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1.
Cardiovasc Diabetol ; 20(1): 69, 2021 03 23.
Artigo em Inglês | MEDLINE | ID: mdl-33757510

RESUMO

BACKGROUND: During COVID-19 pandemic, elective invasive cardiac procedures (ICP) have been frequently cancelled or postponed. Consequences may be more evident in patients with diabetes. OBJECTIVES: The objective was to identify the peculiarities of patients with DM among those in whom ICP were cancelled or postponed due to the COVID-19 pandemic, as well as to identify subgroups in which the influence of DM has higher impact on the clinical outcome. METHODS: We included 2,158 patients in whom an elective ICP was cancelled or postponed during COVID-19 pandemic in 37 hospitals in Spain. Among them, 700 (32.4%) were diabetics. Patients with and without diabetes were compared. RESULTS: Patients with diabetes were older and had a higher prevalence of other cardiovascular risk factors, previous cardiovascular history and co-morbidities. Diabetics had a higher mortality (3.0% vs. 1.0%; p = 0.001) and cardiovascular mortality (1.9% vs. 0.4%; p = 0.001). Differences were especially important in patients with valvular heart disease (mortality 6.9% vs 1.7% [p < 0.001] and cardiovascular mortality 4.9% vs 0.9% [p = 0.002] in patients with and without diabetes, respectively). In the multivariable analysis, diabetes remained as an independent risk factor both for overall and cardiovascular mortality. No significant interaction was found with other clinical variables. CONCLUSION: Among patients in whom an elective invasive cardiac procedure is cancelled or postponed during COVID-19 pandemic, mortality and cardiovascular mortality is higher in patients with diabetes, irrespectively on other clinical conditions. These procedures should not be cancelled in patients with diabetes.


Assuntos
Angiografia Coronária , Diabetes Mellitus , Cardiopatias/diagnóstico por imagem , Cardiopatias/terapia , Intervenção Coronária Percutânea , Tempo para o Tratamento , Listas de Espera , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Bases de Dados Factuais , Diabetes Mellitus/diagnóstico , Diabetes Mellitus/mortalidade , Feminino , Cardiopatias/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Medição de Risco , Fatores de Risco , Espanha/epidemiologia , Fatores de Tempo , Listas de Espera/mortalidade
2.
Transplantation ; 105(4): 861-866, 2021 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-33760792

RESUMO

BACKGROUND: Regional variation in lung transplantation practices due to local coronavirus disease 2019 (COVID-19) prevalence may cause geographic disparities in access to lung transplantation. METHODS: Using the United Network for Organ Sharing registry, we conducted a descriptive analysis of lung transplant volume, donor lung volume, new waitlist activations, and waiting list deaths at high-volume lung transplant centers during the first 3 months of the pandemic (March 1. 2020, to May 30, 2020) and we compared it to the same period in the preceding 5 years. RESULTS: Lung transplant volume decreased by 10% nationally and by a median of 50% in high COVID-19 prevalence centers (range -87% to 80%) compared with a median increase of 10% (range -87% to 80%) in low prevalence centers (P-for-trend 0.006). Donation services areas with high COVID-19 prevalence experienced a greater decrease in organ availability (-28% range, -72% to -11%) compared with low prevalence areas (+7%, range -20% to + 55%, P-for-trend 0.001). Waiting list activations decreased at 18 of 22 centers. Waiting list deaths were similar to the preceding 5 years and independent of local COVID-19 prevalence (P-for-trend 0.36). CONCLUSIONS: Regional variation in transplantation and donor availability in the early months of the pandemic varied by local COVID-19 activity.


Assuntos
/epidemiologia , Transplante de Pulmão , Pandemias , Obtenção de Tecidos e Órgãos , Adulto , Idoso , Estudos de Coortes , Feminino , Humanos , Transplante de Pulmão/estatística & dados numéricos , Transplante de Pulmão/tendências , Masculino , Pessoa de Meia-Idade , Prevalência , Sistema de Registros/estatística & dados numéricos , Estudos Retrospectivos , Doadores de Tecidos/estatística & dados numéricos , Doadores de Tecidos/provisão & distribução , Obtenção de Tecidos e Órgãos/estatística & dados numéricos , Obtenção de Tecidos e Órgãos/tendências , Estados Unidos/epidemiologia , Listas de Espera/mortalidade , Adulto Jovem
3.
Pediatr Nephrol ; 36(1): 143-151, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32980942

RESUMO

BACKGROUND: In March 2020, COVID-19 infections began to rise exponentially in the USA, placing substantial burden on the healthcare system. As a result, there was a rapid change in transplant practices and policies, with cessation of most procedures. Our goal was to understand changes to pediatric kidney transplantation (KT) at the national level during the COVID-19 epidemic. METHODS: Using SRTR data, we examined changes in pediatric waitlist registration, waitlist removal or inactivation, and deceased donor and living donor (DDKT/LDKT) events during the start of the disease transmission in the USA compared with the same time the previous year. RESULTS: We saw an initial decrease in DDKT and LDKT by 47% and 82% compared with expected events and then a continual increase, with numbers reaching expected prepandemic levels by May 2020. In the early phase of the pandemic, waitlist inactivation and removals due to death or deteriorating condition rose above expected values by 152% and 189%, respectively. There was a statistically significant decrease in new waitlist additions (IRR 0.49 0.65 0.85) and LDKT (IRR 0.17 0.38 0.84) in states with high vs. low COVID activity. Transplant recipients during the pandemic were more likely to have received a DDKT, but had similar calculated panel-reactive antibody (cPRA) values, waitlist time, and cause of kidney failure as before the pandemic. CONCLUSIONS: The COVID-19 pandemic initially reduced access to kidney transplantation among pediatric patients in the USA but has not had a sustained effect.


Assuntos
Transplante de Rim/estatística & dados numéricos , Doadores Vivos/estatística & dados numéricos , Listas de Espera/mortalidade , Adolescente , Adulto , Criança , Pré-Escolar , Feminino , Acesso aos Serviços de Saúde/estatística & dados numéricos , Humanos , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Pandemias , Sistema de Registros , Estados Unidos/epidemiologia , Adulto Jovem
4.
PLoS One ; 15(12): e0244744, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33382811

RESUMO

BACKGROUND AND OBJECTIVES: Hispanics are the fastest growing population in the USA, and our objective was to determine their waitlist mortality rates, liver transplantation (LT) rates and post-LT outcomes. METHODS: All adults listed for LT with the UNOS from 2002 to 2018 were included. Competing risk analysis was performed to assess the association between ethnic group with waitlist removal due to death/deterioration and transplantation. For sensitivity analysis, Hispanics were matched 1:1 to Non-Hispanics using propensity scores, and outcomes of interest were compared in matched cohort. RESULTS: During this period, total of 154,818 patients who listed for liver transplant were involved in this study, of them 23,223 (15%) were Hispanics, 109,653 (71%) were Whites, 13,020 (8%) were Blacks, 6,980 (5%) were Asians and 1,942 (1%) were others. After adjusting for differences in clinical characteristics, compared to Whites, Hispanics had higher waitlist removal due to death or deterioration (adjusted cause-specific Hazard Ratio: 1.034, p = 0.01) and lower transplantation rates (adjusted cause-specific Hazard Ratio: 0.90, p<0.001). If Hispanics received liver transplant, they had better patient and graft survival than Non-Hispanics (p<0.001). Compared to Whites, adjusted hazard ratio for Hispanics were 0.88 (95% CI 0.84, 0.92, p<0.001) for patient survival and 0.90 (95% CI 0.86, 0.94, p<0.001) for graft survival. Our analysis in matched cohort showed the consistent results. CONCLUSIONS: This study showed that Hispanics had higher probability to be removed from the waitlist due to death, and lower probability to be transplanted, however they had better post-LT outcomes when compared to whites.


Assuntos
Doença Hepática Terminal/cirurgia , Sobrevivência de Enxerto , Transplante de Fígado/mortalidade , Listas de Espera/mortalidade , Adulto , Idoso , Doença Hepática Terminal/mortalidade , Feminino , Disparidades em Assistência à Saúde , Hispano-Americanos , Humanos , Transplante de Fígado/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Taxa de Sobrevida
5.
Medicine (Baltimore) ; 99(44): e22419, 2020 Oct 30.
Artigo em Inglês | MEDLINE | ID: mdl-33126299

RESUMO

Acute on chronic liver failure (ACLF) is a dynamic syndrome, but frequently associated with a high 1 month mortality rate. This is the first study applying the new European Association for the Study of the Liver- chronic liver failure consortium criteria to explore mortality on the waiting list (WL) and early after liver transplantation (LT) in a cohort of Romanian cirrhotic patients that improved or recovered after an episode of ACLF.To assess frequency and waitlist mortality for different grades of ACLF.An observational study was conducted; 257 patients with liver cirrhosis included on the WL between 2015 and 2017 were analyzed. The cumulative incidence of waitlist mortality or removal was calculated for combination of competing events using multivariable competing risks regression.ACLF-1 occurred in 12.07%, ACLF-2 in 7.39% and ACLF-3 in 8.56% of patients. Median Model for End Stage Liver Diseases (MELD) score at the moment of ACLF was 29. The main event while on the WL was death, followed by ACLF; patients with ACLF-3 had a significantly greater subhazard ratio for mortality of 2.25 (1.55-3.26) compared to patients with ACLF-1 or 2. LT proved to be associated with a significantly lower risk of death on the WL at 6 months after inclusion. One and 12 months post-transplant survival of patients with or without ACLF was similar (P = .77).Occurrence of an ACLF episode while on the WL is associated with a significantly high mortality rate, as well as MELD score at inclusion on the WL, renal and liver failure, presence of hepatic encephalopathy. Overall patient short and long term survival after LT is similar to non-ACLF patients in good selected cases.


Assuntos
Insuficiência Hepática Crônica Agudizada/mortalidade , Cirrose Hepática/mortalidade , Transplante de Fígado/mortalidade , Listas de Espera/mortalidade , Insuficiência Hepática Crônica Agudizada/etiologia , Insuficiência Hepática Crônica Agudizada/cirurgia , Adulto , Estudos de Coortes , Feminino , Humanos , Incidência , Cirrose Hepática/complicações , Cirrose Hepática/cirurgia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Índice de Gravidade de Doença , Resultado do Tratamento
6.
Transplantation ; 104(8): 1612-1618, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32732838

RESUMO

BACKGROUND: Steatotic donor livers (SDLs, ≥30% macrosteatosis on biopsy) are often declined, as they are associated with a higher risk of graft loss, even though candidates may wait an indefinite time for a subsequent organ offer. We sought to quantify outcomes for transplant candidates who declined or accepted an SDL offer. METHODS: We used Scientific Registry of Transplant Recipients offer data from 2009 to 2015 to compare outcomes of 759 candidates who accepted an SDL to 13 362 matched controls who declined and followed candidates from the date of decision (decline or accept) until death or end of study period. We used a competing risk framework to understand the natural history of candidates who declined and Cox regression to compare postdecision survival after declining versus accepting (ie, what could have happened if candidates who declined had instead accepted). RESULTS: Among those who declined an SDL, only 53.1% of candidates were subsequently transplanted, 23.8% died, and 19.4% were removed from the waitlist. Candidates who accepted had a brief perioperative risk period within the first month posttransplant (adjusted hazard ratio [aHR]: 2.493.494.89, P < 0.001), but a 62% lower mortality risk (aHR: 0.310.380.46, P < 0.001) beyond this. Although the long-term survival benefit of acceptance did not vary by candidate model for end-stage liver disease (MELD), the short-term risk period did. MELD 6-21 candidates who accepted an SDL had a 7.88-fold higher mortality risk (aHR: 4.807.8812.93, P < 0.001) in the first month posttransplant, whereas MELD 35-40 candidates had a 68% lower mortality risk (aHR: 0.110.320.90, P = 0.03). CONCLUSIONS: Appropriately selected SDLs can decrease wait time and provide substantial long-term survival benefit for liver transplant candidates.


Assuntos
Seleção do Doador/estatística & dados numéricos , Doença Hepática Terminal/cirurgia , Fígado Gorduroso/patologia , Transplante de Fígado/métodos , Transplantados/estatística & dados numéricos , Idoso , Aloenxertos/patologia , Aloenxertos/provisão & distribução , Biópsia , Tomada de Decisões , Doença Hepática Terminal/mortalidade , Fígado Gorduroso/diagnóstico , Feminino , Seguimentos , Humanos , Fígado/patologia , Transplante de Fígado/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Período Perioperatório/mortalidade , Período Perioperatório/estatística & dados numéricos , Sistema de Registros/estatística & dados numéricos , Medição de Risco/estatística & dados numéricos , Fatores de Risco , Índice de Gravidade de Doença , Análise de Sobrevida , Transplantados/psicologia , Resultado do Tratamento , Estados Unidos/epidemiologia , Listas de Espera/mortalidade
7.
Transplantation ; 104(8): 1627-1632, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32732840

RESUMO

BACKGROUND: In December 2018, United Network for Organ Sharing approved an allocation scheme based on recipients' geographic distance from a deceased donor (acuity circles [ACs]). Previous analyses suggested that ACs would reduce waitlist mortality overall, but their impact on pediatric subgroups was not considered. METHODS: We applied Scientific Registry of Transplant Recipients data from 2011 to 2016 toward the Liver Simulated Allocation Model to compare outcomes by age and illness severity for the United Network for Organ Sharing-approved AC and the existing donor service area-/region-based allocation schemes. Means from each allocation scheme were compared using matched-pairs t tests. RESULTS: During a 3-year period, AC allocation is projected to decrease waitlist deaths in infants (39 versus 55; P < 0.001), children (32 versus 50; P < 0.001), and teenagers (15 versus 25; P < 0.001). AC allocation would increase the number of transplants in infants (707 versus 560; P < 0.001), children (677 versus 547; P < 0.001), and teenagers (404 versus 248; P < 0.001). AC allocation led to decreased median pediatric end-stage liver disease/model for end-stage liver disease at transplant for infants (29 versus 30; P = 0.01), children (26 versus 29; P < 0.001), and teenagers (26 versus 31; P < 0.001). Additionally, AC allocation would lead to fewer transplants in status 1B in children (97 versus 103; P = 0.006) but not infants or teenagers. With AC allocation, 77% of pediatric donor organs would be allocated to pediatric candidates, compared to only 46% in donor service area-/region-based allocation (P < 0.001). CONCLUSIONS: AC allocation will likely address disparities for pediatric liver transplant candidates and recipients by increasing transplants and decreasing waitlist mortality. It is more consistent with federally mandated requirements for organ allocation.


Assuntos
Doença Hepática Terminal/cirurgia , Acesso aos Serviços de Saúde/organização & administração , Transplante de Fígado/métodos , Modelos Organizacionais , Alocação de Recursos/organização & administração , Índice de Gravidade de Doença , Adolescente , Adulto , Fatores Etários , Aloenxertos/provisão & distribução , Criança , Simulação por Computador , Doença Hepática Terminal/diagnóstico , Doença Hepática Terminal/mortalidade , Feminino , Acesso aos Serviços de Saúde/normas , Acesso aos Serviços de Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/normas , Disparidades em Assistência à Saúde/estatística & dados numéricos , Humanos , Lactente , Transplante de Fígado/estatística & dados numéricos , Masculino , Sistema de Registros/estatística & dados numéricos , Alocação de Recursos/normas , Alocação de Recursos/estatística & dados numéricos , Análise de Sobrevida , Transplantados/estatística & dados numéricos , Resultado do Tratamento , Estados Unidos/epidemiologia , Listas de Espera/mortalidade
8.
Transplantation ; 104(8): 1654-1661, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32732844

RESUMO

BACKGROUND: In the United Kingdom, 1 in 3 patients on the National Kidney Transplant Waiting List (NKTWL) is suspended from the list at least once during their wait. The mortality of this large cohort of patients remains underreported and poorly described. METHODS: We linked patient records from the UK transplant registry to mortality data from the Office of National Statistics and evaluated the impact of a clinically induced suspension event by estimating hazard ratios (HRs) that compared mortality and graft survival between those who had experienced a suspension event and those who had not. RESULTS: Between January 1, 2000, and December 31, 2010, 16.7% (2221/13 322) of all patients registered on the NKTWL were suspended. Forty-eight percent (588/1225) of those who were suspended and who were never transplanted died, most often from cardiothoracic causes. A suspension event was associated with increased mortality from the time of listing (adjusted HR [aHR], 1.79; 1.64-1.95) and from the time of transplantation (aHR, 1.20; 1.06-1.37; P = 0.005). Graft survival was also poorer in those who had been suspended (aHR, 1.13; 1.01-1.28; P = 0.04). CONCLUSIONS: Patients suspended on the NKTWL have a significantly higher rate of mortality both on the waiting list and following transplantation. Earlier prioritization of patients at risk of experiencing a suspension event may improve their outcomes.


Assuntos
Rejeição de Enxerto/epidemiologia , Falência Renal Crônica/cirurgia , Transplante de Rim/efeitos adversos , Seleção de Pacientes , Listas de Espera/mortalidade , Adolescente , Adulto , Idoso , Feminino , Seguimentos , Rejeição de Enxerto/etiologia , Humanos , Estimativa de Kaplan-Meier , Falência Renal Crônica/mortalidade , Transplante de Rim/normas , Transplante de Rim/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Sistema de Registros/estatística & dados numéricos , Alocação de Recursos/normas , Alocação de Recursos/estatística & dados numéricos , Medição de Risco/estatística & dados numéricos , Fatores de Risco , Resultado do Tratamento , Reino Unido/epidemiologia , Adulto Jovem
9.
Transplantation ; 104(8): 1738-1745, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32732854

RESUMO

BACKGROUND: Falls occur in 28% of hemodialysis patients and increase the risk of physical impairment, morbidity, and mortality. Therefore, it is likely that kidney transplantation (KT) candidates with recurrent falls are less likely to access KT and more likely to experience adverse post-KT outcomes. METHODS: We used a 2-center cohort study of KT candidates (n = 3666) and recipients (n = 770) (January 2009 to January 2018). Among candidates, we estimated time to listing, waitlist mortality, and transplant rate by recurrent falls (≥2 falls) before evaluation using adjusted regression. Among KT recipients, we estimated risk of mortality, graft loss, and length of stay by recurrent falls before KT using adjusted regression. RESULTS: Candidates with recurrent falls (6.5%) had a lower chance of listing (adjusted hazard ratio [aHR] = 0.68, 95% confidence interval [CI], 0.56-0.83) but not transplant rate; waitlist mortality was 31-fold (95% CI, 11.33-85.93) higher in the first year and gradually decreased over time. Recipients with recurrent falls (5.1%) were at increased risk of mortality (aHR = 51.43, 95% CI, 16.00-165.43) and graft loss (aHR = 33.57, 95% CI, 11.25-100.21) in the first year, which declined over time, and a longer length of stay (adjusted relative ratio [aRR] = 1.13, 95% CI, 1.03-1.25). In summary, 6.5% of KT candidates and 5.1% of recipients experienced recurrent falls which were associated with adverse pre- and post-KT outcomes. CONCLUSIONS: While recurrent falls were relatively rare in KT candidates and recipients, they were associated with adverse outcomes. Transplant centers should consider employing fall prevention strategies for high-risk candidates as part of comprehensive prehabilitation.


Assuntos
Acidentes por Quedas/estatística & dados numéricos , Rejeição de Enxerto/epidemiologia , Falência Renal Crônica/cirurgia , Transplante de Rim/efeitos adversos , Acidentes por Quedas/prevenção & controle , Adulto , Idoso , Feminino , Seguimentos , Rejeição de Enxerto/etiologia , Rejeição de Enxerto/prevenção & controle , Sobrevivência de Enxerto , Humanos , Falência Renal Crônica/complicações , Falência Renal Crônica/mortalidade , Transplante de Rim/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Cuidados Pré-Operatórios/métodos , Estudos Prospectivos , Recidiva , Medição de Risco/estatística & dados numéricos , Fatores de Risco , Transplantados/estatística & dados numéricos , Resultado do Tratamento , Listas de Espera/mortalidade
10.
Transplantation ; 104(8): 1746-1751, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32732855

RESUMO

BACKGROUND: The impact of renal transplantation (RT) in the elderly with many comorbid conditions is a matter of concern. The aim of our study was to assess the impact of RT on the survival of patients older than 60 years compared with those remaining on the waiting list (WL) according to their comorbidities. METHODS: In this multicentric observational retrospective cohort study, we included all patients older than 60 years old admitted on the WL from 01 January 2006 to 31 December 2016. The Charlson comorbidity index (CCI) score was calculated for each patient at inclusion on the WL. Kidney donor risk index was used to assess donor characteristics. RESULTS: One thousand and thirty-six patients were included on the WL of which 371 (36%) received an RT during a median follow-up period of 2.5 (1.4-4.1) years. Patient survival was higher after RT compared to patients remaining on the WL, 87%, 80%, and 72% versus 87%, 55%, and 30% at 1, 3, and 5 years, respectively. After RT survival at 5 years was 37% higher for patients with CCI ≥ 3, and 46% higher in those with CCI < 3, compared with patients remaining on the WL. On univariate and multivariate analysis, patient survival was independently associated with a CCI of ≥3 (hazard ratio 1.62; confidence interval 1.09-2.41; P < 0.02) and the use of calcineurin-based therapy maintenance therapy (hazard ratio 0.53; confidence interval 0.34-0.82; P < 0.004). CONCLUSIONS: Our study showed that RT improved survival in patients older than 60 years even those with high comorbidities. The survival after transplantation was also affected by comorbidities.


Assuntos
Falência Renal Crônica/terapia , Transplante de Rim/estatística & dados numéricos , Diálise Renal/estatística & dados numéricos , Adulto , Fatores Etários , Idoso , Argentina/epidemiologia , Causas de Morte , Comorbidade , Feminino , Seguimentos , Humanos , Falência Renal Crônica/mortalidade , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Análise de Sobrevida , Resultado do Tratamento , Listas de Espera/mortalidade
11.
Transplant Proc ; 52(9): 2631-2636, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32723520

RESUMO

INTRODUCTION: Solid organ transplantation is challenging for waitlist patients during the coronavirus disease 2019 (COVID-19) pandemic. AIM: This study investigates COVID-19 incidence and mortality in patients transplanted in the North Italy Transplant program (NITp) during the outbreak. MATERIALS AND METHODS: All consecutive patients transplanted from February 20 to April 3, 2020 (6 weeks), were included in our cohort and were observed for at least 4 weeks. Survival analyses were performed. RESULTS: In this study, 124 patients were transplanted with 12 (9.7%) hearts, 4 (3.2%) lungs, 39 (31.4%) livers, 67 (54%) kidneys, and 2 (1.6%) combined kidney-pancreas. Recipients' mean age was 51 years (standard deviation [SD] ± 16.6), and 76 of 124 (61%) were men. Five (4%) patients developed COVID-19 after a mean of 13 days (SD ± 6.7), with a cumulative incidence of 4.0% (95% confidence interval [CI], 0.5-7.5). During the follow-up period, 5 of 124 (4%) recipients died; overall mortality was 4.3% (95% CI, 0.6-8.0), with only 1 patient dying of COVID-19, for a COVID-19-related mortality of 0.8% (95% CI, 0-6.0). CONCLUSIONS: This study showed a low COVID-19 incidence and COVID-19-related mortality in patients transplanted during the COVID-19 pandemic. Further studies with a longer follow-up period are mandatory to confirm the safety of transplant procedures.


Assuntos
Betacoronavirus , Infecções por Coronavirus/mortalidade , Transplante de Órgãos/mortalidade , Pneumonia Viral/mortalidade , Complicações Pós-Operatórias/mortalidade , Adulto , Estudos de Coortes , Feminino , Humanos , Incidência , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Pandemias , Complicações Pós-Operatórias/virologia , Análise de Sobrevida , Listas de Espera/mortalidade
13.
Transplantation ; 104(7): e199-e207, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32569004

RESUMO

BACKGROUND: Health disparities plague our healthcare system. Utilizing a novel approach, we sought to assess the effects of geographic disparities on access to lung transplantation (LT) in the United States. METHODS: A total of 13 743 LT adult recipients in the United Network for Organ Sharing Database were identified between May 2005 and December 2014 with a zip code status. Geographic access was defined by global spherical distance from patient zip code centroid to transplant center. Measures analyzed included the association among socioeconomic status (SES), distance to a transplant center, and center switching behavior. RESULTS: Median distance traveled was 62.9 miles. There was an inverse relationship between Diez Roux SES and median distance traveled (90 versus 80.1 versus 60.5 versus 30, P < 0.001). There was no association found between 5-y survival and distance traveled (P = 0.099). However, traveling >158.7 miles was associated with worse survival (hazard ration 1.1; 95% confidence interval, 1.0-1.2; P = 0.005). Over 80% of patients exhibiting center switching were transplanted at a high-volume center than their home institution. Those more likely to switch to a high-volume center were those with an associates/bachelor (P < 0.005) or graduate-level degree (P < 0.05). Recipients with high-volume home institutions had the lowest probability of switching to an alternative center (odds ratio, 0.009; P < 0.001). There was no difference in survival when comparing those transplanted at their home institution versus those who sought transplantation at an alternative institution (55.3% versus 55.0%, P = 0.41). CONCLUSIONS: Although there was no association among SES, distance traveled, and survival, access to LT services varies among populations in the United States.


Assuntos
Acesso aos Serviços de Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/estatística & dados numéricos , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Transplante de Pulmão/estatística & dados numéricos , Doença Pulmonar Obstrutiva Crônica/cirurgia , Adulto , Idoso , Feminino , Geografia , Humanos , Masculino , Pessoa de Meia-Idade , Doença Pulmonar Obstrutiva Crônica/mortalidade , Estudos Retrospectivos , Classe Social , Viagem/estatística & dados numéricos , Estados Unidos/epidemiologia , Listas de Espera/mortalidade
14.
J Surg Res ; 255: 277-284, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32570131

RESUMO

BACKGROUND: The new heart transplant allocation criteria prioritize inpatients who require temporary mechanical circulatory support and give lower urgency to candidates on a durable left ventricular assist device (LVAD) who require a device exchange. This study explores whether the latter group should warrant higher priority to reduce wait-list mortality. METHODS: This is a retrospective observational study of 13,113 adult heart transplant candidates in the Organ Procurement and Transplantation Network database who underwent LVAD implantation between 2007 and 2017. It evaluates the impact of LVAD exchange on the composite endpoint of death or removal from the wait list owing to worsening medical condition 1 y after device implantation. RESULTS: There were 1085 pump exchanges in 954 patients (7% of candidates), of which 22% were women. The pump exchange rate was 5.92 events per 100 patient-years. One-year survival was lower for those who required a pump exchange (76.3% versus 88.5%, logrank P < 0.001). This was congruent with the risk-adjusted mortality 1-y after implantation (hazards ratio: 2.56, 95% confidence interval: 2.18-3.00, P < 0.001). CONCLUSIONS: These findings indicate that among candidates awaiting heart transplantation with a durable LVAD, undergoing pump exchange doubles the risk of 1-y mortality. Giving priority to these candidates may reduce wait-list mortality.


Assuntos
Transplante de Coração , Coração Auxiliar/estatística & dados numéricos , Listas de Espera/mortalidade , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados Unidos
15.
Can J Cardiol ; 36(8): 1308-1312, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32447059

RESUMO

In Ontario on March 16, 2020, a directive was issued to all acute care hospitals to halt nonessential procedures in anticipation of a potential surge in COVID-19 patients. This included scheduled outpatient cardiac surgical and interventional procedures that required the use of intensive care units, ventilators, and skilled critical care personnel, given that these procedures would draw from the same pool of resources required for critically ill COVID-19 patients. We adapted the COVID-19 Resource Estimator (CORE) decision analytic model by adding a cardiac component to determine the impact of various policy decisions on the incremental waitlist growth and estimated waitlist mortality for 3 key groups of cardiovascular disease patients: coronary artery disease, valvular heart disease, and arrhythmias. We provided predictions based on COVID-19 epidemiology available in real-time, in 3 phases. First, in the initial crisis phase, in a worst case scenario, we showed that the potential number of waitlist related cardiac deaths would be orders of magnitude less than those who would die of COVID-19 if critical cardiac care resources were diverted to the care of COVID-19 patients. Second, with better local epidemiology data, we predicted that across 5 regions of Ontario, there may be insufficient resources to resume all elective outpatient cardiac procedures. Finally in the recovery phase, we showed that the estimated incremental growth in waitlist for all cardiac procedures is likely substantial. These outputs informed timely data-driven decisions during the COVID-19 pandemic regarding the provision of cardiovascular care.


Assuntos
Assistência Ambulatorial , Serviço Hospitalar de Cardiologia , Doenças Cardiovasculares , Infecções por Coronavirus , Alocação de Recursos para a Atenção à Saúde/métodos , Pandemias , Pneumonia Viral , Assistência Ambulatorial/organização & administração , Assistência Ambulatorial/tendências , Betacoronavirus , Serviço Hospitalar de Cardiologia/organização & administração , Serviço Hospitalar de Cardiologia/tendências , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/terapia , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/prevenção & controle , Técnicas de Apoio para a Decisão , Humanos , Ontário/epidemiologia , Inovação Organizacional , Pandemias/prevenção & controle , Pneumonia Viral/epidemiologia , Pneumonia Viral/prevenção & controle , Formulação de Políticas , Listas de Espera/mortalidade
16.
J Hepatol ; 73(4): 873-881, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32454041

RESUMO

BACKGROUND & AIMS: The outbreak of COVID-19 has vastly increased the operational burden on healthcare systems worldwide. For patients with end-stage liver failure, liver transplantation is the only option. However, the strain on intensive care facilities caused by the pandemic is a major concern. There is an urgent need for ethical frameworks to balance the need for liver transplantation against the availability of national resources. METHODS: We performed an international multicenter study of transplant centers to understand the evolution of policies for transplant prioritization in response to the pandemic in March 2020. To describe the ethical tension arising in this setting, we propose a novel ethical framework, the quadripartite equipoise (QE) score, that is applicable to liver transplantation in the context of limited national resources. RESULTS: Seventeen large- and medium-sized liver transplant centers from 12 countries across 4 continents participated. Ten centers opted to limit transplant activity in response to the pandemic, favoring a "sickest-first" approach. Conversely, some larger centers opted to continue routine transplant activity in order to balance waiting list mortality. To model these and other ethical tensions, we computed a QE score using 4 factors - recipient outcome, donor/graft safety, waiting list mortality and healthcare resources - for 7 countries. The fluctuation of the QE score over time accurately reflects the dynamic changes in the ethical tensions surrounding transplant activity in a pandemic. CONCLUSIONS: This four-dimensional model of quadripartite equipoise addresses the ethical tensions in the current pandemic. It serves as a universally applicable framework to guide regulation of transplant activity in response to the increasing burden on healthcare systems. LAY SUMMARY: There is an urgent need for ethical frameworks to balance the need for liver transplantation against the availability of national resources during the COVID-19 pandemic. We describe a four-dimensional model of quadripartite equipoise that models these ethical tensions and can guide the regulation of transplant activity in response to the increasing burden on healthcare systems.


Assuntos
Infecções por Coronavirus/epidemiologia , Doença Hepática Terminal , Recursos em Saúde/tendências , Transplante de Fígado , Pandemias , Pneumonia Viral/epidemiologia , Obtenção de Tecidos e Órgãos , Betacoronavirus , Doença Hepática Terminal/mortalidade , Doença Hepática Terminal/cirurgia , Humanos , Cooperação Internacional , Transplante de Fígado/ética , Transplante de Fígado/métodos , Inovação Organizacional , Pandemias/ética , Pandemias/prevenção & controle , Seleção de Pacientes/ética , Inquéritos e Questionários , Obtenção de Tecidos e Órgãos/ética , Obtenção de Tecidos e Órgãos/organização & administração , Obtenção de Tecidos e Órgãos/tendências , Listas de Espera/mortalidade
17.
Acta Orthop ; 91(4): 396-400, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32326789

RESUMO

Background and purpose - Waiting time to surgery for patients with hip fractures and its potential association with mortality has been frequently studied with the hypothesis that longer waiting time is associated with adverse outcomes. However, despite numerous studies, there is no consensus regarding which time frames are appropriate, and whether some patients are more vulnerable to waiting than others. We explored the association between waiting time to surgery and short-term mortality and whether sex, age, surgical method, and comorbidity (ASA) modified this association.Patients and methods - This is a nationwide cohort study of 59,675 patients undergoing hip fracture surgery between January 1, 2013 and December 31, 2017 with a 4-month follow-up of mortality. Data were extracted from the Swedish Registry for Hip Fracture Patients and Treatment (RIKSHÖFT) and mortality was obtained from Statistics Sweden.Results - Unadjusted analyses revealed an association between waiting more than 24 hours for surgery and increased mortality, primarily for women. However, when stratifying for ASA grade, an association persisted only among patients with ASA 3 and 4. Furthermore, the absolute differences in mortality risk between those waiting less or longer than 24 hours were small. Age, fracture type, and surgical method did not modify the association between waiting time and mortality.Interpretation - This study suggests that there may be a need for new guidelines, which take into account the heterogeneity of the patient population.


Assuntos
Fraturas do Quadril/cirurgia , Listas de Espera/mortalidade , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Fraturas do Quadril/mortalidade , Humanos , Masculino , Modelos de Riscos Proporcionais , Suécia/epidemiologia , Fatores de Tempo
19.
Ann Thorac Surg ; 110(2): 414-423, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32251655

RESUMO

BACKGROUND: Sensitized candidates with unacceptable antigens are a group that demands special attention in organ transplantation. Calculated panel reactive antigen (cPRA) is not used to modify allocation priorities in lung transplantation. The impact of cPRA on waiting list time and mortality is unknown. METHODS: We performed a retrospective review of candidates for lung transplantation listed from May 2005 to 2018. Data from the Organ Procurement and Transplantation Network/United Network for Organ Sharing STAR (Standard Analysis and Research) dataset was paired with additional unacceptable human leukocyte antigen (UA-HLA) data, which were used to calculate the listing cPRA. Candidates were stratified based on the lack of UA-HLAs or cPRA level for candidates with unacceptable antigens reported. Unadjusted competing risks and adjusted subdistribution hazard models were fit. RESULTS: A total of 29,085 candidates met inclusion criteria for analysis. Of these, 23,562 (81%) with no UA-HLAs, 3472 (11.9%) with a cPRA less than 50, and 2051 with a cPRA greater than or equal to 50 (7.1%). On adjusted analysis, a cPRA greater than or equal to 50 was independently associated with increased waitlist mortality at 1 year (hazard ratio, 1.71; 95% confidence interval, 1.55-1.88; P < .001) and decreased rate of transplantation (71.9% vs 69.5% vs 44.4%; P < .001). Furthermore, patients with a cPRA greater than or equal to 50 had a longer waitlist time compared with a cPRA less than 50 and no UA-HLA candidates (mean 293.69 days vs 162.38 days and 143.26 days, respectively; P < .001). However, once transplanted, posttransplant survival among the cohorts was similar. CONCLUSIONS: Further evaluation of organ allocation with consideration of a candidate's cPRA may be warranted in order to optimize equity in access to transplants.


Assuntos
Antígenos HLA/sangue , Transplante de Pulmão/mortalidade , Seleção de Pacientes , Imunologia de Transplantes , Listas de Espera/mortalidade , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Tempo , Obtenção de Tecidos e Órgãos/métodos
20.
Transplantation ; 104(7): e188-e198, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32150034

RESUMO

BACKGROUND: Cystatin C (CysC) is an early biomarker of renal dysfunction scarcely studied in patients awaiting liver transplantation (LT). Sarcopenia is frequent in cirrhosis and impacts prognosis. We aimed to assess the capability of these factors to predict survival and acute-on-chronic liver failure (ACLF) in patients awaiting LT, as well as early post-LT outcomes. METHODS: Single-center study that included all cirrhotic patients listed for LT between 2014 and 2017. Competing risk regression analysis was used to evaluate the capability of liver-, kidney-, and global status-related variables at waitlist (WL) inclusion to predict WL mortality and ACLF. Variables associated with post-LT outcomes were evaluated with logistic regression analysis. RESULTS: One-hundred-and-eighty patients were included. Fifty-six (31%) patients developed ACLF, 54 (30%) underwent LT and 35 (19%) died. In the adjusted competing risk regression analysis, CysC ≥ 1.5 mg/L, sarcopenia and MELD-Na were independent predictors of ACLF in the WL, while CysC ≥ 1.5 mg/L, sarcopenia and albumin were independent predictors of mortality. The cumulative incidence of ACLF and mortality at 12 months were 50% and 34% in patients with sarcopenia and CysC ≥1.5 mg/L. An estimated glomerular filtration rate by chronic kidney disease (CKD)-EPI-CysC-creatinine <60 mL/min/1.73 m at WL inclusion was an independent predictor of the need for renal replacement therapy (RRT) in the first month post-LT. CONCLUSIONS: Higher levels of CysC and sarcopenia are strongly associated with the ACLF and mortality in WL. The assessment of both risk factors may improve the prognostic evaluation and allow identifying a group of patients with a very high risk of poor outcomes while awaiting LT.


Assuntos
Insuficiência Hepática Crônica Agudizada/diagnóstico , Cistatina C/sangue , Doença Hepática Terminal/mortalidade , Cirrose Hepática/mortalidade , Transplante de Fígado/efeitos adversos , Sarcopenia/embriologia , Lesão Renal Aguda/sangue , Lesão Renal Aguda/epidemiologia , Lesão Renal Aguda/etiologia , Lesão Renal Aguda/terapia , Insuficiência Hepática Crônica Agudizada/epidemiologia , Insuficiência Hepática Crônica Agudizada/etiologia , Insuficiência Hepática Crônica Agudizada/terapia , Idoso , Biomarcadores/sangue , Creatinina/sangue , Doença Hepática Terminal/sangue , Doença Hepática Terminal/complicações , Doença Hepática Terminal/diagnóstico , Feminino , Taxa de Filtração Glomerular , Humanos , Incidência , Cirrose Hepática/sangue , Cirrose Hepática/complicações , Cirrose Hepática/diagnóstico , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Prognóstico , Insuficiência Renal Crônica/sangue , Insuficiência Renal Crônica/epidemiologia , Insuficiência Renal Crônica/etiologia , Insuficiência Renal Crônica/terapia , Terapia de Substituição Renal/estatística & dados numéricos , Estudos Retrospectivos , Medição de Risco/métodos , Fatores de Risco , Sarcopenia/sangue , Sarcopenia/etiologia , Índice de Gravidade de Doença , Listas de Espera/mortalidade
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