Disparities in Access to Mental Health Services Among Children Diagnosed with Anxiety and Depression in the United States.

Child and adolescent mental health are major public health concerns in the US. Overall, 20% of US children have a reported mental health condition, while an estimated 40% will be diagnosed with one by age 18. Despite these concerns, little is known about factors associated with access to mental health services among children and adolescents. We analyzed data from a sample of 6655 children (aged 6 to 17 years) with either anxiety and/or depression drawn from the 2020-2021 National Survey of Children's Health (NSCH). A multivariable logistic regression model was fit to investigate predisposing, enabling, and need factors associated with caregiver's (i.e., parent or other guardian) perceived access to mental health services for their children. Approximately 50.8% of caregivers perceived obtaining mental health services for their children to be somewhat difficult, very difficult, or impossible. Children meeting criteria for having a medical home had lower odds of experiencing such difficulties (adjusted [a]OR = 0.38; 95% CI: 0.30-0.49). Further, compared to children who sometimes or never had health insurance coverage for mental or behavioral health needs, children who were always insured (aOR: 0.19; 95% CI 0.14, 0.25) and those who usually had coverage (aOR: 0.38; 95% CI 0.28, 0.51) had lower odds of experiencing perceived difficulties in obtaining care. The results indicate several enabling and need predictors of perceived access to mental health services--highlighting potential structural barriers to care access. Efforts to address access challenges should adopt a multifaceted approach and be tailored to families living in poverty, those with limited health coverage, and minoritized children with less than optimal general health.

Food security status and breast cancer screening among women in the United States: Evidence from the Health and Retirement Study and Health Care and Nutrition Study.

PURPOSE: To assess the impact of food insecurity on biennial breast cancer screenings (i.e., mammography or breast X-ray) among older women in the United States (US). METHODS: Data from the 2014 and 2016 waves of the Health and Retirement Study and the 2013 Health Care and Nutrition Study were used. The analyses were limited to a nationally representative sample of 2,861 women between 50 and 74 years of age, residing in the US. We employed a propensity score weighting method to balance observed confounders between food-secure and food-insecure women and fit a binary logistic regression to investigate population-level estimates for the association between food security and breast cancer screening. RESULTS: Food insecurity was significantly associated with failure to obtain a mammogram or breast X-ray within the past two years. Food-insecure women had 54% lower odds of reporting breast cancer screening in the past 2 years (adjusted OR = 0.46; 95% CI 0.30-0.70, p-value < 0.001) as compared to food-secure women. Additional factors associated with a higher likelihood of receiving breast cancer screenings included greater educational attainment, higher household income, regular access to health care/advice, not smoking, and not being physically disabled or experiencing depressive symptoms. CONCLUSION: Results demonstrate a socioeconomic gradient existing in regard to the utilization of regular breast cancer screenings among women. Those who tend to have lower education, lower income, and lack of reliable healthcare access are more likely to be food insecure. Thus, more likely to face the financial, logistical, or environmental barriers in obtaining screening services that accompany food insecurity.

Factors Associated with E-Cigarette Quit Intention Among Adolescents in the United States.

Background: Given increasing use of e-cigarettes among adolescents in the United States and its potential for nicotine addiction, encouraging adolescents to quit using these products has become a public health priority. This study examined factors at various socio-ecological levels associated with e-cigarette quit intention (pre-contemplation, contemplation, or preparation) using the Stages of Change of the Trans-theoretical Model among the U.S. adolescents. Methods: We used cross-sectional data from the past 30-day adolescent exclusive e-cigarette users participating in Wave 4 of the Population Assessment of Tobacco and Health study (n = 349). Weighted adjusted multinomial logistic regression models were used to analyze the data. Results: Compared to pre-contemplators and contemplators, preparators were more likely to believe that nicotine in e-cigarettes was "very/extremely harmful" (vs. "not at all harmful") to health (p < 0.001) and people cause a "lot of harm" (vs. "no harm") to themselves when they use e-cigarettes (p < 0.001). In comparison to pre-contemplators, contemplators and preparators were more likely to report that their parents/guardians talked with them about not using e-cigarettes than those whose parents/guardians did not talk with them (p < 0.001). Additionally, contemplators and preparators were also more likely to report that they "often/very often" (vs. never) noticed health warnings on e-cigarette packages (p < 0.001). Conclusion: Our findings suggest that harm perception, influence of family, and e-cigarette health warnings are some of the important factors associated with the stages of change for intention to quit among adolescent e-cigarette users. This study will help public health practitioners and researchers design multi-level e-cigarette cessation interventions for adolescents.

Effectiveness of Interventions to Improve Oral Cancer Knowledge: a Systematic Review.

Oral cancer is prone to late-stage diagnosis, and subsequent low five-year survival rates. A small number of interventions or campaigns designed to enhance knowledge of risk factors and symptoms associated with oral cancer have been attempted in the UK, US, and some other countries. The purpose of this systematic review is to assess the effectiveness of interventions designed to improve oral cancer knowledge. We searched five databases to identify randomized controlled trials (RCTs) and non-randomized/quasi-experimental (NR/QE) studies targeting the general population or high-risk groups (tobacco users or alcohol consumers), aged ≥15 years, and reporting the outcomes of individual and/or community level interventions. Two co-authors independently identified relevant studies, extracted data, and assessed the risk of bias. Adhering to PRISMA guidelines, 27 (eight RCTs and 19 NR/QE studies) of the 551 studies identified from the five databases met the inclusion criteria. All RCTs and nine NR/QE studies used either printed materials, health education sessions, multimedia aids, or some combinations of these tools. The other ten NR/QE studies were community-based and used mass media campaigns to increase oral cancer awareness. Overall, the majority of studies significantly improved oral cancer knowledge; however, heterogeneity in study design and variation in measurement tools made it difficult to compare outcomes. Findings suggest that individual and/or community level interventions are generally effective in increasing knowledge of oral cancer risk factors, signs and symptoms, and/or its early diagnosis and prevention strategies among the general population or high-risk groups. However, the long-term benefits of these interventions are understudied.

Online Narratives of Methamphetamine Use and Risky Sexual Behavior: Can Shame-Free Guilt Aid in Recovery?

Methamphetamine (meth) use is a recurring public health challenge in the U.S. In 2016, approximately 1.6 million Americans reported using meth. Meth use is associated with a number of adverse outcomes, including those associated with users' sexual health. In particular, meth use is linked to an increased risk for sexually transmitted infections and unplanned pregnancies. While studies have examined associations between substance use of various types-including meth use, and shame and guilt-few studies have examined relationships among substance use, sexual risk behaviors, and shame and guilt. No qualitative studies, to our knowledge, have studied all three of these phenomena in a sample of meth users. The present qualitative study explored the sexual risk behaviors and associated feelings of shame and guilt in relation to meth use. It draws from anonymous letters and stories (N = 202) posted to an online discussion forum by meth users and their family members. A grounded theory analysis of these narratives identified four primary themes pertaining to meth use and sexual behaviors: (1) feeling heightened sexual arousal and stimulation on meth, (2) experiencing sexual dissatisfaction on meth, (3) responding to sexual arousal and dissatisfaction, and (4) feeling ashamed and/or guilty. Ultimately, the present findings indicate that feelings of shame and guilt may arise more from the consequences of sexual risk behaviors stemming from meth use rather than meth use itself. The emotional toll of meth-induced sexual risk behaviors, particularly shame and guilt over the loss of meaningful relationships and self-respect due to multiple sexual partners, may provide an important opportunity for interventionists.

Post-liver transplant outcomes in patients with major psychiatric diagnosis in the United States.

INTRODUCTION AND OBJECTIVES: Higher rates of psychiatric disorders are reported among cirrhotic patients. This study examines the demographic and clinical outcomes post-liver transplant (LT) among cirrhotic patients with a major psychiatric diagnosis (cases) compared to those without psychiatric diagnosis (controls). MATERIALS AND METHODS: Retrospective case control design was used among 189 cirrhotic patients who had undergone LT at Methodist University Hospital Transplant Institute, Memphis, TN between January 2006 and December 2014. Multivariable regression and Cox proportional hazard regression were conducted to compare allograft loss and all-cause mortality. RESULTS: The study sample consisted of a matched cohort of 95 cases and 94 controls with LT. Females and those with Hepatic Encephalopathy (HE) were more likely to have psychiatric diagnosis. Patients with hepatocellular carcinoma (HCC) were twice as likely to have allograft loss. Psychiatric patients with HCC had two and a half times (HR 2.54; 95% CI: 1.20-5.37; p = 0.015) likelihood of all-cause mortality. Data censored at 1-year post-LT revealed that patients with psychiatric diagnosis have a three to four times higher hazard for allograft loss and all-cause mortality compared to controls after adjusting for covariates, whereas when the data is censored at 5 year, allograft loss and all-cause mortality have two times higher hazard ratio. CONCLUSIONS: The Cox proportional hazard regression analysis of censored data at 1 and 5 year indicate higher allograft loss and all-cause mortality among LT patients with psychiatric diagnosis. Patients with well-controlled psychiatric disorders who undergo LT need close monitoring and medication adherence.

Impact of self-assessed health status and physical and functional limitations on healthcare utilization and mortality among older cancer survivors in US.

PURPOSE: The purpose of this study was to examine the impact of physical limitations, functional limitations and self-assessed health status on mortality and healthcare utilization among older cancer survivors. METHODS: National Medicare Current Beneficiary Survey (MCBS) cost and use data from 2008 to 2013 were used for analysis. Physical limitations, Activities of Daily Living (ADL), and Instrumental Activities of Daily Living (IADL) were assessed on multiple questions, and self-assessed health was measured on a five-point scale (1-5: Excellent-Poor). Multivariable logistic regression and Poisson regression models were used for hospitalization, re-hospitalization and mortality rates based on three follow up years. RESULTS: This study included 17,715 cancer patients with a mean age of 75 years and 57% females. Cancer survivors with poor self-assessed health had a higher rate of hospitalizations (adjusted Odds Ratio: aOR: 1.60, 95% Confidence Interval: CI: 1.47-1.72, p < 0.001) relative to non-cancer participants. Compared to participants with no history of cancer, cancer survivors with IADL (aOR: 1.41, 95% CI: 1.25-1.58, p < 0.001) or with poor self-assessed health (aOR: 1.39, 95% CI: 1.21-1.60, p < 0.001) were more likely to have a higher number of hospital readmissions within 30 days of a prior hospitalization. Three-year mortality rate was significantly higher among cancer survivors with poor self-assessed health (Hazard Ratio: 2.81, 95% CI: 2.81-2.82, p < 0.001). CONCLUSION: Self-assessed health and physical and functional limitations significantly and independently impact healthcare utilization and mortality among older cancer survivors. Healthcare providers should incorporate formal assessments of both self-assessed health and functional status among older cancer survivors in their clinical practice. IMPLICATION FOR CANCER SURVIVORS: Self-reported health status is a valuable and independent predictor of healthcare utilization and mortality among cancer survivors.

The Association Between Substance Use and Violence: Results from a Nationally Representative Sample of High School Students in the United States.

With over 52% of high school students reporting that they have tried alcohol or illicit drugs, 16% carrying a weapon, and 23% engaging in a physical fight, substance use and youth violence remain critical public health challenges in the United States. Using data from the 2017 Youth Risk Behavior Survey, study results revealed that youth who reported heavy use of either alcohol, marijuana, or illicit drugs were three to ten times more likely to report carrying a weapon or engaging in a physical fight. Similarly, youth with heavy substance use were one and half times to 14 times more likely to be a victim of violence or sexual or dating violence. The SEM analysis indicated that substance use had a significant effect on all aspects of violence. School-based behavioral health specialists and community-based pediatricians may need to develop targeted messages to address the potential for violence among youth who use alcohol and/or illicit drugs.

Access to Broadband Internet and its Utilization for Health Information Seeking and Health Communication among Informal Caregivers in the United States.

Informal caregivers provide unpaid care to their physically or mentally ill loved ones and play a critical role in the healthcare delivery. eHealth tools, including the broadband internet, can facilitate care processes and impact the caregiving burden through seeking health information and health communication. This study examines the predictors of access to broadband internet and the factors associated with health information seeking and health communication among informal caregivers with broadband internet. We used data from cycles 1 and 2 of the Health Information National Trends Survey (HINTS 5) and employed generalized linear regression models with the maximum likelihood estimation. Specifically, we performed a two-part model: (1) a logistic regression model of broadband internet access among all caregivers (n = 929) and (2) a logistic regression model of health information seeking and health communication among caregivers with broadband internet access (n = 404). We found that caregivers who were younger (18-34 years versus 45+ years), female (versus male), and those who were divorced/widowed/separated (versus singles) were less likely to have broadband internet access. While those who were married/living as married (versus singles), with higher incomes (≥$100,000 versus <$35,000), and those living in metropolitan areas were more likely to have broadband internet access. Among caregivers with broadband internet access, younger, female, non-Hispanic white caregivers, and those with higher levels of education and income, as well as those who cared for cancer patients, were more likely to seek health information for someone else. Additionally, caregivers aged 35-39 years and those with more education were more likely to look for health information for themselves than their counterparts. Furthermore, caregivers who were aged 40-44 years, females, divorced/widowed/separated, those with higher incomes, and those who cared for patients with Alzheimer's, confusion, and dementia were more likely to communicate electronically with a provider. The results suggest disparities in broadband internet access and indicate variations in factors associated with health information seeking and health communication. The findings underscore the need to address barriers attributed to the digital divide among informal caregiving groups.

Posttransplant Outcome of Lean Compared With Obese Nonalcoholic Steatohepatitis in the United States: The Obesity Paradox.

Morbid obesity is considered a relative contraindication for liver transplantation (LT). We investigated if body mass index (BMI; lean versus obese) is a risk factor for post-LT graft and overall survival in nonalcoholic steatohepatitis (NASH) and non-NASH patients. Using the United Network for Organ Sharing (UNOS) database, LT recipients from January 2002 to June 2013 (age ≥18 years) with follow-up until 2017 were included. The association of BMI categories calculated at LT with graft and overall survival after LT were examined. After adjusting for confounders, all obesity cohorts (overweight and class 1, class 2, and class 3 obesity) among LT recipients for NASH had significantly reduced risk of graft and patient loss at 10 years of follow-up compared with the lean BMI cohort. In contrast, the non-NASH group of LT recipients had no increased risk for graft and patient loss for overweight, class 1, and class 2 obesity groups but had significantly increased risk for graft (P < 0.001) and patient loss (P = 0.005) in the class 3 obesity group. In this retrospective analysis of the UNOS database, adult recipients selected for first LT and NASH patients with the lowest BMI have the worse longterm graft and patient survival as opposed to non-NASH patients where the survival was worse with higher BMI.

Psychosocial interventions for informal caregivers of lung cancer patients: A systematic review.

OBJECTIVE: Caregivers of patients with lung cancer often face physical, emotional, and financial distress, which not only negatively affects the caregivers' mental health and quality of life but may also impact patients' well-being. The purpose of this systematic review is to examine the content, delivery, and efficacy of psychosocial interventions targeting caregivers of lung cancer patients. METHODS: Studies included in this systematic review assessed psychosocial interventions for caregivers of lung cancer patients that were published in English between January 2009 and December 2017. These interventions focused on burden, mental health, quality of life, self-efficacy, and/or coping as outcome measures. CINAHL, PubMed, PsycInfo, Science Direct, and Web of Science databases were searched using the terms (lung cancer OR lung neoplasms OR thoracic cancer) AND (caregiver OR caregiving) AND (intervention OR program) to systematically review the relevant literature on this topic. RESULTS: From the 22 studies included in this systematic review, interventions were classified into four categories: communication-based interventions, coping skills training interventions, multicomponent interventions, and stress reduction interventions. The majority of the interventions (especially communication-based and multicomponent) led to improvement, albeit not always statistically significant, in one or more outcomes; however, the most frequently reported improvements included, burden, distress, anxiety, depression, overall quality of life, self-efficacy, and coping abilities. CONCLUSIONS: The unmet needs of informal caregivers of lung cancer patients have a significant impact on their mental health and quality of life, but this burden can be alleviated by psychosocial interventions that offer appropriate support, education, and resources.

Predicting harmful alcohol relapse after liver transplant: The HALT score.

BACKGROUND: Alcohol-associated liver disease (AALD) is a rapidly growing indication for liver transplantation (LT). We aimed to examine various clinical, demographic, and behavioral factors to predict post-LT alcohol relapse and graft survival. METHODS: Retrospective analysis was performed on 241 LT recipients with AALD as either a primary or secondary indication for LT (2006-2015). RESULTS: Patients with <6 months of alcohol abstinence had significantly increased cumulative incidence for alcohol relapse compared to those with >6 months of abstinence (P = .0041, Log-Rank). We identified four variables to predict harmful alcohol relapse post-LT: age at LT, non-alcohol-related criminal history, pre-LT abstinence period (Ref >6 months of alcohol abstinence), and drinks per day (Ref <10 drinks/day). Area under the curve (AUC) for the final model was 0.79 (95% CI: 0.68-0.91). Our multivariable model was evaluated with internal cross-validation; random sampling of the study subjects 100 times yielded a median C statistic of 75 (±SD 0.097) and accuracy of 91 (±SD 0.026). The four-variable model served to form the harmful alcohol use post-LT (HALT) score. Graft survival remained significantly lower in patients with <6 months of pre-LT alcohol abstinence and those with blue-collar jobs. CONCLUSION: The HALT score identifies LT candidates with AALD at significant risk for alcohol relapse, potentially guiding transplant centers for pre- and post-LT interventions for improved patient outcomes.

Effect of opioid treatment on clinical outcomes among cirrhotic patients in the United States.

BACKGROUND: Opioid medications are frequently used to address pain among patients with cirrhosis, including those on the liver transplant (LT) waitlist and after transplantation. However, opioid use has been associated with poor allograft outcomes and reduced transplant survival. We examined the impact of opioid use across the spectrum of advanced liver disease, from the initial hepatology consultation for cirrhosis through transplant referral, listing, and the post-LT process. METHODS: The study includes all patients referred for cirrhosis management in a single healthcare system in the United States. Data were extracted retrospectively through medical chart review. RESULTS: Of 414 patients included in the study, 104 (25%) were treated with opioid. Patients on opioids were more likely to be White, have body mass indices (BMI) >30, have HCV, suffer from hepatic encephalopathy, cigarette smokers, and use benzodiazepines concurrently. Higher doses of opioids were associated with multiple emergency department (ED). Eighty-nine underwent LT, including 20 opioid-treated patients. There was no difference found between the opioid and non-opioid groups with regard to allograft loss, ED visits, and hospital readmissions at 2 years post-LT follow-up. CONCLUSIONS: Opioid treatment was common among patients with cirrhosis. We did not find increased negative outcomes among opioid users across the spectrum of cirrhosis. However, the sample for LT patients was small.

"All boats will rise": Physicians' perspectives on multidisciplinary lung cancer care in a community-based hospital setting.

PURPOSE: We explored the perceived strengths, barriers to implementation, and suggestions for sustainable implementation of a multidisciplinary model within a community-based hospital system from the physicians' perspectives. METHODS: We conducted 9 focus groups with 37 physicians involved in the care of lung cancer patients. Grounded theory methodology guided the identification of recurrent themes that emerged from the qualitative data analysis. RESULTS: The majority of study participants agreed that the multidisciplinary model could benefit patients by promoting high quality, efficient, and well-coordinated care. Co-location, financial disincentives, and time constraints were identified as major deterrents to full participation in a multidisciplinary clinic. Other perceived challenges were the integration of a multidisciplinary care model into the existing healthcare system, maintenance of referral streams, and designation of the physician primarily responsible for a patient's care. Educating physicians about the availability of a multidisciplinary clinic, establishing efficient processes for initial consultations, implementing technology for virtual participation, and using a nurse navigator with reliable closed-loop communication were suggested to improve the implementation of the multidisciplinary model. CONCLUSIONS: Physicians generally agreed that the multidisciplinary model could improve lung cancer care, but they perceived significant personal, institutional, and system-level barriers that need to be addressed for its successful implementation in a community healthcare setting.

Food Insecurity and Influenza and Pneumonia Vaccines Uptake Among Community-Dwelling Older Adults in the United States.

Influenza and pneumonia vaccines can reduce morbidities and mortality associated with infectious diseases among older adults. Food security, good nutrition, and high-quality diets are critical for the wellbeing of older adults. However, little is known about the relationship between food insecurity and use of preventive health services, such as influenza and pneumonia vaccinations, among older adults. In this study, we analyzed data on 40,555 adults aged ≥ 65 years from the 2014-2018 National Health Interview Survey in the United States. Through multiple hierarchical logistic regression models, we investigated the associations between food insecurity and influenza and pneumonia vaccines uptake in this population. We found that, during 2014-2018, about 12.6 million (5.3%) adults aged ≥ 65 years lived in food-insecure households in the United States. Of those, 60.6% reported getting an influenza vaccine in the past 12 months, and 54.2% reported ever getting a pneumonia vaccine. Compared to food-secure older adults, food-insecure individuals were not significantly different in terms of influenza vaccine uptake. However, they were 25% less likely to have ever gotten a pneumonia vaccine (adjusted odds ratio = 0.75, 95% CI 0.65-0.86, P < .001). Efforts should be made to develop strategies to improve immunization rates among food-insecure older adults. Healthcare providers could routinely assess their vaccination status and screen them for food insecurity. Also, community level screening and intervention programs should target food-insecure older adults, who often face structural disadvantages. Future studies could explore and identify the underlying predictive factors contributing to low pneumonia vaccination rates among food-insecure older adults.

A Qualitative Exploration of "Mother First" Identity and Antiretroviral Adherence among African American Women Living with HIV in the Mid-South Region of the United States.

The majority of African American women living with HIV are of child-bearing age and large numbers of these women express a desire to have children. Extant research suggests that motherhood provides HIV-positive women with a sense of hope and normalcy and, in some cases, is associated with positive HIV-related health behaviors. Guided by the tenets of the culture-centered approach (CCA), this qualitative study sought to understand the relationship between motherhood identity and ART adherence among a sample of 50 African American women living with HIV in the Mid-South region of the United States. Our theoretically-informed thematic analysis of in-depth interviews with all 50 women produced three primary themes: (1) experiencing HIV through the lens of motherhood, (2) the physical and social realities of the "mother first" orientation while living with HIV, and (3) the impact of the "mother first" orientation on ART adherence and self-care. These findings identify how participants' "mother first" identity orientation interacts with their sociocultural environment to enable and constrain their attempts at ART adherence. The findings also provide empirical evidence to support the CCA's theorizing regarding the ways in which the materiality of structures interact with symbolic cultural meanings to (re)produce health inequalities.

Self-Check-In Kiosks Utilization and Their Association With Wait Times in Emergency Departments in the United States.

BACKGROUND: Delayed care in emergency departments (EDs) is a serious problem in the United States. Patient wait time is considered a critical measure of delayed care in EDs. Several strategies have been employed by EDs to reduce wait time, including implementation of self-check-in kiosks. However, the effect of kiosks on wait time in EDs is understudied. OBJECTIVES: To assess the association between patient wait time and utilization of self-check-in kiosks in EDs. To investigate a series of other patient-, ED-, and hospital-level predictors of wait time in EDs. METHODS: Using data from the 2015 and 2016 National Hospital Ambulatory Medical Care Survey, we analyzed 40,528 ED visits by constructing a multivariable linear regression model of the log-transformed wait time data as an outcome, then computing percent changes in wait times. RESULTS: During the study period, about 9% of EDs in the United States implemented kiosks. In our linear regression model, the wait time in EDs with kiosk self-check-in services was 56.8% shorter (95% confidence interval ̶ 130% to ̶ 6.4%, p < 0.05) compared with EDs without kiosk services. In addition to kiosks, patients' day of visit, arrival time, triage assessment, arrival by ambulance, chronic medical conditions, ED boarding, hospitals' full-capacity protocol, and hospitals' location were significant predictors of wait time. CONCLUSIONS: Self-check-in kiosks are associated with shorter ED wait time in the United States. However, prolonged ED wait time continues to be a system-wide problem, and warrants multilayered interventions to address this challenge for those who are in acute need of immediate care.

Transforming Healthcare Cybersecurity from Reactive to Proactive: Current Status and Future Recommendations.

The recent rise in cybersecurity breaches in healthcare organizations has put patients' privacy at a higher risk of being exposed. Despite this threat and the additional danger posed by such incidents to patients' safety, as well as operational and financial threats to healthcare organizations, very few studies have systematically examined the cybersecurity threats in healthcare. To lay a firm foundation for healthcare organizations and policymakers in better understanding the complexity of the issue of cybersecurity, this study explores the major type of cybersecurity threats for healthcare organizations and explains the roles of the four major players (cyber attackers, cyber defenders, developers, and end-users) in cybersecurity. Finally, the paper discusses a set of recommendations for the policymakers and healthcare organizations to strengthen cybersecurity in their organization.

Impact of Nonmalignant Portal Vein Thrombosis in Transplant Recipients With Nonalcoholic Steatohepatitis.

Nonalcoholic fatty liver disease is an increasingly prevalent condition, and its more severe progressive state, nonalcoholic steatohepatitis (NASH), is currently the second most common indication for wait-listed adults in the United States. The association of portal vein thrombosis (PVT) prior to or at transplant and poor graft and patient outcomes is not well established, particularly among NASH patients who inherently have an increased hypercoagulable profile. Using the United Network for Organ Sharing data set, we analyzed graft and patient outcomes of patients transplanted for the indication of NASH with and without PVT. Of 3689 NASH transplant recipients, the prevalence of PVT was 12% (450 with PVT and 3239 without PVT). NASH transplant recipients with PVT had inferior graft and patient survival compared with NASH transplant recipients without PVT, even after adjusting for recipient and donor demographic characteristics, body mass index, synthetic dysfunction, and presence of diabetes. In a multivariate Cox regression model, NASH transplant recipients with PVT had a 37% increased risk of graft failure (hazard ratio [HR], 1.37; 95% confidence interval [CI], 1.15-1.63; P < 0.001) and 31% increased risk of overall death (HR, 1.31; 95% CI, 1.09-1.58; P < 0.001) compared with NASH transplant recipients without PVT at transplant. This difference in graft and patient survival was most pronounced in the early posttransplant period. These results demonstrate that NASH patients with PVT have decreased graft and patient survival independent of recipient and donor factors.

Association of Pretransplant Renal Function With Liver Graft and Patient Survival After Liver Transplantation in Patients With Nonalcoholic Steatohepatitis.

Nonalcoholic steatohepatitis (NASH) is one of the top 3 indications for liver transplantation (LT) in Western countries. It is unknown whether renal dysfunction at the time of LT has any effect on post-LT outcomes in recipients with NASH. From the United Network for Organ Sharing-Standard Transplant Analysis and Research data set, we identified 4088 NASH recipients who received deceased donor LT. We divided our recipients a priori into 3 categories: group 1 with estimated glomerular filtration rate (eGFR) <30 mL/minute/1.73 m2 at the time of LT and/or received dialysis within 2 weeks preceding LT (n = 937); group 2 with recipients who had eGFR ≥30 mL/minute/1.73 m2 and who did not receive renal replacement therapy prior to LT (n = 2812); and group 3 with recipients who underwent simultaneous liver-kidney transplantation (n = 339). We examined the association of pretransplant renal dysfunction with death with a functioning graft, all-cause mortality, and graft loss using competing risk regression and Cox proportional hazards models. The mean ± standard deviation age of the cohort at baseline was 58 ± 8 years, 55% were male, 80% were Caucasian, and average exception Model for End-Stage Liver Disease score was 24 ± 9. The median follow-up period was 5 years (median, 1816 days; interquartile range, 1090-2723 days). Compared with group 1 recipients, group 2 recipients had 19% reduced trend for risk for death with a functioning graft (subhazard ratio [SHR], 0.81; 95% confidence interval [CI], 0.64-1.02) and similar risk for graft loss (SHR, 1.25; 95% CI, 0.59-2.62), whereas group 3 recipients had similar risk for death with a functioning graft (SHR, 1.23; 95% CI, 0.96-1.57) and graft loss (SHR, 0.18; 95% CI, 0.02-1.37) using an adjusted competing risk regression model. In conclusion, recipients with preserved renal function before LT showed a trend toward lower risk of death with a functioning graft compared with SLKT recipients and those with pretransplant severe renal dysfunction in patients with NASH.