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The clinical implications of pre-liver transplant diabetes on post-liver transplant outcomes in patients with NASH: analysis of the UNOS database. Hepatol Int 2022; 16:1448-1457. [PMID: 36088499 PMCID: PMC9939002 DOI: 10.1007/s12072-022-10414-8] [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: 01/24/2022] [Accepted: 08/16/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND AND AIMS The presence of perioperative diabetes may lead to increased mortality risks following liver transplant (LT) in patients with non-alcoholic steatohepatitis (NASH). This risk factor was evaluated using a UNOS-STAR national database. METHODS The UNOS-STAR liver transplant registry 2005-2019 was used to select patients with NASH (including cryptogenic liver disease). The following populations were excluded: those younger than 18 years old and those with living donors/dual transplants. Selected patients were stratified into those with and without pre-LT diabetes and compared to the individual mortality endpoints using iterative Cox analyses. RESULTS 6324 recipients with and 8251 without diabetes were selected. The median follow-up time was 3.07 years. Those with diabetes were older (58.50 vs. 54.50 years, p < 0.001), were more likely to be Hispanic or Asian, and had higher BMI than the non-diabetics (31.10 vs. 29.70 kg/m2 p < 0.001); however, there was no difference in gender (female 41.9 vs. 43.1% p = 0.170). Compared to non-diabetics, recipients with diabetes had a higher rate of all-cause mortality (61.68 vs. 47.80 per 1000 person-years). In multivariate iterations, pre-LT diabetes was associated with all-cause mortality (aHR 1.19 95% CI 1.11-1.27) as well as deaths due to cardiac (p = 0.014 aHR 1.24 95% CI 1.04-1.46) and renal causes (p = 0.039 aHR 1.38 95% CI 1.02-1.87). CONCLUSION The presence of pre-LT diabetes is associated with all-cause mortality and deaths due to cardiac and renal causes following LT. The findings warrant an early preoperative screening procedure to ensure that patients with diabetes have their metabolic risk factors optimized prior to LT.
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Nagraj S, Peppas S, Rubianes Guerrero MG, Kokkinidis DG, Contreras-Yametti FI, Murthy S, Jorde UP. Cardiac risk stratification of the liver transplant candidate: A comprehensive review. World J Transplant 2022; 12:142-156. [PMID: 36051452 PMCID: PMC9331410 DOI: 10.5500/wjt.v12.i7.142] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 06/15/2022] [Accepted: 06/27/2022] [Indexed: 02/06/2023] Open
Abstract
Cardiovascular diseases (CVD) form a principal consideration in patients with end-stage liver disease (ESLD) undergoing evaluation for liver transplant (LT) with prognostic implications in the peri- and post-transplant periods. As the predominant etiology of ESLD continues to evolve, addressing CVD in these patients has become increasingly relevant. Likewise, as the number of LTs increase by the year, the proportion of older adults on the waiting list with competing comorbidities increase, and the demographics of LT candidates evolve with parallel increases in their CVD risk profiles. The primary goal of cardiac risk assessment is to preemptively reduce the risk of cardiovascular morbidity and mortality that may arise from hemodynamic stress in the peri- and post-transplant periods. The complex hemodynamics shared by ESLD patients in the pre-transplant period with adverse cardiovascular events occurring in only some of these recipients continue to challenge currently available guidelines and their uniform applicability. This review focusses on cardiac assessment of LT candidates in a stepwise manner with special emphasis on preoperative patient optimization. We hope that this will reinforce the importance of cardiovascular optimization prior to LT, prevent futile LT in those with advanced CVD beyond the stage of optimization, and thereby use the finite resources prudently.
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Affiliation(s)
- Sanjana Nagraj
- Department of Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, New York City, NY 10461, United States
| | - Spyros Peppas
- Department of Gastroenterology, Athens Naval Hospital, Athens 115 21, Greece
| | | | - Damianos G Kokkinidis
- Section of Cardiovascular Medicine, Yale University School of Medicine, Yale New Haven Hospital, New Haven, CT 06510, United States
| | | | - Sandhya Murthy
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York City, NY 10467, United States
| | - Ulrich P Jorde
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York City, NY 10467, United States
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Cardiovascular Evaluation of Liver Transplant Patients by Using Coronary Calcium Scoring in ECG-Synchronized Computed Tomographic Scans. J Clin Med 2021; 10:jcm10215148. [PMID: 34768667 PMCID: PMC8584855 DOI: 10.3390/jcm10215148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/22/2021] [Accepted: 11/01/2021] [Indexed: 12/04/2022] Open
Abstract
Background: The goal of cardiac evaluation of patients awaiting orthotopic liver transplantation (OLT) is to identify the patients at risk for cardiovascular events (CVEs) in the peri- and postoperative periods by opportunistic evaluation of coronary artery calcium (CAC) in non-gated abdominal computed tomographs (CT). Methods: We hypothesized that in patients with OLT, a combination of Lee’s revised cardiac index (RCRI) and CAC scoring would improve diagnostic accuracy and prognostic impact compared to non-invasive cardiac testing. Therefore, we retrospectively evaluated 169 patients and compared prediction of CVEs by both methods. Results: Standard workup identified 22 patients with a high risk for CVEs during the transplant period, leading to coronary interventions. Eighteen patients had a CVE after transplant and a CAC score > 0. The combination of CAC and RCRI ≥ 2 had better negative (NPV) and positive predictive values (PPV) for CVEs (NPV 95.7%, PPV 81.6%) than standard non-invasive stress tests (NPV 92.0%, PPV 54.5%). Conclusion: The cutoff value of CAC > 0 by non-gated CTs combined with RCRI ≥ 2 is highly sensitive for identifying patients at risk for CVEs in the OLT population.
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4
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Raszeja-Wyszomirska J, Glowczynska R, Kostrzewa K, Janik M, Zygmunt M, Zborowska H, Krawczyk M, Niewinski G, Galas M, Krawczyk M, Zieniewicz K, Milkiewicz P, Opolski G. Evaluation of Liver Graft Recipient Workup in Predicting of Early Cardiovascular Events During Liver Transplantation: A Single-Center Experience. Transplant Proc 2018; 50:1997-2001. [PMID: 30177096 DOI: 10.1016/j.transproceed.2018.02.161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 02/06/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cardiovascular events (CVE) contribute to serious complications and death after liver transplantation (LT). Troponin I (TnI) level >0.07 mg/L and prior cardiac disease are known to be the independent predictors for posttransplant CVE. We evaluated single-center cardiac workup to predict early cardiovascular morbidity and mortality after LT. PATIENTS AND METHODS We recruited 105 consecutive liver transplant recipients (male/female, 59/46; mean age, 51.66 ± 11.67 years). The cardiological assessment at evaluation for LT included medical history, electrocardiogram, echocardiography, Holter monitoring, and exercise test. We collected data regarding CVE including hypotonia with catecholamine usage, arrhythmia, sudden cardiac death, pulmonary edema, and myocardial infarction within 7 days after LT. RESULTS CVE during LT occurred in 42 recipients (40%) and after LT in 9 patients (8.57%). Proposed cutoff level of TnI >0.07 mg/L did not correlate with CVE during operation (P = .73) or after LT (P = .47). CVE during LT was associated with arterial hypertension in medical history (P <.001), right ventricular systolic pressure (P< .05), and clinical scores: Child-Pugh (P = .04), Model for End-Stage Liver Disease (MELD) (P = .04), MELD incorporating serum sodium (P<.03), and integrated MELD score (P = .01). CVE after LT correlated only with arrhythmia (P<.001) and catecholamine usage (P < .05) perioperatively. Of interest, catecholamine usage during LT was associated with prolonged stay at the intensive care unit (P < .05). CONCLUSION The single-center algorithm with noninvasive cardiac procedures without TnI assessment is optimal in evaluation before LT; however, medical history and severity of the liver disease are crucial for short-term cardiovascular morbidity after LT.
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Affiliation(s)
- J Raszeja-Wyszomirska
- Liver and Internal Medicine Unit, Department of General, Transplant, and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - R Glowczynska
- 1st Department of Cardiology, Medical University of Warsaw, Warsaw, Poland.
| | | | - M Janik
- Liver and Internal Medicine Unit, Department of General, Transplant, and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - M Zygmunt
- Liver and Internal Medicine Unit, Department of General, Transplant, and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - H Zborowska
- Central Laboratory, Public Central Teaching Clinical Hospital, Warsaw, Poland
| | - M Krawczyk
- Department of Medicine II, Saarland University Medical Center, Homburg, Germany; Laboratory of Metabolic Liver Diseases, Center for Preclinical Research, Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - G Niewinski
- II Department of Anaesthesiology and Intensive Care, Medical University of Warsaw, Warsaw, Poland
| | - M Galas
- 1st Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - M Krawczyk
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - K Zieniewicz
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - P Milkiewicz
- Liver and Internal Medicine Unit, Department of General, Transplant, and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - G Opolski
- 1st Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
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Jain T, Thanseer NTK, Sood A, Parmar M, Bhattacharya A, Mittal B. Scintigraphic findings in end-stage liver disease on Tc-99m sestamibi SPECT/CT myocardial perfusion imaging. J Nucl Cardiol 2018; 25:1051-1052. [PMID: 28374327 DOI: 10.1007/s12350-017-0870-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 03/23/2017] [Indexed: 11/26/2022]
Abstract
Technetium-99m sestamibi myocardial perfusion imaging is commonly employed non-invasive study for evaluation of coronary artery disease; however, incidental extracardiac scintigraphic findings observed may provide additional diagnostic information. The authors present the unusual scintigraphic findings in a case of decompensated liver disease with right hepatic hydrothorax, being planned for orthotopic liver transplant.
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Affiliation(s)
- Tarun Jain
- Department of Nuclear Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - N T K Thanseer
- Department of Nuclear Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ashwani Sood
- Department of Nuclear Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
| | - Madan Parmar
- Department of Nuclear Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Anish Bhattacharya
- Department of Nuclear Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Bhagwant Mittal
- Department of Nuclear Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Muzaffar R, Raslan O, Ahmed F, Goldfarb L, Sterkel B, Osman MM. Incidental Findings on Myocardial Perfusion SPECT Images. J Nucl Med Technol 2017; 45:175-180. [PMID: 28705926 DOI: 10.2967/jnmt.117.195487] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 05/26/2017] [Indexed: 01/10/2023] Open
Affiliation(s)
- Razi Muzaffar
- Division of Nuclear Medicine, Department of Radiology, Saint Louis University, Saint Louis, Missouri; and
| | - Osama Raslan
- Division of Nuclear Medicine, Department of Radiology, Saint Louis University, Saint Louis, Missouri; and
| | - Fatma Ahmed
- Division of Nuclear Medicine, Department of Radiology, Saint Louis University, Saint Louis, Missouri; and
| | - Leonard Goldfarb
- Division of Nuclear Medicine, Department of Radiology, John Cochran VA Medical Center, St. Louis, Missouri
| | - Barbara Sterkel
- Division of Nuclear Medicine, Department of Radiology, John Cochran VA Medical Center, St. Louis, Missouri
| | - Medhat M Osman
- Division of Nuclear Medicine, Department of Radiology, Saint Louis University, Saint Louis, Missouri; and
- Division of Nuclear Medicine, Department of Radiology, John Cochran VA Medical Center, St. Louis, Missouri
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Hogan BJ, Gonsalkorala E, Heneghan MA. Evaluation of coronary artery disease in potential liver transplant recipients. Liver Transpl 2017; 23:386-395. [PMID: 27875636 DOI: 10.1002/lt.24679] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Accepted: 11/08/2016] [Indexed: 12/12/2022]
Abstract
Improvements in the management of patients undergoing liver transplantation (LT) have resulted in a significant increase in survival in recent years. Cardiac disease is now the leading cause of early mortality, and the stress of major surgery, hemodynamic shifts, and the possibilities of hemorrhage or reperfusion syndrome require the recipient to have good baseline cardiac function. The prevalence of coronary artery disease (CAD) is increasing in LT candidates, especially in those with nonalcoholic fatty liver disease. In assessing LT recipients, we suggest a management paradigm of "quadruple assessment" to include (1) history, examination, and electrocardiogram; (2) transthoracic echocardiogram; (3) functional testing; and (4) where appropriate, direct assessment of CAD. The added value of functional testing, such as cardiopulmonary exercise testing, has been shown to be able to predict posttransplant complications independently of the presence of CV disease. This approach gives the assessment team the greatest chance of detecting and preventing complications related to CAD. Liver Transplantation 23 386-395 2017 AASLD.
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Affiliation(s)
- Brian J Hogan
- Institute of Liver Studies, King's College Hospital, National Health Service Foundation Trust, London, UK
| | - Enoka Gonsalkorala
- Institute of Liver Studies, King's College Hospital, National Health Service Foundation Trust, London, UK
| | - Michael A Heneghan
- Institute of Liver Studies, King's College Hospital, National Health Service Foundation Trust, London, UK
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