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Possick S, Khungar V, Deshpande R. Cardiac evaluation of the liver transplant candidate. Curr Opin Organ Transplant 2024; 29:299-304. [PMID: 37995156 DOI: 10.1097/mot.0000000000001122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2023]
Abstract
PURPOSE OF REVIEW This review aims to summarize recent changes in the cardiac evaluation of adult liver transplant candidates. Over the last several years, there have been significant advances in the use of coronary computed tomography angiography (CCTA) with and without fractional flow reserve (FFR) and increasingly widespread availability of coronary calcium scoring for risk stratification for obstructive coronary artery disease. This has led to novel strategies for risk stratification in cirrhotic patients being considered for liver transplant and an updated American Heart Association (AHA) position paper on the evaluation of liver and kidney transplant candidates. The diagnosis of cirrhotic cardiomyopathy has been refined. These new diagnostic criteria require that specific echocardiographic parameters are evaluated in all patients. The definition of pulmonary hypertension on echocardiography has been altered and no longer utilizes right atrium (RA) pressure estimates based on inferior vena cava (IVC) size and collapse. This provides more volume neutral estimates of pulmonary pressure. RECENT FINDINGS Although CCTA has outstanding negative predictive value, false positive results are not uncommon and often lead to further testing. Revised diagnostic criteria for cirrhotic cardiomyopathy improve risk stratification for peri-operative volume overload and outcomes. Refined pulmonary hypertension criteria provide improved guidance for right heart catheterization (RHC) and referral to subspecialists. There are emerging data regarding the safety and efficacy of TAVR for severe aortic stenosis in cirrhotic patients. SUMMARY Increased utilization of noninvasive testing, including CCTA and/or coronary calcium scoring, can improve the negative predictive value of testing for obstructive coronary artery disease and potentially reduce reliance on coronary angiography. Application of the 2020 criteria for cirrhotic cardiomyopathy will improve systolic and diastolic function assessment and subsequent perioperative risk stratification. The use of global strain scores is emphasized, as it provides important information beyond ejection fraction and diastolic parameters. A standardized one-parameter echo cut-off for elevated pulmonary pressures simplifies both evaluation and follow-up. Innovative transcutaneous techniques for valvular stenosis and regurgitation offer new options for patients at prohibitive surgical risk.
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Affiliation(s)
| | - Vandana Khungar
- Yale University School of Medicine, Transplant Hepatology, Hepatology, Gastroenterology
| | - Ranjit Deshpande
- Department of Anesthesia, Yale University School of Medicine, New Haven, Connecticut, USA
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Yakubu I, Flynn S, Khan H, Nguyen M, Razzaq R, Patel V, Kumaran V, Sharma A, Siddiqui MS. Burden of Portal Hypertension Complications Is Greater in Liver Transplant Wait-Listed Registrants with End-Stage Liver Disease and Type 2 Diabetes. Dig Dis Sci 2024:10.1007/s10620-024-08499-2. [PMID: 38987444 DOI: 10.1007/s10620-024-08499-2] [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: 03/23/2024] [Accepted: 05/11/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND AND AIMS Impact of type 2 diabetes mellitus (T2DM) in patients with end-stage liver disease (ESLD) awaiting liver transplantation (LT) remains poorly defined. The objective of the present study is to evaluate the relationship between T2DM and clinical outcomes among patients with LT waitlist registrants. We hypothesize that the presence of T2DM will be associated with worse clinical outcomes. METHODS 593 patients adult (age 18 years or older) who were registered for LT between 1/2010 and 1/2017 were included in this retrospective analysis. The impact of T2DM on liver-associated clinical events (LACE), survival, hospitalizations, need for renal replacement therapy, and likelihood of receiving LT were evaluated over a 12-month period. LACE was defined as variceal hemorrhage, hepatic encephalopathy, and ascites. Kaplan-Meier and Cox regression analysis were used to determine the association between T2DM and clinical outcomes. RESULTS The baseline prevalence of T2DM was 32% (n = 191) and patients with T2DM were more likely to have esophageal varices (61% vs. 47%, p = 0.002) and history of variceal hemorrhage (23% vs. 16%, p = 0.03). The presence of T2DM was associated with increased risk of incident ascites (HR 1.91, 95% CI 1.11, 3.28, p = 0.019). Patients with T2DM were more likely to require hospitalizations (56% vs. 49%, p = 0.06), hospitalized with portal hypertension-related complications (22% vs. 14%; p = 0.026), and require renal replacement therapy during their hospitalization. Patients with T2DM were less likely to receive a LT (37% vs. 45%; p = 0.03). Regarding MELD labs, patients with T2DM had significantly lower bilirubin at each follow-up; however, no differences in INR and creatinine were noted. CONCLUSION Patients with T2DM are at increased risk of clinical outcomes. This risk is not captured in MELD score, which may potentially negatively affect their likelihood of receiving LT.
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Affiliation(s)
- Idris Yakubu
- Department of Pharmacy, Virginia Commonwealth University (VCU), Richmond, USA
| | - Sean Flynn
- Department of Internal Medicine, Virginia Commonwealth University (VCU), Richmond, USA
| | - Hiba Khan
- Department of Internal Medicine, Virginia Commonwealth University (VCU), Richmond, USA
| | - Madison Nguyen
- Department of Internal Medicine, Virginia Commonwealth University (VCU), Richmond, USA
| | - Rehan Razzaq
- Department of Internal Medicine, Virginia Commonwealth University (VCU), Richmond, USA
| | - Vaishali Patel
- Division of Gastroenterology and Hepatology, Virginia Commonwealth University School of Medicine, Richmond, USA
| | | | - Amit Sharma
- Division of Transplant Surgery, VCU, Richmond, USA
| | - Mohammad Shadab Siddiqui
- Division of Gastroenterology and Hepatology, Virginia Commonwealth University School of Medicine, Richmond, USA.
- Virginia Commonwealth University, 1200 East Broad Street, P.O. Box 980204, Richmond, VA, 23298, USA.
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Rühlmann F, Engelhardt D, Mackert AF, Hedicke MS, Tichelbäcker T, Leha A, Bernhardt M, Ghadimi M, Perl T, Azizian A, Gaedcke J. Short- and Long-Term Outcomes of Patients with Postoperative Arrhythmia after Liver Surgery. Biomedicines 2024; 12:271. [PMID: 38397873 PMCID: PMC10886928 DOI: 10.3390/biomedicines12020271] [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: 12/09/2023] [Revised: 01/02/2024] [Accepted: 01/19/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND New-onset postoperative arrhythmia (PA) has previously been described as a pivotal risk factor for postoperative morbidity and mortality after visceral surgery. However, there is a lack of data concerning liver surgery. The incidence and impact of new-onset postoperative arrhythmia after liver surgery was, therefore, analyzed in a monocentric study. METHODS In total, n = 460 patients (221 female, 239 male) who underwent liver surgery between January 2012 and April 2020 without any prior arrhythmia in their medical history were included in this retrospective analysis. Clinical monitoring started with the induction of anesthesia and was terminated with discharge from the intensive care unit (ICU) or intermediate care unit (IMC). Follow-up included documentation of complications during the hospital stay, as well as long-term survival analysis. RESULTS Postoperative arrhythmia after liver surgery was observed in 25 patients, corresponding to an incidence of 5.4%. The occurrence of arrhythmia was significantly associated with intraoperative complications (p < 0.05), liver fibrosis/cirrhosis (p < 0.05), bile fistula/bile leakage/bilioma (p < 0.05), and organ failure (p < 0.01). Survival analysis showed a significantly poorer overall survival of patients who developed postoperative arrhythmia after liver surgery (p < 0.001). CONCLUSIONS New-onset postoperative arrhythmia after liver surgery has an incidence of only 5.4% but is significantly associated with higher postoperative morbidity and poorer overall survival.
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Affiliation(s)
- Felix Rühlmann
- Department of General, Visceral and Paediatric Surgery, University Medical Centre Göttingen, 37075 Göttingen, Germany; (F.R.); (D.E.); (A.F.M.); (M.S.H.); (M.B.); (M.G.); (T.P.); (A.A.)
| | - Deborah Engelhardt
- Department of General, Visceral and Paediatric Surgery, University Medical Centre Göttingen, 37075 Göttingen, Germany; (F.R.); (D.E.); (A.F.M.); (M.S.H.); (M.B.); (M.G.); (T.P.); (A.A.)
| | - Alma Franziska Mackert
- Department of General, Visceral and Paediatric Surgery, University Medical Centre Göttingen, 37075 Göttingen, Germany; (F.R.); (D.E.); (A.F.M.); (M.S.H.); (M.B.); (M.G.); (T.P.); (A.A.)
| | - Mara Sophie Hedicke
- Department of General, Visceral and Paediatric Surgery, University Medical Centre Göttingen, 37075 Göttingen, Germany; (F.R.); (D.E.); (A.F.M.); (M.S.H.); (M.B.); (M.G.); (T.P.); (A.A.)
| | - Tobias Tichelbäcker
- Clinic III for Internal Medicine, Heart Centre of University Hospital of Cologne, 50937 Cologne, Germany;
| | - Andreas Leha
- Institute of Medical Statistics, University Medical Centre Göttingen, 37075 Göttingen, Germany;
| | - Markus Bernhardt
- Department of General, Visceral and Paediatric Surgery, University Medical Centre Göttingen, 37075 Göttingen, Germany; (F.R.); (D.E.); (A.F.M.); (M.S.H.); (M.B.); (M.G.); (T.P.); (A.A.)
| | - Michael Ghadimi
- Department of General, Visceral and Paediatric Surgery, University Medical Centre Göttingen, 37075 Göttingen, Germany; (F.R.); (D.E.); (A.F.M.); (M.S.H.); (M.B.); (M.G.); (T.P.); (A.A.)
| | - Thorsten Perl
- Department of General, Visceral and Paediatric Surgery, University Medical Centre Göttingen, 37075 Göttingen, Germany; (F.R.); (D.E.); (A.F.M.); (M.S.H.); (M.B.); (M.G.); (T.P.); (A.A.)
| | - Azadeh Azizian
- Department of General, Visceral and Paediatric Surgery, University Medical Centre Göttingen, 37075 Göttingen, Germany; (F.R.); (D.E.); (A.F.M.); (M.S.H.); (M.B.); (M.G.); (T.P.); (A.A.)
| | - Jochen Gaedcke
- Department of General, Visceral and Paediatric Surgery, University Medical Centre Göttingen, 37075 Göttingen, Germany; (F.R.); (D.E.); (A.F.M.); (M.S.H.); (M.B.); (M.G.); (T.P.); (A.A.)
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Møller S, Wiese S, Barløse M, Hove JD. How non-alcoholic fatty liver disease and cirrhosis affect the heart. Hepatol Int 2023; 17:1333-1349. [PMID: 37770804 DOI: 10.1007/s12072-023-10590-1] [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: 07/25/2023] [Accepted: 08/29/2023] [Indexed: 09/30/2023]
Abstract
Liver diseases affect the heart and the vascular system. Cardiovascular complications appear to be a leading cause of death in patients with non-alcoholic fatty liver disease (NAFLD) and cirrhosis. The predominant histological changes in the liver range from steatosis to fibrosis to cirrhosis, which can each affect the cardiovascular system differently. Patients with cirrhotic cardiomyopathy (CCM) and NAFLD are at increased risk of impaired systolic and diastolic dysfunction and for suffering major cardiovascular events. However, the pathophysiological mechanisms behind these risks differ depending on the nature of the liver disease. Accurate assessment of symptoms by contemporary diagnostic modalities is essential for identifying patients at risk, for evaluating candidates for treatment, and prior to any invasive procedures. This review explores current perspectives within this field.
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Affiliation(s)
- Søren Møller
- Department Clinical Physiology and Nuclear Medicine 260, Center for Functional and Diagnostic Imaging and Research, Hvidovre Hospital, Copenhagen University Hospital, Kettegaards alle 30, 2650, Hvidovre, Denmark.
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark.
| | - Signe Wiese
- Gastro Unit, Medical Division, Hvidovre Hospital, Hvidovre, Denmark
| | - Mads Barløse
- Department Clinical Physiology and Nuclear Medicine 260, Center for Functional and Diagnostic Imaging and Research, Hvidovre Hospital, Copenhagen University Hospital, Kettegaards alle 30, 2650, Hvidovre, Denmark
| | - Jens D Hove
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Hvidovre Hospital, Hvidovre, Denmark
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Puri P, Malik S. Liver Transplantation: Contraindication and Ineligibility. J Clin Exp Hepatol 2023; 13:1116-1129. [PMID: 37975058 PMCID: PMC10643298 DOI: 10.1016/j.jceh.2023.04.005] [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: 01/24/2023] [Accepted: 04/14/2023] [Indexed: 11/19/2023] Open
Abstract
Liver transplantation (LT) is a life-saving therapeutic modality for patients with various advanced liver diseases. It is crucial to identify that the patient's illness is sufficiently advanced and unlikely to improve with medical management to justify the need for transplantation. At the same time, it is crucial to identify patients with comorbidities and far advanced disease that would result in an unacceptable outcome after LT. Specific care also is required before deciding on LT in the elderly, acute on chronic liver disease, patients with comorbidities, and hepatocellular carcinoma. Transplantation needs to be timed appropriately to avoid unnecessary LT and ensure that the decision is not left too late to avoid losing the patient without a transplant. Also, important is the decision as to when not to transplant. The current review explores some of these issues of contraindications and ineligibility for LT.
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Affiliation(s)
- Pankaj Puri
- Fortis Escorts Liver and Digestive Diseases Institute, Fortis Escorts Hospital, New Delhi 110025, India
| | - Sarthak Malik
- Department of Gastroenterology, Manipal Hospital, Dwarka, New Delhi 110075, India
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Izzy M, Fortune BE, Serper M, Bhave N, deLemos A, Gallegos-Orozco JF, Guerrero-Miranda C, Hall S, Harinstein ME, Karas MG, Kriss M, Lim N, Palardy M, Sawinski D, Schonfeld E, Seetharam A, Sharma P, Tallaj J, Dadhania DM, VanWagner LB. Management of cardiac diseases in liver transplant recipients: Comprehensive review and multidisciplinary practice-based recommendations. Am J Transplant 2022; 22:2740-2758. [PMID: 35359027 PMCID: PMC9522925 DOI: 10.1111/ajt.17049] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/10/2022] [Accepted: 03/27/2022] [Indexed: 01/25/2023]
Abstract
Cardiac diseases are one of the most common causes of morbidity and mortality following liver transplantation (LT). Prior studies have shown that cardiac diseases affect close to one-third of liver transplant recipients (LTRs) long term and that their incidence has been on the rise. This rise is expected to continue as more patients with advanced age and/or non-alcoholic steatohepatitis undergo LT. In view of the increasing disease burden, a multidisciplinary initiative was developed to critically review the existing literature (between January 1, 1990 and March 17, 2021) surrounding epidemiology, risk assessment, and risk mitigation of coronary heart disease, arrhythmia, heart failure, and valvular heart disease and formulate practice-based recommendations accordingly. In this review, the expert panel emphasizes the importance of optimizing management of metabolic syndrome and its components in LTRs and highlights the cardioprotective potential for the newer diabetes medications (e.g., sodium glucose transporter-2 inhibitors) in this high-risk population. Tailoring the multidisciplinary management of cardiac diseases in LTRs to the cardiometabolic risk profile of the individual patient is critical. The review also outlines numerous knowledge gaps to pave the road for future research in this sphere with the ultimate goal of improving clinical outcomes.
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Affiliation(s)
- Manhal Izzy
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University, Nashville, TN, USA
| | - Brett E Fortune
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY, USA
| | - Marina Serper
- Department of Medicine, Division of Gastroenterology, University of Pennsylvania, Philadelphia, PA, USA
| | - Nicole Bhave
- Department of Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Andrew deLemos
- Department of Medicine, Division of Hepatology, Atrium Health, Charlotte, NC, USA
| | - Juan F. Gallegos-Orozco
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Utah School, Salt Lake City, UT, USA
| | - Cesar Guerrero-Miranda
- Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, TX, USA
| | - Shelley Hall
- Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, TX, USA
| | - Matthew E Harinstein
- Department of Medicine, Division of Cardiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Maria G. Karas
- Department of Medicine, Division of Cardiology, Weill Cornell Medical College, New York, NY, USA
| | - Michael Kriss
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Colorado, Aurora, CO, USA
| | - Nicholas Lim
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, MN, USA
| | - Maryse Palardy
- Department of Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Deirdre Sawinski
- Department of Medicine, Division of Nephrology and Hypertension, Weill Cornell Medical College, New York, NY, USA
| | - Emily Schonfeld
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY, USA
| | - Anil Seetharam
- Department of Medicine, Division of Gastroenterology and Hepatology, Banner - University Medical Center Phoenix, Phoenix, AZ, USA
| | - Pratima Sharma
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
| | - Jose Tallaj
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama, Birmingham, AL, USA
| | - Darshana M Dadhania
- Department of Medicine, Division of Nephrology and Hypertension, Weill Cornell Medical College, New York, NY, USA
| | - Lisa B. VanWagner
- Department of Medicine, Division of Gastroenterology & Hepatology, and Department of Preventive Medicine, Division of Epidemiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Outcomes of Liver Transplantation in Patients with Preexisting Coronary Artery Disease. Transplantation 2022; 107:933-940. [PMID: 36397734 DOI: 10.1097/tp.0000000000004402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Advances in surgical and medical technology over the years has made liver transplantation possible for older and higher risk patients. Despite rigorous preoperative cardiac testing, cardiovascular events remain a major cause of death after orthotopic liver transplantation (OLT). However, there are little data on the outcomes of OLT in patients with preexisting coronary artery disease (CAD). This study aimed to compare all-cause and cardiovascular mortality of patients with and without history of CAD undergoing OLT. METHODS Six hundred ninety-three adult patients with cirrhosis underwent liver transplantation between July 2013 and December 2018 (female n = 243, male n = 450; median age 59). RESULTS During the study period of 5 y (median follow-up, 24.1 mo), 92 of 693 patients (13.3%) died. All-cause mortality in the CAD group was significantly higher than in the non-CAD group (26.7% versus 9.6%; P <0.01). Cardiovascular events accounted for 52.5% of deaths (n = 21) in patients with CAD compared with 36.5% (n = 19) in non-CAD patients. At 6 mo, patients with combined nonalcoholic steatohepatitis (NASH)/CAD had significantly worse survival than those with CAD or NASH alone ( P <0.01). After 6 mo, patients with CAD alone had similar survival to those with combined NASH/CAD. CONCLUSIONS Patients with preexisting CAD before liver transplantation are at higher risk of death from any cause, specifically cardiovascular-related death. This risk increases with coexisting NASH. The presence of NASH and CAD at the time of liver transplant should prompt the initiation of aggressive risk factor modification for patients with CAD.
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8
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Preexisting Coronary Artery Disease in Liver Transplant Candidates: Risk Factor or Risk Marker? Transplantation 2022; 107:824-826. [PMID: 36372929 DOI: 10.1097/tp.0000000000004403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Kwon HM, Kim JH, Yang JW, Hwang GS. Temporary postoperative myocardial injury and long-term survival in liver transplant patients with coronary artery disease. Anesth Pain Med (Seoul) 2022; 17:404-411. [DOI: 10.17085/apm.22167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 09/27/2022] [Indexed: 11/05/2022] Open
Abstract
Background: Coronary artery disease (CAD) is increasing worldwide due to the aging population and cardiometabolic syndrome. However, the extent of postoperative myocardial injury, the most common cause of death during the 30 days after noncardiac surgery, remains unclear with respect to liver transplant (LT) patients with CAD. We examined the link between post-LT high sensitivity cardiac troponin I (hs_cTnI) and long-term survival according to liver disease severity.Methods: Consecutive patients who underwent LT (n = 3,220) from 2010 to 2020 were evaluated retrospectively. CAD was defined as a history of coronary artery bypass surgery or percutaneous intervention, or previous myocardial infarction. Peak hs_cTnI levels within 30 days post-transplant were compared in patients with and without CAD. The primary endpoint was defined as an all-cause mortality at 12 years following LT. Secondary endpoints include peak hs_cTnI level within post-transplant 30 days and 30-day mortality. Survival analysis was performed using the Kaplan–Meier method.Results: CAD patients (n = 264, 8.2%) had higher peak hs_cTnI levels within 30 days post-LT than those without CAD (median [interquartile]: 0.068 [0.030–0.154] vs. 0.087 [0.037–0.203] ng/ml, respectively; P = 0.004); however, the mortality rate was comparable (14.7% vs. 14.8%, respectively, P = 0.999), at 12 years, and 1.9% vs. 1.1% (P = 0.522) at 30 days, respectively, at 30 days. Subgroup analysis with stratified liver disease severity identified a similar risk of long-term mortality.Conclusions: Although the peak hs_cTnI level within 30 days was higher in revascularized or treated CAD patients after LT compared those without CAD, long-term mortality rates at 12 years and 30-day mortality rate were comparable.
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Kwon HM, Kim JH, Kim JY, Hwang GS. Five-year all-cause mortality in critically ill liver transplant patients with coronary artery disease: analysis of acute-on chronic liver failure. Anesth Pain Med (Seoul) 2022; 17:412-419. [DOI: 10.17085/apm.22168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 08/01/2022] [Indexed: 11/07/2022] Open
Abstract
Background: Patients with acute-on-chronic liver failure (ACLF) are critically ill and have high waiting-list mortality. Although studies demonstrated that appropriately treated coronary artery disease (CAD) should not be regarded as a contraindication to liver transplant (LT), data regarding long-term outcomes in critically ill liver LT recipients are lacking. The aim of this study was to compare the rates of all-cause death at 5 years following LT in patients with ACLF with or without CAD.Methods: Between 2010 and 2020, we evaluated 921 consecutive LT patients (MELD score, 32 ± 9) and ACLF classified by CLIF-C ACLF score. Up to 5-year all-cause death according to the CAD status was examined. CAD was defined as a preoperative history of coronary artery bypass graft or a percutaneous intervention and old myocardial infarction. Kaplan-Meier survival analysis was used.Results: Up to 5 years, 212 (23.0%) of all ACLF patients (n = 921) in whom 17 (29.3%) of 58 CAD patients died. In patients with CAD (6.3%, 58/921), the Kaplan-Meier cumulative mortality rate at 5 years was numerically higher but was not statistically significant when compared with those without CAD (32.9% vs. 23.5%, log-rank, P = 0.25). In subgr oup analysis, there were comparable risks of cumulative mortalities at 5 years across the stratification of ACLF grade 1, 2, and 3 (log-rank P = 0.062, P = 0.72, and P = 0.999, respectively).Conclusions: All-cause mortality is high in patients with ACLF after LT but is not related to the presence of revascularized or treated CAD, across the stratification of ACLF grades.
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11
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Kozlik A, Wiseman K, Upadhyaya VD, Sharma A, Chatterjee S. Preoperative Coronary Intervention Before Orthotopic Liver Transplantation (from a Review of Literature). Am J Cardiol 2022; 185:94-99. [DOI: 10.1016/j.amjcard.2022.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 08/30/2022] [Accepted: 09/13/2022] [Indexed: 11/28/2022]
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Chan YC, Yeh CH, Li LC, Chen CL, Wang CC, Lin CC, Ong AD, Chiou TY, Yong CC. Excess Risk of Major Adverse Cardiovascular and Kidney Events after Acute Kidney Injury following Living Donor Liver Transplantation. J Clin Med 2022; 11:jcm11113100. [PMID: 35683487 PMCID: PMC9181469 DOI: 10.3390/jcm11113100] [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: 04/19/2022] [Revised: 05/26/2022] [Accepted: 05/29/2022] [Indexed: 12/01/2022] Open
Abstract
Acute kidney injury (AKI) is a well-known risk factor for major adverse kidney events (MAKE) and major adverse cardiovascular events (MACE) in nontransplant settings. However, the association between AKI after liver transplantation (LT) and MACE/MAKE is not established. A retrospective cohort analysis including 512 LT recipients was conducted. The incidence of post-LT AKI was 35.0% (n = 179). In total, 13 patients (2.5%) developed de novo coronary artery disease (CAD), 3 patients (0.6%) diagnosed with heart failure (HF), and 11 patients (2.1%) had stroke. The post-LT AKI group showed a higher incidence of CAD and HF than the no post-LT AKI group (4.5% versus 1.5%, p = 0.042; 1.7% versus 0%, p = 0.018; respectively), while there was no significant difference in the stroke events (2.8% versus 1.8%, p = 0.461). Through Cox regression analysis, history of cardiovascular disease (HR 6.51, 95% CI 2.43–17.46), post-LT AKI (HR 3.06, 95% CI 1.39–6.75), and pre-LT diabetes (HR 2.37, 95% CI 1.09–5.17) were identified as independent predictors of MACE; pre-LT chronic kidney disease (HR 9.54, 95% CI 3.49–26.10), pre-LT diabetes (HR 3.51, 95% CI 1.25–9.86), and post-LT AKI (HR 6.76, 95% CI 2.19–20.91) were risk factors for end-stage renal disease. Post-LT AKI is predictive for the development of MACE and MAKE.
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Affiliation(s)
- Yi-Chia Chan
- Liver Transplantation Center, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (Y.-C.C.); (C.-H.Y.); (C.-L.C.); (C.-C.W.); (C.-C.L.); (A.D.O.)
| | - Cheng-Hsi Yeh
- Liver Transplantation Center, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (Y.-C.C.); (C.-H.Y.); (C.-L.C.); (C.-C.W.); (C.-C.L.); (A.D.O.)
| | - Lung-Chih Li
- Liver Transplantation Center, Department of Internal Medicine, Division of Nephrology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (L.-C.L.); (T.-Y.C.)
| | - Chao-Long Chen
- Liver Transplantation Center, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (Y.-C.C.); (C.-H.Y.); (C.-L.C.); (C.-C.W.); (C.-C.L.); (A.D.O.)
| | - Chih-Chi Wang
- Liver Transplantation Center, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (Y.-C.C.); (C.-H.Y.); (C.-L.C.); (C.-C.W.); (C.-C.L.); (A.D.O.)
| | - Chih-Chi Lin
- Liver Transplantation Center, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (Y.-C.C.); (C.-H.Y.); (C.-L.C.); (C.-C.W.); (C.-C.L.); (A.D.O.)
| | - Aldwin D. Ong
- Liver Transplantation Center, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (Y.-C.C.); (C.-H.Y.); (C.-L.C.); (C.-C.W.); (C.-C.L.); (A.D.O.)
| | - Ting-Yu Chiou
- Liver Transplantation Center, Department of Internal Medicine, Division of Nephrology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (L.-C.L.); (T.-Y.C.)
| | - Chee-Chien Yong
- Liver Transplantation Center, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (Y.-C.C.); (C.-H.Y.); (C.-L.C.); (C.-C.W.); (C.-C.L.); (A.D.O.)
- Correspondence: ; Tel.: +886-7-7317123 (ext. 8093)
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13
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Nayagam JS, Norton BC, Belete S, Rosinhas J, Ramos K, Cramp ME, O'Kane R, Cash WJ, Milan Z, Nicholson C, Menon K, Prachalias A, Srinivasan P, Auzinger G, Byrne J, MacCarthy PA, Melikian N, Agarwal K, Aluvihare VR, Joshi D, Heneghan MA. Invasive coronary angiography as a tool in cardiac evaluation for liver transplant candidates. JOURNAL OF LIVER TRANSPLANTATION 2022. [DOI: 10.1016/j.liver.2022.100100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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14
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Xiao J, Yong JN, Ng CH, Syn N, Lim WH, Tan DJH, Tan EY, Huang D, Wong RC, Chew NWS, Tan EXX, Noureddin M, Siddiqui MS, Muthiah MD. A Meta-Analysis and Systematic Review on the Global Prevalence, Risk Factors, and Outcomes of Coronary Artery Disease in Liver Transplantation Recipients. Liver Transpl 2022; 28:689-699. [PMID: 34626045 DOI: 10.1002/lt.26331] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 10/02/2021] [Accepted: 10/06/2021] [Indexed: 12/12/2022]
Abstract
The shift in the changing etiology of cirrhosis requiring liver transplantation (LT) has resulted in an increasing prevalence of coronary artery disease (CAD) that can potentially impact post-LT outcomes. This systematic review and meta-analysis evaluates the prevalence of CAD, risk factors, and outcomes of patients diagnosed with CAD before LT. MEDLINE and EMBASE were searched for articles describing CAD in pre-LT patients. Meta-analysis of proportions using the generalized linear mix model was conducted to analyze the pooled prevalence of CAD in pre-LT patients. Associated risk factors for CAD in pre-LT patients and outcomes were evaluated in conventional pairwise meta-analysis. A total of 39 studies were included. The pooled prevalence of patients diagnosed with CAD before LT was 15.9% (95% CI, 9.8%-24.7%). Age, male sex, diabetes mellitus, hypertension, hyperlipidemia, smoking, nonalcoholic steatohepatitis, hepatitis B virus, and hepatocellular carcinoma were significantly associated with CAD. Patients from high-income countries especially North America, Europe, and South America, with the associated risk factors were at increased risk for CAD before LT. CAD before LT was associated with an increased odds of overall mortality (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.4-1.4; P = 0.01) and cardiac-related mortality (OR, 1.2; 95% CI, 1.1-1.3; P = 0.03). A total of 48.7% of included articles considered the presence of cardiovascular risk factors for CAD screening. However, 10.3% of the studies screened for CAD in pre-LT patients via invasive coronary angiography only, without stress testing or risk stratification. This study demonstrates the high prevalence of CAD in pre-LT patients, associated risk factors, and outcomes. There is heterogeneity among guidelines and practice in screening for pre-LT CAD, and more studies are needed to establish consensus.
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Affiliation(s)
- Jieling Xiao
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Jie Ning Yong
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Cheng Han Ng
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Nicholas Syn
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore.,Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Wen Hui Lim
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Darren Jun Hao Tan
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - En Ying Tan
- Biostatistics and Modelling Domain, Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore.,National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
| | - Daniel Huang
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore.,Biostatistics and Modelling Domain, Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore.,National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
| | - Raymond C Wong
- Department of Cardiology, National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Nicholas W S Chew
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore.,Department of Cardiology, National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Eunice Xiang Xuan Tan
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore.,Biostatistics and Modelling Domain, Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore.,National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
| | - Mazen Noureddin
- Cedars-Sinai Fatty Liver Program, Division of Digestive and Liver Diseases, Department of Medicine, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Mohammad Shadab Siddiqui
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
| | - Mark D Muthiah
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore.,Biostatistics and Modelling Domain, Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore.,National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
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15
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Lee MS. Diagnostic Yield of Coronary Angiography in Asymptomatic Orthotopic Liver Transplantation Candidates. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 35:59-63. [PMID: 33685794 DOI: 10.1016/j.carrev.2021.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 02/24/2021] [Accepted: 03/01/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND The ideal cardiac risk stratification strategy for orthotopic liver transplantation (OLT) is unknown. Our institution performed coronary angiography for asymptomatic OLT candidates at high risk for CAD: ≥65 years of age, diabetic and ≥55 years of age or diagnosed ≥5 years, abnormal stress test, or at the discretion of the OLT committee. METHODS The analysis included 301 consecutive, asymptomatic OLT candidates who underwent coronary angiography. The primary outcome was the prevalence of obstructive CAD. RESULTS At 2-year follow-up, OLT was performed in 44.9%, and 42.2% died. The prevalence of obstructive CAD, involvement of the proximal or mid LAD, and 3-vessel CAD were 10.3%, 6.6%, and 0.7%, respectively. Percutaneous and surgical revascularization were performed in 7.0% and 1.3%, respectively. Stress test was performed in 54.8%. The sensitivity and specificity of stress testing were 0% and 87.1%, respectively. The negative and positive predictive values of stress testing were 91.4% and 0%, respectively. Chest computed tomography (CT) was performed in 83.1%. Moderate or severe coronary artery calcification (CAC) was present in 47.8%. The sensitivity and specificity of moderate or severe CAC were 88.9% and 57.3%, respectively. The negative and positive predictive values of moderate or severe CAC were 97.7% and 20.2%, respectively. Multivariate analysis demonstrated that CAC was an independent predictor of obstructive CAD (HR 10.7; 95% CI 3.2-37.9; p < 0.001). CONCLUSIONS The prevalence of obstructive CAD in asymptomatic OLT candidates at high risk was uncommon. Alternative diagnostic strategies may be preferred to coronary angiography.
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Affiliation(s)
- Michael S Lee
- Divsion of Cardiology, UCLA Medical Center, 100 Medical Plaza, Suite 630, Los Angeles, CA 90095, United States of America.
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16
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Syed T, Siddiqui MS. Atherogenic Dyslipidemia After Liver Transplantation: Mechanisms and Clinical Implications. Liver Transpl 2021; 27:1326-1333. [PMID: 33837670 DOI: 10.1002/lt.26069] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Revised: 03/17/2021] [Accepted: 04/01/2021] [Indexed: 12/21/2022]
Abstract
Cardiovascular disease (CVD), particularly atherosclerosis-associated CVD, is a major cause of long-term mortality after liver transplantation (LT). The liver is central in lipid homeostasis, and changes associated with insulin resistance, weight gain, adipose tissue inflammation, and development of nonalcoholic fatty liver disease (NAFLD) after LT promote atherogenesis. These factors synergistically alter lipid homeostasis, thereby leading to the production of proatherogenic lipoproteins, which contribute to the heighted risk of CVD-associated events observed in LT recipients. Although the exact mechanism promoting this shift of a proatherogenic lipoprotein profile is currently not known, the choice of immunosuppression and preexisting metabolic risk factors (ie, NAFLD) are likely contributors. This shift in proatherogenic lipoprotein subparticles presents clinical challenges as the traditional lipid profile employed in clinical practice may not fully capture this atherogenic risk. This review focuses on lipoprotein metabolism and atherogenesis in LT recipients.
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Affiliation(s)
- Taseen Syed
- Department of Gastroenterology, Nutrition and Transplant Hepatology, Virginia Commonwealth University, Richmond, VA.,Department of Gastroenterology, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA
| | - Mohammad S Siddiqui
- Department of Gastroenterology, Nutrition and Transplant Hepatology, Virginia Commonwealth University, Richmond, VA.,Hume-Lee Transplant Center, Virginia Commonwealth University, Richmond, VA
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17
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Barman PM, VanWagner LB. Cardiac Risk Assessment in Liver Transplant Candidates: Current Controversies and Future Directions. Hepatology 2021; 73:2564-2576. [PMID: 33219576 PMCID: PMC8220582 DOI: 10.1002/hep.31647] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 09/25/2020] [Accepted: 10/13/2020] [Indexed: 12/12/2022]
Abstract
In the changing landscape of liver transplantation (LT), we are now evaluating older and sicker patients with more cardiovascular comorbidities, and the spectrum of cardiovascular disease is uniquely physiologically impacted by end-stage liver disease. Cardiac complications are now the leading cause of morbidity and mortality in LT recipients, and the pretransplant risk is exacerbated immediately during the transplant operation and continues long term under the umbrella of immunosuppression. Accurate risk estimation of cardiac complications before LT is paramount to guide allocation of limited health care resources and to improve both short-term and long-term clinical outcomes for patients. Current screening and diagnostic testing are limited in their capacity to accurately identify early coronary disease and myocardial dysfunction in persons with end-stage liver disease physiology. Furthermore, a number of testing modalities have not been evaluated in patients with end-stage liver disease. As a result, there is wide variation in cardiac risk assessment practices across transplant centers. In this review, we propose a definition for defining cardiac events in LT, evaluate the current evidence for surgery-related, short-term and long-term cardiac risk assessment in LT candidates, propose an evidence-based testing algorithm, and highlight specific gaps in knowledge and current controversies, identifying areas for future research.
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Affiliation(s)
- Pranab M. Barman
- Department of Medicine-Division of Gastroenterology & Hepatology, University of California San Diego, San Diego, CA
| | - Lisa B. VanWagner
- Department of Medicine-Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL,Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL,Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
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18
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Morelli MC, Rendina M, La Manna G, Alessandria C, Pasulo L, Lenci I, Bhoori S, Messa P, Biancone L, Gesualdo L, Russo FP, Petta S, Burra P. Position paper on liver and kidney diseases from the Italian Association for the Study of Liver (AISF), in collaboration with the Italian Society of Nephrology (SIN). Dig Liver Dis 2021; 53 Suppl 2:S49-S86. [PMID: 34074490 DOI: 10.1016/j.dld.2021.03.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/31/2021] [Accepted: 03/31/2021] [Indexed: 02/07/2023]
Abstract
Liver and kidney are strictly connected in a reciprocal manner, in both the physiological and pathological condition. The Italian Association for the Study of Liver, in collaboration with the Italian Society of Nephrology, with this position paper aims to provide an up-to-date overview on the principal relationships between these two important organs. A panel of well-recognized international expert hepatologists and nephrologists identified five relevant topics: 1) The diagnosis of kidney damage in patients with chronic liver disease; 2) Acute kidney injury in liver cirrhosis; 3) Association between chronic liver disease and chronic kidney disease; 4) Kidney damage according to different etiology of liver disease; 5) Polycystic kidney and liver disease. The discussion process started with a review of the literature relating to each of the five major topics and clinical questions and related statements were subsequently formulated. The quality of evidence and strength of recommendations were graded according to the GRADE system. The statements presented here highlight the importance of strong collaboration between hepatologists and nephrologists for the management of critically ill patients, such as those with combined liver and kidney impairment.
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Affiliation(s)
- Maria Cristina Morelli
- Internal Medicine Unit for the treatment of Severe Organ Failure, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico di S.Orsola, Bologna, Italy, Via Albertoni 15, 40138, Bologna, Italy
| | - Maria Rendina
- Gastroenterology Unit, Department of Emergency and Organ Transplantation, University of Bari, Policlinic Hospital, Piazza G. Cesare 11, 70124, Bari, Italy
| | - Gaetano La Manna
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, St. Orsola Hospital, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - Carlo Alessandria
- Division of Gastroenterology and Hepatology, Città della Salute e della Scienza Hospital, University of Torino, Corso Bramante 88, 10126, Torino, Italy
| | - Luisa Pasulo
- Gastroenterology and Transplant Hepatology, "Papa Giovanni XXIII" Hospital, Piazza OMS 1, 24127, Bergamo, Italy
| | - Ilaria Lenci
- Department of Internal Medicine, Hepatology Unit, Tor Vergata University, Rome Viale Oxford 81, 00133, Rome, Italy
| | - Sherrie Bhoori
- Hepatology and Hepato-Pancreatic-Biliary Surgery and Liver Transplantation, Fondazione IRCCS, Istituto Nazionale Tumori, Via Giacomo Venezian, 1, 20133, Milan, Italy
| | - Piergiorgio Messa
- Unit of Nephrology, Università degli Studi di Milano, Via Commenda 15, 20122, Milano, Italy; Nephrology, Dialysis and Renal Transplant Unit-Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Via Commenda 15, 20122 Milano, Italy
| | - Luigi Biancone
- Division of Nephrology Dialysis and Transplantation, Department of Medical Sciences, Città Della Salute e della Scienza Hospital, University of Turin, Corso Bramante, 88-10126, Turin, Italy
| | - Loreto Gesualdo
- Nephrology Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation, Università degli Studi di Bari "Aldo Moro", Piazza G. Cesare 11, 70124, Bari, Italy
| | - Francesco Paolo Russo
- Multivisceral Transplant Unit, Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University Hospital of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Salvatore Petta
- Section of Gastroenterology and Hepatology, PROMISE, University of Palermo, Piazza delle Cliniche, 2 90127, Palermo, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit, Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University Hospital of Padua, Via Giustiniani 2, 35128, Padua, Italy.
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19
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Sertić Z, Letilović T, Kanižaj TF, Knotek M, Hadžibegović I, Starovečki I, Jerkić H. Cardiovascular mortality in liver and kidney transplant recipients: A retrospective analysis from a single institution. Medicine (Baltimore) 2021; 100:e26019. [PMID: 34011105 PMCID: PMC8137067 DOI: 10.1097/md.0000000000026019] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 04/30/2021] [Indexed: 01/05/2023] Open
Abstract
Previous studies have demonstrated cardiovascular causes to be among the leading causes of death after liver (LT) and kidney transplantation (KT). Although both recipient populations have unique pre-transplant cardiovascular burdens, they share similarities in post-transplant exposure to cardiovascular risk factors. The aim of this study was to compare cardiovascular mortality after LT and KT.We analyzed causes of death in 370 consecutive LT and 207 KT recipients from in-hospital records at a single tertiary transplant center. Cardiovascular causes of death were defined as cardiac arrest, heart failure, pulmonary embolism, or myocardial infarction.After a median follow-up of 36.5 months, infection was the most common cause of death in both cohorts, followed by cardiovascular causes in KT recipients and graft-related causes in LT recipients in whom cardiovascular causes were the third most common. Cumulative incidence curves for cardiovascular mortality computed with death from other causes as the competing risk were not significantly different (P = .36). While 1-year cumulative cardiovascular mortality was similar (1.6% after LT and 1.5% after KT), the estimated 4-year probability was higher post-KT (3.8% vs. 1.6%). Significant pre-transplant risk factors for overall mortality after KT in multivariable analysis were age at transplantation, left ventricular ejection fraction <50%, and diastolic dysfunction grade 2 or greater, while significant risk factors for cardiovascular mortality were peripheral artery disease and left ventricular ejection fraction <50%. In the LT group no variables remained significant in a multivariable model for either overall or cardiovascular mortality.The present study found no significant overall difference in cardiovascular mortality after LT and KT. While LT and KT recipients may have similar early cardiovascular mortality, long-term risk is potentially lower after LT. Differing characteristics of cardiovascular death between these two patient populations should be further investigated.
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Affiliation(s)
- Zrinka Sertić
- Department of Emergency Medicine, University Hospital Centre Zagreb
| | - Tomislav Letilović
- Division of Cardiology, University Hospital Merkur
- School of Medicine, University of Zagreb
| | - Tajana Filipec Kanižaj
- School of Medicine, University of Zagreb
- Division of Gastroenterology, University Hospital Merkur, Zagreb, Croatia
| | | | - Irzal Hadžibegović
- Division of Cardiology, University Hospital Dubrava, Zagreb
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
| | | | - Helena Jerkić
- Division of Cardiology, University Hospital Merkur
- School of Medicine, University of Zagreb
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20
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Sadowski B, Baba T, Rangnekar AS. PRO: Cardiac Catheterization Is the Optimal Strategy for Cardiovascular Risk Stratification in This Patient. Clin Liver Dis (Hoboken) 2021; 17:33-36. [PMID: 33552484 PMCID: PMC7849291 DOI: 10.1002/cld.963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 04/03/2020] [Accepted: 04/22/2020] [Indexed: 02/04/2023] Open
Abstract
Watch a video presentation of this article Watch an interview with the author.
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Affiliation(s)
- Brett Sadowski
- MedStar Georgetown Transplant InstituteMedStar Georgetown University HospitalWashingtonDC,Department of MedicineDivision of GastroenterologyWalter Reed National Military Medical CenterBethesdaMD
| | - Tilak Baba
- MedStar Georgetown Transplant InstituteMedStar Georgetown University HospitalWashingtonDC
| | - Amol S. Rangnekar
- MedStar Georgetown Transplant InstituteMedStar Georgetown University HospitalWashingtonDC
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21
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Abstract
Cardiovascular disease complications are the leading cause of early (short-term) mortality among liver transplant recipients. The increasingly older candidate pool has multiple comorbidities necessitating cardiac and pulmonary vascular disease risk stratification of patients for optimal allocation of scarce donor livers. Arrhythmias, heart failure, stroke, and coronary artery disease are common pretransplant cardiovascular comorbidities and contribute to cardiovascular complications after liver transplant. Valvular heart disease and portopulmonary hypertension present intraoperative challenges during liver transplant surgery. The Cardiovascular Risk in Orthotopic Liver Transplantation score estimates the risk of cardiovascular complications in liver transplant candidates within the first year after transplant.
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22
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Incidence, Predictors, and Impact on Survival of Long-term Cardiovascular Events After Liver Transplantation. Transplantation 2020; 104:317-325. [PMID: 31335770 DOI: 10.1097/tp.0000000000002852] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Information on the risk factors, particularly kidney function, and impact of long-term cardiovascular events (CVE) after liver transplantation (LT) remains scarce. METHODS This is a retrospective, single-center study that included consecutive LT recipients between 2007 and 2017. The incidence of CVE, their risk factors, and their impact on patient survival were investigated. RESULTS We included 627 LT recipients. The incidence of CVE was 8% and 20% at 12 and 60 months after LT, respectively. The independent risk factors of long-term (beyond 12 mo) CVE were age at LT (hazard ratio [HR], 1.04; 95% confidence interval [CI], 1.01-1.07), male gender (HR, 2.48; 95% CI, 1.21-5.05), history of pre-LT cardiovascular disease (HR, 2.19; 95% CI, 1.2-3.98), and immunosuppression with cyclosporine A (HR, 1.93; 95% CI, 1.14-3.3). In patients with pre-LT cardiovascular disease, creatinine levels 12 months after LT significantly impacted the risk of long-term CVE. Long-term CVE (HR, 2.12; 95% CI, 1.24-3.61), hepatitis C as the etiology of liver disease (HR, 2.18; 95% CI, 1.29-3.67), cytomegalovirus infection (HR, 1.89; 95% CI, 1.08-3.3), and donor age (HR, 1.02; 95% CI, 1.01-1.04) were independent factors associated with post-LT patient death. CONCLUSIONS Age, male gender, cardiovascular disease before LT, and cyclosporine A were associated with the risk of long-term CVE. The impact of serum creatinine was restricted to patients with pre-LT cardiovascular disease. In these patients, preservation of kidney function early after LT may lessen the incidence of CVE, which are an independent predictor of post-LT death.
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23
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Shamaa O, Jafri SM, Shamaa MT, Brown K, Venkat D. Takotsubo Cardiomyopathy Following Liver Transplantation: A Report of 2 Cases. Transplant Proc 2020; 53:239-243. [PMID: 32980136 DOI: 10.1016/j.transproceed.2020.07.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 07/11/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE Takotsubo cardiomyopathy, also called apical ballooning syndrome, is characterized by regional left ventricular systolic dysfunction that resembles myocardial infarction in its initial presentation; however, it lacks angiographic evidence of coronary artery disease. We evaluated the incidence of takotsubo cardiomyopathy following liver transplant at a diverse urban transplant program. METHODS This is a retrospective review of patients transplanted at a single center between 2017 and 2019. Here we report 2 cases of takotsubo cardiomyopathy that developed after liver transplantation. RESULTS A 65-year-old woman diagnosed with alcoholic cirrhosis underwent a brain-dead donor liver transplant. The postoperative course was complicated by stroke, pulmonary hypertension, and a left internal jugular thrombus. Six months following transplant, the patient developed takotsubo cardiomyopathy with congestive hepatopathy and died of heart failure complications despite maximal medical care. The second case was a 65-year-old woman with alcoholic cirrhosis admitted for a living donor liver transplant. The postoperative period involved recurrent seizures and elevated troponins with markedly reduced ejection fraction, which were appropriately managed. The patient recovered well with supportive care and was discharged to a rehabilitation facility shortly after. CONCLUSION We present a series of patients with takotsubo cardiomyopathy after liver transplantation. The diagnosis depends on the clinical presentation and findings on electrocardiography, echocardiography, and cardiac enzymes. Our patients met the Mayo Clinic diagnostic criteria and were appropriately managed according to guidelines. Our report highlights the possibility of pulmonary hypertension contributing to the development of takotsubo cardiomyopathy. Additional studies are needed to establish a definite correlation.
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Affiliation(s)
- Omar Shamaa
- Internal Medicine, Henry Ford Hospital, Detroit, Michigan, United States.
| | - Syed-Mohammed Jafri
- Division of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, Michigan, United States
| | - M Tayseer Shamaa
- General Surgery, Henry Ford Hospital, Detroit, Michigan, United States
| | - Kimberly Brown
- Division of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, Michigan, United States
| | - Deepak Venkat
- Division of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, Michigan, United States
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24
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Maliakkal BJ. Pathogenesis of non-alcoholic fatty liver disease and implications on cardiovascular outcomes in liver transplantation. Transl Gastroenterol Hepatol 2020; 5:36. [PMID: 32632387 DOI: 10.21037/tgh.2019.12.02] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 11/05/2019] [Indexed: 12/15/2022] Open
Abstract
Along with the obesity epidemic there has been a major increase in non-alcoholic fatty liver disease (NAFLD) prevalence, paralleling a steady increase in cirrhosis of the liver and hepatocellular cancer (HCC) related to NAFLD. Currently, NAFLD (related HCC and cirrhosis) is the second most common cause for liver transplantation (LT) and it is projected to take the top spot in the next 3-5 years. Patients with NAFLD cirrhosis and HCC have a unique set of comorbidities which potentially increases their risk for cardiovascular disease (CVD) and mortality. However, a review of the published data in NAFLD patients who undergo LT, does not paint a clear picture. While CVD is the most common cause of non-graft related mortality over the long-term, the short and intermediate-term survival post LT in NAFLD cirrhosis appears to be on par with other etiologies when age and comorbidities are factored. The cardiovascular complications are increased in the immediate post-transplant period but there is a shift from ischemic complications to arrhythmias and heart failure (HF). NAFLD recurs in 80-100% patients and occurs de novo in about 50% after LT, potentially impacting their long-term morbidity and mortality. This review summarizes the available data on CVD in NAFLD patients before and after LT, explains what is currently known about the epidemiology and pathogenesis of CVD in NAFLD and posits strategies to improve wait-list and post-transplant survival.
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25
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Buchard B, Boirie Y, Cassagnes L, Lamblin G, Coilly A, Abergel A. Assessment of Malnutrition, Sarcopenia and Frailty in Patients with Cirrhosis: Which Tools Should We Use in Clinical Practice? Nutrients 2020; 12:E186. [PMID: 31936597 PMCID: PMC7020005 DOI: 10.3390/nu12010186] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 01/02/2020] [Accepted: 01/07/2020] [Indexed: 02/07/2023] Open
Abstract
Malnutrition is a common comorbidity in patients with cirrhosis. Its prognostic value is indisputable as it greatly affects the evolution of liver diseases. It has a major impact on both morbi-mortality before and after liver transplantation. Being now integrated in the definition of malnutrition and recognized as a new entity in the international classification of diseases, physicians have taken great interest in sarcopenia. Its negative consequences on the fate of patients with cirrhosis are well-demonstrated. The concept of frailty has recently been enlarged to chronic liver diseases as symptoms of impaired global physical functioning. In this article, we will discuss the definitions of malnutrition and emphasize its links with sarcopenia and frailty. We will show the relevance of frailty and sarcopenia in the course of liver diseases. The emerging role of muscle depletion on the cardiorespiratory system will also be highlighted. The importance of body composition will be demonstrated and the main tools reviewed. Finally, we adapted the definition of malnutrition to patients with cirrhosis based on the assessment of sarcopenia together with reduced food intakes.
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Affiliation(s)
- Benjamin Buchard
- Service de Médecine Digestive et Hépatobiliaire, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France; (G.L.); (A.A.)
| | - Yves Boirie
- Service de Nutrition Clinique, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France;
- Unité de Nutrition Humaine, UMR 1019 INRA-Université Clermont Auvergne, 63000 Clermont-Ferrand, France
| | - Lucie Cassagnes
- Service de radiologie adultes, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France;
- Institut Pascal, Thérapies guidées par l’image, UMR 6602 CNRS-SIGMA-Université Clermont Auvergne, 63000 Clermont-Ferrand, France
| | - Géraldine Lamblin
- Service de Médecine Digestive et Hépatobiliaire, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France; (G.L.); (A.A.)
| | - A. Coilly
- Centre Hépatobiliaire, AP-HP Hôpital Paul-Brousse, UMR 1193 INSERM-Université Paris Sud, 94800 Villejuif, France;
| | - Armando Abergel
- Service de Médecine Digestive et Hépatobiliaire, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France; (G.L.); (A.A.)
- Institut Pascal, Thérapies guidées par l’image, UMR 6602 CNRS-SIGMA-Université Clermont Auvergne, 63000 Clermont-Ferrand, France
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Trankle CR, Vo C, Martin E, Puckett L, Siddiqui MS, Brophy DF, Stravitz T, Guzman LA. Clopidogrel Responsiveness in Patients With Decompensated Cirrhosis of the Liver Undergoing Pre-Transplant PCI. JACC Cardiovasc Interv 2019; 13:661-663. [PMID: 31883726 DOI: 10.1016/j.jcin.2019.08.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 08/09/2019] [Accepted: 08/20/2019] [Indexed: 01/12/2023]
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