Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society
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Hospitals with the highest readmission rates for high-cost conditions may be targeted for payment penalties. The primary aim of this study was to determine clinical predictors of 30-day readmission after discharge for patients undergoing orthotopic liver transplantation (OLT) at the University of Washington from January 2003 to October 2010. Secondary aims included the determination of predictors of institutional care after OLT and differences in survival between patients requiring 30-day readmission and patients not requiring 30-day readmission. ⋯ The predictors of readmission included hospitalization within the 90 days before OLT [29.6% versus 18.4%, relative risk (RR) = 1.33, P = 0.04], pre-OLT portal vein thrombosis (7.9% versus 4.4%, RR = 1.76, P = 0.01), a creatinine level > 1.9 mg/dL (23.9% versus 11.5%, RR = 2.1, P ≤ 0.01), an albumin level < 2.6 mg/dL (51.9% versus 37.6%, RR = 1.57, P < 0.01), postoperative complications (38.7% versus 30.2%, RR = 1.31, P = 0.04), and a high school education or less (14.5% versus 10%, RR = 1.41, P = 0.04). One year after OLT, decreased survival was found for patients requiring 30-day readmission versus patients not requiring readmission (88.2% versus 95.6%, P < 0.05). In conclusion, this study has identified patients at high risk of readmission who may benefit from medical optimization.
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The incidence of Clostridium difficile infection (CDI) is increasing among hospitalized patients. Liver transplantation (LT) patients are at higher risk for acquiring CDI. Small, single-center studies (but no nationwide analyses) have assessed this association. ⋯ CDI was associated with a higher mortality rate: 5.5% for LT patients with CDI versus 3.2% for LT-only patients (adjusted OR = 1.70, 95% CI = 1.29-2.25). In conclusion, the prevalence of CDI is higher for LT patients versus non-LT patients (2.7% versus 0.9%). CDI is an independent risk factor for mortality in the LT population.
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Portopulmonary hypertension (POPH) is a serious complication of cirrhosis that is associated with mortality beyond that predicted by the Model for End-Stage Liver Disease (MELD) score. Increased pulmonary vascular resistance (PVR) may be initiated by pulmonary vasoconstriction, altered levels of circulating mediators, or shear stress, and can eventually lead to the classic vascular remodeling (plexiform lesion) that characterizes POPH. Portal hypertension is a prerequisite for the diagnosis of POPH, although the severity of pulmonary hypertension is unrelated to the severity of portal hypertension or the nature or severity of liver disease. ⋯ The United Network for Organ Sharing recommends MELD exception points for patients with medically controlled POPH, but this varies by region. Patients who undergo LT need specialized intraoperative and postoperative management, which includes the availability of intraoperative transesophageal echocardiography for assessing right ventricular function, and rapidly acting vasodilators (eg, inhaled nitric oxide and/or epoprostenol). Published case series suggest excellent outcomes after LT for patients who respond to medical therapy.
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In the United Kingdom, liver transplantation using donation after circulatory determination of death (DCDD) organs has increased steadily over the last few years and now accounts for 20% of UK transplant activity. The procurement of DCDD livers is actively promoted as a means of increasing the donor pool and bridging the evolving disparity between the wait-list length and the number of transplants performed. The objective of this retrospective study of a cohort of patients who were matched for age, liver disease etiology, and Model for End-Stage Liver Disease score was to determine whether differences in perioperative costs and resource utilization are associated with the use of such organs. ⋯ The overall quality of DCDD grafts is poorer; as a result, the length of the ITU stay and the need for multiorgan support are increased, and this has significant financial and resource implications. We believe that these implications require a careful real-life consideration of benefits. It is essential for DCDD not to be seen as a like-for-like alternative to DBD and for every effort to be continued to be made to increase the number of donations from brain-dead patients as a first resort.
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The aim of this study was to investigate the role of gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI) in predicting the histological grade of hepatocellular carcinoma (HCC) according to the hepatic function. Eighty-one consecutive patients with 122 histologically proven HCCs who underwent Gd-EOB-DTPA-enhanced MRI before resection (45 HCCs in 42 patients) or transplantation (77 HCCs in 39 patients) were analyzed retrospectively. We calculated the relative enhancement ratios (RER), which is the ratio of the relative intensity of a tumor versus the surrounding parenchyma on hepatobiliary phase images to the relative intensity on unenhanced MRI scans. ⋯ In a subgroup analysis based on liver function, the correlation between the histological grade and the enhancement ratio was demonstrated only in the group of patients with Child-Pugh class A cirrhosis. The accuracy of postcontrast RIRs for predicting WD and PD HCCs was favorable; the areas under the receiver operating characteristic curves were 0.896 [95% confidence interval (CI) = 0.817-0.974] and 0.769 (95% CI = 0.658-0.879), respectively. In conclusion, the hepatobiliary phase of Gd-EOB-DTPA-enhanced MRI may help to predict the differentiation of HCCs, especially in HCC patients with Child-Pugh class A cirrhosis before liver transplantation or resection.