[The cost of liver transplantation at a university hospital of Brazil]

Primary Cilia, Hypoxia, and Liver Dysfunction: A New Perspective on Biliary Atresia

Ciliopathies are disorders that affect primary or secondary cellular cilia or structures associated with ciliary function. Primary cilia (PC) are essential for metabolic regulation and embryonic development, and pathogenic variants in cilia-related genes are linked to several pediatric conditions, including renal-hepatic diseases and congenital defects. Biliary atresia (BA) is a progressive infantile cholangiopathy and the leading cause of pediatric liver transplantation. Although the exact etiology of BA remains unclear, evidence suggests a multifactorial pathogenesis influenced by both genetic and environmental factors. Patients with BA and laterality defects exhibit genetic variants associated with ciliopathies. Interestingly, even isolated BA without extrahepatic anomalies presents morphological and functional ciliary abnormalities, suggesting that environmental triggers may disrupt the ciliary function. Among these factors, hypoxia has emerged as a potential modulator of this dysfunction. Hypoxia-inducible factor 1-alpha (HIF-1α) plays a central role in hepatic responses to oxygen deprivation, influencing bile duct remodeling and fibrosis, which are key processes in BA progression. This review explores the crosstalk between hypoxia and hepatic ciliopathies, with a focus on BA. It discusses the molecular mechanisms through which hypoxia may drive disease progression and examines the therapeutic potential of targeting hypoxia-related pathways. Understanding how oxygen deprivation influences ciliary function may open new avenues for treating biliary ciliopathies and improving patient outcomes.

EVALUATION AND SELECTION OF CANDIDATES FOR LIVER TRANSPLANTATION: AN ECONOMIC PERSPECTIVE

BACKGROUND

Over the next 20 years, the number of patients on the waiting list for liver transplantation (LTx) is expected to increase by 23%, while pre-LTx costs should raise by 83%.

OBJECTIVE

To evaluate direct medical costs of the pre-LTx period from the perspective of a tertiary care center.

METHODS

The study included 104 adult patients wait-listed for deceased donor LTx between October 2012 and May 2016 whose treatment was fully provided at the study transplant center. Clinical and economic data were obtained from electronic medical records and from a hospital management software. Outcomes of interest and costs of patients on the waiting list were compared through the Kruskal-Wallis test. A generalized linear model with logit link function was used for multivariate analysis. P-values <0.05 were considered statistically significant.

RESULTS

The costs of patients who underwent LTx ($8,879.83; 95% CI 6,735.24-11,707.27; P<0.001) or who died while waiting ($6,464.73; 95% CI 3,845.75-10,867.28; P=0.04) were higher than those of patients who were excluded from the list for any reason except death ($4,647.78; 95% CI 2,469.35-8,748.04; P=0.254) or those who remained on the waiting list at the end of follow-up.

CONCLUSION

Although protocols of inclusion on the waiting list vary among transplant centers, similar approaches exist and common problems should be addressed. The results of this study may help centers with similar socioeconomic realities adjust their transplant policies.

Hospitalization costs and their determining factors among patients undergoing kidney transplantation: a cross-sectional descriptive study

BACKGROUND

Cost evaluation is a key tool in monitoring expenditure for budget management. It increases the efficiency of possible changes through identifying potential savings and estimating the resources required to make such changes. However, there is a lack of knowledge of the total cost of hospitalization up to the clinical outcome, regarding patients admitted for kidney transplantation. Likewise, there is a lack of data on the factors that influence the amounts spent by hospital institutions and healthcare systems.

OBJECTIVES

To describe the costs and determining factors relating to hospitalization of patients undergoing kidney transplantation.

DESIGN AND SETTING

Cross-sectional descriptive study with a quantitative approach based on secondary data from 81 patients who were admitted for kidney transplantation at a leading transplantation center in southern Brazil.

METHODS

The direct costs of healthcare for patients who underwent kidney transplantation were the dependent variable, and included personnel, expenses, third-party services, materials and medicines. The factors that interfered in the cost of the procedure were indirect variables. The items that made up these variables were gathered from the records of the internal transplantation committee and from the electronic medical records. The billing sector provided information on the direct costs per patient.

RESULTS

The estimated total cost of patients' hospitalization was R$ 1,257,639.11 (US$ 571,010.44). Out of this amount, R$ 1,237,338.31 (US$ 561,793.20) was paid by the Brazilian National Health System and R$ 20,300.80 (US$ 9,217.24) by the transplantation center's own resources. The highest costs related to the length of hospital stay and clinical complications such as sepsis and pneumonia.

CONCLUSIONS

The costs of hospitalization for kidney transplantation relate to the length of hospital stay and clinical complications.

THE COST OF ADULT LIVER TRANSPLANTATION IN A REFERRAL CENTER IN SOUTHERN BRAZIL

BACKGROUND

Liver transplantation (LTx) is the primary and definitive treatment of acute or chronic cases of advanced or end-stage liver disease. Few studies have assessed the actual cost of LTx categorized by hospital unit.

OBJECTIVE

To evaluate the cost of LTx categorized by unit specialty within a referral center in southern Brazil.

METHODS

We retrospectively reviewed the medical records of 109 patients undergoing LTx between April 2013 and December 2014. Data were collected on demographic characteristics, etiology of liver disease, and severity of liver disease according to the Child-Turcotte-Pugh (CTP) and Model for End-stage Liver Disease (MELD) scores at the time of LTx. The hospital bill was transformed into cost using the full absorption costing method, and the costs were grouped into five categories: Immediate Pretransplant Kit; Specialized Units; Surgical Unit; Intensive Care Unit; and Inpatient Unit.

RESULTS

The mean total LTx cost was US$ 17,367. Surgical Unit, Specialized Units, and Intensive Care Unit accounted for 31.9%, 26.4% and 25.3% of the costs, respectively. Multivariate analysis showed that total LTx cost was significantly associated with CTP class C (P=0.001) and occurrence of complications (P=0.002). The following complications contributed to significantly increase the total LTx cost: septic shock (P=0.006), massive blood transfusion (P=0.007), and acute renal failure associated with renal replacement therapy (dialysis) (P=0.005).

CONCLUSION

Our results demonstrated that the total cost of LTx is closely related to liver disease severity scores and the development of complications.

Resource allocations and disparities in the Brazilian health care system: insights from organ transplantation services

Background

To date, few studies have assessed how Brazil’s universal healthcare system’s (SUS, Sistema Único de Saúde) systemic, infrastructural, and geographical challenges affect individuals’ abilities to access organ transplantation services and receive quality treatment.

Discussion

In this article we evaluated the existing literature to examine the impact that SUS has had on an increasingly important healthcare sector: organ transplantation services. We assess how equity challenges within the transplantation system can be explained by wider problems within SUS. Findings suggest stark disparities in access to transplantation services both within and across Brazil’s regions. We found that these regional differences are partially due to logistical challenges, especially in loosely populated areas but are also a consequence of disparities in resource allocations within SUS and under-capacitated health care facilities affecting transplantation services.

Summary

We suggest that Brazil needs to improve its health outcome measurement system for organ transplantations and epidemiological surveillance, to gain more comprehensive and comparable data. Finally, we recommend policy strategies to reduce barriers to access to transplantation services by increasing transplantation service coverage in some areas and investing in emerging technologies.

[Cost-effectiveness in health in Brazil: a systematic review]

A systematic review was performed with the aim of describing the landscape and evolution of cost-effectiveness studies in health in Brazil. The search for articles on cost-effectiveness was performed in the main electronic health databases. The review identified 83 cost-effectiveness studies conducted nationwide. Between the years 1990-2005 there were few studies published on cost-effectiveness, though between 2006 and 2014 there was a significant increase in the number of publications. As for the themes and objectives of the studies, the chronic degenerative diseases and infectious/contagious diseases reflect the epidemiological diversity of Brazil. A predominance of studies on health intervention/treatment was identified. Thus, this review reveals a compatible Brazilian epidemiological reality scenario, indicating a need to increase research and investment of funds in the area of preventive health.

Higher MELD score increases the overall cost on the waiting list for liver transplantation: a micro-costing analysis based study

ABSTRACT BACKGROUND: The pre-transplant period is complex and includes lots of procedures. The severity of liver disease predisposes to a high number of hospitalizations and high costs procedures. Economic evaluation studies are important tools to handle costs on the waiting list for liver transplantation. OBJECTIVE: The objective of the present study was to evaluate the total cost of the patient on the waiting list for liver transplantation and the main resources related to higher costs. METHODS: A cost study in a cohort of 482 patients registered on waiting list for liver transplantation was carried out. In 24 months follow-up, we evaluated all costs of materials, medicines, consultations, procedures, hospital admissions, laboratorial tests and image exams, hemocomponents replacements, and nutrition. The total amount of each resource or component used was aggregated and multiplied by the unitary cost, and thus individual cost for each patient was obtained. RESULTS: The total expenditure of the 482 patients was US$ 6,064,986.51. Outpatient and impatient costs correspond to 32.4% of total cost (US$ 1,965,045.52) and 67.6% (US$ 4,099,940.99) respectively. Main cost drivers in outpatient were: medicines (44.31%), laboratorial tests and image exams (31.68%). Main cost drivers regarding hospitalizations were: medicines (35.20%), bed use in ward and ICU (26.38%) and laboratorial tests (13.72%). Patients with MELD score between 25-30 were the most expensive on the waiting list (US$ 16,686.74 ± 16,105.02) and the less expensive were those with MELD below 17 (US$ 5,703.22 ± 9,318.68). CONCLUSION: Total costs on the waiting list for liver transplantation increased according to the patient’s severity. Individually, hospitalizations, hemocomponents reposition and hepatocellular carcinoma treatment were the main cost drivers to the patient on the waiting list. The longer the waiting time, the higher the total cost on list, causing greater impact on health systems.

Predictors of micro-costing components in liver transplantation

OBJECTIVES:

Although liver transplantation procedures are common and highly expensive, their cost structure is still poorly understood. This study aimed to develop models of micro-costs among patients undergoing liver transplantation procedures while comparing the role of individual clinical predictors using tree regression models.

METHODS:

We prospectively collected micro-cost data from patients undergoing liver transplantation in a tertiary academic center. Data collection was conducted using an Intranet registry integrated into the institution's database for the storing of financial and clinical data for transplantation cases.

RESULTS:

A total of 278 patients were included and accounted for 300 procedures. When evaluating specific costs for the operating room, intensive care unit and ward, we found that in all of the sectors but the ward, human resources were responsible for the highest costs. High cost supplies were important drivers for the operating room, whereas drugs were among the top four drivers for all sectors. When evaluating the predictors of total cost, a MELD score greater than 30 was the most important predictor of high cost, followed by a Donor Risk Index greater than 1.8.

CONCLUSION:

By focusing on the highest cost drivers and predictors, hospitals can initiate programs to reduce cost while maintaining high quality care standards.

Healthcare resource utilization and costs of outpatient follow-up after liver transplantation in a university hospital in São Paulo, Brazil: cost description study

CONTEXT AND OBJECTIVE

Data on the costs of outpatient follow-up after liver transplantation are scarce in Brazil. The purpose of the present study was to estimate the direct medical costs of the outpatient follow-up after liver transplantation, from the first outpatient visit after transplantation to five years after transplantation.

DESIGN AND SETTING

Cost description study conducted in a university hospital in São Paulo, Brazil.

METHODS

Cost data were available for 20 adults who underwent liver transplantation due to acute liver failure (ALF) from 2005 to 2009. The data were retrospectively retrieved from medical records and the hospital accounting information system from December 2010 to January 2011.

RESULTS

Mean cost per patient/year was R$ 13,569 (US$ 5,824). The first year of follow-up was the most expensive (R$ 32,546 or US$ 13,968), and medication was the main driver of total costs, accounting for 85% of the total costs over the five-year period and 71.9% of the first-year total costs. In the second year after transplantation, the mean total costs were about half of the amount of the first-year costs (R$ 15,165 or US$ 6,509). Medication was the largest contributor to the costs followed by hospitalization, over the five-year period. In the fourth year, the costs of diagnostic tests exceeded the hospitalization costs.

CONCLUSION

This analysis provides significant insight into the costs of outpatient follow-up after liver transplantation due to ALF and the participation of each cost component in the Brazilian setting.

Comparable outcome of liver transplantation with histidine-tryptophan-ketoglutarate vs. University of Wisconsin preservation solution: a retrospective observational double-center trial

Background

The question of whether the choice of preservation solution affects outcome after liver transplantation is still not satisfactorily answered. The purpose of this study is to examine the preservation solutions’ impact on outcome after liver transplantation.

Methods

A double-center retrospective study of short- and long-term results of 3134 consecutive liver transplantations with follow-up periods up to 23 years was performed applying multivariate, risk-adjusted analyses with a subset for living-donor transplants, pediatric transplants and cases with prolonged cold ischemic times. An additional focus was put on biliary complications. The primary study endpoints were short- and long-term patient survival and death-censored graft survival. Secondary study endpoints were the occurrence of post-transplant complications, the necessity of operative revisions, the length of hospital stay, and the length of intensive care unit stay.

Results

Although long-term graft survival appears to be increased by Histidine-Tryptophan-Ketoglutarate-use (p = 0.018), this effect could not be confirmed in risk-adjusted analysis (p = 0.641). Multivariate regression analysis revealed that 3-month mortality (p = 0.120), 3-month graft survival (p = 0.103) and long-term patient survival (p = 0.235) were not influenced by the choice of preservation solution. There was no difference in the occurrence of common complications or necessity of operative revisions after liver transplantation. This was confirmed in subgroup analyses for living donor and pediatric transplantation and cases with prolonged cold ischemic time. Analysis of the preservation solutions’ impact on length of hospital (p = 0.113) and intensive care unit stay (p = 0.481) revealed no significant difference.

Conclusions

University of Wisconsin and Histidine-Tryptophan-Ketoglutarate solutions are clinically equivalent. Histidine-Tryptophan-Ketoglutarate solution could have an economically superior profile. The notion that the choice of preservation solution can have an impact on the onset of biliary complications after liver transplantation remains a matter of controversy.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-230X-14-169) contains supplementary material, which is available to authorized users.

An overview of recently published medical papers in Brazilian scientific journals

A brief review intended as information to the readership of Clinics on papers recently published under various medical headings in Brazilian scientific journals recently indexed or about to be indexed in ISI-THOMSON Journal Citation Reports. Journals covered in this review are Acta Ortopédica Brasileira, Arquivos Brasileiros de Cardiologia, Jornal Brasileiro de Pneumologia, Revista Brasileira de Cirurgia Cardiovascular and Revista da Associação Médica Brasileira.