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Kaplan A, Aby ES, Scott S, Sonnenday C, Fox A, Mathur A, Olthoff K, Heimbach J, Ladin K, Emamaullee J. Financial toxicity in living donor liver transplantation: a call to action for financial neutrality. Am J Transplant 2024:S1600-6135(24)00337-X. [PMID: 38763318 DOI: 10.1016/j.ajt.2024.05.012] [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: 01/20/2024] [Revised: 04/22/2024] [Accepted: 05/14/2024] [Indexed: 05/21/2024]
Abstract
After two decades of limited growth, LDLT has been increasingly accepted as a promising solution to the growing organ shortage in the U.S. With experience, LDLT offers superior graft and patient survival with low rates of rejection. However, not all waitlisted patients have equal access to LDLT, with financial toxicity representing a substantial barrier. Potential living liver donors face indirect, direct, and opportunity costs associated with donation as well as insurance-based discrimination and variable employer leave policies. There are multiple potential national, local, and patient-centered solutions to address some of the cost-related issues associated with living LDLT. These include standardization of employer leave policies, creation of federal and state-led tax relief programs, optimization of National Living Donor Assistance Center use, engagement of independent living donor advocates, creation of financial toolkits, and encouragement of recipient or donor-led fundraising. In this piece, members of the North American Living Liver Donation Group, a consortium of 37 LDLT programs, explore these financial challenges and discuss solutions to achieve financial neutrality, where individuals can donate free from financial constraints or gains. As a community, it is imperative that we confront factors driving financial toxicity to improve equity and access to LDLT.
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Affiliation(s)
- Alyson Kaplan
- Department of Gastroenterology and Hepatology, Transplant Institute, Tufts University Medical Center, Boston, MA
| | - Elizabeth S Aby
- Department of Gastroenterology and Hepatology, University of Minnesota, Minneapolis, MN
| | - Sonia Scott
- Department of Gastroenterology and Hepatology, Columbia University Medical Center, New York, NY
| | | | - Alyson Fox
- Department of Gastroenterology and Hepatology, Columbia University Medical Center, New York, NY
| | - Amit Mathur
- Department of Transplant Surgery, Mayo Clinic, Phoenix, AZ
| | - Kim Olthoff
- Department of Transplant Surgery, University of Pennsylvania, Philadelphia, PA
| | - Julie Heimbach
- Department of Transplant Surgery, Mayo Clinic, Rochester, MN
| | - Keren Ladin
- Department of Gastroenterology and Hepatology, Transplant Institute, Tufts University Medical Center, Boston, MA
| | - Juliet Emamaullee
- Department of Transplant Surgery, University of Southern California, Los Angeles, CA.
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De Goeij FHC, De Meijer V, Mergental H, Guarrera JV, Asthana S, Ghinolfi D, Boteon YL, Selzner N, Kalisvaart M, Pulitano C, Sonnenday C, Martins PN, Berlakovich G, Schlegel A. Challenges With the Implementation of Machine Perfusion in Clinical Liver Transplantation. Transplantation 2023:00007890-990000000-00614. [PMID: 38057969 DOI: 10.1097/tp.0000000000004872] [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: 12/08/2023]
Abstract
Dynamic organ preservation is a relatively old technique which has regained significant interest in the last decade. Machine perfusion (MP) techniques are applied in various fields of solid organ transplantation today. The first clinical series of ex situ MP in liver transplantation was presented in 2010. Since then, the number of research and clinical applications has substantially increased. Despite the notable beneficial effect on organ quality and recipient outcome, MP is still not routinely used in liver transplantation. Based on the enormous need to better preserve organs and the subsequent demand to continuously innovate and develop perfusion equipment further, this technology is also beneficial to test and deliver future therapeutic strategies to livers before implantation. This article summarizes the various challenges observed during the current shift from static to dynamic liver preservation in the clinical setting. The different organ perfusion strategies are discussed first, together with ongoing clinical trials and future study design. The current status of research and the impact of costs and regulations is highlighted next. Factors contributing to costs and other required resources for a worldwide successful implementation and reimbursement are presented third. The impact of research on cost-utility and effectivity to guide the tailored decision-making regarding the optimal perfusion strategy is discussed next. Finally, this article provides potential solutions to the challenging field of innovation in healthcare considering the various social and economic factors and the role of clinical, regulatory, and financial stakeholders worldwide.
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Affiliation(s)
- Femke H C De Goeij
- Department of Surgery, Division of Hepatopancreatobiliary and Transplant Surgery, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Vincent De Meijer
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Department of Surgery, Surgical Research Laboratory, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Hynek Mergental
- The Liver Unit, Queen Elizabeth University Hospital, Birmingham, United Kingdom
- The Liver Unit, Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - James V Guarrera
- Division of Abdominal Transplant Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ
| | | | - Davide Ghinolfi
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Yuri L Boteon
- Instituto Israelita de Ensino e Pesquisa Albert Einstein, Faculdade Israelita de Ciências da Saúde Albert Einstein, São Paulo, Brazil
| | - Nazia Selzner
- Ajmera Transplant Center, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Marit Kalisvaart
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Zurich, Switzerland
| | - Carlo Pulitano
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital and Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | | | - Paulo N Martins
- Division of Organ Transplantation, Department of Surgery, University of Massachusetts Memorial Hospital, University of Massachusetts, Worcester, MA
| | - Gabriela Berlakovich
- Division of Transplantation, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Andrea Schlegel
- Transplantation Center, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
- Department of Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
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Chapman WC, Barbas AS, D'Alessandro AM, Vianna R, Kubal CA, Abt P, Sonnenday C, Barth R, Alvarez-Casas J, Yersiz H, Eckhoff D, Cannon R, Genyk Y, Sher L, Singer A, Feng S, Roll G, Cohen A, Doyle MB, Sudan DL, Al-Adra D, Khan A, Subramanian V, Abraham N, Olthoff K, Tekin A, Berg L, Coussios C, Morris C, Randle L, Friend P, Knechtle SJ. Normothermic Machine Perfusion of Donor Livers for Transplantation in the United States: A Randomized Controlled Trial. Ann Surg 2023; 278:e912-e921. [PMID: 37389552 DOI: 10.1097/sla.0000000000005934] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
OBJECTIVE To compare conventional low-temperature storage of transplant donor livers [static cold storage (SCS)] with storage of the organs at physiological body temperature [normothermic machine perfusion (NMP)]. BACKGROUND The high success rate of liver transplantation is constrained by the shortage of transplantable organs (eg, waiting list mortality >20% in many centers). NMP maintains the liver in a functioning state to improve preservation quality and enable testing of the organ before transplantation. This is of greatest potential value with organs from brain-dead donor organs (DBD) with risk factors (age and comorbidities), and those from donors declared dead by cardiovascular criteria (donation after circulatory death). METHODS Three hundred eighty-three donor organs were randomized by 15 US liver transplant centers to undergo NMP (n = 192) or SCS (n = 191). Two hundred sixty-six donor livers proceeded to transplantation (NMP: n = 136; SCS: n = 130). The primary endpoint of the study was "early allograft dysfunction" (EAD), a marker of early posttransplant liver injury and function. RESULTS The difference in the incidence of EAD did not achieve significance, with 20.6% (NMP) versus 23.7% (SCS). Using exploratory, "as-treated" rather than "intent-to-treat," subgroup analyses, there was a greater effect size in donation after circulatory death donor livers (22.8% NMP vs 44.6% SCS) and in organs in the highest risk quartile by donor risk (19.2% NMP vs 33.3% SCS). The incidence of acute cardiovascular decompensation at organ reperfusion, "postreperfusion syndrome," as a secondary outcome was reduced in the NMP arm (5.9% vs 14.6%). CONCLUSIONS NMP did not lower EAD, perhaps related to the inclusion of lower-risk liver donors, as higher-risk donor livers seemed to benefit more. The technology is safe in standard organ recovery and seems to have the greatest benefit for marginal donors.
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Affiliation(s)
- William C Chapman
- Department of Surgery, School of Medicine, Washington University, St. Louis
| | | | | | - Rodrigo Vianna
- Department of Surgery, University of Miami School of Medicine
| | | | - Peter Abt
- Department of Surgery, University of Pennsylvania School of Medicine
| | | | - Rolf Barth
- Department of Surgery, University of Chicago School of Medicine
| | | | - Hasan Yersiz
- Department of Surgery, David Geffen School of Medicine at UCLA
| | - Devin Eckhoff
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School
| | - Robert Cannon
- Department of Surgery, University of Alabama School of Medicine
| | - Yuri Genyk
- Department of Surgery, Keck School of Medicine of USC
| | - Linda Sher
- Department of Surgery, Keck School of Medicine of USC
| | | | - Sandy Feng
- Department of Surgery, UCSF School of Medicine
| | | | - Ari Cohen
- Department of Surgery, Ochsner Clinic
| | - Maria B Doyle
- Department of Surgery, School of Medicine, Washington University, St. Louis
| | - Debra L Sudan
- Department of Surgery, Duke University School of Medicine
| | - David Al-Adra
- Department of Surgery, School of Medicine, University of Wisconsin, Madison
| | - Adeel Khan
- Department of Surgery, School of Medicine, Washington University, St. Louis
| | | | - Nader Abraham
- Department of Surgery, Duke University School of Medicine
| | - Kim Olthoff
- Department of Surgery, University of Pennsylvania School of Medicine
| | - Akin Tekin
- Department of Surgery, University of Miami School of Medicine
| | - Lynn Berg
- Department of Surgery, School of Medicine, University of Wisconsin, Madison
| | | | - Chris Morris
- Department of Surgery, Ochsner Medical Center, New Orleans, LA
| | - Lucy Randle
- Department of Surgery, Ochsner Medical Center, New Orleans, LA
| | - Peter Friend
- Department of Surgery, Ochsner Medical Center, New Orleans, LA
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Palmon I, Brown CS, Highet A, Kulick AA, Barrett ME, Cassidy DE, Herman AE, Gomez-Rexrode AE, O'Reggio R, Sonnenday C, Waits SA, Wakam GK. Microlearning and Social Media: A Novel Approach to Video-Based Learning and Surgical Education. J Grad Med Educ 2021; 13:323-326. [PMID: 34178254 PMCID: PMC8207915 DOI: 10.4300/jgme-d-20-01562.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Itai Palmon
- Itai Palmon, BS, is a Medical Student, Transplant Research, Education and Engagement, Section of Transplant Surgery, Department of Surgery, Michigan Medicine, University of Michigan Medical School
| | - Craig S. Brown
- Craig S. Brown, MD, MSc, is a Resident, Transplant Research, Education and Engagement, Section of Transplant Surgery, Department of Surgery, Michigan Medicine, and Fellow, Center for Health Outcomes and Policy, Michigan Medicine
| | - Alexandra Highet
- Alexandra Highet, MS, is a Medical Student, Transplant Research, Education, and Engagement, Section of Transplant Surgery, Department of Surgery, Michigan Medicine, University of Michigan Medical School, and Fellow, Center for Health Outcomes and Policy, Michigan Medicine
| | - Alexandra A. Kulick
- Alexandra A. Kulick, is a Student, Transplant Research, Education and Engagement, Section of Transplant Surgery, Department of Surgery, Michigan Medicine
| | - Meredith E. Barrett
- Meredith E. Barrett, MD, is a Clinical Lecturer in Transplant Surgery, Transplant Research, Education, and Engagement, Section of Transplant Surgery, Department of Surgery, Michigan Medicine
| | - Devon E. Cassidy
- Devon E. Cassidy, BS, is a Medical Student, Transplant Research, Education, and Engagement, Section of Transplant Surgery, Department of Surgery, Michigan Medicine, University of Michigan Medical School
| | - Alexandra E. Herman
- Alexandra E. Herman, BS, is a Medical Student, Transplant Research, Education, and Engagement, Section of Transplant Surgery, Department of Surgery, Michigan Medicine, University of Michigan Medical School
| | - Amalia E. Gomez-Rexrode
- Amalia E. Gomez-Rexrode, BS, is a Medical Student, Transplant Research, Education, and Engagement, Section of Transplant Surgery, Department of Surgery, Michigan Medicine, University of Michigan Medical School
| | - Rachel O'Reggio
- Rachel O'Reggio, MPH, is a Medical Student, Transplant Research, Education, and Engagement, Section of Transplant Surgery, Department of Surgery, Michigan Medicine, University of Michigan Medical School
| | - Christopher Sonnenday
- Christopher Sonnenday, MD, MHS, is Professor of Surgery, Transplant Research, Education, and Engagement, Section of Transplant Surgery, Department of Surgery, Michigan Medicine
| | - Seth A. Waits
- Seth A. Waits, MD, is Assistant Professor of Surgery and Abdominal Transplant Fellowship Director, Transplant Research, Education, and Engagement, Section of Transplant Surgery, Department of Surgery, Michigan Medicine, and Faculty, Center for Health Outcomes and Policy, Michigan Medicine
| | - Glenn K. Wakam
- Glenn K. Wakam, MD, is a Resident, Transplant Research, Education, and Engagement, Section of Transplant Surgery, Department of Surgery, Michigan Medicine
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Carey EJ, Lai JC, Sonnenday C, Tapper EB, Tandon P, Duarte-Rojo A, Dunn MA, Tsien C, Kallwitz ER, Ng V, Dasarathy S, Kappus M, Bashir MR, Montano-Loza AJ. A North American Expert Opinion Statement on Sarcopenia in Liver Transplantation. Hepatology 2019; 70:1816-1829. [PMID: 31220351 PMCID: PMC6819202 DOI: 10.1002/hep.30828] [Citation(s) in RCA: 102] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 06/06/2019] [Indexed: 12/13/2022]
Abstract
Loss of muscle mass and function, or sarcopenia, is a common feature of cirrhosis and contributes significantly to morbidity and mortality in this population. Sarcopenia is a main indicator of adverse outcomes in this population, including poor quality of life, hepatic decompensation, mortality in patients with cirrhosis evaluated for liver transplantation (LT), longer hospital and intensive care unit stay, higher incidence of infection following LT, and higher overall health care cost. Although it is clear that muscle mass is an important predictor of LT outcomes, many questions remain, including the best modality for assessing muscle mass, the optimal cut-off values for sarcopenia, the ideal timing and frequency of muscle mass assessment, and how to best incorporate the concept of sarcopenia into clinical decision making. For these reasons, we assembled a group of experts to form the North American Working Group on Sarcopenia in Liver Transplantation to use evidence from the medical literature to address these outstanding questions regarding sarcopenia in LT. We believe sarcopenia assessment should be considered in all patients with cirrhosis evaluated for liver transplantation. Skeletal muscle index (SMI) assessed by computed tomography constitutes the best-studied technique for assessing sarcopenia in patients with cirrhosis. Cut-off values for sarcopenia, defined as SMI < 50 cm2 /m2 in male and < 39 cm2 /m2 in female patients, constitute the validated definition for sarcopenia in patients with cirrhosis. Conclusion: The management of sarcopenia requires a multipronged approach including nutrition, exercise, and additional pharmacological therapy as deemed necessary. Future studies should evaluate whether recovery of sarcopenia with nutritional management in combination with an exercise program is sustainable as well as how improvement in muscle mass might be associated with improvement in clinical outcomes.
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Affiliation(s)
- Elizabeth J. Carey
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ, USA
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, University of California-San Francisco, San Francisco, CA, USA
| | | | - Elliot B. Tapper
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - Puneeta Tandon
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Andres Duarte-Rojo
- Center for Liver Diseases, Thomas E. Starzl Transplantation Institute, and Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael A. Dunn
- Center for Liver Diseases, Thomas E. Starzl Transplantation Institute, and Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Cynthia Tsien
- Gastroenterology Department, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Vicky Ng
- Transplant and Regenerative Medicine Centre, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Matthew Kappus
- Division of Gastroenterology, Duke University School of Medicine, Durham, NC, USA
| | - Mustafa R. Bashir
- Division of Abdominal Imaging, Duke University Medical Center Durham, NC, USA
| | - Aldo J. Montano-Loza
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, Alberta, Canada
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Kobashigawa J, Dadhania D, Bhorade S, Adey D, Berger J, Bhat G, Budev M, Duarte-Rojo A, Dunn M, Hall S, Harhay MN, Johansen KL, Joseph S, Kennedy CC, Kransdorf E, Lentine KL, Lynch RJ, McAdams-DeMarco M, Nagai S, Olymbios M, Patel J, Pinney S, Schaenman J, Segev DL, Shah P, Singer LG, Singer JP, Sonnenday C, Tandon P, Tapper E, Tullius SG, Wilson M, Zamora M, Lai JC. Report from the American Society of Transplantation on frailty in solid organ transplantation. Am J Transplant 2019; 19:984-994. [PMID: 30506632 PMCID: PMC6433498 DOI: 10.1111/ajt.15198] [Citation(s) in RCA: 147] [Impact Index Per Article: 29.4] [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: 09/20/2018] [Revised: 11/06/2018] [Accepted: 11/24/2018] [Indexed: 02/06/2023]
Abstract
A consensus conference on frailty in kidney, liver, heart, and lung transplantation sponsored by the American Society of Transplantation (AST) and endorsed by the American Society of Nephrology (ASN), the American Society of Transplant Surgeons (ASTS), and the Canadian Society of Transplantation (CST) took place on February 11, 2018 in Phoenix, Arizona. Input from the transplant community through scheduled conference calls enabled wide discussion of current concepts in frailty, exploration of best practices for frailty risk assessment of transplant candidates and for management after transplant, and development of ideas for future research. A current understanding of frailty was compiled by each of the solid organ groups and is presented in this paper. Frailty is a common entity in patients with end-stage organ disease who are awaiting organ transplantation, and affects mortality on the waitlist and in the posttransplant period. The optimal methods by which frailty should be measured in each organ group are yet to be determined, but studies are underway. Interventions to reverse frailty vary among organ groups and appear promising. This conference achieved its intent to highlight the importance of frailty in organ transplantation and to plant the seeds for further discussion and research in this field.
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Affiliation(s)
| | | | | | - Deborah Adey
- University of California at San Francisco, San Francisco, CA, USA
| | - Joseph Berger
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Geetha Bhat
- Advocate Christ Medical Center, Oak Lawn, IL, USA
| | | | | | | | | | | | | | | | | | - Evan Kransdorf
- Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, USA
| | | | | | | | | | | | - Jignesh Patel
- Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, USA
| | | | | | | | - Palak Shah
- Inova Heart and Vascular Institute, Falls Church, VA, USA
| | | | | | | | | | | | - Stefan G. Tullius
- Division of Transplant Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | - Jennifer C. Lai
- University of California at San Francisco, San Francisco, CA, USA
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Kamarajah SK, Frankel TL, Sonnenday C, Cho CS, Nathan H. Critical evaluation of the American Joint Commission on Cancer (AJCC) 8th edition staging system for patients with Hepatocellular Carcinoma (HCC): A Surveillance, Epidemiology, End Results (SEER) analysis. J Surg Oncol 2017; 117:644-650. [PMID: 29127719 DOI: 10.1002/jso.24908] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [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: 09/01/2017] [Accepted: 10/20/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Recently, the American Joint Committee on Cancer (AJCC) released its 8th edition changes to the staging system for hepatocellular cancer (HCC). We sought to validate the 8th edition staging system and compare the performance to the 7th edition using a population-based data set. METHODS Using the Surveillance, Epidemiology and End Results (SEER) database (1998-2013), patients undergoing resection or transplant for non-metastatic HCC were identified. Overall survival was estimated using the Kaplan-Meier method and compared using log-rank tests. Concordance indices (c-indices) were calculated from Cox proportional hazards models to evaluate discriminatory power. RESULTS The study included 8918 patients resected (63%) or transplanted (37%) for HCC. Nodal staging was performed in 19%, of whom 5% had positive nodes. The c-index for the AJCC 8th edition staging system was 0.60, similar to that for the 7th edition (0.59). Survival was better for solitary tumors >2 cm with vascular invasion than for multifocal tumors <5 cm (median not reached vs 57 months, P < 0.0001), although the staging system groups these tumors together as T2. For multifocal tumors ≤5 cm, those with vascular invasion had worse survival than those without (median 42 vs 50 months, P < 0.001), although the staging system draws no such distinction. CONCLUSION The AJCC 8th edition staging system for HCC performs similarly to the 7th edition. Future revisions should consider substratification of early HCC, specifically by distinguishing solitary tumors >2 cm from multifocal tumors ≤5 cm, and by considering the prognostic impact of vascular invasion in multifocal tumors ≤5 cm. Future studies should aim to validate these findings.
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Affiliation(s)
- Sivesh K Kamarajah
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | | | | | - Clifford S Cho
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Hari Nathan
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
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Hsu EK, Shaffer ML, Gao L, Sonnenday C, Volk ML, Bucuvalas J, Lai JC. Analysis of Liver Offers to Pediatric Candidates on the Transplant Wait List. Gastroenterology 2017; 153:988-995. [PMID: 28711630 PMCID: PMC6288076 DOI: 10.1053/j.gastro.2017.06.053] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 06/13/2017] [Accepted: 06/26/2017] [Indexed: 12/02/2022]
Abstract
BACKGROUND & AIMS Approximately 10% of children on the liver transplant wait-list in the United States die every year. We examined deceased donor liver offer acceptance patterns and their contribution to pediatric wait-list mortality. METHODS We performed a retrospective cohort study of children on the US liver transplant wait-list from 2007 through 2014 using national transplant registry databases. We determined the frequency, patterns of acceptance, and donor and recipient characteristics associated with deceased donor liver organ offers for children who died or were delisted compared with those who underwent transplantation. Children who died or were delisted were classified by the number of donor liver offers (0 vs 1 or more), limiting analyses to offers of livers that were ultimately transplanted into pediatric recipients. The primary outcome was death or delisting on the wait-list. RESULTS Among 3852 pediatric liver transplant candidates, children who died or were delisted received a median 1 pediatric liver offer (inter-quartile range, 0-2) and waited a median 33 days before removal from the wait-list. Of 11,328 donor livers offered to children, 2533 (12%) were transplanted into children; 1179 of these (47%) were immediately accepted and 1354 (53%) were initially refused and eventually accepted for another child. Of 27,831 adults, 1667 (6.0%; median, 55 years) received livers from donors younger than 18 years (median, 15 years), most (97%) allocated locally or regionally. Of children who died or were delisted, 173 (55%) received an offer of 1 or more liver that was subsequently transplanted into another pediatric recipient, and 143 (45%) died or were delisted with no offers. CONCLUSIONS Among pediatric liver transplant candidates in the US, children who died or were delisted received a median 1 pediatric liver offer and waited a median of 33 days. Of livers transplanted into children, 47% were immediately accepted and 53% were initially refused and eventually accepted for another child. Of children who died or were delisted, 55% received an offer of 1 or more liver that was subsequently transplanted into another pediatric recipient, and 45% died or were delisted with no offers. Pediatric prioritization in the allocation and development of improved risk stratification systems is required to reduce wait-list mortality among children.
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Affiliation(s)
- Evelyn K. Hsu
- University of Washington School of Medicine, Seattle, Washington
| | - Michele L. Shaffer
- University of Washington School of Medicine, Seattle, Washington;,Seattle Children’s Core for Biomedical Statistics, Seattle, Washington
| | - Lucy Gao
- Department of Biostatistics, University of Washington, Seattle, Washington
| | | | | | - John Bucuvalas
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, California
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Volk ML, Sonnenday C. Patient-centered liver transplantation. Clin Liver Dis (Hoboken) 2016; 8:24-27. [PMID: 31041058 PMCID: PMC6490190 DOI: 10.1002/cld.564] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 05/09/2016] [Accepted: 05/15/2016] [Indexed: 02/04/2023] Open
Affiliation(s)
- Michael L. Volk
- Liver Transplantation Program, Gastroenterology and Hepatology, and School of MedicineLoma Linda University HealthLoma LindaCA
| | - Christopher Sonnenday
- Liver Transplantation Program, Department of SurgeryUniversity of Michigan Health SystemAnn ArborMI
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10
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Volk ML, Goodrich N, Lai JC, Sonnenday C, Shedden K. Decision support for organ offers in liver transplantation. Liver Transpl 2015; 21:784-91. [PMID: 25779757 PMCID: PMC4744650 DOI: 10.1002/lt.24113] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 02/25/2015] [Accepted: 02/28/2015] [Indexed: 12/22/2022]
Abstract
Organ offers in liver transplantation are high-risk medical decisions with a low certainty of whether a better liver offer will come along before death. We hypothesized that decision support could improve the decision to accept or decline. With data from the Scientific Registry of Transplant Recipients, survival models were constructed for 42,857 waiting-list patients and 28,653 posttransplant patients from 2002 to 2008. Daily covariate-adjusted survival probabilities from these 2 models were combined into a 5-year area under the curve to create an individualized prediction of whether an organ offer should be accepted for a given patient. Among 650,832 organ offers from 2008 to 2013, patient survival was compared by whether the clinical decision was concordant or discordant with model predictions. The acceptance benefit (AB)--the predicted gain or loss of life by accepting a given organ versus waiting for the next organ--ranged from 3 to -22 years (harm) and varied geographically; for example, the average benefit of accepting a donation after cardiac death organ ranged from 0.47 to -0.71 years by donation service area. Among organ offers, even when AB was >1 year, the offer was only accepted 10% of the time. Patient survival from the time of the organ offer was better if the model recommendations and the clinical decision were concordant: for offers with AB > 0, the 3-year survival was 80% if the offer was accepted and 66% if it was declined (P < 0.001). In conclusion, augmenting clinical judgment with decision support may improve patient survival in liver transplantation.
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Affiliation(s)
- Michael L. Volk
- Division of Gastroenterology and Transplantation Institute, Loma Linda University, Loma Linda, CA
| | | | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, CA
| | | | - Kerby Shedden
- Center for Statistical Consultation and Research, University of Michigan, Ann Arbor, MI
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Mathur S, Janaudis-Ferreira T, Wickerson L, Singer LG, Patcai J, Rozenberg D, Blydt-Hansen T, Hartmann EL, Haykowsky M, Helm D, High K, Howes N, Kamath BM, Lands L, Marzolini S, Sonnenday C. Meeting report: consensus recommendations for a research agenda in exercise in solid organ transplantation. Am J Transplant 2014; 14:2235-45. [PMID: 25135579 DOI: 10.1111/ajt.12874] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [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: 12/03/2013] [Revised: 05/16/2014] [Accepted: 05/31/2014] [Indexed: 01/25/2023]
Abstract
With improved survival rates in solid organ transplantation there has been an increased focus on long-term outcomes following transplant, including physical function, health-related quality-of-life and cardiovascular mortality. Exercise training has the potential to affect these outcomes, however, research on the optimal timing, type, dose of exercise, mode of delivery and relevant outcomes is limited. This article provides a summary of a 2-day meeting held in April 2013 (Toronto, Canada) in which a multi-disciplinary group of clinicians, researchers, administrators and patient representatives engaged in knowledge exchange and discussion of key issues in exercise in solid organ transplant (SOT). The outcomes from the meeting were the development of top research priorities and a research agenda for exercise in SOT, which included the need for larger scale, multi-center intervention studies, development of standardized outcomes for physical function and surrogate measures for clinical trials, examining novel modes of exercise delivery and novel outcomes from exercise training studies such as immunity, infection, cognition and economic outcomes. The development and dissemination of "expert consensus guidelines," synthesizing both the best available evidence and expert opinion was prioritized as a key step toward improving program delivery.
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Affiliation(s)
- S Mathur
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
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12
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Caram MV, Bellile EL, Englesbe M, Terjimanian M, Sonnenday C, Griggs JJ, Couriel DR. The Impact of Sarcopenia on Transplant-Related Outcomes in Patients with Non-Hodgkin's and Hodgkin's Lymphoma. Biol Blood Marrow Transplant 2013. [DOI: 10.1016/j.bbmt.2012.11.295] [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: 10/27/2022]
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13
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Ben-Josef E, Schipper M, Francis IR, Hadley S, Ten-Haken R, Lawrence T, Normolle D, Simeone DM, Sonnenday C, Abrams R, Leslie W, Khan G, Zalupski MM. A phase I/II trial of intensity modulated radiation (IMRT) dose escalation with concurrent fixed-dose rate gemcitabine (FDR-G) in patients with unresectable pancreatic cancer. Int J Radiat Oncol Biol Phys 2012; 84:1166-71. [PMID: 22543215 DOI: 10.1016/j.ijrobp.2012.02.051] [Citation(s) in RCA: 133] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Revised: 02/20/2012] [Accepted: 02/21/2012] [Indexed: 01/09/2023]
Abstract
PURPOSE Local failure in unresectable pancreatic cancer may contribute to death. We hypothesized that intensification of local therapy would improve local control and survival. The objectives were to determine the maximum tolerated radiation dose delivered by intensity modulated radiation with fixed-dose rate gemcitabine (FDR-G), freedom from local progression (FFLP), and overall survival (OS). METHODS AND MATERIALS Eligibility included pathologic confirmation of adenocarcinoma, radiographically unresectable, performance status of 0-2, absolute neutrophil count of ≥ 1,500/mm(3), platelets ≥ 100,000/mm(3), creatinine <2 mg/dL, bilirubin <3 mg/dL, and alanine aminotransferase/aspartate aminotransferase ≤ 2.5 × upper limit of normal. FDR-G (1000 mg/m(2)/100 min intravenously) was given on days -22 and -15, 1, 8, 22, and 29. Intensity modulated radiation started on day 1. Dose levels were escalated from 50-60 Gy in 25 fractions. Dose-limiting toxicity was defined as gastrointestinal toxicity grade (G) ≥ 3, neutropenic fever, or deterioration in performance status to ≥ 3 between day 1 and 126. Dose level was assigned using TITE-CRM (Time-to-Event Continual Reassessment Method) with the target dose-limiting toxicity (DLT) rate set to 0.25. RESULTS Fifty patients were accrued. DLTs were observed in 11 patients: G3/4 anorexia, nausea, vomiting, and/or dehydration (7); duodenal bleed (3); duodenal perforation (1). The recommended dose is 55 Gy, producing a probability of DLT of 0.24. The 2-year FFLP is 59% (95% confidence interval [CI]: 32-79). Median and 2-year overall survival are 14.8 months (95% CI: 12.6-22.2) and 30% (95% CI 17-45). Twelve patients underwent resection (10 R0, 2 R1) and survived a median of 32 months. CONCLUSIONS High-dose radiation therapy with concurrent FDR-G can be delivered safely. The encouraging efficacy data suggest that outcome may be improved in unresectable patients through intensification of local therapy.
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Affiliation(s)
- Edgar Ben-Josef
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, USA.
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14
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Ben-Josef E, Schipper M, Francis I, Khan G, Hadley S, Lawrence T, Simeone D, Abrams R, Sonnenday C, Zalupski M. Phase I/II Radiation Dose-Escalation Trial of Intensity Modulated Radiotherapy (IMRT) with Concurrent Fixed Dose-Rate Gemcitabine (FDR-G) for Unresectable Pancreatic Cancer. Int J Radiat Oncol Biol Phys 2011. [DOI: 10.1016/j.ijrobp.2011.06.263] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Hendren S, Birkmeyer JD, Yin H, Banerjee M, Sonnenday C, Morris AM. Surgical complications are associated with omission of chemotherapy for stage III colorectal cancer. Dis Colon Rectum 2010; 53:1587-93. [PMID: 21178851 DOI: 10.1007/dcr.0b013e3181f2f202] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Appropriate use of adjuvant chemotherapy is a widely recognized quality measure of colorectal cancer care. The objective of this study was to test the hypothesis that surgical complications are associated with omission of chemotherapy for colorectal cancer. METHODS We used the 1998 to 2005 Surveillance, Epidemiology and End Results-Medicare database to study adjuvant chemotherapy use among patients with stage III colorectal cancer who underwent surgical resection. Chemotherapy use was compared between patients with and without complications. Univariate analyses and multiple logistic regression were used to test the association between complications and chemotherapy omission, while adjusting for demographics, comorbidity, and other factors. Associations between complications and time to chemotherapy were also studied. RESULTS We identified 17,108 eligible patients with stage III colorectal cancer (median age, 75 y; 24% rectal/rectosigmoid). Using a parsimonious list of complication codes, 18% of patients had ≥ 1 complication. Thirteen percent of patients had medical complications and 3.8% of patients had complications requiring reoperation or another procedure. Adjuvant chemotherapy was omitted among 46% of patients with complications, compared with 31% of patients with no complications (P < .0001). Having a complication was independently associated with omission of chemotherapy in multivariable analysis (adjusted OR, 1.76; 95% CI 1.59-1.95). Other factors significantly associated with chemotherapy omission were age, race, marital status, urgent/emergent admission, and type of operation. Risk ratios increase with multiple complications (P < .0001). Complications were also associated with an increased risk of chemotherapy delay (P < .0001). CONCLUSIONS Surgical complications are independently associated with omission of chemotherapy for stage III colorectal cancer and with a delay in adjuvant chemotherapy. These data suggest that complications of colorectal surgery may affect both short- and long-term cancer outcomes. Thus, the implementation of quality improvement measures that effectively reduce perioperative complications may also provide a long-term cancer survival benefit.
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Affiliation(s)
- Samantha Hendren
- Department of Surgery, University of Michigan, Ann Arbor, Michigan 48109, USA.
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Simpkins CE, Warren D, Sun Z, Allen G, Sonnenday C, Cooke S, Chivukula R, Baldwin W, Wasowska B, Montgomery R. Characterization of two small animal models for the evaluation of antibody-mediated rejection therapies in transplantation. J Am Coll Surg 2006. [DOI: 10.1016/j.jamcollsurg.2006.05.239] [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: 11/30/2022]
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17
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Sonnenday C, Warren D, Montgomery R. The Use of Anti-CD20 in ABO-Incompatible Renal Transplantation. Am J Transplant 2005. [DOI: 10.1111/j.1600-6143.2005.01147.x] [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: 11/30/2022]
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