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Kwon Y, Ahn YJ, Yang J, Kim ES, Choe YH, Lee S, Kim MJ. Long-term outcomes of liver transplantation for biliary atresia and results of policy changes: over 20 years of follow-up experience. Front Pediatr 2024; 11:1242009. [PMID: 38495838 PMCID: PMC10940458 DOI: 10.3389/fped.2023.1242009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 12/26/2023] [Indexed: 03/19/2024] Open
Abstract
Objective Biliary atresia (BA) patients develop chronic liver disease after the Kasai operation and are eventually indicated for liver transplantation (LT). The purposes of this study were to analyze long-term outcomes after LT and risk factors that affect complications to reduce graft failure. Study design Overall, 145 pediatric patients who underwent LT between June 1996 and June 2020 after a diagnosis of BA were included. We performed a retrospective analysis of medical records and evaluated patient and graft survival, cumulative incidence of complications, risk factors, and the results of policy changes. Results Patient and graft survival rates in over 20 years were 95.8% and 91.0%, respectively. Post-transplantation lymphoproliferative disease was frequently observed in the early period of immunosuppression within the first 1-2 years after LT. The incidence of cholangitis and rejection steadily increased over time. Weight-to-portal vein size was evaluated as a risk factor for cholangitis and bile duct strictures (OR = 12.82, p = 0.006 and OR = 16.54, p = 0.015, respectively). When evaluated using 2013 as a reference point, the split graft indication was expanded and the group that received LT after 2013 had a significantly lower survival over time compared with that of the group that received LT before 2013 (p = 0.006). Conclusion This study revealed time differences in prevalence of complications. The evaluation of weight-to-duct or vessel size is a more important factor in considering complications than the graft-to-recipient weight ratio. Survival outcomes may have been altered by a policy change that affects the donor type ratio in transplantation.
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Affiliation(s)
- Yiyoung Kwon
- Department of Pediatrics, Inha University Hospital, Inha University School of Medicine, Incheon, Republic of Korea
| | - Yoon Ji Ahn
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jaehun Yang
- Department of Surgery, Gil Medical Center, Gachon University School of Medicine, Incheon, Republic of Korea
| | - Eun Sil Kim
- Department of Pediatrics, Kangbuk Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yon Ho Choe
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sanghoon Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Mi Jin Kim
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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2
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Cotter TG, Mitchell MC, Patel MJ, Anouti A, Lieber SR, Rich NE, Arab JP, Díaz LA, Louissaint J, Kerr T, Mufti AR, Hanish SI, Vagefi PA, Patel MS, VanWagner LB, Lee WM, O'Leary JG, Singal AG. Racial and Ethnic Disparities in Liver Transplantation for Alcohol-associated Liver Diseases in the United States. Transplantation 2024; 108:225-234. [PMID: 37340542 DOI: 10.1097/tp.0000000000004701] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
BACKGROUND Emerging data suggest disparities exist in liver transplantation (LT) for alcohol-associated liver disease (ALD). As the incidence of ALD increases, we aimed to characterize recent trends in ALD LT frequency and outcomes, including racial and ethnic disparities. METHODS Using United Network for Organ Sharing/Organ Procurement and Transplantation Network data (2015 through 2021), we evaluated LT frequency, waitlist mortality, and graft survival among US adults with ALD (alcohol-associated hepatitis [AH] and alcohol-associated cirrhosis [AAC]) stratified by race and ethnicity. We used adjusted competing-risk regression analysis to evaluate waitlist outcomes, Kaplan-Meier analysis to illustrate graft survival, and Cox proportional hazards modeling to identify factors associated with graft survival. RESULTS There were 1211 AH and 26 526 AAC new LT waitlist additions, with 970 AH and 15 522 AAC LTs performed. Compared with non-Hispanic White patients (NHWs) with AAC, higher hazards of waitlist death were observed for Hispanic (subdistribution hazard ratio [SHR] = 1.23, 95% confidence interval [CI]: 1.16-1.32), Asian (SHR = 1.22, 95% CI:1. 01-1.47), and American Indian/Alaskan Native (SHR = 1.42, 95% CI: 1.15-1.76) candidates. Similarly, significantly higher graft failures were observed in non-Hispanic Black (HR = 1.32, 95% CI: 1.09-1.61) and American Indian/Alaskan Native (HR = 1.65, 95% CI: 1.15-2.38) patients with AAC than NHWs. We did not observe differences in waitlist or post-LT outcomes by race or ethnicity in AH, although analyses were limited by small subgroups. CONCLUSIONS Significant racial and ethnic disparities exist for ALD LT frequency and outcomes in the United States. Compared with NHWs, racial and ethnic minorities with AAC experience increased risk of waitlist mortality and graft failure. Efforts are needed to identify determinants for LT disparities in ALD that can inform intervention strategies.
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Affiliation(s)
- Thomas G Cotter
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Mack C Mitchell
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Mausam J Patel
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Ahmad Anouti
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Sarah R Lieber
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Nicole E Rich
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Juan Pablo Arab
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, ON, Canada
| | - Luis Antonio Díaz
- Departmento de Gastroenterología, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Jeremy Louissaint
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Thomas Kerr
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Arjmand R Mufti
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Steven I Hanish
- Department of Surgery, UT Southwestern Medical Center, Dallas, TX
| | - Parsia A Vagefi
- Department of Surgery, UT Southwestern Medical Center, Dallas, TX
| | - Madhukar S Patel
- Department of Surgery, UT Southwestern Medical Center, Dallas, TX
| | - Lisa B VanWagner
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - William M Lee
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Jacqueline G O'Leary
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Amit G Singal
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
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3
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Cotter TG, Odenwald MA, Perez‐Gutierrez A, Jayant K, DiSabato D, Charlton M, Fung J. Preservation solutions for static cold storage in donation after circulatory death and donation after brain death liver transplantation in the United States. Liver Transpl 2022; 28:1454-1462. [PMID: 35313073 PMCID: PMC9544683 DOI: 10.1002/lt.26457] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/25/2022] [Accepted: 03/15/2022] [Indexed: 01/13/2023]
Abstract
Static cold preservation remains the cornerstone for storing donor livers following procurement; however, the choice between University of Wisconsin solution (UW) and histidine-tryptophan-ketoglutarate solution (HTK) remains controversial. Recent International Liver Transplantation Society (ILTS) guidelines have recommended avoiding HTK for donation after circulatory death (DCD) grafts based on older reports. We studied the latest US adult graft outcomes in three recent eras (2006-2010, 2011-2015, 2016-2020) comparing HTK and UW among 5956 DCD LTs: 3873 (65.0%) used UW and 1944 (32.7%) used HTK. In a total of 82,679 donation after brain death (DBD) liver transplantations (LTs), 63,511 (76.8%) used UW and 15,855 (19.2%) used HTK. The HTK group had higher 1-year and 5-year graft survival rates of 89.7% and 74.3%, respectively, compared with 85.9% and 70.8% in the UW group in the 2016-2020 era (p = 0.005). This difference remained when adjusted for important potential confounders (hazard ratio, 0.78; 95% confidence interval: 0.60, 0.99). There were no differences between groups among DCD LTs in the earlier eras or among DBD LTs in all eras (all p values > 0.05). The latest US data suggest that HTK is at least noninferior to UW for preserving DCD livers. These data support HTK use in DCD LT and contradict ILTS guidance.
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Affiliation(s)
- Thomas G. Cotter
- Division of Digestive and Liver DiseasesUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - Matthew A. Odenwald
- Divison of Gastroenterology and HepatologyThe University of Chicago MedicineChicagoIllinoisUSA
| | - Angelica Perez‐Gutierrez
- Department of SurgerySection of Transplant SurgeryThe University of Chicago MedicineChicagoIllinoisUSA
| | - Kumar Jayant
- Department of SurgerySection of Transplant SurgeryThe University of Chicago MedicineChicagoIllinoisUSA
| | - Diego DiSabato
- Department of SurgerySection of Transplant SurgeryThe University of Chicago MedicineChicagoIllinoisUSA
| | - Michael Charlton
- Divison of Gastroenterology and HepatologyThe University of Chicago MedicineChicagoIllinoisUSA
| | - John Fung
- Department of SurgerySection of Transplant SurgeryThe University of Chicago MedicineChicagoIllinoisUSA
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4
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Model for establishing a new liver transplantation center through mentorship from a university with transplantation expertise. PLoS One 2022; 17:e0266361. [PMID: 35353873 PMCID: PMC8967004 DOI: 10.1371/journal.pone.0266361] [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: 12/19/2021] [Accepted: 03/18/2022] [Indexed: 11/19/2022] Open
Abstract
Background
Setting up new liver transplant (LT) centers is essential for countries with organ shortages. However, good outcomes require experience, because LT learning depends on a high number of surgeries. This study aims to describe how a new center was set up from a partnership between the new center and an experienced one. The step-by-step preparation process, the time needed and the results of the new center are depicted.
Material and methods
The mentoring process lasted 40 months, in which half of the 52 patients included on the transplant list received LT. After the mentorship, a 22-month period was also analyzed, in which 46 new patients were added to the waiting list and nine were operated on.
Results
The 30-day survival rates during (92.3%) and after (66.7%) the partnership were similar to the other LT centers in the same region, as well as the rates of longer periods. The waiting time on the LT list, the characteristics of the donors and the ischemia times did not differ during or after the mentorship.
Conclusion
The partnership between universities is a suitable way to set up LT centers, achieving good results for the institutions and the patients involved.
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5
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The Practice of Retransplantation for Recurrent Alcohol-associated Liver Disease in the United States Is Uncommon With Acceptable Outcomes. Transplant Direct 2022; 8:e1297. [PMID: 35187219 PMCID: PMC8843372 DOI: 10.1097/txd.0000000000001297] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 01/13/2022] [Indexed: 12/26/2022] Open
Abstract
Alcohol-associated liver disease (ALD) is the leading indication for liver transplantation (LT) in the United States. Alcohol use disorder relapse can lead to graft failure and the need for liver retransplantation (re-LT). Despite the rising incidence of LT for ALD, the practice of re-LT for recurrent ALD is not well understood. We aimed to define the practice of re-LT for recurrent ALD during the last 20 y. METHODS Using the US national transplant registry, adults who underwent re-LT for recurrent ALD were compared with LT recipients who died from recurrent ALD and propensity score-matched re-LT recipients with non-ALD indications. All groups had at least 1-y survival of their primary graft. Kaplan-Meier analysis was used to calculate 1- and 5-y survivals. RESULTS Between 2000 and 2020, 74 re-LTs were performed for recurrent ALD (1.0% of all re-LTs). There was an increase in recurrent ALD re-LT practice from 2017 to 2020 versus 2014 to 2016 (20 versus 2). At the time of re-LT, patients with recurrent ALD had a significant decrease in body mass index (median 25.1 versus 28.8 kg/m2; P < 0.001) versus the index LT. Patient and graft survivals were similar between patients who underwent re-LT for ALD and non-ALD (56.4% versus 56.9% 5-y graft survival, P = 0.96; 62.8% versus 59.0% 5-y patient survival, P = 0.58). CONCLUSIONS The practice of re-LT for recurrent ALD is uncommon in the United States. Graft and patient survivals seem to be acceptable and support the occasional practice of re-LT for recurrent ALD should the patient be deemed an appropriate candidate.
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Jose A, Shah SA, Anwar N, Jones CR, Sherman KE, Elwing JM. Pulmonary Vascular Resistance Predicts Mortality and Graft Failure in Transplantation Patients With Portopulmonary Hypertension. Liver Transpl 2021; 27:1811-1823. [PMID: 33964116 PMCID: PMC8573056 DOI: 10.1002/lt.26091] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 04/27/2021] [Accepted: 04/30/2021] [Indexed: 12/13/2022]
Abstract
Portopulmonary hypertension (POPH) is a pulmonary vascular disease associated with significant morbidity and mortality in those with liver disease, conferring a higher mortality in patients awaiting liver transplantation (LT). Although not a transplant indication, patients with POPH can experience significant clinical improvement following LT, and those maintaining a mean pulmonary artery pressure (MPAP) <35mm Hg and a pulmonary vascular resistance (PVR) <5 Woods units (WU) are granted additional listing points to expedite LT. The effect of POPH on posttransplant outcomes such as mortality and graft failure, however, is not well defined. We performed a retrospective cohort study of the US Organ Procurement and Transplantation Network database of all adult patients who underwent LT between January 1, 2006, and December 1, 2020. Using adjusted accelerated failure time models, we examined the relationship between a diagnosis of POPH and outcomes following LT and the relationship between pre-LT hemodynamics and post-LT survival (alive with a functioning graft) in patients with POPH. Compared with those undergoing transplants without exception points, patients with POPH had comparable post-LT survival rates but were significantly more likely to have graft failure. Both pre-LT MPAP and PVR predicted post-LT survival in POPH, with a pre-LT PVR of ≥1.6 WU, more than doubling the hazard for mortality (death or a nonfunctioning graft; coefficient, 2.01; standard error, 0.85; hazard ratio, 2.21; P = 0.02). POPH may confer a significantly higher risk of post-LT graft failure compared with patients with cirrhosis without POPH, and a pre-LT PVR of ≥1.6 WU may predict post-LT survival. Further investigation into the relationship between pre-LT hemodynamics, right ventricular function, and post-LT outcomes of mortality and graft failure in POPH is needed.
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Affiliation(s)
- Arun Jose
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Shimul A Shah
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Nadeem Anwar
- Division of Digestive Diseases, University of Cincinnati, Cincinnati, OH, USA
| | - Courtney R Jones
- Department of Anesthesiology, University of Cincinnati, Cincinnati, OH, USA
| | - Kenneth E Sherman
- Division of Digestive Diseases, University of Cincinnati, Cincinnati, OH, USA
| | - Jean M Elwing
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA
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7
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Sungkar T, Putra A, Lindarto D, Sembiring RJ. Intravenous Umbilical Cord-derived Mesenchymal Stem Cells Transplantation Regulates Hyaluronic Acid and Interleukin-10 Secretion Producing Low-grade Liver Fibrosis in Experimental Rat. Med Arch 2021; 74:177-182. [PMID: 32801431 PMCID: PMC7405996 DOI: 10.5455/medarh.2020.74.177-182] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Introduction: Immunomodulation properties of mesenchymal stem cells have attracted tremendous attention that eventually could regress liver fibrosis process. Aim: The study aims to demonstrate the immunomodulation activities of Umbilical cord-derived Mesenchymal stem cells (UC-MSCs) affecting interleukin-10 (IL-10) and hyaluronic acid (HA) secretion post intraperitoneal injection of CCl4, potent hepatotoxin, induced liver fibrosis among experimental rats. Methods: There were 18 Sprague-Dawley (SD) rats divided into three treatment groups (G1 sham group, G2 untreated liver fibrosis group, and G3 UC-MSCs treated-group) and isolated in Stem Cell and Cancer Research Facility, Semarang, Indonesia. Blood examination was conducted after 3 and 14 days of UC-MSCs transplantation using sandwich based ELISA followed by the histopathological analysis of rat liver tissue. ANOVA and posthoc LSD tests were determined the significance against all groups based on their quantitative measurement. Results: UC-MSCs have been successfully extracted and isolated as well as positive with osteogenic differentiation (Alizarin dye). In further analysis, there were significant mean differences among all groups through the ANOVA test, both IL-10 and HA secretion, concurrent with low-grade liver fibrosis in G3. IL-10 elevates during the early phase of UC-MSCs transplantation, and HA significantly reduced on the 14th day of transplantation, it characterizes the liver fibrosis that has been attenuated. Conclusion: The transplantation of UC-MSCs has given an opportunity for the treatment of a wide range of chronic liver diseases through the immunomodulation properties via its paracrine effects that regulate specific cytokine to suppress fibrosis development.
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Affiliation(s)
- Taufik Sungkar
- Divison of Gastroenterol-hepatology, Department of Internal Medicine, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia
| | - Agung Putra
- Stem Cell And Cancer Research (SCCR), Medical Faculty, Sultan Agung Islamic University (UNISSULA), Semarang, Indonesia.,Department of Pathology, Medical Faculty, Sultan Agung Islamic University (UNISSULA), Semarang, Indonesia
| | - Dharma Lindarto
- Division of Endocrine Metabolic, Department of Internal Medicine, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia
| | - Rosita Juwita Sembiring
- Department of Clinical Pathology, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia
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8
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"Raising HOPE": Improved Outcomes for HIV/HCV-coinfected Liver Transplant Recipients in the Direct-acting Antiviral Era. Transplant Direct 2021; 7:e707. [PMID: 34124343 PMCID: PMC8191686 DOI: 10.1097/txd.0000000000001154] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 03/15/2021] [Indexed: 12/11/2022] Open
Abstract
The 2013 HIV Organ Policy Equity Act has increased liver transplantation (LT) in HIV+ patients; however, transplant centers may remain reluctant to perform LT in HIV/hepatitis C virus (HCV)-coinfected patients due to inferior outcomes. We aimed to assess how direct-acting antivirals (DAAs) have impacted HIV+/HCV+-coinfected LT recipient outcomes.
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9
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van Son J, Stam SP, Gomes-Neto AW, Osté MCJ, Blokzijl H, van den Berg AP, Porte RJ, Bakker SJL, de Meijer VE. Post-transplant obesity impacts long-term survival after liver transplantation. Metabolism 2020; 106:154204. [PMID: 32173406 DOI: 10.1016/j.metabol.2020.154204] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 02/22/2020] [Accepted: 03/11/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Short-term survival after orthotopic liver transplantation (OLT) has improved over the past decades, but long-term survival remains impaired. The effects of obesity on long-term survival after OLT are controversial. Because pre-transplant body mass index (BMI) can be confounded by ascites, we hypothesized that post-transplant BMI at 1 year could predict long-term survival. METHODS A post-hoc analysis was performed of an observational cohort study consisting of adult recipients of a first OLT between 1993 and 2010. Baseline BMI was measured at 1-year post-transplantation to represent a stable condition. Recipients were stratified into normal weight (BMI < 25 kg/m2), overweight (25 ≤ BMI ≤ 30 kg/m2), and obese (BMI > 30 kg/m2). Kaplan-Meier survival analyses were performed with log-rank testing, followed by multivariable Cox proportional hazards regression analysis. RESULTS Out of 370 included recipients, 184 had normal weight, 136 were overweight, and 50 were obese at 1-year post-transplantation. After median follow-up for 12.3 years, 107 recipients had died, of whom 46 (25%) had normal weight, 39 (29%) were overweight, and 22 (44%) were obese (log-rank P = 0.020). Obese recipients had a significantly increased mortality risk compared to normal weight recipients (HR 2.00, 95% CI 1.08-3.68, P = 0.027). BMI was inversely associated with 15 years patient survival (HR 1.08, 95% CI 1.03-1.14, P = 0.001 per kg/m2), independent of age, gender, muscle mass, transplant characteristics, cardiovascular risk factors, kidney- and liver function. CONCLUSION Obesity at 1-year post-transplantation conveys a 2-fold increased mortality risk, which may offer potential for interventional strategies (i.e. dietary advice, lifestyle modification, or bariatric surgery) to improve long-term survival after OLT.
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Affiliation(s)
- Jeffrey van Son
- Department of Surgery, Division of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Suzanne P Stam
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Antonio W Gomes-Neto
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Maryse C J Osté
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Hans Blokzijl
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Aad P van den Berg
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Robert J Porte
- Department of Surgery, Division of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Stephan J L Bakker
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Vincent E de Meijer
- Department of Surgery, Division of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
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10
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Martínez JA, Pacheco S, Bachler JP, Jarufe N, Briceño E, Guerra JF, Benítez C, Wolff R, Barrera F, Arrese M. Accuracy of the BAR score in the prediction of survival after liver transplantation. Ann Hepatol 2020; 18:386-392. [PMID: 31036493 DOI: 10.1016/j.aohep.2019.01.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 12/21/2018] [Accepted: 01/23/2019] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND AIM The Balance of Risk (BAR) Score, a simple scoring system that combines six independent donor and recipient variables to predict outcome after liver transplantation (LT), was validated in a large U.S./European cohort of patients. This study aims to assess the performance of the BAR score to predict survival after liver transplantation and determine the factors associated with short and long-term survival in Latin-American patients. MATERIAL AND METHODS A retrospective cohort study was performed in 194 patients [112 (55.4%) males; mean age 52±14 years] who underwent 202 LT during the period 2003-2015. Demographic, clinical, pathological and surgical variables, as well as mortality and survival rates, were analyzed. The BAR score was investigated through a receiver operating characteristics (ROC) curve with the calculation of the area under the curve (AUC) to evaluate the predictive score power for 3-month, 1 and 5-year mortality in a matched donor-recipient cohort. Youden index was calculated to identify optimal cutoff points. RESULTS The AUC of BAR score in predicting 3-month, 1-year and 5-year mortality were 0.755 (CI95% 0.689-0.812), 0.702 (CI95% 0.634-0.764) and 0.610 (CI95% 0.539-0.678) respectively. The best cut-off point was a BAR score ≥15 points. In the multivariate analysis BAR score <15 was associated with higher survival rates at 3 months and 1 and 5-years. CONCLUSIONS BAR score <15 points is an independent predictor of better short and long-term survival in Latin-American patients undergoing LT. The BAR scoring system has an adequate diagnostic capacity allowing to predict 3 and 12-month mortality.
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Affiliation(s)
- Jorge A Martínez
- Department of Digestive Surgery & Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Región Metropolitana, Chile.
| | - Sergio Pacheco
- Department of Digestive Surgery & Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Región Metropolitana, Chile
| | - Jean P Bachler
- Department of Digestive Surgery & Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Región Metropolitana, Chile
| | - Nicolás Jarufe
- Department of Digestive Surgery & Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Región Metropolitana, Chile
| | - Eduardo Briceño
- Department of Digestive Surgery & Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Región Metropolitana, Chile
| | - Juan F Guerra
- Department of Digestive Surgery & Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Región Metropolitana, Chile
| | - Carlos Benítez
- Department of Digestive Surgery & Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Región Metropolitana, Chile
| | - Rodrigo Wolff
- Department of Digestive Surgery & Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Región Metropolitana, Chile
| | - Francisco Barrera
- Department of Digestive Surgery & Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Región Metropolitana, Chile
| | - Marco Arrese
- Department of Digestive Surgery & Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Región Metropolitana, Chile
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11
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Mark E, Goldsman D, Keskinocak P, Sokol J. Using machine learning to estimate survival curves for patients receiving an increased risk for disease transmission heart, liver, or lung versus waiting for a standard organ. Transpl Infect Dis 2019; 21:e13181. [PMID: 31541522 PMCID: PMC9285951 DOI: 10.1111/tid.13181] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 08/13/2019] [Accepted: 09/15/2019] [Indexed: 12/22/2022]
Abstract
Introduction Over 19% of deceased organ donors are labeled increased risk for disease transmission (IRD) for viral blood‐borne disease transmission. Many potential organ recipients need to decide between accepting an IRD organ offer and waiting for a non–IRD organ. Methods Using machine learning and simulation, we built transplant and waitlist survival models and compared the survival for patients accepting IRD organ offers or waiting for non–IRD organs for the heart, liver, and lung. The simulation consisted of generating 20 000 different scenarios of a recipient either receiving an IRD organ or waiting and receiving a non–IRD organ. Results In the simulations, the 5‐year survival probabilities of heart, liver, and lung recipients who accepted IRD organ offers increased on average by 10.2%, 12.7%, and 7.2%, respectively, compared with receiving a non–IRD organ after average wait times (190, 228, and 223 days, respectively). When the estimated waitlist time was at least 5 days for the liver, and 1 day for the heart and lung, 50% or more of the simulations resulted in a higher chance of 5‐year survival when the patient received an IRD organ versus when the patient remained on the waitlist. We also developed a simple equation to estimate the benefits, in terms of 5‐year survival probabilities, of receiving an IRD organ versus waiting for a non–IRD organ, for a particular set of recipient/donor characteristics. Conclusion For all three organs, the majority of patients are predicted to have higher 5‐year survival accepting an IRD organ offer compared with waiting for a non–IRD organ.
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Affiliation(s)
- Ethan Mark
- H. Milton Stewart School of Industrial and Systems Engineering Georgia Institute of Technology Atlanta GA USA
| | - David Goldsman
- H. Milton Stewart School of Industrial and Systems Engineering Georgia Institute of Technology Atlanta GA USA
| | - Pinar Keskinocak
- H. Milton Stewart School of Industrial and Systems Engineering Georgia Institute of Technology Atlanta GA USA
| | - Joel Sokol
- H. Milton Stewart School of Industrial and Systems Engineering Georgia Institute of Technology Atlanta GA USA
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12
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Stam SP, Osté MCJ, Eisenga MF, Blokzijl H, van den Berg AP, Bakker SJL, de Meijer VE. Posttransplant muscle mass measured by urinary creatinine excretion rate predicts long-term outcomes after liver transplantation. Am J Transplant 2019; 19:540-550. [PMID: 29745020 PMCID: PMC6585633 DOI: 10.1111/ajt.14926] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 03/30/2018] [Accepted: 04/29/2018] [Indexed: 01/25/2023]
Abstract
Long-term survival in orthotopic liver transplant (OLT) recipients remains impaired because of many contributing factors, including a low pretransplant muscle mass (or sarcopenia). However, influence of posttransplant muscle mass on survival is currently unknown. We hypothesized that posttransplant urinary creatinine excretion rate (CER), an established noninvasive marker of total body muscle mass, is associated with long-term survival after OLT. In a single-center cohort study of 382 adult OLT recipients, mean ± standard deviation CER at 1 year posttransplantation was 13.3 ± 3.7 mmol/24 h in men and 9.4 ± 2.6 mmol/24 h in women. During median follow-up for 9.8 y (interquartile range 6.4-15.0 y), 104 (27.2%) OLT recipients died and 44 (11.5%) developed graft failure. In Cox regression analyses, as continuous variable, low CER was associated with increased risk for mortality (HR = 0.43, 95% CI: 0.26-0.71, P = .001) and graft failure (HR = 0.42, 95% CI: 0.20-0.90, P = .03), independent of age, sex, and body surface area. Similarly, OLT recipients in the lowest tertile had an increased risk for mortality (HR = 2.69; 95% CI: 1.47-4.91, P = .001) and graft failure (HR = 2.77, 95% CI: 1.04-7.39, P = .04), compared to OLT recipients in the highest tertile. We conclude that 1 year posttransplant low total body muscle mass is associated with long-term risk of mortality and graft failure in OLT recipients.
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Affiliation(s)
- Suzanne P. Stam
- Division of NephrologyDepartment of Internal MedicineUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Maryse C. J. Osté
- Division of NephrologyDepartment of Internal MedicineUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Michele F. Eisenga
- Division of NephrologyDepartment of Internal MedicineUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Hans Blokzijl
- Department of Gastroenterology and HepatologyUniversity Medical Center GroningenGroningenThe Netherlands
| | - Aad P. van den Berg
- Department of Gastroenterology and HepatologyUniversity Medical Center GroningenGroningenThe Netherlands
| | - Stephan J. L. Bakker
- Division of NephrologyDepartment of Internal MedicineUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Vincent E. de Meijer
- Division of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
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13
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GABA, γ-Aminobutyric Acid, Protects Against Severe Liver Injury. J Surg Res 2018; 236:172-183. [PMID: 30694753 DOI: 10.1016/j.jss.2018.11.047] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 11/01/2018] [Accepted: 11/21/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Acute liver failure (ALF) from severe acute liver injury is a critical condition associated with high mortality. The purpose of this study was to investigate the impact of preemptive administration of γ-aminobutyric acid (GABA) on hepatic injury and survival outcomes in mice with experimentally induced ALF. MATERIALS AND METHODS To induce ALF, C57BL/6NHsd mice were administered GABA, saline, or nothing for 7 d, followed by intraperitoneal administration of 500 μg of tumor necrosis factor α and 20 mg of D-galactosamine. The study mice were humanely euthanized 4-5 h after ALF was induced or observed for survival. Proteins present in the blood samples and liver tissue from the euthanized mice were analyzed using Western blot and immunohistochemical and histopathologic analyses. For inhibition studies, we administered the STAT3-specific inhibitor, NSC74859, 90 min before ALF induction. RESULTS We found that GABA-treated mice had substantial attenuation of terminal deoxynucleotidyl transferase dUTP nick end labeling-positive hepatocytes and hepatocellular necrosis, decreased caspase-3, H2AX, and p38 MAPK protein levels and increased expressions of Jak2, STAT3, Bcl-2, and Mn-SOD, with improved mitochondrial integrity. The reduced apoptotic proteins led to a significantly prolonged survival after ALF induction in GABA-treated mice. The STAT3-specific inhibitor NSC74859 eliminated the survival advantage in GABA-treated mice with ALF, indicating the involvement of the STAT3 pathway in GABA-induced reduction in apoptosis. CONCLUSIONS Our results showed that preemptive treatment with GABA protected against severe acute liver injury in mice via GABA-mediated STAT3 signaling. Preemptive administration of GABA may be a useful approach to optimize marginal donor livers before transplantation.
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14
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McCabe P, Wong RJ. More severe deficits in functional status associated with higher mortality among adults awaiting liver transplantation. Clin Transplant 2018; 32:e13346. [PMID: 29979466 DOI: 10.1111/ctr.13346] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 06/09/2018] [Accepted: 07/04/2018] [Indexed: 01/23/2023]
Abstract
The impact of functional status on liver transplant (LT) waitlist outcomes is not well studied. Early evidence suggests frailty portends increased mortality. We aim to evaluate the association of functional status with LT waitlist survival and the probability of receiving LT among adults with cirrhosis. Using 2005-2016 United Network for Organ Sharing (UNOS) data, we retrospectively assessed the association of functional status, as determined by Karnofsky Performance Status Score (KPSS) with LT waitlist survival and the probability of receiving LT using Kaplan-Meier and multivariate Cox proportional hazard models. Among 118 954 patients listed for LT, patients with worse Karnofsky scores, indicating poor functional status, were progressively more likely to receive liver transplantation compared to patients with better scores, with the most functionally disabled group having 68% higher probability of receiving LT (HR 1.68; 95% CI 1.61-1.75, P < 0.001). Worse functional status was associated with increased waitlist mortality, with the most functionally disabled group 97% more likely to die on the waitlist (HR 1.97; 95% CI 1.81-2.16, P < 0.001). In conclusion, among patients awaiting LT, worse functional status was associated with significantly higher waitlist mortality.
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Affiliation(s)
- Patrick McCabe
- Department of Medicine, Division of Gastroenterology and Hepatology, California Pacific Medical Center, San Francisco, California
| | - Robert J Wong
- Division of Gastroenterology and Hepatology, Alameda Health System - Highland Hospital, Oakland, California
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15
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Arumugam S, Girish Subbiah K, Kemparaju K, Thirunavukkarasu C. Neutrophil extracellular traps in acrolein promoted hepatic ischemia reperfusion injury: Therapeutic potential of NOX2 and p38MAPK inhibitors. J Cell Physiol 2017; 233:3244-3261. [PMID: 28884828 DOI: 10.1002/jcp.26167] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 08/24/2017] [Indexed: 12/24/2022]
Abstract
Neutrophil is a significant contributor to ischemia reperfusion (IR) induced liver tissue damage. However, the exact role of neutrophils in IR induced innate immune activation and liver damage is not quite clear. Our study sheds light on the role of chronic oxidative stress end products in worsening the IR inflammatory process by neutrophil recruitment and activation following liver surgery. We employed specific inhibitors for molecular targets-NOX2 (NADPH oxidase 2) and P38 MAPK (Mitogen activated protein kinase) signal to counteract neutrophil activation and neutrophil extracellular trap (NET) release induced liver damage in IR injury. We found that acrolein initiated neutrophil chemotaxis and induced NET release both in vitro and in vivo. Acrolein exposure caused NET induced nuclear and mitochondrial damage in HepG2 cells as well as aggravated the IR injury in rat liver. Pretreatment with F-apocynin and naringin, efficiently suppressed acrolein induced NET release in vitro. Notably, it suppressed the expression of inflammatory cytokines, P38MAPK-ERK activation, and apoptotic signals in rat liver exposed to acrolein and subjected to IR. Moreover, this combination effectively attenuated acrolein induced NET release and hepatic IR injury. In the current study we have shown that the acrolein accumulation in liver due to chronic stress, is responsible for neutrophil recruitment and its activation leading to NET induced liver damage during surgery. Our study shows that therapeutic targeting of NOX2 and P38MAPK signaling in patients with chronic hepatic disorders would improve post operative hepatic function and survival.
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Affiliation(s)
- Suyavaran Arumugam
- Department of Biochemistry and Molecular Biology, School of life sciences, Pondicherry University, Pondicherry, India
| | | | | | - Chinnasamy Thirunavukkarasu
- Department of Biochemistry and Molecular Biology, School of life sciences, Pondicherry University, Pondicherry, India
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16
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Levesque E, Winter A, Noorah Z, Daurès JP, Landais P, Feray C, Azoulay D. Impact of acute-on-chronic liver failure on 90-day mortality following a first liver transplantation. Liver Int 2017; 37:684-693. [PMID: 28052486 DOI: 10.1111/liv.13355] [Citation(s) in RCA: 114] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 12/10/2016] [Indexed: 02/13/2023]
Abstract
BACKGROUND Acute-on-chronic liver failure (ACLF) is associated with a significant short-term mortality rate (23%-74%), depending on the number of organ failures. Some patients present with ACLF at the time of liver transplantation (LT). The aim of this study was to assess whether ACLF was also a prognostic factor after LT and, if applicable, to construct a score that could predict 90-day mortality. METHODS Three hundred and fifty cirrhotic patients, who underwent LT between January 2008 and December 2013, were enrolled. We used ACLF grades according to EASL-CLIF consortium criteria to categorize the cirrhotic patients. A propensity score was applied with an Inverse Probability Treatment Weighting in a Cox model. A predictive score of early mortality after LT was generated. RESULTS One hundred and forty patients (40%) met the criteria for ACLF. The overall mortality rate at 90 days post-transplant was 10.6% (37/350 patients). ACLF at the time of LT (HR: 5.78 [3.42-9.77], P<.001) was an independent predictor of 90-day mortality. Infection occurring during the month before LT, high recipient age and male recipient, the reason for LT and a female donor were also independent risk factors for early mortality. Using these factors, we have proposed a model to predict 90-day mortality after LT. CONCLUSIONS LT is feasible in cirrhotic patients with ACLF. However, we have shown that ACLF is a significant and independent predictor of 90-day mortality. We propose a score that can identify candidate cirrhotic patients in whom LT might be associated with futile LT.
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Affiliation(s)
- Eric Levesque
- Department of Anaesthesia and Surgical Intensive Care - Liver ICU, AP-HP Henri Mondor Hospital, Créteil, France.,INSERM, Unité U955, Créteil, France
| | - Audrey Winter
- UPRES EA 2415 Department of Biostatistics, Clinical Research University Institute, Montpellier University, Montpellier, France.,Beau Soleil Clinic, Languedoc Mutualité, Montpellier, France
| | - Zaid Noorah
- Department of Anaesthesia and Surgical Intensive Care - Liver ICU, AP-HP Henri Mondor Hospital, Créteil, France
| | - Jean-Pierre Daurès
- UPRES EA 2415 Department of Biostatistics, Clinical Research University Institute, Montpellier University, Montpellier, France.,Beau Soleil Clinic, Languedoc Mutualité, Montpellier, France
| | - Paul Landais
- UPRES EA 2415 Department of Biostatistics, Clinical Research University Institute, Montpellier University, Montpellier, France.,Department of Biostatistics, Epidemiology, Public Health and Medical Information, University Hospital, Nîmes, France
| | - Cyrille Feray
- Department of Hepatology, AP-HP Henri Mondor Hospital, Créteil, France
| | - Daniel Azoulay
- INSERM, Unité U955, Créteil, France.,Digestive Surgery and Liver Transplant Unit, AP-HP Henri Mondor Hospital, Créteil, France
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17
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Suyavaran A, Thirunavukkarasu C. Preconditioning methods in the management of hepatic ischemia reperfusion- induced injury: Update on molecular and future perspectives. Hepatol Res 2017; 47:31-48. [PMID: 26990696 DOI: 10.1111/hepr.12706] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 02/12/2016] [Accepted: 03/11/2016] [Indexed: 12/14/2022]
Abstract
Hepatic IR (ischemia reperfusion) injury is a commonly encountered obstacle in the post-operative management of hepatic surgery. Hepatic IR occurs during 'Pringle maneuver' for reduction of blood loss or during a brief period of cold storage followed by reperfusion of liver grafts. The stress induced during hepatic IR, triggers a spectrum of cellular responses leading to the varying degrees of hepatic complications which in turn affect the post operative care. Different preconditioning methods either activate or subdue different sets of molecular signals, resulting in varied levels of protection against hepatic IR injury. Yet, there is a serious lacuna in the knowledge regarding the choice of preconditioning methods and the resulting molecular changes in order to assess the efficiency and choice of these methods correctly. This review provides an update on the various preconditioning approaches such as surgical/ischemic, antioxidant, pharmaceutical and genetic preconditioning strategies published during last six years (2009-2015). Further, we discuss the attenuation or inhibition of specific inflammatory, apoptotic and necrotic markers in the various experimental models of liver IR subjected to different preconditioning strategies. While enlisting the controversies in the ischemic preconditioning strategy, we bring out the uncertainties in the existing molecular targets and their reliability in the attenuation of hepatic IR injury. Future research studies would include the novel preconditioning strategies employ i) the targeted gene silencing of key molecular targets inducing IR, ii) hyper expression of beneficial molecular signals against IR via gene transfer techniques. The above studies would see the combination of these latest techniques with the established preconditioning strategies for better post-operative hepatic management.
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Affiliation(s)
- Arumugam Suyavaran
- Department of Biochemistry and Molecular Biology, Pondicherry University, Puducherry, India
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18
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Rogal S, Mankaney G, Udawatta V, Good CB, Chinman M, Zickmund S, Bielefeldt K, Jonassaint N, Jazwinski A, Shaikh O, Hughes C, Humar A, DiMartini A, Fine MJ. Association between opioid use and readmission following liver transplantation. Clin Transplant 2016; 30:1222-1229. [PMID: 27409580 DOI: 10.1111/ctr.12806] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2016] [Indexed: 12/21/2022]
Abstract
The aim of this study was to assess the independent association between pre-transplant prescription opioid use and readmission following liver transplantation. We reviewed the medical records of all patients at a single medical center undergoing primary, single-organ, liver transplantation from 2004 to 2014. We assessed factors associated with hospital readmission 30 days and 1 year after hospital discharge using multivariable competing risk regression models. Among 1056 transplant recipients, 49 (4.6%) were prescribed pre-transplant prescription opioids. Readmission occurred in 421 (40%) patients within 30 days and 689 (65%) within 1 year. Patients with pre-transplant opioid use had a significantly higher risk of readmission at 30 days (HR 1.7; 95% CI 1.1-2.5) and a non-significantly elevated risk at 1 year (HR 1.4; 95% CI 1.0-1.9) when controlling for other potential confounders. Although pain was the major reason for readmission in only 12 (3%) patients at 30 days and 33 (6%) patients at 1 year, pre-transplant opioid use was significantly associated with pain-related readmission at both time points. In conclusion, prescription opioid use pre-transplantation was significantly associated with all-cause 30-day readmissions and pain-related readmissions at 30 days and 1 year.
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Affiliation(s)
- Shari Rogal
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA. .,Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. .,Division of Gastroenterology, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA. .,Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Gautham Mankaney
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Viyan Udawatta
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Chester B Good
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.,Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Matthew Chinman
- VISN 4 Mental Illness Research and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.,RAND Corporation, Pittsburgh, PA, USA
| | - Susan Zickmund
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.,Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Klaus Bielefeldt
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Naudia Jonassaint
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alison Jazwinski
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Obaid Shaikh
- Division of Gastroenterology, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.,Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Christopher Hughes
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Abhinav Humar
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Andrea DiMartini
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Michael J Fine
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.,Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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19
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Kang G, Lee I, Ahn K, Kim J, Kwak S, Choi D. One-Year Follow-up of the Changes in Renal Function After Liver Transplantation in Patients Without Chronic Kidney Disease. Transplant Proc 2016; 48:1190-3. [DOI: 10.1016/j.transproceed.2016.02.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2015] [Revised: 01/25/2016] [Accepted: 02/01/2016] [Indexed: 12/13/2022]
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