1
|
Azoulay D, Disabato M, Gomez-Gavara C, Feray C, Salloum C, Ngonggang N, Winter A, Hentati H, Levesque E, Lim C, Compagnon P. Liver Transplantation with "Hors Tour" Allocated Versus Standard MELD Allocated Grafts: Single-Center Audit and Impact on the Liver Pool in France. World J Surg 2019; 44:912-924. [PMID: 31832704 DOI: 10.1007/s00268-019-05271-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND The French transplant governing system defined "Rescue" (the so-called "Hors Tour") livers as those livers which were declined for the five top-listed patients. This study compares the outcomes following liver transplantation (LT) in patients who received a donor liver through a rescue allocation (RA) procedure or according to MELD score priority (standard allocation, SA) and evaluates the impact on the graft pool of a proactive policy to accept RA grafts. METHODS Data from all consecutive patients who underwent LT with SA or RA grafts from 2011 to 2015 were compared in terms of short- and long-term outcomes. RESULTS The 249 elective first LTs were performed with 64 (25.7%) RA and 185 (74.3%) SA grafts. RA grafts were obtained from older donors and were associated with a longer cold ischemia time. Recipients of RA livers were older and had lower MELD scores. The rates of delayed graft function, primary nonfunction, retransplantation, complications, and mortality were similar between the RA and SA groups. At 1 and 3 and 5 years, graft and patient survival rates were similar between the groups. These results were maintained after matching on recipient characteristics. Our proactive policy to accept RA grafts increased the liver pool for elective first transplantation by 25%. CONCLUSIONS RA livers can be safely transplanted into selected recipients and significantly expand the liver pool.
Collapse
Affiliation(s)
- Daniel Azoulay
- Centre Hépato-Biliaire, Department of Hepatobiliary and Pancreatic Surgery and Transplantation, Paul Brousse Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris-Sud, Avenue Paul Vaillant Couturier, 94000, Villejuif, France.
- Department of Hepatobiliary and Pancreatic Surgery and Transplantation, Sheba Medical Center, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Mara Disabato
- Department of Hepatobiliary Surgery and Transplantation, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris-Est, Créteil, France
| | - Concepcion Gomez-Gavara
- Department of Hépato-Pancreato-Biliary and Transplant Surgery, Vall d'Hébron University Hospital, Barcelona, Spain
| | - Cyrille Feray
- Department of Hepatology, Paul Brousse Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris-Sud, Villejuif, France
| | - Chady Salloum
- Centre Hépato-Biliaire, Department of Hepatobiliary and Pancreatic Surgery and Transplantation, Paul Brousse Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris-Sud, Avenue Paul Vaillant Couturier, 94000, Villejuif, France
| | - Norbert Ngonggang
- Department of Hepatobiliary Surgery and Transplantation, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris-Est, Créteil, France
| | - Audrey Winter
- Laboratoire de Biostatistique, IURC, Montpellier, France
| | - Hassen Hentati
- Department of Hepatobiliary Surgery and Transplantation, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris-Est, Créteil, France
| | - Eric Levesque
- Department of Anesthesia and Liver Intensive Care Unit, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris-Est, Créteil, France
| | - Chetana Lim
- Department of Hepatobiliary and Pancreatic Surgery and Transplantation, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Philippe Compagnon
- Department of Hepatobiliary Surgery and Transplantation, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris-Est, Créteil, France
- Service de Transplantation, Hôpitaux Universitaires de Genève, Université de Genève, Faculté de Médecine, Geneva, Switzerland
| |
Collapse
|
2
|
Dhar VK, Wima K, Kim Y, Hoehn RS, Jung AD, Ertel AE, Diwan TS, Paterno F, Shah SA. Cost of achieving equivalent outcomes in sicker patients after liver transplant. HPB (Oxford) 2018; 20:268-276. [PMID: 28988703 DOI: 10.1016/j.hpb.2017.08.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 08/10/2017] [Accepted: 08/30/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND We aimed to characterize variability in cost after straightforward orthotopic liver transplant (OLT). METHODS Using the University HealthSystem Consortium and Scientific Registry of Transplant Recipients databases, we identified patients who underwent OLT between 2011 and 2014. Patients meeting criteria for straightforward OLT, defined as length of stay < 14 days with discharge to home, were selected (n = 5763) and grouped into tertiles (low, medium, high) according to cost of perioperative stay. RESULTS Patients undergoing straightforward OLT were of similar demographics regardless of cost. High cost patients were more likely to require preoperative hemodialysis, had higher severity of illness, and higher model for end-stage liver disease (MELD) (p < 0.01). High cost patients required greater utilization of resources including lab tests, blood transfusions, and opioids (p < 0.01). Despite having higher burden of disease and requiring increased resource utilization, high cost OLT patients with a straightforward perioperative course were shown to have identical 2-year graft and overall survival compared to lower cost patients (p = 0.82 and p = 0.63), respectively. CONCLUSION Providing adequate perioperative care for OLT patients with higher severity of illness and disease burden requires increased cost and resource utilization; however, doing so provides these patients with long term survival equivalent to more routine patients.
Collapse
Affiliation(s)
- Vikrom K Dhar
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Koffi Wima
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Young Kim
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Richard S Hoehn
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Andrew D Jung
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Audrey E Ertel
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Tayyab S Diwan
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Flavio Paterno
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Shimul A Shah
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| |
Collapse
|
4
|
Flores A, Asrani SK. The donor risk index: A decade of experience. Liver Transpl 2017; 23:1216-1225. [PMID: 28590542 DOI: 10.1002/lt.24799] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 05/22/2017] [Accepted: 05/24/2017] [Indexed: 02/07/2023]
Abstract
In 2006, derivation of the donor risk index (DRI) highlighted the importance of donor factors for successful liver transplantation. Over the last decade, the DRI has served as a useful metric of donor quality and has enhanced our understanding of donor factors and their impact upon recipients with hepatitis C virus, those with low Model for End-Stage Liver Disease (MELD) score, and individuals undergoing retransplantation. DRI has provided the transplant community with a common language for describing donor organ characteristics and has served as the foundation for several tools for organ risk assessment. It is a useful tool in assessing the interactions of donor factors with recipient factors and their impact on posttransplant outcomes. However, limitations of statistical modeling, choice of donor factors, exclusion of unaccounted donor and geographic factors, and the changing face of the liver transplant recipient have tempered its widespread use. In addition, the DRI was derived from data before the MELD era but is currently being applied to expand the donor pool while concurrently meeting the demands of a dynamic allocation system. A decade after its introduction, DRI remains relevant but may benefit from being updated to provide guidance in the use of extended criteria donors by accounting for the impact of geography and unmeasured donor characteristics. DRI could be better adapted for recipients with nonalcoholic fatty liver disease by examining and including recipient factors unique to this population. Liver Transplantation 23 1216-1225 2017 AASLD.
Collapse
Affiliation(s)
- Avegail Flores
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO
| | | |
Collapse
|
5
|
Ertel AE, Kaiser TE, Abbott DE, Shah SA. Use of video-based education and tele-health home monitoring after liver transplantation: Results of a novel pilot study. Surgery 2016; 160:869-876. [PMID: 27499142 DOI: 10.1016/j.surg.2016.06.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 06/07/2016] [Accepted: 06/14/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND In this observational study, we analyzed the feasibility and early results of a perioperative, video-based educational program and tele-health home monitoring model on postoperative care management and readmissions for patients undergoing liver transplantation. METHODS Twenty consecutive liver transplantation recipients were provided with tele-health home monitoring and an educational video program during the perioperative period. Vital statistics were tracked and monitored daily with emphasis placed on readings outside of the normal range (threshold violations). Additionally, responses to effectiveness questionnaires were collected retrospectively for analysis. RESULTS In the study, 19 of the 20 patients responded to the effectiveness questionnaire, with 95% reporting having watched all 10 videos, 68% watching some more than once, and 100% finding them effective in improving their preparedness for understanding their postoperative care. Among these 20 patients, there was an observed 19% threshold violation rate for systolic blood pressure, 6% threshold violation rate for mean blood glucose concentrations, and 8% threshold violation rate for mean weights. This subset of patients had a 90-day readmission rate of 30%. CONCLUSION This observational study demonstrates that tele-health home monitoring and video-based educational programs are feasible in liver transplantation recipients and seem to be effective in enhancing the monitoring of vital statistics postoperatively. These data suggest that smart technology is effective in creating a greater awareness and understanding of how to manage postoperative care after liver transplantation.
Collapse
Affiliation(s)
- Audrey E Ertel
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Tiffany E Kaiser
- Department of Digestive Diseases, University of Cincinnati School of Pharmacy, Cincinnati, OH
| | - Daniel E Abbott
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Shimul A Shah
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH.
| |
Collapse
|