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Przybyszewski EM, Wilechansky RM, McLean Diaz P, Allegretti AS, VanWagner LB, Cullaro G, Levitsky J, Ginès P, Piano S, Asrani SK, Patidar KR. Controversies in terlipressin and transplantation in the United States: How do we MELD the two? Liver Transpl 2024; 30:753-759. [PMID: 38537069 DOI: 10.1097/lvt.0000000000000370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 03/15/2024] [Indexed: 04/05/2024]
Abstract
Hepatorenal syndrome-acute kidney injury (HRS-AKI) is a severe complication of cirrhosis that carries a poor prognosis. The recent Food and Drug Administration approval of terlipressin has substantial implications for managing HRS-AKI and liver allocation in the United States. Terlipressin has been available in Europe for over a decade, and several countries have adapted policy changes such as Model for End-Stage Liver Disease (MELD) score "lock" for HRS-AKI. In this article, we outline the European experience with terlipressin use and explore the question of whether terlipressin treatment for HRS-AKI should qualify for the MELD score "lock" in the United States in those who respond to therapy. Arguments for the MELD lock include protecting waitlist priority for terlipressin responders or partial responders who may miss offers due to MELD reduction in the terlipressin treatment window. Arguments against MELD lock include the fact that terlipressin may produce a durable response and improve overall survival and that equitable access to terlipressin is not guaranteed due to cost and availability. We subsequently discuss the proposed next steps for studying terlipressin implementation in the United States. A successful approach will require the involvement of all major stakeholders and the mobilization of our transplant community to spearhead research in this area.
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Affiliation(s)
- Eric M Przybyszewski
- Department of Medicine, Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Robert M Wilechansky
- Department of Medicine, Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Paige McLean Diaz
- Department of Medicine, Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Andrew S Allegretti
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lisa B VanWagner
- Department of Medicine, Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX, USA
| | - Giuseppe Cullaro
- Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Josh Levitsky
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Pere Ginès
- Liver Unit, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Catalonia, Spain
- Fundació Clínic per la Recerca Biomèdica-Institut d'Investigació Biomèdica August Pi-Sunyer (IDIBAPS), Barcelona, Spain
- Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Salvatore Piano
- Department of Medicine, Unit of Internal Medicine and Hepatology, University of Padua, Italy
| | | | - Kavish R Patidar
- Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas 77030, USA
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2
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Sjule HM, Vinter CN, Dueland S, Line PD, Burger EA, Bjørnelv GMW. The Spillover Effects of Extending Liver Transplantation to Patients with Colorectal Liver Metastases: A Discrete Event Simulation Analysis. Med Decis Making 2024:272989X241249154. [PMID: 38828508 DOI: 10.1177/0272989x241249154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
BACKGROUND Liver transplantation is an alternative treatment for patients with nonresectable colorectal cancer liver-only metastases (CRLM); however, the potential effects on wait-list time and life expectancy to other patients on the transplant waiting list have not been considered. We explored the potential effects of expanding liver transplantation eligibility to include patients with CRLM on wait-list time and life expectancy in Norway. METHODS We developed a discrete event simulation model to reflect the Norwegian liver transplantation waiting list process and included 2 groups: 1) patients currently eligible for liver transplantation and 2) CRLM patients. Under 2 alternative CRLM-patient transplant eligibility criteria, we simulated 2 strategies: 1) inclusion of only currently eligible patients (CRLM patients received standard-of-care palliative chemotherapy) and 2) expanding waiting list eligibility to include CRLM patients under 2 eligibility criteria. Model outcomes included median waiting list time, life expectancy, and total life-years. RESULTS For every additional CRLM patient listed per year, the overall median wait-list time, initially 52 d, increased by 8% to 11%. Adding 2 additional CRLM patients under the most restrictive eligibility criteria increased the CRLM patients' average life expectancy by 10.64 y and decreased the average life expectancy for currently eligible patients by 0.05 y. Under these assumptions, there was a net gain of 149.61 life-years over a 10-y programmatic period, which continued to increase under scenarios of adding 10 CRLM patients to the wait-list. Health gains were lower under less restrictive CRLM eligibility criteria. For example, adding 4 additional CRLM patients under the less restrictive eligibility criteria increased the CRLM patients' average life expectancy by 5.64 y and decreased the average life expectancy for currently eligible patients by 0.12 y. Under these assumptions, there was a net gain of 96.36 life-years over a 10-y programmatic period, which continued to increase up to 7 CRLM patients. CONCLUSIONS Our model-based analysis enabled the consideration of the potential effects of enlisting Norwegian CRLM patients for liver transplantation on wait-list time and life expectancy. Enlisting CRLM patients is expected to increase the total health effects, which supports the implementation of liver transplantation for CRLM patients in Norway. HIGHLIGHTS Given the Norwegian donor liver availability, adding patients with nonresectable colorectal cancer liver-only metastases (CRLM) to the liver transplantation waiting list had an overall modest, but varying, impact on total waiting list time.Survival gains for selected CRLM patients treated with liver transplantation would likely outweigh the losses incurred to patients listed currently.To improve the total life-years gained in the population, Norway should consider expanding the treatment options for CRLM patients to include liver transplantation.Other countries may also have an opportunity to gain total life-years by extending the waiting list eligibility criteria; however, country-specific analyses are required.
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Affiliation(s)
- Hanna Meidell Sjule
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | - Caroline N Vinter
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | - Svein Dueland
- Research group for Transplant Oncology, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Pål-Dag Line
- Research group for Transplant Oncology, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
- Section for Transplantation Surgery, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Emily A Burger
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health
| | - Gudrun Marie Waaler Bjørnelv
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
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3
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Soubrane O, Scatton O. The Development of Transplant Oncology May Worsen the Liver Gap and Needs New Technical Options in Liver Transplantation. Ann Surg 2024; 279:226-227. [PMID: 37622319 DOI: 10.1097/sla.0000000000006086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Affiliation(s)
- Olivier Soubrane
- Department of Digestive Surgery, Institut Mutualiste Montsouris, Paris, France
| | - Olivier Scatton
- Department of Digestive, HPB, and Transplantation Surgery, Pitié Salpétriére Hospital, APHP, Sorbonne Université, CRSA, INSERM UMR S-938, Paris, France
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4
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Henson JB, King LY. Post-Transplant Management and Complications of Autoimmune Hepatitis, Primary Biliary Cholangitis, and Primary Sclerosing Cholangitis including Disease Recurrence. Clin Liver Dis 2024; 28:193-207. [PMID: 37945160 PMCID: PMC11033708 DOI: 10.1016/j.cld.2023.07.009] [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: 11/12/2023]
Abstract
Autoimmune liver diseases have unique post-transplant considerations. These recipients are at increased risk of rejection, and recurrent disease may also develop, which can progress to graft loss and increase mortality. Monitoring for and managing these complications is therefore important, though data on associated risk factors and immunosuppression strategies has in most cases been mixed. There are also other disease-specific complications that require management and may impact these decisions, including inflammatory bowel disease in PSC. Further work to better understand the optimal management strategies for these patients post-transplant is needed.
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Affiliation(s)
- Jacqueline B Henson
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, DUMC Box 3913, Durham, NC 27710, USA
| | - Lindsay Y King
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, DUMC Box 3923, Durham, NC 27710, USA.
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Vujasinovic M, Said K, Villard C, Carlsson J, Poli C, Maisonneuve P, Löhr JM. The Role of Immunoglobulin G4 in Outcomes of Primary Sclerosing Cholangitis. J Clin Med 2023; 13:79. [PMID: 38202086 PMCID: PMC10779552 DOI: 10.3390/jcm13010079] [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: 11/13/2023] [Revised: 12/12/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
INTRODUCTION Primary sclerosing cholangitis (PSC) is a chronic, cholestatic liver disease that is characterized by an inflammatory and fibrotic process affecting bile ducts which eventually develops into liver cirrhosis and liver failure. The aim of this study was to investigate serum IgG subclass distribution in patients with PSC and its possible association with PSC outcomes. PATIENTS AND METHODS We performed a retrospective analysis of 181 patients who had been diagnosed with PSC between January 1970 and December 2015 and followed at our outpatient clinic. Their demographic, immunological, and clinical characteristics were recorded and analyzed. RESULTS This study included 181 patients with PSC (120 males, 61 females). There was no association between IgGs and the development of autoimmune hepatitis, cirrhosis, cholangiocarcinoma, liver transplantation, inflammatory bowel disease, and colectomy. Patients with elevated IgG4 had statistically significant higher rates of cholangitis (p = 0.02) and endoscopic retrograde cholangiopancreatography (ERCP) (p = 0.009). High IgG4 values were observed in nine patients who underwent ERCP. In these nine patients, on average, IgG4 was evaluated 5 years after ERCP (min 3 days, max 11 years). Subanalysis considering only IgG4 values evaluated before ERCP showed no significant difference but remains significant if we consider IgG4 values after ERCP. CONCLUSION Elevated IgG4 in our study showed a possible association with higher rates of cholangitis and ERCP among patients with primary sclerosing cholangitis. It seems that IgGs may be a useful tool for the prediction of outcomes in patients with PSC. A prospective study is necessary, especially to study the trends of IgGs values during disease as well as the role of possible seroconversion.
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Affiliation(s)
- Miroslav Vujasinovic
- Department for Upper Abdominal Diseases, Karolinska University Hospital, 141 86 Stockholm, Sweden; (K.S.); (J.-M.L.)
- Department of Medicine Huddinge, Karolinska Institute, 141 86 Stockholm, Sweden; (C.V.); (C.P.)
| | - Karouk Said
- Department for Upper Abdominal Diseases, Karolinska University Hospital, 141 86 Stockholm, Sweden; (K.S.); (J.-M.L.)
| | - Christina Villard
- Department of Medicine Huddinge, Karolinska Institute, 141 86 Stockholm, Sweden; (C.V.); (C.P.)
- Department of Transplantation Surgery, Karolinska Institute, 141 86 Stockholm, Sweden
| | | | - Christopher Poli
- Department of Medicine Huddinge, Karolinska Institute, 141 86 Stockholm, Sweden; (C.V.); (C.P.)
| | - Patrick Maisonneuve
- Division of Epidemiology and Biostatistics, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy;
| | - J.-Matthias Löhr
- Department for Upper Abdominal Diseases, Karolinska University Hospital, 141 86 Stockholm, Sweden; (K.S.); (J.-M.L.)
- Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institute, 171 77 Stockholm, Sweden
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D'Amato D, Carbone M. Prognostic models and autoimmune liver diseases. Best Pract Res Clin Gastroenterol 2023; 67:101878. [PMID: 38103932 DOI: 10.1016/j.bpg.2023.101878] [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: 09/07/2023] [Revised: 10/18/2023] [Accepted: 11/24/2023] [Indexed: 12/19/2023]
Abstract
Autoimmune liver diseases (AILDs) are complex diseases with unknown causes and immune-mediated pathophysiology. In primary biliary cholangitis (PBC) and autoimmune hepatitis (AIH) disease modifying drugs are available which improve patient quality and quantity of life. In primary sclerosing cholangitis (PSC) no medical therapy is available and the only accepted treatment is liver transplantation (LT). PBC, PSC and AIH possess features that describe the archetype of patients within each disorder. On the other hand, the classical disorders are not homogeneous, and patients within each diagnosis may present with a range of clinical, biochemical, serological, and histological findings. Singularly, they are considered rare diseases, but together, they account for approximately 20% of LTs in Europe and USA. Management of these patients is complex, as AILDs are relatively uncommon in clinical practice with challenges in developing expertise, disease presentation can be sneaky, clinical phenotypes and disease course are heterogeneous. Prognostic models are key tools for clinicians to assess patients' risk and to provide personalized care to patients. Aim of this review is to discuss challenges of the management of AILDs and how the available prognostic models can help. We will discuss the prognostic models developed in AILDs, with a special focus on the prognostic models that can support the clinical management of patients with AILDs: in PBC models based on ursodeoxycholic acid (UDCA) response and markers of liver fibrosis; in PSC several markers including biochemistry, disease stage and radiological semiquantitative markers; and finally in AIH, markers of disease stage and disease activity.
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Affiliation(s)
- Daphne D'Amato
- Division of Gastroenterology and Hepatology, Department of Medical Sciences, University of Turin, Turin, Italy.
| | - Marco Carbone
- Division of Gastroenterology, Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.
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Freitas LTDS, Hyppolito EB, Barreto VL, Júnior LHJC, Jorge BCDM, Háteras FCTDSB, Marzola MB, Lima CA, Celedonio RM, Coelho GR, Garcia JHP. Liver transplant in patients with primary sclerosing cholangitis: A retrospective cohort from Northeastern Brazil. World J Hepatol 2023; 15:1033-1042. [PMID: 37900212 PMCID: PMC10600696 DOI: 10.4254/wjh.v15.i9.1033] [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: 05/07/2023] [Revised: 07/07/2023] [Accepted: 08/25/2023] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND Primary sclerosing cholangitis (PSC) manifests within a broad ethnic and racial spectrum, reflecting different levels of access to health care. AIM To evaluate the clinical profile, complications and survival rates of patients with PSC undergoing liver transplantation (LTx) at a Brazilian reference center. METHODS All patients diagnosed with PSC before or after LTx were included. The medical records were reviewed for demographic and clinical variables, including outcomes and survival. The level of statistical significance was set at P < 0.05. RESULTS Our cohort represented 1.6% (n = 34) of the 2113 patients receiving liver grafts at our service over the past two decades. Most were male (n = 19; 56%). The average age (40 ± 14 years) was similar for men and women (P = 0.347). The mean follow-up time from diagnosis to LTx was 68 mo. Most patients had the classic form of PSC. Three women had PSC/autoimmune hepatitis overlap syndrome, and one patient had small-duct PSC. Alkaline phosphatase levels at diagnosis and pre-LTx model for end-stage liver disease. scores were significantly higher in males. Inflammatory bowel research (IBD) was investigated by colonoscopy in 26/34 (76%) and was present in most cases (18/26; 69%). IBD was less common in women than in men (44.4% vs. 55.6%) (P = 0.692). Cholangiocarcinoma (CCA) was diagnosed in 2/34 (5.9%) patients by histopathology of the explant (survival: 3 years 6 mo, and 4 years 11 mo). Two patients had complications requiring a second LTx (one after 7 d due to hepatic artery thrombosis and one after 17 d due to primary graft dysfunction). Five patients (14.7%) developed biliary stricture. The overall median post-LTx survival was 66 mo. Most deaths occurred in the first year (infection n = 2, primary liver graft dysfunction n = 3, unknown cause n = 1). The 1-year and 5-year survival rates of this cohort were 82.3% and 70.6%, respectively, matching the mean overall survival rates of LTx patients at our center (87.1% and 69.43%, respectively) (P = 0.83). CONCLUSION Survival after 1 and 5 years was similar to that of other LTx indications. The observed CCA survival rate suggests CCA may be an indication for LTx in selected cases.
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Affiliation(s)
| | - Elodie Bomfim Hyppolito
- Liver Transplant Department, Walter Cantídio Teaching Hospital, Fortaleza 60430270, Ceará, Brazil
- School of Medicine, University of Fortaleza, Fortaleza 60811905, Ceará, Brazil
- Hospital São José, Ceará State Health Department, Fortaleza 60455610, Ceará, Brazil
| | | | | | | | | | | | - Clébia Azevedo Lima
- Liver Transplant Department, Walter Cantídio Teaching Hospital, Fortaleza 60430270, Ceará, Brazil
| | - Raquel Mendes Celedonio
- Liver Transplant Department, Walter Cantídio Teaching Hospital, Fortaleza 60430270, Ceará, Brazil
| | - Gustavo Rêgo Coelho
- Liver Transplant Department, Walter Cantídio Teaching Hospital, Fortaleza 60430270, Ceará, Brazil
- Department of Surgery, Federal University of Ceará, Fortaleza 60430140, Ceará, Brazil
- Surgery Department, São Carlos Hospital, Fortaleza 60130241, Ceará, Brazil
| | - Jose Huygens Parente Garcia
- Liver Transplant Department, Walter Cantídio Teaching Hospital, Fortaleza 60430270, Ceará, Brazil
- Department of Surgery, Federal University of Ceará, Fortaleza 60430140, Ceará, Brazil
- Surgery Department, São Carlos Hospital, Fortaleza 60130241, Ceará, Brazil
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Shannon AH, Ruff SM, Schenk AD, Washburn K, Pawlik TM. Updates and Expert Opinions on Liver Transplantation for Gastrointestinal Malignancies. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1290. [PMID: 37512101 PMCID: PMC10383519 DOI: 10.3390/medicina59071290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 07/12/2023] [Accepted: 07/12/2023] [Indexed: 07/30/2023]
Abstract
Transplant oncology is a relatively new field in which transplantation is used to treat patients who would otherwise be unresectable. New anticancer treatment paradigms using tumor and transplant immunology and cancer immunogenomics are emerging. In turn, liver transplantation (LT) has become a potential therapy for certain patients with colorectal cancer (CRC) with liver metastasis, hepatocellular (HCC), cholangiocarcinoma (CCA), and metastatic neuroendocrine tumor (NET) of the liver. Although there are established criteria for LT in HCC, evidence regarding LT as a treatment modality for certain gastrointestinal malignancies is still debated. The aim of this review is to highlight updates in the role of LT for certain malignancies, including HCC, metastatic CRC, hilar CCA, and neuroendocrine tumor (NET), as well as contextualize LT use and discuss controversies in transplant oncology.
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Affiliation(s)
- Alexander H Shannon
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, The James Comprehensive Cancer Center, Columbus, OH 43210, USA
| | - Samantha M Ruff
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, The James Comprehensive Cancer Center, Columbus, OH 43210, USA
| | - Austin D Schenk
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, The James Comprehensive Cancer Center, Columbus, OH 43210, USA
| | - Kenneth Washburn
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, The James Comprehensive Cancer Center, Columbus, OH 43210, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, The James Comprehensive Cancer Center, Columbus, OH 43210, USA
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Bergsmark T, Engesæter LK, Rasmussen A, Bennet W, Nordin A, Pall V, Line PD, Ericzon BG, Melum E. Long-term survival after liver transplantation for alcohol-related liver disease in the Nordic countries. Scand J Gastroenterol 2023; 58:923-930. [PMID: 36872559 DOI: 10.1080/00365521.2023.2184193] [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: 12/23/2022] [Revised: 02/17/2023] [Accepted: 02/20/2023] [Indexed: 03/07/2023]
Abstract
OBJECTIVES Alcohol-related liver disease (ALD) is among the most common indications for liver transplantation (LTX) in Europe and North America, with good five-year survival rates post-LTX. Here we evaluated survival up to and beyond 20 years after LTX for patients with ALD compared to a comparison group. METHODS Patients with ALD and a comparison group transplanted in the Nordic countries between 1982 and 2020 were included. Data were analyzed using descriptive statistics, Kaplan-Meier curves and predictors of survival were assessed with Cox-regressions. RESULTS 831 patients with ALD and 2979 patients in the comparison group were included in the study. Patients with ALD were older at the time of LTX (p < .001) and more likely to be male (p < .001). The estimated median follow-up time was 9.1 years for the ALD-group and 11.1 years for the comparison group. 333 (40.1%) patients with ALD and 1010 (33.9%) patients in the comparison group died during follow-up. The overall survival was impaired for patients with ALD compared to the comparison group (p < .001) and was evident for male and female patients, patients transplanted before and after 2005, and observed in all age-groups except patients over 60 years. Age at transplant, waiting time, year of LTX and country of LTX were associated with decreased survival after LTX for patients with ALD. CONCLUSIONS Patients with ALD have a decreased long-term survival following LTX. This difference was evident in most sub-groups of patients and warrants close follow-up of liver transplanted patients with ALD with focus on risk reduction.
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Affiliation(s)
- Thomas Bergsmark
- Section of Gastroenterology, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Lise Katrine Engesæter
- Section of Gastroenterology, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Norwegian PSC Research Center, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital, Oslo, Norway
- Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway
| | - Allan Rasmussen
- Department of Surgical Gastroenterology and Liver Transplantation, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - William Bennet
- Transplant Institute, Sahlgrenska University Hospital, the Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Arno Nordin
- Department of Transplantation and Liver Surgery, University Hospital, Helsinki, Finland
| | - Virge Pall
- Transplantation Centre, Tartu University Hospital, Tartu, Estonia
| | - Pål-Dag Line
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Section of Transplantation Surgery, Department of Transplantation Medicine, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital, Oslo, Norway
| | - Bo-Göran Ericzon
- Division of Transplantation Surgery, Karolinska Institutet, CLINTEC, Stockholm, Sweden
| | - Espen Melum
- Section of Gastroenterology, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Norwegian PSC Research Center, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital, Oslo, Norway
- Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway
- Hybrid Technology Hub-Centre of Excellence, Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, Oslo, Norway
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10
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Riis TH, Møller DL, Høgh J, Knudsen AD, Rostved AA, Akdag D, Kirkby N, Lassen U, Rasmussen A, Hillingsø JG, Pommergaard HC. Characteristics of de novo cancer in liver transplant recipients. APMIS 2023; 131:135-141. [PMID: 36680559 DOI: 10.1111/apm.13296] [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: 12/01/2022] [Accepted: 01/18/2023] [Indexed: 01/22/2023]
Abstract
Liver transplant recipients receive immunosuppressive treatment to avoid organ rejection, increasing the risk of developing de novo cancer after transplantation. We investigated the cumulative incidence of de novo cancer in a cohort of Danish liver transplant recipients. The study was a retrospective cohort study of adult liver transplant recipients transplanted at Rigshospitalet, Copenhagen, Denmark, between January 1, 2010, and December 31, 2019. De novo cancer was defined as cancer arising at least 30 days after liver transplantation, excluding relapses from prior cancers and donor-derived cancers. We determined the incidence of de novo cancer in the cohort using the Aalen-Johansen estimator, with death and retransplantation as competing risks. We included 389 liver transplant recipients and identified 47 recipients (12%) with de novo cancer after liver transplantation, including 25 recipients with non-melanoma skin cancers. The cumulative incidences at 5 years after liver transplantation for all cancers and non-skin cancers were 10.7% and 4.9%, respectively. De novo cancer after liver transplantation is relatively common, with the majority being non-melanoma skin cancer. Future studies of sufficient size are needed to identify risk factors for de novo cancer after liver transplantation.
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Affiliation(s)
- Tine Holm Riis
- Department of Surgery and Transplantation, Centre for Cancer and Organ Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Viro-immunology Research Unit, Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Dina Leth Møller
- Viro-immunology Research Unit, Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Julie Høgh
- Viro-immunology Research Unit, Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Andreas Dehlbaek Knudsen
- Viro-immunology Research Unit, Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Andreas Arendtsen Rostved
- Department of Surgery and Transplantation, Centre for Cancer and Organ Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Delal Akdag
- Department of Surgery and Transplantation, Centre for Cancer and Organ Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Viro-immunology Research Unit, Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Nikolai Kirkby
- Department of Clinical Microbiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Ulrik Lassen
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Allan Rasmussen
- Department of Surgery and Transplantation, Centre for Cancer and Organ Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jens G Hillingsø
- Department of Surgery and Transplantation, Centre for Cancer and Organ Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Hans-Christian Pommergaard
- Department of Surgery and Transplantation, Centre for Cancer and Organ Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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11
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Novruzbekov MS, Lutsyk KN, Olisov OD, Magomedov KM, Kazymov BI, Alekberov KF, Akhmedov AR, Yaremin BI. [Indocyanine green in liver transplantation]. Khirurgiia (Mosk) 2023:63-72. [PMID: 37682549 DOI: 10.17116/hirurgia202309263] [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] [Indexed: 09/09/2023]
Abstract
The purpose of this study was to evaluate the first own experience of using indocyanine green (ICG) in liver transplantation compared to literature data and to determine its potential for clinical practice. Liver transplantation is an effective option for patients with end-stage disease, but this procedure is associated with many problems such as graft rejection, graft dysfunction, surgical risk and postoperative management. Modern methods for assessing graft function have their limitations, so a more efficient method is needed. According to this review, ICG fluorescence is valuable for effective intraoperative blood flow control, assessment of graft function, intraoperative and postoperative monitoring of clinical status. ICG fluorescence can also predict clinical status of patients at all stages of liver transplantation. Routine ICG fluorescence method is advisable in liver transplantation to improve outcomes and optimize treatment process.
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Affiliation(s)
- M S Novruzbekov
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - K N Lutsyk
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| | - O D Olisov
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - K M Magomedov
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| | - B I Kazymov
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| | - K F Alekberov
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| | - A R Akhmedov
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| | - B I Yaremin
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
- Pirogov Russian National Research Medical University, Moscow, Russia
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12
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Jadaun SS, Mehtani R, Hasnain A, Bhatia S, Moond V, Kumar M, Kuhad V, Singh S, Agarwal S, Gupta S, Saigal S. Good outcomes of living donor liver transplant in primary sclerosing cholangitis: an experience from North India. Hepatol Int 2022; 17:499-506. [PMID: 36376772 PMCID: PMC9662766 DOI: 10.1007/s12072-022-10442-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 10/14/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease. In the absence of effective medical therapy, liver transplant is the definitive treatment for advanced stage. However, recurrence of PSC after liver transplant is of concern which can lead to graft failure and may require retransplant. There are limited data on outcomes of living donor liver transplant (LDLT) in PSC. Also, in LDLT as donors are genetically related there can be an increased risk of recurrence. We conducted this retrospective study to analyze the outcomes of LDLT in PSC at a tertiary liver transplant center in north India. METHODS We conducted a retrospective analysis of 3213 transplant recipients who underwent LDLT from January 2006 to May 2021. Of these 26 (0.80%) patients had PSC as indication for liver transplantation (PSC = 24, PSC-AIH overlap = 2). Data analysis was done to look for baseline demographics, clinical details, transplant outcomes, PSC recurrence, and survival. RESULTS Mean age of study group was 42 (± 13.8) years and 19 patients (73.1%) were males. All patients had decompensated cirrhosis at the time of transplant. Mean CTP score and MELD score were 9.5 (± 1.8) and 18.9 (± 7.1), respectively. Sixteen patients received modified right lobe graft, seven extended right lobe graft and five patients received left lateral graft. Median graft weight and mean graft to recipient weight ratio (GRWR) were 633.5 (IQR 473.5-633.5) grams and 1.23 (± 0.42), respectively. Most common biliary anastomosis was hepaticojejunostomy, done in 19 (73.1%) while duct to duct anastomosis was performed in 7 (26.9%) patients. Median follow-up was 96 (36-123) months. One patient had ulcerative colitis and none had cholangiocarcinoma. Two (7.7%) patients had bile leak during early post-transplant period. Three (11.1%) patients developed graft rejection and were managed successfully with steroid pulses. Three patients died during early post-transplant period while seven deaths occurred during long-term follow-up including one death due to COVID-19. Five (21.73%) patients had recurrence of PSC of which two patients had graft loss including one after retransplantation. The one year graft and patient survival rate was 88.5%. CONCLUSION LDLT can be performed in PSC with good long-term outcomes with a risk of PSC recurrence in about one-fifth patients.
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Affiliation(s)
- Shekhar Singh Jadaun
- Department of Gastroenterology and Hepatology, Centre for Liver and Biliary Sciences, Hepatology and Liver Transplant Medicine Saket, Max Super Speciality Hospital, New Delhi, 110017 India
| | - Rohit Mehtani
- Department of Gastroenterology and Hepatology, Centre for Liver and Biliary Sciences, Hepatology and Liver Transplant Medicine Saket, Max Super Speciality Hospital, New Delhi, 110017 India
| | - Ana Hasnain
- Department of Gastroenterology and Hepatology, Centre for Liver and Biliary Sciences, Hepatology and Liver Transplant Medicine Saket, Max Super Speciality Hospital, New Delhi, 110017 India
| | - Sushant Bhatia
- Liver Transplant and Gastrointestinal Surgery, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Vikash Moond
- Liver Transplant and Gastrointestinal Surgery, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Mukesh Kumar
- Liver Transplant and Gastrointestinal Surgery, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Vikash Kuhad
- Student’s Scientific Circle of Surgery, Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, Ul. Smoluchowskiego 17, 80-214 Gdańsk, Poland
| | - Shweta Singh
- Anesthesia and Critical Care, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Shaleen Agarwal
- Liver Transplant and Gastrointestinal Surgery, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Subhash Gupta
- Liver Transplant and Gastrointestinal Surgery, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Sanjiv Saigal
- Department of Gastroenterology and Hepatology, Centre for Liver and Biliary Sciences, Hepatology and Liver Transplant Medicine Saket, Max Super Speciality Hospital, New Delhi, 110017 India
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13
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Chazouilleres O, Beuers U, Bergquist A, Karlsen TH, Levy C, Samyn M, Schramm C, Trauner M. EASL Clinical Practice Guidelines on sclerosing cholangitis. J Hepatol 2022; 77:761-806. [PMID: 35738507 DOI: 10.1016/j.jhep.2022.05.011] [Citation(s) in RCA: 76] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 05/16/2022] [Indexed: 02/07/2023]
Abstract
Management of primary or secondary sclerosing cholangitis is challenging. These Clinical Practice Guidelines have been developed to provide practical guidance on debated topics including diagnostic methods, prognostic assessment, early detection of complications, optimal care pathways and therapeutic (pharmacological, endoscopic or surgical) options both in adults and children.
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14
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Trivedi PJ, Bowlus CL, Yimam KK, Razavi H, Estes C. Epidemiology, Natural History, and Outcomes of Primary Sclerosing Cholangitis: A Systematic Review of Population-based Studies. Clin Gastroenterol Hepatol 2022; 20:1687-1700.e4. [PMID: 34474162 DOI: 10.1016/j.cgh.2021.08.039] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 08/19/2021] [Accepted: 08/23/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The aim of this study was to quantify the global epidemiology of primary sclerosing cholangitis (PSC), alongside the incidence of liver transplantation, cancer, and death, through robust systematic review of population-based data. METHODS We searched MEDLINE and EMBASE up to and including June 30, 2020 to identify population-based studies reporting the incidence and/or prevalence of PSC. Studies that did not report original data, or of exclusively pediatric-onset disease (diagnosis age <16 years) or exclusively PSC-associated with inflammatory bowel disease were excluded. RESULTS Of 4922 published studies, 17 fulfilled inclusion criteria; 16 documenting incidence and 14 prevalence. The highest reported incidence of PSC was reported in Northern Europe (Finland, 1.58 and Norway, 1.3 per-100,000 population, respectively) and North America (Minnesota, 1.47); with the lowest being observed across the Mediterranean Basin (Italy, 0.1). Prevalence ranged from 31.7 in Finland and 23.99 in Minnesota, to 1.33 in Singapore and 0.0 in Alaska. Of studies reporting temporal occurrence, an increase in disease incidence was observed across North America and Northern Europe (4 studies), alongside an increase in prevalence over time (4 studies). The incidence and risks for clinical outcomes were presented by 9 of the included studies. Median transplant-free survival ranged from 9.7 (United States) to 20.6 years (Netherlands), with standardized mortality ratios of 2.5 and 4.2 compared with the control population. The standardized incidence of cholangiocarcinoma ranged from 235 (Finland) to 398 (Netherlands). CONCLUSIONS Estimates of PSC incidence and prevalence vary, with most studies conducted in North America and Western Europe; the latter showing a steady increase in disease occurrence over time. Further research is needed to understand changes in disease epidemiology, including etiological drivers, the implications of rising case burden on health care policy, and better appreciation of PSC in the developing world.
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Affiliation(s)
- Palak J Trivedi
- National Institute for Health Research Birmingham Biomedical Research Centre, Centre for Liver and Gastroenterology Research, University of Birmingham, Birmingham, United Kingdom; Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom; Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom; Liver Unit, University Hospitals Birmingham National Health Service Foundation Trust Queen Elizabeth, Birmingham, United Kingdom
| | | | - Kidist K Yimam
- Department of Hepatology and Liver Transplantation California Pacific Medical Center, San Francisco, California
| | - Homie Razavi
- Center for Disease Analysis Foundation, Lafayette, Colorado
| | - Chris Estes
- Center for Disease Analysis Foundation, Lafayette, Colorado.
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15
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Beheshti-Maal A, Tamimi A, Iravani S, Memarnejadian A, Sorouri M, Aghdaei HA, Zali MR, Hossein Khannazer N, Vosough M. PSC associated inflammatory bowel disease: a distinct entity. Expert Rev Gastroenterol Hepatol 2022; 16:129-139. [PMID: 35078376 DOI: 10.1080/17474124.2022.2031979] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Primary sclerosing cholangitis (PSC) is a rare, chronic, and progressive cholestatic disease involving intra- and/or extrahepatic bile ducts. PSC in many patients results in end-stage liver diseases. Nearly 60% of the PSC patients suffer from concomitant inflammatory bowel diseases (IBDs). Classically, IBDs are divided into two principle types: Crohn's disease (CD) and ulcerative colitis (UC). However, with growing knowledge, PSC-associated IBD (PSC-IBD) seems to be a rather distinct entity with specific genetics, clinical, and microbiota characteristics. AREAS COVERED In this article, we aim to review the unique characteristics of PSC-IBD from clinical, genetic, and microbiota point of view. EXPERT OPINION PSC-IBD's unique characteristics contribute to the notion that it could be a distinct entity. Acknowledgment of PSC-IBD as a novel entity necessitates designing new clinical guidelines for diagnosis and developing novel therapies.
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Affiliation(s)
- Alireza Beheshti-Maal
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Department of Regenerative Medicine, Cell Science Research Center, Royan Institute for Stem Cell Biology and Technology, Acecr, Tehran, Iran
| | - Atena Tamimi
- Department of Regenerative Medicine, Cell Science Research Center, Royan Institute for Stem Cell Biology and Technology, Acecr, Tehran, Iran
| | - Shahrokh Iravani
- Gastroenterology and Hepatobiliary Research Center, Imam Reza Hospital, Tehran, Iran
| | | | - Majid Sorouri
- Digestive Diseases Research Center, Digestive Diseases Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamid Asadzadeh Aghdaei
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Zali
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Nikoo Hossein Khannazer
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Massoud Vosough
- Department of Regenerative Medicine, Cell Science Research Center, Royan Institute for Stem Cell Biology and Technology, Acecr, Tehran, Iran
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16
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Bjørnelv GMW, Zolic-Karlsson Z, Dueland S, Line PD, Aas E. OUP accepted manuscript. Br J Surg 2022; 109:483-485. [PMID: 35576387 PMCID: PMC10364692 DOI: 10.1093/bjs/znac022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 10/22/2021] [Accepted: 01/07/2022] [Indexed: 11/13/2022]
Affiliation(s)
- Gudrun M W Bjørnelv
- Institute of Health and Society, Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | | | - Svein Dueland
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Pål-Dag Line
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Eline Aas
- Institute of Health and Society, Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
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17
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Trivedi PJ, Hirschfield GM. Recent advances in clinical practice: epidemiology of autoimmune liver diseases. Gut 2021; 70:1989-2003. [PMID: 34266966 DOI: 10.1136/gutjnl-2020-322362] [Citation(s) in RCA: 87] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 06/24/2021] [Indexed: 12/13/2022]
Abstract
Autoimmune liver diseases are chronic inflammatory hepatobiliary disorders that when classically defined encompass three distinctive clinical presentations; primary biliary cholangitis (PBC), primary sclerosing cholangitis (PSC) and autoimmune hepatitis (AIH). Meaningful changes in disease epidemiology are reported, with increasing incidence and prevalence of AIH and PSC in Europe, and rising prevalence of PBC across Europe, North America and the Asia-Pacific region. However, there appears to be very significant global variation with contemporary incidence rates of disease per 100 000 ranging from 0.84 to 2.75 for PBC, 0.1 to 4.39 for PSC and 0.4 to 2.39 for AIH. Prevalence corresponds, and per 100 000 estimates for PBC range from 1.91 to 40.2, for PSC between 0.78 and 31.7 and for AIH from 4.8 to 42.9. Population-based studies and multicentre observational cohort series provide improved understanding of the clinical course that patients experience, highlighting variations in presenting phenotypes geographically and temporally. Collectively, while autoimmune liver diseases are rare, the clinical burden is disproportionately high relative to population incidence and prevalence. Age, sex and race also impact clinical outcomes, and patient morbidity and mortality are reflected by high need for gastroenterology, hepatology and organ transplant services.
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Affiliation(s)
- Palak J Trivedi
- National Institute for Health Research (NIHR) Birmingham Liver Biomedical Research Centre, University of Birmingham College of Medical and Dental Sciences, Birmingham, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Liver Unit, University Hospitals Birmingham National Health Service Foundation Trust Queen Elizabeth, Birmingham, UK
| | - Gideon M Hirschfield
- Toronto Centre for Liver Disease, Division of Gastroenterology and Hepatology, University of Toronto, Toronto, Ontario, Canada
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18
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Safarpour AR, Askari H, Ejtehadi F, Azarnezhad A, Raeis-Abdollahi E, Tajbakhsh A, Abazari MF, Tarkesh F, Shamsaeefar A, Niknam R, Sivandzadeh GR, Lankarani KB, Ejtehadi F. Cholangiocarcinoma and liver transplantation: What we know so far? World J Gastrointest Pathophysiol 2021; 12:84-105. [PMID: 34676129 PMCID: PMC8481789 DOI: 10.4291/wjgp.v12.i5.84] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/28/2021] [Accepted: 08/11/2021] [Indexed: 02/06/2023] Open
Abstract
Cholangiocarcinoma (CCA) is a type of cancer with increasing prevalence around the world that originates from cholangiocytes, the epithelial cells of the bile duct. The tumor begins insidiously and is distinguished by high grade neoplasm, poor outcome, and high risk for recurrence. Liver transplantation has become broadly accepted as a treatment option for CCA. Liver transplantation is expected to play a crucial role as palliative and curative therapy for unresectable hilar CCA and intrahepatic CCA. The purpose of this study was to determine which cases with CCA should be subjected to liver transplantation instead of resection, although reported post-transplant recurrence rate averages approximately 20%. This review also aims to highlight the molecular current frontiers of CCA and directions of liver transplantation for CCA.
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Affiliation(s)
- Ali Reza Safarpour
- Department of Gastroenterohepatology Research Center, Shiraz University of Medical Sciences, Shiraz 7134814336, Iran
| | - Hassan Askari
- Department of Gastroenterohepatology Research Center, Shiraz University of Medical Sciences, Shiraz 7134814336, Iran
| | - Farshid Ejtehadi
- The Princess Alexandra Hospital HNS Trust, Harlow, Essex CM20 1QX, United Kingdom
| | - Asaad Azarnezhad
- Liver and Digestive Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj 6617913446, Iran
| | - Ehsan Raeis-Abdollahi
- Department of Basic Medical Sciences, Qom Medical Branch, Islamic Azad University, Qom, Iran
| | - Amir Tajbakhsh
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz 7134814336, Iran
| | - Mohammad Foad Abazari
- Research Center for Clinical Virology, Tehran University of Medical Sciences, Tehran 1417653761, Iran
| | - Firoozeh Tarkesh
- Department of Gastroenterohepatology Research Center, Shiraz University of Medical Sciences, Shiraz 7134814336, Iran
| | - Alireza Shamsaeefar
- Shiraz Organ Transplant Center, Shiraz University of Medical Sciences, Shiraz 7193711351, Iran
| | - Ramin Niknam
- Department of Gastroenterohepatology Research Center, Shiraz University of Medical Sciences, Shiraz 7134814336, Iran
| | - Gholam Reza Sivandzadeh
- Department of Gastroenterohepatology Research Center, Shiraz University of Medical Sciences, Shiraz 7134814336, Iran
| | | | - Fardad Ejtehadi
- Department of Gastroenterohepatology Research Center, Shiraz University of Medical Sciences, Shiraz 7134814336, Iran
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19
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Meyer F, Weil-Verhoeven D, Prati C, Wendling D, Verhoeven F. Safety of biologic treatments in solid organ transplant recipients: A systematic review. Semin Arthritis Rheum 2021; 51:1263-1273. [PMID: 34507811 DOI: 10.1016/j.semarthrit.2021.08.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/29/2021] [Accepted: 08/24/2021] [Indexed: 01/15/2023]
Abstract
BACKGROUND The development of biological treatments has transformed the management of a broad spectrum of autoimmune/inflammatory diseases. However, little is known about their use in solid-organ transplant recipients. This study aimed to evaluate complications occurring with biologic treatments in solid-organ transplant recipients. METHODS A systematic review of the literature was performed in the Medline, Embase and Cochrane databases, up to 01/10/2020, to identify published case reports or series reporting the use of biologic treatments in solid organ transplant recipients with chronic inflammatory diseases. We collected data on patient characteristics and reported complications. RESULTS In total, 57 articles were included, totalling 187 patients (141 liver, 42 kidney, 3 heart, and 1 liver-kidney transplant recipients). Inflammatory bowel diseases represented the most common indication for biologic treatment initiation (80.7%), followed by rheumatic diseases (7.5%), hereditary periodic fever syndromes (5.9%) and psoriasis (4.8%). Anti-TNFα were mainly used (77.5%; mainly monoclonal antibodies (70%) compared to soluble receptor etanercept (7.5%)), followed by the anti-α4β7 integrin, vedolizumab (27.3%) and the anti-IL-1R, anakinra (6.9%). Median treatment duration was 12 months. Infections occurred in 54 patients (28.9%) through 88 recorded events. No therapeutic or demographic factors were associated with occurrence of infection. Sixteen patients (8.6%) developed malignancies, and acute graft rejections occurred in 5 patients (2.7%). Among the 187 patients, 9 deaths were reported (4.8%). CONCLUSIONS This review assembles the largest number of published reports regarding the use of biological treatments in solid organ transplant recipients, providing data about their safety. Further comparative studies are needed to assess the safety of biological treatments in transplanted patients.
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Affiliation(s)
- Frédéric Meyer
- Department of Rheumatology, CHRU Besançon, 3 boulevard Fleming, 25000 Besançon, France
| | - Delphine Weil-Verhoeven
- Department of Hepatology, CHRU Besançon, 3 boulevard Fleming, 25000 Besançon, France; EA 4266; "EPILAB", FHU increase, Université Bourgogne - Franche Comté, UFR Santé, 19 rue Ambroise Paré, bâtiment S 25030 Besançon cedex, France
| | - Clément Prati
- Department of Rheumatology, CHRU Besançon, 3 boulevard Fleming, 25000 Besançon, France; EA 4267: "PEPITE", FHU increase, Université Bourgogne - Franche Comté, UFR Santé, 19 rue Ambroise Paré, bâtiment S 25030 Besançon cedex, France
| | - Daniel Wendling
- Department of Rheumatology, CHRU Besançon, 3 boulevard Fleming, 25000 Besançon, France; EA 4266; "EPILAB", FHU increase, Université Bourgogne - Franche Comté, UFR Santé, 19 rue Ambroise Paré, bâtiment S 25030 Besançon cedex, France
| | - Frank Verhoeven
- Department of Rheumatology, CHRU Besançon, 3 boulevard Fleming, 25000 Besançon, France; EA 4267: "PEPITE", FHU increase, Université Bourgogne - Franche Comté, UFR Santé, 19 rue Ambroise Paré, bâtiment S 25030 Besançon cedex, France.
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20
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Bluhme E, Malenicka S, Fischler B, Nemeth A, Berg UB, Jorns C. Comparison of cystatin C, creatinine, and iohexol clearance in pediatric liver transplantation-a retrospective cohort study. Pediatr Transplant 2021; 25:e13993. [PMID: 34010490 DOI: 10.1111/petr.13993] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 12/10/2020] [Accepted: 02/06/2021] [Indexed: 12/01/2022]
Abstract
Impaired renal function after pediatric (LT) is a recognized problem. Accurate monitoring of (GFR) is imperative to detect declining renal function. GFR can be estimated via s-creatinine and/or p-cystatin C or measured by inulin and or/iohexol clearances. We retrospectively compared eGFRcrea and eGFRcyst, to mGFRiohex after LT. Data from 91 children with 312 concomitant measurements of s-creatinine, p-cystatin C, and iohexol clearance, obtained between 2007 and 2015, were analyzed. eGFR was calculated by using the p-cystatin C-based CAPA and CKD-EPI formulas, and the s-creatinine-based Schwartz-LYON, FAS, revised Schwartz and MDRD formulas. Also, the arithmetic means of cystatin C-based and creatinine-based equations were used. Every calculated eGFR was compared to mGFRiohex in statistical correlation, accuracy, precision, bias, and misclassifications. Among the different equations, p-cystatin C-based formulas (CAPA and CKD-EPI) as well as the s-creatinine-based Schwartz-LYON formula showed the most correct estimates regarding accuracy (84-87.5%), bias (0.19-4.0 ml/min/1.73 m2 ), and misclassification rate (24.7-25%). In patients with renal function <75 ml/min/1.73 m2 , cystatin C-based formulas were significantly more accurate and less biased than creatinine-based formulas. In conclusion, S-creatinine could be used in a clinical setting on a regular basis in liver transplanted pediatric patients, with reliable results, if eGFR is calculated by the Schwartz-LYON formula. When suspected renal dysfunction, cystatin C-based eGFR should be calculated, since it gives more accurate and less biased estimates than creatinine-based eGFR, and should be confirmed by mGFR (iohexol).
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Affiliation(s)
- Emil Bluhme
- Department of Transplantation Surgery, Karolinska University Hospital Huddinge, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Silvia Malenicka
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Astrid Lindgren Children's Hospital, Karolinska University Hospital Huddinge, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Bjorn Fischler
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Astrid Lindgren Children's Hospital, Karolinska University Hospital Huddinge, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Antal Nemeth
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Astrid Lindgren Children's Hospital, Karolinska University Hospital Huddinge, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Ulla B Berg
- Department of Pediatric Nephrology, Astrid Lindgren Children's Hospital, Karolinska University Hospital Huddinge, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Carl Jorns
- Department of Transplantation Surgery, Karolinska University Hospital Huddinge, CLINTEC, Karolinska Institutet, Stockholm, Sweden
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21
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Leung KK, Deeb M, Fischer SE, Gulamhusein A. Recurrent Primary Sclerosing Cholangitis: Current Understanding, Management, and Future Directions. Semin Liver Dis 2021; 41:409-420. [PMID: 34182588 DOI: 10.1055/s-0041-1730950] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Patients with primary sclerosing cholangitis (PSC) constitute 5 to 15% of patients listed for liver transplantation worldwide. Although post-transplant outcomes are favorable, recurrent PSC (rPSC) occurs in an important subset of patients, with higher prevalence rates reported with increasing time from transplant. Given its association with poor graft outcomes and risk of retransplant, effort has been made to understand rPSC, its pathophysiology, and risk factors. This review covers these facets of rPSC and focuses on implicated risk factors including pretransplant recipient characteristics, inflammatory bowel-disease-related factors, and donor-specific and transplant-specific factors. Confirming a diagnosis of rPSC requires thoughtful consideration of alternative etiologies so as to ensure confidence in diagnosis, management, subsequent risk assessment, and counseling for patients. Unfortunately, no cure exists for rPSC; however, future large-scale efforts are underway to better characterize the natural history of rPSC and its associated risk factors with hopes of identifying potential key targets for novel therapies.
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Affiliation(s)
- Kristel K Leung
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Maya Deeb
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sandra E Fischer
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Ontario, Canada
| | - Aliya Gulamhusein
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
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22
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Finotti M, Vitale A, Gringeri E, D'Amico FE, Boetto R, Bertacco A, Lonardi S, Bergamo F, Feltracco P, Cillo U. Colon Rectal Liver Metastases: The Role of the Liver Transplantation in the Era of the Transplant Oncology and Precision Medicine. Front Surg 2021; 8:693387. [PMID: 34355016 PMCID: PMC8329096 DOI: 10.3389/fsurg.2021.693387] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 06/21/2021] [Indexed: 12/24/2022] Open
Abstract
The development of liver metastases in colon rectal cancer has a strong impact on the overall survival (OS) of the patient, with a 5-year survival rate of 5% with palliative treatment. Surgical resection combined with pharmacological treatment can achieve a 5-year OS rate of 31–58%. However, in only 20% of patients with colon rectal liver metastases (CRLMs), liver resection is feasible. In highly selected patients, recent trials and studies proved that liver transplantation (LT) for non-resectable CRLM is a surgical option with an excellent long-term OS. The paper aims to review the indications and outcome of LT for CRLMs, with a special focus on immunosuppressive therapy and the management of local and extrahepatic recurrence after LT.
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Affiliation(s)
- Michele Finotti
- University of Padova, Transplantation and Hepatobiliary Surgery, Padua, Italy
| | - Alessandro Vitale
- University of Padova, Transplantation and Hepatobiliary Surgery, Padua, Italy
| | - Enrico Gringeri
- University of Padova, Transplantation and Hepatobiliary Surgery, Padua, Italy
| | | | - Riccardo Boetto
- University of Padova, Transplantation and Hepatobiliary Surgery, Padua, Italy
| | - Alessandra Bertacco
- University of Padova, Transplantation and Hepatobiliary Surgery, Padua, Italy
| | - Sara Lonardi
- Unit of Oncology 1, Department of Oncology, Veneto Institute of Oncology IOV - Istituto di Ricovero e Cura a Carattere Scientifico, Padua, Italy
| | - Francesca Bergamo
- Unit of Oncology 1, Department of Oncology, Veneto Institute of Oncology IOV - Istituto di Ricovero e Cura a Carattere Scientifico, Padua, Italy
| | - Paolo Feltracco
- Anesthesia and Intensive Care Unit, Azienda Ospedaliera di Padova, Padua, Italy
| | - Umberto Cillo
- University of Padova, Transplantation and Hepatobiliary Surgery, Padua, Italy
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23
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Moeckli B, Majno P, Orci LA, Peloso A, Toso C. Liver Transplantation Selection and Allocation Criteria for Hepatocellular Carcinoma: A European Perspective. Semin Liver Dis 2021; 41:172-181. [PMID: 33957694 DOI: 10.1055/s-0041-1723032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
For patients with early-stage hepatocellular carcinoma (HCC), liver transplantation offers the best chance of cure. Over the past two decades, selection criteria to determine eligibility for liver transplantation have been constantly refined but a fair allocation strategy of liver grafts to HCC patients remains challenging. In Europe, over a dozen transplantation networks apply different liver transplantation criteria for HCC patients. In this review, we explore and compare candidate selection and liver graft allocation strategies for patients with HCC with a European perspective and discuss the ethical and technical challenges involved. In addition, we suggest possible paths for future improvement such as transitioning from fixed selection and allocation criteria to a more flexible model of benefit, which includes criteria concerning the graft, response to treatment, the biology of the tumor, and other relevant recipient factors.
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Affiliation(s)
- Beat Moeckli
- Department of Visceral and Transplantation Surgery, University of Geneva Hospitals, Geneva, Switzerland
| | - Pietro Majno
- Epatocentro, Ospedale Regionale di Lugano, Lugano, Switzerland
| | - Lorenzo A Orci
- Department of Visceral and Transplantation Surgery, University of Geneva Hospitals, Geneva, Switzerland
| | - Andrea Peloso
- Department of Visceral and Transplantation Surgery, University of Geneva Hospitals, Geneva, Switzerland
| | - Christian Toso
- Department of Visceral and Transplantation Surgery, University of Geneva Hospitals, Geneva, Switzerland
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24
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Björnsson ES, Kalaitzakis E. Recent advances in the treatment of primary sclerosing cholangitis. Expert Rev Gastroenterol Hepatol 2021; 15:413-425. [PMID: 33283566 DOI: 10.1080/17474124.2021.1860751] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Introduction: PSC is a rare liver disease that leads frequently to cirrhosis and need for liver transplantation. No medical treatment is of proven value. Liver transplantation is the only curative therapy available. There is a big medical need to find medical therapy that can alter the natural history of the disease.Areas covered: The authors highlight advances in PSC, based on recent literature retrieved from PubMed until September 2020 regarding both medical and endoscopic biliary therapy.Future possibilities for treatment of PSC are discussed.Expert opinion: Biliary endoscopy is the cornerstone in the treatment of dominant strictures. Single-user peroral cholangioscopy is an emerging modality. Balloon dilatation therapy is the treatment of choice of dominant strictures. The most promising medical therapies showing efficacy in phase II trials are nor-Ursodeoxycholic acid, obethicolic acid, the non-steroidal FXR agonist Cilofexor and Aldafermin, a synthetic analogue of FGF-19. Antibiotics, particularly vancomycin have shown potential benefits, particularly in children but phase III studies are lacking. In observational studies of effects of biological therapy in patients with IBD/PSC adalimumab was associated with reduction in ALP. Results of liver transplantation are favorable but recurrence can be of clinical relevance particularly in patients transplanted before the age of 40.
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Affiliation(s)
- Einar S Björnsson
- Department of Internal Medicine, Faculty of Medicine, University of Iceland, Division of Gastroenterology and Hepatology, Landspitali University Hospital of Iceland
| | - Evangelos Kalaitzakis
- Department of Internal Medicine, University Hospital Heraklion, Faculty of Medicine, University of Crete, Rethymno, Greece
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25
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Puia-Negulescu S, Lebossé F, Mabrut JY, Muller X, Rossignol G, Antonini T, Erard D, Radenne S, Guillet M, Souquet JC, Mohkam K, Lesurtel M. Liver Transplantation for Colorectal Liver Metastases: Current Management and Future Perspectives. Int J Mol Sci 2021; 22:ijms22063093. [PMID: 33803503 PMCID: PMC8002956 DOI: 10.3390/ijms22063093] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/07/2021] [Accepted: 03/10/2021] [Indexed: 12/25/2022] Open
Abstract
Patients with nonresectable liver metastases from colorectal cancer have few therapeutic options and a dismal prognosis. Although liver transplantation for this indication has historically a poor reputation, recent advances in the field of chemotherapy and immunosuppression have paved the way to revisit the concept. New data have shown promising results that need to be validated in several ongoing clinical trials. Since liver grafts represent a scarce resource, several new tools are being explored to expand the donor pool for this indication. The purpose of this review is to present all current available data and perspectives about liver transplantation for nonresectable liver metastases from colorectal cancer.
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Affiliation(s)
- Serban Puia-Negulescu
- Department of Digestive Surgery and Liver Transplantation, Croix Rousse University Hospital, University of Lyon I, 69004 Lyon, France; (S.P.-N.); (J.-Y.M.); (X.M.); (K.M.)
| | - Fanny Lebossé
- Department of Hepatology, Croix Rousse University Hospital, University of Lyon I, 69004 Lyon, France; (F.L.); (T.A.); (D.E.); (S.R.)
- Cancer Research Center of Lyon, INSERM U1052, 69008 Lyon, France
| | - Jean-Yves Mabrut
- Department of Digestive Surgery and Liver Transplantation, Croix Rousse University Hospital, University of Lyon I, 69004 Lyon, France; (S.P.-N.); (J.-Y.M.); (X.M.); (K.M.)
- Cancer Research Center of Lyon, INSERM U1052, 69008 Lyon, France
| | - Xavier Muller
- Department of Digestive Surgery and Liver Transplantation, Croix Rousse University Hospital, University of Lyon I, 69004 Lyon, France; (S.P.-N.); (J.-Y.M.); (X.M.); (K.M.)
- Cancer Research Center of Lyon, INSERM U1052, 69008 Lyon, France
| | - Guillaume Rossignol
- Department of Pediatric Surgery, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, University of Lyon I, 69500 Lyon, France;
| | - Teresa Antonini
- Department of Hepatology, Croix Rousse University Hospital, University of Lyon I, 69004 Lyon, France; (F.L.); (T.A.); (D.E.); (S.R.)
| | - Domitille Erard
- Department of Hepatology, Croix Rousse University Hospital, University of Lyon I, 69004 Lyon, France; (F.L.); (T.A.); (D.E.); (S.R.)
| | - Sylvie Radenne
- Department of Hepatology, Croix Rousse University Hospital, University of Lyon I, 69004 Lyon, France; (F.L.); (T.A.); (D.E.); (S.R.)
- Department of Hepatogastroenterology, Croix Rousse University Hospital, University of Lyon I, 69004 Lyon, France; (M.G.); (J.-C.S.)
| | - Marielle Guillet
- Department of Hepatogastroenterology, Croix Rousse University Hospital, University of Lyon I, 69004 Lyon, France; (M.G.); (J.-C.S.)
| | - Jean-Christophe Souquet
- Department of Hepatogastroenterology, Croix Rousse University Hospital, University of Lyon I, 69004 Lyon, France; (M.G.); (J.-C.S.)
| | - Kayvan Mohkam
- Department of Digestive Surgery and Liver Transplantation, Croix Rousse University Hospital, University of Lyon I, 69004 Lyon, France; (S.P.-N.); (J.-Y.M.); (X.M.); (K.M.)
- Cancer Research Center of Lyon, INSERM U1052, 69008 Lyon, France
| | - Mickael Lesurtel
- Department of Digestive Surgery and Liver Transplantation, Croix Rousse University Hospital, University of Lyon I, 69004 Lyon, France; (S.P.-N.); (J.-Y.M.); (X.M.); (K.M.)
- Cancer Research Center of Lyon, INSERM U1052, 69008 Lyon, France
- Correspondence: ; Tel.: +33-472-071100; Fax: +33-472-072927
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26
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Kwong AJ, Flores A, Saracino G, Boutté J, McKenna G, Testa G, Bahirwani R, Wall A, Kim WR, Klintmalm G, Trotter JF, Asrani SK. Center Variation in Intention-to-Treat Survival Among Patients Listed for Liver Transplant. Liver Transpl 2020; 26:1582-1593. [PMID: 32725923 DOI: 10.1002/lt.25852] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 06/08/2020] [Accepted: 07/05/2020] [Indexed: 02/07/2023]
Abstract
In the United States, centers performing liver transplant (LT) are primarily evaluated by patient survival within 1 year after LT, but tight clustering of outcomes allows only a narrow window for evaluation of center variation for quality improvement. Alternate measures more relevant to patients and the transplant community are needed. We examined adults listed for LT in the United States, using data submitted to the Scientific Registry of Transplant Recipients. Intention-to-treat (ITT) survival was defined as survival within 1 year from listing, regardless of transplant. Mixed effects/frailty models were used to assess center variation in ITT survival. Between January 2010 and December 2016, there were 66,428 new listings at 113 centers. Overall, median 1-year ITT survival was 79.8% (interquartile range [IQR], 76.1%-83.4%), whereas 1-year waiting-list (WL) survival was 75.8% (IQR, 71.2%-79.4%), and 1-year post-LT survival was 90.0% (IQR, 87.9%-91.8%). Higher rates of ITT mortality were correlated with increased WL mortality (correlation, r = 0.76), increased post-LT mortality (r = 0.31), lower volume centers (r = -0.34), and lower transplant rate ratio (r = -0.25). Similar patterns were observed in the subgroup of WL candidates listed with Model for End-Stage Liver Disease (MELD) ≥25: median 1-year ITT survival was 65.2% (IQR, 60.2%-72.6%), whereas 1-year post-LT survival was 87.5% (IQR, 84.0%-90.9%), and 1-year WL survival was 36.6% (IQR, 27.9%-47.0%). In mixed effects modeling, the transplant center was an independent predictor of ITT survival even after adjustment for age, sex, MELD, and sociodemographic variables. Center variation for ITT survival was larger compared with post-LT survival. The measurement of ITT outcome offers a complementary method to assess center performance. This is a first step toward understanding differences in program quality beyond patient and graft survival after LT.
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Affiliation(s)
- Allison J Kwong
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA
| | - Avegail Flores
- Department of Medicine, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX
| | | | - Jodi Boutté
- Baylor University Medical Center, Dallas, TX
| | | | | | | | - Anji Wall
- Baylor University Medical Center, Dallas, TX
| | - W Ray Kim
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA
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27
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Hepatocellular carcinoma in patients with chronic renal disease: Challenges of interventional treatment. Surg Oncol 2020; 36:42-50. [PMID: 33307490 DOI: 10.1016/j.suronc.2020.11.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 11/15/2020] [Indexed: 02/06/2023]
Abstract
Hepatocellular carcinoma (HCC) is a common malignancy worldwide, recognized as the fourth most common cause of cancer related death. Many risk factors, leading to liver cirrhosis and associated HCC, have been recognized, among them viral hepatitis infections play an important role worldwide. Patients suffering from chronic kidney disease (CKD), especially those on maintenance dialysis, show a higher prevalence of viral hepatitis than the general population what increases the risk of HCC onset. In addition, renal dysfunction may have a negative prognostic impact on both immediate and long-term outcomes after malignancy treatment. Several interventional procedures for the treatment of HCC are currently available: thermal ablation, transcatheter arterial chemoembolization, liver surgery or even liver transplantation. The Barcelona Clinic Liver Cancer system provides an evidence-based treatment algorithm to address different categories of patients to the most-effective treatment in consideration of the extension of disease, liver function and performance status. Liver resection and transplantation are usually reserved to patients with early stage HCC and acceptable performance status, while the other treatments are more indicated in case of impaired liver function or locally advanced or unresectable tumors. However, there is no validated treatment algorithm for HCC in CKD patients, mainly due to the rarity of reports in this cohort of patients. Hereby we discuss the available evidences on interventional HCC treatments in CKD patients, and briefly report up-to-date pharmacological therapy for HCC patients affected by viral hepatitis.
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28
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Model for end-stage liver disease score predicts complications after liver transplantation. Langenbecks Arch Surg 2020; 406:55-65. [PMID: 33140185 DOI: 10.1007/s00423-020-02018-3] [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: 06/08/2020] [Accepted: 10/20/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Increased model for end-stage liver disease (MELD) score measured in the early postoperative course is associated with one-year mortality and graft loss. However, the correlation with postoperative complications has not been investigated. The aim of this study was to investigate the association between postoperative MELD score and subsequent complications. METHODS Adult liver transplant recipients transplanted from January 2011 until December 2016 were included. MELD score days 1-5 were correlated with complications day 6-30, subdivided into type and severity according to Clavien-Dindo classification. RESULTS We included 246 adult liver transplant recipients. Between days 6 and 30, 671 complications occurred in 201 of the patients (82%) corresponding to 64% of all postoperative complications in the whole postoperative period (days 0-30). In multivariate analyses adjusted for recipient gender and age, preoperative MELD score, and Eurotransplant Donor Risk Index, postoperative MELD score was significantly associated with having one or more complications, any type of complication except cardiovascular and renal complications, and complication severity. CONCLUSIONS Postoperative MELD score days 1-5 were associated with complications arising in the subsequent period 6-30 days after transplantation. An increased MELD score should heighten the clinician's awareness of a possible complication.
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29
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Moeckli B, Ivanics T, Claasen M, Toso C, Sapisochin G. Recent developments and ongoing trials in transplant oncology. Liver Int 2020; 40:2326-2344. [PMID: 33021344 DOI: 10.1111/liv.14621] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/17/2020] [Accepted: 07/21/2020] [Indexed: 12/17/2022]
Abstract
Over the past two decades since the introduction of the Milan criteria, the field of transplant oncology has undergone a rapid development with a rising proportion of liver transplantations being performed for oncological indications. For many patients with liver tumours, transplantation represents the only chance for cure. However, many challenges remain, such as the adequate patient selection, management of post-transplant recurrence and refinement of neoadjuvant treatment protocols. This review provides an overview of the current state of the art of liver transplantation for oncological indications such as hepatocellular carcinoma, cholangiocarcinoma, colorectal liver metastasis and metastatic neuroendocrine tumours. We also summarize the ongoing research and explore future trends. Clinical trials are currently studying new diagnostic modalities, innovative pharmacological treatments, novel surgical techniques, downstaging regimens and new indications for liver transplantation. These emerging results will continue to shape the field of transplant oncology and provide us with the necessary tools to better select, treat and follow patients with liver tumours qualifying for liver transplantation.
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Affiliation(s)
- Beat Moeckli
- Department of Visceral and Transplantation Surgery, University of Geneva Hospitals, Geneva, Switzerland
| | - Tommy Ivanics
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - Marco Claasen
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada.,Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Christian Toso
- Department of Visceral and Transplantation Surgery, University of Geneva Hospitals, Geneva, Switzerland
| | - Gonzalo Sapisochin
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada.,Division of General Surgery, University Health Network, Toronto, ON, Canada
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30
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Emerging therapies in primary sclerosing cholangitis: pathophysiological basis and clinical opportunities. J Gastroenterol 2020; 55:588-614. [PMID: 32222826 PMCID: PMC7242240 DOI: 10.1007/s00535-020-01681-z] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 03/05/2020] [Indexed: 02/04/2023]
Abstract
Primary sclerosing cholangitis (PSC) is a progressive liver disease, histologically characterized by inflammation and fibrosis of the bile ducts, and clinically leading to multi-focal biliary strictures and with time cirrhosis and liver failure. Patients bear a significant risk of cholangiocarcinoma and colorectal cancer, and frequently have concomitant inflammatory bowel disease and autoimmune disease manifestations. To date, no medical therapy has proven significant impact on clinical outcomes and most patients ultimately need liver transplantation. Several treatment strategies have failed in the past and whilst prescription of ursodeoxycholic acid (UDCA) prevails, controversy regarding benefits remains. Lack of statistical power, slow and variable disease progression, lack of surrogate biomarkers for disease severity and other challenges in trial design serve as critical obstacles in the development of effective therapy. Advances in our understanding of PSC pathogenesis and biliary physiology over recent years has however led to a surge of clinical trials targeting various mechanistic compartments and currently raising hopes for imminent changes in patient management. Here, in light of pathophysiology, we outline and critically evaluate emerging treatment strategies in PSC, as tested in recent or ongoing phase II and III trials, stratified per a triad of targets of nuclear and membrane receptors regulating bile acid metabolism, immune modulators, and effects on the gut microbiome. Furthermore, we revisit the UDCA trials of the past and critically discuss relevant aspects of clinical trial design, including how the choice of endpoints, alkaline phosphatase in particular, may affect the future path to novel, effective PSC therapeutics.
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31
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Trivedi PJ. Risk stratification in primary sclerosing cholangitis: It's time to move on from replicating imperfection and break the glass ceiling. J Hepatol 2019; 71:867-870. [PMID: 31515045 DOI: 10.1016/j.jhep.2019.08.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 08/18/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Palak J Trivedi
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Centre for Liver and Gastroenterology Research, University of Birmingham, UK; Institute of Immunology and Immunotherapy, University of Birmingham, UK; Institute of Applied Health Research, University of Birmingham, UK; Liver Unit, University Hospitals Birmingham NHS Foundation Trust Queen Elizabeth, UK.
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32
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Tschuor C, Ferrarese A, Kuemmerli C, Dutkowski P, Burra P, Clavien PA, Imventarza O, Crawford M, Andraus W, D'Albuquerque LAC, Hernandez-Alejandro R, Dokus MK, Tomiyama K, Zheng S, Echeverri GJ, Taimr P, Fronek J, de Rosner-van Rosmalen M, Vogelaar S, Lesurtel M, Mabrut JY, Nagral S, Kakaei F, Malek-Hosseini SA, Egawa H, Contreras A, Czerwinski J, Danek T, Pinto-Marques H, Gautier SV, Monakhov A, Melum E, Ericzon BG, Kang KJ, Kim MS, Sanchez-Velazquez P, Oberkofler CE, Müllhaupt B, Linecker M, Eshmuminov D, Grochola LF, Song Z, Kambakamba P, Chen CL, Haberal M, Yilmaz S, Rowe IA, Kron P. Allocation of liver grafts worldwide - Is there a best system? J Hepatol 2019; 71:707-718. [PMID: 31199941 DOI: 10.1016/j.jhep.2019.05.025] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 05/23/2019] [Accepted: 05/27/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS An optimal allocation system for scarce resources should simultaneously ensure maximal utility, but also equity. The most frequent principles for allocation policies in liver transplantation are therefore criteria that rely on pre-transplant survival (sickest first policy), post-transplant survival (utility), or on their combination (benefit). However, large differences exist between centers and countries for ethical and legislative reasons. The aim of this study was to report the current worldwide practice of liver graft allocation and discuss respective advantages and disadvantages. METHODS Countries around the world that perform 95 or more deceased donor liver transplantations per year were analyzed for donation and allocation policies, as well as recipient characteristics. RESULTS Most countries use the model for end-stage liver disease (MELD) score, or variations of it, for organ allocation, while some countries opt for center-based allocation systems based on their specific requirements, and some countries combine both a MELD and center-based approach. Both the MELD and center-specific allocation systems have inherent limitations. For example, most countries or allocation systems address the limitations of the MELD system by adding extra points to recipient's laboratory scores based on clinical information. It is also clear from this study that cancer, as an indication for liver transplantation, requires special attention. CONCLUSION The sickest first policy is the most reasonable basis for the allocation of liver grafts. While MELD is currently the standard for this model, many adjustments were implemented in most countries. A future globally applicable strategy should combine donor and recipient factors, predicting probability of death on the waiting list, post-transplant survival and morbidity, and perhaps costs. LAY SUMMARY An optimal allocation system for scarce resources should simultaneously ensure maximal utility, but also equity. While the model for end-stage liver disease is currently the standard for this model, many adjustments were implemented in most countries. A future globally applicable strategy should combine donor and recipient factors predicting probability of death on the waiting list, post-transplant survival and morbidity, and perhaps costs.
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Affiliation(s)
- Christoph Tschuor
- Department of Surgery & Transplantation, University Hospital of Zurich, Zurich, Switzerland
| | - Alberto Ferrarese
- Multivisceral Transplant Unit - Gastroenterology, Padua University Hospital, Padua, Italy
| | - Christoph Kuemmerli
- Department of Surgery & Transplantation, University Hospital of Zurich, Zurich, Switzerland
| | - Philipp Dutkowski
- Department of Surgery & Transplantation, University Hospital of Zurich, Zurich, Switzerland
| | - Patrizia Burra
- Multivisceral Transplant Unit - Gastroenterology, Padua University Hospital, Padua, Italy.
| | - Pierre-Alain Clavien
- Department of Surgery & Transplantation, University Hospital of Zurich, Zurich, Switzerland.
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33
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Recent advances in liver transplantation for cancer: The future of transplant oncology. JHEP Rep 2019; 1:377-391. [PMID: 32039389 PMCID: PMC7005652 DOI: 10.1016/j.jhepr.2019.07.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 07/15/2019] [Accepted: 07/16/2019] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation is widely indicated as a curative treatment for selected patients with hepatocellular carcinoma. However, with recent therapeutic advances, as well as efforts to increase the donor pool, liver transplantation has been carefully expanded to patients with other primary or secondary malignancies in the liver. Cholangiocarcinoma, colorectal and neuroendocrine liver metastases, and hepatic epithelioid haemangioendothelioma are amongst the most relevant new indications. In this review we discuss the fundamental concepts of this ambitious undertaking, as well as the newest indications for liver transplantation, with a special focus on future perspectives within the recently established concept of transplant oncology.
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34
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Sars C, Tranäng M, Ericzon BG, Berglund E. Liver transplantation for acute liver failure - a 30-year single center experience. Scand J Gastroenterol 2018; 53:876-882. [PMID: 29848142 DOI: 10.1080/00365521.2018.1477986] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To determine overall long-term patient and graft survival rates among the recipients liver transplanted due to acute liver failure (ALF). Secondary aims included assessment of whether diagnosis, donor-recipient blood group compatibility and time-era of transplantation affected the outcome, and whether prescription-free availability of acetaminophen increased the need for liver transplantation (LTx). MATERIALS AND METHODS A Retrospective cohort study of 78 patients who underwent LTx for ALF at Karolinska University Hospital 1984-2014. Patients were divided into two cohorts according to two 15-year periods: early cohort transplanted 1984-1999 (n = 40) and late cohort transplanted 2000-2014 (n = 38). Survival rates were established using Kaplan-Meier analyses. RESULTS ALF patient survival rates for 1-year, 5-years, 10-years and 20-years were 71%, 63%, 52% and 40%, respectively. Survival for the late cohort at 1, 5 and 10 years was 82%, 76% and 71%, respectively. A high early mortality rate was noted during the first three months after transplantation when compared to LTx patients with chronic disease. Long-term survival rates were comparable between patients with ALF and chronic liver disease. Prescription-free access to acetaminophen did not increase the need for LTx. There was a strong trend towards improved survival in blood group identical donor-recipient pairs and blood group O recipients may have benefitted from this. CONCLUSIONS The high early mortality rate most likely reflects the critical pre-transplant condition in these patients and the urgent need to sometimes accept a marginal donor liver. Long-term survival improved significantly over time and variation in patient access to acetaminophen did not influence the rate of LTx in our region.
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Affiliation(s)
- Carl Sars
- a Division of Transplantation Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden and Department of Transplantation Surgery , Karolinska University Hospital , Stockholm , Sweden
| | - Marie Tranäng
- a Division of Transplantation Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden and Department of Transplantation Surgery , Karolinska University Hospital , Stockholm , Sweden.,b Stockholm County Council , Karolinska University Hospital , Stockholm , Sweden
| | - Bo-Göran Ericzon
- a Division of Transplantation Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden and Department of Transplantation Surgery , Karolinska University Hospital , Stockholm , Sweden
| | - Erik Berglund
- a Division of Transplantation Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden and Department of Transplantation Surgery , Karolinska University Hospital , Stockholm , Sweden
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35
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Holmer M, Melum E, Isoniemi H, Ericzon BG, Castedal M, Nordin A, Aagaard Schultz N, Rasmussen A, Line PD, Stål P, Bennet W, Hagström H. Nonalcoholic fatty liver disease is an increasing indication for liver transplantation in the Nordic countries. Liver Int 2018; 38:2082-2090. [PMID: 29630771 DOI: 10.1111/liv.13751] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 03/23/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Nonalcoholic fatty liver disease(NAFLD) is the second most common cause of liver transplantation in the US. Data on NAFLD as a liver transplantation indication from countries with lower prevalences of obesity are lacking. We studied the temporal trends of NAFLD as an indication for liver transplantation in the Nordic countries, and compared outcomes for patients with NAFLD to patients with other indications for liver transplantation. METHOD Population-based cohort study using data from the Nordic Liver Transplant Registry on adults listed for liver transplantation between 1994 and 2015. NAFLD as the underlying indication for liver transplantation was defined as a listing diagnosis of NAFLD/nonalcoholic steatohepatitis, or cryptogenic cirrhosis with a body mass index ≥25 kg/m2 and absence of other liver diseases. Waiting time for liver transplantation, mortality and withdrawal from the transplant waiting list were registered. Survival after liver transplantation was calculated using multivariable Cox regression, adjusted for age, sex, body mass index and model for end-stage liver disease. RESULTS A total of 4609 patients listed for liver transplantation were included. NAFLD as the underlying indication for liver transplantation increased from 2.0% in 1994-1995 to 6.2% in 2011-2015 (P = .01) and was the second most rapidly increasing indication. NAFLD patients had higher age, model for end-stage liver disease and body mass index when listed for liver transplantation, but overall survival after liver transplantation was comparable to non--NAFLD patients (aHR 1.03, 95% CI 0.70-1.53 P = .87). CONCLUSION NAFLD is an increasing indication for liver transplantation in the Nordic countries. Despite more advanced liver disease, NAFLD patients have a comparable survival to other patients listed for liver transplantation.
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Affiliation(s)
- Magnus Holmer
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden.,Division of Hepatology, Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Espen Melum
- Division of Surgery, Inflammatory Diseases and Transplantation, Section for Gastroenterology, Department of Transplantation Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Division of Surgery, Inflammatory Diseases and Transplantation, Department of Transplantation Medicine, Norwegian PSC Research Center, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Division of Surgery, Inflammatory Diseases and Transplantation, Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway
| | - Helena Isoniemi
- Department of Transplantation and Liver Surgery, University Hospital, Helsinki, Finland
| | - Bo-Göran Ericzon
- Division of Transplantation Surgery, Karolinska Institutet, CLINTEC, Stockholm, Sweden
| | - Maria Castedal
- Transplant Institute, Sahlgrenska University Hospital, the Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Arno Nordin
- Department of Transplantation and Liver Surgery, University Hospital, Helsinki, Finland
| | - Nicolai Aagaard Schultz
- Department of Surgical Gastroenterology and Liver Transplantation, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Allan Rasmussen
- Department of Surgical Gastroenterology and Liver Transplantation, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Pål-Dag Line
- Division of Surgery, Inflammation Medicine and Transplantation, Section for Transplantation surgery, Department of Transplantation Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Per Stål
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden.,Division of Hepatology, Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - William Bennet
- Transplant Institute, Sahlgrenska University Hospital, the Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Hannes Hagström
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden.,Division of Hepatology, Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
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36
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Bjørnelv GMW, Dueland S, Line PD, Joranger P, Fretland ÅA, Edwin B, Sørbye H, Aas E. Cost-effectiveness of liver transplantation in patients with colorectal metastases confined to the liver. Br J Surg 2018; 106:132-141. [PMID: 30325494 DOI: 10.1002/bjs.10962] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 06/28/2018] [Accepted: 06/28/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Patients with non-resectable colorectal metastases are currently treated with chemotherapy. However, liver transplantation can increase the 5-year survival rate from 9 to 56 per cent if the cancer is confined to the liver. The aim of this study was to estimate the cost-effectiveness of liver transplantation for colorectal liver metastases. METHODS A Markov model with a lifetime perspective was developed to estimate the life-years, quality-adjusted life-years (QALYs), direct healthcare costs and cost-effectiveness for patients with non-resectable colorectal liver metastases who received liver transplantation or chemotherapy alone. RESULTS In non-selected cohorts, liver transplantation increased patients' life expectancy by 3·12 life-years (2·47 QALYs), at an additional cost of €209 143, giving an incremental cost-effectiveness ratio (ICER) of €67 140 per life-year (€84 667 per QALY) gained. In selected cohorts (selection based on tumour diameter, time since primary cancer, carcinoembryonic antigen levels and response to chemotherapy), the effect of liver transplantation increased to 4·23 life-years (3·41 QALYs), at a higher additional cost (€230 282), and the ICER decreased to €54 467 per life-year (€67 509 per QALY) gained. Given a willingness to pay of €70 500, the likelihood of transplantation being cost-effective was 0·66 and 0·94 (0·23 and 0·67 QALYs) for non-selected and selected cohorts respectively. CONCLUSION Liver transplantation was cost-effective but only for highly selected patients. This might be possible in countries with good access to grafts and low waiting list mortality.
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Affiliation(s)
- G M W Bjørnelv
- The Intervention Centre, Oslo University Hospital, Oslo, Norway.,Institute of Health and Society, University of Oslo, Oslo, Norway
| | - S Dueland
- Department of Oncology, Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - P-D Line
- Section for Transplantation Surgery, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - P Joranger
- Department of Nursing and Health Promotion, OsloMet-Oslo Metropolitan University, Oslo, Norway
| | - Å A Fretland
- The Intervention Centre, Oslo University Hospital, Oslo, Norway.,Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - B Edwin
- The Intervention Centre, Oslo University Hospital, Oslo, Norway.,Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - H Sørbye
- Department of Oncology and Clinical Science, Haukeland University Hospital, Bergen, Norway
| | - E Aas
- Institute of Health and Society, University of Oslo, Oslo, Norway
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37
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Yoshida EM, Mason A, Peltekian KM, Shah H, Thiele S, Borrelli R, Fischer A. Epidemiology and liver transplantation burden of primary biliary cholangitis: a retrospective cohort study. CMAJ Open 2018; 6:E664-E670. [PMID: 30578275 PMCID: PMC6303180 DOI: 10.9778/cmajo.20180029] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND There is a wealth of data documenting the epidemiology of primary biliary cholangitis (PBC) globally; however, the epidemiology of PBC has not been as well studied in Canada. Our study characterized the Canadian prevalence of PBC and the number of liver transplantations because of PBC. METHODS For this retrospective cohort study we used national hospital administrative records from the Canadian Institute for Health Information, with the exception of Quebec for the prevalence estimate and Quebec and British Columbia for the transplant analysis. Prevalent patients were identified through a diagnostic code for PBC of the Canadian version of the 10th revision of the International Classification of Diseases. PBC transplant patients were identified from their transplant record. Descriptive statistics were used to summarize the characteristics of the study cohorts. RESULTS In 2015, 8680 patients with PBC were identified in Canada, translating to a prevalence of 318 cases per million. Annual prevalence by province varied, ranging from 283 (95% confidence interval [CI] 269-297) cases per million to 465 (95% CI 426-504) cases per million, and the 6-year PBC liver transplantation rate ranged from 3.17 (95% CI 1.27-6.54) to 5.92 (95% CI 3.71-9.08) per million. The Atlantic provinces exhibited the highest PBC prevalence and close to the highest 6-year liver transplantation rate (465 [95% CI 426-504] cases per million and 5.70 [95% CI 426-504, 3.19-9.56] cases per million, respectively). We observed the lowest PBC prevalence (283 [95% CI 269-297] cases per million) and the second lowest 6-year liver transplantation rate in Ontario (3.37 [95% CI 2.47-4.50] cases per million). INTERPRETATION The prevalence of PBC that we found in Canada is similar to the prevalence reported in other studies, but our work also indicates geographic variation within this country. Given our finding of geographic clustering of PBC across Canada, we hypothesize that environmental and genetic factors contribute to the pathogenesis of this condition.
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Affiliation(s)
- Eric M Yoshida
- Division of Gastroenterology (Yoshida), University of British Columbia, Vancouver, BC; Division of Gastroenterology (Mason), University of Alberta, Edmonton, Alta.; Division of Digestive Care & Endoscopy (Peltekian), Dalhousie University and Queen Elizabeth II Health Sciences Centre, Halifax, NS; Toronto Centre for Liver Disease (Shah), University Health Network, Toronto, Ont.; IQVIA (Thiele, Borrelli, Fischer), Mississauga, Ont
| | - Andrew Mason
- Division of Gastroenterology (Yoshida), University of British Columbia, Vancouver, BC; Division of Gastroenterology (Mason), University of Alberta, Edmonton, Alta.; Division of Digestive Care & Endoscopy (Peltekian), Dalhousie University and Queen Elizabeth II Health Sciences Centre, Halifax, NS; Toronto Centre for Liver Disease (Shah), University Health Network, Toronto, Ont.; IQVIA (Thiele, Borrelli, Fischer), Mississauga, Ont
| | - Kevork M Peltekian
- Division of Gastroenterology (Yoshida), University of British Columbia, Vancouver, BC; Division of Gastroenterology (Mason), University of Alberta, Edmonton, Alta.; Division of Digestive Care & Endoscopy (Peltekian), Dalhousie University and Queen Elizabeth II Health Sciences Centre, Halifax, NS; Toronto Centre for Liver Disease (Shah), University Health Network, Toronto, Ont.; IQVIA (Thiele, Borrelli, Fischer), Mississauga, Ont
| | - Hemant Shah
- Division of Gastroenterology (Yoshida), University of British Columbia, Vancouver, BC; Division of Gastroenterology (Mason), University of Alberta, Edmonton, Alta.; Division of Digestive Care & Endoscopy (Peltekian), Dalhousie University and Queen Elizabeth II Health Sciences Centre, Halifax, NS; Toronto Centre for Liver Disease (Shah), University Health Network, Toronto, Ont.; IQVIA (Thiele, Borrelli, Fischer), Mississauga, Ont
| | - Sherri Thiele
- Division of Gastroenterology (Yoshida), University of British Columbia, Vancouver, BC; Division of Gastroenterology (Mason), University of Alberta, Edmonton, Alta.; Division of Digestive Care & Endoscopy (Peltekian), Dalhousie University and Queen Elizabeth II Health Sciences Centre, Halifax, NS; Toronto Centre for Liver Disease (Shah), University Health Network, Toronto, Ont.; IQVIA (Thiele, Borrelli, Fischer), Mississauga, Ont
| | - Richard Borrelli
- Division of Gastroenterology (Yoshida), University of British Columbia, Vancouver, BC; Division of Gastroenterology (Mason), University of Alberta, Edmonton, Alta.; Division of Digestive Care & Endoscopy (Peltekian), Dalhousie University and Queen Elizabeth II Health Sciences Centre, Halifax, NS; Toronto Centre for Liver Disease (Shah), University Health Network, Toronto, Ont.; IQVIA (Thiele, Borrelli, Fischer), Mississauga, Ont
| | - Aren Fischer
- Division of Gastroenterology (Yoshida), University of British Columbia, Vancouver, BC; Division of Gastroenterology (Mason), University of Alberta, Edmonton, Alta.; Division of Digestive Care & Endoscopy (Peltekian), Dalhousie University and Queen Elizabeth II Health Sciences Centre, Halifax, NS; Toronto Centre for Liver Disease (Shah), University Health Network, Toronto, Ont.; IQVIA (Thiele, Borrelli, Fischer), Mississauga, Ont.
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38
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Hagström H, Höijer J, Marschall H, Williamson C, Heneghan MA, Westbrook RH, Ludvigsson JF, Stephansson O. Outcomes of Pregnancy in Mothers With Cirrhosis: A National Population-Based Cohort Study of 1.3 Million Pregnancies. Hepatol Commun 2018; 2:1299-1305. [PMID: 30411076 PMCID: PMC6211327 DOI: 10.1002/hep4.1255] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 08/13/2018] [Indexed: 12/19/2022] Open
Abstract
There are limited data on pregnancy outcomes in women with cirrhosis. To address this gap, we examined the records of singleton births from Sweden’s National Patient Register (NPR), Cause of Death Register (CDR), and Medical Birth Register (MBR) between 1997 and 2011 to assess exposure and pregnancy‐related and liver‐related outcomes of pregnant women with cirrhosis. Exposure status was defined as having an International Classification of Diseases (ICD) code for cirrhosis obtained prior to or during pregnancy. Poisson regression with cluster‐robust standard errors was used to estimate relative risks (RRs) adjusted for maternal age, smoking, and body mass index (BMI). We identified 103 pregnancies in women with cirrhosis and compared these to 1,361,566 pregnancies in women without cirrhosis. Pregnancies in women with cirrhosis were at increased risk of caesarean delivery (36% versus 16%, respectively; adjusted RR [aRR], 2.00; 95% confidence interval [CI], 1.47‐2.73), low birth weight (15% versus 3%; aRR, 3.87; 95% CI, 2.11‐7.06), and preterm delivery (19% versus 5%; aRR, 3.51; 95% CI, 2.16‐5.72). Rates of maternal mortality during pregnancy (no cases), gestational diabetes, preeclampsia, small for gestational age, congenital malformations, and stillbirth were not increased when compared to the pregnant women without cirrhosis. There were 12 hospitalizations during pregnancy due to liver‐related events, including one case with bleeding esophageal varices. Conclusion: Women with cirrhosis are at increased risk for adverse pregnancy outcomes. However, severe maternal and fetal adverse events were rare in our study, and most pregnancies in women with cirrhosis ended without complications.
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Affiliation(s)
- Hannes Hagström
- Center for Digestive Diseases, Division of HepatologyKarolinska University HospitalStockholmSweden
- Clinical Epidemiology Unit, Department of MedicineSolna, Karolinska InstituteStockholmSweden
| | - Jonas Höijer
- Unit of Biostatistics, Institute of Environmental MedicineKarolinska InstituteStockholmSweden
| | - Hanns‐Ulrich Marschall
- Department of Molecular and Clinical Medicine and Wallenberg Laboratory, Institute of MedicineSahlgrenska Academy, University of GothenburgGothenburgSweden
| | | | | | | | - Jonas F. Ludvigsson
- Department of Medical Epidemiology and BiostatisticsKarolinska InstituteStockholmSweden
- Department of PediatricsÖrebro University Hospital, Örebro UniversityÖrebroSweden
| | - Olof Stephansson
- Clinical Epidemiology Unit, Department of MedicineSolna, Karolinska InstituteStockholmSweden
- Department of Women’s and Children’s HealthKarolinska InstituteStockholmSweden
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39
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Trivedi PJ, Reece J, Laing RW, Slaney E, Cooney R, Gunson BK, Kamarajah SK, Pinkney T, Thompson F, Muiesan P, Schlegel A, Hirschfield GM, Iqbal T, Ferguson J. The impact of ileal pouch-anal anastomosis on graft survival following liver transplantation for primary sclerosing cholangitis. Aliment Pharmacol Ther 2018; 48:322-332. [PMID: 29882252 DOI: 10.1111/apt.14828] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 03/25/2018] [Accepted: 05/08/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Liver transplantation is the only life-extending intervention for primary sclerosing cholangitis (PSC). Given the co-existence with colitis, patients may also require colectomy; a factor potentially conferring improved post-transplant outcomes. AIM To determine the impact of restorative surgery via ileal pouch-anal anastomosis (IPAA) vs retaining an end ileostomy on liver-related outcomes post-transplantation. METHODS Graft survival was evaluated across a prospectively accrued transplant database, stratified according to colectomy status and type. RESULTS Between 1990 and 2016, 240 individuals with PSC/colitis underwent transplantation (cumulative 1870 patient-years until first graft loss or last follow-up date), of whom 75 also required colectomy. A heightened incidence of graft loss was observed for the IPAA group vs those retaining an end ileostomy (2.8 vs 0.4 per 100 patient-years, log-rank P = 0.005), whereas rates between IPAA vs no colectomy groups were not significantly different (2.8 vs 1.7, P = 0.1). In addition, the ileostomy group experienced significantly lower graft loss rates vs. patients retaining an intact colon (P = 0.044). The risks conferred by IPAA persisted when taking into account timing of colectomy as related to liver transplantation via time-dependent Cox regression analysis. Hepatic artery thrombosis and biliary strictures were the principal aetiologies of graft loss overall. Incidence rates for both were not significantly different between IPAA and no colectomy groups (P = 0.092 and P = 0.358); however, end ileostomy appeared protective (P = 0.007 and 0.031, respectively). CONCLUSION In PSC, liver transplantation, colectomy + IPAA is associated with similar incidence rates of hepatic artery thrombosis, recurrent biliary strictures and re-transplantation compared with no colectomy. Colectomy + end ileostomy confers more favourable graft outcomes.
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Affiliation(s)
- P J Trivedi
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre (BRC), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.,Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK.,Department of Gastroenterology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK.,Centre for Rare Diseases, Institute of Translational Medicine, University of Birmingham, Birmingham, UK
| | - J Reece
- Department of Gastroenterology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - R W Laing
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre (BRC), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.,Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - E Slaney
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - R Cooney
- Department of Gastroenterology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - B K Gunson
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre (BRC), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.,Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - S K Kamarajah
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre (BRC), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - T Pinkney
- Department of Colorectal Surgery, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - F Thompson
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK.,Centre for Rare Diseases, Institute of Translational Medicine, University of Birmingham, Birmingham, UK
| | - P Muiesan
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - A Schlegel
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK.,Swiss HPB and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - G M Hirschfield
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre (BRC), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.,Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK.,Centre for Rare Diseases, Institute of Translational Medicine, University of Birmingham, Birmingham, UK
| | - T Iqbal
- Department of Gastroenterology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - J Ferguson
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK.,Centre for Rare Diseases, Institute of Translational Medicine, University of Birmingham, Birmingham, UK
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40
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Nordin A, Åberg F, Pukkala E, Pedersen CR, Storm HH, Rasmussen A, Bennet W, Olausson M, Wilczek H, Ericzon BG, Tretli S, Line PD, Karlsen TH, Boberg KM, Isoniemi H. Decreasing incidence of cancer after liver transplantation-A Nordic population-based study over 3 decades. Am J Transplant 2018; 18:952-963. [PMID: 28925583 DOI: 10.1111/ajt.14507] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 08/11/2017] [Accepted: 09/07/2017] [Indexed: 01/25/2023]
Abstract
Cancer remains one of the most serious long-term complications after liver transplantation (LT). Data for all adult LT patients between 1982 and 2013 were extracted from the Nordic Liver Transplant Registry. Through linkage with respective national cancer-registry data, we calculated standardized incidence ratios (SIRs) based on country, sex, calendar time, and age-specific incidence rates. Altogether 461 cancers were observed in 424 individuals of the 4246 LT patients during a mean 6.6-year follow-up. The overall SIR was 2.22 (95% confidence interval [CI], 2.02-2.43). SIRs were especially increased for colorectal cancer in recipients with primary sclerosing cholangitis (4.04) and for lung cancer in recipients with alcoholic liver disease (4.96). A decrease in the SIR for cancers occurring within 10 years post-LT was observed from the 1980s: 4.53 (95%CI, 2.47-7.60), the 1990s: 3.17 (95%CI, 2.70-3.71), to the 2000s: 1.76 (95%CI, 1.51-2.05). This was observed across age- and indication-groups. The sequential decrease for the SIR of non-Hodgkin lymphoma was 25.0-12.9-7.53, and for nonmelanoma skin cancer 80.0-29.7-10.4. Cancer risk after LT was found to be decreasing over time, especially for those cancers that are strongly associated with immunosuppression. Whether immunosuppression minimization contributed to this decrease merits further study.
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Affiliation(s)
- A Nordin
- Transplantation and Liver Surgery Clinic, Helsinki University Hospital, Helsinki, Finland
| | - F Åberg
- Transplantation and Liver Surgery Clinic, Helsinki University Hospital, Helsinki, Finland
| | - E Pukkala
- Finnish Cancer Registry - Institute for Statistical and Epidemiological Cancer Research, Helsinki, Finland.,Faculty of Social Sciences, University of Tampere, Tampere, Finland
| | - C R Pedersen
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen, Denmark
| | - H H Storm
- Danish Cancer Society, Copenhagen, Denmark
| | - A Rasmussen
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen, Denmark
| | - W Bennet
- Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - M Olausson
- Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - H Wilczek
- Division of Transplantation Surgery, Karolinska Institutet and Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - B-G Ericzon
- Division of Transplantation Surgery, Karolinska Institutet and Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - S Tretli
- The Norwegian Cancer Registry, Oslo, Norway
| | - P-D Line
- Department of Transplantation Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - T H Karlsen
- Department of Transplantation Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Norwegian PSC Research Center, Department of Transplantation Medicine, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - K M Boberg
- Department of Transplantation Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Norwegian PSC Research Center, Department of Transplantation Medicine, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - H Isoniemi
- Transplantation and Liver Surgery Clinic, Helsinki University Hospital, Helsinki, Finland
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41
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Kling CE, Perkins JD, Carithers RL, Donovan DM, Sibulesky L. Recent trends in liver transplantation for alcoholic liver disease in the United States. World J Hepatol 2017; 9:1315-1321. [PMID: 29359014 PMCID: PMC5756720 DOI: 10.4254/wjh.v9.i36.1315] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 11/07/2017] [Accepted: 12/05/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To examine temporal changes in the indications for liver transplantation (LT) and characteristics of patients transplanted for alcoholic liver disease (ALD).
METHODS We performed a retrospective cohort analysis of trends in the indication for LT using the United Network for Organ Sharing (UNOS) database between 2002 and 2015. Patients were grouped by etiology of the liver disease and characteristics were compared using χ2 and t-tests. Time series analysis was used identifying any year with a significant change in the number of transplants per year for ALD, and before and after eras were modeled using a general linear model. Subgroup analysis of recipients with ALD was performed by age group, gender, UNOS region and etiology (alcoholic cirrhosis, alcoholic hepatitis and hepatitis C - alcoholic cirrhosis dual listing).
RESULTS Of 74216 liver transplant recipients, ALD (n = 9400, 12.7%) was the third leading indication for transplant after hepatitis C and hepatocellular carcinoma. Transplants for ALD, increased from 12.8% (553) in 2002 to 16.5% (1020) in 2015. Time series analysis indicated a significant increase in the number of transplants per year for ALD in 2013 (P = 0.03). There were a stable number of transplants per year between 2002 and 2012 (linear coefficient 3, 95%CI: -4.6, 11.2) an increase of 177 per year between 2013 and 2015 (95%CI: 119, 234). This increase was significant for all age groups except those 71-83 years old, was observed for both genders, and was incompletely explained by a decrease in transplants for hepatitis C and ALD dual listing. All UNOS regions except region 9 saw an increase in the mean number of transplants per year when comparing eras, and this increase was significant in regions 2, 3, 4, 5, 6, 8, 10 and 11.
CONCLUSION There has been a dramatic increase in the number of transplants for ALD starting in 2013.
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Affiliation(s)
- Catherine E Kling
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, WA 98195, United States
| | - James D Perkins
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, WA 98195, United States
| | - Robert L Carithers
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Washington, Seattle, WA 98195, United States
| | - Dennis M Donovan
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA 98195, United States
| | - Lena Sibulesky
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, WA 98195, United States
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42
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Trivedi PJ, Scalera I, Slaney E, Laing RW, Gunson B, Hirschfield GM, Schlegel A, Ferguson J, Muiesan P. Clinical outcomes of donation after circulatory death liver transplantation in primary sclerosing cholangitis. J Hepatol 2017; 67:957-965. [PMID: 28690174 DOI: 10.1016/j.jhep.2017.06.027] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 06/23/2017] [Accepted: 06/27/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIM Primary sclerosing cholangitis (PSC) is a progressive fibro-inflammatory cholangiopathy for which liver transplantation is the only life-extending intervention. These patients may benefit from accepting liver donation after circulatory death (DCD), however their subsequent outcome is unknown. The aim of this study was to determine the clinical impact of using DCD liver grafts in patients specifically undergoing transplantation for PSC. METHODS Clinical outcomes were prospectively evaluated in PSC patients undergoing transplantation from 2006 to 2016 stratified by donor type (DCD, n=35 vs. donation after brainstem death [DBD], n=108). RESULTS In liver transplantation for PSC; operating time, days requiring critical care support, total ventilator days, incidence of acute kidney injury, need for renal replacement therapy (RRT) or total days requiring RRT were not significantly different between DCD vs. DBD recipients. Although the incidence of ischaemic-type biliary lesions was greater in the DCD group (incidence rate [IR]: 4.4 vs. 0 cases/100-patient-years; p<0.001) there was no increased risk of post-transplant biliary strictures overall (hazard ratio [HR]: 1.20, 0.58-2.46; p=0.624), or in sub-analysis specific to anastomotic strictures or recurrent PSC, between donor types. Graft loss and mortality rates were not significantly different following transplantation with DCD vs. DBD livers (IR: 3.6 vs. 3.1 cases/100-patient-years, p=0.34; and 3.9 vs. 4.7, p=0.6; respectively). DCD liver transplantation in PSC did not impart a heightened risk of graft loss (HR: 1.69, 0.58-4.95, p=0.341) or patient mortality (0.75, 0.25-2.21, p=0.598). CONCLUSION Transplantation with DCD (vs. DBD) livers in PSC patients does not impact graft loss or patient survival. In an era of organ shortage, DCD grafts represent a viable therapeutic option for liver transplantation in PSC patients. Lay summary: This study examines the impact of liver transplantation in primary sclerosing cholangitis (PSC) with organs donated after circulatory death (DCD), compared to donation after brainstem death (DBD). We show that in appropriately selected patients, the outcomes for DCD transplantation mirror those using DBD livers, with no significant differences in complication rate, patient survival or transplanted liver survival. In an era of organ shortage and increasing wait-list times, DCD livers represent a potential treatment option for transplantation in PSC.
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Affiliation(s)
- Palak J Trivedi
- National Institute for Health Research (NIHR) Birmingham Liver Biomedical Research Centre (BRC), Institute of Immunology and Immunotherapy, University of Birmingham, UK; Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK
| | - Irene Scalera
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK
| | - Emma Slaney
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK
| | - Richard W Laing
- National Institute for Health Research (NIHR) Birmingham Liver Biomedical Research Centre (BRC), Institute of Immunology and Immunotherapy, University of Birmingham, UK; Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK
| | - Bridget Gunson
- National Institute for Health Research (NIHR) Birmingham Liver Biomedical Research Centre (BRC), Institute of Immunology and Immunotherapy, University of Birmingham, UK; Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK
| | - Gideon M Hirschfield
- National Institute for Health Research (NIHR) Birmingham Liver Biomedical Research Centre (BRC), Institute of Immunology and Immunotherapy, University of Birmingham, UK; Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK
| | - Andrea Schlegel
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK; Department of Surgery and Transplantation, University Hospital Zürich, Zürich, Switzerland
| | - James Ferguson
- National Institute for Health Research (NIHR) Birmingham Liver Biomedical Research Centre (BRC), Institute of Immunology and Immunotherapy, University of Birmingham, UK; Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK.
| | - Paolo Muiesan
- National Institute for Health Research (NIHR) Birmingham Liver Biomedical Research Centre (BRC), Institute of Immunology and Immunotherapy, University of Birmingham, UK; Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK; Department of Liver Surgery, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK.
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Meijerink H, White RA, Løvlie A, de Blasio BF, Dalgard O, Amundsen EJ, Melum E, Kløvstad H. Modelling the burden of hepatitis C infection among people who inject drugs in Norway, 1973-2030. BMC Infect Dis 2017; 17:541. [PMID: 28774261 PMCID: PMC5543437 DOI: 10.1186/s12879-017-2631-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 07/25/2017] [Indexed: 02/08/2023] Open
Abstract
Background Lack of Hepatitis C virus (HCV) incidence data in (Norwegian) high-risk groups impedes the ability to make informed decisions on prevention measures. Thus we rely on modelling to estimate the incidence and burden of HCV infections. Methods We constructed a compartmental model for HCV infections in Norway among active and former people who inject drugs (PWIDs). We based yearly transition rates on literature. The model was fitted to absolute numbers of hepatitis C associated cirrhosis, hepatocellular carcinoma (HCC) and death from national data sources (2000–2013). We estimated the number (95%CI) of HCV infections, cirrhosis, HCC and death and disability adjusted life years (DALYs) due to HCV infections in Norway, 1973–2030. We assumed treatment rates in the projected period were similar to those in 2013. Results The estimated proportion of chronic HCV (including those with cirrhosis and HCC) among PWIDs was stable from 2000 (49%; 4441/9108) to 2013 (43%; 3667/8587). We estimated that the incidence of HCV among PWIDs was 381 new infections in 2015. The estimated number of people with cirrhosis, HCC, and liver transplant was predicted to increase until 2022 (1537 people). DALYs among active PWIDs estimated to peak in 2006 (3480 DALYs) and decrease to 1870 DALYs in 2030. Chronic HCV infection contributes most to the total burden of HCV infection, and peaks at 1917 DALYs (52%) in 2007. The burden of HCV related to PWID increased until 2006 with 81/100,000 DALYs inhabitants and decreased to 68/100,000 DALYs in 2015. Conclusion The burden of HCV associated with injecting drug use is considerable, with chronic HCV infection contributing most to the total burden. This model can be used to estimate the impact of different interventions on the HCV burden in Norway and to perform cost-benefit analyses of various public health measures. Electronic supplementary material The online version of this article (doi:10.1186/s12879-017-2631-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hinta Meijerink
- Norwegian Institute of Public Health, Postboks 4404 Nydalen, 0403, Oslo, Norway.,European Programme for Intervention Epidemiology Training (EPIET), European Centre for Disease Prevention and Control, (ECDC), Stockholm, Sweden
| | - Richard A White
- Norwegian Institute of Public Health, Postboks 4404 Nydalen, 0403, Oslo, Norway
| | - Astrid Løvlie
- Norwegian Institute of Public Health, Postboks 4404 Nydalen, 0403, Oslo, Norway
| | - Birgitte Freiesleben de Blasio
- Norwegian Institute of Public Health, Postboks 4404 Nydalen, 0403, Oslo, Norway.,Department of Biostatistics, Oslo Centre for Biostatistics and Epidemiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Olav Dalgard
- Akershus University Hospital, Lørenskog, Norway.,Medical Faculty, Oslo University, Oslo, Norway
| | - Ellen J Amundsen
- Norwegian Institute of Public Health, Postboks 4404 Nydalen, 0403, Oslo, Norway
| | - Espen Melum
- Norwegian PSC Research Center, Division of Surgery, Inflammatory Medicine and Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Section of Gastroenterology, Division of Surgery, Inflammatory Medicine and Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Research Institute of Internal Medicine, Division of Surgery, Inflammatory Medicine and Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Hilde Kløvstad
- Norwegian Institute of Public Health, Postboks 4404 Nydalen, 0403, Oslo, Norway.
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Björnsson ES. Primary sclerosing cholangitis: best practices for diagnosis. Expert Opin Orphan Drugs 2017. [DOI: 10.1080/21678707.2017.1358163] [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: 10/19/2022]
Affiliation(s)
- Einar S. Björnsson
- Department of Internal Medicine, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Division of Gastroenterology and Hepatology, The National University Hospital of Iceland
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Weismüller TJ, Trivedi PJ, Bergquist A, Imam M, Lenzen H, Ponsioen CY, Holm K, Gotthardt D, Färkkilä MA, Marschall HU, Thorburn D, Weersma RK, Fevery J, Mueller T, Chazouillères O, Schulze K, Lazaridis KN, Almer S, Pereira SP, Levy C, Mason A, Naess S, Bowlus CL, Floreani A, Halilbasic E, Yimam KK, Milkiewicz P, Beuers U, Huynh DK, Pares A, Manser CN, Dalekos GN, Eksteen B, Invernizzi P, Berg CP, Kirchner GI, Sarrazin C, Zimmer V, Fabris L, Braun F, Marzioni M, Juran BD, Said K, Rupp C, Jokelainen K, Benito de Valle M, Saffioti F, Cheung A, Trauner M, Schramm C, Chapman RW, Karlsen TH, Schrumpf E, Strassburg CP, Manns MP, Lindor KD, Hirschfield GM, Hansen BE, Boberg KM. Patient Age, Sex, and Inflammatory Bowel Disease Phenotype Associate With Course of Primary Sclerosing Cholangitis. Gastroenterology 2017; 152:1975-1984.e8. [PMID: 28274849 PMCID: PMC5546611 DOI: 10.1053/j.gastro.2017.02.038] [Citation(s) in RCA: 311] [Impact Index Per Article: 44.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Revised: 01/09/2017] [Accepted: 02/28/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Primary sclerosing cholangitis (PSC) is an orphan hepatobiliary disorder associated with inflammatory bowel disease (IBD). We aimed to estimate the risk of disease progression based on distinct clinical phenotypes in a large international cohort of patients with PSC. METHODS We performed a retrospective outcome analysis of patients diagnosed with PSC from 1980 through 2010 at 37 centers in Europe, North America, and Australia. For each patient, we collected data on sex, clinician-reported age at and date of PSC and IBD diagnoses, phenotypes of IBD and PSC, and date and indication of IBD-related surgeries. The primary and secondary endpoints were liver transplantation or death (LTD) and hepatopancreatobiliary malignancy, respectively. Cox proportional hazards models were applied to determine the effects of individual covariates on rates of clinical events, with time-to-event analysis ascertained through Kaplan-Meier estimates. RESULTS Of the 7121 patients in the cohort, 2616 met the primary endpoint (median time to event of 14.5 years) and 721 developed hepatopancreatobiliary malignancy. The most common malignancy was cholangiocarcinoma (n = 594); patients of advanced age at diagnosis had an increased incidence compared with younger patients (incidence rate: 1.2 per 100 patient-years for patients younger than 20 years old, 6.0 per 100 patient-years for patients 21-30 years old, 9.0 per 100 patient-years for patients 31-40 years old, 14.0 per 100 patient-years for patients 41-50 years old, 15.2 per 100 patient-years for patients 51-60 years old, and 21.0 per 100 patient-years for patients older than 60 years). Of all patients with PSC studied, 65.5% were men, 89.8% had classical or large-duct disease, and 70.0% developed IBD at some point. Assessing the development of IBD as a time-dependent covariate, Crohn's disease and no IBD (both vs ulcerative colitis) were associated with a lower risk of LTD (unadjusted hazard ratio [HR], 0.62; P < .001 and HR, 0.90; P = .03, respectively) and malignancy (HR, 0.68; P = .008 and HR, 0.77; P = .004, respectively). Small-duct PSC was associated with a lower risk of LTD or malignancy compared with classic PSC (HR, 0.30 and HR, 0.15, respectively; both P < .001). Female sex was also associated with a lower risk of LTD or malignancy (HR, 0.88; P = .002 and HR, 0.68; P < .001, respectively). In multivariable analyses assessing the primary endpoint, small-duct PSC characterized a low-risk phenotype in both sexes (adjusted HR for men, 0.23; P < .001 and adjusted HR for women, 0.48; P = .003). Conversely, patients with ulcerative colitis had an increased risk of liver disease progression compared with patients with Crohn's disease (HR, 1.56; P < .001) or no IBD (HR, 1.15; P = .002). CONCLUSIONS In an analysis of data from individual patients with PSC worldwide, we found significant variation in clinical course associated with age at diagnosis, sex, and ductal and IBD subtypes. The survival estimates provided might be used to estimate risk levels for patients with PSC and select patients for clinical trials.
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Affiliation(s)
- Tobias J Weismüller
- Department of Internal Medicine I, University of Bonn, Germany; Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.
| | - Palak J Trivedi
- National Institute for Health Research (NIHR) Birmingham, Liver Biomedical Research Centre (BRC), University of Birmingham, United Kingdom; Liver Unit, University Hospitals Birmingham Queen Elizabeth, United Kingdom
| | - Annika Bergquist
- Center for Digestive Diseases, Division of Hepatology, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Mohamad Imam
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota; Department of Internal Medicine, University of North Dakota, Grand Forks, North Dakota
| | - Henrike Lenzen
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Kristian Holm
- Norwegian PSC Research Center and Section for Gastroenterology, Department of Transplantation Medicine, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Daniel Gotthardt
- Department of Gastroenterology, Infectious Diseases and Intoxications, University Hospital Heidelberg, Heidelberg, Germany
| | - Martti A Färkkilä
- Helsinki University, Clinic of Gastroenterology, Helsinki University Hospital, Helsinki, Finland
| | - Hanns-Ulrich Marschall
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Douglas Thorburn
- The Sheila Sherlock Liver Centre and UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, United Kingdom
| | - Rinse K Weersma
- Department of Gastroenterology and Hepatology, University of Groningen and University Medical Center, Groningen, The Netherlands
| | - Johan Fevery
- Department of Hepatology, University Hospital Gasthuisberg, Leuven, Belgium
| | - Tobias Mueller
- Department of Internal Medicine, Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany
| | - Olivier Chazouillères
- Service d'Hépatologie, Hôpital Saint Antoine, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Pierre et Marie Curie, Paris, France
| | - Kornelius Schulze
- 1st Department of Medicine, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | | | - Sven Almer
- Division of Gastroenterology and Hepatology, Linköping University, Linköping; Sweden
| | - Stephen P Pereira
- Institute for Liver and Digestive Health, University College London, London, United Kingdom
| | - Cynthia Levy
- Division of Hepatology, University of Miami, Miami, Florida
| | - Andrew Mason
- Division of Gastroenterology and Hepatology, University of Alberta, Edmonton, AB, Canada
| | - Sigrid Naess
- Norwegian PSC Research Center and Section for Gastroenterology, Department of Transplantation Medicine, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Christopher L Bowlus
- Division of Gastroenterology and Hepatology, University of California Davis, Davis, California
| | - Annarosa Floreani
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Emina Halilbasic
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria
| | - Kidist K Yimam
- Department of Hepatology and Liver Transplantation, California Pacific Medical Center, San Francisco, California
| | - Piotr Milkiewicz
- Department of Clinical and Molecular Biochemistry, Pomeranian Medical University, Szczecin, Poland; Liver and Internal Medicine Unit, Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Poland
| | - Ulrich Beuers
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Dep K Huynh
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Albert Pares
- Liver Unit, Hospital Clinic, IDIBAPS, CIBERehd, University of Barcelona, Spain
| | - Christine N Manser
- Division for Gastroenterology and Hepatology, University Hospital Zurich (USZ), Zurich, Switzerland
| | - George N Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, School of Medicine, University of Thessaly, Larissa, Greece
| | - Bertus Eksteen
- University of Calgary, Snyder Institute for Chronic Diseases, Alberta, AB, Canada
| | - Pietro Invernizzi
- Program for Autoimmune Liver Diseases, International Center for Digestive Health, Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Christoph P Berg
- Department of Gastroenterology, Hepatology, and Infectiology, Medical Clinic, University of Tübingen, Germany
| | - Gabi I Kirchner
- Department of Internal Medicine 1, University Hospital of Regensburg, Regensburg, Germany
| | - Christoph Sarrazin
- Department of Internal Medicine 1, Johann Wolfgang Goethe-University Hospital, Frankfurt, Germany
| | - Vincent Zimmer
- Department of Medicine II, Saarland University Medical Center, Homburg, Germany
| | - Luca Fabris
- Department of Molecular Medicine, University of Padua School of Medicine, Padua, Italy
| | - Felix Braun
- Department of General, Visceral, Thoracic, Transplantation and Pediatric Surgery, Campus Kiel, UKSH, Kiel, Germany
| | - Marco Marzioni
- Clinic of Gastroenterology, Università Politecnica delle Marche, Ancona, Italy
| | - Brian D Juran
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Karouk Said
- Center for Digestive Diseases, Division of Hepatology, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Christian Rupp
- Department of Gastroenterology, Infectious Diseases and Intoxications, University Hospital Heidelberg, Heidelberg, Germany
| | - Kalle Jokelainen
- Helsinki University, Clinic of Gastroenterology, Helsinki University Hospital, Helsinki, Finland
| | - Maria Benito de Valle
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Francesca Saffioti
- The Sheila Sherlock Liver Centre and UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, United Kingdom
| | - Angela Cheung
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria
| | - Christoph Schramm
- 1st Department of Medicine, University Medical Center Hamburg Eppendorf, Hamburg, Germany; Martin Zeitz Center for Rare Diseases, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Roger W Chapman
- Nuffield Department of Clinical Medicine, University of Oxford, United Kingdom; Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, United Kingdom
| | - Tom H Karlsen
- Norwegian PSC Research Center and Section for Gastroenterology, Department of Transplantation Medicine, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Erik Schrumpf
- Norwegian PSC Research Center and Section for Gastroenterology, Department of Transplantation Medicine, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Michael P Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Keith D Lindor
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota; Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, Arizona; Arizona State University, College of Health Solutions, Phoenix, Arizona
| | - Gideon M Hirschfield
- National Institute for Health Research (NIHR) Birmingham, Liver Biomedical Research Centre (BRC), University of Birmingham, United Kingdom
| | - Bettina E Hansen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Toronto Centre for Liver Disease, Toronto General Hospital, Toronto, Canada
| | - Kirsten M Boberg
- Norwegian PSC Research Center and Section for Gastroenterology, Department of Transplantation Medicine, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
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Jørgensen SF, Macpherson ME, Bjøro K, Karlsen TH, Reims HM, Grzyb K, Fosby B, Fevang B, Aukrust P, Nordøy I. Liver transplantation in patients with primary antibody deficiency. J Allergy Clin Immunol 2017; 139:1708-1710.e2. [DOI: 10.1016/j.jaci.2016.10.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Revised: 10/03/2016] [Accepted: 10/17/2016] [Indexed: 11/30/2022]
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Abstract
Primary sclerosing cholangitis (PSC) and primary biliary cholangitis (PBC) are the most common cholestatic liver diseases (CLD) in adults. Liver transplant (LT) is desirable for those who progress to end-stage liver disease. CLD have become an uncommon indication for LT. PSC and PBC accounted for 7.1% of all adult LT in 2015. CLD have the best post-LT outcomes compared with other indications for LT. Disease recurrence of PSC and PBC after LT is reported in up to 37% and 43% of LT recipients, respectively. Although recurrent PBC does not affect post-LT outcomes, recurrent PSC is associated with worse post-LT survival.
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Affiliation(s)
- Nathalie A Pena Polanco
- Division of Internal Medicine, Miller School of Medicine, University of Miami, 1611 Northwest 12th Avenue, Suite Central 600-D, Miami, FL 33136, USA
| | - Cynthia Levy
- Division of Hepatology, Miller School of Medicine, University of Miami, 1120 Northwest 14th Street, Suite 1112, Miami, FL 33136, USA
| | - Eric F Martin
- Division of Hepatology, Miller School of Medicine, University of Miami, 1120 Northwest 14th Street, Suite 1112, Miami, FL 33136, USA.
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Abstract
Primary sclerosing cholangitis (PSC) is a chronic disease leading to fibrotic scarring of the intrahepatic and extrahepatic bile ducts, causing considerable morbidity and mortality via the development of cholestatic liver cirrhosis, concurrent IBD and a high risk of bile duct cancer. Expectations have been high that genetic studies would determine key factors in PSC pathogenesis to support the development of effective medical therapies. Through the application of genome-wide association studies, a large number of disease susceptibility genes have been identified. The overall genetic architecture of PSC shares features with both autoimmune diseases and IBD. Strong human leukocyte antigen gene associations, along with several susceptibility genes that are critically involved in T-cell function, support the involvement of adaptive immune responses in disease pathogenesis, and position PSC as an autoimmune disease. In this Review, we survey the developments that have led to these gene discoveries. We also elaborate relevant interpretations of individual gene findings in the context of established disease models in PSC, and propose relevant translational research efforts to pursue novel insights.
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Abstract
Purpose of Review The purpose of this review is to discuss reasons why immunosuppressive therapy so far failed in Primary Biliry Cholangitis. Recent Findings Even targeted immunosuppressive therapy seems ineffective or potentially harmful. Summary Bile acid-mediated cholangiocyte damage, facilitated by insufficient bicarbonate secretion, seems to attenuate the anti-inflammatory and anti-fibrotic actions of immunosuppressant and immunomodulatory drugs in a clinically significant way.
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Affiliation(s)
- Mette Vesterhus
- Norwegian PSC Research Center, Division of Surgery, Inflammatory Medicine and Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,National Centre for Ultrasound in Gastroenterology, Haukeland University Hospital, Bergen, Norway
| | - Espen Melum
- Norwegian PSC Research Center, Division of Surgery, Inflammatory Medicine and Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,K.G. Jebsen Inflammation Research Centre, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Research Institute of Internal Medicine, Division of Surgery, Inflammatory Medicine and Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Section of Gastroenterology, Department of Transplantation Medicine, , Division of Surgery, Inflammatory Medicine and Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway
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