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Moghe A, McGuire BM, Levy C. Acute hepatic porphyrias - a guide for Hepatologists. Hepatology 2024:01515467-990000000-00836. [PMID: 38607698 DOI: 10.1097/hep.0000000000000880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 03/17/2024] [Indexed: 04/14/2024]
Abstract
The acute hepatic porphyrias (AHPs) are a group of rare, inherited disorders of the heme biosynthesis pathway, usually manifesting with attacks of acute abdominal pain and other neurovisceral symptoms, with or without cutaneous manifestations. AHP are characterized by the accumulation of porphyrin precursors, porphobilinogen (PBG) and/or aminolevulinic acid (ALA), in the blood. The diagnosis is often missed or delayed due to both inadequate testing and the improper use of available laboratory tests. In this review, we describe the various clinical presentations of the four AHPs, elucidate the approach to diagnosis, and provide recommendations for immediate as well as long-term management. We also describe the different complications that can occur with long-standing AHP, including the development of hepatocellular carcinoma. The AHPs are very treatable conditions, with excellent outcomes if diagnosed and treated early. A high index of suspicion for the presence of these disorders along with accurate testing and timely treatment will help reduce the burden of disease and prevent irreversible complications in patients with AHP.
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Affiliation(s)
- Akshata Moghe
- Department of Internal Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Texas Health Science Center at Houston, Houston, Texas
| | - Brendan M McGuire
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Cynthia Levy
- Department of Medicine, Division of Digestive Health and Liver Diseases, University of Miami, Miami, Florida
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2
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Arif-Tiwari H, Porter KK, Kamel IR, Bashir MR, Fung A, Kaplan DE, McGuire BM, Russo GK, Smith EN, Solnes LB, Thakrar KH, Vij A, Wahab SA, Wardrop RM, Zaheer A, Carucci LR. ACR Appropriateness Criteria® Abnormal Liver Function Tests. J Am Coll Radiol 2023; 20:S302-S314. [PMID: 38040457 DOI: 10.1016/j.jacr.2023.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 08/22/2023] [Indexed: 12/03/2023]
Abstract
Liver function tests are commonly obtained in symptomatic and asymptomatic patients. Various overlapping lab patterns can be seen due to derangement of hepatocytes and bile ducts function. Imaging tests are pursued to identify underlying etiology and guide management based on the lab results. Liver function tests may reveal mild, moderate, or severe hepatocellular predominance and can be seen in alcoholic and nonalcoholic liver disease, acute hepatitis, and acute liver injury due to other causes. Cholestatic pattern with elevated alkaline phosphatase with or without elevated γ-glutamyl transpeptidase can be seen with various causes of obstructive biliopathy. Acute or subacute cholestasis with conjugated or unconjugated hyperbilirubinemia can be seen due to prehepatic, intrahepatic, or posthepatic causes. We discuss the initial and complementary imaging modalities to be used in clinical scenarios presenting with abnormal liver function tests. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
- Hina Arif-Tiwari
- University of Arizona, Banner University Medical Center, Tucson, Arizona.
| | | | - Ihab R Kamel
- Panel Chair, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Alice Fung
- Oregon Health & Science University, Portland, Oregon
| | - David E Kaplan
- Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania; American Association for the Study of Liver Diseases
| | - Brendan M McGuire
- University of Alabama at Birmingham, Birmingham, Alabama, Primary care physician
| | | | - Elainea N Smith
- University of Alabama at Birmingham Medical Center, Birmingham, Alabama
| | - Lilja Bjork Solnes
- Johns Hopkins Bayview Medical Center, Baltimore, Maryland; Commission on Nuclear Medicine and Molecular Imaging
| | | | - Abhinav Vij
- New York University Langone Medical Center, New York, New York
| | - Shaun A Wahab
- University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Richard M Wardrop
- Cleveland Clinic, Cleveland, Ohio; American College of Physicians, Hospital Medicine
| | | | - Laura R Carucci
- Specialty Chair, Virginia Commonwealth University Medical Center, Richmond, Virginia
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3
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Russo GK, Zaheer A, Kamel IR, Porter KK, Archer-Arroyo K, Bashir MR, Cash BD, Fung A, McCrary M, McGuire BM, Shih RD, Stowers J, Thakrar KH, Vij A, Wahab SA, Zukotynski K, Carucci LR. ACR Appropriateness Criteria® Right Upper Quadrant Pain: 2022 Update. J Am Coll Radiol 2023; 20:S211-S223. [PMID: 37236744 DOI: 10.1016/j.jacr.2023.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 02/27/2023] [Indexed: 05/28/2023]
Abstract
Acute right upper quadrant pain is one of the most common presenting symptoms in hospital emergency departments, as well as outpatient settings. Although gallstone-related acute cholecystitis is a leading consideration in diagnosis, a myriad of extrabiliary sources including hepatic, pancreatic, gastroduodenal, and musculoskeletal should also be considered. This document focuses on the diagnostic accuracy of imaging studies performed specifically to evaluate acute right upper quadrant pain, with biliary etiologies including acute cholecystitis and its complications being the most common. An additional consideration of extrabiliary sources such as acute pancreatitis, peptic ulcer disease, ascending cholangitis, liver abscess, hepatitis, and painful liver neoplasms remain a diagnostic consideration in the right clinical setting. The use of radiographs, ultrasound, nuclear medicine, CT, and MRI for these indications are discussed. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | | | - Ihab R Kamel
- Panel Chair, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kristin K Porter
- Panel Vice-Chair, University of Alabama Medical Center, Birmingham, Alabama; Council Steering Committee, ACR
| | | | | | - Brooks D Cash
- University of Texas Health Science Center at Houston and McGovern Medical School, Houston, Texas; American Gastroenterological Association
| | - Alice Fung
- Oregon Health & Science University, Portland, Oregon; Liver Reporting & Data System Technique Working Group
| | - Marion McCrary
- Duke Signature Care, Durham, North Carolina; American College of Physicians
| | - Brendan M McGuire
- University of Alabama at Birmingham, Birmingham, Alabama; Primary care physician
| | - Richard D Shih
- Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida; American College of Emergency Physicians
| | - John Stowers
- Oregon Health & Science University, Portland, Oregon; American College of Surgeons
| | | | - Abhinav Vij
- New York University Langone Medical Center, New York, New York
| | - Shaun A Wahab
- University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Katherine Zukotynski
- McMaster University, Hamilton, Ontario, Canada; Commission on Nuclear Medicine and Molecular Imaging
| | - Laura R Carucci
- Specialty Chair, Virginia Commonwealth University Medical Center, Richmond, Virginia
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4
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Orandi BJ, McLeod MC, MacLennan PA, Lee WM, Fontana RJ, Karvellas CJ, McGuire BM, Lewis CE, Terrault NM, Locke JE. Association of FDA Mandate Limiting Acetaminophen (Paracetamol) in Prescription Combination Opioid Products and Subsequent Hospitalizations and Acute Liver Failure. JAMA 2023; 329:735-744. [PMID: 36881033 PMCID: PMC9993184 DOI: 10.1001/jama.2023.1080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 01/31/2023] [Indexed: 03/08/2023]
Abstract
Importance In January 2011, the US Food and Drug Administration (FDA) announced a mandate to limit acetaminophen (paracetamol) to 325 mg/tablet in combination acetaminophen and opioid medications, with manufacturer compliance required by March 2014. Objective To assess the odds of hospitalization and the proportion of acute liver failure (ALF) cases with acetaminophen and opioid toxicity prior to and after the mandate. Design, Setting, and Participants This interrupted time-series analysis used hospitalization data from 2007-2019 involving ICD-9/ICD-10 codes consistent with both acetaminophen and opioid toxicity from the National Inpatient Sample (NIS), a large US hospitalization database, and ALF cases from 1998-2019 involving acetaminophen and opioid products from the Acute Liver Failure Study Group (ALFSG), a cohort of 32 US medical centers. For comparison, hospitalizations and ALF cases consistent with acetaminophen toxicity alone were extracted from the NIS and ALFSG. Exposures Time prior to and after the FDA mandate limiting acetaminophen to 325 mg in combination acetaminophen and opioid products. Main Outcomes and Measures Odds of hospitalization involving acetaminophen and opioid toxicity and percentage of ALF cases from acetaminophen and opioid products prior to and after the mandate. Results In the NIS, among 474 047 585 hospitalizations from Q1 2007 through Q4 2019, there were 39 606 hospitalizations involving acetaminophen and opioid toxicity; 66.8% of cases were among women; median age, 42.2 (IQR, 28.4-54.1). In the ALFSG, from Q1 1998 through Q3 2019, there were a total of 2631 ALF cases, of which 465 involved acetaminophen and opioid toxicity; 85.4% women; median age, 39.0 (IQR, 32.0-47.0). The predicted incidence of hospitalizations 1 day prior to the FDA announcement was 12.2 cases/100 000 hospitalizations (95% CI, 11.0-13.4); by Q4 2019, it was 4.4/100 000 hospitalizations (95% CI, 4.1-4.7) (absolute difference, 7.8/100 000 [95% CI, 6.6-9.0]; P < .001). The odds of hospitalizations with acetaminophen and opioid toxicity increased 11%/y prior to the announcement (odds ratio [OR], 1.11 [95% CI, 1.06-1.15]) and decreased 11%/y after the announcement (OR, 0.89 [95% CI, 0.88-0.90]). The predicted percentage of ALF cases involving acetaminophen and opioid toxicity 1 day prior to the FDA announcement was 27.4% (95% CI, 23.3%-31.9%); by Q3 2019, it was 5.3% (95% CI, 3.1%-8.8%) (absolute difference, 21.8% [95% CI, 15.5%-32.4%]; P < .001). The percentage of ALF cases involving acetaminophen and opioid toxicity increased 7% per year prior to the announcement (OR, 1.07 [95% CI, 1.03-1.1]; P < .001) and decreased 16% per year after the announcement (OR, 0.84 [95% CI, 0.77-0.92]; P < .001). Sensitivity analyses confirmed these findings. Conclusions and Relevance The FDA mandate limiting acetaminophen dosage to 325 mg/tablet in prescription acetaminophen and opioid products was associated with a statistically significant decrease in the yearly rate of hospitalizations and proportion per year of ALF cases involving acetaminophen and opioid toxicity.
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Affiliation(s)
- Babak J. Orandi
- University of Alabama at Birmingham Heersink School of Medicine
- Joan & Sanford Weill Medical College of Cornell University, New York, New York
| | | | | | - William M. Lee
- University of Texas Southwestern Medical Center at Dallas
| | | | | | | | - Cora E. Lewis
- University of Alabama at Birmingham School of Public Health
| | - Norah M. Terrault
- University of Southern California Keck School of Medicine, Los Angeles
| | - Jayme E. Locke
- University of Alabama at Birmingham Heersink School of Medicine
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5
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Rao A, Rule JA, Cerro-Chiang G, Stravitz RT, McGuire BM, Lee G, Fontana RJ, Lee WM. Role of Hepatitis C Infection in Acute Liver Injury/Acute Liver Failure in North America. Dig Dis Sci 2023; 68:304-311. [PMID: 35546205 PMCID: PMC9094131 DOI: 10.1007/s10620-022-07524-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 04/18/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND While hepatitis A and B are well-known causes of acute liver failure (ALF), few well-documented cases of hepatitis C virus (HCV) infection (absent preexisting liver disease or other liver insults) have been described that result in ALF. We reviewed the Acute Liver Failure Study Group registry for evidence of HCV as a primary or contributing cause to ALF. METHODS From January 1998 to January 2017, 2,332 patients with ALF (INR ≥ 1.5, any degree of hepatic encephalopathy) and 667 with acute liver injury (ALI; INR ≥ 2.0, no hepatic encephalopathy) were enrolled. Anti-HCV testing was done routinely, with confirmatory RT-PCR testing for HCV RNA where necessary. RESULTS A total of 136 patients were anti-HCV-antibody positive, as follows: 56 HCV RNA negative, 65 HCV RNA positive, and 8 with no result nor sera available for testing. Only three subjects with ALI/ALF were determined to represent acute HCV infection. Case 1: 47-year-old female with morbid obesity (BMI 52.4) developed ALF and recovered, experiencing anti-HCV seroconversion. Case 2: 37-year-old female using cocaine presented with ALI and fully recovered. Case 3: 54-year-old female developed ALF requiring transplantation and was anti-HCV negative but viremic prior to transplant experiencing anti-HCV seroconversion thereafter. Among 1636 APAP overdose patients, the 52 with concomitant chronic HCV had higher 3-week mortality than the 1584 without HCV (31% vs 17%, p = 0.01). CONCLUSIONS ALI/ALF solely related to acute hepatitis C infection is very rare. Chronic HCV infection, found in at least 65 (2.2%) of ALI/ALF patients studied, contributed to more severe outcomes in APAP ALI/ALF; ClinicalTrials.gov number, NCT000518440. Trial Registration ClinicalTrials.gov number NCT000518440.
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Affiliation(s)
- Ashwin Rao
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center at Dallas, 5959 Harry Hines Blvd. Ste. 420, Dallas, TX, 75390-8887, USA
| | - Jody A Rule
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center at Dallas, 5959 Harry Hines Blvd. Ste. 420, Dallas, TX, 75390-8887, USA
| | - Giuliana Cerro-Chiang
- Division of Pulmonary Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Richard T Stravitz
- Lee-Hume Transplant Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Brendan M McGuire
- Division of Gastroenterology, University of Alabama, Birmingham, AL, USA
| | - Goo Lee
- Division of Anatomic Pathology, University of Alabama, Birmingham, AL, USA
| | - Robert J Fontana
- Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - William M Lee
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center at Dallas, 5959 Harry Hines Blvd. Ste. 420, Dallas, TX, 75390-8887, USA.
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McGuire BM. Dr. Joseph R. Bloomer: In Remembrance. Hepatology 2022; 75:1352-1353. [PMID: 35274354 DOI: 10.1002/hep.32338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 01/03/2022] [Indexed: 12/08/2022]
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7
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Fontana RJ, Stravitz RT, Durkalski V, Hanje J, Hameed B, Koch D, Ganger D, Olson J, Liou I, McGuire BM, Clasen K, Lee WM. Prognostic Value of the 13 C-Methacetin Breath Test in Adults with Acute Liver Failure and Non-acetaminophen Acute Liver Injury. Hepatology 2021; 74:961-972. [PMID: 33660316 PMCID: PMC10683007 DOI: 10.1002/hep.31783] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 01/08/2021] [Accepted: 02/01/2021] [Indexed: 01/16/2023]
Abstract
BACKGROUND AND AIMS The 13 C-methacetin breath test (MBT) is a noninvasive, quantitative hepatic metabolic function test. The aim of this prospective, multicenter study was to determine the utility of initial and serial 13 C-MBT in predicting 21-day outcomes in adults with acute liver failure (ALF) and non-acetaminophen acute liver injury (ALI). APPROACH AND RESULTS The 13 C-MBT BreathID device (Exalenz Biosciences, Ltd.) provided the percent dose recovery (PDR) for a duration of 60 minutes after administration of 13 C-methacetin solution as the change in exhaled 13 CO2 /12 CO2 compared with pre-ingestion ratio on study days 1, 2, 3, 5, and 7. Results were correlated with 21-day transplant-free survival and other prognostic indices. A total of 280 subjects were screened for enrollment between May 2016 and August 2019. Median age of the 62 enrolled patients with adequate data was 43 years, 79% were Caucasian, 76% had ALF with the remaining 24% having ALI. The mean PDR peak on day 1 or day 2 was significantly lower in nonsurvivors compared with transplant-free survivors (2.3%/hour vs. 9.1%/hour; P < 0.0001). In addition, serial PDR peaks were consistently lower in nonsurvivors versus survivors (P < 0.0001). The area under the receiver operating characteristic curve (AUROC) of the 13 C-MBT in the combined cohort was 0.88 (95% CI: 0.79-0.97) and higher than that provided by King's College (AUROC = 0.70) and Model for End-Stage Liver Disease scores (AUROC = 0.83). The 13 C-MBT was well tolerated with only two gastrointestinal adverse events reported. CONCLUSIONS The 13 C-MBT is a promising tool to estimate the likelihood of hepatic recovery in patients with ALF and ALI. Use of the PDR peak data from the 13 C-MBT point-of-care test may assist with medical decision making and help avoid unnecessary transplantation in critically ill patients with ALF and ALI.
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Affiliation(s)
- Robert J. Fontana
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - R. Todd Stravitz
- Lee-Hume Transplant Center, Virginia Commonwealth University, Richmond, VA
| | - Valerie Durkalski
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - James Hanje
- Department of Medicine, The Ohio State University, Columbus, OH
| | - Bilal Hameed
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - David Koch
- Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Daniel Ganger
- Division of Gastroenterology, Northwestern University, Chicago, IL
| | - Jody Olson
- Division of Gastroenterology, University of Kansas Medical Center, Kansas City, KS
| | - Iris Liou
- Department of Medicine, University of Washington, Seattle, WA
| | | | - Kristen Clasen
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - William M. Lee
- Department of Internal Medicine, University of Texas Southwestern, Dallas, TX
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Fix OK, Blumberg EA, Chang KM, Chu J, Chung RT, Goacher EK, Hameed B, Kaul DR, Kulik LM, Kwok RM, McGuire BM, Mulligan DC, Price JC, Reau NS, Reddy KR, Reynolds A, Rosen HR, Russo MW, Schilsky ML, Verna EC, Ward JW, Fontana RJ. American Association for the Study of Liver Diseases Expert Panel Consensus Statement: Vaccines to Prevent Coronavirus Disease 2019 Infection in Patients With Liver Disease. Hepatology 2021; 74:1049-1064. [PMID: 33577086 PMCID: PMC8014184 DOI: 10.1002/hep.31751] [Citation(s) in RCA: 125] [Impact Index Per Article: 41.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 02/08/2021] [Indexed: 02/06/2023]
Abstract
The aim of this document is to provide a concise scientific review of the currently available COVID-19 vaccines and those in development, including mRNA, adenoviral vectors, and recombinant protein approaches. The anticipated use of COVID-19 vaccines in patients with chronic liver disease (CLD) and liver transplant (LT) recipients is reviewed and practical guidance is provided for health care providers involved in the care of patients with liver disease and LT about vaccine prioritization and administration. The Pfizer and Moderna mRNA COVID-19 vaccines are associated with a 94%-95% vaccine efficacy compared to placebo against COVID-19. Local site reactions of pain and tenderness were reported in 70%-90% of clinical trial participants, and systemic reactions of fever and fatigue were reported in 40%-70% of participants, but these reactions were generally mild and self-limited and occurred more frequently in younger persons. Severe hypersensitivity reactions related to the mRNA COVID-19 vaccines are rare and more commonly observed in women and persons with a history of previous drug reactions for unclear reasons. Because patients with advanced liver disease and immunosuppressed patients were excluded from the vaccine licensing trials, additional data regarding the safety and efficacy of COVID-19 vaccines are eagerly awaited in these and other subgroups. Remarkably safe and highly effective mRNA COVID-19 vaccines are now available for widespread use and should be given to all adult patients with CLD and LT recipients. The online companion document located at https://www.aasld.org/about-aasld/covid-19-resources will be updated as additional data become available regarding the safety and efficacy of other COVID-19 vaccines in development.
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Affiliation(s)
- Oren K Fix
- Elson S. Floyd College of MedicineWashington State UniversitySpokaneWAUSA
| | | | - Kyong-Mi Chang
- University of PennsylvaniaPhiladelphiaPAUSA.,The Corporal Michael J. Crescenz VA Medical CenterPhiladelphiaPAUSA
| | - Jaime Chu
- Icahn School of Medicine at Mount SinaiNew YorkNYUSA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Mark W Russo
- Atrium HealthCarolinas Medical CenterCharlotteNCUSA
| | | | | | - John W Ward
- Coalition for Global Hepatitis EliminationDecaturGAUSA
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Rajasekaran A, Franco RA, Overton ET, McGuire BM, Towns GC, Locke JE, Sawinski DL, Bell EK. Updated Pathway to Micro-elimination of Hepatitis C Virus in the Hemodialysis Population. Kidney Int Rep 2021; 6:1788-1798. [PMID: 34307975 PMCID: PMC8258460 DOI: 10.1016/j.ekir.2021.04.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 02/25/2021] [Accepted: 04/12/2021] [Indexed: 12/19/2022] Open
Abstract
Chronic hepatitis C virus (HCV) infection continues to be transmitted to hemodialysis (HD) patients within HD facilities globally. The goal of the World Health Organization to micro-eliminate HCV infection from the HD population by the year 2030 is not on target to be achieved. Obstacles to eliminate HCV in HD settings remain daunting due to a complex system created by a confluence of guidelines, legislation, regulation, and economics. HCV prevalence remains high and seroconversion continues among the HD patient population globally as a result of the HD procedure. Preventive strategies that effectively prevent HCV transmission, treatment-as-prevention, and rapid referral to treatment balanced with kidney transplant candidacy should be added to the current universal precautions approach. A safer system must be designed before HCV transmission can be halted and eliminated from the HD population.
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Affiliation(s)
- Arun Rajasekaran
- Department of Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ricardo A. Franco
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Edgar T. Overton
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Brendan M. McGuire
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Graham C. Towns
- Department of Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jayme E. Locke
- Comprehensive Transplant Institute, Department of Medicine and Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Deirdre L. Sawinski
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Emmy K. Bell
- Department of Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama, USA
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10
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Saberi B, Naik H, Overbey JR, Erwin AL, Anderson KE, Bissell DM, Bonkovsky HL, Phillips JD, Wang B, K Singal A, M McGuire B, Desnick RJ, Balwani M. Hepatocellular Carcinoma in Acute Hepatic Porphyrias: Results from the Longitudinal Study of the U.S. Porphyrias Consortium. Hepatology 2021; 73:1736-1746. [PMID: 32681675 DOI: 10.1002/hep.31460] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 06/26/2020] [Accepted: 07/01/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIMS The risk for hepatocellular carcinoma (HCC) is increased in acute hepatic porphyrias (AHP). The aim of this study was to explore the clinicopathologic characteristics, outcomes, and frequency of HCC in patients with AHP in the United States. APPROACH AND RESULTS This cross-sectional analysis evaluated patients with HCC in a multicenter, longitudinal study of AHP. Among 327 patients with AHP, 5 (1.5%) were diagnosed with HCC. Of the 5 HCC cases, 4 had acute intermittent porphyria and 1 had variegate porphyria, confirmed by biochemical and/or genetic testing. All patients were white females, with a median age of 27 years (range 21-75) at diagnosis. The median age at HCC diagnosis was 69 years (range 61-74). AHP was asymptomatic in 2 patients; 2 reported sporadic attacks; and 1 reported recurrent attacks (>4 attacks/year). All patients had a single HCC lesion on liver imaging that was 1.8-6.5 centimeters in diameter. Serum alpha fetoprotein levels were below 10 ng/mL in all 4 patients with available results. Four patients underwent liver resection, and 1 was treated with radioembolization. No significant inflammation or fibrosis was found in adjacent liver tissues of 3 patients who underwent liver resection. Two patients developed recurrence of HCC at 22 and 26 months following liver resection. All patients are alive with survival times from HCC diagnosis ranging from 26-153 months. CONCLUSION In this U.S. study, 1.5% of patients with AHP had HCC. HCC in AHP occurred in the absence of cirrhosis, which contrasts with other chronic liver diseases. Patients with AHP, regardless of clinical attacks, should be screened for HCC, beginning at age 50. The pathogenesis of hepatocarcinogenesis in AHP is unknown and needs further investigation.
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Affiliation(s)
- Behnam Saberi
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Hetanshi Naik
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jessica R Overbey
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Karl E Anderson
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, TX
| | | | - Herbert L Bonkovsky
- Section on Gastroenterology and Hepatology, Department of Internal Medicine, Wake Forest/NC Baptist Medical Center, Winston-Salem, NC
| | - John D Phillips
- Department of Internal Medicine, University of Utah, Salt Lake City, UT
| | - Bruce Wang
- Department of Medicine, University of California, San Francisco, CA
| | - Ashwani K Singal
- Department of Internal Medicine, University of South Dakota, Sioux Falls, SD.,Division of Hepatology, Avera Transplant Institute, Sioux Falls, SD
| | | | - Robert J Desnick
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Manisha Balwani
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
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11
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Fix OK, Hameed B, Fontana RJ, Kwok RM, McGuire BM, Mulligan DC, Pratt DS, Russo MW, Schilsky ML, Verna EC, Loomba R, Cohen DE, Bezerra JA, Reddy KR, Chung RT. Clinical Best Practice Advice for Hepatology and Liver Transplant Providers During the COVID-19 Pandemic: AASLD Expert Panel Consensus Statement. Hepatology 2020; 72:287-304. [PMID: 32298473 PMCID: PMC7262242 DOI: 10.1002/hep.31281] [Citation(s) in RCA: 394] [Impact Index Per Article: 98.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 04/13/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND AIMS Coronavirus disease 2019 (COVID-19), the illness caused by the SARS-CoV-2 virus, is rapidly spreading throughout the world. Hospitals and healthcare providers are preparing for the anticipated surge in critically ill patients, but few are wholly equipped to manage this new disease. The goals of this document are to provide data on what is currently known about COVID-19, and how it may impact hepatologists and liver transplant providers and their patients. Our aim is to provide a template for the development of clinical recommendations and policies to mitigate the impact of the COVID-19 pandemic on liver patients and healthcare providers. APPROACH AND RESULTS This article discusses what is known about COVID-19 with a focus on its impact on hepatologists, liver transplant providers, patients with liver disease, and liver transplant recipients. We provide clinicians with guidance for how to minimize the impact of the COVID-19 pandemic on their patients' care. CONCLUSIONS The situation is evolving rapidly, and these recommendations will need to evolve as well. As we learn more about how the COVID-19 pandemic impacts the care of patients with liver disease, we will update the online document available at https://www.aasld.org/about-aasld/covid-19-and-liver.
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Affiliation(s)
| | - Bilal Hameed
- University of California San FranciscoSan FranciscoCA
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12
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Puri P, Lee WM, Fontana RJ, Kim NK, Durkalski V, McGuire BM, Liou I, Pezzia C, Stravitz RT. Alcohol consumption is associated with the severity and outcome of acute liver injury/failure. Liver Int 2020; 40:360-367. [PMID: 31823452 DOI: 10.1111/liv.14327] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 05/25/2019] [Accepted: 07/30/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND & AIMS Non-medical factors which contribute to the severity of acute liver failure (ALF) remain poorly defined. The association of alcohol consumption on the severity of presentation and outcome were determined in patients with ALF and acute liver injury (ALI) in a large, multicentre registry. METHODS Alcohol consumption during the 6 months prior to study entry was analysed in 1170 patients enrolled in the ALF Study Group Registry. Consumption was categorized as none/minimal (<3 alcoholic beverages/week) or at least moderate (≥3/week). Clinical characteristics, the severity of liver injury at presentation (ALI or ALF) and outcome were compared. RESULTS In patients with acetaminophen (APAP) overdose, at least moderate alcohol consumption was associated with higher peak aminotransferases, bilirubin, creatinine and INR on admission, compared to no/minimal consumption. In patients with non-APAP ALI/ALF, at least moderate alcohol consumption was associated with higher peak aminotransferases and creatinine. In APAP, non-APAP or all aetiologies, at least moderate alcohol consumption was associated with a 75%, 89% and 82% higher odds, respectively, of presenting as ALF rather than ALI (all P < .005). At least moderate alcohol consumption increased the odds of death by 45% (P = .01) across all aetiologies. In multivariate analysis, older age, non-Caucasian race, peak INR, peak bilirubin and at least moderate alcohol consumption were significantly associated with death. Finally, in Kaplan-Meier analysis of patients with all aetiologies, at least moderate alcohol consumption was associated with decreased time-dependent survival (P = .002). CONCLUSION Alcohol consumption adversely affects the presentation and outcome of both APAP- and non-APAP-induced ALI/ALF.
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Affiliation(s)
- Puneet Puri
- GI Section, Hunter Holmes McGuire Department of Veterans Affairs Medical Center, Richmond, VA, USA.,Hume-Lee Transplant Center of Virginia Commonwealth University, Richmond, VA, USA
| | - William M Lee
- University of Texas, Southwestern Medical Center, Dallas, TX, USA
| | | | - Nak-Kyeong Kim
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA
| | | | | | - Iris Liou
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Carla Pezzia
- Department of Human and Social Sciences, University of Dallas, Dallas, TX, USA
| | - R Todd Stravitz
- Hume-Lee Transplant Center of Virginia Commonwealth University, Richmond, VA, USA
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13
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Abstract
Drug-induced liver injury (DILI) is an uncommon but significant cause of liver injury and need for liver transplant. DILI in the setting of chronic liver disease (CLD) is poorly understood. Clinical features of patients presenting with DILI in the setting of CLD are similar to those without CLD with the exception of a higher incidence of diabetes among those with CLD and DILI. Diagnosis of DILI in CLD is difficult because there are no objective biomarkers and current causality assessments have not been studied in this population. Differentiating DILI from exacerbation of underlying liver disease is even more challenging.
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Affiliation(s)
- Nicholas A Hoppmann
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, 1720 2nd Ave South, Birmingham AL 35294-0012, USA.
| | - Meagan E Gray
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, 1720 2nd Ave South, Birmingham AL 35294-0012, USA
| | - Brendan M McGuire
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, 1720 2nd Ave South, Birmingham AL 35294-0012, USA
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14
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Harris PS, Hansen RM, Gray ME, Massoud OI, McGuire BM, Shoreibah MG. Hepatocellular carcinoma surveillance: An evidence-based approach. World J Gastroenterol 2019; 25:1550-1559. [PMID: 30983815 PMCID: PMC6452232 DOI: 10.3748/wjg.v25.i13.1550] [Citation(s) in RCA: 120] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 03/09/2019] [Accepted: 03/16/2019] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma (HCC) makes up 75%-85% of all primary liver cancers and is the fourth most common cause of cancer related death worldwide. Chronic liver disease is the most significant risk factor for HCC with 80%-90% of new cases occurring in the background of cirrhosis. Studies have shown that early diagnosis of HCC through surveillance programs improve prognosis and availability of curative therapies. All patients with cirrhosis and high-risk hepatitis B patients are at risk for HCC and should undergo surveillance. The recommended surveillance modality is abdominal ultrasound (US) given that it is cost effective and noninvasive with good sensitivity. However, US is limited in obese patients and those with non-alcoholic fatty liver disease (NAFLD). With the current obesity epidemic and rise in the prevalence of NAFLD, abdominal computed tomography or magnetic resonance imaging may be indicated as the primary screening modality in these patients. The addition of alpha-fetoprotein to a surveillance regimen is thought to improve the sensitivity of HCC detection. Further investigation of serum biomarkers is needed. Semiannual screening is the suggested surveillance interval. Surveillance for HCC is underutilized and low adherence disproportionately affects certain demographics such as non-Caucasian race and low socioeconomic status.
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Affiliation(s)
- Patrick S Harris
- Tinsley Harrison Internal Medicine Residency Program, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL 35294, United States
| | - Ross M Hansen
- Tinsley Harrison Internal Medicine Residency Program, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL 35294, United States
| | - Meagan E Gray
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL 35294, United States
| | - Omar I Massoud
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL 35294, United States
| | - Brendan M McGuire
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL 35294, United States
| | - Mohamed G Shoreibah
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL 35294, United States
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15
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Allamneni C, Alkurdi B, Naseemuddin R, McGuire BM, Shoreibah MG, Eckhoff DE, Peter S. Orthotopic liver transplantation changes the course of gastric antral vascular ectasia: a case series from a transplant center. Eur J Gastroenterol Hepatol 2017; 29:973-976. [PMID: 28520574 DOI: 10.1097/meg.0000000000000908] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND AIM Gastric antral vascular ectasia (GAVE) is an important cause of upper gastrointestinal bleeding and anemia in patients with cirrhosis. The aim of our study was to evaluate the effect of orthotopic liver transplantation (OLT) on GAVE and associated anemia. PATIENTS AND METHODS We performed a chart review and identified all cirrhotic patients with GAVE who underwent OLT at the University Of Alabama at Birmingham between 2005 and 2013. Population's demographics, etiology of cirrhosis, comorbidities, presentation and treatment modalities of GAVE, endoscopic and histopathologic reports, hemoglobin values before and after transplant, and immunosuppressive regimens were collected. RESULTS Twelve patients were identified, mean age 52.4±4.4 years; seven were men (58.3%); 11 (91.7%) were White; and 6 of 12 patients had biopsy-proven GAVE. The most common etiology of cirrhosis in the cohort was chronic hepatitis C and obesity was the most common chronic condition in 50 and 83.3%, respectively. Anemia resolution was observed in 9/12 (75%) patients who underwent OLT with an increase in hemoglobin from 8.1±2.4 (5.7-13.1) before transplant to 12.0±1.4 (10-15) after transplant (P<0.0001). Esophagogastroduodenoscopy after transplant was performed in all 12 (100%) patients. The mean time between transplant and post-OLT esophagogastroduodenoscopy was 13.8±18.28 (2-57) months; complete resolution of GAVE was observed in 10 (83.3%) patients, with resolving GAVE in one (8.3%) patient. CONCLUSION GAVE is an important cause of anemia and upper gastrointestinal bleeding in patients with liver cirrhosis. Our findings show that liver transplantation can resolve GAVE and related anemia.
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Affiliation(s)
- Chaitanya Allamneni
- aDepartment of Medicine, Division of Gastroenterology and Hepatology bDepartment of Surgery, Division of Transplant Surgery cDepartment of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
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16
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White JA, Gray SH, Li P, Simpson HN, McGuire BM, Eckhoff DE, Abdel Aal AMK, Saddekni S, Dubay DA. Current guidelines for chemoembolization for hepatocellular carcinoma: Room for improvement? Hepatol Commun 2017; 1:338-346. [PMID: 29404463 PMCID: PMC5721390 DOI: 10.1002/hep4.1046] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 03/17/2017] [Accepted: 04/12/2017] [Indexed: 12/21/2022] Open
Abstract
Transarterial chemoembolization (TACE) is the most common oncologic therapy used according to the American Association for the Study of Liver Diseases (AASLD) guidelines established in 2005, revised in 2011. The purpose of this study was to determine how AASLD criteria for the management of hepatocellular carcinoma (HCC) have impacted TACE practice in the community. Clinical, demographic, and cause of death information were collected for patients diagnosed with HCC in the 2012 linkage of the Surveillance, Epidemiology, and End Results Medicare database. Propensity score survival analysis was used to compare survival outcomes in patients whose HCC tumor characteristics were less than, met, or were beyond AASLD criteria. The proportion of patients with HCC receiving TACE who met the AASLD‐recommended criteria increased after the 2005 guidelines were published. Up to 17% of patients treated with TACE had tumor characteristics less than the AASLD criteria and were not offered potentially curative therapies. Propensity score matching demonstrated the largest survival advantage in patients with HCC whose tumor characteristics met the AASLD criteria (hazard ratio, 0.42; 95% confidence interval, 0.38‐0.47). A significant survival advantage was also observed in patients with HCC whose tumor characteristics exceeded the AASLD criteria. Conclusion: The AASLD criteria successfully identify a population of patients with HCC that maximally benefit from TACE therapy. However, patients with HCC with tumor characteristics beyond the AASLD criteria also appear to receive a significant survival advantage with TACE. Further studies are necessary to improve referral patterns and appropriate use of chemoembolization in the management of unresectable HCC. (Hepatology Communications 2017;1:338–346)
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Affiliation(s)
| | | | - Peng Li
- University of Alabama at Birmingham, Birmingham, AL
| | | | | | | | | | | | - Derek A Dubay
- Medical University of South Carolina, Charleston, SC
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17
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Ravi S, Axley P, Jones D, Kodali S, Simpson H, McGuire BM, Singal AK. Unusually High Rates of Hepatocellular Carcinoma After Treatment With Direct-Acting Antiviral Therapy for Hepatitis C Related Cirrhosis. Gastroenterology 2017; 152:911-912. [PMID: 28161225 DOI: 10.1053/j.gastro.2016.12.021] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Revised: 12/06/2016] [Accepted: 12/08/2016] [Indexed: 12/23/2022]
Affiliation(s)
- Sujan Ravi
- Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Page Axley
- Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - DeAnn Jones
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Sudha Kodali
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Heather Simpson
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Brendan M McGuire
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ashwani K Singal
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, Alabama
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18
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Karvellas CJ, Tillman H, Leung AA, Lee WM, Schilsky ML, Hameed B, Stravitz RT, McGuire BM, Fix OK. Acute liver injury and acute liver failure from mushroom poisoning in North America. Liver Int 2016; 36:1043-50. [PMID: 26837055 DOI: 10.1111/liv.13080] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 01/25/2016] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Published estimates of survival associated with mushroom (amatoxin)-induced acute liver failure (ALF) and injury (ALI) with and without liver transplant (LT) are highly variable. We aimed to determine the 21-day survival associated with amatoxin-induced ALI (A-ALI) and ALF (A-ALF) and review use of targeted therapies. METHODS Cohort study of all A-ALI/A-ALF patients enrolled in the US ALFSG registry between 01/1998 and 12/2014. RESULTS Of the 2224 subjects in the registry, 18 (0.8%) had A-ALF (n = 13) or A-ALI (n = 5). At admission, ALF patients had higher lactate levels (5.2 vs. 2.2 mm, P = 0.06) compared to ALI patients, but INR (2.8 vs. 2.2), bilirubin (87 vs. 26 μm) and MELD scores (28 vs. 24) were similar (P > 0.2 for all). Of the 13 patients with ALF, six survived without LT (46%), five survived with LT (39%) and two died without LT (15%). Of the five patients with ALI, four (80%) recovered and one (20%) survived post-LT. Comparing those who died/received LT (non-spontaneous survivors [NSS]) with spontaneous survivors (SS), N-acetylcysteine was used in nearly all patients (NSS 88% vs. SS 80%); whereas, silibinin (25% vs. 50%), penicillin (50% vs. 25%) and nasobiliary drainage (0 vs. 10%) were used less frequently (P > 0.15 for all therapies). CONCLUSION Patients with mushroom poisoning with ALI have favourable survival, while around half of those presenting with ALF may eventually require LT. Further study is needed to define optimal management (including the use of targeted therapies) to improve survival, particularly in the absence of LT.
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Affiliation(s)
- Constantine J Karvellas
- Divisions of Hepatology and Critical Care Medicine, University of Alberta, Edmonton, AB, Canada
| | - Holly Tillman
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Alexander A Leung
- Division of Endocrinology and Metabolism, University of Calgary, Calgary, AB, Canada
| | - William M Lee
- Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Michael L Schilsky
- Division of Digestive Diseases and Transplant and Immunology, Yale University School of Medicine, New Haven, CT, USA
| | - Bilal Hameed
- Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, CA, USA
| | - R Todd Stravitz
- Division of Gastroenterology and Hepatology, Virginia Commonwealth University, Richmond, VA, USA
| | - Brendan M McGuire
- Division of Gastroenterology and Hepatology, University of Alabama, Birmingham, AL, USA
| | - Oren K Fix
- Organ Transplant Program, Swedish Medical Center, Seattle, WA, USA
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19
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Hasanin M, Dubay DA, McGuire BM, Schiano T, Singal AK. Liver transplantation for alcoholic hepatitis: A survey of liver transplant centers. Liver Transpl 2015; 21:1449-52. [PMID: 26136401 DOI: 10.1002/lt.24208] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 06/19/2015] [Accepted: 06/28/2015] [Indexed: 02/07/2023]
Affiliation(s)
- Mohsen Hasanin
- Department of Internal Medicine, University of Alabama at Birmingham, Montgomery, AL
| | - Derek A Dubay
- Division of Transplant Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Brendan M McGuire
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, AL
| | - Thomas Schiano
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ashwani K Singal
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, AL
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20
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Abstract
The increasing incidence of hepatocellular carcinoma (HCC) has led to the need to identify patients at risk for HCC so that a program of screening can be undertaken. Screening for HCC has led to earlier diagnosis of tumors and thus has aided in initiating optimal medical treatment earlier in the disease course. Advances in radiological techniques and the identification of more accurate serum tests to diagnose HCC continue to be important areas of study and exploration. In particular, there have been efforts to develop new tumor markers to aid in the diagnosis of HCC and guide therapy of tumors.
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Affiliation(s)
- Heather N Simpson
- The University of Alabama School of Medicine, Department of Medicine, Division of Gastroenterology & Hepatology, Boshell Diabetes Building, 1808 7th Avenue South, Birmingham, AL 35233, USA
| | - Brendan M McGuire
- The University of Alabama School of Medicine, Department of Medicine, Division of Gastroenterology & Hepatology, Boshell Diabetes Building, 1808 7th Avenue South, Birmingham, AL 35233, USA.
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21
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Bansal S, Singal AK, McGuire BM, Anand BS. Impact of all oral anti-hepatitis C virus therapy: A meta-analysis. World J Hepatol 2015; 7:806-813. [PMID: 25914781 PMCID: PMC4404386 DOI: 10.4254/wjh.v7.i5.806] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 02/03/2015] [Accepted: 03/09/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the efficacy, safety, and cost of treatment of direct acting antivirals (DAAs) with and without peg interferon alfa2a (P), and/or ribavirin (R) in treating hepatitis C virus (HCV) genotype 1 patients.
METHODS: MEDLINE was searched for randomized controlled trials (RCT) using DAAs for HCV treatment. Phase 1 trials and studies with investigational drugs on genotype 2 or 3, and on human immunodeficiency virus patients were excluded. Data were pooled for sustained virologic response (SVR), serious adverse effects, and drug discontinuation rate on various treatment arms in trials: P + R; 1st generation DAA (telaprevir or boceprevir) + P + R; 2nd generation DAA (sofosbuvir or simeprevir) + P + R; 2nd generation DAA + R; two 2nd generation DAA + R; and two 2nd gen DAA. Data were analyzed separately for each arm for treatment naive and non-responders (NR) to previous treatment. The cost of treatment with each regimen for achieving one SVR was also compared.
RESULTS: Twenty three RCTs (n = 9354, 62% male, 11% cirrhosis) were analyzed. All oral (P free) regimens with combination of 2 DAA achieved SVR above 95%. The cost of treatment to achieve an SVR with DAA based regimens was lower for NR compared to P+R regimen. However, the cost per SVR remained higher for treatment naive patients.
CONCLUSION: Second generation and emerging DAAs are promising agents in HCV treatment, with a very high level of safety and efficacy. An important drawback is their high cost. However, the present meta-analysis shows that the cost per SVR for non responders (but not for naive patients) was lower compared to P + R. This finding together with the superior safety profile and better compliance makes these drugs highly attractive. It is possible that further reduction in treatment duration may make them even more cost effective.
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22
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Singal AK, Parker C, Bowden C, Thapar M, Liu L, McGuire BM. Liver transplantation in the management of porphyria. Hepatology 2014; 60:1082-9. [PMID: 24700519 PMCID: PMC4498564 DOI: 10.1002/hep.27086] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2013] [Accepted: 02/17/2014] [Indexed: 12/20/2022]
Abstract
UNLABELLED Porphyrias are a group of eight metabolic disorders, each resulting from a mutation that affects an enzyme of the heme biosynthetic pathway. Porphyrias are classified as hepatic or erythropoietic, depending upon the site where the gene defect is predominantly expressed. Clinical phenotypes are classified as follows: (1) acute porphyrias with neurovisceral symptoms: acute intermittent porphyria; delta amino-levulinic acid hydratase deficiency porphyria; hereditary coproporphyria; and variegate porphyria and (2) cutaneous porphyrias with skin blistering and photosensitivity: porphyria cutanea tarda; congenital erythropoietic porphyria; hepatoerythropoietic porphyria and both erythropoietic protoporphyrias: autosomal dominant and X-linked. Liver transplantation (LT) may be needed for recurrent and/or life-threatening acute attack in acute intermittent porphyria or acute liver failure or end-stage chronic liver disease in erythropoietic protoporphyria. LT in acute intermittent porphyria is curative. Erythropoietic protoporphyria patients needing LT should be considered for bone marrow transplantation to achieve cure. CONCLUSION This article provides an overview of porphyria with diagnostic approaches and management strategies for specific porphyrias and recommendations for LT with indications, pretransplant evaluation, and posttransplant management.
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Affiliation(s)
- Ashwani K. Singal
- the Division of Gastroenterology and Hepatology, University of Alabama (UAB), Birmingham, AL
| | - Charles Parker
- Division of Hematology, University of Utah, Salt Lake City, UT
| | | | - Manish Thapar
- Division of Gastroenterology and Hepatology, Drexel University, Philadelphia, PA
| | - Lawrence Liu
- Division of Gastroenterology and Hepatology, Mount Sinai School of Medicine, New York, NY
| | - Brendan M. McGuire
- the Division of Gastroenterology and Hepatology, University of Alabama (UAB), Birmingham, AL
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23
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Abstract
Hepatic encephalopathy (HE) is a broad spectrum of neuropsychiatric manifestations usually affecting individuals with end-stage liver disease. The presence of HE is a poor prognostic sign, with 1-year mortality rates of almost 60%. There is much debate about the underlying mechanisms that result in this syndrome; however, elevated plasma and central nervous system ammonia levels are considered key factors in its pathogenesis. Initial evaluation of the patient presenting with overt HE should include a careful search for predisposing factors, including underlying infection, gastrointestinal (GI) bleeding, electrolyte disturbances, hepatocellular carcinoma, dehydration, hypotension, and excessive use of benzodiazepines, psychoactive drugs, or alcohol. The mainstay of treatment for many years has been nonabsorbable disaccharides, particularly lactulose. Alternative treatments, which usually are second line in patients who do not respond to lactulose, include zinc, antibiotics (neomycin, metronidazole, and rifaximin), ornithine aspartate, sodium benzoate, probiotics, and surgical intervention. Accepted treatments for HE are associated with significant unpleasant side effects, including diarrhea, renal failure, neuropathy, and other GI disturbance. Newer therapies are still in development, and most are awaiting human trials in order to confirm their benefit. These include manganese chelators, L-carnitine, N-methyl-d-aspartate receptor antagonists, blood purification dialysis system, and an intravenous combination of sodium benzoate and phenylacetate.
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Affiliation(s)
- Nader Dbouk
- University of Alabama at Birmingham, Department of Medicine, 1530 Third Avenue South, MCLM 262A, Birmingham, AL 35294-0005, USA.
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24
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Boeka AG, Solomon AC, Lokken K, McGuire BM, Bynon JS. A biopsychosocial approach to liver transplant evaluation in two patients with Wilson's disease. PSYCHOL HEALTH MED 2011; 16:268-75. [DOI: 10.1080/13548506.2010.532561] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Abbe G. Boeka
- a Department of Psychiatry and Behavioral Neurobiology , University of Alabama at Birmingham , Birmingham, AL, USA
| | - Andrea C. Solomon
- b Division of Neuropsychology, Department of Neurology , University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kristine Lokken
- c Division of Consultation/Liason, Department of Psychiatry and Behavioral Neurobiology , University of Alabama at Birmingham , Birmingham, AL, USA
- d Department of Physical Medicine and Rehabilitation , Birmingham VA Medical Center , Birmingham, AL, USA
| | - Brendan M. McGuire
- e Division of Gastroenterology, Department of Medicine , University of Alabama at Birmingham , Birmingham, AL, USA
| | - J. Steve Bynon
- f Division of Transplantation, Department of Surgery , University of Alabama at Birmingham , Birmingham, AL, USA
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25
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McGuire BM, Rosenthal P, Brown CC, Busch AMH, Calcatera SM, Claria RS, Hunt NK, Korenblat KM, Mazariegos GV, Moonka D, Orloff SL, Perry DK, Rosen CB, Scott DL, Sudan DL. Long-term management of the liver transplant patient: recommendations for the primary care doctor. Am J Transplant 2009; 9:1988-2003. [PMID: 19563332 DOI: 10.1111/j.1600-6143.2009.02733.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
No official document has been published for primary care physicians regarding the management of liver transplant patients. With no official source of reference, primary care physicians often question their care of these patients. The following guidelines have been approved by the American Society of Transplantation and represent the position of the association. The data presented are based on formal review and analysis of published literature in the field and the clinical experience of the authors. These guidelines address drug interactions and side effects of immunosuppressive agents, allograft dysfunction, renal dysfunction, metabolic disorders, preventive medicine, malignancies, disability and productivity in the workforce, issues specific to pregnancy and sexual function, and pediatric patient concerns. These guidelines are intended to provide a bridge between transplant centers and primary care physicians in the long-term management of the liver transplant patient.
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Affiliation(s)
- B M McGuire
- University of Alabama at Birmingham, Birmingham, AL, USA.
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Terrault NA, Tran TT, Schiff E, McGuire BM, Brown RS, Tupper R, Ramanathan S, Enejosa J, Zhong L, Zong J. Pharmacokinetics of tacrolimus co-administered with adefovir dipivoxil to liver transplant recipients. Liver Int 2009; 29:1178-83. [PMID: 19486291 DOI: 10.1111/j.1478-3231.2009.01998.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
BACKGROUND Adefovir dipivoxil has activity against wild-type and lamivudine-resistant hepatitis B virus (HBV) and is frequently used to manage HBV infection in transplant recipients. Calcineurin inhibitors are a central component of immunosuppressive therapy. AIMS Study GS-02-531 was an open-label, multicentre drug interaction trial to examine potential drug interactions between adefovir and tacrolimus in stable post-transplant recipients. MATERIALS AND METHODS Sixteen non-HBV-infected post-transplant recipients with median age 45.5 years (69% male, 44% Caucasian, 50% Hispanic and 6% Black) and stable hepatic and renal function on a stable daily dose of tacrolimus (2-10 mg total daily dose) were studied before (tacrolimus alone) and after co-administration of adefovir 10 mg daily for 14 days (Days 1-14). Pharmacokinetic (PK) analyses utilized non-compartmental methods. RESULTS The median elimination half-life of tacrolimus was 14.47 and 12.59 h for Day 0 and Day 14 respectively. The geometric mean ratios for tacrolimus on Day 14 vs Day 0 were 105.2% [90% confidence interval (90% CI): 89.8-123%] for C(max) and 106.4% (90% CI: 92.9-122%) for AUC(tau). Both 90% CIs for the ratios were contained within the predefined lack of interaction bounds of 80 and 125% (i.e. within the bounds for the equivalence assessment), indicating that these PK parameters of tacrolimus are not significantly altered by co-administration of adefovir. Similarly, the observed adefovir PK parameters after 14 days of co-administration with tacrolimus were comparable to historical data in non-transplant patients receiving adefovir alone. Serum creatinine values were stable during the study period. CONCLUSION There is no significant PK interaction between tacrolimus and adefovir co-administered to liver transplant recipients for 14 days.
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Affiliation(s)
- Norah A Terrault
- Department of Medicine and Surgery, University of California San Francisco, San Francisco, CA 94143-0538, USA.
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Abstract
Hepatic encephalopathy (HE) is a common reversible neuropsychiatric syndrome associated with chronic and acute liver dysfunction and significant morbidity and mortality. Although a clear pathogenesis is yet to be determined, elevated ammonia in the serum and central nervous system are the mainstay for pathogenesis and treatment. Management includes early diagnosis and prompt treatment of precipitating factors (infection, gastrointestinal bleeding, electrolyte disturbances, hepatocellular carcinoma, dehydration, hypotension, and use of benzodiazepines, psychoactive drugs, and/or alcohol). Clinical trials have established the efficacy of lactulose and lactitol enemas in the treatment of acute hepatic encephalopathy. Extensive clinical experience has demonstrated the efficacy of oral lactulose and lactitol with the goal of two to three soft bowel movements a day for the treatment of chronic HE. However, lactulose and lactitol have significant gastrointestinal side effects. For patients unable to tolerate lactulose or lactitol or who still have persistent chronic HE with lactulose or lactitol, neomycin, metronidazole and rifaximin are second-line agents. More recent data supports the benefits of rifaximin used solely and as an additional agent with fewer side effects than neomycin or metronidazole. Newer therapies being investigated in humans with clinical promise include nitazoxanide, the molecular adsorbent recirculating system (MARS), L-ornithine phenylacetate, sodium benzoate, and/or sodium phenylacetate and Kremezin® (AST-120).
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Affiliation(s)
- Mohamad Rasm Al Sibae
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, AL, USA
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McGuire BM, Alkurdi B. Editorial comment: liver transplantation. Curr Opin Organ Transplant 2009; 14:219-20. [PMID: 19455031 DOI: 10.1097/mot.0b013e32832c495e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Hepatic assist remains elusive. Bioartificial livers (BALs), consisting of liver cells or tissue in a synthetic housing, have been promising but have not proven successful in clinical trials. Artificial livers that consist of sophisticated sorbents and membranes cannot support a failing liver but may shorten episodes of acute decompensation in patients with stable cirrhosis. These artificial livers are most likely to find a place as temporary support prior to transplantation. True liver support will require a BAL. This article proposes goals for making a clinically useful BAL, with attention to systems biology and potential sources of hepatocytes.
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Affiliation(s)
- Norman L Sussman
- University of Utah, 30 North 1900 East, SOM 4R118, Salt Lake City, UT 84132-2410, USA.
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30
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Julian BA, Wittke S, Novak J, Good DM, Coon JJ, Kellmann M, Zürbig P, Schiffer E, Haubitz M, Moldoveanu Z, Calcatera SM, Wyatt RJ, Sýkora J, Sládková E, Hes O, Mischak H, McGuire BM. Electrophoretic methods for analysis of urinary polypeptides in IgA-associated renal diseases. Electrophoresis 2008; 28:4469-83. [PMID: 18004714 DOI: 10.1002/elps.200700237] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
We evaluated the utility of SDS-PAGE/Western blot and CE coupled with MS (CE-MS) for detection of urinary polypeptide biomarkers of renal disease in patients with IgA-associated glomerulonephritides. In a reference cohort of 402 patients with various renal disorders and 207 healthy controls, we defined CE-MS patterns of renal damage and IgA nephropathy (IgAN). In a blinded analysis of a separate cohort of patients with IgAN (n = 10), Henoch-Schoenlein purpura (HSP) with nephritis (n = 10), and IgA-associated glomerulonephritis due to hepatitis C virus (HCV)-induced cirrhosis (n = 9), and healthy controls (n = 12), we compared SDS-PAGE/Western blot and CE-MS against clinical urinalysis for detection of urinary proteins/polypeptides. Urinalysis indicated proteinuria for 50, 90, and 33% of patients, respectively, and for none of the healthy controls. SDS-PAGE/Western blot showed urinary polypeptides abnormality for 90, 80, and 67% of patients, respectively, and for none of the healthy controls. CE-MS indicated a Renal Damage Pattern in 80, 80, and 100 of patients, respectively, and in 17% of healthy controls, with the more specific IgAN Pattern in 90, 90, and 1%, respectively, and in none of the healthy controls. Based on differences in CE-MS patterns, the disease mechanisms may differ among various IgA-associated glomerulonephritides. These exploratory findings should be evaluated in a prospective study with contemporaneous renal biopsy and urinary testing. If validated, it may be feasible to adapt the CE-MS methodology to develop novel tests to detect renal injury at earlier stages, assess clinical manifestations, and monitor responses to therapy in patients with IgA-associated renal diseases.
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Affiliation(s)
- Bruce A Julian
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL 35294, USA.
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Stravitz RT, Kramer AH, Davern T, Shaikh AOS, Caldwell SH, Mehta RL, Blei AT, Fontana RJ, McGuire BM, Rossaro L, Smith AD, Lee WM. Intensive care of patients with acute liver failure: recommendations of the U.S. Acute Liver Failure Study Group. Crit Care Med 2008; 35:2498-508. [PMID: 17901832 DOI: 10.1097/01.ccm.0000287592.94554.5f] [Citation(s) in RCA: 243] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To provide a uniform platform from which to study acute liver failure, the U.S. Acute Liver Failure Study Group has sought to standardize the management of patients with acute liver failure within participating centers. METHODS In areas where consensus could not be reached because of divergent practices and a paucity of studies in acute liver failure patients, additional information was gleaned from the intensive care literature and literature on the management of intracranial hypertension in non-acute liver failure patients. Experts in diverse fields were included in the development of a standard study-wide management protocol. MEASUREMENTS AND MAIN RESULTS Intracranial pressure monitoring is recommended in patients with advanced hepatic encephalopathy who are awaiting orthotopic liver transplantation. At an intracranial pressure of > or =25 mm Hg, osmotic therapy should be instituted with intravenous mannitol boluses. Patients with acute liver failure should be maintained in a mildly hyperosmotic state to minimize cerebral edema. Accordingly, serum sodium should be maintained at least within high normal limits, but hypertonic saline administered to 145-155 mmol/L may be considered in patients with intracranial hypertension refractory to mannitol. Data are insufficient to recommend further therapy in patients who fail osmotherapy, although the induction of moderate hypothermia appears to be promising as a bridge to orthotopic liver transplantation. Empirical broad-spectrum antibiotics should be administered to any patient with acute liver failure who develops signs of the systemic inflammatory response syndrome, or unexplained progression to higher grades of encephalopathy. Other recommendations encompassing specific hematologic, renal, pulmonary, and endocrine complications of acute liver failure patients are provided, including their management during and after orthotopic liver transplantation. CONCLUSIONS The present consensus details the intensive care management of patients with acute liver failure. Such guidelines may be useful not only for the management of individual patients with acute liver failure, but also to improve the uniformity of practices across academic centers for the purpose of collaborative studies.
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Affiliation(s)
- R Todd Stravitz
- Section of Hepatology, Virginia Commonwealth University, Richmond, USA.
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32
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Affiliation(s)
- Joseph R Bloomer
- Liver Center and Division of Gastroenterology/Hepatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama 35294-0005, USA.
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McCashland T, Watt K, Lyden E, Adams L, Charlton M, Smith AD, McGuire BM, Biggins SW, Neff G, Burton JR, Vargas H, Donovan J, Trotter J, Faust T. Retransplantation for hepatitis C: results of a U.S. multicenter retransplant study. Liver Transpl 2007; 13:1246-53. [PMID: 17763405 DOI: 10.1002/lt.21322] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
It is widely perceived that outcomes are relatively poor following retransplantation (reTX) for recurrent of hepatitis C virus (HCV) infection. Transplant centers debate the utility of offering another liver to these patients. A U.S. study group was formed to retrospectively compare survival after reTX in patients with recurrent HCV (histologically proven) and those transplanted for other indications greater than 90 days after first transplantation, from 1996 to 2004. Patients were divided into 3 groups; group 1: HCV reTX (n = 43), group 2: non-HCV reTX (n = 73), and group 3: recurrent HCV but no reTX (n = 156). They were predominantly male, Caucasian, with mean age of 47.2 yr. The commonest indications for non-HCV reTX were chronic rejection (36%), hepatic artery thrombosis (31%) and recurrent primary sclerosing cholangitis (17%). Duration of hospitalization, number of intensive care unit (ICU) days, and time interval from listing to transplantation or reTX were similar between reTX groups. The 1-yr and 3-yr survival rates after reTX were also similar for HCV reTX and non-HCV reTX groups (1 yr, 69% vs. 73%; 3 yr, 49% vs. 55%). Model for End-Stage Liver Disease (MELD) scores were not predictive of survival from reTX. However, with a MELD score of >30 in the non HCV group, survival was <50%. In the recurrent HCV not undergoing reTX group, 30% were reevaluated for reTX but only 15% were listed for reTX and the 3-yr survival was 47%. The most common reasons for not listing for reTX were recurrent HCV within 6 months (22%), fibrosing cholestatic hepatitis (19%), and renal dysfunction (9%). In conclusion, patients retransplanted for recurrent HCV had similar 1-yr and 3-yr survival when compared to patients undergoing reTX for other indications. MELD scores were not predictive of post-reTX survival. Survival was <50% in the non-HCV reTx group with MELD score of >30. Many patients with recurrent HCV are not considered for reTX and die from recurrent disease.
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Affiliation(s)
- Timothy McCashland
- Department of Hepatology, University of Nebraska Medical Center, Omaha, NE 68198-3285, USA.
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Julian BA, Wittke S, Haubitz M, Zürbig P, Schiffer E, McGuire BM, Wyatt RJ, Novak J. Urinary biomarkers of IgA nephropathy and other IgA-associated renal diseases. World J Urol 2007; 25:467-76. [PMID: 17619884 DOI: 10.1007/s00345-007-0192-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2007] [Accepted: 06/05/2007] [Indexed: 01/12/2023] Open
Abstract
IgA nephropathy is the most common primary glomerulonephritis and is a frequent cause for chronic kidney disease in children and young adults. Glomerular deposition of IgA also characterizes other renal disorders, including Henoch-Schoenlein purpura nephritis and immune-complex glomerulonephritis afflicting patients with liver disease due to chronic infection with the hepatitis C virus. Several treatment options are often considered, with the goal to prevent end-stage renal failure. Unfortunately, the diagnosis currently requires an invasive procedure, a renal biopsy. Because of the inherent risks, repetitive renal biopsy is frequently foregone as a means to monitor the clinical course or response to treatment. Recent advances in the analysis of the urinary proteome suggest that the excreted polypeptides include disease-specific patterns. We review recent studies of the various techniques for the identification and validation of such urinary biomarkers of IgA-associated glomerulonephritides. Currently, capillary electrophoresis coupled with mass spectrometry (MS) offers the greatest promise. To date, it seems more likely that disease-specific urinary polypeptide biomarkers are comprised of a panel of several distinct and well-defined peptides rather than a single molecule. Even most patients in clinical remission with normal clinical testing (dipstick urinalysis and quantitative proteinuria) were correctly classified by the pattern of polypeptides identified by capillary electrophoresis coupled with MS. With confirmation and refinement, such urinary testing may provide a tool for the diagnosis and monitoring of patients with IgA-associated renal diseases that is more sensitive than current standard clinical testing and far less risky than renal biopsy.
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Affiliation(s)
- Bruce A Julian
- Department of Medicine, University of Alabama at Birmingham, 1530 Third Avenue South, Birmingham, AL 35294, USA.
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Abstract
Cirrhosis is the 12th leading cause of death in the United States. Individuals with cirrhosis are at risk for many potential complications. Complications can be managed or detected early with proper outpatient management. The most lethal of these complications is bleeding esophageal varices. All patients with cirrhosis should be screened for the presence of varices and treated when indicated. The most common complication seen in these patients is ascites. Ascites can be treated with dietary modifications and a diuretic regimen. Other potential complications include spontaneous bacterial peritonitis, hepatocellular carcinoma, hepatic encephalopathy, hepatorenal syndrome, and hepatopulmonary syndrome. The outpatient management of these complications will be discussed in this paper, along with the use of vaccinations, educating patients about the avoidance of hepatotoxic drugs, and when to refer a patient for liver transplant.
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Affiliation(s)
- Ronnie E Mathews
- Division of General Internal Medicine, Department of Medicine, University of Alabama at Birmingham, USA
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McGuire BM, Julian BA, Bynon JS, Cook WJ, King SJ, Curtis JJ, Accortt NA, Eckhoff DE. Brief communication: Glomerulonephritis in patients with hepatitis C cirrhosis undergoing liver transplantation. Ann Intern Med 2006; 144:735-41. [PMID: 16702589 DOI: 10.7326/0003-4819-144-10-200605160-00007] [Citation(s) in RCA: 131] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Patients infected with hepatitis C virus (HCV) frequently develop renal failure after liver transplantation. OBJECTIVE To describe renal histologic characteristics and concomitant clinical features in HCV-infected patients with end-stage cirrhosis. DESIGN Case series. SETTING Single-center liver transplant program in the United States. PATIENTS 30 patients who received liver transplants for HCV-induced cirrhosis. INTERVENTION Kidney biopsy during liver engraftment. MEASUREMENTS Clinical data and laboratory tests of renal function within 6 months before liver transplantation. RESULTS Twenty-five patients had immune-complex glomerulonephritis: membranoproliferative glomerulonephritis type 1 (n = 12), IgA nephropathy (n = 7), and mesangial glomerulonephritis (n = 6). Of these patients, 10 had normal serum creatinine levels, normal urinalysis results, and normal quantitative proteinuria. For 5 others, the only renal abnormality was an increased serum creatinine level. No patient had cryoglobulins in the blood or kidney. LIMITATIONS This small observational study did not include patients with nonviral cirrhosis and did not document post-transplantation outcomes. CONCLUSIONS Immune-complex glomerulonephritis was common in patients with end-stage HCV-induced cirrhosis and was often clinically silent. Its potential to cause renal failure after liver transplantation may be underappreciated.
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Affiliation(s)
- Brendan M McGuire
- University of Alabama at Birmingham, Birmingham, Alabama 35294-0005, USA.
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Squires RH, Shneider BL, Bucuvalas J, Alonso E, Sokol RJ, Narkewicz MR, Dhawan A, Rosenthal P, Rodriguez-Baez N, Murray KF, Horslen S, Martin MG, Lopez MJ, Soriano H, McGuire BM, Jonas MM, Yazigi N, Shepherd RW, Schwarz K, Lobritto S, Thomas DW, Lavine JE, Karpen S, Ng V, Kelly D, Simonds N, Hynan LS. Acute liver failure in children: the first 348 patients in the pediatric acute liver failure study group. J Pediatr 2006; 148:652-658. [PMID: 16737880 PMCID: PMC2662127 DOI: 10.1016/j.jpeds.2005.12.051] [Citation(s) in RCA: 509] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2005] [Revised: 10/03/2005] [Accepted: 12/19/2005] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To determine short-term outcome for children with acute liver failure (ALF) as it relates to cause, clinical status, and patient demographics and to determine prognostic factors. STUDY DESIGN A prospective, multicenter case study collecting demographic, clinical, laboratory, and short-term outcome data on children from birth to 18 years with ALF. Patients without encephalopathy were included if the prothrombin time and international normalized ratio remained > or = 20 seconds and/or >2, respectively, despite vitamin K. Primary outcome measures 3 weeks after study entry were death, death after transplantation, alive with native liver, and alive with transplanted organ. RESULTS The cause of ALF in 348 children included acute acetaminophen toxicity (14%), metabolic disease (10%), autoimmune liver disease (6%), non-acetaminophen drug-related hepatotoxicity (5%), infections (6%), other diagnosed conditions (10%); 49% were indeterminate. Outcome varied between patient sub-groups; 20% with non-acetaminophen ALF died or underwent liver transplantation and never had clinical encephalopathy. CONCLUSIONS Causes of ALF in children differ from in adults. Clinical encephalopathy may not be present in children. The high percentage of indeterminate cases provides an opportunity for investigation.
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Affiliation(s)
- Robert H Squires
- University of Pittsburgh, Children's Hospital of Pittsburgh, PA 15213, USA.
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39
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McGuire BM, Bonkovsky HL, Carithers RL, Chung RT, Goldstein LI, Lake JR, Lok AS, Potter CJ, Rand E, Voigt MD, Davis PR, Bloomer JR. Liver transplantation for erythropoietic protoporphyria liver disease. Liver Transpl 2005; 11:1590-6. [PMID: 16315313 DOI: 10.1002/lt.20620] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In erythropoietic protoporphyria (EPP), there is excessive production of protoporphyrin, primarily in the bone marrow, resulting in increased biliary excretion of this heme precursor. Some patients will develop progressive liver disease that may ultimately require liver transplantation. However, excessive production of protoporphyrin by the bone marrow continues after transplantation, which may cause recurrent disease in the allograft. This study was performed to define post-transplant survival, the risk of recurrent disease, and specific management issues in patients transplanted for EPP liver disease. The patients studied consisted of twelve males and eight females, with an average age of 31 (range, 13-56) years at the time of transplantation. The estimated maximum MELD score prior to transplant was 21 (range, 15-29). Unique complications in the perioperative period were light induced tissue damage in four patients and neuropathy in six, requiring prolonged mechanical ventilation in four. Patient and graft survival rates were 85% at 1 year, 69% at 5 years, and 47% at 10 years. Recurrent EPP liver disease occurred in 11 of 17 patients (65%) who survived more than 2 months. Three patients were retransplanted at 1.8, 12.6, and 14.5 years after the initial transplant for recurrent EPP liver disease. In conclusion, the 5-year patient survival rate in patients transplanted for EPP liver disease is good, but the recurrence of EPP liver disease appears to diminish long term graft and patient survival.
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Affiliation(s)
- Brendan M McGuire
- Department of Medicine, University of Alabama at Birmingham, 1530 Third Avenue South, Birmingham, AL 35294-0005, USA.
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Sellers MT, McGuire BM, Haustein SV, Bynon JS, Hunt SL, Eckhoff DE. Two-dose Daclizumab Induction Therapy in 209 Liver Transplants: A Single-Center Analysis. Transplantation 2004; 78:1212-7. [PMID: 15502722 DOI: 10.1097/01.tp.0000138100.72757.ba] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Patient and graft survival after liver transplantation are adversely affected by early posttransplant renal dysfunction. Therefore, our immunosuppressive strategies should be as "renal sparing" as possible. This is the largest published series to date using daclizumab induction therapy in a renal-sparing regimen. METHODS This is a retrospective, nonrandomized study comparing 209 adult liver transplants with daclizumab induction to 115 transplants with no induction. RESULTS Patient and graft survival were similar, despite higher pretransplant acuity of illness and older age in the induction group. Acute rejection within the first 6 months occurred less commonly in the induction group (25.4% vs. 39.1%, P=0.01), despite significantly delayed initiation and lower doses of a calcineurin inhibitor. Mycophenolate mofetil was used more commonly in induction patients, but the efficacy of daclizumab in preventing rejection was independent of this. Patients with a pretransplant creatinine concentration 1.5 mg/dL or less had less rejection if they received induction. Renal function worsened in noninduction patients but showed sustained improvement throughout follow-up in induction patients with a pretransplant creatinine concentration greater than 1.5 mg/dL. Induction therapy provided better rejection prophylaxis among those requiring temporary calcineurin inhibitor cessation because of renal dysfunction. The incidences of histologic hepatitis C recurrence and cytomegalovirus infection were similar in each group. CONCLUSIONS Liver recipients with and without pretransplant renal dysfunction have less acute rejection with daclizumab induction therapy. This is not associated with an increased risk of over-immunosuppression. Sustained renal improvement in recipients with pretransplant renal dysfunction is possible with daclizumab induction.
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Affiliation(s)
- Marty T Sellers
- Department of Surgery, University of Pennsylvania, 3400 Spruce Street, 4 Silverstein, Philadelphia, PA 19104, USA.
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41
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Demetriou AA, Brown RS, Busuttil RW, Fair J, McGuire BM, Rosenthal P, Am Esch JS, Lerut J, Nyberg SL, Salizzoni M, Fagan EA, de Hemptinne B, Broelsch CE, Muraca M, Salmeron JM, Rabkin JM, Metselaar HJ, Pratt D, De La Mata M, McChesney LP, Everson GT, Lavin PT, Stevens AC, Pitkin Z, Solomon BA. Prospective, randomized, multicenter, controlled trial of a bioartificial liver in treating acute liver failure. Ann Surg 2004; 239:660-7; discussion 667-70. [PMID: 15082970 PMCID: PMC1356274 DOI: 10.1097/01.sla.0000124298.74199.e5] [Citation(s) in RCA: 525] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The HepatAssist liver support system is an extracorporeal porcine hepatocyte-based bioartificial liver (BAL). The safety and efficacy of the BAL were evaluated in a prospective, randomized, controlled, multicenter trial in patients with severe acute liver failure. SUMMARY BACKGROUND DATA In experimental animals with acute liver failure, we demonstrated beneficial effects of the BAL. Similarly, Phase I trials of the BAL in acute liver failure patients yielded promising results. METHODS A total of 171 patients (86 control and 85 BAL) were enrolled. Patients with fulminant/subfulminant hepatic failure and primary nonfunction following liver transplantation were included. Data were analyzed with and without accounting for the following confounding factors: liver transplantation, time to transplant, disease etiology, disease severity, and treatment site. RESULTS For the entire patient population, survival at 30 days was 71% for BAL versus 62% for control (P = 0.26). After exclusion of primary nonfunction patients, survival was 73% for BAL versus 59% for control (n = 147; P = 0.12). When survival was analyzed accounting for confounding factors, in the entire patient population, there was no difference between the 2 groups (risk ratio = 0.67; P = 0.13). However, survival in fulminant/subfulminant hepatic failure patients was significantly higher in the BAL compared with the control group (risk ratio = 0.56; P = 0.048). CONCLUSIONS This is the first prospective, randomized, controlled trial of an extracorporeal liver support system, demonstrating safety and improved survival in patients with fulminant/subfulminant hepatic failure.
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Affiliation(s)
- Achilles A Demetriou
- Liver Support Unit, Department of Surgery, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Suite 8215, North Tower, Los Angeles, CA 90048, USA.
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Abstract
Cirrhosis is associated with decrements in health-related quality of life (HRQOL), but the specific effects of encephalopathy, especially subclinical, on quality of life are incompletely understood. Therefore, the aim of our study was to define the effects of encephalopathy on specific domains of HRQOL in a sample of patients with advanced liver disease. The sample consisted of 160 patients with cirrhosis presenting for liver transplantation evaluation. Health-related quality of life was measured with the Short Form-36 questionnaire. Clinical, demographic, and laboratory data were collected. The presence and degree of encephalopathy was ascertained clinically and by the use of the Reitan trail test. HRQOL scores were compared according to liver disease severity and to the presence and degree of encephalopathy. In addition, scores were compared to US population norms. Data were obtained from 148 patients. Compared to the US general population, the physical and mental component summary scores were lower in patients with cirrhosis. Among patients with cirrhosis, there were no significant differences in the physical and mental component summary scores according to age, gender, ethnicity, and etiology (hepatocellular versus/cholestatic and HCV versus non-HCV). Increasing severity of liver disease (based on the Child-Pugh score), a history of hospitalizations, and a history of ascites were associated with decreased physical component summary scores but not mental component summary scores. Patients with encephalopathy (overt and subclinical) had decreased physical and mental component summary scores compared to patients without encephalopathy. Compared to patients without encephalopathy, those with subclinical encephalopathy had a lower mental component summary score. In conclusion, cirrhosis is associated with a decreased HRQOL, especially at advanced stages. Increased severity of liver disease is associated with decreased physical aspects of quality of life. Overt hepatic encephalopathy negatively affects both physical and mental aspects of quality of life, whereas subclinical encephalopathy affects mainly the mental aspects, independently of liver disease severity.
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Affiliation(s)
- Miguel R Arguedas
- Department of Medicine, Division of Gastroenterology & Hepatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
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43
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McGuire BM. The critically ill liver patient: fulminant hepatic failure. Semin Gastrointest Dis 2003; 14:39-42. [PMID: 12610854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
Fulminant hepatic failure is a challenging medical condition that requires intensive care management to prevent-major complications (cerebral edema, infections, and multi-system organ failure) and assistance from a liver transplant team when it is believed that liver regeneration is unlikely. Unfortunately, there are no specific medical therapies or devices to correct all of the functions of a liver. N-acetylcysteine is used for the treatment of acetaminophen overdose, but for most other causes of fulminant hepatic failure therapy is supportive care. This case illustrates many of the problems that are encountered during medical management of fulminant hepatic failure.
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Affiliation(s)
- Brendan M McGuire
- Division of Gastroenterology & Hepatology, UAB Liver Center, University of Alabama at Birmingham, UAB Liver Center, 1918 University Blvd, Birmingham, AL 35294-0005, USA.
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Haustein SV, McGuire BM, Eckhoff DE, Hudson SL, Jones CA, Bynon JS, Sellers MT. Impact of noncompliance and donor/recipient race matching on chronic liver rejection. Transplant Proc 2002; 34:1497-8. [PMID: 12176455 DOI: 10.1016/s0041-1345(02)02945-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- S V Haustein
- Department of Surgery, Division of Transplantation, University of Alabama at Birmingham, Birmingham, AL 35223, USA
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Sellers MT, Haustein SV, McGuire BM, Jones C, Bynon JS, Diethelm AG, Eckhoff DE. Use of preserved vascular homografts in liver transplantation: hepatic artery aneurysms and other complications. Am J Transplant 2002; 2:471-5. [PMID: 12123215 DOI: 10.1034/j.1600-6143.2002.20513.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Hepatic artery aneurysms/pseudoaneurysms (HAAs) are rare but serious complications after orthotopic liver transplantation (OLT). Revascularization should accompany aneurysmectomy if possible and is more feasible if the aneurysm presents late after transplantation. The optimal conduits for revascularization in this situation are not known. Two patients with hepatic artery aneurysms/pseudoaneurysms who had aneurysmectomy and revascularization with third-party cadaveric iliac arterial grafts 1 and 4 years after OLT are presented in detail, with an emphasis on the preservation method used for the grafts. Both livers were successfully revascularized with arterial grafts preserved for 21 and 26 days after procurement. Hepatic patency was documented in both 5 and 6 months after repair; graft function has remained normal 13 and 32 months after repair. Third-party vessels preserved for shorter periods have been used successfully in four other situations, including living-donor liver transplantation, and are briefly discussed. In conclusion, properly preserved vascular homografts are useful in LT for purposes other than initial vascular reconstruction. They also provide an excellent vascular conduit in recipients of livers from other (possibly living) donors.
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Affiliation(s)
- Marty T Sellers
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL 35294, USA.
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46
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Abstract
Vaccination for hepatitis A, hepatitis B, pneumococcus, and influenza in patients with chronic liver disease is recommended. Our purpose was to determine the degree of adherence to these recommendations in cirrhotics presenting for liver transplantation evaluation. Our sample consisted of 105 patients presenting for evaluation for liver transplantation. Data were obtained by medical record review and patient interview. The age of the patients was 52 +/- 9 years (mean +/- SD) and the Child-Pugh score was 9 +/- 2. Twenty-nine patients had natural immunity for hepatitis A. Of the remaining 76, 20 (26.3%) received vaccine. Of the 89 patients without evidence of prior exposure to hepatitis B, 23 (25.8%) received vaccine. Pneumococcal and influenza vaccination was performed in 36 (34%) and 58 (55%) respectively. In conclusion, vaccination for viral hepatitis, pneumococcus, and influenza not being consistently performed. Public health efforts aimed at raising awareness about implementing vaccination in these patients are strongly encouraged.
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Affiliation(s)
- Miguel R Arguedas
- Department of Medicine, University of Alabama at Birmingham, 35294-0007, USA
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47
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Arguedas MR, McGuire BM, Fallon MB, Abrams GA. The use of screening and preventive therapies for gastroesophageal varices in patients referred for evaluation of orthotopic liver transplantation. Am J Gastroenterol 2001; 96:833-7. [PMID: 11280560 DOI: 10.1111/j.1572-0241.2001.03627.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Screening for varices has been recommended in patients with cirrhosis to prevent variceal hemorrhage (primary prophylaxis). In addition, therapy is recommended after the initial episode of variceal bleeding to prevent recurrence (secondary prophylaxis). However, the degree of adherence to these recommendations remains unclear. The purpose of our study was to determine whether these recommendations are being followed in patients presenting for evaluation of orthotopic liver transplantation. METHODS One hundred twenty-five patients referred for liver transplantation were evaluated. Data regarding demographics, clinical information, relevant time intervals (diagnosis of cirrhosis to screening, screening to initial variceal bleeding, variceal bleeding to referral, diagnosis of cirrhosis to referral), screening strategies used, and implementation of primary or secondary prophylaxis was obtained. The differences among quantitative variables were analyzed with Student's t test. Qualitative variables were evaluated with the Mantel-Haenzel chi2 test or Fisher's exact test. Statistical significance was designated at p < 0.05. RESULTS Our study found that 46% of patients presenting for evaluation of liver transplantation had screening endoscopy or radiological studies to detect the presence of varices. On the contrary, secondary prophylaxis was performed in all patients with a prior history of variceal hemorrhage. Screening for varices displayed no regional differences. CONCLUSIONS In our cohort, screening for varices is not being consistently performed, thus delaying the timely implementation of primary prophylaxis. Therefore, the adherence to currently available practice guidelines and the education of physicians to implement screening in this patient population is an important goal.
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Affiliation(s)
- M R Arguedas
- Department of Medicine, UAB Liver Center, University of Alabama at Birmingham, 35294-0007, USA
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Abstract
During evaluation for liver transplantation, a 63-year-old man with cirrhosis secondary to hepatitis C was diagnosed with severe aortic stenosis (aortic valve area, 0.87 cm(2)) and coronary artery disease. A combined procedure involving aortic valve replacement (pericardial xenograft), coronary artery bypass surgery, and orthotopic liver transplantation was performed. Convalescence was uneventful, and at 2 years after the procedure, the patient has normal cardiac function, good prosthetic valve function, and biochemically normal liver function.
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Affiliation(s)
- D E Eckhoff
- Department of Surgery, Division of Transplant Immunobiology and Transplant Center, University of Alabama, Birmingham, USA.
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McGuire BM. Safety of endoscopy in patients with end-stage liver disease. Gastrointest Endosc Clin N Am 2001; 11:111-30. [PMID: 11175978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Patients with end-stage liver disease routinely undergo an upper endoscopy for the diagnosis and management of complications of portal hypertension. These cirrhotic patients inherently have additional risks and higher rates of complications secondary to their liver disease and the presence of portal hypertension. Additional considerations and precautions must be taken into account to ensure that the endoscopic procedure is performed with the minimal risks possible. This article discusses the management of cirrhotic patients undergoing endoscopy. It addresses clinical clues for identifying the cirrhotic patient, the use of medications and monitoring equipment for vital signs during endoscopy, blood product administration in acute upper gastrointestinal bleeding, and elective and urgent procedures to diagnose and treat cirrhotic patients.
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Affiliation(s)
- B M McGuire
- University of Alabama at Birmingham Liver Center, Birmingham, Alabama 35294-0007, USA.
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50
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Affiliation(s)
- M R Arguedas
- Department of Medicine, University of Alabama at Birmingham, 35294-0007, USA
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