Benefit in liver transplantation: a survey among medical staff, patients, medical students and non-medical university staff and students

Futility and poor outcomes are not the same thing: A clinical perspective of refined outcomes definitions in liver transplantation

The term "futility" in liver transplantation is used inappropriately and inaccurately, as it is frequently applied to patient populations with suboptimal outcomes that are often not truly "futile." The term "futile" is used interchangeably with poor outcomes. Not all poor outcomes fulfill a definition of futility when considering all viewpoints. Definitions of "futility" are variable throughout the medical literature. We review futility in the context of liver transplantation, encompassing various viewpoints, with a goal to propose focused outcome definitions, including futility, that encompass broader viewpoints, and improve the utilization of "futility" to truly futile situations, and improve communication between providers and patients/families. Focused, appropriate definitions will help the transplant community develop better models to more accurately predict and avoid futile transplants, and better predict an individual patient's posttransplant outcome.

Towards machine learning for moral choice analysis in health economics: A literature review and research agenda

BACKGROUND

Discrete choice models (DCMs) for moral choice analysis will likely lead to erroneous model outcomes and misguided policy recommendations, as only some characteristics of moral decision-making are considered. Machine learning (ML) is recently gaining interest in the field of discrete choice modelling. This paper explores the potential of combining DCMs and ML to study moral decision-making more accurately and better inform policy decisions in healthcare.

METHODS

An interdisciplinary literature search across four databases - PubMed, Scopus, Web of Science, and Arxiv - was conducted to gather papers. Based on the Preferred Reporting Items for Systematic and Meta-analyses (PRISMA) guideline, studies were screened for eligibility on inclusion criteria and extracted attributes from eligible papers. Of the 6285 articles, we included 277 studies.

RESULTS

DCMs have shortcomings in studying moral decision-making. Whilst the DCMs' mathematical elegance and behavioural appeal hold clear interpretations, the models do not account for the 'moral' cost and benefit in an individual's utility calculation. The literature showed that ML obtains higher predictive power, model flexibility, and ability to handle large and unstructured datasets. Combining the strengths of ML methods with DCMs has the potential for studying moral decision-making.

CONCLUSIONS

By providing a research agenda, this paper highlights that ML has clear potential to i) find and deepen the utility specification of DCMs, and ii) enrich the insights extracted from DCMs by considering the intrapersonal determinants of moral decision-making.

The Willingness to Donate Organs in Medical Students From an International Perspective: A Meta-Analysis

Attitude toward organ donation mobilizes donation behavior and makes transplant surgery possible. As future health professionals, medical students will be a relevant generating opinion group and will have an important role in the organ requesting process. The goals of this meta-analysis were to obtain polled rates of medical students who are in favor, against, or indecisive toward cadaveric organ donation in the studies conducted around the world, and to explore sociocultural variables influencing the willingness to donate. Electronic search and revision of references from previous literature allowed us to locate 57 studies fulfilling the inclusion criteria. Data extraction and risk of bias assessment were performed by two independent investigators. Pooled estimations were computed assuming a random-effects model. Despite the fact that willingness to donate was elevated in medical students, estimated rates in studies from different geographical areas and sociocultural backgrounds exhibited significant differences. The age and the grade of the students also influenced the rate of students in favor. Donation campaigns should take into account cultural factors, especially in countries where certain beliefs and values could hamper organ donation. Also, knowledge and skills related to organ donation and transplant should be acquired early in the medical curriculum when a negative attitude is less resistant to change.

How Should Deceased Donor Organs Be Allocated? The Patient's Perspective Derived from Semi-Structured Interviews

PURPOSE

The gap between the supply and demand for deceased donor organs is increasing worldwide, while patients on waiting lists for organ transplantation die. This situation requires ethical donor organ allocation rules. The patients' perspective on donor organ allocation rules offers a highly relevant and unique perspective that may differ from the perspectives of physicians and the general public.

PATIENTS AND METHODS

Semi-structured telephone interviews were conducted with the regional group coordinators of the federal self-help organization for organ transplanted patients and their relatives in Germany in early 2021. Twelve interviews were conducted with patients and relatives of transplantation patients who received transplants for the affected organs including the lungs, heart, kidney, and liver. Transcripts were analyzed using the deductive framework method which was based on an earlier study. All criteria were reported following the COREQ statement.

RESULTS

Participants emphasized aspects of "medical urgency" and "effectiveness/benefit" of transplantation and associated trade-offs as well as the recipient's responsibility for organ failure ("own fault"), the appreciation for the gifted graft and the patient's capability of taking care of it ("appreciation/responsibility"). Patients acknowledged that urgent patients should be prioritized and they showed a clear preference toward allocation rules that strive to maximize both the life years and quality of life gained by transplantation.

CONCLUSION

The patients' perspective is unique in that patients agree on certain rules for allocation and share many preferences, but also have a hard time finding clear cutoff points when considering selecting a participant for allocation. Patient representatives should therefore be consulted in the debate on donor organ allocation rules.

Potential Bias and Misconceptions in Liver Transplantation for Alcohol- and Obesity-Related Liver Disease

INTRODUCTION

Bias and misconceptions surrounding alcohol-related liver disease (ALD) and obesity-related liver disease (OLD) may lead to transplant listing inequities. The aim of this study was to evaluate patients, medical students, residents, fellows, and attending physicians for bias and misconceptions regarding liver transplantation (LT) for patients with ALD and OLD.

METHODS

Participants took a survey asking them whether patients with ALD who continue/discontinue drinking alcohol or patients with OLD who do/do not commit to a weight loss program deserve equal LT rights. A Likert scale was used for their responses. Participants also estimated 5-year survival and advanced fibrosis recurrence after LT. The primary outcome of the study was bias measured by expected agreement or disagreement to questions using a Likert scale, significant underestimation of a 5-year survival rate after LT, and significant overestimation of 5-year advanced fibrosis recurrence after LT.

RESULTS

A total of 381 participants were included in the analysis: 153 residents/fellows, 31 attending physicians, 98 medical students, and 99 patients. A higher percentage from all 4 participating groups either were neutral or disagreed with equal LT rights for patients with ALD who discontinue drinking compared with patients with OLD who commit to weight loss program. The attending physician group was the only group with a majority estimating >60% 5-year survival after LT in patients with ALD and OLD (P < 0.05). All 4 groups had a majority estimate >20% 5-year advanced fibrosis recurrence in patients with ALD and OLD (P > 0.05).

DISCUSSION

There seems to be current bias and misconceptions regarding LT for patients with ALD and OLD.

Prospective Intention-Based Lifestyle Contracts: mHealth Technology and Responsibility in Healthcare

As the rising costs of lifestyle-related diseases place increasing strain on public healthcare systems, the individual's role in disease may be proposed as a healthcare rationing criterion. Literature thus far has largely focused on retrospective responsibility in healthcare. The concept of prospective responsibility, in the form of a lifestyle contract, warrants further investigation. The responsibilisation in healthcare debate also needs to take into account innovative developments in mobile health technology, such as wearable biometric devices and mobile apps, which may change how we hold others accountable for their lifestyles. Little is known about public attitudes towards lifestyle contracts and the use of mobile health technology to hold people responsible in the context of healthcare. This paper has two components. Firstly, it details empirical findings from a survey of 81 members of the United Kingdom general public on public attitudes towards individual responsibility and rationing healthcare, prospective and retrospective responsibility, and the acceptability of lifestyle contracts in the context of mobile health technology. Secondly, we draw on the empirical findings and propose a model of prospective intention-based lifestyle contracts, which is both more aligned with public intuitions and less ethically objectionable than more traditional, retrospective models of responsibility in healthcare.

Longterm Outcomes of Patients Undergoing Liver Transplantation for Acute-on-Chronic Liver Failure

Recent data have demonstrated >80% 1-year survival probability after liver transplantation (LT) for patients with severe acute-on-chronic liver failure (ACLF). However, longterm outcomes and complications are still unknown for this population. Our aim was to compare longterm patient and graft survival among patients transplanted across all grades of ACLF. We analyzed the United Network for Organ Sharing database for the years 2004-2017. Patients with ACLF were identified using the European Association for the Study of the Liver-Chronic Liver Failure criteria. Kaplan-Meier and Cox regression methods were used to determine patient and graft survival and associated predictors of mortality in adjusted models. A total of 56,801 patients underwent transplantation of which 31,024 (54.6%) had no ACLF, 8757 (15.4%) had ACLF grade 1, 9039 (15.9%) had ACLF grade 2, and 7891 (14.1%) had ACLF grade 3. The 5-year patient survival after LT was lower in the ACLF grade 3 patients compared with the other groups (67.7%; P < 0.001), although after year 1, the percentage decrease in survival was similar among all groups. Infection was the primary cause of death among all patient groups in the first year. Infection was the primary cause of death among all patient groups in the first year. After the first year, infection was the main cause of death in patients transplanted with ACLF grade 1 (32.1%), ACLF grade 2 (33.9%), and ACLF grade 3 (37.6%), whereas malignancy was the predominant cause of death in those transplanted with no ACLF (28.5%). In conclusion, patients transplanted with ACLF grade 3 had lower 5-year survival as compared with patients with ACLF grades 0-2, but mortality rates were not significantly different after the first year following LT. Graft survival was excellent across all ACLF groups.

Center Variation in Intention-to-Treat Survival Among Patients Listed for Liver Transplant

In the United States, centers performing liver transplant (LT) are primarily evaluated by patient survival within 1 year after LT, but tight clustering of outcomes allows only a narrow window for evaluation of center variation for quality improvement. Alternate measures more relevant to patients and the transplant community are needed. We examined adults listed for LT in the United States, using data submitted to the Scientific Registry of Transplant Recipients. Intention-to-treat (ITT) survival was defined as survival within 1 year from listing, regardless of transplant. Mixed effects/frailty models were used to assess center variation in ITT survival. Between January 2010 and December 2016, there were 66,428 new listings at 113 centers. Overall, median 1-year ITT survival was 79.8% (interquartile range [IQR], 76.1%-83.4%), whereas 1-year waiting-list (WL) survival was 75.8% (IQR, 71.2%-79.4%), and 1-year post-LT survival was 90.0% (IQR, 87.9%-91.8%). Higher rates of ITT mortality were correlated with increased WL mortality (correlation, r = 0.76), increased post-LT mortality (r = 0.31), lower volume centers (r = -0.34), and lower transplant rate ratio (r = -0.25). Similar patterns were observed in the subgroup of WL candidates listed with Model for End-Stage Liver Disease (MELD) ≥25: median 1-year ITT survival was 65.2% (IQR, 60.2%-72.6%), whereas 1-year post-LT survival was 87.5% (IQR, 84.0%-90.9%), and 1-year WL survival was 36.6% (IQR, 27.9%-47.0%). In mixed effects modeling, the transplant center was an independent predictor of ITT survival even after adjustment for age, sex, MELD, and sociodemographic variables. Center variation for ITT survival was larger compared with post-LT survival. The measurement of ITT outcome offers a complementary method to assess center performance. This is a first step toward understanding differences in program quality beyond patient and graft survival after LT.

The Perception of Medical Students at King Abdulaziz University Hospital Regarding the Liver Transplant Allocation System

Background: The benefit of liver transplantation is not only to increase the patient’s lifetime but also for persistent relief of pain and anxiety. Shortage of the organ is the main hindrance of transplantation around the world, leading authorities to pass a general law for the reasonable distribution of organs and come up with the Model for End-Stage Liver Disease (MELD) system which scores the severity of liver disease and risk of mortality in order to detect the mechanism of allocation. 

Objective: This study aims to assess medical students’ perception of the liver transplant and allocation system.

Methods: A cross-sectional survey was carried out among 402 medical students at King Abdulaziz University in Jeddah, Saudi Arabia.

Results: The majority of the medical students (84.4%) believed that a successful liver transplant improves both lifetime and quality of life. Most of the students also saw that the minimum survival rate should be five years after transplantation and that the patient should recover to be at least ambulatory, even if restricted by strenuous physical activity. When asked whether urgency or prospect of success defined a successful transplant, most of the students who chose urgency were preclinical (50.7%), while the prospect of success was the dominant answer chosen by students in their clinical years of study (66.1%).

Conclusion: The criteria determining the success of a liver transplant include a gain in both lifetime and quality of life. The majority of respondents wanted the capacity to benefit to be considered in the liver allocation system.

Recent advances in liver transplantation for cancer: The future of transplant oncology

Liver transplantation is widely indicated as a curative treatment for selected patients with hepatocellular carcinoma. However, with recent therapeutic advances, as well as efforts to increase the donor pool, liver transplantation has been carefully expanded to patients with other primary or secondary malignancies in the liver. Cholangiocarcinoma, colorectal and neuroendocrine liver metastases, and hepatic epithelioid haemangioendothelioma are amongst the most relevant new indications. In this review we discuss the fundamental concepts of this ambitious undertaking, as well as the newest indications for liver transplantation, with a special focus on future perspectives within the recently established concept of transplant oncology.