IU Indianapolis ScholarWorks :: Browsing by Author "Mangus, Richard S."

Browsing by Author "Mangus, Richard S."

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CAD-LT score effectively predicts risk of significant coronary artery disease in liver transplant candidates
(Elsevier, 2021-07) Rachwan, Rayan Jo; Kutkut, Issa; Timsina, Lava R.; Chaaya, Rody G. Bou; El-Am, Edward A.; Sabra, Mohammad; Mshelbwala, Fakilahyel S.; Rahal, Mahmoud A.; Lacerda, Marco A.; Kubal, Chandrashekhar A.; Fridell, Jonathan A.; Ghabril, Marwan S.; Bourdillon, Patrick D.; Mangus, Richard S.; Surgery, School of Medicine
Background & Aims Patients with cirrhosis and significant coronary artery disease (CAD) are at risk of peri-liver transplantation (LT) cardiac events. The coronary artery disease in liver transplantation (CAD-LT) score and algorithm aim to predict the risk of significant CAD in LT candidates and guide pre-LT cardiac evaluation. Methods Patients who underwent pre-LT evaluation at Indiana University (2010-2019) were studied retrospectively. Stress echocardiography (SE) and cardiac catheterization (CATH) reports were reviewed. CATH was performed for predefined CAD risk factors, irrespective of normal SE. Significant CAD was defined as CAD requiring percutaneous or surgical intervention. A multivariate regression model was constructed to assess risk factors. Receiver-operating curve analysis was used to compute a point-based risk score and a stratified testing algorithm. Results A total of 1,771 pre-LT patients underwent cardiac evaluation, including results from 1,634 SE and 1,266 CATH assessments. Risk-adjusted predictors of significant CAD at CATH were older age (adjusted odds ratio 1.05; 95% CI 1.03–1.08), male sex (1.69; 1.16–2.50), diabetes (1.57; 1.12–2.22), hypertension (1.61; 1.14–2.28), tobacco use (pack years) (1.01; 1.00–1.02), family history of CAD (1.63; 1.16–2.28), and personal history of CAD (6.55; 4.33–9.90). The CAD-LT score stratified significant CAD risk as low (≤2%), intermediate (3% to 9%), and high (≥10%). Among patients who underwent CATH, a risk-based testing algorithm (low: no testing; intermediate: non-invasive testing vs. CATH; high: CATH) would have identified 97% of all significant CAD and potentially avoided unnecessary testing (669 SE [57%] and 561 CATH [44%]). Conclusions The CAD-LT score and algorithm (available at www.cad-lt.com) effectively stratify pre-LT risk for significant CAD. This may guide more targeted testing of candidates with fewer tests and faster time to waitlist. Lay summary The coronary artery disease in liver transplantation (CAD-LT) score and algorithm effectively stratify patients based on their risk of significant coronary artery disease. The CAD-LT algorithm can be used to guide a more targeted cardiac evaluation prior to liver transplantation.
Combination therapy for severe portopulmonary hypertension in a child allows for liver transplantation
(Wiley, 2019-08) Serrano, Ryan M.; Subbarao, Girish C.; Mangus, Richard S.; Montgomery, Greg; Johansen, Michael; Pediatrics, School of Medicine
Severe PPHTN is a contraindication to liver transplantation and predicts an abysmal 5‐year outcome. It is defined as a resting mPAP >45 mm Hg with a mean pulmonary artery wedge pressure of <15 mm Hg and pulmonary vascular resistance of >3 wood units in the setting of portal hypertension. There have been limited reports of successful treatment of PPHTN leading to successful liver transplantation in adults, and one reported use of monotherapy as a bridge to successful liver transplant in pediatrics. To our knowledge, we describe the first use of combination therapy as a successful bridge to liver transplantation in a pediatric patient with severe PPHTN. This report adds to the paucity of data in pediatrics on the use of pulmonary vasodilator therapy in patients with severe PPHTN as a bridge to successful liver transplantation. Early diagnosis in order to mitigate or avoid the development of irreversible pulmonary vasculopathy that would preclude candidacy for liver transplantation is crucial, but our report demonstrates that combination therapy can be administered safely, quickly, and may allow for successful liver transplantation in patients with severe PPHTN.
Comparison of methods of providing analgesia after pancreas transplant: IV opioid analgesia versus transversus abdominis plane block with liposomal bupivacaine or continuous catheter infusion
(Wiley, 2019) Yeap, Yar Luan; Fridell, Jonathan A.; Wu, Derrick; Mangus, Richard S.; Kroepf, Elizabeth; Wolfe, John; Powelson, John A.; Anesthesia, School of Medicine
Background Current practices emphasize a multimodal approach to perioperative analgesia due to higher efficacy and decreased opioid usage. Analgesia for pancreas transplant (PT) has traditionally been managed with intravenous (IV) opioids, and reports of transversus abdominis plane (TAP) blocks are limited in this population. Methods Three interventions were compared in adult PT patients, including IV opioids, TAP catheter, and TAP block with liposomal bupivacaine. Time to return of intestinal function and oral diet, postoperative pain scores, opioid usage, and length of stay were recorded. Results Study included 197 PT patients: 62 (32%) standard care, 90 (45%) TAP catheters with continuous 0.2% ropivacaine, and 45 (23%) single liposomal bupivacaine TAP block. Pain scores were lowest for the IV opioid group (P < 0.001). The liposomal bupivacaine group had lower pain scores on postoperative days (POD) 1‐5 than the TAP catheter group. Opioid use during POD 1‐5 was lower for both TAP block groups (P = 0.03). Time to bowel function was faster for the TAP block groups (P < 0.05). Conclusions Compared with IV opioid analgesia, TAP block interventions were associated with lower overall use of opioids and a faster time to intestinal function following pancreas transplant.
Computed tomography measures of nutrition in patients with end-stage liver disease provide a novel approach to characterize deficits
(Elsevier, 2018) Bush, Weston J.; Davis, Jason P.; Maluccio, Mary A.; Kubal, Chandrashekhar A.; Salisbury, Jared B.; Mangus, Richard S.; Surgery, School of Medicine
Aim Patients with cirrhosis and end-stage liver disease (ESLD) develop severe nutrition deficits that impact on morbidity and mortality. Laboratory measures of nutrition fail to fully assess clinical deficits in muscle mass and fat stores. This study employs computed tomography imaging to assess muscle mass and subcutaneous and visceral fat stores in patients with ESLD. Methods This 1:1 case-control study design compares ESLD patients with healthy controls. Study patients were selected from a database of ESLD patients using a stratified method to assure a representative sample based on age, body mass index (BMI), gender, and model for end-stage liver disease score (MELD). Control patients were trauma patients with a low injury severity score (<10) who had a CT scan during evaluation. Cases and controls were matched for age +/- 5 years, gender, and BMI +/- 2. Results There were 90 subjects and 90 controls. ESLD patients had lower albumin levels (p<0.001), but similar total protein levels (p=0.72). ESLD patients had a deficit in muscle mass (-19%, p<0.001) and visceral fat (-13%, p<0.001), but similar subcutaneous fat (-1%, p=0.35). ESLD patients at highest risk for sarcopenia included those over age 60, BMI< 25.0, and female gender. We found degree of sarcopenia to be independent of MELD score. Conclusions These results support previous research demonstrating substantial nutrition deficits in ESLD patients that are not adequately measured by laboratory testing. Patients with ESLD have significant deficits of muscle and visceral fat stores, but a similar amount of subcutaneous fat.
Donation After Circulatory Arrest in Pancreas Transplantation: A Report of 10 Cases
(Elsevier, 2017-12) Fridell, Jonathan A.; Mangus, Richard S.; Thomas, Christopher M.; Kubal, Chandrashekhar A.; Powelson, John A.; Surgery, School of Medicine
Introduction Transplantation of pancreas allografts procured from donation after circulatory death (DCD) remains uncommon. This study reviews a series of pancreas transplants at a single center to assess the donor and recipient characteristics for DCD pancreas transplant and to compare clinical outcomes. Methods DCD procurement was performed with a 5-minute wait time from pronouncement of death to first incision. In 2 patients, tissue plasminogen activator was infused as a thrombolytic during the donor flush. All kidney grafts were placed on pulsatile perfusion. Results There were 606 deceased donor pancreas transplants, 596 standard donors and 10 DCD donors. Of the 10 DCD transplants, 6 were simultaneous pancreas-kidney and 4 were pancreas transplant alone. The average time from incision to aortic cannulation was less than 3 minutes. The median total ischemia time for the DCD grafts was 5.4 hours, compared with 8.0 hours for standard donors (P = .15). Median length of hospital stay was 7 days for both groups, and there were no episode of acute cellular rejection in the first year post-transplant for the DCD group (4.2 % for standard group, P = .65). There was no difference in early or late graft survival, with 100% graft survival in the DCD group up to 1 year post-transplant. Ten-year Kaplan-Meier analysis shows similar graft survival for the 2 groups (P = .92). Conclusions These results support the routine use of carefully selected DCD pancreas donors. There were no differences in graft function, postoperative complications, and early and late graft survival.
Excellent outcomes in combined liver-kidney transplantation: Impact of KDPI and delayed kidney transplantation
(Wiley, 2017) Ekser, Burcin; Mangus, Richard S.; Kubal, Chandrashekhar A.; Powelson, John A.; Fridell, Jonathan A.; Goggins, William C.; Surgery, School of Medicine
The positive impact of delayed kidney transplantation (KT) on patient survival for combined liver-KT (CLKT) has already been demonstrated by our group. The purpose of this study is to identify whether the quality of the kidneys (based on KDPI) or the delayed approach KT contributes to improved patient survival. 130 CLKT were performed between 2002-2015; 69 with simultaneous KT (Group S) and 61 with delayed KT (Group D) (performed as a second operation with a mean cold ischemia time [CIT] of 50±15h). All patients were categorized according to the KDPI score; 1-33%, 34-66%, and 67-99%. Recipient and donor characteristics were comparable within Groups S and D. Transplant outcomes were comparable within Groups S and D, including liver and kidney CIT, warm ischemia time, and delayed graft function. Lower KDPI kidneys (<34%) were associated with increased patient survival in both groups. Combination of delayed KT and KDPI 1-33% resulted in 100% patient survival at 3-years. These results support that delayed KT in CLKT improves patient survival. The combination of delayed KT and low KDPI offers excellent patient survival up to 3-years. Improved outcomes in the delayed KT group including high KDPI kidneys supports expansion of the donor pool with the use of more ECD and DCD kidneys.
Impact of Deceased Donor Cardiac Arrest Time on Postpancreas Transplant Graft Function and Survival
(Wolters Kluwer, 2018-08-21) Schoering, Joel R.; Mangus, Richard S.; Powelson, John A.; Fridell, Jonathan A.; Surgery, School of Medicine
Introduction: Transplantation of pancreas allografts from donors that have experienced preprocurement cardiopulmonary arrest (PPCA) is not common, though use of PPCA grafts is routine in liver and kidney transplantation. This article reviews a large number of PPCA pancreas grafts at a single center and reports posttransplant outcomes including early graft dysfunction, length of hospital stay, rejection, and early and late graft survival. Methods: Preprocurement cardiopulmonary arrest, arrest time, and donor and recipient pancreatic enzyme levels were collected from electronic and written medical records. The PPCA donors were stratified into 4 groups: none, less than 20 minutes, 20-39 minutes, and 40 minutes or greater. Graft survival was assessed at 7 and 90 days and at 1 year. Long-term graft survival was assessed by Cox regression analysis. Results: The records of 606 pancreas transplants were reviewed, including 328 (54%) simultaneous pancreas and kidney transplants. Preprocurement cardiopulmonary arrest occurred in 176 donors (29%; median time, 20 minutes). Median peak donor lipase was higher in PPCA donors (40 μ/L vs 29 μ/L, P = 0.02). Posttransplant, peak recipient amylase, and lipase levels were similar (P = 0.63). Prolonged arrest time (>40 minutes) was associated with higher donor peak lipase and lower recipient peak amylase (P = 0.05 for both). Stratified by donor arrest time, there was no difference in 7-day, 90-day, or 1-year graft survival. Cox regression comparing the 4 groups demonstrated no statistical difference in 10-year survival. Conclusions: These results support transplantation of pancreas allografts from PPCA donors. Prolonged asystole was associated with higher peak donor serum lipase but lower peak recipient serum amylase. There were no differences in allograft survival.
Impact of Donor Pre-Procurement Cardiac Arrest (PPCA) on Clinical Outcomes in Liver Transplantation
(Springer Verlag, 2018-11-20) Mangus, Richard S.; Schroering, Joel R.; Fridell, Jonathan A.; Kubal, Chandrashekhar A.; Surgery, School of Medicine
BACKGROUND Transplantation of liver grafts from deceased donors who experienced cardiac arrest prior to liver procurement is now common. This single-center study analyzed the impact of pre-donation arrest time on clinical outcomes in liver transplantation. MATERIAL AND METHODS Records of all orthotopic liver transplants performed at a single center over a 15-year period were reviewed. Donor records were reviewed and total arrest time was calculated as cumulative minutes. Post-transplant liver graft function was assessed using laboratory values. Graft survival was assessed with Cox regression analysis. RESULTS Records for 1830 deceased donor transplants were reviewed, and 521 donors experienced pre-procurement cardiac arrest (28%). Median arrest time was 21 min (mean 25 min, range 1-120 min). After transplant, the peak alanine aminotransferase and bilirubin levels for liver grafts from donors with arrest were lower compared to those for donors without arrest (p<0.001). Early allograft dysfunction occurred in 25% (arrest) and 28% (no arrest) of patients (p=0.22). There were no differences in risk of early graft loss (3% vs. 3%, p=0.84), length of hospital stay (10 vs. 10 days, p=0.76), and 1-year graft survival (89% vs. 89%, p=0.94). Cox regression analysis comparing 4 groups (no arrest, <20 min, 20-40 min, and >40 min arrest) demonstrated no statistically significant difference in survival at 10 years. Subgroup analysis of 93 donation after cardiac death grafts showed no significant difference for these same outcomes. CONCLUSIONS These results support the use of select deceased liver donors who experience pre-donation cardiac arrest. Pre-donation arrest may be associated with less early allograft dysfunction, but had no impact on long-term clinical outcomes. The results for donation after cardiac death donors were similar.
Impact of Recipient Age in Combined Liver-Kidney Transplantation: Caution Is Needed for Patients ≥70 Years
(Wolters Kluwer, 2020-06-01) Ekser, Burcin; Goggins, William C.; Fridell, Jonathan A.; Mihaylov, Plamen; Mangus, Richard S.; Lutz, Andrew J.; Soma, Daiki; Ghabril, Marwan S.; Lacerda, Marco A.; Powelson, John A.; Kubal, Chandrashekhar A.; Surgery, School of Medicine
Background. Elderly recipients (≥70 y) account for 2.6% of all liver transplants (LTs) in the United States and have similar outcomes as younger recipients. Although the rate of elderly recipients in combined liver-kidney transplant (CLKT) is similar, limited data are available on how elderly recipients perform after CLKT. Methods. We have previously shown excellent outcomes in CLKT using delayed kidney transplant (Indiana) Approach (mean kidney cold ischemia time = 53 ± 14 h). Between 2007 and 2018, 98 CLKTs were performed using the Indiana Approach at Indiana University (IU) and the data were retrospectively analyzed. Recipients were subgrouped based on their age: 18–45 (n = 16), 46–59 (n = 34), 60–69 (n = 40), and ≥70 years (n = 8). Results. Overall, more elderly patients received LT at IU (5.2%) when compared nationally (2.6%). The rate of elderly recipients in CLKT at IU was 8.2% (versus 2% Scientific Registry of Transplant Recipient). Recipient and donor characteristics were comparable between all age groups except recipient age and duration of dialysis. Patient survival at 1 and 3 years was similar among younger age groups, whereas patient survival was significantly lower in elderly recipients at 1 (60%) and 3 years (40%) (P = 0.0077). Control analyses (replicating Scientific Registry of Transplant Recipient’s survival stratification: 18–45, 46–64, ≥65 y) showed similar patient survival in all age groups. Conclusions. Although LT can be safely performed in elderly recipients, extreme caution is needed in CLKT due to the magnitude of operation.
Impact of Recipient Age in Combined Liver-Kidney Transplantation: Caution Is Needed for Patients ≥70 Years
(Wolters Kluwer, 2020-06) Ekser, Burcin; Goggins, William C.; Fridell, Jonathan A.; Mihaylov, Plamen; Mangus, Richard S.; Lutz, Andrew J.; Soma, Daiki; Ghabril, Marwan S.; Lacerda, Marco A.; Powelson, John A.; Kubal, Chandrashekhar A.; Surgery, School of Medicine
Background. Elderly recipients (≥70 y) account for 2.6% of all liver transplants (LTs) in the United States and have similar outcomes as younger recipients. Although the rate of elderly recipients in combined liver-kidney transplant (CLKT) is similar, limited data are available on how elderly recipients perform after CLKT. Methods. We have previously shown excellent outcomes in CLKT using delayed kidney transplant (Indiana) Approach (mean kidney cold ischemia time = 53 ± 14 h). Between 2007 and 2018, 98 CLKTs were performed using the Indiana Approach at Indiana University (IU) and the data were retrospectively analyzed. Recipients were subgrouped based on their age: 18–45 (n = 16), 46–59 (n = 34), 60–69 (n = 40), and ≥70 years (n = 8). Results. Overall, more elderly patients received LT at IU (5.2%) when compared nationally (2.6%). The rate of elderly recipients in CLKT at IU was 8.2% (versus 2% Scientific Registry of Transplant Recipient). Recipient and donor characteristics were comparable between all age groups except recipient age and duration of dialysis. Patient survival at 1 and 3 years was similar among younger age groups, whereas patient survival was significantly lower in elderly recipients at 1 (60%) and 3 years (40%) (P = 0.0077). Control analyses (replicating Scientific Registry of Transplant Recipient’s survival stratification: 18–45, 46–64, ≥65 y) showed similar patient survival in all age groups. Conclusions. Although LT can be safely performed in elderly recipients, extreme caution is needed in CLKT due to the magnitude of operation.

Browsing by Author "Mangus, Richard S."

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