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Kassam AF, Goddard GR, Johnston ME, Cortez AR, Trout AT, Jenkins TM, Miethke AG, Campbell KM, Bezerra JA, Balistreri WF, Nathan JD, Alonso MH, Tiao GM, Bondoc AJ. Natural Course of Pediatric Portal Hypertension. Hepatol Commun 2020; 4:1346-1352. [PMID: 32923837 PMCID: PMC7471417 DOI: 10.1002/hep4.1560] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/09/2020] [Accepted: 05/31/2020] [Indexed: 12/16/2022] Open
Abstract
The etiology of portal hypertension (pHTN) in children differs from that of adults and may require different management strategies. We set out to review the etiology, management, and natural history of pHTN at a pediatric liver center. From 2008 to 2018, 151 children and adolescents with pHTN were identified at a free‐standing children’s hospital. Patients were stratified by etiology of pHTN (intrahepatic disease [IH], defined as cholestatic disease and fibrotic or hepatocellular disease; extrahepatic disease [EH], defined as hepatic vein obstruction and prehepatic pHTN). Patients with EH were more likely to undergo an esophagoduodenscopy for a suspected gastrointestinal bleed (77% vs. 41%; P < 0.01). Surgical interventions differed based on etiology (P < 0.01), with IH more likely resulting in a transplant only (65%) and EH more likely to result in a shunt only (43%); 30% of patients with IH and 47% of patients with EH did not undergo an intervention for pHTN. Kaplan‐Meier analysis revealed a significant increase in mortality in the group that received no intervention compared to shunt, transplant, or both and lower mortality in patients with prehepatic pHTN compared to other etiologies (P < 0.01 each). Multivariate analysis revealed increased odds of mortality in patients with refractory ascites (odds ratio [OR], 4.34; 95% confidence interval [CI], 1.00, 18.88; P = 0.05) and growth failure (OR, 13.49; 95% CI, 3.07, 58.99; P < 0.01). Conclusion: In this single institution study, patients with prehepatic pHTN had better survival and those who received no intervention had higher mortality than those who received an intervention. Early referral to specialized centers with experience managing these complex disease processes may allow for improved risk stratification and early intervention to improve outcomes.
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Affiliation(s)
- Al-Faraaz Kassam
- Division of Pediatric General and Thoracic Surgery Cincinnati Children's Hospital Medical Center Cincinnati OH.,Department of Surgery University of Cincinnati Cincinnati OH
| | - Gillian R Goddard
- Division of Pediatric General and Thoracic Surgery Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Michael E Johnston
- Division of Pediatric General and Thoracic Surgery Cincinnati Children's Hospital Medical Center Cincinnati OH.,Department of Surgery University of Cincinnati Cincinnati OH
| | | | - Andrew T Trout
- Department of Radiology Cincinnati Children's Hospital Medical Center Cincinnati OH.,Department of Radiology University of Cincinnati College of Medicine Cincinnati OH
| | - Todd M Jenkins
- Division of Pediatric General and Thoracic Surgery Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Alexander G Miethke
- Division of Gastroenterology, Hepatology, and Nutrition Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Kathleen M Campbell
- Division of Gastroenterology, Hepatology, and Nutrition Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Jorge A Bezerra
- Division of Gastroenterology, Hepatology, and Nutrition Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - William F Balistreri
- Division of Gastroenterology, Hepatology, and Nutrition Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Jaimie D Nathan
- Division of Pediatric General and Thoracic Surgery Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Maria H Alonso
- Division of Pediatric General and Thoracic Surgery Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Gregory M Tiao
- Division of Pediatric General and Thoracic Surgery Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Alexander J Bondoc
- Division of Pediatric General and Thoracic Surgery Cincinnati Children's Hospital Medical Center Cincinnati OH
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2
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Jesse MT, Abouljoud M, Goldstein ED, Rebhan N, Ho CX, Macaulay T, Bebanic M, Shkokani L, Moonka D, Yoshida A. Racial disparities in patient selection for liver transplantation: An ongoing challenge. Clin Transplant 2019; 33:e13714. [PMID: 31532023 DOI: 10.1111/ctr.13714] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 09/03/2019] [Accepted: 09/07/2019] [Indexed: 01/14/2023]
Abstract
Ample evidence suggests continued racial disparities once listed for liver transplantation, though few studies examine disparities in the selection process for listing. The objective of this study, via retrospective chart review, was to determine whether listing for liver transplantation was influenced by socioeconomic status and race/ethnicity. We identified 1968 patients with end-stage liver disease who underwent evaluation at a large, Midwestern center from January 1, 2004 through December 31, 2012 (72.9% white, 19.6% black, and 7.5% other). Over half (54.6%) of evaluated patients were listed; the three most common reasons for not listing were medical contraindications (11.9%), patient expired during evaluation (7.0%), and psychosocial contraindications (5.9%). In multivariable logistic regressions (listed vs not listed), across the three racial categories, the odds of being listed were lower for alcohol-induced hepatitis (±hepatitis C), unmarried, more than one insurance, inadequate insurance, and lower annual household income quartile. Similar factors predicted time to transplant listing, including being identified as black race. Black race, even when adjusting for the above mentioned medical and socioeconomic factors, was associated with 26% lower odds of being listed and a longer time to listing decision compared to all other patients.
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Affiliation(s)
- Michelle T Jesse
- Transplant Institute, Henry Ford Health System, Detroit, MI.,Consultation-Liaison Psychiatry, Behavioral Health, Henry Ford Health System, Detroit, MI.,Center for Health Policy & Health Services Research, Henry Ford Health System, Detroit, MI
| | - Marwan Abouljoud
- Transplant Institute, Henry Ford Health System, Detroit, MI.,Transplant and Hepatobiliary Surgery, Henry Ford Health System, Detroit, MI
| | | | | | - Chuan-Xing Ho
- Transplant Institute, Henry Ford Health System, Detroit, MI
| | | | - Mubera Bebanic
- Transplant Institute, Henry Ford Health System, Detroit, MI
| | - Lina Shkokani
- Transplant Institute, Henry Ford Health System, Detroit, MI
| | - Dilip Moonka
- Transplant Institute, Henry Ford Health System, Detroit, MI.,Division of Gastroenterology and Hepatology, Henry Ford Health System, Detroit, MI
| | - Atsushi Yoshida
- Transplant Institute, Henry Ford Health System, Detroit, MI.,Transplant and Hepatobiliary Surgery, Henry Ford Health System, Detroit, MI
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3
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Memeo R, de'Angelis N, Salloum C, Compagnon P, Laurent A, Feray C, Duvoux C, Azoulay D. Clinical outcomes of right-lobe split-liver versus orthotopic liver transplants from donors more than 70 years old. Prog Transplant 2018; 25:243-50. [PMID: 26308784 DOI: 10.7182/pit2015303] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Context-The imbalance between the organ supply and the number of potential transplant recipients led to consideration of expanded-criteria liver donors. Objective-To compare right-lobe split-liver transplants (RL-SLTs) with orthotopic liver transplants (OLTs) from donors more than 70 years old (OLT-O) and OLTs from donors less than 55 years old (OLT-Y). Methods-Seventy-one patients who received an RL-SLT were matched for age, sex, and Model for End-stage Liver Disease score with 71 patients who underwent OLT-O and 142 patients who underwent OLT-Y. Clinical outcomes were compared between groups. Results-Longer operation time was associated with RL-SLT (P< .001) as well as more blood loss (P= .03) and transfusions (P= .05). Postoperative morbidity was less in the OLT-Y group, with a lower rate of grades III to IV Clavien-Dindo complication (30%), compared with values in OLT-O (52%) and RL-SLT (38%). Kaplan-Meier analysis demonstrated better 1-year and 3-year survival rates in the OLT-Y group (97% and 92%, respectively), compared with 92% and 86.3%, respectively, in the RL-SLT group; and 84.5% and 73%, respectively, in the OLT-O group (P = .03). Kaplan-Meier analysis also demonstrated differences between the groups in terms of 1-year and 3-year graft survival rates, which were 92% and 86%, respectively, in OLT-Y; 77% and 66%, respectively, in the OLT-O, and 84.2% and 76.6%, respectively, in the RL-SLT group (P= .01). Conclusion-Even if OLT-Y guarantees better patient and graft survival, both RL-SLT and OLT-O can be used safely to expand the pool of liver donors, showing acceptable clinical results and complications rates.
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Affiliation(s)
- Riccardo Memeo
- Hospital Henri-Mondor, Université de Paris Est-Creteil, Paris, France
| | - Nicola de'Angelis
- Hospital Henri-Mondor, Université de Paris Est-Creteil, Paris, France
| | - Chady Salloum
- Hospital Henri-Mondor, Université de Paris Est-Creteil, Paris, France
| | - Philipe Compagnon
- Hospital Henri-Mondor, Université de Paris Est-Creteil, Paris, France
| | - Alexis Laurent
- Hospital Henri-Mondor, Université de Paris Est-Creteil, Paris, France
| | - Cyrille Feray
- Hospital Henri-Mondor, Université de Paris Est-Creteil, Paris, France
| | - Cristoph Duvoux
- Hospital Henri-Mondor, Université de Paris Est-Creteil, Paris, France
| | - Daniel Azoulay
- Hospital Henri-Mondor, Université de Paris Est-Creteil, Paris, France
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Increased Risk of Death for Patients on the Waitlist for Liver Transplant Residing at Greater Distance From Specialized Liver Transplant Centers in the United States. Transplantation 2017; 100:2146-52. [PMID: 27490419 DOI: 10.1097/tp.0000000000001387] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND We have previously shown that patients listed for orthotopic liver transplantation (OLT) in United Network for Organ Sharing Region 4 (Texas and Oklahoma) have higher waitlist mortality rates when residing more than 30 miles from specialized liver transplant centers (LTC). Considering that findings might only be exclusive for this region with its peculiarities in terms of having the highest land surface extensions, lowest population densities, and largest rural populations. We investigated the entire OLT patient population in the United States to assess if our previous regional findings are nationally validated and if a rural, micropolitan, or metropolitan residence location affects outcome of waitlisted OLT patients in the nation. METHODS Patients waiting for OLT in the United States from 2002 to 2012 were stratified by distance from the patients' residence to LTC and by Rural Urban Commuting Area (RUCA) codes classification. Statistical analyses were performed to evaluate risk of mortality on the waitlist and the likelihood to receive an OLT using a Cox proportional hazards model and a generalized additive model with a logistic link. RESULTS Survival time and probability of death while on the waitlist for OLT using distance to LTC showed significant increased risk with the distance (P = 0.001 and P < 0.0001, respectively). At the same time, using RUCA classification as the variable did not show significance (P = 0.14 and P = 0.73, respectively). CONCLUSIONS Distance from an LTC is a risk factor of mortality on the waitlist for OLT, whereas RUCA classification is not a significant factor.
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Zorzi D, Rastellini C, Freeman D, Elias G, Duchini A, Cicalese L. Increase in mortality rate of liver transplant candidates residing in specific geographic areas: analysis of UNOS data. Am J Transplant 2012; 12:2188-97. [PMID: 22845911 PMCID: PMC3410658 DOI: 10.1111/j.1600-6143.2012.04083.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We sought to evaluate survival of liver transplant candidates living in geographic areas with limited access to specialized transplant centers (TxC). We analyzed survival outcome among candidates listed for liver transplant in United Network of Organ Sharing (UNOS) Region 4 from 2004 to 2010. Candidates were stratified into three groups according to the distance from the patient's residence to the closest hospital with a liver transplant program: Group 1 (Gr 1) <30 miles (m), Group 2 (Gr 2) 30-60 m and Group 3 (Gr 3) >60 m. Of the 5673 patients included in the study, 49% resided >30 m from a TxC. Eight percent of the cohort experienced death or dropped out of the list due to medical condition deterioration, with worse outcomes for Gr 2 and Gr 3 (8.5% and 9.9%, respectively, vs. 6.5% for Gr 1 [p < 0.001]). Among patients with a MELD score <20, mortality was higher in Gr 2 and Gr 3 compared to Gr 1 (p < 0.001). We conclude that for Region 4, the mortality risk in patients living >30 m from a TxC is higher. We suggest that the variable "distance from a TxC" should be used to improve the estimate of the mortality risk for patients on the waiting list.
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Affiliation(s)
- D. Zorzi
- Texas Transplant Center, Department of Surgery, Galveston, TX
| | - C. Rastellini
- Texas Transplant Center, Department of Surgery, Galveston, TX
| | - D.H. Freeman
- Department of Biostatistics, University of Texas Medical Branch, Galveston, TX
| | - G. Elias
- Department of Internal Medicine, Galveston, TX
| | - A. Duchini
- Texas Transplant Center, Department of Surgery, Galveston, TX,Department of Internal Medicine, Galveston, TX
| | - L Cicalese
- Texas Transplant Center, Department of Surgery, Galveston, TX
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Uemura T, Nikkel LE, Hollenbeak CS, Ramprasad V, Schaefer E, Kadry Z. How can we utilize livers from advanced aged donors for liver transplantation for hepatitis C? Transpl Int 2012; 25:671-9. [DOI: 10.1111/j.1432-2277.2012.01474.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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