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Duarte T, Fidalgo P, Karvellas CJ, Cardoso FS. What every Intensivist should know about ... Ammonia in liver failure. J Crit Care 2024; 81:154456. [PMID: 37945461 DOI: 10.1016/j.jcrc.2023.154456] [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: 07/15/2023] [Revised: 08/18/2023] [Accepted: 09/12/2023] [Indexed: 11/12/2023]
Abstract
PURPOSE Acute liver failure (ALF) or acute-on-chronic liver failure (ACLF) patients have high short-term mortality and morbidity. In the context of liver failure, increased serum ammonia is associated with worse neurological outcomes, including high-grade hepatic encephalopathy (HE), cerebral edema, and intracranial hypertension. Besides its neurotoxicity, hyperammonemia may contribute to immune dysfunction and the risk of infection, a frequent trigger for multi-organ failure in these patients. MATERIAL AND METHODS We performed a literature-based narrative review. Publications available in PubMed® up to June 2023 were considered. RESULTS In the ICU management of liver failure patients, serum ammonia may play an important role. Accordingly, in this review, we focus on recent insights about ammonia metabolism, serum ammonia measurement strategies, hyperammonemia prognostic value, and ammonia-targeted therapeutic strategies. CONCLUSIONS Serum ammonia may have prognostic value in liver failure. Effective ammonia targeted therapeutic strategies are available, such as laxatives, rifaximin, L-ornithine-l-aspartate, and continuous renal replacement therapy.
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Affiliation(s)
- Tiago Duarte
- Intensive Care Unit, Curry Cabral Hospital, Lisbon, Portugal
| | - Pedro Fidalgo
- Intensive Care Unit, São Francisco Xavier Hospital, Lisbon, Portugal
| | | | - Filipe S Cardoso
- Transplant Unit, Intensive Care Unit, Curry Cabral Hospital, Nova Medical School, Lisbon, Portugal.
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Kapoor S, Tomiyama K, Orloff MS, Sharma AK. Coronavirus disease 2019-related hepatic transplant pseudoaneurysm. J Vasc Surg Cases Innov Tech 2024; 10:101469. [PMID: 38577692 PMCID: PMC10990745 DOI: 10.1016/j.jvscit.2024.101469] [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] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 02/22/2024] [Indexed: 04/06/2024] Open
Abstract
Coronavirus disease 2019-related transplant hepatic pseudoaneurysms have not been reported but can be life-threatening. They can be either solitary or multiple and can grow rapidly within weeks. They should be classified as mycotic and treated on an emergent basis. Both stenting of the vessel and coil embolization can potentially be viable treatment options of coronavirus disease 2019-related pseudoaneurysms.
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Affiliation(s)
| | - Koji Tomiyama
- Division of Solid Organ Transplant, Department of Surgery, University of Rochester, Rochester, NY
| | - Mark S. Orloff
- Division of Solid Organ Transplant, Department of Surgery, University of Rochester, Rochester, NY
| | - Ashwani Kumar Sharma
- Division of Interventional Radiology, Department of Imaging Sciences, University of Rochester, Rochester, NY
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Rodriguez-Merchan EC. Mortality rate after total knee arthroplasty or total hip arthroplasty in patients with a history of liver transplant. World J Orthop 2024; 15:310-311. [DOI: 10.5312/wjo.v15.i4.310] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 01/22/2024] [Accepted: 03/05/2024] [Indexed: 04/16/2024] Open
Abstract
In this editorial I comment on the article by Ahmed et al published in a recent issue of the World J Orthop 2023; 14: 784-790. It is well known that patients who have undergone a liver transplant (LT) may need to have a total hip arthroplasty (THA) or total knee arthroplasty (TKA) implanted. Ahmed et al stated that the mortality rate in these patients was similar to the one of the general population. However, there are three articles previously published that found higher mortality in LT patients who experienced THA/TKA than in the general population (individuals without LT). Therefore, in this Editorial I would like to point out that there is controversy in the literature regarding whether LT patients undergoing THA/TKA have higher mortality than the general population. Therefore, future research should attempt to resolve this controversy.
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Testa I, Indolfi G, Brugha R, Verkade HJ, Terlizzi V. Safety and efficacy of elexacaftor/tezacaftor/ivacaftor in people with Cystic Fibrosis following liver transplantation: A systematic review. J Cyst Fibros 2024:S1569-1993(24)00051-1. [PMID: 38614868 DOI: 10.1016/j.jcf.2024.04.006] [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] [Received: 11/28/2023] [Revised: 04/05/2024] [Accepted: 04/10/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND & AIMS Cystic Fibrosis (CF) liver disease progresses to liver failure requiring transplantation in about 3 % of patients, 0.7 % of CF patients are post liver transplant. The prognosis of CF has improved with the introduction of elexacaftor/tezacaftor/ivacaftor (ETI). Due to the paucity of data and concerns regarding interactions with immunosuppressive drug regimens, there is no general consensus on use of ETI post liver transplantation. The aim of this review is to report the safety and efficacy of ETI in CF patients who underwent liver transplantation. METHODS A systematic review was conducted through MEDLINE/Pubmed and EMBASE databases. English-written articles reporting clinical data on liver transplanted CF patients treated with ETI were included. Article quality was evaluated using the Critical Appraisal Checklist for Case Reports. RESULTS Twenty cases were retrieved from 6 reports. Temporary discontinuation and/or dose reduction due to elevated transaminases was required in 5 cases. ETI restarted on a reduced dose was tolerated in 3 out of 5 patients, 1 patient tolerated full dose. Tacrolimus dose change was required in 14 cases, in 1 case ETI was discontinued due to tacrolimus toxicity. Improvement in percentage predicted FEV1 was noted in 15/19 patients (median +17 %, range 8 %-38 %). CONCLUSIONS In the majority of liver transplanted patients ETI is well tolerated, although adverse events and liver function abnormalities may occur. Close monitoring of liver function and tacrolimus level is warranted. Significant improvement in lung function after ETI initiation is confirmed, highlighting the importance of accessing this medication for this group of patients.
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Affiliation(s)
- Ilaria Testa
- Respiratory Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Giuseppe Indolfi
- Paediatric and Liver Unit, Meyer Children's Hospital IRCCS, Florence, Italy; Department NEUROFARBA, University of Florence, Italy
| | - Rossa Brugha
- Respiratory Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Henkjan J Verkade
- Department of Paediatrics, University of Groningen, Beatrix Children's Hospital/ University Medical Center, Groningen, the Netherlands
| | - Vito Terlizzi
- Meyer Children's Hospital IRCCS, Department of Paediatric Medicine, Cystic Fibrosis Regional Reference Center, Florence, Italy.
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5
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Motta RV, Saffioti F, Mavroeidis VK. Hepatolithiasis: Epidemiology, presentation, classification and management of a complex disease. World J Gastroenterol 2024; 30:1836-1850. [DOI: 10.3748/wjg.v30.i13.1836] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 02/23/2024] [Accepted: 03/13/2024] [Indexed: 04/03/2024] Open
Abstract
The term hepatolithiasis describes the presence of biliary stones within the intrahepatic bile ducts, above the hilar confluence of the hepatic ducts. The disease is more prevalent in Asia, mainly owing to socioeconomic and dietary factors, as well as the prevalence of biliary parasites. In the last century, owing to migration, its global incidence has increased. The main pathophysiological mechanisms involve cholangitis, bile infection and biliary strictures, creating a self-sustaining cycle that perpetuates the disease, frequently characterised by recurrent episodes of bacterial infection referred to as syndrome of “recurrent pyogenic cholangitis”. Furthermore, long-standing hepatolithiasis is a known risk factor for development of intrahepatic cholangiocarcinoma. Various classifications have aimed at providing useful insight of clinically relevant aspects and guidance for treatment. The management of symptomatic patients and those with complications can be complex, and relies upon a multidisciplinary team of hepatologists, endoscopists, interventional radiologists and hepatobiliary surgeons, with the main goal being to offer relief from the clinical presentations and prevent the development of more serious complications. This comprehensive review provides insight on various aspects of hepatolithiasis, with a focus on epidemiology, new evidence on pathophysiology, most important clinical aspects, different classification systems and contemporary management.
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Affiliation(s)
- Rodrigo V. Motta
- Translational Gastroenterology and Liver Unit, Nuffield Department of Medicine, University of Oxford, Oxford OX3 9DU, United Kingdom
| | - Francesca Saffioti
- Department of Gastroenterology and Hepatology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, United Kingdom
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and University College London, London NW3 2QG, United Kingdom
| | - Vasileios K Mavroeidis
- Department of HPB Surgery, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol BS2 8HW, United Kingdom
- Department of Transplant Surgery, North Bristol NHS Trust, Southmead Hospital, Bristol BS10 5NB, United Kingdom
- Department of Gastrointestinal Surgery, North Bristol NHS Trust, Southmead Hospital, Bristol BS10 5NB, United Kingdom
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Shieb M, Hasanain R, Arshad Z, Nawaz F, Kashyap R, Stern E. Incidence, causative organisms, and risk factors of bloodstream infections in pediatric liver transplant patients: a systematic review. Clin Exp Pediatr 2024:cep.2023.01466. [PMID: 38605664 DOI: 10.3345/cep.2023.01466] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 01/03/2024] [Indexed: 04/13/2024] Open
Abstract
Bacterial bloodstream infections (BSI) are the leading cause of mortality and morbidity in pediatric solid organ transplant recipients. This systematic review aimed to pool global data from leading transplant institutions and identify the overall incidence, risk factors, and causative organisms of BSI in pediatric liver transplant recipients. A systematic review of the PubMed and OVID databases was conducted from 2000 to 2022. The initial search yielded 252 unique articles, which were independently reviewed by 2 authors. Articles that reported pediatric-specific data on BSI in isolated liver transplant patients were included, including the incidence of BSI, isolated organisms, and involved risk factors involved. This systematic review was registered with PROSPERO (ID: CRD42023403206). Fourteen articles from the United States, France, Iran, Japan, Korea, South Africa, Thailand, and Turkey were included. A total of 4,812 liver transplants were included in the final analysis. The mean patient age was 25 months (age range, 0-18 years), and 50.9% were male. The overall incidence of BSI was 23.5% (range, 14.7%-55%). The most commonly reported organisms were Staphylococcus epidermidis, Enterococcus, Klebsiella spp., and Escherichia coli. Among the risk factors studied, postoperative biliary complications, a medical history of biliary atresia, and younger age were the risk factors most commonly associated with BSI. Bacterial BSI after pediatric liver transplantation occur at a high incidence, with a unique organism profile notable for a higher percentage of gram-negative organisms. Further studies are required to determine the most appropriate prophylactic and empirical antibiotic management strategies for this population.
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Affiliation(s)
- Mohamad Shieb
- Medstar Georgetown University Hospital, DC, United States
| | - Rand Hasanain
- Al Jalila Children's Hospital, Dubai, United Arab Emirates
| | - Zara Arshad
- Shifa Clinical Research Center, Islamabad, Pakistan
| | - Faisal Nawaz
- Al Amal Pshyiatric Hospital, Dubai, United Arab Emirates
| | | | - Eric Stern
- Medstar Georgetown University Hospital, DC, United States
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Rayar M, Levi Sandri GB. The importance of preoperative imaging in living-donor hepatectomy. Hepatobiliary Surg Nutr 2024; 13:356-358. [PMID: 38617489 PMCID: PMC11007347 DOI: 10.21037/hbsn-24-29] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 02/02/2024] [Indexed: 04/16/2024]
Affiliation(s)
- Michel Rayar
- Service de Chirurgie Hépatobiliaire et Digestif, Centre Hospitalier Universitaire de Rennes, Rennes, France
- NuMeCan Institute (Nutrition, Metabolisms and Cancer), Inserm, INRAE, Univ Rennes 1, Rennes, France
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Wang T, Ren H, Yin D, Qiu H. Nephrotic proteinuria and hematuria with newly diagnosed IgA nephropathy after liver transplant: A case report. Transpl Immunol 2024; 83:102003. [PMID: 38272322 DOI: 10.1016/j.trim.2024.102003] [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] [Received: 09/11/2022] [Accepted: 01/22/2024] [Indexed: 01/27/2024]
Abstract
BACKGROUND IgA nephropathy is a renal lesion in patients with end-stage liver disease, called hepatic IgA nephropathy. The common manifestation of hepatic IgA nephropathy is microscopic hematuria. Sirolimus, often used to prevent organ rejection, has been reported to induce proteinuria after organ transplantation. But few cases of nephrotic proteinuria and hematuria are reported. CASE PRESENTATION In this case, a 45-year-old male with a long history of hepatic B virus infection and liver cirrhosis, received liver transplant and was taking sirolimus as one of his immunosuppression drugs. Overt proteinuria and hematuria occurred. With no proteinuria history before, renal biopsy was performed, which indicated IgA nephropathy. CONCLUSION We reported a liver recipient, who was taking sirolimus, developing nephrotic proteinuria and hematuria with IgA nephropathy. Further studies need to be carried out to disclose mechanism behind this phenomenon.
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Affiliation(s)
- Tingli Wang
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu 610041, PR China
| | - Honghong Ren
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu 610041, PR China
| | - Dan Yin
- Bioinformatics under Biology department, University of California-San Diego, United States of America
| | - Hongyu Qiu
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu 610041, PR China.
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Shah A, Neitzel E, Panda A, Fananapazir G. The use of ferumoxytol for high-resolution vascular imaging and troubleshooting for abdominal allografts. Abdom Radiol (NY) 2024:10.1007/s00261-024-04268-x. [PMID: 38561553 DOI: 10.1007/s00261-024-04268-x] [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] [Received: 02/02/2024] [Revised: 02/20/2024] [Accepted: 02/22/2024] [Indexed: 04/04/2024]
Abstract
Ferumoxytol is an ultrasmall superparamagnetic iron oxide which has been used as an off-label intravenous contrast agent for MRI. Unlike gadolinium-based contrast agents, ferumoxytol remains in the intravascular space with a long half-life of 14-21 h. During the first several hours, it acts as a blood-pool agent and has minimal parenchymal enhancement. Studies have shown adequate intravascular signal for up to 72 h after initial contrast bolus. Ferumoxytol has been shown to be safe, even in patients with renal failure. Ferumoxytol has shown promise in a variety of clinical settings. The exquisite resolution enabled by the long intravascular times and lack of background parenchymal enhancement is of particular interest in the vascular imaging of solid organ allografts. Ferumoxytol magnetic resonance angiography (MRA) may identify clinically actionable findings months before ultrasound, CT angiography, or Gadolinium-enhanced MRA. Ferumoxytol MRA is of particular benefit as a troubleshooting tool in the setting of equivocal ultrasound and CT imaging. In the following review, we highlight the use of ferumoxytol for high-resolution MR vascular imaging for abdominal solid organ allografts, with representative cases.
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Affiliation(s)
- Amar Shah
- Department of Radiology, Mayo Clinic in Arizona, Phoenix, AZ, USA.
| | - Easton Neitzel
- University of Arizona School of Medicine, Phoenix, AZ, USA
| | - Anshuman Panda
- Department of Radiology, Mayo Clinic in Arizona, Phoenix, AZ, USA
- Department of Medical Physics, Mayo Clinic in Arizona, Phoenix, AZ, USA
| | - Ghaneh Fananapazir
- Department of Radiology, Mayo Clinic in Arizona, Phoenix, AZ, USA
- Department of Radiology, University of California Davis School of Medicine, Sacramento, CA, USA
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Vimalesvaran S, Verma A, Dhawan A. Pediatric Liver Transplantation: Selection Criteria and Post-transplant Medical Management. Indian J Pediatr 2024; 91:383-390. [PMID: 38150147 DOI: 10.1007/s12098-023-04963-5] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 11/10/2023] [Indexed: 12/28/2023]
Abstract
Pediatric liver transplantation remains the gold standard for life-threatening acute and chronic liver diseases and multiple liver-based inherited metabolic defects. Advances in surgical techniques, better perioperative care and immunosuppression regimes have resulted in excellent long-term graft and patient survival. The success of pediatric liver transplantation does however bring the additional challenge of long-term patient outcomes including graft hepatitis-related fibrosis and suboptimal biopsychosocial outcomes. In this review, authors will explore the current landscape of pediatric liver transplantation including indications, timing of referral for liver transplantation, surgical techniques and long-term outcomes such as recurrence of pre-transplant liver disease, idiopathic graft hepatitis and biopsychosocial outcomes. Ultimately, early identification and management of potential issues long-term helps ensure our recipients achieve a "meaningful survival".
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Affiliation(s)
- Sunitha Vimalesvaran
- Pediatric Liver GI and Nutrition Centre and Mowat Labs, King's College Hospital, London, SE5 9RS, UK
| | - Anita Verma
- Pediatric Liver GI and Nutrition Centre and Mowat Labs, King's College Hospital, London, SE5 9RS, UK
| | - Anil Dhawan
- Pediatric Liver GI and Nutrition Centre and Mowat Labs, King's College Hospital, London, SE5 9RS, UK.
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D’Amico F, Rinaldi M, Pascale R, Fabbrini M, Morelli MC, Siniscalchi A, Laici C, Coladonato S, Ravaioli M, Cescon M, Ambretti S, Viale P, Brigidi P, Turroni S, Giannella M. Gut microbiome dynamics and Enterobacterales infection in liver transplant recipients: A prospective observational study. JHEP Rep 2024; 6:101039. [PMID: 38524669 PMCID: PMC10960129 DOI: 10.1016/j.jhepr.2024.101039] [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: 12/23/2023] [Revised: 02/03/2024] [Accepted: 02/07/2024] [Indexed: 03/26/2024] Open
Abstract
Background & Aims The aim of this study was to investigate gut microbiome (GM) dynamics in relation to carbapenem-resistant Enterobacterales (CRE) colonization, CRE infection, and non-CRE infection development within 2 months after liver transplant (LT). Methods A single-center, prospective study was performed in patients undergoing LT from November 2018 to January 2020. The GM was profiled through 16S rRNA amplicon sequencing of a rectal swab taken on the day of transplantation, and fecal samples were collected weekly until 1 month after LT. A subset of samples was subjected to shotgun metagenomics, including resistome dynamics. The primary endpoint was to explore changes in the GM in the following groups: (1) CRE carriers developing CRE infection (CRE_I); (2) CRE carriers not developing infection (CRE_UI); (3) non-CRE carriers developing microbial infection (INF); and (4) non-CRE carriers not developing infection (NEG). Results Overall, 97 patients were enrolled, and 91 provided fecal samples. Of these, five, nine, 22, and 55 patients were classified as CRE_I, CRE_UI, INF, and NEG, respectively. CRE_I patients showed an immediate and sustained post-LT decrease in alpha diversity, with depletion of the GM structure and gradual over-representation of Klebsiella and Enterococcus. The proportions of Klebsiella were significantly higher in CRE_I patients than in NEG patients even before LT, serving as an early marker of subsequent CRE infection. CRE_UI patients had a more stable and diverse GM, whose compositional dynamics tended to overlap with those of NEG patients. Conclusions GM profiling before LT could improve patient stratification and risk prediction and guide early GM-based intervention strategies to reduce infectious complications and improve overall prognosis. Impact and implications Little is known about the temporal dynamics of gut microbiome (GM) in liver transplant recipients associated with carbapenem-resistant Enterobacterales (CRE) colonization and infection. The GM structure and functionality of patients colonized with CRE and developing infection appeared to be distinct compared with CRE carriers without infection or patients with other microbial infection or no infection and CRE colonization. Higher proportions of antimicrobial-resistant pathogens and poor representation of bacteria and metabolic pathways capable of promoting overall host health were observed in CRE carriers who developed infection, even before liver transplant. Therefore, pretransplant GM profiling could improve patient stratification and risk prediction and guide early GM-based intervention strategies to reduce infectious complications and improve overall prognosis.
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Affiliation(s)
- Federica D’Amico
- Microbiomics Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Unit of Microbiome Science and Biotechnology, Department of Pharmacy and Biotechnology, University of Bologna, Bologna, Italy
| | - Matteo Rinaldi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Department of Integrated Management of Infectious Risk, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico Sant'Orsola, Bologna, Italy
| | - Renato Pascale
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Department of Integrated Management of Infectious Risk, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico Sant'Orsola, Bologna, Italy
| | - Marco Fabbrini
- Microbiomics Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Unit of Microbiome Science and Biotechnology, Department of Pharmacy and Biotechnology, University of Bologna, Bologna, Italy
| | - Maria Cristina Morelli
- Internal Medicine Unit for the Treatment of Severe Organ Failure, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico Sant'Orsola, Bologna, Italy
| | - Antonio Siniscalchi
- Division of Anesthesiology, Department of Anesthesia and Intensive Care, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Cristiana Laici
- Division of Anesthesiology, Department of Anesthesia and Intensive Care, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Simona Coladonato
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Department of Integrated Management of Infectious Risk, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico Sant'Orsola, Bologna, Italy
| | - Matteo Ravaioli
- General Surgery and Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico Sant'Orsola, Bologna, Italy
| | - Matteo Cescon
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- General Surgery and Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico Sant'Orsola, Bologna, Italy
| | - Simone Ambretti
- Microbiology Operative Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico Sant'Orsola, Bologna, Italy
| | - Pierluigi Viale
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Department of Integrated Management of Infectious Risk, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico Sant'Orsola, Bologna, Italy
| | - Patrizia Brigidi
- Microbiomics Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Silvia Turroni
- Unit of Microbiome Science and Biotechnology, Department of Pharmacy and Biotechnology, University of Bologna, Bologna, Italy
| | - Maddalena Giannella
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Department of Integrated Management of Infectious Risk, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico Sant'Orsola, Bologna, Italy
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12
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González IA, Saeed O, Mustafa M, Segura SE, Collins K, Hou T, Mesa H, Lee SM, Zhang D, Lin J, Cummings OW. Incidental findings during donor liver assessment: Single center experience. Ann Diagn Pathol 2024; 69:152266. [PMID: 38266545 DOI: 10.1016/j.anndiagpath.2024.152266] [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: 09/14/2023] [Revised: 01/15/2024] [Accepted: 01/17/2024] [Indexed: 01/26/2024]
Abstract
Intraoperative consultation of donor liver is an important part of transplant evaluation and determination of liver eligibility. In this study, we describe incidental pathologic findings discovered during the pretransplant evaluation of liver donors in our Institution from 1/2010 to 12/2022. During this 13-year period 369 intraoperative consultations from 262 liver donors were performed. Of those cases, incidental findings were identified in 22 cases (5.9 %) from 19 donors (7.3 %); two donors had more than one lesion. The median age of this subset of patients was 53 years (range: 18-70) and females predominated (63 %). Sixteen of the donors had abnormal findings in the liver: 6 bile duct hamartoma (BDH), 5 hyalinized nodule with Histoplasma capsulatum, 5 focal nodular hyperplasia (FNH), 2 bile duct adenomas (BDA), 1 biliary cyst and 1 hemangioma. One donor had both FNH and a BDH. One BDH and 1 BDA case was misdiagnosed as malignancy during the frozen section evaluation. Three donors had extrahepatic pathologies: a pancreatic tail schwannoma, a low-grade appendiceal mucinous neoplasm, and a lymph node with metastatic endometrial endometrioid adenocarcinoma. Of the 19 livers, the final organ disposition was available for 9: 6 were transplanted (67 %) and 3 were discarded (33 %). Two of the 3 discarded organs were misdiagnosed BDH and BDA cases, and one was incorrectly reported as having 90 % microvesicular steatosis during the frozen assessment. We present the clinicopathologic characteristics of liver donors with incidental findings during the pre-transplant evaluation which could lead to unwarranted graft dismissal if misdiagnosed. Additionally, incidental fungal infections can have implications for immunosuppressive therapy and the decision to use or reject the graft.
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Affiliation(s)
- Iván A González
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, United States of America.
| | - Omer Saeed
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, United States of America
| | - Mohamed Mustafa
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, United States of America
| | - Sheila E Segura
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, United States of America
| | - Katrina Collins
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, United States of America
| | - Tieying Hou
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, United States of America
| | - Hector Mesa
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, United States of America
| | - Sun M Lee
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, United States of America
| | - Dongwei Zhang
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, United States of America
| | - Jingmei Lin
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, United States of America
| | - Oscar W Cummings
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, United States of America
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Nguyen Van R, Houssel-Debry P, Erard D, Dumortier J, Pouvaret A, Bergez G, Danion F, Surgers L, Le Moing V, Kamar N, Lanternier F, Tattevin P. Characteristics, management, and outcome of tuberculosis after liver transplant: A case series and literature review. Infect Dis Now 2024; 54:104869. [PMID: 38401760 DOI: 10.1016/j.idnow.2024.104869] [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: 11/11/2023] [Revised: 02/10/2024] [Accepted: 02/15/2024] [Indexed: 02/26/2024]
Abstract
BACKGROUND Liver transplant recipients are at risk of tuberculosis, which is particularly difficult-to diagnose and to treat in this population. METHODS Retrospective study of all cases of tuberculosis diagnosed from 2007 to 2022 in the French network of liver transplant sites. RESULTS Twenty-three liver transplant recipients were diagnosed with tuberculosis (six females, median age 59 years [interquartile range, 54-62]), with a median time lapse of 10 months [5-40.5] after transplant, and 38 days [26-60] after symptoms onset. Primary modes of pathogenesis were latent tuberculosis reactivation (n = 15) and transplant-related transmission (n = 3). Even though most patients with pre-transplant data had risk factors for tuberculosis (11/20), IFN-gamma release assay was performed in only three. Most cases involved extra-pulmonary tuberculosis (20/23, 87 %). With median follow-up of 63 months [24-108], five patients died (22 %), including four tuberculosis-related deaths. CONCLUSIONS Extrapulmonary tuberculosis is a severe disease in liver transplant recipients. Systematic pre-transplant screening of latent tuberculosis may prevent most of them.
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Affiliation(s)
- Rémi Nguyen Van
- Infectious Disease and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France; Infectious Diseases, Centre Hospitalier Bretagne-Atlantique, Vannes, France
| | - Pauline Houssel-Debry
- Hepatology and Liver Transplantation, Pontchaillou University Hospital, Rennes, France
| | - Domitille Erard
- Hepatology and Liver Transplantation, La Croix Rousse University Hospital, Lyon, France
| | - Jérôme Dumortier
- Hepato-Gastroenterology, Edouard Herriot University Hospital, and University Lyon-1, Lyon, France
| | - Anne Pouvaret
- Infectious Diseases, University Hospital, Saint-Etienne, France
| | - Guillaume Bergez
- Infectious Disease, Beaujon Hospital, AP-HP, University Hospital, Paris, France
| | - François Danion
- Infectious Disease, University Hospital, Inserm UMR_S 1109 Immuno-rhumatologie Moléculaire, Université de Strasbourg, Strasbourg, France
| | - Laure Surgers
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, F75012 Paris, France; GHU APHP, Sorbonne Université, Service des Maladies Infectieuses et Tropicales, Hôpital Saint-Antoine, F75012 Paris, France
| | - Vincent Le Moing
- Infectious Diseases, University Hospital, University of Montpellier, Montpellier, France
| | - Nassim Kamar
- Department of Nephrology and Organ Transplantation, Toulouse Rangueil University Hospital, INSERM UMR 1291, Toulouse Institute for Infectious and Inflammatory Diseases (Infinity), University Paul Sabatier, Toulouse, France
| | - Fanny Lanternier
- Infectious Diseases, Necker-Enfants Malades Hospital, AP-HP, Université Paris-Cité, Paris, France
| | - Pierre Tattevin
- Infectious Disease and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France.
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14
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Kadaba P, Beitia L, Rosen A, Weinberg A, Lewis S, Simpson WL. Utility of nifedipine use for Doppler ultrasound early after liver transplantation to predict short-term complications and long-term outcomes. Abdom Radiol (NY) 2024; 49:1103-1112. [PMID: 38219253 DOI: 10.1007/s00261-023-04152-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 12/01/2023] [Accepted: 12/05/2023] [Indexed: 01/16/2024]
Abstract
PURPOSE To evaluate the response to nifedipine administration measured by changes in hepatic arterial (HA) flow on post-operative Doppler ultrasound (US) to predict short-term complications and long-term outcomes in liver transplant (LT) patients. METHODS Patients who underwent LT with post-operative Doppler US within 3 days between 1 January 2005 and 31 December 2015 were included in this retrospective single center study. The patients who received and did not receive nifedipine during the Doppler US comprised the study and control groups, respectively. A positive response to nifedipine was defined as the detection of HA flow when none was present initially or a reduction in HA resistive index (RI) ≥ 0.1 after nifedipine administration. The rates of re-transplantation, re-operation, percutaneous intervention (PCI), and overall survival (OS) were recorded. Cox proportional hazards regression was used to evaluate the association of clinic-demographic variables and Doppler findings with the outcome measures. RESULTS 444 LT patients (305 M/139F, mean age 51.7 ± 17.4 years, mean interval between LT-Doppler US 1.12 ± 0.9 days) are presented. 220 patients comprised the nifedipine study group [n = 157/220 (71.4%) responder, n = 63/220 (28.6%) nonresponder] and 224 patients comprised the control group. There was no difference in re-transplantation or PCI rates between the groups (all p-values ≥ 0.2 and ≥ 0.08, respectively). The responder group had a lower rate of re-operation vs. the control group (15.9% vs. 24.1%, p = 0.03) and nonresponder group (15.9% vs. 31.8%, p = 0.004). 1-year and 2-year OS were similar between the groups (all p-values > 0.37). CONCLUSION Short-term complication rates and long-term outcomes for patients with liver transplant who responded to nifedipine administration on Doppler US are similar to those who did not require nifedipine administration. A lack of response to nifedipine was associated with a higher re-operation rate.
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Affiliation(s)
- Priyanka Kadaba
- Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, Gustave L Levy Place, Box 1234, New York, NY, 10029, USA
| | - Laura Beitia
- Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, Gustave L Levy Place, Box 1234, New York, NY, 10029, USA
| | - Ally Rosen
- Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, Gustave L Levy Place, Box 1234, New York, NY, 10029, USA
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Alan Weinberg
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Sara Lewis
- Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, Gustave L Levy Place, Box 1234, New York, NY, 10029, USA
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - William L Simpson
- Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, Gustave L Levy Place, Box 1234, New York, NY, 10029, USA.
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Cooper KM, Colletta A, Hebda N, Devuni D. Alcohol associated liver disease and bariatric surgery: Current perspectives and future directions. World J Gastrointest Surg 2024; 16:650-657. [PMID: 38577096 PMCID: PMC10989338 DOI: 10.4240/wjgs.v16.i3.650] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 01/27/2024] [Accepted: 02/26/2024] [Indexed: 03/22/2024] Open
Abstract
Bariatric surgery is a routinely performed procedure and is associated with a reduction in all-cause mortality in patients with obesity. However, bariatric surgery has also been linked to increased alcohol use with up to 30% of these patients developing alcohol use disorder (AUD). The mechanism of AUD after bariatric surgery is multifactorial and includes anatomic, metabolic, and neurohumoral changes associated with post-surgical anatomy. These patients are at increased risk of alcohol associated liver disease and, in some cases, require liver transplantation. In this article, we provide a scoping review of epidemiology, pathophysiology, and clinical outcomes of alcohol-related health conditions after bariatric surgery.
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Affiliation(s)
- Katherine M Cooper
- Department of Medicine, UMass Chan Medical School, Worcester, MA 01655, United States
| | - Alessandro Colletta
- Department of Medicine, UMass Chan Medical School, Worcester, MA 01655, United States
| | - Nicholas Hebda
- Department of Medicine, UMass Chan Medical School, Worcester, MA 01655, United States
| | - Deepika Devuni
- Department of Medicine, UMass Chan Medical School, Worcester, MA 01655, United States
- Division of Gastroenterology, UMass Chan Medical School, Worcester, MA 01655, United States
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Pahari H, Raj A, Sawant A, Ahire DS, Rathod R, Rathi C, Sankalecha T, Palnitkar S, Raut V. Liver transplantation for hepatocellular carcinoma in India: Are we ready for 2040? World J Transplant 2024; 14:88833. [PMID: 38576752 PMCID: PMC10989470 DOI: 10.5500/wjt.v14.i1.88833] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/21/2023] [Accepted: 01/22/2024] [Indexed: 03/15/2024] Open
Abstract
BACKGROUND Liver transplantation (LT) for hepatocellular carcinoma (HCC) has been widely researched and is well established worldwide. The cornerstone of this treatment lies in the various criteria formulated by expert consensus and experience. The variations among the criteria are staggering, and the short- and long-term out comes are controversial. AIM To study the differences in the current practices of LT for HCC at different centers in India and discuss their clinical implications in the future. METHODS We conducted a survey of major centers in India that performed LT in December 2022. A total of 23 responses were received. The centers were classified as high- and low-volume, and the current trend of care for patients und ergoing LT for HCC was noted. RESULTS Of the 23 centers, 35% were high volume center (> 500 Liver transplants) while 52% were high-volume centers that performed more than 50 transplants/year. Approximately 39% of centers had performed > 50 LT for HCC while the percent distribution for HCC in LT patients was 5%-15% in approximately 73% of the patients. Barring a few, most centers were divided equally between University of California, San Francisco (UCSF) and center-specific criteria when choosing patients with HCC for LT, and most (65%) did not have separate transplant criteria for deceased donor LT and living donor LT (LDLT). Most centers (56%) preferred surgical resection over LT for a Child A cirrhosis patient with a resectable 4 cm HCC lesion. Positron-emission tomography-computed tomography (CT) was the modality of choice for metastatic workup in the majority of centers (74%). Downstaging was the preferred option for over 90% of the centers and included transarterial chemoembolization, transarterial radioembolization, stereotactic body radiotherapy and atezolizumab/bevacizumab with varied indications. The alpha-fetoprotein (AFP) cut-off was used by 74% of centers to decide on transplantation as well as to downstage tumors, even if they met the criteria. The criteria for successful downstaging varied, but most centers conformed to the UCSF or their center-specific criteria for LT, along with the AFP cutoff values. The wait time for LT from down staging was at least 4-6 wk in all centers. Contrast-enhanced CT was the preferred imaging modality for post-LT surveillance in 52% of the centers. Approximately 65% of the centers preferred to start everolimus between 1 and 3 months post-LT. CONCLUSION The current predicted 5-year survival rate of HCC patients in India is less than 15%. The aim of transplantation is to achieve at least a 60% 5-year disease free survival rate, which will provide relief to the prediction of an HCC surge over the next 20 years. The current worldwide criteria (Milan/UCSF) may have a higher 5-year survival (> 70%); however, the majority of patients still do not fit these criteria and are dependent on other suboptimal modes of treatment, with much lower survival rates. To make predictions for 2040, we must prepare to arm ourselves with less stringent selection criteria to widen the pool of patients who may undergo transplantation and have a chance of a better outcome. With more advanced technology and better donor outcomes, LDLT will provide a cutting edge in the fight against liver cancer over the next two decades.
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Affiliation(s)
- Hirak Pahari
- Department of Liver Transplant and HPB Surgery, Medicover Hospitals, Navi Mumbai 410210, Maharashtra, India
| | - Amruth Raj
- Department of Liver Transplant and HPB Surgery, Medicover Hospitals, Navi Mumbai 410210, Maharashtra, India
| | - Ambreen Sawant
- Department of Liver Transplant Anaesthesia, Medicover Hospitals, Navi Mumbai 410210, Maharashtra, India
| | - Dipak S Ahire
- Department of Gastroenterology and Hepatology, Medicover Hospitals, Navi Mumbai 410210, India
| | - Raosaheb Rathod
- Department of Gastroenterology and Hepatology, Medicover Hospitals, Navi Mumbai 410210, Maharashtra, India
| | - Chetan Rathi
- Department of Gastroenterology and Hepatology, Medicover Hospitals, Aurangabad 431003, India
| | - Tushar Sankalecha
- Department of Gastroenterology and Hepatology, Medicover Hospitals, Nashik 422009, India
| | - Sachin Palnitkar
- Department of Gastroenterology and Hepatology, Medicover Hospitals, Pune 411026, India
| | - Vikram Raut
- Department of Liver Transplant and HPB Surgery, Medicover Hospitals, Navi Mumbai 410210, Maharashtra, India
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17
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Andacoglu OM, Dennahy IS, Mountz NC, Wilschrey L, Oezcelik A. Impact of sex on the outcomes of deceased donor liver transplantation. World J Transplant 2024; 14:88133. [PMID: 38576760 PMCID: PMC10989474 DOI: 10.5500/wjt.v14.i1.88133] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 11/01/2023] [Accepted: 12/11/2023] [Indexed: 03/15/2024] Open
Abstract
BACKGROUND Data examining the impact of sex on liver transplant (LT) outcomes are limited. It is clear that further research into sex-related differences in transplant patients is necessary to identify areas for improvement. Elucidation of these differences may help to identify specific areas of focus to improve on the organ matching process, as well as the peri- and post-operative care of these patients. AIM To utilize data from a high-volume Eurotransplant center to compare characteristics of male and female patients undergoing liver transplant and assess asso ciation between sex-specific variables with short- and long-term post-transplant outcomes. METHODS A retrospective review of the University of Essen's transplant database was performed with collection of baseline patient characteristics, transplant-related data, and short-term outcomes. Comparisons of these data were made with Shapiro-Wilk, Mann-Whitney U, χ2 and Bonferroni tests applied where app ropriate. A P value of < 0.05 was accepted as statistically significant. RESULTS Of the total 779 LT recipients, 261 (33.5%) were female. Female patients suffered higher incidences of acute liver failure and lower incidences of alcohol-related or viremic liver disease (P = 0.001). Female patients were more likely to have received an organ from a female donor with a higher donor risk index score, and as a high urgency offer (all P < 0.05). Baseline characteristics of male and female recipients were also significantly different. In multivariate hazard regression analysis, recipient lab-Model for End-Stage Liver Disease score and donor cause of death were associated with long-term outcomes in females. Pre-operative diagnosis of hepatocellular carcinoma, age at time of listing, duration of surgery, and units transfused during surgery, were associated with long-term outcomes in males. Severity of complications was associated with long-term outcomes in both groups. Overall survival was similar in both males and females; however, when stratified by age, females < 50 years of age had the best survival. CONCLUSION Female and male LT recipients have different baseline and transplant-related characteristics, with sex-specific variables which are associated with long-term outcomes. Female recipients < 50 years of age demonstrated the best long-term outcomes. Pre- and post-transplant practices should be individualized based on sex-specific variables to optimize long-term outcomes.
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Affiliation(s)
- Oya M Andacoglu
- Division of Transplantation and Advanced Hepatobiliary Surgery, University of Utah, Salt Lake City, UT 84112, United States
- Department of Surgery, University of Essen, Essen D-45122, Germany
| | - Isabel S Dennahy
- Department of Surgery, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73117, United States
| | - Nicole C Mountz
- Department of Surgery, University of Oklahoma College of Medicine, Oklahoma City, OK 73117, United States
| | - Luisa Wilschrey
- Department of Surgery, University of Essen, Essen D-45122, Germany
| | - Arzu Oezcelik
- Department of Surgery, University of Essen, Essen D-45122, Germany
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18
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Toledo E, Canal G, Sánchez S, Echeverri J, Fernández R, Del Mar Achalandabaso M, Anderson EJ, Castillo F, Rodríguez JC. Comparison of abdominal adipose tissue versus Body Mass Index (BMI) as a predictor of complications and survival in liver transplantation. Cir Esp 2024:S2173-5077(24)00083-8. [PMID: 38508388 DOI: 10.1016/j.cireng.2024.02.010] [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] [Received: 10/03/2023] [Accepted: 02/28/2024] [Indexed: 03/22/2024]
Abstract
INTRODUCTION Because of the obesity epidemic, more obese patients are on liver transplant (LT) waiting lists. The diseases associated with obesity may increase complications and limit survival after LT. However, there is no established measure or cut-off point to determine this impact and aid decision making. The aim of the present study is to evaluate obesity in patients undergoing LT via BMI and CT-based measurement of adipose tissue (AAT). These parameters will be used to predict the risk of postoperative complications and 5-year survival. METHODS A retrospective, single-center study was carried out at a tertiary Spanish hospital, including all patients who received LT between January 2012 and July 2019 (n = 164). The patients were adults who underwent LT using the 'piggyback' technique, preserving the recipient vena cava. Visceral adipose tissue (VAT) and BMI were calculated to examine correlations with postoperative complications and 5-year survival. RESULTS No significant association was found between postoperative complications by Comprehensive Complication Index, BMI, AAT/height, subcutaneous fat/height and VAT/height. Kaplan-Meier curves for 5-year survival compared LT recipients with BMI < 30.45 vs ≥30.45, with an estimated survival of 58.97 months versus 43.11 months, respectively (P < .001) (Fig. 3) and for LT recipients with an AAT/height <27.35 mm versus ≥27.35 mm, with an estimated survival of 57.69 months versus 46.34 months (P = .001). CONCLUSIONS This study does not show a higher rate of postoperative complications in obese patients. There is a significantly lower long-term survival in patients with AAT/height ≥27.35 mm and BMI ≥ 30.45. BMI is a valid estimate of obesity and is predictive of survival.
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Affiliation(s)
- Enrique Toledo
- General Surgery, Hospital Universitario Marqués de Valdecilla (HUMV), Santander, Spain.
| | - Gema Canal
- General Surgery, Hospital Universitario Marqués de Valdecilla (HUMV), Santander, Spain
| | | | - Juan Echeverri
- General Surgery, Hospital Universitario Marqués de Valdecilla (HUMV), Santander, Spain
| | - Roberto Fernández
- General Surgery, Hospital Universitario Marqués de Valdecilla (HUMV), Santander, Spain
| | | | - Edward J Anderson
- General Surgery, Hospital Universitario Marqués de Valdecilla (HUMV), Santander, Spain
| | - Federico Castillo
- General Surgery, Hospital Universitario Marqués de Valdecilla (HUMV), Santander, Spain
| | - Juan Carlos Rodríguez
- General Surgery, Hospital Universitario Marqués de Valdecilla (HUMV), Santander, Spain; Universidad de Cantabria, Cantabria, Spain
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19
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Biswas S, Kumar R, Shalimar, Acharya SK. Viral hepatitis-induced acute liver failure. Indian J Gastroenterol 2024:10.1007/s12664-024-01538-w. [PMID: 38451383 DOI: 10.1007/s12664-024-01538-w] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 01/18/2024] [Indexed: 03/08/2024]
Abstract
Viral hepatitis-induced acute liver failure (ALF) is a preventable cause for liver-related mortality worldwide. Viruses are the most common cause for ALF in developing nations in contrast to the west, where acetaminophen is largely responsible. Viruses may be hepatotropic or affect the liver secondary to a systemic infection. In tropical countries, infections such as leptospirosis, scrub typhus and malaria can mimic the symptoms of ALF. Differentiating these ALF mimics is crucial because they require etiology-specific therapy. Treatment of viral hepatitis-induced ALF is two-pronged and directed towards providing supportive care to prevent organ failures and antiviral drugs for some viruses. Liver transplantation (LT) is an effective modality for patients deteriorating despite adequate supportive care. Early referral and correct identification of patients who require a transplant are important. Liver support devices and plasma exchange have evolved into "bridging modalities" for LT. Preventive strategies such as hand hygiene, use of clean and potable water and inclusion of vaccines against viral hepatitis in the national program are simple yet very effective methods focusing on the preventive aspect of this disease.
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Affiliation(s)
- Sagnik Biswas
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna, 801 507, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110 029, India.
| | - Subrat Kumar Acharya
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110 029, India
- KIIT University, Bhubaneswar, 751 024, India
- Fortis Escorts Digestive and Liver Institute, Okhla, New Delhi, 110 025, India
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Guedes LR, Cançado GGL, Santos BC, Jacomassi LDS, Nardelli MJ, Osório FMF, Faria LC, Couto CA. Clinical, biochemical and histological features related to treatment response and prognosis in autoimmune hepatitis. Ann Hepatol 2024:101497. [PMID: 38460715 DOI: 10.1016/j.aohep.2024.101497] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 11/19/2023] [Accepted: 01/02/2024] [Indexed: 03/11/2024]
Abstract
INTRODUCTION AND OBJECTIVES Autoimmune hepatitis (AIH) is a rare disease with a complex and not fully understood pathogenesis. Prognostic factors that might influence treatment response, relapse rates, and transplant-free survival are not well established. This study investigates clinical and biochemical markers associated with response to immunosuppression in patients with AIH. MATERIALS AND METHODS This retrospective cohort study included 101 patients with AIH treated with immunosuppressants and followed at the Federal University of Minas Gerais, Brazil, from 1990 to 2018. Pretreatment data such as clinical profiles, laboratory, and histological exams were analyzed regarding biochemical response at one year, histological remission, relapse, and death/transplantation rates. RESULTS Cirrhosis was present in 59 % of cases at diagnosis. One-year biochemical remission was observed in 55.7 % of the patients and was found to be a protective factor for liver transplant. Overall survival was 89 %. Patients with ascites at disease onset showed a higher aspartate aminotransferase (AST)/ alanine aminotransferase (ALT) ratio and elevated Model of end-stage liver disease (MELD) score. The presence of ascites was significantly associated with a 20-fold increase in mortality rate. CONCLUSIONS AIH has a severe clinical phenotype in Brazilians, with high rates of cirrhosis and low remission rates. Early diagnosis and treatment are essential for achieving remission and reducing complications. The presence of ascites is significantly associated with mortality, emphasizing the importance of monitoring and prompt intervention. This study also stresses the need for further research on AIH in Latin America.
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Affiliation(s)
- Ludmila Resende Guedes
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil; Hospital Mater Dei, Belo Horizonte, Minas Gerais, Brazil.
| | - Guilherme Grossi Lopes Cançado
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil; Hospital da Polícia Militar de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Bruno Campos Santos
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Luma Dos Santos Jacomassi
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Mateus Jorge Nardelli
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Fernanda Maria Farage Osório
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Luciana Costa Faria
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Cláudia Alves Couto
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
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McIntire C, Luna Torres J, Tang P, Vinks AA, Kaplan J, Tang Girdwood S. Piperacillin pharmacokinetics and pharmacodynamics in paediatric patients who received high frequency intra-operative piperacillin/tazobactam dosing. Int J Antimicrob Agents 2024; 63:107079. [PMID: 38161045 PMCID: PMC10923153 DOI: 10.1016/j.ijantimicag.2023.107079] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 11/10/2023] [Accepted: 12/26/2023] [Indexed: 01/03/2024]
Abstract
Piperacillin/tazobactam (PTZ) is a broad-spectrum antibiotic, typically dosed every six hours (q6h). Guidelines recommend dosing PTZ every 2 hours (q2h) intra-operatively for complex abdominal surgery, including liver transplant. The data supporting the guidelines for intra-operative dosing are sparse and the pharmacokinetics/pharmacodynamics (PK/PD) of q2h dosing has not been studied by simulation or in humans. In this study, PK/PD parameters of high-frequency intra-operative dosing and q6h post-operative dosing were compared in critically ill children. Paediatric patients who received PTZ during complex abdominal surgery or transplant and who had intra-operative and post-operative opportunistic samples were included. Using a published PK model and observed concentrations, individual piperacillin PK/PD parameters were estimated using Bayesian estimation. Alternative post-operative dosing strategies were simulated using the patients with the highest and lowest estimated piperacillin clearance. Thirteen patients were included (median age: 3.1 years, 85% liver transplant recipients). PK parameters in the intra-operative and post-operative phases were not significantly different (clearance: 15.8 ± 7.2 vs. 12.6 ± 6.3 L/h/70 kg, P=0.070; central volume: 13.4 [13.1, 13.8] vs. 15.2 [12.2, 16.0] L/70 kg, P=0.22). At an individual level, intra-operative clearance values were -35% to 139% of the post-operative values, whereas central volume intra-operative values were -40% to 77% of the post-operative values. Intra-operative piperacillin exposure was higher during high-frequency dosing compared with the post-operative period (AUC/h: 109 [93.4, 127] vs. 62.8 [41.6, 78.3] mg/L, P=0.002). Simulations showed great variation in optimal dosing strategies that would minimise toxicity and maximise efficacy, indicating a role for individualised dosing in paediatric surgical populations.
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Affiliation(s)
- Carter McIntire
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, United States of America
| | - Julie Luna Torres
- Office of Medical Education, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH, 45229, United States of America
| | - Peter Tang
- Division of Pathology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, United States of America; Department of Paediatrics, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH, 45229, United States of America
| | - Alexander A Vinks
- Department of Paediatrics, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH, 45229, United States of America; Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, United States of America
| | - Jennifer Kaplan
- Department of Paediatrics, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH, 45229, United States of America; Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, United States of America
| | - Sonya Tang Girdwood
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, United States of America; Department of Paediatrics, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH, 45229, United States of America; Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, United States of America.
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22
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Gitto S, Golfieri L, Gabrielli F, Falcini M, Sofi F, Tamè MR, De Maria N, Marzi L, Mega A, Valente G, Borghi A, Forte P, Cescon M, Di Benedetto F, Andreone P, Petranelli M, Morelli MC, De Simone P, Lau C, Stefani L, Vizzutti F, Chiesi F, Marra F. Physical activity in liver transplant recipients: a large multicenter study. Intern Emerg Med 2024; 19:343-352. [PMID: 37985618 PMCID: PMC10954936 DOI: 10.1007/s11739-023-03474-7] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 10/24/2023] [Indexed: 11/22/2023]
Abstract
AIM Healthy lifestyle and appropriate diet are of critical importance after liver transplant (LT). We provided an analysis of the main patterns of physical activity and found factors associated with physical activity itself. METHODS Clinically stable LT recipients were enrolled between June and September 2021. Patients completed a composite questionnaire about physical activity, adherence to Mediterranean Diet (MD), quality of life (QoL), and employment. Correlations were analysed using the Pearson coefficients while different subgroups were compared by t-test for independent samples or ANOVAs. Multivariable logistic regression analysis was conducted to find predictors of inactivity. RESULTS We enrolled 511 subjects (71% males, mean age 63 ± 10.8 years). One hundred and ninety-three patients reported high level of physical activity, 197 a minimal activity and 121 declared insufficient activity. Among these latter, 29 subjects were totally inactive. Considering the 482 LT recipients performing some kind of physical activity, almost all reported a low-quality, non-structured activity. At multivariate analysis, time from LT (odds ratio 0.94, 95% CI 0.89-0.99, p = 0.017), sedentary lifestyle (odds ratio 0.99, 95% CI 0.19-0.81, p = 0.012), low adherence to MD (odds ratio 1.22, 95% CI 1.01-1.48, p = 0.049), and low level of QoL (physical dimension) (odds ratio 1.13, 95% CI 1.08-1.17, p < 0.001), were independently associated with total inactivity. CONCLUSION A large portion of LT recipients report an insufficient level of physical activity or are wholly inactive. Inactivity increases with time from LT and was strongly associated with suboptimal diet and low QoL.
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Affiliation(s)
- Stefano Gitto
- Internal Medicine and Liver Unit, University Hospital Careggi, Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 3, 50134, Florence, Italy.
| | - Lucia Golfieri
- Internal Medicine Unit for the Treatment of Severe Organ Failure, Dipartimento Medico chirurgico delle malattie digestive, epatiche ed endocrino-metaboliche, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico di Sant'Orsola, Bologna, Italy
| | - Filippo Gabrielli
- Internal and Metabolic Medicine, Department of Medical and Surgical Sciences for Children & Adults, AOU di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Margherita Falcini
- Internal Medicine and Liver Unit, University Hospital Careggi, Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 3, 50134, Florence, Italy
| | - Francesco Sofi
- Unit of Clinical Nutrition, Careggi University Hospital, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Maria Rosa Tamè
- Gastroenterology Division, Dipartimento Medico chirurgico delle malattie digestive, epatiche ed endocrino-metaboliche, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico di Sant'Orsola, Bologna, Italy
| | - Nicola De Maria
- Department of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena and University of Modena and Reggio Emilia, Modena, Italy
| | - Luca Marzi
- Division of Gastroenterology, Bolzano Regional Hospital, Bolzano, Italy
| | - Andrea Mega
- Division of Gastroenterology, Bolzano Regional Hospital, Bolzano, Italy
| | - Giovanna Valente
- Liver Unit for Transplant Management - SATTE, Department of Medical Sciences, AORN Sant'Anna e San Sebastiano, Caserta, Italy
| | | | - Paolo Forte
- Gastroenterology Unit, University Hospital Careggi, Florence, Italy
| | - Matteo Cescon
- General Surgery and Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico di Sant'Orsola, Bologna, Italy
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Pietro Andreone
- Internal and Metabolic Medicine, Department of Medical and Surgical Sciences for Children & Adults, AOU di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Marco Petranelli
- Contract Lecturer, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Maria Cristina Morelli
- Internal Medicine Unit for the Treatment of Severe Organ Failure, Dipartimento Medico chirurgico delle malattie digestive, epatiche ed endocrino-metaboliche, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico di Sant'Orsola, Bologna, Italy
| | - Paolo De Simone
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Chloe Lau
- Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Laura Stefani
- Sports Medicine Center Clinical and Experimental Medicine Department, University of Florence, Florence, Italy
| | - Francesco Vizzutti
- Internal Medicine and Liver Unit, University Hospital Careggi, Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 3, 50134, Florence, Italy
| | - Francesca Chiesi
- Department of Neuroscience, Psychology, Drug, and Child's Health (NEUROFARBA), Section of Psychology, University of Florence, Florence, Italy
| | - Fabio Marra
- Internal Medicine and Liver Unit, University Hospital Careggi, Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 3, 50134, Florence, Italy
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23
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Prakash S, Tanaka T. The landscape of inpatient admissions for alcoholic hepatitis in the era of early liver transplantation. Ann Hepatol 2024; 29:101169. [PMID: 37816470 DOI: 10.1016/j.aohep.2023.101169] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 08/28/2023] [Accepted: 09/11/2023] [Indexed: 10/12/2023]
Abstract
INTRODUCTION AND OBJECTIVES Liver transplant (LT) is a recent option available in the United States (US) to treat those with severe, refractory alcoholic hepatitis (AH). We examined changes in clinical characteristics of patients admitted with AH and tracked hospital outcomes as practice changes involving LT have shifted. MATERIALS AND METHODS Using the National Inpatient Sample, we performed a cross-sectional analysis of patients admitted with AH during the years 2016-2020 in the US. Differences in clinical characteristics over time were assessed. To compare outcomes between 2016-2017 (when LT was less common) and 2018-2020 (when LT was more common), we conducted linear and logistic regression. Propensity-score matching was used to compare outcomes between patients with and without LT. RESULTS From 2016-2017 to 2018-2020, patients admitted with AH tended to have a higher frequency of infection (p = 0.006), hepatorenal syndrome (<0.001), and ascites (<0.001). Hospital costs and length of stay (LOS) were highest in transplant hospitals, and costs rose over time in both non-transplant (NT) teaching and non-teaching hospitals (p < 0.001). Mortality decreased in NT teaching hospitals [aOR 0.7 (95% CI: 0.6-0.8)] and slightly decreased in NT non-teaching hospitals [aOR 0.7 (95% CI: 0.5-1.0)]. In the propensity-matched cohort involving LT versus non-LT patients, there was a 10% absolute reduction in-hospital mortality, but this came at a higher cost (p < 0.001) and length of stay (p < 0.001). CONCLUSIONS The severity of AH has been increasing over time, yet mortality has declined after adjusting for severity of disease. Patients who underwent LT survived; however, the healthcare burden of LT is substantial.
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Affiliation(s)
- Shahana Prakash
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, United States; Iowa City Veterans Administration Medical Center, Iowa City, IA, United States
| | - Tomohiro Tanaka
- Iowa City Veterans Administration Medical Center, Iowa City, IA, United States; Division of Gastroenterology-Hepatology, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, United States.
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24
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Abele D, Gäbel M, Oltean M, Varkey J, Mölne J, Ekwall N, Borg H, Jacobsson H, Holgersson J, Herlenius G. Including the liver in the visceral allograft: Impact on donor-specific anti-HLA antibodies and long-term outcomes. Hum Immunol 2024; 85:110767. [PMID: 38418315 DOI: 10.1016/j.humimm.2024.110767] [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: 12/19/2023] [Revised: 02/07/2024] [Accepted: 02/19/2024] [Indexed: 03/01/2024]
Abstract
Humoral immunity emerges as a risk factor for graft failure after visceral transplantation (VTx) and development of donor-specific anti-HLA antibodies (DSAs) has been linked with poor outcomes. In most cases, a simultaneous liver transplant can be safely performed in sensitized patients with DSA and appears protective against lymphocytotoxic antibodies. We investigated the incidence of acute (AR) and chronic rejection (CR) in 32 VTx without any B cell-depleting pre-treatment (6 isolated intestinal transplants (IT) and 26 liver-containing, multivisceral transplants (MVT) and assessed the presence of donor-specific antibodies (DSA) pre- and post-transplantation. Twenty-one patients (65 %) developed AR, 15 (57 %) of the MVT and 6 (100 %) of the IT (p = 0.05). CR occurred in 4 IT (60 %, p < 0.001). At one month, de novo DSA were present in 71 % of VTx (66 % MVT vs 100 % IT, p = 0.09). At the last available follow-up, 69 % of the MVT and 50 % of the IT patients were DSA-free. De novo DSA seemed more persistent (7/19, 37 %) than pre-Tx DSA (1/6, 17 %; p = n.s.), de novo DSA were more frequently specific for HLA class II than class I, 16/19 (84 %) vs. 7/19 (37 %; p = 0.003), and HLA-DQ was their most frequent target HLA. DQ mismatches appeared to be a risk factor for developing de novo DSA. In conclusion, liver-containing visceral allografts have superior short- and long-term outcomes compared with liver-free allografts. De novo DSA develop early and frequently after VTx performed without B cell-depleting induction therapy, but the exact role of DSA in the pathogenesis of rejection remains unclear.
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Affiliation(s)
- Dace Abele
- Department of Clinical Immunology and Transfusion Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Markus Gäbel
- The Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Mihai Oltean
- The Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.
| | - Jonas Varkey
- Division of Gastroenterology, Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Johan Mölne
- Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Clinical Pathology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Nils Ekwall
- Department of Pediatric Medicine, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Pediatrics, Institute of Clinical Sciences, The Sahlgrenska Academy at University of Gothenburgl, Gothenburg, Sweden
| | - Helena Borg
- Department of Pediatrics, Institute of Clinical Sciences, The Sahlgrenska Academy at University of Gothenburgl, Gothenburg, Sweden; Department of Pediatric Surgery, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Hanna Jacobsson
- Biobank West, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jan Holgersson
- Department of Clinical Immunology and Transfusion Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Gustaf Herlenius
- The Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
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25
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Akshat S, Gentry SE, Raghavan S. Heterogeneous donor circles for fair liver transplant allocation. Health Care Manag Sci 2024; 27:20-45. [PMID: 35854169 PMCID: PMC10896798 DOI: 10.1007/s10729-022-09602-7] [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: 12/08/2021] [Accepted: 05/25/2022] [Indexed: 11/04/2022]
Abstract
The United States (U.S.) Department of Health and Human Services is interested in increasing geographical equity in access to liver transplant. The geographical disparity in the U.S. is fundamentally an outcome of variation in the organ supply to patient demand (s/d) ratios across the country (which cannot be treated as a single unit due to its size). To design a fairer system, we develop a nonlinear integer programming model that allocates the organ supply in order to maximize the minimum s/d ratios across all transplant centers. We design circular donation regions that are able to address the issues raised in legal challenges to earlier organ distribution frameworks. This allows us to reformulate our model as a set-partitioning problem. Our policy can be viewed as a heterogeneous donor circle policy, where the integer program optimizes the radius of the circle around each donation location. Compared to the current policy, which has fixed radius circles around donation locations, the heterogeneous donor circle policy greatly improves both the worst s/d ratio and the range between the maximum and minimum s/d ratios. We found that with the fixed radius policy of 500 nautical miles (NM), the s/d ratio ranges from 0.37 to 0.84 at transplant centers, while with the heterogeneous circle policy capped at a maximum radius of 500 NM, the s/d ratio ranges from 0.55 to 0.60, closely matching the national s/d ratio average of 0.5983. Our model matches the supply and demand in a more equitable fashion than existing policies and has a significant potential to improve the liver transplantation landscape.
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Affiliation(s)
- Shubham Akshat
- The Robert H. Smith School of Business, University of Maryland, College Park, MD, 20742, USA
| | - Sommer E Gentry
- Department of Surgery and Department of Population Health, Grossman School of Medicine, New York University, New York, NY, 10016, USA
| | - S Raghavan
- The Robert H. Smith School of Business and Institute for Systems Research, University of Maryland, College Park, MD, 20742, USA.
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26
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Sabate A, Scarlatescu E. Treating periprocedural bleeding in patients with cirrhosis. J Thromb Thrombolysis 2024; 57:531-536. [PMID: 38281228 PMCID: PMC10961284 DOI: 10.1007/s11239-023-02941-4] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/23/2023] [Indexed: 01/30/2024]
Abstract
Patients with cirrhosis are known to have an abnormal coagulation status, which is a particular concern when planning invasive procedures in which blood loss is possible or predictable. Careful consideration must be given to the bleeding risk for each individual patient and coagulation management strategies should be established in advance of procedural interventions, where possible. Perioperative clinical decision-making should utilize viscoelastic testing in addition to usual assessments, where possible, and focus on the well-established three pillars of patient blood management: optimization of erythropoiesis, minimization of bleeding and blood loss, and management of anemia. Restrictive transfusion policies, careful hemostatic monitoring, and a proactive approach to predicting and preventing bleeding on an individual patient basis should be central to managing perioperative bleeding in the fragile patient population with cirrhosis. This review discusses coagulation assessments and bleeding management techniques necessary before, during, and after surgical interventions in patients with cirrhosis, and provides expert clinical opinion and physician experience on the perioperative management of these patients.
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Affiliation(s)
- Antoni Sabate
- Anesthesia Department, Bellvitge University Hospital, University of Barcelona, Idibell, Barcelona, Spain
| | - Ecaterina Scarlatescu
- Anesthesia and Intensive Care Department, University of Medicine and Pharmacy Carol Davila, Bucharest, Romania.
- Department of Anesthesia and Intensive Care Medicine, Fundeni Clinical Institute, Bucharest, Romania.
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27
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Porrello G, Cannella R, Bernuau J, Agman A, Brancatelli G, Dioguardi Burgio M, Vilgrain V. Liver imaging and pregnancy: what to expect when your patient is expecting. Insights Imaging 2024; 15:66. [PMID: 38411871 PMCID: PMC10899155 DOI: 10.1186/s13244-024-01622-x] [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] [Received: 06/08/2023] [Accepted: 01/07/2024] [Indexed: 02/28/2024] Open
Abstract
Liver diseases in pregnancy can be specific to gestation or only coincidental. In the latter case, the diagnosis can be difficult. Rapid diagnosis of maternal-fetal emergencies and situations requiring specialized interventions are crucial to preserve the maternal liver and guarantee materno-fetal survival. While detailed questioning of the patient and a clinical examination are highly important, imaging is often essential to reach a diagnosis of these liver diseases and lesions. Three groups of liver diseases may be observed during pregnancy: (1) diseases related to pregnancy: intrahepatic cholestasis of pregnancy, pre-eclampsia, eclampsia, hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome, and acute fatty liver of pregnancy; (2) liver diseases that are more frequent during or exacerbated by pregnancy: acute herpes simplex hepatitis, Budd-Chiari syndrome, hemorrhagic hereditary telangiectasia, hepatocellular adenoma, portal vein thrombosis, and cholelithiasis; (3) coincidental conditions, including acute hepatitis, incidental focal liver lesions, metabolic dysfunction-associated steatotic liver disease, cirrhosis, hepatocellular carcinoma, liver abscesses and parasitosis, and liver transplantation. Specific knowledge of the main imaging findings is required to reach an early diagnosis, for adequate follow-up, and to avoid adverse consequences in both the mother and the fetus.Critical relevance statement Pregnancy-related liver diseases are the most important cause of liver dysfunction in pregnant patients and, in pregnancy, even common liver conditions can have an unexpected turn. Fear of radiations should never delay necessary imaging studies in pregnancy.Key points• Pregnancy-related liver diseases are the most frequent cause of liver dysfunction during gestation.• Fear of radiation should never delay necessary imaging studies.• Liver imaging is important to assess liver emergencies and for the diagnosis and follow-up of any other liver diseases.• Common liver conditions and lesions may take an unexpected turn during pregnancy.• Pregnancy-specific diseases such as pre-eclampsia and HELLP syndrome must be rapidly identified. However, imaging should never delay delivery when it is considered to be urgent for maternal-fetal survival.
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Affiliation(s)
- Giorgia Porrello
- Service de Radiologie, AP-HP Nord, Hôpital Beaujon, Paris, Clichy, France.
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (Bi.N.D.), University Hospital "Paolo Giaccone", Palermo, Italy.
| | - Roberto Cannella
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (Bi.N.D.), University Hospital "Paolo Giaccone", Palermo, Italy
| | - Jacques Bernuau
- AP-HP Nord, Hôpital Beaujon, Service d'Hépatologie, Paris, Clichy, France
| | - Antoine Agman
- Service de Gynécologie obstétrique maternité, AP-HP Nord, Hôpital Beaujon, Paris, Clichy, France
| | - Giuseppe Brancatelli
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (Bi.N.D.), University Hospital "Paolo Giaccone", Palermo, Italy
| | - Marco Dioguardi Burgio
- Service de Radiologie, AP-HP Nord, Hôpital Beaujon, Paris, Clichy, France
- Université Paris Cité, Inserm, Centre de recherche sur l'inflammation, F-75018, Paris, France
| | - Valérie Vilgrain
- Service de Radiologie, AP-HP Nord, Hôpital Beaujon, Paris, Clichy, France
- Université Paris Cité, Inserm, Centre de recherche sur l'inflammation, F-75018, Paris, France
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28
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Pennington KM, Simonetto D, Taner T, Mangaonkar AA. Pulmonary, Hepatic, and Allogeneic Hematopoietic Stem Cell Transplantation in Patients with Telomere Biology Disorders. Curr Hematol Malig Rep 2024:10.1007/s11899-024-00724-z. [PMID: 38315384 DOI: 10.1007/s11899-024-00724-z] [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] [Accepted: 01/17/2024] [Indexed: 02/07/2024]
Abstract
PURPOSE OF THE REVIEW This study aimed to summarize evidence and provide consensus-based guidelines for management of transplantation in patients with telomere biology disorders (TBD). Specifically, this review focuses on clinical management of lung, liver, and bone marrow transplantation in TBD patients. RECENT FINDINGS TBD patients have specific unique biological vulnerabilities such as T cell immunodeficiency, susceptibility to infections, hypersensitivity to chemotherapy and radiation, and cytopenias. Furthermore, multiple organ involvement at diagnosis makes clinical management especially challenging due to higher degree of organ damage, and stress-induced telomeric crisis. Sequential and combined organ transplants, development of novel radiation and alkylator-free conditioning regimen, and use of novel drugs for graft-versus-host disease prophylaxis are some of the recent updates in the field. Multidisciplinary management is essential to optimize transplant outcomes in patients with TBD. In this review, we provide consensus-based transplant management guidelines for clinical management of transplant in TBD.
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Affiliation(s)
| | - Douglas Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, USA.
| | - Timucin Taner
- Departments of Surgery and Immunology, Mayo Clinic, Rochester, USA.
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29
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Eletta OA, Panayotova GG, Lunsford KE. Liver Transplant for Intrahepatic Cholangiocarcinoma. Surg Clin North Am 2024; 104:215-225. [PMID: 37953037 DOI: 10.1016/j.suc.2023.07.006] [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] [Indexed: 11/14/2023]
Abstract
Intrahepatic cholangiocarcinoma (iCCA) tends to be asymptomatic until late stages, leading most of the patients to present at advanced stages of the disease. A combination of medical and surgical therapy is crucial for patient management. Historically, poor outcomes resulted in liver transplantation being formally contraindicated for patients with iCCA; however, recent advances in patient selection and neoadjuvant therapy have resulted in a paradigm shift in liver transplant oncology. As a result, the feasibility of liver transplantation for iCCA is being reevaluated by several centers as a therapeutic alternative for select patients with locally advanced unresectable disease.
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Affiliation(s)
- Olanrewaju A Eletta
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, 125 Paterson Street, MEB 596, New Brunswick, NJ 08901, USA
| | - Guergana G Panayotova
- Division of Transplant and HPB Surgery, Department of Surgery Rutgers, New Jersey Medical School, 185 South Orange Avenue, Newark, NJ 07103, USA
| | - Keri E Lunsford
- Division of Transplant and HPB Surgery, Department of Surgery Rutgers, New Jersey Medical School, 185 South Orange Avenue, Newark, NJ 07103, USA.
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30
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Hill A, Olumba F, Chapman W. Transplantation for Hepatocellular Carcinoma. Surg Clin North Am 2024; 104:103-111. [PMID: 37953029 DOI: 10.1016/j.suc.2023.09.002] [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] [Indexed: 11/14/2023]
Abstract
Liver transplantation is the only curative treatment of many patients with HCC. To be successful, patients must undergo careful multidisciplinary evaluation and neoadjuvant treatment for bridging or downstaging. Patients with stable disease for 6 months are listed for transplant, after which regular surveillance is required to detect recurrence.
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Affiliation(s)
- Angela Hill
- Division of General Surgery, Washington University School of Medicine, MSC 8109-05-06, 660 South Euclid Avenue, St Louis, MO 63110, USA
| | - Franklin Olumba
- Division of General Surgery, Washington University School of Medicine, MSC 8109-05-06, 660 South Euclid Avenue, St Louis, MO 63110, USA
| | - William Chapman
- Division of General Surgery, Washington University School of Medicine, Section of Transplantation, MSC 8109-05-06, 660 South Euclid Avenue, St Louis, MO 63110, USA.
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Sarmiento IA, Guzmán MF, Chapochnick J, Meier J. Implementation of a Bleeding Management Algorithm in Liver Transplantation: A Pilot Study. Transfus Med Hemother 2024; 51:1-11. [PMID: 38314241 PMCID: PMC10836948 DOI: 10.1159/000530579] [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] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 04/03/2023] [Indexed: 02/06/2024] Open
Abstract
Objectives The aims of the study were to compare the consumption of blood products before and after the implementation of a bleeding management algorithm in patients undergoing liver transplantation and to determine the feasibility of a multicentre, randomized study. Background Liver transplantation remains the only curative therapy for patients with end-stage liver disease, but it carries a high risk of surgical bleeding. Materials and Methods Retrospective study of patients treated before (group 1) and after (group 2) implementation of a haemostatic algorithm guided by viscoelastic testing, including use of lyophilized coagulation factor concentrates (prothrombin complex and fibrinogen concentrates). Primary outcome was the number of units of blood products transfused in 24 h after surgery. Secondary outcomes included hospital stay, mortality, and cost. Results Data from 30 consecutive patients was analysed; 14 in group 1 and 16 in group 2. Baseline data were similar between groups. Median total blood product consumption 24 h after surgery was 33 U (IQR: 11-57) in group 1 and 1.5 (0-23.5) in group 2 (p = 0.028). Significantly fewer units of red blood cells, fresh frozen plasma, and cryoprecipitate were transfused in group 2 versus group 1. There was no significant difference in complications, hospital stay, or in-hospital mortality between groups. The cost of haemostatic therapy was non-significantly lower in group 2 versus group 1 (7,400 vs. 15,500 USD; p = 0.454). Conclusion The haemostatic management algorithm was associated with a significant reduction in blood product use during 24 h after liver transplantation. This study demonstrated the feasibility and provided a sample size calculation for a larger, randomized study.
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Affiliation(s)
| | - María F Guzmán
- Department of Anesthesiology, Universidad de los Andes, Santiago de Chile, Chile
| | | | - Jens Meier
- Department for Anesthesiology and Critical Care, Kepler University Hospital, Johannes Kepler University, Linz, Austria
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Matevish L, Patel MS, Vagefi PA. Downstaging Techniques for Hepatocellular Carcinoma in Candidates Awaiting Liver Transplantation. Surg Clin North Am 2024; 104:145-162. [PMID: 37953033 DOI: 10.1016/j.suc.2023.07.004] [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] [Indexed: 11/14/2023]
Abstract
During the last decade, downstaging for hepatocellular carcinoma has expanded the pool of patients eligible for liver transplantation. The literature is rife with attempts to elucidate best treatment strategies with novel locoregional and systemic therapies continuing to emerge. Several trials have confirmed the large-scale success of downstaging protocols, with equitable long-term survival and recurrence rates after liver transplant. We review the currently available techniques used for downstaging, including their indications, complications, and efficacies. New frontiers have focused on the potential role of immunotherapy in the neoadjuvant setting, although more research is needed to delineate its role in current treatment paradigms.
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Affiliation(s)
- Lauren Matevish
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Madhukar S Patel
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Parsia A Vagefi
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
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Sohal A, Kohli I, Chaudhry H, Singh I, Arora K, Kalra S, Dukovic D, Roytman M. Vaccine-Preventable Illness Leads to Adverse Outcomes in Liver Transplant Recipients. Dig Dis Sci 2024; 69:588-595. [PMID: 38030833 DOI: 10.1007/s10620-023-08202-x] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 11/19/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Liver transplant recipients (LTR) and patients with chronic liver disease (CLD) are at an increased risk of infections. AIMS The objective of our study was to assess the incidence, and impact of vaccine preventable illness (VPI) on outcomes in LTR. METHODS National Inpatient Sample (NIS) 2016-2020 was used to identify adults (age > 18) hospitalized LTR using ICD-10 codes. Data were collected on patient demographics, hospital characteristics, etiology of liver disease, hepatic decompensations and outcomes. Patients were stratified into two groups based on the presence or absence of VPI. Multivariate logistic regression analysis was performed to identify the association between VPI and outcomes. RESULTS Out of 170,650 hospitalized LTR, 13.5% of the patients had VPI. The most common VPI was noted to be influenza (10.7%), followed by pneumococcal infection (2.7%). Incidence of mortality (6.9% vs. 1.6%, p < 0.001), ICU admissions (14.3% vs. 3.4%, p < 0.001), and acute kidney injury (AKI) (43.7% vs 37.35%, p < 0.001) was higher in the VPI group. CONCLUSION More than 13% of the LT hospitalizations had concomitant VPI. VPI in LTR was associated with worse outcomes. Our data suggests the need to identify factors associated with reduced vaccination rates and identify strategies to improve vaccination rates and responses in these patients.
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Affiliation(s)
- Aalam Sohal
- Department of Hepatology, Liver Institute Northwest, 3216 NE 45Th Pl, Suite 212, Seattle, WA, 98105, USA.
| | - Isha Kohli
- Graduate Program in Public Health, Icahn School of Medicine, Mount Sinai, New York, NY, USA
| | - Hunza Chaudhry
- Department of Internal Medicine, University of California, San Francisco, Fresno, CA, USA
| | | | - Kirti Arora
- Dayanand Medical College and Hospital, Ludhiana, India
| | - Shivam Kalra
- Dayanand Medical College and Hospital, Ludhiana, India
| | - Dino Dukovic
- Ross University of Medical Sciences, Miramar, FL, USA
| | - Marina Roytman
- Department of Gastroenterology and Hepatology, University of California, San Francisco, Fresno, CA, USA
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Adjei M, Kim IK. Current Use of Immunosuppression in Liver Transplantation. Surg Clin North Am 2024; 104:11-25. [PMID: 37953030 DOI: 10.1016/j.suc.2023.08.004] [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] [Indexed: 11/14/2023]
Abstract
Since the first successful liver transplant in 1967, immunosuppression has allowed liver transplantation to become the standard treatment of end-stage liver disease. Over the decades, the rates of rejection have decreased, and patient survival outcomes have significantly improved in large part due to the introduction and advancements of immunosuppression medications. However, the adverse effects associated with long-term immunosuppression have created new challenges facing liver transplantation and added significantly to posttransplantation morbidity. This review presents the data and rationale for immunosuppression approaches, addresses the main controversies related to immunosuppression in liver transplantation, and explores some of the newer advancements in immunosuppressive drug therapy.
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Affiliation(s)
- Michie Adjei
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, 8900 Beverly Boulevard, Los Angeles, CA 90048, USA
| | - Irene K Kim
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, 8900 Beverly Boulevard, Los Angeles, CA 90048, USA.
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Cabibbo G, Daniele B, Borzio M, Casadei-Gardini A, Cillo U, Colli A, Conforti M, Dadduzio V, Dionisi F, Farinati F, Gardini I, Giannini EG, Golfieri R, Guido M, Mega A, Minozzi S, Piscaglia F, Rimassa L, Romanini L, Pecorelli A, Sacco R, Scorsetti M, Viganò L, Vitale A, Trevisani F. Multidisciplinary Treatment of Hepatocellular Carcinoma in 2023: Italian practice Treatment Guidelines of the Italian Association for the Study of the Liver (AISF), Italian Association of Medical Oncology (AIOM), Italian Association of Hepato-Bilio-Pancreatic Surgery (AICEP), Italian Association of Hospital Gastroenterologists (AIGO), Italian Association of Radiology and Clinical Oncology (AIRO), Italian Society of Pathological Anatomy and Diagnostic Cytology (SIAPeC-IAP), Italian Society of Surgery (SIC), Italian Society of Gastroenterology (SIGE), Italian Society of Medical and Interventional Radiology (SIRM), Italian Organ Transplant Society (SITO), and Association of Patients with Hepatitis and Liver Disease (EpaC) - Part I - Surgical treatments. Dig Liver Dis 2024; 56:223-234. [PMID: 38030455 DOI: 10.1016/j.dld.2023.10.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 10/07/2023] [Accepted: 10/30/2023] [Indexed: 12/01/2023]
Abstract
Worldwide, hepatocellular carcinoma (HCC) is the third most common cause of cancer-related death. The remarkable improvements in treating HCC achieved in the last years have increased the complexity of HCC management. Following the need to have updated guidelines on the multidisciplinary treatment management of HCC, the Italian Scientific Societies involved in the management of this cancer have promoted the drafting of a new dedicated document. This document was drawn up according to the GRADE methodology needed to produce guidelines based on evidence. Here is presented the first part of guidelines, focused on the multidisciplinary tumor board of experts and surgical treatments of HCC.
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Affiliation(s)
- Giuseppe Cabibbo
- Section of Gastroenterology and Hepatology, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties PROMISE, University of Palermo, Italy; Gastroenterology Unit, Azienda Ospedaliera Universitaria Policlinico "Paolo Giaccone", Palermo, Italy.
| | - Bruno Daniele
- Oncology Unit, Ospedale del Mare, ASL Napoli 1 Centro, Napoli, Italy
| | - Mauro Borzio
- Centro Diagnostico Italiano (CDI), Milano, Italy
| | - Andrea Casadei-Gardini
- Department of Oncology, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute Hospital, Milan, Italy
| | - Umberto Cillo
- General Surgery 2-Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, Padua University Hospital, 35128 Padua, Italy
| | - Agostino Colli
- Dipartimento di Medicina Trasfusionale ed Ematologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | | | - Vincenzo Dadduzio
- Medical Oncology Unit, "Mons. A.R.Dimiccoli" Hospital, Barletta, ASL BT, Italy
| | - Francesco Dionisi
- Department of Radiation Oncology, IRCCS Regina Elena National Cancer Institute - Rome, Italy
| | - Fabio Farinati
- Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy; Gastroenterology Unit, Azienda Ospedale-Università di Padova, 35128 Padova, Italy
| | - Ivan Gardini
- EpaC Onlus, Italian Liver Patient Association, Turin, Italy
| | - Edoardo Giovanni Giannini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Rita Golfieri
- Alma Mater Studiorum" Bologna University, Bologna, Italy; Radiology Unit Madre Fortunata Toniolo Private Hospital, coordinator of Radiology centers Medipass Bologna, Bologna, Italy
| | - Maria Guido
- Department of Medicine, University of Padova, Padova- Italy
| | - Andrea Mega
- Department of Gastronterology, Regional Hospital Bolzano, Italy
| | - Silvia Minozzi
- Oncology Department, Istituto di Ricerche Farmacologiche Mario Negri, IRCCS, Milano, Italy
| | - Fabio Piscaglia
- Division of Internal Medicine, Hepatobiliary and Immunoallergic Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna, Italy
| | - Lorenza Rimassa
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele, Milan, Italy; Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan, Italy
| | - Laura Romanini
- Radiology Unit, Ospedale di Cremona, ASST Cremona, Cremona, Italy
| | - Anna Pecorelli
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Rodolfo Sacco
- Gastroenterology and Endoscopy Unit, Department of Surgical and Medical Sciences, University of Foggia, 71100 Foggia, Italy
| | - Marta Scorsetti
- Department of Biomedical Sciences, Humanitas University, 20090 Pieve Emanuele, Milan, Italy; Department of Radiotherapy and Radiosurgery, Humanitas Research Hospital IRCCS, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Luca Viganò
- Hepatobiliary Unit, Department of Minimally Invasive General & Oncologic Surgery, Humanitas Gavazzeni University Hospital, Viale M. Gavazzeni 21, 24125 Bergamo, Italy; Department of Biomedical Sciences, Humanitas University, Viale Rita Levi Montalcini 4, 20090 Milan, Italy
| | - Alessandro Vitale
- General Surgery 2-Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, Padua University Hospital, 35128 Padua, Italy
| | - Franco Trevisani
- Department of Medical and Surgical Sciences, University of Bologna, Italy; Unit of Semeiotics, Liver and Alcohol-Related Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy.
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Abstract
The goal of autoimmune hepatitis treatment is to achieve clinical and biochemical remission, which is associated with significantly improved outcomes. Induction treatment with corticosteroids and the subsequent addition of steroid-sparing therapy with gradual tapering of corticosteroids remains the standard of care. Several alternatives to azathioprine and second-line agents, such as mycophenolate mofetil, tacrolimus, cyclosporine, sirolimus, or rituximab, have been evaluated in those with intolerance or inadequate response to standard-of-care therapy. Treatment withdrawal is achievable in less than 20% of patients after 2 years of sustained remission. Liver transplantation should be considered in those with progressive liver disease or those with complications such as hepatocellular carcinoma.
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Affiliation(s)
- Aparna Goel
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, CA 94043, USA.
| | - Paul Kwo
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, CA 94043, USA
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Chang MK, Cheah AEJ. The role of reconstructive microsurgeons in liver transplantation-a narrative review. Ann Transl Med 2024; 12:10. [PMID: 38304899 PMCID: PMC10777240 DOI: 10.21037/atm-23-519] [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] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 11/06/2023] [Indexed: 02/03/2024]
Abstract
Background and Objective Liver transplantation is a life-saving procedure, but also associated with complications. Hepatic artery thrombosis is one of the most devastating complications, especially for living donor liver transplantation. The application of microsurgical techniques for hepatic artery reconstruction has greatly reduced the risk of hepatic artery thrombosis. In this narrative review, we discuss the technical considerations and challenges faced in microsurgical reconstruction of hepatic artery in liver transplantation. Methods PubMed, Web of Science, and Google Scholar were searched for keywords relating to "liver transplantation", "microsurgery", "living donor liver transplantation", "deceased donor liver transplantation", "hepatic artery", "hepatic artery thrombosis", "hepatic artery reconstruction" and "microsurgical anastomosis". Relevant articles pertaining to the technical considerations and challenges of microsurgery in liver transplantation were included. Key Content and Findings The conditions of liver transplantation pose unique challenges to the microsurgeon. Nonetheless, there are described strategies that can overcome these conditions, as well as technical details that may improve the outcomes of hepatic artery reconstruction. These strategies start from proper positioning of the patient, conscientious selection of donor and recipient hepatic vessels, and minimizing movements during critical microsurgical anastomosis. Technical details include techniques to overcome vessel delamination, size mismatch, poor quality vessels, and short vessel stump. This review also explores the outcomes of microsurgical hepatic arterial reconstruction. Conclusions There are various strategies to mitigate the challenges of microsurgery in liver transplant. Microsurgery improves the outcome of liver transplantation. Microsurgeons will continue to be a priceless resource that all liver transplant teams should have.
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Affiliation(s)
- Min Kai Chang
- Department of Hand and Reconstructive Microsurgery, National University Hospital, Singapore, Singapore
| | - Andre Eu Jin Cheah
- Department of Hand and Reconstructive Microsurgery, National University Hospital, Singapore, Singapore
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Limia ME, Liu XL, Yu J, Byrnes K. Primary Non-Function of Hepatic Allograft With Preexisting Microvesicular Steatosis/Foamy Degeneration and Mild Large-Droplet Macrovesicular Steatosis. Gastroenterology Res 2024; 17:37-40. [PMID: 38463149 PMCID: PMC10923250 DOI: 10.14740/gr1687] [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: 11/17/2023] [Accepted: 12/30/2023] [Indexed: 03/12/2024] Open
Abstract
It has been established that more than mild large-droplet macrovesicular steatosis (LD-MAS) is associated with increased risk of graft non-function. In contrast, even severe small-droplet macrovesicular steatosis (SD-MAS) has been found to be less prognostically significant. It remains unclear if a donor liver with diffuse microvesicular steatosis is associated with an increased risk of graft dysfunction. A 56-year-old male with alcoholic cirrhosis was transplanted with a liver from a 42-year-old overweight male donor after brain death. The frozen section of the donor liver biopsy taken at harvest showed diffusely enlarged clear/foamy hepatocytes and mild LD-MAS (about 5-10% of total tissue). The reperfusion liver biopsy taken at time 0 of transplantation showed hemorrhage, pale and enlarged hepatocytes, and mild LD-MAS (about 10% of total tissue) with lipopeliosis. The graft became non-functional, and the patient was re-transplanted 24 h after the initial transplantation. Histologic examination of the failed liver allograft showed extensive hemorrhagic necrosis, neutrophilic inflammation, diffuse microvesicular steatosis, and large extracellular fat droplets (about 20% of total tissue). This case demonstrates that precautions are needed to avoid using livers with diffuse and severe microvesicular steatosis.
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Affiliation(s)
- Melissa E. Limia
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
| | - Xiu Li Liu
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
| | - Jennifer Yu
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Kathleen Byrnes
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
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Li XJ, He K. Sarcopenia in cirrhotic patients: Does frailty matter while waiting for a liver transplant? World J Gastrointest Surg 2024; 16:257-259. [PMID: 38328318 PMCID: PMC10845277 DOI: 10.4240/wjgs.v16.i1.257] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 12/07/2023] [Accepted: 12/12/2023] [Indexed: 01/25/2024] Open
Abstract
Sarcopenia reflects patient frailty and should be routinely assessed due to its high prevalence in cirrhotic patients awaiting liver transplants. Pre-transplant nutritional optimization should be tailored for patients with a definitive diagnosis of sarcopenia, therefore improving functional status at transplant and reducing post-transplant mortality. Hepatologists and transplant surgeons should have raised awareness regarding sarcopenia and the reflected frailty that hinder posttransplant outcomes. The policymakers should also take into account when modifying the organ allocation model that sarcopenia or frailty might become a decisive factor in allocating organs for cirrhotic patients, in order to ensure post-transplant survival and quality of life.
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Affiliation(s)
- Xing-Jie Li
- Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ 85054, United States
- Department of Liver Surgery, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
| | - Kang He
- Department of Liver Surgery, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
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Kozlitina J, Cohen NM, Sturtevant D, Cohen JC, Murphey-Half C, Saltarrelli JG, Jindra P, Askar M, Hwang CS, Vagefi PA, Lacelle C, Hobbs HH, MacConmara MP. Effect of donor HSD17B13 genotype on patient survival after liver transplant: a retrospective cohort study. EClinicalMedicine 2024; 67:102350. [PMID: 38169797 PMCID: PMC10758751 DOI: 10.1016/j.eclinm.2023.102350] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 11/15/2023] [Accepted: 11/17/2023] [Indexed: 01/05/2024] Open
Abstract
Background Several genetic variants are associated with chronic liver disease. The role of these variants in outcomes after liver transplantation (LT) is uncertain. The aim of this study was to determine if donor genotype at risk-associated variants in PNPLA3 (rs738409 C>G, p.I148M) and HSD17B13 (rs72613567 T>TA; rs80182459, p.A192Lfs∗8) influences post-LT survival. Methods In this retrospective cohort study, data on 2346 adults who underwent first-time LT between January 1, 1999 and June 30, 2020 and who had donor DNA samples available at five large Transplant Immunology Laboratories in Texas, USA, were obtained from the United Network for Organ Sharing (UNOS). Duplicates, patients with insufficient donor DNA for genotyping, those who were <18 years of age at the time of transplant, had had a previous transplant or had missing genotype data were excluded. The primary outcomes were patient and graft survival after LT. The association between donor genotype and post-LT survival was examined using Kaplan-Meier method and multivariable-adjusted Cox proportional hazards models. Findings Median age of LT recipients was 57 [interquartile range (IQR), 50-62] years; 837 (35.7%) were women; 1362 (58.1%) White, 713 (30.4%) Hispanic, 182 (7.8%) Black/African-American. Median follow-up time was 3.95 years. Post-LT survival was not affected by donor PNPLA3 genotype but was significantly reduced among recipients of livers with two HSD17B13 loss-of-function (LoF) variants compared to those receiving livers with no HSD17B13 LoF alleles (unadjusted one-year survival: 82.6% vs 93.9%, P < 0.0001; five-year survival: 73.1% vs 82.9%, P = 0.0017; adjusted hazard ratio [HR], 2.25; 95% CI, 1.61-3.15 after adjustment for recipient age, sex, and self-reported ethnicity). Excess mortality was restricted to those receiving steroid induction immunosuppression (crude 90-day post-LT mortality, 9.3% [95% CI, 1.9%-16.1%] vs 1.9% [95% CI, 0.9%-2.9%] in recipients of livers with two vs no HSD17B13 LoF alleles, P = 0.0012; age, sex, and ethnicity-adjusted HR, 2.85; 95% CI, 1.72-4.71, P < 0.0001). No reduction was seen among patients who did not receive steroid induction (90-day mortality 3.1% [95% CI, 0%-7.3%] vs 2% [95% CI, 0.9%-3.1%], P = 0.65; adjusted HR, 1.17; 95% CI, 0.66-2.08, P = 0.60). Interpretation Donor HSD17B13 genotype adversely affects post-LT survival in patients receiving steroid induction. Additional studies are required to confirm this association. Funding The National Institutes of Health and American Society of Transplant Surgeons Collaborative Scientist Grant.
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Affiliation(s)
- Julia Kozlitina
- The Eugene McDermott Center for Human Growth and Development, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Naomi M. Cohen
- The Eugene McDermott Center for Human Growth and Development, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Drew Sturtevant
- The Eugene McDermott Center for Human Growth and Development, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Jonathan C. Cohen
- The Eugene McDermott Center for Human Growth and Development, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
- The Center for Human Nutrition, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Cathi Murphey-Half
- Histocompatibility and Immunogenetics Laboratory, Southwest Immunodiagnostics, Inc, San Antonio, TX, USA
| | - Jerome G. Saltarrelli
- Histocompatibility and Immune Evaluation Laboratory, Department of Pathology and Laboratory Medicine, University of Texas Health Science Center, Houston, TX, USA
| | - Peter Jindra
- Immune Evaluation Laboratory, Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Medhat Askar
- Transplant Immunology, Baylor University Medical Center, Dallas, TX, USA
| | - Christine S. Hwang
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Parsia A. Vagefi
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Chantale Lacelle
- Transplant Immunology and Histocompatibility, Department of Pathology, University of Texas Southwestern Medical Center Dallas, TX, 75390, USA
| | - Helen H. Hobbs
- The Eugene McDermott Center for Human Growth and Development, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
- Howard Hughes Medical Institute, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Malcolm P. MacConmara
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
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Tachtatzis P, Spoletini G, Clifton I, Etherington C, Peckham D. Changes in liver biochemistry and tacrolimus levels following the introduction of elexacaftor/tezacaftor/ivacaftor in patients with cystic fibrosis and liver transplant. J Cyst Fibros 2024; 23:99-102. [PMID: 37164896 DOI: 10.1016/j.jcf.2023.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 04/26/2023] [Accepted: 04/28/2023] [Indexed: 05/12/2023]
Abstract
INTRODUCTION Elevated liver function tests (LFTs) are reported in individuals with cystic fibrosis (CF) starting elexacaftor/tezacaftor/ivacaftor (ETI). We report our experience with ETI in CF liver transplant patients. METHOD All CF liver transplant patients under the care of the Leeds CF team were commenced on ETI. Liver biopsies were performed when ALT >3 times upper limit of normal with or without bilirubin elevation. Treatment was guided by transplant hepatology and CF teams. Clinical data including lung function, LFTs and tacrolimus levels were collected. RESULTS Four patients (3 male, 1 female) on tacrolimus were commenced on ETI. Median time post liver transplantation was 6.5 years. Three patients underwent liver biopsy. One biopsy was abnormal with immune-mediated liver injury, which responded to increased immunosuppression. Management of tacrolimus levels proved straightforward. CONCLUSION ETI therapy in CF post liver transplant recipients was encouraging. Normal liver biopsy provides re-assurance to continue treatment despite elevated LFTs.
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Affiliation(s)
- P Tachtatzis
- Liver Transplantation & Hepatology, Leeds Teaching Hospitals NHS Trust, Leeds, UK; Regional Adult Cystic Fibrosis Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
| | - G Spoletini
- Regional Adult Cystic Fibrosis Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - I Clifton
- Regional Adult Cystic Fibrosis Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - C Etherington
- Regional Adult Cystic Fibrosis Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - D Peckham
- Regional Adult Cystic Fibrosis Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK; Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
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Loeb L, Lewis J, Peng Z, Heckman MG, Nakhleh R, Keaveny AP. A clinical review of congenital hepatic fibrosis diagnosed in adulthood: presentation, complications, and outcomes. Ann Hepatol 2024; 29:101164. [PMID: 37802414 DOI: 10.1016/j.aohep.2023.101164] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 09/19/2023] [Accepted: 09/19/2023] [Indexed: 10/10/2023]
Abstract
INTRODUCTION AND OBJECTIVES Congenital hepatic fibrosis (CHF) is a rare condition characterized by biliary tract changes and a geographic pattern of liver fibrosis. Liver biopsy is essential to confirm its diagnosis. The absence of specific clinical indicators in adults often leads to delays in diagnosis and management, while the natural history has not been well described. We sought to define the presentation and outcomes of adults with biopsy-proven CHF. MATERIALS AND METHODS A retrospective chart review was conducted of patients diagnosed with CHF by liver biopsy. Continuous variables were summarized with the sample median and range. Categorical variables were summarized with number and percentage of patients. RESULTS We identified 24 patients evaluated over a 20-year period, with a median age of 51 years (range 22-72 years) at initial presentation; 14 were male. The most common imaging findings were renal cysts (91.3%), splenomegaly (69.6%), and a cirrhotic-appearing liver (60.9%). The most commonly treated liver-related complications were cholangitis (45.8%), varices (45.8%), and hepatic encephalopathy (25%). Two patients died with a median length of follow-up of 2.9 years (range: 0.0-20.0 years). Two patients underwent transjugular intrahepatic portosystemic shunt (TIPS) placement to manage bleeding esophageal varices. Eight patients underwent liver transplantation (LT), the most common indication being decompensated disease (50%). CONCLUSIONS CHF should be considered when patients present with cholangitis and/or complications of portal hypertension and have a cirrhotic appearing liver and renal cysts on imaging. Depending upon the disease severity, interventions such as TIPS or LT may be required.
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Affiliation(s)
- Lauren Loeb
- Department of Internal Medicine, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224, USA
| | - Jason Lewis
- Department of Pathology, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224, USA
| | - Zhongwei Peng
- Clinical Trials and Biostatistics, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA
| | - Michael G Heckman
- Clinical Trials and Biostatistics, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA
| | - Raouf Nakhleh
- Department of Pathology, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224, USA
| | - Andrew P Keaveny
- Department of Transplantation, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
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Abstract
Alcohol is the leading cause of preventable liver morbidity and mortality worldwide, as it is also the most frequent cause of advanced liver disease. Alcohol-associated liver disease (ALD) covers different phenotypes ranging from steatosis to the development of inflammation (steatohepatitis), fibrosis and ultimately, in a proportion of patients, the development of liver cirrhosis and its associated complications. ALD has a complex pathogenesis that includes the interplay of both genetic and environmental factors, yet the precise mechanisms are largely unknown. Alcohol-associated hepatitis (AH) is a severe clinical presentation of ALD, which is characterized by abrupt jaundice and clinical decompensations of liver disease. AH occurs in a percentage of patients with underlying ALD and active alcohol consumption. Currently, there are no approved targeted therapies able to interfere in the pathogenesis of ALD and halt the progression of the disease, therefore alcohol abstinence is the most effective measure to improve prognosis in this patient population. In this regard, alcohol cessation remains the first-line treatment in all stages of alcohol disease. In patients with advanced ALD nonresponding to medical therapy, liver transplantation is the only approach that improves prognosis, and it should be considered in patients with decompensated cirrhosis. In the last years, AH has emerged as a new indication of early liver transplantation in non-responders to medical therapy, with promising results in highly selected patients. In this review, we provide an update on the epidemiology, risk factors, natural history, diagnosis, pathogenesis, and current treatments for ALD, taking into account the importance of assessing and managing alcohol consumption as the etiological factor and the main driver of prognosis in patients with ALD.
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Affiliation(s)
- Helena Hernández-Évole
- Liver Unit, Hospital Clinic, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Natalia Jiménez-Esquivel
- Liver Unit, Hospital Clinic, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Elisa Pose
- Liver Unit, Hospital Clinic, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Ramón Bataller
- Liver Unit, Hospital Clinic, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
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Shehadah A, Yu Naing L, Bapaye J, Malik S, Mohamed M, Khalid N, Munoz A, Jadhav N, Mushtaq A, Okolo P, Eskridge E. Early palliative care referral may improve end-of-life care in end-stage liver disease patients: A retrospective analysis from a non-transplant center. Am J Med Sci 2024; 367:35-40. [PMID: 37923293 DOI: 10.1016/j.amjms.2023.10.006] [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: 03/24/2023] [Revised: 06/22/2023] [Accepted: 10/30/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Patients with end-stage liver disease (ESLD) who are not transplant candidates often have a trajectory of rapid decline and death similar to patients with stage IV cancer. Palliative care (PC) services have been shown to be underutilized for such patients. Most studies examining the role of PC in ESLD have been done at transplant centers. Thus, determining the utilization and benefit of PC at a non-transplant tertiary center may help establish a standard of care in the management of patients with ESLD not eligible for transplant. METHODS We conducted a retrospective analysis of adult (>18 years) patients with ESLD admitted to Rochester Regional Health (RRH) system hospitals from 2012 to 2021. Patients were divided into groups based on the presence or absence of PC involvement. Baseline characteristics were recorded. The impact of PC was assessed by comparing the number of hospitalizations before and after the involvement of PC, comparing code status changes, health care proxy (HCP) assignments, Aspira catheter placements, and frequency of repeated paracentesis. RESULTS In our analysis of 576 patients, 41.1% (237 patients) received a PC consult (PC group), while 58.9% (339 patients) did not (no-PC group). Baseline characteristics were comparable. However, their mean number of admissions significantly decreased (15.66 vs. 3.49, p < 0.001) after PC involvement. Full code status was more prevalent in the no-PC group (67.8% vs. 18.6%, p < 0.001), while comfort care code status was more common in the PC group (59.9% vs. 20.6%, p < 0.001). Changes in code status were significantly higher in the PC group (77.6% vs. 29.2%, p < 0.001). The PC group had a significantly higher mortality rate (83.1% vs. 46.4%, p < 0.01). Patients in the PC group had a higher likelihood of having an assigned HCP (63.7% vs. 37.5%, p < 0.001). PC referral was associated with more frequent use of an Aspira catheter (5.9% vs. 0.9%, p < 0.001) and more frequent paracentesis (30.8% vs. 16.8%, p < 0.001). CONCLUSIONS In conclusion, our study provides compelling evidence of the diverse advantages of palliative care for patients with end-stage liver disease, including reduced admissions, improved goals of care, code status modifications, enhanced healthcare proxy assignments, and targeted interventions. These findings highlight the potential significance of early integration of palliative care in the disease trajectory to provide comprehensive, patient-centered care that addresses the unique needs and preferences of individuals with advanced liver disease.
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Affiliation(s)
- Ahmed Shehadah
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York, United States.
| | - Le Yu Naing
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York, United States
| | - Jay Bapaye
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York, United States
| | - Sheza Malik
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York, United States
| | - Mohamed Mohamed
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York, United States
| | - Nida Khalid
- Department of Gastroenterology, Rochester General Hospital, Rochester, New York, United States
| | - Anisleidys Munoz
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York, United States
| | - Nagesh Jadhav
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York, United States
| | - Asim Mushtaq
- Department of Gastroenterology, Rochester General Hospital, Rochester, New York, United States
| | - Patrick Okolo
- Department of Gastroenterology, Rochester General Hospital, Rochester, New York, United States
| | - Etta Eskridge
- Department of Palliative Care, Rochester General Hospital, Rochester, New York, United States
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Domínguez Garijo P, Llompart Coll MM, Ginestà Martí C. Totally extraperitoneal repair of groin hernia in liver transplant patients: a case series study (TOHER). Hernia 2023; 27:1601-1606. [PMID: 37962710 DOI: 10.1007/s10029-023-02910-z] [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: 07/14/2023] [Accepted: 10/01/2023] [Indexed: 11/15/2023]
Abstract
PURPOSE The present study aims to describe the feasibility and the postoperative results of groin hernia repair in liver transplant patients using a totally extra-peritoneal (TEP) repair approach. METHODS From May 2022 to March 2023, liver transplant patients with groin hernia underwent TEP groin hernia repair, by the single common senior experimented surgeon. Background information, intraoperative findings, postoperative complications, postoperative pain, health, and well-being were registered. RESULTS Thirteen TEP approach groin hernioplasties were performed in 10 patients, completing the procedure in all cases without the need for conversion either to open or transabdominal preperitoneal approaches. 70% of surgical explorations revealed multiple hernia defects: lateral hernias in all patients, medial defects in 62%, and femoral defects in 30.8%. Median hospital stay was 1 day [range (0.3)], with 30% treated as outpatients. Post-surgical complications occurred in 30% of cases: 1 hematoma and 2 seromas. Postoperative pain and physical functioning scored 100 (IQR 44) and 90 (IQR 15), respectively. CONCLUSION TEP groin hernioplasty is safe and feasible for liver transplant patients, with low complication rates, short hospital stays, and a significant proportion treated as outpatients. The posterior approach allows comprehensive repair of myopectineal defects, crucial due to associated hernial defects.
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Affiliation(s)
- P Domínguez Garijo
- General and Digestive Surgery Department, Hospital Clinic of Barcelona, Universistat de Barcelona (UB), Villarroel 170, 08036, Barcelona, Spain.
| | - M M Llompart Coll
- General and Digestive Surgery Department, Hospital Clinic of Barcelona, Universistat de Barcelona (UB), Villarroel 170, 08036, Barcelona, Spain
| | - C Ginestà Martí
- General and Digestive Surgery Department, Hospital Clinic of Barcelona, Universistat de Barcelona (UB), Villarroel 170, 08036, Barcelona, Spain
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Weinberg E, Rahematpura S, Gonzalez SA, Izzy MJ, Simonetto DA, Frederick RT, Rubin RA, Ikahihifo-Bender J, Harte M, Kim-Lee G, Witkiewicz S, Tobin W, Jamil K, Fricker Z, Reddy KR. INFUSE: Rationale and design of a multi-center, open label, collaborative study to treat HRS-AKI with continuous terlipressin infusion. Contemp Clin Trials Commun 2023; 36:101211. [PMID: 37953795 PMCID: PMC10632660 DOI: 10.1016/j.conctc.2023.101211] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/25/2023] [Accepted: 10/01/2023] [Indexed: 11/14/2023] Open
Abstract
Background Hepatorenal syndrome-acute kidney injury (HRS-AKI) carries significant morbidity and mortality among those with end-stage liver disease. Bolus terlipressin for treatment of HRS-AKI received FDA approval in September 2022. US implementation of terlipressin, however, is hindered by the paucity of local data on the optimal patient population and administration mode, as well as the effect on transplant priority. The INFUSE study is designed to evaluate the use of continuous terlipressin infusion among transplant candidates with advanced liver disease and HRS-AKI. Methods Fifty prospective patients with HRS-AKI will receive a single bolus of terlipressin 0.5 mg followed by continuous infusions of terlipressin from 2 to 8 mg/day for up to 14 days. The cohort will be enriched with those listed, in evaluation, or eligible for liver transplantation, while those with ACLF grade 3, MELD ≥35, and serum creatinine >5.0 mg/dL will be excluded. Fifty patients who received midodrine plus octreotide or norepinephrine for HRS-AKI will serve as a retrospective comparator cohort. Conclusion The INFUSE study aims to assess the safety and efficacy of continuous terlipressin infusion among largely transplant-eligible patients with HRS-AKI, and to provide US-based data on transplant outcomes. This novel study design simultaneously mitigates terlipressin adverse events while providing renal benefits to patients, thus addressing the unmet medical need of those with HRS-AKI who have limited treatment options and are awaiting liver transplantation in the US.
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Affiliation(s)
- Ethan Weinberg
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Suditi Rahematpura
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Stevan A. Gonzalez
- Division of Hepatology, Simmons Transplant Institute, Baylor Scott and White All Saints Medical Center, Fort Worth, TX, USA
| | - Manhal J. Izzy
- Department of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - R. Todd Frederick
- Department of Hepatology and Liver Transplantation, California Pacific Medical Center, San Francisco, CA, USA
| | - Raymond A. Rubin
- Department of Transplantation, Piedmont Transplant Institute, Atlanta, GA, USA
| | - Jade Ikahihifo-Bender
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Maggie Harte
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Grace Kim-Lee
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | | | - Khurram Jamil
- Mallinckrodt Ltd, Scientific Affairs, Hampton, NJ, USA
| | - Zachary Fricker
- Division of Gastroenterology, Hepatology, and Nutrition, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - K. Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Stern R, Chen L, Chan AP, Wozniak LJ, Pearl M. Angiotensin II type 1 receptor antibodies and native kidney function in pediatric liver and intestinal transplant recipients. Pediatr Nephrol 2023; 38:4175-4185. [PMID: 37432534 DOI: 10.1007/s00467-023-06055-0] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 05/10/2023] [Accepted: 05/26/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND Angiotensin II type-1 receptor antibody (AT1R-Ab) has been associated with vascular injury and kidney dysfunction in pediatric kidney transplant recipients. The role of AT1R-Ab in the development of chronic kidney disease in pediatric liver and intestinal transplant recipients has not been explored. METHODS Twenty-five pediatric intestinal transplant recipients and 79 pediatric liver transplant recipients had AT1R-Ab levels measured at varying time points in the post-transplant period. Estimated glomerular filtration rate (eGFR) was determined using creatinine based CKiD U25 equation and measured at time of AT1R-Ab measurement, at 1 year post-AT1R-Ab measurement, at 5 years post-AT1R-Ab measurement, and at the most recent routine clinic visit. The prevalence of hypertension and antihypertensive medication use were also evaluated. RESULTS Younger age at time of AT1R-Ab measurement was associated with AT1R-Ab positivity in liver transplant recipients. There was no association between AT1R-Ab status and change in eGFR, prevalence of hypertension, or use of antihypertensive medications at the described time points. CONCLUSIONS AT1R-Ab positivity was not associated with a decline in eGFR or hypertension in pediatric liver and intestinal transplant recipients. Further studies are needed using other markers of kidney function, such as cystatin C, to validate this finding. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Rachel Stern
- Department of Pediatric Nephrology, University of California Los Angeles, Los Angeles, CA, USA.
| | - Lucia Chen
- Department of Medicine Statistics Core, University of California Los Angeles, Los Angeles, CA, USA
| | - Alvin P Chan
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of California Los Angeles, Los Angeles, CA, USA
| | - Laura J Wozniak
- Pediatric Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Meghan Pearl
- Department of Pediatric Nephrology, University of California Los Angeles, Los Angeles, CA, USA
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Moore HB, LaRiviere W, Rodriguez I, Brown K, Hadley K, Pomposelli JJ, Adams MA, Wachs ME, Conzen KD, Kennealey PT, Kaplan B, Pomfret EA, Nydam TL. Early predictors of prolonged intensive care utilization following liver transplantation. Am J Surg 2023; 226:829-834. [PMID: 37604748 DOI: 10.1016/j.amjsurg.2023.06.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 06/21/2023] [Accepted: 06/26/2023] [Indexed: 08/23/2023]
Abstract
INTRODUCTION Creatinine, bilirubin, and fibrinolysis resistance are associated with multi-organ dysfunction and likely risk factors for prolonged intensive care unit (pICU) stay following liver transplantation (LT). We hypothesize postoperative day-1 (POD-1) labs will predict pICU. METHODS LT recipients had clinical laboratories and viscoelastic testing with tissue plasminogen activator thrombelastography (tPA TEG) to quantify fibrinolysis resistance (LY30) on POD-1. pICU was defined as one week or longer in the ICU. Logistic regression was used to identify the relationship between POD-1 labs and pICU. RESULTS Of 304 patients, 50% went to the ICU, with 15% experiencing pICU. Elevated creatinine (OR 6.6, P < 0.001) and low tPA TEG LY30 (OR 3.7, P = 0.004) were independent predictors of pICU after controlling for other risk factors. A 9-fold increase in the rate of 90-day graft loss (19% vs 2% p < 0.001) was observed patients who had these risk factors for pICU. CONCLUSION Elevated creatine and fibrinolysis resistance are associated with pICU and poor outcomes following LT.
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Affiliation(s)
- Hunter B Moore
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Colorado Center for Transplantation Care, Research, and Education, Aurora, CO, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA.
| | - Wells LaRiviere
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA
| | - Ivan Rodriguez
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Kristen Brown
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Kyndall Hadley
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - James J Pomposelli
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Megan A Adams
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Colorado Center for Transplantation Care, Research, and Education, Aurora, CO, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Michael E Wachs
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Colorado Center for Transplantation Care, Research, and Education, Aurora, CO, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Kendra D Conzen
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Peter T Kennealey
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Bruce Kaplan
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Elizabeth A Pomfret
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Trevor L Nydam
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
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Trabelsi NO, Melhem HB, Matouk MA, Borsuk DE, Efanov JI. Rates of hepatic artery thrombosis in liver transplantation with the use of a microscope: A systematic review. J Plast Reconstr Aesthet Surg 2023; 87:352-360. [PMID: 37925927 DOI: 10.1016/j.bjps.2023.10.056] [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: 05/23/2023] [Revised: 09/23/2023] [Accepted: 10/08/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE Hepatic artery anastomosis in liver transplantations requires a meticulous technique to minimize the risk of hepatic artery thrombosis (HAT). The microscope helped improve anastomosis techniques in pediatric patients with small caliber vessels. The aim of this review was to compare microsurgical and non-microsurgical techniques on the incidence of HAT in liver transplantations. The secondary objective was to compare HAT incidence between pediatric and adult cohorts and between plastic and transplant surgeons. METHODS A systematic review of the literature using Medline, Embase, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) was conducted on studies involving HAT in liver transplantations with microsurgery. Three reviewers performed a full article review and data extraction for studies meeting the eligibility criteria of the study. RESULTS Forty-five studies were incorporated in the final analysis. A total of 7346 patients and 7506 liver transplants were included. The mean age was 17 years old with an equivalent distribution between pediatric (51%, n = 3218) and adult patients (49%, n = 3145). A total of 6351 of these transplantations underwent microsurgical repair, against 1157 with non-microsurgical techniques. The overall HAT rate was 4.9%, including 4.2% in the microsurgical group (n = 268) and 8.5% in the non-microsurgical group (n = 98), a statistically significant increase of 4.3%. The occurrence of HAT was 2.6% with a plastic surgeon versus 4.6% with other types of surgeons. When using microsurgical techniques, the HAT rate was 4.2% with living donors versus 7.7% with deceased donors. CONCLUSIONS HAT and subsequent liver transplant failure are lower when microsurgical techniques, living donors, and plastic surgeons with a microsurgical training are involved in the operation.
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Affiliation(s)
- Nadia Oliveira Trabelsi
- Plastic and Reconstructive Surgery, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, QC, Canada
| | - Hassan Bachir Melhem
- Plastic and Reconstructive Surgery, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, QC, Canada
| | - Myra Aït Matouk
- Plastic and Reconstructive Surgery, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, QC, Canada
| | - Daniel Evan Borsuk
- Plastic and Reconstructive Surgery, Centre hospitalier universitaire (CHU) Sainte-Justine, Montréal, QC, Canada
| | - Johnny Ionut Efanov
- Plastic and Reconstructive Surgery, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, QC, Canada.
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Wang SC, Ting CK, Chen CY, Liu C, Lin NC, Loong CC, Wu HT, Lin YT. Arterial blood pressure waveform in liver transplant surgery possesses variability of morphology reflecting recipients' acuity and predicting short term outcomes. J Clin Monit Comput 2023; 37:1521-1531. [PMID: 37436598 DOI: 10.1007/s10877-023-01047-9] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 06/13/2023] [Indexed: 07/13/2023]
Abstract
We investigated clinical information underneath the beat-to-beat fluctuation of the arterial blood pressure (ABP) waveform morphology. We proposed the Dynamical Diffusion Map algorithm (DDMap) to quantify the variability of morphology. The underlying physiology could be the compensatory mechanisms involving complex interactions between various physiological mechanisms to regulate the cardiovascular system. As a liver transplant surgery contains distinct periods, we investigated its clinical behavior in different surgical steps. Our study used DDmap algorithm, based on unsupervised manifold learning, to obtain a quantitative index for the beat-to-beat variability of morphology. We examined the correlation between the variability of ABP morphology and disease acuity as indicated by Model for End-Stage Liver Disease (MELD) scores, the postoperative laboratory data, and 4 early allograft failure (EAF) scores. Among the 85 enrolled patients, the variability of morphology obtained during the presurgical phase was best correlated with MELD-Na scores. The neohepatic phase variability of morphology was associated with EAF scores as well as postoperative bilirubin levels, international normalized ratio, aspartate aminotransferase levels, and platelet count. Furthermore, variability of morphology presents more associations with the above clinical conditions than the common BP measures and their BP variability indices. The variability of morphology obtained during the presurgical phase is indicative of patient acuity, whereas those during the neohepatic phase are indicative of short-term surgical outcomes.
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Affiliation(s)
- Shen-Chih Wang
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chien-Kun Ting
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Cheng-Yen Chen
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Transplantation Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chinsu Liu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Transplantation Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Niang-Cheng Lin
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Transplantation Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Che-Chuan Loong
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Transplantation Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hau-Tieng Wu
- Department of Mathematics, Duke University, Durham, NC, USA.
- Department of Statistical Science, Duke University, Durham, NC, USA.
| | - Yu-Ting Lin
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan.
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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