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Groen RA, Barbero FL, Fischer SE, van Dijkman PRM, Bax JJ, Tushuizen ME, Jukema JW, Coenraad MJ, de Graaf MA. Coronary artery calcium assessment on non-gated chest CT to optimize pre-operative cardiac screening in liver transplantation. Int J Cardiol 2024; 407:132015. [PMID: 38609053 DOI: 10.1016/j.ijcard.2024.132015] [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: 02/06/2024] [Revised: 03/26/2024] [Accepted: 04/02/2024] [Indexed: 04/14/2024]
Abstract
BACKGROUND Guidelines recommend standard pre-operative cardiac screening in all liver transplantation (LT) recipients, despite the relatively low prevalence of obstructive coronary artery disease. Most LT recipients often have non-gated computed tomography (CT) performed of the chest and abdomen. This study evaluated the ability of coronary artery calcification (CAC) assessment on consecutively available scans, to identify a selection of low-risk patients, in whom further cardiac imaging can be safely withheld. METHODS LT recipients with prior non-gated CT chest-abdomen were included. CAC was visually scored on a semi-quantitative ordinal scale. Stress myocardial perfusion, coronary CT angiography (CCTA) and invasive coronary angiography (ICA) were used as golden standard. The sensitivity and specificity of CAC to exclude and predict obstructive CAD were assessed. In addition, peri- and postoperative mortality and cardiac events were analyzed. RESULTS 149 LT recipients (ranged 31-71 years) were included. In 75% of patients, no CAC and mild CAC could rule out obstructive CAD on CCTA and ICA with 100% certainty. The threshold of mild CAC had a sensitivity of 100% for both CCTA and ICA and a specificity of 91% and 68%, respectively. None of the patients with no or mild calcifications experienced peri- and post-operative cardiac events or died of cardiac causes. CONCLUSION Visual evaluation of CAC on prior non-gated CT can accurately and safely exclude obstructive CAD in LT recipients. Incorporation of these already available data can optimize cardiac screening, by safely withholding or correctly allocating dedicated cardiac imaging in LT recipients. Thereby, reducing patients' test burden and save health care expenses.
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Affiliation(s)
- Roos A Groen
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Fei Lynn Barbero
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Susan E Fischer
- Department of Gastro-enterology and Hepatology, Transplant Center, Leiden University Medical Centre, the Netherlands
| | - Paul R M van Dijkman
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Maarten E Tushuizen
- Department of Gastro-enterology and Hepatology, Transplant Center, Leiden University Medical Centre, the Netherlands
| | - J Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands; Netherlands Heart Institute, Utrecht, the Netherlands.
| | - Minneke J Coenraad
- Department of Gastro-enterology and Hepatology, Transplant Center, Leiden University Medical Centre, the Netherlands
| | - Michiel A de Graaf
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
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2
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Chadha RM. CT coronary angiography: Is it the new standard in coronary assessment for liver transplant candidates? Int J Cardiol 2024; 406:131999. [PMID: 38574999 DOI: 10.1016/j.ijcard.2024.131999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 03/27/2024] [Indexed: 04/06/2024]
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3
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Kitkungvan D, Johnson NP, Roby AE, Mendoza P, Bui L, Patel MB, Sander K, Harmon L, Kirkeeide R, Gould KL. Quantitative Myocardial Perfusion in Liver Transplantation Candidates: Poorly metabolized caffeine inhibition of vasodilatory stress. J Nucl Cardiol 2024:101884. [PMID: 38761831 DOI: 10.1016/j.nuclcard.2024.101884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 04/24/2024] [Accepted: 05/10/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Data on cardiac positron emission tomography (PET) in liver transplantation (LT) candidates are limited with no prior study accounting for poorly metabolized caffeine reducing stress perfusion. METHOD Consecutive LT candidates (n=114) undergoing cardiac rest/stress PET were instructed to abstain from caffeine for 2 days extended to 5 and 7 days. Due to persistently high prevalence of measurable blood caffeine after 5-day caffeine abstinence, dipyridamole (n=41) initially used was changed to dobutamine (n=73). Associations of absolute flow, coronary flow reserve (CFR), detectable blood caffeine, and Modified End-Stage Liver Disease (MELD) score for liver failure severity were evaluated. Coronary flow data of LT candidates were compared to non-LT control group (n=102 for dipyridamole, n=29 for dobutamine) RESULTS: Prevalence of patients with detectable blood caffeine was 63.3%, 36.7% and 33.3% after 2-, 5- and 7-day of caffeine abstinence, respectively. MELD score was associated with detectable caffeine (odd ratio 1.18,p<0.001). CFR was higher during dipyridamole stress without-caffeine vs. with-caffeine (2.22±0.80 vs. 1.55±0.37,p=0.048) but lower than dobutamine stress (2.22±0.80 vs. 2.82±1.02,p=0.026). Mediation analysis suggested that the dominant association between CFR and MELD score in dipyridamole group derived from caffeine-impaired CFR and liver failure/caffeine interaction. CFR in LT candidates was lower than non-LT control population in both dipyridamole and dobutamine group. CONCLUSIONS We demonstrate exceptionally high prevalence of detectable blood caffeine in LT candidates undergoing stress PET myocardial perfusion imaging resulting in reduced CFR with dipyridamole compared to dobutamine. The delayed caffeine clearance in LT candidates makes dobutamine a preferred stress agent in this population.
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Affiliation(s)
- Danai Kitkungvan
- Division of Cardiology, McGovern Medical School, University of Texas, Houston.
| | - Nils P Johnson
- Weatherhead Distinguished Chair of Heart Disease, Division of Cardiology, McGovern Medical School, University of Texas, Houston.
| | - Amanda E Roby
- Weatherhead PET Center, McGovern Medical School, University of Texas, Houston.
| | - Patricia Mendoza
- Weatherhead PET Center, McGovern Medical School, University of Texas, Houston.
| | - Linh Bui
- Division of Cardiology, McGovern Medical School, University of Texas, Houston.
| | - Monica B Patel
- Weatherhead PET Center, Division of Cardiology, McGovern Medical School, University of Texas, Houston.
| | - Kelly Sander
- Weatherhead PET Center, Division of Cardiology, McGovern Medical School, University of Texas, Houston.
| | - Lindsey Harmon
- Weatherhead PET Center, Division of Cardiology, McGovern Medical School, University of Texas, Houston.
| | - Richard Kirkeeide
- Weatherhead PET Center, McGovern Medical School, University of Texas, Houston.
| | - K Lance Gould
- Martin Bucksbaum Distinguished University Chair, Weatherhead PET Center for Preventing and Reversing Atherosclerosis, McGovern Medical School, University of Texas, Houston.
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4
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Sampaio Rodrigues T, Narendren A, Cailes B, Lim RP, Weinberg L, Testro A, Majumdar A, Sinclair M, Farouque O, Koshy AN. Enhancing pre-transplant cardiac assessment: Validation and utility of the CAD-LT score with CCTA in liver transplant candidates. Int J Cardiol 2024; 403:131895. [PMID: 38395260 DOI: 10.1016/j.ijcard.2024.131895] [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: 11/20/2023] [Revised: 01/08/2024] [Accepted: 02/18/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Coronary computed tomography angiography (CCTA) is increasingly being used in the preoperative workup for liver transplantation (LT). We sought to assess the utility of integrating CCTA with the novel CAD-LT (Coronary Artery Disease in Liver Transplantation) score and its impact on reducing the need for invasive coronary angiography prior to LT. METHODS We conducted a retrospective cohort study of consecutive patients (age ≥ 18 years) who underwent CCTA for LT workup between 2011 and 2018 at the Victorian Liver Transplant Unit, Melbourne, Australia. CAD-LT scores, a traditional risk factor-based criteria, were calculated, and patients stratified as low-, intermediate- or high-risk. RESULTS Overall, 229 patients underwent CCTA. The mean age was 66 ± 5 years (82% male) with a modest-to-high risk factor burden (diabetes, 53%; hypertension, 46%; current or former smoker, 62%). The mean CAD-LT score of our cohort was 12.4 ± 4.0. No patients were classified as low-risk, 49 patients (21.4%) were deemed intermediate-risk and 180 patients (78.6%) were deemed high-risk. A high CAD-LT score (≥ 9) showed high sensitivity (95.3% [95% CI 86-98%]) and modest specificity (27.8% [95% CI 21-35%]) for the detection of obstructive coronary artery disease on CCTA, with a negative predictive value of 94%. Following multidisciplinary discussions, only 41 patients (18%) of patients proceeded to ICA of which 27% received percutaneous coronary intervention. CONCLUSIONS The use of CCTA in patients deemed intermediate- to high-risk by the CAD-LT score has the potential to reduce the need for invasive coronary angiography in patients undergoing LT workup.
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Affiliation(s)
- Thalys Sampaio Rodrigues
- Department of Cardiology, Austin Health, Melbourne, VIC, Australia; Department of Medicine, The University of Melbourne, VIC, Australia
| | - Ahthavan Narendren
- Department of Cardiology, Austin Health, Melbourne, VIC, Australia; Department of Cardiology, Northern Health, Melbourne, VIC, Australia
| | - Benjamin Cailes
- Department of Cardiology, Austin Health, Melbourne, VIC, Australia; Department of Medicine, The University of Melbourne, VIC, Australia
| | - Ruth P Lim
- Department of Radiology, The University of Melbourne, VIC, Australia; Department of Radiology, Austin Health, Melbourne, VIC, Australia
| | - Laurence Weinberg
- Department of Medicine, The University of Melbourne, VIC, Australia; Department of Anaesthesiology, The University of Melbourne, VIC, Australia
| | - Adam Testro
- Department of Medicine, The University of Melbourne, VIC, Australia; Victorian Liver Transplant Unit, Austin Health, Melbourne, VIC, Australia
| | - Avik Majumdar
- Department of Medicine, The University of Melbourne, VIC, Australia; Victorian Liver Transplant Unit, Austin Health, Melbourne, VIC, Australia
| | - Marie Sinclair
- Department of Medicine, The University of Melbourne, VIC, Australia; Victorian Liver Transplant Unit, Austin Health, Melbourne, VIC, Australia
| | - Omar Farouque
- Department of Cardiology, Austin Health, Melbourne, VIC, Australia; Department of Medicine, The University of Melbourne, VIC, Australia
| | - Anoop N Koshy
- Department of Cardiology, Austin Health, Melbourne, VIC, Australia; Department of Medicine, The University of Melbourne, VIC, Australia; Department of Cardiology, Royal Melbourne Hospital, Melbourne, VIC, Australia.
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5
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Pagano G, Sastre L, Blasi A, Brugaletta S, Mestres J, Martinez-Ocon J, Ortiz-Pérez JT, Viñals C, Prat-Gonzàlez S, Rivas E, Perea RJ, Rodriguez-Tajes S, Muxí Á, Ortega E, Doltra A, Ruiz P, Vidal B, Martínez-Palli G, Colmenero J, Crespo G. CACS, CCTA and mCAD-LT score in the pre-transplant assessment of coronary artery disease and the prediction of post-transplant cardiovascular events. Liver Int 2024. [PMID: 38591767 DOI: 10.1111/liv.15926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 03/19/2024] [Accepted: 03/24/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND The optimal cardiovascular assessment of liver transplant (LT) candidates is unclear. We aimed to evaluate the performance of CT-based coronary tests (coronary artery calcium score [CACS] and coronary CT angiography [CCTA]) and a modification of the CAD-LT score (mCAD-LT, excluding family history of CAD) to diagnose significant coronary artery disease (CAD) before LT and predict the incidence of post-LT cardiovascular events (CVE). METHODS We retrospectively analysed a single-centre cohort of LT candidates who underwent non-invasive tests; invasive coronary angiography (ICA) was performed depending on the results of non-invasive tests. mCAD-LT was calculated in all patients. RESULTS Six-hundred-and-thirty-four LT candidates were assessed and 351 of them underwent LT. CACS, CCTA and ICA were performed in 245, 123 and 120 LT candidates, respectively. Significant CAD was found in 30% of patients undergoing ICA. The AUROCs of mCAD-LT (.722) and CCTA (.654) were significantly higher than that of CACS (.502) to predict the presence of significant CAD. Specificity of the tests ranged between 31% for CCTA and 53% for CACS. Among patients who underwent LT, CACS ≥ 400 and mCAD-LT were independently associated with the incidence of CVE; in patients who underwent CCTA before LT, significant CAD at CCTA also predicted post-LT CVE. CONCLUSION In this cohort, mCAD-LT score and CT-based tests detect the presence of significant CAD in LT candidates, although they tend to overestimate it. Both mCAD-LT score and CT-based tests classify LT recipients according to their risk of post-LT CVE and can be used to improve post-LT risk mitigation.
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Affiliation(s)
- Giulia Pagano
- Liver Transplant Unit, Hospital Clínic, Barcelona, Spain
- Department of Hepatology, Hospital Clínic, Barcelona, Spain
| | - Lydia Sastre
- Department of Gastroenterology and Hepatology, Hospital Son Espases, Palma de Mallorca, Spain
| | - Annabel Blasi
- Department of Anesthesiology, Hospital Clínic, Barcelona, Spain
- University of Barcelona, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- CIBER-EHD, Madrid, Spain
| | - Salvatore Brugaletta
- University of Barcelona, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- Department of Cardiology, Hospital Clínic, Barcelona, Spain
| | - Judit Mestres
- Department of Radiology, Hospital Clínic, Barcelona, Spain
| | | | - Jose T Ortiz-Pérez
- University of Barcelona, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- Department of Cardiology, Hospital Clínic, Barcelona, Spain
| | - Clara Viñals
- Department of Endocrinology and Nutrition, Hospital Clínic, Barcelona, Spain
| | - Susanna Prat-Gonzàlez
- University of Barcelona, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- Department of Cardiology, Hospital Clínic, Barcelona, Spain
| | - Eva Rivas
- Department of Anesthesiology, Hospital Clínic, Barcelona, Spain
| | - Rosario J Perea
- IDIBAPS, Barcelona, Spain
- Department of Radiology, Hospital Clínic, Barcelona, Spain
| | - Sergio Rodriguez-Tajes
- Liver Transplant Unit, Hospital Clínic, Barcelona, Spain
- Department of Hepatology, Hospital Clínic, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- CIBER-EHD, Madrid, Spain
| | - África Muxí
- IDIBAPS, Barcelona, Spain
- Department of Nuclear Medicine, Hospital Clínic, Barcelona, Spain
| | - Emilio Ortega
- University of Barcelona, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- Department of Endocrinology and Nutrition, Hospital Clínic, Barcelona, Spain
- CIBER-OBN, Madrid, Spain
| | - Ada Doltra
- University of Barcelona, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- Department of Cardiology, Hospital Clínic, Barcelona, Spain
| | - Pablo Ruiz
- Liver Transplant Unit, Hospital Clínic, Barcelona, Spain
- Department of Hepatology, Hospital Clínic, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
| | - Bàrbara Vidal
- University of Barcelona, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- Department of Cardiology, Hospital Clínic, Barcelona, Spain
| | - Graciela Martínez-Palli
- Department of Anesthesiology, Hospital Clínic, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- CIBER-RES, Madrid, Spain
| | - Jordi Colmenero
- Liver Transplant Unit, Hospital Clínic, Barcelona, Spain
- Department of Hepatology, Hospital Clínic, Barcelona, Spain
- University of Barcelona, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- CIBER-EHD, Madrid, Spain
| | - Gonzalo Crespo
- Liver Transplant Unit, Hospital Clínic, Barcelona, Spain
- Department of Hepatology, Hospital Clínic, Barcelona, Spain
- University of Barcelona, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- CIBER-EHD, Madrid, Spain
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6
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Chanan EL, Wagener G, Whitlock EL, Berger JC, McAdams-DeMarco MA, Yeh JS, Nunnally ME. Perioperative Considerations in Older Kidney and Liver Transplant Recipients: A Review. Transplantation 2024:00007890-990000000-00716. [PMID: 38557579 DOI: 10.1097/tp.0000000000005000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
With the growth of the older adult population, the number of older adults waitlisted for and undergoing kidney and liver transplantation has increased. Transplantation is an important and definitive treatment for this population. We present a contemporary review of the unique preoperative, intraoperative, and postoperative issues that patients older than 65 y face when they undergo kidney or liver transplantation. We focus on geriatric syndromes that are common in older patients listed for kidney or liver transplantation including frailty, sarcopenia, and cognitive dysfunction; discuss important considerations for older transplant recipients, which may impact preoperative risk stratification; and describe unique challenges in intraoperative and postoperative management for older patients. Intraoperative challenges in the older adult include using evidence-based best anesthetic practices, maintaining adequate perfusion pressure, and using minimally invasive surgical techniques. Postoperative concerns include controlling acute postoperative pain; preventing cardiovascular complications and delirium; optimizing immunosuppression; preventing perioperative kidney injury; and avoiding nephrotoxicity and rehabilitation. Future studies are needed throughout the perioperative period to identify interventions that will improve patients' preoperative physiologic status, prevent postoperative medical complications, and improve medical and patient-centered outcomes in this vulnerable patient population.
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Affiliation(s)
- Emily L Chanan
- Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Grossman School of Medicine, New York, NY
| | - Gebhard Wagener
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY
| | - Elizabeth L Whitlock
- Department of Anesthesia & Perioperative Care, University of California, San Francisco, San Francisco, CA
| | - Jonathan C Berger
- Department of Surgery, NYU Grossman School of Medicine, New York, NY
| | - Mara A McAdams-DeMarco
- Department of Surgery, NYU Grossman School of Medicine, New York, NY
- Department of Population Health, NYU Grossman School of Medicine, New York, NY
| | - Joseph S Yeh
- Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Grossman School of Medicine, New York, NY
| | - Mark E Nunnally
- Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Grossman School of Medicine, New York, NY
- Department of Surgery, NYU Grossman School of Medicine, New York, NY
- Department of Neurology, NYU Grossman School of Medicine, New York, NY
- Department of Medicine, NYU Grossman School of Medicine, New York, NY
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7
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Kim DS, Yoon YI, Kim BK, Choudhury A, Kulkarni A, Park JY, Kim J, Sinn DH, Joo DJ, Choi Y, Lee JH, Choi HJ, Yoon KT, Yim SY, Park CS, Kim DG, Lee HW, Choi WM, Chon YE, Kang WH, Rhu J, Lee JG, Cho Y, Sung PS, Lee HA, Kim JH, Bae SH, Yang JM, Suh KS, Al Mahtab M, Tan SS, Abbas Z, Shresta A, Alam S, Arora A, Kumar A, Rathi P, Bhavani R, Panackel C, Lee KC, Li J, Yu ML, George J, Tanwandee T, Hsieh SY, Yong CC, Rela M, Lin HC, Omata M, Sarin SK. Asian Pacific Association for the Study of the Liver clinical practice guidelines on liver transplantation. Hepatol Int 2024; 18:299-383. [PMID: 38416312 DOI: 10.1007/s12072-023-10629-3] [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: 05/15/2023] [Accepted: 12/18/2023] [Indexed: 02/29/2024]
Abstract
Liver transplantation is a highly complex and challenging field of clinical practice. Although it was originally developed in western countries, it has been further advanced in Asian countries through the use of living donor liver transplantation. This method of transplantation is the only available option in many countries in the Asia-Pacific region due to the lack of deceased organ donation. As a result of this clinical situation, there is a growing need for guidelines that are specific to the Asia-Pacific region. These guidelines provide comprehensive recommendations for evidence-based management throughout the entire process of liver transplantation, covering both deceased and living donor liver transplantation. In addition, the development of these guidelines has been a collaborative effort between medical professionals from various countries in the region. This has allowed for the inclusion of diverse perspectives and experiences, leading to a more comprehensive and effective set of guidelines.
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Affiliation(s)
- Dong-Sik Kim
- Department of Surgery, Korea University College of Medicine, Seoul, Republic of Korea
| | - Young-In Yoon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Beom Kyung Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Jun Yong Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jongman Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dong Hyun Sinn
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dong Jin Joo
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - YoungRok Choi
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jeong-Hoon Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ho Joong Choi
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ki Tae Yoon
- Department of Internal Medicine, Pusan National University College of Medicine, Yangsan, Republic of Korea
| | - Sun Young Yim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Cheon-Soo Park
- Department of Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Deok-Gie Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hae Won Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Won-Mook Choi
- Department of Gastroenterology, Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Young Eun Chon
- Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Woo-Hyoung Kang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jinsoo Rhu
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jae Geun Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yuri Cho
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Ilsan, Republic of Korea
| | - Pil Soo Sung
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Han Ah Lee
- Department of Internal Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Ji Hoon Kim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Si Hyun Bae
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jin Mo Yang
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Mamun Al Mahtab
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Soek Siam Tan
- Department of Medicine, Hospital Selayang, Batu Caves, Selangor, Malaysia
| | - Zaigham Abbas
- Sindh Institute of Urology and Transplantation, Karachi, Pakistan
| | - Ananta Shresta
- Department of Hepatology, Alka Hospital, Lalitpur, Nepal
| | - Shahinul Alam
- Crescent Gastroliver and General Hospital, Dhaka, Bangladesh
| | - Anil Arora
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital New Delhi, New Delhi, India
| | - Ashish Kumar
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital New Delhi, New Delhi, India
| | - Pravin Rathi
- TN Medical College and BYL Nair Hospital, Mumbai, India
| | - Ruveena Bhavani
- University of Malaya Medical Centre, Petaling Jaya, Selangor, Malaysia
| | | | - Kuei Chuan Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jun Li
- College of Medicine, Zhejiang University, Hangzhou, China
| | - Ming-Lung Yu
- Department of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | | | | | | | | | | | - H C Lin
- Endoscopy Center for Diagnosis and Treatment, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Masao Omata
- Department of Gastroenterology, Yamanashi Central Hospital, Yamanashi, Japan
- University of Tokyo, Bunkyo City, Japan
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8
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Martinez-Perez S, McCluskey SA, Davierwala PM, Kalra S, Nguyen E, Bhat M, Borosz C, Luzzi C, Jaeckel E, Neethling E. Perioperative Cardiovascular Risk Assessment and Management in Liver Transplant Recipients: A Review of the Literature Merging Guidelines and Interventions. J Cardiothorac Vasc Anesth 2024; 38:1015-1030. [PMID: 38185566 DOI: 10.1053/j.jvca.2023.11.039] [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: 08/23/2023] [Revised: 11/13/2023] [Accepted: 11/26/2023] [Indexed: 01/09/2024]
Abstract
Liver transplantation (LT) is the second most performed solid organ transplant. Coronary artery disease (CAD) is a critical consideration for LT candidacy, particularly in patients with known CAD or risk factors, including metabolic dysfunction associated with steatotic liver disease. The presence of severe CAD may exclude patients from LT; therefore, precise preoperative evaluation and interventions are necessary to achieve transplant candidacy. Cardiovascular complications represent the earliest nongraft-related cause of death post-transplantation. Timely intervention to reduce cardiovascular events depends on adequate CAD screening. Coronary disease screening in end-stage liver disease is challenging because standard noninvasive CAD screening tests have low sensitivity due to hyperdynamic state and vasodilatation. As a result, there is overuse of invasive coronary angiography to exclude severe CAD. Coronary artery calcium scoring using a computed tomography scan is a tool for the prediction of cardiovascular events, and can be used to achieve risk stratification in LT candidates. Recent literature shows that qualitative assessment on both noncontrast- and contrast-enhanced chest computed tomography can be used instead of calcium score to assess the presence of coronary calcium. With increasing prevalence, protocols to address CAD in LT candidates must be reconsidered. Percutaneous coronary intervention could allow a shorter duration of dual-antiplatelet therapy in simple lesions, with safer perioperative outcomes. Hybrid coronary revascularization is an option for high-risk LT candidates with multivessel disease nonamenable to percutaneous coronary intervention. The objective of this review is to evaluate existing methods for preoperative cardiovascular risk stratification, and to describe interventions before surgery to optimize patient outcomes and reduce cardiovascular event risk.
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Affiliation(s)
- Selene Martinez-Perez
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network and Department of Anesthesiology and Pain Medicine, Temetry Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Stuart A McCluskey
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network and Department of Anesthesiology and Pain Medicine, Temetry Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Piroze M Davierwala
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre Toronto, General Hospital, University Health Network, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Sanjog Kalra
- Division of Cardiology, Interventional Cardiology Section, Peter Munk Cardiac Center Toronto General Hospital, University Health Network and Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Elsie Nguyen
- Department of Medical Imaging, Cardiothoracic Imaging Division Lead, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mamatha Bhat
- Department of Gastroenterology, Hepatology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Cheryl Borosz
- Department of Gastroenterology, Toronto General Hospital, Toronto, Ontario, Canada
| | - Carla Luzzi
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network and Department of Anesthesiology and Pain Medicine, Temetry Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Elmar Jaeckel
- Department of Gastroenterology, Ajmera Transplant Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Elmari Neethling
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network and Department of Anesthesiology and Pain Medicine, Temetry Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
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9
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Gill JS, Chadban SJ. Pretransplant screening for coronary artery disease: data are required before practice change. Kidney Int 2024; 105:470-472. [PMID: 37914085 DOI: 10.1016/j.kint.2023.09.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 09/07/2023] [Accepted: 09/25/2023] [Indexed: 11/03/2023]
Abstract
Declining rates of peritransplant cardiovascular death, an increasing burden of pretransplant tests, and concerns about the effectiveness of screening candidates for coronary artery disease have led many transplant programs to de-escalate screening protocols. Recent Kidney Disease: Improving Global Outcomes and American Heart Association scientific statements and guidelines neatly summarize current evidence, but also identify areas of need. Here, we argue that key questions should be addressed by adequately powered clinical trials before our long-held screening paradigms are completely rewritten.
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Affiliation(s)
- John S Gill
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Steven J Chadban
- Department of Renal Medicine, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia; Kidney Node, Charles Perkins Centre, University of Sydney, New South Wales, Australia.
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10
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Wolff Gowdak LH, Galvão De Lima JJ, Adam EL, Kirnew Abud Manta IC, Reusing JO, David-Neto E, Machado César LA, Bortolotto LA. Coronary Artery Disease Assessment and Cardiovascular Events in Middle-Aged Patients on Hemodialysis. Mayo Clin Proc 2024; 99:411-423. [PMID: 38159095 DOI: 10.1016/j.mayocp.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 04/03/2023] [Accepted: 05/01/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVE To explore whether, in younger patients on dialysis with longer life expectancy, assessment of coronary artery disease (CAD) could identify individuals at higher risk of events and revascularization might improve outcomes in selected patients contrary to what had been observed in elderly patients. METHODS From August 1997 to January 2019, 2265 patients with stage 5 chronic kidney disease were prospectively referred for cardiovascular assessment. For this study, we selected 1374 asymptomatic patients aged between 18 and 64 years. After clinical risk stratification and cardiac scintigraphy by single-photon emission computed tomography, 866 patients underwent coronary angiography. The primary end point was the composite incidence of nonfatal/fatal major adverse cardiovascular events during a follow-up period of 0.1 to 189.7 months (median, 26 months). The secondary end point was all-cause mortality. RESULTS The primary end point occurred in 327 (23.8%) patients. Clinically stratified high-risk patients had a 3-fold increased risk of the primary end point. The prevalence of abnormal findings on perfusion scans was 29.2% (n=375), and significant CAD was found in 449 (51.8%) of 866 patients who underwent coronary angiography. An abnormal finding on myocardial perfusion scan and the presence of CAD were significantly associated with a 74% and 22% increased risk of cardiovascular events, respectively. In patients undergoing percutaneous coronary intervention or coronary artery bypass grafting (n=99), there was an 18% reduction in the risk of all-cause death relative to patients receiving medical treatment (P=.03). CONCLUSION In this cohort of middle-aged, asymptomatic patients on dialysis, assessment of CAD identified individuals at higher risk of events, and coronary intervention was associated with reducing the risk of death in selected patients.
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Affiliation(s)
- Luís Henrique Wolff Gowdak
- Heart Institute (InCor), Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil.
| | - José Jayme Galvão De Lima
- Heart Institute (InCor), Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Eduardo Leal Adam
- Heart Institute (InCor), Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | | | - José Otto Reusing
- Renal Transplantation Unit, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Elias David-Neto
- Renal Transplantation Unit, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Luiz Antonio Machado César
- Heart Institute (InCor), Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Luiz Aparecido Bortolotto
- Heart Institute (InCor), Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
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11
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Soldera J, Corso LL, Rech MM, Ballotin VR, Bigarella LG, Tomé F, Moraes N, Balbinot RS, Rodriguez S, Brandão ABDM, Hochhegger B. Predicting major adverse cardiovascular events after orthotopic liver transplantation using a supervised machine learning model: A cohort study. World J Hepatol 2024; 16:193-210. [PMID: 38495288 PMCID: PMC10941741 DOI: 10.4254/wjh.v16.i2.193] [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: 11/02/2023] [Revised: 12/27/2023] [Accepted: 02/04/2024] [Indexed: 02/27/2024] Open
Abstract
BACKGROUND Liver transplant (LT) patients have become older and sicker. The rate of post-LT major adverse cardiovascular events (MACE) has increased, and this in turn raises 30-d post-LT mortality. Noninvasive cardiac stress testing loses accuracy when applied to pre-LT cirrhotic patients. AIM To assess the feasibility and accuracy of a machine learning model used to predict post-LT MACE in a regional cohort. METHODS This retrospective cohort study involved 575 LT patients from a Southern Brazilian academic center. We developed a predictive model for post-LT MACE (defined as a composite outcome of stroke, new-onset heart failure, severe arrhythmia, and myocardial infarction) using the extreme gradient boosting (XGBoost) machine learning model. We addressed missing data (below 20%) for relevant variables using the k-nearest neighbor imputation method, calculating the mean from the ten nearest neighbors for each case. The modeling dataset included 83 features, encompassing patient and laboratory data, cirrhosis complications, and pre-LT cardiac assessments. Model performance was assessed using the area under the receiver operating characteristic curve (AUROC). We also employed Shapley additive explanations (SHAP) to interpret feature impacts. The dataset was split into training (75%) and testing (25%) sets. Calibration was evaluated using the Brier score. We followed Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis guidelines for reporting. Scikit-learn and SHAP in Python 3 were used for all analyses. The supplementary material includes code for model development and a user-friendly online MACE prediction calculator. RESULTS Of the 537 included patients, 23 (4.46%) developed in-hospital MACE, with a mean age at transplantation of 52.9 years. The majority, 66.1%, were male. The XGBoost model achieved an impressive AUROC of 0.89 during the training stage. This model exhibited accuracy, precision, recall, and F1-score values of 0.84, 0.85, 0.80, and 0.79, respectively. Calibration, as assessed by the Brier score, indicated excellent model calibration with a score of 0.07. Furthermore, SHAP values highlighted the significance of certain variables in predicting postoperative MACE, with negative noninvasive cardiac stress testing, use of nonselective beta-blockers, direct bilirubin levels, blood type O, and dynamic alterations on myocardial perfusion scintigraphy being the most influential factors at the cohort-wide level. These results highlight the predictive capability of our XGBoost model in assessing the risk of post-LT MACE, making it a valuable tool for clinical practice. CONCLUSION Our study successfully assessed the feasibility and accuracy of the XGBoost machine learning model in predicting post-LT MACE, using both cardiovascular and hepatic variables. The model demonstrated impressive performance, aligning with literature findings, and exhibited excellent calibration. Notably, our cautious approach to prevent overfitting and data leakage suggests the stability of results when applied to prospective data, reinforcing the model's value as a reliable tool for predicting post-LT MACE in clinical practice.
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Affiliation(s)
- Jonathan Soldera
- Post Graduate Program at Acute Medicine and Gastroenterology, University of South Wales, Cardiff CF37 1DL, United Kingdom
- Postgraduate Program in Pathology, Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre 90050-170, Brazil.
| | - Leandro Luis Corso
- Department of Engineering, Universidade de Caxias do Sul, Caxias do Sul 95070-560, Brazil
| | - Matheus Machado Rech
- School of Medicine, Universidade de Caxias do Sul, Caxias do Sul 95070-560, Brazil
| | | | | | - Fernanda Tomé
- Department of Engineering, Universidade de Caxias do Sul, Caxias do Sul 95070-560, Brazil
| | - Nathalia Moraes
- Department of Engineering, Universidade de Caxias do Sul, Caxias do Sul 95070-560, Brazil
| | | | - Santiago Rodriguez
- Postgraduate Program in Hepatology, Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre 90050-170, Brazil
| | - Ajacio Bandeira de Mello Brandão
- Postgraduate Program in Hepatology, Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre 90050-170, Brazil
| | - Bruno Hochhegger
- Postgraduate Program in Pathology, Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre 90050-170, Brazil
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12
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Corr M, Orr A, Courtney AE. The Minimisation of Cardiovascular Disease Screening for Kidney Transplant Candidates. J Clin Med 2024; 13:953. [PMID: 38398266 PMCID: PMC10889488 DOI: 10.3390/jcm13040953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 01/29/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
Background: There is increasing evidence that cardiac screening prior to kidney transplantation does not improve its outcomes. However, risk aversion to perioperative events means that, in practice, testing remains common, limiting the availability of 'real-world' data to support any change. Our objective was to assess perioperative and 1-year post-transplant cardiovascular events in a kidney transplant candidate cohort who received minimal cardiovascular screening. Methods: The retrospective cohort study included all adult kidney-only transplant recipients in a single UK region between January 2015 and December 2021. Kidney transplant recipients asymptomatic of cardiac disease, even those with established risk factors, did not receive cardiac stress testing. The perioperative and 1-year post-transplant cardiovascular event incidences were examined. Logistic regression was used to identify variables of statistical significance that predicted cardiovascular or cerebrovascular events. Results: A total of 895 recipients fulfilled the inclusion criteria. Prior to transplantation, 209 (23%) recipients had an established cardiac diagnosis, and 193 (22%) individuals had a diagnosis of diabetes. A total of 18 (2%) patients had a perioperative event, and there was a 5.7% incidence of cardiovascular events 1 year post-transplantation. The cardiovascular mortality rate was 0.0% perioperatively, 0.2% at 3 months post-transplant, and 0.2% at 1 year post-transplant. Conclusions: This study demonstrates comparable rates of cardiovascular events despite reduced screening in asymptomatic recipients. It included higher risk individuals who may, on the basis of screening results, have been excluded from transplantation in other programmes. It provides further evidence that extensive cardiac screening prior to kidney transplantation is unlikely to be offset by reduced rates of cardiovascular events.
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Affiliation(s)
- Michael Corr
- Centre for Public Health, Institute of Clinical Sciences B, Royal Victoria Hospital, Queen’s University Belfast, Belfast BT12 6BA, UK
| | - Amber Orr
- Barnsley Hospital NHS Foundation Trust, Barnsley S75 2EP, UK
| | - Aisling E. Courtney
- Regional Nephrology & Transplant Unit, Belfast City Hospital, Lisburn Road, Belfast BT9 7AB, UK
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13
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Stachel MW, DePasquale EC. Optimizing cardiac status in the preliver transplant candidate. Curr Opin Organ Transplant 2024; 29:50-55. [PMID: 37991086 DOI: 10.1097/mot.0000000000001119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Abstract
PURPOSE OF REVIEW Liver transplant is a widely accepted therapy for end-stage liver disease. With advances in our understanding of transplant, candidates are increasingly older with more cardiac comorbidities. Cardiovascular disease also represents a leading cause of morbidity and mortality posttransplant. RECENT FINDINGS Preoperative cardiac risk stratification and treatment may improve short-term and long-term outcomes after liver transplant. Importantly, the appropriate frequency of surveillance has not been defined. Optimal timing of cardiac intervention in end-stage liver disease is likewise uncertain. SUMMARY The approach to risk stratification of cardiovascular disease in end-stage liver disease is outlined, incorporating the AHA/ACC scientific statement on evaluation of cardiac disease in transplant candidates and more recent expert consensus documents. Further study is needed to clarify the ideal timing and approach for cardiovascular interventions.
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Affiliation(s)
- Maxine W Stachel
- Section of Heart Failure, Heart Transplantation & Mechanical Circulatory Support, Division of Cardiovascular Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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14
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Pint D, Gevaert AB, Vanwolleghem T, Chapelle T, Dams K. Heart failure with severely reduced ejection fraction after liver transplantation: a case report and review of the literature. Acta Clin Belg 2024; 79:46-51. [PMID: 37927044 DOI: 10.1080/17843286.2023.2278240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 10/28/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Liver transplantation (LT) is a strenuous event for the cardiovascular system. Cardiovascular events (CVE), including heart failure (HF), arrhythmias and myocardial ischemia, are important causes of peri- and post-liver transplantation morbidity and mortality. CASE PRESENTATION We describe the case of a 45-year-old male patient who developed heart failure with severely reduced ejection fraction (HFrEF) after receiving liver transplantation (LT) for end-stage post-alcoholic liver cirrhosis. Preoperative transthoracic echocardiography (TTE) demonstrated borderline left ventricular ejection fraction (LVEF) of 50% and diastolic dysfunction grade 2. On coronary angiography, the patient had no coronary stenoses. Persistent vasopressor need, increasing creatinine levels and progressive pleural effusion characterized the early postoperative period. TTE on postoperative day 6 revealed a new finding of a markedly reduced LVEF of 15%, accompanied by a discrete increase in hs-TnI and CK-MB without electrocardiographic (ECG) ST-T abnormalities. LVEF did not recover completely (EF 45%) during follow-up. The patient had a sudden death 4.5 months post-liver transplantation. CONCLUSION Our case demonstrates that the risk of post-LT systolic dysfunction is not excluded by preoperative resting examinations within normal range and highlights the need for preoperative cardiac stress assessment (e.g. dobutamine echocardiography or stress cardiac magnetic resonance imaging) before LT. In addition, patients on a liver-transplant waiting list with cardiac dysfunction should be followed by a multidisciplinary team including a dedicated cardiology team experienced in managing liver-related cardiac pathology.
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Affiliation(s)
- Dorien Pint
- Department of Gastroenterology and Hepatology, Antwerp University Hospital, Antwerp, Belgium
| | - Andreas B Gevaert
- Research Group Cardiovascular Diseases, GENCOR department, University of Antwerp, Antwerp, Belgium
- Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium
| | - Thomas Vanwolleghem
- Department of Gastroenterology and Hepatology, Antwerp University Hospital, Antwerp, Belgium
- Viral Hepatitis Research Group, Laboratory of Experimental Medicine and Pediatrics (LEMP), Antwerp University, Antwerp, Belgium
- European Reference Network RARE-LIVER, Antwerp University Hospital, Antwerp, Belgium
| | - Thiery Chapelle
- Department of Hepatobiliary, Transplantation and Endocrine Surgery, Antwerp University Hospital, Antwerp, Belgium
| | - Karolien Dams
- Department of Critical Care Medicine, Antwerp University Hospital, Antwerp, Belgium
- Laboratory of Experimental Medicine and Paediatrics (LEMP), Faculty of Medicine and Health Sciences, Antwerp University, Antwerp, Belgium
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15
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Kuo SZ, Tincopa M. Predicting cardiovascular events after liver transplant: Is CT coronary angiography the noninvasive test we have been looking for? Liver Transpl 2024; 30:117-118. [PMID: 37773041 DOI: 10.1097/lvt.0000000000000264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 09/13/2023] [Indexed: 09/30/2023]
Affiliation(s)
- Selena Z Kuo
- Division of Gastroenterology & Hepatology, University of California at San Diego, La Jolla, California, USA
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16
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Rajnochova Bloudickova S, Janek B, Machackova K, Hruba P. Standardized risk-stratified cardiac assessment and early posttransplant cardiovascular complications in kidney transplant recipients. Front Cardiovasc Med 2024; 11:1322176. [PMID: 38327495 PMCID: PMC10847279 DOI: 10.3389/fcvm.2024.1322176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 01/11/2024] [Indexed: 02/09/2024] Open
Abstract
Introduction Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in kidney transplant recipient (KTR). There is a dearth of standardized guidelines on optimal cardiovascular evaluation of transplant candidates. Methods This single-center cohort study aims to determine the effectiveness of our standardized risk-stratified pretransplant cardiovascular screening protocol, which includes coronary angiography (CAG), in identifying advanced CVD, the proper pretransplant management of which could lead to a reduction in the incidence of major cardiac events (MACE) in the early posttransplant period. Results Out of the total 776 KTR transplanted between 2017 and 2019, CAG was performed on 541 patients (69.7%), of whom 22.4% were found to have obstructive coronary artery disease (CAD). Asymptomatic obstructive CAD was observed in 70.2% of cases. In 73.6% of cases, CAG findings resulted in myocardial revascularization. MACE occurred in 5.6% (N = 44) of the 23 KTR with pretransplant CVD and 21 without pretransplant CVD. KTR with posttransplant MACE occurrence had significantly worse kidney graft function at the first year posttransplant (p = 0.00048) and worse patient survival rates (p = 0.0063) during the 3-year follow-up period compared with KTR without MACE. After adjustment, the independent significant factors for MACE were arrhythmia (HR 2.511, p = 0.02, 95% CI 1.158-5.444), pretransplant history of acute myocardial infarction (HR 0.201, p = 0.046, 95% CI 0.042-0.970), and pretransplant myocardial revascularization (HR 0.225, p = 0.045, 95% CI 0.052-0.939). Conclusion Asymptomatic CVD is largely prevalent in KTR. Posttransplant MACE has a negative effect on grafts and patient outcomes. Further research is needed to assess the benefits of pretransplant myocardial revascularization in asymptomatic kidney transplant candidates.
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Affiliation(s)
| | - Bronislav Janek
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Karolina Machackova
- Department of Nephrology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Petra Hruba
- Transplant Laboratory, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
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17
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Huck DM, Weber B, Schreiber B, Pandav J, Parks S, Hainer J, Brown JM, Divakaran S, Blankstein R, Dorbala S, Trinquart L, Chandraker A, Di Carli MF. Comparative Effectiveness of PET and SPECT MPI for Predicting Cardiovascular Events After Kidney Transplant. Circ Cardiovasc Imaging 2024; 17:e015858. [PMID: 38227694 PMCID: PMC10794031 DOI: 10.1161/circimaging.123.015858] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 12/08/2023] [Indexed: 01/18/2024]
Abstract
BACKGROUND Advanced chronic kidney disease is associated with high cardiovascular risk, even after kidney transplant. Pretransplant cardiac testing may identify patients who require additional assessment before transplant or would benefit from risk optimization. The objective of the current study was to determine the relative prognostic utility of pretransplant positron emission tomography (PET) and single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) for posttransplant major adverse cardiovascular events (MACEs). METHODS We retrospectively followed patients who underwent MPI before kidney transplant for the occurrence of MACE after transplant including myocardial infarction, stroke, heart failure, and cardiac death. An abnormal MPI result was defined as a total perfusion deficit >5% of the myocardium. To determine associations of MPI results with MACE, we utilized Cox hazard regression with propensity weighting for PET versus SPECT with model factors, including demographics and cardiovascular risk factors. RESULTS A total of 393 patients underwent MPI (208 PET and 185 SPECT) and were followed for a median of 5.9 years post-transplant. Most were male (58%), median age was 58 years, and there was a high burden of hypertension (88%) and diabetes (33%). A minority had abnormal MPI (n=58, 15%). In propensity-weighted hazard regression, abnormal PET result was associated with posttransplant MACE (hazard ratio, 3.02 [95% CI, 1.78-5.11]; P<0.001), while there was insufficient evidence of an association of abnormal SPECT result with MACE (1.39 [95% CI, 0.72-2.66]; P=0.33). The explained relative risk of the PET result was higher than the SPECT result (R2 0.086 versus 0.007). Normal PET was associated with the lowest risk of MACE (2.2%/year versus 3.6%/year for normal SPECT; P<0.001). CONCLUSIONS Kidney transplant recipients are at high cardiovascular risk, despite a minority having obstructive coronary artery disease on MPI. PET MPI findings predict posttransplant MACE. Normal PET may better discriminate lower risk patients compared with normal SPECT, which should be confirmed in a larger prospective study.
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Affiliation(s)
- Daniel M Huck
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Division (D.M.H., B.W., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbalat, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Brittany Weber
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Division (D.M.H., B.W., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbalat, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Brittany Schreiber
- Division of Nephrology (B.S., J.P., A.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Jay Pandav
- Division of Nephrology (B.S., J.P., A.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Sean Parks
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbalat, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Division of Nuclear Medicine and Molecular Imaging (S.P., J.H., S. Divakaran, S. Dorbala, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Jon Hainer
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbalat, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Division of Nuclear Medicine and Molecular Imaging (S.P., J.H., S. Divakaran, S. Dorbala, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Jenifer M Brown
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Division (D.M.H., B.W., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbalat, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Sanjay Divakaran
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Division (D.M.H., B.W., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbalat, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Division of Nuclear Medicine and Molecular Imaging (S.P., J.H., S. Divakaran, S. Dorbala, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ron Blankstein
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Division (D.M.H., B.W., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbalat, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Sharmila Dorbala
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Division (D.M.H., B.W., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Division of Nuclear Medicine and Molecular Imaging (S.P., J.H., S. Divakaran, S. Dorbala, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ludovic Trinquart
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA (L.T.)
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA (L.T.)
| | - Anil Chandraker
- Division of Nephrology (B.S., J.P., A.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Marcelo F Di Carli
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Division (D.M.H., B.W., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbalat, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Division of Nuclear Medicine and Molecular Imaging (S.P., J.H., S. Divakaran, S. Dorbala, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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18
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Sinusas AJ, Asch W. Is PET the Best Screening Tool for Cardiac Assessment Prior to Renal Transplant? Circ Cardiovasc Imaging 2024; 17:e016408. [PMID: 38227693 DOI: 10.1161/circimaging.123.016408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Affiliation(s)
- Albert J Sinusas
- Department of Internal Medicine (A.J.S., W.A.), Yale University School of Medicine, New Haven, CT
- Department of Radiology and Biomedical Imaging (A.J.S.), Yale University School of Medicine, New Haven, CT
- Department of Biomedical Engineering, Yale University, New Haven, CT (A.J.S.)
| | - William Asch
- Department of Internal Medicine (A.J.S., W.A.), Yale University School of Medicine, New Haven, CT
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19
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Nielsen MB, Dahl JN, Jespersen B, Ivarsen P, Birn H, Winther S. External Validation of Proposed American Heart Association Algorithm for Cardiovascular Screening Before Kidney Transplantation. J Am Heart Assoc 2023; 12:e031150. [PMID: 38084711 PMCID: PMC10863782 DOI: 10.1161/jaha.123.031150] [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: 05/26/2023] [Accepted: 09/22/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND Screening for cardiovascular disease is currently recommended before kidney transplantation. The present study aimed to validate the proposed algorithm by the American Heart Association (AHA-2022) considering cardiovascular findings and outcomes in kidney transplant candidates, and to compare AHA-2022 with the previous recommendation (AHA-2012). METHODS AND RESULTS We applied the 2 screening algorithms to an observational cohort of kidney transplant candidates (n=529) who were already extensively screened for coronary heart disease by referral to cardiac computed tomography between 2014 and 2019. The cohort was divided into 3 groups as per the AHA-2022 algorithm, or into 2 groups as per AHA-2012. Outcomes were degree of coronary heart disease, revascularization rate following screening, major adverse cardiovascular events, and all-cause death. Using the AHA-2022 algorithm, 69 (13%) patients were recommended for cardiology referral, 315 (60%) for cardiac screening, and 145 (27%) no further screening. More patients were recommended cardiology referral or screening compared with the AHA-2012 (73% versus 53%; P<0.0001). Patients recommended cardiology referral or cardiac screening had a higher risk of major adverse cardiovascular events (hazard ratio [HR], 5.5 [95% CI, 2.8-10.8]; and HR, 2.1 [95% CI, 1.2-3.9]) and all-cause death (HR, 12.0 [95% [CI, 4.6-31.4]; and HR, 5.3 [95% CI, 2.1-13.3]) compared with patients recommended no further screening, and were more often revascularized following initial screening (20% versus 7% versus 0.7%; P<0.001). CONCLUSIONS The AHA-2022 algorithm allocates more patients for cardiac referral and screening compared with AHA-2012. Furthermore, the AHA-2022 algorithm effectively discriminates between kidney transplant candidates at high, intermediate, and low risk with respect to major adverse cardiovascular events and all-cause death.
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Affiliation(s)
- Marie Bodilsen Nielsen
- Department of BiomedicineAarhus UniversityAarhusDenmark
- Department of Renal MedicineAarhus University HospitalAarhusDenmark
| | - Jonathan Nørtoft Dahl
- Department of Cardiology, Gødstrup HospitalHerningDenmark
- Department of Clinical MedicineAarhus UniversityAarhusDenmark
| | - Bente Jespersen
- Department of Renal MedicineAarhus University HospitalAarhusDenmark
- Department of Clinical MedicineAarhus UniversityAarhusDenmark
| | - Per Ivarsen
- Department of Renal MedicineAarhus University HospitalAarhusDenmark
- Department of Clinical MedicineAarhus UniversityAarhusDenmark
| | - Henrik Birn
- Department of BiomedicineAarhus UniversityAarhusDenmark
- Department of Renal MedicineAarhus University HospitalAarhusDenmark
- Department of Clinical MedicineAarhus UniversityAarhusDenmark
| | - Simon Winther
- Department of Cardiology, Gødstrup HospitalHerningDenmark
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20
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Kleb C, Sims OT, Fares M, Ruthmann N, Ansari K, Esfeh JM. Screening Modalities for Coronary Artery Disease in Liver Transplant Candidates: A Review of the Literature. J Cardiothorac Vasc Anesth 2023; 37:2611-2620. [PMID: 37690949 DOI: 10.1053/j.jvca.2023.08.126] [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: 05/21/2023] [Revised: 07/16/2023] [Accepted: 08/09/2023] [Indexed: 09/12/2023]
Abstract
Patients with cirrhosis undergoing liver transplant (LT) are at high risk of postoperative cardiopulmonary complications. It is known that patients with coronary artery disease (CAD) have greater rates of post-LT morbidity and mortality than patients without CAD. Thus, identifying significant CAD in LT candidates is of the utmost importance to optimize survival posttransplant. Consensus is lacking on the ideal screening test for CAD in LT candidates. Traditional exercise and many pharmacologic stress tests are impractical and inaccurate in patients with cirrhosis due to their unique physiology. The purpose of this review is to describe different screening modalities for CAD among LT candidates. The background, diagnostic accuracy, and limitations of each screening modality are described to achieve this goal.
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Affiliation(s)
- Cerise Kleb
- Department of Gastroenterology, University of Maryland Medical Center, Baltimore, MD.
| | - Omar T Sims
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Maan Fares
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
| | - Nicholas Ruthmann
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
| | - Kianoush Ansari
- Department of Diagnostic Radiology, University Hospital Cleveland Medical Center, Cleveland, OH
| | - Jamak Modaresi Esfeh
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH
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21
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Possick S, Khungar V, Deshpande R. Cardiac evaluation of the liver transplant candidate. Curr Opin Organ Transplant 2023:00075200-990000000-00099. [PMID: 37995156 DOI: 10.1097/mot.0000000000001122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2023]
Abstract
PURPOSE OF REVIEW This review aims to summarize recent changes in the cardiac evaluation of adult liver transplant candidates. Over the last several years, there have been significant advances in the use of coronary computed tomography angiography (CCTA) with and without fractional flow reserve (FFR) and increasingly widespread availability of coronary calcium scoring for risk stratification for obstructive coronary artery disease. This has led to novel strategies for risk stratification in cirrhotic patients being considered for liver transplant and an updated American Heart Association (AHA) position paper on the evaluation of liver and kidney transplant candidates. The diagnosis of cirrhotic cardiomyopathy has been refined. These new diagnostic criteria require that specific echocardiographic parameters are evaluated in all patients. The definition of pulmonary hypertension on echocardiography has been altered and no longer utilizes right atrium (RA) pressure estimates based on inferior vena cava (IVC) size and collapse. This provides more volume neutral estimates of pulmonary pressure. RECENT FINDINGS Although CCTA has outstanding negative predictive value, false positive results are not uncommon and often lead to further testing. Revised diagnostic criteria for cirrhotic cardiomyopathy improve risk stratification for peri-operative volume overload and outcomes. Refined pulmonary hypertension criteria provide improved guidance for right heart catheterization (RHC) and referral to subspecialists. There are emerging data regarding the safety and efficacy of TAVR for severe aortic stenosis in cirrhotic patients. SUMMARY Increased utilization of noninvasive testing, including CCTA and/or coronary calcium scoring, can improve the negative predictive value of testing for obstructive coronary artery disease and potentially reduce reliance on coronary angiography. Application of the 2020 criteria for cirrhotic cardiomyopathy will improve systolic and diastolic function assessment and subsequent perioperative risk stratification. The use of global strain scores is emphasized, as it provides important information beyond ejection fraction and diastolic parameters. A standardized one-parameter echo cut-off for elevated pulmonary pressures simplifies both evaluation and follow-up. Innovative transcutaneous techniques for valvular stenosis and regurgitation offer new options for patients at prohibitive surgical risk.
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Affiliation(s)
| | - Vandana Khungar
- Yale University School of Medicine, Transplant Hepatology, Hepatology, Gastroenterology
| | - Ranjit Deshpande
- Department of Anesthesia, Yale University School of Medicine, New Haven, Connecticut, USA
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22
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Nielsen MB, Iversen MS, Derai A, Dahl JN, Jespersen B, Ivarsen P, Winther S, Birn H. The Diagnostic Yield and Clinical Impact of Systematic Screening of Kidney Transplant Candidates by Cardiac Computed Tomography: A Cohort Study. Transplant Proc 2023; 55:2102-2109. [PMID: 37777365 DOI: 10.1016/j.transproceed.2023.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 07/21/2023] [Indexed: 10/02/2023]
Abstract
BACKGROUND Although cardiovascular screening of kidney transplant candidates is recommended, the optimal approach is debated. Previous studies show that noninvasive imaging provides prognostic information, but systematic screening may have less recognized effects, such as additional investigations, incidental findings, procedural complications, and delay of transplantation. To address this, we characterized the diagnostic yield and clinical implications of systematic screening for cardiovascular disease using cardiac computed tomography (CT) in potential kidney transplant candidates. METHODS This was a single-center, observational cohort study including all potential kidney transplant candidates >40 years of age or with diabetes or on dialysis treatment for >5 years, systematically referred to cardiac computed tomography (CT; non-contrast CT and coronary CT angiography) between 2014 and 2019 before evaluation for kidney transplantation at Aarhus University Hospital. Patient records were examined for data on baseline characteristics, additional investigations and complications, plasma creatinine, dialysis initiation, time until wait-listing, and incidental findings. RESULTS Of 473 patients who underwent cardiac CT, additional cardiac investigations were performed in 156 (33%), and 32 (7%) were revascularized. Twenty-two patients had significant incidental nonvascular findings on cardiac CT. No patient was rejected for transplantation based on cardiac CT. In patients not yet on dialysis, the slope in the estimated glomerular filtration rate decline did not change significantly after coronary CT angiography. CONCLUSION Screening by cardiac CT led to additional cardiac investigations in one-third of patients; only a few patients were revascularized, with unknown benefits in asymptomatic patients. Cardiac CT was safe in this population; however, the clinical consequences of the screening were limited.
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Affiliation(s)
- Marie B Nielsen
- Department of Biomedicine, Aarhus University, Aarhus C, Denmark; Department of Renal Medicine, Aarhus University Hospital, Aarhus N, Denmark.
| | - Malene S Iversen
- Department of Renal Medicine, Aarhus University Hospital, Aarhus N, Denmark
| | - Amal Derai
- Department of Renal Medicine, Aarhus University Hospital, Aarhus N, Denmark
| | - Jonathan N Dahl
- Department of Cardiology, Gødstrup Hospital, Herning, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Bente Jespersen
- Department of Renal Medicine, Aarhus University Hospital, Aarhus N, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Per Ivarsen
- Department of Renal Medicine, Aarhus University Hospital, Aarhus N, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Simon Winther
- Department of Cardiology, Gødstrup Hospital, Herning, Denmark
| | - Henrik Birn
- Department of Biomedicine, Aarhus University, Aarhus C, Denmark; Department of Renal Medicine, Aarhus University Hospital, Aarhus N, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
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23
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Hebestreit H, Thornton CS. Cystic fibrosis and the cardiovascular system: the unexpected heartache. Eur Respir J 2023; 62:2301253. [PMID: 37884293 DOI: 10.1183/13993003.01253-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 08/04/2023] [Indexed: 10/28/2023]
Affiliation(s)
| | - Christina S Thornton
- Division of Respirology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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24
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Parikh NS, Basu E, Hwang MJ, Rosenblatt R, VanWagner LB, Lim HI, Murthy SB, Kamel H. Management of Stroke in Patients With Chronic Liver Disease: A Practical Review. Stroke 2023; 54:2461-2471. [PMID: 37417238 PMCID: PMC10527812 DOI: 10.1161/strokeaha.123.043011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
Chronic liver disease (CLD) is a highly prevalent condition. There is burgeoning recognition that there are many people with subclinical liver disease that may nonetheless be clinically significant. CLD has a variety of systemic aberrations relevant to stroke, including thrombocytopenia, coagulopathy, elevated liver enzymes, and altered drug metabolism. There is a growing body of literature on the intersection of CLD and stroke. Despite this, there have been few efforts to synthesize these data, and stroke guidelines provide scant guidance on this topic. To fill this gap, this multidisciplinary review provides a contemporary overview of CLD for the vascular neurologist while appraising data regarding the impact of CLD on stroke risk, mechanisms, and outcomes. Finally, the review addresses acute and chronic treatment considerations for patients with stroke-ischemic and hemorrhagic-and CLD.
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Affiliation(s)
- Neal S Parikh
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (N.S.P., E.B., S.B.M., H.K.), Weill Cornell Medicine, New York, NY
| | | | - Mu Ji Hwang
- Department of Neurology, Brown University, Providence, RI (M.J.H.)
| | - Russel Rosenblatt
- Division of Gastroenterology and Hepatology, Department of Internal Medicine (R.R.), Weill Cornell Medicine, New York, NY
| | - Lisa B VanWagner
- Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern, Dallas (L.B.V.)
| | - Hana I Lim
- Division of Hematology and Oncology, Department of Internal Medicine.(H.I.L.), Weill Cornell Medicine, New York, NY
| | - Santosh B Murthy
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (N.S.P., E.B., S.B.M., H.K.), Weill Cornell Medicine, New York, NY
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (N.S.P., E.B., S.B.M., H.K.), Weill Cornell Medicine, New York, NY
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25
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Vadalà G, Alaimo C, Buccheri G, Di Fazio L, Di Caccamo L, Sucato V, Cipriani M, Galassi AR. Screening and Management of Coronary Artery Disease in Kidney Transplant Candidates. Diagnostics (Basel) 2023; 13:2709. [PMID: 37627968 PMCID: PMC10453389 DOI: 10.3390/diagnostics13162709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/09/2023] [Accepted: 08/14/2023] [Indexed: 08/27/2023] Open
Abstract
Cardiovascular disease (CVD) is a major cause of morbidity and mortality in patients with chronic kidney disease (CKD), especially in end-stage renal disease (ESRD) patients and during the first year after transplantation. For these reasons, and due to the shortage of organs available for transplant, it is of utmost importance to identify patients with a good life expectancy after transplant and minimize the transplant peri-operative risk. Various conditions, such as severe pulmonary diseases, recent myocardial infarction or stroke, and severe aorto-iliac atherosclerosis, need to be ruled out before adding a patient to the transplant waiting list. The effectiveness of systematic coronary artery disease (CAD) treatment before kidney transplant is still debated, and there is no universal screening protocol, not to mention that a nontailored screening could lead to unnecessary invasive procedures and delay or exclude some patients from transplantation. Despite the different clinical guidelines on CAD screening in kidney transplant candidates that exist, up to today, there is no worldwide universal protocol. This review summarizes the key points of cardiovascular risk assessment in renal transplant candidates and faces the role of noninvasive cardiovascular imaging tools and the impact of coronary revascularization versus best medical therapy before kidney transplant on a patient's cardiovascular outcome.
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Affiliation(s)
- Giuseppe Vadalà
- Division of Cardiology, University Hospital Paolo Giaccone, 90100 Palermo, Italy;
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo, 90100 Palermo, Italy; (C.A.); (G.B.); (L.D.F.); (L.D.C.); (A.R.G.)
| | - Chiara Alaimo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo, 90100 Palermo, Italy; (C.A.); (G.B.); (L.D.F.); (L.D.C.); (A.R.G.)
| | - Giancarlo Buccheri
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo, 90100 Palermo, Italy; (C.A.); (G.B.); (L.D.F.); (L.D.C.); (A.R.G.)
| | - Luca Di Fazio
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo, 90100 Palermo, Italy; (C.A.); (G.B.); (L.D.F.); (L.D.C.); (A.R.G.)
| | - Leandro Di Caccamo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo, 90100 Palermo, Italy; (C.A.); (G.B.); (L.D.F.); (L.D.C.); (A.R.G.)
| | - Vincenzo Sucato
- Division of Cardiology, University Hospital Paolo Giaccone, 90100 Palermo, Italy;
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo, 90100 Palermo, Italy; (C.A.); (G.B.); (L.D.F.); (L.D.C.); (A.R.G.)
| | - Manlio Cipriani
- Institute of Transplant and Highly Specialized Therapies (ISMETT) of Palermo, 90100 Palermo, Italy;
| | - Alfredo Ruggero Galassi
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo, 90100 Palermo, Italy; (C.A.); (G.B.); (L.D.F.); (L.D.C.); (A.R.G.)
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26
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Perricone G, Artzner T, De Martin E, Jalan R, Wendon J, Carbone M. Intensive care management of acute-on-chronic liver failure. Intensive Care Med 2023; 49:903-921. [PMID: 37552333 DOI: 10.1007/s00134-023-07149-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 06/21/2023] [Indexed: 08/09/2023]
Abstract
Acute-on-chronic liver failure (ACLF) is a clinical syndrome defined by an acute deterioration of the liver function associated with extrahepatic organ failures requiring intensive care support and associated with a high short-term mortality. ACLF has emerged as a major cause of mortality in patients with cirrhosis and chronic liver disease. ACLF has a unique pathophysiology in which systemic inflammation plays a key role; this provides the basis of novel therapies, several of which are now in clinical trials. Intensive care unit (ICU) therapy parallels that applied in the general ICU population in some organ failures but has peculiar differential characteristics in others. Critical care management strategies and the option of liver transplantation (LT) should be balanced with futility considerations in those with a poor prognosis. Nowadays, LT is the only life-saving treatment that can radically improve the long-term prognosis of patients with ACLF. This narrative review will provide insights on the current understanding of ACLF with emphasis on intensive care management.
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Affiliation(s)
- Giovanni Perricone
- Hepatology and Gastroenterology Unit, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy.
| | - Thierry Artzner
- Hôpitaux Universitaires de Strasbourg, 67000, Strasbourg, France
| | - Eleonora De Martin
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Inserm UMR-S 1193, Université Paris-Saclay, Villejuif, France
| | - Rajiv Jalan
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, UK
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | - Julia Wendon
- Liver Intensive Therapy Unit, Division of Inflammation Biology, King's College London, London, UK
| | - Marco Carbone
- Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- European Reference Network On Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
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27
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Pullen LC. Rethinking coronary heart disease tests in pretransplant evaluation: Cardiologists no longer screen asymptomatic patients for coronary artery disease-so why are transplant centers still doing it? Am J Transplant 2023; 23:1087-1089. [PMID: 37419453 DOI: 10.1016/j.ajt.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2023]
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28
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Nielsen MB, Dahl JN, Laursen R, Jespersen B, Ivarsen P, Winther S, Birn H. In a real-life setting, risk factors, coronary artery calcium score, and coronary stenosis at computed tomography angiography are associated with major adverse cardiovascular events and all-cause mortality among kidney transplant candidates. Am J Transplant 2023; 23:1194-1208. [PMID: 37172693 DOI: 10.1016/j.ajt.2023.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 05/03/2023] [Accepted: 05/04/2023] [Indexed: 05/15/2023]
Abstract
Kidney failure is associated with an increased risk of cardiovascular disease and death. This single-center, a retrospective study evaluated the association between risk factors, coronary artery calcium score (CACS), coronary computed tomography angiography (CTA), major adverse cardiovascular events (MACEs), and all-cause mortality in kidney transplant candidates. Data on clinical risk factors, MACE, and all-cause mortality were collected from patient records. A total of 529 kidney transplant candidates were included (median follow-up of 4.7 years). CACS was evaluated in 437 patients and CTA in 411. Both the presence of ≥3 risk factors, CACS of ≥400, as well as multiple-vessel stenoses or left main artery disease predicted MACE (hazard ratio, 2.09; [95% confidence interval, 1.35-3.23]; 4.65 [2.20-9.82]; 3.70 [1.81-7.57]; 4.90 [2.40-10.01]) and all-cause mortality (harad ratio, 4.44; [95% confidence interval, 2.54-7.76]; 4.47 [2.22-9.02]; 2.82 [1.34-5.94]; 5.41 [2.81-10.41]) in univariate analyses. Among patients eligible for CACS and CTA (n = 376), only CACS and CTA were associated with both MACE and all-cause mortality. In conclusion, risk factors, CACS, and CTA provide information on the risk of MACE and mortality in kidney transplant candidates. An additional value of CACS and CTA compared with risk factors was observed for the prediction of MACE in a subpopulation undergoing both CACS and CTA.
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Affiliation(s)
- Marie Bodilsen Nielsen
- Department of Biomedicine, Aarhus University, Aarhus C, Denmark; Department of Renal Medicine, Aarhus University Hospital, Aarhus C, Denmark.
| | - Jonathan Nørtoft Dahl
- Department of Cardiology, Gødstrup Hospital, Herning, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus C, Denmark
| | - Rasmus Laursen
- Department of Cardiology, Regional Hospital Central Jutland, Viborg, Denmark
| | - Bente Jespersen
- Department of Renal Medicine, Aarhus University Hospital, Aarhus C, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus C, Denmark
| | - Per Ivarsen
- Department of Renal Medicine, Aarhus University Hospital, Aarhus C, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus C, Denmark
| | - Simon Winther
- Department of Cardiology, Gødstrup Hospital, Herning, Denmark
| | - Henrik Birn
- Department of Biomedicine, Aarhus University, Aarhus C, Denmark; Department of Renal Medicine, Aarhus University Hospital, Aarhus C, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus C, Denmark
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29
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Wisel SA, Steggerda JA, Kim IK. Preoperative Evaluations Before Transplantation-Essential Tools, Not Obstacles. JAMA Intern Med 2023; 183:744-745. [PMID: 37184857 DOI: 10.1001/jamainternmed.2023.1236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Affiliation(s)
- Steven A Wisel
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Justin A Steggerda
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Irene K Kim
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
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30
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Hughes DL, Duarte-Rojo A. Discordance in cardiac risk burden and incidence of adverse cardiac events in liver transplant patients: Account for the means to understand the ends. Liver Transpl 2023; 29:566-567. [PMID: 36724475 DOI: 10.1097/lvt.0000000000000080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 01/11/2023] [Indexed: 02/03/2023]
Affiliation(s)
- Dempsey L Hughes
- Division of Gastroenterology and Hepatology, Northwestern Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Comprehensive Transplant Center, Northwestern Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Andres Duarte-Rojo
- Division of Gastroenterology and Hepatology, Northwestern Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Comprehensive Transplant Center, Northwestern Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Tsochatzis EA, Watt KD, VanWagner LB, Verna EC, Berzigotti A. Evaluation of recipients with significant comorbidity - Patients with cardiovascular disease. J Hepatol 2023; 78:1089-1104. [PMID: 37208096 DOI: 10.1016/j.jhep.2023.03.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 03/24/2023] [Accepted: 03/26/2023] [Indexed: 05/21/2023]
Abstract
Liver transplant(ation) (LT) is the most effective treatment for patients with decompensated liver disease. The increasing prevalence of obesity and type 2 diabetes and the growing number of patients with non-alcoholic fatty liver disease being evaluated for LT, have resulted in a greater proportion of LT candidates presenting with a higher risk of cardiovascular disease. As cardiovascular disease is a major cause of morbidity and mortality after LT, a thorough cardiovascular evaluation pre-LT is crucial. In this review, we discuss the latest evidence on the cardiovascular evaluation of LT candidates and we focus on the most prevalent conditions, namely ischaemic heart disease, atrial fibrillation and other arrhythmias, valvular heart disease, and cardiomyopathies. LT candidates undergo an electrocardiogram, a resting transthoracic echocardiography and an assessment of their cardiopulmonary functional ability as part of their standardised pre-LT work-up. Further diagnostic work-up is undertaken based on the results of the baseline evaluation and may include a coronary computed tomography angiography in patients with cardiovascular risk factors. The evaluation of potential LT candidates for cardiovascular disease requires a multidisciplinary approach, with input from anaesthetists, cardiologists, hepatologists and transplant surgeons.
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Affiliation(s)
- Emmanuel A Tsochatzis
- UCL Institute for Liver and Digestive Health, Royal Free Campus, London, UK; Sheila Sherlock Liver Unit, Royal Free Hospital, London, UK.
| | - Kymberly D Watt
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Lisa B VanWagner
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Elizabeth C Verna
- Center for Liver Disease and Transplantation, Columbia University Irving Medical Center, New York, New York, USA
| | - Annalisa Berzigotti
- Department of Visceral Surgery and Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
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Abstract
Patients with chronic kidney disease (CKD) are at high risk to develop cardiovascular disease with its manifestations coronary artery disease, heart failure, arrhythmias, and sudden cardiac death. In addition, the presence of CKD has a major impact on the prognosis of patients with cardiovascular disease, leading to an increased morbidity and mortality if both comorbidities are present. Therapeutic options including medical therapy and interventional treatment are often limited in patients with advanced CKD, and in most cardiovascular outcome trials, patients with advanced CKD have been excluded. Thus, in many patients, treatment strategies for cardiovascular disease need to be extrapolated from trials conducted in patients without CKD. The current article summarizes the epidemiology, clinical presentation, and treatment options for the most prevalent manifestations of cardiovascular disease in CKD and discusses the currently available treatment options to reduce morbidity and mortality in this high-risk population.
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Affiliation(s)
- Katharina Schuett
- Department of Internal Medicine I (Cardiology), University Hospital, RWTH Aachen University, Germany
| | - Nikolaus Marx
- Department of Internal Medicine I (Cardiology), University Hospital, RWTH Aachen University, Germany
| | - Michael Lehrke
- Department of Internal Medicine I (Cardiology), University Hospital, RWTH Aachen University, Germany
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Fleetwood VA, Caliskan Y, Rub FAA, Axelrod D, Lentine KL. Maximizing opportunities for kidney transplantation in older adults. Curr Opin Nephrol Hypertens 2023; 32:204-211. [PMID: 36633323 DOI: 10.1097/mnh.0000000000000871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE OF REVIEW To summarize the current state of evidence related to the outcomes of older adults who need and receive kidney transplants, and strategies to facilitate appropriate transplant access in this at-risk group. RECENT FINDINGS Older adults are a rapidly growing subgroup of the kidney transplant waitlist. Compared to younger adults, older kidney transplant recipients have increased mortality after kidney transplant and lower death-censored graft survival. In determining suitability for transplantation in older patients, clinicians must balance procedural and immunosuppression-related risk with incremental survival when compared with dialysis. To appropriately increase access to transplantation in this population, clinicians and policy makers consider candidates' chronological age and frailty, as well as the quality of and waiting time for a donated allograft. Given risk of deterioration prior to transplant, candidates should be rapidly evaluated, listed, and transplanted using living donor and or less than ideal deceased donor organs when available. SUMMARY Access to transplantation for older adults can be increased through targeted interventions to address frailty and reduce waiting times through optimized organ use. Focused study and educational interventions for patients and providers are needed to improve the outcomes of this vulnerable group.
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Affiliation(s)
- Vidya A Fleetwood
- Saint Louis University Center for Abdominal Transplantation, SSM-Saint Louis University Hospital
| | - Yasar Caliskan
- Saint Louis University Center for Abdominal Transplantation, SSM-Saint Louis University Hospital
| | - Fadee Abu Al Rub
- Saint Louis University Center for Abdominal Transplantation, SSM-Saint Louis University Hospital
| | | | - Krista L Lentine
- Saint Louis University Center for Abdominal Transplantation, SSM-Saint Louis University Hospital
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Kopparam RV, Grady D, Redberg RF. Coronary Heart Disease Testing Before Kidney Transplant-A Call for Revised Guidance. JAMA Intern Med 2023; 183:287-288. [PMID: 36806879 DOI: 10.1001/jamainternmed.2022.6841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Affiliation(s)
| | - Deborah Grady
- Department of Medicine, University of California, San Francisco.,Deputy Editor, JAMA Internal Medicine
| | - Rita F Redberg
- Division of Cardiology, Department of Medicine, University of California, San Francisco.,Editor, JAMA Internal Medicine
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