Hepatitis C donor positive to recipient negative solid organ transplants: Early direct acting antiviral insurance approval rates with and without documented viremia.

BACKGROUND: Current guidelines support early initiation of direct-acting antivirals (DAA) in hepatitis C virus (HCV) donor positive and recipient negative (D+/R-) solid organ transplants (SOTs). According to experts, access to DAA therapy is a key barrier to early treatment. METHODS: This single-center, retrospective study assessed the rate of DAA prescription approval with or without confirmed HCV viremia, time to approval, and reasons for denial in HCV D+/R- SOTs. RESULTS: All 51 patients received insurance approval for DAA therapy following transplantation regardless of confirmed HCV viremia at time of prior authorization (PA) submission. Same day PA approval was obtained in 51% of cases. Appeals received approval within a median of 2 days from submission. CONCLUSION: Our findings suggest confirmed HCV viremia may not be as significant of a barrier to DAA access and may encourage other health systems to consider early initiation of DAA therapy in their HCV D+/R- transplants.

Liver disease related to the heart.

In this article, we review both acute and chronic liver diseases that occur as a result of heart or circulatory system failure. Ischemic hepatitis, congestive hepatopathy, cardiac cirrhosis, and Fontan liver disease are reviewed. We review clinical presentation, diagnostic data, prognosis, and available therapeutic strategies for these entities. We aim to increase awareness about cardio-hepatic disease as the prevalence of this disorder in adults is increasing. Due to advances in medical and surgical care, patients with heart disease are living longer and thus exposing long-term effects on the liver that are clinically relevant. There may be a role for dual organ transplantation in some cases, but this is a very challenging endeavor, and newer ideas about treatment or prevention are needed.

Beyond a broken heart: circulatory dysfunction in the failing Fontan.

The role of ventricular dysfunction in late morbidity and mortality of univentricular hearts has been described previously. However, a significant proportion of adult Fontan patients who die or require heart transplantation do so with preserved ventricular function. The clinical deterioration in patients who have undergone Fontan palliation requires a broader view of circulatory dysfunction, one that takes into account the complex interaction of regulatory systems affecting hepatic, renal, and pulmonary blood flow, in addition to cardiac function. This review focuses primarily on the pathophysiology of multiple organ involvement in this circulatory dysfunction, with particular focus on the consequences of hepatic dysfunction and portal hypertension. The authors discuss hepatic perfusion, both in health and disease, and review the current understanding of liver histopathology and liver disease in adult Fontan patients and similar clinicopathologic states. They compare and contrast features of postsinusoidal portal hypertension with more typical adult cirrhotic disease. Finally, they delineate the related effects of portal hypertensive physiology on the systemic and pulmonary vasculature, the kidney, and the heart itself and discuss how these changes affect the care of the adult Fontan patient.

Features of portal hypertension are associated with major adverse events in Fontan patients: the VAST study.

BACKGROUND: Chronic congestive hepatopathy is known to cause hepatic fibrosis and portal hypertension in patients post-Fontan operation for single ventricle palliation. The clinical significance of these findings is not clear. We hypothesized that features of portal hypertension would be significantly related to major adverse events. METHODS: A retrospective review of 73 adult and pediatric post-Fontan patients referred for a liver evaluation from 2001 to 2011 was performed. The relationship between features of portal hypertension (VAST score ≥2, 1 point each for Varices, Ascites, Splenomegaly or Thrombocytopenia) and a major adverse event (death, need for transplant, or hepatocellular carcinoma) was examined using logistic regression. RESULTS: 73 post-Fontan patients (30% female, 73% Caucasian, 66% systemic left ventricle (SLV), mean age 24±11 years, mean interval from Fontan 17±6 years) were included in analysis. Features of portal hypertension (VAST score ≥2) were present in 26 (36%), and there were 19 major adverse events: death (n=12), transplant (n=6), and HCC (n=1). A significant relationship was found between VAST score ≥2 and major adverse events (OR=9.8, 95% CI [2.9-32.7]). After adjusting for time since Fontan, SLV, age, hemoglobin and type of failure, VAST score ≥2 remained significant (OR=9.1, 95% CI [1.4-57.6]). CONCLUSION: Fontan patients with features of portal hypertension have a 9-fold increased risk for a major adverse event. Therapies targeted to manage clinical manifestations of portal hypertension, and early referral to heart transplant may help delay major adverse events. Future prospective studies are needed to confirm these findings.

Critical care management of patients before liver transplantation.

The critical care management of patients before liver transplantation is aimed at optimizing hepatic and extrahepatic organ function before the transplant operation, with a goal to favorably influence perioperative and postoperative graft and patient outcomes. Critical illness in liver disease can present in the context of acute liver failure or acute on chronic liver failure. The differing pathophysiologic processes underlying these 2 types of liver failure necessitate specific approaches to their intensive care management. In their extreme presentations, both types of liver failure present as multiorgan system failure; and therefore, the critical care management of these entities requires a systematic multiorgan system approach to address hepatic and extrahepatic organ dysfunction. This review provides a multiorgan system-based description of critical care management of acute liver failure and acute on chronic liver failure before liver transplantation.

HIV/AIDS and Colorectal Cancer: A Review in the Era of Antiretrovirals.

Since the discovery of HIV/AIDS and the introduction of antiretroviral therapy, there have been many observations regarding the causes of HIV/AIDS deaths, opportunistic infections, and coexisting diseases such as non-AIDS-defining malignancies. The bulk of the literature worldwide has been epidemiologic and has involved cross-linkage of both HIV/AIDS and cancer registries. Prior retrospective studies have also utilized death certificates. Initial large-scale studies have not identified an increased risk of colon cancer in the HIV/AIDS population, and scrutiny of the literature has elucidated major limitations, most notably the lack of screening data. Only recently have there been studies addressing the rate of colon cancer screening in the HIV/AIDS population. There have also been reports suggesting an elevated risk and earlier age of onset of colonic neoplasia in the HIV/AIDS population. This review summarizes literature from the last two decades regarding HIV/AIDS and colorectal cancer and endeavors to stimulate interest in further investigation of a possible association.