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Schmidt K, Spann A, Khan MQ, Izzy M, Watt KD. Minimizing Metabolic and Cardiac Risk Factors to Maximize Outcomes After Liver Transplantation. Transplantation 2024; 108:1689-1699. [PMID: 38060378 DOI: 10.1097/tp.0000000000004875] [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: 07/24/2024]
Abstract
Cardiovascular disease (CVD) is a leading complication after liver transplantation and has a significant impact on patients' outcomes posttransplant. The major risk factors for post-liver transplant CVD are age, preexisting CVD, nonalcoholic fatty liver disease, chronic kidney disease, and metabolic syndrome. This review explores the contemporary strategies and approaches to minimizing cardiometabolic disease burden in liver transplant recipients. We highlight areas for potential intervention to reduce the mortality of patients with metabolic syndrome and CVD after liver transplantation.
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Affiliation(s)
- Kathryn Schmidt
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Ashley Spann
- Division of Gastroenterology and Hepatology, Vanderbilit University, Nashville, TN
| | - Mohammad Qasim Khan
- Division of Gastroenterology and Hepatology, University of Western Ontario, London, ON, Canada
| | - Manhal Izzy
- Division of Gastroenterology and Hepatology, Vanderbilit University, Nashville, TN
| | - Kymberly D Watt
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
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Gitto S, Golfieri L, Sofi F, Tamè MR, Vitale G, DE Maria N, Marzi L, Mega A, Valente G, Borghi A, Forte P, Cescon M, DI Benedetto F, Andreone P, Petranelli M, Dinu M, Carrai P, Arcangeli G, Grandi S, Lau C, Morelli MC, DE Simone P, Chiesi F, Marra F. Adherence to Mediterranean diet in liver transplant recipients: a cross-sectional multicenter study. Minerva Gastroenterol (Torino) 2024; 70:42-51. [PMID: 37162468 DOI: 10.23736/s2724-5985.22.03290-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
BACKGROUND Seeing the importance of healthy diet after liver transplant (LT), our study aimed to evaluate the adherence to Mediterranean diet (MD) in a large population of LT recipients. METHODS The present multicenter study was developed in clinically stable, liver transplanted patients, from June to September 2021. Patients completed a survey about adherence to MD, Quality of Life (QoL), sport, and employment. To analyze the correlations, we computed Pearson's coefficients; while to compare subgroups, independent samples t-tests and ANOVAs. We used a multivariable logistic regression analysis to find the predictors of impaired adherence to MD. RESULTS The questionnaire was administered to 511 patients. They were males in 71% of cases with a mean age of 63.1 years (SD±10.8). LT recipients coming from central Italy displayed higher adherence to the MD (M=11.10±1.91) than patients from northern (M=9.94±2.28, P<0.001) or southern Italy (M=10.04±2.16, P<0.001). Patients from central Italy showed a significantly higher consumption of fruit, vegetables, legumes, cereals, olive oil, fish and a significantly lower intake of dairy products than patients resident in the other Italian areas. At multivariate analysis, recipients from central Italy were 3.8 times more likely to report adherence to the MD. Patients with a high physical health score were more adherent to MD, as well as patients transplanted at an earlier time. CONCLUSIONS We demonstrated that place of stay, time from transplant and physical dimension of QoL significantly influences the adherence to MD. Continuous information campaigns about a correct diet and lifestyle would be necessary.
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Affiliation(s)
- Stefano Gitto
- Internal Medicine and Liver Unit, Department of Experimental and Clinical Medicine, University of Florence, Careggi University Hospital, Florence, Italy -
| | - Lucia Golfieri
- Unit of Internal Medicine for the Treatment of Severe Organ Failure, Surgical Department of Digestive, Hepatic and Endocrine-Metabolic Diseases, University Hospital of Bologna, Bologna, Italy
| | - Francesco Sofi
- Unit of Clinical Nutrition, Department of Experimental and Clinical Medicine, Careggi University Hospital, University of Florence, Florence, Italy
| | - Maria R Tamè
- Division of Gastroenterology, Surgical Department of Digestive, Hepatic and Endocrine-Metabolic Diseases, University Hospital of Bologna, Bologna, Italy
| | - Giovanni Vitale
- Unit of Internal Medicine for the Treatment of Severe Organ Failure, Surgical Department of Digestive, Hepatic and Endocrine-Metabolic Diseases, University Hospital of Bologna, Bologna, Italy
| | - Nicola DE Maria
- Department of Gastroenterology, University Hospital of Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Luca Marzi
- Division of Gastroenterology, Bolzano Regional Hospital, Bolzano, Italy
| | - Andrea Mega
- Division of Gastroenterology, Bolzano Regional Hospital, Bolzano, Italy
| | - Giovanna Valente
- Liver Unit for Transplant Management - SATTE, Department of Medical Sciences, AORN Sant'Anna e San Sebastiano, Caserta, Italy
| | - Alberto Borghi
- Unit of Internal Medicine, Hospital of Faenza, Ravenna, Italy
| | - Paolo Forte
- Unit of Gastroenterology, Careggi University Hospital, Florence, Italy
| | - Matteo Cescon
- Unit of General Surgery and Transplants, University Hospital of Bologna, Bologna, Italy
| | - Fabrizio DI Benedetto
- Unit of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Modena and Reggio Emilia, Modena, Italy
| | - Pietro Andreone
- Unit of Internal and Metabolic Medicine, University Hospital of Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Marco Petranelli
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Monica Dinu
- Unit of Clinical Nutrition, Department of Experimental and Clinical Medicine, Careggi University Hospital, University of Florence, Florence, Italy
| | - Paola Carrai
- University of Pisa Medical School, Unit of Hepatobiliary Surgery and Liver Transplantation, Pisa, Italy
| | - Giulio Arcangeli
- Unit of Occupational Health, Department of Experimental and Clinical Medicine, Careggi University Hospital, University of Florence, Florence, Italy
| | - Silvana Grandi
- Department of Psychology, Laboratory of Psychosomatics and Clinimetrics, University of Bologna, Bologna, Italy
| | - Chloe Lau
- Department of Psychology, University of Western Ontario, London, ON, Canada
| | - Maria Cristina Morelli
- Unit of Internal Medicine for the Treatment of Severe Organ Failure, Surgical Department of Digestive, Hepatic and Endocrine-Metabolic Diseases, University Hospital of Bologna, Bologna, Italy
| | - Paolo DE Simone
- University of Pisa Medical School, Unit of Hepatobiliary Surgery and Liver Transplantation, Pisa, Italy
| | - Francesca Chiesi
- Section of Psychology, Department of Neuroscience, Psychology, Drug, and Child's Health (NEUROFARBA), University of Florence, Florence, Italy
| | - Fabio Marra
- Internal Medicine and Liver Unit, Department of Experimental and Clinical Medicine, University of Florence, Careggi University Hospital, Florence, Italy
- Center for Research, Higher Education and Transfer "DENOThe", University of Florence, Florence, Italy
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Soldera J, Corso LL, Rech MM, Ballotin VR, Bigarella LG, Tomé F, Moraes N, Balbinot RS, Rodriguez S, Brandão ABDM, Hochhegger B. Predicting major adverse cardiovascular events after orthotopic liver transplantation using a supervised machine learning model: A cohort study. World J Hepatol 2024; 16:193-210. [PMID: 38495288 PMCID: PMC10941741 DOI: 10.4254/wjh.v16.i2.193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 12/27/2023] [Accepted: 02/04/2024] [Indexed: 02/27/2024] Open
Abstract
BACKGROUND Liver transplant (LT) patients have become older and sicker. The rate of post-LT major adverse cardiovascular events (MACE) has increased, and this in turn raises 30-d post-LT mortality. Noninvasive cardiac stress testing loses accuracy when applied to pre-LT cirrhotic patients. AIM To assess the feasibility and accuracy of a machine learning model used to predict post-LT MACE in a regional cohort. METHODS This retrospective cohort study involved 575 LT patients from a Southern Brazilian academic center. We developed a predictive model for post-LT MACE (defined as a composite outcome of stroke, new-onset heart failure, severe arrhythmia, and myocardial infarction) using the extreme gradient boosting (XGBoost) machine learning model. We addressed missing data (below 20%) for relevant variables using the k-nearest neighbor imputation method, calculating the mean from the ten nearest neighbors for each case. The modeling dataset included 83 features, encompassing patient and laboratory data, cirrhosis complications, and pre-LT cardiac assessments. Model performance was assessed using the area under the receiver operating characteristic curve (AUROC). We also employed Shapley additive explanations (SHAP) to interpret feature impacts. The dataset was split into training (75%) and testing (25%) sets. Calibration was evaluated using the Brier score. We followed Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis guidelines for reporting. Scikit-learn and SHAP in Python 3 were used for all analyses. The supplementary material includes code for model development and a user-friendly online MACE prediction calculator. RESULTS Of the 537 included patients, 23 (4.46%) developed in-hospital MACE, with a mean age at transplantation of 52.9 years. The majority, 66.1%, were male. The XGBoost model achieved an impressive AUROC of 0.89 during the training stage. This model exhibited accuracy, precision, recall, and F1-score values of 0.84, 0.85, 0.80, and 0.79, respectively. Calibration, as assessed by the Brier score, indicated excellent model calibration with a score of 0.07. Furthermore, SHAP values highlighted the significance of certain variables in predicting postoperative MACE, with negative noninvasive cardiac stress testing, use of nonselective beta-blockers, direct bilirubin levels, blood type O, and dynamic alterations on myocardial perfusion scintigraphy being the most influential factors at the cohort-wide level. These results highlight the predictive capability of our XGBoost model in assessing the risk of post-LT MACE, making it a valuable tool for clinical practice. CONCLUSION Our study successfully assessed the feasibility and accuracy of the XGBoost machine learning model in predicting post-LT MACE, using both cardiovascular and hepatic variables. The model demonstrated impressive performance, aligning with literature findings, and exhibited excellent calibration. Notably, our cautious approach to prevent overfitting and data leakage suggests the stability of results when applied to prospective data, reinforcing the model's value as a reliable tool for predicting post-LT MACE in clinical practice.
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Affiliation(s)
- Jonathan Soldera
- Post Graduate Program at Acute Medicine and Gastroenterology, University of South Wales, Cardiff CF37 1DL, United Kingdom
- Postgraduate Program in Pathology, Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre 90050-170, Brazil.
| | - Leandro Luis Corso
- Department of Engineering, Universidade de Caxias do Sul, Caxias do Sul 95070-560, Brazil
| | - Matheus Machado Rech
- School of Medicine, Universidade de Caxias do Sul, Caxias do Sul 95070-560, Brazil
| | | | | | - Fernanda Tomé
- Department of Engineering, Universidade de Caxias do Sul, Caxias do Sul 95070-560, Brazil
| | - Nathalia Moraes
- Department of Engineering, Universidade de Caxias do Sul, Caxias do Sul 95070-560, Brazil
| | | | - Santiago Rodriguez
- Postgraduate Program in Hepatology, Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre 90050-170, Brazil
| | - Ajacio Bandeira de Mello Brandão
- Postgraduate Program in Hepatology, Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre 90050-170, Brazil
| | - Bruno Hochhegger
- Postgraduate Program in Pathology, Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre 90050-170, Brazil
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Flynn SJ, Saxena V, Brandman D. Primary Care Utilization, Preventative Screening, and Control of Metabolic Syndrome in Metabolic Dysfunction-Associated Steatohepatitis Liver Transplant Recipients. J Prim Care Community Health 2024; 15:21501319241247974. [PMID: 38650519 PMCID: PMC11036922 DOI: 10.1177/21501319241247974] [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: 02/03/2024] [Revised: 03/25/2024] [Accepted: 03/29/2024] [Indexed: 04/25/2024] Open
Abstract
OBJECTIVES Patients with pre-transplant metabolic dysfunction-associated steatohepatitis (MASH) are at high risk of metabolic syndrome (MetS) after liver transplant. While many patients are co-managed by a transplant team, most preventative screening and MetS management may occur in the primary care setting. We aimed to evaluate primary care utilization by MASH liver transplant recipients as well as MetS screening and control. METHODS We conducted a retrospective chart review that included adults who underwent liver transplant for MASH or cryptogenic cirrhosis at a single institution from January 2010 to December 2016, had available primary care data, and at least 36-months of follow-up post-transplant. Measures included primary care utilization, adherence to screening guidelines, and control of MetS. We used Fischer's exact test to explore the association of primary care utilization with screening and control. RESULTS A total of 37 patients met inclusion criteria with 366 visits reviewed. The median time to first visit was 68 days post-transplant and patients had a median of 9 total visits. Few patients met screening guidelines for diabetes (8.1%) or hyperlipidemia (10.8%). The percentage of patients with control of obesity, hypertension, diabetes, and hyperlipidemia decreased over the 36-month follow-up period. Primary care utilization was not associated with adherence to screening recommendations for diabetes (P = .141) or hyperlipidemia (P = .103). Higher primary care utilization was not associated with control of hypertension (P = .107), diabetes (P = .871), or hyperlipidemia (P = .999). CONCLUSION More research is needed to investigate barriers to screening and management of MetS conditions in this high-risk patient population in the primary care setting as well as to optimize post-transplant care coordination.
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Affiliation(s)
| | - Varun Saxena
- Kaiser Permanente South San Francisco Medical Center, San Francisco, CA, USA
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Yoon J, Kim H, Choi D, Park B. Causes of death and associated factors with death after liver transplantation: a nationwide database study. HPB (Oxford) 2024; 26:54-62. [PMID: 37775353 DOI: 10.1016/j.hpb.2023.09.011] [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: 07/17/2023] [Revised: 09/07/2023] [Accepted: 09/11/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND/AIMS This study investigated overall, 1-year, and 5-year mortality rate, the causes of death, and associated factors with death in liver transplantation recipients. METHODS A total of 11,590 liver transplant recipients identified from National Health Insurance Service database between 2006 and 2017 were included. Factors associated with all-cause of death were analyzed by Cox proportional regression models. Cumulative mortality rate according to the underlying indication was estimated by Kaplan-Meier method. RESULTS The 12-year survival rate for all liver transplant recipients was 68%. In the overall, 1-year, and 5-year mortality of liver transplant recipients, hepatic death was the highest contributing risk, accounting for >65% of the causes of death. Deaths from cirrhosis and liver failure accounted for a high proportion of deaths within 1 year after transplantation, and deaths from malignant tumors such as hepatocellular carcinoma were high among late-stage deaths. DISCUSSION Although the most common cause of death from liver transplantation is due to primary disease, there was a difference in the pattern of major causes of death according to the period from transplantation to death. If appropriate medical intervention is performed at each period after transplantation, the survival rate can be improved.
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Affiliation(s)
- Junghyun Yoon
- Department of Preventive Medicine, Hanyang University College of Medicine, 222 Wangsimni-ro, Seongdong-gu, Seoul, 04763, Republic of Korea
| | - Hanjoon Kim
- Department of Surgery, Hanyang University College of Medicine, 222 Wangsimni-ro, Seongdong-gu, Seoul, 04763, Republic of Korea
| | - Dongho Choi
- Department of Surgery, Hanyang University College of Medicine, 222 Wangsimni-ro, Seongdong-gu, Seoul, 04763, Republic of Korea
| | - Boyoung Park
- Department of Preventive Medicine, Hanyang University College of Medicine, 222 Wangsimni-ro, Seongdong-gu, Seoul, 04763, Republic of Korea.
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Mehtani R, Saigal S. Long Term Complications of Immunosuppression Post Liver Transplant. J Clin Exp Hepatol 2023; 13:1103-1115. [PMID: 37975039 PMCID: PMC10643541 DOI: 10.1016/j.jceh.2023.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 06/18/2023] [Indexed: 11/19/2023] Open
Abstract
Improvement in immunosuppression has led to a remarkable improvement in short-term and long-term outcomes post-liver transplant (LT). However, with improvements in long-term survival, complications related to immunosuppressive drugs, either directly or indirectly, have also increased. The adverse events could be drug-specific, class-specific, or generic. Calcineurin inhibitors (cyclosporine and tacrolimus) are the backbone of the immunosuppression after LT and the main culprit associated with most of the complications, including renal failure, post-transplant diabetes mellitus (PTDM), and metabolic syndrome. Steroids are also implicated in the development of diabetes, osteoporosis, and metabolic syndrome post-LT. The development of infections and de novo malignancies (DNMs) is a generic effect linked to the overall cumulative immunosuppression. The development of these complications significantly hampers the quality of life and leads to increased morbidity and mortality post-LT. Thus, it is important to minimize the cumulative immunosuppression dose while simultaneously preventing allograft rejection. This review provides up-to-date, comprehensive knowledge of the complications of long-term immunosuppression post-LT along with associated risk factors and strategies to minimize the risk of complications.
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Affiliation(s)
- Rohit Mehtani
- Department of Hepatology, Amrita Institute of Medical Sciences and Research, Faridabad, Haryana - 121001, India
| | - Sanjiv Saigal
- Transplant Hepatology, Centre for Liver and Biliary Sciences, Max Superspecialty Hospital, Saket, New Delhi, India
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Caturano A, Albanese G, Di Martino A, Coppola C, Russo V, Galiero R, Rinaldi L, Monda M, Marfella R, Sasso FC, Salvatore T. Predictive Value of Fatty Liver Index for Long-Term Cardiovascular Events in Patients Receiving Liver Transplantation: The COLT Study. Biomedicines 2023; 11:2866. [PMID: 37893240 PMCID: PMC10604265 DOI: 10.3390/biomedicines11102866] [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: 09/29/2023] [Revised: 10/12/2023] [Accepted: 10/18/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND AND AIMS Cardiovascular disease (CVD) is the leading cause of early mortality in orthotopic liver transplantation (OLT) patients. The fatty liver index (FLI) is strongly associated with carotid and coronary atherosclerosis, as well as cardiovascular mortality, surpassing traditional risk factors. Given the lack of data on FLI as a predictor of cardiovascular events in OLT recipients, we conducted a retrospective study to examine this topic. METHODS AND RESULTS We performed a multicenter retrospective analysis of adult OLT recipients who had regular follow-up visits every three to six months (or more frequently if necessary) from January 1995 to December 2020. The minimum follow-up period was two years post-intervention. Anamnestic, clinical, anthropometric and laboratory data were collected, and FLI was calculated for all patients. CLINICAL TRIAL gov registration ID NCT05895669. A total of 110 eligible patients (median age 57 years [IQR: 50-62], 72.7% male) were followed for a median duration of 92.3 months (IQR: 45.7-172.4) post-liver transplantation. During this period, 16 patients (14.5%) experienced at least one adverse cardiovascular event (including fatal and non-fatal myocardial infarction and stroke). Receiver Operating Characteristic (ROC) analysis identified a cut-off value of 66.0725 for predicting cardiovascular events after OLT, with 86.7% sensitivity and 63.7% specificity (68% vs. 31%; p = 0.001). Kaplan-Meier analysis showed that patients with FLI > 66 had significantly reduced cardiovascular event-free survival than those with FLI ≤ 66 (log-rank: 0.0008). Furthermore, multivariable Cox regression analysis demonstrated that FLI > 66 and pre-OLT smoking were independently associated with increased cardiovascular risk. CONCLUSIONS Our findings suggest that FLI > 66 and pre-OLT smoking predict cardiovascular risk in adult OLT recipients.
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Affiliation(s)
- Alfredo Caturano
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, 80138 Naples, Italy (R.M.)
- Department of Experimental Medicine, University of Campania Luigi Vanvitelli, 80138 Naples, Italy
| | - Gaetana Albanese
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, 80138 Naples, Italy (R.M.)
| | - Anna Di Martino
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, 80138 Naples, Italy (R.M.)
- Area Stabiese Hospital, 80053 Naples, Italy
| | | | - Vincenzo Russo
- Sbarro Institute for Cancer Research and Molecular Medicine, Center for Biotechnology, College of Science and Technology, Temple University, Philadelphia, PA 19122, USA
- Division of Cardiology, Department of Medical Translational Sciences, University of Campania Luigi Vanvitelli, 80131 Naples, Italy
| | - Raffaele Galiero
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, 80138 Naples, Italy (R.M.)
| | - Luca Rinaldi
- Department of Medicine and Health Sciences “Vincenzo Tiberio”, University of Molise, 86100 Campobasso, Italy
| | - Marcellino Monda
- Department of Experimental Medicine, University of Campania Luigi Vanvitelli, 80138 Naples, Italy
| | - Raffaele Marfella
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, 80138 Naples, Italy (R.M.)
| | - Ferdinando Carlo Sasso
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, 80138 Naples, Italy (R.M.)
| | - Teresa Salvatore
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, 80138 Naples, Italy
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Mishra S, Premkumar M. Nutritional Management of a Liver Transplant Candidate. J Clin Exp Hepatol 2023; 13:878-894. [PMID: 37693267 PMCID: PMC10483011 DOI: 10.1016/j.jceh.2023.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 03/28/2023] [Indexed: 09/12/2023] Open
Abstract
Nearly two-thirds of patients with cirrhosis suffer from malnutrition resulting from multiple contributory factors such as poor intake, accelerated starvation, catabolic milieu, and anabolic resistance. Nutritional assessment and optimization are integral to adequate management of a liver transplant (LT) candidate. A detailed nutritional assessment should be done at baseline in all potential transplant candidates with periodic reassessments. Sarcopenia is defined as a reduction in muscle mass, function, and/or performance. Skeletal muscle index at 3rd lumbar vertebra determined by computed tomography is the most objective tool to assess muscle mass. Hand-grip strength and gait speed are simple tools to gauge muscle strength and performance, respectively. Sarcopenia, sarcopenic obesity, and myosteatosis portend poor outcomes. Sarcopenia contributes greatly to frailty, which is a syndrome of reduced physiological reserve and impaired response to stressors. Dietary interventions must ensure adequate calorie (35-40 kcal/kg/day) and protein (1.2-1.5 gm/kg/day) intake via multiple frequent meals and late-evening calorie-dense snack. Micronutrient supplementation is essential, keeping in mind the etiology of cirrhosis. Individualized, gradually up-titrated exercise prescription consisting of both aerobic and resistance training of 150 min/week is advisable after appropriate risk assessment. Early initiation of enteral nutrition within 12-24 h of LT is recommended. Data with respect to immune-nutrition, monomeric formulas, and hormone replacement remain conflicting at present. A multidisciplinary team comprising of hepatologists, transplant surgeons, intensivists, dieticians, and physiotherapists is vital to improve overall nutrition and outcomes in this vulnerable group.
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Affiliation(s)
- Saurabh Mishra
- Department of Gastroenterology and Hepatology, Paras Health, Sector-22, Panchkula, Haryana, 134109, India
| | - Madhumita Premkumar
- Departments of Hepatology, Postgraduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012, India
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Spillman LN, Madden AM, Richardson H, Imamura F, Jones D, Nash M, Lim HK, Hellawell HN, Rennie KL, Oude Griep LM, Allison M, Griffin SJ. Nutritional Intake after Liver Transplant: Systematic Review and Meta-Analysis. Nutrients 2023; 15:2487. [PMID: 37299450 PMCID: PMC10255417 DOI: 10.3390/nu15112487] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 05/21/2023] [Accepted: 05/24/2023] [Indexed: 06/12/2023] Open
Abstract
Cardiovascular disease and its concurrent risk factors are prevalent after liver transplant (LT). Most of these risk factors are modifiable by diet. We aimed to synthesise the literature reporting the nutritional intake of liver transplant recipients (LTR) and the potential determinants of intake. We performed a systematic review and meta-analyses of studies published up until July 2021 reporting the nutritional intake of LTR. The pooled daily mean intakes were recorded as 1998 (95% CI 1889, 2108) kcal, 17 (17, 18)% energy from protein, 49 (48, 51)% energy from carbohydrates, 34 (33, 35)% energy from total fat, 10 (7, 13)% energy from saturated fat, and 20 (18, 21) g of fibre. The average fruit and vegetable intake ranged from 105 to 418 g/day. The length of time post-LT and the age and sex of the cohorts, as well as the continent and year of publication of each study, were sources of heterogeneity. Nine studies investigated the potential determinants of intake, time post-LT, gender and immunosuppression medication, with inconclusive results. Energy and protein requirements were not met in the first month post-transplant. After this point, energy intake was significantly higher and remained stable over time, with a high fat intake and low intake of fibre, fruits and vegetables. This suggests that LTR consume a high-energy, low-quality diet in the long term and do not adhere to the dietary guidelines for cardiovascular disease prevention.
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Affiliation(s)
- Lynsey N. Spillman
- MRC Epidemiology Unit, School of Clinical Medicine, University of Cambridge, Cambridge CB2 0QQ, UK; (F.I.); (D.J.); (K.L.R.); (L.M.O.G.); (S.J.G.)
- Liver Transplant Unit, Cambridge NIHR Biomedical Research Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK;
| | - Angela M. Madden
- School of Life and Medical Sciences, University of Hertfordshire, Hatfield AL10 9AB, UK; (A.M.M.); (H.R.)
| | - Holly Richardson
- School of Life and Medical Sciences, University of Hertfordshire, Hatfield AL10 9AB, UK; (A.M.M.); (H.R.)
| | - Fumiaki Imamura
- MRC Epidemiology Unit, School of Clinical Medicine, University of Cambridge, Cambridge CB2 0QQ, UK; (F.I.); (D.J.); (K.L.R.); (L.M.O.G.); (S.J.G.)
| | - Danielle Jones
- MRC Epidemiology Unit, School of Clinical Medicine, University of Cambridge, Cambridge CB2 0QQ, UK; (F.I.); (D.J.); (K.L.R.); (L.M.O.G.); (S.J.G.)
| | - Marilyn Nash
- Department of Nutrition and Dietetics, East Suffolk and North Essex NHS Foundation Trust, Colchester CO4 5JL, UK
| | - Hong Kai Lim
- School of Clinical Medicine, Addenbrooke’s Hospital, University of Cambridge, Cambridge CB2 0QQ, UK; (H.K.L.); (H.N.H.)
| | - Holly N. Hellawell
- School of Clinical Medicine, Addenbrooke’s Hospital, University of Cambridge, Cambridge CB2 0QQ, UK; (H.K.L.); (H.N.H.)
| | - Kirsten L. Rennie
- MRC Epidemiology Unit, School of Clinical Medicine, University of Cambridge, Cambridge CB2 0QQ, UK; (F.I.); (D.J.); (K.L.R.); (L.M.O.G.); (S.J.G.)
| | - Linda M. Oude Griep
- MRC Epidemiology Unit, School of Clinical Medicine, University of Cambridge, Cambridge CB2 0QQ, UK; (F.I.); (D.J.); (K.L.R.); (L.M.O.G.); (S.J.G.)
| | - Michael Allison
- Liver Transplant Unit, Cambridge NIHR Biomedical Research Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK;
| | - Simon J. Griffin
- MRC Epidemiology Unit, School of Clinical Medicine, University of Cambridge, Cambridge CB2 0QQ, UK; (F.I.); (D.J.); (K.L.R.); (L.M.O.G.); (S.J.G.)
- Department of Public Health and Primary Care, Primary Care Unit, School of Clinical Medicine, University of Cambridge, Cambridge CB2 0SR, UK
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Ntandja Wandji LC, Ningarhari M, Lassailly G, Dharancy S, Boleslawski E, Mathurin P, Louvet A. Liver Transplantation in Alcohol-related Liver Disease and Alcohol-related Hepatitis. J Clin Exp Hepatol 2023; 13:127-138. [PMID: 36647412 PMCID: PMC9840078 DOI: 10.1016/j.jceh.2022.06.013] [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: 04/25/2022] [Accepted: 06/25/2022] [Indexed: 02/07/2023] Open
Abstract
Alcohol-related liver disease (ARLD) remains one of the leading causes of chronic liver disease and the prevalence of alcohol-related cirrhosis is still increasing worldwide. Thus, ARLD is one of the leading indications for liver transplantation (LT) worldwide especially after the arrival of direct-acting antivirals for chronic hepatitis C infection. Despite the risk of alcohol relapse, the outcomes of LT for ARLD are as good as for other indications such as hepatocellular carcinoma (HCC), with 1-, 5-, and 10- year survival rates of 85%, 74%, and 59%, respectively. Despite these good results, certain questions concerning LT for ARLD remain unanswered, in particular because of persistent organ shortages. As a result, too many transplantation centers continue to require 6 months of abstinence from alcohol for patients with ARLD before LT to reduce the risk of alcohol relapse even though compelling data show the poor prognostic value of this criterion. A recent pilot study even observed a lower alcohol relapse rate in patients receiving LT after less than 6 months of abstinence as long as addictological follow-up is reinforced. Thus, the question should not be whether LT should be offered to patients with ARLD but how to select patients who will benefit from this treatment.
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Key Words
- AH, alcohol-related hepatitis
- ARLD, Alcohol-related liver disease
- AUDIT, Alcohol Use Disorders Identification Test
- CLD, chronic liver disease
- ELTR, European Liver Transplant Registry
- HCC, hepatocellular carcinoma
- HCV, hepatitis C virus
- LT, liver transplantation
- NASH, non-alcoholic steatohepatitis
- NIAAA, National Institute on Alcohol Abuse and Alcoholism
- UNOS, United Network for Organ Sharing
- alcohol
- alcohol-related hepatitis
- alcohol-related liver disease
- liver transplantation
- survival
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Affiliation(s)
- Line Carolle Ntandja Wandji
- University of Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, Lille, F-59000 France
| | - Massih Ningarhari
- University of Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, Lille, F-59000 France
| | - Guillaume Lassailly
- University of Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, Lille, F-59000 France
| | - Sébastien Dharancy
- University of Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, Lille, F-59000 France
| | - Emmanuel Boleslawski
- University of Lille, Inserm, CHU Lille, U1189 - ONCO-THAI - Image Assisted Laser Therapy for Oncology, Lille, F-59000 France
| | - Philippe Mathurin
- University of Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, Lille, F-59000 France
| | - Alexandre Louvet
- University of Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, Lille, F-59000 France
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11
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Lopez-Delgado JC, Putzu A, Landoni G. The importance of liver function assessment before cardiac surgery: A narrative review. Front Surg 2022; 9:1053019. [PMID: 36561575 PMCID: PMC9764862 DOI: 10.3389/fsurg.2022.1053019] [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: 09/24/2022] [Accepted: 11/15/2022] [Indexed: 12/12/2022] Open
Abstract
The demand for cardiac surgery procedures is increasing globally. Thanks to an improvement in survival driven by medical advances, patients with liver disease undergo cardiac surgery more often. Liver disease is associated with the development of heart failure, especially in patients with advanced cirrhosis. Cardiovascular risk factors can also contribute to the development of both cardiomyopathy and liver disease and heart failure itself can worsen liver function. Despite the risk that liver disease and cirrhosis represent for the perioperative management of patients who undergo cardiac surgery, liver function is often not included in common risk scores for preoperative evaluation. These patients have worse short and long-term survival when compared with other cardiac surgery populations. Preoperative evaluation of liver function, postoperative management and close postoperative follow-up are crucial for avoiding complications and improving results. In the present narrative review, we discuss the pathophysiological components related with postoperative complications and mortality in patients with liver disease who undergo cardiac surgery and provide recommendations for the perioperative management.
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Affiliation(s)
- Juan C. Lopez-Delgado
- Hospital Clinic de Barcelona, Area de Vigilancia Intensiva (ICMiD), Barcelona, Spain,IDIBELL (Institut d’Investigació Biomèdica Bellvitge; Biomedical Investigation Institute of Bellvitge), L’Hospitalet de Llobregat, Barcelona, Spain,Correspondence: Juan C. Lopez-Delgado Alessandro Putzu
| | - Alessandro Putzu
- Division of Anesthesiology, Department of Acute Medicine, Geneva University Hospitals, Geneva, Switzerland,Correspondence: Juan C. Lopez-Delgado Alessandro Putzu
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy,Vita-Salute San Raffaele University, Milan, Italy
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12
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Gitto S, Magistri P, Marzi L, Mannelli N, De Maria N, Mega A, Vitale G, Valente G, Vizzutti F, Villa E, Marra F, Andreone P, Falcini M, Catellani B, Guerrini GP, Serra V, Di Sandro S, Ballarin R, Piai G, Schepis F, Margotti M, Cursaro C, De Simone P, Petruccelli S, Carrai P, Forte P, Campani C, Zoller H, Di Benedetto F. Predictors of solid extra-hepatic non-skin cancer in liver transplant recipients and analysis of survival: A long-term follow-up study. Ann Hepatol 2022; 27:100683. [PMID: 35151902 DOI: 10.1016/j.aohep.2022.100683] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 02/02/2022] [Accepted: 02/02/2022] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES De novo malignancies represent an important cause of death for liver transplant recipients. Our aim was to analyze predictors of extra-hepatic non-skin cancer (ESNSC) and the impact of ESNSC on the long-term outcome. PATIENTS We examined data from patients transplanted between 2000 and 2005 and followed-up in five Italian transplant clinics with a retrospective observational cohort study. Cox Regression was performed to identify predictors of ESNSC. A 1:2 cohort sub-study was developed to analyze the impact of ESNSC on 10-year survival. RESULTS We analyzed data from 367 subjects (median follow-up: 15 years). Patients with ESNSC (n = 47) more often developed post-LT diabetes mellitus (DM) (57.4% versus 35,9%, p = 0.004). At multivariate analysis, post-LT DM independently predicted ESNSC (HR 1.929, CI 1.029-3.616, p = 0.040). Recipients with ESNSC showed a lower 10-year survival than matched controls (46,8% versus 68,1%, p = 0.023). CONCLUSIONS Post-LT DM seems to be a relevant risk factor for post-LT ESNSC. ESNSC could have a noteworthy impact on the long-term survival of LT recipients.
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Affiliation(s)
- Stefano Gitto
- Internal Medicine and Liver Unit, Department of Experimental and Clinical Medicine, University Hospital Careggi, University of Florence, Largo Brambilla 3, Florence 50134, Italy.
| | - Paolo Magistri
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Luca Marzi
- Division of Gastroenterology, Bolzano Regional Hospital, Bolzano, Italy
| | - Nicolò Mannelli
- Internal Medicine and Liver Unit, Department of Experimental and Clinical Medicine, University Hospital Careggi, University of Florence, Largo Brambilla 3, Florence 50134, Italy
| | - Nicola De Maria
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Andrea Mega
- Division of Gastroenterology, Bolzano Regional Hospital, Bolzano, Italy
| | | | - Giovanna Valente
- Liver Unit for Transplant Management - SATTE, Department of Medical Sciences, AORN Sant'Anna e San Sebastiano, Caserta, Italy
| | - Francesco Vizzutti
- Internal Medicine and Liver Unit, Department of Experimental and Clinical Medicine, University Hospital Careggi, University of Florence, Largo Brambilla 3, Florence 50134, Italy
| | - Erica Villa
- Department of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena and University of Modena and Reggio Emilia, Modena, Italy
| | - Fabio Marra
- Internal Medicine and Liver Unit, Department of Experimental and Clinical Medicine, University Hospital Careggi, University of Florence, Largo Brambilla 3, Florence 50134, Italy
| | - Pietro Andreone
- Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, University of Bologna, Italy; Internal and Metabolic Medicine, AOU di Modena and University of Modena and Reggio Emilia, Italy
| | - Margherita Falcini
- Internal Medicine and Liver Unit, Department of Experimental and Clinical Medicine, University Hospital Careggi, University of Florence, Largo Brambilla 3, Florence 50134, Italy
| | - Barbara Catellani
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Gian Piero Guerrini
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Valentina Serra
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Stefano Di Sandro
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Roberto Ballarin
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Guido Piai
- Liver Unit for Transplant Management - SATTE, Department of Medical Sciences, AORN Sant'Anna e San Sebastiano, Caserta, Italy
| | - Filippo Schepis
- Department of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena and University of Modena and Reggio Emilia, Modena, Italy
| | - Marzia Margotti
- Internal and Metabolic Medicine, AOU di Modena and University of Modena and Reggio Emilia, Italy
| | - Carmela Cursaro
- Internal and Metabolic Medicine, AOU di Modena and University of Modena and Reggio Emilia, Italy
| | - Paolo De Simone
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Stefania Petruccelli
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Paola Carrai
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Paolo Forte
- Gastroenterology Unit, University Hospital Careggi, Florence, Italy
| | - Claudia Campani
- Gastroenterology Unit, University Hospital Careggi, Florence, Italy
| | - Heinz Zoller
- Department of Medicine I, Medical University of Innsbruck, Austria
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
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13
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Maggi P, Calò F, Messina V, Stornaiuolo G, Stanzione M, Rinaldi L, De Pascalis S, Macera M, Coppola N. Cardiovascular disease risk in liver transplant recipients transplanted due to chronic viral hepatitis. PLoS One 2022; 17:e0265178. [PMID: 35294954 PMCID: PMC8926187 DOI: 10.1371/journal.pone.0265178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 02/25/2022] [Indexed: 11/18/2022] Open
Abstract
Background
Cardiovascular disease (CVD) is a major cause of morbidity and mortality after liver transplantation, mostly in patients transplanted for nonalcoholic steatohepatitis, obesity and diabetes. Few data exist on cardiovascular diseases among patients transplanted for viral hepatitis.
Objective
Our aim is to clarify the cardiovascular risk and subclinical vascular damage among liver transplant recipients for chronic viral hepatitis (i.e. hepatits C virus, hepatis B virus and hepatitis D virus infection).
Methods
Adult patients (age ≥ 18 years) with orthotopic liver transplants (OLT) due to viral hepatitis who signed informed consent, and were admitted for a routine follow-up between June 2019 and September 2020 at the Infectious Disease outpatient clinic of the University of Campania Luigi Vanvitelli, Naples, Italy, were prospectively enrolled. An estimation of cardiovascular risk was assessed using three main risk charts, echocolor-Doppler of epiaortic vessels was performed to assess subclinical Intima-Media changes.
Results
A total of 161 patients were evaluated; of these 15 were excluded because not affected by viral hepatitis. 146 patients were considered. 83 patients (56.8%) were considered at high cardiovascular risk according to Framingham, 54 patients (36.9%) to American Heart Association Arteriosclerotic Cardiovascular Disease (ASCVD) score and 19 (13.0%) to Heart Score. Only 8 patients (5.4%) showed a normal carotid ultrasound, while 52 patients (35.6%) had a carotid artery Intima-Media Thickness (IMT) and 86 (58.9%) an atherosclerotic plaque.
Conclusions
Liver transplant recipients for virus-related associated liver disease are, in light of the high percentage of carotid lesions, at high risk of CVD. Risk charts compared to subclinical carotid lesions which represent damage already established and a real localization of the disease, seem to underestimate the cardiovascular risk. A chronic inflammatory status, could play a key role. It’s important to raise the awareness of cardiovascular risk in liver transplant patients to prevent cardiovascular diseases and improve the timing of early diagnosis of premature vascular lesions.
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Affiliation(s)
- Paolo Maggi
- Department of Mental Health and Public Medicine – Infectious Diseases Unit, University of Campania Luigi Vanvitelli, Naples, Italy
- * E-mail:
| | - Federica Calò
- Department of Mental Health and Public Medicine – Infectious Diseases Unit, University of Campania Luigi Vanvitelli, Naples, Italy
| | | | - Gianfranca Stornaiuolo
- Department of Mental Health and Public Medicine – Infectious Diseases Unit, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Maria Stanzione
- Department of Mental Health and Public Medicine – Infectious Diseases Unit, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Luca Rinaldi
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Stefania De Pascalis
- Department of Mental Health and Public Medicine – Infectious Diseases Unit, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Margherita Macera
- Department of Mental Health and Public Medicine – Infectious Diseases Unit, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Nicola Coppola
- Department of Mental Health and Public Medicine – Infectious Diseases Unit, University of Campania Luigi Vanvitelli, Naples, Italy
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Herreras López J, Puchades L, Di Maira T, Cañada AJ, Maupoey J, López-Andújar R, Prieto Castillo M, Berenguer Haym M, Aguilera V. Metabolic syndrome before liver transplantation: does it have an impact on post liver transplantation outcomes? REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2022; 114:586-591. [PMID: 35045717 DOI: 10.17235/reed.2022.8384/2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Metabolic syndrome (MS) and cardiovascular risk factors are commonin liver transplant (LT) candidates and recipients. Cardiovascular events and de novo tumours are increasingly common causes of mortality in liver transplant recipients. The aim of this study is (i) to assess the prevalence of MS in LT recipients and its growth over the years and (ii) if the presence of MS pre-LT is associated with a higher risk of post-LT cardiovascular events (CVE), de novo tumours or early and late survival. PATIENTS AND METHODS Retrospective study that included LT recipients from January 2012 to December 2017. Baseline features (MS before LT and at 1year post-LT) and outcomes (CVE, de novo tumours and survival) were recorded. RESULTS 483 recipients were included, MS was present pre-LT in 20% with an increasing prevalence over time, from16% in 2012 to 34% in 2017 (p=0.025). One-year post-LT, an additional 12% had developed de novo MS .At a median of 56-months follow-up, 13% developed a CVE and 9% a de novo tumour. One and 5-yr survival rates were91% and 83 % in those with pre-LT MS and 93% and 85 % in those without (p=0.94).The presence of MS before LT was independently associated with a higher risk of post-LT CVE (HR: 2.66 IC (95%): 1.6-4.4 p< 0.001), but not with de novo tumors (p=0.94) nor early and late survival (p=0.58 and p=0.87). CONCLUSION Pre-LT MS is increasing among LT candidates and is associated with a higher risk of post-LT morbidity CVE yet without affecting mortality.
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Affiliation(s)
| | - Lorena Puchades
- Medicina Digestiva, Hospital Universitari i Politècnic La Fe
| | | | | | - Javier Maupoey
- Hepatología de Medicina Digestiva, Hospital Politècnic i Universitari La Fe
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15
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Villeret F, Dumortier J, Erard-Poinsot D. How will NAFLD change the liver transplant landscape in the 2020s? Clin Res Hepatol Gastroenterol 2022; 46:101759. [PMID: 34311133 DOI: 10.1016/j.clinre.2021.101759] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 06/21/2021] [Indexed: 02/04/2023]
Abstract
Liver steatosis is the hepatic manifestation of the metabolic syndrome, and is now the leading cause of chronic liver disease worldwide. The treatment of metabolic cirrhosis with liver failure and/or hepatocellular carcinoma is liver transplantation (LT). During the past decade, metabolic cirrhosis represented an increasing cause for LT, especially in the United States. At listing, patients with metabolic cirrhosis are older, with numerous cardiovascular (CV) and renal comorbidities, and this requires multidisciplinary pre-transplant assessment. After LT, 5-year survival is similar to other indications. The leading causes of death are infectious, cancers and CV. The recurrence of the initial disease is very frequent, and a significant part of the patients progress towards graft cirrhosis. No specific immunosuppressive regimen is recommended, but the toxicity profiles must probably be taken into account. In these patients, the only etiological treatment is that of obesity, in the absence of specific therapy for non-alcoholic steatohepatitis. The place of bariatric surgery has to be defined, probably sleeve gastrectomy, in a stable patient, 6-12 months after LT.
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Affiliation(s)
- François Villeret
- Hepatology Department, Croix Rousse Hospital, Hospices Civils de Lyon, Lyon, France; University Claude Bernard Lyon 1, Lyon, France
| | - Jérôme Dumortier
- Hepatogastroenterology Department, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France; University Claude Bernard Lyon 1, Lyon, France.
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16
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The Underutilization, Adverse Reactions and Efficacy of Statins after Liver Transplant: A Meta-Analysis and Systematic Review. TRANSPLANTOLOGY 2021. [DOI: 10.3390/transplantology2030025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
(1) Background: Treatment of dyslipidemia via statin therapy in the non-liver transplant (LT) population is associated with a mortality benefit; however, the impact of statin therapy in post-LT population is not well-defined. This meta-analysis seeks to investigate the safety and efficacy of statin therapy in post-LT patients. (2) Methods: A systematic literature search on Medline and EMBASE database was conducted. A single-arm proportional meta-analysis and conventional pair-wise meta-analysis were performed to compare different outcomes with a random effects model. (3) Results: A total of 11 studies were included in this study, with 697 LT recipients identified to be on statin therapy. Statins were underutilized with only 32% (95% CI: 0.15–0.52) of 1094 post-LT patients on therapy. The incidence of adverse events of 14% (95% CI: 0.05–0.25) related to statin therapy was low. A significant mortality benefit was noted in patients on statin therapy with HR = 0.282 (95% CI: 0.154–0.517, p < 0.001), and improved lipid profiles post LT. The use of statins also significantly decreased odds of graft rejection (OR = 0.33; 95% CI: 0.15–0.73) and hepatocellular carcinoma (HCC) recurrence (HR = 0.32, 95% CI: 0.11–0.89). (4) Conclusions: Statin therapy is safe and efficacious in post-LT patients. Future studies to evaluate the effects of interactions between statins and immunosuppressant therapy are warranted.
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Liver-Related and Cardiovascular Outcome of Patients Transplanted for Nonalcoholic Fatty Liver Disease: A European Single-Center Study. Transplant Proc 2021; 53:1674-1681. [PMID: 34016462 DOI: 10.1016/j.transproceed.2021.02.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 01/18/2021] [Accepted: 02/25/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The increasing rate of liver transplantation (LT) for nonalcoholic fatty liver disease (NAFLD) raises concerns on cardiovascular morbidity and mortality after LT in these patients. METHODS We collected variables regarding the presence of metabolic risk factors, NAFLD recurrence, cardiovascular morbidity, and overall survival at time of listing and after LT of 112 patients with NAFLD and a control group of 120 patients with hepatitis C (HCV). RESULTS Metabolic syndrome and cardiovascular morbidity component rates (24.1% vs 12.5%) at the time of LT listing were higher in patients with NAFLD compared with patients with HCV (for all, P < .0390). Median follow-up after LT was 5.6 years in patients with NAFLD vs 13.5 years in patients with HCV (P = .0009). There was no difference in 6-weeks postoperative mortality (1.7% vs 2.5%) (P =1.0000). Metabolic syndrome components after LT were more frequent in patients with NAFLD than in patients with HCV (for all, P < .0008). The incidence of NAFLD 5 years after LT was higher in patients transplanted for NAFLD compared with HCV (43.5% vs 4.2%) (P < .0001). Patients with recurrent NAFLD more often had myocardial infarction compared with those without recurrence (8.3% vs 0%) (P = .0313). Five years after LT, cardiovascular morbidity was more frequent in the NAFLD group than in the HCV group (12.8% vs 9.3%) (P = .0256), whereas no difference in overall survival was observed. CONCLUSION LT for NAFLD is associated with satisfactory 5-year outcomes; however, our data underscore the need for close monitoring and aggressive management of cardiovascular risk factors in these patients.
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The Danish comorbidity in liver transplant recipients study (DACOLT): a non-interventional prospective observational cohort study. BMC Gastroenterol 2021; 21:145. [PMID: 33794793 PMCID: PMC8017840 DOI: 10.1186/s12876-021-01733-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 03/23/2021] [Indexed: 11/10/2022] Open
Abstract
Background Liver transplantation is the only curative treatment for patients with end-stage liver disease. Short-term survival has improved due to improved surgical techniques and greater efficacy of immunosuppressive drugs. However, long-term survival has not improved to the same extent as the short-term survival, and the 10-year survival after liver transplantation is 60%. In addition to liver- and transplant-related causes, comorbidities such as cardiovascular, pulmonary, renal, and metabolic diseases have emerged as leading causes of morbidity and mortality in liver transplant recipients. The objective of this study is to assess the burden of comorbidities and identify both liver- and transplant-related risk factors as well as traditional risk factors that contribute to the pathogenesis of comorbidity in liver transplant recipients.
Methods/design The Danish Comorbidity in Liver Transplant Recipients (DACOLT) study is an observational, longitudinal study. We aim to include all adult liver transplant recipients in Denmark (n = approx. 600). Participants will be matched by sex and age to controls from the Copenhagen General Population Study (CGPS) and the Copenhagen City Heart Study (CCHS). Physical and biological measures including blood pressure, ankle–brachial index, spirometry, exhaled nitric oxide, electrocardiogram, transthoracic echocardiography, computed tomography (CT) angiography of the heart, unenhanced CT of chest and abdomen and blood samples will be collected using uniform protocols in participants in DACOLT, CGPS, and CCHS. Blood samples will be collected and stored in a research biobank. Follow-up examinations at regular intervals up to 10 years of follow-up are planned. Discussion There is no international consensus standard for optimal clinical care or monitoring of liver transplant recipients. This study will determine prevalence, incidence and risk factors for comorbidity in liver transplant recipients and may be used to provide evidence for guidelines on management, treatment and screening and thereby contribute to improvement of the long-term survival. Trial registration ClinicalTrials.gov: NCT04777032; date of registration: March 02, 2021.
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19
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Choudhary NS, Saraf N, Saigal S, Soin AS. Long-term Management of the Adult Liver Transplantation Recipients. J Clin Exp Hepatol 2021; 11:239-253. [PMID: 33746450 PMCID: PMC7953009 DOI: 10.1016/j.jceh.2020.06.010] [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: 04/07/2020] [Accepted: 06/14/2020] [Indexed: 12/12/2022] Open
Abstract
The survival of liver transplantation (LT) recipients has been improved remarkably in short-term. The major causes of mortality in long-term include nonimmunological causes such as cardiovascular, de novo malignancy, chronic kidney disease, and recurrence of primary disease. Rejection-related mortality is rare in the long-term after LT. We discuss nonrejection causes of long-term morbidity/mortality, risk factors, and management strategies in LT recipients. In addition, we discuss osteoporosis, contraception, and pregnancy in LT recipients.
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Key Words
- AIH, autoimmune hepatitis
- BMI, body mass index
- CKD, chronic kidney disease
- CNI, calcineurin inhibitors
- CVD, cardiovascular disease
- DDLT, deceased donor liver transplantation
- DM, diabetes mellitus
- DNM, de novo malignancy
- HCV, hepatitis C virus
- HR, hazard ratio
- IUCD, Intrauterine contraceptive devices
- LDLT, living donor liver transplantation
- LT, liver transplantation
- MDRD, Modification of Diet in Renal Disease
- MMF, mycophenolate
- MS, metabolic syndrome
- NAFLD, nonalcoholic fatty liver disease
- NASH, nonalcoholic steatohepatitis
- OR, odds ratio
- PBC, primary biliary cholangitis
- PSC, primary sclerosing cholangitis
- PTDM, posttransplantation diabetes mellitus
- PTMS, posttransplantation metabolic syndrome
- SVR, sustained virological response
- cardiovascular disease
- de novo malignancy
- eGFR, estimated glomerular filtration rate
- mTORi, Mammalian target of rapamycin inhibitors
- osteoporosis
- pregnancy
- recurrence
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Affiliation(s)
- Narendra S. Choudhary
- Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Neeraj Saraf
- Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Sanjiv Saigal
- Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Arvinder S. Soin
- Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
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20
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Abstract
Cardiovascular disease complications are the leading cause of early (short-term) mortality among liver transplant recipients. The increasingly older candidate pool has multiple comorbidities necessitating cardiac and pulmonary vascular disease risk stratification of patients for optimal allocation of scarce donor livers. Arrhythmias, heart failure, stroke, and coronary artery disease are common pretransplant cardiovascular comorbidities and contribute to cardiovascular complications after liver transplant. Valvular heart disease and portopulmonary hypertension present intraoperative challenges during liver transplant surgery. The Cardiovascular Risk in Orthotopic Liver Transplantation score estimates the risk of cardiovascular complications in liver transplant candidates within the first year after transplant.
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Spiritos Z, Abdelmalek MF. Metabolic syndrome following liver transplantation in nonalcoholic steatohepatitis. Transl Gastroenterol Hepatol 2021; 6:13. [PMID: 33409407 DOI: 10.21037/tgh.2020.02.07] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 10/16/2019] [Indexed: 12/13/2022] Open
Abstract
Metabolic syndrome is a major clinical disorder involving metabolic dysregulation characterized clinically with features of central obesity, insulin resistance (IR), type 2 diabetes, hypertension, and dyslipidemia. Metabolic syndrome is strongly associated with the rising prevalence nonalcoholic steatohepatitis, a leading indication for orthotopic liver transplantation in the Western world. The presence or recurrence of metabolic syndrome following liver transplantation can contribute to the development and recurrence of nonalcoholic fatty liver disease (NAFLD) in the liver allograft. In this review, we discuss the endogenous and exogenous drivers of post-transplant metabolic syndrome, role of chronic immunosuppression, and the prevalence and clinical significant of post-transplant metabolic syndrome on nonalcoholic steatohepatitis.
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Affiliation(s)
- Zachary Spiritos
- Division of Gastroenterology and Hepatology, Duke University, Durham, NC, USA
| | - Manal F Abdelmalek
- Division of Gastroenterology and Hepatology, Duke University, Durham, NC, USA
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22
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Herzer K, Sterneck M, Welker MW, Nadalin S, Kirchner G, Braun F, Malessa C, Herber A, Pratschke J, Weiss KH, Jaeckel E, Tacke F. Current Challenges in the Post-Transplant Care of Liver Transplant Recipients in Germany. J Clin Med 2020; 9:jcm9113570. [PMID: 33167567 PMCID: PMC7694452 DOI: 10.3390/jcm9113570] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 10/25/2020] [Accepted: 11/04/2020] [Indexed: 02/07/2023] Open
Abstract
Improving long-term patient and graft survival after liver transplantation (LT) remains a major challenge. Compared to the early phase after LT, long-term morbidity and mortality of the recipients not only depends on complications immediately related to the graft function, infections, or rejection, but also on medical factors such as de novo malignancies, metabolic disorders (e.g., new-onset diabetes, osteoporosis), psychiatric conditions (e.g., anxiety, depression), renal failure, and cardiovascular diseases. While a comprehensive post-transplant care at the LT center and the connected regional networks may improve outcome, there is currently no generally accepted standard to the post-transplant management of LT recipients in Germany. We therefore described the structure and standards of post-LT care by conducting a survey at 12 German LT centers including transplant hepatologists and surgeons. Aftercare structures and form of cost reimbursement considerably varied between LT centers across Germany. Further discussions and studies are required to define optimal structure and content of post-LT care systems, aiming at improving the long-term outcomes of LT recipients.
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Affiliation(s)
- Kerstin Herzer
- Department of Gastroenterology and Hepatology, University Hospital Essen, University Duisburg-Essen, 45147 Essen, Germany;
- Knappschafts-Klinik Bad Neuenahr, 53474 Bad Neuenahr-Ahrweiler, Germany
| | - Martina Sterneck
- Department of Medicine, University Medical Center Hamburg Eppendorf, 20251 Hamburg, Germany;
| | - Martin-Walter Welker
- Department of Internal Medicine I, University Hospital Frankfurt, 60590 Frankfurt am Main, Germany;
| | - Silvio Nadalin
- Department for General, Visceral and Transplant Surgery, University Hospital Tuebingen, 72016 Tuebingen, Germany;
| | - Gabriele Kirchner
- Department of Surgery, University Hospital of Regensburg, 93053 Regensburg, Germany;
- Innere Medizin I, Caritaskrankenhaus St. Josef, 93053 Regensburg, Germany
| | - Felix Braun
- Department for Transplantation Surgery, University Hospital Kiel, 24105 Kiel, Germany;
| | - Christina Malessa
- Department of General, Visceral and Vascular Surgery, University Hospital Jena, 07747 Jena, Germany;
| | - Adam Herber
- Department of Gastroenterology and Rheumatology, University Hospital Leipzig, 04103 Leipzig, Germany;
| | - Johann Pratschke
- Department of Surgery, Campus Charité Mitte/Campus Virchow-Klinikum, Charité University Medicine Berlin, 13353 Berlin, Germany;
- Berlin Institute of Health, 13353 Berlin, Germany
| | - Karl Heinz Weiss
- Department of Internal Medicine, University of Heidelberg, 69120 Heidelberg, Germany;
- Department of Internal Medicine, Salem Medical Center, 69120 Heidelberg, Germany
| | - Elmar Jaeckel
- Integrated Research and Treatment Centre Transplantation (IFB-Tx), Hannover Medical School, 30625 Hannover, Germany;
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, 30625 Hannover, Germany
| | - Frank Tacke
- Department of Hepatology & Gastroenterology, Campus Charité Mitte/Campus Virchow-Klinikum, Charité University Medicine Berlin, 13353 Berlin, Germany
- Correspondence:
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Gitto S, Falcini M, Marra F. Metabolic Disorders After Liver Transplantation. Metab Syndr Relat Disord 2020; 19:65-69. [PMID: 33104408 DOI: 10.1089/met.2020.0068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Early after surgery, liver transplant (LT) recipients often develop weight gain due to an increase of caloric intake and fat mass (without recovery of muscle frame). This modification of body composition together with a negative metabolic impact of immunosuppressive drugs leads to a high prevalence of all the main metabolic disorders. Indeed, as expected, transplanted patients show a higher cardiovascular risk in comparison with general population. Notably, seeing the increase of mean age of transplanted population, metabolic disorders represent the true challenge for the transplant community. Considering the lack of evidences or clear indications about prevention, early diagnosis and treatment of metabolic disorders after LT, it would be mandatory to develop targeted further studies on this matter.
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Affiliation(s)
- Stefano Gitto
- Internal Medicine and Liver Unit, Department of Experimental and Clinical Medicine, University Hospital Careggi, University of Florence, Florence, Italy
| | - Margherita Falcini
- Internal Medicine and Liver Unit, Department of Experimental and Clinical Medicine, University Hospital Careggi, University of Florence, Florence, Italy
| | - Fabio Marra
- Internal Medicine and Liver Unit, Department of Experimental and Clinical Medicine, University Hospital Careggi, University of Florence, Florence, Italy
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Dobrindt EM, Allex L, Saipbaev A, Öllinger R, Schöning W, Pratschke J, Eurich D. Association between obesity after liver transplantation and steatosis, inflammation, and fibrosis of the graft. Clin Transplant 2020; 34:e14093. [PMID: 32970896 DOI: 10.1111/ctr.14093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 09/07/2020] [Accepted: 09/13/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Nonalcoholic steatohepatitis has become one of the leading causes of liver transplantation. The development of steatosis, as well as the link to inflammation and fibrosis, after transplantation remain poorly understood. The aim of this analysis was to evaluate the influence of obesity on histopathological changes of the graft during long-term follow-up. METHODS A total of 1494 longitudinal liver biopsies of 271 recipients were evaluated during a follow-up period of 5 to 10 years. Clinical and laboratory parameters as well as histopathological categories of steatosis, inflammation, and fibrosis were explored by routine protocol biopsies. RESULTS The BMI and prevalence of diabetes mellitus significantly increased after transplantation (P < .01). Diabetes and de novo obesity were significantly associated with the degree of graft steatosis. There was no correlation between former steatosis and inflammation or fibrosis. Inflammation was a precursor of fibrosis, and fibrosis increased over the first 3 years (P < .01). No severe graft dysfunction was observed. CONCLUSION Obesity and diabetes mellitus correlated with higher grades of steatosis and de novo steatosis after transplantation. Metabolic syndrome must be considered as a serious post-transplant complication that can cause histopathological alteration. However, the progress from steatosis to steatohepatitis is not as common as expected.
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Affiliation(s)
- Eva M Dobrindt
- Department of Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Laura Allex
- Department of Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Akylbek Saipbaev
- Department of Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Robert Öllinger
- Department of Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Wenzel Schöning
- Department of Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Dennis Eurich
- Department of Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Woodward AJ, Wallen MP, Ryan J, Hall A, Ward LC, Coombes JS, Macdonald GA. Is post-transplant metabolic syndrome associated with pre-liver transplant visceral adipose tissue area? Clin Nutr ESPEN 2020; 39:61-66. [DOI: 10.1016/j.clnesp.2020.07.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 07/25/2020] [Accepted: 07/28/2020] [Indexed: 12/22/2022]
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Di Maira T, Little EC, Berenguer M. Immunosuppression in liver transplant. Best Pract Res Clin Gastroenterol 2020; 46-47:101681. [PMID: 33158467 DOI: 10.1016/j.bpg.2020.101681] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 08/31/2020] [Indexed: 02/07/2023]
Abstract
The increasing potency of immunosuppression (IS) agents resulted in significantly decreased rates of steroid resistant rejection and rejection related graft loss in liver transplantation (LT). Currently, more than two thirds of late mortality after LT is unrelated to graft function. However, the increased benefit of more potent IS drugs, coupled with the prolonged survival of transplant recipients led to longer patients exposure to these drugs and their unwanted adverse effects, creating a double-edged sword. In this article the authors describe the mechanism of action and the adverse effects of the most commonly used immunosuppressed drugs, and the most commonly used IS regimens for both induction and maintenance regimens. The balance between the ideal IS regimen to prevent rejection and the need to minimize the dose of IS drugs in order to prevent the adverse effects related to its use requires the knowledge of the science and the experience with the art of medicine. The different protocols aimed at protecting renal function and preventing the development of de novo cancer and metabolic syndrome are discussed here. The main causes of mortality late after liver transplant are associated with prolonged use of IS medications, and clear evidence exists about over-immunosuppression of recipients of liver transplant. The current status of strategies of IS minimization and withdrawal are reviewed in this article, with evaluation of its benefits and pitfalls.
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Affiliation(s)
- Tommaso Di Maira
- Liver Transplantation and Hepatology Unit, Hospital Universitari I Politècnic La Fe, Avda Fernando Abril Martorell, 106 (Torre F5), Valencia, 46026, Spain; CIBERehd, Instituto de Salud Carlos III, Madrid, 28029, Spain; ISS La Fe, Valencia, 46026, Spain.
| | - Ester Coelho Little
- University of Arizona, College of Medicine, 3110 East Minnesona Avenue, Phoenix, AZ, 85016, USA.
| | - Marina Berenguer
- Liver Transplantation and Hepatology Unit, Hospital Universitari I Politècnic La Fe, Avda Fernando Abril Martorell, 106 (Torre F5), Valencia, 46026, Spain; CIBERehd, Instituto de Salud Carlos III, Madrid, 28029, Spain; ISS La Fe, Valencia, 46026, Spain; Universidad de Valencia, Facultad de Medicina, Valencia, 46010, Spain.
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Gitto S, De Maria N, Marzi L, Magistri P, Falcini M, Vitale G, Olivieri T, Guerrini GP, Serra V, Forte P, Carrai P, De Simone P, Mega A, Zoller H, Piai G, Schepis F, Marocchi M, Villa E, Marra F, Andreone P, Di Benedetto F. Pre-transplant diabetes predicts atherosclerotic vascular events and cardiovascular mortality in liver transplant recipients: a long-term follow-up study. Eur J Intern Med 2020; 79:70-75. [PMID: 32616342 DOI: 10.1016/j.ejim.2020.05.041] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 05/05/2020] [Accepted: 05/27/2020] [Indexed: 12/24/2022]
Abstract
Background Early after surgery, liver transplant (LT) recipients often develop weight gain. Metabolic disorders and cardiovascular disease represent main drivers of morbidity and mortality. Our aim was to identify predictors of atherosclerotic vascular events (AVE) and to assess the impact of AVE on the long-term outcome. Methods We retrospectively analyzed data from patients transplanted between 2000 and 2005 and followed-up in five Italian transplant clinics. Cox Regression analysis was performed to identify predictors of AVE, global mortality, and cardiovascular mortality. Survival analysis was performed using the Kaplan-Meier method. Results We analyzed data from 367 subjects during a median follow-up of 14 years. Thirty-seven post-LT AVE were registered. Patients with AVE more frequently showed pre-LT diabetes mellitus (DM) (48.6 vs 13.9%, p=0.000). In the post-LT period, patients with AVE satisfied criteria of metabolic syndrome in 83.8% vs. 36.7% of subjects without AVE (p=0.000). At multivariate analysis, pre-LT DM independently predicted AVE (HR 2.250, CI 4.848-10.440, p=0.038). Moreover, both pre-LT DM and AVE strongly predicted cardiovascular mortality (HR 5.418, CI 1.060-29.183, p=0.049, and HR 86.097, CI 9.510-779.480, p=0.000, respectively). Conclusions Pre-LT DM is the main risk factor for post-LT AVE. Pre-LT DM and post-LT AVE are strong, long-term predictors of cardiovascular mortality. Patients with pre-LT DM should obtain a personalized follow-up for prevention or early diagnosis of AVE.
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Affiliation(s)
- Stefano Gitto
- Internal Medicine and Liver Unit, University Hospital Careggi, Department of Experimental and Clinical Medicine, University of Florence, Italy (SG current affiliation); Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, University of Bologna, Italy.
| | - Nicola De Maria
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Luca Marzi
- Division of Gastroenterology, Bolzano Regional Hospital, Bolzano, Italy
| | - Paolo Magistri
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Margherita Falcini
- Internal Medicine and Liver Unit, University Hospital Careggi, Department of Experimental and Clinical Medicine, University of Florence, Italy (SG current affiliation)
| | - Giovanni Vitale
- End-stage Liver Disease Unit, Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, University of Bologna, Italy
| | - Tiziana Olivieri
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Gian Piero Guerrini
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Valentina Serra
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Paolo Forte
- Gastroenterology Unit, University Hospital Careggi, Florence, Italy
| | - Paola Carrai
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Paolo De Simone
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Andrea Mega
- Division of Gastroenterology, Bolzano Regional Hospital, Bolzano, Italy
| | - Heinz Zoller
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Guido Piai
- Liver Unit for Transplant Management - SATTE, Department of Medical Sciences, AORN Sant'Anna e San Sebastiano, Caserta, Italy
| | - Filippo Schepis
- Department of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena and University of Modena and Reggio Emilia, Modena, Italy
| | - Margherita Marocchi
- Department of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena and University of Modena and Reggio Emilia, Modena, Italy
| | - Erica Villa
- Department of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena and University of Modena and Reggio Emilia, Modena, Italy
| | - Fabio Marra
- Internal Medicine and Liver Unit, University Hospital Careggi, Department of Experimental and Clinical Medicine, University of Florence, Italy (SG current affiliation)
| | - Pietro Andreone
- Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, University of Bologna, Italy; Internal and Metabolic Medicine, AOU di Modena and University of Modena and Reggio Emilia, Italy
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
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Tsushima T, Osman MN, Josephson RA, Thal SG. First case report: Late-onset coronary artery spasm after radiofrequency catheter ablation for atrial fibrillation in a Caucasian patient. Clin Case Rep 2020; 8:1786-1790. [PMID: 32983496 PMCID: PMC7495811 DOI: 10.1002/ccr3.2977] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 05/04/2020] [Accepted: 05/10/2020] [Indexed: 11/06/2022] Open
Abstract
Most of the coronary vasospasms were found intraprocedurally, and it is very rare to see late-onset vasospasms that happened a few hours after uncomplicated ablations. The recognition of this rare but potentially life-threatening complication is important to improve the conventional practice of catheter ablation for patients with drug-refractory atrial fibrillation.
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Affiliation(s)
- Takahiro Tsushima
- Department of MedicineUniversity Hospitals Cleveland Medical CenterCase Western Reserve UniversityClevelandOHUSA
| | - Mohammed Najeeb Osman
- Division of CardiologyHarrington Heart & Vascular InstituteUniversity Hospitals Cleveland Medical CenterCase Western Reserve UniversityClevelandOHUSA
| | - Richard A. Josephson
- Division of CardiologyHarrington Heart & Vascular InstituteUniversity Hospitals Cleveland Medical CenterCase Western Reserve UniversityClevelandOHUSA
| | - Sergio G. Thal
- Division of CardiologyHarrington Heart & Vascular InstituteUniversity Hospitals Cleveland Medical CenterCase Western Reserve UniversityClevelandOHUSA
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29
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Maliakkal BJ. Pathogenesis of non-alcoholic fatty liver disease and implications on cardiovascular outcomes in liver transplantation. Transl Gastroenterol Hepatol 2020; 5:36. [PMID: 32632387 DOI: 10.21037/tgh.2019.12.02] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 11/05/2019] [Indexed: 12/15/2022] Open
Abstract
Along with the obesity epidemic there has been a major increase in non-alcoholic fatty liver disease (NAFLD) prevalence, paralleling a steady increase in cirrhosis of the liver and hepatocellular cancer (HCC) related to NAFLD. Currently, NAFLD (related HCC and cirrhosis) is the second most common cause for liver transplantation (LT) and it is projected to take the top spot in the next 3-5 years. Patients with NAFLD cirrhosis and HCC have a unique set of comorbidities which potentially increases their risk for cardiovascular disease (CVD) and mortality. However, a review of the published data in NAFLD patients who undergo LT, does not paint a clear picture. While CVD is the most common cause of non-graft related mortality over the long-term, the short and intermediate-term survival post LT in NAFLD cirrhosis appears to be on par with other etiologies when age and comorbidities are factored. The cardiovascular complications are increased in the immediate post-transplant period but there is a shift from ischemic complications to arrhythmias and heart failure (HF). NAFLD recurs in 80-100% patients and occurs de novo in about 50% after LT, potentially impacting their long-term morbidity and mortality. This review summarizes the available data on CVD in NAFLD patients before and after LT, explains what is currently known about the epidemiology and pathogenesis of CVD in NAFLD and posits strategies to improve wait-list and post-transplant survival.
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Gitto S, Aspite S, Golfieri L, Caputo F, Vizzutti F, Grandi S, Patussi V, Marra F. Alcohol use disorder and liver transplant: new perspectives and critical issues. Korean J Intern Med 2020; 35:797-810. [PMID: 32241080 PMCID: PMC7373982 DOI: 10.3904/kjim.2019.409] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 03/03/2020] [Indexed: 12/13/2022] Open
Abstract
Alcoholic liver disease is a consolidated indication for liver transplantation, but many unsolved issues can be highlighted. Patients with alcohol use disorder develop peculiar comorbidities that can become contraindications for transplantation. Moreover, a number of social and psychological patterns should be evaluated to select candidates with a low risk of alcohol relapse and adequate post-transplant adherence. In this context, the 6-month rule is too rigid to be widely applied. A short period of abstinence (1 to 3 months) is useful to estimate recovery of liver function and, possibly to avoid transplant. Cardiovascular disorders and extra-hepatic malignancies represent the main clinical issues after transplant. Patients transplanted due to alcoholic disease are a major risk for other liver diseases. Severe corticosteroid-resistant alcoholic acute hepatitis is a debated indication for transplant. However, available data indicate that well-selected patients have excellent post-transplant outcomes. Behavioral therapy, continued psychological support and a multidisciplinary team are essential to achieve and maintain complete alcohol abstinence during the transplant process. Alcoholic liver disease is an excellent indication for a liver transplant but patients with alcohol use disorder deserve a personalized approach and dedicated resources.
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Affiliation(s)
- Stefano Gitto
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Silvia Aspite
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Lucia Golfieri
- Department of Psychology, University of Bologna, Bologna, Italy
| | - Fabio Caputo
- Department of Internal Medicine, SS Annunziata Hospital, University of Ferrara, Cento, Italy
| | - Francesco Vizzutti
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Silvana Grandi
- Department of Psychology, University of Bologna, Bologna, Italy
| | | | - Fabio Marra
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Research Center Denothe, University of Florence, Italy
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Body Weight Parameters are Related to Morbidity and Mortality After Liver Transplantation: A Systematic Review and Meta-analysis. Transplantation 2020; 103:2287-2303. [PMID: 31283679 DOI: 10.1097/tp.0000000000002811] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Weight gain and obesity are well-known clinical issues in liver transplantation (LTx). However, their impacts on patient outcomes remain unclear, as only the impact of pre-LTx body mass index (BMI) on survival has been meta-analyzed. We summarized and synthesized the evidence on pre- and post-LTx body weight parameters' relations with post-LTx outcomes such as survival, metabolic and cardiovascular comorbidities, and healthcare utilization. METHODS We followed the Cochrane Handbook for Systematic Reviews of Interventions' recommendations. Quality was assessed via a 19-item instrument. Odds ratios and 95% confidence intervals were calculated for outcomes investigated in ≥5 studies. RESULTS Our meta-analysis included 37 studies. Patients with pre-LTx BMI ≥ 30 kg/m and BMI ≥ 35 kg/m had lower overall survival rates than those with pre-LTx normal weight (72.6% and 69.8% versus 84.2%; P = 0.02 and P = 0.03, respectively). Those with pre-LTx BMI ≥ 30 kg/m had worse overall graft survival than normal weight patients (75.8% and 85.4%; P = 0.003). Pre-LTx BMI and pre-LTx overweight were associated with new-onset diabetes (P < 0.001 and P = 0.015, respectively), but post-LTx BMI showed no relationship. No associations were evident with healthcare utilization. CONCLUSIONS Patients with BMI values ≥30 kg/m had worse patient and graft survival than those with normal weight. Few of the reviewed studies examined post-LTx body weight parameters or other relevant outcomes such as cardiovascular comorbidities. High heterogeneity as well as diverse definitions and operationalizations of measurement and outcomes severely impeded comparability.
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32
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Management of metabolic syndrome and cardiovascular risk after liver transplantation. Lancet Gastroenterol Hepatol 2020; 4:731-741. [PMID: 31387736 DOI: 10.1016/s2468-1253(19)30181-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 04/22/2019] [Accepted: 04/23/2019] [Indexed: 12/11/2022]
Abstract
Cardiovascular events are the second most prevalent cause of non-hepatic mortality in liver transplant recipients. The incidence of these events is projected to rise because of the growing prevalence of non-alcoholic steatohepatitis as a transplant indication and the ageing population of liver transplant recipients. Recipients with metabolic syndrome are up to four times more likely to have a cardiovascular event than recipients without, therefore prevention and optimal treatment of the components of metabolic syndrome are key in reducing the risk of these events. Although data on the treatment of metabolic comorbidities specifically in liver transplant recipients are scarce, there is detailed guidance from learned societies that mostly mirrors the guidance for patients at increased cardiovascular risk in the general population. In this Review, we discuss the management of the components of metabolic syndrome following liver transplantation and provide practical stepwise guidance. We also emphasise the need for adequately powered studies for the treatment of metabolic comorbidities in liver transplant recipients.
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33
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The Challenges With the Cardiac Evaluation of Liver and Kidney Transplant Candidates. Transplantation 2020; 104:251-258. [DOI: 10.1097/tp.0000000000002951] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Barnett A, Campbell KL, Mayr HL, Keating SE, Macdonald GA, Hickman IJ. Liver transplant recipients' experiences and perspectives of a telehealth-delivered lifestyle programme: A qualitative study. J Telemed Telecare 2020; 27:590-598. [PMID: 31986966 DOI: 10.1177/1357633x19900459] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Dietary modification and exercise are encouraged to address cardiometabolic risk factors after solid organ transplantation. However, the lived experience of attempting positive lifestyle changes for liver transplant recipients is not known. The aim of this study was to explore the experiences of liver transplant recipients and their perspectives of a 12-week telehealth lifestyle programme and assess the feasibility of this innovative health service. METHODS Focus groups and one-on-one interviews were conducted with participants who had completed a 12-week, group-based, telehealth-delivered diet and exercise programme and thematic qualitative analysis was used to code and theme the data. RESULTS In total, 19 liver transplant recipients participated in the study (25-68 years, median time since transplant 4.4 years, 63% male). Overarching themes included: (a) 'broad telehealth advantages' which highlighted that telehealth reduced the perceived burdens of face-to-face care; (b) 'impact of employment' which identified employment as a competing priority and appeared to effect involvement with the programme; (c) 'adapting Mediterranean eating pattern to meet individual needs' which identified the adaptability of the Mediterranean diet supported by sessions with the dietitian; (d) 'increasing exercise confidence' which recognised that a tailored approach facilitated confidence and acceptability of the exercise component of the programme. DISCUSSION A telehealth lifestyle programme delivered by dietitians and exercise physiologists is an acceptable alternative to face-to-face care that can meet the needs of liver transplant recipients. There is a need to further innovate and broaden the scope of routine service delivery beyond face-to-face consultations.
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Affiliation(s)
- Amandine Barnett
- Department of Nutrition and Dietetics, Princess Alexandra Hospital, Australia.,Bond University Nutrition and Dietetics Research Group, Bond University, Australia
| | - Katrina L Campbell
- Department of Nutrition and Dietetics, Princess Alexandra Hospital, Australia.,Bond University Nutrition and Dietetics Research Group, Bond University, Australia.,Translational Research Institute, Australia
| | - Hannah L Mayr
- Department of Nutrition and Dietetics, Princess Alexandra Hospital, Australia.,Bond University Nutrition and Dietetics Research Group, Bond University, Australia
| | - Shelley E Keating
- School of Human Movement and Nutrition Sciences, The University of Queensland, Australia
| | - Graeme A Macdonald
- Translational Research Institute, Australia.,Queensland Liver Transplant Service, Princess Alexandra Hospital, Australia.,Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Australia
| | - Ingrid J Hickman
- Department of Nutrition and Dietetics, Princess Alexandra Hospital, Australia.,Translational Research Institute, Australia.,Mater Research Institute, The University of Queensland, Australia
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Pisano G, Donato MF, Consonni D, Oberti G, Borroni V, Lombardi R, Invernizzi F, Bertelli C, Caccamo L, Porzio M, Dondossola D, Rossi G, Fargion S, Fracanzani AL. High prevalence of early atherosclerotic and cardiac damage in patients undergoing liver transplantation: Preliminary results. Dig Liver Dis 2020; 52:84-90. [PMID: 31521545 DOI: 10.1016/j.dld.2019.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 07/15/2019] [Accepted: 07/15/2019] [Indexed: 12/11/2022]
Abstract
Liver transplanted patients are at high risk of metabolic syndrome and its complications. We aimed to prospectively evaluate the early onset of cardiovascular alterations in patients submitted to the transplant waiting list. From January 2014 to January 2016, 54 out of 79 patients on the waiting list with decompensated cirrhosis or hepatocellular-carcinoma received the transplant, 50 were followed for 24 months, 2 died post-surgery and 2 were lost to follow-up. A significantly increased prevalence of visceral adiposity (epicardial adipose tissue thickness (p = 0.001) and worsening of carotid damage (p = 0.003) and diastolic dysfunction (E/A p = 0.001) was observed at 6 months after transplant and remained stable at 24 months, corresponding to an increased prevalence of diabetes, metabolic syndrome, hypertension and dyslipidemia. The duration of steroid therapy, withdrawn in the majority of patients at 3 months, did not influence cardiovascular damage. No significant difference in early progression of cardiovascular damage was observed between patients who did or did not receive a graft with steatosis. CONCLUSION: The occurrence of early cardiovascular alterations in the first 6 months after OLT accounts for the reported cardiovascular events in the first years after transplant. In light of these results, new strategies aimed at preventing or delaying cardiovascular alterations should be provided, starting from the first weeks after transplant.
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Affiliation(s)
- Giuseppina Pisano
- Department of Pathophysiology and Transplantation, Unit of Medicine and Metabolic Disorders, Fondazione Ca' Granda IRCCS, Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Maria Francesca Donato
- Division of Gastroenterology and Hepatology, Unit of Transplant Hepatology Fondazione Ca' Granda IRCCS, Ospedale Maggiore Policlinico, RC AM and A Migliavacca Center for the Study of Liver disease University of Milan, Milan, Italy
| | - Dario Consonni
- Epidemiological Unit, Fondazione Ca' Granda IRCCS, Ospedale Maggiore Policlinico, Milan, Italy
| | - Giovanna Oberti
- Department of Pathophysiology and Transplantation, Unit of Medicine and Metabolic Disorders, Fondazione Ca' Granda IRCCS, Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Vittorio Borroni
- Unit of Medicine, ASST Valle Olona, Ospedale di Gallarate, Varese, Italy
| | - Rosa Lombardi
- Department of Pathophysiology and Transplantation, Unit of Medicine and Metabolic Disorders, Fondazione Ca' Granda IRCCS, Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Federica Invernizzi
- Division of Gastroenterology and Hepatology, Unit of Transplant Hepatology Fondazione Ca' Granda IRCCS, Ospedale Maggiore Policlinico, RC AM and A Migliavacca Center for the Study of Liver disease University of Milan, Milan, Italy
| | - Cristina Bertelli
- Department of Pathophysiology and Transplantation, Unit of Medicine and Metabolic Disorders, Fondazione Ca' Granda IRCCS, Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Lucio Caccamo
- Unit of Hepatic Surgery, Department of Pathophysiology and Transplantation, Fondazione Ca' Granda IRCCS, Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Marianna Porzio
- Unit of Emergency Medicine, Fondazione Ca' Granda IRCCS, Ospedale Maggiore Policlinico, Milan, Italy
| | - Daniele Dondossola
- Unit of Hepatic Surgery, Department of Pathophysiology and Transplantation, Fondazione Ca' Granda IRCCS, Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Giorgio Rossi
- Unit of Hepatic Surgery, Department of Pathophysiology and Transplantation, Fondazione Ca' Granda IRCCS, Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Silvia Fargion
- Department of Pathophysiology and Transplantation, Unit of Medicine and Metabolic Disorders, Fondazione Ca' Granda IRCCS, Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Anna Ludovica Fracanzani
- Department of Pathophysiology and Transplantation, Unit of Medicine and Metabolic Disorders, Fondazione Ca' Granda IRCCS, Ospedale Maggiore Policlinico, University of Milan, Milan, Italy.
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Cardiovascular and Metabolic Consequences of Liver Transplantation: A Review. ACTA ACUST UNITED AC 2019; 55:medicina55080489. [PMID: 31443295 PMCID: PMC6722584 DOI: 10.3390/medicina55080489] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 08/03/2019] [Accepted: 08/09/2019] [Indexed: 12/14/2022]
Abstract
Liver transplantation (LT) is considered the curative treatment option for selected patients who suffer from end-stage or acute liver disease or hepatic malignancy (primary). After LT, patients should be carefully monitored for complications that may appear, partially due to immunosuppressive therapy, but not entirely. Cardiovascular diseases are frequently encountered in patients with LT, being responsible for high morbidity and mortality. Patients with underlying cardiovascular and metabolic pathologies are prone to complications after the transplant, but these complications can also appear de novo, mostly associated with immunosuppressants. Metabolic syndrome, defined by obesity, hypertension, dyslipidemia, and hyperglycemia, is diagnosed among LT recipients and is aggravated after LT, influencing the long-term survival. In this review, our purpose was to summarize the current knowledge regarding cardiovascular (CV) diseases and the metabolic syndrome associated with LT and to assess their impact on short and long-term morbidity and mortality.
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Cholongitas Ε, Koukoufiki A, Pipili C, Antoniadis N, Fouzas I, Haidich AB, Goulis I. Is everolimus linked to metabolic syndrome in liver transplant recipients? Indian J Gastroenterol 2019; 38:348-355. [PMID: 31515763 DOI: 10.1007/s12664-019-00971-6] [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: 10/30/2018] [Accepted: 07/03/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND As the mortality rates after liver transplantation (LT) have been reduced, the attention has shifted to additional conditions which still compromise the quality of life and the survival of these patients, such as the post-LT metabolic syndrome (MS). In order to determine the prevalence and the factors associated with the post-LT MS, we carried out the present study. METHODS One hundred and six LT recipients, after completing at least 1 year follow up after LT, were included in the study. Data on clinical, laboratory parameters and immunosuppressive therapy before and after LT were recorded. MS was defined as per current diagnostic criteria. RESULTS MS was prevalent in 47.2% (50 of 106 patients) and was not associated with the LT indications and the time period after LT. Univariate analysis showed that history of diabetes mellitus before (odds ratio [OR] 3.2, 95% confidence interval [CI] 1.046-9.918, p = 0.042) and after LT (OR 6.03, 95% CI 2.18-16.67, p = 0.001), the age at the time of baseline visit (OR 1.077, 95% CI 1.033-1.124, p = 0.001) and the everolimus-based immunosuppression (OR 1.23, 95% CI 1.003-1.33, p = 0.019) were significantly associated with MS. Notably, everolimus administration was the only factor independently associated with the presence of post-LT MS (OR 1.026, 95% CI 1.004-1.047, p = 0.019). More specifically, everolimus was linked to the presence of arterial hypertension (OR 1.02, 95% CI 1.0-1.03, p = 0.05) and hyperlipidemia (OR 2.87, 95% CI 1.28-6.56, p = 0.011). CONCLUSIONS Our study demonstrated for the first time that everolimus was independently associated with post-LT MS. Nevertheless, more robust studies are required to confirm these findings.
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Affiliation(s)
- Εvangelos Cholongitas
- 4th Department of Internal Medicine, Medical School of Aristotle University, Hippokration General Hospital of Thessaloniki, Thessaloniki, Greece. .,First Department of Internal Medicine, Laiko General Hospital, Medical School of National and Kapodistrian University of Athens, Laiko General Hospital, Agiou Thoma 17, 115 27, Athens, Greece.
| | - Argyro Koukoufiki
- 4th Department of Internal Medicine, Medical School of Aristotle University, Hippokration General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Chrysoula Pipili
- Renal Clinical Fellow, Queen Elizabeth University Hospital, Glasgow, UK
| | - Nikolaos Antoniadis
- Department of Transplant Surgery, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Fouzas
- Department of Transplant Surgery, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Anna-Bettina Haidich
- Department of Hygiene and Epidemiology, Medical School of Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Goulis
- 4th Department of Internal Medicine, Medical School of Aristotle University, Hippokration General Hospital of Thessaloniki, Thessaloniki, Greece
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Germani G, Laryea M, Rubbia-Brandt L, Egawa H, Burra P, OʼGrady J, Watt KD. Management of Recurrent and De Novo NAFLD/NASH After Liver Transplantation. Transplantation 2019; 103:57-67. [PMID: 30335694 DOI: 10.1097/tp.0000000000002485] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Nonalcoholic steatohepatitis (NASH) is a growing indication for liver transplant whether the primary or secondary cause of liver disease, and it is expected to be the leading indication in the years to come. Nonalcoholic steatohepatitis recurs after transplant but the impact of the recurrence on allograft and patient outcomes is unclear. A group of multidisciplinary transplant practice providers convened at the International Liver Transplantation Society NASH consensus conference with the purpose of determining the current knowledge and future directions for understanding the recurrence rates, risk and management of NASH in the transplant allograft. Specific questions relating to posttransplant NASH were proposed and reviewed in detail with recommendations on future actions to fill the knowledge gaps.
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Affiliation(s)
- Giacomo Germani
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Marie Laryea
- University of Rochester Medical Center, Rochester NY
| | | | - Hiroto Egawa
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - John OʼGrady
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Kymberly D Watt
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
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39
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Abstract
BACKGROUND Cirrhosis secondary to nonalcoholic steatohepatitis (NASH) is projected to become the leading indication for liver transplantation (LT) in the USA in the next decade. The long-term implications of post-LT NASH, specifically on the development of allograft cirrhosis, are not well known. METHODS A retrospective cohort of patients at a single large center undergoing LT for NASH from 2000 to 2015 was identified using a prospectively collected database. A total of 226 patients undergoing LT for NASH were identified. Mean follow-up for the cohort was 7 years. Seventy-five percent of patients underwent at least one liver biopsy post-LT. RESULTS Eighty-one patients (36%) developed recurrence of biopsy-proven NASH. Fifteen patients developed bridging fibrosis but only four patients (1.8%) progressed to recurrent NASH cirrhosis at a mean of 9 years post-LT. Body mass index at the time of LT was statistically higher in the NASH allograft cirrhosis group. Recurrent disease was less common and less severe in those transplanted with black donors. All four patients with recurrent NASH cirrhosis developed evidence of portal hypertension, but all remained alive at follow-up. CONCLUSION Although recurrent NASH following LT is common, the development of allograft cirrhosis is rare. These findings are useful when counseling patients and important to consider during their post-LT care.
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40
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Beckmann S, Drent G, Ruppar T, Nikolić N, De Geest S. Pre- and post-transplant factors associated with body weight parameters after liver transplantation – A systematic review and meta-analysis. Transplant Rev (Orlando) 2019; 33:39-47. [DOI: 10.1016/j.trre.2018.10.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 10/07/2018] [Indexed: 02/07/2023]
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41
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Naeser V, Brandt AH, Nyhuus B, Borgwardt L, Jørgensen MH, Rasmussen A. Risk markers for later cardiovascular diseases in liver-transplanted children and adolescents. Pediatr Transplant 2018; 22:e13298. [PMID: 30338616 DOI: 10.1111/petr.13298] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 08/15/2018] [Accepted: 09/04/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Increased risk of cardiovascular diseases is well described after adult liver transplantation, whereas the risk in the pediatric population still is discussed. The aim of this study was to investigate the prevalence of metabolic syndrome in pediatric liver transplant recipients and whether measurements of carotid intima media thickness and pulse wave velocity were increased compared to healthy controls. METHODS We included 42 pediatric liver transplantation recipients and examined them for markers of metabolic syndrome, liver fibrosis measured by shear wave velocity, body fat measured by DXA scans and carotid intima-media thickness, and pulse wave velocity (n = 41 for the carotid scans). The ultrasound measurements of carotid intima-media thickness and pulse wave velocity were also conducted on 82 healthy children and adolescents matched on height and age, respectively. RESULTS Participants had a median age of 13.03 years, and median time since transplantation was 8.54 years. Compared to healthy controls, liver-transplanted patients had significantly increased intima-media thickness measurements in both control groups whereas there was no significant difference with regard to pulse wave velocity. Two patients (6.25%) were diagnosed with metabolic syndrome. Within the group of liver-transplanted pediatric patients, only elevated body mass index was associated with elevated carotid intima-media thickness measurement. Elevated pulse wave velocity was only associated with abdominal obesity. Factors not significantly correlated with either were age, sex, metabolic syndrome, hyperglycemia, triglycerides, years since transplantation, fibrosis of the liver, body fat content, smoking habits, HDL cholesterol levels, hypertension, and mono-drug versus multi-drug therapies. CONCLUSION Pediatric liver transplant recipients do have an increased risk of increased carotid intima-media thickness.
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Affiliation(s)
- Vibeke Naeser
- Department of Surgical Gastroenterology and Transplantation, Rigshospitalet, Copenhagen, Denmark
| | | | - Bo Nyhuus
- Department of Radiology, Rigshospitalet, Copenhagen, Denmark
| | - Lise Borgwardt
- Department of Clinical Physiology and Nuclear Medicine, Rigshospitalet, Copenhagen, Denmark
| | | | - Allan Rasmussen
- Department of Surgical Gastroenterology and Transplantation, Rigshospitalet, Copenhagen, Denmark
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42
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Khurmi NS, Chang YH, Eric Steidley D, Singer AL, Hewitt WR, Reddy KS, Moss AA, Mathur AK. Hospitalizations for Cardiovascular Disease After Liver Transplantation in the United States. Liver Transpl 2018; 24:1398-1410. [PMID: 29544033 DOI: 10.1002/lt.25055] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 04/30/2018] [Accepted: 03/10/2018] [Indexed: 02/07/2023]
Abstract
Cardiovascular disease (CVD) is a leading cause of post-liver transplant death, and variable care patterns may affect outcomes. We aimed to describe epidemiology and outcomes of inpatient CVD care across US hospitals. Using a merged data set from the 2002-2011 Nationwide Inpatient Sample and the American Hospital Association Annual Survey, we evaluated liver transplant patients admitted primarily with myocardial infarction (MI), stroke (cerebrovascular accident [CVA]), congestive heart failure (CHF), dysrhythmias, cardiac arrest (CA), or malignant hypertension. Patient-level data include demographics, Charlson comorbidity index, and CVD diagnoses. Facility-level variables included ownership status, payer-mix, hospital resources, teaching status, and physician/nursing-to-bed ratios. We used generalized estimating equations to evaluate patient- and hospital-level factors associated with mortality. There were 4763 hospitalizations that occurred in 153 facilities (transplant hospitals, n = 80). CVD hospitalizations increased overall by 115% over the decade (P < 0.01). CVA and MI declined over time (both P < 0.05), but CHF and dysrhythmia grew significantly (both P < 0.03); a total of 19% of hospitalizations were for multiple CVD diagnoses. Transplant hospitals had lower comorbidity patients (P < 0.001) and greater resource intensity including presence of cardiac intensive care unit, interventional radiology, operating rooms, teaching status, and nursing density (all P < 0.01). Transplant and nontransplant hospitals had similar unadjusted mortality (overall, 3.9%, P = 0.55; by diagnosis, all P > 0.07). Transplant hospitals had significantly longer overall length of stay, higher total costs, and more high-cost hospitalizations (all P < 0.05). After risk adjustment, transplant hospitals were associated with higher mortality and high-cost hospitalizations. In conclusion, CVD after liver transplant is evolving and responsible for growing rates of inpatient care. Transplant hospitals are associated with poor outcomes, even after risk adjustment for patient and hospital characteristics, which may be attributable to selective referral of certain patient phenotypes but could also be related to differences in quality of care. Further study is warranted.
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Affiliation(s)
| | - Yu-Hui Chang
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery
| | | | - Andrew L Singer
- Transplant Surgery, Department of Surgery, Mayo Clinic School of Medicine, Mayo Clinic Arizona, Phoenix, AZ
| | - Winston R Hewitt
- Transplant Surgery, Department of Surgery, Mayo Clinic School of Medicine, Mayo Clinic Arizona, Phoenix, AZ
| | - Kunam S Reddy
- Transplant Surgery, Department of Surgery, Mayo Clinic School of Medicine, Mayo Clinic Arizona, Phoenix, AZ
| | - Adyr A Moss
- Transplant Surgery, Department of Surgery, Mayo Clinic School of Medicine, Mayo Clinic Arizona, Phoenix, AZ
| | - Amit K Mathur
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery.,Transplant Surgery, Department of Surgery, Mayo Clinic School of Medicine, Mayo Clinic Arizona, Phoenix, AZ
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Impact of Allograft Steatosis on Cardiovascular Outcomes. CURRENT TRANSPLANTATION REPORTS 2018. [DOI: 10.1007/s40472-018-0205-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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44
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Park YS, Moon YJ, Jun IG, Song JG, Hwang GS. Application of the Revised Cardiac Risk Index to the Model for End-Stage Liver Disease Score Improves the Prediction of Cardiac Events in Patients Undergoing Liver Transplantation. Transplant Proc 2018; 50:1108-1113. [PMID: 29731076 DOI: 10.1016/j.transproceed.2018.01.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 01/22/2018] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Although the revised cardiac risk index (RCRI) is a useful tool for estimating the risk of postoperative cardiac events, whether it improves the prediction of cardiac events in patients undergoing liver transplantation (LT) has not been sufficiently demonstrated. METHODS We retrospectively analyzed 1429 patients who underwent LT. Cardiac events were defined as myocardial infarction, death, or combined events within 30 days after surgery. The RCRI was defined as the number of independent predictors including high-risk surgery, ischemic heart disease, congestive heart failure, cerebrovascular disease, insulin treatment, and creatinine level >2 mg/dL. Multivariate logistic regression analysis was performed to identify factors independently associated with cardiac events. The additive predictability of RCRI for the Model for End-Stage Liver Disease (MELD) score was assessed using receiver operating characteristic curve analysis. RESULTS Forty-four (3.1%) cardiac events occurred within 30 days after surgery. Both the MELD score (adjusted odds ratio [aOR], 1.05; P = .005) and RCRI (aOR, 4.35; P < .001 for RCRI score 2; aOR, 6.27; P = .009 for RCRI score 3 compared with RCRI score 1) independently predicted postoperative 30-day cardiac events. The model with MELD score plus RCRI was significantly more predictive for postoperative 30-day cardiac events than the model with MELD score alone (C-statistics 0.800 vs 0.757; P = .030). CONCLUSIONS For preoperative risk stratification, RCRI showed additive value to MELD score in predicting postoperative 30-day cardiac events after LT.
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Affiliation(s)
- Y-S Park
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Y-J Moon
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - I-G Jun
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - J-G Song
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - G-S Hwang
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Di Stefano C, Vanni E, Mirabella S, Younes R, Boano V, Mosso E, Nada E, Milazzo V, Maule S, Romagnoli R, Salizzoni M, Veglio F, Milan A. Risk factors for arterial hypertension after liver transplantation. JOURNAL OF THE AMERICAN SOCIETY OF HYPERTENSION : JASH 2018; 12:220-229. [PMID: 29366595 DOI: 10.1016/j.jash.2018.01.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 12/29/2017] [Accepted: 01/01/2018] [Indexed: 12/11/2022]
Abstract
Arterial hypertension represents a common complication of immunosuppressive therapy after liver transplantation (LT). The aim of the study is to evaluate the prevalence and risk factors associated with hypertension after LT. From a cohort of 323 cirrhotic patients who underwent LT from 2008 to 2012, 270 patients were retrospectively evaluated, whereas 53 (16.4%) patients deceased. Hypertension was defined as blood pressure ≥140/90 mm Hg in at least two visits and/or the need for antihypertensive therapy. The prevalence of hypertension was 15% before LT and significantly increased up to 53% after LT (P < .001). Mean follow-up was 43 ± 19 months. In normotensive (NT) subjects at baseline, 35.9% developed sustained hypertension after LT, whereas 15.2% developed transient hypertension within the first month after LT, and then returned NT. The development of sustained hypertension after LT was related to the mammalian target of rapamycin inhibitor treatment (odds ratio [OR], 4.02; 95% confidence interval [CI], 1.26-13.48; P = .02), alcoholic cirrhosis before LT (OR, 3.38; 95% CI, 1.44-8.09; P = .005), and new-onset hepatic steatosis after LT (OR, 2.13; 95% CI, 1.10-4.11; P = .02). Tacrolimus, the etiology and severity of liver disease, and other immunosuppressive regimens were not related to the development of hypertension after LT. In our cohort, the prevalence of arterial hypertension has increased up to 53% after LT, and metabolic comorbidities and immunosuppressive treatment with mammalian target of rapamycin inhibitors are the risk factors for the development of hypertension after LT.
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Affiliation(s)
- Cristina Di Stefano
- Department of Medical Sciences, Hypertension Unit, Città della Salute e della Scienza, University of Torino, Torino, Italy.
| | - Ester Vanni
- Division of Gastroenterology, Department of Medical Sciences, Città della Salute e della Scienza, University of Torino, Torino, Italy
| | - Stefano Mirabella
- Liver Transplant Center, Città della Salute e della Scienza, University of Torino, Torino, Italy
| | - Ramy Younes
- Division of Gastroenterology, Department of Medical Sciences, Città della Salute e della Scienza, University of Torino, Torino, Italy
| | - Valentina Boano
- Division of Gastroenterology, Department of Medical Sciences, Città della Salute e della Scienza, University of Torino, Torino, Italy
| | - Elena Mosso
- Division of Gastroenterology, Department of Medical Sciences, Città della Salute e della Scienza, University of Torino, Torino, Italy
| | - Elisabetta Nada
- Liver Transplant Center, Città della Salute e della Scienza, University of Torino, Torino, Italy
| | - Valeria Milazzo
- Department of Medical Sciences, Hypertension Unit, Città della Salute e della Scienza, University of Torino, Torino, Italy
| | - Simona Maule
- Department of Medical Sciences, Hypertension Unit, Città della Salute e della Scienza, University of Torino, Torino, Italy
| | - Renato Romagnoli
- Liver Transplant Center, Città della Salute e della Scienza, University of Torino, Torino, Italy
| | - Mauro Salizzoni
- Liver Transplant Center, Città della Salute e della Scienza, University of Torino, Torino, Italy
| | - Franco Veglio
- Department of Medical Sciences, Hypertension Unit, Città della Salute e della Scienza, University of Torino, Torino, Italy
| | - Alberto Milan
- Department of Medical Sciences, Hypertension Unit, Città della Salute e della Scienza, University of Torino, Torino, Italy
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Rimbaş RC, Baldea SM, Guerra RDGA, Visoiu SI, Rimbaş M, Pop CS, Vinereanu D. New Definition Criteria of Myocardial Dysfunction in Patients with Liver Cirrhosis: A Speckle Tracking and Tissue Doppler Imaging Study. ULTRASOUND IN MEDICINE & BIOLOGY 2018; 44:562-574. [PMID: 29306590 DOI: 10.1016/j.ultrasmedbio.2017.11.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 10/25/2017] [Accepted: 11/20/2017] [Indexed: 06/07/2023]
Abstract
There are no clear recommendations regarding cirrhotic cardiomyopathy (CC) evaluation in patients with pre-transplant liver cirrhosis. The roles of new methods, tissue Doppler imaging (TDI) and speckle tracking echocardiography (STE) in the diagnosis and prognosis of cirrhotic cardiomyopathy remain controversial. We investigated the utility of TDI/STE parameters in cirrhotic cardiomyopathy diagnosis and also in predicting mortality in patients with liver cirrhosis. Left/right ventricular function was studied using conventional TDI (velocities) and STE (strain/strain rate). We assessed left ventricular diastolic dysfunction, graded into four new classes (I/Ia/II/III). Serum NTproBNP (N-terminal prohormone of brain natriuretic peptide), troponin I, β-crosslaps, QTc interval, arterial compliance and endothelial function were measured. Liver-specific scores (Child-Pugh, MELD, MELDNa) were computed. There was a 1-y follow-up visit to determine mortality. We observed resting biventricular diastolic myocardial dysfunction, not presently included in the definition of cirrhotic cardiomyopathy. We provided an improved characterization of cardiac dysfunction in patients with liver cirrhosis. This might change the current definition. However, the utility of STE/TDI parameters in predicting long-term mortality in patients with liver cirrhosis remains controversial.
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Affiliation(s)
- Roxana Cristina Rimbaş
- Cardiology Department, University and Emergency Hospital, Bucharest, Romania; Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.
| | - Sorina Mihăilă Baldea
- Cardiology Department, University and Emergency Hospital, Bucharest, Romania; Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | | | | | - Mihai Rimbaş
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
| | - Corina Silvia Pop
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; Gastroenterology Department, University and Emergency Hospital, Bucharest, Romania
| | - Dragoş Vinereanu
- Cardiology Department, University and Emergency Hospital, Bucharest, Romania; Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
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Perito ER, Phelps A, Vase T, Feldstein VA, Lustig RH, Rosenthal P. Subclinical Atherosclerosis in Pediatric Liver Transplant Recipients: Carotid and Aorta Intima-Media Thickness and Their Predictors. J Pediatr 2018; 193:119-127.e1. [PMID: 29224938 PMCID: PMC5794603 DOI: 10.1016/j.jpeds.2017.10.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 08/21/2017] [Accepted: 10/10/2017] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To investigate prevalence and predictors of cardiovascular risk in pediatric liver transplant recipients using noninvasive markers of subclinical atherosclerosis: carotid intima-media thickness (cIMT) and aorta intima-media thickness (aIMT). STUDY DESIGN Cross-sectional study of 88 pediatric liver transplant recipients. The cIMT and aIMT were measured by ultrasound imaging using standardized protocol. RESULTS Participants were 15.4 ± 4.8 years of age, and 11.2 ± 5.6 years post-transplantation. The cIMT and aIMT were both higher in males than females. In analyses adjusted for sex, age, and height, the cIMT was higher in subjects transplanted for chronic/cirrhotic liver disease and lower in subjects on cyclosporine (n = 9) than tacrolimus (n = 71). The cIMT was not associated with rejection history or current corticosteroid use. The cIMT increased with increasing diastolic blood pressure and triglycerides. The aIMT (n = 83) also increased with age, and its rate of increase post-transplant varied by age at transplantation. In adjusted analyses, aIMT was higher in subjects with glucose intolerance. In analysis of patients ≤20 years of age for whom blood pressure percentiles could be calculated (n = 66), aIMT increased with increasing diastolic blood pressure percentile (0.010 mm per 5-percentile; 95% CI, 0.000-0.021; P = 0.05). Neither the cIMT nor the aIMT was associated with obesity, systolic hypertension, or other dyslipidemia at study visit. CONCLUSION Measures of long-term cardiovascular risk were associated with conditions that are more common in pediatric liver transplant recipients than nontransplanted peers, namely, diastolic hypertension and glucose intolerance. Larger, longitudinal studies are warranted to investigate whether cIMT could be useful for stratifying these patients' cardiovascular risk-and potential need for proactive intervention-during long-term follow-up.
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Affiliation(s)
- Emily R. Perito
- Department of Pediatrics, UCSF Benioff Children’s Hospital, University of California, San Francisco, San Francisco, CA,Department of Epidemiology and Biostatistics, UCSF Benioff Children’s Hospital, University of California, San Francisco, San Francisco, CA
| | - Andrew Phelps
- Department of Radiology and Biomedical Imaging, UCSF Benioff Children’s Hospital, University of California, San Francisco, San Francisco, CA
| | - Tabitha Vase
- School of Medicine, UCSF Benioff Children’s Hospital, University of California, San Francisco, San Francisco, CA
| | - Vickie A. Feldstein
- Department of Radiology and Biomedical Imaging, UCSF Benioff Children’s Hospital, University of California, San Francisco, San Francisco, CA
| | - Robert H. Lustig
- Department of Pediatrics, UCSF Benioff Children’s Hospital, University of California, San Francisco, San Francisco, CA
| | - Philip Rosenthal
- Department of Pediatrics, UCSF Benioff Children’s Hospital, University of California, San Francisco, San Francisco, CA,Department of Surgery, UCSF Benioff Children’s Hospital, University of California, San Francisco, San Francisco, CA
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Saab S, Sikavi C, Jimenez M, Viramontes M, Allen R, Challita Y, Mai M, Esmailzadeh N, Grotts J, Choi G, Durazo F, El-Kabany M, Han SH, Moreno E. Clinical Food Addiction Is Not Associated with Development of Metabolic Complications in Liver Transplant Recipients. J Clin Transl Hepatol 2017; 5:335-342. [PMID: 29226100 PMCID: PMC5719191 DOI: 10.14218/jcth.2017.00023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 07/07/2017] [Accepted: 08/05/2017] [Indexed: 12/14/2022] Open
Abstract
Background and Aims: Given the increased risk of post-transplant metabolic syndrome (PTMS; defined by hypertension, diabetes mellitus and hyperlipidemia), we aimed to identify the potential role of food addiction in the development of metabolic complications in the post-liver transplant population. Methods: Inclusion criteria included adult liver transplant recipients followed at our institution between June 2016 and November 2016. Participants were administered a demographic survey as well as the Yale Food Assessment Scale 2.0, a 35-item questionnaire used to assess frequency of food addiction in accordance with the DSM-V guidelines of substance use disorders. Demographic and clinical data were collected. Results: Our study included 236 liver transplant recipients (139 males, 97 females). The median (interquartile range [IQR]) BMI of participants was 26.8 kg/m2 (24.2, 30.4), and median (IQR) time since transplantation was 50.9 months (19.6, 119.8). The prevalence rates of hypertension, hypercholesterolemia and diabetes mellitus were 54.7%, 25.0% and 27.1%, respectively. Twelve participants (5.1%) were found to have a diagnosis of food addiction. A diagnosis of food misuse was made in 94 (39.8%) of the transplant recipients. Conclusions: Our findings are consistent with prior data that indicate high prevalence of metabolic complications among liver transplant recipients. Food addiction was not predictive of metabolic complications within this population. Nevertheless, we found that this population was at high risk of demonstrating symptoms of food misuse, and they were not likely to appreciate the risks of pathologic patterns of eating. Given the increasing risk of cardiovascular morbidity and mortality in this population, efforts should be made to identify risk factors for the development of PTMS.
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Affiliation(s)
- Sammy Saab
- Departments of Medicine, the University of California at Los Angeles, Los Angeles, CA, USA
- Departments of Surgery, the University of California at Los Angeles, Los Angeles, CA, USA
- *Correspondence to: Sammy Saab, Pfleger Liver Institute, UCLA Medical Center, 200 Medical Plaza, Suite 214, Los Angeles, CA 90095, USA. Tel: +1-310-206-6705, Fax: +1-310-206-4197, E-mail:
| | - Cameron Sikavi
- Departments of Surgery, the University of California at Los Angeles, Los Angeles, CA, USA
| | - Melissa Jimenez
- Departments of Surgery, the University of California at Los Angeles, Los Angeles, CA, USA
| | - Matthew Viramontes
- Departments of Surgery, the University of California at Los Angeles, Los Angeles, CA, USA
| | - Ruby Allen
- Departments of Surgery, the University of California at Los Angeles, Los Angeles, CA, USA
| | - Youssef Challita
- Departments of Surgery, the University of California at Los Angeles, Los Angeles, CA, USA
| | - Michelle Mai
- Departments of Surgery, the University of California at Los Angeles, Los Angeles, CA, USA
| | - Negin Esmailzadeh
- Departments of Surgery, the University of California at Los Angeles, Los Angeles, CA, USA
| | - Jonathan Grotts
- Departments of Medicine, the University of California at Los Angeles, Los Angeles, CA, USA
| | - Gina Choi
- Departments of Medicine, the University of California at Los Angeles, Los Angeles, CA, USA
- Departments of Surgery, the University of California at Los Angeles, Los Angeles, CA, USA
| | - Francisco Durazo
- Departments of Medicine, the University of California at Los Angeles, Los Angeles, CA, USA
- Departments of Surgery, the University of California at Los Angeles, Los Angeles, CA, USA
| | - Mohamed El-Kabany
- Departments of Medicine, the University of California at Los Angeles, Los Angeles, CA, USA
- Departments of Surgery, the University of California at Los Angeles, Los Angeles, CA, USA
| | - Steven-Huy Han
- Departments of Medicine, the University of California at Los Angeles, Los Angeles, CA, USA
- Departments of Surgery, the University of California at Los Angeles, Los Angeles, CA, USA
| | - Elisa Moreno
- Departments of Psychiatry, the University of California at Los Angeles, Los Angeles, CA, USA
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49
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Cheung A, Levitsky J. Follow-up of the Post-Liver Transplantation Patient: A Primer for the Practicing Gastroenterologist. Clin Liver Dis 2017; 21:793-813. [PMID: 28987263 DOI: 10.1016/j.cld.2017.06.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The focus in liver transplantation in the next 10 years will likely change from preventing viral disease recurrence to minimizing the toll of rejection and fatty liver disease, minimizing the complications from immunosuppression with withdrawal strategies, and more optimal management of long-term risks, such as malignancy, cardiovascular disease, and renal failure. In addition, now that short-term results (<1 year) have improved significantly, there will be a shift toward improving long-term patient and graft survival, as well as a focus on primary care preventive strategies.
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Affiliation(s)
- Amanda Cheung
- Division of Gastroenterology and Hepatology, Northwestern University, 676 North Saint Clair, Suite 1400, Chicago, IL 60611, USA
| | - Josh Levitsky
- Division of Gastroenterology and Hepatology, Northwestern University, 676 North Saint Clair, Suite 1400, Chicago, IL 60611, USA.
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50
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Abstract
Liver transplantation (LT) is a unique surgical procedure that has major hemodynamic and cardiovascular implications. Recently, there has been significant interest focused on cardiovascular issues that affect LT patients in all phases of the perioperative period. The preoperative cardiac evaluation is a major step in the selection of LT candidates. LT candidates are aging in concordance with the general population; cardiovascular disease and their risk factors are highly associated with older age. Underlying cardiovascular disease has the potential to affect outcomes in LT patients and has a major impact on candidate selection. The prolonged hemodynamic and metabolic instability during LT may contribute to adverse outcomes, especially in patients with underlying cardiovascular disease. Cardiovascular events are not unusual during LT; transplant anesthesiologists must be prepared for these events. Advanced cardiovascular monitoring techniques and treatment modalities are now routinely used during LT. Postoperative cardiovascular complications are common in both the early and late posttransplant periods. The impact of cardiac complications on posttransplant mortality is well recognized. Emerging knowledge regarding cardiovascular disease in LT patients and its impact on posttransplant outcomes will have an important role in guiding the future perioperative management of LT patients.
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