Faculty Bibliography

Several treatment options exist for the management of Budd-Chiari syndrome (BCS), yet the relative role and timing of liver transplantation (LT) remain poorly defined. Small case series published to date have not been able to delineate the impact of comorbidities and thromboembolic complications of BCS on survival after LT. To better understand the outcomes after LT for BCS, we analyzed 510 liver transplants performed for this disease in the United States between 1987 and 2006. Risk factors predicting graft loss or patient death included increased recipient age, hyperbilirubinemia, elevated creatinine, life support or hospitalization at the time of transplantation, prior transplantation, prior abdominal surgery, increased donor age, and prolonged cold ischemic time (CIT). Prior transjugular intrahepatic portosystemic shunt (TIPS) was not associated with worse outcomes. Transplantation in the Model for End-Stage Liver Disease (MELD) era was associated with significantly lower risk of graft loss (hazard ratio [HR], 0.50; 95% confidence interval [CI], 0.30-0.86; P = 0.012) and death (HR, 0.52; 95% CI, 0.29-0.93; P = 0.027). Similarly, MELD era was associated with significantly lower risk of early graft loss (odds ratio [OR], 0.35; 95% CI, 0.16-0.79, P = 0.012) and early death (odds ratio, 0.37; 95% CI, 0.14-0.95; P = 0.040). However, patients with BCS transplanted in the MELD era were less likely to have life support, hospitalization, prior transplants, and prolonged cold ischemia times. In conclusion, outcomes of LT for BCS are excellent, with further improvements since 2002 associated with a selection shift imposed by MELD-based organ allocation.

BACKGROUND & AIMS/OBJECTIVE:Advanced liver disease and complications of portal hypertension are common indications for hospitalization. Our objectives were to characterize longitudinal trends in incidence, characteristics, and outcomes of patients hospitalized with complications of portal hypertension using a nationally representative data set. METHODS:Admissions for complications of portal hypertension (hepatic encephalopathy, ascites, or variceal bleed) were identified from the Nationwide Inpatient Sample between 1998 and 2003 using International Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes. International Classification of Diseases, 9th Revision, Clinical Modification procedural codes were used to identify liver transplantation and portosystemic shunt procedures. National estimates for incidence of hospitalization over time, in-hospital mortality, and hospital charges accounted for survey design. RESULTS:Hospitalization rates increased significantly by 5% annually between 1998 and 2003, particularly in the Northeast and the South. The prevalence of hepatitis C-related advanced liver disease among these hospitalized patients increased from 12.9% to 23.7%, and in those with HCV and concurrent alcohol-related disease the rate increased from 5.6% to 11.2%. US population-based in-hospital mortality increased modestly from 1.9 to 2.1 per 100,000 (P<.001), with hepatorenal syndrome as the strongest predictor of death (odds ratio, 9.5; 95% confidence interval, 8.4-10.7). The inflation-adjusted total economic burden of decompensated cirrhosis increased from $1.15 billion to $2.1 billion during the 6-year period (P<.003). CONCLUSIONS:A significant increase in the incidence of hospitalization for complicated portal hypertension between 1998 and 2003 and a growing burden of hepatitis C-related disease have profound economic impact and underscore the need for interventions to prevent progression to advanced liver disease.

It has been suggested that the post-liver transplantation (LT) survival rate of patients with hepatitis C virus infection (HCV) has declined in recent years. To compare the outcome of LT in patients with HCV at various time intervals between 1991 and 2001, we used United Network for Organ Sharing data to compare the post-LT survival of adult patients (age >18 years) with HCV with those without HCV. Of the 37,101 patients who underwent LT during the study period, 28,193 patients (HCV 7,459 and 20,734 non-HCV) were eligible for the study. On the basis of the time of transplantation, patients were divided into 3 groups: 1991-1993 (period 1), 1994-1997 (period 2), and 1998-2001 (period 3). The patient and graft survival rates were adjusted for other known confounding variables that influenced outcomes. The 3-year patient survival rate was lower in HCV patients compared with non-HCV recipients (78.5% vs. 81.4%, hazard ratio 1.14, 95% confidence interval 1.05-1.23, P = 0.001). The graft (72.8%, 71.0%, and 69.8%) and patient (77.4%, 79.6%, and 78.5%) survival of HCV patients remained unchanged during study periods 1-3, respectively. However, the graft and patient survival rates of non-HCV recipients improved markedly during study periods 2 and 3 compared with period 1. The graft and patient survival has remained unchanged between 1991 and 2001 in HCV recipients, but during the same period, there was a great improvement in survival among non-HCV recipients.

UNLABELLED:Having complications of portal hypertension is a harbinger of decompensated cirrhosis and warrants consideration for liver transplantation (LT). Racial disparities in LT have been reported. We sought to characterize disparities in the performing of surgical and endoscopic procedures among hospitalized patients with complications of portal hypertension. We queried the Nationwide Inpatient Sample from 1998 to 2003 to identify patients with cirrhosis and complications of portal hypertension. Logistic regression controlling for confounders was used to evaluate race as a predictor of undergoing a portosystemic shunt and LT and of dying in the hospital. Compared to whites, the adjusted odds ratios of receiving a portosystemic shunt were 0.37 (95% CI: 0.27-0.51) and 0.69 (95% CI: 0.54-0.88) for African Americans (AAs) and Hispanics, respectively. AAs with variceal bleeding were more likely to have endoscopic variceal hemostasis delayed more than 24 hours after admission than were whites (OR 1.6; 95% CI: 1.2-2.1). The adjusted odds ratios of undergoing LT were 0.32 (95% CI:0.20-0.52) and 0.46 (95% CI: 0.25-0.83) for AAs and Hispanics, respectively. Compared to whites, AAs experienced higher in-hospital mortality (OR 1.12; 95% CI: 1.01-1.24), whereas Hispanics had a lower risk of death (OR 0.83; 95% CI: 0.75-0.92). Among variceal bleeders, the odds ratio of death for AAs was 1.7 (95% CI: 1.2-2.4) compared to whites. CONCLUSION/CONCLUSIONS:AAs and Hispanics hospitalized for complications of portal hypertension were less likely to undergo a palliative shunt or LT than whites, which may contribute to the higher in-hospital mortality of AAs. Further studies are warranted to elucidate the mechanisms of these exploratory findings.

Purpose of review. The aim of this article is to review all publications regarding kidney paired donation published over the past 2 years and in doing so provide an evaluation of the current state of development of the field. Recent findings. A few large multicenter paired donation consortia have been developed, and using computer-based matching algorithms have entered significant numbers of donor-recipient pairs (although no program to date has conducted computer match runs with over 75donor-recipient pairs). In addition, significant progress has been made in developing innovative matching strategies and in modeling potential results of paired donation programs. Despite these advances, these programs have only scratched the surface of the estimated potential of paired donation programs to increase living kidney donation. The greatest effects on increasing volume can be made by increasing donor/recipient identification and enrolment. Summary. Significant advances have been made in clinical experience and technological development of paired donation programs. Technical advances have occurred, however, at a more rapid pace than clinical advances in paired donation. Significant work with respect to ethical and educational foundations needs to be accomplished to close this gap.