Donor-recipient race-ethnicity concordance and patient survival after liver transplantation

INTRODUCTION

We assessed the association between patient survival after liver transplantation (LT) and donor-recipient race-ethnicity (R/E) concordance.

METHODS

The Scientific Registry of Transplant Recipients (SRTR) was retrospectively analyzed using data collected between 2002 and 2019. Only adults without history of prior organ transplant and recipients of LT alone were included. The primary outcome was patient survival. Donors and recipients were categorized into five R/E groups: White/Caucasian, African American/Black, Hispanic/Latino, Asian, and Others. Statistical analyses were performed using Kaplan-Meier survival curves and Cox Proportional Hazards models, adjusting for donor and recipient covariates.

RESULTS

85,427 patients were included. Among all the R/E groups, Asian patients had the highest 5-year survival (81.3%; 95% CI = 79.9-82.7), while African American/Black patients had the lowest (71.4%; 95% CI = 70.3-72.6) (P < 0.001). Lower survival rates were observed in recipients who received discordant R/E grafts irrespective of their R/E group. The fully adjusted hazard ratio for death was statistically significant in African American/Black (aHR 1.07-1.18-1.31; P < 0.01) and in White∕Caucasian patients (aHR 1.00-1.04-1.07; P = 0.03) in the presence of donor-recipient R/E discordance.

CONCLUSION

Disparities in post-LT outcomes might be influenced by biological factors in addition to well-known social determinants of health.

Postpartum Treatment for Chronic Hepatitis C Virus Among People With Opioid Use Disorder: A Prospective Pilot Clinical Trial

OBJECTIVE

The objective of this study was to evaluate the feasibility and acceptability of postpartum hepatitis C virus (HCV) treatment integrated within a substance use treatment program for pregnant and postpartum people with opioid use disorder (OUD).

METHODS

We conducted a prospective pilot clinical trial of sofosbuvir/velpatasvir (SOF/VEL) treatment among postpartum people with OUD and HCV. Feasibility outcomes included rates of HCV treatment utilization and completion, medication adherence, and sustained virologic response 12 weeks after treatment completion (SVR12). Acceptability was measured through self-reported adverse effects and medication adherence.

RESULTS

From January 2018 to August 2021, 164 pregnant people received care for OUD at the study site. Among those, 64 (39.0%) were HCV antibody positive and 45 (27.4%) had active HCV infection. Among 45 eligible patients, 32 (71.1%) enrolled and 21 (46.7%) initiated HCV treatment. Of 21 participants who initiated treatment, 16 (76.2%) completed the SOF/VEL treatment, and 11 (52.4%) completed the SVR12. All participants who completed treatment were cured. Common reasons for dropout during the HCV clinical care cascade were OUD treatment discontinuation, illicit substance use recurrence, and lost to follow-up. Participants reported high satisfaction with HCV treatment, including minimal adverse effects, and no HCV treatment concerns.

CONCLUSIONS

Nearly half of pregnant people with HCV initiated postpartum treatment within an integrated care model of HCV treatment within a substance use treatment program. Postpartum SOF/VEL was efficacious, tolerable, and acceptable. Despite this, postpartum HCV treatment among people with OUD remains challenging, and many barriers remain.

Severe Liver and Renal Injury From Tribulus Terrestris

Tribulus terrestris is a shrub that is found worldwide. Although it has been linked to severe jaundice and death in grazing animals, there are only a few case reports of hepatotoxicity in humans. We describe a case of a 46-year-old man who took tribulus supplements daily for 2 months. He developed severe jaundice prompting hospital admission. His total bilirubin peaked at 48 mg/dL, with concomitant renal dysfunction (creatinine of 7.1). His liver biopsy showed features consistent with drug-induced liver injury. He was initiated on a trial of plasmapheresis and underwent 3 sessions with a subsequent decrease in bilirubin with each session. He had appropriate renal recovery and was discharged home and on follow-up, continues to do well with most recent bilirubin of 1.1 mg/dL.

Perspectives on Anti-Black Racism and Mitigation Strategies Among Faculty Experts at Academic Medical Centers

IMPORTANCE

Black faculty and trainees remain underrepresented in academic medicine because of systemic racism. Years of diversity and inclusion efforts have not succeeded in eliminating the unique challenges faced by Black faculty in academic medicine.

OBJECTIVES

To elicit expert faculty perspectives on anti-Black racism in academic medicine based on lived and/or professional experience and to solicit recommendations for an intervention for faculty to dismantle anti-Black racism within academic medical centers.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study included semistructured interviews with experts in understanding and dismantling anti-Black racism within academic medical centers. Participants had expertise in anti-Black racism through their lived experience as a Black faculty member and/or professional experience in diversity, equity, and inclusion efforts. Participants were recruited from academic medical centers from around the United States. Interviews were conducted through an online meeting platform, audio recorded, transcribed verbatim, and subsequently coded following an inductive qualitative description approach. Interviews were completed between October 2020 and March 2021.

MAIN OUTCOMES AND MEASURES

Outcomes include the experiences of Black faculty and trainees in academic medicine and recommendations for developing an intervention to dismantle anti-Black racism within academic medicine.

RESULTS

A total of 16 participants completed this study; most identified as Black or African American (9 [56%]) and female (10 [63%]). Results were sorted into 2 content domains, with several themes within those domains: (1) barriers faced by Black faculty and trainees and potential solutions and (2) recommendations for an intervention directed at faculty to dismantle anti-Black racism in academic medicine. Barriers faced by Black faculty and trainees included lack of representation; challenges with the recruitment, retention, and promotion of Black faculty; and experiences of microaggressions and overt racism. Participants suggested that an intervention should have a comprehensive learning objective; be mandatory for all faculty, with the exception of Black faculty; draw from outside expertise; and receive allocation of resources and funding equal to other important training modules.

CONCLUSIONS AND RELEVANCE

The findings of this study affirm prior work about the unique challenges faced by Black faculty and trainees in academic medicine because of interpersonal and institutional racism and build on this prior work by soliciting recommendations to guide intervention development. An intervention to dismantle anti-Black racism within academic medicine is urgently needed and will require leadership buy-in and financial commitments from institutions for effective development and implementation.

Characteristics of opioid prescribing to outpatients with chronic liver diseases: A call for action

Background

Chronic liver disease (CLD) is among the strongest risk factors for adverse prescription opioid-related events. Yet, the current prevalence and factors associated with high-risk opioid prescribing in patients with chronic liver disease (CLD) remain unclear, making it challenging to address opioid safety in this population. Therefore, we aimed to characterize opioid prescribing patterns among patients with CLD.

Methods

This retrospective cohort study included patients with CLD identified at a single medical center and followed for one year from 10/1/2015-9/30/2016. Multivariable, multinomial regression was used identify the patient characteristics, including demographics, medical conditions, and liver-related factors, that were associated with opioid prescriptions and high-risk prescriptions (≥90mg morphine equivalents per day [MME/day] or co-prescribed with benzodiazepines).

Results

Nearly half (47%) of 12,425 patients with CLD were prescribed opioids over a one-year period, with 17% of these receiving high-risk prescriptions. The baseline factors significantly associated with high-risk opioid prescriptions included female gender (adjusted incident rate ratio, AIRR = 1.32, 95% CI = 1.14–1.53), Medicaid insurance (AIRR = 1.68, 95% CI = 1.36–2.06), cirrhosis (AIRR = 1.22, 95% CI = 1.04–1.43) and baseline chronic pain (AIRR = 3.40, 95% CI = 2.94–4.01), depression (AIRR = 1.93, 95% CI = 1.60–2.32), anxiety (AIRR = 1.84, 95% CI = 1.53–2.22), substance use disorder (AIRR = 2.16, 95% CI = 1.67–2.79), and Charlson comorbidity score (AIRR = 1.27, 95% CI = 1.22–1.32). Non-alcoholic fatty liver disease was associated with decreased high-risk opioid prescriptions (AIRR = 0.56, 95% CI = 0.47–0.66).

Conclusion

Opioid medications continue to be prescribed to nearly half of patients with CLD, despite efforts to curtail opioid prescribing due to known adverse events in this population.

Expanding Donor Selection and Recipient Indications for Living Donor Liver Transplantation

There is an acute shortage of deceased donor organs for liver transplantation in the United States. Nearly a third of patients either die or become too sick for transplant while on the transplant waitlist. Living donor liver transplantation (LDLT) bridges the gap between demand and supply of organs for liver transplantation. This article reviews current living donor selection criteria, and avenues for expansion of criteria with novel surgical techniques and ongoing outcomes research. Ways in which institutions can establish and expand LDLT programs using the Living Donor Champion model are discussed. Efforts to expand recipient indications for LDLT are described.

Pre-Transplant Depression Is Associated with Length of Hospitalization, Discharge Disposition, and Survival after Liver Transplantation

Depression after liver transplantation has been associated with decreased survival, but the effects of pre-transplant depression on early and late post-transplant outcomes remain incompletely evaluated. We assessed all patients who had undergone single-organ liver transplantation at a single center over the prior 10 years. A diagnosis of pre-transplant depression, covariates, and the outcomes of interest were extracted from the electronic medical record. Potential covariates included demographics, etiology and severity of liver disease, comorbidities, donor age, graft type, immunosuppression, and ischemic times. In multivariable models adjusting for these factors, we evaluated the effect of pre-transplant depression on transplant length of stay (LOS), discharge disposition (home vs. facility) and long-term survival. Among 1115 transplant recipients with a median follow-up time of 5 years, the average age was 56±11 and MELD was 12±9. Nineteen percent of the study population had a history of pre-transplant depression. Pre-transplant depression was associated with longer LOS (median = 19 vs. 14 days, IRR = 1.25, CI = 1.13,1.39), discharge to a facility (36% vs. 25%, OR 1.70,CI = 1.18,2.45), and decreased survival (HR = 1.54,CI = 1.14,2.08) in this cohort, accounting for other potential confounders. In conclusion, pre-transplant depression was significantly associated with longer transplant length of stay, discharge to a facility, and mortality in this cohort.

Association between opioid use and readmission following liver transplantation

The aim of this study was to assess the independent association between pre-transplant prescription opioid use and readmission following liver transplantation. We reviewed the medical records of all patients at a single medical center undergoing primary, single-organ, liver transplantation from 2004 to 2014. We assessed factors associated with hospital readmission 30 days and 1 year after hospital discharge using multivariable competing risk regression models. Among 1056 transplant recipients, 49 (4.6%) were prescribed pre-transplant prescription opioids. Readmission occurred in 421 (40%) patients within 30 days and 689 (65%) within 1 year. Patients with pre-transplant opioid use had a significantly higher risk of readmission at 30 days (HR 1.7; 95% CI 1.1-2.5) and a non-significantly elevated risk at 1 year (HR 1.4; 95% CI 1.0-1.9) when controlling for other potential confounders. Although pain was the major reason for readmission in only 12 (3%) patients at 30 days and 33 (6%) patients at 1 year, pre-transplant opioid use was significantly associated with pain-related readmission at both time points. In conclusion, prescription opioid use pre-transplantation was significantly associated with all-cause 30-day readmissions and pain-related readmissions at 30 days and 1 year.