general and transplant hepatologists: how their ... · general and transplant hepatologists: how...

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.

2013

First Official TH Diplomas issued

www.webaisf.org

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.

December, 1992 !

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.

Management of

Modifiable Factors



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



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



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)



�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 !!)

Grazie per l’attenzione

……..

……..

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

• Hepatectomy

• Anhepatic Phase

• Implantation

• Complications

• Primary nonfunction

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

Like any difficult undertaking,

the best outcomes occur when

Expertise (COMPETENZA)(Epatologia)

and

Experience (ESPERIENZA)(Operative, Clinical-epidemiology and Physiopathology)

coincide.

general and transplant hepatologists: how their ... · general and transplant hepatologists: how...

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