Evaluation and selection of candidates for liver transplantation : an economic perspective

Background – Over the next 20 years, the number of patients on the waiting list for liver transplantation (LTx) is expected to increase by 23%, while pre-LTx costs should raise by 83%. Objective – To evaluate direct medical costs of the pre-LTx period from the perspective of a tertiary care center. Methods – The study included 104 adult patients wait-listed for deceased donor LTx between October 2012 and May 2016 whose treatment was fully provided at the study transplant center. Clinical and economic data were obtained from electronic medical records and from a hospital management software. Outcomes of interest and costs of patients on the waiting list were compared through the Kruskal-Wallis test. A generalized linear model with logit link function was used for multivariate analysis. P-values <0.05 were considered statistically significant. Results – The costs of patients who underwent LTx ($8,879.83; 95$6,464.73; 95% CI 3,845.75–10,867.28; P=0.04) were higher than those of patients who were excluded from the list for any reason except death ($4,647.78; 95% CI 2,469.35–8,748.04; P=0.254) or those who remained on the waiting list at the end of follow-up. Conclusion – Although protocols of inclusion on the waiting list vary among transplant centers, similar approaches exist and common problems should be addressed. The results of this study may help centers with similar socioeconomic realities adjust their transplant policies

Propensity-matched analysis of patients with intrahepatic cholangiocarcinoma or mixed hepatocellular-cholangiocarcinoma and hepatocellular carcinoma undergoing a liver transplant

BACKGROUND Cholangiocarcinoma (CC) is a rare tumor that arises from the epithelium of the bile ducts. It is classified according to anatomic location as intrahepatic, perihilar, and distal. Intrahepatic CC (ICC) is rare in patients with cirrhosis due to causes other than primary sclerosing cholangitis. Mixed hepatocellular carcinoma-CC (HCC-CC) is a rare neoplasm that shows histologic findings of both HCC and ICC within the same tumor mass. Due to the difficulties in arriving at the correct diagnosis, patients eventually undergo liver transplantation (LT) with a presumptive diagnosis of HCC on imaging when, in fact, they have ICC or HCC-CC. AIM To evaluate the outcomes of patients with intrahepatic cholangiocarcinoma or mixed hepatocellular-cholangiocarcinoma on pathological examination after liver transplant. METHODS Propensity score matching was used to analyze tumor recurrence (TR), overall mortality (OM), and recurrence-free survival (RFS) in LT recipients with pathologically confirmed ICC or HCC-CC matched 1:8 to those with HCC. Progression-free survival and overall mortality rates were computed with the Kaplan-Meier method using Cox regression for comparison. RESULTS Of 475 HCC LT recipients, 1.7% had the diagnosis of ICC and 1.5% of HCC-CC on pathological examination of the explant. LT recipients with ICC had higher TR (46% vs 11%; P = 0.006), higher OM (63% vs 23%; P = 0.002), and lower RFS (38% vs 89%; P = 0.002) than those with HCC when matched for pretransplant tumor characteristics, as well as higher TR (46% vs 23%; P = 0.083), higher OM (63% vs 35%; P = 0.026), and lower RFS (38% vs 59%; P = 0.037) when matched for posttransplant tumor characteristics. Two pairings were performed to compare the outcomes of LT recipients with HCC-CC vs HCC. There was no significant difference between the outcomes in either pairing. CONCLUSION Patients with ICC had worse outcomes than patients undergoing LT for HCC. The outcomes of patients with HCC-CC did not differ significantly from those of patients with HCC

Comparison between potential risk factors for cardiovascular disease in people living with HIV/AIDS in areas of Brazil

Introduction: Coronary heart disease and its risk factors depend on genetic characteristics, behaviors, and habits, all of which vary in different regions. The use of antiretroviral therapy (ARV) has increased the survival of people living with HIV/AIDS (PLWHA), who begin to present mortality indicators similar to the general population. This study aimed to compare the prevalence of factors potentially associated with coronary heart disease in three cohorts of PLWHA from three different regions of Brazil. Methodology: The study population was composed of participants of the cohorts of Pernambuco, Goiás, and Rio Grande do Sul states. In these sites, adult patients attending reference centers for treatment of HIV/AIDS were consecutively enrolled. Results: Pernambuco and Goiás had a higher proportion of males and of individuals with high-risk high-density lipoprotein (HDL). Pernambuco also had a greater proportion of individuals with hypertension, elevated triglycerides, and CD4 counts below 200 cells/mm3. Lower education was more frequent in Rio Grande do Sul, and the use of cocaine was higher in this state. Conclusions: The results confirm the importance of risk factors for coronary heart disease in PLHIV and highlight differences in the three cohorts. Specific measures against smoking and sedentary lifestyle, avoidance of advanced stages of immunosuppression, and appropriate treatment of dyslipidemia and dysglicemia are urgently needed to cope with the disease in Brazil

A isquemia e reperfusão no transplante hepático : análise de provas de função hepática

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Risk factors for hepatitis C virus infection among blood donors in southern Brazil : a case-control study

Background: In Brazil, it is estimated that between 2.5 and 4.9% of the general population present anti-hepatitis C virus (HCV) antibodies, which corresponds to as many as 3.9 to 7.6 million chronic carriers. Chronic liver disease is associated with HCV infection in 20% to 58% of the Brazilian patients. The objective of this case-control study was to investigate the risk factors for presence of anti-HCV antibody in blood donors in southern Brazil. Methods: One hundred and seventy eight blood donors with two positive ELISA results for anti- HCV were cases, and 356 controls tested negative. A standardized questionnaire was used to collect data concerning demographic and socioeconomic aspects, history of previous hepatitis infection, social and sexual behaviors, and number of donations. Variables were grouped into sets of hierarchical categories. Cases and controls were compared using logistic regression, odds ratios, and 95% confidence intervals. The statistical significance of the associations was assessed through likelihood ratio tests based on a P value 10 years earlier, having had two to four sexually transmitted diseases, incarceration, tattooing, sex with a hepatitis B or C virus carrier or with intravenous drug users. Conclusion: Intravenous drug use, blood transfusion, and tattooing were the main risk factors for anti-HCV positivity among blood donors from southern Brazil, but sexual HCV transmission should also be considered

Boletín oficial de la zona de Protectorado español en Marruecos: Año XXXIII Número 38 - 1945 Noviembre 16

Introdução: O modelo MELD (Model for End-stage Liver Disease) é um preditor acurado de mortalidade em pacientes em lista de espera para transplante hepático. Além dele há outros escores: o Child-Turcotte-Pugh (CTP), amplamente avaliado, e o EMERALD, um escore novo e ainda não completamente validado. A implementação do MELD na alocação de fígados para transplante no Brasil baseou-se em estudos realizados em países desenvolvidos, pois não há dados brasileiros descrevendo o desempenho do MELD para predizer a sobrevida póstransplante hepático. Objetivos: Avaliar o desempenho do escore MELD em predizer mortalidade três e seis meses após inclusão em lista de espera para o primeiro transplante de fígado, em uma coorte de pacientes com doenças hepáticas crônicas, e comparar sua performance com a dos escores CTP e EMERALD. Determinar a acurácia do MELD pré-transplante para predizer a sobrevida pós-transplante hepático e identificar características associadas com a sobrevida de pacientes. Introdução: O modelo MELD (Model for End-stage Liver Disease) é um preditor acurado de mortalidade em pacientes em lista de espera para transplante hepático. Além dele há outros escores: o Child-Turcotte-Pugh (CTP), amplamente avaliado, e o EMERALD, um escore novo e ainda não completamente validado. A implementação do MELD na alocação de fígados para transplante no Brasil baseou-se em estudos realizados em países desenvolvidos, pois não há dados brasileiros descrevendo o desempenho do MELD para predizer a sobrevida póstransplante hepático. Objetivos: Avaliar o desempenho do escore MELD em predizer mortalidade três e seis meses após inclusão em lista de espera para o primeiro transplante de fígado, em uma coorte de pacientes com doenças hepáticas crônicas, e comparar sua performance com a dos escores CTP e EMERALD. Determinar a acurácia do MELD pré-transplante para predizer a sobrevida pós-transplante hepático e identificar características associadas com a sobrevida de pacientes.Resultados: Os resultados do primeiro estudo de coorte referem-se a 271 pacientes em lista de transplante hepático. Na inclusão em lista, a média dos escores MELD e EMERALD foi 14,8 e 26,6, respectivamente. Aproximadamente61% dos pacientes foram classificados como CTP B. Durante o acompanhamento aos três e seis meses após a inclusão em lista, as porcentagens de pacientes que faleceram, foram transplantados ou permaneceram em lista foram 11,8%, 9,2% e 79,0% e 19,2%, 17,7% e 63,1%, respectivamente. A mortalidade em três meses foi igualmente prevista pelos escores MELD, EMERALD e CTP (estatística-c 0,79, 0,74 e 0,70, respectivamente). Para a mortalidade em seis meses, as curvas ROC e a área sob a curva foram similares. O segundo estudo incluiu 436 pacientes submetidos a transplante hepático que foram acompanhados por aproximadamente 14 anos ou até o óbito. Na coorte pós-transplante hepático a maioria dos receptores e doadores eram homens, com média de idade de 51,6 e 38,5 anos, respectivamente. Os valores da estatística-c para mortalidade em três meses foram 0,60 e 0,61 para o MELD e o CTP, respectivamente. O método KM mostrou que a sobrevida em três, seis e 12 meses foi menor em pacientes com MELD O 21 ou CTP C. Análise multivariada revelou que idade do receptor O 65 anos, MELD O 21, CTP categoria C, bilirrubina O 7 mg/dL, creatinina O 1,5 mg/dL, carcinoma hepatocelular e doador com cor da pele não-branca foram preditores de mortalidade. Conclusões: Mortalidade três e seis meses após inclusão em lista de espera para transplante foi predita pelos escores MELD, CTP e EMERALD. Contudo, o escore MELD apresenta vantagens pela menor variabilidade na determinação de seus componentes, comparativamente ao CTP, e o escore EMERALD necessita de avaliação adicional. Em relação à sobrevida pós-transplante, doença hepática grave prétransplante, pacientes com idade O 65 anos, portadores de carcinoma hepatocelular e doador com cor da pele não-branca associaram-se com pior prognóstico.Introduction: The Model for End-stage Liver Disease (MELD) is an accurate predictor of mortality in patients on the waiting list for liver transplantation. Other scores are also available: the Child Turcotte Pugh (CTP), a widely evaluated score, and the EMERALD, a new score not yet fully validated. The MELD is used to allocate livers for transplants in Brazil following studies conducted in developed countries because no Brazilian data are available to describe the performance of MELD in predicting survival after liver transplantation. Objectives: To evaluate the performance of the MELD score to predict mortality three and six months after inclusion in the waiting list for a first liver transplant in a cohort of patients with end-stage liver disease, and to compare its performance with the performances of the CTP and EMERALD scores. To determine the accuracy of pre-transplant MELD scores to predict survival after liver transplant and to identify characteristics associated with patient survival. Method: In this cohort study, patients on the waiting list were followed up for a mean 20 months, and the predictive performance of scores of severity of underlying liver disease was evaluated: MELD, CPT and EMERALD. ROC curves and c-statistics were used to establish score accuracy to predict mortality after inclusion in the transplant waiting list. The second cohort consisted only of patients that underwent liver transplant, and the study analyzed the patient characteristics associated with long-term survival. The Kaplan-Meier (KM) method was used to analyze survival along time according to MELD and CTP scores. The Cox proportional hazards regression model was used to estimate risk of death while on the waiting list and to evaluate the association between risk factors for mortality after liver transplant. Results: The first cohort consisted of 271 patients on the liver transplant waiting list. At the time of inclusion in the list, mean MELD and EMERALD scores were 14.8 and 26.6. About 61% of the patients were classified as CTP B. During follow-up after inclusion in the list, the percentages of patients that died, underwent transplant, or remained on the list were 11.8%, 9.2% and 79.0% at three months and 19.2%, 17.7% and 63.1% at six months. Mortality at threemonths was equally predicted by MELD, EMERALD and CTP scores (c-statistics: 0.79, 0.74 and 0.70). For mortality at six months, ROC curves and areas under the curve were similar. The second cohort study evaluated 436 patients that underwent liver transplant and were followed up for about 14 years or until death. In this cohort, most recipients and donors were men, and their mean age was 51.6 and 38.5 years. C-statistics for mortality at three months was 0.60 and 0.61 for MELD and CTP. The KM method showed that survival at three, six and 12 months was lower in patients with MELD O 21 or CTP C. Multivariate analysis showed that recipient age O 65 years, MELD O 21, CTP C, bilirubin O 7 mg/dL, creatinine O 1.5 mg/dL, hepatocellular carcinoma and non-white donor were predictors of mortality. Conclusions: Mortality at three and six months after inclusion in the transplant waiting list was predicted by the MELD, EMERALD and CTP scores. However, the MELD score had a lower variability in the determination of its components than CTP, and the EMERALD score should be further evaluated. The analysis of survival after transplant showed that severity of underlying liver disease, patient age O 65 years, hepatocellular carcinoma, and non-white donor were factors associated with a poor prognosis

Risk factors for hepatitis C virus infection among blood donors in southern Brazil : a case-control study

Background: In Brazil, it is estimated that between 2.5 and 4.9% of the general population present anti-hepatitis C virus (HCV) antibodies, which corresponds to as many as 3.9 to 7.6 million chronic carriers. Chronic liver disease is associated with HCV infection in 20% to 58% of the Brazilian patients. The objective of this case-control study was to investigate the risk factors for presence of anti-HCV antibody in blood donors in southern Brazil. Methods: One hundred and seventy eight blood donors with two positive ELISA results for anti- HCV were cases, and 356 controls tested negative. A standardized questionnaire was used to collect data concerning demographic and socioeconomic aspects, history of previous hepatitis infection, social and sexual behaviors, and number of donations. Variables were grouped into sets of hierarchical categories. Cases and controls were compared using logistic regression, odds ratios, and 95% confidence intervals. The statistical significance of the associations was assessed through likelihood ratio tests based on a P value 10 years earlier, having had two to four sexually transmitted diseases, incarceration, tattooing, sex with a hepatitis B or C virus carrier or with intravenous drug users. Conclusion: Intravenous drug use, blood transfusion, and tattooing were the main risk factors for anti-HCV positivity among blood donors from southern Brazil, but sexual HCV transmission should also be considered

Absence of occult hepatitis B among blood donors in southern Brazil

Background: Occult hepatitis B virus (HBV) infection is characterized by the detection of HBV DNA in serum and/or in liver in the absence of detectable hepatitis B surface antigen (HBsAg). The reported prevalence of occult hepatitis B varies markedly among populations and according to the sensitivity of the HBV DNA assay. The aim of the present study was to describe the prevalence of occult hepatitis B among HCV-infected and non-infected blood donors in Porto Alegre, Southern Brazil, using a highly sensitive real time polymerase chain reaction (PCR) method. Methodology: Between 1995 and 1997 a sample of 178 blood donors with two positive anti-HCV ELISA tests were consecutively selected as cases, and 356 anti-HCV negative donors were selected as controls. Blood donors were randomly selected from eight blood centers in Porto Alegre, Southern Brazil, representative of the whole blood donor population. Blood samples were kept at 70°C and defrosted for the first time for the analysis of this report. Tests previously performed in the laboratory using the same real time PCR for HBV DNA had sensitivity for detecting as low as 9 copies/mL. Among 158 blood samples from HBsAg-negative blood donors, five were anti-HBc positive, 53 tested positive for anti-HCV and 105 had anti-HCV negative. The samples analysis was performed in duplicate and all blood samples tested negative for HBV DNA. Conclusion: The result reflects a very low prevalence of occult hepatitis B in our setting

Evaluation and selection of candidates for liver transplantation : an economic perspective

Background – Over the next 20 years, the number of patients on the waiting list for liver transplantation (LTx) is expected to increase by 23%, while pre-LTx costs should raise by 83%. Objective – To evaluate direct medical costs of the pre-LTx period from the perspective of a tertiary care center. Methods – The study included 104 adult patients wait-listed for deceased donor LTx between October 2012 and May 2016 whose treatment was fully provided at the study transplant center. Clinical and economic data were obtained from electronic medical records and from a hospital management software. Outcomes of interest and costs of patients on the waiting list were compared through the Kruskal-Wallis test. A generalized linear model with logit link function was used for multivariate analysis. P-values <0.05 were considered statistically significant. Results – The costs of patients who underwent LTx ($8,879.83; 95$6,464.73; 95% CI 3,845.75–10,867.28; P=0.04) were higher than those of patients who were excluded from the list for any reason except death ($4,647.78; 95% CI 2,469.35–8,748.04; P=0.254) or those who remained on the waiting list at the end of follow-up. Conclusion – Although protocols of inclusion on the waiting list vary among transplant centers, similar approaches exist and common problems should be addressed. The results of this study may help centers with similar socioeconomic realities adjust their transplant policies