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Liver Transplant Workup: Take a Deep Breath Before Ordering That Test
Liver Transplant Workup: Take a Deep Breath Before Ordering That Test
Submitted on 14 Jul 2018

Mitchell Phillips, MD; Elizabeth Sigler, MD; Katherine Tinkey, MD; Devin Weinberg, MD PhD; Cinnamon Sullivan, MD
Emory University School of Medicine Department of Anesthesiology
Poster Views: 372
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Poster Abstract
Performed at only 149 transplant centers, orthotopic liver transplantation (OLT) represents one of the most highly specialized surgical operations in modern medicine. Additionally, the scarcity of organs available for transplant elevates the importance of selecting and screening potential recipients. To maximize success rate and the judicious allocation of organs, OLT candidates around the country go through an extensive battery of pre-operative screening tests including pulmonary function testing (PFTs). It is known that a substantial portion of patients with end stage liver disease have secondary pulmonary comorbidities that are associated with post-transplant morbidity and mortality, most notably hepatopulmonary syndrome (HPS) in 8-17% (Arguedas, 2003) and portopulmonary hypertension in approximately 5% of patients (Krowka, 2011). While PFTs are useful prior to lung resection surgery, HPS is more appropriately evaluated by pulse oximetry/blood gas analysis and bubble study on echocardiogram (Arguedas, 2003) and portopulmonary hypertension is diagnosed with echocardiogram plus right heart catheterization (Krowka, 2011), all of which are routine in OLT pre-operative testing. Despite their widespread utilization in OLT evaluation, current literature does not show a definitive role for PFTs as a standard of care in this setting and may present an opportunity for both time, resource, and cost savings. As a high volume OLT center, we at Emory University Hospital sought to examine the utility of routine PFTs in our pre-operative evaluation for transplantation. Working with various members of the multidisciplinary transplant team we retrospectively analyzed the pre-operative evaluation of all patients (641) who were considered for liver (582) or combined liver-kidney (59) transplantation at the Emory Transplant Center between the dates of October 1, 2016 and February 15, 2018. In each of these cases where the patient was deemed not a candidate for transplant or their transplant evaluation status was put on hold, we examined the electronic medical record to ascertain the cause. Particular attention was given to those whose transplant status was affected by medical issues to determine if pulmonary comorbidities were a significant factor and if PFTs had a role in the decision not to list the patient for transplant. We found that in the timeframe of our study no liver transplant candidate at Emory had been denied transplantation based principally on the results of PFTs. Only 3 out of 641 potential transplant patients had their candidacy adversely affected primarily by pulmonary comorbidities and in each of these cases diagnosis was made without PFTs. Through collaboration with the transplant center and case managers, we found that the average cost of PFTs was $152.00 per patient with a total cost of $97,432.00 over the study period. With no clear benefit of PFTs as a screening exam in this population, elimination of this examination could reduce healthcare expenditures by approximately $69,000.00 per year at Emory University Hospital alone.

Arguedas, Miguel R., et al. “Prospective Evaluation of Outcomes and Predictors of Mortality in Patients
with Hepatopulmonary Syndrome Undergoing Liver Transplantation.” Hepatology 37.1 (2003): 192-197

Kia, Leila, et al. “The Utility of Pulmonary Function Testing in Predicting Outcomes Following Liver Transplantation.” Liver Transplantation 22 (2016): 805-811

Krowka, Michael J. “Management of Pulmonary Complications in Pretransplant Patients.” Clinical Liver Disease 15 (2011): 765-777

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