Publications by authors named "Munir Tarazi"

16 Publications

  • Page 1 of 1

Bile duct tumour thrombosis: hepatocellular carcinoma presenting with obstructive jaundice.

Br J Hosp Med (Lond) 2021 Aug 4;82(8). Epub 2021 Aug 4.

Department of Hepatobiliary and Pancreatic Surgery, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK.

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http://dx.doi.org/10.12968/hmed.2021.0030DOI Listing
August 2021

Liver Transplantation for Non-Resectable Liver Metastases from Colorectal Cancer: A Systematic Review and Meta-Analysis.

World J Surg 2021 Nov 28;45(11):3404-3413. Epub 2021 Jul 28.

Department of Hepato-Pancreato-Biliary Surgery, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Oxford Road, Manchester, M13 9WL, UK.

Backgrounds: Colorectal liver metastases were historically considered a contraindication to liver transplantation, but dismal outcomes for those with metastatic colorectal cancer and advancements in liver transplantation (LT) have led to a renewed interest in the topic. We aim to compare the current evidence for liver transplantation for non-resectable colorectal liver metastases (NRCLM) with the current standard treatment of palliative chemotherapy.

Methods: A systematic review and meta-analysis of proportions was conducted following screening of MEDLINE, EMBASE, SCOPUS and CENTRAL for studies reporting liver transplantation for colorectal liver metastases. Post-operative outcomes measured included one-, three- and five-year survival, overall survival, disease-free survival and complication rate.

Results: Three non-randomised studies met the inclusion criteria, reporting a total of 48 patients receiving LT for NRCLM. Survival at one-, three- and five-years was 83.3-100%, 58.3-80% and 50-80%, respectively, with no significant difference detected (p = 0.22, p = 0.48, p = 0.26). Disease-free survival was 35-56% with the most common site of recurrence being lung. Thirteen out of fourteen deaths were due to disease recurrence.

Conclusion: Although current evidence suggests a survival benefit conferred by LT in NRCLM compared to palliative chemotherapy, the ethical implications of organ availability and allocation demand rigorous justification. Concomitant improvements in the management of patients following liver resection and of palliative chemotherapy regimens is paramount.
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http://dx.doi.org/10.1007/s00268-021-06248-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8476371PMC
November 2021

Roux-en-Y versus single loop reconstruction in pancreaticoduodenectomy: A systematic review and meta-analysis.

Int J Surg 2021 Apr 24;88:105923. Epub 2021 Mar 24.

Department of Hepato-Pancreato-Biliary Surgery, Manchester Royal Infirmary, Manchester, UK.

Background: Post-operative pancreatic fistula (POPF) and delayed gastric emptying (DGE) both remain problematic complications following pancreaticoduodenectomy. This systematic review and meta-analysis evaluates whether Roux-en-Y compared to a single loop reconstruction in pancreaticoduodenectomy significantly reduces rates of these complications.

Methods: A systematic review and meta-analysis was conducted according to the PRISMA guidelines by screening EMBASE, MEDLINE/PubMed, CENTRAL and bibliographic reference lists for comparative studies meeting the predetermined inclusion criteria. Post-operative outcome measures included: POPF, DGE, bile leak, operating time, blood loss, need for transfusion, wound infection, intra-abdominal collection, post-pancreatectomy haemorrhage, overall morbidity, re-operation, overall mortality, hospital length of stay. Pooled odds ratios or mean differences with 95% confidence intervals were calculated using either fixed- or random-effects models.

Results: Fourteen studies were identified including four randomised controlled trials (RCTs) and 10 observational studies reporting a total of 2,031 patients. Data synthesis showed no statistically significant difference between the two groups in any of the outcome measures except operating time, which was longer in those undergoing Roux-en-Y reconstruction.

Discussion: Roux-en-Y is not superior to single loop reconstruction in pancreaticoduodenectomy but may prolong operating time. Future high-quality randomised studies with appropriate study design and sample size power calculation may be required to further validate this conclusion.
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http://dx.doi.org/10.1016/j.ijsu.2021.105923DOI Listing
April 2021

Risk Factors of Esophageal Squamous Cell Carcinoma beyond Alcohol and Smoking.

Cancers (Basel) 2021 Feb 28;13(5). Epub 2021 Feb 28.

Department of Surgery and Cancer, Imperial College London, London, W2 1NY, UK.

Esophageal squamous cell carcinoma (ESCC) is the sixth most common cause of death worldwide. Incidence rates vary internationally, with the highest rates found in Southern and Eastern Africa, and central Asia. Initial observational studies identified multiple factors associated with an increased risk of ESCC, with subsequent work then focused on developing plausible biological mechanistic associations. The aim of this review is to summarize the role of risk factors in the development of ESCC and propose future directions for further research. A systematic search of the literature was conducted by screening EMBASE, MEDLINE/PubMed, and CENTRAL for relevant publications. In total, 73 studies were included that sought to identify risk factors associated with the development of esophageal squamous cell carcinoma. Risk factors were divided into seven subcategories: genetic, dietary and nutrition, gastric atrophy, infection and microbiome, metabolic, epidemiological and environmental and other risk factors. Risk factors from each subcategory were summarized and explored with mechanistic explanations for these associations. This review highlights several current risk factors of ESCC. These risk factors were explored, and explanations dissected. Most studies focused on investigating genetic and dietary and nutritional factors, whereas this review identified other potential risk factors that have yet to be fully explored. Furthermore, there is a lack of literature on the association of these risk factors with tumor factors and disease prognosis. Further research to validate these results and their effects on tumor biology is absolutely necessary.
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http://dx.doi.org/10.3390/cancers13051009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7957519PMC
February 2021

The importance of social media to the academic surgical literature: Relationship between Twitter activity and readership metrics.

Surgery 2021 Sep 19;170(3):650-656. Epub 2021 Feb 19.

Department of General Surgery, Manchester Royal Infirmary, Manchester, UK. Electronic address: https://twitter.com/SurgeryHPB.

Background: Social media has an increasing role within professional surgical practice, including the publishing and engagement of academic literature. This study aims to analyze the relationship between social media use and traditional and alternative metrics among academic surgical journals.

Method: Journals were identified through the InCites Journal Citation Reports 2019, and their impact factor, h-index, and CiteScore were noted. Social media platforms were examined, and Twitter activity interrogated between 1 January to 31 December 2019. Healthcare Social Graph score and an aggregated Altmetric Attention Score were also calculated for each journal. Statistical analysis was carried out to look at the correlation between traditional metrics, Twitter activity, and altmetrics.

Results: Journals with a higher impact factor were more likely to use a greater number of social media platforms (R = 0.648; P < .0001). Journals with dedicated Twitter profiles had a higher impact factor than journals without (median, 2.96 vs 1.88; Mann-Whitney U = 390; P < .001); however, over a 1-year period (2018-2019) having a Twitter presence did not alter impact factor (Mann-Whitney U = 744.5; P = .885). Increased Twitter activity was positively correlated with impact factor. Longitudinal analysis over 6 years suggested cumulative tweets correlated with an increased impact factor (R = 0.324, P = .004). Novel alternative measures including Healthcare Social Graph score (R = 0.472, P = .005) and Altmetric Attention Score (R = 0.779, P = .001) positively correlated with impact factor.

Conclusion: Higher impact factor is associated with social media presence and activity, particularly on Twitter, with long-term activity being of particular importance. Modern alternative metrics correlate with impact factor. This relationship is complex, and future studies should look to understand this further.
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http://dx.doi.org/10.1016/j.surg.2021.01.003DOI Listing
September 2021

Procedural Outcomes of Laparoscopic-Assisted Endoscopic Retrograde Cholangiopancreatography in Patients with Previous Roux-en-Y Gastric Bypass Surgery: a Systematic Review and Meta-analysis.

Obes Surg 2021 01 15;31(1):282-298. Epub 2020 Sep 15.

Department of Hepatobiliary and Pancreatic Surgery, Manchester Royal Infirmary Hospital, Manchester, UK.

Purpose: To investigate the procedural outcomes of laparoscopic-assisted endoscopic retrograde cholangiopancreatography (ERCP) in patients with previous Roux-en-Y gastric bypass (RYGB) surgery.

Materials And Methods: We performed a systematic review in accordance with PRISMA statement standards to identify all studies reporting procedural outcomes of laparoscopic-assisted ERCP in patients with previous RYGB. The ROBINS-I tool was used to assess the risk of bias of the included studies. Fixed-effect and random-effects models were applied to calculate pooled outcome data.

Results: A total of 17 case series, enrolling 256 patients, were included. The mean age of included patients was 49. The mean procedure time was 137 min (95% CI 102-172). In terms of procedural success rates, the overall technical success was 95.3% (95% CI 92.5-97.5, I = 0%), papillary access success was 95.3% (95% CI 92.5-97.5, I = 0%), cannulation success was 95.3% (95% CI 92.5-97.5, I = 0%), sphincterotomy success was 96.1% (95% CI 93.5-98.1, I = 0%), and stone removal success was 95.9% (95% CI 92.4-98.4, I = 0%). Conversion to open was required in 4.7% (95% CI 2.5-7.6, I = 0%). In terms of complications, pancreatitis occurred in 4.7% (95% CI 2.3-8, I = 17%), cholangitis in 1.7% (95% CI 0.5-3.6, I = 0%), and perforation in 3.7% (95% CI 1.8-6.3, I = 0%). The length of hospital stay was 3 days (95% CI 2-4).

Conclusions: Laparoscopic-assisted ERCP seems to be feasible, effective, and a safe method to access the biliary tract in patients with previous RYGB as indicated by high technical success rates and low complication rates. There is a need for comparative evidence regarding outcomes of laparoscopic ERCP in comparison with alternative treatment options.
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http://dx.doi.org/10.1007/s11695-020-04954-xDOI Listing
January 2021

Improving knowledge and confidence in foundation doctors during specialty changeover.

Int J Qual Health Care 2020 Nov;32(8):490-494

Department of Hepatobiliary and General Surgery, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Oxford M13 9WL, UK.

Quality Problem: Foundation year junior doctors rotate every 4 months into different specialties. They are often expected to manage patients with complex underlying conditions despite inadequate clinical induction.

Initial Assessment: No structured induction was offered to junior doctors rotating to hepato-pancreatico-biliary surgery, a complex and highly specialized discipline within general surgery. We hypothesized that junior doctors will be lacking in both knowledge and confidence when managing these patients.

Choice Of Solution: Create a structured induction programme and evaluate its effectiveness in improving knowledge and confidence amongst doctors.

Implementation: Plan Do Study Act methodology was used along with driver diagrams to map change. A learning resource was developed in the form of a booklet, which included relevant clinical information, processes for escalation and referral as well as guidance for managing acutely unwell patients. A structured 1-hour teaching programme was delivered to junior doctors alongside this. Pre- and post-session questionnaires and statistical analysis were used to determine effect.

Evaluation: Marked improvements in both knowledge and confidence were seen. The intervention showed a statistically significant improvement.

Lessons Learned: Clinical induction resources can improve junior doctors' knowledge and confidence in managing their patients. Such induction is both valuable and necessary. Similar interventions can be used with allied health professionals and can involve the use of technology and virtual learning.
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http://dx.doi.org/10.1093/intqhc/mzaa070DOI Listing
November 2020

Case Report: Familial Hypocalciuric Hypercalcaemia and Hashimoto's Thyroiditis.

Front Surg 2020 16;7:30. Epub 2020 Jun 16.

Department of Transplant and Endocrine Surgery, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, United Kingdom.

Hypercalcaemia can be caused by many disorders. Primary hyperparathyroidism is the leading cause with parathyroidectomy being the definitive management. Familial hypocalciuric hypercalcaemia is a rarer cause in which resection of the parathyroid tissue does not result in normalized serum calcium. We report the unusual case of a 53-year-old lady who presented with hypercalcaemia and elevated parathyroid hormone with a presumed diagnosis of primary hyperparathyroidism. She remained hypercalcaemic after parathyroidectomy and was later diagnosed with familial hypocalciuric hypercalcaemia. During the first operation, a lymph node was also removed, and the histopathology report suggested a metastasis of follicular variant papillary thyroid carcinoma (FVPTC). After multi-disciplinary team (MDT) discussion, the patient underwent a second exploration where total thyroidectomy and removal of the other parathyroid glands were performed. Hypercalcaemia completely resolved on surgical resection of the thyroid and parathyroid tissue, however histopathology revealed normal parathyroid glands and florid Hashimoto's thyroiditis. The initial diagnosis of FVPTC in the lymph node was revisited and the final histopathology report suggested an accessory thyroid nodule with florid Hashimoto's thyroiditis mimicking a lymph node. Our case demonstrates the diagnostic dilemma in hypercalcaemia that may lead a patient to undergo unnecessary invasive procedures; the misdiagnosis of FVPTC after the first operation resulted in a second more extensive procedure. Patients with no clear surgical target and urine CCCR in the gray/non-diagnostic area should be routinely offered genetic testing despite negative family history.
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http://dx.doi.org/10.3389/fsurg.2020.00030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7308482PMC
June 2020

A Literature Review and Case Series of DVT Patients with Absent IVC Treated with Thrombolysis.

Ann Vasc Surg 2020 Aug 28;67:521-531. Epub 2020 Mar 28.

Department of Vascular Surgery, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK.

Background: Congenital absence of the inferior vena cava is related to deep venous thrombosis (DVT) in 5% of cases with no other risk factors. DVT is normally diagnosed by Duplex, whereas computerized tomography or magnetic resonance imaging is required to visualize this absence, and so, it is often missed but ought to be considered in young patients. There are many existing cases in the literature illustrating this link, but these patients were often managed conservatively with anticoagulation.

Case Series: We report five cases presenting with a DVT who were found to have an absent inferior vena cava after imaging and were treated successfully with thrombolysis and consequently managed with lifelong anticoagulation, between January 2014 and January 2019.

Conclusions: Anomalies of the inferior vena cava can cause unprovoked DVT. These anomalies are often incidental findings after CT but could change the management plan in these patients. Treatment can be with anticoagulants only, thrombolysis, thrombectomy, balloon angioplasty or stents, and long-term or lifelong anticoagulation to prevent DVT recurrence.
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http://dx.doi.org/10.1016/j.avsg.2020.03.021DOI Listing
August 2020

Laparoscopic Versus Open Liver Resection for Tumors in the Posterosuperior Segments: A Systematic Review and Meta-analysis.

Surg Laparosc Endosc Percutan Tech 2020 Apr;30(2):93-105

Department of Hepatobiliary and Pancreatic Surgery, Manchester Royal Infirmary Hospital, Manchester, UK.

Objective: The objective of this study was to compare the outcomes of laparoscopic and open liver resection for tumors in the posterosuperior segments.

Methods: We performed a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards. We conducted a search of electronic information sources to identify all studies comparing outcomes of laparoscopic and open liver resection for tumors in the posterosuperior segments. We used the Risk Of Bias In Nonrandomized Studies-of Interventions (ROBINS-I) tool to assess the risk of bias of the included studies. Fixed-effect or random-effects models were applied to calculate pooled outcome data.

Results: We identified 11 observational studies, enrolling a total of 1023 patients. The included population in both groups were comparable in terms of baseline characteristics. Laparoscopic approach was associated with lower risks of total complications [odds ratio (OR): 0.45; 95% confidence interval (CI): 0.33, 0.61; P<0.00001], major complications (Dindo-Clavien III or more) (OR: 0.52; 95% CI: 0.36, 0.73; P=0.0002), and intraoperative blood loss [mean difference (MD): -114.71; 95% CI: -165.64, -63.79; P<0.0001]. Laparoscopic approach was associated with longer operative time (MD: 50.28; 95% CI: 22.29, 78.27; P=0.0004) and shorter length of hospital stay (MD: -2.01; 95% CI: -2.09, -1.92; P<0.00001) compared with open approach. There was no difference between the 2 groups in terms of need for blood transfusion (OR: 1.23; 95% CI: 0.75, 2.02; P=0.41), R0 resection (OR: 1.09; 95% CI: 0.66, 1.81; P=0.72), postoperative mortality (risk difference: -0.00; 95% CI: -0.02, 0.02; P=0.68), and need for readmission (OR: 0.70; 95% CI: 0.19, 2.60; P=0.60). In terms of oncological outcomes, there was no difference between the groups in terms disease recurrence (OR: 1.58; 95% CI: 0.95, 2.63; P=0.08), overall survival (OS) at maximum follow-up (OR: 1.09; 95% CI: 0.66, 1.81; P=0.73), 1-year OS (OR: 1.53; 95% CI: 0.48, 4.92; P=0.47), 3-year OS (OR: 1.26; 95% CI: 0.67, 2.37; P=0.48), 5-year OS (OR: 0.91; 95% CI: 0.41, 1.99; P=0.80), disease-free survival (DFS) at maximum follow-up (OR: 0.91; 95% CI: 0.65, 1.27; P=0.56), 1-year DFS (OR: 1.04; 95% CI: 0.60, 1.81; P=0.88), 3-year DFS (OR: 1.13; 95% CI: 0.75, 1.69; P=0.57), and 5-year DFS (OR: 0.73; 95% CI: 0.44, 1.24; P=0.25).

Conclusions: Compared with the open approach in liver resection for tumors in the posterosuperior segments, the laparoscopic approach seems to be associated with a lower risk of postoperative morbidity, less intraoperative blood loss, and shorter length of hospital stay with comparable survival and oncological outcomes. The best available evidence is derived from observational studies with moderate quality; therefore, high-quality randomized controlled trials with adequate statistical power are required to provide a more robust basis for definite conclusions.
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http://dx.doi.org/10.1097/SLE.0000000000000746DOI Listing
April 2020

Letter to Editor: Small and Laterally Placed Incisional Hernias Can Be Safely Managed with an Onlay Repair.

World J Surg 2019 11;43(11):2945-2946

Department of Renal and Pancreas Transplantation, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK.

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http://dx.doi.org/10.1007/s00268-019-05088-7DOI Listing
November 2019

Impact of Toupet Versus Nissen Fundoplication on Dysphagia in Patients With Gastroesophageal Reflux Disease and Associated Preoperative Esophageal Dysmotility: A Systematic Review and Meta-Analysis.

Surg Innov 2018 Sep 12:1553350618799549. Epub 2018 Sep 12.

1 North Manchester General Hospital, Manchester, UK.

Background: Controversy exists regarding the best surgical approach for the management of gastroesophageal reflux disease (GORD) and associated preoperative esophageal dysmotility. Our aim was to conduct a systematic review and meta-analysis to compare the outcomes of Toupet fundoplication (TF) and Nissen fundoplication (NF) in patients with GORD and coexistent preoperative esophageal dysmotility.

Methods: We conducted a systematic search of electronic information sources, including MEDLINE, EMBASE, CINAHL, CENTRAL, ClinicalTrials.gov , and bibliographic reference lists. We applied a combination of free text search and controlled vocabulary search adapted to thesaurus headings, search operators, and limits in each of the above-mentioned databases. Postoperative dysphagia and improvement in dysphagia were primary outcome parameters.

Results: We identified 3 randomized controlled trials and 1 observational study reporting a total of 220 patients, of whom 126 underwent TF and the remaining 94 patients had NF. Despite the existence of significantly higher preoperative dysphagia in the TF group (29.3% vs 4.2%, P = .05), TF was associated with significantly lower postoperative dysphagia (odds ratio [OR] = 0.31, P = .002) with low between-study heterogeneity ( I = 11%, P = .34), and significantly higher improved dysphagia (OR = 10.32, P < .0001) with moderate between-study heterogeneity ( I = 31%, P = .23) compared with NF.

Conclusion: TF may be associated with significantly lower postoperative dysphagia than NF in patients with GORD and associated preoperative esophageal dysmotility. However, no definite conclusions can be drawn as the best available evidence comes mainly from a limited number of heterogeneous randomized controlled trials. Future studies are encouraged to include patients with similar preoperative dysphagia status and report the outcomes with respect to recurrence of acid reflux symptoms.
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http://dx.doi.org/10.1177/1553350618799549DOI Listing
September 2018

Two and five year survival for colorectal cancer after resection with curative intent: A retrospective cohort study.

Int J Surg 2018 Jul 30;55:152-155. Epub 2018 May 30.

Department of Colorectal Surgery, Maidstone and Tunbridge Wells NHS Trust, UK. Electronic address:

Introduction: Colorectal cancer is a major cause of illness, disability and death in the United Kingdom. The stage of disease at diagnosis has a major impact on survival rates. The aim of this study is to assess whether the survival rates of patients receiving curative treatment in our centre are comparable with national results published by Cancer Research UK, National Bowel Cancer Audit Annual Report 2016, and NCIN Colorectal Cancer Survival by Stage Data Briefing.

Methods: The study involved a retrospective survival analysis of consecutive patients who underwent colorectal cancer resections with curative intent performed by two surgeons between January 2009 and March 2012. Patients were identified from a prospectively collected database. Data was collected via hospital computer systems including patient notes, laboratory, pathology, and radiology systems. Exclusion criteria included all patients with advanced disease who underwent surgery with palliative intent.

Results: A total of 281 patients were included. The median age at operation was 71. Overall 2-year survival was 82.6% and overall 5-year survival was 69%. 2-year and 5-year survival, respectively, for Dukes A was 93.7% and 92%, Dukes B was 85.6% and 76.7%, Dukes C1 was 81.1% and 57.8%, Dukes C2 was 56.3% and 25%, and Dukes D was 61.9% and 47.6%.

Conclusion: Our data demonstrates that our survival rates compare favourably with current published national survival rates. Dukes C2 patients had the poorest five year survival, highlighting the significance of a positive apical node. Dukes D patients had a particularly good outcome which indicates good patient selection by the multi-disciplinary meeting (MDT) and high quality oncology and tertiary surgical support.
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http://dx.doi.org/10.1016/j.ijsu.2018.05.731DOI Listing
July 2018

Infiltrating angiolipoma of the chest wall: a rare clinical entity.

J Surg Case Rep 2016 Jan 1;2016(1). Epub 2016 Jan 1.

Department of Cardiothoracic Surgery, Cork University Hospital, Cork, Ireland.

Angiolipoma is a rare variant of lipoma. Infiltrating chest wall angiolipoma usually presents as painful subcutaneous lesions. There are only a handful of cases reported in the literature. Malignancy is suspected in the differential diagnosis, and hence a tissue diagnosis is needed to rule out an underlying malignancy. Symptomatic infiltrating angiolipoma warrants surgical excision. We report a case of an infiltrating angiolipoma of the chest wall, which was successfully treated with surgical excision.
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http://dx.doi.org/10.1093/jscr/rjv165DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4697921PMC
January 2016

Bilateral neck of femur fractures secondary to seizure.

Pract Neurol 2013 Dec 18;13(6):420-1. Epub 2013 Sep 18.

Department of Orthopaedic Surgery, Beaumont Hospital, , Dublin, Ireland.

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http://dx.doi.org/10.1136/practneurol-2013-000669DOI Listing
December 2013

Renal allograft loss in the first post-operative month: causes and consequences.

Clin Transplant 2012 Jul-Aug;26(4):544-9

Departments of Nephrology, Beaumont Hospital, Dublin, Ireland.

Early transplant failure is a devastating outcome after kidney transplantation. We report the causes and consequences of deceased donor renal transplant failure in the first 30 d at our center between January 1990 and December 2009. Controls were adult deceased donor transplant patients in the same period with an allograft that functioned >30 d. The incidence of early graft failure in our series of 2381 consecutive deceased donor transplants was 4.6% (n = 109). The causes of failure were allograft thrombosis (n = 48; 44%), acute rejection (n = 19; 17.4%), death with a functioning allograft (n = 17; 15.6%), primary non-function (n = 14;12.8%), and other causes (n = 11; 10.1%). Mean time to allograft failure was 7.3 d. There has been a decreased incidence of all-cause early failure from 7% in 1990 to <1% in 2009. Patients who developed early failure had longer cold ischemia times when compared with patients with allografts lasting >30 d (p < 0.001). Early allograft failure was strongly associated with reduced patient survival (p < 0.001). In conclusion, early renal allograft failure is associated with a survival disadvantage, but has thankfully become less common in recent years.
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http://dx.doi.org/10.1111/j.1399-0012.2011.01581.xDOI Listing
January 2013
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