A.osama Gaber

Background. Acceptance of dual kidney transplantation (DKT) has proven difficult, due to surgical complexity and concerns regarding long-term outcomes. We herein present a standard technique for ipsilateral DKT and compare outcomes to single-kidney transplant (SKT) recipients. Methods. A retrospective single-center comparison of DKT and SKT performed between February 2007 and July 2013. Results. Of 516 deceased donor kidney transplants, 29 were DKT and 487 were SKT. Mean follow-up was 43 ± 67 months. DKT recipients were older and more likely than SKT recipients to receive an extended criteria graft (p < 0.001). For DKT versus SKT, the rates of delayed graft function (10.3 versus 9.2%) and acute rejection (20.7 versus 22.4%) were equivalent (p = ns). A higher than expected urologic complication rate in the DKT cohort (14 versus 2%, p < 0.01) was reduced through modification of the ureteral anastomosis. Graft survival was equivalent between DKT and SKT groups (p = ns) with actua...

To achieve the fullest potential of transplantation, continuing concern for the recipients' quality of life must be a part of the process. Database records of patients who are currently alive and received transplants between 1982 and 1991 were retrospectively analyzed. Recipients were contacted and asked to answer a quality-of-life questionnaire. Of 105 liver transplant recipients, 51 died within 10 years after transplantation; 47 were contacted. Posttransplant complications included hypertension (64%), posttransplant diabetes mellitus (17%), osteopenia (40%), osteoporosis (26%), and heart disease (17%). Most recipients reported all aspects of their life to be average, if not better than their age-matched peers. Although most recipients complained about side effects of immunosuppressive agents, they were all happy to be alive and agreed that their quality of life showed an impressive favorable change to a level exceeding that of the general population. These results suggest that...

Tumor necrosis factor (TNF) is an inflammatory cytokine that may be an important mediator in the development of the systemic sequelae associated with severe acute pancreatitis. The purpose of this study was to determine whether the neutralization of TNF-α with a polyclonal ...

Refinements in surgical techniques and advances in clinical immunosuppression have led to steadily improving results in pancreas transplantation (PTX). Although there is renewed interest in enteric exocrine drainage, most PTXs are performed with systemic venous delivery of insulin. To improve the physiology of PTX, we developed a novel technique of portal venous delivery of insulin and enteric drainage of the exocrine secretions (portal-enteric [P-E]). The purpose of the study was to analyse outcomes in patients undergoing PTX with P-E drainage and contemporary immunosuppression. From January 1997 through September 2002, we performed 67 primary simultaneous kidney-PTXs (SKPT) with P-E drainage. Maintenance immunosuppression consisted of tacrolimus (TAC), mycophenolate mofetil (MMF) and steroids. No antibody induction therapy occurred in 33 patients (49%) with the remainder receiving daclizumab (n = 15), basiliximab (n = 2), or thymoglobulin (n = 14) induction therapy. The patient group included 38 males and 29 females with a mean age of 39.7 year (range 23-58) and a mean duration of pretransplant diabetes of 24.5 year (9-46). Fourteen patients (21%) were African-American. The mean waiting time for SKPT was 3.3 months (range 0.1-10). Mean kidney and pancreas cold ischaemia times were 15.1 and 15.4 h, respectively. Patient, kidney and pancreas graft survival rates were 97%, 92.5% and 82%, respectively, with a mean follow-up of 20 months (range 1-56). Two deaths (one sepsis, one cardiac event) occurred at 1 month after SKPT; both patients died with functioning grafts (DWFG). Three patients (4.5%) had delayed renal allograft function and received temporary dialysis after SKPT. Five kidney graft losses occurred (two DWFG, one thrombosis, two chronic rejection). All but four patients (6%) had immediate PTX function. A total of 12 pancreas graft losses occurred (two DWFG, five thrombosis, five chronic rejection). The incidence of acute rejection was 28%, but no grafts were lost due to isolated acute rejection. The incidence of major infection was 51%, but only five patients (7.5%) developed cytomegalovirus infection. A total of 19 patients (28%) underwent early relaparotomy within 3 months of SKPT. The composite endpoint of no rejection, graft loss, or mortality was attained by 63% of patients. At present, 58 patients (87%) are both dialysis and insulin-independent (including four retransplants). These findings suggest that SKPT with P-E drainage and contemporary immunosuppression may result in excellent intermediate-term outcomes.

To review the safety and efficacy of thymoglobulin in pancreas transplant patients receiving tacrolimus and mycophenolate mofetil. Retrospective, single centre analysis of 45 patients transplanted between 1995 and 2000 who received 54 courses of thymoglobulin, including 36 courses in 29 solitary pancreas transplant recipients (16 pancreas alone, 13 pancreas after kidney transplants) and 18 courses in 16 simultaneous kidney-pancreas transplant patients. Thirty-two patients (71%) were primary pancreas transplants, 10 (22%) were second transplants and three (7%) were third transplants. Of the 54 treatment courses, 19 (35%) were for induction, 27 (50%) were for primary rejection and eight (15%) were rescue therapy for rejection. All rejection episodes were biopsy-proven in at least one organ. The median thymoglobulin dose was 1.5 mg/kg/d with a mean of six doses (range 3-10). Dose reduction or interruption was required in 28 courses (52%), most often due to leukopenia (n = 24), fever (n = 2) and thrombocytopenia (n = 2). Thymoglobulin was resumed in all but three patients, two with persistent fever and one with infection. Infectious complications (n = 25) occurred in 17 patients (38%) within 30 days and included bacterial (n = 16), cytomegalovirus (n = 4), polyoma (n = 1), fungal (Candida albicans, n = 1), toxoplasmosis (n = 1) and ehrlichiosis (n = 2). Post-transplant lymphoproliferative disease occurred in two patients (4%) at a mean of 70 d post-thymoglobulin treatment. In the 19 patients that received thymoglobulin induction, one simultaneous kidney-pancreas transplant, two pancreas alone and four pancreas after kidney transplant recipients developed rejection (37% incidence), while all remaining patients followed by surveillance protocol biopsies were rejection-free. In the 35 patients that received thymoglobulin for rejection, reversal occurred in 26 of the patients (74%). Rejection recurred within 30 d in five patients and post-treatment biopsies revealed persistent rejection in three of 20 pancreas and two of eight renal biopsies. After a mean follow-up of 6 months, the actual patient and pancreas graft survival rates were 93% and 71%, respectively. Thymoglobulin was effective as induction therapy in high-risk pancreas transplant recipients, and resulted in initial reversal of rejection in 74% of patients. Dose adjustments were required in over half the cases and were usually due to leukopenia. Infections occurring subsequent to thymoglobulin were not uncommon and reflected the immunosuppressive burden of the patient population.

Budd-Chiari syndrome (BCS) is uncommon in the children. The cause of BCS comprises several diseases leading to thrombophilia. Activated protein C resistance as a result of a single gene mutation in factor V, the so called factor V Leiden (FVL), is the most common cause of thrombophilia. We report a simultaneous occurrence of BCS in identical twin sisters of 13 years of age with heterozygous FVL mutation. One sister presented with acute BCS leading to fulminant hepatic failure. She underwent liver transplantation with subsequent normalization of activated protein C resistance. The other twin sister, who was diagnosed with extensive thromboses of the inferior vena cava, portal vein, and hepatic veins, was successfully managed by aggressive chemical and mechanical thrombolysis followed by therapeutic anticoagulation. Genomic DNA studies confirmed heterozygosity of FVL mutation in the sisters' father and older brother. The exact cause of the BCS in children should be thoroughly and rapidly investigated, and, if necessary, immediate family members should also be tested for genetic defects in factor V or concomitant thrombophilia.

... Duct-to-duct biliary reconstruction in right lobe adult living donor liver transplantation 1. M.Hosein Shokouh-Amiri, MD (FACS): Affiliations. Division of Transplant Surgery, University of Tennessee, Memphis, TN, USA. ,; Hani P Grewal, MD (FRCS): Affiliations. ...

We retrospectively reviewed long-term outcomes in simultaneous kidney-pancreas transplant (SKPT) recipients with portal-enteric (P-E) versus systemic-bladder (S-B) drainage. Forty-five patients were alive with functioning grafts 1 year after SKPT and were followed up for a minimum of 3 years (mean, 5.9 years), including 26 patients with P-E drainage and 19 patients with S-B drainage. Recipient demographic and transplant characteristics were similar between the two groups. In both groups, hospital admissions decreased significantly with increasing time after SKPT, although significantly fewer readmissions occurred in the first year in the P-E than the S-B group. The most common reason for readmission in both groups was infection, followed by miscellaneous, surgical, and immunologic morbidity. The incidence of readmission for dehydration was significantly less in the P-E group (P < 0.01). Mean systolic and diastolic blood pressures were similar between groups, although the number of antihypertensive medications was significantly less in the S-B group. Although fasting C-peptide levels were significantly greater in the S-B group, the two groups were similar with regard to carbohydrate (fasting serum glucose, hemoglobin A(1c)) and lipid (total cholesterol) metabolism. Renal and pancreas allograft functions were similar between the two groups. At 1 year post-SKPT, stabilization in most diabetic complications was reported. Four quality-of-life surveys that provided 29 scores were completed 6 to 24 months (mean, 18.5 months) after SKPT. Improved quality of life was reported in all but one of the scales, with many dimensions showing significant improvements. At 3 years after SKPT, no activity limitation was reported in 76% of patients with P-E drainage versus 53% with S-B drainage (P = 0.11). Five-year actual patient, kidney, and pancreas graft survival rates after P-E versus S-B drainage are 92% and 84%, 81% and 79%, and 88% and 74%, respectively (P = not significant). SKPT with P-E drainage is a safe and effective method to treat advanced diabetic nephropathy and is associated with decreasing morbidity, improving rehabilitation and quality of life, and stablizing metabolic function over time. The long-term prognosis after the first year is excellent and at least similar to the results achieved with S-B drainage.

s S249 showed superior survival for SLT vs BLT in restrictive lung diseases (p = 0.04), and similar survival for SLT vs BLT in obstructive lung diseases (p = 0.12). The non-inferiority of SLT vs BLT was maintained in different age subgroups within 50-64 year age group (number of recipients deceased within 3 years in 50-59 year age subgroup: 14 % vs 24 %, p = 0.21; and in 60-64 year age subgroup: 15 % vs 38 %, p = 0.01). Conclusion: Within 50-64 year age group, survival in SLT was superior to BLT in restrictive lung disease recipients, and similar to BLT in obstructive lung disease recipients. Preferentially performing SLT in 50-64 age group may result in improved donor lung utilization and superior survival in restrictive lung disease recipients, and improved donor lung utilization without compromising survival in obstructive lung disease recipients. Purpose: Heart failure with preserved ejection fraction (HFpEF) is commonly considered a contraindication to lung transplantation. The outcomes of patients with HFpEF after lung transplantation remain unknown. Methods: To assess the impact of HFpEF on mortality after lung transplan-tation, a multivariable cox regression analysis was performed using UNOS data. HFpEF was defined as having a pulmonary capillary wedge pressure (PCWP) of greater than or equal to 20 mm Hg and a left ventricular ejection fraction (LVEF) of greater than or equal to 50%. As HFpEF is a disease which occurs in middle age to older adults, the analysis was limited to patients over the age of 40 years. Results: There were 9,005 patients who underwent lung transplantation between the years 1987 and 2012 with baseline echocardiogram and hemo-dynamic data available. The median follow up time was 2.6 years (IQR 0.8-5.7 yrs). Patients with HFpEF were slightly younger (56.6 vs. 57.8 yrs, p < 0.0001) and had slightly higher BMIs (26.9 vs. 25.8 kg/m2, p < 0.0001) than recipients with lower left ventricular filling pressures. Patients with HFpEF were also more likely to have diabetes (11.7 vs. 10.8 %, p < 0.0001) and hypertension (11.5 vs. 8.4, p < 0.0001). HFpEF was not associated with an increased hazards of death in the unadjusted or adjusted models (unad-justed, HR 0.99, 95 % CI 0.88-1.12, p = 0.91; adjusted HR 1.0, 95 % CI 0.91-1.17, p = 0.60, Figure 1). Patients with HFpEF had a similar rates of graft failure (adjusted: HR 1.0, 95 % CI 0.88-1.13, p = 0.99). There was a small but statistically significant increase in length of hospital stay after transplantation in patients with HFpEF (1.1 day increase, 95 % CI 1.0-1.2 days, p < 0.0001). Conclusion: HFpEF was not associated with an increase in mortality after lung transplantation in this UNOS analysis. It may be that severe cases of HFpEF were excluded from transplantation; however these data suggest that elevated left sided filling pressures alone should not preclude patients from lung transplantation. Purpose: Surgical strategy for short patients with restrictive pulmonary pathology remains challenging. These recipients traditionally receive pedi-atric size lungs, placing an additional strain on already restricted pediatric donor population. Performing lobar lung transplantation (LLT) can circumvent issues with donor-recipient size mismatch; however, LLT has additional risks that are not experienced in standard LT. Here, we review our experience using LLT and standard lung transplant using pediatric donor lungs (PDLT) for small adult chests. Methods: We retrospectively reviewed patients with end-stage lung diseases and a height < 65 inches who underwent LLT (n= 15) or PDLT (n= 15) between 2006 and 2012 at our institution, a high-volume lung transplant center. Results: All recipients underwent double lung transplants. LLT recipients were older than PDLT recipients (54±10 vs 48±8 years). Furthermore, LLT recipients had higher pulmonary pressures (57±11 vs 52±27mmHg) and higher lung allocation scores (70±9 vs 51±8) compared to PDLT recipients , reflecting a sicker population which could not wait a long time to be transplanted: waiting time was 62 days for PDLT and 9 days for LLT. The incidence of severe PGD requiring ECMO support and acute renal insuffi-ciency was higher, and intensive care unit stay was longer in the LLT group (p< 0.05), whereas the incidence of bronchial anastomotic complications was higher in the PDLT group due to significant size discrepancy in their main bronchus (p< 0.05). Interestingly, long-term functional outcomes were similar between the groups. Conclusion: Both LLT and PDLT are viable surgical options for the patients with small adult chests. Considering for all their potential positive and negative impacts on posttransplant outcomes as well as technical complexity, the decisions must be made by experienced surgeons. Purpose: There has been an increasing preference for performing bilateral lung transplantation for obstructive and restrictive lung disease diagnosis groups in recent years. This trend may result in suboptimal utilization of donor lungs. We present the survival data of single versus bilateral lung transplant recipients in 50-64 year age group in a large volume center. Methods: 501 recipients underwent lung transplantation at Houston Methodist Hospital from January 1, 2009 till September 30, 2013. Among 501 recipients, those in 50-64 year age group were included (n = 219). Spreadsheets maintained for monitoring of lung transplant outcomes within our program were used for reviewing data retrospectively. Survival outcomes (using Kaplan-Meier analysis) were compared between single lung transplant (SLT) recipients and bilateral lung transplant (BLT) recipients in 50-64 year age group. Results: Among 219 recipients in 50-64 year age group, 89 underwent SLT and 130 underwent BLT. 30 day and 1 year survival for SLT vs BLT were 98 % vs 94 %, p = 0.19; and 89 % vs 79 %, p = 0.07 respectively. Among 219 recipients, 143 had transplantation done for restrictive lung diseases (SLT = 55, BLT = 88). 30 day and 1 year for SLT vs BLT for restrictive lung diseases were 98 % vs 92 %, p = 0.16; and 87 % vs 75 %, p = 0.08 respectively. Among 219 recipients, 67 had transplantation done for obstructive lung diseases (SLT = 33, BLT = 34). 30 day and 1 year survival for SLT vs BLT for obstructive lung diseases were 97 % vs 100 %; and 91 % vs 88 %, p = 0.72 respectively. Kaplan-Meier analysis (censored at 36 months post-transplant)