Covid-19 and Kidney Transplantation Akalin, Enver; Azzi, Yorg; Bartash, Rachel ...
The New England journal of medicine,
06/2020, Letnik:
382, Številka:
25
Journal Article
Recenzirano
Odprti dostop
A cohort of 36 consecutive kidney-transplant recipients had less fever, lower CD3, CD4, and CD8 cell counts, more rapid clinical deterioration, and a higher mortality than the general population of ...patients with Covid-19.
Diaphragmatic liver herniation is often associated with thoracoabdominal trauma. Spontaneous diaphragmatic rupture is a thoracoabdominal emergency and requires a high index of suspicion combined with ...high-resolution imaging studies for establishing an accurate and timely diagnosis. We present a case report of a patient who was admitted to the emergency department with severe substernal chest pain and shortness of breath who was diagnosed with spontaneous diaphragmatic rupture and caudate liver herniation. The caudate lobe was incarcerated, contributing to the patient’s symptoms. A celiotomy was performed and the defect was repaired primarily.
Outcomes for adult‐to‐adult living liver donors (LDs) are largely based on short‐term data drawn from single‐center studies. The aim of this study was to determine how living liver donation (LLD) ...impacts self‐reported quality‐of‐life (QOL) up to 6 years after donation in a sample of residents from New York State. New York transplant programs are state‐mandated to track LDs as part of a quality assurance and patient safety effort. Donor‐reported QOL within 1 year of donation and longitudinal data over a 10‐year period were analyzed. Self‐reported surveys include the following domains: employment, finances, health/life insurance, activities of daily living, physical/emotional health, donor experience, relationships, and LD opinions. There were 220 LDs in New York (2004‐2013) who completed a survey over the 10‐year period with many donors completing surveys at several points in time. Overall, longterm LDs remain as comfortable about LLD as they were during the first year after donation (95%). The majority of LDs reported feeling as well as before LLD (72%). At 1 year after donation, 60% of subjects self‐reported medical problems, and 30% reported emotional issues. However, the majority reported that they would willingly donate again. In conclusion, LDs remain satisfied with their decision to donate over time. A minority of LDs report longterm medical and emotional issues. The conclusions provide information for educational interventions to improve informed choice to those considering donation.
Introduction
The advent of direct‐acting antivirals (DAAs) has created an avenue for transplantation of hepatitis C virus (HCV)‐infected donors into uninfected recipients (D+/R−). The donor ...transmission of HCV is then countered by DAA administration during the post‐operative period. However, initiation of DAA treatment is ultimately dictated by insurance companies.
Methods
A retrospective chart review of 52 D+/R− kidney recipients who underwent DAA treatment post‐transplant was performed. Patients were grouped according to their prescription coverage plans, managed by either commercial or government pharmacy benefit managers (PBMs).
Results
Thirty‐nine patients had government PBMs and 13 had commercial PBMs. Demographics were similar between the two groups. All patients developed HCV viremia, but cleared the virus after treatment with DAA. Patients with government PBMs were treated earlier compared to those with commercial PBMs (11 days vs 26 days, P = .01). Longer time to DAA initiation resulted in higher peak viral loads (β = 0.39, R2 = .15, P = .01) and longer time to HCV viral load clearance (β = 0.41, R2 = .17, P = .01).
Conclusions
D+/R− transplantation offers patients an alternative strategy to increase access. However, treatment can be profoundly delayed by a third‐party payer authorization process that may be subjecting patients to unnecessary risks and worsened outcomes.
The advent of direct‐acting antivirals (DAAs) has provided the impetus to transplant kidneys from hepatitis C virus‐positive donors into uninfected recipients (D+/R−). Thirty D+/R− patients received ...DAA treatment. Sustained virologic response (SVR12) was defined as an undetectable viral load in 12 weeks after treatment. An age‐matched cohort of uninfected donor and recipient pairs (D−/R−) transplanted during same time period was used for comparison. The median day of viral detection was postoperative day (POD) 2. The detection of viremia in D+/R− patients was 100%. The initial median viral load was 531 copies/μL (range: 10‐1 × 108 copies/μL) with a median peak viral load of 3.4 × 105 copies/μL (range: 804‐1.0 × 108 copies/μL). DAAs were initiated on median POD 9 (range: 5‐41 days). All 30 patients had confirmed SVR12. During a median follow‐up of 10 months, patient and graft survival was 100%, and acute rejection was 6.6% with no major adverse events related to DAA treatment. Delayed graft function was significantly decreased in D+/R− patients as compared to the age‐matched cohort (27% vs 60%; P = .01). D+/R− transplantation offers patients an alternative strategy to increase access.
The objective of this study was to evaluate the effect of systematic utilization of extended donor criteria liver allografts (EDC), including living donor allografts (LDLT), on patient access to ...liver transplantation (LTX).
Utilization of liver allografts that do not meet traditional donor criteria (EDC) offer immediate expansion of the donor pool. EDC are typically allocated by transplant center rather than regional wait-list priority (RA). This single-institution series compares outcomes of EDC and RA allocation to determine the impact of EDC utilization on donor use and patient access to LTX.
The authors conducted a retrospective analysis of 99 EDC recipients (49 deceased donor, 50 LDLT) and 116 RA recipients from April 2001 through April 2004. Deceased-donor EDC included: age >65 years, donation after cardiac death, positive viral serology (hepatitis C, hepatitis B core antibody, human T-cell lymphotrophic), split-liver, hypernatremia, prior carcinoma, steatosis, and behavioral high-risk donors. Outcome variables included patient and graft survival, hospitalization, initial graft function, and complication categorized as: biliary, vascular, wound, and other.
EDC recipients were more frequently diagnosed with hepatitis C virus or hepatocellular carcinoma and had a lower model for end-stage liver disease (MELD) score at LTX (P < 0.01). Wait-time, technical complications, and hospitalization were comparable. Log-rank analysis of Kaplan-Meier survival estimates demonstrated no difference in patient or graft survival; however, deaths among deceased-donor EDC recipients were frequently the result of patient comorbidities, whereas LDLT and RA deaths resulted from graft failure (P < 0.01). EDC increased patient access to LTX by 77% and reduced pre-LTX mortality by over 50% compared with regional data (P < 0.01).
Systematic EDC utilization maximizes donor use, increases access to LTX, and significantly reduces wait-list mortality by providing satisfactory outcomes to select recipients.
The novel coronavirus severe acute respiratory syndrome coronavirus 2 (SARS‐CoV2) is the causative agent of coronavirus disease 2019 (COVID‐19). The presenting symptoms of this virus are variable, ...and there is an increasing body of literature on risk factors for mortality. The aim of this study was to evaluate the effect of initial aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels and preexisting liver disease, including cirrhosis, in a cohort of patients admitted with COVID‐19 infection at a tertiary care hospital network in the Bronx, New York. We reviewed 3,352 patients who had a positive SARS‐CoV2 nasal swab, were over 18 years of age, and had an associated inpatient admission and discharge (or death) to the Montefiore Medical Center from February 28, 2020, to May 22, 2020. Of these, 39/86 (45%) patients died when the initial ALT was >5 times the upper limit of normal (ULN); 115/230 (50%) patients died when the initial AST was >3 times the ULN. The mortality of patients without preexisting liver disease was 26.6% compared to a mortality rate of 29.5% in patients with liver disease. Subgroup analysis showed a mortality of 36.1% in the patients with cirrhosis. Cirrhosis conferred a hazard ratio for mortality of 1.67 (95% confidence interval, 1.09, 2.55; P = 0.019). The baseline Model for End‐Stage Liver Disease score was not prognostic in the cirrhosis cohort. There was no statistical difference between mortality in patients with a history of compensated or decompensated cirrhosis. The most common cause of death in the cirrhosis cohort was respiratory failure. Conclusion: COVID‐19 hepatitis may lead to poor outcomes in patients who are hospitalized for the disease. Patients with cirrhosis are at a higher risk of COVID‐19‐related mortality.
Orthotopic liver transplantation (OLT) is the most effective treatment for hepatocellular carcinoma (HCC) in patients with underlying cirrhosis and portal hypertension. Availability of OLT is limited ...by donor-organ shortages, which increase patient waiting time until OLT. A variety of bridging therapies (BT) have been used to halt tumor progression in patients on the OLT waiting list. Despite complete radiologic responses following BT, viable tumor is often present in explants.
Treatment outcomes were evaluated in 50 patients who had a total of 125 BT for treatment of 93 nodules. Success of BT was assessed by radiologic response compared to histopathological examination of explanted livers.
Pre-transplant treatments included: transcatheter arterial chemoembolization (TACE), alcohol ablation (ETOH), radiofrequency ablation (RFA), microwave ablation (MWA), selective internal radiation therapy (SIRT) and stereotactic body radiation therapy (SBRT). Fifty-nine (64%) nodules had a complete radiographic response to therapy; however, only 28 nodules (30%) had complete tumor necrosis (CTN) on explant examination. Ten nodules with CTN were treated with TACE alone. Seven of the 28 nodules with CTN were treated with TACE and RFA. Three of seven nodules treated with TACE and SIRT had CTN. Patients underwent a mean of 2.5 BTs. Six of 50 patients (12%) had no residual HCC in their explants. Five of those six patients (83%) had complete response (CR) on pre-transplant imaging.
Although favorable radiologic responses are seen following BT, viable HCC is seen in the majority of liver explants and radiographic imaging cannot always accurately predict pathological response. This underscores the need for aggressive treatment of patients who otherwise may not be eligible for OLT.
The 2014 Pancreas Allocation System established national qualifying criteria for simultaneous kidney pancreas (SPK) transplantation. The 2019 UNOS Pancreas Transplantation Committee Policy 11.3.B ...modified these guidelines to expand transplantation. Subsequent effects on recipient demographics have not been studied. We analyzed 81 SPK transplantations performed at our center from June 2014 to December 2020 to compare recipient demographics and outcomes before and after the 11.3.B policy change. National data were also investigated. Significant increases in age (38.9 v 46.4 years; p = 0.01) and c-peptide levels (1.7 v 4.9 ng/ml; p = 0.01) occurred following the removal of BMI and c-peptide requirements. No differences in BMI, outcomes, or complication rates were found. National and center trends showed increasing numbers of recipients with high c-peptide levels and decreasing numbers of recipients with undetectable c-peptide levels. Policy 11.3.B expanded transplantation access while maintaining suitable outcomes, reflecting its intended goals.
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