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Sastre L, García R, Viñals C, Amor AJ, Yago G, Hervás A, Sánchez L, Trabal J, Molero J, Escudé L, Pagano G, Blasco M, Gilabert R, Ruiz P, Colmenero J, Navasa M, Ortega E, Crespo G. Results of a multidisciplinary strategy to improve the management of cardiovascular risk factors after liver transplantation. Liver Transpl 2022; 28:1332-1344. [PMID: 35224857 DOI: 10.1002/lt.26443] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 02/15/2022] [Accepted: 02/18/2022] [Indexed: 02/07/2023]
Abstract
Although liver transplantation (LT) recipients are at high cardiovascular risk (CVR), the management of CVR factors (CVRF) after LT is far from optimal and needs to be improved. For this reason, we developed a multidisciplinary protocol to standardize the identification, risk stratification, management, and targets of therapy of CVRF during the first post-LT year. The grade of identification and control of CVRF 12 months after LT in the postintervention cohort (LT January 2018-January 2020, n = 150) were compared with a control cohort who underwent LT between July 2015 and December 2016 (n = 100). Before LT, the prevalence of metabolic-associated fatty liver disease as the indication of LT and the presence of obesity were significantly higher in the postintervention cohort, whereas the prevalence of other CVRF and renal dysfunction tended to be higher. Cyclosporine A was used less frequently in the postintervention cohort, whereas everolimus tended to increase. At 12 months after LT, the proportion of patients with measured blood pressure (88% vs. 56%), glycosilated hemoglobin (HbA1c; 96% vs. 72%), and high-density lipoprotein/low-density lipoprotein cholesterol (67% vs. 33%) was higher in the postintervention than in the control cohort (all p < 0.001). Blood pressure (64% vs. 36%, p = 0.02) and HbA1c (85% vs. 70%, p = 0.1) were within target in more individuals with hypertension and diabetes mellitus, respectively, in the postintervention cohort. Median total cholesterol levels were lower in the postintervention (184 mg/dl; interquartile range [IQR], 160-210 mg/dl) than in the control cohort (212 mg/dl; IQR, 186-240 mg/dl; p = 0.02). At 2 years after LT, the incidence of cardiovascular events was 14% in the control cohort and 6% in the postintervention cohort (p = 0.063). In conclusion, a multidisciplinary, multiprofessional strategy can achieve a higher grade of assessment and management of post-LT CVR despite a worsening metabolic profile of LT recipients.
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Affiliation(s)
- Lydia Sastre
- Hepatology and Liver Transplant Unit, Hospital Clinic, Barcelona, Spain.,Department of Gastroenterology and Hepatology, Hospital Son Espases, Palma de Mallorca, Spain
| | - Raquel García
- Hepatology and Liver Transplant Unit, Hospital Clinic, Barcelona, Spain
| | - Clara Viñals
- Endocrinology and Nutrition Department, Hospital Clinic, Barcelona, Spain
| | - Antonio J Amor
- Endocrinology and Nutrition Department, Hospital Clinic, Barcelona, Spain
| | - Gema Yago
- Endocrinology and Nutrition Department, Hospital Clinic, Barcelona, Spain
| | - Alicia Hervás
- Hepatology and Liver Transplant Unit, Hospital Clinic, Barcelona, Spain
| | - Lorena Sánchez
- Endocrinology and Nutrition Department, Hospital Clinic, Barcelona, Spain
| | - Joan Trabal
- Endocrinology and Nutrition Department, Hospital Clinic, Barcelona, Spain
| | - Judit Molero
- Endocrinology and Nutrition Department, Hospital Clinic, Barcelona, Spain
| | - Laia Escudé
- Hepatology and Liver Transplant Unit, Hospital Clinic, Barcelona, Spain
| | - Giulia Pagano
- Hepatology and Liver Transplant Unit, Hospital Clinic, Barcelona, Spain
| | - Miquel Blasco
- Nephrology and Kidney Transplant Department, Hospital Clinic, Barcelona, Spain
| | - Rosa Gilabert
- Radiology Department, Hospital Clinic, Barcelona, Spain
| | - Pablo Ruiz
- Hepatology and Liver Transplant Unit, Hospital Clinic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red-Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Jordi Colmenero
- Hepatology and Liver Transplant Unit, Hospital Clinic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red-Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,University of Barcelona, Barcelona, Spain
| | - Miquel Navasa
- Hepatology and Liver Transplant Unit, Hospital Clinic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red-Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,University of Barcelona, Barcelona, Spain
| | - Emilio Ortega
- Endocrinology and Nutrition Department, Hospital Clinic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red-Fisiopatología de la Obesidad y Nutrición (CIBERobn), Madrid, Spain
| | - Gonzalo Crespo
- Hepatology and Liver Transplant Unit, Hospital Clinic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red-Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,University of Barcelona, Barcelona, Spain
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Qazi-Arisar FA, Uchila R, Chen C, Yang C, Chen SY, Karnam RS, Azhie A, Xu W, Galvin Z, Selzner N, Lilly L, Bhat M. Divergent trajectories of lean vs obese non-alcoholic steatohepatitis patients from listing to post-transplant: A retrospective cohort study. World J Gastroenterol 2022; 28:3218-3231. [PMID: 36051335 PMCID: PMC9331521 DOI: 10.3748/wjg.v28.i26.3218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 04/22/2022] [Accepted: 06/16/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Non-alcoholic steatohepatitis (NASH) cirrhosis is the second most common indication for liver transplantation (LT). The role of body mass index (BMI) on outcomes of NASH cirrhosis has been conflicting.
AIM To compare the longitudinal trajectories of patients with lean vs obese NASH cirrhosis, from listing up to post-transplant, having adjusted their BMI for ascites.
METHODS We retrospectively reviewed all adult NASH patients listed for LT in our program from 2012 to 2019. Fine-Gray Competing Risk analyses and Cox Proportional-Hazard Models were performed to examine the cumulative incidence of transplant and survival outcomes respectively.
RESULTS Out of 265 NASH cirrhosis listed patients, 176 were included. Median age was 61.0 years; 46% were females. 111 patients underwent LT. Obese robust patients had better waitlist survival [hazard ratio (HR): 0.12; 95%CI: 0.05–0.29, P < 0.0001] with higher instantaneous rate of transplant (HR: 5.71; 95%CI: 1.26–25.9, P = 0.02). Lean NASH patients had a substantially higher risk of graft loss within 90 d post-LT (1.2% vs 13.8%, P = 0.032) and death post-LT (2.4% vs 17.2%, P = 0.029). 1- 3- and 5-year graft survival was poor for lean NASH (78.6%, 77.3% and 41.7% vs 98.6%, 96% and 85% respectively). Overall patient survival post-LT was significantly worse in lean NASH (HR: 0.17; 95%CI: 0.03–0.86, P = 0.0142) with 83% lower instantaneous rate of death in obese group.
CONCLUSION Although lean NASH is considered to be more benign than obese NASH, our study suggests a paradoxical correlation of lean NASH with waitlist outcomes, and graft and patient survival post-LT.
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Affiliation(s)
- Fakhar Ali Qazi-Arisar
- Ajmera Transplant Program, Toronto General Hospital, University Health Network, Toronto M5G 2N2, Ontario, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto M5G 2N2, Ontario, Canada
- National Institute of Liver and GI Diseases, Dow University of Health Sciences, Karachi 75330, Pakistan
| | - Raj Uchila
- Ajmera Transplant Program, Toronto General Hospital, University Health Network, Toronto M5G 2N2, Ontario, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto M5G 2N2, Ontario, Canada
| | - Catherine Chen
- Ajmera Transplant Program, Toronto General Hospital, University Health Network, Toronto M5G 2N2, Ontario, Canada
| | - Cathy Yang
- Ajmera Transplant Program, Toronto General Hospital, University Health Network, Toronto M5G 2N2, Ontario, Canada
| | - Shi-Yi Chen
- Department of Biostatistics, Princess Margaret Cancer Center, University Health Network, Toronto M5G 2C1, Ontario, Canada
| | - Ravikiran Sindhuvalada Karnam
- Ajmera Transplant Program, Toronto General Hospital, University Health Network, Toronto M5G 2N2, Ontario, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto M5G 2N2, Ontario, Canada
| | - Amirhossein Azhie
- Ajmera Transplant Program, Toronto General Hospital, University Health Network, Toronto M5G 2N2, Ontario, Canada
| | - Wei Xu
- Department of Biostatistics, Princess Margaret Cancer Center, University Health Network, Toronto M5G 2C1, Ontario, Canada
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto M5G 2C1, Ontario, Canada
| | - Zita Galvin
- Ajmera Transplant Program, Toronto General Hospital, University Health Network, Toronto M5G 2N2, Ontario, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto M5G 2N2, Ontario, Canada
| | - Nazia Selzner
- Ajmera Transplant Program, Toronto General Hospital, University Health Network, Toronto M5G 2N2, Ontario, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto M5G 2N2, Ontario, Canada
| | - Leslie Lilly
- Ajmera Transplant Program, Toronto General Hospital, University Health Network, Toronto M5G 2N2, Ontario, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto M5G 2N2, Ontario, Canada
| | - Mamatha Bhat
- Ajmera Transplant Program, Toronto General Hospital, University Health Network, Toronto M5G 2N2, Ontario, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto M5G 2N2, Ontario, Canada
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