Gregory J. McKenna M.D.

Idriss, R., J. Hasse, T. Wu, F. Khan, G. Saracino, G. McKenna, G. Testa, J. Trotter, G. Klintmalm and S. K. Asrani (2019). “Impact of Prior Bariatric Surgery on Perioperative Liver Transplant Outcomes.” Liver Transpl 25(2): 217-227.

Full text of this article.

Bariatric surgery (BS) is effective in treating morbid obesity, but the impact of prior BS on candidacy for liver transplantation (LT) is unclear. We examined 78 patients with cirrhosis with prior BS compared with a concurrent cohort of 156 patients matched by age, Model for End-Stage Liver Disease score, and underlying liver disease. We compared rates of transplant denial after evaluation, delisting on the waiting list, and survival after LT. The median time from BS to LT evaluation was 7 years. Roux-en-Y gastric bypass was the most common BS procedure performed (63% of cohort). Nonalcoholic fatty liver disease was the leading etiology for liver cirrhosis (47%). Delisting/death on the waiting list was higher among patients with BS (33.3% versus 10.1%; P = 0.002), and the transplantation rate was lower (48.9% versus 65.2%; P = 0.03). Intention-to-treat (ITT) survival from listing to 1 year after LT was lower in the BS cohort versus concurrent cohort (1-year survival, 84% versus 90%; P = 0.05). On adjusted analysis, a history of BS was associated with an increased risk of death on the waiting list (hazard ratio [HR], 5.7; 95% confidence interval [CI], 2.2-15.1), but this impact was attenuated (HR, 4.9; 95% CI, 1.8-13.4) by the presence of malnutrition. When limited to matched controls by sex, mortality attributed to BS was no longer significant for females (P = 0.37) but was significant for males (P = 0.046). Sarcopenia, as captured by skeletal muscle index, was calculated in a subset of patients (n = 49). The total skeletal surface area was lower in the BS group (127 [105-141] cm(2) versus 153 [131-191] cm(2) ; P = 0.005). Rates of sarcopenia were higher among patients delisted after listing (71.4% versus 16.7%; P = 0.04). In conclusion, a history of BS was associated with higher rates of delisting on the waiting list as well as lower survival from the time of listing on ITT analysis. Presence of malnutrition and sarcopenia among patients with BS may contribute to worse outcomes.

Idriss, R., J. Hasse, T. Wu, F. Khan, G. Saracino, G. McKenna, T. Giuliano, J. Trotter, G. Klintmalm and S. K. Asrani (2018). “Impact of prior bariatric surgery on perioperative liver transplant outcomes.” Liver Transpl Oct 28. [Epub ahead of print].

Full text of this article.

Bariatric surgery (BS) is effective in treating morbid obesity but the impact of prior BS on candidacy for liver transplantation (LT) is unclear. We examined 78 cirrhotic patients with prior BS compared with a concurrent cohort of 156 patients matched by age, MELD score, and underlying liver disease. We compared rates of transplant denial after evaluation, delisting on the waitlist (WL) and survival after LT. The median time from BS to LT evaluation was 7 years. Roux-en-Y gastric bypass was the most common BS procedure performed (63% of cohort). Nonalcoholic fatty liver disease was the leading etiology for liver cirrhosis (47%). Delisting/death on WL was higher among patients with BS (33.3% vs 10.1% P = 0.002) and transplantation rate was lower (48.9% vs 65.2% P =0.03). Intent-to-treat survival from listing to 1 year after LT was lower in the BS vs. concurrent cohort (1-year survival 84% vs 90%, p=0.05). On adjusted analysis, history of BS was associated with an increased risk of death on the WL (HR 5.7, 95% CI 2.2-15.1) but this impact was attenuated (HR, 4.9, 95% CI 1.8-13.4) by presence of malnutrition. When limited to matched controls by gender, mortality attributed to BS was no longer significant for women (p=0.37) but was significant for males (p=0.046). Sarcopenia, as captured by skeletal muscle index, was calculated in a subset of patients (n=49). The total skeletal surface area was lower in the BS group (127cm(2) (105-141) vs 153cm(2) (131-191) p = 0.005). Rates of sarcopenia were higher among patients delisted after listing (71.4% vs. 16.7%, p=0.04). Conclusion History of BS was associated with higher rates of delisting on the WL as well as lower survival from time of listing on intent-to-treat analysis. Presence of malnutrition and sarcopenia among patients with BS may contribute to worse outcomes.

McKenna, G. J. (2018). “Medication trade-offs-Not all noncompliance is what it seems.” Transpl Int 31(8): 861-863.

Full text of this article.

“The Prevalence, Risk Factors, and Outcomesof Medications Tradeoffs in Kidney and Liver Tran s-plant Recipients” (Serper et al., 2018) examines a subject that seems familiarat first glance, but is actually one that has not beenstudied or reported in great detail. The authors work isso timely, because these issues are presently in flux andevolving—even as this editorial is being written. U.S.lawmakers are currently debating the survival of theAffordable Care Act, the fate of patient insurance subsi-dies, and the overall accessibility of health insuranceand care in the U.S., and by the time this article is evenpublished, events may further amplify the significanceof the data these authors present regarding the impactof medication trade-offs. (Excerpt from text, p. 861; no abstract available.)

Bayer, J., C. A. Moulton, K. Monden, R. M. Goldstein, G. J. McKenna, G. Testa, R. M. Ruiz, T. L. Anthony, N. Onaca, G. B. Klintmalm and P. T. W. Kim (2018). “The role of multiorgan procurement for abdominal transplant in general surgery resident education.” Am J Surg 216(2): 331-336.

Full text of this article.

BACKGROUND: To assess the impact of participation of multiorgan procurement (MP) by general surgery (GS) residents on surgical knowledge and skills, a prospective cohort study of GS residents during transplant surgery rotation was performed. METHODS: Before and after participation in MPs, assessment of knowledge was performed by written pre and post tests and surgical skills by modified Objective Structured Assessment of Technical Skill (OSATS) score. Thirty-nine residents performed 84 MPs. RESULTS: Significant improvement was noted in the written test scores (63.3% vs 76.7%; P < 0.001). Better surgical score was associated with female gender (15.4 vs 13.3, P = <0.01), prior MP experience (16.2 vs 13.7, P = 0.03), and senior level resident (15.1 vs 13.0, P = 0.03). Supraceliac aortic dissection (P = 0.0017) and instrument handling (P = 0.041) improved with more MP operations. CONCLUSIONS: Participation in MP improves residents' knowledge of abdominal anatomy and surgical technique.

Asrani, S. K., G. Saracino, J. G. O’Leary, S. Gonzales, P. T. Kim, G. J. McKenna, G. Klintmalm and J. Trotter (2018). “Recipient characteristics and morbidity and mortality after liver transplantation.” J Hepatol 69(1): 43-50.

Full text of this article.

BACKGROUND AND AIMS: Over the last decade, liver transplantation of sicker, older non-hepatitis C cirrhotics with multiple co-morbidities has increased in the United States. We sought to identify an easily applicable set of recipient factors among HCV negative adult transplant recipients associated with significant morbidity and mortality within five years after liver transplantation. METHODS: We collected national (n=31,829, 2002-2015) and center-specific data. Coefficients of relevant recipient factors were converted to weighted points and scaled from 0-5. Recipient factors associated with graft failure included: ventilator support (five patients; hazard ratio [HR] 1.59; 95% CI 1.48-1.72); recipient age >60years (three patients; HR 1.29; 95% CI 1.23-1.36); hemodialysis (three patients; HR 1.26; 95% CI 1.16-1.37); diabetes (two patients; HR 1.20; 95% CI 1.14-1.27); or serum creatinine >/=1.5mg/dl without hemodialysis (two patients; HR 1.15; 95% CI 1.09-1.22). RESULTS: Graft survival within five years based on points (any combination) was 77.2% (0-4), 69.1% (5-8) and 57.9% (>8). In recipients with >8points, graft survival was 42% (model for end-stage liver disease [MELD] score <25) and 50% (MELD score 25-35) in recipients receiving grafts from donors with a donor risk index >1.7. In center-specific data within the first year, subjects with >/=5points (vs. 0-4) had longer hospitalization (11 vs. 8days, p<0.01), higher admissions for rehabilitation (12.3% vs. 2.7%, p<0.01), and higher incidence of cardiac disease (14.2% vs. 5.3%, p<0.01) and stage 3 chronic kidney disease (78.6% vs. 39.5%, p=0.03) within five years. CONCLUSION: The impact of co-morbidities in an MELD-based organ allocation system need to be reassessed. The proposed clinical tool may be helpful for center-specific assessment of risk of graft failure in non-HCV patients and for discussion regarding relevant morbidity in selected subsets. LAY SUMMARY: Over the last decade, liver transplantation of sicker, older patient with multiple co-morbidities has increased. In this study, we show that a set of recipient factors (recipient age >60years, ventilator status, diabetes, hemodialysis and creatinine >1.5mg/dl) can help identify patients that may not do well after transplant. Transplanting sicker organs in patients with certain combinations of these characteristics leads to lower survival.