National survey of provider opinions on controversial characteristics of liver transplant candidates

Transplant selection simulation: Liver transplantation for alcohol-associated hepatitis

Liver transplantation (LT) for alcohol-associated hepatitis (AH) remains controversial due to concerns about candidate selection subjectivity, post-LT alcohol relapse, and the potential exacerbation of LT disparities. Our aim was to design, perform, and examine the results of a simulated selection of candidates for LT for AH. Medical histories, psychosocial profiles and scores, and outcomes of 4 simulation candidates were presented and discussed at 2 multidisciplinary societal conferences with real-time polling of participant responses. Candidate psychosocial profiles represented a wide spectrum of alcohol relapse risk. The predictive accuracy of four psychosocial scores, Dallas consensus criteria, sustained alcohol use post-LT, Stanford Integrated Psychosocial Assessment for Transplant, and QuickTrans, were assessed. Overall, 68 providers, mostly academic transplant hepatologists, participated in the simulation. Using a democratic process of selection, a significant majority from both simulations voted to accept the lowest psychosocial risk candidate for LT (72% and 85%) and decline the highest risk candidate (78% and 90%). For the 2 borderline-risk candidates, a narrower majority voted to decline (56% and 65%; 64% and 82%). Two out of 4 patients had post-LT relapse. Predictive accuracies of Dallas, Stanford Integrated Psychosocial Assessment for Transplant, and Quicktrans scores were 50%, while sustained alcohol use post-LT was 25%. The majority of voting outcomes were concordant with post-LT relapse in 3 out of 4 patients. When defining "success" in LT for AH, providers prioritized allograft health and quality of life rather than strict abstinence. In this simulation of LT for AH using a democratic process of selection, we demonstrate its potential as a learning model to evaluate the accuracy of psychosocial scores in predicting post-LT relapse and the concordance of majority voting with post-LT outcomes. Provider definitions of "success" in LT for AH have shifted toward patient-centered outcomes.

Cannabis use in liver transplant candidates and recipients

The increasing legality and acceptance of cannabis sale and consumption across the United States has led to a measurable increase in cannabis use nationwide, including in liver transplant (LT) candidates and recipients. With over 75% of liver transplant recipients transplanted in states with legalized use of medicinal and/or recreational cannabis, liver transplant clinicians must have expertise in the assessment of cannabis use given its potential impact on clinical care. In this review, the authors provide an understanding of nomenclature and tools to assess cannabis use, highlight essential components to guide clinical policy development and implementation, and discuss the potential impacts of cannabis use on patients' transplant course.

Sleeve Gastrectomy Reduces the Need for Liver Transplantation in Patients with Obesity and Non-Alcoholic Steatohepatitis: a Predictive Model

BACKGROUND

Non-alcoholic steatohepatitis (NASH) is one of the leading indications for liver transplantation (LT) in the United States. As with the current obesity epidemic, the incidence of NASH continues to rise. However, the impact of broad utilization of bariatric surgery (BS) for patients with NASH is unknown, particularly in regard to mitigating the need for LT.

METHODS

Markov decision analysis was performed to simulate the lives of 20,000 patients with obesity and concomitant NASH who were deemed ineligible to be waitlisted for LT unless they achieved a body mass index (BMI) < 35 kg/m2. Life expectancy following medical weight management (MWM) and sleeve gastrectomy (SG) were estimated. Base case patients were defined as having NASH without fibrosis and a pre-intervention BMI of 45 kg/m2. Sensitivity analysis of initial BMI was performed.

RESULTS

Simulated base case analysis patients who underwent SG gained 14.3 years of life compared to patients who underwent MWM. One year after weight loss intervention, 9% of simulated MWM patients required LT compared to only 5% of SG patients. Survival benefit for SG was observed above a BMI of 32.2 kg/m2.

CONCLUSION

In this predictive model of 20,000 patients with obesity and concomitant NASH, surgical weight loss is associated with a reduction in the progression of NASH, thereby reducing the need for LT. A reduced BMI threshold of 32 kg/m2 for BS may offer survival benefit for patients with obesity and NASH.

Reexamining "psychosocial clearance": A procedural framework for psychosocial evaluation in liver transplantation

Psychosocial and "nonmedical" phenomena are commonly encountered in liver transplantation (LT) evaluations. They are simultaneously crucial decision-making factors and some of the most difficult and controversial clinical matters clinicians confront. Epidemiology, societal trends, and the preponderance of psychological and behavioral factors underpinning common end-stage liver diseases ensure that LT teams will continue to encounter highly complex psychosocial patient presentations. Psychosocial policies, practices, and opinions vary widely among clinicians and LT centers. Liver clinicians already report insufficient psychosocial expertise, which creates a large gap between the stark need for psychosocial expansion, improvement, and innovation in LT and the lack of accompanying guidance on how to achieve it. While the clinical domains of an LT psychosocial evaluation have been well-described, few articles analyze the procedures by which teams determine candidates' "psychosocial clearance" and no conceptual frameworks exist. This article proposes a framework of core domains of psychosocial evaluation procedures, common pitfalls, and practical improvement strategies.

"But I didn't drink!": What to do with discordant phosphatidylethanol results

Liver transplantation (LT) teams must be adept at detecting, evaluating, and treating patients' alcohol use, given its prominence among psychological and behavioral phenomena which cause and contribute to liver diseases. Phosphatidylethanol (PEth) is a highly useful alcohol biomarker increasingly recommended for routine use in hepatology and LT. PEth is unique among alcohol biomarkers because of its wide detection window, high sensitivity and specificity, and the correlation of its numerical value with different patterns of alcohol use. Alongside myriad clinical opportunities in hepatology and LT, PEth also confers numerous challenges: little guidance exists about its clinical use; fearing loss of LT access and the reactions of their clinicians and families, candidates and recipients are incentivized to conceal their alcohol use; and liver clinicians report lack of expertise diagnosing and treating substance-related challenges. Discordance between patient self-reported alcohol use and toxicology is yet another common and particularly difficult circumstance. This article discusses the general toxicological properties of PEth; explores possible scenarios of concordance and discordance among PEth results, patient history, and self-reported drinking; and provides detailed clinical communication strategies to explore discordance with liver patients, a key aspect of its use.

National survey of second opinions for hospitalized patients in need of liver transplantation

Decisions about patient candidacy for liver transplant (LT) can mean the difference between life and death. We surveyed LT centers across the United States to assess their perceptions of and barriers to second-opinion referrals for inpatients declined for transplant. The medical and surgical directors of 100 unique US LT programs that had done >20 LTs in 2021 were surveyed with a 33-item questionnaire including both multiple-choice and free-response questions. The response rate was 60% (60 LT centers) and included 28 larger-volume ( ≥100 LTs in 2021) and 32 smaller-volume (<100 LTs in 2021) programs. The top 3 reasons for inpatient denial for LT included lack of social support (21%), physical frailty (20%), and inadequate remission duration from alcohol use (11%). Twenty-five percent of the programs reported "frequently" facilitating a second opinion for a declined inpatient, 52% of the programs reported "sometimes" doing so, and 7% of the programs reported never doing so. One hundred percent of the programs reported that they receive referrals for second opinions. Twenty-five percent of the programs reported transplanting these referrals frequently (over 20% of the time). Neither program size nor program location statistically impacted the findings. When asked if centers would be in favor of standardizing the evaluation process, 38% of centers would be in favor, 39% would be opposed, and 23% were unsure. The practices and perceptions of second opinions for hospitalized patients evaluated for LT varied widely across the United States. Opportunities exist to improve equity in LT but must consider maintaining individual program autonomy.

Review of liver transplantation candidacy and outcomes among patients who use cannabis: Is it time for a change in policy?

Background

Recreational cannabis was legalized in Canada in 2018. A controversial contraindication for liver transplantation is cannabis. There is currently no consensus regarding cannabis use in liver transplant candidates. We aim to investigate liver transplantation candidacy and outcomes among cannabis users.

Methods

English peer-reviewed studies on PubMed and Google Scholar were searched on September 9, 2022, using keywords including "cannabis," "liver transplantation," and their synonyms. Titles and abstracts were screened, followed by full texts. Reference lists were reviewed. Studies that investigated liver transplantation candidacy and outcomes among cannabis users were included.

Results

The proportion of patients listed for liver transplantation was significantly less among cannabis users than among non-users. Time to listing was longer for cannabis users than non-users. The incidence of delisting was similar. There is an inconsistency between transplant centres regarding transplantation candidacy for cannabis users. While only 14% of Canadian centres had a policy in place and preferred candidates to abstain or decrease cannabis use before transplantation, a third of Canadian centres rejected cannabis users. Observational studies failed to demonstrate significant differences in patient survival between pre-transplantation cannabis users and non-users. However, self-reported mental health ratings were worse in post-transplantation cannabis users than in non-users and former users.

Conclusions

Current observational data do not support a link between cannabis use and poor patient survival post-transplantation. However, high-quality prospective studies are needed to better elucidate the impact of cannabis use on liver transplantation outcomes. Liver transplant candidacy should be evaluated through a multidisciplinary and comprehensive approach considering all relevant psychosocial factors.

Rethinking Second Chances: When Rejected Liver Transplant Candidates Seek Reevaluation Elsewhere

AbstractLiver transplantation offers a lifesaving treatment for patients suffering from end-stage liver failure, but not all candidates in the United States are eligible owing to center-specific criteria. When a patient is rejected at a transplantation center for medical, surgical, or psychosocial issues, they are often referred to other centers. We focus on this practice of reevaluation at a second center when the candidate was rejected for psychosocial reasons. We review the criteria used by health professionals to determine psychosocial eligibility and present three case examples from a large teaching hospital that demonstrate this phenomenon in practice. The cases illustrate the conflicts among autonomy, beneficence, nonmaleficence, and justice. We present arguments for and against this practice and provide concrete solutions as a path forward.

Substance use disorders in organ transplantation: perennial challenges and interprofessional opportunities

PURPOSE OF REVIEW

The current article examines recent publications regarding ongoing clinical and ethical challenges and opportunities related to substance use disorders (SUD) in solid organ transplantation (SOT) utilizing a lens of interprofessional clinical models and care delivery.

RECENT FINDINGS

Innovative interprofessional clinician skillsets and care models are increasingly emphasized in the SOT literature as the standard of care for common, complex psychosocial problems like substance use and SUD. Cannabinoids are common among candidates and recipients and present several unique quandaries to SOT teams. Opioid use disorder treatment can often be definitively treated with medications that SOT teams may find unfamiliar, controversial, or aversive. Arguably the quintessential example of SUD in SOT, early liver transplantation for patients with alcohol-related liver disease and short periods of sobriety has become increasingly common and accepted in recent years requiring liver teams to rapidly acquire significant interprofessional psychiatric awareness and expertise. The question of retransplantation in patients who have experienced recurrent SUD remains unsettled.

SUMMARY

Regardless of substances used or organs transplanted, interprofessional care continues to emerge as a foundational aspect of clinical care and research in SOT.

MENTAL DISORDERS AND LIVER TRANSPLANTATION: A 2-YEAR COHORT STUDY

BACKGROUND

Psychosocial assessment is a key component in evaluation for liver transplantation and may affect survival rates and outcomes.

OBJECTIVE

The primary aim of this study was to investigate the impact of previous mental disorders and impulsivity on the 2-year surviving rate after liver transplantation.

METHODS

We performed a prospective cohort study assessing end-stage liver disease individuals with and without psychiatric comorbidities for 2 years post-transplant. Psychiatric diagnosis was carried out through Mini-Plus 5.0.0 and impulsivity by using Barratt Impulsiveness Scale in the pre-transplant phase. We followed patient's status for 2 years after transplantation. The main outcome was death. We used a logistic regression to evaluate the association of psychiatric comorbidities with death and performed a survival analysis with Kaplan-Meier and Cox regression models.

RESULTS

Between June 2010 and July 2014, 93 out of 191 transplant candidates received transplants. From the 93 transplant patients, 21 had psychiatric comorbidities and 72 had not. 25 patients died during the study. The presence of psychiatric comorbidities (P=0.353) and high impulsivity (P=0.272) were not associated to 2-year post transplant death.

CONCLUSION

This study found no evidence that the presence of mental disorders and impulsivity worsened prognosis in post-liver transplantation.

The role of bariatric surgery in liver transplantation: timing and type

Introduction

The rise in obesity worldwide has shifted the indications for liver transplantation (LT), with non-alcoholic steatohepatitis (NASH) being the second most common indication for transplantation. There remains an underestimation of cirrhosis being attributed to NASH. Bariatric surgery (BS) is a reliable solution to overcome obesity and its associated comorbidities. The role of BS in LT has been investigated by different studies; however, the type of BS and timing of LT need further investigation.

Methods

A systemic review examining the role of BS in LT patients was performed. After selection of the studies based on inclusion and exclusion criteria, data extraction was performed by two independent reviewers. Primary outcomes included patient and graft survival.

Results

From a total of 2374 articles, five met the prefined criteria. One hundred sixty-two patients had both BS + LT and 1426 underwent LT alone. The percentage of female patients in the BS + LT and LT cohorts was 75% and 35% respectively. The average age in BS + LT and LT cohorts was 43.05 vs. 56.22 years respectively. Patients undergoing BS had comparable outcomes in terms of overall patient survival, graft survival and post-operative morbidity compared to LT alone. When comparing BMI change in patients with prior versus simultaneous BS + LT, no significant difference was found.

Conclusion

BS and LT patients achieve comparable outcomes to general LT populations. Further studies examining simultaneous BS + LT are needed to answer questions concerning patient selection and timing of surgery.

Cannabinoids and solid organ transplantation: Psychiatric perspectives and recommendations

Cannabinoid use in patients seeking solid organ transplantation (SOT) is an important and unsettled matter which all transplantation clinicians regularly encounter. It is also a multifaceted, interprofessional issue, difficult for any specialty alone to adequately address in a research article or during clinical care. Such uncertainty lends itself to bias for or against cannabinoid use accompanied by inconsistent policies and procedures. Scientific literature in SOT regarding cannabinoids often narrowly examines the issue and exists mostly in liver and kidney transplantation. Published recommendations from professional societies are mosaics of vagueness and specificity mirroring the ongoing dilemma. The cannabinoid information SOT clinicians need for clinical care may require data and perspectives from diverse medical literature which are rarely synthesized. SOT teams may not be adequately staffed or trained to address various neuropsychiatric cannabinoid effects and risks in patients. In this article, authors from US transplantation centers conduct a systematized review of the few existing studies regarding clinician perceptions, use rates, and clinical impact of cannabinoid use in SOT patients; collate representative professional society guidance on the topic; draw from diverse medical literature bases to detail facets of cannabinoid use in psychiatry and addiction pertinent to all transplantation clinicians; provide basic clinical and policy recommendations; and indicate areas of future study.

The continuing need to combat disability discrimination in organ transplantation

New evidence provides additional confirmation that when considering persons with intellectual and developmental disabilities, categorical exclusions as well as denials based on the need for support systems are unethical and discriminatory.

Obesity is a risk factor for progression to kidney transplant waitlisting after liver transplantation

BACKGROUND

Non-alcoholic steatohepatitis has emerged as a leading cause of cirrhosis, and obesity-associated comorbidities, including renal disease, have increased in prevalence. Obesity predisposes the kidney to hyperfiltration injury, potentially impairing acute kidney injury recovery. Identification of patients at risk for renal dysfunction is impeded by poor performance of renal function estimating equations among cirrhotics. To better understand obesity among cirrhotics and renal disease progression, we examined likelihood of kidney transplantation (KT) waitlisting after liver transplant alone (LTA) by obesity class.

METHODS

68 607 LTA recipients were identified in SRTR (2005-2018). Fine and Gray competing risks models were used to analyze likelihood of KT waitlisting.

RESULTS

27.4% of recipients were obese (BMI ≥ 30 kg/m² ) and were 10% more likely to require KT waitlisting (aHR: 1.10, 95%CI: 1.01-1.20). Risk was highest among recipients with Classes II and III obesity (BMI: ≥35 kg/m² ) (aHR: 1.37, 95%CI: 1.17-1.56). Moreover, recipients with Classes II and III obesity were 57% more likely to require KT waitlisting within one year post-LTA (aHR: 1.57, 95%CI: 1.18-2.10) compared to non-obese recipients.

DISCUSSION

These findings suggest obesity was a risk factor for renal recovery failure and/or renal disease progression post-LTA and may confound identification of renal dysfunction and/or prediction of renal recovery among cirrhotics.

Psychosocial evaluation for liver transplantation: A brief guide for gastroenterologists

Liver transplantation is a lifesaving treatment that improves survival and quality of life. The procedure requires adequate transplant candidate selection carried out by a multidisciplinary team. Psychosocial evaluation is a necessary part of recipient selection and its primary aims are to identify problems and psychosocial needs of the patient and his/her family, to improve transplantation outcomes. Different psychosocial conditions are considered risk factors for morbidity and mortality after transplantation. The presence of those factors per se is not an absolute contraindication, thus adequate evaluation promotes equal access to healthcare, improves results, and optimizes resources. The present review provides an overview of and guidelines for the most important psychosocial issues during the pretransplantation phase.

The impact of marijuana use on liver transplant recipients: A 900 patient single center experience

INTRODUCTION

Increased societal prevalence of marijuana continues to challenge liver transplant (LT) programs. This study aimed to examine the potential effects of marijuana use on outcomes.

METHODS

This retrospective study included recipients who underwent LT between 1/2012 and 6/2018. According to pre-LT marijuana use, patients were classified into recent (≤6 months of LT), former (chronic use but not ≤6 months), or non-users. Additionally, the impact of post-LT marijuana use on survival was assessed.

RESULTS

Of 926 eligible patients, 184 were pre-LT marijuana users (42 recent; 142 former) (median follow-up: 30.3 months). Pre-users were more likely to be male, White, and have histories of tobacco, alcohol, and illicit drug use. Additionally, recent users were of higher acuity, with higher MELD and requiring ICU admission. Patient survival at 1-year was 89% in non-users, 94% (HR: 0.494, 95% CI: 0.239-1.022 vs. non-users) in former users, and 83% (HR: 1.516, 95% CI: 0.701-3.282) in recent users. Post-operative complications in pre-LT users and the survival analysis for post-LT marijuana users vs. non-users did not show significance.

CONCLUSIONS

Our results demonstrated that marijuana use did not have an adverse impact on post-LT outcomes; however, further studies utilizing larger cohorts are warranted.

Center Variation in Intention-to-Treat Survival Among Patients Listed for Liver Transplant

In the United States, centers performing liver transplant (LT) are primarily evaluated by patient survival within 1 year after LT, but tight clustering of outcomes allows only a narrow window for evaluation of center variation for quality improvement. Alternate measures more relevant to patients and the transplant community are needed. We examined adults listed for LT in the United States, using data submitted to the Scientific Registry of Transplant Recipients. Intention-to-treat (ITT) survival was defined as survival within 1 year from listing, regardless of transplant. Mixed effects/frailty models were used to assess center variation in ITT survival. Between January 2010 and December 2016, there were 66,428 new listings at 113 centers. Overall, median 1-year ITT survival was 79.8% (interquartile range [IQR], 76.1%-83.4%), whereas 1-year waiting-list (WL) survival was 75.8% (IQR, 71.2%-79.4%), and 1-year post-LT survival was 90.0% (IQR, 87.9%-91.8%). Higher rates of ITT mortality were correlated with increased WL mortality (correlation, r = 0.76), increased post-LT mortality (r = 0.31), lower volume centers (r = -0.34), and lower transplant rate ratio (r = -0.25). Similar patterns were observed in the subgroup of WL candidates listed with Model for End-Stage Liver Disease (MELD) ≥25: median 1-year ITT survival was 65.2% (IQR, 60.2%-72.6%), whereas 1-year post-LT survival was 87.5% (IQR, 84.0%-90.9%), and 1-year WL survival was 36.6% (IQR, 27.9%-47.0%). In mixed effects modeling, the transplant center was an independent predictor of ITT survival even after adjustment for age, sex, MELD, and sociodemographic variables. Center variation for ITT survival was larger compared with post-LT survival. The measurement of ITT outcome offers a complementary method to assess center performance. This is a first step toward understanding differences in program quality beyond patient and graft survival after LT.

Genetic disease and intellectual disability as contraindications to transplant listing in the United States: A survey of heart, kidney, liver, and lung transplant programs

Discrimination based on disability is prohibited in organ transplantation, yet studies suggest it continues in listing practices for intellectual disability and genetic diseases. It is not known if this differs between adult and pediatric programs, or by organ type. We performed an online, forced-choice survey of psychosocial listing criteria for adult and pediatric heart, kidney, liver, and lung transplant programs in the United States. Of 650 programs contacted, 343 (52.8%) submitted complete. A minority of programs had formal listing guidelines for any condition considered (Down Syndrome, Duchenne Muscular Dystrophy, Becker Muscular Dystrophy, DiGeorge Syndrome, and Wolf Hirschhorn Syndrome; and mild [IQ < 70] and severe [IQ < 35] intellectual disability), although a majority had encountered most. Pediatric programs were significantly (P < .02) more lenient in the level of contraindication to listing for all genetic conditions considered except Duchenne Muscular Dystrophy, and for mild and severe intellectual disability. Level of contraindication differed significantly by organ type (heart, lung, liver, and kidney) for Duchenne Muscular dystrophy (P = <.001), Becker Muscular Dystrophy (P < .001), DiGeorge Syndrome (P < .001), Wolf-Hirschhorn syndrome (P = .0012), and severe intellectual disability (P < .001). There is significant variation among transplant programs in availability of guidelines for as well as listing practices regarding genetic diseases and intellectual disability, differing by both adult vs pediatric program, and organ type. Programs with absolute contraindications to listing for specific genetic diseases or intellectual disability should reframe their approach, ensuring individualized assessments and avoiding elimination of patients based on membership in a particular group.

Internet Published Policies Regarding Liver Transplant Eligibility and Substance Use in United States Transplant Centers

Liver transplant centers in the United States retain great autonomy in determining eligibility criteria for a liver transplant. This study aims to define the availability and content of liver transplant centers' publicly available Internet policies regarding eligibility criteria for liver transplant. Three trained undergraduate students performed a structured pilot‐tested assessment of official websites of the United Network for Organ Sharing‐registered liver transplant centers. All 141 liver transplant centers had an accessible website. Some account of eligibility criteria was provided by 53% of centers, while 32% of centers discussed substance use. Only 17% discussed their policy regarding alcohol use in candidates with underlying alcohol use disorder, and only 2% stipulated that 6 months of abstinence was required. While exclusion based on substance use or age was discussed infrequently, insurance coverage requirements, the need for social support, and the need for adherence to medical care were mentioned in 21%, 37%, and 23% of centers, respectively. Conclusion: In 2018, half of liver transplant centers provided some information on their official websites regarding eligibility criteria for liver transplant. Detailed information regarding substance use disorders and social health requirements was rare. The Internet is infrequently used by liver transplant centers as a means to publicly share information regarding selection criteria.

Ethical issues associated with solid organ transplantation and substance use: a scoping review

While solid organ transplantation for patients with substance use issues has attracted ethical discussion, a typology of the ethics themes has not been articulated in the literature. We conducted a scoping review of peer-reviewed literature on solid organ transplantation and substance use published between January 1997 and April 2016. We aimed to identify and develop a typology of the main ethical themes discussed in this literature and to identify gaps worthy of future research. Seventy articles met inclusion criteria and underwent inductive content analysis. Four main ethical themes were identified: (1) personal responsibility; (2) utility; (3) moral character; and (4) fairness. Each theme had multiple sub-themes and there was substantial overlap between themes. This scoping review identified a disproportionate emphasis in the literature regarding personal responsibility, which was referenced by each of the other themes, and a narrow focus on alcohol and liver. We recommend future research further investigate these connections between ethical themes and focus on ethical issues associated with transplants from organ groups other than liver for patients who use substances other than alcohol.

Tool to Aid Patients in Selecting a Liver Transplant Center

Variations in candidate and donor acceptance criteria may influence access and mortality for liver transplantation. We sought to understand how recipient and donor characteristics vary across centers and how patients interpret this information, and we used these data to develop a tool to provide tailored information to candidates seeking a center (www.transplantcentersearch.org). We analyzed liver recipient data from the Scientific Registry of Transplant Recipients to determine how recipient and donor characteristics (eg, age, Medicaid use, and human immunodeficiency virus status) varied across programs. Data included recipients and donors at each US program between January 1, 2015, and December 31, 2017. The variation in characteristics was plotted with centers stratified by total transplant volume and by volume of each characteristic. A subset of characteristics was plotted to show variation over 3 years. We created mockups of potential reports displaying recipient characteristics alongside pretransplant and posttransplant outcomes and solicited feedback at patient and family interviews and focus groups, which included 39 individuals: 10 pilot interviews with candidates seeking liver transplant at the University of Minnesota-Fairview (UMNF) and 5 focus groups with 13 UMNF candidates, 6 UMNF family members, and 10 national recipients. Transcripts were analyzed using a thematic analysis. Several themes emerged: (1) Candidates experience gaps in existing education about center options; (2) patients requested information about how selection criteria might impact access to transplant; and (3) information tailored to a candidate's medical characteristics can inform decisions. Characteristics shown on mockups varied across centers (P < 0.01). Variation was widespread for small and large centers. In conclusion, variation exists in recipient and donor characteristics across centers. Liver transplant patients provide positive feedback upon viewing patient-specific search tools.

Medical Contraindications to Transplant Listing in the USA: A Survey of Adult and Pediatric Heart, Kidney, Liver, and Lung Programs

INTRODUCTION

Listing practices for solid organ transplantation are variable across programs in the USA. To better characterize this variability, we performed a survey of psychosocial listing criteria for pediatric and adult heart, lung, liver, and kidney programs in the USA. In this manuscript, we report our results regarding listing practices with respect to obesity, advanced age, and HIV seropositivity.

METHODS

We performed an online, forced-choice survey of adult and pediatric heart, kidney, liver, and lung transplant programs in the USA.

RESULTS

Of 650 programs contacted, 343 submitted complete responses (response rate = 52.8%). Most programs have absolute contraindications to listing for BMI > 45 (adult: 67.5%; pediatric: 88.0%) and age > 80 (adult: 55.4%; pediatric: not relevant). Only 29.5% of adult programs and 25.7% of pediatric programs consider HIV seropositivity an absolute contraindication to listing. We found that there is variation in absolute contraindications to listing in adult programs among organ types for BMI > 45 (heart 89.8%, lung 92.3%, liver 49.1%, kidney 71.9%), age > 80 (heart 83.7%, lung 76.9%, liver 68.4%, kidney 29.2%), and HIV seropositivity (heart 30.6%, lung 59.0%, kidney 16.9%, liver 28.1%).

CONCLUSIONS

We argue that variability in listing enhances access to transplantation for potential recipients who have the ability to pursue workup at different centers by allowing different programs to have different risk thresholds. Programs should remain independent in listing practices, but because these practices differ, we recommend transparency in listing policies and informing patients of reasons for listing denial and alternative opportunities to seek listing at another program.

Being accompanied to liver discharge clinic: An easy measure to identify potential liver transplant candidates among those previously considered ineligible

BACKGROUND

Patients with cirrhosis deemed ineligible for liver transplantation are usually followed in general hepatology or gastroenterology clinics, with the hope of re-evaluation once they meet the appropriate criteria. Specific strategies to achieve liver transplant eligibility for these patients have not been studied.

AIM

To assess clinical and sociodemographic factors associated with future liver transplant eligibility among patients initially considered ineligible.

METHODS

This is a retrospective study of patients with cirrhosis considered non-transplant eligible, but without absolute contraindications, who were scheduled in our transitional care liver clinic (TCLC) after discharge from an inpatient liver service. Transplant candidacy was assessed 1 year after the first scheduled TCLC visit. Data on clinical and sociodemographic factors were collected.

RESULTS

Sixty-nine patients were identified and the vast majority were Caucasian men with alcoholic cirrhosis. 46 patients (67%) presented to the first TCLC visit. Seven of 46 patients that showed to the first TCLC visit became transplant candidates, while 0 of 23 patients that no-showed did (15.2% vs 0%, P = 0.08). Six of 7 patients who showed and became transplant eligible were accompanied by family or friends at the first TCLC appointment, compared to 13 of 39 patients who showed and did not become transplant eligible (85.7% vs 33.3%, P = 0.01).

CONCLUSION

Patients who attended the first post-discharge TCLC appointment had a trend for higher liver transplant eligibility at 1 year. Being accompanied by family or friends during the first TCLC visit correlated with higher liver transplant eligibility at 1 year (attendance by family or friends was not requested). Patient and family engagement in the immediate post-hospitalization period may predict future liver transplant eligibility for patients previously declined.

Outcomes of Sleeve Gastrectomy in Obese Liver Transplant Candidates

Morbid obesity (body mass index [BMI] ≥40 kg/m² ) is a relative contraindication to liver transplantation (LT) at many transplant centers. The safety and efficacy of pre-LT bariatric surgery in morbidly obese LT candidates is unknown. Herein, we describe a cohort study of morbidly obese LT candidates who failed to achieve adequate weight loss through a medically supervised weight loss program and subsequently underwent sleeve gastrectomy (SG) at our institution. In total, 32 LT candidates with a median Model for End-Stage Liver Disease (MELD) score of 12 (interquartile range [IQR], 10-13) underwent SG. All LT candidates had a history of hepatic decompensation, but complications of liver disease were required to be well controlled at the time of SG. Median pre-SG BMI was 45.0 kg/m² (IQR, 42.1-49.0 kg/m² ). There were no perioperative deaths or liver-related morbidity. One patient experienced major perioperative morbidity secondary to a gastric leak, which was managed nonoperatively. Median weight loss at 6 and 12 months after SG was 22.0 kg (IQR, 18.9-26.8 kg) and 31.0 kg (IQR, 23.6-50.3 kg), respectively, corresponding to a percentage of excess body weight lost of 33.4% and 52.4%. Within 6 months after SG, 28 (88%) candidates were deemed eligible for LT. Our center's experience highlights the potential option of SG in morbidly obese LT candidates with advanced liver disease who might otherwise be excluded from pursuing LT.

History of Marijuana Use Does Not Affect Outcomes on the Liver Transplant Waitlist

BACKGROUND

Data are limited on marijuana use and its impact on liver transplant (LT) waitlist outcomes. We aimed to assess the risk of waitlist mortality/delisting and likelihood of LT among prior marijuana users and to determine the prevalence and factors associated with marijuana use.

METHODS

Retrospective cohort of adults evaluated for LT over 2 years at a large LT center. Marijuana use was defined by self-report in psychosocial assessment and/or positive urine toxicology. Ongoing marijuana use was not permitted for LT listing during study period.

RESULTS

Eight hundred eighty-four adults were evaluated, and 585 (66%) were listed for LT (median follow-up, 1.4 years; interquartile range, 0.5-2.0). Prevalence of marijuana use was 48%, with 7% being recent users and 41% prior users. Marijuana use had statistically significant association with alcoholic cirrhosis (incidence rate ratio [IRR], 1.9) and hepatitis C (IRR, 2.1) versus hepatitis B, tobacco use (prior IRR, 1.4; recent IRR, 1.3 vs never), alcohol use (never IRR 0.1; heavy use/abuse IRR 1.2 vs social), and illicit drug use (prior IRR, 2.3; recent, 1.9 vs never). In adjusted competing risk regression, marijuana use was not associated with the probability of LT (prior hazard ratio [HR], 0.9; recent HR, 0.9 vs never) or waitlist mortality/delisting (prior HR, 1.0; recent HR, 1.0 vs never). However, recent illicit drug use was associated with higher risk of death or delisting (HR, 1.8; P = 0.004 vs never).

CONCLUSIONS

Unlike illicit drug use, marijuana use was not associated with worse outcomes on the LT waitlist. Prospective studies are needed to assess ongoing marijuana use on the LT waitlist and post-LT outcomes.

Marijuana use in transplantation: A call for clarity

Transplant centers have varying policies for marijuana (MJ) use in donors, transplant candidates, and recipients. Rationales for these differences range from concerns for fungal complications, impaired adherence, and drug interactions. This paper reviews the current status of MJ policies and practices in transplant centers and results of a survey sent to the American Society of Transplantation (AST) membership by the Executive Committee of the AST Infectious Diseases Community of Practice.The purpose of the survey was to compare policies and concerns of MJ use to actual observed complications. Of the 3321 surveys sent, 225 members (8%) responded. Transplant centers varied in their approval processes, differing even in organ types within the same institutions. Furthermore, there was discordance among transplant centers in their perceived risks of marijuana use as opposed to complications actually observed. An increasing number of states continue to legalize medical and recreational MJ resulting in widespread availability. Further research is needed to assess the validity of concerns for complications of MJ use in potential donors and recipients. Ultimately, standardized guidelines should be established based on studies and evidence-based criteria to assist transplant programs in their policies around the use of cannabis in their donors and recipients.

Contemporary Policies Regarding Alcohol and Marijuana Use Among Liver Transplant Programs in the United States

BACKGROUND

Alcoholic liver disease is a common indication for orthotopic liver transplantation (OLT). Although OLT has been shown to confer survival benefit to patients with acute alcoholic hepatitis (AAH), historically most programs require a 6-month abstinence period before OLT which excludes patients with AAH. Marijuana has become legal in more than half the states in the United States. This survey of liver transplant programs was conducted to evaluate current policies regarding alcohol, marijuana and methadone use.

METHODS

A questionnaire was distributed to 100 United Network for Organ Sharing-approved liver transplant programs in North America that have performed at least 30 liver transplants/year in the last 5 years.

RESULTS

Forty-nine programs responded. Only 43% of the programs required a specific period of abstinence before transplant for alcoholic liver disease and only 26% enforced 6-month abstinence policy. For patients with AAH, 71% programs waived the 6-month abstinence requirement and considered psychosocial factors, such as family support, patient's motivation, or commitment to rehabilitate. Few programs used validated instruments to assess risk of relapse in AAH patients. Fourteen percent of programs transplant patients actively using marijuana and an additional 28% of programs listed patients using marijuana provided they discontinue by the time of OLT. Active methadone users were accepted in 45% of the programs.

CONCLUSIONS

Policies regarding alcohol use have become more flexible particularly toward patients with AAH. Marijuana use is also more accepted. Although policies regarding alcohol and marijuana have changed significantly in the last decade, they remain highly variable among programs.

Specific issues concerning the management of patients on the waiting list and after liver transplantation

The present document is a second contribution collecting the recommendations of an expert panel of transplant hepatologists appointed by the Italian Association for the Study of the Liver (AISF) concerning the management of certain aspects of liver transplantation, including: the issue of prompt referral; the management of difficult candidates; malnutrition; living related liver transplants; hepatocellular carcinoma; and the role of direct acting antiviral agents before and after transplantation. The statements on each topic were approved by participants at the AISF Transplant Hepatology Expert Meeting organized by the Permanent Liver Transplant Commission in Mondello on 12-13 May 2017. They are graded according to the GRADE grading system.

Assessment and enrolment process for liver transplantation: nursing management through quality indicators

Objective

To establish, measure and analyze quality indicators in the evaluation and enrolment process of patients in a liver transplant program.

Methods

A quantitative and non-experimental research, with data collected from the database of a liver transplant program, from September 2012 to September 2014. Descriptive statistics were used to analyze the quality indicators identified.

Results

We analyzed 1,311 visits in the transplant outpatient clinic, most males (66.7%), white (65.1%), mean age of 53 (±12.5) years, from the Southeastern Region (91.2%), and from the State of São Paulo (80.8%). The indicators measured were efficiency of patient admission process (54.8%), efficiency of evaluation of transplant indication (39.9%), efficacy of treatment of patients seen in the program (21.8%), and waiting time to inclusion in the waiting list, median of 84 days (36-142).

Conclusion

The quality indicators analyzed in this study enabled a quantitative view of the process, facilitating management of results and benchmarking with other transplant centers. Continuous monitoring can optimize resource allocation and planning of services in patient's admission process.

Transplant eligibility for patients with affective and psychotic disorders: a review of practices and a call for justice

BACKGROUND

The scarcity of human organs requires the transplant community to make difficult allocation decisions. This process begins at individual medical centers, where transplant teams decide which patients to place on the transplant waiting list. Each transplant center utilizes its own listing criteria to determine if a patient is eligible for transplantation. These criteria have historically considered preexisting affective and psychotic disorders to be relative or absolute contraindications to transplantation. While attitudes within the field appear to be moving away from this practice, there is no data to confirm that eligibility criteria have changed.

MAIN BODY

There are no nationwide guidelines detailing the manner in which affective and psychotic disorders should impact transplant eligibility. Individual transplant centers thus form their own transplant eligibility criteria, resulting in significant inter-institution variability. Data from the 1990s indicates that the majority of transplant programs considered certain psychiatric illnesses, such as active schizophrenia, to be absolute contraindications to transplantation. A review of literature reveals that no comprehensive data has been collected on the topic since that time. Furthermore, the limited data available about current practices suggests that psychiatric illness continues to be viewed as a contraindication to transplantation at some transplant centers. In light of this finding, we review psychiatric literature that examines the impact of affective and psychotic disorders on transplant outcomes and conclude that the presence of these disorders is not an accurate predictor of transplant success. We then discuss the requirements of justice as they relate to the creation of a just organ allocation system.

CONCLUSION

We conclude that transplant eligibility criteria that exclude patients with affective and psychotic disorders on the basis of their psychiatric diagnosis alone are unjust. Just listing criteria must incorporate only those factors that have a causative effect on posttransplant morbidity and mortality. Justice also demands that we eliminate current inter-institution practice variations in favor of national transplant eligibility criteria. Given the limited data available about current practices, we call for an updated study investigating the manner in which affect and psychotic disorders impact transplant eligibility determinations.

Higher Mortality and Survival Benefit in Obese Patients Awaiting Liver Transplantation

BACKGROUND

Over 85% of US centers adhere to practice guidelines that consider morbid obesity to be a contraindication to liver transplantation (LT). The relationship of morbid obesity with LT outcomes and survival benefit in the current era is unknown.

METHODS

We investigated the association of body mass index with waitlist and post-LT outcomes, and survival benefit, using the United Network for Organ Sharing registry. We categorized body mass index as follows: 18.5 to 29.9 kg/m, normal/overweight; 30 to 34.9 kg/m, obese; 35 to 39.9 kg/m, severely obese; and ≥40 kg/m, morbidly obese, and evaluated waitlist outcomes using competing risk regression and post-LT outcomes and survival benefit using Cox regression.

RESULTS

3.9% of 80 221 waitlisted and 3.5% of 38 177 transplanted patients were morbidly obese. Waitlist mortality was higher for morbidly obese than normal/overweight patients (subdistribution hazard ratio, 1.16; 95% confidence interval [CI]:1.08-1.26), but post-LT mortality and graft failure were comparable (hazard ratio [HR], 1.01; 95% CI, 0.86-1.19; and HR, 1.15; 95% CI, 0.95-1.40). Morbidly obese patients also benefited more from LT (88% mortality reduction vs 80% for normal/overweight). Morbid obesity predicted higher post-LT mortality before 2007 (HR, 1.18; 95% CI, 1.04-1.34), but not afterward (HR, 0.98; 95% CI, 0.81-1.18).

CONCLUSIONS

Morbid obesity is associated with higher mortality on the LT waitlist, but no longer predicts inferior outcomes after LT. Morbidly obese patients should be considered potential candidates for LT.

Liver Transplantation to the Active Smoker: Transplant Provider Opinions and How They Have Changed : Transplantation in Smokers: A Survey

Awareness of smoking complications in liver transplantation patients is increasing. No study in the past 15 years has addressed attitudes toward offering transplantation to smokers. Our aim was to determine smoking policies nationwide. We conducted a survey of liver transplantation centers. The seven-question survey was sent to medical and surgical directors of liver transplantation. Results were analyzed in R 3.1.1 using two-tailed t testing and ANOVA. Fifty one of 110 centers (46 %) responded. Volume transplanted annually ranged from 10 to 190. Most respondents acknowledged a policy on smoking (38/51, 75 %). Most centers with policies required cessation (32/38, 84 %). All other centers did encourage attempts at cessation (19/19, 100 %). Whether smoking cessation was required differed by region (p = 0.02). Southern programs more commonly required smoking cessation (87.5 vs. 38.4 %, p < 0.001). The highest rates of smoking cessation were noted in the Southwest (90.0 %) and the lowest in the Northeast (26.2 %). There was a trend toward requiring cessation in larger-volume centers. Most respondents had a tobacco policy and tended to require abstinence; however, ultimately centers were divided on requiring cessation. Regional differences were noted, with the South more commonly requiring cessation. Our results indicate lack of consensus among transplantation centers regarding access of smokers to liver transplantation.

Outcome of hepatectomy for hepatocellular carcinoma in elderly patients with portal hypertension

The outcome of liver resection (LR) for elderly hepatocellular carcinoma (HCC) patients with portal hypertension (PHT) who may be excluded as liver transplantation candidates has not been fully evaluated. One hundred ninety-five patients who underwent initial curative LR for HCC with PHT were divided into 2 groups: age <70 years (n = 131) and age ≥70 years (n = 64). Clinicopathologic data and postoperative complications were compared. Preoperative characteristics and postoperative complications were similar in both groups. However, in-hospital mortality was significantly more frequent in elderly than in younger patients (11% versus 1%, P = 0.002). No significant intergroup differences were observed in the 5-year disease-free survival rate or recurrence rate (19.7% versus 17.2%; P = 0.338, 63% versus 56%; P = 0.339). Although LR for elderly HCC patients with PHT can be performed with curative intent and gives results comparable with those in younger patients, it is associated with higher in-hospital mortality.

High-risk liver transplant candidates: An ethical proposal on where to draw the line

In making liver transplantation (LT) listing decisions, transplant programs accept that very large differences in expected 5-year posttransplant survival should matter and that small differences in expected survival should not matter. To date, the transplant community has not explicitly addressed the difficult question of how to make decisions when the differences are less dramatic. Existing well-accepted transplant policies neither articulate a criterion for where to draw the line nor provide an ethical justification for distinguishing those who should not be eligible for transplantation from those who should be. Herein we analyze a case from our LT program that raises the issue of how much of a difference should separate the eligible from the ineligible. We explain how our ethical analysis is consistent with the Scientific Registry of Transplant Recipients cumulative sum metric for transplant center performance, the United Network for Organ Sharing standard of capping Model for End-Stage Liver Disease scores at 40 for listing purposes, and the longstanding tradition of allocating scarce medical resources in accordance with the principle of triage. We also discuss how subjectivity can influence judgments about likely outcomes. We conclude by calling for research to gather data that could make survival predictions objective and by proposing a policy that would make the treatment of all patients fair.

Health services and policy research in hepatology

PURPOSE OF REVIEW

This article examines recent health services and policy research studies in hepatology and liver transplantation.

RECENT FINDINGS

Critical issues include access to medical care, timeliness of referral and consultation, resource utilization in clinical practice, comparative effectiveness research, and the evaluation of care delivery models. Despite policymaking efforts, there continues to be unwarranted variation in access to subspecialty care and liver transplantation services based on race and geographic location. Variations in primary care and specialist awareness of practice guidelines for liver disease contribute to disparities in appropriateness and timeliness of treatments. Defining the cost-effectiveness of increased resource utilization for novel antiviral therapies and liver transplantation continues to stimulate controversy. Few comparative effectiveness studies in hepatology exist to date, yet a growing number of analyses using national datasets will help inform policy in this arena. Identifying care delivery models that demonstrate high value for populations with chronic liver disease is critical in the context of recent healthcare reform efforts.

SUMMARY

Health services and policy research is a growing field of investigation in hepatology and liver transplantation. Further emphasis on research training and workforce development in this area will be critical for understanding and improving patient-centered outcomes for this population.

Liver, pancreas and small bowel transplantation: current ethical issues

We describe the medical state of the art in liver, pancreas and small bowel transplantation, and portray the ethical issues. Although most ethical questions related to these transplantations are not specific for liver, pancreas and small bowel, they do challenge ethical analysis as well as new policies and clinical procedures. Firstly, outcomes continue to be of utmost concern, as information is only limited available, is developing over time and is surrounded by many uncertainties. Secondly, characteristics of donors and recipients should be carefully evaluated. The question of what qualifies a donor and a recipient should be considered against the background of a quest for extended criteria, embracing marginal cases, and a judgment with regard to what counts as a good enough outcome. Thirdly, ethical principles of autonomy and fairness are pushed, given the circumstance of severe scarcity, towards limits that can easily be crossed.