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INTRODUCTION: Open transplant nephrectomy for failed renal allograft is an invasive procedure associated with significant perioperative morbidity and mortality. Minimally invasive surgical approaches have improved a variety of patient outcomes for many surgeries. Thus, robotic assisted transplant nephrectomy (RATN) potentially offers significant patient benefit. Although previously reported, there remains a paucity of data on RATN outcomes and techniques. METHODS: Four perfused, high-fidelity hydrogel models were created using previously described techniques and used for simulated RATN. Subsequently performed institutional cases were included for analysis. Intra- and postoperative variables along with patient demographics were retrospectively obtained through parsing of patient records. RESULTS: Simulated nephrectomy time was 67.33 minutes (35.75 – 98.91). Five patients underwent RATN. There were four male and one female patients. The average age was 47 years. The most common indication was abdominal pain secondary to rejection (3/5). Mean blood loss was 188 mL; mean operative time was 243 minutes, and mean length of stay was 4.5 days. Intraoperatively there were two incidences of small cystotomies. One patient was readmitted within 30 days for intraabdominal abscess. CONCLUSION: This study adds to the growing literature around RATN, demonstrating the feasibility of the technique and reporting good outcomes for this cohort.

Introduction: Despite strong public support, organ donor registration rates (RR) continue to lag while need only grows. In the United States, the traditional registration site is the Department of Motor Vehicles (DMV), however Primary care provider (PCP) offices have been considered as alternate locations for increasing RR. Methods: Twelve PCP offices across 2 New York Counties were subjected to a control week where participants received only a registration opportunity and an intervention week with the addition of a motivational poster and informational brochure. Zip code level sociodemographic data were obtained for each site. RR from the DMV over the same period served as historical control. Results: There were 1292 participants in the control phase and 1099 in the experimental phase. New registration rate for the control was 33.8% (289/897); experimental phase 7.88% (61/769); DMV registration 21.02% (1902/9050). The intervention was associated with a significant decrease in registrations (OR 0.181 (95% CI 0.135-0.244, P

Invasive fungal infections (IFIs) are associated with a high mortality rate for liver transplantation (LT) recipients. To study the incidence of and risk factors for IFIs in LT recipients and the associated mortality rates, we retrospectively reviewed the records of first-time deceased donor LT recipients (January 2003 to December 2007). The incidence of IFIs was 12%. Non-albicans Candida species accounted for 55% of IFIs; 50% of these IFIs were Candida parapsilosis. Only 43% of Candida isolates were fluconazole-susceptible (minimum inhibitory concentration ≤ 8 μ/mL). All C. parapsilosis isolates were fluconazole-resistant, and this coincided with a surge of these isolates during a peak period of LT. Factors associated with IFIs included a creatinine level2 mg/mL [hazard ratio (OR) = 2.4, 95% confidence interval (CI) = 1.2-5.0, P = 0.01], a Model for End-Stage Liver Disease score25 (OR = 2.4, 95% CI = 1.2-4.9, P = 0.02), pretransplant fungal colonization (OR = 7.0, 95% CI = 3.2-15.3, P0.001), and a daily prophylactic fluconazole dosage200 mg (OR = 2.8, 95% CI = 1.1-7.4, P = 0.03). According to a multivariate analysis, only pretransplant fungal colonization was associated with IFIs (OR = 7.8, 95% CI = 3.9-16.2, P0.001). The 1-year patient survival rates with and without IFIs were 41% and 80%, respectively, and the survival rates with C. parapsilosis, other non-albicans Candida, and Candida albicans IFIs were 28%, 50%, and 75%, respectively. In conclusion, IFIs after LT (especially non-albicans Candida species and fluconazole-resistant C. parapsilosis) were associated with reduced survival. The risk factors highlight the importance of pretransplant risk assessments. The identification of pretransplant fungal colonization may allow for risk modifications before or at the time of LT. Additionally, the number of LT procedures and prophylactic strategies may affect institutional outbreaks of resistant Candida strains.

Alpha 1 antitrypsin (A1A) is a 52 kD glycoprotein that is mainly synthesized in the liver. As a major protease inhibitor, it binds to and neutralizes neutrophil elastase, thereby limiting the damage to the normal tissues after an inflammatory response. A deficiency in A1A leads to end-stage liver disease, both in children and in adults. In addition, the deficiency also has a detrimental effect in the lungs of the adult population. Alpha 1 antitrypsin deficiency is corrected with hepatic replacement; however, the changes in pulmonary functions have not been studied before and after liver transplant. The purpose of this study was to observe the changes in the pulmonary functions of patients who underwent liver transplant for the treatment of A1A deficiency.Nine patients underwent liver transplant for A1A deficiency. Seven patients (5 men, 2 women; mean age, 49.95 -/+ 7.09 years) had their pulmonary function tests available before the liver transplant (mean, 5.6 -/+ 3.4; range, 0.9-10.1 months) and after the liver transplant (mean, 30.3 -/+ 18.4, range 7.8-48.1 months) for analysis.The mean, preliver, transplant, FEV1 was 2.69 -/+ 0.9 L, which was nearly unchanged after the liver transplant to a mean of 2.7 -/+ 1.2 L. During the mean total interval of nearly 3 years, an estimated decline of 250 mL in FEV1 was expected.It appears from the results of our study that liver transplant probably prevented the progression of pulmonary disease in A1A-deficient patients. Further study and close, postliver, transplant follow-up is warranted to support our initial findings.

The number of liver donors has not measurably increased since 2004 and has begun to decrease. Although many waitlisted patients may be suitable candidates to receive a living donor graft, they are often reticent to discuss living donation with close friends and family, partly because of a lack of knowledge about donor health and quality of life outcomes after donation. The objective of this study was to test the effectiveness of an educational intervention that uses testimonials and self-report data from living donors in New York State. The study had an independent sample pretest (n = 437) and posttest (n = 338) design with posttest, between-subjects comparison for intervention exposure. All waitlisted patients at 5 liver transplant centers in New York were provided a peer-based educational brochure and DVD either by mail or at the clinic. The outcome measures were liver candidates' knowledge and self-efficacy to discuss living donation with family and friends. The number and proportion of individuals who presented to centers for living liver donation evaluation were also measured. Liver transplant candidates' self-efficacy to discuss living donation and their knowledge increased from the pretest period to the posttest period. Those exposed to the peer-based intervention reported significantly greater knowledge, a greater likelihood of discussing donation, and increased self-efficacy in comparison with those not exposed to the intervention. The results did not differ by age, length of time on the waiting list, education, or ethnicity. In comparison with the preintervention period, living donation increased 42%, and the number of individuals who presented for donation evaluation increased by 74%.

Liver transplantation (LTx) is a life-saving procedure for end-stage liver disease. However, LTx remains a major surgical procedure with a significant amount of morbidity and mortality. Several different types of post-LTx complications have been studied and reported; however, the numbness of the abdominal skin between the subcostal incision and the umbilicus and its associated complications have not been studied in a large patient population. The aim of this study was to report the incidence of numbness in the abdominal skin post-LTx and its implications in routine life. One hundred and one post-LTx patients were questioned in the clinic about numbness. There were 52 male patients and 49 female patients with a mean age of 51.9 +/- 11.3 years at the time of LTx, and the mean time from transplant was 35.0 +/- 29.5 months (range, 3-113 months). The implications were recorded. All 101 patients (100%) had an area of numbness between the subcostal incision and the umbilicus. Four of these patients had an area of superficial-to-deep burns from hot food (accidentally dropped on the abdomen), heating pads, or a hot cup of tea. One patient had ecchymosis from blunt trauma during gardening. Out of 36 diabetic patients, more than 24 patients were insulin-dependent and used the area for subcutaneous insulin injections. In addition, some of the 43 hepatitis C virus-positive patients used the area for subcutaneous interferon therapy. In conclusion, 100% of the patients had persistent numbness up to 9 years following LTx. Five percent of the patients developed thermal injuries or blunt trauma complications that could have been prevented with better education and awareness. More then 24% of the patients used the area for subcutaneous injections of insulin and/or interferon.

Traditionally, patients who die with a malignancy have been excluded from donation. However, it has become a common practice to accept organs from donors that have low-grade tumors or tumors with low metastatic potential. The aim of this study was to analyze our experience with the use of liver grafts from donors with central nervous system (CNS) tumors. A retrospective review of 1173 liver transplants performed between 1992 and 2006 identified 42 donors diagnosed with a CNS tumor. Thirty-two tumors were malignant, and 10 tumors were benign. Forty-two liver transplant recipients received livers from these donors. All patients were followed until May 2007 with a mean follow-up of 29 +/- 17 months. Among 42 donors, there were 28 males and 14 females. The mean donor risk index was 1.78 +/- 0.39. Twenty (47.6%) of the CNS tumors were glioblastoma multiforme (astrocytoma grade IV), 11 (26.2%) were other astrocytomas, and 1 (2.4%) was an anaplastic ependymoma. Twenty (62.5%) neoplasms were grade IV tumors, 8 (25%) were grade II tumors, and 4 (12.5%) were grade III tumors. Over 80% of the patients had at least 1 kind of invasive procedure violating the blood-brain barrier. The rate of recurrence for the entire group was 2.4% (all CNS tumors). There were 7 (7.2%) deaths in all. The most common cause of death was sepsis (n = 3, 7.2%). There was no difference in survival between recipients of grafts from donors with CNS tumors and recipients of grafts from donors without CNS tumors (1 year: 82% versus 83.3%, P = not significant; 3 years: 77.4% versus 72%, P = not significant). In conclusion, in our experience, despite violation of the blood-brain barrier and high-grade CNS tumors, recurrence was uncommon. Grafts from these donors are often an overlooked source of high-quality organs from younger donors and can be appropriately used, particularly in patients who, despite low Model for End-Stage Liver Disease scores, carry a high risk of mortality.

Alcohol-related end-stage liver disease was the most common reason for liver transplant in the 1990s. Currently, hepatitis C virus (HCV) is the most common reason for transplant. The major HCV risk factor is intravenous drug abuse, which often includes other forms of substance abuse. It is important to understand posttransplant survival outcomes in patients with multiple substance abuse and pretransplant factors that predict relapse.The medical records of patients referred to the transplant psychiatrist were retrospectively reviewed to identify posttransplant patients with pretransplant multisubstance abuse issues including cannabis, cocaine, opioids, and alcohol. Survival outcomes and drug relapse were assessed in relation to demographic variables including age, race, sex, legal history, psychiatric diagnoses or need for psychiatric hospitalization, and substance abuse diagnosis.Twenty-seven patients with polysubstance abuse disorders were identified: substance abuse (n=41), substance dependence (n=33), and other (n=8); a mean of 3.03 substances was used per patient. Eight patients relapsed (29.6%) and 10 patients died (33%) between 2 and 60 months after transplant. Patients were divided into relapse and no-relapse groups, and 1-year patient survival rates in patients were 100% and 83.9%, respectively. No between-group differences were found for age, race, sex, legal history, psychiatric diagnoses or need for psychiatric hospitalization, or having first-degree relatives with substance abuse issues.The rate of recidivism was 26.9%; however, it did not affect survival. No predictors of relapse were identified. Patients with polysubstance abuse issues should not be categorically denied access to liver transplant. Further research regarding these issues is essential.

Biochemical abnormalities after living-donor hepatectomy are attributed to the loss of liver volume and steatosis or fibrosis. In this study, we evaluated the intraoperative biochemical changes caused by the separation of the hepatic lobes before removal and the impact of those changes on postoperative biochemical abnormalities in patients who underwent adult-to-adult living-donor liver transplantation (LDLT).The extent and postoperative impact of the biochemical changes that occur during hepatic parenchymal transection in adult-to- adult LDLT were studied in 38 patients who underwent that procedure (14 men and 24 women; mean age, 39.6 years; age range, 19.5-58.9 years). Preoperative, intraoperative, and postoperative biochemical values for the first 8 postoperative days were compared.The mean total hepatic volume was 1703.0 mL, the mean weight of the resected mass was 887.0 g (52.6%), and the mean weight of the residual mass was 816.0 g (47.4%). The mean total bilirubin, aspartate amino transferase (AST), and amino alanine transferase (ALT) values were 8.6 U/L, 21.4 U/L, and 27.6 U/L, respectively, before surgery, compared with 27.4 U/L (an increase of 3.2 times), 257.9.2 U/L (an increase of 12.0 times), and 224.64 U/L (an increase of 8.1 times), respectively, after separation of the hepatic lobes. Patients (n = 21) with an intraoperative ALT value ofor= 200 had a significantly higher peak postoperative ALT (P = .001) than did those (n = 17) with an ALT value of200.A significant increase in hepatic biochemical parameters occurs at the completion of hepatic parenchymal transection and before the removal of the right hepatic lobe from the donor. This has an impact on postoperative peak enzyme levels in the donor.

A 46-year-old patient supported by a biventricular assist device (BiVAD) was transferred to our institution for evaluation for heart transplant. The patient was found to have a large intracranial hemorrhage with profound deterioration of neurologic status. The poor prognosis prompted the decision to withdraw care and pursue organ donation. Because the patient did not meet brain death criteria, nonheart-beating donor organ donation was pursued. After the termination of care, the BiVAD was modified: the left side to provide organ preservative solution and the right side to allow drainage. Eight liters of cold University of Wisconsin solution were pumped systemically over 10 minutes, the donor was drained, and the liver was harvested. This technique expedited donor perfusion by eliminating the need to cannulate, minimizing ischemic time for the liver. Although the recipient outcome was poor, and retransplantation was eventually necessary, we believe it was most likely not attributable to the quality of organ preservation. This report discusses the technical aspects of this potentially beneficial procedure.

Hepatitis C virus (HCV) is not directly cytopathic to the hepatocytes; however, host immune response against the virus does cause hepatic injury. Production of the HCV antibody is a host immune response to a viral antigen. The currently used HCV antibody assay is a qualitative, not quantitative, assessment. In this study, we sought to quantitatively estimate HCV antibody levels in patients who had undergone liver transplantations at the University of Rochester Medical Center, Rochester, New York, and correlate these levels with HCV RNA viral load, genotype, severity of recurrence, and anti-HCV treatment.From 39 liver transplantation patients, we obtained 141 blood samples for quantitative HCV RNA to measure HCV antibody levels quantitatively.Most antibody levels were within a narrow range with a mean of 32.9+/-5.1. Samples with undetectable RNA had a mean antibody level of 31.4+/-8.0, and samples with a positive RNA had mean level of 33.0+/-4.6. The mean antibody levels were significantly higher for patients with genotype 1 (n=33) compared with those with genotype 2 (n=5) (33.2 vs 29.1; P=.007). No correlation was found between antibody levels and severity of hepatic injury with regard to hepatitis activity index or fibrosis score. Six patients with no response to anti-HCV treatment had no change in their mean antibody levels (33.7 vs 34.5). Ten patients who responded to anti-HCV therapy had lower mean levels after therapy, but the changes were not significant (34.2 vs 30.4).Antibody levels in this study did not correlate with viral load or hepatic injury. However, genotype-2 patients had significantly lower levels compared with genotype-1 patients, and patients who responded to anti-HCV therapy demonstrated decreased antibody levels.

University of Wisconsin solution has twice the cold hepatic preservation time as does Euro-Collins solution. Histidine-tryptophan-ketoglutarate has a lower potassium content than does University of Wisconsin solution and is used more frequently. To date, however, studies comparing University of Wisconsin and histidine-tryptophan-ketoglutarate in live-donor liver transplantation are lacking. We therefore sought to examine the hepatic function of live-donor liver transplantation allografts preserved in University of Wisconsin solution as compared with those preserved in histidine-tryptophan- ketoglutarate solution.Between July 2003 and August 2004, 33 live-donor liver transplantations were performed at the University of Rochester Medical Center, Rochester, NY, USA. University of Wisconsin solution was used for the first 9 allografts, and histidine-tryptophan-ketoglutarate was used for the subsequent 24 allografts. Daily total bilirubin, aspartate amino transferase, amino alanine transferase, alkaline phosphatase, gamma glutamyl transpeptidase, and international normalized ratio levels were measured for the first 8 postoperative days. Peak values were compared between the groups.There was no primary graft nonfunction in either group. Two patients in the histidine-tryptophan- ketoglutarate group developed hepatic artery thromboses and underwent a retransplantation. Mean peak aspartate amino transferase and amino alanine transferase levels were higher in patients in the histidine-tryptophan-ketoglutarate group (aspartate amino transferase, 661+/-801 U/L; amino alanine transferase, 696+/-964 U/L) than they were in patients in the University of Wisconsin group (aspartate amino transferase, 439+/-415 U/L; amino alanine transferase, 464+/-376 U/L); however, this difference was not significant. Mean total bilirubin, alkaline phosphatase, and gamma glutamyl transpeptidase levels, and international normalized ratios were similar in both groups.University of Wisconsin and histidine-tryptophan- ketoglutarate solutions are both effective in preserving live-donor liver allografts. In the current study, patients in the histidine-tryptophan-ketoglutarate group had higher peak aspartate amino transferase and amino alanine transferase levels initially, but these became almost identical by postoperative day 8.

Mycophenolate mofetil (MMF) is used in liver transplantation (LTx) to reduce rejection, nephrotoxicity, neurotoxicity, and the need for steroids. Lower trough concentrations and bioavailability have been reported with oral MMF in first week after LTx. These parameters improve after the first month postoperatively. Previously published studies have used oral formulations of MMF. In this study, we sought to examine survival, rejection, and nephrotoxicity rates using IV MMF in live donor liver transplantation (LDLT).Twenty-eight patients (mean age, 50.1 years; 15 men, 13 women) were examined between January 2000 and January 2004 with a mean follow-up of 17 months for survival, rejection, and renal function.Four patients died at 2, 5, 8, and 18 months after LDLT from sepsis (n = 3) and recurrent hepatocellular carcinoma (n = 1). There were no retransplants; hence, patient and graft survival rates were the same (82.4%). Three patients (10.7%) experienced acute cellular rejection requiring treatment. The mean serum creatinine level prior to LDLT was 0.9 +/- 0.4 mg/dL, which remained stable throughout the study. One patient required hemodialysis during the perioperative period for 8 days.In the current study, we demonstrate a new strategy of IV MMF administration with low-dose tacrolimus that provides for lower rates of acute rejection, better preservation of renal function, and one that is better tolerated compared with historical treatments after LTx.

Toll-like receptor 3 (TLR3), which recognizes double-stranded RNA (dsRNA), was the first identified antiviral TLR, and because dsRNA is a universal viral molecular pattern, TLR3 has been assumed to have a central role in the host response to viruses. Natural killer (NK) cells are a component of innate immunity against viral infections through their rapid cytotoxic activity and cytokine production. The synthetic dsRNA polyinosinic-polycytidylic acid (poly I:C), a mimic of a common product of viral infections, is known to rapidly up-regulate their in vivo functions; however, intrahepatic NK cells’ ability to respond to dsRNA is still mostly unknown. Our results show that poly I:C activates liver NK cells directly in the context of cytokines found in the liver, i.e: poly I:C plus inflammatory cytokines (IL-18, IL-12, and IL-2) induced NK cell IFN-g production and TRAIL expression, and anti-inflammatory cytokines (TGF-β and IL-10) inhibit NK cell IFN-γ production. Neutralization of IFN-g blocks poly I:C plus inflammatory cytokines-induced NK cell TRAIL expression, suggesting that IFN-g is an autocrine differentiation factor for these cells. A better understanding of the intrahepatic NK cell activation against viral infection may help in the design of therapies and vaccines for the control of viral hepatitis.