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Biomedical subjects

James F Trotter

Publications and source records attributed to James F Trotter.

At least 19 recordsLinked to original sources
PubMed2006

Documented deaths of hepatic lobe donors for living donor liver transplantation.

The actual risk of death in hepatic lobe donors for living donor liver transplantation (LDLT) is unknown because of the lack of a comprehensive database. In the absence of a definitive estimate of the risk of donor death, the medical literature has become replete with anecdotal reports of donor deaths, many of which cannot be substantiated. Because donor death is one of the most important outcomes of LDLT, we performed a comprehensive survey of the medical and lay literature to provide a referenced source of worldwide donor deaths. We reviewed all published articles from the medical literature on LDLT and searched the lay literature for donor deaths from 1989 to February 2006. We classified each death as "definitely," "possibly," or "unlikely" related to donor surgery. We identified 19 donor deaths (and one additional donor in a chronic vegetative state). Thirteen deaths and the vegetative donor were "definitely," 2 were "possibly," and 4 were "unlikely" related to donor surgery. The estimated rate of donor death "definitely" related to donor surgery is 0.15%. The rate of donor death which is "definitely" or "possibly" related to the donor surgery is 0.20%. This analysis provides a source document of all identifiable living liver donor deaths, provides a better estimate of donor death rate, and may provide an impetus for centers with unreported deaths to submit these outcomes to the liver transplantation community.

Data Collection↗
PubMed2006

Coagulation abnormalities in patients who have liver disease.

The liver plays a central role in the maintenance of normal hemostatic function. Because liver disease alters pathways of coagulation and anticoagulation, patients who have advanced disease can experience severe bleeding or thrombotic complications. Complications of advanced liver disease may also contribute to bleeding or thrombosis. This article reviews and discusses the management of the most common coagulation problems encountered in patients who have end-stage liver disease, which are thrombocytopenia and impaired humoral coagulation as measured by prolongation of the prothrombin time and international normalized ratio.

Blood Coagulation Disorders↗
PubMed2006

Endoscopic gallbladder stent placement for treatment of symptomatic cholelithiasis in patients with end-stage liver disease.

OBJECTIVES: Symptomatic cholelithiasis is a common disease in the general population with an increased prevalence in patients with cirrhosis. While cholecystectomy is the procedure of choice for the treatment of symptomatic cholelithiasis, cirrhotics have an increased risk of complications associated with this therapy. We have found that placement of an endoscopic gallbladder stent is an alternative, less invasive treatment for cirrhotic patients with symptomatic gallbladder disease and describe our experience here. METHODS: A retrospective medical record review of 23 patients with cirrhosis who underwent endoscopic retrograde cholangiography with gallbladder stent placement for symptomatic gallbladder disease from July 1994 to August 2004. RESULTS: Indications for stent placement included recurrent biliary colic (56.5%), acute calculous cholecystitis (39%), acalculous cholecystitis (8.6%), and gallstone pancreatitis (8.6%). All patients experienced resolution of their symptoms following stent placement. Twenty patients (87%) were asymptomatic from 5 days to 3 years post-procedure until transplantation, death, or end of study period. Nine patients (39%) underwent liver transplantation, 5 days to 34 months after the procedure. Eleven patients are well, with ten patients awaiting liver transplantation. Three patients developed late complications and were treated successfully with antibiotics. CONCLUSION: Endoscopic stenting of the gallbladder may be a potential treatment for symptomatic gallbladder disease in patients with cirrhosis awaiting liver transplantation, considered to be high-risk for cholecystectomy.

Adult↗
PubMed2005

Torulopsis glabrata fungemia from infected transjugular intrahepatic portosystemic shunt stent.

Transjugular intrahepatic portosystemic shunts (TIPS) are used to manage multiple complications of portal hypertension. Accounts of infection of TIPS stents are uncommon. The literature reports two cases of TIPS-associated Torulopsis glabrata (Candida glabrata) fungemia; both patients died within a year of TIPS placement despite therapy with intravenous antifungal agents. This report describes the successful long-term survival of a patient with Torulopsis TIPS stent infection.

Antifungal Agents↗
PubMed2005

Immunosuppression: evolution in practice and trends, 1993-2003.

Immunosuppression trends for solid organ transplantation have undergone a perceptible shift over the past decade. This period is of interest because it was during this time that the Food and Drug Administration (FDA) expanded the variety of medications to allow for alternatives in immunosuppressive management. An organ-by-organ review of SRTR data identifies several important trends. Antibody induction continues to be used for the majority of kidney (70%), simultaneous pancreas-kidney (SPK, 79%) pancreas after kidney (PAK, 74%), and intestine recipients (74%). It is used for under half of thoracic organ recipients and remains uncommon for liver transplant recipients (20%). The type of antibody preparation utilized has shifted from muromonab-CD3 and horse ATG to rabbit ATG and monoclonal anti-IL-2 receptor antagonists. Calcineurin inhibitors continue to be used for maintenance immunosuppression for most recipients, although there has been a shift from cyclosporine to tacrolimus. A clear transition is apparent in the choice of antimetabolite from azathioprine to mycophenolate mofetil. Although corticosteroids continue to be used as maintenance immunosuppression for most recipients prior to discharge, there is evidence that efforts of steroid avoidance protocols are having an impact across all organs, as slight decreases in their use have been observed.

Graft Rejection↗
PubMed2005

Development of the allocation system for deceased donor liver transplantation.

As the number of pre- and post-transplant solid organ recipients continues to grow, it becomes important for all physicians to have an understanding of the process of organ procurement and allocation. In the United States, the current system for allocation and transplantation of human solid organs has been heavily influenced by the experience in deceased donor liver transplantation (DDLT). This review highlights the significant changes that have occurred over the past 10 years in DDLT, with specific attention to the impact of the Model for Endstage Liver Disease (MELD) score on organ allocation and pre- and post-transplant survival. DDLT is managed by the United Network for Organ Sharing (UNOS) which oversees organ procurement and allocation across geographically defined Organ Procurement Organizations (OPOs). For many years, deceased donor livers were allocated to waiting list patients based on subjective parameters of disease severity and accrued waiting time. In addition, organs have traditionally been retained within the OPO where they are procured contributing to geographic disparities in disease severity at the time of transplantation among deceased donor recipients. In response to a perceived unfairness in organ allocation, Congress issued its "Final Rule" in 1998. The Rule called for a more objective ranking of waiting list patients and more parity in disease severity among transplant recipients across OPOs. To date, little progress has been made in eliminating geographic inequities. Patients in the smallest OPOs continue to receive liver transplants at a lower level of disease severity. However, strides have been made to standardize assessments of disease severity and better prioritize waiting list patients. The MELD score has emerged as an excellent predictor of short-term mortality in patients with advanced liver disease, and patients listed for liver transplantation are now ranked based on their respective MELD scores. This has improved organ access to the most severely ill patients without compromising waiting list mortality or post-transplant survival. The current system for DDLT remains imperfect but has improved significantly in the past decade. As the number of patients in need of DDLT grows, the system will continue to evolve to meet this increasing demand.

Cadaver↗
PubMed2004

MELD scores of liver transplant recipients according to size of waiting list: impact of organ allocation and patient outcomes.

CONTEXT: The Model for Endstage Liver Disease (MELD) score serves as the basis for the distribution of deceased-donor (DD) livers and was developed in response to "the final rule" mandate, whose stated principle is to allocate livers according to a patient's medical need, with less emphasis on keeping organs in the local procurement area. However, in selected areas of the United States, organs are kept in organ procurement organizations (OPOs) with small waiting lists and transplanted into less-sick patients instead of being allocated to sicker patients in nearby transplant centers in OPOs with large waiting lists. OBJECTIVE: To determine whether there is a difference in MELD scores for liver transplant recipients receiving transplants in small vs large OPOs. DESIGN AND SETTING: Retrospective review of the US Scientific Registry of Transplant Recipients between February 28, 2002, and March 31, 2003. Transplant recipients (N = 4798) had end-stage liver disease and received DD livers. MAIN OUTCOME MEASURES: MELD score distribution (range, 6-40), graft survival, and patient survival for liver transplant recipients in small (<100) and large (> or =100 on the waiting list) OPOs. RESULTS: The distribution of MELD scores was the same in large and small OPOs; 92% had a MELD score of 18 or less, 7% had a MELD score between 19 and 24, and only 2% of listed patients had a MELD score higher than 24 (P =.85). The proportion of patients receiving transplants in small OPOs and with a MELD score higher than 24 was significantly lower than that in large OPOs (19% vs 49%; P<.001). Patient survival rates at 1 year after transplantation for small OPOs (86.4%) and large OPOs (86.6%) were not statistically different (P =.59), and neither were graft survival rates in small OPOs (80.1%) and large OPOs (81.3%) (P =.80). CONCLUSIONS: There is a significant disparity in MELD scores in liver transplant recipients in small vs large OPOs; fewer transplant recipients in small OPOs have severe liver disease (MELD score >24). This disparity does not reflect the stated goals of the current allocation policy, which is to distribute livers according to a patient's medical need, with less emphasis on keeping organs in the local procurement area.

Humans↗
PubMed2004

Impact of pretransplant diagnosis of hepatocellular carcinoma on cadveric liver allocation in the era of MELD.

The allocation system based on the Model for End-stage Liver Disease (MELD) has led to more patients diagnosed with hepatocellular carcinoma (HCC) being transplanted. We hypothesized that more patients misdiagnosed with HCC are also being transplanted, leading to inappropriate organ allocation. Therefore, we retrospectively analyzed all liver transplants at our center from July 14, 2000, to October 22, 2002 (N = 172; 129 pre-MELD, 43 post-MELD), comparing pretransplant HCC diagnosis to explant histology. Thirty patients met the United Network for Organ Sharing (UNOS) diagnostic criteria for pretransplant HCC diagnosis. There were 25 men (median age, 52.5 yr), and 80% had hepatitis C. The proportion of patients transplanted who had an HCC diagnosis increased from 12% (15/129) pre-MELD to 35% (15/43) post-MELD implementation (P < 0.01). Three of 15 (20%) transplanted pre-MELD and 5 of 15 (33%) transplanted post-MELD lacked HCC in the explant (P = 0.10). Of the three false-positives pre-MELD, one was Status 2B already, and two received living-donor livers. Of the 5 false-positives post-MELD, three had score upgrades that led to early transplantation (13 to 29, 20 to 29, and 9 to 24) while two had MELD scores of 35 and 36 already. The percentage of organs that could have gone to patients with more advanced liver disease without HCC increased from 0% (0/129) pre-MELD to 7% (3/43) post-MELD (P < 0.01). Since the implementation of MELD, the proportion of patients transplanted who had an HCC diagnosis nearly tripled, and a small but significant proportion of organs are now going to patients misdiagnosed with HCC. More stringent HCC diagnostic criteria will be required to decrease the effect that misdiagnosis has on organ allocation.

Carcinoma, Hepatocellular↗
PubMed2004

Specific laboratory methodologies achieve higher model for endstage liver disease (MELD) scores for patients listed for liver transplantation.

Priority for liver transplantation is currently based on the Model for Endstage Liver Disease (MELD) score, a mathematical function which includes the following objective variables: bilirubin, creatinine (Cr), and international normalized ratio (INR). We have noted that specific laboratory methodologies may yield consistently higher values of bilirubin, Cr, and INR. Therefore, we performed a study to determine if higher MELD scores could be obtained by utilizing laboratory methodologies selected to return higher laboratory values than standard methodologies used in our hospital's clinical laboratory. Phlebotomy was performed for routine clinical indications in 29 consecutive patients listed for liver transplantation. MELD scores were calculated using bilirubin, Cr, and INR from laboratory methods in our hospital's clinical laboratory (designated Lab #1) and from 2 other clinical laboratories (designated Lab #2 and Lab #3). The mean MELD score in our hospital's clinical laboratory (Lab #1) (13.6) was not significantly different than in Lab #2 (14.7), but in Lab #3, it was significantly higher by 20% (17.1), P <.03. Virtually all of the difference in MELD score between our hospital's clinical laboratory (Lab #1) and Lab #3 could be attributed to the INR, which was significantly higher by 26% in Lab #3 (1.9) vs. Lab #1 (1.4), P <.00002. Using MELD scores calculated from our hospital's clinical laboratory, the average change in priority for liver transplantation was from the 58th percentile to the 77th percentile (compared to Lab #3), P =.01. In conclusion, patients listed for liver transplantation at our center achieved significantly higher MELD scores and therefore a higher priority for liver transplantation by using laboratory methodologies that yield higher INR values than our hospital laboratory. The selection of laboratory methodologies may have a significant impact on MELD score.

Bilirubin↗
PubMed2004

Hepatic artery chemoembolization for hepatocellular carcinoma in patients listed for liver transplantation.

We retrospectively analyzed all listed patients having hepatic artery chemoembolization (HACE) for hepatocellular carcinoma (HCC) stage T2 or less. Outcomes were transplantation, waiting list removal, death, and HCC recurrence. Twenty patients (mean age 55.7 years; 15 males) were identified. Twelve (60%) were transplanted, seven (35%) were removed from the list and one (5%) remains listed. Fourteen (70%) are alive. All 12 transplanted patients are alive (mean 2.94 years); one of seven removed from the list is alive (mean 1.45 years). Survival was significantly higher for those transplanted or listed vs. removed from the list (100% vs. 14.3%, p = 0.0002). No HCC's recurred. Three patients (15%) were removed from the list after prolonged waiting times before MELD. Hepatic artery chemoembolization induced deterioration and removal from the list of one (5%) patient. Survival for those transplanted was excellent(100%), but overall survival was significantly lower (61.3%) at a mean 5.48 years. Hepatic artery chemoembolization for listed patients with <or=euro T2 stage HCC is beneficial, but must be weighed against decreased waiting times and risk of HACE-induced deterioration. This balance is influenced greatly by the MELD system's determination of waiting times for HCC patients.

Carcinoma, Hepatocellular↗
PubMed2003

Comprehensive cost comparison of adult-adult right hepatic lobe living-donor liver transplantation with cadaveric transplantation.

BACKGROUND: An important long-term consideration for living-donor liver transplantation (LDLT) is the expense compared with cadaveric-liver transplantation. LDLT is a more complex procedure than cadaveric transplantation and the cost of donor evaluation, donor surgery, and postoperative donor care must be included in a cost analysis for LDLT. In this study, we compare the comprehensive cost of LDLT with that of cadaveric-liver transplantation. METHODS: All costs for medical services provided at our institution were recorded for 24 LDLT and 43 cadaveric recipients with greater than 1 year follow-up transplanted between August 1997 and April 2000. The donor costs include donors evaluated and rejected, donors evaluated and accepted, donor right hepatectomy costs, and donor follow-up costs (365 days postdonation). LDLT and cadaveric recipient costs include medical care 90 days pre-LDLT, recipient transplant costs, and recipient follow-up costs (365 days posttransplant) including retransplantation. Cost is expressed as an arbitrary cost unit (CU) that is a value between $500 to $1,500. RESULTS: Total LDLT costs (evaluations of rejected donors+evaluations of accepted donors+donor hepatectomy+donor follow-up care for 1 year+pretransplant recipient care [90 days pretransplant]+recipient transplantation+recipient 1-year posttransplant care)= 162.7 CU. Total mean cadaveric transplant costs (pretransplant recipient care [90 days pretransplant]+recipient transplantation [including organ acquisition cost]+recipient 1-year posttransplant care)= 134.5 CU, (P =ns). CONCLUSIONS: The total comprehensive cost of LDLT is 21% higher than cadaveric transplantation, although this difference is not significant.

Adult↗
PubMed2003

Living donor liver transplantation and hepatitis C.

Preliminary results indicate that living donor liver transplantation patients infected with hepatitis C virus (HCV) develop earlier and more severe recurrence than their cadaveric counterparts. The mechanisms underlying this observation are unknown, but could include hepatic regeneration, differences in living donor liver transplantation recipient demographics, immune homology between donor and recipients, or other factors not previously considered. The optimum clinical approach is to only consider living donor liver transplantation in HCV-infected recipients as a life-saving procedure and to attempt to eradicate HCV before transplantation to prevent recurrent infection.

Graft Survival↗
PubMed2003

Sirolimus as primary immunosuppression in liver transplantation is not associated with hepatic artery or wound complications.

Sirolimus is a new immunosuppressive agent increasingly being used in liver transplant recipients. There is concern that sirolimus may be associated with wound complications and hepatic artery thrombosis (HAT). We have used sirolimus as primary immunosuppression in 170 liver transplant recipients and therefore reviewed our experience with wound complications and HAT in our cohort of patients. Records of all 170 patients administered sirolimus as primary immunosuppression and 180 historic controls were reviewed. Numbers of wound and hepatic artery complications were recorded, as well as the prevalence of obesity, reoperation, diabetes, and OKT3 use, all of which are risk factors for wound complications. The prevalence of wound complications was 12.4% in sirolimus-treated patients compared with 13.9% in historic controls (P = not significant [NS]). The prevalence of hepatic artery complications was 5.3% in sirolimus-treated patients compared with 8.3% in historic controls (P = NS). The prevalence of obesity and OKT3 administration was significantly lower in sirolimus-treated patients. Multivariate analysis failed to show an association between sirolimus therapy and hepatic artery or wound complications. The prevalence of wound and hepatic artery complications is not different in liver transplant recipients administered sirolimus as part of a primary immunosuppressive regimen compared with historic controls.

Cohort Studies↗