Outcome of Liver Transplantation in Hepatocellular Carcinoma Patients at Siriraj Hospital.

BACKGROUND: Liver transplantation (LT) is one of the standard treatments for hepatocellular carcinoma (HCC), and the outcomes have become better after introduction of strict patient selection, such as the Milan criteria. However, several expanded criteria, such as the University of California San Francisco (UCSF) criteria, have demonstrated similar survival outcomes. The aim of this study was to verify survival outcomes of LT for HCC at Siriraj Hospital. METHODS: Sixty-three patients diagnosed with HCC who underwent cadaveric LT at Siriraj Hospital from 2002 to 2011 were included. All patients' characteristics, blood chemistries, size and number of tumors, bridging therapy, and survival and recurrence data were retrospectively reviewed and analyzed. RESULTS: Nearly all (62 patients, 98.4%) fulfilled the Milan criteria based on preoperative imaging. Explant pathology revealed that 40 patients (63.5%) were within Milan criteria and 50 patients (83%) within UCSF criteria. Demographic data, clinical laboratory, and bridging therapy were similar in patients within and outside both Milan and UCSF criteria. The 1-, 3-, and 5-year survival rates of patients within Milan were 85%, 75%, and 67.5%, and of those outside Milan were 69.6%, 52.2%, 52.2%, respectively (P = .25). Interestingly, with the use of the UCSF criteria, the 1-, 3-, and 5-year survival rates of patients within UCSF were significantly better than of those outside UCSF (84%, 76%, and 70% vs 61.5%, 30.8%, and 30.8%, respectively; P = .01). CONCLUSIONS: Outcome of LT in HCC patients within Milan criteria demonstrated good long-term survival. However, providing the opportunity for HCC patients by expanding from Milan to UCSF criteria revealed similar outcomes.

Correlation of Hematocrit and Tacrolimus Level in Liver Transplant Recipients.

BACKGROUND: Tacrolimus is the most widely used immunosuppressive drug after liver transplantation. Whole blood tacrolimus level is used for drug monitoring. Because of strong uptake by erythrocytes (95% to 98%), hematocrit level is an important factor for evaluation whole blood tacrolimus level. There has been no formula to calculate the effect of hematocrit on the whole blood tacrolimus level. The aim of this study is to evaluate the effect of hematocrit on the whole blood tacrolimus level. METHODS: Twenty-five patients were included in this study. Blood samples during routine follow-up were used. All patients received tacrolimus for more than 30 days after liver transplantation. Approximately half of the plasma was removed. Blood samples were remixed and remeasured for hematocrit and whole blood tacrolimus levels. Pearson correlation and linear regression were performed to generate a formula for corrected tacrolimus level. RESULTS: Thirteen male and 12 female patients participated in this study. There was a significant positive correlation between hematocrit ratio and tacrolimus ratio (r = 0.765, r(2) = 0.585, P < .001). The pattern of linear relationship between hematocrit ratio and tacrolimus ratio is defined by the regression equation, and the formula to correct tacrolimus level at hematocrit 40% is as follows: [Formula: see text] CONCLUSION: Hematocrit has a significant effect on tacrolimus level. Better dose adjustment for patients should include the consideration of hematocrit levels. Further studies are required to validate this formula and clinical significance.

Systematic Pharmaceutical Educational Approach to Enhance Drug Adherence in Liver Transplant Recipients.

BACKGROUND: Drug adherence is one of the most important factors determining graft and patient survivals after liver transplantation. A systematic pharmaceutical educational approach has been implemented to improve adherence in immunosuppressive drugs therapy at Siriraj Hospital. METHODS: This study was a single-center cross-sectional study of liver transplant patients who received pharmaceutical care from transplant pharmacists. The clinical pharmacy services, including medication review to emphasize patients' knowledge and awareness of immunosuppressive and general drug therapies with the use of various tools, were used to educate the patients. Drug-related problems (DRPs) and pre- and post-transplantation educational tests (divided into 3 parts: immunosuppressants [12 points], drug monitoring [6 points], and general drugs [2 points]) were analyzed. RESULTS: From October 2012 to September 2014, a total of 50 liver transplant recipients (86 visits) were enrolled. After the systematic pharmaceutical educational program, the average total score of post-transplantation educational test improved from 3.48 to 13.30 (P < .001). Likewise, the mean scores of all 3 parts significantly increased (part I: 2.28 vs 8.18 [P < .001]; part II: 0.75 vs 3.63 (P < .001); and part III: 0.46 vs 1.50 [P < .001]). The incidences of major DRPs, nonadherence, and adverse drug reactions were 8%, 4%, and 2%, respectively. CONCLUSIONS: A systematic pharmaceutical educational approach can significantly improve patients' knowledge and awareness concerning immunosuppressive drug usage.

Immunosuppressive Medication Adherence in Liver Transplant Recipients.

BACKGROUND: Immunosuppressive medication is one of the pivotal factors in the outcome of liver transplant patients. Nonadherence to immunosuppressive therapy is a common problem after transplantation and affects graft and patient survival. This study aimed to assess immunosuppressive medication adherence in liver transplant recipients. METHODS: Liver transplant recipients who underwent the Siriraj-Support Medication Adherence in Organ Transplantation (S-SMAOT) program were included in this cross-sectional study. Immunosuppressive medication adherence was assessed with the use of the Immunosuppressive Therapy Adherence Scale (ITAS, which is scored from 0 to 12; very poor to excellence adherence). The correlations between ITAS scores and the clinical profiles of the patients, duration after transplantation, and transplant educational scores post-test were also analyzed. RESULTS: From October 2012 to September 2014, a total of 50 liver transplant recipients (86 visits) were enrolled in this study. The ratio of male to female patients was 48:52. The proportions of patients with ITAS scores of 12, 10-11, and 0-9 were 82.6%, 16.3% and 1.2%, respectively. ITAS score was significantly correlated with the duration after transplantation (P < .001) and the educational scores (P = .009). CONCLUSIONS: Consistent assessment of patients' immunosuppressive medication adherence is essential to avoid problems of noncompliance and to improve the outcome after liver transplantation. The S-SMAOT program was an effective approach to significantly improve the medication adherence in liver transplant recipients.

Quality of life among liver transplantation patients.

BACKGROUND: Orthotopic liver transplantation (OLT) is the treatment of choice for end-stage disease. It offers a chance to return to an active and prolonged life. Recently, more attention is being paid to the health-related quality of life (HRQoL) of patients and their spouses or caregivers after OLT. The aim of this study was to analyze the pre- versus posttransplantation HRQoL of patients and their spouses or caregivers using generic and disease-specific health questionnaires. MATERIAL AND METHODS: The study was performed between October 2010 and January 2011 using the Short Form-36 (SF-36) and the Chronic Liver Disease Questionnaire (CLDQ) to evaluate the HRQoL. RESULTS: Posttransplantation patients (N=59, mean age 53.39 [range, 23 to 76] years, male 63.2%, female 36.8%) and their spouses and caregivers showed significantly better generic SF-36 HRQoL scores, namely, physical and social functioning, role limitations because of physical or emotional problems, bodily pain, vitality, as well as general and mental health compared with pretransplantation patients (N=57, mean age 54.56 (range, 22 to 69) years, male 71.2%, female 28.8%). Similarly, the posttransplantation group showed significantly improved CLDQ scores in all domains: fatigue, activity, abdominal symptoms, systemic symptoms, emotional function, and worry. CONCLUSION: OLT improved HRQoL of end-stage liver patients and their spouses or caregivers.