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Limited data exist on the safety and efficacy of bariatric surgery (BS) in patients with kidney failure. We examined Medicare billing claims within USRDS registry data (1991–2004) to identify BS cases among renal allograft candidates and recipients. Of 188 cases, 72 were performed pre-listing, 29 on the waitlist, and 87 post-transplant. Roux-en-Y gastric bypass was the most common procedure. Thirty-day mortality after BS performed on the waitlist and post-transplant was 3.5%, and one transplant recipient lost their graft within 30 days after BS. BMI data were available for a subset and suggested median excess body weight loss of 31%-61%. Comparison to published clinical trials of BS in populations without kidney disease indicates comparable weight loss but higher post-BS mortality in the USRDS sample. Given the substantial contributions of obesity to excess morbidity and mortality, BS warrants prospective study as a strategy for improving outcomes before and after kidney transplantation.

The disparity between the organ supply and the de-

In 1958 Francis Moore described the orthotopic liver transplantation technique in dogs. In 1963, Starzl et al. performed the first liver transplantation. In the first five liver transplantations no patient survived more than 23 days. In 1967, stimulated by Calne who used antilymphocytic serum, Starzl began a successful series of liver transplantation. Until 1977, 200 liver transplantations were performed in the world. In that period, technical problems were overcome. Roy Calne, in 1979, used the first time cyclosporine in two patients who had undergone liver transplantation. In 1989, Starzl et al. reported a series of 1,179 consecutives patients who underwent liver transplantation and reported a survival rate between one and five years of 73% and 64%, respectively. Finally, in 1990, Starzl et al. reported successful use of tacrolimus in patents undergoing liver transplantation and who had rejection despite receiving conventional immunosuppressive treatment. Liver Transplantation Program was initiated at Hospital Israelita Albert Einstein in 1990 and so far over 1,400 transplants have been done. In 2013, 102 deceased donors liver transplantations were performed. The main indications for transplantation were hepatocellular carcinoma (38%), hepatitis C virus (33.3%) and alcohol liver cirrhosis (19.6%). Of these, 36% of patients who underwent transplantation showed biological MELD score > 30. Patient and graft survival in the first year was, 82.4% and 74.8%, respectively. A major challenge in liver transplantation field is the insufficient number of donors compared with the growing demand of transplant candidates. Thus, we emphasize that appropriated donor/receptor selection, allocation and organ preservation topics should contribute to improve the number and outcomes in liver transplantation.

Introduction Accurate assessment of the impact of donor quality on liver transplant (LT) costs has been limited by the lack of a large, multicenter study of detailed clinical and economic data. Methods A novel, retrospective database linking information from the University HealthSystem Consortium and the OPTN registry was analyzed using multivariate regression to determine the relationship between donor quality (assessed through the Donor Risk Index (DRI)), recipient illness severity, and total inpatient costs (transplant and all readmissions) for 1 year following LT. Results Cost data were available for 9,059 LT recipients. Increasing MELD score, higher DRI, simultaneous liver kidney transplant, female gender and prior liver transplant were associated with increasing cost of LT (P<0.05). MELD and DRI interact to synergistically increase the cost of LT (P<0.05). Donors in the highest DRI quartile added close to $12,000 to the cost of transplantation and nearly $22,000 to post-transplant costs in comparison to the lowest risk donors. Among the individual components of the DRI, donation after cardiac death (increased $20,769 vs. brain dead donors) had the greatest impact on transplant costs. Overall one year costs were increased in older donors, minority donors, nationally shared organs, and those with cold ischemic times 7–13 hours (p<0.05 for all) Conclusion Donor quality, as measured by the DRI, is an independent predictor of LT costs in the perioperative and post-operative periods. Centers in highly competitive regions who transplant higher MELD patients with high DRI livers may be particularly affected by the synergistic impact of these factors.

We examined the relationship between the total cost incurred by liver transplantation (LT) recipients and their Model for End-Stage Liver Disease (MELD) score at the time of transplant. We used a novel database linking billing claims from a large private payer with the Organ Procurement and Transplantation Network registry. Included were adults who underwent LT from March 2002 through August 2007 (n = 990). Claims within the year preceding and following transplantation were analyzed according to the recipient's calculated MELD score. Cost was the primary endpoint and was assessed by the length of stay and charges. Transplant admission charges represented approximately 50% of the total cost of LT. MELD was a significant cost driver for pretransplant, transplant, and total charges. A MELD score of 28 to 40 was associated with additional charges of $349,213 (P < 0.05) in comparison with a score of 15 to 20. Pretransplant and transplant admission charges were higher by $152,819 (P < 0.05) and $64,286 (P < 0.05), respectively, in this higher MELD group. No differences by MELD score were found for posttransplant charges. Those in the highest MELD group also experienced longer hospital stays both in the pretransplant period and at the time of LT but did not have higher rates of re-admissions. In conclusion, high-MELD patients incur significantly higher costs prior to and at the time of LT. Following LT, the MELD score is not a significant predictor of cost or re-admission.