Publications by authors named "Jean Botha"

49 Publications

Liver Transplant for Nonresectable Colorectal Cancer Liver Metastases in South Africa: A Single-Center Case Series.

Exp Clin Transplant 2020 12 17;18(7):842-846. Epub 2020 Sep 17.

From the Wits Donald Gordon Medical Centre and the Department of Surgery, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.

Objectives: Publication in 2013 of the first Secondary Cancer cohort study returned attention to liver transplant for nonresectable colorectal cancer, demonstrating excellent outcomes for a procedure that was historically contraindicated. The Wits Donald Gordon Medical Centre in Johannesburg, South Africa, hosts the largest liver transplant program in sub-Saharan Africa. The persistent shortage of deceased donor organs in our setting has compelled us to innovate solutions unique to our context, which allows us to perform as many transplants as possible and maximize our resource utilization. Therefore, we initiated a research study to transplant organs in patients with nonresectable colorectal carcinoma with expanded criteria using marginal deceased donor organs that would otherwise have been discarded.

Materials And Methods: Institutional Review Board approval was obtained for this study. We used criteria from the 2013 Secondary Cancer cohort study to determine eligibility of patients with nonresectable colorectal carcinoma for liver transplant. Unlike the study from 2013, we utilized expanded criteria and marginal liver allografts for transplant.

Results: Five patients have undergone liver transplant for nonresectable colorectal carcinoma. At a median follow-up of 36 months (range, 10-52 months), 4 of the 5 (80%) patients are alive. The patient who died had progressive disease on chemotherapy pretransplant and was the only patient who tested positive for the Kirsten rat sarcoma viral oncogene homolog mutant. Recurrence occurred in all patients at a median time of 6 months after transplant (range, 3-13 months).

Conclusions: To our knowledge, this is the only published case series of patients undergoing liver transplant for nonresectable colorectal carcinoma in Africa and is internationally unique in its use of expanded criteria and marginal grafts for this type of transplant. Despite the use of such grafts in our recipients, thus far, these outcomes align with those of the 2013 Secondary Cancer cohort studies from Norway.
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http://dx.doi.org/10.6002/ect.2020.0064DOI Listing
December 2020

Minding the gap-Providing quality transplant care for South African children with acute liver failure.

Pediatr Transplant 2020 12 1;24(8):e13827. Epub 2020 Sep 1.

Faculty of Health Sciences, Wits Donald Gordon Medical Centre, University of the Witwatersrand, Johannesburg, South Africa.

Pediatric ALF is rare but life-threatening and may require urgent transplantation. In low and middle-income countries, access to transplantation is limited, deceased organ donation rates are low, and data on outcomes scarce. The Wits Donald Gordon Medical Centre, in Johannesburg, is one of only two centers in South Africa that perform pediatric liver transplant. We describe the etiology, clinical presentation, and outcomes of children undergoing liver transplant for ALF at our center over the past 14 years. We performed a retrospective chart review of all children undergoing liver transplantation for ALF from November 2005 to September 2019. Recipient data included demographics, clinical and biochemical characteristics pretransplant, post-operative complications, and survival. We conducted descriptive data analysis and used the Kaplan-Meier method for survival analysis. We performed 182 primary pediatric liver transplants. Of these, 27 (15%) were for ALF, mostly from acute hepatitis A infection (11/27;41%). Just over half of the grafts were from living donors (15/27;56%), and five grafts (5/27;19%) were ABO-incompatible. The most frequent post-transplant complications were biliary leaks (9/27;33%). There were two cases of hepatic artery thrombosis (2/27;7%), one of whom required re-transplantation. Unadjusted patient and graft survival at one and 3 years were the same, at 81% (95% CI 61%-92%) and 78% (95% CI 57%-89%), respectively. At WDGMC, our outcomes for children who undergo liver transplantation for ALF are excellent. We found workable solutions that effectively addressed our pervasive organ shortages without compromising patient outcomes.
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http://dx.doi.org/10.1111/petr.13827DOI Listing
December 2020

Risk factors for COVID-19 death in a population cohort study from the Western Cape Province, South Africa.

Authors:
Andrew Boulle Mary-Ann Davies Hannah Hussey Muzzammil Ismail Erna Morden Ziyanda Vundle Virginia Zweigenthal Hassan Mahomed Masudah Paleker David Pienaar Yamanya Tembo Charlene Lawrence Washiefa Isaacs Hlengani Mathema Derick Allen Taryn Allie Jamy-Lee Bam Kasturi Buddiga Pierre Dane Alexa Heekes Boitumelo Matlapeng Themba Mutemaringa Luckmore Muzarabani Florence Phelanyane Rory Pienaar Catherine Rode Mariette Smith Nicki Tiffin Nesbert Zinyakatira Carol Cragg Frederick Marais Vanessa Mudaly Jacqueline Voget Jody Davids Francois Roodt Nellis van Zyl Smit Alda Vermeulen Kevin Adams Gordon Audley Kathleen Bateman Peter Beckwith Marc Bernon Dirk Blom Linda Boloko Jean Botha Adam Boutall Sean Burmeister Lydia Cairncross Gregory Calligaro Cecilia Coccia Chadwin Corin Remy Daroowala Joel A Dave Elsa De Bruyn Martin De Villiers Mimi Deetlefs Sipho Dlamini Thomas Du Toit Wilhelm Endres Tarin Europa Graham Fieggan Anthony Figaji Petro Frankenfeld Elizabeth Gatley Phindile Gina Evashan Govender Rochelle Grobler Manqoba Vusumuzi Gule Christoff Hanekom Michael Held Alana Heynes Sabelo Hlatswayo Bridget Hodkinson Jeanette Holtzhausen Shakeel Hoosain Ashely Jacobs Miriam Kahn Thania Kahn Arvin Khamajeet Joubin Khan Riaasat Khan Alicia Khwitshana Lauren Knight Sharita Kooverjee Rene Krogscheepers Jean Jacque Kruger Suzanne Kuhn Kim Laubscher John Lazarus Jacque Le Roux Scott Lee Jones Dion Levin Gary Maartens Thina Majola Rodgers Manganyi David Marais Suzaan Marais Francois Maritz Deborah Maughan Simthandile Mazondwa Luyanda Mbanga Nomonde Mbatani Bulewa Mbena Graeme Meintjes Marc Mendelson Ernst Möller Allison Moore Babalwa Ndebele Marc Nortje Ntobeko Ntusi Funeka Nyengane Chima Ofoegbu Nectarios Papavarnavas Jonny Peter Henri Pickard Kent Pluke Peter J Raubenheimer Gordon Robertson Julius Rozmiarek A Sayed Matthias Scriba Hennie Sekhukhune Prasun Singh Elsabe Smith Vuyolwethu Soldati Cari Stek Robert van den Berg Le Roux van der Merwe Pieter Venter Barbra Vermooten Gerrit Viljoen Santhuri Viranna Jonno Vogel Nokubonga Vundla Sean Wasserman Eddy Zitha Vanessa Lomas-Marais Annie Lombard Katrin Stuve Werner Viljoen De Vries Basson Sue Le Roux Ethel Linden-Mars Lizanne Victor Mark Wates Elbe Zwanepoel Nabilah Ebrahim Sa'ad Lahri Ayanda Mnguni Thomas Crede Martin de Man Katya Evans Clint Hendrikse Jonathan Naude Moosa Parak Patrick Szymanski Candice Van Koningsbruggen Riezaah Abrahams Brian Allwood Christoffel Botha Matthys Henndrik Botha Alistair Broadhurst Dirkie Claasen Che Daniel Riyaadh Dawood Marie du Preez Nicolene Du Toit Kobie Erasmus Coenraad F N Koegelenberg Shiraaz Gabriel Susan Hugo Thabiet Jardine Clint Johannes Sumanth Karamchand Usha Lalla Eduard Langenegger Eize Louw Boitumelo Mashigo Nonte Mhlana Chizama Mnqwazi Ashley Moodley Desiree Moodley Saadiq Moolla Abdurasiet Mowlana Andre Nortje Elzanne Olivier Arifa Parker Chané Paulsen Hans Prozesky Jacques Rood Tholakele Sabela Neshaad Schrueder Nokwanda Sithole Sthembiso Sithole Jantjie J Taljaard Gideon Titus Tian Van Der Merwe Marije van Schalkwyk Luthando Vazi Abraham J Viljoen Mogamat Yazied Chothia Vanessa Naidoo Lee Alan Wallis Mumtaz Abbass Juanita Arendse Rizqa Armien Rochelle Bailey Muideen Bello Rachel Carelse Sheron Forgus Nosi Kalawe Saadiq Kariem Mariska Kotze Jonathan Lucas Juanita McClaughlin Kathleen Murie Leilah Najjaar Liesel Petersen James Porter Melanie Shaw Dusica Stapar Michelle Williams Linda Aldum Natacha Berkowitz Raakhee Girran Kevin Lee Lenny Naidoo Caroline Neumuller Kim Anderson Kerrin Begg Lisa Boerlage Morna Cornell Renée de Waal Lilian Dudley René English Jonathan Euvrard Pam Groenewald Nisha Jacob Heather Jaspan Emma Kalk Naomi Levitt Thoko Malaba Patience Nyakato Gabriela Patten Helen Schneider Maylene Shung King Priscilla Tsondai James Van Duuren Nienke van Schaik Lucille Blumberg Cheryl Cohen Nelesh Govender Waasila Jassat Tendesayi Kufa Kerrigan McCarthy Lynn Morris Nei-Yuan Hsiao Ruan Marais Jon Ambler Olina Ngwenya Richard Osei-Yeboah Leigh Johnson Reshma Kassanjee Tsaone Tamuhla

Clin Infect Dis 2020 Aug 29. Epub 2020 Aug 29.

Division of Computational Biology, University of Cape Town.

Background: Risk factors for COVID-19 death in sub-Saharan Africa and the effects of HIV and tuberculosis on COVID-19 outcomes are unknown.

Methods: We conducted a population cohort study using linked data from adults attending public sector health facilities in the Western Cape, South Africa. We used Cox-proportional hazards models adjusted for age, sex, location and comorbidities to examine the association between HIV, tuberculosis and COVID-19 death from 1 March-9 June 2020 among (i) public sector "active patients" (≥1 visit in the 3 years before March 2020), (ii) laboratory-diagnosed COVID-19 cases and (iii) hospitalized COVID-19 cases. We calculated the standardized mortality ratio (SMR) for COVID-19 comparing HIV positive vs. negative adults using modelled population estimates.

Results: Among 3,460,932 patients (16% HIV positive), 22,308 were diagnosed with COVID-19, of whom 625 died. COVID-19 death was associated with male sex, increasing age, diabetes, hypertension and chronic kidney disease. HIV was associated with COVID-19 mortality (adjusted hazard ratio [aHR] 2.14; 95% confidence interval [CI] 1.70-2.70), with similar risks across strata of viral load and immunosuppression. Current and previous tuberculosis were associated with COVID-19 death (aHR [95%CI] 2.70 [1.81-4.04] and 1.51 [1.18-1.93] respectively). The SMR for COVID-19 death associated with HIV was 2.39 (95%CI 1.96-2.86); population attributable fraction 8.5% (95%CI 6.1-11.1).

Conclusion: While our findings may over-estimate HIV- and tuberculosis-associated COVID-19 mortality risks due to residual confounding, both HIV and current tuberculosis were independently associated with increased COVID-19 mortality. The associations between age, sex and other comorbidities and COVID-19 mortality were similar to other settings.
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http://dx.doi.org/10.1093/cid/ciaa1198DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7499501PMC
August 2020

Successful ABO-incompatible living donor liver transplant for acute liver failure secondary to Hodgkin's Lymphoma in a child.

Pediatr Transplant 2020 11 28;24(7):e13796. Epub 2020 Jul 28.

Wits Donald Gordon Medical Centre, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.

We present a case of pediatric ALF, secondary to hepatic HL, who underwent a successful ABOi living donor liver transplant. We believe this is the first such case reported in academic literature. HL with liver involvement is extremely rare and is not considered an indication for transplantation. The 12-year-old, male patient presented with a viral illness prodrome, and parvovirus was detected in pre-transplant laboratory cultures. He received an ABOi living donor liver graft followed by a course of plasma exchange and rituximab after which standard immunosuppression was used. The HL was diagnosed on hepatic biopsy post-transplant. Subsequently, the patient commenced six cycles of R-CHOP chemotherapy. During chemotherapy, we stopped tacrolimus and mycophenolate mofetil. Immunosuppression was maintained with corticosteroids in-between cycles. The patient is alive and reports good quality of life 1-year post-transplant. The HL is in remission. During the post-operative period, the patient experienced four episodes of neutropenia, a bile leak, and gram-negative sepsis. One episode of acute rejection has been treated. Although we did not initially transplant the patient for ALF secondary to HL, its subsequent diagnosis and the patient's response to management raises many issues that warrant consideration. While the findings from a single case cannot be generalized, this could be a "proof of concept" for liver transplantation in hepatic HL. We hope it will facilitate discussions and potentially expand therapeutic options available to this very small group patients.
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http://dx.doi.org/10.1111/petr.13796DOI Listing
November 2020

Access to Renal Replacement Therapy in South Africa-A Cry for Action.

Transplantation 2020 06;104(6):1109-1111

Wits Donald Gordon Medical Centre, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.

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http://dx.doi.org/10.1097/TP.0000000000003143DOI Listing
June 2020

Blood stream infections in children in the first year after liver transplantation at Wits Donald Gordon Medical Centre, South Africa.

Pediatr Transplant 2020 03 27;24(2):e13660. Epub 2020 Jan 27.

Wits Donald Gordon Medical Centre, University of the Witwatersrand, Johannesburg, South Africa.

Children who undergo liver transplantation and subsequently develop BSI are at risk for adverse outcomes. Research from high-income settings contrasts the dearth of information from transplant centers in low- and middle-income countries, such as South Africa. Therefore, this study from Johannesburg aimed to describe the clinical and demographic profile of children undergoing liver transplantation, and determine the incidence and pattern of BSI and associated risk factors for BSI during the first year after liver transplant. Pediatric liver transplants performed from 2005 to 2014 were reviewed. Descriptive analyses summarized donor, recipient, and post-transplant infection characteristics. Association between BSI and sex, cause of liver failure, age, nutritional status, PELD/MELD score, graft type, biliary complications, and acute rejection was determined by Fisher's exact test; and association with length of stay by Cox proportional hazards regression analysis. Survival estimates were determined by the Kaplan-Meier method. Sixty-five children received one transplant and four had repeat transplants, totaling 69 procedures. Twenty-nine BSI occurred in 19/69 (28%) procedures, mostly due to gram-negative organisms, namely Klebsiella species. Risk for BSI was independently associated with biliary atresia (44% BSI in BA compared to 17% in non-BA transplants; P = .014) and post-operative biliary complications (55% BSI in transplants with biliary complications compared to 15% in those without; P = .0013). One-year recipient and graft survival was 78% (CI 67%-86%) and 77% (CI 65%-85%), respectively. In Johannesburg, incident BSI, mostly from gram-negative bacteria, were associated with biliary atresia and post-operative biliary complications in children undergoing liver transplantation.
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http://dx.doi.org/10.1111/petr.13660DOI Listing
March 2020

Contemporary outcomes of the pediatric kidney transplant program in Johannesburg, South Africa, between 2004 and 2017: Better or not-And which way forward?

Pediatr Transplant 2020 03 14;24(2):e13644. Epub 2020 Jan 14.

Wits Donald Gordon Medical Centre, University of the Witwatersrand, Johannesburg, South Africa.

Background: Outcomes for the pediatric kidney transplant program in Johannesburg (1984-2003) were found to be suboptimal. In this study, we compared (a) early (era 1:1984-2003) to contemporary (era 2:2004-2017) outcomes and (b) compared contemporary outcomes between the public and private sector hospitals in our program.

Methods: We conducted a retrospective record review of all pediatric (<18 years) KA transplants performed in our kidney transplant program at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) and Wits Donald Gordon Medical Centre (WDGMC) from 2004 to 2017. We collected the following data per site: number of recipients, transplants performed, mean follow-up time, and grafts lost; per recipient: age at time of transplant, sex, self-reported population group; transplant history; donor type; etiology of ESKD; recipient and graft survival. Outcomes for era 1 were based on data published on our kidney transplant program, based at CMJAH.

Results: At CMJAH (public sector), there was no improvement in recipient and graft survival over time. In the contemporary analysis, 1-, 5-, and 10-year recipient survival, as % (95% CI) was 93 (84-97); 76 (64-84); 59 (44-70) for CMJAH, and 98 (90-99); 95 (86-99); 82 (54-94) for WDGMC (private sector). Similarly, 1-, 5- and 10-year graft survival was 75 (63-84); 55 (42-66); 36 (24-49) for CMJAH, and 96 (87-99); 84 (73-91); 64 (48-76) at WDGMC.

Conclusion: Contemporary outcomes for the pediatric kidney transplant program at WDGMC are comparable to outcomes achieved in middle- and high-income settings. However, outcomes at CMJAH are suboptimal, reflecting numerous health system, infrastructural and human resource challenges.
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http://dx.doi.org/10.1111/petr.13644DOI Listing
March 2020

HIV and Solid Organ Transplantation: Where Are we Now.

Curr HIV/AIDS Rep 2019 10;16(5):404-413

Centre for HIV & STIs, National Institute for Communicable Diseases, 1 Modderfontein Road, Sandringham, 2131, Private Bag X4, Sandringham, Johannesburg, 2131, South Africa.

Purpose Of Review: We review the international evolution of HIV and solid organ transplantation over 30 years. We emphasise recent developments in solid organ transplantation from HIV-infected to HIV-uninfected individuals, and their implications.

Recent Findings: In 2017, Johannesburg, South Africa, a life-saving partial liver transplant from an HIV-infected mother to her HIV-uninfected child was performed. This procedure laid the foundation not only for consideration of HIV-infected individuals as living donors, but also for the possibility that HIV-uninfected individuals could receive organs from HIV-infected donors. Recent advances in this field are inclusion of HIV-infected individuals as living organ donors and the possibility of offering HIV-uninfected individuals organs from HIV-infected donors who are well-controlled on combination antiretroviral therapy (cART). The large number of HIV-infected individuals on cART is an unutilised source of otherwise eligible living organ donors. HIV-positive-to-HIV-negative organ transplantation has become a reality, providing possible new therapeutic options to address extreme organ shortages.
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http://dx.doi.org/10.1007/s11904-019-00460-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6813753PMC
October 2019

Needs must: living donor liver transplantation from an HIV-positive mother to her HIV-negative child in Johannesburg, South Africa.

J Med Ethics 2019 05;45(5):287-290

Wits University Donald Gordon Medical Centre, Johannesburg, South Africa.

The world's first living donor liver transplant from an HIV-positive mother to her HIV-negative child, performed by our team in Johannesburg, South Africa (SA) in 2017, was necessitated by disease profile and health system challenges. In our country, we have a major shortage of donor organs, which compels us to consider innovative solutions to save lives. Simultaneously, the transition of the HIV pandemic, from a death sentence to a chronic illness with excellent survival on treatment required us to rethink our policies regarding HIV infection and living donor liver transplantation . Although HIV infection in the donor is internationally considered an absolute contraindication for transplant to an HIV-negative recipient, there have been a very small number of unintentional transplants from HIV-positive deceased donors to HIV-negative recipients. These transplant recipients do well on antiretroviral medication and their graft survival is not compromised. We have had a number of HIV-positive parents in our setting express a desire to be living liver donors for their critically ill children. Declining these parents as living donors has become increasingly unjustifiable given the very small deceased donor pool in SA; and because many of these parents are virally suppressed and would otherwise fulfil our eligibility criteria as living donors. This paper discusses the evolution of HIV and transplantation in SA, highlights some of the primary ethical considerations for us when embarking on this case and considers the new ethical issues that have arisen since we undertook this transplant.
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http://dx.doi.org/10.1136/medethics-2018-105216DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6582740PMC
May 2019

Living donor liver transplant from an HIV-positive mother to her HIV-negative child: opening up new therapeutic options.

AIDS 2018 10;32(16):F13-F19

Centre for HIV & STIs, National Institute for Communicable Diseases, Johannesburg.

Objective: Transplant a liver from an HIV-positive mother to her HIV-negative child to save the child's life.

Design: A unique case of living donor liver transplantation from an HIV-positive mother to her HIV-negative child in South Africa. Two aspects of this case are ground-breaking. First, it involves living donation by someone who is HIV-positive and second it involves controlled transplant of an organ from an HIV-positive donor into an HIV-negative recipient, with the potential to prevent infection in the recipient.

Methods: Standard surgical procedure for living donor liver transplantation at our centre was followed. HIV-prophylaxis was administered preoperatively. Extensive, ultrasensitive HIV testing, over and above standard diagnostic assays, was undertaken to investigate recipient serostatus and is ongoing.

Results: Both mother and child are well, over 1 year posttransplantation. HIV seroconversion in our recipient was detected with serological testing at day 43 posttransplant. However, a decline in HIV antibody titres approaching undetectable levels is now being observed. No plasma, or cell-associated HIV-1 DNA has been detected in the recipient at any time-point since transplant.

Conclusion: This case potentially opens up a new living liver donor pool which might have clinical relevance in countries where there is a high burden of HIV and a limited number of deceased donor organs or limited access to transplantation. However, our recipient's HIV status is equivocal at present and additional investigation regarding seroconversion events in this unique profile is ongoing.
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http://dx.doi.org/10.1097/QAD.0000000000002000DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6200383PMC
October 2018

Takotsubo cardiomyopathy post liver transplantation.

Cardiovasc J Afr 2016 Oct 23;27(5):e1-e3. Epub 2016 Oct 23.

Division of Cardiology, Department of Internal Medicine, University of Witwatersrand and Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa; Wits Donald Gordon Medical Centre, University of Witwatersrand, Parktown, Johannesburg, South Africa.

A patient with end-stage liver disease developed stress-induced Takotsubo cardiomyopathy post liver transplantation, with haemodynamic instability requiring a left ventricular assist device. We discuss the diagnosis and management of this condition.
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http://dx.doi.org/10.5830/CVJA-2016-032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5370358PMC
October 2016

Favourable outcomes for the first 10 years of kidney and pancreas transplantation at Wits Donald Gordon Medical Centre, Johannesburg, South Africa.

S Afr Med J 2016 Jan 7;106(2):172-6. Epub 2016 Jan 7.

Wits Donald Gordon Medical Centre, Johannesburg, South Africa; Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.

Background: It is important for centres participating in transplantation in South Africa (SA) to audit their outcomes. Wits Donald Gordon Medical Centre (WDGMC), Johannesburg, SA, opened a transplant unit in 2004. The first 10 years of kidney and pancreas transplantation were reviewed to determine outcomes in respect of recipient and graft survival.

Methods: A retrospective review was conducted of all kidney-alone and simultaneous kidney-pancreas (SKP) transplants performed at WDGMC from 1 January 2004 to 31 December 2013, with follow-up to 31 December 2014 to ensure at least 1 year of survival data. Information was accessed using the transplant registers and clinical records in the transplant clinic at WDGMC. The Kaplan-Meier method was used to estimate 1-, 5- and 10-year recipient and graft survival rates for primary (first graft) kidney-alone and SKP transplants.

Results: The overall 10-year recipient and graft survival rates were 80.4% and 66.8%, respectively, for kidney-alone transplantation. In the kidney-alone group, children tended towards better recipient and graft survival compared with adults, but this was not statistically significant. In adults, recipient survival was significantly better for living than deceased donor type. Recipient and graft survival were significantly lower in black Africans than in the white (largest proportion in the sample) reference group. For SKP transplants, the 10-year recipient survival rate was 84.7%, while kidney and pancreas graft survival rates were 73.1% and 43.2%, respectively.

Conclusion: Outcomes of the first 10 years of kidney and pancreas transplantation at WDGMC compare favourably with local and international survival data.
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http://dx.doi.org/10.7196/SAMJ.2016.v106i2.10190DOI Listing
January 2016

Paediatric lver transplantation for children treated at public health facilities in South Africa: Time for change.

S Afr Med J 2014 Oct 24;104(11):829-832. Epub 2014 Oct 24.

Department of Paediatrics, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa.

Paediatric liver transplantation (PLT) is the only therapeutic option for many children with end-stage chronic liver disease or irreversible fulminant hepatic failure and is routinely considered as a therapy by paediatric gastroenterologists and surgeons working in developed countries. In South Africa (SA), a PLT programme is available at Red Cross War Memorial Children's Hospital in Cape Town since November 1991, and another has rapidly developed at the Wits Donald Gordon Medical Centre in Johannesburg over the past decade. However, for most children with progressive chronic liver disease who are reliant on the services provided at public health facilities in SA, PLT is not an option because of a lack of resources in a mismanaged public health system. This article briefly outlines the services offered at Chris Hani Baragwanath Academic Hospital - which is typical of public health facilities in SA - and proposes that resources be allocated to establish an innovative, nationally funded centre that would enable greater numbers of children access to a PLT programme.
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http://dx.doi.org/10.7196/samj.8624DOI Listing
October 2014

Paediatric liver transplantation in Johannesburg revisited: 59 transplants and challenges met.

S Afr Med J 2014 Oct 24;104(11):799-802. Epub 2014 Oct 24.

Transplant Division, Wits Donald Gordon Medical Centre, University of the Witwatersrand, Johannesburg, South Africa.

Background: A paediatric liver transplant programme was started at the Wits Donald Gordon Medical Centre, Johannesburg, South Africa (SA), in November 2005. We reported on the first 29 patients in 2012. Since then we have performed a further 30 transplants in 28 patients, having met the major challenge of donor shortage by introducing a living related donor programme and increasing the use of split liver grafts.

Objective: To review the Wits Donald Gordon Medical Centre paediatric liver transplant programme to date. We describe how the programme has evolved and specifically compare the outcomes of the first cohort with the most recent 28 patients.

Methods: Case notes of all paediatric liver transplants performed between 14 November 2005 and 30 June 2014 were retrospectively reviewed. Data were analysed for age and weight at transplantation, indication and type of graft. Morbidity and mortality were documented, specifically biliary and vascular complications. Comparison was made between Era 1 (November 2005 - October 2012) and Era 2 (November 2012 - June 2014).

Results: A total of 59 transplants were performed in 57 patients. Age at transplantation ranged from 9 months to 213 months (mean 82.39 months) and weight ranged from 5 kg to 62 kg (mean 21 kg). A total of 23 whole livers, 10 reduced-size grafts, 14 split liver grafts and 12 living donor liver transplants (LDLTs) were performed. Eight patients were referred with fulminant hepatic failure (FHF), all in Era 2. Of these, three patients were successfully transplanted. Of the 57 patients, 45 are alive and well with actuarial 1-year patient and graft survival of 85% and 84%  and 5-year patient and graft survival of 78% and 74%, respectively. Sixteen (25.42%) biliary complications occurred in 15 of our 59 transplants. Seven patients developed significant vascular complications. Comparing Era 1 with Era 2, mean age at transplant decreased from 100.86 months to 64.73 months, mean weight from 25.2 kg to 16.9 kg, and type of graft utilised changed with a trend away from the use of whole livers and reduced-sized grafts to split livers and segment 2,3 LDLT grafts.

Conclusion: Initially limited by a shortage of donor organs, we aggressively explored optimal utilisation, splitting liver grafts from deceased donors as often as possible and establishing an LDLT programme. This increased access to donor livers allowed us to include patients with FHF and to perform retransplantation in recipients with early graft failure. It remains to offer liver transplantation to the entire paediatric community in SA, in conjunction with the only other established paediatric liver transplant unit, at Red Cross War Memorial Children's Hospital in Cape Town.
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http://dx.doi.org/10.7196/samj.8627DOI Listing
October 2014

Pre-resection gastric bypass reduces post-resection body mass index but not liver disease in short bowel syndrome.

Am J Surg 2014 Jun 4;207(6):942-8. Epub 2014 Jan 4.

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

Background: Obese patients developing short bowel syndrome (SBS) maintain a higher body mass index (BMI) and have increased risk of hepatobiliary complications. Our aim was to determine the effect of pre-resection gastric bypass (GBP) on SBS outcome.

Methods: We reviewed 136 adults with SBS: 69 patients with initial BMI < 35 were controls; 43 patients with BMI > 35 were the obese group; and 24 patients had undergone GBP before SBS.

Results: BMI at 1, 2, and 5 years was similar in control and GBP groups, whereas obese patients had a persistently increased BMI. Eight (33%) of the GBP patients had a pre-resection BMI > 35, but post-SBS BMI was similar to those <35. Obese patients were more likely to wean off PN (47% vs 20% control and 12% GBP, P < .05). Radiographic fatty liver tended to be higher in the GBP group (54% vs 19% control and 35% obese). End-stage liver disease occurred more frequently in obese and GBP patients (30% and 33% vs 13%, P < .05).

Conclusions: Pre-resection GBP prevents the nutritional benefits of obesity but does not eliminate the increased risk of hepatobiliary disease in obese SBS patients. This occurs independent of pre-SBS BMI suggesting the importance of GBP itself or history of obesity rather than weight loss.
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http://dx.doi.org/10.1016/j.amjsurg.2013.10.019DOI Listing
June 2014

Combined paediatric liver-kidney transplantation: analysis of our experience and literature review.

S Afr Med J 2013 Oct 11;103(12):925-9. Epub 2013 Oct 11.

Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa.

Background: Renal insufficiency is increasingly common in end-stage liver disease and allocation of livers to this category of patient has escalated. The frequency of combined liver-kidney transplantation (CLKT) has consequently increased. Indications for CLKT in children differ from those for adults and typically include rare congenital conditions; subsequently limited numbers of this procedure have been performed in paediatric patients worldwide. Scant literature exists on the subject.

Methods: Subsequent to institutional approval, a retrospective chart analysis of all paediatric CLKTs performed at the Transplant Unit, Wits Donald Gordon Medical Centre, University of the Witwatersrand, Johannesburg, South Africa between January 2005 and July 2013 was conducted.

Results: Defining children as younger than 18 years of age, 43 patients had received a liver transplant since 2005, of whom 8 received a CLKT. Indications included autosomal recessive polycystic kidney disease (n=3), primary hyperoxaluria type 1 (n=4) and heterozygous factor H deficiency with atypical haemolytic uraemic syndrome (n=1). Graft combinations included whole liver and one kidney (n=5), whole liver and two kidneys (n=1) and left lateral liver segment and one kidney (n=2), all from deceased donors. Patient age ranged from 4 to 17 years (median 9) and included 4 females and 4 males. Weight ranged from 13 to 42 kg (median 22.5). We describe one in-hospital mortality. The remaining 7 patients were long-term survivors with a survival range from 6 to 65 months.

Conclusions: Although rarely indicated in children, CLKT is an effective treatment option, appropriately utilising a scarce resource and significantly improving quality of life in the recipient.
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http://dx.doi.org/10.7196/samj.7304DOI Listing
October 2013

Preresection obesity increases the risk of hepatobiliary complications in short bowel syndrome.

Nutrients 2012 Sep 26;4(10):1358-66. Epub 2012 Sep 26.

The University of Nebraska Medical Center, Nebraska Medical Center, Omaha, NE 68198, USA.

Patients developing the short bowel syndrome (SBS) are at risk for hepatobiliary disease, as are morbidly obese individuals. We hypothesized that morbidly obese SBS individuals would be at increased risk for developing hepatobiliary complications. We reviewed 79 patients with SBS, 53 patients with initial body mass index (BMI) < 35 were controls. Twenty-six patients with initial BMI > 35 were the obese group. Obese patients were more likely to be weaned off parenteral nutrition (PN) (58% vs. 21%). Pre-resection BMI was significantly lower in controls (26 vs. 41). BMI at 1, 2, and 5 years was decreased in controls but persistently increased in obese patients. Obese patients were more likely to undergo cholecystectomy prior to SBS (42% vs. 32%) and after SBS (80% vs. 39%, p < 0.05). Fatty liver was more frequent in the obese group prior to SBS (23% vs. 0%, p < 0.05) but was similar to controls after SBS (23% vs. 15%). Fibrosis (8% vs. 13%) and cirrhosis/portal hypertension (19% vs. 21%) were similar in obese and control groups. Overall, end stage liver disease (ESLD) was similar in obese and control groups (19% vs. 11%) but was significantly higher in obese patients receiving PN (45% vs. 14%, p < 0.05). Obese patients developing SBS are at increased risk of developing hepatobiliary complications. ESLD was similar in the two groups overall but occurs more frequently in obese patients maintained on chronic PN.
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http://dx.doi.org/10.3390/nu4101358DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3496999PMC
September 2012

Hepatic fibrosis persists and progresses despite biochemical improvement in children treated with intravenous fish oil emulsion.

J Pediatr Gastroenterol Nutr 2013 Apr;56(4):364-9

Department of Surgery, University of Nebraska Medical Center, 983285 Nebraska Medical Center, Omaha, NE 68198–3285, USA.

Objectives: Intestinal failure-associated liver disease (IFALD) is a multifactorial process, which can culminate in cirrhosis and need for transplantation. Fish oil-based lipid emulsions (FOE) reportedly reverse hyperbilirubinemia, but there are little data on their effect on the histopathology of IFALD.

Methods: We blindly examined sequential liver biopsy data on 6 children receiving FOE, with scoring of cholestasis, inflammation, fibrosis, and ductal proliferation based on standardized systems. This information was correlated with biochemical and clinical data to determine any possible relations between biologic and histologic improvement.

Results: The median gestational age was 35 weeks, median birth weight 2064 g, and common most reason for intestinal loss was gastroschisis (5/6 children). Median intestinal length was 26 cm beyond the ligament of Treitz and most children had roughly 2 of 3 of their colonic length. It was observed that although hyperbilirubinemia reversed and hepatic synthetic function was preserved across timepoints, fibrosis was persistent in 2 cases, progressive in 3 cases, and regressed in only 1. It remained severe (grade 2 or higher) in 5 of 6 children at last biopsy. Histologic findings of cholestasis improved in all patients and inflammation improved in 5 of 6 children. There were mixed effects on ductal proliferation and steatosis.

Conclusions: In children treated with FOE, reversal of hyperbilirubinemia is not reflected by a similar histologic regression of fibrosis at the timepoints studied. Children with IFALD should have active ongoing treatment and be considered for early referral to an Intestinal Failure Program even with a normalized bilirubin.
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http://dx.doi.org/10.1097/MPG.0b013e31827e208cDOI Listing
April 2013

Paediatric living donor liver transplantation.

S Afr Med J 2012 Sep 11;102(11 Pt 2):879-80. Epub 2012 Sep 11.

Wits Donald Gordon Medical Centre, University of the Witwatersrand, Johannesburg, South Africa.

Paediatric liver transplantation is a highly effective therapy for children with end-stage liver disease; 1-year survival rates currently exceed 90% and long-term survivors enjoy an almost-normal quality of life. Key to the success of paediatric liver transplantation has been the technical refinement to provide children with suitably sized grafts. Adult-to-paediatric living donor liver transplantation highlights this success and has been instrumental in decreasing waiting list mortality to less than 5%.
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http://dx.doi.org/10.7196/samj.6261DOI Listing
September 2012

Risk of cytomegalovirus disease in high-risk liver transplant recipients on valganciclovir prophylaxis: a systematic review and meta-analysis.

Liver Transpl 2012 Dec;18(12):1440-7

Divisions of Infectious Diseases,University of Nebraska Medical Center, Omaha, NE 68198, USA.

Valganciclovir (VGC) was approved by the Food and Drug Administration in 2004 as cytomegalovirus (CMV) prophylaxis except for liver transplant recipients because of their high incidence of CMV disease with this drug. However, surveys have shown its common off-label use for CMV prophylaxis in liver transplant recipients. We aimed to evaluate the risk of CMV disease with VGC prophylaxis in liver transplant recipients. All studies that evaluated liver transplant recipients and used VGC (900 or 450 mg daily) for the prevention of CMV disease were included. Five controlled studies (n = 483) were pooled with a random effects model; five single-arm studies (n = 380) were pooled for the prevalence rate of CMV disease. The risk of CMV disease with VGC versus ganciclovir was 1.81 [95% confidence interval (CI) = 1.00-3.29, P = 0.05, I(2) = 0%]. For high-risk (donor-positive/recipient-negative) patients, the risk of CMV disease was 1.96 (95% CI = 1.05-3.67, P = 0.035, I(2) = 0%). The risk of CMV disease remained significant with 900 mg of VGC daily (P = 0.04) but not with 450 mg of VGC daily (P = 0.76). The risk of leukopenia with VGC was 1.87 (95% CI = 1.03-3.37, P = 0.04, I(2) = 0%). In single-arm trials, the overall CMV disease rate was 12% (95% CI = 9%-16%, P < 0.001), and the rate for high-risk patients was 20% (95% CI = 10%-38%, P = 0.002). In conclusion, 900 mg of VGC daily may not be safe as CMV prophylaxis in high-risk liver transplant recipients because of the significant 2-fold increase in the risk of CMV disease and the 1.9-fold increase in the risk of leukopenia. Alternative CMV prophylaxis should be used for liver transplant recipients.
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http://dx.doi.org/10.1002/lt.23530DOI Listing
December 2012

Strategies to optimize donor safety with smaller grafts for adult-to-adult living donor liver transplantation.

Curr Opin Organ Transplant 2012 Jun;17(3):230-4

Division of Transplantation, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA.

Purpose Of Review: To describe our current understanding of adult-to-adult living donor liver transplantation (AA-LDLT) in terms of graft size.

Recent Findings: Improved outcomes of small liver graft with the use of portal vein pressure (PVP) modulation.

Summary: AA-LDLT is viewed as a viable alternative to whole liver transplantation on the treatment of end-stage liver disease. Over the past two decades, right lobe AA-LDLT has been the standard because of concerns related to graft size. Small-for-size syndrome (SFSS) is an entity that presents in recipients of small grafts. It negatively affects patient and graft survival and recipients of grafts with a graft weight-to-recipient weight ratio (GW/RW) lower than 1.0 are at the highest risk. Over the last decade, our understanding of SFSS has identified PVP as a major determinant in the development of SFSS. Direct or indirect surgical PVP modulation has demonstrated a way to prevent the development of SFSS in recipients of small grafts and has improved the survival outcomes of small grafts. These improved outcomes coupled with concerns for donor safety have led to the renaissance of the use of left lobe grafts. Based on the current clinical data, the use of small grafts GW/RW greater than 0.6 is viewed as well tolerated when PVP is modulated to achieve a target PVP less than 15 mmHg after reperfusion and the left lobe is currently viewed as the ideal graft for AA-LDLT.
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http://dx.doi.org/10.1097/MOT.0b013e32835365b2DOI Listing
June 2012

Efficacy of neoadjuvant chemoradiation, followed by liver transplantation, for perihilar cholangiocarcinoma at 12 US centers.

Gastroenterology 2012 Jul 12;143(1):88-98.e3; quiz e14. Epub 2012 Apr 12.

William J. von Liebig Transplant Center, Mayo Clinic, Rochester, Minnesota 55905, USA.

Background & Aims: Excellent single-center outcomes of neoadjuvant chemoradiation and liver transplantation for unresectable perihilar cholangiocarcinoma caused the United Network of Organ Sharing to offer a standardized model of end-stage liver disease (MELD) exception for this disease. We analyzed data from multiple centers to determine the effectiveness of this treatment and the appropriateness of the MELD exception.

Methods: We collected and analyzed data from 12 large-volume transplant centers in the United States. These centers met the inclusion criteria of treating 3 or more patients with perihilar cholangiocarcinoma using neoadjuvant therapy, followed by liver transplantation, from 1993 to 2010 (n = 287 total patients). Center-specific protocols and medical charts were reviewed on-site.

Results: The patients completed external radiation (99%), brachytherapy (75%), radiosensitizing therapy (98%), and/or maintenance chemotherapy (65%). Seventy-one patients dropped out before liver transplantation (rate, 11.5% in 3 months). Intent-to-treat survival rates were 68% and 53%, 2 and 5 years after therapy, respectively; post-transplant, recurrence-free survival rates were 78% and 65%, respectively. Patients outside the United Network of Organ Sharing criteria (those with tumor mass >3 cm, transperitoneal tumor biopsy, or metastatic disease) or with a prior malignancy had significantly shorter survival times (P < .001). There were no differences in outcomes among patients based on differences in surgical staging or brachytherapy. Although most patients came from 1 center (n = 193), the other 11 centers had similar survival times after therapy.

Conclusions: Patients with perihilar cholangiocarcinoma who were treated with neoadjuvant therapy followed up by liver transplantation at 12 US centers had a 65% rate of recurrence-free survival after 5 years, showing this therapy to be highly effective. An 11.5% drop-out rate after 3.5 months of therapy indicates the appropriateness of the MELD exception. Rigorous selection is important for the continued success of this treatment.
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http://dx.doi.org/10.1053/j.gastro.2012.04.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3846443PMC
July 2012

Massive small bowel resection during pregnancy causing short bowel syndrome.

Am Surg 2011 Dec;77(12):1589-92

Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska 68198-3280, USA.

Massive small bowel infarction in pregnancy is rare but has devastating complications. Diagnosis is difficult because pregnancy masks the symptoms. Our aim was to assess risk factors and outcomes of massive resection associated with pregnancy. We conducted a review of nine patients with short bowel syndrome (SBS) secondary to massive bowel resection during pregnancy. The most common cause of bowel resection was midgut volvulus in seven patients. Four of these also had malrotation. Three others had previous abdominal operations, including gastric bypass. The two remaining patients had vascular insufficiency. Five of the nine patients presented after a cesarean delivery. There were three fetal deaths. Resulting small bowel length was less than 60 cm in all but one patient. All patients required parenteral nutrition (PN). Seven patients developed significant complications related to SBS and long-term PN. Four patients underwent transplantation. Massive small bowel resection during pregnancy is a devastating complication, which requires a high degree of suspicion to diagnose. Most patients have risk factors, which include previous surgery, congenital malrotation, and a hypercoagulable state. Surviving patients usually need long-term PN or transplantation.
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December 2011

Surgical treatment of intra-abdominal desmoid tumors resulting in short bowel syndrome.

Cancers (Basel) 2012 Jan 19;4(1):31-8. Epub 2012 Jan 19.

Department of Surgery, University of Nebraska Medical Center, The Nebraska Medical Center 3280, Omaha, NE 68198, USA.

Advanced intra-abdominal desmoids tumors present with severe symptoms, complications or rapid growth, which lead to adverse outcomes. Our aim was to evaluate the treatment and outcome of patients with advanced intra-abdominal desmoids tumors, and develop guidelines for surgical management of these patients. We reviewed the clinical courses of 21 adult patients with advanced stage intra-abdominal desmoid tumors who presented to an intestinal rehabilitation and transplantation program. Patients with massive intestinal resection presented in two groups. The first group had a short small intestinal remnant after resection ( < 60 cm). These patients were poor rehabilitation candidates and eventually met criteria for transplant. The second had longer intestinal remnants and were more successfully rehabilitated and have not had complications that would lead to transplantation. Advanced intra-abdominal desmoid tumors have outcomes after resection that merit aggressive resection and planned intestinal rehabilitation and intestinal transplantation as indicated.
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http://dx.doi.org/10.3390/cancers4010031DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3712676PMC
January 2012

Should multivisceral transplantation be considered in patients colonized with multidrug-resistant Pseudomonas aeruginosa?

Microb Drug Resist 2012 Feb 22;18(1):74-8. Epub 2011 Nov 22.

Transplant Infectious Diseases Program, Infectious Diseases Division, University of Nebraska Medical Center, Omaha, Nebraska NE 68198-5400, USA.

This report describes two subsequent liver-small bowel-pancreas-kidney (multivisceral) transplantations in a child colonized with multidrug-resistant Pseudomonas aeruginosa. We discuss the dilemma concerning the transplantation of patients colonized with multidrug-resistant Pseudomonas spp., its potential consequences, and the peri and postoperative management of these patients.
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http://dx.doi.org/10.1089/mdr.2011.0099DOI Listing
February 2012

Radiation therapy increases the risk of hepatobiliary complications in short bowel syndrome.

Nutr Clin Pract 2011 Aug;26(4):474-8

University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE 68198-3280, USA.

Unlabelled: Patients developing short bowel syndrome (SBS) are at risk for hepatobiliary complications. Radiation enteritis and radiation-induced liver disease are potential complications of radiation therapy (XRT). The authors hypothesized that SBS patients with a history of abdominal XRT would be at increased risk for hepatobiliary complications.

Methods: The authors reviewed 92 adult patients developing SBS as a complication of operation for malignancy (n = 37) and/or XRT (n = 55). Hepatobiliary disease was evaluated by liver function tests, radiologic imaging, endoscopy, and histologic studies.

Results: Rectal cancer was the most frequent tumor in both groups (36% vs 35%). There were significantly more ovarian cancers (18% vs 3%, P < .05) in the radiation group and fewer desmoid tumors (0% vs 24%, P < .05). Intestinal remnant length was similar, but radiation patients more frequently had colon present (87% vs 62%, P < .05) and were less likely to have type I anatomy (33% vs 65%, P < .05). Radiation patients were less likely to be weaned off parenteral nutrition (PN; 16% vs 41%, P < .05). Cirrhosis/portal hypertension was more frequent in the radiation group (35% vs 11%, P < .05). Radiographic evidence of fatty liver, end-stage liver disease and the risk of cholelithiasis post-SBS were similar in both groups.

Conclusions: SBS patients with a history of XRT were more likely to develop cirrhosis and portal hypertension than SBS patients with malignancy alone. Radiation SBS patients were less likely to wean from PN despite more favorable intestinal anatomy.
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http://dx.doi.org/10.1177/0884533611414028DOI Listing
August 2011

Stool calprotectin monitoring after small intestine transplantation.

Transplantation 2011 May;91(10):1166-71

Section of Transplantation, Department of Surgery, University of Nebraska Medical Center, Omaha, NE 68198-3285, USA.

Background: Small intestine transplantation is the only life-saving therapy available for patients with intestinal failure and life-threatening complications of parenteral nutrition, but it is still plagued by high levels of early acute rejection. The ability to diagnose rejection noninvasively, ideally before pathologic manifestations, would be a major advance in the care of intestinal transplant patients.

Methods: We measured calprotectin levels in 732 stool samples collected, analyzed over from 72 patients having undergone 74 total transplants, and correlated them with clinical indications, ostomy output, and pathologic findings.

Results: We found that overall patients with rejection have higher mean levels of stool calprotectin than those without, but because of significant interpatient variability, defining an effective general "cutoff" for the test is difficult. Each patient, in effect, has to act as their own control. Patients experiencing rejection episodes have greater fluctuations in calprotectin levels than those without, suggesting increased "reactivity" within the graft. Our most frequent clinical indicator for biopsy, an increase in ostomy output, had no real relationship to the discovery of rejection.

Conclusion: Although more frequent prospective sampling could perhaps demonstrate an advantage in early indication of rejection, based on these data, routine stool calprotectin monitoring is not strongly supported.
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http://dx.doi.org/10.1097/TP.0b013e318215e709DOI Listing
May 2011

Bloodless liver transplantation in a Jehovah's Witness.

Int Anesthesiol Clin 2011 ;49(2):108-15

Department of Anesthesiology, University of Nebraska Medical Center, Omaha, Nebraska, USA.

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http://dx.doi.org/10.1097/AIA.0b013e3181fa1482DOI Listing
July 2011

Intestinal lengthening in adult patients with short bowel syndrome.

J Gastrointest Surg 2010 Dec 24;14(12):1931-6. Epub 2010 Aug 24.

Transplant Surgery Division, Department of General Surgery, 983285 Nebraska Medical Center, Omaha, NE 68198-3285, USA.

Introduction: Limited information regarding the usefulness of bowel lengthening in adult patients with short bowel syndrome is available.

Methods: Retrospective review of a single center series of intestinal lengthening over 15-year period in patients ≥ 18 years old.

Results: Twenty adult patients underwent Bianchi (n = 6) or serial transverse enteroplasty (STEP) (n = 15). Median age was 38 (18-66) years and 11 were female. Indications were (a) to increase the enteral caloric intake thereby reduce or wean parenteral nutrition (PN) (n = 14) or (b) for bacterial overgrowth (n = 6). Twelve patients required additional procedures to relieve the anatomical blockade. Median remnant bowel length prior to surgery, length gained and final bowel length was 60, 20, and 80 cm, respectively. Survival was 90% with mean follow-up of 4.1 years (range = 1-7.9 years). Two patients died during follow-up. Intestinal transplant salvage was required in one patient 4.8 years after STEP. Overall, of 17 patients, ten (59%) patients achieved enteral autonomy and were off PN. Of seven patients who are on PN, three patients showed significant improvement in enteral caloric intake. All except one showed significant improvement in symptoms of bacterial overgrowth.

Conclusions: Bowel lengthening is technically feasible and effectively leads to weaning from PN in more than half of the adult patients. Lengthening procedures may be an underutilized treatment for adults with short bowel syndrome.
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http://dx.doi.org/10.1007/s11605-010-1291-yDOI Listing
December 2010