Faculty Bibliography

Approximately 9% of deceased kidney donors are classified by the Centers for Disease Control as high infectious risk donors (HRDs), donors thought to be at increased risk for having HIV infection. While the use of HRDs expands the organ supply, there is a small risk of infectious transmission. All donors are tested for antibodies to a variety of viral infections including HIV, hepatitis C virus (HCV), and hepatitis B virus; however, infections acquired in the weeks to months before death may not be serologically detectable, but will likely be transmitted to the recipient. Nucleic acid testing (NAT) shortens the window between acquisition of infection and serologic detectability, from approximately 22 days to 9 days for HIV and from 66 days to 7 days for HCV. Nucleic acid testing has not been universally adopted because it is expensive, time consuming, and has a higher rate of false positives compared with an enzyme-linked immunosorbent assay (ELISA), which might lead to discarding viable organs. Further studies are needed to quantify the risk of infectious transmission from HRDs, identify patients on the waitlist who would most benefit from HRD receipt, and guide NAT policies.

It has been suggested that hepatitis C virus (HCV) patients with hepatocellular carcinoma (HCC) may have worse outcomes after liver transplantation (LT) because of more aggressive tumor biology. In this study, we determined the post-LT survival of HCC patients with and without HCV using United Network for Organ Sharing data from January 1994 to March 2008. Patients with HCC were stratified into HCV (HCC-HCV) and non-HCV (HCC-non-HCV) groups. In the era before the Model for End-Stage Liver Disease (MELD), there were 1237 HCC patients (780, HCV; 373, non-HCV; 84, unknown HCV status), and during the MELD era, there were 4933 HCC patients (3272, HCV; 1348, non-HCV; 313, unknown). In the pre-MELD era, 5-year graft (58.6% versus 53.7%) and patient (61.7% versus 59.3%) survival rates were marginally higher for HCC-non-HCV patients than for HCC-HCV patients. In the MELD era also, 5-year graft (61.2% versus 55.5%) and patient (63.7% versus 58.2%) survival rates were marginally higher for HCC-non-HCV patients than for HCC-HCV patients. In patients without HCC, pre-MELD and MELD era graft/patient survival rates for non-HCV patients were higher than those for HCV patients. The differences in survival rates for HCC patients with and without HCV were lower than those for non-HCC patients stratified by their HCV status. HCV had no additional negative impact on the post-LT survival of patients with HCC, and this was further confirmed by multivariate analysis. In conclusion, the survival of HCC patients has remained unchanged in the past 2 decades. HCV patients have a lower survival rate than non-HCV patients, regardless of their HCC status, but HCV has no additional negative impact on survival in patients with HCC.

Partial hepatectomy for hepatocellular carcinoma (HCC) is a high-risk procedure, especially in the presence of portal hypertension. We assessed whether the volume of hospital liver transplant procedures was associated with lower in-hospital mortality independently of the volume of partial hepatectomy procedures. We queried the Nationwide Inpatient Sample (1998-2005) to identify patients who had undergone partial hepatectomy for HCC and used logistic regression to assess the independent effect of volumes of hospital liver transplant and partial hepatectomy procedures on mortality while adjusting for demographic, clinical, and hospital factors. Overall in-hospital mortality was 7.7%. Patients with portal hypertension experienced higher mortality than those who did not (24.5% versus 5.8%, P < 0.0001). Postoperative mortality benefited from a higher volume of hospital liver transplants (>12 per year) and partial hepatectomy procedures (>5 resections per year). Undergoing partial hepatectomy at a center that performed an effective liver transplant volume (eLTV; >12 transplants per year) was associated with lower mortality in both the portal hypertensive group (16.4% versus 33.7%, P = 0.004) and non-portal hypertensive group (4% versus 8%, P = 0.0002). After multivariate adjustment, the odds ratio (OR) of in-hospital death for those with portal hypertension was 4.5 [95% confidence interval (CI), 2.98-6.81]. The lower mortality observed with eLTV (OR, 0.59; 95% CI, 0.37-0.93) was independent of the mortality benefit from an effective partial hepatectomy volume (>5 hepatectomies per year; OR, 0.54; 95% CI, 0.31-0.94). Postoperative complications were also fewer at centers with eLTV compared to those without eLTV (39.2% versus 29.3%, P < 0.0001). In conclusion, given the postoperative mortality benefit independent of the volume of partial hepatectomy procedures, referral to a center with eLTV should be considered for HCC resection, especially in the presence of portal hypertension.