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Do older patients utilize excess health care resources after liver transplantation?

https://arctichealth.org/en/permalink/ahliterature131376
Source
Ann Hepatol. 2011 Oct-Dec;10(4):477-81
Publication Type
Article
Author
Neil Shankar
Mamoun AlBasheer
Paul Marotta
William Wall
Vivian McAlister
Natasha Chandok
Author Affiliation
Division of Gastroenterology, University of Western Ontario, London, Ontario, Canada.
Source
Ann Hepatol. 2011 Oct-Dec;10(4):477-81
Language
English
Publication Type
Article
Keywords
Adult
Age Factors
Aged
Chi-Square Distribution
Delivery of Health Care - economics - utilization
Female
Health Resources - economics - utilization
Humans
Intensive Care - utilization
Length of Stay
Liver Transplantation - adverse effects - economics
Male
Middle Aged
Odds Ratio
Ontario
Patient Readmission
Referral and Consultation - utilization
Regression Analysis
Reoperation
Risk assessment
Risk factors
Time Factors
Treatment Outcome
Abstract
Liver transplantation is a highly effective treatment for end-stage liver disease. However, there is debate over the practice of liver transplantation in older recipients (age = 60 years) given the relative shortage of donor grafts, worse post-transplantation survival, and concern that that older patients may utilize excess resources postoperatively, thus threatening the economic feasibility of the procedure.
To determine if patients = 60 years of age utilize more health resources following liver transplantation compared with younger patients.
Consecutive adult patients who underwent primary liver transplantation (n = 208) at a single center were studied over a 2.5-year period. Data were collected on clinico-demographic characteristics and resource utilization. Descriptive statistics, including means, standard deviations, or frequencies were obtained for baseline variables. Patients were stratified into 2 groups: age = 60 years (n = 51) and
PubMed ID
21911888 View in PubMed
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Early steroid withdrawal after liver transplantation: the Canadian tacrolimus versus microemulsion cyclosporin A trial: 1-year follow-up.

https://arctichealth.org/en/permalink/ahliterature185117
Source
Liver Transpl. 2003 Jun;9(6):587-95
Publication Type
Article
Date
Jun-2003
Author
Paul Greig
Leslie Lilly
Charles Scudamore
Siegfried Erb
Eric Yoshida
Norman Kneteman
Vince Bain
Cameron Ghent
Paul Marotta
David Grant
William Wall
Jean Tchervenkov
Jeffrey Barkun
Andre Roy
Denis Marleau
Vivian McAlister
Kevork Peltekian
Author Affiliation
University of Toronto, Canada. paul.greig@uhn.on.ca
Source
Liver Transpl. 2003 Jun;9(6):587-95
Date
Jun-2003
Language
English
Publication Type
Article
Keywords
Acute Disease
Adolescent
Adrenal Cortex Hormones - administration & dosage - adverse effects
Adult
Aged
Aged, 80 and over
Canada
Child
Chronic Disease
Cyclosporine - administration & dosage
Emulsions
Female
Follow-Up Studies
Graft Rejection - drug therapy - mortality
Graft Survival - drug effects
Humans
Immunosuppressive Agents - administration & dosage
Liver Transplantation
Male
Middle Aged
Prospective Studies
Tacrolimus - administration & dosage
Abstract
Corticosteroid therapy contributes significant toxicity to liver transplantation. The safety and efficacy of early steroid withdrawal were determined in patients treated with either tacrolimus or microemulsion cyclosporin A (micro-CsA). The primary outcome was the proportion of patients who were steroid-free 1 year posttransplantation. From the seven Canadian adult liver transplant centers, 143 patients were randomly allocated oral treatment with either tacrolimus (n = 71) or micro-CsA (n = 72), together with corticosteroids and azathioprine. Eligibility criteria for steroid withdrawal included freedom from acute rejection for a minimum of 3 months, and prednisone
PubMed ID
12783400 View in PubMed
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Early treatment response predicts the need for liver transplantation in autoimmune hepatitis.

https://arctichealth.org/en/permalink/ahliterature174001
Source
Liver Int. 2005 Aug;25(4):728-33
Publication Type
Article
Date
Aug-2005
Author
Patrick Tan
Paul Marotta
Cameron Ghent
Paul Adams
Author Affiliation
Division of Gastroenterology, Department of Medicine, London Health Sciences Centre, London, ON, Canada. ptan@uwo.ca
Source
Liver Int. 2005 Aug;25(4):728-33
Date
Aug-2005
Language
English
Publication Type
Article
Keywords
Adult
Azathioprine - therapeutic use
Canada - epidemiology
Drug Therapy, Combination
Endpoint Determination - methods
Female
Hepatitis, Autoimmune - diagnosis - drug therapy - mortality - surgery
Humans
Immunosuppressive Agents - therapeutic use
Liver Transplantation
Male
Middle Aged
Odds Ratio
Prednisolone - therapeutic use
Prognosis
Recurrence
Remission Induction
Retrospective Studies
Survival Rate
Transaminases - analysis
Treatment Outcome
Abstract
The need for immunosuppression in autoimmune hepatitis is established. Previous studies have investigated short-term outcomes in patients who respond to treatment. This study assesses long-term prognosis of patients who fail to respond to standard immunosuppression.
163 charts were reviewed, composed of 108 non-transplant patients and 55 patients who required liver transplantation (LT). Clinical endpoints were based on aminotransaminases: early treatment response (ER) was a 50% improvement at 6 months of therapy, Complete remission (CR) was an improvement to 3X normal, Incomplete response (IR) was some response but no CR in 3 years, and No response (NR) was no improvement after 3 years.
85% of non-LT and 25% of LT patients achieved ER, 91% of non-LT and 26% of LT patients achieved CR. 41% of non-LT patients relapsed on maintenance treatment, and 41% of non-LT patients relapsed when withdrawn from treatment. 9% of non-LT and 58% of LT patients had IR. 16% in LT group showed NR, while all non-LT patients showed some response. All paired comparisons were statistically different (P
PubMed ID
15998422 View in PubMed
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Evaluation of the updated definition of early allograft dysfunction in donation after brain death and donation after cardiac death liver allografts.

https://arctichealth.org/en/permalink/ahliterature121605
Source
Hepatobiliary Pancreat Dis Int. 2012 Aug 15;11(4):372-6
Publication Type
Article
Date
Aug-15-2012
Author
Kris P Croome
William Wall
Douglas Quan
Sai Vangala
Vivian McAlister
Paul Marotta
Roberto Hernandez-Alejandro
Author Affiliation
Multi-Organ Transplant Program, London Health Sciences Centre, The University of Western Ontario, London, Canada. kris.croome@hotmail.com
Source
Hepatobiliary Pancreat Dis Int. 2012 Aug 15;11(4):372-6
Date
Aug-15-2012
Language
English
Publication Type
Article
Keywords
Adult
Biliary Tract Diseases - etiology
Brain Death
Cholestasis - etiology
Female
Graft Survival
Humans
Incidence
International Normalized Ratio
Liver Transplantation - adverse effects - mortality
Logistic Models
Male
Middle Aged
Ontario
Predictive value of tests
Primary Graft Dysfunction - classification - diagnosis - etiology - mortality
Risk assessment
Risk factors
Terminology as Topic
Time Factors
Tissue Donors
Treatment Outcome
Abstract
An updated definition of early allograft dysfunction (EAD) was recently validated in a multicenter study of 300 deceased donor liver transplant recipients. This analysis did not differentiate between donation after brain death (DBD) and donation after cardiac death (DCD) allograft recipients.
We reviewed our prospectively entered database for all DBD (n=377) and DCD (n=38) liver transplantations between January 1, 2006 and October 30, 2011. The incidence of EAD as well as its ability to predict graft failure and survival was compared between DBD and DCD groups.
EAD was a valid predictor of both graft and patient survival at six months in DBD allograft recipients, but in DCD allograft recipients there was no significant difference in the rate of graft failure in those with EAD (11.5%) compared with those without EAD (16.7%) (P=0.664) or in the rate of death in recipients with EAD (3.8%) compared with those without EAD (8.3%) (P=0.565). The graft failure rate in the first 6 months in those with international normalized ratio =1.6 on day 7 who received a DCD allograft was 37.5% compared with 6.7% for those with international normalized ratio
PubMed ID
22893463 View in PubMed
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Liver transplantation for alcoholic liver disease among Canadian transplant centres: a national study.

https://arctichealth.org/en/permalink/ahliterature107226
Source
Can J Gastroenterol. 2013 Nov;27(11):643-6
Publication Type
Article
Date
Nov-2013
Author
Natasha Chandok
Mohammed Aljawad
Angela White
Roberto Hernandez-Alejandro
Paul Marotta
Eric M Yoshida
Source
Can J Gastroenterol. 2013 Nov;27(11):643-6
Date
Nov-2013
Language
English
Publication Type
Article
Keywords
Acute Disease
Alcohol Drinking - adverse effects - epidemiology
Alcoholism - complications - rehabilitation
Canada
Health Care Surveys
Hepatitis, Alcoholic - physiopathology - surgery
Humans
Liver Diseases, Alcoholic - physiopathology - surgery
Liver Transplantation - statistics & numerical data
Patient Selection
Severity of Illness Index
Social Support
Temperance
Time Factors
Waiting Lists
Abstract
BACKGROUND/
Alcoholic liver disease (ALD) is a controversial yet established indication for liver transplantation (LT), and there is emerging evidence supporting a survival benefit in selected patients with severe acute alcoholic hepatitis. The aim of the present survey was to describe policies among Canadian transplant centres for patients with ALD.
A survey was distributed to the medical directors of all seven liver transplant centres in Canada.
All seven liver transplant programs in Canada participated in the survey. Every centre requires patients to have a minimum of six months of abstinence from alcohol before listing for LT. Completion of a rehabilitation program is only mandatory in one program; the remaining programs do not mandate this if patients have demonstrated prolonged abstinence, and sufficient insight and social supports. No program considers LT for patients with severe acute alcoholic hepatitis, although six of the seven programs are interested in exploring a national policy. Random alcohol checks for waitlisted patients are performed routinely on patients listed for ALD at only one centre; the remaining centres only perform checks if there is clinical suspicion. In the past five years, the mean (± SD) number of patients per centre with graft dysfunction from recidivism was 10±4.36; a mean of 2.5±4.36 patients per centre developed graft failure.
With minor exceptions, LT policies for subjects with ALD are uniform across Canadian transplant programs. Presently, no centres perform LT for acute alcoholic hepatitis, although there is broad interest in exploring a national policy. Recidivism resulting in graft loss is a rare phenomenon.
Notes
Comment In: Can J Gastroenterol. 2013 Nov;27(11):625-624199208
PubMed ID
24040631 View in PubMed
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Long-term outcomes of emergency liver transplantation for acute liver failure.

https://arctichealth.org/en/permalink/ahliterature147166
Source
Liver Transpl. 2009 Dec;15(12):1696-702
Publication Type
Article
Date
Dec-2009
Author
Gabriel Chan
Ali Taqi
Paul Marotta
Mark Levstik
Vivian McAlister
William Wall
Douglas Quan
Author Affiliation
Multi-Organ Transplant Programme, London Health Sciences Centre, London, Ontario, Canada. gabrielk.chan@lhsc.on.ca
Source
Liver Transpl. 2009 Dec;15(12):1696-702
Date
Dec-2009
Language
English
Publication Type
Article
Keywords
Adolescent
Adult
Aged
Brain Edema - complications
Emergency Treatment
Female
Humans
Kaplan-Meier Estimate
Liver Failure, Acute - etiology - mortality - surgery
Liver Transplantation - adverse effects - contraindications - mortality
Male
Middle Aged
Nervous System Diseases - etiology
Ontario - epidemiology
Patient Selection
Proportional Hazards Models
Retrospective Studies
Risk assessment
Risk factors
Survivors - statistics & numerical data
Time Factors
Tissue Donors - supply & distribution
Treatment Outcome
Waiting Lists
Young Adult
Abstract
Acute liver failure continues to be associated with a high mortality rate, and emergency liver transplantation is often the only life-saving treatment. The short-term outcomes are decidedly worse in comparison with those for nonurgent cases, whereas the long-term results have not been reported as extensively. We report our center's experience with urgent liver transplantation, long-term survival, and major complications. From 1994 to 2007, 60 patients had emergency liver transplantation for acute liver failure. The waiting list mortality rate was 6%. The mean waiting time was 2.7 days. Post-transplantation, the perioperative mortality rate was 15%, and complications included neurological problems (13%), biliary problems (10%), and hepatic artery thrombosis (5%). The 5- and 10-year patient survival rates were 76% and 69%, respectively, and the graft survival rates were 65% and 59%. Recipients of blood group-incompatible grafts had an 83% retransplantation rate. Univariate analysis by Cox regression analysis found that cerebral edema and extended criteria donor grafts were associated with worse long-term survival. Severe cerebral edema on a computed tomography scan pre-transplant was associated with either early mortality or permanent neurological deficits. The keys to long-term success and continued progress in urgent liver transplantation are the use of good-quality whole grafts and a short waiting list time, both of which depend on access to a sufficient pool of organ donors. Severe preoperative cerebral edema should be a relative contraindication to transplantation.
PubMed ID
19938124 View in PubMed
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Percutaneous liver biopsy practice patterns among Canadian hepatologists.

https://arctichealth.org/en/permalink/ahliterature106299
Source
Can J Gastroenterol. 2013 Nov;27(11):e31-4
Publication Type
Article
Date
Nov-2013
Author
Mohammed Aljawad
Eric M Yoshida
Julia Uhanova
Paul Marotta
Natasha Chandok
Source
Can J Gastroenterol. 2013 Nov;27(11):e31-4
Date
Nov-2013
Language
English
Publication Type
Article
Keywords
Attitude of Health Personnel
Biopsy, Needle - methods
Canada
Endoscopy - methods
Female
Gastroenterology - methods
Health Care Surveys
Humans
Liver Diseases - diagnosis
Male
Patient Preference
Physician's Practice Patterns - statistics & numerical data
Referral and Consultation - statistics & numerical data
Reimbursement Mechanisms
Abstract
Percutaneous liver biopsy (PLB) is the standard procedure to obtain histological samples essential for the management of various liver diseases. While safe, many hepatologists no longer perform their own PLBs; the reasons for this practice shift are unknown.
To describe the attitudes, practice patterns and barriers to PLB among hepatologists in Canada.
A survey was distributed to all hepatologists in Canada.
Thirty-two of 40 (80%) hepatologists completed the survey; the majority of respondents were male (72%) and had been in practice for >5 years in an academic setting. Fifty-six per cent of hepatologists referred all PLBs to radiology, and only 19% of hepatologists reported performing their own PLBs most or all of the time. There were no sex differences nor were there differences based on years in practice. Fifty per cent of respondents who performed PLB routinely used ultrasound, and PLBs are performed in equal frequency in an ambulatory procedure area (50%) versus the endoscopy suite (36%). For almost one-half of hepatologists (47%), their performance of PLBs decreased in the past five years. The majority of respondents at an academic centre (75%) reported access to FibroScan (Echosens, France), and most estimated a resultant 25% to 50% reduction in the need for PLBs. Lack of resources, patient preference and suboptimal reimbursement were the most common reasons cited for not performing PLBs.
Most hepatologists in Canada do not perform PLBs to the extent that they did in the past, but refer to radiology. The reasons for this shift in practice include lack of resources, improved perception of safety and patient preference. Where available, FibroScan resulted in a perceived 25% to 50% reduction in required liver biopsies.
Notes
Comment In: Can J Gastroenterol Hepatol. 2014 Feb;28(2):109-1024501726
PubMed ID
24199212 View in PubMed
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Recipient ineligibility after liver transplantation assessment: a single centre experience.

https://arctichealth.org/en/permalink/ahliterature113605
Source
Can J Surg. 2013 Jun;56(3):E39-43
Publication Type
Article
Date
Jun-2013
Author
Aman Arya
Roberto Hernandez-Alejandro
Paul Marotta
Julia Uhanova
Natasha Chandok
Author Affiliation
The Division of Gastroenterology, the Multiorgan Transplant Program, Western University, London, Ont., Canada.
Source
Can J Surg. 2013 Jun;56(3):E39-43
Date
Jun-2013
Language
English
Publication Type
Article
Keywords
Adult
Canada
Cohort Studies
Eligibility Determination - organization & administration - statistics & numerical data
End Stage Liver Disease - complications - diagnosis - surgery
Female
Health status
Humans
Liver Transplantation - statistics & numerical data
Male
Middle Aged
Patient Selection
Quality Assurance, Health Care
Severity of Illness Index
Tissue and Organ Procurement - organization & administration - statistics & numerical data
Abstract
Candidacy for liver transplantation is determined through standardized evaluation. There are limited data on the frequency and reasons for denial of transplantation after assessment; analysis may shed light on the short-term utility of the assessment. We sought to describe the frequency and reasons for ineligibility for liver transplantation among referred adults.
We studied all prospectively followed recipient candidates at a single centre who were deemed unsuitable for liver transplantation after assessment. Inclusion criteria were age 18 years and older and completion of a standard liver transplantation evaluation over a 3-year period. Patients were excluded if they had a history of prior assessment or liver transplantation within the study period. Demographic and baseline clinical data and reasons for recipient ineligibility were recorded.
In all, 337 patients underwent their first liver transplantation evaluation during the study period; 166 (49.3%) fulfilled inclusion criteria. The mean age was 55.4 years, and 106 (63.9%) were men. The 3 most common reasons for denial of listing were patient too well (n = 82, 49.4%), medical comorbidities and/or need for medical optimization (n = 43, 25.9%) and need for addiction rehabilitation (n = 28, 16.9%).
Ineligibility for transplantation after assessment was common, occurring in nearly half of the cohort. Most denied candidates could be identified with more discriminate screening before the resource-intensive assessment; however, the assessment likely provides unforeseen positive impacts on patient care.
Notes
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PubMed ID
23706857 View in PubMed
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Recurrent hepatitis C post-transplantation: where are we now and where do we go from here? A report from the Canadian transplant hepatology workshop.

https://arctichealth.org/en/permalink/ahliterature166488
Source
Can J Gastroenterol. 2006 Nov;20(11):725-34
Publication Type
Article
Date
Nov-2006
Author
Kymberly D S Watt
Kelly Burak
Marc Deschênes
Les Lilly
Denis Marleau
Paul Marotta
Andrew Mason
Kevork M Peltekian
Eberhard L Renner
Eric M Yoshida
Author Affiliation
Dalhousie University QEII HSC, Halifax, Canada. wattk@cdha.nshealth.ca
Source
Can J Gastroenterol. 2006 Nov;20(11):725-34
Date
Nov-2006
Language
English
Publication Type
Article
Keywords
Canada - epidemiology
Gastroenterology - methods - trends
Hepatitis C, Chronic - epidemiology - etiology - prevention & control
Humans
Liver Transplantation - adverse effects
Postoperative Complications
Prognosis
Recurrence - prevention & control
Abstract
Approximately 400 liver transplants are performed in Canada every year and close to 6000 per year in the United States. Forty per cent to 45% of all liver transplants are performed for patients with underlying hepatitis C virus (HCV)-related liver disease. These patients have a different natural history, new complication risks and different treatment efficacy than nontransplant HCV patients. Every effort must be made to identify those patients at highest risk for progressive liver disease post-transplant. Recurrent HCV is an Achilles' heel to transplant hepatology. The true natural history of this disease is only starting to unravel and many questions remain unanswered on the optimal management of these patients after liver transplantation. The present report summarizes the literature and ongoing research needs that are specific to HCV-related liver transplantation.
Notes
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PubMed ID
17111055 View in PubMed
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9 records – page 1 of 1.