Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 85
Filtrar
1.
Transplantation ; 2020 Jun 22.
Artigo em Inglês | MEDLINE | ID: mdl-33347261

RESUMO

BACKGROUND: The use of living donor liver transplantation (LDLT) for primary liver transplant (LT) may quell concerns about allocating deceased donor organs if the need for re-transplantation (re-LT) arises because the primary LT did not draw from the limited organ pool. However, outcomes of re-LT after LDLT are poorly studied. The purpose of this study was to analyze the Adult to Adult Living Donor Liver Transplantation Study (A2ALL) data to report outcomes of re-LT after LDLT, with a focus on long-term survival after re-LT. METHODS: A retrospective review of A2ALL data collected between 1998-2014 was performed. Patients were excluded if they received a deceased donor liver transplant. Demographic data, post-operative outcomes and complications, graft and patient survival, and predictors of re-LT and patient survival were assessed. RESULTS: Of the 1065 patients who underwent LDLT during the study time period, 110 recipients (10.3%) required re-LT. In multivariable analyses, HCV, longer LOS at LDLT, HAT, biliary stricture, infection, and disease recurrence were associated with an increased risk of re-LT. Patient survival among re-LT patients was significantly inferior to those who underwent primary transplant only at 1 (86 vs. 92%), 5 (64 vs. 82%), and 10 years (44 vs. 68%). CONCLUSIONS: Approximately 10% of A2ALL patients who underwent primary LDLT required re-LT. Compared with patients who underwent primary LT, survival among re-LT recipients was worse at 1, 5, and 10 years after LT, and re-LT was associated with a significantly increased risk of death in MV modeling (HR 2.29, p<0.001).

2.
JAMA Surg ; 2020 Dec 30.
Artigo em Inglês | MEDLINE | ID: mdl-33377947

RESUMO

Importance: Female liver transplant candidates experience higher rates of wait list mortality than male candidates. Frailty is a critical determinant of mortality in patients with cirrhosis, but how frailty differs between women and men is unknown. Objective: To determine whether frailty is associated with the gap between women and men in mortality among patients with cirrhosis awaiting liver transplantation. Design, Setting, and Participants: This prospective cohort study enrolled 1405 adults with cirrhosis awaiting liver transplant without hepatocellular carcinoma seen during 3436 ambulatory clinic visits at 9 US liver transplant centers. Data were collected from January 1, 2012, to October 1, 2019, and analyzed from August 30, 2019, to October 30, 2020. Exposures: At outpatient evaluation, the Liver Frailty Index (LFI) score was calculated (grip strength, chair stands, and balance). Main Outcomes and Measures: The risk of wait list mortality was quantified using Cox proportional hazards regression by frailty. Mediation analysis was used to quantify the contribution of frailty to the gap in wait list mortality between women and men. Results: Of 1405 participants, 578 (41%) were women and 827 (59%) were men (median age, 58 [interquartile range (IQR), 50-63] years). Women and men had similar median scores on the laboratory-based Model for End-stage Liver Disease incorporating sodium levels (MELDNa) (women, 18 [IQR, 14-23]; men, 18 [IQR, 15-22]), but baseline LFI was higher in women (mean [SD], 4.12 [0.85] vs 4.00 [0.82]; P = .005). Women displayed worse balance of less than 30 seconds (145 [25%] vs 149 [18%]; P = .003), worse sex-adjusted grip (mean [SD], -0.31 [1.08] vs -0.16 [1.08] kg; P = .01), and fewer chair stands per second (median, 0.35 [IQR, 0.23-0.46] vs 0.37 [IQR, 0.25-0.49]; P = .04). In unadjusted mixed-effects models, LFI was 0.15 (95% CI, 0.06-0.23) units higher in women than men (P = .001). After adjustment for other variables associated with frailty, LFI was 0.16 (95% CI, 0.08-0.23) units higher in women than men (P < .001). In unadjusted regression, women experienced a 34% (95% CI, 3%-74%) increased risk of wait list mortality than men (P = .03). Sequential covariable adjustment did not alter the association between sex and wait list mortality; however, adjustment for LFI attenuated the mortality gap between women and men. In mediation analysis, an estimated 13.0% (IQR, 0.5%-132.0%) of the gender gap in wait list mortality was mediated by frailty. Conclusions and Relevance: These findings demonstrate that women with cirrhosis display worse frailty scores than men despite similar MELDNa scores. The higher risk of wait list mortality that women experienced appeared to be explained in part by frailty.

3.
J Hepatol ; 2020 Nov 11.
Artigo em Inglês | MEDLINE | ID: mdl-33188904

RESUMO

BACKGROUND & AIMS: It has been suggested that patients with hepatocellular carcinoma (HCC) at high risk of waitlist dropout would have done poorly after liver transplantation (LT) due to tumor aggressiveness. To test this hypothesis, we analyzed risk of waitlist dropout among HCC patients in long wait regions (LWR) to create a dropout risk score, and applied this score in short (SWR) and mid wait regions (MWR) to evaluate post-LT outcomes. We sought to identify a threshold in dropout risk that predicts worse post-LT outcome. METHODS: Using the UNOS database including all patients with T2 HCC receiving priority listing from 2010-2014, a dropout risk score was created from a developmental cohort of 2,092 LWR patients, and tested in a validation cohort of 1,735 SWR and 2,894 MWR patients. RESULTS: On multivariable analysis, 1 tumor 3.1-5 cm or 2-3 tumors, AFP >20 ng/ml, and increasing Child-Pugh and MELD-Na scores significantly predicted waitlist dropout. A dropout risk score using these four variables (C-statistic 0.74) was able to stratify 1-year cumulative incidence of dropout from 7.1% with a score <7 to 39.5% with a score >23. Patients with a dropout risk score >30 had 5-year post-LT survival of 60.1% versus 71.8% for those with a score <30 (p=0.004). There were no significant differences in post-LT survival below this threshold. CONCLUSIONS: This study provided evidence that HCC patients with the highest dropout risk have aggressive tumor biology that would also result in poor post-LT outcomes when transplanted quickly. Below this threshold risk score of <30, priority status for organ allocation could be stratified based on the predicted risks of waitlist dropout without significant differences in post-LT survival.

4.
Transplant Direct ; 6(10): e605, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-33134485

RESUMO

Nonalcoholic fatty liver disease (NAFLD) is a leading cause of hepatocellular carcinoma (HCC) in the United States. Prior data suggest that NAFLD-HCC patients are less likely to receive liver transplantation (LT) and have worse overall survival; however, the reason for this discrepancy is unknown. Methods: We conducted a retrospective study of 631 HCC patients listed for LT at a large academic center from 2004 to 2013. Waitlist dropout and LT were analyzed using competing risk regression. Results: Compared with other-HCC patients (n = 589), NAFLD-HCC patients (n = 42, 6.7%) were older (65 versus 58, P < 0.001) with more women (50.0 versus 23.6%, P < 0.001), Hispanic ethnicity (40.5 versus 17.7%, P = 0.001), obesity (69.0 versus 29.9%, P < 0.001), diabetes mellitus (59.5 versus 27.8%, P < 0.01), insulin-dependence (23.8 versus 10.2%, P = 0.007), hyperlipidemia (40.5 versus 10.5, P < 0.001), and statin use (33.3 versus 5.3%, P < 0.001). Cumulative incidence of waitlist dropout at 2 y was 17.4% (95% confidence intervals, 7.7-30.4) for NAFLD HCC and 25.4% (95% confidence intervals, 21.9-29.0) for other HCC (P = 0.28). No difference in waitlist dropout or receipt of LT between NAFLD HCC and other HCC was found on regression analysis. Similarly, NAFLD and obesity, obesity alone, diabetes mellitus, insulin-dependence, hyperlipidemia, and statin use were not associated with waitlist outcomes. Finally, we observed no statistically significant difference in 5-y survival from HCC diagnosis between NAFLD HCC and other HCC (78.5% versus 66.9%, P = 0.9). Conclusions: In our single-center cohort, we observed no difference in waitlist outcomes or survival in NAFLD HCC, although conclusions are limited by the small number of NAFLD-HCC patients. Notably, the inclusion of patients with obesity in the NAFLD-HCC group and stratification by individual metabolic factors also showed no difference in waitlist outcomes.

5.
Am J Gastroenterol ; 2020 Oct 28.
Artigo em Inglês | MEDLINE | ID: mdl-33136566

RESUMO

INTRODUCTION: Young adults with alcohol-associated liver disease (ALD) are the fastest increasing demographic contributing to liver-related deaths; their outcomes after liver transplantation (LT) are understudied. METHODS: Using the United Network for Organ Sharing registry, we performed sex-specific analyses because of a significant interaction between sex and the explanatory variable, age. Cox regression was used with overall post-LT death as the primary outcome, adjusted for survival characteristics and center clustering. We calculated the absolute difference in adjusted 5-year post-LT survival between patient groups. Causes of death were supplemented by manual review of free-text entries. RESULTS: Among 42,014 LT recipients, 16,190 women (2,782 with ALD and 13,408 without ALD) and 25,824 men (9,502 with ALD and 16,322 without ALD), age of 40-50 years had the lowest risk of death. Women with ALD younger than 40 years had incrementally lower adjusted 5-year survival (95% confidence interval): 74% (63%-88%) for those aged 18-29 years, 82% (78%-87%) for those aged 30-39 years, and 90% (88%-92%) for those aged 40-49 years. Among women without ALD, men with ALD, and men without ALD, adjusted 5-year survival for ages 18-29, 30-39, and 40-49 years was similar. Among women, not men, there were significant interactions between younger age and ALD. Adjusted hazard for mortality for women with ALD vs without ALD was greater for those who aged 18-29 years (2.82 vs 1.09, P = 0.002) and 30-39 years (1.83 vs 1.09, P = 0.007 [reference age 40-49 years]). Among women with ALD, those aged 18-29 and 30-39 years had an absolute 17.7% and 9.5% excess in adjusted 5-year mortality vs similarly aged women without ALD. DISCUSSION: Young women (age < 40) with ALD have excess mortality beyond one-year post-LT. Recurrent disease or explicit mention of alcohol was the most common identified cause of death in this demographic.

6.
Transplantation ; 104(10): 2078-2086, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32969987

RESUMO

BACKGROUND: We evaluated trends and outcomes of liver transplantation (LT) recipients with/without HIV infection. METHODS: LT recipients between 2008 and 2015 from the United Network for Organ Sharing and Organ Procurement and Transplantation Network and European Liver Transplant Registry were included. Trends and characteristics related to survival among LT recipients with HIV infection were determined. RESULTS: Among 73 206 LT patients, 658 (0.9%) were HIV-infected. The proportion of LT HIV-infected did not change over time (P-trend = 0.16). Hepatitis C virus (HCV) as indication for LT decreased significantly for HIV-infected and HIV-uninfected patients (P-trends = 0.008 and <0.001). Three-year cumulative graft survival in LT recipients with and without HIV infection was 64.4% and 77.3%, respectively (P < 0.001), with improvements over time for both, but with HIV-infected patients having greater improvements (P-trends = 0.02 and 0.03). Adjusted risk of graft loss was 41% higher in HIV-infected versus HIV-uninfected (adjusted hazard ratio [aHR], 1.41; P < 0.001). Among HIV-infected, model of end-stage liver disease (aHR, 1.04; P < 0.001), body mass index <21 kg/m (aHR, 1.61; P = 0.006), and HCV (aHR, 1.83; P < 0.001) were associated with graft loss, whereas more recent period of LT 2012-2015 (aHR, 0.58; P = 0.001) and donor with anoxic cause of death (aHR, 0.51; P = 0.007) were associated with lower risk of graft loss. CONCLUSIONS: Patients with HIV infection account for only 1% of LTs in United States and Europe, with fewer LT for HCV disease over time. A static rate of LT among HIV-infected patients may reflect improvements in cirrhosis management and/or persistent barriers to LT. Graft and patient survival among HIV-infected LT recipients have shown improvement over time.

7.
Hepatology ; 2020 Jun 03.
Artigo em Inglês | MEDLINE | ID: mdl-32491208

RESUMO

BACKGROUND AND AIMS: Frailty, as measured by the Liver Frailty Index (LFI), is associated with liver transplant (LT) waitlist mortality. We sought to identify an optimal LFI cutoff that predicts waitlist mortality. APPROACH AND RESULTS: Adults with cirrhosis awaiting LT without hepatocellular carcinoma at nine LT centers in the United States with LFI assessments were included. Multivariable competing risk analysis assessed the relationship between LFI and waitlist mortality. We identified a single LFI cutoff by evaluating the fit of the competing risk models, searching for the cutoff that gave the best model fit (as judged by the pseudo-log-likelihood). We ascertained the area under the curve (AUC) in an analysis of waitlist mortality to find optimal cutoffs at 3, 6, or 12 months. We used the AUC to compare the discriminative ability of LFI+Model for End Stage Liver Disease-sodium (MELDNa) versus MELDNa alone in 3-month waitlist mortality prediction. Of 1,405 patients, 37 (3%), 82 (6%), and 135 (10%) experienced waitlist mortality at 3, 6, and 12 months, respectively. LFI was predictive of waitlist mortality across a broad LFI range: 3.7-5.2. We identified an optimal LFI cutoff of 4.4 (95% confidence interval [CI], 4.0-4.8) for 3-month mortality, 4.2 (95% CI, 4.1-4.4) for 6-month mortality, and 4.2 (95% CI, 4.1-4.4) for 12-month mortality. The AUC for prediction of 3-month mortality for MELDNa was 0.73; the addition of LFI to MELDNa improved the AUC to 0.79. CONCLUSIONS: LFI is predictive of waitlist mortality across a wide spectrum of LFI values. The optimal LFI cutoff for waitlist mortality was 4.4 at 3 months and 4.2 at 6 and 12 months. The discriminative performance of LFI+MELDNa was greater than MELDNa alone. Our data suggest that incorporating LFI with MELDNa can more accurately represent waitlist mortality in LT candidates.

8.
J Hepatol ; 73(3): 516-522, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32531415

RESUMO

BACKGROUND & AIMS: The prevalence of non-alcoholic fatty liver disease (NAFLD) is rising in young adults, with potential implications for reproductive-aged women. Whether NAFLD during pregnancy confers more serious risks for maternal or perinatal health is unclear. METHODS: Using weighted discharge data from the US national inpatient sample, we evaluated temporal trends of NAFLD in pregnancies after 20 weeks gestation, and compared outcomes to pregnancies with other chronic liver diseases (CLDs) or no CLD. Study outcomes included preterm birth, postpartum hemorrhage, hypertensive complications (pre-eclampsia, eclampsia, and/or hemolysis, elevated liver enzymes, and low platelets syndrome), and maternal or fetal death. NAFLD prevalence was estimated by calendar year and temporal trends tested by linear regression. Outcomes were analyzed by logistic regression adjusted for age, race, multiple gestation, and pre-pregnancy diabetes, obesity, dyslipidemia and hypertension. RESULTS: Among 18,574,225 pregnancies, 5,640 had NAFLD and 115,210 had other, non-NAFLD CLD. Pregnancies with NAFLD nearly tripled from 10.5/100,000 pregnancies in 2007 to 28.9/100,000 in 2015 (p <0.001). Compared to the other groups, patients with NAFLD during pregnancy more frequently experienced gestational diabetes (7-8% vs. 23%), hypertensive complications (4% vs. 16%), postpartum hemorrhage (3-5% vs. 6%), and preterm birth (5-7% vs. 9%), all p values ≤0.01. On adjusted analysis, compared to no CLD, NAFLD was associated with hypertensive complications, preterm birth, postpartum hemorrhage and possibly maternal (but not fetal) death. CONCLUSION: The prevalence of NAFLD in pregnancy has nearly tripled in the last decade and is independently associated with hypertensive complications, postpartum hemorrhage and preterm birth. NAFLD should be considered a high-risk obstetric condition, with clinical implications for pre-conception counseling and pregnancy care. LAY SUMMARY: The prevalence of non-alcoholic fatty liver disease (NAFLD) in pregnancy has almost tripled over the past 10 years. Having NAFLD during pregnancy increases risks for both the mother and the baby, including hypertensive complications of pregnancy, bleeding after delivery, and preterm birth. Thus, pre-conception counseling is warranted with consideration of high-risk obstetric management among women with NAFLD in pregnancy.

9.
Liver Transpl ; 26(9): 1100-1111, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32531867

RESUMO

Liver transplantation (LT) recipients with hepatocellular carcinoma (HCC) receive a higher proportion of livers from donation after circulatory death (DCD) donors compared with non-HCC etiologies. Nevertheless, data on outcomes in patients with HCC receiving DCD grafts are limited. We evaluated the influence of DCD livers on post-LT outcome among HCC patients. We identified 7563 patients in the United Network for Organ Sharing (UNOS) database who underwent LT with Model for End-Stage Liver Disease score exceptions from 2012 to 2016, including 567 (7.5%) who received a DCD donor organ and 6996 (92.5%) who received a donation after brain death (DBD) donor organ. Kaplan-Meier probabilities of post-LT HCC recurrence at 3 years were 7.6% for DCD and 6.4% for DBD recipients (P = 0.67) and post-LT survival at 3 years was 81.1% versus 85.5%, respectively (P = 0.008). On multivariate analysis, DCD donor (hazard ratio, 1.38; P = 0.005) was an independent predictor of post-LT mortality. However, a survival difference after LT was only observed in subgroups at higher risk for HCC recurrence including Risk Estimation of Tumor Recurrence After Transplant (RETREAT) score ≥4 (DCD 57.0% versus DBD 72.6%; P = 0.02), alpha-fetoprotein (AFP) ≥100 (60.1% versus 76.9%; P = 0.049), and multiple viable tumors on last imaging before LT (69.9% versus 83.1%; P = 0.002). In this analysis of HCC patients receiving DCD versus DBD livers in the UNOS database, we found that patients with a low-to-moderate risk of HCC recurrence (80%-90% of the DCD cohort) had equivalent survival regardless of donor type. It appears that DCD donation can best be used to increase the donor pool for HCC patients with decompensated cirrhosis or partial response/stable disease after locoregional therapy with AFP at LT <100 ng/mL.

10.
Aliment Pharmacol Ther ; 52(2): 382-389, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32432816

RESUMO

BACKGROUND: Chronic hepatitis B infection is an important contributor to mortality in the United States, yet impact of available and effective oral antivirals on mortality among infected individuals is unknown. AIMS: To compare risks and predictors of mortality in a recent time period between those with chronic, prior and no hepatitis B infection. METHODS: This is a population-based cohort study of National Health and Nutrition Examination Surveys participants between 1999 and 2014 linked to National Death Index data. Adults aged 20 years or older with hepatitis B serologic testing were included. Outcomes of all-cause and liver-related mortality were evaluated using Cox regression. RESULTS: Of 39 206 participants, 192 (0.5%) had chronic and 2694 (6.9%) had prior hepatitis B infection. The all-cause age/sex-standardised mortality rates for chronic, prior and uninfected were 21.4, 15.1 and 11.8 per 1000 person-years respectively. Liver-related mortality occurred at respective rates of 4.1, 0.3 and 0.1 per 1000 person-years. In multivariable analyses, those with chronic infection had 1.9-fold (95% CI 1.1-3.3) increased hazard of all-cause mortality and 13.3-fold (95% CI 3.9-45.5) increased hazard of liver-related mortality compared to uninfected. Predictors of all-cause mortality among chronic infection included heavy alcohol use (HR 18.3, 95% CI 3.3-100.6) and higher alanine aminotransferase (HR 1.02, 95% CI 1.00-1.03). CONCLUSIONS: Mortality among adults living with chronic hepatitis B infection still exceeds that of uninfected despite availability of improved therapeutics. Identification of chronic infection, initiation of treatment among eligible and modulation of co-factors for disease progression are needed to improve survival.


Assuntos
Hepatite B Crônica/mortalidade , Alanina Transaminase/sangue , Consumo de Bebidas Alcoólicas/sangue , Consumo de Bebidas Alcoólicas/mortalidade , Estudos de Coortes , Feminino , Hepatite B Crônica/sangue , Humanos , Masculino , Pessoa de Meia-Idade , Estados Unidos/epidemiologia
11.
Transplantation ; 2020 May 18.
Artigo em Inglês | MEDLINE | ID: mdl-32433235

RESUMO

BACKGROUND: Share 35 was a policy implemented in 2013 to increase regional sharing of deceased donor livers to patients with MELD ≥ 35 in order to decrease waitlist mortality for the sickest patients awaiting liver transplantation. The purpose of this study was to determine whether LDLT volume was impacted by the shift in allocation of deceased donor livers to patients with higher MELD scores. METHODS: Using UNOS/OPTN Standard Transplant Analysis and Research files, we identified all adults who received a primary LT between October 1, 2008 and March 31, 2018. LT from October 1, 2008 through June 30, 2013 were designated as the pre-Share 35 era and July 1, 2013 through March 31, 2018 as the post-Share 35 era. Primary outcomes included transplant volumes, graft survival, and patient survival in both eras. RESULTS: 48,779 primary adult single-organ LT occurred during the study period (22,255 pre-Share 35, 26,524 post. LDLT increased significantly (6.8% post vs. 5.7% pre, p<0.001). LDLT volume varied significantly by region (p<0.001) with regions 2, 4, 5, and 8 demonstrating significant increases in LDLT volume post-Share 35. The number of centers performing LDLT increased only in regions 4, 6, and 11. Throughout the two eras, there was no difference in graft or patient survival for LDLT recipients. CONCLUSIONS: Overall LDLT volume increased following the implementation of Share 35 which was largely due to increased LDLT volume at centers with experience in LDLT, and corresponded to significant geographic variation in LDLT utilization.

12.
J Hepatol ; 73(3): 575-581, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32240717

RESUMO

BACKGROUND & AIMS: To date, studies evaluating the association between frailty and mortality in patients with cirrhosis have been limited to assessments of frailty at a single time point. We aimed to evaluate changes in frailty over time and their association with death/delisting in patients too sick for liver transplantation. METHODS: Adults with cirrhosis, listed for liver transplantation at 8 US centers, underwent ambulatory longitudinal frailty testing using the liver frailty index (LFI). We used multilevel linear mixed-effects regression to model and predict changes in LFI (ΔLFI) per 3 months, based on age, gender, model for end-stage liver disease (MELD)-Na, ascites, and hepatic encephalopathy, categorizing patients by frailty trajectories. Competing risk regression evaluated the subhazard ratio (sHR) of baseline LFI and predicted ΔLFI on death/delisting, with transplantation as the competing risk. RESULTS: We analyzed 2,851 visits from 1,093 outpatients with cirrhosis. Patients with severe worsening of frailty had worse baseline LFI and were more likely to have non-alcoholic fatty liver disease, diabetes, or dialysis-dependence. After a median follow-up of 11 months, 223 (20%) of the overall cohort died/were delisted because of sickness. The cumulative incidence of death/delisting increased by worsening ΔLFI group. In competing risk regression adjusted for baseline LFI, age, height, MELD-Na, and albumin, a 0.1 unit change in ΔLFI per 3 months was associated with a 2.04-fold increased risk of death/delisting (95% CI 1.35-3.09). CONCLUSION: Worsening frailty was significantly associated with death/delisting independent of baseline frailty and MELD-Na. Notably, patients who experienced improvements in frailty had a lower risk of death/delisting. Our data support the longitudinal measurement of frailty, using the LFI, in patients with cirrhosis and lay the foundation for interventional work aimed at reversing frailty. LAY SUMMARY: Frailty, as measured at a single time point, is predictive of death in patients with cirrhosis, but whether changes in frailty over time are associated with death is unknown. In a study of over 1,000 patients with cirrhosis who underwent frailty testing, we demonstrate that worsening frailty is strongly linked with mortality, regardless of baseline frailty and liver disease severity. Notably, patients who experienced improvements in frailty over time had a lower risk of death/delisting. Our data support the longitudinal measurement of frailty in patients with cirrhosis and lay the foundation for interventional work aimed at reversing frailty.

13.
Am J Transplant ; 20(6): 1642-1649, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-31917505

RESUMO

US deceased donor solid organ transplantation (dd-SOT) depends upon an individual's/family's altruistic willingness to donate organs after death; however, there is a shortage of deceased organ donors in the United States. Informing individuals of their own lifetime risk of needing dd-SOT could reframe the decision-making around organ donation after death. Using United Network for Organ Sharing (UNOS) data (2007-2016), this cross-sectional study identified (1) deceased organ donors, (2) individuals waitlisted for dd-SOT (liver, kidney, pancreas, heart, lung, intestine), and (3) dd-SOT recipients. Using US population projections, life tables, and mortality estimates, we quantified probabilities (Pr) of (1) becoming deceased organ donors, (2) needing dd-SOT, and (3) receiving dd-SOT. Lifetime Pr (per 100 000 US population) for males and females of becoming deceased organ donors were 212 and 146, respectively, and of needing dd-SOT were 1323 and 803, respectively. Lifetime Pr of receiving dd-SOT was 50% for males, 48% for females. Over a lifetime, males were 6.2 and females 5.5 times more likely to need dd-SOT than to become deceased organ donors. Organ donation is traditionally contextualized in terms of charity toward others. Our analyses yield a new tool, in the form of quantifying an individual's own likelihood of needing dd-SOT, which may assist with reframing motivations toward deceased donor organ donation.

14.
Hepatol Commun ; 4(1): 126-133, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31909360

RESUMO

Frailty results from the chronic effects of malnutrition and muscle wasting in patients with cirrhosis. It is well-established that frailty is strongly associated with mortality in this population. However, little is known of its relationship with physical disability, a critical patient-centered outcome. Adults with cirrhosis underwent outpatient testing of frailty using the Liver Frailty Index (LFI) and disability using activities of daily living (ADL; range 0-6) and Instrumental ADL (IADL; range 0-8) scales at one center between 2012 and 2016. We used adjusted multilevel logistic mixed-effects regression to test the association between frailty and current disability (impairment with ≥1 ADL or IADL) and incident disability at 6 months among those without baseline disability. Of the 983 participants, 20% were robust, 32% were less robust, 33% were prefrail, and 15% were frail; 587 (60%) had at least 1 assessment. The percentage of participants with at least 1 baseline ADL or IADL impairment was 28% and 37%, respectively. In adjusted regression models, each point LFI increase was associated with a 3.3 and 4.6 higher odds of current difficulty with at least 1 ADL and IADL (P < 0.001 for each), respectively. Among participants without baseline disability, each point LFI increase was associated with a 2.6 and 1.7 higher odds of having difficulty with at least 1 ADL and IADL at 6 months, respectively. Conclusion: Frailty is strongly associated with concurrent and incident disability in patients with cirrhosis. In the clinic, the LFI can be used to identify those in greatest need for additional support/resources to maintain functional independence. In research settings, the LFI may help to identify an enriched population for clinical trials of interventions aimed at those most vulnerable to disability.

15.
Transplantation ; 104(2): 285-292, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31107823

RESUMO

BACKGROUND: Alcoholic liver disease (ALD) accounts for 15%-30% of transplants performed in the United States and Europe; however, the data on living donor liver transplantation (LDLT) for ALD remain sparse. The purpose of this study was to examine the outcomes following LDLT for ALD using data from the adult-to-adult living donor liver transplantation (A2ALL) study, which represents the largest Western experience with adult-to-adult LDLT. METHODS: A retrospective review of A2ALL data collected between 1998 and 2014 was performed. Patients were excluded if they received a deceased donor liver transplant. Demographic data, postoperative outcomes and complications, graft and patient survival, and predictors of graft and patient survival were assessed. RESULTS: Of the 1065 patients who underwent LDLT during the study time period, 168 (15.8%) were transplanted for a diagnosis of ALD. Comparing patients who underwent transplant for ALD with those who were transplanted for other etiologies of liver disease, there was no significant difference in graft survival at 1 (88% versus 84%), 5 (76% versus 74%), or 10 years following transplant (55% versus 61%, P = 0.29). Similarly, there was no difference in patient survival at 1 (94% versus 91%), 5 (83% versus 79%), or 10 years following transplant (61% versus 66%, P = 0.32). CONCLUSIONS: LDLT for ALD results in excellent 1-, 5-, and 10-year graft and patient survival. Patients with ALD and impaired renal function have a higher risk of graft loss and death. These findings support the notion that early LDLT for patients with ALD may help optimize outcomes.


Assuntos
Hepatopatias Alcoólicas/complicações , Falência Hepática/cirurgia , Transplante de Fígado/métodos , Doadores Vivos/estatística & dados numéricos , Medição de Risco/métodos , Adulto , Seguimentos , Sobrevivência de Enxerto , Humanos , Incidência , Hepatopatias Alcoólicas/cirurgia , Falência Hepática/epidemiologia , Falência Hepática/etiologia , Pessoa de Meia-Idade , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Fatores de Tempo , Estados Unidos/epidemiologia
16.
Hepatology ; 71(3): 943-954, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31344273

RESUMO

BACKGROUND AND AIMS: United Network for Organ Sharing (UNOS) recently implemented a national policy granting priority listing for liver transplantation (LT) in patients who achieved down-staging of hepatocellular carcinoma (HCC) to Milan criteria. We aimed to evaluate the national experience on down-staging by comparing two down-staging groups with (1) tumor burden meeting UNOS down-staging (UNOS-DS) inclusion criteria and (2) "all-comers" (AC-DS) with initial tumor burden beyond UNOS-DS criteria versus patients always within Milan. APPROACH AND RESULTS: This is a retrospective analysis of the UNOS database of 3,819 patients who underwent LT from 2012 to 2015, classified as always within Milan (n = 3,276), UNOS-DS (n = 422), and AC-DS (n = 121). Median time to LT was 12.8 months in long wait regions, 6.5 months in mid wait regions (MWR), and 2.6 months in short wait regions (SWR). On explant, vascular invasion was found in 23.7% of AC-DS versus 16.9% of UNOS-DS and 14.4% of Milan (P = 0.002). Kaplan-Meier 3-year post-LT survival was 83.2% for Milan, 79.1% for UNOS-DS (P = 0.17 vs. Milan), and 71.4% for AC-DS (P = 0.04 vs. Milan). Within down-staging groups, risk of post-LT death in multivariable analysis was increased in SWR or MWR (hazard ratio [HR], 3.1; P = 0.005) and with alpha-fetoprotein (AFP) ≥ 100 ng/mL at LT (HR, 2.4; P = 0.009). The 3-year HCC recurrence probability was 6.9% for Milan, 12.8% for UNOS-DS, and 16.7% for AC-DS (P < 0.001). In down-staging groups, AFP ≥ 100 (HR, 2.6; P = 0.02) was the only independent predictor of HCC recurrence. CONCLUSIONS: Our results validated UNOS-DS criteria based on comparable 3-year survival between UNOS-DS and Milan groups. Additional refinements based on AFP and wait time may further improve post-LT outcomes in down-staging groups, especially given that reported 3-year recurrence was higher than in those always within Milan criteria.

17.
Hepatology ; 72(1): 130-139, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31705545

RESUMO

BACKGROUND AND AIMS: In some states, liver transplantation (LT) for alcohol-associated liver disease (ALD) is covered by Medicaid only with documentation of abstinence and/or alcohol rehabilitation. Different Medicaid policies may affect the distribution of LT for ALD, particularly post-2011, as centers have adopted early (i.e., specific abstinence period not required) LT practices. APPROACH AND RESULTS: We surveyed Medicaid policies in all states actively performing LT and linked state policies to prospectively collected national registry data on LT recipients from 2002 to 2017 with ALD as the primary listing diagnosis. We categorized Medicaid policies for states as "restrictive" (requiring documentation of a specific abstinence period and/or rehabilitation) versus "unrestrictive" (deferring to center eligibility policies). Difference-of-differences analysis, comparing 2002-2011 versus 2012-2017, evaluated whether restrictive policies were associated with decreased proportion of LTs paid by Medicaid among patients with ALD post-2011. We performed sensitivity analyses to account for any differences by diagnosis of hepatocellular carcinoma, hepatitis C virus, nonalcoholic steatohepatitis, or Medicare insurance. We also performed a sensitivity analysis to account for any difference by prevalence of ALD among restrictive versus unrestrictive states. Of 10,836 LT recipients in 2002-2017, 7,091 were from 24 states in the restrictive group and 3,745 from 14 states in the unrestrictive group. The adjusted proportion (95% confidence interval) of LTs paid by Medicaid among restrictive versus unrestrictive states between 2002 and 2011 was 17.6% (15.4%-19.8%) versus 18.9% (15.4%-22.3%) (P = 0.54) and between 2012 and 2017, 17.2% (14.7%-19.7%) versus 23.2% (19.8%-26.6%) (P = 0.005). In difference-of-differences analysis, restrictive (versus unrestrictive) policies were associated with a 4.7% (0.8%-8.6%) (P = 0.02) absolute lower adjusted proportion of LTs for ALD paid by Medicaid post-2011. CONCLUSIONS: Restrictive Medicaid policies are present in most states with active LT centers and are associated with lower proportions of LTs for ALD paid by Medicaid post-2011 compared to states with unrestrictive Medicaid policies. Reevaluation of Medicaid alcohol use policies may be warranted, to align more closely with contemporary center-level practices.

18.
Liver Transpl ; 26(5): 662-672, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-31833634

RESUMO

For patients with hepatocellular carcinoma (HCC) listed for liver transplantation (LT), United Network for Organ Sharing (UNOS) enacted policy changes in 2015 to improve equity between HCC and non-HCC patients. We evaluated the impact of these changes on regional disparities in wait-list dropout and LT. We included patients in the UNOS database listed with Model for End-Stage Liver Disease HCC exceptions in long-wait regions (LWRs), mid-wait regions (MWRs), and short-wait regions (SWRs) before these policy changes (era 1, January 1 to December 31, 2013) and after (era 2, October 7, 2015, to October 7, 2016). Cumulative incidence of wait-list dropout and LT were evaluated using competing risk regression. Median time to LT increased by 3.6 months (3.1 to 6.7 months) in SWRs and 1.3 months (6.9 to 8.2 months) in MWRs (P < 0.001), with a slight decrease in LWRs (13.4 to 12.9 months; P = 0.02). The 2-year cumulative incidence of dropout increased from 9.7% to 14.8% in SWRs (P = 0.03) and from 18.9% to 22.6% in MWRs (P = 0.18) but decreased in LWRs from 26.7% to 24.8% (P = 0.31). Factors predicting wait-list dropout included listing in era 2 (hazard ratio [HR], 1.17), in LWRs (HR, 2.56), and in MWRs (HR, 1.91). Regional differences in wait-list outcomes decreased with policy changes, but HCC patients in SWRs remain advantaged. Recent policy change may narrow these disparities.

19.
Am J Gastroenterol ; Publish Ahead of Print2020 Dec 23.
Artigo em Inglês | MEDLINE | ID: mdl-33394685

RESUMO

INTRODUCTION: We developed the strength training intervention (STRIVE), a home-based exercise program targeting physical function in patients with cirrhosis. In this pilot study, we aimed to evaluate the safety and efficacy of STRIVE. METHODS: Eligible were adult patients with cirrhosis at 3 sites. Patients were randomized 2:1-12 weeks of STRIVE, a 30-minute strength training video plus a health coach or standard of care (SOC). Physical function and quality of life were assessed using the Liver Frailty Index (LFI) and Chronic Liver Disease Questionnaire (CLDQ), respectively. RESULTS: Fifty-eight and 25 were randomized to STRIVE and SOC arms, respectively: 43% women, median age was 61 years, MELDNa, Model for End-Stage Liver Disease Sodium was 14, and 54% were Child-Pugh B/C. Baseline characteristics were similar in the STRIVE vs SOC arms except for rates of hepatic encephalopathy (19 vs 36%). LFI @ 12 weeks was available in 43 STRIVE and 20 SOC participants. After 12 weeks, the median LFI improved from 3.8 to 3.6 (ΔLFI -0.1) in the STRIVE arm and 3.7 to 3.6 (ΔLFI -0.1) in the SOC arm (P = 0.65 for ΔLFI difference). CLDQ scores improved from 4.6 to 5.2 in STRIVE participants (ΔCLDQ 0.38) and did not change in SOC participants (4.2-4.2; ΔCLDQ -0.03) (P = 0.09 for ΔCLDQ difference). One patient died (SOC arm) of bleeding. Only 14% of STRIVE participants adhered to the strength training video for 10-12 weeks. No adverse events were reported by STRIVE participants. DISCUSSION: STRIVE, a home-based structured exercise program for patients with cirrhosis, was safely administered at 3 sites, but adherence was low. Although all participants showed minimal improvement in the LFI, STRIVE was associated with a substantial improvement in quality of life.

20.
JAMA Netw Open ; 2(8): e1910326, 2019 08 02.
Artigo em Inglês | MEDLINE | ID: mdl-31469395

RESUMO

Importance: There are well-documented racial/ethnic and socioeconomic disparities in access to health care among patients with hepatocellular carcinoma (HCC); however, there are little data on the association of insurance type with liver transplant (LT) wait-list outcomes for patients with HCC. Objective: To examine LT wait-list outcomes for patients with HCC and public insurance compared with patients with private insurance. Design, Setting, and Participants: This single-center cohort study included 705 adult patients with HCC who had Model for End-Stage Liver Disease exceptions and were included on a waiting list for LT from January 1, 2010, to December 31, 2016. Patients with Kaiser Permanente medical insurance, other private medical insurance, or public medical insurance were included. Data analysis was conducted from May 2018 to October 2018. Main Outcomes and Measures: The main outcome was cumulative incidence of LT waiting list dropout within 2 years of waiting list enrollment (baseline). Secondary outcomes included competing-risks analysis to identify risk factors associated with wait-list outcomes. Results: Among 705 patients (median [interquartile range] age, 61 [57-65] years; 537 [76.2%] men) with HCC on an LT waiting list, 349 patients (49.5%) had Kaiser Permanente insurance, 157 patients (22.3%) had other private insurance, and 199 patients (28.2%) had public insurance. Median (interquartile range) follow-up was 13.2 (7.8-18.7) months. Tumor characteristics were similar among insurance types. The cumulative incidence of dropout owing to tumor progression or death within 2 years of baseline was 21.8% (95% CI, 17.2%-26.7%) among the Kaiser Permanente insurance group, 25.5% (95% CI, 18.6%-33.0%) among the other private insurance group, and 35.5% (95% CI, 28.3%-42.7%) among the public insurance group (P < .001). The cumulative incidence of LT within 2 years of baseline was 67.3% (95% CI, 61.2%-72.6%) among the Kaiser Permanente insurance group, 64.1% (95% CI, 55.2%-71.7%) among the other private insurance group, and 48.5% (95% CI, 40.4%-56.1%) among the public insurance group (P < .001). In competing-risks multivariable analysis compared with patients with Kaiser Permanente insurance, patients with public insurance were associated with increased risk of dropout (hazard ratio [HR], 1.69 [95% CI, 1.17-2.43]; P = .005), but patients with other private insurance were not (HR, 1.40 [95% CI, 0.94-2.08]; P = .10). Waiting list dropout was also significantly associated with an α-fetoprotein level 100 ng/mL or higher (HR, 2.8 [95% CI, 1.98-3.88]; P < .001), Model for End-Stage Liver Disease score at baseline (HR per point, 1.06 [95% CI, 1.03-1.09]; P < .001), and 3 or more lesions at baseline (HR vs 1 lesion of 2- to 3-cm diameter, 2.07 [95% CI, 1.27-3.37]; P = .004). Conclusions and Relevance: In this large cohort of patients with HCC on an LT waiting list, patients with public insurance were associated with worse wait-list outcomes compared with patients with Kaiser Permanente insurance or other private insurance, despite similar tumor-related characteristics at baseline. Improved health care coordination and delivery may be options to reduce these disparities.


Assuntos
Carcinoma Hepatocelular/cirurgia , Seguro Saúde/tendências , Transplante de Fígado/estatística & dados numéricos , Listas de Espera/mortalidade , Idoso , Carcinoma Hepatocelular/metabolismo , Carcinoma Hepatocelular/patologia , Feminino , Acesso aos Serviços de Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/etnologia , Humanos , Incidência , Seguro Saúde/estatística & dados numéricos , Neoplasias Hepáticas/patologia , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Pacientes Desistentes do Tratamento/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Fatores Socioeconômicos , Estados Unidos/epidemiologia , Estados Unidos/etnologia , alfa-Fetoproteínas/análise
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA