Referral For Transplantation Research Articles

Juvenile Hemochromatosis Connecting Cardiac Arrest and Hypogonadotropic Hypogonadism in a Young Woman

Abstract Juvenile hemochromatosis (JH) is a subtype of hereditary hemochromatosis, a genetic disorder characterized by excessive iron absorption and deposition in various organs, leading to cardiomyopathy, cirrhosis, and diabetes. Endocrine dysfunction is a common manifestation and may appear years before end-organ damage. This report describes a rare case of JH, emphasizing the consequences of delayed diagnosis. A 28-year-old woman with a history of hypogonadotropic hypogonadism presented with cardiac arrest complicated by acute renal failure and cerebral vascular accidents. She initially exhibited signs of severe cardiomyopathy and multiorgan failure, which led to workup for an underlying cause. Laboratory values showed significantly elevated ferritin and transferrin saturation. Subsequent genetic screening revealed HJV gene pathogenic variants consistent with juvenile hemochromatosis. Treatment involved aggressive iron chelation therapy and outpatient referral for cardiac transplant. This case calls for heightened awareness and early screening of JH, particularly among patients with unexplained endocrine dysfunction. Early diagnosis and treatment are paramount in preventing irreversible organ damage and improving patient outcomes.

Transcatheter occlusion of venovenous collaterals in the total cavopulmonary Fontan circulation.

Venovenous collaterals are abnormal connections between the systemic and pulmonary venous systems. They are commonly seen in the Fontan circulation and may lead to significant hypoxaemia. Transcatheter closure of venovenous collaterals is a potential but controversial treatment as the long-term benefits and outcomes are not well understood. This retrospective cohort study utilised data from the Australian and New Zealand Fontan Registry. Patients who underwent transcatheter venovenous collateral occlusion for hypoxemia from the year 2000 onwards were included. Atriopulmonary and Kawashima-type Fontan circulations were excluded to reflect a more contemporary Fontan cohort. Nineteen patients (age 19.3 ± 7.8 years, 53% female) underwent transcatheter venovenous collateral occlusion. Compared to baseline, mean oxygen saturation was improved at latest follow-up (90.5% vs 87.0%; p = 0.003). Nine patients achieved a clinically significant response (defined as an increase of at least 5% to 90% or greater), and this was associated with lower baseline Fontan pressures (12.9 v 15.6 mmHg; p = 0.02). No heart failure hospitalisations, arrhythmia, transplant referrals, or mortality were observed during the median follow-up period of 4 years. Two patients experienced thromboembolic events and five patients underwent re-intervention. Transcatheter occlusion of venovenous collaterals in Fontan patients with chronic hypoxaemia resulted in a modest increase in oxygenation over a median follow-up of 4 years and longer-term prognosis did not appear to be adversely affected. Lower Fontan pressures at baseline were associated with a greater improvement in oxygenation.

Lung transplant referral considerations for individuals with cystic fibrosis.

The cystic fibrosis (CF) Foundation issued guidelines to promote timely lung transplant referral for people with cystic fibrosis (pwCF) in 2019. Since then more has been published to help refine this complex decision. The goal of this review is to summarize the recent literature informing disease severity in CF, barriers to referral for pwCF and guide timely and appropriate lung transplant referrals. Existing guidelines utilize the degree of airflow limitation as the primary criteria to refer for lung transplant, yet this variable has some prognostic uncertainty. Novel prognostic tools may provide more reliable metrics for predicting who with CF is at greatest risk of dying from their lung disease and could be used as an indicator for when to refer. In addition, updated analyses of national registry data have highlighted the significance of hemoptysis, low body mass index, and extra-pulmonary organ failure, as important prognostic markers. PwCF with these complications have historically been under-referred for lung transplant despite data suggesting lung transplant can be safe for some in these populations. Early referral should be considered in the presence of these complications. This review builds on existing guidelines by incorporating novel data to better determine when lung transplant referral is most appropriate. Improved prognostic tools are still needed to decrease the chances of pwCF dying without consideration of lung transplant. It is still unclear how novel therapies for CF may change the need and timing for lung transplant referral.

Experience of a novel lung transplant program in Mexico.

Lung transplantation is the gold standard therapy for patients in the end stages of pulmonary disease. However, in numerous countries, candidates for lung transplants often die on the waiting list due to a shortage of donors and limited access to transplant centers. This article delves into the experience of our hospital, Christus Muguerza in Monterrey, Mexico, as the sole active lung transplant program in the country, having conducted 35 transplants from August 2017 to March 2023. We discuss the actual situation of lung transplantation in Mexico and the challenges we have faced over time, such as late patient referrals for evaluation and eventual transplantation. In addition, we outline the challenges we anticipate as more transplant programs emerge in the country.

Comparison of race-specific and race-neutral spirometry equations on the classification of restrictive lung physiology, interstitial lung disease, and lung transplant referral eligibility

BackgroundRace-specific reference equations for spirometry including forced vital capacity (FVC) are under scrutiny in interstitial lung disease (ILD). Their influence on ILD and transplant decision-making warrants study. MethodsWe performed a retrospective cohort study of adults with FVC measurements at Duke University Medical Center between 1 October 2014 and 1 February 2023. Using Global Lung Initiative 2012 reference equations, we compared how race-specific and race-neutral equations classified FVC with potential restrictive physiology (z-score < -2). In the subgroup of patients diagnosed with ILD, we compared how race-specific and race-neutral equations classified FVC as warranting transplant referral (percent-predicted <80%). We compared overall rates, odds ratios (ORs) and 95% confidence intervals (CIs) using conditional logistic regression, and differences in timing. ResultsWe identified 45,587 patients including 550 with ILD. Race-specific equations classified potential restricted physiology 5.2% more White patients (23.8% versus 18.6%, OR 1.28, 95% CI 1.24-1.32), 14.3% fewer Black patients (24.1% versus 38.4%, OR 0.63, 95% CI 0.60-0.66), and 7.7% fewer Asian patients (14.8% versus 22.5%, OR 0.66, 95% CI 0.53-0.82) compared with race-neutral equations. In the ILD subgroup, race-specific equations classified 13.0% more White patients as warranting transplant referral consideration compared to race-neutral equations (57.8% versus 44.8%, OR 1.29, 95% CI 1.07-1.56). ConclusionRace-specific equations increased classification of potential restrictive physiology and transplant candidacy for White patients but decreased classification of potential restrictive physiology for Black and Asian patients. Race-specific equations in ILD and transplant decision-making warrant greater consideration given their potential to contribute to racial disparities.

EPS7.01 A survey of United States cystic fibrosis physicians’ perspectives on lung transplant referral in the era of highly effective modulator therapy

EPS7.01 A survey of United States cystic fibrosis physicians’ perspectives on lung transplant referral in the era of highly effective modulator therapy

The Impact of Changing Race-Specific Equations for Lung Function Tests among Veterans with Chronic Obstructive Pulmonary Disease.

Rationale: The American Thoracic Society recommended a single reference equation for spirometry, but the impact on patients is not known. Objectives: To estimate the effect of changing to a single reference equation among veterans with chronic obstructive pulmonary disease (COPD). Methods: A cross-sectional study was conducted including veterans aged ⩾40 to ⩽89 years with COPD and spirometry results from 21 facilities between 2010 and 2019. We collected race and ethnicity data from the electronic health record. We estimated the percentage change in the number of veterans with lung function meeting clinical thresholds used to determine eligibility for lung resection for cancer, lung volume reduction surgery (LVRS), and lung transplantation referral. We estimated the change for each level of U.S. Department of Veterans Affairs service connection and financial impact. Results: We identified 44,892 veterans (Asian, 0.5%; Black, 11.8%; White, 80.8%; and Hispanic, 1.8%). When changing to a single reference equation, Asian and Black veterans had reduced predicted lung function that could result in less surgical lung resection (4.4% and 11.1%, respectively) while increasing LVRS (1.7% and 3.8%) and lung transplantation evaluation for Black veterans (1.2%). White veterans had increased predicted lung function and could experience increased lung resection (8.1%), with less LVRS (3.3%) and lung transplantation evaluation (0.9%). Some Asian and Black veterans could experience increases in monthly disability payments (+$540.38 and +$398.38), whereas White veterans could see a decrease (-$588.79). When aggregated, Hispanic veterans experienced changes attributable to their racial identity and, because this sample was predominantly Hispanic White, had similar results to White veterans. Conclusions: Changing the reference equation could affect access to treatment and disability benefits, depending on race. If adopted, the use of discrete clinical thresholds needs to be reassessed, considering patient-centered outcomes.

#1899 Transitional care clinic for incident hemodialysis patients : the Singapore experience

Abstract Background and Aims The period of transition from chronic kidney disease (CKD) to End stage kidney disease (ESKD) presents significant morbidity and mortality risk to the patients. This higher mortality risk is largely contributed by cardiovascular factors and infection. The last 2 decades have seen a remarkable succession of programs to improve outcome in incident dialysis patients. One such initiative is the use of ‘fistula first’ policy. In Singapore, pre-emptive access creation among ESKD patients continues to be low, with up to 80% of incident dialysis patients being commenced on hemodialysis (HD) via a dialysis catheter. Ensuring that incident dialysis patients have definitive vascular access, early referral to transplantation and adequate psychosocial support, amongst other factors, is an important consideration in their journey towards improved health outcomes. In order to achieve this, meticulous care coordination and a multifaceted approach is required. This realization is what led to the inception of our transition care clinic (TCC) in 2019. Conducted bi-monthly by a multidisciplinary team of nephrologists and renal coordinators, with inputs from pharmacists and medical social workers as needed, the TCC engages patients within 4-6 weeks post-hospital discharge. Its focus includes vascular access, dietary and fluid compliance, blood pressure control, HD adherence, transplantation referral, and medication reconciliation. Method A retrospective analysis of 314 ESKD patients who initiated HD between September 2019 and September 2022 compared outcomes between TCC attendees (n=164) and non-attendees Results TCC attendees exhibited a lower 1- year mortality rate (p=0.002) and higher rates for vascular access creation within first 6 months (p=0.001) as compared to non-attendees. However, no statistical differences were observed in hospitalization rates in the first year (p=0.760) and kidney transplantation referrals (p=0.20) between the two groups. Conclusion While notable improvements were observed in mortality rates and vascular access creation, there was no significant difference in hospitalization rates or kidney transplantation referrals between the two groups. In spite of the limitations due to its retrospective nature, this study clearly demonstrates the effectiveness of TCC in enhancing patient outcomes during the critical initial phase of hemodialysis. The study highlights the importance of setting up, refinement and expansion of such services in improving the outcome of this vulnerable patient group.

Barriers to liver transplant referral in safety net settings: A national provider survey.

Safety net systems care for patients with a high burden of liver disease yet experience many barriers to liver transplant (LT) referral. This study aimed to assess safety net providers' perspectives on barriers to LT referrals in the United States. We conducted a nationwide anonymous online survey of self-identified safety net gastroenterologists and hepatologists from March through November 2022. This 27-item survey was disseminated via e-mail, society platforms, and social media. Survey sections included practice characteristics, transplant referral practices, perceived multilevel barriers to referral, potential solutions, and respondent characteristics. Fifty complete surveys were included in analysis. A total of 60.0% of respondents self-identified as White and 54.0% male. A total of 90.0% practiced in an urban setting, 82.0% in tertiary medical centers, and 16.0% in community settings, with all 4 US regions represented. Perceived patient-level barriers ranked as most significant, followed by practice-level, then provider-level barriers. Patient-level barriers such as lack of insurance (72.0%), finances (66.0%), social support (66.0%), and stable housing/transportation (64.0%) were ranked as significant barriers to referral, while medical mistrust and lack of interest were not. Limited access to financial services (36.0%) and addiction/mental health resources (34.0%) were considered important practice-level barriers. Few reported existing access to patient navigators (12.0%), and patient navigation was ranked as most likely to improve referral practices, followed by an expedited/expanded pathway for insurance coverage for LT. In this national survey, safety net providers reported the highest barriers to LT referral at the patient level and practice level. These data can inform the development of multilevel interventions in safety net settings to enhance equity in LT access for vulnerable patients.

Exploring Potential Gender-Based Disparities in Referral for Transplant, Activation on the Waitlist and Kidney Transplantation in a Canadian Cohort

In the United States, women are less likely to be referred, activated on the waitlist, or undergo kidney transplant (KT) than men; contemporary Canadian data regarding access to transplant for women are lacking. Among patients initiating dialysis in Nova Scotia (NS), Canada from 2010 to 2020, we examined the association of candidate gender with overall access to KT, including the following: (i) odds of transplant referral within 1 year of dialysis initiation, (ii) odds of activation on the transplant waitlist (if referred), and (iii) time-to-transplantation (if activated) using logistic regression or Cox proportional hazards models as appropriate. Among 749 patients deemed potentially eligible for transplant, women had lower transplant rates than men (adjusted hazard ratio [aHR]: 0.53, 95% confidence interval [CI]: 0.36-0.78); this was amplified among patients aged >60 years (aHR: 0.25, 95% CI: 0.09-0.69). Compared with men, women had a lower adjusted odds of transplant referral (adjusted odds ratio [aOR]: 0.57, 95% CI: 0.35-0.93) by 1 year after dialysis initiation. Among those referred, women had lower odds of waitlist activation than men (aOR: 0.58, 95% CI: 0.30-1.11); and among those activated, women had lower hazard of KT (aHR: 0.74, 95% CI: 0.51-1.09), though these differences were not statistically significant. Women in NS experience lower overall access to transplant, including less referral, activation and KT compared with men. Gender-based barriers to any of (or in this case each of) referral, activation, or transplantation result in inequities in access; identification of disparities at these critical decision points is an important first step toward ensuring equal access for all.

Two decades of recipient and donor referrals for heart transplantation to Groote Schuur Hospital, Cape Town, South Africa: A retrospective study.

Heart transplantation in South Africa faces numerous challenges related to organ scarcity and unequal access to advanced heart therapy. There is an urgent need to analyse the current transplant referral pathway to optimise equitable access to transplantation. To provide an audit of heart transplant referrals to Groote Schuur Hospital, Cape Town, over a 23-year period, focusing on patient demographics, indications for referral, waiting-list dynamics, and transplant referral outcomes. The study utilised a retrospective patient folder review for the period 1 January 1997 - 31 December 2019 and audited the trends in heart transplant referrals and associated outcomes of the referral at a tertiary academic hospital. A total of 625 recipients were referred for heart transplantation, with the majority being male (n=412; 65.9%), while gender was undocumented for 69 cases (11.0%). The mean age was 38.1 (14.6) years, and 153 (24.5%) were listed for transplant, while 215 (34.4%) were deemed ineligible for listing. Contraindications for listing included social (n=106; 49.3%), medical (n=83; 38.6%) and psychological (n=26; 12.0%) factors, while 134 patients (21.4%) were considered too well. Poor social circumstances (n=38; 39.6%), poor insight (n=28; 29.2%) and poor compliance (n=21; 21.9%) were the most common non-medical reasons for not listing recipients, while obesity (n=30; 31.3%) and smoking (n=23; 24.0%) were notable medical contraindications. Forty-nine patients (7.8%) died during work-up, while 130 (85.0%) of the listed patients received a heart transplant. Of the 429 donor referrals, 139 (32.4%) were accepted for organ procurement. Reasons for declining donors included unsuitability for transplantation (30.3%), lack of capacity (1.8%), and recipient-donor mismatch (66.9%). Three-quarters of the referred patients were deemed unsuitable for heart transplantation for medical and/or social reasons. The ratio of referral to listing has decreased over time. However, once listed, the likelihood of receiving a transplant was high.

Disparities in Access to Liver Transplant Referral and Evaluation among Patients with Hepatocellular Carcinoma in Georgia.

Among patients with early-stage HCC in Georgia, age and insurance type were associated with referral to liver transplant, race, and poverty with evaluation initiation, and insurance type with evaluation completion. Opportunities to improve transplant access include informing referring providers about insurance requirements, addressing barriers to evaluation initiation, and streamlining the evaluation process.

Sex/Gender Disparities in Preemptive Referrals for Kidney Transplantation

BackgroundSex/gender inequities persist in access to kidney transplantation. Whether differences in preemptive referral (i.e., referral prior to dialysis start) explain this inequity remains unknown. MethodsAll adults (18-79 years; N = 44,204) initiating kidney replacement therapy (KRT; dialysis or transplant) in Georgia, North Carolina, or South Carolina between 2015 and 2019 were identified from the United States Renal Data System. Individuals were linked to the Early Steps to Transplant Access Registry to obtain data on preemptive referral and followed through November 13, 2020 for outcomes of waitlisting and living donor transplant. Logistic regression assessed the association between sex/gender and likelihood of preemptive referral among all KRT patients. Cox-proportional hazards assessed the association between sex/gender and waitlisting or living donor among preemptively referred patients. ResultsOverall, men and women were similarly likely to be preemptively referred (OR: 0.99 [0.95-1.04]). Preemptively referred women (vs. men) were, on average, younger and with fewer comorbidities. There were no sex/gender differences in waitlisting once patients were preemptively referred (HR: 0.97 [0.91-1.03]), but women (vs. men) who were preemptively referred remained 25% (HR: 0.75 [0.66-0.86]) less likely to receive a living donor transplant. ConclusionIn the Southeast US, men and women initiating KRT are similarly likely to be preemptively referred for a kidney transplant, and this appears, at least in part, to mitigate known sex/gender inequities in access to waitlisting, but not living donor transplant. Despite this, preemptively referred women, on average, had a more favorable medical profile relative to preemptively referred men.

Risk Factors for Death or Transplant After Stage 2 Palliation for Single Ventricle Heart Disease

BackgroundFor infants with single ventricle heart disease, the time after stage 2 procedure (S2P) is believed to be a lower risk period compared with the interstage period; however, significant morbidity and mortality still occur. ObjectivesThis study aimed to identify risk factors for mortality or transplantation referral between S2P surgery and the first birthday. MethodsRetrospective cohort analysis of infants in the National Pediatric Cardiology Quality Improvement Collaborative who underwent staged single ventricle palliation from 2016 to 2022 and survived to S2P. Multivariable logistic regression and classification and regression trees were performed to identify risk factors for mortality and transplantation referral after S2P. ResultsOf the 1,455 patients in the cohort who survived to S2P, 5.2% died and 2.3% were referred for transplant. Overall event rates at 30 and 100 days after S2P were 2% and 5%, respectively. Independent risk factors for mortality and transplantation referral included the presence of a known genetic syndrome, shunt type at stage 1 procedure (S1P), tricuspid valve repair at S1P, longer time to extubation and reintubation after S1P, ≥ moderate tricuspid regurgitation prior to S2P, younger age at S2P, and the risk groups identified in the classification and regression tree analysis (extracorporeal membrane oxygenation after S1P and longer S2P cardiopulmonary bypass time without extracorporeal membrane oxygenation). ConclusionsMortality and transplantation referral rates after S2P to 1 year of age remain high ∼7%. Many of the identified risk factors after S2P are similar to those established for interstage factors around the S1P, whereas others may be unique to the period after S2P.

Characteristics and Outcomes of a Single-Centre Cohort of Adult Congenital Heart Disease Patients Referred for Heart Transplant

Adult congenital heart disease (ACHD) services increasingly encounter heart failure (HF) in the ageing ACHD population. Optimal timing of referral for heart transplant (HTx) evaluation in this heterogeneous population is complex and ill-defined. We aim to outline the characteristics and outcomes of ACHD patients referred for HTx from a large Australian ACHD centre. Retrospective review of ACHD patients referred for HTx from a primary ACHD centre (1992-2021). Database analysis of patient demographics, characteristics, wait-listing, and transplantation outcomes was performed. A total of 45 patients (mean age 37±9.9 years old; 69% male) were referred for HTx with a mean follow-up of 5.9±6.3 years. Of these, 22 of 45 (49%) were listed and transplanted, including one heart-lung transplant. The commonest diagnosis was dextro-transposition of the great arteries (13/45, 29%). Most patients, 33 of 45 (73.3%) had undergone at least one cardiac surgery in childhood. Indications for HTx referral included HF in 34 of 45 (75%), followed by pulmonary hypertension in 7 of 45 (11%). Median transplant wait-list time was 145 days (interquartile range, 112-256). Of the 23 patients not wait-listed, the reasons included clinical stability in 13 of 45 (29%), psychosocial factors in 2 of 45 (4.4%) and prohibitive surgical risk, including multiorgan dysfunction, in 8 of 45 (17.7%). Transplant was of a single organ in most, 21 of 22 (95.5%). Overall mortality was 5 of 22 (22.7%) in those after HTx, and 14 of 23 (60.9%) in those not listed (p=0.0156). Increasingly, ACHD patients demonstrate the need for advanced HF treatments. HTx decision-making is complex, and increased mortality is seen in those not wait-listed. Ultimately, the referral of ACHD patients for HTx is underpinned by local decision-making and experience, wait-list times and outcomes.

(159) - The Landscape of Referral for Lung Transplantation in Pulmonary Arterial Hypertension: A Report From the Phar

(159) - The Landscape of Referral for Lung Transplantation in Pulmonary Arterial Hypertension: A Report From the Phar

FEV1Q: a race-neutral approach to assessing lung function.

Forced expiratory volume in 1 s quotient (FEV1Q) is a simple approach to spirometry interpretation that compares measured lung function to a lower boundary. This study evaluated how well FEV1Q predicts survival compared with current interpretation methods and whether race impacts FEV1Q. White and Black adults with complete spirometry and mortality data from the National Health and Nutrition Examination Survey (NHANES) III and the United Network for Organ Sharing (UNOS) database for lung transplant referrals were included. FEV1Q was calculated as FEV1 divided by 0.4 L for females or 0.5 L for males. Cumulative distributions of FEV1 were compared across races. Cox proportional hazards models tested mortality risk from FEV1Q adjusting for age, sex, height, smoking, income and among UNOS individuals, referral diagnosis. Harrell's C-statistics were compared between absolute FEV1, FEV1Q, FEV1/height2, FEV1 z-scores and FEV1 % predicted. Analyses were stratified by race. Among 7182 individuals from NHANES III and 7149 from UNOS, 1907 (27%) and 991 (14%), respectively, were Black. The lower boundary FEV1 values did not differ between Black and White individuals in either population (FEV1 first percentile difference ≤0.01 L; p>0.05). Decreasing FEV1Q was associated with increasing hazard ratio (HR) for mortality (NHANES III HR 1.33 (95% CI 1.28-1.39) and UNOS HR 1.18 (95% CI 1.12-1.23)). The associations were not confounded nor modified by race. Discriminative power was highest for FEV1Q compared with alternative FEV1 approaches in both Black and White individuals. FEV1Q is an intuitive and simple race-neutral approach to interpreting FEV1 that predicts survival better than current alternative methods.

Review article: Current indications and selection criteria for early liver transplantation in severe alcohol-associated hepatitis.

Alcohol-associated hepatitis (AH) is a severe inflammatory form of alcohol-associated liver disease (ALD) that carries a high mortality rate. Early liver transplantation for severe AH is increasingly available. However, specific criteria for referral and selection remain a subject of debate. To provide a narrative review of the natural history, diagnostic criteria and indications for referral for early liver transplantation for severe AH. We searched PubMed for articles published through August 2023. Key search terms were 'alcoholic hepatitis,' 'alcohol-associated hepatitis,' 'abstinence,' 'alcohol relapse,' and 'liver transplantation.' Previously, a six-month period of alcohol abstinence was required before patients with ALD were considered for liver transplantation. However, studies in recent years have demonstrated that, among carefully selected patients, patients who received early transplants have much higher survival rates than patients with similarly severe disease who did not undergo transplants (77% vs. 23%). Despite these successes, early liver transplantation remains controversial, as these patients have typically not undergone treatment for alcohol use disorder, with the ensuing risk of returning to alcohol use. While early liver transplantation for AH has survival benefits, many patients would not have received treatment for alcohol use disorder. An integrated approach to evaluating candidacy for early liver transplantation is needed.

A multidimensional classifier to support lung transplant referral in patients with pulmonary fibrosis

BackgroundLung transplantation remains the sole curative option for patients with idiopathic pulmonary fibrosis (IPF), but donor organs remain scarce, and many eligible patients die prior to transplant. Tools to optimize the timing of transplant referral are urgently needed. MethodsLeast absolute shrinkage and selection operator (LASSO) was applied to clinical and proteomic data generated as part of a prospective cohort study of interstitial lung disease (ILD) to derive clinical, proteomic, and multi-dimensional logit models of near-term death or lung transplant within 18 months of blood draw. Model fitted values were dichotomized at the point of maximal sensitivity and specificity and decision curve analysis used to select the best performing classifier. We then applied this classifier to independent IPF and non-IPF ILD cohorts to determine test performance characteristics. Cohorts were restricted to patients aged ≤72 years with body mass index 18-32 to increase likelihood of transplant eligibility. ResultsIPF derivation, IPF validation and non-IPF ILD validation cohorts consisted of 314, 105 and 295 patients, respectively. A multi-dimensional model comprising two clinical variables and 20 proteins outperformed stand-alone clinical and proteomic models. Following dichotomization, the multi-dimensional classifier predicted near-term outcome with 70% sensitivity and 92% specificity in the IPF validation cohort and 70% sensitivity and 80% specificity in the non-IPF ILD validation cohort. ConclusionsA multi-dimensional classifier of near-term outcome accurately discriminated this endpoint with good test performance across independent IPF and non-IPF ILD cohorts. These findings support refinement and prospective validation of this classifier in transplant eligible individuals.

External Vs Internal e-Referrals: Results from a Nationwide Epidemiological Study Utilizing Secondary Collected Data.

E-referral systems, streamlining patient access to specialists, have gained global recognition yet lacked a comparative study between internal and external referrals in Saudi Arabia (KSA). This retrospective study utilized secondary data from the Saudi Medical Appointments and Referrals Centre system. The data covers 2020 and 2021, including socio-demographic data, referral characteristics, and specialties. Logistic regression analysis was used to assess factors associated with external referrals. Out of 645,425 e-referrals from more than 300 hospitals, 19.87% were external. The northern region led with 48.65%. Males were 55%, and those aged 25-64 were 56.68% of referrals. Outpatient clinic referrals comprised 47%, while 61% of referrals were due to a lack of specialty services. Several significant determinants are associated with higher rates of external referral with (p-value <0.001) and a 95% Confidence interval. Younger individuals under 25 exhibit higher referral rates than those aged 25-64. Geographically, compared to the central region, in descending order, there were increasing trends of external referral in the northern, western, and southern regions, respectively (OR = 19.26, OR = 4.48, OR 3.63). External referrals for outpatient departments (OPD) and dialysis services were higher than for routine admissions (OR = 1.38, OR = 1.26). The rate of external referrals due to the lack of available equipment was more predominant than other causes. Furthermore, in descending order, external referrals for organ transplantation and oncology are more frequent than for medical specialties, respectively (OR = 9.39, OR = 4.50). The study reveals trends in e-referrals within the KSA, noting regional differences, demographic factors, and types of specialties regarding external referrals, benefiting the New Model of Care for the 2030 Vision. Findings suggest expanding virtual consultations to reduce external referrals. Strengthening primary care and preventive medicine could also decrease future referrals. Future studies should assess resource distribution, including infrastructure and workforce, to further inform healthcare strategy.