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Feng S, Roll GR, Rouhani FJ, Sanchez Fueyo A. The future of liver transplantation. Hepatology 2024:01515467-990000000-00817. [PMID: 38537154 DOI: 10.1097/hep.0000000000000873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 03/02/2024] [Indexed: 06/15/2024]
Abstract
Over the last 50 years, liver transplantation has evolved into a procedure routinely performed in many countries worldwide. Those able to access this therapy frequently experience a miraculous risk-benefit ratio, particularly if they face the imminently life-threatening disease. Over the decades, the success of liver transplantation, with dramatic improvements in early posttransplant survival, has aggressively driven demand. However, despite the emergence of living donors to augment deceased donors as a source of organs, supply has lagged far behind demand. As a result, rationing has been an unfortunate focus in recent decades. Recent shifts in the epidemiology of liver disease combined with transformative innovations in liver preservation suggest that the underlying premise of organ shortage may erode in the foreseeable future. The focus will sharpen on improving equitable access while mitigating constraints related to workforce training, infrastructure for organ recovery and rehabilitation, and their associated costs. Research efforts in liver preservation will undoubtedly blossom with the aim of optimizing both the timing and conditions of transplantation. Coupled with advances in genetic engineering, regenerative biology, and cellular therapies, the portfolio of innovation, both broad and deep, offers the promise that, in the future, liver transplantation will not only be broadly available to those in need but also represent a highly durable life-saving therapy.
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Affiliation(s)
- Sandy Feng
- Department of Surgery, Division of Transplant Surgery, University of California, San Francisco, California, USA
| | - Garrett R Roll
- Department of Surgery, Division of Transplant Surgery, University of California, San Francisco, California, USA
| | - Foad J Rouhani
- Tissue Regeneration and Clonal Evolution Laboratory, The Francis Crick Institute, London, UK
- Institute of Liver Studies, King's College London, King's College Hospital, NHS Foundation Trust, London, UK
| | - Alberto Sanchez Fueyo
- Institute of Liver Studies, King's College London, King's College Hospital, NHS Foundation Trust, London, UK
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Sastre L, García R, Viñals C, Amor AJ, Yago G, Hervás A, Sánchez L, Trabal J, Molero J, Escudé L, Pagano G, Blasco M, Gilabert R, Ruiz P, Colmenero J, Navasa M, Ortega E, Crespo G. Results of a multidisciplinary strategy to improve the management of cardiovascular risk factors after liver transplantation. Liver Transpl 2022; 28:1332-1344. [PMID: 35224857 DOI: 10.1002/lt.26443] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 02/15/2022] [Accepted: 02/18/2022] [Indexed: 02/07/2023]
Abstract
Although liver transplantation (LT) recipients are at high cardiovascular risk (CVR), the management of CVR factors (CVRF) after LT is far from optimal and needs to be improved. For this reason, we developed a multidisciplinary protocol to standardize the identification, risk stratification, management, and targets of therapy of CVRF during the first post-LT year. The grade of identification and control of CVRF 12 months after LT in the postintervention cohort (LT January 2018-January 2020, n = 150) were compared with a control cohort who underwent LT between July 2015 and December 2016 (n = 100). Before LT, the prevalence of metabolic-associated fatty liver disease as the indication of LT and the presence of obesity were significantly higher in the postintervention cohort, whereas the prevalence of other CVRF and renal dysfunction tended to be higher. Cyclosporine A was used less frequently in the postintervention cohort, whereas everolimus tended to increase. At 12 months after LT, the proportion of patients with measured blood pressure (88% vs. 56%), glycosilated hemoglobin (HbA1c; 96% vs. 72%), and high-density lipoprotein/low-density lipoprotein cholesterol (67% vs. 33%) was higher in the postintervention than in the control cohort (all p < 0.001). Blood pressure (64% vs. 36%, p = 0.02) and HbA1c (85% vs. 70%, p = 0.1) were within target in more individuals with hypertension and diabetes mellitus, respectively, in the postintervention cohort. Median total cholesterol levels were lower in the postintervention (184 mg/dl; interquartile range [IQR], 160-210 mg/dl) than in the control cohort (212 mg/dl; IQR, 186-240 mg/dl; p = 0.02). At 2 years after LT, the incidence of cardiovascular events was 14% in the control cohort and 6% in the postintervention cohort (p = 0.063). In conclusion, a multidisciplinary, multiprofessional strategy can achieve a higher grade of assessment and management of post-LT CVR despite a worsening metabolic profile of LT recipients.
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Affiliation(s)
- Lydia Sastre
- Hepatology and Liver Transplant Unit, Hospital Clinic, Barcelona, Spain.,Department of Gastroenterology and Hepatology, Hospital Son Espases, Palma de Mallorca, Spain
| | - Raquel García
- Hepatology and Liver Transplant Unit, Hospital Clinic, Barcelona, Spain
| | - Clara Viñals
- Endocrinology and Nutrition Department, Hospital Clinic, Barcelona, Spain
| | - Antonio J Amor
- Endocrinology and Nutrition Department, Hospital Clinic, Barcelona, Spain
| | - Gema Yago
- Endocrinology and Nutrition Department, Hospital Clinic, Barcelona, Spain
| | - Alicia Hervás
- Hepatology and Liver Transplant Unit, Hospital Clinic, Barcelona, Spain
| | - Lorena Sánchez
- Endocrinology and Nutrition Department, Hospital Clinic, Barcelona, Spain
| | - Joan Trabal
- Endocrinology and Nutrition Department, Hospital Clinic, Barcelona, Spain
| | - Judit Molero
- Endocrinology and Nutrition Department, Hospital Clinic, Barcelona, Spain
| | - Laia Escudé
- Hepatology and Liver Transplant Unit, Hospital Clinic, Barcelona, Spain
| | - Giulia Pagano
- Hepatology and Liver Transplant Unit, Hospital Clinic, Barcelona, Spain
| | - Miquel Blasco
- Nephrology and Kidney Transplant Department, Hospital Clinic, Barcelona, Spain
| | - Rosa Gilabert
- Radiology Department, Hospital Clinic, Barcelona, Spain
| | - Pablo Ruiz
- Hepatology and Liver Transplant Unit, Hospital Clinic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red-Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Jordi Colmenero
- Hepatology and Liver Transplant Unit, Hospital Clinic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red-Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,University of Barcelona, Barcelona, Spain
| | - Miquel Navasa
- Hepatology and Liver Transplant Unit, Hospital Clinic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red-Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,University of Barcelona, Barcelona, Spain
| | - Emilio Ortega
- Endocrinology and Nutrition Department, Hospital Clinic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red-Fisiopatología de la Obesidad y Nutrición (CIBERobn), Madrid, Spain
| | - Gonzalo Crespo
- Hepatology and Liver Transplant Unit, Hospital Clinic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red-Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,University of Barcelona, Barcelona, Spain
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