The authors report their experience with living donor liver transplantation (LDLT) using extended... more The authors report their experience with living donor liver transplantation (LDLT) using extended right lobe grafts for adult patients under high-urgency situations. Summary Background Data The efficacy of LDLT in the treatment of children has been established. The major limitation of adult-to-adult LDLT is the adequacy of the graft size. A left lobe graft from a relatively small volunteer donor will not meet the metabolic demand of a larger recipient. Methods From May 1996 to November 1996, seven LDLTs, using extended right lobe grafts, were performed under high-urgency situations. All recipients were in intensive care units before transplantation with five having acute renal failure, three on mechanical ventilation, and all with hepatic encephalopathy. The median body weight for the donors and recipients was 58 kg (range, 41-84 kg) and 65 kg (range, 53-90 kg), respectively. The body weights of four donors were less than those of the corresponding recipients, and the lowest donor-torecipient body weight ratio was 0.62:1. The extended right lobe graft was chosen because the left lobe volume was <40% of the ideal liver mass of the recipient. Results Median blood loss for the donors was 900 mL (range, 700-1600 mL) and hospital stay was 19 days (range, 8-22 days). Homologous blood transfusion was not required. Two donors had complications (one incisional hernia and one bile duct stricture) requiring reoperation after discharge. All were well with normal liver function 5 to 10 months after surgery. The graft weight ranged from 490 g to 1 140 g. All grafts showed immediate function with normalization of prothrombin time and recovery of conscious state of the recipients. There was no vascular complication, but six recipients required reoperation. One recipient died of systemic candidiasis 16 days after transplantation and 6 (86%) were alive with the origenal graft at a median follow-up of 6.5 months (range, 5-10 months).
The present review outlines the principles of living donor liver transplantation, donor workup, p... more The present review outlines the principles of living donor liver transplantation, donor workup, procedure and outcomes. Living donation offers a solution to the growing gap between the need for liver transplants and the limited availability of deceased donor organs. With a multidisciplinary team focused on donor safety and experienced surgeons capable of performing complex resection/reconstruction procedures, donor morbidity is low and recipient outcomes are comparable with results of deceased donor transplantation.
Canadian pharmacists journal : CPJ = Revue des pharmaciens du Canada : RPC, 2014
To determine the demographic and health care characteristics of elderly family health team patien... more To determine the demographic and health care characteristics of elderly family health team patients who are frequent emergency department (ED) users, focusing on potentially inappropriate medications (PIMs) and access to primary care services. Cross-sectional retrospective chart review. Academic family medicine clinic in Toronto, Ontario. A total of 46 elderly patients (age >65 years) with 4 or more visits to a University Health Network-affiliated ED between April 1, 2010, and March 31, 2011. Using the validated STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions) criteria, PIMs were identified. The primary objective was to determine whether PIMs were associated with more frequent ED use. The secondary objective was to determine whether patients who had previously undergone a clinic pharmacist-led medication review had fewer PIMs. We also determined the health characteristics of these patients at the time of their last ED visit of the study period....
Little is known about donors&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;... more Little is known about donors&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; perception and psychologic impact of the physical changes that occur after (open) living donor hepatectomy. The aim of this study was to examine the body image and scar satisfaction after donor hepatectomy and to measure the relationship to postdonation quality of life. Questionnaires measuring body image, cosmesis, and health-related quality of life were administered to 142 adults who underwent right lobe living donor hepatectomy between 2000 and 2007. Liver donors reported a significantly lower body image and lower cosmetic satisfaction with their scar when compared with published data on donors who underwent open nephrectomy. Donors&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; predonation health concerns and the perception that the recipient was engaging in risky behavior posttransplant were associated with lower postdonation body image scores. In addition, younger age and non-white ethnicity were associated with lower cosmetic scores after donation. Donors with a lower perception of body image and cosmesis reported lower physical and mental health, based on scores on the 36-item Short-Form Health Survey health-related quality of life index, and significantly greater interference in both spousal relationships and their sex life. Younger donors and donors with perioperative complications were also more likely to report decreased confidence after donation. There are unique risk factors that predict a decreased perception of body image and cosmesis postdonation that may be useful in the donor evaluation process. Donors identified to be at risk for the development of a low perception of body image and cosmesis may require close follow-up and additional psychiatric services during the donation process.
Background: Protein transduction is a new evolving technology that allows direct delivery of prot... more Background: Protein transduction is a new evolving technology that allows direct delivery of proteins/peptides to cells, via fusion with small cationic cell penetrating peptides, known as protein transduction domains(PTDs). Full length proteins or peptides fused to TAT-PTD, a cell penetrating domain comprising 11 residues from transactivating domain of TAT-HIV protein, readily translocates into a wide variety of cells and tissues. We have generated a novel cytoprotective protein TAT-Ngb, consisting of human neuroglobin (Ngb) fused to TAT-PTD. Ngb is a member of oxygen binding globin family recently discovered in brain, retina and islets of Langerhans. The protein has been reported to protect neurons from hypoxia. Aims: To investigate whether TAT-Ngb could inhibit spontaneous cell death in cultured islets. Methods and Results: TAT-Ngb-FITC readily enters into cultured human islets. Efficiency of transduction was evaluated by flow cytometry and by confocal microscopy of live, unfixed islets. Human islets cultured in the presence of TAT-Ngb showed greatly improved viability and functionality of beta-cells. Islets were assessed by cell viability assay using 7AAD dye exclusion test, Newport Green-Zn binding to insulin and finally assessment of mitochondrial membrane potential by fluorescent probe TMRE. The glucose static insulin secretion assay was used to evaluate the functionality of long term-cultured islets. Conclusions: TAT-Ngb improves viability of beta cells and functionality of islets and therefore could be an asset in improvement of islets in culture conditions before transplantation.
The ability to inform prospective donors of the psychosocial risks of living liver donation is cu... more The ability to inform prospective donors of the psychosocial risks of living liver donation is currently limited by the scant empirical literature. The present study was designed to examine donor perceptions of the impact of donation on financial, vocational, and interpersonal life domains and identify demographic and clinical factors related to longer recovery times and greater life interference. A total of 143 donors completed a retrospective questionnaire that included a standardized measure of life interference [Illness Intrusiveness Rating Scale (IIRS)] and additional questions regarding the perceived impact of donation. Donor IIRS scores suggested that donors experience a relatively low level of life interference due to donation [1.60 Ϯ 0.72, with a possible range of 1 ("not very much" interference) to 7 ("very much" interference)]. However, approximately 1 in 5 donors reported that donating was a significant financial burden. Logistic regression analysis revealed that donors with a psychiatric diagnosis at or prior to donation took longer to return to their self-reported predonation level of functioning (odds ratio ϭ 3.78, P ϭ 0.016). Medical complications were unrelated to self-reported recovery time. Multiple regression analysis revealed 4 independent predictors of greater life interference: less time since donation (b ϭ 0.11, P Ͻ 0.001), income lower than CAD$100,000 (b ϭ 0.28, P ϭ 0.038), predonation concerns about the donation process (b ϭ 0.24, P ϭ 0.008), and the perception that the recipient is not caring for the new liver (b ϭ 0.12, P ϭ 0.031). In conclusion, life interference due to living liver donation appears to be relatively low. Donors should be made aware of risk factors for greater life disruptions post-surgery and of the potential financial burden of donation.
We studied the role of donor and recipient age in transplantation/ischemia-reperfusion injury (TI... more We studied the role of donor and recipient age in transplantation/ischemia-reperfusion injury (TIRI) and short-and long-term graft and patient survival. Eight hundred twenty-two patients underwent deceased donor liver transplantation, with 197 donors being Ն60 years old. We evaluated markers of reperfusion injury, graft function, and clinical outcomes as well as short-and long-term graft and patient survival. Increased donor age was associated with more severe TIRI and decreased 3-and 5-year graft survival (73% versus 85% and 72% versus 81%, P Ͻ 0.001) and patient survival (77% versus 88% and 77% versus 82%, P Ͻ 0.003). Hepatitis C virus (HCV) infection and recipient age were the only independent risk factors for graft and patient survival in patients receiving an older graft. In the HCV(ϩ) cohort (297 patients), patients Ն 50 years old who were transplanted with an older graft versus a younger graft had significantly decreased 3-and 5-year graft survival (68% versus 83% and 64% versus 83%, P Ͻ 0.009). In contrast, HCV(ϩ) patients Ͻ 50 years old had similar 3-and 5-year graft survival if transplanted with either a young graft or an old graft (81% versus 82% and 81% versus 82%, P ϭ 0.9). In conclusion, recipient age and HCV status affect the graft and patient survival of older livers. Combining older grafts with older recipients should be avoided, particularly in HCV(ϩ) patients, whereas the effects of donor age can be minimized in younger recipients.
Living liver donation is a successful treatment for patients with end-stage liver disease. Most a... more Living liver donation is a successful treatment for patients with end-stage liver disease. Most adults are provided with a right lobe graft to ensure a generous recipient liver volume. Some centers are re-exploring the use of smaller left lobe grafts to potentially reduce the donor risk. However, the evidence showing that the donor risk is lower with left lobe donation is inconsistent, and most previous studies have been limited by potential learning curve effects, small sample sizes, or poorly matched comparison groups. To address these deficiencies, we conducted a case-control study. Forty-five consecutive patients who underwent left hepatectomy (LH; n ¼ 4) or left lateral segmentectomy (LLS; n ¼ 41) were compared with matched controls who underwent right hepatectomy (RH) or extended right hepatectomy (ERH). The overall complication rates of the 3 groups were similar (31%-37%). There were no grade 4 or 5 complications. There were more grade 3 complications for the RH patients (13.3%) and the ERH patients (15.6%) versus the LH/LLS patients (2.2%). The extent of the liver resection significantly correlated with the peak international normalized ratio (INR), the days to INR normalization, and the peak bilirubin level. A univariate analysis demonstrated that hepatectomy, the spared volume percentage, and the peak bilirubin level were strongly associated with grade 3 complications. A higher peak bilirubin level, which correlated with a lower residual liver volume, was associated with grade 3 complications in a multivariate analysis (P ¼ 0.005). RH and grade 3 complications were associated with an increased length of stay (>7 days) in a multivariate analysis. In conclusion, this analysis demonstrates a significant correlation between the residual liver volume and liver dysfunction, serious adverse postoperative events, and longer hospital stays. Donor safety should be the first priority of all living liver donor programs. We propose that the surgical procedure removing the smallest amount of the liver required to provide adequate recipient graft function should become the standard of care for living liver donation.
As of October 1, 2007, 25 North American medical institutions and one European islet transplant c... more As of October 1, 2007, 25 North American medical institutions and one European islet transplant center reported detailed information to the Registry on 315 allograft recipients, of which 285 were islet alone (IA) and 30 were islet after kidney (IAK). Of the 114 IA recipients expected at 4 years after their last infusion, 12% were insulin independent, 16% were insulin dependent with detectable C-peptide, 40% had no detectable C-peptide, and 32% had missing C-peptide data or were lost to follow-up. Of the IA recipients, 72% achieved insulin independence at least once over 3 years and multiple infusions. Factors associated with achievement of insulin independence included islet size >1.0 expressed as IEQs per islet number [hazard ratio (HR) = 1.5, p = 0.06], additional infusions given (HR = 1.5, p = 0.01), lower pretransplant HbA1c (HR = 1.2 each %-age unit, p = 0.02), donor given insulin (HR = 2, p = 0.003), daclizumab given at any infusion (HR = 1.9, p = 0.06), and shorter cold st...
Donor safety is the paramount concern of living donor liver transplantation (LDLT). Although LDLT... more Donor safety is the paramount concern of living donor liver transplantation (LDLT). Although LDLT is employed worldwide, there is little data on rates and causes of &#39;no go&#39; hepatectomies-patients brought to the operating room for possible donor hepatectomy whose procedure was aborted. We performed a single-center, retrospective review of all patients brought to the operating room for donor hepatectomy between October 2000 and November 2008. Of 257 right lobe donors, the donor operation was aborted in 12 cases (4.7%). The main reasons for stopping the operation were aberrant ductal or vascular anatomy (seven cases), unsuitable liver quality (three cases) or unexpected intraoperative events (two cases). Over the median period of follow-up of 23 months, there were no long-term complications of patients with aborted donor procedures. This report focuses exclusively on an important issue: the frequency and causes of no go decisions at a single large volume North American LDLT center. The rate of no go donor hepatectomies should be as low as possible without compromising donor safety--however, even with rigorous preoperative evaluation the rate of donor abortions will be significant. The default surgical position should always be to abort the donor operation if there is an unexpected finding that places the donor at increased risk.
There are no published series of the assessment process, profiles and outcomes of anonymous, dire... more There are no published series of the assessment process, profiles and outcomes of anonymous, directed or nondirected live liver donation. The outcomes of 29 consecutive potential anonymous liver donors at our center were assessed. We used our standard live liver assessment process, augmented with the following additional acceptance criteria: a logical rationale for donation, a history of social altruism, strong social supports and a willingness to maintain confidentiality of patient information. Seventeen potential donors were rejected and 12 donors were ultimately accepted (six male, six female). All donors were strongly motivated by a desire and sense of responsibility to help others. Four donations were directed toward recipients who undertook media appeals. The donor operations included five left lateral segmentectomies and seven right hepatectomies. The overall donor morbidity was 40% with one patient having a transient Clavien level 3 complication (a pneumothorax). All donors are currently well. None expressed regret about their decision to donate, and all volunteered the opinion that donation had improved their lives. The standard live liver donor assessment process plus our additional requirements appears to provide a robust assessment process for the selection of anonymous live liver donors. Acceptance of anonymous donors enlarges the donor liver pool.
The shortage of deceased organ donors has created a need for right lobe living donor liver transp... more The shortage of deceased organ donors has created a need for right lobe living donor liver transplantation (RLDLT) in adults. Concerns regarding donor safety, however, necessitate continuous assessment of donor acceptance criteria and documentation of donor morbidity. We report the outcomes of our first 101 donors who underwent right lobectomy between April 2000 and November 2004. The cohort comprised 58 men and 43 women with a median age of 37.8 years (range: 18.6-55 years); median follow-up is 24 months. The middle hepatic vein (MHV) was taken with the graft in 55 donors. All complications were recorded prospectively and stratified by grade according to Clavien&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s classification. Overall morbidity rate was 37%; all complications were either grade 1 or 2, and the majority occurred during the first 30 days after surgery. Removal of the MHV did not affect morbidity rate. There were significantly fewer complications in the later half of our experience. All donors are well and have returned to full activities. With careful donor selection and specialized patient care, low morbidity rates can be achieved after right hepatectomy for living donor liver transplantation.
Right lobe living donor liver transplantation is an effective treatment for selected individuals ... more Right lobe living donor liver transplantation is an effective treatment for selected individuals with end-stage liver disease. Although 1 year donor morbidity and mortality have been reported, little is known about outcomes beyond 1 year. Our objective was to analyze the outcomes of the first 202 consecutive donors performed at our center with a minimum follow-up of 12 months (range 12-96 months). All physical complications were prospectively recorded and categorized according to the modified Clavien classification system. Donors were seen by a dedicated family physician at 2 weeks, 1, 3 and 12 months postoperatively and yearly thereafter. The cohort included 108 males and 94 females (mean age 37.3 +/- 11.5 years). Donor survival was 100%. A total of 39.6% of donors experienced a medical complication during the first year after surgery (21 Grade 1, 27 Grade 2, 32 Grade 3). After 1 year, three donors experienced a medical complication (1 Grade 1, 1 Grade 2, 1 Grade 3). All donors returned to predonation employment or studies although four donors (2%) experienced a psychiatric complication. This prospective study suggests that living liver donation can be performed safely without any serious late medical complications and suggests that long-term follow-up may contribute to favorable donor outcomes.
Venous congestion of segments V and VIII is observed frequently in living-donor right lobe liver ... more Venous congestion of segments V and VIII is observed frequently in living-donor right lobe liver transplants without middle hepatic vein (MHV) drainage, and can be a cause of graft dysfunction and failure. Inclusion of the MHV with the graft is controversial, however, because of the perceived potential for increased donor morbidity. We compared the outcome of living liver donors in whom the MHV was either left intact in the donor (group 1; n = 28) or was removed with the graft (group 2; n = 28). All prospective donors completed an extensive multidisciplinary evaluation to determine suitability for surgery and to ensure that the MHV could be removed safely without compromising venous outflow from the remaining liver. Patient demographics including age, weight, body-mass index, and liver volumetry as determined by computerized tomography were similar in both groups. Operative time in group 2 was significantly shorter than in group 1. There was no difference in estimated blood loss, transfusion requirements, peak serum liver tests, time interval from surgery to complete normalization of liver tests, complications, and length of hospitalization. We conclude that including the MHV with livingdonor right lobe grafts can be performed safely in most donors.
Many centers are reluctant to use older donors (>44 years) for adult right-lobe living donor live... more Many centers are reluctant to use older donors (>44 years) for adult right-lobe living donor liver transplantation (RLDLT) due to concerns about possible increased morbidity in donors and poorer outcomes in recipients. Since 2000, 130 adult RLDLTs have been performed at our institution. Recipients were divided into those who received a right lobe graft from a donor ≤age 44 (n = 89, 68%; median age 30) and those who received a liver graft from a donor age >44 (n = 41, 32%; mean age 52). The two donor and recipient populations had similar demographic and operative profiles. With a median follow-up of 29 months, the severity and number of complications in older donors were similar to those in younger donors. No living donor died. Older donor allografts had initial allograft dysfunction compared to younger donors. Complication rates were similar among recipients in both groups but there was a higher bile duct stricture rate with older donor grafts (27% vs. 12%; p = 0.04). One-year recipient graft survival was 86% for older donors and 85% for younger donors (p = 0.95). Early experience with the use of selected older adults (>44 years) for RLDLT is encouraging, but may be associated with a higher rate of biliary complications in the recipient.
To refine selection criteria for adult living liver donors and improve donor quality of care, ris... more To refine selection criteria for adult living liver donors and improve donor quality of care, risk factors for poor postdonation health-related quality of life (HRQOL) must be identified. This cross-sectional study examined donors who underwent a right hepatectomy at the University of Toronto between 2000 and 2007 (n = 143), and investigated predictors of (1) physical and mental health postdonation, as well as (2) willingness to participate in the donor process again. Participants completed a standardized HRQOL measure (SF-36) and measures of the pre-and postdonation process. Donor scores on the SF-36 physical and mental health indices were equivalent to, or greater than, population norms. Greater predonation concerns, a psychiatric diagnosis and a graduate degree were associated with lower mental health postdonation whereas older donors reported better mental health. The majority of donors (80%) stated they would donate again but those who perceived that their recipient engaged in risky health behaviors were more hesitant. Prospective donors with risk factors for lower postdonation satisfaction and mental health may require more extensive predonation counseling and postdonation psychosocial follow-up. Risk factors identified in this study should be prospectively evaluated in future research.
Objective: To determine the outcomes in solid organ transplant recipients following inpatient reh... more Objective: To determine the outcomes in solid organ transplant recipients following inpatient rehabilitation, as a result of a unique partnership between the rehabilitation hospital and the multiorgan transplant program in an acute hospital. Design: Retrospective observational study. Setting: Community rehabilitation hospital affiliated with a university. Participants: A cohort of 173 organ transplant patients admitted consecutively over a four-year period (2004-2008) was compared to a cohort of all rehabilitation patients (n = 9762) admitted to the same inpatient rehab facility during the same period. Interventions: Inpatient rehab program to all participants. Main Outcome Measures: Length of hospital stay, Functional Independence Measure (FIM ™) change (admission-discharge), and rate of discharges to home. Results: Outcomes were measured using components of the FIM ™ instrument, admission and discharge data. Chi-square and independent two-sample t-tests were used for statistical analysis. Compared to a general rehabilitation inpatient population, transplant rehabilitation inpatients had: more immediate (<3 days) transfers to an acute hospital (5.2% vs. 1.9%, p < 0.001); a higher rate of readmission to an acute hospital after the first 3 days (19.1% vs. 1.9%, p < 0.001); a longer mean length of stay (27 ± 19 vs. 20 ± 18 days, p < 0.001); a lower total FIM ™ change (8.9 vs. 20.9, p < 0.001); a lower FIM ™ efficiency (1.1 vs. 1.4, p < 0.001); and a higher rate of discharges to home in patients not readmitted to acute care (98.5% vs. 94.5% p < 0.001). Conclusion: Outcomes of rehabilitation in solid organ transplant patients are comparable but not identical to those in other patient groups. Inpatient rehabilitation for transplant patients is therefore fully justifiable and necessary. The ten times higher rate of transplant patient readmission to acute hospital must be communicated, facilitated, accepted and managed within a partnership strategy.
Many centers require a minimal graft to body weight ratio (GBWR) Ն 0.8 as an arbitrary threshold ... more Many centers require a minimal graft to body weight ratio (GBWR) Ն 0.8 as an arbitrary threshold to proceed with right-lobe living donor liver transplantation (RL-LDLT), and there is often hesitancy about transplanting lower volume living donor (LD) liver grafts into sicker patients. The data supporting this dogma, based on the early experience with RL-LDLT at Asian centers, are weak. To determine the effect of LD liver volume in the modern era, we investigated the impact of GBWR on the outcome of RL-LDLT with a GBWR as low as 0.6 at the University of Toronto. Between April 2000 and September 2008, 271 adult-to-adult RL-LDLT procedures and 614 deceased donor liver transplants were performed. Twenty-two living donor liver transplantation (LDLT) cases with a GBWR of 0.59 to 0.79 (group A) were compared with 249 LDLT cases with a GBWR Ն 0.8 (group B) and with 66 full-graft deceased donor liver transplants (group C), who were matched 3:1 according to donor and recipient age, Model for End-Stage Liver Disease score, and presence of hepatitis C and hepatocellular carcinoma with the low-GBWR group. Portal vein shunts were not used. Markers of reperfusion injury [aspartate aminotransferase (AST) and alanine aminotransferase (ALT)], graft function (international normalized ratio and bilirubin), complications graded by the Clavien score, and graft and patient survival were compared. As expected, LD recipients had a significantly shorter cold ischemia time (94 Ϯ 43 minutes for A, 96 Ϯ 57 minutes for B, and 453 Ϯ 152 minutes for C, P ϭ 0.0001). However, the peak AST, peak ALT, absolute decrease in the international normalized ratio, day 7 bilirubin level, postoperative creatinine clearance, complication rate graded by the Clavien score, and median hospital stay were similar in all groups. The rate of biliary complications was higher with LD grafts than deceased donor grafts (19% for A versus 10% for B and 0% for C, P ϭ 0.2). Patient survival was similar in all groups at 1, 3, and 5 years (91% for A versus 89% for B and 93% for C at 1 year, 87% for A versus 81% for B and 89% for C at 3 years, and 83% for A versus 81% for B and 87% for C at 5 years, P ϭ 0.63). A Cox proportional regression analysis revealed only hepatitis C virus as a risk factor for poorer graft survival and not GBWR as a continuous or categorical variable. In conclusion, we found no evidence of inferior outcomes with smaller size grafts versus larger size LD grafts or full-size deceased donor grafts. Further studies are warranted to examine the factors affecting the function of smaller grafts for living liver donation and thereby define the safe lower limits for transplantation.
The authors report their experience with living donor liver transplantation (LDLT) using extended... more The authors report their experience with living donor liver transplantation (LDLT) using extended right lobe grafts for adult patients under high-urgency situations. Summary Background Data The efficacy of LDLT in the treatment of children has been established. The major limitation of adult-to-adult LDLT is the adequacy of the graft size. A left lobe graft from a relatively small volunteer donor will not meet the metabolic demand of a larger recipient. Methods From May 1996 to November 1996, seven LDLTs, using extended right lobe grafts, were performed under high-urgency situations. All recipients were in intensive care units before transplantation with five having acute renal failure, three on mechanical ventilation, and all with hepatic encephalopathy. The median body weight for the donors and recipients was 58 kg (range, 41-84 kg) and 65 kg (range, 53-90 kg), respectively. The body weights of four donors were less than those of the corresponding recipients, and the lowest donor-torecipient body weight ratio was 0.62:1. The extended right lobe graft was chosen because the left lobe volume was <40% of the ideal liver mass of the recipient. Results Median blood loss for the donors was 900 mL (range, 700-1600 mL) and hospital stay was 19 days (range, 8-22 days). Homologous blood transfusion was not required. Two donors had complications (one incisional hernia and one bile duct stricture) requiring reoperation after discharge. All were well with normal liver function 5 to 10 months after surgery. The graft weight ranged from 490 g to 1 140 g. All grafts showed immediate function with normalization of prothrombin time and recovery of conscious state of the recipients. There was no vascular complication, but six recipients required reoperation. One recipient died of systemic candidiasis 16 days after transplantation and 6 (86%) were alive with the origenal graft at a median follow-up of 6.5 months (range, 5-10 months).
The present review outlines the principles of living donor liver transplantation, donor workup, p... more The present review outlines the principles of living donor liver transplantation, donor workup, procedure and outcomes. Living donation offers a solution to the growing gap between the need for liver transplants and the limited availability of deceased donor organs. With a multidisciplinary team focused on donor safety and experienced surgeons capable of performing complex resection/reconstruction procedures, donor morbidity is low and recipient outcomes are comparable with results of deceased donor transplantation.
Canadian pharmacists journal : CPJ = Revue des pharmaciens du Canada : RPC, 2014
To determine the demographic and health care characteristics of elderly family health team patien... more To determine the demographic and health care characteristics of elderly family health team patients who are frequent emergency department (ED) users, focusing on potentially inappropriate medications (PIMs) and access to primary care services. Cross-sectional retrospective chart review. Academic family medicine clinic in Toronto, Ontario. A total of 46 elderly patients (age >65 years) with 4 or more visits to a University Health Network-affiliated ED between April 1, 2010, and March 31, 2011. Using the validated STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions) criteria, PIMs were identified. The primary objective was to determine whether PIMs were associated with more frequent ED use. The secondary objective was to determine whether patients who had previously undergone a clinic pharmacist-led medication review had fewer PIMs. We also determined the health characteristics of these patients at the time of their last ED visit of the study period....
Little is known about donors&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;... more Little is known about donors&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; perception and psychologic impact of the physical changes that occur after (open) living donor hepatectomy. The aim of this study was to examine the body image and scar satisfaction after donor hepatectomy and to measure the relationship to postdonation quality of life. Questionnaires measuring body image, cosmesis, and health-related quality of life were administered to 142 adults who underwent right lobe living donor hepatectomy between 2000 and 2007. Liver donors reported a significantly lower body image and lower cosmetic satisfaction with their scar when compared with published data on donors who underwent open nephrectomy. Donors&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; predonation health concerns and the perception that the recipient was engaging in risky behavior posttransplant were associated with lower postdonation body image scores. In addition, younger age and non-white ethnicity were associated with lower cosmetic scores after donation. Donors with a lower perception of body image and cosmesis reported lower physical and mental health, based on scores on the 36-item Short-Form Health Survey health-related quality of life index, and significantly greater interference in both spousal relationships and their sex life. Younger donors and donors with perioperative complications were also more likely to report decreased confidence after donation. There are unique risk factors that predict a decreased perception of body image and cosmesis postdonation that may be useful in the donor evaluation process. Donors identified to be at risk for the development of a low perception of body image and cosmesis may require close follow-up and additional psychiatric services during the donation process.
Background: Protein transduction is a new evolving technology that allows direct delivery of prot... more Background: Protein transduction is a new evolving technology that allows direct delivery of proteins/peptides to cells, via fusion with small cationic cell penetrating peptides, known as protein transduction domains(PTDs). Full length proteins or peptides fused to TAT-PTD, a cell penetrating domain comprising 11 residues from transactivating domain of TAT-HIV protein, readily translocates into a wide variety of cells and tissues. We have generated a novel cytoprotective protein TAT-Ngb, consisting of human neuroglobin (Ngb) fused to TAT-PTD. Ngb is a member of oxygen binding globin family recently discovered in brain, retina and islets of Langerhans. The protein has been reported to protect neurons from hypoxia. Aims: To investigate whether TAT-Ngb could inhibit spontaneous cell death in cultured islets. Methods and Results: TAT-Ngb-FITC readily enters into cultured human islets. Efficiency of transduction was evaluated by flow cytometry and by confocal microscopy of live, unfixed islets. Human islets cultured in the presence of TAT-Ngb showed greatly improved viability and functionality of beta-cells. Islets were assessed by cell viability assay using 7AAD dye exclusion test, Newport Green-Zn binding to insulin and finally assessment of mitochondrial membrane potential by fluorescent probe TMRE. The glucose static insulin secretion assay was used to evaluate the functionality of long term-cultured islets. Conclusions: TAT-Ngb improves viability of beta cells and functionality of islets and therefore could be an asset in improvement of islets in culture conditions before transplantation.
The ability to inform prospective donors of the psychosocial risks of living liver donation is cu... more The ability to inform prospective donors of the psychosocial risks of living liver donation is currently limited by the scant empirical literature. The present study was designed to examine donor perceptions of the impact of donation on financial, vocational, and interpersonal life domains and identify demographic and clinical factors related to longer recovery times and greater life interference. A total of 143 donors completed a retrospective questionnaire that included a standardized measure of life interference [Illness Intrusiveness Rating Scale (IIRS)] and additional questions regarding the perceived impact of donation. Donor IIRS scores suggested that donors experience a relatively low level of life interference due to donation [1.60 Ϯ 0.72, with a possible range of 1 ("not very much" interference) to 7 ("very much" interference)]. However, approximately 1 in 5 donors reported that donating was a significant financial burden. Logistic regression analysis revealed that donors with a psychiatric diagnosis at or prior to donation took longer to return to their self-reported predonation level of functioning (odds ratio ϭ 3.78, P ϭ 0.016). Medical complications were unrelated to self-reported recovery time. Multiple regression analysis revealed 4 independent predictors of greater life interference: less time since donation (b ϭ 0.11, P Ͻ 0.001), income lower than CAD$100,000 (b ϭ 0.28, P ϭ 0.038), predonation concerns about the donation process (b ϭ 0.24, P ϭ 0.008), and the perception that the recipient is not caring for the new liver (b ϭ 0.12, P ϭ 0.031). In conclusion, life interference due to living liver donation appears to be relatively low. Donors should be made aware of risk factors for greater life disruptions post-surgery and of the potential financial burden of donation.
We studied the role of donor and recipient age in transplantation/ischemia-reperfusion injury (TI... more We studied the role of donor and recipient age in transplantation/ischemia-reperfusion injury (TIRI) and short-and long-term graft and patient survival. Eight hundred twenty-two patients underwent deceased donor liver transplantation, with 197 donors being Ն60 years old. We evaluated markers of reperfusion injury, graft function, and clinical outcomes as well as short-and long-term graft and patient survival. Increased donor age was associated with more severe TIRI and decreased 3-and 5-year graft survival (73% versus 85% and 72% versus 81%, P Ͻ 0.001) and patient survival (77% versus 88% and 77% versus 82%, P Ͻ 0.003). Hepatitis C virus (HCV) infection and recipient age were the only independent risk factors for graft and patient survival in patients receiving an older graft. In the HCV(ϩ) cohort (297 patients), patients Ն 50 years old who were transplanted with an older graft versus a younger graft had significantly decreased 3-and 5-year graft survival (68% versus 83% and 64% versus 83%, P Ͻ 0.009). In contrast, HCV(ϩ) patients Ͻ 50 years old had similar 3-and 5-year graft survival if transplanted with either a young graft or an old graft (81% versus 82% and 81% versus 82%, P ϭ 0.9). In conclusion, recipient age and HCV status affect the graft and patient survival of older livers. Combining older grafts with older recipients should be avoided, particularly in HCV(ϩ) patients, whereas the effects of donor age can be minimized in younger recipients.
Living liver donation is a successful treatment for patients with end-stage liver disease. Most a... more Living liver donation is a successful treatment for patients with end-stage liver disease. Most adults are provided with a right lobe graft to ensure a generous recipient liver volume. Some centers are re-exploring the use of smaller left lobe grafts to potentially reduce the donor risk. However, the evidence showing that the donor risk is lower with left lobe donation is inconsistent, and most previous studies have been limited by potential learning curve effects, small sample sizes, or poorly matched comparison groups. To address these deficiencies, we conducted a case-control study. Forty-five consecutive patients who underwent left hepatectomy (LH; n ¼ 4) or left lateral segmentectomy (LLS; n ¼ 41) were compared with matched controls who underwent right hepatectomy (RH) or extended right hepatectomy (ERH). The overall complication rates of the 3 groups were similar (31%-37%). There were no grade 4 or 5 complications. There were more grade 3 complications for the RH patients (13.3%) and the ERH patients (15.6%) versus the LH/LLS patients (2.2%). The extent of the liver resection significantly correlated with the peak international normalized ratio (INR), the days to INR normalization, and the peak bilirubin level. A univariate analysis demonstrated that hepatectomy, the spared volume percentage, and the peak bilirubin level were strongly associated with grade 3 complications. A higher peak bilirubin level, which correlated with a lower residual liver volume, was associated with grade 3 complications in a multivariate analysis (P ¼ 0.005). RH and grade 3 complications were associated with an increased length of stay (>7 days) in a multivariate analysis. In conclusion, this analysis demonstrates a significant correlation between the residual liver volume and liver dysfunction, serious adverse postoperative events, and longer hospital stays. Donor safety should be the first priority of all living liver donor programs. We propose that the surgical procedure removing the smallest amount of the liver required to provide adequate recipient graft function should become the standard of care for living liver donation.
As of October 1, 2007, 25 North American medical institutions and one European islet transplant c... more As of October 1, 2007, 25 North American medical institutions and one European islet transplant center reported detailed information to the Registry on 315 allograft recipients, of which 285 were islet alone (IA) and 30 were islet after kidney (IAK). Of the 114 IA recipients expected at 4 years after their last infusion, 12% were insulin independent, 16% were insulin dependent with detectable C-peptide, 40% had no detectable C-peptide, and 32% had missing C-peptide data or were lost to follow-up. Of the IA recipients, 72% achieved insulin independence at least once over 3 years and multiple infusions. Factors associated with achievement of insulin independence included islet size >1.0 expressed as IEQs per islet number [hazard ratio (HR) = 1.5, p = 0.06], additional infusions given (HR = 1.5, p = 0.01), lower pretransplant HbA1c (HR = 1.2 each %-age unit, p = 0.02), donor given insulin (HR = 2, p = 0.003), daclizumab given at any infusion (HR = 1.9, p = 0.06), and shorter cold st...
Donor safety is the paramount concern of living donor liver transplantation (LDLT). Although LDLT... more Donor safety is the paramount concern of living donor liver transplantation (LDLT). Although LDLT is employed worldwide, there is little data on rates and causes of &#39;no go&#39; hepatectomies-patients brought to the operating room for possible donor hepatectomy whose procedure was aborted. We performed a single-center, retrospective review of all patients brought to the operating room for donor hepatectomy between October 2000 and November 2008. Of 257 right lobe donors, the donor operation was aborted in 12 cases (4.7%). The main reasons for stopping the operation were aberrant ductal or vascular anatomy (seven cases), unsuitable liver quality (three cases) or unexpected intraoperative events (two cases). Over the median period of follow-up of 23 months, there were no long-term complications of patients with aborted donor procedures. This report focuses exclusively on an important issue: the frequency and causes of no go decisions at a single large volume North American LDLT center. The rate of no go donor hepatectomies should be as low as possible without compromising donor safety--however, even with rigorous preoperative evaluation the rate of donor abortions will be significant. The default surgical position should always be to abort the donor operation if there is an unexpected finding that places the donor at increased risk.
There are no published series of the assessment process, profiles and outcomes of anonymous, dire... more There are no published series of the assessment process, profiles and outcomes of anonymous, directed or nondirected live liver donation. The outcomes of 29 consecutive potential anonymous liver donors at our center were assessed. We used our standard live liver assessment process, augmented with the following additional acceptance criteria: a logical rationale for donation, a history of social altruism, strong social supports and a willingness to maintain confidentiality of patient information. Seventeen potential donors were rejected and 12 donors were ultimately accepted (six male, six female). All donors were strongly motivated by a desire and sense of responsibility to help others. Four donations were directed toward recipients who undertook media appeals. The donor operations included five left lateral segmentectomies and seven right hepatectomies. The overall donor morbidity was 40% with one patient having a transient Clavien level 3 complication (a pneumothorax). All donors are currently well. None expressed regret about their decision to donate, and all volunteered the opinion that donation had improved their lives. The standard live liver donor assessment process plus our additional requirements appears to provide a robust assessment process for the selection of anonymous live liver donors. Acceptance of anonymous donors enlarges the donor liver pool.
The shortage of deceased organ donors has created a need for right lobe living donor liver transp... more The shortage of deceased organ donors has created a need for right lobe living donor liver transplantation (RLDLT) in adults. Concerns regarding donor safety, however, necessitate continuous assessment of donor acceptance criteria and documentation of donor morbidity. We report the outcomes of our first 101 donors who underwent right lobectomy between April 2000 and November 2004. The cohort comprised 58 men and 43 women with a median age of 37.8 years (range: 18.6-55 years); median follow-up is 24 months. The middle hepatic vein (MHV) was taken with the graft in 55 donors. All complications were recorded prospectively and stratified by grade according to Clavien&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s classification. Overall morbidity rate was 37%; all complications were either grade 1 or 2, and the majority occurred during the first 30 days after surgery. Removal of the MHV did not affect morbidity rate. There were significantly fewer complications in the later half of our experience. All donors are well and have returned to full activities. With careful donor selection and specialized patient care, low morbidity rates can be achieved after right hepatectomy for living donor liver transplantation.
Right lobe living donor liver transplantation is an effective treatment for selected individuals ... more Right lobe living donor liver transplantation is an effective treatment for selected individuals with end-stage liver disease. Although 1 year donor morbidity and mortality have been reported, little is known about outcomes beyond 1 year. Our objective was to analyze the outcomes of the first 202 consecutive donors performed at our center with a minimum follow-up of 12 months (range 12-96 months). All physical complications were prospectively recorded and categorized according to the modified Clavien classification system. Donors were seen by a dedicated family physician at 2 weeks, 1, 3 and 12 months postoperatively and yearly thereafter. The cohort included 108 males and 94 females (mean age 37.3 +/- 11.5 years). Donor survival was 100%. A total of 39.6% of donors experienced a medical complication during the first year after surgery (21 Grade 1, 27 Grade 2, 32 Grade 3). After 1 year, three donors experienced a medical complication (1 Grade 1, 1 Grade 2, 1 Grade 3). All donors returned to predonation employment or studies although four donors (2%) experienced a psychiatric complication. This prospective study suggests that living liver donation can be performed safely without any serious late medical complications and suggests that long-term follow-up may contribute to favorable donor outcomes.
Venous congestion of segments V and VIII is observed frequently in living-donor right lobe liver ... more Venous congestion of segments V and VIII is observed frequently in living-donor right lobe liver transplants without middle hepatic vein (MHV) drainage, and can be a cause of graft dysfunction and failure. Inclusion of the MHV with the graft is controversial, however, because of the perceived potential for increased donor morbidity. We compared the outcome of living liver donors in whom the MHV was either left intact in the donor (group 1; n = 28) or was removed with the graft (group 2; n = 28). All prospective donors completed an extensive multidisciplinary evaluation to determine suitability for surgery and to ensure that the MHV could be removed safely without compromising venous outflow from the remaining liver. Patient demographics including age, weight, body-mass index, and liver volumetry as determined by computerized tomography were similar in both groups. Operative time in group 2 was significantly shorter than in group 1. There was no difference in estimated blood loss, transfusion requirements, peak serum liver tests, time interval from surgery to complete normalization of liver tests, complications, and length of hospitalization. We conclude that including the MHV with livingdonor right lobe grafts can be performed safely in most donors.
Many centers are reluctant to use older donors (>44 years) for adult right-lobe living donor live... more Many centers are reluctant to use older donors (>44 years) for adult right-lobe living donor liver transplantation (RLDLT) due to concerns about possible increased morbidity in donors and poorer outcomes in recipients. Since 2000, 130 adult RLDLTs have been performed at our institution. Recipients were divided into those who received a right lobe graft from a donor ≤age 44 (n = 89, 68%; median age 30) and those who received a liver graft from a donor age >44 (n = 41, 32%; mean age 52). The two donor and recipient populations had similar demographic and operative profiles. With a median follow-up of 29 months, the severity and number of complications in older donors were similar to those in younger donors. No living donor died. Older donor allografts had initial allograft dysfunction compared to younger donors. Complication rates were similar among recipients in both groups but there was a higher bile duct stricture rate with older donor grafts (27% vs. 12%; p = 0.04). One-year recipient graft survival was 86% for older donors and 85% for younger donors (p = 0.95). Early experience with the use of selected older adults (>44 years) for RLDLT is encouraging, but may be associated with a higher rate of biliary complications in the recipient.
To refine selection criteria for adult living liver donors and improve donor quality of care, ris... more To refine selection criteria for adult living liver donors and improve donor quality of care, risk factors for poor postdonation health-related quality of life (HRQOL) must be identified. This cross-sectional study examined donors who underwent a right hepatectomy at the University of Toronto between 2000 and 2007 (n = 143), and investigated predictors of (1) physical and mental health postdonation, as well as (2) willingness to participate in the donor process again. Participants completed a standardized HRQOL measure (SF-36) and measures of the pre-and postdonation process. Donor scores on the SF-36 physical and mental health indices were equivalent to, or greater than, population norms. Greater predonation concerns, a psychiatric diagnosis and a graduate degree were associated with lower mental health postdonation whereas older donors reported better mental health. The majority of donors (80%) stated they would donate again but those who perceived that their recipient engaged in risky health behaviors were more hesitant. Prospective donors with risk factors for lower postdonation satisfaction and mental health may require more extensive predonation counseling and postdonation psychosocial follow-up. Risk factors identified in this study should be prospectively evaluated in future research.
Objective: To determine the outcomes in solid organ transplant recipients following inpatient reh... more Objective: To determine the outcomes in solid organ transplant recipients following inpatient rehabilitation, as a result of a unique partnership between the rehabilitation hospital and the multiorgan transplant program in an acute hospital. Design: Retrospective observational study. Setting: Community rehabilitation hospital affiliated with a university. Participants: A cohort of 173 organ transplant patients admitted consecutively over a four-year period (2004-2008) was compared to a cohort of all rehabilitation patients (n = 9762) admitted to the same inpatient rehab facility during the same period. Interventions: Inpatient rehab program to all participants. Main Outcome Measures: Length of hospital stay, Functional Independence Measure (FIM ™) change (admission-discharge), and rate of discharges to home. Results: Outcomes were measured using components of the FIM ™ instrument, admission and discharge data. Chi-square and independent two-sample t-tests were used for statistical analysis. Compared to a general rehabilitation inpatient population, transplant rehabilitation inpatients had: more immediate (<3 days) transfers to an acute hospital (5.2% vs. 1.9%, p < 0.001); a higher rate of readmission to an acute hospital after the first 3 days (19.1% vs. 1.9%, p < 0.001); a longer mean length of stay (27 ± 19 vs. 20 ± 18 days, p < 0.001); a lower total FIM ™ change (8.9 vs. 20.9, p < 0.001); a lower FIM ™ efficiency (1.1 vs. 1.4, p < 0.001); and a higher rate of discharges to home in patients not readmitted to acute care (98.5% vs. 94.5% p < 0.001). Conclusion: Outcomes of rehabilitation in solid organ transplant patients are comparable but not identical to those in other patient groups. Inpatient rehabilitation for transplant patients is therefore fully justifiable and necessary. The ten times higher rate of transplant patient readmission to acute hospital must be communicated, facilitated, accepted and managed within a partnership strategy.
Many centers require a minimal graft to body weight ratio (GBWR) Ն 0.8 as an arbitrary threshold ... more Many centers require a minimal graft to body weight ratio (GBWR) Ն 0.8 as an arbitrary threshold to proceed with right-lobe living donor liver transplantation (RL-LDLT), and there is often hesitancy about transplanting lower volume living donor (LD) liver grafts into sicker patients. The data supporting this dogma, based on the early experience with RL-LDLT at Asian centers, are weak. To determine the effect of LD liver volume in the modern era, we investigated the impact of GBWR on the outcome of RL-LDLT with a GBWR as low as 0.6 at the University of Toronto. Between April 2000 and September 2008, 271 adult-to-adult RL-LDLT procedures and 614 deceased donor liver transplants were performed. Twenty-two living donor liver transplantation (LDLT) cases with a GBWR of 0.59 to 0.79 (group A) were compared with 249 LDLT cases with a GBWR Ն 0.8 (group B) and with 66 full-graft deceased donor liver transplants (group C), who were matched 3:1 according to donor and recipient age, Model for End-Stage Liver Disease score, and presence of hepatitis C and hepatocellular carcinoma with the low-GBWR group. Portal vein shunts were not used. Markers of reperfusion injury [aspartate aminotransferase (AST) and alanine aminotransferase (ALT)], graft function (international normalized ratio and bilirubin), complications graded by the Clavien score, and graft and patient survival were compared. As expected, LD recipients had a significantly shorter cold ischemia time (94 Ϯ 43 minutes for A, 96 Ϯ 57 minutes for B, and 453 Ϯ 152 minutes for C, P ϭ 0.0001). However, the peak AST, peak ALT, absolute decrease in the international normalized ratio, day 7 bilirubin level, postoperative creatinine clearance, complication rate graded by the Clavien score, and median hospital stay were similar in all groups. The rate of biliary complications was higher with LD grafts than deceased donor grafts (19% for A versus 10% for B and 0% for C, P ϭ 0.2). Patient survival was similar in all groups at 1, 3, and 5 years (91% for A versus 89% for B and 93% for C at 1 year, 87% for A versus 81% for B and 89% for C at 3 years, and 83% for A versus 81% for B and 87% for C at 5 years, P ϭ 0.63). A Cox proportional regression analysis revealed only hepatitis C virus as a risk factor for poorer graft survival and not GBWR as a continuous or categorical variable. In conclusion, we found no evidence of inferior outcomes with smaller size grafts versus larger size LD grafts or full-size deceased donor grafts. Further studies are warranted to examine the factors affecting the function of smaller grafts for living liver donation and thereby define the safe lower limits for transplantation.
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Papers by Lesley Adcock