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Kwong AJ, Devuni D, Wang C, Boike J, Jo J, VanWagner L, Serper M, Jones L, Sharma R, Verna EC, Shor J, German MN, Hristov A, Lee A, Spengler E, Koteish AA, Sehmbey G, Seetharam A, John N, Patel Y, Kappus MR, Couri T, Paul S, Salgia RJ, Nhu Q, Frenette CT, Lai JC, Goel A. Outcomes of Liver Transplantation Among Older Recipients With Nonalcoholic Steatohepatitis in a Large Multicenter US Cohort: the Re-Evaluating Age Limits in Transplantation Consortium. Liver Transpl 2020; 26:1492-1503. [PMID: 33047893 PMCID: PMC7960487 DOI: 10.1002/lt.25863] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 05/20/2020] [Accepted: 06/14/2020] [Indexed: 12/11/2022]
Abstract
The liver transplantation (LT) population is aging, with the need for transplant being driven by the growing prevalence of nonalcoholic steatohepatitis (NASH). Older LT recipients with NASH may be at an increased risk for adverse outcomes after LT. Our objective is to characterize outcomes in these recipients in a large multicenter cohort. All primary LT recipients ≥65 years from 2010 to 2016 at 13 centers in the Re-Evaluating Age Limits in Transplantation (REALT) consortium were included. Of 1023 LT recipients, 226 (22.1%) were over 70 years old, and 207 (20.2%) had NASH. Compared with other LT recipients, NASH recipients were older (68.0 versus 67.3 years), more likely to be female (47.3% versus 32.8%), White (78.3% versus 68.0%), Hispanic (12.1% versus 9.2%), and had higher Model for End-Stage Liver Disease-sodium (21 versus 18) at LT (P < 0.05 for all). Specific cardiac risk factors including diabetes with or without chronic complications (69.6%), hypertension (66.3%), hyperlipidemia (46.3%), coronary artery disease (36.7%), and moderate-to-severe renal disease (44.4%) were highly prevalent among NASH LT recipients. Graft survival among NASH patients was 90.3% at 1 year and 82.4% at 3 years compared with 88.9% at 1 year and 80.4% at 3 years for non-NASH patients (log-rank P = 0.58 and P = 0.59, respectively). Within 1 year after LT, the incidence of graft rejection (17.4%), biliary strictures (20.9%), and solid organ cancers (4.9%) were comparable. Rates of cardiovascular (CV) complications, renal failure, and infection were also similar in both groups. We observed similar posttransplant morbidity and mortality outcomes for NASH and non-NASH LT recipients. Certain CV risk factors were more prevalent in this population, although posttransplant outcomes within 1 year including CV events and renal failure were similar to non-NASH LT recipients.
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Affiliation(s)
- Allison J. Kwong
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University, Palo Alto, CA
| | - Deepika Devuni
- University of Massachusetts Medical Center, Worcester, MA
| | - Connie Wang
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Justin Boike
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, IL
| | - Jennifer Jo
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, IL
| | - Lisa VanWagner
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, IL
| | - Marina Serper
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lauren Jones
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Rajani Sharma
- Center for Liver Disease and Transplantation, Columbia University Medical Center, New York, NY
| | - Elizabeth C. Verna
- Center for Liver Disease and Transplantation, Columbia University Medical Center, New York, NY
| | - Julia Shor
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Margarita N. German
- Division of Gastroenterology and Hepatology, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI
| | - Alexander Hristov
- Division of Gastroenterology and Hepatology, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI
| | - Alexander Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI
| | - Erin Spengler
- Division of Gastroenterology and Hepatology, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI
| | | | - Gurbir Sehmbey
- Transplant Hepatology, Banner University Medical Center, Phoenix, AZ
| | - Anil Seetharam
- Transplant Hepatology, Banner University Medical Center, Phoenix, AZ
| | - Nimy John
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University, Palo Alto, CA
| | - Yuval Patel
- Division of Gastroenterology, Department of Medicine, School of Medicine, Duke University, Durham, NC
| | - Matthew R. Kappus
- Division of Gastroenterology, Department of Medicine, School of Medicine, Duke University, Durham, NC
| | - Thomas Couri
- Center for Liver Diseases, University of Chicago, Chicago, IL
| | - Sonali Paul
- Center for Liver Diseases, University of Chicago, Chicago, IL
| | - Reena J. Salgia
- Division of Gastroenterology, Department of Medicine, Henry Ford, Detroit, MI
| | | | | | | | - Aparna Goel
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University, Palo Alto, CA
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Russo MW, Fix OK, Koteish AA, Duggan K, Ditmyer M, Fuchs M, Chung RT, Reddy G. Modeling the Hepatology Workforce in the United States: A Predicted Critical Shortage. Hepatology 2020; 72:1444-1454. [PMID: 32898922 DOI: 10.1002/hep.31425] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 05/03/2020] [Accepted: 05/26/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS Liver disease is prevalent in the United States, and as the population ages, an increasing number of patients are anticipated to present for care. The state of the current hepatology workforce and future demand for hepatology providers is not known. The aim of this study was to model future projections for hepatology workforce demand. APPROACH AND RESULTS A workforce study of hepatology providers in the United States was completed using primary and secondary data sources. An integrated workforce framework model was used that combined socioeconomic factors that drive economic demand, epidemiological factors that drive need, and utilization rates of health care services. Supply and demand projections were calculated for adult and pediatric hepatology professionals. Sensitivity analyses were conducted to cover the feasible range of these assumptions. An electronic survey of American Association for the Study of Liver Diseases (AASLD) members whose practice included 50% or more hepatology was conducted. In 2018, the adult and pediatric workforce included 7,296 and 824 hepatology providers, respectively, composed of hepatologists, gastroenterologists, and advanced practice providers whose practice was ≥50% hepatology. The modeling analysis projects that in 2023, 2028, and 2033, there will be shortages of 10%, 23%, and 35% adult hepatology providers, respectively, and 19%, 20%, and 16% pediatric hepatology providers, respectively. In sensitivity analyses, a shortage of hepatology providers is predicted even under optimistic assumptions. Among the respondents to the survey, the median age was higher among gastroenterologists and general hepatologists compared with transplant hepatologists. The most common category treated by transplant hepatologists was general hepatology. CONCLUSIONS There is an impending critical shortage of adult and pediatric hepatology providers. Strategies are needed to encourage clinicians to pursue hepatology, especially in areas outside of transplant centers.
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Affiliation(s)
- Mark W Russo
- Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Oren K Fix
- Organ Transplant and Liver Center, Swedish Medical Center, Seattle, WA, USA
| | - Ayman A Koteish
- Advent Health, Orlando, FL, USA.,The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Katie Duggan
- American Association for the Study of Liver Diseases, Alexandria, VA, USA
| | | | - Michael Fuchs
- Central Virginia VA Health Care System, Virginia Commonwealth University, Richmond, VA, USA
| | - Raymond T Chung
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Russo MW, Koteish AA, Fuchs M, Reddy KG, Fix OK. Workforce in hepatology: Update and a critical need for more information. Hepatology 2017; 65:336-340. [PMID: 27628621 DOI: 10.1002/hep.28810] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 06/18/2016] [Accepted: 08/01/2016] [Indexed: 01/01/2023]
Abstract
The field of hepatology has experienced dramatic changes since the last workforce study in hepatology over 15 years ago. Hepatology practice has been dominated by hepatitis C but is now being overtaken by patients with nonalcoholic fatty liver disease. Expertise once attainable only through informal training, hepatology now has an accredited fellowship pathway and is recognized as a distinct discipline from gastroenterology with its own board certification. These changes that have occurred since the last workforce study in the prevalence and therapy of liver diseases and training may impact workforce needs. The time has come to conduct an updated analysis of the state of the hepatology workforce. The purpose of this article is to discuss the current issues facing training and workforce in hepatology and propose the next steps in conducting a workforce study. (Hepatology 2017;65:336-340).
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Affiliation(s)
- Mark W Russo
- Division of Hepatology, Carolinas HealthCare System, Charlotte, NC
| | - Ayman A Koteish
- Florida Hospital Transplant Institute, Orlando, FL.,Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michael Fuchs
- Hunter Holmes McGuire VA Medical Center, Richmond, VA.,Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University, Richmond, VA
| | | | - Oren K Fix
- Organ Transplant and Liver Center, Swedish Medical Center, Seattle, WA
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Eliades M, Spyrou E, Agrawal N, Lazo M, Brancati FL, Potter JJ, Koteish AA, Clark JM, Guallar E, Hernaez R. Meta-analysis: vitamin D and non-alcoholic fatty liver disease. Aliment Pharmacol Ther 2013; 38:246-54. [PMID: 23786213 DOI: 10.1111/apt.12377] [Citation(s) in RCA: 192] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2013] [Revised: 04/16/2013] [Accepted: 05/30/2013] [Indexed: 01/10/2023]
Abstract
BACKGROUND Non-alcoholic fatty liver disease (NAFLD) is a highly prevalent condition. Emerging evidence suggests that vitamin D may play a role in the pathogenesis of NAFLD. AIM To review systematically the association between vitamin D levels, measured as serum 25-hydroxy vitamin D [25(OH)D], and NAFLD. METHODS We used PubMed and EMBASE databases to identify all studies that assessed the association between vitamin D and NAFLD up until 22 April 2013, without language restrictions. We included studies that compared vitamin D levels between NAFLD cases and controls and also those that compared the odds of vitamin D deficiency by NAFLD status. Pooled standardised differences and odds ratios were calculated using an inverse variance method. RESULTS Seventeen cross-sectional and case-control studies have evaluated the association between vitamin D and NAFLD. NAFLD was diagnosed using biopsy (4 studies), ultrasound or CT (10 studies) and liver enzymes (3 studies). Nine studies provided data for a quantitative meta-analysis. Compared to controls, NAFLD patients had 0.36 ng/mL (95% CI: 0.32, 0.40 ng/mL) lower levels of 25(OH)D and were 1.26 times more likely to be vitamin D deficient (OR 1.26, 95% CI: 1.17, 1.35). CONCLUSIONS NAFLD patients have decreased serum 25(OH)D concentrations, suggesting that vitamin D may play a role in the development of NAFLD. The directionality of this association cannot be determined from cross-sectional studies. Demonstration of a causal role of hypovitaminosis D in NAFLD development in future studies could have important therapeutic implications.
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Affiliation(s)
- M Eliades
- Department of Medicine, Medstar Washington Hospital Center, Washington, DC 20010, USA.
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Kaimori A, Potter JJ, Choti M, Ding Z, Mezey E, Koteish AA. Histone deacetylase inhibition suppresses the transforming growth factor beta1-induced epithelial-to-mesenchymal transition in hepatocytes. Hepatology 2010; 52:1033-45. [PMID: 20564330 DOI: 10.1002/hep.23765] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
UNLABELLED Transforming growth factor beta1 (TGFbeta1) plays a crucial role in the induction of the epithelial-to-mesenchymal transition (EMT) in hepatocytes, which contributes to the pathogenesis of liver fibrosis. The inhibition of the TGFbeta1 cascade suppresses EMT and the resultant fibrosis. In this study, we focus on EMT-induced fibrosis in hepatocytes and the epigenetic regulation of the type I collagen gene. Histone acetylation is an important, major epigenetic mechanism that modulates gene transcription. We evaluated the epigenetic regulation of type I collagen in alpha mouse liver 12 hepatocytes (an untransformed mouse cell line) that had undergone EMT after treatment with TGFbeta1. The histone deacetylase inhibitor trichostatin A (TSA) inhibited EMT; this was reflected by the preservation of epithelial markers and function (E-cadherin and albumin). Fibrosis, the ultimate outcome of EMT, was abolished by TSA; this was indicated by the inhibition of type I collagen deposition. TSA exerted its anti-EMT effects by deactivating the mothers against decapentaplegic homolog 3 (Smad3)/Smad4 transcription complex and by interfering with p300, a coactivator of the type I collagen promoter, and preventing its binding to Smad3. TSA also restored Friend leukemia virus integration 1, an inhibitor of the type I collagen gene. TGFbeta1-induced EMT and its inhibition by TSA were replicated in human primary hepatocytes. CONCLUSION Histone deacetylase inhibition abrogates TGFbeta1-induced EMT in hepatocytes and reverses EMT-induced fibrosis by epigenetic modulation of type I collagen.
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Affiliation(s)
- Aki Kaimori
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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