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BACKGROUND: Patients with cirrhosis and end-stage liver disease (ESLD) develop severe nutrition deficits that affect morbidity and mortality. Laboratory measures of nutrition fail to fully assess clinical deficits in muscle mass and fat stores. This study employs computed tomography imaging to assess muscle mass and subcutaneous and visceral fat stores in patients with ESLD. METHODS: This 1:1 case-control study design compares ESLD patients with healthy controls. Study patients were selected from a database of ESLD patients using a stratified method to assure a representative sample based on age, body mass index (BMI), sex, and model for end-stage liver disease score (MELD). Control patients were trauma patients with a low injury severity score (<10) who had a computed tomography scan during evaluation. Cases and controls were matched for age ± 5 years, sex, and BMI ± 2. RESULTS: There were 90 subjects and 90 controls. ESLD patients had lower albumin levels (P < .001), but similar total protein levels (P = .72). ESLD patients had a deficit in muscle mass (-19%, P < .001) and visceral fat (-13%, P < .001), but similar subcutaneous fat (-1%, P = .35). ESLD patients at highest risk for sarcopenia included those over age 60, BMI<25.0, and female sex. We found degree of sarcopenia to be independent of model for end-stage liver disease score. CONCLUSIONS: These results support previous research demonstrating substantial nutrition deficits in ESLD patients that are not adequately measured by laboratory testing. Patients with ESLD have significant deficits of muscle and visceral fat stores, but a similar amount of subcutaneous fat.

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BACKGROUND: Few studies have assessed the ability of inhaled anesthetic agents to ameliorate ischemia-reperfusion injury (IRI) in liver transplantation (LT). This study compares inhaled anesthetics in early liver allograft IRI. LT recipient and organ donor data were extracted retrospectively for all LTs at a single center between 2001 and 2015. METHODS: LT recipient and organ donor data were extracted retrospectively for all LTs at a single center between 2001 and 2015. The choice of primary anesthetic agent was at the discretion of the anesthesiologist. Serum alanine aminotransferase (ALT) and total bilirubin (TB) levels were measured daily in the post-transplant period as measures of early graft injury and function. Survival and clinical outcomes are reported. RESULTS: There were 1291 primary LTs included in the analysis, with 3 primary inhaled agents: isoflurane (62%), desflurane (8%), and sevoflurane (30%). In the first 7 days post-transplant, the peak ALT level was lowest for desflurane (352), followed by sevoflurane (411) and isoflurane (481) (P = .09). All groups had similar ALT and TB by 7 days post-transplant. Graft survival for all 3 groups was statistically similar at 1, 7, and 30 days, with equivalent patient and graft survival at 1 year. CONCLUSIONS: All 3 agents had similar rates of early allograft dysfunction and renal dysfunction. Subgroup analysis of high-risk donor grafts showed no statistical difference. In conclusion, administration of desflurane or sevoflurane may provide some early hepatoprotection against IRI, but longer-term outcomes were equivalent for all agents.

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INTRODUCTION: Transplantation of pancreas allografts procured from donation after circulatory death (DCD) remains uncommon. This study reviews a series of pancreas transplants at a single center to assess the donor and recipient characteristics for DCD pancreas transplant and to compare clinical outcomes. METHODS: DCD procurement was performed with a 5-minute wait time from pronouncement of death to first incision. In 2 patients, tissue plasminogen activator was infused as a thrombolytic during the donor flush. All kidney grafts were placed on pulsatile perfusion. RESULTS: There were 606 deceased donor pancreas transplants, 596 standard donors and 10 DCD donors. Of the 10 DCD transplants, 6 were simultaneous pancreas-kidney and 4 were pancreas transplant alone. The average time from incision to aortic cannulation was less than 3 minutes. The median total ischemia time for the DCD grafts was 5.4 hours, compared with 8.0 hours for standard donors (P = .15). Median length of hospital stay was 7 days for both groups, and there were no episode of acute cellular rejection in the first year post-transplant for the DCD group (4.2 % for standard group, P = .65). There was no difference in early or late graft survival, with 100% graft survival in the DCD group up to 1 year post-transplant. Ten-year Kaplan-Meier analysis shows similar graft survival for the 2 groups (P = .92). CONCLUSIONS: These results support the routine use of carefully selected DCD pancreas donors. There were no differences in graft function, postoperative complications, and early and late graft survival.

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INTRODUCTION: This study compared clinical outcomes for a large number of liver transplant patients receiving intraoperative epsilon-aminocaproic acid (EACA), aprotinin, or no antifibrinolytic agent over an 8-year period. PATIENTS AND METHODS: Records for deceased donor liver transplants were reviewed. Data included antifibrinolytic agent, blood loss, early graft function, and postoperative complications. Study groups included low-dose aprotinin, high-dose aprotinin, EACA (25 mg/kg, 1-hour infusion), or no antifibrinolytic agent. RESULTS: Data were included for 1170 consecutive transplants. Groups included low-dose aprotinin (n = 324 [28%]), high-dose aprotinin (n = 308 [26%]), EACA (n = 216 [18%]), or no antifibrinolytic (n = 322 [28%]). EACA had the lowest intraoperative blood loss and required the fewest transfusions of plasma. Patients receiving no agent required the most blood transfusions. Early graft loss was lowest in the EACA group, and 90-day and 1-year patient survival rates were significantly higher for the low-dose aprotinin and EACA groups according to Cox regression. Complications were similar, but there were more episodes of deep vein thrombosis in patients receiving EACA. CONCLUSIONS: These results suggest that transitioning from aprotinin to EACA did not result in worse outcomes. In addition to decreased intraoperative blood loss, a trend toward improved graft and patient survival was seen in patients receiving EACA.

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Loss of abdominal domain is a common problem in intestinal transplantation. Several surgical options are available perioperatively for abdominal wall reconstruction. This study reports the management and complications for intestinal transplant patients with abdominal wall closure either primarily or with foreign material. This single center study reviews the records of intestinal transplant patients between 2004 and 2010. Study outcomes included reoperation for dehiscence, hernia or enterocutaneous fistula. There were 37 of 146 patients (25%) who required implantation of foreign material at transplant. Of these 37, 30 (81%) had implantation of acellular dermal allograft (ADA) and 7 (19%) implantation of another mesh. Perioperative dehiscence was rare with 2/109 (2%) for primary closure, 0/30 (0%) for ADA and 1/7 (14%) for other mesh. There were 12/146 (8%) patients who underwent ventral hernia repair: primary closure 7/109 (6%), ADA 3/30 (10%) and other mesh 2/7 (28%). There were 4/146 (3%) patients who required surgery for enterocutaneous fistulas: 2/109 (2%) primary closure, 1/30 (3%) ADA and 1/7 (14%) synthetic mesh. Abdominal wall reconstruction with ADA biologic mesh provides an expeditious means of performing a tension-free closure of the fascial layer after intestinal transplantation with complications similar to those seen for primary closure.

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A 49-year-old man underwent living donor renal transplantation in November 2005. The transplant renal artery was anastomosed to the right internal iliac artery with an end-to-end anastomosis. The patient achieved immediate graft function and the allograft was normally perfused. Seven weeks later, renal allograft function deteriorated with a serum creatinine level increased to 244 micromol/L. An ultrasound scan revealed adequate perfusion to the kidney and the absence of hydronephrosis. A transplant biopsy revealed Banff IB rejection, which was treated with high-dose prednisolone. Following biopsy, the patient's renal function rapidly deteriorated with a serum creatinine level increased to 627 micromol/L, requiring hemodialysis. A computed tomography (CT) angiogram demonstrated a 6-cm diameter pseudoaneurysm arising from the internal iliac artery with absence of kidney perfusion. The aneurysm was accessed percutaneously with a 4-F catheter and 1000 U of human thrombin injected, resulting in partial thrombosis of the pseudoaneurysm. A balloon expandable covered metal stent was then placed across the site of the transplant renal artery anastomosis, resulting in successful occlusion of the aneurysm. Intrarenal blood flow was established by dilating 2 intrarenal branches with 3-mm diameter balloons. The serum creatinine level started to decrease within 24 hours of the procedure and renal function improved rapidly to a level achieved immediately after transplantation. Three months later the patient had a well-functioning allograft with a serum creatinine level of 176 micromol/L, follow-up CT scan demonstrated good perfusion of the transplanted kidney with no further change in the pseudoaneurysm. At 12 months follow-up the patient remains with a well-functioning allograft.

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Seven measurements of albumin excretion in overnight, recumbent (OR) and daytime, ambulant (DA) urine samples were carried out at successive intervals of 3 months in 172 insulin-dependent diabetic patients; at entry into the study, all had a resting albumin excretion rate less than 300 micrograms/min. Urinary albumin excretion in both collections was expressed as a concentration (UA, mg/l), as a creatinine ratio (UA/UC, mg/mmol) and as an excretion rate (UAV, micrograms/min). The pooled within-subject standard deviation (log. (base e) transformed data) for each expression of the albumin excretion was: (1) OR sample--UA 0.6824 mg/l, UA/UC 0.5257 mg/mmol, UAV 0.5940 micrograms/min; (2) DA sample--UA 0.7830 mg/l, UA/UC 0.5780 mg/mmol, UAV 0.6334 micrograms/min. The results were used to calculate the 95% range for a difference between two measurements within an individual patient which was lowest with OR UA/UC (chi/divided by 4.42) and highest with the DA UA (chi/divided by 9.16). Variation in the OR sample was also studied in terms of the patterns of microalbuminuria (M; UAV greater than 15 micrograms/min) which were found to be closely associated with the initial level of albumin excretion: persistent non-M was most common in patients with a baseline UAV less than 15 micrograms/min; established M was most common in those with a baseline UAV greater than 70 micrograms/min, some of whom developed clinical albuminuria. The frequency with which patients should be re-screened for M may be determined by the initial value of albumin excretion and by the threshold used to define M.

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Serum lipid and lipoprotein concentrations were measured in 18 insulin-dependent diabetic patients with persistent microalbuminuria and an equal number with persistently normal albumin excretion. The groups were matched for sex, age, duration of diabetes, body mass index, insulin dose, and glycosylated haemoglobin. Diabetic patients with persistent microalbuminuria were found to have a significantly lower high density lipoprotein (HDL) cholesterol concentration (difference 0.29, 95% Cl 0.12 to 0.46, mmol l-1, p less than 0.01) and a higher low density lipoprotein (LDL) cholesterol:HDL cholesterol ratio (difference 0.97, 95% Cl 0.29 to 1.65, p less than 0.01) than patients with normal albumin excretion. No significant differences were found in total cholesterol, triglycerides, LDL cholesterol, apolipoprotein (apo) A-I and apo B concentrations. Compared to an age and sex-matched group of non-diabetic subjects with normal albumin excretion, diabetic patients with persistent microalbuminuria had significantly higher concentrations of total cholesterol (p less than 0.05), LDL cholesterol (p less than 0.05) and apo B (p less than 0.01), but a lower concentration of HDL cholesterol (p less than 0.05). No significant differences were found in serum lipids and lipoproteins between diabetic patients with normal albumin excretion and non-diabetic subjects.

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The onset of diabetic nephropathy is characterized by subclinical elevation of urinary albumin excretion, so-called 'microalbuminuria' (M). Dietary assessments were carried out in 15 insulin-dependent diabetic patients with persistent M and an equal number with persistently normal albumin excretion. The groups were matched for sex, age, duration of diabetes, body mass index, insulin dose and glycosylated haemoglobin; there were no significant differences in systemic blood pressure, glomerular filtration rate, blood glucose and serum albumin concentrations between the groups; retinopathy was significantly more frequent in patients with M. Diabetics with persistent M were found to consume a significantly larger amount of fat (expressed as grams and percentage of total energy) and a significantly smaller percentage of total energy as carbohydrate than patients with normal albumin excretion; total dietary energy was larger in those with persistent M, but the difference was not significant. No significant differences were found in protein and fibre intakes between the groups. Our findings suggest that an excess in the dietary consumption of fat relative to carbohydrate might play an important role in the pathogenesis of early nephropathy in insulin-dependent diabetes mellitus. We emphasize the importance of careful attention to nutrient intake in the prevention and treatment of diabetic complications.

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