Sumeet K. Asrani M.D.

Flores, A. and S. K. Asrani (2017). “The donor risk index: A decade of experience.” Liver Transpl: 2017 Jun [Epub ahead of print].

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In 2006, derivation of the donor risk index (DRI) highlighted the importance of donor factors for successful liver transplantation. Over the last decade, the DRI has served as a useful metric of donor quality and enhanced our understanding of donor factors and their impact upon recipients with hepatitis C, those with low model for end-stage liver disease (MELD) score, and individuals undergoing retransplantation. DRI has provided the transplant community with a common language for describing donor organ characteristics and has served as the foundation for several tools for organ risk assessment. It is a useful tool in assessing the interactions of donor factors with recipient factors and their impact on posttransplant outcomes. However, limitations of statistical modeling, choice of donor factors, exclusion of unaccounted donor and geographic factors, and the changing face of the liver transplant recipient have tempered its widespread use. In addition, the DRI was derived from data before the MELD era but is currently being applied to expand the donor pool while concurrently meeting the demands of a dynamic allocation system. A decade after its introduction, DRI remains relevant but may benefit from being updated to provide guidance in the use of extended criteria donors, tailored for recipients with nonalcoholic fatty liver disease and account for the impact of geography and unmeasured donor characteristics.

Kasiske, B. L., S. K. Asrani, M. A. Dew, M. L. Henderson, C. Henrich, A. Humar, A. K. Israni, K. L. Lentine, A. J. Matas, K. A. Newell, D. LaPointe Rudow, A. B. Massie, J. J. Snyder, S. J. Taler, J. F. Trotter and A. D. Waterman (2017). “The living donor collective: A scientific registry for living donors.” Am J Transplant: 2017 May [Epub ahead of print].

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In the setting of an overall decline in living organ donation and new questions about long-term safety, a better understanding of outcomes after living donation has become imperative. Adequate information on outcomes important to donors may take many years to ascertain and may only be evident by comparing large numbers of donors with suitable controls. Previous studies have been unable to fully answer critical questions, primarily due to lack of appropriate controls, inadequate sample size, and/or follow-up duration too short to allow detection of important risks attributable to donation. The Organ Procurement and Transplantation Network does not follow donors long term and has no prospective control group with which to compare post-donation outcomes. There is a need to establish a national living donor registry, and to prospectively follow donors over their lifetimes. In addition, there is a need to better understand the reasons many potential donors who volunteer to donate do not donate, and whether the reasons are justified. Therefore, the US Health Resources and Services Administration asked the Scientific Registry of Transplant Recipients to establish a national registry to address these important questions. Here, we discuss the efforts, challenges, and opportunities inherent in establishing the Living Donor Collective.

Laskey, H. L., N. Schomaker, K. W. Hung, S. K. Asrani, L. Jennings, T. L. Nydam, J. Gralla, A. Wiseman, H. R. Rosen and S. W. Biggins (2016). “Predicting renal recovery after liver transplant with severe pretransplant subacute kidney injury: The impact of warm ischemic time.” Liver Transpl: 2016 June [Epub ahead of print].

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Identification of which liver transplant (LT) candidates with severe kidney injury will have full recovery of renal function after liver transplant alone (LTA) is difficult. Avoiding unnecessary simultaneous liver-kidney (SLK) transplant can optimize use of scarce kidney grafts. Incorrect predictions of spontaneous renal recovery after LTA can lead to increased morbidity and mortality. We retrospectively analyzed all LTA patients at our institution from 2/2002-2/2013 (n=583) and identified a cohort with severe subacute renal injury (n=40) [creatinine <2mg/dL in the 14-89 days prior to LTA and not on renal replacement therapy yet >/= 2mg/dLwithin 14 days of LTA and/or on renal replacement therapy]. Of 40 LTA recipients, 26 (65%) had renal recovery and 14 (35%) did not. The median (IQR) warm ischemic time (WIT, in minutes) in recipients with and without renal recovery after LTA was 31 (24-46) and 39 (34-49), p=0.02, respectively. Adjusting for severity of subacute kidney injury with either AKIN or RIFLE criteria, increasing WIT was associated with lack of renal recovery [serum creatinine <2 mg/dL after LTA, not on renal replacement therapy], OR 1.08 (1.01-1.16, p=0.03) and OR 1.09 (1.01-1.17, p=0.02), respectively. For each minute of increased WIT, there was an 8% to 9% increase in the risk of lack of renal recovery after LTA. In a separate cohort of 98 LTA recipients with subacute kidney injury, we confirmed the association of WIT and lack of renal recovery, OR 1.04, p=0.04. CONCLUSION: In LT candidates with severe subacute renal injury, operative measures to minimize WIT may improve renal recovery potentially avoiding renal replacement therapy and the need for subsequent kidney transplant.

Flores, A. and S. K. Asrani (2016). “Editorial: Magnetic resonance elastography and non-alcoholic fatty liver disease: Time for an upgrade?” Am J Gastroenterol 111(7): 995-996.

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Elastography techniques, such as two-dimensional magnetic resonance elastography (2D-MRE) are increasingly used for the non-invasive assessment of liver fibrosis in patients with nonalchoholic fatty liver disease (NAFLD). Loomba et al. demonstrate that 3D-MRE (shear wave frequency 40 Hz) had even greater diagnostic accuracy than the commercially available 2D-MRE (shear wave frequency 60 Hz) in diagnosing advanced fibrosis (area under the receiver operator curve, AUROC 0.981 vs. 0.921, P<0. 05) using liver biopsy as reference standard. Despite limitations, MRE serves as an important tool in risk stratification for patients with NAFLD.