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Taber DJ, Bartlett F, Patel N, Sprague T, Patel S, Newman J, Andrade E, Rao N, Salas MAP, Casey M, Dubay D, Rohan V. Impact of converting adult kidney transplant recipients with high tacrolimus variability from twice daily immediate release tacrolimus to once daily LCP-Tacrolimus. Clin Transplant 2023; 37:e14941. [PMID: 36809653 DOI: 10.1111/ctr.14941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 01/14/2023] [Accepted: 02/08/2023] [Indexed: 02/23/2023]
Abstract
BACKGROUND The influence of converting to once daily, extended-release LCP-Tacrolimus (Tac) for those with high tacrolimus variability in kidney transplant recipients (KTRs) is not well-studied. METHODS Single-center, retrospective cohort study of adult KTRs converted from Tac immediate release to LCP-Tac 1-2 years post-transplant. Primary measures were Tac variability, using the coefficient of variation (CV) and time in therapeutic range (TTR), as well as clinical outcomes (rejection, infections, graft loss, death). RESULTS A total of 193 KTRs included with a follow-up of 3.2 ± .7 years and 1.3 ± .3 years since LCP-Tac conversion. Mean age was 52 ± 13 years; 70% were African American, 39% were female, 16% living donor and 12% donor after cardiac death (DCD). In the overall cohort, tac CV was 29.5% before conversion, which increased to 33.4% after LCP-Tac (p = .008). In those with Tac CV >30% (n = 86), conversion to LCP-Tac reduced variability (40.6% vs. 35.5%; p = .019) and for those with Tac CV >30% and nonadherence or med errors (n = 16), LCP-Tac conversion substantially reduced Tac CV (43.4% vs. 29.9%; p = .026). TTR significantly improved for those with Tac CV >30% with (52.4% vs. 82.8%; p = .027) or without nonadherence or med errors (64.8% vs. 73.2%; p = .005). CMV, BK, and overall infections were significantly higher prior to LCP-Tac conversion. In the overall cohort, 3% had rejection before conversion and 2% after (p = NS). At end of follow-up, graft and patient survival were 94% and 96%, respectively. CONCLUSIONS In those with high Tac CV, conversion to LCP-Tac is associated with a significant reduction in variability and improvement in TTR, particularly in those with nonadherence or medication errors.
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Affiliation(s)
- David J Taber
- Department of Surgery, Division of Transplant Surgery, MUSC, Charleston, South Carolina, USA
| | - Felicia Bartlett
- Department of Pharmacy Services, MUSC, Charleston, South Carolina, USA
| | - Neha Patel
- Department of Pharmacy Services, MUSC, Charleston, South Carolina, USA
| | - Taylor Sprague
- Department of Pharmacy Services, MUSC, Charleston, South Carolina, USA
| | - Shikha Patel
- Department of Pharmacy Services, MUSC, Charleston, South Carolina, USA
| | - Jessica Newman
- Department of Pharmacy Services, MUSC, Charleston, South Carolina, USA
| | - Erika Andrade
- College of Medicine, MUSC, Charleston, South Carolina, USA
| | - Nikhil Rao
- Department of Surgery, Division of Transplant Surgery, MUSC, Charleston, South Carolina, USA
| | | | - Michael Casey
- Department of Medicine, Division of Nephrology, MUSC, Charleston, South Carolina, USA
| | - Derek Dubay
- Department of Surgery, Division of Transplant Surgery, MUSC, Charleston, South Carolina, USA
| | - Vinayak Rohan
- Department of Surgery, Division of Transplant Surgery, MUSC, Charleston, South Carolina, USA
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Abstract
BACKGROUND The new kidney allocation changes with elimination of donor service areas (DSAs) and Organ Procurement and Transplantation Network regions were initiated to improve equity in organ allocation. The aim of this evaluation was to determine the operational, financial, and recipient-related effect of the new allocation system on a large rural transplantation program. STUDY DESIGN A retrospective, cross-sectional analysis of organ offers, allograft outcomes, and attributed costs in a comparative time cohort, before (December 16, 2020 to March 14, 2021) and after (March 15, 2021 to June 13, 2021) the allocation change was performed. Outcomes were limited to adult, solitary, deceased donor kidney transplantations. RESULTS We received 198,881 organ offers from 3,886 organ donors at our transplantation center from December 16, 2020 to June 31, 2021: 87,643 (1,792 organ donors) before the change and 111,238 (2094 organ donors) after the change, for a difference of +23,595 more offers (+302 organ donors). This resulted in 6.5 more organs transplanted vs a predicted loss of 4.9 per month. Local organ offers dropped from 70% to 23%. There was a statistically significantly increase in donor terminal serum creatinine (1.2 ± 0.86 mg/dL vs 2.2 ± 2.3 mg/dL, p < 0.001), kidney donor profile index (KDPI) (39 ± 20 vs 48 ± 22, p = 0.017), cold ischemia time (16 ± 7 hours vs 21 ± 6 hours, p < 0.001), and delayed graft function rates (23% vs 40%, p = 0.020). CONCLUSION The new kidney allocation policy has led to an increase in KDPI of donors with longer cold ischemia time, leading to higher delayed graft function rates. This has resulted in increasing logistical and financial burdens on the system. Implementing large-scale changes in allocation based predominantly on predictive modeling needs to be intensely reassessed during a longer follow up.
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Affiliation(s)
- Vinayak S Rohan
- From the Division of Transplant Surgery, Department of Surgery, Medical University of South Carolina, College of Medicine, Charleston, SC
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Rohan VS, Pilch N, Cassidy D, McGillicuddy J, White J, Lin A, Nadig SN, Taber DJ, Dubay D, Baliga PK. Maintaining Equity and Access: Successful Implementation of a Virtual Kidney Transplantation Evaluation. J Am Coll Surg 2020; 232:444-449. [PMID: 33359232 DOI: 10.1016/j.jamcollsurg.2020.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 12/01/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Maintaining access to kidney transplantation during a pandemic is a challenge, particularly for centers that serve a large rural and minority patient population with an additional burden of travel. The aim of this article was to describe our experience with the rollout and use of a virtual pretransplantation evaluation platform to facilitate ongoing transplant waitlisting during the early peak of the COVID-19 pandemic. STUDY DESIGN This is a retrospective analysis of the process improvement project implemented to continue the evaluation of potential kidney transplantation candidates and ensure waitlist placement during the COVID-19 pandemic. Operational metrics include transplantation volume per month, referral volume per month, pretransplantation patients halted before completing an evaluation per month, evaluations completed per month, and patients waitlisted per month. RESULTS Between April and September 2020, a total of 1,258 patients completed an evaluation. Two hundred and forty-seven patients were halted during this time period before completing a full evaluation. One hundred and fifty-two patients were presented at selection and 113 were placed on the waitlist. In addition, the number of patients in the active referral phase was able to be reduced by 46%. More evaluations were completed within the virtual platform (n = 930 vs n = 880), yielding similar additions to the waitlist in 2020 (n = 282) vs 2019 (n = 308) despite the COVID-19 pandemic. CONCLUSIONS The virtual platform allowed continued maintenance of a large kidney transplantation program despite the inability to have in-person visits. The value of this platform will likely transform our approach to the pretransplantation process and provides an additional valuable method to improve patient equity and access to transplantation.
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Affiliation(s)
- Vinayak S Rohan
- Division of Transplant Surgery, Department of Surgery, Medical University of South Carolina, College of Medicine, Charleston, South Carolina.
| | - Nicole Pilch
- Division of Transplant Surgery, Department of Surgery, Medical University of South Carolina, College of Medicine, Charleston, South Carolina
| | - Deborah Cassidy
- Division of Transplant Surgery, Department of Surgery, Medical University of South Carolina, College of Medicine, Charleston, South Carolina
| | - John McGillicuddy
- Division of Transplant Surgery, Department of Surgery, Medical University of South Carolina, College of Medicine, Charleston, South Carolina
| | - Jared White
- Division of Transplant Surgery, Department of Surgery, Medical University of South Carolina, College of Medicine, Charleston, South Carolina
| | - Angello Lin
- Division of Transplant Surgery, Department of Surgery, Medical University of South Carolina, College of Medicine, Charleston, South Carolina
| | - Satish N Nadig
- Division of Transplant Surgery, Department of Surgery, Medical University of South Carolina, College of Medicine, Charleston, South Carolina
| | - David J Taber
- Division of Transplant Surgery, Department of Surgery, Medical University of South Carolina, College of Medicine, Charleston, South Carolina
| | - Derek Dubay
- Division of Transplant Surgery, Department of Surgery, Medical University of South Carolina, College of Medicine, Charleston, South Carolina
| | - Prabhakar K Baliga
- Division of Transplant Surgery, Department of Surgery, Medical University of South Carolina, College of Medicine, Charleston, South Carolina
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4
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Perkins H, Taber D, Patel N, Rohan V, Su Z, Dubay D, McGillicuddy J. Patterns of emergency department utilization between transplant and non-transplant centers and impact on clinical outcomes in kidney recipients. Clin Transplant 2020; 34:e13983. [PMID: 32639652 DOI: 10.1111/ctr.13983] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 05/10/2020] [Accepted: 05/15/2020] [Indexed: 11/29/2022]
Abstract
There is a high rate of Emergency Department (ED) utilization in kidney recipients post-transplant; ED visits are associated with readmission rates and lower survival rates. However, utilization within and outside transplant centers may lead to different outcomes. The objective was to analyze ED utilization patterns at transplant and non-transplant centers as well as common etiologies of ED visits and correlation with hospitalization, graft, and patient outcomes. This was a longitudinal, retrospective, single-center cohort study in kidney transplant recipients evaluating ED utilization. Comparator groups were determined by ED location, time from transplant, and disposition/readmission from ED visit. 1,106 kidney recipients were included in the study. ED utilization dropped at the transplant center after the 1st year (P < .001), while remaining at a similar rate at non-transplant centers (0.22 vs 1.06 VPPY). Infection and allograft complications were the most common causes of ED visits. In multivariable Cox modeling, an ED visit due to allograft complication at a non-transplant center >1 year post-transplant was associated with higher risk for graft loss and death (aHR 2.93 and aHR 1.75, P < .0001). The results of this study demonstrate an increased risk of graft loss among patients who utilize non-transplant center emergency departments. Improved communication and coordination between transplant centers and non-transplant centers may contribute to better long-term outcomes.
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Affiliation(s)
- Haley Perkins
- Pharmacy, Medical University of South Carolina, Charleston, South Carolina, USA
| | - David Taber
- Department of Pharmacy, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Neha Patel
- Pharmacy, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Vinayak Rohan
- Division of Transplant Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Zemin Su
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Derek Dubay
- Division of Transplant Surgery, Medical University of South Carolina, Charleston, South Carolina, USA.,Transplant Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - John McGillicuddy
- Division of Transplant Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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Taber DJ, Posadas‐Salas A, Su Z, Rao V, Rohan V, Nadig S, McGillicuddy JW, Dubay D, Fleming JN. Preliminary assessment of safety and adherence to a once‐daily immunosuppression regimen in kidney transplantation: Results of a randomized controlled pilot study. Clin Transplant 2020; 34:e13844. [DOI: 10.1111/ctr.13844] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 02/13/2020] [Accepted: 02/21/2020] [Indexed: 11/28/2022]
Affiliation(s)
- David J. Taber
- Division of Transplant Surgery College of Medicine Medical University of South Carolina Charleston SC USA
| | - Aurora Posadas‐Salas
- Division of Transplant Nephrology College of Medicine Medical University of South Carolina Charleston SC USA
| | - Zemin Su
- Division of General Internal Medicine College of Medicine Medical University of South Carolina Charleston SC USA
| | - Vinaya Rao
- Division of Transplant Nephrology College of Medicine Medical University of South Carolina Charleston SC USA
| | - Vinayak Rohan
- Division of Transplant Surgery College of Medicine Medical University of South Carolina Charleston SC USA
| | - Satish Nadig
- Division of Transplant Surgery College of Medicine Medical University of South Carolina Charleston SC USA
| | - John W. McGillicuddy
- Division of Transplant Surgery College of Medicine Medical University of South Carolina Charleston SC USA
| | - Derek Dubay
- Division of Transplant Surgery College of Medicine Medical University of South Carolina Charleston SC USA
| | - James N. Fleming
- Department of Pharmacy Services Medical University of South Carolina Charleston SC USA
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6
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Goldberg D, Karp S, Shah MB, Dubay D, Lynch R. Importance of incorporating standardized, verifiable, objective metrics of organ procurement organization performance into discussions about organ allocation. Am J Transplant 2019; 19:2973-2978. [PMID: 31199562 DOI: 10.1111/ajt.15492] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 06/08/2019] [Accepted: 06/08/2019] [Indexed: 02/06/2023]
Abstract
Identifying and supporting specific organ procurement organizations (OPOs) with the greatest opportunity to increase donation rates could significantly increase the number of organs available for transplant. Accomplishing this is complicated by current Scientific Registry of Transplant Recipients/Centers for Medicare & Medicaid Services metrics of donation rates and OPO performance that rely on eligible deaths. These data are self-reported and unverifiable and have been shown to underestimate potential organ donors. We examine the limitations of current OPO performance/donation metrics to inform discussions related to strategies to increase donation. We propose changing to a simple, verifiable, and uniformly applied donation metric. This would allow the transplant community to (1) better understand inherent differences in donor availability based on geography and (2) identify underperforming areas that would benefit from systems improvement agreements to increase donation rates.
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Affiliation(s)
- David Goldberg
- Division of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Epidemiology, Biostatistics, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Seth Karp
- Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Malay B Shah
- Division of Transplantation, Department of Surgery, University of Kentucky Medical Center, Lexington, Kentucky
| | - Derek Dubay
- Division of Transplant Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Raymond Lynch
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
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Taber DJ, Su Z, Fleming JN, Pilch NA, Morinelli T, Mauldin P, Dubay D. The impact of time-varying clinical surrogates on disparities in African-American kidney transplant recipients - a retrospective longitudinal cohort study. Transpl Int 2018; 32:84-94. [PMID: 30176087 DOI: 10.1111/tri.13338] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 05/22/2018] [Accepted: 08/20/2018] [Indexed: 01/06/2023]
Abstract
An improved understanding of the impact of clinical surrogates on disparities in African-American (AA) kidney transplantation (KTX) is needed. We conducted a 10-year retrospective longitudinal cohort study of electronically abstracted clinical data assessing the impact of surrogates on disparities in KTX. Clinical surrogates were assessed by posttransplant year (1, 2, 3 or 4) and defined as acute rejection (Banff ≥1A), mean SBP >140 mmHg, tacrolimus variability (CV) >40%, mean glucose >160 mg/dl and mean hemoglobin <10 g/dl. We utilized landmark methodology to minimize immortal time bias and logistic and survival regression to assess outcomes; 1610 KTX were assessed (54.2% AAs), with 1000, 468, 368 and 303 included in the year 1, 2, 3 and 4 complete case analyses, respectively. AAs had significantly higher odds of developing a clinical surrogate, which increased in posttransplant years three and four [OR year 1 1.99 (1.38-2.88), year 2 1.77 (1.20-2.62), year 3 2.35 (1.49-3.71), year 4 2.85 (1.72-4.70)]. Adjusting for the five clinical surrogates in survival models explained a significant portion of the higher risks of graft loss in AAs in post-transplant years three and four. Results suggest focusing efforts on improving late clinical surrogate management within AAs may help mitigate racial disparities in KTX.
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Affiliation(s)
- David J Taber
- Division of Transplant Surgery, College of Medicine, Medical University of South Carolina, Charleston, SC, USA.,Department of Pharmacy Services, Ralph H Johnson VAMC, Charleston, SC, USA
| | - Zemin Su
- Division of General Internal Medicine & Geriatrics, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - James N Fleming
- Division of Transplant Surgery, College of Medicine, Medical University of South Carolina, Charleston, SC, USA.,Department of Pharmacy Services, Medical University of South Carolina, Charleston, SC, USA
| | - Nicole A Pilch
- Transplant Center, Medical University of South Carolina, Charleston, SC, USA
| | - Thomas Morinelli
- Division of Transplant Surgery, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Patrick Mauldin
- Division of General Internal Medicine & Geriatrics, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Derek Dubay
- Division of Transplant Surgery, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
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Sanchez D, Dubay D, Prabhakar B, Taber DJ. Evolving Trends in Racial Disparities for Peri-Operative Outcomes with the New Kidney Allocation System (KAS) Implementation. J Racial Ethn Health Disparities 2018; 5:1171-1179. [PMID: 29557046 DOI: 10.1007/s40615-018-0464-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 01/16/2018] [Accepted: 01/29/2018] [Indexed: 01/08/2023]
Abstract
INTRODUCTION To improve kidney transplant allocation equitability, a new Kidney Allocation System (KAS) was implemented December 4, 2014. The purpose of this study was to determine if the impact of KAS on peri-operative outcomes differed by recipient race/ethnicity. METHODS This was a time series analysis using data aggregated in monthly intervals from October 2012 through September 2015 using the University HealthSystem Consortium (UHC). This includes national data aggregated at the center level of all US kidney transplant centers that participate in the UHC (416 centers). Segmented regression with interaction terms was used to determine the impact of KAS on outcomes and differences by race/ethnicity. RESULTS A total of 28,809 deceased donor kidney transplants were included with 25 months of pre-KAS data and 10 months of post-KAS data. After KAS implementation, the estimated transplant rate per month decreased significantly for Caucasians by 17.6 cases per month (p = 0.0001), and increased significantly for AAs by 37.8 (p = 0.0001), Hispanics by 16.3 (p = 0.0001), and other races by 8.2 cases per month (p = 0.0001). Delayed graft function, 7- and 14-day readmissions significantly increased after KAS, which did not differ by race. Hispanics saw a 7.7% decrease in ICU admissions after KAS, which differed as compared to other racial/ethnic cohorts (p = 0.0026). Costs of kidney transplantation increased significantly after KAS in all groups except Hispanics. Mortality, length of stay, in-hospital complications, and 30-day readmissions were not significantly impacted by KAS, also not differing by race/ethnicity. CONCLUSION KAS had substantial impact on transplant rates by race/ethnicity. KAS also led to increased costs, readmissions, and delayed graft function (DGF) across all racial/ethnic groups. The impact of KAS on ICU cases solely within Hispanics requires further investigation into potential etiologies.
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Affiliation(s)
- Daisy Sanchez
- College of Medicine, MUSC, Charleston, SC, 29425, USA.
| | - Derek Dubay
- Department of Transplant Surgery, MUSC, Charleston, SC, USA
| | | | - David J Taber
- Department of Transplant Surgery, MUSC, Charleston, SC, USA.,Ralph H Johnson, VAMC, Charleston, SC, USA
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Vranian SC, Covert KL, Mardis CR, McGillicuddy JW, Chavin KD, Dubay D, Taber DJ. Assessment of risk factors for increased resource utilization in kidney transplantation. J Surg Res 2017; 222:195-202.e2. [PMID: 29100587 DOI: 10.1016/j.jss.2017.09.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 08/22/2017] [Accepted: 09/28/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND There are only a limited number of studies that have sought to identify patients at high risk for medication errors and subsequent adverse clinical outcomes. This study sought to identify risk factors for increased health care resource utilization in kidney transplant recipients based on drug-related problems and self-administered surveys. METHODS In this prospective observational study, adult kidney transplant recipients seen in the transplant clinic between September and November 2015 were surveyed for self-reported demographics, medication adherence, and health status/outlook. Subsequently, patients were assessed for associations between survey results, pharmacist-derived drug-related problems, and health resource utilization over a minimum 6-mo follow-up period. Based on univariate associations, two risk cohorts were identified and compared for health care utilization using multivariable Poisson regression. RESULTS A total of 237 patients were included, with a mean follow-up of 8 mo. From the patient survey data, Medicaid insured or self-rated poor health status were identified as a significant risk cohort. From pharmacist assessments, those who received incorrect medication or lacked appropriate follow-up medication monitoring were identified as a significant risk cohort (pharmacy errors). The Medicaid insured or self-rated poor health status cohort experienced 43% more total health care encounters (incident rate ratios [IRR] 1.43, 1.01-2.02) and 35% more transplant clinic visits (IRR 1.35, 1.03-1.77). The pharmacy errors cohort experienced 4.2 times the rate of total health care encounters (IRR 4.17, 1.55-11.2), 4.1 times the rate of hospital readmissions (IRR 4.09, 1.58-10.6), and 2.3 times the rate of transplant clinic visits (IRR 2.31, 1.04-5.11). CONCLUSIONS Medicaid insurance, self-rated poor health status, and errors in the medication regimen or monitoring were significant risk factors for increased health care utilization in kidney transplant recipients. Further research is warranted to validate these potential risk factors, determine the long-term impact on graft/patient survival, and assess the mutability of these risks through prospective identification and intervention.
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Affiliation(s)
- Steven Craig Vranian
- Division of Transplant Surgery, Medical University of South Carolina, Charleston, South Carolina.
| | - Kelly L Covert
- College of Pharmacy, Bill Gatton College of Pharmacy, Johnson City, Tennessee
| | - Caitlin R Mardis
- Transplant Service Line, Medical University of South Carolina, Charleston, South Carolina
| | - John W McGillicuddy
- Division of Transplant Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Kenneth D Chavin
- Department of Surgery, School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Derek Dubay
- Division of Transplant Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - David J Taber
- Division of Transplant Surgery, Medical University of South Carolina, Charleston, South Carolina; Department of Pharmacy Services, Ralph H. Johnson VAMC, Charleston, South Carolina
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Keene K, Dubay D, McGuire B, Desmond R, Jacob R, Dobelbower M, Eckhoff D, Posey J. Stereotactic Body Radiation Therapy Followed by Sorafenib Improves Survival Without Increasing Toxicity. Int J Radiat Oncol Biol Phys 2014. [DOI: 10.1016/j.ijrobp.2014.05.1193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Dover L, Jacob R, Wang T, Oster R, Dubay D. Impact of adjuvant therapies on survival in patients with cholangiocarcinoma. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.3_suppl.360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
360 Background: Surgical resection is the only curative option for Cholangiocarcinoma (CC) and currently there are no clear guidelines for adjuvant therapy following resection. Given the high incidence of local and distant recurrences following resection, we evaluated the impact of adjuvant chemotherapy or chemoradiation (CRT) on median survival (OS). Methods: A retrospective review was performed identifying all patients with CC who underwent curative surgical resection at our institution between 2002 and 2012. Patients who underwent aborted or palliative procedures were excluded. Survival estimates were quantified using Kaplan Meier curves, and differences between groups were compared with the log-rank test and Cox regression models. Results: During the study period, 103 patients underwent curative resection for CC at our institution. Tumor location was intrahepatic, perihilar and distal in 37% (n=38), 23% (n=24) and 40% (n=41) respectively. A total of 49 (48%) patients received adjuvant chemotherapy (n= 28) or CRT (n=21). Observation with no additional therapy was employed in the remaining 54 (52%) patients. No patient was treated using radiation alone. OS was 21.4 and 41.4 months (m) for those receiving adjuvant therapy versus observation (p=0.08). OS for adjuvant therapy versus observation were 28.4 m and 19.4 m respectively, if surgical margins were positive (p=0.036); and 79.1 m and 26.3 m respectively (p=0.4) with negative resection margins. OS was 41.4 m and 38.0 m with adjuvant chemo versus CRT respectively (p=0.1). Tumor stage was the only statistically significant pathologic indicator of outcome (p=0.019). Conclusions: A trend towards significant improvement in OS was observed with the use of adjuvant therapy among all patients following resection of CC. Adjuvant therapy significantly improved OS among CC patients with positive margins of resection. The small number of patients with negative margins of resection also benefitted, though not significantly. These data suggest that while adjuvant therapy should be considered for all patients irrespective of margin status; patients with positive margins are likely to benefit the most.
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Affiliation(s)
- Laura Dover
- University of Alabama at Birmingham, Birmingham, AL
| | - Rojymon Jacob
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL
| | - Thomas Wang
- University of Alabama at Birmingham, Birmingham, AL
| | - Robert Oster
- University of Alabama at Birmingham, Birmingham, AL
| | - Derek Dubay
- University of Alabama at Birmingham, Birmingham, AL
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Nguyen TL, Council L, Winokur T, Dubay D. Highlighting the Need for Correlation of Clinical and Pathologic Features: Discovery of an Epithelioid Hemangioendothelioma Diffusely Involving an Explant Liver. Am J Clin Pathol 2012. [DOI: 10.1093/ajcp/138.suppl2.261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Adcock L, Macleod C, Dubay D, Greig PD, Cattral MS, McGilvray I, Lilly L, Girgrah N, Renner EL, Selzner M, Selzner N, Kashfi A, Smith R, Holtzman S, Abbey S, Grant DR, Levy GA, Therapondos G. Adult living liver donors have excellent long-term medical outcomes: the University of Toronto liver transplant experience. Am J Transplant 2010; 10:364-71. [PMID: 20415904 DOI: 10.1111/j.1600-6143.2009.02950.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Right lobe living donor liver transplantation is an effective treatment for selected individuals with end-stage liver disease. Although 1 year donor morbidity and mortality have been reported, little is known about outcomes beyond 1 year. Our objective was to analyze the outcomes of the first 202 consecutive donors performed at our center with a minimum follow-up of 12 months (range 12-96 months). All physical complications were prospectively recorded and categorized according to the modified Clavien classification system. Donors were seen by a dedicated family physician at 2 weeks, 1, 3 and 12 months postoperatively and yearly thereafter. The cohort included 108 males and 94 females (mean age 37.3 +/- 11.5 years). Donor survival was 100%. A total of 39.6% of donors experienced a medical complication during the first year after surgery (21 Grade 1, 27 Grade 2, 32 Grade 3). After 1 year, three donors experienced a medical complication (1 Grade 1, 1 Grade 2, 1 Grade 3). All donors returned to predonation employment or studies although four donors (2%) experienced a psychiatric complication. This prospective study suggests that living liver donation can be performed safely without any serious late medical complications and suggests that long-term follow-up may contribute to favorable donor outcomes.
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Affiliation(s)
- L Adcock
- Liver Transplant Program, Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
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Dubay D, Gallinger S, Hawryluck L, Swallow C, McCluskey S, McGilvray I. In situ hypothermic liver preservation during radical liver resection with major vascular reconstruction. Br J Surg 2009; 96:1429-36. [PMID: 19918862 DOI: 10.1002/bjs.6740] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The in situ hypothermic liver preservation technique may allow a more aggressive approach to tumours of the caval confluence and/or all three hepatic veins, which would otherwise be deemed irresectable. METHODS All descriptive data regarding patient demographics, operative characteristics, perioperative complications and outcomes of nine patients in whom this technique was used were collected prospectively. RESULTS Seven patients underwent liver trisegmentectomy and two had primary retrohepatic venal caval resection. Total hepatic vascular occlusion with in situ hypothermic liver preservation was used for venous reconstruction in all patients. The vena cava was reconstructed with prosthetic graft in seven patients. All main hepatic veins were reconstructed in the seven liver resections. In situ hypothermic liver preservation was well tolerated as evidenced by preserved hepatic synthetic function early after operation. One patient died 66 days after surgery. There were two recurrences after a median follow-up of 14 (range 2-33) months; local recurrence was identified in one patient after 4 months and distant metastasis in another after 8 months. CONCLUSION The in situ hypothermic liver preservation technique appears to be a useful adjunct to radical hepatobiliary tumour excision procedures that require total hepatic vascular exclusion and major vascular reconstruction.
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Affiliation(s)
- D Dubay
- Liver Transplant Unit, Multiorgan Transplant Program, University of Toronto and Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
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