1
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Mehtani R, Rathi S. Recurrence of Primary Disease After Adult Liver Transplant - Risk Factors, Early Diagnosis, Management, and Prevention. J Clin Exp Hepatol 2024; 14:101432. [PMID: 38975605 PMCID: PMC11222954 DOI: 10.1016/j.jceh.2024.101432] [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: 04/18/2023] [Accepted: 04/14/2024] [Indexed: 07/09/2024] Open
Abstract
Liver transplantation offers a new lease of life to patients with end-stage liver disease and hepatocellular carcinoma. However, the implantation of an exogenous allograft and the accompanying immunosuppression bring their own challenges. Moreover, the persistence of risk factors for the initial liver insult place the new graft at a higher risk of damage. With the increasing number of liver transplants along with the improvement in survival posttransplant, the recurrence of primary disease in liver grafts has become more common. Pre-2015, the most common disease to recur after transplant was hepatitis C. However, directly acting antivirals have nearly eliminated this problem. The greatest challenge of disease recurrence we now face are those of nonalcoholic steatohepatitis, alcohol-related liver disease, and primary sclerosing cholangitis. We focus on the epidemiology and pathophysiology of the recurrence of primary disease after transplant. We also discuss means of early identification, risk stratification, prevention, and management of recurrent primary disease after liver transplantation.
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Affiliation(s)
- Rohit Mehtani
- Department of Hepatology, Amrita Institute of Medical Sciences and Research, Faridabad, Haryana, India
| | - Sahaj Rathi
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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2
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Goswami A, Weinberg E, Coraluzzi L, Bittermann T, Nahas J, Addis S, Weinrieb R, Serper M. A Tailored Virtual Program for Alcohol Use Disorder Treatment Among Liver Transplant Candidates and Recipients Is Feasible and Associated With Lower Post-Transplant Relapse. Clin Transplant 2024; 38:e15381. [PMID: 38940230 PMCID: PMC11273277 DOI: 10.1111/ctr.15381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 05/05/2024] [Accepted: 06/02/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Alcohol-associated liver disease (ALD) is a leading indication for liver transplant (LT) in the United States. Rates of early liver transplant (ELT) with less than 6 months of sobriety have increased substantially. Patients who receive ELT commonly have alcohol-associated hepatitis (AH) and are often too ill to complete an intensive outpatient program (IOP) for alcohol use disorder (AUD) prior to LT. ELT recipients feel alienated from traditional IOPs. METHODS We implemented Total Recovery-LT, a tailored virtual outpatient IOP specific for patients under evaluation or waitlisted for LT who were too ill to attend community-based alcohol treatment programs. The 12-week program consisted of weekly group and individual counseling delivered by a master's level Certified Addiction Counselor trained in the basics of LT. Treatment consisted of 12-Step Facilitation, Motivational Interviewing, and Cognitive Behavioral Therapy. We report on program design, implementation, feasibility and early outcomes. RESULTS From March 2021 to September 2022, 42 patients (36% female, 23 in LT evaluation, 19 post-transplant) enrolled across five cohorts with 76% (32/42) completing the program. Alcohol relapse was more common among noncompleters versus those who completed the program (8/10, 80% vs. 7/32, 22%, p = 0.002). History of trauma or post-traumatic stress symptoms were associated with lower likelihood of completion. Patients' desire for continued engagement after completion led to the creation of a monthly alumni group. CONCLUSIONS Our integrated IOP model for patients with high-risk AUD in LT evaluation or post-transplant is well-received by patients and could be considered a model for LT programs.
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Affiliation(s)
- Arpita Goswami
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia PA
| | - Ethan Weinberg
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia PA
| | | | - Therese Bittermann
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia PA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia PA
| | - Jonathan Nahas
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia PA
| | - Senayish Addis
- Penn Transplant Institute, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Robert Weinrieb
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia PA
| | - Marina Serper
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia PA
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3
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Hu T, Liu CH, Zheng Y, Ji J, Zheng Y, He SK, Wu D, Jiang W, Zeng Q, Zhang N, Tang H. miRNAs in patients with alcoholic liver disease: a systematic review and meta-analysis. Expert Rev Gastroenterol Hepatol 2024; 18:283-292. [PMID: 38937981 DOI: 10.1080/17474124.2024.2374470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 06/26/2024] [Indexed: 06/29/2024]
Abstract
INTRODUCTION Alcoholic liver disease (ALD) encompasses a spectrum of liver conditions, including liver steatosis, alcoholic hepatitis (AH), fibrosis, cirrhosis, and hepatocellular carcinoma (HCC). microRNAs (miRNAs) have garnered significant interest as potential biomarkers for ALD. METHODS We searched PubMed, Embase, Web of Science and Cochrane Central Register of Controlled Trials (CENTRAL) systemically from inception to June 2024. All extracted data was stratified according to the stages of ALD. The vote-counting strategy performed a meta-analysis on miRNA expression profiles. RESULTS We included 40 studies. In serum of individuals with alcohol-use vs. no alcohol-use, miRNA-122 and miRNA-155 were upregulated, and miRNA-146a was downregulated. In patients with ALD vs. healthy controls, miRNA-122 and miRNA-155 were also upregulated, and miRNA-146a was downregulated. However, in patients with AH vs. healthy individuals, only the serum miRNA-122 level was upregulated. Due to insufficient data on diagnostic accuracy, we failed to conclude the ability of miRNAs to distinguish between different stages of ALD-related liver fibrosis. The results for ALD-related HCC were also insufficient and controversial. CONCLUSIONS Circulating miRNA-122 was the most promising biomarker to manage individuals with ALD. More studies were needed for the diagnostic accuracy of miRNAs in ALD. REGISTRATION This protocol was registered on the International Prospective Register of Systematic Reviews (PROSPERO) (www.crd.york.ac.uk/prospero/) with registration number CRD42023391931.
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Affiliation(s)
- Tengyue Hu
- Center of Infectious Diseases, West China Hospital of Sichuan University, Chengdu, China
- Laboratory of Infectious and Liver Diseases, Institution of Infectious Diseases, West China Hospital of Sichuan University, Chengdu, China
| | - Chang Hai Liu
- Center of Infectious Diseases, West China Hospital of Sichuan University, Chengdu, China
- Laboratory of Infectious and Liver Diseases, Institution of Infectious Diseases, West China Hospital of Sichuan University, Chengdu, China
| | - Yurong Zheng
- West China School of Public Health, Sichuan University, Chengdu, China
| | - Jialin Ji
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Yantong Zheng
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Si-Ke He
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Dongbo Wu
- Center of Infectious Diseases, West China Hospital of Sichuan University, Chengdu, China
- Laboratory of Infectious and Liver Diseases, Institution of Infectious Diseases, West China Hospital of Sichuan University, Chengdu, China
| | - Wei Jiang
- Center of Infectious Diseases, West China Hospital of Sichuan University, Chengdu, China
- Laboratory of Infectious and Liver Diseases, Institution of Infectious Diseases, West China Hospital of Sichuan University, Chengdu, China
| | - Qingmin Zeng
- Center of Infectious Diseases, West China Hospital of Sichuan University, Chengdu, China
- Laboratory of Infectious and Liver Diseases, Institution of Infectious Diseases, West China Hospital of Sichuan University, Chengdu, China
| | - Nannan Zhang
- National Center for Birth Defect Monitoring, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second University Hospital, Chengdu, China
| | - Hong Tang
- Center of Infectious Diseases, West China Hospital of Sichuan University, Chengdu, China
- Laboratory of Infectious and Liver Diseases, Institution of Infectious Diseases, West China Hospital of Sichuan University, Chengdu, China
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4
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Narayanan P, Wu T, Shah VH, Curtis BL. Insights into ALD and AUD diagnosis and prognosis: Exploring AI and multimodal data streams. Hepatology 2024:01515467-990000000-00879. [PMID: 38743008 DOI: 10.1097/hep.0000000000000929] [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: 02/16/2024] [Accepted: 05/01/2024] [Indexed: 05/16/2024]
Abstract
The rapid evolution of artificial intelligence and the widespread embrace of digital technologies have ushered in a new era of clinical research and practice in hepatology. Although its potential is far from realization, these significant strides have generated new opportunities to address existing gaps in the delivery of care for patients with liver disease. In this review, we discuss how artificial intelligence and opportunities for multimodal data integration can improve the diagnosis, prognosis, and management of alcohol-associated liver disease. An emphasis is made on how these approaches will also benefit the detection and management of alcohol use disorder. Our discussion encompasses challenges and limitations, concluding with a glimpse into the promising future of these advancements.
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Affiliation(s)
- Praveena Narayanan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Tiffany Wu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Vijay H Shah
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Brenda L Curtis
- Technology and Translational Research Unit, National Institute on Drug Abuse Intramural Research Program, National Institute of Health, Baltimore, Maryland, USA
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Podéus H, Simonsson C, Nasr P, Ekstedt M, Kechagias S, Lundberg P, Lövfors W, Cedersund G. A physiologically-based digital twin for alcohol consumption-predicting real-life drinking responses and long-term plasma PEth. NPJ Digit Med 2024; 7:112. [PMID: 38702474 PMCID: PMC11068902 DOI: 10.1038/s41746-024-01089-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 03/29/2024] [Indexed: 05/06/2024] Open
Abstract
Alcohol consumption is associated with a wide variety of preventable health complications and is a major risk factor for all-cause mortality in the age group 15-47 years. To reduce dangerous drinking behavior, eHealth applications have shown promise. A particularly interesting potential lies in the combination of eHealth apps with mathematical models. However, existing mathematical models do not consider real-life situations, such as combined intake of meals and beverages, and do not connect drinking to clinical markers, such as phosphatidylethanol (PEth). Herein, we present such a model which can simulate real-life situations and connect drinking to long-term markers. The new model can accurately describe both estimation data according to a χ2 -test (187.0 < Tχ2 = 226.4) and independent validation data (70.8 < Tχ2 = 93.5). The model can also be personalized using anthropometric data from a specific individual and can thus be used as a physiologically-based digital twin. This twin is also able to connect short-term consumption of alcohol to the long-term dynamics of PEth levels in the blood, a clinical biomarker of alcohol consumption. Here we illustrate how connecting short-term consumption to long-term markers allows for a new way to determine patient alcohol consumption from measured PEth levels. An additional use case of the twin could include the combined evaluation of patient-reported AUDIT forms and measured PEth levels. Finally, we integrated the new model into an eHealth application, which could help guide individual users or clinicians to help reduce dangerous drinking.
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Affiliation(s)
- Henrik Podéus
- Department of Biomedical Engineering (IMT), Linköping University, Linköping, Sweden
| | - Christian Simonsson
- Department of Biomedical Engineering (IMT), Linköping University, Linköping, Sweden
- Center for Medicine Imaging and Visualization Science (CMIV), Linköping University, Linköping, Sweden
| | - Patrik Nasr
- Department of Health, Medicine, and Caring Sciences, Linköping University, Linköping, Sweden
- Wallenberg Center for Molecular Medicine, Linköping University, Linköping, Sweden
| | - Mattias Ekstedt
- Center for Medicine Imaging and Visualization Science (CMIV), Linköping University, Linköping, Sweden
- Department of Health, Medicine, and Caring Sciences, Linköping University, Linköping, Sweden
| | - Stergios Kechagias
- Department of Health, Medicine, and Caring Sciences, Linköping University, Linköping, Sweden
| | - Peter Lundberg
- Center for Medicine Imaging and Visualization Science (CMIV), Linköping University, Linköping, Sweden
- Department of Radiation Physics, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - William Lövfors
- Department of Biomedical Engineering (IMT), Linköping University, Linköping, Sweden
- School of Medical Sciences and Inflammatory Response and Infection Susceptibility Centre (iRiSC), Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Gunnar Cedersund
- Department of Biomedical Engineering (IMT), Linköping University, Linköping, Sweden.
- Center for Medicine Imaging and Visualization Science (CMIV), Linköping University, Linköping, Sweden.
- School of Medical Sciences and Inflammatory Response and Infection Susceptibility Centre (iRiSC), Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
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Ramirez-Cadiz C, Blaney H, Kubanek N, Díaz LA, Loomba R, Skladany L, Arab JP. Review article: Current indications and selection criteria for early liver transplantation in severe alcohol-associated hepatitis. Aliment Pharmacol Ther 2024; 59:1049-1061. [PMID: 38475893 DOI: 10.1111/apt.17948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 10/17/2023] [Accepted: 03/03/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND Alcohol-associated hepatitis (AH) is a severe inflammatory form of alcohol-associated liver disease (ALD) that carries a high mortality rate. Early liver transplantation for severe AH is increasingly available. However, specific criteria for referral and selection remain a subject of debate. AIMS To provide a narrative review of the natural history, diagnostic criteria and indications for referral for early liver transplantation for severe AH. METHODS We searched PubMed for articles published through August 2023. Key search terms were 'alcoholic hepatitis,' 'alcohol-associated hepatitis,' 'abstinence,' 'alcohol relapse,' and 'liver transplantation.' RESULTS Previously, a six-month period of alcohol abstinence was required before patients with ALD were considered for liver transplantation. However, studies in recent years have demonstrated that, among carefully selected patients, patients who received early transplants have much higher survival rates than patients with similarly severe disease who did not undergo transplants (77% vs. 23%). Despite these successes, early liver transplantation remains controversial, as these patients have typically not undergone treatment for alcohol use disorder, with the ensuing risk of returning to alcohol use. CONCLUSIONS While early liver transplantation for AH has survival benefits, many patients would not have received treatment for alcohol use disorder. An integrated approach to evaluating candidacy for early liver transplantation is needed.
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Affiliation(s)
- Carolina Ramirez-Cadiz
- Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, Ontario, Canada
| | - Hanna Blaney
- Division of Gastroenterology and Hepatology, University of Maryland, College Park, Maryland, USA
| | - Natalia Kubanek
- Division of Hepatology, Gastroenterology and Liver Transplantation, Department of Internal Medicine II, Slovak Medical University Faculty of Medicine, F. D. Roosevelt University Hospital, Banska Bystrica, Slovak Republic
| | - Luis Antonio Díaz
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Rohit Loomba
- Division of Gastroenterology, University of California at San Diego, San Diego, California, USA
| | - Lubomir Skladany
- Division of Hepatology, Gastroenterology and Liver Transplantation, Department of Internal Medicine II, Slovak Medical University Faculty of Medicine, F. D. Roosevelt University Hospital, Banska Bystrica, Slovak Republic
| | - Juan Pablo Arab
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine, Western University, London, Ontario, Canada
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7
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Shaji Mathew J, Shingina A, Khan MQ, Wilson E, Syn N, Rammohan A, Alconchel F, Hakeem AR, Shankar S, Patel D, Keskin O, Liu J, Nasralla D, Mazzola A, Patel MS, Tanaka T, Victor D, Yoon U, Yoon YI, Vinaixa C, Kirchner V, De Martin E, Ghobrial RM, Chadha R. Proceedings of the 28th Annual Congress of the International Liver Transplantation Society. Liver Transpl 2024; 30:544-554. [PMID: 38240602 DOI: 10.1097/lvt.0000000000000330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 12/09/2023] [Indexed: 02/16/2024]
Abstract
The 2023 Joint International Congress of the International Liver Transplantation Society (ILTS), the European Liver and Intestine Transplant Association (ELITA), and the Liver Intensive Care Group of Europe (LICAGE) held in Rotterdam, the Netherlands, marked a significant recovery milestone for the liver transplant community after COVID-19. With 1159 participants and a surge in abstract submissions, the event focused on "Liver Disorders and Transplantation: Innovations and Evolving Indications." This conference report provides a comprehensive overview of the key themes discussed during the event, encompassing Hepatology, Anesthesia and Critical Care, Acute Liver Failure, Infectious Disease, Immunosuppression, Pediatric Liver Transplantation, Living Donor Liver Transplantation, Transplant Oncology, Surgical Approaches, and Machine Perfusion. The congress provided a platform for extensive discussions on a wide range of topics, reflecting the continuous advancements and collaborative efforts within the liver transplant community.
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Affiliation(s)
- Johns Shaji Mathew
- Department of GI, HPB & Multi-Organ Transplant Surgery, Rajagiri Hospital, Kochi, Kerala, India
| | - Alexandra Shingina
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Mohammad Qasim Khan
- Division of Gastroenterology, Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - Elizabeth Wilson
- Department of Anesthesiology, Emory University Hospital, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Nicholas Syn
- Division of Biomedical Informatics, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ashwin Rammohan
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Bharath Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | | | - Abdul Rahman Hakeem
- Department of Hepatobiliary and Liver Transplant Surgery, St James's University Hospital NHS Trust, Leeds, UK
| | - Sadhana Shankar
- Institute of Liver Studies, King's College Hospital, London, UK
| | | | - Onur Keskin
- Department of Gastroenterology, Hacettepe University Medical School, Ankara, Turkey
| | - Jiang Liu
- Hepato-Pancreato-Biliary Center, Department of Medicine, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - David Nasralla
- Department of HPB and Liver Transplant Surgery, The Royal Free Hospital, London, UK
| | - Alessandra Mazzola
- Sorbonne Université, Unité médicale de transplantation hépatique, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Madhukar S Patel
- Division of Surgical Transplantation, Department of Surgery, University of Texas, Southwestern Medical Center, Dallas, Texas, USA
| | - Tomohiro Tanaka
- Department of Internal Medicine, Gastroenterology and Hepatology, University of Iowa, Iowa City, Iowa, USA
| | - David Victor
- Sherrie and Alan Conover Center for Liver Disease and Transplantation. Houston Methodist Hospital, Houston, Texas, USA
| | - Uzung Yoon
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | | | - Carmen Vinaixa
- Hepatology Unit, Digestive Diseases Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Varvara Kirchner
- Department of Surgery, Division of Abdominal Transplantation, Stanford University, Stanford, California, USA
| | - Eleonora De Martin
- AP-HP, Hôpital Paul-Brousse, Centre Hépato- Biliaire, Unité INSERM 1193, Villejuif, France
| | - R Mark Ghobrial
- J.C. Walter Jr, Transplant Center, Department of Surgery, Weill Cornell Medical College, Houston Methodist Institute for Academic Medicine, Houston, Texas, USA
| | - Ryan Chadha
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida, USA
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Branagan WT, Norvell JP. Assessment and Evaluation of Alcohol Use Disorder in Liver Transplant. Transplantation 2024; 108:654-661. [PMID: 37408098 DOI: 10.1097/tp.0000000000004722] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
Alcohol-related liver disease is the most common indication for liver transplantation. It is essential for providers in transplantation to be informed of the state of the science in evaluation of alcohol use disorder (AUD). This review examines the broad range of approaches to the evaluation of AUD ranging from traditional interview approaches to recent literature on artificial intelligence models. The empirical support for methods of evaluation is examined. The authors discuss the use of each method in the context of patients seeking a liver transplant for alcohol-related liver disease. This review emphasizes the importance of using objective assessments so that transplant centers make evidence-based decisions and reduce cognitive bias. The review concludes with a proposed assessment battery for evaluation and bridges to future directions in the field of AUD assessment in liver transplantation.
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Affiliation(s)
- William T Branagan
- Department of Psychiatry, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO
| | - J P Norvell
- Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO
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9
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Germani G, Degré D, Moreno C, Burra P. Workup and management of liver transplantation in alcohol-related liver disease. United European Gastroenterol J 2024; 12:203-209. [PMID: 38456339 PMCID: PMC10954425 DOI: 10.1002/ueg2.12548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 12/26/2023] [Indexed: 03/09/2024] Open
Abstract
Alcohol-related liver disease (ALD) represents the most common indication for liver transplantation (LT) worldwide. Outcomes of LT for ALD are comparable with those of LT for other etiologies; however, ALD is still considered a controversial indication for LT, mainly because it is considered a self-inflicted disease with a high risk of return to alcohol use after LT. Pre-LT evaluation criteria have changed over time, with a progressive re-evaluation of the required pre-transplant duration of abstinence. Despite the fact that some transplant programs still require 6 months of abstinence in order to consider a patient suitable for LT, there is increasing evidence that a pre-transplant abstinence period of <6 months can be considered for well-selected patients. Early LT for severe alcohol-related hepatitis that has not responded to medical therapy has been shown to be an effective therapeutic option with high survival benefit when performed within strict and well-recognized criteria. However, high variability in LT access exists for these patients due to the presence of social and medical stigma. A psycho-social assessment, together with an evaluation by an addiction specialist, should be mandatory in patients with ALD who are potential candidates for LT in order to assess the risk of post-transplant return to alcohol use and to ensure good long-term outcomes. Finally, before LT, attention should be paid to the presence of other potential comorbidities (i.e., cardiovascular and neurological diseases), which could represent a potential contraindication to LT. Similarly, after LT, patients should be adequately monitored for the development of cardiovascular events and screened for "de novo" tumors, although standardized protocols for this monitoring do not exist at this time.
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Affiliation(s)
- Giacomo Germani
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Delphine Degré
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Christophe Moreno
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
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10
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Segal A, Pearl E, Fatabhoy M, Zohr SJ, Bryce K, Gonzalez HC, Miller-Matero LR. Factors associated with a positive phosphatidylethanol test during liver transplantation evaluation. Clin Transplant 2023; 37:e15100. [PMID: 37577900 DOI: 10.1111/ctr.15100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/14/2023] [Accepted: 08/07/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND Early identification of alcohol use is crucial for informing recommendations of appropriate follow-up treatment pre-liver transplant and optimizing post-liver transplant outcomes. The purpose of the study was to investigate whether there are psychosocial factors associated with a positive PEth test. METHODS All patients who underwent a routine pre-surgical psychological evaluation for liver transplant listing (all etiologies, including acute liver failure, dual organ, and re-transplantation) at a single health care system in 2020 were included in a retrospective chart review. Data extraction included results from PEth testing and information from the psychological evaluation (i.e., demographic, psychiatric symptoms, and cognitive functioning). RESULTS There were 158 patients (73.8%) who had a PEth test, of whom 21.5% had a positive result (n = 34). Younger age was associated with a positive PEth (p < .001). ALD status and type of ALD (hepatitis vs. cirrhosis) were also associated with a positive PEth test. Other demographic characteristics and psychiatric symptoms were not associated with a positive PEth result (p > .05). CONCLUSION Younger age was the only significant demographic variable associated with a positive PEth test. Given the difficulty of predicting who may be using alcohol, it may be useful to use PEth testing for all patients during the pre-liver transplant evaluation and while patients are listed for liver transplant. Early identification of alcohol use through routine PEth testing will help identify patients who are using alcohol and need further treatment for alcohol use to optimize health and post-transplant outcomes.
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Affiliation(s)
- Antú Segal
- Behavioral Health Department, Henry Ford Health, Detroit, Michigan, USA
- Transplant Institute, Henry Ford Health, Detroit, Michigan, USA
- Wayne State University, School of Medicine, Detroit, Michigan, USA
| | - Elise Pearl
- Behavioral Health Department, Henry Ford Health, Detroit, Michigan, USA
| | - Megha Fatabhoy
- Behavioral Health Department, Henry Ford Health, Detroit, Michigan, USA
| | - Samantha J Zohr
- Behavioral Health Department, Henry Ford Health, Detroit, Michigan, USA
| | - Kelly Bryce
- Behavioral Health Department, Henry Ford Health, Detroit, Michigan, USA
- Transplant Institute, Henry Ford Health, Detroit, Michigan, USA
- Wayne State University, School of Medicine, Detroit, Michigan, USA
| | - Humberto C Gonzalez
- Transplant Institute, Henry Ford Health, Detroit, Michigan, USA
- Wayne State University, School of Medicine, Detroit, Michigan, USA
- Department of Gastroenterology and Hepatology, Henry Ford Health, Detroit, Michigan, USA
| | - Lisa R Miller-Matero
- Behavioral Health Department, Henry Ford Health, Detroit, Michigan, USA
- Wayne State University, School of Medicine, Detroit, Michigan, USA
- Center for Health Policy and Health Services Research, Henry Ford Health, Detroit, Michigan, USA
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11
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Rabindranath M, Zaya R, Prayitno K, Orchanian-Cheff A, Patel K, Jaeckel E, Bhat M. A Comprehensive Review of Liver Allograft Fibrosis and Steatosis: From Cause to Diagnosis. Transplant Direct 2023; 9:e1547. [PMID: 37854023 PMCID: PMC10581596 DOI: 10.1097/txd.0000000000001547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/11/2023] [Accepted: 09/14/2023] [Indexed: 10/20/2023] Open
Abstract
Despite advances in posttransplant care, long-term outcomes for liver transplant recipients remain unchanged. Approximately 25% of recipients will advance to graft cirrhosis and require retransplantation. Graft fibrosis progresses in the context of de novo or recurrent disease. Recurrent hepatitis C virus infection was previously the most important cause of graft failure but is now curable in the majority of patients. However, with an increasing prevalence of obesity and diabetes and nonalcoholic fatty liver disease as the most rapidly increasing indication for liver transplantation, metabolic dysfunction-associated liver injury is anticipated to become an important cause of graft fibrosis alongside alloimmune hepatitis and alcoholic liver disease. To better understand the landscape of the graft fibrosis literature, we summarize the associated epidemiology, cause, potential mechanisms, diagnosis, and complications. We additionally highlight the need for better noninvasive methods to ameliorate the management of graft fibrosis. Some examples include leveraging the microbiome, genetic, and machine learning methods to address these limitations. Overall, graft fibrosis is routinely seen by transplant clinicians, but it requires a better understanding of its underlying biology and contributors that can help inform diagnostic and therapeutic practices.
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Affiliation(s)
- Madhumitha Rabindranath
- Ajmera Transplant Program, University Health Network, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Rita Zaya
- Ajmera Transplant Program, University Health Network, Toronto, ON, Canada
| | - Khairunnadiya Prayitno
- Ajmera Transplant Program, University Health Network, Toronto, ON, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Ani Orchanian-Cheff
- Library and Information Services, University Health Network, Toronto, ON, Canada
| | - Keyur Patel
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Elmar Jaeckel
- Ajmera Transplant Program, University Health Network, Toronto, ON, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Mamatha Bhat
- Ajmera Transplant Program, University Health Network, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, ON, Canada
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12
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Germani G, D’Arcangelo F, Grasso M, Burra P. Advances and Controversies in Acute Alcohol-Related Hepatitis: From Medical Therapy to Liver Transplantation. Life (Basel) 2023; 13:1802. [PMID: 37763206 PMCID: PMC10532507 DOI: 10.3390/life13091802] [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: 07/11/2023] [Revised: 08/10/2023] [Accepted: 08/18/2023] [Indexed: 09/29/2023] Open
Abstract
Alcohol-related hepatitis (AH) is a clinical syndrome characterized by recent-onset jaundice in the context of alcohol consumption. In patients with severe AH "unresponsive" to steroid therapy, mortality rates exceed 70% within six months. According to European and American guidelines, liver transplantation (LT) may be considered in highly selected patients who do not respond to medical therapy. The aim of this narrative review is to summarize current knowledge from medical therapy to liver transplantation in acute alcohol-related hepatitis. Due to the impossibility to guarantee six-month abstinence, LT for AH is controversial. Principal concerns are related to organ scarcity in the subset of stigma of "alcohol use disorder" (AUD) and the risk of relapse to alcohol use after LT. Return to alcohol use after LT is a complex issue that cannot be assessed as a yes/no variable with heterogeneous results among studies. In conclusion, present data indicate that well-selected patients have excellent outcomes, with survival rates of up to 100% at 24 and 36 months after LT. Behavioral therapy, ongoing psychological support, and strong family support seem essential to improve long-term outcomes after LT and reduce the risk in relapse of alcohol use.
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Affiliation(s)
- Giacomo Germani
- Multivisceral Transplant Unit, Azienda Ospedale—Università Padova, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35122 Padova, Italy
| | - Francesca D’Arcangelo
- Gastroenterology and Multivisceral Transplant Unit, Azienda Ospedale—Università Padova, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35122 Padova, Italy; (F.D.); (M.G.); (P.B.)
| | - Marco Grasso
- Gastroenterology and Multivisceral Transplant Unit, Azienda Ospedale—Università Padova, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35122 Padova, Italy; (F.D.); (M.G.); (P.B.)
| | - Patrizia Burra
- Gastroenterology and Multivisceral Transplant Unit, Azienda Ospedale—Università Padova, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35122 Padova, Italy; (F.D.); (M.G.); (P.B.)
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13
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Winder GS, Clifton EG, Fernandez AC, MacEachern M, Andrews S, Perumalswami P, DiMartini AF, Mellinger JL. Definition and measurement of alcohol-associated insight in early liver transplantation for acute alcohol-associated hepatitis: A systematic review. Liver Transpl 2023; 29:757-767. [PMID: 37016758 DOI: 10.1097/lvt.0000000000000144] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 03/27/2023] [Indexed: 04/06/2023]
Abstract
BACKGROUND Alcohol accounts for a large disease burden in hepatology and liver transplantation (LT) and across the globe. Clinical evaluations and decisions about LT candidacy are challenging because they rely on detailed psychosocial assessments and interpretations of psychiatric and substance use disorder data, which often must occur rapidly according to the acuity of end-stage liver disease. Such difficulties commonly occur during the process of candidate selection and liver allocation, particularly during early LT (eLT) in patients with acute alcohol-associated hepatitis (AAH). Patients with AAH commonly have very recent or active substance use, high short-term mortality, psychiatric comorbidities, and compressed evaluation and treatment timetables. LT clinicians report that patients' alcohol-associated insight (AAI) is among the most relevant psychosocial data in this population, yet no studies exist examining how LT teams define and use AAI in eLT or its effect on clinical outcomes. In April 2022, we searched Ovid MEDLINE, Elsevier Embase, EBSCOhost PsycInfo and CINAHL, and Wiley Cochrane Central Register of Controlled Trials for reports describing AAH populations who underwent eLT, which also described psychosocial evaluation parameters. The searches retrieved 1603 unique reports. After eligibility screening, 8 were included in the qualitative analysis. This systematic review reveals that AAI is a poorly defined construct that is not measured in a standardized way. Yet it is a commonly cited parameter in articles that describe the psychosocial evaluation and decision-making of patients undergoing eLT for AAH. This article also discusses the general challenges of assessing AAI during eLT for AAH, existing AAI definitions and rating scales, how AAI has been used to date in the broader hepatology and LT literature, and future areas for clinical and research progress.
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Affiliation(s)
- Gerald Scott Winder
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
| | - Erin G Clifton
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Anne C Fernandez
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Mark MacEachern
- Taubman Health Sciences Library, University of Michigan, Ann Arbor, Michigan, USA
| | - Sarah Andrews
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ponni Perumalswami
- Gastroenterology Section, Veterans Affairs, Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Andrea F DiMartini
- Departments of Psychiatry, Surgery, and Translational Science, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jessica L Mellinger
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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14
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Bhat M, Rabindranath M, Chara BS, Simonetto DA. Artificial intelligence, machine learning, and deep learning in liver transplantation. J Hepatol 2023; 78:1216-1233. [PMID: 37208107 DOI: 10.1016/j.jhep.2023.01.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 01/11/2023] [Accepted: 01/16/2023] [Indexed: 05/21/2023]
Abstract
Liver transplantation (LT) is a life-saving treatment for individuals with end-stage liver disease. The management of LT recipients is complex, predominantly because of the need to consider demographic, clinical, laboratory, pathology, imaging, and omics data in the development of an appropriate treatment plan. Current methods to collate clinical information are susceptible to some degree of subjectivity; thus, clinical decision-making in LT could benefit from the data-driven approach offered by artificial intelligence (AI). Machine learning and deep learning could be applied in both the pre- and post-LT settings. Some examples of AI applications pre-transplant include optimising transplant candidacy decision-making and donor-recipient matching to reduce waitlist mortality and improve post-transplant outcomes. In the post-LT setting, AI could help guide the management of LT recipients, particularly by predicting patient and graft survival, along with identifying risk factors for disease recurrence and other associated complications. Although AI shows promise in medicine, there are limitations to its clinical deployment which include dataset imbalances for model training, data privacy issues, and a lack of available research practices to benchmark model performance in the real world. Overall, AI tools have the potential to enhance personalised clinical decision-making, especially in the context of liver transplant medicine.
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Affiliation(s)
- Mamatha Bhat
- Ajmera Transplant Program, University Health Network, Toronto, ON, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada; Division of Gastroenterology & Hepatology, Department of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Madhumitha Rabindranath
- Ajmera Transplant Program, University Health Network, Toronto, ON, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Beatriz Sordi Chara
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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15
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Funer F, Salloch S. 'Can I trust my patient?' Machine Learning support for predicting patient behaviour. JOURNAL OF MEDICAL ETHICS 2023:jme-2023-109094. [PMID: 37188507 DOI: 10.1136/jme-2023-109094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 05/04/2023] [Indexed: 05/17/2023]
Affiliation(s)
- Florian Funer
- Institute for Ethics and History of Medicine, Eberhard Karls Universitat Tubingen, Tübingen, Baden-Württemberg, Germany
| | - Sabine Salloch
- Institute for Ethics, History and Philosophy of Medicine, Hannover Medical School, Hannover, Niedersachsen, Germany
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16
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Durkin C, Bittermann T. Liver transplantation for alcohol-associated hepatitis. Curr Opin Organ Transplant 2023; 28:85-94. [PMID: 36512482 PMCID: PMC9992110 DOI: 10.1097/mot.0000000000001044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Early liver transplantation is emerging as a treatment option for severe alcohol-associated hepatitis refractory to pharmacotherapies. This review outlines the current status of transplantation for alcohol-associated hepatitis and the treatment of alcohol use disorder after liver transplantation. RECENT FINDINGS Rates of early liver transplantation for alcohol-associated hepatitis are increasing with significant heterogeneity in practices across the Unites States. Recent studies have demonstrated a substantial survival benefit in patients transplanted for alcohol-associated hepatitis with improved outcomes in early vs. late transplantation, first vs. prior hepatic decompensation, and posttransplant abstinence/delayed relapse vs. early return to alcohol use. Several prediction algorithms have been developed to ascertain patients' risk of alcohol relapse and aid in candidate selection, though data on treatment of alcohol use disorders in transplant recipients remains limited. SUMMARY Although controversial, early liver transplantation for severe alcohol-associated hepatitis has shown to be a lifesaving intervention. Additional research is needed to evaluate its long-term outcomes, optimize candidate selection, and understand treatment of alcohol use disorder posttransplant.
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Affiliation(s)
- Claire Durkin
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Therese Bittermann
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
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17
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Fuochi E, Anastasio L, Lynch EN, Campani C, Dragoni G, Milani S, Galli A, Innocenti T. Main factors influencing long-term outcomes of liver transplantation in 2022. World J Hepatol 2023; 15:321-352. [PMID: 37034235 PMCID: PMC10075010 DOI: 10.4254/wjh.v15.i3.321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/24/2022] [Accepted: 02/22/2023] [Indexed: 04/11/2023] Open
Abstract
Liver transplant (LT) outcomes have markedly improved in the recent decades, even if long-term morbidity and mortality are still considerable. Most of late deaths are independent from graft function and different comorbidities, including complications of metabolic syndrome and de novo neoplasms, seem to play a key role in determining long-term outcomes in LT recipients. This review discusses the main factors associated with late mortality and suggests possible strategies to improve long-term management and follow-up after liver transplantation. In particular, the reduction of drug toxicity, the use of tools to identify high-risk patients, and setting up a multidisciplinary team also for long-term management of LT recipients may further improve survival after liver transplantation.
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Affiliation(s)
- Elisa Fuochi
- Gastroenterology Research Unit, Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, Florence 50134, Italy
| | - Lorenzo Anastasio
- Gastroenterology Research Unit, Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, Florence 50134, Italy
| | - Erica Nicola Lynch
- Gastroenterology Research Unit, Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, Florence 50134, Italy
| | - Claudia Campani
- Department of Experimental and Clinical Medicine, University of Florence, Florence 50134, Italy
| | - Gabriele Dragoni
- Gastroenterology Research Unit, Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, Florence 50134, Italy
- Department of Medical Biotechnologies, University of Siena, Siena 53100, Italy
| | - Stefano Milani
- Gastroenterology Research Unit, Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, Florence 50134, Italy
| | - Andrea Galli
- Gastroenterology Research Unit, Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, Florence 50134, Italy
| | - Tommaso Innocenti
- Gastroenterology Research Unit, Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, Florence 50134, Italy
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18
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Affiliation(s)
- Ramon Bataller
- From the Liver Unit, Hospital Clínic de Barcelona, Barcelona (R.B.); Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago (J.P.A.); the Division of Gastroenterology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, and London Health Sciences Centre, London, ON, Canada (J.P.A.); and the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (V.H.S.)
| | - Juan Pablo Arab
- From the Liver Unit, Hospital Clínic de Barcelona, Barcelona (R.B.); Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago (J.P.A.); the Division of Gastroenterology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, and London Health Sciences Centre, London, ON, Canada (J.P.A.); and the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (V.H.S.)
| | - Vijay H Shah
- From the Liver Unit, Hospital Clínic de Barcelona, Barcelona (R.B.); Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago (J.P.A.); the Division of Gastroenterology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, and London Health Sciences Centre, London, ON, Canada (J.P.A.); and the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (V.H.S.)
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