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De Simone P, Germani G, Lai Q, Ducci J, Russo FP, Gitto S, Burra P. The impact of socioeconomic deprivation on liver transplantation. FRONTIERS IN TRANSPLANTATION 2024; 3:1352220. [PMID: 38993752 PMCID: PMC11235234 DOI: 10.3389/frtra.2024.1352220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 02/13/2024] [Indexed: 07/13/2024]
Abstract
Despite global expansion, social disparities impact all phases of liver transplantation, from patient referral to post-transplant care. In pediatric populations, socioeconomic deprivation is associated with delayed referral, higher waitlist mortality, and reduced access to living donor transplantation. Children from socially deprived communities are twice as much less adherent to immunosuppression and have up to a 32% increased incidence of graft failure. Similarly, adult patients from deprived areas and racial minorities have a higher risk of not initiating the transplant evaluation, lower rates of waitlisting, and a 6% higher risk of not being transplanted. Social deprivation is racially segregated, and Black recipients have an increased risk of post-transplant mortality by up to 21%. The mechanisms linking social deprivation to inferior outcomes are not entirely elucidated, and powered studies are still lacking. We offer a review of the most recent evidence linking social deprivation and post-liver transplant outcomes in pediatric and adult populations, as well as a literature-derived theoretical background model for future research on this topic.
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Affiliation(s)
- Paolo De Simone
- Liver Transplant Program, University of Pisa Medical School Hospital, Pisa, Italy
- Department of Surgical, Medical, Molecular Pathology and Intensive Care, University of Pisa, Pisa, Italy
| | - Giacomo Germani
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Quirino Lai
- General Surgery and Organ Transplantation Unit, La Sapienza University of Rome, Rome, Italy
| | - Juri Ducci
- Liver Transplant Program, University of Pisa Medical School Hospital, Pisa, Italy
| | - Francesco Paolo Russo
- Department of Surgery, Gastroenterology, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Stefano Gitto
- Internal Medicine and Liver Unit, Department of Experimental and Clinical Medicine, University Hospital Careggi, University of Florence, Florence, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
- Department of Surgery, Gastroenterology, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
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Okumura K, Dhand A, Misawa R, Sogawa H, Veillette G, Nishida S. The effects of acuity circle policy on racial disparity in liver transplantation. Surgery 2023; 174:1436-1444. [PMID: 37827898 DOI: 10.1016/j.surg.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 08/03/2023] [Accepted: 09/05/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND A new deceased donor liver allocation policy using an acuity circle-based model was implemented with the goal of providing equitable access to liver transplantation. We assessed the effect of the acuity circle policy on racial disparities in liver transplantation by analyzing waitlist mortality, transplant probability, and post-transplant outcomes. METHODS We conducted a retrospective analysis of 23,717 adult liver transplantation candidates listed during the pre-acuity circle period and 21,051 during the post-acuity circle period (N = 44,768) in the United Network for Organ Sharing database from February 2020 to December 2021. RESULTS Acuity circle-policy implementation was not associated with any significant difference in 90-day waitlist mortality but increased the 90-day probability of all candidates. Implementation did not decrease 90-day waitlist mortality but increased the 90-day transplant probability for all patients. One-year patient and liver graft survival were comparable between the study periods for all recipients, but Black recipients had higher rates of 1-year post-liver transplantation mortality and liver graft failure in both periods. CONCLUSION Although the implementation of the acuity circle policy is associated with an increase in transplant probability in White, Black, and Hispanic liver transplantation candidates, it did not change their waitlist mortality, nor did it lead to any improvement in the preexistent worse post-transplant outcomes in Black liver transplantation recipients.
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Affiliation(s)
- Kenji Okumura
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York. https://twitter.com/KenjiOkumura_MD
| | - Abhay Dhand
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York. https://twitter.com/DhandAbhay
| | - Ryosuke Misawa
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - Hiroshi Sogawa
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York. https://twitter.com/HiroNewYork
| | - Gregory Veillette
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - Seigo Nishida
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York.
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Keeling SS, McDonald MF, Anand A, Handing GE, Prather LL, Christmann CR, Jalal PK, Kanwal F, Cholankeril G, Goss JA, Rana A. Significant improvements, but consistent disparities in survival for African Americans after liver transplantation. Clin Transplant 2022; 36:e14646. [PMID: 35304775 PMCID: PMC9310351 DOI: 10.1111/ctr.14646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 02/20/2022] [Accepted: 03/06/2022] [Indexed: 11/28/2022]
Abstract
Despite improvements in survival across races in the past 20 years, African Americans have worse liver transplant outcomes after orthotopic liver transplantation (OLT). This study aims at quantifying the change in disparities between African Americans and other races in survival after OLT. We retrospectively analyzed the United Network for Organ Sharing (UNOS) database for patient data for candidates who received a liver transplant between January 1, 2007 and December 31, 2017. Multivariate Cox proportional hazards regression indicated similar decreases in mortality over time for each race with a decrease in mortality for African Americans: 2010-2012 (HR = .930), 2012-2015 (HR = .882), and 2015-2017 (HR = .883) when compared to 2007-2010. Risk of mortality for African Americans compared to Caucasians varied across the 4 eras: 2007-2010 (HR = 1.083), 2010-2012 (HR = 1.090), 2012-2015 (HR = 1.070), and 2015-2017 (HR = 1.125). While African Americans have seen increases in survival in the past decade, a similar increase in survival for other races leaves a significant survival disparity in African Americans.
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Affiliation(s)
| | - Malcolm F. McDonald
- Department of Student Affairs, Baylor College of Medicine, Houston, Texas, USA
| | - Adrish Anand
- Department of Student Affairs, Baylor College of Medicine, Houston, Texas, USA
| | - Greta E. Handing
- Department of Student Affairs, Baylor College of Medicine, Houston, Texas, USA
| | - Lyndsey L. Prather
- Department of Student Affairs, Baylor College of Medicine, Houston, Texas, USA
| | | | - Prasun K. Jalal
- Division of Abdominal Transplant, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Fasiha Kanwal
- Division of Abdominal Transplant, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - George Cholankeril
- Division of Abdominal Transplant, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - John A. Goss
- Division of Abdominal Transplant, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Abbas Rana
- Division of Abdominal Transplant, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
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Ross-Driscoll K, Kramer M, Lynch R, Plantinga L, Wedd J, Patzer R. Variation in Racial Disparities in Liver Transplant Outcomes Across Transplant Centers in the United States. Liver Transpl 2021; 27:558-567. [PMID: 37160041 PMCID: PMC8201428 DOI: 10.1002/lt.25918] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 08/28/2020] [Accepted: 09/22/2020] [Indexed: 12/12/2022]
Abstract
Little is known about the role that transplant centers may play in perpetuating racial disparities after liver transplantation, which are unexplained by patient-level factors. We examined variation in between-center and within-center disparities among 34,114 Black and White liver transplant recipients in the United States from 2010 to 2017 using Scientific Registry of Transplant Recipient (SRTR) data. We used Cox proportional hazards models to calculate transplant center-specific Black-White hazard ratios and hierarchical survival analysis to examine potential effect modification of the race-survival association by transplant center characteristics, including transplant volume, proportion of Black patients, SRTR quality rating, and region. Models were sequentially adjusted for clinical, socioeconomic, and center characteristics. After adjustment, Black patients experienced 1.11 excess deaths after liver transplant per 100 person-years compared with White patients (95% confidence interval [CI], 0.65-1.56), corresponding to a 21% increased mortality risk (95% CI, 1.12-1.31). Although there was substantial variation in this disparity across transplant centers, there was no evidence of effect modification by transplant center volume, proportion of minority patients seen, quality rating, or region. We found significant racial disparities in survival after transplant, with substantial variation in this disparity across transplant centers that was not explained by selected center characteristics. This is the first study to directly evaluate the role transplant centers play in racial disparities in transplant outcomes. Further assessment of the qualitative factors that may drive disparities, such as selection processes and follow-up care, is needed to create effective center-level interventions to address health inequity.
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Affiliation(s)
- Katherine Ross-Driscoll
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA,Center for Health Services Research, Emory University School of Medicine, Atlanta, GA
| | - Michael Kramer
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Raymond Lynch
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Laura Plantinga
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Joel Wedd
- Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Rachel Patzer
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA,Center for Health Services Research, Emory University School of Medicine, Atlanta, GA,Department of Surgery, Emory University School of Medicine, Atlanta, GA,Department of Medicine, Emory University School of Medicine, Atlanta, GA
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Liver transplantation at safety net hospitals: Potentially vulnerable patients with noninferior outcomes. Surgery 2019; 166:1135-1141. [DOI: 10.1016/j.surg.2019.06.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 05/28/2019] [Accepted: 06/10/2019] [Indexed: 12/29/2022]
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Pruinelli L, Monsen KA, Gross CR, Radosevich DM, Simon GJ, Westra BL. Predictors of Liver Transplant Patient Survival. Prog Transplant 2016; 27:98-106. [DOI: 10.1177/1526924816680099] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Objective: Liver transplantation is a costly and risky procedure, representing 25 050 procedures worldwide in 2013, with 6729 procedures performed in the United States in 2014. Considering the scarcity of organs and uncertainty regarding prognosis, limited studies address the variety of risk factors before transplantation that might contribute to predicting patient’s survival and therefore developing better models that address a holistic view of transplant patients. This critical review aimed to identify predictors of liver transplant patient survival included in large-scale studies and assess the gap in risk factors from a holistic approach using the Wellbeing Model and the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement. Data Source: Search of the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, and PubMed from the 1980s to July 2014. Study Selection: Original longitudinal large-scale studies, of 500 or more subjects, published in English, Spanish, or Portuguese, which described predictors of patient survival after deceased donor liver transplantation. Data Extraction: Predictors were extracted from 26 studies that met the inclusion criteria. Data Synthesis: Each article was reviewed and predictors were categorized using a holistic framework, the Wellbeing Model (health, community, environment, relationship, purpose, and security dimensions). Conclusions: The majority (69.7%) of the predictors represented the Wellbeing Model Health dimension. There were no predictors representing the Wellbeing Dimensions for purpose and relationship nor emotional, mental, and spiritual health. This review showed that there is rigorously conducted research of predictors of liver transplant survival; however, the reported significant results were inconsistent across studies, and further research is needed to examine liver transplantation from a whole-person perspective.
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Affiliation(s)
| | - Karen A. Monsen
- School of Nursing, University of Minnesota, Minneapolis, MN, USA
| | - Cynthia R. Gross
- School of Nursing and College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
| | - David M. Radosevich
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - György J. Simon
- Department of Health Science Research, Mayo Clinic Rochester, Rochester, MN, USA
| | - Bonnie L. Westra
- School of Nursing and Institute for Health Informatics, University of Minnesota, Minneapolis, MN, USA
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Xu J, Hong JC, Busuttil RW. Cardiac tamponade following liver transplantation after intrapericardial control of the suprahepatic vena cava. Liver Transpl 2015; 21:339-43. [PMID: 25408472 DOI: 10.1002/lt.24047] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 11/02/2014] [Indexed: 02/07/2023]
Abstract
Transabdominal intrapericardial control of the suprahepatic inferior vena cava (SIVC) is a rather uncommon procedure occasionally required in conjunction with complicated liver transplantation (LT) and hepatobiliary surgery. Experience with this technique is limited. Here we report 6 cases of LT in which transabdominal intrapericardial control of the SIVC was necessary. After institutional review board approval was obtained, a single-center, retrospective review was conducted from January 1991 to December 2013 to identify adult cases (age > 18 years) of LT in which transabdominal intrapericardial isolation of the SIVC was necessary. Among 4102 adult LT cases in the study period, 6 such cases were identified. To gain access to the pericardial space, a 6- to 9-cm vertical incision was made above the SIVC. After reperfusion, the diaphragmatic incision was partially closed and selectively drained. Pericardial tamponade developed in 1 patient, and it necessitated emergent reoperation and widespread drainage. In conclusion, transabdominal intrapericardial isolation of the SIVC is easily achieved without the need for a separate thoracic incision. However, to be effective, the pericardial incision should be only partially closed, and the pericardial sac should be drained liberally. Such patients should be carefully monitored for signs and symptoms of pericardial tamponade, the development of which should prompt an immediate return to the operating room for emergent decompression and widespread drainage.
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Affiliation(s)
- Junming Xu
- Department of General Surgery, the First People's Hospital, Shanghai Jiaotong University, Shanghai, People's Republic of China; Dumont-University of California Los Angeles Transplant and Liver Cancer Center, Pfleger Liver Institute, Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
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9
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Hepatitis C in African Americans. Am J Gastroenterol 2014; 109:1576-84; quiz 1575, 1585. [PMID: 25178700 DOI: 10.1038/ajg.2014.243] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Accepted: 07/01/2014] [Indexed: 12/11/2022]
Abstract
The care of hepatitis C virus (HCV) in African Americans represents an opportunity to address a major health disparity in medicine. In all facets of HCV infection, African Americans are inexplicably affected, including in the prevalence of the virus, which is higher among them compared with most of the racial and ethnic groups. Ironically, although fibrosis rates may be slow, hepatocellular carcinoma and mortality rates appear to be higher among African Americans. Sustained viral response (SVR) rates have historically significantly trailed behind Caucasians. The reasons for this gap in SVR are related to both viral and host factors. Moreover, low enrollment rates in clinical trials hamper the study of the efficacy of anti-viral therapy. Nevertheless, the gap in SVR between African Americans and Caucasians may be narrowing with the use of direct-acting agents. Gastroenterologists, hepatologists, primary care physicians, and other health-care providers need to address modifiable risk factors that affect the natural history, as well as treatment outcomes, for HCV among African Americans. Efforts need to be made to improve awareness among health-care providers to address the differences in screening and referral patterns for African Americans.
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Meadows HB, Taber DJ, Pilch NA, Tischer SM, Baliga PK, Chavin KD. The impact of early corticosteroid withdrawal on graft survival in liver transplant recipients. Transplant Proc 2012; 44:1323-8. [PMID: 22664009 DOI: 10.1016/j.transproceed.2012.01.110] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2011] [Accepted: 01/21/2012] [Indexed: 01/13/2023]
Abstract
BACKGROUND There has been increased interest in recent years in reducing or eliminating steroids from the immunosuppression regimen of transplant recipients to reduce adverse effects associated with their use. The purpose of this study was to compare clinical outcomes between early versus late steroid withdrawal after liver transplant to determine the optimal duration of steroid use in this population. METHODS This large-scale, retrospective analysis of liver transplants occurred at our institution between 2000 and 2009. Patients were excluded if they were <18 years old, received a multiorgan transplant, or remained on steroids for >1 year. The early steroid withdrawal group had steroids eliminated by 3 months posttransplant; late steroid withdrawal patients had steroids withdrawn between 3 and 12 months posttransplant. RESULTS A total of 586 liver transplants occurred during the study period; 330 patients were included in the analysis. Graft survival was significantly lower in the early steroid withdrawal group. There was no difference in patient survival or overall acute rejection. However, the late steroid withdrawal group had a significantly higher rate of early acute rejection episodes. There was no difference with regard to new-onset diabetes after transplant, hyperlipidemia, or cardiovascular events between groups. CONCLUSION The results of this study suggest that late corticosteroid withdrawal is associated with better long-term graft survival without increasing the rates of diabetes, hyperlipidemia, or cardiovascular events in liver transplant recipients. A prospective study is warranted to confirm these findings.
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Affiliation(s)
- H B Meadows
- Medical University of South Carolina, Charleston, South Carolina 29425, USA.
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Abstract
In patients with failing liver grafts, hepatic retransplantation cannot be abandoned for the ethical and practical reasons that have been detailed previously. The current recommendations involve a strategy for risk stratification of retransplant candidates. The long-term patient and graft survival outcomes after ReLT are excellent and acceptable for the low and intermediate groups, respectively. However, pursuing ReLT in transplant candidates in the high-risk category cannot be recommended. Furthermore, ReLT should be reserved for centers equipped to manage the difficulties of the endeavor because it is a technically demanding operation that requires surgical expertise and excellent anesthesiology and critical care support both before and after transplantation.
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Affiliation(s)
- Ali Zarrinpar
- Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, 650 C. E. Young Drive South, 77-120 CHS, Box 957054, Los Angeles, CA 90095, USA
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Risk factors for infection after liver transplantation. Best Pract Res Clin Gastroenterol 2012; 26:61-72. [PMID: 22482526 DOI: 10.1016/j.bpg.2012.01.004] [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: 10/22/2011] [Revised: 11/10/2011] [Accepted: 01/13/2012] [Indexed: 01/31/2023]
Abstract
Infection is a common cause of morbidity and mortality after liver transplantation. Risk factors relate to transplantation factors, donor and recipient factors. Transplant factors include ischaemia-reperfusion damage, amount of intra-operative blood transfusion, level and type of immunosuppression, rejection, and complications, prolonged intensive care stay with dialysis or ventilation, type of biliary drainage, repeat operations, re-transplantation, antibiotics, antiviral regimen, and environment. Donor risk factors include infection, prolonged intensive care stay, quality of the donor liver (e.g. steatosis), and viral status. For the recipient the most important are MELD score >30, malnutrition, renal failure, acute liver failure, presence of infection or colonisation, and immune status for viruses like cytomegalovirus. In recent years it has become clear that genetic polymorphisms in innate immunity, especially the lectin pathway of complement activation and in Toll-like receptors importantly contribute to the infection risk after liver transplantation. Therefore, the risk for infections after liver transplantation is a multifactorial problem and all factors need attention to reduce this risk.
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Li H, Xie HY, Zhou L, Feng XW, Wang WL, Liang TB, Zhang M, Zheng SS. Copy number variation in CCL3L1 gene is associated with susceptibility to acute rejection in patients after liver transplantation. Clin Transplant 2011; 26:314-21. [DOI: 10.1111/j.1399-0012.2011.01486.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Pergam SA, Forsberg CW, Boeckh MJ, Maynard C, Limaye AP, Wald A, Smith NL, Young BA. Herpes zoster incidence in a multicenter cohort of solid organ transplant recipients. Transpl Infect Dis 2011; 13:15-23. [PMID: 20636480 DOI: 10.1111/j.1399-3062.2010.00547.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Immunosuppressed patients are at increased risk for herpes zoster (HZ), but incidence in solid organ transplant (SOT) recipients has varied in multiple studies. To assess incidence of HZ, we examined patients who underwent SOT and received follow-up care within the large multicenter US Department of Veteran's Affairs healthcare system. METHODS Incident cases of HZ were determined using ICD-9 coding from administrative databases. A multivariable Cox proportional hazards model, adjusted for a priori risk factors, was used to assess demographic factors associated with development of HZ. RESULTS Among the 1077 eligible SOT recipients, the cohort-specific incidence rate of HZ was 22.2 per 1000 patient-years (95% confidence interval [CI], 18.1-27.4). African Americans (37.6 per 1000 [95% CI, 25.0-56.6]) and heart transplants recipients (40.0 per 1000 [95% CI, 23.2-68.9]) had the highest incidence of HZ. Patients transplanted between 2005 and 2007 had the lowest incidence (15.3 per 1000 [95% CI, 8.2-28.3]). In a multivariable model, African Americans (hazard ratio [HR] 1.88; 95% CI: 1.12, 3.17) and older transplant recipients (HR 1.13; 95% CI: 1.01, 1.27 [per 5-year increment]) had increased relative hazards of HZ. CONCLUSIONS These data demonstrate that HZ is a common infectious complication following SOT. Future studies focused on HZ prevention are needed in this high-risk population.
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Affiliation(s)
- S A Pergam
- Department of Medicine, University of Washington, Seattle, Washington 98109, USA.
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Hurtova M, Bachir D, Lee K, Calderaro J, Decaens T, Kluger MD, Zafrani ES, Cherqui D, Mallat A, Galactéros F, Duvoux C. Transplantation for liver failure in patients with sickle cell disease: challenging but feasible. Liver Transpl 2011; 17:381-92. [PMID: 21445921 DOI: 10.1002/lt.22257] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Sickle cell disease (SCD) frequently affects the liver; if acute liver failure (ALF) develops, the only potentially effective therapeutic option is liver transplantation (LT). Only 12 patients for whom LT was performed for SCD-related ALF have been described so far. We report a retrospective series of 6 adult patients with SCD (3 men and 3 women, median age = 40.1 years) who underwent emergency LT. The indication for LT was ALF complicating cirrhosis in 5 patients (hepatitis C/iron overload-induced cirrhosis in 3 and iron overload-induced cirrhosis in 2); one patient had autoimmune hepatitis. The median follow-up was 52.7 months (0.5-123 months). The 1-, 3-, 5-, and 10-year survival rates were 83.3%, 66.7%, 44.4%, and 44.4%, respectively. One patient died of hepatocellular failure precipitated by hyperacute allograft rejection on post-LT day 10. Soon after LT, 2 patients developed seizures; in 1 case, the seizures were a complication of early calcineurin inhibitor-induced leukoencephalopathy. Four long-term survivors benefited from specific management of SCD; specifically, the hemoglobin S fraction was maintained below 30% and the total hemoglobin level was maintained between 8 and 10 g/dL. Two patients had mild vaso-occlusive crises. Three patients experienced a recurrence of hepatitis C virus (HCV) infection; 2 of these patients experienced reversible neurological complications while they were receiving antiviral treatment. Carefully selected patients with SCD may benefit from emergency LT. However, such patients seem to be particularly susceptible to neurological complications after LT. In contrast, severe SCD-related crises do not seem to recur if specific management is provided. Outcomes may be improved if the neurological complications can be minimized; for example, the administration of a calcineurin inhibitor can be delayed, and the management of HCV infection recurrence can be improved.
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Affiliation(s)
- Monika Hurtova
- Service d'Hépatologie, Université Paris XII Val de Marne-France, Créteil, France.
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