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Pose E, Piano S, Juanola A, Ginès P. Hepatorenal Syndrome in Cirrhosis. Gastroenterology 2024; 166:588-604.e1. [PMID: 38246506 DOI: 10.1053/j.gastro.2023.11.306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 11/10/2023] [Accepted: 11/19/2023] [Indexed: 01/23/2024]
Abstract
Hepatorenal syndrome (HRS) is a form of kidney dysfunction that characteristically occurs in liver cirrhosis. It is characterized by a marked impairment of kidney function in response to circulatory and hemodynamic alterations that occur in advanced stages of liver cirrhosis, aggravated by systemic inflammation and bacterial translocation. The classical definitions of the types of HRS have been recently revisited and 2 forms of HRS have been redefined: the acute form, referred to as acute kidney injury (HRS-AKI), and the chronic form, referred to as chronic kidney disease. HRS-AKI is one of the most severe forms of AKI in patients with cirrhosis and it consists of an abrupt impairment of kidney function, frequently triggered by an infection, appearing in the setting of advanced decompensated cirrhosis. Differential diagnosis with other causes of AKI is crucial because HRS-AKI requires a specific treatment. Differential diagnosis with AKI-acute tubular necrosis may be challenging and kidney biomarkers may be useful in this setting. Treatment of HRS-AKI is based on the administration of vasoconstrictor drugs in combination with volume expansion with albumin. Prognosis of HRS-AKI is poor, and the ideal definitive treatment consists of liver transplantation or simultaneous liver-kidney transplantation. HRS-AKI has a big impact on patients' quality of life. Management of HRS-AKI remains challenging in specific situations such as alcohol-associated hepatitis or metabolic-associated steatotic liver disease cirrhosis. Developing preventive measures for HRS-AKI, improving its early identification, discovering new biomarkers for differential diagnosis, and improving the response to therapy are some of the unmet needs in the field of HRS-AKI.
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Affiliation(s)
- Elisa Pose
- Liver Unit, Hospital Clínic of Barcelona, Barcelona, Catalunya, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalunya, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Salvatore Piano
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine - DIMED, University of Padova, Padova, Italy
| | - Adrià Juanola
- Liver Unit, Hospital Clínic of Barcelona, Barcelona, Catalunya, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalunya, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Pere Ginès
- Liver Unit, Hospital Clínic of Barcelona, Barcelona, Catalunya, Spain; School of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalunya, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalunya, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain.
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2
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Mehtani R, Saigal S. Long Term Complications of Immunosuppression Post Liver Transplant. J Clin Exp Hepatol 2023; 13:1103-1115. [PMID: 37975039 PMCID: PMC10643541 DOI: 10.1016/j.jceh.2023.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 06/18/2023] [Indexed: 11/19/2023] Open
Abstract
Improvement in immunosuppression has led to a remarkable improvement in short-term and long-term outcomes post-liver transplant (LT). However, with improvements in long-term survival, complications related to immunosuppressive drugs, either directly or indirectly, have also increased. The adverse events could be drug-specific, class-specific, or generic. Calcineurin inhibitors (cyclosporine and tacrolimus) are the backbone of the immunosuppression after LT and the main culprit associated with most of the complications, including renal failure, post-transplant diabetes mellitus (PTDM), and metabolic syndrome. Steroids are also implicated in the development of diabetes, osteoporosis, and metabolic syndrome post-LT. The development of infections and de novo malignancies (DNMs) is a generic effect linked to the overall cumulative immunosuppression. The development of these complications significantly hampers the quality of life and leads to increased morbidity and mortality post-LT. Thus, it is important to minimize the cumulative immunosuppression dose while simultaneously preventing allograft rejection. This review provides up-to-date, comprehensive knowledge of the complications of long-term immunosuppression post-LT along with associated risk factors and strategies to minimize the risk of complications.
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Affiliation(s)
- Rohit Mehtani
- Department of Hepatology, Amrita Institute of Medical Sciences and Research, Faridabad, Haryana - 121001, India
| | - Sanjiv Saigal
- Transplant Hepatology, Centre for Liver and Biliary Sciences, Max Superspecialty Hospital, Saket, New Delhi, India
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3
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Cooper KM, Colletta A, Moulton K, Ralto KM, Devuni D. Kidney disease in patients with chronic liver disease: Does sex matter? World J Clin Cases 2023; 11:3980-3992. [PMID: 37388789 PMCID: PMC10303604 DOI: 10.12998/wjcc.v11.i17.3980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/30/2023] [Accepted: 05/16/2023] [Indexed: 06/12/2023] Open
Abstract
Kidney disease in patients with liver disease is serious and increases mortality. Up to 50% of patients hospitalized experience an episode of acute kidney injury. In general, men with liver disease are thought to be at increased risk of kidney disease. However, this association should be considered with caution because most studies use creatinine-based inclusion criteria, which is negatively biased against women. In this review, we synthesize data on sex differences in kidney disease in patients with chronic liver disease in the clinical setting and discuss potential physiologic underpinnings.
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Affiliation(s)
- Katherine M Cooper
- Department of Medicine, UMass Chan Medical School, Worcester, MA 01665, United States
| | - Alessandro Colletta
- Department of Medicine, UMass Chan Medical School, Worcester, MA 01665, United States
| | - Kristen Moulton
- Department of Medicine, Division of Gastroenterology, UMass Chan Medical School, Worcester, MA 01665, United States
| | - Kenneth M Ralto
- Department of Medicine, Division of Renal Medicine, UMass Chan Medical School, Worcester, MA 01665, United States
| | - Deepika Devuni
- Department of Medicine, Division of Gastroenterology, UMass Chan Medical School, Worcester, MA 01665, United States
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Singh N, Watt KD, Bhanji RA. The fundamentals of sex-based disparity in liver transplantation: Understanding can lead to change. Liver Transpl 2022; 28:1367-1375. [PMID: 35289056 DOI: 10.1002/lt.26456] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 02/21/2022] [Accepted: 03/09/2022] [Indexed: 01/13/2023]
Abstract
Liver transplantation (LT) is the definitive treatment for end-stage liver disease. Unfortunately, women are disadvantaged at every stage of the LT process. We conducted a literature review to increase the understanding of this disparity. Hormonal differences, psychological factors, and Model for End-Stage Liver Disease (MELD) score inequalities are some pretransplantation factors that contribute to this disparity. In the posttransplantation setting, women have differing risk than men in most major outcomes (perioperative complications, rejection, long-term renal dysfunction, and malignancy) and assessing the two groups together is disadvantageous. Herein, we propose interventions including standardized criteria for LT referral, using an alternate MELD, education for support of women, and motivating women to seek living donors. Understanding sex-based differences will allow us to improve access, tailor management, and improve overall outcomes for all patients, particularly women.
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Affiliation(s)
- Noreen Singh
- Division of Gastroenterology (Liver Unit), University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Kymberly D Watt
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Rahima A Bhanji
- Division of Gastroenterology (Liver Unit), University of Alberta Hospital, Edmonton, Alberta, Canada
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5
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[Kidney failure after liver transplantation]. Nephrol Ther 2022; 18:89-103. [PMID: 35151596 DOI: 10.1016/j.nephro.2021.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 05/11/2021] [Accepted: 11/06/2021] [Indexed: 02/06/2023]
Abstract
One third of cirrhotic patients present impaired kidney function. It has multifactorial causes and has a harmful effect on patients' morbi-mortality before and after liver transplant. Kidney function does not improve in all patients after liver transplantation and liver-transplant recipients are at high risk of developing chronic kidney disease. Causes for renal dysfunction can be divided in three groups: preoperative, peroperative and postoperative factors. To date, there is no consensus for the modality of evaluation the risk for chronic kidney disease after liver transplantation, and for its prevention. In the present review, we describe the outcome of kidney function after liver transplantation, and the prognostic factors of chronic kidney disease to determine a risk stratification for each patient. Furthermore, we discuss therapeutic options to prevent kidney dysfunction in this setting, and highlight the indications of combined liver-kidney transplantation.
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Pacheco MP, Carneiro-D'Albuquerque LA, Mazo DF. Current aspects of renal dysfunction after liver transplantation. World J Hepatol 2022; 14:45-61. [PMID: 35126839 PMCID: PMC8790396 DOI: 10.4254/wjh.v14.i1.45] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 10/24/2021] [Accepted: 01/06/2022] [Indexed: 02/06/2023] Open
Abstract
The development of chronic kidney disease (CKD) after liver transplantation (LT) exerts a severe effect on the survival of patients. The widespread adoption of the model for end-stage liver disease score strongly impacted CKD incidence after the procedure, as several patients are transplanted with previously deteriorated renal function. Due to its multifactorial nature, encompassing pre-transplantation conditions, perioperative events, and nephrotoxic immunosuppressor therapies, the accurate identification of patients under risk of renal disease, and the implementation of preventive approaches, are extremely important. Methods for the evaluation of renal function in this setting range from formulas that estimate the glomerular filtration rate, to non-invasive markers, although no option has yet proved efficient in early detection of kidney injury. Considering the nephrotoxicity of calcineurin inhibitors (CNI) as a factor of utmost importance after LT, early nephroprotective strategies are highly recommended. They are based mainly on delaying the application of CNI during the immediate postoperative-period, reducing their dosage, and associating them with other less nephrotoxic drugs, such as mycophenolate mofetil and everolimus. This review provides a critical assessment of the causes of renal dysfunction after LT, the methods of its evaluation, and the interventions aimed at preserving renal function early and belatedly after LT.
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Affiliation(s)
- Mariana P Pacheco
- Division of Clinical Gastroenterology and Hepatology, Department of Gastroenterology, University of São Paulo School of Medicine, Sao Paulo 05403-900, Sao Paulo, Brazil
| | - Luiz Augusto Carneiro-D'Albuquerque
- Division of Digestive Organs Transplant, Department of Gastroenterology, University of São Paulo School of Medicine, Sao Paulo 05403-900, Sao Paulo, Brazil
| | - Daniel F Mazo
- Division of Clinical Gastroenterology and Hepatology, Department of Gastroenterology, University of São Paulo School of Medicine, Sao Paulo 05403-900, Sao Paulo, Brazil
- Division of Gastroenterology, Department of Internal Medicine, School of Medical Sciences of University of Campinas, Campinas 13083-878, Sao Paulo, Brazil
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Karnam RS, Chen S, Xu W, Chen C, Elangainesan P, Ghanekar A, McGilvray I, Reichman T, Sayed B, Selzner M, Sapisochin G, Galvin Z, Hirschfield G, Asrani SK, Selzner N, Cattral M, Lilly L, Bhat M. Sex Disparity in Liver Transplant and Access to Living Donation. JAMA Surg 2021; 156:1010-1017. [PMID: 34406347 PMCID: PMC8374729 DOI: 10.1001/jamasurg.2021.3586] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 05/22/2021] [Indexed: 12/15/2022]
Abstract
Importance The Model for End-stage Liver Disease (MELD)-based organ allocation system has significantly decreased mortality on the transplant waiting list for patients with end-stage liver disease. However, women have remained at a disadvantage with respect to access to deceased donor liver transplant (DDLT) even after introduction of the MELD score for organ allocation. Objective To determine whether availability of living donation in a transplant program can offset inequity in liver transplant (LT) allocation for women. Design, Setting, and Participants This cohort study retrospectively analyzed adult patients listed for LT at the University Health Network in Toronto, Ontario, Canada. Patients included had a potential living donor (pLD) at the moment of listing. This study was performed from November 13, 2012, to May 31, 2019. A total of 1289 listed patients (830 men; 459 women) were analyzed during the study period. Main Outcomes and Measures This study performed survival analysis and competing-risk analysis to delineate how access to livers from living donors was associated with events in women vs men on the transplant waiting list (LT, death, or dropout). Results Of 1289 included patients, 459 (35.6%) were women, and the mean (SD) age was 56.1 (10.0) years at assessment and listing. A total of 783 of 1289 listed patients underwent LT. Among those with no pLD at assessment, there was a higher median (range) Model for End-stage Liver Disease incorporating sodium levels (MELD-Na) score at listing (22 [6-50] vs 19 [6-50]; P < .001) and at LT (27 [6-49] vs 20 [6-52]; P < .001) in women receiving DDLT. Women were at a significant disadvantage without a pLD (hazard ratio [HR], 1.29; 95% CI, 1.04-1.60; P = .01); there was no difference in access to LT with availability of a pLD (HR, 0.93; 95% CI, 0.76,-1.14; P = .44). The instantaneous rate of receiving a transplant in men with a pLD was 1.39 times higher than men who did not have a pLD (HR, 1.39; 95% CI; P < .001) and the instantaneous rate of receiving a transplant in women with a pLD was 1.92 times higher than in women who did not (HR, 1.92; 95% CI, 1.51-2.44; P < .001). The HR was 1.38 times higher in women compared with men across the MELD-Na score strata (HR, 1.38; 95% CI, 1.03-1.84; P = .03) and 2.04 times higher when the MELD-Na score was less than 20 (HR, 2.04; 95% CI, 1.31-3.14; P = .001). Conclusions and Relevance These study findings suggest that women can overcome the complex problem of allocation inequity with access to livers from living donors. Women with access only to DDLT were much more unwell than men independent of liver disease at the time of listing, dropout, or LT. Therefore, the wider availability of living donation liver transplant would be helpful in addressing the sex disparity in access to LT in the current MELD-Na era.
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Affiliation(s)
- Ravikiran S. Karnam
- Multi Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
- Ramaiah Medical College, Narayana Health, Bengaluru, India
| | - Shiyi Chen
- Department of Biostatistics, Princess Margaret Cancer Research Centre, Toronto, Ontario, Canada
| | - Wei Xu
- Department of Biostatistics, Princess Margaret Cancer Research Centre, Toronto, Ontario, Canada
| | - Catherine Chen
- Multi Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Praniya Elangainesan
- Multi Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Anand Ghanekar
- Multi Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Ian McGilvray
- Multi Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Trevor Reichman
- Multi Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Blayne Sayed
- Multi Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Markus Selzner
- Multi Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Gonzalo Sapisochin
- Multi Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Zita Galvin
- Multi Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
- Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Gideon Hirschfield
- Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | | | - Nazia Selzner
- Multi Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
- Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Mark Cattral
- Multi Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Leslie Lilly
- Multi Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
- Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Mamatha Bhat
- Multi Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
- Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
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Abstract
One-third of patients with cirrhosis present kidney failure (AKI and CKD). It has multifactorial causes and a harmful effect on morbidity and mortality before and after liver transplantation. Kidney function does not improve in all patients after liver transplantation, and liver transplant recipients are at a high risk of developing chronic kidney disease. The causes of renal dysfunction can be divided into three groups: pre-operative, perioperative and post-operative factors. To date, there is no consensus on the modality to evaluate the risk of chronic kidney disease after liver transplantation, or for its prevention. In this narrative review, we describe the outcome of kidney function after liver transplantation, and the prognostic factors of chronic kidney disease in order to establish a risk categorization for each patient. Furthermore, we discuss therapeutic options to prevent kidney dysfunction in this context, and highlight the indications of combined liver–kidney transplantation.
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Sharma P, Sui Z, Zhang M, Magee JC, Barman P, Patel Y, Schluger A, Walter K, Biggins SW, Cullaro G, Wong R, Lai JC, Jo J, Sinha J, VanWagner L, Verna EC. Renal Outcomes After Simultaneous Liver-Kidney Transplantation: Results from the US Multicenter Simultaneous Liver-Kidney Transplantation Consortium. Liver Transpl 2021; 27:1144-1153. [PMID: 33641218 PMCID: PMC8823286 DOI: 10.1002/lt.26032] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 12/29/2020] [Accepted: 01/26/2021] [Indexed: 12/19/2022]
Abstract
Simultaneous liver-kidney transplantation (SLKT) is increasingly common in the United States. However, little is known about the renal-related outcomes following SLKT, which are essential to maximize the health of these allografts. We examined the factors impacting renal function following SLKT. This is an observational multicenter cohort study from the US Multicenter SLKT Consortium consisting of recipients of SLKT aged ≥18 years of transplantations performed between February 2002 and June 2017 at 6 large US centers in 6 different United Network for Organ Sharing regions. The primary outcome was incident post-SLKT stage 4-5 chronic kidney disease (CKD) defined as <30 mL/minute/1.73 m2 or listing for kidney transplant. The median age of the recipients (n = 570) was 58 years (interquartile range, 51-64 years), and 37% were women, 76% were White, 33% had hepatitis C virus infection, 20% had nonalcoholic steatohepatitis (NASH), and 23% had alcohol-related liver disease; 68% developed ≥ stage 3 CKD at the end of follow-up. The 1-year, 3-year, and 5-year incidence rates of post-SLKT stage 4-5 CKD were 10%, 12%, and 16%, respectively. Pre-SLKT diabetes mellitus (hazard ratio [HR], 1.45; 95% CI, 1.00-2.15), NASH (HR, 1.58; 95% CI, 1.01-2.45), and delayed kidney graft function (HR, 1.72; 95% CI, 1.10-2.71) were the recipient factors independently associated with high risk, whereas the use of tacrolimus (HR, 0.44; 95% CI, 0.22-0.89) reduced the risk. Women (β = -6.22 ± 2.16 mL/minute/1.73 m2 ; P = 0.004), NASH (β = -7.27 ± 3.27 mL/minute/1.73 m2 ; P = 0.027), and delayed kidney graft function (β = -7.25 ± 2.26 mL/minute/1.73 m2 ; P = 0.007) were independently associated with low estimated glomerular filtration rate at last follow-up. Stage 4-5 CKD is common after SLKT. There remains an unmet need for personalized renal protective strategies, specifically stratified by sex, diabetes mellitus, and liver disease, to preserve renal function among SLKT recipients.
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Affiliation(s)
- Pratima Sharma
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI
| | - Zhiyu Sui
- Department of Biostatistics, School of Public Health, Michigan Medicine, Ann Arbor, MI
| | - Min Zhang
- Department of Biostatistics, School of Public Health, Michigan Medicine, Ann Arbor, MI
| | - John C. Magee
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
| | - Pranab Barman
- Division of Gastroenterology and Hepatology, University of California, San Diego, CA
| | - Yuval Patel
- Division of Gastroenterology, Duke University, Durham, NC
| | - Aaron Schluger
- Section of Internal Medicine, Westchester Medical Center, Westchester, NY
| | - Kara Walter
- Division of Digestive Diseases, University of California, Los Angeles, CA
| | - Scott W. Biggins
- Division of Gastroenterology and Hepatology, University of Washington, Seattle, WA
| | - Giuseppe Cullaro
- Center for Liver Disease and Transplantation, Columbia University Irving Medical Center, New York, NY
| | - Randi Wong
- Division of Gastroenterology and Hepatology, University of California, San Francisco, CA
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, University of California, San Francisco, CA
| | - Jennifer Jo
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL
| | - Jasmine Sinha
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL
| | - Lisa VanWagner
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL
| | - Elizabeth C. Verna
- Center for Liver Disease and Transplantation, Columbia University Irving Medical Center, New York, NY
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Kim Y, Reddy S, Mouchli M, Summey R, Walsh C, Mir A, Bierle L, Rubio M. Gender-Specific Risk Factors Contributing to Mortality in Patients Hospitalized With Alcoholic Cirrhosis. Cureus 2021; 13:e16271. [PMID: 34377607 PMCID: PMC8349303 DOI: 10.7759/cureus.16271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2021] [Indexed: 11/05/2022] Open
Abstract
Introduction Identification of gender-specific prognostic factors in patients with alcoholic liver cirrhosis (ALC) is integral to understanding disease severity and mortality rates. We gathered data on various widely-used laboratory values and comorbid conditions among male and female patients with ALC after initial hospitalization. These individual risk factors were assessed for their relationship with mortality based on gender. Methods We performed a retrospective observational study of hospitalized patients with either a new or prior diagnosis of ALC from 2008 to 2016 with follow-up through June 2018. The electronic medical record (EMR) was queried for demographics, comorbidities, lab values, and mortality. The cumulative risks of mortality after the first hospitalization were estimated using Kaplan-Meier curves and compared among both genders. Demographic data, lab values, and comorbidities associated with cirrhosis were assessed using multivariate Cox proportional hazard analysis to determine risk factors associated with mortality. Results We identified 247 male patients (mean age 54.19 ± 13.14 years) and 78 female patients (mean age 51.10 ± 11.60 years) hospitalized at Carilion Clinic with a diagnosis of ALC. About 70% (male) and 46% (female) endorsed alcohol use at the time of admission, 10% (male) and 13% (female) endorsed illicit drug use, and 56% (male and female) endorsed tobacco use. The one-, three- and five-year cumulative mortality after the first hospitalization was 43.4%, 53.2%, and 61.6%, respectively for males and 24.1%, 59.0%, and 67.2%, respectively for females. Median survival for younger male patients with ALC (age < 40 years old) after the first hospitalization was significantly different compared to the older male patients (age > 40 years) (p=0.0009), but age was not a significant factor for survival of female patients. Multivariate analysis further shows that illicit drug use, creatinine level at the time of admission, and age > 40 years had the highest hazard ratios for risk of mortality in male patients. For female patients, history of hepatic encephalopathy (HE) and blood urea nitrogen (BUN) level at the time of discharge were both associated with increased risk of mortality, with a history of HE being associated with a higher hazard ratio for risk of mortality. Conclusion Age, illicit drug use, and creatinine level were risk factors associated with mortality for male patients with ALC but not female patients. Hepatic encephalopathy and BUN were risk factors associated with mortality for female patients. The mortality for male patients was about twice the mortality of female patients at one year, but three-year and five-year mortality was higher in female patients.
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Affiliation(s)
- Youseung Kim
- Internal Medicine, Virginia Tech Carilion School of Medicine, Roanoke, USA
| | - Shravani Reddy
- Gastroenterology and Hepatology, Virginia Tech Carilion School of Medicine, Roanoke, USA
| | - Mohamad Mouchli
- Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland , USA
| | - Robert Summey
- Medicine, University of Pennsylvania, Philadelphia, USA
| | - Chirstopher Walsh
- Internal Medicine, Virginia Tech Carilion School of Medicine, Roanoke, USA
| | - Adil Mir
- Internal Medicine, Carilion Clinic, Ronaoke , USA
| | - Lindsey Bierle
- Internal Medicine, Virginia Tech Carilion School of Medicine, Roanoke, USA
| | - Marrieth Rubio
- Gastroenterology and Hepatology, Virginia Tech Carilion School of Medicine, Roanoke, USA
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DI Renzo C, Vitale A, D'Amico F, Cillo U. NAFLD: a multi-faceted morbid spectrum with uncertain diagnosis and complicated management. Where do we stand? Review of the literature. Minerva Surg 2021; 76:450-466. [PMID: 33855376 DOI: 10.23736/s2724-5691.21.08729-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
NASH can be considered the "contemporary era pandemic", because of its global widespread in parallel with obesity, diabetes and metabolic dysfunction. It is a disease that often poses many difficulties, since making a early diagnosis is often impossible since specific diagnostic tests and criteria are missing: so, it needs a high degree of suspicion. Most of the times the evolution to its more severe and terminal step, NASH cirrhosis, is unavoidable and so are the social pressure on health sistem and economic consequences it brings back. In this work we aim to review the literature about both NAFLD and NASH, thus structuring a wide, comprehensive, 360 degree work with a focus on all major aspects of NAFLD, spanning from diagnosis, physiopathology and its repercussions on liver transplantation. Moreover we also focused on patients related issues both in pre- and post-transplant management (when these patients are listed for liver transplant). NAFLD and NASH are a contemporary plague, and an exaustive knowledge of the problem throughout all its aspects is necessary in order to lower economic weight that metabolic issues bring back and to have a open view to possible solutions to all management issues that NASH patients have and that are oten prohibitive to a definitive cure (for example cardiovascular risk in patients otherwise eligible to liver transplantation). We aim to offer a complete view on the actual knowledge about NAFLD and NASH, by an extensive review of the literature.
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Affiliation(s)
- Chiara DI Renzo
- Hepatobiliary Surgery and Liver Transplantation, Padova University Hospital, Padova, Italy -
| | - Alessandro Vitale
- Hepatobiliary Surgery and Liver Transplantation, Padova University Hospital, Padova, Italy
| | - Francesco D'Amico
- Hepatobiliary Surgery and Liver Transplantation, Padova University Hospital, Padova, Italy
| | - Umberto Cillo
- Hepatobiliary Surgery and Liver Transplantation, Padova University Hospital, Padova, Italy
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12
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Burra P, Becchetti C, Germani G. NAFLD and liver transplantation: Disease burden, current management and future challenges. JHEP Rep 2020; 2:100192. [PMID: 33163950 PMCID: PMC7607500 DOI: 10.1016/j.jhepr.2020.100192] [Citation(s) in RCA: 88] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 08/06/2020] [Accepted: 08/13/2020] [Indexed: 02/07/2023] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD), specifically its progressive form non-alcoholic steatohepatitis (NASH), represents the fastest growing indication for liver transplantation in Western countries. Diabetes mellitus, morbid obesity and cardiovascular disease are frequently present in patients with NAFLD who are candidates for liver transplantation. These factors require specific evaluation, including a detailed pre-surgical risk stratification, in order to improve outcomes after liver transplantation. Moreover, in the post-transplantation setting, the incidence of cardiovascular events and metabolic complications can be amplified by immunosuppressive therapy, which is a well-known driver of metabolic alterations. Indeed, patients with NASH are more prone to developing early post-transplant complications and, in the long-term, de novo malignancy and cardiovascular events, corresponding to higher mortality rates. Therefore, a tailored multidisciplinary approach is required for these patients, both before and after liver transplantation. Appropriate candidate selection, lifestyle modifications and specific assessment in the pre-transplant setting, as well as pharmacological strategies, adjustment of immunosuppression and a healthy lifestyle in the post-transplant setting, play a key role in correct management.
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Key Words
- CKD, chronic kidney disease
- CNI, calcineurin inhibitors
- DM, diabetes mellitus
- DPP-4, dipeptidyl peptidase-4
- ELTR, European Liver Transplant Registry
- ESLD, end-stage liver disease
- GLP1 RAs, glucagon-like peptide-1 receptor agonists
- Graft survival
- HCC, hepatocellular carcinoma
- HR, hazard ratio
- Hypertension
- IRR, incidence rate ratio
- Immunosuppressant
- LT, liver transplant
- MAFLD, metabolic dysfunction-associated fatty liver disease
- Metabolic complication
- NAFLD, non-alcoholic fatty liver disease
- NASH, non-alcoholic steatohepatitis
- New-onset diabetes after transplantation
- Non-alcoholic fatty liver disease
- Non-alcoholic steatohepatitis
- OR, odds ratio
- Obesity
- Patient survival
- SGLT2, sodium-glucose co-transporter-2
- Solid organ transplantation
- UNOS, United Network for Organ Sharing
- mTORi, mammalian target of rapamycin inhibitors
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Affiliation(s)
- Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University Hospital Padua, University of Padua, Padua, Italy
- Corresponding author. Address: Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital. Tel.: +39 0498212892; fax: + 390498217848.
| | - Chiara Becchetti
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University Hospital Padua, University of Padua, Padua, Italy
- Hepatology, Department of Visceral Surgery and Medicine, Inselspital, University Hospital Bern, Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Giacomo Germani
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University Hospital Padua, University of Padua, Padua, Italy
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Transplant Outcomes in Older Patients With Nonalcoholic Steatohepatitis Compared to Alcohol-related Liver Disease and Hepatitis C. Transplantation 2020; 104:e164-e173. [PMID: 32150036 DOI: 10.1097/tp.0000000000003219] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Patients with nonalcoholic steatohepatitis (NASH) are waitlisted at older ages than individuals with other liver diseases, but the effect of age on liver transplantation (LT) outcomes in this population and whether it differs from other etiologies is not known. We aimed to evaluate the impact of age on LT outcomes in NASH. METHODS The United Network for Organ Sharing database was used to identify adults with NASH, hepatitis C virus (HCV) infection, and alcohol-related liver disease (ALD) listed for LT during 2004-2017. Patients were split into age groups (18-49, 50-54, 55-59, 60-64, 65-69, ≥70), and their outcomes were compared. RESULTS From 2004 to 2017, 14 197 adults with NASH were waitlisted, and the proportion ≥65 increased from 15.8% to 28.9%. NASH patients ages 65-69 had an increased risk of waitlist and posttransplant mortality compared to younger groups, whereas the outcomes in ages 60-64 and 55-59 were similar. The outcomes of individuals with NASH were similar to patients of the same age group with ALD or HCV. Functional status and dialysis were predictors of posttransplant mortality in individuals ≥65 with NASH, and cardiovascular disease was the leading cause of death. CONCLUSIONS Older NASH patients (≥65) have an increased risk of waitlist and posttransplant mortality compared to younger individuals, although outcomes were similar to patients with ALD or HCV of corresponding age. These individuals should be carefully evaluated prior to LT, considering their functional status, renal function, and cardiovascular risk. Further studies are needed to optimize outcomes in this growing population of transplant candidates.
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14
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Steggerda JA, Mahendraraj K, Todo T, Noureddin M. Clinical considerations in the management of non-alcoholic steatohepatitis cirrhosis pre- and post-transplant: A multi-system challenge. World J Gastroenterol 2020; 26:4018-4035. [PMID: 32821068 PMCID: PMC7403794 DOI: 10.3748/wjg.v26.i28.4018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/07/2020] [Accepted: 07/14/2020] [Indexed: 02/06/2023] Open
Abstract
Non-alcoholic steatohepatitis (NASH) is the most common chronic liver disease worldwide, and the fastest growing indication for liver transplantation in the United States. NASH is now the leading etiology for liver transplantation in women, the second leading indication for men, and the most common cause amongst recipients aged 65 years and older. Patients with end-stage liver disease related to NASH represent a unique and challenging patient population due the high incidence of associated comorbid diseases, including obesity, type 2 diabetes (T2D), and hypertension. These challenges manifest in the pre-liver transplantation period with increased waitlist times and waitlist mortality. Furthermore, these patients carry considerable risk of morbidity and mortality both before after liver transplantation, with high rates of T2D, cardiovascular disease, chronic kidney disease, poor nutrition, and disease recurrence. Successful transplantation for these patients requires identification and management of their comorbidities in the face of liver failure. Multidisciplinary evaluations include a thorough pre-transplant workup with a complete cardiac evaluation, control of diabetes, nutritional support, and even, potentially, consultation with a bariatric surgeon. This article provides a comprehensive review of the conditions and challenges facing patients with NASH cirrhosis undergoing liver transplantation and provides recommendations for evaluation and management to optimize them before liver transplantation to produce successful outcomes.
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Affiliation(s)
- Justin A Steggerda
- Department of Surgery, Division of Transplantation, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
| | - Krishnaraj Mahendraraj
- Department of Surgery, Division of Transplantation, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
| | - Tsuyoshi Todo
- Department of Surgery, Division of Transplantation, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
| | - Mazen Noureddin
- Division of Digestive and Liver Diseases, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
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15
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Lonardo A, Suzuki A. Sexual Dimorphism of NAFLD in Adults. Focus on Clinical Aspects and Implications for Practice and Translational Research. J Clin Med 2020; 9:jcm9051278. [PMID: 32354182 PMCID: PMC7288212 DOI: 10.3390/jcm9051278] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 04/23/2020] [Accepted: 04/24/2020] [Indexed: 02/07/2023] Open
Abstract
Nonalcoholic fatty liver disease (NAFLD) embraces the clinico-pathological consequences of hepatic lipotoxicity and is a major public health problem globally. Sexual dimorphism is a definite feature of most human diseases but, under this aspect, NAFLD lags behind other medical fields. Here, we aim at summarizing and critically discussing the most prominent sex differences and gaps in NAFLD in humans, with emphasis on those aspects which are relevant for clinical practice and translational research. Sexual dimorphism of NAFLD is covered with references to the following areas: disease prevalence and risk factors, pathophysiology, comorbidities, natural course and complications. Finally, we also discuss selected gender differences and whether sex-specific lifestyle changes should be adopted to contrast NAFLD in men and women.
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Affiliation(s)
- Amedeo Lonardo
- Operating Unit Metabolic Syndrome, Azienda Ospedaliero-Universitaria di Modena, Ospedale Civile di Baggiovara, 41126 Baggiovara MO, Italy
- Correspondence:
| | - Ayako Suzuki
- Division of Gastroenterology, Durham VA Medical Center and Duke University Medical Center, Durham, NC 27705, USA;
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16
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Samji NS, Heda R, Satapathy SK. Peri-transplant management of nonalcoholic fatty liver disease in liver transplant candidates . Transl Gastroenterol Hepatol 2020; 5:10. [PMID: 32190778 DOI: 10.21037/tgh.2019.09.09] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Accepted: 09/23/2019] [Indexed: 12/12/2022] Open
Abstract
The incidence of non-alcoholic fatty liver disease (NAFLD) is rapidly growing, affecting 25% of the world population. Non-alcoholic steatohepatitis (NASH) is the most severe form of NAFLD and affects 1.5% to 6.5% of the world population. Its rising incidence will make end-stage liver disease (ESLD) due to NASH the number one indication for liver transplantation (LT) in the next 10 to 20 years, overtaking Hepatitis C. Patients with NASH also have a high prevalence of associated comorbidities such as type 2 diabetes, obesity, metabolic syndrome, cardiovascular disease, and chronic kidney disease (CKD), which must be adequately managed during the peritransplant period for optimal post-transplant outcomes. The focus of this review article is to provide a comprehensive overview of the unique challenges these patients present in the peritransplant period, which comprises the pre-transplant, intraoperative, and immediate postoperative periods.
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Affiliation(s)
- Naga Swetha Samji
- Tennova Cleveland Hospital, 2305 Chambliss Ave NW, Cleveland, TN, USA
| | - Rajiv Heda
- University of Tennessee Health Science Center, College of Medicine, Memphis, TN, USA
| | - Sanjaya K Satapathy
- Division of Hepatology and Sandra Atlas Bass Center for Liver Diseases, Northwell Health, Manhasset, NY, USA
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17
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Colombo D, Zullo A, Simoni L, Zagni E. The SURF (Italian observational study for renal insufficiency evaluation in liver transplant recipients): a post-hoc between-sex analysis. BMC Nephrol 2019; 20:475. [PMID: 31870321 PMCID: PMC6929500 DOI: 10.1186/s12882-019-1656-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 12/03/2019] [Indexed: 12/15/2022] Open
Abstract
Background Female sex has been reported as an independent predictor of severe post-liver transplantation (LT) chronic kidney disease. We performed a by sex post-hoc analysis of the SURF study, that investigated the prevalence of renal impairment following LT, aimed at exploring possible differences between sexes in the prevalence and course of post-LT renal damage. Methods All patients enrolled in the SURF study were considered evaluable for this sex-based analysis, whose primary objective was to evaluate by sex the proportion of patients with estimated Glomerular Filtration Rate (eGFR) < 60 ml/min/1.73m2 at inclusion and follow-up visit. Results Seven hundred thirty-eight patients were included in our analysis, 76% males. The proportion of patients with eGFR < 60 mL/min/1.73 m2 was significantly higher in females at initial study visit (33.3 vs 22.8%; p = 0.005), but also before, at time of transplantation (22.9 vs 14.7%; p = 0.0159), as analyzed retrospectively. At follow-up, such proportion increased more in males than in females (33.9 vs 26.0%, p = 0.04). Mean eGFR values decreased over the study in both sexes, with no significant differences. Statistically significant M/F differences in patient distribution by O’Riordan eGFR levels were observed at time of transplant and study initial visit (p = 0.0005 and 0.0299 respectively), but not at follow-up. Conclusions Though the limitation of being performed post-hoc, this analysis suggests potential sex differences in the prevalence of renal impairment before and after LT, encouraging further clinical research to explore such differences more in depth.
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Affiliation(s)
- Delia Colombo
- Novartis Farma S.p.A, Largo Umberto Boccioni, 21040, Origgio, VA, Italy
| | | | | | - Emanuela Zagni
- Novartis Farma S.p.A, Largo Umberto Boccioni, 21040, Origgio, VA, Italy.
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18
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Sharma P, Sun Y, Neal J, Erley J, Shen J, Tischer S, Sonnenday CJ, Park JM. Renal Outcomes of Liver Transplantation Recipients Receiving Standard Immunosuppression and Early Renal Sparing Immunosuppression: A Retrospective Single Center Study. Transplant Direct 2019; 5:e480. [PMID: 31579808 PMCID: PMC6739043 DOI: 10.1097/txd.0000000000000917] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 05/24/2019] [Accepted: 06/03/2019] [Indexed: 12/26/2022] Open
Abstract
New-onset stage 4-5 chronic kidney disease (CKD) after liver transplantation (LT) is associated with high morbidity, mortality, and economic burden. In 2010, we instituted an early renal sparing immunosuppression (RSI) protocol for LT recipients with severe renal dysfunction (pre-LT dialysis/estimated glomerular filtration rate (eGFR)<30mL/min/1.73 m2 or post-LT acute kidney injury) consisting of 2 doses of basiliximab for induction and delaying tacrolimus to post-LT day 4-7. We examined the effect of early RSI on post-LT renal outcomes. METHODS Data on all adults who had LT between January 1, 2010, and December 12, 2014 were collected. We calculated the renal risk index (RRI) score for each LT recipient (https://rri.med.umich.edu). Primary outcome was new-onset post-LT stage 4-5 CKD. RESULTS Of 214 LT recipients, 121 (57%) received early RSI and 93 (43%) received standard immunosuppression. Cumulative incidence of new-onset stage 4-5 CKD was higher in early RSI compared with standard immunosuppression (P = 0.03). Female sex and RRI score were the significant risk factors for development of post-LT stage CKD in the entire study cohort as well as the LT recipients with RRI ≥ sixth decile (high-risk group). CONCLUSIONS Delaying tacrolimus initiation combined with basiliximab induction did not have a durable effect on long-term renal outcomes in high-risk LT recipients. Further studies are needed to identify the effective strategies to preserve renal function by targeting patients at high risk for CKD progression.
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Affiliation(s)
- Pratima Sharma
- Division of Gastroenterology and Hepatology, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Yihan Sun
- College of Pharmacy, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Joslyn Neal
- College of Pharmacy, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Jennifer Erley
- College of Pharmacy, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - James Shen
- College of Pharmacy, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Sarah Tischer
- College of Pharmacy, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Christopher J. Sonnenday
- Department of Surgery, Section of Transplantation, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Jeong M. Park
- College of Pharmacy, Michigan Medicine, University of Michigan, Ann Arbor, MI
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19
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O’Leary JG, Bajaj JS, Tandon P, Biggins SW, Wong F, Kamath PS, Garcia-Tsao G, Maliakkal B, Lai J, Fallon M, Vargas HE, Thuluvath P, Subramanian R, Thacker LR, Reddy KR. Outcomes After Listing for Liver Transplant in Patients With Acute-on-Chronic Liver Failure: The Multicenter North American Consortium for the Study of End-Stage Liver Disease Experience. Liver Transpl 2019; 25:571-579. [PMID: 30724010 PMCID: PMC11075742 DOI: 10.1002/lt.25426] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Accepted: 01/08/2019] [Indexed: 02/07/2023]
Abstract
Acute-on-chronic liver failure (ACLF) characterized with ≥2 extrahepatic organ failures in cirrhosis carries a high mortality. Outcomes of patients listed for liver transplantation (LT) after ACLF and after LT are largely unknown. The North American Consortium for the Study of End-Stage Liver Disease prospectively enrolled 2793 nonelectively hospitalized patients with cirrhosis; 768 were listed for LT. Within 3 months, 265 (35%) received a LT, 395 remained alive without LT, and 108 died/delisted. Compared with nonlisted patients, those listed were younger and more often had ACLF, acute kidney injury, and a higher admission Model for End-Stage Liver Disease (MELD) score. ACLF was most common in patients who died/delisted, followed by those alive with and without LT respectively, (30%, 22%, and 7%, respectively; P < 0.001). At LT, median MELD was 27.9% and 70% were inpatients; median time from hospitalization to LT was 26 days. Post-LT survival at 6 months was unchanged between those with and without ACLF (93% each at 6 months). There was no difference in 3- and 6-month mean post-LT creatinine in those with and without ACLF, despite those with ACLF having a higher mean pre-LT creatinine and a higher rate of perioperative dialysis (61%). In conclusion, patients with and without ACLF had similar survival after transplant with excellent renal recovery in both groups.
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Affiliation(s)
| | - Jasmohan S. Bajaj
- Medicine, Virginia Commonwealth University and McGuire VA
Medical Center, Richmond, VA
| | | | | | | | | | | | | | | | | | | | - Paul Thuluvath
- Mercy Medical Center, University of Maryland School of
Medicine, Baltimore, MD
| | | | - Leroy R. Thacker
- Biostatistics, Virginia Commonwealth University and McGuire
VA Medical Center, Richmond, VA
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20
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Piano S, Tonon M, Angeli P. Predicting Outcomes of Liver Transplantation in Patients With Nonalcoholic Steatohepatitis: Pretransplant Renal Function Is Key. Liver Transpl 2019; 25:362-364. [PMID: 30657244 DOI: 10.1002/lt.25413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 01/14/2019] [Indexed: 01/13/2023]
Affiliation(s)
- Salvatore Piano
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padua, Padua, Italy
| | - Marta Tonon
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padua, Padua, Italy
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padua, Padua, Italy
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21
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Gitto S, Marra F, De Maria N, Bihl F, Villa E, Andreone P, Burra P. Nonalcoholic steatohepatitis before and after liver transplant: keeping up with the times. Expert Rev Gastroenterol Hepatol 2019; 13:173-178. [PMID: 30791778 DOI: 10.1080/17474124.2019.1551132] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In the last years, nonalcoholic steatohepatitis (NASH) has become a leading indication for liver transplant (LT). After transplant, both recurrent and de novo nonalcoholic fatty liver disease (NAFLD) can be commonly diagnosed. However, dedicated surveillance programs for patients with pre- or post-transplant NAFLD are not available. Areas covered: Patients waiting for LT for NASH show specific peculiarities and would deserve targeted stratification of mortality risk. Obesity, hyperlipidemia, and diabetes mellitus can be often found after transplant. These conditions, together with immunosuppressive regimen, make LT recipients a high-risk population for both recurrent and de novo NAFLD. Development of fatty liver disease after LT has a relevant impact on both morbidity and mortality. Expert commentary: A targeted stratification of neoplastic and cardiovascular risk for patients with NASH waiting for LT would be mandatory. In both pre- and post-transplant period, NAFLD should be considered not only a liver disease but also a cardiovascular risk factor. Patients within Transplant Program, especially those with known metabolic risk factors, should be followed with personalized diagnostic and life-style interventions before and after LT.
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Affiliation(s)
- Stefano Gitto
- a Department of Experimental and Clinical Medicine , University of Florence , Florence , Italy
| | - Fabio Marra
- a Department of Experimental and Clinical Medicine , University of Florence , Florence , Italy
| | - Nicola De Maria
- b Department of Gastroenterology , Azienda Ospedaliero-Universitaria and University of Modena and Reggio Emilia , Modena , Italy
| | - Florian Bihl
- c Hepatology Service , EOC , Bellinzona , Switzerland
| | - Erica Villa
- b Department of Gastroenterology , Azienda Ospedaliero-Universitaria and University of Modena and Reggio Emilia , Modena , Italy
| | - Pietro Andreone
- d Department of Medical and Surgical Sciences , University of Bologna and Azienda Ospedaliero-Universitaria di Bologna , Bologna , Italy
| | - Patrizia Burra
- e Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology , Padua University Hospital , Padua , Italy
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22
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Choudhary NS, Saigal S. Preventive Strategies for Nonalcoholic Fatty Liver Disease After Liver Transplantation. J Clin Exp Hepatol 2019; 9:619-624. [PMID: 31695252 PMCID: PMC6823688 DOI: 10.1016/j.jceh.2019.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 05/22/2019] [Indexed: 12/12/2022] Open
Abstract
Post-transplant nonalcoholic fatty liver disease (NAFLD) or nonalcoholic steatohepatitis (NASH) is common and can be recurrent or de novo. The available data suggest that progression of fibrosis is accelerated in these patients compared to NASH in general population. The long-term data suggest more risk of metabolic syndrome and associated metabolic comorbidities and cardiovascular disease in these patients. The current review focuses on prevalence and prevention/treatment of post-transplant NAFLD or NASH.
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Affiliation(s)
| | - Sanjiv Saigal
- Address for correspondence: Sanjiv Saigal, Director, Hepatology & Liver Transplant, Medanta Institute of Digestive & Hepatobiliary Sciences &Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, PIN 122001, India.
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23
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Yu JW, Gupta G, Kang L, Bandyopadhyay D, Siddiqui MS, Bhati CS, Stravitz RT, Levy M, Reichman TW. Obesity does not significantly impact outcomes following simultaneous liver kidney transplantation: review of the UNOS database - a retrospective study. Transpl Int 2018; 32:206-217. [DOI: 10.1111/tri.13352] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 02/19/2018] [Accepted: 09/13/2018] [Indexed: 12/14/2022]
Affiliation(s)
- Jonathan W. Yu
- Department of Biostatistics; Virginia Commonwealth, University; Richmond VA USA
| | - Gaurav Gupta
- Division of Nephrology; Department of Medicine; Virginia Commonwealth, University; Richmond VA USA
| | - Le Kang
- Department of Biostatistics; Virginia Commonwealth, University; Richmond VA USA
| | | | - Mohammed S. Siddiqui
- Division of Hepatology; Department of Medicine; Virginia Commonwealth, University; Richmond VA USA
| | - Chandra S. Bhati
- Division of Transplantation; Department of Surgery; Virginia Commonwealth University; Richmond VA USA
| | - Richard T. Stravitz
- Division of Hepatology; Department of Medicine; Virginia Commonwealth, University; Richmond VA USA
| | - Marlon Levy
- Division of Transplantation; Department of Surgery; Virginia Commonwealth University; Richmond VA USA
| | - Trevor W. Reichman
- Division of Transplantation; Department of Surgery; Virginia Commonwealth University; Richmond VA USA
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25
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Busch CJ, Siegler BH, Werle H, Lichtenstern C, Bruckner T, Heininger A, Mehrabi A, Weiss KH, Weigand MA, Hochreiter M. Risk factors for early viral infections after liver transplantation. Langenbecks Arch Surg 2018; 403:509-519. [DOI: 10.1007/s00423-018-1672-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 03/28/2018] [Indexed: 12/12/2022]
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26
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Mikolasevic I, Filipec-Kanizaj T, Mijic M, Jakopcic I, Milic S, Hrstic I, Sobocan N, Stimac D, Burra P. Nonalcoholic fatty liver disease and liver transplantation - Where do we stand? World J Gastroenterol 2018; 24:1491-1506. [PMID: 29662288 PMCID: PMC5897854 DOI: 10.3748/wjg.v24.i14.1491] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 03/19/2018] [Accepted: 03/25/2018] [Indexed: 02/06/2023] Open
Abstract
Nonalcoholic fatty liver disease/nonalcoholic steatohepatitis (NAFLD/NASH) is a challenging and multisystem disease that has a high socioeconomic impact. NAFLD/NASH is a main cause of macrovesicular steatosis and has multiple impacts on liver transplantation (LT), on patients on the waiting list for transplant, on post-transplant setting as well as on organ donors. Current data indicate new trends in the area of chronic liver disease. Due to the increased incidence of metabolic syndrome (MetS) and its components, NASH cirrhosis and hepatocellular carcinoma caused by NASH will soon become a major indication for LT. Furthermore, due to an increasing incidence of MetS and, consequently, NAFLD, there will be more steatotic donor livers and less high quality organs available for LT, in addition to a lack of available liver allografts. Patients who have NASH and are candidates for LT have multiple comorbidities and are unique LT candidates. Finally, we discuss long-term grafts and patient survival after LT, the recurrence of NASH and NASH appearing de novo after transplantation. In addition, we suggest topics and areas that require more research for improving the health care of this increasing patient population.
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Affiliation(s)
- Ivana Mikolasevic
- Department of Gastroenterology, UHC Rijeka, School of Medicine, University of Rijeka, Rijeka 51000, Croatia
| | - Tajana Filipec-Kanizaj
- Department of Gastroenterology, University Hospital Merkur, School of Medicine, University of Zagreb, Zagreb 10000, Croatia
| | - Maja Mijic
- Department of Gastroenterology, University Hospital Merkur, School of Medicine, University of Zagreb, Zagreb 10000, Croatia
| | - Ivan Jakopcic
- Department of Gastroenterology, UHC Rijeka, School of Medicine, University of Rijeka, Rijeka 51000, Croatia
| | - Sandra Milic
- Department of Gastroenterology, UHC Rijeka, School of Medicine, University of Rijeka, Rijeka 51000, Croatia
| | - Irena Hrstic
- Department of Internal medicine, General Hospital Pula, Pula, School of Medicine, University of Rijeka and Zagreb, Pula 52100, Croatia
| | - Nikola Sobocan
- Department of Gastroenterology, University Hospital Merkur, School of Medicine, University of Zagreb, Zagreb 10000, Croatia
| | - Davor Stimac
- Department of Gastroenterology, UHC Rijeka, School of Medicine, University of Rijeka, Rijeka 51000, Croatia
| | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
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Carter D, Dieterich DT, Chang C. Nonalcoholic Fatty Liver Disease/Nonalcoholic Steatohepatitis in Liver Transplantation. Clin Liver Dis 2018; 22:213-227. [PMID: 29128058 DOI: 10.1016/j.cld.2017.08.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The number of transplants caused by nonalcoholic fatty liver disease/nonalcoholic steatohepatitis (NASH) has been progressively increasing and this is expected to become the most common indication for liver transplant in the United States. Patients with NASH show many features of the metabolic syndrome and, as a result, are at higher risk for postoperative cardiovascular morbidity and mortality. Despite this, patients with NASH have long-term graft and patient survival rates comparable with other causes of chronic liver disease. Posttransplant metabolic syndrome is a common occurrence that increases the risk of steatosis in the graft liver.
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Affiliation(s)
- Danielle Carter
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, 17 East 102nd Street, 2nd Floor, New York, NY 10029, USA.
| | - Douglas T Dieterich
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, 17 East 102nd Street, 2nd Floor, New York, NY 10029, USA
| | - Charissa Chang
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, 17 East 102nd Street, 2nd Floor, New York, NY 10029, USA
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Stine JG, Argo CK, Pelletier SJ, Maluf DG, Caldwell SH, Northup PG. Advanced non-alcoholic steatohepatitis cirrhosis: A high-risk population for pre-liver transplant portal vein thrombosis. World J Hepatol 2017; 9:139-146. [PMID: 28217250 PMCID: PMC5295147 DOI: 10.4254/wjh.v9.i3.139] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 10/25/2016] [Accepted: 12/14/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To examine if liver transplant recipients with high-risk non-alcoholic steatohepatitis (NASH) are at increased risk for pre-transplant portal venous thrombosis.
METHODS Data on all liver transplants in the United States from February 2002 through September 2014 were analyzed. Recipients were sorted into three distinct groups: High-risk (age > 60, body mass index > 30 kg/m2, hypertension and diabetes), low-risk and non-NASH cirrhosis. Multivariable logistic regression models were constructed.
RESULTS Thirty-five thousand and seventy-two candidates underwent liver transplantation and of those organ recipients, 465 were transplanted for high-risk and 2775 for low-risk NASH. Two thousand six hundred and twenty-six (7.5%) recipients had pre-transplant portal vein thrombosis; 66 (14.2%) of the high-risk NASH group had portal vein thrombosis vs 328 (11.8%) of the low-risk NASH group. In general, all NASH recipients were less likely to be male or African American and more likely to be obese. In adjusted multivariable regression analyses, high-risk recipients had the greatest risk of pre-transplant portal vein thrombosis with OR = 2.11 (95%CI: 1.60-2.76, P < 0.001) when referenced to the non-NASH group.
CONCLUSION Liver transplant candidates with high-risk NASH are at the greatest risk for portal vein thrombosis development prior to transplantation. These candidates may benefit from interventions to decrease their likelihood of clot formation and resultant downstream hepatic decompensating events. Prospective study is needed.
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La Non Alcoholic Fatty Liver Disease (NAFLD) et la Non Alcoholic Steato-Hepatitis (NASH) des pathologies de système : revue pour le réanimateur. MEDECINE INTENSIVE REANIMATION 2016. [DOI: 10.1007/s13546-016-1253-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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O'Leary JG, Levitsky J, Wong F, Nadim MK, Charlton M, Kim WR. Protecting the Kidney in Liver Transplant Candidates: Practice-Based Recommendations From the American Society of Transplantation Liver and Intestine Community of Practice. Am J Transplant 2016; 16:2516-31. [PMID: 26990924 DOI: 10.1111/ajt.13790] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 02/18/2016] [Accepted: 03/08/2016] [Indexed: 01/25/2023]
Abstract
Acute kidney injury (AKI) and chronic kidney disease (CKD) are common in patients awaiting liver transplantation, and both have a marked impact on the perioperative and long-term morbidity and mortality of liver transplant recipients. Consequently, we reviewed the epidemiology of AKI and CKD in patients with end-stage liver disease, highlighted strategies to prevent and manage AKI, evaluated the changing liver transplant waiting list's impact on kidney function, delineated important considerations in simultaneous liver-kidney transplant selection, and projected possible future transplant policy changes and outcomes. This review was assembled by experts in the field and endorsed by the American Society of Transplantation Liver and Intestinal Community of Practice and Board of Directors and provides practice-based recommendations for preservation of kidney function in patients with end-stage liver disease.
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Affiliation(s)
- J G O'Leary
- Division of Hepatology, Baylor University Medical Center, Dallas, TX
| | - J Levitsky
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - F Wong
- Division of Gastroenterology, Department of Medicine, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - M K Nadim
- Division of Nephology and Hypertension, Department of Medicine, University of Southern California, Los Angeles, CA
| | - M Charlton
- Intermountain Transplant Center, Murray, UT
| | - W R Kim
- Division of Gastroenterology, Department of Medicine, Stanford University, Stanford, CA
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31
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Khan RS, Newsome PN. Non-alcoholic fatty liver disease and liver transplantation. Metabolism 2016; 65:1208-23. [PMID: 26997540 DOI: 10.1016/j.metabol.2016.02.013] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 02/01/2016] [Accepted: 02/23/2016] [Indexed: 02/07/2023]
Abstract
Cirrhosis secondary to non-alcoholic steatohepatitis (NASH) is a common indication for liver transplant. In comparison to other cirrhotic patients, patients with NASH cirrhosis are more likely to be older and have the metabolic syndrome. Pre-transplant, patients require careful evaluation of cardiovascular risk. As the incidence of non-alcoholic fatty liver disease (NAFLD) is rising, a greater proportion of donor grafts have steatosis greater than 30%, which is associated with poor outcomes. Grafts with steatosis greater than 60% are unsuitable for transplant. Overall, post-transplant survival outcomes for patients with NASH cirrhosis are similar to those with cirrhosis without NASH. However, NASH cirrhosis is associated with a higher 30-day mortality, predominantly from an increase in cardiovascular events and infections. Following liver transplant, there is a significant risk of NASH recurrence, although this seldom results in allograft loss. Furthermore, a significant number of patients who had a liver transplant for other reasons develop NASH de novo. When patients with NASH cirrhosis are considered for transplant, one of the major challenges lies in identifying which patients are too high risk for surgery. This review aims to provide information to aid this decision making process, and to provide guidance on the peri-operative care strategies that can modify risk.
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Affiliation(s)
- Reenam S Khan
- Gastroenterology and Hepatology, NIHR Birmingham Liver BRU and Centre for Liver Research, University of Birmingham, Birmingham, UK, B15 2TH.
| | - Philip N Newsome
- Hepatology, NIHR Birmingham Liver BRU and Centre for Liver Research, University of Birmingham, Birmingham, UK, B15 2TH.
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Teegen EM, Krebs I, Langelotz C, Pratschke J, Rau B. Gender Mainstreaming and Transplant Surgery. Visc Med 2016; 32:286-289. [PMID: 27722166 DOI: 10.1159/000446357] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Gender differences in medicine are gaining in importance. In transplant surgery, not only the patient's gender but also that of the donor play an important role in the outcome of transplantation due to sociocultural and genetic factors. METHODS This review article gives an overview of the latest investigations into gender-related influences in the field of visceral transplantation. For this purpose, a systematic review of the literature was performed. RESULTS In general, women are less often evaluated for and subjected to transplantation worldwide. Significantly poorer outcome can be observed in women with liver transplantation following hepatitis C cirrhosis. Furthermore, female renal grafts are less favorable in terms of outcome and survival. Gender disparities affect transplant medicine due to subtle gender-specific immunological factors. Sociocultural factors also lead to differences in the clinical treatment of men and women, which may influence overall survival. CONCLUSION For a better understanding of gender-specific differences in transplant medicine and a possible improvement in outcome, further research in this field is necessary.
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Affiliation(s)
- Eva Maria Teegen
- Department of General, Visceral and Transplant Surgery, Campus Virchow, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Isabell Krebs
- Department of General, Visceral, Vascular and Thoracic Surgery, Campus Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Corinna Langelotz
- Department of General, Visceral, Vascular and Thoracic Surgery, Campus Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Johann Pratschke
- Department of General, Visceral and Transplant Surgery, Campus Virchow, Charité - Universitätsmedizin Berlin, Berlin, Germany; Department of General, Visceral, Vascular and Thoracic Surgery, Campus Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Beate Rau
- Department of General, Visceral, Vascular and Thoracic Surgery, Campus Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Nonalcoholic Steatohepatitis is the Most Rapidly Growing Indication for Simultaneous Liver Kidney Transplantation in the United States. Transplantation 2016; 100:607-12. [PMID: 26479282 DOI: 10.1097/tp.0000000000000945] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Frequency of liver transplantation (LT) is increasing in nonalcoholic steatohepatitis (NASH) with good post-transplant outcomes. Similar data on simultaneous liver kidney (SLK) transplants are limited. METHODS United Network for Organ Sharing database (2002-2011) queried for deceased donor first LT for primary biliary cirrhosis, primary sclerosing cholangitis, or alcoholic cirrhosis (group I), NASH, and cryptogenic cirrhosis with body mass index greater than 30 (group II), and hepatitis C virus with and without alcohol, hepatitis B virus, and hepatocellular carcinoma (group III). RESULTS Of 38 533 LT (9495, 3665, and 25 383 in groups I-III, respectively), about 5.6% (N = 2162) received SLK with 584 (6.2%), 320 (8.7%), and 1258 (5%) in groups I-III, respectively. The SLK performed for group II increased from 6.3% in 2002 to 2003 to 19.2% in 2010 to 2011. Similar trends remained unchanged in group I (26.1 to 26.6%) and decreased in group III (67.6 to 54.5%). Five-year outcomes were similar comparing group II versus group I for liver graft (78 vs 74%, P = 0.14) and patient survival (81 vs 76%, P = 0.07). In contrast, kidney graft outcome was worse for group II (70 vs 79%, P = 0.002). Risk of kidney graft loss was over 1.5-fold higher among group II SLK recipients compared to group I after controlling for recipient characteristics. Estimated glomerular filtration rate remained lower in group II compared with group I at various time points after SLK transplantation. CONCLUSIONS The NASH is the most rapidly growing indication for SLK transplantation with poor renal outcomes. Studies are needed to examine mechanisms of these findings and develop strategies to improve renal outcomes in SLK recipients for NASH.
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Caragata R, Wyssusek KH, Kruger P. Acute kidney injury following liver transplantation: a systematic review of published predictive models. Anaesth Intensive Care 2016; 44:251-61. [PMID: 27029658 DOI: 10.1177/0310057x1604400212] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Acute kidney injury is a frequent postoperative complication amongst liver transplant recipients and is associated with increased morbidity and mortality. This systematic review analysed the existing predictive models, in order to solidify current understanding. Articles were selected for inclusion if they described the primary development of a clinical prediction model (either an algorithm or risk score) to predict AKI post liver transplantation. The database search yielded a total of seven studies describing the primary development of a prediction model or risk score for the development of AKI following liver transplantation. The models span thirteen years of clinical research and highlight a gradual change in the definitions of AKI, emphasising the need to employ standardised definitions for subsequent studies. Collectively, the models identify a diverse range of predictive factors with several common trends. They emphasise the impact of preoperative renal dysfunction, liver disease severity and aetiology, metabolic risk factors as well as intraoperative variables including measures of haemodynamic instability and graft quality. Although several of the models address postoperative parameters, their utility in predictive modelling seems to be of questionable relevance. The common risk factors identified within this systematic review provide a minimum list of variables, which future studies should address. Research in this area would benefit from prospective, multi-site studies with larger cohorts as well as the subsequent internal and external validation of predictive models. Ultimately, the ability to identify patients at high risk of post-transplant AKI may enable early intervention and perhaps prevention.
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Affiliation(s)
- R Caragata
- Department of Anaesthesia, Princess Alexandra Hospital, Queensland, Australia
| | - K H Wyssusek
- Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - P Kruger
- Princess Alexandra Hospital, Queensland, Australia, The University of Queensland, School of Medicine, Herston Rd, 4006 Brisbane, Queensland, Australia
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Giard JM, Terrault NA. Women with Cirrhosis: Prevalence, Natural History, and Management. Gastroenterol Clin North Am 2016; 45:345-58. [PMID: 27261903 DOI: 10.1016/j.gtc.2016.02.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cirrhosis is less frequent in women than in men, in large part due to the lower prevalence of hepatitis B, hepatitis C, and alcohol use in women. The most common causes of cirrhosis among women are hepatitis C, autoimmune etiologies, nonalcoholic steatohepatitis, and alcoholic liver disease. For most chronic liver diseases, the risk of progression to cirrhosis and rates of liver failure and hepatocellular carcinoma are lower in women than in men. Pregnancy is very infrequent in women with cirrhosis due to reduced fertility, but when it occurs, requires specialized management.
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Affiliation(s)
- Jeanne-Marie Giard
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, 400 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Norah A Terrault
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, 400 Parnassus Avenue, San Francisco, CA 94143, USA.
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Gitto S, Vukotic R, Vitale G, Pirillo M, Villa E, Andreone P. Non-alcoholic steatohepatitis and liver transplantation. Dig Liver Dis 2016; 48:587-91. [PMID: 27038703 DOI: 10.1016/j.dld.2016.02.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 01/22/2016] [Accepted: 02/23/2016] [Indexed: 02/08/2023]
Abstract
Non-alcoholic steatohepatitis is a growing liver-related health problem. In Europe, non-alcoholic fatty liver disease is the most usual reason of chronic liver illness while steatohepatitis, its progressive form, affects 1% of Europeans and North Americans. In the United States steatohepatitis-related cirrhosis is one of the main indications for liver transplant. A targeted stratification for patients waiting for transplant and affected by this disease is mandatory especially because of their increased cardiovascular and cancer risk. The adequate treatment of NAFLD is crucial for the reduction of the disease related morbidity and mortality. In post-transplant setting, the recurrent or de novo steatosis might seriously affect the allograft short- and long-term outcome. Many conditions can represent the basis of the post-transplant steatohepatitis: obesity, hyperlipidaemia, diabetes mellitus, arterial hypertension, immunosuppressant treatment, alcoholic habit and liver graft steatosis. Today, the only consolidated therapy is represented by a deep life-style intervention since the use of drug-based alternative strategies is still limited and a very few data are available for the post-transplant period. Targeted and personalized behaviour and pharmacological interventions have to be developed for both the pre- and post-transplant phase.
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Affiliation(s)
- Stefano Gitto
- Department of Gastroenterology, Azienda Ospedaliero-Universitaria and University of Modena and Reggio Emilia, Modena, Italy
| | - Ranka Vukotic
- Dipartimento di Scienze Mediche e Chirurgiche, Centro Studi e Ricerche sulle Epatiti, Alma Mater Studiorum, Univesity of Bologna, Bologna, Italy
| | - Giovanni Vitale
- Dipartimento di Scienze Mediche e Chirurgiche, Centro Studi e Ricerche sulle Epatiti, Alma Mater Studiorum, Univesity of Bologna, Bologna, Italy
| | - Martina Pirillo
- Dipartimento di Scienze Mediche e Chirurgiche, Centro Studi e Ricerche sulle Epatiti, Alma Mater Studiorum, Univesity of Bologna, Bologna, Italy
| | - Erica Villa
- Department of Gastroenterology, Azienda Ospedaliero-Universitaria and University of Modena and Reggio Emilia, Modena, Italy
| | - Pietro Andreone
- Dipartimento di Scienze Mediche e Chirurgiche, Centro Studi e Ricerche sulle Epatiti, Alma Mater Studiorum, Univesity of Bologna, Bologna, Italy.
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Role of cytokine gene polymorphisms in acute and chronic kidney disease following liver transplantation. Hepatol Int 2016; 10:665-72. [PMID: 27003899 DOI: 10.1007/s12072-016-9721-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 03/04/2016] [Indexed: 01/25/2023]
Abstract
PURPOSE Development of renal dysfunction, including acute kidney injury (AKI) and chronic kidney disease (CKD), after liver transplantation (LT) remains a critical issue adversely affecting patient survival in both the short and long term. Previous reports have suggested that inflammatory and antiinflammatory cytokines and their functionally relevant gene polymorphisms may play critical roles in the development of AKI and CKD. However, the involvement of these cytokines and their gene polymorphisms in renal deterioration following LT remains unclear. METHODS We examined 62 recipients who underwent LT at Nagoya University between 2004 and 2009 and who had survived for at least 1 year. The following gene polymorphisms in recipients were analyzed: tumor necrosis factor-A (TNFA) T-1031C, interleukin-2 (IL2) T-330G, IL10 C-819T, IL13 C-1111T, transforming growth factor-B (TGFB) T29C, and IL4 T-33C. RESULTS Thirteen patients (21 %) developed AKI within 4 weeks after LT. Of the investigated gene polymorphisms, the IL4 -33 T/T genotype was significantly associated with higher incidence of AKI compared with the other two genotypes [hazard ratio (HR) = 5.48, 95 % confidence interval (CI) 1.18-25.52, p = 0.03]. On the other hand, 16 patients (26 %) had developed CKD at median follow-up of 9.2 years after LT. We showed the lack of association between investigated gene polymorphisms in recipients and CKD development. CONCLUSIONS The IL4 -33 T/T genotype might be a risk factor for AKI in LT, and this might contribute to earlier withdrawal of immunosuppressive agents to minimize renal toxicity. In contrast, none of the investigated cytokine gene polymorphisms were associated with CKD.
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De Simone P, Saliba F, Dong G, Escrig C, Fischer L. Do patient characteristics influence efficacy and renal outcomes in liver transplant patients receiving everolimus? Clin Transplant 2016; 30:279-88. [PMID: 26717035 DOI: 10.1111/ctr.12687] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/24/2015] [Indexed: 01/04/2023]
Abstract
Data from the 24-month randomized, multicenter, open-label H2304 study in 719 de novo liver transplant recipients were analyzed to evaluate the influence of variables potentially affecting immunological or renal response: recipient age, gender, end-stage disease, hepatitis C virus (HCV) status, and Model for End-stage Liver Disease score and estimated glomerular filtration rate (eGFR) at randomization (day 30). Treated BPAR was similar between everolimus with reduced tacrolimus (EVR + Reduced TAC) vs. conventional tacrolimus-based therapy (TAC Control) in all subpopulations, with a trend to lower risk under everolimus with reduced tacrolimus (EVR + Reduced TAC) in patients < 60 yrs and HCV-negative recipients. Risk of graft loss or death was similar in both treatment groups for all subpopulations. The change in eGFR to month 24 showed a benefit for EVR + Reduced TAC vs. TAC Control in all subpopulations other than those with the lowest baseline eGFR (30 to < 55 mL/min/1.73 m(2)), with a significant difference in favor of EVR + Reduced TAC for younger recipients (< 60 yr), female patients, HCV-negative patients and those with baseline eGFR of 55 to < 70 mL/min/1.73 m(2). Everolimus with reduced tacrolimus maintains efficacy to at least two yr after liver transplantation even in patients with risk factors for rejection, with particular renal benefits in specific patient subpopulations.
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Affiliation(s)
- Paolo De Simone
- Hepatobiliary Surgery and Liver Transplantation, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Faouzi Saliba
- Hepatobiliary Center, AP-HP Hôpital Paul Brousse, Université Paris-Sud, Villejuif, France
| | | | | | - Lutz Fischer
- Department of Hepatobiliary Surgery and Transplantation, University Medical Center Eppendorf, Hamburg, Germany
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Spengler EK, Loomba R. Recommendations for Diagnosis, Referral for Liver Biopsy, and Treatment of Nonalcoholic Fatty Liver Disease and Nonalcoholic Steatohepatitis. Mayo Clin Proc 2015; 90. [PMID: 26219858 PMCID: PMC4567478 DOI: 10.1016/j.mayocp.2015.06.013] [Citation(s) in RCA: 184] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Nonalcoholic fatty liver disease (NAFLD) is the primary cause of chronic liver disease in the United States, afflicting an estimated 80 to 100 million Americans. Nonalcoholic fatty liver disease is a spectrum of liver diseases composed of nonalcoholic fatty liver and nonalcoholic steatohepatitis (NASH). Although nonalcoholic fatty liver has a negligible risk of progression, patients with NASH often develop cirrhosis or hepatocellular carcinoma. Although liver biopsy is required to diagnose NASH, only patients with a high risk of NASH or advanced fibrosis require this evaluation. Despite the high prevalence of NAFLD, well-defined screening recommendations are currently lacking. In this review, suggestions for screening, diagnosis, and initial work-up of NAFLD are given on the basis of established guidelines and recent publications. Proposed drug treatments of NASH are also discussed, highlighting the study outcomes, as well as proposed uses and limitations of these drugs. The literature was searched in PubMed using search terms nonalcoholic fatty liver disease and nonalcoholic steatohepatitis, with filters of "English language." A date range of January 1, 2000, to May 1, 2015, was used for the search. The bibliographies of key references were also searched manually, and seminal publications before the year 2000 were included.
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Affiliation(s)
- Erin K Spengler
- Division of Gastroenterology, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City
| | - Rohit Loomba
- NAFLD Translational Research Unit, Division of Gastroenterology, Department of Medicine, and Division of Epidemiology, Department of Family and Preventive Medicine, University of California San Diego School of Medicine, La Jolla, CA.
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40
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Liver Transplantation for NASH-Related Cirrhosis. CURRENT SURGERY REPORTS 2015. [DOI: 10.1007/s40137-015-0101-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Sarkar M, Watt KD, Terrault N, Berenguer M. Outcomes in liver transplantation: does sex matter? J Hepatol 2015; 62:946-55. [PMID: 25433162 PMCID: PMC5935797 DOI: 10.1016/j.jhep.2014.11.023] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 11/05/2014] [Accepted: 11/16/2014] [Indexed: 02/06/2023]
Abstract
A growing literature has highlighted important differences in transplant-related outcomes between men and women. In the United States there are fewer women than men on the liver transplant waitlist and women are two times less likely to receive a deceased or living-related liver transplant. Sex-based differences exist not only in waitlist but also in post-transplant outcomes, particularly in some specific liver diseases, such as hepatitis C. In the era of individualized medicine, recognition of these differences in the approach to pre and post-liver transplant care may impact short and long-term outcomes.
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Affiliation(s)
- Monika Sarkar
- Division of Gastroenterology and Hepatology, University of California, San Francisco, 513 Parnassus Avenue, S-357, San Francisco, CA 94143, USA.
| | - Kymberly D Watt
- Division of Gastroenterology and Hepatology, Mayo Clinic and Foundation, 200 First St, Rochester, MN 55905, USA
| | - Norah Terrault
- Division of Gastroenterology and Hepatology, University of California, San Francisco, 513 Parnassus Avenue, S-357, San Francisco, CA 94143, USA
| | - Marina Berenguer
- Hepatology and Liver Transplantation Unit, La Fe Hospital and Ciberehd, Universidad Valencia, C/Bulevar Sur sn (Torre F-5) 46026 Valencia, Spain
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Varo E, Bañares R, Guilera M. Underestimation of chronic renal dysfunction after liver transplantation: ICEBERG study. World J Transplant 2015; 5:26-33. [PMID: 25815269 PMCID: PMC4371159 DOI: 10.5500/wjt.v5.i1.26] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 02/10/2015] [Accepted: 03/09/2015] [Indexed: 02/05/2023] Open
Abstract
AIM: To compare prevalence of chronic renal dysfunction (CRD) according to serum creatinine (sCr) vs estimated glomerular filtration rate (eGFR) among maintenance liver transplant patients.
METHODS: The ICEBERG study was an observational, retrospective, cross-sectional, and multicenter study. Consecutive adult patients (aged 18 years or older) with liver transplantation (LT) performed at least two years previously were recruited. Multi-organ transplant recipients were excluded. Chronic renal dysfunction was defined according to sCr based criteria in routine clinical practice (≥ 2 mg/dL) and eGFR using MDRD-4 equation (< 60 mL/min per 1.73 m2). Agreement between sCr definition and eGFR assessment was evaluated using the Kappa index. Cox regression analysis was applied to identify predictive factors for developing CRD after LT.
RESULTS: A total of 402 patients were analyzed (71.6% males). Mean ± SD age at transplant was 52.4 ± 9.8 years. Alcoholic cirrhosis without hepatocellular carcinoma was the most common reason for LT (32.8%). Mean time since LT was 6.9 ± 3.9 years. Based on sCr assessment, 35.3% of patients (95%CI: 30.6-40.0) had CRD; 50.2% (95%CI: 45.3-55.1) according to eGFR. In 32.2% of cases, sCr assessment had underestimated CRD. Multivariate analysis showed the following factors associated with developing CRD: eGFR < 60 mL/min per 1.73 m2 at three months post-transplant [hazard ratio (HR) = 4.76; 95%CI: 2.78-8.33; P < 0.0001]; calcineurin inhibitor use (HR = 2.31; 95%CI: 1.05-5.07; P = 0.0371); male gender (HR = 1.98; 95%CI: 1.09-3.60; P = 0.0260); and ≥ 10 years post-transplantation (HR = 1.95; 95%CI: 1.08-3.54; P = 0.0279).
CONCLUSION: Seven years after LT, CRD affected half our patients, which was underestimated by sCr. An eGFR < 60 mL/min per 1.73 m2 three months post-LT was predictive of subsequent CRD.
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O'Leary JG. Debate--A bridge too far: Nonalcoholic fatty liver disease will not exhaust the donor pool. Liver Transpl 2014; 20 Suppl 2:S38-41. [PMID: 25164795 DOI: 10.1002/lt.23973] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Accepted: 07/30/2014] [Indexed: 01/12/2023]
Affiliation(s)
- Jacqueline G O'Leary
- Division of Hepatology, Annette C. & Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
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