Liver transplantation in the Kingdom of Saudi Arabia

External Vs Internal e-Referrals: Results from a Nationwide Epidemiological Study Utilizing Secondary Collected Data

Background

E-referral systems, streamlining patient access to specialists, have gained global recognition yet lacked a comparative study between internal and external referrals in Saudi Arabia (KSA).

Methods

This retrospective study utilized secondary data from the Saudi Medical Appointments and Referrals Centre system. The data covers 2020 and 2021, including socio-demographic data, referral characteristics, and specialties. Logistic regression analysis was used to assess factors associated with external referrals.

Results

Out of 645,425 e-referrals from more than 300 hospitals, 19.87% were external. The northern region led with 48.65%. Males were 55%, and those aged 25-64 were 56.68% of referrals. Outpatient clinic referrals comprised 47%, while 61% of referrals were due to a lack of specialty services. Several significant determinants are associated with higher rates of external referral with (p-value <0.001) and a 95% Confidence interval. Younger individuals under 25 exhibit higher referral rates than those aged 25-64. Geographically, compared to the central region, in descending order, there were increasing trends of external referral in the northern, western, and southern regions, respectively (OR = 19.26, OR = 4.48, OR 3.63). External referrals for outpatient departments (OPD) and dialysis services were higher than for routine admissions (OR = 1.38, OR = 1.26). The rate of external referrals due to the lack of available equipment was more predominant than other causes. Furthermore, in descending order, external referrals for organ transplantation and oncology are more frequent than for medical specialties, respectively (OR = 9.39, OR = 4.50).

Conclusion

The study reveals trends in e-referrals within the KSA, noting regional differences, demographic factors, and types of specialties regarding external referrals, benefiting the New Model of Care for the 2030 Vision. Findings suggest expanding virtual consultations to reduce external referrals. Strengthening primary care and preventive medicine could also decrease future referrals. Future studies should assess resource distribution, including infrastructure and workforce, to further inform healthcare strategy.

Approach to Liver Transplantation: Is There a Difference between East and West?

Liver transplantation (LT) remains the only curative treatment for end-stage liver disease as well as acute liver failure. With the exponential increase in organ demand due to the increasing incidence and prevalence of liver diseases, the need to overcome the supply and demand mismatch has arisen. In this review, we discuss the current universal status of LT, emphasizing various LT practices worldwide.

International Liver Transplantation Society Global Census: First Look at Pediatric Liver Transplantation Activity Around the World

BACKGROUND

Over 16 000 children under the age of 15 died worldwide in 2017 because of liver disease. Pediatric liver transplantation (PLT) is currently the standard of care for these patients. The aim of this study is to describe global PLT activity and identify variations between regions.

METHODS

A survey was conducted from May 2018 to August 2019 to determine the current state of PLT. Transplant centers were categorized into quintile categories according to the year they performed their first PLT. Countries were classified according to gross national income per capita.

RESULTS

One hundred eight programs from 38 countries were included (68% response rate). 10 619 PLTs were performed within the last 5 y. High-income countries performed 4992 (46.4%) PLT, followed by upper-middle- (4704 [44·3%]) and lower-middle (993 [9·4%])-income countries. The most frequently used type of grafts worldwide are living donor grafts. A higher proportion of lower-middle-income countries (68·7%) performed ≥25 living donor liver transplants over the last 5 y compared to high-income countries (36%; P = 0.019). A greater proportion of programs from high-income countries have performed ≥25 whole liver transplants (52.4% versus 6.2%; P = 0.001) and ≥25 split/reduced liver transplants (53.2% versus 6.2%; P < 0.001) compared to lower-middle-income countries.

CONCLUSIONS

This study represents, to our knowledge, the most geographically comprehensive report on PLT activity and a first step toward global collaboration and data sharing for the greater good of children with liver disease; it is imperative that these centers share the lead in PLT.

Incidence Rate of Incisional Hernia Post Liver and Kidney Transplant at a Tertiary Center in Riyadh, Saudi Arabia

Background 

Incisional hernia post organ transplant increases morbidity and impacts quality of life among patients undergoing abdominal organ transplants.

Objectives

To estimate the incidence rate of incisional hernia and the factors associated with incisional hernia among patients who underwent liver and kidney transplants.

Methods

This was a retrospective cohort study in which all patients from 2015 to 2020 who underwent liver and/or kidney transplants and met inclusion criteria were involved.

Results

A total of 424 patients who received transplantation surgery were included. Out of them, 287 patients (67.6%) underwent kidney transplants while 132 patients (31.1%) underwent a liver transplant. Additionally, five patients (1.1%) received both liver and kidney transplantation. Fourteen patients (3.3%) experienced incisional hernia across all samples. A higher incidence rate was noticed among patients with liver transplants compared to kidney transplants (6.81% in the liver group vs 1.7% in the kidney group), which showed a statistical significance between the two groups (P-value= 0.007). In multivariate analysis, surgical site infection (SSI), donor type, acute organ rejection, mycophenolate mofetil (MMF), and diabetes were all not predictors of incisional hernia among the patients. 

Conclusion

Incisional hernia incidence in between the groups was within the global range of incisional hernia incidence among abdominal organ transplant patients, with a higher incidence among liver transplant patients. All factors associated with incisional hernia, such as SSI, DM, and old age, didn’t show significance as predictors to incisional hernia formation among the samples.

The Impact of Primary Liver Disease and Social Determinants in a Mixed Donor Liver Transplant Program: A Single-Center Analysis

Organ allocation in liver transplantation (LT) remains imperfect. Periodic center reviews ensure programs transparently evaluate the impact of practice on access to transplantation, reflecting, in particular, patient (primary disease, social determinants) and program (deceased versus live donation) factors. Adult Ontario residents waitlisted for first LT at Toronto General Hospital from November 2012 to May 2019 were reviewed. Analyses were performed between distance to transplant center, income, education level, population density and primary liver disease, with LT, deceased donor liver transplant (DDLT), living donor liver transplant (LDLT), and delisting. Of 1735 listed patients, 549 were delisted (32%), while 1071 were transplanted (62%), with 819 DDLT recipients (76%) and 252 LDLT recipients (24%), while 115 (7%) remained actively listed at data census. On univariate analysis, DDLT recipients lived 30% closer (median 39.7 versus 60.6 km; P < 0.001), lived in more populous areas (median 8501.0 versus 6868.5 people in a 1-km radius; P < 0.001), and resided in households that annually earned 10% less (median $92,643.17 versus $102,820.89 Canadian dollars; P < 0.001) compared with LDLT recipients. These findings with population density and income differences between DDLT versus LDLT receival remained significant on multivariate modeling even when accounting for primary liver disease. Primary liver disease was a statistically significant factor on multivariate analyses in LT receival (P = 0.001) as well as DDLT versus LDLT receival (P < 0.001). Of patients listed for end-stage liver disease, more patients with autoimmune cholestatic liver diseases received LDLT (34%-41%) than DDLT (27%-30%); this contrasted with patients with noncholestatic diseases LDLT (8%-19%) versus DDLT (37%-59%) receival (P < 0.001). Review of transplant allocation in a large mixed-donor North American liver transplant program demonstrates how patient social determinants and primary liver disease etiology continue to be significantly associated with ultimate transplantation.

Outcomes of late Kasai portoenterostomy in biliary atresia: a single-center experience

OBJECTIVES

To describe the clinical, histopathologic, and outcomes data for a cohort of patients with biliary atresia (BA), and to identify the factors affecting survival.

METHODS

This was a cross-sectional study of all BA patients diagnosed between 1999 and 2017. Clinical, biochemical, imaging, and histopathologic data were analyzed, and Kaplan-Meier survival rates were compared to identify potential prognostic factors.

RESULTS

We evaluated 23 patients. The median age at the Kasai procedure was 77 ± 34 days, and the median overall survival was 12.5 ± 65 months. Thirteen (56%) patients survived with their native livers, 3 (13%) received a transplant, and 6 died (26%) while awaiting a transplant. Cholangitis and the use of ursodeoxycholic acid were associated with longer survival, while impaired synthetic function was associated with shorter survival.

CONCLUSIONS

Most patients presented late for the Kasai procedure. The survival rate with the native liver was comparable to other cohorts. Therefore, clinicians are encouraged to refer for the Kasai procedure even with late presentation (between 60 and 90 days), provided there is no hepatic decompensation.

Homozygous Familial Hypercholesterolemia (HoFH) in Saudi Arabia and Two Cases of Lomitapide Use in a Real-World Setting

Introduction

Homozygous familial hypercholesterolemia (HoFH) is a rare, genetic condition in which mutations in key peptides involved in the low-density lipoprotein receptor (LDL-R) pathway result in markedly elevated levels of circulating LDL-cholesterol (LDL-C). Patients are at high risk of developing early-onset atherosclerotic cardiovascular disease with associated mortality risks. Treatment options are extremely limited, and aspects of society and medical care in Saudi Arabia have the potential to increase incidence and limit treatment pathways in HoFH.

Methods

Along with a brief review of the evidence available on HoFH we describe the treatment of two Saudi Arabian patients with HoFH diagnosed and treated in accordance with local clinical practices and with the microsomal triglyceride transferase protein inhibitor lomitapide.

Results

HoFH in Saudi Arabia is characterized by problems associated with consanguinity, a lack of access to lipoprotein apheresis, and pressures to proceed to liver transplant. Among the case histories, the first patient was commenced on lomitapide therapy, and underwent a dramatic decrease in LDL-C levels from 16.5 to 2.2 mmol/L (87% decrease). This patient had problems with access to lomitapide and cessation of the drug resulted in rebound in LDL-C to 22 mmol/L. The second patient experienced delayed commencement of lomitapide therapy. Despite a 45% decrease in LDL-C levels from 15.3 to 6.9 mmol/L, the patient died the following year at age 26 years from complications subsequent to cardiovascular surgery. Lomitapide was well tolerated in both patients

Discussion

The experience of these two cases highlights the need for prompt, effective, and sustained intervention in HoFH to prevent cardiovascular morbidity and mortality. Lomitapide is an effective therapy for HoFH, and we look forward to improved access to this drug in Saudi Arabia, where there is a chronic unmet medical need in HoFH.

Saudi association for the study of liver diseases and transplantation position statement on liver transplantation during the COVID-19 pandemic

The World Health Organization (WHO), on March 11^th 2020, upgraded the status of the novel coronavirus disease (COVID-19) from epidemic to pandemic. Over two million individuals have been infected with SARS-CoV-2, the virus causing COVID-19, and as of April, 14^th 2020, there were over 5000 confirmed cases in Saudi Arabia (SA). Many countries, including SA, have imposed major restrictions on travel, and everyday life, and the implications of these necessary changes are being felt in liver transplant (LT) centers in SA. Concerns remain that there is an increased risk for individuals over 65 years of age, with underlying medical conditions, or for those who are immunocompromised. Therefore, the Saudi Association for the Study of Liver Diseases and Transplantation (SASLT) established an urgent task force to launch a statement that can be utilized by LT centers as a guidance in the management of patients with advanced liver disease from the time of LT listing to the post-operative care of transplanted patients.

The Perception of Medical Students at King Abdulaziz University Hospital Regarding the Liver Transplant Allocation System

Background: The benefit of liver transplantation is not only to increase the patient’s lifetime but also for persistent relief of pain and anxiety. Shortage of the organ is the main hindrance of transplantation around the world, leading authorities to pass a general law for the reasonable distribution of organs and come up with the Model for End-Stage Liver Disease (MELD) system which scores the severity of liver disease and risk of mortality in order to detect the mechanism of allocation. 

Objective: This study aims to assess medical students’ perception of the liver transplant and allocation system.

Methods: A cross-sectional survey was carried out among 402 medical students at King Abdulaziz University in Jeddah, Saudi Arabia.

Results: The majority of the medical students (84.4%) believed that a successful liver transplant improves both lifetime and quality of life. Most of the students also saw that the minimum survival rate should be five years after transplantation and that the patient should recover to be at least ambulatory, even if restricted by strenuous physical activity. When asked whether urgency or prospect of success defined a successful transplant, most of the students who chose urgency were preclinical (50.7%), while the prospect of success was the dominant answer chosen by students in their clinical years of study (66.1%).

Conclusion: The criteria determining the success of a liver transplant include a gain in both lifetime and quality of life. The majority of respondents wanted the capacity to benefit to be considered in the liver allocation system.