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1.
Rev Med Chil ; 147(8): 955-964, 2019 Aug.
Artigo em Espanhol | MEDLINE | ID: mdl-31859959

RESUMO

BACKGROUND: Liver transplantation (LT) is an option for people with liver failure who cannot be cured with other therapies and for some people with liver cancer. AIM: To describe, and analyze the first 300 LT clinical results, and to establish our learning curve. MATERIAL AND METHODS: Retrospective cohort study with data obtained from a prospectively collected LT Program database. We included all LT performed at a single center from March 1994 to September 2017. The database gathered demographics, diagnosis, indications for LT, surgical aspects and postoperative courses. We constructed a cumulative summation test for learning curve (LC-CUSUM) using 30-day post-LT mortality. Mortality at 30 days, and actuarial 1-, and 5-year survival rate were analyzed. RESULTS: A total of 281 patients aged 54 (0-71) years (129 women) underwent 300 LT. Ten percent of patients were younger than 18 years old. The first, second and third indications for LT were non-alcoholic steatohepatitis, chronic autoimmune hepatitis and alcoholic liver cirrhosis, respectively. Acute liver failure was the LT indication in 51 cases (17%). The overall complication rate was 71%. Infectious and biliary complications were the most common of them (47 and 31% respectively). The LC-CUSUM curve shows that the first 30 patients corresponded to the learning curve. The peri-operative mortality was 8%. Actuarial 1 and 5-year survival rates were 82 and 71.4%, respectively. CONCLUSIONS: Outcome improvement of a LT program depends on the accumulation of experience after the first 30 transplants and the peri-operative mortality directly impacted long-term survival.


Assuntos
Curva de Aprendizado , Transplante de Fígado/normas , Avaliação de Programas e Projetos de Saúde/normas , Adulto , Idoso , Chile , Doença Hepática Terminal/mortalidade , Doença Hepática Terminal/cirurgia , Feminino , Humanos , Transplante de Fígado/métodos , Transplante de Fígado/mortalidade , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Estudos Retrospectivos , Estatísticas não Paramétricas , Taxa de Sobrevida , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
2.
Tuberk Toraks ; 67(3): 169-178, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31709948

RESUMO

Introduction: Acute pulmonary thromboembolism (PTE) is a highly morbid and fatal condition. Although several risk stratification models exist for prediction of mortality risk in PTE, no study has yet focused on the effect of impaired vital organ function, such as renal or hepatic impairment, on mortality in PTE. MELD-XI (Model for end-stage liver disease excluding INR) score predicts mortality among patients with end-stage hepatic and cardiovascular disorders. Herein, we aimed to test MELD-XI score for predicting in-hospital prognosis of patients with intermediate-to-high risk acute PTE. Materials and Methods: We reviewed the medical records patients older than 18 years hospitalized with intermediate-to-high risk PTE between 01.06.2011 and 01.01.2019. Simplified pulmonary embolism severity index (sPESI) score and MELD-XI score were calculated, and in-hospital mortality determined. MELD-XI score was compared between patients with and without in-hospital mortality and was correlated to sPESI score. The predictive power of MELD-XI score for in-hospital mortality was sought and an in-hospital survival analysis with Kaplan Meier curve and log-rank test was done for MELD-XI score. Result: A total of 104 patients [mean age of 70.8 ± 15.9 years; 68 (65.4%) females]. Fourteen (13.5%) patients died at hospital. MELD-XI and sPESI scores were significantly correlated to each other and were higher in deceased patients than the survivors [17.3 (IQR 14.3) vs. 10.12 (IQR 2.99); p<0.05 and 2 (IQR 1) vs. 1 (IQR 1); p<0.05, respectively]. MELD-XI score and sPESI score were significant predictor of in-hospital mortality in multivariate analysis. A MELD-XI score ≥ 10.25 had a sensitivity of 78.6% and a specificity of 70.0% for in-hospital mortality. A survival analysis revealed that a high MELD-XI category (MELD-XI score ≥ 10.2) significantly worsened in-hospital survival (p<0.01; log rank test). Conclusions: MELD-XI score performs well for mortality prediction among patients with intermediate-to-high risk PTE. This subject needs to be further studied by large, randomized controlled studies.


Assuntos
Doença Hepática Terminal/mortalidade , Mortalidade Hospitalar , Embolia Pulmonar/mortalidade , Índice de Gravidade de Doença , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Medição de Risco , Análise de Sobrevida
3.
Transplant Proc ; 51(9): 2860-2864, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31711575

RESUMO

BACKGROUND: Liver transplantation (LT) is the only definitive and curative treatment for patients with end-stage liver disease and hepatocellular carcinoma. We aimed to evaluate the impact of the Italian score for organ allocation (ISO) in terms of the waiting-list mortality, probability of LT, and patient survival after LT. PATIENT AND METHODS: All of the adult patients on the waiting list for LT at our institute from January 2014 to December 2017 were included in the study. The probabilities of death while on the waiting list, dropout from the list, and LT were compared by means of cumulative incidence functions, in a competing risk time-to-event analysis setting. Uni- and multivariable logistic regression models were used to estimate and compare the probability of death and to find potential risk factors for waiting-list death. RESULTS: There were 286 patients on the waiting list for LT during the study period, 122 of whom entered the waiting list prior to the implementation of ISO (Group A) and 164 afterward (Group B). Group A had 62 transplants, and Group B had 116 transplants. Group B showed a lesser probability of death (P = .005) and a greater probability of transplant (P < .001) compared to Group A. In the 2 groups, post-transplant survival was similar. CONCLUSION: Based on preliminary clinical experience from a single transplant center, the ISO allocation system demonstrated an overall reduced probability of patient death while on the waiting list without impairing post-LT survival, suggesting that the ISO system might represent an improved method of organ allocation, with a more beneficial distribution of livers.


Assuntos
Transplante de Fígado , Índice de Gravidade de Doença , Listas de Espera/mortalidade , Adulto , Carcinoma Hepatocelular/mortalidade , Carcinoma Hepatocelular/cirurgia , Doença Hepática Terminal/mortalidade , Doença Hepática Terminal/cirurgia , Feminino , Humanos , Itália , Neoplasias Hepáticas/mortalidade , Neoplasias Hepáticas/cirurgia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo
4.
Medicine (Baltimore) ; 98(45): e17862, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31702650

RESUMO

Since the progression of cirrhosis is accelerated each time a complication recurs, the management and treatment of the complication is critical in enhancement of the quality of life and expectation of life in patients. The use of model for end-stage liver disease with incorporation of serum-sodium (MELD-Na) with physiological indicators can be used to assess severity and differentiate therapeutic interventions.This study is aimed to determine the mean survival period and cumulative survival rate by classifying patients into high-risk and low-risk groups based on MELD-Na, a predictor of mortality in liver disease, and to investigate the mortality prognostic factors.A retrospective cohort study, which follows the STROBE checklist, was performed. 263 patients who were diagnosed with liver cirrhosis complications for the first time and hospitalized were selected as the subjects of this study. The collected data were analyzed based on the survival package provided by the statistical program R version 3.4.2.Subjects were classified into high-risk and low-risk groups using MELD-Na 14 points where sensitivity and specificity crossed the cut-off point. Gender, age, and primary caregiver were significant variables in the mortality high-risk group, and AST, albumin, and primary caregiver were significant variables in the mortality low-risk group. Based on these mortality prognostic factors, it is possible to present the factors affecting mortality in patients who were diagnosed with liver cirrhosis complications for the first time. The classification of patients by risk level could be the foundation to provide accurate guidelines for management and it is necessary to modify prognostic factors and apply nursing interventions to manage complications.


Assuntos
Doença Hepática Terminal/mortalidade , Cirrose Hepática/mortalidade , Índice de Gravidade de Doença , Sódio/sangue , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Progressão da Doença , Doença Hepática Terminal/sangue , Doença Hepática Terminal/etiologia , Feminino , Humanos , Estimativa de Kaplan-Meier , Cirrose Hepática/sangue , Cirrose Hepática/complicações , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Estudos Retrospectivos
5.
Transplant Proc ; 51(9): 2962-2966, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31607616

RESUMO

INTRODUCTION: Preoperative liver and renal dysfunction remain surgical risk factors for both postoperative morbidity and mortality. The Model of End-Stage Liver Disease Excluding INR (international normalized ratio), or MELD-XI, score calculation may help as a predictor in patients with advanced heart failure. We analyzed the impact of progressive elevated MELD-XI values among recipients of heart transplant at our institution. METHODS: The data of a total of 425 consecutive adult patients who underwent heart transplantation, between January 2000 and August 2018, have been reviewed and divided into 3 cohorts according to preoperative MELD-XI calculations (MELD-XI < 11; MELD-XI 11-18; and MELD-XI > 18). Early and late outcomes have been analyzed. RESULTS: Patients with a MELD-XI score > 18 had a more critical clinical condition preoperatively and had a higher risk of early mortality (hazard ratio [HR] 1.45 [1.11-1.67], P < .001). They showed high risk for postoperative dialysis (HR 2.8 [1.5-5.3], P < .001), rethoracothomy for bleeding (HR 2.1 [1.2-4.1], P = .001), prolonged time of mechanical ventilation, time of intensive care unit stay (HR 2.2 [1.3-3.8], P = .005), and graft failure requiring mechanical circulatory support (HR 1.9 [1.1-3.3], P = .003). After risk adjustment per MELD-XI cohort, ischemic dilated cardiomyopathy, redo operation, and cold ischemic time > 240 minutes resulted in being the strongest predictors of early mortality (P < .001). The 5-year and 10-year survival for MELD-XI > 18 cohort was 63% and 47% vs 72% and 59% in the control group (MELD-XI < 18) (log-rank, P < .001). CONCLUSIONS: Patients with an elevated preoperative MELD-XI profile presented more comorbidities and significantly lower survival. This suggests the MELD-XI score may provide further insight into appropriate recipient and eventual donor selection. Renal insufficiency and congestive hepatopathy should be properly optimized before heart transplantation.


Assuntos
Doença Hepática Terminal/complicações , Transplante de Coração , Nefropatias/complicações , Índice de Gravidade de Doença , Adulto , Estudos de Coortes , Doença Hepática Terminal/mortalidade , Feminino , Transplante de Coração/mortalidade , Humanos , Coeficiente Internacional Normatizado , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Prognóstico , Modelos de Riscos Proporcionais , Fatores de Risco
6.
Arq Gastroenterol ; 56(3): 286-293, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31633727

RESUMO

BACKGROUND: Variceal bleeding remains important cause of upper gastrointestinal bleed. Various risk scores are used in risk stratification for non-variceal bleed. Their utility in variceal bleeding patients is not clear. This study aims to compare probability of these scores in predicting various outcomes in same population. OBJECTIVE: This study aims to compare probability of these scores in predicting various outcomes in same population. To study characteristics and validate AIMS65, Rockall, Glasgow Blatchford score(GBS), Progetto Nazionale Emorragia Digestiva (PNED) score in variceal Upper Gastrointestinal Bleed (UGIB) patients for predicting various outcomes in our population. METHODS: Three hundred subjects with UGIB were screened prospectively. Of these 141 patients with variceal bleeding were assessed with clinical, blood investigations and endoscopy and risk scores were calculated and compared to non-variceal cases. All cases were followed up for 30 days for mortality, rebleeding, requirement of blood transfusion and need of radiological or surgical intervention. RESULTS: Variceal bleeding (141) was more common than non variceal (134) and 25 had negative endoscopy. In variceal group, cirrhosis (85%) was most common etiology. Distribution of age and sex were similar in both groups. Presence of coffee coloured vomitus (P=0.002), painless bleed (P=0.001), edema (P=0.001), ascites (P=0.001), hemoglobin <7.5 gms (P<0.001), pH<7.35 (P<0.001), serum bicarbonate level <17.6 mmol/L (P<0.001), serum albumin<2.75 gms% (P<0.001), platelet count <1.2 lacs/µL (P<0.001), high INR 1.35 (P<0.001), BUN >25mmol/L (P<0.001), and ASA status (P<0.001), high lactate >2.85 mmol/L (P=0.001) were significant. However, no factor was found significant on multivariate analysis. Rockall was found to be significant in predicting mortality and rebleed. AIMS65 was also significant in predicting mortality. GBS was significant in predicting blood transfusion and need of intervention. PNED score was significant in all events except mortality. CONCLUSION: All four scores had lower predictive potential in predicting events in variceal bleed. However, AIMS65 & Rockall score were significant in predicting mortality, while GBS in predicting need of transfusion and intervention. PNED score was significant in all events except mortality.


Assuntos
Varizes Esofágicas e Gástricas/complicações , Hemorragia Gastrointestinal/etiologia , Adulto , Transfusão de Sangue , Doença Hepática Terminal/etiologia , Doença Hepática Terminal/mortalidade , Endoscopia , Feminino , Hemorragia Gastrointestinal/classificação , Hospitalização , Humanos , Ácido Láctico/sangue , Cirrose Hepática/complicações , Cirrose Hepática/mortalidade , Masculino , Pessoa de Meia-Idade , Curva ROC , Medição de Risco , Adulto Jovem
7.
Am Surg ; 85(10): 1184-1188, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31657321

RESUMO

Guidelines suggest targeting a preoperative international normalized ratio (INR) < 1.5. We examined and compared the predictive value of INR relative to the Model for End-Stage Liver Disease (MELD). We reviewed the American College of Surgeons NSQIP from 2005 to 2016 for adult patients undergoing open or laparoscopic cholecystectomy. Patients with a preoperative INR were stratified into groups: ≤1, >1 to ≤1.5, >1.5 to ≤2, and >2. Thirty day postoperative mortality was the primary outcome. Multivariable logistic regressions controlled for baseline differences. Of 58,177 cholecystectomy patients, 15.2 per cent had INR ≤ 1, 80.4 per cent had INR > 1 to ≤1.5, 3.7 per cent had INR > 1.5 to ≤2, and 0.7 per cent had INR > 2. Patients with INR > 2 were older and more likely to have diabetes and hypertension (P < 0.001). Multivariable regression demonstrated a stepwise increase in mortality for INR > 1 to ≤1.5 (odds ratio (OR) = 1.50 [1.10-2.05]), INR > 1.5 to ≤2 (OR = 2.96 [1.97-4.45]), and INR > 2 (OR = 3.21 [1.64-6.31]) relative to INR ≤ 1. C-statistic for INR (0.910) and MELD (0.906) models indicated a similar value in predicting mortality. INR groups also faced an incremental, increased risk of bleeding. Although unable to track preoperative correction of INR, this analysis identifies that INR remains an excellent predictor of postoperative mortality and bleeding after both open and laparoscopic cholecystectomies and is comparable to MELD.


Assuntos
Colecistectomia/mortalidade , Doença Hepática Terminal/sangue , Doença Hepática Terminal/mortalidade , Coeficiente Internacional Normatizado/mortalidade , Adulto , Fatores Etários , Análise de Variância , Colecistectomia Laparoscópica/mortalidade , Diabetes Mellitus/tratamento farmacológico , Doença Hepática Terminal/diagnóstico , Doença Hepática Terminal/cirurgia , Feminino , Humanos , Hipertensão/tratamento farmacológico , Coeficiente Internacional Normatizado/estatística & dados numéricos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Hemorragia Pós-Operatória/mortalidade , Valor Preditivo dos Testes , Estudos Retrospectivos , Medição de Risco
8.
Transplant Proc ; 51(7): 2413-2415, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31474297

RESUMO

BACKGROUND: Liver transplantation (LT) is an important treatment for acute liver failure and end-stage liver disease. Due to the limited supply of livers, there are still thousands of candidates waiting for transplantation in Turkey. We aimed to analyze LT waiting list access by demographics and etiology, particularly the diagnosis of hepatocellular carcinoma (HCC), which has been prioritized for LT in recent years. MATERIALS AND METHODS: Between 2011 and 2018, all patients listed for LT in our center were retrospectively reviewed. Demographic features, etiology of liver disease, waiting time, Model for End-Stage Liver Disease (MELD) score, and survival data were recorded. Differences between the LT group and deceased patients on the waiting list were evaluated. RESULTS: During this period, 266 patients were included in the LT waiting list. Only 119 patients (44.7%) underwent LT (men, 94; women, 25; mean age, 53 years), whereas 103 (38%) died (men, 60; women, 43; mean age, 53 years) in the waiting period. Seventeen patients were status 1A or 1B and of these, 7 patients died from fulminant hepatic failure. MELD score was significantly higher in deceased group (28 ± 7 vs 25 ± 6; P = .014). The frequency of HCC was significantly higher in LT group (29% vs 11%; P = .002). Overall survival of the patients in the waiting list with and without liver transplantation were 63% and 41%, respectively. CONCLUSIONS: HCC is one of the leading etiologies that is considered for cadaveric LT from the waiting list in our center. These patients had slightly lower MELD scores compared to deceased patients with shorter waiting times. We recommend early referral and close monitoring of the patients who are LT candidates.


Assuntos
Carcinoma Hepatocelular/mortalidade , Doença Hepática Terminal/mortalidade , Neoplasias Hepáticas/mortalidade , Transplante de Fígado/estatística & dados numéricos , Listas de Espera/mortalidade , Adulto , Idoso , Doença Hepática Terminal/cirurgia , Feminino , Humanos , Falência Hepática Aguda/mortalidade , Falência Hepática Aguda/cirurgia , Neoplasias Hepáticas/cirurgia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Índice de Gravidade de Doença , Turquia
9.
Transplant Proc ; 51(7): 2434-2438, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31474298

RESUMO

Owing to impaired immune function, surgical procedures, and multiple hospitalizations, patients with end-stage liver disease are at risk for numerous infectious complications while waiting for transplantation. Infection in transplant recipients remains the main cause of mortality and morbidity, despite advances in surgical techniques and the development of new repressive agents. The purpose of this study is to examine the infections that develop during the pretransplantion period in live donor liver transplant recipients and their effect on post-transplant clinical outcomes. The retrospective analysis of adult live donor liver transplant recipients in the last 4 years was conducted at Ankara University Hospital, a 1900-bed tertiary-care university hospital, in Ankara, Turkey. Demographic characteristics, preoperative infections, and clinical outcomes were analyzed. Patients were divided into 2 groups according to whether they had developed an infection before transplantation. The diagnoses were based on clinical, laboratory, and microbiological findings. Statistical analyses were performed using Stata version 9.0 (StataCorp, College Station, Tex., United States), and P < .05 were considered statistically significant. In univariate analyses, having diabetes mellitus or a pretransplant infection, the number of pretransplant infection attacks, the need for a reoperation, and developing a post-transplant infection were the statistically significant factors associated with 1-year mortality (P < .001, χ2 test). In multivariate analyses, diabetes mellitus (Odds ratio [OR] = 7.44, 95% confidence interval [CI], .03-45.79; P = .013), reoperation (OR = .33, 95% CI, .25-2.20; P < .001), having a pretransplantation infection (OR = 12.47, 95% CI, .011-87.67; P = .013), and the number of pretransplantation infection attacks (OR = .028, 95% CI, .013-.47; P < .001) were found to be statistically significant risk factors for 1-year mortality. Our study showed the effect of pretransplantation infections on post-transplant morbidity but not on rejection or mortality. According to the situation of patients, manageable pretransplantation infection is not an absolute contraindication for liver transplantation. Awareness of the increased risk for post-transplant infections and fast-acting antimicrobial coverage are the most important facts for patient survival.


Assuntos
Doença Hepática Terminal/complicações , Transplante de Fígado/mortalidade , Doadores Vivos , Complicações Pós-Operatórias/mortalidade , Adulto , Contraindicações de Procedimentos , Diabetes Mellitus/epidemiologia , Diabetes Mellitus/etiologia , Diabetes Mellitus/mortalidade , Doença Hepática Terminal/mortalidade , Doença Hepática Terminal/cirurgia , Feminino , Hospitalização , Humanos , Transplante de Fígado/métodos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Período Pré-Operatório , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Turquia , Adulto Jovem
10.
World J Gastroenterol ; 25(28): 3738-3752, 2019 Jul 28.
Artigo em Inglês | MEDLINE | ID: mdl-31391769

RESUMO

This review describes current approaches to the management of patients with cirrhotic ascites in relation to the severity of its clinical manifestations. The PubMed database, the Google Scholar retrieval system, the Cochrane Database of Systematic Reviews, and the reference lists from related articles were used to search for relevant publications. Articles corresponding to the aim of the review were selected for 1991-2018 using the keywords: "liver cirrhosis," "portal hypertension," "ascites," "pathogenesis," "diagnostics," and "treatment." Uncomplicated and refractory ascites in patients with cirrhosis were the inclusion criteria. The literature analysis has shown that despite the achievements of modern hepatology, the presence of ascites is associated with poor prognosis and high mortality. The key to successful management of patients with ascites may be the stratification of the risk of an adverse outcome and personalized therapy. Pathogenetically based approach to the choice of pharmacotherapy and optimization of minimally invasive methods of treatment may improve the quality of life and increase the survival rate of this category of patients.


Assuntos
Ascite/terapia , Doença Hepática Terminal/terapia , Hipertensão Portal/terapia , Cirrose Hepática/terapia , Agonistas de Receptores Adrenérgicos alfa 1/uso terapêutico , Ascite/diagnóstico , Ascite/etiologia , Ascite/mortalidade , Ensaios Clínicos como Assunto , Diuréticos/uso terapêutico , Doença Hepática Terminal/diagnóstico , Doença Hepática Terminal/etiologia , Doença Hepática Terminal/mortalidade , Humanos , Hipertensão Portal/diagnóstico , Hipertensão Portal/etiologia , Hipertensão Portal/mortalidade , Cirrose Hepática/complicações , Cirrose Hepática/diagnóstico , Cirrose Hepática/mortalidade , Transplante de Fígado , Paracentese/instrumentação , Paracentese/métodos , Derivação Portossistêmica Transjugular Intra-Hepática , Prognóstico , Qualidade de Vida , Medição de Risco , Índice de Gravidade de Doença , Taxa de Sobrevida , Resultado do Tratamento
11.
Surgery ; 166(6): 1135-1141, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31375321

RESUMO

BACKGROUND: Patients undergoing complex surgery at safety net hospitals have been shown to suffer inferior short-term outcomes. Liver transplantation, one of the most complex surgical interventions, is offered at certain safety net hospitals. We sought to identify whether patients undergoing liver transplantation at safety net hospitals have inferior outcomes compared with lower burden centers. METHODS: Using a link between the University HealthSystem Consortium and Scientific Registry of Transplant Recipient databases, we identified 11,047 patients undergoing liver transplantation at 63 centers between 2009 and 2012. Hospitals were grouped by safety net burden, defined as the proportion of Medicaid or uninsured patient encounters during that time. The highest quartile (safety net hospitals) was compared to medium- and low-burden hospitals regarding recipient and donor characteristics, perioperative outcomes, and long-term survival. RESULTS: Liver transplantation recipients at safety net hospitals were more often black and of lower socioeconomic status (P < .01), but had similar model for end-stage liver disease scores (20 vs 20 vs 18) compared with median-burden hospitals and low burden hospitals. Length of stay and readmission rates were similar; however, safety net hospitals demonstrated higher in-hospital mortality (5.2% vs 4.5% vs 2.9%, P < .01). Despite this, there was no significant difference in overall patient or graft survivals in patients who underwent liver transplantation at safety net hospitals and survived the perioperative setting at a median follow-up of 2 years (P > .05). CONCLUSION: Despite differences in perioperative outcomes at safety net hospitals, these centers achieve noninferior long-term patient and graft survival for potentially vulnerable patients requiring liver transplantation. Strict care standardization, as achieved in liver transplantation, may be a mechanism by which outcomes can be improved at safety net hospitals after other complex surgical procedures.


Assuntos
Doença Hepática Terminal/cirurgia , Sobrevivência de Enxerto , Hospitais/estatística & dados numéricos , Transplante de Fígado/efeitos adversos , Provedores de Redes de Segurança/estatística & dados numéricos , Adolescente , Adulto , Afro-Americanos/estatística & dados numéricos , Idoso , Doença Hepática Terminal/diagnóstico , Doença Hepática Terminal/mortalidade , Feminino , Seguimentos , Mortalidade Hospitalar , Humanos , Tempo de Internação/estatística & dados numéricos , Transplante de Fígado/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Sistema de Registros/estatística & dados numéricos , Estudos Retrospectivos , Índice de Gravidade de Doença , Classe Social , Resultado do Tratamento , Estados Unidos/epidemiologia , Populações Vulneráveis/estatística & dados numéricos , Adulto Jovem
12.
Transplant Proc ; 51(7): 2430-2433, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31280887

RESUMO

PURPOSE: The aim of this study is to investigate the effects of risk scores (Pediatric End-stage Liver Disease [PELD], Child-Turcotte-Pugh [CTP], and Pediatric Risk of Mortality [PRISM-III]) of pediatric liver transplant patients on the postoperative period. METHOD: Seven cadaveric and 45 living donors, totaling 52 pediatric liver transplantation (LT) patients, were reviewed retrospectively. PELD and CTP scores were calculated based on data at hospital admission. PRISM-III score was calculated from data during the first 24 hours of intensive care unit (ICU) admission. Hospital length of stay (LOS), ICU LOS, patients who developed acute kidney injury (AKI), requirement for inotropic-vasopressor therapy, hospital mortality, long-term mortality, duration of mechanical ventilation, metabolic disease, and demographic features were documented.For CTP score, class C was defined as high, and A and B as low. Cutoff values of PELD and PRISM-III scores were detected by using receiver operating characteristic curves. According to these cutoff values, patients were divided into 2 groups as high and low for each score. Documented data was analyzed and compared in groups for each score. RESULTS: Hospital LOS was significantly longer in the high-PELD (P = .01) and high-CTP (P = .01) groups. ICU LOS was significantly longer in the high-PRISM-III group (P = .01). Requirement for inotropic-vasopressor therapy was significantly higher in the high-PELD (P = .04) and high-CTP (P = .04) groups. CONCLUSION: Hemodynamic instability and long hospital LOS can be expected in pediatric post-LT patients with high PELD or CTP scores; there is also the risk that AKI maybe higher for high-PELD score patients. Unexpectedly, the PRISM-III score did not have any correlation with the severity of physiological condition and mortality.


Assuntos
Doença Hepática Terminal/mortalidade , Transplante de Fígado/mortalidade , Medição de Risco/métodos , Índice de Gravidade de Doença , Lesão Renal Aguda/etiologia , Lesão Renal Aguda/mortalidade , Criança , Doença Hepática Terminal/cirurgia , Feminino , Mortalidade Hospitalar , Humanos , Tempo de Internação/estatística & dados numéricos , Transplante de Fígado/métodos , Masculino , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Período Pós-Operatório , Curva ROC , Valores de Referência , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos , Resultado do Tratamento
13.
Med Sci Monit ; 25: 5005-5014, 2019 Jul 06.
Artigo em Inglês | MEDLINE | ID: mdl-31278890

RESUMO

BACKGROUND Inappropriate use of antibiotics results in antimicrobial resistance and dysbacteriosis. Among critically ill cirrhotic patients, consensus regarding the most optimal prescription strategy for antibiotics use has not been achieved. For these patients, the score for end-stage liver disease (MELD) demonstrated its value in predicting prognosis of cirrhosis. This study investigated use of the MELD score to guide antibiotics choice. MATERIAL AND METHODS We enrolled 1250 patients with cirrhosis. We collected patient information, including antibiotics administration. Linear regression analyses were performed to determine independent predictors of antibiotic administration. Survival curves were constructed based on Cox regression models. Cox proportional hazard models were used to calculate the hazard ratio, shown by forest plots. RESULTS The population was equally stratified into 4 groups based on the MELD score (Q1: MELD <10; Q2: 10≤ MELD <17; Q3: 17≤ MELD <26; Q4: 26≤ MELD). In Q1, all the HR (hazard ratio) related to the duration of antibiotics use demonstrated no statistical significance. In Q2, the HR related to the duration of antibiotics use revealed a successive decrease. In Q3, the HR showed statistical significance only with a duration of antibiotics use of 7 days or more. In Q4, all the HR were statistically significant. As for categories of antibiotics use, whatever the MELD score was, the HR continued to increase with ascending categories. CONCLUSIONS For low MELD score patients (MELD <17), changing the duration of antibiotics use was not associated with a better prognosis. For high MELD score patients (MELD ≥17), longer duration of antibiotics use was associated with a reduction in mortality. Whatever the MELD score was, an increase of number of antibiotic categories was positively associat ed with poor prognosis.


Assuntos
Antibacterianos/uso terapêutico , Estado Terminal , Doença Hepática Terminal/complicações , Doença Hepática Terminal/tratamento farmacológico , Cirrose Hepática/complicações , Modelos Biológicos , Antibacterianos/administração & dosagem , Doença Hepática Terminal/mortalidade , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade
14.
Transplant Proc ; 51(8): 2755-2760, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31345598

RESUMO

BACKGROUND: Although electrocardiography (ECG) is routinely used as a preoperative cardiac assessment tool, impact of ECG-detected myocardial ischemia on postoperative outcomes remains unclear. We aimed to assess use of ECG as a predictor of postoperative mortality in patients undergoing liver transplant (LT). METHODS: Electronic medical records of patients who underwent LT were retrospectively analyzed. The primary end point was postoperative 1-year all-cause mortality. Electrocardiographic myocardial ischemia was diagnosed based on automated ECG interpretation suggesting ischemia or infarction. Cox proportional hazard analysis was performed to identify independent risk factors including Model for End-Stage Liver Disease score, revised cardiac risk index, echocardiographic wall motion abnormalities, and myocardial perfusion scan (MPS) abnormalities. RESULTS: Of the 1430 patients, 78 (5.5%) showed ischemic change on ECG. The 1-year mortality of patients with ischemic change on ECG was significantly higher than that of those without (11.5% vs 4.0%; P = .004). In the Cox proportional hazard model, ischemic change on ECG (hazard ratio [HR], 2.91; 95% CI, 1.43-5.92; P = .003), Model for End-Stage Liver Disease score (HR 1.06; 95% CI 1.04-1.09; P < .001), and revised cardiac risk index (HR, 2.84; 95% CI, 1.86-4.35; P < .001) were independent variables predicting 1-year mortality; however, MPS abnormalities and echocardiographic wall motion abnormalities were not. CONCLUSION: In patients undergoing LT, preoperative ischemic ECG findings should not be overlooked, as they are associated with increased mortality, while abnormalities on MPS and resting ECG are not. Thorough evaluations to detect underlying modifiable coronary artery disease are needed in patients with these findings.


Assuntos
Eletrocardiografia , Doença Hepática Terminal/complicações , Doença Hepática Terminal/cirurgia , Transplante de Fígado/mortalidade , Isquemia Miocárdica/complicações , Idoso , Doença Hepática Terminal/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Isquemia Miocárdica/diagnóstico , Prognóstico , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida
15.
World J Gastroenterol ; 25(26): 3283-3290, 2019 Jul 14.
Artigo em Inglês | MEDLINE | ID: mdl-31341355

RESUMO

Since the 1970s, non-selective beta-blockers (NSBB) have been used to prevent variceal upper bleeding in advanced cirrhotic patients. However, several recent studies have raised the doubt about the benefit of NSBB in end-stage cirrhotic patients. In fact, they suggested a detrimental effect in these patients that even reduced survival. All of these studies have been assembled to compose the "window therapy hypothesis", in which NSBB would have traditional indication to be initiated to prevent variceal upper bleeding; however, treatment should be stopped (or not be initiated) in patients with end-stage cirrhosis. NSBB would reduce the cardiac reserve of these patients, worsening systemic perfusion and prognosis. However, it should be emphasized that these studies present important bias issues, and their results also suggested that diuretic treatment may also be behind the effects observed. In this opinion review, we changed the point of view from NSBB to diuretic treatment, based on a physiopathogenic approach of circulatory parameters of cirrhotic patients studied, and based on diuretic effect in blood pressure lowering and in other hypervolemic disease, as heart failure. We suggest a "diuretic window hypothesis", composed by an open window in hypervolemic phase, an attention window when patient present in a normal plasma volume phase, and a closed window during the plasma hypovolemic phase.


Assuntos
Diuréticos/administração & dosagem , Doença Hepática Terminal/complicações , Varizes Esofágicas e Gástricas/tratamento farmacológico , Hemorragia Gastrointestinal/prevenção & controle , Cirrose Hepática/complicações , Antagonistas Adrenérgicos beta/administração & dosagem , Doença Hepática Terminal/mortalidade , Doença Hepática Terminal/patologia , Varizes Esofágicas e Gástricas/etiologia , Varizes Esofágicas e Gástricas/mortalidade , Medicina Baseada em Evidências/métodos , Gastroenterologia/métodos , Hemorragia Gastrointestinal/etiologia , Hemorragia Gastrointestinal/mortalidade , Humanos , Cirrose Hepática/mortalidade , Cirrose Hepática/patologia , Prognóstico , Análise de Sobrevida , Resultado do Tratamento
16.
World J Gastroenterol ; 25(26): 3426-3437, 2019 Jul 14.
Artigo em Inglês | MEDLINE | ID: mdl-31341366

RESUMO

BACKGROUND: In patients with cirrhosis, hepatic encephalopathy (HE) indicates a poor prognosis despite the use of artificial liver and liver transplantation, presenting as frequent hospitalizations and increased mortality rate. AIM: To determine predictors of early readmission and mid-term mortality in cirrhotic patients discharged after the resolution of HE. METHODS: From January to February 2018, 213 patients were enrolled in this observational study assessing all the successive patients with cirrhosis discharged from Department of Gastroenterology and Department of Infectious and Liver Diseases, Second Affiliated Hospital of Chongqing Medical University after the resolution of HE. The patients were followed for 6 mo. For each subject, demographic, clinical, and laboratory variables were assessed at the time of diagnosis of HE, during hospital stay, at discharge, and during follow-up. The primary endpoints were incidence of early readmission and mid-term mortality. RESULTS: During follow-up, 65 (31%) patients experienced an early readmission. International normalized ratio (INR) [odds ratio (OR) = 2.40; P = 0.003) at discharge independently predicted early readmission. The incidence of early readmission was significantly higher in patients with an INR > 1.62 at discharge than in those with an INR ≤ 1.62 (44% vs 19%; P < 0.001). Model for End-stage Liver Disease (MELD) score (OR = 1.11; P = 0.048) at discharge proved to be an independent predictor of early readmission caused by HE. Hemoglobin (OR = 0.97; P = 0.005) at discharge proved to be an independent predictor of non-early readmission. During 6 months of follow-up, 34 (16%) patients died. Artificial liver use (hazard ratio = 6.67; P = 0.021) during the first hospitalization independently predicted mid-term mortality. CONCLUSION: INR could be applied to identify fragile cirrhotic patients, MELD score could be used to predict early relapse of HE, and anemia is a potential target for preventing early readmission.


Assuntos
Anemia/diagnóstico , Doença Hepática Terminal/mortalidade , Encefalopatia Hepática/mortalidade , Coeficiente Internacional Normatizado , Cirrose Hepática/mortalidade , Idoso , Anemia/sangue , Doença Hepática Terminal/diagnóstico , Doença Hepática Terminal/terapia , Feminino , Seguimentos , Encefalopatia Hepática/sangue , Encefalopatia Hepática/terapia , Humanos , Tempo de Internação/estatística & dados numéricos , Cirrose Hepática/diagnóstico , Cirrose Hepática/terapia , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Recidiva , Fatores de Risco , Índice de Gravidade de Doença
17.
Med Sci Monit ; 25: 4521-4526, 2019 Jun 18.
Artigo em Inglês | MEDLINE | ID: mdl-31209196

RESUMO

BACKGROUND Orthotopic liver transplantation (OLT) is the standard of care for end-stage liver disease. The Charlson Comorbidity Index (CCI) was originally created to assess the survival rate of patients with chronic diseases, although it was modified and adopted in OLT recipients as CCI-OLT. MATERIAL AND METHODS In total of 248 consecutive liver transplant recipients with viral cirrhosis in 98 (39.5%) patients were included. CCI-OLT was calculated assigning a weight of 3 to chronic obstructive pulmonary disease; weight of 2 to coronary artery disease, connective tissue disease, and renal insufficiency; and a weight of 1 to diabetes mellitus. RESULTS CCI-OLT was significantly correlated with recipient age (p<0.001; R=0.333) and was a significant risk factor for early post-transplant mortality (p=0.004). The presence of diabetes mellitus significantly increased the odds of early mortality (p=0.010). The optimal cut-off for CCI-OLT in prediction of mortality during the first 90 days after transplantation was ≥1, with an AUROC of 0.780 (95% CI: 0.670-0.891; p<0.001). Increasing CCI-OLT was a significant risk factor for worse 5-year post-transplant survival (p=0.001), along with coronary artery disease (p=0.008) and diabetes mellitus (p=0.021). The optimal cut-off for prediction of 5-year mortality for CCI-OLT was ≥1, with the AUROC of 0.638 (95% CI: 0.544-0.733; p=0.004). CONCLUSIONS CCI-OLT is a useful tool for measuring the effect of pretransplant comorbidities and to stratify the effect of risk on both short- and long-term outcomes after OLT. Recipient age and diabetes strongly affected short-term survival after OLT, and metabolic and vascular complications were the leading causes of death at 5 years after OLT.


Assuntos
Doença Hepática Terminal/mortalidade , Transplante de Fígado/mortalidade , Adulto , Idoso , Doença Crônica , Comorbidade , Doenças do Tecido Conjuntivo/complicações , Doença das Coronárias/complicações , Diabetes Mellitus , Doença Hepática Terminal/complicações , Feminino , Sobrevivência de Enxerto , Humanos , Cirrose Hepática/complicações , Transplante de Fígado/efeitos adversos , Masculino , Pessoa de Meia-Idade , Polônia , Doença Pulmonar Obstrutiva Crônica , Insuficiência Renal/complicações , Fatores de Risco , Taxa de Sobrevida , Resultado do Tratamento
18.
Rev Bras Anestesiol ; 69(3): 279-283, 2019.
Artigo em Português | MEDLINE | ID: mdl-31072607

RESUMO

BACKGROUND: Liver transplantation is the only curative therapeutic modality available for individuals at end-stage liver disease. There is no reliable method of predicting the early postoperative outcome of these patients. The Acute Physiology and Chronic Health Evaluation (APACHE) is a widely used model for predicting hospital survival and benchmarking in critically ill patients. This study evaluated the calibration and discrimination of APACHE IV in the postoperative period of elective liver transplantation in the southern Brazil. METHODS: This was a clinical prospective and unicentric cohort study that included 371 adult patients in the immediate postoperative period of elective liver transplantation from January 1, 2012 to December 31, 2016. RESULTS: In this study, liver transplant patients who evolved to hospital death had a significantly higher APACHE IV score (82.7±5.1 vs. 51.0±15.8; p<0.001) and higher predicted mortality (6.5% [4.4-20.2%] vs. 2.3% [1.4-3.5%]; p<0.001). The APACHE IV score showed an adequate calibration (Hosmer-Lemeshow - H-L=11.37; p=0.181) and good discrimination (Receiver Operator Curve - ROC of 0.797; Confidence Interval 95% - 95% CI 0.713-0.881; p<0.0001), although Standardized Mortality Ratio (SMR=2.63), (95% CI 1.66-4.27; p<0.001) underestimate mortality. CONCLUSIONS: In summary, the APACHE IV score showed an acceptable performance for predicting a hospital outcome in the postoperative period of elective liver transplant recipients.


Assuntos
APACHE , Doença Hepática Terminal/cirurgia , Transplante de Fígado/métodos , Idoso , Brasil , Calibragem , Estudos de Coortes , Doença Hepática Terminal/mortalidade , Mortalidade Hospitalar , Humanos , Transplante de Fígado/mortalidade , Pessoa de Meia-Idade , Período Pós-Operatório , Estudos Prospectivos
19.
World J Gastroenterol ; 25(15): 1879-1889, 2019 Apr 21.
Artigo em Inglês | MEDLINE | ID: mdl-31057301

RESUMO

BACKGROUND: Due to the significant shortage of organs and the increasing number of candidates on the transplant waiting list, there is an urgent need to identify patients who are most likely to benefit from liver transplantation. The albumin-bilirubin (ALBI) grading system was recently developed to identify patients at risk for adverse outcomes after hepatectomy. However, the value of the pretransplant ALBI score in predicting outcomes after liver transplantation has not been assessed. AIM: To retrospectively investigate the value of the pretransplant ALBI score in predicting outcomes after liver transplantation. METHODS: The clinical data of 272 consecutive adult patients who received donation after cardiac death and underwent liver transplantation at our centre from March 2012 to March 2017 were analysed in the cohort study. After the exclusion of patients who met any of the exclusion criteria, 258 patients remained. The performance of the ALBI score in predicting overall survival and postoperative complications after liver transplantation was evaluated. The optimal cut-off value of preoperative ALBI was calculated according to long-term survival status. The outcomes after liver transplantation, including postoperative complications and survival analysis, were measured. RESULTS: The remaining 258 consecutive patients were included in the analysis. The median follow-up time was 17.30 (interquartile range: 8.90-28.98) mo. Death occurred in 35 patients during follow-up. The overall survival rate was 81.0%. The preoperative ALBI score had a significant positive correlation with the overall survival rate after liver transplantation. The calculated cut-off for ALBI scores to predict postoperative survival was -1.48. Patients with an ALBI score > -1.48 had a significantly lower survival rate than those with an ALBI score ≤ -1.48 (73.7% vs 87.6%, P < 0.05), and there were no statistically significant differences in survival rates between patients with a model for end stage liver disease score ≥ 10 and < 10 and different Child-Pugh grades. In terms of the specific complications, a high ALBI score was associated with an increased incidence of biliary complications, intraabdominal bleeding, septicaemia, and acute kidney injury after liver transplantation (P < 0.05 for all). CONCLUSION: The ALBI score predicts overall survival and postoperative complications after liver transplantation. The ALBI grading system may be useful in risk-stratifying patients on the liver transplant waiting list.


Assuntos
Bilirrubina/sangue , Doença Hepática Terminal/cirurgia , Transplante de Fígado/efeitos adversos , Complicações Pós-Operatórias/diagnóstico , Albumina Sérica/análise , Adulto , Biomarcadores/sangue , Doença Hepática Terminal/sangue , Doença Hepática Terminal/mortalidade , Feminino , Seguimentos , Humanos , Incidência , Testes de Função Hepática/métodos , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Valor Preditivo dos Testes , Período Pré-Operatório , Prognóstico , Estudos Retrospectivos , Medição de Risco/métodos , Taxa de Sobrevida
20.
Turk J Gastroenterol ; 30(6): 532-540, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31144659

RESUMO

BACKGROUND/AIMS: Critically ill patients with cirrhosis with pneumonia are at an increased risk for mortality. Only a few accurate predictive models are existing specific to these patients. The aim of the present study was to compare the existing prognostic models and to develop an improved mortality risk model for patients with cirrhosis and pneumonia. MATERIALS AND METHODS: A total of 231 patients were enrolled in our study (70% training and 30% validation cohorts). All participants were followed up for at least 21 days. Model for End-stage Liver Disease and Pneumonia (MELD-P) was derived by the Cox proportional hazards model. The performances of prognostic scoring systems were compared by calculation of the area under the receiver operating characteristic (AUROC) curve. RESULTS: MELD-P showed better discriminative capabilities than existing scoring systems. Four clinical variables, including loge bilirubin (hazard ratio (HR) 1.29, 95% confidence interval (CI) 1.01-1.73), loge international normalized ratio (HR 3.57, 95% CI 1.30-9.78), loge pulse oxygen saturation/fraction of inspired oxygen (HR 0.38, 95% CI 0.14-0.99), and vasopressors used (HR 3.72, 95% CI 1.85-7.49), were considered as independent prognostic values associated with 21-day mortality. MELD-P had AUROC curve values of 0.78 (95% CI 0.71-0.84) in predicting in-hospital mortality, 0.78 (95% CI 0.70-0.84) at 21-day, 0.88 (95% CI 0.82-0.93) at 14-day, and 0.87 (95% CI 0.81-0.92) at 7-day. A similar result was obtained in validation cohort. CONCLUSION: MELD-P, as the first model specifically designed to evaluate the risk of mortality in critically ill patients with cirrhosis and pneumonia, performs well on the mortality assessment of short-term mortality.


Assuntos
Estado Terminal/mortalidade , Doença Hepática Terminal/mortalidade , Cirrose Hepática/mortalidade , Pneumonia/mortalidade , Medição de Risco/métodos , Adulto , Idoso , Área Sob a Curva , Doença Hepática Terminal/complicações , Feminino , Mortalidade Hospitalar , Humanos , Coeficiente Internacional Normatizado , Estimativa de Kaplan-Meier , Cirrose Hepática/complicações , Masculino , Pessoa de Meia-Idade , Pneumonia/complicações , Prognóstico , Modelos de Riscos Proporcionais , Curva ROC , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença
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