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Andacoglu OM, Dennahy IS, Mountz NC, Wilschrey L, Oezcelik A. Impact of sex on the outcomes of deceased donor liver transplantation. World J Transplant 2024; 14:88133. [PMID: 38576760 PMCID: PMC10989474 DOI: 10.5500/wjt.v14.i1.88133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 11/01/2023] [Accepted: 12/11/2023] [Indexed: 03/15/2024] Open
Abstract
BACKGROUND Data examining the impact of sex on liver transplant (LT) outcomes are limited. It is clear that further research into sex-related differences in transplant patients is necessary to identify areas for improvement. Elucidation of these differences may help to identify specific areas of focus to improve on the organ matching process, as well as the peri- and post-operative care of these patients. AIM To utilize data from a high-volume Eurotransplant center to compare characteristics of male and female patients undergoing liver transplant and assess asso ciation between sex-specific variables with short- and long-term post-transplant outcomes. METHODS A retrospective review of the University of Essen's transplant database was performed with collection of baseline patient characteristics, transplant-related data, and short-term outcomes. Comparisons of these data were made with Shapiro-Wilk, Mann-Whitney U, χ2 and Bonferroni tests applied where app ropriate. A P value of < 0.05 was accepted as statistically significant. RESULTS Of the total 779 LT recipients, 261 (33.5%) were female. Female patients suffered higher incidences of acute liver failure and lower incidences of alcohol-related or viremic liver disease (P = 0.001). Female patients were more likely to have received an organ from a female donor with a higher donor risk index score, and as a high urgency offer (all P < 0.05). Baseline characteristics of male and female recipients were also significantly different. In multivariate hazard regression analysis, recipient lab-Model for End-Stage Liver Disease score and donor cause of death were associated with long-term outcomes in females. Pre-operative diagnosis of hepatocellular carcinoma, age at time of listing, duration of surgery, and units transfused during surgery, were associated with long-term outcomes in males. Severity of complications was associated with long-term outcomes in both groups. Overall survival was similar in both males and females; however, when stratified by age, females < 50 years of age had the best survival. CONCLUSION Female and male LT recipients have different baseline and transplant-related characteristics, with sex-specific variables which are associated with long-term outcomes. Female recipients < 50 years of age demonstrated the best long-term outcomes. Pre- and post-transplant practices should be individualized based on sex-specific variables to optimize long-term outcomes.
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Affiliation(s)
- Oya M Andacoglu
- Division of Transplantation and Advanced Hepatobiliary Surgery, University of Utah, Salt Lake City, UT 84112, United States
- Department of Surgery, University of Essen, Essen D-45122, Germany
| | - Isabel S Dennahy
- Department of Surgery, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73117, United States
| | - Nicole C Mountz
- Department of Surgery, University of Oklahoma College of Medicine, Oklahoma City, OK 73117, United States
| | - Luisa Wilschrey
- Department of Surgery, University of Essen, Essen D-45122, Germany
| | - Arzu Oezcelik
- Department of Surgery, University of Essen, Essen D-45122, Germany
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2
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Becker EC, Siddique O, O'Sullivan DM, Dar W, Einstein M, Morgan G, Emmanuel B, Sotil EU, Richardson E, Serrano OK. Disparities in Liver Transplantation for Nonalcoholic Steatohepatitis in Women. Transplantation 2024:00007890-990000000-00680. [PMID: 38419160 DOI: 10.1097/tp.0000000000004964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
BACKGROUND Nonalcoholic steatohepatitis (NASH) is the fastest-growing indication for liver transplantation (LT). Sex disparities among patients with cirrhosis on the LT waitlist are well known. We wanted to understand these disparities further in women with end-stage liver disease patients listed for NASH cirrhosis in a contemporary cohort. METHODS We used data from the Scientific Registry of Transplant Recipients to assess sex racial, and ethnic differences in NASH patients listed for LT. Adults transplanted from August 1997 to June 2021 were included. Inferential statistics were used to evaluate differences with univariate and multivariate comparisons, including competitive risk analysis. RESULTS During the study time period, we evaluated 12 844 LT for NASH cirrhosis. Women were transplanted at a lower rate (46.5% versus 53.5%; P < 0.001) and higher model for end-stage liver disease (MELD) (23.8 versus 22.6; P < 0.001) than men. Non-White women were transplanted at a higher MELD (26.1 versus 23.1; P < 0.001) than White women and non-White male patients (26.1 versus 24.8; P < 0.001). Graft and patient survivals were significantly different (P < 0.001) between non-White women and White women and men (White and non-White). CONCLUSIONS Evaluation of LT candidates in the United States demonstrates women with NASH cirrhosis have a higher MELD than men at LT. Additional disparities exist among non-White women with NASH as they have higher MELD and creatinine at LT compared with White women. After LT, non-White women have worse graft and patient survival compared with men or White women. These data indicate that non-White women with NASH are the most vulnerable on the LT waitlist.
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Affiliation(s)
- Erica C Becker
- Department of Internal Medicine, University of Connecticut Health, Farmington, CT
| | - Osama Siddique
- Department of Gastroenterology, Hartford Hospital, Hartford, CT
| | - David M O'Sullivan
- Department of Research Administration, Hartford HealthCare, Hartford, CT
| | - Wasim Dar
- Transplant Program, Hartford Hospital, Hartford, CT
- Department of Surgery, University of Connecticut Health, Farmington, CT
| | - Michael Einstein
- Department of Internal Medicine, University of Connecticut Health, Farmington, CT
- Transplant Program, Hartford Hospital, Hartford, CT
| | - Glyn Morgan
- Transplant Program, Hartford Hospital, Hartford, CT
- Department of Surgery, University of Connecticut Health, Farmington, CT
| | - Bishoy Emmanuel
- Transplant Program, Hartford Hospital, Hartford, CT
- Department of Surgery, University of Connecticut Health, Farmington, CT
| | - Eva U Sotil
- Department of Internal Medicine, University of Connecticut Health, Farmington, CT
- Transplant Program, Hartford Hospital, Hartford, CT
| | - Elizabeth Richardson
- Department of Internal Medicine, University of Connecticut Health, Farmington, CT
- Transplant Program, Hartford Hospital, Hartford, CT
| | - Oscar K Serrano
- Transplant Program, Hartford Hospital, Hartford, CT
- Department of Surgery, University of Connecticut Health, Farmington, CT
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Parra NS, Schafer M, Ross HM, Bruckbauer J, Yan B, Chen SL, Khan A, Tholey DM, Halegoua-DeMarzio D. Prevalence of post-liver transplant complications and NASH-related cirrhosis in postmenopausal women. Ann Hepatol 2024; 29:101157. [PMID: 37742744 DOI: 10.1016/j.aohep.2023.101157] [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: 03/21/2023] [Revised: 06/01/2023] [Accepted: 09/11/2023] [Indexed: 09/26/2023]
Abstract
INTRODUCTION AND OBJECTIVES Compared to premenopausal women, postmenopausal women are at greater risk of developing NAFLD and NASH, two common indications for liver transplantation (LT). We aim to determine the prevalence of NASH-related cirrhosis in postmenopausal women from a cohort of LT patients and investigate their post-LT complications. MATERIALS AND METHODS Chart review of 1200 LT patients from 2002-2020 was performed. Postmenopausal women were defined as women over 51 and compared to a control group of men over 51. Prevalence of LT indications was determined. Subgroup analysis assessed cardiovascular disease risk. BMI and ASCVD risk scores were calculated at the time of LT and after 1 year. RESULTS 510 patients met the inclusion criteria: 189 (37.1%) women and 321 (62.9%) men. The most common indication was NASH for women (26.5%, p<0.001) and alcohol-related cirrhosis for men (23.1%). 53 men and 46 women underwent subgroup analysis. There was no significant difference in BMI or ASCVD 10-year risk post-LT between sexes. MI occurred more in men (n=9.17%) than women (n=1, 2%, p=0.015), with no significant differences in CAD, CHF, or stroke. LT complications occurred less in men (n=5.9%) than women (n=20, 43%, p=0.0001). CONCLUSIONS Postmenopausal women were significantly more likely to have NASH as an indication for LT than men. Postmenopausal women had greater weight gain and more noncardiac complications than men. Women did not have increased cardiovascular outcomes, ASCVD risk, or mortality. Diet education and weight control in postmenopausal women with existing risk factors for NASH should be encouraged to modulate health outcomes.
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Affiliation(s)
- Natalia Salinas Parra
- Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Department of Internal Medicine, 111 S 11th St, Philadelphia, PA 19107, USA.
| | - Michelle Schafer
- Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Department of Internal Medicine, 111 S 11th St, Philadelphia, PA 19107, USA
| | - Heather M Ross
- Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Department of Internal Medicine, 111 S 11th St, Philadelphia, PA 19107, USA
| | - John Bruckbauer
- Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Department of Internal Medicine, 111 S 11th St, Philadelphia, PA 19107, USA
| | - Brian Yan
- Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Department of Internal Medicine, 111 S 11th St, Philadelphia, PA 19107, USA
| | - Sarah L Chen
- Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Department of Internal Medicine, 111 S 11th St, Philadelphia, PA 19107, USA
| | - Adnan Khan
- Department of Internal Medicine, Thomas Jefferson University Hospital, 111 S 11th St, Philadelphia, PA 19107, USA
| | - Danielle M Tholey
- Department of Internal Medicine, Division of Gastroenterology & Hepatology, Thomas Jefferson University Hospital, 111 S 11th St, Philadelphia, PA 19107, USA
| | - Dina Halegoua-DeMarzio
- Department of Internal Medicine, Division of Gastroenterology & Hepatology, Thomas Jefferson University Hospital, 111 S 11th St, Philadelphia, PA 19107, USA
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Marrone G, Giannelli V, Agnes S, Avolio AW, Baiocchi L, Berardi G, Ettorre GM, Ferri F, Corradini SG, Grieco A, Guglielmo N, Lenci I, Lionetti R, Mennini G, Milana M, Rossi M, Spoletini G, Tisone G, Manzia TM, Lai Q. Superiority of the new sex-adjusted models to remove the female disadvantage restoring equity in liver transplant allocation. Liver Int 2024; 44:103-112. [PMID: 37752798 DOI: 10.1111/liv.15735] [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: 01/10/2023] [Revised: 08/10/2023] [Accepted: 09/02/2023] [Indexed: 09/28/2023]
Abstract
BACKGROUND AND AIMS Model for End-stage Liver Disease (MELD) and MELDNa are used worldwide to guide graft allocation in liver transplantation (LT). Evidence exists that females are penalized in the present allocation systems. Recently, new sex-adjusted scores have been proposed with improved performance respect to MELD and MELDNa. GEMA-Na, MELD 3.0, and sex-adjusted MELDNa were developed to improve the 90-day dropout prediction from the list. The present study aimed at evaluating the accuracy and calibration of these scores in an Italian setting. METHODS The primary outcome of the present study was the dropout from the list up to 90 days because of death or clinical deterioration. We retrospectively analysed data from 855 adults enlisted for liver transplantation in the Lazio region (Italy) (2012-2018). Ninety-day prediction of GEMA-Na, MELD 3.0 and sex-adjusted MELDNa with respect to MELD and MELDNa was analysed. Brier score and Brier Skill score were used for accuracy, and the Greenwood-Nam-D'Agostino test was used to evaluate the calibration of the models. RESULTS GEMA-Na (concordance = .82, 95% CI = .75-.89), MELD 3.0 (concordance = .81, 95% CI = .74-.87) and sex-adjusted MELDNa (concordance = .81, 95% CI = .74-.88) showed the best 90-day dropout prediction. GEMA-Na showed a higher increase in accuracy with respect to MELD (p = .03). No superiority was shown with respect to MELDNa. All the tested scores showed a good calibration of the models. Using GEMA-Na instead of MELD would potentially save one in nine dropouts and could save one dropout per 285 patients listed. CONCLUSIONS Validation and reclassification of the sex-adjusted score GEMA-Na confirm its superiority in predicting short-term dropout also in an Italian setting when compared with MELD.
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Affiliation(s)
- Giuseppe Marrone
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Salvatore Agnes
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alfonso Wolfango Avolio
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | | | | | | | | | | | - Antonio Grieco
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | | | | | - Raffaella Lionetti
- Istituto Nazionale Malattie Infettive Lazzaro Spallanzani-IRCCS, Rome, Italy
| | | | | | | | - Gabriele Spoletini
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
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5
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Lee DU, Ponder R, Sandlow S, Yoo A, Lee KJ, Chou H, Fan GH, Urrunaga NH. The impact of recipient and donor gender-match and mismatch on the post-liver transplant outcomes of patients with primary biliary cholangitis. Dig Liver Dis 2023; 55:1242-1252. [PMID: 37085440 PMCID: PMC10524091 DOI: 10.1016/j.dld.2023.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 03/05/2023] [Accepted: 03/25/2023] [Indexed: 04/23/2023]
Abstract
BACKGROUND & AIMS In this study, we evaluate the effects of donor gender on post-liver transplant (LT) prognosis. We specifically consider patients with primary biliary cholangitis (PBC). METHODS The 2005 to 2019 UNOS transplant registry was used to select patients with PBC. The study cohort was stratified by donor gender. All-cause mortality and graft failure hazards were compared using iterative Cox regression analysis. Subanalyses were performed to evaluate gender mismatch on post-LT prognosis. RESULTS There were 1885 patients with PBC. Of these cases, 965 entries had male donors and 920 had female donors. Median follow-up was 4.82 (25-75% IQR 1.83-8.93) years. Having a male donor was associated with higher all-cause mortality (aHR 1.28 95%CI 1.03-1.58) and graft failure (aHR 1.70 95%CI 1.02-2.82). Corresponding incidence rates were also relatively increased. In the sub-analysis of female recipients (n = 1581), those with gender-mismatch (male donors, n = 769) were associated with higher all-cause mortality (aHR 1.41 95%CI 1.11-1.78) but not graft failure. In the male recipient subanalysis (n = 304), no associations were found between gender-mismatch (female donors, n = 108) and all-cause mortality or graft failure. CONCLUSION This study shows that recipients who have male donors experienced higher rates of all-cause mortality following LT. This finding was consistent in the female recipient-male donor mismatch cohort.
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Affiliation(s)
- David Uihwan Lee
- Division of Gastroenterology and Hepatology, University of Maryland, 620W Lexington St, Baltimore, MD 21201, USA.
| | - Reid Ponder
- Department of Medicine, Tufts University School of Medicine, Washington St, Boston, MA 02111, USA
| | - Sarah Sandlow
- Department of Medicine, Tufts University School of Medicine, Washington St, Boston, MA 02111, USA
| | - Ashley Yoo
- Division of Gastroenterology and Hepatology, University of Maryland, 620W Lexington St, Baltimore, MD 21201, USA
| | - Ki Jung Lee
- Department of Medicine, Tufts University School of Medicine, Washington St, Boston, MA 02111, USA
| | - Harrison Chou
- Department of Medicine, Tufts University School of Medicine, Washington St, Boston, MA 02111, USA
| | - Gregory Hongyuan Fan
- Department of Medicine, Tufts University School of Medicine, Washington St, Boston, MA 02111, USA
| | - Nathalie Helen Urrunaga
- Division of Gastroenterology and Hepatology, University of Maryland, 620W Lexington St, Baltimore, MD 21201, USA
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6
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Walter Costa MB, Gärtner C, Schmidt M, Berg T, Seehofer D, Kaiser T. Revising the MELD Score to Address Sex-Bias in Liver Transplant Prioritization for a German Cohort. J Pers Med 2023; 13:963. [PMID: 37373952 DOI: 10.3390/jpm13060963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/02/2023] [Accepted: 06/05/2023] [Indexed: 06/29/2023] Open
Abstract
(1) Background: Prioritization of patients for liver transplantation in Germany relies on the MELD (model for end-stage liver disease) scoring system that does not consider the patient's sex. Many studies have shown that women are disadvantaged by the MELD score. Using a large patient cohort from a German liver transplant centre, we investigated options to reduce gender inequality in the patient prioritization for liver transplantation. (2) Methods: We calculated female-as-male MELD scores in our cohort by substituting the serum creatinine of a female patient with that of their male equivalent to test for the fairness of the scores. We investigated the effects of the female-as-male scores compared to the original MELD score of 1759 patients listed for liver transplantation. (3) Results: Serum creatinine sex correction (female-as-male) for MELD scores added up to 5.4 points in females, while the median changed by +1.6 points for females. We identified 72 females with an original MELD score < 20, for whom the adjusted female-as-male MELD score would be >20, thus giving them a better chance to receive a liver transplant. (4) Conclusions: Mathematical conversion of female to male creatinine concentrations identified disadvantages in liver transplantation prioritization for females and ascertained MELD 3.0 as having high potential to compensate for these inequalities.
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Affiliation(s)
- Maria Beatriz Walter Costa
- Clinical Chemistry and Molecular Diagnostics, Institute for Laboratory Medicine, Leipzig University Medical Center, Paul-List-Straße 13/15, D-04103 Leipzig, Germany
- Viral Ecology and Omics, Institute of Biodiversity, Faculty of Biological Sciences, Friedrich Schiller University Jena, Rosalind-Franklin Straße 1, D-07745 Jena, Germany
| | - Christiane Gärtner
- Viral Ecology and Omics, Institute of Biodiversity, Faculty of Biological Sciences, Friedrich Schiller University Jena, Rosalind-Franklin Straße 1, D-07745 Jena, Germany
- Academic Department of Laboratory Medicine, Microbiology and Pathobiochemistry, Medical School and University Medical Center East Westphalia-Lippe, Hospital Lippe, Bielefeld University, Röntgenstraße 18, D-32756 Detmold, Germany
| | - Maria Schmidt
- Clinical Chemistry and Molecular Diagnostics, Institute for Laboratory Medicine, Leipzig University Medical Center, Paul-List-Straße 13/15, D-04103 Leipzig, Germany
| | - Thomas Berg
- Division of Hepatology, Department of Medicine II, Leipzig University Medical Center, Liebigstraße 20, D-04103 Leipzig, Germany
| | - Daniel Seehofer
- Division of Hepatobiliary Surgery and Visceral Transplant Surgery, Department of Visceral, Transplant, Thoracic and Vascular Surgery, Leipzig University Medical Center, Liebigstraße 20, D-04103 Leipzig, Germany
| | - Thorsten Kaiser
- Clinical Chemistry and Molecular Diagnostics, Institute for Laboratory Medicine, Leipzig University Medical Center, Paul-List-Straße 13/15, D-04103 Leipzig, Germany
- Academic Department of Laboratory Medicine, Microbiology and Pathobiochemistry, Medical School and University Medical Center East Westphalia-Lippe, Hospital Lippe, Bielefeld University, Röntgenstraße 18, D-32756 Detmold, Germany
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7
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Viscoelastic versus conventional coagulation tests to reduce blood product transfusion in patients undergoing liver transplantation: A systematic review and meta-analysis. Eur J Anaesthesiol 2023; 40:39-53. [PMID: 36412263 DOI: 10.1097/eja.0000000000001780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Recent literature suggests viscoelastic test (VET)-guided transfusion management could be associated with reduced blood product administration in patients undergoing liver transplantation. OBJECTIVES To assess the effectiveness of coagulation management guided by VETs compared with conventional coagulation tests (CCTs) in reducing blood product transfusion in patients undergoing liver transplantation. DESIGN Systematic review and meta-analysis of randomised (RCTs) and nonrandomised clinical trials performed according to PRISMA guidelines. The protocol was previously published (PROSPERO: CRD42021230213). DATA SOURCES The Cochrane Central Library, PubMed/MEDLINE, Embase and the Transfusion Evidence Library were searched up to 30 th January 2022. ELIGIBILITY CRITERIA Setting: operating room. Patients: liver transplantation recipients. Intervention: use of VETs versus CCTs. Main outcome measures: the primary outcome was the mean number of transfused units for each blood product including red blood cells (RBCs), fresh frozen plasma (FFP), platelets (PLTs) and cryoprecipitate. Secondary outcomes included mortality rate, intensive care unit (ICU) and hospital length of stay (LOS). RESULTS Seventeen studies ( n = 5345 patients), 15 observational and two RCTs, were included in this review. There was a mean difference reduction in RBCs [mean difference: -1.40, 95% confidence interval (95% CI), -1.87 to -0.92; P < 0.001, I2 = 61%) and FFP units (mean difference: -2.98, 95% CI, -4.61 to -1.35; P = < 0.001; I2 = 98%) transfused in the VETs group compared with the CCTs one. A greater amount of cryoprecipitate was administered in the VETs group (mean difference: 2.71, 95% CI, 0.84 to 4.58; P = 0.005; I2 = 91%). There was no significant difference in the mean number of PLT units, mortality, hospital and ICU-LOS. CONCLUSION Our meta-analysis demonstrated that VETs implementation was associated with reduced RBC and FFP consumption in liver transplantation patients without effects on mortality and hospital and ICU-LOS. The certainty of evidence ranged from moderate to very low. Further well conducted RCTs are needed to improve the certainty of evidence.
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8
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Wood NL, VanDerwerken D, Segev DL, Gentry SE. Correcting the sex disparity in MELD-Na. Am J Transplant 2021; 21:3296-3304. [PMID: 34174151 PMCID: PMC8500920 DOI: 10.1111/ajt.16731] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/28/2021] [Accepted: 06/19/2021] [Indexed: 02/06/2023]
Abstract
MELD-Na appears to disadvantage women awaiting liver transplant by underestimating their mortality rate. Fixing this problem involves: (1) estimating the magnitude of this disadvantage separately for each MELD-Na, (2) designing a correction for each MELD-Na, and (3) evaluating corrections to MELD-Na using simulated allocation. Using Kaplan-Meier modeling, we calculated 90-day without-transplant survival for men and women, separately at each MELD-Na. For most scores between 15 and 35, without-transplant survival was higher for men by 0-5 percentage points. We tested two proposed corrections to MELD-Na (MELD-Na-MDRD and MELD-GRAIL-Na), and one correction we developed (MELD-Na-Shift) to target the differences we quantified in survival across the MELD-Na spectrum. In terms of without-transplant survival, MELD-Na-MDRD overcorrected sex differences while MELD-GRAIL-Na and MELD-Na-Shift eliminated them. Estimating the impact of implementing these corrections with the liver simulated allocation model, we found that MELD-Na-Shift alone eliminated sex disparity in transplant rates (p = 0.4044) and mortality rates (p = 0.7070); transplant rates and mortality rates were overcorrected by MELD-Na-MDRD (p = 0.0025, p = 0.0006) and MELD-GRAIL-Na (p = 0.0079, p = 0.0005). We designed a corrected MELD-Na that eliminates sex disparities in without-transplant survival, but allocation changes directing smaller livers to shorter candidates may also be needed to equalize women's access to liver transplant.
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Affiliation(s)
- Nicholas L. Wood
- Department of Mathematics, United States Naval Academy,
Annapolis, 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
| | - Sommer E. Gentry
- Department of Mathematics, United States Naval Academy,
Annapolis, MD
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9
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Nephew LD, Serper M. Racial, Gender, and Socioeconomic Disparities in Liver Transplantation. Liver Transpl 2021; 27:900-912. [PMID: 33492795 DOI: 10.1002/lt.25996] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 11/30/2020] [Accepted: 01/13/2021] [Indexed: 12/11/2022]
Abstract
Liver transplantation (LT) is a life-saving therapy; therefore, equitable distribution of this scarce resource is of paramount importance. We searched contemporary literature on racial, gender, and socioeconomic disparities across the LT care cascade in referral, waitlist practices, allocation, and post-LT care. We subsequently identified gaps in the literature and future research priorities. Studies found that racial and ethnic minorities (Black and Hispanic patients) have lower rates of LT referral, more advanced liver disease and hepatocellular carcinoma at diagnosis, and are less likely to undergo living donor LT (LDLT). Gender-based disparities were observed in waitlist mortality and LT allocation. Women have lower LT rates after waitlisting, with size mismatch accounting for much of the disparity. Medicaid insurance has been associated with higher rates of chronic liver disease and poor waitlist outcomes. After LT, some studies found lower overall survival among Black compared with White recipients. Studies have also shown lower literacy and limited educational attainment were associated with increased posttransplant complications and lower use of digital technology. However, there are notable gaps in the literature on disparities in LT. Detailed population-based estimates of the advanced liver disease burden and LT referral and evaluation practices, including for LDLT, are lacking. Similarly, little is known about LT disparities worldwide. Evidence-based strategies to improve access to care and reduce disparities have not been comprehensively identified. Prospective registries and alternative "real-world" databases can provide more detailed information on disease burden and clinical practices. Modeling and simulation studies can identify ways to reduce gender disparities attributed to size or inaccurate estimation of renal function. Mixed-methods studies and clinical trials should be conducted to reduce care disparities across the transplant continuum.
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Affiliation(s)
- Lauren D Nephew
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Marina Serper
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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10
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Darden M, Parker G, Monlezun D, Anderson E, Buell JF. Race and Gender Disparity in the Surgical Management of Hepatocellular Cancer: Analysis of the Surveillance, Epidemiology, and End Results (SEER) Program Registry. World J Surg 2021; 45:2538-2545. [PMID: 33893525 DOI: 10.1007/s00268-021-06091-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND The existence of race and gender disparity has been described in numerous areas of medicine. The management of hepatocellular cancer is no different, but in no other area of medicine, is the treatment algorithm more complicated by local, regional, and national health care distribution policy. METHODS Multivariate logistic regression and Cox-regression were utilized to analyze the treatment of patients with hepatocellular cancer registered in SEER between 1999 and 2013 to determine the incidence and effects of racial and gender disparity. Odd ratios (OR) are relative to Caucasian males, SEER region, and tumor characteristics. RESULTS The analysis of 57,449 patients identified the minority were female (25.31%) and African-American (16.26%). All tumor interventions were protective (p < 0.001) with respect to survival. The mean survival for all registered patients was 13.01 months with conditional analysis, confirming that African-American men were less likely to undergo ablation, resection, or transplantation (p < 0.001). Women were more likely to undergo resection (p < 0.001). African-American women had an equivalent OR for resection but had a significantly lower transplant rate (p < 0.001). CONCLUSIONS Utilizing SEER data as a surrogate for patient navigation in the treatment of hepatocellular cancer, our study identified not only race but gender bias with African-American women suffering the greatest. This is underscored by the lack of navigation of African-Americans to any therapy and a significant bias to navigate female patients to resection potentially limiting subsequent access to definitive therapy namely transplantation.
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Affiliation(s)
- Michael Darden
- Carey Business School, Johns Hopkins University, Baltimore, MD, USA
| | - Geoffrey Parker
- Thayer School of Engineering, Dartmouth College, Hanover, NH, USA
| | | | - Edward Anderson
- University of Texas McCombs Healthcare Innovation Initiative, Austin, TX, USA
| | - Joseph F Buell
- Department of Surgery, Mission Health, HCA North Carolina Division, University of North Carolina, Asheville, NC, USA.
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11
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Nephew LD, Zia Z, Ghabril M, Orman E, Lammert C, Kubal C, Chalasani N. Sex disparities in waitlisting and liver transplant for acute liver failure. JHEP Rep 2021; 3:100200. [PMID: 33511336 PMCID: PMC7817503 DOI: 10.1016/j.jhepr.2020.100200] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 10/08/2020] [Accepted: 10/09/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND & AIMS Sex disparities in liver transplantation (LT) for chronic liver disease have been described. It is unclear if similar disparities exist for acute liver failure (ALF). METHODS Adults waitlisted for LT from 2002 to 2016 with ALF were investigated using the United Network of Organ Sharing database. Clinical characteristics and causative aetiologies were compared between men and women who were waitlisted Status-1. Differences in LT, waitlist removal, and 1-year post-transplant survival were explored. RESULTS Of 8,408 patients waitlisted for LT with ALF, 41.3% of men and 63.9% of women were waitlisted Status-1 (p <0.001). Women had significantly higher international normalised ratio, higher frequency of grade 3-4 hepatic encephalopathy, and different aetiologies of ALF than men. On univariable analysis, women were less likely to undergo LT (subdistribution hazard ratio [SHR] 0.90; 95% CI 0.84-0.97) and were more likely to die or be removed from the waitlist as a result of clinical deterioration (SHR 1.14; 95% CI 1.002-1.30) than men. The disparities in LT (HR 0.95; 95% CI 0.87-1.03) and death/clinical deterioration (SHR 1.13; 95% CI 0.99-1.29) were no longer significant on multivariable analysis. On multivariable analysis, there was no difference in 1-year post-transplant survival between men and women. CONCLUSIONS Women with ALF are more likely to be waitlisted Status-1 than men. There were no clear disparities in LT or waitlist removal. Sex differences in LT and waitlist removal were attenuated on fully adjusted models, suggesting that these disparities may in part be mitigated by Status-1 listing. LAY SUMMARY Women with acute liver failure appear to be sicker than men and more often require urgent Status-1 waitlisting. There were no sex disparities in waitlist removal because of clinical deterioration or liver transplantation. This is in contrast to chronic liver disease, where sex disparities exist. The Status-1 waitlisting that women with acute liver failure receive may in part mitigate sex disparities in liver transplantation.
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Key Words
- AIH, autoimmune hepatitis
- ALF, acute liver failure
- APAP, acetaminophen
- Allocation
- Fulminant
- Gender
- HE, hepatic encephalopathy
- HR, hazard ratio
- INR, international normalised ratio
- LT, liver transplantation
- MELD, model for end-stage liver disease
- SHR, subdistribution hazard ratio
- SRTR, Scientific Registry of Transplant Recipients
- Status-1
- UNOS, United Network of Organ Sharing
- Women
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Affiliation(s)
- Lauren D. Nephew
- Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Zahra Zia
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Marwan Ghabril
- Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Eric Orman
- Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Craig Lammert
- Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Chandrashekhar Kubal
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Naga Chalasani
- Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
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12
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Lim N, Jackson S, Engler C, Lake JR. The Impact of Tenofovir Disoproxil Fumarate on Reduced Bone Mineral Density and Fractures in Liver Transplant Recipients. Transplant Proc 2020; 53:215-220. [PMID: 33139039 DOI: 10.1016/j.transproceed.2020.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 09/02/2020] [Accepted: 09/18/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Tenofovir disoproxil fumarate (TDF) is associated with reduced bone density in patients with human immunodeficiency virus, but the effect of TDF on bone density in liver transplant (LT) recipients is unknown. METHODS We performed a single-center, retrospective study of LT recipients with hepatitis B taking TDF compared to a control group with non-hepatitis B virus viral hepatitis. The primary outcome was reduced bone density, defined as femoral neck or lumbar T-score less than -1. Other outcomes included mean T-score and fractures. RESULTS Three hundred ninety-three patients were studied: 52 patients in the TDF group and 341 patients in the control group; 64.3% patients in the TDF group had reduced bone density vs 71.4% in the control group (P = .58) before LT, compared to 75% and 81.5% (P = .57), respectively, after LT. Mean posttransplant lumbar T-scores were lower in the TDF group (-1.74 vs -0.75, P = .04). There was no difference between the 2 groups for the other outcomes. In a multivariate Cox proportional hazards model, TDF use did not affect the risk of post-LT reduced bone density (hazard ratio = 0.99; 95% confidence interval, 0.56-1.76; P = .97). CONCLUSION TDF use was not associated with reduced bone mineral density or increased rates of fractures in LT recipients compared to controls in this study.
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Affiliation(s)
- N Lim
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota.
| | - S Jackson
- Fairview Health Services, Minneapolis, Minnesota
| | - C Engler
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota
| | - J R Lake
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota
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13
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Darden M, Parker G, Anderson E, Buell JF. Persistent sex disparity in liver transplantation rates. Surgery 2020; 169:694-699. [PMID: 32782116 DOI: 10.1016/j.surg.2020.06.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 06/09/2020] [Accepted: 06/15/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Studies have demonstrated that there are sex disparities in the rate of liver transplantation. However, little is known statistically about whether this disparity is caused by liver compartment size, Model for End-Stage Liver Disease adjustments, or regional differences. METHODS We use retrospective data from the United Network for Organ Sharing Standard Treatment Analysis and Research data files for liver transplantation from 1995 through 2012. The final sample consists of 150,149 patients. These data contain information on all individuals who registered for the liver transplant waiting list as well as updated outcome data. Linear probability and logistic regression models were both used. RESULTS Women were 4.8 percentage points less likely to receive a transplant. Adjustment for race, weight, body mass index, region, education, and other characteristics attenuated the sex difference by roughly 19% (from 4.8 to 3.9 percentage points). The disparity was consistent across the 11 United Network for Organ Sharing allocation regions. Comparing the heaviest women to the lightest men, the disparity flipped. Pairwise comparisons between men and women of various sizes suggest that disparities in favor of men increase with the ratio of male-to-female size. CONCLUSION Our results document persistent sex disparity in liver transplantation, only 19% of which is explained by size differentials between men and women. Differences in rates of transplantation are increasing in the ratio of male-to-female height and weight, suggesting that some of the disparity is explained by differences in liver compartment size.
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Affiliation(s)
- Michael Darden
- Carey Business School, Johns Hopkins University, Baltimore, MD.
| | - Geoff Parker
- Thayer School of Engineering, Dartmouth College, Hanover, NH
| | - Edward Anderson
- Healthcare Innovation Initiative, University of Texas, Austin, TX
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14
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Germani G, Zeni N, Zanetto A, Adam R, Karam V, Belli LS, O'Grady J, Mirza D, Klempnauer J, Cherqui D, Pratschke J, Jamieson N, Salizzoni M, Hidalgo E, Lerut J, Paul A, Garcia-Valdecasas JC, Rodríguez FSJ, Villa E, Burra P. Influence of donor and recipient gender on liver transplantation outcomes in Europe. Liver Int 2020; 40:1961-1971. [PMID: 32418358 DOI: 10.1111/liv.14510] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/21/2020] [Accepted: 05/06/2020] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS The impact of gender and donor/recipient gender mismatch on LT outcomes is controversial. The aim of this study was to compare outcomes of LT in Europe, using the ELTR database, between male and female recipients, including donor/recipient gender mismatch. METHODS Recipient, donor and transplant characteristics were compared between male and female patients. Patient survival was compared between groups, and the impact of donor/recipient gender matching as well as donor and recipient anthropometric characteristics were evaluated as potential risk factors for post-LT death/graft loss. RESULTS A total of 46,334 LT patients were evaluated (70.5% men and 29.5% women). Ten-year survival rate was significantly higher in female than in male recipients (66% vs 59%, P < .0001). At multivariate analysis, adjusted for indication to LT and type of graft, donor/recipient gender mismatch (HR 1.12, 95% CI 1.04-1.2; P = .003), donor age > 60 years (HR 1.09, 95% CI 1.01-1.18; P = .027) and recipient age (HR 1.02, 95% CI 1.1-1.02; P < .0001) were significantly associated with post-LT lower survival rate in men. Conversely in female recipients, donor BMI > 30 (HR 1.32, 95% CI 1.09-1.6; P = .005), donor age > 60 years (HR 1.15, 95% CI 1.01-1.32; P = .027) and recipient age (HR 1.02, 95% CI 1.01-1.02; P < .0001) were significantly associated with lower post-LT survival rate. CONCLUSIONS Donor/recipient gender mismatch in male recipients and the use of obese donor in female recipients are associated with reduced survival after LT. Therefore, the incorporation of donor and recipient anthropometric quantities in the allocation process should be a matter of further studies, as their matching can significantly influence long-term outcomes.
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Affiliation(s)
- Giacomo Germani
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Nicola Zeni
- 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
| | - René Adam
- ELTR, Assistance Publique-Hôpitaux de Paris, Hôpital Paul Brousse, Centre Hepato-Biliaire, Universite´Paris-Sud, Villejuif, France
| | - Vincent Karam
- ELTR, Assistance Publique-Hôpitaux de Paris, Hôpital Paul Brousse, Centre Hepato-Biliaire, Universite´Paris-Sud, Villejuif, France
| | - Luca S Belli
- Gastroenterology and Hepatology, Liver Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | | | | | | | | | | | | | | | - Jan Lerut
- Universitè Catholique Louvain, Brussels, Belgium
| | | | | | | | - Erica Villa
- Department of Gastroenterology, Policlinico of Modena University Hospital of Modena, Modena, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
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15
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Kabar I, Hüsing-Kabar A, Maschmeier M, Völler C, Dümke M, Schmidt HH, Heinzow H. Pictorial Representation of Illness and Self Measure (PRISM): A Novel Visual Instrument to Quantify Suffering in Liver Cirrhosis Patients and Liver Transplant Recipients. Ann Transplant 2018; 23:674-680. [PMID: 30262798 PMCID: PMC6248009 DOI: 10.12659/aot.910278] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background The level of suffering of chronically ill patients does not necessarily correlate with illness severity. In this study, we evaluated the burden of suffering and its impact on health-related quality of life in liver transplant recipients and liver cirrhosis patients. Material/Methods The Pictorial Representation of Illness and Self Measure (PRISM) was used to explore levels of suffering in outpatients of Münster University Hospital, Germany. Self-illness separation scores were analyzed as a measure of disease-specific burden of suffering. Health-related quality of life was measured using the Short Form Health Survey (SF-36). Results Data from 201 subjects were statistically analyzed. Median Self-illness separation scores for liver transplant recipients and patients with liver cirrhosis were 13.5 (minimum/maximum: 0.2/25.6) cm and 6.3 (0.1/25.6) cm (p<0.001), respectively. The median SF-36 Mental Component Summary and Physical Component Summary scores were 46.4 (12.5/66.2) and 40.1 (12.3/61.1), respectively. Higher health-related quality of life was associated with greater self–illness separation. Liver transplant recipients showed normal Mental Component Summary scores compared with the general German population; patients with liver cirrhosis had significantly lower Mental Component Summary scores. Physical Component Summary scores were significantly higher in liver transplant recipients than in patients with liver cirrhosis, but still lower than in the general population. Conclusions PRISM is a novel, simple tool for measuring the illness burden in liver transplant recipients and patients with liver cirrhosis. This measure may help to identify patients at a higher risk of psychological disorders.
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Affiliation(s)
- Iyad Kabar
- Department of Gastroenterology and Hepatology, Münster University Hospital, Münster, Germany
| | - Anna Hüsing-Kabar
- Department of Gastroenterology and Hepatology, Münster University Hospital, Münster, Germany
| | - Miriam Maschmeier
- Department of Gastroenterology and Hepatology, Münster University Hospital, Münster, Germany
| | - Carolin Völler
- Department of Gastroenterology and Hepatology, Münster University Hospital, Münster, Germany
| | - Marina Dümke
- Department of Gastroenterology and Hepatology, Münster University Hospital, Münster, Germany
| | - Hartmut H Schmidt
- Department of Gastroenterology and Hepatology, Münster University Hospital, Münster, Germany
| | - Hauke Heinzow
- Department of Gastroenterology and Hepatology, Münster University Hospital, Münster, Germany
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16
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Dogan N, Hüsing-Kabar A, Schmidt HH, Cicinnati VR, Beckebaum S, Kabar I. Acute allograft rejection in liver transplant recipients: Incidence, risk factors, treatment success, and impact on graft failure. J Int Med Res 2018; 46:3979-3990. [PMID: 29996675 PMCID: PMC6136012 DOI: 10.1177/0300060518785543] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 06/06/2018] [Indexed: 12/12/2022] Open
Abstract
Objective This study was performed to identify risk factors for acute cellular rejection after liver transplantation (LT). Methods Consecutive LT recipients who underwent surgery in our institution from 2002 to 2015 were retrospectively evaluated. Results In total, 176 patients were eligible for statistical analysis. During a mean observation period of 61.1 ± 36.3 months, 43 episodes of acute rejection were evident. Of these, 34 (79.0%) were responsive to methylprednisolone, 3 (7.0%) were treated by adjusting the dosage of immunosuppressive agents, and 6 (14.0%) were methylprednisolone-resistant and treated using anti-thymocyte globulin. Biliary complications (odds ratio [OR] = 4.89, 95% confidence interval [CI] = 2.00-11.98); donor-negative, recipient-positive CMV mismatch (OR = 9.88, 95% CI = 1.18-82.36); sex mismatch (OR = 3.16, 95% CI = 1.31-8.10); and sex mismatch with a female donor (OR = 3.00, 95% CI = 1.10-7.58) were identified as significant risk factors for acute graft rejection after LT. Conclusion In patients who develop acute cellular rejection after LT, biliary complications should be evaluated as a potential cause. Most acute rejections after LT respond to bolus corticosteroid therapy.
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Affiliation(s)
- Nurettin Dogan
- Department of Gastroenterology and Hepatology,
University Hospital Muenster, Muenster, Germany
| | - Anna Hüsing-Kabar
- Department of Gastroenterology and Hepatology,
University Hospital Muenster, Muenster, Germany
| | - Hartmut H. Schmidt
- Department of Gastroenterology and Hepatology,
University Hospital Muenster, Muenster, Germany
| | - Vito R. Cicinnati
- Department of Gastroenterology and Hepatology,
University Hospital Muenster, Muenster, Germany
| | - Susanne Beckebaum
- Department of Gastroenterology and Hepatology,
University Hospital Muenster, Muenster, Germany
| | - Iyad Kabar
- Department of Gastroenterology and Hepatology,
University Hospital Muenster, Muenster, Germany
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17
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Loy VM, Joyce C, Bello S, VonRoenn N, Cotler SJ. Gender disparities in liver transplant candidates with nonalcoholic steatohepatitis. Clin Transplant 2018; 32:e13297. [DOI: 10.1111/ctr.13297] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2018] [Indexed: 12/15/2022]
Affiliation(s)
- Veronica M. Loy
- Department of Hepatology; Loyola University Medical Center; Maywood IL USA
- Loyola University Chicago; Maywood IL USA
| | - Cara Joyce
- Loyola University Chicago; Maywood IL USA
| | | | - Natasha VonRoenn
- Department of Hepatology; Loyola University Medical Center; Maywood IL USA
- Loyola University Chicago; Maywood IL USA
| | - Scott J. Cotler
- Department of Hepatology; Loyola University Medical Center; Maywood IL USA
- Loyola University Chicago; Maywood IL USA
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18
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Sobotka L, Hinton A, Conteh L. Women receive more inpatient resections and ablations for hepatocellular carcinoma than men. World J Hepatol 2017; 9:1346-1351. [PMID: 29359018 PMCID: PMC5756724 DOI: 10.4254/wjh.v9.i36.1346] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Revised: 11/14/2017] [Accepted: 12/05/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate disparities in the treatment of hepatocellular carcinoma (HCC) based on gender.
METHODS A retrospective database analysis using the Nationwide Inpatient Sample (NIS) was performed between 2010 and 2013. Adult patients with a primary diagnosis of hepatocellular carcinoma determined by International Classification of Disease 9 (ICD-9) codes were included. Univariate analysis and multivariate logistic regressions were performed to analyze differences in treatment, mortality, features of decompensation, and metastatic disease based on the patient’s gender.
RESULTS The analysis included 62582 patients with 45908 men and 16674 women. Women were less likely to present with decompensated liver disease (OR = 0.84, P < 0.001) and had less risk of inpatient mortality when compared to men (OR = 0.75, P < 0.001). Women were more likely to receive inpatient resection (OR = 1.31, P < 0.001) or an ablation (OR = 1.22, P = 0.028) than men. There was no significant difference between men and women in regard to liver transplantation and transcatheter arterial chemoembolization (TACE).
CONCLUSION Gender impacts treatment for hepatocellular carcinoma. Women are more likely to undergo an ablation or resection then men. Gender disparities in transplantation have resolved.
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Affiliation(s)
- Lindsay Sobotka
- Department of Internal Medicine, the Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Alice Hinton
- Division of Biostatistics, College of Public Health, the Ohio State University, Columbus, OH 43210, United States
| | - Lanla Conteh
- Section of Hepatology, Division of Gastroenterology, Hepatology and Nutrition, the Hepatocellular Carcinoma Multidisciplinary Clinic, the James Comprehensive Cancer Center, the Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
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19
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Disparities in Waitlist and Posttransplantation Outcomes in Liver Transplant Registrants and Recipients Aged 18 to 24 Years: Analysis of the UNOS Database. Transplantation 2017; 101:1616-1627. [PMID: 28230640 DOI: 10.1097/tp.0000000000001689] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND We evaluated liver transplantation waitlist and posttransplantation outcomes in those aged 18 to 24 years compared with both younger (0-17 years) and older (25-34 years) registrants and recipients. METHODS Using national data from the United Network for Organ Sharing, competing risk, Cox regression and Kaplan-Meier analyses were performed on first-time liver transplant registrants (n = 13 979) and recipients (n = 8718) ages 0 to 34 years between 2002 and 2015. RESULTS Nonstatus 1A registrants, registrants aged 0 to 17 and 25 to 34 years were less likely to experience dropout from the waiting list compared with those aged 18 to 24 years (adjusted hazard ratio, 0-5 years = 0.36; 6-11 = 0.29; 12-17 = 0.48; 18-24 = 1.00; 25-34 = 0.82). Although there was no difference in risk of graft failure across all age groups, both younger and older age groups had significantly lower risk of posttransplant mortality compared with those aged 18 to 24 years (adjusted hazard ratio, for 0-5 years = 0.53, 6-11 = 0.48, 12-17 = 0.70, 18-24 = 1.00, 25-34 = 0.77). This may be related to lower likelihood of retransplantation after graft failure in those aged 18 to 24 years. CONCLUSIONS This national registry study demonstrates for the first time poorer waitlist and postliver transplant outcomes in young adults ages 18 to 24 years at the time of listing and transplantation compared to older and younger age groups. Given the potential survival benefit in transplanting young adults and the shortage of solid organs for transplant, future studies are critical to identify and target modifiable risk factors to improve waitlist and long-term posttransplant outcomes in 18- to 24-year-old registrants and recipients.
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20
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Kappus M, Abdelmalek M. De Novo and Recurrence of Nonalcoholic Steatohepatitis After Liver Transplantation. Clin Liver Dis 2017; 21:321-335. [PMID: 28364816 DOI: 10.1016/j.cld.2016.12.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease in developing countries. Approximately 25% of patients with NAFLD develop nonalcoholic steatohepatitis (NASH). NASH-related cirrhosis is now a leading listing indication for liver transplantation in the United States. Although posttransplant survival for NASH-related cirrhosis is comparable with that of other liver diseases, many patients have features of metabolic syndrome, which can contribute to a recurrence of NAFLD or NASH. This article reviews the epidemiology, pathophysiology, and treatment of de novo and recurrence of NASH after liver transplantation.
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Affiliation(s)
- Matthew Kappus
- Division of Gastroenterology, Duke University Medical Center, 40 Duke Medicine Circle, PO Box 3913, Durham, NC 27710, USA
| | - Manal Abdelmalek
- Division of Gastroenterology, Duke University Medical Center, 40 Duke Medicine Circle, PO Box 3913, Durham, NC 27710, USA.
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21
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Wang A, An X, Xia VW. Female Gender of the Recipient Is Independently Associated With Prolonged Ventilation Time and Hospital Stay After Liver Transplantation. Transplant Proc 2016; 48:120-2. [PMID: 26915855 DOI: 10.1016/j.transproceed.2016.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2015] [Accepted: 01/05/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Although female patients are associated with several complications after liver transplantation (OLT), its role in short-term postoperative outcomes is not known. The aims of this study were to investigate the relationship between female gender and ventilation time and hospital stay after OLT. METHODS After receiving institutional review board approval, we studied adult patients who underwent OLT at our center between 2004 and 2013. Female and male recipients were compared by using Student t and χ(2) tests. Risk factors were confirmed in multivariate logistic models. RESULTS Of 1476 patients, 490 were female. Compared with male counterparts, female recipients had more severe disease and comorbidities. Intraoperatively, the 2 groups were similar except for blood transfusion. Postoperatively, female recipients required significantly longer ventilation time (median, 3 days [interquartile range (IQR), 2-5], vs median, 2 [IQR, 1-5]; P = .009) and duration of hospital stay (median, 23 [IQR, 15-46] vs median, 18 [IQR, 12-34]; P < .001) compared with male recipients. Female gender was an independent risk factor for prolonged posttransplant ventilation time (≥3 days; odds ratio [OR], 1.65; P < .001) and hospital stay (≥19 days; OR, 1.48; P = .003). CONCLUSIONS Female gender of the recipient is associated with significantly longer ventilation time and hospital stay after OLT and the management should be tailored to the unique characteristics and susceptibility to postoperative complications in female patients.
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Affiliation(s)
- A Wang
- Departments of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - X An
- Departments of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - V W Xia
- Departments of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.
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22
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Wang W, Ye Y, Wang T, Zhang F, Geng L, Yu J, Zhou L, Yan S, Zheng S. Prognostic prediction of male recipients selected for liver transplantation: With special attention to neutrophil to lymphocyte ratio. Hepatol Res 2016; 46:899-907. [PMID: 26666880 DOI: 10.1111/hepr.12633] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 10/07/2015] [Accepted: 12/11/2015] [Indexed: 12/13/2022]
Abstract
AIM Neutrophil to lymphocyte ratio (NLR) is an inflammatory biomarker that has a close relationship with tumor progression and metastasis. In this study, we aimed to investigate the role of NLR in the prognosis of male candidates with hepatocellular carcinoma (HCC) undergoing liver transplantation (LT). METHODS We analyzed the clinical data of 248 male HCC candidates who underwent LT in our Liver Transplantation Center between 2002 and 2012. All risk factors were analyzed by univariate and multivariate Cox analysis and survival rates were calculated by Kaplan-Meier log-rank test. RESULTS NLR was proved to be an independent risk factor affecting overall survival (OS) (P < 0.001) and tumor-free survival (TFS) (P = 0.003) of male candidates with HCC following LT. Additionally, our study showed that elevated NLR (>4) was associated with early tumor recurrence by Kaplan-Meier analysis. Furthermore, we established Model_OS and Model_TFS to predict prognosis based on multivariate Cox analysis. Our study showed that male candidates with HCC who exceeded the Milan criteria but within Model_OS could achieve similar OS as those within the Milan criteria (P = 0.220). Similarly, male patients who exceeded the Milan criteria but within Model_TFS could achieve similar TFS as those within the Milan criteria (P = 0.197). CONCLUSION Proper inflammatory response may effectively reduce tumor recurrence after LT. Elevated NLR (>4) within a certain range is associated with early tumor recurrence. NLR-based models are efficient and safe for prognostic prediction among male candidates with HCC for LT.
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Affiliation(s)
- Wei Wang
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - Yufu Ye
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - Ting Wang
- Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - Feng Zhang
- Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - Lei Geng
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - Jun Yu
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - Lin Zhou
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - Sheng Yan
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - Shusen Zheng
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou, China.,Collaborative innovation center for Diagnosis treatment of infectious diseases
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AISF position paper on liver transplantation and pregnancy: Women in Hepatology Group, Italian Association for the Study of the Liver (AISF). Dig Liver Dis 2016; 48:860-8. [PMID: 27267817 DOI: 10.1016/j.dld.2016.04.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 04/11/2016] [Indexed: 12/11/2022]
Abstract
After the first successful pregnancy in a liver transplant recipient in 1978, much evidence has accumulated on the course, outcomes and management strategies of pregnancy following liver transplantation. Generally, liver transplantation restores sexual function and fertility as early as a few months after transplant. Considering that one third of all liver transplant recipients are women, that approximately one-third of them are of reproductive age (18-49 years), and that 15% of female liver transplant recipients are paediatric patients who have a >70% probability of reaching reproductive age, the issue of pregnancy after liver transplantation is rather relevant, and obstetricians, paediatricians, and transplant hepatologists ever more frequently encounter such patients. Pregnancy outcomes for both the mother and infant in liver transplant recipients are generally good, but there is an increased incidence of preterm delivery, hypertension/preeclampsia, foetal growth restriction, and gestational diabetes, which, by definition, render pregnancy in liver transplant recipients a high-risk one. In contrast, the risk of congenital anomalies and the live birth rate are comparable to those of the general population. Currently there are still no robust guidelines on the management of pregnancies after liver transplantation. The aim of this position paper is to review the available evidence on pregnancy in liver transplant recipients and to provide national Italian recommendations for clinicians caring for these patients.
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Wu SY, Chen TW, Feng AC, Fan HL, Hsieh CB, Chung KP. Comprehensive risk assessment for early neurologic complications after liver transplantation. World J Gastroenterol 2016; 22:5548-5557. [PMID: 27350733 PMCID: PMC4917615 DOI: 10.3748/wjg.v22.i24.5548] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 04/26/2016] [Accepted: 05/23/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine risk factors for early neurologic complications (NCs) after liver transplantation from perspective of recipient, donor, and surgeon.
METHODS: In all, 295 adult recipients were enrolled consecutively between August 2001 and February 2014 from a single medical center in Taiwan. Any NC in the first 30 d post-liver transplantation, and perioperative variables from multiple perspectives were collected and analyzed. The main outcome was a 30-d NC. Generalized additive models were used to detect the non-linear effect of continuous variables on outcome, and to determine cut-off values for categorizing risk. Risk factors were identified using multiple logistic regression analysis.
RESULTS: In all, 288 recipients were included, of whom 142 (49.3%) experienced at least one NC, with encephalopathy being the most common 106 (73%). NCs prolonged hospital stay (35.15 ± 43.80 d vs 20.88 ± 13.58 d, P < 0.001). Liver recipients’ age < 29 or ≥ 60 years, body mass index < 21.6 or > 27.6 kg/m2, Child-Pugh class C, history of preoperative hepatoencephalopathy or mental disorders, day 7 tacrolimus level > 8.9 ng/mL, and postoperative intra-abdominal infection were more likely associated with NCs. Novel risk factors for NCs were donor age < 22 or ≥ 40 years, male-to-male gender matching, graft-recipient weight ratio 0.9%-1.9%, and sequence of transplantation between 31 and 174.
CONCLUSION: NCs post- liver transplantation occurs because of factors related to recipient, donor, and surgeon. Our results provide a basis of risk stratification for surgeon to minimize neurotoxic factors during transplantation.
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