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Zhao X, Kotha S, Nayyar D, Ma X, Lilly L, Castel H, Gupta S. Physiologic changes in the hepatopulmonary syndrome before and after liver transplant: A longitudinal and predictor analysis. Hepatology 2024; 79:636-649. [PMID: 37732952 PMCID: PMC10871618 DOI: 10.1097/hep.0000000000000605] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 08/27/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND AND AIMS Hepatopulmonary syndrome (HPS) is a common complication of liver disease defined by abnormal oxygenation and intrapulmonary vascular dilatation, treated with liver transplantation. Little is known about changes in HPS physiological parameters over time. We sought to describe baseline clinical and physiological characteristics in HPS and their relationships, temporal changes in physiological parameters before and after transplant, and predictors of changes in oxygenation. APPROACH AND RESULTS This was a retrospective cohort study in the Canadian HPS Program (n = 132). Rates of change after diagnosis were: -3.7 (-6.4, -0.96) mm Hg/year for partial pressure of arterial oxygen (PaO 2 ); -26 (-96, 44) m/year for 6-minute walk distance, and 3.3% (-6.6, -0.011) predicted/year for diffusion capacity. Noninvasive shunt of ≥ 20% predicted a slower PaO 2 decline by 0.88 (0.36, 1.4) mm Hg/month. We identified 2 PaO 2 deterioration classes-"very severe disease, slow decliners" (PaO 2 45.0 mm Hg; -1.0 mm Hg/year); and "moderate disease, steady decliners" (PaO 2 65.5 mm Hg; -2.5 mm Hg/year). PaO 2 increased by 6.5 (5.3, 7.7) mm Hg/month in the first year after transplant. The median time to normalization was 149 (116, 184) days. Posttransplant improvement in PaO 2 was 2.5 (0.1, 4.9) mm Hg/month faster for every 10 mm Hg greater pretransplant orthodeoxia. CONCLUSIONS We present a large and long longitudinal data analysis in HPS. In addition to rates of physiological decline and improvement before and after liver transplantation, we present novel predictors of PaO 2 decline and improvement rates. Our findings enhance our understanding of the natural history of HPS and provide pathophysiologic clues. Importantly, they may assist providers in prognostication and prioritization before and after transplant.
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Affiliation(s)
- Xun Zhao
- Department of Gastroenterology and Hepatology, McGill University, Montreal, Canada
- Department of Multi-Organ Transplant, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Sreelakshmi Kotha
- Department of Hepatology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Dhruv Nayyar
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Xiayi Ma
- Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Unity Health Toronto, University of Toronto, Toronto, Canada
| | - Leslie Lilly
- Department of Multi-Organ Transplant, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Hélène Castel
- Department of Hepatology and Liver Transplantation, Centre Hospitalier de l’Université de Montréal (CHUM), Montreal, Canada
| | - Samir Gupta
- Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Unity Health Toronto, University of Toronto, Toronto, Canada
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Qazi Arisar FA, Varghese R, Chen S, Xu W, Selzner M, McGilvray I, Sayed B, Reichman T, Shwaartz C, Cattral M, Ghanekar A, Sapisochin G, Jaeckel E, Tsien C, Selzner N, Lilly L, Bhat M. Trajectories of patients relisted for liver transplantation. Ann Hepatol 2024; 29:101168. [PMID: 37858675 DOI: 10.1016/j.aohep.2023.101168] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 09/01/2023] [Accepted: 09/12/2023] [Indexed: 10/21/2023]
Abstract
INTRODUCTION AND OBJECTIVES Recurrent cirrhosis complicates 10-30% of Liver transplants (LT) and can lead to consideration for re-transplantation. We evaluated the trajectories of relisted versus primary listed patients on the waitlist using a competing risk framework. MATERIALS AND METHODS We retrospectively examined 1,912 patients listed for LT at our centre between from 2012 to 2020. Cox proportional hazard models were used to assess overall survival (OS) by listing type and competing risk analysis Fine-Gray models were used to assess cumulative incidence of transplant by listing type. RESULTS 1,731 patients were included (104 relisted). 44.2% of relisted patients received exception points vs. 19.8% of primary listed patients (p<0.001). Patients relisted without exceptions, representing those with graft cirrhosis, had the worst OS (HR: 4.17, 95%CI 2.63 - 6.67, p=<0.0001) and lowest instantaneous rate of transplant (HR: 0.56, 95%CI 0.38 - 0.83, p=0.006) than primary listed with exception points. On multivariate analysis listing type, height, bilirubin and INR were associated with cumulative incidence of transplant, while listing type, bilirubin, INR, sodium, creatinine were associated with OS. Within relisted patients, there was a trend towards higher mortality (HR: 1.79, 95%CI 0.91 - 3.52, p=0.08) and low transplant incidence (HR: 0.51, 95%CI 0.22 - 1.15, p=0.07) for graft cirrhosis vs other relisting indications. CONCLUSIONS Patients relisted for LT are carefully curated and comprise a minority of the waitlist population. Despite their younger age, they have worse liver/kidney function, poor waitlist survival, and decreased transplant incidence suggesting the need for early relisting, while considering standardized exception points.
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Affiliation(s)
- Fakhar Ali Qazi Arisar
- University Health Network, 585 University Avenue, Toronto, M5G 2N2, Canada; University of Toronto, 27 King's College Clr, Toronto, M5S 1A1, Canada
| | - Rhea Varghese
- University Health Network, 585 University Avenue, Toronto, M5G 2N2, Canada; McMaster University, Faculty of Health Sciences, 1280 Main St W, Hamilton, ON L8S 4L8, Hamilton, Canada
| | - Shiyi Chen
- University of Toronto, 27 King's College Clr, Toronto, M5S 1A1, Canada; Princess Margaret Cancer Centre, 620 University Ave, Toronto, ON M5G 2C1, Canada
| | - Wei Xu
- University of Toronto, 27 King's College Clr, Toronto, M5S 1A1, Canada; Princess Margaret Cancer Centre, 620 University Ave, Toronto, ON M5G 2C1, Canada; Dalla Lana School of Public Health, 155 College St Room 500, Toronto, M5T 3M7 Canada
| | - Markus Selzner
- University Health Network, 585 University Avenue, Toronto, M5G 2N2, Canada; University of Toronto, 27 King's College Clr, Toronto, M5S 1A1, Canada
| | - Ian McGilvray
- University Health Network, 585 University Avenue, Toronto, M5G 2N2, Canada; University of Toronto, 27 King's College Clr, Toronto, M5S 1A1, Canada
| | - Blayne Sayed
- University Health Network, 585 University Avenue, Toronto, M5G 2N2, Canada; University of Toronto, 27 King's College Clr, Toronto, M5S 1A1, Canada
| | - Trevor Reichman
- University Health Network, 585 University Avenue, Toronto, M5G 2N2, Canada; University of Toronto, 27 King's College Clr, Toronto, M5S 1A1, Canada
| | - Chaya Shwaartz
- University Health Network, 585 University Avenue, Toronto, M5G 2N2, Canada; University of Toronto, 27 King's College Clr, Toronto, M5S 1A1, Canada
| | - Mark Cattral
- University Health Network, 585 University Avenue, Toronto, M5G 2N2, Canada; University of Toronto, 27 King's College Clr, Toronto, M5S 1A1, Canada
| | - Anand Ghanekar
- University Health Network, 585 University Avenue, Toronto, M5G 2N2, Canada; University of Toronto, 27 King's College Clr, Toronto, M5S 1A1, Canada
| | - Gonzalo Sapisochin
- University Health Network, 585 University Avenue, Toronto, M5G 2N2, Canada; University of Toronto, 27 King's College Clr, Toronto, M5S 1A1, Canada
| | - Elmar Jaeckel
- University Health Network, 585 University Avenue, Toronto, M5G 2N2, Canada; University of Toronto, 27 King's College Clr, Toronto, M5S 1A1, Canada
| | - Cynthia Tsien
- University Health Network, 585 University Avenue, Toronto, M5G 2N2, Canada; University of Toronto, 27 King's College Clr, Toronto, M5S 1A1, Canada
| | - Nazia Selzner
- University Health Network, 585 University Avenue, Toronto, M5G 2N2, Canada; University of Toronto, 27 King's College Clr, Toronto, M5S 1A1, Canada
| | - Leslie Lilly
- University Health Network, 585 University Avenue, Toronto, M5G 2N2, Canada; University of Toronto, 27 King's College Clr, Toronto, M5S 1A1, Canada
| | - Mamatha Bhat
- University Health Network, 585 University Avenue, Toronto, M5G 2N2, Canada; University of Toronto, 27 King's College Clr, Toronto, M5S 1A1, Canada; Toronto General Hospital Research Institute, 200 Elizabeth Street, Toronto, M5G 2C4, Canada.
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Ray S, Shwaartz C, Sayed BA, Sapisochin G, Ghanekar A, McGilvray I, Cattral M, Lilly L, Selzner N, Tsien C, Bhat M, Jaeckel E, Selzner M, Reichman TW. Should advanced donor age be a deterrent in the utilization of grafts from donation after cardiac death in deceased donor liver transplantation? The Toronto experience. Can J Surg 2023; 66:E561-E571. [PMID: 38016726 DOI: 10.1503/cjs.001123] [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] [Accepted: 09/06/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND Advanced donor age paired with donation after cardiac death (DCD) increases the risk of transplantation, precluding widespread use of grafts from such donors worldwide. Our aim was to analyze outcomes of liver transplantation using grafts from older DCD donors and donation after brain death (DBD) donors. METHODS Patients who underwent liver transplantation using grafts from deceased donors between January 2016 and December 2021 were included in the study. Short-and long-term outcomes were analyzed for 4 groups of patients: those who received DCD and DBD grafts from younger (< 50 yr) and older (≥ 50 yr) donors. RESULTS Of the 807 patients included in the analysis, 44.7% (n = 361) of grafts were received from older donors, with grafts for older DCD donors comprising 4.7% of the total cohort (n = 38). Patients who received grafts from older donors had a lower incidence of biliary strictures than those who received grafts from younger donors (7.9% v. 20.0% for DCD donation, p = 0.14, and 4.9% v. 6.8% for DBD donation, p = 0.34), with a significantly lower incidence of ischemic-type biliary strictures in patients who received grafts from older versus younger DCD donors (2.6% v. 18.0%, p = 0.04). There was no difference in 1- and 3-year graft survival rates among patients who received grafts from older and younger DCD donors (92.1% v. 90.8% and 80.2% v. 80.9%, respectively) and those who received grafts from older and younger DBD donors (90.1% v. 93.2% and 85.3% v. 84.4%, respectively) (p = 0.85). Pretransplantation admission to the intensive care unit (hazard ratio [HR] 9.041, p < 0.001) and nonalcoholic steatohepatitis (HR 2.197, p = 0.02) were found to significantly affect survival of grafts from older donors. CONCLUSION Donor age alone should not be the criterion to determine the acceptability of grafts in liver transplantation. With careful selection criteria, older DCD donors could make a valuable contribution to expanding the liver donor pool, with grafts that produce comparable results to those obtained with standard-criteria grafts.
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Affiliation(s)
- Samrat Ray
- From the Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ont. (Ray, Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman); and the Department of Surgery, University of Toronto, Toronto, Ont. (Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman)
| | - Chaya Shwaartz
- From the Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ont. (Ray, Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman); and the Department of Surgery, University of Toronto, Toronto, Ont. (Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman)
| | - Blayne Amir Sayed
- From the Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ont. (Ray, Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman); and the Department of Surgery, University of Toronto, Toronto, Ont. (Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman)
| | - Gonzalo Sapisochin
- From the Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ont. (Ray, Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman); and the Department of Surgery, University of Toronto, Toronto, Ont. (Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman)
| | - Anand Ghanekar
- From the Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ont. (Ray, Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman); and the Department of Surgery, University of Toronto, Toronto, Ont. (Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman)
| | - Ian McGilvray
- From the Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ont. (Ray, Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman); and the Department of Surgery, University of Toronto, Toronto, Ont. (Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman)
| | - Mark Cattral
- From the Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ont. (Ray, Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman); and the Department of Surgery, University of Toronto, Toronto, Ont. (Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman)
| | - Leslie Lilly
- From the Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ont. (Ray, Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman); and the Department of Surgery, University of Toronto, Toronto, Ont. (Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman)
| | - Nazia Selzner
- From the Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ont. (Ray, Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman); and the Department of Surgery, University of Toronto, Toronto, Ont. (Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman)
| | - Cynthia Tsien
- From the Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ont. (Ray, Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman); and the Department of Surgery, University of Toronto, Toronto, Ont. (Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman)
| | - Mamatha Bhat
- From the Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ont. (Ray, Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman); and the Department of Surgery, University of Toronto, Toronto, Ont. (Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman)
| | - Elmar Jaeckel
- From the Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ont. (Ray, Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman); and the Department of Surgery, University of Toronto, Toronto, Ont. (Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman)
| | - Markus Selzner
- From the Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ont. (Ray, Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman); and the Department of Surgery, University of Toronto, Toronto, Ont. (Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman)
| | - Trevor W Reichman
- From the Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ont. (Ray, Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman); and the Department of Surgery, University of Toronto, Toronto, Ont. (Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman)
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Arisar FAQ, Chen S, Chen C, Shaikh N, Karnam RS, Xu W, Asrani SK, Galvin Z, Hirschfield G, Patel K, Tsien C, Selzner N, Cattral M, Lilly L, Bhat M. Availability of living donor optimizes timing of liver transplant in high-risk waitlisted cirrhosis patients. Aging (Albany NY) 2023; 15:8594-8612. [PMID: 37665673 PMCID: PMC10522397 DOI: 10.18632/aging.204982] [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: 01/08/2023] [Accepted: 07/17/2023] [Indexed: 09/06/2023]
Abstract
Liver transplant (LT) candidates have become older and frailer, with growing Non-alcoholic steatohepatitis (NASH) and comorbid disease burden in recent years, predisposing them for poor waitlist outcomes. We aimed to evaluate the impact of access to living donor liver transplantation (LDLT) in waitlisted patients at highest risk of dropout. We reviewed all adult patients with decompensated cirrhosis listed for LT from November 2012 to December 2018. Patients with a potential living donor (pLD) available were identified. Survival analyses with Cox Proportional Hazards models and time to LT with Competing risk models were performed followed by prediction model development. Out of 860 patients who met inclusion criteria, 360 (41.8%) had a pLD identified and 496 (57.6%) underwent LT, out of which 170 (34.2%) were LDLT. The benefit of pLD was evident for all, but patients with moderate to severe frailty at listing (interaction p = 0.03), height <160 cm (interaction p = 0.03), and Model for end stage liver disease (MELD)-Na score <20 (interaction p < 0.0001) especially benefited. Our prediction model identified patients at highest risk of dropout while waiting for deceased donor and most benefiting of pLD (time-dependent area under the receiver operating characteristic curve 0.82). Access to LDLT in a transplant program can optimize the timing of transplant for the increasingly older, frail patient population with comorbidities who are at highest risk of dropout.
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Affiliation(s)
- Fakhar Ali Qazi Arisar
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario M5G 2N2, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, Ontario M5G 2N2, Canada
- National Institute of Liver and GI Diseases, Dow University of Health Sciences, Karachi, Sindh 75330, Pakistan
| | - Shiyi Chen
- Department of Biostatistics, Princess Margaret Cancer Center, University Health Network, Toronto, Ontario M5G 2C1, Canada
| | - Catherine Chen
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario M5G 2N2, Canada
| | - Noorulsaba Shaikh
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario M5G 2N2, Canada
| | - Ravikiran Sindhuvalada Karnam
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario M5G 2N2, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, Ontario M5G 2N2, Canada
| | - Wei Xu
- Department of Biostatistics, Princess Margaret Cancer Center, University Health Network, Toronto, Ontario M5G 2C1, Canada
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario M5G 2C1, Canada
| | - Sumeet K. Asrani
- Division of Hepatology, Department of Medicine, Baylor University Medical Center, Dallas, TX 75246, USA
| | - Zita Galvin
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario M5G 2N2, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, Ontario M5G 2N2, Canada
| | - Gideon Hirschfield
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, Ontario M5G 2N2, Canada
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario M5G 2C4, Canada
| | - Keyur Patel
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, Ontario M5G 2N2, Canada
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario M5G 2C4, Canada
| | - Cynthia Tsien
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario M5G 2N2, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, Ontario M5G 2N2, Canada
| | - Nazia Selzner
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario M5G 2N2, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, Ontario M5G 2N2, Canada
| | - Mark Cattral
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario M5G 2N2, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario M5G 2N2, Canada
| | - Leslie Lilly
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario M5G 2N2, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, Ontario M5G 2N2, Canada
| | - Mamatha Bhat
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario M5G 2N2, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, Ontario M5G 2N2, Canada
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Karnam RS, Azhie A, Yang C, Rogalsky A, Chen S, Xu W, Patel K, Selzner N, Lilly L, Cattral M, Bhat M. Impact of living donor liver transplantation on long-term cardiometabolic and graft outcomes in cirrhosis due to nonalcoholic steatohepatitis. Clin Transplant 2023; 37:e15008. [PMID: 37143204 DOI: 10.1111/ctr.15008] [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: 06/11/2022] [Revised: 11/04/2022] [Accepted: 04/09/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND AND AIM Non-alcoholic steatohepatitis (NASH) is a leading indication for liver transplantation (LT). This study aimed to determine whether living donor LT (LDLT) recipients experienced less recurrent NASH, cirrhosis, and cardiometabolic complications compared to deceased donor LT (DDLT). METHOD Patients with LDLT and DDLT for NASH between February 2002 and May 2018 at University Health Network (UHN) were compared. Cox Proportional Hazard model was used to analyze overall survival (OS), Fine and Gray's Competing Risk models were conducted to analyze cumulative incidence of post LT outcomes. RESULTS One hundred and ninety-nine DDLTs and 66 LDLTs were performed for NASH cirrhosis. Time and rate of recurrence of NAFLD and NASH were comparable in both groups. Graft cirrhosis was more common in DDLT recipients (n = 14) versus LDLT (n = 0) (p < .0001). Significant fibrosis (Fibrosis ≥ F2) developed in 50 recipients (12 LDLT and 38 DDLT) post LT (DDLT vs. LDLT: HR = 1.00, 95% CI = (.52-1.93), p = .91) and there was no difference in time to significant fibrosis (p = .57). There was no difference in development of post-transplant diabetes, dyslipidemia, metabolic syndrome, cardiovascular disease, and cancers. LDLT group had better renal function at 10 years (MDRD eGFR of 57.0 mL/min vs. 48.5 mL/min, p = .047). Both groups had a comparable OS (HR = 1.83 (95% CI = .92-3.62), p = .08). CONCLUSION Overall, LDLT recipients had significantly better renal function by virtue of having early transplantation in their disease course. LDLT was also associated with significantly less graft cirrhosis, although OS and cardiometabolic outcomes were comparable between LDLT and DDLT.
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Affiliation(s)
- Ravikiran S Karnam
- Ajmera Transplant Program, University Health Network, Toronto, Ontario, Canada
- Narayana Health, Bengaluru, India
| | - Amirhossein Azhie
- Ajmera Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Cathy Yang
- Ajmera Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Andrew Rogalsky
- Ajmera Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Shiyi Chen
- Department of Biostatistics, Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Wei Xu
- Department of Biostatistics, Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Keyur Patel
- Ajmera Transplant Program, University Health Network, Toronto, Ontario, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, Canada
| | - Nazia Selzner
- Ajmera Transplant Program, University Health Network, Toronto, Ontario, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, Canada
| | - Leslie Lilly
- Ajmera Transplant Program, University Health Network, Toronto, Ontario, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, Canada
| | - Mark Cattral
- Ajmera Transplant Program, University Health Network, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Canada
| | - Mamatha Bhat
- Ajmera Transplant Program, University Health Network, Toronto, Ontario, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, Canada
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6
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Onofrio F, Zheng K, Xu C, Chen S, Xu W, Vyas M, Bingham K, Patel K, Lilly L, Cattral M, Selzner N, Jaeckel E, Tsien C, Gulamhusein A, Hirschfield GM, Bhat M. Living donor liver transplantation can address disparities in transplant access for patients with primary sclerosing cholangitis. Hepatol Commun 2023; 7:e0219. [PMID: 37534935 PMCID: PMC10552969 DOI: 10.1097/hc9.0000000000000219] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 05/04/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND Liver transplantation (LT) is frequently lifesaving for people living with primary sclerosing cholangitis (PSC). However, patients are waitlisted for LT according to the model for end-stage liver disease-sodium (MELD-Na) score, which may not accurately reflect the burden of living with PSC. We sought to describe and analyze the clinical trajectory for patients with PSC referred for LT, in a mixed deceased donor/living donor transplant program. METHODS This was a retrospective cohort study from November 2012 to December 2019, including all patients with PSC referred for assessment at the University Health Network Liver Transplant Clinic. Patients who required multiorgan transplant or retransplantation were excluded. Liver symptoms, hepatobiliary malignancy, MELD-Na progression, and death were abstracted from chart review. Competing risk analysis was used for timing of LT, transplant type, and death. RESULTS Of 172 PSC patients assessed, 84% (n = 144) were listed of whom 74% were transplanted. Mean age was 47.6 years, and 66% were male. Overall mortality was 18.2% at 2 years. During the follow-up, 16% (n = 23) were removed from the waitlist for infection, clinical deterioration, liver-related mortality or new cancer; 3 had clinical improvement. At listing, 82% (n = 118) had a potential living donor (pLD). Patients with pLD had significantly lower waitlist and liver-related waitlist mortality (HR 0.20, p<0.001 and HR 0.17, p<0.001, respectively), and higher rates of transplantation (HR 1.83, p = 0.05). Exception points were granted to 13/172 (7.5%) patients. CONCLUSIONS In a high-volume North American LT center, most patients with PSC assessed for transplant were listed and subsequently transplanted. However, this was a consequence of patients engaging in living donor transplantation. Our findings support the concern from patients with PSC that MELD-Na allocation does not adequately address their needs.
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Affiliation(s)
- Fernanda Onofrio
- Ajmera Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Katina Zheng
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Cherry Xu
- Ajmera Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Shiyi Chen
- Biostatistics Department, Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada
| | - Wei Xu
- Biostatistics Department, Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada
| | | | | | - Keyur Patel
- Ajmera Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Leslie Lilly
- Ajmera Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Mark Cattral
- Ajmera Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Nazia Selzner
- Ajmera Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Elmar Jaeckel
- Ajmera Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Cynthia Tsien
- Ajmera Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Aliya Gulamhusein
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - Gideon M. Hirschfield
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - Mamatha Bhat
- Ajmera Transplant Program, University Health Network, Toronto, Ontario, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, University Health Network, Toronto, Ontario, Canada
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7
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Azhie A, Sharma D, Sheth P, Qazi-Arisar FA, Zaya R, Naghibzadeh M, Duan K, Fischer S, Patel K, Tsien C, Selzner N, Lilly L, Jaeckel E, Xu W, Bhat M. A deep learning framework for personalised dynamic diagnosis of graft fibrosis after liver transplantation: a retrospective, single Canadian centre, longitudinal study. Lancet Digit Health 2023; 5:e458-e466. [PMID: 37210229 DOI: 10.1016/s2589-7500(23)00068-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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] [Received: 07/14/2022] [Revised: 03/13/2023] [Accepted: 03/23/2023] [Indexed: 05/22/2023]
Abstract
BACKGROUND Recurrent graft fibrosis after liver transplantation can threaten both graft and patient survival. Therefore, early detection of fibrosis is essential to avoid disease progression and the need for retransplantation. Non-invasive blood-based biomarkers of fibrosis are limited by moderate accuracy and high cost. We aimed to evaluate the accuracy of machine learning algorithms in detecting graft fibrosis using longitudinal clinical and laboratory data. METHODS In this retrospective, longitudinal study, we trained machine learning algorithms, including our novel weighted long short-term memory (LSTM) model, to predict the risk of significant fibrosis using follow-up data from 1893 adults who had a liver transplantation between Feb 1, 1987, and Dec 30, 2019, with at least one liver biopsy post transplantation. Liver biopsy samples with indefinitive fibrosis stage and those from patients with multiple transplantations were excluded. Longitudinal clinical variables were collected from transplantation to the date of last available liver biopsy. Deep learning models were trained on 70% of the patients as the training set and 30% of the patients as the test set. The algorithms were also separately tested on longitudinal data from patients in a subgroup of patients (n=149) who had transient elastography within 1 year before or after the date of liver biopsy. Weighted LSTM model performance for diagnosing significant fibrosis was compared against LSTM, other deep learning models (recurrent neural network and temporal convolutional network), and machine learning models (Random Forest, Support vector machines, Logistic regression, Lasso regression, and Ridge regression) and aspartate aminotransferase-to-platelet ratio index (APRI), fibrosis-4 index (FIB-4), and transient elastography. FINDINGS 1893 people who had a liver transplantation (1261 [67%] men and 632 [33%] women) with at least one liver biopsy between Jan 1, 1992, and June 30, 2020, were included in the study (591 [31%] cases and 1302 [69%] controls). The median age at liver transplantation was 53·7 years (IQR 47·3-59·0) for cases and 55·3 years (48·0 to 61·2) for controls. The median time interval between transplant and liver biopsy was 21 months (5 to 71). The weighted LSTM model (area under the curve 0·798 [95% CI 0·790 to 0·810]) consistently outperformed other methods, including unweighted LSTM (0·761 [0·750 to 0·769]; p=0·031) Recurrent Neural Network (0·736 [0·721 to 0·744]), Temporal Convolutional Networks (0·700 [0·662 to 0·747], and Random Forest 0·679 [0·652 to 0·707]), FIB-4 (0·650 [0·636 to 0·663]) and APRI (0·682 [0·671 to 0·694]) when diagnosing F2 or worse stage fibrosis. In a subgroup of patients with transient elastography results, weighted LSTM was not significantly better at detecting fibrosis (≥F2; 0·705 [0·687 to 0·724]) than transient elastography (0·685 [0·662 to 0·704]). The top ten variables predictive for significant fibrosis were recipient age, primary indication for transplantation, donor age, and longitudinal data for creatinine, alanine aminotransferase, aspartate aminotransferase, total bilirubin, platelets, white blood cell count, and weight. INTERPRETATION Deep learning algorithms, particularly weighted LSTM, outperform other routinely used non-invasive modalities and could help with the earlier diagnosis of graft fibrosis using longitudinal clinical and laboratory variables. The list of most important predictive variables for the development of fibrosis will enable clinicians to modify their management accordingly to prevent onset of graft cirrhosis. FUNDING Canadian Institute of Health Research, American Society of Transplantation, Toronto General and Western Hospital Foundation, and Paladin Labs.
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Affiliation(s)
- Amirhossein Azhie
- Ajmera Transplant Program, University Health Network, Toronto, ON, Canada
| | - Divya Sharma
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Priya Sheth
- Ajmera Transplant Program, University Health Network, Toronto, ON, Canada
| | - Fakhar Ali Qazi-Arisar
- Ajmera Transplant Program, University Health Network, Toronto, ON, Canada; Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, ON, Canada; National Institute of Liver & Gastrointestinal Diseases, Dow University of Health Sciences, Karachi, Pakistan
| | - Rita Zaya
- Ajmera Transplant Program, University Health Network, Toronto, ON, Canada
| | - Maryam Naghibzadeh
- Ajmera Transplant Program, University Health Network, Toronto, ON, Canada
| | - Kai Duan
- Department of Pathology, University Health Network, Toronto, ON, Canada
| | - Sandra Fischer
- Department of Pathology, University Health Network, Toronto, ON, Canada
| | - Keyur Patel
- Toronto Centre for Liver Disease, University Health Network, Toronto, ON, Canada; Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Cynthia Tsien
- Ajmera Transplant Program, University Health Network, Toronto, ON, Canada; Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Nazia Selzner
- Ajmera Transplant Program, University Health Network, Toronto, ON, Canada; Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Leslie Lilly
- Ajmera Transplant Program, University Health Network, Toronto, ON, Canada; Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Elmar Jaeckel
- Ajmera Transplant Program, University Health Network, Toronto, ON, Canada; Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Wei Xu
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; Biostatistics Division, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Mamatha Bhat
- Ajmera Transplant Program, University Health Network, Toronto, ON, Canada; Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, ON, Canada.
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8
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Ray S, Torres-Hernandez A, Bleszynski MS, Parmentier C, McGilvray I, Sayed BA, Shwaartz C, Cattral M, Ghanekar A, Sapisochin G, Tsien C, Selzner N, Lilly L, Bhat M, Jaeckel E, Selzner M, Reichman TW. Medical Assistance in Dying (MAiD) as a Source of Liver Grafts: Honouring the Ultimate Gift. Ann Surg 2023; 277:713-718. [PMID: 36515405 DOI: 10.1097/sla.0000000000005775] [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: 12/15/2022]
Abstract
OBJECTIVE To report the clinical outcomes of liver transplants from donors after medical assistance in dying (MAiD) versus donors after cardiac death (DCD) and deceased brain death (DBD). SUMMARY BACKGROUND DATA In North America, the number of patients needing liver transplants exceeds the number of available donors. In 2016, MAiD was legalized in Canada. METHODS All patients undergoing deceased donor liver transplantation at Toronto General Hospital between 2016 and 2021 were included in the study. Recipient perioperative and postoperative variables and donor physiological variables were compared among 3 groups. RESULTS Eight hundred seven patients underwent deceased donor liver transplantation during the study period, including DBD (n=719; 89%), DCD (n=77; 9.5%), and MAiD (n=11; 1.4%). The overall incidence of biliary complications was 6.9% (n=56), the most common being strictures (n=55;6.8%), highest among the MAiD recipients [5.8% (DBD) vs. 14.2% (DCD) vs. 18.2% (MAiD); P =0.008]. There was no significant difference in 1 year (98.4% vs. 96.4% vs. 100%) and 3-year (89.3% vs. 88.7% vs. 100%) ( P =0.56) patient survival among the 3 groups. The 1- and 3- year graft survival rates were comparable (96.2% vs. 95.2% vs. 100% and 92.5% vs. 91% vs. 100%; P =0.37). CONCLUSION With expected physiological hemodynamic challenges among MAiD and DCD compared with DBD donors, a higher rate of biliary complications was observed in MAiD donors, with no significant difference noted in short-and long-term graft outcomes among the 3 groups. While ethical challenges persist, good initial results suggest that MAiD donors can be safely used in liver transplantation, with results comparable with other established forms of donation.
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Affiliation(s)
- Samrat Ray
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network
| | | | | | | | - Ian McGilvray
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Blayne Amir Sayed
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Chaya Shwaartz
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Mark Cattral
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Anand Ghanekar
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Gonzalo Sapisochin
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Cynthia Tsien
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Nazia Selzner
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Leslie Lilly
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Mamatha Bhat
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Elmar Jaeckel
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Markus Selzner
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Trevor W Reichman
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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9
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Zheng K, Onofrio F, Xu C, Chen S, Xu W, Vyas M, Bingham K, Patel K, Lilly L, Selzner N, Jaeckel E, Tsien C, Gulamhusein A, Hirschfield GM, Bhat M. A42 LIVE DONOR LIVER TRANSPLANTATION IN PRIMARY SCLEROSING CHOLANGITIS: AN INDICATOR OF AN ORGAN ALLOCATION SYSTEM NOT ADDRESSING PATIENT NEED. J Can Assoc Gastroenterol 2023. [PMCID: PMC9991265 DOI: 10.1093/jcag/gwac036.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 03/09/2023] Open
Abstract
Background Liver transplantation is frequently lifesaving for people living with primary sclerosing cholangitis (PSC). However, patients are waitlisted for liver transplant (LT) according to the MELD-Na score, which may not accurately reflect the burden of living with PSC. Purpose We sought to describe and analyze the clinical trajectory for patients with PSC referred for LT, in a mixed deceased donor/live donor transplant programme. Method This was a retrospective cohort study from November 2012 to December 2019 including all patients with PSC referred for assessment at the University Health Network Liver Transplant Clinic. Patients who required multiorgan transplant or re-transplantation were excluded. Liver symptoms, hepatobiliary malignancy, MELD-Na progression, and death were abstracted from chart review. Competing Risk analysis was used for timing of LT, transplant type, and death. Result(s) Of 172 PSC patients assessed, 144 (84%) were listed, of whom 106/144 (74%) were transplanted. Mean age was 47.6 years and 66% were male. During follow-up through to 2021, 23/144 (16%) were removed from the waitlist due to infection, clinical deterioration, liver-related mortality or new cancer; 3 had clinical improvement. At the time of listing, 118/144 (81.95%) had a potential Living Donor (pLD) of whom 94 were transplanted: 64 live donor and 30 deceased donor. Patients with pLD had 79% lower mortality (p<0.001), and higher rates of transplantation (80% vs 46%). Exception points were granted to 13/172 (7.5%) patients. Conclusion(s) In a high-volume North American liver transplant centre, most patients with PSC assessed for transplant were listed and subsequently transplanted. However, this was a consequence of patients engaging in live donor transplantation. Our findings support the concern from patients with PSC that MELD-Na allocation does not adequately address their needs. Please acknowledge all funding agencies by checking the applicable boxes below CIHR, Other Please indicate your source of funding; This study was supported by PSC Partners Canada, Canadian Institutes of Health Research (CIHR), Toronto General and Western Hospital Foundation. Disclosure of Interest None Declared
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Affiliation(s)
- K Zheng
- Faculty of Medicine, University of Toronto
| | - F Onofrio
- Ajmera Transplant Program, University Health Network,
| | - C Xu
- Ajmera Transplant Program, University Health Network
| | - S Chen
- Biostatistics Department, Princess Margaret Cancer Center
| | - W Xu
- Biostatistics Department, Princess Margaret Cancer Center
| | | | | | - K Patel
- Ajmera Transplant Program, University Health Network,
| | - L Lilly
- Ajmera Transplant Program, University Health Network,
| | - N Selzner
- Ajmera Transplant Program, University Health Network
| | - E Jaeckel
- Ajmera Transplant Program, University Health Network,
| | - C Tsien
- Ajmera Transplant Program, University Health Network
| | - A Gulamhusein
- Division of Gastroenterology and Hepatology, University of Toronto, Toronto, Canada
| | - G M Hirschfield
- Division of Gastroenterology and Hepatology, University of Toronto, Toronto, Canada
| | - M Bhat
- Ajmera Transplant Program, University Health Network,,Division of Gastroenterology and Hepatology, University of Toronto, Toronto, Canada
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10
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Karnam RS, Punchhi G, Mitsakakis N, Chen S, Saracino G, Lilly L, Asrani SK, Bhat M. Predicting the outcome of liver transplantation in patients with non-alcoholic steatohepatitis cirrhosis: The NASH LT risk-benefit calculator. Clin Transplant 2023; 37:e14930. [PMID: 36762716 DOI: 10.1111/ctr.14930] [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] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 11/14/2022] [Accepted: 02/03/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND Non-alcoholic Steatohepatitis (NASH) cirrhosis is the second most common indication for liver transplantation (LT) in the US and often is associated with significant co-morbidities. We validated a model and risk prediction score that reflects the benefit derived from LT for NASH cirrhosis by predicting 5-year survival post-LT. METHODS We developed a prediction score utilizing 6515 NASH deceased donor LT (DDLT) recipients from 2002 to 2019 from the Scientific Registry of Transplant Recipients (SRTR) database to identify a parsimonious set of independent predictors of survival. Coefficients of relevant recipient factors were converted to weighted points to construct a risk scoring system that was then externally validated. RESULTS The final risk score includes the following independent recipient predictors and corresponding points: recipient age (5 points for age ≥70 years), functional status (3 points for total assistance), presence of TIPSS (2 points), hepatic encephalopathy (1 point), serum creatinine (5 points if >1.45 mg/dl), need for mechanical ventilation (3 points), and dialysis within 1 week prior to LT (7 points). Diabetes is a stratifying variable for baseline risk. Scores range from 0 to 20 with scores above 13 having an overall survival of <65% at 5 years post-LT. Internal and external validation indicated good predictive ability. CONCLUSION Our practically useable and validated risk score helps to identify and stratify candidates who will derive the most long-term benefit from LT for NASH cirrhosis.
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Affiliation(s)
- Ravikiran S Karnam
- Ajmera Transplant Program, University Health Network, Toronto, Ontario, Canada.,Narayana Health, Bengaluru, India
| | - Gopika Punchhi
- Ajmera Transplant Program, University Health Network, Toronto, Ontario, Canada.,Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Nicholas Mitsakakis
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Shiyi Chen
- Biostatistics Department, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | | | - Leslie Lilly
- Ajmera Transplant Program, University Health Network, Toronto, Ontario, Canada.,Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | | | - Mamatha Bhat
- Ajmera Transplant Program, University Health Network, Toronto, Ontario, Canada.,Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Toronto General Hospital Research Institute, Toronto, Ontario, Canada
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11
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Qazi-Arisar FA, Uchila R, Chen C, Yang C, Chen SY, Karnam RS, Azhie A, Xu W, Galvin Z, Selzner N, Lilly L, Bhat M. Divergent trajectories of lean vs obese non-alcoholic steatohepatitis patients from listing to post-transplant: A retrospective cohort study. World J Gastroenterol 2022; 28:3218-3231. [PMID: 36051335 PMCID: PMC9331521 DOI: 10.3748/wjg.v28.i26.3218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 04/22/2022] [Accepted: 06/16/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Non-alcoholic steatohepatitis (NASH) cirrhosis is the second most common indication for liver transplantation (LT). The role of body mass index (BMI) on outcomes of NASH cirrhosis has been conflicting.
AIM To compare the longitudinal trajectories of patients with lean vs obese NASH cirrhosis, from listing up to post-transplant, having adjusted their BMI for ascites.
METHODS We retrospectively reviewed all adult NASH patients listed for LT in our program from 2012 to 2019. Fine-Gray Competing Risk analyses and Cox Proportional-Hazard Models were performed to examine the cumulative incidence of transplant and survival outcomes respectively.
RESULTS Out of 265 NASH cirrhosis listed patients, 176 were included. Median age was 61.0 years; 46% were females. 111 patients underwent LT. Obese robust patients had better waitlist survival [hazard ratio (HR): 0.12; 95%CI: 0.05–0.29, P < 0.0001] with higher instantaneous rate of transplant (HR: 5.71; 95%CI: 1.26–25.9, P = 0.02). Lean NASH patients had a substantially higher risk of graft loss within 90 d post-LT (1.2% vs 13.8%, P = 0.032) and death post-LT (2.4% vs 17.2%, P = 0.029). 1- 3- and 5-year graft survival was poor for lean NASH (78.6%, 77.3% and 41.7% vs 98.6%, 96% and 85% respectively). Overall patient survival post-LT was significantly worse in lean NASH (HR: 0.17; 95%CI: 0.03–0.86, P = 0.0142) with 83% lower instantaneous rate of death in obese group.
CONCLUSION Although lean NASH is considered to be more benign than obese NASH, our study suggests a paradoxical correlation of lean NASH with waitlist outcomes, and graft and patient survival post-LT.
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Affiliation(s)
- Fakhar Ali Qazi-Arisar
- Ajmera Transplant Program, Toronto General Hospital, University Health Network, Toronto M5G 2N2, Ontario, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto M5G 2N2, Ontario, Canada
- National Institute of Liver and GI Diseases, Dow University of Health Sciences, Karachi 75330, Pakistan
| | - Raj Uchila
- Ajmera Transplant Program, Toronto General Hospital, University Health Network, Toronto M5G 2N2, Ontario, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto M5G 2N2, Ontario, Canada
| | - Catherine Chen
- Ajmera Transplant Program, Toronto General Hospital, University Health Network, Toronto M5G 2N2, Ontario, Canada
| | - Cathy Yang
- Ajmera Transplant Program, Toronto General Hospital, University Health Network, Toronto M5G 2N2, Ontario, Canada
| | - Shi-Yi Chen
- Department of Biostatistics, Princess Margaret Cancer Center, University Health Network, Toronto M5G 2C1, Ontario, Canada
| | - Ravikiran Sindhuvalada Karnam
- Ajmera Transplant Program, Toronto General Hospital, University Health Network, Toronto M5G 2N2, Ontario, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto M5G 2N2, Ontario, Canada
| | - Amirhossein Azhie
- Ajmera Transplant Program, Toronto General Hospital, University Health Network, Toronto M5G 2N2, Ontario, Canada
| | - Wei Xu
- Department of Biostatistics, Princess Margaret Cancer Center, University Health Network, Toronto M5G 2C1, Ontario, Canada
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto M5G 2C1, Ontario, Canada
| | - Zita Galvin
- Ajmera Transplant Program, Toronto General Hospital, University Health Network, Toronto M5G 2N2, Ontario, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto M5G 2N2, Ontario, Canada
| | - Nazia Selzner
- Ajmera Transplant Program, Toronto General Hospital, University Health Network, Toronto M5G 2N2, Ontario, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto M5G 2N2, Ontario, Canada
| | - Leslie Lilly
- Ajmera Transplant Program, Toronto General Hospital, University Health Network, Toronto M5G 2N2, Ontario, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto M5G 2N2, Ontario, Canada
| | - Mamatha Bhat
- Ajmera Transplant Program, Toronto General Hospital, University Health Network, Toronto M5G 2N2, Ontario, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto M5G 2N2, Ontario, Canada
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12
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Ivanics T, Rajendran L, Abreu P, Claasen M, Shwaartz C, Patel M, Choi W, Doyle A, Muaddi H, McGilvray I, Selzner M, Beecroft R, Kachura J, Bhat M, Selzner N, Ghanekar A, Cattral M, Sayed B, Reichman T, Lilly L, Sapisochin G. Long-term outcomes of ablation, liver resection, and liver transplant as first-line treatment for solitary HCC of 3 cm or less using an intention-to-treat analysis: A retrospective cohort study. Ann Med Surg (Lond) 2022; 77:103645. [PMID: 35637985 PMCID: PMC9142643 DOI: 10.1016/j.amsu.2022.103645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 04/13/2022] [Accepted: 04/15/2022] [Indexed: 11/25/2022] Open
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13
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Karnam RS, Mitsakakis N, Saracino G, Lilly L, Asrani SK, Bhat M. Predicting Long-term Survival After Liver Transplantation in Patients With NASH Cirrhosis. Clin Gastroenterol Hepatol 2022; 20:704-705. [PMID: 33465480 DOI: 10.1016/j.cgh.2021.01.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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: 08/05/2020] [Revised: 01/12/2021] [Accepted: 01/13/2021] [Indexed: 02/07/2023]
Abstract
Nonalcoholic steatohepatitis (NASH) cirrhosis is the second most common indication for liver transplantation (LT) in the United States.1 Patients are increasingly older at presentation, with higher rates of metabolic syndrome, obesity, hyperlipidemia, diabetes mellitus, and renal failure.2 They are also at higher risk of cardiovascular events and mortality while on the waiting list1 and in the post-transplant period.3,4 We sought to identify predictors of long-term benefit based on 5-year survival post-LT in NASH cirrhosis, thereby delineating those patients that derive a clear benefit from LT versus those in whom LT may be futile.
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Affiliation(s)
- Ravikiran S Karnam
- Multi Organ Transplant Program, University Health Network, Toronto, Ontario, Canada; Ramaiah Medical College and Narayana Health, Bengaluru, India
| | - Nicholas Mitsakakis
- Biostatistics Research Unit, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
| | | | - Leslie Lilly
- Multi Organ Transplant Program, University Health Network, Toronto, Ontario, Canada; Division of Gastroenterology, Department of Medicine, University of Toronto, and Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | | | - Mamatha Bhat
- Multi Organ Transplant Program, University Health Network, Toronto, Ontario, Canada; Division of Gastroenterology, Department of Medicine, University of Toronto, and Toronto General Hospital Research Institute, Toronto, Ontario, Canada.
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Chruscinski A, Rojas-Luengas V, Moshkelgosha S, Issachar A, Luo J, Yowanto H, Lilly L, Smith R, Renner E, Zhang J, Epstein M, Grant D, McEvoy CM, Konvalinka A, Humar A, Adeyi O, Fischer S, Volmer FH, Taubert R, Jaeckel E, Juvet S, Selzner N, Levy GA. Evaluation of a gene expression biomarker to identify operationally tolerant liver transplant recipients: the LITMUS trial. Clin Exp Immunol 2022; 207:123-139. [PMID: 35020854 PMCID: PMC8802178 DOI: 10.1093/cei/uxab011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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] [Received: 08/07/2021] [Revised: 10/07/2021] [Accepted: 10/27/2021] [Indexed: 02/06/2023] Open
Abstract
LITMUS was a single-centre, Phase 2a study designed to investigate whether the gene biomarker FGL2/IFNG previously reported for the identification of tolerance in murine models could identify operationally tolerant liver transplant recipients. Multiplex RT-PCR was used to amplify eight immunoregulatory genes in peripheral blood mononuclear cells (PBMC) from 69 adult liver transplant recipients. Patients with PBMC FGL2/IFNG ≥ 1 and a normal liver biopsy underwent immunosuppression (IS) withdrawal. The primary end point was the development of operational tolerance. Secondary end points included correlation of tolerance with allograft gene expression and immune cell markers. Twenty-eight of 69 patients (38%) were positive for the PBMC tolerance biomarker and 23 proceeded to IS withdrawal. Nine of the 23 patients had abnormal baseline liver biopsies and were excluded. Of the 14 patients with normal biopsies, eight (57%) have achieved operational tolerance and are off IS (range 12–57 months). Additional studies revealed that all of the tolerant patients and only one non-tolerant patient had a liver gene ratio of FOXP3/IFNG ≥ 1 prior to IS withdrawal. Increased CD4+ T regulatory T cells were detected both in PBMC and livers of tolerant patients following IS withdrawal. Higher expression of SELE (gene for E-selectin) and lower expression of genes associated with inflammatory responses (GZMB, CIITA, UBD, LSP1, and CXCL9) were observed in the pre-withdrawal liver biopsies of tolerant patients by RNA sequencing. These results suggest that measurement of PBMC FGL2/IFNG may enrich for the identification of operationally tolerant liver transplant patients, especially when combined with intragraft measurement of FOXP3/IFNG. Clinical Trial Registration: ClinicalTrials.gov (LITMUS: NCT02541916).
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Affiliation(s)
- Andrzej Chruscinski
- Multi-Organ Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Vanessa Rojas-Luengas
- Multi-Organ Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Sajad Moshkelgosha
- Multi-Organ Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Assaf Issachar
- Multi-Organ Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | | | | | - Leslie Lilly
- Multi-Organ Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Robert Smith
- Multi-Organ Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Eberhard Renner
- Multi-Organ Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Jianhua Zhang
- Multi-Organ Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Maor Epstein
- Multi-Organ Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - David Grant
- Multi-Organ Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Caitriona M McEvoy
- Multi-Organ Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Ana Konvalinka
- Multi-Organ Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Atul Humar
- Multi-Organ Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Oyedele Adeyi
- Multi-Organ Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Sandra Fischer
- Multi-Organ Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Felix H Volmer
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Richard Taubert
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Elmar Jaeckel
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Stephen Juvet
- Multi-Organ Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Nazia Selzner
- Multi-Organ Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Gary A Levy
- Multi-Organ Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Canada
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Karnam RS, Chen S, Xu W, Chen C, Elangainesan P, Ghanekar A, McGilvray I, Reichman T, Sayed B, Selzner M, Sapisochin G, Galvin Z, Hirschfield G, Asrani SK, Selzner N, Cattral M, Lilly L, Bhat M. Sex Disparity in Liver Transplant and Access to Living Donation. JAMA Surg 2021; 156:1010-1017. [PMID: 34406347 PMCID: PMC8374729 DOI: 10.1001/jamasurg.2021.3586] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 05/22/2021] [Indexed: 12/15/2022]
Abstract
Importance The Model for End-stage Liver Disease (MELD)-based organ allocation system has significantly decreased mortality on the transplant waiting list for patients with end-stage liver disease. However, women have remained at a disadvantage with respect to access to deceased donor liver transplant (DDLT) even after introduction of the MELD score for organ allocation. Objective To determine whether availability of living donation in a transplant program can offset inequity in liver transplant (LT) allocation for women. Design, Setting, and Participants This cohort study retrospectively analyzed adult patients listed for LT at the University Health Network in Toronto, Ontario, Canada. Patients included had a potential living donor (pLD) at the moment of listing. This study was performed from November 13, 2012, to May 31, 2019. A total of 1289 listed patients (830 men; 459 women) were analyzed during the study period. Main Outcomes and Measures This study performed survival analysis and competing-risk analysis to delineate how access to livers from living donors was associated with events in women vs men on the transplant waiting list (LT, death, or dropout). Results Of 1289 included patients, 459 (35.6%) were women, and the mean (SD) age was 56.1 (10.0) years at assessment and listing. A total of 783 of 1289 listed patients underwent LT. Among those with no pLD at assessment, there was a higher median (range) Model for End-stage Liver Disease incorporating sodium levels (MELD-Na) score at listing (22 [6-50] vs 19 [6-50]; P < .001) and at LT (27 [6-49] vs 20 [6-52]; P < .001) in women receiving DDLT. Women were at a significant disadvantage without a pLD (hazard ratio [HR], 1.29; 95% CI, 1.04-1.60; P = .01); there was no difference in access to LT with availability of a pLD (HR, 0.93; 95% CI, 0.76,-1.14; P = .44). The instantaneous rate of receiving a transplant in men with a pLD was 1.39 times higher than men who did not have a pLD (HR, 1.39; 95% CI; P < .001) and the instantaneous rate of receiving a transplant in women with a pLD was 1.92 times higher than in women who did not (HR, 1.92; 95% CI, 1.51-2.44; P < .001). The HR was 1.38 times higher in women compared with men across the MELD-Na score strata (HR, 1.38; 95% CI, 1.03-1.84; P = .03) and 2.04 times higher when the MELD-Na score was less than 20 (HR, 2.04; 95% CI, 1.31-3.14; P = .001). Conclusions and Relevance These study findings suggest that women can overcome the complex problem of allocation inequity with access to livers from living donors. Women with access only to DDLT were much more unwell than men independent of liver disease at the time of listing, dropout, or LT. Therefore, the wider availability of living donation liver transplant would be helpful in addressing the sex disparity in access to LT in the current MELD-Na era.
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Affiliation(s)
- Ravikiran S. Karnam
- Multi Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
- Ramaiah Medical College, Narayana Health, Bengaluru, India
| | - Shiyi Chen
- Department of Biostatistics, Princess Margaret Cancer Research Centre, Toronto, Ontario, Canada
| | - Wei Xu
- Department of Biostatistics, Princess Margaret Cancer Research Centre, Toronto, Ontario, Canada
| | - Catherine Chen
- Multi Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Praniya Elangainesan
- Multi Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Anand Ghanekar
- Multi Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Ian McGilvray
- Multi Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Trevor Reichman
- Multi Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Blayne Sayed
- Multi Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Markus Selzner
- Multi Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Gonzalo Sapisochin
- Multi Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Zita Galvin
- Multi Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
- Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Gideon Hirschfield
- Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | | | - Nazia Selzner
- Multi Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
- Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Mark Cattral
- Multi Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Leslie Lilly
- Multi Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
- Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Mamatha Bhat
- Multi Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
- Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
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Nitski O, Azhie A, Qazi-Arisar FA, Wang X, Ma S, Lilly L, Watt KD, Levitsky J, Asrani SK, Lee DS, Rubin BB, Bhat M, Wang B. Long-term mortality risk stratification of liver transplant recipients: real-time application of deep learning algorithms on longitudinal data. Lancet Digit Health 2021; 3:e295-e305. [PMID: 33858815 DOI: 10.1016/s2589-7500(21)00040-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 02/06/2021] [Accepted: 02/17/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Survival of liver transplant recipients beyond 1 year since transplantation is compromised by an increased risk of cancer, cardiovascular events, infection, and graft failure. Few clinical tools are available to identify patients at risk of these complications, which would flag them for screening tests and potentially life-saving interventions. In this retrospective analysis, we aimed to assess the ability of deep learning algorithms of longitudinal data from two prospective cohorts to predict complications resulting in death after liver transplantation over multiple timeframes, compared with logistic regression models. METHODS In this machine learning analysis, model development was done on a set of 42 146 liver transplant recipients (mean age 48·6 years [SD 17·3]; 17 196 [40·8%] women) from the Scientific Registry of Transplant Recipients (SRTR) in the USA. Transferability of the model was further evaluated by fine-tuning on a dataset from the University Health Network (UHN) in Canada (n=3269; mean age 52·5 years [11·1]; 1079 [33·0%] women). The primary outcome was cause of death, as recorded in the databases, due to cardiovascular causes, infection, graft failure, or cancer, within 1 year and 5 years of each follow-up examination after transplantation. We compared the performance of four deep learning models against logistic regression, assessing performance using the area under the receiver operating characteristic curve (AUROC). FINDINGS In both datasets, deep learning models outperformed logistic regression, with the Transformer model achieving the highest AUROCs in both datasets (p<0·0001). The AUROC for the Transformer model across all outcomes in the SRTR dataset was 0·804 (99% CI 0·795-0·854) for 1-year predictions and 0·733 (0·729-0·769) for 5-year predictions. In the UHN dataset, the AUROC for the top-performing deep learning model was 0·807 (0·795-0·842) for 1-year predictions and 0·722 (0·705-0·764) for 5-year predictions. AUROCs ranged from 0·695 (0·680-0·713) for prediction of death from infection within 5 years to 0·859 (0·847-0·871) for prediction of death by graft failure within 1 year. INTERPRETATION Deep learning algorithms can incorporate longitudinal information to continuously predict long-term outcomes after liver transplantation, outperforming logistic regression models. Physicians could use these algorithms at routine follow-up visits to identify liver transplant recipients at risk for adverse outcomes and prevent these complications by modifying management based on ranked features. FUNDING Canadian Donation and Transplant Research Program, CIFAR AI Chairs Program.
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Affiliation(s)
- Osvald Nitski
- Faculty of Applied Science and Engineering, University of Toronto, Toronto, ON, Canada; Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Amirhossein Azhie
- Multi Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - Fakhar Ali Qazi-Arisar
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Toronto, Toronto, ON, Canada; Multi Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - Xueqi Wang
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Shihao Ma
- Department of Computer Science, University of Toronto, Toronto, ON, Canada
| | - Leslie Lilly
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Multi Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - Kymberly D Watt
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Josh Levitsky
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Douglas S Lee
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada; Ted Rogers Centre for Heart Research, Toronto, ON, Canada; Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Barry B Rubin
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Mamatha Bhat
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Division of Gastroenterology & Hepatology, Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada; Multi Organ Transplant Program, University Health Network, Toronto, ON, Canada; Toronto General Hospital Research Institute, Toronto, ON, Canada
| | - Bo Wang
- Department of Computer Science, University of Toronto, Toronto, ON, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada; Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada; Vector Institute, Toronto, ON, Canada.
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Galante A, Adeyi O, Lau L, Humar A, Galvin Z, Selzner N, Lilly L, Sapisochin G, Bhat M. Liver Transplantation for Acute Liver Failure Due to Dengue Fever. Hepatology 2019; 70:1863-1865. [PMID: 31162847 DOI: 10.1002/hep.30803] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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: 02/05/2019] [Accepted: 04/30/2019] [Indexed: 01/02/2023]
Affiliation(s)
- Antonio Galante
- Department of Medicine, Multi-Organ Transplant Program, Toronto General Hospital, Toronto, Canada
| | - Oyedele Adeyi
- Department of Pathology, Toronto General Hospital, Toronto, Canada
| | - Lawrence Lau
- Department of Surgery, Multi-Organ Transplant Program, Toronto General Hospital, Toronto, Canada
| | - Atul Humar
- Division of Infectious Diseases, Multi-Organ Transplant Program, Toronto General Hospital, Toronto, Canada
| | - Zita Galvin
- Department of Medicine, Multi-Organ Transplant Program, Toronto General Hospital, Toronto, Canada
| | - Nazia Selzner
- Department of Medicine, Multi-Organ Transplant Program, Toronto General Hospital, Toronto, Canada
| | - Leslie Lilly
- Department of Medicine, Multi-Organ Transplant Program, Toronto General Hospital, Toronto, Canada
| | - Gonzalo Sapisochin
- Department of Surgery, Multi-Organ Transplant Program, Toronto General Hospital, Toronto, Canada
| | - Mamatha Bhat
- Department of Medicine, Multi-Organ Transplant Program, Toronto General Hospital, Toronto, Canada
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Al-Shaibani Z, Kotha S, Lam W, Galvin Z, Lilly L, Lipton JH, Law AD. Sequential liver and haematopoietic stem cell transplantation in a case of fulminant hepatitis associated liver failure and aplastic anaemia. Eur J Haematol 2019; 102:375-377. [PMID: 30667559 DOI: 10.1111/ejh.13213] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 01/17/2019] [Indexed: 01/13/2023]
Abstract
The management of severe aplastic anaemia is particularly challenging when it occurs in the context of recent liver transplantation. Rapid identification of a suitable donor followed by allogeneic haematopoietic stem cell transplantation is the only curative option. This scenario is often complicated by potentially life-threatening infections that develop as a consequence of immunosuppression. Alternative donor transplantation using suitably matched unrelated donors can be potentially life-saving when suitably matched sibling donors are unavailable. Above all, a dedicated interdisciplinary approach with seamless communication between hepatology, transplant surgery, haematology, and stem cell transplant services is essential to achieving optimal outcomes. Herein, we describe a case of severe hepatitis leading to hepatic failure who was treated with liver transplantation from a deceased donor, and later received an allogeneic haematopoietic stem cell transplantation from a matched unrelated donor for hepatitis-associated aplastic anaemia.
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Affiliation(s)
- Zeyad Al-Shaibani
- Hans Messner Allogeneic Blood and Marrow Transplant Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | | | - Wilson Lam
- Hans Messner Allogeneic Blood and Marrow Transplant Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Zita Galvin
- Multiorgan Transplant Program, Toronto General Hospital, Toronto, Ontario, Canada
| | - Leslie Lilly
- Multiorgan Transplant Program, Toronto General Hospital, Toronto, Ontario, Canada
| | - Jeffrey H Lipton
- Hans Messner Allogeneic Blood and Marrow Transplant Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Arjun Datt Law
- Hans Messner Allogeneic Blood and Marrow Transplant Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
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Feng S, Fallah-Rad N, Cao Y, Knox JJ, Jang RWJ, Dhani NC, Sapisochin G, Grant D, Greig PD, Lilly L, Gorgen A, Chen EX. An updated retrospective review of the safety and efficacy of sorafenib for recurrent hepatocellular carcinoma post-liver transplantation. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.4_suppl.313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
313 Background: Orthotopic liver transplantation (OLT) is a potentially curative treatment for hepatocellular carcinoma (HCC). Despite an estimated recurrence rate between 15%-20%, there is currently no proven systemic therapy for the treatment of HCC relapse post OLT. Sorafenib has been a standard therapy for advanced HCC however data is lacking for the safety and efficacy of sorafenib in the setting of concurrent immunosuppressive agents. Methods: A retrospective review was performed of patients who received sorafenib for HCC relapse after OLT. Data on patient characteristics, treatment toxicity and efficacy was collected. The primary objectives were to evaluate toxicity and safety of sorafenib when used in combination with immunosuppressive therapies such as calcineurin and mTOR inhibitors. Secondary objectives were objective response rate, progression free survival (PFS), and time on therapy. Results: 35 patients over the last 11 years received sorafenib for HCC recurrence following OLT. 54.3% of patients received concurrent immunosuppression with tacrolimus. Toxicity from sorafenib was as expected, with no cases of acute or chronic organ rejection whilst on treatment. The median maximum tolerated dose was 400 mg a day with 40% of patients requiring dose reductions. The incidence of any adverse events (AEs) was 88.6%, with 17.1% having Grade 3-4 toxicity. Incidence of Grade 3-4 liver dysfunction was higher than historical studies at 6%. The overall response rate was 2.8% with a median PFS of 2.8 months. Median time on sorafenib was 3.1 months. Conclusions: There is a paucity of evidence guiding treatment of HCC recurrence following OLT. This retrospective review is one of the largest in the literature and shows that sorafenib used concurrently with immunosuppressive therapy for organ transplant is safe, with no precipitation of acute or chronic rejection, although liver function should be monitored closely. The median PFS in our cohort was shorter than expected. The efficacy of other agents should be explored in this population.[Table: see text]
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Affiliation(s)
| | | | - Yanshuo Cao
- Peking University Cancer Hospital and Institute, Beijing, China
| | | | | | - Neesha C. Dhani
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Gonzalo Sapisochin
- Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - David Grant
- Toronto General Hospital, Toronto, ON, Canada
| | - Paul D Greig
- Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | | | - Andre Gorgen
- Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Eric Xueyu Chen
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
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Yoshida EM, Kwo P, Agarwal K, Duvoux C, Durand F, Peck-Radosavljevic M, Lilly L, Willems B, Vargas H, Kumar P, Brown RS, Horsmans Y, De-Oertel S, Arterburn S, Dvory-Sobol H, Brainard DM, McHutchison JG, Terrault N, Rizzetto M, Müllhaupt B. Persistence of Virologic Response after Liver Transplant in Hepatitis C Patients Treated with Ledipasvir / Sofosbuvir Plus Ribavirin Pretransplant. Ann Hepatol 2017; 16:375-381. [PMID: 28425407 DOI: 10.5604/16652681.1235480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Recurrence of HCV infection in patients with chronic hepatitis C virus (HCV) at the time of liver transplantation is nearly universal and reduces the likelihood of graft and patient survival. MATERIALS AND METHODS We evaluated outcomes of 17 patients (16 with HCV genotype 1 and 1 with genotype 4) who received up to 12 or 24 weeks of ledipasvir/sofosbuvir plus ribavirin prior to or up to the time of liver transplant in the SOLAR-1 and SOLAR-2 trials. In all patients, HCV RNA was < 15 IU/mL prior to transplant. At screening, 6 patients were Child-Pugh-Turcotte (CPT) class B and 11 were CPT class C. Seven patients underwent transplant prior to completing assigned treatment, with 4 treated for < 12 weeks. The primary endpoint was posttransplant virologic response 12 weeks after transplant (pTVR12) in patients with HCV RNA < 15 IU/mL at their last measurement prior to transplant. RESULTS Overall, 94% (16/17) achieved pTVR12. All who achieved pTVR12 received at least 11 weeks of treatment. The single patient who did not achieve pTVR12 discontinued study drug on day 21 and underwent liver transplant the following day. The patient had HCV RNA < 15 IU/mL at post-transplant week 2 but died 15 days post-transplant because of multi-organ failure and septic shock. CONCLUSION Among a small population of HCV patients with decompensated cirrhosis, virologic response to ledipasvir / sofosbuvir plus ribavirin prior to liver transplantation was maintained after transplantation, even if treatment was stopped early. Administration of ledipasvir / sofosbuvir plus ribavirin before liver transplant can prevent post-transplant HCV recurrence.
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Affiliation(s)
- Eric M Yoshida
- Division of Gastroenterology, Vancouver General Hospital and University of British Columbia, Vancouver, BC, Canada
| | - Paul Kwo
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Kosh Agarwal
- Institute of Liver Studies, King's College Hospital Foundation Trust, London UK
| | - Christophe Duvoux
- Unite d'Hepatologie et de Transplantation Hepatique, Centre Hospitalier Universitaire Henri-Mondor, Service d'Hepatologie et de Gastroenterologie, Universite Paris-Est Creteil, Val-de-Marne, Paris, France
| | - François Durand
- Hepatology & Liver Intensive Care, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, University Paris Diderot, Clichy, France
| | | | - Leslie Lilly
- Multi-Organ Transplant Program, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Bernard Willems
- Hospital Saint Luc, Universite de Montreal, Montreal, QC, Canada
| | - Hugo Vargas
- Division of Gastroenterology and Hepatology, Department of Transplant Hepatology, Mayo Clinic, Phoenix, AZ, USA
| | - Princy Kumar
- Division of Infectious Diseases, Georgetown University, Washington, DC, USA
| | - Robert S Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY, USA
| | | | | | | | | | | | | | - Norah Terrault
- Division of Gastroenterology and Hepatology, University of California, San Francisco, CA, USA
| | - Mario Rizzetto
- Department of Gastroenterology, University of Torino, Torino, Italy
| | - Beat Müllhaupt
- Department for Gastroenterology and Hepatology, University Hospital Zurich, Switzerland
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Maragoudakis S, Heiss C, Lilly L. Effect of Resistant Starch Supplementation on the Glycemic Effect of a High Carbohydrate Breakfast. J Acad Nutr Diet 2017. [DOI: 10.1016/j.jand.2017.06.160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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22
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Fallah-Rad N, Cao Y, Sapisochin G, Dhani NC, Knox JJ, Grant D, Jang RWJ, Greig PD, Lilly L, Chen EX. Sorafenib treatment in recurrent hepatocellular carcinoma post liver transplantation. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.e15613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e15613 Background: Liver transplantation (LT) is a potentially curative treatment for patients (pts) with selective hepatocellular carcinoma (HCC). HCC recurrence post LT is estimated to be 15-20%. Data on systemic therapy post-recurrence is scarce and limited case series suggest that sorafenib (SOR) may have benefit in this population. We reviewed a single center experience with SOR in recurrent HCC post LT Methods: A retrospective review was conducted on pts with recurrent HCC post LT at University Health Network (UHN) who were treated with SOR. Pt characteristics were collected including age, gender, comorbidities, background liver disease, type of LT, and time to recurrence after LT. Treatment information collected included: initial SOR dose (and adjustments), adverse events (AEs), duration of treatment and survival. Results: Between 2006 and 2016, 24 pts were identified. The average age was 60 years (range: 18-72), most pts were male (20/4), living/cadaveric transplant: 11/13. HCC etiology included hepatitis B (10), alcohol (4), NASH (3), hepatitis C (2), hemochromatosis (2), Budd-Chiari (2) and unknown (1). The average time to recurrence of HCC was 16.08 (range: 1.5-60) months post OLT. There was a bimodal time to recurrence with a median of 6 months. SOR starting doses were 200 mg BID in 18 pts, 300 mg BID in 1 and 400 mg BID in 4. 14 pts required dose adjustment due to AEs, mainly relating to fatigue and palmar-plantar syndrome. The median time on treatment was 2.5 (range: 0.25-37) months. The average time to progression on SOR and/or discontinuation due to AEs was 4.30 (+/- 7.2) months. Conclusions: SOR is reasonably tolerated in pts with recurrent HCC post LT, with expected AE profiles. In this small case series, the median time on SOR was short and estimated time to progression was shorter than that in non-transplant HCC population. Overall, SOR has limited activity in this population, but selected pts may derive extended benefit. Better understanding of responders and investigations of other therapies are needed for this population.
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Affiliation(s)
| | - Yanshuo Cao
- University Health Network, Toronto, ON, Canada
| | | | - Neesha C. Dhani
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Jennifer J. Knox
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - David Grant
- University Health Network, Toronto, ON, Canada
| | - Raymond Woo-Jun Jang
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | | | | | - Eric Xueyu Chen
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
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23
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Yoshida EM, Kwo P, Agarwal K, Duvoux C, Durand F, Peck-Radosavljevic M, Lilly L, Willems B, Vargas H, Kumar P, Brown Jr. RS, Horsmans Y, De-Oertel S, Arterburn S, Dvory-Sobol H, Brainard DM, McHutchison JG, Terrault N, Rizzetto M, Müllhaupt B. Persistence of Virologic Response after Liver Transplant in Hepatitis C Patients Treated with Ledipasvir / Sofosbuvir Plus Ribavirin Pretransplant. Ann Hepatol 2017; 16:375-381. [DOI: 10.5604/01.3001.0009.8592] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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24
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Knaak M, Goldaracena N, Doyle A, Cattral MS, Greig PD, Lilly L, McGilvray ID, Levy GA, Ghanekar A, Renner EL, Grant DR, Selzner M, Selzner N. Donor BMI >30 Is Not a Contraindication for Live Liver Donation. Am J Transplant 2017; 17:754-760. [PMID: 27545327 DOI: 10.1111/ajt.14019] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 08/10/2016] [Accepted: 08/13/2016] [Indexed: 01/25/2023]
Abstract
The increased prevalence of obesity worldwide threatens the pool of living liver donors. Although the negative effects of graft steatosis on liver donation and transplantation are well known, the impact of obesity in the absence of hepatic steatosis on outcome of living donor liver transplantation (LDLT) is unknown. Consequently, we compared the outcome of LDLT using donors with BMI <30 versus donors with BMI ≥30. Between April 2000 and May 2014, 105 patients received a right-lobe liver graft from donors with BMI ≥30, whereas 364 recipients were transplanted with grafts from donors with BMI <30. Liver steatosis >10% was excluded in all donors with BMI >30 by imaging and liver biopsies. None of the donors had any other comorbidity. Donors with BMI <30 versus ≥30 had similar postoperative complication rates (Dindo-Clavien ≥3b: 2% vs. 3%; p = 0.71) and lengths of hospital stay (6 vs. 6 days; p = 0.13). Recipient graft function, assessed by posttransplant peak serum bilirubin and international normalized ratio was identical. Furthermore, no difference was observed in recipient complication rates (Dindo-Clavien ≥3b: 25% vs. 20%; p = 0.3) or lengths of hospital stay between groups. We concluded that donors with BMI ≥30, in the absence of graft steatosis, are not contraindicated for LDLT.
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Affiliation(s)
- M Knaak
- Department of Surgery, Multi Organ Transplant Program, Toronto General Hospital, Toronto, ON, Canada.,General-, Visceral- and Transplantation Surgery, University Hospital of Frankfurt am Main, Frankfurt, Germany
| | - N Goldaracena
- Department of Surgery, Multi Organ Transplant Program, Toronto General Hospital, Toronto, ON, Canada
| | - A Doyle
- Department of Medicine, Multi Organ Transplant Program, Toronto General Hospital, Toronto, ON, Canada
| | - M S Cattral
- Department of Surgery, Multi Organ Transplant Program, Toronto General Hospital, Toronto, ON, Canada
| | - P D Greig
- Department of Surgery, Multi Organ Transplant Program, Toronto General Hospital, Toronto, ON, Canada
| | - L Lilly
- Department of Medicine, Multi Organ Transplant Program, Toronto General Hospital, Toronto, ON, Canada
| | - I D McGilvray
- Department of Surgery, Multi Organ Transplant Program, Toronto General Hospital, Toronto, ON, Canada
| | - G A Levy
- Department of Medicine, Multi Organ Transplant Program, Toronto General Hospital, Toronto, ON, Canada
| | - A Ghanekar
- Department of Surgery, Multi Organ Transplant Program, Toronto General Hospital, Toronto, ON, Canada
| | - E L Renner
- Department of Medicine, Multi Organ Transplant Program, Toronto General Hospital, Toronto, ON, Canada
| | - D R Grant
- Department of Surgery, Multi Organ Transplant Program, Toronto General Hospital, Toronto, ON, Canada
| | - M Selzner
- Department of Surgery, Multi Organ Transplant Program, Toronto General Hospital, Toronto, ON, Canada
| | - N Selzner
- Department of Medicine, Multi Organ Transplant Program, Toronto General Hospital, Toronto, ON, Canada
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25
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Fallah-Rad N, Cao Y, Knox JJ, Jang RWJ, Dhani NC, Sapisochin G, Grant D, Greig PD, Lilly L, Chen E. Sorafenib treatment in recurrent hepatocellular carcinoma post liver transplantation. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.4_suppl.479] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
479 Background: Liver transplantation (LT) is a potentially curative treatment for patients (pts) with selective hepatocellular carcinoma (HCC). HCC recurrence post LT is estimated to be 15-20%. Data on systemic therapy post-recurrence is scarce and limited case series suggest that sorafenib (SOR) may have benefit in this population. We reviewed a single center experience with SOR in recurrent HCC post LT. Methods: A retrospective review was conducted on patients with recurrent HCC post LT at University Health Network (UHN) who were treated with SOR. Pt characteristics were collected including age, gender, comorbidities, background liver disease, type of LT, and time to recurrence after LT. Treatment information collected included: initial SOR dose and subsequent adjustments, adverse events (AEs), duration of treatment and survival. Results: Between 2006 and 2016, 24 patients were identified. The average age was 60 years (range: 18-72), most patients were male (20/4), living/cadaveric transplant: 11/13. HCC etiology included hepatitis B (10), alcohol (4), NASH (3), hepatitis C (2), hemochromatosis (2), Budd-Chiari (2) and unknown (1). The average time to recurrence of HCC was 16.08 (range: 1.5-60) months post LT. There was a bimodal time to recurrence with a median of 6 months. SOR starting doses were 200 mg BID in 18 pts, 300 mg BID in 1 and 400 mg BID in 4. 14 pts required dose adjustment due to AEs, mainly relating to fatigue and palmar-plantar syndrome. The median time on treatment was 2.5 (range: 0.25-37) months, 4/24 patients were on treatment > 6 months. The average time to progression on SOR and/or discontinuation due to AEs was 4.30 (+/- 7.2) months. Conclusions: SOR is reasonably tolerated in patients with recurrent HCC post LT, with expected AE profiles. In this small case series, the median time on sorafenib was short and estimated time to progression was shorter than that in non-transplant HCC population. Overall, sorafenib has limited activity in this population, but selected patients may derive extended benefit. Better understanding of responders and investigations of other therapies are needed for this population.
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Affiliation(s)
| | - Yanshuo Cao
- Princess Margaret Cancer Center, Toronto, ON, Canada
| | - Jennifer J. Knox
- Princess Margaret Cancer Centre, University Health Network, Department of Medical Oncology and Hematology, Toronto, ON, Canada
| | - Raymond Woo-Jun Jang
- Princess Margaret Cancer Centre, University Health Network, Department of Medical Oncology and Hematology, Toronto, ON, Canada
| | - Neesha C. Dhani
- Princess Margaret Cancer Centre, University Health Network, Division of Medical Oncology and Hematology, Toronto, ON, Canada
| | | | - David Grant
- Toronto General Hospital, Toronto, ON, Canada
| | - Paul D Greig
- Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | | | - Eric Chen
- Division of Medical Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada
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26
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Selzner M, Goldaracena N, Echeverri J, Kaths JM, Linares I, Selzner N, Serrick C, Marquez M, Sapisochin G, Renner EL, Bhat M, McGilvray ID, Lilly L, Greig PD, Tsien C, Cattral MS, Ghanekar A, Grant DR. Normothermic ex vivo liver perfusion using steen solution as perfusate for human liver transplantation: First North American results. Liver Transpl 2016; 22:1501-1508. [PMID: 27339754 DOI: 10.1002/lt.24499] [Citation(s) in RCA: 140] [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: 03/19/2016] [Revised: 05/08/2016] [Accepted: 05/23/2016] [Indexed: 12/12/2022]
Abstract
The European trial investigating normothermic ex vivo liver perfusion (NEVLP) as a preservation technique for liver transplantation (LT) uses gelofusine, a non-US Food and Drug Administration-approved, bovine-derived, gelatin-based perfusion solution. We report a safety and feasibility clinical NEVLP trial with human albumin-based Steen solution. Transplant outcomes of 10 human liver grafts that were perfused on the Metra device at 37 °C with Steen solution, plus 3 units of erythrocytes were compared with a matched historical control group of 30 grafts using cold storage (CS) as the preservation technique. Ten liver grafts were perfused for 480 minutes (340-580 minutes). All livers cleared lactate (final lactate 1.46 mmol/L; 0.56-1.74 mmol/L) and produced bile (61 mL; 14-146 mL) during perfusion. No technical problems occurred during perfusion, and all NEVLP-preserved grafts functioned well after LT. NEVLP versus CS had lower aspartate aminotransferase and alanine aminotransferase values on postoperative days 1-3 without reaching significance. No difference in postoperative graft function between NEVLP and CS grafts was detected as measured by day 7 international normalized ratio (1.1 [1-1.56] versus 1.1 [1-1.3]; P = 0.5) and bilirubin (1.5; 1-7.7 mg/dL versus 2.78; 0.4-15 mg/dL; P = 0.5). No difference was found in the duration of intensive care unit stay (median, 1 versus 2 days; range, 0-8 versus 0-23 days; P = 0.5) and posttransplant hospital stay (median, 11 versus 13 days; range, 8-17 versus 7-89 days; P = 0.23). Major complications (Dindo-Clavien ≥ 3b) occurred in 1 patient in the NEVLP group (10%) compared with 7 (23%) patients in the CS group (P = 0.5). No graft loss or patient death was observed in either group. Liver preservation with normothermic ex vivo perfusion with the Metra device using Steen solution is safe and results in comparable outcomes to CS after LT. Using US Food and Drug Administration-approved Steen solution will avoid a potential regulatory barrier in North America. Liver Transplantation 22 1501-1508 2016 AASLD.
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Affiliation(s)
- Markus Selzner
- Departments of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | | | - Juan Echeverri
- Departments of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Johan M Kaths
- Departments of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Ivan Linares
- Departments of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Nazia Selzner
- Departments of Medicine, Toronto General Hospital, Toronto, Ontario, Canada
| | - Cyril Serrick
- Perfusion Services, Multi-Organ Transplant Program, Toronto General Hospital, Toronto, Ontario, Canada
| | - Max Marquez
- Departments of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Gonzalo Sapisochin
- Departments of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Eberhard L Renner
- Departments of Medicine, Toronto General Hospital, Toronto, Ontario, Canada
| | - Mamatha Bhat
- Departments of Medicine, Toronto General Hospital, Toronto, Ontario, Canada
| | - Ian D McGilvray
- Departments of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Leslie Lilly
- Departments of Medicine, Toronto General Hospital, Toronto, Ontario, Canada
| | - Paul D Greig
- Departments of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Cynthia Tsien
- Departments of Medicine, Toronto General Hospital, Toronto, Ontario, Canada
| | - Mark S Cattral
- Departments of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Anand Ghanekar
- Departments of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - David R Grant
- Departments of Surgery, Toronto General Hospital, Toronto, Ontario, Canada.
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27
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Doyle A, Adeyi O, Khalili K, Fischer S, Dib M, Goldaracena N, Dillon J, Grant D, Cattral M, McGilvray I, Greig P, Ghanekar A, Lilly L, Renner E, Levy G, Selzner N. Treatment with Optifast reduces hepatic steatosis and increases candidacy rates for living donor liver transplantation. Liver Transpl 2016; 22:1295-300. [PMID: 27314458 DOI: 10.1002/lt.24495] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [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: 03/04/2016] [Accepted: 05/18/2016] [Indexed: 12/15/2022]
Affiliation(s)
- Adam Doyle
- Multi Organ Transplant Program, University Health Network, University of Toronto, Ontario, Canada
| | - Oyedele Adeyi
- Departments of Pathology, University Health Network, University of Toronto, Ontario, Canada
| | - Korosh Khalili
- Radiology, University Health Network, University of Toronto, Ontario, Canada
| | - Sandra Fischer
- Departments of Pathology, University Health Network, University of Toronto, Ontario, Canada
| | - Martin Dib
- Multi Organ Transplant Program, University Health Network, University of Toronto, Ontario, Canada
| | - Nicolas Goldaracena
- Multi Organ Transplant Program, University Health Network, University of Toronto, Ontario, Canada
| | - Jayne Dillon
- Multi Organ Transplant Program, University Health Network, University of Toronto, Ontario, Canada
| | - David Grant
- Multi Organ Transplant Program, University Health Network, University of Toronto, Ontario, Canada
| | - Mark Cattral
- Multi Organ Transplant Program, University Health Network, University of Toronto, Ontario, Canada
| | - Ian McGilvray
- Multi Organ Transplant Program, University Health Network, University of Toronto, Ontario, Canada
| | - Paul Greig
- Multi Organ Transplant Program, University Health Network, University of Toronto, Ontario, Canada
| | - Anand Ghanekar
- Multi Organ Transplant Program, University Health Network, University of Toronto, Ontario, Canada
| | - Leslie Lilly
- Multi Organ Transplant Program, University Health Network, University of Toronto, Ontario, Canada
| | - Eberhard Renner
- Multi Organ Transplant Program, University Health Network, University of Toronto, Ontario, Canada
| | - Gary Levy
- Multi Organ Transplant Program, University Health Network, University of Toronto, Ontario, Canada
| | - Nazia Selzner
- Multi Organ Transplant Program, University Health Network, University of Toronto, Ontario, Canada
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28
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Doyle A, Rabie RN, Mokhtari A, Cattral M, Ghanekar A, Grant D, Greig P, Levy G, Lilly L, McGilvray I, Selzner M, Selzner N, Renner EL. Recipient factors associated with having a potential living donor for liver transplantation. Liver Transpl 2015; 21:897-903. [PMID: 25891165 DOI: 10.1002/lt.24148] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [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: 01/08/2015] [Revised: 04/06/2015] [Accepted: 04/07/2015] [Indexed: 02/07/2023]
Abstract
Because of a persistent discrepancy between the demand for liver transplantation (LT) and the supply of deceased donor organs, there is an interest in increasing living donation rates at centers trained in this method of transplantation. We examined a large socioeconomically heterogeneous cohort of patients listed for LT to identify recipient factors associated with living donation. We retrospectively reviewed 491 consecutive patients who were listed for LT at our center over a 24-month period. Demographic, medical, and socioeconomic data were extracted from electronic records and compared between those who had a potential living donor (LD) volunteer for assessment and those who did not; 245 patients (50%) had at least 1 potential LD volunteer for assessment. Multivariate logistic regression analysis identified that patients with a LD were more likely to have Child-Pugh C disease (odds ratio [OR], 2.44; P = 0.02), and less likely to be older (OR, 0.96; P = 0.002), single (OR, 0.34; P = 0.006), divorced (OR, 0.53; P = 0.03), immigrants (OR, 0.38; P = 0.049), or from the lowest income quintile (OR, 0.44; P = 0.02). In conclusion, this analysis has identified several factors associated with access to living donation. More research is warranted to define and overcome barriers to living donor liver transplantation through targeted interventions in underrepresented populations.
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Affiliation(s)
- Adam Doyle
- Liver Transplant Program/Multi-Organ Transplant Program, University Health Network, Toronto General Hospital, Toronto, ON, Canada
| | - Rania N Rabie
- Liver Transplant Program/Multi-Organ Transplant Program, University Health Network, Toronto General Hospital, Toronto, ON, Canada.,Department of Medicine, Southlake Regional Health Centre, Newmarket, ON, Canada
| | - Arastoo Mokhtari
- Liver Transplant Program/Multi-Organ Transplant Program, University Health Network, Toronto General Hospital, Toronto, ON, Canada
| | - Mark Cattral
- Liver Transplant Program/Multi-Organ Transplant Program, University Health Network, Toronto General Hospital, Toronto, ON, Canada
| | - Anand Ghanekar
- Liver Transplant Program/Multi-Organ Transplant Program, University Health Network, Toronto General Hospital, Toronto, ON, Canada
| | - David Grant
- Liver Transplant Program/Multi-Organ Transplant Program, University Health Network, Toronto General Hospital, Toronto, ON, Canada
| | - Paul Greig
- Liver Transplant Program/Multi-Organ Transplant Program, University Health Network, Toronto General Hospital, Toronto, ON, Canada
| | - Gary Levy
- Liver Transplant Program/Multi-Organ Transplant Program, University Health Network, Toronto General Hospital, Toronto, ON, Canada
| | - Leslie Lilly
- Liver Transplant Program/Multi-Organ Transplant Program, University Health Network, Toronto General Hospital, Toronto, ON, Canada
| | - Ian McGilvray
- Liver Transplant Program/Multi-Organ Transplant Program, University Health Network, Toronto General Hospital, Toronto, ON, Canada
| | - Markus Selzner
- Liver Transplant Program/Multi-Organ Transplant Program, University Health Network, Toronto General Hospital, Toronto, ON, Canada
| | - Nazia Selzner
- Liver Transplant Program/Multi-Organ Transplant Program, University Health Network, Toronto General Hospital, Toronto, ON, Canada
| | - Eberhard L Renner
- Liver Transplant Program/Multi-Organ Transplant Program, University Health Network, Toronto General Hospital, Toronto, ON, Canada
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29
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Konidis SV, Hrycko A, Nightingale S, Renner E, Lilly L, Therapondos G, Fu A, Avitzur Y, Ng VL. Health-related quality of life in long-term survivors of paediatric liver transplantation. Paediatr Child Health 2015; 20:189-94. [PMID: 26038635 DOI: 10.1093/pch/20.4.189] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2015] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Long-term survival after paediatric liver transplantation is now the rule rather than the exception. Improving long-term outcomes after transplantation must consider not only the quantity but also the quality of life years restored. OBJECTIVES To characterize health-related quality of life (HRQOL) of LT recipients ≥15 years after paediatric LT. METHODS Recipients of a paediatric LT performed before December 1996 in a single institution with continuous follow-up at either the paediatric or adult partner centre were identified. Patients with severe developmental or neurological impairment were excluded. HRQOL was assessed using the Pediatric Quality of Life Inventory 4.0, the Medical Outcomes Study Short Form-36 version 2 and the Pediatric Liver Transplant Quality of Life Tool. RESULTS A total of 27 (67% male) subjects (mean age 24.3±6.7 years [median 23.2 years; range 16.6 to 40.3 years]) participated. The median age at transplant was 1.7 years (range 0.5 to 17.0 years). Seven (26%) participants underwent retransplantation. Seventeen (63%) participants were engaged in full-time work/study. Mean Short Form-36 version 2 scores included physical (49.6±11.1) and mental (45.3±12.5) subscale scores. The mean score for the disease-specific quality of life tool for paediatric liver transplant recipients (the Pediatric Liver Transplant Quality of Life Tool) was 64.70±15.2. The physical health of the young adults strongly correlated with level of involvement in work/study (r=0.803; P<0.05). CONCLUSIONS The self-reported HRQOL of participants <18 years of age was comparable with a standardized healthy population. In contrast, participants between 18 and 25 years of age had HRQOL scores that were more similar to a group with chronic illness. Participants engaged in full-time work/study experienced enhanced physical health.
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Affiliation(s)
- Stacey V Konidis
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto; ; Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario
| | - Alexander Hrycko
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto
| | - Scott Nightingale
- Department of Gastroenterology, John Hunter Children's Hospital, Newcastle, New South Wales, Australia
| | - Eberhard Renner
- Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario
| | - Leslie Lilly
- Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario
| | - George Therapondos
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, Ochsner Medical Center, New Orleans, Louisiana, USA
| | - Ann Fu
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto
| | - Yaron Avitzur
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto
| | - Vicky Lee Ng
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto
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30
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Goldaracena N, Spetzler VN, Marquez M, Selzner N, Cattral MS, Greig PD, Lilly L, McGilvray ID, Levy GA, Ghanekar A, Renner EL, Grant DR, Selzner M. Live donor liver transplantation: a valid alternative for critically ill patients suffering from acute liver failure. Am J Transplant 2015; 15:1591-7. [PMID: 25799890 DOI: 10.1111/ajt.13203] [Citation(s) in RCA: 25] [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] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 09/19/2014] [Accepted: 10/07/2014] [Indexed: 01/25/2023]
Abstract
We report the outcome of live donor liver transplantation (LDLT) for patients suffering from acute liver failure (ALF). From 2006 to 2013, all patients with ALF who received a LDLT (n = 7) at our institution were compared to all ALF patients receiving a deceased donor liver transplantation (DDLT = 26). Groups were comparable regarding pretransplant ICU stay (DDLT: 1 [0-7] vs. LDLT: 1 days [0-10]; p = 0.38), mechanical ventilation support (DDLT: 69% vs. LDLT: 57%; p = 0.66), inotropic drug requirement (DDLT: 27% vs. LDLT: 43%; p = 0.64) and dialysis (DDLT: 2 vs. LDLT: 0 patients; p = 1). Median evaluation time for live donors was 24 h (18-72 h). LDLT versus DDLT had similar incidence of overall postoperative complications (31% vs. 43%; p = 0.66). No difference was detected between LDLT and DDLT patients regarding 1- (DDLT: 92% vs. LDLT: 86%), 3- (DDLT: 92% vs. LDLT: 86%), and 5- (DDLT: 92% vs. LDLT: 86%) year graft and patient survival (p = 0.63). No severe donor complication (Dindo-Clavien ≥3 b) occurred after live liver donation. ALF is a severe disease with high mortality on liver transplant waiting lists worldwide. Therefore, LDLT is an attractive option since live donor work-up can be expedited and liver transplantation can be performed within 24 h with excellent short- and long-term outcomes.
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Affiliation(s)
- N Goldaracena
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - V N Spetzler
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - M Marquez
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - N Selzner
- Department of Medicine, Toronto General Hospital, Toronto, ON, Canada
| | - M S Cattral
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - P D Greig
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - L Lilly
- Department of Medicine, Toronto General Hospital, Toronto, ON, Canada
| | - I D McGilvray
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - G A Levy
- Department of Medicine, Toronto General Hospital, Toronto, ON, Canada
| | - A Ghanekar
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - E L Renner
- Department of Medicine, Toronto General Hospital, Toronto, ON, Canada
| | - D R Grant
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - M Selzner
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, ON, Canada
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31
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Sapisochin G, Goldaracena N, Astete S, Laurence JM, Davidson D, Rafael E, Castells L, Sandroussi C, Bilbao I, Dopazo C, Grant DR, Lázaro JL, Caralt M, Ghanekar A, McGilvray ID, Lilly L, Cattral MS, Selzner M, Charco R, Greig PD. Benefit of Treating Hepatocellular Carcinoma Recurrence after Liver Transplantation and Analysis of Prognostic Factors for Survival in a Large Euro-American Series. Ann Surg Oncol 2014; 22:2286-94. [PMID: 25472651 DOI: 10.1245/s10434-014-4273-6] [Citation(s) in RCA: 111] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Indexed: 02/06/2023]
Abstract
PURPOSE To identify prognostic factors after hepatocellular carcinoma (HCC) recurrence after liver transplantation (LT). METHODS We retrospectively reviewed the combined experience at Toronto General Hospital and Hospital Vall d'Hebron managing HCC recurrence after LT (n = 121) between 2000 and 2012. We analyzed prognostic factors by uni- and multi-variate analysis. Median follow-up from LT was 29.5 (range 2-129.4) months. Median follow-up from HCC recurrence was 12.2 (range 0.1-112.5) months. RESULTS At recurrence, 31.4 % were treated with curative-intent treatments (surgery or ablation), 42.1 % received palliative treatment, and 26.4 % received best supportive care. The 1-, 3-, and 5-year survivals, respectively, after HCC recurrence were 75, 60, and 31 %, vs. 60, 19, and 12 %, vs. 52, 4, and 5 % (p < 0.001). By multivariate analysis, not being amenable to a curative-intent treatment [hazard ratio (HR) 4.7, 95 % confidence interval (CI) 2.7-8.3, p < 0.001], α-fetoprotein of ≥100 ng/mL at the time of HCC recurrence (HR 2.1, 95 % CI 1.3-2.3, p = 0.002) and early recurrence (<12 months) after LT (HR 1.6, 95 % CI 1.1-2.5, p = 0.03) were found to be poor prognosis factors. A prognostic score was devised on the basis of these three independent variables. Patients were divided into three groups, as follows: good prognosis, 0 points (n = 22); moderate prognosis, 1 or 2 points (n = 84); and poor prognosis, 3 points (n = 15). The 1-, 3-, and 5-year actuarial survival for each group was 91, 50, and 50 %, vs. 52, 7, and 2 %, vs. 13, 0, and 0 %, respectively (p < 0.001). CONCLUSIONS Patients with HCC recurrence after transplant amenable to curative-intent treatments can experience significant long-term survival (~50 % at 5 years), so aggressive management should be offered. Poor prognosis factors after recurrence are not being amenable to a curative-intent treatment, α-fetoprotein of ≥100 ng/mL, and early (<1 year) recurrence after LT.
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Affiliation(s)
- G Sapisochin
- Department of Surgery, Toronto General Hospital, University of Toronto, Toronto, Canada,
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Goldaracena N, Marquez M, Selzner N, Spetzler VN, Cattral MS, Greig PD, Lilly L, McGilvray ID, Levy GA, Ghanekar A, Renner EL, Grant DR, Selzner M. Living vs. deceased donor liver transplantation provides comparable recovery of renal function in patients with hepatorenal syndrome: a matched case-control study. Am J Transplant 2014; 14:2788-95. [PMID: 25277134 DOI: 10.1111/ajt.12975] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 07/22/2014] [Accepted: 08/04/2014] [Indexed: 01/25/2023]
Abstract
Outcomes of living versus deceased donor liver transplantation in patients with chronic liver disease and hepatorenal syndrome (HRS) was compared using a matched pair study design. Thirty patients with HRS receiving a live donor liver transplantation (LDLT) and 90 HRS patients receiving a full graft deceased donor liver transplantation (DDLT) were compared. LDLT versus DDLT of patients with HRS was associated with decreased peak aspartate aminotransferase levels (339 ± 214 vs. 935 ± 1253 U/L; p = 0.0001), and similar 7-day bilirubin (8.42 ± 7.89 vs. 6.95 ± 7.13 mg/dL; p = 0.35), and international normalized ratio levels (1.93 ± 0.62 vs. 1.78 ± 0.78; p = 0.314). LDLT vs. DDLT had a decreased intensive care unit (2 [1-39] vs. 4 [0-93] days; p = 0.004), and hospital stay (17 [4-313] vs. 26 [0-126] days; p = 0.016) and a similar incidence of overall postoperative complications (20% vs. 27%; p = 0.62). No difference was detected between LDLT and DDLT patients regarding graft survival at 1 (80% vs. 82%), at 3 (69% vs. 76%) and 5 years (65% vs. 76%) (p = 0.63), as well as patient survival at 1 (83% vs. 82%), 3 (72% vs. 77%) and 5 years (72% vs. 77%) (p = 0.93). The incidence of chronic kidney disease post-LT (10% vs. 6%; p = 0.4) was similar between both groups. LDLT results in identical long-term outcome when compared with DDLT in patients with HRS.
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Affiliation(s)
- N Goldaracena
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
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Fernandez-Ruiz M, Kumar D, Husain S, Lilly L, Renner E, Mazzulli T, Moussa G, Humar A. Utility of a Monitoring Strategy for Human Herpesviruses 6 and 7 Viremia in Liver Transplant Recipients: A Randomized Clinical Trial. Transplantation 2014. [DOI: 10.1097/00007890-201407151-02645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Guillaud O, Gurram KC, Puglia M, Lilly L, Adeyi O, Renner EL, Selzner N. Angiotensin blockade does not affect fibrosis progression in recurrent hepatitis C after liver transplantation. Transplant Proc 2014; 45:2331-6. [PMID: 23953545 DOI: 10.1016/j.transproceed.2013.01.067] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Accepted: 01/14/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Liver transplantation (LT) for hepatitis C virus (HCV)-related end-stage liver disease is impaired by universal disease recurrence and suboptimal response to antiviral therapy. Inhibition of angiotensin-II signalling by angiotensin-converting enzyme inhibitors (ACE-I) or angiotensin-II receptor blockers (ARB) decreases hepatic stellate cell activation in vitro and hepatic fibrogenesis in animal models. A single-center retrospective analysis suggested that angiotensin blockade (AB) inhibits fibrosis progression in recurrent HCV post-LT. This study assessed the effect of AB on fibrosis progression in an independent patient cohort. METHODS Chart review of all patients who underwent transplantation in our institution for HCV-related ESLD between January 2000 and February 2008 revealed 109 patients with ≥2 protocol liver biopsies and free of antiviral therapy post-LT up to the last biopsy analyzed; 27 of 109 patients were treated with ACE-I/ARB for ≥12 months, 82 were not. Fibrosis was staged using METAVIR. RESULTS Live-donor LT was more frequent in controls than in the AB group (25% vs 11%; P < .05). However, parameters known to affect outcome of recurrent HCV, including donor age, prevalence of diabetes, acute cellular rejection, and immunosuppression, were similar in both groups. Time between first and last biopsy (median, 23 months), stage of fibrosis, fibrosis progression rates (median 0.47 vs 0.45 unit/y; P = .46), and time to develop fibrosis stage ≥2 did not differ between groups. Results held true if deceased-donor LT were analyzed separately. CONCLUSION Our study does not support the contention of a previous report that use of AB reduces fibrosis progression in recurrent HCV post-LT.
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Affiliation(s)
- O Guillaud
- Multiorgan Transplant Program, and Department of Pathology, University Health Network, University of Toronto, Toronto, ON, Canada
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Aberer F, Lilly L, Mader JK, Pachatz J, Korsatko S, Dambso P, Pieber TR. PaQ, ein einfach anzuwendendes Insulinabgabegerät zur Basis/Bolustherapie für Patienten mit Typ 2 Diabetes. DIABETOL STOFFWECHS 2013. [DOI: 10.1055/s-0033-1341842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Ghanekar A, Kashfi A, Cattral M, Selzner N, McGilvray I, Selzner M, Renner E, Lilly L, Levy G, Grant D, Greig P. Routine induction therapy in living donor liver transplantation prevents rejection but may promote recurrence of hepatitis C. Transplant Proc 2012; 44:1351-6. [PMID: 22664014 DOI: 10.1016/j.transproceed.2012.01.117] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Accepted: 01/25/2012] [Indexed: 12/15/2022]
Abstract
BACKGROUND Routine induction therapy in living donor liver transplantation (LDLT) has not been well described. METHODS We reviewed outcomes of induction therapy with rabbit antithymocyte globulin (rATG) or basiliximab within 1 year of LDLT. RESULTS Between 2002 and 2007, 184 adults underwent LDLT and received induction therapy in addition to standard immunosuppression. Acute cellular rejection (ACR) developed in 17 of 130 patients (13.1%) who received rATG and 13 of 54 patients (24.1%) who received basiliximab (P = .066). The interval between transplantation and rejection as well as rejection severity was similar in patients who received rATG and those who received basiliximab. Hepatitis C (HCV) recurrence requiring initiation of antiviral therapy was more common in patients who received rATG compared with basiliximab (34.5% vs 8.7%; P = .021), and in those who received induction combined with tacrolimus as opposed to cyclosporine (38.5% vs 3.9%; P = .001). rATG and basiliximab were associated with excellent patient and graft survivals well as low rates of opportunistic infections and malignancies. CONCLUSION Induction with rATG or basiliximab was well tolerated and highly effective at preventing ACR within 1 year of LDLT, but may be associated with a higher risk of clinically significant HCV recurrence in some patients.
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Affiliation(s)
- A Ghanekar
- University of Toronto Liver Transplant Program, Toronto General Hospital, Toronto, Ontario, Canada.
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Hosseini-Moghaddam SM, Iran-Pour E, Rotstein C, Husain S, Lilly L, Renner E, Mazzulli T. Hepatitis C core Ag and its clinical applicability: Potential advantages and disadvantages for diagnosis and follow-up? Rev Med Virol 2011; 22:156-65. [DOI: 10.1002/rmv.717] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2011] [Revised: 09/18/2011] [Accepted: 09/19/2011] [Indexed: 12/20/2022]
Affiliation(s)
- SM Hosseini-Moghaddam
- Division of Infectious Diseases; University of Toronto, University Health Network, Transplant Infectious Diseases, Toronto General Hospital; Toronto ON Canada
- Urology and Nephrology Research Center (UNRC); Shahid Beheshti University of Medical Sciences; Tehran IR Iran
| | - E. Iran-Pour
- Islamic Azad University; Tehran Medical Branch; Tehran IR Iran
| | - C. Rotstein
- Division of Infectious Diseases; University of Toronto, University Health Network, Transplant Infectious Diseases, Toronto General Hospital; Toronto ON Canada
| | - S. Husain
- Division of Infectious Diseases; University of Toronto, University Health Network, Transplant Infectious Diseases, Toronto General Hospital; Toronto ON Canada
| | - L. Lilly
- Hepatology; University of Toronto, University Health Network, Transplant Hepatology, Toronto General Hospital; Toronto ON Canada
| | - E. Renner
- Hepatology; University of Toronto, University Health Network, Transplant Hepatology, Toronto General Hospital; Toronto ON Canada
| | - T. Mazzulli
- Virology, Department of Microbiology; University of Toronto, University Health Network, Mount Sinai Hospital; Toronto ON Canada
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Madill J, Arendt B, Aghdassi E, Chow C, Guindi M, Therapondos G, Lilly L, Allard J. Oxidative Stress and Nutritional Factors in Hepatitis C Virus–Positive Liver Recipients, Controls, and Hepatitis C Virus–Positive Nontransplant Patients. Transplant Proc 2010; 42:1744-9. [DOI: 10.1016/j.transproceed.2010.03.141] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2009] [Accepted: 03/10/2010] [Indexed: 01/25/2023]
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Madill J, Arendt BM, Aghdassi E, Therapondos G, Lilly L, Chow CW, Guindi M, Allard JP. Hepatic lipid peroxidation and antioxidant micronutrients in hepatitis virus C liver recipients with and without disease recurrence. Transplant Proc 2010; 41:3800-5. [PMID: 19917391 DOI: 10.1016/j.transproceed.2009.06.185] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2009] [Accepted: 06/24/2009] [Indexed: 12/31/2022]
Abstract
BACKGROUND Hepatitis C virus (HCV) reinfection after liver transplantation is universal and progresses to cirrhosis in 10% to 30% of patients. Several risk factors are associated with progression. Oxidative stress may be involved because it has a role in the pathogenesis of HCV. OBJECTIVE To determine whether HCV liver recipients with disease recurrence are more oxidatively stressed than those with no recurrence. METHODS Measurements were performed at 12 months posttransplantation, and in a subgroup of patients at 6 months. Liver lipid peroxidation (LPO), antioxidant potential, plasma vitamin E, retinol, and vitamin C were measured. Demographic data, pretransplantation viral load, anthropometry, and 3-day food records were also obtained. Data were log-transformed; analysis was performed using the independent t test, Pearson correlation, and multivariate regression analysis. RESULTS Recipients of HCV livers with recurrence (n = 21) had higher liver LPO (mean [SEM] micromoles of malondialdehyde per gram of liver tissue, 1.66 [0.28]) vs those with no recurrence (n = 16; 0.88 [0.13]) (P = .02). A significant relationship was found between liver LPO and HCV recurrence, and this significance continued when accounting for pretransplantation viral load and donor age. Six patients with recurrence and 11 with no recurrence also had measurements obtained at 6 months posttransplantation. Those with recurrence at 12 months had significantly higher hepatic LPO at 6 months (1.86 [0.62]) compared with those with no recurrence (0.75 [0.14]) (P = .04). CONCLUSIONS Recipients of HCV livers with recurrence are more oxidatively stressed at 6 and 12 months compared with those with no recurrence. Accounting for viral load and donor age, oxidative stress was independently associated with recurrence. More research is needed to confirm this association.
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Affiliation(s)
- J Madill
- Multi-Organ Transplant Department, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada.
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Gupta S, Castel H, Rao RV, Picard M, Lilly L, Faughnan ME, Pomier-Layrargues G. Improved survival after liver transplantation in patients with hepatopulmonary syndrome. Am J Transplant 2010; 10:354-63. [PMID: 19775311 DOI: 10.1111/j.1600-6143.2009.02822.x] [Citation(s) in RCA: 144] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Hepatopulmonary syndrome (HPS) is present in 10-32% of chronic liver disease patients, carries a poor prognosis and is treatable by liver transplantation (LT). Previous reports have shown high LT mortality in HPS and severe HPS (arterial oxygen (PaO(2)) < or =50 mmHg). We reviewed outcomes in HPS patients who received LT between 2002 and 2008 at two transplant centers supported by a dedicated HPS clinic. We assessed mortality, complications and gas exchange in 21 HPS patients (mean age 51 years, MELD score 14), including 11/21 (52%) with severe HPS and 5/21 (24%) with living donor LT (median follow-up 20.2 months after LT). Overall mortality was 1/21 (5%); mortality in severe HPS was 1/11 (9%). Peritransplant hypoxemic respiratory failure occurred in 5/21 (24%), biliary complications in 8/21 (38%) and bleeding or vascular complications in 6/21 (29%). Oxygenation improved in all 19 patients in whom PaO(2) or SaO(2) were recorded. PaO(2) increased from 52.2 +/- 13.2 to 90.3 +/- 11.5 mmHg (room air) (p < 0.0001) (12 patients); a higher baseline macroaggregated albumin shunt fraction predicted a lower rate of postoperative improvement (p = 0.045) (7 patients). Liver transplant survival in HPS and severe HPS was higher than previously demonstrated. Severity of HPS should not be the basis for transplant refusal.
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Affiliation(s)
- S Gupta
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
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Adcock L, Macleod C, Dubay D, Greig PD, Cattral MS, McGilvray I, Lilly L, Girgrah N, Renner EL, Selzner M, Selzner N, Kashfi A, Smith R, Holtzman S, Abbey S, Grant DR, Levy GA, Therapondos G. Adult living liver donors have excellent long-term medical outcomes: the University of Toronto liver transplant experience. Am J Transplant 2010; 10:364-71. [PMID: 20415904 DOI: 10.1111/j.1600-6143.2009.02950.x] [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] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Right lobe living donor liver transplantation is an effective treatment for selected individuals with end-stage liver disease. Although 1 year donor morbidity and mortality have been reported, little is known about outcomes beyond 1 year. Our objective was to analyze the outcomes of the first 202 consecutive donors performed at our center with a minimum follow-up of 12 months (range 12-96 months). All physical complications were prospectively recorded and categorized according to the modified Clavien classification system. Donors were seen by a dedicated family physician at 2 weeks, 1, 3 and 12 months postoperatively and yearly thereafter. The cohort included 108 males and 94 females (mean age 37.3 +/- 11.5 years). Donor survival was 100%. A total of 39.6% of donors experienced a medical complication during the first year after surgery (21 Grade 1, 27 Grade 2, 32 Grade 3). After 1 year, three donors experienced a medical complication (1 Grade 1, 1 Grade 2, 1 Grade 3). All donors returned to predonation employment or studies although four donors (2%) experienced a psychiatric complication. This prospective study suggests that living liver donation can be performed safely without any serious late medical complications and suggests that long-term follow-up may contribute to favorable donor outcomes.
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Affiliation(s)
- L Adcock
- Liver Transplant Program, Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
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DuBay D, Smith RJ, Qiu KG, Levy GA, Lilly L, Therapondos G. Sirolimus in liver transplant recipients with renal dysfunction offers no advantage over low-dose calcineurin inhibitor regimens. Liver Transpl 2008; 14:651-9. [PMID: 18433069 DOI: 10.1002/lt.21429] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [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] [Indexed: 12/12/2022]
Abstract
The purpose of this study is to review the clinical experience with sirolimus immunosuppression in liver transplant patients with calcineurin inhibitor-induced chronic renal insufficiency. The study design is a case-control retrospective series. Fifty-seven liver transplant patients with renal insufficiency that were started on sirolimus at greater than 90 days postoperatively and treated for more than 90 days were identified. A control group of 57 patients maintained on low-dose calcineurin inhibitors, matched for gender, year of transplant, and baseline creatinine clearance, was also identified. There were no significant differences in the absolute creatinine clearance values between the sirolimus and control groups from 6 months before sirolimus conversion to 12 months after sirolimus conversion. Patients exposed to calcineurin inhibitors for more than 5 years or those with an initial creatinine clearance of less than 30 mL/minute who were converted to sirolimus did worse than control patients maintained on low-dose calcineurin inhibitors. Progression to renal replacement therapy, episodes of acute and chronic rejection, and death were similar between the sirolimus and control groups. The overall prevalence of side effects was significantly higher in the sirolimus group compared with the control group, although these were generally tolerable in most patients. In conclusion, this study suggests that conversion to sirolimus in liver transplant patients with chronic renal insufficiency is associated with stabilization of renal function but confers no additional benefit to low-dose calcineurin inhibitor regimens and may in fact be disadvantageous in patients with a creatinine clearance of less than 30 mL/minute.
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Affiliation(s)
- Derek DuBay
- Liver Transplant Unit, Multiorgan Transplant Program, University of Toronto and Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
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Roy A, Kneteman N, Lilly L, Marotta P, Peltekian K, Scudamore C, Tchervenkov J. Tacrolimus as intervention in the treatment of hyperlipidemia after liver transplant. Transplantation 2006; 82:494-500. [PMID: 16926593 DOI: 10.1097/01.tp.0000231711.82193.41] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [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: 12/13/2022]
Abstract
BACKGROUND To measure the effect on serum lipids and other risk factors for cardiovascular disease, we converted the primary immunosuppression of dyslipidemic stable liver transplant recipients from cyclosporine A to tacrolimus. METHODS Patients underwent a four-month dietary stabilization period (American Heart Association Step II diet) and serum lipid samples were collected for analysis at a central laboratory. After conversion, dietary counseling and lipid analyses were performed over a six-month postconversion observation period. RESULTS Enrollment was terminated prematurely due to low patient recruitment rates. Thirteen patients were enrolled and provided postconversion data showing surprisingly strong results. At six months postconversion, total cholesterol (C) was reduced by a mean of 0.61 mmol/L (P=0.017), high density lipoprotein cholesterol (HDL-C) remained unchanged; the mean total C:HDL-C ratio was reduced by 0.87 (P=0.001). Low density lipoprotein cholesterol (LDL-C) reductions were not statistically significant, but we observed a significant and persistent decrease in apolipoprotein B (-0.15 g/L six months postconversion, P=0.031). No changes in homocysteine or in vitamins B6 and B12 were discerned, but although red cell folate remained stable, serum folate increased after conversion. We observed no rejection episodes or any other clinically notable events following conversion. CONCLUSIONS In this study, conversion from cyclosporine to tacrolimus provided a safe and well-tolerated alternative that reduced hyperlipidemia and other recognized cardiovascular risk factors.
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Affiliation(s)
- André Roy
- University of Montreal, CHUM-Hopital St-Luc, Montreal, Quebec, Canada.
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Schiff ER, Lai CL, Hadziyannis S, Neuhaus P, Terrault N, Colombo M, Tillmann HL, Samuel D, Zeuzem S, Lilly L, Rendina M, Villeneuve JP, Lama N, James C, Wulfsohn MS, Namini H, Westland C, Xiong S, Choy GS, Van Doren S, Fry J, Brosgart CL. Adefovir dipivoxil therapy for lamivudine-resistant hepatitis B in pre- and post-liver transplantation patients. Hepatology 2003; 38:1419-27. [PMID: 14647053 DOI: 10.1016/j.hep.2003.09.040] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Three-hundred and twenty-four patients were enrolled in an open-label, multicenter, international study in which pre- and post-liver transplantation (LT) patients with recurrent chronic hepatitis B (CHB) and evidence of lamivudine-resistant HBV were treated with adefovir dipivoxil 10 mg once daily. In the pre- and post-LT cohorts, 128 and 196 patients were treated for a median duration of 18.7 and 56.1 weeks, respectively. In patients who received 48 weeks of treatment, 81% of the pre-LT and 34% of the post-LT cohort achieved undetectable serum hepatitis B virus (HBV) DNA (Roche Amplicor Monitor polymerase chain reaction [PCR] assay lower limit of quantification [LLQ] < 400 copies/mL) with a median change in serum HBV DNA from baseline of -4.1 log(10) and -4.3 log(10) copies/mL, respectively. Serum alanine aminotransferase (ALT), albumin, bilirubin, and prothrombin time normalized in 76%, 81%, 50%, and 83% of pre-LT patients and 49%, 76%, 75%, and 20% of post-LT patients. The Child-Pugh-Turcotte (CPT) score improved in over 90% of patients in both cohorts. Genotypic analysis of 122 HBV baseline samples revealed that 98% of these patients had lamivudine-resistant mutant HBV. No adefovir resistance mutations were identified in patients after 48 weeks of therapy. One-year survival was 84% for pre-LT and 93% for post-LT patients (Kaplan-Meier analysis). Treatment-related adverse effects associated with adefovir dipivoxil in this setting were primarily mild to moderate in severity. In conclusion, 48 weeks of adefovir dipivoxil resulted in significant improvements in virologic, biochemical, and clinical parameters in CHB patients pre- and post-LT with lamivudine-resistant HBV.
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Affiliation(s)
- Eugene R Schiff
- Center for Liver Diseases, University of Miami, Miami, FL 33136, USA.
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Abstract
PURPOSE The purpose of this study was to determine the outcome of patients with inflammatory bowel disease who underwent liver transplantation for primary sclerosing cholangitis. METHODS All patients who underwent liver transplantation for primary sclerosing cholangitis at our institution were identified. A review of patients' hospital and office charts was performed; all patients were then contacted, and a detailed survey was administered by telephone. RESULTS Sixty-nine patients were identified. There were 53 males (76.8 percent) and 16 females, with a mean age of 45.3 (+/- 13.3) years. Fifty-two (75.4 percent) of the 69 patients had documented inflammatory bowel disease; of these, 40 had ulcerative colitis (76.9 percent), 11 had Crohn's disease, and 1 had indeterminate colitis. Thirty-one patients (60 percent) were diagnosed with inflammatory bowel disease before primary sclerosing cholangitis, with a mean interval to diagnosis of primary sclerosing cholangitis of 10.8 (+/- 10.3) years. Seven patients had both diagnoses made at roughly the same time, and 14 patients initially were diagnosed with primary sclerosing cholangitis and subsequently were found to have inflammatory bowel disease, with a mean interval of 5.2 (+/- 4.4) years; 5 (35.7 percent) of those 14 patients were only diagnosed with inflammatory bowel disease after their liver transplant. The mean time from diagnosis of primary sclerosing cholangitis to liver transplantation was 6.1 (+/- 4.9) years. Since their transplant, 30.8 percent of patients rated their colitis as worse, 38.5 percent felt it was unchanged, and 30.8 percent felt that their colitis was better controlled. Eight (15.4 percent) of the 52 patients with inflammatory bowel disease denied having any knowledge of an increased risk of colorectal neoplasia. Four patients have required colectomy for colorectal neoplasia after liver transplantation, at a mean of 4.7 years after transplantation. Of the patients with inflammatory bowel disease, 42 (80.1 percent) had at least 1 posttransplant surveillance colonoscopy. Eight of the remaining ten patients had a colectomy, leaving only two patients (3.8 percent) who had not been surveyed. However, only 32 (61.5 percent) of the patients with inflammatory bowel disease have been on a surveillance regimen that would approximately conform to current screening recommendations. CONCLUSIONS The activity of inflammatory bowel disease after transplantation is highly variable. Patients appeared to lack knowledge of their increased risk for colorectal neoplasia. Colorectal cancer is an uncommon but important complication in patients after liver transplantation for primary sclerosing cholangitis, and ongoing surveillance is required. Patients may require education to increase their awareness of the cancer risk and compliance with surveillance.
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Affiliation(s)
- A R MacLean
- Department of Surgery, Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada
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Greig P, Lilly L, Scudamore C, Erb S, Yoshida E, Kneteman N, Bain V, Ghent C, Marotta P, Grant D, Wall W, Tchervenkov J, Barkun J, Roy A, Marleau D, McAlister V, Peltekian K. Early steroid withdrawal after liver transplantation: the Canadian tacrolimus versus microemulsion cyclosporin A trial: 1-year follow-up. Liver Transpl 2003; 9:587-95. [PMID: 12783400 DOI: 10.1053/jlts.2003.50102] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Corticosteroid therapy contributes significant toxicity to liver transplantation. The safety and efficacy of early steroid withdrawal were determined in patients treated with either tacrolimus or microemulsion cyclosporin A (micro-CsA). The primary outcome was the proportion of patients who were steroid-free 1 year posttransplantation. From the seven Canadian adult liver transplant centers, 143 patients were randomly allocated oral treatment with either tacrolimus (n = 71) or micro-CsA (n = 72), together with corticosteroids and azathioprine. Eligibility criteria for steroid withdrawal included freedom from acute rejection for a minimum of 3 months, and prednisone </=0.15 mg/kg/d. In eligible patients, the daily steroid dose was reduced by 2.5 mg each month until complete discontinuation was achieved. At 1 year after transplantation, 75% of the tacrolimus patients and 63% of the micro-CsA patients were steroid-free (P =.20). Of all of the patients who became eligible for steroid withdrawal, steroid discontinuation was achieved in over 80%. One-year patient survival was 97% with tacrolimus and 89% with micro-CsA (P =.052). Graft survival was 97% and 86%, respectively (P =.017). The overall incidence of acute rejection during the first year was 35% with tacrolimus and 43% with micro-CsA (P =.26). There was no difference in survival, acute rejection, or rate of steroid withdrawal when adjusting for hepatitis C. All acute rejection episodes experienced during steroid withdrawal were steroid-responsive. Steroid-resistant rejection occurred in 5.6% of the tacrolimus and 9.7% of the micro-CsA patients. One patient, in the micro-CsA group, experienced refractory rejection. Chronic rejection was not observed in either group. The toxicity profiles were similar. Postoperative serum creatinine levels were similar, and dialysis was required in less than 10% of patients in each group. Infectious complications were similar in both groups. Neurotoxicity was a serious adverse event in 13% and 10% of patients receiving tacrolimus and micro-CsA, respectively. Early steroid withdrawal is safe and effective after liver transplantation using either tacrolimus plus azathioprine or micro-CsA plus azathioprine immunoprophylaxis.
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Asano TK, McLeod RS, Blitz M, Butts C, Kneteman N, Bigam D, Oosthuizen JFM, Phang PT, Gouthro D, Ravid A, Liu M, O'Connor BI, MacRae HM, Cohen Z, McLeod RS, Al-Obeed O, Penning J, Stern HS, Colquhoun P, Nogueras J, Dipasquale B, Petras J, Wexner S, Woodhouse S, Raval MJ, Heine JA, May GR, Bass S, Brown CJ, MacLean AR, Asano T, Cohen Z, MacRae HM, O'Connor BI, McLeod RS, Asano TK, Toma D, Stern HS, McLeod RS, Irshad K, Ghitulescu GA, Gordon PH, MacLean AR, Lilly L, Cohen Z, O'Connor B, McLeod RS, Ravid A, O'Connor BI, Liu M, MacRae HM, Cohen Z, McLeod RS, St Germaine RL, de Gara CJ, Fox R, Kenwell Z, Blitz S, Wong JT, Mc-Mulkin HM, Porter GA, Jayaraman S, Gray D, Burpee SE, Schlachta CM, Mamazza J, Pace K, Poulin EC, Freeman J, Tranqui P, Trottier D, Bodurtha A, Sarma A, Bheerappa N, Sastry RA, de Gara CJ, Hanson J, Hamilton S, Taylor MC, Haase E, Stevens J, Rigo V, Richards J, Bigam DL, Cheung PY, Burpee SE, Schlachta CM, Mamazza J, Pace K, Poulin EC, Grace DM, Gupta S, Sarma A, Bheerappa N, Radhakrishna P, Sastry RA, Malik S, Duffy P, Schulte P, Cameron R, Pace KT, Dyer S, Phan V, Poulin E, Schlachta C, Mamazza J, Stewart R, Honey RJ, Kanthan R, Kanthan SC, Jayaraman S, Aarts MA, Solomon MJ, McLeod RS, Ong S, Pitt D, Stephen W, Latulippe J, Girotti M, Bloom S, Pace K, Dyer S, Stewart R, Honey RJ, Poulin E, Schlachta C, Mamazza J, Furlan JC, Rosen IB, Asano TK, Haigh PI, McLeod RS, Al Saleh N, Taylor B, Karimuddin AA, Marschall J, McFadden A, Pollett WG, Dicks E, Tranqui P, Trottier D, Freeman J, Bodurtha A, Urbach DR, Bell CM, Austin PC, Cleary SP, Gyfe R, Greig P, Smith L, Mackenzie R, Strasberg S, Hanna S, Taylor B, Langer B, Gallinger S, Marschall J, Nechala P, Chibbar R, Colquhoun P, Zhou J, Lee TDG, Meneghetti AT, McKenna GJ, Owen D, Scudamore CH, McMaster RM, Chung SW, Aarts MA, Granton J, Cook DJ, Bohnen JMA, Marshall JC, Colquhoun P, Weiss E, Efron J, Nogueras J, Vernava A, Wexner S, Poulin EC, Schlachta CM, Burpee SE, Pace KT, Mamazza J, Rosen IB, Furlan JC, Charghi R, Schricker T, Backman S, Rouah F, Christou NV, Obayan A, Keith R, Juurlink BHJ, Skaro AI, Liwski RS, Zhou J, Lee TDG, Hirsch GM, Powers KA, Khadaroo RG, Papia G, Kapus A, Rotstein OD, Furlan JC, Rosen IB, Stratford AFC, George RL, VanManen L, Klassen DR, Feldman LS, Mayrand S, Mercier L, Stanbridge D, Fried GM, Nanji SA, Hancock WW, Anderson C, Shapiro AMJ, Butter A, Martins L, Taylor B, Ott MC, Rycroft K, Wall WJ, Burpee SE, Schlachta CM, Mamazza J, Pace K, Poulin EC, Taylor MC, Christou NV, Jarand J, Sylvestre JL, McLean APH, Behzadi A, Tan L, Unruh H, Brandt MG, Darling GE, Miller L, Seely AJE, Maziak DE, Gunning D, Do MT, Bukhari M, Shamji FM, Abdurahman A, Darling G, Ginsberg R, Johnston M, Waddell T, Keshavjee S, Cuccarolo G, Charyk-Stewart T, Inaba K, Malthaner R, Gray D, Girotti M, Grondin SC, Tutton SM, Sichlau MJ, Pozdol C, McDonough TJ, Masters GA, Ray DW, Liptay MJ. Abstracts of presentations to the Annual Meetings of the Canadian Society of Colon and Rectal Surgeons Canadian Association of General Surgeons Canadian Association of Thoracic Surgeons: Canadian Surgery Forum, London, Ont., Sept. 19 to 22, 2002. Can J Surg 2002; 45:3-26. [PMID: 37381180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023] Open
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - D Pitt
- Ottawa Hospital, University of Ottawa, Ottawa, Ont
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Abstract
Recombinant human bone morphogenetic protein-2 is an osteoinductive protein that plays a pivotal role in bone growth and regeneration. Several hundred studies were conducted in the past 7 years in numerous animal models to establish unequivocally the efficacy, safety, mechanism of action, pharmacokinetics, and surgical handling properties of recombinant human bone morphogenetic protein-2, building a solid foundation for clinical development programs. Pilot clinical trials have shown the feasibility and safety of recombinant human bone morphogenetic protein-2 treatment, and defined the effective dose for its use in open long bone fractures and for augmentation or preservation of the alveolar bone in the dental ridge. Prospective observational clinical studies helped define clinical efficacy end points, identify significant variables, and estimate appropriate population sample size for pivotal clinical trials. Pivotal clinical trials of recombinant human bone morphogenetic protein-2 are underway in patients with open tibial shaft fractures and in patients with a deficiency of the alveolar ridge.
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Abstract
BACKGROUND In the 1980s, primary biliary cirrhosis (PBC) patients were shown to benefit from transplantation when compared to a mathematical model. This study, using the same model, evaluates a cohort of patients who underwent transplantation in the late 1980s and early 1990s before and after the introduction of therapy with ursodeoxycholic acid (UDCA). METHODS All 73 PBC patients transplanted at the University of Toronto between 1985 and 1997 were included in the study. Actual survival posttransplantation, calculated with the Kaplan-Meier product-limit estimator, was compared to predicted survival without transplantation, as determined by the Mayo model. The effect of UDCA therapy on outcome was studied by dividing the cohort into those transplanted before and after 1992, the year in which UDCA use for PBC was introduced. RESULTS At 2 years posttransplant, predicted survival without transplant was 55% whereas actual survival was 79%. At 7 years posttransplant, these figures were 22% and 68%, respectively (P=3 x 10(-8)). There was a nonsignificant trend towards improved survival in those transplanted during the UDCA era compared to those transplanted in the pre-UDCA era. CONCLUSIONS Liver transplantation remains extremely beneficial for patients with end-stage PBC. There was no difference in outcome after liver transplantation in those transplanted during the UDCA era when compared to their pre-UDCA counterparts.
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Malkan G, Humar A, Lilly L, Greig PD, Grant D, Wanless IW, Cameron R, Levy GA, Cattrall MS. Natural history of recurrent hepatitis C after liver transplantation. Transplant Proc 2001; 33:1468. [PMID: 11267376 DOI: 10.1016/s0041-1345(00)02554-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- G Malkan
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
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