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Burnout among surgeons has been attributed to increased workload and decreased autonomy. Although prior studies have examined burnout among transplant surgeons, no studies have evaluated burnout in abdominal transplant surgery fellows. The objective of our study was to identify predictors of burnout and understand its impact on personal and patient care during fellowship. A survey was sent to all abdominal transplant surgery fellows in an American Society of Transplant Surgeons-accredited fellowship. The response rate was 59.2% (n = 77) and 22.7% (n = 17) of fellows met criteria for burnout. Fellows with lower grit scores were more likely to exhibit burnout compared with fellows with higher scores (3.6 vs 4.0, P = .026). Those with burnout were more likely to work >100 hours per week (58.8% vs 27.6%, P = .023), have severe work-related stress (58.8% vs 22.4%, P = .010), consider quitting fellowship (94.1% vs 20.7%, P < .001), or make a medical error (35.3% vs 5.2%, P = .003). This national analysis of abdominal transplant fellows found that burnout rates are relatively low, but few fellows engage in self-care. Personal and program-related factors attribute to burnout and it has unacceptable effects on patient care. Transplant societies and fellowship programs should develop interventions to give fellows tools to prevent and combat burnout.

Background Although laparoscopic sleeve gastrectomy is known, in general, to improve renal function in patients with obesity and chronic kidney disease (CKD), its effect on estimated glomerular filtration rate (eGFR) stratified by the stage of CKD is less clear. Objectives We aimed to evaluate the impact of sleeve gastrectomy on renal function in a stratified cohort of patients with CKD. Setting University Hospital. Methods We performed a retrospective review of 1932 patients who met National Institutes of Health’s guidelines for metabolic surgery and underwent laparoscopic sleeve gastrectomy performed by 1 of 3 surgeons. One hundred sixty-four patients with CKD stages 1 through 4 were identified. Results Mean follow-up period was 1.57 ± 1.0 years. Mean age was 56.4 ± 9.9 years with a preoperative body mass index of 47 ± 9 kg/m2, which decreased to 38.9 ± 8.7 kg/m2 at most recent follow-up (P Conclusion Renal function, as measured by eGFR, in patients with stages 1 and 4 CKD did not improve after laparoscopic sleeve gastrectomy; in contrast, eGFR in patients with CKD stages 2 and 3 significantly improved. Early surgical referral and intervention may be important in achieving the greatest improvement in eGFR and possibly delaying or reversing progression to end-stage renal disease.

Simultaneous liver-kidney transplantation (SLKT) is indicated for patients with end-stage liver disease (ESLD) and concurrent renal insufficiency. En bloc SLKT is an alternative to traditional separate implantations, but studies comparing the two techniques are limited. The en bloc technique maintains renal outflow via donor infrahepatic vena cava and inflow via anastomosis of donor renal artery to donor splenic artery. Comparison of recipients of en bloc (n = 17) vs traditional (n = 17) SLKT between 2013 and 2017 was performed. Recipient demographics and comorbidities were similar. More recipients of traditional SLKT were dialysis dependent (82.4% vs 41.2%, P = .01) with lower baseline pretransplant eGFR (14 vs 18, P = .01). En bloc SLKT was associated with shorter kidney cold ischemia time (341 vs 533 minutes, P < .01) and operative time (374 vs 511 minutes, P < .01). Two en bloc patients underwent reoperation for kidney allograft inflow issues due to kinking and renal steal. Early kidney allograft dysfunction (23.5% in both groups), 1-year kidney graft survival (88.2% vs 82.4%, P = 1.0), and posttransplantation eGFR were similar between groups. In our experience, the en bloc SLKT technique is safe and feasible, with comparable outcomes to the traditional method.

Morbid obesity is a barrier to kidney transplant in patients with end-stage renal disease (ESRD). Laparoscopic sleeve gastrectomy (SG) is an increasingly considered intervention, but the safety and long-term outcomes are uncertain. We reviewed prospectively collected data on patients with ESRD and chronic kidney disease (CKD) undergoing SG from 2011 to 2018. There were 198 patients with ESRD and 45 patients with CKD (stages 1-4) who met National Institutes of Health guidelines for bariatric surgery and underwent SG; 72% and 48% achieved a body mass index of ≤ 40 and ≤ 35 kg/m2 , respectively. The mean percentages of total weight loss and excess weight loss were 18.9 ± 10.8% and 38.2 ± 20.3%, respectively. SG reduced hypertension (85.8% vs 52.1%), decreased antihypertensive medication use (1.6 vs 1.0) (P < .01 each), and reduced incidence of diabetes (59.6% vs 32.5%, P < .01). Of the 71 patients with ESRD who achieved a body mass index of ≤ 40 kg/m2 , 45 were waitlisted and received a kidney transplant, whereas 10 remain on the waitlist. Mortality rate after SG was 1.8 per 100 patient-years, compared with 7.3 for non-SG. Patients with stage 3a or 3b CKD exhibited improved glomerular filtration rate (43.5 vs 58.4 mL/min, P = .01). In conclusion, SG safely improves transplant candidacy while providing significant, sustainable effects on weight loss, reducing medical comorbidities, and possibly improving renal function in stage 3 patients.

Morbid obesity serves as a barrier to kidney transplantation (KT) due to potential suboptimal posttransplant outcomes. Laparoscopic sleeve gastrectomy (LSG) has previously been shown to improve transplant eligibility through weight loss.We aimed to examine the role LSG plays in improving patient outcomes postrenal transplantation, including possible impact on new-onset diabetes after transplant (NODAT).University Hospital.A single-center analysis was performed identifying all patients who underwent KT after LSG from 2011 to 2017 (n = 41). Exclusion criteria included type I diabetes and previous pancreas transplantation. NODAT was defined as a new insulin requirement after KT. Delayed graft function was defined as need for dialysis within the first week after KT. Mean posttransplant follow-up period was 22 months.Forty-one patients underwent KT after LSG after median time of 16 months. Median age of postLSG patients undergoing KT was 56.0 years at time of KT. Average body mass index decreased by 9 from the time of LSG to KT, and no patients regained weight at 1-year follow-up. After LSG, the number of patients with hypertension (85.4% versus 48.5%) and the number of antihypertensive medications used decreased significantly (1.6 versus .6) at time of KT (P.001 each). At 1-year follow-up, the improvement in hypertension persisted (51.2% versus 48.5%, P = nonsignificant). The average insulin regimen decreased from 33.0 ± 51.6 to 11.7 ± 21.5 units at KT (P.001). This improvement also persisted at 1-year follow-up (11.9 versus 11.7 units, P = nonsignificant). Zero patients suffered NODAT over the follow-up period (versus institutional rate of NODAT at 15.8%). One patient developed delayed graft function (2.4%, versus institutional rate of 13.3%). After 1 year postKT, there was 1 graft loss (2.4%) and no mortality.This is the largest reported series of KT after planned LSG in morbidly obese patients. Our results confirm excellent posttransplant outcomes among patients who otherwise would have been denied KT eligibility.

Although increased hospital volume has been correlated with improved outcomes in certain surgical procedures, the effect of center volume on pancreas transplantation (PT) is less understood. Our study aims to establish whether a volume-outcome effect exists for PT.Through an established linkage between the University HealthSystem Consortium and the Scientific Registry of Transplant Recipients (SRTR) databases, we performed a retrospective cohort analysis of adult PT recipients between 2009 and 2012. Surgical volume was divided equally into low volume (LV), middle volume (MV), and high volume (HV) tertiles for each year that was studied. Hospital outcomes were measured through University HealthSystem Consortium, and long-term outcomes were measured through Scientific Registry of Transplant Recipients. Statistical analysis was performed using regression analyses and the Kaplan-Meier method. Median follow-up period was 2 y.Among the 2309 PT recipients included, 815 (35.3%) were performed at LV centers, 755 (32.7%) at MV centers, and 739 (32.0%) at HV centers. Compared with MV and LV centers, organs transplanted at HV centers were more frequently donation after cardiac death (5.1% versus 2.4% versus 3.3%, P = 0.01) and from older donors (2.8% [50 y] versus 0.8% versus 0.1%, P 0.001). In addition, HV recipients were older (31.5% [50 y] versus 20.9% versus 19.7%, P 0.001) and had worse functional status (39.5% dependent versus 9.7% versus 9.9%, P 0.001). Patient and graft survival were similar across hospital volume tertiles. Center volume was not predictive of readmission rates, total length of stay, intensive care unit length of stay, or total direct cost on multivariate analysis (all P 0.05).Short- and long-term outcomes after PT are not affected by hospital volume. Although LV centers confine their cases to low-risk patients, HV centers transplant a higher percentage of high-risk donor and recipient combinations with equivalent outcomes.

A growing number of renal transplant recipients have a body mass index ≥40. While previous studies have shown that patient and graft survival are significantly decreased in renal transplant recipients with body mass indexes ≥40, less is known about perioperative outcomes and resource utilization in morbidly obese patients. We aimed to analyze the effects of morbid obesity on these parameters in renal transplant.Using a linkage between the Scientific Registry of Transplant Recipients and the databases of the University HealthSystem Consortium, we identified 29,728 adult renal transplant recipients and divided them into 2 cohorts based on body mass index (40 vs ≥40 kg/mBody mass index ≥40 recipients incurred greater direct costs ($84,075 vs $79,580, P .01), index admission costs ($91,169 vs $86,141, P .01), readmission costs ($5,306 vs $4,596, P = .01), and combined costs ($99,590 vs $93,939, P .001). Thirty-day readmission rates were also greater among body mass index ≥40 recipients (33.92% vs 26.9%, P .01). Morbid obesity was not predictive of stay (odds ratio 1.01, P = .75).Morbidly obese renal transplant recipients incur greater costs and readmission rates compared with nonobese patients. Recognition of increased resource utilization should be accompanied by appropriate, risk-adjustment reimbursement.

Sensitized renal transplant recipients with high levels of donor-specific alloantibody (DSA) commonly develop antibody-mediated rejection (AMR), which may cause acute graft loss or shorten allograft survival. We examined the efficacy of terminal complement inhibition with the humanized anti-C5 antibody, eculizumab, in the prevention AMR in renal transplant recipients with a positive crossmatch against their living donor. The incidence of biopsy-proven AMR in the first 3 months posttransplant in 26 highly sensitized recipients of living donor renal transplants who received eculizumab posttransplant was compared to a historical control group of 51 sensitized patients treated with a similar plasma exchange (PE)-based protocol without eculizumab. The incidence of AMR was 7.7% (2/26) in the eculizumab group compared to 41.2% (21/51) in the control group (p = 0.0031). Eculizumab also decreased AMR in patients who developed high levels of DSA early after transplantation that caused proximal complement activation. With eculizumab, AMR episodes were easily treated with PE reducing the need for splenectomy. On 1-year protocol biopsy, transplant glomerulopathy was found to be present in 6.7% (1/15) eculizumab-treated recipients and in 35.7% (15/42) of control patients (p = 0.044). Inhibition of terminal complement activation with eculizumab decreases the incidence of early AMR in sensitized renal transplant recipients (ClincalTrials.gov number NCT006707).

The aim of the present study was to evaluate anti-HLA antibody eluted from fine needle allograft biopsies. Methods Two tissue-pieces and ten core fine needle biopsies were obtained in 9 transplant patients: 7 with biopsy-proven C4d+ antibody mediated rejection (ABMR), and two without rejection; 6 kidneys, 3 livers and one combined kidney–liver transplants. Tissue pieces weight was 0.33 g and 2.24 g, respectively. The weight of core biopsy ranged from 0.004 g to 0.008 g, average 0.006 g/core. Elution was performed by an acidic method, and then eluates were tested for donor-specific anti-HLA antibody (eDSA) by Luminex in parallel with serum samples. Cluster analysis considered both theoretical and adsorption/elution proved epitopes. Results We identified eDSA in all ABMR patients (6/7 with circulating DSA), and in none of controls. There was a linear correlation between antibody strength (MFI) and tissue weight (figure), both for class I, and class II DSAs. However, since the MFI average in eluates was only in the range of hundreds, epitope clustering was the tool for eDSA identification. We noted higher MFI in liver versus kidney biopsy cores (>80% class I, >75% class II). The epitope distribution of DSA eluted from biopsy is summarized in the table and were previously described by adsorption/elution cell lines (El-Awar et al). In contrast, circulating antibodies exhibited combinations of theoretical and elution-proved epitope patterns. Conclusions Given the low amount of HLA-specific antibody eluted from fine-needle core allograft biopsy, epitope cluster analysis can be used for antibody identification, even in ABMR cases where circulating DSA cannot be documented. Download full-size image Download full-size image

Morbid obesity is a barrier to renal transplantation and is inadequately addressed by medical therapy. We present results of a prospective evaluation of laparoscopic sleeve gastrectomy (LSG) for patients failing to achieve significant weight loss with medical therapy. Over a 25-month period, 52 obese renal transplant candidates meeting NIH guidelines for metabolic surgery underwent LSG. Mean age was 50.0 ± 10.0 years with an average preoperative BMI of 43.0 ± 5.4 kg/m(2) (range 35.8-67.7 kg/m(2)). Follow-up after LSG was 220 ± 152 days (range 26-733 days) with last BMI of 36.3 ± 5.3 kg/m(2) (range 29.2-49.8 kg/m(2)) with 29 (55.8%) patients achieving goal BMI of