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Llovet LP, Sciarrone S, Rodríguez-Tajes S, Montironi C, Mescoli C, Rugge M, Crespo G, Burra P, Forns X, Diaz A, Londoño MC. Ductular reaction and hepatocyte ballooning identify patients with fibrosing cholestatic hepatitits after liver transplantation. GASTROENTEROLOGIA Y HEPATOLOGIA 2019; 43:14-21. [PMID: 31495536 DOI: 10.1016/j.gastrohep.2019.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 06/18/2019] [Accepted: 07/04/2019] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Diagnosis of severe hepatitis C recurrence is based on analytical and histological criteria but there is little information about their correlation. AIM To assess the accuracy of laboratory criteria for the diagnosis of fibrosing cholestatic hepatitis (FCH). PATIENTS AND METHODS Retrospective analysis of prospectively collected data form HCV positive patients who underwent liver transplantation (LT) between 2000 and 2014 in two European university hospitals. Patients were classified according to laboratory criteria such as FCH, cholestatic hepatitis (CH) and non-cholestatic acute hepatitis (NCAH). Histological characteristics were also evaluated. RESULTS Seventy patients with acute HCV recurrence within the first year after LT with an available liver biopsy were included in the study. Most patients were male (70%) with a median age of 58 years (50-64) and infected with genotype 1b (71.4%). Median time from LT to diagnosis of recurrence was 2.96 months (2.1-5.3). Thirty-nine patients were classified as FCH, 21 as CH and 10 as NCAH. Marked hepatocyte ballooning and ductular reaction were associated with the presence of FCH with an OR of 4.66 (p=0.047) and 20.58 (p=0.025), respectively. Considering liver biopsy as the gold standard, the sensitivity, specificity, positive and negative predictive values of the analytical criteria were 0.8, 0.5, 0.3 and 0.9, respectively. However, correlation between histological and analytical criteria was poor (k=0.033). DISCUSSION Analytical criteria may be used to rule out the presence of FCH, but a biopsy is mandatory to confirm the diagnosis. Ductular reaction and hepatocyte ballooning were independent predictors of FCH.
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Affiliation(s)
| | - Salvatore Sciarrone
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | | | - Carla Montironi
- Pathology Department, Hospital Clínic Barcelona, Barcelona, Spain
| | - Claudia Mescoli
- Surgical Pathology & Cytopathology Unit, Department of Medicine (DIMED), Padua University Hospital, Padua, Italy
| | - Massimo Rugge
- Surgical Pathology & Cytopathology Unit, Department of Medicine (DIMED), Padua University Hospital, Padua, Italy
| | - Gonzalo Crespo
- Liver Unit, Hospital Clínic Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Xavier Forns
- Liver Unit, Hospital Clínic Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | - Alba Diaz
- Pathology Department, Hospital Clínic Barcelona, Barcelona, Spain
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Koo J, Wang HL. Acute, Chronic, and Humoral Rejection: Pathologic Features Under Current Immunosuppressive Regimes. Surg Pathol Clin 2018; 11:431-452. [PMID: 29751884 DOI: 10.1016/j.path.2018.02.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Under current immunosuppressive regimes, T-cell-mediated acute and chronic rejection remain common and important posttransplant complications. The definition of humoral (antibody-mediated) rejection has been greatly expanded in recent years. The histopathologic assessment of allograft biopsies continues to serve an important role in the diagnosis of rejection and to facilitate patient management. The diagnosis of both acute and chronic antibody-mediated rejection requires integration of the results of donor-specific antibody testing and C4d immunostaining, as well as exclusion of other potential etiologies of allograft dysfunction. Chronic antibody-mediated rejection should also be included in the differential diagnosis for unexplained allograft fibrosis.
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Affiliation(s)
- Jamie Koo
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Room 8707, Los Angeles, CA 90048, USA
| | - Hanlin L Wang
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, 27-061-C8 CHS, Los Angeles, CA 90095, USA.
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Abstract
Surgical pathology results can play a crucial role in the management of immunocompromised patients. Here we highlight factors that differ between immunocompromised and immunocompetent hosts, such as variation in inflammatory response. Conditions that are covered include drug reactions, disease within solid organ allografts, immune reconstitution inflammatory syndrome, specific immunodeficiency syndromes, neoplasms related to viral infections, and viral, bacterial, fungal, and parasitic infections. Special techniques including immunohistochemistry, in situ hybridization and molecular detection of pathogen nucleic acid from formalin-fixed, paraffin-embedded tissue are discussed.
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Romagnoli R, Martini S, Tandoi F, Dell Olio D, Magistroni P, Bertinetto FE, Dametto E, Rizzetto M, Salizzoni M, Amoroso A. Early reduced liver graft survival in hepatitis C recipients identified by two combined genetic markers. Transpl Int 2016; 29:1070-84. [PMID: 27172242 DOI: 10.1111/tri.12795] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 02/23/2016] [Accepted: 05/09/2016] [Indexed: 01/08/2023]
Abstract
HLA and IL-28B genes were independently associated with severity of HCV-related liver disease. We investigated the effects of these combined genetic factors on post-transplant survival in HCV-infected recipients, aiming to provide new data to define the optimal timing of novel antiviral therapies in the transplant setting. HLA-A/B/DRB1 alleles and IL-28B rs12979860 (C > T) polymorphism frequencies were determined in 449 HCV viremic recipients and in their donors. Median follow-up was 10 years; study outcome was graft survival. HLA-DRB1*11 phenotype and IL-28B C/C genotype were significantly less frequent in recipients than donors (27.8% vs. 45.9% and 27.4% vs. 44.9%, respectively, P < 0.00001). Ten-year graft survival was better in patients with HLA-DRB1*11 (P = 0.0183) or IL-28B C/C (P = 0.0436). Conversely, concomitant absence of HLA-DRB1*11 and IL-28B C/C in 228 (50.8%) predicted worse survival (P = 0.0006), which was already evident at the first post-transplant year (P = 0.0370). In multivariable Cox analysis, absence of both markers ranked second as risk factor for survival (HR = 1.74), following donor age ≥ 70 years (HR = 1.77). In the current era of direct-acting antiviral agents, the negative effects of this common immunogenetic profile in HCV-infected recipients could be most effectively neutralized by peri-transplant treatment. This should be particularly relevant in countries where elderly donors represent an unavoidable resource.
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Affiliation(s)
- Renato Romagnoli
- Liver Transplantation Center, General Surgery Unit 2U, AOU Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Silvia Martini
- Liver Transplantation Center, Gastrohepatology Unit, AOU Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Francesco Tandoi
- Liver Transplantation Center, General Surgery Unit 2U, AOU Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Dominic Dell Olio
- Regional Transplantation Center - Piedmont, AOU Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Paola Magistroni
- Regional Transplantation Center - Piedmont, AOU Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
- Immunogenetics Laboratory, AOU Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Francesca E Bertinetto
- Regional Transplantation Center - Piedmont, AOU Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
- Immunogenetics Laboratory, AOU Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Ennia Dametto
- Regional Transplantation Center - Piedmont, AOU Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
- Immunogenetics Laboratory, AOU Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Mario Rizzetto
- Liver Transplantation Center, Gastrohepatology Unit, AOU Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Mauro Salizzoni
- Liver Transplantation Center, General Surgery Unit 2U, AOU Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Antonio Amoroso
- Regional Transplantation Center - Piedmont, AOU Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy.
- Immunogenetics Laboratory, AOU Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy.
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Kerola A, Lampela H, Lohi J, Heikkilä P, Mutanen A, Hagström J, Tervahartiala T, Sorsa T, Haglund C, Jalanko H, Pakarinen MP. Increased MMP-7 expression in biliary epithelium and serum underpins native liver fibrosis after successful portoenterostomy in biliary atresia. JOURNAL OF PATHOLOGY CLINICAL RESEARCH 2016; 2:187-98. [PMID: 27499927 PMCID: PMC4958739 DOI: 10.1002/cjp2.50] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 04/24/2016] [Indexed: 12/14/2022]
Abstract
The molecular mechanisms underlying progressive liver fibrosis following surgical treatment of biliary atresia (BA) remain unclear. Our aim was to address hepatic gene and protein expression and serum levels of matrix metalloproteinases (MMPs) and their tissue inhibitors (TIMPs) after successful portoenterostomy (PE), and relate them to histological signs of liver injury, clinical follow‐up data and biochemical markers of hepatic function. LIver biopsies and serum samples were obtained from 25 children after successful PE at median age of 3.3 years. Serum MMP concentrations were determined by enzyme‐linked immune sorbent assay. Hepatic gene expression of MMPs and TIMPs was analyzed using real‐time reverse‐transcription PCR. Liver expression of MMP‐7 and cytokeratin‐7 was studied using immunohistochemistry. Despite effective clearance of biochemical and histological cholestasis following PE, BA patients showed increased hepatic gene expression of MMP‐7 (29‐fold, p < 0.001), MMP‐2 (3.1‐fold, p < 0.001), MMP‐14 (1.7‐fold, p = 0.007), and TIMP‐1 (1.8‐fold, p < 0.001), when compared to controls. Similar to a biliary epithelial marker cytokeratin‐7, expression of MMP‐7 localized in biliary epithelium of bile ducts and ductal proliferations and periportal hepatocytes and was increased (p < 0.001) in relation to controls. BA patients had 6‐fold higher serum levels of MMP‐7 (p < 0.001), which correlated positively with hepatic MMP‐7 gene (r = 0.548, p = 0.007) and protein (r = 0.532, p = 0.007) expression. Patients showed a positive correlation between biliary MMP‐7 expression and Metavir fibrosis stage (r = 0.605, p = 0.001) and portal fibrosis grade (r = 0.606, p = 0.001). Neither similarly increased MMP‐7 expression nor correlation with liver fibrosis was observed in patients with intestinal failure‐associated liver disease and comparable Metavir stage. In conclusion, our findings support an unique role of altered hepatic expression of MMP‐7 in the progression of liver fibrosis after successful PE and introduce a potential therapeutic target to pharmacologically extend native liver survival by inhibiting MMP‐7 hyperactivity. Serum MMP‐7 may be a valuable postoperative prognostic tool in BA.
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Affiliation(s)
- Anna Kerola
- Pediatric Surgery and Pediatric Transplantation Surgery, Pediatric Liver and Gut Research Group, Children's Hospital, University of Helsinki and Helsinki University HospitalHelsinkiFinland; Department of SurgeryNorth Karelia Central HospitalJoensuuFinland
| | - Hanna Lampela
- Pediatric Surgery and Pediatric Transplantation Surgery, Pediatric Liver and Gut Research Group, Children's Hospital, University of Helsinki and Helsinki University HospitalHelsinkiFinland; Gastroenterological Surgery, University of Helsinki and Helsinki University HospitalHelsinkiFinland
| | - Jouko Lohi
- Pathology, University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Päivi Heikkilä
- Pathology, University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Annika Mutanen
- Pediatric Surgery and Pediatric Transplantation Surgery, Pediatric Liver and Gut Research Group, Children's Hospital, University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Jaana Hagström
- Pathology and Oral Pathology University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Taina Tervahartiala
- Oral and Maxillofacial Diseases University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Timo Sorsa
- Oral and Maxillofacial DiseasesUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland; Division of Periodontology, Department of Dental MedicineKarolinska InstitutetHuddingeSweden
| | - Caj Haglund
- Department of SurgeryUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland; Research Programs Unit, Translational Cancer Biology, University of Helsinki and Helsinki University HospitalHelsinkiFinland
| | - Hannu Jalanko
- Pediatric Nephrology and Transplantation, University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Mikko P Pakarinen
- Pediatric Surgery and Pediatric Transplantation Surgery, Pediatric Liver and Gut Research Group, Children's Hospital, University of Helsinki and Helsinki University Hospital Helsinki Finland
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Oliver M, Ortiz CC, Ortiz J. Challenging hepatitis C-infected liver transplant patients. Hepat Med 2016; 8:1-8. [PMID: 26889091 PMCID: PMC4723095 DOI: 10.2147/hmer.s96110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Caring for liver transplant patients suffering from chronic hepatitis C virus (HCV) infection is a challenging task for transplant surgeons and primary physicians alike. HCV is the leading cause of liver transplantation in the USA and comes with a myriad of complications that increase morbidity and mortality. This review focuses on patient follow-up, spanning from before the liver transplant occurs to the patient's long-term health. Pretransplant, both donor and recipient variables, must be carefully chosen to ensure optimal surgical success. Risk factors must be identified and HCV viral load must be reduced to a minimum. In addition to standard transplant complications, HCV patients suffer from additional problems, such as fibrosing cholestatic hepatitis and widespread viremia. Physicians must focus on the balance of immunosuppressive and antiviral medications, while considering possible side effects from these potent drugs. Over the years following surgery, physicians must identify any signs of failing liver health, as HCV-positive patients have an increased risk for cirrhosis and certain life-threatening malignancies.
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Affiliation(s)
| | | | - Jorge Ortiz
- Department of Transplant Surgery, University of Toledo Medical Center, Toledo, OH, USA
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7
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Saab S, Jimenez M, Bau S, Goo T, Zhao D, Durazo F, Han S, El Kabany M, Kaldas F, Tong MJ, Busuttil RW. Treating fibrosing cholestatic hepatitis C with sofosbuvir and ribavirin: a matched analysis. Clin Transplant 2015; 29:813-9. [PMID: 26147216 DOI: 10.1111/ctr.12584] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND Fibrosing cholestatic hepatitis (FCH) is an uncommon but potentially fatal complication of recurrent hepatitis C (HCV) in liver transplant recipients. METHODS We matched the treatment outcomes of 10 liver transplant recipients who developed FCH with those of 10 recipients with recurrent HCV without FCH treated with sofosbuvir and ribavirin. RESULTS Baseline mean alanine transaminase, aspartate transaminase, alkaline phosphatase, and total bilirubin were 186 U/L, 197 U/L, 243 U/L, and 6.7 mg/dL, respectively, in the FCH recipients and 82 U/L, 60 U/L, 110 U/L, and 0.99 mg/dL, respectively, in non-FCH recipients. The sustained viral response in FCH and non-FCH recipients was 40% and 80%, respectively. One-yr patient and graft survival rates were 90% and 80%, respectively, in FCH recipients, and 100% in non-FCH recipients. Seven FCH and six non-FCH recipients were treated for anemia with blood transfusion and/or erythropoietin growth factors. CONCLUSION Our results suggest that the use of sofosbuvir and ribavirin is effective and tolerable in liver transplant recipients treated for recurrent FCH. There is a trend of lower sustained viral response, patient survival, and graft survival in the FCH recipients.
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Affiliation(s)
- Sammy Saab
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.,Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA
| | - Melissa Jimenez
- Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA
| | - Sherona Bau
- Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA
| | - Tyralee Goo
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | - Difan Zhao
- Department of Biostatistics, University of California at Los Angeles, Los Angeles, CA, USA
| | - Francisco Durazo
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.,Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA
| | - Steven Han
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.,Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA
| | - Mohammed El Kabany
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.,Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA
| | - Fady Kaldas
- Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA
| | - Myron J Tong
- Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA.,Liver Center, Huntington Medical Research Institutes, Pasadena, CA, USA
| | - Ronald W Busuttil
- Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA
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Fibrosing cholestatic hepatitis C after hematopoietic cell transplantation: report of 3 fatal cases. Am J Surg Pathol 2015; 39:212-20. [PMID: 25517948 DOI: 10.1097/pas.0000000000000345] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Development of liver disease after hematopoietic cell transplantation is common and the causes diverse. Infection by hepatitis C virus (HCV) can be seen in patients who are chronically infected before transplant or from passage of virus from an infected donor; the normal 10-year course of hepatitis C after transplant is one of waxing and waning of serum aminotransferase enzymes, with little morbidity. In the series of 3 patients reported here, the course of hepatitis C was rapidly fatal, with the onset of jaundice at day 60 to 80 after transplant and liver histology typical of fibrosing cholestatic hepatitis (marked bile ductular proliferation, ballooned hepatocytes, and associated collagenous fibrosis centered around ductules). The bile ductular reaction pattern varied from elongated structures without a recognizable lumen to a pattern of cuboidal cells with a clear lumen. There was significant cholestasis with bile within hepatocytes and canalicular bile plugs. In situ HCV RNA hybridization studies from 1 patient showed a robust infection with high levels of HCV-infected hepatocytes and active viral replication. All 3 patients were on immunosuppressive drugs after transplant, including mycophenolate mofetil (MMF), which irreversibly inhibits inosine monophosphate dehydrogenase, on which T and B lymphocytes are dependent. We speculate that fatal fibrosing cholestatic hepatitis C in these cases was related to the immunosuppressive effects of MMF, as we had not recognized this presentation of HCV infection before the introduction of MMF.
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Kakati B, Seetharam A. Hepatitis C Recurrence after Orthotopic Liver Transplantation: Mechanisms and Management. J Clin Transl Hepatol 2014; 2:189-96. [PMID: 26355427 PMCID: PMC4521242 DOI: 10.14218/jcth.2014.00016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Revised: 06/06/2014] [Accepted: 07/07/2014] [Indexed: 12/04/2022] Open
Abstract
Chronic Hepatitis C (HCV) infection is the leading indication for orthotopic liver transplantation and recurrence is nearly universal. Chronic HCV infection is frequently established through evasion of the innate immune system. Priming of adaptive immune responses modulate the severity and rate of fibrosis progression. Those with demonstrable viremia entering the transplant period uniformly suffer recurrence post-transplant. Progression to cirrhosis is accelerated post-transplant secondary to systemic immunosuppression. In addition, a number of factors, including donor, host, and viral characteristics, influence severity and rate of fibrosis progression. Interferon-based therapy, the previous standard of care, in those with advanced cirrhosis or post-transplant has been limited by a number of issues. These include a relative lack of efficacy and poor tolerability with higher incidence of infection and anemia. Recently, approval of direct acting antivirals have ushered in a new era in HCV therapeutics and have applicability in these special populations. Their use immediately prior to or post-transplant is expected to improve both morbidity and mortality.
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Affiliation(s)
- Bobby Kakati
- Banner Transplant and Advanced Liver Disease Center, Phoenix, AZ, USA
| | - Anil Seetharam
- Banner Transplant and Advanced Liver Disease Center, Phoenix, AZ, USA
- University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
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