Ayman B. Ibrahim

MELD fails to measure quality of life in liver transplant candidates

Previous studies have demonstrated an association between Child Turcotte‐Pugh (CTP) class and impaired quality of life. However, the relationship between the model for end‐stage liver disease (MELD) score and quality of life (QOL) has not been well studied. In this study, quality of life questionnaires (Medical Outcomes Short Form 36 [SF‐36] and the Chronic Liver Disease Questionnaire [CLDQ]) were administered to 150 adult patients awaiting liver transplantation. We also collected demographic data and laboratory results and recorded manifestations of hepatic decompensation. The study found that all domains of the SF‐36 and CLDQ were significantly lower in our patient cohort than in normal controls (P < .001). There was a moderate negative correlation between CPT class and physical components of the SF‐36 (r = −.30), while there was a weak negative correlation (r = −.10) between CPT class and the mental component. There was a negative moderate correlation between CPT class and overall CLDQ (r = −.39, P < .001) and a weak correlation (r = −.20) between MELD score and overall CLDQ score. Both encephalopathy (correlation coefficient = −.713, P = .004) and ascites (correlation coefficient = −.68, P = .006) were predictive of the QOL using CLDQ (adjusted R2 = .1494 and f = 0.000). In conclusion, in liver transplant candidates, the severity of liver disease assessed by the MELD score was not predictive of QOL. The presence of ascites and/or encephalopathy was significantly associated with poor quality of life. CTP correlates better to QOL, probably because it contains ascites and encephalopathy. (Liver Transpl 2005;11:218–223.)

Employment and quality of life in liver transplant recipients

The purposes of liver transplantation (LT) include the extension of survival, improvement in quality of life, and the return of the recipient as a contributing member of society. Employment is one measure of the ability to return to society. The aim of this study is to determine the factors affecting employment/subemployment after LT. A total of 308 adult liver transplant recipients who were seen at the University of California, Los Angeles were administered the Medical Outcomes Short Form 36 (SF‐36) and a questionnaire regarding work history and insurance coverage. Multivariate analysis were used to identify independent variables associated with posttransplantation employment. Interaction terms were used to examine effect modification. Of 308 transplant recipients, 218 (70.8%) worked prior to transplantation, and 78 (27%) worked posttransplantation. Pretransplant variables that were independently associated with posttransplantation employment included the following: lack of disability income (odds ratio [OR] = 1.86; 95% confidence interval [CI], 1.32‐7.18; P = 0.36); health maintenance organization (HMO)/preferred provider organization (PPO) insurance (OR = 3.08; 95% CI, 1.32‐7.18; P < 0.01); the number of hours worked (OR = 1.17; 95% CI, 1.08‐1.28; P < 0.01); and the lack of diabetes mellitus (OR = 0.23; 95% CI, 0.70‐0.73; P < 0.01). An interaction term between disability income and hours worked prior to transplantation (OR = 0.16; 95 % CI, 0.03‐0.83; P = 0.03) was independently associated with posttransplantation employment. In a separate regression model of SF‐36 responses, posttransplantation physical functioning (OR = 1.17; 95% CI, 1.10‐1.26; P < 0.01) and role‐physical (OR = 1.1; 95% CI, 1.02‐1.16; P < 0.01) were independently associated with employment after transplantation. In conclusion, HMO or PPO insurance, lack of disability income coverage prior to transplant, the absence of diabetes mellitus, the number of hours worked prior to transplantation, and high physical functioning were associated with posttransplantation employment. Liver Transpl 13:1330–1338, 2007.

Hepatitis C Positive Grafts may be used in Orthotopic Liver Transplantation: A Matched Analysis

Hepatitis C (HCV)‐positive liver grafts have been increasingly used in patients with decompensated liver disease from HCV because of critical shortage of available organs. Fifty‐nine recipients of HCV‐positive grafts were matched to patients who received HCV‐negative grafts. All recipients were transplanted for HCV liver disease. Matching variables were (1) status, (2) pre‐transplant creatinine, (3) recipient age, (4) donor age, (5) warm ischemia time, and (6) year of transplantation. Both unmatched and matched analyses were performed on patient survival, graft survival, and time to HCV recurrence. There was no significant statistical difference in patient, graft, or HCV recurrence‐free survival between recipients of HCV‐positive and HCV‐negative grafts with matched and unmatched analyses (p > 0.05). The 3‐year estimates of HCV disease‐free survival were 12% (± 9%) and 19% (± 7%) using HCV‐positive and –negative grafts, respectively. The use of HCV‐positive grafts in recipients with HCV does not appear to affect patient survival, graft survival, or HCV recurrence when compared with the use of HCV‐negative grafts. Our results suggest that HCV‐positive grafts can be used in a HCV liver transplant recipient.

Anemia in liver transplant recipients undergoing antiviral treatment for recurrent hepatitis C

Adherence to antiviral therapy is essential to achieve sustained virological responses in patients treated for hepatitis C. An important limitation to use of appropriate doses of ribavirin is development of anemia. The aim of this study is to identify risk factors associated with anemia in liver transplant recipients undergoing treatment for recurrent hepatitis C virus (HCV). Retrospective analysis was performed on 115 adult liver transplantation (LT) recipients who received antiviral treatment. Anemia was defined as hemoglobin of <10 gm/dL or the use of erythropoietin replacement therapy. Variables found to be significant in univariate analysis were further studied in multivariate analysis. The mean (± standard deviation [SD]) age of our cohort was 52.1 (± 8.8) yr. Anemia developed in 44 patients (38.3%). Mean (± SD) onset of anemia was 8.9 (± 6.8) weeks after initiation of antiviral therapy. A total of 30 patients (26%) required erythropoietin replacement, at a mean (± SD) of 7.9 (± 6.0) weeks after start of antiviral treatment. A total of 27 patients (24%) required ribavirin dose reduction, at a mean (± SD) time to dose reduction of 8.1 (± 6.3) weeks. In univariate analysis, body mass index (BMI) (P < 0.01), mycophenolate mofetil use (P = 0.05), trimethoprim‐sulfamethoxazole (P = 0.02), and age (P = 0.02) were statistically significant. In conclusion, in multivariate analysis, BMI (P < 0.01) and age (P = 0.02) were found to be independent predictors of anemia. Anemia is common in liver transplant recipients treated for recurrent HCV. Special vigilance is required for older patients and patients with a low BMI. Liver Transpt 13:1032–1038, 2007.

Management of patients with cirrhosis in southern california : Results of a practitioner survey

Introduction: Cirrhosis is an important medical and public health concern. A paucity of data exists on how patients with cirrhosis are managed. Our aims were to determine how cirrhosis is managed and whether current management practices follow established recommendations. Methods: A questionnaire was mailed to Southern California Society of Gastroenterology members. Most had practiced for more than 15 years (67%) in a private practice setting (69%). Proportions of physicians who followed established guidelines versus those who had not were compared using χ2 test. Results: Hepatitis A, hepatitis B, influenza, and pneumococcus vaccinations were recommended by most respondents. Ninety-one percent of respondents routinely screened patients for hepatocellular carcinoma. A significantly greater proportion of respondents screened for hepatocellular carcinoma using either alpha-fetoprotein or ultrasound every 6 months (P < 0.05). Seventy-six percent recommended antibiotic prophylaxis in patients with prior spontaneous bacterial peritonitis, whereas less than half recommended prophylaxis in patients with ascitic protein fluid <1g/dL, current variceal bleed, and those on the liver transplant list. Sixty-seven percent of respondents performed screening esophagogastroduodenoscopy upon diagnosis of cirrhosis. Most respondents did not recommend repeating endoscopy in 1 to 2 years if a patient was found to have small varices (P < 0.05), and would repeat an endoscopy if large varices were found (P < 0.05). Conclusion: The management of patients with cirrhosis in the community varied and did not always conform to established guidelines. These results should be confirmed in a larger group of physicians, and the rationales for physicians accepting or rejecting established guidelines should be further assessed.

Discordance Between ALT Values and Fibrosis in Liver Transplant Recipients Treated with Ribavirin for Recurrent Hepatitis C

Hepatitis C virus (HCV) recurrence is a serious problem after orthotopic liver transplantation (OLT). The role of ribavirin as a single agent to treat recurrent HCV is controversial. Our aim was to evaluate the correlation between alanine aminotransferase (ALT) levels and histological findings in OLT recipients treated with ribavirin monotherapy for recurrent HCV. The mean [± standard error (SE)] age of 11 patients was 50.1 (SE ± 8.6) years. The estimated mean dose and duration of ribavirin treatment (± SE) was 661.5 (± 52.5) mg and 20.4 (± 1.7) months, respectively. Five patients required either dose reduction or erythropoietin. We found a significant decrease of mean (± SE) ALT value from 246 ± 44.8 U/L to 109.4 ± 49.1 U/L (p = 0.002) in patients treated with ribavirin. However, there was also significant worsening of interface activity (p = 0.03) and fibrosis (p = 0.02). No significant association was found between ALT values and (i) stage of hepatic fibrosis, (ii) interface activity, (iii) lobular activity and (iv) HCV RNA values. Our results suggest that HCV disease can progress despite a significant decrease in ALT values. ALT values are inadequate markers of the ribavirin monotherapy and can lead to erroneous conclusions of efficacy.

Pretransplant variables associated with quality of life in liver transplant recipients

Objective: With an increasing number of liver transplant recipients living, understanding quality‐of‐life issues is essential. Our goal is to identify pretransplant variables associated with post‐transplant quality of life in liver transplant recipients.