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1.
Hepatology ; 74(1): 312-321, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33219592

RESUMO

BACKGROUND AND AIMS: In February 2020, the Organ Procurement and Transplantation Network replaced donor service area-based allocation of livers with acuity circles, a system based on three homogeneous circles around each donor hospital. This system has been criticized for neglecting to consider varying population density and proximity to coast and national borders. APPROACH AND RESULTS: Using Scientific Registry of Transplant Recipients data from July 2013 to June 2017, we designed heterogeneous circles to reduce both circle size and variation in liver supply/demand ratios across transplant centers. We weighted liver demand by Model for End-Stage Liver Disease (MELD)/Pediatric End-Stage Liver Disease (PELD) because higher MELD/PELD candidates are more likely to be transplanted. Transplant centers in the West had the largest circles; transplant centers in the Midwest and South had the smallest circles. Supply/demand ratios ranged from 0.471 to 0.655 livers per MELD-weighted incident candidate. Our heterogeneous circles had lower variation in supply/demand ratios than homogeneous circles of any radius between 150 and 1,000 nautical miles (nm). Homogeneous circles of 500 nm, the largest circle used in the acuity circles allocation system, had a variance in supply/demand ratios 16 times higher than our heterogeneous circles (0.0156 vs. 0.0009) and a range of supply/demand ratios 2.3 times higher than our heterogeneous circles (0.421 vs. 0.184). Our heterogeneous circles had a median (interquartile range) radius of only 326 (275-470) nm but reduced disparities in supply/demand ratios significantly by accounting for population density, national borders, and geographic variation of supply and demand. CONCLUSIONS: Large homogeneous circles create logistical burdens on transplant centers that do not need them, whereas small homogeneous circles increase geographic disparity. Using carefully designed heterogeneous circles can reduce geographic disparity in liver supply/demand ratios compared with homogeneous circles of radius ranging from 150 to 1,000 nm.


Assuntos
Aloenxertos/provisão & distribuição , Doença Hepática Terminal/cirurgia , Transplante de Fígado/estatística & dados numéricos , Obtenção de Tecidos e Órgãos/organização & administração , Doença Hepática Terminal/diagnóstico , Geografia , Disparidades em Assistência à Saúde/estatística & dados numéricos , Humanos , Sistema de Registros/estatística & dados numéricos , Índice de Gravidade de Doença , Doadores de Tecidos/estatística & dados numéricos , Obtenção de Tecidos e Órgãos/estatística & dados numéricos , Transplantados/estatística & dados numéricos , Estados Unidos
2.
Am J Transplant ; 21(3): 1179-1185, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-32808468

RESUMO

Recently, the Organ Procurement and Transplant Network approved a plan to allocate kidneys within 250-nm circles around donor hospitals. These homogeneous circles might not substantially reduce geographic differences in transplant rates because deceased donor kidney supply and demand differ across the country. Using Scientific Registry of Transplant Recipients data from 2016-2019, we used an integer program to design unique, heterogeneous circles with sizes between 100 and 500 nm that reduced supply/demand ratio variation across transplant centers. We weighted demand according to wait time because candidates who have waited longer have higher priority. We compared supply/demand ratios and average travel distance of kidneys, using heterogeneous circles and 250 and 500-nm fixed-distance homogeneous circles. We found that 40% of circles could be 250 nm or smaller, while reducing supply/demand ratio variation more than homogeneous circles. Supply/demand ratios across centers for heterogeneous circles ranged from 0.06 to 0.13 kidneys per wait-year, compared to 0.04 to 0.47 and 0.05 to 0.15 kidneys per wait-year for 250-nm and 500-nm homogeneous circles, respectively. The average travel distance for kidneys using heterogeneous, and 250-nm and 500-nm fixed-distance circles was 173 nm, 134 nm, and 269 nm, respectively. Heterogeneous circles reduce geographic disparity compared to homogeneous circles, while maintaining reasonable travel distances.


Assuntos
Transplante de Rim , Obtenção de Tecidos e Órgãos , Seleção do Doador , Humanos , Rim , Doadores de Tecidos
3.
Am J Transplant ; 21(1): 198-207, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32506639

RESUMO

Infections remain a major threat to successful kidney transplantation (KT). To characterize the landscape and impact of post-KT infections in the modern era, we used United States Renal Data System (USRDS) data linked to the Scientific Registry of Transplant Recipients (SRTR) to study 141 661 Medicare-primary kidney transplant recipients from January 1, 1999 to December 31, 2014. Infection diagnoses were ascertained by International Classification of Diseases, Ninth Revision (ICD-9) codes. The cumulative incidence of a post-KT infection was 36.9% at 3 months, 53.7% at 1 year, and 78.0% at 5 years. The most common infections were urinary tract infection (UTI; 46.8%) and pneumonia (28.2%). Five-year mortality for kidney transplant recipients who developed an infection was 24.9% vs 7.9% for those who did not, and 5-year death-censored graft failure (DCGF) was 20.6% vs 10.1% (P < .001). This translated to a 2.22-fold higher mortality risk (adjusted hazard ratio [aHR]: 2.15 2.222.29 , P < .001) and 1.92-fold higher DCGF risk (aHR: 1.84 1.911.98 , P < .001) for kidney transplant recipients who developed an infection, although the magnitude of this higher risk varied across infection types (for example, 3.11-fold higher mortality risk for sepsis vs 1.62-fold for a UTI). Post-KT infections are common and substantially impact mortality and DCGF, even in the modern era. Kidney transplant recipients at high risk for infections might benefit from enhanced surveillance or follow-up to mitigate these risks.


Assuntos
Transplante de Rim , Idoso , Rejeição de Enxerto/epidemiologia , Rejeição de Enxerto/etiologia , Humanos , Transplante de Rim/efeitos adversos , Medicare , Fatores de Risco , Transplantados , Estados Unidos/epidemiologia
4.
Am J Transplant ; 21(10): 3305-3311, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-33870635

RESUMO

Recently, model for end-stage liver disease (MELD)-based liver allocation in the United States has been questioned based on concerns that waitlist mortality for a given biologic MELD (bMELD), calculated using laboratory values alone, might be higher at certain centers in certain locations across the country. Therefore, we aimed to quantify the center-level variation in bMELD-predicted mortality risk. Using Scientific Registry of Transplant Recipients (SRTR) data from January 2015 to December 2019, we modeled mortality risk in 33 260 adult, first-time waitlisted candidates from 120 centers using multilevel Poisson regression, adjusting for sex, and time-varying age and bMELD. We calculated a "MELD correction factor" using each center's random intercept and bMELD coefficient. A MELD correction factor of +1 means that center's candidates have a higher-than-average bMELD-predicted mortality risk equivalent to 1 bMELD point. We found that the "MELD correction factor" median (IQR) was 0.03 (-0.47, 0.52), indicating almost no center-level variation. The number of centers with "MELD correction factors" within ±0.5 points, and between ±0.5-± 1, ±1.0-±1.5, and ±1.5-±2.0 points was 62, 41, 13, and 4, respectively. No centers had waitlisted candidates with a higher-than-average bMELD-predicted mortality risk beyond ±2 bMELD points. Given that bMELD similarly predicts waitlist mortality at centers across the country, our results support continued MELD-based prioritization of waitlisted candidates irrespective of center.


Assuntos
Doença Hepática Terminal , Transplante de Fígado , Obtenção de Tecidos e Órgãos , Doença Hepática Terminal/cirurgia , Humanos , Índice de Gravidade de Doença , Listas de Espera
5.
Am J Transplant ; 21(5): 1838-1847, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33107180

RESUMO

COVID-19 has profoundly affected the American health care system; its effect on the liver transplant (LT) waitlist based on COVID-19 incidence has not been characterized. Using SRTR data, we compared observed LT waitlist registrations, waitlist mortality, deceased donor LTs (DDLT), and living donor LTs (LDLT) 3/15/2020-8/31/2020 to expected values based on historical trends 1/2016-1/2020, stratified by statewide COVID-19 incidence. Overall, from 3/15 to 4/30, new listings were 11% fewer than expected (IRR = 0.84 0.890.93 ), LDLTs were 49% fewer (IRR = 0.37 0.510.72 ), and DDLTs were 9% fewer (IRR = 0.85 0.910.97 ). In May, new listings were 21% fewer (IRR = 0.74 0.790.84 ), LDLTs were 42% fewer (IRR = 0.39 0.580.85 ) and DDLTs were 13% more (IRR = 1.07 1.151.23 ). Centers in states with the highest incidence 3/15-4/30 had 59% more waitlist deaths (IRR = 1.09 1.592.32 ) and 34% fewer DDLTs (IRR = 0.50 0.660.86 ). By August, waitlist outcomes were occurring at expected rates, except for DDLT (13% more across all incidences). While the early COVID-affected states endured major transplant practice changes, later in the pandemic the newly COVID-affected areas were not impacted to the same extent. These results speak to the adaptability of the transplant community in addressing the pandemic and applying new knowledge to patient care.


Assuntos
COVID-19 , Transplante de Fígado/estatística & dados numéricos , Humanos , Transplante de Fígado/tendências , Pandemias , Estudos Retrospectivos , Estados Unidos/epidemiologia , Listas de Espera
6.
Am J Transplant ; 20(10): 2842-2846, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32372460

RESUMO

Organs from uncontrolled DCD donors (uDCDs) have expanded donation in Europe since the 1980s, but are seldom used in the United States. Cited barriers include lack of knowledge about the potential donor pool, lack of robust outcomes data, lack of standard donor eligibility criteria and preservation methods, and logistical and ethical challenges. To determine whether it would be appropriate to invest in addressing these barriers and building this practice, we sought to enumerate the potential pool of uDCD donors. Using data from the Nationwide Emergency Department Sample, the largest all-payer emergency department (ED) database, between 2013 and 2016, we identified patients who had refractory cardiac arrest in the ED. We excluded patients with contraindications to both deceased donation (including infection, malignancy, cardiopulmonary disease) and uDCD (including hemorrhage, major polytrauma, burns, and poisoning). We identified 9828 (range: 9454-10 202) potential uDCDs/y; average age was 32 years, and all were free of major comorbidity. Of these, 91.1% had traumatic deaths, with major causes including nonhead blunt injuries (43.2%) and head injuries (40.1%). In the current era, uDCD donors represent a significant potential source of unused organs. Efforts to address barriers to uDCD in the United States should be encouraged.


Assuntos
Parada Cardíaca , Obtenção de Tecidos e Órgãos , Adulto , Europa (Continente) , Humanos , Fatores de Risco , Doadores de Tecidos , Estados Unidos/epidemiologia
7.
Am J Transplant ; 20(8): 2101-2112, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32065704

RESUMO

Prioritization of highly sensitized (HS) candidates under the kidney allocation system (KAS) and growth of large, multicenter kidney-paired donation (KPD) clearinghouses have broadened the transplant modalities available to HS candidates. To quantify temporal trends in utilization of these modalities, we used SRTR data from 2009 to 2017 to study 39 907 adult HS (cPRA ≥ 80%) waitlisted candidates and 19 003 recipients. We used competing risks regression to quantify temporal trends in likelihood of DDKT, KPD, and non-KPD LDKT for HS candidates (Era 1: January 1, 2009-December 31, 2011; Era 2: January 1, 2012-December 3, 2014; Era 3: December 4, 2014-December 31, 2017). Although the likelihood of DDKT and KPD increased over time for all HS candidates (adjusted subhazard ratio [aSHR] Era 3 vs 1 for DDKT: 1.74 1.851.97 , P < .001 and for KPD: 1.70 2.202.84 , P < .001), the likelihood of non-KPD LDKT decreased (aSHR: 0.69 0.820.97 , P = .02). However, these changes affected HS recipients differently based on cPRA. Among recipients, more cPRA 98%-99.9% and 99.9%+ recipients underwent DDKT (96.2% in Era 3% vs 59.1% in Era 1 for cPRA 99.9%+), whereas fewer underwent non-KPD LDKT (1.9% vs 30.9%) or KPD (2.0% vs 10.0%). Although KAS increased DDKT likelihood for the most HS candidates, it also decreased the use of non-KPD LDKT to transplant cPRA 98%+ candidates.


Assuntos
Transplante de Rim , Obtenção de Tecidos e Órgãos , Transplantes , Adulto , Seleção do Doador , Humanos , Doadores Vivos , Coleta de Tecidos e Órgãos , Estados Unidos
8.
Am J Transplant ; 20(8): 2234-2242, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32012451

RESUMO

Stakeholders have expressed concerns regarding decreased deceased donor kidney transplant (DDKT) rates for pediatric candidates under the Kidney Allocation System (KAS). To better understand what might be driving this, we studied Scientific Registry of Transplant Recipients kidney offer data for 3642 pediatric (age <18 years) kidney-only transplant candidates between December 31, 2012 to December 3, 2014 (pre-KAS) and December 4, 2014 to January 6, 2017 (post-KAS). We used negative binomial regression and multilevel logistic regression to compare offer and acceptance rates pre- and post-KAS. We stratified by donor age (<18, 18-34, and 35+ years) and KDPI (<35% and ≥35%) to reflect differing allocation prioritization pre-KAS and post-KAS. As might be expected from prioritization changes, post-KAS candidates were less likely to receive offers for donors 18-34 years old with KDPI ≥ 35% (adjusted incidence rate ratio [aIRR]: 0.18 0.210.25 , P < .001), and more likely to receive offers for donors 18-34 years old and KDPI < 35% (aIRR: 1.12 1.201.29 , P < .001). However, offer acceptance practices also changed post-KAS: kidneys from donors 18-34 years old and KDPI < 35% were 23% less likely to be accepted post-KAS (adjusted odds ratio: 0.61 0.770.98 , P = .03). Using kidneys from donors 18-34 years old with KDPI < 35% post-KAS to the same extent they were used pre-KAS might be an effective strategy to mitigate any decrease in DDKT rates for pediatric candidates.


Assuntos
Transplante de Rim , Obtenção de Tecidos e Órgãos , Adolescente , Adulto , Criança , Humanos , Rim , Doadores de Tecidos , Transplantados , Adulto Jovem
9.
Am J Transplant ; 20(7): 1809-1818, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32282982

RESUMO

COVID-19 is a novel, rapidly changing pandemic: consequently, evidence-based recommendations in solid organ transplantation (SOT) remain challenging and unclear. To understand the impact on transplant activity across the United States, and center-level variation in testing, clinical practice, and policies, we conducted a national survey between March 24, 2020 and March 31, 2020 and linked responses to the COVID-19 incidence map. Response rate was a very high 79.3%, reflecting a strong national priority to better understand COVID-19. Complete suspension of live donor kidney transplantation was reported by 71.8% and live donor liver by 67.7%. While complete suspension of deceased donor transplantation was less frequent, some restrictions to deceased donor kidney transplantation were reported by 84.0% and deceased donor liver by 73.3%; more stringent restrictions were associated with higher regional incidence of COVID-19. Shortage of COVID-19 tests was reported by 42.5%. Respondents reported a total of 148 COVID-19 recipients from <1 to >10 years posttransplant: 69.6% were kidney recipients, and 25.0% were critically ill. Hydroxychloroquine (HCQ) was used by 78.1% of respondents; azithromycin by 46.9%; tocilizumab by 31.3%, and remdesivir by 25.0%. There is wide heterogeneity in center-level response across the United States; ongoing national data collection, expert discussion, and clinical studies are critical to informing evidence-based practices.


Assuntos
Infecções por Coronavirus/prevenção & controle , Infecções por Coronavirus/transmissão , Transplante de Órgãos/tendências , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Pneumonia Viral/transmissão , Monofosfato de Adenosina/análogos & derivados , Monofosfato de Adenosina/uso terapêutico , Alanina/análogos & derivados , Alanina/uso terapêutico , Anticorpos Monoclonais Humanizados/uso terapêutico , Betacoronavirus , COVID-19 , Teste para COVID-19 , Técnicas de Laboratório Clínico/estatística & dados numéricos , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/tratamento farmacológico , Estado Terminal , Medicina Baseada em Evidências , Política de Saúde , Humanos , Hidroxicloroquina/uso terapêutico , Incidência , Falência Renal Crônica/complicações , Falência Renal Crônica/cirurgia , Transplante de Rim/estatística & dados numéricos , Transplante de Rim/tendências , Transplante de Fígado/estatística & dados numéricos , Transplante de Fígado/tendências , Doadores Vivos , Transplante de Órgãos/legislação & jurisprudência , Transplante de Órgãos/estatística & dados numéricos , Alocação de Recursos , SARS-CoV-2 , Inquéritos e Questionários , Doadores de Tecidos , Transplantados , Estados Unidos , Tratamento Farmacológico da COVID-19
10.
Am J Transplant ; 20(11): 3131-3139, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32594606

RESUMO

In March 2020, coronavirus disease 2019 (COVID-19) spread rapidly nationally, causing widespread emergent changes to the health system. Our goal was to understand the impact of the epidemic on kidney transplantation (KT), at both the national and center levels, accounting statistically for waitlist composition. Using Scientific Registry of Transplant Recipients data, we compared data on observed waitlist registrations, waitlist mortality, and living-donor and deceased-donor kidney transplants (LDKT/DDKT) March 15-April 30, 2020 to expected events calculated from preepidemic data January 2016-February 2020. There were few changes before March 15, at which point the number of new listings/DDKT/LDKT dropped to 18%/24%/87% below the expected value (all P < .001). Only 12 centers performed LDKT March 15-31; by April 30, 40 centers had resumed LDKT. The decline in new listings and DDKT was greater among states with higher per capita confirmed COVID-19 cases. The number of waitlist deaths was 2.2-fold higher than expected in the 5 states with highest COVID-19 burden (P < .001). DCD DDKT and regional/national imports declined nationwide but most steeply in states with the highest COVID-19 burden. The COVID-19 epidemic has resulted in substantial changes to KT; we must adapt and learn rapidly to continue to provide safe access to transplantation and limit the growing indirect toll of an already deadly disease.


Assuntos
COVID-19/epidemiologia , Transplante de Rim/estatística & dados numéricos , Doadores Vivos/provisão & distribuição , Pandemias , Sistema de Registros , SARS-CoV-2 , Obtenção de Tecidos e Órgãos/organização & administração , Adolescente , Adulto , Idoso , Criança , Pré-Escolar , Comorbidade , Feminino , Sobrevivência de Enxerto , Humanos , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Insuficiência Renal/epidemiologia , Estudos Retrospectivos , Transplantados , Estados Unidos/epidemiologia , Listas de Espera , Adulto Jovem
11.
Clin Transplant ; 34(12): e14086, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-32918766

RESUMO

In our first survey of transplant centers in March 2020, >75% of kidney and liver programs were either suspended or operating under restrictions. To safely resume transplantation, we must understand the evolving impact of COVID-19 on transplant recipients and center-level practices. We therefore conducted a six-week follow-up survey May 7-15, 2020, and linked responses to the COVID-19 incidence map, with a response rate of 84%. Suspension of live donor transplantation decreased from 72% in March to 30% in May for kidneys and from 68% to 52% for livers. Restrictions/suspension of deceased donor transplantation decreased from 84% to 58% for kidneys and from 73% to 42% for livers. Resuming transplantation at normal capacity was envisioned by 83% of programs by August 2020. Exclusively using local recovery teams for deceased donor procurement was reported by 28%. Respondents reported caring for a total of 1166 COVID-19-positive transplant recipients; 25% were critically ill. Telemedicine challenges were reported by 81%. There was a lack of consensus regarding management of potential living donors or candidates with SARS-CoV-2. Our findings demonstrate persistent heterogeneity in center-level response to COVID-19 even as transplant activity resumes, making ongoing national data collection and real-time analysis critical to inform best practices.


Assuntos
COVID-19/prevenção & controle , Acessibilidade aos Serviços de Saúde/tendências , Transplante de Órgãos/tendências , Política Organizacional , Padrões de Prática Médica/tendências , Telemedicina/tendências , Obtenção de Tecidos e Órgãos/tendências , Adulto , COVID-19/diagnóstico , COVID-19/epidemiologia , COVID-19/etiologia , Teste para COVID-19 , Tomada de Decisão Clínica , Seguimentos , Pesquisas sobre Atenção à Saúde , Acessibilidade aos Serviços de Saúde/organização & administração , Humanos , Incidência , Controle de Infecções/métodos , Controle de Infecções/tendências , Transplante de Órgãos/métodos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Complicações Pós-Operatórias/virologia , Obtenção de Tecidos e Órgãos/organização & administração , Estados Unidos/epidemiologia
12.
Am J Transplant ; 19(11): 3079-3086, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31062464

RESUMO

The Kidney Allocation System (KAS) has resulted in fewer pediatric kidneys being allocated to pediatric deceased donor kidney transplant (pDDKT) recipients. This had prompted concerns that post-pDDKT outcomes may worsen. To study this, we used SRTR data to compare the outcomes of 953 pre-KAS pDDKT (age <18 years) recipients (December 4, 2012-December 3, 2014) with the outcomes of 934 post-KAS pDDKT recipients (December 4, 2014-December 3, 2016). We analyzed mortality and graft loss by using Cox regression, delayed graft function (DGF) by using logistic regression, and length of stay (LOS) by using negative binomial regression. Post-KAS recipients had longer pretransplant dialysis times (median 1.26 vs 1.07 years, P = .02) and were more often cPRA 100% (2.0% vs 0.1%, P = .001). Post-KAS recipients had less graft loss than pre-KAS recipients (hazard ratio [HR]: 0.35 0.540.83 , P = .005) but no statistically significant differences in mortality (HR: 0.29 0.721.83 , P = .5), DGF (odds ratio: 0.93 1.321.93 , P = .2), and LOS (LOS ratio: 0.96 1.061.19 , P = .4). After adjusting for donor-recipient characteristics, there were no statistically significant post-KAS differences in mortality (adjusted HR: 0.37 1.042.92 , P = .9), DGF (adjusted odds ratio: 0.94 1.412.13 , P = .1), or LOS (adjusted LOS ratio: 0.93 1.041.16 , P = .5). However, post-KAS pDDKT recipients still had less graft loss (adjusted HR: 0.38 0.590.91 , P = .02). KAS has had a mixed effect on short-term posttransplant outcomes for pDDKT recipients, although our results are limited by only 2 years of posttransplant follow-up.


Assuntos
Função Retardada do Enxerto/mortalidade , Rejeição de Enxerto/mortalidade , Falência Renal Crônica/cirurgia , Transplante de Rim/mortalidade , Alocação de Recursos/estatística & dados numéricos , Doadores de Tecidos/provisão & distribuição , Obtenção de Tecidos e Órgãos/estatística & dados numéricos , Adolescente , Adulto , Criança , Morte , Função Retardada do Enxerto/etiologia , Função Retardada do Enxerto/patologia , Feminino , Seguimentos , Rejeição de Enxerto/etiologia , Rejeição de Enxerto/patologia , Sobrevivência de Enxerto , Humanos , Transplante de Rim/efeitos adversos , Masculino , Prognóstico , Fatores de Risco , Adulto Jovem
13.
J Vasc Surg ; 68(1): 153-160, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29276108

RESUMO

OBJECTIVE: The objective of this study was to compare conduit use and surgical outcomes of hemodialysis-dependent men and women after open lower extremity bypass surgery. METHODS: Using the United States Renal Data System, we studied all hemodialysis patients in the United States who underwent infrainguinal bypass surgery between January 1, 2006, and December 31, 2011. Univariate methods (χ2, analysis of variance) were employed to compare patient and bypass characteristics between men and women. Kaplan-Meier, univariate and multivariate logistic, and Cox regression analyses were employed to evaluate outcomes that included patency, graft failure, and mortality at 30 days. In addition, we compared limb salvage and patient survival rates between men and women. RESULTS: There were 9739 bypasses performed in 5927 (61%) men and 3812 (39%) women who presented most commonly with critical limb ischemia (men, 73%; women, 71%; P = .04). Bypass configurations were femoral-popliteal (48%), femoral-tibial (34%), and popliteal-tibial (18%). The prevalence of autogenous conduits was higher for men (61 vs 55%; P < .001), and they were associated with higher patency compared with prosthetics (adjusted hazard ratio [aHR], 1.10; 95% confidence interval [CI], 1.01-1.19; P = .03). The risk-adjusted analyses revealed higher odds of acute graft failure for women compared with men who received prosthetic conduits (adjusted odds ratio, 1.23; 95% CI, 1.03-1.46; P = .021) but not among patients who received autogenous conduits (adjusted odds ratio, 1.07; 95% CI, 0.91-1.25; P = .41). Despite the difference in choice of conduit, there was no significant difference in primary patency (aHR, 1.00; 95% CI, 0.95-1.06; P = .90), primary assisted patency (aHR, 1.03; 95% CI, 0.97-1.10; P = .28), secondary patency (aHR, 1.01; 95% CI, 0.95-1.08; P = .75), limb salvage (aHR, 0.97; 95% CI, 0.90-1.04; P = .41), and survival (aHR, 0.97; 95% CI, 0.92-1.03; P = .45) for women compared with men. CONCLUSIONS: We found lower use of autogenous conduits in women than in men. In patients who received prosthetic conduit, acute graft failure was higher for women than for men. The benefits of autogenous conduits over prosthetic grafts underscore the need to improve the selection of appropriately sized autogenous conduits for bypass irrespective of gender.


Assuntos
Implante de Prótese Vascular , Nefropatias/terapia , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/cirurgia , Diálise Renal , Veias/transplante , Idoso , Amputação Cirúrgica , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Distribuição de Qui-Quadrado , Tomada de Decisão Clínica , Bases de Dados Factuais , Intervalo Livre de Doença , Feminino , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Humanos , Estimativa de Kaplan-Meier , Nefropatias/complicações , Nefropatias/fisiopatologia , Salvamento de Membro , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Doença Arterial Periférica/complicações , Doença Arterial Periférica/diagnóstico por imagem , Modelos de Riscos Proporcionais , Desenho de Prótese , Diálise Renal/efeitos adversos , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução Vascular
15.
Int J Gynecol Cancer ; 26(2): 318-24, 2016 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-26588234

RESUMO

OBJECTIVE: To determine patients' perceptions of provider-based counseling and behavior changes made by endometrial cancer survivors. MATERIALS AND METHODS: Endometrial cancer survivors (diagnosed from 2011 to 2012) from a single institution were surveyed. Exclusion criteria included persistent or recurrent disease or those actively undergoing treatment. Information collected included demographics, weight assessments, health behaviors, and physician counseling. Statistical analysis was performed using descriptive statistics, Fisher exact test, McNemar test, and the κ statistic as a measure of agreement. RESULTS: Of 233 surveys sent, 46% were returned. Median body mass index was 29.8 kg/m (range, 17.1-64.8 kg/m). Comparing primary care providers with gynecologic oncologists (GOs), 47% (n = 46) versus 25% (n = 23) provided dietary counseling and 62% (n = 60) versus 37% (n = 34) provided physical activity counseling (Fisher exact test, P = 0.001 and P < 0.001, respectively). Only 29% (n = 30) reported being told of the link between endometrial cancer and obesity. Fifty-two percent of responders attempted weight loss after their diagnosis. Fifty-nine percent of responders reported making changes in their diet. Fifty-six percent of patients made dietary changes within 3 months of diagnosis. Forty-eight percent of responders increased physical activity, with 62% implementing changes within 3 to 6 months of their diagnosis. The responders most likely to attempt weight loss were those who received counseling by a provider. All patients reporting attempted weight loss after their cancer diagnosis report being counseled by either a primary care provider or a GO to lose weight. Weight loss counseling was significantly associated with attempting weight loss (P < 0.001). CONCLUSIONS: One third of endometrial cancer survivors report counseling by their GO to lose weight. One half of endometrial cancer survivors reported attempted weight loss. All patients reporting weight loss counseling from their oncologist reported attempted weight loss. Most behavioral change occurred 3 to 6 months after a cancer diagnosis. Obesity in endometrial cancer survivors is not adequately addressed and represents a critical area for improvement.


Assuntos
Conhecimentos, Atitudes e Prática em Saúde , Obesidade/psicologia , Sobreviventes/psicologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Aconselhamento Diretivo , Neoplasias do Endométrio/etiologia , Feminino , Humanos , Estilo de Vida , Pessoa de Meia-Idade , Obesidade/complicações , Inquéritos e Questionários , Sobreviventes/estatística & dados numéricos
16.
Transplantation ; 107(12): e339-e347, 2023 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-37726882

RESUMO

BACKGROUND: In the context of the organ shortage, donation after circulatory death (DCD) provides an opportunity to expand the donor pool. Although deceased-donor liver transplantation from DCD donors has expanded, DCD livers continue to be discarded at elevated rates; the use of DCD livers from older donors, or donors with comorbidities, is controversial. METHODS: Using US registry data from 2009 to 2020, we identified 1564 candidates on whose behalf a DCD liver offer was accepted ("acceptors") and 16 981 candidates on whose behalf the same DCD offers were declined ("decliners"). We characterized outcomes of decliners using a competing risk framework and estimated the survival benefit (adjusted hazard ratio [95% confidence interval]) of accepting DCD livers using Cox regression. RESULTS: Within 10 y of DCD offer decline, 50.9% of candidates died or were removed from the waitlist before transplantation with any type of allograft. DCD acceptors had lower mortality compared with decliners at 10 y postoffer (35.4% versus 48.9%, P < 0.001). After adjustment for candidate covariates, DCD offer acceptance was associated with a 46% reduction in mortality (0.54 [0.49-0.61]). Acceptors of older (age ≥50), obese (body mass index ≥30), hypertensive, nonlocal, diabetic, and increased risk DCD livers had 44% (0.56 [0.42-0.73]), 40% (0.60 [0.49-0.74]), 48% (0.52 [0.41-0.66]), 46% (0.54 [0.45-0.65]), 32% (0.68 [0.43-1.05]), and 45% (0.55 [0.42-0.72]) lower mortality risk compared with DCD decliners, respectively. CONCLUSIONS: DCD offer acceptance is associated with considerable long-term survival benefits for liver transplant candidates, even with older DCD donors or donors with comorbidities. Increased recovery and utilization of DCD livers should be encouraged.


Assuntos
Transplante de Fígado , Obtenção de Tecidos e Órgãos , Humanos , Estados Unidos , Transplante de Fígado/efeitos adversos , Doadores Vivos , Doadores de Tecidos , Fígado , Transplante Homólogo , Sobrevivência de Enxerto , Morte , Estudos Retrospectivos
17.
Transplant Direct ; 8(10): e1373, 2022 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-36204185

RESUMO

Recently, the misuse of race as a biological variable, rather than a social construct, in biomedical research has received national attention for its contributions to medical bias. In national transplant registry data, bias may arise from measurement imprecision because of the collection of provider-perceived race rather than patients' own self-report. Methods: We linked Scientific Registry of Transplant Recipients data to a prospective, multicenter cohort study of adult kidney transplant patients (December 2008-February 2020) that collects patient-reported race. We computed Cohen's kappa statistic to estimate agreement between provider-perceived and patient-reported race in the 2 data sources. We used an unadjusted generalized linear model to examine changes in agreement over time. Results: Among 2942 kidney transplant patients, there was almost perfect agreement among Asian (kappa = 0.88, 95% confidence interval [CI], 0.84-0.92), Black (kappa = 0.97, 95% CI, 0.96-0.98), and White categories (kappa = 0.95, 95% CI, 0.93-0.96) and worse agreement among Hispanic/Latino (kappa = 0.66, 95% CI, 0.57-0.74) and Native Hawaiian/Other Pacific Islander categories (kappa = 0.40, 95% CI, 0.01-0.78). The percent agreement decreased over time (difference in percent agreement = -0.55, 95% CI, -0.75 to -0.34). However, there were differences in these trends by race: -0.07/y, 95% CI, -0.21 to 0.07 for Asian; -0.06/y, 95% CI, -0.28 to 0.16 for Black; -0.01/y, 95% CI, -0.21 to 0.19 for Hispanic/Latino; -0.43/y, 95% CI, -0.58 to -0.28 for White categories. Conclusions: Race misclassification has likely led to increasingly biased research estimates over time, especially for Asian, Hispanic/Latino, and Native Hawaiian/Other Pacific Islander study populations. Improvements to race measurement include mandating patient-reported race, expanding race categories to better reflect contemporary US demographics, and allowing write-ins on data collection forms, as well as supplementing data with qualitative interviews or validated measures of cultural identity, ancestry, and discrimination.

18.
Transplantation ; 106(8): 1600-1608, 2022 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-35238851

RESUMO

BACKGROUND: Living donor liver transplants (LDLTs) including those from nondirected donors (NDDs) have increased during the past decade, and center-level variations in LDLTs have not yet been described. We sought to quantify changes in the volume of NDD transplants over time and variation in NDD volume between transplant centers. We further examined characteristics of living liver donors and identified factors potentially associated with receiving an NDD liver transplant. METHODS: Using Scientific Registry of Transplant Recipients data between March 01, 2002, and December 31, 2020, we compared 173 NDDs with 5704 DLDs and 167 NDD recipients with 1153 waitlist candidates. RESULTS: NDDs increased from 1 (0.4% of LDLTs) in 2002 to 58 (12% of LDLTs) in 2020. Of 150 transplant centers, 35 performed at least 1 NDD transplant. Compared with waitlist candidates, adult NDD recipients were less frequently males (39% versus 62%, P < 0.001), had a lower model for end-stage liver disease (16 versus 18, P = 0.01), and spent fewer days on the waitlist (173 versus 246, P = 0.02). Compared with waitlist candidates, pediatric NDD recipients were younger (50% versus 12% age <2 y, P < 0.001) and more often diagnosed with biliary atresia (66% versus 41%, P < 0.001). Compared with DLDs, NDDs were older (40 versus 35 y, P < 0.001), college educated (83% versus 64%, P < 0.001), White (92% versus 78%, P < 0.001), and more frequently donated left-lateral segment grafts (32.0% versus 14%, P < 0.001). CONCLUSIONS: Liver NDD transplants continue to expand but remain concentrated at a few centers. Graft distribution favors female adults and pediatric patients with biliary atresia. Racial inequities in adult or pediatric center-level NDD graft distribution were not observed.


Assuntos
Atresia Biliar , Doença Hepática Terminal , Transplante de Fígado , Adulto , Criança , Feminino , Sobrevivência de Enxerto , Humanos , Transplante de Fígado/efeitos adversos , Doadores Vivos , Masculino , Índice de Gravidade de Doença , Estados Unidos
19.
Circ Heart Fail ; 14(2): e006107, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33525893

RESUMO

BACKGROUND: Black heart transplant recipients have higher risk of mortality than White recipients. Better understanding of this disparity, including subgroups most affected and timing of the highest risk, is necessary to improve care of Black recipients. We hypothesize that this disparity may be most pronounced among young recipients, as barriers to care like socioeconomic factors may be particularly salient in a younger population and lead to higher early risk of mortality. METHODS: We studied 22 997 adult heart transplant recipients using the Scientific Registry of Transplant Recipients data from January 2005 to 2017 using Cox regression models adjusted for recipient, donor, and transplant characteristics. RESULTS: Among recipients aged 18 to 30 years, Black recipients had 2.05-fold (95% CI, 1.67-2.51) higher risk of mortality compared with non-Black recipients (P<0.001, interaction P<0.001); however, the risk was significant only in the first year post-transplant (first year: adjusted hazard ratio, 2.30 [95% CI, 1.60-3.31], P<0.001; after first year: adjusted hazard ratio, 0.84 [95% CI, 0.54-1.29]; P=0.4). This association was attenuated among recipients aged 31 to 40 and 41 to 60 years, in whom Black recipients had 1.53-fold ([95% CI, 1.25-1.89] P<0.001) and 1.20-fold ([95% CI, 1.09-1.33] P<0.001) higher risk of mortality. Among recipients aged 61 to 80 years, no significant association was seen with Black race (adjusted hazard ratio, 1.12 [95% CI, 0.97-1.29]; P=0.1). CONCLUSIONS: Young Black recipients have a high risk of mortality in the first year after heart transplant, which has been masked in decades of research looking at disparities in aggregate. To reduce overall racial disparities, clinical research moving forward should focus on targeted interventions for young Black recipients during this period.


Assuntos
Negro ou Afro-Americano , Cardiomiopatias/cirurgia , Disparidades em Assistência à Saúde/etnologia , Cardiopatias Congênitas/cirurgia , Transplante de Coração , Imunossupressores/uso terapêutico , Mortalidade , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Soro Antilinfocitário/uso terapêutico , Causas de Morte , Diabetes Mellitus/epidemiologia , Escolaridade , Feminino , Glucocorticoides/uso terapêutico , Rejeição de Enxerto/prevenção & controle , Hispânico ou Latino , Histocompatibilidade , Humanos , Seguro Saúde/estatística & dados numéricos , Interleucina-2/uso terapêutico , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Ácido Micofenólico/uso terapêutico , Modelos de Riscos Proporcionais , Sistema de Registros , Fatores Sexuais , Tacrolimo/uso terapêutico , População Branca , Adulto Jovem , Indígena Americano ou Nativo do Alasca
20.
JAMA Surg ; 156(4): e207083, 2021 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-33566079

RESUMO

Importance: Historically, deceased organ donation was lower among Black compared with White populations, motivating efforts to reduce racial disparities. The overarching effect of these efforts in Black and other racial/ethnic groups remains unclear. Objective: To examine changes in deceased organ donation over time. Design, Setting, and Participants: This population-based cohort study used data from January 1, 1999, through December 31, 2017, from the Scientific Registry of Transplant Recipients to quantify the number of actual deceased organ donors, and from the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research Detailed Mortality File to quantify the number of potential donors (individuals who died under conditions consistent with organ donation). Data were analyzed from December 2, 2019, to May 14, 2020. Exposures: Race and ethnicity of deceased and potential donors. Main Outcomes and Measures: For each racial/ethnic group and year, a donation ratio was calculated as the number of actual deceased donors divided by the number of potential donors. Direct age and sex standardization was used to allow for group comparisons, and Poisson regression was used to quantify changes in donation ratio over time. Results: A total of 141 534 deceased donors and 5 268 200 potential donors were included in the analysis. Among Black individuals, the donation ratio increased 2.58-fold from 1999 to 2017 (yearly change in adjusted incidence rate ratio [aIRR], 1.05; 95% CI, 1.05-1.05; P < .001). This increase was significantly greater than the 1.60-fold increase seen in White individuals. Nevertheless, substantial racial differences remained, with Black individuals still donating at only 69% the rate of White individuals in 2017 (P < .001). Among other racial minority populations, changes were less drastic. Deceased organ donation increased 1.80-fold among American Indian/Alaska Native and 1.40-fold among Asian or Pacific Islander populations, with substantial racial differences remaining in 2017 (American Indian/Alaska Native population donation at 28% and Asian/Pacific Islander population donation at 85% the rate of the White population). Deceased organ donation differences between Hispanic/Latino and non-Hispanic/Latino populations increased over time (4% lower in 2017). Conclusions and Relevance: The findings of this cohort study suggest that differences in deceased organ donation between White and some racial minority populations have attenuated over time. The greatest gains were observed among Black individuals, who have been the primary targets of study and intervention. Despite improvements, substantial differences remain, suggesting that novel approaches are needed to understand and address relatively lower rates of deceased organ donation among all racial minorities.


Assuntos
Minorias Étnicas e Raciais , Obtenção de Tecidos e Órgãos/estatística & dados numéricos , Feminino , Humanos , Masculino , Estados Unidos
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