RESUMO
BACKGROUND: Intestinal transplantation (ITx) is the most expensive abdominal organ transplant. Detailed studies about exact costs and cost-effectiveness compared to home parenteral nutrition (HPN) therapy in chronic intestinal failure are lacking. The aim is to provide an in-depth analysis of ITx costs and evaluate cost-effectiveness compared to HPN. METHODS: To calculate costs before and after ITx, costs were analyzed in 12 adult patients. To calculate the costs of patients with uncomplicated chronic intestinal failure, 28 adults, stable HPN patients were studied. Total costs including surgery, admissions, diagnostics, HPN therapy, medication, and ambulatory care were included. Median (range) costs are given. RESULTS: Costs before ITx were 69 160 (60 682-90 891) in year 2, and 104 146 (83 854-186 412) in year 1. After ITx, costs were 172 133 (122 483-351 407) in the 1st year, 40 619 (3905-113 154) in the 2nd year, and dropped to 15 743 (4408-138 906) in the 3rd year. In stable HPN patients, the costs were 83 402 (35 364-169 146) in the 1st year, 70 945 (31 955-117 913) in the 2nd year, and stabilized to 60 242 (29 161-238 136) in the 3rd year. CONCLUSIONS: ITx, although initially very expensive, is cost-effective compared to HPN in adults by year 4, and cost-saving by year 5.
Assuntos
Custos de Cuidados de Saúde , Enteropatias/economia , Enteropatias/terapia , Intestinos/transplante , Transplante de Órgãos/economia , Nutrição Parenteral no Domicílio/economia , Adulto , Idoso , Idoso de 80 Anos ou mais , Doença Crônica , Redução de Custos , Análise Custo-Benefício , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Transplante de Órgãos/efeitos adversos , Nutrição Parenteral no Domicílio/efeitos adversos , Estudos Retrospectivos , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND & AIMS: Chronic intestinal failure is a complex medical condition which is associated with high costs. These patients require long-term home parenteral nutrition (HPN) and costs are compounded by frequent admissions for the underlying disease and HPN. However, it is unknown what the specific costs subdivisions are and how they evolve over time. The aim of the study was to evaluate the cost dynamics of HPN care in a cohort of stable, long-term intestinal failure patients. METHODS: A retrospective analysis of our single-center long-term (>2 years), benign HPN population was performed. All relevant clinical and financial data were collected: costs of hospital admissions, diagnostics, treatments, out-patient clinics, home care, medication, materials and HPN education. The costs were tabulated and assigned by cause (HPN related, underlying disease-related or -unrelated). Patients with complicated intestinal failure (defined as impending loss of vascular access, liver failure or recurrent fluid/electrolyte disorders) were excluded. Data are presented as median (range). RESULTS: Thirty-seven patients (24 female; age 58.6 ± 13.3 years) were included in the study. HPN duration was 5.3 years (2.1-15.1) at 4.3 infusion days per week (1.5-7). Total cost of the first HPN year was 83,503 (35,364-256,780). HPN-related costs accounted for 69% (57,593) vs 27% for underlying disease-related costs (22,505) and 4% for disease-unrelated costs (3065). HPN complications cost 16,077 in the first year and accounted for 31% of HPN costs. The total cost dropped by 15% in the second year to 71,311. This reduction was due to fewer hospital admissions and fewer HPN complications. This trend continued and by year 5 the annual cost was 40% cheaper compared to year 1 (58,187 vs 83,503). CONCLUSIONS: HPN related costs accounted for the majority of the total expenses in IF patients. The costs declined after the first year due to a reduction in complications and hospital admissions.
Assuntos
Custos de Cuidados de Saúde/estatística & dados numéricos , Enteropatias , Nutrição Parenteral no Domicílio/economia , Bélgica , Doença Crônica , Análise Custo-Benefício , Feminino , Hospitalização/economia , Humanos , Enteropatias/economia , Enteropatias/epidemiologia , Enteropatias/terapia , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosAssuntos
Prestação Integrada de Cuidados de Saúde , Transplante de Órgãos , Obtenção de Tecidos e Órgãos , Bélgica , Prestação Integrada de Cuidados de Saúde/história , Prestação Integrada de Cuidados de Saúde/legislação & jurisprudência , Prestação Integrada de Cuidados de Saúde/organização & administração , Prestação Integrada de Cuidados de Saúde/tendências , Difusão de Inovações , Previsões , Política de Saúde/história , História do Século XX , História do Século XXI , Humanos , Modelos Organizacionais , Transplante de Órgãos/história , Transplante de Órgãos/legislação & jurisprudência , Transplante de Órgãos/tendências , Formulação de Políticas , Fatores de Tempo , Doadores de Tecidos/provisão & distribuição , Obtenção de Tecidos e Órgãos/história , Obtenção de Tecidos e Órgãos/legislação & jurisprudência , Obtenção de Tecidos e Órgãos/organização & administração , Obtenção de Tecidos e Órgãos/tendências , Listas de EsperaRESUMO
Liver allocation in Eurotransplant is complex because allocation rules need to follow not only the guidelines of the European Commission but also the specific regulations of each of the 7 Eurotransplant countries with active liver transplant programs. Thirty-eight liver transplant centers served a population of about 135 million in 2015. Around 1600 deceased donor livers are transplanted annually. The number of deceased organ donors remains stable but donor age is increasing. Nevertheless, liver utilization rates are unchanged at around 80%. Donation after circulatory determination of death (DCD) increased fourfold in the past decade. In Belgium and the Netherlands, DCDs were responsible for 30% of deceased donor liver transplant activity in 2015; Austria only occasionally transplants a DCD liver; other Eurotransplant countries do not have active DCD programs. The most frequent indications for liver transplantation are alcoholic liver disease, hepatocellular carcinoma, and viral hepatitis. Livers are allocated first internationally to high urgency status patients or those with an approved combined organ status (for a liver in combination with heart, lung, intestine, or pancreas) and then on a national basis where allocation is recipient-driven or center-driven, depending on country-specific rules. Median waiting time for an elective liver transplant was 4,4 months in 2015; high urgency status patients waited a median of 2 days for a suitable liver. Mortality on the waiting list was 18% in 2015, 4% of patients were delisted because they became unfit for transplantation. One-year and 5-year risk unadjusted adult patient survival after transplantation is 80% and 65%, respectively.
Assuntos
Doença Hepática Terminal/cirurgia , Acessibilidade aos Serviços de Saúde/tendências , Disparidades em Assistência à Saúde/tendências , Transplante de Fígado/tendências , Padrões de Prática Médica/tendências , Avaliação de Processos em Cuidados de Saúde/tendências , Doadores de Tecidos/provisão & distribuição , Adulto , Seleção do Doador/tendências , Doença Hepática Terminal/diagnóstico , Doença Hepática Terminal/mortalidade , Europa (Continente) , Sobrevivência de Enxerto , Política de Saúde/tendências , Humanos , Transplante de Fígado/efeitos adversos , Transplante de Fígado/métodos , Transplante de Fígado/mortalidade , Seleção de Pacientes , Formulação de Políticas , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Listas de EsperaRESUMO
We present a 12-yr-old boy who received a combined liver-pancreas small bowel transplantation at the age of two. The post-operative period was complicated by wound closure problems resulting in a large asymptomatic abdominal wall defect. Further follow-up was uneventful, with the exception of new onset growth failure not explained by extensive routine investigations. An indirect calorimetry was performed. The resting energy expenditure (REE) was significantly increased (126% of predicted), demanding a daily caloric intake of 123 kcal/kg body weight (normal for age: 80 kcal/kg). In the absence of classic reasons for increased REE, a thermal camera revealed increased dermal heat loss at the abdominal wall defect (estimated surplus in energy loss of at least 29 kcal/day: 10.4% of the elevated REE). In addition, we found lower total lung capacity due to impaired abdominal breathing. In the exploration of growth failure in children after (ITx), increased REE must be taken into account. Indirect calorimetry can serve as a valuable diagnostic tool for evaluating individual energy requirements and nutritional support. In this child, exaggerated heat loss through an aberrant abdominal wall could be a potential important contributor to the patient's increased energy requirements.
Assuntos
Metabolismo Energético , Transtornos do Crescimento/etiologia , Intestino Delgado/transplante , Transplante de Órgãos/efeitos adversos , Calorimetria , Calorimetria Indireta , Criança , Ingestão de Energia , Transtornos do Crescimento/diagnóstico , Temperatura Alta , Humanos , Transplante de Fígado/métodos , Masculino , Transplante de Pâncreas/métodos , Período Pós-Operatório , Resultado do TratamentoRESUMO
BACKGROUND & AIMS: Polycystic liver disease (PCLD) may lead to extensive hepatomegaly and invalidating complaints. Therapeutic decisions, including somatostatin-analogues (SAs) and (non)-transplant surgery are besides the existence of hepatomegaly, also guided by the severity of complaints. We developed and validated a self-report instrument to capture the presence and severity of disease specific complaints for PCLD. METHODS: The study population consisted of 129 patients. Items for the PCLD-complaint-specific assessment (POLCA) were developed based on the chart review of symptomatic PCLD patients (n=68) and literature, and discussed during expert-consensus-meetings. 61 patients who needed therapy were asked to complete the POLCA and the short form health survey version 2 (SF36V2) at baseline and after 6 months of SA-treatment. CT-scans were used to calculate liver volumes (LV). Factor analysis was conducted to identify subscales and remove suboptimal items. Reliability was assessed by Cronbach's alpha. Convergent, criterion validity and responsiveness were tested using prespecified hypotheses. RESULTS: In the validation group (n=61), 47 received lanreotide (LAN) and 14 were offered LAN as bridge to liver transplantation (LTx). Factor analysis identified four subscales, which correlated with the physical component summary (PCS). Baseline POLCA scores were significantly higher in LTx-listed patients. In contrast to SF36V2, POLCA-paired observations in 47 patients demonstrated that 2 subscales were lowered significantly and 2 borderline. LV reduction of ⩾ 120 ml resulted in a numerical, more pronounced relative decrease of all scores. CONCLUSIONS: In contrast to SF36V2, the POLCA shows good validity and responsiveness to measure complaint severity in PCLD.
Assuntos
Cistos/diagnóstico , Hepatopatias/diagnóstico , Autorrelato , Adulto , Idoso , Cistos/fisiopatologia , Cistos/terapia , Feminino , Inquéritos Epidemiológicos/estatística & dados numéricos , Hepatomegalia/patologia , Humanos , Hepatopatias/fisiopatologia , Hepatopatias/terapia , Transplante de Fígado , Masculino , Pessoa de Meia-Idade , Peptídeos Cíclicos/uso terapêutico , Índice de Gravidade de Doença , Somatostatina/análogos & derivados , Somatostatina/uso terapêuticoRESUMO
PURPOSE OF REVIEW: The enduring donor shortage necessitates the development of tools capable of objectively assessing kidney graft quality and thereby allowing the safer and wider use of expanded criteria donors and kidneys donated after cardiac death. We summarize current assessment tools available prior to procurement and during preservation. RECENT FINDINGS: Several donor risk scores, combining donor and recipient risk factors of inferior graft outcome, exist but all lack predictive power. Histological scoring of glomerulosclerosis, tubular atrophy, interstitial fibrosis, and vascular damage in pretransplantation kidney biopsies can supply reliable, reproducible data on the actual kidney state but prospective data on their use in graft assessment are lacking. Renal resistance and certain perfusate biomarker concentrations during machine perfusion are independent risk factors of delayed graft function, but neither method has sufficient predictive power to allow kidney discard. SUMMARY: Available tools for graft quality assessment have their intrinsic value but none offer the necessary power to predict graft outcome for a specific donor-recipient pair. This is probably due to the multitude of donor, preservation, and recipient factors at stake. Only combining these factors might improve prediction of graft outcome and allow safer use of expanded criteria donors and kidneys donated after cardiac death.
Assuntos
Transplante de Rim , Nefrectomia , Preservação de Órgãos , Doadores de Tecidos/provisão & distribuição , Obtenção de Tecidos e Órgãos , Biópsia , Seleção do Doador , Humanos , Transplante de Rim/efeitos adversos , Preservação de Órgãos/efeitos adversos , Perfusão , Valor Preditivo dos Testes , Medição de Risco , Fatores de Risco , Resultado do TratamentoRESUMO
Although hepatocellular carcinoma (HCC) has become a recognized indication for liver transplantation, the rules governing priority and access to the waiting list are not well defined. Patient- and tumor-related variables were evaluated in 226 patients listed primarily for HCC in Belgium, a region where the allocation system is patient-driven, priority being given to sicker patients, based on the Child-Turcotte-Pugh (CTP) score. Intention-to-treat and posttransplantation survival rates at 4 years were 56.5 and 66%, respectively, and overall HCC recurrence rate was 10%. The most significant predictors of failure to receive a transplant in due time were baseline CTP score equal to or above 9 (relative risk [RR] 4.1; confidence interval [CI]: 1.7-9.9) and alpha fetoprotein above 100 ng/mL (RR 3.0; CI: 1.2-7.1). Independent predictors of posttransplantation mortality were age equal to or above 50 years (RR 2.5; CI: 1.0-3.7) and United Network for Organ Sharing pathological tumor nodule metastasis above the Milan criteria (RR 2.1; CI: 1.0-5.9). Predictors of recurrence (10%) were alpha fetoprotein above 100 ng/mL (RR 3.2; CI:1.1-10) and vascular involvement of the tumor on the explant (RR 3.6; CI: 1.1-11.3). Assessing the value of the pretransplantation staging by imaging compared to explant pathology revealed 34% accuracy, absence of carcinoma in 8.3%, overstaging in 36.2%, and understaging in 10.4%. Allocation rules for HCC should consider not only tumor characteristics but also the degree of liver impairment. Patients older than 50 years with a stage above the Milan criteria at transplantation have a poorer prognosis after transplantation.
Assuntos
Carcinoma Hepatocelular/cirurgia , Alocação de Recursos para a Atenção à Saúde/métodos , Neoplasias Hepáticas/cirurgia , Transplante de Fígado/estatística & dados numéricos , Alocação de Recursos/métodos , Adolescente , Adulto , Idoso , Europa (Continente) , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Listas de EsperaRESUMO
CONTEXT: The shortage of donor organs remains the most important factor of waiting list mortality in organ transplantation worldwide. Donor detection is influenced by the legal system, family refusal, and underreporting caused by erroneous knowledge of donation criteria and lack of familiarity with the procedure. OBJECTIVE: To identify possible key factors of donor referral patterns within an existing cooperation with donor hospitals and donor units across the Dutch-speaking part of Belgium, an area of approximately 3 million inhabitants. An intervention plan to optimize the cooperation and procedure quality and efficiency was designed. DESIGN: The intervention plan was based on 3 essential principles in donor referral by donor reporters, information on donor criteria, facilitation of the donor procedure, and communication between donor reporters and the transplant center. The interventions were structured to optimize all 3 of these principles. Two successive periods of 4 years were retrospectively compared. PARTICIPANTS: Data were collected retrospectively on donor referral behavior from a total of 37 donor hospitals and donor units over an 8-year period. MAIN OUTCOME MEASURES: The referrals were reviewed for potential donors, effective donors, percentage of effective donors, refusal rate of relatives, number of tissue donors, impact on local and national transplant programs, and national donor numbers. RESULTS: Data showed a significant positive impact on donor referrals and donor referral behavior (+27% potential donors, +30% effective donors, +172.7% tissue donors, -7% family refusals rates, +9.63% national donors). The results stress the importance of reduced workload and optimization of communication and information availability in an existing donor hospital network.