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Trasplante de Hígado , Listas de Espera , Humanos , Trasplante de Hígado/estadística & datos numéricos , Trasplante de Hígado/normas , Listas de Espera/mortalidad , Masculino , Femenino , Persona de Mediana Edad , Enfermedad Hepática en Estado Terminal/cirugía , Enfermedad Hepática en Estado Terminal/mortalidad , Centros Médicos Académicos/estadística & datos numéricos , Centros Médicos Académicos/organización & administración , Selección de Paciente , Estudios Retrospectivos , Adulto , Instituciones de Atención Ambulatoria/organización & administración , Instituciones de Atención Ambulatoria/estadística & datos numéricos , AncianoAsunto(s)
Accesibilidad a los Servicios de Salud , Trasplante de Hígado , Trasplante de Hígado/normas , Trasplante de Hígado/métodos , Trasplante de Hígado/estadística & datos numéricos , Humanos , Accesibilidad a los Servicios de Salud/organización & administración , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Disparidades en Atención de Salud/estadística & datos numéricos , Enfermedad Hepática en Estado Terminal/cirugía , Enfermedad Hepática en Estado Terminal/mortalidad , Instituciones de Atención Ambulatoria/organización & administración , Instituciones de Atención Ambulatoria/estadística & datos numéricos , Instituciones de Atención Ambulatoria/normas , Comercialización de los Servicios de Salud/métodos , Comercialización de los Servicios de Salud/organización & administración , Listas de EsperaAsunto(s)
Accesibilidad a los Servicios de Salud , Trasplante de Hígado , Trasplante de Hígado/normas , Trasplante de Hígado/estadística & datos numéricos , Trasplante de Hígado/métodos , Humanos , Accesibilidad a los Servicios de Salud/organización & administración , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Accesibilidad a los Servicios de Salud/normas , Instituciones de Atención Ambulatoria/organización & administración , Instituciones de Atención Ambulatoria/estadística & datos numéricos , Instituciones de Atención Ambulatoria/normas , Enfermedad Hepática en Estado Terminal/cirugía , Enfermedad Hepática en Estado Terminal/mortalidad , Listas de Espera/mortalidadRESUMEN
BACKGROUND: Liver transplantation (LT) for alcohol-associated liver disease (ALD) is increasing and may impact LT outcomes for patients listed for HCC and other indications. METHODS: Using US adults listed for primary LT (grouped as ALD, HCC, and other) from October 8, 2015, to December 31, 2021, we examined the impact of center-level ALD LT volume (ATxV) on waitlist outcomes in 2 eras: Era 1 (6-month wait for HCC) and Era 2 (MMaT-3). The tertile distribution of ATxV (low to high) was derived from the listed candidates as Tertile 1 (T1): <28.4%, Tertile 2 (T2): 28.4%-37.6%, and Tertile 3 (T3): >37.6% ALD LTs per year. Cumulative incidence of waitlist death and LT within 18 months from listing by LT indication were compared using the Gray test, stratified on eras and ATxV tertiles. Multivariable competing risk regression estimated the adjusted subhazard ratios (sHRs) for the risk of waitlist mortality and LT with interaction effects of ATxV by LT indication (interaction p). RESULTS: Of 56,596 candidates listed, the cumulative waitlist mortality for those with HCC and other was higher and their LT probability was lower in high (T3) ATxV centers, compared to low (T1) ATxV centers in Era 2. However, compared to ALD (sHR: 0.92 [0.66-1.26]), the adjusted waitlist mortality for HCC (sHR: 1.15 [0.96-1.38], interaction p = 0.22) and other (sHR: 1.13 [0.87-1.46], interaction p = 0.16) were no different suggesting no differential impact of ATxV on the waitlist mortality. The adjusted LT probability for HCC (sHR: 0.89 [0.72-1.11], interaction p = 0.08) did not differ by AtxV while it was lower for other (sHR: 0.82 [0.67-1.01], interaction p = 0.02) compared to ALD (sHR: 1.04 [0.80-1.34]) suggesting a differential impact of ATxV on LT probability. CONCLUSIONS: The high volume of LT for ALD does not impact waitlist mortality for HCC and others but affects LT probability for other in the MMAT-3 era warranting continued monitoring.
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Carcinoma Hepatocelular , Hepatopatías Alcohólicas , Neoplasias Hepáticas , Trasplante de Hígado , Listas de Espera , Humanos , Trasplante de Hígado/mortalidad , Trasplante de Hígado/estadística & datos numéricos , Carcinoma Hepatocelular/cirugía , Carcinoma Hepatocelular/mortalidad , Listas de Espera/mortalidad , Neoplasias Hepáticas/cirugía , Neoplasias Hepáticas/mortalidad , Masculino , Femenino , Persona de Mediana Edad , Hepatopatías Alcohólicas/cirugía , Hepatopatías Alcohólicas/mortalidad , Estados Unidos/epidemiología , Adulto , Estudios Retrospectivos , AncianoRESUMEN
INTRODUCTION: retransplantation is the only viable treatment for patients with irreversible graft loss. The objective of this study was to analyze the indications and outcomes of liver retransplantation in three medical centers. METHODS: a total of 66 patients who underwent liver retransplantation from September 1991 to December 2021 were included in the study. A retrospective analysis was performed evaluating patients demographic, clinical, primary diagnosis, indications for and time interval to retransplantation, complications and patient survival. RESULTS: from a total of 1293 primary liver transplants performed, 70 required one or more liver retransplant. The main indication for primary transplant was hepatitis C cirrhosis (21,2%). Hepatic artery thrombosis was the main cause of retransplantation (60,6%), with almost half (46,9%) of retransplants having occurred within 30 days from initial procedure. The average survival time after a repeat liver transplant, was 89,1 months, with confidence interval from 54 to 124,2. The 1-,5- and 10- year survival rate following liver retransplant were 48,4%, 38% and 30,1%, respectively. Male gender, primary non function as the cause for retransplant, prolonged operative time and higher MELD were associated with higher mortality. CONCLUSIONS: operative mortality and morbidity rates of liver retransplantation are higher than those of the first transplantation. Male gender, primary non function, prolonged operative time and higher MELD were associated with less favorable outcomes.
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Trasplante de Hígado , Reoperación , Humanos , Trasplante de Hígado/estadística & datos numéricos , Trasplante de Hígado/mortalidad , Masculino , Reoperación/estadística & datos numéricos , Femenino , Estudios Retrospectivos , Persona de Mediana Edad , Adulto , Resultado del Tratamiento , Anciano , Complicaciones Posoperatorias/epidemiología , Adulto Joven , Tasa de Supervivencia , Factores de TiempoRESUMEN
Biliary atresia (BA) is a progressive inflammatory fibrosclerosing disease of the biliary system and a major cause of neonatal cholestasis. It affects 1:5,000-20,000 live births, with the highest incidence in Asia. The pathogenesis is still unknown, but emerging research suggests a role for ciliary dysfunction, redox stress and hypoxia. The study of the underlying mechanisms can be conceptualized along the likely prenatal timing of an initial insult and the distinction between the injury and prenatal and postnatal responses to injury. Although still speculative, these emerging concepts, new diagnostic tools and early diagnosis might enable neoadjuvant therapy (possibly aimed at oxidative stress) before a Kasai portoenterostomy (KPE). This is particularly important, as timely KPE restores bile flow in only 50-75% of patients of whom many subsequently develop cholangitis, portal hypertension and progressive fibrosis; 60-75% of patients require liver transplantation by the age of 18 years. Early diagnosis, multidisciplinary management, centralization of surgery and optimized interventions for complications after KPE lead to better survival. Postoperative corticosteroid use has shown benefits, whereas the role of other adjuvant therapies remains to be evaluated. Continued research to better understand disease mechanisms is necessary to develop innovative treatments, including adjuvant therapies targeting the immune response, regenerative medicine approaches and new clinical tests to improve patient outcomes.
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Atresia Biliar , Atresia Biliar/fisiopatología , Atresia Biliar/diagnóstico , Atresia Biliar/terapia , Atresia Biliar/epidemiología , Atresia Biliar/complicaciones , Humanos , Portoenterostomía Hepática/métodos , Trasplante de Hígado/métodos , Trasplante de Hígado/estadística & datos numéricosRESUMEN
BACKGROUND: MELD3.0 has been proposed to stratify patients on the liver transplant waiting list (WL) to reduce the historical disadvantage of women in accessing liver transplant. Our aim was to validate MELD3.0 in 2 unique populations. METHODS: This study is a 2-center retrospective cohort study from Toronto, Canada, and Valencia, Spain, of all adults added to the liver transplant WL between 2015 and 2019. Listing indications whose short-term survival outcome is not adequately captured by the MELD score were excluded. All patients analyzed had a minimum follow-up of 3 months after inclusion in the WL. RESULTS: Six hundred nineteen patients were included; 61% were male, with a mean age of 56 years. Mean MELD at inclusion was 18.00 ± 6.88, Model for End-Stage Liver Disease Sodium (MELDNa) 19.78 ± 7.00, and MELD3.0 20.25 ± 7.22. AUC to predict 90-day mortality on the WL was 0.879 (95% CI: 0.820, 0.939) for MELD, 0.921 (95% CI: 0.876, 0.967) for MELDNa, and 0.930 (95% CI: 0.888, 0.973) for MELD3.0. MELDNa and MELD3.0 were better predictors than MELD (p = 0.055 and p = 0.024, respectively), but MELD3.0 was not statistically superior to MELDNa (p = 0.144). The same was true when stratified by sex, although the difference between MELD3.0 and MELD was only significant for women (p = 0.032), while no statistical significance was found in either sex when compared with MELDNa. In women, AUC was 0.835 (95% CI: 0.744, 0.926) for MELD, 0.873 (95% CI: 0.785, 0.961) for MELDNa, and 0.886 (95% CI: 0.803, 0.970) for MELD3.0; differences for the comparison between AUC in women versus men for all 3 scores were nonsignificant. Compared to MELD, MELD3.0 was able to reclassify 146 patients (24%), the majority of whom belonged to the MELD 10-19 interval. Compared to MELDNa, it reclassified 68 patients (11%), most of them in the MELDNa 20-29 category. CONCLUSIONS: MELD3.0 has been validated in centers with significant heterogeneity and offers the highest mortality prediction for women on the WL without disadvantaging men. However, in these cohorts, it was not superior to MELDNa.
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Enfermedad Hepática en Estado Terminal , Trasplante de Hígado , Índice de Severidad de la Enfermedad , Listas de Espera , Humanos , Femenino , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Trasplante de Hígado/estadística & datos numéricos , Listas de Espera/mortalidad , Enfermedad Hepática en Estado Terminal/mortalidad , Enfermedad Hepática en Estado Terminal/cirugía , España , Anciano , Adulto , Factores SexualesRESUMEN
BACKGROUND: Introducing new liver transplantation (LT) practices, like unconventional donor use, incurs higher costs, making evaluation of their prognostic justification crucial. This study reexamines the spread pattern of new LT practices and its prognosis across the United States. METHODS: The study investigated the spread pattern of new practices using the UNOS database (2014-2023). Practices included LT for hepatitis B/C (HBV/HCV) nonviremic recipients with viremic donors, LT for COVID-19-positive recipients, and LT using onsite machine perfusion (OMP). One year post-LT patient and graft survival were also evaluated. RESULTS: LTs using HBV/HCV donors were common in the East, while LTs for COVID-19 recipients and those using OMP started predominantly in California, Arizona, Texas, and the Northeast. K-means cluster analysis identified three adoption groups: facilities with rapid, slow, and minimal adoption rates. Rapid adoption occurred mainly in high-volume centers, followed by a gradual increase in middle-volume centers, with little increase in low-volume centers. The current spread patterns did not significantly affect patient survival. Specifically, for LTs with HCV donors or COVID-19 recipients, patient and graft survivals in the rapid-increasing group was comparable to others. In LTs involving OMP, the rapid- or slow-increasing groups tended to have better patient survival (p = 0.05) and significantly improved graft survival rates (p = 0.02). Facilities adopting new practices often overlap across different practices. DISCUSSION: Our analysis revealed three distinct adoption groups across all practices, correlating the adoption aggressiveness with LT volume in centers. Aggressive adoption of new practices did not compromise patient and graft survivals, supporting the current strategy. Understanding historical trends could predict the rise in future LT cases with new practices, aiding in resource distribution.
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COVID-19 , Supervivencia de Injerto , Trasplante de Hígado , SARS-CoV-2 , Humanos , Trasplante de Hígado/estadística & datos numéricos , Estados Unidos/epidemiología , COVID-19/epidemiología , Femenino , Masculino , Persona de Mediana Edad , Obtención de Tejidos y Órganos/estadística & datos numéricos , Donantes de Tejidos/provisión & distribución , Donantes de Tejidos/estadística & datos numéricos , Adulto , Tasa de Supervivencia , Pronóstico , Pautas de la Práctica en Medicina/estadística & datos numéricosRESUMEN
OBJECTIVE: To analyze the features and outcomes of 500 liver transplantations in adults over a 12-year period. MATERIALS AND METHODS: The study included data on 500 liver transplantations between May 2010 and April 2023. We analyzed 483 adults who underwent transplantation and 438 candidates for this procedure. All data were obtained from local liver transplantation registry. Clinical outcomes were recorded as of June 1, 2023. Statistical analysis was performed using the Statistica 12 (StatSoft Inc., USA) and Jamovi version 2.3.21.0 software (Jamovi project). RESULTS: Among 438 patients in the waiting list between January 2012 and May 2023, liver transplantation was performed in 198 (45%) cases including 27 (6%) transplantations from living-related donors and 37 (8%) procedures in other centers. There were 109 (25%) deaths. The 1- and 3-year survival rates were 81% (95% CI 76-85%) and 50% (95% CI 42-59%), respectively. Organs from deceased donors (n=134, 27%) and living-related donors (n=366, 73%) were used for transplantations. Redo transplantations were necessary in 21 (4%) cases. The median age of recipients was 45 years (range 18-72), median MELD-Na score - 16 (range 6-43). The most common indications for transplantation were viral cirrhosis (37%), cholestatic liver disease (16%), and hepatocellular carcinoma (14%). Monotherapy with calcineurin inhibitors was performed in 39% of cases, combination of calcineurin inhibitors and glucocorticoids, antimetabolites or mTOR inhibitors - 52%, three-component schemes - 8% of cases. Annual, 5- and 7-year survival rates of recipients after primary transplantation were 87% (95% CI: 84-90%), 79% (95% CI: 75-83%) and 75% (95% CI: 70-80%), respectively. In case of liver transplantation from living-related donors, these values were 89% (95% CI: 86-92%), 84% (95% CI: 80-88%) and 80% (95% CI: 75-85%), after transplantation from deceased donors - 81% (95% CI: 74-88%), 66% (95% CI: 57-76%) and 58% (95% CI: 45-72%), respectively. CONCLUSION: Liver transplantation is highly effective for patients with diffuse and focal liver diseases. Living donors not only significantly improve availability of this technology, but also provide substantial advantages in outcomes compared to liver transplantation from deceased donors, reducing the likelihood of recipient mortality by 10% after one post-transplantation year and by more than 20% after five years.
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Trasplante de Hígado , Humanos , Trasplante de Hígado/métodos , Trasplante de Hígado/estadística & datos numéricos , Trasplante de Hígado/efectos adversos , Masculino , Femenino , Persona de Mediana Edad , Adulto , Listas de Espera , Donadores Vivos/estadística & datos numéricos , Tasa de Supervivencia/tendencias , Federación de Rusia/epidemiología , Sistema de Registros/estadística & datos numéricosRESUMEN
BACKGROUND AND AIMS: Chronic hepatitis delta represents a major global health burden. Clinical features of hepatitis D virus (HDV) infection vary largely between different regions worldwide. Treatment approaches are dependent on the approval status of distinct drugs and financial resources. METHODS: The Hepatitis Delta International Network (HDIN) registry involves researchers from all continents (Wranke, Liver International 2018). We here report long-term follow-up data of 648 hepatitis D patients recruited by 14 centres in 11 countries. Liver-related clinical endpoints were defined as hepatic decompensation (ascites, encephalopathy and variceal bleeding), liver transplantation, hepatocellular carcinoma or liver-related death. RESULTS: Patient data were available from all continents but Africa: 22% from Eastern Mediterranean, 32% from Eastern Europe and Central Asia, 13% from Central and Southern Europe, 14% from South Asia (mainly Pakistan) and 19% from South America (mainly Brazil). The mean follow-up was 6.4 (.6-28) years. During follow-up, 195 patients (32%) developed a liver-related clinical event after 3.5 (±3.3) years. Liver cirrhosis at baseline and a detectable HDV RNA test during follow-up were associated with a worse clinical outcome in multivariate regression analysis while patients receiving interferon alfa-based therapies developed clinical endpoints less frequently. Patients from South Asia developed endpoints earlier and had the highest mortality. CONCLUSIONS: The HDIN registry confirms the severity of hepatitis D and provides further evidence for HDV viraemia as a main risk factor for disease progression. Hepatitis D seems to take a particularly severe course in patients born in Pakistan. There is an urgent need to extend access to antiviral therapies and to provide appropriate education about HDV infection.
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Antivirales , Virus de la Hepatitis Delta , Cirrosis Hepática , Sistema de Registros , Humanos , Masculino , Femenino , Persona de Mediana Edad , Adulto , Cirrosis Hepática/virología , Virus de la Hepatitis Delta/genética , Antivirales/uso terapéutico , Neoplasias Hepáticas/virología , Estudios de Seguimiento , Trasplante de Hígado/estadística & datos numéricos , Hepatitis D Crónica/tratamiento farmacológico , Carcinoma Hepatocelular/virología , Salud GlobalRESUMEN
Health care transition (HCT) is a vulnerable period that continues into adulthood, even after the transfer of care. Given the growing population of pediatric liver transplant recipients reaching young adulthood, the need for a standardized and multidisciplinary approach to transition that spans from pediatric to adult care is becoming more imperative. In this article, we review the unique challenges and barriers to successful HCT that adolescent and young adults (AYAs) who have undergone liver transplant face, highlight the gap in transition care in the adult setting, and present the Six Core Elements of Health Care Transition TM as a framework that can be used by adult providers to incorporate AYAs systematically and collaboratively into adult practice. Multidisciplinary HCT programs should be the standard of care for all AYAs with liver transplant, and while implementation is a necessary first step, ongoing efforts to increase awareness, funding, and research on HCTs into adulthood are needed.
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Trasplante de Hígado , Transición a la Atención de Adultos , Humanos , Trasplante de Hígado/normas , Trasplante de Hígado/efectos adversos , Trasplante de Hígado/estadística & datos numéricos , Transición a la Atención de Adultos/organización & administración , Transición a la Atención de Adultos/normas , Adolescente , Adulto Joven , Receptores de Trasplantes/estadística & datos numéricos , Niño , Adulto , Factores de EdadRESUMEN
BACKGROUND: Donor blood transfusion may potentially affect transplant outcomes through an inflammatory response, recipient sensitization, or transmission of infection. The aim of this study was to evaluate the association of donor blood transfusion with outcomes of liver transplantation (LT). METHODS: From January 2004 to December 2022, donor blood transfusion information was available for 113,017 adult recipients of LT in the United Network for Organ Sharing database and was classified into 4 levels of transfusion: no-transfusion (N = 68,130), transfusion of 1-5 units (N = 33,629), 6-10 units (N = 8067), and >10 units (N = 5329). Recipient survival analysis was performed by Kaplan-Meier method and multivariable Cox-hazard model. RESULTS: Among this cohort, 40.8% of donors (N = 46,261) received blood transfusion during the index hospitalization. Compared to no-blood transfusion donors, blood transfusion donors were younger (median age 37 versus 46 y P < 0.001) and were more brain death donors (94.5% versus 92.1%, P < 0.001). An increased risk of rejection at 6-mo (transfusion 10.3% versus no-transfusion 9.9%, P = 0.055) and 1 y (transfusion 12.5% versus no-transfusion 11.9%, P = 0.0036) post-LT was noted in this cohort. Multivariable Cox-hazard model showed blood transfusion was associated with increased 1-y mortality (transfusion 1.07; 95% CI 1.02-1.12, P = 0.007) and graft failure (transfusion 1.09; 95% CI 1.04-1.13, P < 0.001). CONCLUSIONS: Donor blood transfusion was associated with an increased risk of rejection at 6 mo and 1 y among LT recipients and worse post-transplant graft and overall survival. Additional information regarding donor blood transfusion, along with other known factors, may be considered when deciding the optimization of overall immune suppression in LT recipients to decrease the risk of delayed rejection.
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Transfusión Sanguínea , Trasplante de Hígado , Humanos , Trasplante de Hígado/efectos adversos , Trasplante de Hígado/estadística & datos numéricos , Trasplante de Hígado/mortalidad , Masculino , Persona de Mediana Edad , Femenino , Adulto , Estados Unidos/epidemiología , Transfusión Sanguínea/estadística & datos numéricos , Rechazo de Injerto/epidemiología , Rechazo de Injerto/prevención & control , Supervivencia de Injerto , Estudios Retrospectivos , Anciano , Donantes de Tejidos/estadística & datos numéricos , Resultado del TratamientoRESUMEN
BACKGROUND: Liver transplantation is the gold standard treatment for end-stage liver disease. This study evaluates post-transplantation survival compared with the general population by quantifying standardized mortality ratios in a nested case-control study. METHODS: Controls were noninstitutionalized United States inhabitants from the National Longitudinal Mortality Study. Cases underwent liver transplantation from 1990 to 2007 identified through the Organ Procurement and Transplantation Network database. Propensity matching (5:1, nearest neighbor, caliper 0.1) identified controls based on age, sex, race, and state. The primary endpoint was 10-year survival. RESULTS: 62,788 cases were matched to 313,381 controls. The overall standardized mortality ratio was 2.46 (95% CI â= â2.44-2.48). The standardized mortality ratio was higher for males (2.59 vs. 2.25) and Hispanic patients (4.80). Younger patients and those transplanted earlier (1990-1995) had higher standardized mortality ratios. CONCLUSIONS: Liver recipients have a standardized mortality ratio 2.46 times higher than the general population. Long-term mortality has declined over time.
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Trasplante de Hígado , Humanos , Trasplante de Hígado/mortalidad , Trasplante de Hígado/estadística & datos numéricos , Masculino , Femenino , Estudios de Casos y Controles , Persona de Mediana Edad , Estados Unidos/epidemiología , Adulto , Anciano , Enfermedad Hepática en Estado Terminal/cirugía , Enfermedad Hepática en Estado Terminal/mortalidad , Tasa de Supervivencia/tendencias , Puntaje de Propensión , Adulto Joven , AdolescenteRESUMEN
OBJECTIVES: Our aim was to provide an up-to-date, large-scale overview of the trends and clinicodemographics for NASH LTs performed in the United States compared with all other LT indications between 2000 and 2022. We also examined the demographic factors that will predict future demand for NASH LT. METHODS: Our analysis of NASH LT from the Organ Procurement & Transplantation Network database spanning 2000-2022 consisted primarily of descriptive statistics and hypothesis testing with corrections for multiple testing when necessary. Trend lines and linear correlations were also explored. RESULTS: NASH LTs have experienced a remarkable surge, escalating from 0.12% of all LTs in 2000 to a substantial 14.7% in 2022, marking a 100-fold increase. Examining demographic trends, a significant proportion of NASH LTs recipients fall within the 50- to 64-year-old age group. Moreover, 52% of these recipients concurrently exhibit type 2 diabetes mellitus, a notably higher percentage than the 19% observed in all LT recipients. Type 2 diabetes mellitus emerges as a prominent risk factor for NASH progressing to end-stage liver disease. The phenomenon of repeat transplantation is noteworthy; although 6% of all LTs necessitate repeat procedures, this figure dramatically drops to 0.6% for NASH LTs. Ethnic disparities are apparent, with African Americans representing a mere 2% of NASH LT recipients, significantly lower than their representation in the overall population. Regionally, the East Coast has a higher proportion of NASH LT recipients compared with waitlist additions. This trend holds true across demographics. CONCLUSIONS: Our findings underscore the need for increased resources, particularly for minority, uninsured, or noncitizen individuals requiring LT for NASH. This analysis provides valuable insights into the dynamic landscape of LTs in the context of NASH, shaping the trajectory of medical interventions in the 21st century.
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Bases de Datos Factuales , Trasplante de Hígado , Enfermedad del Hígado Graso no Alcohólico , Humanos , Trasplante de Hígado/estadística & datos numéricos , Trasplante de Hígado/tendencias , Enfermedad del Hígado Graso no Alcohólico/cirugía , Enfermedad del Hígado Graso no Alcohólico/epidemiología , Persona de Mediana Edad , Femenino , Masculino , Estados Unidos/epidemiología , Adulto , Anciano , Factores de Riesgo , Diabetes Mellitus Tipo 2/epidemiología , Diabetes Mellitus Tipo 2/complicacionesAsunto(s)
Política de Salud , Disparidades en Atención de Salud , Trasplante de Hígado , Obtención de Tejidos y Órganos , Humanos , Política de Salud/economía , Política de Salud/legislación & jurisprudencia , Política de Salud/tendencias , Disparidades en Atención de Salud/etnología , Disparidades en Atención de Salud/legislación & jurisprudencia , Disparidades en Atención de Salud/estadística & datos numéricos , Disparidades en Atención de Salud/tendencias , Trasplante de Hígado/economía , Trasplante de Hígado/legislación & jurisprudencia , Trasplante de Hígado/estadística & datos numéricos , Trasplante de Hígado/tendencias , Obtención de Tejidos y Órganos/economía , Obtención de Tejidos y Órganos/legislación & jurisprudencia , Obtención de Tejidos y Órganos/estadística & datos numéricos , Obtención de Tejidos y Órganos/tendencias , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Liver-directed treatments - ablative therapy (AT), surgical resection (SR), liver transplantation (LT), and transarterial chemoembolization (TACE) - improve the overall survival of patients with early-stage hepatocellular carcinoma (HCC). Although racial and socioeconomic disparities affect access to liver-directed therapies, the temporal trends for the curative-intent treatment of HCC remain to be elucidated. METHODS: This study performed chi-square, logistic regression, and temporal trends analyses on data from the Nationwide Inpatient Sample from 2011 to 2019. The outcome of interest was the rate of AT, SR, LT (curative-intent treatments), and TACE utilization, and the primary predictors were racial/ethnic group and socioeconomic status (SES; insurance status). RESULTS: African American and Hispanic patients had lower odds of receiving AT (African American: odds ratio [OR], 0.78; P < .001; Hispanic: OR, 0.84; P = .005) and SR (African American: OR, 0.71; P < .001; Hispanics: OR, 0.64; P < .001) than White patients. Compared with White patients, the odds of LT was lower in African American patients (OR, 0.76; P < .001) but higher in Hispanic patients (OR, 1.25; P = .001). Low SES was associated with worse odds of AT (OR, 0.79; P = .001), SR (OR, 0.66; P < .001), and LT (OR, 0.84; P = .028) compared with high SES. Although curative-intent treatments showed significant upward temporal trends among White patients (10.6%-13.9%; P < .001) and Asian and Pacific Islander/other patients (14.4%-15.7%; P = .007), there were nonsignificant trends among African American patients (10.9%-10.1%; P = .825) or Hispanic patients (12.2%-13.7%; P = .056). CONCLUSION: Our study demonstrated concerning disparities in the utilization of curative-intent treatment for HCC based on race/ethnicity and SES. Moreover, racial/ethnic disparities have widened rather than improved over time.
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Carcinoma Hepatocelular , Quimioembolización Terapéutica , Disparidades en Atención de Salud , Hispánicos o Latinos , Neoplasias Hepáticas , Trasplante de Hígado , Humanos , Carcinoma Hepatocelular/terapia , Carcinoma Hepatocelular/etnología , Neoplasias Hepáticas/terapia , Neoplasias Hepáticas/etnología , Masculino , Femenino , Disparidades en Atención de Salud/estadística & datos numéricos , Disparidades en Atención de Salud/tendencias , Persona de Mediana Edad , Hispánicos o Latinos/estadística & datos numéricos , Quimioembolización Terapéutica/estadística & datos numéricos , Quimioembolización Terapéutica/tendencias , Trasplante de Hígado/estadística & datos numéricos , Trasplante de Hígado/tendencias , Anciano , Estados Unidos , Hepatectomía/estadística & datos numéricos , Hepatectomía/tendencias , Negro o Afroamericano/estadística & datos numéricos , Población Blanca/estadística & datos numéricos , Técnicas de Ablación/estadística & datos numéricos , Técnicas de Ablación/tendencias , Cobertura del Seguro/estadística & datos numéricosAsunto(s)
Trasplante de Hígado , Trasplante de Hígado/tendencias , Trasplante de Hígado/estadística & datos numéricos , Trasplante de Hígado/normas , Humanos , Estados Unidos , Enfermedad Hepática en Estado Terminal/cirugía , Enfermedad Hepática en Estado Terminal/mortalidad , Obtención de Tejidos y Órganos/estadística & datos numéricos , Obtención de Tejidos y Órganos/tendencias , Obtención de Tejidos y Órganos/organización & administración , Optimismo , PredicciónRESUMEN
There is no recent update on the clinical course of retransplantation (re-LT) after living donor liver transplantation (LDLT) in the US using recent national data. The UNOS database (2002-2023) was used to explore patient characteristics in initial LT, comparing deceased donor liver transplantation (DDLT) and LDLT for graft survival (GS), reasons for graft failure, and GS after re-LT. It assesses waitlist dropout and re-LT likelihood, categorizing re-LT cohort based on time to re-listing as acute or chronic (≤ or > 1 mo). Of 132,323 DDLT and 5955 LDLT initial transplants, 3848 DDLT and 302 LDLT recipients underwent re-LT. Of the 302 re-LT following LDLT, 156 were acute and 146 chronic. Primary nonfunction (PNF) was more common in DDLT, although the difference was not statistically significant (17.4% vs. 14.8% for LDLT; p = 0.52). Vascular complications were significantly higher in LDLT (12.5% vs. 8.3% for DDLT; p < 0.01). Acute re-LT showed a larger difference in primary nonfunction between DDLT and LDLT (49.7% vs. 32.0%; p < 0.01). Status 1 patients were more common in DDLT (51.3% vs. 34.0% in LDLT; p < 0.01). In the acute cohort, Kaplan-Meier curves indicated superior GS after re-LT for initial LDLT recipients in both short-term and long-term ( p = 0.02 and < 0.01, respectively), with no significant difference in the chronic cohort. No significant differences in waitlist dropout were observed, but the initial LDLT group had a higher re-LT likelihood in the acute cohort (sHR 1.40, p < 0.01). A sensitivity analysis focusing on the most recent 10-year cohort revealed trends consistent with the overall study findings. LDLT recipients had better GS in re-LT than DDLT. Despite a higher severity of illness, the DDLT cohort was less likely to undergo re-LT.
Asunto(s)
Bases de Datos Factuales , Supervivencia de Injerto , Trasplante de Hígado , Donadores Vivos , Reoperación , Listas de Espera , Humanos , Trasplante de Hígado/estadística & datos numéricos , Trasplante de Hígado/efectos adversos , Trasplante de Hígado/métodos , Donadores Vivos/estadística & datos numéricos , Femenino , Masculino , Estados Unidos/epidemiología , Reoperación/estadística & datos numéricos , Persona de Mediana Edad , Adulto , Bases de Datos Factuales/estadística & datos numéricos , Listas de Espera/mortalidad , Resultado del Tratamiento , Factores de Tiempo , Anciano , Rechazo de Injerto/epidemiología , Rechazo de Injerto/etiología , Rechazo de Injerto/prevención & control , Factores de RiesgoRESUMEN
BACKGROUND: Liver transplantation (LT) has been shown to be superior to resection in highly selected patients with perihilar cholangiocarcinoma (CCA), yet has traditionally been contraindicated for intrahepatic CCA (iCCA). Herein, we aimed to examine contemporary trends and outcomes for surgical resection and LT for iCCA. METHODS: The National Cancer Database was queried for patients presenting with stage I-III iCCA between 2010 and 2018 who underwent resection or LT. Overall survival (OS) was compared with Kaplan-Meier and multivariable Cox proportional hazards methods stratified by management. Secondary analysis of patients undergoing transplant for CCA was performed with the United Network for Organ Sharing database. RESULTS: Of 2565 patients, 2412 (94.0%) underwent resection and 153 (5.96%) LT of whom 84 (54.9%) received neoadjuvant therapy. Utilization of LT remained between 3.9% and 7.8% annually. Unadjusted 5-year OS was higher for LT than resection (59.8% vs 39.9%, P = .0067), yet adjusted analysis revealed no significant difference in mortality (hazard ratio, 0.91; 95% CI, 0.66-1.27; P = .58). On secondary analysis including 437 patients with all subtypes of CCA, unadjusted 5-year OS was higher for non-CCA indications (79% vs 52%-54%, P < .001). CONCLUSION: Utilization of LT for iCCA remains low and many cases are likely incidental. Although partial hepatectomy remains the standard of care for patients with resectable disease, our findings suggest that highly selected patients with unresectable iCCA may achieve favorable outcomes after LT. Granular, prospective data are needed to identify patients most likely to benefit from transplant and allocate scarce liver grafts.
Asunto(s)
Neoplasias de los Conductos Biliares , Colangiocarcinoma , Hepatectomía , Trasplante de Hígado , Humanos , Trasplante de Hígado/estadística & datos numéricos , Masculino , Femenino , Neoplasias de los Conductos Biliares/cirugía , Neoplasias de los Conductos Biliares/mortalidad , Neoplasias de los Conductos Biliares/patología , Persona de Mediana Edad , Anciano , Colangiocarcinoma/cirugía , Colangiocarcinoma/mortalidad , Colangiocarcinoma/patología , Resultado del Tratamiento , Terapia Neoadyuvante/estadística & datos numéricos , Tasa de Supervivencia , Bases de Datos Factuales , Modelos de Riesgos Proporcionales , Estimación de Kaplan-Meier , Estudios Retrospectivos , Estadificación de NeoplasiasRESUMEN
Sex inequities in liver transplantation (LT) have been documented in several, mostly US-based, studies. Our aim was to describe sex-related differences in access to LT in a system with short waiting times. All adult patients registered in the RETH-Spanish Liver Transplant Registry (2000-2022) for LT were included. Baseline demographics, presence of hepatocellular carcinoma, cause and severity of liver disease, time on the waiting list (WL), access to transplantation, and reasons for removal from the WL were assessed. 14,385 patients were analysed (77% men, 56.2 ± 8.7 years). Model for end-stage liver disease (MELD) score was reported for 5,475 patients (mean value: 16.6 ± 5.7). Women were less likely to receive a transplant than men (OR 0.78, 95% CI 0.63, 0.97) with a trend to a higher risk of exclusion for deterioration (HR 1.17, 95% CI 0.99, 1.38), despite similar disease severity. Women waited longer on the WL (198.6 ± 338.9 vs. 173.3 ± 285.5 days, p < 0.001). Recently, women's risk of dropout has reduced, concomitantly with shorter WL times. Even in countries with short waiting times, women are disadvantaged in LT. Policies directed at optimizing the whole LT network should be encouraged to guarantee a fair and equal access of all patients to this life saving resource.