Multicultural Awareness and a Comprehensive Team Approach to Liver Transplantation: A Case Report

Patients being considered for a liver transplant undergo a rigorous evaluation process to identify the medical and psychosocial factors that may impact transplant success. The American Association for the Study of Liver Disease outlines recommendations for medical factors, but guidelines for psychosocial factors, such as multiculturalism, are less clear. The aim of this unique case study was to highlight the importance of multicultural awareness in the context of liver transplantation. More specifically, the report follows an American Indian man from initial diagnosis through psychological assessment and transplantation in order to illustrate the benefits of a comprehensive, multicultural team approach. Various components of multiculturalism are discussed, including the patient's ethnicity, intellectual functioning, socioeconomic status, and mental health history. Consideration of these factors by the patient's treatment team ultimately led to the patient's candidacy for transplant, as well as effective psychosocial support throughout the transplant process and recovery. Incorporation more specific psychosocial recommendations into national liver transplantation guidelines would likely improve the evaluation process and outcomes.

PNPLA3 gene predicts clinical recovery after sustained virological response in decompensated hepatitis C cirrhosis

Background

Patients with decompensated hepatitis C virus (HCV) cirrhosis experience various outcomes after sustained virological response (SVR), ranging from clinical recovery to further deterioration. We hypothesised that the genetic risk for steatosis, namely the polymorphisms rs738409 of Patatin-like Phospholipase Domain-Containing 3 (PNPLA3), rs58542926 of Transmembrane-6-Superfamily-2 (TM6SF2), and rs641738 of Membrane-bound O-acyltransferase Domain-Containing 7 (MBOAT7), is predictive of recovery.

Methods

We prospectively enrolled 56 patients with Child-Pugh (CPT) B/C cirrhosis who underwent antiviral therapy. The primary outcome was change in CPT score at 12, 24, and 48 weeks after SVR. We used a linear mixed-effects model for analysis.

Results

Forty-five patients (PNPLA3: 21 CC, 19 CG, 5 GG) survived to the first endpoint without liver transplantation. The mean change in CPT score at 12, 24, and 48 weeks was −1.57 (SE=0.30), –1.76 (SE=0.32), and −2.0 (SE=0.36), respectively, among the patients with the PNPLA3 CC genotype and −0.50 (SE=0.20), –0.41 (SE=0.25), and −0.24 (SE=0.27), respectively, among the other 24 patients. After adjustment for baseline characteristics, the PNPLA3 CG/GG genotypes were associated with a 1.29 (SE=0.30, p<0.0001) point higher CPT score. Most of the difference came from differences in hepatic encephalopathy and bilirubin. The results for rs58542926 and rs641738 were not significant.

Conclusion

The PNPLA3 CG/GG genotypes could identify a subgroup of patients with decompensated HCV cirrhosis that had suboptimal clinical recovery despite SVR. An understanding of the genetic factors that influence clinical outcomes will help target patients for liver transplant based on individual genetic risk factors and provide insight leading to new therapeutic approaches.