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Thuluvath AJ, Duarte-Rojo A, Lai JC, Peipert J, Dietch ZC, Siddiqui O, Morrissey S, Belfanti K, Zhao L, Guo K, Nizamuddin M, Polineni P, Levitsky J, Flores AM, Ladner DP. Brief PROMIS Assessment Screens for Frailty and Predicts Hospitalizations in Liver Transplant Candidates. Transplantation 2024; 108:491-497. [PMID: 37496147 DOI: 10.1097/tp.0000000000004741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
BACKGROUND Frailty is prevalent in patients with end-stage liver disease and predicts waitlist mortality, posttransplant mortality, and frequency of hospitalizations. The Liver Frailty Index (LFI) is a validated measure of frailty in liver transplant (LT) candidates but requires an in-person assessment. METHODS We studied the association between patient-reported physical function and LFI in a single-center prospective study of adult patients with cirrhosis undergoing LT evaluation from October 2020 to December 2021. Frailty was assessed with the LFI and 4-m gait speed. Patient-reported physical function was evaluated using a brief Patient-Reported Outcomes Measurement Information System (PROMIS) survey. RESULTS Eighty-one LT candidates were enrolled, with a mean model of end-stage liver disease-sodium of 17.6 (±6.3). The mean LFI was 3.7 (±0.77; 15% frail and 59% prefrail) and the mean PROMIS Physical Function score was 45 (±8.6). PROMIS Physical Function correlated with LFI ( r = -0.54, P < 0.001) and 4-m gait speed ( r = 0.48, P < 0.001). The mean hospitalization rate was 1.1 d admitted per month. After adjusting for age, sex, and model of end-stage liver disease-sodium, patient-reported physical function-predicted hospitalization rate ( P = 0.001). CONCLUSIONS This study suggests that a brief patient-reported outcome measure can be used to screen for frailty and predict hospitalizations in patients with cirrhosis.
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Affiliation(s)
- Avesh J Thuluvath
- Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Andres Duarte-Rojo
- Division of Gastroenterology and Hepatology, Starzl Transplantation Institute, and Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, PA
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, CA
| | - John Peipert
- Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Zachary C Dietch
- Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Division of Transplant, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Osama Siddiqui
- Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Sheila Morrissey
- Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Department of Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Kimberly Belfanti
- Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Department of Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Lihui Zhao
- Department of Preventive Medicine, Biostatistics Collaboration Center, Northwestern Medicine, Chicago, IL
| | - Kexin Guo
- Department of Preventive Medicine, Biostatistics Collaboration Center, Northwestern Medicine, Chicago, IL
| | - Mohammad Nizamuddin
- Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Praneet Polineni
- Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Josh Levitsky
- Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Ann-Marie Flores
- Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Department of Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Cancer Survivorship Institute, Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL
| | - Daniela P Ladner
- Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Division of Transplant, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
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Thuluvath AJ, Siddiqui O, Lai JC, Peipert J, Levitsky J, Daud A, Mazumder NR, Flores AM, Borja-Cacho D, Caicedo JC, Loftus C, Wong R, Mroczek D, Ladner DP. Personality Traits in Patients With Cirrhosis Are Different From Those of the General Population and Impact Likelihood of Liver Transplantation. Transplantation 2023; 107:420-428. [PMID: 36173424 PMCID: PMC10294608 DOI: 10.1097/tp.0000000000004304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Personality traits influence clinical outcomes in chronic diseases, but their impact in cirrhosis is unknown. We studied the personality of patients with cirrhosis undergoing liver transplant (LT) evaluation and determined their correlation to clinical outcomes. METHODS A multicenter' prospective study of adult patients undergoing LT evaluation was performed from January 2018 to October 2019. The "Big Five" personality traits of conscientiousness, extraversion, openness, neuroticism, and agreeableness plus agency were assessed with the Midlife Development Inventory Personality Scale and compared with the general population. Frailty was assessed with the Liver Frailty Index. RESULTS Two hundred sixty-three LT candidates were enrolled. Twenty-four percent had hepatitis C virus, 25% nonalcoholic steatohepatitis, and 25% ethyl alcohol (mean model for end-stage liver disease = 15.7). Compared with the general population, LT candidates had higher openness (3.1 versus 2.9; P < 0.001), extraversion (3.2 versus 3.1; P < 0.001), agreeableness (3.5 versus 3.4; P = 0.04), agency (2.9 versus 2.6; P < 0.001), neuroticism (2.2 versus 2.1; P = 0.001), and lower conscientiousness (3.3 versus 3.4; P = 0.007). Patients with higher conscientiousness were more likely to receive an LT (HR = 2.76; P = 0.003). CONCLUSIONS Personality traits in LT candidates differ significantly from the general population, with higher conscientiousness associated with a higher likelihood of receiving a transplant.
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Affiliation(s)
- Avesh J. Thuluvath
- Northwestern University Transplant Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, IL
- Division of Hepatology, Department of Medicine, Northwestern Medicine, Chicago, IL
| | - Osama Siddiqui
- Northwestern University Transplant Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, CA
| | - John Peipert
- Northwestern University Transplant Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, IL
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Josh Levitsky
- Division of Hepatology, Department of Medicine, Northwestern Medicine, Chicago, IL
| | - Amna Daud
- Northwestern University Transplant Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Nikhilesh R. Mazumder
- Northwestern University Transplant Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, IL
- Division of Hepatology, Department of Medicine, Northwestern Medicine, Chicago, IL
| | - Anne-Marie Flores
- Northwestern University Transplant Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Daniel Borja-Cacho
- Northwestern University Transplant Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, IL
- Division of Transplant, Department of Surgery, Northwestern Medicine, Chicago, IL
| | - Juan C. Caicedo
- Northwestern University Transplant Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, IL
- Division of Transplant, Department of Surgery, Northwestern Medicine, Chicago, IL
| | - Corinne Loftus
- Northwestern University Transplant Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Randi Wong
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, CA
| | - Dan Mroczek
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Department of Psychology, Weinberg College of Arts & Sciences, Northwestern University, Evanston, IL
| | - Daniela P. Ladner
- Northwestern University Transplant Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, IL
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Division of Transplant, Department of Surgery, Northwestern Medicine, Chicago, IL
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Thuluvath AJ, Peipert J, Berkowitz R, Siddiqui O, Whitehead B, Thomas A, Levitsky J, Caicedo-Ramirez J, Ladner DP. Donor quality of life after living donor liver transplantation: a review of the literature. Dig Med Res 2021; 4. [PMID: 35252845 PMCID: PMC8895483 DOI: 10.21037/dmr-20-151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Living donor liver transplantation (LDLT) provides a source for transplant in the setting of the deceased donor organ shortage. Seeing as living donors do not derive any medical benefit from the procedure, fully understanding the impact of donation on donor health-related quality of life (HRQOL) is essential. A systematic search of the MEDLINE database was performed from 2008–2020, using relevant Medical Subject Headings. Articles were evaluated for study design, cohort size and follow-up time and excluded if they contained significant methodological flaws. A total of 43 articles were included: 20 (47%) were cross-sectional and 23 (53%) were longitudinal. The mean number of donors per study was 142 (range:8–578) with follow-up ranging from 12–132 months. Forty-two unique HRQOL metrics were implemented across the 43 studies, the majority of which were questionnaires. Of the 31 studies that used the Medical Outcomes Study Short Form 36 questionnaire, 9.1% of donors reported physical QOL did not return to pre-LDLT levels for at least 2 years after donation. Mental QOL remained stable or improved after LDLT, with mean mental composite scores increasing from 50 to 52 at 3 months post-LDLT in one study. The predicted probability of poor sexual desire decreased at 1-year post-LDLT (male: 0.08, female: 0.26) relative to pre-LDLT (male: 0.44, female: 0.76; P<0.001) and three months post-LDLT (male: 0.35, female 0.69; P=0.001). Forty percent of donors found LDLT to be financially burdensome at 3 months and 19% at 2 years post-LDLT. Female gender and obesity were consistent predictors of worse HRQOL. Laparoscopy-assisted donor hepatectomy was associated with shorter hospitalizations than open donor hepatectomy (10.3 vs. 18.3 days, P=0.02). No studies used the National Institutes of Health Patient Reported Outcomes Measurement Information System (PROMIS) measures of HRQOL. Our review demonstrates that LDLT can have a long-lasting negative impact on physical QOL in 9.1% of donors and can cause both sexual dysfunction and significant financial strain. Future studies should consider using standardized and extensively validated patient reported outcomes measures, such as PROMIS, in order to directly compare outcomes across studies and gain further insight into the impact of LDLT on D-HRQOL.
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Affiliation(s)
- Avesh J. Thuluvath
- Northwestern University Transplant Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Division of Hepatology, Department of Medicine, Northwestern Medicine, Chicago, IL, USA
| | - John Peipert
- Northwestern University Transplant Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Department of Medical Social Sciences, Feinberg School of Medicine, Chicago, IL, USA
| | - Rachel Berkowitz
- Northwestern University Transplant Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Osama Siddiqui
- Northwestern University Transplant Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Bridget Whitehead
- Northwestern University Transplant Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Arielle Thomas
- Northwestern University Transplant Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- American College of Surgeons, Committee on Trauma, Chicago, IL, USA
| | - Josh Levitsky
- Department of Medical Social Sciences, Feinberg School of Medicine, Chicago, IL, USA
| | - Juan Caicedo-Ramirez
- Northwestern University Transplant Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Division of Transplant, Department of Surgery, Northwestern Medicine, Chicago, IL, USA
| | - Daniela P. Ladner
- Northwestern University Transplant Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Division of Transplant, Department of Surgery, Northwestern Medicine, Chicago, IL, USA
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Abstract
GOALS AND BACKGROUND There are limited data on post-liver transplantation (LT) outcomes of patients with sarcoidosis. STUDY We examined the clinical characteristics and post-LT outcomes of patients with sarcoidosis using the United Network for Organ Sharing database from 1985 to 2016 and compared them to patients (entire cohort as well as age, gender, and year of LT-matched counterparts) with primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC). For the matched design, a conditional logistic regression was used for categorical variables and marginal generalized estimating equation regression models for continuous variables. Survival functions were constructed using the Kaplan-Meier estimator. RESULTS A total of 206 patients with sarcoidosis, transplanted during the study period, were compared with 3933 patients with PBC and 5323 with PSC. In total, 197 patients with sarcoidosis were compared with 576 with PBC and 576 with PSC in the 1:3 matched analysis. The sarcoidosis group had a higher proportion of blacks (53.3%) and a higher prevalence of obesity and type II diabetes mellitus. The graft and patient survival for sarcoidosis patients were lower when compared with unmatched PBC and PSC patients. The results remained unchanged in the matched analysis. At 5-year, patient survival was ~15% lower for the sarcoidosis group when compared with PBC and PSC. In multivariate analysis using matched data, hazard ratios (HRs) for graft (HR=1.68, 95% confidence interval=1.03-2.75, P=0.04), and patient (HR=2.01, confidence interval=1.22-3.34, P<0.01) survival were higher for sarcoidosis. CONCLUSIONS Patients who underwent LT for sarcoidosis had a lower graft and patient survival when compared with those with PBC or PSC. That being said, 66% of patients survived 5 years after transplantation, suggesting that LT is an acceptable option in this population.
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Affiliation(s)
| | - Yulia Savva
- The Institute of Digestive Health and Liver Disease, Mercy Medical Center, Baltimore, MD
| | - Po-Hung Chen
- Department of Medicine
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine
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Thuluvath AJ, Ahn JC, Rattan P, Kurdi AT, Peeraphatdit TB, Kamath MJ, Lennon RJ, Poterucha JJ, Petersen BT, Kamath PS. Evaluation of Charcot Triad, Reynolds Pentad, and Tokyo Guidelines for Diagnosis of Cholangitis Secondary to Choledocholithiasis Across Patient Age Groups. Mayo Clin Proc Innov Qual Outcomes 2021; 5:377-387. [PMID: 33997636 PMCID: PMC8105521 DOI: 10.1016/j.mayocpiqo.2021.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Objective To determine the prevalence of Charcot triad, Reynolds pentad, and Tokyo Guidelines criteria and clinical outcomes among patients with cholangitis across different age groups. Patients and Methods We conducted a retrospective analysis of 257 consecutive hospitalized adult patients with acute cholangitis due to endoscopic retrograde cholangiopancreatography–confirmed choledocholithiasis between January 1, 2015, and December 31, 2019. Patients were divided into 3 age groups: less than 65 years, 65 to 79 years, and 80 years or older. Symptoms, vital signs, and laboratory data on admission were collected. Outcomes included length of hospitalization, intensive care unit stay, and 3-month mortality. Nominal variables were tested with the Pearson χ2 test, and continuous variables were tested with the Wilcoxon rank sum test. Results Charcot triad decreased with older ages. In the group that was age 80 years or older, malaise was the most common symptom; 33.6% (37 of 110) presented with altered sensorium, 9.1% (10 of 110) had no pain, fever, or jaundice, and positive blood culture results were more frequent. Tokyo cholestasis criterion was present in 96.0% (247 of 257), while inflammation (considered essential for diagnosis) was present in 75.9% (195 of 257). Patients 80 years or older had significantly higher mean length of hospital stay (P<.001) and mean length of intensive care unit stay (P=.021). Conclusion Compared with patients in younger age groups, patients with cholangitis who are 80 years or older are less likely to have Charcot triad, are more likely to have features of Reynolds pentad, or present with unexplained malaise. Within the Tokyo Guidelines, cholestasis should replace inflammation as an essential diagnostic criterion.
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Key Words
- ALT, alanine aminotransferase
- AP, alkaline phosphatase
- AST, aspartate aminotransferase
- CBD, common bile duct
- CRP, C-reactive protein
- CT, computed tomography
- ERCP, endoscopic retrograde cholangiopancreatography
- ICU, intensive care unit
- US, ultrasonography
- WBC, white blood cell
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Affiliation(s)
- Avesh J. Thuluvath
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Joseph C. Ahn
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Puru Rattan
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Ahmed T. Kurdi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | | | | | - Ryan J. Lennon
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - John J. Poterucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Bret T. Petersen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Patrick S. Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
- Correspondence: Address to Patrick S. Kamath, MD, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First St SW, Rochester, MN 55905.
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Abstract
INTRODUCTION There are only limited data on the survival outcomes after transplanting HCV RNA-positive liver into HCV RNA-negative recipients. The objective of our study was to determine whether there were graft and patient survival differences when HCV-negative patients received HCV RNA (nucleic acid amplification testing [NAT] positive)-positive liver grafts. METHODS We queried the United Network for Organ Sharing data sets from January 2014 to December 2018, and recipients (N = 24,724) were stratified into 6 groups based on the status of HCV antibody and RNA of recipients and donors. The Cox proportional hazard regression was used to estimate the relationship between groups and 1-year post-LT graft or patient survival. RESULTS During the study period, 1,358 recipients received NAT-positive liver grafts. Two hundred ten of the recipients were HCV negative. During the same period, 707 HCV antibody-positive but NAT-negative grafts were transplanted into 516 HCV-positive and 191 HCV-negative recipients. There were no differences in survival in HCV-positive recipients whether they received NAT-positive grafts (n = 1,148) or HCV antibody-negative/NAT-negative grafts (n = 6,321). Recipients of grafts from HCV antibody-positive/NAT-negative donors had similar survival whether recipients were HCV-negative patients (n = 191) or HCV-positive patients (n = 516), and their survival probabilities were similar to those of HCV-negative recipients (n = 6,321) receiving grafts from HCV antibody-negative/NAT-negative donors. Patient survival was lower (P = 0.049) when HCV-negative recipients (n = 210) received NAT-positive grafts compared with HCV-positive patients (n = 1,148) receiving NAT-positive grafts; however, when adjusted for recipient and donor characteristics, the difference was not significant. DISCUSSION HCV-negative recipients receiving HCV-positive liver grafts (NAT positive) have excellent 1-year survival outcomes.
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Affiliation(s)
- Paul J Thuluvath
- Institute of Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, Maryland, USA
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - David A Bruno
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Joseph Alukal
- Institute of Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, Maryland, USA
| | - Sanjaya K Satapathy
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Manhasset, New York, USA
| | - Avesh J Thuluvath
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Talan Zhang
- Institute of Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, Maryland, USA
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Thuluvath PJ, Thuluvath AJ, Savva Y, Zhang T. Karnofsky Performance Status Following Liver Transplantation in Patients With Multiple Organ Failures and Probable Acute-on-Chronic Liver Failure. Clin Gastroenterol Hepatol 2020; 18:234-241. [PMID: 30885883 DOI: 10.1016/j.cgh.2019.03.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 02/26/2019] [Accepted: 03/10/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Little is known about outcomes of patients who underwent liver transplantation for acute on chronic liver failure (ACLF) and multiple organ failures. We compared Karnofsky Performance Status (KPS) before and after liver transplantation among patients with different numbers of organ failures and probable ACLF. METHODS We performed a retrospective cohort study of adults who underwent liver transplantation within 30 days of listing with the United Network for Organ Sharing (UNOS) network from January 1, 2006, through September 30, 2016. We determined the prevalence of organ failures using a modified version of the Chronic Liver Failure-Sequential Organ Failure Assessment scale and collected KPS scores at the time of transplantation and at intervals of 3 to 12 months after liver transplantation. Multivariate analyses were performed to adjust for confounders including UNOS region. RESULTS At the time of liver transplantation, 2838 patients had no organ failure, 2944 had 1 to 2 organ failures, and 1342 patients had 3 or more organ failures. KPS scores following liver transplantation improved significantly in all groups; scores ranged from 81 in patients with no organ failure to 72 in patients with 5 to 6 organ failures. Excellent performance status (KPS score, ≥80) by 1 year after transplantation was achieved by 60% of patients with 5 to 6 organ failures, 64% to 66% of patients with 3 to 4 organ failures, and 70% to 71% of patients with 1 to 2 organ failures, compared with 72.5% of patients without organ failure. Patients with 1 to 4 organ failure were more likely to achieve KPS scores of 80 or more than patients without organ failure, after we adjusted for other covariates and UNOS region. In addition, black patients were less likely, and patients with alcoholic cirrhosis were more likely, to have KPS scores of 80 or more after liver transplantation. CONCLUSIONS In a retrospective cohort study of patients with probable ACLF who underwent liver transplantation within 30 days of listing with the UNOS network, 60% to 66% of patients with 3 or more organ failures achieved excellent performance 3 to 12 months later.
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Affiliation(s)
- Paul J Thuluvath
- Department of Medicine, Mercy Medical Center, Baltimore, Maryland; University of Maryland School of Medicine, Baltimore, Maryland.
| | | | - Yulia Savva
- Department of Medicine, Mercy Medical Center, Baltimore, Maryland
| | - Talan Zhang
- Department of Medicine, Mercy Medical Center, Baltimore, Maryland
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Thuluvath PJ, Thuluvath AJ, Hanish S, Savva Y. Reply to: "Type of organ failure and acute insult have important bearings in outcomes of liver transplantation: A pragmatic discourse". J Hepatol 2019; 70:549-550. [PMID: 30396699 DOI: 10.1016/j.jhep.2018.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 10/18/2018] [Indexed: 12/04/2022]
Affiliation(s)
- Paul J Thuluvath
- Institute of Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, MD, United States; University of Maryland School of Medicine, Baltimore, United States.
| | - Avesh J Thuluvath
- Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Steve Hanish
- University of Maryland School of Medicine, Baltimore, United States
| | - Yulia Savva
- Institute of Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, MD, United States
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Affiliation(s)
- Sergey V Kantsevoy
- Institute for Digestive Health and Liver Diseases, Mercy Medical Center, Baltimore, Maryland, USA
| | | | | | - Avesh J Thuluvath
- Institute for Digestive Health and Liver Diseases, Mercy Medical Center, Baltimore, Maryland, USA
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Thuluvath PJ, Thuluvath AJ, Hanish S, Savva Y. Liver transplantation in patients with multiple organ failures: Feasibility and outcomes. J Hepatol 2018; 69:1047-1056. [PMID: 30071241 DOI: 10.1016/j.jhep.2018.07.007] [Citation(s) in RCA: 121] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 07/06/2018] [Accepted: 07/12/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Multiple organ failures (OFs) are common in patients with cirrhosis, but the independent effect of the number or type of OFs on liver transplantation (LT) outcomes is not well defined. METHOD United Network for Organ Sharing data were analyzed from 2002 to 2016 for all adults listed for LT who received an LT within 30 days after listing. We estimated post-LT survival stratified by number and type of pre-transplant OFs before and after adjusting for confounding variables. RESULTS During the study period, 4,714 (4.1%) patients died and 19,375 (16.6%) patients were transplanted within 30 days of listing. One or more OF were more common in those who were transplanted (57.4%) compared to those without LT (9.5%). The probability of staying alive more than 30 days on the waiting list without LT decreased with increasing number of OFs; while 90% were alive without OF, only 20% were alive with two OFs, and 2-8% with three or more OFs. The interval between listing and transplantation decreased with an increase in OFs, and the median time to transplant after listing was only 4-5 days with three or more OFs. Although the risk of post-LT mortality increased with increasing number of OFs, the 90-day patient survival was 90% and one-year survival was 81% in the presence of 5-6 OFs. The number of OFs was an independent predictor of survival, but the maximum difference in one-year graft or patient survival between those without OF and those with 5-6 OFs was only 9%. Additionally, the type of OF had minimal impact on outcomes. CONCLUSIONS Liver transplantation is feasible with excellent outcomes, even in the presence of five or six OFs. LAY SUMMARY Multiple organ failures, ranging from 1-6, are common in hospitalized patients with cirrhosis. The survival without liver transplant is dismal in the presence of three or more organ failures. Small retrospective studies have shown that liver transplant is feasible with good outcomes even in the presence of multiple organ failures. In this study, using a large national dataset, we show that survival chances for more than 30 days in those with three or more organ failures are less than 8%. However, if a liver transplant is performed quickly, the survival chances are very high with one-year survival ranging from 84% with three organ failures to 81% with 5-6 organ failures.
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Affiliation(s)
- Paul J Thuluvath
- Institute of Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, MD, United States; University of Maryland School of Medicine, Baltimore, MD, United States.
| | - Avesh J Thuluvath
- Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Steven Hanish
- University of Maryland School of Medicine, Baltimore, MD, United States
| | - Yulia Savva
- Institute of Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, MD, United States
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Thuluvath PJ, Kantsevoy S, Thuluvath AJ, Savva Y. Reply to: "NASH-related and cryptogenic cirrhosis similarities extend beyond cirrhosis": Cryptogenic cirrhosis should not be equated with NASH cirrhosis based on UNOS data mining and Bayesian 'doctrine of chances'. J Hepatol 2018; 69:973-975. [PMID: 29983203 DOI: 10.1016/j.jhep.2018.06.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 06/19/2018] [Indexed: 12/04/2022]
Affiliation(s)
- Paul J Thuluvath
- Institute of Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, United States; Departments of Surgery & Medicine, University of Maryland School of Medicine, Baltimore, MD, United States.
| | - Sergey Kantsevoy
- Institute of Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, United States; Departments of Surgery & Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Avesh J Thuluvath
- Johns Hopkins University School of Medicine, Baltimore, United States
| | - Yulia Savva
- Institute of Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, United States
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Thuluvath PJ, Thuluvath AJ, Savva Y. Karnofsky performance status before and after liver transplantation predicts graft and patient survival. J Hepatol 2018; 69:818-825. [PMID: 29883596 DOI: 10.1016/j.jhep.2018.05.025] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 05/20/2018] [Accepted: 05/28/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND & AIMS The Karnofsky performance status (KPS) has been used for almost 70 years for clinical assessment of patients. Our objective was to determine whether KPS is an independent predictor of post-liver transplant (LT) survival after adjusting for known confounders. METHOD Adult patients listed with the United Network for Organ Sharing (UNOS) from 2006 to 2016 were grouped into low (10-40%, n = 15,103), intermediate (50-70%, n = 22,183) and high (80-100%, n = 13,131) KPS groups based on KPS scores at the time of LT, after excluding those on ventilators or life support. We determined the trends in KPS before and after LT, and survival probabilities based on KPS. RESULTS There was a decline in KPS scores between listing and LT and there was significant improvement after LT. The graft and patient survival differences were significantly lower (p <0.0001) in those with low KPS. After adjusting for other confounders, the hazard ratios for graft failure were 1.17 (1.12-1.22, p <0.01) for the intermediate and 1.38 (1.31-1.46, p <0.01) for the low group. Similarly, hazard ratios for patient failure were 1.18 (1.13-1.24, p <0.01) for the intermediate and 1.43 (1.35-1.52, p <0.01) for the low group. Other independent negative predictors for graft and patient survival were older age, Black ethnicity, presence of hepatic encephalopathy and donor risk index. Those who did not show significant improvements in post-LT KPS scores had poorer outcomes in all three KPS groups, but it was most obvious in the low KPS group with one-year patient survival of 33%. CONCLUSION The KPS, before and after LT, is an independent predictor of graft and patient survival after adjusting for other important predictors of survival. LAY SUMMARY The overall health of liver transplant recipients could be assessed by a simple clinical assessment tool called the Karnofsky performance status, which assesses an individual's overall functional status on an 11-point scale, in increments of 10, where a score of 0 is considered dead and 100 is considered perfect health. In this study, using a large dataset, we show that the performance status before and after liver transplant is a predictor of survival. More importantly, those who have low performance status before transplant and do not show an improvement in performance status between 3-12 months after liver transplant have very poor survival.
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Affiliation(s)
- Paul J Thuluvath
- Department of Medicine, Mercy Medical Center, University of Maryland School of Medicine & Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | | | - Yulia Savva
- Department of Medicine, Mercy Medical Center, University of Maryland School of Medicine & Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Thuluvath PJ, Kantsevoy S, Thuluvath AJ, Savva Y. Is cryptogenic cirrhosis different from NASH cirrhosis? J Hepatol 2018; 68:519-525. [PMID: 29162389 DOI: 10.1016/j.jhep.2017.11.018] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 10/21/2017] [Accepted: 11/02/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS We hypothesized that patients currently diagnosed with cryptogenic cirrhosis (CC) have truly 'cryptogenic' liver disease, which is unlikely to have evolved from NASH. The aim of this study is to characterize patients with CC, and compare their characteristics to patients with cirrhosis of other etiologies. METHODS To investigate this, we compared the clinical characteristics of adults with CC (n = 7,999) to those with cirrhosis caused by non-alcoholic steatohepatitis (NASH) (n = 11,302), alcohol (n = 21,714) and autoimmune hepatitis (n = 3,447), using the UNOS database from 2002-16. We performed an age, gender and year of listing matched comparison of CC and NASH (n = 7,201 in each group), and also stratified patients by the presence of obesity or diabetes mellitus (DM). RESULTS From 2002 to 2016, patients listed with a diagnosis of NASH increased from about 1% to 16% while CC decreased from 8% to 4%. A logistic regression model using the entire United Network for Organ Sharing data (n = 138,021) suggested that the strongest predictors of NASH were type 2 DM, obesity, age ≥60 years, female gender and white race. Type 2 DM was more common in patients with NASH (53%) than those with CC (29%), alcoholic cirrhosis (16%) and autoimmune hepatitis (16%), and obesity was more common in NASH (65.3%) compared to the other three groups (33-42%). There were more white individuals (82.3%) in the NASH group and a lower prevalence of black, Hispanic and Asian individuals, compared to the other three groups. Hepatocellular carcinoma was more commonly seen in NASH (19% vs. 9-13% in the other groups) and this is not influenced by obesity and type 2 DM. The differences between CC and NASH remained unchanged even when two groups were matched for age, gender and year of listing, or when stratified by the presence or absence of obesity or type 2DM. CONCLUSIONS Based on risk perspectives, CC should not be equated with the term 'NASH cirrhosis'. LAY SUMMARY We hypothesized that cryptogenic cirrhosis is a distinct condition from cirrhosis caused by non-alcoholic steatohepatitis (NASH). By comparing cryptogenic cirrhosis with cirrhosis of other causes, we found clear clinical differences. Therefore, cryptogenic cirrhosis should not be considered the same as NASH cirrhosis. Further investigations are required to identify unknown causes of cirrhosis.
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Affiliation(s)
- Paul J Thuluvath
- Institute of Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, United States; Departments of Surgery & Medicine, University of Maryland School of Medicine, Baltimore, MD, United States.
| | - Sergey Kantsevoy
- Institute of Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, United States; Departments of Surgery & Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Avesh J Thuluvath
- Johns Hopkins University School of Medicine, Baltimore, United States
| | - Yulia Savva
- Institute of Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, United States
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Abstract
Up to 40% of patients report persistent gastroesophageal reflux disease (GERD) symptoms despite proton pump inhibitor (PPI) therapy. This review outlines the evidence for medical therapy for PPI nonresponsive GERD. A literature search for GERD therapies from 2005 to 2015 in PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews identified 2928 unique citations. Of those, 40 unique articles specific to the impact of PPI metabolizer genotype on PPI response and the use adjunctive medical therapies were identified. Thirteen articles reported impacts on CYP genotypes on PPI metabolism demonstrating lower endoscopic healing rates in extensive metabolizers; however, outcomes across genotypes were more uniform with more CYP independent PPIs rabeprazole and esomeprazole. Twenty-seven publications on 11 adjunctive medications showed mixed results for adjunctive therapies including nocturnal histamine-2 receptor antagonists, promotility agents, transient lower esophageal sphincter relaxation inhibitors, and mucosal protective agents. Utilizing PPI metabolizer genotype or switching to a CYP2C19 independent PPI is a simple and conservative measure that may be useful in the setting of incomplete acid suppression. The use of adjunctive medications can be considered particularly when the physiologic mechanism for PPI nonresponse is suspected. Future studies using adjunctive medications with improved study design and patient enrollment are needed to better delineate medical management options before proceeding to antireflux interventions.
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Affiliation(s)
- L Hillman
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - R Yadlapati
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - A J Thuluvath
- Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
| | - M A Berendsen
- Galter Health Sciences Library, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - J E Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
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