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Rodrigues-Filho EM, Franke CA, Junges JR. [Liver transplants and organ allocation in Brazil: from Rawls to utilitarianism]. CAD SAUDE PUBLICA 2018; 34:e00155817. [PMID: 30427414 DOI: 10.1590/0102-311x00155817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 08/03/2018] [Indexed: 11/22/2022] Open
Abstract
The process of liver donations and transplants in Brazil reveals major inequalities between regions and states of the country, ranging from uptake of the organs to their transplantation. In 2006, the MELD score (Model for End-stage Liver Disease), inspired by the U.S. model and based on the principle of need, was introduced in Brazil for liver transplant allocation. However, Brazil's inequalities have partially undermined the initiative's success. Other countries have already benefited from growing discussion on the benefits of models that seek to harmonize utilitarianism and need. The current article reviews the relevant literature with a special focus on the Brazilian reality.
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Schlegel A, Linecker M, Kron P, Györi G, De Oliveira ML, Müllhaupt B, Clavien PA, Dutkowski P. Risk Assessment in High- and Low-MELD Liver Transplantation. Am J Transplant 2017; 17:1050-1063. [PMID: 27676319 DOI: 10.1111/ajt.14065] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 08/23/2016] [Accepted: 09/21/2016] [Indexed: 01/25/2023]
Abstract
Allocation of liver grafts triggers emotional debates, as those patients, not receiving an organ, are prone to death. We analyzed a high-Model of End-stage Liver Disease (MELD) cohort (laboratory MELD score ≥30, n = 100, median laboratory MELD score of 35; interquartile range 31-37) of liver transplant recipients at our center during the past 10 years and compared results with a low-MELD group, matched by propensity scoring for donor age, recipient age, and cold ischemia time. End points of our study were cumulative posttransplantation morbidity, cost, and survival. Six different prediction models, including donor age x recipient MELD (D-MELD), Difference between listing MELD and MELD at transplant (Delta MELD), donor-risk index (DRI), Survival Outcomes Following Liver Transplant (SOFT), balance-of-risk (BAR), and University of California Los Angeles-Futility Risk Score (UCLA-FRS), were applied in both cohorts to identify risk for poor outcome and high cost. All score models were compared with a clinical-oriented decision, based on the combination of hemofiltration plus ventilation. Median intensive care unit and hospital stays were 8 and 26 days, respectively, after liver transplantation of high-MELD patients, with a significantly increased morbidity compared with low-MELD patients (median comprehensive complication index 56 vs. 36 points [maximum points 100] and double cost [median US$179 631 vs. US$80 229]). Five-year survival, however, was only 8% less than that of low-MELD patients (70% vs. 78%). Most prediction scores showed disappointing low positive predictive values for posttransplantation mortality, such as mortality above thresholds, despite good specificity. The clinical observation of hemofiltration plus ventilation in high-MELD patients was even superior in this respect compared with D-MELD, DRI, Delta MELD, and UCLA-FRS but inferior to SOFT and BAR models. Of all models tested, only the BAR score was linearly associated with complications. In conclusion, the BAR score was most useful for risk classification in liver transplantation, based on expected posttransplantation mortality and morbidity. Difficult decisions to accept liver grafts in high-risk recipients may thus be guided by additional BAR score calculation, to increase the safe use of scarce organs.
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Affiliation(s)
- A Schlegel
- Department of Surgery and Transplantation, Swiss HPB and Transplant Center, University Hospital Zürich, Zürich, Switzerland
| | - M Linecker
- Department of Surgery and Transplantation, Swiss HPB and Transplant Center, University Hospital Zürich, Zürich, Switzerland
| | - P Kron
- Department of Surgery and Transplantation, Swiss HPB and Transplant Center, University Hospital Zürich, Zürich, Switzerland
| | - G Györi
- Department of Surgery and Transplantation, Swiss HPB and Transplant Center, University Hospital Zürich, Zürich, Switzerland
| | - M L De Oliveira
- Department of Surgery and Transplantation, Swiss HPB and Transplant Center, University Hospital Zürich, Zürich, Switzerland
| | - B Müllhaupt
- Department of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland
| | - P-A Clavien
- Department of Surgery and Transplantation, Swiss HPB and Transplant Center, University Hospital Zürich, Zürich, Switzerland
| | - P Dutkowski
- Department of Surgery and Transplantation, Swiss HPB and Transplant Center, University Hospital Zürich, Zürich, Switzerland
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Dabbous H, Sakr M, Abdelhakam S, Montasser I, Bahaa M, Said H, El-Meteini M. Living donor liver transplantation for high model for end-stage liver disease score: What have we learned? World J Hepatol 2016; 8:942-948. [PMID: 27574548 PMCID: PMC4976213 DOI: 10.4254/wjh.v8.i22.942] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 05/02/2016] [Accepted: 07/13/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess the impact of model for end-stage liver disease (MELD) score on patient survival and morbidity post living donor liver transplantation (LDLT).
METHODS: A retrospective study was performed on 80 adult patients who had LDLT from 2011-2013. Nine patients were excluded and 71 patients were divided into two groups; Group 1 included 38 patients with a MELD score < 20, and Group 2 included 33 patients with a MELD score > 20. Comparison between both groups was done regarding operative time, intra-operative blood requirement, intensive care unit (ICU) and hospital stay, infection, and patient survival.
RESULTS: Eleven patients died (15.5%); 3/38 (7.9%) patients in Group 1 and 8/33 (24.2%) in Group 2 with significant difference (P = 0.02). Mean operative time, duration of hospital stay, and ICU stay were similar in both groups. Mean volume of blood transfusion and cell saver re-transfusion were 8 ± 4 units and 1668 ± 202 mL, respectively, in Group 1 in comparison to 10 ± 6 units and 1910 ± 679 mL, respectively, in Group 2 with no significant difference (P = 0.09 and 0.167, respectively). The rates of infection and systemic complications (renal, respiratory, cardiovascular and neurological complications) were similar in both groups.
CONCLUSION: A MELD score > 20 may predict mortality after LDLT.
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Friedrich K, Smit M, Wannhoff A, Rupp C, Scholl SG, Antoni C, Dollinger M, Neumann-Haefelin C, Stremmel W, Weiss KH, Schemmer P, Gotthardt DN. Coffee consumption protects against progression in liver cirrhosis and increases long-term survival after liver transplantation. J Gastroenterol Hepatol 2016; 31:1470-5. [PMID: 26880589 DOI: 10.1111/jgh.13319] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 01/25/2016] [Accepted: 02/10/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Therapeutic options to treat progression of end-stage liver disease (ESLD) or improve long-term survival after liver transplantation remain scarce. We investigated the impact of coffee consumption under these conditions. METHODS We recorded coffee consumption habits of 379 patients with ESLD awaiting liver transplantation and 260 patients after liver transplantation. Survival was analyzed based on coffee intake. RESULTS One hundred ninety-five patients with ESLD consumed coffee on a daily basis, while 184 patients did not. Actuarial survival was impaired (P = 0.041) in non-coffee drinkers (40.4 ± 4.3 months, 95% confidence interval [CI]: 32.0-48.9) compared with coffee drinkers (54.9 ± 5.5 months, 95% CI: 44.0-65.7). In subgroup analysis, the survival of patients with alcoholic liver disease (ALD; P = 0.020) and primary sclerosing cholangitis (PSC; P = 0.017) was increased with coffee intake while unaffected in patients with chronic viral hepatitis (P = 0.517) or other liver disease entities (P = 0.652). Multivariate analysis showed that coffee consumption of PSC and ALD patients retained as an independent risk factor (odds ratio [OR]: 1.94; 95% CI: 1.15-3.28; P = 0.013) along with MELD score (OR: 1.13; 95% CI: 1.09-1.17; P = 0.000). Following liver transplantation, long-term survival was longer in coffee drinkers (coffee: 61.8 ± 2.0 months, 95% CI: 57.9-65.8) than non-drinkers (52.3 ± 3.5 months, 95% CI: 45.4-59.3; P = 0.001). CONCLUSIONS Coffee consumption delayed disease progression in ALD and PSC patients with ESLD and increased long-term survival after liver transplantation. We conclude that regular coffee intake might be recommended for these patients.
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Affiliation(s)
- Kilian Friedrich
- Department of Internal Medicine IV, University Hospital of Heidelberg, Heidelberg, Germany
| | - Mark Smit
- Department of Internal Medicine IV, University Hospital of Heidelberg, Heidelberg, Germany
| | - Andreas Wannhoff
- Department of Internal Medicine IV, University Hospital of Heidelberg, Heidelberg, Germany
| | - Christian Rupp
- Department of Internal Medicine IV, University Hospital of Heidelberg, Heidelberg, Germany
| | - Sabine G Scholl
- Department of Social Psychology, University of Mannheim, Mannheim, Germany
| | - Christoph Antoni
- Department of Medicine II (Gastroenterology, Hepatology and Infectious Diseases), University Hospital of Heidelberg at Mannheim, Mannheim, Germany
| | - Matthias Dollinger
- Department of Internal Medicine I, University of Ulm, Ulm, Baden-Wuerttemberg, Germany
| | - Christoph Neumann-Haefelin
- Department of Medicine II, Freiburg University Medical Center, University of Freiburg, Freiburg, Germany
| | - Wolfgang Stremmel
- Department of Internal Medicine IV, University Hospital of Heidelberg, Heidelberg, Germany
| | - Karl Heinz Weiss
- Department of Internal Medicine IV, University Hospital of Heidelberg, Heidelberg, Germany
| | - Peter Schemmer
- Department of Surgery, University Hospital of Heidelberg, Heidelberg, Germany
| | - Daniel Nils Gotthardt
- Department of Internal Medicine IV, University Hospital of Heidelberg, Heidelberg, Germany
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Abstract
We reviewed the current status of liver transplantation in Latin America. We used data from the Latin American and Caribbean Transplant Society and national organizations and societies, as well as information obtained from local transplant leaders. Latin America has a population of 589 million (8.5% of world population) and more than 2,500 liver transplantations are performed yearly (17% of world activity), resulting in 4.4 liver transplants per million people (pmp) per year. The number of liver transplantations grows at 6% per year in the region, particularly in Brazil. The top liver transplant rates were found in Argentina (10.4 pmp), Brazil (8.4 pmp), and Uruguay (5.5 pmp). The state of liver transplantation in some countries rivals those in developed countries. Model for End-Stage Liver Disease-based allocation, split, domino, and living-donor adult and pediatric transplantations are now routinely performed with outcomes comparable to those in advanced economies. In contrast, liver transplantation is not performed in 35% of Latin American countries and lags adequate resources in many others. The lack of adequate financial coverage, education, and organization is still the main limiting factor in the development of liver transplantation in Latin America. The liver transplant community in the region should push health care leaders and authorities to comply with the Madrid and Istambul resolutions on organ donation and transplantation. It must pursue fiercely the development of registries to advance the science and quality control of liver transplant activities in Latin America.
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Roma J, Balbi E, Pacheco-Moreira L, Zyngier I, Araujo A, Agoglia L, Steinbruck K, Velaverde LG, Martinho JM. Impact of model for end-stage liver disease score on long-term survival following liver transplantation for hepatocellular carcinoma. Transplant Proc 2013; 44:2423-7. [PMID: 23026611 DOI: 10.1016/j.transproceed.2012.07.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Survival rates after orthotopic liver transplantation (OLT) for hepatocellular carcinoma (HCC) have significantly increased after Milan criteria and Model for End-Stage Liver Disease (MELD) score implementation. However, few studies have reported this survival in countries with organ donor shortages over a period of 10 years and long waiting lists. METHODS This retrospective analysis of clinical data from 93 consecutive HCC patients who underwent OLT from June 2001 to September 2011 excluded 22 who underwent living donor liver transplantation (LDLT). Seventy-one deceased donor liver transplantations (DDLT) were evaluated before and after the MELD era. Kaplan-Meier analysis was used to plot survival rates. The follow-up was 2 months to 10 years. RESULTS The overall survival and recurrence rates at 10 years were 67% and 12.2%, respectively. After MELD, patient survival at 5 years decreased from 70% to 64% and the recurrence rate decreased from 15.3% to 12.5%. The most frequent recurrence sites were lung and liver. CONCLUSION In our center MELD score implementation had a small impact on long-term survival post OLT for HCC.
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Affiliation(s)
- J Roma
- Liver Transplantation Unit, Bonsucesso General Hospital, Rio de Janeiro, Brazil.
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Batista TP, Sabat BD, Melo PSVD, Miranda LEC, Fonseca-Neto OCLD, Amorim AG, Lacerda CM. Employment of MELD score for the prediction of survival after liver transplantation. Rev Col Bras Cir 2012. [PMID: 22664516 DOI: 10.1590/s0100-69912012000200005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To assess the overall accuracy of the preoperative MELD score for predicting survival after liver transplantation (LT) and appraise medium-term (24 months) predictors of survival. METHODS We conducted a cross-sectional study including patients transplanted by the Department of General Surgery and Liver Transplantation of the Oswaldo Cruz University Hospital, University of Pernambuco, between July 15th, 2003 and July 14th, 2009. We used analysis of area under ROC (receiver operating characteristic) as a summary measure of the performance of the MELD score and assessed predictors of medium-term survival using univariate and multivariate analysis. RESULTS The cumulative survival of three, six, 12 and 24 months of the 208 patients studied was 85.1%, 79.3%, 74.5% and 71.1%, respectively. The preoperative MELD score showed a low discriminatory power for predicting survival after TH. By univariate analysis, we identified intraoperative transfusion of red blood cells (p <0.001) and platelets (p = 0.004) and type of venous hepatocaval anastomosis (p = 0.008) as significantly related to medium-term survival of the patients studied. However, by multivariate analysis only red blood cell transfusion was a significant independent predictor of outcome. CONCLUSION The MELD score showed low overall accuracy for predicting post-transplant survival of patients studied, among which only intraoperative transfusion of red blood cells was identified as an independent predictor of survival in the medium term after TH.
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Affiliation(s)
- Thales Paulo Batista
- Department of General Surgery and Liver Transplantation of the Oswaldo Cruz University Hospital, University of Pernambuco, Recife, Pernambuco, Brazil.
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Batista TP, Miranda LEC, Sabat BD, Melo PSVD, Fonseca Neto OCLD, Amorim AG, Lacerda CM. Non-cancerous prognostic factors of hepatocellular carcinoma after liver transplantation. Acta Cir Bras 2012; 27:396-403. [PMID: 22666757 DOI: 10.1590/s0102-86502012000600007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Accepted: 04/16/2012] [Indexed: 11/22/2022] Open
Abstract
PURPOSE To explore non-cancerous factors that may be related with medium-term survival (24 months) after liver transplantation (LT) in this data from northeast Brazil. METHODS A cross-sectional study was carried out in patients who underwent deceased-donor orthotopic LT because hepatocellular carcinoma (HCC) at the University of Pernambuco, Brazil. Non-cancerous factors (i.e.: donor-, receptor-, surgery- and center-related variables) were explored as prognostic factors of medium-term survival using univariate and multivariate approachs. RESULTS Sixty-one patients were included for analysis. Their three, six, 12 and 24-month overall cumulative survivals were 88.5%, 80.3%, 73.8% and 65.6%, respectively. Our univariate analysis identified red blood cell transfusion (Exp[b]=1.26; p<0.01) and hepato-venous reconstruction technique (84.6% vs. 51.4%, p<0.01; respectively for piggyback and conventional approaches) as significantly related to post-LT survival. The multivariate analysis confirmed the hepato-venous reconstruction technique was an independent prognostic factor. CONCLUSION The piggyback technique was related to improved medium-term survival of hepatocellular carcinoma patients after liver transplantation in this northeast Brazilian sample.
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Fonseca-Neto OCLD, Miranda LEC, Melo PSVD, Sabat BD, Amorim AG, Lacerda CM. Preditores de injúria renal aguda em pacientes submetidos ao transplante ortotópico de fígado convencional sem desvio venovenoso. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2011. [DOI: 10.1590/s0102-67202011000200012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
RADICAL: Injúria renal aguda é uma das complicações mais comuns do transplante ortotópico de fígado. A ausência de critério universal para sua definição nestas condições dificulta as comparações entre os estudos. A técnica convencional para o transplante consiste na excisão total da veia cava inferior retro-hepática durante a hepatectomia nativa. Controvérsias sobre o efeito da técnica convencional sem desvio venovenoso na função renal continuam. OBJETIVO: Estimar a incidência e os fatores de risco de injúria renal aguda entre os receptores de transplante ortotópico de fígado convencional sem desvio venovenoso. MÉTODOS: Foram avaliados 375 pacientes submetidos a transplante ortotópico de fígado. Foram analisadas as variáveis pré, intra e pós-operatórias em 153 pacientes submetidos a transplante ortotópico de fígado convencional sem desvio venovenoso. O critério para a injúria renal aguda foi valor da creatinina sérica > 1,5 mg/dl ou débito urinário < 500 ml/24h dentro dos primeiros três dias pós-transplante. Foi realizada análise univariada e multivariada por regressão logística. RESULTADOS: Todos os transplantes foram realizados com enxerto de doador falecido. Sessenta pacientes (39,2%) apresentaram injúria renal aguda. Idade, índice de massa corpórea, escore de Child-Turcotte-Pugh, ureia, hipertensão arterial sistêmica e creatinina sérica pré-operatória apresentaram maiores valores no grupo injúria renal aguda. Durante o período intraoperatório, o grupo injúria renal aguda apresentou mais síndrome de reperfusão, transfusão de concentrado de hemácias, plasma fresco e plaquetas. No pós-operatório, o tempo de permanência em ventilação mecânica e creatinina pós-operatória também foram variáveis, com diferenças significativas para o grupo injúria renal aguda. Após regressão logística, a síndrome de reperfusão, a classe C do Child-Turcotte-Pugh e a creatinina sérica pós-operatória apresentaram diferenças. CONCLUSÃO: Injúria renal aguda após transplante ortotópico de fígado convencional sem desvio venovenoso é uma desordem comum, mas apresenta bom prognóstico. Síndrome de reperfusão, creatinina sérica no pós-operatório e Child C são fatores associados a injúria renal aguda pós-transplante ortotópico de fígado convencional sem desvio venovenoso.
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Batista TP, Sabat BD, Melo PSV, Miranda LEC, Fonseca-Neto OCL, Amorim AG, Lacerda CM. Impact of MELD allocation policy on survival outcomes after liver transplantation: a single-center study in northeast Brazil. Clinics (Sao Paulo) 2011; 66:57-64. [PMID: 21437437 PMCID: PMC3044564 DOI: 10.1590/s1807-59322011000100011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2010] [Accepted: 10/13/2010] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To analyze the impact of model for end-stage liver disease (MELD) allocation policy on survival outcomes after liver transplantation (LT). INTRODUCTION Considering that an ideal system of grafts allocation should also ensure improved survival after transplantation, changes in allocation policies need to be evaluated in different contexts as an evolutionary process. METHODS A retrospective cohort study was carried out among patients who underwent LT at the University of Pernambuco. Two groups of patients transplanted before and after the MELD allocation policy implementation were identified and compared using early postoperative mortality and post-LT survival as end-points. RESULTS Overall, early postoperative mortality did not significantly differ between cohorts (16.43% vs. 8.14%; p = 0.112). Although at 6 and 36-months the difference between pre-vs. post-MELD survival was only marginally significant (p = 0.066 and p = 0.063; respectively), better short, medium and long-term post-LT survival were observed in the post-MELD period. Subgroups analysis showed special benefits to patients categorized as nonhepatocellular carcinoma (non-HCC) and moderate risk, as determined by MELD score (15-20). DISCUSSION This study ensured a more robust estimate of how the MELD policy affected post-LT survival outcomes in Brazil and was the first to show significantly better survival after this new policy was implemented. Additionally, we explored some potential reasons for our divergent survival outcomes. CONCLUSION Better survival outcomes were observed in this study after implementation of the MELD criterion, particularly amongst patients categorized as non-HCC and moderate risk by MELD scoring. Governmental involvement in organ transplantation was possibly the main reason for improved survival.
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Affiliation(s)
- Thales Paulo Batista
- Department of Surgery and Liver Transplantation, Oswaldo Cruz University Hospital, University of Pernambuco, Recife, PE, Brazil.
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