1
|
Delicce MJ, Mauch J, Sims OT, Lyu R, Kren H, Bartow R, Ferchill D, Joseph A, Fares M, Wakim-Fleming J. A comparison between patients with various etiologies of cirrhosis and examination of cardiac risk factors limiting survival to liver transplantation. Clin Transplant 2024; 38:e15210. [PMID: 38041421 DOI: 10.1111/ctr.15210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 11/03/2023] [Accepted: 11/18/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND & AIMS Objectives of this retrospective cohort study were to assess differences in patient survival between etiologies of cirrhosis while on the waitlist for liver transplantation (LT), and to identify cardiac risk factors that predict survival failure while on the waitlist for LT. METHODS This single-center retrospective cohort design included adult patients who were listed for LT at a tertiary academic hospital with a high-volume liver transplant center. RESULTS Of the 653 patients listed for LT during the study period, 507 (77.6%) survived to transplant and 146 (22.4%) died or clinically deteriorated prior to transplant. Cumulative incidence of death or clinical deterioration did not differ statistically between patient groups (log rank p = .11). In multivariate analysis, compared to patients with NAFLD, there were no significant differences between patients with alcoholic cirrhosis (HR .95, 95%, CI, .62-1.45), cryptogenic cirrhosis (HR 1.31, 95%, CI, .77-2.23), or hepatitis C cirrhosis (HR 1.12, 95%, CI, .66-1.90). However, higher MELD scores (HR = 1.52, 95% CI, 1.12-1.19), severe coronary artery disease (HR = 2.09 95% CI, 1.23-3.55), and tricuspid regurgitation (HR = 2.62, 95% CI, 1.31-5.26) were independently associated with increased risk for survival failure to LT. CONCLUSIONS The presence of severe coronary artery disease and tricuspid regurgitation at the time of listing for transplant are associated with survival failure while on the LT waitlist across etiologies of liver disease. Diagnostic assessment of coronary and valvular disease should be considered in all patients undergoing evaluation for LT, such as cardiac catheterization and/or stress echocardiogram.
Collapse
Affiliation(s)
| | - Joseph Mauch
- Lerner College of Medicine at Case Western Reserve University, Cleveland Clinic, Cleveland, USA
| | - Omar T Sims
- Department of Gastroenterology, Hepatology & Nutrition, Cleveland Clinic, Cleveland, USA
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, USA
| | - Ruishen Lyu
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, USA
| | - Heather Kren
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, USA
| | - Rose Bartow
- Department of Liver Transplantation, Cleveland Clinic, Cleveland, USA
| | - Donna Ferchill
- Department of Liver Transplantation, Cleveland Clinic, Cleveland, USA
| | - Abel Joseph
- Department of Internal Medicine, Cleveland Clinic, Cleveland, USA
| | - Maan Fares
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, USA
| | - Jamile Wakim-Fleming
- Department of Gastroenterology, Hepatology & Nutrition, Cleveland Clinic, Cleveland, USA
| |
Collapse
|
2
|
Shen K, Singh AD, Modaresi Esfeh J, Wakim-Fleming J. Therapies for non-alcoholic fatty liver disease: A 2022 update. World J Hepatol 2022; 14:1718-1729. [PMID: 36185717 PMCID: PMC9521452 DOI: 10.4254/wjh.v14.i9.1718] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 06/22/2022] [Accepted: 08/18/2022] [Indexed: 02/06/2023] Open
Abstract
The incidence of non-alcoholic fatty liver disease (NAFLD) is rapidly increasing and lifestyle interventions to treat this disease by addressing the underlying metabolic syndrome are often limited. Many pharmacological interventions are being studied to slow or even reverse NAFLD progression. This review for hepatologists aims to provide an updated understanding of the pathogenesis of NAFLD, current recommended therapies, and the most promising treatment options that are currently under development.
Collapse
Affiliation(s)
- Katie Shen
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Achintya D Singh
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Jamak Modaresi Esfeh
- Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Jamile Wakim-Fleming
- Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| |
Collapse
|
3
|
Aggarwal M, Garg R, Kumar P, Lindenmeyer CC, Wakim-Fleming J, Jansson-Knodell C, Rubio-Tapia A. Bi-directional Relationship Between Celiac Disease and Liver Chemistries: A Systematic Review and Meta-Analysis. Dig Dis Sci 2022; 68:1369-1380. [PMID: 36002677 DOI: 10.1007/s10620-022-07663-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 05/11/2022] [Accepted: 08/05/2022] [Indexed: 12/20/2022]
Abstract
AIMS Previous studies have reported conflicting results regarding prevalence of elevated LC (2-70%) in celiac disease (CD). This systematic review and meta-analysis assessed the prevalence of elevated LC at time of CD diagnosis and associated response to GFD. We also report the prevalence of CD in patients with unexplained elevation of LC. METHODS Studies assessing LC (aspartate aminotransferase [AST] and alanine aminotransferase [ALT]) in CD patients were eligible. Studies with < 50 cases or in pediatric populations were excluded. RESULTS In total, 20 studies assessing prevalence of elevated LC in 4,265 participants with newly diagnosed CD (mean age = 35.6 ± 6.5 years, 69.8% female) were included. Pooled prevalence of elevated LC was 18.7% (95% CI 13.8-24.8; I2 = 95%). Normalization of elevated LC was seen in 83.1% (95% CI 73.4-89.7; I2 = 79%, 11 studies) of patients after GFD. On meta-regression, age at CD diagnosis, gender, and Marsh grading were not associated with elevated LC. Among 979 participants (7 studies) with unexplained elevation of LC, pooled seroprevalence and biopsy-proven CD was 6.4% (95% CI 2.9-10.3, I2 = 71%) and 4.5% (95% CI 2.6-7.7, I2 = 67%), respectively. CONCLUSION Elevated LC are seen in approximately one-fifth of patients at CD diagnosis with majority normalizing after GFD. Age, gender, and degree of intestinal damage are not predictive of elevated LC. In the appropriate clinical scenario, liver tests should be serially monitored in CD reserving workup for additional causes after a trial of GFD. Patients with unexplained elevation of liver tests should be screened for celiac disease.
Collapse
Affiliation(s)
- Manik Aggarwal
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA.,Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Rajat Garg
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Prabhat Kumar
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Christina C Lindenmeyer
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Jamile Wakim-Fleming
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Claire Jansson-Knodell
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH, USA.,Celiac Disease Program, Department of Gastroenterology, Hepatology & Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, 9500 Euclid Avenue, A3-208, Cleveland, OH, 44195, USA
| | - Alberto Rubio-Tapia
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH, USA. .,Celiac Disease Program, Department of Gastroenterology, Hepatology & Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, 9500 Euclid Avenue, A3-208, Cleveland, OH, 44195, USA.
| |
Collapse
|
4
|
Delicce M, Mauch J, Joseph A, Lyu R, Kren H, Bartow R, Ferchill D, Fares M, Wakim-Fleming J. Cardiac risk factors limiting survival to liver transplantation in patients with nonalcoholic fatty liver disease. World J Hepatol 2022; 14:1398-1407. [PMID: 36158912 PMCID: PMC9376786 DOI: 10.4254/wjh.v14.i7.1398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 05/10/2022] [Accepted: 06/26/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Nonalcoholic fatty liver disease (NAFLD) describes the hepatic manifestations of metabolic syndrome, which is estimated to affect 25% of adults, and currently represents the second most common indication for liver transplant in the United States. Studies have shown that patients with NAFLD are at an increased risk for heart failure, arrhythmia, and coronary artery disease (CAD), which may impact outcomes of liver transplantation. However, it remains unclear whether the presence of cardiac disease affects survival prior to liver transplant. If so, this would represent an important opportunity to optimize cardiac status and improve outcomes before liver transplant.
AIM To identify cardiac factors that impact survival to liver transplantation in patients with NAFLD and on the transplant waitlist.
METHODS The aim of this study was to identify cardiac risk factors that limit survival to transplant in patients with NAFLD. We performed a retrospective analysis of patients with NAFLD listed for liver transplant at a tertiary academic medical center in the United States from January 2015 to January 2021, identified through United Network of Organ Sharing registry. Exclusion criteria included a concurrent etiology of liver disease and removal from the transplant list due to chemical dependency, lack of social support, improvement in liver disease, or being lost to follow-up. We manually reviewed patient charts including electrocardiogram, echocardiogram, and cardiac catheterization reports as well as physician notes to identify cardiac disease states (i.e., heart failure, arrhythmia, valvular disease and CAD) and other related diagnoses. We performed a survival analysis by Cox proportional hazards regression model to analyze the association between cardiac factors at the time listed for transplant and death or clinical deterioration prior to transplant.
RESULTS Between January 2015 and January 2021, 265 patients with nonalcoholic fatty liver disease were listed for liver transplant at our institution. Our patient sample had a median age of 63 and an even distribution between sexes. The median Model for End-Stage Liver Disease (MELD) score was 17 and the median body mass index was 31.6. Of these 265 patients, 197 (74.3%) survived to transplant and 68 (25.7%) died or clinically deteriorated prior to transplant. The presence of mild or moderate CAD represented a hazard ratio of 2.013 (95%CI 1.078-3.759, P = 0.029) for death or clinical deterioration when compared to patients without CAD, after adjustment for age, sex, and MELD. MELD represented an adjusted hazard ratio of 1.188.
CONCLUSION Mild or moderate CAD represents a hazard for waitlist mortality prior to liver transplant in patients with NAFLD. Aggressive management of CAD may be needed to improve patient outcomes.
Collapse
Affiliation(s)
- Michael Delicce
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Joseph Mauch
- Lerner College of Medicine at Case Western Reserve University, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Abel Joseph
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Ruishen Lyu
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Heather Kren
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Rose Bartow
- Department of Liver Transplantation, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Donna Ferchill
- Department of Liver Transplantation, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Maan Fares
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Jamile Wakim-Fleming
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH 44195, United States
| |
Collapse
|
5
|
Shah RS, Alsuleiman B, Bena J, Stoller JK, Wakim-Fleming J. Alpha-1 antitrypsin deficiency is under-recognized in individuals with cirrhosis undergoing liver transplantation. Eur J Gastroenterol Hepatol 2021; 33:e233-e238. [PMID: 33252420 DOI: 10.1097/meg.0000000000002005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 12/10/2022]
Abstract
OBJECTIVE Under-recognition of alpha-1 antitrypsin deficiency (AATD) is well documented in AATD-lung disease but is rarely reported in patients with liver cirrhosis requiring liver transplantation. This report examines the frequency of newly diagnosed AATD based on pathologic examination of explanted livers following liver transplantation, trends in diagnosis over time, and prognostic correlates of under-recognition outcomes following liver transplantation. METHODS This study retrospectively reviewed 1473 pathology reports from adult patients (>18 years) undergoing liver transplantation at Cleveland Clinic between 2004 and 2017. Pathology reports of explanted livers exhibiting periodic acid-Schiff, diastase-resistant inclusion bodies (PAS+G) suggestive of AATD were included and medical records were reviewed regarding demographics, AATD genotype, alternative etiologies for cirrhosis, presence of emphysema, and survival outcomes. Kaplan-Meier estimates of survival outcomes were compared between patients diagnosed pre-liver transplantation and that newly diagnosed post-liver transplantation. RESULTS Of 1473 explanted liver pathology reports examined, 117 (7.9%) showed PAS+G suggestive of AATD. The diagnosis of AATD in these 117 patients was established pre-liver transplantation in 36 (30.8%, group 1) and in 46 (39.3%) post-liver transplantation (group 2a). Testing for AATD was not undertaken in 35 (29.9%) of patients despite having PAS+G on explanted livers (group 2b). Post-liver transplantation survival analysis showed a trend (P = 0.098) towards enhanced survival in group 1 vs. group 2 at 10 years. CONCLUSIONS This study shows that diagnosis of AATD is overlooked and frequently delayed in patients with cirrhosis undergoing liver transplantation. The observed trend towards higher survival in patients diagnosed with AATD pre-liver transplantation suggests the opportunity to enhance outcomes by earlier recognition of AATD.
Collapse
Affiliation(s)
- Ravi S Shah
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Bayan Alsuleiman
- Department of Gastroenterology and Hepatology, State University of New York Downstate Health Sciences University, Brooklyn, New York
| | | | | | - Jamile Wakim-Fleming
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio, USA
| |
Collapse
|
6
|
Wakim-Fleming J, Pagadala MR, McCullough AJ, Lopez R, Bennett AE, Barnes DS, Carey WD. Prevalence of celiac disease in cirrhosis and outcome of cirrhosis on a gluten free diet: a prospective study. J Hepatol 2014; 61:558-63. [PMID: 24842303 DOI: 10.1016/j.jhep.2014.05.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [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: 12/16/2013] [Revised: 04/17/2014] [Accepted: 05/07/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Current consensus suggests CD to be a multi-systemic disease that could affect any organ system including the liver. It remains under-diagnosed in the US and its prevalence and management in cirrhotic patients has not been studied. Our aim was (1) to estimate the prevalence of CD in cirrhosis, (2) to characterize cirrhotic patients with abnormal celiac serology and normal small bowel biopsy and (3) to evaluate the effect of a GFD on the liver. METHODS A total of 204 consecutive patients with biopsy proven cirrhosis scheduled for an upper endoscopy (EGD) to assess and treat gastro-esophageal varices (GEV) at the Cleveland Clinic between 5/1/2008 and 5/30/2010 were enrolled in the study and followed for 2 years. RESULTS CD affects 2.5% of cirrhotic patients and more than twice the prevalence in the general population. Abnormal EMA >1/10 and high hTTG levels >20 IU can be used to diagnose CD in cirrhosis. Sensitivities and specificities are 100% for EMA and 80% and 94% for hTTG, respectively. After a GFD, patients with CD showed a return to normal levels of their celiac serology, small bowel biopsy and liver enzyme abnormalities. CONCLUSIONS CD is at least twice more common in cirrhotic patients than in the general population and GFD improves liver tests. CD can occur coincidentally with other liver disorders and screening may be warranted during the evaluation of patients with cirrhosis. Abnormal EMA and high hTTG levels can be used to diagnose CD in cirrhosis.
Collapse
Affiliation(s)
- Jamile Wakim-Fleming
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, United States.
| | - Mangesh R Pagadala
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, United States
| | - Arthur J McCullough
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, United States
| | - Rocio Lopez
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, United States
| | - Ana E Bennett
- Anatomic Pathology, Cleveland Clinic, Cleveland, OH, United States
| | - David S Barnes
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, United States
| | - William D Carey
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, United States
| |
Collapse
|
7
|
Choi EH, Mergener K, Semrad C, Fisher L, Cave DR, Dodig M, Burke C, Leighton JA, Kastenberg D, Simpson P, Sul J, Bhattacharya K, Charles R, Gerson L, Weber L, Eisen G, Reidel W, Vargo JJ, Wakim-Fleming J, Lo SK. A multicenter, prospective, randomized comparison of a novel signal transmission capsule endoscope to an existing capsule endoscope. Gastrointest Endosc 2013; 78:325-32. [PMID: 23664161 DOI: 10.1016/j.gie.2013.02.039] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [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: 01/20/2013] [Accepted: 02/28/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND MiroCam, a capsule endoscope, uses a novel transmission technology, electric-field propagation, which uses the human body as a conduction medium for data transmission. OBJECTIVE To compare the ability of the MiroCam (MC) and PillCam (PC) to identify sources of obscure GI bleeding (OGIB). DESIGN Prospective, multicenter, comparative study. SETTING Six academic hospitals. PATIENTS A total of 105 patients with OGIB. INTERVENTION Patients ingested both the MC and PC capsules sequentially in a randomized fashion. MAIN OUTCOME MEASUREMENTS Concordance of rates in identifying a source of OGIB, operational times, and rates of complete small-bowel examination. RESULTS Data analysis resulted in 43 (48%) "abnormal" cases identifying a source of OGIB by either capsule. Twenty-four cases (55.8%) were positive by both capsules. There was negative agreement in 46 of 58 cases (79.3%). The κ index was 0.547 (χ(2) = 1.32; P = .36). In 12 cases, MC positively identified a source that was not seen on PC, whereas in 7 cases, PC positively identified a source that was not seen on MC. MC had a 5.6% higher rate of detecting small-bowel lesions (P = .54). MC captured images at 3 frames per second for 11.1 hours, and PC captured images at 2 frames per second for 7.8 hours (P < .0001). Complete small-bowel examination was achieved in 93.3% for MC and 84.3% for PC (P = .10). LIMITATIONS Readers were not blinded to the particular capsule they were reading. CONCLUSION A positive diagnostic finding for OGIB was identified by either capsule in 48% of cases. The concordance rate between the 2 capsules was comparable to that of prior studies in identifying sources of small-bowel bleeding. The longer operational time of the MC may result in higher rates of complete small-bowel examination, which may, in turn, translate into a higher rate of detecting small-bowel lesions. ( CLINICAL TRIAL REGISTRATION NUMBER NCT00878982.).
Collapse
Affiliation(s)
- Eric H Choi
- Division of Gastroenterology and Hepatology, Riverside Medical Clinic, Riverside, California, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|