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IMPORTANCE: A new liver allocation policy was implemented by United Network for Organ Sharing (UNOS) in February 2020 with the stated intent of improving access to liver transplant (LT). There are growing concerns nationally regarding the implications this new system may have on LT costs, as well as access to a chance for LT, which have not been captured at a multicenter level. OBJECTIVE: To characterize LT volume and cost changes across the US and within specific center groups and demographics after the policy implementation. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study collected and reviewed LT volume from multiple centers across the US and cost data with attention to 8 specific center demographics. Two separate 12-month eras were compared, before and after the new UNOS allocation policy: March 4, 2019, to March 4, 2020, and March 5, 2020, to March 5, 2021. Data analysis was performed from May to December 2022. MAIN OUTCOMES AND MEASURES: Center volume, changes in cost. RESULTS: A total of 22 of 68 centers responded comparing 1948 LTs before the policy change and 1837 LTs postpolicy, resulting in a 6% volume decrease. Transplants using local donations after brain death decreased 54% (P < .001) while imported donations after brain death increased 133% (P = .003). Imported fly-outs and dry runs increased 163% (median, 19; range, 1-75, vs 50, range, 2-91; P = .009) and 33% (median, 3; range, 0-16, vs 7, range, 0-24; P = .02). Overall hospital costs increased 10.9% to a total of $46 360 176 (P = .94) for participating centers. There was a 77% fly-out cost increase postpolicy ($10 600 234; P = .03). On subanalysis, centers with decreased LT volume postpolicy observed higher overall hospital costs ($41 720 365; P = .048), and specifically, a 122% cost increase for liver imports ($6 508 480; P = .002). Transplant centers from low-income states showed a significant increase in hospital (12%) and import (94%) costs. Centers serving populations with larger proportions of racial and ethnic minority candidates and specifically Black candidates significantly increased costs by more than 90% for imported livers, fly-outs, and dry runs despite lower LT volume. Similarly, costs increased significantly (>100%) for fly-outs and dry runs in centers from worse-performing health systems. CONCLUSIONS AND RELEVANCE: Based on this large multicenter effort and contrary to current assumptions, the new liver distribution system appears to place a disproportionate burden on populations of the current LT community who already experience disparities in health care. The continuous allocation policies being promoted by UNOS could make the situation even worse.

IMPORTANCE: Normothermic regional perfusion (NRP) is an emerging recovery modality for transplantable allografts from controlled donation after circulatory death (cDCD) donors. In the US, only 11.4% of liver recipients who are transplanted from a deceased donor receive a cDCD liver. NRP has the potential to safely expand the US donor pool with improved transplant outcomes as compared with standard super rapid recovery (SRR). OBJECTIVE: To assess outcomes of US liver transplants using controlled donation after circulatory death livers recovered with normothermic regional perfusion vs standard super rapid recovery. DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective, observational cohort study comparing liver transplant outcomes from cDCD donors recovered by NRP vs SRR. Outcomes of cDCD liver transplant from January 2017 to May 2023 were collated from 17 US transplant centers and included livers recovered by SRR and NRP (thoracoabdominal NRP [TA-NRP] and abdominal NRP [A-NRP]). Seven transplant centers used NRP, allowing for liver allografts to be transplanted at 17 centers; 10 centers imported livers recovered via NRP from other centers. EXPOSURES: cDCD livers were recovered by either NRP or SRR. MAIN OUTCOMES AND MEASURES: The primary outcome was ischemic cholangiopathy (IC). Secondary end points included primary nonfunction (PNF), early allograft dysfunction (EAD), biliary anastomotic strictures, posttransplant length of stay (LOS), and patient and graft survival. RESULTS: A total of 242 cDCD livers were included in this study: 136 recovered by SRR and 106 recovered by NRP (TA-NRP, 79 and A-NRP, 27). Median (IQR) NRP and SRR donor age was 30.5 (22-44) years and 36 (27-49) years, respectively. Median (IQR) posttransplant LOS was significantly shorter in the NRP cohort (7 [5-11] days vs 10 [7-16] days; P < .001). PNF occurred only in the SRR allografts group (n = 2). EAD was more common in the SRR cohort (123 of 136 [56.1%] vs 77 of 106 [36.4%]; P = .007). Biliary anastomotic strictures were increased 2.8-fold in SRR recipients (7 of 105 [6.7%] vs 30 of 134 [22.4%]; P = .001). Only SRR recipients had IC (0 vs 12 of 133 [9.0%]; P = .002); IC-free survival by Kaplan-Meier was significantly improved in NRP recipients. Patient and graft survival were comparable between cohorts. CONCLUSION AND RELEVANCE: There was comparable patient and graft survival in liver transplant recipients of cDCD donors recovered by NRP vs SRR, with reduced rates of IC, biliary complications, and EAD in NRP recipients. The feasibility of A-NRP and TA-NRP implementation across multiple US transplant centers supports increasing adoption of NRP to improve organ use, access to transplant, and risk of wait-list mortality.

Despite improving results, the management of exoerine complications after pancreas transplantation remains problematic. During a 30-month period, we performed 65 pancreas transplants with bladder drainage. A total of 23 patients (35%) were managed with a long-acting somatostatin analogue (Sandostatin) for persistent hyperamylasemia or a!lograft pancreatitis. Sandostatin was begun at a mean of 29 days after transplant with a mean duration of therapy of 13 days. Sandostatin therapy was associated with significant reductions in the serum, urine, and peritoneal fluid amylase levels (p We conclude that panereatitis remains a major cause of morbidity after pancreas transplantation. The selective use of Sandestatin can result in excellent graft salvage with low morbidity. Sandostatin appears to be safe and effective in reducing the exocrine output of the denervated pancreas allograft but also reduces cyclosporine levels.

The benefits of pancreas transplantation (PT) must be weighed against the morbidity associated with the operative procedure and long-term immunosuppression. Over a 32-month period, we performed 73 PTs including 61 combined pancreas-kidney transplants (PKT) and 12 solitary Pts. In the PKT group, 25 reoperations were performed in 18 patients (29.5%) at a mean of 39 [+ or -] 12 days after transplant. In the solitary PT group, 16 reoperations were performed in 8 recipients (66.7%, p = 0.03) at a mean of 87 [+ or -] 12 days after PT (p

An unusual type of diffuse biliary tract injury after liver transplantation that is characterized by multiple intrahepatic biliary strictures, ductal dilatations, fluid collections, or intrahepatic abscesses has been identified. Over a 5-year period, a total of 10 patients (2%) developed diffuse intrahepatic biliary injury with established vascular patency and no obvious source for their biliary tract pathology. All patients received livers preserved in University of Wisconsin solution with a mean preservation time of 16 hours. This biliary tract injury was associated with the presence of revere preservation injury and Roux limb biliary reconstruction. Of the 10 patients, 5 were treated nonoperatively with multiple stricture dilations and stent placements, 3 underwent retransplantation, 1 was treated operatively with hepaticojejunostomy, and 1 died of sepsis. This study suggests that this complication appears to be related to preservation injury and that the etiology may be ischemic in origin.

In an analysis of surgical complications following 500 consecutive orthotopic liver transplants, we identified 12 patients who developed the syndrome of multiple bowel perforations that was not due to iatrogenic injury. All cases occurred in small children (mean weight: 9.0 kg), who represented 7% of the pediatric population. Each patient had a minimum of three perforations. The typical intraoperative findings were pin-point perforations in areas of normal-appearing bowel. With only one possible exception (a patient with cytomegalovirus enteritis), no specific etiology could be determined. Management was based on multiple exploratory laparotomies and individualized operative procedures. All patients are currently alive (mean follow-up: 34.9 months). The pathogenesis of the syndrome of multiple bowel perforations remains unclear but is possibly multifactorial or related to high doses of steroids. Aggressive surgical management with semiopen treatment of peritonitis and frequent explorations has afforded excellent results., Patients who currently undergo liver transplant surgery experience longer survival as a result of improvements in anesthesia techniques and critical care. However, there is still a relatively high incidence of postoperative complications. An analysis of 500 liver transplant patients identified 12 patients who developed a syndrome of multiple bowel (intestine) perforations following liver transplant. These perforations were not due to injury during surgery. All bowel perforations occurred in very young children, ranging in age from two weeks to five years. These children represent 7 percent of the 500 children who underwent liver transplant at the University of Nebraska Medical Center from 1985 to 1990. A study was undertaken to identify the possible cause of the syndrome and describe the course of the affected patients. Patients had at least three perforations, typically pinpoint perforations in normal-appearing intestine. The children underwent many exploratory operations and specific operative procedures. At average follow-up of 34.9 months, all patients are alive. The cause of this syndrome remains unclear; it appears to have multiple causes, but may be related to high-dose steroid therapy. (Consumer Summary produced by Reliance Medical Information, Inc.)

Liver transplants are associated with a high incidence of fungal infections - as high as 28 percent. Prolonged use of antibiotics, indwelling catheters and immunosuppressive therapy may predispose the transplant recipient to these fungal infections. A retrospective study was undertaken of 307 liver transplant patients to determine the incidence and severity of these fungal infections, identify risk factors, and evaluate outcome and treatments. There were 91 infections identified in 72 liver transplants (23.8 percent). Candida, an organism normally found in the gastrointestinal tract and other areas of the body, was responsible for 83.5 percent of the infections. The infections included generalized infection (19 cases), inflammation of the abdominal cavity (17), and inflammation of the lungs (15). The infection was identified within the first two months in 84.7 percent of cases; the average was 16 days after transplant. Early identification is a problem; the main clinical problem was widespread infection. Risk factors identified included: retransplantation, reintubation, need for blood transfusion during surgery, urgent need for the operation, as well as number of steroid doses given, bacterial infection with antibiotic treatment, and vascular complications. Fungal infection was associated with decreased survival; 50 percent, versus 16.5 percent of patients without fungal infection. Treatment with amphotericin B was successful in 63 cases (74.1 percent). These findings indicate that fungal infection is a major cause of morbidity and mortality in liver transplant patients; this is related to specific risk factors, suggesting the need for effective preventive measures. (Consumer Summary produced by Reliance Medical Information, Inc.)

Liver transplants are a major surgical undertaking, and vascular complications can cause graft failure and death. These complications include thrombosis (clot formation) in the hepatic (liver) artery, thrombosis of the portal vein, and rupture of the hepatic artery. A study was undertaken to determine the incidence, available treatment options, and outcomes of these complications. Within a 57-month period, 430 liver transplants were performed on 372 patients. The incidence of vascular complications was 9 percent, and included 24 incidents of hepatic artery thrombosis (76 percent of all complications), six cases of portal vein thrombosis, three cases of combined hepatic artery and portal vein thrombosis, and five patients with a ruptured hepatic artery. Among the 140 children included in the study, the main reason for transplant was biliary atresia (absence or underdevelopment of one or more of the normal bile duct structures causing liver damage). Among the adults, the main indication for transplant was liver cirrhosis, degenerative disease of the liver in which the lobes are covered with fibrous tissue and the lobules are infiltrated with fat. Complications were signaled by liver failure, graft dysfunction, and bile infection; problems were also identified by screening ultrasound. Treatment of the complications included revascularization, revascularization and retransplantation, only retransplantation, and some patients were just closely observed. Four patients had infectious arteritis (inflammation of the artery). The six-month survival was 70 percent for patients who developed vascular complications following liver transplantation. It is concluded that early diagnosis of transplant failure is essential, and surgical intervention usually is the main treatment. (Consumer Summary produced by Reliance Medical Information, Inc.)

No published study has explored gender differences in letters of recommendation for applicants entering surgical subspecialty fellowships.

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Cytomegalovirus (CMV) has become the most important infectious agent in patients who undergo organ transplantation, due, in large measure, to the immunocompromised condition of the host. Infection with CMV may be the result of exposure to infected blood products or the transplanted organ, of reactivation of latent virus, or of reinfection. Liver transplant patients often develop infections, which are a serious cause of illness and death. To learn more about CMV disease among liver transplant recipients, the records of 211 patients (127 adults, 84 children) at one medical facility were reviewed. Patients were followed-up for an average of 13 months. Thirty-seven retransplantation procedures were performed for the whole group. When CMV disease was diagnosed, antiviral therapy with intravenous ganciclovir was initiated and patients' clinical, viral, and tissue biopsy results noted. Results showed that 73 patients (34.6 percent) experienced at least one episode of CMV disease, with a slightly higher incidence among adults. The diseases that necessitated liver transplantation are enumerated; in adults, there was no diagnosis consistently associated with subsequent CMV disease. In children, however, postnecrotic cirrhosis (a degenerative condition associated with tissue death) tended to be followed by CMV disease more than other disorders, with a lower CMV disease frequency among children with metabolic disorders. The risk of CMV disease was highest in patients who received livers from donors whose blood tested positive for CMV, from those who underwent treatment with agents to suppress lymphocyte proliferation for immunosuppression, and from those who underwent retransplantation. Primary disease (11 people) usually developed in the transplanted liver and had a high recurrence rate; however, it responded to ganciclovir in all cases. Control of CMV disease by this drug was achieved in approximately 94 percent of all cases. A discussion is provided of CMV disease in transplant recipients, and the lack of information regarding the effects of ganciclovir on liver transplant recipients is noted. Prompt diagnosis and preventive therapy are the key elements of treating this disorder in such patients. (Consumer Summary produced by Reliance Medical Information, Inc.)

The American Society of Transplantation (AST) and American Society of Transplant Surgeons (ASTS) convened a workshop on June 2–3, 2014, to explore increasing both living and deceased organ donation in the United States. Recent articles in the lay press on illegal organ sales and transplant tourism highlight the impact of the current black market in kidneys that accompanies the growing global organ shortage. We believe it important not to conflate the illegal market for organs, which we reject in the strongest possible terms, with the potential in the United States for concerted action to remove all remaining financial disincentives for donors and critically consider testing the impact and acceptability of incentives to increase organ availability in the United States. However, we do not support any trials of direct payments or valuable considerations to donors or families based on a process of market-assigned values of organs. This White Paper represents a summary by the authors of the deliberations of the Incentives Workshop Group and has been approved by both AST and ASTS Boards.

Healthcare reform and transplant center alignment require a comprehensive new approach to transplant physician and surgeon compensation. See editorial by Abecassis and Pearson on page 579, as well as a related brief communication by Jesse et al on page 772.

The Registry has gathered information on intestine transplantation (IT) since 1985. During this time, individual centers have reported progress but small case volumes potentially limit the generalizability of this information. The present study was undertaken to examine recent global IT activity. Activity was assessed with descriptive statistics, Kaplan–Meier survival curves and a multiple variable analysis. Eighty-two programs reported 2887 transplants in 2699 patients. Regional practices and outcomes are now similar worldwide. Current actuarial patient survival rates are 76%, 56% and 43% at 1, 5 and 10 years, respectively. Rates of graft loss beyond 1 year have not improved. Grafts that included a colon segment had better function. Waiting at home for IT, the use of induction immune-suppression therapy, inclusion of a liver component and maintenance therapy with rapamycin were associated with better graft survival. Outcomes of IT have modestly improved over the past decade. Case volumes have recently declined. Identifying the root reasons for late graft loss is difficult due to the low case volumes at most centers. The high participation rate in the Registry provides unique opportunities to study these issues.

Extracorporealliver perfusion (ECLP) has been used for detoxifying blood in patients in class IV hepatic encephalopathy. Palliation of the moribund patient utilizing extracorporeal devices with cross-circulation of a cadaver liver has been documented for over three decades. Common problems associated with this procedure which appear in the literature include cadaver liver distention, increased resistance to blood flow, and limited time of extracorporeal support due to cadaver liver failure. This report summarizes the experiences of the perfusion team in utilizing an extracorporeal circuit with an otherwise non-transplantable cadaveric liver, to support the decompensating hepatic patient as a bridge to transplantation.

The authors describe two cases of parvovirus B19–associated fulminant hepatic failure and aplastic anemia managed with sequential liver and bone marrow transplantation and excellent long‐term outcome.

Intestinal failure–associated liver disease (IFALD) is a multifactorial process, which can culminate in cirrhosis and need for transplantation. Fish oil–based lipid emulsions (FOE) reportedly reverse hyperbilirubinemia, but there are little data on their effect on the histopathology of IFALD.

Liver transplantation (LTx) is a life-saving treatment of end-stage liver disease. Cardiac complications including heart failure (HF) are among the leading causes of death after LTx.

Little information regarding bloodstream infections (BSIs) in small bowel transplantation has been published.

Fungal infections are an important cause of morbidity and mortality after small bowel transplantation (SBT). Little information about risk factors for Candidainfections in pediatric SBT is available.

No studies have evaluated the risk factors and outcomes of Staphylococcus aureus(SA) infections in small bowel (SBT) and multivisceral (including small bowel) transplantation (MVT).

Massive small bowel infarction in pregnancy is rare but has devastating complications. Diagnosis is difficult because pregnancy masks the symptoms. Our aim was to assess risk factors and outcomes of massive resection associated with pregnancy. We conducted a review of nine patients with short bowel syndrome (SBS) secondary to massive bowel resection during pregnancy. The most common cause of bowel resection was midgut volvulus in seven patients. Four of these also had malrotation. Three others had previous abdominal operations, including gastric bypass. The two remaining patients had vascular insufficiency. Five of the nine patients presented after a cesarean delivery. There were three fetal deaths. Resulting small bowel length was less than 60 cm in all but one patient. All patients required parenteral nutrition (PN). Seven patients developed significant complications related to SBS and long-term PN. Four patients underwent transplantation. Massive small bowel resection during pregnancy is a devastating complication, which requires a high degree of suspicion to diagnose. Most patients have risk factors, which include previous surgery, congenital malrotation, and a hypercoagulable state. Surviving patients usually need long-term PN or transplantation.

Small intestine transplantation is the only life-saving therapy available for patients with intestinal failure and life-threatening complications of parenteral nutrition, but it is still plagued by high levels of early acute rejection. The ability to diagnose rejection noninvasively, ideally before pathologic manifestations, would be a major advance in the care of intestinal transplant patients.

Like all other areas of transplantation, vascularized composite allografts (VCA) has the capacity to transform the lives of patients, for the better or for the worse. It is this duality that mandates VCA be performed in centers prepared for the intricacies accompanying other transplant procedures. Similarly, the complexities of VCA require that the procedures be driven by surgeons and physicians with experience in the multidisciplinary management of immunocompromised postsurgical patients. Furthermore, the grafts should be considered as organs rather than tissues from a regulatory and a biological standpoint. The ASTS supports the field of VCA and has demonstrated its support and leadership by actively formulating a strategy for its systematic development. The goal of this document is to provide a framework for the prospective, thoughtful realization of VCA in the United States from the American Society of Transplant Surgeons (ASTS) perspective.

Like all other areas of transplantation, vascularized composite allografts (VCA) has the capacity to transform the lives of patients, for the better or for the worse. It is this duality that mandates VCA be performed in centers prepared for the intricacies accompanying other transplant procedures. Similarly, the complexities of VCA require that the procedures be driven by surgeons and physicians with experience in the multidisciplinary management of immunocompromised postsurgical patients. Furthermore, the grafts should be considered as organs rather than tissues from a regulatory and a biological standpoint. The ASTS supports the field of VCA and has demonstrated its support and leadership by actively formulating a strategy for its systematic development. The goal of this document is to provide a framework for the prospective, thoughtful realization of VCA in the United States from the American Society of Transplant Surgeons (ASTS) perspective.

Adenovirus is commonly isolated from pediatric small bowel transplant recipients, but its clinical consequences remain poorly understood.

Improving short-term results with intestine transplantation have allowed more patients to benefit with nearly 700 patients alive in the United States with a functioning allograft at the end of 2007. This success has led to an increase in demand. Time to transplant and waiting list mortality have significantly improved over the decade, but mortality remains high, especially for infants and adults with concomitant liver failure. The approximately 200 intestines recovered annually from deceased donors represent less than 3% of donors who have at least one organ recovered. Consent practice varies widely by OPTN region. Opportunities for improving intestine recovery and utilization include improving consent rates and standardizing donor selection criteria. One-year patient and intestine graft survival is 89% and 79% for intestine only recipients and 72% and 69% for liver-intestine recipients, respectively. By 10years, patient and intestine survival falls to 46% and 29% for intestine-only recipients, and 42% and 39% for liver-intestine, respectively.Immunosuppression practice employs peri-operative antibody induction therapy in 60% of cases; acute re-jection is reported in 30%–40% of recipients at one year. Data on long-term nutritional outcomes and morbidities are limited, while the cause and therapy for late graft loss from chronic rejection are areas of ongoing investigation.

Small bowel transplantation provides a potentially life-saving treatment of severe intestinal failure. Lack of a noninvasive marker of disease makes diagnosis of rejection dependent on frequent endoscopy and biopsy. We hypothesized that increased plasma nitrite and nitrate (NOx) levels measured after small bowel transplant would be associated with abnormal final pathology.

The American Society of Transplant Surgeons (ASTS) was asked to endorse the ‘The Declaration of Istanbul on Organ Trafficking and Transplant Tourism.’ The document has been reviewed by the ASTS Ethics Committee and their ensuing report was presented, discussed and approved by the ASTS Council. The ASTS vigorously supports the principles outlined in the Declaration and details specific current obstacles to implementation of some of its proposals in the United States.

Objective.To characterize infection control experience during a 6.5-year period in a cooperative care center for transplant patients.Design.Descriptive analysis.Setting.A cooperative care center for transplanted patients, in which patients and care partners are housed in a homelike environment, and care partners assume responsibility for patient care duties.Patients.Nine hundred ninety one transplant patients.Methods.Infection control definitions from the Centers for Disease Control and Prevention were used to ascertain infection rates. Environmental cultures were used to detect methicillin-resistant Staphylococcus aureus(MRSA), vancomycin-resistant Enterococcus(VRE), Clostridium difficile,and fungi during the first 18 months. Surveillance cultures were performed for a subset of patients and care partners.Results.From June 1999 through December 2005, there were 19,365 patient-days observed. The most common healthcare-associated infection encountered was intravascular catheter-related bloodstream infection, with infection rates of 5.74 and 4.94 cases per 1,000 patient-days for hematopoietic stem cell transplant (HSCT) and solid organ transplant (SOT) patients, respectively. G difficile-associated diarrhea was observed more frequentiy in HSCT patients than in SOT patients (3.97 vs 0.57 cases per 1000 patient-days; P< .0001 ). There was no evidence of environmental contamination with MRSA, VRE, or C. difficile.Acquisition of MRSA was not observed. Acquisition of VRE was documented.Conclusion.This study documented that cooperative care was associated with some risk of healthcare-associated infection, most notably intravascular catheter-associated bloodstream infection and C. difficile-associated diarrhea, it appears the incidences of these infections were roughly commensurate with those in other care settings.

Feasibility of repeat lengthening has been demonstrated in animals, but in humans, none of the three clinical case reports have achieved enteral autonomy after secondary lengthening with serial transverse enteroplasty (STEP).

The optimal dosing protocol for rabbit anti-thymocyte globulin (rATG) induction in renal transplantation has not been determined, but evidence exists that rATG infusion before renal allograft reperfusion improves early graft function. Infusing a large rATG dose over a short interval has not previously been evaluated for its effect on renal function and allograft nephropathy in a prospective, randomized comparison against conventional rATG induction.

To analyze outcomes in children with intestinal failure treated by our Intestinal Rehabilitation Program (IRP) in a 4-year period.

Inflammatory bowel disease (IBD) is associated with primary sclerosing cholangitis (PSC) and autoimmune hepatitis (AIH) and can recur or develop de novo after orthotopic liver transplantation (OLT). The aim of this study was to investigate the incidence and severity of IBD after liver transplantation and to perform a multivariate analysis for possible risk factors. In this retrospective study, 91 patients transplanted for PSC or AIH, without prior colectomy, were included. Sixty patients were transplanted for PSC, 31 for AIH. IBD activity before and after OLT and other possible risk factors were analysed in a multivariate model. Forty-nine patients (54%) had IBD before OLT. Forty patients (44%) had active IBD after transplantation: recurrence in 32 and de novo in 8. Cumulative risk for IBD after OLT was 15, 39 and 54% after 1, 5 and 10 years, respectively. In 59% of patients with IBD prior to OLT the disease was more active after transplantation. Risk factors for recurrent disease were: symptoms at time of OLT, short interval of IBD before OLT and use of tacrolimus. 5-aminosalicylates were protective. A cytomegalovirus positive donor/negative recipient combination increased the risk for de novo IBD.

A retrospective chart review of 1065 consecutive liver allograft recipients in 11 centers from January 1997 to September 1998 was performed. Patients were followed for 3 years or until graft loss. Patients received either tacrolimus (n = 594), cyclosporine (n = 450) or no calcineurin inhibitor (n = 21). Model for end-stage liver disease (MELD) scores at time of transplant were similar between the two groups. During follow-up, more patients switched from cyclosporine to tacrolimus (26.7%) than from tacrolimus to cyclosporine (12.8%; p < 0.0001). Patient and graft survival were equivalent. Corticosteroid use was more common in cyclosporine-treated patients (p < 0.00001). Patients receiving tacrolimus experienced lower serum cre-atinine levels at months 3 through 36 (p < 0.0001). Systolic blood pressure was lower in patients receiving tacrolimus (p < 0.001) despite a reduced requirement for anti-hypertensive agents (p < 0.0001). In addition, tacrolimus was associated with lower total cholesterol and triglyceride levels for months 3 through 24 and 3 through 12, respectively (p < 0.01), despite a reduced requirement for anti-hyperlipidemic agents. The incidence of new-onset diabetes mellitus was similar in both groups. While both calcineurin inhibitors were associated with excellent patient and graft survival, renal function, blood pressure and serum lipid levels were significantly better with tacrolimus treatment.

Intestinal transplantation has become the treatment of choice for patients who are experiencing life-threatening complications of intestinal failure. Early attempts with intestinal transplantation were unsuccessful as a consequence of both technical and immunologic failures. The introduction of tacrolimus provided the immunologic foundation needed for the field to advance. Guidelines for patient selection combined with standardization of operative procedures and postoperative management has allowed for improved patient and graft survival. There has been a gradual improvement in patient survival over the past 10 years, most notably in the past 3 years. Nutritional autonomy has been achieved in hundreds of patients worldwide. Further advancements in the understanding of the immune response to the transplanted intestine are still needed and will allow the use of new antirejection medications, resulting in improved outcomes.

The most significant development in liver transplantation in the USA over the past year was the full implementation of the MELD- and PELD-based allocation policy in March 2002, which shifted emphasis from waiting time within broad medical urgency status to prioritization by risk of waiting list death. The implementation of this system has led to a decrease in pretransplant mortality without increasing post-transplant mortality, despite a higher severity of illness at the time of transplant.

Historically, antibody induction has been used because of the higher immunologic risk of graft loss or rejection observed in simultaneous pancreas and kidney (SPK) transplantation compared with kidney transplantation alone. This trial was designed to assess the effect of antibody induction in SPK transplant recipients receiving tacrolimus, mycophenolate mofetil, and corticosteroids. Induction agents included T-cell–depleting and interleukin-2 receptor antibodies.

The objective was to examine the perception of physical and psychosocial functioning of pediatric intestinal transplant recipients who are beyond the perioperative period and compare these with normal and chronically ill children.

The syndrome of multiple intestinal atresia with immunodeficiency is a rare, invariably fatal congenital disorder. At 16 months of age, a child with this syndrome underwent liver-small bowel transplantation from a 1-of-6 HLA-matched donor. He acquired full enteral tolerance and normal liver function and has never shown evidence of allograft rejection. After mild graft-versus-host disease developed, studies revealed that more than 99% of his CD3+ lymphocytes and 50% of his CD19+ lymphocytes were of donor origin, whereas granulocytes and monocytes remained of recipient origin. He synthesizes polyclonal immunoglobulin G (IgG), IgA, and IgM and has developed antibodies to cytomegalovirus (CMV) and parainfluenza 3. His T lymphocytes are predominately CD3+CD4-CD8- with T-cell receptor γδ heterodimers and CD3+CD4-CD8+ with CD8αα homodimers, populations consistent with an intraepithelial lymphocyte phenotypic profile. We postulate that he has engrafted a donor intestine-derived immune system and is incapable of rejecting his engrafted organs. (Blood. 2004;103:1171-1174)

Results of liver transplantation in the treatment of cholangiocarcinoma have been poor as a result of the high incidence of locoregional dissemination and tumor recurrence. This study evaluates the effect of neoadjuvant chemoradiation therapy combined with orthotopic liver transplantation in a carefully selected group of patients with hilar cholangiocarcinoma.

Seventeen patients were included in the study. The neoadjuvant protocol included 6000 cgy biliary brachytherapy delivered through percutaneous transhepatic catheters and intravenous infusion of 5-fluorouracil (300 mg/m²/day) until transplantation.

Five of the 17 patients demonstrated tumor progression precluding transplantation. One patient died of sepsis on the waiting list. Eleven patients underwent liver transplantation, a median of 3.4 months (range = 1-26 months) after diagnosis. Five of the 11 (45%) are alive without evidence of tumor recurrence with a median follow up of 7.5 years (range = 2.8-14.5 years). Six deaths occurred in the transplanted patients. Tumor recurrence was responsible for two deaths at 10 and 18 months, respectively, after transplantation. Three mortalities resulted from bacterial or fungal peritonitis and sepsis. One patient underwent re-transplantation for chronic rejection and died from graft failure resulting from hepatic artery thrombosis 16 months after diagnosis without evidence of tumor recurrence. Complications of transhepatic catheter placement included bile duct perforation (n = 4) and biliary-portal vein fistula (n = 1). All these patients died of tumor recurrence or sepsis.

Cholangiocarcinoma should not be considered an absolute exclusion criteria for orthotopic liver transplantation. Long-term, tumor-free survival was achieved in 45% of the transplanted patients. Complications of biliary catheter placement for brachytherapy were associated with poor outcome.