preop levels and were stable. Mean EWL was 45% at 12 mos. 19/20 patients reached our institution's BMI limit for transplantation (BMI< 40) within 6 mos of LSG and were activated on the waitlist. They have all maintained stable weight loss for the duration of the follow-up period. One patient was lost to followup. To date, 3 patients have received liver transplants and 1 underwent a combined liver and kidney transplant. All are doing well with stable graft function.Conclusion: This is the largest case series involving pre-transplant candidates and LSG. We demonstrate that LSG in selected patients with ESLD is safe, well tolerated, and improves candidacy for transplantation. Given the poor results achieved with non-surgical methods of weight loss, LSG can be safely integrated into a treatment program for morbidly obese patients with ESLD awaiting transplantation.

Laparoscopic Sleeve Gastrectomy (LSG) Is Safe, Well Tolerated and Improves Candidacy in Morbidly Obese Patients Awaiting Liver Transplantation

Introduction: Morbid obesity is a relative contraindication to liver transplantation due to higher risks of perioperative morbidity and worse long-term outcomes. We evaluated the safety and efficacy of laparoscopic sleeve gastrectomy (LSG) as a strategy for achieving long-lasting weight loss and improving transplant candidacy in morbidly obese patients with end stage liver disease (ESLD) awaiting liver transplantation. Methods: We collected data on patients with ESLD who were not eligible for transplantation due to morbid obesity and underwent LSG at our institution between 2006 -2011. Parameters included demographics, operative details, complications, percent excess weight loss (EWL), laboratory data, and transplant candidacy. Results: 20 patients with ESLD (8 NASH, 8 HCV, 2 Alcohol, and 2 autoimmune hepatitis) underwent LSG (Table 1). Mean age was 56 6y, 60% of the cohort was female, and mean follow-up was 2.5 1.7y. Mean preop body mass index (BMI) was 46 5 kg/m2 (range 38-55). There were 5 postop complications: 2 superficial wound infections, 1 staple line leak, 1 with transient encephalopathy, 1 temporary renal insufficiency, but no mortalities. Serum albumin and other nutritional parameters 12 months or later after surgery were similar to preop levels and were stable. Mean EWL was 45% at 12 mos. 19/20 patients reached our institution's BMI limit for transplantation (BMI< 40) within 6 mos of LSG and were activated on the waitlist. They have all maintained stable weight loss for the duration of the follow-up period. One patient was lost to follow-up. To date, 3 patients have received liver transplants and 1 underwent a combined liver and kidney transplant. All are doing well with stable graft function.Conclusion: This is the largest case series involving pre-transplant candidates and LSG. We demonstrate that LSG in selected patients with ESLD is safe, well tolerated, and improves candidacy for transplantation. Given the poor results achieved with non-surgical methods of weight loss, LSG can be safely integrated into a treatment program for morbidly obese patients with ESLD awaiting transplantation.

Colorrectal Cancer and Liver Transplant

Introduction: Liver transplantation recipients have an increased risk for developing de novo malignancies, because of the severe immunosuppression necessary to avoid acute and chronic rejections. Neoplasm in transplanted patients is one of the biggest problems recipients could get for the success of the transplant process, so that we must analyze it carefully. A variety of cancers are identified, especially skin cancers and lymphoproliferative disease. But the increased risk for colorectal cancer (CRC) is yet unclear. Methods: We analyze a total of 1500 patients who underwent liver transplantion from April 1986 to April 2011. Of all those patients, 15 of them (1%) were diagnosed of CRC during their evolution. Results: 73.4% of the recipients who has been diagnosed of CRC are men. Enolism is the most common cause of liver transplantation in these patients (26.6%). The mean age at diagnosis was 59.25 years (± 8.5). The average time between transplantation and diagnosis of CRC was 5.3 years (± 5.97). The 69.2% of CRC are located on the left colon, and 26.7% of them were located in the rectum. Surgery was performed in 100% of cases and with curative intention in 86.6%. 54.5% of tumors are well differentiated. 45.6% of CRC are diagnosed in early stages (Stages I and II of the AJCC/TNM). 33.3% of the cases develop colonic polyps during follow-up. Almost 100% oftumors showed microsatellite stability (MS). Recipient's overall survival and recipient's survival without disease recurrence was 70 months (± 40.47) and 55.6 months (± 39.24) respectively. Conclusions: CRC in liver transplant patients has clinical and anatomic characteristics similar to those who appear in general population. The location is also similar. However, they could have an aggressive behavior, probably due to immunosuppression. Prolonged immunosuppression encourages the development of tumors in these patients. However there are patients in our series diagnosed with CRC, only a year after transplantation, which would suggest the need to study more closely pretransplant candidates on the waiting list.

Predicting Cardiovascular Events after Liver Transplantation: Does Degree of Coronary Vessel Disease Play a Role?: ACG/AstraZeneca Fellow Award

Purpose: Recipients of orthotopic liver transplantation (OLT) are at increased risk of developing cardiovascular complications. Identifying candidates at highest risk of postoperative complications is a cornerstone of optimizing outcomes and utility. There is ongoing debate in regards to pre-transplant candidates deemed to be low vascular risk, with mild to moderate coronary artery disease (CAD) and their risk of post-OLT cardiac complications in comparison to candidates without CAD. We sought to investigate whether the number of diseased vessels (none vs. single or multi-vessel) or extent of coronary disease on angiography predicts risk of major adverse cardiac events (MACE) post transplant. Methods: Cardiac catheterization reports of all adult patients who underwent OLT at our institution from January 2000 to June 2008 were reviewed. Extent of coronary disease was categorized as mild < 50%, moderate 50-70%, or severe >70%. MACE was defined as acute coronary syndrome (ACS), coronary artery disease (CAD), cerebrovascular accident (CVA), percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), cardiac arrest and death. Results: 474 adult patients (mean age 56.1 + 9.8 years, 69% males) who underwent OLT with a median follow up of 6.3 years were studied. The majority of patients transplanted with single or multi-vessel had mild-to-moderate disease and those with severe disease either had PCI or CABG prior to OLT. Pre-transplant history of multi-vessel disease in comparison to no CAD [9.7 (3.0, 30.9); p < 0.001] was predictive of MACE post-LT. We found no significant difference between single- vs. multi-vessel disease [1.6 (0.18, 14.1); p = 0.69], although there was a trend toward significance when comparing single vessel disease vs. no CAD [6.1 (0.79, 48.0); p = 0.083]. Conclusion: In summary, candidates who were deemed low-vascular risk and subsequently underwent OLT, are actually at higher risk than previously surmised. Those with multi-vessel disease (low to moderate severity), and those who received CABG for severe disease, are almost 10 times more likely to experience a post-transplant cardiac event than those without coronary disease.Figure: No Caption available.

4-OR

To elaborate the importance of HLA-DPB1 typing in Pre-transplant solid organ candidates. To show that HLA-DPB1 typing on Deceased Donors can enhance the virtual crossmatch system, especially with highly sensitized pre-transplant candidates. Currently UNOS does not require or accept HLA-DBP1 typing. This excludes HLA-DPB1 from the virtual crossmatch algorithm. HLA-DPB1 can cause antibody-mediated rejection. Molecular typing performed for HLA-A, B, C, DQB1, and DPB1 using SSP (Olerup). Antibody tests were performed with LabScreen Single antigen beads Class I and II beads (One Lambda) on serum samples treated with DTT. Reviewed highly sensitized renal pre and post transplant cases involving HLA-DPB1 antibodies. Case 1: Highly sensitized 65 yr female renal candidate with a cPRA of 100%, received a transplant with a deceased donor in October 2010. Donor typing was considered a zero mismatch. Early antibody mediated rejection was suspected due to an increase in serum creatinine and decrease in urine output. Anti-HLA antibody specificity analysis revealed strong HLA-DPB1 antibodies. Molecular typing for HLA-DPB1 was performed [ Table 1 ]. DSA performed two days post transplant showed the HLA-DPB1 ∗ 0101 at 4900 MFI. By the tenth day post transplant HLA-DPB1 ∗ 0101 was 17,100 MFI. The kidney had stopped functioning and showed intense C4d deposition. Case 2: Highly sensitized 56 yr male renal candidate active on the waitlist having had three previous transplants and a current cPRA of 91%. Since he was listed in May 2011 he has had several deceased donor offers. However, Single Antigen Beads revealed multiple HLA-DPB1 antibodies leading to both positive flow cell and virtual crossmatches. It is now our protocol to perform molecular HLA-DPB1 typing on deceased donors, as well as, potential recipients. The more complete a donor’s HLA typing the more we are able to assign DSA (post-transplant) and help in the diagnosis and treatment.