Lecture: Part 1- quality improvement in cirrhotic care; part 2- xenotransplantation

Today’s lecture series featured two disparate topics, the first of which related to quality assessment for inpatient cirrhotic care.  To be certain, care in general for the cirrhotic patient is lacking; citing multiple studies, only 65% of those with SBP receive secondary antibiotic prophylaxis; 35% of those with variceal bleed receive secondary prophylaxis; 6-22% of those with large varices receive beta-blockade; 12% of HCV-cirrhotics are screened for HCC.

In a recent journal article published in Dig Dis & Sci. (Bassett J, Volk M et al.) a single institution performed a retrospective chart review, and created quality-of-care indicators (ie. if a patient has large ascites, then they should receive salt restriction and diuretics). 

After reviewing their charts and assessing their performance, they found themselves adherent to quality of care indicators anywhere from 46% (EGD performed wihin 24 hrs of variceal bleed) to 100% (beta-blocker plus repeat EGD in 1-2 weeks after a variceal bleed).  The authors believe electronic medical records should always be used; there should be openness and collaboration between clinicians; and educating patient’s friends and family can be helpful. Editorialists add that quality-of-care may be best performed in a checklist fashion.   

The second part of this lecture focused on xenotransplantation.  Why persue xenotransplantation (one species into another)? In the current state of affairs, there is a shortage of organs, cellular rejection is common, and there are many side effects to current immunosuppression methods.  Perhaps some of these factors can be alleviated with novel practices.

Research in concordant species (baboons) is waning due to ethical considerations, although the benefit is the absence of hyperacute rejection.  For discordant species (pigs), research activity is more robust; pancreatic islets, neurons and corneas have proven successful (>100 days of survival) when transplanted into primates. For livers, the sucess is not so great- around 9 days of survival.

One major holdup in the successful pig-to-primate liver xenotransplant is the profound thrombocytopenia in the recipient.  They appear to be sequestered in the liver’s sinusoidal endothelial cells.  Thromboregulatory transgenic models may help pave the way around this roadblock in the future.  The good news is this: there is no hyperacute rejection, no extrinsic pathway coagulopathy, and little liver dysfunction.  We are probably 15 years away from a safe liver xenotransplant model system.

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