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Raja K, Panackel C. Post Liver Transplant Renal Dysfunction-Evaluation, Management and Immunosuppressive Practice. J Clin Exp Hepatol 2024; 14:101306. [PMID: 38274509 PMCID: PMC10806298 DOI: 10.1016/j.jceh.2023.101306] [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: 01/10/2023] [Accepted: 11/21/2023] [Indexed: 01/27/2024] Open
Abstract
Liver transplantation (LT) is an effective and lifesaving treatment for patients with end-stage liver disease and hepatocellular carcinoma. Significant improvement in intermediate and long-term survival has been possible due to advancements in immunosuppressive therapy, perioperative care, and surgical techniques. Despite these advances, metabolic complications, including diabetes mellitus, cardiovascular diseases, malignancies, and renal dysfunction, are challenging issues after LT. Acute kidney injury (AKI) and chronic kidney disease (CKD) after LT are common and result in significant morbidity and mortality. Early diagnosis of kidney injury after LT is challenging, and no technique has yet proven effective in prediction of renal dysfunction. The methods for assessing renal function range from formulas that predict glomerular filtration rate to non-invasive biomarkers. The universal adoption of the model for end-stage liver disease has a direct impact on the incidence of peri-transplant AKI and development of CKD in the long-term. Post-LT renal dysfunction is multifactorial and is usually a result of pre-transplantation comorbidities, occurrence of renal dysfunction on the waiting list, perioperative events, and post-transplant nephrotoxic immunosuppressive medication use. Early identification of patients at risk for renal dysfunction and adoption of preventive measures are crucial in the pre-transplant period. No data are currently available to suggest a surgical technique that reliably demonstrates renal protection. Nephroprotective strategies during LT follow accepted surgical practice guidelines, such as maintenance of intravascular volume and mean arterial pressure. The management of kidney disease following LT is challenging, as by the time the serum creatinine is significantly elevated, few interventions impact the course of progression. Early nephroprotective measures are strongly advised and they mostly center on delaying the administration of calcineurin inhibitors (CNIs) during the initial postoperative period, lowering CNI dosage and combining CNI with mycophenolate mofetil and everolimus. The reasons for renal failure following LT, the techniques used to diagnose it, and the therapies designed to preserve renal function both immediately and late after LT are all critically evaluated in this review.
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Affiliation(s)
- Kaiser Raja
- Department of Gastroenterology and Hepatology, King's College Hospital London, Dubai, United Arab Emirates
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2
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Ting JA, Induruwage D, Yoshida EM, Dhruve M, Zalunardo NY. Albuminuria post-liver transplant is a predictor of kidney disease progression and mortality. CANADIAN LIVER JOURNAL 2023; 6:2-13. [PMID: 36908578 PMCID: PMC9997516 DOI: 10.3138/canlivj-2022-0019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 06/05/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND: Albuminuria is a marker of chronic kidney disease (CKD) associated with an increased risk of end-stage kidney disease (ESKD) and mortality in the general population, but it is uncertain whether the same association exists in liver transplant (LT) recipients. This study examined the association between albuminuria and kidney failure and mortality in LT recipients.METHODS: Retrospective cohort study of 294 adults who received a LT between January 1, 1989, and December 31, 2011, in British Columbia, Canada. Cox multivariable regression was used to determine the association between ACR and a primary combined outcome of mortality, doubling of serum creatinine, or ESKD; and a secondary outcome of a decrease in estimated glomerular filtration rate (eGFR) ≥30%. RESULTS: At baseline, mean eGFR was 67 (SD 20.9) mL/min/1.73 m2, and 10% had severe albuminuria (ACR >30 mg/mmol). The primary outcome occurred in 20.4% (60) of patients and was associated with ACR >30 mg/mmol (HR 2.77, 95% CI 1.28-6.04; P = 0.01). A decline in eGFR ≥30% occurred in 21.8% (64) of patients, and was associated with ACR >30 mg/mmol (HR 4.77, 95% CI 2.31-9.86; P < 0.0001). CONCLUSIONS: Severe albuminuria (ACR >30 mg/mmol) was associated with an increased risk of loss of kidney function and mortality after LT. Prospective studies are needed to determine if specific interventions directed at reducing albuminuria can improve long-term outcomes in LT recipients.
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Affiliation(s)
- Julie Anne Ting
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Eric M Yoshida
- Division of Gastroenterology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Miten Dhruve
- Division of Nephrology, Michael Garron Hospital, Toronto, Ontario, Canada
| | - Nadia Y Zalunardo
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
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3
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Farshbafnadi M, Razi S, Rezaei N. Transplantation. Clin Immunol 2023. [DOI: 10.1016/b978-0-12-818006-8.00008-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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4
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Azizieh Y, Westhaver LP, Badrudin D, Boudreau JE, Gala-Lopez BL. Changing liver utilization and discard rates in clinical transplantation in the ex-vivo machine preservation era. FRONTIERS IN MEDICAL TECHNOLOGY 2023; 5:1079003. [PMID: 36908294 PMCID: PMC9996101 DOI: 10.3389/fmedt.2023.1079003] [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: 10/24/2022] [Accepted: 01/30/2023] [Indexed: 02/25/2023] Open
Abstract
Liver transplantation is a well-established treatment for many with end-stage liver disease. Unfortunately, the increasing organ demand has surpassed the donor supply, and approximately 30% of patients die while waiting for a suitable liver. Clinicians are often forced to consider livers of inferior quality to increase organ donation rates, but ultimately, many of those organs end up being discarded. Extensive testing in experimental animals and humans has shown that ex-vivo machine preservation allows for a more objective characterization of the graft outside the body, with particular benefit for suboptimal organs. This review focuses on the history of the implementation of ex-vivo liver machine preservation and how its enactment may modify our current concept of organ acceptability. We provide a brief overview of the major drivers of organ discard (age, ischemia time, steatosis, etc.) and how this technology may ultimately revert such a trend. We also discuss future directions for this technology, including the identification of new markers of injury and repair and the opportunity for other ex-vivo regenerative therapies. Finally, we discuss the value of this technology, considering current and future donor characteristics in the North American population that may result in a significant organ discard.
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Affiliation(s)
- Yara Azizieh
- Department of Pathology, Dalhousie University, Halifax, NS, Canada
| | | | - David Badrudin
- Department of Surgery, Université de Montréal, Montréal, QC, Canada
| | - Jeanette E Boudreau
- Department of Pathology, Dalhousie University, Halifax, NS, Canada.,Department of Microbiology and Immunology, Dalhousie University, Halifax, NS, Canada.,Beatrice Hunter Cancer Research Institute, Halifax, NS, Canada
| | - Boris L Gala-Lopez
- Department of Pathology, Dalhousie University, Halifax, NS, Canada.,Department of Microbiology and Immunology, Dalhousie University, Halifax, NS, Canada.,Beatrice Hunter Cancer Research Institute, Halifax, NS, Canada.,Department of Surgery, Dalhousie University, Halifax, NS, Canada
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Disparate Intent-to-Treat Outcomes for Pediatric Liver Transplantation Based on Indication. Can J Gastroenterol Hepatol 2023; 2023:2859384. [PMID: 36911338 PMCID: PMC9998153 DOI: 10.1155/2023/2859384] [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: 11/03/2022] [Revised: 02/16/2023] [Accepted: 02/24/2023] [Indexed: 03/06/2023] Open
Abstract
Background The impact of indication for pediatric liver transplantation on waitlist and post-transplant mortality outcomes is well known, but the impact on intent-to-treat outcomes has not been investigated. Intent-to-treat survival analysis is important in this study because it is more comprehensive, combining the transplant outcomes of waitlist mortality, post-transplant mortality, and transplant rate into a single metric to elucidate any disparities in outcomes based on indication. Methods Cox regression was used to analyze factors impacting survival in 8,002 children listed for liver transplant in the UNOS database between 2006 and 2016. The Kaplan-Meier method and log-rank test were used to assess differences in waitlist, post-transplant, and intent-to-treat mortality among the top 5 indications of biliary atresia, acute hepatic necrosis, metabolic disorders, hepatoblastoma, and autoimmune cirrhosis. Results When compared to the reference group of biliary atresia, multivariate analyses showed that every indication was associated with inferior intent-to-treat outcomes except for metabolic disorders. Hepatoblastoma (hazard ratio (HR): 3.73), autoimmune cirrhosis (HR: 1.86), and AHN (HR: 1.77) were associated with significantly increased intent-to-treat mortality. Hepatoblastoma was also associated with increased post-transplant mortality (HR: 3.77) and was the only indication significantly associated with increased waitlist mortality (HR: 6.43). Conclusion Significant disparity exists across all indications with respect to an increased intent-to-treat mortality, along with an increased post-transplant and waitlist mortality, when compared to the biliary atresia reference group. If further studies validate these findings, a reexamination of the equitable distribution of allografts for transplant may be warranted as well as a focus on disparities in survival after transplant.
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6
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Joharji H, Alkortas D, Ajlan A, Ahmed M, Al‐Ashgar H, Al‐Quaiz M, Broering D, Al‐Sebayel M, Elsiesy H, Alkhail FA, Al‐Hamoudi WK, De Vol E, Amirah Almuhayshir E, Al‐Jedai A. Efficacy of generic sofosbuvir with daclatasvir compared to sofosbuvir/ledipasvir in genotype 4 hepatitis C virus: A prospective comparison with historical control. Health Sci Rep 2022; 6:e980. [PMID: 36514327 PMCID: PMC9731361 DOI: 10.1002/hsr2.980] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/21/2022] [Accepted: 11/27/2022] [Indexed: 12/13/2022] Open
Abstract
Background and Aim Management of genotype 4 hepatitis C virus (HCV) has shifted to interferon-free regimens with a high sustained virological response (SVR-12), especially with NS5B/NS5A inhibitor combinations such as sofosbuvir and ledipasvir (Sof-Led). The guidelines have recommended the combination of sofosbuvir and another NS5A inhibitor, daclatasvir, to manage HCV genotypes 1-3. However, its use was extended to genotype 4 HCV based on extrapolating evidence. Our aim is to assess the efficacy of generic sofosbuvir + branded daclatasvir (Sof-Dac) compared to the Sof-Led combination in treating genotype 4 HCV. Methods This study is an open-label, 2-period, noninferiority study that compared patients receiving a combination of generic sofosbuvir 400 mg and daclatasvir 60 mg orally daily (Group 2) prospectively to a historical control (Group 1) that included patients who received a combination of sofosbuvir/ledipasvir 400/90 mg orally daily. The primary endpoint is the proportion of patients who achieved SVR-12. Results The study included 111 patients in the (Sof-Led) Group 1 and 109 patients (Sof-Dac) Group 2. For the primary outcome, SVR-12 was achieved in 106 (95.5%) of the patients in Group 1 versus 108 (99.1%) in Group 2 (p = 0.2). In addition, all patients who achieved SVR-12 also achieved SVR-24. Conclusion Generic sofosbuvir combined with branded daclatasvir was safe and effective for treating genotype 4 HCV compared to Sof-Led. This combination may significantly reduce the cost burden, enabling a larger pool of treated patients. Office of research affairs at KFSHRC RAC# 2171 036.
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Affiliation(s)
- Hala Joharji
- King Faisal Specialist Hospital and Research Centre Organ Transplant Center of ExcellenceRiyadhSaudi Arabia
| | - Delal Alkortas
- King Faisal Specialist Hospital and Research Centre Organ Transplant Center of ExcellenceRiyadhSaudi Arabia
| | - Aziza Ajlan
- King Faisal Specialist Hospital and Research Centre Organ Transplant Center of ExcellenceRiyadhSaudi Arabia
| | - Mohamed Ahmed
- King Faisal Specialist Hospital and Research Centre Organ Transplant Center of ExcellenceRiyadhSaudi Arabia
| | - Hamad Al‐Ashgar
- Department of MedicineKing Faisal Specialist Hospital and Research CentreRiyadhSaudi Arabia
| | - Mohammed Al‐Quaiz
- Department of MedicineKing Faisal Specialist Hospital and Research CentreRiyadhSaudi Arabia
| | - Dieter Broering
- King Faisal Specialist Hospital and Research Centre Organ Transplant Center of ExcellenceRiyadhSaudi Arabia
| | - Mohammed Al‐Sebayel
- Liver and Small Bowel Transplant and Hepatology Surgical DepartmentKing Faisal Specialist Hospital and Research CentreRiyadhSaudi Arabia
| | - Hussien Elsiesy
- Liver and Small Bowel Transplant and Hepatology Surgical DepartmentKing Faisal Specialist Hospital and Research CentreRiyadhSaudi Arabia
| | - Faisal A. Alkhail
- Liver and Small Bowel Transplant and Hepatology Surgical DepartmentKing Faisal Specialist Hospital and Research CentreRiyadhSaudi Arabia
| | - Waleed K. Al‐Hamoudi
- Liver and Small Bowel Transplant and Hepatology Surgical DepartmentKing Faisal Specialist Hospital and Research CentreRiyadhSaudi Arabia
| | - Edward De Vol
- Biostatistics, Epidemiology and Science Computing DepartmentKing Faisal Specialist Hospital and Research CentreRiyadhSaudi Arabia
| | - Epi Amirah Almuhayshir
- Biostatistics, Epidemiology and Science Computing DepartmentKing Faisal Specialist Hospital and Research CentreRiyadhSaudi Arabia
| | - Ahmed Al‐Jedai
- King Faisal Specialist Hospital and Research Centre Organ Transplant Center of ExcellenceRiyadhSaudi Arabia,Therapeutic Affairs, Ministry of HealthRiyadhSaudi Arabia,Alfaisal UniversityColleges of Medicine and PharmacyRiyadhSaudi Arabia
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7
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The Effect of Artificial Liver Support System on Prognosis of HBV-Derived Hepatorenal Syndrome: A Retrospective Cohort Study. DISEASE MARKERS 2022; 2022:3451544. [PMID: 35692884 PMCID: PMC9177308 DOI: 10.1155/2022/3451544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 03/23/2022] [Accepted: 04/25/2022] [Indexed: 11/25/2022]
Abstract
Hepatorenal syndrome (HRS) could occur when patients get decompensated liver cirrhosis. Meanwhile, hepatitis B virus (HBV) infection raises the risk of mortality of the end-stage liver diseases. As the artificial liver support system (ALSS) has been applied in liver failure, whether ALSS could benefit HBV-derived HRS remains uncertain. We retrospectively enlisted eligible HRS patients and compared the baseline characteristics and prognosis between HBV-derived HRS and non-HBV-derived HRS. Furthermore, propensity score matching (PSM) and Cox regression analyses were used to assess the beneficial effect of ALSS on HBV-derived HRS. In addition, a stratified analysis was carried out according to the degree of acute kidney injury (AKI) and the number of organ failures to observe in which populations ALSS can obtain the most excellent therapeutic effect. 669 patients were diagnosed as HRS, including 298 HBV negative and 371 HBV positive. Baseline characteristics were different between patients with HBV positive and HBV negative. HBV-derived HRS has higher 28-day mortality, though without a statistical difference. After PSM, 50 patients treated with ALSS and 150 patients treated with standard medical treatment (SMT) constituted a new cohort for the following analysis. We found that ALSS could significantly benefit HRS patients (P = 0.025). Moreover, the median survival time of patients treated with ALSS was longer than those treated with SMT. INR, neutrophil percentage, and treatment with ALSS were independent predictive factors for short-term mortality in HBV-derived HRS. The stratified analysis showed that ALSS could reduce the 28-day mortality of patients with HBV-derived HRS, especially those in AKI stage 3 and with organ failure ≥ 2. Additionally, serum bilirubin was significantly lower after ALSS, and the alteration of INR and creatinine were independent predictive elements for the mortality of HBV-derived HRS. HBV-derived HRS is more severe than non-HBV-derived HRS and has a worse prognosis. ALSS could reduce the short-term mortality of patients with HBV-derived HRS, especially those in AKI stage 3 and with organ failure ≥ 2. INR and the change of creatinine and INR could predict the prognosis of HBV-derived HRS. ChiCTR2200060123.
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8
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Rasaei N, Malekmakan L, Mashayekh M, Gholamabbas G. Chronic Kidney Disease Following Liver Transplant: Associated Outcomes and Predictors. EXP CLIN TRANSPLANT 2022; 21:93-103. [PMID: 36656117 DOI: 10.6002/ect.2022.0288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVES Liver transplant as a life-saving procedure in patients with end-stage liver disease may have some complications such as renal dysfunction. Improved postoperative management and immuno- suppressive therapy have increased long-term survival and thus increased late complications like chronic kidney disease. Our study aimed to investigate outcomes of chronic kidney disease in liver transplant recipients and the incidence, progression rates, and adjustable risk factors of chronic kidney disease after liver transplant. MATERIALS AND METHODS Related studies published in English were elicited from various international sources like the ISI Web of Science, PubMed/Medline, Google Scholar, and Scopus. RESULTS AND CONCLUSIONS Chronic kidney disease as a long-term complication is common in liver transplant recipients whose survival is affected by renal function. Risk assessment of renal function before liver transplant and some nonrenal causes of chronic kidney disease after transplant could help reduce the risks associated with future renal outcomes.
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Affiliation(s)
- Nakisa Rasaei
- From the Shiraz Nephro-Urology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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9
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Pageaux GP, Nzinga CL, Ganne N, Samuel D, Dorival C, Zoulim F, Cagnot C, Decaens T, Thabut D, Asselah T, Mathurin P, Habersetzer F, Bronowicki JP, Guyader D, Rosa I, Leroy V, Chazouilleres O, de Ledinghen V, Bourliere M, Causse X, Cales P, Metivier S, Loustaud-Ratti V, Riachi G, Alric L, Gelu-Simeon M, Minello A, Gournay J, Geist C, Tran A, Abergel A, Portal I, d'Alteroche L, Raffi F, Fontaine H, Carrat F, Pol S. Clinical outcomes after treatment with direct antiviral agents: beyond the virological response in patients with previous HCV-related decompensated cirrhosis. BMC Infect Dis 2022; 22:94. [PMID: 35086481 PMCID: PMC8796427 DOI: 10.1186/s12879-022-07076-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 01/19/2022] [Indexed: 11/18/2022] Open
Abstract
Background In HCV-infected patients with advanced liver disease, the direct antiviral agents-associated clinical benefits remain debated. We compared the clinical outcome of patients with a previous history of decompensated cirrhosis following treatment or not with direct antiviral agents from the French ANRS CO22 HEPATHER cohort. Methods We identified HCV patients who had experienced an episode of decompensated cirrhosis. Study outcomes were all-cause mortality, liver-related or non-liver-related deaths, hepatocellular carcinoma, liver transplantation. Secondary study outcomes were sustained virological response and its clinical benefits. Results 559 patients met the identification criteria, of which 483 received direct antiviral agents and 76 remained untreated after inclusion in the cohort. The median follow-up time was 39.7 (IQR: 22.7–51) months. After adjustment for multivariate analysis, exposure to direct antiviral agents was associated with a decrease in all-cause mortality (HR 0.45, 95% CI 0.24–0.84, p = 0.01) and non-liver-related death (HR 0.26, 95% CI 0.08–0.82, p = 0.02), and was not associated with liver-related death, decrease in hepatocellular carcinoma and need for liver transplantation. The sustained virological response was 88%. According to adjusted multivariable analysis, sustained virological response achievement was associated with a decrease in all-cause mortality (HR 0.29, 95% CI 0.15–0.54, p < 0.0001), liver-related mortality (HR 0.40, 95% CI 0.17–0.96, p = 0.04), non-liver-related mortality (HR 0.17, 95% CI 0.06–0.49, p = 0.001), liver transplantation (HR 0.17, 95% CI 0.05–0.54, p = 0.003), and hepatocellular carcinoma (HR 0.52, 95% CI 0.29–0.93, p = 0.03). Conclusion Treatment with direct antiviral agents is associated with reduced risk for mortality. The sustained virological response was 88%. Thus, direct antiviral agents treatment should be considered for any patient with HCV-related decompensated cirrhosis. Trial registration: ClinicalTrials.gov registry number: NCT01953458. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-022-07076-0.
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Affiliation(s)
- Georges-Philippe Pageaux
- Department of Hepatology and Gastroenterology, Centre Hospitalo-Universitaire Saint Eloi, Université de Montpellier, 34295, Montpellier, France.
| | - Clovis Lusivika Nzinga
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris, France
| | - Nathalie Ganne
- Department of Hepatology, Hôpitaux Universitaires Paris Seine-Saint-Denis, Site Avicenne, AP-HP, Bobigny, France.,Université Paris 13, Sorbonne Paris Cité et INSERM UMR 1162, Paris, France
| | - Didier Samuel
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, 94800, Villejuif, France.,Université Paris-Saclay, Inserm, Physiopathogénèse et Traitement des Maladies du Foie, 94800, Villejuif, France.,Inserm, Unité 1193, Université Paris-Saclay, Hepatinov, 94800, Villejuif, France
| | - Céline Dorival
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris, France
| | - Fabien Zoulim
- Department of Hepatology, Hospices Civils de Lyon, INSERM U1052, Université de Lyon, Lyon, France
| | - Carole Cagnot
- Unit for Basic and Clinical Research on Viral Hepatitis, ANRS (France REcherche Nord&Sud Sida-Vih Hépatites), Paris, France
| | - Thomas Decaens
- Université Grenoble Alpes, 38000, Grenoble, France.,Institute for Advanced Biosciences, Research Center Inserm U1209, CNRS UMR5309, 38700, La Tronche, France.,Service d'hépatogastroentérologie, Pôle Digidune, CHU Grenoble Alpes, 38700, La Tronche, France
| | - Dominique Thabut
- Department of Hepatology and Gastroenterology, Groupe Hospitalier Pitié-Salpétrière, AP-HP, INSERM UMR-S938, Sorbonne Université, Paris, France
| | - Tarik Asselah
- INSERM UMR 1149, Hepatology, Hospital Beaujon, Centre de Recherche sur l'Inflammation, (CRI), University Paris Diderot, Clichy, France
| | - Philippe Mathurin
- Service des Maladies de l'appareil Digestif, Université Lille 2 and Inserm U795, Lille, France
| | - François Habersetzer
- CIC, Inserm 1110 et Pôle Hépato-digestif des Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Jean-Pierre Bronowicki
- Inserm U1254 and Department of Hepato-Gastroenterology, University Hospital of Nancy Brabois, Université de Lorraine, Vandoeuvre-les-Nancy, France
| | - Dominique Guyader
- CHU de Rennes, Service d'hépatologie, 35033, Rennes, France.,Univ Rennes1, Inra, Inserm, Institut NUMECAN (Nutrition, Métabolismes et Cancer), UMR_A 1341, UMR_S 1241, 35033, Rennes, France
| | - Isabelle Rosa
- Department of Hepatology and Gastroenterology, Centre Hospitalier Intercommunal, Créteil, France
| | - Vincent Leroy
- Department of Hepatology and Gastroenterology, Hôpital Henri Mondor, AP-HP, Université Paris-Est, INSERM U955, Créteil, France
| | - Olivier Chazouilleres
- Department of Hepatology, Hôpital Saint-Antoine, AP-HP, Sorbonne Université, Paris, France
| | - Victor de Ledinghen
- Hepatology Unit Hôpital Haut-Lévêque, Pessac, INSERM U1053, Université Bordeaux Segalen, Bordeaux, France
| | - Marc Bourliere
- Department of Hepatology and Gastroenterology, Hôpital Saint Joseph, Marseille, France
| | - Xavier Causse
- Department of Hepatology and Gastroenterology, CHR Orléans, Orléans, France
| | - Paul Cales
- Hepatology Department, University Hospital, Angers, France.,HIFIH Laboratory, Angers University, Angers, France
| | | | - Véronique Loustaud-Ratti
- Department of Hepatology and Gastroenterology, CHU Limoges, U1248 INSERM, Univ. Limoges, 87000, Limoges, France
| | - Ghassan Riachi
- Department of Hepatology and Gastroenterology, CHU Charles Nicolle, Rouen, France
| | - Laurent Alric
- Department of Internal Medicine and Digestive Diseases, CHU Purpan, UMR 152 Pharma Dev, IRD Toulouse 3 University, Toulouse, France
| | - Moana Gelu-Simeon
- Service d'Hépato-Gastroentérologie, CHU de la Guadeloupe-Faculté de Médecine, Université des Antilles, 97110, Pointe-à-Pitre Cedex, France.,INSERM, UMR-S1085/IRSET, 35043, Rennes, France
| | - Anne Minello
- Department of Hepatology and Gastroenterology, University Hospital Dijon, INSERM UMR 1231, Dijon, France
| | - Jérôme Gournay
- Gastroenterology and Hepatology Department, Institut des Maladies de l'Appareil Digestif, University Hospital of Nantes, Nantes, France
| | - Claire Geist
- Department of Hepatology and Gastroenterology, Centre Hospitalier Régional, Metz, France
| | - Albert Tran
- Digestive Center, Centre Hospitalier Universitaire de Nice, INSERM U1065-8, Nice, France
| | - Armand Abergel
- Department of Digestive and Hepatobiliary Diseases, Estaing University Hospital, Clermont-Ferrand, France.,UMR 6602 CNRS-Sigma-Université Clermont Auvergne, Clermont-Ferrand, France
| | - Isabelle Portal
- Service d'Hépato-Gastroentérologie, Hôpital de la Timone, Aix-Marseille Université, AP-HM, Marseille, France
| | - Louis d'Alteroche
- Unit of Hepatology, Hépatogastroentérologie, CHU Trousseau, 37044, Tours, France
| | - François Raffi
- Department of Infectious Diseases, Hotel-Dieu Hospital-INSERM CIC 1413, Nantes University Hospital, Nantes, France
| | - Hélène Fontaine
- Assistance Publique-Hôpitaux de Paris, Hôpital Cochin, Unité d'Hépatologie, Paris, France
| | - Fabrice Carrat
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris, France.,Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, Unité de Santé Publique, Paris, France
| | - Stanislas Pol
- Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, Unité de Santé Publique, Paris, France.,Université Paris Descartes, Paris, France.,INSERM U-1223 et USM20, Institut Pasteur, Paris, France
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Guo D, Wang H, Liu J, Liu H, Zhang M, Fu Z, Liu X. Prediction of chronic kidney disease after orthotopic liver transplantation: development and validation of a nomogram model. BMC Nephrol 2022; 23:33. [PMID: 35034618 PMCID: PMC8761273 DOI: 10.1186/s12882-021-02650-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 12/15/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND We aimed to develop and validate a nomogram model for predicting CKD after orthotopic liver transplantation (OLT). METHODS The retrospective data of 399 patients who underwent transplantation and were followed in our centre were collected. They were randomly assigned to the training set (n = 293) and validation set (n = 106). Multivariable Cox regression analysis was performed in the training set to identify predictors of CKD. According to the Cox regression analysis results, a nomogram model was developed and validated. The renal function of recipients was monitored, and the long-term survival prognosis was assessed. RESULTS The incidence of CKD at 5 years after OLT was 25.6%. Cox regression analysis identified several predictors of post-OLT CKD, including recipient age at surgery (HR 1.036, 95% CI 1.006-1.068; p = 0.018), female sex (HR 2.867, 95% CI 1.709-4.810; p < 0.001), preoperative hypertension (HR 1.670, 95% CI 0.962-2.898; p = 0.068), preoperative eGFR (HR 0.996, 95% CI 0.991-1.001; p = 0.143), uric acid at 3 months (HR 1.002, 95% CI 1.001-1.004; p = 0.028), haemoglobin at 3 months (HR 0.970, 95% CI 0.956-0.983; p < 0.001), and average concentration of cyclosporine A at 3 months (HR 1.002, 95% CI 1.001-1.003; p < 0.001). According to these parameters, a nomogram model for predicting CKD after OLT was constructed and validated. The C-indices were 0.75 and 0.80 in the training and validation sets. The calibration curve of the nomogram showed that the CKD probabilities predicted by the nomogram agreed with the observed probabilities at 1, 3, and 5 years after OLT (p > 0.05). Renal function declined slowly year by year, and there were significant differences between patients divided by these predictors. Kaplan-Meier survival analysis showed that the survival prognosis of recipients decreased significantly with the progression of renal function. CONCLUSIONS With excellent predictive abilities, the nomogram may be a simple and reliable tool to identify patients at high risk for CKD and poor long-term prognosis after OLT.
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Affiliation(s)
- Dandan Guo
- Department of Nephrology, The Affiliated Hospital of Qingdao University, No. 16 Jiangsu Road, Qingdao, 266003, Shandong, China
| | - Huifang Wang
- Department of Nephrology, The Affiliated Hospital of Qingdao University, No. 16 Jiangsu Road, Qingdao, 266003, Shandong, China
| | - Jun Liu
- Department of Nephrology, The Affiliated Hospital of Qingdao University, No. 16 Jiangsu Road, Qingdao, 266003, Shandong, China
| | - Hang Liu
- Department of Nephrology, The Affiliated Hospital of Qingdao University, No. 16 Jiangsu Road, Qingdao, 266003, Shandong, China
| | - Ming Zhang
- Department of Nephrology, The Affiliated Hospital of Qingdao University, No. 16 Jiangsu Road, Qingdao, 266003, Shandong, China
| | - Zixuan Fu
- Department of Nephrology, The Affiliated Hospital of Qingdao University, No. 16 Jiangsu Road, Qingdao, 266003, Shandong, China
| | - Xuemei Liu
- Department of Nephrology, The Affiliated Hospital of Qingdao University, No. 16 Jiangsu Road, Qingdao, 266003, Shandong, China.
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11
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Abstract
In the 1970s, an unknown virus was suspected for documented cases of transfusion-associated hepatitis, a phenomenon called non-A, non-B hepatitis. In 1989, the infectious transmissible agent was identified and named hepatitis C virus (HCV) and, soon enough, the first diagnostic HCV antibody test was developed, which led to a dramatic decrease in new infections. Today, HCV infection remains a global health burden and a major cause of liver cirrhosis, hepatocellular carcinoma and liver transplantation. However, tremendous advances have been made over the decades, and HCV became the first curable, chronic viral infection. The introduction of direct antiviral agents revolutionized antiviral treatment, leading to viral eradication in more than 98% of all patients infected with HCV. This Perspective discusses the history of HCV research, which reads like a role model for successful translational research: starting from a clinical observation, specific therapeutic agents were developed, which finally were implemented in national and global elimination programmes.
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Affiliation(s)
- Michael P. Manns
- grid.10423.340000 0000 9529 9877Hannover Medical School, Hannover, Germany
| | - Benjamin Maasoumy
- grid.10423.340000 0000 9529 9877Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
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12
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Indication for Liver Transplantation After Direct-Acting Agents in the Treatment of Patients With Hepatitis C. Transplant Proc 2021; 54:32-34. [PMID: 34911619 DOI: 10.1016/j.transproceed.2021.08.058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 08/25/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND The development of new direct-acting antivirals (DAA) for hepatitis C virus (HCV) treatment has reduced the indications for liver transplantation (LT). We analyzed the indications, characteristics, and evolution of patients with HCV infection who were treated with DAA-based therapies and who underwent LT. MATERIAL AND METHODS A retrospective single-center study was performed. Data were collected of patients undergoing LT owing to HCV infection between January 2016 and August 2020. Overall characteristics of the patients were analyzed and divided into 2 groups according to the indication for LT: hepatocellular carcinoma (HCC) or decompensated cirrhosis (DC). Differences between biliary and vascular complications after surgery and survival time were compared. RESULTS Of 156 LTs, 33 (22%) were performed in patients with HCV infection in this period, which shows a decrease of nearly 16% when comparing this period with the interferon/ribavirin era. Indications for LT were 56.7% in patients with HCC and 43.3% in patients with DC. After DAA treatment, all patients developed a sustained viral response. Mean age of the global series, HCC group, and DC group were 56.9, 58.71, and 54.4 years, respectively (P = .041); 53.8% of the HCV-DC group initiated DAA treatment by the time to be included at the waiting list, compared with 17.6% of HCV-HCC group (P = .045). There were no statistically significant differences in terms of survival or biliary and vascular complications after LT. CONCLUSION Patients with HCV are still part of the waiting list, mainly because of HCC. No statistical differences were shown in terms of postoperative complications or survival. Studies with a higher number of patients are needed.
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13
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Drezza JPDO, Boteon APCDS, Calil IL, Anna RSS, Viveiros MDM, Rezende MBD, Pecora RAA, Boteon YL. Disposal of donor livers in Brazil: how to optimize their utilization rate in transplants? EINSTEIN-SAO PAULO 2021; 19:eAO6770. [PMID: 34878072 PMCID: PMC8670423 DOI: 10.31744/einstein_journal/2021ao6770] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 08/20/2021] [Indexed: 11/17/2022] Open
Abstract
Objective: To understand the professionals´ perception of the use of deceased donor liver for transplantation, the reasons to decline them, and propose strategies to increase their use safely. Methods: This is a cross-sectional, descriptive qualitative-quantitative study. Professionals working with liver transplantation answered a self-administered, structured, and electronic questionnaire comprising 17 questions distributed into four sessions (demographic factors, perception of use of organs, reasons for disposal, and measures to favor their usage). Results: A total of 42 professionals participated in the study. The rate of use of organs was considered low by 71.43% (n=30) of respondents or very low by 19.05% (n=8). Everyone agreed that it was possible to increase it. Thirty-one (73.81%) participants believed the expansion of the population of extended criteria donors affected this index negatively. Donor-related conditions were the most frequent category of reasons for refusing a liver for transplantation, being the findings during organ retrieval the most frequent reason in clinical practice. Enhanced training of intensive care teams in the treatment of donors was the primary measure selected to favor the use of the organs, followed by investment in new technologies to optimize its preservation/evaluate its function before transplantation. Conclusion: Implementation of strategies to increase the rate of acceptance of livers is expected. Improvements in donor intensive care and implementation of new preservation technologies should favor the use of the organs.
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Affiliation(s)
| | | | | | | | | | | | | | - Yuri Longatto Boteon
- Instituto Israelita de Ensino e Pesquisa Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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14
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Riveros S, Marino C, Ochoa G, Morales E, Soto D, Alegría L, Zenteno MJ, Brañes A, Achurra P, Rebolledo RA. Implementation and design of customized ex vivo machine perfusion. Analysis of its first results. Artif Organs 2021; 46:210-218. [PMID: 34519358 DOI: 10.1111/aor.14060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 08/19/2021] [Accepted: 08/23/2021] [Indexed: 12/14/2022]
Abstract
The lack of organs available for transplantation is a global problem. The high mortality rates on the waiting list and the high number of discarded livers are reasons to develop new tools in the preservation and transplantation process. New tools should also be available for low-income countries. This article reports the development of customized normothermic machine perfusion (NMP). An ex vivo dual perfusion machine was designed, composed of a common reservoir organ box (CRO), a centrifugal pump (portal system, low pressure), and a roller pump (arterial system, high pressure). Porcine livers (n = 5) were perfused with an oxygenated normothermic (37℃) strategy for 3 hours. Hemodynamic variables, metabolic parameters, and bile production during preservation were analyzed. Arterial and portal flow remain stable during perfusion. Total bilirubin production was 11.25 mL (4-14.5) at 180 minutes. The median pH value reached 7.32 (7.25-7.4) at 180 minutes. Lactate values decreased progressively to normalization at 120 minutes. This perfusion setup was stable and able to maintain the metabolic activity of a liver graft in a porcine animal model. Design and initial results from this customized NMP are promising for a future clinical application in low-income countries.
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Affiliation(s)
- Sergio Riveros
- Department of Digestive Surgery, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Carlo Marino
- Department of Digestive Surgery, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Gabriela Ochoa
- Department of Digestive Surgery, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Emilio Morales
- Department of Digestive Surgery, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Dagoberto Soto
- Department of Intensive Care, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Leyla Alegría
- Department of Intensive Care, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Alejandro Brañes
- Department of Digestive Surgery, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile.,Hepato-Pancreato-Biliary Surgery Unit, Surgery Service, Complejo Asistencial Dr. Sótero Del Río, Santiago, Chile
| | - Pablo Achurra
- Department of Digestive Surgery, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Rolando A Rebolledo
- Institute for Biological and Medical Engineering, Schools of Engineering, Medicine and Biological Sciences, Pontificia Universidad Católica de Chile, Santiago, Chile.,Hepato-Pancreato-Biliary Surgery Unit, Surgery Service, Complejo Asistencial Dr. Sótero Del Río, Santiago, Chile
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15
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Lee SG, Jeng LB, Saliba F, Singh Soin A, Lee WC, De Simone P, Nevens F, Suh KS, Fischer L, Jin Joo D, Fung J, Joh JW, Kaido T, Grant D, Meier M, Rauer B, Sips C, Kaneko S, Levy G. Efficacy and Safety of Everolimus With Reduced Tacrolimus in Liver Transplant Recipients: 24-month Results From the Pooled Analysis of 2 Randomized Controlled Trials. Transplantation 2021; 105:1564-1575. [PMID: 33741847 PMCID: PMC8221719 DOI: 10.1097/tp.0000000000003394] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 06/17/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND METHODS Data from 2 randomized liver transplant trials (N = 772; H2304 [deceased donor, n = 488], H2307 [living donor, n = 284]) were pooled to further evaluate the efficacy and safety of everolimus with reduced tacrolimus (EVR + rTAC) versus standard tacrolimus (sTAC) regimen at month 24. RESULTS EVR + rTAC was comparable to sTAC for composite efficacy failure of treated biopsy-proven acute rejection, graft loss, or death (9.8% versus 10.8%; difference, -1.0%; 95% confidence interval, -5.4 to 3.4; P = 0.641) at month 24. EVR + rTAC was superior to sTAC for the mean change in estimated glomerular filtration rate (eGFR) from randomization to month 24 (-8.37 versus -13.40 mL/min/1.73 m2; P = 0.001). A subanalysis of renal function by chronic kidney disease (CKD) stage at randomization showed significantly lower decline in eGFR from randomization to month 24 for patients with CKD stage 1/2 (eGFR ≥ 60 mL/min/1.73 m2) in EVR + rTAC group versus sTAC (-12.82 versus -17.67 mL/min/1.73 m2, P = 0.009). In patients transplanted for hepatocellular carcinoma (HCC) beyond Milan criteria, HCC recurrence was numerically lower although not statistically significant with EVR + rTAC versus sTAC group (5.9% [1 of 17] versus 23.1% [6 of 26], P = 0.215), while comparable in patients within Milan criteria (2.9% [3 of 102] versus 2.1% [2 of 96], P = 1.000), irrespective of pretransplant alpha-fetoprotein levels. CONCLUSIONS EVR + rTAC versus sTAC showed comparable efficacy and safety with significantly better renal function, particularly in patients with normal/mildly decreased renal function (CKD stage 1/2) at randomization and a trend toward lower HCC recurrence in patients transplanted with HCC beyond Milan at month 24. Further long-term data would be required to confirm these results.
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Affiliation(s)
- Sung-Gyu Lee
- Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea
| | | | - Faouzi Saliba
- AP-HPHôpital Paul Brousse, Villejuif; Université Paris-Saclay, INSERM Unit 935, and 1193, France
| | | | - Wei-Chen Lee
- Chang Gung Memorial Hospital, Tao-Yuan, Lin-Ko, Taiwan
| | | | - Frederik Nevens
- University Hospital Gasthuisberg, KU Leuven, Leuven, Belgium
| | - Kyung-Suk Suh
- Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Lutz Fischer
- University Medical Center Eppendorf, Hamburg, Germany
| | - Dong Jin Joo
- Yonsei University College of Medicine, Seoul, Republic of Korea
| | - John Fung
- Cleveland Clinic Foundation, Cleveland, OH
| | - Jae-Won Joh
- Samsung Medical Center, Seoul, Republic of Korea
| | | | | | | | | | | | | | - Gary Levy
- University of Toronto, Toronto, Canada
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16
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Dumortier T, Heimann G, Fink M. Exposure-response modeling for extrapolation from adult to pediatric patients who differ with respect to prognostic factors: Application to everolimus. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2021; 10:589-598. [PMID: 33932133 PMCID: PMC8213418 DOI: 10.1002/psp4.12622] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 03/15/2021] [Indexed: 11/11/2022]
Abstract
Pediatric extrapolation is essential for bringing treatments to the pediatric population, especially for indications where the recruitment of pediatric patients into clinical trials is difficult and where fully powered trials are impossible. Often a similar exposure-response relationship between adult and pediatric patients can be assumed, but just matching exposures can be misleading when some prognostic factors for efficacy differ between those two patient populations. We present an example in liver transplantation where different study designs led to different (time-dependent) hazards between populations. Only after accounting for this difference an apparent mismatch between the extrapolation from adults and the pediatric study could be resolved. This article also exemplifies a clear scientific, methodological approach of pediatric extrapolation, including model building in adults, extrapolation to pediatrics, qualification of the extrapolation, and derivation of the actual pediatric efficacy.
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Affiliation(s)
| | | | - Martin Fink
- Pharmacometrics, Novartis Pharma AG, Basel, Switzerland
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17
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Almazroo OA, Miah MK, Pillai VC, Shaik IH, Xu R, Dharmayan S, Johnson HJ, Ganesh S, Planinsic RM, Demetris AJ, Al-Khafaji A, Lopez R, Molinari M, Tevar AD, Hughes C, Humar A, Venkataramanan R. An evaluation of the safety and preliminary efficacy of peri- and post-operative treprostinil in preventing ischemia and reperfusion injury in adult orthotopic liver transplant recipients. Clin Transplant 2021; 35:e14298. [PMID: 33764591 PMCID: PMC8243925 DOI: 10.1111/ctr.14298] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 03/17/2021] [Indexed: 12/29/2022]
Abstract
Background Orthotopic liver transplantation (OLT) is the only treatment option for various end‐stage liver diseases. Ischemia and reperfusion (I/R) injury is one of the unavoidable complications/conditions in OLT. In 2019, a total of 8896 livers were transplanted of which >94% organs were procured from deceased donors. An increase in the use of extended criteria donor (ECD) livers for transplantation further unraveled the role of hepatic I/R injury on short‐term and long‐term graft outcomes. Despite promising outcomes with the use of antioxidants, free radical scavengers, and vasodilators; I/R‐mediated liver injury persists and significantly influences the overall clinical outcomes. Treprostinil, a synthetic prostacyclin I2 (PGI2) analog, due to its vasodilatory property, antiplatelet activity, and its ability to downregulate pro‐inflammatory cytokines can potentially minimize I/R injury. Aim We investigated the safety and preliminary efficacy of continuous intravenous infusion of treprostinil in liver transplant recipients in a prospective, single‐center, non‐randomized, interventional study. Material and methods This was a dose escalation (3 + 3 design) phase 1/2 study. Deceased donor liver transplant recipients received 5 ng/kg/min for two days, or 2.5, 5, and 7.5 ng/min/kg for 5 days as a continuous infusion. Multiple blood samples were collected for biochemical parameter assessment and for measuring treprostinil levels. Indocyanine green plasma disappearance rate was used as a measure of hepatic functional capacity. Results Subjects tolerated continuous infusion of treprostinil up to 5 ng/kg/min for 120 h with no occurrence of primary graft non‐function (PNF), minimized need for ventilation support, reduced hospitalization time, 100% graft and patient survival, and improved hepatobiliary excretory function comparable to normal healthy adults. Discussion Treprostinil can be administered to liver transplant patients safely during the perioperative period. Conclusion Based on this phase 1/2 study, further efficacy studies of treprostinil in preventing I/R injury of liver should be conducted to potentially increase the number of livers available for transplantation.
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Affiliation(s)
- Omar Abdulhameed Almazroo
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Mohammad Kowser Miah
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Venkateswaran C Pillai
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Imam H Shaik
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ruichao Xu
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Stalin Dharmayan
- Thomas Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Heather J Johnson
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Swaytha Ganesh
- Thomas Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Raymond M Planinsic
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Anthony J Demetris
- Thomas Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ali Al-Khafaji
- Thomas Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Critical Care Medicine, Univeristy of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Roberto Lopez
- Thomas Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michele Molinari
- Thomas Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Amit D Tevar
- Thomas Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Christopher Hughes
- Thomas Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Abhinav Humar
- Thomas Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Raman Venkataramanan
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA.,Thomas Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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18
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Frankul L, Frenette C. Hepatocellular Carcinoma: Downstaging to Liver Transplantation as Curative Therapy. J Clin Transl Hepatol 2021; 9:220-226. [PMID: 34007804 PMCID: PMC8111105 DOI: 10.14218/jcth.2020.00037] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 10/04/2020] [Accepted: 03/04/2021] [Indexed: 12/24/2022] Open
Abstract
Hepatocellular carcinoma (HCC) ranks among the leading cancer-related causes of morbidity and mortality worldwide. Downstaging of HCC has prevailed as a key method to curative therapy for patients who present with unresectable HCC outside of the listing criteria for liver transplantation (LT). Even though LT paves the way to lifesaving curative therapy for HCC, perpetually severe organ shortage limits its broader application. Debate over the optimal protocol and assessment of response to downstaging treatment has fueled immense research activity and is pushing the boundaries of LT candidate selection criteria. The implicit obligation of refining downstaging protocol is to ensure the maximization of the transplant survival benefit by taking into account the waitlist life expectancy. In the following review, we critically discuss strategies to best optimize downstaging HCC to LT on the basis of existing literature.
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Affiliation(s)
| | - Catherine Frenette
- Correspondence to: Catherine Frenette, Scripps Center for Organ Transplant, Scripps Clinic/Green Hospital, 10666 N. Torrey Pines Rd N200, La Jolla, CA 92037, USA. ORCID: https://orcid.org/0000-0002-2245-8173 Tel: +1-858-554-4310, Fax: +1-858-554-3009, E-mail:
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19
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Health Care Transition: A Time of Increased Vulnerability for Pediatric Liver Transplant Recipients. J Pediatr Gastroenterol Nutr 2020; 71:704-706. [PMID: 32925552 DOI: 10.1097/mpg.0000000000002938] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Improvements in pediatric liver transplantation (LT) have led to an increased number of patients reaching young adulthood. Young adult LT recipients transferring from pediatric to adult models of care have increased rates of rejection, graft loss, and medical complications. The goal of a health care transition program is to optimize health and assist youth in reaching their full potential. The means to achieve this goal requires an organized transition process to support youth in acquiring independent health care skills, preparing for an adult model of care, and transferring to new providers without disruption in treatment. This can only be achieved through a multidisciplinary approach to transition planning. This is often a labor and resource-intensive undertaking, which may not receive the necessary support from local institutions. Widespread implementation requires the assistance and endorsement from governing organizations at the national and international level.
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20
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Hyponatremia Is Associated With Increased Mortality in Children on the Waiting List for Liver Transplantation. Transplant Direct 2020; 6:e604. [PMID: 33134484 PMCID: PMC7591120 DOI: 10.1097/txd.0000000000001050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 07/13/2020] [Accepted: 07/14/2020] [Indexed: 12/21/2022] Open
Abstract
Our aim was to determine whether hyponatremia is associated with waiting list or posttransplantation mortality in children having liver transplantation (LT).
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21
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Lacquaniti A, Campo S, Casuscelli Di Tocco T, Rovito S, Bucca M, Ragusa A, Monardo P. Acute and chronic kidney disease after pediatric liver transplantation: An underestimated problem. Clin Transplant 2020; 34:e14082. [PMID: 32949054 DOI: 10.1111/ctr.14082] [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] [Received: 03/01/2020] [Revised: 08/02/2020] [Accepted: 08/15/2020] [Indexed: 12/13/2022]
Abstract
Acute and chronic kidney injuries represent critical issues after liver transplantation (LTx), but whereas renal dysfunction in adult transplant patients is well documented, little is known about its prevalence in childhood. It is a challenge to accurately evaluate renal function in patients with liver disease, due to several confounding factors. Creatinine-based equations estimating glomerular filtration rate, validated in nephropathic patients without hepatic issues, are frequently inaccurate in end-stage liver disease, underestimating the real impact of renal disease. Moreover, whereas renal issues observed within 1 year from LTx were often related to acute injuries, kidney damage observed after 5-7 years from LTx, is due to chronic, irreversible mechanisms. Most immunosuppression protocols are based on calcineurin inhibitors (CNIs) and corticosteroids, but mycophenolate mofetil or sirolimus could play significant roles, also in children. Early diagnosis and personalized treatment represent the bases of kidney disease management, in order to minimize its close relation with increased mortality. This review analyzed acute and chronic kidney damage after pediatric LTx, also discussing the impact of pre-existent renal disease. The main immunosuppressant strategies have been reviewed, highlighting their impact on kidney function. Different methods assessing renal function were reported, with the potential application of new renal biomarkers.
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Affiliation(s)
- Antonio Lacquaniti
- Department of Internal Medicine, Nephrology and Dialysis Unit, Papardo Hospital of Messina, Messina, Italy
| | - Susanna Campo
- Department of Internal Medicine, Nephrology and Dialysis Unit, Papardo Hospital of Messina, Messina, Italy
| | - Teresa Casuscelli Di Tocco
- Department of Internal Medicine, Nephrology and Dialysis Unit, Papardo Hospital of Messina, Messina, Italy
| | - Stefania Rovito
- Department of Internal Medicine, Nephrology and Dialysis Unit, Papardo Hospital of Messina, Messina, Italy
| | - Maurizio Bucca
- Department of Internal Medicine, Nephrology and Dialysis Unit, Papardo Hospital of Messina, Messina, Italy
| | - Antonino Ragusa
- Department of Internal Medicine, Nephrology and Dialysis Unit, Papardo Hospital of Messina, Messina, Italy
| | - Paolo Monardo
- Department of Internal Medicine, Nephrology and Dialysis Unit, Papardo Hospital of Messina, Messina, Italy
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22
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Abstract
Multiple research groups have demonstrated that the outcome of patients receiving liver grafts from brain death donors (DBD) is poorer when compared with patients receiving grafts from living donors. This might be due to an increased hepatocyte apoptosis induced after brain death (BD). In this work, we found that the activity of PP2A-Akt pathway is significantly increased in clinical donor ex vivo hepatocytes after BD by iTRAQ protein quantification analysis. The same results were confirmed in animal models. A time-dependent promotion of apoptosis was also found in DBD rabbit liver, as demonstrated by the increased levels of cleaved Caspase 3 and the decreased of Bcl-2. To further investigate the roles of PP2A and Akt in regulating apoptosis of hepatocytes after BD, we cultivated human liver cell line L02 with serum deprivation and hypoxia, to simulate the ischemic and hypoxic conditions of hepatocytes in DBD. Increased apoptosis and decreased viability were observed during the time in this model. Meanwhile PP2A activity and Akt activity were respectively increased and decreased. Notably, the proportion of Akt phosphorylation at Ser473 decreased, while other known targets of PP2A (p38, JNK and ERK) were not affected in terms of protein levels or phosphorylation. These results suggested that PP2A is involved in apoptotic induction of hepatocytes after brain death by specific suppression of Akt. This discovery was further confirmed with pharmaceutical and genetic methods. Our work implied potential targets for reducing liver cell apoptosis and improving organ donor quality after BD.
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Prior Relapse, Ongoing Alcohol Consumption, and Failure to Engage in Treatment Predict Alcohol Relapse After Liver Transplantation. Dig Dis Sci 2020; 65:2089-2103. [PMID: 31707529 DOI: 10.1007/s10620-019-05937-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 11/02/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Alcohol-related liver disease (ALD) is the leading indication for liver transplantation (LT) in the USA. Alcohol relapse post-LT can negatively impact long-term outcomes, and prognostic scoring systems are available for further study. AIMS Our study aims were to: (1) evaluate the relationship between alcohol relapse and rejection and mortality, (2) investigate risk factors for relapse, and (3) assess predictive validity of the SIPAT (Stanford Integrated Psychosocial Assessment for Transplant) and SALT (Sustained Alcohol Use Post-Liver Transplant) scores on post-LT alcohol relapse. METHODS We conducted a retrospective chart review of 155 patients transplanted for chronic ALD at a single transplant center. Cox proportional hazard models assessed the relationship between alcohol relapse and allograft rejection and psychosocial risk factors for relapse. RESULTS 20% of patients met criteria for alcohol relapse. Alcohol relapse was associated with allograft rejection (HR 2.33, 95% CI 1.11-4.91, p = .03). Three variables most strongly associated with alcohol relapse: prior relapse, failure to engage in recommended alcohol treatment, and continued drinking with liver disease, which were combined into a psychosocial model. SIPAT score≥ 21 and SALT score ≥ 7 were associated with alcohol relapse (HR 6.40, 95% CI 1.36-30.18, p = .019 and HR 2.30, 95% CI 1.12-4.75, p = .024). Receiver operator characteristic analysis compared predictive ability of our psychosocial model to SIPAT (C-statistic .83 compared to .71) and SALT (C-statistic = .77 compared to .62). CONCLUSION We identified important psychosocial predictors of post-LT alcohol relapse and validated SIPAT and SALT scores as pre-transplant risk factors for alcohol relapse.
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Kiyoshi Takano de Saidneuy AE, Bruno de Rezende M, Rogerio de Oliveira Salvalaggio P. A Direct Comparison Between Institut Georges Lopez 1 and Histidine-Tryptophan-Ketoglutarate Preservation Solutions in Liver Transplantation. Transplant Proc 2020; 52:1262-1264. [PMID: 32507487 DOI: 10.1016/j.transproceed.2020.01.172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 01/22/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND The Institut Georges Lopez 1 (IGL-1) solution was developed to improve the outcomes of solid organ transplantation. Nevertheless, follow-up of liver transplants using IGL-1-preserved organs is still scarce. AIM To compare morbidity, postoperative complications, and early survival between liver grafts perfused with IGL-1 and those perfused with histidine-tryptophan-ketoglutarate (HTK) solutions. METHODS Prospective liver grafts perfused with IGL-1 (n = 65) were paired with a historical control group of recipients whose grafts were preserved with HTK solution (n = 130). The primary endpoint was the sum of the incidence of primary graft dysfunction (PGD) and primary graft nonfunction (PGNF). Secondary endpoints included resource utilization, complications, and survival analysis. RESULTS In the HTK group, 52 patients (40%) exhibited either PGD or PGNF, compared to 20 patients (31%) in the IGL-1 group (P = .208). Patients from the HTK group had higher mean values for cryoprecipitate transfusion (P = .0064), first day serum lactate (P = .0099), higher incidence of vascular complications (11% vs 2% in the IGL-1 group; P = .0226), but a lower incidence of infection (7% vs 28% in the IGL-1 group; P < .0001). The IGL-1 group presented a lower mean aspartate aminotransferase and alanine aminotransferase (ALT) on the first and second postoperative day and a lower ALT on the seventh day. Recipients of grafts perfused with IGL-1 had a better early survival than those whose grafts were perfused with HTK. CONCLUSIONS Both solutions are safe and present good results. Grafts perfused with IGL-1 showed decreased enzymatic peaks and better short-term survival rates than the HTK group. The use of the IGL-1 solution might be preferable.
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Shi C, Wang Q, Rao Z, Shi Y, Wei S, Wang H, Lu X, Wang P, Lu L, Zhou H, Cheng F. Diabetes induces hepatocyte pyroptosis by promoting oxidative stress-mediated NLRP3 inflammasome activation during liver ischaemia and reperfusion injury. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:739. [PMID: 32647664 PMCID: PMC7333130 DOI: 10.21037/atm-20-1839] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background Although diabetes mellitus has been reported to aggravate liver ischaemia and reperfusion (IR) injury, the basic mechanism remains largely unknown. The object of the present study was to determine the role of oxidative stress and hepatocellular pyroptosis in liver IR injury in diabetic mice. Methods Db/db and C57BL/6 mice at 8 weeks of age were subjected to liver IR injury. Liver injury and hepatocyte cell death were analyzed. A NOD-like receptor family pyrin domain-containing 3 protein (NLRP3) inflammasome antagonist (CY09) and a reactive oxygen species (ROS) antagonist (N-Acetyl-L-cysteine, NAC) were used to determine the role of ROS-mediated hepatocellular pyroptosis in diabetic mice post-IR. Results Aggravated liver IR injury was found in db/db mice compared to C57BL/6 control mice, as demonstrated by increased serum alanine aminotransaminase (ALT) and aspartate aminotransaminase (AST) levels, liver architecture damage and Suzuki scores. Interestingly, IR induces the pyroptosis of hepatocytes in db/db mice, as evidenced by enhanced NLRP3 inflammasome activation, increased numbers of terminal deoxynucleotidyl transferase dUTP nick end labelling (TUNEL)-positive hepatocytes and increased gene expression of interleukin-1β (IL-1β) and IL-18 in livers post-IR. The inhibitory effect of CY09, an NLRP3 antagonist, efficiently abrogated the exacerbation effects of diabetes on liver IR injury in db/db mice. Furthermore, increased ROS expression was detected in db/db mice compared to control mice after IR. ROS scavenging by NAC pretreatment markedly inhibited hepatocellular NLRP3 inflammasome activation and pyroptosis in the db/db mice post-IR, indicating that ROS play an essential role in mediating hepatocyte pyroptosis in the setting of diabetes mellitus. Conclusions Our results demonstrate that diabetes induces hepatocyte pyroptosis by promoting oxidative stress-mediated NLRP3 inflammasome activation during liver IR injury. Strategies targeting ROS and NLRP3 inflammasome activation would be beneficial for preventing liver IR injury in diabetic patients.
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Affiliation(s)
- Chengyu Shi
- Hepatobiliary Center, The First Affiliated Hospital of Nanjing Medical University, Research Unit of Liver Transplantation and Transplant Immunology, Chinese Academy of Medical Sciences, Nanjing, China.,Key Laboratory of Liver Transplantation, Chinese Academy of Medical Sciences, Nanjing, China.,NHC Key Laboratory of Living Donor Liver Transplantation, Nanjing, China
| | - Qi Wang
- Hepatobiliary Center, The First Affiliated Hospital of Nanjing Medical University, Research Unit of Liver Transplantation and Transplant Immunology, Chinese Academy of Medical Sciences, Nanjing, China.,Key Laboratory of Liver Transplantation, Chinese Academy of Medical Sciences, Nanjing, China.,NHC Key Laboratory of Living Donor Liver Transplantation, Nanjing, China.,School of Medical, Southeast University, Nanjing, China
| | - Zhuqing Rao
- Department of Anesthesiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yong Shi
- Hepatobiliary Center, The First Affiliated Hospital of Nanjing Medical University, Research Unit of Liver Transplantation and Transplant Immunology, Chinese Academy of Medical Sciences, Nanjing, China.,Key Laboratory of Liver Transplantation, Chinese Academy of Medical Sciences, Nanjing, China.,NHC Key Laboratory of Living Donor Liver Transplantation, Nanjing, China
| | - Song Wei
- Hepatobiliary Center, The First Affiliated Hospital of Nanjing Medical University, Research Unit of Liver Transplantation and Transplant Immunology, Chinese Academy of Medical Sciences, Nanjing, China.,Key Laboratory of Liver Transplantation, Chinese Academy of Medical Sciences, Nanjing, China.,NHC Key Laboratory of Living Donor Liver Transplantation, Nanjing, China.,School of Medical, Southeast University, Nanjing, China
| | - Hao Wang
- Hepatobiliary Center, The First Affiliated Hospital of Nanjing Medical University, Research Unit of Liver Transplantation and Transplant Immunology, Chinese Academy of Medical Sciences, Nanjing, China.,Key Laboratory of Liver Transplantation, Chinese Academy of Medical Sciences, Nanjing, China.,NHC Key Laboratory of Living Donor Liver Transplantation, Nanjing, China
| | - Xu Lu
- Hepatobiliary Center, The First Affiliated Hospital of Nanjing Medical University, Research Unit of Liver Transplantation and Transplant Immunology, Chinese Academy of Medical Sciences, Nanjing, China.,Key Laboratory of Liver Transplantation, Chinese Academy of Medical Sciences, Nanjing, China.,NHC Key Laboratory of Living Donor Liver Transplantation, Nanjing, China
| | - Ping Wang
- Hepatobiliary Center, The First Affiliated Hospital of Nanjing Medical University, Research Unit of Liver Transplantation and Transplant Immunology, Chinese Academy of Medical Sciences, Nanjing, China.,Key Laboratory of Liver Transplantation, Chinese Academy of Medical Sciences, Nanjing, China.,NHC Key Laboratory of Living Donor Liver Transplantation, Nanjing, China
| | - Ling Lu
- Hepatobiliary Center, The First Affiliated Hospital of Nanjing Medical University, Research Unit of Liver Transplantation and Transplant Immunology, Chinese Academy of Medical Sciences, Nanjing, China.,Key Laboratory of Liver Transplantation, Chinese Academy of Medical Sciences, Nanjing, China.,NHC Key Laboratory of Living Donor Liver Transplantation, Nanjing, China.,School of Medical, Southeast University, Nanjing, China.,Department of General Surgery, People's Hospital of Qinghai Province, Xining, Qinghai, China
| | - Haoming Zhou
- Hepatobiliary Center, The First Affiliated Hospital of Nanjing Medical University, Research Unit of Liver Transplantation and Transplant Immunology, Chinese Academy of Medical Sciences, Nanjing, China.,Key Laboratory of Liver Transplantation, Chinese Academy of Medical Sciences, Nanjing, China.,NHC Key Laboratory of Living Donor Liver Transplantation, Nanjing, China
| | - Feng Cheng
- Hepatobiliary Center, The First Affiliated Hospital of Nanjing Medical University, Research Unit of Liver Transplantation and Transplant Immunology, Chinese Academy of Medical Sciences, Nanjing, China.,Key Laboratory of Liver Transplantation, Chinese Academy of Medical Sciences, Nanjing, China.,NHC Key Laboratory of Living Donor Liver Transplantation, Nanjing, China
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Deceased Brain Dead Donor Liver Transplantation and Utilization in the United States: Nighttime and Weekend Effects. Transplantation 2020; 103:1392-1404. [PMID: 30444802 DOI: 10.1097/tp.0000000000002533] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Understanding factors that contribute to liver discards and nonusage is urgently needed to improve organ utilization. METHODS Using Scientific Registry of Transplant Recipient data, we studied a national cohort of all US adult, deceased brain dead donor, isolated livers available for transplantation from 2003 to 2016, including organ-specific and system-wide factors that may affect organ procurement and discard rates. RESULTS Of 73 686 available livers, 65 316 (88.64%) were recovered for transplant, of which 6454 (9.88%) were ultimately discarded. Livers that were not procured or, on recovery, discarded were more frequently from older, heavier, hepatitis B virus (HCV)+, and more comorbid donors (P < 0.001). However, even after adjustment for organ quality, the odds of liver nonusage were 11% higher on the weekend (defined as donor procurements with cross-clamping occurring from 5:00 PM Friday until 11:59 AM Sunday) compared with weekdays (P < 0.001). Nonuse rates were also higher at night (P < 0.001), defined as donor procurements with cross-clamping occurring from 5:00 PM to 5:00 AM; however, weekend nights had significantly higher nonuse rates compared with weekday nights (P = 0.005). After Share 35, weekend nonusage rates decreased from 21.77% to 19.51% but were still higher than weekday nonusage rates (P = 0.065). Weekend liver nonusage was higher in all 11 United Network of Organ Sharing regions, with an absolute average of 2.00% fewer available livers being used on the weekend compared with weekdays. CONCLUSIONS Although unused livers frequently have unfavorable donor characteristics, there are also systemic and operational factors, including time of day and day of the week a liver becomes available, that impact the chance of liver nonprocurement and discard.
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Adherence, Medical Outcomes, and Health Care Costs in Adolescents/Young Adults Following Pediatric Liver Transplantation. J Pediatr Gastroenterol Nutr 2020; 70:183-189. [PMID: 31978014 DOI: 10.1097/mpg.0000000000002553] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE Improved outcomes after pediatric liver transplantation (LT) have led to increasing numbers of adolescent and young adult recipients entering into adult health care systems. The aim of this study was to evaluate the impact of transition from pediatric to adult health care models on medical outcomes, measures of adherence, and health care utilization for pediatric LT recipients. METHODS We evaluated the course of patients who received an LT while followed in pediatrics and transferred to an adult care provider within our institution. Data were collected from 2 years preceding and 2 years following transfer of care. RESULTS A total of 32 patients were eligible for analysis. Median age at time of transfer was 22.9 years (interquartile range 21.7-23.6). Nine patients (28%) died following transfer of care. There was a significant decrease in office visit adherence following transfer of care (P = 0.02). Although not achieving significance, an increase in alanine aminotransferase values, episodes of acute cellular rejection, progression to cirrhosis, evolution to chronic rejection, and hospital admission rates post transfer were found. These findings were associated with an increase in health care costs related to required interventions. CONCLUSIONS Our study demonstrates trends toward worse health outcomes, decreased adherence, and increased health care utilization following transfer of care. These findings and poor patient survival suggest that the time around transition from pediatric to adult health care models represents a period of increased vulnerability for pediatric LT recipients. Larger, multicenter, prospective studies are needed to identify factors and interventions that affect adolescent and young adult to improve the transition process.
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Sun H, McKeen T, Wang H, Ni HM. Necroptosis in ischemia-reperfusion injury of lean and steatotic livers. LIVER RESEARCH 2019. [DOI: 10.1016/j.livres.2019.09.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Artificial Liver Support System Improves Short-Term Outcomes of Patients with HBV-Associated Acute-on-Chronic Liver Failure: A Propensity Score Analysis. BIOMED RESEARCH INTERNATIONAL 2019; 2019:3757149. [PMID: 31871940 PMCID: PMC6907045 DOI: 10.1155/2019/3757149] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 11/09/2019] [Indexed: 12/25/2022]
Abstract
Background Hepatitis B virus-associated acute-on-chronic liver failure (HBV-ALCF) is a complicated syndrome with extremely high short-term mortality. The artificial liver support system (ALSS) may improve the liver function for patients with HBV-ACLF, but the data on its short-term outcomes are insufficient in China. Methods We recruited HBV-ACLF patients in this nationwide, multicenter, retrospective study. Patients with HBV-ACLF were diagnosed by the COSSH-ACLF criteria. Propensity score matching (PSM) analysis was used to generate compared pairs. The short-term (28/90 days) survival rates between the standard medical therapy (SMT) group and ALSS group were calculated using a Kaplan–Meier graph. Result In total, 790 patients with HBV-ACLF were included in this retrospective study; 412 patients received SMT only (SMT group), and 378 patients received SMT and ALSS treatment (ALSS group). PSM generated 310 pairs and eliminated the baseline differences between the two groups (p > 0.05 for all baseline variables). The probabilities of survival on day 28 were 65.2% (205/310) in the ALSS group and 59.0% (185/310) in the SMT group; on day 90, they were 51.0% (163/310) and 42.3% (136/310). The short-term (28/90 days) survival rates of the ALSS group were significantly higher than those of the SMT group (p=0.0452 and p=0.0187, respectively). Compared to receiving SMT alone, treatment with ALSS was associated with a significant reduction in serum bilirubin levels and the model for end-stage liver disease (MELD) scores at day 7 and day 28. Multivariate logistic regression analysis revealed that older age, high total bilirubin (T-Bil), low albumin, high ALT, high MELD scores, and high COSSH-ACLF grade were independent baseline factors associated with poor prognosis. Conclusions This retrospective study found that compared to SMT, the ALSS improved the short-term (28/90 days) survival rates and laboratory parameters in HBV-ACLF patients. The ALSS had a better therapeutic effect than SMT for patients with HBV-ACLF in China.
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Restrictive fluid management strategies and outcomes in liver transplantation: a systematic review. Can J Anaesth 2019; 67:109-127. [PMID: 31556006 DOI: 10.1007/s12630-019-01480-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 06/12/2019] [Accepted: 06/14/2019] [Indexed: 02/07/2023] Open
Abstract
PURPOSE Restrictive fluid management strategies have been proposed to reduce complications in liver transplant recipients. We conducted a systematic review to evaluate the effects of restrictive perioperative fluid management strategies, compared with liberal ones, on postoperative outcomes in adult liver transplant recipients. Our primary outcome was acute kidney injury (AKI). Our secondary outcomes were bleeding, mortality, and other postoperative complications. SOURCE We searched major databases (CINAHL, EMB Reviews, EMBASE, MEDLINE, and the grey literature) from their inception to 10 July 2018 for randomized-controlled trials (RCTs) and observational studies comparing two fluid management strategies (or observational studies reporting two outcomes with available data on fluid volume received) in adult liver transplant recipients. Study selection, data abstraction, and risk of bias assessment were performed by at least two investigators. Data from RCTs were pooled using risk ratios (RR) and mean differences (MD) with random-effect models. PRINCIPAL FINDINGS We found seven RCTs and 29 observational studies. Based on RCTs, fluid management strategies did not have any effect on AKI, mortality, or any other postoperative complications. Intraoperative RCTs suggested that a restrictive fluid management strategy reduced pulmonary complications (RR, 0.69; 95% confidence interval [CI], 0.47 to 0.99; n = 283; I2 = 27%), duration of mechanical ventilation (MD, -13.04 hr; 95% CI, -22.2 to -3.88; n = 130; I2 = 0%) and blood loss (MD, -1.14 L; 95% CI, -1.72 to -0.57; n = 151; I2 = 0%). CONCLUSION Based on low or very low levels of evidence, we did not find any association between restrictive fluid management strategies and AKI, but we observed possible protective effects of intraoperative restrictive fluid management strategies on other outcomes. TRIAL REGISTRATION PROSPERO (CRD42017054970); registered 18 May, 2017.
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Vondrak K, Parisi F, Dhawan A, Grenda R, Webb NJA, Marks SD, Debray D, Holt RCL, Lachaux A, Kelly D, Kazeem G, Undre N. Efficacy and safety of tacrolimus in de novo pediatric transplant recipients randomized to receive immediate- or prolonged-release tacrolimus. Clin Transplant 2019; 33:e13698. [PMID: 31436896 PMCID: PMC6900073 DOI: 10.1111/ctr.13698] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 08/06/2019] [Accepted: 08/19/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS This multicenter trial compared immediate-release tacrolimus (IR-T) vs prolonged-release tacrolimus (PR-T) in de novo kidney, liver, and heart transplant recipients aged <16 years. Each formulation had similar pharmacokinetic (PK) profiles. Follow-up efficacy and safety results are reported herein. MATERIALS AND METHODS Patients, randomized 1:1, received once-daily, PR-T or twice-daily, IR-T within 4 days of surgery. After a 4-week PK assessment, patients continued randomized treatment for 48 additional weeks. At Year 1, efficacy assessments included the number of clinical acute rejections, biopsy-confirmed acute rejection (BCAR) episodes (including severity), patient and graft survival, and efficacy failure (composite of death, graft loss, BCAR, or unknown outcome). Adverse events were assessed throughout. RESULTS The study included 44 children. At Year 1, mean ± standard deviation tacrolimus trough levels were 6.6 ± 2.2 and 5.4 ± 1.6 ng/mL, and there were 2 and 7 acute rejection episodes in the PR-T and IR-T groups, respectively. No cases of graft loss or death were reported during the study. The overall efficacy failure rate was 18.2% (PR-T n = 1; IR-T n = 7). CONCLUSIONS In pediatric de novo solid organ recipients, the low incidence of BCAR and low efficacy failure rate suggest that PR-T-based immunosuppression is effective and well tolerated to 1-year post-transplantation.
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Affiliation(s)
| | | | | | - Ryszard Grenda
- The Children's Memorial Health Institute, Warsaw, Poland
| | | | - Stephen D Marks
- Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | | | | | - Alain Lachaux
- Université Lyon 1 et Hospices Civils de Lyon, Lyon, France
| | - Deirdre Kelly
- Birmingham Women's & Children's Hospital, Birmingham, UK
| | - Gbenga Kazeem
- Astellas Pharma Europe Ltd, Chertsey, UK.,BENKAZ Consulting Ltd, Cambridge, UK
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Ni HM, Chao X, Kaseff J, Deng F, Wang S, Shi YH, Li T, Ding WX, Jaeschke H. Receptor-Interacting Serine/Threonine-Protein Kinase 3 (RIPK3)-Mixed Lineage Kinase Domain-Like Protein (MLKL)-Mediated Necroptosis Contributes to Ischemia-Reperfusion Injury of Steatotic Livers. THE AMERICAN JOURNAL OF PATHOLOGY 2019; 189:1363-1374. [PMID: 31026418 DOI: 10.1016/j.ajpath.2019.03.010] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 02/12/2019] [Accepted: 03/21/2019] [Indexed: 02/07/2023]
Abstract
Increased hepatic ischemia-reperfusion (IR) injury in steatotic livers is a major reason for rejecting the use of fatty livers for liver transplantation. Necroptosis is implicated in the pathogenesis of fatty liver diseases. Necroptosis is regulated by three key proteins: receptor-interacting serine/threonine-protein kinase (RIPK)-1, RIPK3, and mixed-lineage kinase domain-like protein (MLKL). Here, we found that marked steatosis of the liver was induced when a Western diet was given in mice; steatosis was associated with the inhibition of hepatic proteasome activities and with increased levels of key necroptosis-related proteins. Mice fed a Western diet had more severe liver injury, as demonstrated by increases in serum alanine aminotransferase and necrotic areas of liver, after IR than did mice fed a control diet. Although hepatic steatosis was not different between Mlkl knockout mice and wild-type mice, Mlkl knockout mice had decreased hepatic neutrophil infiltration and inflammation and were protected from hepatic IR injury, irrespective of diet. Intriguingly, Ripk3 knockout or Ripk3 kinase-dead knock-in mice were protected against IR injury at the late phase but not the early phase, irrespective of diet. Overall, our findings indicate that liver steatosis exacerbates hepatic IR injury via increased MLKL-mediated necroptosis. Targeting MLKL-mediated necroptosis may help to improve outcomes in steatotic liver transplantation.
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Affiliation(s)
- Hong-Min Ni
- Department of Pharmacology, Toxicology and Therapeutics, University of Kansas Medical Center, Kansas City, Kansas.
| | - Xiaojuan Chao
- Department of Pharmacology, Toxicology and Therapeutics, University of Kansas Medical Center, Kansas City, Kansas
| | - Joshua Kaseff
- Department of Pharmacology, Toxicology and Therapeutics, University of Kansas Medical Center, Kansas City, Kansas
| | - Fengyan Deng
- Department of Pharmacology, Toxicology and Therapeutics, University of Kansas Medical Center, Kansas City, Kansas
| | - Shaogui Wang
- Department of Pharmacology, Toxicology and Therapeutics, University of Kansas Medical Center, Kansas City, Kansas
| | - Ying-Hong Shi
- Department of Liver Surgery, Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Tiangang Li
- Department of Pharmacology, Toxicology and Therapeutics, University of Kansas Medical Center, Kansas City, Kansas
| | - Wen-Xing Ding
- Department of Pharmacology, Toxicology and Therapeutics, University of Kansas Medical Center, Kansas City, Kansas
| | - Hartmut Jaeschke
- Department of Pharmacology, Toxicology and Therapeutics, University of Kansas Medical Center, Kansas City, Kansas
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Yang J, Yang L, Wu L, Zhao Q, Chen M, He X. Efficacy and Safety of Steroid Therapy for Posttransplant Hyperbilirubinemia Caused by Early Allograft Dysfunction: A Randomized Controlled Trial. Med Sci Monit 2019; 25:1936-1944. [PMID: 30870403 PMCID: PMC6429985 DOI: 10.12659/msm.915128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Hyperbilirubinemia is a common event that occurs after liver transplantation. Hyperbilirubinemia is usually caused by early allograft dysfunction. Glucocorticoid is widely used for immunosuppression, but few studies have analyzed the effects of steroid therapy on posttransplantation hyperbilirubinemia. The aim of this study was to assess whether glucocorticoid was beneficial in treating hyperbilirubinemia caused by early allograft dysfunction. MATERIAL AND METHODS Patients with postoperative hyperbilirubinemia (those with conditions such as biliary complications and rejections were excluded) were randomly assigned, in a 2: 1 ratio, to the steroid and control groups. Patients in the steroid group were treated with glucocorticoid combined with ursodeoxycholic acid, whereas patients in the control group were only treated with ursodeoxycholic acid. The primary endpoint was decrease in bilirubin and the secondary endpoint was safety. RESULTS From 1st June 2016 to 30th April 2018, 40 patients were enrolled into the steroid group, and 20 were enrolled into the control group. Donor, recipient, and operative data were similar between the 2 groups. The decrease in bilirubin levels in the steroid group was significantly greater than that in the control group on the first day after the intervention was finished (9.25±1.30 mg/dL vs. 3.11±1.45 mg/dL, p=0.005), and after 2 weeks (15.01±1.20 mg/dL vs. 8.88±1.98 mg/dL, p=0.007). The steroid group did not have a higher complication rate but it did have a shorter postoperative hospital stay than in the control group. CONCLUSIONS Low-dose steroid therapy was effective and safe for treating hyperbilirubinemia caused by early graft dysfunction, and it improved liver function.
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Affiliation(s)
- Jie Yang
- Department of Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland)
| | - Lei Yang
- Department of Thoracic Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland)
| | - Linwei Wu
- Department of Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland)
| | - Qiang Zhao
- Department of Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland)
| | - Maogen Chen
- Department of Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland)
| | - Xiaoshun He
- Department of Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland)
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Russell TA, Fritschel E, Do J, Donovan M, Keckeisen M, Agopian VG, Farmer DG, Wang T, Rubin Z, Busuttil RW, Kaldas FM. Minimizing central line-associated bloodstream infections in a high-acuity liver transplant intensive care unit. Am J Infect Control 2019; 47:305-312. [PMID: 30333081 DOI: 10.1016/j.ajic.2018.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 08/05/2018] [Accepted: 08/05/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND Increases in liver transplant patient perioperative acuity have resulted in frail immunosuppressed patients at elevated risk for nosocomial infections. Avoiding central line-associated bloodstream infections (CLABSIs) is paramount to facilitate transplantation and post-transplant recovery. In 2015, our liver transplant intensive care unit (ICU) CLABSIs accounted for more than 25% of all CLABSI at our institution. We therefore undertook a multidisciplinary collaborative among clinical epidemiology, nursing, transplant surgery, and critical care to eliminate CLABSI events. METHODS From 2014-2016, using Lean methodology and plan-do-study-act (PDSA) cycles, 14 interventions were implemented in the liver transplant ICU. Interventions were aimed at infection prevention, care standardization, and team-based monitoring. Implementation used quality improvement methodology including audit and feedback, education, standardization, multidisciplinary stakeholder involvement, and PDSA cycles. Process measures were monitored and audited. CLABSI rates per 1,000 central venous catheter (CVC) days were tracked by clinical epidemiology. RESULTS During the intervention, 901 CVC catheter audits were completed. Improvements were seen on all process measures, and complete compliance increased from 25%-67%. CLABSI infection rates dropped from 4.2 to 1.8 in 1,000 CVC days, with an average of less than 1 CLABSI per month. This marked a 61.2% annual reduction, which correlated with an estimated $935,000 annual savings. CONCLUSION Concerted ongoing multidisciplinary collaboratives are essential to minimize CLABSI and optimize value and quality in a challenging, high-acuity patient population.
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Liu J, Ma B, Cao W, Li M, Bramer WM, Peppelenbosch MP, Pan Q. Direct-acting antiviral agents for liver transplant recipients with recurrent genotype 1 hepatitis C virus infection: Systematic review and meta-analysis. Transpl Infect Dis 2019; 21:e13047. [PMID: 30615227 PMCID: PMC6850617 DOI: 10.1111/tid.13047] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 12/18/2018] [Accepted: 12/23/2018] [Indexed: 12/15/2022]
Abstract
Background Comprehensive evaluation of safety and efficacy of different combinations of direct‐acting antivirals (DAAs) in liver transplant recipients with genotype 1 (GT1) hepatitis C virus (HCV) recurrence remains limited. Therefore, we performed this systematic review and meta‐analysis in order to evaluate the clinical outcome of DAA treatment in liver transplant patients with HCV GT1 recurrence. Methods Studies were included if they contained information of 12 weeks sustained virologic response (SVR12) after DAA treatment completion as well as treatment related complications for liver transplant recipients with GT1 HCV recurrence. Results We identified 16 studies comprising 885 patients. The overall pooled estimate proportion of SVR12 was 93% (95% confidence interval (CI): 0.89, 0.96), with moderate heterogeneity observed (τ2 = 0.01, P < 0.01, I2=75%). High tolerability was observed in liver transplant recipients reflected by serious adverse events (sAEs) with pooled estimate proportion of 4% (95% CI: 0.01, 0.07; τ2 = 0.02, P < 0.01, I2 = 81%). For subgroup analysis, a total of five different DAA regimens were applied for treating these patients. Sofosbuvir/Ledipasvir (SOF/LDV) led the highest pooled estimate SVR12 proportion, followed by Paritaprevir/Ritonavir/Ombitasivir/Dasabuvir (PrOD), Daclatasvir (DCV)/Simeprevir (SMV) ± Ribavirin (RBV), and SOF/SMV ± RBV, Asunaprevir (ASV)/DCV. There was a tendency for favoring a higher pooled SVR12 proportion in patients with METAVIR Stage F0‐F2 of 97% (95% CI: 0.93, 0.99) compared to 85% (95% CI: 0.79, 0.90) for stage F3‐F4 (P < 0.01). There was no significant difference between LT recipients treated with or without RBV (P = 0.23). Conclusions Direct‐acting antiviral treatment is highly effective and well‐tolerated in liver transplant recipients with recurrent GT1 HCV infection.
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Affiliation(s)
- Jiaye Liu
- Biomedical Research Center, Northwest Minzu University, Lanzhou, China.,Erasmus MC Cancer Institute, Erasmus MC-University Medical Center, Rotterdam, The Netherlands
| | - Buyun Ma
- Erasmus MC Cancer Institute, Erasmus MC-University Medical Center, Rotterdam, The Netherlands
| | - Wanlu Cao
- Erasmus MC Cancer Institute, Erasmus MC-University Medical Center, Rotterdam, The Netherlands
| | - Meng Li
- Erasmus MC Cancer Institute, Erasmus MC-University Medical Center, Rotterdam, The Netherlands
| | - Wichor M Bramer
- Department of Medical Library, Erasmus MC-University Medical Center, Rotterdam, The Netherlands
| | - Maikel P Peppelenbosch
- Erasmus MC Cancer Institute, Erasmus MC-University Medical Center, Rotterdam, The Netherlands
| | - Qiuwei Pan
- Biomedical Research Center, Northwest Minzu University, Lanzhou, China.,Erasmus MC Cancer Institute, Erasmus MC-University Medical Center, Rotterdam, The Netherlands
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Gil E, Kim JM, Jeon K, Park H, Kang D, Cho J, Suh GY, Park J. Recipient Age and Mortality After Liver Transplantation: A Population-based Cohort Study. Transplantation 2018; 102:2025-2032. [PMID: 30153223 PMCID: PMC6257104 DOI: 10.1097/tp.0000000000002246] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 03/17/2018] [Accepted: 03/30/2018] [Indexed: 01/03/2023]
Abstract
BACKGROUND The feasibility of liver transplantation (LT) in elderly recipients remains a topic of debate. METHODS This cohort study evaluated the impact of recipient's age on LT outcome between January 2007 and May 2016 covered by the Korean National Health Insurance system (n = 9415). Multilevel regression models were used to determine the impact of recipient's age on in-hospital and long-term mortality after LT. RESULTS All patients had a first LT, with 2473 transplanted with liver from deceased donors (DD) and 6942 from living donors. The mean age was 52.2 ± 9.0 years. Most LT were performed on patients in their 50s (n = 4290, 45.6%) and 0.9% (n = 84) of the LT was performed on patients older 70 years. The overall in-hospital mortality was 6.3%, and the 3-year mortality was 11.3%. The in-hospital mortality included, 13.5% associated with DDLT and 3.7% involved living donor LT. When compared with that for patients aged 51 to 55 years, the risk of death among recipients older than 70 years was about fourfold higher after adjusting for baseline liver disease (odds ratio, 4.1; 95% confidence interval, 2.21-7.58), and was nearly threefold higher after adjusting for baseline liver disease and perioperative complications (odds ratio, 2.92; 95% confidence interval, 1.37-6.24). Also, the cost of LT increased significantly with age. CONCLUSIONS The data show that age remains an important risk factor for LT, suggesting that LT should be considered with caution in elderly recipients.
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Affiliation(s)
- Eunmi Gil
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jong Man Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyeongman Jeon
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Division of Pulmonology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyejeong Park
- Center for Clinical Epidemiology, Samsung Medical Center, Seoul, Republic of Korea
| | - Danbee Kang
- Center for Clinical Epidemiology, Samsung Medical Center, Seoul, Republic of Korea
- Department of Clinical Research Design & Evaluation, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
| | - Juhee Cho
- Department of Clinical Research Design & Evaluation, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
| | - Gee Young Suh
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Division of Pulmonology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Department of Clinical Research Design & Evaluation, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
| | - Jinkyeong Park
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Transjugular intrahepatic portosystemic shunt as a bridge to liver transplant: Current state and future directions. Transplant Rev (Orlando) 2018; 33:64-71. [PMID: 30477811 DOI: 10.1016/j.trre.2018.10.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 10/27/2018] [Accepted: 10/29/2018] [Indexed: 02/07/2023]
Abstract
Liver transplantation is one of the mainstays of treatment for liver failure due to severe chronic liver disease. Bridging therapies, such as placement of a transjugular intrahepatic portosystemic shunt (TIPS), are frequently employed to control complications of portal hypertension such as ascites, hydrothorax, and variceal bleeding, and thereby reduce morbidity in patients awaiting transplant. There is no significant difference seen in either graft survival or patient survival between those receiving TIPS pre-transplant and those who do not, although those receiving TIPS placement on average have a longer waiting time on the transplant waitlist. Locoregional therapies, such as thermal ablation or chemoembolization, can be efficacious in patients with HCC and pre-existing TIPS; however there is a risk for increased adverse events in patients receiving these therapies who have TIPS compared to those who do not. In summary, TIPS is a safe, effective treatment that can be used to ameliorate the complications that are sequelae of portal hypertension. While it does not appear to improve survival post-transplant, TIPS placement pre-transplant may increase survival time to transplant, thus improving overall survival as well as quality of life.
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Molina-Ortega A, Martín-Gandul C, Mena-Romo JD, Rodríguez-Hernández MJ, Suñer M, Bernal C, Sánchez M, Sánchez-Céspedes J, Pérez Romero P, Cordero E. Impact of pretransplant CMV-specific T-cell immune response in the control of CMV infection after solid organ transplantation: a prospective cohort study. Clin Microbiol Infect 2018; 25:753-758. [PMID: 30292792 DOI: 10.1016/j.cmi.2018.09.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 09/19/2018] [Accepted: 09/27/2018] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Although solid organ transplant (SOT) recipients with pretransplant serology for cytomegalovirus (CMV-R+) are considered at intermediate risk for CMV infection post transplantation, CMV infection remains a major cause of morbidity in this population. We prospectively characterized whether having pretransplant CMV-specific cellular immunity is independently associated with controlling infection after transplantation in R + SOT recipients. METHODS A prospective cohort of consecutive R + SOT recipients that received pre-emptive treatment for CMV infection was monitored after transplantation and variables were recorded during the follow-up. The cytomegalovirus-specific T-cell immune response was characterized by intracellular cytokine staining and viral loads determined using real-time PCR. RESULTS One hundred and thirty-five R + SOT recipients were included (67 kidney, 64 liver, four liver-kidney). Only one-third of the patients (42; 31.85%) had CMV-specific T-cell immunity (CD8+CD69+INF-γ+ T cells >0.25%) before transplantation. Patients with negative pretransplant immunity had more CMV infection (49, 52.7% vs. 15, 35.7%; p 0.07) and received more antiviral therapy than those with immunity (32, 34.4% vs. 6, 14.3%, p 0.016). Having CMV specific immunity was an independent factor for protection from developing viraemia ≥2000 IU/mL (OR 0.276, 95% CI 0.105-0.725, p < 0.01) and lower administration of treatment (OR 0.398, 95% CI 0.175-0.905, p 0.028). Only patients with no pretransplant CMV-specific T-cell response were diagnosed with CMV-disease (8, 8.6% vs. 0, 0%, p 0.05). DISCUSSION Our results show that having a pretransplant CMV specific T-cell response may be associated with a lower rate of CMV viraemia and less antiviral treatment after transplantation; however, more prospective studies are needed to confirm these findings.
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Affiliation(s)
- A Molina-Ortega
- Instituto de Biomedicina de Sevilla (IBIS)/CSIC/University of Sevilla, Unit of Infectious Diseases, Microbiology and Preventive Medicine. University Hospital Virgen del Rocío, Sevilla, Spain
| | - C Martín-Gandul
- Instituto de Biomedicina de Sevilla (IBIS)/CSIC/University of Sevilla, Unit of Infectious Diseases, Microbiology and Preventive Medicine. University Hospital Virgen del Rocío, Sevilla, Spain
| | - J D Mena-Romo
- Instituto de Biomedicina de Sevilla (IBIS)/CSIC/University of Sevilla, Unit of Infectious Diseases, Microbiology and Preventive Medicine. University Hospital Virgen del Rocío, Sevilla, Spain
| | - M J Rodríguez-Hernández
- Instituto de Biomedicina de Sevilla (IBIS)/CSIC/University of Sevilla, Unit of Infectious Diseases, Microbiology and Preventive Medicine. University Hospital Virgen del Rocío, Sevilla, Spain
| | - M Suñer
- Service of Nephrology, University Hospital Virgen del Rocío, Sevilla, Spain
| | - C Bernal
- Hepatobiliary and Pancreatic Surgery and Hepatic Transplant Unit, University Hospital Virgen del Rocío, Sevilla, Spain
| | - M Sánchez
- Instituto de Biomedicina de Sevilla (IBIS)/CSIC/University of Sevilla, Unit of Infectious Diseases, Microbiology and Preventive Medicine. University Hospital Virgen del Rocío, Sevilla, Spain; Department of Medicine, University of Seville, Seville, Spain
| | - J Sánchez-Céspedes
- Instituto de Biomedicina de Sevilla (IBIS)/CSIC/University of Sevilla, Unit of Infectious Diseases, Microbiology and Preventive Medicine. University Hospital Virgen del Rocío, Sevilla, Spain; Department of Medicine, University of Seville, Seville, Spain
| | - P Pérez Romero
- National Centre for Microbiology, Instituto de Salud Carlos III. Majadahonda, Madrid, Spain.
| | - E Cordero
- Instituto de Biomedicina de Sevilla (IBIS)/CSIC/University of Sevilla, Unit of Infectious Diseases, Microbiology and Preventive Medicine. University Hospital Virgen del Rocío, Sevilla, Spain
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Belli LS, Perricone G, Adam R, Cortesi PA, Strazzabosco M, Facchetti R, Karam V, Salizzoni M, Andujar RL, Fondevila C, De Simone P, Morelli C, Fabregat-Prous J, Samuel D, Agarwaal K, Moreno Gonzales E, Charco R, Zieniewicz K, De Carlis L, Duvoux C. Impact of DAAs on liver transplantation: Major effects on the evolution of indications and results. An ELITA study based on the ELTR registry. J Hepatol 2018; 69:810-817. [PMID: 29940268 DOI: 10.1016/j.jhep.2018.06.010] [Citation(s) in RCA: 164] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 06/05/2018] [Accepted: 06/14/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Direct-acting antivirals (DAAs) have dramatically improved the outcome of patients with hepatitis C virus (HCV) infection including those with decompensated cirrhosis (DC). We analyzed the evolution of indications and results of liver transplantation (LT) in the past 10 years in Europe, focusing on the changes induced by the advent of DAAs. METHODS This is a cohort study based on data from the European Liver Transplant Registry (ELTR). Data of adult LTs performed between January 2007 to June 2017 for HCV, hepatitis B virus (HBV), alcohol (EtOH) and non-alcoholic steatohepatitis (NASH) were analyzed. The period was divided into different eras: interferon (IFN/RBV; 2007-2010), protease inhibitor (PI; 2011-2013) and second generation DAA (DAA; 2014-June 2017). RESULTS Out of a total number of 60,527 LTs, 36,382 were performed in patients with HCV, HBV, EtOH and NASH. The percentage of LTs due to HCV-related liver disease varied significantly over time (p <0.0001), decreasing from 22.8% in the IFN/RBV era to 17.4% in the DAA era, while those performed for NASH increased significantly (p <0.0001). In the DAA era, the percentage of LTs for HCV decreased significantly (p <0.0001) from 21.1% (first semester 2014) to 10.6% (first semester 2017). This decline was more evident in patients with DC (HCV-DC, -58.0%) than in those with hepatocellular carcinoma (HCC) associated with HCV (HCV-HCC, -41.2%). Conversely, three-year survival of LT recipients with HCV-related liver disease improved from 65.1% in the IFN/RBV era to 76.9% in the DAA era, and is now comparable to the survival of recipients with HBV infection (p = 0.3807). CONCLUSIONS In Europe, the number of LTs due to HCV infection is rapidly declining for both HCV-DC and HCV-HCC indications and post-LT survival has dramatically improved over the last three years. This is the first comprehensive study of the overall impact of DAA treatment for HCV on liver transplantation in Europe. LAY SUMMARY After the advent of direct-acting antivirals in 2014, a dramatic decline was observed in the number of liver transplants performed both in patients with decompensated cirrhosis due to hepatitis C virus (HCV), minus 60%, and in those with hepatocellular carcinoma associated with HCV, minus 41%. Furthermore, this is the first large-scale study demonstrating that the survival of liver transplant recipients with HCV-related liver disease has dramatically improved over the last three years and is now comparable to the survival of recipients with hepatitis B virus infection. The reduction in HCV-related indications for LT means that there is a greater availability of livers, at least 600 every year, which can be allocated to patients with indications other than HCV.
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Affiliation(s)
- Luca Saverio Belli
- Gastroenterology and Hepatology, Liver Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.
| | - Giovanni Perricone
- Gastroenterology and Hepatology, Liver Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Rene Adam
- Centre Hépatobiliaire, Université Paris-Sud, Hôpital Paul Brousse, F-94804 Villejuif, France
| | - Paolo A Cortesi
- Research Centre on Public Health (CESP), University of Milan-Bicocca, Monza, Italy
| | | | - Rita Facchetti
- Research Centre on Public Health (CESP), University of Milan-Bicocca, Monza, Italy
| | - Vincent Karam
- Centre Hépatobiliaire, Université Paris-Sud, Hôpital Paul Brousse, F-94804 Villejuif, France
| | - Mauro Salizzoni
- Centro trapianti di fegato, AO San Giovanni Battista, Torino, Italy
| | - Rafael Lopez Andujar
- Hospital Universitario y Politecnico La Fe, Unidad de Chirurgia HPB y TX, Valencia, Spain
| | - Costantino Fondevila
- Hospital Clinic de Barcelona, Dep. of Surgery, University of Barcelona Villaroel, Barcelona, Spain
| | - Paolo De Simone
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Cristina Morelli
- Liver and Multiorgan Transplantation, Policlinico Sant'Orsola-Malpighi, Bologna, Italy
| | - Joan Fabregat-Prous
- Hospital Universitari de Bellvitge, Unidad de Transplante Hepatico, Barcelona, Spain
| | - Didier Samuel
- Centre Hépatobiliaire, Université Paris-Sud, Hôpital Paul Brousse, F-94804 Villejuif, France
| | - Kosh Agarwaal
- Institute of Liver Diseases, King's College Hospital, Liver Unit, London, UK
| | | | - Ramon Charco
- Hospital Universitario Vall D Hebron HBP, Surgery & Transplant Department, Barcelona, Spain
| | - Krzysztof Zieniewicz
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Poland
| | - Luciano De Carlis
- Chirurgia generale 2 e Trapianti, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Christophe Duvoux
- Department of Hepatology and Liver Transplant Unit, Henri Mondor Hospital, AssistancePublique-Hôpitaux de Paris, Paris-Est University, Creteil, France
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Akateh C, Beal EW, Whitson BA, Black SM. Normothermic Ex-vivo Liver Perfusion and the Clinical Implications for Liver Transplantation. J Clin Transl Hepatol 2018; 6:276-282. [PMID: 30271739 PMCID: PMC6160298 DOI: 10.14218/jcth.2017.00048] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 02/07/2018] [Accepted: 03/01/2018] [Indexed: 12/13/2022] Open
Abstract
Despite significant improvements in outcomes after liver transplantation, many patients continue to die on the waiting list, while awaiting an available organ for transplantation. Organ shortage is not only due to an inadequate number of available organs, but also the inability to adequately assess and evaluate these organs prior to transplantation. Over the last few decades, ex-vivo perfusion of the liver has emerged as a useful technique for both improved organ preservation and assessment of organs prior to transplantation. Large animal studies have shown the superiority of ex-vivo perfusion over cold static storage. However, these studies have not, necessarily, been translatable to human livers. Small animal studies have been essential in understanding and improving this technology. Similarly, these results have yet to be translated into clinical use. A few Phase 1 clinical trials have shown promise and confirmed the viability of this technology. However, more robust studies are needed before ex-vivo liver perfusion can be widely accepted as the new clinical standard of organ preservation. Here, we aimed to review all relevant large and small animal research, as well as human liver studies on normothermic ex-vivo perfusion, and to identify areas of deficiency and opportunities for future research endeavors.
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Affiliation(s)
- Clifford Akateh
- General and Gastrointestinal Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- *Correspondence to: Clifford Akateh, General and Gastrointestinal Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, 395 W 12th Ave, Room 654, Columbus, OH-43210-1267, USA. Tel: +1-614-293-8704, Fax: +1-614-293-4063, E-mail:
| | - Eliza W. Beal
- General and Gastrointestinal Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Bryan A. Whitson
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Sylvester M. Black
- Division of Transplant Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Ayloo S, Pentakota SR, Molinari M. Trends of characteristics and outcomes of donors and recipients of deceased donor liver transplantation in the United States: 1990 to 2013. World J Transplant 2018; 8:167-177. [PMID: 30211025 PMCID: PMC6134273 DOI: 10.5500/wjt.v8.i5.167] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 07/23/2018] [Accepted: 08/03/2018] [Indexed: 02/05/2023] Open
Abstract
AIM To compare trends in donor/recipient characteristics and outcomes using four period cohorts of liver transplant recipients from 1990 to 2009. METHODS Seventy thousand three hundred and seventy-seven adult first-time recipients of whole-organ deceased-donor liver grafts from 1990 to 2009 were followed up until September 2013. Four periods based on transplantation dates were considered to account for developments in transplantation. Descriptive statistics were used to describe donor/recipient characteristics and transplant outcomes. Statistical comparisons between periods were performed using χ2/Fischer's exact test (categorical variables) and t-tests/Mann-Whitney U test (continuous variables). Univariate descriptive statistics/survival data were generated using Kaplan-Meier curves. Cox Proportional Hazards models were used for regression analyses of patient and graft survival. RESULTS Mean age (years), body mass index (kg/m2), and the proportion of males were, respectively, 39.1 (± 17.4), 25.9 (± 5.7) and 60.3 for donors, and 51.3 (± 10.5), 27.7 (± 5.6), and 64.4 for recipients. Donor and transplantation rates differed between racial/ethnic groups. Median (Q1-Q3) cold and warm ischemia, waitlist, and hospital stay times were 8 (6.0-10.0) h and 45 (35-59) min, 93 (21-278) d, and 12 (8-20) d. Total functional assistance was required by 8% of recipients at wait-listing and 13.4% at transplantation. Overall survival at 1, 3, 5, 10, 15, and 20 years was 87.3%, 79.4%, 73.6%, 59.8%, 46.7%, and 35.9%, respectively. The 2005-2009 cohort had better patient and graft survival than the 1990-1994 cohort overall [HR 0.67 (0.62-0.72) and 0.66 (0.62-0.71)] and at five years [HR 0.73 (0.66-0.80) and 0.71 (0.65-0.77)]. CONCLUSION Despite changes in donor quality, recipient characteristics, and declining functional status among transplant recipients, overall patient survival is superior and post-transplant outcomes continue to improve.
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Affiliation(s)
- Subhashini Ayloo
- Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ 07103, United States
| | - Sri Ram Pentakota
- Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ 07103, United States
| | - Michele Molinari
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, United States
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Welling TH, Eddinger K, Carrier K, Zhu D, Kleaveland T, Moore DE, Schaubel DE, Abt PL. Multicenter Study of Staging and Therapeutic Predictors of Hepatocellular Carcinoma Recurrence Following Transplantation. Liver Transpl 2018; 24:1233-1242. [PMID: 29729113 PMCID: PMC6153067 DOI: 10.1002/lt.25194] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 04/23/2018] [Indexed: 12/12/2022]
Abstract
Orthotopic liver transplantation (OLT) and resection are effective treatments for hepatocellular carcinoma (HCC). However, optimizing OLT and limiting HCC recurrence remains a vexing problem. New HCC Model for End-Stage Liver Disease and allocation algorithms provide greater observation of HCC patients, many while receiving local-regional treatments. Potential benefits of local-regional treatment for limiting HCC recurrence after OLT remain incompletely understood. Therefore, we aimed to define HCC-specific prognostic factors affecting recurrence in a contemporary, multicenter cohort of HCC patients undergoing OLT and specifically whether local-regional therapies limited recurrence. We identified 441 patients undergoing OLT for HCC at 3 major transplant centers from 2008 to 2013. Cox regression was used to analyze covariate-adjusted recurrence and mortality rates after OLT. "Bridging" or "downstaging" therapy was used in 238 (54%) patients with transarterial chemoembolization (TACE) being used in 170 (71%) of treated patients. The survival rate after OLT was 88% and 78% at 1 and 3 years, respectively, with HCC recurrence (28% of deaths) significantly increasing the mortality rate (hazard ratio [HR], 19.87; P < 0.001). Tumor size, not tumor number, either at presentation or on explant independently predicted HCC recurrence (HR, 1.36 and 1.73, respectively; P < 0.05) with a threshold effect noted at 4.0-cm size. Local-regional therapy (TACE) reduced HCC recurrence by 64% when adjusting for presenting tumor size (HR, 0.36; P < 0.05). Explant tumor size and microvascular invasion predicted mortality (HR, 1.19 and 1.51, respectively; P < 0.05) and pathologic response to therapy (TACE or radiofrequency ablation) significantly decreased explant tumor size (0.56-1.62 cm diameter reduction; P < 0.05). In conclusion, HCC tumor size at presentation or explant is the most important predictor for HCC recurrence after OLT. Local-regional therapy to achieve a pathologic response (decreasing tumor size) can limit HCC recurrences after OLT. Liver Transplantation 00 000-000 2018 AASLD.
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Affiliation(s)
| | - Kevin Eddinger
- Department of Surgery, Hospital of the University of Pennsylvania
| | | | - Danting Zhu
- School of Public Health, University of Michigan, Ann Arbor, MI
| | | | | | | | - Peter L. Abt
- Department of Surgery, Hospital of the University of Pennsylvania
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James TW, Shay JES, Furfaro D, Ozseker B, Russell SD, Pustavoitau A, Rizkalla N, Saberi B, Philosophe B, Cameron AM, Gurakar A. Cardiac Events Within the 30-Day Postoperative Period Is Associated With Increased 1-Year Mortality Among Deceased-Donor Liver Transplant Recipients. EXP CLIN TRANSPLANT 2018; 17:370-374. [PMID: 30084756 DOI: 10.6002/ect.2017.0276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Each year in the United States, approximately 40000 patients with a liver disorder will progress to end-stage liver disease and about 30000 of those patients will subsequently die from this condition. Liver transplant remains the definitive treatment option for end-stage liver disease, and understanding the causes of posttransplant mortality is an ongoing area of investigation. MATERIALS AND METHODS In this retrospective cohort study, patients who underwent orthotopic liver transplant between January 2012 and January 2015 at the Johns Hopkins Hospital Liver Transplant Program were reviewed by a single reviewer for cardiac events in the 30 days after transplant or during the index admission. RESULTS Of the 145 patients included, 30 (20.6%) were identified as having experienced a cardiac event during the defined postoperative period. Overall 1-year mortality for the cohort of 145 patients was 11.7%; however, 1-year mortality in those who had a cardiac event was 36.7% compared with 5.2% in the noncardiac event group (odds ratio = 18.17; P < .001). Although there was a statistically significant difference in age between the groups (58.6 vs 52.3 years old), once accounted for in multivariate analysis, a posttransplant cardiac event was still a statistically significant variable in 1-year mortality (odds ratio = 89.16; 95% confidence interval, 2.71-2933.95; P = .012). Similarly, hepatocellular carcinoma, sex, age, and presence of diabetes had little effect on 1-year mortality when we compared those patients who experienced a cardiac event in the first 30 days versus those who did not (odds ratio = 100.82; 95% confidence interval, 2.15-4726.12; P = .019). CONCLUSIONS Recipients who experience cardiac events within 30 days after transplant have increased 1-year posttransplant mortality. This highlights the importance of cardiac risk stratification before transplant.
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Affiliation(s)
- Theodore W James
- From the Osler Internal Medicine Residency Program, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Brooks JT, Koizumi N, Neglia E, Gdoura B, Wong TW, Kwon C, Smith TE, Ortiz J. Improved retransplant outcomes: early evidence of the share35 impact. HPB (Oxford) 2018; 20:649-657. [PMID: 29500002 DOI: 10.1016/j.hpb.2018.01.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Revised: 12/28/2017] [Accepted: 01/18/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Share 35 prioritizes offers of deceased donor livers to regional candidates with Model for End-Stage Liver Disease (MELD) ≥35 over local candidates with lower MELD scores. Analysis of Share35 has shown that overall 1- or 2-year post-transplant (LTx) outcomes have been unchanged while waitlist mortality has been reduced. However, these studies exclude retransplant (reLTx) recipients. This study aims to investigate the outcomes of liver retransplants in evaluating the impact of the Share35 policy. METHODS A retrospective analysis of data from the United Network for Organ Sharing database over the period June 2011-June 2015 was performed. RESULTS A total of 19,748 LTx and 312 reLTx recipients were identified. Of the LTx recipients, 9626 (48.7%) underwent transplant pre-Share 35 and 10,122 (51.3%) post-Share 35. 123 (39.4%) reLTx recipients underwent retransplantation pre-Share 35 and 189 (60.6%) post-Share 35. ReLTx recipients experienced improved 2-year graft survival post-Share 35 compared to pre-Share 35 (67% vs. 21.1%). Patient survival also improved at 2-years for reLTx recipients post-Share 35 compared to pre-Share 35 (69.2% vs. 33.1%). Transplant post-Share 35 was protective for both 2-year graft (HR = 0.669, CI = 0.454-0.985, p = 0.04) and patient (HR = 0.659, CI = 0.44-0.987, p = 0.003) survival. CONCLUSION Share35 is associated with improved outcomes after retransplantation.
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Affiliation(s)
- Joseph T Brooks
- Department of Surgery, University of Toledo, Toledo, OH, USA
| | - Naoru Koizumi
- Schar School of Policy and Government, George Mason University, Arlington, VA, USA; Department of Surgery, George Washington University Hospital, Washington, DC, USA.
| | - Elizabeth Neglia
- Schar School of Policy and Government, George Mason University, Arlington, VA, USA
| | - Bilel Gdoura
- Schar School of Policy and Government, George Mason University, Arlington, VA, USA
| | - Tina W Wong
- Department of Surgery, Maricopa Medical Center, Phoenix, AZ, USA
| | - Chang Kwon
- Schar School of Policy and Government, George Mason University, Arlington, VA, USA
| | - Tony E Smith
- Department of Systems Engineering, University of Pennsylvania, Philadelphia, PA, USA
| | - Jorge Ortiz
- Department of Surgery, George Washington University Hospital, Washington, DC, USA
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Adekunle R, Jonchhe S, Ravichandran B, Wilson E, Husson J. Hepatitis C genotype change after transplantation utilizing hepatitis C positive donor organs. Transpl Infect Dis 2018; 20:e12925. [PMID: 29797655 DOI: 10.1111/tid.12925] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 01/07/2018] [Accepted: 01/14/2018] [Indexed: 12/15/2022]
Abstract
A shortage in organs for transplantation has led to the increased use of hepatitis C (HCV) infected donor organs for solid organ transplant recipients infected with HCV. However, the donor HCV genotype is not routinely checked or known prior to transplant. Here, we report 4 cases of genotype conversion after transplantation in patients receiving HCV infected donor organs. This change in genotype may potentially impact HCV progression as well as treatment choice for these patients.
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Affiliation(s)
- R Adekunle
- Department of Medicine, University of Maryland Medical Center, Baltimore, MD, USA
| | - S Jonchhe
- University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - B Ravichandran
- University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - E Wilson
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - J Husson
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
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The feasibility of a group stress management Liver SMART intervention for patients with end-stage liver disease: A pilot study. Palliat Support Care 2018; 17:35-41. [PMID: 29860964 DOI: 10.1017/s147895151800024x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Structured, empirically supported psychological interventions are lacking for patients who require organ transplantation. This stage IA psychotherapy development project developed and tested the feasibility, acceptability, tolerability, and preliminary efficacy of an 8-week group cognitive behavioral stress management intervention adapted for patients with end-stage liver disease awaiting liver transplantation. METHOD Twenty-nine English-speaking United Network for Organ Sharing-registered patients with end-stage liver disease from a single transplantation center enrolled in 8-week, group cognitive-behavioral liver stress management and relaxation training intervention adapted for patients with end-stage liver disease. Patients completed pre- and postintervention surveys that included the Beck Depression Inventory II and the Beck Anxiety Inventory. Feasibility, acceptability, tolerability, and preliminary efficacy were assessed.ResultAttendance rate was 69.40%. The intervention was rated as "good" to "excellent" by 100% of participants who completed the postintervention survey in teaching them new skills to relax and to cope with stress, and by 94.12% of participants in helping them feel supported while waiting for a liver transplant. No adverse events were recorded over the course of treatment. Attrition was 13.79%. Anxious and depressive symptoms were not statistically different after the intervention.Significance of resultsThe liver stress management and relaxation training intervention is feasible, acceptable, and tolerable to end-stage liver disease patients within a transplant clinic setting. Anxious and depressive symptoms remained stable postintervention. Randomized controlled trials are needed to study the intervention's effectiveness in this population.
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Mehta N, Guy J, Frenette CT, Dodge JL, Osorio RW, Minteer WB, Roberts JP, Yao FY. Excellent Outcomes of Liver Transplantation Following Down-Staging of Hepatocellular Carcinoma to Within Milan Criteria: A Multicenter Study. Clin Gastroenterol Hepatol 2018; 16:955-964. [PMID: 29175528 PMCID: PMC6053266 DOI: 10.1016/j.cgh.2017.11.037] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 11/16/2017] [Accepted: 11/17/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Single-center studies have reported excellent outcomes of patients who underwent liver transplantation for hepatocellular carcinoma (HCC) after successful down-staging (reduction of tumor burden with local-regional therapy), but multi-center studies are lacking. We performed a multi-center study, applying a uniform down-staging protocol, to assess outcomes of liver transplantation and performed an intention to treat analysis. We analyzed factors associated with treatment failure, defined as dropout from the liver transplant waitlist due to tumor progression, liver-related death without transplant, or recurrence of HCC after transplant. METHODS We performed a retrospective multi-center study of 187 consecutive adults with HCC enrolled in the down-staging protocol at 3 liver transplant centers in California (Region 5), from 2002 through 2012. All patients underwent abdominal imaging 1 month after each local-regional treatment, and at a minimum of once every 3 months. The primary outcome was probability of treatment failure. RESULTS Liver transplantation was performed after successful down staging in 109 patients (58%). Tumor explant from only 1 patient had poorly differentiated grade and 7 (6.4%) had vascular invasion. Based on Kaplan-Meier analysis of data collected a median 4.3 years after liver transplantation, 95% of patients would survive 1 year and 80% of patients would survive 5 years; probabilities of recurrence-free survival were 95% and 87%, respectively. There were no center-specific differences in survival in the intention to treat analysis (P = .62), in survival after liver transplantation (P = .95), or in recurrence of HCC (P = .99). Patients were removed from the liver transplantation waitlist due to tumor progression in (n = 59; 32%) or liver-related death without liver transplantation (n = 9; 5%). Factors associated with treatment failure, based on multivariable analysis, were pre-treatment levels of alpha-fetoprotein (AFP) >1000 ng/mL (hazard ratio, 3.3; P < .001) and Child Pugh class B or C (hazard ratio, 1.6; P < .001). The probability of treatment failure at 2 years from the first down-staging procedure was 100% for patients with levels of AFP >1000 and Child Pugh class B or C vs 29.4% for patients with neither risk factor (P < .001). CONCLUSIONS In a retrospective, multi-center study on HCC down staging under a uniform protocol, we found patients to have excellent outcomes following liver transplantation, with no center-specific effects. Our findings support application of the down-staging protocol on a broader scale. Patients with Child Pugh class B or C and AFP >1000 are unlikely to benefit from down staging.
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Affiliation(s)
- Neil Mehta
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Jennifer Guy
- Department of Transplantation, California Pacific Medical Center, San Francisco, California
| | - Catherine T Frenette
- Center for Organ and Cell Transplantation, Scripps Green Hospital, La Jolla, California
| | - Jennifer L Dodge
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, California
| | - Robert W Osorio
- Department of Transplantation, California Pacific Medical Center, San Francisco, California
| | - William B Minteer
- Center for Organ and Cell Transplantation, Scripps Green Hospital, La Jolla, California
| | - John P Roberts
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, California
| | - Francis Y Yao
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, San Francisco, California; Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, California.
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Stoklosa TM, Morley KC, Volovets A, Haber PS. Pharmacotherapy for Alcohol Use Disorder in the Context of Liver Disease. CURRENT ADDICTION REPORTS 2018. [DOI: 10.1007/s40429-018-0211-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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50
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Nguyen JH, Harnois DM. Incidence and Outcome of Small-for-Size Liver Grafts Transplanted in Adult Recipients. Transplant Proc 2018; 50:198-201. [PMID: 29407308 DOI: 10.1016/j.transproceed.2017.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 11/08/2017] [Accepted: 12/04/2017] [Indexed: 02/04/2023]
Abstract
Small-for-size liver transplantation (SFS-LT) carries high morbidity and mortality after transplantation. SFS-LT is usually associated with living-donor or deceased-donor split LT; however its incidence and outcome are poorly defined in adult LT recipients who receive whole grafts (WLT). In this study, we retrospectively reviewed our cohort of 3,106 deceased-donor LT in adult recipients. We found that among the 31 split LTs, 11 (35.5%) were SFS. In contrast, there only 1.08% of the whole-graft transplants (31 out of 2,868) were SFS. Although less common, SFS-WLT is associated with poorer long-term outcome of both graft and patient survivals.
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Affiliation(s)
- J H Nguyen
- Divisions of Transplant Surgery and Transplant Hepatology, Department of Transplantation, Mayo Clinic Florida, Jacksonville, Florida.
| | - D M Harnois
- Divisions of Transplant Surgery and Transplant Hepatology, Department of Transplantation, Mayo Clinic Florida, Jacksonville, Florida
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