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Artru F, Trovato F, Morrison M, Bernal W, McPhail M. Liver transplantation for acute-on-chronic liver failure. Lancet Gastroenterol Hepatol 2024; 9:564-576. [PMID: 38309288 DOI: 10.1016/s2468-1253(23)00363-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 10/02/2023] [Accepted: 10/13/2023] [Indexed: 02/05/2024]
Abstract
Acute-on-chronic liver failure (ACLF) occurs in the context of advanced liver disease and is associated with hepatic and extrahepatic organ failure, eventually leading to a major risk of short-term mortality. To date, there are very few effective therapeutic options for ACLF. In many cases, liver transplantation is the only life-saving treatment that has acceptable outcomes in carefully selected recipients. This Review addresses key aspects of the use of liver transplantation for patients with ACLF, providing an in-depth discussion of existing evidence regarding candidate selection, the optimal window for transplantation, potential prioritisation of liver grafts for this indication, and the global management of ACLF to bridge patients to liver transplantation.
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Affiliation(s)
- Florent Artru
- Liver Intensive Care Unit, Institute of Liver Studies, King's College Hospital, London, UK; Department of Inflammation Biology, School of Infection and Microbial Sciences, King's College London, London, UK; Liver Disease Unit, Rennes University Hospital, Rennes, France; Inerm 1241 NuMeCan, University of Rennes, Rennes, France
| | - Francesca Trovato
- Liver Intensive Care Unit, Institute of Liver Studies, King's College Hospital, London, UK; Department of Inflammation Biology, School of Infection and Microbial Sciences, King's College London, London, UK
| | - Maura Morrison
- Liver Intensive Care Unit, Institute of Liver Studies, King's College Hospital, London, UK
| | - William Bernal
- Liver Intensive Care Unit, Institute of Liver Studies, King's College Hospital, London, UK.
| | - Mark McPhail
- Liver Intensive Care Unit, Institute of Liver Studies, King's College Hospital, London, UK; Department of Inflammation Biology, School of Infection and Microbial Sciences, King's College London, London, UK
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2
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Vogel AS, Roediger R, von Ahrens D, Fortune BE, Schwartz JM, Frager S, Chacko KR, Tow CY. The Impact of Metabolic Health and Obesity on Liver Transplant Candidates and Recipients. Life (Basel) 2024; 14:685. [PMID: 38929668 PMCID: PMC11204519 DOI: 10.3390/life14060685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 04/12/2024] [Accepted: 05/21/2024] [Indexed: 06/28/2024] Open
Abstract
Poor metabolic health and obesity have significant impacts on the outcomes of patients suffering from chronic liver disease, particularly those with metabolic dysfunction-associated steatotic liver disease. Patients with such comorbidities who require liver transplant evaluation for advancing liver disease or liver failure require special consideration due to increased risk of cardiovascular disease, renal dysfunction, sarcopenic obesity, and cancer. Those who have had a history of prior bariatric surgery pose specific anatomical constraints and may also be at increased risk of alcohol use disorder. Pre-operative risk assessment as well as strict control of metabolic risk factors are essential to reduce intra-operative and post-liver transplant complications. As immunosuppressive therapy exacerbates metabolic dysfunction and risk for cancer, post-liver transplant care must focus on balancing the need to prevent rejection and the impact of progressive metabolic dysfunction in this unique, but growing, patient population.
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Affiliation(s)
| | | | | | | | | | | | | | - Clara Y. Tow
- Correspondence: ; Tel.: +1-888-795-4837; Fax: +1-602-563-8224
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3
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Bajwa R, Singh L, Molina Garcia S, Imperio-Lagabon K, Sims OT, Modaresi Esfeh J. Post liver transplant short term and survival outcomes in patients living with obesity. Dig Liver Dis 2024:S1590-8658(24)00720-5. [PMID: 38729903 DOI: 10.1016/j.dld.2024.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 04/09/2024] [Accepted: 04/11/2024] [Indexed: 05/12/2024]
Abstract
The objectives of our study were to examine and compare patient and graft survival over a 5-year period across BMI groups, and examine immediate and short-term complications post-LT. This was a retrospective study that examined all liver transplants that occurred at our institution between January 2015-October 2022. Patients were divided into 4 BMI groups (n = 888): normal-overweight (BMI 18.5- 29.9 kg/m2), class I obesity (BMI 30-34.9 kg/m2), class II obesity (BMI 35-39.9 kg/m2), and class III obesity (BMI ≥40 kg/m2) patients. Kaplan Meier curves with the log rank test were created to assess survival outcomes and multivariate Cox regression analysis was performed. Patient and graft survival did not differ statistically between each BMI group. However, patient survival was significantly lower in patients with BMI ≥40 compared to patients with BMI <40. In multivariate analysis, BMI ≥40, admission to the ICU, and age were independent predictors of increased risk of mortality. Infection, arrhythmia, cardiac arrest, and myocardial infarction were more frequent immediate complications in the class III obesity group. Efforts to closely monitor patients with BMI ≥40 post LT to maximize survival are needed. Further studies are needed to improve post LT survival among patients with BMI ≥40.
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Affiliation(s)
- Ramanpreet Bajwa
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
| | - Lovepreet Singh
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Sofia Molina Garcia
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | | | - Omar T Sims
- Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, OH 44195, USA; Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Jamak Modaresi Esfeh
- Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
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4
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Müller M, Grasshoff C. [The Role of the Anaesthesiologist in Liver Transplantation - Preoperative Evaluation]. Anasthesiol Intensivmed Notfallmed Schmerzther 2024; 59:283-295. [PMID: 38759684 DOI: 10.1055/a-2152-7350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2024]
Abstract
Preoperative evaluation prior to listing for orthotopic liver transplantation (LT) requires a careful multidisciplinary approach with specialized teams including surgeons, hepatologists and anesthesiologists in order to improve short- and long-term clinical outcomes. Due to inadequate supply of donor organs and changing demographics, patients listed for LT have become older, sicker and share more comorbidities. As cardiovascular events are the leading cause for early mortality precise evaluation of risk factors is mandatory. This review focuses on the detection and management of coronary artery disease, cirrhotic cardiomyopathy, portopulmonary hypertension and hepatopulmonary syndrome in patients awaiting LT. Further insights are being given into scoring systems, patients with Acute-on-chronic-liver-failure (ACLF), frailty, NASH cirrhosis and into psychologic evaluation of patients with substance abuse.
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Pagano G, Sastre L, Blasi A, Brugaletta S, Mestres J, Martinez-Ocon J, Ortiz-Pérez JT, Viñals C, Prat-Gonzàlez S, Rivas E, Perea RJ, Rodriguez-Tajes S, Muxí Á, Ortega E, Doltra A, Ruiz P, Vidal B, Martínez-Palli G, Colmenero J, Crespo G. CACS, CCTA and mCAD-LT score in the pre-transplant assessment of coronary artery disease and the prediction of post-transplant cardiovascular events. Liver Int 2024. [PMID: 38591767 DOI: 10.1111/liv.15926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 03/19/2024] [Accepted: 03/24/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND The optimal cardiovascular assessment of liver transplant (LT) candidates is unclear. We aimed to evaluate the performance of CT-based coronary tests (coronary artery calcium score [CACS] and coronary CT angiography [CCTA]) and a modification of the CAD-LT score (mCAD-LT, excluding family history of CAD) to diagnose significant coronary artery disease (CAD) before LT and predict the incidence of post-LT cardiovascular events (CVE). METHODS We retrospectively analysed a single-centre cohort of LT candidates who underwent non-invasive tests; invasive coronary angiography (ICA) was performed depending on the results of non-invasive tests. mCAD-LT was calculated in all patients. RESULTS Six-hundred-and-thirty-four LT candidates were assessed and 351 of them underwent LT. CACS, CCTA and ICA were performed in 245, 123 and 120 LT candidates, respectively. Significant CAD was found in 30% of patients undergoing ICA. The AUROCs of mCAD-LT (.722) and CCTA (.654) were significantly higher than that of CACS (.502) to predict the presence of significant CAD. Specificity of the tests ranged between 31% for CCTA and 53% for CACS. Among patients who underwent LT, CACS ≥ 400 and mCAD-LT were independently associated with the incidence of CVE; in patients who underwent CCTA before LT, significant CAD at CCTA also predicted post-LT CVE. CONCLUSION In this cohort, mCAD-LT score and CT-based tests detect the presence of significant CAD in LT candidates, although they tend to overestimate it. Both mCAD-LT score and CT-based tests classify LT recipients according to their risk of post-LT CVE and can be used to improve post-LT risk mitigation.
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Affiliation(s)
- Giulia Pagano
- Liver Transplant Unit, Hospital Clínic, Barcelona, Spain
- Department of Hepatology, Hospital Clínic, Barcelona, Spain
| | - Lydia Sastre
- Department of Gastroenterology and Hepatology, Hospital Son Espases, Palma de Mallorca, Spain
| | - Annabel Blasi
- Department of Anesthesiology, Hospital Clínic, Barcelona, Spain
- University of Barcelona, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- CIBER-EHD, Madrid, Spain
| | - Salvatore Brugaletta
- University of Barcelona, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- Department of Cardiology, Hospital Clínic, Barcelona, Spain
| | - Judit Mestres
- Department of Radiology, Hospital Clínic, Barcelona, Spain
| | | | - Jose T Ortiz-Pérez
- University of Barcelona, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- Department of Cardiology, Hospital Clínic, Barcelona, Spain
| | - Clara Viñals
- Department of Endocrinology and Nutrition, Hospital Clínic, Barcelona, Spain
| | - Susanna Prat-Gonzàlez
- University of Barcelona, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- Department of Cardiology, Hospital Clínic, Barcelona, Spain
| | - Eva Rivas
- Department of Anesthesiology, Hospital Clínic, Barcelona, Spain
| | - Rosario J Perea
- IDIBAPS, Barcelona, Spain
- Department of Radiology, Hospital Clínic, Barcelona, Spain
| | - Sergio Rodriguez-Tajes
- Liver Transplant Unit, Hospital Clínic, Barcelona, Spain
- Department of Hepatology, Hospital Clínic, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- CIBER-EHD, Madrid, Spain
| | - África Muxí
- IDIBAPS, Barcelona, Spain
- Department of Nuclear Medicine, Hospital Clínic, Barcelona, Spain
| | - Emilio Ortega
- University of Barcelona, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- Department of Endocrinology and Nutrition, Hospital Clínic, Barcelona, Spain
- CIBER-OBN, Madrid, Spain
| | - Ada Doltra
- University of Barcelona, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- Department of Cardiology, Hospital Clínic, Barcelona, Spain
| | - Pablo Ruiz
- Liver Transplant Unit, Hospital Clínic, Barcelona, Spain
- Department of Hepatology, Hospital Clínic, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
| | - Bàrbara Vidal
- University of Barcelona, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- Department of Cardiology, Hospital Clínic, Barcelona, Spain
| | - Graciela Martínez-Palli
- Department of Anesthesiology, Hospital Clínic, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- CIBER-RES, Madrid, Spain
| | - Jordi Colmenero
- Liver Transplant Unit, Hospital Clínic, Barcelona, Spain
- Department of Hepatology, Hospital Clínic, Barcelona, Spain
- University of Barcelona, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- CIBER-EHD, Madrid, Spain
| | - Gonzalo Crespo
- Liver Transplant Unit, Hospital Clínic, Barcelona, Spain
- Department of Hepatology, Hospital Clínic, Barcelona, Spain
- University of Barcelona, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- CIBER-EHD, Madrid, Spain
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Jang HY, Han SB, Jeong JH, Kwon HM, Kim KS, Kim JH, Kim SH, Jun IG, Song JG, Hwang GS. Prognostic Value of Mitral Annular Calcification in Liver Transplant Patients: Implication in Posttransplant Outcomes. Transplantation 2024:00007890-990000000-00700. [PMID: 38499508 DOI: 10.1097/tp.0000000000004981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
BACKGROUND With the rise of metabolic diseases and aging in liver transplant (LT) candidates, mitral annular calcification (MAC) is more recognizable. Despite cardiovascular risk becoming a leading cause of mortality in LT recipients, the influence of MAC remains unexamined. This study investigates the prevalence, related factors, and impact of MAC on LT outcomes. METHODS We explored 4148 consecutive LT patients who underwent routine pretransplant echocardiography from 2008 to 2019. Multivariate logistic analysis and the tree-based Shapley additive explanation scores in machine learning were used to evaluate the significant and important related factors. The primary outcome was 30-d major adverse cardiac events (MACE), and the secondary outcome was a median of 5-y cumulative all-cause mortality. RESULTS MAC was found in 123 (3.0%) patients. Significant and important related factors included age, alcoholic liver disease, chronic kidney disease, hyperuricemia, hypertension, and coronary artery disease. The MACE rate was higher in patients with MAC compared with those without MAC at 30 d (P < 0.001, adjusted hazard ratio 1.67; 95% confidence interval, 1.08-2.57). Patients with MAC had poorer cumulative overall survival probability compared with those without MAC (P = 0.0016; adjusted hazard ratio 1.47; 95% confidence interval, 1.01-2.15). Specifically, women with MAC had a poorer survival probability compared with men without MAC (65.0% versus 80.7%, P < 0.001) >10 y post-LT. CONCLUSIONS The presence of MAC before LT was linked to increased 30-d MACE and lower long-term survival rates, especially in women. Identification and management of MAC and potential risk factors are crucial for improving post-LT survival.
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Affiliation(s)
- Hwa-Young Jang
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Stachel MW, DePasquale EC. Optimizing cardiac status in the preliver transplant candidate. Curr Opin Organ Transplant 2024; 29:50-55. [PMID: 37991086 DOI: 10.1097/mot.0000000000001119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Abstract
PURPOSE OF REVIEW Liver transplant is a widely accepted therapy for end-stage liver disease. With advances in our understanding of transplant, candidates are increasingly older with more cardiac comorbidities. Cardiovascular disease also represents a leading cause of morbidity and mortality posttransplant. RECENT FINDINGS Preoperative cardiac risk stratification and treatment may improve short-term and long-term outcomes after liver transplant. Importantly, the appropriate frequency of surveillance has not been defined. Optimal timing of cardiac intervention in end-stage liver disease is likewise uncertain. SUMMARY The approach to risk stratification of cardiovascular disease in end-stage liver disease is outlined, incorporating the AHA/ACC scientific statement on evaluation of cardiac disease in transplant candidates and more recent expert consensus documents. Further study is needed to clarify the ideal timing and approach for cardiovascular interventions.
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Affiliation(s)
- Maxine W Stachel
- Section of Heart Failure, Heart Transplantation & Mechanical Circulatory Support, Division of Cardiovascular Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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8
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Pint D, Gevaert AB, Vanwolleghem T, Chapelle T, Dams K. Heart failure with severely reduced ejection fraction after liver transplantation: a case report and review of the literature. Acta Clin Belg 2024; 79:46-51. [PMID: 37927044 DOI: 10.1080/17843286.2023.2278240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 10/28/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Liver transplantation (LT) is a strenuous event for the cardiovascular system. Cardiovascular events (CVE), including heart failure (HF), arrhythmias and myocardial ischemia, are important causes of peri- and post-liver transplantation morbidity and mortality. CASE PRESENTATION We describe the case of a 45-year-old male patient who developed heart failure with severely reduced ejection fraction (HFrEF) after receiving liver transplantation (LT) for end-stage post-alcoholic liver cirrhosis. Preoperative transthoracic echocardiography (TTE) demonstrated borderline left ventricular ejection fraction (LVEF) of 50% and diastolic dysfunction grade 2. On coronary angiography, the patient had no coronary stenoses. Persistent vasopressor need, increasing creatinine levels and progressive pleural effusion characterized the early postoperative period. TTE on postoperative day 6 revealed a new finding of a markedly reduced LVEF of 15%, accompanied by a discrete increase in hs-TnI and CK-MB without electrocardiographic (ECG) ST-T abnormalities. LVEF did not recover completely (EF 45%) during follow-up. The patient had a sudden death 4.5 months post-liver transplantation. CONCLUSION Our case demonstrates that the risk of post-LT systolic dysfunction is not excluded by preoperative resting examinations within normal range and highlights the need for preoperative cardiac stress assessment (e.g. dobutamine echocardiography or stress cardiac magnetic resonance imaging) before LT. In addition, patients on a liver-transplant waiting list with cardiac dysfunction should be followed by a multidisciplinary team including a dedicated cardiology team experienced in managing liver-related cardiac pathology.
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Affiliation(s)
- Dorien Pint
- Department of Gastroenterology and Hepatology, Antwerp University Hospital, Antwerp, Belgium
| | - Andreas B Gevaert
- Research Group Cardiovascular Diseases, GENCOR department, University of Antwerp, Antwerp, Belgium
- Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium
| | - Thomas Vanwolleghem
- Department of Gastroenterology and Hepatology, Antwerp University Hospital, Antwerp, Belgium
- Viral Hepatitis Research Group, Laboratory of Experimental Medicine and Pediatrics (LEMP), Antwerp University, Antwerp, Belgium
- European Reference Network RARE-LIVER, Antwerp University Hospital, Antwerp, Belgium
| | - Thiery Chapelle
- Department of Hepatobiliary, Transplantation and Endocrine Surgery, Antwerp University Hospital, Antwerp, Belgium
| | - Karolien Dams
- Department of Critical Care Medicine, Antwerp University Hospital, Antwerp, Belgium
- Laboratory of Experimental Medicine and Paediatrics (LEMP), Faculty of Medicine and Health Sciences, Antwerp University, Antwerp, Belgium
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Kuo SZ, Tincopa M. Predicting cardiovascular events after liver transplant: Is CT coronary angiography the noninvasive test we have been looking for? Liver Transpl 2024; 30:117-118. [PMID: 37773041 DOI: 10.1097/lvt.0000000000000264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 09/13/2023] [Indexed: 09/30/2023]
Affiliation(s)
- Selena Z Kuo
- Division of Gastroenterology & Hepatology, University of California at San Diego, La Jolla, California, USA
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10
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Dakroub A, Anouti A, Cotter TG, Lee WM. Mortality and Morbidity Among Adult Liver Retransplant Recipients. Dig Dis Sci 2023; 68:4039-4049. [PMID: 37597085 DOI: 10.1007/s10620-023-08065-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 07/25/2023] [Indexed: 08/21/2023]
Abstract
BACKGROUND Liver transplantation (LT) is life-saving procedure for patients with end-stage liver failure with up to 20% of patients suffering graft failure following primary transplantation. Retransplantation (ReLT) remains the only definitive treatment for irreversible graft failure. AIMS We aimed to explore the postoperative outcomes following liver ReLT. METHODS Patients who had received a liver transplant between 2003 and 2016 were retrospectively identified using the Scientific Registry of Transplant Recipients (SRTRs). Patients were stratified based on previous liver transplant history. The primary outcomes of this study were 5-year postoperative mortality, morbidity, and length of hospital stay following LT. RESULTS 60,554 (96%) recipients were first LT recipients and 2524 (4%) were ReLT recipients. Compared with first LT, ReLT recipients had significantly higher rates of mortality (OR 1.93, 95%CI 1.76-2.12), overall morbidity (OR 1.80, 95%CI 1.65-1.96), and prolonged length of stay (OR 1.66, 95%CI 1.52-1.81) on multivariate analysis. Morbidity including cardiovascular (CVD) complications (OR 1.32, 95%CI 1.08-1.60), graft failure (OR 2.18, 95%CI 1.84-2.57), infection (OR 2.13, 95%CI 1.82-2.50), and hemorrhage (OR 2.67, 95%CI 2.00-3.61) were significantly greater in ReLT recipients. Compared to first LT, ReLT patients had a significant increase in overall 5-year mortality (p < 0.001), 5-year mortality due to CVD complications (p < 0.001), infection (p = 0.009), but not graft failure (p = 0.3543). CONCLUSION ReLT is associated with higher rates of 5-year mortality, overall morbidity, CVD morbidity, infection, and graft failure. Higher 5-year mortality in ReLT is due to CVD and infections. These results could be used in preoperative patient assessment and prognostic counseling for ReLT.
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Affiliation(s)
- Ali Dakroub
- St. Francis Hospital and Heart Center, Roslyn, NY, USA
| | - Ahmad Anouti
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA
| | - Thomas G Cotter
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA
| | - William M Lee
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA.
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Hughes DL, Pan J, Answine AR, Sonnenday CJ, Waits SA, Kumar SS, Menees DS, Wanamaker B, Bhave NM, Tincopa MA, Fontana RJ, Sharma P. Positron emission tomography myocardial perfusion imaging (PET MPI) findings predictive of post-liver transplant major adverse cardiac events. Liver Transpl 2023; 29:970-978. [PMID: 36879556 DOI: 10.1097/lvt.0000000000000118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 01/24/2023] [Indexed: 03/08/2023]
Abstract
Positron emission tomography myocardial perfusion imaging (PET MPI) is a noninvasive diagnostic test capable of detecting coronary artery disease, structural heart disease, and myocardial flow reserve (MFR). We aimed to determine the prognostic utility of PET MPI to predict post-liver transplant (LT) major adverse cardiac events (MACE). Among the 215 LT candidates that completed PET MPI between 2015 and 2020, 84 underwent LT and had 4 biomarker variables of clinical interest on pre-LT PET MPI (summed stress and difference scores, resting left ventricular ejection fraction, global MFR). Post-LT MACE were defined as acute coronary syndrome, heart failure, sustained arrhythmia, or cardiac arrest within the first 12 months post-LT. Cox regression models were constructed to determine associations between PET MPI variable/s and post-LT MACE. The median LT recipient age was 58 years, 71% were male, 49% had NAFLD, 63% reported prior smoking, 51% had hypertension, and 38% had diabetes mellitus. A total of 20 MACE occurred in 16 patients (19%) at a median of 61.5 days post-LT. One-year survival of MACE patients was significantly lower than those without MACE (54% vs. 98%, p =0.001). On multivariate analysis, reduced global MFR ≤1.38 was associated with a higher risk of MACE [HR=3.42 (1.23-9.47), p =0.019], and every % reduction in left ventricular ejection fraction was associated with an 8.6% higher risk of MACE [HR=0.92 (0.86-0.98), p =0.012]. Nearly 20% of LT recipients experienced MACE within the first 12 months of LT. Reduced global MFR and reduced resting left ventricular ejection fraction on PET MPI among LT candidates were associated with increased risk of post-LT MACE. Awareness of these PET-MPI parameters may help improve cardiac risk stratification of LT candidates if confirmed in future studies.
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Affiliation(s)
- Dempsey L Hughes
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, USA
| | - Jason Pan
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Adeline R Answine
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Seth A Waits
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Sathish S Kumar
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Daniel S Menees
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Brett Wanamaker
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Nicole M Bhave
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Monica A Tincopa
- Division of Gastroenterology and Hepatology, University of California San Diego, San Diego, California
| | - Robert J Fontana
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Pratima Sharma
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
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12
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Lee DU, Menegas S, Lee KJ, Pu A, Bhowmick K, Ponder R, Fan GH, Chou H, Lee K, Urrunaga NH. Impact of Inflammatory Bowel Disease Subtypes on the Post-liver Transplant Outcomes of Patients with Primary Sclerosing Cholangitis. Dig Dis Sci 2023; 68:3781-3800. [PMID: 37450231 PMCID: PMC10789194 DOI: 10.1007/s10620-023-08023-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 06/24/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND AND AIMS Liver transplant patients with primary sclerosing cholangitis often present with concurrent inflammatory bowel disease. The effect of comorbid conditions on post-transplant prognosis was evaluated. METHODS The 2005-2019 United Network of Organ Sharing Standard Transplant Analysis and Research database was used to identify patients with primary sclerosing cholangitis. Patients were categorized as having Crohn's Disease, ulcerative colitis, unclassified inflammatory bowel disease, or no inflammatory bowel disease. Baseline characteristics were assessed between cohorts, and outcomes were examined using Cox regression. Outcomes included all-cause mortality, graft failure, infection-induced mortality, and organ system-delineated mortality. Supplementary analyses with unique exclusion and stratification criteria were also performed. RESULTS Among 2829 patients undergoing transplant, 1360 were considered to have ulcerative colitis, 372 were considered to have Crohn's Disease, and 69 were considered to have an unclassified form of inflammatory bowel disease. Primary sclerosing cholangitis patients with some form of inflammatory bowel disease had no increased risk for any outcomes. However, patients with ulcerative colitis had lower risks of general infectious (aHR 0.65 95%CI 0.44-0.95) and sepsis-induced (aHR 0.56 95%CI 0.35-0.91) mortality, whereas patients with Crohn's Disease had higher risks of sepsis-induced mortality (aHR 2.13 95%CI 1.22-3.70). Supplementary analyses showed effect modification by abdominal surgery history and era. CONCLUSION The type of inflammatory bowel disease in liver transplant patients with primary sclerosing cholangitis was found to portend risk difference for infection-induced mortality, with ulcerative colitis found to be protective and Crohn's Disease predictive of increased mortality secondary to infectious etiologies. These associations warrant further investigation.
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Affiliation(s)
- David Uihwan Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, 22 S. Greene Street, N3W50, Baltimore, 21201, USA.
| | - Samantha Menegas
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, 22 S. Greene Street, N3W50, Baltimore, 21201, USA
| | - Ki Jung Lee
- Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Alex Pu
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, 22 S. Greene Street, N3W50, Baltimore, 21201, USA
| | - Kuntal Bhowmick
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Reid Ponder
- Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Gregory Hongyuan Fan
- Division of Gastroenterology, Liver Center, Tufts Medical Center, Boston, MA, USA
| | - Harrison Chou
- Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - KeeSeok Lee
- Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Nathalie H Urrunaga
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, 22 S. Greene Street, N3W50, Baltimore, 21201, USA
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13
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De Gasperi A, Petrò L, Cerutti E. Liver Transplantation and the Elderly Candidate: Perioperative Considerations. Anesthesiol Clin 2023; 41:595-611. [PMID: 37516497 DOI: 10.1016/j.anclin.2023.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2023]
Abstract
Pioneered by Thomas Starzl in the early 1970s, liver transplant (LT) is nowadays often considered a final intervention and standard of care to cure many forms of acute and chronic end-stage liver diseases. Started in recipients younger than 60 years old, LT indications are now much broader, and at least, one-fifth of the candidates are older than 65 years. Problems associated with ageing and frailty in LT recipients and their impact on the entire perioperative course are discussed according to a modern anesthesiological perspective and the anesthesiologist covering the role of the perioperative (transplant) physician.
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Affiliation(s)
| | - Laura Petrò
- ANRI1 - Emergency and Intensive Care, ASST Ospedale Giovanni XXIII, Bergamo, Italy; ASST Papa Giovanni XXII, Piazza MSO 1, 24100 Bergamo, Italy
| | - Elisabetta Cerutti
- Anestesia e Rianimazione dei Trapianti e Chirurgia Maggiore, Azienda Ospedaliero Universitaria delle Marche, Via Conca 71, 60020, Ancona, Italy; Azienda Ospedaliero Universitaria "Ospedali Riuniti", Via Conca 71, 60020, Ancona, Italy
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14
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Tsochatzis EA, Watt KD, VanWagner LB, Verna EC, Berzigotti A. Evaluation of recipients with significant comorbidity - Patients with cardiovascular disease. J Hepatol 2023; 78:1089-1104. [PMID: 37208096 DOI: 10.1016/j.jhep.2023.03.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 03/24/2023] [Accepted: 03/26/2023] [Indexed: 05/21/2023]
Abstract
Liver transplant(ation) (LT) is the most effective treatment for patients with decompensated liver disease. The increasing prevalence of obesity and type 2 diabetes and the growing number of patients with non-alcoholic fatty liver disease being evaluated for LT, have resulted in a greater proportion of LT candidates presenting with a higher risk of cardiovascular disease. As cardiovascular disease is a major cause of morbidity and mortality after LT, a thorough cardiovascular evaluation pre-LT is crucial. In this review, we discuss the latest evidence on the cardiovascular evaluation of LT candidates and we focus on the most prevalent conditions, namely ischaemic heart disease, atrial fibrillation and other arrhythmias, valvular heart disease, and cardiomyopathies. LT candidates undergo an electrocardiogram, a resting transthoracic echocardiography and an assessment of their cardiopulmonary functional ability as part of their standardised pre-LT work-up. Further diagnostic work-up is undertaken based on the results of the baseline evaluation and may include a coronary computed tomography angiography in patients with cardiovascular risk factors. The evaluation of potential LT candidates for cardiovascular disease requires a multidisciplinary approach, with input from anaesthetists, cardiologists, hepatologists and transplant surgeons.
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Affiliation(s)
- Emmanuel A Tsochatzis
- UCL Institute for Liver and Digestive Health, Royal Free Campus, London, UK; Sheila Sherlock Liver Unit, Royal Free Hospital, London, UK.
| | - Kymberly D Watt
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Lisa B VanWagner
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Elizabeth C Verna
- Center for Liver Disease and Transplantation, Columbia University Irving Medical Center, New York, New York, USA
| | - Annalisa Berzigotti
- Department of Visceral Surgery and Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
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15
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Ferjani M, Trouve-Buisson T, Godon A, Barone-Rochette G, Bonadona A, Bouzat P. Response to "Postoperative Myocardial Injury and Outcomes in Liver and Kidney Transplant Patients". CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 46:119-120. [PMID: 35989177 DOI: 10.1016/j.carrev.2022.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 08/15/2022] [Indexed: 02/05/2023]
Affiliation(s)
- Malik Ferjani
- Univ. Grenoble Alpes, Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences, 38000 Grenoble, France.
| | - Thibaut Trouve-Buisson
- Univ. Grenoble Alpes, Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences, 38000 Grenoble, France
| | - Alexandre Godon
- Univ. Grenoble Alpes, Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences, 38000 Grenoble, France
| | - Gilles Barone-Rochette
- Univ. Grenoble Alpes, Department of Cardiology, CHU Grenoble Alpes, 38000 Grenoble, France
| | - Agnès Bonadona
- Univ. Grenoble Alpes, Department of Hepatology and Gastroenterology, CHU Grenoble Alpes, 38000 Grenoble, France
| | - Pierre Bouzat
- Univ. Grenoble Alpes, Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences, 38000 Grenoble, France
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16
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Izzy M, Fortune BE, Serper M, Bhave N, deLemos A, Gallegos-Orozco JF, Guerrero-Miranda C, Hall S, Harinstein ME, Karas MG, Kriss M, Lim N, Palardy M, Sawinski D, Schonfeld E, Seetharam A, Sharma P, Tallaj J, Dadhania DM, VanWagner LB. Management of cardiac diseases in liver transplant recipients: Comprehensive review and multidisciplinary practice-based recommendations. Am J Transplant 2022; 22:2740-2758. [PMID: 35359027 PMCID: PMC9522925 DOI: 10.1111/ajt.17049] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/10/2022] [Accepted: 03/27/2022] [Indexed: 01/25/2023]
Abstract
Cardiac diseases are one of the most common causes of morbidity and mortality following liver transplantation (LT). Prior studies have shown that cardiac diseases affect close to one-third of liver transplant recipients (LTRs) long term and that their incidence has been on the rise. This rise is expected to continue as more patients with advanced age and/or non-alcoholic steatohepatitis undergo LT. In view of the increasing disease burden, a multidisciplinary initiative was developed to critically review the existing literature (between January 1, 1990 and March 17, 2021) surrounding epidemiology, risk assessment, and risk mitigation of coronary heart disease, arrhythmia, heart failure, and valvular heart disease and formulate practice-based recommendations accordingly. In this review, the expert panel emphasizes the importance of optimizing management of metabolic syndrome and its components in LTRs and highlights the cardioprotective potential for the newer diabetes medications (e.g., sodium glucose transporter-2 inhibitors) in this high-risk population. Tailoring the multidisciplinary management of cardiac diseases in LTRs to the cardiometabolic risk profile of the individual patient is critical. The review also outlines numerous knowledge gaps to pave the road for future research in this sphere with the ultimate goal of improving clinical outcomes.
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Affiliation(s)
- Manhal Izzy
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University, Nashville, TN, USA
| | - Brett E Fortune
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY, USA
| | - Marina Serper
- Department of Medicine, Division of Gastroenterology, University of Pennsylvania, Philadelphia, PA, USA
| | - Nicole Bhave
- Department of Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Andrew deLemos
- Department of Medicine, Division of Hepatology, Atrium Health, Charlotte, NC, USA
| | - Juan F. Gallegos-Orozco
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Utah School, Salt Lake City, UT, USA
| | - Cesar Guerrero-Miranda
- Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, TX, USA
| | - Shelley Hall
- Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, TX, USA
| | - Matthew E Harinstein
- Department of Medicine, Division of Cardiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Maria G. Karas
- Department of Medicine, Division of Cardiology, Weill Cornell Medical College, New York, NY, USA
| | - Michael Kriss
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Colorado, Aurora, CO, USA
| | - Nicholas Lim
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, MN, USA
| | - Maryse Palardy
- Department of Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Deirdre Sawinski
- Department of Medicine, Division of Nephrology and Hypertension, Weill Cornell Medical College, New York, NY, USA
| | - Emily Schonfeld
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY, USA
| | - Anil Seetharam
- Department of Medicine, Division of Gastroenterology and Hepatology, Banner - University Medical Center Phoenix, Phoenix, AZ, USA
| | - Pratima Sharma
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
| | - Jose Tallaj
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama, Birmingham, AL, USA
| | - Darshana M Dadhania
- Department of Medicine, Division of Nephrology and Hypertension, Weill Cornell Medical College, New York, NY, USA
| | - Lisa B. VanWagner
- Department of Medicine, Division of Gastroenterology & Hepatology, and Department of Preventive Medicine, Division of Epidemiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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17
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Cheng XS, VanWagner LB, Costa SP, Axelrod DA, Bangalore S, Norman SP, Herzog C, Lentine KL. Emerging Evidence on Coronary Heart Disease Screening in Kidney and Liver Transplantation Candidates: A Scientific Statement From the American Heart Association: Endorsed by the American Society of Transplantation. Circulation 2022; 146:e299-e324. [PMID: 36252095 PMCID: PMC10124159 DOI: 10.1161/cir.0000000000001104] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Coronary heart disease is an important source of mortality and morbidity among kidney transplantation and liver transplantation candidates and recipients and is driven by traditional and nontraditional risk factors related to end-stage organ disease. In this scientific statement, we review evidence from the past decade related to coronary heart disease screening and management for kidney and liver transplantation candidates. Coronary heart disease screening in asymptomatic kidney and liver transplantation candidates has not been demonstrated to improve outcomes but is common in practice. Risk stratification algorithms based on the presence or absence of clinical risk factors and physical performance have been proposed, but a high proportion of candidates still meet criteria for screening tests. We suggest new approaches to pretransplantation evaluation grounded on the presence or absence of known coronary heart disease and cardiac symptoms and emphasize multidisciplinary engagement, including involvement of a dedicated cardiologist. Noninvasive functional screening methods such as stress echocardiography and myocardial perfusion scintigraphy have limited accuracy, and newer noninvasive modalities, especially cardiac computed tomography-based tests, are promising alternatives. Emerging evidence such as results of the 2020 International Study of Comparative Health Effectiveness With Medical and Invasive Approaches-Chronic Kidney Disease trial emphasizes the vital importance of guideline-directed medical therapy in managing diagnosed coronary heart disease and further questions the value of revascularization among asymptomatic kidney transplantation candidates. Optimizing strategies to disseminate and implement best practices for medical management in the broader end-stage organ disease population should be prioritized to improve cardiovascular outcomes in these populations.
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Affiliation(s)
| | | | | | | | | | | | - Charles Herzog
- Hennepin Healthcare/University of Minnesota, Minneapolis, MN
| | - Krista L. Lentine
- Saint Louis University Center for Abdominal Transplantation, St. Louis, MO
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18
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Preexisting Coronary Artery Disease in Liver Transplant Candidates: Risk Factor or Risk Marker? Transplantation 2022; 107:824-826. [PMID: 36372929 DOI: 10.1097/tp.0000000000004403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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19
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Kwon HM, Kim JH, Yang JW, Hwang GS. Temporary postoperative myocardial injury and long-term survival in liver transplant patients with coronary artery disease. Anesth Pain Med (Seoul) 2022; 17:404-411. [DOI: 10.17085/apm.22167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 09/27/2022] [Indexed: 11/05/2022] Open
Abstract
Background: Coronary artery disease (CAD) is increasing worldwide due to the aging population and cardiometabolic syndrome. However, the extent of postoperative myocardial injury, the most common cause of death during the 30 days after noncardiac surgery, remains unclear with respect to liver transplant (LT) patients with CAD. We examined the link between post-LT high sensitivity cardiac troponin I (hs_cTnI) and long-term survival according to liver disease severity.Methods: Consecutive patients who underwent LT (n = 3,220) from 2010 to 2020 were evaluated retrospectively. CAD was defined as a history of coronary artery bypass surgery or percutaneous intervention, or previous myocardial infarction. Peak hs_cTnI levels within 30 days post-transplant were compared in patients with and without CAD. The primary endpoint was defined as an all-cause mortality at 12 years following LT. Secondary endpoints include peak hs_cTnI level within post-transplant 30 days and 30-day mortality. Survival analysis was performed using the Kaplan–Meier method.Results: CAD patients (n = 264, 8.2%) had higher peak hs_cTnI levels within 30 days post-LT than those without CAD (median [interquartile]: 0.068 [0.030–0.154] vs. 0.087 [0.037–0.203] ng/ml, respectively; P = 0.004); however, the mortality rate was comparable (14.7% vs. 14.8%, respectively, P = 0.999), at 12 years, and 1.9% vs. 1.1% (P = 0.522) at 30 days, respectively, at 30 days. Subgroup analysis with stratified liver disease severity identified a similar risk of long-term mortality.Conclusions: Although the peak hs_cTnI level within 30 days was higher in revascularized or treated CAD patients after LT compared those without CAD, long-term mortality rates at 12 years and 30-day mortality rate were comparable.
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20
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Kwon HM, Kim JH, Kim JY, Hwang GS. Five-year all-cause mortality in critically ill liver transplant patients with coronary artery disease: analysis of acute-on chronic liver failure. Anesth Pain Med (Seoul) 2022; 17:412-419. [DOI: 10.17085/apm.22168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 08/01/2022] [Indexed: 11/07/2022] Open
Abstract
Background: Patients with acute-on-chronic liver failure (ACLF) are critically ill and have high waiting-list mortality. Although studies demonstrated that appropriately treated coronary artery disease (CAD) should not be regarded as a contraindication to liver transplant (LT), data regarding long-term outcomes in critically ill liver LT recipients are lacking. The aim of this study was to compare the rates of all-cause death at 5 years following LT in patients with ACLF with or without CAD.Methods: Between 2010 and 2020, we evaluated 921 consecutive LT patients (MELD score, 32 ± 9) and ACLF classified by CLIF-C ACLF score. Up to 5-year all-cause death according to the CAD status was examined. CAD was defined as a preoperative history of coronary artery bypass graft or a percutaneous intervention and old myocardial infarction. Kaplan-Meier survival analysis was used.Results: Up to 5 years, 212 (23.0%) of all ACLF patients (n = 921) in whom 17 (29.3%) of 58 CAD patients died. In patients with CAD (6.3%, 58/921), the Kaplan-Meier cumulative mortality rate at 5 years was numerically higher but was not statistically significant when compared with those without CAD (32.9% vs. 23.5%, log-rank, P = 0.25). In subgr oup analysis, there were comparable risks of cumulative mortalities at 5 years across the stratification of ACLF grade 1, 2, and 3 (log-rank P = 0.062, P = 0.72, and P = 0.999, respectively).Conclusions: All-cause mortality is high in patients with ACLF after LT but is not related to the presence of revascularized or treated CAD, across the stratification of ACLF grades.
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21
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Evaluation of right ventricular function during liver transplantation with transesophageal echocardiography. PLoS One 2022; 17:e0275301. [PMID: 36194610 PMCID: PMC9531831 DOI: 10.1371/journal.pone.0275301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 09/13/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The pathophysiology of advanced liver cirrhosis may induce alterations in the circulatory system that may be challenging for the anesthesiologist to manage intraoperatively, and perioperative cardiovascular events are associated with worse outcomes in cirrhotic patients undergoing liver transplantation. It remains controversial whether right ventricular function is impaired during this procedure. Studies using transesophageal echocardiography for quantitative analysis of the right ventricle remain scarce in this setting, yielding conflicting results. The aim of this study was to perform a quantitative assessment of right ventricular function with two parameters derived from transesophageal echocardiography during liver transplantation. METHODS Nineteen adult patients of both genders undergoing liver transplantation were evaluated in this observational study. The exclusion criteria were age under 18 or above 65 years old, fulminant hepatic failure, hepatopulmonary syndrome, portopulmonary hypertension, cardiopulmonary disease, and contraindications to the transesophageal echocardiogram. Right ventricular function was assessed at five stages during liver transplantation: baseline, hepatectomy, anhepatic, postreperfusion, and closure by measuring tricuspid annular plane systolic excursion and right ventricular fractional area change obtained with transesophageal echocardiography. RESULTS Right ventricular function was found to be normal throughout the procedure. The tricuspid annular plane systolic excursion showed a trend toward a decrease in the anhepatic phase compared to baseline (2.0 ± 0.9 cm vs. 2.4 ± 0.7 cm; P = 0.24) but with full recovery after reperfusion. Right ventricular fractional area change remained nearly constant during all stages studied (minimum: 50% ± 10 at baseline and anhepatic phase; maximum: 56% ± 12 at postreperfusion; P = 0.24). CONCLUSIONS Right ventricular function was preserved during liver transplantation at the time points evaluated by two quantitative parameters derived from transesophageal echocardiogram.
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22
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Lonardo A, Mantovani A, Petta S, Carraro A, Byrne CD, Targher G. Metabolic mechanisms for and treatment of NAFLD or NASH occurring after liver transplantation. Nat Rev Endocrinol 2022; 18:638-650. [PMID: 35840803 DOI: 10.1038/s41574-022-00711-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/07/2022] [Indexed: 11/08/2022]
Abstract
The rising tide of non-alcoholic fatty liver disease (NAFLD) associated with the obesity epidemic is a major health concern worldwide. NAFLD - specifically its more advanced form, non-alcoholic steatohepatitis (NASH)-related cirrhosis - is now the fastest growing indication for liver transplantation in the USA and Europe. Although the short-term and mid-term overall survival rates of patients who receive a liver transplant for NASH-related cirrhosis are essentially similar to those of patients who receive a transplant for other liver indications, recipients with NASH-related cirrhosis have an increased risk of waiting-list mortality and of developing recurrent liver disease and cardiometabolic complications in the longer term after liver transplantation. This Review provides a brief overview of the epidemiology of NAFLD and NASH and the occurrence of NAFLD or NASH in patients after liver transplantation for NASH and other liver indications. It also discusses the putative metabolic mechanisms underlying the emergence of NAFLD or NASH after liver transplantation as well as optimal therapeutic approaches for recipients of liver transplants, including the management of cardiometabolic comorbidities, tailored immunosuppression, lifestyle changes and pharmacotherapy for NAFLD.
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Affiliation(s)
- Amedeo Lonardo
- Metabolic Syndrome Unit, University of Modena, Modena, Italy
| | - Alessandro Mantovani
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Verona, Verona, Italy
| | - Salvatore Petta
- Section of Gastroenterology and Hepatology, PROMISE, University of Palermo, Palermo, Italy
| | - Amedeo Carraro
- Liver Transplant Unit, University of Verona, Verona, Italy
| | - Christopher D Byrne
- Nutrition and Metabolism, Faculty of Medicine, University of Southampton, Southampton, UK
- Southampton National Institute for Health Research Biomedical Research Centre, University Hospital Southampton, Southampton General Hospital, Southampton, UK
| | - Giovanni Targher
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Verona, Verona, Italy.
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23
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Izzy M, DuBrock HM. CAQ Corner: Cardiovascular and pulmonary evaluation of liver transplantation candidates: What you need to know for the board exam. Liver Transpl 2022; 28:1529-1538. [PMID: 35470532 DOI: 10.1002/lt.26495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 04/18/2022] [Accepted: 04/21/2022] [Indexed: 01/13/2023]
Affiliation(s)
- Manhal Izzy
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Hilary M DuBrock
- Division of Pulmonary and Critical Care, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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24
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Xiao J, Yong JN, Ng CH, Syn N, Lim WH, Tan DJH, Tan EY, Huang D, Wong RC, Chew NWS, Tan EXX, Noureddin M, Siddiqui MS, Muthiah MD. A Meta-Analysis and Systematic Review on the Global Prevalence, Risk Factors, and Outcomes of Coronary Artery Disease in Liver Transplantation Recipients. Liver Transpl 2022; 28:689-699. [PMID: 34626045 DOI: 10.1002/lt.26331] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 10/02/2021] [Accepted: 10/06/2021] [Indexed: 12/12/2022]
Abstract
The shift in the changing etiology of cirrhosis requiring liver transplantation (LT) has resulted in an increasing prevalence of coronary artery disease (CAD) that can potentially impact post-LT outcomes. This systematic review and meta-analysis evaluates the prevalence of CAD, risk factors, and outcomes of patients diagnosed with CAD before LT. MEDLINE and EMBASE were searched for articles describing CAD in pre-LT patients. Meta-analysis of proportions using the generalized linear mix model was conducted to analyze the pooled prevalence of CAD in pre-LT patients. Associated risk factors for CAD in pre-LT patients and outcomes were evaluated in conventional pairwise meta-analysis. A total of 39 studies were included. The pooled prevalence of patients diagnosed with CAD before LT was 15.9% (95% CI, 9.8%-24.7%). Age, male sex, diabetes mellitus, hypertension, hyperlipidemia, smoking, nonalcoholic steatohepatitis, hepatitis B virus, and hepatocellular carcinoma were significantly associated with CAD. Patients from high-income countries especially North America, Europe, and South America, with the associated risk factors were at increased risk for CAD before LT. CAD before LT was associated with an increased odds of overall mortality (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.4-1.4; P = 0.01) and cardiac-related mortality (OR, 1.2; 95% CI, 1.1-1.3; P = 0.03). A total of 48.7% of included articles considered the presence of cardiovascular risk factors for CAD screening. However, 10.3% of the studies screened for CAD in pre-LT patients via invasive coronary angiography only, without stress testing or risk stratification. This study demonstrates the high prevalence of CAD in pre-LT patients, associated risk factors, and outcomes. There is heterogeneity among guidelines and practice in screening for pre-LT CAD, and more studies are needed to establish consensus.
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Affiliation(s)
- Jieling Xiao
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Jie Ning Yong
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Cheng Han Ng
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Nicholas Syn
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore.,Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Wen Hui Lim
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Darren Jun Hao Tan
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - En Ying Tan
- Biostatistics and Modelling Domain, Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore.,National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
| | - Daniel Huang
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore.,Biostatistics and Modelling Domain, Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore.,National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
| | - Raymond C Wong
- Department of Cardiology, National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Nicholas W S Chew
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore.,Department of Cardiology, National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Eunice Xiang Xuan Tan
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore.,Biostatistics and Modelling Domain, Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore.,National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
| | - Mazen Noureddin
- Cedars-Sinai Fatty Liver Program, Division of Digestive and Liver Diseases, Department of Medicine, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Mohammad Shadab Siddiqui
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
| | - Mark D Muthiah
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore.,Biostatistics and Modelling Domain, Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore.,National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
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25
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Barman PM, Chadha RM, VanWagner LB. Cardiac Risk Assessment in Liver Transplant Candidates: A Survey of National Practice Patterns. Liver Transpl 2022; 28:501-504. [PMID: 34536331 DOI: 10.1002/lt.26307] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 08/23/2021] [Accepted: 09/13/2021] [Indexed: 01/13/2023]
Affiliation(s)
- Pranab M Barman
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Diego, San Diego, CA
| | - Ryan M Chadha
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - Lisa B VanWagner
- Department of Medicine-Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL.,Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL.,Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
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Truby LK, Mentz RJ, Agarwal R. Cardiovascular risk stratification in the noncardiac solid organ transplant candidate. Curr Opin Organ Transplant 2022; 27:22-28. [PMID: 34939961 PMCID: PMC9946722 DOI: 10.1097/mot.0000000000000942] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Solid organ transplantation (SOT) has become a widely accepted therapy for end-stage disease across the spectrum of thoracic and abdominal organs. With contemporary advances in medical and surgical therapies in transplantation, candidates for SOT are increasingly older with a larger burden of comorbidities, including cardiovascular disease (CVD). CVD, in particular, is a leading cause of morbidity and mortality in SOT candidates with end-stage disease of noncardiac organs [1]. RECENT FINDINGS Identification of coronary artery disease (CAD), heart failure, and valvular disease are important in noncardiac SOT to ensure both appropriate peri-transplant management and equitable organ allocation. Although the American College of Cardiology (ACC) and the American Heart Association (AHA) have published guidelines and recommendations for the perioperative cardiovascular evaluation of patients undergoing noncardiac surgery, the implications of both symptomatic and asymptomatic CVD differ in patients with end-stage organ failure being considered for SOT when compared to the general population. SUMMARY Herein, we review the epidemiology, diagnosis, and evidence for the management of CVD in kidney and liver transplantation, combining current guidelines from the 2012 ACC/AHA scientific statement on cardiac disease evaluation in SOT with more contemporary evidenced-based algorithms.
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Affiliation(s)
- Lauren K. Truby
- Division of Cardiology, Department of Medicine, Durham, North Carolina, USA
- Duke Molecular Physiology Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Robert J. Mentz
- Division of Cardiology, Department of Medicine, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Richa Agarwal
- Division of Cardiology, Department of Medicine, Durham, North Carolina, USA
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Akhtar S. Preoperative evaluation of geriatric patients undergoing liver transplantation. Curr Opin Anaesthesiol 2022; 35:96-104. [PMID: 34878418 DOI: 10.1097/aco.0000000000001084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW As the population of the world is aging the number of geriatric patients undergoing liver transplantation (LT) is also increasing. They pose a unique challenge for the caregivers, as they have age-related physiological changes, multiple comorbidities and cirrhosis-related pathologies. RECENT FINDINGS Twenty-two percent of patients who undergo LT are older than 65 years. Many patients suffer from nonalcoholic steatohepatitis (NASH), hepatocellular carcinoma and hepatitis-C virus. Incidence of NASH tends to increase with age, obesity, diabetes and metabolic syndrome. Elderly patients require comprehensive cognitive, cardiac and pulmonary evaluation prior to LT. Cirrhotic cardiomyopathy, hepatopulmonary syndrome, portopulmonary hypertension and frailty are of specific concern. SUMMARY Proportion of elderly patients who are undergoing LT continues to increase. These patients require comprehensive cardiopulmonary and frailty evaluation. Consensus-based practice advisories need to be developed to standardize preoperative evaluation of geriatric patients awaiting LT.
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Affiliation(s)
- Shamsuddin Akhtar
- Department of Anesthesiology and Pharmacology, Yale School of Medicine, New Haven, Connecticut, USA
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De Gasperi A, Zorzi A. Cardiac evaluation before liver transplantation: A step forward? J Hepatol 2021; 75:19-21. [PMID: 33985819 DOI: 10.1016/j.jhep.2021.04.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 04/22/2021] [Accepted: 04/23/2021] [Indexed: 12/04/2022]
Affiliation(s)
- Andrea De Gasperi
- Former Head, 2° Anaesthesia Intensive Care Service ASST GOM Niguarda, Milan, Italy.
| | - Alessandro Zorzi
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Padova, Italy
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Crespo G. Moving Forward in the Stratification of Cardiac Risk in Liver Transplantation Candidates. Liver Transpl 2021; 27:957-958. [PMID: 33550711 DOI: 10.1002/lt.26005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 02/04/2021] [Indexed: 12/23/2022]
Affiliation(s)
- Gonzalo Crespo
- Liver Transplant Unit, Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBERehd), University of Barcelona, Barcelona, Spain
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