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Seth R, Andreoni KA. Changing landscape of liver transplant in the United States- time for a new innovative way to define and utilize the "non-standard liver allograft"-a proposal. FRONTIERS IN TRANSPLANTATION 2024; 3:1449407. [PMID: 39176402 PMCID: PMC11338891 DOI: 10.3389/frtra.2024.1449407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2024] [Accepted: 07/22/2024] [Indexed: 08/24/2024]
Abstract
Since the first liver transplant was performed over six decades ago, the landscape of liver transplantation in the US has seen dramatic evolution. Numerous advancements in perioperative and operative techniques have resulted in major improvements in graft and patient survival rates. Despite the increase in transplants performed over the years, the waitlist mortality rate continues to remain high. The obesity epidemic and the resultant metabolic sequelae continue to result in more marginal donors and challenging recipients. In this review, we aim to highlight the changing characteristics of liver transplant recipients and liver allograft donors. We focus on issues relevant in successfully transplanting a high model for end stage liver disease recipient. We provide insights into the current use of terms and definitions utilized to discuss marginal allografts, discuss the need to look into more consistent ways to describe these organs and propose two new concepts we coin as "Liver Allograft Variables" (LAV) and "Liver Allograft Composite Score" (LACS) for this. We discuss the development of spectrum of risk indexes as a dynamic tool to characterize an allograft in real time. We believe that this concept has the potential to optimize the way we allocate, utilize and transplant livers across the US.
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Affiliation(s)
- Rashmi Seth
- Department of Surgery, Division of Transplant Surgery, University of Tennessee Health Sciences Center, Methodist University Hospital Transplant Institute, Memphis, TN, United States
| | - Kenneth A. Andreoni
- Department of Surgery, Division of Abdominal Transplantation, Thomas Jefferson University, Philadelphia, PA, United States
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Wehrle CJ, Zhang M, Khalil M, Pita A, Modaresi Esfeh J, Diago-Uso T, Kim J, Aucejo F, Kwon DCH, Ali K, Cazzaniga B, Miyazaki Y, Liu Q, Fares S, Hong H, Tuul M, Jiao C, Sun K, Fairchild RL, Quintini C, Fujiki M, Pinna AD, Miller C, Hashimoto K, Schlegel A. Impact of Back-to-Base Normothermic Machine Perfusion on Complications and Costs: A Multicenter, Real-World Risk-Matched Analysis. Ann Surg 2024; 280:300-310. [PMID: 38557793 DOI: 10.1097/sla.0000000000006291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
OBJECTIVE Assess cost and complication outcomes after liver transplantation (LT) using normothermic machine perfusion (NMP). BACKGROUND End-ischemic NMP is often used to aid logistics, yet its impact on outcomes after LT remains unclear, as does its true impact on costs associated with transplantation. METHODS Deceased donor liver recipients at 2 centers (January 1, 2019, to June 30, 2023) were included. Retransplants, splits, and combined grafts were excluded. End-ischemic NMP (OrganOx-Metra) was implemented in October 2022 for extended-criteria donation after brain death (DBDs), all donations after circulatory deaths (DCDs), and logistics. NMP cases were matched 1:2 with static cold storage controls (SCS) using the Balance-of-Risk [donation after brain death (DBD)-grafts] and UK-DCD Score (DCD-grafts). RESULTS Overall, 803 transplantations were included, 174 (21.7%) receiving NMP. Matching was achieved between 118 NMP-DBDs with 236 SCS; and 37 NMP-DCD with 74 corresponding SCS. For both graft types, median inpatient comprehensive complications index values were comparable between groups. DCD-NMP grafts experienced reduced cumulative 90-day comprehensive complications index (27.6 vs 41.9, P =0.028). NMP also reduced the need for early relaparotomy and renal replacement therapy, with subsequently less frequent major complications (Clavien-Dindo ≥IVa). This effect was more pronounced in DCD transplants. NMP had no protective effect on early biliary complications. Organ acquisition/preservation costs were higher with NMP, yet NMP-treated grafts had lower 90-day pretransplant costs in the context of shorter waiting list times. Overall costs were comparable for both cohorts. CONCLUSIONS This is the first risk-adjusted outcome and cost analysis comparing NMP and SCS. In addition to logistical benefits, NMP was associated with a reduction in relaparotomy and bleeding in DBD grafts, and overall complications and post-LT renal replacement for DCDs. While organ acquisition/preservation was more costly with NMP, overall 90-day health care costs-per-transplantation were comparable.
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Affiliation(s)
| | | | | | | | - Jamak Modaresi Esfeh
- Department of Gastroenterology and Transplant Hepatology, Cleveland Clinic, Cleveland, OH
| | - Teresa Diago-Uso
- Department of Liver Transplantation, Cleveland Clinic Abu Dhabi, Cleveland, OH
| | - Jaekeun Kim
- Transplantation Center, Cleveland Clinic, OH
| | | | | | - Khaled Ali
- Transplantation Center, Cleveland Clinic, OH
| | | | | | - Qiang Liu
- Transplantation Center, Cleveland Clinic, OH
| | - Sami Fares
- Transplantation Center, Cleveland Clinic, OH
| | - Hanna Hong
- Transplantation Center, Cleveland Clinic, OH
| | | | - Chunbao Jiao
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, OH
| | - Keyue Sun
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, OH
| | - Robert L Fairchild
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, OH
| | - Cristiano Quintini
- Department of Liver Transplantation, Cleveland Clinic Abu Dhabi, Cleveland, OH
| | | | | | | | - Koji Hashimoto
- Transplantation Center, Cleveland Clinic, OH
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, OH
| | - Andrea Schlegel
- Transplantation Center, Cleveland Clinic, OH
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, OH
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Stoltz DJ, Gallo AE, Lum G, Mendoza J, Esquivel CO, Bonham A. Technical Variant Liver Transplant Utilization for Pediatric Recipients: Equal Graft Survival to Whole Liver Transplants and Promotion of Timely Transplantation Only When Performed at High-volume Centers. Transplantation 2024; 108:703-712. [PMID: 37635278 DOI: 10.1097/tp.0000000000004772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
BACKGROUND Technical variant liver transplantation (TVLT) is a strategy to mitigate persistent pediatric waitlist mortality in the United States, although its implementation remains stagnant. This study investigated the relationship between TVLT utilization, transplant center volume, and graft survival. METHODS Pediatric liver transplant recipients from 2010 to 2020 (n = 5208) were analyzed using the Scientific Registry of Transplant Recipients database. Transplant centers were categorized according to the average number of pediatric liver transplants performed per year (high-volume, ≥5; low-volume, <5). Graft survival rates were compared using Kaplan-Meier curves and log-rank tests. Cox proportional hazards models were used to identify predictors of graft failure. RESULTS High-volume centers demonstrated equivalent whole liver transplant and TVLT graft survival ( P = 0.057) and significantly improved TVLT graft survival compared with low-volume centers ( P < 0.001). Transplantation at a low-volume center was significantly associated with graft failure (adjusted hazard ratio, 1.6; 95% confidence interval, 1.14-2.24; P = 0.007 in patients <12 y old and 1.8; 95% confidence interval, 1.13-2.87; P = 0.013 in patients ≥12 y old). A subset of high-volume centers with a significantly higher rate of TVLT use demonstrated a 23% reduction in waitlist mortality. CONCLUSIONS Prompt transplantation with increased TVLT utilization at high-volume centers may reduce pediatric waitlist mortality without compromising graft survival.
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Affiliation(s)
- Daniel J Stoltz
- Division of Abdominal Transplantation, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Amy E Gallo
- Division of Abdominal Transplantation, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Grant Lum
- Division of Abdominal Transplantation, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Julianne Mendoza
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Carlos O Esquivel
- Division of Abdominal Transplantation, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Andrew Bonham
- Division of Abdominal Transplantation, Department of Surgery, Stanford University School of Medicine, Stanford, CA
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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] [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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5
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Handley TJ, Arnow KD, Melcher ML. Despite Increasing Costs, Perfusion Machines Expand the Donor Pool of Livers and Could Save Lives. J Surg Res 2023; 283:42-51. [PMID: 36368274 DOI: 10.1016/j.jss.2022.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 08/27/2022] [Accepted: 10/07/2022] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Liver transplantation is a highly successful treatment for liver failure and disease. However, demand continues to outstrip our ability to provide transplantation as a treatment. Many livers initially considered for transplantation are not used because of concerns about their viability or logistical issues. Recent clinical trials have shown discarded livers may be viable if they undergo machine perfusion, which allows a more objective assessment of liver quality. METHODS Using the Scientific Registry of Transplant Recipients dataset, we examined discarded and unretrieved organs to determine their eligibility for perfusion. We then used a Markov decision-analytic model to perform a cost-effectiveness analysis of two competing transplant strategies: Static Cold Storage (SCS) alone versus Static Cold Storage and Normothermic Machine Perfusion (NMP) of discarded organs. RESULTS The average predicted successful transplants after perfusion was 385, representing a 5.8% increase in the annual yield of liver transplants. Our cost-effectiveness analysis found that the SCS strategy generated 4.64 quality-adjusted life years (QALYs) and cost $479,226. The combined SCS + NMP strategy generated 4.72 QALYs and cost $481,885. The combined SCS + NMP strategy had an incremental cost-effectiveness ratio of $33,575 per additional QALY over the 10-year study horizon. CONCLUSIONS Machine perfusion of livers currently not considered viable for transplant could increase the number of transplantable grafts by approximately 5% per year and is cost-effective compared to Static Cold Storage alone.
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Affiliation(s)
- Thomas J Handley
- Department of Health Policy, Stanford University School of Medicine, Stanford, California; Stanford-Surgery Policy Improvement Research & Education Center (S-SPIRE), Stanford, California; Department of Surgery, Stanford University School of Medicine, Stanford, California.
| | - Katherine D Arnow
- Stanford-Surgery Policy Improvement Research & Education Center (S-SPIRE), Stanford, California
| | - Marc L Melcher
- Department of Surgery, Stanford University School of Medicine, Stanford, California
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Raigani S, De Vries RJ, Carroll C, Chen YW, Chang DC, Shroff SG, Uygun K, Yeh H. Viability testing of discarded livers with normothermic machine perfusion: Alleviating the organ shortage outweighs the cost. Clin Transplant 2020; 34:e14069. [PMID: 32860634 DOI: 10.1111/ctr.14069] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/01/2020] [Accepted: 08/15/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Over 700 donor livers are discarded annually in the United States due to high risk of poor graft function. The objective of this study was to determine the impact of using normothermic machine perfusion to identify transplantable livers among those currently discarded. STUDY DESIGN A series of 21 discarded human livers underwent viability assessment during normothermic machine perfusion. Cross-sectional analysis of the Scientific Registry of Transplant Recipients database and cost analysis was performed to extrapolate the case series to national experience. RESULTS 21 discarded human livers were included in the perfusion cohort. 11 of 20 (55%) eligible grafts met viability criteria for transplantation. Grafts in the perfusion cohort had a similar donor risk index compared with discarded grafts (n = 1402) outside of New England in 2017 and 2018 (median [IQR]: 2.0 [1.5, 2.4] vs. 2.0 [1.7, 2.3], P = .40). 705 (IQR 677-741) livers were discarded annually in the United States since 2005, translating to the potential for 398 additional transplants nationally. The median cost to identify a transplantable graft with machine perfusion was $28,099 USD. CONCLUSIONS Normothermic machine perfusion of discarded livers could identify a significant number of transplantable grafts, significantly improving access to liver transplantation.
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Affiliation(s)
- Siavash Raigani
- Division of Transplant Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Center for Engineering in Medicine, Massachusetts General Hospital and Shriners Hospital for Children, Boston, MA, USA
| | - Reinier J De Vries
- Center for Engineering in Medicine, Massachusetts General Hospital and Shriners Hospital for Children, Boston, MA, USA.,Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Cailah Carroll
- Center for Engineering in Medicine, Massachusetts General Hospital and Shriners Hospital for Children, Boston, MA, USA
| | - Ya-Wen Chen
- Division of Transplant Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - David C Chang
- Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Stuti G Shroff
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Korkut Uygun
- Division of Transplant Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Center for Engineering in Medicine, Massachusetts General Hospital and Shriners Hospital for Children, Boston, MA, USA
| | - Heidi Yeh
- Division of Transplant Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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7
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Rodríguez S, Motta FD, Balbinoto Neto G, Brandão A. EVALUATION AND SELECTION OF CANDIDATES FOR LIVER TRANSPLANTATION: AN ECONOMIC PERSPECTIVE. ARQUIVOS DE GASTROENTEROLOGIA 2020; 57:31-38. [PMID: 32294733 DOI: 10.1590/s0004-2803.202000000-07] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 10/30/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Over the next 20 years, the number of patients on the waiting list for liver transplantation (LTx) is expected to increase by 23%, while pre-LTx costs should raise by 83%. OBJECTIVE To evaluate direct medical costs of the pre-LTx period from the perspective of a tertiary care center. METHODS The study included 104 adult patients wait-listed for deceased donor LTx between October 2012 and May 2016 whose treatment was fully provided at the study transplant center. Clinical and economic data were obtained from electronic medical records and from a hospital management software. Outcomes of interest and costs of patients on the waiting list were compared through the Kruskal-Wallis test. A generalized linear model with logit link function was used for multivariate analysis. P-values <0.05 were considered statistically significant. RESULTS The costs of patients who underwent LTx ($8,879.83; 95% CI 6,735.24-11,707.27; P<0.001) or who died while waiting ($6,464.73; 95% CI 3,845.75-10,867.28; P=0.04) were higher than those of patients who were excluded from the list for any reason except death ($4,647.78; 95% CI 2,469.35-8,748.04; P=0.254) or those who remained on the waiting list at the end of follow-up. CONCLUSION Although protocols of inclusion on the waiting list vary among transplant centers, similar approaches exist and common problems should be addressed. The results of this study may help centers with similar socioeconomic realities adjust their transplant policies.
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Affiliation(s)
- Santiago Rodríguez
- Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Programa de Graduação em Medicina, Porto Alegre, RS, Brasil
| | - Fabio Da Motta
- Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brasil
| | - Giacomo Balbinoto Neto
- Universidade Federal de Rio Grande do Sul (UFRGS), Programa de Graduação em Economia, Porto Alegre, RS, Brasil.,Instituto de Avaliações de Tecnologias e Saúde (IATS), Porto Alegre, RS, Brasil
| | - Ajacio Brandão
- Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Programa de Graduação em Medicina, Porto Alegre, RS, Brasil.,Santa Casa de Misericórdia de Porto Alegre, Grupo de Transplante de Fígado, Porto Alegre, RS, Brasil
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Axelrod DA, Caliskan Y, Schnitzler MA, Xiao H, Dharnidharka VR, Segev DL, McAdams-DeMarco M, Brennan DC, Randall H, Alhamad T, Kasiske BL, Hess G, Lentine KL. Economic impacts of alternative kidney transplant immunosuppression: A national cohort study. Clin Transplant 2020; 34:e13813. [PMID: 32027049 PMCID: PMC10401861 DOI: 10.1111/ctr.13813] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 01/25/2020] [Accepted: 02/03/2020] [Indexed: 08/06/2023]
Abstract
Understanding the economic implications of induction and maintenance immunosuppression (ISx) is important in developing personalized kidney transplant (KTx) care. Using data from a novel integrated data set including financial records from the University Health System Consortium, Medicare, and pharmacy claims (2007-2014), we estimated the differences in the impact of induction and maintenance ISx regimens on transplant hospitalization costs and Medicare payments from KTx to 3 years. Use of thymoglobulin (TMG) significantly increased transplant hospitalization costs ($12 006; P = .02), compared with alemtuzumab and basiliximab. TMG resulted in lower Medicare payments in posttransplant years 1 (-$2058; P = .05) and 2 (-$1784; P = .048). Patients on steroid-sparing ISx incurred relatively lower total Medicare spending (-$10 880; P = .01) compared with patients on triple therapy (tacrolimus, antimetabolite, and steroids). MPA/AZA-sparing, mammalian target of rapamycin inhibitors-based, and cyclosporine-based maintenance ISx regimens were associated with significantly higher payments. Alternative ISx regimens were associated with different KTx hospitalization costs and longer-term payments. Future studies of clinical efficacy should also consider cost impacts to define the economic effectiveness of alternative ISx regimens.
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Affiliation(s)
| | - Yasar Caliskan
- Saint Louis University Center for Abdominal Transplantation, St. Louis, Missouri
| | - Mark A. Schnitzler
- Saint Louis University Center for Abdominal Transplantation, St. Louis, Missouri
| | - Huiling Xiao
- Saint Louis University Center for Abdominal Transplantation, St. Louis, Missouri
| | - Vikas R. Dharnidharka
- Division of Nephrology, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Dorry L. Segev
- Johns Hopkins University Transplant Center, Johns Hopkins University, Baltimore, Maryland
| | - Mara McAdams-DeMarco
- Johns Hopkins University Transplant Center, Johns Hopkins University, Baltimore, Maryland
| | - Daniel C. Brennan
- Johns Hopkins University Transplant Center, Johns Hopkins University, Baltimore, Maryland
| | - Henry Randall
- Saint Louis University Center for Abdominal Transplantation, St. Louis, Missouri
| | - Tarek Alhamad
- Division of Nephrology, Washington University School of Medicine, St. Louis, Missouri
| | - Bertram L. Kasiske
- Division of Nephrology, Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Gregory Hess
- Drexel University School of Medicine, Philadelphia, Pennsylvania
| | - Krista L. Lentine
- Saint Louis University Center for Abdominal Transplantation, St. Louis, Missouri
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9
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Lebovitz EE, Nguyen AVT, Sakai T. Economic considerations in abdominal transplantation. Best Pract Res Clin Anaesthesiol 2020; 34:15-23. [DOI: 10.1016/j.bpa.2020.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 12/26/2019] [Accepted: 01/08/2020] [Indexed: 12/16/2022]
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10
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Harries L, Gwiasda J, Qu Z, Schrem H, Krauth C, Amelung VE. Potential savings in the treatment pathway of liver transplantation: an inter-sectorial analysis of cost-rising factors. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2019; 20:281-301. [PMID: 30051153 DOI: 10.1007/s10198-018-0994-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 07/13/2018] [Indexed: 06/08/2023]
Abstract
INTRODUCTION Identification of cost-driving factors in patients undergoing liver transplantation is essential to target reallocation of resources and potential savings. AIM The aim of this study is to identify main cost-driving factors in liver transplantation from the perspective of the Statutory Health Insurance. METHODS Variables were analyzed with multivariable logistic regression to determine their influence on high cost cases (fourth quartile) in the outpatient, inpatient and rehabilitative healthcare sectors as well as for medications. RESULTS Significant cost-driving factors for the inpatient sector of care were a high labMELD-score (OR 1.042), subsequent re-transplantations (OR 7.159) and patient mortality (OR 3.555). Expenditures for rehabilitative care were significantly higher in patients with a lower adjusted Charlson comorbidity index (OR 0.601). The indication of viral cirrhosis and hepatocellular carcinoma resulted in significantly higher costs for medications (OR 21.618 and 7.429). For all sectors of care and medications each waiting day had a significant impact on high treatment costs (OR 1.001). Overall, cost-driving factors resulted in higher median treatment costs of 211,435 €. CONCLUSIONS Treatment costs in liver transplantation were significantly influenced by identified factors. Long pre-transplant waiting times that increase overall treatment costs need to be alleviated by a substantial increase in donor organs to enable transplantation with lower labMELD-scores. Disease management programs, the implementation of a case management for vulnerable patients, medication plans and patient tracking in a transplant registry may enable cost savings, e.g., by the avoidance of otherwise necessary re-transplants or incorrect medication.
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Affiliation(s)
- Lena Harries
- Department of Health Economics and Health Policy, Institute of Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
- Core Facility Quality Management Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Jill Gwiasda
- Core Facility Quality Management Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Zhi Qu
- Department of Health Economics and Health Policy, Institute of Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
- Core Facility Quality Management Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Harald Schrem
- Core Facility Quality Management Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
- Department of General, Visceral and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - Christian Krauth
- Department of Health Economics and Health Policy, Institute of Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
- Core Facility Quality Management Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Volker Eric Amelung
- Department of Health Economics and Health Policy, Institute of Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
- Core Facility Quality Management Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
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Rubin JB, Sinclair M, Rahimi RS, Tapper EB, Lai JC. Women on the liver transplantation waitlist are at increased risk of hospitalization compared to men. World J Gastroenterol 2019; 25:980-988. [PMID: 30833803 PMCID: PMC6397730 DOI: 10.3748/wjg.v25.i8.980] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 01/13/2019] [Accepted: 01/18/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hospital admissions are common among patients with cirrhosis, but patient factors associated with hospitalization have not been well characterized. Given recent data suggesting increased liver transplant waitlist dropout among women, we hypothesized that women on the liver transplant waitlist would have increased rates of hospitalization compared with men.
AIM To evaluate the role of gender on risk of hospitalization for patients on the liver transplant waitlist, in order to help explain gender disparities in waitlist outcomes.
METHODS Patients listed for liver transplant at a single center in the United States were prospectively enrolled in the Functional Assessment in Liver Transplantation Study. Patients included in this retrospective analysis included those enrolled between March 2012 and December 2014 with at least 12 mo of follow up and without hepatocellular carcinoma. The primary and secondary outcomes were hospitalization and total inpatient days within 12 mo, respectively. Logistic and negative binomial regression associated baseline factors with outcomes.
RESULTS Of the 392 patients, 41% were female, with median (interquartile range) age 58 years (52-63) and model for end- stage liver disease 18 (15-22). Within 12 mo, 186 (47%) patients were hospitalized ≥ 1 time; 48% were readmitted, with a median of 8 (4-15) inpatient days. More women than men were hospitalized (54% vs 43%; P = 0.03). In univariable analysis, female sex was associated with an increased risk of hospitalization [odds ratios (OR) 1.6, 95% confidence interval (CI) 1.0-2.4; P = 0.03], which remained significant on adjusted multivariable analysis (OR 1.6, 95%CI: 1.1-2.6; P = 0.03). Female gender was also associated with an increased number of inpatient days within 12 mo in both univariable and multivariable regression.
CONCLUSION Women with cirrhosis on the liver transplant waitlist have more hospitalizations and inpatient days in one year compared with men, suggesting that the experience of cirrhosis differs between men and women, despite similar baseline illness severity. Future studies should explore gender-specific vulnerabilities to help explain waitlist disparities.
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Affiliation(s)
- Jessica B Rubin
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, CA 94143 United States
| | - Marie Sinclair
- Department of Gastroenterology and Hepatology, Austin Health, Heidelberg 3084, Victoria, Australia
- Department of Medicine, the University of Melbourne, Melbourne 3010, Victoria, Australia
| | - Robert S Rahimi
- Division of Hepatology, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX 75346, United States
| | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI 48109, United States
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, CA 94143 United States
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12
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Główczyńska R, Raszeja-Wyszomirska J, Janik M, Kostrzewa K, Zygmunt M, Zborowska H, Krawczyk M, Galas M, Niewińsk G, Krawczyk M, Zieniewicz K, Milkiewicz P, Opolski G. Troponin I Is Not a Predictor of Early Cardiovascular Morbidity in Liver Transplant Recipients. Transplant Proc 2018; 50:2022-2026. [DOI: 10.1016/j.transproceed.2018.02.136] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 02/06/2018] [Indexed: 01/06/2023]
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13
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Asrani SK, Saracino G, O'Leary JG, Gonzalez S, Kim PT, McKenna GJ, Klintmalm G, Trotter J. Recipient characteristics and morbidity and mortality after liver transplantation. J Hepatol 2018; 69:43-50. [PMID: 29454069 DOI: 10.1016/j.jhep.2018.02.004] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 02/01/2018] [Accepted: 02/08/2018] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND AIMS Over the last decade, liver transplantation of sicker, older non-hepatitis C cirrhotics with multiple co-morbidities has increased in the United States. We sought to identify an easily applicable set of recipient factors among HCV negative adult transplant recipients associated with significant morbidity and mortality within five years after liver transplantation. METHODS We collected national (n = 31,829, 2002-2015) and center-specific data. Coefficients of relevant recipient factors were converted to weighted points and scaled from 0-5. Recipient factors associated with graft failure included: ventilator support (five patients; hazard ratio [HR] 1.59; 95% CI 1.48-1.72); recipient age >60 years (three patients; HR 1.29; 95% CI 1.23-1.36); hemodialysis (three patients; HR 1.26; 95% CI 1.16-1.37); diabetes (two patients; HR 1.20; 95% CI 1.14-1.27); or serum creatinine ≥1.5 mg/dl without hemodialysis (two patients; HR 1.15; 95% CI 1.09-1.22). RESULTS Graft survival within five years based on points (any combination) was 77.2% (0-4), 69.1% (5-8) and 57.9% (>8). In recipients with >8 points, graft survival was 42% (model for end-stage liver disease [MELD] score <25) and 50% (MELD score 25-35) in recipients receiving grafts from donors with a donor risk index >1.7. In center-specific data within the first year, subjects with ≥5 points (vs. 0-4) had longer hospitalization (11 vs. 8 days, p <0.01), higher admissions for rehabilitation (12.3% vs. 2.7%, p <0.01), and higher incidence of cardiac disease (14.2% vs. 5.3%, p <0.01) and stage 3 chronic kidney disease (78.6% vs. 39.5%, p = 0.03) within five years. CONCLUSION The impact of co-morbidities in an MELD-based organ allocation system need to be reassessed. The proposed clinical tool may be helpful for center-specific assessment of risk of graft failure in non-HCV patients and for discussion regarding relevant morbidity in selected subsets. LAY SUMMARY Over the last decade, liver transplantation of sicker, older patient with multiple co-morbidities has increased. In this study, we show that a set of recipient factors (recipient age >60 years, ventilator status, diabetes, hemodialysis and creatinine >1.5 mg/dl) can help identify patients that may not do well after transplant. Transplanting sicker organs in patients with certain combinations of these characteristics leads to lower survival.
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Affiliation(s)
- Sumeet K Asrani
- Baylor University Medical Center, Dallas, TX, United States.
| | | | | | | | - Peter T Kim
- Baylor University Medical Center, Dallas, TX, United States
| | - Greg J McKenna
- Baylor University Medical Center, Dallas, TX, United States
| | | | - James Trotter
- Baylor University Medical Center, Dallas, TX, United States
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14
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Luo X, Leanza J, Massie AB, Garonzik-Wang JM, Haugen CE, Gentry SE, Ottmann SE, Segev DL. MELD as a metric for survival benefit of liver transplantation. Am J Transplant 2018; 18:1231-1237. [PMID: 29316310 PMCID: PMC6116532 DOI: 10.1111/ajt.14660] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 12/01/2017] [Accepted: 12/27/2017] [Indexed: 01/25/2023]
Abstract
Currently, there is debate among the liver transplant community regarding the most appropriate mechanism for organ allocation: urgency-based (MELD) versus utility-based (survival benefit). We hypothesize that MELD and survival benefit are closely associated, and therefore, our current MELD-based allocation already reflects utility-based allocation. We used generalized gamma parametric models to quantify survival benefit of LT across MELD categories among 74 196 adult liver-only active candidates between 2006 and 2016 in the United States. We calculated time ratios (TR) of relative life expectancy with transplantation versus without and calculated expected life years gained after LT. LT extended life expectancy (TR > 1) for patients with MELD > 10. The highest MELD was associated with the longest relative life expectancy (TR = 1.05 1.201.37 for MELD 11-15, 2.29 2.492.70 for MELD 16-20, 5.30 5.726.16 for MELD 21-25, 15.12 16.3517.67 for MELD 26-30; 39.26 43.2147.55 for MELD 31-34; 120.04 128.25137.02 for MELD 35-40). As a result, candidates with the highest MELD gained the most life years after LT: 0.2, 1.5, 3.5, 5.8, 6.9, 7.2 years for MELD 11-15, 16-20, 21-25, 26-30, 31-34, 35-40, respectively. Therefore, prioritizing candidates by MELD remains a simple, effective strategy for prioritizing candidates with a higher transplant survival benefit over those with lower survival benefit.
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Affiliation(s)
- Xun Luo
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Joseph Leanza
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Allan B. Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | | | - Christine E. Haugen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sommer E. Gentry
- Department of Mathematics, United States Naval Academy, Baltimore, MD
| | - Shane E. Ottmann
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
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15
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Bittermann T, Hubbard RA, Serper M, Lewis JD, Hohmann SF, VanWagner LB, Goldberg DS. Healthcare utilization after liver transplantation is highly variable among both centers and recipients. Am J Transplant 2018; 18:1197-1205. [PMID: 29024364 PMCID: PMC5895535 DOI: 10.1111/ajt.14539] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 09/26/2017] [Accepted: 10/03/2017] [Indexed: 01/25/2023]
Abstract
The relationship between healthcare utilization before and after liver transplantation (LT), and its association with center characteristics, is incompletely understood. This was a retrospective cohort study of 34 402 adult LTs between 2002 and 2013 using Vizient inpatient claims data linked to the United Network for Organ Sharing (UNOS) database. Multivariable mixed-effects linear regression models evaluated the association between hospitalization 90 days pre-LT and the number of days alive and out of the hospital (DAOH) 1 year post-LT. Of those patients alive at LT discharge, 24.7% spent ≥30 days hospitalized during the first year. Hospitalization in the 90 days pre-LT was inversely associated with DAOH (β = -3.4 DAOH/week hospitalized pre-LT; P = .002). Centers with >30% of their liver transplant recipients hospitalized ≥30 days in the first LT year were typically smaller volume and/or transplanting higher risk recipients (Model for End-Stage Liver Disease [MELD] score ≥35, inpatient or ventilated pre-LT). In conclusion, pre-LT hospitalization predicts 1-year post-LT hospitalization independent of MELD score at the patient-level, whereas center-specific post-LT healthcare utilization is associated with certain center behaviors and selection practices.
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Affiliation(s)
- T Bittermann
- Division of Gastroenterology & Hepatology, University of Pennsylvania, Philadelphia, PA, USA
| | - R A Hubbard
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
- Division of Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | - M Serper
- Division of Gastroenterology & Hepatology, University of Pennsylvania, Philadelphia, PA, USA
| | - J D Lewis
- Division of Gastroenterology & Hepatology, University of Pennsylvania, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | - S F Hohmann
- Center for Advanced Analytics, Vizient, Chicago, IL, USA
| | - L B VanWagner
- Division of Gastroenterology & Hepatology and Department of Preventive Medicine, Northwestern University, Chicago, IL, USA
| | - D S Goldberg
- Division of Gastroenterology & Hepatology, University of Pennsylvania, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
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16
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Serper M, Bittermann T, Rossi M, Goldberg DS, Thomasson AM, Olthoff KM, Shaked A. Functional status, healthcare utilization, and the costs of liver transplantation. Am J Transplant 2018; 18:1187-1196. [PMID: 29116679 DOI: 10.1111/ajt.14576] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 10/30/2017] [Accepted: 10/30/2017] [Indexed: 01/25/2023]
Abstract
The Model for End-Stage Liver Disease (MELD) score predicts higher transplant healthcare utilization and costs; however, the independent contribution of functional status towards costs is understudied. The study objective was to evaluate the association between functional status, as measured by Karnofsky Performance Status (KPS), and liver transplant (LT) costs in the first posttransplant year. In a cohort of 598 LT recipients from July 1, 2009 to November 30, 2014, multivariable models assessed associations between KPS and outcomes. LT recipients needing full assistance (KPS 10%-40%) vs being independent (KPS 80%-100%) were more likely to be discharged to a rehabilitation facility after LT (22% vs 3%) and be rehospitalized within the first posttransplant year (78% vs 57%), all P < .001. In adjusted generalized linear models, in addition to MELD (P < .001), factors independently associated with higher 1-year post-LT transplant costs were older age, poor functional status (KPS 10%-40%), living donor LT, pre-LT hemodialysis, and the donor risk index (all P < .001). One-year survival for patients in the top cost decile was 83% vs 93% for the rest of the cohort (log rank P < .001). Functional status is an important determinant of posttransplant resource utilization; therefore, standardized measurements of functional status should be considered to optimize candidate selection and outcomes.
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Affiliation(s)
- Marina Serper
- Division of Gastroenterology & Hepatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Therese Bittermann
- Division of Gastroenterology & Hepatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael Rossi
- Corporate Finance, Decision Support & Reimbursement, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - David S Goldberg
- Division of Gastroenterology & Hepatology, University of Pennsylvania, Philadelphia, PA, USA.,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | - Arwin M Thomasson
- Division of Transplant Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Kim M Olthoff
- Division of Transplant Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Abraham Shaked
- Division of Transplant Surgery, University of Pennsylvania, Philadelphia, PA, USA
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17
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Oldani G, Peloso A, Lacotte S, Meier R, Toso C. Xenogeneic chimera-Generated by blastocyst complementation-As a potential unlimited source of recipient-tailored organs. Xenotransplantation 2017; 24. [PMID: 28736957 DOI: 10.1111/xen.12327] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 07/05/2017] [Accepted: 07/08/2017] [Indexed: 12/13/2022]
Abstract
Blastocyst complementation refers to the injection of cells into a blastocyst. The technology allows for the creation of chimeric animals, which have the potential to be used as an unlimited source of organ donors. Pluripotent stem cells could be generated from a patient in need of a transplantation and injected into a large animal blastocyst (potentially of a pig), leading to the creation of organ(s) allowing immunosuppression-free transplantation. Various chimera combinations have already been generated, but one of the most recent steps leads to the creation of human-pig chimeras, which could be studied at an embryo stage. Although still far from clinical reality, the potential application is almost unlimited. The present review illustrates the historical steps of intra- and interspecific blastocyst complementation in rodents and large animals, specifically looking at its potential for generation of organ grafts. We also speculate on how it could change transplant indications, on its economic impact, and on the linked ethical concerns.
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Affiliation(s)
- Graziano Oldani
- Division of Abdominal Surgery, Department of Surgery, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,HepatoPancreato-Biliary Centre, Geneva University Hospitals, Geneva, Switzerland
| | - Andrea Peloso
- Division of Abdominal Surgery, Department of Surgery, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Division of General Surgery, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Stéphanie Lacotte
- Division of Abdominal Surgery, Department of Surgery, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Raphael Meier
- Division of Abdominal Surgery, Department of Surgery, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,HepatoPancreato-Biliary Centre, Geneva University Hospitals, Geneva, Switzerland
| | - Christian Toso
- Division of Abdominal Surgery, Department of Surgery, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,HepatoPancreato-Biliary Centre, Geneva University Hospitals, Geneva, Switzerland
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18
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Ahmed A, Gonzalez SA, Cholankeril G, Perumpail RB, McGinnis J, Saab S, Beckerman R, Younossi ZM. Treatment of patients waitlisted for liver transplant with all-oral direct-acting antivirals is a cost-effective treatment strategy in the United States. Hepatology 2017; 66:46-56. [PMID: 28257591 DOI: 10.1002/hep.29137] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 01/13/2017] [Accepted: 02/24/2017] [Indexed: 12/15/2022]
Abstract
UNLABELLED All-oral direct acting antivirals (DAAs) have been shown to have high safety and efficacy in treating patients with hepatitis C virus (HCV) awaiting liver transplant (LT). However, there is limited empirical evidence comparing the health and economic outcomes associated with treating patients pre-LT versus post-LT. The objective of this study was to analyze the cost-effectiveness of pre-LT versus post-LT treatment with an all-oral DAA regimen among HCV patients with hepatocellular carcinoma (HCC) or decompensated cirrhosis (DCC). We constructed decision-analytic Markov models of the natural disease progression of HCV in HCC patients and DCC patients waitlisted for LT. The model followed hypothetical cohorts of 1,000 patients with a mean age of 50 over a 30-year time horizon from a third-party US payer perspective and estimated their health and cost outcomes based on pre-LT versus post-LT treatment with an all-oral DAA regimen. Transition probabilities and utilities were based on the literature and hepatologist consensus. Sustained virological response rates were sourced from ASTRAL-4, SOLAR-1, and SOLAR-2. Costs were sourced from RedBook, Medicare fee schedules, and published literature. In the HCC analysis, the pre-LT treatment strategy resulted in 11.48 per-patient quality-adjusted life years and $365,948 per patient lifetime costs versus 10.39 and $283,696, respectively, in the post-LT arm. In the DCC analysis, the pre-LT treatment strategy resulted in 9.27 per-patient quality-adjusted life years and $304,800 per patient lifetime costs versus 8.7 and $283,789, respectively, in the post-LT arm. As such, the pre-LT treatment strategy was found to be the most cost-effective in both populations with an incremental cost-effectiveness ratio of $74,255 (HCC) and $36,583 (DCC). Sensitivity and scenario analyses showed that results were most sensitive to the utility of patients post-LT, treatment sustained virological response rates, LT costs, and baseline Model for End-Stage Liver Disease score (DCC analysis only). CONCLUSION The timing of initiation of antiviral treatment for HCV patients with HCC or DCC relative to LT is an important area of clinical and policy research; our results indicate that pre-LT treatment with a highly effective, all-oral DAA regimen provides the best health outcomes and is the most cost-effective strategy for the treatment of HCV patients with HCC or DCC waitlisted for LT. (Hepatology 2017;66:46-56).
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Affiliation(s)
- Aijaz Ahmed
- Stanford University School of Medicine, Stanford, CA
| | | | | | | | | | - Sammy Saab
- University of California Los Angeles, Los Angeles, CA
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19
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Belarmino G, Gonzalez MC, Sala P, Torrinhas RS, Andraus W, D’Albuquerque LAC, Pereira RMR, Caparbo VF, Ferrioli E, Pfrimer K, Damiani L, Heymsfield SB, Waitzberg DL. Diagnosing Sarcopenia in Male Patients With Cirrhosis by Dual-Energy X-Ray Absorptiometry Estimates of Appendicular Skeletal Muscle Mass. JPEN J Parenter Enteral Nutr 2017; 42:24-36. [DOI: 10.1177/0148607117701400] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 02/21/2017] [Indexed: 12/17/2022]
Affiliation(s)
- Giliane Belarmino
- Department of Gastroenterology (LIM 35), Surgical Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Maria Cristina Gonzalez
- Postgraduate Program in Health and Behavior, Universidade Católica de Pelotas, Rio Grande do Sul, Brazil
- Pennington Biomedical Research Center, Baton Rouge, Louisiana, USA
| | - Priscila Sala
- Department of Gastroenterology (LIM 35), Surgical Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Raquel Susana Torrinhas
- Department of Gastroenterology (LIM 35), Surgical Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Wellington Andraus
- Department of Gastroenterology (LIM 35), Surgical Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | - Rosa Maria R. Pereira
- Laboratory of Bone Metabolism, Rheumatology Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Valéria F. Caparbo
- Laboratory of Bone Metabolism, Rheumatology Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Eduardo Ferrioli
- Department of Medical Clinic, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, São Paulo, Brazil
| | - Karina Pfrimer
- Department of Medical Clinic, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, São Paulo, Brazil
| | - Lucas Damiani
- Research Institute, Hospital do Coração de São Paulo, São Paulo, Brazil
| | | | - Dan L. Waitzberg
- Department of Gastroenterology (LIM 35), Surgical Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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20
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Belarmino G, Gonzalez MC, Torrinhas RS, Sala P, Andraus W, D'Albuquerque LAC, Pereira RMR, Caparbo VF, Ravacci GR, Damiani L, Heymsfield SB, Waitzberg DL. Phase angle obtained by bioelectrical impedance analysis independently predicts mortality in patients with cirrhosis. World J Hepatol 2017; 9:401-408. [PMID: 28321276 PMCID: PMC5340995 DOI: 10.4254/wjh.v9.i7.401] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Revised: 12/22/2016] [Accepted: 01/11/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the prognostic value of the phase angle (PA) obtained from bioelectrical impedance analysis (BIA) for mortality prediction in patients with cirrhosis. METHODS In total, 134 male cirrhotic patients prospectively completed clinical evaluations and nutritional assessment by BIA to obtain PAs during a 36-mo follow-up period. Mortality risk was analyzed by applying the PA cutoff point recently proposed as a malnutrition marker (PA ≤ 4.9°) in Kaplan-Meier curves and multivariate Cox regression models. RESULTS The patients were divided into two groups according to the PA cutoff value (PA > 4.9°, n = 73; PA ≤ 4.9°, n = 61). Weight, height, and body mass index were similar in both groups, but patients with PAs > 4.9° were younger and had higher mid-arm muscle circumference, albumin, and handgrip-strength values and lower severe ascites and encephalopathy incidences, interleukin (IL)-6/IL-10 ratios and C-reactive protein levels than did patients with PAs ≤ 4.9° (P ≤ 0.05). Forty-eight (35.80%) patients died due to cirrhosis, with a median of 18 mo (interquartile range, 3.3-25.6 mo) follow-up until death. Thirty-one (64.60%) of these patients were from the PA ≤ 4.9° group. PA ≤ 4.9° significantly and independently affected the mortality model adjusted for Model for End-Stage Liver Disease score and age (hazard ratio = 2.05, 95%CI: 1.11-3.77, P = 0.021). In addition, Kaplan-Meier curves showed that patients with PAs ≤ 4.9° were significantly more likely to die. CONCLUSION In male patients with cirrhosis, the PA ≤ 4.9° cutoff was associated independently with mortality and identified patients with worse metabolic, nutritional, and disease progression profiles. The PA may be a useful and reliable bedside tool to evaluate prognosis in cirrhosis.
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Affiliation(s)
- Giliane Belarmino
- Giliane Belarmino, Raquel S Torrinhas, Priscila Sala, Wellington Andraus, Luiz Augusto Carneiro D'Albuquerque, Graziela R Ravacci, Dan L Waitzberg, Department of Gastroenterology, Surgical Division, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-000, Brazil
| | - Maria Cristina Gonzalez
- Giliane Belarmino, Raquel S Torrinhas, Priscila Sala, Wellington Andraus, Luiz Augusto Carneiro D'Albuquerque, Graziela R Ravacci, Dan L Waitzberg, Department of Gastroenterology, Surgical Division, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-000, Brazil
| | - Raquel S Torrinhas
- Giliane Belarmino, Raquel S Torrinhas, Priscila Sala, Wellington Andraus, Luiz Augusto Carneiro D'Albuquerque, Graziela R Ravacci, Dan L Waitzberg, Department of Gastroenterology, Surgical Division, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-000, Brazil
| | - Priscila Sala
- Giliane Belarmino, Raquel S Torrinhas, Priscila Sala, Wellington Andraus, Luiz Augusto Carneiro D'Albuquerque, Graziela R Ravacci, Dan L Waitzberg, Department of Gastroenterology, Surgical Division, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-000, Brazil
| | - Wellington Andraus
- Giliane Belarmino, Raquel S Torrinhas, Priscila Sala, Wellington Andraus, Luiz Augusto Carneiro D'Albuquerque, Graziela R Ravacci, Dan L Waitzberg, Department of Gastroenterology, Surgical Division, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-000, Brazil
| | - Luiz Augusto Carneiro D'Albuquerque
- Giliane Belarmino, Raquel S Torrinhas, Priscila Sala, Wellington Andraus, Luiz Augusto Carneiro D'Albuquerque, Graziela R Ravacci, Dan L Waitzberg, Department of Gastroenterology, Surgical Division, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-000, Brazil
| | - Rosa Maria R Pereira
- Giliane Belarmino, Raquel S Torrinhas, Priscila Sala, Wellington Andraus, Luiz Augusto Carneiro D'Albuquerque, Graziela R Ravacci, Dan L Waitzberg, Department of Gastroenterology, Surgical Division, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-000, Brazil
| | - Valéria F Caparbo
- Giliane Belarmino, Raquel S Torrinhas, Priscila Sala, Wellington Andraus, Luiz Augusto Carneiro D'Albuquerque, Graziela R Ravacci, Dan L Waitzberg, Department of Gastroenterology, Surgical Division, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-000, Brazil
| | - Graziela R Ravacci
- Giliane Belarmino, Raquel S Torrinhas, Priscila Sala, Wellington Andraus, Luiz Augusto Carneiro D'Albuquerque, Graziela R Ravacci, Dan L Waitzberg, Department of Gastroenterology, Surgical Division, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-000, Brazil
| | - Lucas Damiani
- Giliane Belarmino, Raquel S Torrinhas, Priscila Sala, Wellington Andraus, Luiz Augusto Carneiro D'Albuquerque, Graziela R Ravacci, Dan L Waitzberg, Department of Gastroenterology, Surgical Division, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-000, Brazil
| | - Steven B Heymsfield
- Giliane Belarmino, Raquel S Torrinhas, Priscila Sala, Wellington Andraus, Luiz Augusto Carneiro D'Albuquerque, Graziela R Ravacci, Dan L Waitzberg, Department of Gastroenterology, Surgical Division, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-000, Brazil
| | - Dan L Waitzberg
- Giliane Belarmino, Raquel S Torrinhas, Priscila Sala, Wellington Andraus, Luiz Augusto Carneiro D'Albuquerque, Graziela R Ravacci, Dan L Waitzberg, Department of Gastroenterology, Surgical Division, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-000, Brazil
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21
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Caire MT, Kumar A, Stravitz RT, Kemmer N. Preliver transplant red cell distribution width predicts postliver transplant mortality. Clin Transplant 2017; 31. [PMID: 28054385 DOI: 10.1111/ctr.12908] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2017] [Indexed: 12/19/2022]
Abstract
PURPOSE Prognostication following liver transplantation is limited. Red cell distribution width (RDW) has been associated with morbidity and mortality in a variety of diseases. We hypothesize RDW is predictive of mortality postliver transplantation. METHODS We performed a retrospective cohort study of all consecutive liver transplantation recipients at a tertiary care center from January 1, 2012 to December 31, 2012. The primary end point was association of RDW with one-year mortality. Statistical analysis was performed using the Mann-Whitney test, independent samples t test, and regression analysis. Discrimination was assessed by calculating area under receiver operating curves (AUC). A P-value <.05 was considered significant. RESULTS RDW was positively associated with one-year mortality (P<.001). The mean difference for survivors compared to nonsurvivors was 3.9% (95% CI 1.9%-5.9%). The AUC for RDW was 0.831 (95% CI 0.727-0.935), compared to 0.723 (0.539-0.908) for total bilirubin and 0.704 (0.479-0.929) for the international normalized ratio. CONCLUSIONS To our knowledge, this is the first report of an association of RDW with post-LT mortality and the results show the predictive value of pre-LT RDW for one-year mortality.
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Affiliation(s)
- M Thure Caire
- Hepatology and Liver Transplant, Tampa General Medical Group, Tampa, FL, USA
| | - Ambuj Kumar
- Evidence Based Medicine & Outcomes Research, University of South Florida, Tampa, FL, USA
| | - R Todd Stravitz
- Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University, Richmond, VA, USA
| | - Nyingi Kemmer
- Hepatology and Liver Transplant, Tampa General Medical Group, Tampa, FL, USA
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22
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Axelrod D, Schnitzler MA, Xiao H, Naik AS, Segev DL, Dharnidharka VR, Brennan DC, Lentine KL. The Changing Financial Landscape of Renal Transplant Practice: A National Cohort Analysis. Am J Transplant 2017; 17:377-389. [PMID: 27565133 PMCID: PMC5524376 DOI: 10.1111/ajt.14018] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 07/17/2016] [Accepted: 08/07/2016] [Indexed: 01/25/2023]
Abstract
Kidney transplantation has become more resource intensive as recipient complexity has increased and average donor quality has diminished over time. A national retrospective cohort study was performed to assess the impact of kidney donor and recipient characteristics on transplant center cost (exclusive of organ acquisition) and Medicare reimbursement. Data from the national transplant registry, University HealthSystem Consortium hospital costs, and Medicare payments for deceased donor (N = 53 862) and living donor (N = 36 715) transplants from 2002 to 2013 were linked and analyzed using multivariate linear regression modeling. Deceased donor kidney transplant costs were correlated with recipient (Expected Post Transplant Survival Score, degree of allosensitization, obesity, cause of renal failure), donor (age, cause of death, donation after cardiac death, terminal creatinine), and transplant (histocompatibility matching) characteristics. Living donor costs rose sharply with higher degrees of allosensitization, and were also associated with obesity, cause of renal failure, recipient work status, and 0-ABDR mismatching. Analysis of Medicare payments for a subsample of 24 809 transplants demonstrated minimal correlation with patient and donor characteristics. In conclusion, the complexity in the landscape of kidney transplantation increases center costs, posing financial disincentives that may reduce organ utilization and limit access for higher-risk populations.
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Affiliation(s)
- David Axelrod
- Department of Surgery, Brody School of Medicine, Greenville,
NC
| | - Mark A. Schnitzler
- Saint Louis University Center for Transplantation, Saint Louis
University School of Medicine, St. Louis, MO
| | - Huiling Xiao
- Saint Louis University Center for Transplantation, Saint Louis
University School of Medicine, St. Louis, MO
| | - Abhijit S. Naik
- Division of Nephrology, Department of Medicine, University of
Michigan, Ann Arbor, MI
| | - Dorry L. Segev
- Division of Abdominal Transplantation, Department of Surgery, Johns
Hopkins University, Baltimore, MD
| | - Vikas R. Dharnidharka
- Division of Nephrology, Department of Pediatrics, Washington
University School of Medicine, St. Louis, MO
| | - Daniel C. Brennan
- Division of Nephrology, Department of Medicine, Washington
University School of Medicine, St. Louis, MO
| | - Krista L. Lentine
- Saint Louis University Center for Transplantation, Saint Louis
University School of Medicine, St. Louis, MO
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23
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Nicolas CT, Nyberg SL, Heimbach JK, Watt K, Chen HS, Hathcock MA, Kremers WK. Liver transplantation after share 35: Impact on pretransplant and posttransplant costs and mortality. Liver Transpl 2017; 23:11-18. [PMID: 27658200 DOI: 10.1002/lt.24641] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 09/06/2016] [Indexed: 12/31/2022]
Abstract
Share 35 was implemented in 2013 to direct livers to the most urgent candidates by prioritizing Model for End-Stage Liver Disease (MELD) ≥ 35 patients. We aim to evaluate this policy's impact on costs and mortality. Our study includes 834 wait-listed patients and 338 patients who received deceased donor, solitary liver transplants at Mayo Clinic between January 2010 and December 2014. Of these patients, 101 (30%) underwent transplantation after Share 35. After Share 35, 29 (28.7%) MELD ≥ 35 patients received transplants, as opposed to 46 (19.4%) in the pre-Share 35 era (P = 0.06). No significant difference in 90-day wait-list mortality (P = 0.29) nor 365-day posttransplant mortality (P = 0.68) was found between patients transplanted before or after Share 35. Mean costs were $3,049 (P = 0.30), $5226 (P = 0.18), and $10,826 (P = 0.03) lower post-Share 35 for the 30-, 90-, and 365-day pretransplant periods, and mean costs were $5010 (P = 0.41) and $5859 (P = 0.57) higher, and $9145 (P = 0.54) lower post-Share 35 for the 30-, 90-, and 365-day posttransplant periods. In conclusion, the added cost of transplanting more MELD ≥ 35 patients may be offset by pretransplant care cost reduction. Despite shifting organs to critically ill patients, Share 35 has not impacted mortality significantly. Liver Transplantation 23:11-18 2017 AASLD.
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Affiliation(s)
- Clara T Nicolas
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
| | - Scott L Nyberg
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN.,Division of General Surgery, Mayo Clinic, Rochester, MN
| | - Julie K Heimbach
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN.,Division of General Surgery, Mayo Clinic, Rochester, MN
| | - Kymberly Watt
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN.,Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Harvey S Chen
- Division of General Surgery, Mayo Clinic, Rochester, MN
| | | | - Walter K Kremers
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN.,Department of Health Sciences Research, Mayo Clinic, Rochester, MN
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24
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Gentry SE, Chow EKH, Dzebisashvili N, Schnitzler MA, Lentine KL, Wickliffe CE, Shteyn E, Pyke J, Israni A, Kasiske B, Segev DL, Axelrod DA. The Impact of Redistricting Proposals on Health Care Expenditures for Liver Transplant Candidates and Recipients. Am J Transplant 2016; 16:583-93. [PMID: 26779694 DOI: 10.1111/ajt.13569] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 08/27/2015] [Accepted: 09/04/2015] [Indexed: 01/25/2023]
Abstract
Redistricting, which means sharing organs in novel districts developed through mathematical optimization, has been proposed to reduce pervasive geographic disparities in access to liver transplantation. The economic impact of redistricting was evaluated with two distinct data sources, Medicare claims and the University HealthSystem Consortium (UHC). We estimated total Medicare payments under (i) the current allocation system (Share 35), (ii) full regional sharing, (iii) an eight-district plan, and (iv) a four-district plan for a simulated population of patients listed for liver transplant over 5 years, using the liver simulated allocation model. The model predicted 5-year transplant volumes (Share 35, 29,267; regional sharing, 29,005; eight districts, 29,034; four districts, 28,265) and a reduction in overall mortality, including listed and posttransplant patients, of up to 676 lives. Compared with current allocation, the eight-district plan was estimated to reduce payments for pretransplant care ($1638 million to $1506 million, p < 0.001), transplant episode ($5607 million to $5569 million, p < 0.03) and posttransplant care ($479 million to $488 million, p < 0.001). The eight-district plan was estimated to increase per-patient transportation costs for organs ($8988 to $11,874 per patient, p < 0.001) and UHC estimated hospital costs ($4699 per case). In summary, redistricting appears to be potentially cost saving for the health care system but will increase the cost of performing liver transplants for some transplant centers.
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Affiliation(s)
- S E Gentry
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.,Department of Mathematics, United States Naval Academy, Baltimore, MD.,Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN
| | - E K H Chow
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - N Dzebisashvili
- St. Louis University Center for Outcomes Research, Saint Louis, MO.,Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - M A Schnitzler
- St. Louis University Center for Outcomes Research, Saint Louis, MO
| | - K L Lentine
- St. Louis University Center for Outcomes Research, Saint Louis, MO
| | - C E Wickliffe
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - E Shteyn
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN
| | - J Pyke
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN
| | - A Israni
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN.,Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN.,Department of Medicine, Hennepin County Medical Center, University of Minnesota, Minneapolis, MN
| | - B Kasiske
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN.,Department of Medicine, Hennepin County Medical Center, University of Minnesota, Minneapolis, MN
| | - D L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.,Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN
| | - D A Axelrod
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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25
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Abstract
Hyperglycemia is common following organ transplantation, regardless of the pre-transplant diabetes status. Transient post-transplant hyperglycemia and/or new-onset diabetes after transplantation (NODAT) are common and are associated with increased morbidity and mortality. NODAT and type 2 diabetes share similar characteristics, but the pathophysiology may differ. Immunosuppressive agents and steroids play a key role in the development of NODAT. Glycemic control is challenging in this population due to fluctuating renal/end-organ function, immunosuppressive dosing, nutritional status, and drug-drug interactions. A proactive and multidisciplinary approach is essential, along with flexible protocols to adjust to patient status, type of organ transplanted, and corticosteroid regimens. Insulin is the preferred agent for hospitalized patients and during the early post-transplant period; optimal glycemic control (BG < 180 mg/dl with minimal hypoglycemia [<70 mg/dl]) is desired.
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Affiliation(s)
- Rodolfo J Galindo
- Division of Endocrinology, Diabetes, and Bone Diseases, Icahn School of Medicine at Mount Sinai, Mount Sinai St. Luke's Hospital, 1111 Amsterdam Ave, Babcock Building, 10th floor, Room 1020, New York, NY, 10025, USA.
| | - Amisha Wallia
- Division of Endocrinology, Metabolism and Molecular Medicine, Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, 654 N Michigan Avenue, Suite 530, Chicago, IL, 60611, USA.
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26
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Panchal HJ, Durinka JB, Patterson J, Karipineni F, Ashburn S, Siskind E, Ortiz J. Survival outcomes in liver transplant recipients with Model for End-stage Liver Disease scores of 40 or higher: a decade-long experience. HPB (Oxford) 2015; 17:1074-84. [PMID: 26373873 PMCID: PMC4644359 DOI: 10.1111/hpb.12485] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 07/01/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND The Model for End-stage Liver Disease (MELD) has been used as a prognostic tool since 2002 to predict pre-transplant mortality. Increasing proportions of transplant candidates with higher MELD scores, combined with improvements in transplant outcomes, mandate the need to study surgical outcomes in patients with MELD scores of ≥40. METHODS A retrospective longitudinal analysis of United Network for Organ Sharing (UNOS) data on all liver transplantations performed between February 2002 and June 2011 (n = 33,398) stratified by MELD score (<30, 30-39, ≥40) was conducted. The primary outcomes of interest were short- and longterm graft and patient survival. A Kaplan-Meier product limit method and Cox regression were used. A subanalysis using a futile population was performed to determine futility predictors. RESULTS Of the 33,398 transplant recipients analysed, 74% scored <30, 18% scored 30-39, and 8% scored ≥40 at transplantation. Recipients with MELD scores of ≥40 were more likely to be younger (P < 0.001), non-White and to have shorter waitlist times (P < 0.001). Overall patient survival correlated inversely with increasing MELD score; this trend was consistent for both short-term (30 days and 90 days) and longterm (1, 3 and 5 years) graft and patient survival. In multivariate analysis, increasing age, African-American ethnicity, donor obesity and diabetes were negative predictors of survival. Futility predictors included patient age of >60 years, obesity, peri-transplantation intensive care unit hospitalization with ventilation, and multiple comorbidities. CONCLUSIONS Liver transplantation in recipients with MELD scores of ≥40 offers acceptable longterm survival outcomes. Futility predictors indicate the need for prospective follow-up studies to define the population to gain the highest benefit from this precious resource.
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Affiliation(s)
- Hina J Panchal
- Department of Genetics & Genomic Science and Gastroenterology, Icahn School of Medicine at Mount SinaiNew York, NY, USA
| | - Joel B Durinka
- Department of Surgery, Albert Einstein Medical CenterPhiladelphia, PA, USA
| | - Jeromy Patterson
- Department of Surgery, Emory University School of MedicineAtlanta, GA, USA
| | - Farah Karipineni
- Department of Surgery, Albert Einstein Medical CenterPhiladelphia, PA, USA
| | - Sarah Ashburn
- Department of Surgery, Hofstra–North Shore LIJ School of MedicineHempstead, NY, USA
| | - Eric Siskind
- Department of Transplantation, North Shore LIJ HospitalManhasset, NY, USA
| | - Jorge Ortiz
- Department of Transplantation, University of Toledo Medical CenterToledo, OH, USA
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27
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Pardo F, Pons JA, Briceño J. V Reunión de Consenso de la Sociedad Española de Trasplante Hepático sobre receptores de riesgo elevado, escenarios actuales de inmunosupresión y manejo del hepatocarcinoma en espera de trasplante. Cir Esp 2015; 93:619-37. [DOI: 10.1016/j.ciresp.2015.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 04/17/2015] [Indexed: 12/11/2022]
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28
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V Reunión de Consenso de la Sociedad Española de Trasplante Hepático sobre receptores de riesgo elevado, escenarios actuales de inmunosupresión y manejo del hepatocarcinoma en espera de trasplante. GASTROENTEROLOGIA Y HEPATOLOGIA 2015; 38:600-18. [DOI: 10.1016/j.gastrohep.2015.06.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 06/11/2015] [Accepted: 06/30/2015] [Indexed: 12/14/2022]
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29
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Gentry S, Chow E, Massie A, Segev D. Gerrymandering for Justice: Redistricting U.S. Liver Allocation. INTERFACES 2015; 45:462-480. [PMID: 34421152 PMCID: PMC8376030 DOI: 10.1287/inte.2015.0810] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
U.S. organ allocation policy sequesters livers from deceased donors within arbitrary geographic boundaries, frustrating the intent of those who wish to offer the livers to transplant candidates based on medical urgency. We used a zero-one integer program to partition 58 donor service areas into between four and eight sharing districts that minimize the disparity in liver availability among districts. Because the integer program necessarily suppressed clinically significant differences among patients and organs, we tested the optimized district maps with a discrete-event simulation tool that represents liver allocation at a per-person, per-organ level of detail. In April 2014, the liver committee of the Organ Procurement and Transplantation Network (OPTN) decided in a unanimous vote of 22-0-0 to write a policy proposal based on our eight-district and four-district maps. The OPTN board of directors could implement the policy after the proposal and public-comment period.Redistricting liver allocation would save hundreds of lives over the next five years and would attenuate the serious geographic inequity in liver transplant offers.
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Affiliation(s)
- Sommer Gentry
- Mathematics Department, United States Naval Academy, Annapolis, Maryland 21402; and Johns Hopkins University School of Medicine, Baltimore, Maryland 21287
| | - Eric Chow
- Johns Hopkins University School of Medicine, Baltimore, Maryland 21287
| | - Allan Massie
- Johns Hopkins University School of Medicine, Baltimore, Maryland 21287; and Johns Hopkins University School of Public Health, Baltimore, Maryland 21287
| | - Dorry Segev
- Johns Hopkins University School of Medicine, Baltimore, Maryland 21287; and Johns Hopkins University School of Public Health, Baltimore, Maryland 21287
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30
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Goldberg DS, French B, Abt PL, Gilroy RK. Increasing the Number of Organ Transplants in the United States by Optimizing Donor Authorization Rates. Am J Transplant 2015; 15:2117-25. [PMID: 26031323 DOI: 10.1111/ajt.13362] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 02/23/2015] [Accepted: 02/26/2015] [Indexed: 01/25/2023]
Abstract
While recent policies have focused on allocating organs to patients most in need and lessening geographic disparities, the only mechanism to increase the actual number of transplants is to maximize the potential organ supply. We conducted a retrospective cohort study using OPTN data on all "eligible deaths" from 1/1/08 to 11/1/13 to evaluate variability in donor service area (DSA)-level donor authorization rates, and to quantify the potential gains associated with increasing authorization rates. Despite adjustments for donor demographics (age, race/ethnicity, cause of death) and geographic factors (rural/urban status of donor hospital, statewide participation in deceased-donor registries) among 52 571 eligible deaths, there was significant variability (p < 0.001) in donor authorization rates across the 58 DSAs. Overall DSA-level adjusted authorization rates ranged from 63.5% to 89.5% (median: 72.7%). An additional 773-1623 eligible deaths could have been authorized, yielding 2679-5710 total organs, if the DSAs with authorization rates below the median and 75th percentile, respectively, implemented interventions to perform at the level of the corresponding reference DSA. Opportunities exist within the current organ acquisition framework to markedly improve DSA-level donor authorization rates. Such initiatives would mitigate waitlist mortality while increasing the number of transplants.
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Affiliation(s)
- D S Goldberg
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - B French
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - P L Abt
- Division of Transplantation, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - R K Gilroy
- Center for Transplantation and Department of Medicine, University of Kansas Medical Center, Kansas City, KS
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31
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Habka D, Mann D, Landes R, Soto-Gutierrez A. Future Economics of Liver Transplantation: A 20-Year Cost Modeling Forecast and the Prospect of Bioengineering Autologous Liver Grafts. PLoS One 2015; 10:e0131764. [PMID: 26177505 PMCID: PMC4503760 DOI: 10.1371/journal.pone.0131764] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 06/05/2015] [Indexed: 12/13/2022] Open
Abstract
During the past 20 years liver transplantation has become the definitive treatment for most severe types of liver failure and hepatocellular carcinoma, in both children and adults. In the U.S., roughly 16,000 individuals are on the liver transplant waiting list. Only 38% of them will receive a transplant due to the organ shortage. This paper explores another option: bioengineering an autologous liver graft. We developed a 20-year model projecting future demand for liver transplants, along with costs based on current technology. We compared these cost projections against projected costs to bioengineer autologous liver grafts. The model was divided into: 1) the epidemiology model forecasting the number of wait-listed patients, operated patients and postoperative patients; and 2) the treatment model forecasting costs (pre-transplant-related costs; transplant (admission)-related costs; and 10-year post-transplant-related costs) during the simulation period. The patient population was categorized using the Model for End-Stage Liver Disease score. The number of patients on the waiting list was projected to increase 23% over 20 years while the weighted average treatment costs in the pre-liver transplantation phase were forecast to increase 83% in Year 20. Projected demand for livers will increase 10% in 10 years and 23% in 20 years. Total costs of liver transplantation are forecast to increase 33% in 10 years and 81% in 20 years. By comparison, the projected cost to bioengineer autologous liver grafts is $9.7M based on current catalog prices for iPS-derived liver cells. The model projects a persistent increase in need and cost of donor livers over the next 20 years that’s constrained by a limited supply of donor livers. The number of patients who die while on the waiting list will reflect this ever-growing disparity. Currently, bioengineering autologous liver grafts is cost prohibitive. However, costs will decline rapidly with the introduction of new manufacturing strategies and economies of scale.
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Affiliation(s)
| | - David Mann
- Cellular Dynamics International, Madison, WI, United States of America
| | - Ronald Landes
- Solving Organ Shortage, Austin, TX, United States of America
- * E-mail: (ASG); (RL)
| | - Alejandro Soto-Gutierrez
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA, United States of America
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, United States of America
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
- SOS Whole Liver Research Community, Austin, TX, United States of America
- * E-mail: (ASG); (RL)
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32
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Asrani SK, Kamath PS. Model for end-stage liver disease score and MELD exceptions: 15 years later. Hepatol Int 2015; 9:346-54. [PMID: 26016462 DOI: 10.1007/s12072-015-9631-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 04/06/2015] [Indexed: 02/06/2023]
Abstract
The model for end-stage liver disease (MELD) score has been used as an objective scale of disease severity for management of patients with end-stage liver disease; it currently serves as the basis of an urgency-based organ-allocation policy in several countries. Implementation of the MELD score led to a reduction in waiting-list registration and waiting-list mortality and an increase in the number of deceased-donor transplants without adversely affecting long-term outcomes after liver transplantation (LT). The MELD score has been used for management of non-transplant patients with chronic liver disease. MELD exceptions serve as a mechanism to advance the needs of subsets of patients with liver disease not adequately addressed by MELD-based organ allocation. Several models have been proposed to refine and improve the MELD score as the environment within which it operates continues to evolve toward transplantation for sicker patients. The MELD score continues to serve and be used as a template to improve upon as an objective gauge of disease severity and as a metric enabling optimization of allocation of scarce donor organs for LT.
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Affiliation(s)
- Sumeet K Asrani
- Baylor University Medical Center, 3410 Worth Street Suite 860, Dallas, TX, 75246, USA,
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33
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Sarkar M, Watt KD, Terrault N, Berenguer M. Outcomes in liver transplantation: does sex matter? J Hepatol 2015; 62:946-55. [PMID: 25433162 PMCID: PMC5935797 DOI: 10.1016/j.jhep.2014.11.023] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 11/05/2014] [Accepted: 11/16/2014] [Indexed: 02/06/2023]
Abstract
A growing literature has highlighted important differences in transplant-related outcomes between men and women. In the United States there are fewer women than men on the liver transplant waitlist and women are two times less likely to receive a deceased or living-related liver transplant. Sex-based differences exist not only in waitlist but also in post-transplant outcomes, particularly in some specific liver diseases, such as hepatitis C. In the era of individualized medicine, recognition of these differences in the approach to pre and post-liver transplant care may impact short and long-term outcomes.
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Affiliation(s)
- Monika Sarkar
- Division of Gastroenterology and Hepatology, University of California, San Francisco, 513 Parnassus Avenue, S-357, San Francisco, CA 94143, USA.
| | - Kymberly D Watt
- Division of Gastroenterology and Hepatology, Mayo Clinic and Foundation, 200 First St, Rochester, MN 55905, USA
| | - Norah Terrault
- Division of Gastroenterology and Hepatology, University of California, San Francisco, 513 Parnassus Avenue, S-357, San Francisco, CA 94143, USA
| | - Marina Berenguer
- Hepatology and Liver Transplantation Unit, La Fe Hospital and Ciberehd, Universidad Valencia, C/Bulevar Sur sn (Torre F-5) 46026 Valencia, Spain
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34
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Patel MS, Kohn R, Kratz JR, Shah JA, Markmann JF, Vagefi PA. The race to liver transplantation: a comparison of patients with and without hepatocellular carcinoma from listing to post-transplantation. J Am Coll Surg 2015; 220:1001-7. [PMID: 25868408 DOI: 10.1016/j.jamcollsurg.2014.12.050] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Revised: 12/12/2014] [Accepted: 12/15/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND There are geographic and disease-specific inequities in liver allograft distribution. We examined differences between hepatocellular carcinoma (HCC) and non-HCC liver transplantation (LT) candidates from listing through LT in a region with prolonged wait times. STUDY DESIGN We performed a single-center retrospective study, from 2005 to 2013, of adult, primary, nonstatus 1 candidates who were listed and subsequently underwent LT (n=270), or were removed because of death or clinical deterioration (n=277). RESULTS Of the HCC candidates removed from the waitlist (n=184), 5.5% died waiting, 25.5% deteriorated clinically, and 69% had LT. Of the non-HCC candidates (n=363), 38.8% died waiting, 21.8% clinically deteriorated, and 39.4% had LT. Of the LT recipients, 127 (47%) had HCC. When compared with non-HCC transplant recipients, HCC recipients spent more time on the waitlist (435±475 vs 301±604 days, p=0.045) and from listing until LT had higher total pre-transplant hospital admissions per patient (1.1±1.2 vs 0.8±1.8, p<0.001). These admissions were more often planned (0.65±0.88 vs 0.17±0.52 planned admissions per patient, p<0.001) and of shorter duration (2.7±2.8 vs 5.2±4.6 days, p<0.001). The HCC and non-HCC recipients demonstrated similar overall post-transplant survival (5 year 80% vs. 83%, respectively; p=0.84). CONCLUSIONS Despite a shorter wait to have LT, non-HCC candidates at our center have inferior waitlist outcomes. National reprioritization of liver allocation to improve access for non-HCC candidates may lead to increased wait time and resource use for the HCC population; however, a mortality benefit may exist for the non-HCC candidate lacking the benefit of time.
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Affiliation(s)
- Madhukar S Patel
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Rachel Kohn
- Department of Pulmonary and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Johannes R Kratz
- Department of Surgery, University of California San Francisco, San Francisco, CA
| | - Jigesh A Shah
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - James F Markmann
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Parsia A Vagefi
- Department of Surgery, Massachusetts General Hospital, Boston, MA.
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Abstract
The success of liver transplantation in the past three decades as a life-saving procedure for patients with end-stage liver disease has led to the ever-increasing disparity between the demands for liver transplantation and the supply of donor liver organs. Donor allocation and distribution remains a challenge and a moral issue as to how these organs can be equitably distributed. This article reviews the evolution of the liver allocation policy and discusses in detail the challenges clinicians face today in this area of medicine.
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Abstract
PURPOSE OF REVIEW This article examines recent health services and policy research studies in hepatology and liver transplantation. RECENT FINDINGS Critical issues include access to medical care, timeliness of referral and consultation, resource utilization in clinical practice, comparative effectiveness research, and the evaluation of care delivery models. Despite policymaking efforts, there continues to be unwarranted variation in access to subspecialty care and liver transplantation services based on race and geographic location. Variations in primary care and specialist awareness of practice guidelines for liver disease contribute to disparities in appropriateness and timeliness of treatments. Defining the cost-effectiveness of increased resource utilization for novel antiviral therapies and liver transplantation continues to stimulate controversy. Few comparative effectiveness studies in hepatology exist to date, yet a growing number of analyses using national datasets will help inform policy in this arena. Identifying care delivery models that demonstrate high value for populations with chronic liver disease is critical in the context of recent healthcare reform efforts. SUMMARY Health services and policy research is a growing field of investigation in hepatology and liver transplantation. Further emphasis on research training and workforce development in this area will be critical for understanding and improving patient-centered outcomes for this population.
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Abouljoud MS, Brown KA, Nerenz DR. Sicker patients with end-stage liver disease cost more: a quick fix?: an editorial on assessing variation in the costs of care among patients awaiting liver transplantation. Am J Transplant 2014; 14:9-10. [PMID: 24165228 DOI: 10.1111/ajt.12498] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Revised: 09/03/2013] [Accepted: 09/06/2013] [Indexed: 01/25/2023]
Affiliation(s)
- M S Abouljoud
- Division of Transplant/Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI
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