Publications by authors named "David D Lee"

46 Publications

Disparities in living donation.

Curr Opin Organ Transplant 2021 Oct;26(5):542-546

Department of Surgery, Division of Intra-Abdominal Transplantation, Stritch School of Medicine, Maywood, Illinois, USA.

Purpose Of Review: Living organ donation provides improved access to transplantation, thereby shortening transplant wait times and allowing for more deceased organ transplants. However, disparity in access to living donation has resulted in decreased rates of living donor transplants for some populations of patients.

Recent Findings: Though there have been marked improvements in deceased donor equity, there are still challenges as it relates to gender, racial/ethnic, and socio-economic disparity. Improvements in living donation rates in Hispanic and Asian populations are tempered by challenges in African American rates of organ donation. Socio-economic disparity may drive gender disparities in organ donation resulting in disproportionate female living donors. Tailored approaches relating to language-specific interventions as well as directed educational efforts have helped mitigate disparity. Additionally, the use of apolipoprotein1 testing and modifications of glomerular filtration rate calculators may improve rates of African American donation. This review will evaluate recent data in living donor disparity as well as highlight successes in mitigating disparity.

Summary: Though there are still challenges in living donor disparity, many efforts at tailoring education and access as well as modifying living donor evaluation and identifying systemic policy changes may result in improvements in living donation rates.
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http://dx.doi.org/10.1097/MOT.0000000000000912DOI Listing
October 2021

Posttransplant Outcomes in Older Patients With Hepatocellular Carcinoma Are Driven by Non-Hepatocellular Carcinoma Factors.

Liver Transpl 2021 05 1;27(5):684-698. Epub 2021 Mar 1.

Department of Surgery, University of Nebraska Medical Center, Omaha, NE.

The incidence of hepatocellular carcinoma (HCC) is growing in the United States, especially among the elderly. Older patients are increasingly receiving transplants as a result of HCC, but the impact of advancing age on long-term posttransplant outcomes is not clear. To study this, we used data from the US Multicenter HCC Transplant Consortium of 4980 patients. We divided the patients into 4 groups by age at transplantation: 18 to 64 years (n = 4001), 65 to 69 years (n = 683), 70 to 74 years (n = 252), and ≥75 years (n = 44). There were no differences in HCC tumor stage, type of bridging locoregional therapy, or explant residual tumor between the groups. Older age was confirmed to be an independent and significant predictor of overall survival even after adjusting for demographic, etiologic, and cancer-related factors on multivariable analysis. A dose-response effect of age on survival was observed, with every 5-year increase in age older than 50 years resulting in an absolute increase of 8.3% in the mortality rate. Competing risk analysis revealed that older patients experienced higher rates of non-HCC-related mortality (P = 0.004), and not HCC-related death (P = 0.24). To delineate the precise cause of death, we further analyzed a single-center cohort of patients who received a transplant as a result of HCC (n = 302). Patients older than 65 years had a higher incidence of de novo cancer (18.1% versus 7.6%; P = 0.006) after transplantation and higher overall cancer-related mortality (14.3% versus 6.6%; P = 0.03). Even carefully selected elderly patients with HCC have significantly worse posttransplant survival rates, which are mostly driven by non-HCC-related causes. Minimizing immunosuppression and closer surveillance for de novo cancers can potentially improve the outcomes in elderly patients who received a transplant as a result of HCC.
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http://dx.doi.org/10.1002/lt.25974DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8140549PMC
May 2021

Development and Application of a Peroxyl Radical Clock Approach for Measuring Both Hydrogen-Atom Transfer and Peroxyl Radical Addition Rate Constants.

J Org Chem 2021 01 3;86(1):153-168. Epub 2020 Dec 3.

Department of Medicinal Chemistry, University of Washington, Seattle, Washington 98195, United States.

The rate-determining step in free radical lipid peroxidation is the propagation of the peroxyl radical, where generally two types of reactions occur: (a) hydrogen-atom transfer (HAT) from a donor to the peroxyl radical; (b) peroxyl radical addition (PRA) to a "C═C" double bond. Peroxyl radical clocks have been used to determine the rate constants of HAT reactions (), but no radical clock is available to measure the rate constants of PRA reactions (). In this work, we modified the analytical approach on the linoleate-based peroxyl radical clock to enable the simultaneous measurement of both and . Compared to the original approach, this new approach involves the use of a strong reducing agent, LiAlH, to completely reduce both HAT and PRA-derived products and the relative quantitation of total linoleate oxidation products with or without reduction. The new approach was then applied to measuring the and values for several series of organic substrates, including para- and meta-substituted styrenes, substituted conjugated dienes, and cyclic alkenes. Furthermore, the and values for a variety of biologically important lipids were determined for the first time, including conjugated fatty acids, sterols, coenzyme Q10, and lipophilic vitamins, such as vitamins D and A.
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http://dx.doi.org/10.1021/acs.joc.0c01920DOI Listing
January 2021

Finding the Right Balance for the Use of Donation After Circulatory Death Livers for Patients With Hepatocellular Carcinoma.

Liver Transpl 2020 09 22;26(9):1081-1082. Epub 2020 Jul 22.

Division of Gastroenterology, Department of Medicine, Stritch School of Medicine, Loyola University of Chicago, Maywood, IL.

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http://dx.doi.org/10.1002/lt.25826DOI Listing
September 2020

Impact of beta-lactam allergy label in liver transplant recipients.

J Allergy Clin Immunol Pract 2020 Jul - Aug;8(7):2434-2436.e1. Epub 2020 Apr 15.

Division of Pulmonary, Allergy and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla. Electronic address:

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http://dx.doi.org/10.1016/j.jaip.2020.03.042DOI Listing
May 2021

Liver Transplantation Outcomes in a U.S. Multicenter Cohort of 789 Patients With Hepatocellular Carcinoma Presenting Beyond Milan Criteria.

Hepatology 2020 12;72(6):2014-2028

Division of Transplant Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI.

Background And Aims: The Organ Procurement and Transplantation Network recently approved liver transplant (LT) prioritization for patients with hepatocellular carcinoma (HCC) beyond Milan Criteria (MC) who are down-staged (DS) with locoregional therapy (LRT). We evaluated post-LT outcomes, predictors of down-staging, and the impact of LRT in patients with beyond-MC HCC from the U.S. Multicenter HCC Transplant Consortium (20 centers, 2002-2013).

Approach And Results: Clinicopathologic characteristics, overall survival (OS), recurrence-free survival (RFS), and HCC recurrence (HCC-R) were compared between patients within MC (n = 3,570) and beyond MC (n = 789) who were down-staged (DS, n = 465), treated with LRT and not down-staged (LRT-NoDS, n = 242), or untreated (NoLRT-NoDS, n = 82). Five-year post-LT OS and RFS was higher in MC (71.3% and 68.2%) compared with DS (64.3% and 59.5%) and was lowest in NoDS (n = 324; 60.2% and 53.8%; overall P < 0.001). DS patients had superior RFS (60% vs. 54%, P = 0.043) and lower 5-year HCC-R (18% vs. 32%, P < 0.001) compared with NoDS, with further stratification by maximum radiologic tumor diameter (5-year HCC-R of 15.5% in DS/<5 cm and 39.1% in NoDS/>5 cm, P < 0.001). Multivariate predictors of down-staging included alpha-fetoprotein response to LRT, pathologic tumor number and size, and wait time >12 months. LRT-NoDS had greater HCC-R compared with NoLRT-NoDS (34.1% vs. 26.1%, P < 0.001), even after controlling for clinicopathologic variables (hazard ratio [HR] = 2.33, P < 0.001) and inverse probability of treatment-weighted propensity matching (HR = 1.82, P < 0.001).

Conclusions: In LT recipients with HCC presenting beyond MC, successful down-staging is predicted by wait time, alpha-fetoprotein response to LRT, and tumor burden and results in excellent post-LT outcomes, justifying expansion of LT criteria. In LRT-NoDS patients, higher HCC-R compared with NoLRT-NoDS cannot be explained by clinicopathologic differences, suggesting a potentially aggravating role of LRT in patients with poor tumor biology that warrants further investigation.
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http://dx.doi.org/10.1002/hep.31210DOI Listing
December 2020

Surveillance for HCC After Liver Transplantation: Increased Monitoring May Yield Aggressive Treatment Options and Improved Postrecurrence Survival.

Transplantation 2020 10;104(10):2105-2112

Department of Transplantation, Mayo Clinic, Jacksonville, FL.

Background: Currently, no surveillance guidelines for hepatocellular carcinoma (HCC) recurrence after liver transplantation (LT) exist. In this retrospective, multicenter study, we have investigated the role of surveillance imaging on postrecurrence outcomes.

Methods: Patients with recurrent HCC after LT from 2002 to 2016 were reviewed from 3 transplant centers (University of California San Francisco, Mayo Clinic Florida, and University of Toronto). For this study, we proposed the term cumulative exposure to surveillance (CETS) as a way to define the cumulative sum of all the protected intervals that each surveillance test provides. In our analysis, CETS has been treated as a continuous variable in months.

Results: Two hundred twenty-three patients from 3 centers had recurrent HCC post-LT. The median follow-up was 31.3 months, and median time to recurrence was 13.3 months. Increasing CETS was associated with improved postrecurrence survival (hazard ratio, 0.94; P < 0.01) as was treatment of recurrence with resection or ablation (hazard ratio, 0.31; P < 0.001). An receiver operating characteristic curve (area under the curve, 0.64) for CETS covariate showed that 252 days of coverage (or 3 surveillance scans) within the first 24 months provided the highest probability for aggressive postrecurrence treatment.

Conclusions: In this review of 223 patients with post-LT HCC recurrence, we found that increasing CETS does lead to improved postrecurrence survival as well as a higher probability for aggressive recurrence treatment. We found that 252 days of monitoring (ie, 3 surveillance scans) in the first 24 months was associated with the ability to offer potentially curative treatment.
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http://dx.doi.org/10.1097/TP.0000000000003117DOI Listing
October 2020

Comparison of Supraceliac and Infrarenal Aortic Conduits in Liver Transplantation: Is There a Difference in Patency and Postoperative Renal Dysfunction?

Transplant Direct 2019 Nov 8;5(11):e499. Epub 2019 Oct 8.

Department of Transplantation, Mayo Clinic Florida, Jacksonville, FL.

Aorto-hepatic conduits can provide arterial inflow for liver transplants in cases where the native hepatic artery is unsuitable for use.

Methods: Clinical outcomes of all patients undergoing liver transplantation (LT) with an aorto-hepatic conduit between 2000 and 2016 were included. Recipients were divided into 2 groups: those with a supraceliac (SC) aortic conduit (N = 22) and those with an infrarenal (IR) aortic conduit (N = 82).

Results: There was no difference in calculated model for end-stage liver disease score between the 2 groups. The SC group received grafts with a higher mean donor risk index (1.69 versus 1.48; = 0.02). Early allograft dysfunction was 18.2% in the SC group and 29.3% in the IR group ( = 0.30). In the SC group, 10.5% of patients required initiation of postoperative continuous renal replacement therapy compared to 12.1% of patients in the IR group ( = 0.69). No difference in the rate of postoperative acute kidney injury was seen between the 2 groups ( = 0.54). No significant difference in median creatinine at 1 year was seen between the SC (1.2 mg/dL; IQR 1-1.3) and IR (1.2 mg/dL; IQR 0.9-1.5) groups ( = 0.85). At a median follow-up of 5.3 years, thrombosis of the aortic conduit occurred in 0% of patients in the SC group and 6.1% of patients in the IR group ( = 0.24). Graft survival was not significantly different between the 2 groups ( = 0.47).

Conclusions: No difference in renal dysfunction as demonstrated by need for post-LT continuous renal replacement therapy, acute kidney injury, or creatinine at 1 year post-LT was seen between SC and IR aortic conduits. A slight trend of higher conduit thrombosis rate was seen with IR compared to SC aortic conduits; however, this did not reach statistical significance. Both SC and IR aortic conduits represent reasonable options when the native hepatic artery is unsuitable for use.
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http://dx.doi.org/10.1097/TXD.0000000000000949DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6831123PMC
November 2019

Acute Pancreatitis in Advanced Chronic Kidney Disease and Kidney Transplant Recipients: Results of a US Nationwide Analysis.

Mayo Clin Proc Innov Qual Outcomes 2019 Jun 27;3(2):160-168. Epub 2019 May 27.

Department of Transplantation, Mayo Clinic, Jacksonville, FL.

Objective: To study the prevalence, etiology, and outcome of acute pancreatitis (AP) in kidney transplant and stage 5 chronic kidney disease (CKD) populations in comparison to a non-CKD cohort.

Patients And Methods: Using the Nationwide Inpatient Sample database, we identified patients with acute pancreatitis as the primary discharge diagnosis, after which propensity scores were used to create 2 cohorts of patients: 1 with CKD (n=13,425) and 1 without CKD (n=13,425). The CKD group was subsequently subdivided into dialysis-independent stage 5 CKD (n=690), dialysis-dependent stage 5 CKD (n=11,415), and kidney transplant recipients (n=1320). Patients younger than 18 years old, those who received a kidney transplant during the incident admission, and pancreas transplant recipients were excluded.

Results: The adjusted odds ratios (ORs) of AP were comparable between the no CKD, stage 5 CKD, and kidney transplant populations. Adjusted inpatient mortality was highest in patients with dialysis-dependent stage 5 CKD (OR, 2.72; 95% CI, 2.2-3.3; <.01), followed by kidney transplant recipients (OR, 2.29; 95% CI, 1.12-4.51; =.02), compared to the non-CKD group. Patients with stage 5 CKD experienced higher rates of shock and intensive care unit admission and had more prolonged and costly hospitalizations than the non-CKD group (<.01 for all). Hypercalcemia was the most common cause of AP in both dialysis-dependent and dialysis-independent patients with stage 5 CKD, while viral and drug-induced pancreatitis were more prevalent in the transplant recipients.

Conclusion: Despite comparable adjusted prevalence of AP among the stage 5 CKD, transplant, and non-CKD populations, mortality, morbidity, and resource utilization were higher in the patients with stage 5 CKD and transplant recipients. Hypercalcemia is the most common cause of AP in the stage 5 CKD population irrespective of dialysis requirement.
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http://dx.doi.org/10.1016/j.mayocpiqo.2019.03.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6543454PMC
June 2019

Does Donor Allograft Microsteatosis Matter? Comparison of Outcomes in Liver Transplantation With a Propensity-Matched Cohort.

Liver Transpl 2019 10 8;25(10):1533-1540. Epub 2019 Jul 8.

Department of Transplant, Mayo Clinic Florida, Jacksonville, FL.

It has been suggested that microsteatosis does not negatively impact graft survival following liver transplantation (LT). The present study represents the largest series on donor livers with significant microsteatosis and investigates the impact of microsteatosis on perioperative factors such as postreperfusion syndrome (PRS), early allograft dysfunction (EAD), and postoperative renal dysfunction. Clinical outcomes of all patients undergoing LT with donor livers with isolated microsteatosis (≥30%; n = 239) between 2000 and 2017 were compared with a propensity score-matched cohort of patients undergoing LT with donor livers with no steatosis (n = 239). Patients in the microsteatosis group had a higher rate of PRS (33.1% versus 24.2%; P = 0.03), EAD (38.2% versus 23.0%; P < 0.001), and continuous renal replacement therapy (CRRT) requirement following LT (10.9% versus 3.6%; P = 0.002) than the no steatosis group. No difference in patient (P = 0.33) or graft survival (P = 0.18) was observed between the 2 groups. On multivariate regression, livers with microsteatosis had an increased risk of graft loss with retransplant recipients (hazard ratio [HR], 1.59; P < 0.001), increasing Model for End-Stage Liver Disease (MELD) score (HR, 1.13; P = 0.01), and organs from donation after circulatory death donors (HR, 1.46; P = 0.003). In conclusion, recipients of donor livers with significant microsteatosis are at an increased risk of PRS, EAD, and postoperative renal dysfunction requiring CRRT. Livers with significant microsteatosis should be avoided in retransplant recipients and in recipients with high biological MELD scores. Once appropriately selected recipients of these livers are able to overcome the initial perioperative implications of using these donor livers, longterm patient and graft survival is similar to recipients receiving grafts with no steatosis.
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http://dx.doi.org/10.1002/lt.25583DOI Listing
October 2019

Pathologic Response to Pretransplant Locoregional Therapy is Predictive of Patient Outcome After Liver Transplantation for Hepatocellular Carcinoma: Analysis From the US Multicenter HCC Transplant Consortium.

Ann Surg 2020 04;271(4):616-624

Department of Surgery, Duke University Medical Center, Durham, NC.

Objective: The aim of the study was to determine the rate, predictors, and impact of complete pathologic response (cPR) to pretransplant locoregional therapy (LRT) in a large, multicenter cohort of hepatocellular carcinoma (HCC) patients undergoing liver transplantation (LT).

Background: LRT is used to mitigate waitlist dropout for patients with HCC awaiting LT. Degree of tumor necrosis found on explant has been associated with recurrence and overall survival, but has not been evaluated in a large, multicenter study.

Methods: Comparisons were made among patients receiving pre-LT LRT with (n = 802) and without (n = 2637) cPR from the United States Multicenter HCC Transplant Consortium (UMHTC), and multivariable predictors of cPR were identified using logistic regression.

Results: Of 3439 patients, 802 (23%) had cPR on explant. Compared with patients without cPR, cPR patients were younger; had lower Model for End-stage Liver Disease (MELD) scores, AFP levels, and neutrophil-lymphocyte ratios (NLR); were more likely to have tumors within Milan criteria and fewer LRT treatments; and had significantly lower 1-, 3-, and 5-year incidence of post-LT recurrence (1.3%, 3.5%, and 5.2% vs 6.2%, 13.5%, and 16.4%; P < 0.001) and superior overall survival (92%, 84%, and 75% vs 90%, 78%, and 68%; P < 0.001). Multivariable predictors of cPR included age, sex, liver disease diagnosis, MELD, AFP, NLR, radiographic Milan status, and number of LRT treatments (C-statistic 0.67).

Conclusions: For LT recipients with HCC receiving pretransplant LRT, achieving cPR portends significantly lower posttransplant recurrence and superior survival. Factors predicting cPR are identified, which may help prioritize patients and guide LRT strategies to optimize posttransplant cancer outcomes.
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http://dx.doi.org/10.1097/SLA.0000000000003253DOI Listing
April 2020

The impact of postreperfusion syndrome during liver transplantation using livers with significant macrosteatosis.

Am J Transplant 2019 09 26;19(9):2550-2559. Epub 2019 Mar 26.

Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida.

The impact of postreperfusion syndrome (PRS) during liver transplantation (LT) using donor livers with significant macrosteatosis is largely unknown. Clinical outcomes of all patients undergoing LT with donor livers with moderate macrosteatosis (30%-60%) (N = 96) between 2000 and 2017 were compared to propensity score matched cohorts of patients undergoing LT with donor livers with mild macrosteatosis (10%-29%) (N = 96) and no steatosis (N = 96). Cardiac arrest at the time of reperfusion was seen in eight (8.3%) of the patients in the moderate macrosteatosis group compared to one (1.0%) of the patients in the mild macrosteatosis group (P = .02) and zero (0%) of the patients in the no steatosis group (P = .004). Patients in the moderate macrosteatosis group had a higher rate of PRS (37.5% vs 18.8%; P = .004), early allograft dysfunction (EAD) (76.4% vs 25.8%; P < .001), renal dysfunction requiring continuous renal replacement therapy following transplant (18.8% vs 8.3%; P = .03) and return to the OR within 30 days (24.0% vs 7.3%; P = .002), than the no steatosis group. Both long-term patient (P = .30 and P = .08) and graft survival (P = .15 and P = .12) were not statistically when comparing the moderate macrosteatosis group to the mild macrosteatosis and no steatosis groups. Recipients of LT using livers with moderate macrosteatosis are at a significant increased risk of PRS. If patients are able to overcome the initial increased perioperative risk of using these donor livers, long-term graft survival does not appear to be different than matched recipients receiving grafts with no steatosis.
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http://dx.doi.org/10.1111/ajt.15330DOI Listing
September 2019

The "Skinny" on Assessment and Utilization of Steatotic Liver Grafts: A Systematic Review.

Liver Transpl 2019 03;25(3):488-499

Department of Transplant, Mayo Clinic Florida, Jacksonville, FL.

The frequency at which steatotic deceased donor liver grafts are encountered will likely continue to increase. Utilization of liver grafts with moderate-to-severe steatosis for liver transplantation (LT) has been previously shown to be associated with increased rates of primary nonfunction and decreased recipient survival. In order to better inform clinical decision making and guide future research, critical evaluation of the literature on donor liver steatosis and posttransplantation outcome is needed. This literature review aims to provide the "skinny" on using deceased donor steatotic livers for LT.
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http://dx.doi.org/10.1002/lt.25408DOI Listing
March 2019

Response to Loco-Regional Therapy Predicts Outcomes After Liver Transplantation for Combined Hepatocellular-Cholangiocarcinoma.

Ann Hepatol 2018 Oct;17(6):969-979

Department of Transplantation, Mayo Clinic, Jacksonville, FL, USA.

Introduction And Aim: Combined hepatocellular-cholangiocarcinoma (HCC-CCA) is a rare liver malignancy distinct from either hepatocellular carcinoma (HCC) or cholangiocarcinoma. Liver transplantation (LT) is not recommended for HCC-CCA because of suboptimal outcomes. Non-invasive diagnosis of HCC-CCA is extremely challenging; thus, some HCC-CCAs are presumed as HCC on imaging and listed for LT with the correct diagnosis ultimately made on explant pathology. We compared HCC-CCA with HCC to determine the utility of response to pre-transplant loco-regional therapy (LRT) in predicting outcomes for HCC-CCA after LT as a potential means of identifying appropriate HCC-CCA patients for LT.

Material And Methods: Retrospective review of 19 patients with pathologically confirmed HCC-CCA were individually matched to 38 HCC patients (1:2) based on age, sex, and Milan criteria at listing was performed. The modified response evaluation criteria in solid tumors was used to categorize patients as responders or non-responders to pre-transplant LRT based on imaging performed before and after LRT. Overall survival (OS) and recurrence-free survival (RFS) were examined.

Results: OS at 3 years post-transplant was 74% for HCC-CCA and 87% for HCC. RFS at 3 years was 74% for HCC-CCA, and 87% for HCC. Among responders to LRT, the 3-year OS was 92% for HCC-CCA and 88% for HCC; among non-responders, 3-year OS was 43% for HCC-CCA and 83% for HCC. Higher 3-year OS was observed among HCC-CCA responders (77%) compared with HCC-CCA non-responders (23%).

Conclusions: OS was similarly high among.
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http://dx.doi.org/10.5604/01.3001.0012.7197DOI Listing
October 2018

Equivalent Outcomes With Retransplantation and Primary Liver Transplantation in the Direct-acting Antiviral Era.

Transplantation 2019 06;103(6):1168-1174

Department of Transplant, Mayo Clinic Florida, Jacksonville, FL.

Background: The present multicenter study investigated whether equivalent outcomes to primary liver transplant (LT) could be achieved with liver retransplant (reLT) and whether improvements in outcomes have taken place over time, particularly in the direct-acting antiviral era.

Methods: All reLT performed at Mayo Clinic Florida, Mayo Clinic Rochester, and Mayo Clinic Arizona were divided into era 1 (2002-2007), era 2 (2008-2012), and era 3 (2013-2017) based on the date of reLT.

Results: Improvement in graft survival (GS) after reLT was seen over the 3 eras (P < 0.001). In era 1, GS after reLT was inferior to primary LT (P < 0.001), whereas no difference was seen between reLT and primary LT in era 2 (P = 0.68) or era 3 (P = 0.36). A significantly higher proportion of patients achieved sustained viral response (SVR) within the first year after reLT in each subsequent era (era 1: 10.3%, era 2: 22.5%, and era 3: 100%) (P < 0.001). Graft survival was superior in patients undergoing reLT for recurrent hepatitis C virus who achieved SVR after reLT compared with those who did not (P = 0.03).

Conclusions: Results similar to primary LT were achieved in era 3. These improvements coincide with the availability of direct-acting antivirals, which resulted in a 100% SVR rate in era 3 and a decrease in the number of patients undergoing reLT for recurrent hepatitis C virus. The historic dogma that reLT results in inferior outcomes should be revisited.
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http://dx.doi.org/10.1097/TP.0000000000002460DOI Listing
June 2019

Hepatic artery stenosis after liver transplant: Donation after cardiac death donor vs donation after brain death donor grafts.

Clin Transplant 2018 11 28;32(11):e13413. Epub 2018 Oct 28.

Department of Transplantation, Mayo Clinic Florida and Mayo Clinic Collaborative in Transplant Research and Outcomes, Jacksonville, Florida.

Background: Hepatic artery stenosis (HAS) after liver transplant (LT) is a source of significant morbidity. Some reports have suggested higher arterial complications in patients who receive donation after cardiac death (DCD) livers.

Methods: A total of 2860 consecutive LT were reviewed from a prospectively collected database. All angiograms performed in LT recipients were reviewed and primary patency rates determined by need for further intervention or graft loss due to HAT.

Results: Hepatic artery stenosis was seen in 4.6% of DCD and donation after brain death (DBD) recipients. Recipient male gender, age at transplant, complex donor hepatic artery anatomy, and prolonged operative time were all associated with HAS, but not DCD status. While HAS in recipients of DCD grafts required more stents (1.7% vs 0.6%, P = 0.04) and had worse primary patency rates (logrank, P = 0.02), outcomes as defined by HAT, patient and graft survival were not significantly different between the recipients of DCD or DBD grafts.

Conclusion: We observed no significant difference in the incidence of hepatic artery complications, patient survival, or graft survival in recipients of DCD or DBD grafts. However, HAS in DCD recipients had worse primary patency and a higher need for stent placement.
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http://dx.doi.org/10.1111/ctr.13413DOI Listing
November 2018

The mRECIST Classification Provides Insight into Tumor Biology for Patients With Hepatocellular Carcinoma Awaiting Liver Transplantation.

Liver Transpl 2019 02;25(2):228-241

Department of Transplantation, Mayo Clinic, Jacksonville, FL.

With recent changes in United Network for Organ Sharing policy, patients in the United States with hepatocellular carcinoma (HCC) are likely to spend more time on the liver transplantation (LT) waiting list. The increasing wait time will allow for an opportunity to assess tumor biology prior to LT. Modified Response Evaluation Criteria in Solid Tumors (mRECIST) paradigm provides such a framework for this assessment, and yet little is understood of its utility as it would apply for patients listed for LT in the United States. Through a collaboration between the University of California, San Francisco, and the Mayo Clinic, Jacksonville, Florida, the experience of 772 patients listed for LT were retrospectively reviewed to study the impact of immediate mRECIST classification following locoregional therapy (LRT) on pre- and post-LT outcomes. Patients who had progression of disease (PD; n = 72), failed to respond to LRT (n = 89) at any time point, or did not achieve radiologic complete response (CR; n = 224) were all at significant risk for wait-list dropout (odds ratio [OR] = 12.11, 4.81, and 2.48; respectively). CR identified a cohort of patients who were at a reduced risk for wait-list dropout. However, 24.9% eventually required further intervention while waiting for transplant, and as many as 82.4% were found to have residual HCC on explant pathology. Failure to respond to LRT was associated with increased risk for recurrence (OR = 3.00) more so than PD (OR = 1.36), suggesting that despite PD, patients who eventually can respond to LRT may represent favorable candidates for LT. In conclusion, for patients awaiting LT, the mRECIST assessment provides critical guidance for patient management. Although PD portends a poor prognosis, our findings suggest that further aggressive LRT should be pursued because a response to LRT may yield acceptable results for patients awaiting LT as well as after LT.
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http://dx.doi.org/10.1002/lt.25333DOI Listing
February 2019

Outcomes of Donation After Circulatory Death Liver Grafts From Donors 50 Years or Older: A Multicenter Analysis.

Transplantation 2018 07;102(7):1108-1114

Department of Transplant, Mayo Clinic Florida, Jacksonville, FL.

Background: As the population in the United States continues to age, an increase in the number of potential donation after circulatory death (DCD) donors with advanced chronological age can be expected. The aim of this study was to analyze a multi-institutional experience in liver transplantation using DCD donors 50 years or older.

Methods: All DCD liver transplant (LT) performed at Mayo Clinic Florida, Mayo Clinic Rochester, and Mayo Clinic Arizona from 2002 to 2016 were included. Recipients of DCD LT were divided into 2 groups: those with donors 50 years or older (N = 155) and those with donors younger than 50 years(N = 316).

Results: Graft survival was similar between the DCD donors 50 years or older group and DCD donors younger than 50 group(P = 0.99). Graft survival at 1, 3, and 5 years was 87.0%, 75.6%, and 71.8% in the DCD donors 50 years or older group and 85.8%, 76.0%, and 70.4% in the DCD donors younger than 50 group.The rate of total biliary complications (32.3% vs 23.7%; P = 0.049) and of anastomotic strictures (16.1% vs 8.2%; P = 0.01) were higher in the DCD donors 50 years or older compared with the DCD donors younger than 50 group. No statistical significant difference in the rate of ischemic cholangiopathy (11.6% vs 7.6%; P = 0.15) was seen between the 2 groups. Due to homogeneous practice patterns at the involved institutions, additional Cox regression analysis using national data obtained from Scientific Registry of Transplant Recipients was used to evaluate predictors of graft failure in DCD donors 50 years or older. Significant predictors of graft failure included: a calculated Model for End-Stage Liver Disease score of 30 or higher (P < 0.001), mechanical ventilation at the time of transplant (P < 0.001), medical condition (in intensive care unit) (P = 0.002), and cold ischemia time (P < 0.001).

Conclusions: The present study demonstrates that acceptable graft and patient survival can be achieved with the usage of DCD LT with donors 50 years or older. Optimizing recipient selection criteria and minimizing cold ischemia time may further improve outcomes.
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http://dx.doi.org/10.1097/TP.0000000000002120DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7228627PMC
July 2018

Early Allograft Dysfunction Is Associated With Higher Risk of Renal Nonrecovery After Liver Transplantation.

Transplant Direct 2018 Apr 14;4(4):e352. Epub 2018 Mar 14.

Mayo Clinic Collaborative in Transplant Research and Outcomes, Department of Transplant, Mayo Clinic Florida, Jacksonville, FL.

Early allograft dysfunction (EAD) identifies allografts with marginal function soon after liver transplantation (LT) and is associated with poor LT outcomes. The impact of EAD on post-LT renal recovery, however, has not been studied. Data on 69 primary LT recipients (41 with and 28 without history of renal dysfunction) who received renal replacement therapy (RRT) for a median (range) of 9 (13-41) days before LT were retrospectively analyzed. Primary outcome was renal nonrecovery defined as RRT requirement 30 days from LT. Early allograft dysfunction developed in 21 (30%) patients, and 22 (32%) patients did not recover renal function. Early allograft dysfunction was more common in the renal nonrecovery group (50% vs 21%, = 0.016). Multivariate logistic regression analysis demonstrated that EAD (odds ratio, 7.25; 95% confidence interval, 2.0-25.8; = 0.002) and baseline serum creatinine (odds ratio, 3.37; 95% confidence interval, 1.4-8.1; = 0.007) were independently associated with renal nonrecovery. History of renal dysfunction, duration of renal dysfunction, and duration of RRT were not related to renal recovery ( > 0.2 for all). Patients who had EAD and renal nonrecovery had the worst 1-, 3-, and 5-year patient survival, whereas those without EAD and recovered renal function had the best outcomes ( < 0.001). Post-LT EAD was independently associated with renal nonrecovery in LT recipients on RRT for a short duration before LT. Furthermore, EAD in the setting of renal nonrecovery resulted in the worst long-term survival. Measures to prevent EAD should be undertaken in LT recipients on RRT at time of LT.
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http://dx.doi.org/10.1097/TXD.0000000000000771DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5908457PMC
April 2018

Liver transplantation for intrahepatic cholangiocarcinoma.

Liver Transpl 2018 05;24(5):634-644

Department of Transplant, Mayo Clinic, Jacksonville, FL.

Although hepatocellular carcinoma (HCC) has become a common indication for liver transplantation (LT), intrahepatic cholangiocarcinoma (ICC) and combined hepatocellular carcinoma-cholangiocarcinoma (cHCC-CCA) are historically contraindicated due to their aggressive behavior. On the basis of recent experiences, some groups have proposed a clinical trial investigating the role of LT for patients with early cholangiocarcinoma (CCA), defined as a single lesion ≤ 2 cm. The purpose of this study is to assess the clinicopathologic features and outcomes following LT for patients who were initially diagnosed with HCC and subsequently found to have either ICC or cHCC-CCA on explant. Patients with the diagnosis of primary liver cancer (PLC) after LT from a single center were retrospectively reviewed. Outcomes for patients with early CCA were compared with patients with HCC within Milan criteria (MC). Out of 618 patients transplanted with PLC, 44 patients were found to have CCA on explant. On the basis of preoperative imaging, 12 patients met criteria for early CCA and were compared with 319 patients who had HCC within MC. The 1- and 5-year overall survival for early CCA versus HCC was 63.6% versus 90.0% and 63.6% versus 70.3% (log-rank, P = 0.25), respectively. Overall recurrence was 33.3% for early CCA versus 11% for HCC. On explant the patients with CCA were more likely understaged with higher tumor grade and vascular invasion. In conclusion, patients with CCA present a diagnostic challenge, which often leads to the finding of more aggressive lesions on explant after LT, higher recurrence rates, and worse post-LT survival. Careful consideration of this diagnostic conundrum needs to be made before a clinical trial is undertaken. Liver Transplantation 24 634-644 2018 AASLD.
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http://dx.doi.org/10.1002/lt.25052DOI Listing
May 2018

The impact of cold ischemia time at the higher end of the KDPI spectrum: what is the risk?

Transpl Int 2018 07;31(7):706-707

Department of Transplant, Mayo Clinic Florida, Jacksonville, FL, USA.

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http://dx.doi.org/10.1111/tri.13135DOI Listing
July 2018

Intraregional model for end-stage liver disease score variation in liver transplantation: Disparity in our own backyard.

Liver Transpl 2018 04;24(4):488-496

Department of Transplant, Mayo Clinic Florida, Jacksonville, FL.

Variation in average Model for End-Stage Liver Disease (MELD) score at liver transplantation (LT) by United Network for Organ Sharing (UNOS) regions is well documented. The present study aimed to investigate MELD variation at the interregional, intraregional, and intra-donation service area (DSA) levels. Patients undergoing LT between 2015 and 2016 were obtained from the UNOS standard analysis and research file. The distribution of allocation MELD score including median, skew, and kurtosis was examined for all transplant programs. Intraregional median allocation MELD varied significantly within all 11 UNOS regions. The largest variation between programs was seen in region 5 (MELD 24.0 versus 38.5) and region 3 (MELD 20.5 versus 32.0). Regions 1, 5, and 9 had the largest proportion of programs with a highly negative skewed MELD score (50%, 57%, and 57%, respectively), whereas regions 3, 6, 10, and 11 did not have any programs with a highly negative skew. MELD score distribution was also examined in programs located in the same DSA, where no barriers exist and theoretically no significant difference in allocation should be observed. The largest DSA variation in median allocation MELD score was seen in NYRT-OP1 LiveOnNY (MELD score variation 11), AZOB-OP1 Donor Network of Arizona (MELD score variation 11), MAOB-OP1 New England Organ Bank (MELD score variation 9), and TXGC-OP1 LifeGift Organ Donation Ctr (MELD score variation 9). In conclusion, the present study demonstrates that this MELD disparity is not only present at the interregional level but can be seen within regions and even within DSAs between programs located as close as several city blocks away. Although organ availability likely accounts for a component of this disparity, the present study suggests that transplant center behavior may also play a significant role. Liver Transplantation 24 488-496 2018 AASLD.
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http://dx.doi.org/10.1002/lt.25021DOI Listing
April 2018

What are the outcomes of declining a public health service increased risk liver donor for patients on the liver transplant waiting list?

Liver Transpl 2018 04;24(4):497-504

Department of Transplant, Mayo Clinic Florida, Jacksonville, FL.

The tragedy of the national opioid epidemic has resulted in a significant increase in the number of opioid-related deaths and accordingly an increase in the number of potential donors designated Public Health Service (PHS) increased risk. Previous studies have demonstrated reluctance to use these PHS organs, and as a result, higher discard rates for these organs have been observed. All patients listed for liver transplantation in the United States from January 2005 to December 2016 were investigated. Patients on the waiting list were divided into 2 groups: those in which a PHS liver was used for transplantation (accepted PHS group) and those in which a PHS liver was declined and transplanted into a recipient lower on the match run (declined PHS group). Intention-to-treat patient survival from the time of PHS offer was significantly higher in the accepted PHS compared with the declined PHS group (P < 0.001). On Cox multivariate regression, declining a PHS donor liver was associated with a hazard ratio of 2.36 (95% confidence interval, 2.23-2.49; P < 0.001). For patients in which a PHS organ offer was declined, 11.6% died or were delisted for being too sick within the subsequent year. Donor liver allografts implanted in the accepted PHS group were of a lower donor risk index (1.28 versus 1.44) compared with the non-PHS organs that patients in the declined PHS group ultimately received if they underwent transplantation. In conclusion, there is a significantly higher survival for patients in which a PHS liver is accepted and used compared with those patients in which a PHS organ is declined. These data will help inform decisions about whether or not to accept a PHS donor liver for both patients and transplant professionals. Liver Transplantation 24 497-504 2018 AASLD.
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http://dx.doi.org/10.1002/lt.25009DOI Listing
April 2018

Looking inward: The impact of operative time on graft survival after liver transplantation.

Surgery 2017 10 3;162(4):937-949. Epub 2017 Jul 3.

Mayo Clinic Collaborative in Transplant Research and Outcomes, Department of Transplant, Mayo Clinic Florida, Jacksonville, FL. Electronic address:

Background: Operative time often has been cited as an important factor for postoperative outcomes. Despite this belief, most efforts to improve liver transplant outcomes have largely focused on only patient and donor factors, and little attention has been paid on operative time. The primary objective of this project was to determine the impact of operative time on graft survival after liver transplant.

Methods: A retrospective review of 2,877 consecutive liver transplants performed at a single institution was studied. Data regarding recipient, donor, and operative characteristics, including detailed granular operative times were collected prospectively and retrospectively reviewed. Using an instrument variable approach, Cox multivariate modeling was performed to assess the impact of operative time without the confounding of known and unknown variables.

Results: Of the 2,396 patients who met the criteria for review, the most important factors determining liver transplant graft survival included recipient history of Hepatitis C (hazard ratio 1.45, P = .02), donor age (hazard ratio 1.23, P = .03), use of liver graft from donation after cardiac death donor (hazard ratio 1.50, P < .01), and operative time (hazard ratio 1.26, P = .01). In detailed analysis of stages of the liver transplant operation, the time interval from incision to anhepatic phase was associated with graft survival (hazard ratio 1.33; P = .02).

Conclusion: Using a novel instrument variable approach, we demonstrate that operative time (in particular, the time interval from incision to anhepatic time) has a significant impact on graft survival. It also seems that some of this efficiency is under the influence of the transplant surgeon.
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http://dx.doi.org/10.1016/j.surg.2017.05.010DOI Listing
October 2017

Impact of Pretransplant Bridging Locoregional Therapy for Patients With Hepatocellular Carcinoma Within Milan Criteria Undergoing Liver Transplantation: Analysis of 3601 Patients From the US Multicenter HCC Transplant Consortium.

Ann Surg 2017 09;266(3):525-535

*Dumont-UCLA Liver Transplant and Cancer Centers, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA †Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX ‡Recanati/Miller Transplantation Institute, Mount Sinai Medical Center, New York, NY §Penn Transplant Institute, University of Pennsylvania, Philadelphia, PA ¶Department of Transplantation, Mayo Clinic, Jacksonville, FL ||New York Presbyterian Hospital, Columbia University, New York, NY **New York Presbyterian Hospital, Weill Cornell, New York, NY ††Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA ‡‡Cleveland Clinic Foundation, Cleveland, OH §§Section of Transplantation, Department of Surgery, Washington University in St. Louis, St. Louis, MO ¶¶Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, CA ||||Department of Surgery, Stanford University, Palo Alto, CA ***Division of Transplant Surgery, Department of Surgery, University of Colorado School of Medicine, Denver, CO †††Sherrie & Alan Conover Center for Liver Disease & Transplantation, Houston Methodist Hospital, Houston, TX ‡‡‡Division of Transplant Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA §§§Department of Surgery, University of Nebraska Medical Center, Omaha, NE ¶¶¶Division of Transplantation and Hepatobiliary Surgery, Department of Surgery, University of California, San Diego, San Diego, CA ||||||Department of Surgery, Duke University Medical Center; Durham, NC ****Division of Transplant Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI ††††Department of Surgery, Baylor College of Medicine, Houston, TX ‡‡‡‡Section of Hepatobiliary and Transplant Surgery, University of Louisville School of Medicine, Louisville, KY §§§§Medstar Georgetown Transplant Institute, Georgetown University, Washington, District of Columbia.

Objective: To evaluate the effect of pretransplant bridging locoregional therapy (LRT) on hepatocellular carcinoma (HCC) recurrence and survival after liver transplantation (LT) in patients meeting Milan criteria (MC).

Summary Background Data: Pre-LT LRT mitigates tumor progression and waitlist dropout in HCC patients within MC, but data on its impact on post-LT recurrence and survival remain limited.

Methods: Recurrence-free survival and post-LT recurrence were compared among 3601 MC patients with and without bridging LRT utilizing competing risk Cox regression in consecutive patients from 20 US centers (2002-2013).

Results: Compared with 747 LT recipients not receiving LRT, 2854 receiving LRT had similar 1, 3, and 5-year recurrence-free survival (89%, 77%, 68% vs 85%, 75%, 68%; P = 0.490) and 5-year post-LT recurrence (11.2% vs 10.1%; P = 0.474). Increasing LRT number [3 LRTs: hazard ratio (HR) 2.1, P < 0.001; 4+ LRTs: HR 2.5, P < 0.001), and unfavorable waitlist alphafetoprotein trend significantly predicted post-LT recurrence, whereas LRT modality did not. Treated patients achieving complete pathologic response (cPR) had superior 5-year RFS (72%) and lower post-LT recurrence (HR 0.52, P < 0.001) compared with both untreated patients (69%; P = 0.010; HR 1.0) and treated patients not achieving cPR (67%; P = 0.010; HR 1.31, P = 0.039), who demonstrated increased recurrence compared with untreated patients in multivariate analysis controlling for pretransplant and pathologic factors (HR 1.32, P = 0.044).

Conclusions: Bridging LRT in HCC patients within MC does not improve post-LT survival or HCC recurrence in the majority of patients who fail to achieve cPR. The need for increasing LRT treatments and lack of alphafetoprotein response to LRT independently predict post-LT recurrence, serving as a surrogate for underlying tumor biology which can be utilized for prioritization of HCC LT candidates.
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http://dx.doi.org/10.1097/SLA.0000000000002381DOI Listing
September 2017

Extracellular vesicles from bone marrow-derived mesenchymal stem cells protect against murine hepatic ischemia/reperfusion injury.

Liver Transpl 2017 06;23(6):791-803

Departments of Transplantation and Cancer Biology, Mayo Clinic, Jacksonville, Florida.

Hepatic ischemia/reperfusion injury (IRI) and associated inflammation contributes to liver dysfunction and complications after liver surgery and transplantation. Mesenchymal stem cells (MSCs) have been reported to reduce hepatic IRI because of their reparative immunomodulatory effects in injured tissues. Recent studies have highlighted beneficial effects of extracellular vesicles from mesenchymal stem cells (MSC-EV) on tissue injury. The effects of systemically administered mouse bone marrow-derived MSC-EV were evaluated in an experimental murine model of hepatic IRI induced by cross-clamping the hepatic artery and portal vein for 90 minutes followed by reperfusion for periods of up to 6 hours. Compared with controls, intravenous administration of MSC-EV 30 minutes prior to IRI dramatically reduced the extent of tissue necrosis, decreased caspase 3-positive and apoptotic cells, and reduced serum aminotransferase levels. MSC-EV increased hepatic messenger RNA (mRNA) expression of NACHT, LRR, and PYD domains-containing protein 12, and the chemokine (C-X-C motif) ligand 1, and reduced mRNA expression of several inflammatory cytokines such as interleukin 6 during IRI. MSC-EV increased cell viability and suppressed both oxidative injury and nuclear factor kappa B activity in murine hepatocytes in vitro. In conclusion, the administration of extracellular vesicles derived from bone marrow-derived MSCs may ameliorate hepatic IRI by reducing hepatic injury through modulation of the inflammatory response.Liver Transplantation 23 791-803 2017 AASLD.
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http://dx.doi.org/10.1002/lt.24770DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5495137PMC
June 2017

Effects of the Share 35 Rule on Waitlist and Liver Transplantation Outcomes for Patients with Hepatocellular Carcinoma.

PLoS One 2017 25;12(1):e0170673. Epub 2017 Jan 25.

Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida.

Introduction: Several studies have investigated the effects following the implementation of the "Share 35" policy; however none have investigated what effect this policy change has had on waitlist and liver transplantation (LT) outcomes for hepatocellular carcinoma(HCC).

Methods: Data were obtained from the UNOS database and a comparison of the 2 years post-Share 35 with data from the 2 years pre-Share 35 was performed.

Results: In the pre-Share35 era, 23% of LT were performed for HCC exceptions compared to 22% of LT in the post-Share35 era (p = 0.21). No difference in wait-time for HCC patients was seen in any of the UNOS regions between the 2 eras. Competing risk analysis demonstrated that HCC candidates in post-Share 35 era were more likely to die or be delisted for "too sick" while waiting (7.2% vs. 5.3%; p = 0.005) within 15 months. A higher proportion of ECD (p<0.001) and DCD (p<0.001) livers were used for patients transplanted for HCC, while lower DRI organs were used for those patients transplanted with a MELD≥35 between the 2 eras (p = 0.007).

Conclusion: No significant change to wait-time for patients listed for HCC was seen following implementation of "Share 35". Transplant program behavior has changed resulting use of higher proportion of ECD and DCD liver grafts for patients with HCC. A higher rate of wait list mortality was observed in patients with HCC in the post-Share 35 era.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0170673PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5266291PMC
August 2017

Comparison of longterm outcomes and quality of life in recipients of donation after cardiac death liver grafts with a propensity-matched cohort.

Liver Transpl 2017 03;23(3):342-351

Department of Transplant, Mayo Clinic Florida, Jacksonville, FL.

The use of liver grafts from donation after cardiac death (DCD) has been limited due to the increased rate of graft failure, mostly related to ischemic cholangiopathy (IC). It is our hypothesis that longterm outcomes and quality of life (QOL) similar to patients undergoing liver transplantation (LT) with donation after brain death (DBD) can be achieved. Clinical outcomes of all patients undergoing DCD LT (n = 300) between 1998 and 2015 were compared with a propensity score-matched cohort of patients undergoing DBD LT (n = 300). Patients were contacted for a follow-up questionnaire and short-form (SF)-12 QOL Survey administration. Median follow-up was >5 years. Graft survival at 1-, 3-, and 5-years was 83.8%, 75.5%, and 70.1% in the DCD LT group and 88.4%, 80.3%, and 73.9% in the DBD LT group (P = 0.27). Patient survival at 1-, 3-, and 5-years was 92.3%, 86.1%, and 80.3% in the DCD LT group and 92.3%, 85.1%, and 79.5% in the DBD LT group (P = 0.81). IC developed in 11.7% and 2% of patients in the DCD LT group and DBD LT group, respectively (P < 0.001). DCD LT recipients who developed IC had inferior graft survival compared with both the DCD non-IC group (P < 0.001) and the DBD LT group (P < 0.001); no difference in graft survival was observed between the DCD non-IC group and the DBD LT group (P = 0.50). Physical and Mental Composite Scores on the SF-12 QOL questionnaire were similar between the DCD LT and DBD LT groups (44.0 versus 45.4; P = 0.34 and 51.9 versus 52.2; P = 0.83), respectively. Similar longterm survival and QOL scores can be achieved between DCD LT and DBD LT. Prevention of IC in DCD LT yields excellent graft and patient survival with virtually no difference compared with DBD LT. Liver Transplantation 23 342-351 2017 AASLD.
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http://dx.doi.org/10.1002/lt.24713DOI Listing
March 2017

Improving National Results in Liver Transplantation Using Grafts From Donation After Cardiac Death Donors.

Transplantation 2016 Dec;100(12):2640-2647

1 Department of Transplant, Mayo Clinic, Jacksonville, FL.

Background: Published reports describing the national experience with liver grafts from donation after cardiac death (DCD) donors have resulted in reservations with their widespread utilization. The present study aimed to investigate if temporal improvements in outcomes have been observed on a national level and to determine if donor and recipient selection have been modified in a fashion consistent with published data on DCD use in liver transplantation (LT).

Methods: Patients undergoing DCD LT between 2003 and 2014 were obtained from the United Network of Organ Sharing Standard Transplant Analysis and Research file and divided into 3 equal eras based on the date of DCD LT: era 1 (2003-2006), era 2 (2007-2010), and era 3 (2011-2014).

Results: Improvement in graft survival was seen between era 1 and era 2 (P = 0.001) and between era 2 and era 3 (P < 0.001). Concurrently, an increase in the proportion of patients with hepatocellular carcinoma and a decrease in critically ill patients, retransplant recipients, donor age, warm ischemia time greater than 30 minutes and cold ischemic time also occurred over the same period. On multivariate analysis, significant predictors of graft survival included: recipient age, biologic MELD score, recipient on ventilator, recipient hepatitis C virus + serology, donor age and cold ischemic time. In addition, even after adjustment for all of the aforementioned variables, both era 2 (hazard ratio, 0.81; confidence interval, 0.69-0.94; P = 0.007), and era 3 (hazard ratio, 0.61; confidence interval, 0.5-0.73; P < 0.001) had a protective effect compared to era 1.

Conclusions: The national outcomes for DCD LT have improved over the last 12 years. This change was associated with modifications in both recipient and donor selection. Furthermore, an era effect was observed, even after adjustment for all recipient and donor variables on multivariate analysis.
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http://dx.doi.org/10.1097/TP.0000000000001483DOI Listing
December 2016

 Simultaneous liver and kidney transplantation in elderly patients: Outcomes and validation of a clinical risk score for patient selection.

Ann Hepatol 2016 Nov-Dec 2016;15(6):870-880

Mayo Clinic Collaborative in Transplant Research and Outcomes. Department of Transplant. Mayo Clinic, Jacksonville, Florida, USA.

 Introduction and aim. Many transplant programs have expanded eligibility to include patients previously ineligible because of advanced age. Outcomes of simultaneous liver-kidney transplantation (SLK) in recipients with advanced age are not known.

Material And Methods: Data from patients undergoing transplantation between 2002 and 2015 were obtained from the UNOS Standard Analysis and Research file.

Results: SLK recipients aged ≥ 65 years (N = 677), SLK recipients aged < 65 years (N = 4517), and recipients of liver transplant alone(LTA) aged ≥ 65 years(N = 8495) were compared. Recipient characteristics were similar between the SLK groups. Similar patient and graft survival were observed in SLK recipients aged ≥ 65 years compared to SLK recipients aged < 65 years and LTA recipients aged ≥ 65 years. Importantly, in a subgroup analysis, superior survival was seen in the SLK group aged ≥ 65 years compared to LTA recipients aged ≥ 65 years who underwent dialysis in the week prior to transplantation (p < 0.001). A prediction model of patient survival was developed for the SLK group aged ≥ 65 years with predictors including: age ≥ 70 years (3 points), calculated MELD score (-1 to 2 points), and recipient ventilator status at the time of SLK (4 points). The risk score predicted patient survival, with a significantly inferior survival seen in patients with a score ≥ 4 (p < 0.001).

Conclusions: Age should not be used as a contraindication for SLK transplantation. The validated scoring system provides a guide for patient selection and can be used when evaluating elderly patients for SLK transplantation listing.
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http://dx.doi.org/10.5604/16652681.1222103DOI Listing
February 2017
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