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Saeed H, Cano EJ, Khan MQ, Yetmar ZA, Smith B, Rizza SA, Badley AD, Mahmood M, Leise MD, Cummins NW. Changing Landscape of Liver Transplantation in the Post-DAA and Contemporary ART Era. Life (Basel) 2022; 12:1755. [PMID: 36362910 PMCID: PMC9693252 DOI: 10.3390/life12111755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 10/28/2022] [Accepted: 10/30/2022] [Indexed: 07/30/2023] Open
Abstract
Combination anti-retroviral therapy has drastically improved solid organ transplantation outcomes in persons living with HIV. DAA therapy has led to the successful eradication of HCV. While recent data have suggested improvement in outcomes in HIV/HCV-coinfected liver transplant recipients, temporal trends in patient survival within pre- and post-DAA eras are yet to be elucidated. The UNOS database was utilized to identify deceased donor liver transplant recipients between 1 January 2000 and 30 September 2020 and stratify them by HIV and HCV infection status. A total of 85,730 patients met the inclusion criteria. One-year and five-year patient survival improved (93% and 80%, respectively) for all transplants performed post-2015. For HIV/HCV-coinfected recipients, survival improved significantly from 78% (pre-2015) to 92% (post-2015). Multivariate regression analyses identified advanced recipient age, Black race, diabetes mellitus and decompensated cirrhosis as risk factors associated with higher one-year mortality. Liver transplant outcomes in HIV/HCV-coinfected liver transplant recipients have significantly improved over the last quinquennium in the setting of the highly effective combination of ART and DAA therapy. The presence of HIV, HCV, HIV/HCV-coinfection and active HCV viremia at the time of transplant do not cause higher mortality risk in liver transplant recipients in the current era.
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Affiliation(s)
- Huma Saeed
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN 55902, USA
| | - Edison J. Cano
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN 55902, USA
| | - Mohammad Qasim Khan
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55902, USA
| | - Zachary A. Yetmar
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN 55902, USA
| | - Byron Smith
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN 55902, USA
| | - Stacey A. Rizza
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN 55902, USA
- Department of Molecular Medicine, Mayo Clinic, Rochester, MN 55902, USA
| | - Andrew D. Badley
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN 55902, USA
- Department of Molecular Medicine, Mayo Clinic, Rochester, MN 55902, USA
| | - Maryam Mahmood
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN 55902, USA
| | - Michael D. Leise
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55902, USA
| | - Nathan W. Cummins
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN 55902, USA
- Department of Molecular Medicine, Mayo Clinic, Rochester, MN 55902, USA
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2
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Aseem SO, Leise MD, Law RJ. Diffuse Common Bile Duct Mural Thickening in a Patient With Pancreatitis. Gastroenterology 2022; 163:825-827. [PMID: 35716770 DOI: 10.1053/j.gastro.2022.06.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 06/04/2022] [Indexed: 12/02/2022]
Affiliation(s)
- Sayed Obaidullah Aseem
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota.
| | - Michael D Leise
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Ryan J Law
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota
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3
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Khan MQ, Chin JYL, Azhari H, Rosen CB, Leise MD. Pseudo-Wilsonian Crisis in a ATP7B Heterozygote. Liver Transpl 2022; 28:131-133. [PMID: 34388305 DOI: 10.1002/lt.26263] [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: 04/19/2021] [Revised: 07/16/2021] [Accepted: 08/06/2021] [Indexed: 01/13/2023]
Affiliation(s)
| | | | - Hassan Azhari
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Charles B Rosen
- Division of Transplantation Surgery, Mayo Clinic, Rochester, MN
| | - Michael D Leise
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
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4
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Garg SK, Goyal H, Obaitan I, Shah PA, Sarvepalli S, Jophlin LL, Singh D, Asrani S, Kamath PS, Leise MD. Incidence and predictors of 30-day hospital readmissions for liver cirrhosis: insights from the United States National Readmissions Database. Ann Transl Med 2021; 9:1052. [PMID: 34422964 PMCID: PMC8339830 DOI: 10.21037/atm-20-1762] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 05/23/2021] [Indexed: 12/12/2022]
Abstract
Background Cirrhosis is associated with substantial inpatient morbidity and mortality. This study aimed to determine the trends in 30-day hospital readmission rates among patients with cirrhosis and identify factors associated with these readmissions. Methods We conducted a retrospective analysis of data retrieved from the Nationwide Readmissions Database to determine trends in 30-day readmission for patients discharged with a diagnosis of cirrhosis in 2010 through 2014. Multivariate logistic regression analysis was used to identify predictors of readmission. Results Among 303,346 patients identified from the database, the 30-day readmission rate for patients with a discharge diagnosis of cirrhosis was 31.4% (n=95,298). The trends in the readmission rates remained steady during the study period. On multivariate analysis, female sex, age 45 years or older, esophagogastroduodenoscopy (EGD) during admission, and disposition to a short-term care facility or skilled nursing facility protected against readmissions. In contrast, coverage by Medicaid insurance, admission during a weekend, nonalcoholic cause of cirrhosis, and history of hepatic encephalopathy and ascites were associated with readmission. Conclusions We found an exceptionally high 30-day readmission rate in patients with cirrhosis, although it remained stable during the study period. This study identified some modifiable factors such as disposition to a short-term care facility or skilled nursing facility and patients’ attendance of alcohol rehabilitation facilities that could decrease the likelihood of readmission and could inform local and national healthcare policymakers.
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Affiliation(s)
- Sushil Kumar Garg
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Hemant Goyal
- Mercer University School of Medicine, Macon, GA, USA
| | - Itegbemie Obaitan
- Department of Gastroenterology and Hepatology, University of Minnesota, Minneapolis, MN, USA
| | | | | | - Loretta Lynn Jophlin
- Division of Gastroenterology-Hepatology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Dupinder Singh
- Department of Gastroenterology and Hepatology, University of Minnesota, Minneapolis, MN, USA
| | - Sumeet Asrani
- Baylor University Medical Center, Baylor Scott and White, Dallas, TX, USA
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Michael D Leise
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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5
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Yohanathan L, Campioli CC, Mousa OY, Watt K, Friedman DZP, Shah V, Ramkissoon R, Hines AS, Kamath PS, Razonable RR, Badley AD, DeMartino ES, Joyner MJ, Graham R, Vergidis P, Simonetto DA, Sanchez W, Taner T, Heimbach JK, Beam E, Leise MD. Liver transplantation for acute liver failure in a SARS-CoV-2 PCR-positive patient. Am J Transplant 2021; 21:2890-2894. [PMID: 33792185 PMCID: PMC8251077 DOI: 10.1111/ajt.16582] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [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: 12/22/2020] [Revised: 03/22/2021] [Accepted: 03/22/2021] [Indexed: 01/25/2023]
Abstract
Current guidelines recommend deferring liver transplantation (LT) in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection until clinical improvement occurs and two PCR tests collected at least 24 hours apart are negative. We report a case of an 18-year-old, previously healthy African-American woman diagnosed with COVID-19, who presents with acute liver failure (ALF) requiring urgent LT in the context of SARS-CoV-2 polymerase chain reaction (PCR) positivity. The patient was thought to have acute Wilsonian crisis on the basis of hemolytic anemia, alkaline phosphatase:bilirubin ratio <4, AST:ALT ratio >2.2, elevated serum copper, and low uric acid, although an unusual presentation of COVID-19 causing ALF could not be excluded. After meeting criteria for status 1a listing, the patient underwent successful LT, despite ongoing SARS-CoV-2 PCR positivity. Remdesivir was given immediately posttransplant, and mycophenolate mofetil was withheld initially and the SARS-CoV-2 PCR test eventually became negative. Three months following transplantation, the patient has made a near-complete recovery. This case highlights that COVID-19 with SARS-CoV-2 PCR positivity may not be an absolute contraindication for transplantation in ALF. Criteria for patient selection and timing of LT amid the COVID-19 pandemic need to be validated in future studies.
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Affiliation(s)
- Lavanya Yohanathan
- Division of Transplant SurgeryThe William J. Von Liebig Center for Transplantation and Clinical RegenerationMayo ClinicRochesterMinnesotaUSA
| | | | - Omar Y. Mousa
- Division of GastroenterologyMayo Clinic Health SystemMankatoMinnesotaUSA,Division of Gastroenterology and HepatologyMayo ClinicRochesterMinnesotaUSA
| | - Kymberly Watt
- Division of Gastroenterology and HepatologyMayo ClinicRochesterMinnesotaUSA
| | | | - Vijay Shah
- Division of Gastroenterology and HepatologyMayo ClinicRochesterMinnesotaUSA
| | - Resham Ramkissoon
- Division of Gastroenterology and HepatologyMayo ClinicRochesterMinnesotaUSA
| | | | - Patrick S. Kamath
- Division of Gastroenterology and HepatologyMayo ClinicRochesterMinnesotaUSA
| | | | - Andrew D. Badley
- Division of Infectious DiseasesMayo Clinic RochesterMinnesotaUSA
| | - Erin S. DeMartino
- Division of Pulmonology and Critical CareMayo Clinic RochesterMinnesotaUSA
| | | | - Rondell Graham
- Department ofLaboratory Medicine and PathologyMayo ClinicRochesterMinnesotaUSA
| | | | - Doug A. Simonetto
- Division of Gastroenterology and HepatologyMayo ClinicRochesterMinnesotaUSA
| | - William Sanchez
- Division of Gastroenterology and HepatologyMayo ClinicRochesterMinnesotaUSA
| | - Timucin Taner
- Division of Transplant SurgeryThe William J. Von Liebig Center for Transplantation and Clinical RegenerationMayo ClinicRochesterMinnesotaUSA
| | - Julie K. Heimbach
- Division of Transplant SurgeryThe William J. Von Liebig Center for Transplantation and Clinical RegenerationMayo ClinicRochesterMinnesotaUSA
| | - Elena Beam
- Division of Infectious DiseasesMayo Clinic RochesterMinnesotaUSA
| | - Michael D. Leise
- Division of Gastroenterology and HepatologyMayo ClinicRochesterMinnesotaUSA
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6
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Díaz LA, Idalsoaga F, Cannistra M, Candia R, Cabrera D, Barrera F, Soza A, Graham R, Riquelme A, Arrese M, Leise MD, Arab JP. High prevalence of hepatic steatosis and vascular thrombosis in COVID-19: A systematic review and meta-analysis of autopsy data. World J Gastroenterol 2020; 26:7693-7706. [PMID: 33505145 PMCID: PMC7789052 DOI: 10.3748/wjg.v26.i48.7693] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [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: 10/21/2020] [Revised: 11/26/2020] [Accepted: 12/06/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) disease can frequently affect the liver. Data on hepatic histopathological findings in COVID-19 is scarce.
AIM To characterize hepatic pathological findings in patients with COVID-19.
METHODS We conducted a systematic review with meta-analysis registered on PROSPERO (CRD42020192813), following PRISMA guidelines. Eligible trials were those including patients of any age and COVID-19 diagnosis based on a molecular test. Histopathological reports from deceased COVID-19 patients undergoing autopsy or liver biopsy were reviewed. Articles including less than ten patients were excluded. Proportions were pooled using random-effects models. Q statistic and I2 were used to assess heterogeneity and levels of evidence, respectively.
RESULTS We identified 18 studies from 7 countries; all were case reports and case series from autopsies. All the patients were over 15 years old, and 67.2% were male. We performed a meta-analysis of 5 studies, including 116 patients. Pooled prevalence estimates of liver histopathological findings were hepatic steatosis 55.1% [95% confidence interval (CI): 46.2-63.8], congestion of hepatic sinuses 34.7% (95%CI: 7.9-68.4), vascular thrombosis 29.4% (95%CI: 0.4-87.2), fibrosis 20.5% (95%CI: 0.6-57.9), Kupffer cell hyperplasia 13.5% (95%CI: 0.6-54.3), portal inflammation 13.2% (95%CI: 0.1-48.8), and lobular inflammation 11.6% (95%CI: 0.3-35.7). We also identified the presence of venous outflow obstruction, phlebosclerosis of the portal vein, herniated portal vein, periportal abnormal vessels, hemophagocytosis, and necrosis.
CONCLUSION We found a high prevalence of hepatic steatosis and vascular thrombosis as major histological liver features. Other frequent findings included portal and lobular inflammation and Kupffer cell hyperplasia or proliferation. Further studies are needed to establish the mechanisms and implications of these findings.
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Affiliation(s)
- Luis Antonio Díaz
- Department of Gastroenterology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago 8320000, Chile
| | - Francisco Idalsoaga
- Department of Internal Medicine, Pontificia Universidad Católica de Chile, Santiago 8320000, Chile
| | - Macarena Cannistra
- School of Medicine, Pontificia Universidad Católica de Chile, Santiago 8320000, Chile
| | - Roberto Candia
- Department of Gastroenterology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago 8320000, Chile
| | - Daniel Cabrera
- Facultad de Ciencias Médicas, Universidad Bernardo O'Higgins, Santiago 8320000, Chile
| | - Francisco Barrera
- Department of Gastroenterology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago 8320000, Chile
| | - Alejandro Soza
- Department of Gastroenterology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago 8320000, Chile
| | - Rondell Graham
- Department of Laboratory Medicine and Pathology, Mayo Clinic Rochester, Minnesota, MN 55902, United States
| | - Arnoldo Riquelme
- Department of Gastroenterology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago 8320000, Chile
| | - Marco Arrese
- Department of Gastroenterology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago 8320000, Chile
| | - Michael D Leise
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Minnesota, MN 55905, United States
| | - Juan Pablo Arab
- Department of Gastroenterology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago 8320000, Chile
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7
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Sarmast N, Ogola GO, Kouznetsova M, Leise MD, Bahirwani R, Maiwall R, Tapper E, Trotter J, Bajaj JS, Thacker LR, Tandon P, Wong F, Reddy KR, O'Leary JG, Masica A, Modrykamien AM, Kamath PS, Asrani SK. Model for End-Stage Liver Disease-Lactate and Prediction of Inpatient Mortality in Patients With Chronic Liver Disease. Hepatology 2020; 72:1747-1757. [PMID: 32083761 DOI: 10.1002/hep.31199] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [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: 05/03/2019] [Revised: 01/11/2020] [Accepted: 01/29/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIMS Compared to other chronic diseases, patients with chronic liver disease (CLD) have significantly higher inpatient mortality; accurate models to predict inpatient mortality are lacking. Serum lactate (LA) may be elevated in patients with CLD due to both tissue hypoperfusion as well as decreased LA clearance. We hypothesized that a parsimonious model consisting of Model for End-Stage Liver Disease (MELD) and LA at admission may predict inpatient mortality in patients with CLD. APPROACH AND RESULTS We examined all patients with CLD in two large and diverse health care systems in Texas (North Texas [NTX] and Central Texas [CTX]) between 2010 and 2015. We developed (n = 3,588) and validated (n = 1,804) a model containing MELD and LA measured at the time of hospitalization. We further validated the model in a second cohort of 14 tertiary care hepatology centers that prospectively enrolled nonelective hospitalized patients with cirrhosis (n = 726). MELD-LA was an excellent predictor of inpatient mortality in development (concordance statistic [C-statistic] = 0.81, 95% confidence interval [CI] 0.79-0.82) and both validation cohorts (CTX cohort, C-statistic = 0.85, 95% CI 0.78-0.87; multicenter cohort C-statistic = 0.82, 95% CI 0.74-0.88). MELD-LA performed especially well in patients with specific cirrhosis diagnoses (C-statistic = 0.84, 95% CI 0.81-0.86) or sepsis (C-statistic = 0.80, 95% CI 0.78-0.82). For MELD score 25, inpatient mortality rates were 11.2% (LA = 1 mmol/L), 19.4% (LA = 3 mmol/L), 34.3% (LA = 5 mmol/L), and >50% (LA > 8 mmol/L). A linear increase (P < 0.01) was seen in MELD-LA and increasing number of organ failures. Overall, use of MELD-LA improved the risk prediction in 23.5% of patients compared to MELD alone. CONCLUSIONS MELD-LA (bswh.md/meldla) is an early and objective predictor of inpatient mortality and may serve as a model for risk assessment and guide therapeutic options.
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Affiliation(s)
- Naveed Sarmast
- Baylor University Medical Center, Baylor Scott and White, Dallas, TX
| | - Gerald O Ogola
- Center for Clinical Effectiveness, Baylor Scott and White, Dallas, TX
| | - Maria Kouznetsova
- Center for Clinical Effectiveness, Baylor Scott and White, Dallas, TX
| | | | | | - Rakhi Maiwall
- Institute of Liver and Biliary Sciences, New Delhi, India
| | | | - James Trotter
- Baylor University Medical Center, Baylor Scott and White, Dallas, TX
| | | | | | | | | | | | | | - Andrew Masica
- Center for Clinical Effectiveness, Baylor Scott and White, Dallas, TX
| | | | | | - Sumeet K Asrani
- Baylor University Medical Center, Baylor Scott and White, Dallas, TX
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8
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Abstract
Hepatic encephalopathy (HE) is a complication of acute or chronic liver failure; its mechanism is complex, involving multiple organ systems, and is still being elucidated. The standard of care, lactulose, has remained generally unchanged for decades. However, in recent years, better understanding of the pathophysiology has yielded new therapeutic targets for this reversible condition. These novel treatments act both on traditional pathways established in the ammonia hypothesis and through more recently discovered mechanisms. Here, we review contemporary investigational therapies for HE. We used narrative reviews and searched ClinicalTrials.gov database for the condition "hepatic encephalopathy" through August 29, 2019. Our review yielded six key areas of therapeutic focus: (1) antibiotics against urease-producing gut bacteria, (2) intravenous ammonia scavengers, (3) modified synthetic probiotics, (4) fecal microbiota transplant, (5) brain steroid-modulating agents, and 6) nonlactulose laxatives. Active trials are ongoing in each of these therapeutic areas.
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Key Words
- CHESS, clinical hepatic encephalopathy staging scale
- FMT, fecal microbiota transplant
- HE, hepatic encephalopathy
- HESA, hepatic encephalopathy scoring algorithm
- MAD, multiple-ascending dose
- MES, modified encephalopathy scale
- ORT, object recognition test
- PEG, polyethylene glycol-3350
- SAD, single-ascending dose
- SEV, saccadic eye velocity
- ammonia
- antibiotics
- fecal microbiota transplant
- hepatic encephalopathy
- lactulose
- therapy
- trials
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Affiliation(s)
- Alexander J. Ryu
- Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN, United States
| | - Robert S. Rahimi
- Division of Hepatology, Baylor Scott & White Health, Dallas, TX, United States
| | - Michael D. Leise
- Division of Gastroenterology & Hepatology, Mayo Clinic College of Medicine, Rochester, MN, United States
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9
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Asrani SK, Jennings LW, Kim WR, Kamath PS, Levitsky J, Nadim MK, Testa G, Leise MD, Trotter JF, Klintmalm G. MELD-GRAIL-Na: Glomerular Filtration Rate and Mortality on Liver-Transplant Waiting List. Hepatology 2020; 71:1766-1774. [PMID: 31523825 DOI: 10.1002/hep.30932] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [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: 02/15/2019] [Accepted: 08/22/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIMS Among patients with cirrhosis awaiting liver transplantation, prediction of wait-list (WL) mortality is adjudicated by the Model for End Stage Liver Disease-Sodium (MELD-Na) score. Replacing serum creatinine (SCr) with estimated glomerular filtration rate (eGFR) in the MELD-Na score may improve prediction of WL mortality, especially for women and highest disease severity. APPROACH AND RESULTS We developed (2014) and validated (2015) a model incorporating eGFR using national data (n = 17,095) to predict WL mortality. Glomerular filtration rate (GFR) was estimated using the GFR assessment in liver disease (GRAIL) developed among patients with cirrhosis. Multivariate Cox proportional hazard analysis models were used to compare the predicted 90-day WL mortality between MELD-GRAIL-Na (re-estimated bilirubin, international normalized ratio [INR], sodium, and GRAIL) versus MELD-Na. Within 3 months, 27.8% were transplanted, 4.3% died on the WL, and 4.7% were delisted for other reasons. GFR as estimated by GRAIL (hazard ratio [HR] 0.382, 95% confidence interval [CI] 0.344-0.424) and the re-estimated model MELD-GRAIL-Na (HR 1.212, 95% CI 1.199-1.224) were significant predictors of mortality or being delisted on the WL within 3 months. MELD-GRAIL-Na was a better predictor of observed mortality at highest deciles of disease severity (≥ 27-40). For a score of 32 or higher (observed mortality 0.68), predicted mortality was 0.67 (MELD-GRAIL-Na) and 0.51 (MELD-Na). For women, a score of 32 or higher (observed mortality 0.67), the predicted mortality was 0.69 (MELD-GRAIL-Na) and 0.55 (MELD-Na). In 2015, use of MELD-GRAIL-Na as compared with MELD-Na resulted in reclassification of 16.7% (n = 672) of patients on the WL. CONCLUSION Incorporation of eGFR likely captures true GFR better than SCr, especially among women. Incorporation of MELD-GRAIL-Na instead of MELD-Na may affect outcomes for 12%-17% awaiting transplant and affect organ allocation.
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Affiliation(s)
| | | | - W R Kim
- Stanford University, Stanford, CA
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10
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Welle CL, Welch BT, Brinjikji W, Ehman EC, Venkatesh SK, Johnson MP, Iyer VN, Leise MD, Wood CP. Abdominal manifestations of hereditary hemorrhagic telangiectasia: a series of 333 patients over 15 years. Abdom Radiol (NY) 2019; 44:2384-2391. [PMID: 30888464 DOI: 10.1007/s00261-019-01976-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant multi-organ vascular disorder that commonly affects the gastrointestinal tract and the liver resulting in telangiectasias and arteriovenous malformations (AVMs). Previous studies looking at the prevalence of liver and abdominal organ involvement in HHT have been limited by differing imaging techniques and sample size limitations. We sought to define the prevalence of HHT related abdominal vascular abnormalities using optimized multiphasic contrast-enhanced abdominal computed tomography (CT) exams in a large cohort of HHT patients. METHODS Between January 2001 and May 2015; we identified a total of 333 consecutive HHT patients who had undergone a dedicated HHT protocol multiphase abdominal CT at our institution. The CT exams were reviewed by three board certified abdominal radiologists for the presence of vascular abnormalities involving the liver, pancreas, spleen, and other abdominal organs. Vascular abnormalities involving the liver were further categorized as telangiectasias, large confluent vascular masses, perfusion abnormalities, or hepatic shunts. RESULTS In patients with abdominal vascular abnormalities, the liver was the most commonly involved organ, with 180 out of 333 (54.1%) patients demonstrating at least one hepatic vascular abnormality (telangiectasia, confluent vascular mass, transient perfusion abnormalities, and hepatic shunts), with most (70.0%) demonstrating multiple hepatic vascular abnormalities. The other most common organs involved included the pancreas (18.0%), spleen (6.3%), and small bowel (4.5%). CONCLUSION In patients with the clinical diagnosis of HHT, greater than half demonstrate an abdominal vascular abnormality, with the most commonly involved organ being the liver. These may be under recognized on routine or single phase contrast-enhanced CT of the abdomen. This supports the use of optimized multiphasic abdominal CT exams as an important tool for the evaluation and screening of patients with HHT.
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11
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Kim GY, Schmelkin LA, Davis MD, El-Azhary RA, Wieland CN, Leise MD, Meves A, Lehman JS. Clinical and histopathologic manifestations of solid organ transplantation-associated graft-versus-host disease involving the skin: A single-center retrospective study. J Cutan Pathol 2018; 45:817-823. [DOI: 10.1111/cup.13326] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 07/06/2018] [Accepted: 07/13/2018] [Indexed: 12/30/2022]
Affiliation(s)
- Grace Y. Kim
- Mayo Clinic School of Medicine; Rochester Minnesota
| | - Leah A. Schmelkin
- Mayo Clinic School of Graduate Medical Education; Mayo Clinic; Rochester Minnesota
| | - Mark D. Davis
- Department of Dermatology; Mayo Clinic; Rochester Minnesota
| | | | - Carilyn N. Wieland
- Department of Dermatology; Mayo Clinic; Rochester Minnesota
- Department of Laboratory Medicine and Pathology; Mayo Clinic; Rochester Minnesota
| | - Michael D. Leise
- Department of Gastroenterology and Hepatology; Mayo Clinic; Rochester Minnesota
| | | | - Julia S. Lehman
- Department of Dermatology; Mayo Clinic; Rochester Minnesota
- Department of Laboratory Medicine and Pathology; Mayo Clinic; Rochester Minnesota
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12
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Reuter B, Walter K, Bissonnette J, Leise MD, Lai J, Tandon P, Kamath PS, Biggins SW, Rose CF, Wade JB, Bajaj JS. Assessment of the spectrum of hepatic encephalopathy: A multicenter study. Liver Transpl 2018; 24:587-594. [PMID: 29457869 PMCID: PMC5912984 DOI: 10.1002/lt.25032] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [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: 12/20/2017] [Revised: 02/02/2018] [Accepted: 02/07/2018] [Indexed: 12/12/2022]
Abstract
Hepatic encephalopathy (HE) is a major cause of morbidity in cirrhosis. However, its severity assessment is often subjective, which needs to be studied systematically. The aim was to determine how accurately trainee and nontrainee practitioners grade and manage HE patients throughout its severity. We performed a survey study using standardized simulated patient videos at 4 US and 3 Canadian centers. Participants were trainees (gastroenterology/hepatology fellows) and nontrainees (faculty, nurse practitioners, physician assistants). We determined the accuracy of HE severity identification and management options between grades <2 or ≥2 HE and trainees/nontrainees. In total, 108 respondents (62 trainees, 46 nontrainees) were included. For patients with grades <2 versus ≥2 HE, a higher percentage of respondents were better at correctly diagnosing grades ≥2 compared with grades <2 (91% versus 64%; P < 0.001). Specialized cognitive testing was checked significantly more often in grades <2, whereas more aggressive investigation for precipitating factors was ordered in HE grades >2. Serum ammonia levels were ordered in almost a third of grade ≥2 patients. For trainees and nontrainees, HE grades were identified similarly between groups. Trainees were less likely to order serum ammonia and low-protein diets, more likely to order rifaximin, and more likely to perform a more thorough workup for precipitating factors compared with nontrainee respondents. There was excellent concordance in the classification of grade ≥2 HE between nontrainees versus trainees, but lower grades showed discordance. Important differences were seen regarding blood ammonia, specialized testing, and nutritional management between trainees and nontrainees. These results have important implications at the patient level, interpreting multicenter clinical trials, and in the education of practitioners. Liver Transplantation 24 587-594 2018 AASLD.
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Affiliation(s)
- Bradley Reuter
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond VA, USA
| | | | | | | | - Jennifer Lai
- University of California, San Francisco, CA, USA
| | | | | | | | | | - James B Wade
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond VA, USA
| | - Jasmohan S Bajaj
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond VA, USA
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13
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Iyer VN, Apala DR, Pannu BS, Kotecha A, Brinjikji W, Leise MD, Kamath PS, Misra S, Begna KH, Cartin-Ceba R, DuBrock HM, Krowka MJ, O'Brien EK, Pruthi RK, Schroeder DR, Swanson KL. Intravenous Bevacizumab for Refractory Hereditary Hemorrhagic Telangiectasia-Related Epistaxis and Gastrointestinal Bleeding. Mayo Clin Proc 2018; 93:155-166. [PMID: 29395350 DOI: 10.1016/j.mayocp.2017.11.013] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [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] [Received: 09/07/2017] [Revised: 11/02/2017] [Accepted: 11/20/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To present a multiyear clinical experience with intravenous bevacizumab for the management of severe gastrointestinal bleeding and/or epistaxis in patients with hereditary hemorrhagic telangiectasia (HHT). PATIENTS AND METHODS All patients treated with intravenous bevacizumab for severe hereditary hemorrhagic telangiectasia-related bleeding from June 1, 2013, through January 31, 2017, were included in this report. Severity of epistaxis (determined using the Epistaxis Severity Score questionnaire); hemoglobin, iron, and ferritin levels; and quality of life data were collected serially in all patients. RESULTS Intravenous bevacizumab was administered to 34 patients using a standardized treatment protocol. Anemia was primarily related to severe epistaxis (n=15, 44%), severe gastrointestinal bleeding (n=4, 12%), or both (n=15, 44%), with a median baseline hemoglobin level of 9.1 g/dL (range, 8.3-10.5 gm/dL; to convert to mmol/L, multiply by 0.62). Red blood cell (RBC) transfusions had been administered to 28 patients (82%). Of these, 16 patients (47%) were RBC transfusion dependent and had received a median of 75 RBC transfusions (range, 4->500 RBC units) before bevacizumab initiation. The median length of follow-up was 17.6 months from the beginning of bevacizumab treatment (range, 3-42.5 months). There was a significant reduction in epistaxis severity scores (P<.001) and RBC transfusion requirements (P=.007) after completion of the initial bevacizumab treatment cycle. New-onset or worsened hypertension was noted in 4 patients, with 1 patient experiencing hypertensive urgency with a temporary decline in renal function. CONCLUSION Intravenous bevacizumab is an effective treatment option for patients with severe anemia related to epistaxis and/or gastrointestinal bleeding. Further studies are needed to establish a dose-response relationship as well as clinical, genetic, and biomarker predictors of response.
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Affiliation(s)
- Vivek N Iyer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN.
| | - Dinesh R Apala
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Bibek S Pannu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Aditya Kotecha
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | | | - Michael D Leise
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Sanjay Misra
- Department of Radiology, Mayo Clinic, Rochester, MN
| | | | | | - Hilary M DuBrock
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Michael J Krowka
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Erin K O'Brien
- Division of Otorhinolaryngology, Mayo Clinic, Rochester, MN
| | | | - Darrell R Schroeder
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
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Segraves JM, Cartin-Ceba R, Leise MD, Krowka MJ. Relationship between portopulmonary hypertension and splenectomy: Mayo Clinic experience and review of published works. Hepatol Res 2018; 48:E340-E346. [PMID: 28667665 DOI: 10.1111/hepr.12930] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [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: 06/14/2017] [Accepted: 06/23/2017] [Indexed: 12/31/2022]
Abstract
AIM Portopulmonary hypertension is a serious complication of portal hypertension that can lead to right heart failure and death. To our knowledge, an association between portopulmonary hypertension and prior splenectomy has not been described previously. The goals of this study were to describe the frequency of splenectomy in portopulmonary hypertension and compare selected parameters between portopulmonary hypertension subgroups. METHODS This is a retrospective analysis of patients diagnosed with portopulmonary hypertension between 1 January 1988 and 30 June 2015 at Mayo Clinic (Rochester, MN, USA). We compared age, sex, right ventricle systolic pressure by echocardiography, and right heart catheterization measurements/calculations among subgroups of portopulmonary hypertension patients with splenectomy and/or autoimmune liver disease (autoimmune hepatitis/primary biliary cirrhosis/primary sclerosing cholangitis). RESULTS The cohort consisted of 141 patients, of whom 8 (6%) had a history of splenectomy prior to the development of portopulmonary hypertension. Twenty-seven (19%) portopulmonary hypertension patients had autoimmune liver disease, and 5 of 8 (62.5%) splenectomized portopulmonary hypertension patients had autoimmune liver disease. No significant difference was noted in right heart catheterization measurements/calculations between splenectomized and non-splenectomized portopulmonary hypertension patients. Right ventricle systolic pressure by echocardiography was significantly higher in those splenectomized. CONCLUSIONS Prior history of splenectomy in portopulmonary hypertension was 6% in this cohort. The combination of autoimmune liver disease and splenectomy in portopulmonary hypertension was not uncommon. History of splenectomy in patients with portal hypertension and/or autoimmune liver disease may have clinical implications.
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Affiliation(s)
- Justin M Segraves
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Rodrigo Cartin-Ceba
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Scottsdale, Arizona, USA
| | - Michael D Leise
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael J Krowka
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
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15
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Yang JD, Leise MD. Reply to: "Interferon-free therapy of hepatitis C during wait list and post transplant risk of hepatocellular carcinoma recurrence". J Hepatol 2017; 67:1357. [PMID: 28800877 DOI: 10.1016/j.jhep.2017.08.001] [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: 08/02/2017] [Accepted: 08/03/2017] [Indexed: 12/04/2022]
Affiliation(s)
- Ju Dong Yang
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Michael D Leise
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN, USA.
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16
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Affiliation(s)
- Ju Dong Yang
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Michael D Leise
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota
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17
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Haffar S, Bazerbachi F, Leise MD, Dillon JJ, Albright RC, Murad MH, Kamath PS, Watt KD. Systematic review with meta-analysis: the association between hepatitis E seroprevalence and haemodialysis. Aliment Pharmacol Ther 2017; 46:790-799. [PMID: 28869287 DOI: 10.1111/apt.14285] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [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: 06/15/2017] [Revised: 07/10/2017] [Accepted: 08/13/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Hepatitis E virus (HEV) infection appears to be more common than previously thought. HEV seroprevalence in patients on maintenance haemodialysis (HD) is unclear with a range from 0% to 44%. In addition, risk factors of transmission of HEV in patients on haemodialysis are unknown. AIM To perform a systematic review and meta-analysis of HEV seroprevalence in HD patients compared with controls. METHODS A systematic search of several databases identified all observational studies with comparative arms. Two reviewers extracted data and assessed the methodological quality. A random-effects model was used for pooled odds ratio (OR) and 95% confidence interval (CI) of positive anti-HEV IgG in both groups. Heterogeneity and publication bias were assessed with appropriate tests. RESULTS We identified 31 studies from 17 countries between 1994 and 2016. Sixteen studies were judged to have adequate quality and 15 to have moderate limitations. HEV infection was more prevalent in patients on haemodialysis compared with controls (OR 2.47, 95% CI 1.79-3.40, I2 = 75.2%, P < .01). We conducted several subgroup analyses without difference in results. Egger regression test did not suggest publication bias (P = .83). Specific risk factors of HEV transmission in patients on haemodialysis were not clearly identified. CONCLUSIONS Hepatitis E virus infection is more prevalent in patients on haemodialysis compared with non-haemodialysis control groups. Further studies are needed to determine risk factors of acquisition, impact on health, and risk for chronic HEV especially among those patients going to receive organ transplantation.
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Affiliation(s)
- S Haffar
- Digestive Center for Diagnosis & Treatment, Damascus, Syrian Arab Republic
| | - F Bazerbachi
- Digestive Center for Diagnosis & Treatment, Damascus, Syrian Arab Republic
| | - M D Leise
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - J J Dillon
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - R C Albright
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - M H Murad
- Division of Preventive Medicine, Mayo Clinic, Rochester, MN, USA
| | - P S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - K D Watt
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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18
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Yang JD, Leise MD. Damned if you do, damned if you don't: The evolving story of de novo and recurrent hepatocellular carcinoma amongst those treated with direct-acting antivirals for hepatitis C virus. Liver Int 2017; 37:809-811. [PMID: 28544691 DOI: 10.1111/liv.13422] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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: 03/07/2017] [Accepted: 03/13/2017] [Indexed: 02/06/2023]
Affiliation(s)
- Ju Dong Yang
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Michael D Leise
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN, USA
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19
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Leise MD, Findlay JY. Hyponatremia in the perioperative period: When and how to correct. Clin Liver Dis (Hoboken) 2017; 9:111-114. [PMID: 30992972 PMCID: PMC6467151 DOI: 10.1002/cld.630] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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: 09/07/2016] [Revised: 12/22/2016] [Accepted: 01/28/2017] [Indexed: 02/04/2023] Open
Affiliation(s)
- Michael D. Leise
- William J. von Liebig Center for Transplantation and Clinical Regeneration,Division of Gastroenterology & Hepatology
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20
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Bazerbachi F, Leise MD, Watt KD, Murad MH, Prokop LJ, Haffar S. Systematic review of mixed cryoglobulinemia associated with hepatitis E virus infection: association or causation? Gastroenterol Rep (Oxf) 2017; 5:178-184. [PMID: 28852522 PMCID: PMC5554391 DOI: 10.1093/gastro/gox021] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 02/19/2017] [Accepted: 03/15/2017] [Indexed: 02/06/2023] Open
Abstract
Background and aim: Mixed cryoglobulinemia (MC) has been associated with several viral infections, and chronic hepatitis C is recognized as a major cause. MC associated with hepatitis E virus (HEV) has been described and little is known about this rare association. The aim of this study is to perform a systematic review of MC associated with HEV, and examine the presence of a causal relationship. Methods: An experienced librarian conducted a search of databases from each database’s inception to 12 December 2016 based on a priori criteria. The risk of bias was assessed, and Hill’s criteria were applied to determine causality. Results: Five publications met inclusion criteria, with a total of 15 cases. Three studies had low, one low to moderate and one moderate risk of bias. Median age was 43 years, and all patients came from Western Europe. Two patients were immunocompetent, while 13 were immunosuppressed, post solid organ transplant and had chronic hepatitis E. Renal involvement was observed in seven patients, mild to moderately severe cryoglobulinemic disease in one patient and severe cryoglobulinemic disease in three patients. One patient improved spontaneously, and another was treated with immunosuppressant reduction leading to viral clearance. Ten patients treated with peg-interferon or ribavirin for 3 months achieved loss of cryoglobulinemia and end-of-treatment response, but sustained virologic response was reported and achieved in two. Immunosuppressant achieved loss of cryoglobulinemia in three patients. One case of chronic renal failure, three cases of end-stage renal disease and one death were observed. Five of the nine Hill’s criteria were fulfilled. Conclusion: MC has been described with HEV infection. A causal relationship between HEV infection and cryoglobulinemia is highly probable.
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Affiliation(s)
- Fateh Bazerbachi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Michael D Leise
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Kymberly D Watt
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - M Hassan Murad
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Larry J Prokop
- Library Public Services, Mayo Clinic, Rochester, MN, USA
| | - Samir Haffar
- Digestive Centre for Diagnosis and Treatment, Damascus, Syrian Arab Republic
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21
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Yang JD, Larson JJ, Watt KD, Allen AM, Wiesner RH, Gores GJ, Roberts LR, Heimbach JA, Leise MD. Hepatocellular Carcinoma Is the Most Common Indication for Liver Transplantation and Placement on the Waitlist in the United States. Clin Gastroenterol Hepatol 2017; 15:767-775.e3. [PMID: 28013117 PMCID: PMC5401787 DOI: 10.1016/j.cgh.2016.11.034] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [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: 11/18/2016] [Accepted: 11/20/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Management strategies for patients with hepatitis C virus (HCV) infection and hepatocellular carcinoma (HCC) have changed, along with liver allocation policies based on model for end-stage liver disease score. We investigated etiologic-specific trends in liver transplantation in the United States during different time periods. METHODS We performed a retrospective study, using the United Network for Organ Sharing/Organ Procurement and Transplantation Network registry data, to identify all adult patients registered for liver transplantation in the United States from January 1, 2004, through December 31, 2015. For subjects listed with multiple diagnoses, HCC was considered the primary listing diagnosis. To determine whether availability of direct-acting antiviral agents, which began in 2011, affected pretransplant (death or drop-out) and post-transplant outcomes for patients with HCV infection, we compared data from the time periods of 2004 to 2010 and 2011 to 2014. We used competing-risk analysis to compare differences in end points between these periods. Differences between periods in pretransplantation and post-transplantation outcomes were estimated using Kaplan-Maier analysis and compared using the log-rank test. Associations between year of listing and pre-liver transplant outcome, and year of liver transplant and survival after transplant, were examined using the log-rank test. Proportional hazard regression was used to evaluate the reliability of the time period effect with potential confounders. RESULTS Among 109,018 registrants, 18.5% were registered for liver transplantation because of HCC. In 2015, HCC was the leading diagnosis among registrants (23.9% of registrations) and recipients (27.2% of recipients). Between 2004 and 2015, the ratio of registrants with vs without HCC increased 5.6-fold for patients with HCV infection, 1.9-fold for patients with hepatitis B virus (HBV) infection, 2.7-fold for patients with alcohol abuse, and 10.2-fold for patients with nonalcoholic steatohepatitis. After adjusting for covariates, we associated the period of 2011 to 2014 with a decreased probability that HCC registrants would undergo liver transplantation (hazard ratio [HR], 0.62; P < .0001). The period of 2011 to 2014 also was associated with a decreased probability of drop-out owing to deterioration or death from HCV-induced (HR, 0.90; P = .0003), HBV-induced (HR, 0.71; P = .002), or alcohol-induced (HR, 0.90; P = .01) liver disease, and an increased probability of delisting as a result of clinical improvement in patients with HCV infection (HR, 3.4; P < .0001), HBV infection (HR, 2.3; P = .004), or alcohol abuse (HR, 2.2; P < .0001). The period of 2011 to 2014 was associated with a decreased risk of graft loss or death, with the largest effect seen in HCV-infected recipients (HR, 0.76; P < .0001). CONCLUSIONS HCC was the leading indication for liver transplantation in the United States in 2015. Despite this, the probability of liver transplantation decreased the most in registrants with HCC. Pretransplantation and post-transplantation outcomes have improved, particularly in patients with HCV infection.
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Affiliation(s)
- Ju Dong Yang
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN
| | - Joseph J. Larson
- Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine, Rochester, MN
| | - Kymberly D. Watt
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN
| | - Alina M. Allen
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN
| | - Russell H. Wiesner
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN
| | - Gregory J. Gores
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN
| | - Lewis R. Roberts
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN
| | - Julie A. Heimbach
- Division of Transplant Surgery, Mayo Clinic College of Medicine, Rochester, MN
| | - Michael D. Leise
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN
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22
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Ahmed Mohammed HA, Yang JD, Giama NH, Choi J, Ali HM, Mara KC, Harmsen WS, Wiesner RH, Leise MD, Therneau TM, Roberts LR. Factors Influencing Surveillance for Hepatocellular Carcinoma in Patients with Liver Cirrhosis. Liver Cancer 2017; 6:126-136. [PMID: 28275579 PMCID: PMC5340216 DOI: 10.1159/000450833] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [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] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE Hepatocellular carcinoma (HCC) is the second most common cause of cancer-related mortality worldwide, and a rising cause of cancer mortality in the U.S. Liver cirrhosis is the major risk factor for HCC. Surveillance of persons with cirrhosis facilitates early detection and improves outcomes. We assessed the surveillance rate for HCC within a major academic health system and identified factors influencing surveillance. PATIENTS AND METHODS We examined the surveillance rate for HCC using liver ultrasound, CT, or MRI, and factors influencing surveillance in a cohort of 369 Minnesota residents with cirrhosis seen at the Mayo Clinic between 2007 and 2009. RESULTS Ninety-three percent of cirrhosis patients received at least one surveillance study, but only 14% received the recommended uninterrupted semiannual surveillance. Thirty percent received ≥75% of recommended surveillance, and 59% received ≥50% of recommended surveillance. Factors increasing surveillance included gastroenterology or hepatology specialist visits (p < 0.0001), advanced liver disease as assessed by hepatic encephalopathy (p = 0.0008), and comorbid illness as assessed by diabetes mellitus (p = 0.02). Age, sex, race, residence, cirrhosis etiology, or number of primary care visits did not significantly affect the rate of surveillance. CONCLUSIONS While the rate of surveillance in a major academic health system was higher than reported in other studies, surveillance was heavily dependent on visits to a subspecialist. This suggests a major and urgent national need to improve identification of individuals at risk for HCC in the primary care setting and the initiation and maintenance of surveillance by primary care practitioners.
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Affiliation(s)
- Hager A. Ahmed Mohammed
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minn., USA
| | - Ju Dong Yang
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minn., USA
| | - Nasra H. Giama
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minn., USA
| | - Jonggi Choi
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minn., USA
| | - Hawa M. Ali
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minn., USA
| | - Kristin C. Mara
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minn., USA
| | - William S. Harmsen
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minn., USA
| | - Russell H. Wiesner
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minn., USA
| | - Michael D. Leise
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minn., USA
| | - Terry M. Therneau
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minn., USA
| | - Lewis R. Roberts
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minn., USA,*Lewis R. Roberts, MB, ChB, PhD, Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905 (USA), E-Mail
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23
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Lynn AM, Leise MD. Reply. Liver Transpl 2016; 22:1736-1737. [PMID: 27731936 DOI: 10.1002/lt.24647] [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: 09/13/2016] [Accepted: 09/16/2016] [Indexed: 01/13/2023]
Affiliation(s)
- Amanda M Lynn
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Michael D Leise
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
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24
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Dines VA, Leise MD. Direct acting antivirals for hepatitis c and hepatocellular carcinoma recurrence: an unsolved mystery. Transl Cancer Res 2016. [DOI: 10.21037/tcr.2016.12.33] [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: 11/06/2022]
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25
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Yang JD, Aqel BA, Pungpapong S, Gores GJ, Roberts LR, Leise MD. Direct acting antiviral therapy and tumor recurrence after liver transplantation for hepatitis C-associated hepatocellular carcinoma. J Hepatol 2016; 65:859-860. [PMID: 27392425 DOI: 10.1016/j.jhep.2016.06.023] [Citation(s) in RCA: 111] [Impact Index Per Article: 13.9] [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: 05/17/2016] [Revised: 06/20/2016] [Accepted: 06/21/2016] [Indexed: 02/08/2023]
Affiliation(s)
- Ju Dong Yang
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN, United States
| | - Bashar A Aqel
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Mayo Clinic, Scottsdale, AZ, United States
| | - Surakit Pungpapong
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Gregory J Gores
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN, United States
| | - Lewis R Roberts
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN, United States
| | - Michael D Leise
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN, United States.
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26
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Lynn AM, Singh S, Congly SE, Khemani D, Johnson DH, Wiesner RH, Kamath PS, Andrews JC, Leise MD. Embolization of portosystemic shunts for treatment of medically refractory hepatic encephalopathy. Liver Transpl 2016; 22:723-31. [PMID: 26970243 PMCID: PMC4917293 DOI: 10.1002/lt.24440] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [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: 11/17/2015] [Revised: 01/28/2016] [Accepted: 02/06/2016] [Indexed: 01/13/2023]
Abstract
Treatment options for refractory hepatic encephalopathy (HE) are limited. Patients who fail medical management may harbor large portosystemic shunts (PSSs) which are possible therapeutic targets. This study aims to describe patient selection, effectiveness, and safety of percutaneous PSS embolization in those with medically refractory HE. A retrospective evaluation of consecutive adult patients with medically refractory HE referred for PSS embolization at a tertiary center was performed (2003-2015). Patient data collected included the type of HE, medications, Model for End-Stage Liver Disease (MELD) score, shunt type, embolization approach, and materials used. Outcomes of interest were immediate (7 days), intermediate (1-4 months), and longer-term (6-12 months) effectiveness and periprocedural safety. Effectiveness was determined based on changes in hospitalization frequency, HE medications, and symptoms. Twenty-five patients with large PSS were evaluated for shunt embolization. Five were excluded due to high MELD scores (n = 1), comorbid conditions (n = 1), or technical considerations (n = 3). Of 20 patients who underwent embolization, 13 had persistent and 7 had recurrent HE; 100% (20/20) achieved immediate improvement. Durable benefit was achieved in 100% (18/18) and 92% (11/12) at 1-4 and 6-12 months, respectively. The majority (67%; 8/12) were free from HE-related hospitalizations over 1 year; 10% developed procedural complications, and all resolved. Six developed new or worsening ascites. In conclusion, PSS embolization is a safe and effective treatment strategy that should be considered for select patients with medically refractory HE. Liver Transplantation 22 723-731 2016 AASLD.
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Affiliation(s)
- Amanda M. Lynn
- Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Siddharth Singh
- Division of Gastroenterology, University of California, San Diego, La Jolla, CA
| | - Stephen E. Congly
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Disha Khemani
- Department of Gastroenterology and Hepatology, William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
| | - David H. Johnson
- Department of Gastroenterology and Hepatology, William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
| | - Russell H. Wiesner
- Department of Gastroenterology and Hepatology, William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
| | - Patrick S. Kamath
- Department of Gastroenterology and Hepatology, William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
| | - James C. Andrews
- Department of Division of Vascular and Interventional Radiology, Mayo Clinic, Rochester, MN
| | - Michael D. Leise
- Department of Gastroenterology and Hepatology, William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
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Abstract
The intestinal microbiome and immune system are in close symbiotic relationship in health. Gut microbiota plays a role in many chronic liver diseases and cirrhosis. However, alterations in the gut microbiome after liver transplantation and the implications for liver transplant recipients are not well understood and rely mainly on experimental animal studies. Recent advances in molecular techniques have identified that increased intestinal permeability, decreased beneficial bacteria, and increased pathogenic species may play important roles in the early posttransplant period. The associations between microbiota perturbation and postliver transplant infections and acute rejection are evolving. The link with metabolic syndrome, obesity, and cardiac disease in the general population require translation into the transplant recipient. This review focuses on our current knowledge of the known and potential interaction of the microbiome in the liver transplant recipient. Future human studies focused on microbiota changes in liver transplant patients are warranted and expected.
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Affiliation(s)
- Iliana Doycheva
- 1 Division of Gastroenterology and Hepatology, Medical University, Sofia, Bulgaria. 2 Division of Gastroenterology and Hepatology, Mayo Clinic Transplant Center, Rochester, MN
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28
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Fenstad ER, Dzyubak B, Oh JK, Williamson EE, F Glockner J, Young PM, Anavekar NS, Leise MD, Ehman RL, Araoz PA, Venkatesh SK. Evaluation of liver stiffness with magnetic resonance elastography in patients with constrictive pericarditis: Preliminary findings. J Magn Reson Imaging 2015; 44:81-8. [PMID: 26691749 DOI: 10.1002/jmri.25126] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 12/01/2015] [Indexed: 01/26/2023] Open
Abstract
PURPOSE To evaluate with magnetic resonance elastography (MRE) whether patients with constrictive pericarditis (CP) have increased hepatic stiffness. CP results in reduced pericardial compliance, ventricular interdependence, and right heart failure. Patients with untreated CP may develop liver fibrosis and ultimately cirrhosis due to chronic venous congestion. Chronic venous congestion ± fibrosis may lead to increased liver stiffness. MATERIALS AND METHODS Prospectively, patients with suspected CP underwent 2D transthoracic echocardiography, cardiac MRI, and liver MRE. An automated method was used to draw regions of interest (ROIs) on the stiffness maps to calculate the mean liver stiffness in kilopascals (kPa). A t-test with α = 0.05 was performed between stiffness values of patients with positive and negative CP findings based on previously published echocardiography criteria. RESULTS Nineteen patients met inclusion criteria with a mean ± standard deviation (SD) age of 51 ± 16 years. Nine patients (47%) had CP. Mean liver stiffness trended higher in patients with CP compared to those without CP (4.04 kPa vs. 2.46; P = 0.045). Liver stiffness correlated with MRI septal bounce (P = 0.04), inferior vena cava size (P = 0.003), echo abnormal septal motion (P = 0.04), and echo mitral inflow variation >25% (P = 0.02). Only MRI septal bounce predicted CP by echocardiography (P < 0.001). CONCLUSION CP was associated with increased liver stiffness. The increased stiffness is most likely secondary to chronic hepatic venous congestion and/or fibrosis. MRE may be useful for noninvasive liver stiffness assessment in CP. J. Magn. Reson. Imaging 2016;44:81-88.
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Affiliation(s)
- Eric R Fenstad
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Bogdan Dzyubak
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jae K Oh
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Phillip M Young
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Nandan S Anavekar
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael D Leise
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Richard L Ehman
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Philip A Araoz
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
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29
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Affiliation(s)
- Larissa L Fujii-Lau
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael D Leise
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ferga C Gleeson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael J Levy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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30
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Fussner LA, Heimbach JK, Fan C, Dierkhising R, Coss E, Leise MD, Watt KD. Cardiovascular disease after liver transplantation: When, What, and Who Is at Risk. Liver Transpl 2015; 21:889-96. [PMID: 25880971 DOI: 10.1002/lt.24137] [Citation(s) in RCA: 127] [Impact Index Per Article: 14.1] [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] [Received: 12/31/2014] [Revised: 03/09/2015] [Accepted: 03/22/2015] [Indexed: 12/11/2022]
Abstract
The evolution of metabolic and cardiovascular disease (CVD) complications after liver transplantation (LT) is poorly characterized. We aim to illustrate the prevalence of obesity and metabolic syndrome (MS), define the cumulative incidence of CVD, and characterize risk factors associated with these comorbidities after LT. A retrospective review of 455 consecutive LT recipients from 1999 to 2004 with an 8- to 12-year follow-up was performed. Obesity increased from 23.8% (4 months) to 40.8% (3 years) after LT. Increase in body mass index predicted MS at 1 year after LT (odds ratio, 1.1; P < 0.001, per point). CVD developed in 10.6%, 20.7%, and 30.3% of recipients within 1, 5, and 8 years, respectively. Age, diabetes, hypertension, glomerular filtration rate < 60 mL/minute, prior CVD, ejection fraction < 60%, left ventricular hypertrophy, and serum troponin (TN) > 0.07 ng/mL were associated with CVD on univariate analysis. Age (hazard ratio [HR], 1.03; 95% confidence interval [CI], 1.01-1.06; P = 0.019), diabetes (HR, 1.78; 95% CI, 1.09-2.92; P = 0.022), prior history of CVD (HR, 2.46; 95% CI, 1.45-4.16; P < 0.001), and serum TN > 0.07 ng/mL (HR, 1.98; 95% CI, 1.23-3.18; P = 0.005) were independently associated with CVD in the long term. Smoking history (ever), sex, hyperlipidemia, and serum ferritin levels were not predictive of CVD. Tacrolimus use versus noncalcineurin-based immunosuppression (HR, 0.26; 95% CI, 0.14-0.49; P < 0.001) was associated with reduced risk of CVD but not versus cyclosporine (HR, 0.67; 95% CI, 0.30-1.49; P = 0.322). CVD is common after LT. Independent of MS, more data are needed to identify nonconventional risk factors and biomarkers like serum TN. Curbing weight gain in the early months after transplant may impact MS and subsequent CVD in the long term.
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Affiliation(s)
- Lynn A Fussner
- Department of Internal Medicine, Transplant Center, Mayo Clinic, Rochester, MN
| | | | - Chun Fan
- Division of Biomedical Statistics and Informatics, Transplant Center, Mayo Clinic, Rochester, MN
| | - Ross Dierkhising
- Division of Biomedical Statistics and Informatics, Transplant Center, Mayo Clinic, Rochester, MN
| | - Elizabeth Coss
- Department of Internal Medicine, Transplant Center, Mayo Clinic, Rochester, MN
| | - Michael D Leise
- Department of Internal Medicine, Transplant Center, Mayo Clinic, Rochester, MN.,Gastroenterology and Hepatology, Transplant Center, Mayo Clinic, Rochester, MN
| | - Kymberly D Watt
- Department of Internal Medicine, Transplant Center, Mayo Clinic, Rochester, MN.,Gastroenterology and Hepatology, Transplant Center, Mayo Clinic, Rochester, MN
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Shih HH, Law RJ, Leise MD. 64-year-old woman with diarrhea and increased abdominal girth. Mayo Clin Proc 2015; 90:e35-9. [PMID: 25841264 DOI: 10.1016/j.mayocp.2014.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Revised: 07/04/2014] [Accepted: 07/15/2014] [Indexed: 11/21/2022]
Affiliation(s)
- Henry H Shih
- Resident in Internal Medicine, Mayo School of Graduate Medical Education, Rochester, MN
| | - Ryan J Law
- Resident in Internal Medicine, Mayo School of Graduate Medical Education, Rochester, MN
| | - Michael D Leise
- Advisor to residents and Consultant in Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.
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32
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Affiliation(s)
- Michael D Leise
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
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33
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Leise MD, Leung N, El-Zoghby Z, Gonzalez Gonzalez HC, Cerhan JH, Nyberg SL. Treatment of persistent/medically refractory covert hepatic encephalopathy with the molecular adsorbent recirculating system. Liver Transpl 2014; 20:867-8. [PMID: 24700610 DOI: 10.1002/lt.23883] [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: 01/18/2014] [Accepted: 03/26/2014] [Indexed: 01/12/2023]
Affiliation(s)
- Michael D Leise
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
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34
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Leise MD, Yun BC, Larson JJ, Benson JT, DongYang J, Therneau TM, Rosen CB, Heimbach JK, Biggins SW, Kim WR. Effect of the pretransplant serum sodium concentration on outcomes following liver transplantation. Liver Transpl 2014; 20:687-97. [PMID: 24616214 PMCID: PMC4128788 DOI: 10.1002/lt.23860] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [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: 10/03/2013] [Revised: 02/04/2014] [Accepted: 02/18/2014] [Indexed: 12/23/2022]
Abstract
Hyponatremia is associated with an increased risk of mortality on the liver transplantation (LT) waiting list. Although the incorporation of the serum sodium (Na) level into the Model for End-Stage Liver Disease score may reduce wait-list mortality, concerns remain about a potential association between pre-LT hyponatremia and decreased post-LT survival. Furthermore, the relationship between pre-LT hypernatremia and post-LT survival remains unexplored. The purpose of this study was to investigate the impact of the entire spectrum of pre-LT serum Na levels on post-LT outcomes. We identified 19,537 patients from 2003 to 2010 for whom serum Na levels immediately before LT were available. The patients were divided into 3 groups [hyponatremic (Na ≤ 130 mEq/L), normonatremic (Na = 131-145 mEq/L), and hypernatremic (Na > 145 mEq/L)], and their post-LT outcomes were compared. There was no difference in in-hospital mortality or 90-day survival between patients with hyponatremia and patients with normonatremia. A fraction of the patients (2.4%) had hypernatremia, which was associated with increased in-hospital mortality (11.2% versus 4.2%, P < 0.001) and diminished 90-day survival (86.4% versus 94.0.%, P < 0.001). After adjustments for important clinical variables, the association of pre-LT hypernatremia with posttransplant mortality remained significant with a hazard ratio of 1.13 for each unit increase in the Na level > 145 mEq/L (P < 0.001). The duration of the hospitalization after LT was significantly longer for hypernatremic patients (P < 0.001). In conclusion, hyponatremia per se does not affect post-LT survival. Pre-LT hypernatremia is a highly significant risk factor for post-LT mortality.
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Affiliation(s)
| | - Byung Cheol Yun
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | | | | | - Ju DongYang
- William J. von Leibig Transplant Center, Mayo Clinic, Rochester
| | | | | | | | - Scott W. Biggins
- Division of Gastroenterology and Hepatology, University of Colorado Denver Anschutz Medical Campus, Aurora Colorado
| | - W. Ray Kim
- William J. von Leibig Transplant Center, Mayo Clinic, Rochester
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35
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Congly SE, Leise MD. Rifaximin for episodic, overt hepatic encephalopathy: the data are catching up to clinical practice, but questions remain. Am J Gastroenterol 2014; 109:598. [PMID: 24698864 DOI: 10.1038/ajg.2013.480] [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: 12/11/2022]
Affiliation(s)
- Stephen E Congly
- Liver Unit, Division of Gastroenterology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Michael D Leise
- Department of Gastroenterology and Hepatology, Mayo Clinic and Foundation, Rochester, Minnesota, USA
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36
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Singh S, Kamath PS, Andrews JC, Leise MD. Embolization of spontaneous portosystemic shunts for management of severe persistent hepatic encephalopathy. Hepatology 2014; 59:735-6. [PMID: 23775720 DOI: 10.1002/hep.26575] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [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: 04/29/2013] [Revised: 05/01/2013] [Accepted: 05/07/2013] [Indexed: 12/07/2022]
Affiliation(s)
- Siddharth Singh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
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37
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Abstract
Hepatic encephalopathy (HE) develops in up to 50% of patients with cirrhosis and is a feature of decompensated cirrhosis. With the goal of reviewing the evidence for treatment and prevention of overt hepatic encephalopathy, pubmed was searched using search terms hepatic encephalopathy AND treatment, limited to human studies from January 1, 2003, through December 1, 2013, and supplemented by key references. The inpatient incidence of HE is approximately 23,000 annually, and management of these patients is common for internists and subspecialists. Treatment of the hospitalized patient with HE has changed in recent years. Treatment entails 2 phases: induction and maintenance of remission. Most cases of significant HE are precipitated by infection, gastrointestinal bleeding, medications, or other culprits. All patients should be evaluated for secondary triggers of HE, and treatment should be initiated with a nonabsorbable disaccharide (ie, lactulose) in most patients. Rifaximin (off label) can be added in patients not responding to lactulose. Neomycin is a less preferred alternative to rifaximin owing to its adverse effect profile. Other therapies, including zinc, L-ornithine-L-aspartate, and branched-chain amino acids, can be considered for patients not responding to disaccharides and nonabsorbable antibiotics. Large portosystemic shunts may be embolized in patients with medically refractory recurrent or severe HE with otherwise well-compensated cirrhosis. Molecular Adsorbent Recirculating System is now available for patients with severe HE who do not respond to medical therapy. It is critically important that patients hospitalized with significant HE continue maintenance therapy at the time of dismissal to prevent further episodes. Patients with a first-time episode of HE can be administered lactulose, and careful instructions should be provided to patients and caregivers about dose titration to achieve 3 bowel movements daily. Patients with recurrent HE episodes despite lactulose use benefit from the addition of rifaximin, which decreases the frequency of recurrent HE episodes and related hospitalizations. Last, patients and their families should be counseled about the risk of motor vehicle accidents, which require mandatory reporting to the Department of Motor Vehicles in some states.
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Affiliation(s)
- Michael D Leise
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.
| | - John J Poterucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - W Ray Kim
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
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38
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Abstract
Drug hepatoxicity can be nonidiosyncratic (predictable), as in the case of acetaminophen, or idiosyncratic (unpredictable). This review article focuses primarily on idiosyncratic drug-induced liver injury (DILI). New epidemiologic data suggest that approximately 20 new cases of DILI per 100,000 persons occur each year. Idiosyncratic DILI accounts for 11% of the cases of acute liver failure in the United States. Risk factors for DILI include medication dose, drug lipophilicity, and extent of hepatic metabolism. There is mixed evidence to support the role of host factors such as age, sex, and chronic liver disease in the development of DILI. For specific drugs, a genetic predisposition appears to be a risk factor for DILI. Suspected cases of idiosyncratic DILI should be categorized as hepatitic, cholestatic, or mixed on the basis of the degree/ratio of abnormalities in the alanine aminotransferase and alkaline phosphatase. A careful evaluation for other causes of liver disease should be performed, though a liver biopsy is rarely needed. There is evidence that some patients with DILI may actually have hepatitis E and this diagnosis should be considered. Amoxicillin/clavulanate isoniazid, and nonsteroidal anti-inflammatory drugs are among the most common causes of DILI. Drug discontinuation or dechallenge should lead to an improvement in liver biochemistries in most patients, though a bilirubin value of more than 3 g/dL is associated with mortality of at least 10%. New biomarkers for DILI using proteomics and micro RNA appear promising but require further study. New studies on drugs with potential for causing DILI are reviewed herein, including tumor necrosis factor-alpha antagonists, fluoroquinolones, tyrosine kinase inhibitors, statins, and supplements. PubMed was used with search terms of drug induced liver injury OR DILI with filter settings of "English language" and "humans" and custom date range of "January 1, 2000." The authors also manually searched bibliographies from key references and included seminal references before the year 2000.
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Affiliation(s)
- Michael D Leise
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.
| | - John J Poterucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
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39
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Law R, Leal C, Dayyeh BA, Leise MD, Balderramo D, Baron TH, Cardenas A. Role of immunosuppression in post-endoscopic retrograde cholangiopancreatography pancreatitis after liver transplantation: a retrospective analysis. Liver Transpl 2013; 19:1354-60. [PMID: 24115362 DOI: 10.1002/lt.23758] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [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: 07/03/2013] [Accepted: 08/27/2013] [Indexed: 12/11/2022]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is frequently used for diagnosis and therapeutic interventions in recipients of liver transplantation (LT) who develop biliary complications. Post-endoscopic retrograde cholangiopancreatography acute pancreatitis (PEP) is the most common major adverse event after ERCP; however, the frequency of PEP in LT recipients is not well established. We aimed to determine the rate of PEP in this population and to identify its predictors, especially among immunosuppressive agents. We reviewed all ERCP procedures performed in LT recipients after duct-to-duct biliary anastomoses at 2 high-volume transplant centers. Patients who had undergone sphincterotomy or had a surgically altered pancreaticobiliary anatomy before LT were excluded. Electronic medical records and endoscopy databases were used to obtain clinical, endoscopic, and medication data. A multivariate logistic regression analysis was used to determine predictors of PEP in this cohort. In all, 730 ERCP procedures were performed in 301 patients during the study period with an observed PEP rate of 3% (22/730). A univariate analysis revealed an increased risk of PEP with index ERCP after LT [odds ratio (OR) = 4.04, 95% confidence interval (CI) = 1.40-11.65] and in cases with difficult biliary cannulation (OR = 2.89, 95% CI = 1.10-7.65), whereas prednisone use was found to have a protective effect in both univariate (OR = 0.34, 95% CI = 0.14-0.84) and multivariate analyses (OR = 0.22, 95% CI = 0.09-0.57) after adjustments for difficult biliary cannulation and post-LT index ERCP. This retrospective analysis demonstrates that corticosteroid therapy has a protective role in the development of PEP in LT recipients. Further studies are warranted to confirm our findings.
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Affiliation(s)
- Ryan Law
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
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40
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Law R, Leise MD, Baron TH. Transduodenal drainage of a malignant ovarian pseudocyst for palliation of gastroduodenal and biliary obstruction (with video). Gastrointestinal Intervention 2013. [DOI: 10.1016/j.gii.2013.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Leise MD, Bakken JC, Zielinski MD, Baron TH. Complete endoscopic removal of a necrotic spleen (with video). Gastrointest Endosc 2012; 75:694-5. [PMID: 21741638 DOI: 10.1016/j.gie.2011.04.026] [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: 03/23/2011] [Accepted: 04/19/2011] [Indexed: 02/08/2023]
Affiliation(s)
- Michael D Leise
- Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota 55905, USA
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42
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Affiliation(s)
- Michael Charlton
- Division of Gastroenterology and Hepatology, Mayo Clinic and Foundation, Rochester, MN, USA
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43
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Affiliation(s)
- Michael D Leise
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
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44
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Leise MD, Kim WR, Kremers WK, Larson JJ, Benson JT, Therneau TM. A revised model for end-stage liver disease optimizes prediction of mortality among patients awaiting liver transplantation. Gastroenterology 2011; 140:1952-60. [PMID: 21334338 PMCID: PMC4546828 DOI: 10.1053/j.gastro.2011.02.017] [Citation(s) in RCA: 108] [Impact Index Per Article: 8.3] [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: 06/30/2010] [Revised: 01/16/2011] [Accepted: 02/14/2011] [Indexed: 12/22/2022]
Abstract
BACKGROUND & AIMS The Model for End Stage Liver Disease (MELD) was originally developed based on data from patients who underwent the transjugular intrahepatic portosystemic shunt procedure. An updated MELD based on data from patients awaiting liver transplantation should improve mortality prediction and allocation efficiency. METHODS Wait-list data from adult primary liver transplantation candidates from the Organ Procurement and Transplantation Network were divided into a model derivation set (2005-2006; n=14,214) and validation set (2007-2008; n=13,945). Cox regression analysis was used to derive and validate an optimized model that updated coefficients and upper and lower bounds for MELD components and included serum levels of sodium. Main outcomes measure was ability to predict 90-day mortality of patients on the liver transplantation wait list. RESULTS Optimized MELD score updated coefficients and implemented new upper and lower bounds for creatinine (0.8 and 3.0 mg/dL, respectively) and international normalized ratio (1 and 3, respectively). Serum sodium concentrations significantly predicted mortality, even after adjusting for the updated MELD model. The final model, based on updated fit of the 4 variables (ie, bilirubin, creatinine, international normalized ratio, and sodium) had a modest yet statistically significant gain in discrimination (concordance: 0.878 vs 0.865; P<.01) in the validation dataset. Utilization of the new score could affect up to 12% of patients (based on changed score for 459 of 3981 transplants in the validation set). CONCLUSIONS Modification of MELD score to update coefficients, change upper and lower bounds, and incorporate serum sodium levels improved wait-list mortality prediction and should increase efficiency of allocation of donated livers.
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Affiliation(s)
- Michael D. Leise
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN
| | - W. Ray Kim
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN,Division of Health Care Policy and Research, Mayo Clinic College of Medicine, Rochester, MN
| | - Walter K. Kremers
- Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine, Rochester, MN,Division of Health Care Policy and Research, Mayo Clinic College of Medicine, Rochester, MN
| | - Joseph J. Larson
- Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine, Rochester, MN
| | - Joanne T. Benson
- Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine, Rochester, MN
| | - Terry M. Therneau
- Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine, Rochester, MN
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Leise MD, Smyrk TC, Takahashi N, Sweetser SR, Vege SS, Chari ST. IgG4-associated cholecystitis: another clue in the diagnosis of autoimmune pancreatitis. Dig Dis Sci 2011; 56:1290-4. [PMID: 21082348 DOI: 10.1007/s10620-010-1478-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [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] [Received: 06/05/2010] [Accepted: 10/26/2010] [Indexed: 12/24/2022]
Abstract
PURPOSE Autoimmune pancreatitis (AIP) is the pancreatic manifestation of IgG4-associated systemic disease (ISD). Criteria for diagnosis of AIP include recognition of extra-pancreatic organ involvement. Because the diagnosis of AIP can be challenging, even for experts, it is important for clinicians to recognize other target organ damage in this disease. Typical gallbladder findings in AIP have been increasingly recognized. Because cholecystectomy is common in the community, the availability of previous tissue from the gallbladder can provide an important supportive clue in the diagnosis of AIP. The objective of this review is to examine the literature on common gallbladder pathology findings in AIP, and discuss their clinical utility. RESULTS Gallbladder involvement in AIP seems to be common. Transmural lymphoplasmacytic inflammatory infiltrates, extramural inflammatory nodules, the presence of tissue eosinophilia, phlebitis, and increased tissue IgG4 are all seen more frequently in the gallbladders of patients with AIP. These findings are not 100% specific, because some can be seen in primary sclerosing cholangitis and pancreatic adenocarcinoma. CONCLUSION Cholecystectomy for the purpose of diagnosing AIP is not recommended. However, if gallbladder specimens from a previous cholecystectomy are available, an expert review of gallbladder slides with IgG4 immunostaining may help to provide additional criteria for diagnosis of autoimmune pancreatitis.
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Affiliation(s)
- Michael D Leise
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Gonda Building 9th Floor, 200 First Street SW, Rochester, MN 55905, USA
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Affiliation(s)
- Michael D Leise
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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Asrani SK, Leise MD, West CP, Murad MH, Pedersen RA, Erwin PJ, Tian J, Wiesner RH, Kim WR. Use of sirolimus in liver transplant recipients with renal insufficiency: a systematic review and meta-analysis. Hepatology 2010; 52:1360-70. [PMID: 20815021 PMCID: PMC4130484 DOI: 10.1002/hep.23835] [Citation(s) in RCA: 69] [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] [Indexed: 01/30/2023]
Abstract
UNLABELLED Sirolimus is used in patients with renal insufficiency after liver transplantation (LT) and especially in those with calcineurin inhibitor (CNI)-associated nephrotoxicity. We conducted a systematic review of all randomized controlled trials and observational studies to test the hypothesis that the use of sirolimus is associated with an improvement in renal function at 1 year in LT recipients with renal insufficiency [glomerular filtration rate (GFR) < 60 mL/minute or creatinine level ≥ 1.5 mg/dL]. We performed a search of all major databases, conference proceedings, and relevant journals through December 2009 and contacted content experts, corresponding authors, and the pharmaceutical manufacturer. A random effects model was used to determine the pooled estimate of the change in renal function and pooled risk estimates of adverse events that may be associated with sirolimus-based therapy at 1 year. Eleven studies (three randomized controlled trials and eight observational studies) met the final inclusion criteria. A nonsignificant improvement of 3.38 mL/minute [95% confidence interval (CI) = -2.93 to 9.69] was observed in methodologically sound observational studies and controlled trials reporting the primary outcome. In controlled trials, baseline GFR >50 mL/min sirolimus use was associated with an improvement of 10.35 mL/minute (95% CI = 3.98-16.77) in GFR or creatinine clearance. Sirolimus was not significantly associated with death [relative risk (RR) = 1.12, 95% CI = 0.66-1.88] or graft failure (RR = 0.80, 95% CI = 0.45-1.41), although reporting was incomplete. It was associated with a statistically significant risk of infection (RR = 2.47, 95% CI = 1.14-5.36), rash (RR = 7.57, 95% CI = 1.75-32.70), ulcers (RR = 7.44, 95% CI = 2.03-27.28), and discontinuation of therapy (RR = 3.61, 95% CI = 1.32-9.89). CONCLUSION Conversion to sirolimus from CNIs is associated with a nonsignificant improvement in renal function in LT recipients with renal insufficiency, although the results are limited by heterogeneity, a risk of bias, and a lack of standardized reporting.
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Affiliation(s)
- Sumeet K Asrani
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Michael D Leise
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Colin P West
- Division of General Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota,Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine, Rochester, Minnesota,Mayo Knowledge and Encounter Research Unit, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - M. Hassan Murad
- Mayo Knowledge and Encounter Research Unit, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Rachel A Pedersen
- Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Patricia J Erwin
- Mayo Knowledge and Encounter Research Unit, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Jianmin Tian
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Russell H. Wiesner
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - W. Ray Kim
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota,Corresponding Author W Ray Kim, 200 First Street SW, Rochester, Minnesota 55905, fax: 507-538-3974, telephone: 507-538-0254,
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Affiliation(s)
- S Sweetser
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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Affiliation(s)
- Seth Sweetser
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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Leise MD, Locke GR, Dierkhising RA, Zinsmeister AR, Reeder GS, Talley NJ. Patients dismissed from the hospital with a diagnosis of noncardiac chest pain: cardiac outcomes and health care utilization. Mayo Clin Proc 2010; 85:323-30. [PMID: 20194143 PMCID: PMC2848420 DOI: 10.4065/mcp.2009.0428] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [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: 12/13/2022]
Abstract
OBJECTIVE To determine the proportion of patients with noncardiac chest pain (NCCP) who see a gastroenterologist, the type and frequency of gastrointestinal (GI) and cardiac tests performed, and the frequency of cardiac death. PATIENTS AND METHODS A cohort of Olmsted County, Minnesota, residents presenting to the emergency department (ED) with chest pain between January 1, 1985, and December 31, 1992, was identified through the Rochester Epidemiology Project. We assessed the frequency of ED, cardiology, and gastroenterology visits and corresponding tests after a diagnosis of NCCP (n=320). We also assessed the frequency of cardiac events. RESULTS During follow-up, 49% of patients sought care in the ED, 42% had repeated cardiology evaluations, and 15% were seen by a gastroenterologist. Thirty-eight percent underwent esophagogastroduodenoscopy, but very few underwent manometry or a pH probe. Patients with NCCP of unknown origin had 3 times the rate of GI consultations as their counterparts with a GI disorder. Survival free of cardiac death in the subset with NCCP with a GI disorder was 90.2% at 10 years and 84.8% at 20 years, compared with 93.7% at 10 years and 88.1% at 20 years for the subset with NCCP of unknown origin. CONCLUSION The frequency of health care utilization in NCCP patients is high, but relatively few GI consultations and even fewer GI tests are performed. Patients dismissed from the hospital with NCCP continue to experience cardiac events, which may highlight a need for more aggressive cardiovascular risk factor management in this population.
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Affiliation(s)
| | - G. Richard Locke
- Individual reprints of this article are not available. Address correspondence to G. Richard Locke III, MD, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First St SW, Rochester, MN 55905 ()
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