Significant Predictors Of Graft Failure Research Articles

Graft Patency Assessment with CCTA Using a Comprehensive Singlebranch Bridging Score.

This study aims to assess the prognostic value of graft patency with coronary computed tomography angiography (CCTA) using a comprehensive single-branch targeted atherosclerotic risk score (CSBS) in patients before coronary artery bypass grafting (CABG). This retrospective study contains a total of 88 patients who underwent clinical CCTA before off-pump CABG surgery between 2015 and 2018. Graft failure was defined as patients with missing multi-slice CCTA or coronary angiography. The predictive value of CSBS (ranging from 0-70 and divided into 2 groups: < 20 and ≥20) was analyzed using Kaplan-Meier analysis and Cox regression models. Patients' mean age was 61.2 ± 10.5 years, with a mean follow-up of 20.4 ± 15.2 months. A total of 203 grafts (21.5% arterial grafts) were analyzed and 30 of the vessels were occluded (14.8%). There was no significant difference in graft occlusion among the three targeted vessel groups. The Cox proportional hazard analysis showed that CSBS < 20 was a significant predictor of graft failure. Lower comprehensive single-branch targeted atherosclerotic risk score evaluated by CCTA is an independent prognostic factor for graft failure in patients before CABG surgery.

Secondary Alveolar Bone Grafting in Patients with Unilateral and Bilateral Complete Cleft Lip and Palate: A Single-Institution Outcomes Evaluation Using Three-Dimensional Cone Beam Computed Tomography.

Secondary alveolar bone grafting of autologous bone from the iliac crest is a widely accepted modality for repair of residual alveolar cleft in patients with mixed dentition with previously repaired complete cleft lip and palate. There remains debate regarding surgical timing and preoperative, perioperative, and postoperative management of these cases. This retrospective study reviewed patient demographic information in addition to preoperative, perioperative, and postoperative course to evaluate how patient and practice factors impact graft outcomes as assessed by three-dimensional cone beam computed tomographic evaluation at the 6-month postoperative visit. On univariate analysis, age at operation older than 9 years, history of oronasal fistula, history of cleft lip or palate revision, and history of international adoption were all found to significantly increase likelihood of graft failure (p < 0.05). On multivariate analysis, age older than 9 years was found to be the single most significant predictor of graft failure (p < 0.05). There was no significant difference in graft outcomes between patients with unilateral or bilateral cleft lip and palate, and no single variable was found to significantly correlate to increased complication rates. The graft success rate overall of the authors' practice was 86.2 percent, with a complication rate of 7.7 percent. Secondary alveolar bone grafting is an integral part of the cleft lip and palate surgical treatment series; this study identified several outcome predictors for both graft failure and adverse events, the most significant of which was age at operation. Although the mixed dentition phase often extends to 12 years of age, it is recommended that bone grafting be performed before 9 years of age to optimize outcomes. Risk, III.

Uncovering a Long-term Graft Survival Advantage Afforded by Infant Renal Transplants-An Organ Procurement and Transplantation Network Database Analysis.

Background.Renal transplants (Tx) are performed infrequently in infants, due to concerns related to poor outcomes. The aim of our study was to compare graft failure rates in infant (<1 y) renal Tx recipients compared with older children.Methods.Retrospective cohort study of pediatric renal Tx recipients from 2000 to 2015, using the Organ Procurement and Transplant Network database. A log-linear event history regression model for time to graft failure, adjusting for age group and important confounders, was used to estimate post-Tx graft failure probabilities.Results.In 2696 Tx followed for a median of 6.1 y, 704 failures were observed. Significant predictors of graft failure were year of Tx (for each year after 2000, rates were 8.6% lower), Black race-ethnicity (63% higher compared with Whites), and number of HLA matches. For infants (n = 27), estimated graft failure percentage (95% confidence interval) within the first 1-, 2-, and 5-y post-Tx were 10.4 (0.1–21.1), 11.9 (1.2–22.6), and 16.4 (4.9–27.9). For the 1- to 11-y-olds (n = 1429), these were 3.8 (3.0–4.6), 6.3 (5.4–7.3), and 13.6 (12.2–15.0), respectively, and for the 12+ y olds (n = 1240), they were 3.8 (3.1–4.5), 8.1 (7.2–9.0), and 19.9 (18.1–21.7), respectively (P < 0.001 for 5-y graft failure rate across age groups).Conclusions.Infant renal Tx recipients experience a higher graft failure rate in the first year, compared with older cohorts, but over longer intervals, cumulative failure rates are comparable or even lower. To minimize early graft losses such Tx should be performed in experienced centers.

Peri-transplant glycaemic control as a predictor of pancreas transplant survival.

The relationship between peri-transplant glycaemic control and outcomes following pancreas transplantation is unknown. We aimed to relate peri-transplant glycaemic control to pancreas graft survival and to develop a framework for defining early graft dysfunction. Peri-transplant glycaemic control profiles over the first 5 days postoperatively were determined by an area under the curve [AUC; average daily glucose level (mmol/L) × time (days)] and the coefficient of variation of mean daily glucose levels. Peri-transplant hyperglycaemia was defined as an AUC ≥35 mmol/day/L (daily mean blood glucose ≥7 mmol/L). Risks of graft failure associated with glycaemic control and variability and peri-transplant hyperglycaemia were determined using covariate-adjusted Cox regression. We collected 7606 glucose readings over 5 days postoperatively from 123 pancreas transplant recipients. Glucose AUC was a significant predictor of graft failure during 3.6 years of follow-up (unadjusted HR [95% confidence interval] 1.17 [1.06-1.30], P = .002). Death censored non-technical graft failure occurred in eight (10%) recipients with peri-transplant normoglycaemia, and eight (25%) recipients with peri-transplant hyperglycaemia such that hyperglycaemia predicted a 3-fold higher risk of graft failure [HR (95% confidence interval): 3.0 (1.1-8.0); P = .028]. Peri-transplant hyperglycaemia is strongly associated with graft loss and could be a valuable tool guiding individualized graft monitoring and treatment. The 5-day peri-transplant glucose AUC provides a robust and responsive framework for comparing graft function.

Early postoperative complications after Latarjet procedure: a single-institution experience over 10 years

The Latarjet procedure is an effective procedure for the treatment of anterior glenohumeral joint instability; however, the complications are concerning. The purpose of this study was to review a single institution's experience with the Latarjet procedure for recurrent anterior glenohumeral instability specifically focusing on early complications. This was a retrospective review of all Latarjet procedures performed at a single institution from August 2008 to July 2018. The 90-day complication rate and associated risk factors for all complications and graft failure were recorded. Postoperative radiographs were reviewed for coracoid graft position and screw divergence. During the study period, 190 Latarjet procedures were performed with 90-day follow-up. The average age was 28.7 ± 11.3 years, male patients comprised 84.2% of the population, and 62.6% of patients had undergone a prior stabilization procedure. We observed 15 complications, for a 90-day complication rate of 9.0%; of the patients, 8 (4.2%) underwent reoperations. Graft or hardware failure occurred in 9 patients (4.7%) with loosened or broken screws, and 6 required reoperations (revision Latarjet procedure in 4, distal tibia allograft in 1, and iliac crest autograft in 1). Fixation with only 1 screw (P < .001) and an increased screw divergence angle (37° ± 8° vs. 24° ± 11°, P = .0257) were statistically associated with graft failure, whereas the use of cannulated screws (P = .487) was not. There were 6 nerve injuries (3.2%), including 2 combined axillary and suprascapular nerve injuries, 1 musculocutaneous nerve injury, 1brachial plexopathy, 1 peripheral sensory nerve deficit (likely axillary), and 1 sensory plexopathy. Suprascapular nerve injury at the spinoglenoid notch was associated with a longer superior screw (41.0 ± 1.4 mm vs. 33.5 ± 3.5 mm, P = .035) and increased screw divergence angle (40° ± 6° vs. 24° ± 11°, P = .0197). The coracoid graft was correctly positioned in the axial plane in 71% of cases and in the coronal plane in 73% of cases. The Latarjet procedure is a procedure that can reliably restore shoulder stability; however, graft- and nerve-related complications are relatively common. Two-thirds of the graft failures required reoperations, and half of the nerve injuries in this study led to residual symptoms. Fixation with only 1 screw and an increased screw divergence angle were significant predictors of graft failure. Suprascapular nerve injury at the spinoglenoid notch was associated with an increased screw divergence angle and longer superior screw.

Human leukocyte antigen eplet mismatches and long‐term clinical outcomes in pediatric renal transplantation: A pragmatic, registry‐based study

HLA epitope-based matching offers the potential to improve immunological risk prediction and management in children receiving renal allografts; however, studies demonstrating the association between systems for defining epitope mismatches and clinical end-points are lacking in this population. We conducted a pragmatic, retrospective, registry-based study of pediatric recipients of primary renal allografts in Victoria, Australia between 1990 and 2014 to determine the association between HLA EpMM and clinical outcomes including graft failure, re-transplantation and dnDSA formation. A total of 196 patients were included in the analysis with a median age of 11years. Median follow-up period was 15years during which time 108 (55%) primary grafts failed and 72 patients were re-transplanted. HLA class I but not class II EpMM was a significant predictor of graft failure on univariate analysis but not in adjusted models. EpMM was associated with reduced likelihood of re-transplantation in univariate but not adjusted analysis. Within the limitations of the study, class-specific EpMM was a strong predictor of dnDSA formation. Associations were stronger when considering only the subset of antibody-verified EpMM. Associations between HLA EpMM and clinical outcomes in pediatric renal allograft recipients seen on univariate analysis were attenuated following adjustment for confounders. These findings are inconclusive but suggest that HLA EpMM may provide one tool for assessing long-term risk in this population while highlighting the need for further clinical studies.

Physiologic Preoperative Knee Hyperextension Is a Predictor of Failure in an Anterior Cruciate Ligament Revision Cohort: A Report From the MARS Group

Background: The occurrence of physiologic knee hyperextension (HE) in the revision anterior cruciate ligament reconstruction (ACLR) population and its effect on outcomes have yet to be reported. Hypothesis/Purpose: The prevalence of knee HE in revision ACLR and its effect on 2-year outcome were studied with the hypothesis that preoperative physiologic knee HE ≥5° is a risk factor for anterior cruciate ligament (ACL) graft rupture. Study Design: Cohort study; Level of evidence, 2. Methods: Patients undergoing revision ACLR were identified and prospectively enrolled between 2006 and 2011. Study inclusion criteria were patients undergoing single-bundle graft reconstructions. Patients were followed up at 2 years and asked to complete an identical set of outcome instruments (International Knee Documentation Committee, Knee injury and Osteoarthritis Outcome Score, WOMAC, and Marx Activity Rating Scale) as well as provide information regarding revision ACL graft failure. A regression model with graft failure as the dependent variable included age, sex, graft type at the time of the revision ACL surgery, and physiologic preoperative passive HE ≥5° (yes/no) to assess these as potential risk factors for clinical outcomes 2 years after revision ACLR. Results: Analyses included 1145 patients, for whom 2-year follow-up was attained for 91%. The median age was 26 years, with age being a continuous variable. Those below the median were grouped as “younger” and those above as “older” (age: interquartile range = 20, 35 years), and 42% of patients were female. There were 50% autografts, 48% allografts, and 2% that had a combination of autograft plus allograft. Passive knee HE ≥5° was present in 374 (33%) patients in the revision cohort, with 52% being female. Graft rupture at 2-year follow-up occurred in 34 cases in the entire cohort, of which 12 were in the HE ≥5° group (3.2% failure rate) and 22 in the non-HE group (2.9% failure rate). The median age of patients who failed was 19 years, as opposed to 26 years for those with intact grafts. Three variables in the regression model were significant predictors of graft failure: younger age (odds ratio [OR] = 3.6; 95% CI, 1.6-7.9; P = .002), use of allograft (OR = 3.3; 95% CI, 1.5-7.4; P = .003), and HE ≥5° (OR = 2.12; 95% CI, 1.1-4.7; P = .03). Conclusion: This study revealed that preoperative physiologic passive knee HE ≥5° is present in one-third of patients who undergo revision ACLR. HE ≥5° was an independent significant predictor of graft failure after revision ACLR with a >2-fold OR of subsequent graft rupture in revision ACL surgery. Registration: NCT00625885 (ClinicalTrials.gov identifier).

Impact on mid-term kidney graft outcomes of pretransplant anti-HLA antibodies detected by solid-phase assays: Do donor-specific antibodies tell the whole story?

The detrimental impact of preformed anti-HLA donor-specific antibodies (DSA) is well defined, contrarily to non-donor-specific antibodies (NDSA). We sought to evaluate their clinical impact in a cohort of 724 kidney graft recipients in whom anti-HLA antibodies were thoroughly screened and identified in pre-transplant sera by solid-phase assays. NDSA or DSA were detected in 100 (13.8%) and 47 (6.5%) recipients respectively, while 577 (79.7%) were non-allosensitized (NaS). Incidence of antibody-mediated rejection at 1-year was 0.7%, 4.0% and 25.5% in NaS, NDSA and DSA patients, respectively (NaS vs. NDSA P=0.004; NaS vs. DSA P<0.001; NDSA vs. DSA P<0.001). Graft survival was lowest in DSA (78.7%), followed by NDSA (88.0%) and NaS (93.8%) recipients (NaS vs. NDSA P=0.015; NaS vs. DSA P<0.001; NDSA vs. DSA P=0.378). Multivariable competing risk analysis confirmed both NDSA (sHR=2.19; P=0.025) and DSA (sHR=2.87; P=0.012) as significant predictors of graft failure. The negative effect of NDSA and DSA on graft survival was significant in patients receiving no induction (P=0.019) or an anti-IL-2 receptor antibody (P<0.001), but not in those receiving anti-thymocyte globulin (P=0.852). The recognition of the immunological risk associated with preformed DSA but also NDSA have important implications in patients’ risk stratification, and may impact clinical decisions at transplant.

Factors That Predict Failure in Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction

Background: Anatomic graft placement in anterior cruciate ligament (ACL) reconstruction has become the preferred technique for many surgeons. The predictive factors for graft failure in anatomic single-bundle ACL reconstruction are relatively unknown. Purpose: To determine the risk factors for graft failure and the relative importance of those factors in anatomic single-bundle ACL reconstruction. Study Design: Case-control study; Level of evidence, 3. Methods: All primary anatomic ACL reconstructions undertaken at a single institution over a 2-year period were evaluated for subjective and objective measures of graft failure. Risk factors evaluated included time since ACL rupture, age, sex, body mass index, intact or deficient medial and lateral meniscus, meniscal repair, hamstring graft size, and femoral and tibial tunnel position as assessed by 3D computed tomography (CT) scan. The significant factors predicting failure and the relative importance of those factors were determined. Results: At a median follow-up of 26 months, 123 patients were available for analysis. Ninety-seven patients underwent postoperative 3D CT for tunnel positions, including all 20 cases with graft failure. The significant predictors of graft failure were medial meniscal deficiency (hazard ratio [HR] 15.1; 95% CI, 4.7-48.5; P < .001), lateral meniscal deficiency (HR 9.9; 95% CI, 3-33; P < .001), shallow nonanatomic femoral tunnel positioning (HR 4.3; 95% CI, 1.6-11.6; P = .004), and younger patient age (HR 0.9; 95% CI, 0.9-1; P = .008). Conclusion: Meniscal deficiency is the most significant factor to predict graft failure in single-bundle anatomic ACL reconstruction. Shallow nonanatomic femoral tunnel positioning and younger patient age are additional risk factors for failure, but their relative importance is less.

Bovine carotid artery biologic graft outperforms expanded polytetrafluoroethylene for hemodialysis access

ObjectiveArteriovenous grafts remain reliable substitutes for permanent hemodialysis access in patients without a suitable autogenous conduit. Advances in conduit design and endovascular management of access-related complications question the preference for synthetic conduits over biologic grafts in contemporary practice. In this study, we compared outcomes between a bovine carotid artery (BCA) biologic graft and expanded polytetrafluoroethylene (ePTFE) grafts for hemodialysis access in a recent cohort of patients. MethodsThis was a single-institution retrospective review of 120 consecutive grafts placed in 98 patients between January 1, 2011, and June 30, 2014. Univariate methods (χ2, analysis of variance, t-test) were used to compare demographic and medical characteristics of patients who received each graft type. Kaplan-Meier, log-rank tests, univariate and multivariate logistic analyses, and Cox regression analyses were used to evaluate patency and graft complications. Outcomes were defined and analyzed according to reporting guidelines published by the Society for Vascular Surgery. ResultsOf the 120 grafts studied, 52 (43%) were BCA and 68 (57%) were ePTFE. Successful graft use for dialysis was 96% (95% confidence interval [CI], 90%-100%) for BCA and 84% (95% CI, 74%-93%) for ePTFE (P = .055). Comparing BCA vs ePTFE, estimates for primary patency were 30% vs 43% at 1 year and 16% vs 29% at 2 years (P = .27). Primary assisted patency was 36% vs 45% at 1 year and 24% vs 35% at 2 years (P = .57). Secondary patency was 67% vs 48% at 1 year and 67% vs 38% at 2 years (P = .05). There were no differences in primary (hazard ratio [HR], 0.70; 95% CI, 0.40-1.28; P = .25) and primary assisted (HR, 0.87; 95% CI, 0.46-1.65; P = .67) patency for BCA compared with ePTFE. However, secondary patency was higher for BCA compared with ePTFE (HR, 2.92; 95% CI, 1.29-6.61; P = .01). Graft infection rates during the study period were 15.4% for BCA and 20.6% for ePTFE (P = .47). The significant predictors of graft failure were higher body mass index (HR, 1.06; 95% CI, 1.00-1.11; P = .04) and hyperlipidemia (HR, 2.94; 95% CI, 1.27-6.76; P = .01). ConclusionsIn this study of a recent cohort of patients who received arteriovenous grafts, primary and primary assisted patencies were similar between BCA and ePTFE grafts. However, secondary patency was higher for BCA, indicating better durability for the biologic graft than for ePTFE grafts in patients whose anatomy preclude placement of an arteriovenous fistula.

The Kupffer Cell Number Affects the Outcome of Living Donor Liver Transplantation from Elderly Donors.

BackgroundThere have been no previous reports how Kupffer cells affect the outcome of living donor liver transplantation (LDLT) with an elderly donor. The aim of this study was to elucidate the influence of Kupffer cells on LDLT.MethodsA total of 161 adult recipients underwent LDLT. The graft survival, prognostic factors for survival, and graft failure after LDLT were examined between cases with a young donor (<50, n = 112) and an elderly donor (≥50, N = 49). The Kupffer cells, represented by CD68-positive cell in the graft, were examined in the young and elderly donors.ResultsIn a multivariable analysis, a donor older than 50 years, sepsis, and diabetes mellitus were significant predictors of graft failure after LDLT. The CD68 in younger donors was significantly more expressed than that in elderly donors. The group with a less number of CD68-positive cells in the graft had a significantly poor survival in the elderly donor group and prognostic factor for graft failure.ConclusionsThe worse outcome of LDLT with elderly donors might be related to the lower number of Kupffer cells in the graft, which can lead to impaired recovery of the liver function and may predispose patients to infectious diseases after LDLT.

Knee Hyperextension as a Predictor of Failure in Revision ACL Reconstruction

Objectives:We studied the minimum 2 year follow-up outcomes in an ACL revision cohort. The hypothesis is that knees that hyperextend will have a worse outcome and greater odds of graft failure than knees that do not hyperextend. The null hypothesis is that there is no difference in outcomes or graft rupture between the two groups.Methods:Revision ACL reconstruction patients were identified and prospectively enrolled between 2006 and 2011. Data collected included baseline demographics, surgical technique and pathology, and a series of validated patient reported outcome instruments (IKDC, KOOS, WOMAC, and Marx activity rating score). Patients were followed up for 2 years, and asked to complete the identical set of outcome instruments. A regression model using graft failure as the dependent variable included graft type, age, and hyperextension greater than or equal to 5 degrees yes/no (HE) in order to assess these potential surgical risk factors for clinical outcomes 2 years after revision ACL reconstruction.Results:There were 1,145 subjects included in the analyses. The median age of the cohort was 26 (IQR= 20, 35), and 58% were male. The proportion that were enrolled for their first revision surgery was 88%, their second 10%, and third or greater 2%. The number of subjects categorized as HE was 375 (33%). The median age of subjects that failed was 18, compared to 26 for those with intact grafts. All three variables included in our regression model were significant predictors of graft failure: younger age, inter-quartile range odds ratio (IQROR) = 3.32 (95%CI 1.5, 7.2) p= 0.002; use of allograft OR = 3.1 (95%CI 1.4, 6.9) p= 0.01, and HE 2.1 (95%CI 1.02, 4.42) p= 0.04.Conclusion:The MARS Study Group has previously reported that young age and the use of allograft as a graft source are independent predictors (over 3X odds ratio) of graft rupture after revision ACLR. This study found that knee hyperextension greater than or equal to 5 degrees is present in 1/3 of patients who undergo revision ACLR. HE is also an independent predictor of graft failure after revision ACLR. This is the first study to investigate and confirm knee physiologic hyperextension as a risk factor (over 2X odds ratio) of graft rupture in ACL surgery. Future reports on ACL reconstruction results should separately evaluate the group of knees that hyperextend 5 degrees or more as compared to those that do not.

Contemporary Outcomes for Open Infrainguinal Bypass in the Endovascular Era

The role of infrainguinal bypasses in this era of increasing endovascular interventions remains the subject of significant debate. In this study, we evaluate contemporary long-term outcomes of lower-extremity open revascularization for peripheral arterial disease (PAD). We evaluated all patients who underwent infrainguinal bypass with autogenous vein conduits for claudication or critical limb ischemia in our institution between January 1st, 2007 and July 31st, 2014. Kaplan-Meier and Cox regression analyses were used to evaluate graft failure and identify its predictors. Outcomes were defined per the Society for Vascular Surgery standards. There were 428 autogenous vein grafts (femoro-popliteal: 32%, femoro-tibial: 39%, popliteo-tibial: 27%, and tibio-tibial: 2%) placed in 368 patients (mean age of 67 ± 11.4 years). Most patients were male (59%), white (73%), and presented with critical limb ischemia (81%). Sixty-five cases (15%) were redo bypasses. Arm veins and spliced vein conduits were used in 15% and 14% of cases, respectively. Primary patency at 1, 3, and 5 years was 66%, 59%, and 55%, respectively. Primary-assisted patency was 78%, 69%, and 64% at 1, 3, and 5 years, respectively. Secondary patency was 88%, 84%, and 82% at 1, 3, and 5 years, respectively. Patency was higher for grafts harvested from the lower versus upper extremities and for proximal versus distal bypass (all P < 0.05). Limb salvage rate was 88% after a mean follow-up of 2 ± 1.8 years. Significant predictors of graft failure were younger age, diabetes mellitus, and hyperlipidemia (all P < 0.05). In this contemporary cohort of patients, we have demonstrated that infrainguinal bypass for lower-extremity revascularization has good long-term outcomes in patients with symptomatic PAD. Patency and limb salvage rates are optimized with careful selection of autogenous conduits, close monitoring of high-risk groups and management of comorbidities.

Impact of the center on graft failure after liver transplantation

The hospital at which liver transplantation (LT) is performed has a substantial impact on post-LT outcomes. Center-specific outcome data are closely monitored not only by the centers themselves but also by patients and government regulatory agencies. However, the true magnitude of this center effect, apart from the effects of the region and donor service area (DSA) as well as recipient and donor determinants of graft survival, has not been examined. We analyzed data submitted to the Organ Procurement and Transplantation Network for all adult (age ≥ 18 years) primary LT recipients (2005-2008). Using a mixed effects, proportional hazards regression analysis, we modeled graft failure within 1 year after LT on the basis of center (de-identified), region, DSA, and donor and recipient characteristics. At 115 unique centers, 14,654 recipients underwent transplantation. Rates of graft loss within a year varied from 5.9% for the lowest quartile of centers to 20.2% for the highest quartile. Gauged by a comparison of the 75th and 25th percentiles of the data, the magnitude of the center effect on graft survival (1.49-fold change) was similar to that of the recipient Model for End-Stage Liver Disease (MELD) score (1.47) and the donor risk index (DRI; 1.45). The center effect was similar across the DRI and MELD score quartiles and was not associated with a center's annual LT volume. After stratification by region and DSA, the magnitude of the center effect, though decreased, remained significant and substantial (1.30-fold interquartile difference). In conclusion, the LT center is a significant predictor of graft failure that is independent of region and DSA as well as donor and recipient characteristics.

Trends in Immunologic Risk Among Kidney Transplant Recipients in the United States

Introduction: Despite advances in immunosuppressive therapy, immune factors remain important predictors of graft failure following renal transplantation. However, development of a composite measure of immunologic risk is necessary to better inform clinician decision making and organ allocation policy reform. Methods: We retrospectively examined 208,560 recipients of kidney transplants from the United Network for Organ Sharing (UNOS) database preformed between 1995 and 2010. Graft survival according to a composite (re-transplantation, panel reactive antibody >40%, human leukocyte antigen mismatch, recipient hepatitis C virus seropositive, and African American race) Immunologic Risk Index (IRI) was analyzed using Kaplan-Meier and log-rank methodology. Cox proportional hazards regression was utilized to examine both the performance of individual immune risk factors and the IRI as predictors of graft failure. Stratified analysis and calculation of the Rothman Synergy Index were used to characterize the interaction between immune risk factors. Results: A decline in unadjusted graft survival was observed with escalating Immunologic Risk Index score (Figure 1). After risk adjustment for donor and recipient covariates, the Immunologic Risk Index remains a significant predictor of graft failure (HR 1.21 per point, 95% CI 1.19-1.22, p<0.0001). Recipient Hepatitis C virus (HR 1.36, 95% CI 1.31-1.41, p<0.0001) was the strongest and panel reactive antibody >40% (HR 1.12, 95% CI 1.09-1.16, p<0.0001) the weakest predictor of graft failure. in contrast, the transplant era 2005-2010 (HR 0.90, 95% CI 0.86-0.95, p=0.0001) and high (>1000 cases) transplant center volume (HR 0.82, 95% CI 0.78-0.88, p<0.0001) protected against graft failure. Interestingly, the mean Immunologic Risk Index score increased from 1.47 in 1995 to a peak of 1.52 in 2003, but abruptly declined thereafter reaching a nadir of 1.40 in 2005. Conclusions: the Immunologic Risk Index is a superior risk predictor compared to individual immune risk factors. A decline in the Immunologic Risk Index after 2003 might explain the improvement in graft survival observed in the 2005-2010 transplant era. Immunologic risk aversion and/or the unintended consequences of changes made to kidney allocation policy in 2003 are implicated. Policy reform may be necessary to preserve equal access to renal transplantation among high immunologic risk patients.

Allograft Versus Autograft Anterior Cruciate Ligament Reconstruction

Background:Tearing an anterior cruciate ligament (ACL) graft is a devastating occurrence after ACL reconstruction (ACLR). Identifying and understanding the independent predictors of ACLR graft failure is important for surgical planning, patient counseling, and efforts to decrease the risk of graft failure.Hypothesis:Patient and surgical variables will predict graft failure after ACLR.Study Design:Prospective cohort study.Methods:A multicenter group initiated a cohort study in 2002 to identify predictors of ACLR outcomes, including graft failure. First, to control for confounders, a single surgeon’s data (n = 281 ACLRs) were used to develop a multivariable regression model for ACLR graft failure. Evaluated variables were graft type (autograft vs allograft), sex, age, body mass index, activity at index injury, presence of a meniscus tear, and primary versus revision reconstruction. Second, the model was validated with the rest of the multicenter study’s data (n = 645 ACLRs) to evaluate the generalizability of the model.Results:Patient age and ACL graft type were significant predictors of graft failure for all study surgeons. Patients in the age group of 10 to 19 years had the highest percentage of graft failures. The odds of graft rupture with an allograft reconstruction are 4 times higher than those of autograft reconstructions. For each 10-year decrease in age, the odds of graft rupture increase 2.3 times.Conclusion:There is an increased risk of ACL graft rupture in patients who have undergone allograft reconstruction. Younger patients also have an increased risk of ACL graft failure.Clinical Relevance:Given these risks for ACL graft rupture, allograft ACLRs should be performed with caution in the younger patient population.

Skin-Autofluorescence Is an Independent Predictor of Graft Loss in Renal Transplant Recipients

Skin-autofluorescence (skin-AF) noninvasively measures the tissue accumulation of advanced glycation end products (AGEs). AGEs are nephrotoxic and potential effectors of cardiovascular mortality. We investigated whether skin-AF predicted graft loss after kidney transplantation. A total of 302 renal transplant recipients were enrolled at a median time of 6.1 (2.6-12.1) years after transplantation and were subsequently followed up for first occurrence of graft loss (i.e., graft failure or all-cause mortality) for 5.2 (4.6-5.4) years. The association of baseline skin-AF with graft loss was investigated with univariable and multivariable Cox-regression and receiver-operator-characteristic curve analyses. Baseline skin-AF was 2.7+/-0.8 arbitrary units. Skin-AF predicted graft loss in a univariable Cox regression analysis (Hazard ratios 2.40 [1.75-3.29], P<0.001) and in a multivariable model (Hazard ratios 1.83 [1.22-2.75], P=0.003), adjusted for other identified risk-factors, including patient age, creatinine clearance, protein excretion, high sensitivity C-reactive protein (hsCRP), and human leukocyte antigen-DR mismatching. The area under the receiver-operator-characteristic curve for skin-AF as predictor of graft loss was significantly different from 0.5. Skin-AF was also a significant predictor of graft failure and mortality as separate end points. We conclude that skin-AF is an independent predictor of graft loss in kidney transplant recipients. Although skin-AF is not a direct measurement for AGEs, we believe that our results do support the hypothesis that accumulation of AGEs in renal transplant recipients contributes to the development of graft loss.

Increasing calories, decreasing morbidity and mortality: Is improved nutrition the answer to better outcomes in patients with biliary atresia?

Increasing calories, decreasing morbidity and mortality: Is improved nutrition the answer to better outcomes in patients with biliary atresia?

Outcomes of 385 Adult-to-Adult Living Donor Liver Transplant Recipients

The objective of this study was to characterize the patient population with respect to patient selection, assess surgical morbidity and graft failures, and analyze the contribution of perioperative clinical factors to recipient outcome in adult living donor liver transplantation (ALDLT). Previous reports have been center-specific or from large databases lacking detailed variables. The Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL) represents the first detailed North American multicenter report of recipient risk and outcome aiming to characterize variables predictive of graft failure. Three hundred eighty-five ALDLT recipients transplanted at 9 centers were studied with analysis of over 35 donor, recipient, intraoperative, and postoperative variables. Cox regression models were used to examine the relationship of variables to the risk of graft failure. Ninety-day and 1-year graft survival were 87% and 81%, respectively. Fifty-one (13.2%) grafts failed in the first 90 days. The most common causes of graft failure were vascular thrombosis, primary nonfunction, and sepsis. Biliary complications were common (30% early, 11% late). Older recipient age and length of cold ischemia were significant predictors of graft failure. Center experience greater than 20 ALDLT was associated with a significantly lower risk of graft failure. Recipient Model for End-stage Liver Disease score and graft size were not significant predictors. This multicenter A2ALL experience provides evidence that ALDLT is a viable option for liver replacement. Older recipient age and prolonged cold ischemia time increase the risk of graft failure. Outcomes improve with increasing center experience.

Femoropopliteal bypass with externally supported knitted Dacron grafts: a follow-up of 200 grafts for one to twelve years.

This article reports our experience with externally supported, preclotted knitted Dacron grafts in femoropopliteal bypass. This is a retrospective analysis of a consecutive series of 154 patients who received 200 grafts (175 above knee and 25 below knee). Follow-up extended to 12 years (mean 59 1/2 months). Primary patency rates for the entire series were 75%, 70%, and 47% at 3, 5, and 10 years, respectively. Above-knee grafts had 76%, 71%, and 50% rates and 3, 5, and 10 years, respectively. Below-knee grafts had 65% and 57% at 3 and 5 years, respectively. Limb-salvage rates were 87%, 79%, and 73% at 3, 5, and 10 years, respectively, for the 57 limbs operated on because of critical ischemia. The most significant predictor of graft failure was poor runoff as determined by preoperative arteriography. The effect of poor runoff was most pronounced in the first 3 months. Externally supported, preclotted knitted Dacron grafts provide encouraging primary patency rates for above-knee femoropopliteal bypass. Poor leg vessel runoff is a major determinant of early graft failure.