卫生系统文献信息资源共享服务网络建设的困境与对策

分析了当前卫生系统共建共享服务网络建设所面临的困境,探讨了如何依托现有全国或区域医疗信息资源共享分中心建立系统内资源共享服务网络,提高地方文献资源保障能力和服务水平,并提出了有针对性的建议。     

Disparity in utilization of combined kidney–liver transplantation in the United States

Abstract: Background: Orthotopic liver transplantation (OLT) is performed as a definitive treatment of acute and chronic liver failure. The prevalence of acute and chronic kidney diseases is substantially higher in this population secondary to diverse etiologies. Combined kidney–liver transplantation (CKLT) is widely performed in some centers, even though there are no definitive studies which support or contradict this practice. Methods: We comprehensively reviewed OLT as well as CKLT data from US transplant centers provided by United Network of Organ Sharing (UNOS). Results: The incidence of CKLT as a percentage of total OLTs performed has been increasing, especially in the post‐MELD era (2002 and after). Moreover, there is a great disparity among centers in regard to percentage of CKLTs to total OLTs. Conclusion: We conclude that there is much difference of opinion among US transplant centers as to indications for CKLT. A more scientific approach to this problem including studies to assess the role of kidney biopsy in determining renal outcome after OLT is needed.     

Survival of liver transplant recipients with hemochromatosis in the United States

BACKGROUND AND AIMS: Earlier studies have suggested that patients with hemochromatosis have poor post-transplantation survival. We aimed to compare patients with hemochromatosis to those with other causes of liver disease with regard to post-transplantation survival. METHODS: We compared the post-transplant survival of patients with and without hemochromatosis using data provided by the United Network for Organ Sharing on 50,306 adult, cadaveric liver transplantations performed in the United States between January 1, 1990, and July 18, 2006. RESULTS: During 1990-1996, the post-transplantation survival of patients with hemochromatosis (n = 177) at 1 year (79.1%), 3 years (71.8%), and 5 years (64.6%) was lower than the average 1-year (86.4%), 3-year (79.5%), and 5-year (73.8%) survival of all other transplant recipients (hazard ratio for death, 1.38; 95% confidence interval [CI], 1.12-1.71). In contrast, during 1997-2006, patients with hemochromatosis (n = 217) had excellent 1-year (86.1%), 3-year (80.8%), and 5-year (77.3%) post-transplantation survival, which was not different from the 1-year (88.4%), 3-year (80.3%), and 5-year (74.0%) post-transplantation survival of all other transplant recipients (hazard ratio for death, 0.89; 95% CI, 0.65-1.22). Adjustment for donor and recipient characteristics did not substantially change these results. Compared with recipients without hemochromatosis, those with hemochromatosis were more likely to die of cardiovascular diseases and less likely to die as a result of graft failure. CONCLUSIONS: The post-transplantation survival of patients with hemochromatosis, which was previously reported to be poor, has been excellent in the United States during the past 10 years.     

Calculated panel reactive antibody with decimals: A refined metric of access to transplantation for highly sensitized candidates

The use of the calculated panel reactive antibody (CPRA) value and the implementation of allocation points for sensitized candidates by the United Network for Organ Sharing (UNOS) have improved access to kidney transplantation for highly sensitized candidates (98% CPRA and above). Despite this, a large population of highly sensitized candidates remain awaiting transplantation. To better define this population, we propose the use of two refinements of the standard UNOS CPRA, the CPRA with decimals or CPRAd, and the likelihood of a compatible donor (LCD). These refined metrics of the standard UNOS CPRA will allow transplant programs to describe their patients’ access to transplantation with increased granularity and will help in decisions regarding the use of desensitization.     

Cancer after Kidney Transplantation in the United States

Previous reports of cancer after kidney transplantation have been limited by small numbers of patients in single-center studies and incomplete ascertainment of cases in large registries. We examined rates of malignancies among first-time recipients of deceased or living donor kidney transplantations in 1995-2001 (n = 35 765) using Medicare billing claims. For most common tumors, e.g. colon, lung, prostate, stomach, esophagus, pancreas, ovary and breast, cancer rates were roughly twofold higher after kidney transplantation compared with the general population. Melanoma, leukemia, hepatobiliary tumors, cervical and vulvovaginal tumors were each approximately fivefold more common. Testicular and bladder cancers were increased approximately threefold, while kidney cancer was approximately 15-fold more common. Kaposi's sarcoma, non-Hodgkin's lymphomas, and nonmelanoma skin cancers were more than 20-fold increased than in the general population. Compared with patients on the waiting list, several tumors were more common after transplantation (p < 0.01): nonmelanoma skin cancers (2.6-fold), melanoma (2.2-fold), Kaposi's sarcoma (9.0-fold), non-Hodgkin's lymphoma (3.3-fold), cancer of the mouth (2.2-fold), and cancer of the kidney (39% higher). The rates for most malignancies are higher after kidney transplantation compared with the general population. Cancer should continue to be a major focus of prevention in kidney transplantation.