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Umbaugh DS, Nguyen NT, Curry SC, Rule JA, Lee WM, Ramachandran A, Jaeschke H. The chemokine CXCL14 is a novel early prognostic biomarker for poor outcome in acetaminophen-induced acute liver failure. Hepatology 2024; 79:1352-1364. [PMID: 37910653 PMCID: PMC11061265 DOI: 10.1097/hep.0000000000000665] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 10/12/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND AND AIMS Patients with acetaminophen-induced acute liver failure are more likely to die while on the liver transplant waiting list than those with other causes of acute liver failure. Therefore, there is an urgent need for prognostic biomarkers that can predict the need for liver transplantation early after an acetaminophen overdose. APPROACH AND RESULTS We evaluated the prognostic potential of plasma chemokine C-X-C motif ligand 14 (CXCL14) concentrations in patients with acetaminophen (APAP) overdose (n=50) and found that CXCL14 is significantly higher in nonsurviving patients compared to survivors with acute liver failure ( p < 0.001). Logistic regression and AUROC analyses revealed that CXCL14 outperformed the MELD score, better discriminating between nonsurvivors and survivors. We validated these data in a separate cohort of samples obtained from the Acute Liver Failure Study Group (n = 80), where MELD and CXCL14 had similar AUC (0.778), but CXCL14 demonstrated higher specificity (81.2 vs. 52.6) and positive predictive value (82.4 vs. 65.4) for death or need for liver transplantation. Next, combining the patient cohorts and using a machine learning training/testing scheme to mimic the clinical scenario, we found that CXCL14 outperformed MELD based on AUC (0.821 vs. 0.787); however, combining MELD and CXCL14 yielded the best AUC (0.860). CONCLUSIONS We find in 2 independent cohorts of acetaminophen overdose patients that circulating CXCL14 concentration is a novel early prognostic biomarker for poor outcomes, which may aid in guiding decisions regarding patient management. Moreover, our findings reveal that CXCL14 performs best when measured soon after patient presentation to the clinic, highlighting its importance for early warning of poor prognosis.
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Affiliation(s)
- David S. Umbaugh
- Department of Pharmacology, Toxicology & Therapeutics, University of Kansas Medical Center, Kansas City, KS, USA
| | - Nga T. Nguyen
- Department of Pharmacology, Toxicology & Therapeutics, University of Kansas Medical Center, Kansas City, KS, USA
| | - Steven C. Curry
- Department of Medical Toxicology, Banner – University Medical Center Phoenix, Phoenix, AZ, USA
- Department of Medicine, and Division of Clinical Data Analytics and Decision Support, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA
| | - Jody A. Rule
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - William M. Lee
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Anup Ramachandran
- Department of Pharmacology, Toxicology & Therapeutics, University of Kansas Medical Center, Kansas City, KS, USA
| | - Hartmut Jaeschke
- Department of Pharmacology, Toxicology & Therapeutics, University of Kansas Medical Center, Kansas City, KS, USA
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Lemos GT, Terrabuio DRB, Nunes NN, Song ATW, Oshiro ICV, D'Albuquerque LAC, Levin AS, Abdala E, Freire MP. Pre-transplant multidrug-resistant infections in liver transplant recipients-epidemiology and impact on transplantation outcome. Clin Transplant 2024; 38:e15173. [PMID: 37877950 DOI: 10.1111/ctr.15173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 09/22/2023] [Accepted: 10/17/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND Cirrhotic patients are highly exposed to healthcare services and antibiotics. Although pre-liver transplantation (LT) infections are directly related to the worsening of liver function, the impact of these infections on LT outcomes is still unclear. This study aimed to identify the effect of multidrug-resistant microorganism (MDRO) infections before LT on survival after LT. METHODS Retrospective study that included patients who underwent LT between 2010 and 2019. Variables analyzed were related to patients' comorbidities, underlying diseases, time on the waiting list, antibiotic use, LT surgery, and occurrences post-LT. Multivariate analyses were performed using logistic regression, and Cox regression for survival analysis. RESULTS A total of 865 patients were included; 351 infections were identified in 259 (30%) patients, of whom 75 (29%) had ≥1 pre-LT MDRO infection. The most common infection was spontaneous bacterial peritonitis (34%). The agent was identified in 249(71%), 53(15%) were polymicrobial. The most common microorganism was Klebsiella pneumoniae (18%); the most common MDRO was ESBL-producing Enterobacterales (16%), and carbapenem-resistant (CR) Enterobacterales (10%). Factors associated with MDRO infections before LT were previous use of therapeutic cephalosporin (p = .001) and fluoroquinolone (p = .001), SBP prophylaxis (p = .03), ACLF before LT (p = .03), and days of hospital stay pre-LT (p < .001); HCC diagnosis was protective (p = .01). Factors associated with 90-day mortality after LT were higher MELD on inclusion to the waiting list (p = .02), pre-LT MDRO infection (p = .04), dialysis after LT (p < .001), prolonged duration of LT surgery (p < .001), post-LT CR-Gram-negative bacteria infection (p < .001), and early retransplantation (p = .004). CONCLUSION MDRO infections before LT have an important impact on survival after LT.
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Affiliation(s)
- Gabriela T Lemos
- Department of Infectious Diseases, University of São Paulo School of Medicine Hospital das Clínicas, Sao Paulo, Brazil
| | - Debora R B Terrabuio
- Division of Clinical Gastroenterology and Hepatology, Hospital das Clínicas, Department of Gastroenterology of University of São Paulo School of Medicine, Sao Paulo, Brazil
| | - Nathalia N Nunes
- Department of Infectious Diseases, University of São Paulo School of Medicine Hospital das Clínicas, Sao Paulo, Brazil
| | - Alice T W Song
- Division of Liver and Gastrointestinal Transplant, Hospital das Clínicas, Department of Surgery, University of São Paulo School of Medicine, Sao Paulo, Brazil
| | - Isabel C V Oshiro
- Working Committee for Hospital Epidemiology and Infection Control, University of São Paulo School of Medicine Hospital das Clínicas, Sao Paulo, Brazil
| | - Luiz Augusto C D'Albuquerque
- Division of Liver and Gastrointestinal Transplant, Hospital das Clínicas, Department of Surgery, University of São Paulo School of Medicine, Sao Paulo, Brazil
| | - Anna S Levin
- Department of Infectious Diseases, University of São Paulo School of Medicine Hospital das Clínicas, Sao Paulo, Brazil
| | - Edson Abdala
- Department of Infectious Diseases, University of São Paulo School of Medicine Hospital das Clínicas, Sao Paulo, Brazil
| | - Maristela P Freire
- Department of Infectious Diseases, University of São Paulo School of Medicine Hospital das Clínicas, Sao Paulo, Brazil
- Working Committee for Hospital Epidemiology and Infection Control, University of São Paulo School of Medicine Hospital das Clínicas, Sao Paulo, Brazil
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Malamon JS, Kaplan B, Jackson WE, Saben JL, Schold JD, Pomfret EA, Pomposelli JJ. Reassessing the survival benefit of deceased donor liver transplantation: retrospective cohort study. Int J Surg 2023; 109:2714-2720. [PMID: 37226874 PMCID: PMC10498891 DOI: 10.1097/js9.0000000000000498] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 05/08/2023] [Indexed: 05/26/2023]
Abstract
INTRODUCTION Currently in the United States, deceased donor liver transplant (DDLT) allocation priority is based on the model for end-stage liver disease including sodium (MELD-Na) score. The United Network for organ sharing's 'Share-15' policy states that candidates with MELD-Na scores of 15 or greater have priority to receive local organ offers compared to candidates with lower MELD-Na scores. Since the inception of this policy, major changes in the primary etiologies of end-stage liver disease have occurred and previous assumptions need to be recalibrated. METHODS The authors retrospectively analyzed the Scientific Registry of Transplant Recipients database between 2012 and 2021 to determine life years saved by DDLT at each interval of MELD-Na score and the time-to-equal risk and time-to-equal survival versus remaining on the waitlist. The authors stratified our analysis by MELD exception points, primary disease etiology, and MELD score. RESULTS On aggregate, compared to remaining on the waitlist, a significant 1-year survival advantage of DDLT at MELD-Na scores as low as 12 was found. The median life years saved at this score after a liver transplant was estimated to be greater than 9 years. While the total life years saved were comparable across all MELD-Na scores, the time-to-equal risk and time-to-equal survival decreased exponentially as MELD-Na scores increased. CONCLUSION Herein, the authors challenge the perception as to the timing of DDLT and when that benefit occurs. The national liver allocation policy is transitioning to a continuous distribution framework and these data will be instrumental to defining the attributes of the continuos allocation score.
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Affiliation(s)
- John S. Malamon
- Department of Surgery
- Department of Medicine, University of Colorado Anschutz Medical Campus
| | - Bruce Kaplan
- Department of Surgery
- Department of Medicine, University of Colorado Anschutz Medical Campus
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), Aurora, Colorado, USA
| | - Whitney E. Jackson
- Department of Medicine, University of Colorado Anschutz Medical Campus
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), Aurora, Colorado, USA
| | - Jessica L. Saben
- Department of Surgery
- Department of Medicine, University of Colorado Anschutz Medical Campus
| | - Jesse D. Schold
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), Aurora, Colorado, USA
| | - Elizabeth A. Pomfret
- Department of Surgery
- Department of Medicine, University of Colorado Anschutz Medical Campus
| | - James J. Pomposelli
- Department of Surgery
- Department of Medicine, University of Colorado Anschutz Medical Campus
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Stawinski PM, Dziadkowiec KN, Al-Abbasi B, Suarez L, Simms L, Dewaswala N, Torres P, Al Rubaye A, Pino J, Marcus A. Model of End-Stage Liver Disease ( MELD) Score as a Predictor of In-Hospital Mortality in Patients with COVID-19: A Novel Approach to a Classic Scoring System. Cureus 2021; 13:e15179. [PMID: 34178500 PMCID: PMC8216703 DOI: 10.7759/cureus.15179] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background Limited data is available for reliable and accurate predictors of in-hospital mortality in patients diagnosed with COVID-19. Methods This scientific study is a retrospective cohort study of patients without a known history of liver diseases who were hospitalized with COVID-19 viral infection. Patients were stratified into low score groups (Model of End-Stage Liver Disease [MELD] score <10) and high score groups (MELD ≥10). Clinical outcomes were evaluated, including in-hospital mortality, hospital length of stay, and intensive care unit length of stay (ICU LOS). Results Our cohort of 186 COVID-19 positive patients included 88 (47%) women with a mean age of 60 years in the low score group and mean age of 73 years in the high score group. Patients in the high score group were older in age (p<0.0001) and more likely to have history of diabetes mellitus (p=0.0020), stage 3 chronic kidney disease (CKD) (p=0.0013), hypertension (p<0.0001), stroke/transient ischemic attack (TIA) (p=0.0163), asthma (p=0.0356), dementia (p<0.0001), and chronic heart failure (p=0.0055). The in-hospital mortality or discharge to hospice rate was significantly higher in the high-score group as opposed to the low-score group (p=0.0014). Conversely, there was no significant difference among both groups in the hospital length of stay (LOS) and ICU LOS (p=0.6929 and p=0.7689, respectively). Conclusion Patients hospitalized with COVID-19 infection and found to have a MELD score greater than or equal to 10 were found to have a higher mortality as compared to their counterparts. Conversely a low MELD score is a very strong indicator of a more favorable prognosis, indicating hospital survival. We propose using the MELD score as an adjunct for risk stratifying patients diagnosed with COVID-19 without prior history of liver dysfunction.
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Affiliation(s)
- Peter M Stawinski
- Internal Medicine, University of Miami JFK Medical Center, Atlantis, USA
| | | | - Baher Al-Abbasi
- Internal Medicine, University of Miami JFK Medical Center, Atlantis, USA
| | - Laura Suarez
- Internal Medicine, University of Miami JFK Medical Center, Atlantis, USA
| | - Larnelle Simms
- Internal Medicine, University of Miami JFK Medical Center, Atlantis, USA
| | - Nakeya Dewaswala
- Internal Medicine, University of Miami JFK Medical Center, Atlantis, USA
| | - Pedro Torres
- Internal Medicine, University of Miami JFK Medical Center, Atlantis, USA
| | - Ayat Al Rubaye
- Internal Medicine, University of Miami JFK Medical Center, Atlantis, USA
| | - Jesus Pino
- Cardiology, University of Miami JFK Medical Center, Atlantis, USA
| | - Akiva Marcus
- Gastroenterology and Hepatology, University of Miami JFK Medical Center, Atlantis, USA
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Asghar MS, Ahsan MN, Rasheed U, Hassan M, Jawed R, Abbas MB, Yaseen R, Ali Naqvi SA, Rizvi H, Syed M. Severity of Non-B and Non-C Hepatitis Versus Hepatitis B and C Associated Chronic Liver Disease: A Retrospective, Observational, Comparative Study. Cureus 2020; 12:e12294. [PMID: 33520498 PMCID: PMC7834553 DOI: 10.7759/cureus.12294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background and objectives Chronic liver disease (CLD) encompasses a variety of etiologies, and the infectious causes are mainly hepatitis B and hepatitis C virus. Chronic alcohol abuse and non-alcoholic fatty liver disease also have a major contribution to CLD. The Child-Pugh scoring system indicates the probable prognosis and mortality risk of a patient with cirrhosis. The primary objective of this research is to observe the mortality risks of CLD caused by a variety of etiologies mentioned above. The secondary objective is to determine the biochemical markers that are correlating with the severity of the study groups. Another aim was to determine the Model for End-Stage Liver Disease (MELD) scoring of each study group predicting the severity of disease among the Child-Pugh classification. Materials and methods We broadly classified the etiologies into two study groups: (1) hepatitis B, C associated CLD (hepatitis B, C-CLD) and (2) non-hepatitis B, C associated CLD (non-hepatitis B, C-CLD). This study was conducted as a descriptive, retrospective study involving patients admitted to the Gastroenterology Department at Dow University Hospital between July 2019 and December 2019. All patients who met the inclusion criteria were included in the study in order to document their levels of severity markers of CLD. A total of 167 individuals met the inclusion criteria, and the sampling was done through non-probability consecutive methods. All continuous variables were described as mean and standard deviations, which were then compared using an independent sample t-test. The comparison of categorical data was done either using the chi-square test or Fisher’s exact test accordingly. A p-value of <0.05 was considered statistically significant (two-tailed). Results The mean age of the study population was 51.83 ± 13.67, with no difference in gender and type of CLD. The frequent co-morbidities (other than CLD) found in the study population were diabetes, hypertension, ischemic heart disease, and chronic kidney disease, with most of them having significant association with non-hepatitis B, C-CLD. Both types of CLD had equal gender proportion (p=0.708). Among the study groups, 56.28% (n=94) had hepatitis B, C-CLD, out of which 18 (19%) belonged to Child-Pugh class A, 36 (38%) to Child-Pugh class B, and 40 (43%) to Child-Pugh class C, whereas 43.72% (n=71) had non-hepatitis B, C-CLD, comprising of 13% (n=10) of Child-Pugh class A patients, 42% (n=31) of Child-Pugh class B patients, and 44% (n=32) of Child-Pugh class C patients (p=0.631). Bilirubin levels (p=0.055), serum creatinine (p=0.201), and International normalized ratio (INR) are found higher in non-hepatitis B, C-CLD (p=0.312), whereas thrombocytopenia was more likely to be associated with hepatitis B, C-CLD (p=0.205). Hyponatremia was slightly associated with non-hepatitis B, C-CLD (p=0.281). The mean MELD score was comparable among the two study groups in both Child-Pugh classes A and B, but in Child-Pugh class C it was significantly higher in non-hepatitis B, C-CLD patients as compared to hepatitis B, C-CLD (p=0.006). Conclusion Non-hepatitis B, C-CLD was proved to be milder in Child-Pugh class A as compared to hepatitis B, C-CLD, but its mortality risk increases with severity, as mean MELD score was found significantly higher in Child-Pugh class C. Our research was able to identify severe biochemical markers in both types of CLD.
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Affiliation(s)
| | | | - Uzma Rasheed
- Internal Medicine, Liaquat National Hospital, Karachi, PAK
| | - Maira Hassan
- Internal Medicine, Liaquat National Hospital, Karachi, PAK
| | - Rumael Jawed
- Internal Medicine , Liaquat National Hospital, Karachi, PAK
| | - Marium B Abbas
- Internal Medicine, Dow International Medical College, Karachi, PAK
| | - Rabail Yaseen
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | | | - Hera Rizvi
- General Surgery, Dow International Medical College, Karachi, PAK
| | - Mashaal Syed
- Gastroenterology and Hepatology, Dow International Medical College, Karachi, PAK
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Oyelade T, Canciani G, Bottaro M, Zaccaria M, Formentin C, Moore K, Montagnese S, Mani AR. Heart Rate Turbulence Predicts Survival Independently From Severity of Liver Dysfunction in Patients With Cirrhosis. Front Physiol 2020; 11:602456. [PMID: 33362578 PMCID: PMC7755978 DOI: 10.3389/fphys.2020.602456] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 11/16/2020] [Indexed: 12/20/2022] Open
Abstract
Background Reduced heart rate variability (HRV) is an independent predictor of mortality in patients with cirrhosis. However, conventional HRV indices can only be interpreted in individuals with normal sinus rhythm. In patients with recurrent premature ventricular complexes (PVCs), the predictive capacity of conventional HRV indices is compromised. Heart Rate Turbulence (HRT) represents the biphasic change of the heart rate after PVCs. This study was aimed to define whether HRT parameters could predict mortality in cirrhotic patients. Materials and Methods 24 h electrocardiogram recordings were collected from 40 cirrhotic patients. Turbulence Onset was calculated as HRT indices. The enrolled patients were followed up for 12 months after the recruitment in relation to survival and/or transplantation. Results During the follow-up period, 21 patients (52.5%) survived, 12 patients (30%) died and 7 patients (17.5%) had liver transplantation. Turbulence Onset was found to be strongly linked with mortality on Cox regression (Hazard ratio = 1.351, p < 0.05). Moreover, Turbulence Onset predicted mortality independently of MELD and Child-Pugh's Score. Conclusion This study provides further evidence of autonomic dysfunction in cirrhosis and suggests that HRT is reliable alternative to HRV in patients with PVCs.
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Affiliation(s)
- Tope Oyelade
- Institute for Liver and Digestive Health, Division of Medicine, UCL, London, United Kingdom
| | - Gabriele Canciani
- Institute for Liver and Digestive Health, Division of Medicine, UCL, London, United Kingdom.,School of Medicine, Sapienza University of Rome, Rome, Italy
| | - Matteo Bottaro
- Department of Medicine, University of Padova, Padua, Italy
| | - Marta Zaccaria
- Institute for Liver and Digestive Health, Division of Medicine, UCL, London, United Kingdom
| | | | - Kevin Moore
- Institute for Liver and Digestive Health, Division of Medicine, UCL, London, United Kingdom
| | | | - Ali R Mani
- Institute for Liver and Digestive Health, Division of Medicine, UCL, London, United Kingdom
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Tapper EB, Zhao L, Nikirk S, Baki J, Parikh ND, Lok AS, Waljee AK. Incidence and Bedside Predictors of the First Episode of Overt Hepatic Encephalopathy in Patients With Cirrhosis. Am J Gastroenterol 2020; 115:2017-25. [PMID: 32773463 DOI: 10.14309/ajg.0000000000000762] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Hepatic encephalopathy (HE) is associated with marked increases in morbidity and mortality for patients with cirrhosis. We aimed to determine the risk of and predictors for HE in contemporary patients. METHODS We prospectively enrolled 294 subjects with Child A-B (70% Child A) cirrhosis and portal hypertension without previous HE from July 2016 to August 2018. The primary outcome was the development of overt HE (grade >2). We assessed the predictive power of model for end-stage liver disease-sodium (MELD-Na) score, the Inhibitory Control Test, the Sickness Impact Profile score, and the Bilirubin-Albumin-Beta-Blocker-Statin score. We also derived a novel predictive model incorporating MELD-Na score, impact of cirrhosis on daily activity (Likert 1-9), frailty (chair-stands per 30 seconds), and health-related quality of life (Short-Form 8, 0-100). RESULTS The cohort's median age was 60 years, 56% were men, and the median MELD-Na score was 9. During a follow-up of 548 ± 281 days, 62 (21%) had incident overt HE with 1-year probability of 14% ± 2%, 10% ± 2%, and 25% ± 5% for Child A and B. The best model for predicting the risk of overt HE included MELD-Na, Short-Form 8, impact on activity rating, and chair-stands within 30 seconds. This model-MELDNa-Actvity-Chairstands-Quality of Life Hepatic Encephalopathy Score-offered an area under the receiver operating curve (AUROC) for HE development at 12 months of 0.82 compared with 0.55, 0.61, 0.70, and 0.72 for the Inhibitory Control Test, Sickness Impact Profile, Bilirubin-Albumin-Beta-Blocker-Statin, and MELD-Na, respectively. The AUROC for HE-related hospitalization was 0.92. DISCUSSION This study provides the incidence of HE in a well-characterized cohort of contemporary patients. Bedside measures such as activity, quality of life, and physical function accurately stratified the patient's risk for overt HE.
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Patidar KR, Shamseddeen H, Xu C, Ghabril MS, Nephew LD, Desai AP, Anderson M, El-Achkar TM, Ginès P, Chalasani NP, Orman ES. Hospital-Acquired Versus Community-Acquired Acute Kidney Injury in Patients With Cirrhosis: A Prospective Study. Am J Gastroenterol 2020; 115:1505-1512. [PMID: 32371628 PMCID: PMC7483791 DOI: 10.14309/ajg.0000000000000670] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [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] [Indexed: 12/11/2022]
Abstract
INTRODUCTION In patients with cirrhosis, differences between acute kidney injury (AKI) at the time of hospital admission (community-acquired) and AKI occurring during hospitalization (hospital-acquired) have not been explored. We aimed to compare patients with hospital-acquired AKI (H-AKI) and community-acquired AKI (C-AKI) in a large, prospective study. METHODS Hospitalized patients with cirrhosis were enrolled (N = 519) and were followed for 90 days after discharge for mortality. The primary outcome was mortality within 90 days; secondary outcomes were the development of de novo chronic kidney disease (CKD)/progression of CKD after 90 days. Cox proportional hazards and logistic regressions were used to determine the independent association of either AKI for primary and secondary outcomes, respectively. RESULTS H-AKI occurred in 10%, and C-AKI occurred in 25%. In multivariable Cox models adjusting for significant confounders, only patients with C-AKI had a higher risk for mortality adjusting for model for end-stage liver disease-Na: (hazard ratio 1.64, 95% confidence interval [CI] 1.04-2.57, P = 0.033) and adjusting for acute on chronic liver failure: (hazard ratio 2.44, 95% CI 1.63-3.65, P < 0.001). In univariable analysis, community-acquired-AKI, but not hospital-acquired-AKI, was associated with de novo CKD/progression of CKD (odds ratio 2.13, 95% CI 1.09-4.14, P = 0.027), but in multivariable analysis, C-AKI was not independently associated with de novo CKD/progression of CKD. However, when AKI was dichotomized by stage, C-AKI stage 3 was independently associated with de novo CKD/progression of CKD (odds ratio 4.79, 95% CI 1.11-20.57, P = 0.035). DISCUSSION Compared with H-AKI, C-AKI is associated with increased mortality and de novo CKD/progression of CKD in patients with cirrhosis. Patients with C-AKI may benefit from frequent monitoring after discharge to improve outcomes.
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Affiliation(s)
- Kavish R. Patidar
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis IN, USA
| | - Hani Shamseddeen
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis IN, USA
| | - Chenjia Xu
- Department of Biostatistics, Indiana University, Indianapolis IN, USA
| | - Marwan S. Ghabril
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis IN, USA
| | - Lauren D. Nephew
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis IN, USA
| | - Archita P. Desai
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis IN, USA
| | - Melissa Anderson
- Division of Nephrology, Indiana University School of Medicine, Indianapolis IN USA
| | - Tarek M. El-Achkar
- Division of Nephrology, Indiana University School of Medicine, Indianapolis IN USA
| | - Pere Ginès
- Liver Unit Hospital Clínic. Institut D’investigacions Biomèdiques August Pi I Sunyer (IDIBAPS). Centro de Investigación En Red de Enfermedades Hepáticas Y Digestivas (Ciberehd). Barcelona, Faculty of Medicine and Health Sciences, University of Barcelona, Spain
| | - Naga P. Chalasani
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis IN, USA
| | - Eric S. Orman
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis IN, USA
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Hawkins RB, Young BAC, Mehaffey JH, Speir AM, Quader MA, Rich JB, Ailawadi G. Model for End-Stage Liver Disease Score Independently Predicts Mortality in Cardiac Surgery. Ann Thorac Surg 2019; 107:1713-1719. [PMID: 30639362 PMCID: PMC6541453 DOI: 10.1016/j.athoracsur.2018.12.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Revised: 10/29/2018] [Accepted: 12/10/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Although liver disease increases surgical risk, it is not considered in The Society for Thoracic Surgeons (STS) risk calculator. This study assessed the impact of Model for End-Stage Liver Disease (MELD) on outcomes after cardiac surgical procedures and the additional predictive value of MELD in the STS risk model. METHODS Deidentified records of 21,272 patients were extracted from a regional STS database. Inclusion criteria were any cardiac operation with a risk score available (2011-2016). Exclusion criteria included missing MELD (n = 2,895) or preoperative anticoagulation (n = 144). Patients were stratified into three categories, MELD < 9 (low), MELD 9 to 15 (moderate), and MELD > 15 (high). Univariate and multivariate logistic regression assessed risk-adjusted associations between MELD and operative outcomes. RESULTS Increasing MELD scores were associated with greater comorbid disease, mitral operation, prior cardiac operation, and higher STS-predicted risk of mortality (1.1%, 2.3%, and 6.0% by MELD category; p < 0.0001). The operative mortality rate increased with increasing MELD score (1.6%, 3.9%, and 8.4%; p < 0.0001). By logistic regression MELD score was an independent predictor of operative mortality (odds ratio, 1.03 per MELD score point; p < 0.0001) as were the components total bilirubin (odds ratio, 1.22 per mg/dL; p = 0.002) and international normalized ratio (odds ratio, 1.40 per unit; p < 0.0001). Finally, MELD score was independently associated with STS major morbidity and the component complications renal failure and stroke. CONCLUSIONS Increasing MELD score, international normalized ratio, and bilirubin all independently increase risk of operative mortality. Because high rates of missing data currently limit utilization of MELD, efforts to simplify and improve data collection would help improve future risk models.
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Affiliation(s)
- Robert B Hawkins
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - Bree Ann C Young
- Department of Cardiothoracic Surgery, University of Michigan, Ann Arbor, Michigan
| | - J Hunter Mehaffey
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - Alan M Speir
- INOVA Heart and Vascular Institute, Falls Church, Virginia
| | - Mohammed A Quader
- Division of Cardiothoracic Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Jeffrey B Rich
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Gorav Ailawadi
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia.
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10
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Dumitrescu G, Januszkiewicz A, Ågren A, Magnusson M, Wahlin S, Wernerman J. Thromboelastometry: Relation to the severity of liver cirrhosis in patients considered for liver transplantation. Medicine (Baltimore) 2017; 96:e7101. [PMID: 28591054 PMCID: PMC5466232 DOI: 10.1097/md.0000000000007101] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The severity of liver disease is assessed by scoring systems, which include the conventional coagulation test prothrombin time-the international normalized ratio (PT-INR). However, PT-INR is not predictive of bleeding in liver disease and thromboelastometry (ROTEM) has been suggested to give a better overview of the coagulation system in these patients. It has now been suggested that coagulation as reflected by tromboelastomety may also be used for prognostic purposes. The objective of our study was to investigate whether thrombelastometry may discriminate the degree of liver insufficiency according to the scoring systems Child Pugh and Model for End-stage Liver Disease (MELD).Forty patients with chronic liver disease of different etiologies and stages were included in this observational cross-sectional study. The severity of liver disease was evaluated using the Child-Pugh score and the MELD score, and blood samples for biochemistry, conventional coagulation tests, and ROTEM were collected at the time of the final assessment for liver transplantation. Statistical comparisons for the studied parameters with scores of severity were made using Spearman correlation test and receiver-operating characteristic (ROC) curves.Spearman correlation coefficients indicated that the thromboelastometric parameters did not correlate with Child-Pugh or MELD scores. The ROC curves of the thromboelastometric parameters could not differentiate advanced stages from early stages of liver cirrhosis.Standard ROTEM cannot discriminate the stage of chronic liver disease in patients with severe chronic liver disease.
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Affiliation(s)
- Gabriel Dumitrescu
- Department of Anesthesia and Intensive Care Medicine, Karolinska University Hospital
| | - Anna Januszkiewicz
- Department of Anesthesia and Intensive Care Medicine, Karolinska University Hospital
| | - Anna Ågren
- Department of Medicine, Division of Hematology, Coagulation Unit, Karolinska University Hospital
| | - Maria Magnusson
- CLINTEC, Division of Pediatrics, Astrid Lindgren Children's Hospital
- MMK, Clinical Chemistry and Blood Coagulation Research, Karolinska Institute
| | - Staffan Wahlin
- Division of Hepatology, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Jan Wernerman
- Department of Anesthesia and Intensive Care Medicine, Karolinska University Hospital
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11
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Levi Sandri GB, de Werra E, Mascianà G, Colasanti M, Santoro R, D'Andrea V, Ettorre GM. Laparoscopic and robotic approach for hepatocellular carcinoma-state of the art. Hepatobiliary Surg Nutr 2016; 5:478-484. [PMID: 28124002 DOI: 10.21037/hbsn.2016.05.05] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Hepatocellular carcinoma (HCC) is the sixth most common malignant tumor worldwide and the most common primary liver cancer, in over 80% of cases HCC grown on a cirrhotic liver. Laparoscopic liver resection (LLR) is now worldwide accepted considering the excellent results shown. Minimally invasive surgical approach for HCC is increasing continuously and in specialized centers seems to become the first-line approach for those patients. The aim of this review presents and discusses state of the art in the laparoscopic and robotic surgical treatment of HCC. An electronic search was performed to identify all studies dealing with HCC resected with laparoscopy or robotic approach. Indications for laparoscopic resection, robotic assisted and totally robotic resection of HCC will be doubtless increased in future years. LLR and robotic approach for HCC is safe and feasible.
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Affiliation(s)
- Giovanni Battista Levi Sandri
- Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Rome, Lazio, Italy;; Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | - Edoardo de Werra
- Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Rome, Lazio, Italy
| | - Gianluca Mascianà
- Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Rome, Lazio, Italy
| | - Marco Colasanti
- Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Rome, Lazio, Italy
| | - Roberto Santoro
- Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Rome, Lazio, Italy
| | - Vito D'Andrea
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | - Giuseppe Maria Ettorre
- Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Rome, Lazio, Italy
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12
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Gordon FD, Goldberg DS, Goodrich NP, Lok AS, Verna EC, Selzner N, Stravitz RT, Merion RM. Recurrent primary sclerosing cholangitis in the Adult-to-Adult Living Donor Liver Transplantation Cohort Study: Comparison of risk factors between living and deceased donor recipients. Liver Transpl 2016; 22:1214-22. [PMID: 27339253 PMCID: PMC4996691 DOI: 10.1002/lt.24496] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [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: 02/08/2016] [Accepted: 06/12/2016] [Indexed: 12/24/2022]
Abstract
Primary sclerosing cholangitis (PSC) recurs in 15%-25% of patients transplanted for PSC. In the United States, PSC transplant patients are more likely to receive an organ from a living donor (LD) than patients without PSC. Our aims were to (1) compare risk of PSC recurrence in LD versus deceased donor recipients and (2) identify risk factors for PSC recurrence. There were 241 living donor liver transplantations (LDLTs) and 65 deceased donor liver transplantation (DDLT) patients transplanted between 1998 and 2013 enrolled in the Adult-to-Adult Living Donor Liver Transplantation Cohort Study who were evaluated. PSC recurrence risk for LDLT and DDLT recipients was compared using Kaplan-Meier survival curves and log-rank tests. Cox models were used to evaluate PSC risk factors. Overall PSC recurrence probabilities were 8.7% and 22.4% at 5 and 10 years after liver transplantation (LT), respectively. The risk of PSC recurrence was not significantly different for DDLT versus LDLT recipients (P = 0.36). For DDLT versus LDLT recipients, unadjusted 5- and 10-year PSC recurrence was 9.4% versus 9.5% and 36.9% versus 21.1%. Higher laboratory Model for End-Stage Liver Disease (MELD) score at LT, onset of a biliary complication, cholangiocarcinoma, and higher donor age were associated with increased risks of PSC recurrence: for MELD (hazard ratio [HR] = 1.06; 95% confidence interval [CI] 1.02-1.10 per MELD point, P = 0.002); for biliary complication (HR, 2.82; 95% CI, 1.28-6.25; P = 0.01); for cholangiocarcinoma (HR, 3.98; 95% CI, 1.43-11.09; P = 0.008); for donor age (per 5-years donor age; HR, 1.17; 95% CI, 1.02-1.35; P = 0.02). Factors not significantly associated with PSC recurrence included the following: first-degree relative donor (P = 0.11), post-LT cytomegalovirus infection (P = 0.38), and acute rejection (P = 0.22). Risk of recurrent PSC was not significantly different for DDLT and LDLT recipients. Biliary complications, cholangiocarcinoma, MELD, and donor age were significantly associated with risk of PSC recurrence. Liver Transplantation 22 1214-1222 2016 AASLD.
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Affiliation(s)
| | | | | | | | | | | | | | - Robert M. Merion
- Arbor Research Collaborative for Health, Ann Arbor, MI,University of Michigan, Ann Arbor, MI
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13
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Abstract
Hepatocellular carcinoma (HCC) is the sixth most common malignant tumor worldwide and the most common primary liver cancer. Liver resection or liver transplantation is the therapeutic gold standards in patient with HCC related with or without underline liver disease. We present a video case of a 68-year-old woman admitted to our surgical and liver transplantation unit for HCC on liver segment VII. Patient has HCV cirrhosis. Patient underwent to previous right portal vein embolization. Model of end staged liver disease was 7. Body mass index (BMI) was 26.3 and ASA score was 2. Alpha-fetoprotein was 768. According with our multidisciplinary group, we suggest a laparoscopic right hepatectomy for the patient. Operation time was 343 min and blood loss estimation was 200 CC. No transfusion was required. Post-operative course was uneventful, grade 0 of Clavien-Dindo Classification. Patient was discharged in day 7. Pathology report describes a 17 mm × 15 mm HCC grade 4, pT2N0. Laparoscopic liver resection (LLR) for HCC should be performed by dedicated surgical teams in hepatobiliary and laparoscopic surgery. The use of LLR in cirrhotic patients is in many centers proposed as the first-line treatment for HCC or as bridge treatment before liver transplantation.
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Affiliation(s)
- Giovanni Battista Levi Sandri
- 1 Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Rome, Lazio, Italy ; 2 Department of Surgical Sciences, Advanced Surgical Technology, Sapienza, Italy
| | - Marco Colasanti
- 1 Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Rome, Lazio, Italy ; 2 Department of Surgical Sciences, Advanced Surgical Technology, Sapienza, Italy
| | - Roberto Santoro
- 1 Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Rome, Lazio, Italy ; 2 Department of Surgical Sciences, Advanced Surgical Technology, Sapienza, Italy
| | - Giuseppe Maria Ettorre
- 1 Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Rome, Lazio, Italy ; 2 Department of Surgical Sciences, Advanced Surgical Technology, Sapienza, Italy
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14
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Kwong AJ, Lai JC, Dodge JL, Roberts JP. Outcomes for liver transplant candidates listed with low model for end-stage liver disease score. Liver Transpl 2015; 21:1403-9. [PMID: 26289624 PMCID: PMC4838198 DOI: 10.1002/lt.24307] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [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: 05/25/2015] [Revised: 07/27/2015] [Accepted: 08/08/2015] [Indexed: 12/21/2022]
Abstract
The Model for End-Stage Liver Disease (MELD) score, which estimates mortality within 90 days, determines priority for liver transplantation (LT). However, longer-term outcomes on the wait list for patients who are initially listed with low MELD scores are not well characterized. All adults listed for primary LT at a single, high-volume center from 2005 to 2012 with an initial laboratory MELD score of 22 or lower were evaluated. Excluded were those patients listed with MELD exception points who underwent living donor liver transplantation (LDLT) or transplantation at another center, or who were removed from the wait list for nonmedical reasons. Outcomes and causes of death were identified by United Network for Organ Sharing, the National Death Index, and an electronic medical record review. Multivariate competing risk analysis evaluated predictors of death compared to deceased donor liver transplantation (DDLT); 893 patients were listed from 2005 to 2012. By the end of follow-up, 27% had undergone DDLT, and 31% were removed from the wait list for death or clinical deterioration. In a competing risks assessment, only MELD score of 6-9, older age, lower serum albumin, lower body mass index, and diabetes conferred an increased risk of wait-list dropout compared to DDLT. Listing for simultaneous liver-kidney transplantation was protective against wait-list dropout. Of the patients included, 275 patients died or were delisted for being too sick; 87% of the identifiable causes of death were directly related to end-stage liver disease or hepatocellular carcinoma. In conclusion, patients with low listing MELD scores remain at a significant risk for death due to liver-related causes and may benefit from early access to transplantation, such as LDLT or acceptance of high-risk donor livers. Predictors of death compared to transplantation may allow for early identification of patients who are at risk for wait-list mortality.
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Affiliation(s)
- Allison J Kwong
- Departments of Medicine, University of California, San Francisco, CA
| | - Jennifer C Lai
- Department of Division of Gastroenterology, University of California, San Francisco, CA
| | - Jennifer L Dodge
- Department of Surgery, University of California, San Francisco, CA
| | - John P Roberts
- Department of Surgery, University of California, San Francisco, CA
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15
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Cardoso FS, Karvellas CJ, Kneteman NM, Meeberg G, Fidalgo P, Bagshaw SM. Postoperative resource utilization and survival among liver transplant recipients with Model for End-stage Liver Disease score ≥ 40: A retrospective cohort study. Can J Gastroenterol Hepatol 2015; 29:185-91. [PMID: 25965438 DOI: 10.1155/2015/954656] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Cirrhotic patients with Model for End-stage Liver Disease (MELD) score ≥ 40 have high risk for death without liver transplant (LT). OBJECTIVE To evaluate these patients' outcomes after LT. METHODS The present study analyzed a retrospective cohort of 519 cirrhotic adult patients who underwent LT at a single Canadian centre between 2002 and 2012. Primary exposure was severity of liver disease measured by MELD score at LT (≥ 40 versus < 40). Primary outcome was duration of first intensive care unit (ICU) stay after LT. Secondary outcomes were duration of first hospital stay after LT, rate of ICU readmission, re-LT and survival rates. RESULTS On the day of LT, 5% (28 of 519) of patients had a MELD score ≥ 40. These patients had longer first ICU stays after LT (14 versus two days; P < 0.001). MELD score ≥ 40 at LT was independently associated with first ICU stay after LT ≥ 10 days (OR 3.21). These patients had longer first hospital stays after LT (45 versus 18 days; P < 0.001); however, there was no significant difference in the rate of ICU readmission (18% versus 22%; P = 0.58) or re-LT rate (4% versus 4%; P = 1.00). Cumulative survival at one month, three months, one year, three years and five years was 98%, 96%, 90%, 79% and 72%, respectively. There was no significant difference in cumulative survival stratified according to MELD score ≥ 40 versus < 40 at LT (P = 0.59). CONCLUSIONS Cirrhotic patients with MELD score ≥ 40 at LT utilize greater postoperative health resources; however, they derive similar long-term survival benefit from LT.
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16
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Nashan B, Schemmer P, Braun F, Dworak M, Wimmer P, Schlitt H. Evaluating the efficacy, safety and evolution of renal function with early initiation of everolimus-facilitated tacrolimus reduction in de novo liver transplant recipients: Study protocol for a randomized controlled trial. Trials 2015; 16:118. [PMID: 25873064 PMCID: PMC4384314 DOI: 10.1186/s13063-015-0626-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 03/02/2015] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Introduction of calcineurin inhibitors had led to improved survival rates in liver transplant recipients. However, long-term use of calcineurin inhibitors is associated with a higher risk of chronic renal failure, neurotoxicity, de novo malignancies, recurrence of hepatitis C viral (HCV) infection and hepatocellular carcinoma. Several studies have shown that everolimus has the potential to provide protection against viral replication, malignancy, and progression of fibrosis, as well as preventing nephrotoxicity by facilitating calcineurin inhibitor reduction without compromising efficacy. The Hephaistos study evaluates the beneficial effects of early initiation of everolimus in de novo liver transplant recipients. METHODS/DESIGN Hephaistos is an ongoing 12-month, multi-center, open-label, controlled study aiming to enroll 330 de novo liver transplant recipients from 15 centers across Germany. Patients are randomized in a 1:1 ratio (7-21 days post-transplantation) to receive everolimus (trough levels 3-8 ng/mL) with reduced tacrolimus (trough levels <5 ng/mL), or standard tacrolimus (trough levels 6-10 ng/mL) after entering a run-in period (3-5 days post-transplantation). In the run-in period, patients are treated with induction therapy, mycophenolate mofetil, tacrolimus, and corticosteroids according to local practice. Randomization is stratified by HCV status and model of end-stage liver disease scores at transplantation. The primary objective of the study is to exhibit superior renal function (estimated glomerular filtration rate assessed by the Modification of Diet in Renal Disease (MDRD)-4 formula) with everolimus plus reduced tacrolimus compared to standard tacrolimus at Month 12. Other objectives are: to assess the incidence of treated biopsy-proven acute rejection, graft loss, or death; the incidences of components of the composite efficacy endpoint; renal function via estimated glomerular filtration rate using various formulae (MDRD-4, Nankivell, Cockcroft-Gault, chronic kidney disease epidemiology collaboration and Hoek formulae); the incidence of proteinuria; the incidence of adverse events and serious adverse events; the incidence and severity of cytomegalovirus and HCV infections and HCV-related fibrosis. DISCUSSION This study aims to demonstrate superior renal function, comparable efficacy, and safety in de novo liver transplant recipients receiving everolimus with reduced tacrolimus compared with standard tacrolimus. This study also evaluates the antiviral benefit by early initiation of everolimus. TRIAL REGISTRATION NCT01551212 .
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Affiliation(s)
- Bjorn Nashan
- Department of Hepatobiliary Surgery and Visceral Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Peter Schemmer
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany.
| | - Felix Braun
- Department of General Surgery and Thoracic Surgery, University Hospital Schleswig, Kiel, Holstein, Germany.
| | | | | | - Hans Schlitt
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany.
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17
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Wedd J, Bambha KM, Stotts M, Laskey H, Colmenero J, Gralla J, Biggins SW. Stage of cirrhosis predicts the risk of liver-related death in patients with low Model for End-Stage Liver Disease scores and cirrhosis awaiting liver transplantation. Liver Transpl 2014; 20:1193-201. [PMID: 24916539 PMCID: PMC4177271 DOI: 10.1002/lt.23929] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2014] [Accepted: 06/06/2014] [Indexed: 01/12/2023]
Abstract
The Model for End-Stage Liver Disease (MELD) score has reduced predictive ability in patients with cirrhosis and MELD scores ≤ 20. We aimed to assess whether a 5-stage clinical model could identify liver transplantation (LT) candidates with low MELD scores who are at increased risk for death. We conducted a case-control study of subjects with cirrhosis and MELD scores ≤ 20 who were awaiting LT at a single academic medical center between February 2002 and May 2011. Conditional logistic regression was used to evaluate the risk of liver-related death according to the cirrhosis stage. We identified 41 case subjects who died from liver-related causes with MELD scores ≤ 20 within 90 days of death while they were waiting for LT. The cases were matched with up to 3 controls (66 controls in all) on the basis of the listing year, age, sex, liver disease etiology, presence of hepatocellular carcinoma, and MELD score. The cirrhosis stage was assessed for all subjects: (1) no varices or ascites, (2) varices, (3) variceal bleeding, (4) ascites, and (5) ascites and variceal bleeding. The MELD scores were similar for cases and controls. Clinical states contributing to death in cases were: sepsis 49%, spontaneous bacterial peritonitis 15%, variceal bleeding 24%, and hepatorenal syndrome 22%. In a univariate analysis, variceal bleeding [odds ratio (OR) = 5.6, P = 0.003], albumin (OR = 0.5, P = 0.041), an increasing cirrhosis stage (P = 0.003), reaching cirrhosis stage 2, 3, or 4 versus lower stages (OR = 3.6, P = 0.048; OR = 7.4, P < 0.001; and OR = 4.1, P = 0.008), a sodium level < 135 mmol/L (OR = 3.4, P = 0.006), and hepatic encephalopathy (OR = 2.3, P = 0.082) were associated with liver-related death. In a multivariate model including the cirrhosis stage, albumin, sodium, and hepatic encephalopathy, an increasing cirrhosis stage (P = 0.010) was independently associated with liver-related death. In conclusion, assessing the cirrhosis stage in patients with low MELD scores awaiting LT may help to select candidates for more aggressive monitoring or for living or extended criteria donation.
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Affiliation(s)
- Joel Wedd
- University of Colorado Denver Division of Gastroenterology and Hepatology
| | - Kiran M. Bambha
- University of Colorado Denver Division of Gastroenterology and Hepatology
| | - Matt Stotts
- Saint Louis University Division of Gastroenterology and Hepatology
| | - Heather Laskey
- University of Colorado Denver Division of Gastroenterology and Hepatology
| | - Jordi Colmenero
- University of Colorado Denver Division of Gastroenterology and Hepatology
,Liver Transplant Unit, Hospital Clinic, Institut D’Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona
| | - Jane Gralla
- University of Colorado Denver Departments of Pediatrics and Biostatistics and Informatics
| | - Scott W. Biggins
- University of Colorado Denver Division of Gastroenterology and Hepatology
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18
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Abstract
BACKGROUND The proportion of older patients awaiting liver transplantation (LT) is rising. Although increased age and LT-MELD are known to increase the risk of graft loss, no studies have explored whether there is a synergistic effect between LT-age and LT-MELD. METHODS All US adult, non-Status 1 recipients of primary deceased donor LT from 2/05 to 1/10 without MELD exceptions were included (n=15,677). Recipients were categorized by LT-age [18-59 yr (n=11,966), 60-64 yr (n=2181), 65-69 yr (n=1177), and ≥70 yr (n=343)] and LT-MELD [low (<20, n=5290), mid (20-27, n=5112), and high (≥28, n=5265)]. Adjusted Cox models evaluated the independent and combined effects of LT-age and LT-MELD on graft loss (death or re-LT). RESULTS LT-age ≥70 yr (HR=1.65, 95% CI 1.08-1.82) and LT-MELD ≥28 (HR=1.46, 95% CI 1.02-1.47) were independently associated with increased risk of graft loss (P<0.001). In a model allowing for the interaction between LT-age and LT-MELD, the risk of graft loss for recipients ≥70 years with MELD ≥28 was higher than predicted by the additive model (HR=2.38, 95% CI 1.73-3.27, P<0.001) resulting in 1-year graft survival of 56%. However, the increased risk of graft loss in recipients ≥70 years was attenuated at lower LT-MELD <28. Furthermore, the interaction term was not significant for any other LT-age and LT-MELD combination. CONCLUSION Our analyses suggest that recipients should not be excluded solely based on age; however, LT for recipients ≥70 years at high LT-MELD scores should be undertaken cautiously.
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Affiliation(s)
| | - Sandy Feng
- Department of Surgery, University of California, San Francisco
| | - Bilal Hameed
- Department of Medicine, University of California, San Francisco
| | - Francis Yao
- Department of Medicine, University of California, San Francisco
| | - Jennifer C. Lai
- Department of Medicine, University of California, San Francisco
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19
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Rockey DC. To transfuse or not to transfuse in upper gastrointestinal hemorrhage? That is the question. Hepatology 2014; 60:422-4. [PMID: 24390775 PMCID: PMC4151512 DOI: 10.1002/hep.26994] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Revised: 12/08/2013] [Accepted: 12/23/2013] [Indexed: 01/21/2023]
Abstract
BACKGROUND The hemoglobin threshold for transfusion of red cells in patients with acute gastrointestinal bleeding is controversial. We compared the efficacy and safety of a restrictive transfusion strategy with those of a liberal transfusion strategy. METHODS We enrolled 921 patients with severe acute upper gastrointestinal bleeding and randomly assigned 461 of them to a restrictive strategy (transfusion when the hemoglobin level fell below 7 g per deciliter) and 460 to a liberal strategy (transfusion when the hemoglobin fell below 9 g per deciliter). Randomization was stratified according to the presence or absence of liver cirrhosis. RESULTS A total of 225 patients assigned to the restrictive strategy (51%), as compared with 65 assigned to the liberal strategy (15%), did not receive transfusions (P<0.001). The probability of survival at 6 weeks was higher in the restrictive-strategy group than in the liberal-strategy group (95% vs. 91%; hazard ratio for death with restrictive strategy, 0.55; 95% confidence interval [CI], 0.33 to 0.92; P = 0.02). Further bleeding occurred in 10% of the patients in the restrictive-strategy group as compared with 16% of the patients in the liberal-strategy group (P = 0.01), and adverse events occurred in 40% as compared with 48% (P = 0.02). The probability of survival was slightly higher with the restrictive strategy than with the liberal strategy in the subgroup of patients who had bleeding associated with a peptic ulcer (hazard ratio, 0.70; 95% CI, 0.26 to 1.25) and was significantly higher in the subgroup of patients with cirrhosis and Child–Pugh class A or B disease (hazard ratio, 0.30; 95% CI, 0.11 to 0.85), but not in those with cirrhosis and Child–Pugh class C disease (hazard ratio, 1.04; 95% CI, 0.45 to 2.37). Within the first 5 days, the portal-pressure gradient increased significantly in patients assigned to the liberal strategy (P = 0.03) but not in those assigned to the restrictive strategy. CONCLUSIONS As compared with a liberal transfusion strategy, a restrictive strategy significantly improved outcomes in patients with acute upper gastrointestinal bleeding.
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Affiliation(s)
- Don C. Rockey
- Department of Internal Medicine, Medical University of South Carolina, Charleston, SC
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20
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Hagan MT, Sayuk GS, Lisker-Melman M, Korenblat KM, Kerr TA, Chapman WC, Crippin JS. Liver volume in the cirrhotic patient: does size matter? Dig Dis Sci 2014; 59:886-91. [PMID: 24504591 PMCID: PMC4565509 DOI: 10.1007/s10620-014-3038-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Accepted: 01/12/2014] [Indexed: 01/07/2023]
Abstract
BACKGROUND While it is established that cirrhosis results in a decrease in liver volume (LV), whether LV itself predicts patient survival is unknown. We hypothesize that estimated LV is an important prognostic indicator in patients with cirrhosis. METHODS Data was gathered retrospectively from consecutive patients evaluated for a liver transplant from January 2001 to June 2006. Of 500 patients identified, 323 patients met both inclusion and exclusion criteria. LV per ideal body weight (IBW) was used to correct for body size, and LV/IBW was stratified by median split for survival analyses. Patients were classified into one of three clinical groups: hepatocellular disease (n = 229), cholestatic disease (n = 56), and miscellaneous (n = 38). One of three possible clinical outcomes (survival, liver transplantation, or death) was recorded during the 5-year follow-up, the latter two grouped together as "transplant/death." RESULTS Transplant/death occurred in 283 (88 %) subjects. Overall, there was a significant increase in transplant/death in those with lower LV/IBW (χ(2) = 5.27, p = 0.022). When considering the subset with hepatocellular disease, lower LV/IBW was a robust predictor of transplant/death (χ(2) = 9.62, p = 0.002). In multivariate analyses, the LV/IBW trended toward predicting transplant/death (ExpB = 0.943, p = 0.053) independent of Model for End stage Liver Disease (MELD) (ExpB = 1.13, p = 0.001). DISCUSSION LV has important predictive value in patients with cirrhosis from hepatocellular disease. This observation appears to be independent of MELD, suggesting LV may impart important prognostic information that is not captured by the MELD score alone. Thus, LV may serve as an important adjunct to the MELD score in patients with hepatocellular disease.
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Affiliation(s)
- Michael T. Hagan
- Division of Gastroenterology, Department of Internal Medicine, Washington University School of Medicine, 660 South Euclid, Campus Box 8124, St. Louis, MO, USA
| | - Gregory S. Sayuk
- Division of Gastroenterology, Department of Internal Medicine, Washington University School of Medicine, 660 South Euclid, Campus Box 8124, St. Louis, MO, USA
| | - Mauricio Lisker-Melman
- Division of Gastroenterology, Department of Internal Medicine, Washington University School of Medicine, 660 South Euclid, Campus Box 8124, St. Louis, MO, USA
| | - Kevin M. Korenblat
- Division of Gastroenterology, Department of Internal Medicine, Washington University School of Medicine, 660 South Euclid, Campus Box 8124, St. Louis, MO, USA
| | - Thomas A. Kerr
- Division of Gastroenterology, Department of Internal Medicine, Washington University School of Medicine, 660 South Euclid, Campus Box 8124, St. Louis, MO, USA
| | - William C. Chapman
- Department of General Surgery, Section of Abdominal Transplantation, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Jeffrey S. Crippin
- Division of Gastroenterology, Department of Internal Medicine, Washington University School of Medicine, 660 South Euclid, Campus Box 8124, St. Louis, MO, USA
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21
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Tanikella R, Fallon MB. Hepatopulmonary syndrome and liver transplantation: who, when, and where? Hepatology 2013; 57:2097-9. [PMID: 23471874 PMCID: PMC10963044 DOI: 10.1002/hep.26367] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Revised: 02/19/2013] [Accepted: 02/23/2013] [Indexed: 12/15/2022]
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Urrunaga NH, Singal AG, Cuthbert JA, Rockey DC. Hemorrhagic ascites. Clinical presentation and outcomes in patients with cirrhosis. J Hepatol 2013; 58:1113-8. [PMID: 23348236 PMCID: PMC4092117 DOI: 10.1016/j.jhep.2013.01.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2012] [Revised: 12/03/2012] [Accepted: 01/10/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Hemorrhagic ascites can pose diagnostic and therapeutic dilemmas in patients with cirrhosis. We aimed at exploring the characteristics and outcomes of patients with cirrhosis and hemorrhagic ascites. METHODS The records of all patients with cirrhosis and ascites, who underwent paracentesis between 2003 and 2010 at Parkland Memorial Hospital, were retrospectively reviewed. Hemorrhagic ascites was defined as an ascitic fluid red blood cell (RBC) count ≥ 10,000/μl. We compared each patient with 3 age- and gender-matched controls (cirrhotic patients with ascites and an ascitic RBC count <10,000/μl). Survival curves were generated using Kaplan-Meier plots and compared using the log rank test. RESULTS 1113 cirrhotic patients underwent paracentesis; 214 (19%) had hemorrhagic ascites. Patients with hemorrhagic ascites had higher rates of spontaneous bacterial peritonitis (p <0.001), acute kidney injury (AKI, p <0.001), and were more likely to require intensive care unit (ICU)-level care (p=0.01) compared to patients without hemorrhagic ascites. Patients with hemorrhagic ascites had a higher mortality than controls at one month (87% vs. 72%), 1 year (72% vs. 50%) and 3 years (61% vs. 41%). Using multivariate regression analysis, hemorrhagic ascites was also an independent predictor of mortality (HR 1.34, 95% CI 1.07-1.68) after adjusting for the model for end-stage liver disease score (HR 1.04, 1.03-1.05), ICU-level care (HR 2.02, 1.63-2.51) and presence of hepatocellular carcinoma (HR 2.27, 1.61-3.19). CONCLUSIONS Patients with hemorrhagic ascites had a significantly higher rate of ICU care, AKI, and mortality than patients with portal hypertension and ascites but without hemorrhagic ascites. We conclude that hemorrhagic ascites is a marker of advanced liver disease and poor outcome.
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Affiliation(s)
| | | | | | - Don C. Rockey
- Corresponding author. Current address: Department of Internal Medicine, Medical University of South Carolina, 96 Jonathan Lucas Street, Suite 803, Charleston, SC 29425, United States. Tel.: +1 843 792 2914; fax: +1 843 792 5265. (D.C. Rockey)
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23
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Mindikoglu AL, Emre SH, Magder LS. Impact of estimated liver volume and liver weight on gender disparity in liver transplantation. Liver Transpl 2013; 19:89-95. [PMID: 23008117 PMCID: PMC3535518 DOI: 10.1002/lt.23553] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [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: 07/23/2012] [Accepted: 09/13/2012] [Indexed: 12/12/2022]
Abstract
Although lower Model for End-Stage Liver Disease (MELD) scores due to lower levels of serum creatinine in women might account for some of the gender disparity in liver transplantation (LT) rates, even within MELD scores, women undergo transplantation at lower rates than men. It is unclear what causes this disparity, but transplant candidate/donor liver size mismatch may be a factor. We analyzed Organ Procurement and Transplantation Network data for patients with end-stage liver disease on the waiting list. A pooled conditional logistic regression analysis was used to assess the association between gender and LT and to determine the degree to which this association was explained by lower MELD scores or liver size. In all, 28,866 patients and 424,001 person-months were included in the analysis. The median estimated liver volume (eLV) and the median estimated liver weight (eLW) were significantly lower for women versus men on the LT waiting list (P < 0.001). When we controlled for the region and the blood type, women were 25% less likely to undergo LT in a given month in comparison with men (P < 0.001). When the MELD score was included in the model, the odds ratio (OR) for gender increased to 0.84, and this suggested that 9 percentage points of the 25% gender disparity were due to the MELD score. When eLV was added to the model, there was an additional 3% increase in the OR for gender, and this suggested that transplant candidate/donor liver size mismatch was an underlying factor for the lower LT rates in women versus men (OR = 0.87, P < 0.001). In conclusion, lower LT rates among women on the waiting list can be explained in part by lower MELD scores, eLVs, and eLWs in comparison with men. However, at least half of the gender disparity still remains unexplained.
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Affiliation(s)
- Ayse L Mindikoglu
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
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24
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Rivera MN, Jowsey S, Alsina AE, Torres EA. Factors contributing to health disparities in liver transplantation in a Hispanic population. P R Health Sci J 2012; 31:199-204. [PMID: 23844467 PMCID: PMC4063410] [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] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
OBJECTIVE Among the challenges that Puerto Rico transplant patients face are a lack of social support that would enable them to move away from Puerto Rico, the difficulty of obtaining insurance coverage, and limitations imposed by language barriers. These factors may lead to reduced access to liver transplantation, which is a form of healthcare disparity. The objective of the study is to describe a group of Puerto Rican liver transplant candidates for the first time and to determine whether the above-named factors limit the possibilities of these candidates to be listed for transplant. METHODS Using non-public databases from the referral and the transplant center, we performed a retrospective analysis of the medical records of patients who had been evaluated for liver transplant candidacy. Candidates (137) from the Liver Transplant Clinic at the University of Puerto Rico School of Medicine pre-evaluated for transplant candidacy during the period of 2002 to 2008 were selected. RESULTS Records from 86 men and 51 women were reviewed. The most predominant etiologies of liver disease were hepatitis C virus (36%), a combination of etiologies (26%), alcoholic liver disease (16%), and cryptogenic cirrhosis (10%). While social support and history of psychiatric disorders did not affect listing, private insurance increased the odds of being enlisted for liver transplant (OR = 2.97) 195%CI: 1.067-8.242) (p<0.05). CONCLUSION Access to private insurance increases the possibility of patient's being enlisted for liver transplantation. Recommendations for overcoming the gap in access to transplants by patients without private insurance are discussed.
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Affiliation(s)
- Miladys N Rivera
- School of Medicine, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico.
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25
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Kronenberger B, Rudloff I, Bachmann M, Brunner F, Kapper L, Filmann N, Waidmann O, Herrmann E, Pfeilschifter J, Zeuzem S, Piiper A, Mühl H. Interleukin-22 predicts severity and death in advanced liver cirrhosis: a prospective cohort study. BMC Med 2012; 10:102. [PMID: 22967278 PMCID: PMC3519550 DOI: 10.1186/1741-7015-10-102] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Accepted: 09/11/2012] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Interleukin-22 (IL-22), recently identified as a crucial parameter of pathology in experimental liver damage, may determine survival in clinical end-stage liver disease. Systematic analysis of serum IL-22 in relation to morbidity and mortality of patients with advanced liver cirrhosis has not been performed so far. METHODS This is a prospective cohort study including 120 liver cirrhosis patients and 40 healthy donors to analyze systemic levels of IL-22 in relation to survival and hepatic complications. RESULTS A total of 71% of patients displayed liver cirrhosis-related complications at study inclusion. A total of 23% of the patients died during a mean follow-up of 196 ± 165 days. Systemic IL-22 was detectable in 74% of patients but only in 10% of healthy donors (P < 0.001). Elevated levels of IL-22 were associated with ascites (P = 0.006), hepatorenal syndrome (P < 0.0001), and spontaneous bacterial peritonitis (P = 0.001). Patients with elevated IL-22 (>18 pg/ml, n = 57) showed significantly reduced survival compared to patients with regular (≤18 pg/ml) levels of IL-22 (321 days versus 526 days, P = 0.003). Other factors associated with reduced overall survival were high CRP (≥2.9 mg/dl, P = 0.005, hazard ratio (HR) 0.314, confidence interval (CI) (0.141 to 0.702)), elevated serum creatinine (P = 0.05, HR 0.453, CI (0.203 to 1.012)), presence of liver-related complications (P = 0.028, HR 0.258, CI (0.077 to 0.862)), model of end stage liver disease (MELD) score ≥20 (P = 0.017, HR 0.364, CI (0.159 to 0.835)) and age (P = 0.011, HR 0.955, CI (0.922 to 0.989)). Adjusted multivariate Cox proportional-hazards analysis identified elevated systemic IL-22 levels as independent predictors of reduced survival (P = 0.007, HR 0.218, CI (0.072 to 0.662)). CONCLUSIONS In patients with liver cirrhosis, elevated systemic IL-22 levels are predictive for reduced survival independently from age, liver-related complications, CRP, creatinine and the MELD score. Thus, processes that lead to a rise in systemic interleukin-22 may be relevant for prognosis of advanced liver cirrhosis.
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Affiliation(s)
- Bernd Kronenberger
- Medizinische Klinik 1, Klinikum der J.W. Goethe Universität, Theodor-Stern-Kai 7, D-60590 Frankfurt am Main, Germany
| | - Ina Rudloff
- Pharmazentrum Frankfurt, Klinikum der J.W. Goethe Universität, Theodor-Stern-Kai 7, D-60590 Frankfurt am Main, Germany
| | - Malte Bachmann
- Pharmazentrum Frankfurt, Klinikum der J.W. Goethe Universität, Theodor-Stern-Kai 7, D-60590 Frankfurt am Main, Germany
| | - Friederike Brunner
- Medizinische Klinik 1, Klinikum der J.W. Goethe Universität, Theodor-Stern-Kai 7, D-60590 Frankfurt am Main, Germany
| | - Lisa Kapper
- Medizinische Klinik 1, Klinikum der J.W. Goethe Universität, Theodor-Stern-Kai 7, D-60590 Frankfurt am Main, Germany
| | - Natalie Filmann
- Institut für Biostatistik und mathematische Modellierung, Klinikum der J.W. Goethe Universität, Theodor-Stern-Kai 7, D-60590 Frankfurt am Main, Germany
| | - Oliver Waidmann
- Medizinische Klinik 1, Klinikum der J.W. Goethe Universität, Theodor-Stern-Kai 7, D-60590 Frankfurt am Main, Germany
| | - Eva Herrmann
- Institut für Biostatistik und mathematische Modellierung, Klinikum der J.W. Goethe Universität, Theodor-Stern-Kai 7, D-60590 Frankfurt am Main, Germany
| | - Josef Pfeilschifter
- Pharmazentrum Frankfurt, Klinikum der J.W. Goethe Universität, Theodor-Stern-Kai 7, D-60590 Frankfurt am Main, Germany
| | - Stefan Zeuzem
- Medizinische Klinik 1, Klinikum der J.W. Goethe Universität, Theodor-Stern-Kai 7, D-60590 Frankfurt am Main, Germany
| | - Albrecht Piiper
- Medizinische Klinik 1, Klinikum der J.W. Goethe Universität, Theodor-Stern-Kai 7, D-60590 Frankfurt am Main, Germany
| | - Heiko Mühl
- Pharmazentrum Frankfurt, Klinikum der J.W. Goethe Universität, Theodor-Stern-Kai 7, D-60590 Frankfurt am Main, Germany
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26
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Eltawil KM, Berry R, Abdolell M, Molinari M. Analysis of survival predictors in a prospective cohort of patients undergoing transarterial chemoembolization for hepatocellular carcinoma in a single Canadian centre. HPB (Oxford) 2012; 14:162-70. [PMID: 22321034 PMCID: PMC3371198 DOI: 10.1111/j.1477-2574.2011.00420.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Despite advances in the treatment of hepatocellular carcinoma (HCC), a great proportion of patients are eligible only for palliative therapy for reasons of advanced-stage disease or poor hepatic reserve. The use of transarterial chemoembolization (TACE) in the palliation of non-resectable HCC has shown a survival benefit in European and Asian populations. The aim of this study was to assess the efficacy of TACE by analysing overall 5-year survival, interval changes of tumour size and serum alpha-fetoprotein (AFP) levels in a prospective North American cohort. METHODS From September 2005 to December 2010, 46 candidates for TACE were enrolled in the study. Collectively, they underwent 102 TACE treatments. Data on tumour response, serum AFP and survival were prospectively collected. RESULTS In compensated cirrhotic patients, serial treatment with TACE had a stabilizing effect on tumour size and reduced serum AFP levels during the first 12 months. Overall survival rates at 1, 2 and 3 years were 69%, 58% and 20%, respectively. Younger individuals and patients with a lower body mass index, affected by early-stage HCC with involvement of a single lobe, had better survival in univariate analysis. After adjustment for risk factors, early tumour stage (T1 and T2 vs. T3 and T4) at diagnosis was the only statistically significant predictor for survival. CONCLUSIONS In compensated cirrhotic patients, TACE is an effective palliative intervention and HCC stage at diagnosis seems to be the most important predictor of longterm outcomes.
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Affiliation(s)
- Karim M Eltawil
- Department of Surgery, Queen Elizabeth II Health Sciences CenterHalifax, NS, Canada
| | - Robert Berry
- Section of Vascular and Interventional Radiology, Department of Diagnostic Radiology, Queen Elizabeth II Health Sciences CenterHalifax, NS, Canada
| | - Mohamed Abdolell
- Department of Diagnostic RadiologyHalifax, NS, Canada,Division of Medical Education, Dalhousie UniversityHalifax, NS, Canada
| | - Michele Molinari
- Department of Surgery, Queen Elizabeth II Health Sciences CenterHalifax, NS, Canada
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Abstract
The Model for End-stage Liver Disease (MELD) score is the basis for allocation of liver allografts for transplantation in the United States. The MELD score, as an objective scale of disease severity, is also used in the management of patients with chronic liver disease in the nontransplant setting. Several models have been proposed to improve the MELD score. The authors believe that the MELD score is, by design, continually evolving and lends itself to continued refinement and improvement to serve as a metric to optimize organ allocation in the future.
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Affiliation(s)
- Sumeet K Asrani
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - W. Ray Kim
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota
- Corresponding Author, W Ray Kim, 200 First Street SW, Rochester, Minnesota 55905, fax: 507-538-3974, telephone: 507-538-0254,
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Abstract
BACKGROUND A growth in the utilization of high-risk allografts is reflective of a critical national shortage and the increasing waiting list mortality. Using risk-adjusted models, the aim of the present study was to determine whether a volume-outcome relationship existed among liver transplants at high risk for allograft failure. METHODS From 2002 to 2008, the Scientific Registry of Transplant Recipients (SRTR) database for all adult deceased donor liver transplants (n = 31 587) was queried. Transplant centres (n = 102) were categorized by volume into tertiles: low (LVC; 31 cases/year), medium (MVC: 64 cases/year) and high (HVC: 102 cases/year). Donor risk comparison groups were stratified by quartiles of the Donor Risk Index (DRI) spectrum: low risk (DRI ≤ 1.63), moderate risk (1.64 > DRI > 1.90), high risk (1.91 > DRI > 2.26) and very high risk (DRI ≥ 2.27). RESULTS HVC more frequently used higher-risk livers (median DRI: LVC: 1.82, MVC: 1.90, HVC: 1.97; P < 0.0001) and achieved better risk adjusted allograft survival outcomes compared with LVC (HR: 0.90, 95%CI: 0.85-0.95). For high and very high risk groups, transplantation at a HVC did contribute to improved graft survival [high risk: hazard ratio (HR): 0.85, 95% confidence interval (CI): 0.76-0.96; Very High Risk: HR: 0.88, 95%CI: 0.78-0.99]. CONCLUSION While DRI remains an important aspect of allograft survival prediction models, liver transplantation at a HVC appears to result in improved allograft survival with high and very high risk DRI organs compared with LVC.
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Affiliation(s)
- Deepak K Ozhathil
- Department of Surgery, Surgical Outcomes Analysis & Research, University of Massachusetts Medical School, Worcester, MA, USA
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29
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Somsouk M, Kornfield R, Vittinghoff E, Inadomi JM, Biggins SW. Moderate ascites identifies patients with low model for end-stage liver disease scores awaiting liver transplantation who have a high mortality risk. Liver Transpl 2011; 17:129-36. [PMID: 21280185 PMCID: PMC3058247 DOI: 10.1002/lt.22218] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Donor livers are offered to patients with the highest risk of death. How ascites could inform risk models to reduce liver transplant wait-list mortality is unclear. All adult candidates for primary liver transplantation for cirrhosis without exception points who were registered with the Organ Procurement and Transplantation Network from 2005 to 2007 composed our study cohort. Using Cox models and advanced discriminative metrics and paying attention to geographic disparities, we evaluated the additional risk discrimination of moderate ascites over that of the Model for End-Stage Liver Disease (MELD) or the Model for End-Stage Liver Disease plus serum sodium (MELD-Na) alone for the prediction of 90-day wait-list mortality. Additional analyses examined lower mortality risk candidates and those listed in high-demand, low-supply United Network for Organ Sharing regions in which accounting for ascites may most significantly affect wait-list mortality. Between 2005 and 2007, 18,124 subjects were listed for liver transplantation. Mortality was higher in patients with moderate ascites (15.4% versus 6.0%, P < 0.0001), and this risk persisted despite adjustments for MELD (hazard ratio = 1.58, 95% confidence interval = 1.42-1.76) and MELD-Na (hazard ratio = 1.42, 95% confidence interval = 1.28-1.58). The effect of moderate ascites was more prominent with a MELD score <21 (equal to 4.7 MELD units) or with a MELD-Na score <21 (equal to 3.5 MELD-Na units). Wait-list mortality was higher in patients with moderate ascites who were listed in high-demand, limited-supply regions (25.8% versus 17.5% at 1 year, P < 0.01). With the addition of moderate ascites, there was improvement in the overall risk model, particularly with a MELD score <21, as measured by the C index and integrated discrimination improvement. Moderate ascites informed risk prediction, particularly with a MELD score <21 and in high-demand, limited-supply regions. Under the MELD system, the presence of moderate ascites should prompt clinicians to consider strategies to expand access to transplantation, such as the use of extended donor liver grafts.
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Affiliation(s)
- Ma Somsouk
- Department: Medicine, Division of Gastroenterology and Hepatology, Institution: San Francisco General Hospital. San Francisco, CA, Department: GI Health Outcomes, Policy and Economics (HOPE) Research Program, Institution: University of California, San Francisco. San Francisco, CA
| | - Rachel Kornfield
- Department: Medicine, Division of Gastroenterology and Hepatology, Institution: San Francisco General Hospital. San Francisco, CA, Department: GI Health Outcomes, Policy and Economics (HOPE) Research Program, Institution: University of California, San Francisco. San Francisco, CA
| | - Eric Vittinghoff
- Department: Epidemiology and Biostatistics, Institution: University of California, San Francisco. San Francisco, CA
| | - John M. Inadomi
- Department: Medicine, Division Gastroenterology and Hepatology, Institution: University of Washington. Seattle, WA
| | - Scott W. Biggins
- Department: Medicine, Division Gastroenterology and Hepatology, Institution: University of Colorado Health Sciences Center. Denver, CO
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30
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Abstract
Previous studies of men and women on the liver transplantation (LT) waiting list, without taking transplantation rates into account, have suggested a higher risk of mortality for women on the waiting list. The objective of this study was to compare men and women with respect to dying within 3 years of registration on the LT waiting list and to take into account both the immediate mortality risks and the transplantation rates. The analysis was based on Organ Procurement and Transplantation Network data for patients with end-stage liver disease (ESLD) on the waiting list who were registered between February 2002 and August 2009. Competing risk survival analysis was performed to assess the gender disparity in waiting-list mortality; 42,322 patients and 610,762 person-months of waiting-list experience were included in the analysis. The risk of dying within 3 years of listing was 19% and 17% in women and men, respectively (P < 0.0001). Among patients with kidney disease and especially those not on dialysis with an estimated glomerular filtration rate (eGFR) ≥15 and <30 mL/minute/1.73 m(2), women had a substantially higher risk of dying on the waiting list within 3 years of registration versus men (26% versus 20%, P = 0.001). This disparity was related to lower transplantation rates in women (transplantation rate ratio = 0.68, P < 0.0001). Controlling for eGFR and other variables related to mortality risk, we found that the overall female-male disparity disappeared. In conclusion, among patients with ESLD and kidney dysfunction who are not on dialysis, there is a substantial gender disparity in LT waiting-list mortality. Our analysis suggests as an explanation the fact that women have lower transplantation rates than men in this group. The lower transplantation rates can be explained in part by the fact that Model for End-Stage Liver Disease scores tend to be lower for women versus men because they are based on serum creatinine rather than the glomerular filtration rate.
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Affiliation(s)
- Ayse L Mindikoglu
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
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31
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Lim YS, Larson TS, Benson JT, Kamath PS, Kremers WK, Therneau TM, Kim WR. Serum sodium, renal function, and survival of patients with end-stage liver disease. J Hepatol 2010; 52:523-8. [PMID: 20185195 DOI: 10.1016/j.jhep.2010.01.009] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2009] [Revised: 09/15/2009] [Accepted: 10/22/2009] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Serum creatinine, a component of the model for end-stage liver disease (MELD), is an important prognostic indicator in patients with end-stage liver disease (ESLD). In addition, serum sodium has recently been recognized as an important predictor of mortality in patients with ESLD. We investigate the role of serum creatinine and sodium, and glomerular filtration rate (GFR) as determinants of survival in patients with ESLD. METHODS A prospective database was utilized to identify all adults listed for primary liver transplantation (LTx) at the Mayo Clinic, Rochester, between 1990 and 1999. GFR was measured by iothalamate clearance. RESULTS Among 837 patients listed for LTx, 660 had complete data including measured GFR. There was a significant association between GFR and survival after adjustment for MELD, with a linear rise in the risk of death as GFR decreased between 60 and 20ml/min/1.73m(2). Multivariable models showed that GFR is superior to creatinine in predicting mortality - a model consisting of total bilirubin (hazard ratio (HR)=2.17, p<0.01), INR (HR=3.26, p<0.01) and GFR (HR=0.42, p<0.01) was superior to MELD (chi-square 65.6 vs. 59.4, c-statistic 0.792 vs. 0.780). Serum sodium did not contribute to survival prediction when accurately measured GFR data were available. CONCLUSIONS Serum concentrations of creatinine and sodium in patients with end-stage liver disease reflect a reduction in renal function, the underlying event that decreases survival.
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32
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Abstract
More candidates with creatinine levels >or= 2 mg/dL have undergone liver transplantation (LT) since the implementation of Model for End-Stage Liver Disease (MELD)-based allocation. These candidates have higher posttransplant mortality. This study examined the effect of serum creatinine on survival benefit among candidates undergoing LT. Scientific Registry of Transplant Recipients data were analyzed for adult LT candidates listed between September 2001 and December 2006 (n = 38,899). The effect of serum creatinine on survival benefit (contrast between waitlist and post-LT mortality rates) was assessed by sequential stratification, an extension of Cox regression. At the same MELD score, serum creatinine was inversely associated with survival benefit within certain defined MELD categories. The survival benefit significantly decreased as creatinine increased for candidates with MELD scores of 15 to 17 or 24 to 40 at LT (MELD scores of 15-17, P < 0.0001; MELD scores of 24-40, P = 0.04). Renal replacement therapy at LT was also associated with significantly decreased LT benefit for patients with MELD scores of 21 to 23 (P = 0.04) or 24 to 26 (P = 0.01). In conclusion, serum creatinine at LT significantly affects survival benefit for patients with MELD scores of 15 to 17 or 24 to 40. Given the same MELD score, patients with higher creatinine levels receive less benefit on average, and the relative ranking of a large number of wait-listed candidates with MELD scores of 15 to 17 or 24 to 40 would be markedly affected if these findings were incorporated into the allocation policy.
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Affiliation(s)
- Pratima Sharma
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Douglas E. Schaubel
- Department of Biostatistics, University of Michigan, Ann Arbor, MI
,
Scientific Registry of Transplant Recipients, Ann Arbor, MI
| | - Mary K. Guidinger
- Scientific Registry of Transplant Recipients, Ann Arbor, MI
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Arbor Research Collaborative for Health, Ann Arbor, MI
| | - Robert M. Merion
- Scientific Registry of Transplant Recipients, Ann Arbor, MI
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Department of Surgery, University of Michigan, Ann Arbor, MI
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33
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SOMSOUK M, GUY J, BIGGINS S, VITTINGHOFF E, KOHN M, INADOMI J. Ascites improves upon [corrected] serum sodium plus [corrected] model for end-stage liver disease ( MELD) for predicting mortality in patients with advanced liver disease. Aliment Pharmacol Ther 2009; 30:741-8. [PMID: 19604177 PMCID: PMC2742706 DOI: 10.1111/j.1365-2036.2009.04096.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The clinical impact of ascites has historically been well recognized; however, its value is unclear in the context of current prognostic models. AIM To determine whether ascites can improve risk discrimination beyond model for end-stage liver disease (MELD) and serum sodium (MELDNa). METHODS Consecutive cirrhotic patients were evaluated for ascites on the basis of an outpatient CT along with concurrent MELD and Na values. Cox models were used to determine the added value of ascites for predicting 1-year mortality. Increases in the C-index, integrated discrimination improvement (IDI) and the net reclassification index (NRI) were used to assess improvements in discrimination after the addition of ascites. RESULTS A total of 1003 patients had Na and MELD scores available within 30 days of the CT scan. A total of 60 deaths occurred within 1 year, with mortality higher in patients with ascites (21.4% vs. 4.0%, HR 6.08, 95% CI 3.62-10.19, P < 0.0005). In the presence of ascites, the MELD and MELDNa scores underestimated mortality risk when the scores were less than 21. The addition of ascites to the MELDNa model substantially improved discrimination by the C-index (0.804 vs. 0.770, increase of 3.4%, 95% CI 0.2-9.9%), IDI (1.8%, P = 0.016) and NRI (15.8%, P = 0.0006). CONCLUSION The incorporation of radiographic ascites significantly improves upon MELDNa for predicting 1-year mortality. The presence of ascites may help identify patients at increased risk for mortality, not otherwise captured by either MELD or MELDNa.
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Affiliation(s)
- M. SOMSOUK
- Department: Medicine, Division of Gastroenterology Institution: San Francisco General Hospital. San Francisco, CA, Department: GI Health Outcomes, Policy and Economics (HOPE) Research Program Institution: University of California, San Francisco. San Francisco, CA
| | - J. GUY
- Department: Medicine, Division of Gastroenterology Institution: San Francisco General Hospital. San Francisco, CA, Department: GI Health Outcomes, Policy and Economics (HOPE) Research Program Institution: University of California, San Francisco. San Francisco, CA
| | - S.W. BIGGINS
- Department: GI Health Outcomes, Policy and Economics (HOPE) Research Program Institution: University of California, San Francisco. San Francisco, CA, Department: Medicine, Division of Gastroenterology and Hepatology Institution: University of California, San Francisco
| | - E. VITTINGHOFF
- Department: Epidemiology and Biostatistics Institution: University of California, San Francisco. San Francisco, CA
| | - M.A. KOHN
- Department: Epidemiology and Biostatistics Institution: University of California, San Francisco. San Francisco, CA
| | - J.M. INADOMI
- Department: Medicine, Division of Gastroenterology Institution: San Francisco General Hospital. San Francisco, CA, Department: GI Health Outcomes, Policy and Economics (HOPE) Research Program Institution: University of California, San Francisco. San Francisco, CA
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Boetticher NC, Peine CJ, Kwo P, Abrams GA, Patel T, Aqel B, Boardman L, Gores GJ, Harmsen WS, McClain CJ, Kamath PS, Shah VH. A randomized, double-blinded, placebo-controlled multicenter trial of etanercept in the treatment of alcoholic hepatitis. Gastroenterology 2008; 135:1953-60. [PMID: 18848937 PMCID: PMC2639749 DOI: 10.1053/j.gastro.2008.08.057] [Citation(s) in RCA: 225] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2008] [Revised: 07/28/2008] [Accepted: 08/28/2008] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Alcoholic hepatitis is a cause of major morbidity and mortality that lacks effective therapies. Both experimental and clinical evidence indicate that the multifunctional cytokine tumor necrosis factor-alpha (TNF-alpha) contributes to pathogenesis and clinical sequelae of alcoholic hepatitis. A pilot study demonstrated that the TNF-alpha-neutralizing molecule etanercept could be an effective treatment for patients with alcoholic hepatitis. METHODS Forty-eight patients with moderate to severe alcoholic hepatitis (Model for End-Stage Liver Disease score > or = 15) were enrolled and randomized to groups that were given up to 6 subcutaneous injections of either etanercept or placebo for 3 weeks. Primary study end points included mortality at 1- and 6-month time points. RESULTS There were no significant baseline differences between the placebo and etanercept groups in demographics or disease severity parameters including age, gender, and Model for End-Stage Liver Disease score. The 1-month mortality rates of patients receiving placebo and etanercept were similar on an intention-to-treat basis (22.7% vs 36.4%, respectively; OR, 1.8; 95% CI, 0.5-6.5). The 6-month mortality rate was significantly higher in the etanercept group compared with the placebo group (57.7% vs 22.7%, respectively; OR, 4.6; 95% CI, 1.3-16.4; P = .017). Rates of infectious serious adverse events were significantly higher in the etanercept group compared with the placebo group (34.6% vs 9.1%, respectively, P = .04). CONCLUSIONS In patients with moderate to severe alcoholic hepatitis, etanercept was associated with a significantly higher mortality rate after 6 months, indicating that etanercept is not effective for the treatment of patients with alcoholic hepatitis.
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Affiliation(s)
| | - Craig J. Peine
- Division of Gastroenterology/Department of Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Paul Kwo
- Department of Medicine, Indiana University, Indianapolis, IN
| | | | - Tushar Patel
- Department of Medicine, Scott & White Clinic, Temple, TX
| | - Bashar Aqel
- Division of Gastroenterology/Department of Medicine, Mayo Clinic, Scottsdale, AZ
| | - Lisa Boardman
- Miles and Shirley Fiterman Center for Digestive Diseases, Mayo Clinic, Rochester MN
| | - Gregory J. Gores
- Miles and Shirley Fiterman Center for Digestive Diseases, Mayo Clinic, Rochester MN
| | | | - Craig J. McClain
- Departments of Medicine and Pharmacology & Toxicology, University of Louisville and Louisville VAMC, Louisville, KY
| | - Patrick S. Kamath
- Miles and Shirley Fiterman Center for Digestive Diseases, Mayo Clinic, Rochester MN
| | - Vijay H. Shah
- Miles and Shirley Fiterman Center for Digestive Diseases, Mayo Clinic, Rochester MN
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Mayo MJ, Parkes J, Adams-Huet B, Combes B, Mills AS, Markin RS, Rubin R, Wheeler D, Contos M, West AB, Saldana S, Getachew Y, Butsch R, Luketic V, Peters M, Di Bisceglie A, Bass N, Lake J, Boyer T, Martinez E, Boyer J, Garcia-Tsao G, Barnes D, Rosenberg WM. Prediction of clinical outcomes in primary biliary cirrhosis by serum enhanced liver fibrosis assay. Hepatology 2008; 48:1549-57. [PMID: 18846542 PMCID: PMC2597274 DOI: 10.1002/hep.22517] [Citation(s) in RCA: 145] [Impact Index Per Article: 9.1] [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] [Indexed: 01/06/2023]
Abstract
UNLABELLED Primary biliary cirrhosis (PBC) is sometimes diagnosed based on a positive antimitochondrial antibody in the appropriate clinical setting without a liver biopsy. Although a liver biopsy can assess the extent of liver fibrosis and provide prognostic information, serum fibrosis markers avoid biopsy complications and sampling error and provide results as a continuous variable, which may be more precise than categorical histological stages. The current study was undertaken to evaluate serum fibrosis markers as predictors of clinical progression in a large cohort of PBC patients. Serial liver biopsy specimens and serum samples were collected every 2 years in 161 PBC subjects for a median of 7.3 years. Clinical progression was defined as development of one or more of the following events: varices, variceal bleed, ascites, encephalopathy, liver transplantation, or liver-related death. Serum hyaluronic acid, tissue inhibitor of metalloproteinase 1, and procollagen III aminopeptide were measured and entered into the previously validated enhanced liver fibrosis (ELF) algorithm. The ability of ELF, histological fibrosis, bilirubin, Model for End-Stage Liver Disease (MELD), and Mayo Risk Score to differentiate between individuals who would experience a clinical event from those who would not was evaluated at different time points. Event-free survival was significantly lower in those with high baseline ELF. Each 1-point increase in ELF was associated with a threefold increase in future complications. The prognostic performance of all tests was similar when performed close to the time of the first event. However, at earlier times in the disease process (4 and 6 years before the first event), the prognostic performance of ELF was significantly better than MELD or Mayo R score. CONCLUSION The ELF algorithm is a highly accurate noninvasive measure of PBC disease severity that provides useful long-term prognostic information.
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Affiliation(s)
- Marlyn J Mayo
- University of Texas Southwestern Medical Center, Dallas, TX 75390-9151, USA.
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Abstract
Cirrhosis is defined as the histological development of regenerative nodules surrounded by fibrous bands in response to chronic liver injury, which leads to portal hypertension and end-stage liver disease. Recent advances in the understanding of the natural history and pathophysiology of cirrhosis, and in treatment of its complications, have resulted in improved management, quality of life, and life expectancy of patients. Liver transplantation remains the only curative option for a selected group of patients, but pharmacological treatments that can halt progression to decompensated cirrhosis or even reverse cirrhosis are currently being developed. This Seminar focuses on the diagnosis, complications, and management of cirrhosis, and new clinical and scientific developments.
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Affiliation(s)
- Detlef Schuppan
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA.
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37
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Fisher RA, Kulik LM, Freise CE, Lok ASF, Shearon TH, Brown RS, Ghobrial RM, Fair JH, Olthoff KM, Kam I, Berg CL. Hepatocellular carcinoma recurrence and death following living and deceased donor liver transplantation. Am J Transplant 2007; 7:1601-8. [PMID: 17511683 PMCID: PMC3176596 DOI: 10.1111/j.1600-6143.2007.01802.x] [Citation(s) in RCA: 190] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We examined mortality and recurrence of hepatocellular carcinoma (HCC) among 106 transplant candidates with cirrhosis and HCC who had a potential living donor evaluated between January 1998 and February 2003 at the nine centers participating in the Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL). Cox regression models were fitted to compare time from donor evaluation and time from transplant to death or HCC recurrence between 58 living donor liver transplant (LDLT) and 34 deceased donor liver transplant (DDLT) recipients. Mean age and calculated Model for End-Stage Liver Disease (MELD) scores at transplant were similar between LDLT and DDLT recipients (age: 55 vs. 52 years, p = 0.21; MELD: 13 vs. 15, p = 0.08). Relative to DDLT recipients, LDLT recipients had a shorter time from listing to transplant (mean 160 vs. 469 days, p < 0.0001) and a higher rate of HCC recurrence within 3 years than DDLT recipients (29% vs. 0%, p = 0.002), but there was no difference in mortality or the combined outcome of mortality or recurrence. LDLT recipients had lower relative mortality risk than patients who did not undergo LDLT after the center had more experience (p = 0.03). Enthusiasm for LDLT as HCC treatment is dampened by higher HCC recurrence compared to DDLT.
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Affiliation(s)
- R. A. Fisher
- Department of Surgery, Medical College of Virginia Hospitals, Virginia Commonwealth University, Richmond, VA
| | - L. M. Kulik
- Department of Medicine, Northwestern University, Chicago, IL
| | - C. E. Freise
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - A. S. F. Lok
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - T. H. Shearon
- Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | - R. S. Brown
- Department of Medicine and Surgery, Columbia University College of Physicians and Surgeons, New York, NY
| | - R. M. Ghobrial
- Department of Surgery, University of California, Los Angeles, Los Angeles, CA
| | - J. H. Fair
- Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - K. M. Olthoff
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - I. Kam
- Department of Medicine, University of Colorado, Denver, CO
| | - C. L. Berg
- Department of Medicine, University of Virginia, Charlottesville, VA
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Botta F, Giannini E, Romagnoli P, Fasoli A, Malfatti F, Chiarbonello B, Testa E, Risso D, Colla G, Testa R. MELD scoring system is useful for predicting prognosis in patients with liver cirrhosis and is correlated with residual liver function: a European study. Gut 2003; 52:134-9. [PMID: 12477775 PMCID: PMC1773509 DOI: 10.1136/gut.52.1.134] [Citation(s) in RCA: 247] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/30/2002] [Indexed: 12/28/2022]
Abstract
BACKGROUND Indices for predicting survival are essential for assessing prognosis and assigning priority for liver transplantation in patients with liver cirrhosis. The model for end stage liver disease (MELD) has been proposed as a tool to predict mortality risk in cirrhotic patients. However, this model has not been validated beyond its original setting. AIM To evaluate the short and medium term survival prognosis of a European series of cirrhotic patients by means of MELD compared with the Child-Pugh score. We also assessed correlations between the MELD scoring system and the degree of impairment of liver function, as evaluated by the monoethylglycinexylidide (MEGX) test. PATIENTS AND METHODS We retrospectively evaluated survival of a cohort of 129 cirrhotic patients with a follow up period of at least one year. The Child-Pugh score was calculated and the MELD score was computed according to the original formula for each patient. All patients had undergone a MEGX test. Multivariate analysis was performed on all variables to identify the parameters independently associated with one year and six month survival. MELD values were correlated with both Child-Pugh scores and MEGX test results. RESULTS Thirty one patients died within the first year of follow up. Child-Pugh and MELD scores, and MEGX serum levels were significantly different among patients who survived and those who died. Serum creatinine, international normalised ratio, and MEGX(60) were independently associated with six month mortality while the same variables and the presence of ascites were associated with one year mortality. MELD scores showed significant correlations with both MEGX values and Child-Pugh scores. CONCLUSIONS In a European series of cirrhotic patients the MELD score is an excellent predictor of both short and medium term survival, and performs at least as well as the Child-Pugh score. An increase in MELD score is associated with a decrease in residual liver function.
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Affiliation(s)
- F Botta
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Italy
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