Effect of a Hispanic outreach program on referral and liver transplantation volume at a single center.

BACKGROUND: Although Hispanic patients have high rates of end-stage liver disease and liver cancer, for which liver transplantation (LT) offers the best long-term outcomes, they are less likely to receive LT. Studies of end-stage renal disease patients and kidney transplant candidates have shown that targeted, culturally relevant interventions can increase the likelihood of Hispanic patients receiving kidney transplant. However, similar interventions remain largely unstudied in potential LT candidates. METHODS: Referrals to a single center in Texas with a large Hispanic patient population were compared before (01/2018-12/2019) and after (7/2021-6/2023) the implementation of a targeted outreach program. Patient progress toward LT, reasons for ineligibility, and differences in insurance were examined between the two eras. RESULTS: A greater proportion of Hispanic patients were referred for LT after the implementation of the outreach program (23.2% vs 26.2%, p = 0.004). Comparing the pre-outreach era to the post-outreach era, more Hispanic patients achieved waitlisting status (61 vs 78, respectively) and received a LT (971 vs 82, respectively). However, the proportion of Hispanic patients undergoing LT dropped from 30.2% to 20.3%. In the post-outreach era, half of the Hispanic patients were unable to get LT for financial reasons (112, 50.5%). CONCLUSIONS: A targeted outreach program for Hispanic patients with end-stage liver disease effectively increased the total number of Hispanic LT referrals and recipients. However, many of the patients who were referred were ineligible for LT, most frequently for financial reasons. These results highlight the need for additional research into the most effective ways to ameliorate financial barriers to LT in this high-need community.

Outcomes of Liver Transplantation for Hepatocellular Carcinoma Beyond the University of California San Francisco Criteria: A Single-center Experience.

BACKGROUND: Hepatocellular carcinoma (HCC) is the most common primary malignant liver tumor. Currently, liver transplantation may be the optimal treatment for HCC in cirrhotic patients. Patient selection is currently based on tumor size. We developed a program to offer liver transplantation to selected patients with HCC outside of traditional criteria. METHODS: Retrospective review for patients transplanted with HCC between April 2008 and June 2017. Patients were grouped by tumor size according to Milan, University of California San Francisco (UCSF), and outside UCSF criteria. Patient demographics, laboratory values, and outcomes were compared. Patients radiographically outside Milan criteria were selected based on tumor control with locoregional therapy (LRT) and 9 months of stability from LRT. α-fetoprotein values were not exclusionary. RESULTS: Two hundred twenty HCC patients were transplanted, 138 inside Milan, 23 inside UCSF, and 59 beyond UCSF criteria. Patient survival was equivalent at 1, 3, or 5 years despite pathologic tumor size. Waiting time to transplantation was not significantly different at an average of 344 days. In patients outside UCSF, tumor recurrence was equivalent to Milan and UCSF criteria recipients who waited >9 months from LRT. Although tumor recurrence was more likely in outside of UCSF patients (3% versus 9% versus 15%; P = 0.02), recurrence-free survival only trended toward significance among the groups (P = 0.053). CONCLUSIONS: Selective patients outside of traditional size criteria can be effectively transplanted with equivalent survival to patients with smaller tumors, even when pathologic tumor burden is considered. Tumor stability over time can be used to help select patients for transplantation.

Chronic Hepatitis C Therapy in Liver Cirrhosis Complicated by Telaprevir-Induced DRESS.

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare yet severe adverse drug-induced reaction with up to 10% mortality rate. Recent clinical trials reported an association between DRESS and telaprevir (TVR), an NS3/4A protease inhibitor of chronic hepatitis C (CHC) virus genotype 1. Its diagnosis is challenging given the variable pattern of cutaneous eruption and the myriad internal organ involvement. We present two patients who are middle-aged, obese, and white with CHC cirrhosis. They both developed a progressive diffuse, painful pruritic maculopapular rash at weeks 8 and 10 of CHC therapy with TVR, Peg-Interferon alfa-2a, and Ribavirin. They had no exposures to other medications that can cause this syndrome. Physical exam and labs and skin biopsy supported a "Definite" clinical diagnosis of DRESS, per RegiSCAR criteria. Thus Telaprevir-based triple therapy was discontinued and both patients experienced rapid resolution of the systemic symptoms with gradual improvement of eosinophilia and the skin eruption. These two cases illustrate the paramount importance of having a high index of suspicion for TVR-induced DRESS, critical for early diagnosis. Immediate discontinuation of TVR is essential in prevention of a potentially life-threatening complication. Risk factors for development of DRESS in patients receiving TVR remain to be elucidated.

Outcomes in lymphoma patients with obstructive jaundice: a cancer center experience.

BACKGROUND: Little information is available to guide clinicians on the optimal approach to managing obstructive jaundice in lymphoma patients. AIMS: The aim of this study was to review our experience in treating lymphoma patients with obstructive jaundice in order to develop guidelines as to the best interventional approach. METHODS: We reviewed the medical records of all lymphoma patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) and/or percutaneous biliary drainage (PBD) for obstructive jaundice between June 2002 and October 2008. RESULTS: We identified 35 lymphoma patients who underwent ERCP and/or PBD for obstructive jaundice. The mean age was 57.6 years. Most patients (66%) had diffuse large B-cell lymphoma. Stents were placed by ERCP in 25 patients and PBD in nine. Serum bilirubin levels normalized following ERCP or PBD in 29 of 33 (85%) patients with stricture. Stricture resolution occurred in 12 cases. Patients who had obstructive jaundice at the time of their lymphoma diagnosis had significantly longer mean overall survival following intervention than patients in whom obstructive jaundice developed later in the course of their disease (21.3 months vs. 4.5 months, P = 0.0001). CONCLUSIONS: ERCP and/or PBD effectively normalized serum bilirubin levels. Plastic stents should be used in patients who have obstructive jaundice at the time of lymphoma diagnosis because these strictures tend to resolve before stent exchanges are necessary. For patients in whom obstructive jaundice develops later in the course of their disease, the limited prognosis often makes a single intervention with insertion of a plastic stent sufficient to provide adequate biliary decompression.

X-linked hyper-IgM syndrome associated with poorly differentiated neuroendocrine tumor presenting as obstructive jaundice secondary to extensive adenopathy.

X-Linked Hyper IgM Syndrome (XHIGM) is a rare B-cell immunodeficiency disease. Patients with XHIGM are unable to switch immunoglobulin production from IgM to IgG, IgA, and IgE. Patients with XHIGM require periodic intravenous immune globulin to help prevent infections, and are also at risk for a variety of neoplasms. We describe a young man with XHIGM who presented with obstructive jaundice from malignant adenopathy from widespread, poorly differentiated neuroendocrine tumor. This has not previously been reported and represents a new association with XHIGM.