Publications by authors named "Kristin Mekeel"

51 Publications

Impact of diabetes and chronic dialysis on post-transplant survival in combined heart-kidney transplant recipients.

Clin Transplant 2021 May 4:e14338. Epub 2021 May 4.

Division of Transplantation, Department of Surgery, University of California San Diego, La Jolla, CA, USA.

Growing research supports an increased survival benefit of combined heart and kidney transplantation in patients with both heart and renal failure. As a result, the frequency of these combined transplants continues to increase. Despite this trend, little has been done to quantify the impact of chronic illness in this population. We identified adult recipients of combined heart-kidney transplant from the Scientific Registry of Transplant Recipients (SRTR) database between 2005 and 2018. We focused on renal disease secondary to diabetes and duration of dialysis as markers of chronic illness. The primary outcome was post-transplant mortality. Our final multivariable Cox proportional hazard model found that diabetes-associated renal disease (HR 1.57, 95% CI 1.14-2.15, p = .01) and dialysis duration (HR 1.08, 95% CI 1.01-1.15, p = .02) were significant predictors of post-transplant mortality. Given the significant impact of dialysis duration and renal disease secondary to diabetes mellitus, these chronically ill patients should be closely examined for conditions such as peripheral vascular disease and frailty, which have been shown to affect mortality in heart transplant recipients and are prevalent in the chronic dialysis population.
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http://dx.doi.org/10.1111/ctr.14338DOI Listing
May 2021

Understanding the Impact of Pneumonia and Other Complications in Elderly Liver Transplant Recipients: An Analysis of NSQIP Transplant.

Transplant Direct 2021 May 23;7(5):e692. Epub 2021 Apr 23.

Division of Transplant and Hepatobiliary Surgery, Department of Surgery, University of California San Diego, San Diego, CA.

Despite an increasing demand for liver transplantation in older patients, our understanding of posttransplant outcomes in older recipients is limited to basic recipient and graft survival. Using National Surgical Quality Improvement Program Transplant, we tracked early outcomes after liver transplantation for patients >65.

Methods: We conducted a retrospective analysis of patients in National Surgical Quality Improvement Program Transplant between March 1, 2017 and March 31, 2019. Recipients were followed for 1 y after transplant with follow-up at 30, 90, and 365 d. Data were prospectively gathered using standard definitions across all sites.

Results: One thousand seven hundred thirty-one adult liver transplants were enrolled; 387 (22.4%) were >65 y old. The majority of older recipients were transplanted for hepatocellular carcinoma. The older cohort had a lower lab Model for End-Stage Liver Disease and was less likely to be hospitalized at time of transplant. Overall, older recipients had higher rates of pneumonia but no difference in intensive care unit length of stay (LOS), total LOS, surgical site infection, or 30-d readmission. Subgroup analysis of patients with poor functional status revealed a significant difference in intensive care unit and total LOS. Pneumonia was even more common in older patients and had a significant impact on overall survival.

Conclusions: By targeting patients with hepatocellular carcinoma and lower Model for End-Stage Liver Diseases, transplant centers can achieve nearly equivalent outcomes in older recipients. However, older recipients with poor functional status require greater resources and are more likely to develop pneumonia. Pneumonia was strongly associated with posttransplant survival and represents an opportunity for improvement. By truly understanding the outcomes of elderly and frail recipients, transplant centers can improve outcomes for these higher-risk recipients.
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http://dx.doi.org/10.1097/TXD.0000000000001151DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8078357PMC
May 2021

Liver fibrosis: Pathophysiology and clinical implications.

Wiley Interdiscip Rev Syst Biol Med 2021 Jan 26;13(1):e1499. Epub 2020 Jul 26.

Department of Surgery, University of California, San Diego, California, USA.

Liver fibrosis is a clinically significant finding that has major impacts on patient morbidity and mortality. The mechanism of fibrosis involves many different cellular pathways, but the major cell type involved appears to be hepatic stellate cells. Many liver diseases, including Hepatitis B, C, and fatty liver disease cause ongoing hepatocellular damage leading to liver fibrosis. No matter the cause of liver disease, liver-related mortality increases exponentially with increasing fibrosis. The progression to cirrhosis brings more dramatic mortality and higher incidence of hepatocellular carcinoma. Fibrosis can also affect outcomes following liver transplantation in adult and pediatric patients and require retransplantation. Drugs exist to treat Hepatitis B and C that reverse fibrosis in patients with those viral diseases, but there are currently no therapies to directly treat liver fibrosis. Several mouse models of chronic liver diseases have been successfully reversed using novel drug targets with current therapies focusing mostly on prevention of myofibroblast activation. Further research in these areas could lead to development of drugs to treat fibrosis, which will have invaluable impact on patient survival. This article is categorized under: Metabolic Diseases > Molecular and Cellular Physiology.
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http://dx.doi.org/10.1002/wsbm.1499DOI Listing
January 2021

Post-transplant survey to assess patient experiences with donor-derived HCV infection.

Transpl Infect Dis 2020 Dec 23;22(6):e13402. Epub 2020 Jul 23.

Department of Medicine, University of California, San Diego, California, USA.

Background: Despite increased utilization of hepatitis C virus-infected (HCV+) organs for transplantation into HCV-uninfected recipients, there is lack of standardization in HCV-related patient education/consent and limited data on financial and social impact on patients.

Methods: We conducted a survey on patients with donor-derived HCV infection at our center transplanted between 4/1/2017 and 11/1/2019 to assess: why patients chose to accept HCV+ organ(s), the adequacy of their pre-transplant HCV education and informed consent process, financial issues related to copays after discharge, and social challenges they faced.

Results: Among 49 patients surveyed, transplanted organs included heart (n = 19), lung (n = 9), kidney (n = 11), liver (n = 4), heart/kidney (n = 4), and liver/kidney (n = 2). Many recipients accepted an HCV-viremic (HCV-V) organ due to perceived reduction in waitlist time (n = 33) and/or trust in their physician's recommendation (n = 29). Almost all (n = 47) felt that pre-transplant education and consent was appropriate. Thirty patients had no copay for direct-acting antivirals (DAA) for HCV, including 21 with household income <$20 000; seven had copays of <$100 and one had a copay >$1000. Two patients reported feeling isolated due to HCV infection and eight reported higher than anticipated medication costs. Patients' biggest concern was potential HCV transmission to partners (n = 18) and family/friends (n = 15). Overall almost all (n = 47) patients reported a positive experience with HCV-V organ transplantation.

Conclusion: We demonstrate that real-world patient experiences surrounding HCV-V organ transplantation have been favorable. Almost all patients report comprehensive HCV-related pre-transplant consent and education. Additionally, medication costs and social isolation/exclusion were not barriers to the use of these organs.
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http://dx.doi.org/10.1111/tid.13402DOI Listing
December 2020

Association of Electronic Surgical Consent Forms With Entry Error Rates.

JAMA Surg 2020 08;155(8):777-778

Division of Biomedical Informatics, Department of Medicine, University of California, San Diego, La Jolla.

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http://dx.doi.org/10.1001/jamasurg.2020.1014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7240641PMC
August 2020

Successful heart-kidney transplantation from a Hepatitis C viremic donor to negative recipient: One year of follow-up.

Transpl Infect Dis 2019 Feb 2;21(1):e13002. Epub 2018 Oct 2.

Division of Infectious Diseases and Global Public Health, University of California, San Diego, California.

Every year the number of patients waiting for a heart transplant increases faster than the number of available donor organs. Some potential donor organs are from donors with active communicable diseases, including hepatitis C virus (HCV), potentially making donation prohibitive. The advent of direct-acting antiviral agents for HCV has drastically changed the treatment of HCV. Recently, these agents have been used to treat HCV in organ donor recipients who acquired the disease from the donor organ. We report a case of heart-kidney transplantation from an HCV viremic donor to HCV negative recipient with successful treatment and sustained virologic response.
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http://dx.doi.org/10.1111/tid.13002DOI Listing
February 2019

Nonalcoholic fatty liver disease with cirrhosis increases familial risk for advanced fibrosis.

J Clin Invest 2017 Jun 19;127(7):2697-2704. Epub 2017 Jun 19.

NAFLD Research Center, Department of Medicine, UCSD, La Jolla, California, USA.

Background: The risk of advanced fibrosis in first-degree relatives of patients with nonalcoholic fatty liver disease and cirrhosis (NAFLD-cirrhosis) is unknown and needs to be systematically quantified. We aimed to prospectively assess the risk of advanced fibrosis in first-degree relatives of probands with NAFLD-cirrhosis.

Methods: This is a cross-sectional analysis of a prospective cohort of 26 probands with NAFLD-cirrhosis and 39 first-degree relatives. The control population included 69 community-dwelling twin, sib-sib, or parent-offspring pairs (n = 138), comprising 69 individuals randomly ascertained to be without evidence of NAFLD and 69 of their first-degree relatives. The primary outcome was presence of advanced fibrosis (stage 3 or 4 fibrosis). NAFLD was assessed clinically and quantified by MRI proton density fat fraction (MRI-PDFF). Advanced fibrosis was diagnosed by liver stiffness greater than 3.63 kPa using magnetic resonance elastography (MRE).

Results: The prevalence of advanced fibrosis in first-degree relatives of probands with NAFLD-cirrhosis was significantly higher than that in the control population (17.9% vs. 1.4%, P = 0.0032). Compared with controls, the odds of advanced fibrosis among the first-degree relatives of probands with NAFLD-cirrhosis were odds ratio 14.9 (95% CI, 1.8-126.0, P = 0.0133). Even after multivariable adjustment by age, sex, Hispanic ethnicity, BMI, and diabetes status, the risk of advanced fibrosis remained both statistically and clinically significant (multivariable-adjusted odds ratio 12.5; 95% CI, 1.1-146.1, P = 0.0438).

Conclusion: Using a well-phenotyped familial cohort, we demonstrated that first-degree relatives of probands with NAFLD-cirrhosis have a 12 times higher risk of advanced fibrosis. Advanced fibrosis screening may be considered in first-degree relatives of NAFLD-cirrhosis patients.

Trial Registration:

Ucsd Irb: 140084.

Funding: National Institute of Diabetes and Digestive and Kidney Diseases and National Institute of Environmental Health Sciences, NIH.
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http://dx.doi.org/10.1172/JCI93465DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5490764PMC
June 2017

The effects of Share 35 on the cost of liver transplantation.

Clin Transplant 2017 05 30;31(5). Epub 2017 Mar 30.

Department of Surgery, University of California San Diego, San Diego, CA, USA.

On June 18, 2013, the United Network for Organ Sharing (UNOS) instituted a change in the liver transplant allocation policy known as "Share 35." The goal was to decrease waitlist mortality by increasing regional sharing of livers for patients with a model for end-stage liver disease (MELD) score of 35 or above. Several studies have shown Share 35 successful in reducing waitlist mortality, particularly in patients with high MELD. However, the MELD score at transplant has increased, resulting in sicker patients, more complications, and longer hospital stays. Our study aimed to explore factors, along with Share 35, that may affect the cost of liver transplantation. Our results show Share 35 has come with significantly increased cost to transplant centers across the nation, particularly in regions 2, 5, 10, and 11. Region 5 was the only region with a median MELD above 35 at transplant, and cost was significantly higher than other regions. Several other recipient factors had changes with Share 35 that may significantly affect the cost of liver transplant. While access to transplantation for the sickest patients has improved, it has come at a cost and regional disparities remain. Financial implications with proposed allocation system changes must be considered.
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http://dx.doi.org/10.1111/ctr.12937DOI Listing
May 2017

Combined liver transplant and pancreaticoduodenectomy for inflammatory hilar myofibroblastic tumor: Case report and review of the literature.

Pediatr Transplant 2017 Mar 20;21(2). Epub 2016 Dec 20.

University of California San Diego - Surgery, La Jolla, CA, USA.

IMT, previously known as IPT, is a relatively rare tumor that was originally described in the lungs, but case reports have reported the tumor in almost every organ system. Surgical resection is typically the mainstay of therapy; however, tumors have also been shown to respond to chemotherapy or anti-inflammatory therapy and some have spontaneously regressed. We present a literature review and case report representing the first documentation to date of liver transplant combined with PD for surgical resection of a myofibroblastic tumor non-responsive to medical therapy.
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http://dx.doi.org/10.1111/petr.12846DOI Listing
March 2017

Hepatitis B and Hepatocellular Carcinoma.

Clin Liver Dis 2016 11 9;20(4):703-720. Epub 2016 Aug 9.

Division of Transplantation and Hepatobiliary Surgery, Department of Surgery, University of California, San Diego, 9300 Campus Point Drive, # 7745 La Jolla, CA 92037-1300, USA.

Hepatocellular carcinoma (HCC) is one of the leading causes of cancer death worldwide, and its incidence has been increasing in the last decade largely in parallel to the incidence and duration of exposure to hepatitis B and C. The widespread implementation of hepatitis B vaccine, hepatitis B antivirals, and the introduction of direct antiviral therapies for hepatitis C virus may have a substantial impact in reducing the incidence of HCC. This report reviews the risk factors and underlying mechanisms associated with the development of HCC in hepatitis B, along with advances in the diagnosis, imaging, and management of HCC.
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http://dx.doi.org/10.1016/j.cld.2016.06.007DOI Listing
November 2016

Living Donor Hepatectomy: Is it Safe?

Am Surg 2015 Oct;81(10):1101-6

Transplant Division, Department of Surgery, University of California San Diego, San Diego, California, USA.

Living donor hepatectomy (LDH) is high risk to a healthy donor and remains controversial. Living donor nephrectomy (LDN), conversely, is a common practice. The objective is to examine the outcomes of LDH and compare this risk profile to LDN. The Nationwide Inpatient Sample was queried for hepatectomies and nephrectomies from 1998 to 2011. LDH or LDN were identified by donor ICD-9 codes. Outcomes included in-hospital mortality and complications. Bivariate analysis compared nondonor hepatectomy or nondonor nephrectomy (NDN). Multivariate analyses adjusted for baseline organ disease, malignancy, or benign lesions. There were 430 LDH and 9211 nondonor hepatectomy. In-hospital mortality was 0 and 6 per cent, respectively (P < 0.001); complications 4 and 33 per cent (P < 0.001). LDH had fewer complications [odds ratio (OR) 0.15 (0.08-0.26)]. There were 15,631 LDN and 117,966 NDN. Mortality rates were 0.8 per cent LDN and 1.8 per cent NDN (P < 0.001). Complications were 1 and 21 per cent (P < 0.001). LDN had fewer complications [OR 0.06 (0.05-0.08)] and better survival [OR 0.32 (0.18-0.58)]. Complication rates were higher in LDH than LDN (4% vs 1%, P < 0.001), but survival was similar (0% vs 0.8% mortality, P = 0.06). In conclusion, morbidity and mortality rates of LDH are significantly lower than hepatectomy for other disease. This study suggests that the risk profile of LDH is comparable with the widely accepted LDN.
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October 2015

ECD kidney transplantation outcomes are improved when matching donors to recipients using a novel creatinine clearance match ratio (CCMR).

Clin Transplant 2015 Sep 6;29(9):738-46. Epub 2015 Aug 6.

Department of Surgery, University of California, San Diego, CA, USA.

Improved outcomes have been associated with various methods of size matching between expanded criteria (ECD) donors and recipients. A novel method for improved functional based matching was developed utilizing manipulation of Cockcroft-Gault estimated creatinine clearances for donor and recipient. We hypothesized that optimal clearance-based matches would have superior outcomes for both immediate graft function and long-term graft survival. For the analysis, recipients of ECD kidneys in the Scientific Registry of Transplant Recipients (SRTR) transplanted between October 1, 1987 and August 31, 2011 were included. Univariate and multivariate analyses predicted the hazard ratio of graft failure and the odds ratio of requiring dialysis within the first week. A total of 25,640 ECD kidney transplants were analyzed. On multivariate analysis, higher creatinine clearance match ratio (CCMR) was associated with increased graft failure and odds of requiring dialysis within the first week (comparing highest ratio quintile versus lowest ratio quintile: HR 1.43, p < 0.001; OR 2.08, p < 0.001). This study suggests that ECD kidneys have improved outcomes when the recipient/donor CCMR is optimized.
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http://dx.doi.org/10.1111/ctr.12555DOI Listing
September 2015

Kidney clamp, perfuse, re-implant: a useful technique for graft salvage after vascular complications during kidney transplantation.

Clin Transplant 2015 Apr 9;29(4):373-8. Epub 2015 Mar 9.

Division of Transplantation and Hepatobiliary Surgery, University of California San Diego, San Diego, CA, USA.

Although intra-operative vascular complications during renal transplantation are rare, injuries associated with prolonged ischemia may lead to graft threatening early and late complications. This series describes a novel technique for intra-operative repair of vascular complications in five patients over a three-yr period. The method consists of rapid graft nephrectomy and re-preservation of the graft with cold University of Wisconsin solution, which allows for controlled/precise back table repair of the vascular injury without incurring prolonged warm ischemia time. In three cases, the donor renal vein (2) and donor renal artery (1) were damaged and required back table reconstruction. In two cases, the recipient iliac artery needed reconstruction. Three of the five cases used deceased donor iliac vessels from another donor for reconstruction. Two patients required postoperative dialysis for delayed graft function for three to nine d (average six d) and two patients had slow graft function. All grafts were functioning at 17 months (mean) after transplant, with a median serum of 1.61 mg/dL (0.74-3.69). This series demonstrates the effectiveness of kidney clamp, perfuse, resuscitate as an effective intra-operative technique to salvage grafts after vascular injury. Although the grafts may suffer from delayed or slow graft function, excellent long-term function is attainable.
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http://dx.doi.org/10.1111/ctr.12526DOI Listing
April 2015

Evolving role of vascular resection and reconstruction in hepatic surgery for malignancy.

Hepat Oncol 2014 Jan 20;1(1):53-65. Epub 2013 Dec 20.

Division of Transplant & Hepatobiliary Surgery, University of California, San Diego, CA 92103, USA.

Primary and secondary hepatic malignancies, including hepatocellular cancer, cholangiocarcinoma and metastatic disease from colorectal cancer continue to increase in incidence worldwide, and remain diseases with a high mortality. Liver resection, with negative margins, is associated with improved survival and better quality of life over nonoperative treatment. As liver resection continues to evolve, aggressive centers are increasingly using vascular resection and reconstruction to achieve negative margins and improve outcomes. As these resections become more common, the morbidity and mortality associated with these complex surgical procedures is decreasing. Currently, resections of the portal vein are becoming routine in major liver and pancreatic resections, and experience with hepatic artery, hepatic vein and inferior vena cava resections is increasing. This review paper looks at the current indications, techniques and outcomes for major vascular resection in hepatic malignancy.
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http://dx.doi.org/10.2217/hep.13.5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6114016PMC
January 2014

Resection of the liver and inferior vena cava for hepatic malignancy.

J Am Coll Surg 2013 Jul 1;217(1):115-24; discussion 124-5. Epub 2013 Feb 1.

Department of Surgery, Center for Hepatobiliary Diseases, University of California San Diego, San Diego, CA 92103-8401, USA.

Background: Involvement of the IVC has traditionally been considered a relative contraindication to resection for advanced tumors of the liver. Combined resection of the liver and IVC for malignancy can be performed safely and results in long-term survival in select patients.

Study Design: Sixty patients undergoing hepatic and IVC resection by the primary author from 1996 to 2012 were reviewed. Median age was 52 years. Resections were carried out for cholangiocarcinoma (n = 26), hepatocellular carcinoma (n = 16), colorectal metastases (n = 13), gastrointestinal stromal tumor (n = 2), hepatoblastoma (n = 2), and squamous cell carcinoma (n = 1). Resections performed included 27 right and 5 left trisegmentectomies and 25 right and 3 left lobectomies, including the caudate lobe. Ex vivo procedures were performed in 6 patients using veno-venous bypass and the other 54 procedures were performed using varying degrees of vascular isolation. In situ cold perfusion of the liver was used in 8 patients. The IVC was reconstructed using a tube graft (n = 38) primarily (n = 8) or with patches (n = 14).

Results: There were 5 perioperative deaths (8%). Three patients died of liver failure, 1 patient died of pulmonary hemorrhage, and 1 patient died of massive pulmonary embolism. Nine patients had evidence of postoperative liver failure that resolved with supportive management. Three patients required temporary dialysis. With a median follow-up of 31 months, 14 patients have died of recurrent malignancy between 22 and 44 months, and an additional 4 patients are alive with disease at 16 to 33 months. Actuarial 1- and 5-year survival rates were 89% and 35%, respectively.

Conclusions: Inferior vena cava involvement by malignancy does not obviate liver resection. The procedure's increased risk is balanced by the possible benefits, given the lack of alternative curative approaches.
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http://dx.doi.org/10.1016/j.jamcollsurg.2012.12.003DOI Listing
July 2013

Endoscopic treatment of anastomotic biliary strictures after living donor liver transplantation: outcomes after maximal stent therapy.

Gastrointest Endosc 2013 Jan 11;77(1):47-54. Epub 2012 Oct 11.

Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, AZ 85259, USA.

Background: Living-donor liver transplantation (LDLT) has emerged as a viable strategy in an era of organ shortage. However, biliary strictures are a common complication of LDLT, and these strictures frequently require surgical revision after unsuccessful endoscopic therapy. The optimal endoscopic treatment for anastomotic biliary strictures (ABSs) after LDLT is undefined.

Objective: To determine the outcome of an aggressive endoscopic approach to ABSs after LDLT that uses endoscopic dilation followed by maximal stent placement.

Design: A retrospective study.

Setting: A tertiary-care academic medical center.

Patients: Forty-one patients with a diagnosis of ABS.

Interventions: Endoscopic retrograde cholangiography with balloon dilation and maximal stenting.

Main Outcome Measurements: Stricture resolution, stricture recurrence, and complication rates.

Results: Of 110 LDLTs completed, a biliary stricture developed after transplantation in 41 (37.3%), which included 38 patients with duct-to-duct anastomosis. The median (interquartile range [IQR]) follow-up time is 74.2 (2.5-120.8) months. Among them, 23 (60.5%) were male, and 20 (52.6%) had bile leakage associated with ABSs. The median time (IQR) to the development of an ABS after LDLT was 2.1 (1.2-4.1) months. Endoscopic retrograde cholangiography was attempted as initial therapy in all patients: 32 were managed entirely by endoscopic therapy, and 6 required initial percutaneous transhepatic cholangiography (PTC) to cross the biliary stricture, with endoscopic therapy performed thereafter. A median (IQR) of 4.0 (3.0-5.3) endoscopic interventions and 7.0 (4.0-10.3) stents were required to resolve the stricture. The time from the first intervention to stricture resolution was 5.3 (range 3.8-8.9) months. Biochemical markers including aspartate transaminase (76 vs 39 U/L, P = .001), alanine transaminase (127.5 vs 45.5 U/L, P < .001), alkaline phosphatase (590 vs 260 IU/L, P < .001), and total bilirubin (2.57 vs 1.73 mg/dL, P = .017) significantly improved after intervention. Recurrent stricture was observed after initial treatment in 8 (21%) patients. All recurrences were successfully re-treated endoscopically. All patients have been managed without surgical revision or retransplantation, resulting in 100% success by an intention-to-treat analysis.

Limitations: Retrospective study, small sample size.

Conclusions: In this series, aggressive endoscopy-based treatment with maximal stent placement strategy allows 100% resolution of all duct-to-duct ABSs after LDLT without the need for surgical intervention or retransplantation.
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http://dx.doi.org/10.1016/j.gie.2012.08.034DOI Listing
January 2013

Laparoscopic bilateral native nephrectomies with simultaneous kidney transplantation.

BJU Int 2012 Dec 9;110(11 Pt C):E1003-7. Epub 2012 Aug 9.

Department of Urology, Mayo Clinic, Phoenix, AZ, USA.

Unlabelled: Study Type--Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? Extirpation of polycystic kidneys for various medical reasons has been performed using many different approaches in attempts to limit morbidity from such a large operation. In indicated patients, it has usually been offered in a staged approach with renal transplantation to avoid graft complications. We published the first case of simultaneous laparoscopic bilateral native nephrectomy with kidney transplant in 2008. The present study shows our continued experience with offering this minimally invasive, single surgery alternative. The results are comparable to a staged laparoscopic approach with significantly shorter total hospital stay and one recovery for the patient and his/her family.

Objective: • To analyse the perioperative outcomes of native bilateral laparoscopic nephrectomy (BLN) with simultaneous kidney transplantation.

Patients And Methods: • From November 2000 to April 2011, 37 patients were seen for renal failure secondary to autosomal-dominant polycystic kidney disease (ADPKD) and underwent renal transplant with native nephrectomies at a single tertiary academic centre. • In all, 15 patients underwent BLN for ADPKD followed by simultaneous kidney transplantation. • The other 22 patients underwent BLN for ADPKD with kidney transplant performed at a separate setting. • Demographic data, perioperative outcomes, complications regardless of need for intervention, and graft function were analysed in both groups.

Results: • The combined surgery was completed without intraoperative complication in all cases. • The median total operative duration was 372 min, estimated blood loss was 300 mL with two patients requiring transfusion, and the median (range) hospital stay was 5 (3-7) days. • All patients had immediate graft function with additional relief of compressive symptoms. • In comparison to our staged cohort, the simultaneous group had a significantly shorter total hospital stay. • All other outcomes and complication rates were comparable.

Conclusion: • In ADPKD, a less invasive laparoscopic approach for native nephrectomies with simultaneous renal transplant offers comparable morbidity without graft compromise and the convenience of one operation and one recovery for the patient.
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http://dx.doi.org/10.1111/j.1464-410X.2012.11379.xDOI Listing
December 2012

Surgical management trends for cholangiocarcinoma in the USA 1998-2009.

J Gastrointest Surg 2012 Dec 31;16(12):2225-32. Epub 2012 Jul 31.

Department of Surgery, University of California, San Diego, San Diego, CA 92103-8401, USA.

Background: Surgical advancements have improved outcomes for cholangiocarcinoma (CCA) patients, but this expertise is not uniformly available. This research examines CCA surgical treatment patterns.

Methods: A retrospective analysis of the U.S. Nationwide Inpatient Sample from 1998-2009 identified CCA patients at high-volume (HV) versus low-volume (LV) hospitals, and teaching versus nonteaching hospitals. We performed multinomial and multivariate logistic regressions to compare differences of surgical treatment between HV vs. LV hospitals, and teaching vs. nonteaching hospitals. Liver resection (LR), pancreaticoduodenectomy, bile duct (BD) resection, and combined liver/BD resection were considered more aggressive therapy than BD stent or bypass.

Results: A total of 32,561 patients with CCA were identified. The proportion receiving surgery declined from 36 to 30 %. There was no increase in the proportion of LRs or combined liver/BD resection. Patients at HV or teaching hospitals were more likely to receive surgical treatment [odds ratio (OR), 1.3, p < 0.001; OR, 1.4, p < 0.001].

Discussion: Despite increasing evidence that surgical resection increases survival, the number of patients receiving surgery has decreased. Although combined liver/BD resection has been advocated as standard management for proximal CCA, the practice has not increased. All patients with CCA should be considered for assessment at a HV teaching hospital.
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http://dx.doi.org/10.1007/s11605-012-1980-9DOI Listing
December 2012

Laparoscopic distal pancreatectomy: does splenic preservation affect outcomes?

Surg Laparosc Endosc Percutan Tech 2011 Oct;21(5):362-5

Division of Transplant and Hepatobiliary Surgery, University of California, San Diego, CA 92103-8401, USA.

Although the spleen is often routinely resected during both open and laparoscopic distal pancreatectomies, a splenectomy can increase the risk of postoperative and life-long infectious complications. Spleen-preserving laparoscopic pancreatectomies can technically be more difficult because of the delicate dissection of the splenic vessels. We performed a retrospective review of 34 laparoscopic pancreatectomies done at our institution. All procedures were done laparoscopically without hand assistance. Attempts were made in all patients to conserve the spleen, which was successful in 10 patients (29%). In the splenectomy group, 9 patients had 12 surgical complications (26%), which was statistically significant compared with the spleen-preserving group, in which there were no complications. This included 7 patients with a pancreatic leak (20%) and 3 with postoperative hemorrhage requiring reexploration (9%). Patients with spleen-preserving pancreatectomies had significantly less blood loss and shorter operative time compared with patients who underwent concomitant splenectomy. Splenic preservation should be attempted in all patients undergoing laparoscopic distal pancreatectomy unless there are overriding oncological or anatomic concerns.
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http://dx.doi.org/10.1097/SLE.0b013e31822e0ea8DOI Listing
October 2011

Portal vein resection in management of hilar cholangiocarcinoma.

J Am Coll Surg 2011 Apr;212(4):604-13; discussion 613-6

Department of Surgery, Center for Hepatobiliary Disease and Abdominal Transplantation, University of California San Diego, San Diego, CA 92013-8401, USA.

Background: Vascular reconstruction along with major liver resection in the setting of liver dysfunction caused by biliary obstruction can be associated with increased risk. The purpose of this report is to assess the role of portal vein resection and reconstruction in the surgical management of hilar cholangiocarcinoma.

Study Design: Ninety-five patients with hilar cholangiocarcinoma who underwent resection between 1999 and 2010 were reviewed. Liver resections performed along with biliary resection included 84 trisegmentectomies (63 right, 21 left) and 11 lobectomies (8 left, 3 right). Thirteen patients also had simultaneous pancreaticoduodenectomy performed. Forty-two patients underwent portal vein resection and reconstruction. Five patients required reconstruction of the hepatic artery. Preoperative portal vein embolization was used in 38 patients.

Results: Patients undergoing resection had a 5% mortality rate, with an overall morbidity rate of 36%. Patients who underwent portal vein resection had perioperative mortality and morbidity similar to those who did not have portal vein resection. Median survival was 38 months (95% CI, 29-51 months), with a 5-year survival rate of 43%. There was no difference in long-term survival between those patients who had portal vein resection and those that did not. Negative margins were achieved in 84% of cases and were associated with improved survival (p < 0.01). Five-year survival rate in patients undergoing R0 resection was 50%. Patients with positive lymph nodes appeared to have a worse 5-year survival rate than patients with node-negative status (23% versus 49%); however, only negative margin status was associated with improved survival by multivariate analysis.

Conclusions: Surgical resection of hilar cholangiocarcinoma that requires resection of the portal vein can be performed safely and should not be a contraindication to resection.
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http://dx.doi.org/10.1016/j.jamcollsurg.2010.12.028DOI Listing
April 2011

Living donor kidney transplantation with multiple renal arteries in the laparoscopic era.

Urology 2011 May 8;77(5):1116-21. Epub 2010 Dec 8.

Department of Urology, Mayo Clinic, Phoenix, Arizona 85054, USA.

Objectives: To compare the postoperative complications and survival metrics after multiple renal arteries (MRA) and single renal artery (SRA) laparoscopically procured living donor kidney transplantation (LLDKT). MRA are the most frequently encountered anatomic variation during kidney transplantation. The long-term outcomes of LLDKT with MRA are not well characterized.

Methods: A retrospective review of our institution's LLDKT database was performed. All surgeries were performed at a single tertiary care academic center between June 1999 and September 2008. Patients were divided into 2 cohorts (MRA vs SRA), and analysis was limited to patients with at least 1-year follow-up.

Results: Of 584 LLDKTs, 510 had at least 1-year follow-up (median: 36 months). A total of 393 grafts had an SRA, whereas 117 (23%) had MRA. When complications were stratified by the Clavien classification system, no differences were noted between groups (P = .5). Furthermore, rates of vascular (P = .2) and urological (P = .9) complications were similar between groups. There was, however, a higher incidence of slow graft function in the MRA group (P = .01), despite similar rates of delayed graft function (P = .9) and acute rejection (P = .4). Furthermore, allograft survival was similar between both groups with 76% of MRA and 81% of SRA grafts functioning at 5 years (P = .49). Patient overall survival was likewise similar between groups with 88% of MRA and 86% of SRA recipients surviving at 5 years (P = .76).

Conclusions: Despite a higher incidence slow graft function, MRA in LLDKT does not adversely affect long-term allograft and patient overall survival.
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http://dx.doi.org/10.1016/j.urology.2010.07.503DOI Listing
May 2011

Six-minute walk distance predicts mortality in liver transplant candidates.

Liver Transpl 2010 Dec;16(12):1373-8

Divisions of Hepatology and Gastroenterology, Mayo Clinic Arizona, Phoenix, AZ 85054, USA.

The 6-minute walk distance (6MWD) is a simple test measuring global physical function. It is commonly used to predict mortality in patients with cardiac and pulmonary diseases, but it is also useful in assessing the functional status of patients with a variety of other medical conditions. We sought to determine (1) the characteristics of the 6MWD in patients listed for liver transplantation (LT), (2) the existence of a relationship between the 6MWD and the quality of life, and (3) the relationship between the 6MWD and survival in LT candidates. The 6MWD was prospectively measured in all patients listed for LT. The 6MWD was determined when the listed Model for End-Stage Liver Disease (MELD) score was ≥ 15. Patients were followed until LT, death, removal from the wait list, or the end of the study period. Quality of life was assessed with the Short Form 36 (SF-36). In 121 patients, the mean 6MWD was 369 ± 122 m; it was not related to age, height, weight, body mass index, albumin level, or etiology of liver disease and showed a moderate correlation with the physical component score (PCS) on the SF-36 (r = 0.4) and a moderate inverse correlation with the native MELD score (r = -0.61). In an unadjusted analysis, a high native MELD score, a low 6MWD, and a low PCS were associated with mortality, with only the 6MWD retaining significance after adjustment for covariates. Each 100-m increase in the 6MWD was significantly associated with increased survival (hazard ratio = 0.48, P = 0.0001), with 6MWD < 250 m being associated with an increased risk of death (P = 0.0001). In conclusion, the 6MWD is significantly reduced in patients awaiting LT and is inversely correlated with the native MELD score. A pretransplant 6MWD < 250 m is a risk for death on the wait list.
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http://dx.doi.org/10.1002/lt.22167DOI Listing
December 2010

Early graft function after laparoscopically procured living donor kidney transplantation.

J Urol 2010 Oct 19;184(4):1434-9. Epub 2010 Aug 19.

Dartmouth Medical School, Hanover, New Hampshire, USA.

Purpose: We determined predictors of poor early graft function after laparoscopic living donor kidney transplantation.

Materials And Methods: We performed an institutional review board approved review of the living donor kidney transplantation database at our institution.

Results: Seven of the 510 transplants (1%) were excluded from study due to immediate graft nephrectomy for vascular complications. Of the remaining 503 transplants 48 (9.5%) and 18 (3.6%) had slow and delayed graft function, respectively. Recipient male gender (OR 2.03, 95% CI 1.05-3.91, p = 0.035), black ethnicity (OR 1.59, 95% CI 1.08-2.34, p = 0.020) and donor age (OR 1.03, 95% CI 1.00-1.05, p = 0.021) emerged as independent predictors of poor early graft function in multivariate logistic regression models. Poor early graft function strongly redisposed patients to acute rejection during year 1 (HR 3.43, 95% CI 2.04-5.77, p <0.0001) while grafts from genetically related donors conferred a protective effect (HR 0.40, 95% CI 0.24-0.66, p <0.0001). Three-year death censored allograft survival was lower in the delayed and slow graft function groups than in the immediate function group (89% and 87% vs 98%, p = 0.0068 and 0.0002, respectively). Overall 3-year patient survival was lower in the delayed than in the immediate function group (81% vs 94%, p <0.0001).

Conclusions: Male black recipients of laparoscopically procured living donor kidney transplants from donors older than 50 years are at higher risk for poor early graft function, which in turn strongly predicts acute rejection during year 1. This is significant since excellent early graft function confers specific recipient and allograft survival advantages, and may assist physicians in better understanding the various recipient, donor and perioperative parameters that influence clinical outcomes.
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http://dx.doi.org/10.1016/j.juro.2010.06.013DOI Listing
October 2010

Treatment of hepatitis C in renal transplantation candidates: a single-center experience.

Transplantation 2010 Aug;90(4):407-11

Division of Hepatology, Mayo Clinic Arizona, Phoenix, AZ, USA.

Background: There is no consensus on hepatitis C virus (HCV) treatment in patients with renal failure. Toxicity of pegylated interferon (PEG-IFN) and ribavirin limit options; hence the ideal approach for therapy in these patients deserves attention. We report the results of kidney transplantation (KTx) candidates infected with HCV treated with PEG-IFN monotherapy.

Methods: KTx candidates with HCV infection treated with PEG-IFN monotherapy between January 2001 and February 2009 were included. Liver biopsies were performed before therapy. Response was assessed using accepted virological time points.

Results: From 2636 patients listed for KTx, 60 patients were tested positive for anti-HCV. Twenty-two patients were eligible for treatment. All patients were HCV treatment naïve. One patient had biopsy-confirmed cirrhosis. Mean Ishak-Knodell fibrosis stage was 1.3. Ten patients (45%) achieved sustained viral response. In genotype 1 patients, there were no relapsers among early responders, despite the limited regimen. Nine patients (40%) in the cohort have had KTx. Of these, there were four responders and five nonresponders. None of the responders have had recurrence of their HCV after their KTx.

Conclusions: End-stage renal disease patients with HCV can be treated successfully with PEG-IFN monotherapy. Our sustained viral response rate was 45% (10/22) in patients treated before KTx.
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http://dx.doi.org/10.1097/TP.0b013e3181e72837DOI Listing
August 2010

Risk factors for pancreatic adenocarcinoma and prospects for screening.

Gastroenterol Hepatol (N Y) 2010 Apr;6(4):246-54

Pancreatic cancer has one of the worst survival rates of any cancer and is the fourth leading cause of cancer mortality. Early detection and surgery are the patient's best chance for cure. However, symptoms are typically vague and occur when the cancer is unresectable. Population-based mass screening is not practical for this rare disease, though screening and early detection in asymptomatic high-risk patient populations may be indicated.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2886484PMC
April 2010

Relationship between inpatient hyperglycemia and insulin treatment after kidney transplantation and future new onset diabetes mellitus.

Clin J Am Soc Nephrol 2010 Sep 17;5(9):1669-75. Epub 2010 Jun 17.

Division of Nephrology, Mayo Clinic Hospital, Phoenix, AZ 85054, USA.

Background And Objectives: Approximately two-thirds of kidney transplant recipients with no previous history of diabetes experience inpatient hyperglycemia immediately after kidney transplant surgery; whether inpatient hyperglycemia predicts future new onset diabetes after transplant (NODAT) is not established.

Design, Setting, Participants, & Measurements: A retrospective study was conducted to determine the risk conferred by inpatient hyperglycemia on development of NODAT within 1 year posttransplant. All adult nondiabetic kidney transplant recipients between June 1999 and January 2008 were included. Posttransplant inpatient hyperglycemia was defined as any bedside capillary blood glucose > or = 200 mg/dl or insulin therapy during hospitalization. NODAT was defined as HbA1C > or = 6.5%, fasting venous serum glucose > or = 126 mg/dl, or prescribed diet or medical therapy for diabetes mellitus.

Results: The study cohort included 377 patients. NODAT developed in 1 (4%) of the 28 patients without inpatient hyperglycemia, 4 (18%) of the 22 patients with inpatient hyperglycemia but not treated with insulin, and in 98 (30%) of the 327 of the patients who were diagnosed with inpatient hyperglycemia and were treated with insulin. In adjusted analyses, requirement of insulin therapy during hospitalization posttransplant was associated with a 4-fold increase in NODAT (relative risk 4.01; confidence interval, 1.49 to 10.7; P = 0.006).

Conclusion: Development of inpatient hyperglycemia after kidney transplantation in nondiabetic patients significantly increased the risk of NODAT. Additionally, we observed a significantly increased risk of cardiovascular events in patients who developed NODAT.
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http://dx.doi.org/10.2215/CJN.09481209DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2974410PMC
September 2010

Successful transplantation of a split crossed fused ectopic kidney into a patient with end-stage renal disease.

J Transplant 2010 25;2010:383972. Epub 2010 Mar 25.

Division of Transplant, Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Phoenix, AZ 85054, USA.

Potential donors with congenital renal anomalies but normal renal function are often overlooked because of a possible increase in technical difficulty and complications associated with the surgery. However, as the waiting list for a deceased donor kidney transplant continues to grow, it is important to consider these kidneys for potential transplant. This paper describes the procurement of a crossed fused ectopic kidney, and subsequent parenchymal transection prior to transplantation as part of a combined simultaneous kidney pancreas transplant. The transplant was uncomplicated, and the graft had immediate function. The patient is now two years from transplant with excellent function.
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http://dx.doi.org/10.1155/2010/383972DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2846343PMC
July 2011

Hyperglycemia during the immediate period after kidney transplantation.

Clin J Am Soc Nephrol 2009 Apr 1;4(4):853-9. Epub 2009 Apr 1.

Division of Nephrology, Mayo Clinic, Scottsdale, Arizona, USA.

Background And Objectives: Hyperglycemia and new-onset diabetes occurs frequently after kidney transplantation. The stress of surgery and exposure to immunosuppression medications have metabolic effects and can cause or worsen preexisting hyperglycemia. To our knowledge, hyperglycemia in the immediate posttransplantation period has not been studied.

Design, Setting, Participants, & Measurements: We conducted a retrospective, observational study to characterize the prevalence and assess the pharmacologic management of hyperglycemia in kidney transplant recipients who underwent transplantation at our center between June 1999 and December 2006. Data were abstracted from electronic and pharmacy databases.

Results: The study cohort included 424 patients (mean age 51 yr; 58% men; 25% with pretransplantation diabetes). All patients with and 87% without pretransplantation diabetes had evidence of hyperglycemia (bedside glucose >or=200 mg/dl or physician-instituted insulin therapy), whereas the prevalence of hypoglycemia was low (4.5%). Hyperglycemia was sustained throughout hospitalization. All patients with and 66% without pretransplantation diabetes required insulin at hospital discharge. Patients with pretransplantation diabetes were treated primarily with short-acting insulin during the first 24 h after transplantation but were transitioned to long-acting insulin as the hospital stay progressed.

Conclusions: Investigators have historically attempted to identify hyperglycemia after hospital discharge. Our data indicate that a substantial number of patients without pretransplantation diabetes develop hyperglycemia and require insulin during the hospital phase of their care immediately after kidney transplantation. Prospective studies are needed to delineate factors that contribute to development of new-onset diabetes after transplantation among patients with transient hyperglycemia.
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http://dx.doi.org/10.2215/CJN.05471008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2666437PMC
April 2009

Sclerosing peritonitis and mortality after liver transplantation.

Liver Transpl 2009 Apr;15(4):435-9

Division of Transplant Surgery, Mayo Clinic Hospital, Phoenix, AZ 85254, USA.

Sclerosing peritonitis describes the development of a peel or rind of fibrosis that spreads over the peritoneal surface and can lead to recalcitrant ascites, bowel obstruction, and sepsis. It is well described as a complication of peritoneal dialysis, especially with episodes of bacterial peritonitis. It is also a complication of end-stage liver disease with ascites and liver transplantation. This article describes 3 cases of sclerosing peritonitis present at the time of liver transplantation or soon after. All 3 patients had massive refractory ascites with episodes of spontaneous bacterial peritonitis prior to transplantation. Two patients had evidence of a fibrous peel at the time of transplantation. Postoperatively, all 3 patients continued to have refractory ascites and episodes of peritonitis, along with partial small bowel obstructions, abdominal pain, and malnutrition. Two patients also had constriction of the graft, including biliary obstruction and inferior vena cava and outflow obstruction, which has not been previously described. All 3 patients eventually died from complications related to the sclerosing peritonitis.
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http://dx.doi.org/10.1002/lt.21702DOI Listing
April 2009