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Terrault NA, Francoz C, Berenguer M, Charlton M, Heimbach J. Liver Transplantation 2023: Status Report, Current and Future Challenges. Clin Gastroenterol Hepatol 2023; 21:2150-2166. [PMID: 37084928 DOI: 10.1016/j.cgh.2023.04.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 03/29/2023] [Accepted: 04/04/2023] [Indexed: 04/23/2023]
Abstract
Liver transplantation offers live-saving therapy for patients with complications of cirrhosis and stage T2 hepatocellular carcinoma. The demand for organs far outstrips the supply, and innovations aimed at increasing the number of usable deceased donors as well as alternative donor sources are a major focus. The etiologies of cirrhosis are shifting over time, with more need for transplantation among patients with alcohol-associated liver disease and nonalcoholic/metabolic fatty liver disease and less for viral hepatitis, although hepatitis B remains an important indication for transplant in countries with high endemicity. The rise in transplantation for alcohol-associated liver disease and nonalcoholic/metabolic fatty liver disease has brought attention to how patients are selected for transplantation and the strategies needed to prevent recurrent disease. In this review, we present a status report on the most pressing topics in liver transplantation and future challenges.
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Affiliation(s)
- Norah A Terrault
- Division of Gastrointestinal and Liver Diseases, University of Southern California, Los Angeles, California.
| | - Claire Francoz
- Liver Intensive Care and Liver Transplantation Unit, Hepatology, Hospital Beaujon, Clichy, France
| | - Marina Berenguer
- Hepatology and Liver Transplantation Unit, Hospital Universitario la Fe - IIS La Fe Valencia; CiberEHD and University of Valencia, Valencia, Spain
| | - Michael Charlton
- Transplantation Institute, University of Chicago, Chicago, Illinois
| | - Julie Heimbach
- William von Liebig Center for Transplantation, Mayo Clinic Rochester, Minnesota
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2
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CHIERICI A, ALROMAYAN M, DEFATICO S, DRAI C, VINCI D, ANTY R, SCHIAVO L, IANNELLI A. Is bariatric surgery safer before, during, or after liver transplantation? A systematic review and meta-analysis. JOURNAL OF LIVER TRANSPLANTATION 2023. [DOI: 10.1016/j.liver.2023.100139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
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3
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Sarno G, Schiavo L, Calabrese P, Álvarez Córdova L, Frias-Toral E, Cucalón G, Garcia-Velasquez E, Fuchs-Tarlovsky V, Pilone V. The Impact of Bariatric-Surgery-Induced Weight Loss on Patients Undergoing Liver Transplant: A Focus on Metabolism, Pathophysiological Changes, and Outcome in Obese Patients Suffering NAFLD-Related Cirrhosis. J Clin Med 2022; 11:jcm11185293. [PMID: 36142939 PMCID: PMC9503676 DOI: 10.3390/jcm11185293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 08/28/2022] [Accepted: 09/05/2022] [Indexed: 11/30/2022] Open
Abstract
Because of their condition, patients with morbid obesity develop several histopathological changes in the liver, such as non-alcoholic fatty liver disease (NAFLD), non-alcoholic steatohepatitis (NASH), cirrhosis, and end-stage liver disease (ESLD). Hence, a liver transplant (LT) becomes an opportune solution for them. Due to many challenges during the perioperative and postoperative periods, these patients are recommended to lose weight before the surgery. There are many proposals to achieve this goal, such as intragastric balloons and many different bariatric surgery (BS) procedures in combination with a preparation diet (very-low-calorie diet, ketogenic diet, etc.). All the interventions focus on losing weight and keeping the continuity and functionality of the digestive tract to avoid postoperative complications. Thus, this review analyzes recent publications regarding the metabolic and pathophysiological impacts of BS in LT patients suffering from NAFLD-related cirrhosis, the effect of weight loss on postoperative complications, and exposes the cost-effectiveness of performing BS before, after, and at liver transplantation. Finally, the authors recommend BS before the LT since there are many positive effects and better outcomes for patients who lose weight before the procedure. Nevertheless, further multicentric studies are needed to determine the generalizability of these recommendations due to their impact on public health.
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Affiliation(s)
- Gerardo Sarno
- San Giovanni di Dio e Ruggi D’Aragona University Hospital, Scuola Medica Salernitana, 84131 Salerno, Italy
| | - Luigi Schiavo
- Center of Excellence of Bariatric Surgery of the Italian Society of Obesity Surgery and Metabolic Disease (SICOB), Unit of General and Emergency Surgery, University Hospital San Giovanni di Dio e Ruggi d’Aragona, P.O. Gaetano Fucito Mercato San Severino, 84085 Salerno, Italy
- Department of Medicine, Surgery and Dentistry, Scuola Medica Salernitana, University of Salerno, 84081 Baronissi, Italy
- Correspondence: ; Tel.: +39-089-965062
| | - Pietro Calabrese
- Center of Excellence of Bariatric Surgery of the Italian Society of Obesity Surgery and Metabolic Disease (SICOB), Unit of General and Emergency Surgery, University Hospital San Giovanni di Dio e Ruggi d’Aragona, P.O. Gaetano Fucito Mercato San Severino, 84085 Salerno, Italy
- Department of Medicine, Surgery and Dentistry, Scuola Medica Salernitana, University of Salerno, 84081 Baronissi, Italy
| | - Ludwig Álvarez Córdova
- Carrera de Nutrición y Dietética, Facultad de Ciencias Médicas, Universidad Católica De Santiago de Guayaquil, Av. Pdte. Carlos Julio Arosemena Tola, Guayaquil 090615, Ecuador
| | - Evelyn Frias-Toral
- School of Medicine, Universidad Católica Santiago de Guayaquil, Av. Pdte. Carlos Julio Arosemena Tola, Guayaquil 090615, Ecuador
- Universidad de Especialidades Espìritu Santo, Samborondòn 0901952, Ecuador
| | - Gabriela Cucalón
- Lifescience Faculty, ESPOL Polytechnic University, Escuela Superior Politécnica del Litoral (ESPOL), Campus Gustavo Galindo Km. 30.5 Vía Perimetral, Guayaquil 090615, Ecuador
| | | | | | - Vincenzo Pilone
- Center of Excellence of Bariatric Surgery of the Italian Society of Obesity Surgery and Metabolic Disease (SICOB), Unit of General and Emergency Surgery, University Hospital San Giovanni di Dio e Ruggi d’Aragona, P.O. Gaetano Fucito Mercato San Severino, 84085 Salerno, Italy
- Department of Medicine, Surgery and Dentistry, Scuola Medica Salernitana, University of Salerno, 84081 Baronissi, Italy
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Updated S2k Clinical Practice Guideline on Non-alcoholic Fatty Liver Disease (NAFLD) issued by the German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS) - April 2022 - AWMF Registration No.: 021-025. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:e733-e801. [PMID: 36100201 DOI: 10.1055/a-1880-2388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
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5
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Roeb E, Canbay A, Bantel H, Bojunga J, de Laffolie J, Demir M, Denzer UW, Geier A, Hofmann WP, Hudert C, Karlas T, Krawczyk M, Longerich T, Luedde T, Roden M, Schattenberg J, Sterneck M, Tannapfel A, Lorenz P, Tacke F. Aktualisierte S2k-Leitlinie nicht-alkoholische Fettlebererkrankung der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – April 2022 – AWMF-Registernummer: 021–025. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:1346-1421. [PMID: 36100202 DOI: 10.1055/a-1880-2283] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- E Roeb
- Gastroenterologie, Medizinische Klinik II, Universitätsklinikum Gießen und Marburg, Gießen, Deutschland
| | - A Canbay
- Medizinische Klinik, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Deutschland
| | - H Bantel
- Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover (MHH), Hannover, Deutschland
| | - J Bojunga
- Medizinische Klinik I Gastroent., Hepat., Pneum., Endokrin., Universitätsklinikum Frankfurt, Frankfurt, Deutschland
| | - J de Laffolie
- Allgemeinpädiatrie und Neonatologie, Zentrum für Kinderheilkunde und Jugendmedizin, Universitätsklinikum Gießen und Marburg, Gießen, Deutschland
| | - M Demir
- Medizinische Klinik mit Schwerpunkt Hepatologie und Gastroenterologie, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum und Campus Charité Mitte, Berlin, Deutschland
| | - U W Denzer
- Klinik für Gastroenterologie und Endokrinologie, Universitätsklinikum Gießen und Marburg, Marburg, Deutschland
| | - A Geier
- Medizinische Klinik und Poliklinik II, Schwerpunkt Hepatologie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - W P Hofmann
- Gastroenterologie am Bayerischen Platz - Medizinisches Versorgungszentrum, Berlin, Deutschland
| | - C Hudert
- Klinik für Pädiatrie m. S. Gastroenterologie, Nephrologie und Stoffwechselmedizin, Charité Campus Virchow-Klinikum - Universitätsmedizin Berlin, Berlin, Deutschland
| | - T Karlas
- Klinik und Poliklinik für Onkologie, Gastroenterologie, Hepatologie, Pneumologie und Infektiologie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - M Krawczyk
- Klinik für Innere Medizin II, Gastroent., Hepat., Endokrin., Diabet., Ern.med., Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - T Longerich
- Pathologisches Institut, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - T Luedde
- Klinik für Gastroenterologie, Hepatologie und Infektiologie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - M Roden
- Klinik für Endokrinologie und Diabetologie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - J Schattenberg
- I. Medizinische Klinik und Poliklinik, Universitätsmedizin Mainz, Mainz, Deutschland
| | - M Sterneck
- Klinik für Hepatobiliäre Chirurgie und Transplantationschirurgie, Universitätsklinikum Hamburg, Hamburg, Deutschland
| | - A Tannapfel
- Institut für Pathologie, Ruhr-Universität Bochum, Bochum, Deutschland
| | - P Lorenz
- Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS), Berlin, Deutschland
| | - F Tacke
- Medizinische Klinik mit Schwerpunkt Hepatologie und Gastroenterologie, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum und Campus Charité Mitte, Berlin, Deutschland
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Safavi D, Creavin B, Gallagher TK, Kelly ME. The role of bariatric surgery in liver transplantation: timing and type. Langenbecks Arch Surg 2022; 407:3249-3258. [DOI: 10.1007/s00423-022-02606-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 07/09/2022] [Indexed: 11/29/2022]
Abstract
Abstract
Introduction
The rise in obesity worldwide has shifted the indications for liver transplantation (LT), with non-alcoholic steatohepatitis (NASH) being the second most common indication for transplantation. There remains an underestimation of cirrhosis being attributed to NASH. Bariatric surgery (BS) is a reliable solution to overcome obesity and its associated comorbidities. The role of BS in LT has been investigated by different studies; however, the type of BS and timing of LT need further investigation.
Methods
A systemic review examining the role of BS in LT patients was performed. After selection of the studies based on inclusion and exclusion criteria, data extraction was performed by two independent reviewers. Primary outcomes included patient and graft survival.
Results
From a total of 2374 articles, five met the prefined criteria. One hundred sixty-two patients had both BS + LT and 1426 underwent LT alone. The percentage of female patients in the BS + LT and LT cohorts was 75% and 35% respectively. The average age in BS + LT and LT cohorts was 43.05 vs. 56.22 years respectively. Patients undergoing BS had comparable outcomes in terms of overall patient survival, graft survival and post-operative morbidity compared to LT alone. When comparing BMI change in patients with prior versus simultaneous BS + LT, no significant difference was found.
Conclusion
BS and LT patients achieve comparable outcomes to general LT populations. Further studies examining simultaneous BS + LT are needed to answer questions concerning patient selection and timing of surgery.
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Su R, Wei X, Wei Q, Lu D, Lin Z, Wang S, Shao C, Xu X. Extrahepatic organs in the development of non-alcoholic fatty liver disease in liver transplant patients. Hepatobiliary Surg Nutr 2022; 11:400-411. [PMID: 35693397 PMCID: PMC9186206 DOI: 10.21037/hbsn-20-568] [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: 07/02/2020] [Accepted: 09/23/2020] [Indexed: 08/30/2023]
Abstract
BACKGROUND AND OBJECTIVE Non-alcoholic fatty liver disease (NAFLD) is highly prevalent in patients who undergo liver transplantation (LT). Whereas there is huge data on NAFLD, little is known about NAFLD in LT. In this review, we aim to explore extrahepatic organs and their potential mechanisms in the development of NAFLD in LT patients and discuss current limitations in preclinical and clinical scenarios with suggestions for future study. METHODS The following keywords, such as NAFLD, NASH, liver transplant, therapy, pathogenesis and biomarkers, were set for literature retrieval. The articles which were published articles in English till 25th June 2020 in PubMed database were included, and there is no limit for the study design type. KEY CONTENT AND FINDINGS Following LT, there are significant shifts in the microbiota and farnesoid X receptor may be a potential therapeutic target for NAFLD in LT settings. The roles of probiotics and diet on NALFD remain inconclusive in LT background. Nevertheless, the adipokines and cytokines disorder and local insulin resistance of adipose tissue may contribute to NAFLD process. Bariatric surgeries are promising in controlling de novo and recurrent NAFLD with significant reduction in abdominal adipose tissue, despite the optimal timing is inconclusive in LT cases. Furthermore, circumstantial evidence indicates that miRNA-33a may function as a mediator bridging sarcopenia and NAFLD of post-LT. β-Hydroxy-β-Methyl-Butyrate treatment could improve muscle status in graft recipients and shows protective potential for NAFLD in LT settings. CONCLUSIONS Gut, adipose tissue and muscle are intricately intertwined in promoting NAFLD in LT cases. Further animal studies are needed to deepen our understanding of mechanisms in multi-organ crosstalk. High quality clinical trials are warrant for making guidelines and developing management strategies on NAFLD after LT.
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Affiliation(s)
- Renyi Su
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
- NHC Key Laboratory of Combined Multi-Organ Transplantation, Hangzhou, China
| | - Xuyong Wei
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qiang Wei
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Di Lu
- NHC Key Laboratory of Combined Multi-Organ Transplantation, Hangzhou, China
| | - Zuyuan Lin
- NHC Key Laboratory of Combined Multi-Organ Transplantation, Hangzhou, China
| | - Shuo Wang
- Department of Hepatobiliary and Pancreatic Surgery, Shu Lan Hospital, Shu Lan International Medical College of Zhejiang Shuren University, Hangzhou, China
| | - Chuxiao Shao
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Lishui Hospital, Zhejiang University School of Medicine, Lishui, China
| | - Xiao Xu
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
- NHC Key Laboratory of Combined Multi-Organ Transplantation, Hangzhou, China
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Brodosi L, Petta S, Petroni ML, Marchesini G, Morelli MC. Management of Diabetes in Candidates for Liver Transplantation and in Transplant Recipients. Transplantation 2022; 106:462-478. [PMID: 34172646 PMCID: PMC9904447 DOI: 10.1097/tp.0000000000003867] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 05/31/2021] [Accepted: 06/02/2021] [Indexed: 11/25/2022]
Abstract
Diabetes is common in patients waitlisted for liver transplantation because of end-stage liver disease or hepatocellular cancer as well as in posttransplant phase (posttransplantation diabetes mellitus). In both conditions, the presence of diabetes severely affects disease burden and long-term clinical outcomes; careful monitoring and appropriate treatment are pivotal to reduce cardiovascular events and graft and recipients' death. We thoroughly reviewed the epidemiology of diabetes in the transplant setting and the different therapeutic options, from lifestyle intervention to antidiabetic drug use-including the most recent drug classes available-and to the inclusion of bariatric surgery in the treatment cascade. In waitlisted patients, the old paradigm that insulin should be the treatment of choice in the presence of severe liver dysfunction is no longer valid; novel antidiabetic agents may provide adequate glucose control without the risk of hypoglycemia, also offering cardiovascular protection. The same evidence applies to the posttransplant phase, where oral or injectable noninsulin agents should be considered to treat patients to target, limiting the impact of disease on daily living, without interaction with immunosuppressive regimens. The increasing prevalence of liver disease of metabolic origin (nonalcoholic fatty liver) among liver transplant candidates, also having a higher risk of noncirrhotic hepatocellular cancer, is likely to accelerate the acceptance of new drugs and invasive procedures, as suggested by international guidelines. Intensive lifestyle intervention programs remain however mandatory, both before and after transplantation. Achievement of adequate control is mandatory to increase candidacy, to prevent delisting, and to improve long-term outcomes.
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Affiliation(s)
- Lucia Brodosi
- IRCCS – Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater University, Bologna, Italy
| | - Salvatore Petta
- Section of Gastroenterology and Hepatology, PROMISE, University of Palermo, Palermo, Italy
| | - Maria L. Petroni
- IRCCS – Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater University, Bologna, Italy
| | - Giulio Marchesini
- IRCCS – Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater University, Bologna, Italy
| | - Maria C. Morelli
- IRCCS – Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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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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Mendoza YP, Becchetti C, Watt KD, Berzigotti A. Risks and Rewards of Bariatric Surgery in Advanced Chronic Liver Diseases. Semin Liver Dis 2021; 41:448-460. [PMID: 34243194 PMCID: PMC8492193 DOI: 10.1055/s-0041-1731705] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The burden of obesity and metabolic syndrome has determined a sharp increase in bariatric surgery (BS) procedures, which lead to marked weight loss, improved metabolic syndrome, reduced cardiovascular risk, and even improvement in nonalcoholic steatohepatitis (NASH). Despite these promising results, BS in patients with chronic liver disease can rarely lead to worsening of liver function, progression to cirrhosis and its complications, and even liver transplantation. On the other hand, since obesity in patients with cirrhosis is a major cofactor for progression to a decompensated stage of the disease and a risk factor for hepatocellular carcinoma, BS has been used to achieve weight loss in this population. In this review, we critically analyze the existing data on outcomes of BS in patients with cirrhosis and the possible mechanisms leading to fibrosis progression and worsening liver function in patients undergoing BS. Finally, we propose a set of measures that could be taken to improve the multidisciplinary management of liver disease in patients undergoing BS, including early recognition of malnutrition and alcohol misuse.
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Affiliation(s)
- Yuly P. Mendoza
- Department of Hepatology, University Clinic for Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland,Hepatology, Department of Biomedical Research, University of Bern, Switzerland,Graduate School for Health Sciences (GHS), University of Bern, Switzerland
| | - Chiara Becchetti
- Department of Hepatology, University Clinic for Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland,Hepatology, Department of Biomedical Research, University of Bern, Switzerland
| | - Kymberly D. Watt
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Annalisa Berzigotti
- Department of Hepatology, University Clinic for Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland,Hepatology, Department of Biomedical Research, University of Bern, Switzerland,Address for correspondence Annalisa Berzigotti, MD, PhD Hepatology, University Clinic for Visceral Surgery and Medicine, Bern University Hospital, University of BernSwitzerland, Murtenstrasse 35, 3008 BerneSwitzerland
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Sharpton SR, Terrault NA, Tavakol MM, Posselt AM. Sleeve gastrectomy prior to liver transplantation is superior to medical weight loss in reducing posttransplant metabolic complications. Am J Transplant 2021; 21:3324-3332. [PMID: 33780129 DOI: 10.1111/ajt.16583] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 02/23/2021] [Accepted: 03/15/2021] [Indexed: 01/25/2023]
Abstract
Strategies to optimize the management of obesity-related metabolic complications after liver transplantation (LT) are needed. We examined the effect of pre-LT sleeve gastrectomy (SG), as compared to medical weight loss (MWL), on post-LT outcomes. This is a cohort study of adults (≥18 years) with medically complicated obesity who were eligible for pre-LT SG and underwent LT from January 1, 2006 to June 1, 2016. Logistic regression models evaluated the association of SG on post-LT diabetes and hypertension, defined as new-onset or progressive disease post-LT. Cox regression models evaluated the association of SG on recurrent and de novo nonalcoholic fatty liver disease (NAFLD). Among 70 LT recipients who were eligible for pre-LT SG, 14 (20%) underwent SG and 56 (80%) underwent MWL only. Mean follow-up was 5.2 years post-LT. The SG cohort sustained higher % total body weight loss at 3 years post-LT (28.9% vs. 5.4%, p < .001). In multivariable analyses, SG was associated with significantly lower risk of post-LT diabetes (OR 0.04, 95% CI 0.00-0.41, p = .01), hypertension (OR 0.15, 95% CI 0.04-0.67, p = .01), and recurrent and de novo NAFLD (HR 0.19, 95% CI 0.04-0.91, p = .04). When compared to MWL, SG resulted in sustained weight loss and significantly lower risk of diabetes, hypertension, and recurrent and de novo NAFLD post-LT.
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Affiliation(s)
- Suzanne R Sharpton
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, California, USA
| | - Norah A Terrault
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine at the University of Southern California, Los Angeles, California, USA
| | - Mehdi M Tavakol
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Andrew M Posselt
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
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Hsu CS, Kao JH. Management of non-alcoholic fatty liver disease in patients with sarcopenia. Expert Opin Pharmacother 2021; 23:221-233. [PMID: 34541964 DOI: 10.1080/14656566.2021.1978978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Sarcopenia usually occurs with aging, sedentary lifestyle, unhealthy dietary habits, and chronic disorders pathophysiologically and bi-directionally linked to obesity and nonalcoholic fatty liver disease (NAFLD). Because of the global increase in aging and obesity populations, patients with concomitant sarcopenia and NAFLD are common, accompanied by various disorders relevant to obesity and sarcopenia, with across-the-board impact on socio-economic and public health life worldwide. Therefore, developing effective and practical management of these patients has become a pressing clinical issue. AREAS COVERED The authors searched literature from PubMed and Ovid MEDLINE up until Feb 2020. Emerging data on the management of sarcopenia and nonalcoholic fatty liver disease were examined and discussed. EXPERT OPINION Although NAFLD in patients with sarcopenia has become a critical problem worldwide, we still don't know much about the management of such patients. Based on theoretical speculations, we can recommend lifestyle intervention, including diet control with adequate protein intake, exercise intervention, and weight reduction as the mainstay of management at the first stage. More studies are needed in the future to identify the most suitable treatment and solve this important problem.
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Affiliation(s)
- Ching-Sheng Hsu
- Division of Gastroenterology, Department of Internal Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chia-Yi, Taiwan.,School of Post-Baccalaureate Chinese Medicine, Tzu Chi University, Taiwan, Hualien, Taiwan
| | - Jia-Horng Kao
- Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan.,Department of Internal Medicine, National Taiwan University College of Medicine and National Taiwan University Hospital, Taipei, Taiwan.,Department of Medical Research, National Taiwan University College of Medicine and National Taiwan University Hospital, Taipei, Taiwan.,Hepatitis Research Center, National Taiwan University College of Medicine and National Taiwan University Hospital, Taipei, Taiwan
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13
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Iannelli A, Bulsei J, Debs T, Tran A, Lazzati A, Gugenheim J, Anty R, Petrucciani N, Fontas E. Clinical and Economic Impact of Previous Bariatric Surgery on Liver Transplantation: a Nationwide, Population-Based Retrospective Study. Obes Surg 2021; 32:55-63. [PMID: 34499293 PMCID: PMC8752569 DOI: 10.1007/s11695-021-05684-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 08/18/2021] [Accepted: 08/20/2021] [Indexed: 02/06/2023]
Abstract
Purpose The present study aims to determine the impact of previous bariatric surgery (BS) on the length of hospital stay; the incidence of mortality, re-transplantation, and re-hospitalization after LT; and the related economic costs, through the analysis of the French National Health Insurance Information System. Materials and Methods All patients aged > 18 years who underwent LT in France in the period from 2010 to 2019 were included. Thirty-nine patients with a history of BS (study group) were compared with 1798 obese patients without previous BS (control group). Results At the time of LT, patients with a history of BS were significantly younger than those of the control group and had lower Charlson comorbidity index. Female sex was significantly more represented in the study group. No significant differences were detected between the two groups regarding the postoperative mortality rate after LT (10.3% in the study group versus 8.0% in the control group), long-term mortality (0.038 versus 0.029 person-year of follow-up, respectively), re-transplantation (adjusted hazard ratio (HR) = 2.15, p = 0.2437), re-hospitalization (adjusted analysis, IRR = 0.93, p = 0.7517), and costs of LT hospitalization (73,515 € in the study group versus 65,878 € in the control group). After 1:2 propensity score matching, the duration of the LT hospital stay was significantly longer in the study group (58.3 versus 33.4 days, p = 0.0172). Conclusion No significant differences were detected between patients with previous BS versus obese patients without history of BS undergoing LT concerning the rates of mortality, re-LT, re-hospitalization after LT, and costs of hospitalization and re-hospitalizations. Graphical abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s11695-021-05684-4.
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Affiliation(s)
- Antonio Iannelli
- Université Côte D'Azur, Nice, France. .,Centre Hospitalier Universitaire de Nice - Digestive Surgery and Liver Transplantation Unit, Archet 2 Hospital, 151 Route Saint Antoine de Ginestière, BP 3079, Nice Cedex 3, France. .,Inserm, U1065, Team 8 "Hepatic Complications of Obesity and Alcohol", Nice, France.
| | - Julie Bulsei
- Centre Hospitalier Universitaire de Nice, Department of Clinical Research and Innovation, Université Côte D'Azur, Nice, France
| | - Tarek Debs
- Centre Hospitalier Universitaire de Nice - Digestive Surgery and Liver Transplantation Unit, Archet 2 Hospital, 151 Route Saint Antoine de Ginestière, BP 3079, Nice Cedex 3, France
| | - Albert Tran
- Université Côte D'Azur, Nice, France.,Centre Hospitalier Universitaire de Nice - Digestive Surgery and Liver Transplantation Unit, Archet 2 Hospital, 151 Route Saint Antoine de Ginestière, BP 3079, Nice Cedex 3, France.,Inserm, U1065, Team 8 "Hepatic Complications of Obesity and Alcohol", Nice, France
| | - Andrea Lazzati
- Department of General Surgery, Centre Hospitalier Intercommunal de Creteil, Creteil, France
| | - Jean Gugenheim
- Université Côte D'Azur, Nice, France.,Centre Hospitalier Universitaire de Nice - Digestive Surgery and Liver Transplantation Unit, Archet 2 Hospital, 151 Route Saint Antoine de Ginestière, BP 3079, Nice Cedex 3, France.,Inserm, U1065, Team 8 "Hepatic Complications of Obesity and Alcohol", Nice, France
| | - Rodolphe Anty
- Université Côte D'Azur, Nice, France.,Centre Hospitalier Universitaire de Nice - Digestive Surgery and Liver Transplantation Unit, Archet 2 Hospital, 151 Route Saint Antoine de Ginestière, BP 3079, Nice Cedex 3, France.,Inserm, U1065, Team 8 "Hepatic Complications of Obesity and Alcohol", Nice, France
| | - Niccolo Petrucciani
- Centre Hospitalier Universitaire de Nice - Digestive Surgery and Liver Transplantation Unit, Archet 2 Hospital, 151 Route Saint Antoine de Ginestière, BP 3079, Nice Cedex 3, France.,Department of Medical and Surgical Sciences and Translational Medicine, Faculty of Medicine and Psychology, St. Andrea Hospital, Sapienza University, Rome, Italy
| | - Eric Fontas
- Centre Hospitalier Universitaire de Nice, Department of Clinical Research and Innovation, Université Côte D'Azur, Nice, France
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14
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Watt KD, Heimbach JK, Rizk M, Jaruvongvanich P, Sanchez W, Port J, Venkatesh SK, Bamlet H, Tiedtke K, Malhi H, Acosta Cardenas A, Grothe K, Clark M, Mundi MS, Abu Dayyeh BK. Efficacy and Safety of Endoscopic Balloon Placement for Weight Loss in Patients With Cirrhosis Awaiting Liver Transplantation. Liver Transpl 2021; 27:1239-1247. [PMID: 33866660 DOI: 10.1002/lt.26074] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 03/25/2021] [Accepted: 04/02/2021] [Indexed: 12/13/2022]
Abstract
The efficacy and safety of a fluid-filled intragastric balloon (IGB) for weight loss in patients with cirrhosis on the liver transplantation (LT) waiting list is unknown. We enrolled stable compensated patients with body mass index >35 kg/m2 and on the waiting list for IGB placement endoscopically for a maximum of 6 months. A total of 8 patients (7 men) aged mean ± SD, 56 ± 4.6 years with Model for End-Stage Liver Disease-sodium (MELD-Na) scores 14.1 ± 3.4 experienced weight reduction (146 ± 22.2 kg versus 127 ± 21.6 kg [P = 0.005] with IGB in place and 130 ± 24.6 kg [P = 0.014] at 6 months), with a total body weight loss of 12.2% ± 8.8% with IGBs in place and 10.9% ± 8.9% at 6 months. Body fat decreased from 48.6% ± 5.8% to 40.6% ± 6.4% (P = 0.001) and lean mass increased from 51.3% ± 6% to 59.4% ± 6.4% (P = 0.001). No change in MELD-Na scores occurred (P = 0.770). Early balloon retrieval was attributed to accommodative symptoms (n = 2) and liver decompensation (n = 1). Mallory Weiss tears (n = 3), but no portal hypertensive bleeding, occurred. Liver decompensation and/or hepatocellular carcinoma (HCC) developed in 3 patients. A total of 4 patients with LT ± sleeve gastrectomy maintained overall weight loss. Of 4 patients who did not receive transplants, 2 experienced weight regain. IGB results in short-term weight loss in patients with cirrhosis awaiting LT, with body fat loss without lean mass loss. Adverse effects were common. Decompensation and HCC did occur, with uncertainty of the relation to weight loss, and thus careful patient selection and close follow-up are required.
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Affiliation(s)
- Kymberly D Watt
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | | | - Monika Rizk
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | | | - William Sanchez
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - John Port
- Department of Radiology, Mayo Clinic, Rochester, MN
| | | | - Heather Bamlet
- Department of Clinical Nutrition, Mayo Clinic, Rochester, MN
| | - Kathryn Tiedtke
- Department of Clinical Nutrition, Mayo Clinic, Rochester, MN
| | - Harmeet Malhi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | | | - Karen Grothe
- Department of Psychology, Mayo Clinic, Rochester, MN
| | - Matthew Clark
- Department of Psychology, Mayo Clinic, Rochester, MN
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15
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Lefere S, Onghena L, Vanlander A, van Nieuwenhove Y, Devisscher L, Geerts A. Bariatric surgery and the liver-Mechanisms, benefits, and risks. Obes Rev 2021; 22:e13294. [PMID: 34002452 DOI: 10.1111/obr.13294] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 05/01/2021] [Accepted: 05/03/2021] [Indexed: 12/18/2022]
Abstract
The prevalence of obesity and metabolic diseases such as type 2 diabetes and nonalcoholic fatty liver disease (NAFLD) has risen dramatically over the past decades. At present, bariatric surgery is the most effective treatment for this global health problem, through effects on food intake, gut hormone secretion, metabolic signaling pathways, and adipose tissue dysfunction. The liver occupies a central role in carbohydrate, protein, and lipid metabolism. Notably, a reduction in hepatic fat content and an improvement in hepatic insulin resistance are among the earliest beneficial effects of bariatric surgery, which has therefore emerged as an attractive treatment option for NAFLD. However, as the scope and popularity of weight loss surgery have expanded, new questions have arisen regarding its safety in patients with liver cirrhosis, the outcome of liver transplantation in patients with a history of bariatric surgery, and over incidental reports of liver failure following surgery. Studies in humans and rodents have also linked bariatric surgery to an increased risk of developing alcohol use disorder, a major risk factor for liver disease. This review integrates data from clinical and translational research to delineate both the beneficial impact of bariatric surgery on the liver and the potential risks involved.
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Affiliation(s)
- Sander Lefere
- Hepatology Research Unit, Department of Internal Medicine and Pediatrics, Liver Research Center Ghent, Ghent University, Ghent, Belgium.,Gut-Liver Immunopharmacology Unit, Department of Basic and Applied Medical Sciences, Liver Research Center Ghent, Ghent University, Ghent, Belgium
| | - Louis Onghena
- Department of Gastrointestinal Surgery, Ghent University, Ghent, Belgium.,Department of General and Hepatobiliary Surgery, Liver Transplantation Service, Ghent University, Ghent, Belgium
| | - Aude Vanlander
- Department of General and Hepatobiliary Surgery, Liver Transplantation Service, Ghent University, Ghent, Belgium
| | | | - Lindsey Devisscher
- Gut-Liver Immunopharmacology Unit, Department of Basic and Applied Medical Sciences, Liver Research Center Ghent, Ghent University, Ghent, Belgium
| | - Anja Geerts
- Hepatology Research Unit, Department of Internal Medicine and Pediatrics, Liver Research Center Ghent, Ghent University, Ghent, Belgium
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16
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Clinical Impact of Antecedent Bariatric Surgery on Liver Transplant Outcomes: A Retrospective Matched Case-control Study. Transplantation 2021; 105:1280-1284. [PMID: 32590608 DOI: 10.1097/tp.0000000000003378] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Bariatric surgery (BS) may be associated with significant malabsorption and nutritional deficiencies. METHODS Between March 1987 and January 2017, we performed 922 liver transplants (LT) at our institution; 33 had antecedent BS. We matched the BS cohort to LT recipients without BS (1:3 matching) based on exact matching for gender and cancer and inverse variance matching for age, LT body mass index, MELD score, and transplant date. RESULTS We analyzed outcomes in 132 LT recipients (33 BS; 99 non-BS). The BS cohort comprised 26 (79%) women with a mean age of 52.4 years. The BS procedures included 20 Roux-en-Y gastric bypass (61%), 6 jejunoileal bypass (18%), 3 gastric band (9%), 2 sleeve gastrectomy (6%), and 1 duodenal switch (3%). The primary indications for LT listing were alcoholic cirrhosis (9; 27%), nonalcoholic steatohepatitis (7; 21%), hepatitis C (8; 24%), and hepatocellular carcinoma (3; 9%). At LT, body mass index for the BS cohort was 29.6, and MELD was 24. Compared with matched controls, BS recipients did not have longer LT length of hospital stay (17.8 versus 15.7 d, P = 0.71), longer intensive care unit length of stay (5.3 versus 4.1 d, P = 0.16), or higher 30-day complication rate (76% versus 85%, P = 0.43). Overall patient survival was similar (1- and 3-y survival was 90.1% and 75.9% for BS; 90.9% and 76.4% for non-BS, P = 0.34). CONCLUSIONS A history of BS does not portend a deleterious effect on LT outcomes.
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17
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Finotti M, Romano M, Auricchio P, Scopelliti M, Brizzolari M, Grossi U, Piccino M, Benvenuti S, Morana G, Cillo U, Zanus G. Target Therapies for NASH/NAFLD: From the Molecular Aspect to the Pharmacological and Surgical Alternatives. J Pers Med 2021; 11:499. [PMID: 34199535 PMCID: PMC8229090 DOI: 10.3390/jpm11060499] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 05/25/2021] [Accepted: 05/28/2021] [Indexed: 02/06/2023] Open
Abstract
Non-alcoholic fatty liver disease represents an increasing cause of chronic hepatic disease in recent years. This condition usually arises in patients with multiple comorbidities, the so-called metabolic syndrome. The therapeutic options are multiple, ranging from lifestyle modifications, pharmacological options, to liver transplantation in selected cases. The choice of the most beneficial one and their interactions can be challenging. It is mandatory to stratify the patients according to the severity of their disease to tailor the available treatments. In our contribution, we review the most recent pharmacological target therapies, the role of bariatric surgery, and the impact of liver transplantation on the NAFLD outcome.
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Affiliation(s)
- Michele Finotti
- 4th Surgery Unit, Regional Hospital Treviso, DISCOG, University of Padua, 31100 Padua, Italy; (M.R.); (M.S.); (M.B.); (U.G.); (M.P.); (G.Z.)
| | - Maurizio Romano
- 4th Surgery Unit, Regional Hospital Treviso, DISCOG, University of Padua, 31100 Padua, Italy; (M.R.); (M.S.); (M.B.); (U.G.); (M.P.); (G.Z.)
| | - Pasquale Auricchio
- Hepatobiliary Surgery and Liver Transplantation Unit, DISCOG, University of Padua, 35121 Padua, Italy; (P.A.); (U.C.)
| | - Michele Scopelliti
- 4th Surgery Unit, Regional Hospital Treviso, DISCOG, University of Padua, 31100 Padua, Italy; (M.R.); (M.S.); (M.B.); (U.G.); (M.P.); (G.Z.)
| | - Marco Brizzolari
- 4th Surgery Unit, Regional Hospital Treviso, DISCOG, University of Padua, 31100 Padua, Italy; (M.R.); (M.S.); (M.B.); (U.G.); (M.P.); (G.Z.)
| | - Ugo Grossi
- 4th Surgery Unit, Regional Hospital Treviso, DISCOG, University of Padua, 31100 Padua, Italy; (M.R.); (M.S.); (M.B.); (U.G.); (M.P.); (G.Z.)
| | - Marco Piccino
- 4th Surgery Unit, Regional Hospital Treviso, DISCOG, University of Padua, 31100 Padua, Italy; (M.R.); (M.S.); (M.B.); (U.G.); (M.P.); (G.Z.)
| | - Stefano Benvenuti
- Gastroenterology Unit (IV), Cà Foncello Regional Hospital, 31100 Treviso, Italy;
| | - Giovanni Morana
- Division of Radiology, Treviso Regional Hospital, 31100 Treviso, Italy;
| | - Umberto Cillo
- Hepatobiliary Surgery and Liver Transplantation Unit, DISCOG, University of Padua, 35121 Padua, Italy; (P.A.); (U.C.)
| | - Giacomo Zanus
- 4th Surgery Unit, Regional Hospital Treviso, DISCOG, University of Padua, 31100 Padua, Italy; (M.R.); (M.S.); (M.B.); (U.G.); (M.P.); (G.Z.)
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18
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Heimbach JK, Taner T. What Is Past Is Prologue. Transplantation 2021; 105:1169-1170. [PMID: 32590609 DOI: 10.1097/tp.0000000000003379] [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]
Affiliation(s)
- Julie K Heimbach
- Division of Transplant Surgery, Mayo Clinic College of Medicine, Rochester, MN
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19
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Pomenti S, Mehta S, Guo A, Wattacheril J. Bariatric Surgery in the Peritransplant Period. Clin Liver Dis (Hoboken) 2021; 17:282-291. [PMID: 33968390 PMCID: PMC8087907 DOI: 10.1002/cld.1052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 10/04/2020] [Accepted: 10/11/2020] [Indexed: 02/04/2023] Open
Affiliation(s)
- Sydney Pomenti
- Division of Digestive and Liver DiseasesDepartment of MedicineColumbia University Irving Medical Center
| | - Sanket Mehta
- Columbia University Vagelos College of Physicians and Surgeons
| | - Averill Guo
- Department of MedicineColumbia University Irving Medical CenterNew YorkNY
| | - Julia Wattacheril
- Division of Digestive and Liver DiseasesDepartment of MedicineColumbia University Irving Medical Center
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20
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AGA Clinical Practice Update on Bariatric Surgery in Cirrhosis: Expert Review. Clin Gastroenterol Hepatol 2021; 19:436-445. [PMID: 33393473 PMCID: PMC8872426 DOI: 10.1016/j.cgh.2020.10.034] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 10/19/2020] [Accepted: 10/20/2020] [Indexed: 02/07/2023]
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21
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Abstract
Obesity is increasing in prevalence in liver transplant candidates and recipients. The rise in liver transplantation for nonalcoholic steatohepatitis reflects this increase. Management of obesity in liver transplant candidates can be challenging due to the presence of decompensated cirrhosis and sarcopenia. Obesity may increase peritransplant morbidity but does not have an impact on long-term post-transplant survival. Bariatric surgery may be a feasible option in select patients before, during, or after liver transplantation. Use of weight loss drugs and/or endoscopic therapies for obesity management ultimately may play a role in liver transplant patients, but more research is needed to determine safety.
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22
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Kriss M, Biggins SW. Evaluation and selection of the liver transplant candidate: updates on a dynamic and evolving process. Curr Opin Organ Transplant 2021; 26:52-61. [PMID: 33278150 DOI: 10.1097/mot.0000000000000829] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Although conceptually unchanged, the evaluation and selection of the liver transplant candidate has seen significant recent advances. Expanding criteria for transplant candidacy, improved diagnostics for risk stratification and advances in prognostic models have paralleled recent changes in allocation and distribution that require us to revisit core concepts of candidate evaluation and selection while recognizing its now dynamic and continuous nature. RECENT FINDINGS The liver transplant evaluation revolves around three interrelated themes: candidate selection, donor selection and transplant outcome. Introduction of dynamic frailty indices, bariatric surgery at the time of liver transplant in obese patients and improved therapies and prognostic tools for hepatobiliary malignancy have transformed candidate selection. Advances in hypothermic organ preservation have improved outcomes in marginal donor organs. Combined with expansion of hepatitis C virus positive and split donor organs, donor selection has become an integral part of candidate evaluation. In addition, with liver transplant for acute alcohol-related hepatitis now widely performed and increasing recognition of acute-on-chronic liver failure, selection of critically ill patients is refining tools to balance futility versus utility. SUMMARY Advances in liver transplant candidate evaluation continue to transform the evaluation process and require continued incorporation into our clinical practice amidst a dynamic backdrop of demographic and policy changes.
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Affiliation(s)
- Michael Kriss
- Division of Gastroenterology & Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Scott W Biggins
- Division of Gastroenterology and Hepatology
- Center for Liver Investigation Fostering discovEry (C-LIFE), University of Washington, Seattle, Washington, USA
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23
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Riveros S, Inzunza M, Crovari F, Briceño E, Achurra P, Quezada N. Laparoscopic Revisional Conversion of Sleeve Gastrectomy to Gastric Bypass After Liver Transplantation. Obes Surg 2021; 31:2305-2307. [PMID: 33415610 DOI: 10.1007/s11695-020-05203-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 12/22/2020] [Accepted: 12/29/2020] [Indexed: 11/24/2022]
Affiliation(s)
- Sergio Riveros
- Department of Digestive Surgery, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Martín Inzunza
- School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Fernando Crovari
- Department of Digestive Surgery, Faculty of Medicine, Pontificia Universidad Católica de Chile, 362 Diagonal Paraguay, 4th Floor, Office 410, Santiago, Chile
| | - Eduardo Briceño
- Department of Digestive Surgery, Faculty of Medicine, Pontificia Universidad Católica de Chile, 362 Diagonal Paraguay, 4th Floor, Office 410, Santiago, Chile
| | - Pablo Achurra
- Department of Digestive Surgery, Faculty of Medicine, Pontificia Universidad Católica de Chile, 362 Diagonal Paraguay, 4th Floor, Office 410, Santiago, Chile
| | - Nicolás Quezada
- Department of Digestive Surgery, Faculty of Medicine, Pontificia Universidad Católica de Chile, 362 Diagonal Paraguay, 4th Floor, Office 410, Santiago, Chile.
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24
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Gill MG, Majumdar A. Metabolic associated fatty liver disease: Addressing a new era in liver transplantation. World J Hepatol 2020; 12:1168-1181. [PMID: 33442446 PMCID: PMC7772736 DOI: 10.4254/wjh.v12.i12.1168] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 10/08/2020] [Accepted: 10/26/2020] [Indexed: 02/06/2023] Open
Abstract
Metabolic associated fatty liver disease (MAFLD), previously termed non-alcoholic fatty liver disease, is the leading global cause of liver disease and is fast becoming the most common indication for liver transplantation. The recent change in nomenclature to MAFLD refocuses the conceptualisation of this disease entity to its metabolic underpinnings and may help to spur a paradigm shift in the approach to its management, including in the setting of liver transplantation. Patients with MAFLD present significant challenges in the pre-, peri- and post-transplant settings, largely due to the presence of medical comorbidities that include obesity, metabolic syndrome and cardiovascular risk factors. As the community prevalence of MAFLD increases concurrently with the obesity epidemic, donor liver steatosis is also a current and future concern. This review outlines current epidemiology, nomenclature, management issues and outcomes of liver transplantation in patients with MAFLD.
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Affiliation(s)
- Madeleine G Gill
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney 2050, New South Wales, Australia
| | - Avik Majumdar
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney 2050, New South Wales, Australia
- Central Clinical School, The University of Sydney, Sydney 2050, New South Wales, Australia
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25
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Frey S, Santarpia L, Chassang M, Schneck AS, Anty R, Gugenheim J, Iannelli A. A case report of liver transplantation following a biliopancreatic diversion: A friendly cohabitation? TRANSPLANTATION REPORTS 2020. [DOI: 10.1016/j.tpr.2020.100067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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26
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Lopez-Lopez V, Ruiz-Manzanera JJ, Eshmuminov D, Lehmann K, Schneider M, von der Groeben M, de Angulo DR, Gajownik U, Pons JA, Sánchez-Bueno F, Robles-Campos R, Ramírez-Romero P. Are We Ready for Bariatric Surgery in a Liver Transplant Program? A Meta-Analysis. Obes Surg 2020; 31:1214-1222. [PMID: 33225408 DOI: 10.1007/s11695-020-05118-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 10/30/2020] [Accepted: 11/10/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Obesity-related non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) are two main causes of end-stage liver disease requiring a liver transplantation. Studies exploring bariatric surgery in the liver transplantation setting have increased in recent years; however, a systematic analysis of the topic is lacking to date. This meta-analysis was conducted to explore the perioperative and long-term outcomes of bariatric surgery in obese patients undergoing liver transplantation. METHODS Electronic databases were systematically searched for studies reporting bariatric surgery in patients undergoing liver transplantation. The primary outcomes were postoperative complications and mortality. We also extracted data about excess weight loss, body mass index, and improvement of comorbidities after bariatric surgery. RESULTS A total of 96 patients from 8 articles were included. Bariatric surgery-related morbidity and mortality rates were 37% (95% CI 0.27-0.47) and 0.6% (95% CI 0.02-0.13), respectively. Body mass index at 24 months was 31.02 (95% CI 25.96-36.09) with a percentage excess weight loss at 12 and 24 months of 44.08 (95% CI 27.90-60.26) and 49.2 (95% CI 31.89-66.66), respectively. After bariatric surgery, rates of improvement of arterial hypertension and diabetes mellitus were 61% (95% CI 0.45-0.75) and 45% (95% CI 0.25-0.66), respectively. In most patients, bariatric surgery was performed after liver transplant and the most frequent technique was sleeve gastrectomy. CONCLUSIONS Bariatric surgery can be performed safely in the setting of liver transplantation resulting in improvement of obesity-related comorbidities. The optimal timing and technique require further studies.
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Affiliation(s)
- Víctor Lopez-Lopez
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de la Arrixaca, IMIB-ARRIXACA, Murcia, Spain.
| | - Juan José Ruiz-Manzanera
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de la Arrixaca, IMIB-ARRIXACA, Murcia, Spain
| | - Dilmurodjon Eshmuminov
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary (HPB) Center, University Hospital Zurich, Zurich, Switzerland
| | - Kuno Lehmann
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary (HPB) Center, University Hospital Zurich, Zurich, Switzerland
| | - Marcel Schneider
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary (HPB) Center, University Hospital Zurich, Zurich, Switzerland
| | | | - David Ruiz de Angulo
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de la Arrixaca, IMIB-ARRIXACA, Murcia, Spain
| | - Ursula Gajownik
- Department of Hepatology, Clinic and University Hospital Virgen de la Arrixaca, IMIB-ARRIXACA, Murcia, Spain
| | - Jose Antonio Pons
- Department of Hepatology, Clinic and University Hospital Virgen de la Arrixaca, IMIB-ARRIXACA, Murcia, Spain
| | - Francisco Sánchez-Bueno
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de la Arrixaca, IMIB-ARRIXACA, Murcia, Spain
| | - Ricardo Robles-Campos
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de la Arrixaca, IMIB-ARRIXACA, Murcia, Spain
| | - Pablo Ramírez-Romero
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de la Arrixaca, IMIB-ARRIXACA, Murcia, Spain
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Lee Y, Tian C, Lovrics O, Soon MS, Doumouras AG, Anvari M, Hong D. Bariatric surgery before, during, and after liver transplantation: a systematic review and meta-analysis. Surg Obes Relat Dis 2020; 16:1336-1347. [DOI: 10.1016/j.soard.2020.05.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/09/2020] [Accepted: 05/13/2020] [Indexed: 12/18/2022]
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Quezada N, Maturana G, Irarrázaval MJ, Muñoz R, Morales S, Achurra P, Azócar C, Crovari F. Bariatric Surgery in Cirrhotic Patients: a Matched Case-Control Study. Obes Surg 2020; 30:4724-4731. [PMID: 32808168 DOI: 10.1007/s11695-020-04929-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/06/2020] [Accepted: 08/11/2020] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Laparoscopic bariatric surgery (LBS) in liver end-stage organ disease has been proven to improve organ function and patients' symptoms. A series of LBS in patients with cirrhosis have shown good results in weight loss, but increased risk of complications. Current literature is based on clinical series. This paper aims to compare LBS (69% gastric bypass) between patients with cirrhosis and without cirrhosis. METHODS We conducted a retrospective 1:3 matched case-control study including bariatric patients with cirrhosis and without cirrhosis. Demographics, operative variables, postoperative complications, long-term weight loss, and comorbidity resolution were compared between groups. RESULTS Sixteen Child A patients were included in the patients with cirrhosis (PC) group and 48 in patients without cirrhosis (control) group. Mean age was 50 years; preoperative BMI was 39 ± 6.8 kg/m2. Laparoscopic gastric bypass and laparoscopic sleeve gastrectomy were performed in 69% and 31%, respectively. Follow-up was 81% at 2 years for both groups. PC group had a higher rate of overall (31% vs. 6%; p < 0.05) and severe (Clavien-Dindo ≥ III; 13% vs. 0%; p = 0.013) complications than that of the control group. Mean %EWL of PC at 2 years of follow-up was 84.9%, without differences compared with that of the control group (83.1%). Comorbidity remission in PC was 14%, 50%, and 85% for hypertension, type 2 diabetes, and dyslipidemia, respectively. Patients without cirrhosis had a higher resolution rate of hypertension (65% vs. 14%, p = 0.03). CONCLUSION LBS is effective for weight loss and comorbidity resolution in patients with obesity and Child A liver cirrhosis. However, these results are accompanied by significantly increased risk of complications.
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Affiliation(s)
- Nicolás Quezada
- Department of Digestive Surgery, Upper Gastrointestinal and Hernia surgery division, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile, 362 Diagonal Paraguay, 4th Floor - Office 410, Santiago, Región Metropolitana, Chile.
| | - Gregorio Maturana
- Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile, Avda. Libertador Bernando O'Higgins 340, Santiago, Chile
| | - María Jesús Irarrázaval
- Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile, Avda. Libertador Bernando O'Higgins 340, Santiago, Chile
| | - Rodrigo Muñoz
- Department of Digestive Surgery, Upper Gastrointestinal and Hernia surgery division, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile, 362 Diagonal Paraguay, 4th Floor - Office 410, Santiago, Región Metropolitana, Chile
| | - Sebastián Morales
- Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile, Avda. Libertador Bernando O'Higgins 340, Santiago, Chile
| | - Pablo Achurra
- Department of Digestive Surgery, Upper Gastrointestinal and Hernia surgery division, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile, 362 Diagonal Paraguay, 4th Floor - Office 410, Santiago, Región Metropolitana, Chile
| | - Cristóbal Azócar
- Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile, Avda. Libertador Bernando O'Higgins 340, Santiago, Chile
| | - Fernando Crovari
- Department of Digestive Surgery, Upper Gastrointestinal and Hernia surgery division, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile, 362 Diagonal Paraguay, 4th Floor - Office 410, Santiago, Región Metropolitana, Chile
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Romano DN, Smith NK, Vasisko CR, Zerillo J, Sakai T. Abdominal Organ Transplantation: Noteworthy Literature in 2019. Semin Cardiothorac Vasc Anesth 2020; 24:159-174. [PMID: 32342763 DOI: 10.1177/1089253220920497] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In the year 2019, we identified and screened over 400 peer-reviewed publications on pancreatic transplantation, over 200 on intestinal transplantation, and over 1900 on kidney transplantation. The liver transplantation section focuses on and features selected articles among 70 clinical trials published in 2019. This review highlights noteworthy literature pertinent to anesthesiologists and critical care physicians caring for patients undergoing abdominal organ transplantation. We explore a broad range of topics, including risks for and prediction of perioperative complications, updated indications for transplantation, recommendations on perioperative management, including Enhanced Recovery After Surgery programs, and topics relevant to optimization of patient and graft outcomes and survival.
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Affiliation(s)
- Diana N Romano
- The Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Natalie K Smith
- The Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Corey R Vasisko
- The Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Jeron Zerillo
- The Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Tetsuro Sakai
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Chandrakumaran A, Siddiqui MS. Implications of Nonalcoholic Steatohepatitis as the Cause of End-Stage Liver Disease Before and After Liver Transplant. Gastroenterol Clin North Am 2020; 49:165-178. [PMID: 32033762 PMCID: PMC7008719 DOI: 10.1016/j.gtc.2019.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease. Nonalcoholic steatohepatitis (NASH) is the clinically aggressive variant of NAFLD and has a propensity for fibrosis progression and cirrhosis. The prevalence of NAFLD and NASH is projected to increase rapidly in the near future and dramatically add to the already substantial health care burden. Cirrhosis and end-stage liver disease resulting from NASH is now the fastest growing indication for liver transplant (LT) in the United States. Patients with NASH cirrhosis have higher prevalence of cardiometabolic diseases. Following LT, recurrence of NAFLD and NASH is common.
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Affiliation(s)
| | - Mohammad Shadab Siddiqui
- Department of Internal Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University, Richmond, VA 23298-0341, USA.
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Samji NS, Heda R, Satapathy SK. Peri-transplant management of nonalcoholic fatty liver disease in liver transplant candidates . Transl Gastroenterol Hepatol 2020; 5:10. [PMID: 32190778 DOI: 10.21037/tgh.2019.09.09] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Accepted: 09/23/2019] [Indexed: 12/12/2022] Open
Abstract
The incidence of non-alcoholic fatty liver disease (NAFLD) is rapidly growing, affecting 25% of the world population. Non-alcoholic steatohepatitis (NASH) is the most severe form of NAFLD and affects 1.5% to 6.5% of the world population. Its rising incidence will make end-stage liver disease (ESLD) due to NASH the number one indication for liver transplantation (LT) in the next 10 to 20 years, overtaking Hepatitis C. Patients with NASH also have a high prevalence of associated comorbidities such as type 2 diabetes, obesity, metabolic syndrome, cardiovascular disease, and chronic kidney disease (CKD), which must be adequately managed during the peritransplant period for optimal post-transplant outcomes. The focus of this review article is to provide a comprehensive overview of the unique challenges these patients present in the peritransplant period, which comprises the pre-transplant, intraoperative, and immediate postoperative periods.
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Affiliation(s)
- Naga Swetha Samji
- Tennova Cleveland Hospital, 2305 Chambliss Ave NW, Cleveland, TN, USA
| | - Rajiv Heda
- University of Tennessee Health Science Center, College of Medicine, Memphis, TN, USA
| | - Sanjaya K Satapathy
- Division of Hepatology and Sandra Atlas Bass Center for Liver Diseases, Northwell Health, Manhasset, NY, USA
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Obesity in the Liver Transplant Setting. Nutrients 2019; 11:nu11112552. [PMID: 31652761 PMCID: PMC6893648 DOI: 10.3390/nu11112552] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 09/23/2019] [Accepted: 09/25/2019] [Indexed: 12/12/2022] Open
Abstract
The obesity epidemic has resulted in an increased prevalence of obesity in liver transplant (LT) candidates and in non-alcoholic fatty liver disease (NAFLD) becoming the fastest growing indication for LT. LT teams will be dealing with obesity in the coming years, and it is necessary for them to recognize some key aspects surrounding the LT in obese patients. Obesity by itself should not be considered a contraindication for LT, but it should make LT teams pay special attention to cardiovascular risk assessment, in order to properly select candidates for LT. Obese patients may be at increased risk of perioperative respiratory and infectious complications, and it is necessary to establish preventive strategies. Data on patient and graft survival after LT are controversial and scarce, especially for long-term outcomes, but morbid obesity may adversely affect these outcomes, particularly in NAFLD. The backbone of obesity treatment should be diet and exercise, whilst being careful not to precipitate or worsen frailty and sarcopenia. Bariatric surgery is an alternative for treatment of obesity, and the ideal timing regarding LT is still unknown. Sleeve gastrectomy is probably the procedure that has the best evidence in LT because it offers a good balance between safety and efficacy.
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Selzner N, Grant D. Obesity: Weighty Challenges for the Liver Transplant Community. Liver Transpl 2019; 25:531-532. [PMID: 30811874 DOI: 10.1002/lt.25437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 02/22/2019] [Indexed: 01/12/2023]
Affiliation(s)
- Nazia Selzner
- Multi-Organ Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - David Grant
- Multi-Organ Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Asrani SK, Hasse J. Reply. Liver Transpl 2019; 25:516. [PMID: 30582771 DOI: 10.1002/lt.25399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 11/29/2018] [Indexed: 01/13/2023]
Affiliation(s)
- Sumeet K Asrani
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Jeanette Hasse
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
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Sharpton SR, Terrault NA. Prior Bariatric Surgery in Liver Transplant Candidates: Unforeseen Consequences? Liver Transpl 2019; 25:203-204. [PMID: 30585696 PMCID: PMC6548714 DOI: 10.1002/lt.25401] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 12/19/2018] [Indexed: 01/03/2023]
Affiliation(s)
- Suzanne R. Sharpton
- Department of Medicine, Division of Gastroenterology University of California San Francisco San Francisco CA
| | - Norah A. Terrault
- Department of Medicine, Division of Gastroenterology University of California San Francisco San Francisco CA
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