With the increase in patients having impaired renal function at liver transplant due to MELD, accurate predictors of posttransplant native renal recovery are needed to select candidates for simultaneous liverkidney transplantation (SLK). Current UNOS guidelines rely on specific clinical criteria for SLK allocation. To examine these guidelines and other variables predicting nonrecovery, we analyzed 155 SLK recipients, focusing on a subset (n = 78) that had post-SLK native GFR (nGFR) determined by radionuclide renal scans. The 77 patients not having renal scans received a higher number of extended criteria donor organs and had worse posttransplant survival. Of the 78 renal scan patients, 31 met and 47 did not meet pre-SLK UNOS criteria. The UNOS criteria were more predictive than our institutional criteria for all nGFR recovery thresholds (20-40 mL/min), although at the most conservative cut-off (nGFR ≤ 20) it had low sensitivity (55.3%), specificity (75%), PPV (67.6%) and NPV (63.8%) for predicting post-SLK nonrecovery. On multivariate analysis, the only predictor of native renal nonrecovery (nGFR ≤ 20) was abnormal pre-SLK renal imaging (OR 3.85, CI 1.22-12.5). Our data support the need to refine SLK selection utilizing more definitive biomarkers and predictors of native renal recovery than current clinical criteria.

Maintenance of cardiac function is critical to the survival of patients with end-stage liver disease after liver transplantation (LT). We sought to determine whether pre-LT echocardiographic indices of right heart structure and function were independently predictive of morbidity and mortality post-LT. We retrospectively studied 216 consecutive patients who underwent pre-LT 2-dimensional/Doppler echocardiography with subsequent LT from 2007 to 2010. A blinded reader analyzed multiple echocardiographic parameters, including right ventricular structure and function, pulmonary artery systolic pressure (PASP) and the presence and severity of tricuspid regurgitation (TR). On univariate analysis, Model of End-Stage Liver Disease (MELD) score, PASP, presence of !mild TR, post-operative renal replacement therapy (RRT) and spontaneous bacterial peritonitis were found to be significant predictors of adverse outcomes. On multivariate analysis, only !mild TR was found to predict both patient mortality (p ¼ 0.0024, HR ¼ 3.91, 95% CI: 1.62-9.44) and graft failure (p ¼ 0.0010, HR ¼ 3.70, 95% CI: 1.70-8.06). PASP and MELD correlated with post-LT intensive care unit length of stay (LOS) and, along with hemodialysis, were associated with hospital LOS and time on ventilator. In conclusion, pre-LT echocardiographic assessments of the right heart may be useful in predicting post-LT morbidity and mortality and guiding the selection of appropriate LT candidates.

BK virus nephropathy (BKVN) is

Patients listed for liver-intestine transplantation suffer higher waiting list mortality than those listed for liver-only, thus leading to policy revisions seeking to close the gap. We sought to determine the impact of key model for end-stage liver disease (MELD)/pediatric end-stage liver disease (PELD) policy modifications on the waiting list mortality of adult and pediatric liverintestine candidates as compared to liver-only candidates. Analysis of UNOS data separated into adult and pediatric categories and based on time periods of policy implementation revealed higher mortality in liver-intestine candidates over all time periods studied (p < 0.001 pediatric and adult). After implementation of a revision to augment their MELD scores based on a sliding scale, adult liver-intestine candidates with calculated MELD > 15 no longer suffered higher mortality although this change did not completely eliminate the mortality disparity for candidates with MELD < 15 (p < 0.01). The waiting list mortality of pediatric liver-intestine candidates dropped significantly after a revision that gave them 23 additional MELD/PELD points (p < 0.01) although the mortality disparity with pediatric liver-only candidates was not eliminated. Following this revision, mortality in pediatric liver-only and liver-intestine Status 1 candidates was similar, however more liver-intestine candidates were listed as Status 1B. This data demonstrates that a mortality disparity remains for liver-intestine candidates compared with candidates listed for liver-only.

Postpartum haemorrhage is an infrequent but potentially life-threatening obstetrical emergency amenable to simulation. An educational programme consisting of a lecture and high-fidelity simulation exercise was given to incoming obstetrics and gynaecology (OB) and family medicine (FM) residents. Residents reported pre- and post-intervention confidence scores on a 1-5 Likert scale and a subset completed a postpartum haemorrhage knowledge assessment. Residents reported significant improvements in confidence in parameters involved in diagnosis and management of postpartum haemorrhage. The postpartum haemorrhage test mean scores significantly increased (57.4 ± 9.6% vs 77.1 ± 7.9%, p < 0.01) and were significantly correlated to confidence scores (Spearman's coefficient of 0.651, p < 0.001). In conclusion, an education programme that incorporates high-fidelity simulation of postpartum haemorrhage improves the confidence and knowledge of incoming residents and appears to be an effective educational approach.