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General and Transplant Hepatologists:
how their interaction produces the best care for the patient
Stefano Fagiuoli
U.S.C. Gastroenterologia ed Epatologia dei Trapianti
Ospedale Papa Giovanni XXIII - Bergamo
Cosa «NON Siamo»
Definizione epatologo
Cosa NON lo definisce
Non definito da corporazione di lavoro (GI, infettivi, medicina etc….)
� NB: 70-80% GI, Mal. Infettive, Medicina: non epatologo (e raramente a tempo pieno !!)
Non più definito da «scuola di specializzazione»
Mancanza di riconoscimenti «formali» / «istituzionali»
Nella pratica:
Esperienza sul campo (autoreferenzialità?)
Master II livello (es Epatologia / Trapiantologia) non cogente per avviamento
/ progressione di carriera
Documentata (?) attività di ricerca clinica / di base in epatologia
DURATION OF TRAINING
Should be of at least 6 years duration:
• at least 2 yrs of common trunk• at least 3 yrs full-time G&H• 1 yr (Scientific , Practice in developing countries or Advanced)
Partire dalla Complessità !!!!
Definizione epatologo dei trapianti
Cosa NON lo definisce
Non definito da corporazione di lavoro (GI, infettivi, medicina, chirurgia,
immunologia, etc….)
Mai definito da «scuola di specializzazione»
Mancanza di riconoscimenti «formali» / «istituzionali»
Nella pratica:
Diploma AISF e UEMS !!!
Esperienza sul campo
Master II livello non cogente per avviamento / progressione di carriera
Documentata (?) attività di ricerca clinica / di base in epatologia
• Proficiency of a master Internist� Liver disease = multi-systemic perturbations
• Expertise in liver pathophysiology� Managing complications of portal hypertension and liver failure
• Understanding of hepatobiliary anatomy� Immediate post-operative complications
• Aptitude in immunology, pathology and infectious diseases� Management of rejection/infection, disease recurrence
Expertise Required
Expertise Required
Title
Minimum of 3 liver procurements and transplants
Participate in the primary care of 30 or more:•Selection of appropriate recipients and donors•Immediate post-operative care LT recipients•Histologic evaluations, Rx tests•Lonf-term LT recipent care
…. the best operation will fall short if
• Pre-transplant patient selection is inadequate (late….)
and,
• After discharge, the patient would not be cared for by a very
expert team of medical personnel both in and outside the
transplanting unit………
Expertise Required
Title Yrs
Internal Medicine Residency 5
Fellowship in Gastroenterology 3
Certificate of Addictional Qualification (CAQ) in Advanced Hepatology 1
AISF strongly feels that the time has come for health care institutions
to recognize the role of the transplant hepatologist in Italy.
Accordingly, specific training programmes leading to the obtainment of
this title must be implemented and should receive institutional
endorsement.
UNOS approved LT program.
Affiliated with an ACGME accredited GI training program
Patient volumes must include a minimum of 30 LT/year or 20/approved fellowship position
Institutionmust provide fulltime faculty including a medical director, (fully trained hepatologist,
who has expertise in managing patients with liver disease)
AASLD standards for training transplant hepatologists
Istitutionally (Ministry of Health? CNT?, ?? ) approved LT program.
Affiliated with MIUR accredited GI (IM, ID?) training program (additonal credits?)
Patient volumes must include a minimum of 30 LT/year or 20/approved fellowship position
Institutionmust provide fulltime faculty including a Medical Director, (fully trained hepatologist,
who has expertise in managing patients with liver disease)
Italian standards for training transplant hepatologists ??
….A complete and functional Liver Transplant Department should be the result of a
close interaction between the Surgery Unit, headed by a SurgicalDirector,
and the Gastroenterology or Internal Medicine Unit (with specific expertise in hepatology),
headed by a MedicalDirector.
Accordingly, the transplant hepatologist should be present in the Medical Unit of each
Liver Transplant Department.
Management of patients with cirrhosis
“has truly become an art and requires more expertise than ever before”
Killemberg and Clavien, 2006
Like any difficult undertaking,
the best outcomes occur when
Expertise (COMPETENZA)(Epatologia)
and
Experience (ESPERIENZA)(Operative, Clinical-epidemiology and Physiopathology)
coincide
Waitlist advantage Transplant Advantage
The survival benefit of liver transplantation
One-year mortality risk for OLT recipients compared to candidates on the waiting list
Merion et al. Am J Transplantation 2005; 5:307-313
(Most) liver transplants with MELD <15 are futile !!!
NB: MELD Exceptions• Presence of HCC
• Refractory upper variceal bleeding
• Refractory ascites and/or pleural effusions when TIPS is contraindicated,• Biliary strictures, recurrent biliary sepsis,
• Severe polycystic liver disease, • Hepatopulmonary syndrome and portopulmonary hypertension
Considering when a patient is appropriate for LT
should include consideration of
how to optimize the patient’s likelihood of being a
transplant candidate.
General and Transplant Hepatologists:
how their interaction produces the best care for the patient
HCC:
E’ la Strategia che conta, non le metodiche disponibili !!!!
Alla diagnosi (anche piccoli HCC):
� Valutazione «prospettica» outcome a lungo termine (OLT Si o No?)
� Se SI: collaborazione gestionale con Centro trapianti
� Periodico aggiornamento su andamento clinico
� Avviamento alla valutazione OLT con timing condiviso
General and Transplant Hepatologists:
how their interaction produces the best care for the patient
Acute Liver Failure
E’ la Diagnosi che conta….. !!!! (encefalopatia insorta su citolisi e colestasi severe + Eziologia)
Alla diagnosi:
� Contattare Centro Trapianti (disponibilità ICU !!)per concordare Gestione
� Timing essenziale
� Scheda di referral per assessment generale
General and Transplant Hepatologists:
how their interaction produces the best care for the patient
Cirrotico
E’ la Prognosi che conta….. !!!! (Storia naturale, Score prognostici)
Criteri per «contatto» con Centro Trapianti:
� Meld ≥ 10
� Primo scompenso di malattia (ascite, emorragia, encefalopatia etc…)
Follow-up condiviso
� Timing inizio valutazione (condivisa)
General and Transplant Hepatologists:
how their interaction produces the best care for the patient
�Fase pre: − definizione strategia globale, referral, timing
�Fase post: − condivisione protocolli, scambio conoscenze/routine
Condivisione protocolli su:
• Gestione Emorragie (Baveno !!: Screening , Gestione, Sorveglianza)• Gestione Ascite/complicanze/HRS• Diagnosi/Gestione HCC• Diagnosi/Gestione HPS/PPS• Diagnosi/Gestione ALF/AoCLF
Condivisione protocolli su:
• Gestione Emorragie (Baveno !!: Screening , Gestione, Sorveglianza)• Gestione Ascite/complicanze/HRS• Diagnosi/Gestione HCC• Diagnosi/Gestione HPS/PPS• Diagnosi/Gestione ALF/AoCLF
The decision to perform liver transplantation for a particular patient
is never the decision of one single individual……
……..although a single individual
could preclude transplant as an option if the opportunity for referral is
missed
…..once a patient is in medical care,
inadequate physician knowledge
should never be the cause for late timing or missing the opportunity for referral.
Qualifica Professionale
…. bensì dalle le Sue capacità
-Expertise = Hepatology
and
- Experience = Operative, Clinical-epidemiology and Physiopathology
nel contesto di una “Value Health Based Medicine”
Qualità e Professionalità, Affidabilità di un Epatologo
Non dovrebbero essere definite da:
•Metodiche e Tecnologie (= Tecnica, NON strategia e condivisione)
•DGR-based system (= Chi e Cosa, NON Come !!)
OUTLINE
Definizione epatologo !!
Definizione epatologo dei trapianti
Bartali !!!!! …gli è ttutto sbajato……
Definizione «qualità» dell’attività /valore professionale !!! (non che strumento usi, non DRG ma……)
Definizione ruolo RETE !!!!
Specificamente per TRAPIANTO (no European/Italian DATA !!)
� Fase pre: definizione strategia globale, referral, timing,
� Fase post: condivisione protocolli, scambio conoscenze /routine
AISF strongly feels that the time has come for health care institutions and
organizations, hospitals, and medical scientific societies active in the field of liver
transplantation (hepatology, gastroenterology, internal medicine, infectious diseases, organ pro-curement)
to recognize the role of the transplant hepatologist in Italy.
Accordingly, specific training programmes leading to the obtainment of
this title must be implemented and should receive institutional
endorsement.
www.webaisf.org
Eligiblity for the examination:
• 2 letters of support from heads of Liver TransplantUnits
• CV: adequate training in the field of liver diseases
• Log-Book with detailed Range of skills
Eligible candidate must pass 2 examinations:
• 1° General principles of organ transplantation (organ donation rates, outcomes following
organ transplantation, history of transplantation, ethics, legal aspects, management and organization
of liver transplant centres, immunosuppression, complications of organ transplant, etc.);
• 2° specific transplanted organs (liver, intestine, heart and lung,kidney and pancreas)
Ambulatorio
OLT
Degenza altro
Reparto OO.RR.
Degenza Gastro
MAPSpecialista esterno
MAPSpecialista esterno
Altro Ospedale
Degenza altro
Ospedale
Coordinamento
OLT
DH
Degenza
Gastro
Valutazione OLT1° e 2° Livello *
° Riunione
Multidisciplinare
STOP
Valutazione 3°
Livello
Degenza
Gastro
DH
* Riunione
Multidisciplinare
LISTING
*
Laboratorio
MicrobiologiaRadiologia
Anatomia patologiaMal. Infettive
Cardiologia
NefrologiaPneumologia
Neurologia
°
Chirurgo
EpatologoRianimatore
Psicologo+
Specialista a la demand
Transplant Surgery
Heart & Lung Kidney Abdominal Organs
Transplant Medicine
Heart & Lung Kidney Abdominal Organs
Chair: N. Zuhdi, MD
Chair: N. Zuhdi, MD• D. Cooper, MD• J. Chaffin, MD
• S. Fagiuoli, MD• D. Parker, MD• AS Dahr, MD• M. Clark, MD
• N. Imes, MDChair: D.VanThiel, MD
Chair: E. Samara, MD• W. Miller, MD
Chair: L. Mieles, MD• H. Merhav, MD
• Y. Ye, MD
• B. Voss, MDChair: JM El-Amm, MD
• S. Fagiuoli, MD• P. Caraceni, MD
• T. Hassanein, MD• A. Gurakhar, MD
• H. Wright, MDChair: D.VanThiel, MD
Chair: DH Van Thiel, MD
Nurse Transplant coordinators