Bio


I am committed to figuring out how more people can benefit from liver and kidney transplants. Patients are dying while waiting for these organs. Therefore, my clinical and research efforts are focused on increasing the number of patients whose lives can be saved with transplantation.

Clinical Focus


  • Liver Transplantation
  • Kidney Transplantation
  • Hepatobiliary
  • General Surgery

Academic Appointments


Administrative Appointments


  • Division Chief, Stanford Abdominal Transplant Surgery (2023 - Present)
  • Program Director, Stanford Abdominal Transplant Surgery Fellowship (2019 - Present)
  • Program Director, Stanford Surgery Residency (2011 - 2019)
  • Associate Program Director, Stanford Multi-Organ Transplant Fellowship (2010 - 2019)
  • Associate Program Director, Stanford Surgery Residency (2006 - 2011)
  • Administrative Chief Resident, Stanford Surgery Residency (2003 - 2004)

Honors & Awards


  • President, San Francisco Surgical Society (2019-20)
  • John Austin Collins, Award for "academic mentorship, teaching, and dedication to resident training.", Stanford Surgery (2019)
  • Stanford Medicine Program Director GME Award, Stanford Graduate Medical Education (2019)
  • Vice-President, San Francisco Surgical Society (2016-17)
  • Member, Society of University Surgeons (2015 -)
  • Surgery Chiefs Award for leadership, mentorship, and dedication., Stanford Surgery (2013)
  • Member, Pacific Coast Surgical Society (2012 -)
  • Program Director, San Francisco Surgical Society (2010-11)
  • Poster of Distinction, American Transplant Congress (2010)
  • Member, San Francisco Surgical Society (2009-)
  • Fellow, American College of Surgeons (2009 -)
  • Member, Transplantation Society (2009 -)
  • Member, Association for Academic Surgery (2007-)
  • Member, American Society of Transplant Surgeons (2004-)
  • Alpha Omega Alpha, Columbia Medical School (1999)
  • Harvard College Scholarship, Harvard College (1988)
  • Thomas J. Watson Scholarship, Harvard College (1985-1989)

Boards, Advisory Committees, Professional Organizations


  • Co-Chair, Business Practice Committee, American Society of Transplant Surgeons (2022 - Present)
  • Council Member, Transplant Accreditation & Certification Council (2022 - Present)
  • President, San Francisco Surgical Society (2019 - 2020)
  • Chair, Curriculum Committee, American Society of Transplant Surgery (2016 - 2019)
  • Board Member, National Kidney Registry (2015 - 2018)

Professional Education


  • Residency: Stanford University Dept of General Surgery (2004) CA
  • Fellowship: University of California San Francisco (2006) CA
  • Medical Education: Columbia University College of Physicians and Surgeons (1999) NY
  • Board Certification: American Board of Surgery, General Surgery (2006)
  • Fellowship, UC, San Francisco, Multi-organ Transplantation (2006)
  • MD, Columbia University, P&S, Medicine (1999)
  • PhD, Univ. of California, Berkeley, Molecular Biology (1995)
  • BA, Harvard University, Biochemistry (1989)

Community and International Work


  • International Medicine, Guatemala

    Partnering Organization(s)

    Remote Area Medical

    Location

    International

    Ongoing Project

    No

    Opportunities for Student Involvement

    No

Patents


  • Marc Melcher. "United States Patent 17075535 Quantification of Liver Steatosis from a biopsy using a Computer Imaging Platform", The Board of Trustees of the Leland Stanford Junior University, Apr 29, 2021

Current Research and Scholarly Interests


Broadly, I enjoy applying rigorous algorithms to the complex decision making processes in organ transplantation.

For example, I have studied ways to increase the impact of paired exchange kidney transplantation and ensure as many people as possible can benefit from it.

Currently, I am studying ways artificial intelligence can facilitate decision making in organ transplantation. There is potential to improve the assessment of donor organs, mortality risk, and outcomes prediction using innovations in AI.

Clinical Trials


  • Inducing Graft Tolerance in HLA Haplotype Matched Related and 3 Ag Matched Unrelated Living Donor Kidney Transplantation Recruiting

    This research study is to determine if donor blood stem cells given after living, related, HLA antigen (Ag) haplotype match or living, unrelated donor kidney transplantation. Minimal HLA antigen matching will include matching of 2 HLA antigens that can be either HLA A, B, and /or DR. This research will change the immune system such that immunosuppressive drugs can be completely withdrawn or reduced to minimal dose without kidney rejection.

    View full details

  • Combined Blood Stem Cell and Kidney Transplant of One Haplotype Match Living Donor Pairs. Not Recruiting

    The Stanford Medical Center Program in Multi-Organ Transplantation and the Division of Bone marrow Transplantation are enrolling patients into a research study to determine if donor stem cells given after a living related one Haplotype match kidney transplantation will change the immune system such that immunosuppressive drugs can be completely withdrawn.

    Stanford is currently not accepting patients for this trial. For more information, please contact Asha Shori, CCRP, 650-736-0245.

    View full details

  • Comparative Renal Function of Young (18-45 Years) and Ageing (55 Years and Above) Kidney Donors Not Recruiting

    It is our purpose in this study to compare the kidney structure and function of older patients to that of young patients before and after removal of a single kidney for transplant donation and to examine the remaining kidney's ability to adapt and maintain function over time. More specifically, we aim to examine the effect of uninephrectomy on adaptive hyperfiltration in the remaining kidney. A secondary aim is to investigate whether subjects in the aging population undergo compensation to the same extent as younger subjects. We will also examine the compensatory rise in GFR (glomerular filtration rate) that follows uninephrectomy in both groups, and, again, compare the results in the aged versus young subjects. This will help in delineating the extent to which the aging population can be a potential source of living kidney donors for kidney transplantation. It is also our purpose with this study to refine the tests to be used in the donor evaluation process so as to accurately identify ideal candidates for safe kidney donation.

    Stanford is currently not accepting patients for this trial. For more information, please contact Geraldine Derby, R.N., 650-723-5985.

    View full details

  • Emollient Therapy for Severe Acute Malnutrition Not Recruiting

    The investigators hypothesize that the absorption of topically applied EFA-containing emollient (SSO) into the skin and thence into the bloodstream in children with SAM will improve skin barrier function and accelerate weight gain and clinical rehabilitation beyond that possible through normal standard-of-care

    Stanford is currently not accepting patients for this trial.

    View full details

Projects


  • AI facilitated assessment of donor liver histopathology, Stanford University

    Location

    Stanford University, Palo Alto, CA

2024-25 Courses


Stanford Advisees


All Publications


  • Continuous Risk Score Predicts Waitlist & Post-Transplant Outcomes in Hepatocellular Carcinoma Despite Exception Changes. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association Akabane, M., McVey, J. C., Firl, D. J., Kwong, A. J., Melcher, M. L., Kim, W. R., Sasaki, K. 2024

    Abstract

    Continuous risk stratification of candidates and urgency-based prioritization have been utilized for liver transplantation (LT) in non-hepatocellular carcinoma (HCC) patients in the United States. Instead, for HCC patients, a dichotomous criterion with exception points is still used. This study evaluated the utility of the hazard associated with LT for HCC (HALT-HCC), an oncological continuous risk score, to stratify waitlist dropout and post-LT outcomes.A competing risk model was developed and validated using the UNOS database (2012-2021) through multiple policy changes. The primary outcome was to assess the discrimination ability of waitlist dropouts and LT outcomes. The study focused on the HALT-HCC score, compared to other HCC risk scores.Among 23,858 candidates, 14,646 (59.9%) underwent LT and 5,196 (21.8%) dropped out of the waitlist. Higher HALT-HCC scores correlated with increased dropout incidence and lower predicted five-year overall survival after LT. HALT-HCC demonstrated the highest AUC values for predicting dropout at various intervals post-listing (0.68 at six months, 0.66 at one year), with excellent calibration (R2=0.95 at six months, 0.88 at one year). Its accuracy remained stable across policy periods and locoregional therapy applications.This study highlights the predictive capability of the continuous oncological risk score to forecast waitlist dropout and post-LT outcomes in HCC patients, independent of policy changes. The study advocates integrating continuous scoring systems like HALT-HCC in liver allocation decisions, balancing urgency, organ utility, and survival benefit.

    View details for DOI 10.1016/j.cgh.2024.05.046

    View details for PubMedID 38908731

  • ChatGPT versus Bing: Clinicians Assessment of the Accuracy of AI Platforms in Responding to COPD Questions. The European respiratory journal Imtiaz, A., King, J., Holmes, S., Gupta, A., Bafadhel, M., Melcher, M. L., Hurst, J. R., Farewell, D., Bolton, C. E., Duckers, J. 2024

    View details for DOI 10.1183/13993003.00163-2024

    View details for PubMedID 38811043

  • Transplant surgeons already account for inaccuracies in the Kidney Donor Profile Index (KDPI) calculation. Clinical transplantation Guan, G., Ashlagi, I., Melcher, M. L. 2024; 38 (5): e15323

    View details for DOI 10.1111/ctr.15323

    View details for PubMedID 38690616

  • Where is the perfect triangle in the liver allocation system? The lancet. Healthy longevity Sasaki, K., Melcher, M. L. 2024; 5 (5): e310-e311

    View details for DOI 10.1016/S2666-7568(24)00064-3

    View details for PubMedID 38705149

  • Enhancing the Usability of older DCD donors through strategic approaches in liver transplantation in the US. Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society Akabane, M., Melcher, M. L., Esquivel, C. O., Imaoka, Y., Kim, W. R., Sasaki, K. 2024

    Abstract

    The use of older donors after circulatory death(DCD) for liver transplantation(LT) has increased over the past decade. This study examined whether outcomes of LT using older DCD(≥50 y) have improved with advancements in surgical/perioperative care and normothermic machine perfusion(NMP) technology.7,602 DCD LT cases from the UNOS database(2003-2022) were reviewed. The impact of older DCD donors on graft survival(GS) was assessed using Kaplan-Meier and hazard ratio(HR) analyses.1,447 LT cases(19.0%) involved older DCD donors. Although there was a decrease in their use from 2003-2014, a resurgence was noted post-2015 and reached 21.9% of all LT in the last four years(2019-2022). Initially, 90-day and one-year GS for older DCDs were worse than younger DCDs, but this difference decreased over time and there was no statistical difference after 2015. Similarly, HRs for graft loss in older DCD have recently become insignificant. In older DCD LT, NMP usage has increased recently, especially in cases with extended donor-recipient distances, while the median time from asystole to aortic cross-clamp has decreased. Multivariable Cox regression analyses revealed that in the early phase, asystole to cross-clamp time had the highest HR for graft loss in older DCD LT without NMP, while in the later phases, the CIT(>5.5 h) was a significant predictor.LT outcomes using older DCD donors have become comparable to those from young DCD donors, with recent HRs for graft loss becoming insignificant. The strategic approach in the recent period could mitigate risks, including managing CIT(≤5.5 h), reducing asystole to cross-clamp time, and adopting NMP for longer distances. Optimal use of older DCD donors may alleviate the donor shortage.

    View details for DOI 10.1097/LVT.0000000000000376

    View details for PubMedID 38625836

  • The Current Status of Organ Recovery Surgeon Remuneration in the United States CURRENT TRANSPLANTATION REPORTS Marvin, M. R., Kadri, H., Wellen, J. R., Melcher, M. L. 2024
  • Impact of donor characteristics on hepatocellular carcinoma recurrence after liver transplantation. The British journal of surgery Akabane, M., Bekki, Y., Imaoka, Y., Inaba, Y., Esquivel, C. O., Melcher, M. L., Kwong, A., Sasaki, K. 2024; 111 (4)

    View details for DOI 10.1093/bjs/znae080

    View details for PubMedID 38630794

  • LightGBM outperforms other machine learning techniques in predicting graft failure after liver transplantation: Creation of a predictive model through large-scale analysis. Clinical transplantation Yanagawa, R., Iwadoh, K., Akabane, M., Imaoka, Y., Bozhilov, K. K., Melcher, M. L., Sasaki, K. 2024; 38 (4): e15316

    Abstract

    The incidence of graft failure following liver transplantation (LTx) is consistent. While traditional risk scores for LTx have limited accuracy, the potential of machine learning (ML) in this area remains uncertain, despite its promise in other transplant domains. This study aims to determine ML's predictive limitations in LTx by replicating methods used in previous heart transplant research.This study utilized the UNOS STAR database, selecting 64,384 adult patients who underwent LTx between 2010 and 2020. Gradient boosting models (XGBoost and LightGBM) were used to predict 14, 30, and 90-day graft failure compared to conventional logistic regression model. Models were evaluated using both shuffled and rolling cross-validation (CV) methodologies. Model performance was assessed using the AUC across validation iterations.In a study comparing predictive models for 14-day, 30-day and 90-day graft survival, LightGBM consistently outperformed other models, achieving the highest AUC of.740,.722, and.700 in shuffled CV methods. However, in rolling CV the accuracy of the model declined across every ML algorithm. The analysis revealed influential factors for graft survival prediction across all models, including total bilirubin, medical condition, recipient age, and donor AST, among others. Several features like donor age and recipient diabetes history were important in two out of three models.LightGBM enhances short-term graft survival predictions post-LTx. However, due to changing medical practices and selection criteria, continuous model evaluation is essential. Future studies should focus on temporal variations, clinical implications, and ensure model transparency for broader medical utility.

    View details for DOI 10.1111/ctr.15316

    View details for PubMedID 38607291

  • Overexpression of Senescence-Associated Genes, SFN and CDC6, Correlates with Poor Survival in Patients with Stage II Hepatocellular Carcinoma (HCC) Badshah, J., Subramanian, S., Melcher, M., Sasaki, K., Visser, B., Delitto, D., Pruett, T., Niedernhofer, L., Kirchner, V. ELSEVIER SCIENCE INC. 2024: S64
  • Breaking distance barriers in liver transplantation: Risk factors and outcomes of long-distance liver grafts. Surgery Imaoka, Y., Bozhilov, K. K., Bekki, Y., Akabane, M., Kwong, A. J., Ohira, M., Ohdan, H., Esquivel, C. O., Melcher, M. L., Sasaki, K. 2023

    Abstract

    Long-distance-traveling liver grafts in liver transplantation present challenges due to prolonged cold ischemic time and increased risk of ischemia-reperfusion injury. We identified long-distance-traveling liver graft donor and recipient characteristics and risk factors associated with long-distance-traveling liver graft use.We conducted a retrospective analysis of data from donor liver transplantation patients registered from 2014 to 2020 in the United Network for Organ Sharing registry database. Donor, recipient, and transplant factors of graft survival were compared between short-travel grafts and long-distance-traveling liver grafts (traveled >500 miles).During the study period, 28,265 patients received a donation after brainstem death liver transplantation and 3,250 a donation after circulatory death liver transplantation. The long-distance-traveling liver graft rate was 6.2% in donation after brainstem death liver transplantation and 7.1% in donation after circulatory death liver transplantation. The 90-day graft survival rates were significantly worse for long-distance-traveling liver grafts (donation after brainstem death: 95.7% vs 94.5%, donation after circulatory death: 94.5% vs 93.9%). The 3-year graft survival rates were similar for long-distance-traveling liver grafts (donation after brainstem death: 85.5% vs 85.1%, donation after circulatory death: 81.0% vs 80.4%). Cubic spline regression analyses revealed that travel distance did not linearly worsen the prognosis of 3-year graft survival. On the other hand, younger donor age, lower donor body mass index, and shorter cold ischemic time mitigated the negative impact of 90-day graft survival in long-distance-traveling liver grafts.The use of long-distance-traveling liver grafts negatively impacts 90-day graft survival but not 3-year graft survival. Moreover, long-distance-traveling liver grafts are more feasible with appropriate donor and recipient factors offsetting the extended cold ischemic time. Mechanical perfusion can improve long-distance-traveling liver graft use. Enhanced collaboration between organ procurement organizations and transplant centers and optimized transportation systems are essential for increasing long-distance-traveling liver graft use, ultimately expanding the donor pool.

    View details for DOI 10.1016/j.surg.2023.09.052

    View details for PubMedID 37980203

  • Alcohol Use in Liver Transplant Recipients With Alcohol-related Liver Disease: A Comparative Assessment of Relapse Prediction Models. Transplantation Sedki, M., Kwong, A., Bhargava, M., Ahmed, A., Daugherty, T., Kwo, P., Dronamraju, D., Kumari, R., Kim, W. R., Esquivel, C., Melcher, M., Bonham, C. A., Gallo, A., Nelson, A., Norwood, A., Hussain, F., Goel, A. 2023

    Abstract

    The selection of liver transplant (LT) candidates with alcohol-related liver disease (ALD) is influenced by the risk of alcohol relapse (AR), yet the ability to predict AR is limited. We evaluate psychosocial factors associated with post-LT AR and compare the performance of high-risk alcoholism risk (HRAR), sustained alcohol use post-LT (SALT), and the Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) scores in predicting relapse.A retrospective analysis of ALD patients undergoing LT from 2015 to 2021 at a single US transplant center was performed. Risk factors associated with post-LT AR were evaluated and test characteristics of 3 prediction models were compared.Of 219 ALD LT recipients, 23 (11%) had AR during a median study follow-up of 37.5 mo. On multivariate analysis, comorbid psychiatric illness (odds ratio 5.22) and continued alcohol use after advice from a health care provider (odds ratio 3.8) were found to be significantly associated with post-LT AR. On sensitivity analysis, SIPAT of 30 was optimal on discriminating between ALD LT recipients with and without post-LT AR. SIPAT outperformed both the HRAR and SALT scores (c-statistic 0.67 versus 0.59 and 0.62, respectively) in identifying post-LT AR. However, all scores had poor positive predictive value (<25%).AR after LT is associated with comorbid psychiatric illness and lack of heeding health care provider advice to abstain from alcohol. Although SIPAT outperformed the HRAR and SALT scores in predicting AR, all are poor predictors. The current tools to predict post-LT AR should not be used to exclude LT candidacy.

    View details for DOI 10.1097/TP.0000000000004800

    View details for PubMedID 37899485

  • The short and long-term prognostic influences of liver grafts with high bilirubin levels at the time of organ recovery. Clinical transplantation Akabane, M., Bekki, Y., Imaoka, Y., Inaba, Y., Kwong, A. J., Esquivel, C. O., Melcher, M. L., Sasaki, K. 2023: e15155

    Abstract

    Donors with hyperbilirubinemia are often not utilized for liver transplantation (LT) due to concerns about potential liver dysfunction and graft survival. The potential to mitigate organ shortages using such donors remains unclear.This study analyzed adult deceased donor data from the United Network for Organ Sharing database (2002-2022). Hyperbilirubinemia was categorized as high total bilirubin (3.0-5.0 mg/dL) and very high bilirubin (≥5.0 mg/dL) in brain-dead donors. We assessed the impact of donor hyperbilirubinemia on 3-month and 3-year graft survival, comparing these outcomes to donors after circulatory death (DCD).Of 138 622 donors, 3452 (2.5%) had high bilirubin and 1999 (1.4%) had very high bilirubin levels. Utilization rates for normal, high, and very high bilirubin groups were 73.5%, 56.4%, and 29.2%, respectively. No significant differences were found in 3-month and 3-year graft survival between groups. Donors with high bilirubin had superior 3-year graft survival compared to DCD (hazard ratio .83, p = .02). Factors associated with inferior short-term graft survival included recipient medical condition in intensive care unit (ICU) and longer cold ischemic time; factors associated with inferior long-term graft survival included older donor age, recipient medical condition in ICU, older recipient age, and longer cold ischemic time. Donors with ≥10% macrosteatosis in the very high bilirubin group were also associated with worse 3-year graft survival (p = .04).The study suggests that despite many grafts with hyperbilirubinemia being non-utilized, acceptable post-LT outcomes can be achieved using donors with hyperbilirubinemia. Careful selection may increase utilization and expand the donor pool without negatively affecting graft outcome.

    View details for DOI 10.1111/ctr.15155

    View details for PubMedID 37812571

  • Reply: ChatGPT and unknown clinical questions about liver transplantation. Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society Akabane, M., Iwadoh, K., Melcher, M. L., Sasaki, K. 2023

    View details for DOI 10.1097/LVT.0000000000000282

    View details for PubMedID 37801561

  • Has the risk of liver re-transplantation improved over the two decades? Clinical transplantation Akabane, M., Bekki, Y., Imaoka, Y., Inaba, Y., Esquivel, C. O., Kwong, A., Melcher, M. L., Sasaki, K. 2023: e15127

    Abstract

    Despite advancements in liver transplantation (LT) over the past two decades, liver re-transplantation (re-LT) presents challenges. This study aimed to assess improvements in re-LT outcomes and contributing factors.Data from the United Network for Organ Sharing database (2002-2021) were analyzed, with recipients categorized into four-year intervals. Trends in re-LT characteristics and postoperative outcomes were evaluated.Of 128,462 LT patients, 7254 received re-LT. Graft survival (GS) for re-LT improved (91.3%, 82.1%, and 70.8% at 30 days, 1 year, and 3 years post-LT from 2018 to 2021). However, hazard ratios (HRs) for GS remained elevated compared to marginal donors including donors after circulatory death (DCD), although the difference in HRs decreased in long-term GS. Changes in re-LT causes included a reduction in hepatitis C recurrence and an increase in graft failure post-primary LT involving DCD. Trends identified included recent decreased cold ischemic time (CIT) and increased distance from donor hospital in re-LT group. Meanwhile, DCD cohort exhibited less significant increase in distance and more marked decrease in CIT. The shortest CIT was recorded in urgent re-LT group. The highest Model for End-Stage Liver Disease score was observed in urgent re-LT group, while the lowest was recorded in DCD group. Analysis revealed shorter time interval between previous LT and re-listing, leading to worse outcomes, and varying primary graft failure causes influencing overall survival post-re-LT.While short-term re-LT outcomes improved, challenges persist compared to DCD. Further enhancements are required, with ongoing research focusing on optimizing risk stratification models and allocation systems for better LT outcomes.

    View details for DOI 10.1111/ctr.15127

    View details for PubMedID 37772621

  • Characterizing the risk of HLA-incompatible living donor kidney transplantation in older recipients. American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons Long, J. J., Motter, J. D., Jackson, K. R., Chen, J., Orandi, B. J., Montgomery, R. A., Stegall, M. D., Jordan, S. C., Benedetti, E., Dunn, T. B., Ratner, L. E., Kapur, S., Pelletier, R. P., Roberts, J. P., Melcher, M. L., Singh, P., Sudan, D. L., Posner, M. P., El-Amm, J. M., Shapiro, R., Cooper, M., Verbesey, J. E., Lipkowitz, G. S., Rees, M. A., Marsh, C. L., Sankari, B. R., Gerber, D. A., Wellen, J. R., Bozorgzadeh, A., Gaber, A. O., Heher, E. C., Weng, F. L., Djamali, A., Helderman, J. H., Concepcion, B. P., Brayman, K. L., Oberholzer, J., Kozlowski, T., Covarrubias, K., Massie, A. B., McAdams-DeMarco, M. A., Segev, D. L., Garonzik-Wang, J. M. 2023

    Abstract

    Older compatible living donor kidney transplant recipients (CLDKT) have higher mortality and death-censored graft failure compared to younger recipients. These risks may be amplified in older incompatible living donor kidney transplant recipients (ILDKT) who undergo desensitization and intense immunosuppression. In a 25-center cohort of ILDKT recipients transplanted between September 24, 1997 and December 15, 2016, we compared mortality, death-censored graft failure (DCGF), delayed graft function (DGF), acute rejection (AR), and length of stay (LOS) between 234 older (age≥60) and 1172 younger (age 18-59) recipients. To investigate whether the impact of age was different for ILDKT recipients compared to 17,542 CLDKT recipients, we used an interaction term to determine whether the relationship between post-transplant outcomes and transplant type (ILDKT vs. CLDKT) was modified by age. Overall, older recipients had higher mortality (HR: 1.632.072.65, p<0.001), lower DCGF (HR: 0.360.530.77, p=0.001) and AR (OR: 0.390.540.74, p<0.001), and similar DGF (OR: 0.461.032.33, p=0.9) and LOS (IRR: 0.880.981.10, p=0.8) compared to younger recipients. The impact of age on mortality (interaction p=0.052), DCGF (interaction p=0.7), AR interaction p=0.2), DGF (interaction p=0.9), and LOS (interaction p=0.5) was similar in ILDKT and CLDKT recipients. Age alone should not preclude eligibility for ILDKT.

    View details for DOI 10.1016/j.ajt.2023.09.010

    View details for PubMedID 37748554

  • Publisher Accreditation Fails to Reflect Higher Content Quality in Liver Transplant YouTube Videos. The Journal of surgical research Kadri, H., Muhammad, H. A., Narayan, R. R., Melcher, M. L. 2023; 293: 95-101

    Abstract

    INTRODUCTION: In 2021, the National Academy of Medicine began collaborating with YouTube to highlight high-quality channels for patients seeking medical information. This study evaluates whether YouTube videos from accredited publishers are useful for patients searching for information regarding liver transplantation.METHODS: After searching "Liver Transplant" on YouTube, the first 100 results under 10min long with English text or audio were transcribed. The Flesch-Kincaid grade level was used to quantify reading grade level. Viewership metrics and the accreditation status of the video publisher were identified. The DISCERN score was used to grade the quality of medical information. We adapted an informed consent curriculum for surgical interns to create an eight-point content metric that we coined the "Anderson-Lau score". Higher scores indicated higher content quality. Statistical significance was calculated using Wilcoxon rank-sum and chi-squared tests with a significance level of P=0.05.RESULTS: Of the 100 videos assessed, 37 met the average American reading level (8th grade) and none met the reading level of the average Medicare patient (5th grade). The median Flesch-Kincaid grade level was 9th grade. The median content ("Anderson-Lau") and quality (DISCERN) scores were 2/8 and 1/5, respectively. While 56% of videos mentioned operative indications and benefits, under 25% mentioned operative steps, risks, alternatives, and postoperative expectations. A total of 75 videos were from accredited publishers, and there was no significant difference between the quality of videos from accredited and unaccredited publishers.CONCLUSIONS: Videos made by accredited sources regarding liver transplantation were not of higher educational quality or content. More informative educational materials are needed to advise patients about liver transplantation, help them understand the procedure, and to supplement discussions with their transplant team.

    View details for DOI 10.1016/j.jss.2023.08.016

    View details for PubMedID 37734297

  • Defining tumor-associated macrophages subpopulation in intrahepatic cholangiocarcinoma as prognostic and therapeutic targets Badshah, J., Aliwaisi, A., Subramanian, S., Hong, S., Teavir, W., Sasaki, K., Melcher, M., Bonham, C., Pham, T., Gallo, A., Esquivel, C., Busque, S., Reitsma, A., Krams, S., Pruett, T., Martinez, O., Kirchner, V. LIPPINCOTT WILLIAMS & WILKINS. 2023: 122-123
  • Overcoming the hurdles of steatotic grafts in liver transplantation: insights into survival and prognostic factors. Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society Akabane, M., Imaoka, Y., Esquivel, C. O., Melcher, M. L., Kwong, A., Sasaki, K. 2023

    Abstract

    With increasing metabolic dysfunction associated steatotic liver disease (MASLD), the use of steatotic grafts in liver transplantation (LT) and their impact on postoperative graft survival (GS) needs further exploration.Analyzing adult LT recipient data (2002-2022) from the United Network for Organ Sharing database, outcomes of LT using steatotic (≥30% macrosteatosis) and non-steatotic donor livers, donors after circulatory death (DCD), and standard-risk older donors (age 45-50) were compared. GS predictors were evaluated using Kaplan-Meier and Cox regression analyses.Of the 35,345 LT donors, 8.9% (3,155) were fatty livers. Initial 30-day postoperative period revealed significant challenges with fatty livers, demonstrating inferior GS. However, the GS discrepancy between fatty and non-fatty livers subsided over time (p=0.10 at 5 y). Long-term GS outcomes showed comparable or even superior results in fatty livers relative to non-steatotic livers, conditional on surviving the initial 90 postoperative days (p=0.90 at 1 y) or 1 year (p=0.03 at 5 y). In the multivariable Cox regression analysis, high body surface area (BSA) ratio (≥1.1) (hazard ratio [HR] 1.42, p=0.02), calculated as donor BSA divided by recipient BSA, long cold ischemic time (≥6.5 hours) (HR 1.72, p<0.01), and recipient medical condition (ICU hospitalization) (HR 2.53, p<0.01) emerged as significant adverse prognostic factors. Young (<40 y) fatty donors showed a high BSA ratio, diabetes, and ICU hospitalization as significant indicators of worse prognosis (p<0.01).Our study emphasizes the initial postoperative 30-day survival challenge in LT using fatty livers. However, with careful donor-recipient matching, e.g. avoiding use of steatotic donors with long cold ischemic time and high BSA ratios for recipients in the ICU, it is possible to enhance immediate GS, and in a longer time, outcomes comparable to those using non-fatty livers, DCD livers, or standard-risk older donors, can be anticipated. These novel insights into decision-making criteria for steatotic liver use provide invaluable guidance for clinicians.

    View details for DOI 10.1097/LVT.0000000000000245

    View details for PubMedID 37616509

  • Exploring the potential of ChatGPT in generating unknown clinical questions about liver transplantation: a feasibility study. Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society Akabane, M., Iwadoh, K., Melcher, M. L., Sasaki, K. 2023

    View details for DOI 10.1097/LVT.0000000000000246

    View details for PubMedID 37616504

  • Decreased Utilization Rate of Grafts for Liver Transplantation After Implementation of Acuity Circle-based Allocation. Transplantation Bekki, Y., Myers, B., Tomiyama, K., Imaoka, Y., Akabane, M., Kwong, A. J., Melcher, M. L., Sasaki, K. 2023

    Abstract

    The allocation system for livers began using acuity circles (AC) in 2020. In this study, we sought to evaluate the impact of AC policy on the utilization rate for liver transplantation (LT).Using the US national registry data between 2018 and 2022, LTs were equally divided into 2 eras: pre-AC (before February 4, 2020) and post-AC (February 4, 2020, and after). Deceased potential liver donors were defined as deceased donors from whom at least 1 organ was procured.The annual number of deceased potential liver donors increased post-AC (from 10 423 to 12 259), approaching equal to that of new waitlist registrations for LT (n = 12 801). Although the discard risk index of liver grafts was comparable between the pre- and post-AC eras, liver utilization rates in donation after brain death (DBD) and donation after circulatory death (DCD) donors were lower post-AC (P < 0.01; 79.8% versus 83.4% and 23.7% versus 26.0%, respectively). Recipient factors, ie, no recipient located, recipient determined unsuitable, or time constraints, were more likely to be reasons for nonutilization after implementation of the AC allocation system compared to the pre-AC era (20.0% versus 12.3% for DBD donors and 50.1% versus 40.8% for DCD donors). Among non-high-volume centers, centers with lower utilization of marginal DBD donors or DCD donors were more likely to decrease LT volume post-AC.Although the number of deceased potential liver donors has increased, overall liver utilization among deceased donors has decreased in the post-AC era. To maximize the donor pool for LT, future efforts should target specific reasons for liver nonutilization.

    View details for DOI 10.1097/TP.0000000000004751

    View details for PubMedID 37585345

  • Debating the indication: re-transplant for patients whose initial transplant indication was hepatocellular carcinoma. HPB : the official journal of the International Hepato Pancreato Biliary Association Akabane, M., Melcher, M. L., Sasaki, K. 2023

    View details for DOI 10.1016/j.hpb.2023.08.003

    View details for PubMedID 37633744

  • Are Transplant Centers Where We Need Them?A Geospatial Analysis of Supply and Demand Handley, T. J., Russell, E., Kadri, H., Melcher, M. L. ELSEVIER SCIENCE INC. 2023: S676
  • Redefining Warm Ischemia: Time to Focus on Temperature Hansen, K. S., Porter, N. J., Freise, J., Roll, G., Gardner, J. M., Melcher, M. L. ELSEVIER SCIENCE INC. 2023: S1130
  • Should We Hesitate to Do Re-Transplants for Hepatocellular Carcinoma Patients with High Malignancy in Explant Pathology After Initial Transplants Akateh, C., Kirchner, V., Melcher, M. L., Gallo, A., Bonham, C., Sasaki, K. ELSEVIER SCIENCE INC. 2023: S727-S728
  • Development and validation of a REcurrent Liver cAncer Prediction ScorE (RELAPSE) following liver transplantation in patients with hepatocellular carcinoma: analysis of the us multicenter hcc transplant consortium. Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society Tran, B. V., Moris, D., Markovic, D., Zaribafzadeh, H., Henao, R., Lai, Q., Florman, S. S., Tabrizian, P., Haydel, B., Ruiz, R. M., Klintmalm, G. B., Lee, D. D., Taner, C. B., Hoteit, M., Levine, M. H., Cillo, U., Vitale, A., Verna, E. C., Halazun, K. J., Tevar, A. D., Humar, A., Chapman, W. C., Vachharajani, N., Aucejo, F., Lerut, J., Ciccarelli, O., Nguyen, M. H., Melcher, M. L., Viveiros, A., Schaefer, B., Hoppe-Lotichius, M., Mittler, J., Nydam, T. L., Markmann, J. F., Rossi, M., Mobley, C., Ghobrial, M., Langnas, A. N., Carney, C. A., Berumen, J., Schnickel, G. T., Sudan, D. L., Hong, J. C., Rana, A., Jones, C. M., Fishbein, T. M., Busuttil, R. W., Barbas, A. S., Agopian, V. G. 2023

    Abstract

    Hepatocellular carcinoma (HCC) recurrence following liver transplantation (LT) is highly morbid and occurs despite strict patient selection criteria. Individualized prediction of post-LT HCC recurrence risk remains an important need.Clinico-radiologic and pathologic data of 4981 patients with HCC undergoing LT from the United States Multicenter HCC Transplant Consortium (UMHTC) were analyzed to develop a REcurrent Liver cAncer Prediction ScorE (RELAPSE). Multivariable Fine and Gray competing risk analysis and machine learning algorithms (MLA; Random Survival Forest [RSF] and Classification and Regression Tree (CART) models) identified variables to model HCC recurrence. RELAPSE was externally validated in 1160 HCC LT recipients from the European Hepatocellular Cancer Liver Transplant (EurHeCaLT) study group.Of 4981 UMHTC patients with HCC undergoing LT, 71.9% were within Milan criteria (MC), 16.1% were initially beyond MC with 9.4% downstaged prior to LT, and 12.0% had incidental HCC on explant pathology. Overall and recurrence-free survival at 1-, 3-, and 5-years was 89.7%, 78.6%, 69.8% and 86.8%, 74.9%, 66.7%, respectively, with a 5-year incidence of HCC recurrence of 12.5% (median 16 mo) and non-HCC mortality of 20.8%. A multivariable model identified maximum AFP (HR = 1.35 per-log SD, 95%-CI:1.22-1.50,p < 0.001), neutrophil-lymphocyte ratio (HR = 1.16 per-log SD, 95%-CI:1.04-1.28,p < 0.006), pathologic maximum tumor diameter (HR = 1.53 per-log SD, 95%-CI 1.35-1.73,p < 0.001), microvascular (HR = 2.37, 95%-CI:1.87-2.99,p < 0.001) and macrovascular (HR = 3.38, 95%-CI:2.41-4.75,p < 0.001) invasion, and tumor differentiation (moderate HR = 1.75, 95%-CI:1.29-2.37,p < 0.001; poor HR = 2.62, 95%-CI:1.54-3.32,p < 0.001) as independent variables predicting post-LT HCC recurrence (C-statistic = 0.78). MLAs incorporating additional covariates improved prediction of recurrence (RSF C-statistic = 0.81). Despite significant differences in EurHeCaLT recipient radiologic, treatment, and pathologic characteristics, external validation of RELAPSE demonstrated consistent 2 and 5-year recurrence risk discrimination (AUC 0.77 and 0.75, respectively).We develop and externally validate a RELAPSE score which accurately discriminates post-LT HCC recurrence risk, and may allow for individualized post-LT surveillance, immunosuppression modification, and selection of high-risk patients for adjuvant therapies.

    View details for DOI 10.1097/LVT.0000000000000145

    View details for PubMedID 37029083

  • Evaluating the outcomes of donor-recipient age differences in young adults undergoing liver transplantation. Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society Snyder, A., Kojima, L., Imaoka, Y., Akabane, M., Kwong, A., Melcher, M. L., Sasaki, K. 2023

    Abstract

    BACKGROUND: The current liver allocation system may be disadvantaging younger adult recipients as it does not incorporate the donor-recipient age difference. Given the longer life expectancy of younger recipients, the influences of older donor grafts on their long-term prognosis should be elucidated. This study sought to reveal the long-term prognostic influence of the donor-recipient age difference in young adult recipients.METHODS: Adult patients who received initial liver transplants from deceased donors between 2002-2021 were identified from the UNOS database. Young recipients (patients ≤45 y.o) were categorized into 4 groups: donor age younger than the recipient, 0-9 years older, 10-19 years older, or ≥20 years older. Older recipients were defined as patients ≥65 y.o. To examine the influence of the age difference in long-term survivors, conditional graft survival (CGS) analysis was conducted on both younger and older recipients.RESULTS: Among 91,952 transplant recipients, 15,170 patients were ≤45 years old (16.5%); these were categorized into 6,114 (40.3%), 3,315 (21.9%), 2,970 (19.6%), and 2,771 (18.3%) for groups 1-4, respectively. Group 1 demonstrated the highest probability of survival followed by groups 2, 3, and 4 for the actual graft survival and CGS analyses. In younger recipients who survived at least 5 years post-transplant, inferior long-term survival was observed when there was an age difference of ≥10 years (86.9% vs. 80.6%, log-rank P<0.01) while there was no difference in older recipients (72.6% vs. 74.2%, log-rank P=0.89).CONCLUSION: In younger patients who are not in emergent need of a transplant, preferential allocation of younger aged donor offers would optimize organ utility by increasing postoperative graft survival time.

    View details for DOI 10.1097/LVT.0000000000000109

    View details for PubMedID 36847140

  • ASO Visual Abstract: The Current State of Liver Transplantation for Colorectal Liver Metastases in the United States: A Call for Standardized Reporting. Annals of surgical oncology Sasaki, K., Ruffolo, L. I., Kim, M. H., Fujiki, M., Hashimoto, K., Imaoka, Y., Melcher, M. L., Aucejo, F. N., Tomiyama, K., Hernandez-Alejandro, R. 2023

    View details for DOI 10.1245/s10434-023-13234-8

    View details for PubMedID 36807717

  • The impact of geographic location vs center practice on center volume in liver transplantation after acuity circle policy. Clinical transplantation Bekki, Y., Myers, B., Tomiyama, K., Melcher, M. L., Sasaki, K. 2023: e14932

    Abstract

    The allocation system for livers used the Acuity Circles (AC) beginning in 2020. In this study, we sought to evaluate the effect of the AC policy on center transplant volumes, from geographic and center practice perspectives.Using the US national registry data between 2018 and 2022, adult liver transplantations (LT) were separated into 2 eras: before AC and after AC.The number of LT for Model for End-Stage Liver Disease (MELD) scores ≥ 29 have significantly increased by 10%, and waitlist times for those patients have been significantly shorter after AC. These benefits were not found in patients with MELD scores < 29. The geographic distribution of transplant centers reveals that the majority of centers which increased their transplant volume (18 out of 25 centers) are located in high population states while there are 7 transplant centers in non-high population states. The centers in the non-high population states utilized more marginal donation after brain death (DBD) and donation after circulatory death (DCD) donors by 27% and 155%, respectively. MELD scores were significantly lower in the non-high population states compared with those in the high population states (p < 0.01).AC improved the LT access for patients with MELD scores ≥ 29, which benefited the high population states. However, aggressive center practice to utilize marginal DBD and DCD donors were able to increase transplant volume and lower median allocation MELD scores. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1111/ctr.14932

    View details for PubMedID 36756928

  • The Current State of Liver Transplantation for Colorectal Liver Metastases in the United States: A Call for Standardized Reporting. Annals of surgical oncology Sasaki, K., Ruffolo, L. I., Kim, M. H., Fujiki, M., Hashimoto, K., Imaoka, Y., Melcher, M. L., Aucejo, F. N., Tomiyama, K., Hernandez-Alejandro, R. 2023

    Abstract

    BACKGROUND: Current success in transplant oncology for select liver tumors, such as hepatocellular carcinoma, has ignited international interest in liver transplantation (LT) as a therapeutic option for nonresectable colorectal liver metastases (CRLM). In the United States, the CRLM LT experience is limited to reports from a handful of centers. This study was designed to summarize donor, recipient, and transplant center characteristics and posttransplant outcomes for the indication of CRLM.METHODS: Adult, primary LT patients listed between December 2017 and March 2022 were identified by using United Network Organ Sharing database. LT for CRLM was identified from variables: "DIAG_OSTXT"; "DGN_OSTXT_TCR"; "DGN2_OSTXT_TCR"; and "MALIG_TY_OSTXT."RESULTS: During this study period, 64 patients were listed, and 46 received LT for CRLM in 15 centers. Of 46 patients who underwent LT for CRLM, 26 patients (56.5%) received LTs using living donor LT (LDLT), and 20 patients received LT using deceased donor (DDLT) (43.5%). The median laboratory MELD-Na score at the time of listing was statistically similar between the LDLT and DDLT groups (8 vs. 9, P = 0.14). This persisted at the time of LT (8 vs. 12, P = 0.06). The 1-, 2-, and 3-year, disease-free, survival rates were 75.1, 53.7, and 53.7%. Overall survival rates were 89.0, 60.4, and 60.4%, respectively.CONCLUSIONS: This first comprehensive U.S. analysis of LT for CRLM suggests a burgeoning interest in high-volume U.S. transplant centers. Strategies to optimize patient selection are limited by the scarce oncologic history provided in UNOS data, warranting a separate registry to study LT in CRLM.

    View details for DOI 10.1245/s10434-023-13147-6

    View details for PubMedID 36719568

  • ASO Author Reflections: At the Crossroad-Liver Transplantation for Unresectable Colorectal Liver Metastases in the United States. Annals of surgical oncology Bozhilov, K., Melcher, M. L., Hernandez-Alejandro, R., Sasaki, K. 2023

    View details for DOI 10.1245/s10434-023-13169-0

    View details for PubMedID 36715859

  • Why are we not optimising healthcare? BMJ LEADER Handley, T., Denning, M., Melcher, M. L. 2023
  • Why are we not optimising healthcare? BMJ leader Handley, T., Denning, M., Melcher, M. L. 2023

    View details for DOI 10.1136/leader-2022-000674

    View details for PubMedID 37192100

  • Outcomes in liver transplant recipients with nonalcoholic fatty liver disease-related HCC: results from the US multicenter HCC transplant consortium. Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society Verna, E. C., Phipps, M. M., Halazun, K. J., Markovic, D., Florman, S. S., Haydel, B. M., Ruiz, R., Klintmalm, G., Lee, D. D., Taner, B., Hoteit, M. A., Tevar, A. D., Humar, A., Chapman, W. C., Vachharajani, N., Aucejo, F. N., Melcher, M. L., Nguyen, M. H., Nydam, T. L., Markmann, J. F., Mobley, C., Ghobrial, R. M., Langnas, A. N., Berumen, J., Schnickel, G. T., Sudan, D., Hong, J. C., Rana, A., Jones, C. M., Fishbein, T. M., Busuttil, R. W., Agopian, V. 2023; 29 (1): 34-47

    Abstract

    NAFLD will soon be the most common indication for liver transplantation (LT). In NAFLD, HCC may occur at earlier stages of fibrosis and present with more advanced tumor stage, raising concern for aggressive disease. Thus, adult LT recipients with HCC from 20 US centers transplanted between 2002 and 2013 were analyzed to determine whether NAFLD impacts recurrence-free post-LT survival. Five hundred and thirty-eight (10.8%) of 4981 total patients had NAFLD. Patients with NAFLD were significantly older (63 vs. 58, p<0.001), had higher body mass index (30.5 vs. 27.4, p<0.001), and were more likely to have diabetes (57.3% vs. 28.8%, p<0.001). Patients with NAFLD were less likely to receive pre-LT locoregional therapy (63.6% vs. 72.9%, p<0.001), had higher median lab MELD (15 vs. 13, p<0.001) and neutrophil-lymphocyte ratio (3.8 vs. 2.9, p<0.001), and were more likely to have their maximum pre-LT alpha fetoprotein at time of LT (44.1% vs. 36.1%, p<0.001). NAFLD patients were more likely to have an incidental HCC on explant (19.4% vs. 10.4%, p<0.001); however, explant characteristics including tumor differentiation and vascular invasion were not different between groups. Comparing NAFLD and non-NAFLD patients, the 1, 3, and 5-year cumulative incidence of recurrence (3.1%, 9.1%, 11.5% vs. 4.9%, 10.1%, 12.6%, p=0.36) and recurrence-free survival rates (87%, 76%, and 67% vs. 87%, 75%, and 67%, p=0.97) were not different. In competing risks analysis, NAFLD did not significantly impact recurrence in univariable (HR: 0.88, p=0.36) nor in adjusted analysis (HR: 0.91, p=0.49). With NAFLD among the most common causes of HCC and poised to become the leading indication for LT, a better understanding of disease-specific models to predict recurrence is needed. In this NAFLD cohort, incidental HCCs were common, raising concerns about early detection. However, despite less locoregional therapy and high neutrophil-lymphocyte ratio, explant tumor characteristics and post-transplant recurrence-free survival were not different compared to non-NAFLD patients.

    View details for DOI 10.1097/LVT.0000000000000007

    View details for PubMedID 36630156

  • IDENTIFYING NOVEL GENE TARGETS FOR DIAGNOSIS AND TREATEMENT OF HCC IN ASIAN AND CAUCASIAN POPULATIONS BASED ON WHOLE GENOME SEQUENCING Hong, S., Badshah, J., Aliwaisi, A., Sasaki, K., Pruett, T., Melcher, M., Bonham, C., Gallo, A., Martinez, O., Krams, S., Pham, K., Busque, S., Reitsma, A., Esquivel, C., Kirchner, V. ELSEVIER SCIENCE INC. 2023: S28
  • Despite Increasing Costs, Perfusion Machines Expand the Donor Pool of Livers and Could Save Lives. The Journal of surgical research Handley, T. J., Arnow, K. D., Melcher, M. L. 2022; 283: 42-51

    Abstract

    INTRODUCTION: Liver transplantation is a highly successful treatment for liver failure and disease. However, demand continues to outstrip our ability to provide transplantation as a treatment. Many livers initially considered for transplantation are not used because of concerns about their viability or logistical issues. Recent clinical trials have shown discarded livers may be viable if they undergo machine perfusion, which allows a more objective assessment of liver quality.METHODS: Using the Scientific Registry of Transplant Recipients dataset, we examined discarded and unretrieved organs to determine their eligibility for perfusion. We then used a Markov decision-analytic model to perform a cost-effectiveness analysis of two competing transplant strategies: Static Cold Storage (SCS) alone versus Static Cold Storage and Normothermic Machine Perfusion (NMP) of discarded organs.RESULTS: The average predicted successful transplants after perfusion was 385, representing a 5.8% increase in the annual yield of liver transplants. Our cost-effectiveness analysis found that the SCS strategy generated 4.64 quality-adjusted life years (QALYs) and cost $479,226. The combined SCS+NMP strategy generated 4.72 QALYs and cost $481,885. The combined SCS+NMP strategy had an incremental cost-effectiveness ratio of $33,575 per additional QALY over the 10-year study horizon.CONCLUSIONS: Machine perfusion of livers currently not considered viable for transplant could increase the number of transplantable grafts by approximately 5% per year and is cost-effective compared to Static Cold Storage alone.

    View details for DOI 10.1016/j.jss.2022.10.002

    View details for PubMedID 36368274

  • Reevaluating Liver Donor Risk in the Era of Improved Hepatitis C Virus Treatment. JAMA surgery Handley, T. J., Arnow, K., Sasaki, K., Kwong, A., Melcher, M. L. 2022

    Abstract

    This cohort study examines the risk of graft failure associated with donors with hepatitis C virus (HCV) infection before and after the introduction of direct-acting antiviral medications.

    View details for DOI 10.1001/jamasurg.2022.3922

    View details for PubMedID 36197654

  • MELD 3.0 AS A PREDICTOR OF POST-TRANSPLANT OUTCOMES IN THE COVID ERA Chung, N., Wu, W., Kwong, A. J., Charu, V., Mannalithara, A., Melcher, M., Kim, W. WILEY. 2022: S77-S78
  • CALIBRATION OF WAITLIST SURVIVAL PREDICTION BY MELD 3.0 IN THE PANDEMIC ERA Wu, W., Chung, N., Vidovszky, A., Mannalithara, A., Melcher, M., Charu, V., Kwong, A. J., Kim, W. WILEY. 2022: S76-S77
  • Has the Risk of Liver Re-Transplantation Improved Over the Two Decades? A UNOS Data Analysis Kim, M. H., Melcher, M. L., Kirchner, V. A., Gallo, A. E., Bonham, C. A., Esquivel, C., Sasaki, K. LIPPINCOTT WILLIAMS & WILKINS. 2022: S294
  • Impact of Donor Liver Macrovesicular Steatosis on Deceased Donor Yield and Posttransplant Outcome. Transplantation Kwong, A. J., Kim, W. R., Lake, J., Stock, P. G., Wang, C. J., Wetmore, J. B., Melcher, M. L., Wey, A., Salkowski, N., Snyder, J. J., Israni, A. K. 2022

    Abstract

    The Scientific Registry of Transplant Recipients (SRTR) had not traditionally considered biopsy results in risk-adjustment models, yet biopsy results may influence outcomes and thus decisions regarding organ acceptance.Using SRTR data, which includes data on all donors, waitlisted candidates, and transplant recipients in the United States, we assessed (1) the impact of macrovesicular steatosis on deceased donor yield (defined as number of livers transplanted per donor) and 1-y posttransplant graft failure and (2) the effect of incorporating this variable into existing SRTR risk-adjustment models.There were 21 559 donors with any recovered organ and 17 801 liver transplant recipients included for analysis. Increasing levels of macrovesicular steatosis on donor liver biopsy predicted lower organ yield: ≥31% macrovesicular steatosis on liver biopsy was associated with 87% to 95% lower odds of utilization, with 55% of these livers being discarded. The hazard ratio for graft failure with these livers was 1.53, compared with those with no pretransplant liver biopsy and 0% to 10% steatosis. There was minimal change on organ procurement organization-specific deceased donor yield or program-specific posttransplant outcome assessments when macrovesicular steatosis was added to the risk-adjustment models.Donor livers with macrovesicular steatosis are disproportionately not transplanted relative to their risk for graft failure. To avoid undue risk aversion, SRTR now accounts for macrovesicular steatosis in the SRTR risk-adjustment models to help facilitate use of these higher-risk organs. Increased recognition of this variable may also encourage further efforts to standardize the reporting of liver biopsy results.

    View details for DOI 10.1097/TP.0000000000004291

    View details for PubMedID 36042548

  • Impact of the donor hepatectomy time on short-term outcomes in liver transplantation using donation after circulatory death: A review of the US national registry. Clinical transplantation Bekki, Y., Kozato, A., Kusakabe, J., Tajima, T., Fujiki, M., Gallo, A., Melcher, M. L., Bonham, C. A., Sasaki, K. 2022: e14778

    Abstract

    BACKGROUND: During the donor hepatectomy time (dHT), defined as the time from the start of cold perfusion to the end of the hepatectomy, liver grafts have a suboptimal temperature. The aim of this study was to analyze the impact of prolonged dHT on outcomes in donation after circulatory death (DCD) liver transplantation (LT).METHODS: Using the US national registry data between 2012 and 2020, DCD LT patients were separated into 2 groups based on their dHT: standard dHT (<42 min) and prolonged dHT (≥42 min).RESULTS: There were 3810 DCD LTs during the study period. Median dHT was 32 min (IQR 25-41 min). Kaplan- Meier graft survival curves demonstrated inferior outcomes in the prolonged dHT group at 1-year after DCD LT compared to those in the standard dHT group (85.3% vs 89.9%; p < 0.01). Multivariate Cox proportional hazards models for 1-year graft survival identified that prolonged dHT [hazard ratio (HR) 1.46, 95% confidence interval (CI) 1.19 - 1.79], recipient age ≥ 64 years (HR 1.40, 95% CI 1.14 - 1.72), and MELD score ≥ 24 (HR 1.43, 95% CI 1.16 - 1.76) were significant predictors of 1-year graft loss. Spline analysis shows that the dHT effects on the risk for 1-year graft loss with an increase in the slope after median dHT of 32 min.CONCLUSION: Prolonged dHTs significantly reduced graft and patient survival after DCD LT. Because dHT is a modifiable factor, donor surgeons should take on cases with caution by setting the dHT target of < 32 min. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1111/ctr.14778

    View details for PubMedID 35866342

  • Allocation Based on Acuity Circles: Effects on Pediatric Liver Allocation. Kim, M., Kim, M. H., Gallo, A., Pham, T., Melcher, M. L., Busque, S., Esquivel, C., Bonham, C. WILEY. 2022: 475-476
  • Surgical Outcomes of Limited Sobriety versus Standard Sobriety Liver Transplantation for Alcohol-Associated Liver Disease. Fu, S., Pan, J. H., Goel, A., Kwong, A. J., Melcher, M. L. WILEY. 2022: 723
  • Development of a Portable Device to Quantify Hepatic Steatosis in Donated Livers Using an AI Algorithm. Klinkachorn, S., Tsoi-A-Sue, C. J., Narayan, R. R., Melcher, M. L. WILEY. 2022: 474-475
  • Anti-HLA Antibodies Do Not Increase in Kidney Transplant Recipients During COVID-19 Infection. Girnita, A., Wang, L., Ahearn, P., Colovai, A., Fernandez-Vina, M., Woodle, E., Yalamarti, T., Menon, M., Azzi, Y., Melcher, M., Bray, R., Gebel, H., Cravedi, P., Maltzman, J., Akalin, E. WILEY. 2022: 709
  • Allocation Based on Acuity Circles Decreases Waiting Time for Liver Transplant Patients. Kim, M. H., Sasaki, K., Gallo, A., Pham, T., Melcher, M. L., Busque, S., Esquivel, C., Bonham, C. WILEY. 2022: 829-830
  • Explaining a Potential Interview Match for Graduate Medical Education. Journal of graduate medical education Wapnir, I., Ashlagi, I., Roth, A. E., Skancke, E., Vohra, A., Lo, I., Melcher, M. L. 1800; 13 (6): 764-767

    View details for DOI 10.4300/JGME-D-20-01422.1

    View details for PubMedID 35070086

  • CALL FOR AN INTERNATIONAL STUDY TO IDENTIFY TRAJECTORIES TO EARLY ALLOGRAFT FAILURE AND ASSESS HOW EARLY RETRANSPLANT MAY IMPACT ON PATIENT SURVIVAL Avolio, A. W., Moschetta, G., Contegiacomo, A., Romagnoli, R., Muiesan, P., Lai, Q., Melcher, M. L., Burra, P., Agnes, S., Cillo, U. WILEY. 2021: 315
  • Availability of a Web and Smartphone Application to Stratify the Risk of of Early Allograft Failure Requiring Liver Retransplantation. Hepatology communications Avolio, A. W., Contegiacomo, A., Agnes, S., Marrone, G., Moschetta, G., Miele, L., Melcher, M. L. 2021

    View details for DOI 10.1002/hep4.1754

    View details for PubMedID 34558843

  • Quantification of Multiple Isotypes of Anti-SARS-CoV-2 Antibodies in Kidney Transplant Recipients Maltzman, J. S., Wang, L., Ahearn, P., Yalamarti, T., Menon, M., Azzi, Y., Melcher, M., Fernandez-Vina, M., Bray, R., Gebel, H., Woodle, E., Akalin, E., Girnita, A., Cravedi, P. WILEY. 2021: 863
  • Donor-specific Anti-HLA Alloantibody in Kidney Transplant Recipients with COVID-19 Exhibit a Different Immunoglobulin Class and Subclass Profile When Compared to Anti-SARS-CoV-2 Antibodies Girnita, A., Wang, L., Fernandez-Vina, M., Woodle, E., Ahearn, P., Yalamarti, T., Menon, M., Azzi, Y., Melcher, M., Bray, R., Gebel, H., Akalin, E., Cravedi, P., Maltzman, J. S. WILEY. 2021: 863
  • Predictors of Outcomes of Patients Referred to a Transplant Center for Urgent Liver Transplantation Evaluation. Hepatology communications Alshuwaykh, O., Kwong, A., Goel, A., Cheung, A., Dhanasekaran, R., Ahmed, A., Daugherty, T., Dronamraju, D., Kumari, R., Kim, W. R., Nguyen, M. H., Esquivel, C. O., Concepcion, W., Melcher, M., Bonham, A., Pham, T., Gallo, A., Kwo, P. Y. 2021; 5 (3): 516-525

    Abstract

    Liver transplantation (LT) is definitive treatment for end-stage liver disease. This study evaluated factors predicting successful evaluation in patients transferred for urgent inpatient LT evaluation. Eighty-two patients with cirrhosis were transferred for urgent LT evaluation from January 2016 to December 2018. Alcohol-associated liver disease was the common etiology of liver disease (42/82). Of these 82 patients, 35 (43%) were declined for LT, 27 (33%) were wait-listed for LT, 5 (6%) improved, and 15 (18%) died. Psychosocial factors were the most common reasons for being declined for LT (49%). Predictors for listing and receiving LT on multivariate analysis included Hispanic race (odds ratio [OR], 1.89; P = 0.003), Asian race (OR, 1.52; P = 0.02), non-Hispanic ethnicity (OR, 1.49; P = 0.04), hyponatremia (OR, 1.38; P = 0.04), serum albumin (OR, 1.13; P = 0.01), and Model for End-Stage Liver Disease (MELD)-Na (OR, 1.02; P = 0.003). Public insurance (i.e., Medicaid) was a predictor of not being listed for LT on multivariate analysis (OR, 0.77; P = 0.02). Excluding patients declined for psychosocial reasons, predictors of being declined for LT on multivariate analysis included Chronic Liver Failure Consortium (CLIF-C) score >51.5 (OR, 1.26; P = 0.03), acute-on-chronic liver failure (ACLF) grade 3 (OR, 1.41; P = 0.01), hepatorenal syndrome (HRS) (OR, 1.38; P = 0.01), and respiratory failure (OR, 1.51; P = 0.01). Predictors of 3-month mortality included CLIF-C score >51.5 (hazard ratio [HR], 2.52; P = 0.04) and intensive care unit (HR, 8.25; P < 0.001). Conclusion: MELD-Na, albumin, hyponatremia, ACLF grade 3, HRS, respiratory failure, public insurance, Hispanic race, Asian race, and non-Hispanic ethnicity predicted liver transplant outcome. Lack of psychosocial support was a major reason for being declined for LT. The CLIF-C score predicted being declined for LT and mortality.

    View details for DOI 10.1002/hep4.1644

    View details for PubMedID 33681683

    View details for PubMedCentralID PMC7917272

  • Artificial Intelligence for Prediction of Donor Liver Allograft Steatosis and Early Post-Transplantation Graft Failure Narayan, R., Abadilla, N., Yang, L., Chen, S., Higgins, J., Melcher, M. WILEY. 2021: 16–17
  • "Toward a novel evidence-based definition of early allograft failure in the perspective of liver retransplant". Transplant international : official journal of the European Society for Organ Transplantation Avolio, A. W., Contegiacomo, A., Spoletini, G., Moschetta, G., Bianco, G., Agnes, S., Melcher, M. L., Burra, P. 2021

    Abstract

    We read with interest the study of Van den Eynde et al. on the effect of perfusion solutions on liver transplant outcome.(1) Graft dysfunction was analyzed applying two indicators: Early Allograft Dysfunction (EAD, a dichotomous system based on transaminase, bilirubin, and coagulation cut-off values)(2) and Model of Early Allograft Function (MEAF, a continuous score based on the same variables as EAD).( 3).

    View details for DOI 10.1111/tri.14162

    View details for PubMedID 34784075

  • Artificial intelligence for prediction of donor liver allograft steatosis and early post-transplantation graft failure. HPB : the official journal of the International Hepato Pancreato Biliary Association Narayan, R. R., Abadilla, N., Yang, L., Chen, S. B., Klinkachorn, M., Eddington, H. S., Trickey, A. W., Higgins, J. P., Melcher, M. L. 2021

    Abstract

    Donor livers undergo subjective pathologist review of steatosis before transplantation to mitigate the risk for early allograft dysfunction (EAD). We developed an objective, computer vision artificial intelligence (CVAI) platform to score donor liver steatosis and compared its capability for predicting EAD against pathologist steatosis scores.Two pathologists scored digitized donor liver biopsy slides from 2014 to 2019. We trained four CVAI platforms with 1:99 training:prediction split. Mean intersection-over-union (IU) characterized CVAI model accuracy. We defined EAD using liver function tests within 1 week of transplantation. We calculated separate EAD logistic regression models with CVAI and pathologist steatosis and compared the models' discrimination and internal calibration.From 90 liver biopsies, 25,494 images trained CVAI models yielding peak mean IU = 0.80. CVAI steatosis scores were lower than pathologist scores (median 3% vs 20%, P < 0.001). Among 41 transplanted grafts, 46% developed EAD. The median CVAI steatosis score was higher for those with EAD (2.9% vs 1.9%, P = 0.02). CVAI steatosis was independently associated with EAD after adjusting for donor age, donor diabetes, and MELD score (aOR = 1.34, 95%CI = 1.03-1.75, P = 0.03).The CVAI steatosis EAD model demonstrated slightly better calibration than pathologist steatosis, meriting further investigation into which modality most accurately and reliably predicts post-transplantation outcomes.

    View details for DOI 10.1016/j.hpb.2021.10.004

    View details for PubMedID 34815187

  • Pathologic Response to Pretransplant Locoregional Therapy is Predictive of Patient Outcome After Liver Transplantation for Hepatocellular Carcinoma Analysis From the US Multicenter HCC Transplant Consortium ANNALS OF SURGERY DiNorcia, J., Florman, S. S., Haydel, B., Tabrizian, P., Ruiz, R. M., Klintmalm, G. B., Senguttuvan, S., Lee, D. D., Taner, C., Verna, E. C., Halazun, K. J., Hoteit, M., Levine, M. H., Chapman, W. C., Vachharajani, N., Aucejo, F., Nguyen, M. H., Melcher, M. L., Tevar, A. D., Humar, A., Mobley, C., Ghobrial, M., Nydam, T. L., Amundsen, B., Markmann, J. F., Berumen, J., Hemming, A. W., Langnas, A. N., Carney, C. A., Sudan, D. L., Hong, J. C., Kim, J., Zimmerman, M. A., Rana, A., Kueht, M. L., Jones, C. M., Fishbein, T. M., Markovic, D., Busuttil, R. W., Agopian, V. G. 2020; 271 (4): 616–24
  • Improving Liver Transplant (LT) Waitlist Attrition Concepcion, W., Ahmed, A., Tulu, Z., Hogan, L., Bonham, A., Gallo, A., Melcher, M., Kwo, P., Esquivel, C. WILEY. 2020: 284–85
  • Center-level Variation in HLA-incompatible Living Donor Kidney Transplantation Outcomes. Transplantation Jackson, K. R., Long, J., Motter, J., Bowring, M. G., Chen, J., Waldram, M. M., Orandi, B. J., Montgomery, R. A., Stegall, M. D., Jordan, S. C., Benedetti, E., Dunn, T. B., Ratner, L. E., Kapur, S., Pelletier, R. P., Roberts, J. P., Melcher, M. L., Singh, P., Sudan, D. L., Posner, M. P., El-Amm, J. M., Shapiro, R., Cooper, M., Verbesey, J. E., Lipkowitz, G. S., Rees, M. A., Marsh, C. L., Sankari, B. R., Gerber, D. A., Wellen, J., Bozorgzadeh, A., Gaber, A. O., Heher, E., Weng, F. L., Djamali, A., Helderman, J. H., Concepcion, B. P., Brayman, K. L., Oberholzer, J., Kozlowski, T., Covarrubias, K., Desai, N., Massie, A. B., Segev, D. L., Garonzik-Wang, J. 2020

    Abstract

    BACKGROUND: Desensitization protocols for HLA-incompatible living donor kidney transplantation (ILDKT) vary across centers. The impact of these, as well as other practice variations, on ILDKT outcomes remain unknown.METHODS: We sought to quantify center-level variation in mortality and graft loss following ILDKT using a 25-center cohort of 1358 ILDKT recipients with linkage to SRTR for accurate outcome ascertainment. We used multilevel Cox regression with shared frailty to determine the variation in post-ILDKT outcomes attributable to between-center differences, and to identify any center-level characteristics associated with improved post-ILDKT outcomes.RESULTS: After adjusting for patient-level characteristics, only 6 centers (24%) had lower mortality and 1 (4%) had higher mortality than average. Similarly, only 5 centers (20%) had higher graft loss and 2 had lower graft loss than average. Only 4.7% of the differences in mortality (p<0.01) and 4.4% of the differences in graft loss (p<0.01) were attributable to between-center variation. These translated to a median hazard ratio of 1.36 for mortality and 1.34 of graft loss for similar candidates at different centers. Post-ILDKT outcomes were not associated with the following center-level characteristics: ILDKT volume and transplanting a higher proportion of highly sensitized, prior transplant, preemptive, or minority candidates.CONCLUSION: Unlike most aspects of transplantation where center-level variation and volume impact outcomes, we did not find substantial evidence for this in ILDKT. Our findings support the continued practice of ILDKT across these diverse centers.

    View details for DOI 10.1097/TP.0000000000003254

    View details for PubMedID 32235255

  • Influence of Student Loan Debt on General Surgery Resident Career and Lifestyle Decision-Making Gray, K., Kaji, A. H., Wolfe, M., Calhoun, K., Amersi, F., Donahue, T., Smith, B. R., Salcedo, E. S., Murayama, K., de Virgilio, C., Neville, A., Arnell, T., Jarman, B., Inaba, K., Melcher, M., Morris, J. B., Reeves, M., Gauvin, J., Sidwell, R., Damewood, R., Poola, V., Dent, D., Surg Educators Workgrp ELSEVIER SCIENCE INC. 2020: 173–81

    Abstract

    The average medical school debt in 2011 was $170,000 and by 2017 it increased to $190,000. High debt burden has been shown to affect career choices for residents in primary care specialties; however, it has not been well studied among surgical residents. The purpose of this multi-institutional study is to assess the amount of debt among general surgery residents and its effects on their career and lifestyle decisions.Surveys were distributed to 607 categorical general surgery residents at 19 different residency programs. Degree of debt was assessed and responses compared.Overall, 427(70.3%) residents completed the survey, of which 317(74.2%) reported having student loan debt. Of those with debt, 262(82.6%) felt that repaying debt was a significant financial burden in residency, 248 (78.3%) felt it would remain a burden after residency, 210(66.2%) felt their debt would influence their future job choice, and 225(71%) felt their debt will delay their ability to buy a home. Debt did not affect decisions to get married or have children. There were 109(25.6%) residents with no debt, 131(30.8%) with <$200,000, 103(24.2%) with $200,000-300,000, and 83(19.5%) with >$300,000. Residents with high debt were less likely to feel financially secure now (p<0.0001) and when thinking about their future (p-0.0001). They also had higher minimum starting salary goals (p=0.002) and were less likely to have had assistance paying for their education (p=0.0001).Surgical residents feel their debt is a significant financial burden. Furthermore, high debt significantly influences their financial security, practice location, and salary goals.

    View details for DOI 10.1016/j.jamcollsurg.2019.10.016

    View details for Web of Science ID 000508903700002

    View details for PubMedID 31783093

  • Post-Transplant Outcomes in Older Patients with Hepatocellular Carcinoma (HCC) are Driven by non-HCC Factors. Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society Adeniji, N. n., Arjunan, V. n., Prabhakar, V. n., Mannalithara, A. n., Ghaziani, T. n., Ahmed, A. n., Kwo, P. n., Nguyen, M. n., Melcher, M. L., Busuttil, R. W., Florman, S. S., Haydel, B. n., Ruiz, R. M., Klintmalm, G. B., Lee, D. D., Taner, C. B., Hoteit, M. A., Verna, E. C., Halazun, K. J., Tevar, A. D., Humar, A. n., Chapman, W. C., Vachharajani, N. n., Aucejo, F. n., Nydam, T. L., Markmann, J. F., Mobley, C. n., Ghobrial, M. n., Langnas, A. N., Carney, C. A., Berumen, J. n., Schnickel, G. T., Sudan, D. L., Hong, J. C., Rana, A. n., Jones, C. M., Fishbein, T. M., Agopian, V. n., Dhanasekaran, R. n. 2020

    Abstract

    The incidence of hepatocellular carcinoma (HCC) is growing in the US, especially among the elderly. Older patients are increasingly getting transplanted for HCC, but the impact of advancing age on long-term post-transplant outcomes is not clear. To study this, we used data from the US Multicenter HCC Transplant Consortium (UMHTC) of 4980 patients. We divided the patients into 4 groups by age at transplantation- 18-64 (n = 4001), 65-69 (n = 683), 70-74 (n = 252) and ≥ 75 years (n = 44). There were no differences in HCC tumor stage, type of bridging locoregional therapy or explant residual tumor between the groups. Older age was confirmed to be an independent and significant predictor of overall survival even after adjusting for demographic, etiologic and cancer-related factors on multivariable analysis. A dose-response effect of age on survival was observed, with every 5-year increase in age over 50 years resulting in an absolute increase of 8.3% in the mortality rate. Competing risk analysis revealed that older patients experienced higher rates of non-HCC-related mortality (p = 0.004), and not HCC-related death (p = 0.24). To delineate the precise cause of death, we further analyzed a single-center cohort of patients transplanted for HCC (n = 302). Patients older than 65 years had a higher incidence of de-novo cancer (18.1% vs 7.6%, p = 0.006) after transplantation and higher overall cancer-related mortality (14.3% vs 6.6%, p = 0.03). CONCLUSION: Even carefully selected elderly patients with HCC have significantly worse post-transplant survival, which are mostly driven by non-HCC related causes. Minimizing immunosuppression and closer surveillance for de novo cancers can potentially improve outcomes in elderly patients transplanted for HCC.

    View details for DOI 10.1002/lt.25974

    View details for PubMedID 33306254

  • What Solid Organ Transplant Healthcare Providers should know about Renin-Angiotensin-Aldosterone System Inhibitors and COVID-19. Clinical transplantation Wong, S. Y., Brubaker, A. L., Wang, A. X., Taiwo, A. A., Melcher, M. L. 2020: e13991

    Abstract

    The data on the outcomes of solid organ transplant recipients who have contracted coronavirus disease 2019 (COVID-19) are still emerging. Kidney transplant recipients are commonly prescribed renin-angiotensin-aldosterone system (AAS) inhibitors given the prevalence of hypertension, diabetes, and cardiovascular disease. As the angiotensin-converting enzyme 2 (ACE2) facilitates the entry of coronaviruses into target cells, there have been hypotheses that preexisting use of Renin-Angiotensin-Aldosterone System (RAAS) inhibitors may increase the risk of developing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Given the common use of RAAS inhibitors among solid organ transplant recipients, we sought to review the RAAS cascade, the mechanism of SARS-CoV-2 entry, and pertinent data related to the effect of RAAS inhibitors on ACE2 to guide management of solid organ transplant recipients during the COVID-19 pandemic. At present there is no clear evidence to support the discontinuation of RAAS inhibitors in solid organ transplant recipients during the COVID-19 pandemic.

    View details for DOI 10.1111/ctr.13991

    View details for PubMedID 32446267

  • NuSeT: A deep learning tool for reliably separating and analyzing crowded cells PLoS Computational Biology Yang, L., et al 2020
  • Underrepresented Minorities in General Surgery Residency: Analysis of Interviewed Applicants, Residents, and Core Teaching Faculty. Journal of the American College of Surgeons Jarman, B. T., Borgert, A. J., Kallies, K. J., Joshi, A. R., Smink, D. S., Sarosi, G. A., Chang, L. n., Green, J. M., Greenberg, J. A., Melcher, M. L., Nfonsam, V. n., Whiting, J. n. 2020

    Abstract

    The ACGME requires diversity in residency. The self-identified race/ethnicity of general surgery applicants, residents, and core teaching faculty were assessed to evaluate underrepresented minority (URM) representation in surgery residency programs and to determine the impact of URM faculty and resident on URM applicants' selection for interview or match.Data from the 2018 application cycle was collated for 10 general surgery programs. Applicants without a self-identified race/ethnicity were excluded. URMs were defined as those identifying as Black/African American, Hispanic/Latino/of Spanish origin, American Indian/Alaskan Native/Native Hawaiian/Pacific Islander-Samoan. Statistical analyses included chi-square tests, and a multivariate model.Ten surgery residency programs received 9,143 applications from 3,067 unique applicants. Applications from White, Asian, Hispanic/Latino, Black/African American and American Indian applicants constituted 66%, 19%, 8%, 7% and 1% of those applications selected to interview and 66%, 13%, 11%, 8% and 2% of applications resulting in a match. Among programs' 272 core faculty and 318 current residents, 10% and 21%, respectively, were identified as URMs. As faculty diversity increased, there was no difference in selection to interview for URM (OR=0.83; 95%CI:0.54-1.28, per 10% increase in faculty diversity) or non-URM applicants (OR=0.68; 95%CI:0.57-0.81). Similarly, greater URM representation among current residents did not impact likelihood of being selected for an interview for URM (OR=1.20; 95%CI:0.90-1.61) vs. non-URM applicants (OR=1.28; 95%CI:1.13-1.45). Current resident and faculty URM representation was correlated (r=0.8; P=0.005).Programs with a greater proportion of URM core faculty or residents did not select a greater proportion of URM applicants for interview. However, core faculty and resident racial diversity were correlated. Recruitment of racially/ethnically diverse trainees and faculty will require ongoing analysis to develop effective recruitment strategies.

    View details for DOI 10.1016/j.jamcollsurg.2020.02.042

    View details for PubMedID 32156654

  • Delayed Graft Function and Acute Rejection Following HLA-Incompatible Living Donor Kidney Transplantation. American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons Motter, J. D., Jackson, K. R., Long, J. J., Waldram, M. M., Orandi, B. J., Montgomery, R. A., Stegall, M. D., Jordan, S. C., Benedetti, E. n., Dunn, T. B., Ratner, L. E., Kapur, S. n., Pelletier, R. P., Roberts, J. P., Melcher, M. L., Singh, P. n., Sudan, D. L., Posner, M. P., El-Amm, J. M., Shapiro, R. n., Cooper, M. n., Verbesey, J. E., Lipkowitz, G. S., Rees, M. A., Marsh, C. L., Sankari, B. R., Gerber, D. A., Wellen, J. R., Bozorgzadeh, A. n., Gaber, A. O., Heher, E. C., Weng, F. L., Djamali, A. n., Helderman, J. H., Concepcion, B. P., Brayman, K. L., Oberholzer, J. n., Kozlowski, T. n., Covarrubias, K. n., Massie, A. B., Segev, D. L., Garonzik-Wang, J. M. 2020

    Abstract

    Incompatible living donor kidney transplant recipients (ILDKT) have pre-existing donor-specific antibody (DSA) that, despite desensitization, may persist or reappear with resulting consequences, including delayed graft function (DGF) and acute rejection (AR). To quantify the risk of DGF and AR in ILDKT and downstream effects, we compared 1,406 ILDKT to 17,542 compatible LDKT (CLDKT) recipients using a 25-center cohort with novel SRTR linkage. We characterized DSA strength as positive-Luminex, negative-flow crossmatch (PLNF); positive-flow, negative-cytotoxic crossmatch (PFNC); or positive-cytotoxic crossmatch (PCC). DGF occurred in 3.1% of CLDKT, 3.5% of PLNF, 5.7% of PFNC, and 7.6% of PCC recipients, which translated to higher DGF for PCC recipients (aOR=1.03 1.682 .72 ). However, the impact of DGF on mortality and DCGF risk was no higher for ILDKT than CLDKT (p interaction>0.1). AR developed in 8.4% of CLDKT, 18.2% of PLNF, 21.3% of PFNC, and 21.7% of PCC recipients, which translated to higher AR (aOR PLNF=1.45 2.093.02 ;PFNC=1.67 2.403.46 ;PCC=1.48 2.243.37 ). Although the impact of AR on mortality was no higher for ILDKT than CLDKT (p interaction=0.1), its impact on DCGF risk was less consequential for ILDKT (aHR=1.34 1.621.95 ) than CLDKT (aHR=1.96 2.292.67 ) (p interaction=0.004). Providers should consider these risks during pre-operative counselling, and strategies to mitigate them should be considered.

    View details for DOI 10.1111/ajt.16471

    View details for PubMedID 33370502

  • Understanding Health Care Utilization and Mortality After Emergency General Surgery in Patients With Underlying Liver Disease. The American surgeon Tennakoon, L. n., Baiu, I. n., Concepcion, W. n., Melcher, M. L., Spain, D. A., Knowlton, L. M. 2020; 86 (6): 665–74

    Abstract

    Mortality and complications are not well defined nationally for emergency general surgery (EGS) patients presenting with underlying all-cause liver disease (LD).We analyzed the 2012-2014 National Inpatient Sample for adults (aged ≥ 18 years) with a primary EGS diagnosis. Underlying LD included International Classification of Diseases, Ninth Revision, Clinical Modification codes for alcoholic and viral hepatitis, malignancy, congenital etiologies, and cirrhosis. The primary outcome was mortality; secondary outcomes included complications, operative intervention, and costs.Of the 6.8 million EGS patients, 358 766 (5.3%) had underlying LD. 59.1% had cirrhosis, 6.7% had portal hypertension, and 13.7% had ascites. Compared with other EGS patients, EGS-LD patients had higher mean costs ($12 847 vs $10 234, P < .001). EGS-LD patients were less likely to have surgery (26.1% vs 37.0%, P < .001) but for those who did, mortality was higher (4.8% vs 1.8%, P < .001). Risk factors for mortality included ascites (adjusted odds ratio [aOR] = 2.68, P < .001), dialysis (aOR = 3.44, P < .001), sepsis (aOR = 8.97, P < .001), and respiratory failure requiring intubation (aOR = 10.40, P < .001). Odds of death increased in both surgical (aOR = 4.93, P < .001) and non-surgical EGS-LD patients (aOR = 2.56, P < .001).Underlying all-cause LD among EGS patients is associated with increased in-hospital mortality, even in the absence of surgical intervention.

    View details for DOI 10.1177/0003134820923304

    View details for PubMedID 32683972

  • Liver Transplantation Outcomes in a U.S. Multicenter Cohort of 789 Patients with Hepatocellular Carcinoma Presenting Beyond Milan Criteria. Hepatology (Baltimore, Md.) Kardashian, A. n., Florman, S. S., Haydel, B. n., Ruiz, R. M., Klintmalm, G. B., Lee, D. D., Taner, C. B., Aucejo, F. n., Tevar, A. D., Humar, A. n., Verna, E. C., Halazun, K. J., Chapman, W. C., Vachharajani, N. n., Hoteit, M. n., Levine, M. H., Nguyen, M. H., Melcher, M. L., Langnas, A. N., Carney, C. A., Mobley, C. n., Ghobrial, M. n., Amundsen, B. n., Markmann, J. F., Sudan, D. L., Jones, C. M., Berumen, J. n., Hemming, A. W., Hong, J. C., Kim, J. n., Zimmerman, M. A., Nydam, T. L., Rana, A. n., Kueht, M. L., Fishbein, T. M., Markovic, D. n., Busuttil, R. W., Agopian, V. G. 2020

    Abstract

    The Organ Procurement and Transplantation Network recently approved liver transplant (LT) prioritization for patients with hepatocellular carcinoma (HCC) beyond Milan Criteria (MC) who are downstaged (DS) with locoregional therapy (LRT). We evaluated post-LT outcomes, predictors of downstaging, and the impact of LRT in beyond-MC HCC patients from the US Multicenter HCC Transplant Consortium (20 centers, 2002-2013). Clinicopathologic characteristics, overall survival (OS), recurrence-free survival (RFS), and HCC recurrence (HCC-R) were compared between patients within MC (n=3,570) and beyond MC (n=789) who were downstaged (DS, n=465), treated with LRT and not downstaged (LRT-NoDS, n=242), or untreated (NoLRT-NoDS, n=82). Five-year post-LT OS and RFS was higher in MC (71.3% and 68.2%) compared to DS (64.3% and 59.5%), and lowest in NoDS (n=324; 60.2% and 53.8%; overall P<0.001). DS patients had superior RFS (60% vs 54%,P=0.043) and lower 5-year HCC-R (18% vs 32%,P<0.001) compared to NoDS, with further stratification by maximum radiologic tumor diameter (5-year HCC-R of 15.5% in DS/< 5cm and 39.1% in NoDS/>5cm,P<0.001). Multivariate predictors of downstaging included alpha-fetoprotein response to LRT, pathologic tumor number and size, and wait time >12 months. LRT-NoDS had greater HCC-R compared to NoLRT-NoDS (34.1% vs 26.1%,P<0.001), even after controlling for clinicopathologic variables (HR=2.33,P<0.001) and inverse probability of treatment weighted propensity matching (HR=1.82,P<0.001). Conclusion In LT recipients with HCC presenting beyond MC, successful downstaging is predicted by wait time, alpha-fetoprotein response to LRT, and tumor burden, and results in excellent post-LT outcomes, justifying expansion of LT criteria. In LRT-NoDS patients, higher HCC-R compared to NoLRT-NoDS cannot be explained by clinicopathologic differences, suggesting a potentially aggravating role of LRT in patients with poor tumor biology that warrants further investigation.

    View details for DOI 10.1002/hep.31210

    View details for PubMedID 32124453

  • The Role of Desensitization in Kidney Paired Donation CURRENT TRANSPLANTATION REPORTS Pham, T., Lee, L., Melcher, M. L. 2019; 6 (4): 294-299
  • THE ROLE OF LOCOREGIONAL THERAPY (LRT), POST LRT IMAGING, AND EXPLANT PATHOLOGY AS PREDICTORS OF HEPATOCELLULAR CARCINOMA (HCC) RECURRENCE POST ORTHOTOPIC LIVER TRANSPLANT (OLT) Prabhakar, V., Dhanasekaran, R., Arjunan, V., Tulu, Z., Ahmed, A., Daugherty, T., Kumari, R., Patel, B., Kim, W., Goel, A., Esquivel, C. O., Concepcion, W., Melcher, M., Bonham, C., Gallo, A., Kwo, P. WILEY. 2019: 691A–692A
  • Health Care Utilization and Mortality after Emergency General Surgery in Patients with Underlying Liver Disease: A National Perspective Tennakoon, L., Concepcion, W., Melcher, M. L., Spain, D. A., Knowlton, L. M. ELSEVIER SCIENCE INC. 2019: E139
  • Matching Kidneys with Priority in Kidney Exchange Programs. Medical decision making : an international journal of the Society for Medical Decision Making Liu, W., Melcher, M. L. 2019: 272989X19849457

    Abstract

    Kidney exchanges were developed to match kidney failure patients with willing but incompatible donors to other donor-patient pairs. Finding a match in a large candidate pool can be modeled as an integer program. However, these exchanges accumulate participants with characteristics that increase the difficulty of finding a match and, therefore, increase patients' waiting time. Therefore, we sought to fine-tune the formulation of the integer program by more accurately assigning priorities to patients based on their difficulty of matching. We provide a detailed formulation of prioritized kidney exchange and propose a novel prioritization algorithm. Our approach takes advantage of the global knowledge of the donor-patient compatibility within a pool of pairs and calculates an iterative, paired match power (iPMP) to represent the donor-patient pairs' abilities to match. Monte Carlo simulation shows that an algorithm using the iPMP reduces the waiting time more than using paired match power (PMP) for the difficult-to-match pairs with hazard ratios of 1.3480 and 1.1100, respectively. Thus, the iPMP may be a more accurate assessment of the difficulty of matching a pair in a pool than PMP is, and its use may improve matching algorithms being used to match donors and recipients.

    View details for DOI 10.1177/0272989X19849457

    View details for PubMedID 31142192

  • Liver transplantation for hepatitis C virus (HCV) non-viremic recipients with HCV viremic donors AMERICAN JOURNAL OF TRANSPLANTATION Kwong, A. J., Wall, A., Melcher, M., Wang, U., Ahmed, A., Subramanian, A., Kwo, P. Y. 2019; 19 (5): 1380–87

    View details for DOI 10.1111/ajt.15162

    View details for Web of Science ID 000471342300016

  • Using Liver Transplant (LT) Data And Analytics to Improve Program Clinical and Financial Performance. Bonham, A., Tulu, Z., Concepcion, W., Gallo, A., Melcher, M., Kwo, P., Ahmed, A., Esquivel, C. WILEY. 2019: 583–84
  • Increasing the Number of Liver Ttransplants through Active Review of Offers Turned Down. Melcher, M. L., Bonham, C. A., Gallo, A., Concepcion, W., Jacobson, I., Esquivel, C. O. WILEY. 2019: 995–96
  • Reducing the Burden of Fellowship Interviews Reply JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Melcher, M. L., Ashlagi, I., Wapnir, I. 2019; 321 (11): 1107
  • Living Kidney Donation: Strategies to Increase the Donor Pool. The Surgical clinics of North America Lee, L., Pham, T. A., Melcher, M. L. 2019; 99 (1): 37–47

    Abstract

    End-stage renal disease (ESRD) is a significant health care burden. Although kidney transplantation is the optimal treatment modality, less than 25% of waiting list patients are transplanted because of organ shortage. Living kidney donation can lead to better recipient and graft survival and increase the number of donors. Not all ESRD patients have potential living donors, and not all living donors are a compatible match to recipients. Kidney paired exchanges allow incompatible pairs to identify compatible living donors for living donor kidney transplants for multiple recipients. Innovative modifications of kidney paired donation can increase the number of kidney transplants, with excellent outcomes.

    View details for PubMedID 30471740

  • Pathologic Response to Pretransplant Locoregional Therapy is Predictive of Patient Outcome After Liver Transplantation for Hepatocellular Carcinoma: Analysis From the US Multicenter HCC Transplant Consortium. Annals of surgery DiNorcia, J. n., Florman, S. S., Haydel, B. n., Tabrizian, P. n., Ruiz, R. M., Klintmalm, G. B., Senguttuvan, S. n., Lee, D. D., Taner, C. B., Verna, E. C., Halazun, K. J., Hoteit, M. n., Levine, M. H., Chapman, W. C., Vachharajani, N. n., Aucejo, F. n., Nguyen, M. H., Melcher, M. L., Tevar, A. D., Humar, A. n., Mobley, C. n., Ghobrial, M. n., Nydam, T. L., Amundsen, B. n., Markmann, J. F., Berumen, J. n., Hemming, A. W., Langnas, A. N., Carney, C. A., Sudan, D. L., Hong, J. C., Kim, J. n., Zimmerman, M. A., Rana, A. n., Kueht, M. L., Jones, C. M., Fishbein, T. M., Markovic, D. n., Busuttil, R. W., Agopian, V. G. 2019

    Abstract

    MINI: In a large, multicenter study of patients undergoing liver transplantation for hepatocellular carcinoma, complete pathologic response (cPR) to pretransplant locoregional therapy (LRT) portended significantly superior overall and recurrence-free survival. Multivariable predictors of cPR included age, sex, liver disease diagnosis, MELD, AFP, NLR, radiographic Milan status, and number of LRT treatments.The aim of the study was to determine the rate, predictors, and impact of complete pathologic response (cPR) to pretransplant locoregional therapy (LRT) in a large, multicenter cohort of hepatocellular carcinoma (HCC) patients undergoing liver transplantation (LT).LRT is used to mitigate waitlist dropout for patients with HCC awaiting LT. Degree of tumor necrosis found on explant has been associated with recurrence and overall survival, but has not been evaluated in a large, multicenter study.Comparisons were made among patients receiving pre-LT LRT with (n = 802) and without (n = 2637) cPR from the United States Multicenter HCC Transplant Consortium (UMHTC), and multivariable predictors of cPR were identified using logistic regression.Of 3439 patients, 802 (23%) had cPR on explant. Compared with patients without cPR, cPR patients were younger; had lower Model for End-stage Liver Disease (MELD) scores, AFP levels, and neutrophil-lymphocyte ratios (NLR); were more likely to have tumors within Milan criteria and fewer LRT treatments; and had significantly lower 1-, 3-, and 5-year incidence of post-LT recurrence (1.3%, 3.5%, and 5.2% vs 6.2%, 13.5%, and 16.4%; P < 0.001) and superior overall survival (92%, 84%, and 75% vs 90%, 78%, and 68%; P < 0.001). Multivariable predictors of cPR included age, sex, liver disease diagnosis, MELD, AFP, NLR, radiographic Milan status, and number of LRT treatments (C-statistic 0.67).For LT recipients with HCC receiving pretransplant LRT, achieving cPR portends significantly lower posttransplant recurrence and superior survival. Factors predicting cPR are identified, which may help prioritize patients and guide LRT strategies to optimize posttransplant cancer outcomes.

    View details for PubMedID 30870180

  • Career Goals, Salary Expectations, and Salary Negotiation Among Male and Female General Surgery Residents. JAMA surgery Gray, K. n., Neville, A. n., Kaji, A. H., Wolfe, M. n., Calhoun, K. n., Amersi, F. n., Donahue, T. n., Arnell, T. n., Jarman, B. n., Inaba, K. n., Melcher, M. n., Morris, J. B., Smith, B. n., Reeves, M. n., Gauvin, J. n., Salcedo, E. S., Sidwell, R. n., Murayama, K. n., Damewood, R. n., Poola, V. P., Dent, D. n., de Virgilio, C. n. 2019

    Abstract

    In general surgery, women earn less money and hold fewer leadership positions compared with their male counterparts.To assess whether differences exist between the perspectives of male and female general surgery residents on future career goals, salary expectations, and salary negotiation that may contribute to disparity later in their careers.This study was based on an anonymous and voluntary survey sent to 19 US general surgery programs. A total of 606 categorical residents at general surgery programs across the United States received the survey. Data were collected from August through September 2017 and analyzed from September through December 2017.Comparison of responses between men and women to detect any differences in career goals, salary expectation, and perspectives toward salary negotiation at a resident level.A total of 427 residents (70.3%) responded, and 407 responses (230 male [58.5%]; mean age, 30.0 years [95% CI, 29.8-30.4 years]) were complete. When asked about salary expectation, female residents had lower expectations compared with men in minimum starting salary ($249 502 [95% CI, $236 815-$262 190] vs $267 700 [95% CI, $258 964-$276 437]; P = .003) and in ideal starting salary ($334 709 [95% CI, $318 431-$350 987] vs $364 663 [95% CI, $351 612-$377 715]; P < .001). Women also had less favorable opinions about salary negotiation. They were less likely to believe they had the tools to negotiate (33 of 177 [18.6%] vs 73 of 230 [31.7%]; P = .03) and were less likely to pursue other job offers as an aid in negotiating a higher salary (124 of 177 [70.1%] vs 190 of 230 [82.6%]; P = .01). Female residents were also less likely to be married (61 of 177 [34.5%] vs 116 of 230 [50.4%]; P = .001), were less likely to have children (25 of 177 [14.1%] vs 57 of 230 [24.8%]; P = .008), and believed they would have more responsibility at home than their significant other (77 of 177 [43.5%] vs 35 of 230 [15.2%]; P < .001). Men and women anticipated working the same number of hours, expected to retire at the same age, and had similar interest in holding leadership positions, having academic careers, and pursuing research.This study found no difference in overall career goals between male and female residents; however, female residents' salary expectations were lower, and they viewed salary negotiation less favorably. Given the current gender disparities in salary and leadership within surgery, strategies are needed to help remedy this inequity.

    View details for DOI 10.1001/jamasurg.2019.2879

    View details for PubMedID 31461140

  • Factors associated with general surgery residents' decisions regarding fellowship and subspecialty stratified by burnout and quality of life. American journal of surgery McClintock, N. C., Gray, K. E., Neville, A. L., Kaji, A. H., Wolfe, M. M., Calhoun, K. E., Amersi, F. F., Donahue, T. R., Arnell, T. D., Jarman, B. T., Inaba, K. n., Melcher, M. L., Morris, J. B., Smith, B. R., Reeves, M. E., Gauvin, J. M., Salcedo, E. S., Sidwell, R. A., Dent, D. L., Murayama, K. M., Damewood, R. B., Poola, V. P., de Virgilio, C. M. 2019

    Abstract

    Although most surgery residents pursue fellowships, data regarding those decisions are limited. This study describes associations with interest in fellowship and specific subspecialties.Anonymous surveys were distributed to 607 surgery residents at 19 US programs. Subspecialties were stratified by levels of burnout and quality of life using data from recent studies.407 (67%) residents responded. 372 (91.4%) planned to pursue fellowship. Fellowship interest was lower among residents who attended independent or small programs, were married, or had children. Residents who received AOA honors or were married were less likely to choose high burnout subspecialties (trauma/vascular). Residents with children were less likely to choose low quality of life subspecialties (trauma/transplant/cardiothoracic).Surgery residents' interest in fellowship and specific subspecialties are associated with program type and size, AOA status, marital status, and having children. Variability in burnout and quality of life between subspecialties may affect residents' decisions.

    View details for DOI 10.1016/j.amjsurg.2019.08.003

    View details for PubMedID 31421896

  • Predicting skin cancer in organ transplant recipients: Development of the SUNTRAC screening tool using data from a multi-center cohort study. Transplant international : official journal of the European Society for Organ Transplantation Jambusaria-Pahlajani, A. n., Crow, L. D., Lowenstein, S. n., Garrett, G. L., Melcher, M. L., Chan, A. W., Boscardin, J. n., Arron, S. T. 2019

    Abstract

    Skin cancer is a common post-transplant complication. In this study, the Skin and Ultraviolet Neoplasia Trasnplant Risk Assessment Calculator (SUNTRAC) was developed to stratify patients into risk groups for post-transplant skin cancer.Data for this study were obtained from the Transplant Skin Cancer Network (TSCN), which conducted a multicenter study across 26 transplant centers in the United States. In total, 6340 patients, transplanted from 2003 to 2008, were included. Weighted point values were assigned for each risk factor based on beta coefficients from multivariable modeling: white race (9 points), pre-transplant history of skin cancer (6 points), age ≥ 50 years (4 points), male sex (2 points), and thoracic transplant (1 point).Good prognostic discrimination (optimism-corrected c statistic of 0.74) occurred with a 4-tier system: 0-6 points indicating Low Risk, 7-13 points indicating Medium Risk,14-17 points indicating High Risk,and 18-22 points indicating Very High Risk. The 5 year cumulative incidence of development of skin cancer was 1.01%, 6.15%, 15.14%, and 44.75%, for Low, Medium, High, and Very High SUNTRAC categories, respectively.Based on the skin cancer risk in different groups, the authors propose skin cancer screening guidelines based on this risk model. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1111/tri.13493

    View details for PubMedID 31423648

  • Microvascular Free Flaps as the Vascularized Foundation for Hepatic Tissue Engineering Than, P., Davis, C., Rustad, K., Mittermiller, P., Findlay, M., Liu, W., Whittam, A., Le, T., Khong, S., Ma, K., Melcher, M., Melcher, M., Gurtner, G. WILEY. 2019: 21
  • Underrepresented Minorities are Underrepresented Among General Surgery Applicants Selected to Interview. Journal of surgical education Jarman, B. T., Kallies, K. J., Joshi, A. R., Smink, D. S., Sarosi, G. A., Chang, L. n., Green, J. M., Greenberg, J. A., Melcher, M. L., Nfonsam, V. n., Ramirez, L. D., Borgert, A. J., Whiting, J. n. 2019

    Abstract

    Diversity is an ill-defined entity in general surgery training. The Accreditation Council for Graduate Medical Education recently proposed new common program requirements including verbiage requiring diversity in residency. "Recruiting" for diversity can be challenging within the constraints of geographic preference, type of program, and applicant qualifications. In addition, the Match process adds further uncertainty. We sought to study the self-identified racial/ethnic distribution of general surgery applicants to better ascertain the characteristics of underrepresented minorities (URM) within the general surgery applicant pool.Program-specific data from the Electronic Residency Application Service was collated for the 2018 medical student application cycle. Data were abstracted for all participating programs' applicants and those selected to interview. Applicants who did not enter a self-identified race/ethnicity were excluded from analysis. URM were defined as those identifying as Black/African American, Hispanic/Latino/of Spanish origin, American Indian/Alaskan Native, or Native Hawaiian/Pacific Islander-Samoan. Appropriate statistical analyses were accomplished.Ten general surgery residency programs-5 independent programs and 5 university programs.Residency applicants to the participating general surgery residency programs.Ten surgery residency programs received 10,312 applications from 3192 unique applicants. Seven hundred and seventy-eight applications did not include a self-identified race/ethnicity and were excluded from analysis. The racial/ethnic makeup of applicants in this study cohort was similar to that from 2017 to 2018 Electronic Residency Application Service data of 4262 total applicants to categorical general surgery. Programs received a median of 1085 (range: 485-1264) applications each and altogether selected 617 unique applicants for interviews. Overall, 2148 applicants graduated from US medical schools, and of those, 595 (28%) were offered interviews. The mean age of applicants was 28.8 ± 3.8 years and 1316 (41%) were female. Hispanic/Latino/of Spanish origin, Black, and American Indian/Alaskan Native/Hawaiian/Pacific Islander-Samoan applicants constituted 12%, 8%, and 1% of total applicants, but only 8%, 6%, and 1% of those selected for interview. Overall, 29% of applicants had United States Medical Licensing Examination (USMLE) Step 1 scores ≤220; 37 (6%) of those selected for interviews had a USMLE Step 1 score of ≤220. A higher proportion of URM applicants had USMLE scores ≤220 compared to White and Asian applicants. Non-white self-identification was a significant independent predictor of a lower likelihood of interview selection. Female gender, USMLE Step 1 score >220, and graduating from a US medical school were associated with an increased likelihood of being selected to interview.URM applicants represented a disproportionately smaller percentage of applicants selected for interview. USMLE Step 1 scores were lower among the URM applicants. Training programs that use discreet USMLE cutoffs are likely excluding URM at a higher rate than their non-URM applicants. Attempts to recruit racially/ethnically diverse trainees should include program-level analysis to determine disparities and a focused strategy to interview applicants who might be overlooked by conventional screening tools.

    View details for DOI 10.1016/j.jsurg.2019.05.018

    View details for PubMedID 31175064

  • May the Interview Be With You: Signal Your Preferences. Journal of graduate medical education Melcher, M. L., Wapnir, I. n., Ashlagi, I. n. 2019; 11 (1): 39–40

    View details for DOI 10.4300/JGME-D-19-00002.1

    View details for PubMedID 30805095

    View details for PubMedCentralID PMC6375331

  • Preparation for the Diversity of 21st Century Surgical Leadership Opportunities Demands Diverse Opportunities for "Professional Development'' ANNALS OF SURGERY Melcher, M. L., Greco, R. S., Krummel, T. M., Morris, A. M., Hawn, M. T. 2018; 268 (6): E52–E53
  • Liver Transplantation for HCV Non-Viremic Recipients with HCV Viremic Donors. American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons Kwong, A. J., Wall, A., Melcher, M., Wang, U., Ahmed, A., Subramanian, A., Kwo, P. Y. 2018

    Abstract

    In the context of organ shortage, the opioid epidemic, and effective direct-acting antiviral (DAA) therapy for hepatitis C (HCV), more HCV-infected donor organs may be used for liver transplantation. Current data regarding outcomes after donor-derived HCV in previously non-viremic liver transplant recipients are limited. Clinical data for adult liver transplant recipients with donor-derived HCV infection from March 2017 to January 2018 at our institution were extracted from the medical record. Ten patients received livers from donors known to be infected with HCV based on positive nucleic acid testing (NAT). Seven had a prior diagnosis of HCV and were treated before liver transplantation. All recipients were non-viremic at the time of transplantation. All 10 recipients derived hepatitis C infection from their donor and achieved sustained virologic response at 12 weeks post-treatment (SVR-12) with DAA-based regimens, with a median time from transplant to treatment initiation of 43 days (IQR 20-59). There have been no instances of graft loss or death, with median follow-up of 380 days (IQR 263-434) post-transplant. Transplantation of HCV-viremic livers into non-viremic recipients results in acceptable short-term outcomes. Such strategies may be used to expand the donor pool and increase access to liver transplantation. This article is protected by copyright. All rights reserved.

    View details for PubMedID 30378723

  • Matching for Fellowship Interviews. JAMA Melcher, M. L., Ashlagi, I., Wapnir, I. 2018; 320 (16): 1639-1640

    View details for DOI 10.1001/jama.2018.13080

    View details for PubMedID 30422279

  • Matching for Fellowship Interviews JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Melcher, M. L., Ashlagi, I., Wapnir, I. 2018; 320 (16): 1639–40
  • Antiviral Therapy for Donor-Derived Hepatitis C Virus Infection after Solid Organ Transplantation. Kwong, A., Wall, A., Melcher, M., Wang, U., Ahmed, A., Khush, K., Subramanian, A., Tan, J., Kwo, P. WILEY. 2018: 464
  • Pragmatic Surgical Risk Assessment Criteria in Critically Ill Patients Prior to Liver Transplantation. Bonham, C., Tulu, Z., Melcher, M., Kwo, P., Concepcion, W., Ahmed, A., Esquivel, C. WILEY. 2018: 849–50
  • Structured Reporting of Multiphasic CT for Hepatocellular Carcinoma: Effect on Staging and Suitability for Transplant. AJR. American journal of roentgenology Poullos, P. D., Tseng, J. J., Melcher, M. L., Concepcion, W. n., Loening, A. M., Rosenberg, J. n., Willmann, J. K. 2018: 1–9

    Abstract

    The purpose of this study is to evaluate whether use of a standardized radiology report template would improve the ability of liver transplant surgeons to diagnose stage T2 hepatocellular carcinoma (HCC) and determine patient suitability to undergo orthotopic liver transplant (OLT).In this retrospective study, a standardized template was devised, and its use was mandated for reporting of liver CT findings for patients with cirrhosis and HCC. Two surgeons analyzed 200 reports (100 before and 100 after template implementation) for descriptions of cirrhosis, portal hypertension, lesion enhancement characteristics, tumor thrombus, portal and superior mesenteric vein patency, and Organ Procurement Transplantation Network (OPTN) class. Ability to determine Milan criteria and surgeon satisfaction were also assessed. Data obtained before and after template implementation were statistically analyzed using the Cochran-Mantel-Haenszel test.Template implementation increased the percentage of reports documenting the presence or absence of portal hypertension (74% to 88% for surgeon 1 and 86% to 87% for surgeon 2; p = 0.042); lesion number (76% to 88% for surgeon 2 [no change for surgeon 1]; p = 0.038), size (95% to 96% for surgeon 1 and 82% to 93% for surgeon 2; p = 0.03), and enhancement (93% to 94% for surgeon 1 and 80% to 91% for surgeon 2; p = 0.049); presence of tumor thrombus (10% to 57% for surgeon 1 and 31% to 63% for surgeon 2; p < 0.001); and OPTN class (8% to 82% for surgeon 1 and 2% to 81% for surgeon 2; p < 0.001). The surgeons were significantly more able to determine the presence of T2 disease and qualification for exception points after implementation of the template (increasing from 80% to 94%; p = 0.025). Satisfaction with reports also improved (p < 0.0001).The reporting template improved determination of patient suitability to undergo transplant according to the Milan criteria.

    View details for PubMedID 29470153

  • Socioeconomic Status in Non-directed and Voucher-based Living Kidney Donation. European urology focus Nassiri, N., Baskin, A. S., Herbert, L. K., Connor, S., Pham, T., Melcher, M. L., Sinacore, J., Veale, J. L. 2018; 4 (2): 185–89

    Abstract

    BACKGROUND: Little has been reported about the socioeconomic status (SES) and demographics of non-directed (altruistic) and voucher-based donation.OBJECTIVE: To analyze common characteristics amongst altruistic donors in order to promote non-directed and voucher-based donation.DESIGN, SETTING, AND PARTICIPANTS: Information regarding altruistic donations from 2008 to 2015 and voucher-based donors was obtained from the National Kidney Registry.OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: An SES index, created and validated by the Agency for Healthcare Research and Quality (AHRQ), was created by geocoding the donor's zip code and linking it to seven publicly available SES variables found in the 2010 United States Census data.RESULTS AND LIMITATIONS: In total, 267 non-directed and 3 voucher-based donations were identified. Non-directed donors were predominantly female (58%), with an average age of 45.6 yr (range, 21-72). The mean SES index score was 55.6 (SD=3.2), which corresponds to the 77th percentile of 1.5 million MediCare beneficiaries as reported by the AHRQ in 2008. Voucher-based donors were Caucasian males of high SES. The study was limited by the number of voucher-based donations.CONCLUSIONS: Non-directed and voucher-based donors are in the upper end of the economic spectrum. The voucher-based program has built within it the inherent capacity to remove disincentives to donation, which currently limit altruistic donation.PATIENT SUMMARY: We wanted to determine what types of people donated their kidneys altruistically, so that we could understand how to motivate more people to donate their kidneys. The voucher-based program was recently started and is a promising tool to motivate many people to donate kidneys by removing major disincentives to donation.

    View details for PubMedID 30122635

  • A Multicenter Prospective Comparison of the Accreditation Council for Graduate Medical Education Milestones: Clinical Competency Committee vs. Resident Self-Assessment. Journal of surgical education Watson, R. S., Borgert, A. J., O Heron, C. T., Kallies, K. J., Sidwell, R. A., Mellinger, J. D., Joshi, A. R., Galante, J. M., Chambers, L. W., Morris, J. B., Josloff, R. K., Melcher, M. L., Fuhrman, G. M., Terhune, K. P., Chang, L., Ferguson, E. M., Auyang, E. D., Patel, K. R., Jarman, B. T. 2017; 74 (6): e8–e14

    Abstract

    OBJECTIVE: The Accreditation Council for Graduate Medical Education requires accredited residency programs to implement competency-based assessments of medical trainees based upon nationally established Milestones. Clinical competency committees (CCC) are required to prepare biannual reports using the Milestones and ensure reporting to the Accreditation Council for Graduate Medical Education. Previous research demonstrated a strong correlation between CCC and resident scores on the Milestones at 1 institution. We sought to evaluate a national sampling of general surgery residency programs and hypothesized that CCC and resident assessments are similar.DESIGN: Details regarding the makeup and process of each CCC were obtained. Major disparities were defined as an absolute mean difference of ≥0.5 on the 4-point scale. A negative assessment disparity indicated that the residents evaluated themselves at a lower level than did the CCC. Statistical analysis included Wilcoxon rank sum and Sign tests.SETTING: CCCs and categorical general surgery residents from 15 residency programs completed the Milestones document independently during the spring of 2016.RESULTS: Overall, 334 residents were included; 44 (13%) and 43 (13%) residents scored themselves ≥0.5 points higher and lower than the CCC, respectively. Female residents scored themselves a mean of 0.08 points lower, and male residents scored themselves a mean of 0.03 points higher than the CCC. Median assessment differences for postgraduate year (PGY) 1-5 were 0.03 (range: -0.94 to 1.28), -0.11 (range: -1.22 to 1.22), -0.08 (range: -1.28 to 0.81), 0.02 (range: -0.91 to 1.00), and -0.19 (range: -1.16 to 0.50), respectively. Residents in university vs. independent programs had higher rates of negative assessment differences in medical knowledge (15% vs. 6%; P = 0.015), patient care (17% vs. 5%; P = 0.002), professionalism (23% vs. 14%; P = 0.013), and system-based practice (18% vs. 9%; P = 0.031) competencies. Major assessment disparities by sex or PGY were similar among individual competencies.CONCLUSIONS: Surgery residents in this national cohort demonstrated self-awareness when compared to assessments by their respective CCCs. This was independent of program type, sex, or level of training. PGY 5 residents, female residents, and those from university programs consistently rated themselves lower than the CCC, but these were not major disparities and the significance of this is unclear.

    View details for PubMedID 28666959

  • Preparation for the Diversity of 21st Century Surgical Leadership Opportunities Demands Diverse Opportunities for "Professional Development". Annals of surgery Melcher, M. L., Greco, R. S., Krummel, T. M., Morris, A. M., Hawn, M. T. 2017

    View details for PubMedID 29064907

  • Recurrence-Free Survival in Liver Transplant Recipients with Non-Alcoholic Fatty Liver Disease-Related Hepatocellular Carcinoma: Results from the US Multicenter HCC Transplant Consortium Verna, E. C., Abdelmessih, R. M., Florman, S. S., Haydel, B. M., Ruiz, R., Klintmalm, G., Lee, D. D., Taner, B., Hoteit, M. A., Halazun, K. J., Tevar, A. D., Humar, A., Chapman, W. C., Vachharajani, N., Aucejo, F. N., Melcher, M. L., Nguyen, M. H., Nydam, T. L., Amundsen, B., Markmann, J. F., Mobley, C., Ghobrial, R. M., Langnas, A. N., Carney, C., Berumen, J., Hemming, A. W., Sudan, D., Hong, J. C., Kim, J., Zimmerman, M. A., Rana, A., Kueht, M. L., Jones, C., Fishbein, T., Busuttil, R. W., Agopian, V. WILEY. 2017: 900A–901A
  • Evaluating the Impact of Blinded vs Non-Blinded Interviews on the General Surgery Resident Selection Process Shipper, E. S., Forrester, J., Lau, J. N., Melcher, M. L. ELSEVIER SCIENCE INC. 2017: S174–S175
  • Advanced Donation Programs and Deceased Donor Initiated Chains - 2 Innovations in Kidney Paired Donation. Transplantation Wall, A. E., Veale, J. L., Melcher, M. L. 2017

    Abstract

    Kidney paired donation strategies have facilitated compatible living-donor kidney transplants for end stage renal disease patients with willing but incompatible living donors. Success has inspired further innovations that expand opportunities for kidney-paired donation. Two such innovations are the advanced donation strategy in which a donor provides a kidney before their recipient is matched, or even in need of, a kidney transplant, and deceased donor initiated chains in which chains are started with deceased donors rather than altruistic living donors. While these innovations may expand kidney paired donation, they raise several ethical issues. Specific concerns raised by advanced donation include the management of uncertainty, the extent of donor and recipient consent, the scope of the obligation that the organization has to the kidney exchange paired recipient, the naming of alternative recipients, and the potential to unfairly advantage the recipient. Use of deceased donors for chain initiating kidneys raises ethical issues concerning the consent process for each involved party, the prioritization of deceased donor kidneys, the allocation of chain ending kidneys, and the value of a living donor kidney versus a deceased donor kidney. We outline each ethical issue and discuss how it can be conceptualized and managed so that these kidney paired donation innovations programs are ultimately successful.

    View details for DOI 10.1097/TP.0000000000001838

    View details for PubMedID 28574902

  • A multi-institution analysis of general surgery resident peer-reviewed publication trends JOURNAL OF SURGICAL RESEARCH Forrester, J. D., Ansari, P., Are, C., Auyang, E., Galante, J. M., Jarman, B. T., Smith, B. R., Watkins, A. C., Melcher, M. L. 2017; 210: 92-98

    Abstract

    The process of taking a research project from conception to publication is one way to encourage surgeons to communicate hypothesis, critically assess literature and data, and defend research conclusions to a broad audience. The goal of this study was to define surgery resident publishing epidemiology and identify characteristics of residents and residency programs that might predict increased publication productivity.A survey was administered to eight general surgery residency programs to collect residency and resident variables from 1993-2013. The primary endpoint was the number of first-author publications produced per resident. Secondary endpoints included clinical setting at which the former resident was practicing, fellowship pursued, and manuscript quality.Between 1993 and 2013, 676 residents graduated, median age was 33 years (range: 29-43 years) and 182 (27%) were female. Three hundred and sixty-six (54%) residents produced 1229 first-author publications. Of these, 112 (31%) residents produced one manuscript, 125 (34%) produced two-three manuscripts, 107 (29%) produced four-nine manuscripts, and 22 (6%) produced 10 or more manuscripts. Publishing ≥1 manuscript in residency was associated with a 1.5 (P = 0.01) increased odds of having attended a top-tier research institution for medical school and a 2.3 (P < 0.001) increased odds of having dedicated research years incorporated into residency. Surgeons practicing at academic centers had 1.7 (P = 0.003) greater odds of having attended top-tier medical schools, and 1.5 (P = 0.02) greater odds of publishing during residency.Additional research directed at identifying interventions promoting resident publishing and scholastic achievement should benefit all surgery training programs looking to cultivate the next generation of critically thinking surgeons.

    View details for DOI 10.1016/j.jss.2016.11.015

    View details for PubMedID 28457346

  • SOCIAL ECONOMIC STATUS AND DEMOGRAPHIC DATA OF NON-DIRECTED LIVING KIDNEY DONORS Baskin, A., Kwan, L., Waterman, A., Connor, S., Melcher, M., Veale, J. ELSEVIER SCIENCE INC. 2017: E391
  • Impact of Pretransplant Bridging Locoregional Therapy for Patients With Hepatocellular Carcinoma Within Milan Criteria Undergoing Liver Transplantation: Analysis of 3601 Patients from the US Multicenter HCC Transplant Consortium. Annals of surgery Agopian, V. G., Harlander-Locke, M. P., Ruiz, R. M., Klintmalm, G. B., Senguttuvan, S. n., Florman, S. S., Haydel, B. n., Hoteit, M. n., Levine, M. H., Lee, D. D., Taner, C. B., Verna, E. C., Halazun, K. J., Abdelmessih, R. n., Tevar, A. D., Humar, A. n., Aucejo, F. n., Chapman, W. C., Vachharajani, N. n., Nguyen, M. H., Melcher, M. L., Nydam, T. L., Mobley, C. n., Ghobrial, R. M., Amundsen, B. n., Markmann, J. F., Langnas, A. N., Carney, C. A., Berumen, J. n., Hemming, A. W., Sudan, D. L., Hong, J. C., Kim, J. n., Zimmerman, M. A., Rana, A. n., Kueht, M. L., Jones, C. M., Fishbein, T. M., Busuttil, R. W. 2017

    Abstract

    To evaluate the effect of pretransplant bridging locoregional therapy (LRT) on hepatocellular carcinoma (HCC) recurrence and survival after liver transplantation (LT) in patients meeting Milan criteria (MC).Pre-LT LRT mitigates tumor progression and waitlist dropout in HCC patients within MC, but data on its impact on post-LT recurrence and survival remain limited.Recurrence-free survival and post-LT recurrence were compared among 3601 MC patients with and without bridging LRT utilizing competing risk Cox regression in consecutive patients from 20 US centers (2002-2013).Compared with 747 LT recipients not receiving LRT, 2854 receiving LRT had similar 1, 3, and 5-year recurrence-free survival (89%, 77%, 68% vs 85%, 75%, 68%; P = 0.490) and 5-year post-LT recurrence (11.2% vs 10.1%; P = 0.474). Increasing LRT number [3 LRTs: hazard ratio (HR) 2.1, P < 0.001; 4+ LRTs: HR 2.5, P < 0.001), and unfavorable waitlist alphafetorotein trend significantly predicted post-LT recurrence, whereas LRT modality did not. Treated patients achieving complete pathologic response (cPR) had superior 5-year RFS (72%) and lower post-LT recurrence (HR 0.52, P < 0.001) compared with both untreated patients (69%; P = 0.010; HR 1.0) and treated patients not achieving cPR (67%; P = 0.010; HR 1.31, P = 0.039), who demonstrated increased recurrence compared with untreated patients in multivariate analysis controlling for pretransplant and pathologic factors (HR 1.32, P = 0.044).Bridging LRT in HCC patients within MC does not improve post-LT survival or HCC recurrence in the majority of patients who fail to achieve cPR. The need for increasing LRT treatments and lack of alphafetoprotein response to LRT independently predict post-LT recurrence, serving as a surrogate for underlying tumor biology which can be utilized for prioritization of HCC LT candidates.

    View details for PubMedID 28654545

  • Pilot evaluation of the Computer-Based Assessment for Sampling Personal Characteristics test. The Journal of surgical research Shipper, E. S., Mazer, L. M., Merrell, S. B., Lin, D. T., Lau, J. N., Melcher, M. L. 2017; 215: 211–18

    Abstract

    High attrition rates hint at deficiencies in the resident selection process. The evaluation of personal characteristics representative of success is difficult. Here, we evaluate a novel tool for assessing personal characteristics.To evaluate feasibility, we used an anonymous voluntary survey questionnaire offered to study participants before and after contact with the CASPer test. To evaluate the CASPer test as a predictor of success, we compared CASPer test assessments of personal characteristics versus traditional faculty assessment of personal characteristics with applicant rank list position.All applicants (n = 77) attending an in-person interview for general surgery residency, and all faculty interviewers (n = 34) who reviewed these applications were invited to participate. Among applicants, 84.4% of respondents (65 of 77) reported that a requirement to complete the CASPer test would have no bearing or would make them more likely to apply to the program (mean = 3.30, standard deviation = 0.96). Among the faculty, 62.5% respondents (10 of 16) reported that the same condition would have no bearing or would make applicants more likely to apply to the program (mean = 3.19, standard deviation = 1.33). The Spearman's rank-order correlation coefficients for the relationships between traditional faculty assessment of personal characteristics and applicant rank list position, and novel CASPer assessment of personal characteristics and applicant rank list position, were -0.45 (P = 0.033) and -0.41 (P = 0.055), respectively.The CASPer test may be feasibly implemented as component of the resident selection process, with the potential to predict applicant rank list position and improve the general surgery resident selection process.

    View details for PubMedID 28688650

  • Association of General Surgery Resident Remediation and Program Director Attitudes With Resident Attrition. JAMA surgery Schwed, A. C., Lee, S. L., Salcedo, E. S., Reeves, M. E., Inaba, K. n., Sidwell, R. A., Amersi, F. n., Are, C. n., Arnell, T. D., Damewood, R. B., Dent, D. L., Donahue, T. n., Gauvin, J. n., Hartranft, T. n., Jacobsen, G. R., Jarman, B. T., Melcher, M. L., Mellinger, J. D., Morris, J. B., Nehler, M. n., Smith, B. R., Wolfe, M. n., Kaji, A. H., de Virgilio, C. n. 2017

    Abstract

    Previous studies of resident attrition have variably included preliminary residents and likely overestimated categorical resident attrition. Whether program director attitudes affect attrition has been unclear.To determine whether program director attitudes are associated with resident attrition and to measure the categorical resident attrition rate.This multicenter study surveyed 21 US program directors in general surgery about their opinions regarding resident education and attrition. Data on total resident complement, demographic information, and annual attrition were collected from the program directors for the study period of July 1, 2010, to June 30, 2015. The general surgery programs were chosen on the basis of their geographic location, previous collaboration with some coauthors, prior work in surgical education and research, or a program director willing to participate. Only categorical surgical residents were included in the study; thus, program directors were specifically instructed to exclude any preliminary residents in their responses.Five-year attrition rates (2010-2011 to 2014-2015 academic years) as well as first-time pass rates on the General Surgery Qualifying Examination and General Surgery Certifying Examination of the American Board of Surgery (ABS) were collected. High- and low-attrition programs were compared.The 21 programs represented different geographic locations and 12 university-based, 3 university-affiliated, and 6 independent program types. Programs had a median (interquartile range [IQR]) number of 30 (20-48) categorical residents, and few of those residents were women (median [IQR], 12 [5-17]). Overall, 85 of 966 residents (8.8%) left training during the study period: 15 (17.6%) left after postgraduate year 1, 34 (40.0%) after postgraduate year 2, and 36 (42.4%) after postgraduate year 3 or later. Forty-four residents (51.8%) left general surgery for another surgical discipline, 21 (24.7%) transferred to a different surgery program, and 18 (21.2%) exited graduate medical education altogether. Each program had an annual attrition rate ranging from 0.73% to 6.0% (median [IQR], 2.5% [1.5%-3.4%]). Low-attrition programs were more likely than high-attrition programs to use resident remediation (21.0% vs 6.8%; P < .001). Median (IQR) Qualifying Examination pass rates (93% [90%-98%] vs 92% [86%-100%]; P = .92) and Certifying Examination pass rates (83% [68%-84%] vs 81% [71%-86%]; P = .47) were similar. Program directors at high-attrition programs were more likely than their counterparts at low-attrition programs to agree with this statement: "I feel that it is my responsibility as a program director to redirect residents who should not be surgeons."The overall 5-year attrition rate of 8.8% was significantly lower than previously reported. Program directors at low-attrition programs were more likely to use resident remediation. Variations in attrition may be explained by program director attitudes, although larger studies are needed to further define program factors affecting attrition.

    View details for PubMedID 28813585

  • Hospital readmissions following HLA-incompatible live donor kidney transplantation: A multi-center study. American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons Orandi, B. J., Luo, X. n., King, E. A., Garonzik-Wang, J. M., Bae, S. n., Montgomery, R. A., Stegall, M. D., Jordan, S. C., Oberholzer, J. n., Dunn, T. B., Ratner, L. E., Kapur, S. n., Pelletier, R. P., Roberts, J. P., Melcher, M. L., Singh, P. n., Sudan, D. L., Posner, M. P., El-Amm, J. M., Shapiro, R. n., Cooper, M. n., Lipkowitz, G. S., Rees, M. A., Marsh, C. L., Sankari, B. R., Gerber, D. A., Nelson, P. W., Wellen, J. n., Bozorgzadeh, A. n., Osama Gaber, A. n., Segev, D. L. 2017

    Abstract

    Thirty percent of kidney transplant recipients are readmitted in the first month posttransplantation. Those with donor-specific antibody requiring desensitization and incompatible live donor kidney transplantation (ILDKT) constitute a unique subpopulation that might be at higher readmission risk. Drawing on a 22-center cohort, 379 ILDKTs with Medicare primary insurance were matched to compatible transplant-matched controls and to waitlist-only matched controls on panel reactive antibody, age, blood group, renal replacement time, prior kidney transplantation, race, gender, diabetes, and transplant date/waitlisting date. Readmission risk was determined using multilevel, mixed-effects Poisson regression. In the first month, ILDKTs had a 1.28-fold higher readmission risk than compatible controls (95% confidence interval [CI] 1.13-1.46; P < .001). Risk peaked at 6-12 months (relative risk [RR] 1.67, 95% CI 1.49-1.87; P < .001), attenuating by 24-36 months (RR 1.24, 95% CI 1.10-1.40; P < .001). ILDKTs had a 5.86-fold higher readmission risk (95% CI 4.96-6.92; P < .001) in the first month compared to waitlist-only controls. At 12-24 (RR 0.85, 95% CI 0.77-0.95; P = .002) and 24-36 months (RR 0.74, 95% CI 0.66-0.84; P < .001), ILDKTs had a lower risk than waitlist-only controls. These findings of ILDKTs having a higher readmission risk than compatible controls, but a lower readmission risk after the first year than waitlist-only controls should be considered in regulatory/payment schemas and planning clinical care.

    View details for PubMedID 28834181

  • Effect of match-run frequencies on the number of transplants and waiting times in kidney exchange. American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons Ashlagi, I. n., Bingaman, A. n., Burq, M. n., Manshadi, V. n., Gamarnik, D. n., Murphey, C. n., Roth, A. E., Melcher, M. L., Rees, M. A. 2017

    Abstract

    Numerous kidney exchange (kidney paired donation [KPD]) registries in the United States have gradually shifted to high-frequency match-runs, raising the question of whether this harms the number of transplants. We conducted simulations using clinical data from 2 KPD registries-the Alliance for Paired Donation, which runs multihospital exchanges, and Methodist San Antonio, which runs single-center exchanges-to study how the frequency of match-runs impacts the number of transplants and the average waiting times. We simulate the options facing each of the 2 registries by repeated resampling from their historical pools of patient-donor pairs and nondirected donors, with arrival and departure rates corresponding to the historical data. We find that longer intervals between match-runs do not increase the total number of transplants, and that prioritizing highly sensitized patients is more effective than waiting longer between match-runs for transplanting highly sensitized patients. While we do not find that frequent match-runs result in fewer transplanted pairs, we do find that increasing arrival rates of new pairs improves both the fraction of transplanted pairs and waiting times.

    View details for PubMedID 29087017

  • Shipping Living Donor Kidneys and Transplant Recipient Outcomes. American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons Treat, E. n., Chow, E. K., Peipert, J. D., Waterman, A. n., Kwan, L. n., Massie, A. B., Thomas, A. G., Bowring, M. G., Leeser, D. n., Flechner, S. n., Melcher, M. L., Kapur, S. n., Segev, D. L., Veale, J. n. 2017

    Abstract

    Kidney paired donation (KPD) is an important tool to facilitate living donor kidney transplantation (LDKT). Concerns remain over prolonged cold ischemia times (CIT) associated with shipping kidneys long distances through KPD. We examined the association between CIT and delayed graft function (DGF), allograft survival, and patient survival for 1,267 shipped and 205 non-shipped/internal KPD LDKTs facilitated by the National Kidney Registry in the United States from 2008-2015, compared to 4,800 unrelated, non-shipped, non-KPD LDKTs. Shipped KPD recipients had a median CIT of 9.3 hours (range = 0.25 to 23.9 hours), compared to 1.0 hour for internal KPD transplants and 0.93 hours for non-KPD LDKTs. Each hour of CIT was associated with a 5% increased odds of DGF (adjusted odds ratio: 1.05, 95% CI: 1.02-1.09, p<0.01). However, there was not a significant association between CIT and all-cause graft failure (aHR: 1.01, 95% CI: 0.98-1.04, p=0.4), death-censored graft failure (aHR: 1.02, 95% CI: 0.98-1.06, p=0.4), or mortality (aHR 1.00, 95% CI: 0.96-1.04, p>0.9). This study of KPD-facilitated LDKTs found no evidence that long CIT is a concern for reduced graft or patient survival. Studies with longer follow-up are needed to refine our understanding of the safety of shipping donor kidneys through KPD. This article is protected by copyright. All rights reserved.

    View details for PubMedID 29165871

  • Kidney paired exchange and desensitization: Strategies to transplant the difficult to match kidney patients with living donors TRANSPLANTATION REVIEWS Pham, T. A., Lee, J. I., Melcher, M. L. 2017; 31 (1): 29-34

    Abstract

    With organs in short supply, only a limited number of kidney transplants can be performed a year. Live donor donation accounts for 1/3rd of all kidney transplants performed in the United States. Unfortunately, not every donor recipient pair is feasible because of Human leukocyte antigen (HLA) sensitization and ABO incompatibility. To overcome these barriers to transplant, strategies such as kidney paired donation (KPD) and desensitization have been developed. KPD is the exchange of donors between at least two incompatible donor-recipient pairs such that they are now compatible. Desensitization is the removal of circulating donor specific antibodies to prevent graft rejection. Regardless of the treatment strategy, highly sensitized patients whose calculated panel reactive antibody (cPRA) is ≥95% remain difficult to transplant with match rates as low as 15% in KPD pools. Desensitization has proved to be difficult in those with high antibody titers. A novel approach is the combination of both KPD and desensitization to facilitate compatible and successful transplantation. A highly sensitized patient can be paired with a better immunological match in the KPD pool and subsequently desensitized to a lesser degree. This article reviews the current progress in KPD and desensitization and their use as a combined therapy.

    View details for DOI 10.1016/j.trre.2017.01.003

    View details for PubMedID 28284304

  • The incremental cost of Incompatible Living Donor Kidney Transplant: A National Cohort Analysis. American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons Axelrod, D. n., Lentine, K. L., Schnitzler, M. A., Luo, X. n., Xiao, H. n., Orandi, B. J., Massie, A. n., Garonzik-Wang, J. n., Stegall, M. D., Jordan, S. C., Oberholzer, J. n., Dunn, T. B., Ratner, L. E., Kapur, S. n., Pelletier, R. P., Roberts, J. P., Melcher, M. L., Singh, P. n., Sudan, D. L., Posner, M. P., El-Amm, J. M., Shapiro, R. n., Cooper, M. n., Lipkowitz, G. S., Rees, M. A., Marsh, C. L., Sankari, B. R., Gerber, D. A., Nelson, P. W., Wellen, J. n., Bozorgzadeh, A. n., Gaber, A. O., Montgomery, R. A., Segev, D. L. 2017

    Abstract

    Incompatible living donor kidney transplant (ILDKT) has been established as an effective option for end stage renal disease (ESRD) patients with willing but HLA incompatible live donors, reducing mortality and improving quality of life. Depending upon antibody titer, ILDKT can require highly resource intensive procedure including intravenous immunoglobulin, plasma exchange and/or cell depleting antibody treatment as well as protocol biopsies and DSA testing. This study sought to compare the cost and Medicare reimbursement, exclusive of organ acquisition payment, for ILDKT recipients (N=926) with varying antibody titers to matched compatible transplants (N=2762) performed between 2002-2011. Data were assembled from a national cohort study of ILDKT and a unique dataset linking hospital cost accounting data, and Medicare claims. Overall, ILDKT transplants were 41% more expensive than their compatible counterparts ($151,024 vs. $106,636, p<.0001). The incremental cost varied by antibody titers: positive on Luminex assay but negative flow cytometric crossmatch 20% increase, positive flow cytometric crossmatch but negative cytotoxic crossmatch 26% increase, and positive cytotoxic crossmatch 39% increase (p<.0001 for all). ILDKT was associated with higher Medicare payments ($91,330 vs. $63,782 p<.0001), longer median length of stay (12.9 vs. 7.8 days), and greater outlier payments. In conclusion, ILDKT increases the cost of and payments for kidney transplant. This article is protected by copyright. All rights reserved.

    View details for PubMedID 28613436

  • HLA Matching Trumps Donor Age: Donor-Recipient Pairing Characteristics That Impact Long-Term Success in Living Donor Kidney Transplantation in the Era of Paired Kidney Exchange. Transplantation direct Milner, J., Melcher, M. L., Lee, B., Veale, J., Ronin, M., D'Alessandro, T., Hil, G., Fry, P. C., Shannon, P. W. 2016; 2 (7)

    Abstract

    We sought to identify donor characteristics influencing long-term graft survival, expressed by a novel measure, kidney life years (KLYs), in living donor kidney transplantation (LDKT).Cox and multiple regression analyses were applied to data from the Scientific Registry for Transplant Research from 1987 to 2015. Dependent variable was KLYs.Living donor kidney transplantation (129 273) were performed from 1987 to 2013 in the United States. To allow sufficient time to assess long-term results, outcomes of LDKTs between 1987 and 2001 were analyzed. After excluding cases where a patient died with a functioning graft (8301) or those missing HLA data (9), 40 371 cases were analyzed. Of 18 independent variables, the focus became the 4 variables that were the most statistically and clinically significant in that they are potentially modifiable in donor selection (P <0.0001; ie, HLA match points, donor sex, donor biological sibling and donor age). HLA match points had the strongest relationship with KLYs, was associated with the greatest tendency toward graft longevity on Cox regression, and had the largest increase in KLYs (2.0 year increase per 50 antigen Match Points) based on multiple regression.In cases when a patient has multiple potential donors, such as through paired exchange, graft life might be extended when a donor with favorable matching characteristics is selected.

    View details for PubMedID 27830179

  • Utilization of Deceased Donor Kidneys to Initiate Living Donor Chains AMERICAN JOURNAL OF TRANSPLANTATION Melcher, M. L., Roberts, J. P., Leichtman, A. B., Roth, A. E., Rees, M. A. 2016; 16 (5): 1367-1370

    Abstract

    We propose that some deceased donor (DD) kidneys be allocated to initiate nonsimultaneous extended altruistic donor chains of living donor (LD) kidney transplants to address, in part, the huge disparity between patients on the DD kidney waitlist and available donors. The use of DD kidneys for this purpose would benefit waitlisted candidates in that most patients enrolled in kidney paired donation (KPD) systems are also waitlisted for a DD kidney transplant, and receiving a kidney through the mechanism of KPD will decrease pressure on the DD pool. In addition, a LD kidney usually provides survival potential equal or superior to that of DD kidneys. If KPD chains that are initiated by a DD can end in a donation of an LD kidney to a candidate on the DD waitlist, the quality of the kidney allocated to a waitlisted patient is likely to be improved. We hypothesize that a pilot program would show a positive impact on patients of all ethnicities and blood types.

    View details for DOI 10.1111/ajt.13740

    View details for PubMedID 26833680

  • Prehabilitation in our most frail surgical patients: are wearable fitness devices the next frontier? Current opinion in organ transplantation Rumer, K. K., Saraswathula, A., Melcher, M. L. 2016; 21 (2): 188-193

    Abstract

    Frailty is the concept of accumulating physiologic declines that make people less able to deal with stressors, including surgery. Prehabilitation is intervention to enhance functional capacity before surgery. Frailty and prehabilitation among transplant populations and the role of wearable fitness tracking devices (WFTs) in delivering fitness-based interventions will be discussed.Frailty is associated with increased complications, longer length of hospital stay and increased mortality after surgery. Frail kidney transplant patients have increased delayed graft function, mortality and early hospital readmission. Frail lung or liver transplant patients are more likely to delist or die on the waitlist. Prehabilitation can mitigate frailty and has resulted in decreased length of hospital stay and fewer postsurgical complications among a variety of surgical populations. Increasingly, WFTs are used to monitor patient activity and improve patient health. Interventions using WFTs have resulted in improved activity, weight loss and blood pressure.Frailty is a measurable parameter that identifies patients at risk for worse health outcomes and can be mitigated through intervention. Prehabilitation to reduce frailty has been shown to improve postsurgical outcomes in a variety of populations. WFTs are being integrated in healthcare delivery for monitoring and changing health behavior with promising results.

    View details for DOI 10.1097/MOT.0000000000000295

    View details for PubMedID 26859220

  • Survival Benefit with Kidney Transplants from HLA-Incompatible Live Donors NEW ENGLAND JOURNAL OF MEDICINE Orandi, B. J., Luo, X., Massie, A. B., Garonzik-Wang, J. M., Lonze, B. E., Ahmed, R., Van Arendonk, K. J., Stegall, M. D., Jordan, S. C., Oberholzer, J., Dunn, T. B., Ratner, L. E., Kapur, S., Pelletier, R. P., Roberts, J. P., Melcher, M. L., Singh, P., Sudan, D. L., Posner, M. P., El-Amm, J. M., Shapiro, R., Cooper, M., Lipkowitz, G. S., Rees, M. A., Marsh, C. L., Sankari, B. R., Gerber, D. A., Nelson, P. W., Wellen, J., Bozorgzadeh, A., Gaber, A. O., Montgomery, R. A., Segev, D. L. 2016; 374 (10): 940-950

    Abstract

    A report from a high-volume single center indicated a survival benefit of receiving a kidney transplant from an HLA-incompatible live donor as compared with remaining on the waiting list, whether or not a kidney from a deceased donor was received. The generalizability of that finding is unclear.In a 22-center study, we estimated the survival benefit for 1025 recipients of kidney transplants from HLA-incompatible live donors who were matched with controls who remained on the waiting list or received a transplant from a deceased donor (waiting-list-or-transplant control group) and controls who remained on the waiting list but did not receive a transplant (waiting-list-only control group). We analyzed the data with and without patients from the highest-volume center in the study.Recipients of kidney transplants from incompatible live donors had a higher survival rate than either control group at 1 year (95.0%, vs. 94.0% for the waiting-list-or-transplant control group and 89.6% for the waiting-list-only control group), 3 years (91.7% vs. 83.6% and 72.7%, respectively), 5 years (86.0% vs. 74.4% and 59.2%), and 8 years (76.5% vs. 62.9% and 43.9%) (P<0.001 for all comparisons with the two control groups). The survival benefit was significant at 8 years across all levels of donor-specific antibody: 89.2% for recipients of kidney transplants from incompatible live donors who had a positive Luminex assay for anti-HLA antibody but a negative flow-cytometric cross-match versus 65.0% for the waiting-list-or-transplant control group and 47.1% for the waiting-list-only control group; 76.3% for recipients with a positive flow-cytometric cross-match but a negative cytotoxic cross-match versus 63.3% and 43.0% in the two control groups, respectively; and 71.0% for recipients with a positive cytotoxic cross-match versus 61.5% and 43.7%, respectively. The findings did not change when patients from the highest-volume center were excluded.This multicenter study validated single-center evidence that patients who received kidney transplants from HLA-incompatible live donors had a substantial survival benefit as compared with patients who did not undergo transplantation and those who waited for transplants from deceased donors. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases.).

    View details for DOI 10.1056/NEJMoa1508380

    View details for PubMedID 26962729

  • We Need to Take the Next Step. American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons Melcher, M. L., Roberts, J. P., Leichtman, A. B., Roth, A. E., Rees, M. A. 2016

    View details for PubMedID 27515865

  • Match Offer Failure and Its Impact on Kidney Paired Donation Liu, W., Melcher, M. WILEY-BLACKWELL. 2016: 55-56
  • Program Factors That Influence American Board of Surgery In-Training Examination Performance: A Multi-Institutional Study. Journal of surgical education Kim, J. J., Gifford, E. D., Moazzez, A., Sidwell, R. A., Reeves, M. E., Hartranft, T. H., Inaba, K., Jarman, B. T., Are, C., Galante, J. M., Amersi, F., Smith, B. R., Melcher, M. L., Nelson, M. T., Donahue, T., Jacobsen, G., Arnell, T. D., Lee, S., Neville, A., De Virgilio, C. 2015; 72 (6): e236-42

    Abstract

    To determine the influence of program strategies, such as program directors' (PD) attitudes about the American Board of Surgery In-Training Examination (ABSITE) and approach to ABSITE preparation, on residents' ABSITE performance.A 17-item questionnaire was sent to PDs at surgical residency programs. The questions were designed to elicit information regarding the educational curriculum, remediation protocols, and opinions relating to the ABSITE. Main outcome measure was categorical resident ABSITE percentile scores from the January 2014 examination. Statistical analysis was performed using the Student t-test, analysis of variance, and linear regression as appropriate.The study was carried out at general surgery residency programs across the country.In total, 15 general surgery residency PDs participated in the study.The PD response rate was 100%. All 460 resident ABSITE scores from the 15 programs were obtained. In total, 10 programs (67%) identified as university affiliated, 4 programs (27%) as independent academic, and 1 program (7%) as hybrid. The mean number of residents per program was 30.7 (range: 15-57). In total, 14 PDs (93%) indicated that an ABSITE review curriculum was in place and 13 PDs (87%) indicated they had a remediation protocol for residents with low ABSITE scores (with differing thresholds of <30th, <35th, and <40th percentile). The median overall ABSITE score for all residents was 61st percentile (interquartile range = 39.5). The mean ABSITE score for each program ranged from 39th to 75th percentile. Program factors associated with higher ABSITE scores included tracking resident reading throughout the year (median 63rd percentile with tracking vs 59th percentile without, p = 0.040) and the type of remediation (by PD: 77th percentile, by PD and faculty: 57th percentile, faculty only: 64th percentile, with Surgical Education and Self-Assessment Program (SESAP): 63rd percentile, outside review course: 43rd percentile; p < 0.001). Programs with a remediation protocol trended toward higher ABSITE scores compared with programs without remediation protocols (median 61st percentile vs 53rd percentile, p = 0.098). Factors not significantly associated with ABSITE performance included number of structured educational hours per week and frequency of ABSITE review sessions.Program factors appear to significantly influence ABSITE performance. Programs where the PD was actively involved in remediation mentorship and the tracking of resident reading achieved higher ABSITE percentile scores on the January 2014 examination. Counterintuitively, residents from programs with a lower ABSITE threshold for remediation performed better on the examination.

    View details for DOI 10.1016/j.jsurg.2015.06.014

    View details for PubMedID 26319103

  • Saving Supersick Patients Undergoing Liver Transplant. JAMA surgery Melcher, M. L. 2015; 150 (11): 1073-?

    View details for DOI 10.1001/jamasurg.2015.1881

    View details for PubMedID 26309213

  • Reading Habits of General Surgery Residents and Association With American Board of Surgery In-Training Examination Performance JAMA SURGERY Kim, J. J., Kim, D. Y., Kaji, A. H., Gifford, E. D., Reid, C., Sidwell, R. A., Reeves, M. E., Hartranft, T. H., Inaba, K., Jarman, B. T., Are, C., Galante, J. M., Amersi, F., Smith, B. R., Melcher, M. L., Nelson, T., Donahue, T., Jacobsen, G., Arnell, T. D., de Virgilio, C. 2015; 150 (9): 882-889

    Abstract

    Few large-scale studies have quantified and characterized the study habits of surgery residents. However, studies have shown an association between American Board of Surgery In-Training Examination (ABSITE) scores and subsequent success on the American Board of Surgery Qualifying and Certifying examinations.To identify the quantity of studying, the approach taken when studying, the role that ABSITE preparation plays in resident reading, and factors associated with ABSITE performance.An anonymous 39-item questionnaire including demographic information, past performance on standardized examinations, reading habits, and study sources during the time leading up to the 2014 ABSITE and opinions pertaining to the importance of the ABSITE was administered August 1, 2014, to August 25, 2014, to 371 surgery residents in 15 residency programs nationwide.Scores from the 2014 ABSITE.A total of 273 residents (73.6%) responded to the survey. Seven respondents did not provide their January 2014 ABSITE score, leaving 266 for statistical analysis. Most respondents were male (162 of 266 [60.9%]), with a mean (SD) age of 29.8 (2.6) years. The median number of minutes spent studying per month was 240 (interquartile range, 120-600 minutes) for patient care or clinical duties and 120 for the ABSITE (interquartile range, 30-360 minutes). One hundred sixty-four of 266 respondents (61.7%) reported reading consistently throughout the year for patient care or clinical duties. With respect to ABSITE preparation, 72 of 266 residents (27.1%) reported reading consistently throughout the year, while 247 of 266 residents (92.9%) reported preparing between 1 and 8 weeks prior to the examination. Univariate analysis (with results reported as effect on median ABSITE percentile scores [95% CIs]) identified the following factors as positively correlated with ABSITE scores: prior United States Medical Licensing Examination (USMLE) 1 and 2 scores (per 1-point increase: USMLE 1, 0.1 [0.02-0.14], P = .03; USMLE 2, 0.3 [0.19-0.44], P < .001), prior Medical College Admission Test (MCAT) scores (per 1-point increase, 1.2 [1.3-2.0]; P = .002), high opinion of ABSITE significance (P < .001), surgical textbook use (11 [6-16]; P = .02), daily studying (13 [4-23]; P = .02), and high satisfaction with study materials (P < .001). On multivariable analysis, USMLE 2 score (per 1-point increase, 0.4 [0.2-0.6]; P < .001), MCAT score (0.6 [0.2-1.0]; P = .003), opinion of ABSITE significance (9.2 [6.9-11.6]; P < .001), and having an equal focus on patient care and ABSITE preparation during study (6.1 [0.6-11.5]; P = .03) were identified as positive predictors of ABSITE performance.Most residents reported reading consistently for patient care throughout the year. Daily studying and textbook use were associated with higher ABSITE scores on univariate analysis. Scores on the USMLE 2 and MCAT, as well as resident attitude regarding the importance of the ABSITE results, were independent predictors of ABSITE performance.

    View details for DOI 10.1001/jamasurg.2015.1698

    View details for Web of Science ID 000367584100013

  • Reading Habits of General Surgery Residents and Association With American Board of Surgery In-Training Examination Performance. JAMA surgery Kim, J. J., Kim, D. Y., Kaji, A. H., Gifford, E. D., Reid, C., Sidwell, R. A., Reeves, M. E., Hartranft, T. H., Inaba, K., Jarman, B. T., Are, C., Galante, J. M., Amersi, F., Smith, B. R., Melcher, M. L., Nelson, M. T., Donahue, T., Jacobsen, G., Arnell, T. D., de Virgilio, C. 2015; 150 (9): 882-9

    Abstract

    Few large-scale studies have quantified and characterized the study habits of surgery residents. However, studies have shown an association between American Board of Surgery In-Training Examination (ABSITE) scores and subsequent success on the American Board of Surgery Qualifying and Certifying examinations.To identify the quantity of studying, the approach taken when studying, the role that ABSITE preparation plays in resident reading, and factors associated with ABSITE performance.An anonymous 39-item questionnaire including demographic information, past performance on standardized examinations, reading habits, and study sources during the time leading up to the 2014 ABSITE and opinions pertaining to the importance of the ABSITE was administered August 1, 2014, to August 25, 2014, to 371 surgery residents in 15 residency programs nationwide.Scores from the 2014 ABSITE.A total of 273 residents (73.6%) responded to the survey. Seven respondents did not provide their January 2014 ABSITE score, leaving 266 for statistical analysis. Most respondents were male (162 of 266 [60.9%]), with a mean (SD) age of 29.8 (2.6) years. The median number of minutes spent studying per month was 240 (interquartile range, 120-600 minutes) for patient care or clinical duties and 120 for the ABSITE (interquartile range, 30-360 minutes). One hundred sixty-four of 266 respondents (61.7%) reported reading consistently throughout the year for patient care or clinical duties. With respect to ABSITE preparation, 72 of 266 residents (27.1%) reported reading consistently throughout the year, while 247 of 266 residents (92.9%) reported preparing between 1 and 8 weeks prior to the examination. Univariate analysis (with results reported as effect on median ABSITE percentile scores [95% CIs]) identified the following factors as positively correlated with ABSITE scores: prior United States Medical Licensing Examination (USMLE) 1 and 2 scores (per 1-point increase: USMLE 1, 0.1 [0.02-0.14], P = .03; USMLE 2, 0.3 [0.19-0.44], P < .001), prior Medical College Admission Test (MCAT) scores (per 1-point increase, 1.2 [1.3-2.0]; P = .002), high opinion of ABSITE significance (P < .001), surgical textbook use (11 [6-16]; P = .02), daily studying (13 [4-23]; P = .02), and high satisfaction with study materials (P < .001). On multivariable analysis, USMLE 2 score (per 1-point increase, 0.4 [0.2-0.6]; P < .001), MCAT score (0.6 [0.2-1.0]; P = .003), opinion of ABSITE significance (9.2 [6.9-11.6]; P < .001), and having an equal focus on patient care and ABSITE preparation during study (6.1 [0.6-11.5]; P = .03) were identified as positive predictors of ABSITE performance.Most residents reported reading consistently for patient care throughout the year. Daily studying and textbook use were associated with higher ABSITE scores on univariate analysis. Scores on the USMLE 2 and MCAT, as well as resident attitude regarding the importance of the ABSITE results, were independent predictors of ABSITE performance.

    View details for DOI 10.1001/jamasurg.2015.1698

    View details for PubMedID 26176352

  • Identifying Opportunities to Increase the Throughput of Kidney Paired Donation. Transplantation Liu, W., Treat, E., Veale, J. L., Milner, J., Melcher, M. L. 2015; 99 (7): 1410-1415

    Abstract

    Although kidney paired donation (KPD) has led to thousands of transplants, the 2012 KPD Consensus Conference concluded that more could be done. Perceptions are that a large number of match offers never resulted in transplantations, and unfruitful matches have both financial and emotional costs.To describe, quantify, and analyze the unrealized match offers, we studied the matching process from registration to transplantation in the National Kidney Registry, a large KPD registry, over a 25-month period.Of the 3,180 match offers, 454 were turned down. The most common reasons were the donor was not acceptable (50%) and their recipient had unacceptably high donor-specific antibodies (28%). Of the 2,228 accepted offers, 1,335 advanced to the cell-based cross-match stage because 893 of these were part of chains that fell through. Fifty-five of 887 recorded cell-based cross-matches were positive, 20 donors were unacceptable, and 22 recipients had unacceptably high donor-specific antibodies. Six hundred ninety transplantations were performed.Despite the success of KPD, by analyzing the matching process, we identify several strategies to increase the number of KPD transplantations, including recruiting more participants, processing the match offers more quickly at the transplant center level, enhancing the donor preselection tools, improving communication between centers and the registries, and combining desensitization with KPD.

    View details for DOI 10.1097/TP.0000000000000527

    View details for PubMedID 25606799

  • Inside Out Autologous Neo-Liver Fabrication Than, P., Davis, C., Findlay, M., Liu, W., Le, T., Khong, S., Melcher, M., Gurtner, G. WILEY-BLACKWELL. 2015
  • Paired Match Power and Challenges for O-Patients in Kidney Paired Donation Liu, W., Melcher, M. WILEY-BLACKWELL. 2015
  • Recurrent Hepatocellular Carcinoma and Poorer Overall Survival in Patients Undergoing Left-sided Compared With Right-sided Partial Hepatectomy. Journal of clinical gastroenterology Valenzuela, A., Ha, N. B., Gallo, A., Bonham, C., Ahmed, A., Melcher, M., Kim, L. H., Esquivel, C., Concepcion, W., Ayoub, W. S., Lutchman, G. A., Daugherty, T., Nguyen, M. H. 2015; 49 (2): 158-164

    Abstract

    We aimed to determine the incidence and predictors of recurrent hepatocellular carcinoma (HCC) after partial hepatectomy.Liver transplantation is the preferred treatment for selected patients with HCC, but access to donor organs is limited. Partial hepatectomy is another accepted treatment option; however, postoperative recurrence is frequently observed.This is a retrospective cohort study of 107 consecutive patients who underwent partial hepatectomy for HCC between January 1993 and February 2011 at a US University Medical Center. Study endpoints were recurrent HCC, death, loss to follow-up, or last visit without HCC.The study cohort was 78% male with a median age of 61 years and 59% Asians. A total of 50 patients developed recurrent HCC (46.7%) after a median follow-up of 12 (1 to 69) months postresection. Recurrent HCC was significantly higher in patients with left-sided resection (41% at year 1, 54% at year 2, 62% at year 3, 81% at year 4, and 90% at year 5) compared with right-sided resection (18% at year 1, 34% at year 2, 36% at year 3, 44% at year 4, and 72% at year 5). In multivariate Cox proportional hazards model also inclusive of anatomic resection and TNM stage 3/4, left-sided resection was significantly associated with increased HCC recurrence (hazard ratio, 2.13; P=0.02; 95% confidence interval, 1.08-4.2) compared with right-sided resection.HCC recurrence rate is higher among those undergoing left-sided resection: 54% at year 2 and 81% at year 4. Liver transplantation should be considered in patients who are at high risk for recurrence.

    View details for DOI 10.1097/MCG.0000000000000144

    View details for PubMedID 24804988

  • Is Informed Consent Enough? American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons Liu, W. n., Krawiec, K. D., Melcher, M. L. 2015

    Abstract

    As illustrated by Flechner et al (1), patients with renal failure continue to benefit from rapid innovations within multiple Kidney Paired Donation (KPD) registries. The development of the Advanced Donation Program (ADP) facilitates transplants by enabling the donors to donate even when their intended recipients (IR) are not matched yet. However, as with any innovation, ADP introduces new challenges including risks to the IRs and registries, vagueness in the definition of priority granted to the IR, and concerns about fairness to the donor should the IR become untransplantable. This article is protected by copyright. All rights reserved.

    View details for PubMedID 26603607

  • Demographic and Clinical Characteristics of 207 Non-Directed Donors Participating in Paired Exchange Through the National Kidney Registry Pham, T., Waterman, A., Veale, J., Melcher, M. WILEY-BLACKWELL. 2015: 79
  • Factors Associated With General Surgery Residents' Desire to Leave Residency Programs A Multi-institutional Study JAMA SURGERY Gifford, E., Galante, J., Kaji, A. H., Nguyen, V., Nelson, M. T., Sidwell, R. A., Hartranft, T., Jarman, B., Melcher, M., Reeves, M., Reid, C., Jacobsen, G. R., Thompson, J., Are, C., Smith, B., Arnell, T., Hines, O. J., de Virgilio, C. 2014; 149 (9): 948-953

    Abstract

    General surgical residency continues to experience attrition. To date, work hour amendments have not changed the annual rate of attrition.To determine how often categorical general surgery residents seriously consider leaving residency.At 13 residency programs, an anonymous survey of 371 categorical general surgery residents and 10-year attrition rates for each program. Responses from those who seriously considered leaving surgical residency were compared with those who did not.Factors associated with the desire to leave residency.The survey response rate was 77.6%. Overall, 58.0% seriously considered leaving training. The most frequent reasons for wanting to leave were sleep deprivation on a specific rotation (50.0%), an undesirable future lifestyle (47.0%), and excessive work hours on a specific rotation (41.4%). Factors most often cited that kept residents from leaving were support from family or significant others (65.0%), support from other residents (63.5%), and perception of being better rested (58.9%). On univariate analysis, older age, female sex, postgraduate year, training in a university program, the absence of a faculty mentor, and lack of Alpha Omega Alpha status were associated with serious thoughts of leaving surgical residency. On multivariate analysis, only female sex was significantly associated with serious thoughts of leaving residency (odds ratio, 1.2; 95% CI, 1.1-1.3; P = .003). Eighty-six respondents were from historically high-attrition programs, and 202 respondents were from historically low-attrition programs (27.8% vs 8.4% 10-year attrition rate, P = .04). Residents from high-attrition programs were more likely to seriously consider leaving residency (odds ratio, 1.8; 95% CI, 1.0-3.0; P = .03).A majority of categorical general surgery residents seriously consider leaving residency. Female residents are more likely to consider leaving. Thoughts of leaving seem to be associated with work conditions on specific rotations rather than with overall work hours and are more prevalent among programs with historically high attrition rates.

    View details for DOI 10.1001/jamasurg.2014.935

    View details for Web of Science ID 000342389000020

  • Resolution of Acute Kidney Injury After Liver Transplantation: A Single Center Experience. Todo, T., Gallo, A., Berumen, J., Feinberg, E., Melcher, M., Bonham, C., Busque, S., Concepcion, W., Esquivel, C. LIPPINCOTT WILLIAMS & WILKINS. 2014: 759
  • Incompatible Kidney Transplantation Risk and Its Relationship to CMS Regulation: A Multi-Center Study. Orandi, B., Garonzik-Wang, J., Massie, A., Zachary, A., Montgomery, J., Van Arendonk, K., Stegall, M., Jordan, S., Oberholzer, J., Dunn, T., Ratner, L., Kapur, S., Pelletier, R., Roberts, J., Melcher, M., Singh, P., Sudan, D., Posner, M., El-Amm, J., Shapiro, R., Cooper, M., Lipkowitz, G., Rees, M., Marsh, C., Sankari, B., Gerber, D., Nelson, P., Wellen, J., Bozorgzadeh, A., Gaber, A., Montgomery, R., Segev, D. LIPPINCOTT WILLIAMS & WILKINS. 2014: 201
  • Utility, Equality, and the Tradeoff Between Quality of Graft and Waiting Time in KPD Liu, W., Melcher, M. LIPPINCOTT WILLIAMS & WILKINS. 2014: 125
  • Early Excellent Outcomes of Flow Cross-Match Negative Kidney Transplant Recipients With Pre-Formed IgG DSA, C1q Negative With or Without Peri-Operative IVIg Infusion. Busque, S., Yabu, J., Melcher, M., Gallo, A., Kong, S., Makki, T., Burke-Barber, K., Scandling, J., Tyan, D. LIPPINCOTT WILLIAMS & WILKINS. 2014: 512
  • Center-Defined Unacceptable HLA Antigens Facilitate Transplants for Sensitized Patients in a Multi-Center Kidney Exchange Program AMERICAN JOURNAL OF TRANSPLANTATION Baxter-Lowe, L. A., Cecka, M., Kamoun, M., Sinacore, J., Melcher, M. L. 2014; 14 (7): 1592-1598

    Abstract

    Multi-center kidney paired donation (KPD) is an exciting new transplant option that has not yet approached its full potential. One barrier to progress is accurate virtual crossmatching for KPD waitlists with many highly sensitized patients. Virtual crossmatch results from a large multi-center consortium, the National Kidney Registry (NKR), were analyzed to determine the effectiveness of flexible center-specific criteria for virtual crossmatching. Approximately two-thirds of the patients on the NKR waitlist are highly sensitized (>80% CPRA). These patients have antibodies against HLA-A (63%), HLA-B (66%), HLA-C (41%), HLA-DRB1 (60%), HLA-DRB3/4/5 (18-22%), HLA-DQB1 (54%) and HLA-DPB1 (26%). With donors typed for these loci before activation, 91% of virtual crossmatches accurately predicted an acceptable cell-based donor crossmatch. Failed virtual crossmatches were attributed to equivocal virtual crossmatches (46%), changes in HLA antibodies (21%), antibodies against HLA-DQA (6%), transcription errors (6%), suspected non-HLA antibodies (5%), allele-specific antibodies (1%) and unknown causes (15%). Some failed crossmatches could be prevented by modifiable factors such as more frequent assessment of HLA antibodies, DQA1 typing of donors and auditing data entry. Importantly, when transplant centers have flexibility to define crossmatch criteria, it is currently feasible to use virtual crossmatching for highly sensitized patients to reliably predict acceptable cell-based crossmatches.

    View details for DOI 10.1111/ajt.12734

    View details for Web of Science ID 000338024700019

  • Quantifying the Risk of Incompatible Kidney Transplantation: A Multicenter Study AMERICAN JOURNAL OF TRANSPLANTATION Orandi, B. J., Garonzik-Wang, J. M., Massie, A. B., Zachary, A. A., Montgomery, J. R., Van Arendonk, K. J., Stegall, M. D., Jordan, S. C., Oberholzer, J., Dunn, T. B., Ratner, L. E., Kapur, S., Pelletier, R. P., Roberts, J. P., Melcher, M. L., Singh, P., Sudan, D. L., Posner, M. P., El-Amm, J. M., Shapiro, R., Cooper, M., Lipkowitz, G. S., Rees, M. A., Marsh, C. L., Sankari, B. R., Gerber, D. A., Nelson, P. W., Wellen, J., Bozorgzadeh, A., Gaber, A. O., Montgomery, R. A., Segev, D. L. 2014; 14 (7): 1573-1580

    Abstract

    Incompatible live donor kidney transplantation (ILDKT) offers a survival advantage over dialysis to patients with anti-HLA donor-specific antibody (DSA). Program-specific reports (PSRs) fail to account for ILDKT, placing this practice at regulatory risk. We collected DSA data, categorized as positive Luminex, negative flow crossmatch (PLNF) (n = 185), positive flow, negative cytotoxic crossmatch (PFNC) (n = 536) or positive cytotoxic crossmatch (PCC) (n = 304), from 22 centers. We tested associations between DSA, graft loss and mortality after adjusting for PSR model factors, using 9669 compatible patients as a comparison. PLNF patients had similar graft loss; however, PFNC (adjusted hazard ratio [aHR] = 1.64, 95% confidence interval [CI]: 1.15-2.23, p = 0.007) and PCC (aHR = 5.01, 95% CI: 3.71-6.77, p < 0.001) were associated with increased graft loss in the first year. PLNF patients had similar mortality; however, PFNC (aHR = 2.04; 95% CI: 1.28-3.26; p = 0.003) and PCC (aHR = 4.59; 95% CI: 2.98-7.07; p < 0.001) were associated with increased mortality. We simulated Centers for Medicare & Medicaid Services flagging to examine ILDKT's effect on the risk of being flagged. Compared to equal-quality centers performing no ILDKT, centers performing 5%, 10% or 20% PFNC had a 1.19-, 1.33- and 1.73-fold higher odds of being flagged. Centers performing 5%, 10% or 20% PCC had a 2.22-, 4.09- and 10.72-fold higher odds. Failure to account for ILDKT's increased risk places centers providing this life-saving treatment in jeopardy of regulatory intervention.

    View details for DOI 10.1111/ajt.12786

    View details for Web of Science ID 000338024700017

  • PREDICT: Instituting an Educational Time Out in the Operating Room. Journal of graduate medical education Yang, R. L., Esquivel, M., Erdrich, J., Lau, J., Melcher, M. L., Wapnir, I. L. 2014; 6 (2): 382-383

    View details for DOI 10.4300/JGME-D-14-00086.1

    View details for PubMedID 24949168

  • The First 1000 Kidney Paired Donation Transplants through the National Kidney Registry: Graft Function and Survival Outcomes Treat, E., Peipert, J., Waterman, A., Kwan, L., Connor, S., Melcher, M., Flechner, S., Kapur, S., Leeser, D., Sinacore, J., Veale, J. WILEY-BLACKWELL. 2014: 153
  • Incompatible Kidney Transplantation Risk and Its Relationship to CMS Regulation: A Multi-Center Study. Orandi, B., Garonzik-Wang, J., Massie, A., Zachary, A., Montgomery, J., Van Arendonk, K., Stegall, M., Jordan, S., Oberholzer, J., Dunn, T., Ratner, L., Kapur, S., Pelletier, R., Roberts, J., Melcher, M., Singh, P., Sudan, D., Posner, M., El-Amm, J., Shapiro, R., Cooper, M., Lipkowitz, G., Rees, M., Marsh, C., Sankari, B., Gerber, D., Nelson, P., Wellen, J., Bozorgzadeh, A., Gaber, A., Montgomery, R., Segev, D. WILEY-BLACKWELL. 2014: 201
  • Resolution of Acute Kidney Injury After Liver Transplantation: A Single Center Experience. Todo, T., Gallo, A., Berumen, J., Feinberg, E., Melcher, M., Bonham, C., Busque, S., Concepcion, W., Esquivel, C. WILEY-BLACKWELL. 2014: 759
  • HIGH DONOR-AGE VS HIGH MELD IN LIVER TX. WHICH IS THE MOST EFFECTIVE APPROACH? EVIDENCES FROM THE ITALY-US D-MELD STUDY Avolio, A. W., Cillo, U., Burra, P., Lirosi, M. C., Humar, A., Romagnoli, R., Toniutto, P. L., Cucchetti, A., Chang, D., Spada, M., Melcher, M. L., Belli, L., Mazzaferro, V., Rendina, M., Caccamo, L., Lai, Q., Ettorre, G. M., Gasbarrini, A., Agnes, S., Halldorson, J. B. ELSEVIER SCIENCE INC. 2014: E7-E8
  • Primary surgical resection versus liver transplantation for transplant-eligible hepatocellular carcinoma patients. Digestive diseases and sciences Wong, R. J., Wantuck, J., Valenzuela, A., Ahmed, A., Bonham, C., Gallo, A., Melcher, M. L., Lutchman, G., Concepcion, W., Esquivel, C., Garcia, G., Daugherty, T., Nguyen, M. H. 2014; 59 (1): 183-191

    Abstract

    Hepatocellular carcinoma (HCC) is a leading cause of mortality worldwide. Existing studies comparing outcomes after liver transplantation (LT) versus surgical resection among transplant-eligible patients are conflicting.The purpose of this study was to compare long-term survival between consecutive transplant-eligible HCC patients treated with resection versus LT.The present retrospective matched case cohort study compares long-term survival outcomes between consecutive transplant-eligible HCC patients treated with resection versus LT using intention-to-treat (ITT) and as-treated models. Resection patients were matched to LT patients by age, sex, and etiology of HCC in a 1:2 ratio.The study included 171 patients (57 resection and 114 LT). Resection patients had greater post-treatment tumor recurrence (43.9 vs. 12.9 %, p < 0.001) compared to LT patients. In the as-treated model of the pre-model for end stage liver disease (MELD) era, LT patients had significantly better 5-year survival compared to resection patients (100 vs. 69.5 %, p = 0.04), but no difference was seen in the ITT model. In the multivariate Cox proportional hazards model, inclusive of age, sex, ethnicity, tumor stage, and MELD era (pre-MELD vs. post-MELD), treatment with resection was an independent predictor of poorer survival (HR 2.72; 95 % CI, 1.08-6.86).Transplant-eligible HCC patients who received LT had significantly better survival than those treated with resection, suggesting that patients who can successfully remain on LT listing and actually undergo LT have better outcomes.

    View details for DOI 10.1007/s10620-013-2947-8

    View details for PubMedID 24282054

  • Quantifying the Risk of Incompatible Kidney Transplantation: A Multi-Center Study Orandi, B., Garonzik-Wang, J., Montgomery, J., Massie, A., Van Arendonk, K., Stegall, M., Jordan, S., Oberholzer, J., Dunn, T., Ratner, L., Kapur, S., Pelletier, R., Roberts, J., Melcher, M., Singh, P., Sudan, D., Posner, M., El-Amm, J., Shapiro, R., Cooper, M., Lipkowitz, G., Rees, M., Marsh, C., Mongtomery, R., Segev, D. WILEY-BLACKWELL. 2014: 67
  • Measuring Utility and Fairness in Kidney Paired Donation (KPD) Liu, W., Milner, J., Veale, J., Melcher, M. WILEY-BLACKWELL. 2014: 79
  • Resolution of Acute Kidney Injury after Liver Transplantation: Single Center Experience Todo, T., Gallo, A., Beruman, J., Feinberg, E., Melcher, M., Bonham, C., Busque, S., Concepcion, W., Esquivel, C. WILEY-BLACKWELL. 2014: 101
  • HIGH MELD VERSUS HIGH DONOR AGE: LESSONS LEARNED COMPARING THE AMERICAN AND THE ITALIAN LIVER TRANSPLANT EXPERIENCES Avolio, A. W., Cillo, U., Agnes, S., Lirosi, M. C., Perkins, J., Romagnoli, R., Cucchetti, A., Humar, A., Spada, M., Melcher, M. L., Caccamo, L., Santaniello, W., Baccarani, U., Ponziani, F. R., Burra, P., Halldorson, J. B. WILEY-BLACKWELL. 2013: 31
  • HIGH MELD vs HIGH DONOR AGE in liver tx. Who is the winner ? Evidences from the US-ITALY D-MELD study Avolio, A. W., Burra, P., Mariano, G., Chang, D., Cillo, U., Cucchetti, A., Romagnoli, R., Humar, A., Spada, M., Melcher, M. L., De Carlis, L., Colledan, M., Mazzaferro, V., Caccamo, L., Lai, Q., Calise, F., Agnes, S., Halldorson, J. B. WILEY-BLACKWELL. 2013: 765A-766A
  • Effect of the 16-Hour Work Limit on General Surgery Intern Operative Case Volume A Multi-institutional Study JAMA SURGERY Schwartz, S. I., Galante, J., Kaji, A., Dolich, M., Easter, D., Melcher, M. L., Patel, K., Reeves, M. E., Salim, A., Senagore, A. J., Takanishi, D. M., de Virgilio, C. 2013; 148 (9): 829-833

    Abstract

    The 80-hour work-week limit for all residents was instituted in 2003 and studies looking at its effect have been mixed. Since the advent of the 16-hour mandate for postgraduate year 1 residents in July 2011, no data have been published regarding the effect of this additional work-hour restriction.To determine whether the 16-hour intern work limit, implemented in July 2011, has adversely affected operative experience.A retrospective review of categorical postgraduate year 1 Accreditation Council for Graduate Medical Education case logs from the intern class (N = 52) (with 16-hour work limit) compared with the 4 preceding years (2007-2010; N = 197) (without 16-hour work limit). A total of 249 categorical general surgery interns from 10 general surgery residency programs in the western United States were included.Total, major, first-assistant, and defined-category case totals.As compared with the preceding 4 years, the 2011-2012 interns recorded a 25.8% decrease in total operative cases (65.9 vs 88.8, P = .005), a 31.8% decrease in major cases (54.9 vs 80.5, P < .001), and a 46.3% decrease in first-assistant cases (11.1 vs 20.7, P = .008). There were statistically significant decreases in cases within the defined categories of abdomen, endocrine, head and neck, basic laparoscopy, complex laparoscopy, pediatrics, thoracic, and soft tissue/breast surgery in the 16-hour shift intern era, whereas there was no decrease in trauma, vascular, alimentary, endoscopy, liver, and pancreas cases.The 16-hour work limit for interns, implemented in July 2011, is associated with a significant decrease in categorical intern operative experience. If the 16-hour shift were to be extended to all postgraduate year levels, one can anticipate that additional years of training will be needed to maintain the same operative volume.

    View details for DOI 10.1001/jamasurg.2013.2677

    View details for Web of Science ID 000325212300009

    View details for PubMedID 23843028

  • Kidney failure in a transplant from an identical twin. American journal of kidney diseases Lum, E. L., Morton, J. M., Melcher, M. L. 2013; 62 (2): xxi-xxiii

    View details for DOI 10.1053/j.ajkd.2013.03.046

    View details for PubMedID 23883662

  • High MELD vs High Donor Age: Two Different Approaches, Similar Results. Evidences from US and Italy. Avolio, A. W., Cillo, U., Lirosi, M. C., Perkins, J., Pinna, A. D., Romagnoli, R., Humar, A., Spada, M., Melcher, M. L., De Carlis, L., Zamboni, F., Colledan, M., Mazzaferro, V., Ettorre, G., Rossi, M., Tisone, G., Vivarelli, M., Burra, P., Agnes, S., Halldorson, J. B., D2R Liver Tx Study Grp WILEY-BLACKWELL. 2013: S128-S129
  • Decreased Long-Term Survival in Patients With Hepatocellular Carcinoma (HCC) Following Left-Sided Compared to Right-Sided Partial Hepatectomy Vergara, A., Ha, N. B., Gallo, A., Bonham, C. A., Melcher, M. L., Ahmed, A., Kim, L. H., Esquivel, C. O., Concepcion, W., Ayoub, W., Daugherty, T., Lutchman, G. A., Nguyen, M. H. W B SAUNDERS CO-ELSEVIER INC. 2013: S1043
  • A Comparison of Primary Surgical Resection to Liver Transplantation Among Transplant-Eligible Hepatocellular Carcinoma (HCC) Patients Using an Intention-to-Treat (ITT) Model Wong, R. J., Wantuck, J. M., Vergara, A., Ahmed, A., Bonham, C. A., Gallo, A., Melcher, M. L., Lutchman, G. A., Concepcion, W., Esquivel, C. O., Garcia, G., Daugherty, T., Nguyen, M. H. W B SAUNDERS CO-ELSEVIER INC. 2013: S1032
  • Dynamic Challenges Inhibiting Optimal Adoption of Kidney Paired Donation: Findings of a Consensus Conference AMERICAN JOURNAL OF TRANSPLANTATION Melcher, M. L., Blosser, C. D., Baxter-Lowe, L. A., Delmonico, F. L., Gentry, S. E., Leishman, R., Knoll, G. A., Leffell, M. S., Leichtman, A. B., Mast, D. A., Nickerson, P. W., Reed, E. F., Rees, M. A., Rodrigue, J. R., Segev, D. L., Serur, D., Tullius, S. G., Zavala, E. Y., Feng, S. 2013; 13 (4): 851-860

    Abstract

    While kidney paired donation (KPD) enables the utilization of living donor kidneys from healthy and willing donors incompatible with their intended recipients, the strategy poses complex challenges that have limited its adoption in United States and Canada. A consensus conference was convened March 29-30, 2012 to address the dynamic challenges and complexities of KPD that inhibit optimal implementation. Stakeholders considered donor evaluation and care, histocompatibility testing, allocation algorithms, financing, geographic challenges and implementation strategies with the goal to safely maximize KPD at every transplant center. Best practices, knowledge gaps and research goals were identified and summarized in this document.

    View details for DOI 10.1111/ajt.12140

    View details for PubMedID 23398969

  • Impact of Matching Frequency in Kidney Paired Donation. Ashlagi, I., Anderson, R., Gamarnik, D., Hil, G., Melcher, M., Roth, A. WILEY-BLACKWELL. 2013: 136
  • A COMPARISON OF PRIMARY SURGICAL RESECTION TO LIVER TRANSPLANTATION (LT) AMONG TRANSPLANT-ELIGIBLE HEPATOCELLULAR CARCINOMA (HCC) PATIENTS USING AN INTENTION-TO-TREAT MODEL Wong, R. J., Wantuck, J., Valenzuela, A., Ahmed, A., Bonham, C., Gallo, A., Melcher, M., Lutchman, G., Concepcion, W., Esquivel, C., Garcia, G., Daugherty, T., Nguyen, M. H. ELSEVIER SCIENCE BV. 2013: S117
  • The influence of intern home call on objectively measured perioperative outcomes. JAMA surgery Kastenberg, Z. J., Rhoads, K. F., Melcher, M. L., Wren, S. M. 2013; 148 (4): 347-351

    Abstract

    HYPOTHESIS In July 2011, surgical interns were prohibited from being on call from home by the new residency review committee guidelines on work hours. In support of the new Accreditation Council for Graduate Medical Education work-hour restrictions, we expected that a period of intern home call would correlate with increased rates of postoperative morbidity and mortality. DESIGN Prospective cohort. SETTING University-affiliated tertiary Veterans Affairs Medical Center. PATIENTS All patients identified in the Veterans Affairs National Surgical Quality Improvement Program database who underwent an operation performed by general, vascular, urologic, or cardiac surgery services between fiscal years (FYs) 1999 and 2010 were included. MAIN OUTCOME MEASURES During FYs 1999-2003, the first call for all patients went to an in-hospital intern. In the subsequent period (FYs 2004-2010), the first call went to an intern on home call. Thirty-day unadjusted morbidity and mortality rates and risk-adjusted observed to expected ratios were analyzed by univariate analysis and joinpoint regression, respectively. RESULTS Unadjusted overall morbidity rates decreased between 1999-2003 and 2004-2010 (12.14% to 10.19%, P =  .003). The risk-adjusted morbidity observed to expected ratios decreased at a uniform annual percentage change of -6.03% (P < .001). Unadjusted overall mortality rates also decreased between the 2 periods (1.76% to 1.26%; P =  .05). There was no significant change in the risk-adjusted mortality observed to expected ratios during the study. CONCLUSIONS The institution of an intern home call schedule was not associated with increased rates of postoperative morbidity or mortality.

    View details for DOI 10.1001/jamasurg.2013.1063

    View details for PubMedID 23715944

  • Evaluating Deceased Donor Registries: Identifying Predictive Factors of Donor Designation AMERICAN SURGEON Hajhosseini, B., Stewart, B., Tan, J. C., Busque, S., Melcher, M. L. 2013; 79 (3): 235-241

    Abstract

    The objectives of this study were to evaluate and compare the performance of the deceased donor registries of the 50 states and the District of Columbia and to identify possible predictive factors of donor designation. Data were collected retrospectively by Donate Life America using a questionnaire sent to Donor Designation Collaborative state teams between 2007 and 2010. By the end of 2010, there were 94,669,081 designated donors nationwide. This accounted for 39.8 per cent of the U.S. population aged 18 years and over. The number of designated organ donors and registry-authorized recovered donors increased each year; however, the total number of recovered donors in 2010 was the lowest since 2004. Donor designation rate was significantly higher when license applicants were verbally questioned at the Department of Motor Vehicles (DMV) regarding their willingness to register as a donor and when DMV applicants were not given an option on DMV application forms to contribute money to support organ donation, compared with not being questioned verbally, and being offered an option to contribute money. State registries continue to increase the total number of designated organ donors; however, the current availability of organs remains insufficient to meet the demand. These data suggest that DMV applicants who are approached verbally regarding their willingness to register as a donor and not given an option on DMV application forms to contribute money to support organ donation might be more likely to designate themselves to be a donor.

    View details for Web of Science ID 000315606500003

    View details for PubMedID 23461946

  • Kidney Transplant Chains Amplify Benefit of Nondirected Donors JAMA SURGERY Melcher, M. L., Veale, J. L., Javaid, B., Leeser, D. B., Davis, C. L., Hil, G., Milner, J. E. 2013; 148 (2): 165-169

    Abstract

    Despite the potential for altruistic nondirected donors (NDDs) to trigger multiple transplants through nonsimultaneous transplant chains, concerns exist that these chains siphon NDDs from the deceased donor wait list and that donors within chains might not donate after their partner receives a transplant.To determine the number of transplantations NDDs trigger through chains.Retrospective review of large, multicenter living donor-recipient database.Fifty-seven US transplant centers contributing donor-recipient pairs to the database.The NDDs initiating chain transplantation.Number of transplants per NDD.Seventy-seven NDDs enabled 373 transplantations during 46 months starting February 2008. Mean chain length initiated by NDDs was 4.8 transplants (median, 3; range, 1-30). The 40 blood type O NDDs triggered a mean chain length of 6.0 (median, 4; range, 2-30). During the interval, 66 of 77 chains were closed to the wait list, 4 of 77 were ongoing, and 7 of 77 were broken because bridge donors became unavailable. No chains were broken in the last 15 months, and every recipient whose incompatible donor donated received a kidney. One hundred thirty-three blood type O recipients were transplanted. CONCLUSION AND RELEVANCE: This large series demonstrates that NDDs trigger almost 5 transplants on average, more if the NDD is blood type O. There were more blood type O recipients than blood type O NDDs participating. The benefits of transplanting 373 patients and enabling others without living donors to advance outweigh the risk of broken chains that is decreasing with experience. Even 66 patients on the wait list without living donors underwent transplantation with living-donor grafts at the end of these chains.

    View details for PubMedID 23426593

  • Desensitization Combined With Paired Exchange Leads to Successful Transplantation in Highly Sensitized Kidney Transplant Recipients: Strategy and Report of Five Cases TRANSPLANTATION PROCEEDINGS Yabu, J. M., Pando, M. J., Busque, S., Melcher, M. L. 2013; 45 (1): 82-87

    Abstract

    Sensitization remains a major barrier to kidney transplantation. Sensitized patients comprise 30% of the kidney transplant waiting list but fewer than 15% of highly sensitized patients are transplanted each year. Options for highly sensitized patients with an immunologically incompatible living donor include desensitization or kidney paired donation (KPD). However, these options when used alone may still not be sufficient to allow a compatible transplant for recipients who are broadly sensitized with cumulative calculated panel-reactive antibody (cPRA) > 95%. We describe in this report the combined use of both desensitization and KPD to maximize the likelihood of finding a compatible match with a more immunologically favorable donor through a kidney exchange program. This combined approach was used in five very highly sensitized patients, all with cPRA 100%, who ultimately received compatible living and deceased donor kidney transplants. We conclude that early enrollment in paired kidney donor exchange and tailored desensitization protocols are key strategies to improve care and rates of kidney transplantation in highly sensitized patients.

    View details for DOI 10.1016/j.transproceed.2012.08.007

    View details for PubMedID 23375278

  • Reoperation in Pediatric Liver Transplantation: A Five Year Review 13th Annual State of the Art Winter Symposium of the American-Society-of-Transplant-Surgeons (ASTS) Held in Conjunction with the NATCO Symposium for Advanced Transplant Professionals Feinberg, E. J., Beruman, J. A., Campos, B. D., Lodhia, N., Gallo, A. E., Melcher, M., Bonham, C. A., Concepcion, W., Esquivel, C. O. WILEY-BLACKWELL. 2013: 84–84
  • Symbiotic or Parasitic? A Review of the Literature on the Impact of Fellowships on Surgical Residents ANNALS OF SURGERY Plerhoples, T. A., Greco, R. S., Krummel, T. M., Melcher, M. L. 2012; 256 (6): 904-908

    Abstract

    We conducted a systematic review of published literature to gain a better understanding of the impact of advanced fellowships on surgical resident training and education.As fellowship opportunities rise, resident training may be adversely impacted.PubMed, MEDLINE, Scopus, BIOSIS, Web of Science, and a manual search of article bibliographies. Of the 139 citations identified through the initial electronic search and screened for possible inclusion, 23 articles were retained and accepted for this review. Data were extracted regarding surgical specialty, methodology, sample population, outcomes measured, and results.Eight studies retrospectively compared the eras before and after the introduction of a fellowship or trended data over time. Approximately half used data from a single institution, whereas the other half used some form of national data or survey. Only 3 studies used national case data. Fourteen studies looked at general surgery, 6 at obstetrics-gynecology, 2 at urology, and 1 at otolaryngology. Only one study concluded that fellowships have a generally positive impact on resident education, whereas 9 others found a negative impact. The remaining 13 studies found mixed results (n = 6) or minimal to no impact (n = 7).The overall impact of advanced surgical fellowships on surgical resident education and training remains unclear, as most studies rely on limited data of questionable generalizability. A careful study of the national database of surgery resident case logs is essential to better understand how early surgical specialization and fellowships will impact the future of general surgery education.

    View details for DOI 10.1097/SLA.0b013e318262edd5

    View details for Web of Science ID 000312261000012

    View details for PubMedID 22968071

  • Chain Transplantation: Initial Experience of a Large Multicenter Program AMERICAN JOURNAL OF TRANSPLANTATION Melcher, M. L., Leeser, D. B., Gritsch, H. A., Milner, J., Kapur, S., Busque, S., Roberts, J. P., Katznelson, S., Bry, W., Yang, H., Lu, A., Mulgaonkar, S., Danovitch, G. M., Hil, G., VEALE, J. L. 2012; 12 (9): 2429-2436

    Abstract

    We report the results of a large series of chain transplantations that were facilitated by a multicenter US database in which 57 centers pooled incompatible donor/recipient pairs. Chains, initiated by nondirected donors, were identified using a computer algorithm incorporating virtual cross-matches and potential to extend chains. The first 54 chains facilitated 272 kidney transplants (mean chain length = 5.0). Seven chains ended because potential donors became unavailable to donate after their recipient received a kidney; however, every recipient whose intended donor donated was transplanted. The remaining 47 chains were eventually closed by having the last donor donate to the waiting list. Of the 272 chain recipients 46% were ethnic minorities and 63% of grafts were shipped from other centers. The number of blood type O-patients receiving a transplant (n = 90) was greater than the number of blood type O-non-directed donors (n = 32) initiating chains. We have 1-year follow up on the first 100 transplants. The mean 1-year creatinine of the first 100 transplants from this series was 1.3 mg/dL. Chain transplantation enables many recipients with immunologically incompatible donors to be transplanted with high quality grafts.

    View details for DOI 10.1111/j.1600-6143.2012.04156.x

    View details for PubMedID 22812922

  • General Surgery Resident Remediation and Attrition A Multi-institutional Study ARCHIVES OF SURGERY Yaghoubian, A., Galante, J., Kaji, A., Reeves, M., Melcher, M., Salim, A., Dolich, M., de Virgilio, C. 2012; 147 (9): 829-833

    Abstract

    To determine the rates and predictors of remediation and attrition among general surgery residents.Eleven-year retrospective analysis of 348 categorical general surgery residents at 6 West Coast programs.Rates and predictors of remediation and attrition.Three hundred forty-eight categorical general surgery residents were included. One hundred seven residents (31%) required remediation, of which 27 were remediated more than once. Fifty-five residents (15.8%) left their programs, although only 2 were owing to failed remediation. Remediation was not a predictor of attrition (20% attrition for those remediated vs 15% who were not [P = .40]). Remediation was most frequently initiated owing to a deficiency in medical knowledge (74%). Remediation consisted of monthly meetings with faculty (79%), reading assignments (72%), required conferences (27%), therapy (12%), and repeating a clinical year (6.5%). On univariate analysis, predictors of remediation included receiving honors in the third-year surgery clerkship, United States Medical Licensing Examination (USMLE) step 1 and/or step 2, and American Board of Surgery In-Training Examination scores at postgraduate years 1 through 4. On multivariable regression analysis, remediation was associated with receiving honors in surgery (odds ratio, 1.9; P = .01) and USMLE step 1 score (odds ratio, 0.9; P = .02). On univariate analysis, the only predictor of attrition was the American Board of Surgery In-Training Examination score at the postgraduate year 3 level (P = .04).Almost one third of categorical general surgery residents required remediation during residency, which was most often owing to medical knowledge deficits. Lower USMLE step 1 scores were predictors of the need for remediation. Most remediated residents successfully completed the program. Given the high rates of remediation and the increased educational burden on clinical faculty, medical schools need to focus on better preparing students to enter surgical residency.

    View details for Web of Science ID 000308883700013

    View details for PubMedID 22987173

  • Incidental kidney stones: a single center experience with kidney donor selection CLINICAL TRANSPLANTATION Kim, I. K., Tan, J. C., Lapasia, J., Elihu, A., Busque, S., Melcher, M. L. 2012; 26 (4): 558-563

    Abstract

    The presence of kidney stones has been a relative contraindication for living donation. With the widespread use of more sensitive imaging techniques as part of the routine living donor workup, kidney stones are more frequently detected, and their clinical significance in this setting is largely unknown. Records from 325 potential kidney donors who underwent MRA or CT-angiography were reviewed; 294 proceeded to donation. The prevalence of kidney stones found incidentally during donor evaluation was 7.4% (24 of 325). Sixteen donors with stones proceeded with kidney donation. All incidental calculi were nonobstructing and small (median 2 mm; range 1-9 mm). Eleven recipients were transplanted with allografts containing stones. One recipient developed symptomatic nephrolithasis after transplantation. This recipient was found to have newly formed stones secondary to hyperoxaluria, suggesting a recipient-driven propensity for stone formation. The remaining ten recipients have stable graft function, postoperative ultrasound negative for nephrolithiasis, and no sequelae from stones. No donor developed symptomatic nephrolithiasis following donation. Judicious use of allografts with small stones in donors with normal metabolic studies may be acceptable, and careful follow-up in recipients of such allografts is warranted.

    View details for DOI 10.1111/j.1399-0012.2011.01567.x

    View details for PubMedID 22168332

  • Multiple renal arteries and non-contrast magnetic resonance angiography in transplant renal artery stenosis. Clinical kidney journal Munoz Mendoza, J., Melcher, M. L., Daniel, B., Tan, J. C. 2012; 5 (3): 272-275

    View details for DOI 10.1093/ckj/sfs027

    View details for PubMedID 26069784

  • High Incidence of Recurrent Hepatocellular Carcinoma (HCC) in Patients Following Left-Sided Partial Hepatectomy Vergara, A., Ha, N. B., Gallo, A., Kim, L. H., Bonham, C., Esquivel, C. O., Concepcion, W., Melcher, M. L., Daugherty, T., Ayoub, W., Lutchman, G. A., Ahmed, A., Nguyen, M. H. W B SAUNDERS CO-ELSEVIER INC. 2012: S983-S984
  • Efficient Use of Unstandardized Virtual Crossmatching Enables Transplants through Multicenter Kidney Paired Donation Kamoun, M., Cecka, M., Baxter-Lowe, L. A., Milner, J., Veale, J. L., Leeser, D. B., Melcher, M. L. WILEY-BLACKWELL. 2012: 58
  • WAIT-TIME VARIES BY BLOOD-TYPE AND CALCULATED PANEL REACTIVE ANTIBODY FOR INCOMPATIBLE PAIRS IN KIDNEY EXCHANGE Veale, J., Melcher, M., Davis, C., Berger, E., Sinacore, J., Ronin, M., Hil, G., Milner, J. LIPPINCOTT WILLIAMS & WILKINS. 2012: E919-E920
  • EFFICIENT USE OF ONLINE PRE-SELECTED PAIRS FOLLOWED BY VIRTUAL CROSSMATCHING ENABLES TRANSPLANTS THROUGH MULTICENTER KIDNEY PAIRED DONATION (KPD) Kamoun, M., Cecka, M., Baxter-Lowe, L., Sinacore, J., Melcher, M. L. ELSEVIER SCIENCE INC. 2012: 68
  • High Proportion of Kidney Exchange Match Offers Fail for Logistical Reasons Kim, I., Milner, J. E., Veale, J., Leeser, D., Hil, G., Melcher, M. L. WILEY-BLACKWELL. 2012: 73
  • Potential Nutritional Conflicts in Bariatric and Renal Transplant Patients OBESITY SURGERY Lightner, A. L., Lau, J., Obayashi, P., Birge, K., Melcher, M. L. 2011; 21 (12): 1965-1970

    Abstract

    An increasing number of morbidly obese patients with end stage renal disease (ESRD) are sequentially undergoing bariatric surgery followed by renal transplantation. Discrepancies between the nutritional recommendations for obesity and chronic kidney disease (CKD) are often confusing for the obese patient in renal failure. However, when recommendations are structured according to stage and treatment of disease, a consistent plan can be clearly communicated to the patient. Therefore, to optimize patient and graft outcomes we present nutritional recommendations tailored to three patient populations: obese patients with ESRD, patients post Roux-en-Y gastric bypass (RYGBP) with ESRD, and patients post RYGBP and post renal transplantation.

    View details for DOI 10.1007/s11695-011-0423-0

    View details for PubMedID 21526378

  • Cytomegalovirus in the transplanted kidney: a report of two cases and review of prophylaxis. NDT plus Anand, S., Yabu, J. M., Melcher, M. L., Kambham, N., Laszik, Z., Tan, J. C. 2011; 4 (5): 342-345

    View details for DOI 10.1093/ndtplus/sfr074

    View details for PubMedID 25984184

  • Incidence and Predictors of Recurrent Hepatocellular Carcinoma (HCC) Following Partial Hepatectomy 76th Annual Scientific Meeting of the American-College-of-Gastroenterology Vergara, A. M., Gallo, A., Nghiem Ha, N., Bonham, C., Esquivel, C., Concepcion, W., Melcher, M., Daugherty, T., Ayoub, W., Lutchman, G., Ahmed, A., Mindie Nguyen, M. NATURE PUBLISHING GROUP. 2011: S103–S104
  • Managing Finances of Shipping Living Donor Kidneys for Donor Exchanges AMERICAN JOURNAL OF TRANSPLANTATION Mast, D. A., Vaughan, W., Busque, S., VEALE, J. L., Roberts, J. P., Straube, B. M., Flores, N., Canari, C., Levy, E., Tietjen, A., Hil, G., Melcher, M. L. 2011; 11 (9): 1810-1814

    Abstract

    Kidney donor exchanges enable recipients with immunologically incompatible donors to receive compatible living donor grafts; however, the financial management of these exchanges, especially when an organ is shipped, is complex and thus has the potential to impede the broader implementation of donor exchange programs. Representatives from transplant centers that utilize the National Kidney Registry database to facilitate donor exchange transplants developed a financial model applicable to paired donor exchanges and donor chain transplants. The first tenet of the model is to eliminate financial liability to the donor. Thereafter, it accounts for the donor evaluation, donor nephrectomy hospital costs, donor nephrectomy physician fees, organ transport, donor complications and recipient inpatient services. Billing between hospitals is based on Medicare cost report defined costs rather than charges. We believe that this model complies with current federal regulations and effectively captures costs of the donor and recipient services. It could be considered as a financial paradigm for the United Network for Organ Sharing managed donor exchange program.

    View details for DOI 10.1111/j.1600-6143.2011.03690.x

    View details for PubMedID 21831153

  • Successful Avoidance of Post-Transplant Antibody Mediated Rejection When Desensitizing Patients with IVIG: In Vitro C1q Test Predicts and Monitors In Vivo Efficacy and Time to Transplant Tyan, D., Yabu, J., Chen, G., Lou, C., Melcher, M., Scandling, J., Busque, S. WILEY-BLACKWELL. 2011: 91
  • Renal Transplants Can Be Performed in High CPRA Patients without a Prospective Crossmatch Tyan, D., Lou, C., Melcher, M., Scandling, J., Busque, S. WILEY-BLACKWELL. 2011: 58
  • Transporting Live Donor Kidneys for Kidney Paired Donation: Initial National Results AMERICAN JOURNAL OF TRANSPLANTATION Segev, D. L., VEALE, J. L., Berger, J. C., Hiller, J. M., Hanto, R. L., Leeser, D. B., GEFFNER, S. R., Shenoy, S., BRY, W. I., Katznelson, S., Melcher, M. L., Rees, M. A., Samara, E. N., Israni, A. K., Cooper, M., Montgomery, R. J., Malinzak, L., Whiting, J., Baran, D., Tchervenkov, J. I., Roberts, J. P., Rogers, J., Axelrod, D. A., Simpkins, C. E., Montgomery, R. A. 2011; 11 (2): 356-360

    Abstract

    Optimizing the possibilities for kidney-paired donation (KPD) requires the participation of donor-recipient pairs from wide geographic regions. Initially it was envisaged that donors would travel to the recipient center; however, to minimize barriers to participation and simplify logistics, recent trends have involved transporting the kidneys rather than the donors. The goal of this study was to review outcomes of this practice. KPD programs throughout the United States were directly queried about all transplants involving live donor kidney transport. Early graft function was assessed by urine output in the first 8 h, postoperative serum creatinine trend, and incidence of delayed graft function. Between April 27, 2007 and April 29, 2010, 56 live donor kidneys were transported among 30 transplant centers. Median CIT was 7.2 h (IQR 5.5-9.7, range 2.5-14.5). Early urine output was robust (>100 cc/h) in all but four patients. Creatinine nadir was <2.0 mg/dL in all (including the four with lower urine output) but one patient, occurring at a median of 3 days (IQR 2-5, range 1-49). No patients experienced delayed graft function as defined by the need for dialysis in the first week. Current evidence suggests that live donor kidney transport is safe and feasible.

    View details for DOI 10.1111/j.1600-6143.2010.03386.x

    View details for Web of Science ID 000286626700023

    View details for PubMedID 21272238

  • Sclerosing Peritonitis After Kidney Transplantation: A Not-So-Silky Cocoon DIGESTIVE DISEASES AND SCIENCES Morrow, E. H., Gallo, A. E., Melcher, M. L. 2011; 56 (2): 307-310

    View details for DOI 10.1007/s10620-010-1471-3

    View details for PubMedID 21063775

  • Donors with Kidney Stones: Should We Pass? Congress of the American-Society-of-Transplant-Surgeons Kim, I. K., Lapasia, J., Elihu, A., Tan, J., Scandling, J., Busque, S., Melcher, M. WILEY-BLACKWELL PUBLISHING, INC. 2011: 66–66
  • Cytomegalovirus in the transplanted kidney: a report of two cases and review of prophylaxis Nephrology Dialysis Transplantation Anand S, Yabu JM, Melcher ML, Kambham N, Laszik Z, Tan JC. 2011; 4 (5): 342-345
  • Population Pharmacokinetic Analysis of Mycophenolic Acid Coadministered With Either Tasocitinib (CP-690,550) or Tacrolimus in Adult Renal Allograft Recipients THERAPEUTIC DRUG MONITORING Lamba, M., Tafti, B., Melcher, M., Chan, G., Krishnaswami, S., Busque, S. 2010; 32 (6): 778-781

    Abstract

    Tasocitinib (CP-690,550) is an orally active Janus kinase inhibitor that is in development for prophylaxis of acute rejection after kidney transplantation and for the treatment of select autoimmune diseases. The current study was conducted to evaluate the systemic exposure of mycophenolic acid (MPA) in de novo kidney transplant patients when coadministered with tasocitinib compared with exposure in patients receiving tacrolimus, which has no effect on MPA pharmacokinetics. Plasma MPA concentrations were obtained from 17 adult patients who received either 15 mg or 30 mg tasocitinib twice daily (eight patients) or tacrolimus (nine patients) after kidney transplantation. All patients also received concomitant mycophenolate mofetil, prednisone, and basiliximab induction. The median mycophenolate mofetil dose was 1000 mg twice daily. A two-compartment population pharmacokinetic model estimating oral clearance, between-patient variability in oral clearance, central volume of distribution, and residual variability in combination with historical estimates of first-order absorption rate constant, intercompartmental clearance, and peripheral volume of distribution adequately described the sparse MPA data. Based on individual estimates oral clearance from the population pharmacokinetic model, mean steady-state area under the concentration-time curve values for a mycophenolate mofetil dose of 1000 mg twice daily were 63 mg·hr/L (22%) and 59 mg·hr/L (36%) for the tasocitinib and tacrolimus groups, respectively. These results indicate that tasocitinib does not influence systemic MPA exposure.

    View details for DOI 10.1097/FTD.0b013e3181f361c9

    View details for Web of Science ID 000284103400017

    View details for PubMedID 20926996

  • Outcomes of surgical repair of bile leaks and strictures after adult-to-adult living donor liver transplant CLINICAL TRANSPLANTATION Melcher, M. L., Freise, C. E., Ascher, N. L., Roberts, J. P. 2010; 24 (6): E230-E235

    Abstract

    We sought to determine factors that predict the successful surgical repair of biliary complications after adult living donor liver transplantation (ALDLT).Records of 82 consecutive ALDLT right lobe recipients were reviewed. Operations were performed on 19 recipients for biliary complications. Post-operative biliary complications were analyzed. Fisher's exact test was used to identify variables that correlated with successful surgical repair.A total of 29 recipients had biliary complications, of which 19 had a surgical repair. The five recipients, operated on for a stricture without history of leaks, did not develop further complications. However, nine of 14 with a history of a leak developed further complications after surgical repair (p-value = 0.044). All five who presented with a biliary complication more than 100 d after transplant had successful surgical repair; however, nine out of 13 who presented within 57 d had additional complications after repair.Operations for strictures after ALDLT are more successful than operations for leaks. Recipients with isolated biliary strictures after ALDLT can be managed surgically; however, recipients with history of a leak often require additional interventions after surgical repair.

    View details for DOI 10.1111/j.1399-0012.2010.01289.x

    View details for PubMedID 20529098

  • Comparison of biliary complications in adult living-donor liver transplants performed at two busy transplant centers CLINICAL TRANSPLANTATION Melcher, M. L., Pomposelli, J. J., Verbesey, J. E., McTaggart, R. A., Freise, C. E., Ascher, N. L., Roberts, J. P., Pomfret, E. A. 2010; 24 (5): E137-E144

    Abstract

    Adult living-donor liver transplantation (ALDLT) has a high rate of biliary complications. We identified risk factors that correlate with biliary leaks and strictures by combining data from two centers. Records of ALDLT right lobe recipients (n = 156) at two centers between December 1998 and February 2005 were reviewed. Leak rate was analyzed in 144 recipients after we excluded those with hepatic artery thrombosis or death within 30 d of transplant. Stricture rate was also analyzed in 132 recipients after we excluded those with graft survival or follow-up <180 d. Biliary reconstructions were performed using either duct-to-duct (DD) or Roux-en-Y hepaticojejunostomy and were subclassified by anatomic type, number of anastomoses performed, and stent use. Prevalence of a leak and/or a stricture was 39%; 11% of recipients developed both. Single DD anastomoses between the graft right hepatic duct to the recipient common duct had significantly lower incidence of leaks compared to all other anastomotic types. Early leak was predictive of late stricture development (p = 0.006), but recipient demographics, diagnosis, warm ischemia time, anastomosis type, duct number, year of transplant, stent use, and transplant center were not. The results suggest donors with a single right hepatic duct reconstructed to the recipient common bile duct are the most likely to avoid biliary problems after ALDLT.

    View details for DOI 10.1111/j.1399-0012.2009.01189.x

    View details for PubMedID 20047615

  • Predicting Performance on the American Board of Surgery Qualifying and Certifying Examinations A Multi-institutional Study ARCHIVES OF SURGERY de Virgilio, C., Yaghoubian, A., Kaji, A., Collins, J. C., Deveney, K., Dolich, M., Easter, D., Hines, O. J., Katz, S., Liu, T., Mahmoud, A., Melcher, M. L., Parks, S., Reeves, M., Salim, A., Scherer, L., Takanishi, D., Waxman, K. 2010; 145 (9): 852-856

    Abstract

    We sought to determine whether US Medical Licensing Examination (USMLE) Step 1 score, American Board of Surgery (ABS) In-Training Examination (ABSITE) score, and other variables are associated with failing the ABS qualifying and certifying examinations. Identifying such factors may assist in the early implementation of an academic intervention for at-risk residents.Retrospective review.Seventeen general surgery training programs in the western United States.Six hundred seven residents who graduated in 2000-2007.First-time pass rates on the qualifying and certifying examinations, US vs non-US medical school graduation, USMLE Steps 1 and 2 scores, ABSITE scores, operative case volume, fellowship training, residency program type, and mandatory research.The first-time qualifying and certifying examination pass rates for the 607 graduating residents were 78% and 74%, respectively. On multivariable analysis, scoring below the 35th percentile on the ABSITE at any time during residency was associated with an increased risk of failing both examinations (odds ratio, 0.23 [95% confidence interval, 0.08-0.68] for the qualifying examination and 0.35 [0.20-0.61] for the certifying examination), as was scoring less than 200 on the USMLE Step 1 (0.36 [0.21-0.62] for the qualifying examination and 0.62 [0.42-0.93] for the certifying examination). A mandatory research year was associated with an increased likelihood of passing the certifying examination (odds ratio, 3.3 [95% confidence interval, 1.6-6.8]).Residents who are more likely to fail the ABS qualifying and certifying examinations can be identified by a low USMLE Step 1 score and by poor performance on the ABSITE at any time during residency. These findings support the use of the USMLE Step 1 score in the surgical residency selection process and a formal academic intervention for residents who perform poorly on the ABSITE.

    View details for Web of Science ID 000281764400010

    View details for PubMedID 20855755

  • Impact of Short Term Pre-Transplant Dialysis on Kidney Transplant Outcomes 10th American Transplant Congress Javaid, B., Kim, J., Yabu, J., Tan, J., Melcher, M., Busque, S., Scandling, J. WILEY-BLACKWELL. 2010: 525–525
  • Chain Donation Can Dramatically Reduce the Wait Time of Individuals Awaiting Kidney Transplant. Melcher, M. L., Leeser, D. B., Katznelson, S., Gritch, H., Bry, W., Hil, G., Busque, S., Mulgaonkar, S., Yang, H., Roberts, J., Kapur, S., Jeffery, V. L. WILEY-BLACKWELL. 2010: 277
  • Transporting Kidneys for Live Donor Kidney Transplants: National Results Segev, D., Veale, J., Leeser, D., Hiller, J., Bry, W., Melcher, M., Malinzak, L., Katznelson, S., Tchervenkov, J., Kapur, S., Hanto, R., Roberts, J., Rees, M., Montgomery, R. WILEY-BLACKWELL PUBLISHING, INC. 2010: 79-80
  • NEAD Chain Transplantation Does Not Favor Less Sensitized Patients. Melcher, M. L., Leeser, D. B., Katznelson, S., Busque, S., Mulgaonkar, S., Bry, W., Gritsch, H., Yang, H., Hil, G., Roberts, J., Kapur, S., Veale, J. L. WILEY-BLACKWELL. 2010: 277
  • Wealthy Patients Are More Likely To Be Listed at Multiple Transplant Centers and Be Transplanted. Melcher, M. L., Javaid, B., Esquivel, C. O. WILEY-BLACKWELL PUBLISHING, INC. 2010: 288
  • Risk of Graft Failure Due to Disease Recurrence in Patients with FSGS 10th American Transplant Congress Kim, J., Yabu, J., Tan, J., Scandling, J., Melcher, M., Busque, S., Javaid, B. WILEY-BLACKWELL. 2010: 196–197
  • Liver Allograft Won't Always Immunologically Protect a Simultaneous Kidney Transplant Melcher, M. L., Pando, M. J., Tyan, D., Concepcion, W., Bonham, C. A., Busque, S. WILEY-BLACKWELL PUBLISHING, INC. 2010: 63-64
  • Asynchronous, Out-of-Sequence, Transcontinental Chain Kidney Transplantation: A Novel Concept AMERICAN JOURNAL OF TRANSPLANTATION Butt, F. K., Gritsch, H. A., Schulam, P., Danovitch, G. M., Wilkinson, A., Del Pizzo, J., Kapur, S., Serur, D., Katznelson, S., Busque, S., Melcher, M. L., McGuire, S., Charlton, M., Hil, G., Veale, J. L. 2009; 9 (9): 2180-2185

    Abstract

    The organ donor shortage has been the most important hindrance in getting listed patients transplanted. Living kidney donors who are incompatible with their intended recipients are an untapped resource for expanding the donor pool through participation in transplant exchanges. Chain transplantation takes this concept further, with the potential to benefit even more recipients. We describe the first asynchronous, out of sequence transplant chain that was initiated by transcontinental shipment of an altruistic donor kidney 1 week after that recipient's incompatible donor had already donated his kidney to the next recipient in the chain. The altruistic donor kidney was transported from New York to Los Angeles and functioned immediately after transplantation. Our modified-sequence asynchronous transplant chain (MATCH) enabled eight recipients, at four different institutions, to benefit from the generosity of one altruistic donor and warrants further exploration as a promising step toward addressing the organ donor shortage.

    View details for DOI 10.1111/j.1600-6143.2009.02730.x

    View details for Web of Science ID 000269180500027

    View details for PubMedID 19563335

  • Recovery of Renal Function in a Dialysis-Dependent Patient Following Gastric Bypass Surgery OBESITY SURGERY Tafti, B. A., Haghdoost, M., ALVAREZ, L., Curet, M., Melcher, M. L. 2009; 19 (9): 1335-1339

    Abstract

    There is increasing evidence that obesity, independently from other comorbidities such as diabetes and hypertension, can cause renal dysfunction. While this indolent dysfunction may be asymptomatic, it can render patients more susceptible to renal insufficiency when the kidneys are further injured by other pathological processes. Here, we present a morbidly obese patient whose type-A aortic dissection was complicated by acute renal failure that subsequently progressed into end-stage renal disease. However, his renal function improved dramatically following substantial weight reduction after gastric bypass surgery obviating the need for dialysis and transplantation. The potential mechanisms by which a patient's obesity may lead to renal dysfunction are discussed. This case and other similar reports suggest that obese patients with renal failure can safely undergo bariatric surgery and that bariatric surgery may have a role in treating chronic kidney disease in select morbidly obese patients.

    View details for DOI 10.1007/s11695-009-9907-6

    View details for PubMedID 19693639

  • TARGETED QUANTITATIVE METABOLOMICS IN RATS DURING EARLY REPERFUSION. Dang, K., Melcher, M. L., Park, Y., Serkova, N. J., Niemann, C. U. JOHN WILEY & SONS INC. 2009: S176
  • Postoperative infectious complications of abdominal solid organ transplantation. Journal of intensive care medicine Hlava, N., Niemann, C. U., Gropper, M. A., Melcher, M. L. 2009; 24 (1): 3-17

    Abstract

    There is a rapidly growing population of immunocompromised organ transplant recipients. These patients are at risk of a large variety of infections that have significant consequences on mortality, graft dysfunction, and graft loss. The diagnosis and treatment of these infections are facilitated by an understanding of the preoperative, perioperative, and postoperative risk factors; the typical pathogens; and their characteristic time of presentation. On the basis of these factors, we put forth an algorithm for diagnosing and treating suspected infections in solid organ transplant recipients.

    View details for DOI 10.1177/0885066608327127

    View details for PubMedID 19017663

  • The MATCH: Modified-Sequence Asynchronous Transplant Chain. Butt, F. K., Gritsch, H., Schulam, P., Danovitch, G., Wilkinson, A., Del Pizzo, J., Kapur, S., Serur, D., Katznelson, S., Busque, S., Melcher, M. L., McGuire, S., Charlton, M., Hil, G., Veale, J. L. WILEY-BLACKWELL PUBLISHING, INC. 2009: 284-285
  • Accounting for Donor Charges in Kidney Donor Chains. 9th Joint Meeting of the American-Society-of-Transplant-Surgeon/American-Society-of-Transplantation Melcher, M. L., Veale, J., Mast, D., Standridge, K., Goldberg, S., MOYLE, C., Flores, N., Busque, S. WILEY-BLACKWELL. 2009: 435–436
  • "Something Special in the Air": Transcontinental Shipments of Living Donor Kidneys for Transplantation. 9th Joint Meeting of the American-Society-of-Transplant-Surgeon/American-Society-of-Transplantation Veale, J. L., Butt, F. K., Gritsch, H. A., Danovitch, G., Wilkinson, A., Schulam, P., Del Pizzo, J., Kapur, S., Leeser, D., Serur, D., Katznelson, S., Busque, S., Melcher, M. L., McGuire, S., Charlton, M., Hil, G., Cecka, J. M. WILEY-BLACKWELL. 2009: 435–435
  • Overcoming Immunological Barriers to Living Donor Kidney Transplantation At Stanford University Medical Center SGH Proceedings Ladner DP, Busque S, Melcher ML 2008; 17 (1): 5-19
  • Thymoglobulin-associated Cd4+ T-cell depletion and infection risk in HIV-infected renal transplant recipients AMERICAN JOURNAL OF TRANSPLANTATION Carter, J. T., Melcher, M. L., Carlson, L. L., Roland, M. E., Stock, P. G. 2006; 6 (4): 753-760

    Abstract

    HIV-infected patients are increasingly referred for kidney transplantation, and may be at an increased risk for rejection. Treatment for rejection frequently includes thymoglobulin. We studied thymoglobulin's effect on CD4+ T-cell count, risk of infection and rejection reversal in 20 consecutive HIV-infected kidney recipients. All patients used antiretroviral therapy and opportunistic infection prophylaxis. Maintenance immunosuppression consisted of prednisone, mycophenolate mofetil and cyclosporine. Eleven patients received thymoglobulin (7 for rejection and 4 for delayed/slow graft function) while 9 did not. These two groups were similar in age, gender, race, donor characteristics and immunosuppression. Mean CD4+ T-cell counts remained stable in patients who did not receive thymoglobulin, but became profoundly suppressed in those who did, decreasing from 475 +/- 192 to 9 +/- 10 cells/microL (p < 0.001). Recovery time ranged from 3 weeks to 2 years despite effective HIV suppression. Although opportunistic infections were successfully suppressed, low CD4+ T-cell count was associated with increased risk of serious infections requiring hospitalization. Rejection reversed in 6 of 7 patients receiving thymoglobulin. We conclude that thymoglobulin reverses acute rejection in HIV-infected kidney recipients, but produces profound and long-lasting suppression of the CD4+ T-cell count associated with increased risk of infections requiring hospitalization.

    View details for DOI 10.1111/j.1600-6143.2006.01238.x

    View details for Web of Science ID 000235839900015

    View details for PubMedID 16539632

  • Antibody-mediated rejection of a pancreas allograft AMERICAN JOURNAL OF TRANSPLANTATION Melcher, M. L., Olson, J. L., Baxter-Lowe, L. A., Stock, P. G., Posselt, A. M. 2006; 6 (2): 423-428

    Abstract

    The role of antibody-mediated rejection (AMR) in pancreas transplantation is poorly understood. Here, we report on a patient who developed AMR of his pancreas allograft after receiving a simultaneous pancreas-kidney transplant. Pre-operative enhanced cytotoxicity and flow cytometry T-cell crossmatches were negative; B-cell crossmatches were not performed as per institutional protocol. The patient's post-operative course was significant for elevated serum amylase levels and development of hyperglycemia approximately 1 month after transplantation. A pancreatic biopsy at this time showed no cellular infiltrate but strong immunofluorescent staining for C4d in the interacinar capillaries. Analysis of the patient's serum identified donor-specific HLA-DR alloantibodies. He received intravenous immunoglobulin (IVIg), rituximab and plasmapheresis, and his pancreatic function normalized. We conclude that clinically significant AMR can develop in a pancreas allograft and recommend that pancreatic biopsies be assessed for C4d deposition if the patient has risk factors for AMR and/or the pathologic evidence for cell-mediated rejection is underwhelming.

    View details for DOI 10.1111/j.1600-6143.2005.01185.x

    View details for Web of Science ID 000234735200025

    View details for PubMedID 16426331

  • Spontaneous splenic rupture: The masquerade of minor trauma 35th Annual Meeting of the Western-Trauma-Association Tataria, M., Dicker, R. A., Melcher, M., Spain, D. A., Brundage, S. I. LIPPINCOTT WILLIAMS & WILKINS. 2005: 1228–30

    View details for DOI 10.1097/01.ta.0000196439.77828.9d

    View details for PubMedID 16385305

  • Safety and efficacy of thymoglobulin in HIV-positive renal transplant recipients Carter, J. T., Melcher, M. L., Carlson, L. L., Roland, M. E., Freise, C. E., Hirose, R., Stock, P. G. BLACKWELL PUBLISHING. 2005: 547
  • Gastric carcinoid tumors in multiple endocrine neoplasia-1 patients with Zollinger-Ellison syndrome can be symptomatic, demonstrate aggressive growth, and require surgical treatment 25th Annua Meeting of the American-Association-of-Endocrine-Surgeons NORTON, J. A., Melcher, M. L., Gibril, F., Jensen, R. T. MOSBY-ELSEVIER. 2004: 1267–73

    Abstract

    Gastric carcinoid tumors occur in 15% to 50% of patients with multiple endocrine neoplasia-1/Zollinger-Ellison syndrome (MEN-1/ZES) but are thought to be benign. We report 5 patients with MEN-1/ZES with symptomatic, aggressive gastric carcinoid tumors that required surgical procedures.This was a retrospective chart review.Each patient had MEN-1/ZES. Each patient had innumerable gastric carcinoid tumors with symptoms. The fasting gastrin level was 47,000 pg/mL (normal, <200 pg/mL); the basal acid output was 79 mEq/hr (n = 3), and the age at surgical exploration was 47 +/- 6 years, with a duration of MEN-1 of 21 +/- 3 years and of ZES of 15 +/- 2 years. All patients had elevated 5-HIAA or serotonin levels. Somatostatin receptor scintigraphy showed increased stomach uptake in 4 patients (80%). Four patients had a total gastrectomy; 4 patients had lymph node metastases removed, and 3 patients had liver metastases resected. One patient who did not have a total gastrectomy had liver carcinoid metastases.These results demonstrate that gastric carcinoid tumors in patients with longstanding MEN-1/ZES may be symptomatic, aggressive, and metastasize to the liver. With increased long-term medical treatment and life expectancy, these tumors will become an important determinant of survival.

    View details for DOI 10.1016/j.surg.2004.06.057

    View details for PubMedID 15657586

  • A novel technique to treat ruptured umbilical hernias in patients with liver cirrhosis and severe ascites JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES-PART A Melcher, M. L., Lobato, R. L., Wren, S. M. 2003; 13 (5): 331-332

    Abstract

    The full-thickness skin erosion (rupture) of an umbilical hernia in a patient with end-stage liver disease can lead to significant morbidity and mortality. Here, we present a case report of the use of a novel technique to treat a patient with this condition. The use of a fibrin-based tissue adhesive provides a means of managing such patients medically.

    View details for PubMedID 14617394

  • Ileocolic intussusception in an adult JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Melcher, M. L., Safadi, B. 2003; 197 (3): 518-518

    View details for DOI 10.1016/S1072-7515(03)00589-1

    View details for PubMedID 12946809

  • Identification and characterization of the CLK1 gene product, a novel CaM kinase-like protein kinase from the yeast Saccharomyces cerevisiae JOURNAL OF BIOLOGICAL CHEMISTRY Melcher, M. L., Thorner, J. 1996; 271 (47): 29958-29968

    Abstract

    The CLK1 gene of Saccharomyces cerevisiae encodes a 610-residue protein kinase that resembles known type II Ca2+/calmodulin-dependent protein kinases (CaM kinases), including the CMK1 and CMK2 gene products from the same yeast. The Clk1 kinase domain is preceded by a 162-residue N-terminal extension, followed by a 132-residue C-terminal extension (which contains a basic segment resembling known calmodulin-binding sites) and is as similar to mammalian CaM kinase (38% identity to rat CaM kinase alpha) as it is to yeast CaM kinase (37% identity to Cmk2). However, Clk1 shares 52% identity with Rck1, another putative protein kinase encoded in the S. cerevisiae genome. Clk1 tagged with a c-myc epitope (expressed in yeast) and a GST-Clk1 fusion (expressed in bacteria) underwent autophosphorylation and phosphorylated an exogenous substrate (yeast protein synthesis elongation factor 2), primarily on Ser. Neither Clk1 activity was stimulated by purified yeast calmodulin (CMD1 gene product), with or without Ca2+; no association of Clk1 with Cmd1 was detectable by other methods. C-terminally truncated Clk1(Delta487-610) was growth-inhibitory when overexpressed, whereas catalytically inactive Clk1(K201R Delta487-610) was not, suggesting that the C terminus is a negative regulatory domain. Using immunofluorescence, Clk1 was localized to the cytosol and excluded from the nucleus. A clk1Delta mutant, a clk1Delta rck1Delta double mutant, a clk1Delta cmk1Delta cmk2Delta triple mutant, and a clk1Delta rck1Delta cmk1Delta cmk2Delta quadruple mutant were all viable and manifested no other overt growth phenotype.

    View details for Web of Science ID A1996VU52500069

    View details for PubMedID 8939941