RESUMO
OBJECTIVES: 'Hub-and-spoke' networks may be one solution to reduce the geographical inequality in access to liver transplantation (LT) and the growing demands on, and saturation of, LT centres. It is not clear if such networks improve equity of access, deliver comparable patient outcomes or effect patient satisfaction. STUDY DESIGN: Retrospective evaluation of outcomes and patient satisfaction within the Royal Free liver transplant 'hub-and-spoke' network. METHODS: Patient outcomes in those assessed for LT between September 2011 and 2014 at spoke centres (n = 4) were compared retrospectively with those assessed at the LT hub centre. Patient satisfaction questionnaires were completed and changes in LT referral patterns were explored with data obtained directly from NHS Blood and Transplant (NHSBT). RESULTS: A total of 655 patients (180 spoke; 475 hub) were assessed for LT. Patients referred from spoke centres were more likely to have viral hepatitis as an underlying aetiology (72/180 vs 110/475; P < 0.001), or hepatocellular carcinoma (48/180 vs 60/475; P < 0.001) as an indication for LT and were more likely to be listed for LT when compared with hub patients (139/180 vs 312/475, P = 0.005). Mortality on the waiting list (9/123 vs 25/269, P = 0.57), waiting time to LT (64-days vs 78-days, P = 0.91) and Model for End-Stage liver disease (MELD)/United Kingdom End-Stage Liver Disease (UKELD) score (P = 0.24/0.26) in listed patients were equivalent as were 1- and 3-year patient and graft survival rates. Patient satisfaction rates were high at both types of centre, with significantly more patients preferring 'locally delivered care' at spoke vs hub (11/50 vs 70/73, P≤0.0001). Since the development of formal hub-and-spoke networks data from NHSBT based on postcode confirmed a significant increase in patients undergoing LT (153%) from spoke centres, whereas numbers assessed and transplanted from the hub centre have remained static. CONCLUSION: Hub-and-spoke LT networks are effective in offering equivalent clinical outcomes, high patient satisfaction and alleviate clinical pressure on the hub centre. They have to potential to help eliminate the geographical disparity in mortality rates from chronic liver disease.
Assuntos
Atenção à Saúde/organização & administração , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Hospitais , Transplante de Fígado/estatística & dados numéricos , Modelos Organizacionais , Adolescente , Adulto , Idoso , Feminino , Humanos , Hepatopatias/mortalidade , Hepatopatias/cirurgia , Masculino , Pessoa de Meia-Idade , Encaminhamento e Consulta , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Reino Unido/epidemiologia , Listas de Espera/mortalidade , Adulto JovemAssuntos
Técnicas Hemostáticas/efeitos adversos , Artéria Hepática/diagnóstico por imagem , Fígado/patologia , Imageamento por Ressonância Magnética , Veia Porta/diagnóstico por imagem , Idoso , Varizes Esofágicas e Gástricas/etiologia , Varizes Esofágicas e Gástricas/terapia , Esofagoscopia/métodos , Técnicas Hemostáticas/instrumentação , Artéria Hepática/anormalidades , Hepatite Autoimune/complicações , Humanos , Ligadura/efeitos adversos , Cirrose Hepática/complicações , Cirrose Hepática/etiologia , Imageamento por Ressonância Magnética/métodos , Masculino , Veia Porta/anormalidades , Valor Preditivo dos Testes , Sensibilidade e EspecificidadeRESUMO
We are not aware of a report detailing the complex obstetrical and medical management of twin pregnancy in the context of HIV infection and early post-liver transplantation period. Here we describe the successful outcome of a twin pregnancy in a 28-year-old HIV-positive female receiving antiretroviral therapy and immunosuppressive therapy who was the recipient of a liver transplant for previous drug-induced liver failure.
Assuntos
Inibidores de Calcineurina , Subunidade p35 da Interleucina-12/genética , Cirrose Hepática Biliar/diagnóstico , Transplante de Fígado/efeitos adversos , Imunoprecipitação da Cromatina , Marcadores Genéticos , Estudo de Associação Genômica Ampla , Humanos , Interleucina-2/metabolismo , Cirrose Hepática Biliar/etiologia , Polimorfismo de Nucleotídeo Único , Modelos de Riscos Proporcionais , Recidiva , Fatores de Risco , Transdução de SinaisAssuntos
Varizes Esofágicas e Gástricas/diagnóstico por imagem , Hemorragia Gastrointestinal/diagnóstico por imagem , Hipertensão Portal/diagnóstico por imagem , Esplenomegalia/diagnóstico por imagem , Tomografia Computadorizada por Raios X/métodos , Diagnóstico Diferencial , Varizes Esofágicas e Gástricas/complicações , Varizes Esofágicas e Gástricas/cirurgia , Seguimentos , Hemorragia Gastrointestinal/etiologia , Hemorragia Gastrointestinal/cirurgia , Humanos , Hipertensão Portal/complicações , Masculino , Pessoa de Meia-Idade , Veia Porta/diagnóstico por imagem , Esplenectomia , Esplenomegalia/complicações , Esplenomegalia/cirurgiaRESUMO
Severe liver disease in pregnancy is generally considered to have a favorable prognosis. The limited data available have not yielded disease-specific prognostic criteria or guidance on who should undergo liver transplantation (LT). We retrospectively evaluated 54 admissions with pregnancy-related liver disease to (1) evaluate if any admission parameters were associated with death and/or transplantation and (2) identify maternal complications. Eighteen had acute fatty liver of pregnancy and 32 had hypertension/eclampsia related disease. Seven patients (13%) died and four (7%) underwent LT. Survival rates were 43/48 if not listed for LT and 4/6 if listed. Of the four transplanted, three survived. Patients who died and/or underwent LT were more likely to have encephalopathy (p = 0.04) and hyperlactaemia (p = 0.03). Serum lactate was the best discriminant (ROC AUC 0.84). An admission lactate greater than 2.8mg/dL had 73% sensitivity and 75% specificity for predicting death or LT. The addition of encephalopathy to this parameter increased sensitivity and specificity to 90% and 86%, respectively. The King's College criteria were not effective in predicting outcome. This study confirms the overall favorable prognosis in pregnancy-related liver failure but indicates that elevated lactate levels in the presence of encephalopathy best identify patients at greatest risk of death or LT.
Assuntos
Falência Hepática Aguda/etiologia , Complicações na Gravidez/cirurgia , Adulto , Fígado Gorduroso/complicações , Feminino , Humanos , Hipertensão Induzida pela Gravidez/cirurgia , Ácido Láctico/sangue , Hepatopatias/etiologia , Hepatopatias/cirurgia , Falência Hepática Aguda/mortalidade , Falência Hepática Aguda/cirurgia , Transplante de Fígado , Gravidez , Complicações na Gravidez/mortalidade , Estudos Retrospectivos , Resultado do Tratamento , Reino Unido/epidemiologiaRESUMO
BACKGROUND: Occult myeloproliferative disorders (MPD) are present in 25% of patients with chronic portal, splenic and mesenteric venous thrombosis (PSMVT). A somatic mutation of JAK2 (JAK2V617F) can be used to identify patients with latent MPD. AIM: We evaluated the prevalence and clinical significance of JAK2V617F in patients with chronic PSMVT. METHODS: Allele-specific polymerase chain reaction was performed to screen for JAK2V617F. RESULTS: Thirty-five patients were tested for JAK2V617F. The underlying pro-coagulant condition was MPD in seven of 35 (20.0%) patients; other aetiologies included hereditary thrombophilia (n = 5), chronic pancreatitis (n = 2), liver abscess (n = 1) and umbilical vein sepsis (n = 3). The remainder were labelled idiopathic, i.e. 17/35 (48.6%) patients. JAK2V617F was detected in 16/35 (45.7%) patients: seven of seven (100%) with MPD, two of 11 (18.1%) with non-MPD acquired conditions and seven of 17 (41.2%) with 'idiopathic' chronic PSMVT. Mean haemoglobin concentration (P = 0.04), haematocrit (P = 0.04), white cell count (P = 0.002) and platelet count (P = 0.05) were significantly higher in patients with JAK2V617F. None of the seven patients with latent MPD have progressed to overt MPD over median follow-up of 85 months. CONCLUSION: JAK2V617F occurs in 41% of patients with idiopathic chronic portal, splenic and mesenteric venous thrombosis, confirming the presence of latent myeloproliferative disorders, and should form part of the routine pro-coagulant screen.