Comparative analysis of outcome following liver transplantation in US veterans

A low-volume polyethylene glycol solution was associated with an increased suboptimal bowel preparation rate but had similar recommendations for an early repeat colonoscopy, procedure times, and adenoma detection rates

Background/Aims

Low-volume polyethylene glycol (PEG) bowel preparations are better tolerated by patients than high-volume preparations and may achieve similar preparation quality. However, there is little data comparing their effects on a recommendation for an early repeat colonoscopy (because of a suboptimal preparation), procedure times, adenoma detection rate (ADR), and advanced adenoma detection rate (AADR).

Methods

This is a retrospective cohort study of outpatient colonoscopies performed during a one-year period at a single academic medical center in which low-volume MoviPrep^® (n = 1841) or high-volume Colyte^® (n = 1337) was used. All preparations were split-dosed. Appropriate covariates were included in regression models assessing suboptimal preparation quality (fair, poor, or inadequate), procedure times, recommendation for an early repeat colonoscopy, ADR, and AADR.

Results

MoviPrep^® was associated with an increase in having a suboptimal bowel preparation (OR 1.36; 95% CI: 1.06–1.76), but it was not associated with differences in insertion (p = 0.43), withdrawal (p = 0.22), or total procedure times (p = 0.10). The adjusted percentage with a suboptimal preparation was 11.7% for patients using MoviPrep^® and 8.8% for patients using Colyte^®. MoviPrep^® was not associated with a significant difference in overall ADR (OR 0.93; 95% CI: 0.78–1.11), AADR (OR 1.18; 95% CI: 0.87–1.62), or recommendation for early repeat colonoscopy (OR 1.16; 95% CI: 0.72–1.88).

Conclusions

MoviPrep^® was associated with a small absolute increase in having a suboptimal preparation, but did not affect recommendations for an early repeat colonoscopy, procedure times, or adenoma detection rates. Mechanisms to reduce financial barriers limiting low-volume preparations should be considered because of their favorable tolerability profile.

Preoperative selective desensitization of live donor liver transplant recipients considering the degree of T lymphocyte cross-match titer, model for end-stage liver disease score, and graft liver volume

Several studies have suggested that a positive lymphocyte cross-matching (XM) is associated with low graft survival rates and a high prevalence of acute rejection after adult living donor liver transplantations (ALDLTs) using a small-for-size graft. However, there is still no consensus on preoperative desensitization. We adopted the desensitization protocol from ABO-incompatible LDLT. We performed desensitization for the selected patients according to the degree of T lymphocyte cross-match titer, model for end-stage liver disease (MELD) score, and graft liver volume. We retrospectively evaluated 230 consecutive ALDLT recipients for 5 yr. Eleven recipients (4.8%) showed a positive XM. Among them, five patients with the high titer (> 1:16) by antihuman globulin-augmented method (T-AHG) and one with a low titer but a high MELD score of 36 were selected for desensitization: rituximab injection and plasmapheresis before the transplantation. There were no major side effects of desensitization. Four of the patients showed successful depletion of the T-AHG titer. There was no mortality and hyperacute rejection in lymphocyte XM-positive patients, showing no significant difference in survival outcome between two groups (P=1.000). In conclusion, this desensitization protocol for the selected recipients considering the degree of T lymphocyte cross-match titer, MELD score, and graft liver volume is feasible and safe.

Thrombotic microangiopathy-like disorder after living-donor liver transplantation: A single-center experience in Japan

AIM: To investigate thrombotic microangiopathy (TMA) in liver transplantion, because TMA is an infrequent but life-threatening complication in the transplantation field.

METHODS: A total of 206 patients who underwent living-donor liver transplantation (LDLT) were evaluated, and the TMA-like disorder (TMALD) occurred in seven recipients.

RESULTS: These TMALD recipients showed poor outcomes in comparison with other 199 recipients. Although two TMALD recipients successfully recovered, the other five recipients finally died despite intensive treatments including repeated plasma exchange (PE) and re-transplantation. Histopathological analysis of liver biopsies after LDLT revealed obvious differences according to the outcomes. Qualitative analysis of antibodies against a disintegrin-like domain and metalloproteinase with thrombospondin type 1 motifs (ADAMTS-13) were negative in all patients. The fragmentation of red cells, the microhemorrhagic macules and the platelet counts were early markers for the suspicion of TMALD after LDLT. Although the absolute values of von Willebrand factor (vWF) and ADAMTS-13 did not necessarily reflect TMALD, the vWF/ADAMTS-13 ratio had a clear diagnostic value in all cases. The establishment of adequate treatments for TMALD, such as PE for ADAMTS-13 replenishment or treatments against inhibitory antibodies, must be decided according to each case.

CONCLUSION: The optimal induction of adequate therapies based on early recognition of TMALD by the reliable markers may confer a large advantage for TMALD after LDLT.

Does a positive lymphocyte cross-match contraindicate living-donor liver transplantation?

BACKGROUND

There is still no consensus on the importance of lymphocyte cross-matching (LCM) in the field of living-donor liver transplantation (LDLT).

METHODS

LCM examinations are routinely performed before LDLT, and the results of complement-dependent cytotoxicity were used in this study. A total of 1157 LDLT cases were evaluated. The recipients were divided into four groups based on the LCM and ABO compatibilities: (1) negative LCM and identical/compatible ABO; (2) negative LCM and incompatible ABO; (3) positive LCM and identical/compatible ABO; and (4) positive LCM and incompatible ABO. The diagnosis of antibody-mediated rejection (AMR) was made based on the clinical course, immunological assays and histopathological findings. C4d immunostaining was added if AMR was suspected.

RESULTS

The LCM-positive LDLT recipients showed significantly poorer outcomes than the LCM-negative recipients. Among the LCM-positive recipients, 44.1% of recipients eventually died and 85.2% of recipients revealed positive C4d findings. The survival rate of LCM-positive and ABO-incompatible group was 0.50. The survival days were compared with the LCM-negative and ABO-identical/compatible group, and the LCM-positive and ABO-identical/compatible group clearly showed early death after LDLT, although the ABO-incompatible groups did not show significant. The factors of age, disease, pre-transplant scores, LCM, ABO compatibility and graft-recipient weight ratio showed statistical significance in multivariate analysis for important factors of LDLT outcomes. However, the LCM and ABO compatibilities had no synergetic effects on the LDLT survival.

CONCLUSION

HLA antigens are more widely expressed than ABO antigens, and advanced immunological strategies must be established for LCM-positive LDLT as well as for ABO-incompatible LDLT.

Impact of the MELD score on waiting time and disease severity in liver transplantation in United States veterans

Organ allocation for liver transplantation (LT) in the United States is based on the Model for End-Stage Liver Disease (MELD) score. The MELD score prioritizes organ distribution to sicker patients. There is limited data on the effect of this policy on transplantation in the Veterans Affairs (VA) healthcare system. The aim of this study was to determine the impact of the MELD score on U.S. veteran patients undergoing LT. Comparison of MELD scores and waiting time of LT recipients before and after the introduction of the MELD system was done. A total of 192 LT recipients were analyzed. Blood type, diagnosis, listing MELD score, and Child-Turcotte-Pugh (CTP) score at transplant did not differ although MELD era recipients were older (mean 54.3 vs. 51.3 yr, P = 0.009). Mean waiting time decreased from 461 days (pre-MELD) to 252 days (MELD era) (P = 0.004). Mean MELD score at LT increased from 23.4 (MELD era) compared to 20.3 (pre-MELD) (P = 0.01). In conclusion, waiting time for LT in U.S. veterans has decreased significantly in the MELD era. The MELD score of patients transplanted in the MELD era is significantly higher and patients are still being listed at a high MELD score. The MELD system has lead to sicker veterans being transplanted with shorter waiting times.

Recidiva da ingesta alcoólica em pacientes candidatos a transplante hepático: análise de fatores de risco

RACIONAL: A recidiva do consumo do álcool após transplante representa grande preocupação nos centros transplantadores e é objeto de debate e controvérsia. OBJETIVO: Avaliar a recidiva da ingesta alcoólica e eventuais fatores a ela relacionados, em pacientes cirróticos, referidos para transplante hepático. MÉTODOS: Estudo retrospectivo de julho de 1995 a setembro de 2005 incluindo 90 pacientes adultos com cirrose hepática, listados para transplante. Os critérios de exclusão eram: ausência de 6 meses de abstinência, não liberação da equipe de psicologia. O diagnóstico da recidiva (ingesta de qualquer quantidade de bebida alcoólica) era feito com base nas informações contidas nos prontuários e fornecidas por contato telefônico. RESULTADOS: A recidiva encontrada foi de 18,9%, que correspondeu a 14,6% do número total de homens e 62,5% do número total das mulheres. A raça, média das idades, classificação de disfunção hepática, tempo de etilismo, quantidade da ingesta alcoólica e realização ou não de transplante, não mostraram correlação significativa com a recidiva da ingesta alcoólica. A comparação tempo de abstinência e recidiva guardou relação inversamente proporcional. CONCLUSÃO: A recidiva da ingesta alcoólica é baixa. Sexo feminino e tempo de abstinência inferior a 1 ano têm influência sobre a recidiva da ingesta alcoólica.

Comparison of Risk-Adjusted 30-Day Postoperative Mortality and Morbidity in Department of Veterans Affairs Hospitals and Selected University Medical Centers: General Surgical Operations in Men

BACKGROUND

We used data from the Patient Safety in Surgery Study to compare patient populations, operative characteristics, and unadjusted and risk-adjusted 30-day postoperative mortality and morbidity between the Veterans Affairs (VA) (n = 94,098) and private (n = 18,399) sectors for general surgery operations in men.

STUDY DESIGN

This is a prospective cohort study. Trained nurses collected preoperative risk factors, operative variables, and 30-day postoperative mortality and morbidity outcomes in male patients undergoing major general surgery operations at 128 VA medical centers and 14 university medical centers from October 1, 2001, to September 30, 2004. Multiple logistic regression analysis was used to identify preoperative predictors of postoperative mortality and morbidity. An indicator variable for VA versus private-sector medical center was added to the model to determine if risk-adjusted outcomes were significantly different in the two systems.

RESULTS

The unadjusted 30-day mortality rate was higher in the VA compared with the private sector (2.62% versus 2.03%, p = 0.0002); unadjusted morbidity rate was lower in the VA compared with the private sector (12.24% versus 13.99%, p < 0.0001). After risk adjustment, odds ratio for mortality for the VA versus private sector was 1.23 (95% CI, 1.08-1.41). For morbidity after risk adjustment, the indicator variable for health-care system just missed statistical significance (p = 0.0585). Thirty-day postoperative mortality was comparable in the VA and private sector for very common operations but was higher in the VA for less common, more complex operations.

CONCLUSIONS

In general surgery operations in men, the VA appeared to have a higher risk-adjusted mortality rate compared with the private sector, but differences in mortality ascertainment in the two sectors might account for some of this effect. The higher mortality in the VA could be the result of higher mortality in the less common, more complex operations. There is a trend toward lower risk-adjusted morbidity in the VA compared with the private sector.

Comparison of Risk-Adjusted 30-Day Postoperative Mortality and Morbidity in Department of Veterans Affairs Hospitals and Selected University Medical Centers: General Surgical Operations in Women

BACKGROUND

In 1985, Congress mandated that the Department of Veterans Affairs (VA) compare its risk-adjusted surgical results with those in the private sector. The National Surgical Quality Improvement Program was developed as a result, in the VA system, and subsequently trialed in 14 university medical centers in the private sector. This report examines the results of the comparison between patient characteristics and outcomes of female general surgical patients in the two health care environments.

STUDY DESIGN

Preoperative patient characteristics and laboratory variables, operative variables, and unadjusted postoperative outcomes were compared between VA and the private sector populations. In addition, stepwise logistic regression models were developed for 30-day postoperative mortality and morbidity. Finally, the effect of being treated in a VA or private sector hospital was assessed by adding an indicator variable to the models and testing it for statistical significance.

RESULTS

Data from 5,157 female general surgical VA patients who underwent eligible procedures were compared with those from 27,467 patients in the private sector. Unadjusted 30-day mortality was virtually identical in the two groups (1.3%). The unadjusted morbidity rate was slightly, but notably, higher in the private sector (10.9%) as compared with that observed in the VA (8.5%, p < 0.0001). Predictive models were generated for mortality and morbidity combining both groups; top variables in these models were similar to those described previously in the National Surgical Quality Improvement Program. The indicator variable for system of care (VA versus private sector) was not statistically significant in the mortality model, but substantially favored the VA in the morbidity model (odds ratio=0.80, 95% CI=0.71, 0.90).

CONCLUSIONS

The data demonstrate that in female general surgical patients, risk-adjusted mortality rates are comparable in the VA and the private sector, but risk-adjusted morbidity is higher in the private sector. Rates of urinary tract infections in the two populations may account for much of the latter difference.

Comparison of Risk-Adjusted 30-Day Postoperative Mortality and Morbidity in Department of Veterans Affairs Hospitals and Selected University Medical Centers: Vascular Surgical Operations in Men

BACKGROUND

In response to a Congressional mandate to compare risk-adjusted surgical outcomes from Department of Veterans Affairs (VA) hospitals with those from private-sector hospitals, the National Surgical Quality Improvement Program was initiated in the VA system and then was developed in a select group of university medical centers in the private sector. This article analyzes risk-adjusted outcomes after vascular surgical operations in men performed at VA hospitals as compared with private-sector hospitals.

STUDY DESIGN

This is a prospective cohort study of a sample of vascular surgical operations in men performed at 128 VA medical centers as compared with 14 university medical centers from October 1, 2001 to September 30, 2004. Patient and operative characteristics, and both unadjusted and risk-adjusted 30-day postoperative morbidity and mortality outcomes were compared.

RESULTS

Data from 30,058 vascular operations in men at VA hospitals were compared with 5,174 cases performed at private-sector hospitals. The unadjusted 30-day mortality rate was notably lower in the VA system as compared with the private-sector group (3.4% versus 4.2%, p = 0.004). After risk-adjustment, there was no marked difference in mortality between the two hospital types. The unadjusted 30-day morbidity rate was also considerably lower in the VA hospitals as compared with the private sector (17.3% versus 22.3%, p < 0.0001). After risk-adjustment, morbidity in the VA system remained considerably lower than in the private sector, with an odds ratio of 0.84 (95% CI, 0.78 to 0.92).

CONCLUSIONS

In vascular surgical operations in men, the VA hospitals demonstrated a lower risk-adjusted 30-day morbidity rate than the private-sector group. There is no marked difference in adjusted mortality rates between the two types of institutions.

Prognostic factors and survival in patients with hereditary hemochromatosis and cirrhosis

OBJECTIVES

The survival of treated, noncirrhotic patients with hereditary hemochromatosis is similar to that of the general population. Less is known about the outcome of cirrhotic hereditary hemochromatosis patients. The present study evaluated the survival of patients with hereditary hemochromatosis and cirrhosis.

METHODS

From an established hereditary hemochromatosis database, all cirrhotic patients diagnosed from January 1972 to August 2004 were identified. Factors associated with survival were determined using univariate and multivariate regression. Survival differences were assessed using the Kaplan-Meier life table method.

RESULTS

Ninety-five patients were identified. Sixty patients had genetic testing, 52 patients (87%) were C282Y homozygotes. Median follow-up was 9.2 years (range 0 to 30 years). Nineteen patients (20%) developed hepatocellular carcinoma, one of whom was still living following transplantation. Cumulative survival for all patients was 88% at one year, 69% at five years and 56% at 20 years. Factors associated with death on multivariate analysis included advanced Child-Pugh score and hepatocellular carcinoma. Patients with hepatocellular carcinoma were older at the time of diagnosis of cirrhosis (mean age 61 and 54.6 years, respectively; P=0.03). The mean age at the time of diagnosis of hepatocellular carcinoma was 70 years (range 48 to 79 years). No other differences were found between the groups.

CONCLUSIONS

Patients with hereditary hemochromatosis and cirrhosis are at significant risk of developing hepatocellular carcinoma. These patients are older when diagnosed with carcinoma and may have poorer survival following transplantation than patients with other causes of liver disease. Early diagnosis and treatment of hereditary hemochromatosis by preventing the development of cirrhosis may reduce the incidence of hepatocellular carcinoma in the future.

A systematic review of the performance of the model for end-stage liver disease (MELD) in the setting of liver transplantation

The Model for End-Stage Liver Disease (MELD) score is now used for allocation in liver transplantation (LT) waiting lists, replacing the Child-Turcotte-Pugh (CTP) score. However, there is debate as whether it is superior to CTP score to predict mortality in patients with cirrhosis on the LT waiting list and after LT. We reviewed studies comparing the accuracy of MELD vs. CTP score in transplantation settings. We found that in studies of the LT waiting list (12,532 patients with cirrhosis), only 4 of 11 showed MELD to be superior to CTP in predicting short-term (3-month) mortality. In addition, 2 of 3 studies (n = 1,679) evaluating the changes in MELD score (DeltaMELD) showed that DeltaMELD had better prediction for mortality than the baseline MELD score. The impact of MELD on post-LT mortality was assessed in 15 studies (20,456 patients); only 6 (9,522 patients) evaluated the discriminative ability of MELD score using the concordance (c) statistic (the MELD score had always a c-statistic < 0.70). In 11 studies (19,311 patients), high MELD score indicated poor post-LT mortality for cutoff values of 24-40 points. In re-LT patients, 2 of 4 studies evaluated the discriminative ability of MELD score on post-LT mortality. Finally, several studies have shown that the predictive ability of MELD score increases by adding clinical variables (hepatic encephalopathy, ascites) or laboratory (sodium) parameters. On the basis of the current literature, MELD score does not perform better than the CTP score for patients with cirrhosis on the waiting list and cannot predict post-LT mortality.

Evaluation for liver transplantation: adherence to AASLD referral guidelines in a large Veterans Affairs center

Access of patients to liver transplantation involves three levels: referral for evaluation for transplantation, placement on a waiting list for transplantation, and receipt of a liver transplant. No study has formally evaluated access to liver transplantation at the referral level. Therefore, we sought to estimate the magnitude and determinants of consideration of liver transplantation in patients at a single, large Veterans Affairs medical center. Patients with liver disease were identified between October 2002 and September 2003, and their entire medical records were examined for encounters involving potential indications for liver transplantation according to American Association for the Study of Liver Diseases (AASLD) guidelines, mention of liver transplantation, and potential contraindications. Liver transplantation was mentioned in only 59 (20%) of 300 encounters, constituting 41 (21%) of 199 patients satisfying AASLD guidelines for referral. The significant negative independent determinants of mention of liver transplantation were older age (adjusted odds ratio [OR]: 0.31; 95% confidence interval [CI]: 0.13-0.77, P = 0.01), alcoholic liver disease (adjusted OR: 0.10; 95% CI: 0.02-0.57, P = 0.01), and black race (OR: 0.15; 95% CI: 0.02-0.96, P = 0.045). Most patients had potential contraindications that were inferred (but not documented) as reasons for not being evaluated for transplantation; however, a small but significant proportion (7%) had no recorded evidence of contraindications. In conclusion, we found a low rate of mention of liver transplantation in patients who satisfied AASLD guidelines for referral, particularly among patients with alcoholic liver disease and blacks. Deficiencies at the referral level may lead to disparities at further levels of access to liver transplantation.