Nat Clin Pract Gastroenterol Hepatol
August 2007
Background: Cytomegalovirus (CMV) is a major cause of morbidity after transplantation. Valganciclovir (VGCV) is commonly utilized for CMV prophylaxis but can cause leukopenia, with risk compounded by the use of myelosuppressive immunosuppression. By utilizing a preemptive therapeutic strategy with VGCV targeted only toward patients at risk for developing CMV disease, the rate and extent of leukopenia may be reduced.
View Article and Find Full Text PDFThe disparity between the organ supply and the demand for liver transplantation (LT) has resulted in the growing utilization of 'marginal donor' organs. While economic outcomes for subsets of 'marginal' organs have been described for renal transplantation, similar analyses have not been performed for LT. Using UNOS data for 17 710 LTs performed between 2002 and 2005, we assessed the relationship between recipient model for end-stage liver disease (MELD) score, organ quality as defined by donor risk index (DRI, Feng et al.
View Article and Find Full Text PDFWe have used a spleen explant model to investigate mechanisms of murine cytomegalovirus latency and reactivation. Induction of immediate-early (ie) gene expression occurs in explants after approximately 9 days in culture and virus reactivation follows induction of ie gene expression with kinetics similar to that of productive infection in vitro. This occurs independently of TNF receptor signalling.
View Article and Find Full Text PDFObjective: To evaluate the outcome and prognostic factors of patients who underwent local graft irradiation for acute renal allograft rejection refractory to modern immunosuppressive medications.
Methods: From 1996 to 2005, 33 patients received local graft irradiation (LGI), with 3 patients receiving 2 courses of radiation. Graft rejection was diagnosed when a rise in creatinine prompted a renal biopsy that demonstrated acute allograft rejection.
Laparoscopic liver surgery has evolved rapidly over the past 5 years in a select number of centers. The growing experience with these procedures has resulted in a shift in the diagnostic and therapeutic approach to common liver tumors. The fact that resection of benign and malignant hepatic masses can now be accomplished laparoscopically with relatively low morbidity has influenced the decision-making process for physicians involved in the diagnosis and management of these lesions.
View Article and Find Full Text PDFAm J Transplant
December 2006
Organ Acquisition Cost Centers (OACC) were designed to encourage and incentivize hospitals to provide transplantation services. The purpose of this article (Part I) is to familiarize transplant professionals and transplant center administrators with the regulations that govern OACC. An historical perspective of the evolution of these regulations is necessary to better understand the basic principles underlying this complex area of transplant finance.
View Article and Find Full Text PDFAm J Transplant
December 2006
Decreasing organ acquisition costs (OAC) reduces the cost of transplantation. The purpose of this article (Part II) is to build on the platform of definitions and concepts developed in Part I to achieve cost-savings in OAC. We propose several concrete strategies to decrease OAC.
View Article and Find Full Text PDFPurpose: To present the clinical data of 35 patients with T3 unresectable hepatocellular carcinoma (HCC) that were treated with (90)Y with the specific intent of downstaging to resection, radiofrequency ablation (RFA) candidate, United Network for Organ Sharing (UNOS) stage T2 or liver transplantation.
Materials And Methods: One hundred fifty patients with unresectable HCC were treated with (90)Y microspheres. Of these, 35 patients were UNOS stage T3 at the time of treatment.
The major impediment to a wider application of living donor hepatectomy, particularly of the right lobe, is its associated morbidity. The recent interest in a minimally invasive approach to liver surgery has raised the possibility of applying these techniques to living donor right lobectomy. Herein, we report the first case of a laparoscopic, hand-assisted living donor right hepatic lobectomy.
View Article and Find Full Text PDFObjectives: A standardized classification for the potential complications of living donor nephrectomy is an essential step in establishing a construct for monitoring and reporting the outcomes of this procedure. It is also helpful in informing potential donors about the inherent risks of the donor operation as part of the informed choice process.
Methods: We reviewed 600 laparoscopic live donor nephrectomies performed at our center.
Despite a relatively large body of literature on health-care economics, including the economics of transplantation, there is a paucity of literature on financial outcomes of transplant procedures. Yet, there is a great need for transplant professionals to understand the financial elements of their transplant programs. These include, among others, reimbursement, cost and net income.
View Article and Find Full Text PDFThree years of survival data are now available and the impact of the model for end-stage liver disease (MELD) allocation system is becoming clear. After a decline in new registrants to the waiting list in 2002, the number increased to 10 856 new patients in 2004. Since the implementation of MELD, the percentage of patients who have been on the list for 1-2 years has declined from 24% to 19%.
View Article and Find Full Text PDFEverolimus is a macrolide immunosuppressive agent with known consistent absorption. In this double-blind study, we examined the safety and tolerability of everolimus vs. placebo in de novo liver transplant recipients.
View Article and Find Full Text PDFBackground: Chronic renal failure (CRF) is a major cause of morbidity and mortality after orthotopic liver transplantation (OLTX) and is predominantly caused by calcineurin inhibitors (CI)-induced nephrotoxicity. The activation of the renin angiotensin system (RAS) has been implicated in the pathogenesis of chronic nephrotoxicity from CI.
Methods: We retrospectively investigated the genes coding for components of the RAS (ACE gene, Angiotensin II receptor 1 gene, Angiotensinogen gene) in 233 liver transplant recipients receiving Cyclosporine (CsA) or Tacrolimus (Tac) as maintenance immunosuppressant.
Estimation of graft volume (GV) is critical in living donor liver transplantation. This study examines the accuracy of formula-derived GV estimates and compares them to both radiogically-derived estimates and actual measurements. We first compared formula-derived estimates of GV and compared them to actual volumes to provide estimates for both right lobe (RL) and left lateral segment (LLS) GV.
View Article and Find Full Text PDFObjective: The objective of this study was to characterize the patient population with respect to patient selection, assess surgical morbidity and graft failures, and analyze the contribution of perioperative clinical factors to recipient outcome in adult living donor liver transplantation (ALDLT).
Summary Background Data: Previous reports have been center-specific or from large databases lacking detailed variables. The Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL) represents the first detailed North American multicenter report of recipient risk and outcome aiming to characterize variables predictive of graft failure.
Prior to therapy, model for end stage liver disease (MELD) scoring, diagnostic imaging and tumor staging were performed in a patient with T3 HCC. The patient received an orthotopic liver transplant (OLT) 42 days after treatment. The explant specimen showed complete necrosis of the target tumor.
View Article and Find Full Text PDFAdoption of the model for end stage liver disease (MELD) system prioritized patients awaiting liver transplant (LT) by severity of illness including progressive renal dysfunction. Unfortunately, current reimbursement for LT is not adjusted by severity of illness or need for simultaneous liver-kidney transplantation (LKT). This study examines hospital cost and reimbursement for LT and LKT to determine the effect of MELD on transplant center (TC) financial outcomes given current reimbursement practices as well as DRG outlier threshold limits.
View Article and Find Full Text PDFReactivation of latent human cytomegalovirus is of significant concern in immunocompromised transplant patients and is likely to occur through transcriptional activation of immediate early (ie) gene expression through mechanisms that are not well understood. TNF-mediated activation of NF-kappaB has been proposed to be one pathway leading to transcriptional activation of CMV ie gene expression. Using transgenic mice carrying a lacZ reporter gene under the control of the HCMV major ie promoter/enhancer (MIEP-lacZ mice) and MIEP-lacZ mice deficient in TNF receptor 1 and TNF receptor 2 (MIEP-lac Z TNFR DKO mice), we demonstrate that renal ischemia/reperfusion (I/R) injury activates the HCMV enhancer independently of TNF.
View Article and Find Full Text PDFAdult-to-adult living donor liver transplantation (ALDLT) is being increasingly utilized to treat patients with locally advanced hepatocellular carcinoma and cholangiocarcinoma who are not prioritized under the MELD allocation system. A single institution retrospective chart review examined ALDLTs performed for malignancy to identify indications, complications, and transplant outcome. Since 1997, 18 ALDLTs have been performed for malignancy as the primary indication.
View Article and Find Full Text PDFTransjugular intrahepatic shunts (TIPSs) are widely used in the management of portal hypertension complications including variceal bleeding, refractory ascites, and hepatic hydrothorax. Vena cava filters (VCFs) are an important therapeutic modality in the prevention of pulmonary emboli in patients suffering deep venous thrombosis and clinical contraindications for anticoagulation. Stent and filter misplacement or migration may occur, complicating liver transplantation (LT) surgery.
View Article and Find Full Text PDFThe incidence of hepatocellular carcinoma (HCC) is increasing at an alarming rate in the United States, such that HCC has become an important indication for liver transplantation. The role of liver transplantation in patients with HCC has evolved over the past 2 decades, and transplantation has become one of the few curative treatment modalities for patients with HCC, especially in selected patients with favorable tumors. The advent of living donor liver transplantation for adult recipients provides another therapeutic venue, in particular for patients with HCC who are disadvantaged by current allocation algorithms for grafts from deceased donors.
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