Impact of transjugular intrahepatic porto-systemic shunt on post liver transplantation outcomes: Study based on the United Network for Organ Sharing database

AIM To determine the impact of transjugular intrahepatic porto-systemic shunt(TIPS) on post liver transplantation(LT) outcomes.METHODS Utilizing the United Network for Organ Sharing(UNOS) database, we compared patients who underwent LT from 2002 to 2013 who had underwent TIPS to those without TIPS for the management of ascites while on the LT waitlist. The impact of TIPS on 30-d mortality, length of stay(LOS), and need for re-LT were studied. For evaluation of mean differences between baseline characteristics for patients with and without TIPS, we used unpaired t-tests for continuous measures and χ~2 tests for categorical measures. We estimated the impact of TIPS on each of the outcome measures. Multivariate analyses were conducted on the study population to explore the effect of TIPS on 30-d mortality post-LT, need for re-LT and LOS. All covariates were included in logistic regression analysis.RESULTS We included adult patients(age ≥ 18 years) who underwent LT from May 2002 to September 2013. Only those undergoing TIPS after listing and before liver transplant were included in the TIPS group. We excluded patients with variceal bleeding within two weeks of listing for LT and those listed for acute liver failure or hepatocellular carcinoma. Of 114770 LT in the UNOS database, 32783(28.5%) met inclusion criteria. Of these 1366(4.2%) had TIPS between the time of listing and LT. We found that TIPS increased the days on waitlist(408 ± 553 d) as compared to those without TIPS(183 ± 330 d), P < 0.001. Multivariate analysis showed that TIPS had no effect on 30-d post LT mortality(OR = 1.26; 95%CI: 0.91-1.76) and re-LT(OR = 0.61; 95%CI: 0.36-1.05). Pre-transplant hepatic encephalopathy added 3.46 d(95%CI: 2.37-4.55, P < 0.001), followed by 2.16 d(95%CI: 0.92-3.38, P = 0.001) by TIPS to LOS. CONCLUSION TIPS did increase time on waitlist for LT. More importantly, TIPS was not associated with 30-d mortality and re-LT, but it did lengthen hospital LOS after transplantation.

Effect of transplant center volume on post-transplant survival in patients listed for simultaneous liver and kidney transplantation

AIM To examine the effect of center size on survival differences between simultaneous liver kidney transplantation(SLKT) and liver transplantation alone(LTA) in SLKT-listed patients.METHODS The United Network of Organ Sharing database was queried for patients ≥ 18 years of age listed for SLKT between February 2002 and December 2015. Posttransplant survival was evaluated using stratified Cox regression with interaction between transplant type(LTA vs SLKT) and center volume.RESULTS During the study period, 393 of 4580 patients(9%) listed for SLKT underwent a LTA. Overall mortality was higher among LTA recipients(180/393, 46%) than SLKT recipients(1107/4187, 26%). The Cox model predicted a significant survival disadvantage for patients receiving LTA vs SLKT [hazard ratio, hazard ratio(HR) = 2.85; 95%CI: 2.21, 3.66; P < 0.001] in centers performing 30 SLKT over the study period. This disadvantage was modestly attenuated as center SLKT volume increased, with a 3% reduction(HR = 0.97; 95%CI: 0.95, 0.99; P = 0.010) for every 10 SLKs performed.CONCLUSION In conclusion, LTA is associated with increased mortality among patients listed for SLKT. This difference is modestly attenuated at more experienced centers and may explain inconsistencies between smaller-center and larger registry-wide studies comparing SLKT and LTA outcomes.

Development of necrotizing enterocolitis after blood transfusion in very premature neonates

Background Prior studies report conflicting evidence on the association between packed red blood cell(PRBC)transfu-sions and necrotizing enterocolitis(NEC),especially in early weeks of life where transfusions are frequent and spontaneous intestinal perforation can mimic NEC.The primary objective of this study was to evaluate the association between PRBC transfusions and NEC after day of life(DOL)14 in very premature neonates.Methods A retrospective cohort analysis of very premature neonates was conducted to investigate association between PRBC transfusions and NEC after DOL 14.Primary endpoints were PRBC transfusions after DOL 14 until the date of NEC diagnosis,discharge,or death.Wilcoxon ranked-sum and Fisher's exact tests,Cox proportional hazards regression,and Kaplan-Meier curves were used to analyze data.Results Of 549 premature neonates,186(34%)received transfusions after DOL 14 and nine(2%)developed NEC(median DOL=38;interquartile range=32-46).Of the nine with NEC after DOL 14,all were previously transfused(P<0.001);therefore,hazard of NEC could not be estimated.Post hoc analysis of patients from DOL 10 onward included five additional patients who developed NEC between DOL 10 and DOL 14,and the hazard of NEC increased by a factor of nearly six after PRBC transfusion(hazard ratio=5.76,95%confidence interval=1.02-32.7;P=0.048).Conclusions Transfusions were strongly associated with NEC after DOL 14.Prospective studies are needed to determine if restrictive transfusion practices can decrease incidence of NEC after DOL 14.

Cohort contributions to trends in the incidence and mortality of intrahepatic cholangiocarcinoma

Background: The incidence and mortality of intrahepatic cholangiocarcinoma (ICC) are increasing worldwide. We used age-period-cohort (APC) modeling to evaluate the contribution of cohort effects to trends in ICC incidence and mortality in the US. Methods: Incidence data were acquired from the Surveillance, Epidemiology and End-Results (SEER) program. Mortality data were obtained from the Centers for Disease Control and Prevention WONDER Database. APC models using restricted cubic splines were fitted to estimate change in incidence and mortality risk over age, and modification of incidence and mortality risks according to birth cohort and period of diagnosis or death. Likelihood ratio tests were used to summarize improvement in model fit with APC modeling. Results: There were 4,053 cases of ICC at SEER registry sites between 1973–2012. ICC incidence increased with older age and across all birth cohorts examined. Inclusion of cohort effects tended to improve model fit relative to an age-period model (likelihood ratio test P=0.082). The national crude ICC-related mortality rate increased from 2.9 to 5.0 per 100,000 among males and 2.7 to 4.6 per 100,000 among females. Among males, ICC mortality risk varied across birth cohorts, and inclusion of cohort effects in a model predicting ICC mortality risk improved model fit (likelihood ratio test P=0.001), but cohort effects did not alter model fit among females (P=0.223). Conclusions: ICC incidence and mortality have increased over time in the United States. Birth cohort effects influenced increased ICC incidence and ICC mortality among males, but were not evident in the trend of ICC mortality among females.