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Howie CM, Cichos KH, Shoreibah MG, Jordan EM, Niknam KR, Chen AF, Hansen EN, McGwin GG, Ghanem ES. Racial Disparities in Treatment and Outcomes of Patients With Hepatitis C Undergoing Elective Total Joint Arthroplasty. J Arthroplasty 2024; 39:1671-1678. [PMID: 38331360 DOI: 10.1016/j.arth.2024.01.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 01/25/2024] [Accepted: 01/29/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND African Americans have the highest prevalence of chronic Hepatitis C virus (HCV) infection. Racial disparities in outcome are observed after elective total hip arthroplasty (THA) and total knee arthroplasty (TKA). This study sought to identify if disparities in treatments and outcomes exist between Black and White patients who have HCV prior to elective THA and TKA. METHODS Patient demographics, comorbidities, HCV characteristics, perioperative variables, in-hospital outcomes, and postoperative complications at 1-year follow-up were collected and compared between the 2 races. Patients who have preoperative positive viral load (PVL) and undetectable viral load were identified. Chi-square and Fisher's exact tests were used to compare categorical variables, while 2-tailed Student's Kruskal-Wallis t-tests were used for continuous variables. A P value of less than .05 was statistically significant. RESULTS The liver function parameters, including aspartate aminotransferase and model for end-stage liver disease scores, were all higher preoperatively in Black patients undergoing THA (P = .01; P < .001) and TKA (P = .03; P = .003), respectively. Black patients were more likely to undergo THA (65.8% versus 35.6%; P = .002) and TKA (72.1% versus 37.3%; 0.009) without receiving prior treatment for HCV. Consequently, Black patients had higher rates of preoperative PVL compared to White patients in both THA (66% versus 38%, P = .006) and TKA (72% versus 37%, P < .001) groups. Black patients had a longer length of stay for both THA (3.7 versus 3.3; P = .008) and TKA (4.1 versus 3.0; P = .02). CONCLUSIONS The HCV treatment prior to THA and TKA with undetectable viral load has been shown to be a key factor in mitigating postoperative complications, including joint infection. We noted that Black patients were more likely to undergo joint arthroplasty who did not receive treatment and with a PVL. While PVL rates decreased over time for both races, a significant gap persists for Black patients.
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Affiliation(s)
- Cole M Howie
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Kyle H Cichos
- Hughston Foundation, Columbus, Georgia; Hughston Clinic, Columbus, Georgia
| | - Mohamed G Shoreibah
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Eric M Jordan
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Kian R Niknam
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California
| | - Antonia F Chen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Erik N Hansen
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California
| | - Gerald G McGwin
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - Elie S Ghanem
- Department of Orthopaedic Surgery, University of Missouri at Columbia, Columbia, Missouri
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Shaikh A, Goli K, Lee TH, Rich NE, Benhammou JN, Keeling S, Kim D, Ahmed A, Goss J, Rana A, Singal AG, Kanwal F, Cholankeril G. Reduction in Racial and Ethnic Disparity in Survival Following Liver Transplant for Hepatocellular Carcinoma in the Direct-acting Antiviral Era. Clin Gastroenterol Hepatol 2023; 21:2288-2297.e4. [PMID: 36521738 PMCID: PMC10686256 DOI: 10.1016/j.cgh.2022.11.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 11/24/2022] [Accepted: 11/30/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND & AIMS Black patients with hepatocellular cancer (HCC), often attributed to hepatitis C virus (HCV) infection, have suboptimal survival following liver transplant (LT). We evaluated the impact of direct-acting antiviral (DAA) availability on racial and ethnic disparities in wait list burden post-LT survival for candidates with HCC. METHODS Using the United Network for Organ Sharing registry, we identified patients with HCC who were listed and/or underwent LT from 2009 to 2020. Based on date of LT, patients were categorized into 2 era-based cohorts: the pre-DAA era (LT between 2009 and 2011) and DAA era (LT between 2015 and 2017, with follow-up through 2020). Kaplan-Meier and Cox proportional hazards analyses were used to compare post-LT survival, stratified by era and race and ethnicity. RESULTS Annual wait list additions for HCV-related HCC decreased significantly in White and Hispanic patients during the DAA era, with no change (P = .14) in Black patients. Black patients had lower 3-year survival than White patients in the pre-DAA era (70.6% vs 80.1%, respectively; P < .001) but comparable survival in the DAA era (82.1% vs 85.5%, respectively; P = .16). 0n multivariable analysis, Black patients in the pre-DAA era had a 53% higher risk (adjusted hazard ratio [HR], 1.53; 95% confidence interval [CI], 1.28-1.84), for mortality than White patients, but mortality was comparable in the DAA era (adjusted HR, 1.23; 95% CI, 0.99-1.52). In a stratified analysis in Black patients, HCV-related HCC carried more than a 2-fold higher risk of mortality in the pre-DAA era (adjusted HR, 2.86; 95% CI, 1.50-5.43), which was reduced in the DAA era (adjusted HR, 1.34; 95% CI, 0.78-2.30). CONCLUSIONS With the availability of DAA therapy, racial disparities in post-LT survival have improved.
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Affiliation(s)
- Anjiya Shaikh
- Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Karthik Goli
- Department of Student Affairs, Baylor College of Medicine, Houston, Texas
| | - Tzu-Hao Lee
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Hepatology Program, Division of Abdominal Transplantation, Michael E DeBakey Department of General Surgery, Baylor College of Medicine, Houston, Texas
| | - Nicole E Rich
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas
| | - Jihane N Benhammou
- The Vatche and Tamar Manoukian Division of Digestive Diseases, University of California at Los Angeles, Los Angeles, California
| | - Stephanie Keeling
- Department of Student Affairs, Baylor College of Medicine, Houston, Texas
| | - Donghee Kim
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford, California
| | - Aijaz Ahmed
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford, California
| | - John Goss
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Abbas Rana
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Amit G Singal
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas
| | - Fasiha Kanwal
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - George Cholankeril
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Hepatology Program, Division of Abdominal Transplantation, Michael E DeBakey Department of General Surgery, Baylor College of Medicine, Houston, Texas.
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Abu S, Chen PH, Harris CM. Comparisons between White and Black Patients Hospitalized with Postliver Transplant Complications/Failure. South Med J 2023; 116:524-529. [PMID: 37400095 DOI: 10.14423/smj.0000000000001578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2023]
Abstract
OBJECTIVES The impact of race on patients presenting to North American hospitals with postliver transplant complications/failure (PLTCF) has not been studied fully. We compared in-hospital mortality and resource utilization outcomes between White and Black patients hospitalized with PLTCF. METHODS This was a retrospective cohort study that evaluated the years 2016 and 2017 from the National Inpatient Sample. Regression analysis was used to determine in-hospital mortality and resource utilization. RESULTS There were 10,805 hospitalizations for adults with liver transplants who presented with PLTCF. White and Black patients with PLTCF made up 7925 (73.3%) hospitalizations from this population. Among this group, 6480 were White (81.7%) and 1445 were Black (18.2%). Blacks were younger than Whites (mean age ± standard error of the mean: 46.8 ± 1.1 vs 53.6 ± 0.39 years, P < 0.01). Blacks were more likely to be female (53.9% vs 37.4%, P < 0.01). Charlson Comorbidity Index scores were not significantly different (scores ≥3: 46.7% vs 44.2%, P = 0.83). Blacks had significantly higher odds for in-hospital mortality (adjusted odds ratio 2.9, confidence interval [CI] 1.4-6.1; P < 0.01). Hospital charges were higher for Blacks compared with Whites (adjusted mean difference $48,432; 95% CI $2708-$94,157, P = 0.03). Blacks had significantly longer lengths of hospital stays (adjusted mean difference 3.1 days, 95% CI 1.1-5.1, P < 0.01). CONCLUSIONS Compared with White patients hospitalized for PLTCF, Black patients had higher in-hospital mortality and resource use. Investigation into causes leading to this health disparity is needed to improve in-hospital outcomes.
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D'Aiello A, Rahman N, Patrik Brodin N, Dave M, Jasra S, Kaubisch A, Kabarriti R, Chuy J. Hepatocellular Carcinoma in HIV-Infected Patients: Clinical Presentation and Outcomes in a Racially Diverse Urban Population. J Gastrointest Cancer 2023; 54:536-544. [PMID: 35534673 DOI: 10.1007/s12029-022-00833-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE As life expectancy for HIV patients improve, hepatocellular carcinoma (HCC) has become a non-AIDS defining illness with a high impact on morbidity and mortality of HIV-infected individuals. We sought to compare outcomes in HIV- versus non-HIV-infected patients treated for HCC at a multiethnic academic medical health system. METHODS A retrospective chart review of patients diagnosed with HCC from 1/1/2005 to 12/31/2016 was performed. Differences in characteristics among HIV and non-HIV subjects were assessed. Associations between HIV status, viral load, CD4 count, and overall survival (OS) were also assessed. RESULTS We identified 915 subjects (842 non-HIV and 73 with HIV). HIV-infected subjects were younger, predominantly male non-Hispanic Blacks, and more likely to have HBV and HCV co-infection, and alcohol use at diagnosis compared to non-HIV counterparts. Stage, MELD score, Child-Pugh, and ECOG performance status were similar. HIV-positive patients received systemic therapy at significantly higher rates and liver transplantation for HCC at significantly lower rates than those without HIV. The actuarial 3- and 5-year overall survival (OS) for all patients was 48.3% and 39.4%. For HIV-infected subjects, 3- and 5-year OS was significantly worse at 36.8% and 28.3% compared to 49.3% and 40.4%, respectively, for non-HIV subjects (log rank p = 0.033). CONCLUSIONS HIV-infected HCC patients have lower survival rates compared to those without HIV. Despite younger age and similar stage, MELD, and ECOG at diagnosis, HIV portends worse outcomes in patients with HCC.
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Affiliation(s)
- Angelica D'Aiello
- Department of Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, 10461, USA
| | - Numa Rahman
- Department of Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, 10461, USA
| | - N Patrik Brodin
- Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, 10461, USA
| | - Manish Dave
- Department of Medicine (Hematology & Oncology), Saint Barnabas Medical Center, Livingston, NY, 07039, USA
| | - Sakshi Jasra
- Division of Hematology & Medical Oncology, University of Vermont, Larner College of Medicine, Burlington, VT, 05405, USA
| | - Andreas Kaubisch
- Department of Medicine (Hematology & Oncology), Saint Barnabas Medical Center, Livingston, NY, 07039, USA
| | - Rafi Kabarriti
- Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, 10461, USA
| | - Jennifer Chuy
- Division of Hematology & Medical Oncology, NYU Langone Health, New York, NY, 10016, USA.
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Kaplan A, Wahid N, Fortune BE, Verna E, Halazun K, Samstein B, Brown RS, Rosenblatt R. Black patients and women have reduced access to liver transplantation for alcohol-associated liver disease. Liver Transpl 2023; 29:259-267. [PMID: 37160081 DOI: 10.1002/lt.26544] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 06/13/2022] [Accepted: 06/14/2022] [Indexed: 12/13/2022]
Abstract
Although sex and racial disparities for liver transplantation (LT) are known, it is unclear if disparities exist for patients with alcohol-associated liver disease (ALD). We aimed to compare sex and racial/ethnic differences in mortality, LT listing, and LT rates in patients with and without ALD. We analyzed patients who were listed for LT and/or died of end-stage liver disease (ESLD) between 2014 and 2018 using the United Network for Organ Sharing Standard Transplant Analysis and Research and Centers for Disease Control and Prevention Wide-ranging OnLine Data for Epidemiologic Research databases, respectively. Patients with ALD were compared with non-ALD patients. Our primary outcome was the ratio of listings for LT to deaths from ESLD-listing-to-death ratio (LDR)-a previously derived metric to assess access to the waiting list. Differences between sex and race/ethnicity were analyzed with chi-square tests and multivariable linear regression. There were 65,588 deaths and 16,133 listings for ALD compared with 75,020 deaths and 40,194 listings for non-ALD. LDR was lower for ALD (0.25 vs. 0.54; p < 0.001). Black patients had the lowest LDR in both ALD and non-ALD (0.13 and 0.39 for Black patients vs. 0.26 and 0.54 for White patients; p < 0.001). Women with ALD had a lower LDR (0.21 vs. 0.26; p < 0.001), whereas women without ALD had higher LDR than men (0.69 vs. 0.47; p < 0.001). There were significant negative interactions between women and ALD in LDR and the transplant-to-death ratio. Multivariable analysis and a sensitivity analysis, with more liberal definitions of ALD and non-ALD, confirmed these findings. Patients with ALD have lower access to LT. Among those with ALD, female and Black patients have the lowest access. New initiatives are needed to eliminate these inequities.
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Affiliation(s)
- Alyson Kaplan
- Division of Gastroenterology and Hepatology , Weill Cornell Medicine , New York , New York , USA
| | - Nabeel Wahid
- Division of Gastroenterology and Hepatology , Weill Cornell Medicine , New York , New York , USA
| | - Brett E Fortune
- Division of Gastroenterology and Hepatology , Weill Cornell Medicine , New York , New York , USA.,Center for Liver Disease and Transplantation , New York , New York , USA
| | - Elizabeth Verna
- Division of Digestive and Liver Disease , Columbia University Irving Medical Center , New York , New York , USA
| | - Karim Halazun
- Center for Liver Disease and Transplantation , New York , New York , USA.,Liver Transplant and Hepatobiliary Surgery , Weill Cornell Medical College , New York , New York , USA
| | - Benjamin Samstein
- Center for Liver Disease and Transplantation , New York , New York , USA.,Liver Transplant and Hepatobiliary Surgery , Weill Cornell Medical College , New York , New York , USA
| | - Robert S Brown
- Division of Gastroenterology and Hepatology , Weill Cornell Medicine , New York , New York , USA.,Center for Liver Disease and Transplantation , New York , New York , USA
| | - Russell Rosenblatt
- Division of Gastroenterology and Hepatology , Weill Cornell Medicine , New York , New York , USA.,Center for Liver Disease and Transplantation , New York , New York , USA
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The closing survival gap after liver transplantation for hepatocellular carcinoma in the United States. HPB (Oxford) 2022; 24:1994-2005. [PMID: 35981946 DOI: 10.1016/j.hpb.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 07/06/2022] [Accepted: 07/13/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Socio-economic inequalities among different racial/ethnic groups have increased in many high-income countries. It is unclear, however, whether increasing socio-economic inequalities are associated with increasing differences in survival in liver transplant (LT) recipients. METHODS Adults undergoing first time LT for hepatocellular carcinoma (HCC) between 2002 and 2017 recorded in the Scientific Registry of Transplant Recipients (SRTR) were included and grouped into three cohorts. Patient survival and graft survival stratified by race/ethnicity were compared among the cohorts using unadjusted and adjusted analyses. RESULTS White/Caucasians comprised the largest group (n=9,006, 64.9%), followed by Hispanic/Latinos (n=2,018, 14.5%), Black/African Americans (n=1,379, 9.9%), Asians (n=1,265, 9.1%) and other ethnic/racial groups (n=188, 1.3%). Compared to Cohort I (2002-2007), the 5-year survival of Cohort III (2012-2017) increased by 18% for Black/African Americans, by 13% for Whites/Caucasians, by 10% for Hispanic/Latinos, by 9% for patients of other racial/ethnic groups and by 8% for Asians (All P values<0.05). Despite Black/African Americans experienced the highest survival improvement, their overall outcomes remained significantly lower than other ethnic∕racial groups (adjusted HR for death=1.20; 95%CI 1.05-1.36; P=0.005; adjusted HR for graft loss=1.21; 95%CI 1.08-1.37; P=0.002). CONCLUSION The survival gap between Black/African Americans and other ethnic/racial groups undergoing LT for HCC has significantly decreased over time. However, Black/African Americans continue to have the lowest survival among all racial/ethnic groups.
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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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Huang DC, Fricker ZP, Alqahtani S, Tamim H, Saberi B, Bonder A. The influence of equitable access policies and socioeconomic factors on post-liver transplant survival. EClinicalMedicine 2021; 41:101137. [PMID: 34585128 PMCID: PMC8452797 DOI: 10.1016/j.eclinm.2021.101137] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 08/27/2021] [Accepted: 09/03/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Survival following liver transplant (LT) is influenced by a variety of factors, including donor risk factors and recipient disease burden and co-morbidities. It is difficult to separate these effects from those of socioeconomic factors, such as income or insurance. The United Network for Organ Sharing (UNOS) created equitable access policies, such as Share 35, to ensure that organs are distributed to individuals with greatest medical need; however, the effect of Share 35 on disparities in post-LT survival is not clear. This study aimed to (1) characterize associations between post-transplant survival and race and ethnicity, income, insurance, and citizenship status, when adjusted for other clinical and demographic factors that may influence survival, and (2) determine if the direction of associations changed after Share 35. METHODS A retrospective, cohort study of adult LT recipients (n = 83,254) from the UNOS database from 2005 to 2019 was conducted. Kaplan-Meier survival graphs and stepwise multivariate cox-regression analyses were performed to characterize the effects of socioeconomic status on post-LT survival, adjusted for recipient and donor characteristics, across the time period and after Share 35. FINDINGS Male sex (HR: 0.93 (95% CI: 0.90-0.96)), private insurance (0.91 (0.88-0.94)), income (0.82 (0.79-0.85)), U.S. citizenship, and Asian (0.81 (0.75-0.88)) or Hispanic (0.82 (0.79-0.86)) race and ethnicity were associated with higher post-transplant survival, after adjustment for clinical and demographic factors (Table 3). These associations were found across the entire time period studied and many persisted after the implementation of Share 35 in 2013 (Table 3; male sex (0.84 (0.79-0.90)), private insurance (0.94 (0.89-1.00)), income (0.82 (0.77-0.89)), and Asian (0.87 (0.73-1.02)) or Hispanic (0.88 (0.81-0.96)) race and ethnicity). INTERPRETATION Recipients' socioeconomic factors at time of transplant may impact long-term post-transplant survival, and a single policy may not significantly alter these structural health inequalities. FUNDING None.
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Key Words
- DDLT, deceased donor living transplant
- DM, diabetes mellitus
- DRI, donor risk index
- HCC, hepatocellular carcinoma
- HCV, hepatitis c virus
- HE, hepatic encephalopathy
- Health disparities
- IQR, interquartile range
- IRB, institutional review board
- LT, liver transplant
- Liver transplant
- MELD, Model for End-Stage Liver Disease
- NAFLD, Non-alcoholic fatty liver disease
- OPTN, Organ Procurement and Transplantation Network
- STAR, Standard Transplant Analysis and Research
- Socioeconomic factors
- UNOS, United Network for Organ Sharing
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Affiliation(s)
- Dora C Huang
- Department of Internal Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, United States
| | - Zachary P Fricker
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Saleh Alqahtani
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Hani Tamim
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Behnam Saberi
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Alan Bonder
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
- Corresponding author.
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Siddiqui NA, Ullah N, Shaikh JR, Bhandari S, Ullah U, Khan SF, Khan OQ, Mohammed Abdul MK. Worse Outcomes Associated With Liver Transplants: An Increasing Trend. Cureus 2021; 13:e17534. [PMID: 34646593 PMCID: PMC8478692 DOI: 10.7759/cureus.17534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 08/29/2021] [Indexed: 11/05/2022] Open
Abstract
Background and aim Since individuals in the early stages of liver cirrhosis are typically asymptomatic, the prevalence of liver cirrhosis may be underestimated. Liver cirrhosis has a significant morbidity and mortality rate, with 1.03 million deaths worldwide each year. For end-stage liver disease, liver transplantation is a potential therapeutic option. The goal of our research was to examine the current trend in liver transplants using data from a national database. Methods Using the International Classification of Diseases (ICD)-9 codes, we identified individuals who had a liver transplant during the index hospital admission in the Nationwide Inpatient Sample from 2007 to 2011. This national sample of patients is from the United States. We looked at the yearly trend in liver transplants and related outcomes, such as duration of hospitalization (DOH), hospital expenses, and mortality in the hospital. In order to find determinants of mortality, we used a multivariate analysis. Results There were 25,331 patients hospitalized (weighted for national estimate). Between 2007 and 2011, the number of transplants grew by 1.2%. The majority of transplant recipients were Caucasian (57%), with an average age of 54 years, had a private healthcare plan (53%), and had average earnings in the upper quartile by zip code (26%). Patients with a higher Charlson Comorbidity Index (79% had a score of four) were more likely to be admitted to a southern hospital (33%), an academic hospital (>99%), and a large capacity hospital (90%). Seventy percent of liver transplant recipients received cadaver donors. Hepatitis C was the most prevalent reason for transplant (30%), followed by hepatocellular carcinoma (HCC) (29%) and alcoholic liver disease (25%). In 2011, compared to 2007, there was an upward rise in fatality (from 3.8% to 5.1%), average hospital expenditures (from $335,504 to $498,369), and DOH (from 17.4 to 22.7 days). The cost of hospitalization was two billion dollars per year. The independent variables related to an increased mortality on multivariate analysis were African American race (OR: 2.0, 95%, CI: 1.2-3.2; p=0.005) and large capacity hospitals (OR: 2.5, 95% CI: 1.6-4.1; p=0.0002). Predictors linked to lower mortality included private healthcare coverage (vs. Medicare: OR: 0.7, 95%, CI: 0.51-0.97; p=0.03), academic hospital (OR: 0.6, 95% CI: 0.4-0.8; p=0.005), cadaver donor (OR: 0.6, 95% CI: 0.5-0.8; p=0.002), HCC (OR: 0.6, 95% CI: 0.4-0.9; p=0.01), and non-alcoholic steatohepatitis (NASH) cirrhosis (OR: 0.4, 95% CI: 0.2-0.9; p=0.02). Conclusion Our study found an increasing trend in worse outcomes (increased mortality, average hospital costs, and average DOH) after a liver transplant. Patients of the African American race and large capacity hospitals were associated with a higher risk of death, whereas private healthcare plans, academic hospitals, cadaver donors, HCC, and NASH cirrhosis were associated with a lower risk.
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Affiliation(s)
- Nabeel A Siddiqui
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Nayaab Ullah
- Hematology and Oncology, Windsor University School of Medicine, Cayon, KNA
| | | | - Sanjay Bhandari
- Internal Medicine, Medical College of Wisconsin, Milwaukee, USA
| | - Uzma Ullah
- Medicine, Loyola University Chicago, Chicago, USA
| | - Summaya F Khan
- Medicine, Windsor University School of Medicine, Cayon, KNA
| | - Omar Q Khan
- Biology, University of California, Riverside, USA
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Malespin M, May EJ, Nephew LD, Paul S, McCary A, Kilaru S, Mukhtar NA, Hassan MA, Brady CW. AASLD Deepens Commitment to Diversity, Equity, and Inclusion. Hepatology 2021; 74:2216-2225. [PMID: 34028073 DOI: 10.1002/hep.31918] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 04/07/2021] [Accepted: 04/23/2021] [Indexed: 01/24/2023]
Affiliation(s)
| | | | - Lauren D Nephew
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN
| | - Sonali Paul
- Section of Gastroenterology Center for Liver Diseases, University of Chicago Medicine, Chicago, IL
| | - Alexis McCary
- Department of Gastroenterology, Mid-Atlantic Permanente Medical Group, Upper Marlboro, MD
| | - Saikiran Kilaru
- Division of Gastroenterology and Hepatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY
| | - Nizar A Mukhtar
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA
| | - Mohamed A Hassan
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, MN
| | - Carla W Brady
- Department of Medicine, Division of Gastroenterology, Duke University, Durham, NC
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11
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Waitlist Mortality and Posttransplant Outcomes in African Americans with Autoimmune Liver Diseases. J Transplant 2021; 2021:6692049. [PMID: 34394979 PMCID: PMC8357471 DOI: 10.1155/2021/6692049] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 02/11/2021] [Accepted: 07/25/2021] [Indexed: 11/17/2022] Open
Abstract
Background Liver transplantation is indicated in end-stage liver disease due to autoimmune diseases. The liver allocation system can be affected by disparities such as decreased liver transplant referrals for racial minorities, especially African Americans that negatively impact the pre- and posttransplant outcomes. Aim To determine differences in waitlist survival and posttransplant graft survival rates between African American and Caucasian patients with autoimmune liver diseases. Study. The United Network for Organ Sharing database was used to identify all patients with autoimmune hepatitis, primary biliary cholangitis, and primary sclerosing cholangitis who underwent liver transplant from 1988 to 2019. We compared waitlist survival and posttransplant graft survival between Caucasians and African Americans using Kaplan–Meier curves and Cox regression models. We also evaluated the cumulative incidence of death or delisting for deterioration and posttransplant incidence of death and retransplantation using competing risk analysis. Results African Americans were more likely to be removed from the waitlist for death or clinical deterioration (subdistribution hazard ratio (SHR) 1.26, 95% CI 1–1.58, P=0.046) using competing risk analysis. On multivariate Cox regression analysis, there was no difference in posttransplant graft survival among the two groups (hazard ratio (HR) 1.10, 95% CI 0.98–1.23, P=0.081). Conclusions Despite the current efforts to reduce racial disparities, we found that African Americans are more likely to die on the waitlist for liver transplant and are less likely to be transplanted, with no differences in graft survival rates. The persistence of healthcare disparities continues to negatively impact African Americans.
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12
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Mazumder NR, Simpson D, Atiemo K, Jackson K, Zhao L, Daud A, Kho A, Gabra LG, Caicedo JC, Levitsky J, Ladner DP. Black Patients With Cirrhosis Have Higher Mortality and Lower Transplant Rates: Results From a Metropolitan Cohort Study. Hepatology 2021; 74:926-936. [PMID: 34128254 DOI: 10.1002/hep.31742] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 11/30/2020] [Accepted: 01/19/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND AIMS Estimates of racial disparity in cirrhosis have been limited by lack of large-scale, longitudinal data, which track patients from diagnosis to death and/or transplant. APPROACH AND RESULTS We analyzed a large, metropolitan, population-based electronic health record data set from seven large health systems linked to the state death registry and the national transplant database. Multivariate competing risk analyses, adjusted for sex, age, insurance status, Elixhauser score, etiology of cirrhosis, HCC, portal hypertensive complication, and Model for End-Stage Liver Disease-Sodium (MELD-Na), examined the relationship between race, transplant, and cause of death as defined by blinded death certificate review. During the study period, 11,277 patients met inclusion criteria, of whom 2,498 (22.2%) identified as Black. Compared to White patients, Black patients had similar age, sex, MELD-Na, and proportion of alcohol-associated liver disease, but higher comorbidity burden, lower rates of private insurance, and lower rates of portal hypertensive complications. Compared to White patients, Black patients had the highest rate all-cause mortality and non-liver-related death and were less likely to be listed or transplanted (P < 0.001 for all). In multivariate competing risk analysis, Black patients had a 26% increased hazard of liver-related death (subdistribution HR, 1.26; 95% CI, [1.15-1.38]; P < 0.001). CONCLUSIONS Black patients with cirrhosis have discordant outcomes. Further research is needed to determine how to address these real disparities in the field of hepatology.
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Affiliation(s)
- Nikhilesh R Mazumder
- Department of Gastroenterology and HepatologyNorthwestern University Feinberg School of MedicineChicagoIL.,Comprehensive Transplant CenterNorthwestern University Feinberg School of MedicineNorthwestern University Transplant Outcomes Research Collaborative (NUTORC)ChicagoIL
| | - Dinee Simpson
- Comprehensive Transplant CenterNorthwestern University Feinberg School of MedicineNorthwestern University Transplant Outcomes Research Collaborative (NUTORC)ChicagoIL.,Division of TransplantDepartment of SurgeryNorthwestern MedicineChicagoIL
| | - Kofi Atiemo
- Comprehensive Transplant CenterNorthwestern University Feinberg School of MedicineNorthwestern University Transplant Outcomes Research Collaborative (NUTORC)ChicagoIL.,Tulane Abdominal Transplant InstituteDepartment of SurgeryTulane University School of MedicineNew OrleansLA
| | - Kathryn Jackson
- Institute for Public Health and Medicine-Center for Health Information PartnershipsNorthwestern University, Feinberg School of MedicineChicagoIL
| | - Lihui Zhao
- Comprehensive Transplant CenterNorthwestern University Feinberg School of MedicineNorthwestern University Transplant Outcomes Research Collaborative (NUTORC)ChicagoIL.,Department of Preventative MedicineNorthwestern University Feinberg School of MedicineChicagoIL
| | - Amna Daud
- Comprehensive Transplant CenterNorthwestern University Feinberg School of MedicineNorthwestern University Transplant Outcomes Research Collaborative (NUTORC)ChicagoIL
| | - Abel Kho
- Comprehensive Transplant CenterNorthwestern University Feinberg School of MedicineNorthwestern University Transplant Outcomes Research Collaborative (NUTORC)ChicagoIL.,Institute for Public Health and Medicine-Center for Health Information PartnershipsNorthwestern University, Feinberg School of MedicineChicagoIL
| | - Lauren G Gabra
- Feinberg School of MedicineNorthwestern University Feinberg School of MedicineChicagoIL
| | - Juan C Caicedo
- Comprehensive Transplant CenterNorthwestern University Feinberg School of MedicineNorthwestern University Transplant Outcomes Research Collaborative (NUTORC)ChicagoIL.,Division of TransplantDepartment of SurgeryNorthwestern MedicineChicagoIL
| | - Josh Levitsky
- Department of Gastroenterology and HepatologyNorthwestern University Feinberg School of MedicineChicagoIL.,Comprehensive Transplant CenterNorthwestern University Feinberg School of MedicineNorthwestern University Transplant Outcomes Research Collaborative (NUTORC)ChicagoIL
| | - Daniela P Ladner
- Comprehensive Transplant CenterNorthwestern University Feinberg School of MedicineNorthwestern University Transplant Outcomes Research Collaborative (NUTORC)ChicagoIL.,Division of TransplantDepartment of SurgeryNorthwestern MedicineChicagoIL
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13
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Darden M, Parker G, Monlezun D, Anderson E, Buell JF. Race and Gender Disparity in the Surgical Management of Hepatocellular Cancer: Analysis of the Surveillance, Epidemiology, and End Results (SEER) Program Registry. World J Surg 2021; 45:2538-2545. [PMID: 33893525 DOI: 10.1007/s00268-021-06091-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND The existence of race and gender disparity has been described in numerous areas of medicine. The management of hepatocellular cancer is no different, but in no other area of medicine, is the treatment algorithm more complicated by local, regional, and national health care distribution policy. METHODS Multivariate logistic regression and Cox-regression were utilized to analyze the treatment of patients with hepatocellular cancer registered in SEER between 1999 and 2013 to determine the incidence and effects of racial and gender disparity. Odd ratios (OR) are relative to Caucasian males, SEER region, and tumor characteristics. RESULTS The analysis of 57,449 patients identified the minority were female (25.31%) and African-American (16.26%). All tumor interventions were protective (p < 0.001) with respect to survival. The mean survival for all registered patients was 13.01 months with conditional analysis, confirming that African-American men were less likely to undergo ablation, resection, or transplantation (p < 0.001). Women were more likely to undergo resection (p < 0.001). African-American women had an equivalent OR for resection but had a significantly lower transplant rate (p < 0.001). CONCLUSIONS Utilizing SEER data as a surrogate for patient navigation in the treatment of hepatocellular cancer, our study identified not only race but gender bias with African-American women suffering the greatest. This is underscored by the lack of navigation of African-Americans to any therapy and a significant bias to navigate female patients to resection potentially limiting subsequent access to definitive therapy namely transplantation.
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Affiliation(s)
- Michael Darden
- Carey Business School, Johns Hopkins University, Baltimore, MD, USA
| | - Geoffrey Parker
- Thayer School of Engineering, Dartmouth College, Hanover, NH, USA
| | | | - Edward Anderson
- University of Texas McCombs Healthcare Innovation Initiative, Austin, TX, USA
| | - Joseph F Buell
- Department of Surgery, Mission Health, HCA North Carolina Division, University of North Carolina, Asheville, NC, USA.
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14
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Samji NS, Snell PD, Singal AK, Satapathy SK. Racial Disparities in Diagnosis and Prognosis of Nonalcoholic Fatty Liver Disease. Clin Liver Dis (Hoboken) 2020; 16:66-72. [PMID: 32922753 PMCID: PMC7474141 DOI: 10.1002/cld.948] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 01/29/2020] [Accepted: 02/11/2020] [Indexed: 02/04/2023] Open
Affiliation(s)
- Naga Swetha Samji
- Department of Internal MedicineTennova Cleveland HospitalClevelandTN
| | - Peter D. Snell
- Department of Internal MedicineUniversity of Tennessee Health Science CenterMemphisTN
| | - Ashwani K. Singal
- Department of Internal MedicineUniversity of South Dakota Sanford School of Medicine and Avera Transplant InstituteSioux FallsSD
| | - Sanjaya K. Satapathy
- Division of Hepatology, Sandra Atlas Bass Center for Liver DiseasesNorthwell HealthManhassetNY
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15
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A Comprehensive Analysis of Liver Transplantation Outcomes Among Ethnic Minorities in the United States. J Clin Gastroenterol 2020; 54:263-270. [PMID: 31169758 DOI: 10.1097/mcg.0000000000001236] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
GOALS The aim of this study was to perform a comprehensive assessment of liver transplant (LT) outcomes among US adults with a specific focus on understanding race/ethnicity-specific disparities. BACKGROUND Despite improvements in the liver allocation and LT-related care, disparities in LT outcomes persist. STUDY Using data from the 2005 to 2016 United Networks for Organ Sharing LT registry, we evaluated waitlist survival, probability of receiving LT, and post-LT survival among US adults stratified by race/ethnicity and liver disease etiology. Kaplan-Meier methods evaluated unadjusted waitlist and post-LT outcomes, and multivariate regression models evaluated adjusted waitlist and post-LT outcomes. RESULTS Among 88,542 listed for LT patients (41.3% hepatitis C virus, 25.3% alcoholic liver disease, 22.3% nonalcoholic steatohepatitis, 11.1% hepatitis C virus/alcoholic liver disease), significant race/ethnicity-specific disparities were observed. Compared with non-Hispanic whites, Hispanics had a significantly lower risk of waitlist death [hazard ratio (HR)=0.84, 95% confidence interval (CI): 0.79-0.90, P<0.001]. Compared with non-Hispanic whites, significantly lower likelihood of receiving LT was observed in African Americans (HR=0.94, 95% CI: 0.91-0.98, P<0.001), Hispanics (HR=0.70, 95% CI: 0.68-0.73, P<0.001) and Asians (HR=0.74, 95% CI: 0.69-0.80, P<0.001). Compared with non-Hispanic whites, African Americans had a significantly higher risk of 5-year post-LT death (HR=1.31, 95% CI: 1.23-1.39, P<0.001). CONCLUSION Among US adults awaiting LT, significant race/ethnicity-specific disparities in LT outcomes were observed. Despite evaluating an era after implementation of the Model for End-Stage Liver Disease, ethnic minorities continue to demonstrate a lower probability of receiving LT, and significantly higher risk of death post-LT in African Americans.
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16
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Ochoa-Allemant P, Ezaz G, Trivedi HD, Sanchez-Fernandez L, Bonder A. Long-term outcomes after liver transplantation in the Hispanic population. Liver Int 2020; 40:437-446. [PMID: 31505081 DOI: 10.1111/liv.14248] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 09/03/2019] [Accepted: 09/04/2019] [Indexed: 02/12/2023]
Abstract
BACKGROUND & AIMS Racial/ethnic disparities in liver transplantation (LT) are well-recognized. Although Hispanics represent the largest and youngest minority group in the United States, limited data exist on long-term outcomes. We aimed to investigate long-term post-liver transplant outcomes in Hispanic patients and identify potential disparities compared to a baseline demographic of non-Hispanic white patients. METHODS We performed a retrospective cohort study of first-time liver transplant recipients using the United Network for Organ Sharing database from 2002 to 2013, with follow-up through 2018. The primary outcomes of interest were overall patient and graft survival after LT. RESULTS 45 767 patients underwent LT (85.0% non-Hispanic white, 15.0% Hispanic). Hispanics had lower socioeconomic status, higher prevalence of pretransplant comorbidities and more severe liver disease compared to non-Hispanic whites. Hispanics had similar patient (76.6% vs 75.6%; P = .12) and graft (71.7% vs 70.8%; P = .28) survival at 5 years and significantly better patient (62.9% vs 59.7%; P < .001) and graft (58.6% vs 55.6%; P = .002) survival at 10 years. In multivariable analysis, Hispanics had lower associated all-cause mortality (HR 0.86, 95% CI, 0.82-0.91; P < .001) and graft failure (HR 0.89, 95% CI, 0.85-0.93; P < .001) compared to non-Hispanic whites. In etiology-specific subanalysis, Hispanics transplanted for ALD, NASH and HCV had lower all-cause mortality compared to non-Hispanic whites. CONCLUSIONS Hispanics have similar or better long-term post-LT outcomes compared to non-Hispanic whites despite a worse pretransplant risk factor profile. Further research is needed to clarify if this survival advantage reflects uncaptured protective factors or more stringent transplant selection in the Hispanic population.
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Affiliation(s)
- Pedro Ochoa-Allemant
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ghideon Ezaz
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Hirsh D Trivedi
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Lady Sanchez-Fernandez
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Alan Bonder
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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17
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Bucher JN, Koenig M, Schoenberg MB, Crispin A, Thomas M, Angele MK, Eser-Valeri D, Gerbes AL, Werner J, Guba MO. Liver transplantation in patients with a history of migration-A German single center comparative analysis. PLoS One 2019; 14:e0224116. [PMID: 31639158 PMCID: PMC6804963 DOI: 10.1371/journal.pone.0224116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 10/04/2019] [Indexed: 11/28/2022] Open
Abstract
Liver transplant (LT) programs in Germany increasingly face a multiethnic patient population. To date no outcome data for LT in patients with a history of migration is available for Germany. This complicates decision-making before wait-listing such patients. We conducted a single-center cohort analysis of all primary LT between April 2007 and December 2015, stratified for the history of migration to investigate differences in the outcome. We found transplant rates resembling the proportion of persons with a history of migration in the general public in the region of our center. Differences were found concerning age at LT and prevalence of underlying diseases. Re-Transplant rates, Kaplan-Meier Estimates for overall survival, also after stratification for viral hepatitis, sex, ethnicity or presence of a language-barrier showed no statistical differences. The multivariate analysis showed no migration-related covariate associated with a negative outcome. These results stand in contrast to most of the previous evidence from North America and the UK and need to be taken into consideration during the wait-listing process of patients with a history of migration in need of a LT in centers in the Eurotransplant region.
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Affiliation(s)
- Julian Nikolaus Bucher
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
- * E-mail:
| | - Maximilian Koenig
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Markus Bo Schoenberg
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Alexander Crispin
- Institute of Medical Informatics, Biometry and Epidemiology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Michael Thomas
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Martin Kurt Angele
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Daniela Eser-Valeri
- Department of Psychiatry, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Alexander Lutz Gerbes
- Department of Medicine 2, Ludwig-Maximilians-University Munich, Munich, Germany
- Transplantation Centre Munich, Ludwig-Maximilians-University Munich, Munich, Germany
- Liver Centre Munich, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Jens Werner
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Markus Otto Guba
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
- Transplantation Centre Munich, Ludwig-Maximilians-University Munich, Munich, Germany
- Liver Centre Munich, Ludwig-Maximilians-University Munich, Munich, Germany
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18
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More Severe Deficits in Performance Status at Time of Liver Transplant is Associated With Significantly Higher Risk of Death Following Liver Transplantation. J Clin Gastroenterol 2019; 53:e392-e399. [PMID: 30762610 DOI: 10.1097/mcg.0000000000001187] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
GOAL To evaluate the impact of Karnofsky Performance Status score (KPSS) at the time of liver transplantation (LT) on post-LT survival. BACKGROUND While the Model for End-Stage Liver Disease (MELD) score is used to prioritize individuals for LT, it does not specifically incorporate functional status into patient assessment for LT. METHODS Using 2005 to 2016 United Network for Organ Sharing data, all adults (age 18 y and above) undergoing LT were identified. The association of KPSS at the time of LT (KPSS 1: functional status 80% to 100%, KPSS 2: 60% to 70%, KPSS 3: 40% to 50%, KPSS 4: 10% to 30%) with post-LT survival was evaluated using Kaplan-Meier methods and adjusted multivariate logistic regression models. RESULTS Among 66,397 LT recipients (68% male, 72% non-Hispanic white, 22% hepatocellular carcinoma, median age: 55 to 57), women were more likely to be KPSS 4 at the time of LT compared with men (27.95% vs. 22.79%; P<0.001) and African Americans (25.43% vs. 23.03%; P<0.001) and Hispanics (31.69% vs. 23.03%; P<0.001) were more likely to be KPSS 4 than non-Hispanic whites. Worse KPSS at LT correlated with higher post-LT mortality [compared with KPSS 1: Hazard Ratio (HR) for KPSS 2: 1.16, 95% confidence interval (CI): 1.10-1.22; HR for KPSS 3: 1.40; 95% CI: 1.32-1.49; HR for KPSS 4: 1.67; 95% CI: 1.55-1.79]. This increased mortality seen with worse KPSS was observed among all liver disease etiologies and in patients with and without hepatocellular carcinoma. CONCLUSIONS Worse functional status at the time of LT is strongly associated with higher risk of mortality following LT, emphasizing the importance of optimizing performance status in the preoperative period.
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19
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Cho SS, Ju YS, Park H, Kim YK, Hwang S, Choi SS. Impact of educational levels on survival rate: A cohort study of 2007 living donor liver transplant recipients at a single large center. Medicine (Baltimore) 2019; 98:e13979. [PMID: 30702556 PMCID: PMC6380783 DOI: 10.1097/md.0000000000013979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Among living donor liver transplantation recipients, the impact of educational levels on survival has rarely explored. Thus, the purpose of study is to analyze the survival rate differences across educational levels among recipients who underwent living donor liver transplantation.We retrospectively analyzed 2007 adult recipients who underwent living donor liver transplantation in a single large center. The educational level was divided into three categories: middle school or lower, high school, and college or higher. The primary outcome was all-cause mortality after living donor liver transplantation. Stratified log-rank test and Cox proportional hazard model were employed for statistical analysis.The incidence rates of all-cause mortality were 23.85, 20.19, and 18.75 per 1000 person-year in recipients with middle school or lower, high school, and college or higher education groups, respectively. However, the gender-stratified log-rank test has not shown a statistically significant difference (P = .3107). In the unadjusted model, hazard ratio (HR) was 1.02 [95% confidence interval (CI) = 0.79-1.33] in high school and 1.23 (95% CI = 0.93-1.64) and in middle school or lower educational level, respectively; In the full adjusted model, the HR of high school was 0.98 (95% CI = 0.75-1.28) and the HR of middle school or lower was 1.01 (95% CI = 0.74-1.37).Although study population of this study is large, we could not find significant survival rate differences by the levels of education. Social selection and high compliance rate might contribute to this result.
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Affiliation(s)
- Seong-Sik Cho
- Department of Occupational and Environmental Medicine, Hallym University Sacred Heart Hospital, Anyang
| | - Young-Su Ju
- Department of Occupational and Environmental Medicine, Hallym University Sacred Heart Hospital, Anyang
| | - Hanwool Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center
| | - Young-Kug Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center
| | - Shin Hwang
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seong-Soo Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center
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20
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Dave S, Dodge JL, Terrault NA, Sarkar M. Racial and Ethnic Differences in Graft Loss Among Female Liver Transplant Recipients. Transplant Proc 2018; 50:1413-1423. [PMID: 29880364 DOI: 10.1016/j.transproceed.2018.02.059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 01/29/2018] [Accepted: 02/17/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Racial differences in post-liver transplantation (LT) outcomes are identified in predominantly male cohorts. Despite known sex differences in a spectrum of liver-related outcomes, it is not known how race influences graft outcomes in women. METHODS Using the Scientific Registry of Transplant Recipients, we examined race and ethnicity and graft loss (death or retransplant) in women transplanted from 2002 to 2012. Covariates included recipient and donor characteristics, socioeconomics, and medical comorbidities. RESULTS The eligible cohort (n = 15,860) included 11,051 Caucasians, 2171 Hispanics, 1876 African Americans (AAs), and 762 Asian women with median follow-up of 3.1 years. Five-year graft survival was lower in AA women (60%) compared with Caucasians (71%), Hispanics (70%), and Asians (73%) (P < .001). Graft loss was 45% higher among AA women <40 years at transplant compared with AA women aged 50 to 59 (hazard ratio 1.45, 95% confidence interval 1.17-1.81) and aged 60 to 69 years (hazard ratio 1.33, 95% confidence interval 1.03-1.71), and risk increased after age 60 among Caucasians (P < .001 for race-age interactions). Increased graft loss among young AA women was limited to the first 2 years post-LT (P = .002). CONCLUSION Younger AA women are at particularly high risk for graft loss, which predominates in the first 2 years post-LT. Prospective studies of immunosuppression adherence and pharmacokinetics, particularly in relation to patient age, may help to explain the mechanisms underlying the higher rates of graft loss in younger AA women.
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Affiliation(s)
- S Dave
- Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - J L Dodge
- Department of Surgery, Division of Transplant, University of California-San Francisco, San Francisco, California, USA
| | - N A Terrault
- Division of Gastroenterology and Hepatology, University of California-San Francisco, San Francisco, California, USA; Department of Surgery, Division of Transplant, University of California-San Francisco, San Francisco, California, USA
| | - M Sarkar
- Division of Gastroenterology and Hepatology, University of California-San Francisco, San Francisco, California, USA.
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21
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Jones PD, Diaz C, Wang D, Gonzalez-Diaz J, Martin P, Kobetz E. The Impact of Race on Survival After Hepatocellular Carcinoma in a Diverse American Population. Dig Dis Sci 2018; 63:515-528. [PMID: 29275448 DOI: 10.1007/s10620-017-4869-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 11/23/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Hepatocellular carcinoma (HCC) incidence is increasing at differential rates depending on race. We aimed to identify associations between race and survival after HCC diagnosis in a diverse American population. METHODS Using the cancer registry from Sylvester Comprehensive Cancer Center, University of Miami and Jackson Memorial Hospitals, we performed retrospective analysis of 999 patients diagnosed with HCC between 9/24/2004 and 12/19/2014. We identified clinical characteristics by reviewing available electronic medical records. The association between race and survival was analyzed using Cox proportional hazards regression. RESULTS Median survival in days was 425 in Blacks, 904.5 in non-Hispanic Whites, 652 in Hispanics, 570 in Asians, and 928 in others, p < 0.01. Blacks and Asians presented at more advanced stages with larger tumors. Although Whites had increased severity of liver disease at diagnosis compared to other races, they had 36% reduced rate of death compared to Blacks, [hazard ratio (HR) 0.64, 95% confidence interval (CI) 0.51-0.8, p < 0.01]. After adjusting for significant covariates, Whites had 22% (HR 0.78, 95% CI 0.61-0.99, p 0.04) reduced risk of death, compared to Blacks. Transplant significantly reduced rate of death; however, only 13.3% of Blacks had liver transplant, compared to 40.1% of Whites, p < 0.01. CONCLUSIONS In this diverse sample of patients, survival among Blacks is the shortest after HCC diagnosis. Survival differences reflect a more advanced tumor stage at presentation rather than severity of underlying liver disease precluding treatment. Improving survival in minority populations, in whom HCC incidence is rapidly increasing, requires identification and modification of factors contributing to late-stage presentation.
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Affiliation(s)
- Patricia D Jones
- Division of Hepatology, Department of Medicine, University of Miami Miller School of Medicine, 1120 NW 14th Street, Miami, FL, 33136, USA.
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, 33136, USA.
| | - Carlos Diaz
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, 33136, USA
| | - Danlu Wang
- Department of Medicine, University of Miami Miller School of Medicine/JFK Medical Center Palm Beach Regional GME Consortium, Miami, FL, 33136, USA
| | - Joselin Gonzalez-Diaz
- Division of Hepatology, Department of Medicine, University of Miami Miller School of Medicine, 1120 NW 14th Street, Miami, FL, 33136, USA
| | - Paul Martin
- Division of Hepatology, Department of Medicine, University of Miami Miller School of Medicine, 1120 NW 14th Street, Miami, FL, 33136, USA
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, 33136, USA
| | - Erin Kobetz
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, 33136, USA
- Division of Computational Medicine and Population Health, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, 33136, USA
- Jay Weiss Institute for Health Equity, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, 33136, USA
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22
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Rademacher S, Seehofer D, Eurich D, Schoening W, Neuhaus R, Oellinger R, Denecke T, Pascher A, Schott E, Sinn M, Neuhaus P, Pratschke J. The 28-year incidence of de novo malignancies after liver transplantation: A single-center analysis of risk factors and mortality in 1616 patients. Liver Transpl 2017; 23:1404-1414. [PMID: 28590598 DOI: 10.1002/lt.24795] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 05/08/2017] [Accepted: 05/14/2017] [Indexed: 12/13/2022]
Abstract
De novo malignancies (DNMs) are one of the leading causes of late mortality after liver transplantation (LT). We analyzed 1616 consecutive patients who underwent LT between 1988 and 2006 at our institution. All patients were prospectively observed over a study period of 28 years by our own outpatient clinic. Complete follow-up data were available for 96% of patients, 3% were incomplete, and only 1% were lost to follow-up. The median follow-up of the patients was 14.1 years. Variables with possible prognostic impact on the development of DNMs were analyzed, as was the incidence of malignancies compared with the nontransplant population by using standardized incidence ratios. In total, 266 (16.5%) patients developed 322 DNMs of the following subgroups: hematological malignancies (n = 49), skin cancer (n = 83), and nonskin solid organ tumors (SOT; n = 190). The probability of developing any DNM within 10 and 25 years was 12.9% and 23.0%, respectively. The respective probability of developing SOT was 7.8% and 16.2%. Mean age at time of diagnosis of SOT was 57.4 years (range, 18.3-81.1 years). In the multivariate analysis, an increased recipient age (hazard ratio [HR], 1.03; P < 0.001) and a history of smoking (HR, 1.92; P < 0.001) were significantly associated with development of SOT. Moreover, the development of SOT was significantly increased in cyclosporine A-treated compared with tacrolimus-treated patients (HR, 1.53; P = 0.03). The present analysis shows a disproportionate increase of de novo SOT with an increasing follow-up period. Increased age and a history of smoking are confirmed as major risk factors. Moreover, the importance of immunosuppression is highlighted. Liver Transplantation 23 1404-1414 2017 AASLD.
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Affiliation(s)
- Sebastian Rademacher
- Departments of Surgery, Campus Charité Mitte and Campus Virchow Klinikum.,Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Daniel Seehofer
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Dennis Eurich
- Departments of Surgery, Campus Charité Mitte and Campus Virchow Klinikum
| | - Wenzel Schoening
- Department of General, Visceral and Transplantation Surgery, University Hospital Aachen, Aachen, Germany
| | - Ruth Neuhaus
- Departments of Surgery, Campus Charité Mitte and Campus Virchow Klinikum
| | - Robert Oellinger
- Departments of Surgery, Campus Charité Mitte and Campus Virchow Klinikum
| | | | - Andreas Pascher
- Departments of Surgery, Campus Charité Mitte and Campus Virchow Klinikum
| | | | - Mariann Sinn
- Hematology and Oncology, Charité Campus Virchow, Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Neuhaus
- Departments of Surgery, Campus Charité Mitte and Campus Virchow Klinikum
| | - Johann Pratschke
- Departments of Surgery, Campus Charité Mitte and Campus Virchow Klinikum
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23
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Sharma P, Goodrich NP, Schaubel DE, Smith AR, Merion RM. National assessment of early hospitalization after liver transplantation: Risk factors and association with patient survival. Liver Transpl 2017; 23:1143-1152. [PMID: 28688150 PMCID: PMC5568939 DOI: 10.1002/lt.24813] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 06/21/2017] [Accepted: 06/26/2017] [Indexed: 12/24/2022]
Abstract
Hospitalization is known to occur frequently in the first 6 months following liver transplantation (LT). Using a novel data linkage between the Scientific Registry of Transplant Recipients and Centers for Medicare and Medicaid Services, our study has 2 objectives: (1) to determine risk factors for "early" hospitalization (ie, within 6 months of LT); and (2) to quantify the importance of hospitalization history in the first 6 months with respect to subsequent patient survival (ie, survival, conditional on surviving 6 months post-LT). The study population consisted of patients aged ≥18 years who underwent deceased donor LT between January 1, 2003 and December 31, 2010, with Medicare as primary or secondary insurance and were discharged alive from the index LT hospitalization (n = 7220). The early hospitalization rate was 2.76 per patient-year and was significantly associated with many recipient factors (eg, recipient age, hepatitis C, diabetes, poor renal function including dialysis, and recipient of transjugular intrahepatic portosystemic shunt procedure before LT), as well as donor race and donation after cardiac death. Conditional on surviving 6 months after LT, the covariate-adjusted death rate increased by 22% for each additional hospitalization occurring in the first 6 months (hazard ratio, 1.22; P < 0.001). In conclusion, several LT recipient factors are significantly associated with early hospitalization. Moreover, a patient's hospitalization profile during follow-up months 0-6 is a very strong predictor of survival thereafter. Efforts and resources should be devoted toward identifying LT recipients at risk for early hospitalization and modifying the actionable risk factors such as hepatitis C, diabetes, and body mass index to improve resource utilization and overall outcomes. Liver Transplantation 23 1143-1152 2017 AASLD.
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Affiliation(s)
- Pratima Sharma
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan
| | | | - Douglas E Schaubel
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Abigail R Smith
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Robert M Merion
- Arbor Research Collaborative for Health, Ann Arbor, Michigan,Department of Surgery, University of Michigan, Ann Arbor, Michigan
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24
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Smith AA, Darden M, Al-Qurayshi Z, Paramesh AS, Killackey M, Kandil E, Parker G, Balart L, Friedlander P, Buell JF. Liver transplantation in New Orleans: parity in a world of disparity? HPB (Oxford) 2017. [PMID: 28647164 DOI: 10.1016/j.hpb.2017.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Racial disparity in access to liver transplantation among African Americans (AA) compared to Caucasians (CA) has been well described. The aim of this investigation was to examine the presentation of AA liver transplant recipients in a socioeconomically challenged region. METHODS 680 adult liver transplant candidates and 233 resultant recipients between 2007 and 2015 were analyzed using univariate and multivariate analyses to evaluate factors significant for transplantation. RESULTS Percentages of wait list patients transplanted were similar between CA and AA (34.9% vs. 32.2%, p = 0.5205). AA were younger (50.4 ± 1.8 vs. 56.3 ± 0.7 yrs, p = 0.0003) with higher average MELD scores (22.9 ± 1.6 vs. 19.4 ± 0.7, p = 0.0230). Overall patient mortality was similar (AA 22.7% vs. CA 26.3%, p = 0.5931). A multiple linear regression showed that male gender was strongly associated with transplantation. CONCLUSIONS Equal access to liver transplantation remains challenging for racial minorities. At our institution, AA were accepted and transplanted at an equivalent rate as CA despite a higher AA population, HCV rate and diagnosed HCC. AA were younger and sicker at the time of transplant, but overall had similar outcomes compared to CA. Our study highlights the need for studies to delineate the underpinnings of disparity in transplantation access.
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Affiliation(s)
- Alison A Smith
- Tulane University School of Medicine, Louisiana State University School of Medicine, USA
| | - Michael Darden
- Department of Economics, Tulane University, New Orleans, LA, USA
| | - Zaid Al-Qurayshi
- Tulane University School of Medicine, Louisiana State University School of Medicine, USA
| | - Anil S Paramesh
- Tulane University School of Medicine, Louisiana State University School of Medicine, USA
| | - Mary Killackey
- Tulane University School of Medicine, Louisiana State University School of Medicine, USA
| | - Emad Kandil
- Tulane University School of Medicine, Louisiana State University School of Medicine, USA
| | - Geoffrey Parker
- Tuck School of Business Administration at Dartmouth, Hannover, NH, USA
| | - Luis Balart
- Tulane University School of Medicine, Louisiana State University School of Medicine, USA
| | - Paul Friedlander
- Tulane University School of Medicine, Louisiana State University School of Medicine, USA
| | - Joseph F Buell
- Tulane University School of Medicine, Louisiana State University School of Medicine, USA; Department of Economics, Tulane University, New Orleans, LA, USA.
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25
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Green DJ, Brooks MM, Burckart GJ, Chinnock RE, Canter C, Addonizio LJ, Bernstein D, Kirklin JK, Naftel DC, Girnita DM, Zeevi A, Webber SA. The Influence of Race and Common Genetic Variations on Outcomes After Pediatric Heart Transplantation. Am J Transplant 2017; 17:1525-1539. [PMID: 27931092 DOI: 10.1111/ajt.14153] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 11/16/2016] [Accepted: 11/25/2016] [Indexed: 01/25/2023]
Abstract
Significant racial disparity remains in the incidence of unfavorable outcomes following heart transplantation. We sought to determine which pediatric posttransplantation outcomes differ by race and whether these can be explained by recipient demographic, clinical, and genetic attributes. Data were collected for 80 black and 450 nonblack pediatric recipients transplanted at 1 of 6 centers between 1993 and 2008. Genotyping was performed for 20 candidate genes. Average follow-up was 6.25 years. Unadjusted 5-year rates for death (p = 0.001), graft loss (p = 0.015), acute rejection with severe hemodynamic compromise (p = 0.001), late rejection (p = 0.005), and late rejection with hemodynamic compromise (p = 0.004) were significantly higher among blacks compared with nonblacks. Black recipients were more likely to be older at the time of transplantation (p < 0.001), suffer from cardiomyopathy (p = 0.004), and have public insurance (p < 0.001), and were less likely to undergo induction therapy (p = 0.0039). In multivariate regression models adjusting for age, sex, cardiac diagnosis, insurance status, and genetic variations, black race remained a significant risk factor for all the above outcomes. These clinical and genetic variables explained only 8-19% of the excess risk observed for black recipients. We have confirmed racial differences in survival, graft loss, and several rejection outcomes following heart transplantation in children, which could not be fully explained by differences in recipient attributes.
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Affiliation(s)
- D J Green
- Pediatric Clinical Pharmacology Staff, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD
| | - M M Brooks
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA
| | - G J Burckart
- Pediatric Clinical Pharmacology Staff, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD
| | - R E Chinnock
- Department of Pediatrics, Loma Linda University, Loma Linda, CA
| | - C Canter
- Division of Cardiology, Department of Pediatrics, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO
| | - L J Addonizio
- Division of Cardiology, Department of Pediatrics, Columbia University, New York, NY
| | - D Bernstein
- Division of Cardiology, Department of Pediatrics, Stanford University, Lucile Packard Children's Hospital, Palo Alto, CA
| | - J K Kirklin
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - D C Naftel
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - D M Girnita
- Department of Pathology, Thomas E Starzl Transplant Institute, University of Pittsburgh, Pittsburgh, PA
| | - A Zeevi
- Department of Pathology, Thomas E Starzl Transplant Institute, University of Pittsburgh, Pittsburgh, PA
| | - S A Webber
- Department of Pediatrics, Vanderbilt University, Nashville, TN
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26
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Ahn J, Liu B, Bhuket T, Wong RJ. Race/Ethnicity-Specific Outcomes Among Chronic Hepatitis C Virus Patients Listed for Liver Transplantation. Dig Dis Sci 2017; 62:1051-1057. [PMID: 28168576 DOI: 10.1007/s10620-017-4469-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 01/20/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Chronic hepatitis C virus (HCV) infection is a leading cause of hepatocellular carcinoma (HCC) and need for liver transplantation (LT). It is unclear if HCV-related LT outcomes vary by race/ethnicity. AIMS We aim to evaluate ethnic disparities specifically among patients with chronic HCV in the USA. METHODS Using data from the United Network for Organ Sharing 2003-2013 LT registry, we evaluated race/ethnicity-specific disparities in LT waitlist survival and probability of receiving LT among chronic HCV patients listed for LT. RESULTS Among 43,478 HCV patients listed for LT (70.0% non-Hispanic white, 10.8% black, 16.3% Hispanic, 2.9% Asian), HCV-related LT waitlist registrations increased by 21.5% from 2003 to 2013. During this period, the proportion of HCV patients with HCC increased by 237%, and in 2013, HCV patients with HCC accounted for 33.0% of HCV-related waitlist registrations. When stratified by race/ethnicity, Hispanics with HCV had significantly lower waitlist mortality (OR 0.83; 95% CI 0.74-0.94; p < 0.01) compared to non-Hispanic whites, but no significant differences were seen among blacks and Asians. Furthermore, compared to non-Hispanic whites, Hispanics were significantly less likely to receive LT (OR 0.58; 95% CI 0.53-0.62; p < 0.001), but no differences were seen among blacks or Asians. CONCLUSION Among patients with chronic HCV in the USA, the MELD score has reduced race/ethnicity-specific disparities in waitlist mortality. However, Hispanic HCV patients had significantly better waitlist survival and lower probability of receiving LT, possibly reflecting slower disease progression compared to non-Hispanic whites with chronic HCV.
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Affiliation(s)
- Joseph Ahn
- Department of Medicine, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Benny Liu
- Division of Gastroenterology and Hepatology, Alameda Health System - Highland Hospital, Highland Hospital - Highland Care Pavilion 5th Floor, Endoscopy Unit, 1411 East 31st Street, Oakland, CA, 94602, USA
| | - Taft Bhuket
- Division of Gastroenterology and Hepatology, Alameda Health System - Highland Hospital, Highland Hospital - Highland Care Pavilion 5th Floor, Endoscopy Unit, 1411 East 31st Street, Oakland, CA, 94602, USA
| | - Robert J Wong
- Division of Gastroenterology and Hepatology, Alameda Health System - Highland Hospital, Highland Hospital - Highland Care Pavilion 5th Floor, Endoscopy Unit, 1411 East 31st Street, Oakland, CA, 94602, USA.
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27
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Lam P, Obirieze A, Ortega G, Nwokeabia I, Onyewu S, Purnell S, Samimi M, Weeks C, Lee E, Shokrani B, Frederick W, Callender C, Wilson L. Characterization of Hepatitis B and C Among Liver Transplant Recipients With Hepatocellular Carcinoma: An Analysis of the Nationwide Inpatient Sample Database. Transplant Proc 2016; 48:123-7. [DOI: 10.1016/j.transproceed.2015.12.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 12/07/2015] [Indexed: 02/07/2023]
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28
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Abstract
PURPOSE OF REVIEW To review and highlight recent literature regarding the medical management of adult patients undergoing liver transplantation. RECENT FINDINGS The addition of serum sodium concentration to the model for end-stage liver disease (MELD) score more accurately predicts 90-day waitlist mortality. Predictors of waitlist mortality and posttransplant survival include lower albumin and the presence of ascites, varices, and encephalopathy, as well as more nontraditional predictors such as older age, obesity, frailty, and sarcopenia. Indications for liver transplantation are evolving with the advent of effective therapy for hepatitis C and the increased prevalence of nonalcoholic steatohepatitis. Disparities persist in the current allocation system, including geographic variation and MELD inflation for hepatocellular carcinoma. Share 35 allows for broader regional sharing of organs for patients with the highest need, without detrimental effects on waitlist mortality or survival. Everolimus is a recently approved option for posttransplant immunosuppression that spares renal function. SUMMARY The MELD score has enabled the liver transplant community to equitably allocate organs. Recent literature has focused on the limitations of the MELD score and the disparities inherent in the current system. The next steps for liver transplantation will be to develop strategies to further optimize waitlist prioritization and organ allocation.
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