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Hasan M, Bidargaddi N, Muller K, Ramachandran J, Narayana S, Wigg AJ. Integrating smart phone applications in the management of cirrhotic patients: A scoping review. JGH Open 2023; 7:826-831. [PMID: 38162857 PMCID: PMC10757474 DOI: 10.1002/jgh3.13021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 10/27/2023] [Accepted: 12/01/2023] [Indexed: 01/03/2024]
Abstract
Background and Aim Chronic liver disease and cirrhosis is a significant cause of healthcare utilization and patient morbidity and mortality worldwide. Smartphone applications have high uptake in most communities and therefore have great potential to provide remote support solutions to this patient population. The aim of this scoping review was therefore to provide a comprehensive overview using narrative synthesis on the use of smartphone-application-based digital interventions in cirrhotic populations. Materials and Methods PRISMA guidelines were followed, with two independent researchers identifying 10 relevant studies. Patients studied were predominantly those with decompensated cirrhosis, and hepatic encephalopathy was the most common complication studied. Results Smartphones were the most common platform used, but training periods, prior to commencement of the study, were rarely offered. Patient engagement rates with the technology were reported only in three studies, but all reported high (>50%) rates of engagement. Only one study examined the clinical effects of their digital intervention, with a 38% reduction in readmission rate reported. Conclusion Overall, the use of smartphone apps in cirrhosis is in an early phase of development and evaluation but preliminary studies suggest significant potential as an adjunct to routine medical care. Further high-quality studies of well-designed digital interventions are needed to advance this promising early experience.
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Affiliation(s)
- Mohamed Hasan
- Hepatology and Liver Transplantation Medicine UnitSouthern Adelaide Local Health NetworkBedford ParkSouth AustraliaAustralia
| | - Niranjan Bidargaddi
- College of Medicine and Public HealthFlinders University of South AustraliaBedford ParkSouth AustraliaAustralia
| | - Kate Muller
- Hepatology and Liver Transplantation Medicine UnitSouthern Adelaide Local Health NetworkBedford ParkSouth AustraliaAustralia
- College of Medicine and Public HealthFlinders University of South AustraliaBedford ParkSouth AustraliaAustralia
| | - Jeyamani Ramachandran
- Hepatology and Liver Transplantation Medicine UnitSouthern Adelaide Local Health NetworkBedford ParkSouth AustraliaAustralia
- College of Medicine and Public HealthFlinders University of South AustraliaBedford ParkSouth AustraliaAustralia
| | - Sumudu Narayana
- Hepatology and Liver Transplantation Medicine UnitSouthern Adelaide Local Health NetworkBedford ParkSouth AustraliaAustralia
| | - Alan J Wigg
- Hepatology and Liver Transplantation Medicine UnitSouthern Adelaide Local Health NetworkBedford ParkSouth AustraliaAustralia
- College of Medicine and Public HealthFlinders University of South AustraliaBedford ParkSouth AustraliaAustralia
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2
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Kimber JS, Woodman RJ, Narayana SK, John L, Ramachandran J, Schembri D, Chen JWC, Muller KR, Wigg AJ. Association of physiological reserve measures with adverse outcomes following liver transplantation. JGH Open 2022; 6:132-138. [PMID: 35155823 PMCID: PMC8829098 DOI: 10.1002/jgh3.12702] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 11/28/2021] [Accepted: 12/08/2021] [Indexed: 11/20/2022]
Abstract
Background and Aim The comparative utility of physiological reserve measures in predicting important clinical outcomes following liver transplantation (LT) requires further study. The aim of this work was therefore to compare the utility of physiological reserve measures in predicting early adverse clinical outcomes post‐LT. Methods A single‐center, retrospective cohort study of LT patients consecutively recruited between 1 January 2015, and 31 August 2020. Outcomes measured were sepsis and death within 12 months of LT, hospital length of stay (LOS), and intensive care LOS. Physiological reserve measures were handgrip strength, mid‐arm muscle circumference, and cardiopulmonary exercise testing (CPET) measures. Analysis was performed using univariate and multivariate logistic regression for sepsis and death, and univariate and multivariate Cox regression for hospital and intensive care LOS. Results Data were obtained for 109 subjects. Patients were predominantly (64%) male with a median (interquartile range [IQR]) age of 57 (49–63) and median (IQR) Model for End‐Stage Liver Disease score of 16 (11–21). In multivariate analysis, the odds of sepsis were lower in patients in the highest versus lowest tertile (odds ratio = 0.004; 95% confidence interval [CI] 0.00–0.13; P = 0.002). Hospital LOS was linearly associated with handgrip strength (hazard ratio [HR] = 1.03; 95% CI 1.00–1.06; P = 0.03) in multivariate analysis. Intensive care LOS was associated with peak VO2 (HR 1.83; 95% CI 1.06–3.16; P = 0.03) and VE/VCO2 slope (HR 0.71; 95% CI 0.58–0.88; P = 0.002) in multivariate analysis. Conclusion Handgrip strength and CPET both identify candidates at high risk of adverse outcomes after LT.
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Affiliation(s)
- James S Kimber
- Faculty of Health and Medical Sciences University of Adelaide Adelaide South Australia Australia
| | - Richard J Woodman
- College of Medicine and Public Health Flinders University of South Australia Adelaide South Australia Australia
| | - Sumudu K Narayana
- Hepatology and Liver Transplant Unit Flinders Medical Centre Adelaide South Australia Australia
| | - Libby John
- South Australian Liver Transplant Unit Flinders Medical Centre Adelaide South Australia Australia
| | - Jeyamani Ramachandran
- College of Medicine and Public Health Flinders University of South Australia Adelaide South Australia Australia
- Hepatology and Liver Transplant Unit Flinders Medical Centre Adelaide South Australia Australia
- South Australian Liver Transplant Unit Flinders Medical Centre Adelaide South Australia Australia
| | - David Schembri
- Respiratory Function Unit Flinders Medical Centre Adelaide South Australia Australia
| | - John W C Chen
- Hepatology and Liver Transplant Unit Flinders Medical Centre Adelaide South Australia Australia
| | - Kate R Muller
- College of Medicine and Public Health Flinders University of South Australia Adelaide South Australia Australia
- Hepatology and Liver Transplant Unit Flinders Medical Centre Adelaide South Australia Australia
- South Australian Liver Transplant Unit Flinders Medical Centre Adelaide South Australia Australia
| | - Alan J Wigg
- College of Medicine and Public Health Flinders University of South Australia Adelaide South Australia Australia
- Hepatology and Liver Transplant Unit Flinders Medical Centre Adelaide South Australia Australia
- South Australian Liver Transplant Unit Flinders Medical Centre Adelaide South Australia Australia
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3
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Wigg AJ, Narayana SK, Hartel G, Medlin L, Pratt G, Powell EE, Clark P, Davies J, Campbell K, Toombs M, Larkin M, Valery PC. Hepatocellular carcinoma amongst Aboriginal and Torres Strait Islander peoples of Australia. EClinicalMedicine 2021; 36:100919. [PMID: 34142069 PMCID: PMC8187829 DOI: 10.1016/j.eclinm.2021.100919] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 04/25/2021] [Accepted: 05/06/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Liver disease and hepatocellular carcinoma (HCC) are important contributors to the mortality gap between Indigenous and non-Indigenous Australians. However, there is a lack of population based high quality data assessing the differences in HCC epidemiology and outcomes according to Indigenous status. The aim of this study was therefore to perform a large epidemiological study of HCC investigating differences between Indigenous and non-Indigenous Australians with HCC. METHODS Study design was a retrospective cohort study. Data linkage methodology was used to link data from cancer registries with hospital separation summaries across three Australian jurisdictions during 2000-2017. Cumulative survival (Kaplan-Meier) and the differences in survival (Multivariable Cox-regression) by Indigenous status were assessed. FINDINGS A total of 229 Indigenous and 3587 non-Indigenous HCC cases were included in the analyses. Significant epidemiological differences identified for Indigenous HCC cases included younger age at onset, higher proportion of females, higher rurality, lower socioeconomic status, and higher comorbidity burden (all p < 0.001). The distribution of cofactors was also significantly different for Indigenous Australians including higher prevalence of alcohol misuse, hepatitis B, and diabetes and more frequent presence of multiple HCC cofactors (all p < 0.001). Indigenous Australians received curative HCC therapies less frequently (6.6% vs. 14.5%, p < 0.001) and had poorer 5-year survival (10.0% vs. 17.3%, p < 0.001; unadjusted hazard ratio (HR) =1.42 96%CI 1.21-1.65) compared to non-Indigenous Australians. The strength of the association between indigenous status and survival was weaker and statistically non-significant after adjusting for rurality, comorbidity burden and lack of curative therapy (adjusted-HR=1.20 95%CI 0.97-1.47). INTERPRETATION Such data provide a call to action to help design and implement health literacy, liver management and HCC surveillance programs for Indigenous people to help close the liver cancer mortality gap.
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Affiliation(s)
- Alan J Wigg
- Hepatology and Liver Transplant Medicine Unit, Southern Adelaide Local Health Network, Adelaide, SA, Australia
- Flinders University of South Australia, Adelaide, South Australia, Australia
- Corresponding author.
| | - Sumudu K Narayana
- Hepatology and Liver Transplant Medicine Unit, Southern Adelaide Local Health Network, Adelaide, SA, Australia
- Flinders University of South Australia, Adelaide, South Australia, Australia
| | - Gunter Hartel
- QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
| | - Linda Medlin
- Aboriginal and Torres Strait Islander Health and Wellbeing, Central Queensland Hospital and Health Service, Queensland, Australia
| | - Greg Pratt
- QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
| | - Elizabeth E. Powell
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- Centre for Liver Disease Research, Translational Research Institute, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Paul Clark
- Mater Hospitals, Brisbane, Queensland, Australia
| | - Jane Davies
- Menzies School of Health Research, Royal Darwin Hospital, Darwin, The Northern Territory, Australia
- Royal Darwin Hospital, Darwin, The Northern Territory, Australia
| | - Kirsty Campbell
- Royal Darwin Hospital, Darwin, The Northern Territory, Australia
| | - Maree Toombs
- University of Queensland, Herston, Queensland, Australia
| | - Michael Larkin
- The Aboriginal Health Council of South Australia, Adelaide, Australia
| | - Patricia C Valery
- QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
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4
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Wigg AJ, Tashkent Y, Chen JW. Is Transesophageal Echocardiography Really Safe During Liver Transplant Surgery in Patients With High-Risk Varices? Liver Transpl 2021; 27:767-768. [PMID: 33665958 DOI: 10.1002/lt.26037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 02/26/2021] [Indexed: 01/13/2023]
Affiliation(s)
- Alan J Wigg
- South Australian Liver Transplant Unit, Flinders Medical Centre, Adelaide, Australia.,Hepatology and Liver Transplant Medicine Unit, Southern Adelaide Local Health Network, Adelaide, Australia.,College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia
| | - Yasmina Tashkent
- South Australian Liver Transplant Unit, Flinders Medical Centre, Adelaide, Australia.,Hepatology and Liver Transplant Medicine Unit, Southern Adelaide Local Health Network, Adelaide, Australia
| | - John W Chen
- South Australian Liver Transplant Unit, Flinders Medical Centre, Adelaide, Australia
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5
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Tandon B, Ramachandran J, Narayana S, Muller K, Pathi R, Wigg AJ. Outcomes of transjugular intrahepatic portosystemic shunt procedures: a 10-year experience. J Med Imaging Radiat Oncol 2021; 65:655-662. [PMID: 33687155 DOI: 10.1111/1754-9485.13168] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 04/24/2020] [Revised: 01/24/2021] [Accepted: 02/15/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Transjugular intrahepatic portosystemic shunt (TIPSS) is an effective modality in reducing portal pressure, and its current main indications are for the management of recurrent ascites and variceal bleeding. The demand and indications for TIPSS are growing. However, it is a complicated and technically demanding procedure with poorer outcomes associated with low volume centres. The aim of this study was, therefore, to review the outcomes of TIPSS at a 'low volume' single centre. Outcomes assessed included indications, safety, efficacy and survival. METHODS A retrospective study was undertaken of all patients who underwent a TIPSS procedure over 10 years at tertiary referral centre for complex liver disease and transplantation. Kaplan-Meier method was used to calculate actuarial survival and log-rank analysis was used to determine significant differences in survival. RESULTS Thirty-eight patients underwent the TIPSS procedure between January 2008 and December 2018. Technical, haemodynamic and clinical success were 95%, 92% and 92% respectively. Cumulative survival at one month, one year and five years were 86.8%, 72% and 44.7% respectively. Results achieved standards published in practice parameters to evaluate TIPSS safety and efficacy. CONCLUSION At a low volume centre, TIPSS usage was associated with high rates of technical, haemodynamic (HPVG reduction) and clinical success. Low volume should not be a contraindication to providing a TIPSS service; however, auditing outcomes and understanding specific institutional factors that influence quality are important requirements for low volume centres.
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Affiliation(s)
- Bhuwan Tandon
- Hepatology and Transplant Medicine Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Jeyamani Ramachandran
- Hepatology and Transplant Medicine Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Sumudu Narayana
- Hepatology and Transplant Medicine Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Kate Muller
- Hepatology and Transplant Medicine Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Ramon Pathi
- Department of Radiology, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Alan J Wigg
- Hepatology and Transplant Medicine Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
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6
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Jeffrey AW, Jeffrey GP, Stormon M, Thomas G, O'Loughlin E, Shun A, Hardikar W, Jones R, McCall J, Evans H, Starkey G, Hodgkinson P, Ee LC, Moore D, Mews C, McCaughan GW, Angus PW, Wigg AJ, Crawford M, Fawcett J. Outcomes for children after second liver transplantations are similar to those after first transplantations: a binational registry analysis. Med J Aust 2020; 213:464-470. [DOI: 10.5694/mja2.50802] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 07/10/2020] [Indexed: 11/17/2022]
Affiliation(s)
| | - Gary P Jeffrey
- Sir Charles Gairdner Hospital Perth WA
- The University of Western Australia Perth WA
| | - Michael Stormon
- Australian National Liver Transplantation Service Children's Hospital at Westmead Sydney NSW
- The University of Sydney Sydney NSW
| | - Gordon Thomas
- Australian National Liver Transplantation Service Children's Hospital at Westmead Sydney NSW
- The University of Sydney Sydney NSW
| | - Edward O'Loughlin
- Australian National Liver Transplantation Service Children's Hospital at Westmead Sydney NSW
- The University of Sydney Sydney NSW
| | - Albert Shun
- Australian National Liver Transplantation Service Children's Hospital at Westmead Sydney NSW
- The University of Sydney Sydney NSW
| | | | - Robert Jones
- Victorian Liver Transplant Unit Austin Hospital Melbourne VIC
- Victorian Liver Transplant Unit Royal Children's Hospital Melbourne VIC
| | - John McCall
- New Zealand Liver Transplant Unit Auckland City Hospital Auckland New Zealand
- Starship Children's Health Auckland New Zealand
| | - Helen Evans
- Starship Children's Health Auckland New Zealand
| | - Graham Starkey
- Victorian Liver Transplant Unit Austin Hospital Melbourne VIC
- Victorian Liver Transplant Unit Royal Children's Hospital Melbourne VIC
| | - Peter Hodgkinson
- Queensland Liver Transplantation Service Princess Alexandra Hospital Brisbane QLD
- The University of Queensland Brisbane QLD
| | - Looi C Ee
- Lady Cilento Children's Hospital Brisbane QLD
| | | | | | - Geoff W McCaughan
- Australian National Liver Transplantation Unit Royal Prince Alfred Hospital Sydney NSW
- Sydney Medical School , the University of Sydney Sydney NSW
| | - Peter W Angus
- Victorian Liver Transplant Unit Austin Hospital Melbourne VIC
- Victorian Liver Transplant Unit Royal Children's Hospital Melbourne VIC
| | - Alan J Wigg
- South Australian Liver Transplantation Service Flinders Medical Centre Adelaide SA
| | - Michael Crawford
- The University of Sydney Sydney NSW
- Australian National Liver Transplantation Unit Royal Prince Alfred Hospital Sydney NSW
| | - Jonathan Fawcett
- Queensland Liver Transplantation Service Princess Alexandra Hospital Brisbane QLD
- The University of Queensland Brisbane QLD
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7
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Ramachandran J, Woodman RJ, Muller KR, Wundke R, McCormick R, Kaambwa B, Wigg AJ. Validation of Knowledge Questionnaire for Patients With Liver Cirrhosis. Clin Gastroenterol Hepatol 2020; 18:1867-1873.e1. [PMID: 31809918 DOI: 10.1016/j.cgh.2019.11.045] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 11/13/2019] [Accepted: 11/22/2019] [Indexed: 01/21/2023]
Abstract
BACKGROUND & AIMS There is no validated questionnaire to assess disease knowledge and self-management in patients with liver cirrhosis. We developed and validated a Cirrhosis Knowledge Questionnaire (CKQ). METHODS We created a preliminary CKQ comprising 10 questions relevant to self-management of cirrhosis, based on publications and clinical experiences. The CKQ was given to a pilot sample of 17 patients with decompensated cirrhosis to assess its face validity. In consultation with experts, we developed a second version of CKQ, comprising 14 multiple choice questions, and administered it to 116 patients with cirrhosis participating in a Chronic Liver Failure Program. The dimensionality of the construct was assessed using exploratory factor analysis and internal consistency was assessed with Cronbach's alpha. Known-group validity of the resulting instrument was assessed by comparing the performance of the CKQ in 69 patients with decompensated cirrhosis (mean age, 62 ± 13 years; 109 responses), with (n = 42) vs without (n = 67) case management. RESULTS A 3-factor model with 7 questions related to variceal bleeding, ascites, and hepatic encephalopathy was considered the optimal dimensionality with excellent internal consistency (Cronbach's alpha = 0.82). The mean knowledge score was higher in patients with case management (5.6 ± 1.1) than in patients without case management (4.3 ± 2.1) (P = .002). CONCLUSIONS We developed and validated a questionnaire with 7 questions on ascites, variceal bleeding, and hepatic encephalopathy to assess knowledge and self-management in patients with liver cirrhosis. Studies are needed to confirm its dimensionality and assess association of scores with patient outcomes.
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Affiliation(s)
- Jeyamani Ramachandran
- Hepatology and Liver Transplant Unit, Flinders Medical Centre, Adelaide, South Australia, Australia; College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.
| | - Richard J Woodman
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Kate R Muller
- Hepatology and Liver Transplant Unit, Flinders Medical Centre, Adelaide, South Australia, Australia; College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Rachel Wundke
- Hepatology and Liver Transplant Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Rosemary McCormick
- Hepatology and Liver Transplant Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Billingsley Kaambwa
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Alan J Wigg
- Hepatology and Liver Transplant Unit, Flinders Medical Centre, Adelaide, South Australia, Australia; College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
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8
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Marinelli T, Anagnostou N, Daniel S, Wigg AJ, Teh J. Very early-onset of Cryptococcus neoformans disease following liver transplantation: Report of two cases and a review of the literature. Transpl Infect Dis 2019; 22:e13227. [PMID: 31785187 DOI: 10.1111/tid.13227] [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: 08/19/2019] [Revised: 11/10/2019] [Accepted: 11/24/2019] [Indexed: 01/14/2023]
Abstract
Cryptococcosis is the third most common invasive fungal infection following solid organ transplantation, and mortality is high. Most cases occur late and are due to reactivation of latent infection; however, very early reactivation and donor-derived transmission can occur. Routine screening pre-transplant and antifungal prophylaxis for cryptococcosis post-transplant in solid organ transplantation are not standard practice. We present two cases of very early-onset Cryptococcus neoformans disease following liver transplantation to highlight the need to consider individualized pre-transplant screening and be aware that reactivation of Cryptococcosis neoformans can occur in the immediate post-transplant period.
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Affiliation(s)
- Tina Marinelli
- Department of Infectious Diseases, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Nicholas Anagnostou
- Department of Infectious Diseases, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Santhosh Daniel
- Department of Infectious Diseases, Flinders Medical Centre, Bedford Park, South Australia, Australia.,College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Alan J Wigg
- College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia.,Hepatology and Transplantation Unit, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Joanne Teh
- Department of Infectious Diseases, Flinders Medical Centre, Bedford Park, South Australia, Australia
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9
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Barnes A, Woodman RJ, Kleinig P, Briffa M, To T, Wigg AJ. Early palliative care referral in patients with end stage liver disease is associated with reduced resource utilisation. J Gastroenterol Hepatol 2019; 35:840-845. [PMID: 31613397 DOI: 10.1111/jgh.14877] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 09/14/2019] [Accepted: 09/17/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIMS Palliative care referral for end stage liver disease (ESLD) is uncommon and usually occurs late. We aimed to review the rate of early palliative care referral (EPCR) in ESLD patients, its associations, and its impacts on resource utilisation and survival. METHODS A retrospective review of all patients with ESLD admitted to a single hepatology unit between 2013 and 2016. Inclusion criteria for study entry were at least two admissions for decompensated liver disease within a six month period and not eligible for liver transplantation. The EPCR group was defined as those patients who received palliative care referral at least 30 days prior to mortality. RESULTS 74 patients were included in the study. EPCR rate was 19%. On multivariate analysis EPCR was associated with hepatocellular carcinoma (OR 4.47, 95% CI 1.02-19.5, p=0.047), and negatively associated with alcoholic liver disease (OR 0.16, 95% CI 0.032-0.88 p=0.035). There was no difference in survival based on EPCR status. Hospitalization costs were lower in the EPCR group (p=0.027). There was also a significantly lower number of endoscopies (p=0.009), and blood transfusions (p=0.001) in the EPCR group. EPCR was also associated with higher rates of outpatient palliative care and advanced care planning. CONCLUSIONS EPCR in ESLD was uncommon and associated with hepatocellular carcinoma and lack of alcoholic liver disease. EPCR was associated with decreased resource utilisation and further high quality studies are required to confirm the benefits of EPCR in ESLD.
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Affiliation(s)
- Alex Barnes
- Hepatology and Liver Transplantation Medicine Unit, Flinders Medical Centre, Adelaide, Australia
| | - Richard J Woodman
- Department of Epidemiliology and Biostatistics, College of Medicine and Public Health, Flinders University of South Australia, Australia
| | - Paul Kleinig
- Southern Adelaide Palliative Care Services, Australia
| | | | - Timothy To
- Southern Adelaide Palliative Care Services, Australia
| | - Alan J Wigg
- Hepatology and Liver Transplantation Medicine Unit, Flinders Medical Centre, Adelaide, Australia
- College of Medicine and Public Health, Flinders University of South Australia, Australia
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10
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Ramachandran J, Hossain M, Hrycek C, Tse E, Muller KR, Woodman RJ, Kaambwa B, Wigg AJ. Coordinated care for patients with cirrhosis: fewer liver-related emergency admissions and improved survival. Med J Aust 2019; 209:301-305. [PMID: 30257622 DOI: 10.5694/mja17.01164] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [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: 11/27/2017] [Accepted: 05/03/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To compare the incidence of liver-related emergency admissions and survival of patients after hospitalisation for decompensated cirrhosis at two major hospitals, one applying a coordinated chronic disease management model (U1), the other standard care (U2); to examine predictors of mortality for these patients. DESIGN Retrospective observational cohort study. SETTING Two major tertiary hospitals in an Australian capital city. PARTICIPANTS Patients admitted with a diagnosis of decompensated cirrhosis during October 2013 - October 2014, identified on the basis of International Classification of Diseases (ICD-10) codes. MAIN OUTCOME MEASURES Incident rates of liver-related emergency admissions; survival (to 3 years). RESULTS Sixty-nine patients from U1 and 54 from U2 were eligible for inclusion; the median follow-up time was 530 days (range, 21-1105 days). The incidence of liver-related emergency admissions was lower for U1 (mean, 1.14 admissions per person-year; 95% CI, 0.95-1.36) than for U2 (mean, 1.55 admissions per person-year; 95% CI, 1.28-1.85; adjusted incidence rate ratio [U1 v U2], 0.52; 95% CI, 0.28-0.98; P = 0.042). The adjusted probabilities of transplantation-free survival at 3 years were 67.7% (U1) and 37.2% (U2) (P = 0.009). Independent predictors of reduced transplantation-free free survival were Charlson comorbidity index score (per point: hazard ratio [HR], 1.27; 95% CI, 1.05-1.54, P = 0.014), liver-related emergency admissions within 90 days of discharge (HR, 3.60; 95% CI, 1.87-6.92; P < 0.001), and unit (U2 v U1: HR, 2.54, 95% CI, 1.26-5.09; P = 0.009). CONCLUSIONS A coordinated care model for managing patients with decompensated cirrhosis was associated with improved survival and fewer liver-related emergency admissions than standard care.
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Affiliation(s)
| | | | | | | | | | - Richard J Woodman
- Flinders Centre for Epidemiology and Biostatistics, Flinders University, Adelaide, SA
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11
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Wigg AJ, Wundke R, McCormick R, Muller KR, Ramachandran J, Narayana SK, Woodman RJ. Efficacy of High-Dose, Rapid, Hepatitis A and B Vaccination Schedules in Patients With Cirrhosis. Clin Gastroenterol Hepatol 2019; 17:1210-1212.e1. [PMID: 30144521 DOI: 10.1016/j.cgh.2018.08.047] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 06/01/2018] [Revised: 08/11/2018] [Accepted: 08/16/2018] [Indexed: 02/07/2023]
Abstract
Patients with cirrhosis have increased morbidity from hepatitis A virus (HAV) and hepatitis B virus (HBV) infections, and vaccination against these infections is an important standard of care.1,2 However, vaccination in patients with cirrhosis is hindered by immune dysfunction and there is limited high-quality literature available. The aim of this work therefore was to compare immune responses of standard dose (SD) with high-dose accelerated (HDA) vaccination in cirrhotic patients.
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Affiliation(s)
- Alan J Wigg
- Hepatology and Liver Transplant Medicine Unit, Flinders Medical Centre, Adelaide, Australia.
| | - Rachel Wundke
- Hepatology and Liver Transplant Medicine Unit, Flinders Medical Centre, Adelaide, Australia
| | - Rosemary McCormick
- Hepatology and Liver Transplant Medicine Unit, Flinders Medical Centre, Adelaide, Australia
| | - Kate R Muller
- Hepatology and Liver Transplant Medicine Unit, Flinders Medical Centre, Adelaide, Australia
| | - Jeyamani Ramachandran
- Hepatology and Liver Transplant Medicine Unit, Flinders Medical Centre, Adelaide, Australia
| | - Sumudu K Narayana
- Hepatology and Liver Transplant Medicine Unit, Flinders Medical Centre, Adelaide, Australia
| | - Richard J Woodman
- Flinders Centre for Epidemiology and Biostatistics, Flinders University, Adelaide, Australia
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12
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Wigg AJ, Narayana SK, Anwar S, Ramachandran J, Muller K, Chen JW, John L, Hissaria P, Kaambwa B, Woodman RJ. High rates of indeterminate interferon‐gamma release assays for the diagnosis of latent tuberculosis infection in liver transplantation candidates. Transpl Infect Dis 2019; 21:e13087. [DOI: 10.1111/tid.13087] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 02/17/2019] [Accepted: 03/17/2019] [Indexed: 12/31/2022]
Affiliation(s)
- Alan J. Wigg
- Hepatology and Liver Transplantation Medicine Unit Flinders Medical Centre Bedford Park SA Australia
- South Australian Liver Transplantation Unit Flinders Medical Centre Bedford Park SA Australia
| | - Sumudu K. Narayana
- Hepatology and Liver Transplantation Medicine Unit Flinders Medical Centre Bedford Park SA Australia
| | - Shahzaib Anwar
- Hepatology and Liver Transplantation Medicine Unit Flinders Medical Centre Bedford Park SA Australia
- South Australian Liver Transplantation Unit Flinders Medical Centre Bedford Park SA Australia
| | - Jeyamani Ramachandran
- Hepatology and Liver Transplantation Medicine Unit Flinders Medical Centre Bedford Park SA Australia
| | - Kate Muller
- Hepatology and Liver Transplantation Medicine Unit Flinders Medical Centre Bedford Park SA Australia
- South Australian Liver Transplantation Unit Flinders Medical Centre Bedford Park SA Australia
| | - John W. Chen
- South Australian Liver Transplantation Unit Flinders Medical Centre Bedford Park SA Australia
| | - Libby John
- Hepatology and Liver Transplantation Medicine Unit Flinders Medical Centre Bedford Park SA Australia
- South Australian Liver Transplantation Unit Flinders Medical Centre Bedford Park SA Australia
| | | | - Billingsley Kaambwa
- Health Economics Unit, College of Medicine and Public Health Flinders University of South Australia Adelaide SA Australia
| | - Richard J. Woodman
- Flinders Centre for Epidemiology and Biostatistics, College of Medicine and Public Health Flinders University of South Australia Adelaide SA Australia
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Wigg AJ, Narayana SK, Le H, Iankov I, Chinnaratha MA, Tse E, Chen JW, Gowda R. Stereotactic body radiation therapy for early hepatocellular carcinoma: a retrospective analysis of the South Australian experience. ANZ J Surg 2019; 89:1138-1143. [PMID: 30983104 DOI: 10.1111/ans.15130] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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: 11/23/2018] [Revised: 01/11/2019] [Accepted: 01/15/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Stereotactic body radiation therapy (SBRT) is an emerging treatment option for liver tumours unsuitable for established curative treatment such as ablation or surgery. The aim of the study is to evaluate the efficacy and safety of SBRT in the treatment of small hepatocellular carcinoma (HCC) in South Australia. METHODS From 2014 to 2018, 13 HCC patients were treated with SBRT. Eligibility criteria for SBRT included: unsuitable for standard curative therapies (resection or percutaneous ablation), lack of complete response to prior transarterial chemoembolization, Child-Pugh classification ≤B7, tumours ≤5 cm and minimum of up to 6 months follow-up post-SBRT. The prescribed radiation dose was determined by liver function with doses ranging from 40 to 45 Gy in three or five fractions. Records for all patients were reviewed, and treatment response was scored according to the modified response evaluation criteria in solid tumours. Toxicity was graded according to the Common Terminology Criteria for Adverse Events version 4.0. RESULTS The median follow-up time was 22.7 months, and the median tumour size was 40 mm. The 1 year local control was 92.3%, recurrence-free survival was 67.7% and overall survival was 86.4% at end of study. Three patients underwent liver transplant. No grade ≥3 non-haematological toxicities were observed. One patient experienced acute grade ≥3 haematological toxicity. CONCLUSION SBRT is a safe, effective and non-invasive alternative treatment option for patients with small HCCs, unsuitable for standard, evidence-based therapies and lacking complete response to transarterial chemoembolization. Randomized controlled trials are required to further investigate the role of SBRT in HCC.
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Affiliation(s)
- Alan J Wigg
- Hepatology and Liver Transplantation Medicine Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Sumudu K Narayana
- Hepatology and Liver Transplantation Medicine Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Hien Le
- Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Ivan Iankov
- Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Mohamed A Chinnaratha
- Department of Gastroenterology and Hepatology, Lyell McEwin Hospital, Adelaide, South Australia, Australia
| | - Edmund Tse
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - John W Chen
- South Australian Liver Transplant Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Raghu Gowda
- Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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14
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Hall SAL, Shaikh A, Teh K, Tantiongco M, Coghlan D, Karapetis CS, Chinnaratha MA, Woodman R, Muller KR, Wigg AJ. Hepatitis B screening before rituximab therapy: a multicentre South Australian study of adherence. Intern Med J 2019; 48:936-943. [PMID: 29345413 DOI: 10.1111/imj.13740] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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: 07/28/2017] [Revised: 12/18/2017] [Accepted: 12/19/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND International guidelines recommend screening for hepatitis B virus (HBV) infection prior to administration of rituximab, due to high risk of HBV reactivation in at-risk patients. AIMS To determine: (i) adherence to the South Australian (SA) protocol for HBV screening; (ii) HBV prevalence in patients receiving rituximab; and (iii) outcomes of patients at risk of HBV reactivation. METHODS All patients commenced on rituximab at the six major SA public hospitals during a 12-month period were included in the study. Adherence was assessed by documentation of both hepatitis B surface antigen (HBsAg) and hepatitis B core antibody (HBcAb) prior to initiation of rituximab. Patients were observed for a minimum of 6 months following rituximab initiation. RESULTS Four hundred and thirty eight patients were included in the study. The main indication for rituximab therapy was haematological malignancy (76.0%). Two hundred and nine (47.7%) failed to receive appropriate HBV screening, 86 (19.6%) had neither HBsAg nor HBcAb performed, and 119 (27.2%) had only HBsAg performed. The identified prevalence of at-risk cases (either HBsAg- or HBcAb-positive) within the study population was 4.6% (20/438 cases). One case of HBV reactivation was identified, but none led to acute liver failure, transplantation or death. CONCLUSIONS Poor adherence to HBV screening protocols suggests the need for targeted clinician education and system redesign. While the rate of reactivation was low, the prevalence of at-risk patients in this population was high and justifies further initiatives to increase adherence rates to HBV screening pre-rituximab.
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Affiliation(s)
- Samuel A L Hall
- Hepatology and Liver Transplant Medicine Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Abdul Shaikh
- Department of Medicine, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Kailin Teh
- Department of Pharmacy, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Mahsa Tantiongco
- Department of Pharmacy, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Douglas Coghlan
- Department of Haematology, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Chris S Karapetis
- Department of Medical Oncology Flinders Medical Centre, Flinders Centre for Innovation and Cancer, Flinders University, Adelaide, South Australia, Australia
| | - Mohammad A Chinnaratha
- Department of Gastroenterology, Lyell McEwin Hospital, Adelaide, South Australia, Australia
| | - Richard Woodman
- Centre for Epidemiology and Biostatistics, Flinders University, Adelaide, South Australia, Australia
| | - Kate R Muller
- Hepatology and Liver Transplant Medicine Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Alan J Wigg
- Hepatology and Liver Transplant Medicine Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
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Chinnaratha MA, Campbell K, Mathias R, McCormick RJ, Woodman RJ, Wigg AJ. Improved Survival of Hepatocellular Carcinoma Patients Diagnosed with a Dedicated Screening Programme-a Propensity Score Adjusted Analysis. J Gastrointest Cancer 2018; 50:888-893. [PMID: 30345486 DOI: 10.1007/s12029-018-0171-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
AIM To assess the overall survival (OS) in those with hepatocellular carcinoma (HCC) diagnosed within a programmatic, centrally co-ordinated, regional screening programme. METHODS A retrospective cohort analysis of consecutive HCC patients diagnosed between 2004 and 2013. Patients were followed up till death or end of study period (30 April 2015). A dedicated screening programme was commenced in 2009 to screen high-risk patients for HCC. Primary objective is to compare the OS between HCC patients diagnosed within the screening group versus those diagnosed outside this group. Other objectives were to compare tumour stage at diagnosis and the proportion having curative treatments in the two groups. Propensity score adjustments were performed to assess the survival benefit. RESULTS HCC was diagnosed in 130 subjects during the study period (82.3% males, median [IQR] age 62 [± 19] years and median [IQR] follow-up of 11.3 (± 23.5) months). Ninety-six patients (73.8%) died during the follow-up, and the median (95%CI) OS was 15.7 (9.7-21.8) months. HCC diagnosed within the screening programme had a better OS compared to those diagnosed outside this programme (26.8 vs 11.5 months, p = 0.01). Further, those diagnosed within the programme had an earlier stage HCC ([58.3% vs 23.6%], Ӽ2 = 11.3, p = 0.001), and a significant proportion were treated with curative intent ([62.5% vs 31.1%], Ӽ2 = 8.3, p = 0.004). Propensity score adjustment showed a 58% reduction in mortality for HCC diagnosed within the screening programme (HR [95%CI] 0.42 [0.20-0.89], p = 0.02). CONCLUSION A programmatic, regional HCC screening programme improved the OS and detected tumours at an earlier stage enabling more patients to have curative therapies.
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Affiliation(s)
- Mohamed A Chinnaratha
- Hepatology and Liver Transplant Medicine Unit, Flinders Medical Centre, Bedford Park, SA, Australia. .,School of Medicine, Flinders University, Bedford Park, Australia. .,School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia.
| | - Kirsty Campbell
- Hepatology and Liver Transplant Medicine Unit, Flinders Medical Centre, Bedford Park, SA, Australia
| | - Ryan Mathias
- Hepatology and Liver Transplant Medicine Unit, Flinders Medical Centre, Bedford Park, SA, Australia
| | - Rosemary J McCormick
- Hepatology and Liver Transplant Medicine Unit, Flinders Medical Centre, Bedford Park, SA, Australia
| | | | - Alan J Wigg
- Hepatology and Liver Transplant Medicine Unit, Flinders Medical Centre, Bedford Park, SA, Australia.,School of Medicine, Flinders University, Bedford Park, Australia
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16
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Mayo MJ, Wigg AJ, Leggett BA, Arnold H, Thompson AJ, Weltman M, Carey EJ, Muir AJ, Ling L, Rossi SJ, DePaoli AM. NGM282 for Treatment of Patients With Primary Biliary Cholangitis: A Multicenter, Randomized, Double-Blind, Placebo-Controlled Trial. Hepatol Commun 2018; 2:1037-1050. [PMID: 30202819 PMCID: PMC6128239 DOI: 10.1002/hep4.1209] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 05/16/2018] [Indexed: 01/07/2023] Open
Abstract
Patients with primary biliary cholangitis (PBC) who had an inadequate response to ursodiol have few treatment options. Alkaline phosphatase (ALP) and bilirubin levels correlate with the risk of liver transplant or death in PBC patients. Fibroblast growth factor (FGF) 19 is a hormone that acts directly in the liver to regulate bile acid synthesis. We evaluated NGM282, an engineered analogue of FGF19, for the treatment of PBC. In this 28-day, double-blind, placebo-controlled phase 2 trial, 45 PBC patients who had an inadequate response to ursodiol were randomly assigned 1:1:1 to receive subcutaneous daily doses of either NGM282 at 0.3 mg (n = 14), 3 mg (n = 16), or placebo (n = 15). The primary endpoint was a change in ALP from baseline after 28 days of treatment. At day 28, ALP was significantly reduced with NGM282 treatment at both 0.3 mg (least-squares mean -51.0 IU/L [standard error (SE) 15.4]) and 3 mg (-66.0 IU/L [SE 16.0]) versus placebo (3.3 IU/L [SE 14.8]), with least-squares mean differences of -54.3 IU/L (95% confidence interval -104.2 to -4.5; P = 0.0149) and -69.3 IU/L (95% confidence interval -120.5 to -18.3; P = 0.0030), respectively. Fifty percent (7 of 14) of patients receiving NGM282 0.3 mg and 46% (6 of 13) of those receiving NGM282 3mg achieved 15% or greater reduction in ALP levels from baseline, compared with 7% (1 of 15) of patients receiving placebo. NGM282 also significantly reduced serum concentrations of transaminases and immunoglobulins. Most adverse events were grade 1 (mild) to grade 2 (moderate) in severity, with gastrointestinal disorders more frequent in the NGM282 treatment groups. No worsening of pruritus was observed with NGM282 treatment. Conclusion: NGM282 administered for 28 days resulted in significant improvements in ALP and transaminase levels compared with placebo, with an acceptable safety profile in patients with PBC. (Hepatology Communications 2018; 00:000-000).
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Affiliation(s)
- Marlyn J Mayo
- University of Texas Southwestern Medical Center Dallas Texas
| | - Alan J Wigg
- Flinders Medical Center Adelaide South Australia Australia
| | - Barbara A Leggett
- Royal Brisbane and Women's Hospital and School of Medicine University of Queensland Brisbane Queensland Australia
| | | | | | | | | | | | - Lei Ling
- NGM Biopharmaceuticals Inc. South San Francisco California
| | | | - Alex M DePaoli
- NGM Biopharmaceuticals Inc. South San Francisco California
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17
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Wigg AJ, Mangira D, Chen JW, Woodman RW. Outcomes and predictors of harmful relapse following liver transplantation for alcoholic liver disease in an Australian population. Intern Med J 2018; 47:656-663. [PMID: 28321963 DOI: 10.1111/imj.13431] [Citation(s) in RCA: 7] [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] [Received: 10/21/2016] [Revised: 03/10/2017] [Accepted: 03/13/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND Limited studies of patient survival and alcoholic relapse following transplantation for alcoholic liver disease have been described in Australian populations. AIM To describe these outcomes in an Australian population, to determine the association between harmful alcoholic relapse and patient survival, and to examine pre-transplant variables associated with harmful relapse. METHODS Single centre, retrospective review of consecutive patients transplanted at the South Australian Liver Transplant Unit. Relapse was identified by an independent investigator using case note review and confidential patient questionnaire. RESULTS A total of 87 patients (median age 52 years, 84% male, median Model for End-Stage Liver Disease (MELD) score 18) was included in the study with a median follow-up time of 50 months. The 1-, 3- and 5-year survival of patients was 93.1, 87.4 and 82.0% respectively. Two deaths were directly attributable to graft failure due to alcohol. Fourteen (16%) patients fulfilled criteria for harmful relapse and 18 (21%) patients experienced any form of relapse to alcohol. Harmful relapse was associated with increased mortality (hazard ratio (HR) 3.2, 95% confidence interval (CI) 1.1-9.7, P = 0.041). Only two factors were independently associated with harmful relapse on multivariate analysis; prior alcohol rehabilitation (HR 8.4, 95% CI 2.5-28.4, P = 0.001) and single versus married status (HR 0.09, 95% CI 0.02-1.2, P = 0.019). CONCLUSION Good patient survival outcomes were seen for this South Australian population. Harmful alcohol relapse occurs in a minority of patients and rarely results in direct graft loss. Modifiable pre-transplant factors that predict harmful relapse were not identified.
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Affiliation(s)
- Alan J Wigg
- South Australian Liver Transplant Unit, Flinders Medical Centre, Adelaide, South Australia, Australia.,Hepatology and Liver Transplantation Unit, Flinders Medical Centre, Adelaide, South Australia, Australia.,School of Medicine, Flinders University, Adelaide, South Australia, Australia
| | - Dileep Mangira
- South Australian Liver Transplant Unit, Flinders Medical Centre, Adelaide, South Australia, Australia.,Hepatology and Liver Transplantation Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - John W Chen
- South Australian Liver Transplant Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Richard W Woodman
- School of Medicine, Flinders University, Adelaide, South Australia, Australia
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18
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Wigg AJ, Chin JK, Muller KR, Ramachandran J, Woodman RJ, Kaambwa B. Cost-effectiveness of a chronic disease management model for cirrhosis: Analysis of a randomized controlled trial. J Gastroenterol Hepatol 2018; 33:1634-1640. [PMID: 29462834 DOI: 10.1111/jgh.14127] [Citation(s) in RCA: 7] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 01/26/2018] [Accepted: 02/11/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS In this follow-up study to a randomized controlled trial of a chronic disease management (CDM) model in cirrhosis, our aim was to assess the relative cost-effectiveness of this model compared with usual care during the 12-month study period, using incremental costs per death avoided as the primary outcome. METHODS Mean differences in hospitalization costs, deaths avoided, and change in Chronic Liver Disease Questionnaire (CLDQ) total scores were presented with 95% non-parametric bootstrapped confidence intervals. Results were also presented using a cost-effectiveness plane (CEP) and cost-effectiveness acceptability curve. RESULTS The CDM intervention was more expensive, by 18 521 AUD per participant, but more effective (% of deaths at 12 months: 10% vs 15% and 0.67 units increase per patient in CLDQ total scores). The resultant incremental cost-effectiveness ratios were 370 425 AUD per death avoided (95% confidence interval: -14 564 AUD to 2 059 373 AUD) and 27 547 AUD per unit improvement in the CLDQ total score (95% CI: 7455 AUD to 143 874 AUD). The CEPs demonstrated some uncertainty around cost-effectiveness. The cost-effectiveness acceptability curves demonstrated that at willingness to pay values of 400 000 AUD per additional death avoided and 40 000 AUD per unit improvement in the CLDQ, there was at least a 70% probability of CDM being more cost-effective than usual care. At 24 months, CDM was much more effective (12% less deaths but now also cheaper by 985 AUD per patient). CONCLUSIONS The analysis of data from a randomized controlled trial suggests that the CDM intervention used is likely to be cost-effective, relative to usual care, due to fewer patient deaths.
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Affiliation(s)
- Alan J Wigg
- Hepatology and Liver Transplantation Medicine Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
- School of Medicine, Flinders University of South Australia, Adelaide, South Australia, Australia
| | - Jong K Chin
- Hepatology and Liver Transplantation Medicine Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Kate R Muller
- Hepatology and Liver Transplantation Medicine Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
- School of Medicine, Flinders University of South Australia, Adelaide, South Australia, Australia
| | - Jeyamani Ramachandran
- Hepatology and Liver Transplantation Medicine Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
- School of Medicine, Flinders University of South Australia, Adelaide, South Australia, Australia
| | - Richard J Woodman
- School of Medicine, Flinders University of South Australia, Adelaide, South Australia, Australia
| | - Billingsley Kaambwa
- Health Economics Unit, School of Medicine, Flinders University, Adelaide, South Australia, Australia
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19
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Chinnaratha MA, Kaambwa B, Woodman RJ, Fraser RJ, Wigg AJ. Assessing the clinical and economic impact of increasing treatment uptake in chronic hepatitis B infection using a Markov model. J Gastroenterol Hepatol 2017; 32:1370-1377. [PMID: 28002881 DOI: 10.1111/jgh.13679] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 11/22/2016] [Accepted: 12/12/2016] [Indexed: 12/14/2022]
Abstract
UNLABELLED Treatment uptake in chronic hepatitis B virus (HBV) infection is low in South Australia, and the cost-effectiveness of increasing treatment uptake rates in this population has not been assessed. AIMS AND METHODS Using a cohort Markov model, cost-effectiveness was assessed for three different treatment uptake scenarios: 2.9% (current level-scenario 1), 10% (scenario 2), and 15% (scenario 3). The initial HBV population included 2550 treatment eligible patients who transitioned between six different health states over a 10-year period. Treatment transition probabilities were based on tenofovir therapy, while those not assigned to treatment followed the natural history transition probabilities. We estimated the incremental cost per quality adjusted life year gained using the prevented number of deaths, hepatocellular carcinoma, and liver transplants. RESULTS Scenario 3 was associated with the lowest mean cost/person over 10 years (AU$60 133), compared with scenario 2 (AU$61 964) and scenario 1 (AU$64 597). Scenario 3 was also associated with the highest quality adjusted life year gained (8.196) compared with scenario 2 (7.985) and scenario 1 (7.684). Scenario 3 would result in 50% reduction in hepatocellular carcinoma and 30% reduction in HBV-related mortality compared with scenario 1, over a 10-year period. Higher treatment uptake was found to be cost-effective with at least 2 years of treatment at either 10% or 15% of the target population. CONCLUSION Maximizing the treatment uptake in the existing HBV population from 2.9% to 15% was cost-effective for periods of 2 years or more. This was due to a reduction in the number of expected clinical events.
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Affiliation(s)
- Mohamed A Chinnaratha
- Hepatology and Liver Transplantation Medicine Unit, Flinders Medical Centre, Bedford Park, South Australia, Australia.,School of Medicine, Flinders University, Bedford Park, South Australia, Australia
| | - Billingsley Kaambwa
- Flinders Health Economics Group, Flinders University, Bedford Park, South Australia, Australia
| | - Richard J Woodman
- School of Medicine, Flinders University, Bedford Park, South Australia, Australia
| | - Robert J Fraser
- Hepatology and Liver Transplantation Medicine Unit, Flinders Medical Centre, Bedford Park, South Australia, Australia.,School of Medicine, Flinders University, Bedford Park, South Australia, Australia
| | - Alan J Wigg
- Hepatology and Liver Transplantation Medicine Unit, Flinders Medical Centre, Bedford Park, South Australia, Australia.,School of Medicine, Flinders University, Bedford Park, South Australia, Australia
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20
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Su YL, Woodman RJ, Silva MF, Muller K, Libby J, Chen JW, Padbury R, Wigg AJ. Good outcomes of liver transplantation for hepatitis C at a low volume centre. Ann Hepatol 2017; 15:207-14. [PMID: 26845598 DOI: 10.5604/16652681.1193713] [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
BACKGROUND AND AIMS Concerns exist about outcomes of liver transplantation (LT) from low volume centres, especially for hepatitis C (HCV) patients. The aim of the study was to assess patient outcomes as well as their predictors post LT for HCV in a small volume Australian unit (< 25 LTs/year), comparing these with the average outcomes obtained from national and international transplant registries. Patients transplanted for HCV at the South Australian Liver Transplant Unit between 1992 and 2012 were studied. Outcomes assessed were patient and graft survival at 1,3, and 5 years. Factors independently associated with the outcomes were assessed using Cox regression model. RESULTS 1, 3, and 5-year patient survival for HCV patients was 95.2, 82.9, and 78.2%, graft survival were 93.7, 80.1, and 75.5% respectively. The total follow-up time observed was 299.9 years amongst 61 patients in which there were 16 deaths. The expected number of deaths was 40.4 and the standardized mortality ratio 0.40 (95% CI = 0.24, 0.65). These results compared favourably to those obtained from the SRTR registry. Variables independently associated with lower patient survival: donor age (HR = 1.06, 95% CI 1.02 - 1.11; P = 0.003), and post LT cytomegalovirus (CMV) disease requiring treatment (HR = 4.03, 95% CI 1.48 - 10.92;P = 0.06). CONCLUSION In conclusion, high rates of patient and graft survival for HCV liver transplantation can be obtained in a small volume unit. Young donor age and lack of CMV disease post-transplant were associated with better outcomes. Institutional factors may be influential determinants of outcomes.
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Affiliation(s)
- Yin Lau Su
- Hepatology and Liver Transplant Medicine Unit, Flinders Medical Centre, Adelaide, South Australia; The South Australian Liver Transplant Unit, Flinders Medical Centre, Adelaide, South Australia
| | - Richard J Woodman
- Flinders Centre for Epidemiology and Biostatistics, School of Medicine, Flinders University of South Australia, Adelaide, South Australia
| | - Mauricio F Silva
- The South Australian Liver Transplant Unit, Flinders Medical Centre, Adelaide, South Australia; LiverTransplant Unit, Irmandade Santa Casa de Misericordiade Porto Alegre, Brazil
| | - Kate Muller
- Hepatology and Liver Transplant Medicine Unit, Flinders Medical Centre, Adelaide, South Australia; The South Australian Liver Transplant Unit, Flinders Medical Centre, Adelaide, South Australia
| | - John Libby
- The South Australian Liver Transplant Unit, Flinders Medical Centre, Adelaide, South Australia
| | - John W Chen
- The South Australian Liver Transplant Unit, Flinders Medical Centre, Adelaide, South Australia
| | - Robert Padbury
- The South Australian Liver Transplant Unit, Flinders Medical Centre, Adelaide, South Australia
| | - Alan J Wigg
- Hepatology and Liver Transplant Medicine Unit, Flinders Medical Centre, Adelaide, South Australia; The South Australian Liver Transplant Unit, Flinders Medical Centre, Adelaide, South Australia
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21
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Chinnaratha MA, Chaudhary S, Doogue M, McCormick RJ, Woodman RJ, Wigg AJ. Prevalence of hepatic osteodystrophy and vitamin D deficiency in cirrhosis. Intern Med J 2016; 45:1230-5. [PMID: 26247615 DOI: 10.1111/imj.12866] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [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: 05/04/2015] [Accepted: 07/20/2015] [Indexed: 01/19/2023]
Abstract
BACKGROUND Hepatic osteodystrophy (HO) is a major complication of cirrhosis. However, the prevalence of HO in a general cirrhotic patient population is not well defined as previous studies were in single aetiology or pre-liver transplant patients. AIMS The aims of this study were to investigate the prevalence of HO and vitamin D deficiency in patients with cirrhosis of mixed aetiology and disease severity and to determine the risk factors for HO. METHODS This is a single-centre cross-sectional study of all patients newly diagnosed with cirrhosis between September 2009 and December 2012. All patients underwent bone mineral density assessment using dual energy X-ray absorptiometry within 3 months of diagnosis. Demographic and biochemical factors, severity of underlying liver disease, previous fragility fractures, smoking status and alcohol use were collected on diagnosis. Logistic regression analysis was used to assess risk factors for HO. RESULTS Among the 406 patients (67% males), the median (range) age was 56 years (21-85) and most (84%) were Childs-Pugh A or B with a median (range) model for end-stage liver disease score of 11 (5-40). Alcohol (41%) was the most common underlying aetiology. The prevalence of HO and vitamin D deficiency (≤50 nmol/L) was 56% and 54%, respectively, and previous fragility fractures had occurred in 3%. Increasing age (odds ratio (95% confidence interval): 1.49 per 10 years (1.02-2.18), P = 0.04), excessive alcohol intake (2.34 (1.03-5.32), P = 0.04) and lower body mass index (0.92 per kg/m2 (0.87-0.98), P = 0.009) were independent risk factors for HO. CONCLUSION There is a high prevalence of HO and vitamin D deficiency in patients with cirrhosis at presentation irrespective of disease severity or underlying aetiology.
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Affiliation(s)
- M A Chinnaratha
- Hepatology and Liver Transplant Medicine Unit, Flinders Medical Centre, Adelaide, South Australia, Australia.,School of Medicine, Flinders University of South Australia, Adelaide, South Australia, Australia
| | - S Chaudhary
- Hepatology and Liver Transplant Medicine Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - M Doogue
- Southern Adelaide Diabetes and Endocrine Services, Southern Area Local Health Network, Adelaide, South Australia, Australia
| | - R J McCormick
- Hepatology and Liver Transplant Medicine Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - R J Woodman
- School of Medicine, Flinders University of South Australia, Adelaide, South Australia, Australia
| | - A J Wigg
- Hepatology and Liver Transplant Medicine Unit, Flinders Medical Centre, Adelaide, South Australia, Australia.,School of Medicine, Flinders University of South Australia, Adelaide, South Australia, Australia
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22
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Adams LA, Arauz O, Angus PW, Sinclair M, MacDonald GA, Chelvaratnam U, Wigg AJ, Yeap S, Shackel N, Lin L, Raftopoulos S, McCaughan GW, Jeffrey GP. Additive impact of pre-liver transplant metabolic factors on survival post-liver transplant. J Gastroenterol Hepatol 2016; 31:1016-24. [PMID: 26589875 DOI: 10.1111/jgh.13240] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 10/06/2015] [Accepted: 11/14/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Diabetes at time of liver transplantation is associated with reduced post-transplant survival. We aimed to assess whether additional metabolic conditions such as obesity or hypertension had additive prognostic impact on post-transplantation survival. METHODS A multi-center cohort study of 617 adult subjects undergoing liver transplantation between 2003 and 2009 has been used. Dry body mass index was calculated following adjustment for ascites. RESULTS After a median follow-up of 5.8 years (range 0-10.5), 112 (18.2%) patients died. Diabetes was associated with reduced post-transplant survival (hazard ratio 1.89, 95% confidence interval [CI] 1.25-2.86, P = 0.003), whereas obesity, hypertension, dyslipidemia, and the metabolic syndrome itself were not (P > 0.3 for all). Patients with concomitant diabetes and obesity had lower survival (adjusted Hazard Ratio [aHR] 2.40, 95%CI 1.32-4.38, P = 0.004), whereas obese non-diabetic patients or diabetic non-obese patients had similar survival compared with non-diabetic, non-obese individuals. The presence of hypertension or dyslipidemia did not impact on survival in patients with diabetes (P > 0.1 for both). Obese diabetic patients had longer intensive care and hospital stays than non-obese diabetic or obese, non-diabetic patients (P < 0.05). The impact of concomitant obesity and diabetes on survival was greater in subjects aged 50+ years (52.6% 5-year survival, aHR 3.04, 95% CI 1.54-5.98) or those transplanted with hepatocellular carcinoma (34.1% 5-year survival, aHR 3.35, 95% CI 1.31-5.57). Diabetes without obesity was not associated with an increased mortality rate in these sub-groups. CONCLUSIONS Concomitant diabetes and obesity but not each condition in the absence of the other is associated with reduced post-liver transplant survival. The impact of diabetes and obesity is greater in older patients and those with hepatocellular carcinoma.
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Affiliation(s)
- Leon A Adams
- Sir Charles Gairdner Hospital, Perth, Australia.,School of Medicine and Pharmacology, The University of Western Australia, Perth, Western Australia
| | - Oscar Arauz
- Sir Charles Gairdner Hospital, Perth, Australia
| | - Peter W Angus
- The Austin Hospital, Melbourne, Victoria, South Australia
| | - Marie Sinclair
- The Austin Hospital, Melbourne, Victoria, South Australia
| | | | | | - Alan J Wigg
- Flinders Medical Centre, Adelaide, South Australia
| | - Sze Yeap
- Flinders Medical Centre, Adelaide, South Australia
| | - Nicholas Shackel
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Linda Lin
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | | | | | - Gary P Jeffrey
- Sir Charles Gairdner Hospital, Perth, Australia.,School of Medicine and Pharmacology, The University of Western Australia, Perth, Western Australia
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23
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Chinnaratha MA, Chuang MYA, Fraser RJL, Woodman RJ, Wigg AJ. Percutaneous thermal ablation for primary hepatocellular carcinoma: A systematic review and meta-analysis. J Gastroenterol Hepatol 2016; 31:294-301. [PMID: 26114968 DOI: 10.1111/jgh.13028] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 05/28/2015] [Accepted: 06/01/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Percutaneous thermal ablation using radiofrequency ablation (RFA) and microwave ablation (MWA) are both widely available curative treatments for hepatocellular carcinoma. Despite significant advances, it remains unclear which modality results in better outcomes. This meta-analysis of randomized controlled trials (RCT) and observational studies was undertaken to compare the techniques in terms of effectiveness and safety. METHODS Electronic reference databases (Medline, EMBASE and Cochrane Central) were searched between January 1980 and May 2014 for human studies comparing RFA and MWA. The primary outcome was the risk of local tumor progression (LTP). Secondary outcomes were complete ablation (CA), overall survival, and major adverse events (AE). The ORs were combined across studies using the random-effects model. RESULTS Ten studies (two prospective and eight retrospective) were included, and the overall LTP rate was 13.6% (176/1298). There was no difference in LTP rates between RFA and MWA [OR (95% CI): 1.01(0.67-1.50), P = 0.9]. The CA rate, 1- and 3-year overall survival and major AE were similar between the two modalities (P > 0.05 for all). In subgroup analysis, there was no difference in LTP rates according to study quality, but LTP rates were lower with MWA for treatment of larger tumors [1.88(1.10-3.23), P = 0.02]. There was no significant publication bias or inter-study heterogeneity (I(2) < 50% and P > 0.1) observed in any of the measured outcomes. CONCLUSION Overall, both RFA and MWA are equally effective and safe, but MWA may be more effective compared to RFA in preventing LTP when treating larger tumors. Well-designed, larger, multicentre RCTs are required to confirm these findings.
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Affiliation(s)
- Mohamed A Chinnaratha
- School of Medicine, Flinders University of South Australia, Adelaide, Australia.,Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Ming-yu Anthony Chuang
- Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Robert J L Fraser
- School of Medicine, Flinders University of South Australia, Adelaide, Australia.,Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Richard J Woodman
- School of Medicine, Flinders University of South Australia, Adelaide, Australia
| | - Alan J Wigg
- School of Medicine, Flinders University of South Australia, Adelaide, Australia.,Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia
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24
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Wigg AJ, Chinnaratha MA, Wundke R, Volk ML. A chronic disease management model for chronic liver failure. Hepatology 2015; 61:725-8. [PMID: 24677213 DOI: 10.1002/hep.27152] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [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: 03/07/2014] [Accepted: 03/27/2014] [Indexed: 01/18/2023]
Affiliation(s)
- Alan J Wigg
- Hepatology and Liver Transplantation Medicine Unit, Flinders Medical Centre, Adelaide, Australia; Flinders University of South Australia, Adelaide, Australia
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25
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Ramachandran J, Teo M, Kimber R, Wigg AJ. Successful liver transplantation for a hepatitis B flare following cessation of prolonged chemotherapy prophylaxis. ACTA ACUST UNITED AC 2014; 35:51-3. [PMID: 25276909 DOI: 10.7869/tg.166] [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: 11/30/2022]
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26
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Mangira D, Wigg AJ. Education and Imaging. Gastrointestinal: embedded metal biliary stent. J Gastroenterol Hepatol 2014; 29:1661. [PMID: 25154443 DOI: 10.1111/jgh.12681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- D Mangira
- Department of Gastroenterology and Hepatology, Flinders Medical Centre, Adelaide, South Australia, Australia
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27
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Chinnaratha MA, Chelvaratnam U, Stuart KA, Strasser SI, McCaughan GW, Gow P, Adams LA, Wigg AJ. Liver transplantation outcomes for Australian Aboriginal and Torres Strait Islanders. Liver Transpl 2014; 20:798-806. [PMID: 24753233 DOI: 10.1002/lt.23894] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2013] [Accepted: 03/26/2014] [Indexed: 02/07/2023]
Abstract
An increased liver disease burden has been reported for Aboriginal and Torres Strait Islanders (ATSIs) in Australia; however, few proceed to liver transplantation (LT). We aimed to compare overall survival and graft survival after LT between ATSI and non-ATSI populations, assess the factors influencing survival within ATSIs, and finally examine the proportion of ATSIs undergoing LT. This study was a retrospective review of the Australia and New Zealand Liver Transplant Registry from 1985 to 2012 and examined consecutive primary LT performed in Australia. Overall and graft survival were compared between ATSI and non-ATSI groups. The Accessibility/Remoteness Index of Australia (ARIA) was used to calculate the remoteness of individuals. There were 3493 primary LT performed, and 45 patients (1.3%; 14 children and 31 adults) were ATSIs. The median (range) ages of the ATSI children and adults at the time of LT were 9.6 (0.2-15.3) years and 44.5 (19.5-65.5) years, respectively. There were 10 deaths in the ATSI cohort. The median (range) overall survival was similar for ATSI and non-ATSI children [6.5 (0.1-23.5) years versus 9.0 (0-28.2) years, P = 0.9] and adults [7.1 (0.1-15.7) years versus 6.3 0-26.7) years, P = 0.8]. The cumulative graft survival was similar for ATSI and non-ATSI children (P = 0.8) and adults (P = 0.8). High ARIA scores [hazard ratio (HR) = 1.2, 95% confidence interval (CI) = 1.01-1.53, P = 0.03] in children and blood group O (HR = 3.8, 95% CI = 1.1-12.7, P = 0.03) in adults predicted worse outcomes for ATSIs. Although ATSIs accounted for 4.7% and 1.8% of the Australian pediatric and adult populations, respectively, they represented only 2.2% of pediatric LT recipients (χ(2) = 8.2, P = 0.004) and 1.1% of adult LT recipients (χ(2) = 7.9, P = 0.005). In conclusion, overall survival and graft survival after LT are comparable in ATSIs and non-ATSIs. There is a trend toward increased death/retransplantation in ATSIs from remote areas. ATSI children and adults appear to be underrepresented in the Australian LT population.
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Affiliation(s)
- Mohamed A Chinnaratha
- South Australian Liver Transplant Unit, Flinders Medical Centre, Bedford Park, Australia; Flinders University of South Australia, Adelaide, Australia
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28
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Kennedy NA, Rodgers A, Altus R, McCormick R, Wundke R, Wigg AJ. Optimisation of hepatocellular carcinoma surveillance in patients with viral hepatitis: a quality improvement study. Intern Med J 2014; 43:772-7. [PMID: 23611607 DOI: 10.1111/imj.12166] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Accepted: 04/06/2013] [Indexed: 12/31/2022]
Abstract
BACKGROUND Surveillance for hepatocellular carcinoma (HCC) with 6-monthly ultrasound is a standard of care for higher-risk patients with viral hepatitis. Adherence to screening guidelines is an important quality indicator in hepatology, but multiple studies have demonstrated poor HCC surveillance practices in real-world settings. AIMS The aim of this project was to audit and then optimise HCC surveillance of viral hepatitis patients, who fulfilled criteria for screening, associated with a large tertiary hospital. METHODS Clinical practice improvement principles were utilised. A baseline audit of 22 consecutive viral hepatitis patients was performed. Major barriers preventing adequate surveillance were identified and three interventions to improve adherence to guidelines were introduced. These included: improved doctor education, system redesign and improved patient education. The effects of interventions were measured by serial random audits of patients. A final audit occurred over 3 years after the initial baseline audit. RESULTS At baseline, 46% and 0% of patients had appropriate surveillance performed during the prior 6 months (one surveillance cycle) and 2 years (four surveillance cycles) respectively. Three years after initiation of these strategies, a final audit revealed 92% (vs 46% at baseline) and 64% (vs 0% at baseline) of patients had appropriate HCC surveillance performed during the preceding 6 months and 2 years intervals respectively (P < 0.001 in each case). CONCLUSIONS Simple and low-cost interventions can considerably improve the clinical effectiveness of HCC screening programmes in real world settings. Clinical practice improvement principles appear to be a valid methodology for achieving this positive change.
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Affiliation(s)
- N A Kennedy
- Hepatology and Liver Transplant Medicine Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
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29
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Wigg AJ, McCormick R, Wundke R, Woodman RJ. Coordinated care in cirrhosis; the need for further randomized controlled trials. J Hepatol 2014; 60:465-6. [PMID: 24211742 DOI: 10.1016/j.jhep.2013.09.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 09/25/2013] [Indexed: 12/04/2022]
Affiliation(s)
- Alan J Wigg
- Hepatology and Liver Transplant Unit, Flinders Medical Centre, Adelaide, Australia.
| | - Rosemary McCormick
- Hepatology and Liver Transplant Unit, Flinders Medical Centre, Adelaide, Australia
| | - Rachel Wundke
- Hepatology and Liver Transplant Unit, Flinders Medical Centre, Adelaide, Australia
| | - Richard J Woodman
- Division of General Practice, School of Medicine, Flinders University, Adelaide, Australia
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30
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Affiliation(s)
- Alan J Wigg
- Hepatology and Liver Transplant Medicine Unit, Flinders Medical Centre, Adelaide, Australia
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31
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Wigg AJ, McCormick R, Wundke R, Woodman RJ. Efficacy of a chronic disease management model for patients with chronic liver failure. Clin Gastroenterol Hepatol 2013; 11:850-8.e1-4. [PMID: 23375997 DOI: 10.1016/j.cgh.2013.01.014] [Citation(s) in RCA: 95] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Revised: 01/04/2013] [Accepted: 01/11/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Despite the economic impacts of chronic liver failure (CLF) and the success of chronic disease management (CDM) programs in routine clinical practice, there have been no randomized controlled trials of CDM for CLF. We investigated the efficacy of CDM programs for CLF patients in a prospective, controlled trial. METHODS Sixty consecutive patients with cirrhosis and complications from CLF were assigned randomly to groups given intervention (n = 40) or usual care (n = 20), from 2009 to 2010. The 12-month intervention comprised 4 CDM components: delivery system redesign, self-management support, decision support, and clinical information systems. The primary outcome was the number of days spent in a hospital bed for liver-related reasons. Secondary outcomes were rates of other hospital use measures, rate of attendance at planned outpatient care, disease severity, quality of life, and quality of care. RESULTS The intervention did not reduce the number of days patients spent in hospital beds for liver-related reasons, compared with usual care (17.8 vs 11.0 bed days/person/y, respectively; incidence rate ratio, 1.6; 95% confidence interval, 0.5-4.8; P = .39), or affect other measures of hospitalization. Patients given the intervention had a 30% higher rate of attendance at outpatient care (incidence rate ratio, 1.3; 95% confidence interval, 1.1-1.5; P = .004) and significant increases in quality of care, based on adherence to hepatoma screening, osteoporosis and vaccination guidelines, and referral to transplant centers (P < .05 for all). CONCLUSIONS In a pilot study to determine the efficacy of CDM for patients with CLF, patients receiving CDM had significant increases in attendance at outpatient centers and quality of care, compared with patients who did not receive CDM. However, CDM did not appear to reduce hospital admission rates or disease severity or improve patient quality of life. Larger trials with longer follow-up periods are required to confirm these findings and assess cost effectiveness.
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Affiliation(s)
- Alan J Wigg
- Hepatology and Liver Transplant Medicine Unit, Flinders Medical Centre, Adelaide, Australia.
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32
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Silva MF, Sapisochin G, Strasser SI, Hewa-Geeganage S, Chen J, Wigg AJ, Jones R, Saraiva R, Kikuchi L, Carrilho F, Fontes PRO, Charco R. Liver resection and transplantation offer similar 5-year survival for Child-Pugh-Turcotte A HCC-patients with a single nodule up to 5 cm: a multicenter, exploratory analysis. Eur J Surg Oncol 2013; 39:386-95. [PMID: 23375469 DOI: 10.1016/j.ejso.2012.12.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Revised: 11/15/2012] [Accepted: 12/07/2012] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND AIM The current guideline of the American Association for the Study of Liver Diseases recommends liver resection for Child-Pugh-Turcotte A patients with a single hepatocellular carcinoma, total serum bilirubin ≤ 1 mg/dL and absence of significant portal hypertension. This subset of patients would have a long-term survival comparable to transplantation. The main aim of this study is to evaluate the survival rates in patients with a single nodule ≤ 5 cm following resection. METHODS Medical records of 105 Child-Pugh-Turcotte A patients who underwent liver resection between 1997 and 2009 were analyzed in 3 countries. RESULTS One, 3-, and 5-year survival rate was 97%, 83%, and 66%, respectively, and no variable that can be assessed prior to liver resection predicted survival probabilities. CONCLUSIONS Liver resection offers 5-year survival similar to transplantation for Child-Pugh-Turcotte A patients with hepatocellular carcinoma and a single nodule up to 5 cm, independently of any patient baseline characteristics.
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Affiliation(s)
- M F Silva
- Department of Gastroenterology, Flinders University, Adelaide, Australia.
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33
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Abstract
Liver transplantation (LT) for hepatocellular carcinoma (HCC) has progressed rapidly over the last decade from a futile therapy to the first choice therapy for suitable patients. Excellent outcomes of LT for HCC can be largely attributed to the use of the Milan Criteria, which have restricted LT to patients with early stage tumors. These criteria may be conservative, and it is likely that a subset of patients with tumors beyond these criteria can have acceptable outcomes. However, there is currently insufficient data to accept more liberal criteria as a standard of care, and a higher quality evidence base must be achieved to prevent poor utilization of valuable donor liver resources. In the future, it is probable that more sophisticated selection criteria will emerge incorporating aspects of tumor biology beyond tumor size and number. Dropout from the waiting list due to tumor progression remains a clinical challenge particularly in regions with prolonged waiting times. Priority allocation using HCC MELD points is a practical and transparent solution that has successfully reduced waitlist dropout for HCC patients. Further refinements of the HCC MELD point system are required to ensure equity of access to LT for non-HCC patients and prioritization of HCC patients with the highest risk of dropout. Improving the evidence base for pre-LT locoregional therapy to prevent waitlist dropout is an urgent and difficult challenge for the LT community. In the interim transplant clinicians must restrict the use of these therapies to those patients who are most likely to benefit from them.
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Affiliation(s)
- Mauricio F Silva
- Department of Gastroenterology and Hepatology, Flinders University, Adelaide, Australia.
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34
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Wigg AJ, Palumbo K, Wigg DR. Radiotherapy for hepatocellular carcinoma: systematic review of radiobiology and modeling projections indicate reconsideration of its use. J Gastroenterol Hepatol 2010; 25:664-71. [PMID: 20074152 DOI: 10.1111/j.1440-1746.2009.06126.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [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] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS External beam radiotherapy currently has a limited role in the treatment of hepatocellular carcinoma (HCC). The purpose of this article was to review available radiobiological data on HCC and normal liver and incorporate these data into radiobiological models that may be used to explain and improve treatment. METHODS Volume doubling times of HCC were described and used to demonstrate growth of HCC with time, assuming both exponential and logistic growth. Radiosensitivity of HCC was described and used to demonstrate the probability of uncomplicated tumor control as tumor size increases. The relationship between tolerance of liver to irradiation and volume irradiated was examined. RESULTS The median volume doubling time for untreated HCC was 130 days. HCC have a long period of subclinical growth. Radiosensitivity of HCC lies within the range of other tumors commonly treated with radiotherapy. When treating small volumes of normal liver, relatively high doses may be used with low risk of late radiation damage. There is a high probability of sterilizing subclinical disease and small HCC with tolerable radiation doses. CONCLUSION New radiobiological data, modeling, emerging clinical data and the advantages offered by standard external beam radiotherapy techniques suggest the need for reconsidering the use of radiotherapy and for new trials.
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Affiliation(s)
- Alan J Wigg
- Hepatology and Liver Transplant Medicine Unit, Flinders Medical Centre, Adelaide, South Australia, Australia.
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35
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Wigg AJ, Barritt GJ, Young GP, Phillips JW. Inhibition of oxidative stress and apoptosis enables extended maintenance of integrity and function of isolated hepatocytes in suspension. J Gastroenterol Hepatol 2009; 24:1082-8. [PMID: 19638086 DOI: 10.1111/j.1440-1746.2009.05798.x] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
AIMS Isolated hepatocytes in suspension may offer an alternative culture system for bioartificial liver devices. However, maintenance of isolated hepatocyte suspensions in conventional media leads to rapid loss of cell integrity. The aim of this study was to develop a modified medium to better maintain hepatocyte integrity. METHODS Isolated rat hepatocytes were prepared by collagenase digestion. Hepatocytes were purified in a Percoll gradient, suspended in bicarbonate buffered isotonic saline supplemented with d-alpha-tocopherol succinate and glucose and medium changed at 24 h (modified medium). The properties of cells treated this way were compared with those prepared by collagenase digestion and suspension in bicarbonate buffered isotonic saline (basic medium). Both media were maintained at 30 degrees C for 48 h on an orbital shaker. Markers for oxidative stress, apoptosis and metabolic function were measured enzymatically. Cell morphology was assessed by electron microscopy. RESULTS When compared to collagenase-isolated hepatocytes maintained in basic medium, hepatocytes purified by Percoll (Amersham Biosciences, Castle Hill, Australia) and maintained in modified medium demonstrated significantly increased glutathione (GSH) and GSH : glutathione disulphide (GSSH) ratios, decreased lipid peroxidation product formation, decreased caspase-3 protease activity, reduced uptake of trypan blue and loss of lactate dehydrogenase (LDH) and increase preservation of cellular adenosine triphosphate concentration ([ATP]), urea synthesis, ammonia removal and glycogen content. Cell morphology was substantially preserved following 48 h of maintenance in the modified medium. CONCLUSIONS The use of Percoll and modified medium reduces cell injury and apoptosis and greatly improves maintenance of cell function and morphology. The modifications reported here and the use of isolated hepatocyte suspensions in bioartificial liver devices are worthy of further investigation.
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Affiliation(s)
- Alan J Wigg
- Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia.
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36
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Abstract
Effective liver support is needed for a variety of indications. A large number of both biological (containing hepatocytes) and non-biological extracorporeal liver support systems have been described in the literature over the last 50 years. Despite this, there is a paucity of good quality randomized control data examining the effectiveness of these therapies in human liver failure. In this review article, we examine the available data, with particular emphasis on the current front runners, the MARS and HepatAssist systems. Other problems associated with the development of these liver support systems are also discussed. Although promising in animal studies, we conclude that the use of these technologies is not supported currently by a sufficient evidence base to recommend them for routine clinical use and that a lack of understanding about the critical functions required of a liver support system is retarding a more rational approach to the design of these systems.
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Affiliation(s)
- Alan J Wigg
- South Australian Liver Transplantation Unit, Flinders Medical Center, Adelaide, South Australia, Australia.
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37
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Wigg AJ, Gunson BK, Mutimer DJ. Outcomes following liver transplantation for seronegative acute liver failure: experience during a 12-year period with more than 100 patients. Liver Transpl 2005; 11:27-34. [PMID: 15690533 DOI: 10.1002/lt.20289] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.6] [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: 12/16/2022]
Abstract
Seronegative hepatitis is a common cause of acute liver failure (ALF) requiring liver transplantation. The primary aim of this study was to examine outcomes following transplantation in this group and to identify factors associated with early (<2 months) mortality. Patients studied were 110 consecutive cases of seronegative ALF transplanted at the Queen Elizabeth Hospital, Birmingham, between January 1992 and January 2004. Univariate analysis of 44 pretransplantation recipient, donor, and operative variables was performed initially to identify factors associated with early posttransplantation mortality. Variables identified as significant or approaching significance were analyzed using stepwise multiple logistic regression analysis. Survival following transplantation for seronegative hepatitis was 83%, 81%, and 73% at 2, 12, and 60 months, respectively. The majority (71%) of deaths occurred within the 1st 2 months and sepsis / multiorgan dysfunction was the most common cause of early death. Univariate analysis revealed 9 variables predicting early death. Subsequent multivariate analysis identified high donor body mass index (BMI; a possible surrogate marker for hepatic steatosis) as the most important predictor of early death (P = .009; odds ratio, 1.2; 95% confidence interval, 1.0-1.3). Recipient age >50 (P = .015; odds ratio, 4.2; 95% confidence interval, 1.3-14.1) and non-Caucasian recipient ethnicity (P = .015; odds ratio, 4.9; 95% confidence interval, 1.2-19.2) were other variables associated with early death on multivariate analysis. This study specifically examined factors that determine the early outcome of transplanted seronegative ALF patients. In conclusion, we found that donor and recipient factors identify patients who have a high chance of early death after transplantation.
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Affiliation(s)
- Alan J Wigg
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK.
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38
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Abstract
Isolated hepatocytes in suspension provide a number of advantages for use in bioartificial liver device, however, poor stability of this cell preparation at physiological temperatures is an apparent barrier preventing their use. We therefore investigated the integrity and differentiated function of isolated rat hepatocytes under conditions of mild hypothermia. Isolated hepatocytes were suspended in a bicarbonate buffered saline medium, supplemented with glucose and bovine serum albumin (BSA), and maintained for 48 h at 25 degrees C on a rotary shaker under an atmosphere of 95% O2 and 5% CO2. Under these conditions there was no significant decline in cell viability and good preservation of cellular morphology on transmission electron microscopy for at least 24 h. Isolated hepatocytes in suspension at 25 degrees C were also able to maintain normal Na+ and K+ ion gradients. The cellular energy status ([ATP], ATP/ADP ratio, cytoplasmic and mitochondrial redox potentials), metabolic function (urea synthesis and ammonia removal), albumin synthesis and phase I and phase II drug detoxification activity of these cells were also maintained for at least 24 h post isolation. These observations demonstrate the robust nature of mildly hypothermic isolated hepatocytes in suspension and encourage further studies re-examining the feasibility of using this cell preparation in bioartificial livers.
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Affiliation(s)
- Alan J Wigg
- Departments of Gastroenterology and Hepatology, Flinders Medical Centre, Flinders University, Adelaide, Australia.
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Abstract
The assessment of cell concentration and viability of freshly isolated hepatocyte preparations has been traditionally performed using manual counting with a Neubauer counting chamber and staining for trypan blue exclusion. Despite the simple and rapid nature of this assessment, concerns about the accuracy of these methods exist. Simple flow cytometry techniques which determine cell concentration and viability are available yet surprisingly have not been extensively used or validated with isolated hepatocyte preparations. We therefore investigated the use of flow cytometry using TRUCOUNT Tubes and propidium iodide staining to measure cell concentration and viability of isolated rat hepatocytes in suspension. Analysis using TRUCOUNT Tubes provided more accurate and reproducible measurement of cell concentration than manual cell counting. Hepatocyte viability, assessed using propidium iodide, correlated more closely than did trypan blue exclusion with all indicators of hepatocyte integrity and function measured (lactate dehydrogenase leakage, cytochrome p450 content, cellular ATP concentration, ammonia and lactate removal, urea and albumin synthesis). We conclude that flow cytometry techniques can be used to measure cell concentration and viability of isolated hepatocyte preparations. The techniques are simple, rapid, and more accurate than manual cell counting and trypan blue staining and the results are not affected by protein-containing media.
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Affiliation(s)
- Alan J Wigg
- Department of Medical Biochemistry, Flinders University, Bedford Park, South Australia 5042, Australia.
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Abstract
We observed the development of phenotypic hereditary haemochromatosis in a non-hereditary haemochromatosis liver transplant recipient, following transplantation with a liver from a C282Y heterozygous donor. No cause for secondary iron overload was identified. Subsequent sequencing of the HFE gene of both donor and recipient revealed a strong candidate for a novel pathogenic HFE mutation. In the recipient, heterozygosity for a single base substitution in exon 1, g.18 G>C, resulting in the substitution of arginine by serine at codon 6 (R6S), was detected. This R6S variation is likely to represent a novel pathogenic missense mutation of the HFE gene. An interaction between R6S heterozygosity in the recipient and C282Y heterozygosity in the donor liver is the most likely explanation for the development of iron overload in this patient. The report suggests that an hepatic defect is required for expression of hereditary haemochromatosis and that the intestinal HFE genotype is not the exclusive determinant of iron status. It also raises the possibility that a hereditary haemochromatosis phenotype may result from transplantation of C282Y heterozygous donor livers into recipients with heterozygous pathogenic HFE mutations. This possibility may have significant implications for the common practice of transplanting C282Y heterozygous livers.
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Affiliation(s)
- A J Wigg
- Department of Gastroenterology and Hepatology, Flinders Medical Centre, Adelaide, South Australia, Australia.
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Wigg AJ, Roberts-Thomson IC, Dymock RB, McCarthy PJ, Grose RH, Cummins AG. The role of small intestinal bacterial overgrowth, intestinal permeability, endotoxaemia, and tumour necrosis factor alpha in the pathogenesis of non-alcoholic steatohepatitis. Gut 2001; 48:206-11. [PMID: 11156641 PMCID: PMC1728215 DOI: 10.1136/gut.48.2.206] [Citation(s) in RCA: 598] [Impact Index Per Article: 26.0] [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] [Indexed: 12/15/2022]
Abstract
BACKGROUND Small intestinal bacterial overgrowth may contribute to the development of non-alcoholic steatohepatitis, perhaps by increasing intestinal permeability and promoting the absorption of endotoxin or other enteric bacterial products. AIMS To investigate the prevalence of small intestinal bacterial overgrowth, increased intestinal permeability, elevated endotoxin, and tumour necrosis factor alpha (TNF-alpha) levels in patients with non-alcoholic steatohepatitis and in control subjects. PATIENTS AND METHODS Twenty two patients with non-alcoholic steatohepatitis and 23 control subjects were studied. Small intestinal bacterial overgrowth was assessed by a combined (14)C-D-xylose and lactulose breath test. Intestinal permeability was assessed by a dual lactulose-rhamnose sugar test. Serum endotoxin levels were determined using the limulus amoebocyte lysate assay and TNF-alpha levels using an ELISA. RESULTS Small intestinal bacterial overgrowth was present in 50% of patients with non-alcoholic steatosis and 22% of control subjects (p=0.048). Mean TNF-alpha levels in non-alcoholic steatohepatitis patients and control subjects were 14.2 and 7.5 pg/ml, respectively (p=0.001). Intestinal permeability and serum endotoxin levels were similar in the two groups. CONCLUSIONS Patients with non-alcoholic steatohepatitis have a higher prevalence of small intestinal bacterial overgrowth, as assessed by the (14)C-D-xylose-lactulose breath test, and higher TNF-alpha levels in comparison with control subjects. This is not accompanied by increased intestinal permeability or elevated endotoxin levels.
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Affiliation(s)
- A J Wigg
- Department of Gastroenterology, Queen Elizabeth Hospital, Adelaide, South Australia, Australia.
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Affiliation(s)
- A J Wigg
- Department of Gastroenterology, Queen Elizabeth Hospital, Woodville, South Australia, Australia
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Wigg AJ, Roberts-Thomson IC. Gastrointestinal: herpes simplex oesophagitis. J Gastroenterol Hepatol 1998; 13:1285. [PMID: 9918439 DOI: 10.1046/j.1440-1746.1998.01794.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- A J Wigg
- Department of Gastroenterology, The Queen Elizabeth Hospital, Woodville, South Australia, Australia
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Wigg AJ, Pollard IL, Roberts-Thomson IC. Gastrointestinal: Cronkhite-Canada syndrome. J Gastroenterol Hepatol 1998; 13:1173. [PMID: 9870808 DOI: 10.1111/j.1440-1746.1998.tb00596.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- A J Wigg
- Department of Gastroenterology, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
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Affiliation(s)
- A J Wigg
- Department of Gastroenterology, The Queen Elizabeth Hospital, Woodville, South Australia, Australia
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Affiliation(s)
- G P Davidson
- Department of Gastroenterology, The Women's and Children's Hospital, South Australia, Australia
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48
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Affiliation(s)
- A J Wigg
- Department of Gastroenterology, The Queen Elizabeth Hospital, Woodville, South Australia, Australia
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