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Outcomes of Liver Transplantation for Hepatocellular Carcinoma Beyond the Milan Criteria: A Systematic Review and Meta-Analysis
Su1420
AASLD Abstracts
A PROTOCOL THAT REDUCES 30 AND 90 DAY READMISSIONS AND COSTS AFTER LIVER TRANSPLANTATION Joseph H. Zeidan, Donna Biege, Mark W. Russo Background: Liver transplantation (OLT) is a resource intensive procedure. The current healthcare environment emphasizes providing high quality, affordable care. In a prior study we demonstrated that a prospective protocol designed to reduce readmission rates was effective in reducing 30 day readmission rates from 40% to 20% after liver transplantation. Aim: To determine if a protocol that was effective in reducing 30 day inpatient readmission rates after tranplant was effective in reducing 90 day readmissions and costs. Methods: From January 1, 2012 until October 31, 2016, 283 adult primary liver transplants were performed and data in 30 and 90 day inpatient readmission rates and 30 day and 90 day inpatient hospital charges after OLT were collected. 30 day inpatient readmission was from time of discharge from initial hospitalization for OLT and 90 day inpatient readmission included from time of discharge from initial OLT to 90 days. Inpatient status is defined as an admission for more than 24 hours, if before October 2013, or more than 2 midnight stay, if after October 2013. The preprotocol group (n=120), transplant recipients from Jan 1, 2012-Dec 31, 2013, were compared to the postprotocol group Jan 1, 2014-October 31, 2016 (n=163). The protocol focused on expanding outpatient services, enhanced patient education and providing alternatives to ED visits. Results: Among the 283 liver transplant recipients, 71 (25%) were readmitted within 30 days of original discharge and 101 (36%) were readmitted within 90 days. The total cost from January 1 ,2012 until May 31, 2016 for 30 days and 90 day readmissions were $1,398,401 and $2,682,248, respectively. The 30 day inpatient readmission rates before and after implementation of the protocol were 48/120 (40%) and 23/163 (14%), respectively and 90 day inpatient readmission rates before and after the protocol were 63/120 (53%) and 38/163 (23%), respectively (Table). Total costs for 90 day readmission pre and postprotocol were $1,781,755 and $900,493, respectively. However, average cost per 90 day readmission were similar pre and post protocol equaling $16,652 and $16,373, respectively, indicating that costs were reduced by reducing the total readmission rate. 30 day and 1 year graft survival were not significantly different over the study period and remained 97% and 90%, respectively Conclusions: A protocol designed to reduce 30 day inpatient readmission rates after OLT was associated with reduction in 90 day inpatient readmission rates and lower total costs for inpatient readmissions. Our protocol may be of interest to other liver transplant centers and serve as a blueprint for reducing healthcare utilization without compromising quality. Readmission Rates and Cost
Figure 1. Pooled relative risks of HCC recurrence after LT for HCC with various extended criteria, adjusted for type of donor.
Su1421 Figure 2. Pooled relative risks of overall death after LT for HCC with various extended criteria, adjusted for type of donor.
OUTCOMES OF LIVER TRANSPLANTATION FOR HEPATOCELLULAR CARCINOMA BEYOND THE MILAN CRITERIA: A SYSTEMATIC REVIEW AND META-ANALYSIS Thapanakul Emyoo, Piyapon Utako, Noriyo Yamashiki, Thunyarat Anothaisintawee, Ammarin Thakkinstian, Abhasnee Sobhonslidsuk
Su1422
Background and Aims: Liver transplantation (LT) is recommended for early-stage hepatocellular carcinoma (HCC). The Milan criteria (MC) is used to select HCC candidates for LT. However, many patients who might get benefit from LT may be ineligible because the MC may be too strict. Extended criteria beyond the MC, such as UCSF, Up-to-7, Kyoto, TTV/ AFP, Hangzhou have been proposed but results were conflictingly reported. We therefore conducted a systematic review to estimate and compare the risk of post-LT HCC recurrence and mortality among these extended criteria. Methods: Medline and Scopus were searched from 1 January 1996 to 31 December 2015 to identify studies involving LT for HCC patients within the MC and five extended criteria. Exclusion criteria were studies with insufficient data, non-cohort design or undecipherable language. Two authors performed the study independently. Mortality and recurrence rate were pooled and analyzed. Results: A total of 39 cohorts out of 39 studies (n = 17,655 HCC patients) were included in our review, with 3,892 deaths and 3,191 HCC recurrences after LT. The pooled overall post-LT HCC recurrence rate for patients with HCC beyond the MC but within the UCSF, Hangzhou, Kyoto, TTV/AFP were 28.1%, 22.9%, 25.0%, 18.0% respectively comparing to the MC (15.8%). Among these criteria, the risks of recurrence were statistically significant for UCSF vs MC and Hangzhou vs MC criteria with the pooled risk ratios (RR) of 1.78 (95%CI 1.42-2.24) and 1.44 (95%CI 1.31-1.59), respectively (Figure 1). Contrastingly, the pooled overall recurrence rate was lower in Up-to-7 when compared with MC (8% vs 15.8%) with the pooled RR of 0.44 (95%CI 0.27-0.72). The pooled overall mortality rate for patients with HCC beyond the MC but within the UCSF criteria was significant higher than those within the MC (29.0% vs 19.4%) with the pooled RR of 1.69 ( 95%CI 1.46-1.95) (Figure 2), whereas the Up-to-7 and Hangzhou criteria were a little higher but not significant. In addition, the overall recurrence and mortality rate of LT with the Kyoto and TTV/AFP criteria were not different from the MC. Conclusions: Among extended criteria beyond MC, the Up-to-7 criteria, Kyoto, and TTV/AFP criteria have been applied without increasing recurrence and mortality comparing to the MC. Patients with HCC beyond MC but within UCSF have higher risk of recurrence and mortality than patients with HCC within MC. Patients with HCC beyond MC but within Hangzhou criteria have a higher risk of recurrence than those within MC without difference in mortality. Further study is required to confirm the results.
AASLD Abstracts
S-1124
OUTCOMES OF LIVING DONOR LIVER TRANSPLANTATION (LDLT) VERSUS DECEASED DONOR LIVER TRANSPLANTATION (DDLT) AND A NATIONAL INPATIENT SAMPLE (NIS) STUDY Richa Bhardwaj, Gaurav Bhardwaj, Dorothy B. Wakefield, Raffi Karagozian Aim: To determine mortality, length of stay (LOS), hospital charges and procedure related complications in hospitalized patients undergoing LDLT versus DDLT. Introduction: Liver Transplant (LT) is the standard of care for advanced-stage liver disease. There is a significant disparity between the number of patients needing liver transplantation and the availability of donors. LDLT is a promising alternative to DDLT as it curtails the waiting time for transplant significantly, allowing the procedure to be performed during early stages of end stage liver disease in relatively less sick patients. However, unavoidable significant morbidity and mortality of living donors and complications related to a more complex procedure are the concerns that have been raised. Multicenter consortiums have compared LDLT and DDLT outcomes including graft survival, however limited data is available in terms of mortality, resource utilization and inpatient hospitalization trends in nationwide studies. Methods: Data from the NIS for the year 2012, containing data from 44 states and 4,378 hospitals, accounting for over 7 million discharges were analyzed. LT patients were identified using ICD-9 procedure codes 50.5, 50.51, 50.59. LDLT and DDLT patients were further identified using procedure codes 00.91, 00.92 and 00.93.Primary outcomes included inpatient mortality, LOS and hospital charges. Secondary outcomes were identified using ICD9 diagnosis codes. Results: A total of 1091 nationwide LT hospital admissions were identified with a total of 801 DDLT and 69 LDLT procedures. The mean age of patients for DDLT and LDLT was 54.7 and 55.3 years respectively. Females were more likely to receive LDLT as compared to DDLT (43.4 % versus 32.5 % , p 0.007 ). Overall the most prevalent underlying liver conditions were Hepatitis C, HCC, NASH and Alcoholic liver disease (ALD) with NASH being a more common underlying etiology in LDLT patients (18,8%, p <0.001) and Hepatitis C (46.8%,p <0.001) in DDLT patients. The rates of overall mortality, sepsis, ARDS and Clostridium difficile infection were comparable between the two groups but the rates of transplant related complications were significantly higher in the LDLT group (26.1%, p 0.01) Conclusion: LDLT recipients had significantly lower LOS and mean hospitalization charges likely due to a relatively healthier population with lower MELD scores. The overall mortality rates for DDLT and LDLT are comparable. The LOS and mean hospitalization charges were significantly higher in the DDLT group. NASH patients were more likely to be living donor recipients. LDLT patients had a higher rate of transplant related complication
AASLD Abstracts
A PROTOCOL THAT REDUCES 30 AND 90 DAY READMISSIONS AND COSTS AFTER LIVER TRANSPLANTATION Joseph H. Zeidan, Donna Biege, Mark W. Russo Background: Liver transplantation (OLT) is a resource intensive procedure. The current healthcare environment emphasizes providing high quality, affordable care. In a prior study we demonstrated that a prospective protocol designed to reduce readmission rates was effective in reducing 30 day readmission rates from 40% to 20% after liver transplantation. Aim: To determine if a protocol that was effective in reducing 30 day inpatient readmission rates after tranplant was effective in reducing 90 day readmissions and costs. Methods: From January 1, 2012 until October 31, 2016, 283 adult primary liver transplants were performed and data in 30 and 90 day inpatient readmission rates and 30 day and 90 day inpatient hospital charges after OLT were collected. 30 day inpatient readmission was from time of discharge from initial hospitalization for OLT and 90 day inpatient readmission included from time of discharge from initial OLT to 90 days. Inpatient status is defined as an admission for more than 24 hours, if before October 2013, or more than 2 midnight stay, if after October 2013. The preprotocol group (n=120), transplant recipients from Jan 1, 2012-Dec 31, 2013, were compared to the postprotocol group Jan 1, 2014-October 31, 2016 (n=163). The protocol focused on expanding outpatient services, enhanced patient education and providing alternatives to ED visits. Results: Among the 283 liver transplant recipients, 71 (25%) were readmitted within 30 days of original discharge and 101 (36%) were readmitted within 90 days. The total cost from January 1 ,2012 until May 31, 2016 for 30 days and 90 day readmissions were $1,398,401 and $2,682,248, respectively. The 30 day inpatient readmission rates before and after implementation of the protocol were 48/120 (40%) and 23/163 (14%), respectively and 90 day inpatient readmission rates before and after the protocol were 63/120 (53%) and 38/163 (23%), respectively (Table). Total costs for 90 day readmission pre and postprotocol were $1,781,755 and $900,493, respectively. However, average cost per 90 day readmission were similar pre and post protocol equaling $16,652 and $16,373, respectively, indicating that costs were reduced by reducing the total readmission rate. 30 day and 1 year graft survival were not significantly different over the study period and remained 97% and 90%, respectively Conclusions: A protocol designed to reduce 30 day inpatient readmission rates after OLT was associated with reduction in 90 day inpatient readmission rates and lower total costs for inpatient readmissions. Our protocol may be of interest to other liver transplant centers and serve as a blueprint for reducing healthcare utilization without compromising quality. Readmission Rates and Cost
Figure 1. Pooled relative risks of HCC recurrence after LT for HCC with various extended criteria, adjusted for type of donor.
Su1421 Figure 2. Pooled relative risks of overall death after LT for HCC with various extended criteria, adjusted for type of donor.
OUTCOMES OF LIVER TRANSPLANTATION FOR HEPATOCELLULAR CARCINOMA BEYOND THE MILAN CRITERIA: A SYSTEMATIC REVIEW AND META-ANALYSIS Thapanakul Emyoo, Piyapon Utako, Noriyo Yamashiki, Thunyarat Anothaisintawee, Ammarin Thakkinstian, Abhasnee Sobhonslidsuk
Su1422
Background and Aims: Liver transplantation (LT) is recommended for early-stage hepatocellular carcinoma (HCC). The Milan criteria (MC) is used to select HCC candidates for LT. However, many patients who might get benefit from LT may be ineligible because the MC may be too strict. Extended criteria beyond the MC, such as UCSF, Up-to-7, Kyoto, TTV/ AFP, Hangzhou have been proposed but results were conflictingly reported. We therefore conducted a systematic review to estimate and compare the risk of post-LT HCC recurrence and mortality among these extended criteria. Methods: Medline and Scopus were searched from 1 January 1996 to 31 December 2015 to identify studies involving LT for HCC patients within the MC and five extended criteria. Exclusion criteria were studies with insufficient data, non-cohort design or undecipherable language. Two authors performed the study independently. Mortality and recurrence rate were pooled and analyzed. Results: A total of 39 cohorts out of 39 studies (n = 17,655 HCC patients) were included in our review, with 3,892 deaths and 3,191 HCC recurrences after LT. The pooled overall post-LT HCC recurrence rate for patients with HCC beyond the MC but within the UCSF, Hangzhou, Kyoto, TTV/AFP were 28.1%, 22.9%, 25.0%, 18.0% respectively comparing to the MC (15.8%). Among these criteria, the risks of recurrence were statistically significant for UCSF vs MC and Hangzhou vs MC criteria with the pooled risk ratios (RR) of 1.78 (95%CI 1.42-2.24) and 1.44 (95%CI 1.31-1.59), respectively (Figure 1). Contrastingly, the pooled overall recurrence rate was lower in Up-to-7 when compared with MC (8% vs 15.8%) with the pooled RR of 0.44 (95%CI 0.27-0.72). The pooled overall mortality rate for patients with HCC beyond the MC but within the UCSF criteria was significant higher than those within the MC (29.0% vs 19.4%) with the pooled RR of 1.69 ( 95%CI 1.46-1.95) (Figure 2), whereas the Up-to-7 and Hangzhou criteria were a little higher but not significant. In addition, the overall recurrence and mortality rate of LT with the Kyoto and TTV/AFP criteria were not different from the MC. Conclusions: Among extended criteria beyond MC, the Up-to-7 criteria, Kyoto, and TTV/AFP criteria have been applied without increasing recurrence and mortality comparing to the MC. Patients with HCC beyond MC but within UCSF have higher risk of recurrence and mortality than patients with HCC within MC. Patients with HCC beyond MC but within Hangzhou criteria have a higher risk of recurrence than those within MC without difference in mortality. Further study is required to confirm the results.
AASLD Abstracts
S-1124
OUTCOMES OF LIVING DONOR LIVER TRANSPLANTATION (LDLT) VERSUS DECEASED DONOR LIVER TRANSPLANTATION (DDLT) AND A NATIONAL INPATIENT SAMPLE (NIS) STUDY Richa Bhardwaj, Gaurav Bhardwaj, Dorothy B. Wakefield, Raffi Karagozian Aim: To determine mortality, length of stay (LOS), hospital charges and procedure related complications in hospitalized patients undergoing LDLT versus DDLT. Introduction: Liver Transplant (LT) is the standard of care for advanced-stage liver disease. There is a significant disparity between the number of patients needing liver transplantation and the availability of donors. LDLT is a promising alternative to DDLT as it curtails the waiting time for transplant significantly, allowing the procedure to be performed during early stages of end stage liver disease in relatively less sick patients. However, unavoidable significant morbidity and mortality of living donors and complications related to a more complex procedure are the concerns that have been raised. Multicenter consortiums have compared LDLT and DDLT outcomes including graft survival, however limited data is available in terms of mortality, resource utilization and inpatient hospitalization trends in nationwide studies. Methods: Data from the NIS for the year 2012, containing data from 44 states and 4,378 hospitals, accounting for over 7 million discharges were analyzed. LT patients were identified using ICD-9 procedure codes 50.5, 50.51, 50.59. LDLT and DDLT patients were further identified using procedure codes 00.91, 00.92 and 00.93.Primary outcomes included inpatient mortality, LOS and hospital charges. Secondary outcomes were identified using ICD9 diagnosis codes. Results: A total of 1091 nationwide LT hospital admissions were identified with a total of 801 DDLT and 69 LDLT procedures. The mean age of patients for DDLT and LDLT was 54.7 and 55.3 years respectively. Females were more likely to receive LDLT as compared to DDLT (43.4 % versus 32.5 % , p 0.007 ). Overall the most prevalent underlying liver conditions were Hepatitis C, HCC, NASH and Alcoholic liver disease (ALD) with NASH being a more common underlying etiology in LDLT patients (18,8%, p <0.001) and Hepatitis C (46.8%,p <0.001) in DDLT patients. The rates of overall mortality, sepsis, ARDS and Clostridium difficile infection were comparable between the two groups but the rates of transplant related complications were significantly higher in the LDLT group (26.1%, p 0.01) Conclusion: LDLT recipients had significantly lower LOS and mean hospitalization charges likely due to a relatively healthier population with lower MELD scores. The overall mortality rates for DDLT and LDLT are comparable. The LOS and mean hospitalization charges were significantly higher in the DDLT group. NASH patients were more likely to be living donor recipients. LDLT patients had a higher rate of transplant related complication