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Ferri F, Milana M, Abbatecola A, Pintore A, Lenci I, Parisse S, Vitale A, Di Croce G, Mennini G, Lai Q, Rossi M, Angelico R, Tisone G, Anselmo A, Angelico M, Corradini SG. Electronic Outpatient Referral System for Liver Transplant Improves Appropriateness and Allows First Visit Triage. Clin Gastroenterol Hepatol 2022; 20:e1388-e1415. [PMID: 34648952 DOI: 10.1016/j.cgh.2021.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 09/07/2021] [Accepted: 10/05/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Missed or inappropriate referrals of potential candidates for liver transplantation (LT) are common and traditional referral methods (tRs) do not allow for efficient triage. We investigated the effects of a website developed for electronic outpatient referral to LT (eRW-LT) on these issues. METHODS We prospectively collected data on all consecutive outpatient referrals to 2 Italian LT centers from January 2015 to December 2019. In the second half of the study, starting from July 2017, referring physicians had the option of using eRW-LT, quickly obtaining the judgment on the appropriateness and urgency of the visit from a transplant hepatologist. RESULTS In the second half of the study, there were 99 eRW-LTs and 96 traditional referrals (new tRs), representing a 17.4% increase over the 161 traditional referrals (old tRs) of the first half. With eRW-LT, 11.1% of referrals were judged inappropriate online without booking a visit. Appropriateness, judged at the time of the first visit, was 59.6%, 56.2%, and 94.3% with old tRs, new tRs, and eRW-LT, respectively. Considering the appropriate visits, the median waiting time in days between referral date and first visit appointment was significantly shorter for urgent visits referred with eRW-LT (5.0; 95% CI, 4.8-9.3) compared with nonurgent visits sent with the same system (17.0; 95% CI, 11.5-25.0; P < .0001), those referred with old tRs (14.0; 95% CI, 8.0-23.0; P < .001) and with new tRs (16.0; 95% CI, 10.0-23.0; P < .001). CONCLUSIONS eRW-LT allows an increase in the number of referrals for LT, ensuring effective triage and better appropriateness of visits.
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Affiliation(s)
- Flaminia Ferri
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy.
| | - Martina Milana
- Hepatology and Liver Transplant Unit, University of Tor Vergata, Rome, Italy
| | - Aurelio Abbatecola
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Alessandro Pintore
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Ilaria Lenci
- Hepatology and Liver Transplant Unit, University of Tor Vergata, Rome, Italy
| | - Simona Parisse
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | | | | | - Gianluca Mennini
- General Surgery and Organ Transplantation Unit, Department of Specialistic and Transplant Surgery "Paride Stefanini", Sapienza University of Rome, Rome, Italy
| | - Quirino Lai
- General Surgery and Organ Transplantation Unit, Department of Specialistic and Transplant Surgery "Paride Stefanini", Sapienza University of Rome, Rome, Italy
| | - Massimo Rossi
- General Surgery and Organ Transplantation Unit, Department of Specialistic and Transplant Surgery "Paride Stefanini", Sapienza University of Rome, Rome, Italy
| | - Roberta Angelico
- Hepatology and Liver Transplant Unit, University of Tor Vergata, Rome, Italy
| | - Giuseppe Tisone
- Hepatology and Liver Transplant Unit, University of Tor Vergata, Rome, Italy
| | - Alessandro Anselmo
- Hepatology and Liver Transplant Unit, University of Tor Vergata, Rome, Italy
| | - Mario Angelico
- Hepatology and Liver Transplant Unit, University of Tor Vergata, Rome, Italy
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Burra P, Giannini EG, Caraceni P, Ginanni Corradini S, Rendina M, Volpes R, Toniutto P. Specific issues concerning the management of patients on the waiting list and after liver transplantation. Liver Int 2018; 38:1338-1362. [PMID: 29637743 DOI: 10.1111/liv.13755] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 03/27/2018] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Patrizia Burra
- Multivisceral Transplant Unit, University Hospital, Padova, Italy
| | - Edoardo G Giannini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Ospedale Policlinico San Martino, Genoa, Italy
| | | | | | | | - Riccardo Volpes
- Hepatology and Gastroenterology Unit, ISMETT-IRCCS, Palermo, Italy
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Bruns H, Lozanovski VJ, Schultze D, Hillebrand N, Hinz U, Büchler MW, Schemmer P. Prediction of postoperative mortality in liver transplantation in the era of MELD-based liver allocation: a multivariate analysis. PLoS One 2014; 9:e98782. [PMID: 24905210 PMCID: PMC4048202 DOI: 10.1371/journal.pone.0098782] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Accepted: 05/06/2014] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND AND AIMS Liver transplantation is the only curative treatment for end-stage liver disease. While waiting list mortality can be predicted by the MELD-score, reliable scoring systems for the postoperative period do not exist. This study's objective was to identify risk factors that contribute to postoperative mortality. METHODS Between December 2006 and March 2011, 429 patients underwent liver transplantation in our department. Risk factors for postoperative mortality in 266 consecutive liver transplantations were identified using univariate and multivariate analyses. Patients who were <18 years, HU-listings, and split-, living related, combined or re-transplantations were excluded from the analysis. The correlation between number of risk factors and mortality was analyzed. RESULTS A labMELD ≥20, female sex, coronary heart disease, donor risk index >1.5 and donor Na+>145 mmol/L were identified to be independent predictive factors for postoperative mortality. With increasing number of these risk-factors, postoperative 90-day and 1-year mortality increased (0-1: 0 and 0%; 2: 2.9 and 17.4%; 3: 5.6 and 16.8%; 4: 22.2 and 33.3%; 5-6: 60.9 and 66.2%). CONCLUSIONS In this analysis, a simple score was derived that adequately identified patients at risk after liver transplantation. Opening a discussion on the inclusion of these parameters in the process of organ allocation may be a worthwhile venture.
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Affiliation(s)
- Helge Bruns
- Department of General and Transplant Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Vladimir J Lozanovski
- Department of General and Transplant Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Daniel Schultze
- Department of General and Transplant Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Norbert Hillebrand
- Department of General and Transplant Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Ulf Hinz
- Department of General and Transplant Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Markus W Büchler
- Department of General and Transplant Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Peter Schemmer
- Department of General and Transplant Surgery, Ruprecht-Karls University, Heidelberg, Germany
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Siciliano M, Parlati L, Maldarelli F, Rossi M, Ginanni Corradini S. Liver transplantation in adults: Choosing the appropriate timing. World J Gastrointest Pharmacol Ther 2012; 3:49-61. [PMID: 22966483 PMCID: PMC3437446 DOI: 10.4292/wjgpt.v3.i4.49] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2011] [Revised: 06/27/2012] [Accepted: 07/08/2012] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation is indicated in patients with acute liver failure, decompensated cirrhosis, hepatocellular carcinoma and rare liver-based genetic defects that trigger damage of other organs. Early referral to a transplant center is crucial in acute liver failure due to the high mortality with medical therapy and its unpredictable evolution. Referral to a transplant center should be considered when at least one complication of cirrhosis occurs during its natural history. However, because of the shortage of organ donors and the short-term mortality after liver transplantation on one hand and the possibility of managing the complications of cirrhosis with other treatments on the other, patients are carefully selected by the transplant center to ensure that transplantation is indicated and that there are no medical, surgical and psychological contraindications. Patients approved for transplantation are placed on the transplant waiting list and prioritized according to disease severity. Thus, the appropriate timing of transplantation depends on recipient disease severity and, although this is still a matter of debate, also on donor quality. These two variables are known to determine the “transplant benefit” (i.e., when the expected patient survival is better with, than without, transplantation) and should guide donor allocation.
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Affiliation(s)
- Maria Siciliano
- Maria Siciliano, Lucia Parlati, Federica Maldarelli, Stefano Ginanni Corradini, Department of Clinical Medicine, Division of Gastroenterology, Sapienza University of Rome, 00185 Rome, Italy
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Engelmann G, Schmidt J, Weitz J, Flechtenmacher C, Schenk JP, Weigand MA, Lenhartz H, Wenning D, Holland-Cunz S, Hoffmann GF, Martin E, Büchler MW, Schmitt CP, Burdelski M, Meyburg J. A new pediatric liver transplantation program in Southern Germany. The Heidelberg experience. Pediatr Transplant 2010; 14:12-8. [PMID: 19793222 DOI: 10.1111/j.1399-3046.2009.01247.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
pLTx is a highly complex procedure. It can only be performed safely by experienced teams. Starting a new pLTx program in a country with established centers must therefore avoid a learning curve. We have initiated a liver transplantation program for children in 2003. Medical standards were defined by a team of surgeons, pediatricians, radiologists, anesthesiologists, and pathologists before the first transplantation. An external expert in the field of pLTx supervised the whole process. In a pilot phase, six children weighing more than 20 kg were successfully transplanted. Following this series, the clinical pathways were re-evaluated, and the program was opened for children of all age groups. Between 2003 and 2008, 32 children received 34 organs. Sixty-eight percent of patients received a split-liver, 26% a full size organ, and 6% a reduced size graft. Four LRLTx were performed. Patient survival rate was 91%. We conclude that a new pLTx program can be established without a significant learning curve regarding mortality if a strict strategy of team-building is followed. In the pilot phase, small children and infants have to be referred and transplanted in an established center. An interdisciplinary team of specialists closely working together is the key for sustained success.
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Affiliation(s)
- Guido Engelmann
- Department of Pediatrics, University Hospital, Heidelberg, Germany.
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Granger B, Savoye E, Tenaillon A, Loty B, Tuppin P. Factors associated with regional disparities for registration on the French national liver transplantation waiting list. ACTA ACUST UNITED AC 2008; 32:589-95. [DOI: 10.1016/j.gcb.2008.02.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2007] [Revised: 02/13/2008] [Accepted: 02/29/2008] [Indexed: 11/15/2022]
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Current concepts in transplant surgery: liver transplantation today. Langenbecks Arch Surg 2008; 393:245-60. [PMID: 18309513 DOI: 10.1007/s00423-007-0262-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2007] [Accepted: 12/06/2007] [Indexed: 12/29/2022]
Abstract
INTRODUCTION The discipline of liver transplantation (LTx) has been developed over the past decades, and LTx is now considered the gold standard for the treatment of patients with end-stage liver diseases and early liver tumors in cirrhotic livers. This procedure is now performed routinely in many transplant centers, and it has provided an enormous technical innovation to the field of hepatobiliary surgery. Allocation decision of liver organs is based on medical need and timing. MATERIALS AND METHODS The Mayo Model for End Stage Liver Disease based on patient-specific criteria was developed and applied to prioritize patients on the waiting list. From the donor aspects of LTx, sources of organ, excluding xenotransplantation, can be brain-dead donors, living donors, and non-heart-beating donors. Today, the majority of livers are procured from cadaveric donors. In addition to the conventional LTx, other types are living-donor LTx, reuse of grafts as domino transplantation, ex situ as well as in situ split LTx, and reduced-size LTx. The transplantation procedure consists of several steps including donor selection and management, liver procurement and preservation, back-table preparation, recipient operation with liver implantation, postoperative care, immunosuppression, and follow-up. RESULTS The postoperative complications are divided into surgical, non-surgical, and multifactorial complications. Surgical complications account about 34% of morbidities after LTx and are mainly categorized to vascular and biliary complications. The main medical ones are non-surgical bleeding and infections. The multifactorial complications include primary non- or poor function and small-for-size syndrome. The pretransplant outcome predictors of LTx can be divided into donor, recipient, operative, and postoperative factors. CONCLUSION LTx is now considered a safe and standardized procedure with a substantially improved graft and patient survival and acceptable morbidity rates. However, the new problems, including recurrence of hepatitis C or hepatocellular carcinoma, chronic biliary complications, opportunistic infections, and development of de-novo malignancies are the major problems affecting the long-term outcome of transplanted patients.
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Engelmann G, Meyburg J, Schmidt J, Lenhartz H. Pediatric liver transplantation. Introduction of a program for southern Germany in Heidelberg. Clin Transplant 2006; 20 Suppl 17:124-30. [PMID: 17100712 DOI: 10.1111/j.1399-0012.2006.00611.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Pediatric liver transplantation in Germany is exclusively performed in four centers in the north of Germany. We report our experience with the implementation of a new pediatric liver transplantation program in Heidelberg for children living in the south of Germany. In a pilot phase, we have transplanted eight children with various transplantation techniques including reduced size, left lateral split (segments 2 and 3), and full left split (segments 1-4). All transplantations were successful. No vascular complications occurred. The immunosuppressive regimen we used was cyclosporine A and methylprednisolone. The rate of acute rejection was three of eight patients. No patient required a retransplantation. One patient died due to a severe fungal sepsis he had acquired prior to transplantation. We conclude that in a multidisciplinary approach with careful patient selection a new program for pediatric liver transplantation can be successfully established.
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Affiliation(s)
- Guido Engelmann
- Department of Pediatric Gastroenterology and Hepatology, University Children's Hospital, Heidelberg, Germany.
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