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Rubin JB, Aby ES, Barman P, Tincopa M. Opioid use and risks in candidates and recipients of liver transplant. Liver Transpl 2024:01445473-990000000-00369. [PMID: 38669598 DOI: 10.1097/lvt.0000000000000388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 04/18/2024] [Indexed: 04/28/2024]
Abstract
Opioid use is extremely prevalent among patients with cirrhosis and those who received liver transplant (LT), despite concerns regarding opioid-related risks in this population. While there are many theoretical risks of opioids in patients with hepatic dysfunction, there is limited evidence on the effect of opioid use on clinical outcomes in cirrhosis and patients before and after LT specifically. As a result, there is significant center-level variability in opioid-related practices and policies. The existing data-largely based on retrospective observational studies-do suggest that opioids are associated with increased health resource utilization pre-LT and post-LT and that they may precipitate HE in patients with cirrhosis and increase the risk of graft loss and death after LT. The strongest predictor of opioid use after LT is opioid use before transplant; thus, a focus on safe opioid use in the pretransplant and peritransplant periods is essential for minimizing opioid-related harms. We describe 3 strategies to guide LT providers including (1) improved characterization of pain, mental health symptoms, and opioid and polysubstance use; (2) minimization of opioid prescriptions for those at highest risk of adverse events; and (3) safe prescribing strategies for those who do use opioids and for the management of opioid use disorder. Ultimately, our goal is to improve the quality of life and transplant outcomes among patients with cirrhosis and those who received LT, particularly those living with concurrent pain, mental health, and substance use disorders.
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Affiliation(s)
- Jessica B Rubin
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
- Department of Medicine, Gastroenterology Section, San Francisco VA Health Care System, San Francisco, California, USA
| | - Elizabeth S Aby
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Pranab Barman
- Division of Digestive Diseases, Department of Medicine, University of California-San Diego, San Diego, California, USA
| | - Monica Tincopa
- Division of Digestive Diseases, Department of Medicine, University of California-San Diego, San Diego, California, USA
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2
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Varshney M, Dhingra K, Choudhury A. Psychosocial Assessment and Management-related Issues Among Liver Transplant Recipients. J Clin Exp Hepatol 2023. [DOI: 10.1016/j.jceh.2023.07.414] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2023] Open
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3
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Yau MTK, Hussaini T, Yoshida EM. Review of liver transplantation candidacy and outcomes among patients who use cannabis: Is it time for a change in policy? CANADIAN LIVER JOURNAL 2023; 6:269-277. [PMID: 37503517 PMCID: PMC10370722 DOI: 10.3138/canlivj-2022-0038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 10/15/2022] [Indexed: 07/29/2023]
Abstract
Background Recreational cannabis was legalized in Canada in 2018. A controversial contraindication for liver transplantation is cannabis. There is currently no consensus regarding cannabis use in liver transplant candidates. We aim to investigate liver transplantation candidacy and outcomes among cannabis users. Methods English peer-reviewed studies on PubMed and Google Scholar were searched on September 9, 2022, using keywords including "cannabis," "liver transplantation," and their synonyms. Titles and abstracts were screened, followed by full texts. Reference lists were reviewed. Studies that investigated liver transplantation candidacy and outcomes among cannabis users were included. Results The proportion of patients listed for liver transplantation was significantly less among cannabis users than among non-users. Time to listing was longer for cannabis users than non-users. The incidence of delisting was similar. There is an inconsistency between transplant centres regarding transplantation candidacy for cannabis users. While only 14% of Canadian centres had a policy in place and preferred candidates to abstain or decrease cannabis use before transplantation, a third of Canadian centres rejected cannabis users. Observational studies failed to demonstrate significant differences in patient survival between pre-transplantation cannabis users and non-users. However, self-reported mental health ratings were worse in post-transplantation cannabis users than in non-users and former users. Conclusions Current observational data do not support a link between cannabis use and poor patient survival post-transplantation. However, high-quality prospective studies are needed to better elucidate the impact of cannabis use on liver transplantation outcomes. Liver transplant candidacy should be evaluated through a multidisciplinary and comprehensive approach considering all relevant psychosocial factors.
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Affiliation(s)
| | - Trana Hussaini
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Eric M Yoshida
- Division of Gastroenterology, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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Marijuana use and post-transplant complications and non-compliance in liver transplant patients. Am J Med Sci 2023; 365:115-120. [PMID: 36202161 DOI: 10.1016/j.amjms.2022.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 09/16/2022] [Accepted: 09/29/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Liver transplant (LT) is a lifesaving treatment for patients with end stage liver disease. Historically, institutions across the United States have deemed active marijuana use as an exclusion criterion for listing. This study aims to investigate LT outcomes in patients with history of marijuana use prior to LT. METHODS We performed a retrospective review of 111 patients who tested positive for marijuana on urine drug screen during initial LT evaluation between February 2016 and January 2021. 100 non-marijuana users who underwent LT were cross matched for control. Patient demographics, substance use history, and transplant decisions were recorded. Post-LT variables were also collected up to 1 year post surgery including postoperative infections, issues with non-compliance, and continued substance use. Chi-square analysis was used to assess the association between pre-transplant marijuana use and post-transplant complications. Logistics regression was implemented to measure associations amongst the entire cohort. RESULTS From 111 marijuana users, 32 (29%) received a transplant. There was no statistical difference in post-LT outcomes between marijuana and non-marijuana users, including incidence of cardiac, respiratory, renal, psychiatric, or neurological complications, as well as readmission rates post-surgery. There were no statistically significant associations between marijuana use with post-transplant bacterial or fungal infections, medication non-compliance, or continued substance use (all p>0.05). Marijuana use was associated with pre-LT tobacco use (p = 0.020). CONCLUSIONS Our data indicates that marijuana is not associated with increased risk of postoperative noncompliance, other organ complications, infections, or death. As a single factor, marijuana may not need to be a contraindication for LT.
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Winder GS, Clifton EG, Mellinger JL. Substance use disorders in organ transplantation: perennial challenges and interprofessional opportunities. Curr Opin Organ Transplant 2022; 27:495-500. [PMID: 36170560 DOI: 10.1097/mot.0000000000001026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW The current article examines recent publications regarding ongoing clinical and ethical challenges and opportunities related to substance use disorders (SUD) in solid organ transplantation (SOT) utilizing a lens of interprofessional clinical models and care delivery. RECENT FINDINGS Innovative interprofessional clinician skillsets and care models are increasingly emphasized in the SOT literature as the standard of care for common, complex psychosocial problems like substance use and SUD. Cannabinoids are common among candidates and recipients and present several unique quandaries to SOT teams. Opioid use disorder treatment can often be definitively treated with medications that SOT teams may find unfamiliar, controversial, or aversive. Arguably the quintessential example of SUD in SOT, early liver transplantation for patients with alcohol-related liver disease and short periods of sobriety has become increasingly common and accepted in recent years requiring liver teams to rapidly acquire significant interprofessional psychiatric awareness and expertise. The question of retransplantation in patients who have experienced recurrent SUD remains unsettled. SUMMARY Regardless of substances used or organs transplanted, interprofessional care continues to emerge as a foundational aspect of clinical care and research in SOT.
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Affiliation(s)
- Gerald S Winder
- Department of Psychiatry
- Department of Surgery
- Department of Neurology
| | | | - Jessica L Mellinger
- Department of Psychiatry
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Winder GS, Andrews SR, Banerjee AG, Hussain F, Ivkovic A, Kuntz K, Omary L, Shenoy A, Thant T, VandenBerg A, Zimbrean P. Cannabinoids and solid organ transplantation: Psychiatric perspectives and recommendations. Transplant Rev (Orlando) 2022; 36:100715. [PMID: 35853383 DOI: 10.1016/j.trre.2022.100715] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 07/10/2022] [Indexed: 01/01/2023]
Abstract
Cannabinoid use in patients seeking solid organ transplantation (SOT) is an important and unsettled matter which all transplantation clinicians regularly encounter. It is also a multifaceted, interprofessional issue, difficult for any specialty alone to adequately address in a research article or during clinical care. Such uncertainty lends itself to bias for or against cannabinoid use accompanied by inconsistent policies and procedures. Scientific literature in SOT regarding cannabinoids often narrowly examines the issue and exists mostly in liver and kidney transplantation. Published recommendations from professional societies are mosaics of vagueness and specificity mirroring the ongoing dilemma. The cannabinoid information SOT clinicians need for clinical care may require data and perspectives from diverse medical literature which are rarely synthesized. SOT teams may not be adequately staffed or trained to address various neuropsychiatric cannabinoid effects and risks in patients. In this article, authors from US transplantation centers conduct a systematized review of the few existing studies regarding clinician perceptions, use rates, and clinical impact of cannabinoid use in SOT patients; collate representative professional society guidance on the topic; draw from diverse medical literature bases to detail facets of cannabinoid use in psychiatry and addiction pertinent to all transplantation clinicians; provide basic clinical and policy recommendations; and indicate areas of future study.
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Affiliation(s)
| | - Sarah R Andrews
- Johns Hopkins Department of Psychiatry and Behavioral Sciences, Baltimore, Maryland, USA
| | | | - Filza Hussain
- Stanford University Department of Psychiatry and Behavioral Sciences, Palo Alto, California, USA
| | - Ana Ivkovic
- Massachusetts General Hospital Department of Psychiatry, Boston, Massachusetts, USA
| | - Kristin Kuntz
- Ohio State University Department of Psychiatry and Behavioral Health, Columbus, Ohio, USA
| | - Lesley Omary
- Vanderbilt University Department of Psychiatry and Behavioral Sciences, Nashville, Tennessee, USA
| | - Akhil Shenoy
- Columbia University Department of Psychiatry, New York City, New York, USA
| | - Thida Thant
- University of Colorado Department of Psychiatry, Aurora, Colorado, USA
| | - Amy VandenBerg
- University of Michigan Department of Psychiatry, Ann Arbor, Michigan, USA
| | - Paula Zimbrean
- Yale University Department of Psychiatry, New Haven, Connecticut, USA
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7
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Jowsey-Gregoire S, Jannetto PJ, Jesse MT, Fleming J, Winder GS, Balliet W, Kuntz K, Vasquez A, Weinland S, Hussain F, Weinrieb R, Fireman M, Nickels MW, Peipert JD, Thomas C, Zimbrean PC. Substance use screening in transplant populations: Recommendations from a consensus workgroup. Transplant Rev (Orlando) 2022; 36:100694. [DOI: 10.1016/j.trre.2022.100694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 04/20/2022] [Indexed: 02/07/2023]
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Sobotka LA, Mumtaz K, Hinton A, Kelly SG, Conteh LF, Michaels AJ, Hanje AJ, Wellner MR. Cannabis use may reduce healthcare utilization and improve hospital outcomes in patients with cirrhosis. Ann Hepatol 2022; 23:100280. [PMID: 33157269 DOI: 10.1016/j.aohep.2020.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 10/26/2020] [Accepted: 10/26/2020] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES Previous studies reveal conflicting data on the effect of cannabis use in patients with cirrhosis. This research evaluates the impact of cannabis on hepatic decompensation, health care utilization, and mortality in patients with cirrhosis. MATERIAL AND METHODS A retrospective analysis of the State Inpatient Database (SID) was performed evaluating patients from Colorado and Washington in 2011 to represent pre-cannabis legalization and 2015 to represent post-cannabis legalization. Multivariable analysis was performed to study the impact of cannabis on the rate of admissions with hepatic decompensations, healthcare utilization, and mortality in patients with cirrhosis. RESULTS Cannabis use was detected in 370 (2.1%) of 17,520 cirrhotics admitted in 2011 and in 1162 (5.3%) of 21,917 cirrhotics in 2015 (p-value <0.001). On multivariable analysis, cirrhotics utilizing cannabis after its legalization experienced a decreased rate of admissions related to hepatorenal syndrome (Odds Ratio (OR): 0.51; 95% Confidence Interval (CI): 0.34-0.78) and ascites (OR: 0.73; 95% CI: 0.63-0.84). Cirrhotics with an etiology of disease other than alcohol and hepatitis C had a higher risk of admission for hepatic encephalopathy if they utilized cannabis [OR: 1.57; 95% CI: 1.16-2.13]. Decreased length of stay (-1.15 days; 95% CI: -1.62, -0.68), total charges (-$15,852; 95% CI: -$21,009, -$10,694), and inpatient mortality (OR: 0.68; 95% CI: 0.51-0.91) were also observed in cirrhotics utilizing cannabis after legalization compared to cirrhotics not utilizing cannabis or utilizing cannabis prior to legalization. CONCLUSION Cannabis use in patients with cirrhosis resulted in mixed outcomes regarding hospital admissions with hepatic decompensation. A trend towards decreased hospital utilization and mortality was noted in cannabis users after legalization. These observations need to be confirmed with a longitudinal randomized study.
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Affiliation(s)
- Lindsay A Sobotka
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, The Ohio State Wexner Medical Center, Columbus, Ohio, 43210 US
| | - Khalid Mumtaz
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, The Ohio State Wexner Medical Center, Columbus, Ohio, 43210 US
| | - Alice Hinton
- Division of Biostatistics, College of Public Heath, The Ohio State University, Columbus Ohio, 43210 US
| | - Sean G Kelly
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, The Ohio State Wexner Medical Center, Columbus, Ohio, 43210 US
| | - Lanla F Conteh
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, The Ohio State Wexner Medical Center, Columbus, Ohio, 43210 US
| | - Anthony J Michaels
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, The Ohio State Wexner Medical Center, Columbus, Ohio, 43210 US
| | - A James Hanje
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, The Ohio State Wexner Medical Center, Columbus, Ohio, 43210 US
| | - Michael R Wellner
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, The Ohio State Wexner Medical Center, Columbus, Ohio, 43210 US.
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Yan K, Forman L. Cannabinoid Use Among Liver Transplant Recipients. Liver Transpl 2021; 27:1623-1632. [PMID: 34018308 DOI: 10.1002/lt.26103] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 05/11/2021] [Accepted: 05/14/2021] [Indexed: 01/06/2023]
Abstract
The effect of cannabinoids on liver transplant outcomes is an area of active research. We aimed to investigate marijuana (MJ) and cannabidiol (CBD) use among liver transplant recipients at the University of Colorado Hospital (UCH), specifically prevalence, habits, and predictors of use. Liver transplant recipients followed at UCH with valid email addresses were sent an informed consent postcard and survey invitation. This exploratory survey was conducted using REDCap. IBM SPSS Statistics software was used for statistical analysis. Of 1227 recipients who were sent surveys, 538 people responded. On average, respondents were 59 years old, with 63.7% male and 81.7% White. Hepatitis C virus (HCV; 30.4%) and alcohol use (17.7%) were the most common etiologies of liver disease. Among respondents, 23.8% reported current MJ use. Methods of use included smoking (72.4%), ingestion (55.3%), and vaporization (31.7%). Top reasons for MJ use were recreation (56.5%), anxiety (54.8%), and pain (53.2%). Among respondents, 21.0% currently used CBD, usually in the form of creams or lotions (58.9%) and to relieve pain (84.9%) and anxiety (31.1%). In multivariable analysis, age (odds ratio [OR], 0.941; 95% confidence interval [CI], 0.923-0.959; P < 0.001), diabetes mellitus (OR, 0.357; 95% CI, 0.171-0.746; P = 0.01), HCV cirrhosis (OR, 3.949; 95% CI, 2.281-6.835; P < 0.001), alcohol-related cirrhosis (OR, 2.101; 95% CI, 1.202-3.671; P = 0.01), and current tobacco use (OR, 2.918; 95% CI, 1.065-7.990; P = 0.04) were significant predictors of MJ use. Our study shows that cannabinoid use after liver transplant is common. MJ use is associated with decreasing age, alcohol-related and HCV cirrhosis, and tobacco use. Anxiety, pain, and recreation were top reasons for its use. Transplant teams should address reasons why their patients use MJ and CBD and develop programs to mitigate anxiety and pain after transplant. Further studies are needed to examine effects of cannabinoids on liver transplant outcomes.
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Affiliation(s)
- Kathleen Yan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Lisa Forman
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Colorado School of Medicine, Aurora, CO
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Qi M, Kaddis JS, Chen KT, Rawson J, Omori K, Chen ZB, Dhawan S, Isenberg JS, Kandeel F, Roep BO, Al-Abdullah IH. Chronic marijuana usage by human pancreas donors is associated with impaired islet function. PLoS One 2021; 16:e0258434. [PMID: 34705837 PMCID: PMC8550598 DOI: 10.1371/journal.pone.0258434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 09/27/2021] [Indexed: 11/18/2022] Open
Abstract
We investigated the effect of chronic marijuana use, defined as 4 times weekly for more than 3 years, on human pancreatic islets. Pancreata from deceased donors who chronically used marijuana were compared to those from age, sex and ethnicity matched non-users. The islets from marijuana-users displayed reduced insulin secretion as compared to islets from non-users upon stimulation with high glucose (AUC, 3.41 ± 0.62 versus 5.14 ±0.47, p<0.05) and high glucose plus KCl (AUC, 4.48 ± 0.41 versus 7.69 ± 0.58, p<0.001). When human islets from chronic marijuana-users were transplanted into diabetic mice, the mean reversal rate of diabetes was 35% versus 77% in animals receiving islets from non-users (p<0.01). Immunofluorescent staining for cannabinoid receptor type 1 (CB1R) was shown to be colocalized with insulin and enhanced significantly in beta cells from marijuana-users vs. non-users (CB1R intensity/islet area, 14.95 ± 2.71 vs. 3.23 ± 0.87, p<0.001). In contrast, CB1R expression was not co-localized with glucagon or somatostatin. Furthermore, isolated islets from chronic marijuana-users appeared hypertrophic. In conclusion, excessive marijuana use affects islet endocrine phenotype and function in vitro and in vivo. Given the increasing use of marijuana, our results underline the importance of including lifestyle when evaluating human islets for transplantation or research.
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Affiliation(s)
- Meirigeng Qi
- Department of Translational Research and Cellular Therapeutics, Beckman Research Institute, City of Hope, Duarte, California, United States of America
| | - John S. Kaddis
- Department of Diabetes Immunology, Beckman Research Institute, City of Hope, Duarte, California, United States of America
- Department of Diabetes and Cancer Discovery Science, Beckman Research Institute, City of Hope, Duarte, California, United States of America
| | - Kuan-Tsen Chen
- Department of Translational Research and Cellular Therapeutics, Beckman Research Institute, City of Hope, Duarte, California, United States of America
| | - Jeffrey Rawson
- Department of Translational Research and Cellular Therapeutics, Beckman Research Institute, City of Hope, Duarte, California, United States of America
| | - Keiko Omori
- Department of Translational Research and Cellular Therapeutics, Beckman Research Institute, City of Hope, Duarte, California, United States of America
| | - Zhen Bouman Chen
- Department of Diabetes Complications & Metabolism, Arthur Riggs Diabetes & Metabolism Research Institute, Beckman Research Institute, City of Hope, Duarte, California, United States of America
| | - Sangeeta Dhawan
- Department of Translational Research and Cellular Therapeutics, Beckman Research Institute, City of Hope, Duarte, California, United States of America
| | - Jeffrey S. Isenberg
- Department of Translational Research and Cellular Therapeutics, Beckman Research Institute, City of Hope, Duarte, California, United States of America
| | - Fouad Kandeel
- Department of Translational Research and Cellular Therapeutics, Beckman Research Institute, City of Hope, Duarte, California, United States of America
| | - Bart O. Roep
- Department of Diabetes Immunology, Beckman Research Institute, City of Hope, Duarte, California, United States of America
| | - Ismail H. Al-Abdullah
- Department of Translational Research and Cellular Therapeutics, Beckman Research Institute, City of Hope, Duarte, California, United States of America
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Greenberg R, Goldberg A, Anthony S, Buchman DZ, Delaney S, Gruben V, Holdsworth S, Le Foll B, Leung M, Lien D, Lynch MJ, Selzner N, Chandler JA, Fortin MC. Canadian Society of Transplantation White Paper: Ethical and Legal Considerations for Alcohol and Cannabis Use in Solid Organ Listing and Allocation. Transplantation 2021; 105:1957-1964. [PMID: 33587429 PMCID: PMC8376271 DOI: 10.1097/tp.0000000000003618] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 11/16/2020] [Accepted: 11/20/2020] [Indexed: 11/26/2022]
Abstract
Alcohol and cannabis use as a contraindication to organ transplantation is a controversial issue. Until recently, patients in Canada with alcohol-associated liver disease were required to demonstrate abstinence for 6 mo to receive a liver transplant. There is no equivalent rule that is applied consistently for cannabis use. There is some evidence that alcohol and cannabis use disorder pretransplant could be associated with worse outcomes posttransplantation. However, early liver transplantation for patients with alcohol-associated liver disease in France and in the United States has led to challenges of the 6-mo abstinence rule in Canada in the media. It has also resulted in several legal challenges arguing that the rule violates human rights laws regarding discrimination in the provision of medical services and that the rule is also unconstitutional (this challenge is still before the court). Recent legalization of cannabis use for adults in Canada has led to questions about the appropriateness of limiting transplant access based on cannabis use. The ethics committee of the Canadian Society of Transplantation was asked to provide an ethical analysis of cannabis and alcohol abstinence policies. Our conclusions were as follows: neither cannabis use nor the 6-mo abstinence rule for alcohol use should be an absolute contraindication to transplantation, and transplant could be offered to selected patients, further research should be conducted to ensure evidence-based policies; and the transplant community has a duty not to perpetuate stigma associated with alcohol and cannabis use disorders.
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Affiliation(s)
- Rebecca Greenberg
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Mount Sinai Hospital, Toronto, ON, Canada
| | - Aviva Goldberg
- Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
| | - Samantha Anthony
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
- Factor-Inwentash Faculty of Social Work, University of Toronto, ON, Canada
| | - Daniel Z. Buchman
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
| | | | - Vanessa Gruben
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
- Faculty of Law, University of Ottawa, Ottawa, ON, Canada
| | - Sandra Holdsworth
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
| | - Bernard Le Foll
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | | | - Dale Lien
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Marie-Josee Lynch
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto General Research Institute, Toronto, ON, Canada
| | - Nazia Selzner
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
- Toronto General Research Institute, Toronto, ON, Canada
| | - Jennifer A. Chandler
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
- Faculty of Law, University of Ottawa, Ottawa, ON, Canada
| | - Marie-Chantal Fortin
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
- Centre de recherche du CHUM, Montreal, QC, Canada
- Faculty of Medicine, University of Montreal, QC, Canada
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Guorgui J, Ito T, Markovic D, Aziz A, Younan S, Severance A, Lu M, Lee J, DiNorcia J, Agopian VG, Farmer DG, Busuttil RW, Kaldas FM. The impact of marijuana use on liver transplant recipients: A 900 patient single center experience. Clin Transplant 2021; 35:e14215. [PMID: 33406299 DOI: 10.1111/ctr.14215] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 09/16/2020] [Accepted: 12/21/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Increased societal prevalence of marijuana continues to challenge liver transplant (LT) programs. This study aimed to examine the potential effects of marijuana use on outcomes. METHODS This retrospective study included recipients who underwent LT between 1/2012 and 6/2018. According to pre-LT marijuana use, patients were classified into recent (≤6 months of LT), former (chronic use but not ≤6 months), or non-users. Additionally, the impact of post-LT marijuana use on survival was assessed. RESULTS Of 926 eligible patients, 184 were pre-LT marijuana users (42 recent; 142 former) (median follow-up: 30.3 months). Pre-users were more likely to be male, White, and have histories of tobacco, alcohol, and illicit drug use. Additionally, recent users were of higher acuity, with higher MELD and requiring ICU admission. Patient survival at 1-year was 89% in non-users, 94% (HR: 0.494, 95% CI: 0.239-1.022 vs. non-users) in former users, and 83% (HR: 1.516, 95% CI: 0.701-3.282) in recent users. Post-operative complications in pre-LT users and the survival analysis for post-LT marijuana users vs. non-users did not show significance. CONCLUSIONS Our results demonstrated that marijuana use did not have an adverse impact on post-LT outcomes; however, further studies utilizing larger cohorts are warranted.
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Affiliation(s)
- Jacob Guorgui
- Department of Surgery, The Dumont-UCLA Transplant and Liver Cancer, Division of Liver and Pancreas Transplantation, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Takahiro Ito
- Department of Surgery, The Dumont-UCLA Transplant and Liver Cancer, Division of Liver and Pancreas Transplantation, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Daniela Markovic
- Department of Medicine Statics, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Antony Aziz
- Department of Surgery, The Dumont-UCLA Transplant and Liver Cancer, Division of Liver and Pancreas Transplantation, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Stephanie Younan
- Department of Surgery, The Dumont-UCLA Transplant and Liver Cancer, Division of Liver and Pancreas Transplantation, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Alyscia Severance
- Department of Surgery, The Dumont-UCLA Transplant and Liver Cancer, Division of Liver and Pancreas Transplantation, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Michelle Lu
- Department of Surgery, The Dumont-UCLA Transplant and Liver Cancer, Division of Liver and Pancreas Transplantation, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Jane Lee
- Department of Surgery, The Dumont-UCLA Transplant and Liver Cancer, Division of Liver and Pancreas Transplantation, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Joseph DiNorcia
- Department of Surgery, The Dumont-UCLA Transplant and Liver Cancer, Division of Liver and Pancreas Transplantation, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Vatche G Agopian
- Department of Surgery, The Dumont-UCLA Transplant and Liver Cancer, Division of Liver and Pancreas Transplantation, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Douglas G Farmer
- Department of Surgery, The Dumont-UCLA Transplant and Liver Cancer, Division of Liver and Pancreas Transplantation, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Ronald W Busuttil
- Department of Surgery, The Dumont-UCLA Transplant and Liver Cancer, Division of Liver and Pancreas Transplantation, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Fady M Kaldas
- Department of Surgery, The Dumont-UCLA Transplant and Liver Cancer, Division of Liver and Pancreas Transplantation, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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13
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Abstract
PURPOSE OF REVIEW Timely referral of eligible candidates for consideration of advanced therapies, such as a heart transplantation or mechanical circulatory support is essential. The characteristics of heart transplantation candidates have changed significantly over the years, leading to a more complex evaluation process. The present review summarizes recent advances in the evaluation process for heart transplantation eligibility. RECENT FINDINGS The heart transplantation allocation policy was recently reviewed in the USA in an effort to reduce waitlist mortality and to ensure fair geographic allocation of organs to the sickest patients. Moreover, patients with chronic infectious diseases, as well as malignancies, are being currently considered acceptable candidates for transplantation. Listing practices for heart transplantation vary between programmes, with a greater willingness to consider high-risk candidates at higher-volume centres. SUMMARY The ultimate decision to place high-risk candidates on the heart transplantation waitlist should be based on a combination of quantitative and qualitative data analysis informed by clinical judgement, and the chronic shortage of organ donors makes this process an important ethical concern for any society. Future guidelines should discuss approaches to achieve fair organ allocation while preserving improved outcomes after transplantation.
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Affiliation(s)
- Jefferson L Vieira
- Heart and Vascular Center, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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14
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Syed A, Sadler MD, Borman MA, Burak KW, Congly SE. Assessment of Canadian policies regarding liver transplant candidacy of people who use alcohol, tobacco, cannabis, and opiates. CANADIAN LIVER JOURNAL 2020; 3:372-380. [PMID: 35990508 PMCID: PMC9202737 DOI: 10.3138/canlivj.2020-0005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 03/18/2020] [Indexed: 07/29/2023]
Abstract
BACKGROUND When last assessed in 2013, all Canadian liver transplant programs required 6 months of abstinence from alcohol. New studies have questioned the validity of this policy. Moreover, with recreational cannabis now legal in Canada, more transplant candidates may use cannabis. Given these changes, our objective was to obtain an understanding of current Canadian practices regarding liver transplantation and candidates with addiction or alcohol, tobacco, cannabis, or opiate use. METHODS Electronic surveys were distributed to the medical directors of all seven adult liver transplant programs in Canada. Questions were based on either a Likert-scale ranking or free response. The complete data set was aggregated to provide a national perspective on this topic and ensure each individual program remained anonymous. RESULTS All seven programs responded to the survey. Of these programs, 43% always require 6-month abstinence from alcohol, 29% usually require it, and 14% sometimes require it. Formal alcohol rehabilitation is mandatory in two programs. The majority (57%) of programs never or rarely consider transplant for patients with acute alcoholic hepatitis; 29% require smoking cessation before consideration for transplant; and 71% felt that cannabis use is rarely or never a contraindication to liver transplantation. CONCLUSIONS Significantly more Canadian programs now perform liver transplant for patients who have less than 6 months abstinence from alcohol, and alcoholic hepatitis is no longer an absolute contraindication in Canada. Policies on smoking and opiates are quite variable. Further study and discussion are critical for development of national policies to obtain equitable access to liver transplant for all.
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Affiliation(s)
- Ahsan Syed
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matthew D Sadler
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Meredith A Borman
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kelly W Burak
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Stephen E Congly
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute of Public Health, University of Calgary, Calgary, Alberta, Canada
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15
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Majumder P, Sarkar S. A Review of the Prevalence of Illicit Substance Use in Solid-Organ Transplant Candidates and the Effects of Illicit Substance Use on Solid-Organ Transplant Treatment Outcomes. Cureus 2020; 12:e8986. [PMID: 32775068 PMCID: PMC7402423 DOI: 10.7759/cureus.8986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Solid-organ transplantation is one of the significant advances in the medical field that have improved the quality of life and survival rates of numerous patients with end-organ dysfunction. Substance use is a common condition of individuals who are in need of solid-organ transplantation. The implications of substance use on solid-organ transplants are gaining increasing attention over the past decade. The current review seeks to explore the prevalence rate of illicit substance use among those who receive solid-organ transplantation (pre and post-transplant) and whether illicit substance use before solid-organ transplantation affects the outcome of solid-organ transplants. We searched the Medline database for all the articles available in English on the prevalence of substance use in the context of solid-organ transplant and the effect on outcome measures. We found 21 relevant articles. It appears that substance use is fairly common among solid-organ transplant candidates, with cannabis being the most common substance of abuse. A heterogeneous sample precludes the drawing of a clear-cut conclusion. But it appears that substance use may affect various outcomes of solid-organ transplants. The existing literature may not be sufficient to adequately assess the risk but limited evidence indicates that illicit substance use, particularly cannabis use, may not affect the overall survival following a solid-organ transplant.
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Affiliation(s)
| | - Siddharth Sarkar
- Addiction, All India Institute of Medical Sciences, New Delhi, IND
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16
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Fabbri KR, Anderson‐Haag TL, Spenningsby AM, Israni A, Nygaard RM, Stahler PA. Marijuana use should not preclude consideration for kidney transplantation. Clin Transplant 2019; 33:e13706. [DOI: 10.1111/ctr.13706] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 08/28/2019] [Accepted: 08/30/2019] [Indexed: 12/13/2022]
Affiliation(s)
| | | | | | - Ajay Israni
- Department of Nephrology Hennepin Healthcare Minneapolis MN USA
| | | | - Paul A. Stahler
- Department of Surgery Hennepin Healthcare Minneapolis MN USA
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17
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Serrano Rodriguez P, Strassle PD, Barritt AS, Watkins R, Gerber DA, Hayashi PH, Desai CS. Marijuana Consumption in Liver Transplant Recipients. Liver Transpl 2019; 25:734-740. [PMID: 30693668 DOI: 10.1002/lt.25417] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 01/20/2019] [Indexed: 02/07/2023]
Abstract
Marijuana is legalized for either medical or recreational use in over half of the states in the United States and in Canada, but many transplant centers will not list patients who are using marijuana. However, the effect of marijuana on transplant outcomes remains unclear. Thus, we performed a retrospective analysis of all adult (≥18 years old) liver transplant patients treated at our center between 2007 and 2017. Patients were grouped according to their marijuana use and tobacco smoking status. We also evaluated tobacco smoking status for the comparative evaluation. Posttransplant morbidity, mortality, and graft survival were evaluated. In total, 316 patients were included: 171 (54%) patients were tobacco smokers (70 current; 101 former), 81 (26%) patients were marijuana smokers (13 current; 68 former), and 64 (20#x0025;) patients were both marijuana and tobacco smokers. A total of 136 (43%) reported never smoking marijuana or tobacco. After adjustment, current tobacco users were over 3 times as likely to die within 5 years compared with never users (hazard ratio [HR], 3.25; 95% confidence interval [CI], 1.63-6.46; P < 0.001), but no difference was seen between current/former and never marijuana users (HR, 0.52; 95% CI, 0.26-1.04; P = 0.06). No significant differences in inpatient respiratory complications, reintubation, or >24-hour intubation was seen. Overall, pretransplant marijuana use, past or current, does not appear to impact liver transplant outcomes, though tobacco smoking remains detrimental.
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Affiliation(s)
- Pablo Serrano Rodriguez
- Department of Surgery, Division of Abdominal Transplant Surgery, University of North Carolina, Chapel Hill, NC
| | - Paula Diane Strassle
- Department of Surgery, Division of Abdominal Transplant Surgery, University of North Carolina, Chapel Hill, NC
| | | | - Randall Watkins
- UNC Health Care, University of North Carolina, Chapel Hill, NC
| | - David A Gerber
- Department of Surgery, Division of Abdominal Transplant Surgery, University of North Carolina, Chapel Hill, NC
| | - Paul Hideyo Hayashi
- Liver Center, Department of Medicine, University of North Carolina, Chapel Hill, NC
| | - Chirag Sureshchandra Desai
- Department of Surgery, Division of Abdominal Transplant Surgery, University of North Carolina, Chapel Hill, NC
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18
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Neuberger J. Liver Transplantation and Marijuana Use: Needing a Joint Approach. Liver Transpl 2019; 25:688-689. [PMID: 30913351 DOI: 10.1002/lt.25456] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 03/22/2019] [Indexed: 02/07/2023]
Affiliation(s)
- James Neuberger
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
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19
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Marijuana use and candidacy for heart transplantation. J Heart Lung Transplant 2019; 38:589-592. [PMID: 31128599 DOI: 10.1016/j.healun.2019.03.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 03/24/2019] [Accepted: 03/29/2019] [Indexed: 12/18/2022] Open
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20
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Levi ME, Montague BT, Thurstone C, Kumar D, Huprikar SS, Kotton CN. Marijuana use in transplantation: A call for clarity. Clin Transplant 2019; 33:e13456. [PMID: 30506888 DOI: 10.1111/ctr.13456] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 10/31/2018] [Accepted: 11/26/2018] [Indexed: 12/22/2022]
Abstract
Transplant centers have varying policies for marijuana (MJ) use in donors, transplant candidates, and recipients. Rationales for these differences range from concerns for fungal complications, impaired adherence, and drug interactions. This paper reviews the current status of MJ policies and practices in transplant centers and results of a survey sent to the American Society of Transplantation (AST) membership by the Executive Committee of the AST Infectious Diseases Community of Practice.The purpose of the survey was to compare policies and concerns of MJ use to actual observed complications. Of the 3321 surveys sent, 225 members (8%) responded. Transplant centers varied in their approval processes, differing even in organ types within the same institutions. Furthermore, there was discordance among transplant centers in their perceived risks of marijuana use as opposed to complications actually observed. An increasing number of states continue to legalize medical and recreational MJ resulting in widespread availability. Further research is needed to assess the validity of concerns for complications of MJ use in potential donors and recipients. Ultimately, standardized guidelines should be established based on studies and evidence-based criteria to assist transplant programs in their policies around the use of cannabis in their donors and recipients.
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Affiliation(s)
- Marilyn E Levi
- Department of Internal Medicine/Division of Infectious Diseases, University of Colorado, Aurora, Colorado
| | - Brian T Montague
- Department of Internal Medicine/Division of Infectious Diseases, University of Colorado, Aurora, Colorado
| | - Christian Thurstone
- Department of Psychiatry, Denver Health and Hospital Authority and University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Deepali Kumar
- Transplant Infectious Diseases and Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Shirish S Huprikar
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Camille N Kotton
- Transplant and Immunocompromised Host Infectious Diseases Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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21
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Andrews CN, Devlin SM, Le Foll B, Fischer B, Tse F, Storr M, Congly SE. Canadian Association of Gastroenterology Position Statement: Use of Cannabis in Gastroenterological and Hepatic Disorders. J Can Assoc Gastroenterol 2018; 2:37-43. [PMID: 31294362 PMCID: PMC6507278 DOI: 10.1093/jcag/gwy064] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 10/17/2018] [Indexed: 12/19/2022] Open
Affiliation(s)
- Christopher N Andrews
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Correspondence: Christopher N Andrews, MD, MSc, FRCPC, Clinical Professor, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, 6th Floor, TRW Building, 3280 Hospital Drive NW, Calgary, AB T2N 4Z6, Canada. E-mail
| | - Shane M Devlin
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Bernard Le Foll
- Translational Addiction Research Laboratory, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Acute Care Program, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Departments of Family and Community Medicine, Pharmacology and Toxicology, Psychiatry, Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Benedikt Fischer
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Frances Tse
- Department of Gastroenterology and Hepatology, McMaster University, Hamilton, Ontario, Canada
| | - Martin Storr
- Department of Medicine, University of Munich and Center of Endoscopy, Starnberg, Germany
| | - Stephen E Congly
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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22
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Burra P, Giannini EG, Caraceni P, Ginanni Corradini S, Rendina M, Volpes R, Toniutto P. Specific issues concerning the management of patients on the waiting list and after liver transplantation. Liver Int 2018; 38:1338-1362. [PMID: 29637743 DOI: 10.1111/liv.13755] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 03/27/2018] [Indexed: 02/06/2023]
Abstract
The present document is a second contribution collecting the recommendations of an expert panel of transplant hepatologists appointed by the Italian Association for the Study of the Liver (AISF) concerning the management of certain aspects of liver transplantation, including: the issue of prompt referral; the management of difficult candidates; malnutrition; living related liver transplants; hepatocellular carcinoma; and the role of direct acting antiviral agents before and after transplantation. The statements on each topic were approved by participants at the AISF Transplant Hepatology Expert Meeting organized by the Permanent Liver Transplant Commission in Mondello on 12-13 May 2017. They are graded according to the GRADE grading system.
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Affiliation(s)
- Patrizia Burra
- Multivisceral Transplant Unit, University Hospital, Padova, Italy
| | - Edoardo G Giannini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Ospedale Policlinico San Martino, Genoa, Italy
| | | | | | | | - Riccardo Volpes
- Hepatology and Gastroenterology Unit, ISMETT-IRCCS, Palermo, Italy
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23
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Affiliation(s)
- Willscott E Naugler
- Liver Transplantation and the Multidisciplinary Liver Tumor Group, Department of Medicine/GI and Hepatology, Oregon Health and Sciences University, Portland, OR
| | - Susan L Orloff
- Division of Abdominal Organ Transplantation/Hepatobiliary Surgery, Department of Surgery, Oregon Health and Sciences University, Portland, OR
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