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Piñero F, Marciano S, Villamil A, Bandi J, Casciato P, Galdame O, Giannasi S, de Santibañes E, Gadano A. Sicker Patients for Liver Transplantation: Meld, Meld Sodium, and Integrated Meld’s Prognostic Accuracy in the Assessment of Posttransplantation Events at a Single Center from Argentina. ACTA ACUST UNITED AC 2013. [DOI: 10.5402/2013/102590] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background. MELD or MELD sodium promotes sicker patients for earlier liver transplantation (LT); the balance between pre- and post-LT outcomes is still controversial. Aim. To compare MELD and related scores’ risk assessment of short-term morbidity and mortality after LT. Methods. We included only transplanted cirrhotic patients from 6/2005 to 6/2010 (). Immediate pre-LT MELD, integrated MELD (iMELD), and two MELD sodium formulas “MELD Na1” and “MELDNa2” were calculated. Results. Pre-LT scores for nonsurvivors were higher than those for survivors: MELD (28 ± 8 versus 22 ± 7, ), MELD Na1 (33 ± 8 versus 27 ± 10, ), and iMELD (51 ± 6 versus 46 ± 8, ). Patient survival assessment was performed by AUROC analysis (95% CI): MELD 0.694 (0.56–0.82; ), MELD Na1 0.682 (0.56–0.79; ), MELD Na2 0.651 (0.54–0.76; ), and iMELD 0.698 (0.593–0.80; ). Patients with MELD ≥25 points had longer intensive care stay (mean 10 versus 7 days, ) and longer mechanical ventilatory support (5.4 versus 1.9 days, ). Conclusions. The addition of serum sodium to MELD does not improve assessment of mortality after LT. Patients with higher MELD may preclude higher morbidity after transplantation.
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Affiliation(s)
- Federico Piñero
- Hepatology Unit, Hospital Italiano de Buenos Aires, Avenida Presidente Perón 1500, Derqui, B1629HJ Buenos Aires, Argentina
- Liver Transplant Unit, Hospital Italiano de Buenos Aires, Avenida Presidente Perón 1500, Derqui, B1629HJ Buenos Aires, Argentina
| | - Sebastián Marciano
- Hepatology Unit, Hospital Italiano de Buenos Aires, Avenida Presidente Perón 1500, Derqui, B1629HJ Buenos Aires, Argentina
- Liver Transplant Unit, Hospital Italiano de Buenos Aires, Avenida Presidente Perón 1500, Derqui, B1629HJ Buenos Aires, Argentina
| | - Alejandra Villamil
- Hepatology Unit, Hospital Italiano de Buenos Aires, Avenida Presidente Perón 1500, Derqui, B1629HJ Buenos Aires, Argentina
- Liver Transplant Unit, Hospital Italiano de Buenos Aires, Avenida Presidente Perón 1500, Derqui, B1629HJ Buenos Aires, Argentina
| | - Juan Bandi
- Hepatology Unit, Hospital Italiano de Buenos Aires, Avenida Presidente Perón 1500, Derqui, B1629HJ Buenos Aires, Argentina
- Liver Transplant Unit, Hospital Italiano de Buenos Aires, Avenida Presidente Perón 1500, Derqui, B1629HJ Buenos Aires, Argentina
| | - Paola Casciato
- Hepatology Unit, Hospital Italiano de Buenos Aires, Avenida Presidente Perón 1500, Derqui, B1629HJ Buenos Aires, Argentina
- Liver Transplant Unit, Hospital Italiano de Buenos Aires, Avenida Presidente Perón 1500, Derqui, B1629HJ Buenos Aires, Argentina
| | - Omar Galdame
- Hepatology Unit, Hospital Italiano de Buenos Aires, Avenida Presidente Perón 1500, Derqui, B1629HJ Buenos Aires, Argentina
- Liver Transplant Unit, Hospital Italiano de Buenos Aires, Avenida Presidente Perón 1500, Derqui, B1629HJ Buenos Aires, Argentina
| | - Sergio Giannasi
- Adult Intensive Care Unit, Hospital Italiano de Buenos Aires, Avenida Presidente Perón 1500, Derqui, B1629HJ Buenos Aires, Argentina
| | - Eduardo de Santibañes
- Liver Transplant Unit, Hospital Italiano de Buenos Aires, Avenida Presidente Perón 1500, Derqui, B1629HJ Buenos Aires, Argentina
| | - Adrian Gadano
- Hepatology Unit, Hospital Italiano de Buenos Aires, Avenida Presidente Perón 1500, Derqui, B1629HJ Buenos Aires, Argentina
- Liver Transplant Unit, Hospital Italiano de Buenos Aires, Avenida Presidente Perón 1500, Derqui, B1629HJ Buenos Aires, Argentina
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52
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Croome KP, Hernandez-Alejandro R, Chandok N. Early allograft dysfunction is associated with excess resource utilization after liver transplantation. Transplant Proc 2013; 45:259-64. [PMID: 23375312 DOI: 10.1016/j.transproceed.2012.07.147] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Accepted: 07/19/2012] [Indexed: 12/27/2022]
Abstract
BACKGROUND There are limited data on length of stay (LOS) following liver transplantation (LT), yet this is an important health services metric that directly correlates with early post-LT health care costs. The primary objective of this study was to examine the relationship between early allograft dysfunction (EAD) and LOS after LT. The secondary objective was to identify additional recipient, donor, and operative factors associated with LOS. METHODS Adult patients undergoing primary LT over a 32-month period were prospectively examined at a single center. Subjects fulfilling standard criteria for EAD were compared with those not meeting the definition. Variables associated with increased LOS on ordinal logistic regression were identified. RESULTS Subjects with EAD had longer mean hospital LOS than those without (42.5 ± 38.9 days vs 27.4 ± 31 days; P = .003). Subjects with EAD also had longer mean intensive care LOS (8.61 ± 10.28 days vs 5.45 ± 11.6 days; P = .048). Additional factors significantly associated with LOS included Model for End-Stage Liver Disease (MELD) score, recipient location before LT, and postoperative surgical complications. CONCLUSIONS EAD is associated with longer hospitalization after LT. MELD score, preoperative recipient location, and postoperative complications were significantly associated with LOS. From a cost-containment perspective, these findings have implications on resource allocation.
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Affiliation(s)
- K P Croome
- Multi-Organ Transplant Program, London Health Sciences Centre, Western University, London, Ontario, Canada
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54
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Survival outcomes of right-lobe living donor liver transplantation for patients with high Model for End-stage Liver Disease scores. Hepatobiliary Pancreat Dis Int 2013; 12:256-62. [PMID: 23742770 DOI: 10.1016/s1499-3872(13)60042-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Controversy exists over whether living donor liver transplantation (LDLT) should be offered to patients with high Model for End-stage Liver Disease (MELD) scores. This study tried to determine whether a high MELD score would result in inferior outcomes of right-lobe LDLT. METHODS Among 411 consecutive patients who received right-lobe LDLT at our center, 143 were included in this study. The patients were divided into two groups according to their MELD scores: a high-score group (MELD score ≥25; n=75) and a low-score group (MELD score <25; n=68). Their demographic data and perioperative conditions were compared. Univariable and multivariable analyses were performed to identify risk factors affecting patient survival. RESULTS In the high-score group, more patients required preoperative intensive care unit admission (49.3% vs 2.9%; P<0.001), mechanical ventilation (21.3% vs 0%; P<0.001), or hemodialysis (13.3% vs 0%; P=0.005); the waiting time before LDLT was shorter (4 vs 66 days; P<0.001); more blood was transfused during operation (7 vs 2 units; P<0.001); patients stayed longer in the intensive care unit (6 vs 3 days; P<0.001) and hospital (21 vs 15 days; P=0.015) after transplantation; more patients developed early postoperative complications (69.3% vs 50.0%; P=0.018); and values of postoperative peak blood parameters were higher. However, the two groups had comparable hospital mortality. Graft survival and patient overall survival at one year (94.7% vs 95.6%; 95.9% vs 96.9%), three years (91.9% vs 92.6%; 93.2% vs 95.3%), and five years (90.2% vs 90.2%; 93.2% vs 95.3%) were also similar between the groups. CONCLUSIONS Although the high-score group had significantly more early postoperative complications, the two groups had comparable hospital mortality and similar satisfactory rates of graft survival and patient overall survival. Therefore, a high MELD score should not be a contraindication to right-lobe LDLT if donor risk and recipient benefit are taken into full account.
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Donor-recipient matching: myths and realities. J Hepatol 2013; 58:811-20. [PMID: 23104164 DOI: 10.1016/j.jhep.2012.10.020] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Revised: 09/17/2012] [Accepted: 10/13/2012] [Indexed: 12/23/2022]
Abstract
Liver transplant outcomes keep improving, with refinements of surgical technique, immunosuppression and post-transplant care. However, these excellent results and the limited number of organs available have led to an increasing number of potential recipients with end-stage liver disease worldwide. Deaths on waiting lists have led liver transplant teams maximize every organ offered and used in terms of pre and post-transplant benefit. Donor-recipient (D-R) matching could be defined as the technique to check D-R pairs adequately associated by the presence of the constituents of some patterns from donor and patient variables. D-R matching has been strongly analysed and policies in donor allocation have tried to maximize organ utilization whilst still protecting individual interests. However, D-R matching has been written through trial and error and the development of each new score has been followed by strong discrepancies and controversies. Current allocation systems are based on isolated or combined donor or recipient characteristics. This review intends to analyze current knowledge about D-R matching methods, focusing on three main categories: patient-based policies, donor-based policies and combined donor-recipient systems. All of them lay on three mainstays that support three different concepts of D-R matching: prioritarianism (favouring the worst-off), utilitarianism (maximising total benefit) and social benefit (cost-effectiveness). All of them, with their pros and cons, offer an exciting controversial topic to be discussed. All of them together define D-R matching today, turning into myth what we considered a reality in the past.
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Outcomes After Liver Transplantation in Patients Achieving a Model for End-Stage Liver Disease Score of 40 or Higher. Transplantation 2013; 95:507-12. [DOI: 10.1097/tp.0b013e3182751ed2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Lichtenstern C, Hochreiter M, Zehnter VD, Brenner T, Hofer S, Mieth M, Büchler MW, Martin E, Weigand MA, Schemmer P, Busch CJ. Pretransplant model for end stage liver disease score predicts posttransplant incidence of fungal infections after liver transplantation. Mycoses 2013; 56:350-7. [DOI: 10.1111/myc.12041] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Boerr E, Anders M, Mella J, Quiñonez E, Goldaracena N, Orozco F, McCormack L, Mastai R. [Cost analysis of liver transplantation in a community hospital: association with the Model for End-stage Liver Disease, a prognostic index to prioritize the most severe patients]. GASTROENTEROLOGIA Y HEPATOLOGIA 2012; 36:1-6. [PMID: 23123035 DOI: 10.1016/j.gastrohep.2012.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2012] [Revised: 08/23/2012] [Accepted: 08/28/2012] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The aim of the present study was to investigate the impact of the Model for End-stage Liver Disease (MELD) on transplantation costs. MATERIAL AND METHODS We included all patients who received a liver transplant for end-stage liver disease between 2006 and 2010. The study period encompassed the day of transplantation until hospital discharge. The patients were classified into two groups: those with a MELD score of 6-19 and those with a score of 20-40. RESULTS The mean MELD score at transplantation was 19.2±7.0 (mean±SD). The mean cost per procedure in the study period was USD 33,461 per patient (range 21,795-104,629). The cost of transplantation was USD 30,493±8,825 in patients with a MELD score of 6-19 and was USD 36,506±15,833 in those with a score of 20-40; this difference was statistically significant (P=.04). In a stepwise logistic regression analysis, the only independent predictor of high cost was having a MELD score of 20 (OR 11.8; CI 1.6-87). In the linear regression model, the most important predictor of cost was the length of hospital stay (r(2)=43%). DISCUSSION Our results demonstrate that the MELD score directly affects transplantation costs. We suggest that reimbursement systems compensate the distinct financing bodies according to the severity of the underlying disease, evaluated with the MELD.
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Affiliation(s)
- Elisabeth Boerr
- Programa de Trasplante Hepático, Hospital Alemán, Buenos Aires, Argentina
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59
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Abstract
Liver resection is the most available, efficient treatment for patients with hepatocellular carcinoma. Better liver function assessment, increased understanding of segmental liver anatomy using more accurate imaging studies, and surgical technical progress are the most important factors that have led to reduced mortality, with an expected 5 year survival of 70%. Impairment of liver function and the risk of tumor recurrence lead to consideration of liver transplantation (LT) as the ideal treatment for removal of the existing tumor and the preneoplastic underlying liver tissue. However, LT, which is not available in many countries, is restricted to patients with minimum risk of tumor recurrence under immunosuppression. Limited availability of grafts as well as the risk and the cost of the LT procedure has led to considerable interest in combined treatment involving resection and LT. An increasing amount of evidence has shown that initial liver resection in transplantable patients with a single limited tumor and good liver function is a valid indication. Histological analysis of specimens allows identification of the subgroup of patients who could benefit from follow-up with LT in case of recurrence.
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Affiliation(s)
- J. Belghiti
- *Jacques Belghiti, MD, Department of HPB Surgery and Transplantation, Beaujon Hospital, 100 Boulevard du Général Leclerc, 92118 Clichy Cedex (France), Tel. +33 1 40 87 58 95, E-Mail
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60
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Siciliano M, Parlati L, Maldarelli F, Rossi M, Ginanni Corradini S. Liver transplantation in adults: Choosing the appropriate timing. World J Gastrointest Pharmacol Ther 2012; 3:49-61. [PMID: 22966483 PMCID: PMC3437446 DOI: 10.4292/wjgpt.v3.i4.49] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2011] [Revised: 06/27/2012] [Accepted: 07/08/2012] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation is indicated in patients with acute liver failure, decompensated cirrhosis, hepatocellular carcinoma and rare liver-based genetic defects that trigger damage of other organs. Early referral to a transplant center is crucial in acute liver failure due to the high mortality with medical therapy and its unpredictable evolution. Referral to a transplant center should be considered when at least one complication of cirrhosis occurs during its natural history. However, because of the shortage of organ donors and the short-term mortality after liver transplantation on one hand and the possibility of managing the complications of cirrhosis with other treatments on the other, patients are carefully selected by the transplant center to ensure that transplantation is indicated and that there are no medical, surgical and psychological contraindications. Patients approved for transplantation are placed on the transplant waiting list and prioritized according to disease severity. Thus, the appropriate timing of transplantation depends on recipient disease severity and, although this is still a matter of debate, also on donor quality. These two variables are known to determine the “transplant benefit” (i.e., when the expected patient survival is better with, than without, transplantation) and should guide donor allocation.
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Affiliation(s)
- Maria Siciliano
- Maria Siciliano, Lucia Parlati, Federica Maldarelli, Stefano Ginanni Corradini, Department of Clinical Medicine, Division of Gastroenterology, Sapienza University of Rome, 00185 Rome, Italy
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Macomber CW, Shaw JJ, Santry H, Saidi RF, Jabbour N, Tseng JF, Bozorgzadeh A, Shah SA. Centre volume and resource consumption in liver transplantation. HPB (Oxford) 2012; 14:554-9. [PMID: 22762404 PMCID: PMC3406353 DOI: 10.1111/j.1477-2574.2012.00503.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Using SRTR/UNOS data, it has previously been shown that increased liver transplant centre volume improves graft and patient survival. In the current era of health care reform and pay for performance, the effects of centre volume on quality, utilization and cost are unknown. METHODS Using the UHC database (2009-2010), 63 liver transplant centres were identified that were organized into tertiles based on annual centre case volume and stratified by severity of illness (SOI). Utilization endpoints included hospital and intensive care unit (ICU) length of stay (LOS), cost and in-hospital mortality. RESULTS In all, 5130 transplants were identified. Mortality was improved at high volume centres (HVC) vs. low volume centres (LVC), 2.9 vs. 3.4%, respectively. HVC had a lower median LOS than LVC (9 vs. 10 days, P < 0.0001), shorter median ICU stay than LVC and medium volume centres (MVC) (2 vs. 3 and 3 days, respectively, P < 0.0001) and lower direct costs than LVC and MVC ($90,946 vs. $98,055 and $101,014, respectively, P < 0.0001); this effect persisted when adjusted for severity of illness. CONCLUSIONS This UHC-based cohort shows that increased centre volume results in improved long-term post-liver transplant outcomes and more efficient use of hospital resources thereby lowering the cost. A better understanding of these mechanisms can lead to informed decisions and optimization of the pay for performance model in liver transplantation.
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Affiliation(s)
- Christopher W Macomber
- Department of Surgery Outcomes Analysis & Research, University of MassachusettsWorcester
| | - Joshua J Shaw
- Department of Surgery Outcomes Analysis & Research, University of MassachusettsWorcester
| | - Heena Santry
- Department of Surgery Outcomes Analysis & Research, University of MassachusettsWorcester
| | - Reza F Saidi
- Department of Surgery Outcomes Analysis & Research, University of MassachusettsWorcester
| | - Nicolas Jabbour
- Department of Surgery Outcomes Analysis & Research, University of MassachusettsWorcester
| | | | - Adel Bozorgzadeh
- Department of Surgery Outcomes Analysis & Research, University of MassachusettsWorcester
| | - Shimul A Shah
- Department of Surgery Outcomes Analysis & Research, University of MassachusettsWorcester
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Milan Z, Gordon J. The latest developments in liver transplantation. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2012. [DOI: 10.1016/j.tacc.2012.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Broomhead RH, Patel S, Fernando B, O'Beirne J, Mallett S. Resource implications of expanding the use of donation after circulatory determination of death in liver transplantation. Liver Transpl 2012; 18:771-8. [PMID: 22315207 DOI: 10.1002/lt.23406] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
In the United Kingdom, liver transplantation using donation after circulatory determination of death (DCDD) organs has increased steadily over the last few years and now accounts for 20% of UK transplant activity. The procurement of DCDD livers is actively promoted as a means of increasing the donor pool and bridging the evolving disparity between the wait-list length and the number of transplants performed. The objective of this retrospective study of a cohort of patients who were matched for age, liver disease etiology, and Model for End-Stage Liver Disease score was to determine whether differences in perioperative costs and resource utilization are associated with the use of such organs. Our results showed an increased prevalence of reperfusion syndrome in the DCDD cohort (P < 0.001), a prolonged heparin effect (P = 0.01), a greater incidence of hyperfibrinolysis (P = 0.002), longer periods of postoperative ventilator use (P = 0.03) and vasopressor support (P = 0.002), and a prolonged length of stay in the intensive therapy unit (ITU; P = 0.02). The peak posttransplant aspartate aminotransferase level was higher in the DCDD group (P = 0.007), and there was significantly more graft failure at 12 months (P = 0.03). In conclusion, we have demonstrated different perioperative and early postoperative courses for DCDD and donation after brain death (DBD) liver transplants. The overall quality of DCDD grafts is poorer; as a result, the length of the ITU stay and the need for multiorgan support are increased, and this has significant financial and resource implications. We believe that these implications require a careful real-life consideration of benefits. It is essential for DCDD not to be seen as a like-for-like alternative to DBD and for every effort to be continued to be made to increase the number of donations from brain-dead patients as a first resort.
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Kelly DM, Bennett R, Brown N, McCoy J, Boerner D, Yu C, Eghtesad B, Barsoum W, Fung JJ, Kattan MW. Predicting the discharge status after liver transplantation at a single center: a new approach for a new era. Liver Transpl 2012; 18:796-802. [PMID: 22454258 DOI: 10.1002/lt.23434] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The aim of this study was to develop a tool for preoperatively predicting the need of a patient to attend an extended care facility after orthotopic liver transplantation (OLT). A multidisciplinary group, which included 2 transplant surgeons, 2 transplant nurses, 1 nurse manager, 2 physical therapists, 1 case manager, 1 home health care professional, 1 rehabilitation physician, and 1 statistician, met to identify preoperative factors relevant to discharge planning. The parameters that were examined as potential predictors of the discharge status were as follows: age, sex, language, Karnofsky score, OLT alone (versus a combined procedure), creatinine, bilirubin, international normalized ratio (INR), albumin, body mass index (BMI), Child-Turcotte-Pugh score, chemical Model for End-Stage Liver Disease score, renal dialysis, location before transplantation, comorbidities (encephalopathy, ascites, hydrothorax, and hepatopulmonary syndrome), diabetes mellitus (DM), cardiac ejection fraction and right ventricular systolic pressure, sex and availability of the primary caregiver, donor risk index, and donor characteristics. Between January 2004 and April 2010, 730 of 777 patients (94%) underwent only liver transplantation, and 47 patients (6%) underwent combined procedures. Five hundred nineteen patients (67%) were discharged home, 215 (28%) were discharged to a facility, and 43 (6%) died early after OLT. A multivariate logistic regression analysis identified the following parameters as significantly influencing the discharge status: a low Karnofsky score, an older age, female sex, an INR of 2.0, a creatinine level of 2.0 mg/dL, DM, a high bilirubin level, a low albumin level, a low or high BMI, and renal dialysis before OLT. The nomogram was prospectively validated with a population of 126 OLT recipients with a concordance index of 0.813. In conclusion, a new approach to improving the efficiency of hospital care is essential. We believe that this tool will aid in reducing lengths of stay and improving the experience of patients by facilitating early discharge planning.
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Affiliation(s)
- Dympna M Kelly
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA.
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65
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Abstract
This review will highlight some of the important recent trends in liver transplantation. When possible, we will compare and contrast these trends across various regions of the world, in an effort to improve global consensus and better recognition of emerging data.
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Affiliation(s)
- Patrizia Burra
- Department of Surgical and Gastroenterological Sciences, University of Padua, Padua, Italy
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Shawcross DL, Austin MJ, Abeles RD, McPhail MJW, Yeoman AD, Taylor NJ, Portal AJ, Jamil K, Auzinger G, Sizer E, Bernal W, Wendon JA. The impact of organ dysfunction in cirrhosis: survival at a cost? J Hepatol 2012; 56:1054-1062. [PMID: 22245890 DOI: 10.1016/j.jhep.2011.12.014] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Revised: 12/05/2011] [Accepted: 12/11/2011] [Indexed: 12/21/2022]
Abstract
BACKGROUND & AIMS The incidence of cirrhosis and subsequent development of organ dysfunction (OD) requiring intensive care unit (ICU) support is rising. Historically, critically ill cirrhotics are perceived as having poor prognosis and substantial cost of care. METHODS The aim was to prospectively analyse resource utilisation and cost of a large cohort of patients (n=660) admitted to a Liver ICU from 2000 to 2007 with cirrhosis and OD. Child Pugh, MELD, SOFA, APACHE II, and organ support requirements were collected. The Therapeutic Intervention Scoring System (TISS) score, a validated tool for estimating cost in ICU, was calculated daily. Logistic regression was used to determine independent predictors of increased cost. RESULTS Alcohol was the most common etiology (47%) and variceal bleeding (VB) the most common reason for admission (35%). Invasive ventilatory support was required in 74% of cases, vasopressors in 49%, and 50% required renal replacement therapy. Forty-nine per cent of non-transplanted patients survived to ICU discharge. Median TISS score and ICU cost per patient were 261 and €14,139, respectively. VB patients had the highest survival rates (53% vs. 24%; p<0.001) and lower associated cost. A combination of VB (OR 0.48), need for ventilation (OR 2.81), low PO(2)/FiO(2) on admission (OR 0.97), and lactate (OR 0.93) improved cost prediction on multivariate analysis (AUROC 0.7; p<0.001) but organ failure scores per se were poor predictors of cost. CONCLUSIONS Patients with cirrhosis and OD result in considerable resource expenditure but have acceptable hospital survival. Further health economic assessment and outcome prediction tools are required to appropriately target resource utilisation.
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Affiliation(s)
- Debbie L Shawcross
- Liver Intensive Care Unit and Institute of Liver Studies and Transplantation, King's College London School of Medicine at King's College Hospital, Denmark Hill, London SE5 9RS, UK
| | - Mark J Austin
- Liver Intensive Care Unit and Institute of Liver Studies and Transplantation, King's College London School of Medicine at King's College Hospital, Denmark Hill, London SE5 9RS, UK
| | - Robin Daniel Abeles
- Liver Intensive Care Unit and Institute of Liver Studies and Transplantation, King's College London School of Medicine at King's College Hospital, Denmark Hill, London SE5 9RS, UK
| | - Mark J W McPhail
- Liver Intensive Care Unit and Institute of Liver Studies and Transplantation, King's College London School of Medicine at King's College Hospital, Denmark Hill, London SE5 9RS, UK
| | - Andrew D Yeoman
- Liver Intensive Care Unit and Institute of Liver Studies and Transplantation, King's College London School of Medicine at King's College Hospital, Denmark Hill, London SE5 9RS, UK
| | - Nicholas J Taylor
- Liver Intensive Care Unit and Institute of Liver Studies and Transplantation, King's College London School of Medicine at King's College Hospital, Denmark Hill, London SE5 9RS, UK
| | - Andrew J Portal
- Liver Intensive Care Unit and Institute of Liver Studies and Transplantation, King's College London School of Medicine at King's College Hospital, Denmark Hill, London SE5 9RS, UK
| | - Khaleel Jamil
- Liver Intensive Care Unit and Institute of Liver Studies and Transplantation, King's College London School of Medicine at King's College Hospital, Denmark Hill, London SE5 9RS, UK
| | - Georg Auzinger
- Liver Intensive Care Unit and Institute of Liver Studies and Transplantation, King's College London School of Medicine at King's College Hospital, Denmark Hill, London SE5 9RS, UK
| | - Elizabeth Sizer
- Liver Intensive Care Unit and Institute of Liver Studies and Transplantation, King's College London School of Medicine at King's College Hospital, Denmark Hill, London SE5 9RS, UK
| | - William Bernal
- Liver Intensive Care Unit and Institute of Liver Studies and Transplantation, King's College London School of Medicine at King's College Hospital, Denmark Hill, London SE5 9RS, UK
| | - Julia A Wendon
- Liver Intensive Care Unit and Institute of Liver Studies and Transplantation, King's College London School of Medicine at King's College Hospital, Denmark Hill, London SE5 9RS, UK.
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Cauchy F, Fuks D, Belghiti J. HCC: current surgical treatment concepts. Langenbecks Arch Surg 2012; 397:681-95. [DOI: 10.1007/s00423-012-0911-2] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Accepted: 01/17/2012] [Indexed: 12/28/2022]
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El Khoury AC, Wallace C, Klimack WK, Razavi H. Economic burden of hepatitis C-associated diseases: Europe, Asia Pacific, and the Americas. J Med Econ 2012; 15:887-96. [PMID: 22458755 DOI: 10.3111/13696998.2012.681332] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Globally, hepatitis C virus (HCV) infects ∼3% of the population. The objective of this study was to review published work and determine the direct medical costs for diseases associated with HCV infection globally, with the exception of the US. METHODS A systematic literature search was conducted to identify studies reporting the costs of hepatitis C sequelae between January 1990 and January 2011. Over 400 references were identified, of which 45 were pertinent. The costs were compiled, converted to US dollars, and adjusted to 2010 costs using the medical component of the consumer price index. RESULTS The median cost of liver transplants was estimated at $139,070 ($15,430-$443,700), refractory ascites at $16,740 ($8990-$35,940), hepatocellular carcinoma (HCC) at $15,310 ($3370-$84,710), decompensated cirrhosis at $14,660 ($3810-$48,360), variceal hemorrhage at $12,190 ($3550-$46,120), hepatic encephalopathy at $9180 ($5370-$50,120), diuretic sensitive ascites at $3400 ($1320-$7470), compensated cirrhosis at $820 ($50-$2890), and chronic hepatitis C at $280 ($90-$1860). The variation among studies was mainly due to the methodology used to assess cost, local cost and government reimbursement, and country-specific treatment protocols. LIMITATIONS All costs were adjusted to 2010 US dollars using the US medical component of the consumer price index (CPI) which may not reflect the change in medical costs in other countries. In addition, the costs, in the local currency were converted to US dollars in the year of the study. However, medical expenses may not vary with exchange rate, leading to artificial variations. Finally, there was no assessment of the quality of individual studies, which resulted in the same weighting to all studies. CONCLUSIONS Hepatitis C imposes a high economic burden globally. Knowing the burden of HCV sequelae is useful for policy decisions as well as serving as a basis for determining the value of HCV screening and treatment.
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Value of the SOFA score as a predictive model for short-term survival in high-risk liver transplant recipients with a pre-transplant labMELD score ≥30. Langenbecks Arch Surg 2011; 397:717-26. [DOI: 10.1007/s00423-011-0881-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Accepted: 11/21/2011] [Indexed: 12/13/2022]
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Li C, Mi K, Wen TF, Yan LN, Li B, Yang JY, Xu MQ, Wang WT, Wei YG. Outcomes of patients with benign liver diseases undergoing living donor versus deceased donor liver transplantation. PLoS One 2011; 6:e27366. [PMID: 22087299 PMCID: PMC3210164 DOI: 10.1371/journal.pone.0027366] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Accepted: 10/15/2011] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND/AIMS The number of people undergoing living donor liver transplantation (LDLT) has increased rapidly in many transplant centres. Patients considering LDLT need to know whether LDLT is riskier than deceased donor liver transplantation (DDLT). The aim of this study was to compare the outcomes of patients undergoing LDLT versus DDLT. METHODS A total of 349 patients with benign liver diseases were recruited from 2005 to 2011 for this study. LDLT was performed in 128 patients, and DDLT was performed in 221 patients. Pre- and intra-operative variables for the two groups were compared. Statistically analysed post-operative outcomes include the postoperative incidence of complication, biliary and vascular complication, hepatitis B virus (HBV) recurrence, long-term survival rate and outcomes of emergency transplantation. RESULTS The waiting times were 22.10±15.31 days for the patients undergoing LDLT versus 35.81±29.18 days for the patients undergoing DDLT. The cold ischemia time (CIT) was 119.34±19.75 minutes for the LDLT group and 346±154.18 for DDLT group. LDLT group had higher intraoperative blood loss, but red blood cell (RBC) transfusion was not different. Similar ≥ Clavien III complications, vascular complications, hepatitis B virus (HBV) recurrence and long-term survival rates were noted. LDLT patients suffered a higher incidence of biliary complications in the early postoperative days. However, during the long-term follow-up period, biliary complication rates were similar between the two groups. The long-term survival rate of patients undergoing emergency transplantation was lower than of patients undergoing elective transplantation. However, no significant difference was observed between emergency LDLT and emergency DDLT. CONCLUSIONS Patients undergoing LDLT achieved similar outcomes to patients undergoing DDLT. Although LDLT patients may suffer a higher incidence of early biliary complications, the total biliary complication rate was similar during the long-term follow-up period.
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Affiliation(s)
- Chuan Li
- Division of Liver Transplantation, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Kai Mi
- Division of Liver Transplantation, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Tian fu Wen
- Division of Liver Transplantation, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
- * E-mail:
| | - Lu nan Yan
- Division of Liver Transplantation, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Bo Li
- Division of Liver Transplantation, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Jia ying Yang
- Division of Liver Transplantation, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Ming qing Xu
- Division of Liver Transplantation, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Wen tao Wang
- Division of Liver Transplantation, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Yong gang Wei
- Division of Liver Transplantation, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
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71
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Åberg F, Mäklin S, Räsänen P, Roine RP, Sintonen H, Koivusalo AM, Höckerstedt K, Isoniemi H. Cost of a quality-adjusted life year in liver transplantation: the influence of the indication and the model for end-stage liver disease score. Liver Transpl 2011; 17:1333-43. [PMID: 21770017 DOI: 10.1002/lt.22388] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Cost issues in liver transplantation (LT) have received increasing attention, but the cost-utility is rarely calculated. We compared costs per quality-adjusted life year (QALY) from the time of placement on the LT waiting list to 1 year after transplantation for 252 LT patients and to 5 years after transplantation for 81 patients. We performed separate calculations for chronic liver disease (CLD), acute liver failure (ALF), and different Model for End-Stage Liver Disease (MELD) scores. For the estimation of QALYs, the health-related quality of life was measured with the 15D instrument. The median costs and QALYs after LT were €141,768 and 0.895 for 1 year and €177,618 and 3.960 for 5 years, respectively. The costs of the first year were 80% of the 5-year costs. The main cost during years 2 to 5 was immunosuppression drugs (59% of the annual costs). The cost/QALY ratio improved from €158,400/QALY at 1 year to €44,854/QALY at 5 years, and the ratio was more beneficial for CLD patients (€42,500/QALY) versus ALF patients (€63,957/QALY) and for patients with low MELD scores versus patients with high MELD scores. Although patients with CLD and MELD scores > 25 demonstrated markedly higher 5-year costs (€228,434) than patients with MELD scores < 15 (€169,541), the cost/QALY difference was less pronounced (€59,894/QALY and €41,769/QALY, respectively). The cost/QALY ratio for LT appears favorable, but it is dependent on the assessed time period and the severity of the liver disease.
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Affiliation(s)
- Fredrik Åberg
- Transplantation and Liver Surgery Clinic, Helsinki University Hospital, Helsinki, Finland.
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72
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Neuberger J. Rationing life-saving resources - how should allocation policies be assessed in solid organ transplantation. Transpl Int 2011; 25:3-6. [PMID: 21902728 DOI: 10.1111/j.1432-2277.2011.01327.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Cortés L, Campillo A, Fiteni I, Lorente S, Garcia-Gil A, Tejero E, Serrano T. Liver transplanted patients with donors older than 60 years require more hospital resources. Transplant Proc 2011; 43:735-6. [PMID: 21486586 DOI: 10.1016/j.transproceed.2011.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The increasing utilization of organs from older donors to fulfill the increasing demand for transplantation has been associated with an increased complication rate and shorter graft survival. Nevertheless, few studies have evaluated the impact of these donors on resource utilization. We sought to evaluate hospital resource utilization during the first year after liver transplantation among patients receiving a liver from a donor >60 years versus a younger donor. METHODS This prospective study evaluated 149 consecutive liver transplantations performed in our center between 2000 and 2005. We divided the patients into 2 groups according to the donor's age; group A <60 and group B, ≥ 60 years. The follow-up was for the first year. Herein we have reported data related to resource utilization, such as number and length of stay hospitalizations, length of ICU stay; surgical and diagnostic procedures including ultrasounds, cholangiography, computed tomography or magnetic resonance imaging, as well as external consultations. RESULT Group B patient required a greater number of hospitalizations (2.7 ± 2.4 vs 1.7 ± 1.5; P = .006), and a longer length of initial stay (37.5 ± 20.9 vs 27.8 ± 17.5 days; P = .012). There were no differences between groups concerning diagnostic and surgical procedures or external consultations. CONCLUSION Patients transplanted from donors >60 years required more hospital resources in the first year after transplantation.
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Affiliation(s)
- L Cortés
- Department of Gastroenterology, Clinic University Hospital Lozano, Blesa, Zaragoza, Spain
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74
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San Juan F, Cortes M. Mortality on the waiting list for liver transplantation: management and prioritization criteria. Transplant Proc 2011; 43:687-9. [PMID: 21486574 DOI: 10.1016/j.transproceed.2011.01.106] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The excellent outcomes of liver transplantation (OLT) have increased its demand and the size of the waiting list, resulting in a substantial mortality rate before OLT, which is a treatment failure owing to disease development. We have reviewed the medical literature on this theme, focusing on prioritization methods.
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Affiliation(s)
- F San Juan
- Unidad de Cirugía y Trasplante Hepático, Hospital Universitario La Fe, Valencia, Spain.
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75
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Frequency of musculoskeletal complications among the patients receiving solid organ transplantation in a tertiary health-care center. Rheumatol Int 2011; 32:2363-6. [PMID: 21644040 DOI: 10.1007/s00296-011-1970-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2010] [Accepted: 05/22/2011] [Indexed: 10/18/2022]
Abstract
Solid organ transplantation is an important lifesaving procedure mainly performed in patients with end-stage organ failure such as liver cirrhosis, congestive heart failure, and end-stage renal disease. While these complications are among the most preventable adverse effects of solid organ transplantation, these are generally neglected by physicians. Accordingly, this study was performed to evaluate the frequency of musculoskeletal complications among the patients receiving solid organ transplantation in a tertiary health-care center in a developing country. This cohort study was performed from 2000 to 2009, among fifty patients receiving organ transplantation (liver, heart, and lung) attending to a training hospital in Tehran, Iran. The main variables were musculoskeletal complaints and findings that were measured according to patients' self-report and clinical examination. The mean age of the patients was 40.2 ± 10.9 years ranging from 5 to 58 years. Twenty out of 50 patients (40%) had musculoskeletal complaints that the most common complaint was the arthralgia. Also, the mechanical arthritis was the most common clinical finding in clinical examination (24%). Low serum level of vitamin D (74.4%) and high serum alkaline phosphatase level (27.9%) were the most common biochemical abnormalities in understudy population. Finally, it may be concluded that nearly forty percent of patients receiving solid organ transplantation may develop musculoskeletal findings and/or complaints. These complications may be found and treated with regular examinations to reduce the burden of disease.
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76
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Freeman RB. The price of "doing the right thing". Liver Transpl 2011; 17:631-2. [PMID: 21618683 DOI: 10.1002/lt.22253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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77
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Bhangui P, Vibert E, Majno P, Salloum C, Andreani P, Zocrato J, Ichai P, Saliba F, Adam R, Castaing D, Azoulay D. Intention-to-treat analysis of liver transplantation for hepatocellular carcinoma: living versus deceased donor transplantation. Hepatology 2011; 53:1570-9. [PMID: 21520172 DOI: 10.1002/hep.24231] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
UNLABELLED For patients who have cirrhosis with hepatocellular carcinoma (HCC), living donor liver transplantation (LDLT) reduces waiting time and dropout rates. We performed a comparative intention-to-treat analysis of recurrence rates and survival outcomes after LDLT and deceased donor liver transplantation (DDLT) in HCC patients. Our study included 183 consecutive patients with HCC who were listed for liver transplantation over a 9-year period at our institution. Tumor recurrence was the primary endpoint. At listing, patient and tumor characteristics were comparable in the two groups (LDLT, n = 36; DDLT, n = 147). Twenty-seven (18.4%) patients dropped out, all from the DDLT waiting list, mainly due to tumor progression (19/27 [70%] patients). The mean waiting time was shorter in the LDLT group (2.6 months versus 7.9 months; P = 0.001). The recurrence rates in the two groups were similar (12.9% and 12.7%, P = 0.78), and there was a trend toward a longer time to recurrence after LDLT (38 ± 27 months versus 16 ± 13 months, P = 0.06). Tumors exceeding the University of California, San Francisco (UCSF) criteria, tumor grade, and microvascular invasion were independent predictive factors for recurrence. On an intention-to-treat basis, the overall survival (OS) in the two groups was comparable. Patients beyond the Milan and UCSF criteria showed a trend toward worse outcomes with LDLT compared with DDLT (P = 0.06). CONCLUSION The recurrence and survival outcomes after LDLT and DDLT were comparable on an intent-to-treat analysis. Shorter waiting time preventing dropouts is an additional advantage with LDLT. LDLT for HCC patients beyond validated criteria should be proposed with caution.
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Affiliation(s)
- Prashant Bhangui
- Hôpital Paul Brousse, Assistance Publique-Hôpitaux de Paris, Villejuif, France
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Razonable RR, Findlay JY, O'Riordan A, Burroughs SG, Ghobrial RM, Agarwal B, Davenport A, Gropper M. Critical care issues in patients after liver transplantation. Liver Transpl 2011; 17:511-27. [PMID: 21384524 DOI: 10.1002/lt.22291] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The majority of patients who undergo liver transplantation (LT) spend some time in the intensive care unit during the postoperative period. For some, this is an expected part of the immediate posttransplant recovery period, whereas for others, the stay is more prolonged because of preexisting conditions, intraoperative events, or postoperative complications. In this review, 4 topics that are particularly relevant to the postoperative intensive care of LT recipients are discussed, with an emphasis on current knowledge specific to this patient group. Infectious complications are the most common causes of early posttransplant morbidity and mortality. The common patterns of infection seen in patients after LT and their management are discussed. Acute kidney injury and renal failure are common in post-LT patients. Kidney injury identification, etiologies, and risk factors and approaches to management are reviewed. The majority of patients will require weaning from mechanical ventilation in the immediate postoperative period; the approach to this is discussed along with the approach for those patients who require a prolonged period of mechanical ventilation. A poorly functioning graft requires prompt identification and appropriate management if the outcomes are to be optimized. The causes of poor graft function are systematically reviewed, and the management of these grafts is discussed.
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Affiliation(s)
- Raymund R Razonable
- Division of Infectious Diseases, Mayo Clinic College of Medicine, Rochester, MN, USA
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Palmiero HOM, Kajikawa P, Boin IFSF, Coria S, Pereira LA. Liver recipient survival rate before and after model for end-stage liver disease implementation and use of donor risk index. Transplant Proc 2011; 42:4113-5. [PMID: 21168639 DOI: 10.1016/j.transproceed.2010.09.092] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2010] [Accepted: 09/22/2010] [Indexed: 12/15/2022]
Abstract
BACKGROUND The progressive increase in the demand for liver transplantation has led to changes in donor selection and allocation, such as the Model for End-Stage Liver Disease Score (MELD). Characteristics related to the donor, recipient, and transplantation procedure influence the results. The use of expanded-criteria donors (ECDs) and the donor risk index (DRI) are strategies that have been proposed to increase the donors pool. OBJECTIVE We sought to study liver recipient survival before and after MELD implementation as well as the use of DRI. METHODS This retrospective study of prospectively collected data analyzed 1,786 liver recipients and their donors according to gender, age, cause of brain death, intensive care unit time, split liver, infection, ECD, cardiac arrest, cold ischemia time, waiting list time, and donor origin. MELD (without special scoring) and DRI were calculated from the recorded data. The periods of this study were 2004-2006 (pre-MELD) and 2006-2008 (post-MELD). For survival times, we performed the Kaplan-Meier method with log-rank tests and Cox regression analysis (prediction). The Kolmogorov-Sminorv test was used for sample comparisons. RESULTS The 1-year survivals were similar in the 2 periods (65.4% vs 67.6%). The predictive factors for death among the whole population were DRI >1.5, cold ischemia time ≥9 hours, MELD ≥25, female recipient, and longer waiting list time. CONCLUSIONS MELD is an important tool for allocation, resulting in a reduced waiting list, increased number of split-liver procedures, and use of ECDs without deterioration of survival times. DRI >1.7 was associated with shorter survival.
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Metselaar HJ, Lerut J, Kazemier G. The true merits of liver allocation according to MELD scores: survival after transplantation tells only one side of the story. Transpl Int 2011; 24:132-3. [PMID: 21208292 DOI: 10.1111/j.1432-2277.2010.01177.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Herold J Metselaar
- Department of Gastroenterology & Hepatology, Erasmus MC, University Hospital Rotterdam, Rotterdam, The Netherlands.
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Abstract
There are three possible policies for prioritization for liver transplantation: medical urgency, utility and transplant benefit. The first is based on the severity of cirrhosis, using Child-Turcotte-Pugh score and, more recently, the Model for End-stage Liver Disease (MELD) score, or variants of MELD, for allocation. Although prospectively developed and validated, the MELD score has several limitations, including interlaboratory variations for measurement of serum creatinine and international normalized ratio of prothrombin time, and a systematic adverse female gender bias. Adjustments to the original MELD equation and new scoring systems have been proposed to overcome these limitations; incorporation of serum sodium improves its predictive accuracy. The MELD score poorly predicts outcomes after liver transplantation due to the absence of donor factors incorporated into the scoring system. Several utility models are based on donor and recipient characteristics. Combined poor recipient and donor characteristics lead to very poor outcomes, which in a utility system would be considered unacceptable. Finally, transplant benefit models rank patients according to the net survival benefit that they would derive from transplantation. However, complex statistical models are required, and unmeasured characteristics may unduly affect the models. Well-designed prospective studies and simulation models are necessary to establish the optimal allocation system in liver transplantation.
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Affiliation(s)
- Evangelos Cholongitas
- 4th Department of Internal Medicine, Medical School of Aristotle University, Hippocration General Hospital of Thessaloniki, 54642 Thessaloniki, Greece
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