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Germani G, Ferrarese A, D'Arcangelo F, Russo FP, Senzolo M, Gambato M, Zanetto A, Cillo U, Feltracco P, Persona P, Serra E, Feltrin G, Carretta G, Capizzi A, Donato D, Tessarin M, Burra P. The role of an integrated referral program for patients with liver disease: A network between hub and spoke centers. United European Gastroenterol J 2024; 12:76-88. [PMID: 38087960 PMCID: PMC10859718 DOI: 10.1002/ueg2.12475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 07/31/2023] [Indexed: 02/13/2024] Open
Abstract
INTRODUCTION Access to Liver transplantation (LT) can be affected by several barriers, resulting in delayed referral and increased risk of mortality due to complications of the underlying liver disease. AIM To assess the clinical characteristics and outcomes of patients with acute or chronic liver disease referred using an integrated referral program. MATERIALS AND METHODS An integrated referral program was developed in 1 October 2017 based on email addresses and a 24/7 telephone availability. All consecutive adult patients with liver disease referred for the first time using this referral program were prospectively collected until 1 October 2021. Characteristics and outcomes of inpatients were compared with a historical cohort of patients referred without using the integrated referral program (1 October 2015-1 October 2017). Patients were further divided according to pre- and post-Covid-19 pandemic. RESULTS Two hundred eighty-one referred patients were considered. End stage liver disease was the most common underlying condition (79.3%), 50.5% of patients were referred as inpatients and 74.7% were referred for LT evaluation. When inpatient referrals (n = 142) were compared with the historical cohort (n = 86), a significant increase in acute liver injury due to drugs/herbals and supplements was seen (p = 0.01) as well as an increase in End stage liver disease due to alcohol-related liver disease and NASH, although not statistically significant. A significant increase in referrals for evaluation for Trans-jugular intrahepatic portosystemic shunt placement was seen over time (5.6% vs. 1%; p = 0.01) as well as for LT evaluation (84.5% vs. 81%; p = 0.01). Transplant-free survival was similar between the study and control groups (p = 0.3). The Covid-19 pandemic did not affect trends of referrals and patient survival. CONCLUSIONS The development of an integrated referral program for patients with liver disease can represent the first step to standardize already existing referral networks between hub and spoke centers. Future studies should focus on the timing of referral according to different etiologies to optimize treatment options and outcomes.
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Affiliation(s)
- Giacomo Germani
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Alberto Ferrarese
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Francesca D'Arcangelo
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Francesco Paolo Russo
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Marco Senzolo
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Martina Gambato
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Alberto Zanetto
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Umberto Cillo
- Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Paolo Feltracco
- Intensive Care Unit, Padua University Hospital, Padua, Italy
| | - Paolo Persona
- Intensive Care Unit, Padua University Hospital, Padua, Italy
| | - Eugenio Serra
- Intensive Care Unit, Padua University Hospital, Padua, Italy
| | | | | | - Alfio Capizzi
- Medical Direction, Padua University Hospital, Padua, Italy
| | - Daniele Donato
- Medical Direction, Padua University Hospital, Padua, Italy
| | | | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
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Steinberg I, Patrono D, De Cesaris E, Lucà M, Catalano G, Marro M, Rizza G, Simonato E, Brazzi L, Romagnoli R, Zanierato M. Viability assessment of livers donated after circulatory determination of death during normothermic regional perfusion. Artif Organs 2023; 47:1592-1603. [PMID: 37548353 DOI: 10.1111/aor.14622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 06/14/2023] [Accepted: 07/25/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND Abdominal normothermic regional perfusion (A-NRP) allows in-situ reperfusion and recovery of abdominal organs metabolism in donors after circulatory death (DCD). Besides improving liver transplantation outcomes, liver injury and function can be assessed during A-NRP. METHODS To refine liver viability assessment during A-NRP, prospectively collected data of controlled DCD donors managed at our Institution between October 2019 and May 2022 were retrospectively analyzed. Baseline characteristics, procedural variables and A-NRP parameters of donors whose liver was successfully transplanted were compared to those of donors whose liver was discarded. RESULTS Twenty-seven donors were included and in 20 (74%) the liver was accepted (positive outcome). No differences between study groups were observed concerning baseline characteristics and warm ischemia times (WIT). Initial lactate levels were positively correlated with functional WIT (r2 = 0.4, p = 0.04), whereas transaminase levels were not. Blood flow during A-NRP was comparable, whereas oxygen consumption (VO2 ) was significantly higher in the positive outcome group after 1 h. Time courses of lactate, AST and ALT were significantly different between study groups (p < 0.001). Donors whose liver was accepted showed faster lactate clearance, a difference which was amplified by normalizing lactate clearance to oxygen delivery (DO2 ) and VO2 . Lactate clearance was correlated to transaminase levels and DO2 -normalized lactate clearance was the parameter best discriminating between study groups. CONCLUSIONS DO2 -normalized lactate clearance may represent an element of liver viability assessment during A-NRP.
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Affiliation(s)
- Irene Steinberg
- Department of Anesthesia and Critical Care, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
- Department of Surgical Sciences, University of Turin, Turin, Italy
- Department of Mechanical and Aerospace Engineering, Polytechnic University of Turin, Turin, Italy
| | - Damiano Patrono
- General Surgery 2U - Liver Transplant Center, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Enrico De Cesaris
- Department of Anesthesia and Critical Care, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Michele Lucà
- Department of Anesthesia and Critical Care, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Giorgia Catalano
- General Surgery 2U - Liver Transplant Center, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Matteo Marro
- Cardiovascular Surgery, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Giorgia Rizza
- General Surgery 2U - Liver Transplant Center, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Erika Simonato
- Cardiovascular Surgery, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Luca Brazzi
- Department of Anesthesia and Critical Care, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Renato Romagnoli
- Department of Surgical Sciences, University of Turin, Turin, Italy
- General Surgery 2U - Liver Transplant Center, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Marinella Zanierato
- Department of Anesthesia and Critical Care, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
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Ivanics T, Claasen MPAW, Patel MS, Giorgakis E, Khorsandi SE, Srinivasan P, Prachalias A, Menon K, Jassem W, Cortes M, Sayed BA, Mathur AK, Walker K, Taylor R, Heaton N, Mehta N, Segev DL, Massie AB, van der Meulen JHP, Sapisochin G, Wallace D. Outcomes after liver transplantation using deceased after circulatory death donors: A comparison of outcomes in the UK and the US. Liver Int 2023; 43:1107-1119. [PMID: 36737866 DOI: 10.1111/liv.15537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 01/08/2023] [Accepted: 01/23/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIMS Identifying international differences in utilization and outcomes of liver transplantation (LT) after donation after circulatory death (DCD) donation provides a unique opportunity for benchmarking and population-level insight. METHODS Adult (≥18 years) LT data between 2008 and 2018 from the UK and US were used to assess mortality and graft failure after DCD LT. We used time-dependent Cox-regression methods to estimate hazard ratios (HR) for risk-adjusted short-term (0-90 days) and longer-term (90 days-5 years) outcomes. RESULTS One-thousand five-hundred-and-sixty LT receipts from the UK and 3426 from the US were included. Over the study period, the use of DCD livers increased from 15.7% to 23.9% in the UK compared to 5.1% to 7.6% in the US. In the UK, DCD donors were older (UK:51 vs. US:33 years) with longer cold ischaemia time (UK: 437 vs. US: 333 min). Recipients in the US had higher Model for End-stage Liver Disease (MELD) scores, higher body mass index, higher proportions of ascites, encephalopathy, diabetes and previous abdominal surgeries. No difference in the risk-adjusted short-term mortality or graft failure was observed between the countries. In the longer-term (90 days-5 years), the UK had lower mortality and graft failure (adj.mortality HR:UK: 0.63 (95% CI: 0.49-0.80); graft failure HR: UK: 0.72, 95% CI: 0.58-0.91). The cumulative incidence of retransplantation was higher in the UK (5 years: UK: 11.9% vs. 4.6%; p < .001). CONCLUSIONS For those receiving a DCD LT, longer-term post-transplant outcomes in the UK are superior to the US, however, significant differences in recipient illness, graft quality and access to retransplantation were seen between the two countries.
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Affiliation(s)
- Tommy Ivanics
- Multi-Organ Transplant Program, University Health Network, University of Toronto.,Department of Surgery, Henry Ford Hospital, Detroit, Michigan, USA.,Department of Surgical Sciences, Akademiska Sjukhuset, Uppsala University, Uppsala, Sweden
| | - Marco P A W Claasen
- Multi-Organ Transplant Program, University Health Network, University of Toronto.,Department of Surgery, Division of HPB & Transplant Surgery, Erasmus MC Transplant Institute, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Madhukar S Patel
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Emmanouil Giorgakis
- Division of Transplantation, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.,Hepatopancreatobiliary Surgery, Department of Surgical Oncology, Rockefeller Cancer Center Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.,Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | - Shirin E Khorsandi
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK.,The Roger Williams Institute of Hepatology, Foundation for Liver Research, London, UK.,Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Parthi Srinivasan
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | - Andreas Prachalias
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | - Krishna Menon
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | - Wayel Jassem
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | - Miriam Cortes
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | - Blayne A Sayed
- Multi-Organ Transplant Program, University Health Network, University of Toronto
| | - Amit K Mathur
- Division of Transplantation, Department of Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Kate Walker
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Rhiannon Taylor
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Department of Statistics, National Health Service Blood and Transplant, Bristol, UK
| | - Nigel Heaton
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | - Neil Mehta
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, California, USA
| | - Dorry L Segev
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Surgery, NYU Grossman School of Medicine and NYU Langone Health, New York, New York, USA
| | - Allan B Massie
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Surgery, NYU Grossman School of Medicine and NYU Langone Health, New York, New York, USA
| | - Jan H P van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Gonzalo Sapisochin
- Multi-Organ Transplant Program, University Health Network, University of Toronto
| | - David Wallace
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK.,Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Ivanics T, Wallace D, Abreu P, Claasen MPAW, Callaghan C, Cowling T, Walker K, Heaton N, Mehta N, Sapisochin G, van der Meulen J. Survival After Liver Transplantation: An International Comparison Between the United States and the United Kingdom in the Years 2008-2016. Transplantation 2022; 106:1390-1400. [PMID: 34753895 DOI: 10.1097/tp.0000000000003978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Compared with the United States, risk-adjusted mortality in the United Kingdom has historically been worse in the first 90 d following liver transplantation (LT) and better thereafter. In the last decade, there has been considerable change in the practice of LT internationally, but no contemporary large-scale international comparison of posttransplant outcomes has been conducted. This study aimed to determine disease-specific short- and long-term mortality of LT recipients in the United States and the United Kingdom. METHODS This retrospective international multicenter cohort study analyzed adult (≥18 y) first-time LT recipients between January 2, 2008, and December 31, 2016, using the Organ Procurement and Transplantation Network/United Network for Organ Sharing and the UK Transplant Registry databases. Time-dependent Cox regression estimated hazard ratios (HRs) comparing disease-specific risk-adjusted mortality in the first 90 d post-LT, between 90 d and 1 y, and between 1 and 5 y. RESULTS Forty-two thousand eight hundred seventy-four US and 4950 UK LT recipients were included. The main LT indications in the United States and the United Kingdom were hepatocellular carcinoma (25.4% and 24.9%, respectively) and alcohol-related liver disease (20.3% and 27.1%, respectively). There were no differences in mortality during the first 90 d post-LT (reference: United States; HR, 0.96; 95% confidence interval [CI], 0.82-1.12). However, between 90 d and 1 y (HR, 0.71; 95% CI, 0.59-0.85) and 1 and 5 y (HR, 0.71; 95% CI, 0.63-0.81]) the United Kingdom had lower mortality. The mortality differences between 1 and 5 y were most marked in hepatocellular carcinoma (HR, 0.71; 95% CI, 0.58-0.88) and alcohol-related liver disease patients (HR, 0.64; 95% CI, 0.45-0.89). CONCLUSIONS Risk-adjusted mortality in the United States and the United Kingdom was similar in the first 90 d post-LT but better in the United Kingdom thereafter. International comparisons of LT may highlight differences in healthcare delivery and help benchmarking by identifying modifiable factors that can facilitate improved global outcomes in LT.
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Affiliation(s)
- Tommy Ivanics
- Division of General Surgery, Multi-organ Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada
- Department of Surgery, Henry Ford Hospital, Detroit, MI
| | - David Wallace
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Department of Nephrology and Transplantation, Guys and St Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - Phillipe Abreu
- Division of General Surgery, Multi-organ Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Marco P A W Claasen
- Division of General Surgery, Multi-organ Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada
- Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Chris Callaghan
- Department of Nephrology and Transplantation, Guys and St Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - Thomas Cowling
- Institute of Liver Studies, King's College Hospital National Health Service Foundation Trust, London, United Kingdom
| | - Kate Walker
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Nigel Heaton
- Institute of Liver Studies, King's College Hospital National Health Service Foundation Trust, London, United Kingdom
| | - Neil Mehta
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Gonzalo Sapisochin
- Division of General Surgery, Multi-organ Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Ferrarese A, Sartori G, Orrù G, Frigo AC, Pelizzaro F, Burra P, Senzolo M. Machine learning in liver transplantation: a tool for some unsolved questions? Transpl Int 2021; 34:398-411. [PMID: 33428298 DOI: 10.1111/tri.13818] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/24/2020] [Accepted: 01/08/2021] [Indexed: 12/13/2022]
Abstract
Machine learning has recently been proposed as a useful tool in many fields of Medicine, with the aim of increasing diagnostic and prognostic accuracy. Models based on machine learning have been introduced in the setting of solid organ transplantation too, where prognosis depends on a complex, multidimensional and nonlinear relationship between variables pertaining to the donor, the recipient and the surgical procedure. In the setting of liver transplantation, machine learning models have been developed to predict pretransplant survival in patients with cirrhosis, to assess the best donor-to-recipient match during allocation processes, and to foresee postoperative complications and outcomes. This is a narrative review on the role of machine learning in the field of liver transplantation, highlighting strengths and pitfalls, and future perspectives.
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Affiliation(s)
- Alberto Ferrarese
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Giuseppe Sartori
- Forensic Neuropsychology and Forensic Neuroscience, PhD Program in Mind Brain and Computer Science, Department of General Psychology, Padua University, Padua, Italy
| | - Graziella Orrù
- Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Pisa, Italy
| | - Anna Chiara Frigo
- Department of Cardiac-Thoracic-Vascular Sciences and Public Health, Biostatistics, Epidemiology and Public Health Unit, University of Padua, Padova, Veneto, Italy
| | - Filippo Pelizzaro
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Marco Senzolo
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
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Tschuor C, Ferrarese A, Kuemmerli C, Dutkowski P, Burra P, Clavien PA, Imventarza O, Crawford M, Andraus W, D'Albuquerque LAC, Hernandez-Alejandro R, Dokus MK, Tomiyama K, Zheng S, Echeverri GJ, Taimr P, Fronek J, de Rosner-van Rosmalen M, Vogelaar S, Lesurtel M, Mabrut JY, Nagral S, Kakaei F, Malek-Hosseini SA, Egawa H, Contreras A, Czerwinski J, Danek T, Pinto-Marques H, Gautier SV, Monakhov A, Melum E, Ericzon BG, Kang KJ, Kim MS, Sanchez-Velazquez P, Oberkofler CE, Müllhaupt B, Linecker M, Eshmuminov D, Grochola LF, Song Z, Kambakamba P, Chen CL, Haberal M, Yilmaz S, Rowe IA, Kron P. Allocation of liver grafts worldwide - Is there a best system? J Hepatol 2019; 71:707-718. [PMID: 31199941 DOI: 10.1016/j.jhep.2019.05.025] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 05/23/2019] [Accepted: 05/27/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS An optimal allocation system for scarce resources should simultaneously ensure maximal utility, but also equity. The most frequent principles for allocation policies in liver transplantation are therefore criteria that rely on pre-transplant survival (sickest first policy), post-transplant survival (utility), or on their combination (benefit). However, large differences exist between centers and countries for ethical and legislative reasons. The aim of this study was to report the current worldwide practice of liver graft allocation and discuss respective advantages and disadvantages. METHODS Countries around the world that perform 95 or more deceased donor liver transplantations per year were analyzed for donation and allocation policies, as well as recipient characteristics. RESULTS Most countries use the model for end-stage liver disease (MELD) score, or variations of it, for organ allocation, while some countries opt for center-based allocation systems based on their specific requirements, and some countries combine both a MELD and center-based approach. Both the MELD and center-specific allocation systems have inherent limitations. For example, most countries or allocation systems address the limitations of the MELD system by adding extra points to recipient's laboratory scores based on clinical information. It is also clear from this study that cancer, as an indication for liver transplantation, requires special attention. CONCLUSION The sickest first policy is the most reasonable basis for the allocation of liver grafts. While MELD is currently the standard for this model, many adjustments were implemented in most countries. A future globally applicable strategy should combine donor and recipient factors, predicting probability of death on the waiting list, post-transplant survival and morbidity, and perhaps costs. LAY SUMMARY An optimal allocation system for scarce resources should simultaneously ensure maximal utility, but also equity. While the model for end-stage liver disease is currently the standard for this model, many adjustments were implemented in most countries. A future globally applicable strategy should combine donor and recipient factors predicting probability of death on the waiting list, post-transplant survival and morbidity, and perhaps costs.
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Affiliation(s)
- Christoph Tschuor
- Department of Surgery & Transplantation, University Hospital of Zurich, Zurich, Switzerland
| | - Alberto Ferrarese
- Multivisceral Transplant Unit - Gastroenterology, Padua University Hospital, Padua, Italy
| | - Christoph Kuemmerli
- Department of Surgery & Transplantation, University Hospital of Zurich, Zurich, Switzerland
| | - Philipp Dutkowski
- Department of Surgery & Transplantation, University Hospital of Zurich, Zurich, Switzerland
| | - Patrizia Burra
- Multivisceral Transplant Unit - Gastroenterology, Padua University Hospital, Padua, Italy.
| | - Pierre-Alain Clavien
- Department of Surgery & Transplantation, University Hospital of Zurich, Zurich, Switzerland.
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7
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Patrono D, Surra A, Catalano G, Rizza G, Berchialla P, Martini S, Tandoi F, Lupo F, Mirabella S, Stratta C, Salizzoni M, Romagnoli R. Hypothermic Oxygenated Machine Perfusion of Liver Grafts from Brain-Dead Donors. Sci Rep 2019; 9:9337. [PMID: 31249370 PMCID: PMC6597580 DOI: 10.1038/s41598-019-45843-3] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 06/06/2019] [Indexed: 02/08/2023] Open
Abstract
Hypothermic oxygenated machine perfusion (HOPE) was introduced in liver transplantation (LT) to mitigate ischemia-reperfusion injury. Available clinical data mainly concern LT with donors after circulatory-determined death, whereas data on brain-dead donors (DBD) are scarce. To assess the impact of end-ischemic HOPE in DBD LT, data on primary adult LTs performed between March 2016 and June 2018 were analyzed. HOPE was used in selected cases of donor age >80 years, apparent severe graft steatosis, or ischemia time ≥10 hours. Outcomes of HOPE-treated cases were compared with those after static cold storage. Propensity score matching (1:2) and Bayesian model averaging were used to overcome selection bias. During the study period, 25 (8.5%) out of 294 grafts were treated with HOPE. After matching, HOPE was associated with a lower severe post-reperfusion syndrome (PRS) rate (4% versus 20%, p = 0.13) and stage 2–3 acute kidney injury (AKI) (16% versus 42%, p = 0.046). Furthermore, Bayesian model averaging showed lower transaminases peak and a lower early allograft dysfunction (EAD) rate after HOPE. A steeper decline in arterial graft resistance throughout perfusion was associated with lower EAD rate. HOPE determines a significant reduction of ischemia reperfusion injury in DBD LT.
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Affiliation(s)
- Damiano Patrono
- General Surgery 2U - Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Astrid Surra
- General Surgery 2U - Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Giorgia Catalano
- General Surgery 2U - Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Giorgia Rizza
- General Surgery 2U - Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Paola Berchialla
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Silvia Martini
- Gastrohepatology Unit, A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy
| | - Francesco Tandoi
- General Surgery 2U - Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Francesco Lupo
- General Surgery 2U - Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Stefano Mirabella
- General Surgery 2U - Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Chiara Stratta
- Anesthesia Department 2, A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy
| | - Mauro Salizzoni
- General Surgery 2U - Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Renato Romagnoli
- General Surgery 2U - Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy.
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Brett KE, Ritchie LJ, Ertel E, Bennett A, Knoll GA. Quality Metrics in Solid Organ Transplantation: A Systematic Review. Transplantation 2018; 102:e308-e330. [PMID: 29557915 PMCID: PMC7228649 DOI: 10.1097/tp.0000000000002149] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 12/20/2017] [Accepted: 01/14/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND The best approach for determining whether a transplant program is delivering high-quality care is unknown. This review aims to identify and characterize quality metrics in solid organ transplantation. METHODS Medline, Embase, and Cochrane Central Register of Controlled Trials were searched from inception until February 1, 2017. Relevant full text reports and conference abstracts that examined quality metrics in organ transplantation were included. Two reviewers independently extracted study characteristics and quality metrics from 52 full text reports and 24 abstracts. PROSPERO registration: CRD42016035353. RESULTS Three hundred seventeen quality metrics were identified and condensed into 114 unique indicators with sufficient detail to be measured in practice; however, many lacked details on development and selection, were poorly defined, or had inconsistent definitions. The process for selecting quality indicators was described in only 5 publications and patient involvement was noted in only 1. Twenty-four reports used the indicators in clinical care, including 12 quality improvement studies. Only 14 quality metrics were assessed against patient and graft survivals. CONCLUSIONS More than 300 quality metrics have been reported in transplantation but many lacked details on development and selection, were poorly defined, or had inconsistent definitions. Measures have focused on safety and effectiveness with very few addressing other quality domains, such as equity and patient-centeredness. Future research will need to focus on transparent and objective metric development with proper testing, evaluation, and implementation in practice. Patients will need to be involved to ensure that transplantation quality metrics measure what is important to them.
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Affiliation(s)
- Kendra E Brett
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Lindsay J Ritchie
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Emily Ertel
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Alexandria Bennett
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Greg A Knoll
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Division of Nephrology, Kidney Research Centre, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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