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BACKGROUND & AIMS: Acute kidney injury (AKI) frequently complicates the course of hospitalized patients with cirrhosis and negatively affects their prognosis. How AKI response influences the timing of liver transplantation (LT) remains unclear. We sought to assess the impact of AKI response to treatment on survival and LT rates in cirrhosis patients awaiting LT. APPROACH & RESULTS: This was a retrospective multicenter study of cirrhosis patients waitlisted for LT and hospitalized with AKI in 2019. The exposure was AKI response versus no response during hospitalization. Outcomes were 90-day overall and transplant-free survival, and rates of LT with time to transplant. We adjusted for age, sex, race, cirrhosis etiology, site, and MELD-Na score. Among the 317 patients in this study, 170 had AKI response (53.6%), and 147 had no response (46.4%). Compared to non-responders, responders had better 90-day overall survival (89.4% vs. 76.2%, adjusted sHR for mortality 0.34, p=0.001), and transplant-free survival (63.5% vs. 25.2%, aHR for probability of death or transplant 0.35, p<0.001). The LT rate was lower in responders (45.9% vs. 61.2%, adjusted sHR 0.55, p=0.005). 79% of transplants in responders occurred after discharge, at a median of 103 days, while 62% of transplants in non-responders occurred during hospitalization, with the remainder occurring post-discharge at a median of 58 days. CONCLUSIONS: In patients with cirrhosis waitlisted for LT who are hospitalized with AKI, AKI response to therapy is associated with improved 90-day survival, despite a reduced LT rate and longer time to LT.
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BACKGROUND & AIMS: The development of acute kidney injury (AKI) in the setting of alcohol-associated hepatitis (AH) portends a poor prognosis. Whether the presence of AH itself drives worse outcomes in patients with cirrhosis and AKI is unknown. METHODS: Retrospective cohort study of 11 hospital networks of consecutive adult patients admitted in 2019 with cirrhosis and AKI. AKI phenotypes, clinical course, and outcomes were compared between AH and non-AH groups. RESULTS: A total of 2062 patients were included, of which 303 (15%) had AH, as defined by National Institute on Alcohol Abuse and Alcoholism (NIAAA) criteria. Patients with AH, compared to those without, were younger and had higher Model for End-stage Liver Disease-Sodium (MELD-Na) scores on admission. AKI phenotypes significantly differed between groups (p < 0.001) with acute tubular necrosis occurring more frequently in patients with AH. Patients with AH reached more severe peak AKI stage, required more renal replacement therapy, and had higher 90-day cumulative incidence of death (45% [95% CI: 39%-51%] vs. 38% [95% CI: 35%-40%], p = 0.026). Using no AH as reference, the unadjusted sHR for 90-day mortality was higher for AH (sHR: 1.24 [95% CI: 1.03-1.50], p = 0.024), but was not significant when adjusting for MELD-Na, age and sex. However, in patients with hepatorenal syndrome, AH was an independent predictor of 90-day mortality (sHR: 1.82 [95% CI: 1.16-2.86], p = 0.009). CONCLUSIONS: Hospitalised patients with cirrhosis and AKI presenting with AH had higher 90-day mortality than those without AH, but this may have been driven by higher MELD-Na rather than AH itself. However, in patients with hepatorenal syndrome, AH was an independent predictor of mortality.
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Alcohol-associated liver disease poses a significant global health burden, with rising alcohol consumption and prevalence of alcohol use disorder (AUD) contributing to increased morbidity and mortality. This review examines the challenges and opportunities in the care of candidates and recipients of liver transplant (LT) with AUD. Despite advancements in posttransplant patient survival, the risk of disease recurrence and alcohol relapse remains substantial. Several challenges have been identified, including (1) rising disease burden of alcohol-associated liver disease, variable transplant practices, and systemic barriers; (2) disparities in mental health therapy access and the impact on transplant; (3) variable definitions, underdiagnosis, and stigma affecting access to care; and (4) post-LT relapse, its risk factors, and consequential harm. The review focuses on the opportunities to improve AUD care for candidates and recipients of LT through effective biochemical monitoring, behavioral and pharmacologic approaches, creating Centers of Excellence for post-LT AUD care, advocating for policy reforms, and ensuring insurance coverage for necessary services as essential steps toward improving patient outcomes. The review also highlights unmet needs, such as the scarcity of addiction specialists, and calls for further research on personalized behavioral treatments, digital health, and value-based care models to optimize AUD care in the LT setting.
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Alcoholismo , Hepatopatías Alcohólicas , Trasplante de Hígado , Humanos , Trasplante de Hígado/efectos adversos , Trasplante de Hígado/normas , Hepatopatías Alcohólicas/cirugía , Hepatopatías Alcohólicas/terapia , Hepatopatías Alcohólicas/epidemiología , Hepatopatías Alcohólicas/diagnóstico , Hepatopatías Alcohólicas/etiología , Alcoholismo/complicaciones , Alcoholismo/terapia , Alcoholismo/epidemiología , Factores de Riesgo , Accesibilidad a los Servicios de Salud , Recurrencia , Disparidades en Atención de Salud , Prevalencia , Receptores de Trasplantes/estadística & datos numéricos , Consumo de Bebidas Alcohólicas/efectos adversos , Consumo de Bebidas Alcohólicas/epidemiología , Enfermedad Hepática en Estado Terminal/cirugía , Enfermedad Hepática en Estado Terminal/diagnóstico , Enfermedad Hepática en Estado Terminal/terapia , Enfermedad Hepática en Estado Terminal/complicaciones , Enfermedad Hepática en Estado Terminal/mortalidadRESUMEN
Blockchain Technology has garnered significant attention due to its immense potential to transform the way transactions are conducted and information is managed. Blockchain is a decentralized digital ledger that is spread across a network of computers, ensuring the secure, transparent, and unchangeable recording of transactions. However, the energy consumption of certain blockchain networks like Bitcoin, Litecoin, Monero, Zcash, and others has generated apprehensions regarding the sustainability of this technology. Bitcoin alone consumes approximately 100 terawatt-hours annually, contributing significantly to global carbon emissions. The substantial energy requirements not only contribute to carbon emissions but also pose a risk to the long-term viability of the blockchain industry. This study reviews articles from eight reputable databases between 2017 to August 2023, employing the systematic review and preferred reporting items for systematic reviews and meta-analyses approach for screening. Therefore, explore the applications of sustainable blockchain networks aimed at reducing environmental impact while ensuring efficiency and security. This survey also assesses the challenges and limitations posed by diverse blockchain applications regarding sustainability and provides valuable foresight into potential future advancements. Through this survey, the aim is to track and verify sustainable practices, facilitating the transition to a low-carbon economy, and promoting environmental stewardship, with a specific focus on highlighting the potential of sustainable blockchain networks in enabling secure and transparent tracking of these practices. Finally, the paper sheds light on pertinent research challenges and provides a roadmap of future directions, stimulating further research in this promising field.
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Cadena de Bloques , Conservación de los Recursos Naturales , Desarrollo SostenibleRESUMEN
Hepatorenal syndrome-acute kidney injury (HRS-AKI), a serious complication of decompensated cirrhosis, has limited therapeutic options and significant morbidity and mortality. Terlipressin improves renal function in some patients with HRS-1, while liver transplantation (LT) is a curative treatment for advanced chronic liver disease. Renal failure post-LT requiring renal replacement therapy (RRT) is a major risk factor for graft and patient survival. A post hoc analysis with a 12-month follow-up of LT recipients from a placebo-controlled trial of terlipressin (CONFIRM; NCT02770716) was conducted to evaluate the need for RRT and overall survival. Patients with HRS-1 were treated with terlipressin plus albumin or placebo plus albumin for up to 14 days. RRT was defined as any type of procedure that replaced kidney function. Outcomes compared between groups included the incidence of HRS-1 reversal, the need for RRT (pretransplant and posttransplant), and overall survival. Of the 300 patients in CONFIRM (terlipressin n = 199; placebo, n = 101), 70 (23%) underwent LT alone (terlipressin, n = 43; placebo, n = 27) and 5 had simultaneous liver-kidney transplant (terlipressin, n = 3, placebo, n = 2). The rate of HRS reversal was significantly higher in the terlipressin group compared with the placebo group (37%, n = 16 vs. 15%, n = 4; p = 0.033). The pretransplant need for RRT was significantly lower among those who received terlipressin ( p = 0.007). The posttransplant need for RRT, at 12 months, was significantly lower among those patients who received terlipressin and were alive at Day 365, compared to placebo ( p = 0.009). Pretransplant treatment with terlipressin plus albumin in patients with HRS-1 decreased the need for RRT pretransplant and posttransplant.
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Síndrome Hepatorrenal , Trasplante de Hígado , Humanos , Terlipresina/efectos adversos , Síndrome Hepatorrenal/etiología , Síndrome Hepatorrenal/terapia , Vasoconstrictores/uso terapéutico , Trasplante de Hígado/efectos adversos , Terapia de Reemplazo Renal/efectos adversos , Albúminas/efectos adversos , Lipresina/efectos adversos , Resultado del Tratamiento , Cirrosis Hepática/complicacionesRESUMEN
Two patients presented with acute on chronic liver failure and multiorgan failure and, as typical for this disorder, they presented with hyperinflammation and anticipated high mortality rates. Both cases were diagnosed with hepatorenal syndrome (HRS). Under a FDA approved Investigational Device Exemption clinical trial, they underwent treatment with an extracorporeal cell-directed immunomodulatory device, called selective cytopheretic device. Both patients showed rapid clinical improvement associated with a decline in elevated blood cytokine concentrations and diminution of activation levels of circulating leukocytes. On follow-up, one patient was alive at day 90 after treatment and undergoing liver transplantation evaluation and the other patient had a successful liver transplantation 6 days after selective cytopheretic device therapy ended. These cases represent the first in human evaluation of extracorporeal cell-directed immunomodulation therapy in acute on chronic liver failure with successful clinical outcomes in a disorder with dismal prognosis.
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Insuficiencia Hepática Crónica Agudizada , Enfermedad Hepática en Estado Terminal , Humanos , Insuficiencia Hepática Crónica Agudizada/terapia , Enfermedad Hepática en Estado Terminal/complicaciones , Enfermedad Hepática en Estado Terminal/terapia , Inmunomodulación , Insuficiencia Multiorgánica/etiología , Insuficiencia Multiorgánica/terapia , PronósticoRESUMEN
Background and Aims: The effectiveness of coronavirus disease 2019 (COVID-19) vaccines in reducing symptoms, disease advancement, complications, and mortality in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has been well-established. This case-control study aimed to compare different blood parameters, and prognostic and survival outcomes of COVID-19 patients based on vaccination status. Methods: We performed a case-control study that included hospitalized patients with COVID-19 at Tribhuvan University Teaching Hospital, Kathmandu, Nepal. Individuals who received vaccination were designated as cases and unvaccinated individuals as controls. Demographics, co-morbidity, clinical data, laboratory data, and disease outcomes were recorded for both groups. Multivariate, Cox, and linear regression were used for analysing blood parameters, hospital admission, survival, and hospital stay, respectively, between cases and controls. Results: Out of 100 participants enrolled, 46 were vaccinated, and 54 weren't. At admission, ferritin and erythrocyte sedimentation rate (ESR) were significantly lower in cases. At discharge, cases showed a higher monocyte than controls. Ferritin, ESR, and d-imer showed excellent performance in determining the severity of symptoms. Significant correlation and regression of ferritin and ESR with the length of hospital stay was observed. Length of hospital stay was significantly lower in cases than in controls. No significant differences between cases and controls were observed in mortality. Conclusion: COVID-19 vaccines effectively reduced hospitalization duration. Ferritin and ESR were significantly lower in vaccinated individuals and showed the best utility in monitoring the disease.
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Acute kidney injury in patients with cirrhosis is quite common, and is seen in up to 50% of patients hospitalized for decompensated cirrhosis. Causes of acute kidney injury include prerenal, renal, or postrenal etiologies. The diagnosis and early institution of nonpharmacologic and pharmacologic management are key to the recovery of renal function. The objective of this review is to provide a practical approach to the use of diagnostic biomarkers and highlight the nonpharmacologic management and prevention of acute kidney injury.
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Lesión Renal Aguda , Cirrosis Hepática , Humanos , Cirrosis Hepática/complicaciones , Cirrosis Hepática/diagnóstico , Cirrosis Hepática/terapia , Lesión Renal Aguda/diagnóstico , Lesión Renal Aguda/etiología , Lesión Renal Aguda/terapia , Riñón , Pacientes , Instituciones de SaludRESUMEN
BACKGROUND: Globally by 2030, 38% of the world's population would be overweight, and another 20% would be obese. This has led to rising concerns regarding how swiftly and substantially the world is moving towards this epidemic of "globesity". India too is facing an increased burden of overweight and obese population. The changing dietary patterns are significantly associated with the increasing prevalence of overweight/obesity and related complications, especially among women. Hence, the present study aims to observe the spatial patterns of overweight or obesity among women in reproductive age group in India and factors associated with it. METHODS: The study analyzed data from a cross-sectional nationwide household survey, i.e. National Family Health Survey (NFHS-4), 2015-16. The primary outcome variable of this study was overweight/obesity among reproductive-age women, which was measured through the body mass index (BMI) of the women. Bivariate and multivariate logistic regression analysis was used to analyze the data. Additionally, for spatial analysis in terms of overweight/obesity among women in India, univariate and bivariate Moran's I index measurements were used along with the usage of spatial regression models. RESULTS: The value of spatial-autocorrelation for overweight or obese was 0.64, which depicts the moderately high prevalence of the overweight/obesity coverage over districts of India. The overall prevalence overweight/obesity among women in India is around 25% and higher proportion of women from urban areas (37.8%), and non-poor (33.4%) economic group reported to be overweight or obese. From spatial lag model, the lag coefficient was found to be 0.28, implying that a change in the prevalence of overweight/obesity among women in a certain district may statistically lag the prevalence of overweight/obesity by 28% in the neighbouring districts. There were significantly high clustering of overweight/obese women and non-poor wealth quintiles in 132 districts, mainly from states of Punjab, Haryana, Gujarat, Maharashtra, Kerala, Tamil Nadu, Karnataka and Andhra Pradesh. Additionally, there was high-high clustering of overweight/obese women and those who ever had caesarean in 82 districts, mostly from Kerala, Tamil Nadu, Andhra Pradesh and Karnataka. CONCLUSION: The spatial patterns on the prevalence of overweight and obesity in India show that the women belonging to the southern states' districts are more overweight or obese in comparison to other states. The determinants like older age, higher education, urban residence, higher economic status are the key factors contributing to the prevalence of overweight or obesity among women in the reproductive age group. The study concludes and recommends an urgent need of interventions catering to urban women belonging to higher socio-economic status, to reduce the risks of health consequences due to overweight and obesity.
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Lepidópteros , Sobrepeso , Embarazo , Animales , Femenino , Humanos , Sobrepeso/epidemiología , India/epidemiología , Estudios Transversales , Obesidad/epidemiología , Análisis EspacialRESUMEN
BACKGROUND & AIMS: Acute kidney injury (AKI) in cirrhosis is common and associated with high morbidity, but the incidence rates of different etiologies of AKI are not well described in the US. We compared incidence rates, practice patterns, and outcomes across etiologies of AKI in cirrhosis. METHODS: We performed a retrospective cohort study of 11 hospital networks, including consecutive adult patients admitted with AKI and cirrhosis in 2019. The etiology of AKI was adjudicated based on pre-specified clinical definitions (prerenal/hypovolemic AKI, hepatorenal syndrome [HRS-AKI], acute tubular necrosis [ATN], other). RESULTS: A total of 2,063 patients were included (median age 62 [IQR 54-69] years, 38.3% female, median MELD-Na score 26 [19-31]). The most common etiology was prerenal AKI (44.3%), followed by ATN (30.4%) and HRS-AKI (12.1%); 6.0% had other AKI, and 7.2% could not be classified. In our cohort, 8.1% of patients received a liver transplant and 36.5% died by 90 days. The lowest rate of death was observed in patients with prerenal AKI (22.2%; p <0.001), while death rates were higher but not significantly different from each other in those with HRS-AKI and ATN (49.0% vs. 52.7%; p = 0.42). Using prerenal AKI as a reference, the adjusted subdistribution hazard ratio (sHR) for 90-day mortality was higher for HRS-AKI (sHR 2.78; 95% CI 2.18-3.54; p <0.001) and ATN (sHR 2.83; 95% CI 2.36-3.41; p <0.001). In adjusted analysis, higher AKI stage and lack of complete response to treatment were associated with an increased risk of 90-day mortality (p <0.001 for all). CONCLUSION: AKI is a severe complication of cirrhosis. HRS-AKI is uncommon and is associated with similar outcomes to ATN. The etiology of AKI, AKI stage/severity, and non-response to treatment were associated with mortality. Further optimization of vasoconstrictors for HRS-AKI and supportive therapies for ATN are needed. IMPACT AND IMPLICATIONS: Acute kidney injury (AKI) in cirrhosis carries high morbidity, and management is determined by the etiology of injury. However, a large and well-adjudicated multicenter database from US centers that uses updated AKI definitions is lacking. Our findings demonstrate that acute tubular necrosis and hepatorenal syndrome have similar outcomes (â¼50% mortality at 90 days), though hepatorenal syndrome is uncommon (12% of all AKI cases). These findings represent practice patterns at US transplant/tertiary centers and can be used as a baseline, presenting the situation prior to the adoption of terlipressin in the US.
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Lesión Renal Aguda , Síndrome Hepatorrenal , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Lesión Renal Aguda/epidemiología , Lesión Renal Aguda/etiología , Lesión Renal Aguda/terapia , Síndrome Hepatorrenal/epidemiología , Síndrome Hepatorrenal/etiología , Incidencia , Cirrosis Hepática/complicaciones , Cirrosis Hepática/epidemiología , Necrosis/complicaciones , Estudios RetrospectivosRESUMEN
Positron emission tomography myocardial perfusion imaging (PET MPI) is a noninvasive diagnostic test capable of detecting coronary artery disease, structural heart disease, and myocardial flow reserve (MFR). We aimed to determine the prognostic utility of PET MPI to predict post-liver transplant (LT) major adverse cardiac events (MACE). Among the 215 LT candidates that completed PET MPI between 2015 and 2020, 84 underwent LT and had 4 biomarker variables of clinical interest on pre-LT PET MPI (summed stress and difference scores, resting left ventricular ejection fraction, global MFR). Post-LT MACE were defined as acute coronary syndrome, heart failure, sustained arrhythmia, or cardiac arrest within the first 12 months post-LT. Cox regression models were constructed to determine associations between PET MPI variable/s and post-LT MACE. The median LT recipient age was 58 years, 71% were male, 49% had NAFLD, 63% reported prior smoking, 51% had hypertension, and 38% had diabetes mellitus. A total of 20 MACE occurred in 16 patients (19%) at a median of 61.5 days post-LT. One-year survival of MACE patients was significantly lower than those without MACE (54% vs. 98%, p =0.001). On multivariate analysis, reduced global MFR ≤1.38 was associated with a higher risk of MACE [HR=3.42 (1.23-9.47), p =0.019], and every % reduction in left ventricular ejection fraction was associated with an 8.6% higher risk of MACE [HR=0.92 (0.86-0.98), p =0.012]. Nearly 20% of LT recipients experienced MACE within the first 12 months of LT. Reduced global MFR and reduced resting left ventricular ejection fraction on PET MPI among LT candidates were associated with increased risk of post-LT MACE. Awareness of these PET-MPI parameters may help improve cardiac risk stratification of LT candidates if confirmed in future studies.
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Enfermedad de la Arteria Coronaria , Trasplante de Hígado , Imagen de Perfusión Miocárdica , Humanos , Masculino , Persona de Mediana Edad , Femenino , Volumen Sistólico , Trasplante de Hígado/efectos adversos , Imagen de Perfusión Miocárdica/métodos , Función Ventricular Izquierda , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Tomografía de Emisión de Positrones/métodos , PronósticoRESUMEN
BACKGROUND: We describe demographic features, treatments and clinical outcomes in the International Severe Acute Respiratory and emerging Infection Consortium (ISARIC) COVID-19 cohort, one of the world's largest international, standardized data sets concerning hospitalized patients. METHODS: The data set analysed includes COVID-19 patients hospitalized between January 2020 and January 2022 in 52 countries. We investigated how symptoms on admission, co-morbidities, risk factors and treatments varied by age, sex and other characteristics. We used Cox regression models to investigate associations between demographics, symptoms, co-morbidities and other factors with risk of death, admission to an intensive care unit (ICU) and invasive mechanical ventilation (IMV). RESULTS: Data were available for 689â572 patients with laboratory-confirmed (91.1%) or clinically diagnosed (8.9%) SARS-CoV-2 infection from 52 countries. Age [adjusted hazard ratio per 10 years 1.49 (95% CI 1.48, 1.49)] and male sex [1.23 (1.21, 1.24)] were associated with a higher risk of death. Rates of admission to an ICU and use of IMV increased with age up to age 60 years then dropped. Symptoms, co-morbidities and treatments varied by age and had varied associations with clinical outcomes. The case-fatality ratio varied by country partly due to differences in the clinical characteristics of recruited patients and was on average 21.5%. CONCLUSIONS: Age was the strongest determinant of risk of death, with a â¼30-fold difference between the oldest and youngest groups; each of the co-morbidities included was associated with up to an almost 2-fold increase in risk. Smoking and obesity were also associated with a higher risk of death. The size of our international database and the standardized data collection method make this study a comprehensive international description of COVID-19 clinical features. Our findings may inform strategies that involve prioritization of patients hospitalized with COVID-19 who have a higher risk of death.
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COVID-19 , Humanos , Masculino , Niño , Persona de Mediana Edad , COVID-19/terapia , SARS-CoV-2 , Unidades de Cuidados Intensivos , Modelos de Riesgos Proporcionales , Factores de Riesgo , HospitalizaciónRESUMEN
Cardiovascular disease is a leading complication after both liver and kidney transplantation. Factors associated with and rates of cardiovascular events (CVEs) after simultaneous liver-kidney transplant (SLKT) are unknown. This was a retrospective cohort study of adult SLKT recipients between 2002 and 2017 at six centers in six United Network for Organ Sharing regions in the US Multicenter SLKT Consortium. The primary outcome was a CVE defined as hospitalization due to acute coronary syndrome, arrhythmia, congestive heart failure, or other CV causes (stroke or peripheral vascular disease) within 1 year of SLKT. Among 515 SLKT subjects (mean age ± SD, 55.4 ± 10.6 years; 35.5% women; 68.1% White), 8.7% had a CVE within 1 year of SLKT. The prevalence of a CVE increased from 3.3% in 2002-2008 to 8.9% in 2009-2011 to 14.0% in 2012-2017 ( p = 0.0005). SLKT recipients with a CVE were older (59.9 vs. 54.9 years, p < 0.0001) and more likely to have coronary artery disease (CAD) (37.8% vs. 18.4%, p = 0.002) and atrial fibrillation (AF) (27.7% vs. 7.9%, p = 0.003) than those without a CVE. There was a trend toward older age by era of SLKT ( p = 0.054). In multivariate analysis adjusted for cardiac risk factors at transplant, age (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.02, 1.11), CAD (OR, 3.62; 95% CI, 1.60, 8.18), and AF (OR, 2.36; 95% CI, 1.14, 4.89) were associated with a 1-year CVE after SLKT. Conclusion : Among SLKT recipients, we observed a 4-fold increase in the prevalence of 1-year CVEs over time. Increasing age, CAD, and AF were the main potential explanatory factors for this trend independent of other risk factors. These findings suggest that CV risk protocols may need to be tailored to this high-risk population.
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Enfermedades Cardiovasculares , Trasplante de Riñón , Trasplante de Hígado , Adulto , Humanos , Femenino , Masculino , Trasplante de Riñón/efectos adversos , Trasplante de Riñón/métodos , Estudios Retrospectivos , Hígado , Trasplante de Hígado/efectos adversos , Enfermedades Cardiovasculares/epidemiologíaRESUMEN
Length of stay (LOS) during index solid organ transplant impacts morbidity and healthcare costs. To date, there are no studies evaluating characteristics and outcomes of simultaneous liver-kidney transplant (SLKT) index hospitalization. We examined factors associated with LOS and mortality during index SLKT admission. Methods: Adult SLKT recipients between 2002 and 2017 at 6 transplant centers across 6 UNOS regions were retrospectively enrolled in the US-Multicenter SLKT Consortium. Multivariable regression analyses assessed predictors of SLKT LOS and death during index admission. Results: Median age of cohort (N = 570) was 58 y (interquartile range: 51-64); 63% male, 75% White, 32.3% hepatitis C, 23.3% alcohol-related, 20.1% nonalcoholic steatohepatitis with median MELD-Na at SLKT 28 (23-34). Seventy-one percent were hospitalized at the time of SLKT with median LOS pretransplant of 10 d. Majority of patients were discharged alive (N = 549; 96%)' and 36% were discharged to subacute rehab facility. LOS for index SLKT was 19 d (Q1: 10, Q3: 34 d). Female sex (P = 0.003), Black race (P = 0.02), advanced age (P = 0.007), ICU admission at time of SLKT (P = 0.03), high MELD-Na (P = 0.003), on cyclosporine during index hospitalization (P = 0.03), pre-SLKT dialysis (P < 0.001), and kidney delayed graft function (P < 0.001) were the recipient factors associated with prolonged LOS during index SLKT hospitalization. Prolonged LOS also contributed to overall mortality (HR = 1.007; P = 0.03). Conclusions: Despite excellent survival, index SLKT admission was associated with high-resource utilization with more than half the patients with LOS >2 wk and affected overall patient survival. Further investigation is needed to optimize healthcare resources for these patients in a financially strained healthcare landscape.
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INTRODUCTION AND IMPORTANCE: Pituitary apoplexy is a very rare cause of sudden and severe headache with a neuro-ophthalmic deficit during pregnancy due to hemorrhage or infarction in the pituitary gland. Delayed identification can be life-threatening to both mother and baby. CASE PRESENTATION: A 40-year-old nulliparous female without any prior comorbidities in her 21 weeks of gestation presented with complaints of severe headache, vomiting, decreased vision, and altered sensorium for five days. On a low index of suspicion of pituitary apoplexy, she was managed in the line of impending eclampsia at a local center. On presentation to our center; the neurological deficit had progressed. CT head showed massive pituitary apoplexy with sellar and suprasellar extension. She underwent emergency right pterional craniotomy and resection of the tumor with hematoma evacuation but lost her life on her 2nd postoperative day. DISCUSSION: In the context of pregnancy, the diagnosis of pituitary apoplexy can get tricky and overlap with other common conditions such as preeclampsia or eclampsia. Magnetic resonance imaging (MRI) is the most sensitive investigation to confirm the diagnosis. Corticotropic deficiency with adrenal insufficiency is a potentially life-threatening disorder for both mother and the fetus if left untreated. The choice between conservative management and surgical approach depends on the neuro-ophthalmic signs, MRI findings, and gestational week. CONCLUSION: Pituitary apoplexy should be a differential diagnosis of acute severe headache in pregnancy which when suspected should be investigated promptly. Early identification and multi-disciplinary team management are imperative for better outcomes.
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Accurate assessment of donor quality at the time of organ offer for liver transplantation candidates may be inadequately captured by the donor risk index (DRI). We sought to develop and validate a novel objective and simple model to assess donor risk using donor level variables available at the time of organ offer. We utilized national data from candidates undergoing primary LT (2013-2019) and assessed the prediction of graft failure 1 year after LT. The final components were donor Insulin-dependent diabetes mellitus, Donor type (DCD or DBD), cause of Death = CVA, serum creatinine, Age, height, and weight (length). The ID2 EAL score had better discrimination than DRI using bootstrap corrected concordant index over time, especially in the current era. We explored donor-recipient matching. Relative risk of graft failure ranged from 1.15 to 3.5 based on relevant donor-recipient matching by the ID2 EAL score. As an example, for certain recipients, a young DCD donor offer was preferable to an older DBD with relevant comorbidities. The ID2 EAL score may serve as an important tool for patient discussion about donor risk and decisions regarding offer acceptance. In addition, the score may be preferable to succinctly capture donor risk in future organ allocation that considers continuous distribution (www.iddealscore.com).
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Enfermedad Hepática en Estado Terminal , Trasplante de Hígado , Obtención de Tejidos y Órganos , Humanos , Trasplante de Hígado/efectos adversos , Enfermedad Hepática en Estado Terminal/cirugía , Selección de Donante , Supervivencia de Injerto , Donantes de Tejidos , Estudios RetrospectivosRESUMEN
The burden of early hospitalization (within 6 months) following simultaneous liver-kidney transplant (SLKT) is not known. We examined risk factors associated with early hospitalization after SLKT and their impact on patient mortality conditional on 6-month survival. We used data from the US Multicenter SLKT Consortium cohort study of all adult SLKT recipients between 2002 and 2017 who were discharged alive following SLKT. We used Poisson regression to model rates of early hospitalizations after SLKT. Cox regression was used to identify risk factors associated with mortality conditional on survival at 6 months after SLKT. Median age (N = 549) was 57.7 years (interquartile range [IQR], 50.6-63.9) with 63% males and 76% Whites; 33% had hepatitis C virus, 20% had non-alcohol-associated fatty liver disease, 23% alcohol-associated liver disease, and 24% other etiologies. Median body mass index (BMI) and Model for End-Stage Liver Disease-sodium scores were 27.2 kg/m2 (IQR, 23.6-32.2 kg/m2 ) and 28 (IQR, 23-34), respectively. Two-thirds of the cohort had at least one hospitalization within the first 6 months of SLKT. Age, race, hospitalization at SLKT, diabetes mellitus, BMI, and discharge to subacute rehabilitation (SAR) facility after SLKT were independently associated with a high incidence rate ratio of early hospitalization. Number of hospitalizations within the first 6 months did not affect conditional survival. Early hospitalizations after SLKT were very common but did not affect conditional survival. Although most of the risk factors for early hospitalization were nonmodifiable, discharge to SAR after initial SLKT was associated with a significantly higher incidence rate of early hospitalization. Efforts and resources should be focused on identifying SLKT recipients at high risk for early hospitalization to optimize their predischarge care, discharge planning, and long-term follow-up.