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Salmon MK, Cohen WG, Hu F, Aydin A, Coskun AK, Schilsky M, Doty RL. Taste and smell function in Wilson's disease. J Neurol Sci 2024; 459:122949. [PMID: 38493734 DOI: 10.1016/j.jns.2024.122949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 02/20/2024] [Accepted: 03/04/2024] [Indexed: 03/19/2024]
Abstract
OBJECTIVE Wilson's disease (WD) is a metabolic disorder associated with abnormal copper metabolism that results in hepatic, psychiatric, and neurologic symptoms. No investigation of taste function has been made in patients with WD, although olfactory dysfunction has been evaluated. METHODS Quantitative taste and smell test scores of 29 WD patients were compared to those of 790 healthy controls. Taste was measured using the 53-item Waterless Empirical Taste Test (WETT®) and smell using the 40-item revised University of Pennsylvania Smell Identification Test (R-UPSIT®). Multiple linear regression analysis controlled for age and sex. RESULTS Average WETT® scores did not differ meaningfully between WD and control subjects (respective medians & IQRs = 32 [28-42] & 34 [27-41]); linear regression coefficient = 1.19, 95% CI [-0.81, 3.19], p = 0.242). In contrast, WD was associated with significantly reduced olfactory function [respective median (IQR) R-UPSIT® scores = 35 (33-37) vs. 37 (35-38); adjusted linear regression coefficient = -1.59, 95% CI [-2.34, -0.833]; p < 0.001)]. Neither olfaction nor taste were influenced by WD symptom subtype [23 (79.3%) were hepatic-predominant; 6 (20.7%) neurologic predominant]; R-UPSIT®, p = 0.774; WETT®, p = 0.912). No effects of primary medication or years since diagnosis (R-UPSIT®, p = 0.147; WETT®, p = 0.935) were found. Weak correlations were present between R-UPSIT® and WETT® scores for both control (r=0.187, p < 0.0001) and WD (r=0.237) subjects, although the latter correlation did not reach the 0.05 α level (p = 0.084). CONCLUSION Although WD negatively impacts smell function, taste is spared. Research is needed to understand the pathophysiologic mechanisms responsible for this divergence.
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Affiliation(s)
- Mandy K Salmon
- Department of Otorhinolaryngology- Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - William G Cohen
- Department of Otorhinolaryngology- Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Fengling Hu
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Adem Aydin
- Department of Medicine and Surgery, Yale University Medical Center, New Haven, CT, USA
| | - Ayse K Coskun
- Department of Medicine and Surgery, Yale University Medical Center, New Haven, CT, USA
| | - Michael Schilsky
- Department of Medicine and Surgery, Yale University Medical Center, New Haven, CT, USA
| | - Richard L Doty
- Department of Otorhinolaryngology- Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Smell and Taste Center, Department of Otorhinolaryngology- Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Pericleous M, Kelly C, Schilsky M, Dhawan A, Ala A. Defining and characterising a toolkit for the development of a successful European registry for rare liver diseases: a model for building a rare disease registry. Clin Med (Lond) 2022; 22:340-347. [PMID: 38589134 PMCID: PMC9345223 DOI: 10.7861/clinmed.2021-0725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION A rare disease is defined by the European Health Commission as a disorder affecting less than 5/10,000 of the population. There are at least 20 rare liver diseases (RLDs) seen frequently in the adult and paediatric liver clinic, signifying that the hepatology community can be influential in developing such patient databases for registering patients with rare hepatic conditions. The aim of this review was, first, to identify registries for RLDs in Europe, and, second, to design a universal blueprint for the development of a registry for RLD by using lessons learnt from the European registries that have already been established. METHODS We searched PubMed, Google Scholar and clinicaltrials.gov using the MESH terms 'registries', 'database management systems', 'database' and the non-MESH terms 'database$', 'registry', 'repository' and 'repositories'. We only included studies in English from countries/consortia of the European Union (EU). Our literature search was performed in 2020. RESULTS We identified 37 registries for RLDs in Europe. Using information from the design of these registries we designed a blueprint for the development of a patient registry for an RLD consisting of a theoretical, technical and maintenance phase. DISCUSSION It is believed that rare diseases may affect as much as 6-8% of the EU population across its 28 member states. Here we have provided a toolkit for designing a registry for an RLD. Our article will complement the efforts of loco-regional, national and international groups seeking to establish robust systems for data collection and analysis for orphan liver diseases.
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Affiliation(s)
- Marinos Pericleous
- Royal Surrey NHS Foundation Trust, Guildford, UK, and postgraduate researcher, University of Surrey, Guildford, UK
| | | | - Michael Schilsky
- Yale-New Haven Transplantation Center, Yale University, New Haven, USA
| | - Anil Dhawan
- King's College Hospital NHS Foundation Trust, London, UK
| | - Aftab Ala
- Institute of Liver Studies, Kings College Hospital NHS Foundation Trust, London, UK, Faculty of Health and Medical Sciences (FHMS), University of Surrey and professional director of research, development and Innovation Royal Surrey NHS Foundation Trust, Guildford, UK.
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Schilsky M. Presentations of Wilson Disease. Gastroenterol Hepatol (N Y) 2020; 16:581-583. [PMID: 34035694 PMCID: PMC8132624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- Michael Schilsky
- Professor of Medicine and Surgery Yale University School of Medicine New Haven, Connecticut
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Solovyev N, Ala A, Schilsky M, Mills C, Willis K, Harrington CF. Biomedical copper speciation in relation to Wilson’s disease using strong anion exchange chromatography coupled to triple quadrupole inductively coupled plasma mass spectrometry. Anal Chim Acta 2020; 1098:27-36. [DOI: 10.1016/j.aca.2019.11.033] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 11/08/2019] [Accepted: 11/13/2019] [Indexed: 12/16/2022]
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Ferenci P, Pfeiffenberger J, Stättermayer AF, Stauber RE, Willheim C, Weiss KH, Munda-Steindl P, Trauner M, Schilsky M, Zoller H. HSD17B13 truncated variant is associated with a mild hepatic phenotype in Wilson's Disease. JHEP Rep 2019; 1:2-8. [PMID: 32039348 PMCID: PMC7001574 DOI: 10.1016/j.jhepr.2019.02.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 01/31/2019] [Accepted: 02/02/2019] [Indexed: 12/13/2022] Open
Abstract
HSD17B13 encodes hydroxysteroid 17-β dehydrogenase 13, a novel liver lipid-droplet associated protein that is involved in the regulation of lipid biosynthetic processes. A protein-truncating HSD17B13 variant (rs72613567) was shown to protect individuals from alcoholic and non-alcoholic liver disease. Since steatosis is a common feature in Wilson's disease (WD), we aimed to assess whether the HSD17B13 variant modulates the phenotypic presentation and progression of WD. METHODS The HSD17B13:TA (rs72613567) variant was determined by allelic discrimination real-time PCR in 586 patients. The HSD17B13 genotype was correlated with the phenotypic presentation. The age of onset and the type of symptoms at presentation were used as markers of the WD phenotype. RESULTS The overall HSD17B13:TA allele frequency in patients with WD was 23.3% (273/1,172), not significantly different from the reported minor allele frequency. There was a significantly lower HSD17B13:TA allele frequency in patients with fulminant WD compared to all other phenotypic WD groups (11.0% vs. 24.0%, p < 0.01). Among the patients with fulminant WD there was a trend for a gender effect; none of the male patients carried the HSD17B13:TA allele. HSD17B13:TA allele frequency was more common in patients with minimal or no fibrosis (49 [31.1%] had simple steatosis and 20 minimal changes at biopsy) than in patients with cirrhosis or advanced fibrosis (22.3%, p = 0.025). CONCLUSIONS The HSD17B13:TA allele modulates the phenotype and outcome of WD. This allele likely ameliorates hepatic fibrosis and reduces the transition from copper induced hemolysis to fulminant disease in patients with WD. LAY SUMMARY Wilson's disease is a hereditary disease caused by accumulation of copper in the liver and other tissues. It presents with a variety of clinical symptoms. In this study we explored the role of a recently described gene mutation (HSD17B13:TA) which apparently protects the liver against toxins like alcohol. The results indicate that this mutation plays a role in the evolution of liver disease. Patients with Wilson's disease who carry this mutation are more likely to have mild disease, while the absence of the mutation is associated with the most severe form - fulminant Wilson's disease.
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Affiliation(s)
- Peter Ferenci
- Internal Medicine III, Dvision of Gastroenterology and Hepatology, Medical University of Vienna, Austria
| | | | | | | | - Claudia Willheim
- Internal Medicine III, Dvision of Gastroenterology and Hepatology, Medical University of Vienna, Austria
| | - Karl H. Weiss
- Internal Medicine IV, Medical University of Heidelberg, Germany
| | - Petra Munda-Steindl
- Internal Medicine III, Dvision of Gastroenterology and Hepatology, Medical University of Vienna, Austria
| | - Michael Trauner
- Internal Medicine III, Dvision of Gastroenterology and Hepatology, Medical University of Vienna, Austria
| | - Michael Schilsky
- Departments of Medicine and Surgery, Division of Digestive Diseases and Immunology and Transplant, Yale University, New Haven, CT, USA
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Stravitz RT, Ellerbe C, Durkalski V, Schilsky M, Fontana RJ, Peterseim C, Lee WM. Bleeding complications in acute liver failure. Hepatology 2018; 67:1931-1942. [PMID: 29194678 PMCID: PMC5906191 DOI: 10.1002/hep.29694] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 09/09/2017] [Accepted: 11/27/2017] [Indexed: 01/09/2023]
Abstract
In patients with acute liver failure (ALF), elevated prothrombin time and thrombocytopenia can fuel a perception of a bleeding tendency. However, the incidence, site, risk factors, and clinical significance of bleeding complications have not been quantified in a large cohort of patients with ALF. We studied 1,770 adult patients enrolled in the ALF Study Group Registry between 1998 and 2016. Bleeding complications and blood component transfusions were collected for 7 days after admission. The relationship of bleeding complications to 21-day mortality was assessed. Despite a median international normalized ratio of 2.7 and platelet count of 96 × 109 /L on admission, bleeding complications were observed in only 187 patients (11%), including 173 spontaneous and 22 postprocedural bleeding episodes. Eighty-four percent of spontaneous bleeding episodes were from an upper gastrointestinal source and rarely resulted in red blood cell transfusion. Twenty patients experienced an intracranial bleed; half of these occurred spontaneously and half after intracranial pressure monitor placement, and this was the proximate cause of death in 20% and 50%, respectively. Bleeders and patients who received red blood cell transfusions were more acutely ill from extrahepatic organ system failure but not from hepatocellular failure. Consistent with this observation, bleeding complications were associated with lower platelet counts but not higher international normalized ratio. Transfusion of any blood component was associated with nearly 2-fold increased death or need for liver transplantation at day 21, but bleeding complications were the proximate cause of death in only 5% of cases. CONCLUSIONS Despite a perceived bleeding diathesis, clinically significant bleeding is uncommon in patients with ALF; bleeding complications in patients with ALF are markers of severe systemic inflammation rather than of coagulopathy and so portend a poor prognosis. (Hepatology 2018;67:1931-1942).
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Affiliation(s)
- R. Todd Stravitz
- Hume-Lee Transplant Center of Virginia Commonwealth University, Richmond, VA
| | - Caitlyn Ellerbe
- Department of Biostatistics, Medical University of South Carolina, Charleston, SC
| | - Valerie Durkalski
- Department of Biostatistics, Medical University of South Carolina, Charleston, SC
| | - Michael Schilsky
- Division of Gastroenterology and Hepatology, Yale University, New Haven, CT
| | | | - Carolyn Peterseim
- Department of Biostatistics, Medical University of South Carolina, Charleston, SC
| | - William M. Lee
- University of Texas-Southwestern Medical Center, Dallas, TX
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Kulkarni S, Thiessen C, Formica RN, Schilsky M, Mulligan D, D'Aquila R. The Long-Term Follow-up and Support for Living Organ Donors: A Center-Based Initiative Founded on Developing a Community of Living Donors. Am J Transplant 2016; 16:3385-3391. [PMID: 27500361 DOI: 10.1111/ajt.14005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [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: 01/08/2016] [Revised: 07/08/2016] [Accepted: 08/04/2016] [Indexed: 01/25/2023]
Abstract
Transplant professionals recognize that the long-term follow-up of living organ donors is a priority, yet there has been no implemented solution to this problem. This critical gap is essential, because the transplant field is now emphasizing living donation as a means to address the organ shortage. We detail our living donor initiative, which sets several priorities we recognize as fundamental to persons who have donated organs at our transplant center. This intervention attempts to mitigate the donor and center factors that are known to contribute to the lack of long-term follow-up. Beyond that, our goals are aimed at providing ongoing engagement, wellness, clinical data accrual, laboratory follow-up, and social support for our living donors, in continuity. Our ultimate goal is to nurture the development of local living donor community networks by providing social engagement for current and past donors, which also serves as a platform for greater population education on the societal importance of living donation. This initiative is based on joint recognition by our transplant team and our hospital leadership that supporting the long-term welfare of living donors is essential to accomplishing the goal of expanding living donor transplantation. The transplant team and hospital missions are aligned, and both contribute resources to the initiative.
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Affiliation(s)
- S Kulkarni
- The Center for Living Organ Donors, Yale-New Haven Hospital, New Haven, CT.,Department of Surgery, Yale University School of Medicine, New Haven, CT.,Department of Medicine, Yale University School of Medicine, New Haven, CT
| | - C Thiessen
- The Center for Living Organ Donors, Yale-New Haven Hospital, New Haven, CT.,Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - R N Formica
- The Center for Living Organ Donors, Yale-New Haven Hospital, New Haven, CT.,Department of Surgery, Yale University School of Medicine, New Haven, CT.,Department of Medicine, Yale University School of Medicine, New Haven, CT
| | - M Schilsky
- The Center for Living Organ Donors, Yale-New Haven Hospital, New Haven, CT.,Department of Surgery, Yale University School of Medicine, New Haven, CT.,Department of Medicine, Yale University School of Medicine, New Haven, CT
| | - D Mulligan
- The Center for Living Organ Donors, Yale-New Haven Hospital, New Haven, CT.,Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - R D'Aquila
- The Center for Living Organ Donors, Yale-New Haven Hospital, New Haven, CT.,Office of the President, Yale-New Haven Hospital, New Haven, CT
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Hillman L, Gottfried M, Whitsett M, Rakela J, Schilsky M, Lee WM, Ganger D. Corrigendum: Clinical Features and Outcomes of Complementary and Alternative Medicine Induced Acute Liver Failure and Injury. Am J Gastroenterol 2016; 111:1504. [PMID: 27694861 DOI: 10.1038/ajg.2016.349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Reuben A, Tillman H, Fontana RJ, Davern T, McGuire B, Stravitz RT, Durkalski V, Larson AM, Liou I, Fix O, Schilsky M, McCashland T, Hay JE, Murray N, Shaikh OS, Ganger D, Zaman A, Han SB, Chung RT, Smith A, Brown R, Crippin J, Harrison ME, Koch D, Munoz S, Reddy KR, Rossaro L, Satyanarayana R, Hassanein T, Hanje AJ, Olson J, Subramanian R, Karvellas C, Hameed B, Sherker AH, Robuck P, Lee WM. Outcomes in Adults With Acute Liver Failure Between 1998 and 2013: An Observational Cohort Study. Ann Intern Med 2016; 164:724-32. [PMID: 27043883 PMCID: PMC5526039 DOI: 10.7326/m15-2211] [Citation(s) in RCA: 238] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Acute liver failure (ALF) is a rare syndrome of severe, rapid-onset hepatic dysfunction-without prior advanced liver disease-that is associated with high morbidity and mortality. Intensive care and liver transplantation provide support and rescue, respectively. OBJECTIVE To determine whether changes in causes, disease severity, treatment, or 21-day outcomes have occurred in recent years among adult patients with ALF referred to U.S. tertiary care centers. DESIGN Prospective observational cohort study. (ClinicalTrials .gov: NCT00518440). SETTING 31 liver disease and transplant centers in the United States. PATIENTS Consecutively enrolled patients-without prior advanced liver disease-with ALF (n = 2070). MEASUREMENTS Clinical features, treatment, and 21-day outcomes were compared over time annually for trends and were also stratified into two 8-year periods (1998 to 2005 and 2006 to 2013). RESULTS Overall clinical characteristics, disease severity, and distribution of causes remained similar throughout the study period. The 21-day survival rates increased between the two 8-year periods (overall, 67.1% vs. 75.3%; transplant-free survival [TFS], 45.1% vs. 56.2%; posttransplantation survival, 88.3% vs. 96.3% [P < 0.010 for each]). Reductions in red blood cell infusions (44.3% vs. 27.6%), plasma infusions (65.2% vs. 47.1%), mechanical ventilation (65.7% vs. 56.1%), and vasopressors (34.9% vs. 27.8%) were observed, as well as increased use of N-acetylcysteine (48.9% vs. 69.3% overall; 15.8% vs. 49.4% [P < 0.001] in patients with ALF not due to acetaminophen toxicity). When examined longitudinally, overall survival and TFS increased throughout the 16-year period. LIMITATIONS The duration of enrollment, the number of patients enrolled, and possibly the approaches to care varied among participating sites. The results may not be generalizable beyond such specialized centers. CONCLUSION Although characteristics and severity of ALF changed little over 16 years, overall survival and TFS improved significantly. The effects of specific changes in intensive care practice on survival warrant further study. PRIMARY FUNDING SOURCE National Institutes of Health.
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Khan S, Schilsky M, Silber G, Morgenstern B, Miloh T. The Challenges of Diagnosing and Following Wilson Disease in the Presence of Proteinuria. Pediatr Gastroenterol Hepatol Nutr 2016; 19:139-42. [PMID: 27437191 PMCID: PMC4942312 DOI: 10.5223/pghn.2016.19.2.139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 11/11/2015] [Accepted: 01/04/2016] [Indexed: 11/14/2022] Open
Abstract
The coexistence of Wilson disease with Alport syndrome has not previously been reported. The diagnosis of Wilson disease and its ongoing monitoring is challenging when associated with an underlying renal disease such as Alport syndrome. Proteinuria can lead to low ceruloplasmin since it is among serum proteins inappropriately filtered by the damaged glomerulus, and can also lead to increased urinary loss of heavy metals such as zinc and copper. Elevated transaminases may be attributed to dyslipidemia or drug induced hepatotoxicity. The accurate diagnosis of Wilson disease is essential for targeted therapy and improved prognosis. We describe a patient with a diagnosis of Alport syndrome who has had chronic elevation of transaminases eventually diagnosed with Wilson disease based on liver histology and genetics.
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Affiliation(s)
- Soofia Khan
- Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Michael Schilsky
- Department of Gastroenterology, Yale University Medical Center, New Haven, CT, USA
| | - Gary Silber
- Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Bruce Morgenstern
- Department of Pediatrics, Roseman University of Health Sciences, Las Vegas, NV, USA
| | - Tamir Miloh
- Department of Pediatrics, Texas Children's Hospital, Houston, TX, USA
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Rosen HR, Biggins SW, Niki T, Gralla J, Hillman H, Hirashima M, Schilsky M, Lee WM. Association Between Plasma Level of Galectin-9 and Survival of Patients With Drug-Induced Acute Liver Failure. Clin Gastroenterol Hepatol 2016; 14:606-612.e3. [PMID: 26499927 DOI: 10.1016/j.cgh.2015.09.040] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [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: 12/16/2013] [Revised: 09/23/2015] [Accepted: 09/30/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Fewer than 50% of patients with acute liver failure (ALF) recover spontaneously, and ALF has high mortality without liver transplantation. Kupffer cells have been reported to mediate liver inflammation during drug-induced injury. Galectin-9 is produced by Kupffer cells and has diverse roles in regulating immunity. We investigated whether plasma levels of galectin-9 are associated with outcomes of patients with ALF. METHODS We analyzed plasma samples (collected at time of hospital admission) and clinical data from 149 patients included in the Acute Liver Failure Study Group from July 2006 through November 2010 (110 had acetaminophen-induced hepatotoxicity and 39 had nonacetaminophen drug-induced liver injury). We compared data with those from all patients enrolled in the study (from July 1, 2006 through October 30, 2013), and from healthy individuals of similar ages with no evidence of liver disease (control subjects). Plasma levels of galectin-9 were measured using a polyclonal antibody and colorimetric assay. RESULTS Patients with ALF had statistically higher plasma levels of galectin-9 than control subjects, but levels did not differ significantly between patients with acetaminophen-induced liver injury and drug-induced liver injury. A level of galectin-9 above 690 pg/mL was associated with a statistically significant increase in risk for mortality or liver transplantation caused by ALF. Competing risk analyses associated level of galectin-9 with transplant-free survival, independently of Model For End-Stage Liver Disease score or systemic inflammatory response syndrome. CONCLUSIONS A one-time measurement of plasma galectin-9 level can be used to assign patients with ALF to high-, intermediate-, and low-risk groups. The combination of galectin-9 level and Model For End-Stage Liver Disease score was more closely associated with patient outcome than either value alone. These data might be used to determine patient prognoses and prioritize patients for liver transplantation. ClinicalTrials.gov ID NCT00518440.
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Affiliation(s)
- Hugo R Rosen
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Colorado, Aurora, Colorado; Integrated Program in Immunology, University of Colorado, Aurora, Colorado.
| | - Scott W Biggins
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Colorado, Aurora, Colorado
| | - Toshiro Niki
- Department of Immunology, Kagawa University, Kagawa, Japan; GalPharma Co., Kagawa, Japan
| | - Jane Gralla
- University of Colorado Denver, Department of Pediatrics, Aurora, Colorado; University of Colorado Denver, Department of Biostatistics and Informatics, Aurora, Colorado
| | - Holly Hillman
- Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina
| | - Mitsuomi Hirashima
- Department of Immunology, Kagawa University, Kagawa, Japan; GalPharma Co., Kagawa, Japan
| | - Michael Schilsky
- Division of Digestive Diseases and Section of Transplantation and Immunology, Departments of Medicine and Surgery, Yale University Medical Center, New Haven, Connecticut
| | - William M Lee
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
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Reddy KR, Ellerbe C, Schilsky M, Stravitz RT, Fontana RJ, Durkalski V, Lee WM. Determinants of outcome among patients with acute liver failure listed for liver transplantation in the United States. Liver Transpl 2016; 22:505-15. [PMID: 26421889 PMCID: PMC4809785 DOI: 10.1002/lt.24347] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [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: 04/12/2015] [Revised: 09/11/2015] [Accepted: 09/20/2015] [Indexed: 12/22/2022]
Abstract
Analyses of outcomes after acute liver failure (ALF) have typically included all ALF patients regardless of whether they were listed for liver transplantation (LT). We hypothesized that limiting analysis to listed patients might provide novel insights into factors associated with outcome, focusing attention on disease evolution after listing. Listed adult ALF patients enrolled in the US Acute Liver Failure Study Group registry between 2000 and 2013 were analyzed to determine baseline factors associated with 21-day outcomes after listing. We classified 617 patients (36% of overall ALF group) by 3-week outcome after study admission: 117 were spontaneous survivors (SSs; survival without LT), 108 died without LT, and 392 underwent LT. Only 22% of N-acetyl-p-aminophenol (APAP) ALF patients were listed; however, this group of 173 patients demonstrated greater illness severity: higher coma grades and more patients requiring ventilator, vasopressor, or renal replacement therapy support. Only 62/173 (36%) of APAP patients received a graft versus 66% for drug-induced liver injury patients, 86% for autoimmune-related ALF, and 71% for hepatitis B-related ALF. APAP patients were more likely to die than non-APAP patients (24% versus 17%), and the median time to death was sooner (2 versus 4.5 days). Despite greater severity of illness, the listed APAP group still had a SS rate of 40% versus 11% for non-APAP causes (P < 0.001). APAP outcomes evolve rapidly, mainly to SS or death. Patients with APAP ALF listed for LT had the highest death rate of any etiology, whereas more slowly evolving etiologies yielded higher LT rates and, consequently, fewer deaths. Decisions to list and transplant must be made early in all ALF patients, particularly in those with APAP ALF.
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Affiliation(s)
- K. Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Caitlyn Ellerbe
- Division of Biostatistics, Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Michael Schilsky
- Section of Transplantation and Immunology, Yale University, New Haven, CT, USA
| | - R. Todd Stravitz
- Department of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Robert J. Fontana
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Valerie Durkalski
- Division of Biostatistics, Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - William M. Lee
- Division of Digestive & Liver Diseases, Department of Internal Medicine, University of Texas Southwestern, Dallas, TX, USA
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Thiessen C, Patrón-Lozano R, Schilsky M, Rodríguez-Dávalos MI. Right homonymous hemianopsia and seizures in a liver transplant recipient. Am J Transplant 2014; 14:2427-9. [PMID: 25231067 DOI: 10.1111/ajt.12870] [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] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- C Thiessen
- Department of Surgery, Division of Transplantation and Immunology, Yale School of Medicine, New Haven, CT
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14
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Abstract
UNLABELLED Drug-induced and indeterminate acute liver failure (ALF) might be due to an autoimmune-like hepatitis that is responsive to corticosteroid therapy. The aim of this study was to evaluate whether corticosteroids improve survival in fulminant autoimmune hepatitis, drug-induced, or indeterminate ALF, and whether this benefit varies according to the severity of illness. We conducted a retrospective analysis of autoimmune, indeterminate, and drug-induced ALF patients in the Acute Liver Failure Study Group from 1998-2007. The primary endpoints were overall and spontaneous survival (SS, survival without transplant). In all, 361 ALF patients were studied, 66 with autoimmune (25 steroids, 41 no steroids), 164 with indeterminate (21 steroids, 143 no steroids), and 131 with drug-induced (16 steroids, 115 no steroids) ALF. Steroid use was not associated with improved overall survival (61% versus 66%, P = 0.41), nor with improved survival in any diagnosis category. Steroid use was associated with diminished survival in certain subgroups of patients, including those with the highest quartile of the Model for Endstage Liver Disease (MELD) (>40, survival 30% versus 57%, P = 0.03). In multivariate analysis controlling for steroid use and diagnosis, age (odds ratio [OR] 1.37 per decade), coma grade (OR 2.02 grade 2, 2.65 grade 3, 5.29 grade 4), MELD (OR 1.07), and pH < 7.4 (OR 3.09) were significantly associated with mortality. Although steroid use was associated with a marginal benefit in SS overall (35% versus 23%, P = 0.047), this benefit did not persistent in multivariate analysis; mechanical ventilation (OR 0.24), MELD (OR 0.93), and alanine aminotransferase (1.02) were the only significant predictors of SS. CONCLUSION Corticosteroids did not improve overall survival or SS in drug-induced, indeterminate, or autoimmune ALF and were associated with lower survival in patients with the highest MELD scores.
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Affiliation(s)
- Jamuna Karkhanis
- Department of Medicine, Columbia University College of Physicians & Surgeons, New York, NY
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15
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Rodriguez-Davalos MI, Arvelakis A, Umman V, Tanjavur V, Yoo PS, Kulkarni S, Luczycki SM, Schilsky M, Emre S. Segmental Grafts in Adult and Pediatric Liver Transplantation. JAMA Surg 2014; 149:63-70. [DOI: 10.1001/jamasurg.2013.3384] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Manuel I. Rodriguez-Davalos
- Section of Transplantation and Immunology, Department of Surgery, Yale University School of Medicine, Yale–New Haven Transplantation Center, New Haven, Connecticut
| | - Antonios Arvelakis
- Section of Transplantation and Immunology, Department of Surgery, Yale University School of Medicine, Yale–New Haven Transplantation Center, New Haven, Connecticut
| | - Veysel Umman
- Section of Transplantation and Immunology, Department of Surgery, Yale University School of Medicine, Yale–New Haven Transplantation Center, New Haven, Connecticut
| | - Vijayakumar Tanjavur
- Section of Transplantation and Immunology, Department of Surgery, Yale University School of Medicine, Yale–New Haven Transplantation Center, New Haven, Connecticut
| | - Peter S. Yoo
- Section of Transplantation and Immunology, Department of Surgery, Yale University School of Medicine, Yale–New Haven Transplantation Center, New Haven, Connecticut
| | - Sanjay Kulkarni
- Section of Transplantation and Immunology, Department of Surgery, Yale University School of Medicine, Yale–New Haven Transplantation Center, New Haven, Connecticut
| | - Stephen M. Luczycki
- Section of Transplantation and Immunology, Department of Surgery, Yale University School of Medicine, Yale–New Haven Transplantation Center, New Haven, Connecticut
| | - Michael Schilsky
- Section of Transplantation and Immunology, Department of Surgery, Yale University School of Medicine, Yale–New Haven Transplantation Center, New Haven, Connecticut
| | - Sukru Emre
- Section of Transplantation and Immunology, Department of Surgery, Yale University School of Medicine, Yale–New Haven Transplantation Center, New Haven, Connecticut
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16
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Radmand R, Schilsky M, Jakab S, Khalaf M, Falace DA. Pre-liver transplant protocols in dentistry. Oral Surg Oral Med Oral Pathol Oral Radiol 2013; 115:426-30. [PMID: 23522643 DOI: 10.1016/j.oooo.2012.12.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2012] [Revised: 11/15/2012] [Accepted: 12/04/2012] [Indexed: 11/28/2022]
Abstract
The number of adults with end stage liver disease in the U.S., awaiting liver transplantation, has maintained a steady upward trend in recent years. Concurrently, the survival rate of liver transplant recipients has also been on the rise. To be able to safely treat this population, dentists should have familiarity with special management requirements of patients with end stage liver disease. This article reviews the historical background on liver transplantation and provides updated information on indications and evaluation protocols, treatment considerations in end stage liver disease, clinical dental management protocols prior to surgical procedures and dental considerations in the pre-liver transplant candidates.
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Affiliation(s)
- Reza Radmand
- Hospital Dentistry, Dental Department, Yale New Haven Hospital, New Haven, CT 06519, USA.
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17
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Chung RT, Gordon FD, Curry MP, Schiano TD, Emre S, Corey K, Markmann J, Hertl M, Pomposelli JJ, Pomfret EA, Florman S, Schilsky M, Broering TJ, Finberg RW, Szabo G, Zamore PD, Khettry U, Babcock GJ, Ambrosino DM, Leav B, Leney M, Smith HL, Molrine DC. Human monoclonal antibody MBL-HCV1 delays HCV viral rebound following liver transplantation: a randomized controlled study. Am J Transplant 2013; 13:1047-1054. [PMID: 23356386 PMCID: PMC3618536 DOI: 10.1111/ajt.12083] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [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: 10/25/2012] [Revised: 11/20/2012] [Accepted: 12/04/2012] [Indexed: 01/25/2023]
Abstract
Rapid allograft infection complicates liver transplantation (LT) in patients with hepatitis C virus (HCV). Pegylated interferon-α and ribavirin therapy after LT has significant toxicity and limited efficacy. The effect of a human monoclonal antibody targeting the HCV E2 glycoprotein (MBL-HCV1) on viral clearance was examined in a randomized, double-blind, placebo-controlled pilot study in patients infected with HCV genotype 1a undergoing LT. Subjects received 11 infusions of 50 mg/kg MBL-HCV1 (n=6) or placebo (n=5) intravenously with three infusions on day of transplant, a single infusion on days 1 through 7 and one infusion on day 14 after LT. MBL-HCV1 was well-tolerated and reduced viral load for a period ranging from 7 to 28 days. Median change in viral load (log10 IU/mL) from baseline was significantly greater (p=0.02) for the antibody-treated group (range -3.07 to -3.34) compared to placebo group (range -0.331 to -1.01) on days 3 through 6 posttransplant. MBL-HCV1 treatment significantly delayed median time to viral rebound compared to placebo treatment (18.7 days vs. 2.4 days, p<0.001). As with other HCV monotherapies, antibody-treated subjects had resistance-associated variants at the time of viral rebound. A combination study of MBL-HCV1 with a direct-acting antiviral is underway.
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Affiliation(s)
- R. T. Chung
- Massachusetts General Hospital, Boston, MA, United States
| | - F. D. Gordon
- Lahey Clinic Medical Center, Burlington, MA, United States
| | - M. P. Curry
- Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - T. D. Schiano
- Mount Sinai Medical Center, New York, NY, United States
| | - S. Emre
- Yale New Haven Hospital, New Haven, CT, United States
| | - K. Corey
- Massachusetts General Hospital, Boston, MA, United States
| | - J. Markmann
- Massachusetts General Hospital, Boston, MA, United States
| | - M. Hertl
- Massachusetts General Hospital, Boston, MA, United States
| | | | - E. A. Pomfret
- Lahey Clinic Medical Center, Burlington, MA, United States
| | - S. Florman
- Mount Sinai Medical Center, New York, NY, United States
| | - M. Schilsky
- Yale New Haven Hospital, New Haven, CT, United States
| | - T. J. Broering
- MassBiologics, University of Massachusetts Medical School, Boston, MA, United States
| | - R. W. Finberg
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States
| | - G. Szabo
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States
| | - P. D. Zamore
- Howard Hughes Medical Institute and Department of Biochemistry & Molecular Pharmacology, University of Massachusetts Medical School, Worcester, MA, United States
| | - U. Khettry
- Lahey Clinic Medical Center, Burlington, MA, United States
| | - G. J. Babcock
- MassBiologics, University of Massachusetts Medical School, Boston, MA, United States
| | - D. M. Ambrosino
- MassBiologics, University of Massachusetts Medical School, Boston, MA, United States
| | - B. Leav
- MassBiologics, University of Massachusetts Medical School, Boston, MA, United States
| | - M. Leney
- MassBiologics, University of Massachusetts Medical School, Boston, MA, United States
| | - H. L. Smith
- MassBiologics, University of Massachusetts Medical School, Boston, MA, United States
| | - D. C. Molrine
- MassBiologics, University of Massachusetts Medical School, Boston, MA, United States
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18
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Abstract
Nearly a century after Dr. Samuel Alexander Kinnier Wilson composed his doctoral thesis on the pathologic findings of "lenticular degeneration" in the brain associated with cirrhosis of the liver we know that the underlying molecular basis for this autosomal recessive inherited disorder that now bears his name is mutation of a copper transporting ATPase, ATP7B, an intracellular copper transporter mainly expressed in hepatocytes. Loss of ATP7B function is the basis for reduced hepatic biliary copper excretion and reduced incorporation of copper into ceruloplasmin. During the intervening years, there was recognition of the clinical signs, histologic, biochemical features, and mutation analysis of ATP7B that characterize and enable diagnosis of this disorder. These include the presence of signs of liver or neurologic disease and detection of Kayser-Fleischer rings, low ceruloplasmin, elevated urine and hepatic copper, and associated histologic changes in the liver. Medical therapies and liver transplantation can effectively treat patients with this once uniformly fatal disorder. The earlier detection of the disease led to the initiation of treatment to prevent disease progression and reverse pathologic findings if present, and family screening to detect the disorder in first-degree relatives is warranted. Gene therapy and hepatocyte cell transplantation for Wilson disease has only been tested in animal models but represent future areas for study. Despite all the advances we still have to consider the diagnosis of Wilson disease to test patients for this disorder and properly establish the diagnosis before committing to life-long treatment.
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Affiliation(s)
- Richard Rosencrantz
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA
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19
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Affiliation(s)
- Antonello Pietrangelo
- Division of Internal Medicine 2 and Center for Hemochromatosis, "Mario Coppo" Liver Research Center, University Hospital of Modena, Modena, Italy.
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20
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Cimsit B, Schilsky M, Moini M, Cartiera K, Arvelakis A, Kulkarni S, Formica R, Caldwell C, Taddei T, Asch W, Emre S. Combined liver kidney transplantation: critical analysis of a single-center experience. Transplant Proc 2011; 43:901-4. [PMID: 21486624 DOI: 10.1016/j.transproceed.2011.02.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Combined liver kidney transplantation (LKT) can be successfully performed on patients with liver and renal failure; however, outcomes are inferior to liver transplantation alone (OLT). Our aim was to determine the indications for and outcome of LKT and whether patients with longer wait times required more frequent LKT versus OLT alone. We included 18/93 adults who underwent LKT from August 2007 to August 2010 for hepatitis C virus (HCV, n = 7), alcohol (n = 5), nonalcoholic steatohepatitis (n = 2), primary biliary sclerosis, polycystic kidney disease with liver involvement, hepatic adenomatosis, and ischemic hepatitis. Eleven were originally listed for LKT and 7 required listing for-kidney transplantation while awaiting OLT. Eight were on dialysis when first listed and 10 had a low glomerular filtration rate or known kidney disease. The mean calculated Model for End-Stage Liver Disease (MELD) score for LKT was 31.2 ± 3.54. Seven had hepatocellular carcinoma in explants. Two patients had acute cellular kidney rejection that responded to treatment. Recurrence of HCV was documented in 5 patients within 6 months of LKT; 2/5 received HCV therapy (interferon and ribavirin) without renal allograft rejection. One-year liver graft/patient survival was 94% after LKT. One patient died at 6 months post LKT due to severe HCV recurrence. Last mean serum creatinine level was 1.35 ± 0.28 mg/dL for LKT patients. LKT is a safe procedure with favorable outcomes even in patients with a high MELD score. Transplantation of patients with a high MELD score due to regional variations in organ allocation results in additional use of kidneys by OLT patients. Improved organ allocation algorithms in OLT would help to reduce combined transplants, sparing more kidneys.
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Affiliation(s)
- B Cimsit
- Yale School of Medicine, Department of Surgery, New Haven, CT, USA
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21
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Abstract
The genetic background of patients with liver diseases modulates hepatic injury, with some individuals being predisposed to better defenses and regenerative capacity. In this review, we focus our description of this phenomenon on inherited disorders affecting the liver, with a particular emphasis on Wilson disease (WD), genetic hemochromatosis, and α-1 anti-trypsin disease (A1-AT). Wide variations in the clinical phenotype of WD may in part be related to the mutations of the ATP7B genotype, though modifier genes and environmental factors also likely play an important role. There is also a significant variability in the expression of iron overload in patients with genetic hemochromatosis that are homozygous for the C282Y mutation. Homozygosity for the A1-ATZ mutation is generally required for the development of liver disease in A1-AT although there is increasing evidence for modifier effects from a heterozygous genotype in other liver diseases.
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Affiliation(s)
- Aftab Ala
- Centre for Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Frimley Park Hospital NHS Foundation Trust, Surrey, United Kingdom.
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22
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Cimsit B, Assis D, Caldwell C, Arvelakis A, Taddei T, Kulkarni S, Schilsky M, Emre S. Successful Treatment of Fibrosing Cholestatic Hepatitis After Liver Transplantation. Transplant Proc 2011; 43:905-8. [DOI: 10.1016/j.transproceed.2011.02.034] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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23
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Emre S, Rodriguez-Davalos M, Umman V, Cartiera K, Wollwerth S, Arnott L, Arvelakis A, Schilsky M. Liver transplantation at Yale-New Haven Transplantation Center. Clin Transpl 2011:187-201. [PMID: 22755413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
It is possible to achieve better results after liver transplantation in adult and pediatric patients. An approach driven by multidisciplinary protocol is the most important factor, along with excellent communication skills, technical expertise, application of new technologies such as MARS and Arctic-Sun for ALF, and new knowledge/treatment protocols such as escalating-dose interferon ribavirin treatment, protocol biopsies, routine use of IL28B gene mutation and new protease inhibitors as part of antiviral therapy for hepatitis C.
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Affiliation(s)
- Sukru Emre
- Yale-New Haven Transplantation Center, New Haven, Connecticut, USA.
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24
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Arnon R, Annunziato R, Schilsky M, Miloh T, Willis A, Sturdevant M, Sakworawich A, Suchy F, Kerkar N. Liver transplantation for children with Wilson disease: comparison of outcomes between children and adults. Clin Transplant 2010. [PMID: 20946468 DOI: 10.1111/j.1399‐0012.2010.01327.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
UNLABELLED Liver transplantation (LT) is lifesaving for patients with Wilson disease (WD) presenting with fulminant hepatic failure (FHF) or chronic liver disease (CLD) unresponsive to treatment. AIM To determine the outcome of LT in pediatric and adult patients with WD. METHODS United Network for Organ Sharing data on LT from 1987 to 2008 were analyzed. Outcomes were compared for patients requiring LT for FHF and CLD after 2002. Multivariate logistic regression was used to determine risk factors for death and graft loss. RESULTS Of 90,867 patients transplanted between 1987 and 2008, 170 children and 400 adults had WD. The one- and five-yr patient survival of children was 90.1% and 89% compared to 88.3% and 86% for adults, p = 0.53, 0.34. After 2002, 103 (41 children) were transplanted for FHF and 67 (10 children) for CLD. One- and five-yr patient survival was higher in children transplanted for CLD compared to FHF; 100%, 100% vs. 90%, 87.5% respectively, p = 0.30, 0.32. One- and five-yr patient survival was higher in adults transplanted for CLD compared to FHF; 94.7%, 90.1% vs. 90.3%, 89.7%, respectively, p = 0.36, 0.88. Encephalopathy, partial graft, and ventilator use were risk factors for death by logistic regression. CONCLUSION LT is an excellent treatment option for patients with WD. Patients transplanted for CLD had higher patient survival rates than patients with FHF.
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Affiliation(s)
- Ronen Arnon
- Mount Sinai School of Medicine, Department of Pediatrics, Mount Sinai Medical Center, New York, NY 10029, USA.
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25
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Arnon R, Annunziato R, Schilsky M, Miloh T, Willis A, Sturdevant M, Sakworawich A, Suchy F, Kerkar N. Liver transplantation for children with Wilson disease: comparison of outcomes between children and adults. Clin Transplant 2010; 25:E52-60. [PMID: 20946468 DOI: 10.1111/j.1399-0012.2010.01327.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
UNLABELLED Liver transplantation (LT) is lifesaving for patients with Wilson disease (WD) presenting with fulminant hepatic failure (FHF) or chronic liver disease (CLD) unresponsive to treatment. AIM To determine the outcome of LT in pediatric and adult patients with WD. METHODS United Network for Organ Sharing data on LT from 1987 to 2008 were analyzed. Outcomes were compared for patients requiring LT for FHF and CLD after 2002. Multivariate logistic regression was used to determine risk factors for death and graft loss. RESULTS Of 90,867 patients transplanted between 1987 and 2008, 170 children and 400 adults had WD. The one- and five-yr patient survival of children was 90.1% and 89% compared to 88.3% and 86% for adults, p = 0.53, 0.34. After 2002, 103 (41 children) were transplanted for FHF and 67 (10 children) for CLD. One- and five-yr patient survival was higher in children transplanted for CLD compared to FHF; 100%, 100% vs. 90%, 87.5% respectively, p = 0.30, 0.32. One- and five-yr patient survival was higher in adults transplanted for CLD compared to FHF; 94.7%, 90.1% vs. 90.3%, 89.7%, respectively, p = 0.36, 0.88. Encephalopathy, partial graft, and ventilator use were risk factors for death by logistic regression. CONCLUSION LT is an excellent treatment option for patients with WD. Patients transplanted for CLD had higher patient survival rates than patients with FHF.
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Affiliation(s)
- Ronen Arnon
- Mount Sinai School of Medicine, Department of Pediatrics, Mount Sinai Medical Center, New York, NY 10029, USA.
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26
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Caldwell C, Werdiger N, Jakab S, Schilsky M, Arvelakis A, Kulkarni S, Emre S. Use of model for end-stage liver disease exception points for early liver transplantation and successful reversal of hepatic myelopathy with a review of the literature. Liver Transpl 2010; 16:818-26. [PMID: 20583082 DOI: 10.1002/lt.22077] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Hepatic myelopathy (HM) is a rarely reported disorder characterized by progressive spastic paraparesis due to impaired corticospinal tract function in the setting of cirrhosis or portosystemic shunting. HM has not to date been recognized as a Model for End-Stage Liver Disease (MELD) exception for transplantation. Outcomes for a small number of patients from Europe and Asia who have undergone liver transplantation (LT) for HM suggest a potential neurological benefit, especially with earlier transplantation. We report the first use of MELD exception points for the condition of HM to enable early LT resulting in the reversal of marked spastic paraparesis. Our patient, whose myelopathy had markedly progressed without further hepatic decompensation, underwent LT 14 months after the diagnosis of HM with an adjusted MELD score of 30, which was granted as a United Network for Organ Sharing exception. After LT, there was significant neurological improvement as the patient progressed from wheelchair dependency to full ambulation. We reviewed the literature of other HM patients who had undergone LT. With our patient, there were in all 15 reported cases of LT in individuals with HM. LT can lead to a marked improvement in HM, particularly in the earlier clinical stages of the disorder. Early LT can be accomplished, as in our case, by the submission of an appeal for a MELD upgrade.
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Affiliation(s)
- Cary Caldwell
- Department of Medicine, Section of Digestive Disease, Yale University School of Medicine, New Haven, CT, USA.
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27
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29
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Møller HJ, Grønbaek H, Schiødt FV, Holland-Fischer P, Schilsky M, Munoz S, Hassanein T, Lee WM. Soluble CD163 from activated macrophages predicts mortality in acute liver failure. J Hepatol 2007; 47:671-6. [PMID: 17629586 PMCID: PMC2179895 DOI: 10.1016/j.jhep.2007.05.014] [Citation(s) in RCA: 123] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2007] [Revised: 05/01/2007] [Accepted: 05/12/2007] [Indexed: 12/21/2022]
Abstract
BACKGROUND/AIMS Soluble CD163 (sCD163) is a scavenger receptor shed in serum during inflammatory activation of macrophages. We investigated if sCD163 was increased and predicted outcome in acute liver failure (ALF). METHODS Samples from 100 consecutive patients enrolled in the U.S. ALF Study Group for whom sera were available were collected on days 1 and 3, and clinical data were obtained prospectively. sCD163 levels were determined by ELISA. RESULTS The median level of sCD163 was significantly increased in ALF (21.1mg/l (range 3.6-74.9)) as compared to healthy controls (2.3mg/l (0.65-5.6), p<0.0001) and patients with stable liver cirrhosis (9.8mg/l (3.6-16.9), p=0.0002). sCD163 on day 1 correlated significantly with ALT, AST, bilirubin, and creatinine. sCD163 concentrations on day 3 were elevated in patients with fatal outcome of disease compared to spontaneous survivors, 29.0mg/l (7.2-54.0) vs. 14.6mg/l (3.5-67.2), respectively (p=0.0025). Patients that were transplanted had intermediate levels. Sensitivity and specificity at a cut-off level of 26mg/l was 62% and 81%, respectively. CONCLUSIONS Activated macrophages are involved in ALF resulting in a 10-fold increase in sCD163. A high level (>26mg/l) of sCD163 was significantly correlated with fatal outcome and might be used with other parameters to determine prognosis.
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MESH Headings
- Adult
- Antigens, CD/analysis
- Antigens, CD/blood
- Antigens, Differentiation, Myelomonocytic/analysis
- Antigens, Differentiation, Myelomonocytic/blood
- Chemotaxis, Leukocyte/immunology
- Disease Progression
- Female
- Humans
- Liver/cytology
- Liver/immunology
- Liver/physiopathology
- Liver Cirrhosis/diagnosis
- Liver Cirrhosis/immunology
- Liver Cirrhosis/mortality
- Liver Failure, Acute/diagnosis
- Liver Failure, Acute/immunology
- Macrophages/immunology
- Macrophages/metabolism
- Male
- Monitoring, Immunologic
- Predictive Value of Tests
- Prognosis
- Prospective Studies
- ROC Curve
- Receptors, Cell Surface/analysis
- Receptors, Cell Surface/blood
- Sensitivity and Specificity
- Solubility
- Survival Rate
- Up-Regulation/immunology
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Affiliation(s)
- Holger Jon Møller
- Department of Clinical Biochemistry AS, Aarhus University Hospital, Aarhus, Denmark.
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30
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Arnon R, Calderon JF, Schilsky M, Emre S, Shneider BL. Wilson disease in children: serum aminotransferases and urinary copper on triethylene tetramine dihydrochloride (trientine) treatment. J Pediatr Gastroenterol Nutr 2007; 44:596-602. [PMID: 17460493 DOI: 10.1097/mpg.0b013e3180467715] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To evaluate the efficacy of and adherence to trientine and/or zinc therapy in children with Wilson disease (WD). MATERIALS AND METHODS We retrospectively reviewed the clinical records of all children with WD in the pediatric liver/liver transplant program at our institution between 1998 and 2006. RESULTS A total of 22 children with WD were evaluated and treated. Seven with fulminant disease required liver transplantation and 15 were treated with trientine and/or zinc. Ten of those 15 had follow-up for 12 to 60 months and 6 of the latter 10 were followed for 12 to 18 months. All 10 patients were started on a trientine treatment regimen. Mean alanine aminotransferase (ALT) levels decreased from 183 +/- 103 IU at presentation (n = 10) to 80 +/- 46 IU at 12 months (n = 10) and 66 +/- 40 IU at 18 months (n = 7). Mean 24-hour urinary copper levels increased from 156 microg at presentation to 494 microg at 1 to 2 months, then decreased to 71 microg after 21 to 24 months of treatment. Three of 10 patients had normalized ALT levels and 1 patient with cirrhosis continued with normal ALT levels since presentation. Four of 10 patients were documented to be nonadherent, as manifested by increased ALT levels (99 +/- 31 IU); 1 patient had previously normalized ALT levels. In 3 of 10 patients, ALT level decreased but remained at an abnormal level (93 +/- 53 IU). CONCLUSIONS Trientine and/or zinc therapy is effective for children with WD. Nonadherence is a common cause of increased aminotransferase levels in patients with WD.
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Affiliation(s)
- Ronen Arnon
- Department of Pediatrics, Mount Sinai Medical Center, Mount Sinai School of Medicine, New York, New York, USA
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31
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Brewer GJ, Askari F, Lorincz MT, Carlson M, Schilsky M, Kluin KJ, Hedera P, Moretti P, Fink JK, Tankanow R, Dick RB, Sitterly J. Treatment of Wilson disease with ammonium tetrathiomolybdate: IV. Comparison of tetrathiomolybdate and trientine in a double-blind study of treatment of the neurologic presentation of Wilson disease. ACTA ACUST UNITED AC 2006; 63:521-7. [PMID: 16606763 DOI: 10.1001/archneur.63.4.521] [Citation(s) in RCA: 177] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To compare tetrathiomolybdate and trientine in treating patients with the neurologic presentation of Wilson disease for the frequency of neurologic worsening, adverse effects, and degree of neurologic recovery. DESIGN A randomized, double-blind, controlled, 2-arm study of 48 patients with the neurologic presentation of Wilson disease. Patients either received 500 mg of trientine hydrochloride 2 times per day or 20 mg of tetrathiomolybdate 3 times per day with meals and 20 mg 3 times per day between meals for 8 weeks. All patients received 50 mg of zinc 2 times per day. Patients were hospitalized for 8 weeks, with neurologic and speech function assessed weekly; discharged taking 50 mg of zinc 3 times per day, and returned annually for follow-up. SETTING A university hospital referral setting. PATIENTS Primarily newly diagnosed patients with Wilson disease presenting with neurologic symptoms who had not been treated longer than 4 weeks with an anticopper drug. INTERVENTION Treatment with either trientine plus zinc or tetrathiomolybdate plus zinc. MAIN OUTCOME MEASURES Neurologic function was assessed by semiquantitative neurologic and speech examinations. Drug adverse events were evaluated by blood cell counts and biochemical measures. RESULTS Six of 23 patients in the trientine arm and 1 of 25 patients in the tetrathiomolybdate arm underwent neurologic deterioration (P<.05). Three patients receiving tetrathiomolybdate had adverse effects of anemia and/or leukopenia, and 4 had further transaminase elevations. One patient receiving trientine had an adverse effect of anemia. Four patients receiving trientine died during follow-up, 3 having shown initial neurologic deterioration. Neurologic and speech recovery during a 3-year follow-up period were quite good. CONCLUSION Tetrathiomolybdate is a better choice than trientine for preserving neurologic function in patients who present with neurologic disease.
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Affiliation(s)
- George J Brewer
- Department of Human Genetics, University of Michigan Medical School, 5024 Kresge Bldg. II, Ann Arbor, MI 48109-0534, USA.
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Abstract
Wilson Disease (WD) usually presents in the first decades of life, although rare patients have a later presentation. We report the clinical features, diagnostic evaluation, and outcome with treatment of two septuagenarian siblings evaluated as part of a research trial for treatment of neurological WD. The index case was a 72-year-old woman who suffered progressive neurological disability, then developed sub-fulminant liver failure. Her sibling was a 70-year-old man with minimal neurological symptoms and a mild depressive disorder. His liver biopsy revealed only steatosis and minimal fibrosis and an elevated hepatic copper content (671 mug/g dry weight liver). Molecular studies demonstrated compound heterozygosity for disease specific ATP7B mutations E1064A and H1069Q in both patients. Both individuals were treated with trientine and Zn followed by Zn maintenance therapy. Over the last 5 years, the clinical course stabilized and improved, although the index case recently died from bronchopneumonia. In conclusion, advanced age and different clinical presentations of these two subjects with identical ATP7B mutations raises the question of the degree of penetrance for these and other ATP7B mutations. Environmental and extragenic factors are pivotal determinants of disease phenotype. We suggest that WD must be considered at all ages in patients with hepatic disease, neurological disease, or psychiatric symptoms.
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Affiliation(s)
- Aftab Ala
- Division of Liver Diseases, Recanati/Miller Transplant Institute, The Mount Sinai Medical Center, New York, NY, USA
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Abstract
Wilson disease is an inherited autosomal recessive disorder of hepatic copper metabolism leading to copper accumulation in hepatocytes and in extrahepatic organs such as the brain and the cornea. Originally Wilson disease was described as a neurodegerative disorder associated with cirrhosis of the liver. Later, Wilson disease was observed in children and adolescents presenting with acute or chronic liver disease without any neurologic symptoms. While diagnosis of neurologic Wilson disease is straightforward, it may be quite difficult in non-neurologic cases. Up to now, no single diagnostic test can exclude or confirm Wilson disease with 100% certainty. In 1993, the gene responsible for Wilson disease was cloned and localized on chromosome 13q14.3 (MIM277900) (1, 2). The Wilson disease gene ATP7B encodes a P-type ATPase. More than 200 disease causing mutations of this gene have been described so far (3). Most of these mutations occur in single families, only a few are more frequent (like H1069Q, 3400delC and 2299insC in Caucasian (4-6) or R778L in Japanese (7), Chinese and Korean patients). Studies of phenotype-genotype relations are hampered by the lack of standard diagnostic criteria and phenotypic classifications. To overcome this problem, a working party discussed these problems in depth at the 8th International Meeting on Wilson disease and Menkes disease in Leipzig/Germany (April 16-18, 2001). After the meeting, a preliminary draft of a consensus report was mailed to all active participants and their comments were incorporated in the final text.
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Abstract
Thrombopoietin (TPO) is the primary regulator of platelet production. TPO is produced in the liver and levels are low in patients with cirrhosis. Because thrombocytopenia is common in patients with acute liver failure (ALF), we measured TPO concentrations (normal TPO range, 31 to 136 pg/mL) in 51 patients with ALF to determine if low levels were associated with thrombocytopenia. TPO levels from hospital day 2 were elevated in 43% of patients, normal in 47%, and decreased in 10% of patients. Levels were higher in acetaminophen-induced than in non-acetaminophen-induced ALF, 160 (12 to 549) pg/mL versus 73 (18 to 563) pg/mL, respectively, P =.031. TPO levels did not correlate with platelet count and were not related with survival or infection. We analyzed daily TPO levels for the first week of hospitalization in 12 patients with acetaminophen-induced ALF and observed a gradual increase from a median admission level of 50 (5 to 339) pg/mL to a median peak level of 406 (125 to 1,081) pg/mL occurring on day 5 (3 to 6). Platelets were reduced in 11 of the 12 patients with a nadir platelet count of 52 (19 to 156) x 10(9) cells/L occurring on day 5.5 (1 to 6). The peak TPO level did not correlate with the nadir platelet count (P =.43). In conclusion, the normal inverse relationship between platelet count and TPO levels was not observed in ALF. Despite severe hepatic dysfunction, serum TPO levels were initially normal and increased during hospitalization in acetaminophen-induced ALF, but did not prevent the development of thrombocytopenia.
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Affiliation(s)
- Frank V Schiødt
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX 75390-9151, USA
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Abstract
We studied autonomic cardiovascular function in fourteen patients with Wilson's disease. Four had abnormalities on autonomic testing and, of these, three had evidence of severe central nervous system abnormalities. In contrast, of the remaining ten patients with normal cardiovascular reflexes, only two had severe deficits of the central nervous system. We suggest that autonomic impairment in Wilson's disease is due to involvement of central autonomic neurons.
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Affiliation(s)
- Kirsty Bhattacharya
- Department of Neurology, Mount Sinai School of Medicine, New York, NY 10029, USA
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Emre S, Atillasoy EO, Ozdemir S, Schilsky M, Rathna Varma CV, Thung SN, Sternlieb I, Guy SR, Sheiner PA, Schwartz ME, Miller CM. Orthotopic liver transplantation for Wilson's disease: a single-center experience. Transplantation 2001; 72:1232-6. [PMID: 11602847 DOI: 10.1097/00007890-200110150-00008] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Wilson's disease is an inherited disorder of copper metabolism characterized by reduced biliary copper excretion, which results in copper accumulation in tissues with liver injury and failure. Orthotopic liver transplantation (OLT) can be lifesaving for patients with Wilson's disease who present with fulminant liver failure and for patients unresponsive to medical therapy. The aim of this study is to review our experience with OLT for patients with Wilson's disease. METHODS Between 1988 and 2000, 21 OLTs were performed in 17 patients with Wilson's disease. Patient demographics, pre-OLT laboratory data, operative data, and early and late postoperative complications were reviewed retrospectively. One-year patient and graft survival was calculated. RESULTS Eleven patients had fulminant Wilson's disease; in six patients the presentation was chronic. Mean patient age at presentation was 28 years (range 4-51 years); mean follow-up was 5.27 years (range 0.4-11.4 years). Neurologic features of Wilson's disease were not prominent preoperatively and did not develop post-OLT except in one patient who developed acute neuropsychiatric illness and seizure. Renal failure, present in 45% of patients with fulminant Wilson's disease, resolved post-OLT with supportive care. One-year patient and graft survivals were 87.5% and 62.5%, respectively. Fifteen survivors have remained well with normal liver function and no disease recurrence. CONCLUSION Liver transplantation for hepatic complications of Wilson's disease cures and corrects the underlying metabolic defect and leads to long-term survival in patients who present with either acute or chronic liver disease. Acute renal failure develops frequently in patients with fulminant Wilsonian hepatitis and typically resolves postoperatively.
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Affiliation(s)
- S Emre
- The Recanati-Miller Transplant Institute, Department of Medicine, The Mount Sinai School of Medicine, New York, NY, USA.
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