Gregory J. McKenna M.D.

McKenna, G. J. (2018). “Medication Tradeoffs – Not All Noncompliance Is What It Seems.” Transpl Int. May 15. [Epub ahead of print].

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Admit it. More than once, you’ve scanned a transplant journal, searching for a novel topic, something different from the many ubiquitous registry reviews. You hope you can find something topical, relevant for your patients and timely to current events. You probably didn’t even realize this issue of Transplant International would be the one containing that very topical, relevant and timely manuscript.

Teixeira, P. G. R., C. V. R. Brown, B. Emigh, M. Long, M. Foreman, B. Eastridge, S. Gale, M. S. Truitt, S. Dissanaike, T. Duane, J. Holcomb, A. Eastman and J. Regner (2018). “Civilian Prehospital Tourniquet Use Is Associated with Improved Survival in Patients with Peripheral Vascular Injury.” J Am Coll Surg 226(5): 769-776.e761.

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BACKGROUND: Tourniquet use has been proven to reduce mortality on the battlefield. Although empirically transitioned to the civilian environment, data substantiating survival benefit attributable to civilian tourniquet use is lacking. We hypothesized that civilian prehospital tourniquet use is associated with reduced mortality in patients with peripheral vascular injuries. STUDY DESIGN: We conducted a multicenter retrospective review of all patients sustaining peripheral vascular injuries admitted to 11 Level I trauma centers (January 2011 through December 2016). The study population was divided into 2 groups based on prehospital tourniquet use. Baseline characteristics were compared and factors associated with mortality identified. Logistic regression, adjusting for demographic, physiologic and injury-related parameters, was used to evaluate the association between prehospital tourniquet use and mortality. Delayed amputation was the secondary end point. RESULTS: During 6 years, 1,026 patients with peripheral vascular injuries were admitted. Prehospital tourniquets were used in 181 (17.6%) patients. Tourniquet time averaged 77.3 +/- 63.3 minutes (interquartile range 39.0 to 92.3 minutes). Traumatic amputations occurred in 98 patients (35.7% had a tourniquet). Mortality was 5.2% in the non-tourniquet group compared with 3.9% in the tourniquet group (odds ratio 1.36; 95% CI 0.60 to 1.65; p = 0.452). After multivariable analysis, the use of tourniquets was found to be independently associated with survival (adjusted odds ratio 5.86; 95% CI 1.41 to 24.47; adjusted p = 0.015). Delayed amputation rates were not significantly different between the 2 groups (1.1% vs 1.1%; adjusted odds ratio 1.82; 95% CI 0.36 to 9.99; adjusted p = 0.473). CONCLUSIONS: Although still underused, civilian prehospital tourniquet application was independently associated with a 6-fold mortality reduction in patients with peripheral vascular injuries. More aggressive prehospital application of extremity tourniquets in civilian trauma patients with extremity hemorrhage and traumatic amputation is warranted.

Warren, A. M., G. Testa, T. Anthony, G. J. McKenna, G. B. Klintmalm, K. Wallis, E. C. Koon, R. T. Gunby, Jr. and L. Johannesson (2018). “Live nondirected uterus donors: Psychological characteristics and motivation for donation.” Am J Transplant 18(5): 1122-1128

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Emerging research suggests that uterus transplantation is a viable option for women without a uterus who want to become pregnant and carry a child to term. Currently, no knowledge exists regarding nondirected uterus donors. This study (NCT 02656550) explored the baseline psychological characteristics of nondirected uterus donors at a single study site. Of the 62 potential donors who underwent initial screening, 6 nondirected donors were chosen and participated in uterus donation. Participants received a comprehensive evaluation, which included clinical history and psychological assessments. The mean age of the donors was 42 years; most (83%) were white/not Hispanic, and all had a college degree. Current depression was reported by 2 participants, past depression was reported in 2 participants, and past anxiety was reported in 3 participants. Based on several different psychological measures, donors had a higher general well-being than the normative sample, and none of the participants’ scores indicated psychological distress. All 6 women indicated that giving another woman an opportunity to carry her own child was a motivation for pursuing uterus donation. Further research on potential psychological motives and gains for the donor as well as long-term effects on donors is crucial for ethical practice.

Leal-Leyte, P., G. J. McKenna, R. M. Ruiz, T. L. Anthony, G. Saracino, T. Giuliano, G. B. Klintmalm and P. T. Kim (2018). “Eversion Bile Duct Anastomosis: A Safe Alternative for Bile Duct Size Discrepancy in Deceased Donor Liver Transplantation.” Liver Transpl. Apr 10. [Epub ahead of print].

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Introduction: Bile duct size discrepancy in liver transplantation may increase the risk of biliary complications. The aim of this study was to evaluate the safety and outcomes of the eversion bile duct anastomosis technique in deceased donor liver transplantation (DDLT) with duct to duct anastomosis. Methods: A total of 210 patients who received a DDLT with duct to duct anastomosis from 2012 to 2017 were divided into two groups: those who had eversion bile duct anastomosis (N=70) and standard bile duct anastomosis (N=140). Biliary complications rates were compared between the two groups. Results: There was no difference in the cumulative incidence of biliary strictures (P=0.20) and leaks (P=0.17) between the two groups. The biliary complication rate in the eversion group was 14.3% and 11.4% in the standard anastomosis group. All the biliary complications in the eversion group were managed with endoscopic stenting. A severe size mismatch (>/=3:1 ratio) was associated with a significantly higher incidence of biliary strictures (44.4%) compared to 2:1 ratio (8.2%), (P=0.002). Conclusion: The use of the eversion technique is a safe alternative for bile duct discrepancy in deceased donor liver transplantation; however, severe bile duct size mismatch may be a risk factor for biliary strictures with such technique.

Testa, G., G. J. McKenna, R. T. Gunby, T. Anthony, E. C. Koon, A. M. Warren, J. M. Putman, L. Zhang, G. dePrisco, J. M. Mitchell, K. Wallis, G. B. Klintmalm, M. Olausson and L. Johannesson (2018). “First live birth after uterus transplantation in the United States.” Am J Transplant Mar 25. [Epub ahead of print].

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Uterus transplantation has proven to be a successful treatment for women with absolute uterine infertility, caused either by the absence of a uterus or the presence of a nonfunctioning uterus. We report the first birth of a healthy child following uterus transplantation in the United States, from a recipient of a uterus allograft procured from an altruistic living donor. Two major modifications from the previously reported live births characterized this uterus transplant. First, the transplanted uterus relied upon and sustained the pregnancy while having only the utero-ovarian vein as venous outflow. The implication is a significantly simplified living donor surgery that paves the way for minimally invasive laparoscopic or robot-assisted techniques for the donor hysterectomy. Second, the time from transplantation to embryo transfer was significantly shortened from prior protocols, allowing for an overall shorter exposure to immunosuppression by the recipient and lowering the risk for potential adverse effects from these medications.