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Czarnecka K, Czarnecka P, Tronina O, Bączkowska T, Durlik M. MASH Continues as a Significant Burden on Metabolic Health of Liver Recipients. Transplant Proc 2024; 56:822-831. [PMID: 38403537 DOI: 10.1016/j.transproceed.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 02/04/2024] [Accepted: 02/14/2024] [Indexed: 02/27/2024]
Abstract
BACKGROUND Metabolic complications are a recognized health concern in liver transplant recipients that result in inferior patient-reported outcomes. Patients with MASH are known to be disproportionately affected by metabolic diseases compared to other indications for transplantation. PURPOSE The aim of this study was to investigate the incidence of metabolic abnormalities in liver recipients with specific focus on differences between patients transplanted for MASH and non-MASH-causes. PATIENTS AND METHODS An observational, monocentric, and retrospective analysis was performed. Patients who received a cadaveric-donor-liver transplant between 2010 and 2019 were eligible. RESULTS 282 patients were enrolled with a median age of 52 years (66.7% males). Metabolic dysfunction-associated steatohepatitis (MASH) led to liver transplant in 8.2% of cases. De-novo metabolic syndrome was diagnosed in 36% of the study population. Patients that underwent transplant owing to MASH showed significantly higher incidence of metabolic complications in both pre- and post-transplant period. Considerable differences were noted in the pattern of weight gain between patients transplanted for MASH and non-MASH patients. The MASH etiology (OR: 5.5; 95% CI: 1.624-22.868; P = .010), higher BMI at 1-year post-transplant (OR: 1.321; 95% CI: 1.214-1.449; P = <.001), and older age at transplant (OR: 1.038; 95% CI: 1.006-1.074; P = .022) were independently associated with new-onset metabolic syndrome in liver recipients. CONCLUSION Metabolic complications were prevalent in liver recipients. Liver recipients with underlying MASH significantly surpassed patients transplanted for other indications in terms of metabolic complications incidence and demonstrated an unfavorable trajectory of weight gain post-transplant.
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Affiliation(s)
- Kinga Czarnecka
- Department of Transplant Medicine, Immunology, Nephrology and Internal Diseases, Medical University of Warsaw, Warsaw, Poland.
| | - Paulina Czarnecka
- Department of Transplant Medicine, Immunology, Nephrology and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Olga Tronina
- Department of Transplant Medicine, Immunology, Nephrology and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Teresa Bączkowska
- Department of Transplant Medicine, Immunology, Nephrology and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Magdalena Durlik
- Department of Transplant Medicine, Immunology, Nephrology and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
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Palazzo CC, Leghi BE, Diez-Garcia RW. Does feeling what you eat change how you eat? Implications of an intervention to promote consciousness of eating experiences. Front Psychol 2024; 14:1229105. [PMID: 38239476 PMCID: PMC10795314 DOI: 10.3389/fpsyg.2023.1229105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 12/06/2023] [Indexed: 01/22/2024] Open
Abstract
Introduction This work aims to understand the experience of participating in the Food and Nutrition Education Program workshops with Sensory and Cognitive Exercises (PESC) and measure its impact on eating behavior. Methods The PESC consists of four workshops with exercises stimulating perception and reflection on bodily sensations triggered in eating situations. It was developed to promote consciousness of eating experiences in women who reported difficulty in controlling their body weight and who increased over 5% of their body weight in the previous year. This is a mixed-methods study designed as a controlled trial. The intervention group (n = 19) was evaluated before the first workshop (T0) and after the last workshop (T1) and the control group (n = 18), which did not participate in the workshops, was evaluated twice (T0 and T1), with an interval of 3 to 4 weeks. At T0 and T1, it was applied the Intuitive Eating Scale (IES-2) and the Three Factor Eating Questionnaire (TFEQ-R21). In T1, the intervention group also participated in a qualitative interview. Results After participating in the PESC, the intervention group showed an increase in the IES-2 total score (95% Confidence Interval = (0.10, 0.39)) and a decrease in the emotional eating scale score (95% Confidence Interval = (-16.03; -3.85)). The interviews' analysis revealed the participants' self-observation process, which led to the perception of their practices, priorities, intentions, eating difficulties, and the connection between these aspects and environmental issues. The following themes were considered: Food management/control, Body dissatisfaction, Reflection/re-signification, and Different ways of being in familiar contexts. Discussion The results allow us to infer that, after participating in the PESC, the intention to manage food intake became more effective, less susceptible to oscillations imposed by the external environment, and more supported by internal resources.
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Affiliation(s)
- Carina Carlucci Palazzo
- Internal Medicine Department, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, Brazil
- Laboratory of Food Practices and Behaviour – PrátiCA, University of São Paulo (USP), Ribeirão Preto, Brazil
| | - Barbara Esteves Leghi
- Internal Medicine Department, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, Brazil
- Laboratory of Food Practices and Behaviour – PrátiCA, University of São Paulo (USP), Ribeirão Preto, Brazil
| | - Rosa Wanda Diez-Garcia
- Laboratory of Food Practices and Behaviour – PrátiCA, University of São Paulo (USP), Ribeirão Preto, Brazil
- Department of Health Sciences, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Preto, Brazil
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Ravaioli F, De Maria N, Di Marco L, Pivetti A, Casciola R, Ceraso C, Frassanito G, Pambianco M, Pecchini M, Sicuro C, Leoni L, Di Sandro S, Magistri P, Menozzi R, Di Benedetto F, Colecchia A. From Listing to Recovery: A Review of Nutritional Status Assessment and Management in Liver Transplant Patients. Nutrients 2023; 15:2778. [PMID: 37375682 DOI: 10.3390/nu15122778] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 06/04/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023] Open
Abstract
Liver transplantation (LT) is a complex surgical procedure requiring thorough pre- and post-operative planning and care. The nutritional status of the patient before, during, and after LT is crucial to surgical success and long-term prognosis. This review aims to assess nutritional status assessment and management before, during, and after LT, with a focus on patients who have undergone bariatric surgery. We performed a comprehensive topic search on MEDLINE, Ovid, In-Process, Cochrane Library, EMBASE, and PubMed up to March 2023. It identifies key factors influencing the nutritional status of liver transplant patients, such as pre-existing malnutrition, the type and severity of liver disease, comorbidities, and immunosuppressive medications. The review highlights the importance of pre-operative nutritional assessment and intervention, close nutritional status monitoring, individualised nutrition care plans, and ongoing nutritional support and monitoring after LT. The review concludes by examining the effect of bariatric surgery on the nutritional status of liver transplant recipients. The review offers valuable insights into the challenges and opportunities for optimising nutritional status before, during, and after LT.
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Affiliation(s)
- Federico Ravaioli
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Nicola De Maria
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Lorenza Di Marco
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Alessandra Pivetti
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Riccardo Casciola
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Carlo Ceraso
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Gabriella Frassanito
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Martina Pambianco
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Maddalena Pecchini
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Chiara Sicuro
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Laura Leoni
- Division of Metabolic Diseases and Clinical Nutrition, Department of Specialistic Medicines, University Hospital of Modena and Reggio Emilia, Largo del Pozzo 71, 41125 Modena, Italy
| | - Stefano Di Sandro
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Paolo Magistri
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Renata Menozzi
- Division of Metabolic Diseases and Clinical Nutrition, Department of Specialistic Medicines, University Hospital of Modena and Reggio Emilia, Largo del Pozzo 71, 41125 Modena, Italy
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Antonio Colecchia
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
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Fernández MS, Pilatti A, Pautassi RM. Eating-to-Cope Motives and Uncontrolled Eating as Mediators Between Negative Emotional States and Food Addiction Among Argentinean Young Adults. Int J Ment Health Addict 2022:1-19. [PMID: 36275610 PMCID: PMC9579650 DOI: 10.1007/s11469-022-00934-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/28/2022] [Indexed: 10/31/2022] Open
Abstract
Negative emotional states (NES; i.e., depression, anxiety and stress) are likely contributors to the development of food addiction (FA). The association between NES and FA symptoms may be mediated by altered eating behaviors or by eating-to-cope motives. This study examined, in a sample of Argentinean young adults, the association between NES and FA symptoms via eating-to-cope motives and three patterns of eating behaviors. We also examined whether the model was invariant across college status. The transition from high school to college is usually associated with increased exposure to stress, which promotes the probability of engaging in altered eating behaviors. A sample of 499 Argentinean young adults (mean age = 24.9 ± 3.51 years) completed a survey that assessed FA symptoms, eating behaviors (i.e., uncontrolled, emotional, and restrained eating), eating-to-cope motives and NES. A path analysis tested the indirect association between NES and FA symptoms via uncontrolled, emotional or restrained eating, or by eating-to-cope. Stress and depression symptoms were indirectly associated with FA symptoms via uncontrolled eating and eating-to-cope motives. The model was invariant across college status. The findings suggest that NES are associated with FA symptoms by increasing uncontrolled eating and eating-to-cope motives. Young adults exhibiting greater depressive or stress symptoms, higher eating-to-cope, or higher uncontrolled eating may be at risk for FA. Future research should examine the significance of this pattern by tailoring interventions to these characteristics.
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Affiliation(s)
- Macarena Soledad Fernández
- Instituto de Investigaciones Psicológicas, IIPsi-CONICET-UNC, Bv. de la Reforma, 1936 Córdoba (5000), Argentina
- Facultad de Psicología, Universidad Nacional de Córdoba, Bv. de la Reforma 1936, Ciudad Universitaria, C.P. 5000 Córdoba, Argentina
| | - Angelina Pilatti
- Instituto de Investigaciones Psicológicas, IIPsi-CONICET-UNC, Bv. de la Reforma, 1936 Córdoba (5000), Argentina
- Facultad de Psicología, Universidad Nacional de Córdoba, Bv. de la Reforma 1936, Ciudad Universitaria, C.P. 5000 Córdoba, Argentina
| | - Ricardo Marcos Pautassi
- Facultad de Psicología, Universidad Nacional de Córdoba, Bv. de la Reforma 1936, Ciudad Universitaria, C.P. 5000 Córdoba, Argentina
- Instituto de Investigación Médica M. Y M. Ferreyra, INIMEC-CONICET, Universidad Nacional de Córdoba, Friuli 2434, C.P. 5000 Córdoba, Argentina
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5
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Mensah FZ, Lane KE, Richardson LD. Determinants of eating behaviour in Black, Asian and Minority Ethnic (BAME) university students when living at and away from home: With a focus on the influence of food enculturation and food acculturation. Appetite 2022; 171:105932. [PMID: 35051546 DOI: 10.1016/j.appet.2022.105932] [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: 08/17/2021] [Revised: 01/07/2022] [Accepted: 01/12/2022] [Indexed: 11/02/2022]
Abstract
For some students, university, can be a period of increased autonomy in food choice and for black, Asian and minority ethnic (BAME) and international students, the addition of culture may be a governing factor. This study aimed to examine the extent of dietary acculturation and dietary enculturation on the influence of student's food choices using a phenomenological approach. Sixty participants (forty-one home students and nineteen international students) recruited by purposive sampling, were included in the study. Data collection involved self-administered multiple choice and short answer questionnaires and semi structured interviews. The results were analysed using thematic analysis. When living away from home, six major themes influenced the eating behaviour of the studied population: social environment, individual factors, physical environment, university life, enculturation and acculturation. When at home, five major themes were influential: social environment, individual factors, physical environment, enculturation and acculturation. The main findings suggest dietary enculturation is a factor which influences the dietary behaviour of both international students and BAME home students.
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Affiliation(s)
- Fiona Z Mensah
- Research Institute for Sport and Exercise Sciences, School of Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, United Kingdom
| | - Katie E Lane
- Research Institute for Sport and Exercise Sciences, School of Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, United Kingdom.
| | - Lucinda D Richardson
- Research Institute for Sport and Exercise Sciences, School of Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, United Kingdom
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Spillman LN, Melville-Claxton A, Gatiss GA, Fernandez N, Madden AM. Diet and physical activity after liver transplant: A qualitative study of barriers and facilitators to following advice. J Hum Nutr Diet 2021; 34:910-919. [PMID: 33646641 DOI: 10.1111/jhn.12874] [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: 10/24/2020] [Revised: 01/10/2021] [Accepted: 02/04/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Liver transplant recipients are given diet and physical activity advice to aid recovery and promote long-term health. The present study aimed to explore patients' experiences of receiving and implementing diet and physical activity advice after liver transplant and identify barriers and facilitators to following recommendations. METHODS A qualitative descriptive design included purposive sampling of 13 liver transplant recipients. Semi-structured audio-recorded interviews and inductive thematic analysis using a framework were undertaken concurrently to enable recruitment until saturation of themes occurred. RESULTS Overall experiences varied between participants and settings, as well as over time. Seven themes emerged, all representing both barriers and facilitators to implementing advice. Poor capability and loss of confidence were barriers that improved in hospital because healthcare professionals enabled participants to set and achieve goals but remained key barriers after discharge from hospital. The format and consistency of advice influenced participants' confidence in the healthcare team. Social support helped participants to return to and implement advice, although social networks could also have a negative influence. Advice and modelling of behaviour from other transplant recipients were facilitators. Symptoms, side effects, comorbidities and the environment presented barriers and facilitators. The desire to return to normal and coping strategies were drivers of behaviours, which were also influenced by participants' beliefs and values. CONCLUSIONS The variation in experiences indicates a need for individually tailored advice that is consistent across the multidisciplinary team. Interventions for behaviour change that merit further investigation include goal setting, improving coping strategies, peer support and modifying the hospital and home environment.
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Affiliation(s)
- Lynsey N Spillman
- Department of Nutrition and Dietetics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Arabella Melville-Claxton
- Department of Nutrition and Dietetics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Gillian A Gatiss
- Department of Nutrition and Dietetics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Nicola Fernandez
- Department of Nutrition and Dietetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Angela M Madden
- School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
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Dąbrowski FA, Kobryń E, Jarmużek P, Rykowski P, Zieniewicz K, Wielgoś M, Jabiry-Zieniewicz Z. Pregnancy Weight Gain as a Predictor of Fetal Wellbeing in Liver Transplant Recipients. Ann Transplant 2020; 25:e923804. [PMID: 32855382 PMCID: PMC7480087 DOI: 10.12659/aot.923804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 04/30/2020] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Gestational weight gain (GWG) is an important index influencing perinatal outcomes. Inappropriate weight gain during pregnancy is strongly associated with multiple pregnancy complications. In pregnant liver transplant recipients whose risk of adverse pregnancy outcomes is already high, this aspect may be even more significant. The present study analyzed the gestational weight gain in female liver transplant recipients and its effect on neonatal complications. MATERIAL AND METHODS A cohort study of retrospective data was performed in the 1st Department of Obstetrics and Gynecology, Medical University of Warsaw. There were 23 patients who fulfilled all inclusion criteria. The gestational weight gain was analyzed in the context of pre-pregnancy BMI, immunosuppression, and perinatal outcomes. RESULTS The preterm delivery rate was 39.13% and GWG increased according to the duration of pregnancy. The model adjusted to week of delivery revealed no association between weight gain and the length of pregnancy (p=0.82). GWG in liver transplant recipients did not affect hypotrophy incidence, adverse perinatal outcomes, or caesarian delivery rate. A positive correlation between GWG and neonatal birth weight was observed (p=0.06). One patient, with coexisting PIH, had a stillbirth at 23 weeks. In all other cases, the 5-min Apgar score was 10 points. CONCLUSIONS Current obstetrical recommendations do not consider patients with chronic diseases undergoing immunosuppressive treatment. Proper counselling and preparing liver transplant recipients for pregnancy, especially optimizing maternal pre-pregnancy BMI, may be an important element in improving perinatal outcomes by lowering the risk of maternal complications. GWG itself is not relevant as a predictor of term gestation, but it might be important in achieving eutrophic fetus growth.
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Affiliation(s)
- Filip A. Dąbrowski
- 1 Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland
| | - Eliza Kobryń
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Patrycja Jarmużek
- 1 Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland
| | - Paweł Rykowski
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Krzysztof Zieniewicz
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Mirosław Wielgoś
- 1 Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland
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Santos BC, Correia MITD, Anastácio LR. Energy Expenditure and Liver Transplantation: What We Know and Where We Are. JPEN J Parenter Enteral Nutr 2020; 45:456-464. [DOI: 10.1002/jpen.1985] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 07/24/2020] [Accepted: 07/27/2020] [Indexed: 12/17/2022]
Affiliation(s)
- Bárbara Chaves Santos
- Food Science Post Graduation Program Universidade Federal de Minas Gerais Belo Horizonte Brazil
| | - Maria Isabel Toulson Davisson Correia
- Food Science Post Graduation Program Universidade Federal de Minas Gerais Belo Horizonte Brazil
- Surgery Department Universidade Federal de Minas Gerais Belo Horizonte Brazil
| | - Lucilene Rezende Anastácio
- Food Science Post Graduation Program Universidade Federal de Minas Gerais Belo Horizonte Brazil
- Food Science Department Universidade Federal de Minas Gerais Belo Horizonte Brazil
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Samji NS, Heda R, Satapathy SK. Peri-transplant management of nonalcoholic fatty liver disease in liver transplant candidates . Transl Gastroenterol Hepatol 2020; 5:10. [PMID: 32190778 DOI: 10.21037/tgh.2019.09.09] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Accepted: 09/23/2019] [Indexed: 12/12/2022] Open
Abstract
The incidence of non-alcoholic fatty liver disease (NAFLD) is rapidly growing, affecting 25% of the world population. Non-alcoholic steatohepatitis (NASH) is the most severe form of NAFLD and affects 1.5% to 6.5% of the world population. Its rising incidence will make end-stage liver disease (ESLD) due to NASH the number one indication for liver transplantation (LT) in the next 10 to 20 years, overtaking Hepatitis C. Patients with NASH also have a high prevalence of associated comorbidities such as type 2 diabetes, obesity, metabolic syndrome, cardiovascular disease, and chronic kidney disease (CKD), which must be adequately managed during the peritransplant period for optimal post-transplant outcomes. The focus of this review article is to provide a comprehensive overview of the unique challenges these patients present in the peritransplant period, which comprises the pre-transplant, intraoperative, and immediate postoperative periods.
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Affiliation(s)
- Naga Swetha Samji
- Tennova Cleveland Hospital, 2305 Chambliss Ave NW, Cleveland, TN, USA
| | - Rajiv Heda
- University of Tennessee Health Science Center, College of Medicine, Memphis, TN, USA
| | - Sanjaya K Satapathy
- Division of Hepatology and Sandra Atlas Bass Center for Liver Diseases, Northwell Health, Manhasset, NY, USA
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