Blood Safety Surveillance and Health Care Acquired Infection Division, Centre for Infectious Disease Prevention and Control, Public Health Agency of Canada, Ottawa, Ontario. firstname.lastname@example.org
Liver transplantation is an important health care issue for Canadians. Very few studies have assessed survival and determinants of survival in liver transplant patients in Canada.
We carried out an epidemiological analysis of 1 year survival and determinants of 1 year survival in liver transplant patients, using Canadian Organ Replacement Registry data (1997-2002). Survival curves were plotted by the Kaplan-Meier method. Cox proportional hazards analysis was applied to evaluate hazard ratios with different age groups, gender, ethnicity, blood groups, donor type, pretransplantation medical status, and HBV infection status.
A total of 1164 liver transplant patients were included in the analysis. One-year survival rate was 84.7%. Male recipients had a 21% higher risk of developing organ failure than females. Recipients over 60 years of age had a 5% lower survival probability in comparison with recipients below 20 years of age. Pacific Islanders and Aboriginals had 32% and 9% lower survival probabilities, respectively, in comparison with Caucasians. Type B blood recipients had a 12% higher survival probability, whereas type AB blood recipients had a 7% lower survival probability compared with type O blood recipients. Twenty-six live organ recipients had 40% higher survival probabilities than 1138 cadaveric organ recipients. Patients with fulminant hepatitis (status 3F) had the highest survival, while patients with fulminant failure in ICU with intubation/ventilation (status 4F) had the lowest survival. One hundred sixty-seven recipients with positive HBsAg antigen showed 10% lower survival probability than 997 cases with negative HBsAg antigen.
In Canada, the first year survival rate is about 85%, which is comparable with other industrialized countries. Type of donor organs and recipient gender, ethnicity, ABO blood group, pretransplantation medical status, and HBV infection status had significant affects on the recipient survival.
BACKGROUND: Liver transplantation has become an established therapeutic option for patients with life-threatening liver disease. The aim of the present study was to analyse the results of and developments in liver transplantation in the Nordic countries during a 15-year period. METHODS: Data on all patients receiving a liver allograft in the Nordic countries during 1982-98 and waiting list data for all patients listed for a liver transplantation after 1989 were obtained from the Nordic Liver Transplantation Registry. RESULTS: A total of 1485 first liver transplantations were performed during 1982-98. The annual number of first liver transplantations increased steadily up to 1993, thereafter remaining around 150-170 per year. There are major differences between countries both in the number of transplants adjusted to populations performed per year, with more than twice as many performed in Sweden as in Norway, and in the relative distribution of patients in accordance with diagnosis. The number of patients more than 60 years old increased and comprised 13%-14% of the total patient population during 1996-98. Primary biliary cirrhosis, primary sclerosing cholangitis, acute hepatic failure, malignant liver disease, and alcoholic cirrhosis are the five most frequent diagnoses. The over-all 1-year patient survival probability has increased from 66% among patients receiving a transplant in 1982-89 to 83% in 1995-1998. The waiting time remains stable, with a median waiting time of 35 days during 1990-98. The mortality of patients while on the waiting list is 7.4% and is not increasing. CONCLUSION: Results of liver transplantation in the Nordic countries are very similar to those obtained in other countries. Waiting time and mortality remain low. There are, however, major differences between the countries both as to the number of transplantations performed and as to distribution of diagnoses.
Cancer incidence and mortality risks were evaluated in a combined cohort of patients who were hospitalized for porphyria in Denmark (1977-1989) and Sweden (1965-1983). Patients were identified by using population-based hospitalization registries. The unique individual identification numbers of 530 patients with porphyria cutanea tarda (PCT) and 296 with acute intermittent porphyria (AIP) were linked to the nationwide cancer and death registries. Among patients with both types of porphyria, the authors found small but significantly elevated risks of all cancers combined (PCT: standardized incidence ratio (SIR) = 1.7, 95% confidence interval (CI) 1.3-2.2; AIP: SIR = 1.8, 95% CI 1.1-2.8) due to pronounced excesses of primary liver cancer (PCT: SIR = 21.2, 95% CI 8.5-43.7; AIP: SIR = 70.4, 95% CI 22.7-164.3) and moderate increases in lung cancer (PCT: SIR = 2.9, 95% CI 1.5-5.2; AIP: SIR = 2.8, 95% CI 0.3-10.2). PCT patients had a significantly increased risk of mortality from liver cirrhosis (standardized mortality ratio (SMR) = 8.4, 95% CI 3.1-18.4) or chronic obstructive pulmonary disease (SMR = 3.1, 95% CI 1.1-6.7). The increased risk of primary liver cancer and the increased risk of mortality from cirrhosis of the liver are consistent with findings from previous clinical surveys, but the new observations of excess lung cancer and chronic obstructive pulmonary disease require confirmation.
To examine the association between gallstones and cholecystectomy, we conducted a nationwide population-based cohort study in Denmark. Patients with a discharge diagnosis of gallstones from 1977 to 1989 were identified from the Danish National Registry of Patients and followed up for cancer occurrence until death or the end of 1993 by record linkage to the Danish Cancer Registry. Included in the cohort were 60 176 patients, with 471 450 person-years of follow-up. Cancer risks were estimated by standardized incidence ratios (SIRs) and 95% confidence intervals (CIs) stratified by years of follow-up and by cholecystectomy status. Among patients without cholecystectomy, the risks at 5 or more years of follow-up were significantly elevated for cancers of liver (SIR = 2.0, CI = 1.2-3.1) and gallbladder (SIR = 2.7, CI = 1.5-4.4) and near unity for cancers of extrahepatic bile duct (SIR = 1.1), ampulla of Vater (SIR = 1.0) and pancreas (SIR = 1.1). The excess risk of liver cancer was seen only among patients with a history of hepatic disease. Among cholecystectomy patients, the risks at 5 or more years of follow-up declined for cancers of liver (SIR = 1.1) and extrahepatic bile duct (SIR = 0.7), but were elevated for cancers of ampulla of Vater (SIR = 2.0, CI = 1.0-3.7) and pancreas (SIR = 1.3, CI = 1.1-1.6). These findings confirm that gallstone disease increases the risk of gallbladder cancer, whereas cholecystectomy appears to increase the risk of cancers of ampulla of Vater and pancreas. Further research is needed to clarify the carcinogenic risks associated with gallstones and cholecystectomy and to define the mechanisms involved.
Among 4,184 patients with cancer of the esophagus, 55 second primary cancers were observed, whereas 64 were expected [relative risk (RR) = 0.86]. The absence of an excess risk of alcohol- and tobacco-related cancers was not anticipated. A significant 19% deficit of second cancers was found among 30,843 patients with stomach cancer. Cancer of the rectum, kidney, and lung all occurred significantly below expectation. An excess risk of ovarian cancer (RR = 1.9) was seen in women. Reasons for these findings are not entirely clear. Cancer of the small intestine is rare, and despite a relatively short survival expectation, a moderate excess of second cancers was seen among 868 patients (36 vs. 26.8). Only cancers of the liver and gallbladder were significantly elevated, and the possibility of misclassified metastases is discussed. Colon cancer is one of the most common cancers in Denmark, and 29,490 patients with this disease were at slightly lower risk for development of second cancer (RR = 0.96; 95% confidence interval = 0.9-1.0) than the general Danish population, excluding secondary colon cancers. Esophageal, stomach, and liver cancers occurred less frequently than expected. That cancers of the uterine corpus and ovary were significantly increased supports the notion that common risk factors, such as diet and endogenous hormones, influence the development of these cancers. A significant 23% deficit of second cancers was also found among 26,597 patients with cancer of the rectum, excluding secondary rectal cancer. Significant deficits were seen for cancers of the stomach (RR = 0.5), lung (RR = 0.8), and brain (RR = 0.5), and for multiple myeloma (RR = 0.4). The likelihood of underreporting of second cancers, especially of the digestive system, is discussed. However, cancer of sites previously reported to be associated with rectal cancer, e.g., the colon, breast, and uterus, did not occur below expectation. Cancers of the liver and biliary tract occurred in 4,453 patients; their average survival was only 1 year. Except for a slight excess of cancer of the ovary (5 vs. 1.6), the risk of second cancer development for all sites was consistent with unity (RR = 0.90). The risk of second cancers among 7,752 persons with cancer of the pancreas was not greater than expected (88 vs. 85.2). Males were at significant risk of kidney cancer (RR = 3.2), whereas females showed elevated rates of cancers of the uterine corpus (RR = 3.2) and ovary (RR = 3.1). No site occurred significantly below expectation.
We examined 30-year nationwide trends in heart failure hospitalization and mortality rates, and the prognostic impact of co-morbidity.
We conducted a population-based cohort study of 317 161 patients with first-time inpatient hospitalizations for heart failure during 1983-2012. We computed the standardized hospitalization rate and 5-year mortality risk. Co-morbidity levels and calendar periods of diagnosis were compared by means of mortality rate ratios (MRRs) based on Cox regression. The standardized hospitalization rate (per 100 000 persons) decreased between 1983 and 2012 by 25% for women (from 192 to 144) and by 14% for men (from 217 to 186). The decrease reflected an average annual 1% increase until 2000 and a 3.5% decline thereafter. Between 1983-1987 and 2008-2012, 1-year mortality declined from 45% to 33% and 1- to 5-year mortality from 59% to 43%. The decline occurred independently of patients' co-morbidity levels. Comparing 2008-2012 with 1983-1987, the 5-year age-, sex-, and co-morbidity-adjusted MRR was 0.57 [95% confidence interval (CI) 0.56-0.58]. Using low co-morbidity as reference, the adjusted 5-year MRR in 2003-2007 was increased by 43% for moderate, 66% for severe, and 2.2-fold for very severe co-morbidity. The magnitude of co-morbidity-associated mortality increased over time and was highest in the youngest patients.
Hospitalization rates for heart failure have declined markedly since 2000 in Denmark. One- and five-year mortality declined >40% over the last three decades. The decline in mortality occurred for patients with all levels of co-morbidity, but co-morbidity burden was a strong prognostic factor.
Cancers of the digestive organs (including the oesophagus, stomach, small intestine, colon, rectum and anus, liver, gallbladder, and pancreas) constitute one-fifth of all cancer cases in the Nordic countries and is a group of diseases with diverse time trends and varying consequences for public health. In this study we examine trends in relative survival in relation to the corresponding incidence and mortality rates in the Nordic countries during the period 1964-2003. MATERIAL AND METHODS: Data were retrieved from the NORDCAN database for the period 1964 to 2003, grouped into eight 5-year periods of diagnosis. The patients were followed up until the end of 2006. Analysis comprised trends in 5-year relative survival, excess mortality and age-specific relative survival. RESULTS: Survival following cancers of the colon and rectum has increased continuously over the observed period, yet Danish patients fall behind those in the other Nordic countries. The largest inter-country variation is seen for the rare cancers in the small intestine. There has been little increase in prognosis for patients diagnosed with cancers of the liver, gallbladder or pancreas; 5-year survival is generally below 15%. Survival also remains consistently low for patients with oesophageal cancer, while minor increases in survival are seen among stomach cancer patients in all countries except Denmark. The concomitant incidence and mortality rates of stomach cancer have steadily decreased in each Nordic country at least since 1964. CONCLUSION: While the site-specific variations in mortality and survival largely reflect the extent of changing and improving diagnostic and clinical practices, the incidence trends highlight the importance of risk factor modification. Alongside the ongoing clinical advances, effective primary prevention measures, including the control of alcohol and tobacco consumption as well as changing dietary pattern, will reduce the incidence and mortality burden of digestive cancers in the Nordic countries.
BACKGROUND: American Indians and Alaska Natives (AI/AN) experience higher morbidity and mortality from primary liver cancer than other United States (US) populations, but racial misclassification in medical records results in underestimates of disease burden. METHODS: To reduce misclassification, National Program of Cancer Registries and Surveillance, Epidemiology, and End Results data were linked with Indian Health Service (IHS) enrollment records to compare primary liver cancer incidence and stage at diagnosis between AI/AN and non-Hispanic whites (NHW) living within the regionalized IHS Contract Health Service Delivery Area counties. Incidence rates are expressed per 100,000 persons and age-adjusted by 19 age groups to the 2000 US standard population. RESULTS: Overall, AI/AN have a higher proportion of hepatocellular carcinoma compared with NHW, 77.8% versus 66.7%. Liver cancer incidence rates among AI/AN males and females were higher than those among NHW males and females for all regions except for the East. Among males, rates ranged from 7.3 (95% confidence interval [CI], 3.8-12.6) in the East to 17.2 (95% CI, 10.4-26.3) in Alaska. Among females, rates ranged from 3.8 (95% CI, 1.4-8.2) in the East to 6.9 (95% CI, 3.6-11.6) in Alaska. The AI/AN rates for all regions were consistently higher than the NHW rates at every age. An increasing trend among AI/AN was suggested but did not achieve statistical significance. CONCLUSIONS: Reducing racial misclassification revealed higher disparities in primary liver cancer incidence between NHW and AI/AN populations than previously reported. Further description of the reasons for regional differences in this disparity is needed, as are programs to reduce risk factors and to diagnose primary liver cancer at earlier, more treatable stages.
Primary sclerosing cholangitis (PSC) is a rare cholestatic liver disease in children. The aim of this study was to determine the characteristics and outcomes of children with PSC who were listed for liver transplantation (LT). Children who underwent transplantation for PSC according to the Studies of Pediatric Liver Transplantation (SPLIT) registry were compared to age-matched children with chronic liver disease who underwent transplantation for other indications. Seventy-nine patients (2.6% of the SPLIT cohort) required LT for PSC. The mean duration of the post-LT follow-up was 36.6 ± 32.7 months. Ulcerative colitis and Crohn's disease were diagnosed before LT in 46.0% and 3.3% of the patients, respectively, and inflammatory bowel disease (IBD) was diagnosed after LT in another 9.8%. The mean age at LT was 12.6 ± 3.9 years, and the mean waiting time was 10.2 ± 12.9 months. The mean z scores for height and weight at LT were significantly lower for the PSC group versus the non-PSC group. For the PSC group, the 1- and 5-year patient survival rates were 98.7% and 86.6%, respectively, and the 1- and 5-year graft survival rates were 93.0% and 76.1%, respectively. Intrahepatic biliary strictures in the first 6 months post-LT and cholangitis in the first 30 days post-LT were more common in the PSC group versus the non-PSC group (3.8% versus 0.8% for intrahepatic biliary strictures, P = 0.03, and 5.1% versus 1.1% for cholangitis, P = 0.01). Recurrent PSC was diagnosed in 9.8% of the patients at a mean of 18.7 ± 13.8 months after LT. IBD was associated with an increased risk of death (log-rank P = 0.01) and recurrent PSC (P = 0.02). Five years post-LT, the mean aspartate aminotransferase level was 60 ± 45 IU/L, and the mean gamma-glutamyltransferase level was 209 ± 302 IU/L; both levels were significantly higher than the levels for non-PSC patients. In conclusion, children with PSC had patient and graft survival rates equaling those of age-matched children who underwent transplantation for other indications. IBD was associated with worse outcomes. Recurrence was observed in 9.8%, and the PSC patients had higher mean liver enzyme levels 5 years post-LT.