The Impact of Obesity on Long-term Outcomes in Liver Transplant Recipients—Results of the NIDDK Liver Transplant Database

The impact of obesity on outcomes following liver transplantation has been difficult to determine, in part due to the confounding effects of ascites on BMI. We evaluated the impact of pretransplant recipient obesity on outcomes following liver transplantation using the NIDDK Liver Transplantation Database. Pretransplant BMI, corrected for ascites, was categorized as underweight (BMI <18 kg/m²), normal weight (BMI 18–25 kg/m²), overweight (BMI 25.1–30 kg/m²), Class I obese (BMI 30.1–35 kg/m²), Class II obese (BMI 35.1–40 kg/m²) and Class III obese (BMI >40 kg/m²). Primary outcomes were patient and graft survival. Secondary outcomes included days in hospital and days in ICU. Data from 704 adult liver transplant recipients from the NIDDK LTD and a further 609 patients from the Mayo Clinic were analyzed. Early and late patient and graft survival was similar across all BMI categories. Correcting for ascites volume resulted in 11–20% of patients moving into a lower BMI classification. The relative risk for mortality increased by 7% for each liter of ascites removed. We conclude that corrected BMI is not independently predictive of patient or graft survival. Obesity, within the ranges observed in this study, should not be considered to be a contraindication to liver transplantation in the absence of other relative contraindications.     

Increased early morbidity and mortality with acceptable long-term function in severely obese patients undergoing liver transplantation

The effect of obesity on outcomes following liver transplantation remains unclear. We reviewed our experience with 302 liver transplants in 277 patients from September 1989 to September 1996 to determine the effect of body mass on outcome. Two hundred and seventeen transplants were performed in patients with a body mass index (BMI)<30 kg/m², 55 in patients with a BMI of 30–34 kg/m² (obese), and 30 in patients with a BMI>35 kg/m² (severely obese). Non-weight related pre-operative demographics were similar between groups with the exception of an increased frequency of cryptogenic cirrhosis among the obese and severely obese patients. Intra-operative transfusion requirements were greater for the severely obese group (16.2±3.5 units versus 9.1±0.8 units for the non-obese, p=0.0004), though not when normalized to body weight (0.14±0.03 units/kg versus 0.13±0.01 units/kg, p>0.05). Post-operatively, severely obese patients had a higher rate of wound infection (20 versus 4%, p=0.0001) and death attributed to multisystem organ failure (15 versus 2%, p=0.0001), although overall mortality prior to discharge and total complications were not different between groups. Actual 1-yr graft survival showed a negative trend in the severely obese group (67 versus 81% for non-obese, p=0.07), but both 3-yr graft survival and patient survival were similar to non-obese patients (p=0.12 and 0.17, respectively by the Cox–Mantel test). Liver transplantation in severely obese patients is associated with wound infection and early death from multisystem organ failure, but has similar long-term outcomes when compared to non-obese controls.     

18F-FDG-Uptake of Hepatocellular Carcinoma on PET Predicts Microvascular Tumor Invasion in Liver Transplant Patients

Vascular invasion of hepatocellular carcinoma (HCC) is a major risk factor for poor outcome after liver transplantation (LT). The aim of this retrospective analysis was to assess the value of preoperative positron emission tomography (PET) using ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) in liver transplant candidates with HCC for predicting microvascular tumor invasion (MVI) and posttransplant tumor recurrence.
Forty-two patients underwent LT for HCC after PET evaluation. Sixteen patients had an increased ¹⁸F-FDG tumor uptake on preoperative PET scans (PET +), while 26 recipients revealed negative PET findings (PET−) pre-LT. PET− recipients demonstrated a significantly better 3-year recurrence-free survival (93%) than PET + patients (35%, p < 0.001). HCC recurrence rate was 50% in the PET + group, and 3.8% in the PET—population (p < 0.001). PET + status was identified as independent predictor of MVI [hazard ratio: 13.4]. Patients with advanced PET negative tumors and patients with HCC meeting the Milan criteria had a comparable 3-year-recurrence-free survival (80% vs. 94%, p = 0.6).
Increased ¹⁸F-FDG uptake on PET is predictive for MVI and tumor recurrence after LT for HCC. Its application may identify eligible liver transplant candidates with tumors beyond the Milan criteria.     

Cardiovascular mortality among liver transplant recipients with nonalcoholic steatohepatitis in the United States—a retrospective study

Nonalcoholic steatohepatitis (NASH) has become an increasingly important indication for liver transplantation (LT), and there has been a particular concern of excessive cardiovascular‐related mortality in this group. Using the United Network for Organ Sharing‐Standard Transplant Analysis and Research (UNOS STAR) dataset, we reviewed data on 56,995 adult transplants (January 2002 through June 2013). A total of 3,170 NASH liver‐only recipients were identified and were matched with 3,012 non‐NASH HCV+ and 3,159 non‐NASH HCV? controls [matched 1:1 based on gender, age at LT (±3 years), and MELD score (±3)]. Cox regression analysis revealed significantly lower hazard of all‐cause (HR 0.669; P < 0.0001) and cardiovascular‐related mortality (HR 0.648; P < 0.0001) in the NASH compared to the non‐NASH group after adjusting for diabetes, BMI, and race. Relative to the non‐NASH HCV‐positive group, NASH group has lower hazard of all‐cause (HR 0.539; P < 0.0001) and cardiovascular‐related mortality (HR 0.491; P < 0001). A lower hazard of all‐cause mortality (HR 0.844; P = 0.0094) was also observed in NASH patients compared to non‐NASH HCV‐negative group, but cardiovascular mortality was similar (HR 0.892; P = 0.3276). LT recipients with NASH have either lower or similar risk of all‐cause and cardiovascular‐related mortality compared to its non‐NASH counterparts after adjusting for diabetes, BMI, and race.     

Left Ventricular Mass Is Associated With Ventricular Repolarization Heterogeneity One Year After Renal Transplantation

Ventricular repolarization heterogeneity (VRH) is associated with the risk of arrhythmia and cardiac death. This study investigated the association between VRH and left ventricular mass (LVM) in renal transplant recipients 1 year after transplantation. Echocardiography and 5-min 12-lead electrocardiogram were recorded and GFR was estimated (eGFR) in 68 nondiabetic patients. Beat-to-beat QT interval variability algorithm was used to calculate SDNN-QT and rMSSD-QT indices of VRH. To quantify QT interval variability relative to heart rate fluctuations, QTRR index was calculated. Left ventricular hypertrophy (LVH) was present in 44 patients (65%). LVM and incidence of LVH were increased in 28 patients with eGFR <60 mL/min/1.73 m² compared with 40 patients with eGFR ≥60 mL/min/1.73 m² (248 ± 61 g and 86% vs. 210 ± 46 g and 50%, respectively; p < 0.01). A direct correlation was found between LVM and SDNN-QT (R = 0.47, R²= 0.23; p < 0.001), rMSSD-QT (R = 0.27; R²= 0.10; p = 0.034), and QTRR (R = 0.55; R²= 0.31; p < 0.001) indices. In conclusion, greater LVM is associated with increased VRH in renal transplant recipients, providing a link with the high risk of arrhythmia and cardiac death, specifically in patients with decreased graft function .     

Central venous oxygen saturation for the diagnosis of low cardiac output in septic shock patients

Background: Simple diagnostic tests are needed to screen septic patients for low cardiac output because intervention is recommended in these patients. We assessed the diagnostic value of central venous oxygen saturation in the superior vena cava (ScvO₂) for detecting low cardiac output in patients with septic shock.
Methods: We conducted a prospective observational study in three general intensive care units (ICUs) of adult patients with septic shock, who were to have a catheter inserted for thermodilution measurement of cardiac index (CI_TD). Paired measurements of CI_TD and central venous oximetry values were obtained when the clinician first measured CI_TD.
Results: We included 56 patients with septic shock and a mean sequential organ failure assessment score of 12 (range 3–20). Baseline CI_TD was 3.5 l/min/m² (1.0–6.2) and ScvO₂ of 70% (33–87). The best cut-off of ScvO₂ for CI_TD>2.5 l/min/m² ( n =42) was a value ≥64% with positive and negative predictive values of 91% (95% confidence interval 79–98) and 91% (59–100), respectively. The diagnostic values were not improved by using instead central venous O₂ tension or the difference between arterial and central venous O₂ saturation.
Conclusions: This prospective, observational study found that a ScvO₂ measurement of ≥64% indicated CI_TD>2.5 l/min/m² in ICU patients with septic shock.     

Echocardiographic features, mortality, and adrenal function in patients with cirrhosis and septic shock

Objectives: Cirrhosis of the liver is associated with an increased susceptibility to bacterial infections capable of causing septic shock and with a basal hyperdynamic circulatory state. The primary objective of this study was to delineate the echocardiographic characteristics and outcomes of septic shock in patients with liver cirrhosis. The secondary objective was to determine whether adrenal insufficiency, which may contribute to hyperdynamic syndrome, was more marked in patients with cirrhosis than in other patients with septic shock.
Design: Prospective single-center cohort study.
Patients and methods: Thirty-four patients admitted to the intensive care unit (ICU) for septic shocks were included, 14 with and 20 without liver cirrhosis. Echocardiography was performed within the first 24 h to measure the cardiac index (CI), systolic index (SI), and left ventricular ejection fraction (LVEF). A Synacthen test was performed.
Results: Patients with cirrhosis had higher values for the CI (3.69±1.0 vs. 2.86±0.8 l/min/m²; P =0.02), SI (37.5±8 vs. 32.4±7 ml/m²; P =0.04), and LVEF (67±7 vs. 55.9±12%; P =0.005). ICU mortality was 53% overall, 64% in patients with cirrhosis, and 45% in patients without cirrhosis ( P =0.27). Serum cortisol levels under basal conditions (H0) and after stimulation (H1) showed no significant differences between patients with and without cirrhosis. The proportion of patients with no response to Synacthen was 77% among patients with cirrhosis and 50% among patients without cirrhosis ( P =0.18).
Conclusion: In a population with septic shock, left ventricular function was more hyperdynamic in the subset with cirrhosis. Relative adrenal insufficiency occurred in similar proportions of patients with and without cirrhosis.     

Recurrence-Free Long-Term Survival After Liver Transplantation in Patients with 18F-FDG Non-Avid Hilar Cholangiocarcinoma on PET

The aim of this retrospective study was to assess the value of ¹⁸F-fluorodeoxyglucose positron emission tomography (¹⁸F-FDG-PET) for predicting biological tumor behavior and outcome after liver transplantation (LT) in patients with otherwise unresectable hilar cholangiocarcinoma (HC). Preoperative ¹⁸F-FDG-PET scanning was performed in 13 patients with type IV Klatskin tumor before LT. PET+ status indicated patients with an increased pretransplant ¹⁸F-FDG uptake, whereas PET− recipients had no increased preoperative ¹⁸F-FDG uptake on PET. Pretransplant PET findings were correlated with histopathological tumor characteristics and patient outcome after LT. Eight patients demonstrated positive preoperative PET findings (61.5%), whereas five patients had no increased preoperative ¹⁸F-FDG tumor uptake (38.5%) on PET. One PET+ patient died after 1 month due to liver allograft dysfunction. Seven PET+ liver recipients developed tumor recurrence, whereas five PET− patients were tumor-free alive after a median of 76 months post-LT (p = 0.001). The 2-year recurrence-free survival rate after LT was 100% in PET− patients and 28.6% in the PET+ population (log-rank = 0.008). Our results suggest that patients with ¹⁸F-FDG non-avid HC on PET may achieve recurrence-free long-term survival after LT.     

Non-Alcoholic Fatty Liver Disease, Non-Alcoholic Steatohepatitis and Orthotopic Liver Transplantation

Obesity, non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) are becoming increasingly common medical problems in the developed world, often in the setting of the metabolic or insulin resistance syndrome (IRS). It is predicted that by the year 2025 > 25 million Americans may have NASH-related liver disease. NASH and NAFLD also affect the donor population. The use of steatotic donor livers for liver transplantation (LT) is associated with an increased risk of primary nonfunction (PNF) in the allograft. There is particular reluctance to use steatotic livers for living donor LT. There is indirect evidence to suggest that patients undergoing LT for cirrhosis resulting from NASH may have poorer outcome, despite careful selection of LT candidates. Indeed it is likely that many potential LT candidates with NASH are excluded from LT due to co-morbid conditions related to IRS. The post-LT patient is at risk of several components of IRS, such as diabetes mellitus, hypertension, hyperlipidaemia and obesity and there is increasing recognition of de novo and recurrent NAFLD and NASH after LT. Thus NAFLD and NASH affect all aspects of LT including donors, patients in evaluation and the LT recipient.     

Twenty-Year Experience With Heart Transplantation for Infants and Children With Restrictive Cardiomyopathy: 1986–2006

Idiopathic restrictive cardiomyopathy (RCM) is a rare cardiomyopathy in children notable for severe diastolic dysfunction and progressive elevation of pulmonary vascular resistance (PVR). Traditionally, those with pulmonary vascular resistance indices (PVRI) >6 W.U. × m² have been precluded from heart transplantation (HTX). The clinical course of all patients transplanted for RCM between 1986 and 2006 were reviewed. Preoperative, intraoperative and postoperative variables were evaluated. A total of 23 patients underwent HTX for RCM, with a mean age of 8.8 ± 5.6 years and a mean time from listing to HTX of 43 ± 60 days. Preoperative and postoperative (114 ± 40 days) PVRI were 5.9 ± 4.4 and 2.9 ± 1.5 W.U. × m², respectively. At time of most recent follow-up (mean = 5.7 ± 4.6 years), the mean PVRI was 2.0 ± 1.0 W.U. × m². Increasing preoperative mean pulmonary artery pressure (PA) pressure (p = 0.04) and PVRI > 6 W.U. × m² (χ²= 7.4, p < 0.01) were associated with the requirement of ECMO postoperatively. Neither PVRI nor mean PA pressure was associated with posttransplant mortality; 30-day and 1-year actuarial survivals were 96% and 86%, respectively. Five of the seven patients with preoperative PVRI > 6 W.U. × m² survived the first postoperative year. We report excellent survival for patients undergoing HTX for RCM despite the high proportion of high-risk patients.     

Effect of body mass index on the survival benefit of liver transplantation.

Obese patients are at higher risk for morbidity and mortality after liver transplantation (LT) than nonobese recipients. However, there are no reports assessing the survival benefit of LT according to recipient body mass index (BMI). A retrospective cohort of liver transplant candidates who were initially wait-listed between September 2001 and December 2004 was identified in the Scientific Registry of Transplant Recipients database. Adjusted Cox regression models were fitted to assess the association between BMI and liver transplant survival benefit (posttransplantation vs. waiting list mortality). During the study period, 25,647 patients were placed on the waiting list. Of these, 4,488 (17%) underwent LT by December 31, 2004. At wait-listing and transplantation, similar proportions were morbidly obese (BMI>or=40; 3.8% vs. 3.4%, respectively) and underweight (BMI<20; 4.5% vs. 4.0%, respectively). Underweight patients experienced a significantly higher covariate-adjusted risk of death on the waiting list (hazard ratio [HR]=1.61; P<0.0001) compared to normal weight candidates (BMI 20 to <25), but underweight recipients had a similar risk of posttransplantation death (HR=1.28; P=0.15) compared to recipients of normal weight. In conclusion, compared to patients on the waiting list with a similar BMI, all subgroups of liver transplant recipients demonstrated a significant (P<0.0001) survival benefit, including morbidly obese and underweight recipients. Our results suggest that high or low recipient BMI should not be a contraindication for LT.     

Impact of recipient morbid obesity on outcomes after liver transplantation

The aim of this study was to analyze the impact of morbid obesity in recipients on peritransplant resource utilization and survival outcomes. Using a linkage between the University HealthSystem Consortium and Scientific Registry of Transplant Recipients databases, we identified 12 445 patients who underwent liver transplantation (LT) between 2007 and 2011 and divided them into two cohorts based on recipient body mass index (BMI; <40 vs. ≥40 kg/m²). Recipients with BMI ≥40 comprised 3.3% (n = 416) of all LTs in the studied population. There were no significant differences in donor characteristics between two groups. Recipients with BMI ≥40 were significant for being female, diabetic, and with NASH cirrhosis. Patients with a BMI ≥40 had a higher median MELD score, limited physical capacity, and were more likely to be hospitalized at LT. BMI ≥40 recipients had higher post‐LT length of stay and were less often discharged to home. With a median follow‐up of 2 years, patient and graft survival were equivalent between the two groups. In conclusion, morbidly obese LT recipients appear sicker at time of LT with an increase in resource utilization but have similar short‐term outcomes.     

Impact of low-dose rituximab on splenic B cells in ABO-incompatible renal transplant recipients

The purpose of this study was to assess the effect of a low-dose rituximab (RIT) at <375 mg/m² on B cells in the spleen and peripheral blood. Five renal transplant recipients received a single dose of RIT at 10, 15, 35, 150, or 300 mg/m² 3–13 days before transplantation. One patient who received the same immunosuppressive regimen except for RIT was also enrolled as a control. Splenectomy was performed at the time of transplantation in all patients. The B-cell count in the peripheral blood was analysed with a fluorescence-activated cell sorter using anti-CD19 antibodies, and the B cells in the spleen were analysed by immunohistochemistry using anti-CD20 and -CD79a antibodies. All but one dosage (10 mg/m²) of RIT completely eliminated B cells from the circulation within 30 days. Immunohistochemical examination of the spleen showed a marked reduction of B cells in the white pulps in all five recipients compared with that in the control patient. The observations in this study indicated that RIT has a potent effect of depleting B cells in the spleen and peripheral blood at low-doses of <375 mg/m².     

Assessing Glomerular Filtration Rate by Estimation Equations in Kidney Transplant Recipients

Surveillance of glomerular filtration rate (GFR) is crucial in the management of kidney transplant recipients. With especial emphasis on serum creatinine (SCr) calibration assay, we assessed the performance of estimation equations as compared to iothalamate GFR (iGFR) in 209 patients using the modification of diet in renal disease (MDRD), Nankivell and Cockcroft-Gault methods. Fifty-five percent of patients were treated with a calcineurin inhibitor (CNI) and all were taken trimethroprim-sulfametoxazole at the time of SCr measurement. The mean iGFR was 44 ± 26 mL/min/1.73 m². The MDRD equation showed a median difference of 0.9 mL/min/1.73 m² with 53% of estimated GFR within 20% of iGFR. Median differences were 7.5 and 7.0 mL/min/1.73 m² for Nankivell and Cockcroft-Gault formulas, respectively. The accuracy of the Nankivell and Cockcroft-Gault formulas was such that only 38% and 37% of estimations, respectively, fell within 20% of iGFR. The performance of all equations was not uniform throughout the whole range of GFR, with some deterioration at the extremes of GFR levels. In addition, good performance of the MDRD equation was seen in subjects taking CNI. In conclusion, the overall performance of the MDRD equation was superior to the Nankivell and Cockcroft-Gault formulas in renal transplant recipients including subjects treated with CNI.     

Combined liver transplantation and sleeve gastrectomy for end-stage liver disease in a bariatric patient: First European case-report

IntroductionObesity is a contributor to the global burden of chronic diseases, including non-alcoholic fatty liver disease and non-alcoholic steatohepatitis (NASH). NASH cirrhosis is becoming a leading indication for liver transplant (LT). Obese transplanted patients have higher morbidity and mortality rates. One strategy, to improve the outcomes in these patients, includes bariatric surgery at the time of LT. Herein we report the first European combined LT and sleeve gastrectomy (SG).Case presentationA 53 years old woman with Hepatocellular carcinoma and Hepatitis C virus related cirrhosis, was referred to our unit. She also presented with severe morbid obesity (BMI 40 kg/m²) and insulin-dependent diabetes. Once listed for LT, she was assessed by the bariatric surgery team to undergo a combined LT/SG. At the time of transplantation the patient had a model for end-stage liver disease calculated score of 14 and a BMI of 38 kg/m².The LT was performed using a deceased donor. An experienced bariatric surgeon, following completion of the LT, performed the SG. Operation time was 8 h and 50 min. The patient had an uneventful recovery and is currently alive, 5 months after the combined procedure, with normal allograft function, significant weight loss (BMI = 29 kg/m²), and diabetes resolution.ConclusionDespite the ideal approach to the management of the obese LT patients remains unknown, we strongly support the combined procedure during LT in selected patients, offering advantages in terms of allograft and patient survival, maintenance of weigh loss that will ultimately reduce obese related co-morbidities.     

Improved cyclosporine pharmacokinetics in maintenance renal transplant recipients converted to cyclosporine for microemulsion

Abstract Background: Variability in cyclosporine drug exposure of ≥ 20% has been shown to be a risk factor for the development of chronic renal allograft rejection. We tested the hypothesis that a cyclosporine microemulsion (CsA-ME) would result in reduced variability in stable maintenance renal transplant patients when compared with the original formulation of cyclosporine (CsA).
Methods: The 31 maintenance renal transplant recipients were part of a multicenter, randomized, double-blind, prospective study comparing the CsA formulation with the CsA-ME formulation. Pharmacokinetics analyses were performed at two centers 1, 4, 12, and 52 weeks after patients were randomized to continue receiving CsA or to convert to CsA-ME.
Results: The means of the week 1-, 4-, and 12-week areas under the concentration-time curves (AUC), and Cmax were significantly higher and the Tmax was significantly shorter in those patients converted to CsA-ME than in those remaining on CsA. There was no correlation between change in AUC after conversion and change in serum creatinine. The coefficient of variation values for dose-adjusted AUC, expressed as a percentage (%CV_AUC), were lower in CsA-ME patients than CsA patients after both 12 and 52 weeks. Over the initial 12 weeks, %CV_AUC values of ≤ 20% were seen in a significantly greater proportion of CsA-ME patients than CsA patients.
Conclusions. Conversion of maintenance renal transplant recipients from CsA to CsA-ME resulted in improved absorption of cyclosporine. The CsA-ME formulation resulted in long-term reduction in the variability of cyclosporine exposure and more consistent pharmacokinetics.     

Does Additional Doxorubicin Chemotherapy Improve Outcome in Patients with Hepatocellular Carcinoma Treated by Liver Transplantation?

The aim of this prospective randomized study was to determine whether additional doxorubicin chemotherapy improves outcome in patients with hepatocellular carcinoma (HCCA) treated by liver transplantation. Stratification parameters were tumor stage (UICC I-IVa), gender, age 50 years, α-fetoprotein 20 ng/mL, cirrhosis and HbsAg status. For pre-operative chemotherapy doxorubicin (15 mg/m²) was given biweekly, intra-operative chemotherapy was a single dose administered before surgical manipulation. Post-operative chemotherapy from day 10 was as given preoperatively for a total dosage of 300 mg/m². Outcome parameters were overall survival (OS) and disease-free survival. Of the 75 consecutive patients who received liver transplantation for treatment of HCCA, 62 patients were enrolled. Thirty-four patients were randomized in the chemotherapy group; 28 patients were in the control group and transplanted only. OS rates at 5 years were 38% in the chemotherapy group and 40% in the control group, disease-free survival rates at 5 years 43% and 53%, respectively. Tumor stage and vascular invasion were identified as independent risk factors for recurrence of disease. Doxorubicin chemotherapy did not improve organ survival and disease-free survival in patients undergoing liver transplantation for HCCA.     

Implications of worse renal dysfunction and medical comorbidities in patients with NASH undergoing liver transplant evaluation: impact on MELD and more

Increasing numbers of patients with non-alcoholic steatohepatitis (NASH) are referred for liver transplant (LT). Our objective was to characterize patients with NASH among referred LT candidates (from 1998 to 2008), and we compared demographics, etiology of liver disease, diabetes, hypertension, smoking, obesity, cardiac disease, cancer, laboratory data, model for end-stage liver disease (MELD), and outcomes between NASH and non-NASH patients. Patients with NASH (n = 71) were compared to other chronic liver disease (n = 472). Patients with NASH were older (58.7 vs. 52.5 yr, p < 0.0001), Asian (53.5% vs. 34.7%, p = 0.03) and women (50.7% vs. 32.1%, p = 0.003). Patients with NASH had more diabetes, hypertension, obesity, cardiac disease, and smoking history (p < 0.05). Patients with NASH were equally likely to have liver cancer, but more likely to have non-liver cancers (20.8% vs. 4.4%, p = 0.008). There was no difference in MELD, but patients with NASH had lower protime/international normalized ratio (1.14 vs. 1.27, p = 0.04) and higher creatinine (1.26 vs. 0.98 mg/dL, p = 0.0018). Patients with NASH were equally likely to undergo evaluation, listing, and transplantation compared to non-NASH patients. While all patients with chronic liver disease can have renal dysfunction because of hepatorenal syndrome, patients with NASH have more renal dysfunction, perhaps related to diabetes, hypertension, and cardiovascular disease. Transplant centers should consider this carefully in selection of candidates for LT.     

Influence of nutritional status in lung transplant recipients

OBJECTIVE: To assess the influence of nutritional status on mortality in lung transplant (LT) recipients. METHODS: A total of 114 patients underwent lung-transplantation between January 1999 and June 2005. Mortality after lung transplantation was examined based upon body mass index (BMI) categories: BMI < 18.5 kg/m(2) (group I); BMI 18.5 to 24.9 kg/m(2) (group II, reference group); BMI 25 to 27.5 kg/m(2) (group III); and BMI > 27.5 kg/m(2) (group IV). Levels of serum albumin and serum prealbumin were determined before transplantation. We constructed a Cox proportional hazards model for overall survival considering mortality as the outcome. The final model was adjusted by age. RESULTS: We analyzed 114 transplants in 112 patients. The population included 44 single and 70 bilateral LTs. Mean recipient age was 53.9 +/- 10.9 years. The hazard ratio of the risk of death in group IV was higher than in the reference group (hazard ratio: 3.55, 95% CI: 1.19 to 10.66; P = .024). Serum prealbumin 27.5 kg/m(2) was a predictor of increased mortality after transplantation. Low pretransplant prealbumin levels in lung recipients were associated with mortality after transplantation.     

Correlation of Nuclear Morphometry and Immunostaining for p53 and Proliferating Cell Nuclear Antigen in Transitional Cell Carcinoma of the Bladder

Background :
In an attempt to determine the biological significance of nuclear morphometric findings, measurements of mean nuclear volume (MNV) and nuclear roundness factor (NRF) were compared to the immunoreactivityof p53 expression and proliferating cell nuclear antigen (PCNA) in human bladder cancer.
Methods :
MNV and NRF were measured using stereological methods. Expression of p53 and PCNA were determined by immunohistochemical staining. Specimens from 111 patients with previously untreated bladder cancer were analyzed.
Results :
The mean MNV was 235.8 ± 1 33.6 μm³ for the 81 patients with p53-labeling index (LI) less than 10% and 337.2 ± 141.0 μn³ for the 30 patients with p53 LI greater than 10% (P = 0.008). There was Resign if icant correlation between NRF and expression of p53. The mean MNV was 220.1 ± 1 20.5 μm³ for the 67 patients with PCNA LI less than 28% (the mean value of PCNA LI) and 328.9 ± 149.2 μm³ in 44 patients with PCNA LI greater than 28% (P= 0.0001). The mean NRF was 80.7 ± 4.2 for the 67 patients with PCNA LI less than 28%, and 82.3 ± 3.4 for the 44 patients with PCNA LI more than 28% (P= 0.04). Conclusion: Nuclear morphometric findings may reflect the proliferative potential of cancer eel Is of the bladder, as indicated by findings of immunostaining for p53 and PCNA.