Archita P. Desai

Co-management Between Hospitalist and Hepatologist Improves the Quality of Care of Inpatients With Chronic Liver Disease

Background and Goals: Our institution shifted the care of patients with chronic liver disease (CLD) from Internal Medicine faculty, house staff, and consulting hepatology service to a co-managed unit staffed by academic hospitalists and hepatologists. The effect of co-management between hospitalists and hepatologists on the care of patients hospitalized with complications of CLD such as spontaneous bacterial peritonitis (SBP) is unknown. Study: A retrospective chart review of 56 adult patients admitted with CLD and SBP from July 1, 2004 to June 30, 2010 was performed. Adherence rates to current management guidelines were measured along with costs and outcomes of care. Results: Patients admitted under the 2 models of care were similar; however, they consistently underwent paracentesis within 24 hours (100% vs. 79%, P=0.013), had appropriate avoidance of fresh-frozen plasma use (75% vs. 43%, P=0.05), received albumin (97% vs. 65%, P=0.002), and were discharged on SBP prophylaxis (91% vs. 37%, P<0.001) under the co-managed model compared with the conventional model. Costs of care were similar between the 2 groups. We note a trend toward improved outcomes of care under the co-management model as measured by transfer rates to the intensive care unit, inpatient mortality, 30-day readmission, and mortality rates. Conclusions: These results support co-management between hospitalists and hepatologists as a superior model of care for hospitalized patients with SBP. Furthermore, this study adds to the growing literature indicating that efforts are needed to improve the quality of care delivered to CLD patients.

Persistent spontaneous bacterial peritonitis: a common complication in patients with spontaneous bacterial peritonitis and a high score in the model for end-stage liver disease

Objectives: Spontaneous bacterial peritonitis (SBP) is associated with a high mortality rate. After antibiotic therapy, improvement in fluid polymorphonuclear (PMN) cell count is expected within 2 days. However, our institution recognized cases unresponsive to standard treatment. Methods: To study these recalcitrant cases, we completed a retrospective chart review of patients admitted for SBP to the University of Chicago from 2002 to 2007. SBP was defined by an ascitic PMN cell count ≥250/ml. Results: Of 55 patients with SBP, 15 did not show improvement in fluid PMN cell count to below 250/ml with standard treatment, leading to a prevalence of 27%. The patients with persistent SBP were younger than those with nonpersistent SBP [mean (SD) 51.80 (9.84) compared with 58.13 (8.79); p = 0.0253]. Persistent SBP had a higher serum ascites albumin gradient (SAAG) [median (Q1, Q3) 1.85 (1.50, 2.41) compared with 1.10 (0.60, 1.60)] and a higher score in the model for end-stage liver disease (MELD) [mean (SD) 27.98 (8.09) compared with 22.22 (8.10)] than nonpersistent SBP patients; p = 0.027 and p = 0.023, respectively. In addition, persistent SBP patients were more likely to have a positive ascitic fluid culture than nonpersistent SBP patients [odds ratio (OR) (95% CI) 4.33 (1.21, 15.47); p = 0.024]. Importantly, in-hospital mortality in the persistent SBP group was 40%, compared with 22.5% in the nonpersistent SBP group [OR = 2.30 (0.64, 8.19); p = 0.20]. Conclusions: The risk of persistent SBP is nearly 40% in patients with MELD score >25, SAAG >1.5 or positive ascitic fluid culture. Furthermore, patients who develop persistent SBP tend to experience a higher mortality rate. This study underscores the importance of further examination of this vulnerable population.

Naives, Nonresponders, Relapsers: Who Is There Left to Treat?

Hepatitis C has a high prevalence in the United States, and the disease burden of HCV will increase over the next 20 to 30 years by many estimates. Trials to evaluate new therapies and optimize the use of triple drug therapies are needed if HCV is to be successfully controlled and its incumbent morbidity and mortality drastically lowered for all groups of patients. With improvements in ability to achieve SVR with agents such as telaprevir and boceprevir, efforts to improve treatment uptake rates and to re-examine the utility of universal or more inclusive screening for chronic hepatitis C are warranted.

The Burden of Rehospitalization for Patients With Liver Cirrhosis

ABSTRACT Advanced liver disease is becoming more prevalent in the United States. This increase has been attributed largely to the growing epidemic of nonalcoholic fatty liver disease and an aging population infected with hepatitis C. Complications of cirrhosis are a major cause of hospital admissions and readmissions. It is important to target efforts for preventing rehospitalization toward patients with cirrhosis who are at the highest risk for readmission, such as those who have high Model for End-Stage Liver Disease scores, are at risk for fluid/electrolyte abnormalities or overt hepatic encephalopathy recurrence, and those who have comorbid conditions (e.g. diabetes). The heart failure management paradigm may provide valuable insights for managing patients with cirrhosis, given the extensive research on preventing hospital readmission and improving health care utilization in this subpopulation. As quality measures related to hospital readmissions for cirrhosis and its complications are adopted by the Centers for Medicare & Medicaid Services and private payers in the future, understanding drivers of hospital readmissions and health care utilization in this vulnerable population are key to improving quality measure performance.

Liver Transplantation in the Obese Cirrhotic Patient

Abstract Despite the rapidly increasing prevalence of obesity in the transplant population, the optimal management of obese liver transplant candidates remains undefined. Setting strict body mass index cutoffs for transplant candidacy remains controversial, with limited data to guide this practice. Body mass index is an imperfect measure of surgical risk in this population, partly due to volume overload and variable visceral adiposity. Weight loss before transplantation may be beneficial, but it remains important to avoid protein calorie malnutrition and sarcopenia. Intensive lifestyle modifications appear to be successful in achieving weight loss, though the durability of these interventions is not known. Pretransplant and intraoperative bariatric surgeries have been performed, but large randomized controlled trials are lacking. Traditional cardiovascular comorbidities are more prevalent in obese individuals and remain the basis for pretransplant cardiovascular evaluation and risk stratification. The recent US liver transplant experience demonstrates comparable patient and graft survival between obese and nonobese liver transplant recipients, but obesity presents important medical and surgical challenges during and after transplant. Specifically, obesity is associated with an increased incidence of wound infections, wound dehiscence, biliary complications and overall infection, and confers a higher risk of posttransplant obesity and metabolic syndrome-related complications. In this review, we examine current practices in the obese liver transplant population, offer recommendations based on the currently available data, and highlight areas where additional research is needed.

A Rare Case of Downhill Esophageal Varices in the Absence of Superior Vena Cava Obstruction

A Rare Case of Downhill Esophageal Varices in the Absence of Superior Vena Cava Obstruction

Closing the Quality Chasm in Cirrhosis

Chronic liver disease (CLD) is the fourth leading cause of death in 2015 for adults aged 45 to 64 years, ranking higher than diabetes and cerebrovascular diseases in this age group. Despite significant improvements in medical knowledge and therapeutics for patients with CLD, multiple studies over the past decade report suboptimal quality of care (Table 1). Several efforts have been undertaken to establish quality indicators for patients with CLD, but reliably monitoring and measuring the indicators on an ongoing basis can be a challenge. Future initiatives aimed at closing the quality chasm should adopt a three-pronged strategy to achieve sustainable improvements in quality of care: (1) efforts to support adherence to guideline-driven care, (2) healthsystem-level interventions to reduce readmissions, and (3) focus on improving patient-reported outcomes (PROs).

Vanishing Bile Duct Syndrome with Hemophagocytic Lymphohistiocytosis After Minimal Change Disease

Vanishing Bile Duct Syndrome with Hemophagocytic Lymphohistiocytosis After Minimal Change Disease Kai Rou Tey, MD, Kristen Barrett, MD, Richa Jain, MD, Thomas D. Boyer, MD, Archita Desai, MD Department of Internal Medicine, University of Arizona College of Medicine South Campus, Tucson; Department of Gastroenterology, University of Arizona College of Medicine, Tucson; Department of Pathology, University of Arizona College of Medicine, Tucson.

What Is the Best Way to Screen Cirrhotic Patients for Hepatocellular Carcinoma in the United States

Hepatocellular carcinoma (HCC) continues to be a significant cause of mortality in the United States. However, HCC is curable if detected early in its course. Cirrhosis is a well-established risk factor for HCC, but direct evidence demonstrating the benefit of screening for HCC in this population remains under contention today. Ultrasound (US) every 6 months is currently the proposed screening methodology. Serum alpha-feto protein (AFP) has been dropped from screening guidelines, yet recent prospective data reported an added efficacy with the combination of serum AFP and US. Technological advances in cross-sectional imaging have dramatically impacted the field of hepatobiliary imaging, making them attractive alternatives for HCC screening in selected populations. While computed tomography (CT) does not appear to confer any significant advantage to US performed by trained personnel, magnetic resonance imaging (MRI) with hepatobiliary phase (HBP) and diffuse weighted imaging (DWI) offers the best sensitivity and specificity for HCC largely due to its superiority in detecting and characterizing lesions <2 cm. Its cost-effectiveness as a screening tool, however, remains to be seen.

Budd-Chiari Syndrome in a Patient with Hepatitis C.

Chronic Budd-Chiari syndrome can present with cirrhosis and signs and symptoms similar to those of other chronic liver diseases. We present a case of Budd-Chiari syndrome discovered during attempted transjugular intrahepatic portosystemic shunting in a patient with decompensated cirrhosis believed to be secondary to hepatitis C. Although the patient had hepatocellular carcinoma, the Budd-Chiari syndrome was a primary disease due to hepatic venous webs. Angioplasty was performed in this case, which resolved the patients symptoms related to portal hypertension. Follow-up venography 5 months after angioplasty demonstrated continued patency of the hepatic veins. A biopsy was obtained in the same setting, which showed centrilobular fibrosis indicating that venous occlusion was indeed the cause of cirrhosis. It is important to consider a second disease when treating a patient with difficult to manage portal hypertension.