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Li M, Pai RA, Gomel R, Vyas M, Callif SC, Hatchett J, Bowlus CL, Lai JC. Patient-focused drug development in primary sclerosing cholangitis: Insights on patient priorities and involvement in clinical trials. Hepatol Commun 2024; 8:e0433. [PMID: 38727680 PMCID: PMC11093571 DOI: 10.1097/hc9.0000000000000433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 02/16/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND According to the new AASLD Practice Guidance, all patients with primary sclerosing cholangitis (PSC) should be considered for participation in clinical trials. However, PSC's rarity has posed challenges to characterizing patient interest in trial participation and identifying predictors of patient willingness to participate in drug trials. METHODS PSC Partners Seeking a Cure developed the "Our Voices" survey to inform the development of the Externally-Led Patient-Focused Drug Development Forum, an FDA initiative to capture patient experiences and perspectives on drug development. RESULTS Of 797 survey respondents from over 30 countries, 536 (67%) identified slowing disease progression as the most important outcome. Eighty-nine percent identified their hepatologist/gastroenterologist as someone they would approach for advice about trials. Although 61% reported being willing to participate in drug trials, only 26% had ever been asked to participate. Notable barriers to trial involvement included unknown long-term risks (71%), long travel times to the study center (32%), and a liver biopsy requirement (27%). On multivariable logistic regression, pruritus (OR 1.62, 95% CI: 1.09-2.40, p = 0.017) was positively associated with willingness to participate in disease-modifying therapy trials, while jaundice (OR 0.34, 95% CI: 0.19-0.61, p < 0.001) and inflammatory bowel disease (OR 0.64, 95% CI: 0.42-0.98, p = 0.038) were negatively associated. Pruritus (OR 2.25, 95% CI: 1.50-3.39, p < 0.001) was also independently associated with willingness to participate in symptom treatment trials. CONCLUSIONS Most patients with PSC report interest in participating in clinical trials, but few have been asked to participate. Referral of patients with PSC by their hepatologist/gastroenterologist to clinical trials and patient education on trial participation are vital to closing the gap between trial interest and participation. Pruritus may serve as a key indicator of patient interest in trial participation.
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Affiliation(s)
- Michael Li
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California, San Francisco, California, USA
| | - Ruth-Anne Pai
- PSC Partners Seeking a Cure, Greenwood Village, Colorado, USA
| | - Rachel Gomel
- PSC Partners Seeking a Cure, Greenwood Village, Colorado, USA
| | - Mary Vyas
- PSC Partners Seeking a Cure Canada, Toronto, ON, Canada
| | | | - Joanne Hatchett
- PSC Partners Seeking a Cure, Greenwood Village, Colorado, USA
| | - Christopher L. Bowlus
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California Davis Health, Sacramento, California, USA
| | - Jennifer C. Lai
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California, San Francisco, California, USA
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2
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LaHue SC, Fuentealba M, Roa Diaz S, Seetharaman S, Garcia T, Furman D, Lai JC, Newman JC. Association of biological aging with frailty and post-transplant outcomes among adults with cirrhosis. GeroScience 2024; 46:3287-3295. [PMID: 38246968 PMCID: PMC11009173 DOI: 10.1007/s11357-024-01076-5] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 01/13/2024] [Indexed: 01/23/2024] Open
Abstract
Frailty is classically associated with advanced age but is also an important predictor of clinical outcomes in comparatively young adults with cirrhosis. We examined the association of biological aging with frailty and post-transplant outcomes in a pilot of adults with cirrhosis undergoing liver transplantation (LT). Frailty was measured via the Liver Frailty Index (LFI). The primary epigenetic clock DNA methylation (DNAm) PhenoAge was calculated from banked peripheral blood mononuclear cells; we secondarily explored two first-generation clocks (Hannum; Horvath) and two additional second-generation clocks (GrimAge; GrimAge2). Twelve adults were included: seven frail (LFI ≥ 4.4, mean age 55 years) and five robust (LFI < 3.2, mean age 55 years). Mean PhenoAge age acceleration (AgeAccel) was + 2.5 years (P = 0.23) for frail versus robust subjects. Mean PhenoAge AgeAccel was + 2.7 years (P = 0.19) for subjects who were readmitted or died within 30 days of discharge post-LT versus those without this outcome. When compared with first-generation clocks, the second-generation clocks demonstrated greater average AgeAccel for subjects with frailty or poor post-LT outcomes. Measuring biological age using DNAm-derived epigenetic clocks is feasible in adults undergoing LT. While frail and robust subjects had the same average chronological age, average biological age as measured by second-generation epigenetic clocks tended to be accelerated among those who were frail or experienced a poor post-LT outcome. These results suggest that frailty in these relatively young subjects with cirrhosis may involve similar aging mechanisms as frailty classically observed in chronologically older adults and warrant validation in a larger cohort.
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Affiliation(s)
- Sara C LaHue
- Department of Neurology, School of Medicine, University of California, San Francisco, CA, USA.
- Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, 505 Parnassus Ave, Box 0114, San Francisco, CA, 94143, USA.
- Buck Institute for Research On Aging, Novato, CA, USA.
| | | | - Stephanie Roa Diaz
- Buck Institute for Research On Aging, Novato, CA, USA
- Division of Geriatrics, Department of Medicine, School of Medicine, University of California, San Francisco, CA, USA
| | - Srilakshmi Seetharaman
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, CA, USA
| | - Thelma Garcia
- Buck Institute for Research On Aging, Novato, CA, USA
- Division of Geriatrics, Department of Medicine, School of Medicine, University of California, San Francisco, CA, USA
| | - David Furman
- Buck Institute for Research On Aging, Novato, CA, USA
- Instituto de Investigaciones en Medicina Traslacional, Universidad Austral, Consejo Nacional de Investigaciones Científicas y Técnicas, 1629, Pilar, Argentina
- Stanford 1000 Immunomes Project, Stanford University School of Medicine, Stanford, CA, USA
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, CA, USA
| | - John C Newman
- Buck Institute for Research On Aging, Novato, CA, USA
- Division of Geriatrics, Department of Medicine, School of Medicine, University of California, San Francisco, CA, USA
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Cullaro G, Allegretti AS, Patidar KR, Verna EC, Lai JC. Applying Metabolomics and Aptamer-based Proteomics to Determine Pathophysiologic Differences in Decompensated Cirrhosis Patients Hospitalized with Acute Kidney Injury. Res Sq 2024:rs.3.rs-4344179. [PMID: 38765962 PMCID: PMC11100905 DOI: 10.21203/rs.3.rs-4344179/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
Methods A case-control study of 97 patients hospitalized at our institution. We performed aptamer-based proteomics and metabolomics on serum biospecimens obtained within 72 hours of admission. We compared the proteome and metabolome by the AKI phenotype (i.e., HRS-AKI, ATN) and by AKI recovery (decrease in sCr within 0.3 mg/dL of baseline) using ANCOVA analyses adjusting for demographics and clinical characteristics. We completed Random Forest (RF) analyses to identify metabolites and proteins associated with AKI phenotype and recovery. Lasso regression models were developed to highlight metabolites and proteins could improve diagnostic accuracy. Results: ANCOVA analyses showed no metabolomic or proteomic differences by AKI phenotype while identifying differences by AKI recovery status. Our RF and Lasso analyses showed that metabolomics can improve the diagnostic accuracy of both AKI diagnosis and recovery, and aptamer-based proteomics can enhance the diagnostic accuracy of AKI recovery. Discussion: Our analyses provide novel insight into pathophysiologic pathways, highlighting the metabolomic and proteomic similarities between patients with cirrhosis with HRS-AKI and ATN while also identifying differences between those with and without AKI recovery.
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Gutierrez SA, Chiou SH, Rhee S, Lai JC, Wadhwani SI. The influence of neighborhood income on healthcare utilization in pediatric liver transplant. J Pediatr Gastroenterol Nutr 2024. [PMID: 38693791 DOI: 10.1002/jpn3.12234] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 02/08/2024] [Accepted: 04/13/2024] [Indexed: 05/03/2024]
Abstract
OBJECTIVES Neighborhood contextual factors are associated with liver transplant outcomes. We analyzed associations between neighborhood-level socioeconomic status and healthcare utilization for pediatric liver transplant recipients. METHODS We merged the Pediatric Health Information System and Scientific Registry of Transplant Recipients databases and included liver transplant recipients ≤21 years hospitalized between January 2004 and May 2022. Outcomes were annual inpatient bed-days, risk of hospitalizations, and risk of liver biopsies. The primary exposure was zip code-based neighborhood income at transplant. We applied causal inference for variable selection in multivariable analysis. We modeled annual inpatient bed-days with mixed-effect zero-inflated Poisson regression, and rates of hospitalization and liver biopsy with a Cox-type proportional rate model. RESULTS We included 1006 participants from 29 institutions. Children from low-income neighborhoods were more likely to be publicly insured (67% vs. 46%), Black (20% vs. 12%), Hispanic (30% vs. 17%), and have higher model for end-stage liver disease/pediatric end-stage liver disease model scores at transplant (17 vs. 13) than the remaining cohort. We found no differences in inpatient bed-days or rates of hospitalization across neighborhood groups. In univariable analysis, low-income neighborhoods were associated with increased rates of liver biopsy (RR: 1.57, 95% CI: 1.04-2.34, p = 0.03). These findings persisted after adjusting for insurance, race, and ethnicity (RR: 1.86, 95% CI: 1.23-2.83, p < 0.01). CONCLUSIONS Children from low-income neighborhoods undergo more liver biopsies than other children. These procedures are invasive and potentially preventable. In addition to improving outcomes, interventions to mitigate health inequities among liver transplant recipients may reduce resource utilization.
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Affiliation(s)
- Susan A Gutierrez
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
| | - Sy Han Chiou
- Department of Surgery, University of California, San Francisco, San Francisco, California, USA
- Department of Statistics and Data Science, Southern Methodist University, Dallas, Texas, USA
| | - Sue Rhee
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
| | - Jennifer C Lai
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Sharad I Wadhwani
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
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Wang M, Ge J, Ha N, Shui AM, Huang CY, Cullaro G, Lai JC. Clinical Characteristics Associated With Posttransplant Survival Among Adults 70 Years Old or Older Undergoing Liver Transplantation. J Clin Gastroenterol 2024; 58:516-521. [PMID: 37279205 PMCID: PMC10700658 DOI: 10.1097/mcg.0000000000001870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 04/24/2023] [Indexed: 06/08/2023]
Abstract
GOALS We sought to identify pre-liver transplantation (LT) characteristics among older adults associated with post-LT survival. BACKGROUND The proportion of older patients undergoing deceased-donor liver transplantation (DDLT) has increased over time. STUDY We analyzed adult DDLT recipients in the United Network for Organ Sharing registry from 2016 through 2020, excluding patients listed as status 1 or with a model of end-stage liver disease exceptions for hepatocellular carcinoma. Kaplan-Meier methods were used to estimate post-LT survival probabilities among older recipients (age ≥70 y). Associations between clinical covariates and post-LT mortality were assessed using Cox regressions. RESULTS Of 22,862 DDLT recipients, 897 (4%) were 70 years old or older. Compared with younger recipients, older recipients had worse overall survival ( P < 0.01) (1 y: 88% vs 92%, 3 y: 77% vs 86%, and 5 y: 67% vs 78%). Among older adults, in univariate Cox regressions, dialysis [hazards ratio (HR): 1.96, 95% CI: 1.38-2.77] and poor functional status [defined as Karnofsky Performance Score (KPS) <40] (HR: 1.82, 95% CI: 1.31-2.53) were each associated with mortality, remaining significant on multivariable Cox regressions. The effect of dialysis and KPS <40 at LT on post-LT survival (HR: 2.67, 95% CI: 1.77-4.01) was worse than the effects of either KPS <40 (HR: 1.52, 95% CI: 1.03-2.23) or dialysis alone (HR: 1.44, 95% CI: 0.62-3.36). Older recipients with KPS >40 without dialysis had comparable survival rates compared with younger recipients ( P = 0.30). CONCLUSIONS While older DDLT recipients had worse overall post-LT survival compared with younger recipients, favorable survival rates were observed among older adults who did not require dialysis and had poor functional status. Poor functional status and dialysis at LT may be useful to stratify older adults at higher risk for poor post-LT outcomes.
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Affiliation(s)
| | - Jin Ge
- Division of Gastroenterology and Hepatology, Department of Medicine
| | - Nghiem Ha
- Division of Gastroenterology and Hepatology, Department of Medicine
| | - Amy M Shui
- Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, CA
| | - Chiung-Yu Huang
- Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, CA
| | - Giuseppe Cullaro
- Division of Gastroenterology and Hepatology, Department of Medicine
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, Department of Medicine
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Lai JC. Frailty, Sarcopenia, and Nutrition in Patients With Cirrhosis. Gastroenterol Hepatol (N Y) 2024; 20:244-246. [PMID: 38682125 PMCID: PMC11047146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2024]
Affiliation(s)
- Jennifer C Lai
- Endowed Professor of Liver Health and Transplantation Professor of Medicine Physician Nutrition Specialist University of California, San Francisco San Francisco, California
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7
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Ge J, Li M, Delk MB, Lai JC. A Comparison of a Large Language Model vs Manual Chart Review for the Extraction of Data Elements From the Electronic Health Record. Gastroenterology 2024; 166:707-709.e3. [PMID: 38151192 DOI: 10.1053/j.gastro.2023.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 12/10/2023] [Accepted: 12/18/2023] [Indexed: 12/29/2023]
Affiliation(s)
- Jin Ge
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, San Francisco, California.
| | - Michael Li
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Molly B Delk
- Section of Gastroenterology and Hepatology, Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, San Francisco, California
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8
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Wadhwani SI, Kruse G, Squires J, Ebel N, Gupta N, Campbell K, Hsu E, Zielsdorf S, Vittorio J, Desai DM, Bucuvalas JC, Gottlieb LM, Lai JC. Caregiver Perceptions of Social Risk Screening in Pediatric Liver Transplantation: From the Multicenter SOCIAL-Tx Study. Transplantation 2024; 108:940-946. [PMID: 37831642 PMCID: PMC10963151 DOI: 10.1097/tp.0000000000004835] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
BACKGROUND The social determinants of health contribute to adverse post-liver transplant outcomes. Identifying unmet social risks may enable transplant teams to improve long-term outcomes for at-risk children. However, providers may feel uncomfortable asking about household-level social risks in the posttransplant period because they might make their patients/families uncomfortable. METHODS We conducted a mixed-methods analysis of caregiver participants (ie, parents/guardians of pediatric liver transplant recipients) in the Social and Contextual Impact on Children Undergoing Liver Transplantation study to assess their perceptions of provider-based social risk screening. Participants (N = 109) completed a 20-min social determinants of health questionnaire that included questions on the acceptability of being asked intimate social risk questions. A subset of participants (N = 37) engaged in an in-depth qualitative interview to share their perceptions of social risk screening. RESULTS Of 109 participants across 9 US transplant centers, 60% reported financial strain and 30% reported at least 1 material economic hardship (eg, food insecurity, housing instability). Overall, 65% of respondents reported it very or somewhat appropriate and 25% reported being neutral to being screened for social risks in a liver transplant setting. In qualitative analyses, participants reported trust in the providers and a clear understanding of the intention of the screening as prerequisites for liver transplant teams to perform social risk screening. CONCLUSIONS Only a small minority of caregivers found social risk screening unacceptable. Pediatric liver transplant programs should implement routine social risk screening and prioritize the patient and family voices when establishing a screening program to ensure successful implementation.
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Affiliation(s)
| | - Gina Kruse
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - James Squires
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | | | | | - Evelyn Hsu
- Seattle Children’s Hospital, Seattle, WA
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9
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Cruz C, Prado CM, Gillis C, Martindale R, Bémeur C, Lai JC, Tandon P. Nutritional aspects of prehabilitation in adults with cirrhosis awaiting liver transplant. Hepatology 2024:01515467-990000000-00825. [PMID: 38546288 DOI: 10.1097/hep.0000000000000818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 01/20/2024] [Indexed: 04/21/2024]
Abstract
Malnutrition, sarcopenia (low muscle mass), and physical frailty have gained increasing recognition in candidates for liver transplant (LT) as these conditions can impact postoperative functional capacity. Multidimensional prehabilitation programs have been proposed as a safe intervention in adults awaiting LT but the nutritional pillar of prehabilitation has been understudied. This review summarizes the nutritional recommendations for prehabilitation for individuals with cirrhosis awaiting LT. Three major aspects of nutritional prehabilitation are discussed: (1) Assess: Evaluate nutritional status and assess for malnutrition, sarcopenia, and frailty to guide the nutritional prehabilitation intervention intensity, increasing across universal, targeted, and specialist levels; (2) Intervene: Prescribe a nutritional prehabilitation intervention to meet established nutrition guidelines in cirrhosis with a targeted focus on improving nutritional status and muscle health; (3) Reassess: Follow-up based on the required intensity of nutritional care with as needed intervention adjustment. Topics covered in the review include nutritional care levels for prehabilitation, energy prescriptions across body mass index strata, detailed considerations around protein intake (amount, distribution, and quality), carbohydrate and fat intake, other nutritional considerations, and the potential role of dietary supplements and nutraceuticals. Future research is warranted to more accurately evaluate energy needs, evaluate emerging dietary supplementation strategies, and establish the role of nutraceuticals alongside food-based interventions. While the general principles of nutritional prehabilitation are ready for immediate application, future large-scale randomized controlled trials in this space will help to quantify the benefit that can be gained by transitioning the LT approach from passive "transplant waitlist time" to active "transplant preparation time."
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Affiliation(s)
- Christofer Cruz
- Department of Medicine, Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Alberta, Canada
| | - Carla M Prado
- Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, Alberta, Canada
| | - Chelsia Gillis
- School of Human Nutrition, McGill University, Montreal, Quebec, Canada
- Department of Nutrition, Université de Montréal, Montreal, Quebec, Canada
| | - Robert Martindale
- Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Chantal Bémeur
- Department of Nutrition, Université de Montréal, Montreal, Quebec, Canada
| | - Jennifer C Lai
- Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Puneeta Tandon
- Department of Medicine, Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Alberta, Canada
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Cullaro G, Chiou SH, Fenton C, Ge J, McCulloch CE, Rubin J, Shui AM, Yao F, Lai JC. Outpatient mean arterial pressure: A potentially modifiable risk for acute kidney injury and death among patients with cirrhosis. Liver Transpl 2024:01445473-990000000-00352. [PMID: 38535488 DOI: 10.1097/lvt.0000000000000359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 02/21/2024] [Indexed: 04/05/2024]
Abstract
Mean arterial blood pressure (MAP), which decreases as portal hypertension progresses, may be a modifiable risk factor among patients with cirrhosis. We included adults enrolled in the Functional Assessment in Liver Transplantation study. We completed latent class trajectory analyses to define MAP trajectories. We completed time-dependent Cox-regression analyses to test the association between outpatient MAP and 3 cirrhosis-related outcomes: (1) stage 2 acute kidney injury (AKI), defined as a ≥200% increase in serum creatinine from baseline; (2) a 5-point increase in the MELD-Na score, defined as the incidence of increase from initial MELD-Na; (3) waitlist mortality, defined as death on the waitlist. For each outcome, we defined MAP cut points by determining the maximally selected Log-rank statistic after univariable Cox-regression analyses. Among the 1786 patients included in this analysis, our latent class trajectory analyses identified 3 specific outpatient MAP trajectories: "stable-low," "stable-high," and "increasing-to-decreasing." However, >80% of patients were in a "stable-low" trajectory. We found in adjusted analyses that outpatient MAP was associated with each of our outcomes: Stage 2 AKI (adjusted hazard ratio 0.88 per 10 mm Hg increase in MAP [95% CI: 0.79-0.99]); 5-point increase in MELD-Na (adjusted hazard ratio: 0.91 [95% CI: 0.86-0.96]; waitlist mortality (adjusted hazard ratio: 0.89 [95% CI: 0.81-0.96]). For each outcome, we found that an outpatient MAP of 82 mm Hg was most associated with outcomes ( p <0.05 for all). Our study informs the association between outpatient MAP and cirrhosis-related outcomes. These findings, coupled with the identification of specific thresholds, lay the foundation for the trial of targeted outpatient MAP modulation in patients with cirrhosis.
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Affiliation(s)
- Giuseppe Cullaro
- Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Sy Han Chiou
- Department of Mathematical Sciences, University of Texas at Dallas, Richardson, Texas, USA
| | - Cynthia Fenton
- Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Jin Ge
- Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - Jessica Rubin
- Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Amy M Shui
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - Frederick Yao
- Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Jennifer C Lai
- Department of Medicine, University of California-San Francisco, San Francisco, California, USA
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11
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Cullaro G, Allegretti AS, Fenton C, Ge J, Patidar KR, Rubin J, Sharma A, Lai JC. The association between mean arterial pressure and acute kidney injury reversal among patients with decompensated cirrhosis. Hepatology 2024:01515467-990000000-00824. [PMID: 38537129 DOI: 10.1097/hep.0000000000000858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 03/06/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND AND AIMS This study informs how mean arterial pressure (MAP) impacts acute kidney injury (AKI) recovery among all patients hospitalized with cirrhosis, regardless of etiology. APPROACH AND RESULTS We identified incident AKI episodes among subjects in our cohort of patients with decompensated cirrhosis. AKI was defined as a ≥50% increase in creatinine from an outpatient baseline (≥7 days prior) that required hospitalization. Linear mixed effects models were completed to determine the impact between AKI recovery, MAP, and time. To determine the impact of MAP on AKI reversal, we completed time-dependent Cox regression models with time beginning at the time of peak creatinine and ending at death, discharge, or AKI reversal, among those hospitalized with AKI and those with persistent AKI (≥48 h) We identified 702 hospitalized patients with cirrhosis with AKI. We found those with AKI reversal had, on average, higher MAP (2.1 mm Hg, p <0.05) and a greater increase in MAP over time (0.1 mm Hg per hour, p <0.001). Among all 702 hospitalized patients with AKI and adjusted for confounders, each 5 mm Hg increase in MAP was associated with 1.07× the hazard of AKI reversal ( p <0.01). Similarly, among those with persistent AKI after adjusting for confounders, each 5 mm Hg increase in MAP was associated with a 1.19× greater likelihood of AKI reversal ( p <0.001). DISCUSSION Our data demonstrate that MAP significantly increases the likelihood of AKI recovery regardless of severity or injury or AKI phenotype. We believe these data highlight the importance of MAP as a clinical tool to promote kidney function recovery among patients with cirrhosis hospitalized with AKI.
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Affiliation(s)
- Giuseppe Cullaro
- Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Andrew S Allegretti
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Cynthia Fenton
- Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Jin Ge
- Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Kavish R Patidar
- Section of Gastroenterology, Department of Medicine, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston Texas, USA
| | - Jessica Rubin
- Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Arjun Sharma
- Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Jennifer C Lai
- Department of Medicine, University of California-San Francisco, San Francisco, California, USA
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12
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Brahmania M, Kuo A, Tapper EB, Volk ML, Vittorio JM, Ghabril M, Morgan TR, Kanwal F, Parikh ND, Martin P, Mehta S, Winder GS, Im GY, Goldberg D, Lai JC, Duarte-Rojo A, Paredes AH, Patel AA, Sahota A, McElroy LM, Thomas C, Wall AE, Malinis M, Aslam S, Simonetto DA, Ufere NN, Ramakrishnan S, Flynn MM, Ibrahim Y, Asrani SK, Serper M. Quality measures in pre-liver transplant care by the Practice Metrics Committee of the American Association for the Study of Liver Diseases. Hepatology 2024:01515467-990000000-00816. [PMID: 38536021 DOI: 10.1097/hep.0000000000000870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 03/11/2024] [Indexed: 05/19/2024]
Abstract
The liver transplantation (LT) evaluation and waitlisting process is subject to variations in care that can impede quality. The American Association for the Study of Liver Diseases (AASLD) Practice Metrics Committee (PMC) developed quality measures and patient-reported experience measures along the continuum of pre-LT care to reduce care variation and guide patient-centered care. Following a systematic literature review, candidate pre-LT measures were grouped into 4 phases of care: referral, evaluation and waitlisting, waitlist management, and organ acceptance. A modified Delphi panel with content expertise in hepatology, transplant surgery, psychiatry, transplant infectious disease, palliative care, and social work selected the final set. Candidate patient-reported experience measures spanned domains of cognitive health, emotional health, social well-being, and understanding the LT process. Of the 71 candidate measures, 41 were selected: 9 for referral; 20 for evaluation and waitlisting; 7 for waitlist management; and 5 for organ acceptance. A total of 14 were related to structure, 17 were process measures, and 10 were outcome measures that focused on elements not typically measured in routine care. Among the patient-reported experience measures, candidates of LT rated items from understanding the LT process domain as the most important. The proposed pre-LT measures provide a framework for quality improvement and care standardization among candidates of LT. Select measures apply to various stakeholders such as referring practitioners in the community and LT centers. Clinically meaningful measures that are distinct from those used for regulatory transplant reporting may facilitate local quality improvement initiatives to improve access and quality of care.
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Affiliation(s)
- Mayur Brahmania
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Alexander Kuo
- Karsh Division of Gastroenterology and Hepatology, Department of Medicine, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael L Volk
- Department of Medicine, Baylor Scott and White Health, Temple, Texas, USA
| | - Jennifer M Vittorio
- Division of Pediatric Gastroenterology, Department of Medicine, New York University (NYU) Langone Health, New York, New York, USA
| | - Marwan Ghabril
- Division of Gastroenterology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Timothy R Morgan
- Division of Gastroenterology, Department of Medicine, University of California, Irvine, California, USA
- Medical Service, VA Long Beach Healthcare System, Long Beach, California, USA
| | - Fasiha Kanwal
- Division of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Neehar D Parikh
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Paul Martin
- Division of Gastroenterology, Department of Medicine, University of Miami, Miami, Florida, USA
| | - Shivang Mehta
- Department of Medicine, Baylor University Medical Center, Dallas, Texas, USA
| | | | - Gene Y Im
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - David Goldberg
- Division of Gastroenterology, Department of Medicine, University of Miami, Miami, Florida, USA
| | - Jennifer C Lai
- Division of Gastroenterology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Andres Duarte-Rojo
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern Medicine, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Angelo H Paredes
- Division of Gastroenterology, Department of Medicine, University of San Antonio, San Antonio, Texas, USA
| | - Arpan A Patel
- Division of Gastroenterology, Department of Medicine, University of California Los Angeles, Los Angeles, California, USA
- Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Amandeep Sahota
- Department of Transplant Hepatology, Southern California Permanente Medical Group, Los Angeles, California, USA
| | - Lisa M McElroy
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Charlie Thomas
- Banner University Medical Center Phoenix Transplant Program, Phoenix, Arizona, USA
| | - Anji E Wall
- Department of Surgery, Baylor University Medical Center, Dallas, Texas, USA
| | - Maricar Malinis
- Section of Infectious Diseases, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Saima Aslam
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, USA
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Nneka N Ufere
- Department of Medicine, Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Mary Margaret Flynn
- Division of Gastroenterology, Department of Medicine, University of Massachusetts, Boston, Massachusetts, USA
| | | | - Sumeet K Asrani
- Department of Medicine, Baylor University Medical Center, Dallas, Texas, USA
| | - Marina Serper
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Ge J, Chen IY, Pletcher MJ, Lai JC. Prompt Engineering for Generative Artificial Intelligence in Gastroenterology and Hepatology. Am J Gastroenterol 2024:00000434-990000000-01003. [PMID: 38294157 DOI: 10.14309/ajg.0000000000002689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 12/28/2023] [Indexed: 02/01/2024]
Affiliation(s)
- Jin Ge
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Irene Y Chen
- UCSF and UC Berkeley Joint Program in Computational Precision Health, Berkeley, California, USA
| | - Mark J Pletcher
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
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Ge J, Sun S, Owens J, Galvez V, Gologorskaya O, Lai JC, Pletcher MJ, Lai K. Development of a liver disease-specific large language model chat interface using retrieval-augmented generation. Hepatology 2024:01515467-990000000-00791. [PMID: 38451962 DOI: 10.1097/hep.0000000000000834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 02/24/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND AND AIMS Large language models (LLMs) have significant capabilities in clinical information processing tasks. Commercially available LLMs, however, are not optimized for clinical uses and are prone to generating hallucinatory information. Retrieval-augmented generation (RAG) is an enterprise architecture that allows the embedding of customized data into LLMs. This approach "specializes" the LLMs and is thought to reduce hallucinations. APPROACH AND RESULTS We developed "LiVersa," a liver disease-specific LLM, by using our institution's protected health information-complaint text embedding and LLM platform, "Versa." We conducted RAG on 30 publicly available American Association for the Study of Liver Diseases guidance documents to be incorporated into LiVersa. We evaluated LiVersa's performance by conducting 2 rounds of testing. First, we compared LiVersa's outputs versus those of trainees from a previously published knowledge assessment. LiVersa answered all 10 questions correctly. Second, we asked 15 hepatologists to evaluate the outputs of 10 hepatology topic questions generated by LiVersa, OpenAI's ChatGPT 4, and Meta's Large Language Model Meta AI 2. LiVersa's outputs were more accurate but were rated less comprehensive and safe compared to those of ChatGPT 4. RESULTS We evaluated LiVersa's performance by conducting 2 rounds of testing. First, we compared LiVersa's outputs versus those of trainees from a previously published knowledge assessment. LiVersa answered all 10 questions correctly. Second, we asked 15 hepatologists to evaluate the outputs of 10 hepatology topic questions generated by LiVersa, OpenAI's ChatGPT 4, and Meta's Large Language Model Meta AI 2. LiVersa's outputs were more accurate but were rated less comprehensive and safe compared to those of ChatGPT 4. CONCLUSIONS In this demonstration, we built disease-specific and protected health information-compliant LLMs using RAG. While LiVersa demonstrated higher accuracy in answering questions related to hepatology, there were some deficiencies due to limitations set by the number of documents used for RAG. LiVersa will likely require further refinement before potential live deployment. The LiVersa prototype, however, is a proof of concept for utilizing RAG to customize LLMs for clinical use cases.
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Affiliation(s)
- Jin Ge
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California-San Francisco, San Francisco, California, USA
| | - Steve Sun
- UCSF Health Information Technology, University of California-San Francisco, San Francisco, California, USA
| | - Joseph Owens
- UCSF Health Information Technology, University of California-San Francisco, San Francisco, California, USA
| | - Victor Galvez
- UCSF Health Information Technology, University of California-San Francisco, San Francisco, California, USA
| | - Oksana Gologorskaya
- UCSF Health Information Technology, University of California-San Francisco, San Francisco, California, USA
- Bakar Computational Health Sciences Institute, University of California-San Francisco, San Francisco, California, USA
| | - Jennifer C Lai
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California-San Francisco, San Francisco, California, USA
| | - Mark J Pletcher
- Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, California, USA
| | - Ki Lai
- UCSF Health Information Technology, University of California-San Francisco, San Francisco, California, USA
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15
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Sheshadri A, Elia JR, Garcia G, Abrams G, Adey DB, Lai JC, Sudore RL. Barriers and Facilitators to Exercise in Older Adults Awaiting Kidney Transplantation and Their Care Partners. Kidney Med 2024; 6:100779. [PMID: 38419789 PMCID: PMC10900112 DOI: 10.1016/j.xkme.2023.100779] [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] [Indexed: 03/02/2024] Open
Abstract
Rationale & Objective Despite guidelines calling to improve physical activity in older adults, and evidence suggesting that prekidney transplant physical function is highly associated with posttransplant outcomes, only a small percentage of older patients treated with dialysis are engaged in structured exercise. We sought to elucidate barriers and facilitators of exercise among older adults treated with dialysis awaiting transplant and their care partners. Study Design Individual, in-depth, cognitive interviews were conducted separately for patients and care partners through secure web-conferencing. Setting & Participants Twenty-three patients (≥50 years of age, treated with dialysis from the University of San Francisco kidney transplantation clinic, with a short physical performance battery of ≤10) and their care partners. Analytical Approach All audio interviews were transcribed verbatim. Three investigators independently coded data and performed qualitative thematic content. The interview guide was updated iteratively based on the Capability Opportunity Motivation Behavior model. Results Patients' median age was 60 years (57 ± 63.5) and care partners' median ages was 57 years (49.5 ± 65.5). Thirty-nine percent of patients and 78% of care partners were female, 39% of patients and 30% of care partners self-identified as African American, and 47% of dyads were spouse or partner relationships. Major themes for barriers to pretransplant exercise included lack of understanding of an appropriate regimen, physical impairments, dialysis schedules, and safety concerns. Major facilitators included having individualized or structured exercise programs, increasing social support for patients and care partners, and motivation to regain independence or functionality or to promote successful transplantation. Limitations Participants geographically limited to Northern California. Conclusions Although patients and care partners report numerous barriers to pretransplant exercise and activity, they also reported many facilitators. An individualized, structured, home-based exercise program could circumvent many of the reported barriers and allow older patients to improve pretransplant physical function.
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Affiliation(s)
- Anoop Sheshadri
- Division of Nephrology, Department of Medicine, University of California, San Francisco
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Jessica R. Elia
- Division of Nephrology, Department of Medicine, University of California, San Francisco
| | - Gabriel Garcia
- Division of Nephrology, Department of Medicine, University of California, San Francisco
| | - Gary Abrams
- University of California Weill Institute for Neurosciences, San Francisco, California
| | - Deborah B. Adey
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Jennifer C. Lai
- Division of Gastroenterology/Hepatology, Department of Medicine, University of California, San Francisco
| | - Rebecca L. Sudore
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California
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Yalung JE, Shifman HP, Manning ER, Beck A, Bucuvalas J, Lai JC, Wadhwani SI. Ambient air pollution is associated with graft failure/death in pediatric liver transplant recipients. Am J Transplant 2024; 24:448-457. [PMID: 37898318 PMCID: PMC10922359 DOI: 10.1016/j.ajt.2023.10.015] [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: 06/10/2023] [Revised: 09/28/2023] [Accepted: 10/12/2023] [Indexed: 10/30/2023]
Abstract
Children exposed to disproportionately higher levels of air pollution experience worse health outcomes. In this population-based, observational registry study, we examine the association between air pollution and graft failure/death in children following liver transplantation (LT) in the US. We modeled the associations between air pollution (PM2.5) levels localized to the patient's ZIP code at the time of transplant and graft failure or death using Cox proportional-hazards models in pediatric LT recipients aged <19 years in the US from 2005-2015. In univariable analysis, high neighborhood PM2.5 was associated with a 56% increased hazard of graft failure/death (HR: 1.56; 95% CI: 1.32, 1.83; P < .001). In multivariable analysis, high neighborhood PM2.5 was associated with a 54% increased risk of graft failure/death (HR: 1.54; 95% CI: 1.29, 1.83; P < .001) after adjusting for race as a proxy for racism, insurance status, rurality, and neighborhood socioeconomic deprivation. Children living in high air pollution neighborhoods have an increased risk of graft failure and death posttransplant, even after controlling for sociodemographic variables. Our findings add further evidence that air pollution contributes to adverse health outcomes for children posttransplant and lay the groundwork for future studies to evaluate underlying mechanisms linking PM2.5 to adverse LT outcomes.
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Affiliation(s)
- Jared E Yalung
- School of Medicine, University of California, San Francisco, San Francisco, California, USA; UC Berkeley-UCSF Joint Medical Program, School of Public Health, University of California, Berkeley, Berkeley, California, USA
| | - Holly P Shifman
- School of Medicine, Oakland University William Beaumont, Rochester, Michigan, USA
| | | | - Andrew Beck
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - John Bucuvalas
- Department of Pediatrics, Division of Hepatology, Mount Sinai Kravis Children's Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jennifer C Lai
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of California, San Francisco, San Francisco, California, USA
| | - Sharad I Wadhwani
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of California, San Francisco, San Francisco, California, USA.
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17
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Ge J, Buenaventura A, Berrean B, Purvis J, Fontil V, Lai JC, Pletcher MJ. Applying human-centered design to the construction of a cirrhosis management clinical decision support system. Hepatol Commun 2024; 8:e0394. [PMID: 38407255 PMCID: PMC10898661 DOI: 10.1097/hc9.0000000000000394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 12/13/2023] [Indexed: 02/27/2024] Open
Abstract
BACKGROUND Electronic health record (EHR)-based clinical decision support is a scalable way to help standardize clinical care. Clinical decision support systems have not been extensively investigated in cirrhosis management. Human-centered design (HCD) is an approach that engages with potential users in intervention development. In this study, we applied HCD to design the features and interface for a clinical decision support system for cirrhosis management, called CirrhosisRx. METHODS We conducted technical feasibility assessments to construct a visual blueprint that outlines the basic features of the interface. We then convened collaborative-design workshops with generalist and specialist clinicians. We elicited current workflows for cirrhosis management, assessed gaps in existing EHR systems, evaluated potential features, and refined the design prototype for CirrhosisRx. At the conclusion of each workshop, we analyzed recordings and transcripts. RESULTS Workshop feedback showed that the aggregation of relevant clinical data into 6 cirrhosis decompensation domains (defined as common inpatient clinical scenarios) was the most important feature. Automatic inference of clinical events from EHR data, such as gastrointestinal bleeding from hemoglobin changes, was not accepted due to accuracy concerns. Visualizations for risk stratification scores were deemed not necessary. Lastly, the HCD co-design workshops allowed us to identify the target user population (generalists). CONCLUSIONS This is one of the first applications of HCD to design the features and interface for an electronic intervention for cirrhosis management. The HCD process altered features, modified the design interface, and likely improved CirrhosisRx's overall usability. The finalized design for CirrhosisRx proceeded to development and production and will be tested for effectiveness in a pragmatic randomized controlled trial. This work provides a model for the creation of other EHR-based interventions in hepatology care.
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Affiliation(s)
- Jin Ge
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California—San Francisco, San Francisco, California, USA
| | - Ana Buenaventura
- School of Medicine Technology Services, University of California—San Francisco, San Francisco, California, USA
| | - Beth Berrean
- School of Medicine Technology Services, University of California—San Francisco, San Francisco, California, USA
| | - Jory Purvis
- School of Medicine Technology Services, University of California—San Francisco, San Francisco, California, USA
| | - Valy Fontil
- Family Health Centers, NYU-Langone Medical Center, Brooklyn, New York, USA
| | - Jennifer C. Lai
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California—San Francisco, San Francisco, California, USA
| | - Mark J. Pletcher
- Department of Epidemiology and Biostatistics, University of California—San Francisco, San Francisco, California, USA
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18
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Li M, Wong D, Sack JS, Vogel AS, Hodi FS, Fong L, Lai JC, Zucker SD, Grover S. Outcomes of High-Grade Immune Checkpoint Inhibitor Hepatitis in Hospitalized and Nonhospitalized Patients. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00210-6. [PMID: 38401693 DOI: 10.1016/j.cgh.2024.02.006] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 01/26/2024] [Accepted: 02/05/2024] [Indexed: 02/26/2024]
Abstract
BACKGROUND & AIMS Guidelines recommend hospitalization for severe immune checkpoint inhibitor (ICI) hepatitis. We compared patient outcomes in the inpatient versus outpatient settings. METHODS We conducted a multicenter, retrospective cohort study of 294 ICI-treated patients who developed grade 3-4 ICI hepatitis. The primary outcome was time to alanine aminotransferase (ALT) normalization (≤40); secondary outcomes included time to ALT ≤100 U/L and time to death. To account for confounding by indication, inverse probability of treatment weighting was applied to perform Cox regression. A sensitivity analysis was performed excluding patients with grade 4 hepatitis. RESULTS One hundred and sixty-six patients (56.5%) were hospitalized for a median of 6 (interquartile range, 3-11) days. On inverse probability of treatment weighting Cox regression, hospitalization was not associated with time to ALT normalization (hazard ratio [HR], 1.11; 95% confidence interval [CI], 0.86-1.43; P = .436) or time to ALT ≤100 U/L (HR, 1.11; 95% CI, 0.86-1.43; P = .420). In the sensitivity analysis limited to patients with grade 3 hepatitis, hospitalization was also not associated with time to ALT normalization (HR, 1.11; 95% CI, 0.83-1.50; P = .474) or time to ALT ≤100 U/L (HR, 1.19; 95% CI, 0.90-1.58; P = .225). In a subgroup analysis of 152 patients with melanoma, hospitalization was not associated with reduced risk of all-cause death (HR, 0.93; 95% CI, 0.53-1.64; P = .798). Notably, despite their Common Terminology Criteria for Adverse Events classification of high-grade hepatitis, 94% of patients had "mild" liver injury based on International Drug-Induced Liver Injury Criteria. CONCLUSIONS Hospitalization of patients with high-grade ICI hepatitis was not associated with faster hepatitis resolution and did not affect mortality. Routine hospitalization may not be necessary in all patients with high-grade ICI hepatitis and Common Terminology Criteria for Adverse Events criteria may overestimate severity of liver injury.
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Affiliation(s)
- Michael Li
- Division of Gastroenterology and Hepatology, University of California, San Francisco, San Francisco, California.
| | - Danny Wong
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham & Women's Hospital, Boston, Massachusetts
| | - Jordan S Sack
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham & Women's Hospital, Boston, Massachusetts
| | - Alexander S Vogel
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham & Women's Hospital, Boston, Massachusetts
| | - F Stephen Hodi
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Lawrence Fong
- Division of Hematology/Oncology, University of California, San Francisco, San Francisco, California
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, University of California, San Francisco, San Francisco, California
| | - Stephen D Zucker
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham & Women's Hospital, Boston, Massachusetts
| | - Shilpa Grover
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham & Women's Hospital, Boston, Massachusetts
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Ufere NN, Serper M, Kaplan A, Horick N, Indriolo T, Li L, Satapathy N, Donlan J, Castano Jimenez JC, Lago-Hernandez C, Lieber S, Gonzalez C, Keegan E, Schoener K, Bethea E, Dageforde LA, Yeh H, El-Jawahri A, Park ER, Vodkin I, Schonfeld E, Nipp R, Desai A, Lai JC. Financial burden following adult liver transplantation is common and associated with adverse recipient outcomes. Liver Transpl 2024:01445473-990000000-00333. [PMID: 38353602 DOI: 10.1097/lvt.0000000000000348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 01/31/2024] [Indexed: 03/09/2024]
Abstract
The financial impact of liver transplantation has been underexplored. We aimed to identify associations between high financial burden (≥10% annual income spent on out-of-pocket medical costs) and work productivity, financial distress (coping behaviors in response to the financial burden), and financial toxicity (health-related quality of life, HRQOL) among adult recipients of liver transplant. Between June 2021 and May 2022, we surveyed 207 adult recipients of liver transplant across 5 US transplant centers. Financial burden and distress were measured by 25 items adapted from national surveys of cancer survivors. Participants also completed the Work Productivity and Activity Impairment and EQ-5D-5L HRQOL questionnaires. In total, 23% of recipients reported high financial burden which was significantly associated with higher daily activity impairment (32.9% vs. 23.3%, p =0.048). In adjusted analyses, the high financial burden was significantly and independently associated with delayed or foregone medical care (adjusted odds ratio, 3.95; 95% CI, 1.85-8.42) and being unable to afford basic necessities (adjusted odds ratio, 5.12; 95% CI: 1.61-16.37). Recipients experiencing high financial burden had significantly lower self-reported HRQOL as measured by the EQ-5D-5L compared to recipients with low financial burden (67.8 vs. 76.1, p =0.008) and an age-matched and sex-matched US general population (67.8 vs. 79.1, p <0.001). In this multicenter cohort study, nearly 1 in 4 adult recipients of liver transplant experienced a high financial burden, which was significantly associated with delayed or foregone medical care and lower self-reported HRQOL. These findings underscore the need to evaluate and address the financial burden in this population before and after transplantation.
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Affiliation(s)
- Nneka N Ufere
- Department of Medicine, Gastrointestinal Division, Liver Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Marina Serper
- Department of Medicine, Division of Gastroenterology & Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Alyson Kaplan
- Department of Medicine, Tufts Abdominal Transplant Institute, Tufts University Medical Center, Boston, Massachusetts, USA
| | - Nora Horick
- Department of Statistics, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Teresa Indriolo
- Department of Medicine, Gastrointestinal Division, Liver Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lucinda Li
- Department of Medicine, Gastrointestinal Division, Liver Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nishant Satapathy
- University of Arizona College of Medicine-Phoenix, Phoenix, Arizona, USA
| | - John Donlan
- Harvard Medical School, Boston, Massachusetts, USA
| | - Janeth C Castano Jimenez
- Department of Medicine, Division of Gastroenterology & Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Carlos Lago-Hernandez
- Department of Medicine, Division of Hospital Medicine, University of California San Diego, La Jolla, California, USA
| | - Sarah Lieber
- Department of Medicine, Division of Digestive and Liver Diseases, University of Texas Southwestern (UTSW) Medical Center, Dallas, Texas, USA
| | - Carolina Gonzalez
- Department of Social Service, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Eileen Keegan
- Department of Social Service, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kimberly Schoener
- Department of Social Service, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Emily Bethea
- Department of Medicine, Gastrointestinal Division, Liver Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Leigh-Anne Dageforde
- Department of Surgery, Division of Transplantation, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Heidi Yeh
- Department of Surgery, Division of Transplantation, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Areej El-Jawahri
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Elyse R Park
- Department of Psychiatry, Mongan Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Irine Vodkin
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California, San Diego, California, USA
| | - Emily Schonfeld
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Ryan Nipp
- Department of Medicine, University of Oklahoma Health Sciences Center, Stephenson Cancer Center, Oklahoma City, Oklahoma, USA
| | - Archita Desai
- Department of Medicine, Division of Gastroenterology & Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jennifer C Lai
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, California, USA
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Shifman HP, Huang CY, Beck AF, Bucuvalas J, Perito ER, Hsu EK, Ebel NH, Lai JC, Wadhwani SI. Association of state Medicaid expansion policies with pediatric liver transplant outcomes. Am J Transplant 2024; 24:239-249. [PMID: 37776976 PMCID: PMC10843745 DOI: 10.1016/j.ajt.2023.09.017] [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: 03/19/2023] [Revised: 08/22/2023] [Accepted: 09/14/2023] [Indexed: 10/02/2023]
Abstract
Children from minoritized/socioeconomically deprived backgrounds suffer disproportionately high rates of uninsurance and graft failure/death after liver transplant. Medicaid expansion was developed to expand access to public insurance. Our objective was to characterize the impact of Medicaid expansion policies on long-term graft/patient survival after pediatric liver transplantation. All pediatric patients (<19 years) who received a liver transplant between January 1, 2005, and December 31, 2020 in the US were identified in the Scientific Registry of Transplant Recipients (N = 8489). Medicaid expansion was modeled as a time-varying exposure based on transplant and expansion dates. We used Cox proportional hazards models to evaluate the impact of Medicaid expansion on a composite outcome of graft failure/death over 10 years. As a sensitivity analysis, we conducted an intention-to-treat analysis from time of waitlisting to death (N = 1 1901). In multivariable analysis, Medicaid expansion was associated with a 30% decreased hazard of graft failure/death (hazard ratio, 0.70; 95% confidence interval, 0.62, 0.79; P < .001) after adjusting for Black race, public insurance, neighborhood deprivation, and living in a primary care shortage area. In intention-to-treat analyses, Medicaid expansion was associated with a 72% decreased hazard of patient death (hazard ratio, 0.28; 95% confidence interval, 0.23-0.35; P < .001). Policies that enable broader health insurance access may help improve outcomes and reduce disparities for children undergoing liver transplantation.
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Affiliation(s)
- Holly Payton Shifman
- Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
| | - Chiung-Yu Huang
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Andrew F Beck
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA
| | - John Bucuvalas
- Division of Pediatric Hepatology, Department of Pediatrics Icahn School of Medicine at Mount Sinai, New York, New York, USA; Division of Pediatric Hepatology, Department of Pediatrics, Kravis Children's Hospital, New York, New York, USA
| | - Emily R Perito
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
| | - Evelyn K Hsu
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Noelle H Ebel
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children's Hospital, Stanford, California, USA
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Sharad I Wadhwani
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA.
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21
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Thuluvath AJ, Duarte-Rojo A, Lai JC, Peipert J, Dietch ZC, Siddiqui O, Morrissey S, Belfanti K, Zhao L, Guo K, Nizamuddin M, Polineni P, Levitsky J, Flores AM, Ladner DP. Brief PROMIS Assessment Screens for Frailty and Predicts Hospitalizations in Liver Transplant Candidates. Transplantation 2024; 108:491-497. [PMID: 37496147 DOI: 10.1097/tp.0000000000004741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
BACKGROUND Frailty is prevalent in patients with end-stage liver disease and predicts waitlist mortality, posttransplant mortality, and frequency of hospitalizations. The Liver Frailty Index (LFI) is a validated measure of frailty in liver transplant (LT) candidates but requires an in-person assessment. METHODS We studied the association between patient-reported physical function and LFI in a single-center prospective study of adult patients with cirrhosis undergoing LT evaluation from October 2020 to December 2021. Frailty was assessed with the LFI and 4-m gait speed. Patient-reported physical function was evaluated using a brief Patient-Reported Outcomes Measurement Information System (PROMIS) survey. RESULTS Eighty-one LT candidates were enrolled, with a mean model of end-stage liver disease-sodium of 17.6 (±6.3). The mean LFI was 3.7 (±0.77; 15% frail and 59% prefrail) and the mean PROMIS Physical Function score was 45 (±8.6). PROMIS Physical Function correlated with LFI ( r = -0.54, P < 0.001) and 4-m gait speed ( r = 0.48, P < 0.001). The mean hospitalization rate was 1.1 d admitted per month. After adjusting for age, sex, and model of end-stage liver disease-sodium, patient-reported physical function-predicted hospitalization rate ( P = 0.001). CONCLUSIONS This study suggests that a brief patient-reported outcome measure can be used to screen for frailty and predict hospitalizations in patients with cirrhosis.
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Affiliation(s)
- Avesh J Thuluvath
- Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Andres Duarte-Rojo
- Division of Gastroenterology and Hepatology, Starzl Transplantation Institute, and Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, PA
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, CA
| | - John Peipert
- Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Zachary C Dietch
- Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Division of Transplant, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Osama Siddiqui
- Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Sheila Morrissey
- Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Department of Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Kimberly Belfanti
- Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Department of Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Lihui Zhao
- Department of Preventive Medicine, Biostatistics Collaboration Center, Northwestern Medicine, Chicago, IL
| | - Kexin Guo
- Department of Preventive Medicine, Biostatistics Collaboration Center, Northwestern Medicine, Chicago, IL
| | - Mohammad Nizamuddin
- Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Praneet Polineni
- Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Josh Levitsky
- Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Ann-Marie Flores
- Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Department of Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Cancer Survivorship Institute, Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL
| | - Daniela P Ladner
- Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Division of Transplant, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
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22
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Gutierrez SA, Pathak S, Raghu V, Shui A, Huang CY, Rhee S, McKenzie-Sampson S, Lai JC, Wadhwani SI. Neighborhood Income Is Associated with Health Care Use in Pediatric Short Bowel Syndrome. J Pediatr 2024; 265:113819. [PMID: 37940084 PMCID: PMC10847979 DOI: 10.1016/j.jpeds.2023.113819] [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: 07/25/2023] [Revised: 09/27/2023] [Accepted: 11/01/2023] [Indexed: 11/10/2023]
Abstract
OBJECTIVE To evaluate associations between neighborhood income and burden of hospitalizations for children with short bowel syndrome (SBS). STUDY DESIGN We used the Pediatric Health Information System (PHIS) database to evaluate associations between neighborhood income and hospital readmissions, readmissions for central line-associated bloodstream infections (CLABSI), and hospital length of stay (LOS) for patients <18 years with SBS hospitalized between January 1, 2006, and October 1, 2015. We analyzed readmissions with recurrent event analysis and analyzed LOS with linear mixed effects modeling. We used a conceptual model to guide our multivariable analyses, adjusting for race, ethnicity, and insurance status. RESULTS We included 4289 children with 16 347 hospitalizations from 43 institutions. Fifty-seven percent of the children were male, 21% were Black, 19% were Hispanic, and 67% had public insurance. In univariable analysis, children from low-income neighborhoods had a 38% increased risk for all-cause hospitalizations (rate ratio [RR] 1.38, 95% CI 1.10-1.72, P = .01), an 83% increased risk for CLABSI hospitalizations (RR 1.83, 95% CI 1.37-2.44, P < .001), and increased hospital LOS (β 0.15, 95% CI 0.01-0.29, P = .04). In multivariable analysis, the association between low-income neighborhoods and elevated risk for CLABSI hospitalizations persisted (RR 1.70, 95% CI 1.23-2.35, P < .01, respectively). CONCLUSIONS Children with SBS from low-income neighborhoods are at increased risk for hospitalizations due to CLABSI. Examination of specific household- and neighborhood-level factors contributing to this disparity may inform equity-based interventions.
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Affiliation(s)
- Susan A Gutierrez
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA
| | - Sagar Pathak
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA
| | - Vikram Raghu
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA
| | - Amy Shui
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Chiung-Yu Huang
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Sue Rhee
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA
| | - Safyer McKenzie-Sampson
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Jennifer C Lai
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Sharad I Wadhwani
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA.
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23
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Teles MS, Ruck JM, Jefferis A, Helmy S, Oh ES, Murriel EC, Lai JC, King EA. A pragmatic tool to screen for pre-transplant cognitive impairment among potential candidates for liver transplant. Clin Transplant 2024; 38:e15232. [PMID: 38289890 DOI: 10.1111/ctr.15232] [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: 05/23/2023] [Revised: 12/01/2023] [Accepted: 12/10/2023] [Indexed: 02/01/2024]
Abstract
INTRODUCTION Cognitive impairment (CI) among liver transplant (LT) candidates is associated with increased risk of waitlist mortality and inferior outcomes. While formal neurocognitive evaluation is the gold standard for CI diagnosis, the Montreal Cognitive Assessment (MoCA) is often used for first-line cognitive screening. However, MoCA requires specialized training and may be too lengthy for a busy evaluation appointment. An alternate approach may be the Quick Dementia Rating System (QDRS), which is patient- and informant-based and can be administered quickly. We compared potential LT candidates identified by MoCA and QDRS as potentially benefiting from further formal cognitive evaluation. METHODS We identified 46 potential LT candidates enrolled at a single center of a prospective, observational cohort study who were administered MoCA and QDRS during transplant evaluation (12/2021-12/2022). Scores were dichotomized as (1) normal versus abnormal and (2) normal/mild impairment versus more-than-mild impairment. We calculated sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of QDRS compared to MoCA. RESULTS By MoCA, this population had a prevalence of 48% normal cognition, 48% mild, 4% moderate, and 0% severe impairment. This was categorized as 96% normal/mild and 4% more-than-mild impairment. When comparing to MoCA cognitive screening, QDRS had a sensitivity of 61%, specificity of 56%, NPV of 56%, and PPV of 61%. When identifying more-than-mild impairment, QDRS had a sensitivity of 100%, specificity of 73%, NPV of 100%, and PPV of 10%. CONCLUSION The high sensitivity and NPV of QDRS in identifying more-than-mild impairment suggests it could identify potential LT candidates who would benefit from further formal cognitive evaluation. The ability to administer QDRS quickly and remotely makes it a pragmatic option for pre-transplant screening.
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Affiliation(s)
- Mayan S Teles
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jessica M Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Alexa Jefferis
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sherif Helmy
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Esther S Oh
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Emily C Murriel
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jennifer C Lai
- Department of Medicine, University of California San Francisco Medical Center, San Francisco, California, USA
| | - Elizabeth A King
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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24
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Wang M, Shui AM, Ruck J, King E, Rahimi R, Kappus M, Volk ML, Ganger DR, Ladner DP, Duarte-Rojo A, Huang CY, Verna EC, Lai JC. The liver frailty index is a predictor of healthcare utilization after liver transplantation in older adults. Clin Transplant 2024; 38:e15219. [PMID: 38064281 PMCID: PMC11042074 DOI: 10.1111/ctr.15219] [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: 06/12/2023] [Revised: 11/15/2023] [Accepted: 11/26/2023] [Indexed: 01/31/2024]
Abstract
BACKGROUND Older adults have higher healthcare utilization after liver transplantation (LT), yet objective risk stratification tools in this population are lacking. We evaluated the Liver Frailty Index (LFI) as one potential tool. METHODS Ambulatory LT candidates ≥65 years without hepatocellular carcinoma (HCC) who underwent LT from 1/2012 to 6/2022 at 8 U.S. centers were included. Estimates of the difference in median using quantile regression were used to assess the adjusted association between LFI and hospitalized days within 90 days post-LT. RESULTS Of 131 LT recipients, median (interquartile range [IQR]) (1st -3rd quartiles) age was 68 years (66-70); median pre-LT MELD-Na was 19 (15-24). Median LFI was 4.1 (3.6-4.7); 27% were frail (LFI≥4.5). Median hospitalized days within 90 days post-LT was 11 (7-20). Compared with non-frail patients, frail patients were hospitalized for a median of 5 days longer post-LT (95% CI .30-9.7, p = .04). Each .5 unit increase in pre-LT LFI was associated with an increase of 1.16 days (95%CI .42-2.69, p = .02) in hospitalized days post-LT. CONCLUSION Among older adults undergoing LT, frailty was associated with more hospitalized days within 90 days after LT. The LFI can identify older adults who might benefit from pre-LT or early post-LT programs which may reduce post-LT healthcare utilization, such as early rehabilitation or post-hospital discharge programs.
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Affiliation(s)
- Melinda Wang
- Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Amy M. Shui
- Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, California, USA
| | - Jessica Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth King
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Robert Rahimi
- Division of Gastroenterology and Hepatology, Department of Medicine, Baylor Scott and White Health, Dallas, Texas, USA
| | - Matthew Kappus
- Division of Gastroenterology, Department of Medicine, Duke University Hospital, Durham, North Carolina, USA
| | - Michael L. Volk
- Division of Gastroenterology and Nutrition, Department of Medicine, Loma Linda University, Loma Linda, California, USA
| | - Daniel R. Ganger
- Division of Gastroenterology and Nutrition, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Daniela P. Ladner
- Division of Organ Transplantation, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Andres Duarte-Rojo
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Chiung-Yu Huang
- Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, California, USA
| | - Elizabeth C. Verna
- Center for Liver Division of Digestive and Liver Diseases, Diseases and Transplantation, Columbia University Medical Center, New York, New York, USA
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
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25
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Berry K, Ruck JM, Barry F, Shui AM, Cortella A, Kent D, Seetharaman S, Wong R, VandeVrede L, Lai JC. Prevalence of cognitive impairment in liver transplant recipients. Clin Transplant 2024; 38:e15229. [PMID: 38113284 PMCID: PMC10842727 DOI: 10.1111/ctr.15229] [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: 08/30/2023] [Revised: 11/06/2023] [Accepted: 12/10/2023] [Indexed: 12/21/2023]
Abstract
Liver transplant (LT) recipients have a high burden of cognitive impairment risk factors identified in other populations, yet little work has explored cognition in the United States LT population. We characterized prevalence of cognitive impairment (CI) in LT recipients pre-LT and ≥3 months post-LT. Adult LT recipients with cirrhosis but without active pre-LT hepatic encephalopathy (HE) were screened for CI using the Montreal Cognitive Assessment (MoCA) for CI (MoCA <24) both pre-LT and ≥3 months post-LT. The association between cognitive performance and recipient characteristics was assessed using logistic regression. Of 107 LT recipients, 36% had pre-LT CI and 27% had post-LT CI [median (Q1-Q3) MoCA 26 (23-28)]. Each 1-point increase in pre-LT MoCA was associated with 26% lower odds of post-LT cognitive impairment (aOR .74, 95% CI .63-.87, p < .001), after adjusting for recipient age, history of HE, and time since LT. In this study of cirrhosis recipients without active pre-LT HE, cognitive impairment was prevalent before LT and remained prevalent ≥3 months after LT (27%), long after effects of portal hypertension on cognition would be expected to have resolved. Our data expose an urgent need for more comprehensive neurologic examination of LT recipients to better identify, characterize, and address predictors of post-LT cognitive impairment.
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Affiliation(s)
- Kacey Berry
- Memory and Aging Center, Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Jessica M Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Fawzy Barry
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, California, USA
| | - Amy M Shui
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, California, USA
| | - Aly Cortella
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, California, USA
| | - Dorothea Kent
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, California, USA
| | - Srilakshmi Seetharaman
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, California, USA
| | - Randi Wong
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, California, USA
| | - Lawren VandeVrede
- Memory and Aging Center, Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Jennifer C Lai
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, California, USA
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26
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Ruck JM, Shui AM, Jefferis AA, Rojo AD, Rahimi RS, Ganger DR, Verna EC, Kappus M, Ladner DP, Segev DL, Volk M, Tevar A, King EA, Lai JC. Association of body mass index with post-liver transplant outcomes. Clin Transplant 2024; 38:e15205. [PMID: 38041450 PMCID: PMC10918560 DOI: 10.1111/ctr.15205] [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: 02/24/2023] [Revised: 08/18/2023] [Accepted: 11/19/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND Patients with obesity have inferior outcomes after general surgery procedures, but studies evaluating post-liver transplant (LT) outcomes have been limited by small sample sizes or lack of granularity of outcomes. We evaluated the relationship between obesity and post-LT outcomes, including those observed in other populations to be obesity-related. METHODS Included were 1357 LT recipients prospectively enrolled in the ambulatory pre-LT setting at 8 U.S. CENTERS Recipient were categorized by body mass index (BMI, kg/m2 ): non-obese (BMI < 30), class 1 obesity (BMI 30-<35), and classes 2-3 obesity (BMI ≥ 35). Post-transplant complications were compared by BMI using Chi-square and rank-sum testing, logistic regression, Kaplan-Meier curves, and Cox regression. RESULTS Classes 2-3 obesity was associated with higher adjusted odds than non-obesity of venous thrombosis [adjusted odds ratio (aOR) 2.06, 95% CI 1.01-4.23, p = .047] and wound dehiscence (aOR 2.45, 95% CI 1.19-5.06, p = .02). Compared with non-obese recipients, post-LT hospital stay was significantly longer for recipients with classes 2-3 obesity [p = .01; median (Q1-Q3) 9 (6-14) vs. 8 (6-12) days) or class 1 obesity [p = .002; 9 (6-14) vs. 8 (6-11) days]. Likelihood of ICU readmission, infection, discharge to a non-home facility, rejection, 30-day readmission, and 1-year readmission were similar across BMI categories (all p > .05). CONCLUSION Compared to non-obese recipients, obese recipients had similar post-LT survival but longer hospital stay and higher likelihood of wound dehiscence and venous thrombosis. These findings underscore that obesity alone should not preclude LT, but recipients with obesity should be monitored for obesity-related complications such as wound dehiscence and venous thrombosis.
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Affiliation(s)
- Jessica M. Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Amy M. Shui
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Alexis A. Jefferis
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Andres Duarte Rojo
- Center for Liver Diseases, Thomas A. Starzl Transplantation Institute, Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Robert S. Rahimi
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Baylor Scott and White Health, Dallas, Texas, USA
| | - Daniel R. Ganger
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern Medicine, Chicago, Illinois, USA
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Elizabeth C. Verna
- Center for Liver Disease and Transplantation, Columbia University Irving Medical Center, New York, New York, USA
| | - Matthew Kappus
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Daniela P. Ladner
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Division of Transplantation, Department of Surgery, Northwestern Medicine, Chicago, Illinois, USA
| | - Dorry L. Segev
- Department of Surgery, New York University Grossman School of Medicine and Langone Health, New York, New York, USA
- Department of Population Health, New York University Grossman School of Medicine and Langone Health, New York, New York, USA
| | - Michael Volk
- Division of Gastroenterology & Hepatology, and Transplantation Institute, Loma Linda University Health, Loma Linda, California, USA
| | - Amit Tevar
- Department of Medicine, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Elizabeth A. King
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jennifer C. Lai
- Department of Medicine, University of California San Francisco School of Medicine, San Francisco, California, USA
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27
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Cullaro G, Ge J, Lee BP, Lai JC, Wadhwani SI. Association between neighborhood-based material deprivation and liver transplant waitlist registrants demographics and mortality. Clin Transplant 2024; 38:e15189. [PMID: 37937349 PMCID: PMC10842435 DOI: 10.1111/ctr.15189] [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: 04/24/2023] [Revised: 09/29/2023] [Accepted: 10/28/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND & AIMS Liver transplantation for alcohol-related liver disease (ARLD) has increased. We examined temporal trends in ARLD listing practices by neighborhood deprivation and evaluated the impact of neighborhood deprivation on waitlist mortality. METHODS We included all adults > 18 years listed 2008-2019 in the UNOS registry. Our primary exposure was the neighborhood socioeconomic deprivation index based on patients' listing zip codes. We determined temporal trends in an ARLD listing diagnosis. We modeled ARLD listing diagnosis using logistic regression and waitlist mortality using Cox proportional hazards models. RESULTS The waitlist contained an increasing proportion of patients listed with ARLD over the study period; however, this rate increased the least for patients from the most deprived tertile (p < .001). Patients from the most deprived tertile were the least likely to be listed with ARLD (OR: .97, 95CI: .95-.98). In our adjusted model, patients from the most deprived tertile had an increased hazard of waitlist mortality (OR: 1.10, 95CI: 1.06-1.14). CONCLUSION Neighborhood deprivation was associated with a decreased likelihood of being listed with ARLD, suggesting that transplant for ARLD is inequitably available. The increased mortality associated with neighborhood deprivation demands future work to uncover the underlying reasons for this disparity.
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Affiliation(s)
- Giuseppe Cullaro
- Division of Gastroenterology, University of California, San Francisco, CA, USA
| | - Jin Ge
- Division of Gastroenterology, University of California, San Francisco, CA, USA
| | - Brian P Lee
- Division of Gastroenterology and Liver Diseases, University of Southern California, Los Angeles, CA, USA
| | - Jennifer C. Lai
- Division of Gastroenterology, University of California, San Francisco, CA, USA
| | - Sharad I Wadhwani
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
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28
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Wadhwani SI, Alvarado A, Shifman HP, Bautista B, Yalung J, Squires JE, Campbell K, Ebel NH, Hsu E, Vittorio J, Zielsdorf S, Desai DM, Bucuvalas JC, Gottlieb L, Kotagal U, Lyles CR, Ackerman SL, Lai JC. Caregivers' and providers' perspectives of social and medical care after pediatric liver transplant: Results from the multicenter SOCIAL-Tx study. Liver Transpl 2023:01445473-990000000-00310. [PMID: 38166123 DOI: 10.1097/lvt.0000000000000327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 12/12/2023] [Indexed: 01/04/2024]
Abstract
Disparities exist in pediatric liver transplant (LT). We characterized barriers and facilitators to providing transplant and social care within pediatric LT clinics. This was a multicenter qualitative study. We oversampled caregivers reporting household financial strain, material economic hardship, or demonstrating poor health literacy. We also enrolled transplant team members. We conducted semistructured interviews with participants. Caregiver interviews focused on challenges addressing transplant and household needs. Transplant provider interviews focused on barriers and facilitators to providing social care within transplant teams. Interviews were recorded, transcribed, and coded according to the Capability, Opportunity, Motivation-Behavior model. We interviewed 27 caregivers and 27 transplant team members. Fifty-two percent of caregivers reported a household income <$60,000, and 62% reported financial resource strain. Caregivers reported experiencing (1) high financial burdens after LT, (2) added caregiving labor that compounds the financial burden, (3) dependency on their social network's generosity for financial and logistical support, and (4) additional support being limited to the perioperative period. Transplant providers reported (1) relying on the pretransplant psychosocial assessment for identifying social risks, (2) discomfort initiating social risk discussions in the post-transplant period, (3) reliance on social workers to address new social risks, and (4) social workers feeling overburdened by quantity and quality of the social work referrals. We identified barriers to providing effective social care in pediatric LT, primarily a lack of comfort in assessing and addressing new social risks in the post-transplant period. Addressing these barriers should enhance social care delivery and improve outcomes for these children.
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Affiliation(s)
- Sharad I Wadhwani
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
| | - Alejandra Alvarado
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
| | - Holly P Shifman
- Oakland University Beaumont School of Medicine, Rochester, Michigan, USA
| | - Bethany Bautista
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
| | - Jared Yalung
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
| | - James E Squires
- Department of Pediatrics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kathleen Campbell
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Noelle H Ebel
- Department of Pediatrics, Stanford University, Stanford, California, USA
| | - Evelyn Hsu
- Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington, USA
| | - Jennifer Vittorio
- Department of Pediatrics, Columbia University Medical Center, New York, New York, USA
- Department of Pediatrics, New York University Langone Health, New York, New York, USA
| | - Shannon Zielsdorf
- Department of Surgery, Children's Hospital of Los Angeles, Los Angeles, California, USA
| | - Dev M Desai
- Department of Surgery, UT Southwestern Medical Center, Dallas, Texas, USA
| | - John C Bucuvalas
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Laura Gottlieb
- Department of Family & Community Medicine, San Francisco, San Francisco, California, USA
| | - Uma Kotagal
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Courtney R Lyles
- Department of Medicine, San Francisco, San Francisco, California, USA
| | - Sara L Ackerman
- Department of Social & Behavioral Sciences, San Francisco, San Francisco, California, USA
| | - Jennifer C Lai
- Department of Medicine, San Francisco, San Francisco, California, USA
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Tapper EB, Lai JC. Time to embrace PROMIS-29 as the standard health-related quality of life instrument for patients with cirrhosis. Hepatology 2023; 78:1688-1691. [PMID: 37278246 PMCID: PMC10700645 DOI: 10.1097/hep.0000000000000508] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 05/31/2023] [Indexed: 06/07/2023]
Affiliation(s)
- Elliot B. Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, San Francisco
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, University of California, San Francisco
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Ge J, Digitale JC, Fenton C, McCulloch CE, Lai JC, Pletcher MJ, Gennatas ED. Predicting post-liver transplant outcomes in patients with acute-on-chronic liver failure using Expert-Augmented Machine Learning. Am J Transplant 2023; 23:1908-1921. [PMID: 37652176 PMCID: PMC11018271 DOI: 10.1016/j.ajt.2023.08.022] [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: 03/03/2023] [Revised: 08/04/2023] [Accepted: 08/25/2023] [Indexed: 09/01/2023]
Abstract
Liver transplantation (LT) is a treatment for acute-on-chronic liver failure (ACLF), but high post-LT mortality has been reported. Existing post-LT models in ACLF have been limited. We developed an Expert-Augmented Machine Learning (EAML) model to predict post-LT outcomes. We identified ACLF patients who underwent LT in the University of California Health Data Warehouse. We applied the RuleFit machine learning (ML) algorithm to extract rules from decision trees and create intermediate models. We asked human experts to rate the rules generated by RuleFit and incorporated these ratings to generate final EAML models. We identified 1384 ACLF patients. For death at 1 year, areas under the receiver-operating characteristic curve were 0.707 (confidence interval [CI] 0.625-0.793) for EAML and 0.719 (CI 0.640-0.800) for RuleFit. For death at 90 days, areas under the receiver-operating characteristic curve were 0.678 (CI 0.581-0.776) for EAML and 0.707 (CI 0.615-0.800) for RuleFit. In pairwise comparisons, both EAML and RuleFit models outperformed cross-sectional models. Significant discrepancies between experts and ML occurred in rankings of biomarkers used in clinical practice. EAML may serve as a method for ML-guided hypothesis generation in further ACLF research.
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Affiliation(s)
- Jin Ge
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA.
| | - Jean C Digitale
- Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, California, USA
| | - Cynthia Fenton
- Division of Hospital Medicine, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, California, USA
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Mark J Pletcher
- Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, California, USA
| | - Efstathios D Gennatas
- Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, California, USA
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Ge J, Sun S, Owens J, Galvez V, Gologorskaya O, Lai JC, Pletcher MJ, Lai K. Development of a Liver Disease-Specific Large Language Model Chat Interface using Retrieval Augmented Generation. medRxiv 2023:2023.11.10.23298364. [PMID: 37986764 PMCID: PMC10659484 DOI: 10.1101/2023.11.10.23298364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
Background Large language models (LLMs) have significant capabilities in clinical information processing tasks. Commercially available LLMs, however, are not optimized for clinical uses and are prone to generating incorrect or hallucinatory information. Retrieval-augmented generation (RAG) is an enterprise architecture that allows embedding of customized data into LLMs. This approach "specializes" the LLMs and is thought to reduce hallucinations. Methods We developed "LiVersa," a liver disease-specific LLM, by using our institution's protected health information (PHI)-complaint text embedding and LLM platform, "Versa." We conducted RAG on 30 publicly available American Association for the Study of Liver Diseases (AASLD) guidelines and guidance documents to be incorporated into LiVersa. We evaluated LiVersa's performance by comparing its responses versus those of trainees from a previously published knowledge assessment study regarding hepatitis B (HBV) treatment and hepatocellular carcinoma (HCC) surveillance. Results LiVersa answered all 10 questions correctly when forced to provide a "yes" or "no" answer. Full detailed responses with justifications and rationales, however, were not completely correct for three of the questions. Discussions In this study, we demonstrated the ability to build disease-specific and PHI-compliant LLMs using RAG. While our LLM, LiVersa, demonstrated more specificity in answering questions related to clinical hepatology - there were some knowledge deficiencies due to limitations set by the number and types of documents used for RAG. The LiVersa prototype, however, is a proof of concept for utilizing RAG to customize LLMs for clinical uses and a potential strategy to realize personalized medicine in the future.
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Affiliation(s)
- Jin Ge
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California – San Francisco, San Francisco, CA
| | - Steve Sun
- UCSF Health Information Technology, University of California – San Francisco, San Francisco, CA
| | - Joseph Owens
- UCSF Health Information Technology, University of California – San Francisco, San Francisco, CA
| | - Victor Galvez
- UCSF Health Information Technology, University of California – San Francisco, San Francisco, CA
| | - Oksana Gologorskaya
- UCSF Health Information Technology, University of California – San Francisco, San Francisco, CA
- Bakar Computational Health Sciences Institute, University of California – San Francisco, San Francisco, CA
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California – San Francisco, San Francisco, CA
| | - Mark J. Pletcher
- Department of Epidemiology and Biostatistics, University of California – San Francisco, San Francisco, CA
| | - Ki Lai
- UCSF Health Information Technology, University of California – San Francisco, San Francisco, CA
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Sheshadri A, Lai M, Hsu FC, Bauer SR, Chen SH, Tse W, Jotwani V, Tranah GJ, Lai JC, Hallan S, Fielding RA, Liu C, Ix JH, Coca SG, Shlipak MG. Structured Moderate Exercise and Biomarkers of Kidney Health in Sedentary Older Adults: The Lifestyle Interventions and Independence for Elders Randomized Clinical Trial. Kidney Med 2023; 5:100721. [PMID: 37915963 PMCID: PMC10616412 DOI: 10.1016/j.xkme.2023.100721] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023] Open
Abstract
Rationale & Objective In the Lifestyle Interventions and Independence for Elders (LIFE) trial, a structured exercise intervention slowed kidney function decline in sedentary older adults. Biomarkers of kidney health could distinguish potential mechanisms for this beneficial effect. Study Design Randomized controlled trial. Setting & Population A total of 1,381 sedentary adults aged 70-89 years enrolled in the LIFE trial. Intervention Structured, 2-year, moderate-intensity exercise intervention versus health education. Outcomes Physical activity was measured by step count. Primary outcomes were changes in 14 serum and urine biomarkers of kidney health collected at baseline, year 1, and year 2. We determined the effect of randomization on changes in kidney measures and then evaluated observational associations of achieved activity on each measure. Results Participants assigned to exercise walked on average 291 more steps per day than participants assigned to health education. The intervention was not significantly associated with changes in biomarkers of kidney health. In observational analyses, persons in the highest versus lowest quartile of activity (≥3,470 vs <1,568 steps/day) had significant improvement in urine albumin (mean, -0.22 mg albumin/g urine creatinine [interquartile range (IQR), -0.37 to -0.06]), alpha-1-microglobulin (-0.18 mg/L [-0.28 to -0.08]), trefoil factor-3 (-0.24 pg/mL [-0.35 to -0.13]), epidermal growth factor (0.19 pg/mL [0.06-0.32]), uromodulin (0.06 pg/mL [0.00-0.12]), interleukin 18 (-0.09 pg/mL [-0.15 to -0.03]), neutrophil gelatinase-associated lipocalin (-0.16 pg/mL [-0.24 to -0.07]), monocyte chemoattractant protein-1 (-0.25 pg/mL [-0.36 to -0.14]), clusterin (-0.16 pg/mL [-0.30 to -0.02]), serum tumor necrosis factor receptor-1 (-0.25 mg/dL [-0.39 to -0.11]) and tumor necrosis factor receptor-2 (-0.30 mg/dL [-0.44 to -0.16]). In sensitivity analyses, incremental changes in activity were most impactful on urine interleukin 18 and serum tumor necrosis factor-1. Limitations The original study was not designed to assess the impact on kidney health. Non-white individuals and patients with advanced chronic kidney disease are underrepresented. Conclusions Randomization to structured exercise did not improve kidney health at a group level. However, higher exercise was associated with concurrent improvements in biomarkers of glomerular injury, tubular function/repair, tubular injury, generalized inflammation, and tubulointerstitial repair/fibrosis. Plain-Language Summary In the Lifestyle Interventions For Elders (LIFE) study, randomization to an exercise and physical activity intervention improved the slope of estimated glomerular filtration rate over 2 years compared with health education among older adults. In this study, we sought to determine whether there were specific biomarkers of kidney health that were affected by the exercise and physical activity intervention to investigate potential mechanisms for this positive impact on kidney decline. We found that randomization to the intervention did not improve any of the 14 measures of kidney tubule health. However, in observational analyses, higher activity was independently associated with improvements in several domains, especially tubular injury and generalized inflammation. These results help to clarify the impact of physical activity on kidney health.
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Affiliation(s)
- Anoop Sheshadri
- Department of Medicine, University of California San Francisco, San Francisco, CA
- Department of Medicine, San Francisco VA Health Care System, San Francisco, CA
| | - Mason Lai
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Fang-Chi Hsu
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Scott R. Bauer
- Department of Medicine, University of California San Francisco, San Francisco, CA
- Department of Medicine, San Francisco VA Health Care System, San Francisco, CA
| | - Shyh-Huei Chen
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Warren Tse
- Department of Medicine, San Francisco VA Health Care System, San Francisco, CA
| | - Vasantha Jotwani
- Department of Medicine, University of California San Francisco, San Francisco, CA
- Department of Medicine, San Francisco VA Health Care System, San Francisco, CA
| | | | - Jennifer C. Lai
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Stein Hallan
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Roger A. Fielding
- Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University, Boston, MA
| | - Christine Liu
- Department of Medicine, Stanford University School of Medicine, Stanford, CA
- Geriatric Research Education and Clinical Center, Palo Alto VA Health Care System, Palo Alto, CA
| | - Joachim H. Ix
- Department of Medicine, University of California San Diego, La Jolla, CA
| | - Steven G. Coca
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michael G. Shlipak
- Department of Medicine, University of California San Francisco, San Francisco, CA
- Department of Medicine, San Francisco VA Health Care System, San Francisco, CA
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Ge J, Digitale JC, Pletcher MJ, Lai JC. Reply: What is the actual role of decompensated cirrhosis in the breakthrough SARS-CoV-2 infection? Hepatology 2023; 78:E78-E79. [PMID: 37459558 DOI: 10.1097/hep.0000000000000536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 06/27/2023] [Indexed: 09/10/2023]
Affiliation(s)
- Jin Ge
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California, San Francisco, San Francisco, California, USA
| | - Jean C Digitale
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Mark J Pletcher
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
- Department of Medicine, Division of General Internal Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Jennifer C Lai
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California, San Francisco, San Francisco, California, USA
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Lai M, Fenton C, Ge J, Rubin J, Lai JC, Cullaro G. Nonselective beta-blockers may lead to stage 2 acute kidney injury and waitlist mortality in child class C cirrhosis. Hepatol Commun 2023; 7:e0255. [PMID: 37756037 PMCID: PMC10531476 DOI: 10.1097/hc9.0000000000000255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 07/21/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND AND AIMS Nonselective beta-blockers (NSBB) protect patients with compensated cirrhosis; however, it is unclear if NSBB is associated with acute kidney injury (AKI) in patients with decompensated cirrhosis. We aimed to determine if the use of NSBB was associated with an increased risk of stage II AKI or greater and waitlist mortality (WLM) among patients with decompensated cirrhosis awaiting liver transplant stratified by cirrhosis severity. METHODS Included were 1816 outpatients listed for liver transplantation at UCSF from June 2012 to April 2022. Our primary outcome was stage 2 AKI (>200% increase in serum creatinine). Our secondary outcome was WLM (all-cause mortality). Our primary exposure was the use of any NSBB derived using natural language processing of clinical notes. Multivariable Cox proportional hazards models with time-dependent variables were used to determine the HR of NSBB use on stage 2 AKI and WLM, stratified by Child-Pugh Score. RESULTS The average age of the cohort was 58 years old, with 35% identifying as female. In multivariable time-dependent models, NSBB use was associated with 1.53 × (95 CI 1.19-1.97) the hazard of stage 2 AKI in the cohort overall and 1.80 × (95 CI 1.26-2.57) among those with Child C cirrhosis, respectively. Similarly, NSBB use was associated with 1.30 × (95 CI 1.07-1.59) and 1.45 × (95 CI 1.03-2.03) the hazard of WLM, overall and in Child C, respectively. NSBB use was not significantly associated with AKI nor WLM among those with Child A. CONCLUSION NSBB use is associated with Stage 2 AKI and WLM in patients awaiting liver transplantation and Child C cirrhosis. These data suggest cautious use of NSBBs in patients in this population.
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Ha NB, Seetharaman S, Kent DS, Yao F, Shui AM, Huang CY, Walston J, Lai JC. Serum and plasma protein biomarkers associated with frailty in patients with cirrhosis. Liver Transpl 2023; 29:1089-1099. [PMID: 36932707 PMCID: PMC10509322 DOI: 10.1097/lvt.0000000000000128] [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: 08/30/2022] [Accepted: 02/23/2023] [Indexed: 03/19/2023]
Abstract
Frailty, a clinical phenotype of decreased physiological reserve, is a strong determinant of adverse health outcomes in patients with cirrhosis. The only cirrhosis-specific frailty metric is the Liver Frailty Index (LFI), which must be administered in person and may not be feasible for every clinical scenario. We sought to discover candidate serum/plasma protein biomarkers that could differentiate frail from robust patients with cirrhosis. A total of 140 adults with cirrhosis awaiting liver transplantation in the ambulatory setting with LFI assessments and available serum/plasma samples were included. We selected 70 pairs of patients on opposite ends of the frailty spectrum (LFI>4.4 for frail and LFI<3.2 for robust) who were matched by age, sex, etiology, HCC, and Model for End-Stage Liver Disease-Sodium. Twenty-five biomarkers with biologically plausible associations with frailty were analyzed using ELISA by a single laboratory. Conditional logistic regression was used to examine their association with frailty. Of the 25 biomarkers analyzed, we identified 7 proteins that were differentially expressed between frail and robust patients. We observed differences in 6 of the 7 proteins in the expected direction: (a) higher median values in frail versus robust with growth differentiation factor-15 (3682 vs. 2249 pg/mL), IL-6 (17.4 vs. 6.4 pg/mL), TNF-alpha receptor 1 (2062 vs. 1627 pg/mL), leucine-rich alpha-2 glycoprotein (44.0 vs. 38.6 μg/mL), and myostatin (4066 vs. 6006 ng/mL) and (b) lower median values in frail versus robust with alpha-2-Heremans-Schmid glycoprotein (0.11 vs. 0.13 mg/mL) and free total testosterone (1.2 vs. 2.4 ng/mL). These biomarkers represent inflammatory, musculoskeletal, and endocrine/metabolic systems, reflecting the multiple physiological derangements observed in frailty. These data lay the foundation for confirmatory work and development of a laboratory frailty index for patients with cirrhosis to improve diagnosis and prognostication.
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Affiliation(s)
- Nghiem B. Ha
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, CA, USA
| | - Srilakshmi Seetharaman
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, CA, USA
| | - Dorothea S. Kent
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, CA, USA
| | - Frederick Yao
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, CA, USA
| | - Amy M. Shui
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Chiung-Yu Huang
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Jeremy Walston
- Division of Geriatric Medicine, Department of Medicine, John Hopkins Medicine, Baltimore, MD, USA
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, CA, USA
- Liver Center, University of California, San Francisco, CA, USA
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Nguyen VV, Wang S, Whitlock R, Xu C, Taneja S, Singh S, Abraldes JG, Burak K, Bailey RJ, Grab JD, Lai JC, Tandon P. A chair-stand time of greater than 15 seconds is associated with an increased risk of death and hospitalization in cirrhosis. Can Liver J 2023; 6:358-362. [PMID: 38020188 PMCID: PMC10652985 DOI: 10.3138/canlivj-2022-0021] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 08/09/2022] [Indexed: 12/01/2023]
Abstract
Background Frailty is a clinical state of increased vulnerability and is common in patients with cirrhosis. The liver frailty index (LFI) is a validated tool to evaluate frailty in cirrhosis, comprising of grip strength, chair stands, and balance tests. The chair-stand test is an easy to conduct frailty subcomponent that does not require specialized equipment and may be valuable to predict adverse clinical outcomes in cirrhosis. The objective of this study was to determine if the chair-stand test is an independent predictor of mortality and hospitalization in cirrhosis. Methods A retrospective review of 787 patients with cirrhosis was conducted. Chair-stand times were collected at baseline in person and divided into three groups: <10 seconds (n = 276), 10-15 seconds (n = 290), and >15 seconds (n = 221). Fine-Gray proportional hazards regression models were used to evaluate the association between chair-stand times and the outcomes of mortality and non-elective hospitalization. Results The hazard of mortality (HR 3.21, 95% CI 2.16%-4.78%, p <0.001) and non-elective hospitalization (HR 2.24, 95% CI 1.73%-2.91%, p <0.001) was increased in group 3 in comparison to group 1. A chair-stand test time >15 seconds had increased all-cause mortality (HR 2.78, 95% CI 2.01%-3.83%, p <0.001) and non-elective hospitalizations (HR 1.84, 95% CI 1.48%-2.29%, p <0.001) compared to <15 seconds. Conclusions A chair-stand test time of >15 seconds is independently associated with mortality and non-elective hospitalizations. This test holds promise as a rapid prognostication tool in cirrhosis. Future work will include external validation and virtual assessment in this population.
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Affiliation(s)
- Vivian V Nguyen
- Department of Medicine, University of Alberta Faculty of Medicine, Edmonton, Alberta, Canada
| | - Sarah Wang
- Division of Gastroen terology and Liver Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Reid Whitlock
- Chronic Disease Innovation Centre, Win- nipeg, Manitoba, Canada
| | - Chelsea Xu
- Department of Medicine, University of California, San Francisco, California, United States
| | - Sunil Taneja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Surender Singh
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Juan G Abraldes
- Division of Gastroen terology and Liver Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Kelly Burak
- Liver Unit, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Robert J Bailey
- Division of Gastroenterol ogy, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Joshua D Grab
- Division of Gastroenterology and Hepatology, University of California, San Francisco, California, United States
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, University of California, San Francisco, California, United States
| | - Puneeta Tandon
- Division of Gastroen terology and Liver Unit, University of Alberta, Edmonton, Alberta, Canada
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Ha NB, Fan B, Seetharaman S, Kent DS, Yao F, Shui AM, Huang C, Wadhwani SI, Lai JC. Variation in skeletal muscle mass among patients with cirrhosis of different self-identified race/ethnicity. JGH Open 2023; 7:724-727. [PMID: 37908292 PMCID: PMC10615169 DOI: 10.1002/jgh3.12976] [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] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 09/10/2023] [Accepted: 09/11/2023] [Indexed: 11/02/2023]
Abstract
Skeletal muscle index (SMI) remains a strong predictor of mortality in cirrhosis patients. However, the extent to which SMI varies by race/ethnicity has not been fully evaluated. Among 317 patients, 55% identified themselves as non-Hispanic White (NHW), 26% Hispanic White (HW), 13% Asian, and 6% Black. There was significant variation in SMI by race/ethnicity; median SMI was lowest in Asian and highest in Black patients. There were significant differences of sarcopenia by race/ethnicity using established SMI cutpoints: 48% NHW, 33% HW, 67% Asian, and 37% Black (P = 0.003). Using these cutpoints, SMI was significantly associated with waitlist mortality only in NHW patients but not in other racial/ethnic groups.
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Affiliation(s)
- Nghiem B Ha
- Division of Gastroenterology and Hepatology, Department of MedicineUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Bo Fan
- Department of Radiology and Biomedical ImagingUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Srilakshmi Seetharaman
- Division of Gastroenterology and Hepatology, Department of MedicineUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Dorothea S Kent
- Division of Gastroenterology and Hepatology, Department of MedicineUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Frederick Yao
- Division of Gastroenterology and Hepatology, Department of MedicineUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Amy M Shui
- Department of Epidemiology and BiostatisticsUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Chiung‐Yu Huang
- Department of Epidemiology and BiostatisticsUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Sharad I. Wadhwani
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Department of PediatricsUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, Department of MedicineUniversity of CaliforniaSan FranciscoCaliforniaUSA
- Liver CenterUniversity of CaliforniaSan FranciscoCaliforniaUSA
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Ge J, Li M, Delk MB, Lai JC. A comparison of large language model versus manual chart review for extraction of data elements from the electronic health record. medRxiv 2023:2023.08.31.23294924. [PMID: 37693398 PMCID: PMC10491368 DOI: 10.1101/2023.08.31.23294924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
Importance Large language models (LLMs) have proven useful for extracting data from publicly available sources, but their uses in clinical settings and with clinical data are unknown. Objective To determine the accuracy of data extraction using "Versa Chat," a chat implementation of the general-purpose OpenAI gpt-35-turbo LLM model, versus manual chart review for hepatocellular carcinoma (HCC) imaging reports. Design We engineered a prompt for the data extraction task of six distinct data elements and input 182 abdominal imaging reports that were also manually tagged. We evaluated performance by calculating accuracy, precision, recall, and F1 scores. Setting/Participants Cross-sectional abdominal imaging reports of patients diagnosed with hepatocellular carcinoma enrolled in the Functional Assessment in Liver Transplantation (FrAILT) study.
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Affiliation(s)
- Jin Ge
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California – San Francisco, San Francisco, CA
| | - Michael Li
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California – San Francisco, San Francisco, CA
| | - Molly B. Delk
- Section of Gastroenterology and Hepatology, Department of Medicine, Tulane University School of Medicine, New Orleans, LA
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California – San Francisco, San Francisco, CA
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Wang M, Auerbach A, Oreper SM, Hohmann SF, Lai JC, Rubin JB. Leveraging a New ICD-10 Diagnosis Code to Characterize Hospitalized Patients With Primary Sclerosing Cholangitis. Clin Gastroenterol Hepatol 2023; 21:2692-2694. [PMID: 36113826 PMCID: PMC10011011 DOI: 10.1016/j.cgh.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Melinda Wang
- Department of Medicine, University of California-San Francisco, San Francisco, California
| | - Andy Auerbach
- Division of Hospital Medicine, Department of Medicine, University of California-San Francisco, San Francisco, California
| | - Sandra M Oreper
- Division of Hospital Medicine, Department of Medicine, University of California-San Francisco, San Francisco, California
| | - Samuel F Hohmann
- Department of Health Systems Management, Rush University, Chicago, Illinois, Vizient, Inc, Chicago, Illinois
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, California
| | - Jessica B Rubin
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, California.
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Ge J, Fontil V, Ackerman S, Pletcher MJ, Lai JC. Clinical decision support and electronic interventions to improve care quality in chronic liver diseases and cirrhosis. Hepatology 2023:01515467-990000000-00546. [PMID: 37611253 PMCID: PMC10998693 DOI: 10.1097/hep.0000000000000583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 07/17/2023] [Indexed: 08/25/2023]
Abstract
Significant quality gaps exist in the management of chronic liver diseases and cirrhosis. Clinical decision support systems-information-driven tools based in and launched from the electronic health record-are attractive and potentially scalable prospective interventions that could help standardize clinical care in hepatology. Yet, clinical decision support systems have had a mixed record in clinical medicine due to issues with interoperability and compatibility with clinical workflows. In this review, we discuss the conceptual origins of clinical decision support systems, existing applications in liver diseases, issues and challenges with implementation, and emerging strategies to improve their integration in hepatology care.
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Affiliation(s)
- Jin Ge
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California – San Francisco, San Francisco, California, USA
| | - Valy Fontil
- Department of Medicine, NYU Grossman School of Medicine and Family Health Centers at NYU-Langone Medical Center, Brooklyn, New York, USA
| | - Sara Ackerman
- Department of Social and Behavioral Sciences, University of California – San Francisco, San Francisco, California, USA
| | - Mark J. Pletcher
- Department of Epidemiology and Biostatistics, University of California – San Francisco, San Francisco, California, USA
| | - Jennifer C. Lai
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California – San Francisco, San Francisco, California, USA
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Wang M, Wadhwani SI, Cullaro G, Lai JC, Rubin JB. Racial and Ethnic Disparities Among Patients Hospitalized for Acute Cholangitis in the United States. J Clin Gastroenterol 2023; 57:731-736. [PMID: 35997698 PMCID: PMC9938839 DOI: 10.1097/mcg.0000000000001743] [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: 03/25/2022] [Accepted: 06/21/2022] [Indexed: 12/10/2022]
Abstract
GOALS We sought to determine whether race/ethnicity is associated with hospitalization outcomes among patients admitted with acute cholangitis. BACKGROUND Few studies have evaluated the association between race and outcomes in patients with acute cholangitis. STUDY We analyzed United States hospitalizations from 2009 to 2018 using the Nationwide Inpatient Sample (NIS). We included patients 18 years old or above admitted with an ICD9/10 diagnosis of cholangitis. Race/ethnicity was categorized as White, Black, Hispanic, or Other. We used multivariable regression to determine the association between race/ethnicity and in-hospital outcomes of interest, including endoscopic retrograde cholangiopancreatography (ERCP), early ERCP (<48 h from admission), length of stay (LOS), and in-hospital mortality. RESULTS Of 116,889 hospitalizations for acute cholangitis, 70% identified as White, 10% identified as Black, 11% identified as Hispanic, and 9% identified as Other. The proportion of non-White patients increased over time. On multivariate analysis controlling for clinical and sociodemographic variables, compared with White patients, Black patients had higher in-hospital mortality (adjusted odds ratio: 1.4, 95% confidence interval: 1.2-1.6, P <0.001). Black patients were also less likely to undergo ERCP, more likely to undergo delayed ERCP, and had longer LOS ( P <0.001 for all). CONCLUSIONS In this contemporary cohort of hospitalized patients with cholangitis, Black race was independently associated with fewer and delayed ERCP procedures, longer LOS, and higher mortality rates. Future studies with more granular social determinants of health data should further explore the underlying reasons for these disparities to develop interventions aimed at reducing racial disparities in outcomes among patients with acute cholangitis.
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Affiliation(s)
| | | | - Giuseppe Cullaro
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California, San Francisco, CA
| | - Jennifer C Lai
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California, San Francisco, CA
| | - Jessica B Rubin
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California, San Francisco, CA
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Wong RJ, Ge J, Boike J, German M, Morelli G, Spengler E, Said A, Desai A, Couri T, Paul S, Frenette C, Verna EC, Goel A, Fallon M, Thornburg B, VanWagner L, Lai JC, Kolli KP. Change in Platelet Count after Transjugular Intrahepatic Portosystemic Shunt Creation: An Advancing Liver Therapeutic Approaches (ALTA) Group Study. J Vasc Interv Radiol 2023; 34:1364-1371. [PMID: 37100199 PMCID: PMC10998695 DOI: 10.1016/j.jvir.2023.04.015] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 04/02/2023] [Accepted: 04/18/2023] [Indexed: 04/28/2023] Open
Abstract
PURPOSE To evaluate recovery of platelet count after transjugular intrahepatic portosystemic shunt (TIPS) creation and patient factors predicting platelet recovery after TIPS creation. MATERIALS AND METHODS Adults with cirrhosis who underwent TIPS creation at 9 U.S. hospitals from 2010 to 2015 were included in this retrospective analysis. Change in platelets from before TIPS to 4 months after TIPS creation was characterized. Logistic regression was used to assess factors associated with top quartile percentage platelet increase after TIPS. Subgroup analyses were performed among patients with a pre-TIPS platelet count of ≤50 ×109/L. RESULTS A total of 601 patients were included. The median absolute change in platelets was 1 × 109/L (-26 × 109/L to 25 × 109/L). Patients with top quartile percent platelet increase experienced ≥32% platelet increase. In multivariable analysis, pre-TIPS platelet counts (odds ratio [OR], 0.97 per 109/L; 95% CI, 0.97-0.98), age (OR, 1.24 per 5 years; 95% CI, 1.10-1.39), and pre-TIPS model for end-stage liver disease (MELD) scores (OR, 1.06 per point; 95% CI, 1.02-1.09) were associated with top quartile (≥32%) platelet increase. Ninety-four (16%) patients had a platelet count of ≤50 × 109/L before TIPS. The median absolute platelet change was 14 × 109/L (2 × 109/L to 34 × 109/L). Fifty-four percent of patients in this subgroup were in the top quartile for platelet increase. In multivariable logistic regression, age (OR, 1.50 per 5 years; 95% CI, 1.11-2.02) was the only factor associated with top quartile platelet increase in this subgroup. CONCLUSIONS TIPS creation did not result in significant platelet increase, except among patients with a platelet count of ≤50 × 109/L before TIPS. Lower pre-TIPS platelet counts, older age, and higher pre-TIPS MELD scores were associated with top quartile (≥32%) platelet increase in the entire cohort, whereas only older age was associated with this outcome in the patient subset with a pre-TIPS platelet count of ≤50 × 109/L.
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Affiliation(s)
- Randi J Wong
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of California San Francisco, San Francisco, California
| | - Jin Ge
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of California San Francisco, San Francisco, California
| | - Justin Boike
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Margarita German
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Giuseppe Morelli
- Division of Gastroenterology, Hepatology, Department of Medicine, and Nutrition, University of Florida Health, Gainesville, Florida
| | - Erin Spengler
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Adnan Said
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Archita Desai
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana
| | - Thomas Couri
- Section of Gastroenterology, Hepatology & Nutrition, Department of Medicine, The University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Sonali Paul
- Section of Gastroenterology, Hepatology & Nutrition, Department of Medicine, The University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Catherine Frenette
- Department for Organ and Cell Transplantation, The Scripps Clinic, La Jolla, California
| | - Elizabeth C Verna
- Department of Medicine, Center for Liver Disease and Transplantation, Columbia University College of Physicians & Surgeons, New York, New York
| | - Aparna Goel
- Department of Internal Medicine, Banner University Medical Center, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona
| | - Michael Fallon
- Department of Internal Medicine, Banner University Medical Center, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona
| | - Bartley Thornburg
- Division of Vascular Interventional Radiology, Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lisa VanWagner
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of California San Francisco, San Francisco, California
| | - K Pallav Kolli
- Division of Interventional Radiology, Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California.
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Bajaj JS, Lai JC, Tandon P, O'Leary JG, Wong F, Garcia-Tsao G, Vargas HE, Kamath PS, Biggins SW, Limon-Miro A, Shaw J, Mbachi C, Chew M, Golob Deeb J, Thacker LR, Reddy KR. Role of Oral Health, Frailty, and Minimal Hepatic Encephalopathy in the Risk of Hospitalization: A Prospective Multi-Center Cohort of Outpatients With Cirrhosis. Clin Gastroenterol Hepatol 2023; 21:1864-1872.e2. [PMID: 36328307 PMCID: PMC11057906 DOI: 10.1016/j.cgh.2022.10.023] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/23/2022] [Accepted: 10/17/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND & AIMS Hospitalizations are a sentinel event in cirrhosis; however, the changing demographics in patients with cirrhosis require updated hospitalization prediction models. Periodontitis is a risk factor for liver disease and potentially progression. The aim of this study was to determine factors, including poor oral health, associated with 3-month hospitalizations in a multi-center cohort of outpatients with cirrhosis. METHODS North American Consortium for Study of End-stage Liver Disease (NACSELD-3), a new study cohort, recruits outpatients with cirrhosis. Cirrhosis details, demographics, minimal hepatic encephalopathy (MHE), frailty, and comorbid conditions including oral health were collected. All patients were followed for 3 months for nonelective hospitalizations. Multi-variable models were created for this outcome using demographics, cirrhosis details, oral health, MHE, frailty, and comorbid conditions with K-fold internal validation using 25%/75% split. RESULTS A total of 442 outpatients (70% men; 37% compensated; Model for End-stage Liver Disease-Sodium, 12; 42% ascites; and 33% prior HE) were included. MHE was found in 70%, frailty in 10%; and both in 8%. In terms of oral health, 15% were edentulous and 10% had prior periodontitis. Regarding 3-month hospitalizations, 14% were admitted for mostly liver-related reasons. These patients were more likely to be decompensated with higher cirrhosis complications, MHE, frailty and periodontitis history. Multi-variable analysis showed prior periodontitis (P = .026), composite MHE + frailty score (P = .0016), ascites (P = .004), prior HE (P = .008), and hydrothorax (P = .004) were associated with admissions using the training and validation subsets. CONCLUSIONS In a contemporaneous, prospective, multi-center cohort study in outpatients with cirrhosis, poor oral health is significantly associated with 3-month hospitalizations independent of portal hypertensive complications, MHE, and frailty. Potential strategies to reduce hospitalizations should consider oral evaluation in addition to MHE and frailty assessment in practice pathways.
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Affiliation(s)
- Jasmohan S Bajaj
- Department of Medicine, Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, Virginia.
| | - Jennifer C Lai
- Department of Medicine, University of California, San Francisco, California
| | - Puneeta Tandon
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Florence Wong
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Hugo E Vargas
- Department of Medicine, Mayo Clinic, Phoenix, Arizona
| | | | - Scott W Biggins
- Department of Medicine, University of Washington, Seattle, Washington
| | - Ana Limon-Miro
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Jawaid Shaw
- Department of Medicine, Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, Virginia
| | - Chimezie Mbachi
- Department of Medicine, West Haven VA Medical Center, West Haven, Connecticut
| | - Michael Chew
- Department of Medicine, West Haven VA Medical Center, West Haven, Connecticut
| | - Janina Golob Deeb
- Department of Periodontics, Virginia Commonwealth University, Richmond, Virginia
| | - Leroy R Thacker
- Department of Biostatistics, Virginia Commonwealth University, Richmond, Virginia
| | - K Rajender Reddy
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Deng LX, Sharma A, Gedallovich SM, Tandon P, Hansen L, Lai JC. Caregiver Burden in Adult Solid Organ Transplantation. Transplantation 2023; 107:1482-1491. [PMID: 36584379 PMCID: PMC10993866 DOI: 10.1097/tp.0000000000004477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The informal caregiver plays a critical role in supporting patients with various end-stage diseases throughout the solid organ transplantation journey. Caregiver responsibilities include assistance with activities of daily living, medication management, implementation of highly specialized treatments, transportation to appointments and treatments, and health care coordination and navigation. The demanding nature of these tasks has profound impacts across multiple domains of the caregiver's life: physical, psychological, financial, logistical, and social. Few interventions targeting caregiver burden have been empirically evaluated, with the majority focused on education or mindfulness-based stress reduction techniques. Further research is urgently needed to develop and evaluate interventions to improve caregiver burden and outcomes for the patient-caregiver dyad.
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Affiliation(s)
- Lisa X. Deng
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Arjun Sharma
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Seren M. Gedallovich
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University, Palo Alto, CA
| | - Puneeta Tandon
- Division of Gastroenterology, Liver Unit, University of Alberta, Edmonton, AB, Canada
| | - Lissi Hansen
- School of Nursing, Oregon Health and Science University, Portland, OR
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, San Francisco, CA
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Jones PD, Lai JC, Bajaj JS, Kanwal F. Actionable Solutions to Achieve Health Equity in Chronic Liver Disease. Clin Gastroenterol Hepatol 2023; 21:1992-2000. [PMID: 37061105 PMCID: PMC10330625 DOI: 10.1016/j.cgh.2023.03.043] [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: 10/28/2022] [Revised: 02/08/2023] [Accepted: 03/26/2023] [Indexed: 04/17/2023]
Abstract
There are well-described racial and ethnic disparities in the burden of chronic liver diseases. Hispanic persons are at highest risk for developing nonalcoholic fatty liver disease, the fastest growing cause of liver disease. Hepatitis B disproportionately affects persons of Asian or African descent. The highest rates of hepatitis C occur in American Indian and Alaskan Native populations. In addition to disparities in disease burden, there are also marked racial and ethnic disparities in access to treatments, including liver transplantation. Disparities also exist by gender and geography, especially in alcohol-related liver disease. To achieve health equity, we must address the root causes that drive these inequities. Understanding the role that social determinants of health play in the disparate health outcomes that are currently observed is critically important. We must forge and/or strengthen collaborations between patients, community members, other key stakeholders, health care providers, health care institutions, professional societies, and legislative bodies. Herein, we provide a high-level review of current disparities in chronic liver disease and describe actionable strategies that have potential to bridge gaps, improve quality, and promote equity in liver care.
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Affiliation(s)
- Patricia D Jones
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida; Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida.
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, California
| | - Jasmohan S Bajaj
- Virginia Commonwealth University and Central Virginia Veterans Health Care System, Richmond, Virginia
| | - Fasiha Kanwal
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas; VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey VA Medical Center, Houston, Texas
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46
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Li M, Wong D, Sack JS, Vogel AS, Hodi FS, Fong L, Lai JC, Grover S, Zucker SD. Early Liver Specialist Consultation is Associated With Faster Biochemical Resolution of Severe Immune Checkpoint Inhibitor-Induced Hepatitis. J Natl Compr Canc Netw 2023; 21:617-626.e3. [PMID: 37308118 DOI: 10.6004/jnccn.2023.7013] [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: 10/13/2022] [Accepted: 02/13/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND We evaluated the impact of gastroenterology/hepatology consultation, as recommended by guidelines, on the management of severe immune checkpoint inhibitor (ICI)-induced hepatitis. METHODS We conducted a multicenter, retrospective cohort study of 294 patients who developed grade ≥3 (alanine aminotransferase [ALT] >200 U/L) ICI-induced hepatitis, with early gastroenterology/hepatology consultation defined as occurring within 7 days of diagnosis. The primary outcome was time to ALT normalization (≤40 U/L), and the secondary outcome was time to ALT improvement to ≤100 U/L. RESULTS A total of 117 patients received early consultation. In the 213 patients with steroid-responsive hepatitis, early consultation was not associated with faster ALT normalization (hazard ratio [HR], 1.12; 95% CI, 0.83-1.51; P=.453). A total of 81 patients developed steroid-refractory hepatitis, with 44 (54.3%) receiving early consultation. In contrast to the patients whose hepatitis responded to steroid treatment, early consultation in those with steroid-refractory disease was associated with faster ALT normalization (HR, 1.89; 95% CI, 1.12-3.19; P=.017) and ALT improvement to ≤100 U/L (HR, 1.72; 95% CI, 1.04-2.84; P=.034). Notably, additional immunosuppressive therapy for steroid-refractory disease was initiated sooner after diagnosis in the early consult group (median 7.5 vs 13.0 days; log-rank P=.001). When time to additional immunosuppression was added as a covariate to the Cox model in mediation analysis, early consultation was no longer associated with time to ALT normalization (HR, 1.39; 95% CI, 0.82-2.38; P=.226) or with time to ALT improvement to ≤100 U/L (HR, 1.25; 95% CI, 0.74-2.11; P=.404). Time to additional immunosuppression remained associated with faster ALT normalization and faster ALT improvement to ≤100 U/L in the model, suggesting that the faster hepatitis resolution in the early consultation group was primarily attributable to earlier initiation of additional immunosuppression. CONCLUSIONS Early gastroenterology/hepatology consultation is associated with faster resolution of biochemical abnormalities in patients with steroid-refractory hepatitis. This beneficial effect appears to be mediated by earlier initiation of additional immunosuppressive therapy in those receiving early consultation.
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Affiliation(s)
- Michael Li
- Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, California
| | - Danny Wong
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham & Women's Hospital, Boston, Massachusetts
| | - Jordan S Sack
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham & Women's Hospital, Boston, Massachusetts
| | - Alexander S Vogel
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham & Women's Hospital, Boston, Massachusetts
| | - F Stephen Hodi
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Lawrence Fong
- Division of Hematology/Oncology, University of California San Francisco, San Francisco, California
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, California
| | - Shilpa Grover
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham & Women's Hospital, Boston, Massachusetts
| | - Stephen D Zucker
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham & Women's Hospital, Boston, Massachusetts
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Bommena S, Mahmud N, Boike JR, Thornburg BG, Kolli KP, Lai JC, German M, Morelli G, Spengler E, Said A, Desai AP, Junna S, Paul S, Frenette C, Verna EC, Goel A, Gregory D, Padilla C, VanWagner LB, Fallon MB. The impact of right atrial pressure on outcomes in patients undergoing TIPS, an ALTA group study. Hepatology 2023; 77:2041-2051. [PMID: 36651170 PMCID: PMC10192025 DOI: 10.1097/hep.0000000000000283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 12/08/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND AIMS Single-center studies in patients undergoing TIPS suggest that elevated right atrial pressure (RAP) may influence survival. We assessed the impact of pre-TIPS RAP on outcomes using the Advancing Liver Therapeutic Approaches (ALTA) database. APPROACH AND RESULTS Total 883 patients in ALTA multicenter TIPS database from 2010 to 2015 from 9 centers with measured pre-TIPS RAP were included. Primary outcome was mortality. Secondary outcomes were 48-hour post-TIPS complications, post-TIPS portal hypertension complications, and post-TIPS inpatient admission for heart failure. Adjusted Cox Proportional hazards and competing risk model with liver transplant as a competing risk were used to assess RAP association with mortality. Restricted cubic splines were used to model nonlinear relationship. Logistic regression was used to assess RAP association with secondary outcomes.Pre-TIPS RAP was independently associated with overall mortality (subdistribution HR: 1.04 per mm Hg, 95% CI, 1.01, 1.08, p =0.009) and composite 48-hour complications. RAP was a predictor of TIPS dysfunction with increased odds of post-90-day paracentesis in outpatient TIPS, hospital admissions for renal dysfunction, and heart failure. Pre-TIPS RAP was positively associated with model for end-stage liver disease, body mass index, Native American and Black race, and lower platelets. CONCLUSIONS Pre-TIPS RAP is an independent risk factor for overall mortality after TIPS insertion. Higher pre-TIPS RAP increased the odds of early complications and overall portal hypertensive complications as potential mechanisms for the mortality impact.
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Affiliation(s)
- Shoma Bommena
- Department of Internal Medicine, Banner University Medical Center, University of Arizona College of Medicine-Phoenix, Phoenix, Phoenix, Arizona, USA
| | - Nadim Mahmud
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Justin R. Boike
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Bartley G. Thornburg
- Division of Vascular and Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois, USA
| | - Kanti P. Kolli
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Margarita German
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Giuseppe Morelli
- Division of Gastroenterology, Hepatology, Department of Medicine, and Nutrition, University of Florida Health, Gainesville, Florida, USA
| | - Erin Spengler
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Adnan Said
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Archita P. Desai
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Shilpa Junna
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Sonali Paul
- Department of Internal Medicine, Section of Gastroenterology and Nutrition, The University of Chicago Medicine, Chicago, Illinois, USA
| | - Catherine Frenette
- Department for Organ and Cell Transplantation, The Scripps Clinic, La Jolla, California, USA
| | - Elizabeth C. Verna
- Department of Medicine, Center for Liver Disease and Transplantation, Columbia University College of Physicians & Surgeons, New York, New York, USA
| | - Aparna Goel
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University, Stanford, California, USA
| | - Dyanna Gregory
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Cynthia Padilla
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Lisa B. VanWagner
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Michael B. Fallon
- Department of Internal Medicine, Banner University Medical Center, University of Arizona College of Medicine-Phoenix, Phoenix, Phoenix, Arizona, USA
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48
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Patel AA, Tapper EB, Kanwal F, Woodrell CD, Hansen L, Lai JC, Rogal S, McDermott C, Rakoski M, Ufere NN. Targets and study design for symptom-focused trials aimed at patients with cirrhosis: An expert consensus. Hepatol Commun 2023; 7:e0135. [PMID: 37267219 PMCID: PMC10241502 DOI: 10.1097/hc9.0000000000000135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 03/07/2023] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND Symptom-focused trials are critically needed for patients with cirrhosis. However, this work would benefit from standard processes and validated measures. METHODS A writing group was formed among hepatologists, nurses, palliative care providers, pharmacists, and clinical trial experts focused on symptom management in patients with cirrhosis to define the key (1) components of trial design, (2) symptom targets, (3) measurement, and (4) outcomes for each target. From July 2022 to January 2023, panelists participated in an iterative process of developing and arriving at a consensus for each component. The goal was to provide consensus definitions that can be operationalized in future clinical trials, including for patients with cirrhosis. RESULTS The panel reached a consensus on key reporting features for clinical trials, along with considerations for study design. Nine key symptom targets (muscle cramps, pruritus, pain, fatigue, sexual dysfunction, sleep disorders, depression and anxiety, nausea/vomiting, and dyspnea/breathlessness) were identified. The panel selected instruments that can be considered for clinical trials based on psychometric validation and previous experience. The panel identified ongoing needs, including instrument validation, safety data, evidence about non-pharmacologic interventions, and comparative effectiveness studies. CONCLUSION This expert panel identified key design, reporting, and measurement elements to standardize processes and measures in future symptom-focused clinical trials in the context of cirrhosis.
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Affiliation(s)
- Arpan A. Patel
- Tamar and Vatche Manoukian Division of Digestive Diseases, University of California, Los Angeles, Los Angeles, California, USA
- VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Elliot B. Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Fasiha Kanwal
- Baylor College of Medicine and Michael E DeBakey VA Medical Center, Houston, Texas, USA
| | - Christopher D. Woodrell
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Geriatric Research, Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA
| | - Lissi Hansen
- Oregon Health & Science University, School of Nursing, Portland, Oregon, USA
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, University of California, San Francisco, California, USA
| | - Shari Rogal
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Cara McDermott
- Division of Geriatrics, Department of Medicine, Duke University, Durham, New Carolina, USA
- Geriatric Research, Education and Clinical Center, Durham VA Medical Center, Durham, New Carolina, USA
| | - Mina Rakoski
- Division of Gastroenterology and Hepatology, Loma Linda University Health, Loma Linda, California, USA
| | - Nneka N. Ufere
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachussetts, USA
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49
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Ha NB, Fan B, Shui AM, Huang CY, Brandman D, Lai JC. CT-quantified sarcopenic visceral obesity is associated with poor transplant waitlist mortality in patients with cirrhosis. Liver Transpl 2023; 29:476-484. [PMID: 36735830 PMCID: PMC10193893 DOI: 10.1097/lvt.0000000000000010] [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: 07/15/2022] [Accepted: 10/25/2022] [Indexed: 02/05/2023]
Abstract
Sarcopenic obesity is associated with higher rates of morbidity and mortality than seen with either sarcopenia or obesity alone. We aimed to define sarcopenic visceral obesity (SVO) using CT-quantified skeletal muscle index and visceral-to-subcutaneous adipose tissue ratio and to examine its association with waitlist mortality in patients with cirrhosis. Included were 326 adults with cirrhosis awaiting liver transplantation in the ambulatory setting with available abdominal CT within 6 months from enrollment between February 2015 and January 2018. SVO was defined as patients with sarcopenia (skeletal muscle index <50 cm 2 /m 2 in men and <39 cm 2 /m 2 in women) and visceral obesity (visceral-to-subcutaneous adipose tissue ratio ≥1.21 in men and ≥0.48 in women). The percentage who met criteria for sarcopenia, visceral obesity, and SVO were 44%, 29%, and 13%, respectively. Cumulative incidence of waitlist mortality was higher in patients with SVO compared to patients with sarcopenia without visceral obesity or visceral obesity without sarcopenia at 12 months (40% vs. 21% vs. 12%) (overall logrank p =0.003). In univariable Cox regression, SVO was associated with waitlist mortality (HR: 3.42, 95% CI: 1.58-7.39), which remained significant after adjusting for age, sex, diabetes, ascites, encephalopathy, MELDNa, liver frailty index, and different body compositions (HR: 2.64, 95% CI: 1.11-6.30). SVO was associated with increase waitlist mortality in patients with cirrhosis in the ambulatory setting awaiting liver transplantation. Concurrent loss of skeletal muscle and gain of adipose tissue seen in SVO quantified by CT may be a useful and objective measurement to identify patients at risk for suboptimal pretransplant outcomes.
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Affiliation(s)
- Nghiem B. Ha
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, CA, USA
| | - Bo Fan
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Amy M. Shui
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Chiung-Yu Huang
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Danielle Brandman
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, CA, USA
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, CA, USA
- Liver Center, University of California, San Francisco, CA, USA
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50
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Wang M, Shui AM, Barry F, Verna E, Kent D, Yao F, Seetharaman S, Berry K, Grubbs RK, George G, Huang CY, Duarte-Rojo A, Lai JC. The TeLeFI (Tele-Liver Frailty Index): Development of a novel frailty tool in patients with cirrhosis via telemedicine. Am J Transplant 2023:S1600-6135(23)00409-4. [PMID: 37061188 DOI: 10.1016/j.ajt.2023.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 03/23/2023] [Accepted: 04/10/2023] [Indexed: 04/17/2023]
Abstract
Frailty is a critical determinant of outcomes in cirrhosis patients. Increasing use of telemedicine has created an unmet need for virtual frailty assessment. We aimed to develop a telemedicine-enabled frailty tool [tele-Liver Frailty Index (TeLeFI)]. Adults with cirrhosis in the liver transplant (LT) setting underwent ambulatory frailty testing with the Liver Frailty Index (LFI) in-person, then virtual administration of: 1) validated surveys [e.g., SARC-F, Duke Activity Status Index (DASI)], 2) chair stands, 3) balance. Two models were selected and internally validated for predicting LFI≥4.4 using: 1) Bayesian information criterion (BIC), 2) C-statistics, and 3) ease of use. Of 145 patients, median [IQR] LFI was 3.7 (3.3-4.2); 15% were frail. Frail (vs. not-frail) patients reported significantly greater impairment on all virtually assessed instruments. We selected 2 parsimonious models: 1) DASI + chair/bed transfer (SARC-F) [BIC 255, C-statistics 0.78], and 2) DASI + chair/bed transfer (SARC-F) + virtually assessed chair stands (BIC 244, C-statistics 0.79). Both models had high C-statistics (0.76-0.78) for predicting frailty. In conclusion, the TeLeFI is a novel tool to pragmatically screen frailty in LT patients via telemedicine and may be used to identify patients who require in-person frailty assessment, more frequent follow-up, or frailty intervention.
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Affiliation(s)
- Melinda Wang
- Department of Medicine, University of California- San Francisco, San Francisco, CA
| | - Amy M Shui
- Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, CA
| | - Fawzy Barry
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, CA
| | - Elizabeth Verna
- University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Dorothea Kent
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, CA
| | - Frederick Yao
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, CA
| | - Srilakshmi Seetharaman
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, CA
| | - Kacey Berry
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, CA
| | - Rachel K Grubbs
- Columbia University Irving Medical Center, New York, NY, United States
| | - Geena George
- University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Chiung-Yu Huang
- Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, CA
| | | | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, CA.
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