Background and Aims Hepatitis C virus (HCV)‐viremic organs are underutilized, and there is limited real‐world experience on the transplantation of HCV‐viremic solid organs into recipients who are HCV negative. Approach and Results Patients listed or being evaluated for solid organ transplant after January 26, 2018, were educated and consented by protocol on the transplantation of HCV‐viremic organs. All recipients were HCV nucleic acid test and anti‐HCV antibody negative at the time of transplant and received an HCV‐viremic organ. The primary outcome was sustained virological response (SVR) at 12 weeks after completion of direct‐acting antiviral (DAA) therapy (SVR12). Seventy‐seven patients who were HCV negative underwent solid organ transplantation from a donor who was HCV viremic. No patients had evidence of advanced hepatic fibrosis. Treatment regimen and duration were at the discretion of the hepatologist. Sixty‐four patients underwent kidney transplant (KT), and 58 KT recipients had either started or completed DAA therapy. Forty‐one achieved SVR12, 10 had undetectable viral loads but are not eligible for SVR12, and 7 remain on treatment. One KT recipient was a nonresponder because of nonstructural protein 5A resistance. Four patients underwent liver transplant and 2 underwent liver‐kidney transplant. Three patients achieved SVR12, 1 has completed DAA therapy, and 2 remain on treatment. Six patients underwent heart transplant and 1 underwent heart‐kidney transplant. Six patients achieved SVR12 and 1 patient remains on treatment. Conclusions Limited data exist on the transplantation of HCV‐viremic organs into recipients who are HCV negative. Our study is the largest to describe a real‐world experience of the transplantation of HCV‐viremic organs into recipients who are aviremic. In carefully selected patients, the use of HCV‐viremic grafts in the DAA era appears to be efficacious and well tolerated.

No abstract

Background Necrotizing soft tissue infections (NSTI) are rare, potentially fatal surgical emergencies. We studied a national cohort of patients to determine recent trends in incidence, treatment, and outcomes for NSTI. Methods We queried the Nationwide Inpatient Sample (1998–2010) for patients with a primary diagnosis of NSTI. Temporal trends in patient characteristics, treatment (debridement, amputation, hyperbaric oxygen therapy (HBOT)), and outcomes were determined using Cochran-Armitage Trend Tests and Linear Regression. To account for trends in case mix (age group, sex, race, insurance, Elixhauser index) or receipt of HBOT on outcomes, multivariable analyses were conducted to determine the independent effect of year of treatment on mortality, any major complication, and length of stay for NSTI. Results We identified 56,527 weighted NSTI admissions; incidence ranging from approximately 3,800–5,800 cases annually. The number of cases peaked in 2004 and then decreased for an overall statistically significant decrease between 1998 and 2010 (p<0.0001). The percentage of female patients decreased slightly over time (38.6 to 34.1%, p<0.0001). Patients were increasingly in the 18–34 year old (8.8 to 14.6% p<0.0001) and 50–64 year old age groups (33.2 to 43.5, p<0.0001), Hispanic (6.8 to 10.5%, p<0.0001), obese (8.9 to 24.6%, p<0.0001), and admitted with >3 co-morbidities (14.5 to 39.7%, p<0.0001). The percentage of patients requiring only one surgical debridement increased (43.2 to 46.2%, p<0.0001) while the utilization of HBOT was rare and decreasing (1.6 to 0.8%, p<0.0001). The percentage of patients requiring operative wound closure decreased (23.5 to 20.8%, p<0.0001). Although major complication rates increased (30.9 to 48.2%, p<0.0001), LOS remained stable (18–19 days) and mortality decreased (9.0 to 4.9%, p<0.0001) on univariate analyses. On multivariable analyses each one-year incremental increase in year was associated with a 5% increased odds of complication (OR 1.05), 0.4 times decrease in hospital LOS (coefficient −0.41), and 11% decreased odds of mortality (OR 0.89) Conclusions There were significant national trends in patient characteristics and treatment patterns for NSTI between 1998 and 2010. Importantly, though patient acuity worsened and complication rates increased, LOS remained relatively stable and mortality decreased. Improvements in early diagnosis, wound care, and critical care delivery may be the cause.

Background: The utility of hyperbaric oxygen therapy (HBOT) in the treatment of necrotizing soft tissue infections (NSTIs) has not been proved. Previous studies have been subject to substantial selection bias because HBOT is not available universally at all medical centers, and there is often considerable delay associated with its initiation. We examined the utility of HBOT for the treatment of NSTI in the modern era by isolating centers that have their own HBOT facilities. Methods: We queried all centers in the University Health Consortium (UHC) database from 2008 to 2010 that have their own HBOT facilities (n = 14). Cases of NSTI were identified by International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes, which included Fournier gangrene (608.83), necrotizing fasciitis (728.86), and gas gangrene (040.0). Status of HBOT was identified by the presence (HBOT) or absence (control) of ICD-9 procedure code 93.95. Our cohort was risk-stratified and matched by UHC's validated severity of illness (SOI) score. Comparisons were then made using univariate tests of association and multivariable logistic regression. Results: There were 1,583 NSTI cases at the 14 HBOT-capable centers. 117 (7%) cases were treated with HBOT. Univariate analysis showed that there was no difference between HBOT and control groups in hospital length of stay, direct cost, complications, and mortality across the three less severe SOI classes (minor, moderate, and major). However, for extreme SOI the HBOT group had fewer complications (45% vs. 66%; p < 0.01) and fewer deaths (4% vs. 23%; p < 0.01). Multivariable analysis showed that patients who did not receive HBOT were less likely to survive their index hospitalization (odds ratio, 10.6; 95% CI 5.2-25.1). Conclusion: At HBOT-capable centers, receiving HBOT was associated with a significant survival benefit. Use of HBOT in conjunction with current practices for the treatment of NSTI can be both a cost-effective and life-saving therapy, in particular for the sickest patients.

This UHC-based cohort shows that increased centre volume results in improved long-term post-liver transplant outcomes and more efficient use of hospital resources thereby lowering the cost. A better understanding of these mechanisms can lead to informed decisions and optimization of the pay for performance model in liver transplantation.