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BACKGROUND & AIMS: This study assessed the worldwide burden of digestive diseases between 1990 and 2019. METHODS: We analyzed data from the Global Burden of Diseases study, covering 18 digestive diseases across 204 countries and territories. Key disease burden indicators, including incidence, prevalence, mortality, and disability-adjusted life years (DALYs), were studied. Linear regression analysis was applied to the natural logarithm of age-standardized outcomes to determine the annual percent change. RESULTS: In 2019, there were 7.32 billion incidents and 2.86 billion prevalent cases of digestive diseases, resulting in 8 million deaths and 277 million DALYs lost. Little to no decrease in global age-standardized incidence and prevalence of digestive diseases was observed between 1990 and 2019, with 95,582 and 35,106 cases per 100,000 individuals in 2019, respectively. The age-standardized death rate was 102 per 100,000 individuals. Digestive diseases accounted for a significant portion of the overall disease burden, with more than one-third of prevalent cases having a digestive etiology. Enteric infections were the primary contributor to incidence, death, and DALYs lost, whereas cirrhosis and other chronic liver diseases had the highest prevalence rate. The burden of digestive diseases was inversely related to the sociodemographic index, with enteric infections being the predominant cause of death in low and low-middle quintiles and colorectal cancer in the high quintile. CONCLUSIONS: Despite significant reductions in deaths and DALYs due to digestive diseases from 1990 to 2019, they remain prevalent. A significant disparity in the burden of digestive diseases exists among countries with different development levels.
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Costo de Enfermedad , Carga Global de Enfermedades , Humanos , Años de Vida Ajustados por Calidad de Vida , Cirrosis Hepática , Salud Global , Incidencia , Factores de RiesgoRESUMEN
INTRODUCTION: Hospitalized patients with cirrhosis can develop respiratory failure (RF), which is associated with a poor prognosis, but predisposing factors are unclear. METHODS: We prospectively enrolled a multicenter North American cirrhosis inpatient cohort and collected admission and in-hospital data (grading per European Association for the Study of Liver-Chronic Liver Failure scoring system, acute kidney injury [AKI], infections [admission/nosocomial], and albumin use) in an era when terlipressin was not available in North America. Multivariable regression to predict RF was performed using only admission day and in-hospital events occurring before RF. RESULTS: A total of 511 patients from 14 sites (median age 57 years, admission model for end-stage liver disease [MELD]-Na 23) were enrolled: RF developed in 15%; AKI occurred in 24%; and 11% developed nosocomial infections (NI). At admission, patients who developed RF had higher MELD-Na, gastrointestinal (GI) bleeding/AKI-related admission, and prior infections/ascites. During hospitalization, RF developers had higher NI (especially respiratory), albumin use, and other organ failures. RF was higher in patients receiving albumin (83% vs 59%, P < 0.0001) with increasing doses (269.5 ± 210.5 vs 208.6 ± 186.1 g, P = 0.01) regardless of indication. Admission for AKI, GI bleeding, and high MELD-Na predicted RF. Using all variables, NI (odds ratio [OR] = 4.02, P = 0.0004), GI bleeding (OR = 3.1, P = 0.002), albumin use (OR = 2.93, P = 0.01), AKI (OR = 3.26, P = 0.008), and circulatory failure (OR = 3.73, P = 0.002) were associated with RF risk. DISCUSSION: In a multicenter inpatient cirrhosis study of patients not exposed to terlipressin, 15% of patients developed RF. RF risk was highest in those admitted with AKI, those who had GI bleeding on admission, and those who developed NI and other organ failures or received albumin during their hospital course. Careful volume monitoring and preventing nosocomial respiratory infections and renal or circulatory failures could reduce this risk.
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Lesión Renal Aguda , Infección Hospitalaria , Enfermedad Hepática en Estado Terminal , Humanos , Persona de Mediana Edad , Pacientes Internos , Enfermedad Hepática en Estado Terminal/complicaciones , Índice de Severidad de la Enfermedad , Cirrosis Hepática/complicaciones , Lesión Renal Aguda/etiología , Lesión Renal Aguda/complicaciones , AlbúminasRESUMEN
INTRODUCTION AND OBJECTIVES: Congenital hepatic fibrosis (CHF) is a rare condition characterized by biliary tract changes and a geographic pattern of liver fibrosis. Liver biopsy is essential to confirm its diagnosis. The absence of specific clinical indicators in adults often leads to delays in diagnosis and management, while the natural history has not been well described. We sought to define the presentation and outcomes of adults with biopsy-proven CHF. MATERIALS AND METHODS: A retrospective chart review was conducted of patients diagnosed with CHF by liver biopsy. Continuous variables were summarized with the sample median and range. Categorical variables were summarized with number and percentage of patients. RESULTS: We identified 24 patients evaluated over a 20-year period, with a median age of 51 years (range 22-72 years) at initial presentation; 14 were male. The most common imaging findings were renal cysts (91.3%), splenomegaly (69.6%), and a cirrhotic-appearing liver (60.9%). The most commonly treated liver-related complications were cholangitis (45.8%), varices (45.8%), and hepatic encephalopathy (25%). Two patients died with a median length of follow-up of 2.9 years (range: 0.0-20.0 years). Two patients underwent transjugular intrahepatic portosystemic shunt (TIPS) placement to manage bleeding esophageal varices. Eight patients underwent liver transplantation (LT), the most common indication being decompensated disease (50%). CONCLUSIONS: CHF should be considered when patients present with cholangitis and/or complications of portal hypertension and have a cirrhotic appearing liver and renal cysts on imaging. Depending upon the disease severity, interventions such as TIPS or LT may be required.
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Cirrosis Hepática , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Adulto Joven , Colangitis , Várices Esofágicas y Gástricas/diagnóstico , Várices Esofágicas y Gástricas/etiología , Várices Esofágicas y Gástricas/terapia , Hemorragia Gastrointestinal/etiología , Enfermedades Renales Quísticas/complicaciones , Cirrosis Hepática/diagnóstico , Cirrosis Hepática/etiología , Cirrosis Hepática/terapia , Estudios RetrospectivosRESUMEN
The number of kidney after liver transplants (KALT) increased after the implementation of the United Network of Organ Sharing (UNOS) safety net policy, but the effects of the policy on KALT outcomes remain unknown. Using the UNOS database, we identified KALT between 60 and 365 days from liver transplant from January 1, 2010, to December 31, 2020. The main outcome was 1- and 3-year patient, liver, and kidney graft survival. Secondary outcomes included 6-month and 1-year acute rejection (AR) of liver and kidney, and 1-year kidney allograft function. Of the 256 KALT, 90 were pre-policy and 166 post-policy. Compared to pre-policy, post-policy 1- and 3-year liver graft survival was higher (54% and 54% vs. 86% and 81%, respectively, p <0.001), while 1- and 3-year kidney graft survival (99% and 75% vs. 92% and 79%, respectively, p =0.19), and 1- and 3-year patient survival (99% and 99% vs. 95% and 89%, respectively, p =0.11) were not significantly different. Subgroup analysis revealed similar trends in patients with and without renal failure at liver transplant. Liver AR at 6 months was lower post-policy (6.3% vs. 18.3%, p =0.006) but was similar (10.5% vs. 13%, p =0.63) at 1 year. Kidney AR was unchanged post-policy at 6 months and 1 year. Creatinine at 1 year did not differ post-policy versus pre-policy (1.4 vs. 1.3 mg/dL, p =0.07) despite a higher proportion of deceased donors, higher Kidney Donor Profile Index, and longer kidney cold ischemia time post-policy ( p <0.05 for all). This 3-year follow-up after the 2017 UNOS policy revision demonstrated that the safety net implementation has resulted in improved liver outcomes for patients who underwent KALT with no increased AR of the liver or the kidney allografts.
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BACKGROUND: Post-operative cardiac complications occur infrequently but contribute to mortality after liver transplantation (LT). Artificial intelligence-based algorithms based on electrocardiogram (AI-ECG) are attractive for use during pre-operative evaluation to screen for risk of post-operative cardiac complications, but their use for this purpose is unknown. AIMS: The aim of this study was to evaluate the performance of an AI-ECG algorithm in predicting cardiac factors such as asymptomatic left ventricular systolic dysfunction or potential for developing post-operative atrial fibrillation (AF) in cohorts of patients with end-stage liver disease either undergoing evaluation for transplant or receiving a liver transplant. METHODS: A retrospective study was performed in two consecutive adult cohorts of patients who were either evaluated for LT or underwent LT at a single center between 2017 and 2019. ECG were analyzed using an AI-ECG trained to recognize patterns from a standard 12-lead ECG which could identify the presence of left ventricular systolic dysfunction (LVEF < 50%) or subsequent atrial fibrillation. RESULTS: The performance of AI-ECG in patients undergoing LT evaluation is similar to that in a general population but was lower in the presence of prolonged QTc. AI-ECG analysis on ECG in sinus rhythm had an AUROC of 0.69 for prediction of de novo post-transplant AF. Although post-transplant cardiac dysfunction occurred in only 2.3% of patients in the study cohorts, AI-ECG had an AUROC of 0.69 for prediction of subsequent low left ventricular ejection fraction. CONCLUSIONS: A positive screen for low EF or AF on AI-ECG can alert to risk of post-operative cardiac dysfunction or predict new onset atrial fibrillation after LT. The use of an AI-ECG can be a useful adjunct in persons undergoing transplant evaluation that can be readily implemented in clinical practice.
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Fibrilación Atrial , Trasplante de Hígado , Disfunción Ventricular Izquierda , Adulto , Humanos , Inteligencia Artificial , Fibrilación Atrial/complicaciones , Trasplante de Hígado/efectos adversos , Estudios Retrospectivos , Volumen Sistólico , Función Ventricular Izquierda , Electrocardiografía , Disfunción Ventricular Izquierda/complicaciones , Medición de RiesgoRESUMEN
PURPOSE: There are limited data regarding hospital and intensive care unit (ICU) outcomes in patients with hepatopulmonary syndrome (HPS) following liver transplantation (LT). METHODS: Data were retrospectively collected from consecutive HPS adult patients who underwent LT and were immediately admitted to the ICU at three transplant centers with shared management protocols, from 2002 to 2018. Demographic, clinical, surgical, laboratory, and outcome data were extracted. RESULTS: We identified 137 patients (74 male, 54%), with a median age at LT of 58 years (IQR: 52-63). One hundred and 31 (95.6%) patients were admitted to the ICU on invasive mechanical ventilation (MV). The median time on invasive MV in the ICU was 12 hours (IQR: 5-28) and 97 patients (74%) were extubated within 24 hours of ICU admission. The median highest positive end expiratory pressure and fraction of inspired oxygen (FiO2) were 7 (IQR: 5-8) and 0.6 (IQR: 0.5-0.7), respectively. 7 patients (5%) developed severe post-transplant hypoxemia. Of all patients, 42 (30.4%) required vasopressors and the median ICU and hospital length of stay (LOS) were 3 (IQR: 1-5) and 10 (IQR: 7-20) days, respectively. The in-hospital mortality rate was 3.6% (5/137). HPS severity was not associated with hospital mortality. CONCLUSION: Most HPS patients have short durations of MV, ICU, and hospital LOS post-LT. HPS severity does not impact hospital mortality.
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Síndrome Hepatopulmonar , Unidades de Cuidados Intensivos , Trasplante de Hígado , Adulto , Femenino , Síndrome Hepatopulmonar/etiología , Síndrome Hepatopulmonar/cirugía , Mortalidad Hospitalaria , Hospitales , Humanos , Trasplante de Hígado/efectos adversos , Masculino , Persona de Mediana Edad , Respiración Artificial , Estudios RetrospectivosRESUMEN
The palatin-like phospholipase domain-containing 3 (PNPLA3) rs738409 G allele is associated with nonalcoholic fatty liver disease (NAFLD), hepatocellular carcinoma,1 and all-cause or cardiovascular mortality in the general population.2 One recent Italian study reported an association between PNPLA3 polymorphism and liver-related events and mortality in biopsy-confirmed NAFLD.3 Regarding extrahepatic cancer-related mortality, one study showed that only women carrying the G allele without hepatic steatosis had a 60% lower risk for cancer-related mortality.4 However, owing to insufficient follow-up and selected populations, the results from these studies cannot generalize about the association between PNPLA3 polymorphism and liver- and extrahepatic cancer-related mortality at a population level. Thus, we investigated the association between PNPLA3 polymorphism and liver- and extrahepatic cancer-related mortality based on the presence of NAFLD in the U.S. general population.
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Carcinoma Hepatocelular , Neoplasias Hepáticas , Enfermedad del Hígado Graso no Alcohólico , Carcinoma Hepatocelular/genética , Femenino , Predisposición Genética a la Enfermedad , Humanos , Lipasa/genética , Hígado , Neoplasias Hepáticas/genética , Proteínas de la Membrana/genética , Enfermedad del Hígado Graso no Alcohólico/genética , Polimorfismo de Nucleótido Simple , Estados Unidos/epidemiologíaRESUMEN
The number of steatotic deceased donor livers encountered has continued to rise as a result of the obesity epidemic. Little is known about the histological characteristics of moderately macrosteatotic livers over time in the recipient following liver transplantation (LT). All recipients undergoing LT at Mayo Clinic Florida with donor livers with moderate macrosteatosis (30%-60%) from 2000-2017 were identified (n = 96). Routine protocol liver biopsies were performed 1-week and 6-months following LT. All liver donor and protocol biopsies were read by an experienced liver pathologist. Of the 96 moderate macrosteatosis LTs, 70 recipients had post-LT protocol liver biopsies available and comprised the study cohort. Median donor allograft macrosteatosis at the time of transplant was 33% (IQR, 30%-40%) compared with 0% (IQR, 0%-2%) at 1-week (P < 0.001) and 0% (IQR, 0%-0%) at 6-months (P < 0.001) following LT. Biopsies at 1-week post-LT displayed pericentral necrosis in 57.1% of recipients and lipopeliosis in 34.3% of recipients. In the 6-month post-LT biopsies, cholestasis was seen in 3 (4.3%) of the recipients, whereas grade 2 fibrosis was seen in 6 recipients (8.6%). Graft survival at 5 years in the present cohort was 74.0%. Moderate macrosteatosis (30%-60%) in the donor allograft demonstrates complete reversal on liver biopsies performed as early as 7 days following LT and remains absent at 6-months following LT. Both pericentral necrosis and lipopeliosis are common features on day 7 biopsies. Despite these encouraging findings, the perioperative risks of using these livers (postreperfusion cardiac arrest and primary nonfunction) should not be understated. Long-term graft survival is acceptable in patients who are able to overcome the immediate perioperative risk of using moderately steatotic donor livers.
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Trasplante de Hígado , Biopsia , Florida/epidemiología , Supervivencia de Injerto , Humanos , Trasplante de Hígado/efectos adversos , Estudios Retrospectivos , Donantes de TejidosRESUMEN
Pre-liver transplantation (LT) renal dysfunction is associated with poor post-LT survival. We studied whether early allograft dysfunction (EAD) modifies this association. Data on 2,856 primary LT recipients who received a transplant between 1998 and 2018 were retrospectively reviewed. Patients who died within the first post-LT week or received multiorgan transplants and previous LT recipients were excluded. EAD was defined as (1) total bilirubin ≥ 10 mg/dL on postoperative day (POD) 7, (2) international normalized ratio ≥1.6 on POD 7, and/or (3) alanine aminotransferase or aspartate aminotransferase ≥2000 IU/mL in the first postoperative week. Pre-LT renal dysfunction was defined as serum creatinine >1.5 mg/dL or on renal replacement therapy at LT. Patients were divided into 4 groups according to pre-LT renal dysfunction and post-LT EAD development. Recipients who had both pre-LT renal dysfunction and post-LT EAD had the worst unadjusted 1-year, 3-year, and 5-year post-LT patient and graft survival, whereas patients who had neither renal dysfunction nor EAD had the best survival (P < 0.001). After adjusting for multiple factors, the risk of death was significantly higher only in those with both pre-LT renal dysfunction and post-LT EAD (adjusted hazard ratio [aHR], 2.19; 95% confidence interval [CI], 1.58-3.03; P < 0.001), whereas those with renal dysfunction and no EAD had a comparable risk of death to those with normal kidney function at LT (aHR, 1.12; 95% CI, 0.86-1.45; P = 0.41). Results remained unchanged when pre-LT renal dysfunction was redefined using different glomerular filtration rate cutoffs. Pre-LT renal dysfunction negatively impacts post-LT survival only in patients who develop EAD. Livers at higher risk of post-LT EAD should be used with caution in recipients with pre-LT renal dysfunction.
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Enfermedades Renales , Trasplante de Hígado , Aloinjertos , Supervivencia de Injerto , Humanos , Riñón , Hígado , Trasplante de Hígado/efectos adversos , Estudios Retrospectivos , Factores de RiesgoRESUMEN
INTRODUCTION AND OBJECTIVES: Renal dysfunction before liver transplantation (LT) is associated with higher post-LT mortality. We aimed to study if this association still persisted in the contemporary transplant era. MATERIALS AND METHODS: We retrospectively reviewed data on 2871 primary LT performed at our center from 1998 to 2018. All patients were listed for LT alone and were not considered to be simultaneous liver-kidney (SLK) transplant candidates. SLK recipients and those with previous LT were excluded. Patients were grouped into 4 eras: era-1 (1998-2002, nâ¯=â¯488), era-2 (2003-2007, nâ¯=â¯889), era-3 (2008-2012, nâ¯=â¯703) and era-4 (2013-2018, nâ¯=â¯791). Pre-LT renal dysfunction was defined as creatinine (Cr) >1.5â¯mg/dl or on dialysis at LT. The effect of pre-LT renal dysfunction on post-LT patient survival in each era was examined using Kaplan Meier estimates and univariate and multivariate Cox proportional hazard analyses. RESULTS: Pre-LT renal dysfunction was present in 594 (20%) recipients. Compared to patients in era-1, patients in era-4 had higher Cr, lower eGFR and were more likely to be on dialysis at LT (Pâ¯<â¯0.001). Pre-LT renal dysfunction was associated with worse 1, 3 and 5-year survival in era-1 and era-2 (Pâ¯<â¯0.005) but not in era-3 or era-4 (Pâ¯=â¯0.13 and Pâ¯=â¯0.08, respectively). Multivariate analysis demonstrated the lack of independent effect of pre-LT renal dysfunction on post-LT mortality in era-3 and era-4. A separate analysis using eGFR <60â¯mL/min/1.73â¯m2 at LT to define renal dysfunction showed similar results. CONCLUSIONS: Pre-LT renal dysfunction had less impact on post-LT survival in the contemporary transplant era.
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Hepatopatías/complicaciones , Hepatopatías/mortalidad , Trasplante de Hígado , Insuficiencia Renal/complicaciones , Anciano , Creatinina/sangre , Femenino , Tasa de Filtración Glomerular , Supervivencia de Injerto , Humanos , Estimación de Kaplan-Meier , Hepatopatías/cirugía , Masculino , Persona de Mediana Edad , Modelos de Riesgos Proporcionales , Diálisis Renal , Insuficiencia Renal/diagnóstico , Insuficiencia Renal/mortalidad , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia , Factores de TiempoRESUMEN
BACKGROUND AND AIM: The association between palatin-like phospholipase domain-containing 3 (PNPLA3) I148M (rs738409) polymorphism and mortality is not well understood. We investigated the impact of PNPLA3 I148M (rs738409) polymorphism on overall and cardiovascular mortality based on the presence of nonalcoholic fatty liver disease (NAFLD). METHODS: The third National Health and Nutrition Examination Survey (NHANES) from 1991 to 1994 and National Health and Nutrition Examination Survey III-linked mortality data through 31 December 2015 were utilized in this study. RESULTS: Of 4814 participants, 50.7% were homozygous for the C-allele and 12.6% were homozygous for the G-allele. During a follow up of 20 years, there were a total of 1255 deaths, 422 attributed to cardiovascular disease. There was a significant association with overall mortality among those with the PNPLA3 I148M (rs738409) GG genotype (hazard ratio [HR] 1.34, 95% confidence interval [CI] 1.02-1.77) or G-allele (HR 1.22, 95% CI 1.09-1.36) in the general population. NAFLD with homozygous PNPLA3 I148M (rs738409) GG genotype had higher overall mortality after adjusting for multiple metabolic risk factors (HR 1.45, 95% CI 1.01-2.08). The PNPLA3 I148M (rs738409) G-allele had a tendency of increased cardiovascular mortality in the total population. This association was not noted in those with NAFLD. CONCLUSIONS: The homozygous PNPLA3 I148M (rs738409) GG genotype showed an increase in overall mortality in the general population and NAFLD independent of multiple metabolic risk factors.
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Enfermedades Cardiovasculares/genética , Enfermedades Cardiovasculares/mortalidad , Estudios de Asociación Genética , Predisposición Genética a la Enfermedad/genética , Lipasa/genética , Proteínas de la Membrana/genética , Polimorfismo Genético/genética , Adulto , Alelos , Enfermedades Cardiovasculares/epidemiología , Comorbilidad , Femenino , Estudios de Seguimiento , Genotipo , Humanos , Masculino , Enfermedad del Hígado Graso no Alcohólico/mortalidad , Factores de Riesgo , Factores de Tiempo , Estados Unidos/epidemiologíaRESUMEN
We sought to determine the incidence and outcomes of malnutrition in patients with cirrhosis. We performed a retrospective chart review of 134 patients listed for liver transplant (LT) to assess the presence and degree of malnutrition identified by the Subjective Global Assessment score at the time of initial transplant evaluation, follow-up nutrition visits, and at the time of transplant. Number of admissions/readmissions to the hospital, reason for hospitalization(s), and length of stay were determined. Malnutrition was prevalent at initial nutrition visit (51.9%) and underdiagnosed. By the time of transplant, 61% of the patients were identified as malnourished. Most patients (52%) were awaiting LT for more than 180 days. The change in Subjective Global Assessment score after the initial nutrition assessment was statistically significant (p ≤ .007), with worsening malnutrition severity. Seventy-one patients (53%) required hospitalization while awaiting transplant, with a median hospital stay of 9 days. Nutrition expertise is required for prompt and accurate diagnosis of malnutrition in patients with cirrhosis. Nurses caring for patients with advanced liver disease are in a prime position to provide guidance to optimize patient outcomes.
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Cirrosis Hepática/complicaciones , Desnutrición/diagnóstico , Desnutrición/epidemiología , Adulto , Anciano , Nutrición Enteral , Femenino , Hospitalización , Humanos , Incidencia , Cirrosis Hepática/diagnóstico , Cirrosis Hepática/cirugía , Trasplante de Hígado , Masculino , Persona de Mediana Edad , Evaluación Nutricional , Evaluación de Resultado en la Atención de Salud , Prevalencia , Estudios Retrospectivos , Evaluación de SíntomasRESUMEN
The impact of postreperfusion syndrome (PRS) during liver transplantation (LT) using donor livers with significant macrosteatosis is largely unknown. Clinical outcomes of all patients undergoing LT with donor livers with moderate macrosteatosis (30%-60%) (N = 96) between 2000 and 2017 were compared to propensity score matched cohorts of patients undergoing LT with donor livers with mild macrosteatosis (10%-29%) (N = 96) and no steatosis (N = 96). Cardiac arrest at the time of reperfusion was seen in eight (8.3%) of the patients in the moderate macrosteatosis group compared to one (1.0%) of the patients in the mild macrosteatosis group (P = .02) and zero (0%) of the patients in the no steatosis group (P = .004). Patients in the moderate macrosteatosis group had a higher rate of PRS (37.5% vs 18.8%; P = .004), early allograft dysfunction (EAD) (76.4% vs 25.8%; P < .001), renal dysfunction requiring continuous renal replacement therapy following transplant (18.8% vs 8.3%; P = .03) and return to the OR within 30 days (24.0% vs 7.3%; P = .002), than the no steatosis group. Both long-term patient (P = .30 and P = .08) and graft survival (P = .15 and P = .12) were not statistically when comparing the moderate macrosteatosis group to the mild macrosteatosis and no steatosis groups. Recipients of LT using livers with moderate macrosteatosis are at a significant increased risk of PRS. If patients are able to overcome the initial increased perioperative risk of using these donor livers, long-term graft survival does not appear to be different than matched recipients receiving grafts with no steatosis.
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Enfermedad Hepática en Estado Terminal/cirugía , Hígado Graso/cirugía , Trasplante de Hígado , Hígado/patología , Daño por Reperfusión/fisiopatología , Adulto , Anciano , Biopsia , Enfermedad Hepática en Estado Terminal/complicaciones , Femenino , Supervivencia de Injerto , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Periodo Perioperatorio , Complicaciones Posoperatorias/etiología , Puntaje de Propensión , Reperfusión , Factores de Riesgo , Donantes de Tejidos , Obtención de Tejidos y Órganos , Resultado del TratamientoRESUMEN
Renal dysfunction is common in liver transplantation (LT) candidates, but differentiating between reversible and irreversible renal injury can be difficult. Kidney biopsy might be helpful in differentiating reversible from irreversible renal injury, but it is associated with significant complications. We aimed to identify pre-LT predictors of potentially reversible renal injury using histological information obtained on pre-LT renal biopsy. Data on 128 LT candidates who underwent pre-LT kidney biopsy were retrospectively collected and correlated with renal histological findings. Indications for kidney biopsy were iothalamate glomerular filtration rate (iGFR) ≤40 mL/minute, proteinuria >500 mg/day, and/or hematuria. According to the biopsy diagnosis, patients were grouped into the following categories: normal (n = 13); acute tubular necrosis (ATN; n = 25); membranoproliferative glomerulonephritis (n = 19); minimal histological changes (n = 24); and advanced interstitial fibrosis (IF) and glomerulosclerosis (GS) (n = 47). Compared with patients having advanced IF/GS, patients with normal biopsies and those with ATN had lower systolic blood pressure (SBP) and diastolic blood pressure (DBP) and higher international normalized ratio and total bilirubin levels (<0.05 for all). Both SBP and DBP directly correlated with the degree of IF and GS (R = 0.3, P ≤ 0.02 for all). SBP ≤90 mm Hg was 100% sensitive and 98% specific in correlating with normal biopsies or ATN, whereas SBP ≥140 mm Hg was 22% sensitive and 90% specific in correlating with advanced IF/GS. Model for End-Stage Liver Disease score, serum creatinine, iGFR, urinary sodium excretion, and renal size did not correlate with biopsy diagnosis or degree of IF or GS. In conclusion, SBP at the time of LT evaluation correlates with renal histology, and it should be included along with other clinical and laboratory markers in the decision-making process to list patients with renal dysfunction for LT alone versus simultaneous liver-kidney transplantation.
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Presión Arterial/fisiología , Enfermedad Hepática en Estado Terminal/cirugía , Enfermedades Renales/diagnóstico , Trasplante de Hígado/efectos adversos , Complicaciones Posoperatorias/epidemiología , Anciano , Biopsia/estadística & datos numéricos , Determinación de la Presión Sanguínea/estadística & datos numéricos , Toma de Decisiones Clínicas/métodos , Creatinina/sangre , Diagnóstico Diferencial , Enfermedad Hepática en Estado Terminal/complicaciones , Enfermedad Hepática en Estado Terminal/diagnóstico , Enfermedad Hepática en Estado Terminal/fisiopatología , Femenino , Estudios de Seguimiento , Tasa de Filtración Glomerular/fisiología , Humanos , Riñón/patología , Riñón/fisiopatología , Enfermedades Renales/etiología , Enfermedades Renales/fisiopatología , Enfermedades Renales/terapia , Trasplante de Hígado/normas , Masculino , Persona de Mediana Edad , Selección de Paciente , Cuidados Posoperatorios/estadística & datos numéricos , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/fisiopatología , Complicaciones Posoperatorias/terapia , Guías de Práctica Clínica como Asunto , Periodo Preoperatorio , Terapia de Reemplazo Renal/estadística & datos numéricos , Estudios Retrospectivos , Medición de Riesgo/métodos , Medición de Riesgo/normas , Índice de Severidad de la EnfermedadRESUMEN
BACKGROUND: Increasing numbers of patients over the age of 60 are undergoing liver transplantation. OBJECTIVE: We sought to determine whether age or clinical morbidities were associated with pre- and post-transplant executive and memory performance using the Brief Test of Adult Cognition by Telephone (BTACT). METHODS: Participants included 36 recipients with nâ¯=â¯20 in the older group (>60 y) and nâ¯=â¯16 in the younger group (≤60 years). The BTACT was administered an average of 3 months before transplant, and at follow-up post-transplant intervals of 3, 6, and 9 months. BTACT composite scores for memory and executive function with age and education norms were obtained. RESULTS: Older recipients were more likely to have hepatocellular carcinoma, a lower biological MELD score at transplant, less cellular rejection, and fewer post-operative hospital days. Older and younger recipients showed comparable pre-transplant executive and memory function and comparable post-transplant improvement. Both older and younger patients showed statistically significant improvement in executive function scores at 3 months post-transplant and maintained improvement at 6 and 9 months. Memory function improved significantly in older patients by 6 months post-transplant but did not improve significantly in the younger group. CONCLUSION: Older liver transplant recipients were more likely to have hepatocellular carcinoma and a lower biological MELD score than younger recipients, but both age groups showed comparable pre-transplant cognitive performance and post-transplant cognitive improvement. Additionally, a normed telephone test can be used to effectively screen and track executive and memory function post-transplant.
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Trastornos del Conocimiento/epidemiología , Función Ejecutiva/fisiología , Trasplante de Hígado/estadística & datos numéricos , Memoria/fisiología , Complicaciones Posoperatorias/epidemiología , Adulto , Factores de Edad , Anciano , Trastornos del Conocimiento/fisiopatología , Femenino , Florida/epidemiología , Estudios de Seguimiento , Humanos , Trasplante de Hígado/efectos adversos , Masculino , Persona de Mediana Edad , Pruebas Neuropsicológicas/estadística & datos numéricos , Complicaciones Posoperatorias/fisiopatologíaRESUMEN
Hospitalized patients with cirrhosis have a high rate of mortality. In the report by Bajaj et al., the negative impact of fungal infections (FI) on outcomes in a large US cohort of hospitalized cirrhotics is highlighted. Risk factors for FI are identified. Increasing awareness of FI along with the application of new diagnostic tools in species identification will provide the opportunity to improve patient outcomes.
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Cirrosis Hepática , Micosis , Estudios de Cohortes , Humanos , Factores de RiesgoRESUMEN
The tragedy of the national opioid epidemic has resulted in a significant increase in the number of opioid-related deaths and accordingly an increase in the number of potential donors designated Public Health Service (PHS) increased risk. Previous studies have demonstrated reluctance to use these PHS organs, and as a result, higher discard rates for these organs have been observed. All patients listed for liver transplantation in the United States from January 2005 to December 2016 were investigated. Patients on the waiting list were divided into 2 groups: those in which a PHS liver was used for transplantation (accepted PHS group) and those in which a PHS liver was declined and transplanted into a recipient lower on the match run (declined PHS group). Intention-to-treat patient survival from the time of PHS offer was significantly higher in the accepted PHS compared with the declined PHS group (P < 0.001). On Cox multivariate regression, declining a PHS donor liver was associated with a hazard ratio of 2.36 (95% confidence interval, 2.23-2.49; P < 0.001). For patients in which a PHS organ offer was declined, 11.6% died or were delisted for being too sick within the subsequent year. Donor liver allografts implanted in the accepted PHS group were of a lower donor risk index (1.28 versus 1.44) compared with the non-PHS organs that patients in the declined PHS group ultimately received if they underwent transplantation. In conclusion, there is a significantly higher survival for patients in which a PHS liver is accepted and used compared with those patients in which a PHS organ is declined. These data will help inform decisions about whether or not to accept a PHS donor liver for both patients and transplant professionals. Liver Transplantation 24 497-504 2018 AASLD.
Asunto(s)
Selección de Donante/normas , Enfermedad Hepática en Estado Terminal/cirugía , Trasplante de Hígado/normas , Aceptación de la Atención de Salud/estadística & datos numéricos , Listas de Espera/mortalidad , Adulto , Anciano , Aloinjertos/patología , Aloinjertos/estadística & datos numéricos , Toma de Decisiones Clínicas , Toma de Decisiones , Selección de Donante/organización & administración , Selección de Donante/estadística & datos numéricos , Enfermedad Hepática en Estado Terminal/mortalidad , Femenino , Humanos , Hígado/patología , Trasplante de Hígado/estadística & datos numéricos , Trasplante de Hígado/tendencias , Masculino , Persona de Mediana Edad , Guías de Práctica Clínica como Asunto , Sistema de Registros/estadística & datos numéricos , Medición de Riesgo , Factores de Riesgo , Estados Unidos , United States Public Health Service/organización & administración , United States Public Health Service/normas , United States Public Health Service/estadística & datos numéricosRESUMEN
Variation in average Model for End-Stage Liver Disease (MELD) score at liver transplantation (LT) by United Network for Organ Sharing (UNOS) regions is well documented. The present study aimed to investigate MELD variation at the interregional, intraregional, and intra-donation service area (DSA) levels. Patients undergoing LT between 2015 and 2016 were obtained from the UNOS standard analysis and research file. The distribution of allocation MELD score including median, skew, and kurtosis was examined for all transplant programs. Intraregional median allocation MELD varied significantly within all 11 UNOS regions. The largest variation between programs was seen in region 5 (MELD 24.0 versus 38.5) and region 3 (MELD 20.5 versus 32.0). Regions 1, 5, and 9 had the largest proportion of programs with a highly negative skewed MELD score (50%, 57%, and 57%, respectively), whereas regions 3, 6, 10, and 11 did not have any programs with a highly negative skew. MELD score distribution was also examined in programs located in the same DSA, where no barriers exist and theoretically no significant difference in allocation should be observed. The largest DSA variation in median allocation MELD score was seen in NYRT-OP1 LiveOnNY (MELD score variation 11), AZOB-OP1 Donor Network of Arizona (MELD score variation 11), MAOB-OP1 New England Organ Bank (MELD score variation 9), and TXGC-OP1 LifeGift Organ Donation Ctr (MELD score variation 9). In conclusion, the present study demonstrates that this MELD disparity is not only present at the interregional level but can be seen within regions and even within DSAs between programs located as close as several city blocks away. Although organ availability likely accounts for a component of this disparity, the present study suggests that transplant center behavior may also play a significant role. Liver Transplantation 24 488-496 2018 AASLD.
Asunto(s)
Enfermedad Hepática en Estado Terminal/cirugía , Disparidades en Atención de Salud/estadística & datos numéricos , Trasplante de Hígado/normas , Índice de Severidad de la Enfermedad , Obtención de Tejidos y Órganos/normas , Adulto , Enfermedad Hepática en Estado Terminal/patología , Humanos , Factores de Tiempo , Obtención de Tejidos y Órganos/organización & administración , Estados Unidos , Listas de EsperaRESUMEN
Malnutrition is prevalent in cirrhosis. Vitamin and mineral deficiencies, including vitamin D, vitamin A, and zinc, are common and have been shown to correlate with survival. Our aim was to review the mechanisms of vitamin D, vitamin A, and zinc deficiencies in cirrhosis and the clinical assessment of affected patients, their outcomes based on the current literature, and management. This is a narrative review including the relevant literature for cirrhosis and vitamin D, vitamin A, and zinc deficiencies. Vitamin D deficiency has important effects in cirrhosis, regardless of the cause of chronic liver disease.These effects include associations with fibrosis and outcomes such as infections, hepatocellular carcinoma, and mortality. Vitamin A deficiency is associated with liver disease progression to cirrhosis and clinical decompensation, including occurrence of ascites or hepatic encephalopathy. Zinc deficiency can lead to hepatic encephalopathy and impaired immune function. Such deficiencies correlate with patient survival and disease severity. Caution should be applied when replacing vitamin D, vitamin A, and zinc to avoid toxicity. Identification and appropriate treatment of vitamin and mineral deficiencies in cirrhosis may reduce specific nutritional and cirrhosis-related adverse events. Routine monitoring of vitamin A, vitamin D and zinc levels in cirrhosis should be considered.
Asunto(s)
Cirrosis Hepática/sangre , Deficiencia de Vitamina A/sangre , Vitamina A/sangre , Deficiencia de Vitamina D/sangre , Vitamina D/sangre , Zinc/deficiencia , Biomarcadores/sangre , Humanos , Cirrosis Hepática/diagnóstico , Cirrosis Hepática/epidemiología , Estado Nutricional , Valor Predictivo de las Pruebas , Pronóstico , Factores de Riesgo , Deficiencia de Vitamina A/diagnóstico , Deficiencia de Vitamina A/epidemiología , Deficiencia de Vitamina D/diagnóstico , Deficiencia de Vitamina D/epidemiología , Zinc/sangreRESUMEN
INTRODUCTION AND AIM: Approximately 10%-15% of patients with hepatitis C genotype 1 (HCV GT1) experience virological relapse after all-oral antiviral regimen using simeprevir (SMV) and sofosbuvir (SOF). The efficacy and safety of treating such relapsers using ledipasvir/sofosbuvir (LDV/SOF) with/without ribavirin (RBV) has been limited. OBJECTIVE: Report the virological response and safety of LDV/SOF with/without RBV for 12-24 weeks in treating HCV GT1 relapsers after SMV + SOF. MATERIAL AND METHODS: Patients treated with standardized clinical protocol utilizing LDV/SOF with/without RBV at three transplant centers were retrospectively reviewed. RESULTS: Forty-five patients (29% post-LT, 82% male, 13% non-white, 73% subtype 1a, 86% IL28B CT/TT, 78% F3-4) started LDV/SOF with/without RBV at a median of 22 weeks (range 7-55 weeks) after the last dose of SMV+SOF treatment. Thirty-seven patients received LDV/SOF for 24 weeks (24/37 patients with RBV) and eight patients received LDV/SOF for 12 weeks (5/8 patients with RBV). RBV dose was adjusted for renal function. Sixteen patients who were RBV-ineligible received LDV/SOF without RBV for 12 or 24 weeks. SVR 12 was achieved in 96% (43/45) of patients. Baseline viral load, RBV use, or GT1 subtype did not impact SVR 12. Minimal adverse events were reported in those without RBV; 45% of patients who received RBV developed significant anemia requiring RBV dose reduction and/or discontinuation. In LT recipients, minimal immunosuppression dose adjustments were required and no biopsy-proven acute rejection occurred. CONCLUSIONS: Treatment with LDV/SOF with/without RBV for 12-24 weeks was very well tolerated and resulted in high SVR 12 rates (96%) in HCV GT1 relapsers to SMV + SOF treatment.