C.A. Rogers

Health-related Quality of Life After Cardiac Transplantation : Results of a UK National Survey With Norm-based Comparisons

BACKGROUNDnHealth-related quality of life (HRQOL) is an important measure of outcome that is known to improve after cardiac transplantation, and some studies have suggested that the HRQOL approaches levels found in normal populations. This study presents descriptive analyses of HRQOL and norm-based comparisons after cardiac transplantation in the UK.nnnMETHODSnA cross-sectional postal survey of cardiac transplant recipients at their first-, third- or fifth-year anniversary after transplantation was undertaken using the Short Form-36 (SF-36), EuroQol (EQ-5D) and Hospital Anxiety and Depression Scale (HADS) questionnaires. Data from the SF-36 and EQ-5D were then compared with normative data from the UK.nnnRESULTSnOf 429 questionnaires issued, 323 were completed and returned, a response rate of 75%. One year after surgery, 66% and 28% of respondents reported much better and somewhat better health, respectively. No deterioration in general health was reported at 3 and 5 years after transplantation. Norm-based comparisons suggested significantly poorer (p < 0.05) HRQOL for the EQ-5D and all dimensions of the SF-36 except mental health. Data from the HADS showed that 89% of respondents had symptoms compatible with normality or mild depression. There was no statistically significant difference in HRQOL between respondents at 1, 3 or 5 years after transplantation for any of the dimensions tested.nnnCONCLUSIONSnCardiac transplant recipients in the UK indicated an improvement in general health after transplantation. Respondents at 3 and 5 years after transplantation reported stability, or improvement, but no deterioration in their general health. Norm-based comparisons suggested lower HRQOL for all dimensions except mental health. Some dimensions of health identified in this study may be areas for further investigation that may ultimately be amenable to focused medical management.

Variations in cardiac transplantation: comparisons between the United Kingdom and the United States

BACKGROUNDnInternational practice variations have been documented in various health care specialties. This study compares cardiac transplantation in the UK with practice in the US.nnnMETHODSnUK data were from an ongoing multi-center prospective study, the UK Cardiothoracic Transplant Audit. The UK population comprised 620 listings and 463 transplants. US data were obtained from UNOS and comprised 3946 listings and 4704 transplants.nnnRESULTSnThere was a mean of 14 transplants per center per year in the US compared with 34 in the UK. Notable differences in practice include rarity of listing in the UK of patients > 65 years (0.2% vs 4.1% in US) and patients with previous transplants (UK 0.9%, US 3.2%). Patients listed in the US were more likely to be on ventricular assist devices (odds ratio 8.0, 95% CI 3.0-21.7) or inotropes (odds ratio 4.9, 95% CI 3.7-6.4). Living donor (domino) transplants, although comprising 7% of transplants in the UK, are virtually non-existent in the US (1 domino in 4704 transplants). Heterotopic transplants were more common in the UK (4.4% vs 0.5%). Indications for transplant were similar (except retransplantation). The donor age was > 35 years in 43% of UK donors vs 33% of US donors.nnnCONCLUSIONnThis study reveals substantial practice differences between the UK and US. Further studies are required to examine the reasons for these practice differences, the influence on transplant outcome, and their ethical and economic implications.

A simple approach to risk stratification in adult heart transplantation

OBJECTIVEnWhile there are numerous reports in the literature of risk factors for graft failure after heart transplantation, simple models for risk stratification are lacking. This study describes a simple method for risk stratification in adult heart transplantation that can be applied when the size of a dataset is insufficient for formal regression modelling.nnnMETHODSnMulti-centre prospective cohort study. Fourteen risk factors documented in the literature as increasing post transplant graft failure were used to formulate a model. Risk factors included in the model were recipient age >50 years, pre-operative ventilatory support, pre-operative circulatory support, >1 previous sternotomy, pulmonary vascular resistance >2.5 wood units, male with body surface area >2.5 m2, retransplant, ischaemic time >3.5 h, donor age >45 years, donor inotropic support >10 microg/kg per min dopamine, female donor, ratio donor/recipient body surface area <0.7, donor with diabetes and history of donor drug abuse. Four risk groups were defined depending on the number of risk factors present: Low, none; moderate, 1; high, 2 or 3; very high, 4 or more. Graft survival to 30 days was chosen as the primary outcome. The model was tested on 373 adult transplants performed in the UK between April 1995 and December 1996.nnnRESULTSnTwenty eight transplants were low risk, 82 moderate, 201 high and 62 very high. The 30-day survival (70% CI) for the risk groups was low, 97% (93-100), moderate 95% (92-98), high 87% (84-89) and very high 80% (75-83) (P = 0.02).nnnCONCLUSIONSnThis preliminary model enables some stratification of heart transplant procedures according to donor and recipient risk profile. Further work will be directed at refining and validating the model.

Does splitting the lung block into two single lung grafts equate to doubling the societal benefit from bilateral lung donors? Comparisons between two single versus one bilateral lung transplant

Abstract Multi‐organ thoracic transplantation, although beneficial to one recipient, has an opportunity cost of denied transplants to others. This paper compares population based outcomes of splitting lung blocks for two single lung transplants compared to doing one bilateral lung transplant, and suggests that the benefit of splitting lung blocks may not necessarily be double that of using each block for one recipient.

Immediate renal replacement therapy and outcome after cardiac transplantation - a multivariate analysis of risk factors.

Background: Renal failure is a serious complication following cardiac transplantation, and studies suggest that acute renal failure requiring renal replacement therapy in the early postoperative period may be predictive of poor outcome. Aim: To examine survival in cardiac transplant recipients who did or did not require immediate haemodialysis/filtration, and examine potential risk factors predisposing to this complication. Subjects: All adult cardiac transplant recipients transplanted in the UK between July 1995 and June 2000. Methods: Prospective multi-centre cohort study. Survival curves for patients surviving .30 days were estimated using the Kaplan-Meier method.Stepwise logistic regression was used to examine a range of potential donor and recipient risk factors for haemodialysis/filtration in patients surviving .2 days. Results: Of 1108 cardiac transplants, 128 (11.6%) required haemodialysis/filtration in the first 30 days post-transplant. One and three year patient survival for patients needing haemodialys/filtration was significantly worse (p50.0001, log rank test) than for those who did not. Risk factors for renal replacement therapy identified were (p,0.10) a pre-operative creatinine .150 mmol/l (OR 2.1, 95%CI 1.2-3.7), donor size mismatch .80% (OR 2.4, 95% CI 0.99-5.7), recipient age , 45 years (OR 1.5, 95% CI 0.93-2.4) and recipient diabetes (OR 1.8, 95% CI 0.97-3.5). Conclusion: The initiation of renal support in the early post-transplant period is a strong marker of poor short and mid-term survival. Predictors of this serious complication include a preoperative creatinine . 150 mmol/l (a significant risk factor), recipient diabetes, recipient age and donor: recipient size mismatch. Knowledge of these facts provides valuable prognostic information, and may help to refine patient selection for transplantation. 316