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Milan Kinkhabwala

Publications and source records attributed to Milan Kinkhabwala.

17 recordsLinked to original sources
PubMed2006

Extended-donor criteria liver allografts.

Extended-donor criteria liver allografts do not meet traditional criteria for transplantation. Although these organs offer immediate expansion of the donor pool, transplantation of extended-donor criteria liver allografts increases potential short- and long-term risk to the recipient. This risk may manifest as impaired allograft function or donor-transmitted disease. Guidelines defining this category of donor, level of acceptable risk, principles of consent, and post-transplantation surveillance have not been defined. This article reviews the utilization, ethical considerations, and outcomes of extended-donor criteria liver allografts.

Donor Selection↗
PubMed2005

Retraction.

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Retraction Notice↗
PubMed2005

Utilization of extended donor criteria liver allografts maximizes donor use and patient access to liver transplantation.

OBJECTIVE: The objective of this study was to evaluate the effect of systematic utilization of extended donor criteria liver allografts (EDC), including living donor allografts (LDLT), on patient access to liver transplantation (LTX). SUMMARY BACKGROUND DATA: Utilization of liver allografts that do not meet traditional donor criteria (EDC) offer immediate expansion of the donor pool. EDC are typically allocated by transplant center rather than regional wait-list priority (RA). This single-institution series compares outcomes of EDC and RA allocation to determine the impact of EDC utilization on donor use and patient access to LTX. METHODS: The authors conducted a retrospective analysis of 99 EDC recipients (49 deceased donor, 50 LDLT) and 116 RA recipients from April 2001 through April 2004. Deceased-donor EDC included: age >65 years, donation after cardiac death, positive viral serology (hepatitis C, hepatitis B core antibody, human T-cell lymphotrophic), split-liver, hypernatremia, prior carcinoma, steatosis, and behavioral high-risk donors. Outcome variables included patient and graft survival, hospitalization, initial graft function, and complication categorized as: biliary, vascular, wound, and other. RESULTS: EDC recipients were more frequently diagnosed with hepatitis C virus or hepatocellular carcinoma and had a lower model for end-stage liver disease (MELD) score at LTX (P < 0.01). Wait-time, technical complications, and hospitalization were comparable. Log-rank analysis of Kaplan-Meier survival estimates demonstrated no difference in patient or graft survival; however, deaths among deceased-donor EDC recipients were frequently the result of patient comorbidities, whereas LDLT and RA deaths resulted from graft failure (P < 0.01). EDC increased patient access to LTX by 77% and reduced pre-LTX mortality by over 50% compared with regional data (P < 0.01). CONCLUSION: Systematic EDC utilization maximizes donor use, increases access to LTX, and significantly reduces wait-list mortality by providing satisfactory outcomes to select recipients.

Adolescent↗
PubMed2005

The impact of pre-operative loco-regional therapy on outcome after liver transplantation for hepatocellular carcinoma.

No prior studies have shown that pre-operative loco-regional therapy for hepatocellular carcinoma (HCC) improves survival following orthotopic liver transplantation (OLT). We performed subgroup analyses according to pathologic HCC stage among 168 patients who underwent OLT to test the hypothesis that pre-operative loco-regional therapy confers a survival advantage in a subgroup at intermediate risk for HCC recurrence. Patients with pathologic T3 HCC meeting the proposed UCSF expanded criteria (single lesion not exceeding 6.5 cm or two to three lesions none > 4.5 cm with total tumor diameter within 8 cm) had a similar 5-year recurrence-free survival as patients with pathologic T2 HCC (88.5% vs. 93.8%; p = 0.56). In the subgroup with pathologic T2 or T3 HCC, the 5-year recurrence-free survival was 93.8% for the 85 patients who received pre-operative loco-regional therapy, versus 80.6% for the other 41 patients without treatment (p = 0.049). The treatment benefit, according to 5-year recurrence-free survival, appeared greater for pathologic T3 (85.9% vs. 51.4%; p = 0.05) than T2 HCC (96.4% versus 87.1%; p = 0.12). In conclusion, although the lack of a randomized controlled design precludes drawing firm conclusions, our results suggest that pre-operative loco-regional therapy may confer a survival benefit after OLT in the subgroup with pathologic T2 and T3 HCC.

Adult↗
PubMed2005

Predictors of candidate maturation among potential living donors.

The shortage of deceased donor allografts and improved outcomes in partial organ transplantation have led to widespread application of adult-to-adult living donor liver transplantation. Donor selection limits overall utilization of this technique and predictors of candidate maturation have been inadequately studied to date. We therefore collected data on 237 consecutive potential donors including their age, sex, ethnicity, relationship to the recipient, education, employment and religious beliefs and practices. Of these 237 candidates, 91 (38%) were excluded for medical and psychosocial reasons, 53 (22%) withdrew from the process predonation and 93 (39%) underwent partial liver donation. In multivariate analyses, the relationship between the donor and the recipient was highly predictive of successful donation. For pediatric recipients, no parents voluntarily withdrew from the evaluation process. For adult recipients, spouses are the most likely to donate, followed by parents, children and siblings. Additional predictors for donation included self-description as religious but not regularly practicing, part-time employment and higher education. Race, ethnicity, gender and age did not predict donation in multivariate analysis. Further understanding of the complex decision to donate may improve donation rates as well as permit more efficient and cost-effective donor evaluation strategies.

Adolescent↗
PubMed2004

Microvascular hepatic artery anastomosis in pediatric segmental liver transplantation: microscope vs loupe.

Use of operative microscopy (OM) has dramatically reduced the incidence of hepatic artery thrombosis (HAT) in children undergoing segmental liver transplantation. We used OM (12-16x) in our early experience. We changed to high power loupe magnification (6x) after 14 cases. We examined our experience with microvascular hepatic artery reconstruction in 28 consecutive children (< 18 years) who underwent living donor (LDLT) or split liver transplantation (SLT). Reconstructions were done with interrupted, end-to-end anastomoses with 8-0 polypropylene using microvascular techniques. Group 1 consisted of 14 children who underwent LDLT employing OM for the hepatic artery anastomosis. Group 2 consisted of the subsequent 14 children (11 LDLT, 3 SLT) in whom 6x loupe optics were used for the arterial anastomosis. Grafts included 25 left lateral segments, 2 left lobes, and 1 right lobe. Recipients' median age was 1.0 years (range 3 months to 17 years). The mean follow-up time was 27.1 months. There were no cases of HAT. Variables of age, sex, graft type, number of Doppler ultrasound exams (DUS), and biliary complications were similar between groups. Microvascular hepatic artery reconstruction in children with 6x loupe magnification can yield results as good as operative microscopy.

Adolescent↗
PubMed2004

Pulsatile machine perfusion with Vasosol solution improves early graft function after cadaveric renal transplantation.

BACKGROUND: Cold storage is the most common method of preservation in renal transplantation, but pulsatile machine perfusion (MP) is increasingly used for purposes of ex vivo assessment and resuscitation of high risk allografts. Vasosol (VSL) MP solution (MPS) (Pike Laboratories Inc, Eagle, PA) is a novel perfusate with enhanced vasodilatory and antioxidant capacity. We report our experience with VSL in machine preservation of renal allografts. METHODS: Locally procured cadaver kidney pairs undergoing MP were randomized to VSL or control solution (Belzer MPS; Trans-Med, Elk River, MN). En bloc perfusion was performed according to standard MP procedures. Transplantation was performed at 1 of 12 local transplant centers. Donor and recipient data were collected prospectively. RESULTS: Data from 162 transplanted kidneys were analyzed. A total of 82 renal grafts were perfused with VSL, and 80 were perfused with control solution. No organs were lost secondary to the technique of MP. There was no difference in donor or recipient age between groups. Kidneys perfused with VSL exhibited significantly higher rates of immediate function and significantly less delayed graft function (12.2% vs. 21.2%). Discharge creatinine and length of stay were also significantly improved in the VSL group. One-year graft and patient survivals were equivalent (95%) in both groups. CONCLUSIONS: VSL improved early graft function and shortened the length of stay compared with Belzer MPS. Further improvement in preservation solutions in conjunction with pulsatile perfusion shows promise in improving early outcomes after renal transplantation, especially for extended criteria donor kidneys.

Adenosine↗
PubMed2004

One-year morbidity after donor right hepatectomy.

Live donors are becoming an increasingly important source of donor organs in liver transplantation; however, long-term functional aspects of recovery from donor right hepatectomy are unknown. We analyzed donor outcomes at 1-year follow-up. We performed a single-center retrospective analysis of 70 right hepatectomy donors. Six-week and 1-year postoperative follow-up results were compared to preoperative baseline values. Ultrasonography was performed in all donors at 6 weeks and as clinically indicated. All donors were alive and well at the end of the study period. Of 66 right hepatic donors, only 22 (32%) were fully compliant with a 1-year follow-up visit. All those not compliant were contacted by phone. All complications except 1 (late finding of portal vein thrombosis) occurred in the perioperative (90-day) period. The incidence of bile leak was 4.3%, incisional hernia 20%, and autologous transfusion 1.0%. There were no aborted procedures. In those compliant with full 1-year follow-up, total bilirubin, aspartate aminotransferase, and alanine aminotransferase were normal in 97%. A total of 5 donors were noted to have persistence of asymptomatic thrombocytopenia beyond the perioperative period (90 days). These were investigated with Doppler sonography. Sonography was unremarkable in 3 of the 5, while 2 had abnormal findings: splenomegaly alone in 1, and splenomegaly with portal vein thrombosis in the other. Magnetic resonance angiography was performed in both, and the patient with portal vein thrombosis underwent endoscopy, which failed to reveal varices. Neither has clinical portal hypertension. Both remain asymptomatic albeit with stable thrombocytopenia. In conclusion, the majority of complications after donor right hepatectomy occur in the perioperative period. Later findings may include asymptomatic thrombocytopenia, with an incidence possibly as high as 23%, though the significance of this finding remains uncertain. Larger-scale studies are needed to confirm the true incidence and clinical significance of persistent thrombocytopenia in the donor hepatectomy population. Strategies to improve compliance with 1-year follow-up visits need to be developed.

Adult↗
PubMed2004

Interpretation of liver chemistries in adult donors after living donor liver transplantation.

OBJECTIVES: The safety of donors is paramount in adult living donor liver transplantation. Our goal is to compare the pattern of recovery of hepatic synthetic function and aminotransferases in healthy adult donors with and without complications. METHODS: We reviewed 47 consecutive patients undergoing right donor hepatectomy at our center. Laboratory data were collected through the first 2 postoperative weeks and results from donors with and without complications were compared. RESULTS: Donor morbidity was 25% and there were no donor deaths. Total bilirubin peaked on postoperative day 3, whereas aminotransferases and international normalized ratio peaked on postoperative day 1. Peak total bilirubin was higher in patients with fluid collections (n = 7) compared with those without fluid collections (n = 40), 4.6 mg/dL and 2.3 mg/dL, respectively, P = 0.02. On postoperative day 3 the peak total bilirubin was greater than 3.0 mg/dL in 86% of donors with fluid collections and 15% of donors without fluid collections, (P = 0.0005) whereas aminotransferases and alkaline phosphatase were not significantly different between these 2 groups. CONCLUSIONS: After right donor hepatectomy a total bilirubin greater than 3.0 mg/dL on postoperative day 3 should prompt an evaluation for a fluid collection, even if other liver tests are normal or declining.

Adult↗
PubMed2004

Impact of adult living donor liver transplantation on waiting time survival in candidates listed for liver transplantation.

Studies comparing adult living donor liver transplantation to deceased donor liver transplantation have focused on post-transplant survival. Our aim was to focus on the impact of living donor liver transplant on waiting time mortality and overall mortality. We analyzed the affect of living donor liver transplantation on waiting time mortality and overall mortality (from listing until last follow up) in a cohort of 116 transplant candidates. Fifty-eight candidates who had individuals present as potential living donors (volunteer group) were matched by MELD score to 58 liver transplant candidates who did not have individuals present as a potential living donor (no volunteer group). Twenty-seven percent of candidates in the no volunteer group and 62% of candidates in the volunteer group underwent liver transplantation, p = 0.0003. One-year waiting list mortality for the volunteer group and no volunteer group was 10% and 20%, respectively, p = 0.03. Patient survival from the time of listing to last follow up was similar between the two groups. In our study group, living donor liver transplantation is associated with a higher rate of liver transplantation and lower waiting time mortality. In the era of living donor liver transplantation, estimates of patient survival should incorporate waiting time mortality.

Female↗
PubMed2003

Analysis of failure in living donor liver transplantation: differential outcomes in children and adults.

Over the past decade we have reported excellent outcomes in pediatric living-donor liver transplantation (LDLT) with recipient survival exceeding 90%. Principles established in these patients were extended to LDLT in adults. To compare outcomes in donors and recipients between adult and pediatric LDLT in a single center, we reviewed patient records of 45 LDLT performed between 1/98 and 2/01: 23 adult LDLT (54 +/- 6.5 yr) and 22 pediatric LDLT (33.7 +/- 53.5 months). Preoperative liver function was worse in adults (International Normalized Ratio [INR] 1.5 +/- 0.4 vs. INR 1.2 +/- 0.5; p = 0.032). 4 adults (17%) met criteria for status 1 or 2A. Only 1 child was transplanted urgently. Analysis included descriptive statistics and Kaplan-Meier estimation. Donor mortality was 0% with 1 re-exploration, 2.4%. Median hospital stay (LOS) was 6.0 days (range, 4-12 days). Donor morbidity and LOS did not differ by sex, extent of hepatectomy, or adult and pediatric LDLT ( p = 0.49). In contrast, recipient outcomes were worse for adults. Adult 1 year graft survival was 65% (3 retransplants [ReTx], 5 deaths) vs. 91% for children (1 ReTx, 1 death) p = 0.02. Graft losses in adults were due to sepsis (n = 3), small for size (n = 2), suicide, and hepatic artery thrombosis (HAT), whereas in children graft losses were due to portal thrombosis and total parenteral nutrition (TPN) liver failure. Biliary leaks occurred in 22% of adults and 9% of children. Hepatic vein obstruction occurred in 17% of adults and in none of the children. Median LOS was comparable (adult, 16.5 days (range, 7-149 days); child, 17 days (range, 10-56 days), p = 0.2). Graft function (total bilirubin (TBili) < 5mg/dl, INR < 1.2, aspartate aminotransferase (AST) < 100 U/l) normalizing by day 4 in children and by day 14 in adults. Adults fared worse, with an array of problems not seen in children, in particular, hepatic vein obstruction and small-for-size syndrome. Biliary leaks were diagnosed later in adults and were lethal in 3 cases; this was later avoided with biliary drainage in adult recipients. Finally, use of LDLT in decompensated adults led to death in 3 of 4 patients, and should be restricted to elective use.

Adolescent↗
PubMed2003

Multicenter randomized prospective trial of steroid withdrawal in renal transplant recipients receiving basiliximab, cyclosporine microemulsion and mycophenolate mofetil.

Corticosteroids withdrawal from immunosuppressive regimens has thus far been associated with increased risk of acute rejection episodes. In this study, basiliximab, a chimeric monoclonal interleukin-2 receptor antagonist, added to a maintenance regimen consisting of cyclosporine microemulsion and mycophenolate mofetil was studied for its effectiveness in allowing early corticosteroid withdrawal in de novo renal allograft recipients. Primary renal transplant recipients receiving basiliximab, cyclosporine-microemulsion, and mycophenolate mofetil, were randomized to either corticosteroid withdrawal at day four post-transplantation (n = 40) or standard steroid therapy (n = 43). The primary endpoint was the incidence of biopsy-proven acute rejection episodes. Randomized subjects who underwent transplantation and received at least one dose of basiliximab were analyzed in an intent-to-treat fashion. The incidence of biopsy-proven acute rejection at 12 months was not significantly different between the steroid withdrawal group (20%) and the standard treatment group (16%). Patient and graft survival was 100% in the steroid withdrawal group while one death in a patient with a functioning graft occurred in the standard steroid group. Seventy-two percent of the steroid withdrawal group remained off steroids at 6 months post-transplant. Allograft function and incidence of adverse events and infections were similar between the two groups. Rapid and early corticosteroid withdrawal among renal transplant recipients receiving basiliximab induction and daily therapy with cyclosporine-microemulsion and mycophenolate mofetil was not associated with an increased risk of acute rejection.

Adolescent↗
PubMed2003

Increased risk of cholestatic hepatitis C in recipients of grafts from living versus cadaveric liver donors.

Histologic injury caused by recurrent hepatitis C virus (HCV) has been reported in up to 90% of HCV-infected patients who undergo liver transplantation with a cadaveric graft. However, the natural history of HCV after living donor liver transplantation (LDLT) is not well described. We performed a retrospective analysis of 68 consecutive HCV-infected adult patients: 45 recipients of cadaveric grafts (CAD) were compared with 23 LDLT patients. Elevated serum transaminases, positive HCV RNA, and liver biopsy consistent with histologic evidence of HCV defined recurrence. When comparing CAD with LDLT, both the incidence of HCV recurrence and time to recurrence were not different. The overall incidence of severe sequelae of HCV recurrence, either cholestatic hepatitis, grade III-IV inflammation, and/or HCV-induced graft failure requiring retransplantation, was also not different when comparing CAD with LDLT. However, when comparing CAD versus LDLT, no CAD patient developed cholestatic hepatitis C, compared with 17% of LDLT who developed this complication (P =.001). Thus, in this patient population, the timing and incidence of HCV recurrence were not different when comparing CAD versus LDLT, but the incidence of cholestatic hepatitis was significantly greater in patients with HCV who underwent LDLT.

Adult↗
PubMed2002

Analysis of donor risk in living-donor hepatectomy: the impact of resection type on clinical outcome.

The progressive shortage of liver donors has mandated investigation of living-donor transplantation (LDT). Concerns about increasing risk to the donor are evident, but the impact of the degree of parenchymal loss has not been quantified. We analyzed clinical and biological variables in 45 LDT performed by our team over 2years to assess risks faced in adult LDT. All donors are alive and well with complete follow-up through to February 2001. When the three operations were compared, right hepatectomy (RH) was significantly longer in terms of anesthesia time and blood loss compared with left hepatectomy (LH) and left lobectomy (LL). Donor remnant liver was significantly reduced after RH compared with LH and LL. There were significant functional differences as a consequence of the remnant size, measured by an increase in peak prothrombin time after RH. RH for adults represents a markedly different insult from pediatric donations in terms of parenchymal loss and early functional impairment. Left hepatectomy donation offers modest advantage over right lobes but seems to confer substantial technical risk for a small gain in graft size. Unless novel strategies are developed to enhance liver function of the LH graft in the adult recipient, right lobe donation will be necessary for adult LDT.

Adult↗
PubMed2002

Successful sequential liver and stem cell transplantation for hepatic failure due to primary AL amyloidosis.

We report on a patient with primary AL amyloidosis who presented with progressive liver failure secondary to hepatic infiltration in the absence of significant extrahepatic involvement. Orthotopic liver transplantation was performed successfully. After an uneventful postoperative course, the patient developed evidence of significant recurrent amyloidosis requiring treatment. He then underwent stem cell transplantation 10 and 14 months after liver transplantation. After 28 months of follow-up posttransplantation, the patient continues to do well, with no clinical evidence of recurrent disease. This is the first reported patient with primary amyloidosis to undergo sequential liver and stem cell transplantation leading to resolution of the disease and only the second to undergo successful liver transplantation for this disorder.

Aged↗
PubMed2002

Model for end-stage liver disease and Child-Turcotte-Pugh score as predictors of pretransplantation disease severity, posttransplantation outcome, and resource utilization in United Network for Organ Sharing status 2A patients.

The Model for End-Stage Liver Disease (MELD) has been proposed as a replacement for the Child-Turcotte-Pugh (CTP) classification to stratify patients for prioritization for orthotopic liver transplantation (OLT). Improved classification of patients with decompensated cirrhosis might allow timely OLT before the development of life-threatening complications, reducing the number of critically ill patients listed as United Network for Organ Sharing (UNOS) status 2A at the time of OLT. We compared the ability of the MELD and CTP scores to predict pre-OLT disease severity, as well as outcome and resource utilization post-OLT. Data from 42 consecutive UNOS status 2A patients undergoing OLT at a single center were used to calculate MELD and CTP scores at the time of status 2A listing. Multivariate analysis was used to determine the relationship between these scores and pre-OLT disease severity measures, survival post-OLT, and measures of resource use post-OLT. The MELD was superior to CTP score in predicting pre-OLT requirements for mechanical ventilation and dialysis. Neither score correlated with the resource utilization parameters studied. Only two patients died within 3 months post-OLT; neither score was predictive of survival in this cohort. In summary, the MELD is superior to CTP score in estimating pre-OLT disease severity in UNOS status 2A patients and thus may help risk stratify status 2A or decompensated status 2B OLT candidates and optimize the timing of OLT. However, neither score correlated with resource use post-OLT in the strata of critically ill patients.

Adult↗