Neehar D. Parikh

Quality of life for donors after living donor liver transplantation: A review of the literature†

Living donor liver transplantation (LDLT) decreases the shortage of liver grafts for patients in need of a liver transplant, but it involves 2 patients: a recipient and a living donor. Despite the magnitude of the procedure for LDLT donors, only a few studies have investigated the effect of LDLT on the quality of life (QOL) of donors. We performed a systematic search of the MEDLINE database to identify peer‐reviewed articles assessing QOL in adults after LDLT donation. Nineteen studies describing 768 unique donors met our inclusion criteria for this review. The median number of donors enrolled in each study was 30 (range = 10‐143), and the median follow‐up period was 10.4 months (range = 3‐51.3 months). Before donation, donor QOL was significantly better than that in control adult populations across all measured QOL domains. Within the first 3 months after donation, the physical domains of QOL were significantly worse than the predonation levels, but they returned to baseline levels within 6 months for the majority of patients (80%‐93%). Mental domains of QOL remained unchanged throughout the donation process. Common donor concerns after LDLT included bloating, loss of muscle tone, poor body image, and fatigue. In conclusion, according to our review of the existing literature, most LDLT donors return to their baseline QOL within 6 months. However, there is a lack of long‐term data on donor QOL after LDLT, and few standardized assessments include measures of common patient concerns. Additional studies are necessary to develop a comprehensive risk profile for LDLT that includes a rigorous assessment of donor QOL. Liver Transpl 16:1352–1358, 2010.

Posttransplant Hyperglycemia is Associated With Increased Risk of Liver Allograft Rejection

Background. Intensive glycemic control has been shown to positively impact outcomes in an intensive care setting. Whether this practice is beneficial after liver transplantation (LT) is not known. Methods. A retrospective review of patients undergoing LT from February 2002 to July 2007 was conducted to analyze the association between perioperative hyperglycemia and outcomes after LT. Covariates included preexisting diabetes, mean glucose 3 months pre-LT, need for insulin drip post-LT, mean total glucose during the post-LT hospitalization, age, sex, type of transplant, and model for end-stage liver disease score. Outcomes within 1 year of LT included rejection, infection, rehospitalization, prolonged ventilation, and patient/graft survival. Results. One hundred thirteen LT and 31 liver-kidney recipients were included. By multivariate logistic regression adjusting for covariates, the rejection rate was significantly lower for patients with postoperative glucose levels less than 200 mg/dL (n=114) vs. more than 200 mg/dL (n=30) (odds ratio: 0.055; 95% confidence interval: 0.0154–0.200; P<0.001). The need for prolonged ventilation was more common in patients with glucose less than 200 vs. more than 200 mg/dL (odds ratio: 4.30; 95% confidence interval: 1.284–14.388; P=0.018). Although other outcomes, infection, rehospitalization, patient/graft survival, were not different among the glucose control groups, rejection was associated with increased rehospitalizations and infections. Conclusion. Our data demonstrate an association between the immediate posttransplant glycemic control and the development of subsequent rejection. Prospective trials investigating the effects of perioperative glycemic control on outcomes and morbidity after LT are warranted.

Comparative effectiveness of donation after cardiac death versus donation after brain death liver transplantation: Recognizing who can benefit

Due to organ scarcity and wait‐list mortality, transplantation of donation after cardiac death (DCD) livers has increased. However, the group of patients benefiting from DCD liver transplantation is unknown. We studied the comparative effectiveness of DCD versus donation after brain death (DBD) liver transplantation. A Markov model was constructed to compare undergoing DCD transplantation with remaining on the wait‐list until death or DBD liver transplantation. Differences in life years, quality‐adjusted life years (QALYs), and costs according to candidate Model for End‐Stage Liver Disease (MELD) score were considered. A separate model for hepatocellular carcinoma (HCC) patients with and without MELD exception points was constructed. For patients with a MELD score <15, DCD transplantation resulted in greater costs and reduced effectiveness. Patients with a MELD score of 15 to 20 experienced an improvement in effectiveness (0.07 QALYs) with DCD liver transplantation, but the incremental cost‐effectiveness ratio (ICER) was >

Patient‐reported barriers are associated with lower hepatocellular carcinoma surveillance rates in patients with cirrhosis

2,000,000/QALY. Patients with MELD scores of 21 to 30 (0.25 QALYs) and >30 (0.83 QALYs) also benefited from DCD transplantation with ICERs of

A Cost-efficacy Decision Analysis of Prophylactic Clip Placement After Endoscopic Removal of Large Polyps

478,222/QALY and

An assessment of benefits and harms of hepatocellular carcinoma surveillance in patients with cirrhosis

120,144/QALY, respectively. Sensitivity analyses demonstrated stable results for MELD scores <15 and >20, but the preferred strategy for the MELD 15 to 20 category was uncertain. DCD transplantation was associated with increased costs and reduced survival for HCC patients with exception points but led to improved survival (0.26 QALYs) at a cost of

The Safety of Drugs Used in Acid-related Disorders and Functional Gastrointestinal Disorders

392,067/QALY for patients without exception points. In conclusion, DCD liver transplantation results in inferior survival for patients with a MELD score <15 and HCC patients receiving MELD exception points, but provides a survival benefit to patients with a MELD score >20 and to HCC patients without MELD exception points. Liver Transpl,18:630–640, 2012.

Predictors of adequate ultrasound quality for hepatocellular carcinoma surveillance in patients with cirrhosis.

Over 20% of patients with cirrhosis are nonadherent with hepatocellular carcinoma (HCC) surveillance recommendations; however, few studies have evaluated the impact of patient‐level factors on surveillance receipt. We characterized the association between HCC surveillance receipt and patient knowledge, attitudes, and perceived barriers in a racially diverse and socioeconomically disadvantaged cohort of patients with cirrhosis. Patients with cirrhosis followed at a large urban hospital were invited to complete a survey about HCC surveillance between August 2014 and December 2015. Multivariable logistic regression was performed to identify factors associated with HCC surveillance receipt during the 12‐month period preceding and 6‐month period after survey administration. We achieved a response rate of 71.8% (n = 541 of 753). Patients demonstrated high levels of HCC‐related knowledge (summary score, 77.7%); however, 48.6% believed that eating a healthy diet precluded the need for HCC surveillance, and 34.0% believed that HCC surveillance was not necessary if they had a normal physical exam and/or lacked clinical symptoms. Patients expressed worry about developing and dying from HCC, but nearly half (49.9%) of patients reported barriers to receiving HCC surveillance, including difficulty with the scheduling process (30.5%), costs of surveillance testing (25.3%), and transportation difficulties (17.3%). HCC surveillance receipt was significantly higher in patients who knew cirrhosis is a risk factor for developing HCC (odds ratio [OR], 3.09; 95% confidence interval [CI], 1.25‐7.62) and significantly lower in those reporting barriers to surveillance (OR, 0.42; 95% CI, 0.25‐0.70). Conclusion: Patients with cirrhosis are knowledgeable and interested in HCC surveillance; however, patient‐reported barriers are associated with lower surveillance rates in clinical practice and represent potential intervention targets to improve HCC surveillance effectiveness. (Hepatology 2017;65:875‐884).

Glycemic Control by a Glucose Management Service and Infection Rates After Liver Transplantation

BACKGROUND & AIMS Delayed bleeding after lower endoscopy and polypectomy can cause significant morbidity. One strategy to reduce bleeding is to place an endoscopic clip on the polypectomy site. We used decision analysis to investigate the cost-effectiveness of routine clip placement after colon polypectomy. METHODS Probabilities and plausible ranges were obtained from the literature, and a decision analysis was conducted by using TreeAge Pro 2011 Software. Our cost-effectiveness threshold was an incremental cost-effectiveness ratio of

Patient-Reported Barriers are Associated with Lower HCC Surveillance Rates in Patients with Cirrhosis

100,000 per quality-adjusted life year. The reference case was a 50-year-old patient who had a single 1.0- to 1.5-cm polyp removed during colonoscopy. We estimated postpolypectomy bleeding rates for patients receiving no medications, those with planned resumption of antiplatelet therapy (nonaspirin), or those receiving anticoagulation therapy after polypectomy. We performed several sensitivity analyses, varying the cost of a clip and hospitalization, number of clips placed, clip effectiveness in reducing postpolypectomy bleeding, reduction in patient utility days related to gastrointestinal bleeding, and probability of harm from clip placement. RESULTS On the basis of the reference case, when patients did not receive anticoagulation therapy, clip placement was not cost-effective. However, for patients who did receive anticoagulation and antiplatelet therapies, prophylactic clip placement was a cost-effective strategy. The cost-effectiveness of a prophylactic clip strategy was sensitive to the costs of clips and hospitalization, number of clips placed, and clip effectiveness. CONCLUSIONS Placement of a prophylactic endoscopic clip after polypectomy appears to be a cost-effective strategy for patients who receive antiplatelet or anticoagulation therapy. This approach should be studied in a controlled trial.