Geographic disparities limit access to liver transplantation

Abstract

Background: Piggy-back (PB) anastomosis with implantation on the common trunk is the standard technique for patients undergoing whole graft liver transplantation with caval preservation. While piggy back anastomosis with right hepatic vein (RHV-PB) implantation allows decreasing the risk of caval twisting in case of partial graft liver transplantation, its value in patients receiving small sized whole liver grafts and large hepatic fossa, remains poorly described. Methods: From 2010 to 2016, all patients undergoing whole graft liver transplantation with RHV-PB implantation were retrospectively analyzed. The choice of IVC anastomosis was decided during LT based on both graft size and recipient right upper quadrant depth. Operative time, cold and warm ischemia times, postoperative bleeding, and long-term patency were analyzed. Results: Among 596 patients receiving whole graft LT, 173 (29%) patients had RHV-PB. The rate of RHV-PB significantly increased from 8% in 2010 to 54% in 2016 (p < 0.001). Median age was 52.8 years (18e73) and 112 (64.7%) patients were male. Median graft weight and graft weight/recipients' weight were 1239 g (770e2000) and 1.7% (0.9e3.0), respectively. No IVC cross-clamping was required during the anhepatic phase. Skin only closure was required in 5 (2.9%) patients. Postoperative mortality occurred in 17 patients (9.8%) but no complication related to RHV-PB occurred during follow up (0e72 months). Conclusion: PB-RHV anastomosis is a safe and well tolerated technique, which may avoid the risk of caval twisting in patients receiving small whole liver grafts.

Bridging the rural-urban gap in access to liver transplantation

“…Once referred, however, rural residents were 14% less likely to be waitlisted for LT (risk ratio = 0.86; 95% CI, 0.83-0.89) and 20% less likely to receive a transplant (risk ratio = 0.80; 95% CI, 0.77-0.84) when compared to urban residents in a cohort study from an older era (1999)(2000)(2001)(2002)(2003)(2004)). [8] More recent single-center data showed that urban compared to rural residents had 33% higher odds of LT. [9] Importantly, thus far, studies have not shown any significant differences in outcomes after transplant between the 2 groups. [8,9] The clear gap in data means lower investment in the problem: more robust and up-to-date studies on transplant outcomes across the rural-urban continuum, including pre/post-Acuity Circle implementation, are needed as a call to action.…”

“…Once referred, however, rural residents were 14% less likely to be waitlisted for LT (risk ratio=0.86; 95% CI, 0.83–0.89) and 20% less likely to receive a transplant (risk ratio=0.80; 95% CI, 0.77–0.84) when compared to urban residents in a cohort study from an older era (1999–2004) 8 . More recent single-center data showed that urban compared to rural residents had 33% higher odds of LT 9 . Importantly, thus far, studies have not shown any significant differences in outcomes after transplant between the 2 groups 8,9 .…”

“…[11] However, 1 study found that urban residents living 200+ miles from the listing center were still twice as likely to get LT than rural residents living within 50 miles, suggesting that distance alone does not explain rural-urban disparities. [9] Compared with urban areas, rural areas are characterized by higher rates of poverty, worse health outcomes, and higher age-adjusted mortality. In fact, US counties with the least economic gains over time have the highest age-adjusted liver-related mortality rates.…”

“…More recent single-center data showed that urban compared to rural residents had 33% higher odds of LT 9 . Importantly, thus far, studies have not shown any significant differences in outcomes after transplant between the 2 groups 8,9 . The clear gap in data means lower investment in the problem: more robust and up-to-date studies on transplant outcomes across the rural-urban continuum, including pre/post–Acuity Circle implementation, are needed as a call to action.…”

“…A UNOS study identified the highest mortality when individuals with Model for End-Stage Liver Disease <20 lived over 30 miles from an LT center 11 . However, 1 study found that urban residents living 200+ miles from the listing center were still twice as likely to get LT than rural residents living within 50 miles, suggesting that distance alone does not explain rural-urban disparities 9 …”