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Primary sclerosing cholangitis (PSC) is a progressive liver disease for which there is no effective therapy. Hepatocytes and cholangiocytes from a PSC patient were cocultured with mesenchymal stem cells (MSCs) to assess in vitro change. A single patient with progressive PSC was treated with 150 million MSCs via direct injection into the common bile duct. Coculture of MSCs with cholangiocytes and hepatocytes showed in vitro improvement. Local delivery of MSCs into a single patient with progressive PSC was safe. Radiographic and endoscopic evaluation showed stable distribution of multifocal structuring in the early postoperative period. MSCs may be effective for the treatment of PSC.

Graft verus host disease (GVHD) following Liver transplantation is rare life threatening complication with very high mortality rate around 85%. Due to increased recognition of this condition management approach is rapidly evolving due to newer diagnostic methods and drugs. Etiology, risk factors, pathogenesis, preventive strategies, management approach and newer drugs are discussed. We present our experience of 2 cases from a large cohort of 1052 Liver transplant operations over a decade.

Most global companies operate in multiple countries and locations all around the world. The focus on technology and economics is not enough as the global corporations have affiliates and subsidiaries that carry social and political undertones stemming from cultural and geographical diversity. The execution of digitalization/technology strategy is governed by the interplay of social structures and technology. Orlikowski, Sabatier and other researchers found that social aspects significantly contribute to strategy execution success. Lindbolm, Dunshire and others have brought into limelight the bipartisan politics, mutual adjustment etc. This chapter discusses major elements of technology strategy viz. Technological considerations, Operational considerations, Economic aspects, Social aspects and Political issues. Converging, the chapter presents aspects of technology strategy of national companies and multinational companies, specifically focusing on social and political angles of a multinational companies. Third part focuses on technology strategy formulation process, concluding that it is the strength of the process of strategy formulation that will help the companies in the changing dynamic environment business scenario. The model offered here is titled IPCRC model adapted from Vaidya that addresses meeting socio-political challenges of a multinational company. Conceptually this model may be used in any business or functional strategy formulation.

Healthy ageing is becoming a demand rather than a privilege from personal to societal perspective. One of the inevitable components of healthy ageing is wellbeing which is dependent on the quality of the consciousness. Mindfulness nurtures consciousness leading to behaviour regulation and well-being. Generativity is an attribute which connects individual to the society and predicts well-being significantly. The primary objective of the research was to find the relationship between mindfulness, generativity and subjective well-being among the older adults. Whether pursuing hobbies and social engagements affect the mindfulness, generativity and subjective well-being of olds was also investigated. With the help of standardized questionnaires the data was collected from 205 willing male and female older adults between 60 and 70 years from selected areas of Mumbai and Pune Metropolitan Region. Independent sample t tests and regression analysis were used to test the hypotheses. The results revealed significant effect of pursuing hobbies and social engagement in mindfulness, generativity and subjective well-being of older adults from their counterparts. Mindfulness was found to be a significant predictor of generativity and wellbeing of older adults. Mindfulness and generativity together significantly predicted the subjective wellbeing although generativity did not individually contribute significant variance in the subjective wellbeing. The implications of the research are discussed in the context of enhancing subjective well-being in the older adults by mindfulness training and promoting activities to pursue hobbies and social engagement which would help them for healthy ageing.

To report our experience with the combination of radical surgical excision and intestinal transplantation in patients with recurrent Pseudomyxoma Peritonei (PMP) not amenable to further Cytoreductive surgery (CRS).CRS and heated intra-operative peritoneal chemotherapy is an effective treatment for many patients with PMP. In patients with extensive small bowel involvement, or non-resectable recurrence, disease progression results in small bowel obstruction, nutritional failure, fistulation, with resulting abdominal wall failure.Between 2013-2022, patients with PMP who had nutritional failure and were not suitable for further CRS underwent radical debulking and intestinal transplantation at our centre.15 patients underwent radical exenteration of affected intra-abdominal organs, and transplantation adapted according to the individual case. Eight patients had isolated small bowel transplantation and seven patients underwent modified multi-visceral transplantation. Additionally, in seven patients with significant abdominal wall tumour involvement, a full thickness vascularized abdominal wall transplant was performed. Two of the 15 patients died within 90 days due to surgically related complications. Actuarial 1-year and 5-year patient survivals were 79% and 55% respectively. The majority of the patients had significant improvement in quality of life after transplantation. Progression/recurrence of disease was detected in 91% of patients followed up for more than six months.Intestinal/multi-visceral transplantation enables a more radical approach to the management of PMP than can be achieved with conventional surgical methods and is suitable for patients for whom there is no conventional surgical option. This complex surgical intervention requires combined skills of both peritoneal malignancy and transplant teams.

The chattering of cold rolling mills is an undesirable phenomenon of mechanical vibrations, which reduces the productivity and product quality. Generally, chatter phenomenon observed in mostly high speed cold rolling of thin gauge at last and second last stand of tandem cold rolling mill. The chatter vibration causes unacceptable variation of gauge of the strip and visible pattern on the strip surface. This undesirable mill vibration also inflicts serious damage on mill equipment, limiting the rolling speed below designed operating rolling speed leading to production loss. This paper described the practical aspect of chatter vibration with case study from four stand aluminum cold rolling mill at Maaden aluminum rolling mill, KSA. The four stand cold rolling mill is four HI equipped with CVC for a shape control system capable of producing thinner gauge of 0.15 mm 2100 mm wide aluminum Alloy grade AA3104. An online monitoring of vibrations is installed which detects chatter and prevent further damage. The mill rolling speed is designed for 1800 m per minute, but speed limited to 1000 mpm due to mill chatter vibration. The causes and remedies are discussed and most influential factors which enable the chatter are addressed. End result obtained after application of optimum values of most influential active control factors shows there is improvement observed but not up to desired level.

Presenting two different cases of new onset peripheral neuropathy after pancreatic transplantation. One demyelinating in type which is rare in literature ,recovered spontaneously and other one is axonal in type improved with early aggressive intra-venous immunoglobulin therapy. Keywords: Tacrolimus, Post transplant, IV-IG(Intravenous immunoglobulin), Demyelinating and Axonal neuropathy

The single stand cold rolling mills are generally called as reversing mills, whereby the metal strip is successively wound and unwound in the form of coil as it is repeatedly passed back and forth through the one mill stand. Rolling Pass schedule consists of setting of control parameters at each pass depending on various factor like input and output thickness, width of the coil, material to be rolled, mill capability etc. Majority Quality related problem faced by cold rolled producers using single stand cold rolling are strip thickness variation and strip flatness, also they are concerned about power consumption and production rate. This happens because there is no standard pass schedule available which can predict these Performance parameters. The operator uses thumb rule to make pass schedule. There is no Theoretical model available for such complex cold rolling process. Experimental Model using Taguchi based Single Optimization Method can improve the quality and process performance of the Mill. The main objective of this paper is to show the capability of the Taguchi Quality loss function based multi response optimization methods in increasing productivity of cold rolling process while controlling the Quality and cost of Production. The proposed methodology is used to optimize Multi process performance namely thickness variation, strip flatness, production rate and Power consumption by obtaining optimal solution for control factors exit tension, entry tension, Mill speed and Roll bending pressure for cold rolling of low carbon steel in single stand reversible cold rolling mill. A L_27 orthogonal array was selected and total 27 experiments were conducted after selecting control factors and its levels. Interaction plot shows no interaction among the control parameters. The ANOVA carried out which shows the mill speed is most significant control factor. The optimal values obtained using the multi characteristics optimization Model using Taguchi loss function has been validated by confirmation experiment.

The evolution of multi-visceral and isolated intestinal transplant techniques over the last 3 decades has highlighted the technical challenges related to the closure of the abdomen at the end of the procedure. Two key factors that contribute to this challenge include: (1) Volume/edema of donor graft; and (2) loss of abdominal domain in the recipient. Not being able to close the abdominal wall leads to a variety of complications and morbidity that range from complex ventral hernias to bowel perforation. At the end of the 90’s this challenge was overcome by graft reduction during the donor operation or bench table procedure (especially reducing liver and small intestine), as well as techniques to increase the volume of abdominal cavity by pre-operative expansion devices. Recent reports from a few groups have demonstrated the ability of transplanting a full-thickness, vascularized abdominal wall from the same donor. Thus, a spectrum of techniques have co-evolved with multi-visceral and intestinal transplantation, ranging from graft reduction to enlarging the volume of the abdominal cavity. None of these techniques are free from complications, however in large-volume centers the combinations of both (graft reduction and abdominal widening, sometimes used in the same patient) could decrease the adverse events related to recipient’s closure, allowing a faster recovery. The quest for a solution to this unique challenge has led to the proposal and implementation of innovative solutions to enlarge the abdominal cavity.

Small intestinal neuroendocrine neoplasms (SI-NEN) frequently metastasise to regional lymph nodes, and surgery is the mainstay of therapy for such patients. However, despite the possible use of advanced surgical techniques, the resection of both primary and locoregional diseases is not always attainable. Intestinal and multivisceral transplantation has been performed in a small number of patients with conventionally nonresectable, slow-growing tumours threatening the mesenteric root but has remained controversial. The use of donor skin in “sentinel flaps” in transplantation theoretically offers advantages in tailoring immunosuppression and monitoring for rejection. We represent (with extended follow-up) the first case of a patient with inoperable extensive mesenteric metastases from SI-NEN, who underwent neoadjuvant peptide receptor radionuclide therapy before a modified multivisceral transplant with a concomitant vascularised sentinel forearm flap. At 48 months after transplantation, our patient remained at full physical activity with no evidence of disease recurrence on either tumour biochemistry or radiological imaging.

Background: Nations with emerging deceased-donor liver transplantation programs, such as India, face problems associated with poor donor maintenance. Cold ischemic time (CIT) is typically maintained short by matching donor organ recovery and recipient hepatectomy to achieve maximum favorable outcome. We analyzed different extended criteria donor factors including donor acidosis, which may act as a surrogate marker of poor donor maintenance, to quantify the risk of primary nonfunction (PNF) or initial poor function (IPF). Methods: A single-center retrospective outcome analysis of prospectively collected data of patients undergoing deceased-donor liver transplantation over 2 years to determine the impact of different extended criteria donor factors on IPF and PNF. Results: From March 2013 to February 2015, a total of 84 patients underwent deceased-donor liver transplantation. None developed PNF. Thirteen (15.5%) patients developed IPF. Graft macrosteatosis and donor acidosis were only related to IPF ( P = .002 and P = .032, respectively). Cold ischemic time was maintained short (81 cases ≤8 hours, maximum 11 hours) in all cases. Conclusion: Poor donor maintenance as evidenced by donor acidosis and graft macrosteatosis had significant impact in developing IPF when CIT is kept short. Similar study with larger sample size is required to establish extended criteria cutoff values.

In many countries, hydropower development is rapidly becoming a focus of green growth policies. This represents a significant opportunity for ecosystem services-based land management that integrates environmental and development goals to benefit the hydropower sector and support economic growth. In this study, we present an approach for targeting ecosystem-provision investment in hydropower catchments coupled with hydrologic modeling to quantify the benefits of soil and water conservation activities. We demonstrate the application of this approach in five hydropower facility catchments in the state of Himachal Pradesh, India. The results show that there is a high potential for targeted soil and water conservation to increase sediment retention services that benefit hydropower facilities (up to a 44% reduction in sediment transported from uplands into streams), although this benefit is distributed non-uniformly across catchments and levels of investment. The extent to which services can be improved is strongly driven by current land use and management practices that impact how and where conservation activities can be located. Iterative use of the method described here, in a process of stakeholder engagement and capacity-building, enables policy makers to determine the optimal mix of land management strategies and budget allocation to maximize service improvements that support hydropower production.

The follow-up after intestinal transplantation (ITX) is complex and limited to specialized centers. ITX recipients often travel all over the country to be seen in the outpatient clinic of specialized centers which is costly and time-consuming. Videoconferences through Skype have been implemented to eliminate travel time, costs, and to improve patient compliance without jeopardizing safety. Eighteen of 19 patients followed up after ITX or modified multivisceral transplantation (MMVTX) in conventional outpatient clinics in Oxford agreed to attend additional Skype clinics. All patients who were followed up through Skype clinics after ITX/MMVTX received a questionnaire to measure their satisfaction with methods and technical aspects of videoconferencing as well as time/mode of traveling, travel expenses/costs, waiting time in outpatient clinic and patients' satisfaction. Mean travel distance to Oxford was 236 ± 168 miles, mean travel time was 277 ± 175 min, and mean travel cost was 200 ± 56 Great Britain Pounds. A total of 56% had to take time off work and/or find child/family care for the time spent in travel. These patients reported a satisfaction score of 4.38 ± 0.77 of 5 points as opposed to 2.88 ± 0.90 for attending the conventional outpatient clinic. Skype clinics have been proven successful and feasible in highly specialized fields like ITX in eligible patients.

Primary closure of the abdominal wall remains one of the early challenges of intestinal transplantation. Our aim is to review the role of abdominal wall transplantation in achieving tension-free closure of the abdomen.In total, 38 full-thickness vascularized abdominal wall transplants, six partial-thickness vascularized and 17 partial-thickness nonvascularized rectus facia grafts have been reported worldwide. Different techniques have been described. The most popular choice seems to be the full-thickness vascularized abdominal wall allograft, where the anastomosis is performed either in a micro- or macrovascular fashion. Temporary 'remote' revascularisation of the allograft has been performed in some cases onto the recipient's forearm vessels when there is a long anticipated cold ischaemia time (5 h). Preliminary data suggest that the abdominal wall skin rejection might be an early predictor of intestinal rejection. Vascularized and nonvascularized rectus fascia may be effective when there is inadequate healthy muscle/fascia but sufficient skin cover.Several centres have already proved the technical and immunologic feasibility of partial or full-thickness abdominal wall transplantation. It is an effective option to achieve primary abdominal closure following intestinal transplantation and in its full-thickness form, it may be useful for monitoring rejection in visceral organs.

The deficit of organs for renal transplant is a global issue. The United Kingdom Hospital Episode Statistics indicates there that were 8168 nephrectomies undertaken in 2014. Furthermore, according to the British Association of Urological Surgeons 2014 nephrectomy report, 71.8% of patients undergoing a nephrectomy had creatinine levels of less than 120 IU/L and roughly 20% had the procedure for benign and functional causes.We report a prospective case series from March 2014 to March 2016 involving 6 patients showing 3 successful transplants performed following 3 native nephrectomies.All recipients had normal creatinine levels with good function at 12 months, and all nephrectomy patients, in addition to maintaining normal renal function, had definitive resolution of symptoms. The main limitation of this series was the small sample size.There is no doubt that all should be done to save native organ function, and all salvage procedures and psychological testing must be robust before considering this route. However, within the group that proceeds to nephrectomy, some cases may have the potential to generate a new pool of donor organs suitable for transplant, helping to tackle the organ deficit in renal transplantation.

Aim: To compare health-related quality of life (HRQoL) descriptions and utility scores in newly diagnosed peripheral arterial disease (PAD) patients, using two most widely used instruments, EuroQol 5D (EQ-5D) and Medical Outcome Study 36-item Short-Form Health Status Survey (SF-36). Methods: Patients’ self-assessment of HRQoL was measured by the Dutch versions of the EQ-5D and SF-36 in the 204 patients. Results: Mean utility scores ranged from 0.675 for Short-Form Six-Dimension, 0.648 for the EQ-5D UK tariff and 0.715 for the Dutch EQ-5D tariff. A moderate correlation between the utility scores was found due to different valuation techniques of these instruments. Conclusion: Both instruments have clinical validity for use in the PAD and can be used alongside each other to provide a holistic assessment of the HRQoL. Before using these two instruments interchangeably for utility score calculations and healthcare resource allocation, a thorough sensitivity analysis is necessary to explore the robustness of the value argument based on these utility scores.

Our study aimed to determine whether antithrombin plays a synergistic role in accentuating the effects of intestinal ischemic preconditioning.Fifty rats were randomly allocated to 5 groups (10 rats/group) as follows: sham treatment (group 1); ischemia-reperfusion (group 2); ischemic preconditioning followed by ischemia-reperfusion (group 3); antithrombin + ischemia-reperfusion, similar to group 2 but including antithrombin administration (group 4); and antithrombin + ischemic preconditioning, similar to group 3 but including antithrombin administration (group 5). Blood samples and liver specimens were obtained for measurement of cytokines, myeloperoxidase, and malondialdehyde. Liver biopsies were examined by electron microscopy.Intestinal ischemia-reperfusion induced a remote hepatic inflammatory response as evidenced by the striking increase of proinflammatory cytokines, myeloperoxidase, and malondialdehyde. Tumor necrosis factor-α levels in group 5 (12.48 ± 0.7 pg/mL) were significantly lower than in group 3 (13.64 ± 0.78 pg/mL; P = .014). Mean interleukin 1β was lower in group 5 (9.52 ± 0.67pg/mL) than in group 3 (11.05 ± 1.9 pg/mL; P.99). Mean interleukin 6 was also significantly lower in group 5 (17.13 ± 0.54 pg/mL) than in group 3 (23.82 ± 1 pg/mL; P ≤ .001). Myeloperoxidase levels were significantly higher in group 3 (20.52 ± 2.26 U/g) than in group 5 (18.59 ± 1.03 U/g; P = .025). However, malondialdehyde levels did not significantly improve in group 5 (4.55 ± 0.46 μmol) versus group 3 (5.17 ± 0.61 μmol; P = .286). Tumor necrosis factor-α, interleukin 6, and myeloperoxidase findings show that antithrombin administration further attenuated the inflammatory response caused by ischemia-reperfusion, suggesting a synergistic effect with ischemic preconditioning. These findings were confirmed by electron microscopy.The addition of antithrombin to ischemic preconditioning may act to attenuate or prevent damage from ischemia-reperfusion injury by inhibiting the release of cytokines and neutrophil infiltration.

Both authors contributed equally to this work.Primary abdominal wall closure following small boweltransplantation is frequently impossible due to con-traction of the abdominal domain. Although abdomi-nalwalltransplantationwasreported10yearsago,thistechnique has not been widely adopted, partly due toits complexity, but largely because of concerns thatstoring the abdominal allograft until the end of aprolongedintestinaltransplantprocedurewouldcausesevereischemia-reperfusioninjury.Wereportsixcasesof combined small bowel and abdominal wall trans-plantation where the ischemic time was minimized byremotely revascularizing the abdominal wall on theforearm vessels, synchronous to the intestinal proce-dure. When the visceral transplant was complete, theabdominal wall was removed from the forearm andrevascularizedontheabdomen(n¼4),orusedtoclosethe abdomen while still vascularized on the forearm(n¼2). Primary abdominal wall closure was achievedin all. Mean cold ischemia was 305min (300–330min),and revascularization on the arm was 50min (30–60min). Three patients had proven abdominal wallrejection, all treated successfully. Immediate revascu-larization of the abdominal wall allograft substantiallyreduces cold ischemia without imposing constraintson the intestinal transplant. Reducing storage timemay also have benefits with respect to ischemia-reperfusion-related graft immunogenicity.Keywords: Abdominal wall, composite vascularizedallograft, ischemiaAbbreviations: CVA, composite vascularized allograft;LAD, loss of abdominal domain; UW, University ofWisconsinReceived 18 November 2013, revised 11 February 2014and accepted for publication 23 February 2014

Aim: The objective of this study was to explore the cost–effectiveness of D-dimer biomarker and the societal value (headroom) of a hypothetical perfect biomarker for risk assessment and subsequent treatment stratification of prophylactic treatment for peripheral arterial disease (PAD). Patients & methods: Decision analytic modeling. Results: Use of the D-dimer biomarker to prescribe oral anticoagulants in the high-risk subset of patients is a cost-effective healthcare intervention. The headroom (societal willingness to pay multiplied by incremental quality-adjusted life years) available for the hypothetical perfect biomarker amounted to €83,877. Conclusion: D-dimer-based PAD risk assessment and treatment tailoring is cost effective. Identification of high-risk PAD patients and prescription of oral anticoagulants could potentially save substantial costs and improve chances of survival for high-risk PAD patients. However, further research of risk stratifying biomarkers test accuracy is needed to support and strengthen the results of this modeling study.

We report our outcomes following combined intestinal and abdominal wall transplantation, focusing on the presentation and treatment of acute rejection of the abdominal wall vascularized composite allograft (VCA). Retrospective analysis of all patients with combined intestinal/VCA transplantation was undertaken. Graft abnormalities were documented photographically and biopsies taken, with histological classification of rejection according to Banff 2007 guidelines. We have performed five combined intestinal and abdominal wall transplants to date. Two patients developed erythematous, maculopapular to papular eruptions confined to the VCA, histologically confirmed as grade II/III rejection, yet with normal bowel on endoscopy. Both patients' rashes resolved within 72 h of increasing immunosuppressive treatment. One patient later developed a recurrence of the rash, confirmed as skin rejection, but did not immediately seek medical attention. Treatment was therefore delayed, and mild intestinal rejection developed. We describe the rash associated with VCA rejection, and propose that while the skin of an abdominal wall VCA may reject independently of the intestinal allograft, delay in treatment of rejection episodes may result in rejection of the intestinal graft.

Nations with emerging deceased-donor liver transplantation programs, such as India, face problems associated with poor donor maintenance. Cold ischemic time (CIT) is typically maintained short by matching donor organ recovery and recipient hepatectomy to achieve maximum favorable outcome. We analyzed different extended criteria donor factors including donor acidosis, which may act as a surrogate marker of poor donor maintenance, to quantify the risk of primary nonfunction (PNF) or initial poor function (IPF).A single-center retrospective outcome analysis of prospectively collected data of patients undergoing deceased-donor liver transplantation over 2 years to determine the impact of different extended criteria donor factors on IPF and PNF.From March 2013 to February 2015, a total of 84 patients underwent deceased-donor liver transplantation. None developed PNF. Thirteen (15.5%) patients developed IPF. Graft macrosteatosis and donor acidosis were only related to IPF ( P = .002 and P = .032, respectively). Cold ischemic time was maintained short (81 cases ≤8 hours, maximum 11 hours) in all cases.Poor donor maintenance as evidenced by donor acidosis and graft macrosteatosis had significant impact in developing IPF when CIT is kept short. Similar study with larger sample size is required to establish extended criteria cutoff values.

HIV is no longer an absolute contraindication to solid organ transplantation. However, few reports have been published with regards to pancreas or simultaneous pancreas kidney transplantation in the HIV-positive recipient. We report, to our knowledge, the first simultaneous pancreas kidney transplantation (SPK) performed in an HIV-positive patient in the United Kingdom. We reflect on the article recently published by Miro et al in Transplantation Proceedings and highlight strategies used by our department to prevent drug interactions in these complex patients.

Clopidogrel is a potent inhibitor of platelet aggregation and has been used as an alternative, or as an adjunct to aspirin in reducing the risk of thrombosis. A 34-year-old uremic type 1 male diabetic patient who underwent simultaneous kidney-pancreas transplantation was given clopidogrel as he was allergic to aspirin. He developed polyarthralgia one week later, followed in a few days by symmetrical migratory polyarthritis, which resolved completely on withdrawing the drug. The implications to clinical management in a transplant setting are discussed.

Sir:We were interested in this recent article reporting on muscle mass, myofibril cross-sectional area, and neuromuscular junction reinnervation in a murine model of neurotized abdominal wall allotransplantation.1 In their article, Broyles et al. describe the series of human abdominal wall transplan

Chatzizacharias NA, Vaidya A, Sinha S, Sharples E, Smith R, Jones G, Brockmann J, Friend PJ. Risk analysis for deterioration of renal function after pancreas alone transplant. Clin Transplant 2011 DOI: 10.1111/j.1399-0012.2011.01534.x. © 2011 John Wiley & Sons A/S. Abstract: The risk of progression to renal replacement after pancreas transplant alone (PTA) is a concern in patients with pre-transplant estimated glomerular filtration rate (eGFR) 12 mg/dL) at six months post-transplant was the only independent risk factor identifying a substantial decline in native renal function by Cox regression analysis (HR = 14.300, CI = 1.271-160.907, p = 0.031). The presence of severe pre-transplant proteinuria (urine Pr/Cr ≥100 mg/mmol) marginally failed to reach significance (p = 0.056). Low eGFR levels alone (≤45 and ≤40 mL/min/1.73 m(2) ) at the time of transplant did not correlate with substantial decline in renal function. Our data suggest that PTA is a justifiable therapy for patients with hypoglycemia unawareness or other life-threatening diabetic complications, even in those with borderline renal function, provided that they do not suffer from severe proteinuria and appropriate monitoring and tailoring of immunosuppression is ensured. © 2011 John Wiley & Sons A/S.

The effect of pancreas transplantation on renal function remains a matter of debate. The purpose of this retrospective, single-unit study is a preliminary analysis of renal function one yr after pancreas transplant (pancreas alone [PTA] or pancreas after kidney [PAK]). Fifty-nine patients were included. Serum creatinine and estimated glomerular filtration rate (eGFR) levels were compared three, six, and 12 months post-transplantation for the whole sample and separately for PTA and PAK and high (>45 mL/min/1.73 m(2)) and low (≤45 mL/min/1.73 m(2)) pre-transplant eGFR subgroups. Overall, eGFR did not change significantly (p = 0.228) at the end of the first year post-transplant, with patients of low initial eGFR presenting a more prominent trend toward stable or improved levels. In the PAK subgroup, eGFR was significantly improved (p = 0.035). High eGFR subgroup demonstrated no significant deterioration in renal function, while patients with low initial eGFR had significantly higher levels 3 (p = 0.012) and six months (p = 0.009) post-transplant. Our study shows that renal function did not deteriorate significantly one yr after pancreas transplant (PTA or PAK), even in patients with substantial pre-existing renal dysfunction. Evaluation at a wider scale and identification of risk factors for potential deterioration are challenges for future research.

Background: The left upper quadrant of the abdomen may be occupied by a wide range of urologic pathology. When these lesions are large, safely resecting them often presents a significant technical challenge, with the possibility of resultant morbidity and mortality. Objective: We describe a technique derived from our experience with multivisceral transplant and organ procurement, which provides excellent exposure of this anatomic region. Design, setting, and participants: From May 1999 to April 2006, 70 patients underwent en bloc mobilization of the spleen and the pancreas and, as necessary, the stomach for masses in the left upper retroperitoneum. Pathology included malignant and benign lesions, including renal cell carcinoma (RCC) with or without inferior vena cava (IVC) involvement, adrenal tumors, retrocrural lymphadenopathy from testicular cancer, and transitional cell carcinoma of the renal pelvis. Surgical procedure: An extended subcostal transabdominal approach was used to resect large tumors in the left upper abdomen. This approach offers significant advantages over conventional approaches, including a flank, thoracoabdominal, or midline transabdominal incision with reflection of the descending colon. Measurements: Intraoperative variables, including operative time, blood loss, transfusion rate, and extent of mobilization were recorded. Postoperative complications, including prolonged intubation, ileus, and deep venous thrombosis were also noted. Results and limitations: Mean estimated blood loss during surgery was 973 ml. There were no perioperative deaths. No patients had pancreatitis or acute renal failure. Deep venous thrombosis was not seen. Cardiopulmonary bypass was used in one patient with an atrial thrombus. At a median follow-up of 42 mo, two patients died due to metastasis. Conclusions: Techniques acquired from organ harvesting as well as our experience at multivisceral transplant, such as en bloc mobilization of the spleen, pancreas, and stomach, can be utilized safely and effectively to gain excellent exposure to the left upper retroperitoneum via an extended subcostal incision with no additional morbidity for the patient.

Alemtuzumab is a humanized anti-CD52 antibody that depletes lymphocytes and has been increasingly used as induction agent in transplantation. The impact of alemtuzumab induction immunosuppression in pancreas transplantation was evaluated, with particular reference to steroid avoidance in maintenance. A total of 100 patients who received 102 pancreas transplants (83 simultaneous kidney–pancreas [SPK], 15 pancreas after kidney transplantation [PAK] and 4 pancreas transplant alone [PTA]) were included. All patients received two doses of 30-mg alemtuzumab i.v. with tacrolimus (trough level 8–12 ng/mL) and mycophenolate mofetil (MMF,1g/day) with no maintenance steroids. This analysis included 62 male and 38 female recipients, with mean (±SD) age of 42 (±7.6) years. Median follow-up was 17 months (range 8–41 months). One-year patient, pancreas and kidney graft survival (actuarial) was 97%, 89% and 94%, respectively. Overall incidence of rejection was 25%. Side effects of alemtuzumab administration included thrombocytopenia (14%), pulmonary edema (2%) and rash (1%). Twenty-five percent required reoperations (12% for bleeding). Infectious complications included Cytomegalovirus (CMV,6.8%) BK viruria (3.8%), fungal infections (4%), primary varicella (1%) and posttransplant lymphoproliferative disorders (PTLD,1%). Eighty-three percent did not require any steroids posttransplant. These results indicate that alemtuzumab is safe and enables pancreas transplantation to be carried out without maintenance steroids in 83% of cases and acceptable rejection rate.

Inflammatory bowel disease (IBD), in particular Crohn’s disease (CD), can result in Intestinal Failure (IF) requiring long-term home parenteral nutrition (HPN). Where patients experience life-threatening complications associated with HPN, small bowel intestinal transplantation (SBITx) provides a realistic alternative therapeutic option, but comes with its own set of risks and complications associated with surgery and immunosuppression. This chapter will provide an overview of IF, the indications for SBITx, types of SBITx and outcomes and economic considerations of SBITx pertinent to patients with IBD.

Individuals with arterial vascular diseases (AVDs) are at significantly increased risk of heart attack, stroke, and death. Early diagnosis and appropriate management of AVDs may help prevent these life-threatening events and associated costs. There is substantial evidence that the majority of AVDs remain under detected and under treated in routine clinical practice. This research synthesized clinical and economic evidence in support of targeted screening for detection of AVDs and personalized, stratified treatment based on the patient risk profile. Given the cost-effectiveness results of AVDs screening and risk based customized treatment findings presented in this dissertation, current screening and treatment guidelines need to be reconsidered.

The aim of this study was to see whether lessons could be learned from the prospectively maintained nationwide database on solitary pancreas transplantation (SPTx) performed in the UK.Two hundred and forty-five SPTx were utilized from the 2004-2013 period (113 pancreas transplant alone and 132 pancreas after kidney). The statistical analysis included donor, recipient, transplant variables, and the effect of a rejection episode on graft survival.Cold ischemia time (CIT), CIT12 h, donor body mass index (BMI)30, and non-lymphocyte-depleting induction immunosuppression achieved p-value0.05 in the unadjusted univariate hazard model analysis. In a multivariate analysis, variables that persisted in demonstrating increased independent risk included CIT12 h (hazard ratio [HR] 1.94, p = 0.035) and the use of non-depleting induction immunosuppression (HR 1.95, p = 0.002). Factors such as bladder-drained grafts and donor variables including age, BMI, and donation after cardiac death (DCD) vs. donation after brain-stem death did not attain significance. Rejection reduces the overall graft survival by approximately 1000 d (1841 ± 114 d vs. 915 ± 119 d, p = 0.001).Cold ischemia time12 h and the use of depleting antibodies as induction immunosuppression have a positive effect on pancreas allograft survival. Other factors such as bladder-drained grafts and donor variables such as age, BMI, and DCD status did not attain significance in a multivariate analysis.

Abdominal wall transplantation (AWTX) has revolutionized difficult abdominal closure after intestinal transplantation (ITX). More important, the skin of the transplanted abdominal wall (AW) may serve as an immunological tool for differential diagnosis of bowel dysfunction after transplant. Between August 2008 and October 2014, 29 small bowel transplantations were performed in 28 patients (16 male, 12 female; aged 41 ± 13 years). Two groups were identified: the solid organ transplant (SOT) group (n = 15; 12 ITX and 3 modified multivisceral transplantation [MMVTX]) and the SOT-AWTX group (n = 14; 12 ITX and 2 MMVTX), with the latter including one ITX-AWTX retransplantation. Two doses of alemtuzumab were used for induction (30 mg, 6 and 24 h after reperfusion), and tacrolimus (trough levels 8-12 ng/mL) was used for maintenance immunosuppression. Patient survival was similar in both groups (67% vs. 61%); however, the SOT-AWTX group showed faster posttransplant recovery, better intestinal graft survival (79% vs. 60%), a lower intestinal rejection rate (7% vs. 27%) and a lower rate of misdiagnoses in which viral infection was mistaken and treated as rejection (14% vs. 33%). The skin component of the AW may serve as an immune modulator and sentinel marker for immunological activity in the host. This can be a vital tool for timely prevention of intestinal graft rejection and, more important, avoidance of overimmunosuppression in cases of bowel dysfunction not related to graft rejection.

A 49-year-old man presented with a 15-year history of problematic pelviureteric junction obstruction of his left kidney. Surgical management had failed to sufficiently control his symptoms and he was keen to have the kidney removed. Following preoperative discussion, the patient consented to his kidney being used for transplant. Following a total nephrectomy, the kidney was successfully transplanted into a 61-year-old woman, with a cold ischaemic time of 3 h and 22 min. There was primary function in the transplanted kidney and creatinine at 6 weeks was 60. This case highlights the potential for using organs with pelviureteric junction obstruction for living donor transplant and thereby expanding the donor pool.

Background. Orthotopic liver transplantation (OLT) in adult patients has traditionally been performed using conventional caval reconstruction technique (CV) with veno-venous bypass. Patients and methods. Recently, the piggyback technique (PB) without veno-venous bypass has begun to be widely used. The aim of this study was to assess the effect of routine use of PB on OLTs in adult patients.A retrospective analysis was undertaken of 1067 orthotopic cadaveric whole liver transplantations in adult patients treated between June 1994 and July 2001. PB was used as the routine procedure. Patient demographics, factors including cold ischemia time (CIT), warm ischemia time (WIT), operative time, transfusions, blood loss, and postoperative results were assessed. The effects of clinical factors on graft survival were assessed by univariate and multivariate analyses. Results. In all, 918 transplantations (86%) were performed with PB. Blood transfusion, WIT, and usage of veno-venous bypass were less with PB. Seventy-five (8.3%) cases with PB had refractory ascites following OLT (p=NS). Five venous outflow stenosis cases (0.54%) with PB were noted (p=NS). The liver and renal function during the postoperative periods was similar. Overall 1-, 3-, and 5-year patient survival rates were 85%, 78%, and 72% with PB. Univariate analysis showed that cava reconstruction method, CIT, WIT, amount of transfusion, length of hospital stay, donor age, and tumor presence were significant factors influencing graft survival. Multivariate analysis further reinforced the fact that CIT, donor age, amount of transfusion, and hospital stay were prognostic factors for graft survival. Conclusions. PB can be performed safely in the majority of adult OLTs. Results of OLT with PB are as same as for CV. Liver function, renal function, morbidity, mortality, and patient and graft survival are similar to CV. However, amount of transfusion, WIT, and use of veno-venous bypass are less with PB.

Background. Intrahepatic biliary strictures (IHBS) without hepatic artery thrombosis (HAT) is a serious complication and known to increase the risk of graft failure after liver transplantation. This manuscript describes the incidence, risk factors, clinical pictures, management, and outcomes. Methods. Between 1994 and 2002, 1,113 liver transplantations were performed in 974 adult patients. Data was retrospectively analyzed in terms of incidence, risk factors, clinical pictures (type of strictures), management (radiologic, surgical management), and outcomes. Results. Sixteen (1.4%) grafts had IHBS without HAT. Specific risk factors were not identified from donors or recipients. However, ischemic factors from the donors were suspected from non-heart-beating donors (n=1) and cardiac-arrest donors (n=2). Three types of IHBS were identified: (1) diffuse type (n=7), (2) bilateral proximal type (n=7), and (3) unilateral type (n=2). Overall success rate of radiologic interventions was 31.3% (5/16). Of the 11 patients who did not improve, 6 died: diffuse type (3/7, 42.9%), bilateral type (3/7, 42.9%), and unilateral (0/2, 0%). Three patients had retransplantation, and two patients are waiting retransplantation. The majority of the IHBS were diffuse or bilateral (14/16, 87.5%), and rate of the graft failure was high (10/14, 71.4 %). Overall graft survival of IHBS was lower than that without IHBS (P=0.025). Conclusions. The majority of the IHBS without HAT were of a diffuse or bilateral proximal type. Patients with diffuse or bilateral proximal type have a low success rate from radiologic intervention and may benefit from early retransplantation.