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1.
Am J Transplant ; 17(12): 3123-3130, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-28613436

RESUMO

Incompatible living donor kidney transplantation (ILDKT) has been established as an effective option for end-stage renal disease patients with willing but HLA-incompatible living donors, reducing mortality and improving quality of life. Depending on antibody titer, ILDKT can require highly resource-intensive procedures, including intravenous immunoglobulin, plasma exchange, and/or cell-depleting antibody treatment, as well as protocol biopsies and donor-specific antibody testing. This study sought to compare the cost and Medicare reimbursement, exclusive of organ acquisition payment, for ILDKT (n = 926) with varying antibody titers to matched compatible transplants (n = 2762) performed between 2002 and 2011. Data were assembled from a national cohort study of ILDKT and a unique data set linking hospital cost accounting data and Medicare claims. ILDKT was more expensive than matched compatible transplantation, ranging from 20% higher adjusted costs for positive on Luminex assay but negative flow cytometric crossmatch, 26% higher for positive flow cytometric crossmatch but negative cytotoxic crossmatch, and 39% higher for positive cytotoxic crossmatch (p < 0.0001 for all). ILDKT was associated with longer median length of stay (12.9 vs. 7.8 days), higher Medicare payments ($91 330 vs. $63 782 p < 0.0001), and greater outlier payments. In conclusion, ILDKT increases the cost of and payments for kidney transplantation.


Assuntos
Incompatibilidade de Grupos Sanguíneos/economia , Rejeição de Enxerto/economia , Teste de Histocompatibilidade/economia , Falência Renal Crônica/cirurgia , Transplante de Rim/economia , Doadores Vivos , Complicações Pós-Operatórias/economia , Estudos de Casos e Controles , Feminino , Seguimentos , Taxa de Filtração Glomerular , Rejeição de Enxerto/epidemiologia , Sobrevivência de Enxerto , Humanos , Testes de Função Renal , Masculino , Pessoa de Meia-Idade , Prognóstico , Qualidade de Vida , Estudos Retrospectivos , Fatores de Risco
2.
Am J Transplant ; 16(8): 2368-76, 2016 08.
Artigo em Inglês | MEDLINE | ID: mdl-27111897

RESUMO

There is an increased risk of acute rejection (AR) in human immunodeficiency virus-positive (HIV+) kidney transplant (KT) recipients. Induction immunosuppression is standard of care for those at high risk of AR; however, use in HIV+ patients is controversial, given fears of increased infection rates. We sought to compare clinical outcomes between HIV+ KT recipients who were treated with (i) anti-thymocyte globulin (ATG), (ii) IL-2 receptor blocker, and (iii) no induction. We studied 830 HIV+ KT recipients between 2000 and 2014, as captured in the Scientific Registry of Transplant Recipients, and compared rates of delayed graft function (DGF), AR, graft loss and death. Infections and hospitalizations were ascertained by International Classification of Diseases, Ninth Revision codes in a subset of 308 patients with Medicare. Compared with no induction, neither induction agent was associated with an increased risk of infection (weighted hazard ratio [wHR] 0.80, 95% confidence interval [CI] 0.55-1.18). HIV+ recipients who received induction spent fewer days in the hospital (weighted relative risk [wRR] 0.70, 95% CI 0.52-0.95), had lower rates of DGF (wRR 0.66, 95% CI 0.51-0.84), less graft loss (wHR 0.47, 95% CI 0.24-0.89) and a trend toward lower mortality (wHR 0.60, 95% CI 0.24-1.28). Those who received induction with ATG had lower rates of AR (wRR 0.59, 95% CI 0.35-0.99). Induction in HIV+ KT recipients was not associated with increased infections; in fact, those receiving ATG, the most potent agent, had the lowest rates. In light of the high risk of AR in this population, induction therapy should be strongly considered.


Assuntos
Rejeição de Enxerto/tratamento farmacológico , Infecções por HIV/complicações , Imunossupressores/uso terapêutico , Falência Renal Crônica/cirurgia , Transplante de Rim/efeitos adversos , Adulto , Soro Antilinfocitário/farmacologia , Feminino , Seguimentos , Taxa de Filtração Glomerular , Rejeição de Enxerto/etiologia , Sobrevivência de Enxerto , Infecções por HIV/imunologia , Infecções por HIV/virologia , HIV-1/isolamento & purificação , Humanos , Terapia de Imunossupressão , Quimioterapia de Indução , Falência Renal Crônica/complicações , Testes de Função Renal , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Prognóstico , Fatores de Risco
3.
Am J Transplant ; 16(10): 3041-3045, 2016 10.
Artigo em Inglês | MEDLINE | ID: mdl-27214874

RESUMO

Patients requiring desensitization prior to renal transplantation are at risk for developing severe antibody-mediated rejection (AMR) refractory to treatment with plasmapheresis and intravenous immunoglobulin (PP/IVIg). We have previously reported success at graft salvage, long-term graft survival and protection against transplant glomerulopathy with the use of eculizumab and splenectomy in addition to PP/IVIg. Splenectomy may be an important component of this combination therapy and is itself associated with a marked reduction in donor-specific antibody (DSA) production. However, splenectomy represents a major operation, and some patients with severe AMR have comorbid conditions that substantially increase their risk of complications during and after surgery. In an effort to spare recipients the morbidity of a second operation, we used splenic irradiation in lieu of splenectomy in two incompatible live donor kidney transplant recipients with severe AMR in addition to PP/IVIg, rituximab and eculizumab. This novel approach to the treatment of severe AMR was associated with allograft salvage, excellent graft function and no short- or medium-term adverse effects of the radiation therapy. One-year surveillance biopsies did not show transplant glomerulopathy (tg) on light microscopy, but microcirculation inflammation and tg were present on electron microscopy.


Assuntos
Rejeição de Enxerto/radioterapia , Sobrevivência de Enxerto/efeitos da radiação , Isoanticorpos/efeitos adversos , Falência Renal Crônica/cirurgia , Transplante de Rim/efeitos adversos , Baço/efeitos da radiação , Esplenectomia/efeitos adversos , Adulto , Dessensibilização Imunológica , Feminino , Raios gama , Taxa de Filtração Glomerular , Rejeição de Enxerto/etiologia , Sobrevivência de Enxerto/imunologia , Teste de Histocompatibilidade , Humanos , Imunoglobulinas Intravenosas/administração & dosagem , Imunossupressores/uso terapêutico , Testes de Função Renal , Pessoa de Meia-Idade , Plasmaferese , Complicações Pós-Operatórias , Prognóstico , Baço/imunologia , Baço/patologia
4.
Am J Transplant ; 16(1): 292-300, 2016 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-26317315

RESUMO

The Open Payments Program (OPP) was recently implemented to publicly disclose industry payments to physicians, with the goal of enabling patient awareness of potential conflicts of interests. Awareness of OPP, its data, and its implications for transplantation are critical. We used the first wave of OPP data to describe industry payments made to transplant surgeons. Transplant surgeons (N = 297) received a total of $759 654. The median (interquartile range [IQR]) payment to a transplant surgeon was $125 ($39-1018), and the highest payment to an individual surgeon was $83 520; 122 surgeons received <$100, and 17 received >$10 000. A higher h-index was associated with 30% higher chance of receiving >$1000 (relative risk/10 unit h-index increase = 1.18 1.301.44 , p < 0.001). The highest payment category was consulting fees, with a total of $314 448 paid in this reported category. Recipients of consulting fees had higher h-indices, median (IQR) of 20 (10-35) versus nine (3-17) (p < 0.001). Ten of 122 companies accounted for 62% of all payments. Kidney transplant and liver transplant (LT) centers that received >$1000 had higher center volumes (p < 0.001). LT centers that received payments of >$1000 had a higher percentage of private-insurance/self-pay patients (p < 0.01). Continued surveillance of industry payments may further elucidate the relationship between industry payments and physician practices.


Assuntos
Bases de Dados Factuais/economia , Indústria Farmacêutica/economia , Transplante de Órgãos/economia , Padrões de Prática Médica/economia , Cirurgiões/economia , Revelação da Verdade , Gastos em Saúde , Humanos , Patient Protection and Affordable Care Act/legislação & jurisprudência , Relatório de Pesquisa
5.
Am J Transplant ; 16(12): 3468-3478, 2016 12.
Artigo em Inglês | MEDLINE | ID: mdl-27184779

RESUMO

Antibody-mediated rejection (AMR) is typically treated with plasmapheresis (PP) and intravenous immunoglobulin (standard of care; SOC); however, there is an unmet need for more effective therapy. We report a phase 2b, multicenter double-blind randomized placebo-controlled pilot study to evaluate the use of human plasma-derived C1 esterase inhibitor (C1 INH) as add-on therapy to SOC for AMR. Eighteen patients received 20 000 units of C1 INH or placebo (C1 INH n = 9, placebo n = 9) in divided doses every other day for 2 weeks. No discontinuations, graft losses, deaths, or study drug-related serious adverse events occurred. While the study's primary end point, a difference between groups in day 20 pathology or graft survival, was not achieved, the C1 INH group demonstrated a trend toward sustained improvement in renal function. Six-month biopsies performed in 14 subjects (C1 INH = 7, placebo = 7) showed no transplant glomerulopathy (TG) (PTC+cg≥1b) in the C1 INH group, whereas 3 of 7 placebo subjects had TG. Endogenous C1 INH measured before and after PP demonstrated decreased functional C1 INH serum concentration by 43.3% (p < 0.05) for both cohorts (C1 INH and placebo) associated with PP, although exogenous C1 INH-treated patients achieved supraphysiological levels throughout. This new finding suggests that C1 INH replacement may be useful in the treatment of AMR.


Assuntos
Proteína Inibidora do Complemento C1/farmacologia , Inativadores do Complemento/farmacologia , Rejeição de Enxerto/tratamento farmacológico , Isoanticorpos/efeitos adversos , Transplante de Rim/efeitos adversos , Método Duplo-Cego , Feminino , Seguimentos , Taxa de Filtração Glomerular , Rejeição de Enxerto/etiologia , Sobrevivência de Enxerto , Humanos , Imunoglobulinas Intravenosas/administração & dosagem , Falência Renal Crônica/cirurgia , Testes de Função Renal , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Plasmaferese , Prognóstico , Fatores de Risco
6.
Am J Transplant ; 16(5): 1465-73, 2016 05.
Artigo em Inglês | MEDLINE | ID: mdl-26603690

RESUMO

The infrequent use of ABO-incompatible (ABOi) kidney transplantation in the United States may reflect concern about the costs of necessary preconditioning and posttransplant care. Medicare data for 26 500 live donor kidney transplant recipients (2000 to March 2011), including 271 ABOi and 62 A2-incompatible (A2i) recipients, were analyzed to assess the impact of pretransplant, transplant episode and 3-year posttransplant costs. The marginal costs of ABOi and A2i versus ABO-compatible (ABOc) transplants were quantified by multivariate linear regression including adjustment for recipient, donor and transplant factors. Compared with ABOc transplantation, patient survival (93.2% vs. 88.15%, p = 0.0009) and death-censored graft survival (85.4% vs. 76.1%, p < 0.05) at 3 years were lower after ABOi transplant. The average overall cost of the transplant episode was significantly higher for ABOi ($65 080) compared with A2i ($36 752) and ABOc ($32 039) transplantation (p < 0.001), excluding organ acquisition. ABOi transplant was associated with high adjusted posttransplant spending (marginal costs compared to ABOc - year 1: $25 044; year 2: $10 496; year 3: $7307; p < 0.01). ABOi transplantation provides a clinically effective method to expand access to transplantation. Although more expensive, the modest increases in total spending are easily justified by avoiding long-term dialysis and its associated morbidity and cost.


Assuntos
Sistema ABO de Grupos Sanguíneos/imunologia , Incompatibilidade de Grupos Sanguíneos/economia , Rejeição de Enxerto/economia , Falência Renal Crônica/economia , Transplante de Rim/economia , Doadores Vivos , Adolescente , Adulto , Bases de Dados Factuais , Feminino , Seguimentos , Taxa de Filtração Glomerular , Rejeição de Enxerto/etiologia , Humanos , Falência Renal Crônica/cirurgia , Testes de Função Renal , Transplante de Rim/efeitos adversos , Masculino , Medicare , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Estados Unidos , Adulto Jovem
7.
Am J Transplant ; 16(1): 213-20, 2016 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-26317487

RESUMO

The updated Banff classification allows for the diagnosis of antibody-mediated rejection (AMR) in the absence of peritubular capillary C4d staining. Our objective was to quantify allograft loss risk in patients with consistently C4d-negative AMR (n = 51) compared with C4d-positive AMR patients (n = 156) and matched control subjects without AMR. All first-year posttransplant biopsy results from January 2004 through June 2014 were reviewed and correlated with the presence of donor-specific antibody (DSA). C4d-negative AMR patients were not different from C4d-positive AMR patients on any baseline characteristics, including immunologic risk factors (panel reactive antibody, prior transplant, HLA mismatch, donor type, DSA class, and anti-HLA/ABO-incompatibility). C4d-positive AMR patients were significantly more likely to have a clinical presentation (85.3% vs. 54.9%, p < 0.001), and those patients presented substantially earlier posttransplantation (median 14 [interquartile range 8-32] days vs. 46 [interquartile range 20-191], p < 0.001) and were three times more common (7.8% vs 2.5%). One- and 2-year post-AMR-defining biopsy graft survival in C4d-negative AMR patients was 93.4% and 90.2% versus 86.8% and 82.6% in C4d-positive AMR patients, respectively (p = 0.4). C4d-negative AMR was associated with a 2.56-fold (95% confidence interval, 1.08-6.05, p = 0.033) increased risk of graft loss compared with AMR-free matched controls. No clinical characteristics were identified that reliably distinguished C4d-negative from C4d-positive AMR. However, both phenotypes are associated with increased graft loss and thus warrant consideration for intervention.


Assuntos
Complemento C4b/imunologia , Rejeição de Enxerto/etiologia , Isoanticorpos/imunologia , Falência Renal Crônica/cirurgia , Transplante de Rim/efeitos adversos , Complicações Pós-Operatórias , Adulto , Estudos de Casos e Controles , Feminino , Seguimentos , Taxa de Filtração Glomerular , Rejeição de Enxerto/patologia , Sobrevivência de Enxerto , Humanos , Isoanticorpos/sangue , Testes de Função Renal , Masculino , Pessoa de Meia-Idade , Prognóstico , Fatores de Risco
8.
Am J Transplant ; 15(2): 445-52, 2015 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-25612497

RESUMO

Pediatric kidney transplant recipients experience a high-risk age window of increased graft loss during late adolescence and early adulthood that has been attributed primarily to sociobehavioral mechanisms such as nonadherence. An examination of how this age window affects recipients of other organs may inform the extent to which sociobehavioral mechanisms are to blame or whether kidney-specific biologic mechanisms may also exist. Graft loss risk across current recipient age was compared between pediatric kidney (n = 17,446), liver (n = 12,161) and simultaneous liver-kidney (n = 224) transplants using piecewise-constant hazard rate models. Kidney graft loss during late adolescence and early adulthood (ages 17-24 years) was significantly greater than during ages <17 (aHR = 1.79, 95%CI = 1.69-1.90, p < 0.001) and ages >24 (aHR = 1.11, 95%CI = 1.03-1.20, p = 0.005). In contrast, liver graft loss during ages 17-24 was no different than during ages <17 (aHR = 1.03, 95%CI = 0.92-1.16, p = 0.6) or ages >24 (aHR = 1.18, 95%CI = 0.98-1.42, p = 0.1). In simultaneous liver-kidney recipients, a trend towards increased kidney compared to liver graft loss was observed during ages 17-24 years. Late adolescence and early adulthood are less detrimental to pediatric liver grafts compared to kidney grafts, suggesting that sociobehavioral mechanisms alone may be insufficient to create the high-risk age window and that additional biologic mechanisms may also be required.


Assuntos
Rejeição de Enxerto/epidemiologia , Transplante de Rim/estatística & dados numéricos , Transplante de Fígado/estatística & dados numéricos , Transplantados , Adolescente , Fatores Etários , Criança , Pré-Escolar , Feminino , Humanos , Incidência , Lactente , Masculino , Avaliação de Resultados em Cuidados de Saúde , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Adulto Jovem
9.
Am J Transplant ; 15(2): 489-98, 2015 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-25611786

RESUMO

Unlike antibody-mediated rejection (AMR) with clinical features, it remains unclear whether subclinical AMR should be treated, as its effect on allograft loss is unknown. It is also uncertain if AMR's effect is homogeneous across donor (deceased/live) and (HLA/ABO) antibody types. We compared 219 patients with AMR (77 subclinical, 142 clinical) to controls matched on HLA/ABO-compatibility, donor type, prior transplant, panel reactive antibody (PRA), age and year. One and 5-year graft survival in subclinical AMR was 95.9% and 75.7%, compared to 96.8% and 88.4% in matched controls (p = 0.0097). Subclinical AMR was independently associated with a 2.15-fold increased risk of graft loss (95% CI: 1.19-3.91; p = 0.012) compared to matched controls, but not different from clinical AMR (p = 0.13). Fifty three point two percent of subclinical AMR patients were treated with plasmapheresis within 3 days of their AMR-defining biopsy. Treated subclinical AMR patients had no difference in graft loss compared to matched controls (HR 1.73; 95% CI: 0.73-4.05; p = 0.21), but untreated subclinical AMR patients did (HR 3.34; 95% CI: 1.37-8.11; p = 0.008). AMR's effect on graft loss was heterogeneous when stratified by compatible deceased donor (HR = 4.73; 95% CI: 1.57-14.26; p = 0.006), HLA-incompatible deceased donor (HR = 2.39; 95% CI: 1.10-5.19; p = 0.028), compatible live donor (no AMR patients experienced graft loss), ABO-incompatible live donor (HR = 6.13; 95% CI: 0.55-67.70; p = 0.14) and HLA-incompatible live donor (HR = 6.29; 95% CI: 3.81-10.39; p < 0.001) transplant. Subclinical AMR substantially increases graft loss, and treatment seems warranted.


Assuntos
Anticorpos/imunologia , Rejeição de Enxerto/epidemiologia , Rejeição de Enxerto/imunologia , Transplante de Rim , Doadores Vivos , Adulto , Aloenxertos , Biópsia , Estudos de Casos e Controles , Feminino , Seguimentos , Histocompatibilidade/imunologia , Humanos , Incidência , Rim/patologia , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Fatores de Tempo
10.
Am J Transplant ; 14(2): 459-65, 2014 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-24400968

RESUMO

Renal transplantation in patients with antiphospholipid antibodies has historically proven challenging due to increased risk for thrombosis and allograft failure. This is especially true for patients with antiphospholipid antibody syndrome (APS) and its rare subtype, the catastrophic antiphospholipid antibody syndrome (CAPS). Since a critical mechanism of thrombosis in APS/CAPS is one mediated by complement activation, we hypothesized that preemptive treatment with the terminal complement inhibitor, eculizumab, would reduce the extent of vascular injury and thrombosis, enabling renal transplantation for patients in whom it would otherwise be contraindicated. Three patients with APS, two with a history of CAPS, were treated with continuous systemic anticoagulation together with eculizumab prior to and following live donor renal transplantation. Two patients were also sensitized to human leukocyte antigens (HLA) and required plasmapheresis for reduction of donor-specific antibodies. After follow-up ranging from 4 months to 4 years, all patients have functioning renal allografts. No systemic thrombotic events or early graft losses were observed. While the appropriate duration of treatment remains to be determined, this case series suggests that complement inhibitors such as eculizumab may prove to be effective in preventing the recurrence of APS after renal transplantation.


Assuntos
Anticorpos Monoclonais Humanizados/uso terapêutico , Síndrome Antifosfolipídica/prevenção & controle , Inativadores do Complemento/uso terapêutico , Rejeição de Enxerto/prevenção & controle , Falência Renal Crônica/complicações , Transplante de Rim/efeitos adversos , Complicações Pós-Operatórias/prevenção & controle , Adulto , Síndrome Antifosfolipídica/etiologia , Seguimentos , Rejeição de Enxerto/etiologia , Humanos , Falência Renal Crônica/cirurgia , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Recidiva , Indução de Remissão
11.
Am J Transplant ; 14(7): 1573-80, 2014 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-24913913

RESUMO

Incompatible live donor kidney transplantation (ILDKT) offers a survival advantage over dialysis to patients with anti-HLA donor-specific antibody (DSA). Program-specific reports (PSRs) fail to account for ILDKT, placing this practice at regulatory risk. We collected DSA data, categorized as positive Luminex, negative flow crossmatch (PLNF) (n = 185), positive flow, negative cytotoxic crossmatch (PFNC) (n = 536) or positive cytotoxic crossmatch (PCC) (n = 304), from 22 centers. We tested associations between DSA, graft loss and mortality after adjusting for PSR model factors, using 9669 compatible patients as a comparison. PLNF patients had similar graft loss; however, PFNC (adjusted hazard ratio [aHR] = 1.64, 95% confidence interval [CI]: 1.15-2.23, p = 0.007) and PCC (aHR = 5.01, 95% CI: 3.71-6.77, p < 0.001) were associated with increased graft loss in the first year. PLNF patients had similar mortality; however, PFNC (aHR = 2.04; 95% CI: 1.28-3.26; p = 0.003) and PCC (aHR = 4.59; 95% CI: 2.98-7.07; p < 0.001) were associated with increased mortality. We simulated Centers for Medicare & Medicaid Services flagging to examine ILDKT's effect on the risk of being flagged. Compared to equal-quality centers performing no ILDKT, centers performing 5%, 10% or 20% PFNC had a 1.19-, 1.33- and 1.73-fold higher odds of being flagged. Centers performing 5%, 10% or 20% PCC had a 2.22-, 4.09- and 10.72-fold higher odds. Failure to account for ILDKT's increased risk places centers providing this life-saving treatment in jeopardy of regulatory intervention.


Assuntos
Anticorpos/imunologia , Incompatibilidade de Grupos Sanguíneos/epidemiologia , Rejeição de Enxerto/etiologia , Antígenos HLA/imunologia , Transplante de Rim/legislação & jurisprudência , Transplante de Rim/estatística & dados numéricos , Doadores Vivos/provisão & distribuição , Adulto , Incompatibilidade de Grupos Sanguíneos/diagnóstico , Incompatibilidade de Grupos Sanguíneos/imunologia , Feminino , Seguimentos , Sobrevivência de Enxerto , Humanos , Incidência , Falência Renal Crônica/mortalidade , Falência Renal Crônica/cirurgia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Padrões de Prática Médica/estatística & dados numéricos , Prognóstico , Fatores de Risco , Taxa de Sobrevida
12.
Am J Transplant ; 13(4): 936-942, 2013 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-23414232

RESUMO

Organ shortage has led to increased utilization of higher risk liver allografts. In kidneys, aggressive center-level use of one type of higher risk graft clustered with aggressive use of other types. In this study, we explored center-level behavior in liver utilization. We aggregated national liver transplant recipient data between 2005 and 2009 to the center-level, assigning each center an aggressiveness score based on relative utilization of higher risk livers. Aggressive centers had significantly more patients reaching high MELDs (RR 2.19, 2.33 and 2.28 for number of patients reaching MELD>20, MELD>25 and MELD>30, p<0.001), a higher organ shortage ratio (RR 1.51, 1.60 and 1.51 for number of patients reaching MELD>20, MELD>25 and MELD>30 divided by number of organs recovered at the OPO, p<0.04), and were clustered within various geographic regions, particularly regions 2, 3 and 9. Median MELD at transplant was similar between aggressive and nonaggressive centers, but average annual transplant volume was significantly higher at aggressive centers (RR 2.27, 95% CI 1.47-3.51, p<0.001). In cluster analysis, there were no obvious phenotypic patterns among centers with intermediate levels of aggressiveness. In conclusion, highwaitlist disease severity, geographic differences in organ availability, and transplant volume are the main factors associated with the aggressive utilization of higher risk livers.


Assuntos
Doença Hepática Terminal/cirurgia , Transplante de Fígado/métodos , Obtenção de Tecidos e Órgãos , Transplantes/provisão & distribuição , Adulto , Idoso , Análise por Conglomerados , Doença Hepática Terminal/diagnóstico , Sobrevivência de Enxerto , Humanos , Testes de Função Hepática , Pessoa de Meia-Idade , Fenótipo , Análise de Regressão , Fatores de Risco , Índice de Gravidade de Doença , Doadores de Tecidos , Transplante Homólogo
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