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Organ transplant
Patient Information
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Transplant Update
August 2004
Issue No.1
Dinesh Ranjan, MD
Chief, Transplant Section
Professor of Surgery
UK College of Medicine
dranj1@email.uky.edu
This year, as the University of Kentucky Transplant Center celebrates its 40th anniversary, it is my pleasure to introduce Transplant Update, the UK Transplant Center newsletter. Since the first kidney transplantation at UK in 1964, we have been on the leading edge of transplant technology. The current liver and pancreas transplant programs were initiated in 1995 and 1996 respectively. Those programs perform at or above the national benchmarks, a remarkable achievement considering that we provide care for a regional Appalachian population with a high incidence of co-morbidities, including Diabetes, COPD, malnutrition and obesity.
Along with an introduction to the UK HealthCare Transplant team on the back page, you will find discussions of two current topics in this issue; liver transplantation for hepatocellular carcinoma and hand assisted laparoscopic living donor nephrectomy (HALLDN).
Liver transplantation for hepatocellular carcinoma has become an acceptable and common therapeutic option. All cirrhotic patients are at risk for developing hepatocellular carcinoma (HCC), therefore a routine screening with alpha-fetoprotein and imaging not only is conducive to an early diagnosis – it also allows us to upgrade the patient on the transplant waiting list.
Hand assisted laparoscopic living donor nephrectomy (HALLDN) is a relatively new addition to the ever popular minimally invasive approach to surgical procedures. HALLDN combines the benefits of laparoscopic as well as open procedures. This alternative is offered to living kidney donors at UK Transplant Center.
Referring physicians are an integral part of our team, both in the pre-transplant and post-transplant phase. For additional information on the UK Transplant Center, please call (859) 231-9922, or toll-free at 1-800-888-5533.
Thank you for your continued support. I hope you find this introductory issue of Transplant Update useful and informative.
Hoonbae Jeon, MD
Assistant Professor of Surgery
jhoon2@email.uky.edu
Because of emerging outbreaks of hepatitis C in the United States, hepatocellular carcinoma (HCC) is no longer a rare neoplasm in this country. In contrast to the strong association between hepatitis B and HCC in non-Western countries, cirrhosis associated with alcoholism and hepatitis C infection shows the strongest association with HCC in the western countries. Resectional surgery has been a gold standard of treatment, however only 10-15 percent of patients are found to be resectable at the time of diagnosis. Multifocality of the tumor and underlying cirrhosis are main reasons that preclude resection. At the time of diagnosis 20 percent to 60 percent of cases of small HCCs are found to be multifocal and up to 30 percent of tumors in cirrhotic patients are under-staged despite an elaborate preoperative workup.
Liver transplantation (LTx) has emerged as a potential treatment for tumors not amenable to resection as it not only removes the lesion, LTx also treats the underlying liver disease that may lead to other (metachronous) tumors later (Ranjan D et al in Hepatogastroenterology. 1998 Sep-Oct;45 (23):1369-74). In the 1970s and 1980s, while some LTx recipients with HCC experienced long-term survival, many had a high rate of recurrence, usually within the first two post-transplant years. An early stage of the tumor before transplantation seemed to have strong correlation with a better long-term prognosis in the early experience. This benefit was established in a landmark paper (Mazzaferro et al in N Engl J Med. 1996 Mar 14;334 (11):693-9) where LTx was shown as an effective treatment for small tumors (single lesions 5 cm or less in diameter, or three or fewer lesions none >3 cm in diameter) in patients with cirrhosis. TNM status, number of tumors, serum AFP levels, and treatment before LTx did not significantly affect survival. At present, UNOS favorably allocates donor livers to recipients who fulfill these strict criteria in the current MELD allocation system. However, a recent study has shown that patients with solitary tumors <6.5 cm in diameter, or three or fewer nodules with the largest lesion <4.5 cm and total tumor diameter <8 cm, had one- and five-year survival rates of 90 percent and 75 percent respectively, after liver transplantation. Pre-transplant non-surgical treatments such as radiofrequency ablation (RFA) or transarterial chemoembolization (TACE) can be performed to achieve down staging of the bigger tumor beyond these criteria. The severity of the underlying liver disease is almost always the key factor in deciding whether to consider liver resection or transplantation as the treatment for HCC. While the majority of patients with underlying cirrhosis with HCC do not qualify for surgical resection, surgical resection could still be the treatment of choice in selected patients. In case the HCC recurs after resection, salvage LTx could still be considered. Although LTx is the best treatment for many patients in terms of both quality and quantity of life, it is still far from being a general solution, because of the severe shortage of donor organs.
At the UK Transplant Center, we offer a variety of treatment modalities for HCC including resection, RFA, TACE and an ultimately transplantation in orchestrated fashion. For more information or a discussion about your patient, please contact the UK Transplant Center at (859) 231-9922, or toll-free at 1-800-888-5533.
Thomas Johnston, MD
Associate Professor of Surgery
tdjohn1@email.uky.edu
Laparoscopic live donor nephrectomy (LLDN) is becoming increasingly popular, as it has been shown to minimize donor morbidity, length of hospitalization, and length of recovery time. Increased incidence of delayed graft function or ureteral complication that was associated with laparoscopically procured kidneys in the initial experience in the 1990s have become less common with increasing skill and we reported excellent outcomes with this procedure (Reddy et al in Clin Transplant. 2003;17 Suppl 9:44-7).
Hand-assisted laparoscopic living donor nephrectomy (HALLDN) is a relatively newer technique offering a more acceptable alteration to the standard technique of LLDN. The UK Transplant Center has offered laparoscopic live donor nephrectomy since 1998. In this conventional laparoscopic technique, the surgeon works through a few laparoscopic ports and makes a small incision to retrieve the kidney. Because of the limitations in dissection with a small port the kidney may have a shorter pedicle as reported by us (Johnston et al in Clin Transplant. 2001;15 Suppl 6:62-5). We have offered the newly introduced “hand-assisted” HALLDN technique since 2003. In this technique, the operating surgeon makes a small incision in the beginning of the procedure, placing his hand in the abdomen of the donor to ensure better operating control and additional safety with inputs through the tactile sensation. In this way, not only is the duration of the procedure shortened, but the product of this procedure, the donor kidney, is more surgeon-friendly in the implantation procedure. Therefore, this procedure offers all of the advantages of the conventional LLDN while avoiding the problem of a shorter pedicle that was sometimes seen with LLDN. Since the introduction of this new technique, none of our patients (n=10) have experienced delayed graft function. Additionally, none of our donors have experienced post-operative complications.
Not only does the live donor kidney transplantation have better long-term graft survival than cadaveric kidneys after transplantation, it also offers the patient other benefits such as shorter stays on dialysis, better pre-transplant medical preparation and significantly reduced emotional stress as compared to waiting for cadaveric kidney. We strongly encourage our patients to pursue the live donor kidney transplant option, and ask that they discuss this option with their family, friends and other .For more information or discussion about the live donor kidney transplantation or HALLDN, please contact the UK Transplant Center at 859-231-9922, or toll-free at 1-800-888-5533.
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