Hwan Y. Yoo

Graft and patient survival after adult live donor liver transplantation compared to a matched cohort who received a deceased donor transplantation.

Live donor liver transplantation (LDLT) has become increasingly common in the United States and around the world. In this study, we compared the outcome of 764 patients who received LDLT in the United States and compared the results with a matched population that received deceased donor transplantation (DDLT) using the United Network for Organ Sharing (UNOS) database. For each LDLT recipient (n = 764), two DDLT recipients (n = 1,470), matched for age, gender, race, diagnosis, and year of transplantation, were selected from the UNOS data after excluding multiple organ transplantation or retransplantation, children, and those with incomplete data. Despite our matching, recipients of LDLT had more stable liver disease, as shown by fewer patients with UNOS status 1 or 2A, in an intensive care unit, or on life support. Creatinine and cold ischemia time were also lower in the LDLT group. Primary graft nonfunction, hyperacute rejection rates, and patient survival by Kaplan‐Meier analysis were similar in both groups (2‐year survival was 79.0% in LDLT vs. 80.7% in case‐controls; P = .5), but graft survival was significantly lower in LDLT (2‐year graft survival was 64.4% vs. 73.3%; P < .001). Cox regression (after adjusting for confounding variables) analysis showed that LDLT recipients were 60% more likely to lose their graft compared to DDLT recipients (hazard ratio [HR] 1.6; confidence interval 1.1‐2.5). Among hepatitis C virus (HCV) patients, LDLT recipients showed lower graft survival when compared to those who received DDLT. In conclusion, short‐term patient survival in LDLT is similar to that in the DDLT group, but graft survival is significantly lower in LDLT recipients. LDLT is a reasonable option for patients who are unlikely to receive DDLT in a timely fashion. (Liver Transpl 2004;10:1263–1268.)

Portal hypertensive gastropathy

Portal hypertensive gastropathy (PHG), a term used to describe the endoscopic appearance of gastric mucosa with a characteristic mosaic-like pattern with or without red spots, is a common finding in patients with portal hypertension. Current classification systems that describe the severity of PHG have many limitations, but it appears that simple grading systems have better inter- and intraobserver agreement. The wide variation in the reported prevalence of PHG is probably related to selection bias, absence of uniform criteria and classification, and more importantly, the differences in inter- and intraobserver variation. Pathogenesis of PHG is not clearly defined, but there is a very close relationship between portal hypertension and development of PHG. GAVE is a separate entity from PHG, but patients with severe PHG may have a GAVE-like appearance in the gastric antrum. Acute bleeding from PHG, seen usually in the presence of severe PHG, is often mild and self-limiting. Currently, the only treatment that could be recommended for prophylaxis of bleeding from PHG is nonselective ß-blockers.

Trends in post-liver transplant survival in patients with hepatitis C between 1991 and 2001 in the United States

It has been suggested that the post–liver transplantation (LT) survival rate of patients with hepatitis C virus infection (HCV) has declined in recent years. To compare the outcome of LT in patients with HCV at various time intervals between 1991 and 2001, we used United Network for Organ Sharing data to compare the post‐LT survival of adult patients (age >18 years) with HCV with those without HCV. Of the 37,101 patients who underwent LT during the study period, 28,193 patients (HCV 7,459 and 20,734 non‐HCV) were eligible for the study. On the basis of the time of transplantation, patients were divided into 3 groups: 1991‐1993 (period 1), 1994‐1997 (period 2), and 1998‐2001 (period 3). The patient and graft survival rates were adjusted for other known confounding variables that influenced outcomes. The 3‐year patient survival rate was lower in HCV patients compared with non‐HCV recipients (78.5% vs. 81.4%, hazard ratio 1.14, 95% confidence interval 1.05‐1.23, P = 0.001). The graft (72.8%, 71.0%, and 69.8%) and patient (77.4%, 79.6%, and 78.5%) survival of HCV patients remained unchanged during study periods 1‐3, respectively. However, the graft and patient survival rates of non‐HCV recipients improved markedly during study periods 2 and 3 compared with period 1. The graft and patient survival has remained unchanged between 1991 and 2001 in HCV recipients, but during the same period, there was a great improvement in survival among non‐HCV recipients. Liver Transpl 13:719–724, 2007.

Long-Term Outcome of Liver Transplantation in Patients With PSC: A Comparative Analysis With PBC

BACKGROUND:Primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC) are reported to have the best outcomes after liver transplantation. Based on excellent 5-yr survival results after transplantation, it has been suggested that PSC patients may benefit from “preemptive” transplantation to reduce the risk of cholangiocarcinoma. In this study, we compared 10-yr survival of patients with PSC and PBC using a large database after adjusting for other confounding risk factors.METHODS:The United Network for Organ Sharing (UNOS) database of all patients who had liver transplantation from 1987 to 2001 was used for analysis after excluding patients with multiple organ transplantation, children, and incomplete data.RESULTS:Patients with PSC (n = 3,309) were younger than those with PBC (n = 3,254). Retransplantation rate was high in PSC (12.4% vs 8.5%; p< 0.01), and PSC was an independent predictor for retransplantation on multivariate analysis. Cox regression analysis showed that PSC patients had significantly lower graft and patient survival compared to PBC patients after adjusting for other risk factors. Lower survival in PSC became apparent 7 yr after transplantation.CONCLUSIONS:Patients with PSC had a higher retransplantation rate and lower survival when compared to PBC. Based on this analysis, we do not recommend preemptive liver transplantation for patients with PSC.

Relationship of the model for end-stage liver disease (MELD) scale to hepatic encephalopathy, as defined by electroencephalography and neuropsychometric testing, and ascites.

OBJECTIVE:It has recently been suggested that the Model for End-Stage Liver Disease (MELD) is a better and a more objective predictor of mortality in patients with end-stage liver disease. The aim of our study was to determine the relationship of the MELD score to hepatic encephalopathy (HE), as determined by electroencephalography (EEG) and clinical and neuropsychometric examination, and ascites.METHODS:A total of 66 patients underwent EEG, a neuropsychometric screening by Mini-Mental State Examination, Trails Making Tests, Rey-Osterreith Complex Figure, and Hopkins Verbal Learning Tests, and a clinical assessment for HE. The MELD score was calculated as previously described by using serum creatinine, bilirubin, and international normalized ratio. Subclinical HE was diagnosed if clinical examination did not detect HE but neuropsychometric tests and EEG were abnormal.RESULTS:Sixteen patients had no HE, 28 had subclinical HE, and 22 had clinical HE. Age, sex, race, and cause of liver disease were similar in all three groups. Child-Turcotte-Pugh score was significantly higher in patients with clinical HE compared with the other two groups. There was only a modest correlation (r = 0.5) between Child-Turcotte-Pugh and the MELD scores. The distribution and mean MELD scores were similar in patients with or without HE as determined by clinical or neuropsychometric examination and EEG. Approximately 90% of patients with clinical HE or abnormal EEG and neuropsychometric tests had a MELD score less than 25. Similarly, the MELD score was not affected by the severity of ascites.CONCLUSION:The MELD score does not correlate well with severity of HE or ascites. Patients with HE and ascites might not receive liver transplantation in a timely manner if MELD scores were to be used exclusively for organ allocation.

Short-term postliver transplant survival after the introduction of MELD scores for organ allocation in the United States

Background: It has been suggested that the introduction of model for end‐stage liver disease (MELD) for organ allocation may reduce overall graft and patient survival since elevated serum creatinine is an important predictor of poor outcome after liver transplantation.

Prevalence of transaminase abnormalities in asymptomatic, healthy subjects participating in an Executive Health-Screening Program

The objective of this study was to characterize the prevalence of asymptomatic liver transminase (LT) abnormalities in a healthy, low-risk adult population and identify associated risk factors. We reviewed 2340 completed medical records of participants in our Executive Health Program, which provided screening medical evaluations for executives. LT (alanine aminotransferase and aspartate aminotransferase) were considered abnormal if they above normal range for our laboratory. Subjects were excluded if they had a history of viral hepatitis, nonviral liver disease, or an identifiable cause of LT elevation. Of the 2340 subjects 2294 met inclusion criteria and all had AST recorded, but only 1309 had ALT recorded. In all, 341 subjects (14.9%) were found to have abnormal LT and in those who had less than 3 drinks per day, 13.9% had elevated LT and 3.6% had LT twice the upper limit of normal. Of the 1309 subjects in whom both AST and ALT were measured, 20.8% had abnormal LT and 6.3% had LT twice the upper limit of normal. On univariate analysis age < 60 (P = 0.005), male sex (P < 0.0001), body mass index ≥ 30 (P < 0.0001), cholesterol ≥ 200 mg/dl (P = 0.018), and triglycerides ≥ 200 mg/dl (P < 0.0001) were associated with abnormal LT; all these variables except cholesterol were significant by logistic regression analysis. The odds ratio of abnormal LT and LT 2 times normal was 1.79 (CI 1.20–2.68) and 2.50 (CI 1.04–6), respectively, in subjects with one risk factor, and 2.80 (CI 1.07–7.34) and 4.73 (CI 0.91–24.5), respectively, in subjects with four risk factors. In conclusion, there is a high prevalence of LT abnormalities in this healthy population. Subjects with multiple risk factorsshould be considered for screening.

Accuracy and reliability of the endoscopic classification of portal hypertensive gastropathy

BACKGROUND There is no consensus regarding the endoscopic classification of the severity of portal hypertensive gastropathy. This study compared the accuracy and reproducibility of the 2-category classification system (2-CCS) with the 3-category classification system (3-CCS). METHODS Ninety-eight endoscopic pictures of portal hypertensive gastropathy and 22 of nonspecific gastritis were selected. Eight duplicate sets were generated, each in a different random order. These were shown to 6 experienced endoscopists during 2 sessions 1 week apart with 4 slide sets at each session. Each picture was scored by using either the 2-CCS or 3-CCS. Kappa statistics and percent agreement were used to estimate the reproducibility and agreement. RESULTS The mean percentage agreement among the 4 separate readings for each observer was significantly lower for the 3-CCS compared with the 2-CCS (mean [standard deviation] = 33.5% [8.9%] vs. 64.9% [9.1%]; p = 0.0001). The mean (SD) interobserver kappa values were 0.44 (0.03) for the 3-CCS and 0.52 (0.04) for the 2-CCS (p = 0.02), and the respective intraobserver kappa values were 0.43 (0.1) and 0.63 (0.06) (p = 0.002). CONCLUSIONS Even though both the 2-CCS and 3-CCS have substantial limitations with regard to specificity and reliability, there were better agreement and reproducibility with the simpler classification system for portal hypertensive gastropathy.