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Zhang X, Dutton M, Liu R, Ali AA, Sherbeny F. Deep Learning-Based Survival Analysis for Receiving a Steatotic Donor Liver Versus Waiting for a Standard Liver. Transplant Proc 2023; 55:2436-2443. [PMID: 37872066 DOI: 10.1016/j.transproceed.2023.09.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 08/12/2023] [Accepted: 09/22/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND An emerging strategy to expand the donor pool is the use of a steatotic donor liver (SDLs; ≥ 30% macrosteatosis on biopsy). With the obesity epidemic and prevalence of nonalcoholic fatty liver disease, SDLs have been reported in 59% of all deceased donors. Many potential candidates need to decide whether to accept an SDL offer or remain on the waitlist for a nonsteatotic donor liver (non-SDL). The objective of this study was to compare the survival of accepting an SDL vs using a non-SDL after waiting various times. METHODS Using data from the United States' organ procurement and transplantation network, deep survival learning predictive models were built to compare post-decision survival after accepting an SDL vs waiting for a non-SDL. The comparison subjects contain simulated 20,000 different scenarios of a candidate either accepting an SDL immediately or receiving a non-SDL after waiting various times. The research variables were selected using the LASSO-Cox and Random Survival Forest (RSF) models. The Cox proportional hazards and RSF models were also comparatively included for survival prediction. In addition, personalized survival curves for randomly selected candidates were generated. RESULT Deep survival learning outperformed Cox proportional hazards and RSF in predicting the survival of liver transplants. Among the simulations, 25% to 30% of scenarios demonstrated a higher 3-year survival post-decision for candidates accepting an SDL than waiting and receiving a non-SDL. The difference was only 1.43% in 3-year survival post-decision between accepting an SDL and waiting 260 days (mean waitlist time) for a non-SDL. As the number of days on the waitlist increases, the difference in survival between accepting SDLs and waiting for non-SDLs decreases. CONCLUSIONS Appropriately used SDLs could expand the donor pool and relieve the candidates' unmet need for donor livers, which presents long-term survival benefits for recipients.
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Affiliation(s)
- Xiao Zhang
- Economic, Social and Administrative Pharmacy, College of Pharmacy and Pharmaceutical Sciences, Florida A&M University, Tallahassee, Florida.
| | - Matthew Dutton
- Economic, Social and Administrative Pharmacy, College of Pharmacy and Pharmaceutical Sciences, Florida A&M University, Tallahassee, Florida
| | - Rongjie Liu
- Department of Statistics, Florida State University, Tallahassee, Florida
| | - Askal A Ali
- Economic, Social and Administrative Pharmacy, College of Pharmacy and Pharmaceutical Sciences, Florida A&M University, Tallahassee, Florida
| | - Fatimah Sherbeny
- Economic, Social and Administrative Pharmacy, College of Pharmacy and Pharmaceutical Sciences, Florida A&M University, Tallahassee, Florida
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2
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Yong JN, Lim WH, Ng CH, Tan DJH, Xiao J, Tay PWL, Lin SY, Syn N, Chew N, Nah B, Dan YY, Huang DQ, Tan EXX, Sanyal AJ, Noureddin M, Siddiqui MS, Muthiah MD. Outcomes of Nonalcoholic Steatohepatitis After Liver Transplantation: An Updated Meta-Analysis and Systematic Review. Clin Gastroenterol Hepatol 2023; 21:45-54.e6. [PMID: 34801743 DOI: 10.1016/j.cgh.2021.11.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 11/05/2021] [Accepted: 11/10/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Nonalcoholic steatohepatitis (NASH) is the fastest growing indication of liver transplantation (LT) and is projected to be the leading cause of LT in the near future. The systemic pathogenesis of NASH increases risks of adverse clinical outcomes in patients with NASH receiving LT. Thus, this study aimed to conduct a time-dependent survival analysis between LT recipients with and without NASH using hazard ratios. METHODS A search was conducted on Medline and Embase databases for articles relating to LT outcomes for NASH recipients. A survival analysis was conducted of hazard ratios using the DerSimonian and Laird random-effects model with meta-regression. To account for censoring, survival data were reconstructed from published Kaplan-Meier curves and pooled to derive more accurate hazard estimates and all-cause mortality in NASH patients after LT. Pairwise meta-analysis was conducted to analyze secondary outcomes. RESULTS Fifteen studies involving 119,327 LT recipients were included in our analysis with a prevalence of NASH of 20.2% (95% CI, 12.9-30.2). The pooled 1-year, 5-year, and 10-year all-cause mortality in NASH patients after LT were 12.5%, 24.4%, and 37.9%, respectively. Overall survival was comparable between LT recipients for NASH vs non-NASH (hazard ratio, 0.910; 95% CI, 0.760 to 1.10; P = .34). Meta-regression showed that a higher model for end-stage liver disease score was associated with significantly worse overall survival in NASH compared with non-NASH after LT (95% CI, -0.0856 to -0.0181; P = .0026). CONCLUSIONS This study shows that patients undergoing LT for NASH cirrhosis have comparable complication rates, overall survival, and graft survival compared with non-NASH patients, although close monitoring may be indicated for those with higher model for end-stage liver disease scores.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Nicholas Chew
- Department of Cardiology, National University Heart Centre
| | - Benjamin Nah
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore; National University Centre for Organ Transplantation, National University Health System, Singapore
| | - Yock Young Dan
- Yong Loo Lin School of Medicine; Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore; National University Centre for Organ Transplantation, National University Health System, Singapore; Cancer Science Institute of Singapore, National University of Singapore, Singapore
| | - Daniel Q Huang
- Yong Loo Lin School of Medicine; Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore; National University Centre for Organ Transplantation, National University Health System, Singapore
| | - Eunice Xiang Xuan Tan
- Yong Loo Lin School of Medicine; Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore; National University Centre for Organ Transplantation, National University Health System, Singapore
| | - Arun J Sanyal
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Mazen Noureddin
- Cedars-Sinai Fatty Liver Program, Division of Digestive and Liver Diseases, Department of Medicine, Comprehensive Transplant Center, Cedars-Sinai Medical Centre, Los Angeles, California
| | - Mohammad Shadab Siddiqui
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Mark D Muthiah
- Yong Loo Lin School of Medicine; Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore; National University Centre for Organ Transplantation, National University Health System, Singapore.
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Saeed N, Glass LM, Habbal H, Mahmood A, Sengstock D, Saini SD, Tincopa MA. Primary care and referring physician perspectives on non-alcoholic fatty liver disease management: a nationwide survey. Therap Adv Gastroenterol 2021; 14:17562848211042200. [PMID: 34567270 PMCID: PMC8460969 DOI: 10.1177/17562848211042200] [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] [Received: 03/19/2021] [Accepted: 07/12/2021] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION The optimal approach to screening and risk stratification for non-alcoholic fatty liver disease is challenging given disease burden and variable progression. The aim of this study was to assess primary care physician and referring physician practice patterns regarding non-alcoholic fatty liver disease. METHODS An anonymous nationwide survey was administered to primary care physicians, endocrinologists, and cardiologists in a: (1) tertiary academic hospital, (2) community hospital, and (3) the American College of Physicians Insider Panel. Survey domains assessed non-alcoholic fatty liver disease knowledge, recommendations for screening, risk stratification, treatment, and referral patterns. RESULTS A total of 440 providers completed the survey (35.2% completion rate; N = 82 academic hospital, N = 21 community hospital, N = 337 American College of Physicians). Half were male (51.7%), 78% from internal medicine, with 5% subspecialists. Providers were knowledgeable regarding prevalence and risk factors for non-alcoholic fatty liver disease. 58% would support screening for non-alcoholic fatty liver disease and used liver enzymes to do so. Only 22.5% used serum biomarkers and 23% used transient elastography for risk stratification. Primary reason for referral was advanced fibrosis/cirrhosis. 80% reported barriers to treating non-alcoholic fatty liver disease. There was no consistent diet recommended. CONCLUSION In this nationwide survey, we demonstrated that while overall disease knowledge was good, there was an important disconnect between current guidelines and real-world clinical practice. There is also significant heterogeneity in practice patterns for first-line therapy of non-alcoholic fatty liver disease and the majority of provider's report barriers to treating non-alcoholic fatty liver disease. These findings highlight the potential role for reevaluating screening and risk stratification recommendations in primary care to better align with needs in that setting.
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Affiliation(s)
- Naba Saeed
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Kentucky, Lexington, KY, USA,Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Lisa M. Glass
- Department of Internal Medicine, John D. Dingell VA Medical Center, Detroit, MI, USA,Department of Internal Medicine, Wayne State University, Detroit, MI, USA
| | - Heba Habbal
- Department of Internal Medicine, Beaumont Health, Dearborn, MI, USA
| | - Asad Mahmood
- Department of Internal Medicine, John D. Dingell VA Medical Center, Detroit, MI, USA,Department of Internal Medicine, Wayne State University, Detroit, MI, USA
| | - David Sengstock
- Department of Internal Medicine, Beaumont Health, Dearborn, MI, USA
| | - Sameer D. Saini
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA,VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
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Liu Y, Zen Y, Yeh MM. Steatohepatitis-Like Changes in Hepatocellular Adenoma. Am J Clin Pathol 2020; 154:525-532. [PMID: 32561910 DOI: 10.1093/ajcp/aqaa075] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVES Our aim was to investigate the frequency of steatohepatitic morphology in hepatocellular adenoma (HCA) and correlate with its clinical parameters and risk factors underlying nonalcoholic fatty liver disease (NAFLD) or nonalcoholic steatohepatitis (NASH). METHODS We examined a series of 41 liver resection specimens diagnosed with HCA for steatohepatitic changes. Background nonneoplastic liver was also evaluated. Clinical records were reviewed for risk factors of NAFLD/NASH. RESULTS Six steatohepatitic HCAs (SH-HCAs) were identified, with an overall prevalence of six (14.6%) of 41, of which three were HNF1α inactivated and three were inflammatory, but none were β-catenin mutated. Five of the six patients with SH-HCA had at least one known risk factor for NAFLD/NASH, including obesity (n = 4; 66.7%), diabetes (n = 5; 83.3%), hypertension (n = 3; 50%), and dyslipidemia (n = 1; 16.7%). Compared with the patients without SH-HCA, the patients with SH-HCA had a higher frequency of type 2 diabetes, obesity, and hypertension. Of the six SH-HCAs, background nonneoplastic liver showed significant steatosis in three (50%) cases and steatohepatitic changes in one (16.7%) case. CONCLUSIONS Approximately 15% of HCAs in our series demonstrated steatohepatitic changes. Lack of such morphology in β-catenin-mutated subtype suggests reassurance in this morphologic variant of HCA.
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Affiliation(s)
- Yongjun Liu
- Department of Pathology, University of Washington School of Medicine, Seattle
- Department of Pathology, University of Wisconsin School of Medicine and Public Health, Madison
| | - Yoh Zen
- Department of Diagnostic Pathology, Kobe University Graduate School of Medicine, Kobe, Japan
- Institute of Liver Studies, King’s College Hospital & King’s College London, London, UK
| | - Matthew M Yeh
- Department of Pathology, University of Washington School of Medicine, Seattle
- Department of Medicine, University of Washington School of Medicine, Seattle
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Jackson KR, Bowring MG, Holscher C, Haugen CE, Long JJ, Liyanage L, Massie AB, Ottmann S, Philosophe B, Cameron AM, Segev DL, Garonzik-Wang J. Outcomes After Declining a Steatotic Donor Liver for Liver Transplant Candidates in the United States. Transplantation 2020; 104:1612-1618. [PMID: 32732838 PMCID: PMC8547552 DOI: 10.1097/tp.0000000000003062] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Steatotic donor livers (SDLs, ≥30% macrosteatosis on biopsy) are often declined, as they are associated with a higher risk of graft loss, even though candidates may wait an indefinite time for a subsequent organ offer. We sought to quantify outcomes for transplant candidates who declined or accepted an SDL offer. METHODS We used Scientific Registry of Transplant Recipients offer data from 2009 to 2015 to compare outcomes of 759 candidates who accepted an SDL to 13 362 matched controls who declined and followed candidates from the date of decision (decline or accept) until death or end of study period. We used a competing risk framework to understand the natural history of candidates who declined and Cox regression to compare postdecision survival after declining versus accepting (ie, what could have happened if candidates who declined had instead accepted). RESULTS Among those who declined an SDL, only 53.1% of candidates were subsequently transplanted, 23.8% died, and 19.4% were removed from the waitlist. Candidates who accepted had a brief perioperative risk period within the first month posttransplant (adjusted hazard ratio [aHR]: 2.493.494.89, P < 0.001), but a 62% lower mortality risk (aHR: 0.310.380.46, P < 0.001) beyond this. Although the long-term survival benefit of acceptance did not vary by candidate model for end-stage liver disease (MELD), the short-term risk period did. MELD 6-21 candidates who accepted an SDL had a 7.88-fold higher mortality risk (aHR: 4.807.8812.93, P < 0.001) in the first month posttransplant, whereas MELD 35-40 candidates had a 68% lower mortality risk (aHR: 0.110.320.90, P = 0.03). CONCLUSIONS Appropriately selected SDLs can decrease wait time and provide substantial long-term survival benefit for liver transplant candidates.
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Affiliation(s)
- Kyle R. Jackson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Mary G. Bowring
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Courtenay Holscher
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Christine E. Haugen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jane J. Long
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Luckmini Liyanage
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Allan B. Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Shane Ottmann
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Benjamin Philosophe
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andrew M. Cameron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
- Scientific Registry of Transplant Recipients, Minneapolis, MN
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6
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Konerman MA, Jones JC, Harrison SA. Pharmacotherapy for NASH: Current and emerging. J Hepatol 2018; 68:362-375. [PMID: 29122694 DOI: 10.1016/j.jhep.2017.10.015] [Citation(s) in RCA: 208] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 10/16/2017] [Accepted: 10/17/2017] [Indexed: 12/13/2022]
Abstract
Non-alcoholic fatty liver disease (NAFLD) has become one of the most prominent forms of chronic liver disease worldwide, reflecting the epidemic of global obesity. Those with the progressive variant of NAFLD, non-alcoholic steatohepatitis (NASH), are at significantly increased risk of multisystem morbidity and mortality. However, there are currently no approved pharmacologic therapies for NASH. Given the disease burden, there is an important unmet need for pharmacologic treatment options for this patient population. The underlying pathophysiologic mechanisms that contribute to the development and progression of NAFLD and NASH are complex and reflected by the myriad of therapies, with different targets, currently under investigation. In broad strokes, drug development has focused on modulation of metabolic pathways, inflammatory cascades, and/or mechanisms impacting fibrosis. Although much progress has been made in enhancing our understanding of NAFLD pathogenesis, development of pharmacologic treatments has been hindered by challenges in clinical trial enrollment and complexities in clinical trial design. The compounds in phase IIa have provided promising results in terms of potential benefits on various aspects of histopathology. Agents in later stages of development have shown fairly modest results in terms of reduction of hepatic steatosis, necroinflammation and fibrosis. If longer term safety and efficacy are established among heterogeneous cohorts, these medications may help mitigate potential morbidity and mortality for this burgeoning patient population.
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Affiliation(s)
- Monica A Konerman
- University of Michigan, Department of Internal Medicine, Division of Gastroenterology and Hepatology, Ann Arbor, MI, USA
| | | | - Stephen A Harrison
- University of Oxford, Radcliffe Department of Medicine, Oxford, United Kingdom.
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7
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Satapathy SK, Jiang Y, Eason JD, Kedia SK, Wong E, Singal AK, Tolley EA, Hathaway D, Nair S, Vanatta JM. Cardiovascular mortality among liver transplant recipients with nonalcoholic steatohepatitis in the United States-a retrospective study. Transpl Int 2017. [DOI: 10.1111/tri.13001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Sanjaya K. Satapathy
- Department of Surgery; Methodist University Hospital Transplant Institute; University of Tennessee Health Sciences Center; Memphis TN USA
| | - Yu Jiang
- Division of Epidemiology, Biostatistics, & Environmental Health; School of Public Health; University of Memphis; Memphis TN USA
| | - James D. Eason
- Department of Surgery; Methodist University Hospital Transplant Institute; University of Tennessee Health Sciences Center; Memphis TN USA
| | - Satish K. Kedia
- Division of Social and Behavioral Sciences; School of Public Health; University of Memphis; Memphis TN USA
| | - Emily Wong
- Department of Surgery; Methodist University Hospital Transplant Institute; University of Tennessee Health Sciences Center; Memphis TN USA
| | - Ashwani K. Singal
- Division of Gastroenterology and Hepatology; Department of Medicine; University of Alabama at Birmingham; Birmingham AL USA
| | - Elizabeth A. Tolley
- Department of Biostatistics and Epidemiology; University of Tennessee Health Sciences Center; Memphis TN USA
| | - Donna Hathaway
- Department of Advanced Practice and Doctoral Studies; University of Tennessee Health Sciences Center; Memphis TN USA
| | - Satheesh Nair
- Department of Surgery; Methodist University Hospital Transplant Institute; University of Tennessee Health Sciences Center; Memphis TN USA
| | - Jason M. Vanatta
- Department of Surgery; Methodist University Hospital Transplant Institute; University of Tennessee Health Sciences Center; Memphis TN USA
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8
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Soto-Gutierrez A, Gough A, Vernetti LA, Taylor DL, Monga SP. Pre-clinical and clinical investigations of metabolic zonation in liver diseases: The potential of microphysiology systems. Exp Biol Med (Maywood) 2017; 242:1605-1616. [PMID: 28467181 DOI: 10.1177/1535370217707731] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The establishment of metabolic zonation within a hepatic lobule ascribes specific functions to hepatocytes based on unique, location-dependent gene expression patterns. Recently, there have been significant developments in the field of metabolic liver zonation. A little over a decade ago, the role of β-catenin signaling was identified as a key regulator of gene expression and function in pericentral hepatocytes. Since then, additional molecules have been identified that regulate the pattern of Wnt/β-catenin signaling within a lobule and determine gene expression and function in other hepatic zones. Currently, the molecular basis of metabolic zonation in the liver appears to be a 'push and pull' between signaling pathways. Such compartmentalization not only provides an efficient assembly line for hepatocyte functions but also can account for restricting the initial hepatic damage and pathology from some hepatotoxic drugs to specific zones, possibly enabling effective regeneration and restitution responses from unaffected cells. Careful analysis and experimentation have also revealed that many pathological conditions in the liver lobule are spatially heterogeneous. We will review current research efforts that have focused on examination of the role and regulation of such mechanisms of hepatocyte adaptation and repair. We will discuss how the pathological organ-specific microenvironment affects cell signaling and metabolic liver zonation, especially in steatosis, viral hepatitis, and hepatocellular carcinoma. We will discuss how the use of new human microphysiological platforms will lead to a better understanding of liver disease progression, diagnosis, and therapies. In conclusion, we aim to provide insights into the role and regulation of metabolic zonation and function using traditional and innovative approaches. Impact statement Liver zonation of oxygen tension along the liver sinusoids has been identified as a critical liver microenvironment that impacts specific liver functions such as intermediary metabolism of amino acids, lipids, and carbohydrates, detoxification of xenobiotics and as sites for initiation of liver diseases. To date, most information on the role of zonation in liver disease including, non-alcoholic fatty liver disease (NAFLD), non-alcoholic steatohepatitis (NASH), cirrhosis, and hepatocellular carcinoma (HCC) have been obtained from animal models. It is now possible to complement animal studies with human liver, microphysiology systems (MPS) containing induced pluripotent stem cells engineered to create disease models where it is also possible to control the in vitro liver oxygen microenvironment to define the role of zonation on the mechanism(s) of disease progression. The field now has the tools to investigate human liver disease progression, diagnosis, and therapeutic development.
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Affiliation(s)
| | - Albert Gough
- 2 Drug Discovery Institute, University of Pittsburgh, Pittsburgh, PA 15260, USA.,3 Department of Computational & Systems Biology, University of Pittsburgh, Pittsburgh, PA 15260, USA
| | - Lawrence A Vernetti
- 2 Drug Discovery Institute, University of Pittsburgh, Pittsburgh, PA 15260, USA.,3 Department of Computational & Systems Biology, University of Pittsburgh, Pittsburgh, PA 15260, USA
| | - D L Taylor
- 2 Drug Discovery Institute, University of Pittsburgh, Pittsburgh, PA 15260, USA.,3 Department of Computational & Systems Biology, University of Pittsburgh, Pittsburgh, PA 15260, USA.,4 Cancer Institute, University of Pittsburgh, Pittsburgh PA 15232, USA
| | - Satdarshan P Monga
- 1 Department of Pathology, University of Pittsburgh, Pittsburgh, PA 15260, USA.,5 Department of Medicine, Pittsburgh, University of Pittsburgh, PA 15260, USA
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Abstract
Non-alcoholic fatty liver disease (NAFLD) comprises a disease spectrum ranging from benign hepatic steatosis to non-alcoholic steatohepatitis with inflammation (NASH) and liver cirrhosis. NAFLD is now recognised as the hepatic manifestation of the metabolic syndrome. Simple steatosis is benign, whereas NASH can progress to cirrhosis with its resultant complications. Liver biopsy remains the gold standard in the diagnosis of NAFLD/NASH. Lifestyle and dietary modifications to achieve sustained weight loss is the cornerstone of NAFLD/NASH treatment.
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Affiliation(s)
- Hui-Hui Tan
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Jason Pik-Eu Chang
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
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10
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Liver Transplantation for NASH-Related Cirrhosis. CURRENT SURGERY REPORTS 2015. [DOI: 10.1007/s40137-015-0101-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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11
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Conzen KD, Vachharajani N, Collins KM, Anderson CD, Lin Y, Wellen JR, Shenoy S, Lowell JA, Doyle MBM, Chapman WC. Morbid obesity in liver transplant recipients adversely affects longterm graft and patient survival in a single-institution analysis. HPB (Oxford) 2015; 17:251-7. [PMID: 25322849 PMCID: PMC4333787 DOI: 10.1111/hpb.12340] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 08/18/2014] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The effects of obesity in liver transplantation remain controversial. Earlier institutional data demonstrated no significant difference in postoperative complications or 1-year mortality. This study was conducted to test the hypothesis that obesity alone has minimal effect on longterm graft and overall survival. METHODS A retrospective, single-institution analysis of outcomes in patients submitted to primary adult orthotopic liver transplantation was conducted using data for the period from 1 January 2002 to 31 December 2012. Recipients were divided into six groups by pre-transplant body mass index (BMI), comprising those with BMIs of <18.0 kg/m(2) , 18.0-24.9 kg/m(2) , 25.0-29.9 kg/m(2) , 30.0-35.0 kg/m(2) , 35.1-40.0 kg/m(2) and >40 kg/m(2) , respectively. Pre- and post-transplant parameters were compared. A P-value of <0.05 was considered to indicate statistical significance. Independent predictors of patient and graft survival were determined using multivariate analysis. RESULTS A total of 785 patients met the study inclusion criteria. A BMI of >35 kg/m(2) was associated with non-alcoholic steatohepatitis (NASH) cirrhosis (P < 0.0001), higher Model for End-stage Liver Disease (MELD) score, and longer wait times for transplant (P = 0.002). There were no differences in operative time, intensive care unit or hospital length of stay, or perioperative complications. Graft and patient survival at intervals up to 3 years were similar between groups. Compared with non-obese recipients, recipients with a BMI of >40 kg/m(2) showed significantly reduced 5-year graft (49.0% versus 75.8%; P < 0.02) and patient (51.3% versus 78.8%; P < 0.01) survival. CONCLUSIONS Obesity increasingly impacts outcomes in liver transplantation. Although the present data are limited by the fact that they were sourced from a single institution, they suggest that morbid obesity adversely affects longterm outcomes despite providing similar short-term results. Further analysis is indicated to identify risk factors for poor outcomes in morbidly obese patients.
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Affiliation(s)
- Kendra D Conzen
- Section of Abdominal Transplantation, Department of Surgery, School of Medicine, Washington University in St LouisSt Louis, MO, USA
| | - Neeta Vachharajani
- Section of Abdominal Transplantation, Department of Surgery, School of Medicine, Washington University in St LouisSt Louis, MO, USA
| | - Kelly M Collins
- Section of Abdominal Transplantation, Department of Surgery, School of Medicine, Washington University in St LouisSt Louis, MO, USA
| | - Christopher D Anderson
- Division of Transplant Surgery, Department of Surgery, University of Mississippi Medical CenterJackson, MS, USA
| | - Yiing Lin
- Section of Abdominal Transplantation, Department of Surgery, School of Medicine, Washington University in St LouisSt Louis, MO, USA
| | - Jason R Wellen
- Section of Abdominal Transplantation, Department of Surgery, School of Medicine, Washington University in St LouisSt Louis, MO, USA
| | - Surendra Shenoy
- Section of Abdominal Transplantation, Department of Surgery, School of Medicine, Washington University in St LouisSt Louis, MO, USA
| | - Jeffrey A Lowell
- Section of Abdominal Transplantation, Department of Surgery, School of Medicine, Washington University in St LouisSt Louis, MO, USA
| | - M B Majella Doyle
- Section of Abdominal Transplantation, Department of Surgery, School of Medicine, Washington University in St LouisSt Louis, MO, USA
| | - William C Chapman
- Section of Abdominal Transplantation, Department of Surgery, School of Medicine, Washington University in St LouisSt Louis, MO, USA,Correspondence, William C. Chapman, Section of Abdominal Transplantation, Department of Surgery, Washington University, 660 South Euclid Avenue, Box 8109, St Louis, MO 63110, USA. Tel: + 1 314 362 2538. Fax: + 1 314 361 4197. E-mail:
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12
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Tanaka T, Sugawara Y, Tamura S, Kaneko J, Takazawa Y, Aoki T, Hasegawa K, Sakamoto Y, Yamashiki N, Kokudo N. Living donor liver transplantation for non-alcoholic steatohepatitis: A single center experience. Hepatol Res 2014; 44:E3-E10. [PMID: 23834427 DOI: 10.1111/hepr.12200] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 06/18/2013] [Accepted: 07/03/2013] [Indexed: 12/13/2022]
Abstract
AIM The number of patients referred for liver transplantation (LT) with non-alcoholic steatohepatitis (NASH) continues to increase, but information about living donor liver transplantation (LDLT) for NASH is scarce. We conducted this study to document the details of LDLT for NASH in a Japanese LT center. METHODS Among all LDLT recipients in our institution from March 1996 to March 2013 (n = 425), we identified seven patients that underwent LDLT for NASH. RESULTS Of all the seven recipients, most of the patients (86%) were obese. The median follow-up period post-LDLT was 5.3 years. All were alive at the last follow-up. Recurrent NASH was detected in one patient (14%), and no recurrent hepatic steatosis was detected among the remaining six recipients on prospectively performed ultrasonography. No significant comorbidities were observed following donor surgery among the respective living donors during the follow-up period. We also retrospectively reviewed 22 patients with NASH-related end-stage liver disease (ESLD) who were evaluated but rejected for LDLT during the same period. The reasons for rejection for LDLT were presumably associated with the nature of NAFLD/NASH in either potential recipients or donors. CONCLUSION The post-transplant outcome of LDLT for NASH-related ESLD in our institution was feasible, although the sample size was small. Further studies in a larger patient cohort are warranted to investigate the long-term outcome of LDLT for NASH, both for recipients and living donors.
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Affiliation(s)
- Tomohiro Tanaka
- Organ Transplantation Service, The University of Tokyo Hospital, Tokyo, Japan
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Kim H, Lee K, Lee KW, Yi NJ, Lee HW, Hong G, Choi Y, You T, Suh SW, Jang JJ, Suh KS. Histologically proven non-alcoholic fatty liver disease and clinically related factors in recipients after liver transplantation. Clin Transplant 2014; 28:521-9. [PMID: 24579874 DOI: 10.1111/ctr.12343] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2014] [Indexed: 12/27/2022]
Abstract
Non-alcoholic fatty liver disease (NAFLD) affects a substantial proportion of the world population, and its prevalence has been increasing. The study was aimed at evaluating the prevalence and peri-transplant risk factors for post-liver transplantation (LT) NAFLD. A retrospective review was performed for adult recipients who underwent late protocol biopsy (>1 yr after LT) between August 2010 and December 2012. Hepatic steatosis was reviewed and graded by hepatopathologists, and the peri-transplant factors were analyzed for relationships to histologically proven NAFLD. Total 166 biopsies had been performed in 156 recipients. NAFLD was present in 27.1% at a mean period of 35.4 months between LT and biopsy, moderate and severe steatosis (≥33%) consisted of 28.9%. In multivariate analysis, pre-LT alcoholic cirrhosis (odds ratio [OR] 8.031, p = 0.003), obesity at biopsy (OR 3.873, p = 0.001), and preexisting donor graft steatosis (OR 3.147, p = 0.022) were significant risk factors for post-LT NAFLD. In conclusion, NAFLD represented a considerable portion of recipients, but this prevalence was not higher than those for general population. Three risk factors were significantly related to post-LT NAFLD, and recipients with those factors should be monitored for NAFLD. Furthermore, possible progression to non-alcoholic steatohepatitis (NASH) or fibrosis and metabolic syndrome should be considered in future studies.
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Affiliation(s)
- Hyeyoung Kim
- Department of Surgery, College of Medicine, Seoul National University, Seoul, Republic of Korea; Department of Surgery, Seoul Metropolitan Government, Boramae Medical Center, Seoul National University, Seoul, Republic of Korea
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Outcomes of liver transplantation for nonalcoholic steatohepatitis: a systematic review and meta-analysis. Clin Gastroenterol Hepatol 2014; 12:394-402.e1. [PMID: 24076414 DOI: 10.1016/j.cgh.2013.09.023] [Citation(s) in RCA: 132] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Revised: 09/01/2013] [Accepted: 09/04/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Little is known about outcomes of patients with nonalcoholic steatohepatitis (NASH) who receive liver transplants. We performed a systematic review and meta-analysis to estimate post-transplant outcomes, survival times, and mortality from cardiovascular complications, sepsis, and graft failure in these patients. METHODS We searched PubMed and EMBASE, and Cochrane library and Web of Science databases for studies published through September 1, 2012 of patients who underwent liver transplantation for NASH or nonalcoholic fatty liver disease (NAFLD). All original studies from single institutions that reported outcomes of patients with or without NASH after liver transplantation were considered. Odds ratios (ORs) were calculated for patients with NASH, compared with patients without NASH; 95% confidence intervals (CIs) were calculated. RESULTS Our final analysis included 9 publications, on 717 patients with NASH and 3520 without, all of whom underwent liver transplantation. Similar proportions of patients with and without NASH who received liver transplants survived for 1, 3, and 5 years (OR for survival of patient with NASH 1 year after liver transplantation, 0.77; 95% CI, 0.59-1.00; P = .05; OR 3 years after transplantation, 0.97; 95% CI, 0.67-1.40; P = .86; OR 5 years after transplantation, 1.09; 95% CI, 0.77-1.56; P = .63). Patients with NASH had a greater risk of death from cardiovascular complications after liver transplantation (OR, 1.65; 95% CI, 1.01-2.70; P = .05) and from sepsis (OR, 1.71; 95% CI, 1.17-2.50; P = .006). However, patients with NASH were at lower risk of graft failure compared with patients without NASH (OR, 0.21; 95% CI, 0.05-0.89; P = .03). CONCLUSIONS Similar proportions of patients with and without NASH survive for 1, 3, and 5 years after liver transplantation. However, patients with NASH are more likely to die from cardiovascular complications or sepsis. More attention and careful consideration are therefore required in selecting patients with NASH for liver transplantation, along with aggressive management of cardiovascular complications and sepsis after transplantation.
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Weight loss interventions for morbidly obese patients with compensated cirrhosis: a Markov decision analysis model. J Gastrointest Surg 2014; 18:321-7. [PMID: 23918085 DOI: 10.1007/s11605-013-2298-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2013] [Accepted: 07/16/2013] [Indexed: 01/31/2023]
Abstract
Many transplant centers require that patients maintain a BMI below 40 kg/m(2) in order to be eligible for listing, rendering many morbidly obese patients with end-stage liver disease unable to access liver transplantation as a method of treatment. In order to determine the safest and most efficacious weight loss regimen in this challenging population, Roux-en-Y gastric bypass (RYGB), adjustable gastric banding (AGB), and diet and exercise were modeled to assess their impact on life expectancy in morbidly obese patients with cirrhosis. A Markov state transition model was developed to assess the survival benefit of undergoing RYGB, AGB, or 1 year of diet and exercise in morbidly obese patients with compensated cirrhosis. A base case analysis of no weight loss intervention in a 45-year-old patient with compensated cirrhosis and a BMI of 45 kg/m(2) revealed an average survival of 7.93 years. The average survival for the weight loss simulations was 9.14, 8.84, and 8.16 years for RYGB, AGB, and diet and exercise, respectively. In morbidly obese patients with compensated cirrhosis, RYGB allows patients to lose more weight more rapidly than is probable with either AGB or diet and exercise, thus having the greatest impact on survival.
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Handa K, Matsubara K, Fukumitsu K, Guzman-Lepe J, Watson A, Soto-Gutierrez A. Assembly of human organs from stem cells to study liver disease. THE AMERICAN JOURNAL OF PATHOLOGY 2013; 184:348-57. [PMID: 24333262 DOI: 10.1016/j.ajpath.2013.11.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Revised: 11/04/2013] [Accepted: 11/18/2013] [Indexed: 01/01/2023]
Abstract
Recently, significant developments in the field of liver tissue engineering have raised new possibilities for the study of complex physiological and pathophysiological processes in vitro, as well as the potential to assemble entire organs for transplantation. Human-induced pluripotent stem cells have been differentiated into relatively functional populations of hepatic cells, and novel techniques to generate whole organ acellular three-dimensional scaffolds have been developed. In this review, we highlight the most recent advances in organ assembly regarding the development of liver tissue in vitro. We emphasize applications that involve multiple types of cells with a biomimetic spatial organization for which three-dimensional configurations could be used for drug development or to explain mechanisms of disease. We also discuss applications of liver organotypic surrogates and the challenges of translating the highly promising new field of tissue engineering into a proven platform for predicting drug metabolism and toxicity.
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Affiliation(s)
- Kan Handa
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania; Transplantation Section, Children's Hospital of Pittsburgh, Thomas E. Starzl Transplantation Institute and McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kentaro Matsubara
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania; Transplantation Section, Children's Hospital of Pittsburgh, Thomas E. Starzl Transplantation Institute and McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ken Fukumitsu
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania; Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Jorge Guzman-Lepe
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania; Transplantation Section, Children's Hospital of Pittsburgh, Thomas E. Starzl Transplantation Institute and McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Alicia Watson
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Alejandro Soto-Gutierrez
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania; Transplantation Section, Children's Hospital of Pittsburgh, Thomas E. Starzl Transplantation Institute and McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.
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Cryptogenic cirrhosis is the leading cause for listing for liver transplantation in Sri Lanka. Indian J Gastroenterol 2013; 32:397-9. [PMID: 23999684 DOI: 10.1007/s12664-013-0376-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Accepted: 07/29/2013] [Indexed: 02/04/2023]
Abstract
Hepatitis B and C are rare in Sri Lanka. Nonalcoholic fatty liver disease is increasing in the country. Eighty-one patients referred for liver transplantation (LT) over a period of 18 months were prospectively evaluated. Ninety-two percent (n = 74) were males. Cryptogenic cirrhosis was the leading indication for LT (58%, n = 47) followed by alcohol in 27% (n = 33). Hepatitis B and C were not seen in our cases. The liver biochemistry and clinical status of cirrhosis were similar in cryptogenic and alcoholic cirrhotics. Fourteen patients died while waiting for transplant, and nine transplants were performed. Cryptogenic cirrhosis is the leading cause for LT in Sri Lanka.
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Hakeem AR, Cockbain AJ, Raza SS, Pollard SG, Toogood GJ, Attia MA, Ahmad N, Hidalgo EL, Prasad KR, Menon KV. Increased morbidity in overweight and obese liver transplant recipients: a single-center experience of 1325 patients from the United Kingdom. Liver Transpl 2013; 19:551-62. [PMID: 23408499 DOI: 10.1002/lt.23618] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2012] [Accepted: 01/11/2013] [Indexed: 12/13/2022]
Abstract
Obesity levels in the United Kingdom have risen over the years. Studies from the United States and elsewhere have reported variable outcomes for obese liver transplant recipients in terms of post-liver transplant morbidity, mortality, and graft survival. This study was designed to analyze the impact of the body mass index (BMI) on outcomes following adult liver transplantation. Data from 1994 to 2009 were retrieved from a prospectively maintained database. Patients were stratified into 5 World Health Organization BMI categories: underweight (<18.5 kg/m(2)), normal weight (18.5-24.9 kg/m(2)), overweight (25.0-29.9 kg/m(2)), obese (30.0-34.9 kg/m(2)), and morbidly obese (≥35.0 kg/m(2)). The primary outcome was an evaluation of graft and patient survival, and the secondary outcome was an assessment of postoperative morbidity. Bonferroni correction was applied with statistical significance set at P < 0.012. Kaplan-Meier curves were used to study the effects of BMI on graft and patient survival. A total of 1325 patients were included in the study: underweight (n = 47 or 3.5%), normal-weight (n = 643 or 48.5%), overweight (n = 417 or 31.5%), obese (n = 145 or 10.9%), and morbidly obese patients (n = 73 or 5.5%). The rate of postoperative infective complications was significantly higher in the overweight (60.7%, P < 0.01) and obese recipients (65.5%, P < 0.01) versus the normal-weight recipients (50.4%). The morbidly obese patients had a longer mean intensive care unit (ICU) stay than the normal-weight patients (4.7 versus 3.2 days, P = 0.03). The mean hospital stay was longer for the overweight (22.4 days, P < 0.001), obese (21.3 days, P = 0.04), and morbidly obese recipients (22.4 days, P = 0.047) versus the normal-weight recipients (18.0 days). There was no difference in death-censored graft survival or patient survival between the groups. In conclusion, this is the largest and only reported UK series on BMI and outcomes following liver transplantation. Overweight and obese patients have significantly increased morbidity in terms of infective complications after liver transplantation and, consequently, longer ICU and hospital stays.
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Affiliation(s)
- Abdul R Hakeem
- Department of Hepatopancreatobiliary and Transplant Surgery, St. James's University Hospital, Leeds Teaching Hospitals National Health Service Trust, Leeds, United Kingdom
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Cuschieri JR, John BK, Miick R, Ortiz JA, Hashemi N. Successful Treatment of Rapid Onset, Symptomatic de novo Non-alcoholic Steatohepatitis Following Liver Transplantation: A Case Report. J Clin Exp Hepatol 2013; 3:70-4. [PMID: 25755474 PMCID: PMC3940098 DOI: 10.1016/j.jceh.2013.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Accepted: 01/15/2013] [Indexed: 12/12/2022] Open
Abstract
A 45 year old female with a body mass index (BMI) of 24 underwent successful liver transplantation (LT) for alcoholic cirrhosis using a donor liver from an obese woman with microvesicular steatosis (80%) and minimal macrovesicular steatosis (5-10%) on liver biopsy. Ascites and hepatosplenomegaly developed soon after LT with progressive increase of serum alkaline phosphatase to 1340 IU/L while aspartate aminotransferase (AST), and alanine transaminase (ALT), and total bilirubin remained normal. Imaging showed marked hepatomegaly, extensive fatty infiltration of the liver, and compression of the hepatic veins with narrowing of the intrahepatic inferior vena cava (IVC). Liver biopsy on post-operative day 39 revealed 90-100% macrovesicular steatosis, steatohepatitis, and portal fibrosis. A hepatic venogram showed a 10 cm segment of intrahepatic IVC stenosis that was stented, improving portal venous pressure measurements. However, portal hypertension requiring diuretic therapy and multiple paracenteses remained. By 3 months after LT, her liver had grown to 22 cm, transaminases increased 2-4 times the upper limit of normal with a 2:1 AST to ALT ratio. Liver biopsy at post-LT day 82 showed no change in steatosis and steatohepatitis despite corticosteroid withdrawal and interval periportal and perisinusoidal fibrosis. 12 weeks after LT, the patient was found to have low apolipoprotein B (65 mg/dL), high-density lipoprotein (HDL) (<10 mg/dL), low-density lipoproteins (LDL) (9 mg/dL), and total cholesterol (<50 mg/dL) levels. Therapy was started for NASH with high dose (800 IU daily) vitamin E and pioglitazone 15 mg daily, and she received topical vegetable oil and oral essential fatty acid supplements. Liver enzymes normalized after 3 months and her lipid profile improved markedly (HDL 27 mg/dL, total cholesterol 128 mg/dL), with progressive decrease in liver size and resolution of ascites after 5 months of therapy. At 2 years post-LT, the liver enzymes remain normal and lipids have normalized.
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Key Words
- ALT, alanine transaminase
- AST, aspartate aminotransferase
- BMI, body mass index
- CT, computed tomography
- EFAD, essential fatty acid deficiency
- HDL, high-density lipoproteins
- HVPG, hepatic venous pressure gradient
- IVC, inferior vena cava
- LDL, low-density lipoproteins
- LT, liver transplantation
- NAFLD
- NAFLD, non-alcoholic fatty liver disease
- NASH
- NASH, non-alcoholic steatohepatitis
- PIVENS, pioglitazone versus vitamin E versus placebo for the treatment of non-diabetic patients with non-alcoholic steatohepatitis
- PO, per os (oral)
- liver transplantation
- non-alcoholic fatty liver disease
- portal hypertension
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Affiliation(s)
- Justin R. Cuschieri
- Division of Gastroenterology, Albert Einstein Medical Center, Philadelphia, PA, United States
| | - Bijo K. John
- Division of Gastroenterology, University of Florida College of Medicine, United States
| | - Ronald Miick
- Department of Pathology, Albert Einstein Medical Center, United States
| | - Jorge A. Ortiz
- Division of Transplant Surgery, Albert Einstein Medical Center, United States
| | - Nikroo Hashemi
- Division of Hepatology and Liver Transplantation, Albert Einstein Medical Center, United States,Address for correspondence. Nikroo Hashemi, Division of Hepatology and Liver Transplantation, Albert Einstein Medical Center, United States. Tel.: +1 267 421 7425.
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Shimizu H, Phuong V, Maia M, Kroh M, Chand B, Schauer PR, Brethauer SA. Bariatric surgery in patients with liver cirrhosis. Surg Obes Relat Dis 2012. [PMID: 23201210 DOI: 10.1016/j.soard.2012.07.021] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Data regarding the management of bariatric patients with cirrhosis are scarce, and there is no strong evidence that supports a specific approach for this group of patients. The aim of this study was to review our experience with cirrhotic patients undergoing bariatric surgery. METHODS A prospectively maintained database was reviewed to assess the outcomes of bariatric surgery for patients with known cirrhosis and for patients with cirrhosis discovered at surgery (unknown cirrhosis). RESULTS From April 2004 to September 2011, 23 patients (12 with known cirrhosis and 11 with unknown cirrhosis) met inclusion criteria. There were 14 females and 9 males with a mean age of 51.5 ± 8.3 and a mean body mass index of 48.2 ± 8.6 kg/m2. Child-Pugh classes were A (n = 22) and B (n = 1). Patients had a high frequency of diabetes (83%), dyslipidemia (61%), and hypertension (83%). Procedures performed were laparoscopic Roux-en-Y gastric bypass (LRYGB) (n = 14), laparoscopic sleeve gastrectomy (LSG) (n = 8), and laparoscopic adjustable gastric banding (n = 1). Two patients underwent LSG successfully after transjugular intrahepatic portosystemic shunt. Mean length of hospital stay was 4.3 ± 2.7 days. Complications developed in 8 patients. One patient died of unknown cause 9 months after surgery. No patients had liver decompensation after surgery. The patients lost 67.4% ± 30.9% of their excess weight at 12 months follow-up and 67.7% ± 24.8% at 37 months follow-up. CONCLUSION LRYGB and LSG can be performed without prohibitive complication rates in carefully selected patients with cirrhosis. In our experience, bariatric patients with cirrhosis achieved excellent weight loss and improvement in obesity-related co-morbidities.
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Affiliation(s)
- Hideharu Shimizu
- Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA
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Afzali A, Berry K, Ioannou GN. Excellent posttransplant survival for patients with nonalcoholic steatohepatitis in the United States. Liver Transpl 2012; 18:29-37. [PMID: 21932374 DOI: 10.1002/lt.22435] [Citation(s) in RCA: 102] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Because of the ongoing epidemics of obesity and diabetes, nonalcoholic steatohepatitis (NASH) may become a leading indication for liver transplantation. There are concerns about the posttransplant survival of patients with NASH because of associated cardiovascular and metabolic risk factors. We aimed to determine recent trends in the proportion of patients undergoing transplantation for NASH-related cirrhosis in the United States and to estimate their posttransplant survival. We used data provided by the United Network for Organ Sharing for first-time adult cadaveric liver transplants performed in the United States between January 1, 1997 and October 31, 2010 (n = 53,738). The proportion of liver transplants performed for NASH-related cirrhosis increased dramatically from 1.2% in 1997-2003 to 7.4% in 2010 when NASH was the fourth most common indication for transplantation. The posttransplant survival of patients with NASH (n = 1810) at 1 (87.6%), 3 (82.2%), and 5 years (76.7%) was superior to the survival of patients with hepatocellular carcinoma, hepatitis C virus, alcoholic liver disease, acute hepatic necrosis, hemochromatosis, or cryptogenic liver disease and was inferior to the survival of only 4 groups of patients (those with primary biliary cirrhosis, primary sclerosing cholangitis, autoimmune hepatitis, or hepatitis B virus). In conclusion, NASH-related cirrhosis is increasing rapidly as an indication for liver transplantation in the United States and is associated with excellent posttransplant survival.
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Affiliation(s)
- Anita Afzali
- Department of Medicine, Division of Gastroenterology, Veterans Affairs Puget Sound Health Care System and University of Washington, 1959 N.E. Pacific Street, Seattle, WA 98195, USA.
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The steatohepatitic variant of hepatocellular carcinoma and its association with underlying steatohepatitis. Hum Pathol 2011; 43:737-46. [PMID: 22018903 DOI: 10.1016/j.humpath.2011.07.005] [Citation(s) in RCA: 121] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2011] [Revised: 06/30/2011] [Accepted: 07/01/2011] [Indexed: 02/07/2023]
Abstract
Steatohepatitis and metabolic syndrome are increasingly recognized as important risk factors for development of hepatocellular carcinoma. We have recently described a histologic subtype of hepatocellular carcinoma termed steatohepatitic hepatocellular carcinoma, which shows features resembling steatohepatitis in the nonneoplastic liver. The present study is undertaken to assess the association between the steatohepatitic hepatocellular carcinoma variant and underlying steatohepatitis and features of metabolic syndrome. We examined all hepatocellular carcinomas diagnosed on resections and explant specimens over a 3.5-year period at our institution. Tumors were classified as either conventional hepatocellular carcinoma or steatohepatitic hepatocellular carcinoma variant based on their predominant histopathologic pattern. The underlying chronic liver disease in each case was determined. The steatohepatitic hepatocellular carcinoma variant represented 13.5% (16/118) of cases. All but one case of steatohepatitic hepatocellular carcinoma occurred in patients with underlying steatohepatitis. Steatohepatitic hepatocellular carcinoma was diagnosed in 35.7% of patients with either nonalcoholic steatohepatitis or alcoholic liver disease compared with 1.3% of patient with other chronic liver diseases (P < .0001). The steatohepatitic hepatocellular carcinoma group had a significantly higher number of metabolic syndrome risk factors (2.44 versus 1.48, P = .01) and a higher percentage of patients with at least 3 metabolic syndrome components (50% versus 22.5%, P = .02). Immunohistochemically, there were diffuse loss of cytoplasmic CK8/18 and increased numbers of activated hepatic stellate cells within steatohepatitic hepatocellular carcinoma, in a pattern identical to that seen in steatohepatitis in nonneoplastic liver. Hepatocellular carcinomas showing a "steatohepatitic" histologic phenotype are strongly associated with underlying steatohepatitis and metabolic syndrome. This association further supports a possible role of steatohepatitis in human hepatocarcinogenesis.
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Mechanisms and implications of age-related changes in the liver: nonalcoholic Fatty liver disease in the elderly. Curr Gerontol Geriatr Res 2011; 2011:831536. [PMID: 21918648 PMCID: PMC3171768 DOI: 10.1155/2011/831536] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2011] [Accepted: 07/09/2011] [Indexed: 12/11/2022] Open
Abstract
Nonalcoholic fatty liver disease (NAFLD) is hepatic steatosis associated with metabolic abnormalities such as overweight/central obesity, insulin resistance, type 2 diabetes (T2D), and dyslipidemia. NAFLD is becoming the most common liver disease in contemporary society, with the highest prevalence in those over 60 years. NAFLD pathology ranges from simple steatosis to a necroinflammatory fibrosing disorder called steatohepatitis (SH), the latter associated with high risk of developing cirrhosis, often occuring in the seventh to ninth decades of life. While the main health implications of NAFLD are increased risk of developing T2D, cardiovascular diseases, and common cancers, there is substantantially increased standardized mortality, and deaths from decompensated cirrhosis and hepatocellular carcinoma (HCC). Little is known about the interactive effects of ageing and NAFLD, with most studies focusing on the younger population. This paper summarises the epidemiology, pathogenesis, and clinical course of NAFLD, with particular attention to persons over age 60 years. An approach to the management of NASH and its complications in the elderly, will also be presented here.
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Dureja P, Mellinger J, Agni R, Chang F, Avey G, Lucey M, Said A. NAFLD recurrence in liver transplant recipients. Transplantation 2011; 91:684-9. [PMID: 21248661 DOI: 10.1097/tp.0b013e31820b6b84] [Citation(s) in RCA: 124] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Nonalcoholic fatty liver disease (NAFLD) is a common indication for liver transplantation and can recur in the graft. To describe this recurrence, we performed a cohort study of individuals undergoing liver transplantation for NAFLD-related cirrhosis between 1993 and 2007. Predictors of NAFLD recurrence and outcomes in this cohort were also studied. METHODS Eighty-eight liver transplant recipients were included in this study. NAFLD recurrence was described by performing a blinded reevaluation of posttransplant liver biopsies and classified according to histologic activity (NAFLD activity score) and fibrosis. RESULTS Recurrent NAFLD was seen in 34 (39%) recipients with isolated steatosis in 9 and steatohepatitis in 25 recipients. Severe recurrence was seen in 3 of 34 recipients (NAFLD activity score ≥ 5) and advanced fibrosis in 3 recipients. NAFLD recurrence correlated with higher pretransplant (P=0.001) and posttransplant body mass index (P<0.0001) and increased triglyceride levels posttransplantation. Serum triglyceride levels at 6 and 12 months were 280 ± 129 and 324 ± 265 mg/dL, respectively, in those with NAFLD recurrence versus 206 ± 96 mg/dL at 6 months and 190 ± 103 mg/dL in those without NAFLD recurrence (P=0.007 at 6 months and P=0.005 at 12 months). Average steroid dose at 6 months posttransplant was also higher in those with NALFD recurrence than those without (11 ± 8.5 and 7.2 ± 5.7 mg/day, P=0.04). Posttransplant survival did not differ between those with and without NAFLD recurrence during the entire follow-up period (P=0.78). Posttransplant cardiovascular disease was significantly and adversely correlated with posttransplant survival. CONCLUSIONS NAFLD recurrence is common in the first 5 years postliver transplantation and is associated with features of the metabolic syndrome. Although NAFLD recurrence was not associated with higher mortality in our cohort, cardiovascular mortality and morbidity were common, suggesting that the metabolic syndrome is an important link to NAFLD recurrence and cardiovascular deaths posttransplantation.
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Affiliation(s)
- Parul Dureja
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin, School of Medicine and Public Health, Madison, WI 53705, USA
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Nobili V, Alisi A, de Ville de Goyet J. Metabolic syndrome and nonalcoholic steatohepatitis recurrence after liver transplantation in children. Liver Transpl 2011; 17:620-1. [PMID: 21351243 DOI: 10.1002/lt.22285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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El-Masry M, Puig CA, Saab S, Saab S. Recurrence of non-viral liver disease after orthotopic liver transplantation. Liver Int 2011; 31:291-302. [PMID: 21281429 DOI: 10.1111/j.1478-3231.2010.02434.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Liver transplant remains the ultimate treatment for decompensated liver disease. However, many diseases do recur after orthotopic liver transplant, which may affect recipients' quality of life and survival rate. We performed a systematic review of relevant epidemiological studies available on Medline that provided information on the recurrence of non-viral hepatitis after orthotopic liver transplantation in adult patients published until August 2010. All data were compiled from either review articles or retrospective studies. Primary sclerosing cholangitis, primary biliary cirrhosis, autoimmune hepatitis, non-alcoholic steatohepatitis, alcoholic steatohepatitis and haemochromatosis can recur after liver transplantation. The rates for disease recurrence varied according to the indication for transplantation, and ranged from 7 to 50%. Although the survival rate of patients with liver disease has increased with the advent of liver transplantation and novel immunosuppressive protocols, recurrence of the primary liver disease remains a concern. The recurrence rates differ not only according to the cause of underlying liver disease but also vary within the indication for transplant. Further studies are needed to elucidate the risk factors for varied disease recurrence.
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Affiliation(s)
- Monica El-Masry
- Department of Medicine, Olive View - UCLA Medical Center, Sylmar, CA, USA
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Behari J, Chalasani N. Challenging the rodent hegemony: a new rabbit model of nonalcoholic steatohepatitis. THE AMERICAN JOURNAL OF PATHOLOGY 2010; 177:10-12. [PMID: 20489152 PMCID: PMC2893644 DOI: 10.2353/ajpath.2010.100410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/29/2010] [Indexed: 05/29/2023]
Abstract
This Commentary discusses the advent of a new animal model of fatty liver disease.
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