James F. Trotter, M.D.

Trotter, J. F. (2017). “An ectopically expressed serum mirna signature is prognostic, diagnostic, and biologically related to liver allograft rejection.” Hepatology 65(1): 15-17.

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As its efficacy has continually improved overthe past three decades, liver transplantation(LT) has become an established therapy forselected patients with end-stage liver disease. Long-term survival rates are excellent, with approximately60% of patients surviving beyond 10 years. In fact, thereare more LT recipients alive than ever before, estimatedat more than 65,000 by the Scientific Registry of Trans-plant Recipients.(1)However, with this success comesnew challenges. As more liver recipients survive wellinto the second decade, their exposure to immunosup-pression and its side effects accumulate over the years.While required to sustain graft function, immunosup-pression is also the source of complications primarilyresponsible for graft loss and death. Specifically, recur-rent progressive hepatitis C, malignancy, and renal fail-ure, all a direct result of immunosuppression, are thethree greatest contributors to long-term graft loss.(2)

Trotter, J. F. and A. Cardenas (2016). “Liver transplantation around the world.” Liver Transpl 22(8): 1059-1061.

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In the recent issues of Liver Transplantation, we have asked transplant doctors and colleagues from around the world to share insights about the state of liver transplantation in their countries. The purpose of these articles is to provide a perspective for each of us to learn how our colleagues organize and provide transplant services based on the challenges and opportunities in their different settings. By learning from the experience of these different countries, we hope that individual physicians might improve their own programs or appreciate the benefits that they might enjoy. To a great extent, the practice of liver transplantation within each country is a reflection of its own unique culture. Western countries are more organized, regulated, and have reached a plateau of transplant volume, whereas emerging countries are less systematic and growing rapidly in both their capabilities and volumes. We hope that these reviews will help provide a better appreciation for the practice of liver transplant within each of our countries by reviewing the experiences reported by Australia, New Zealand, Brazil, Germany, India, Ireland, Japan, Spain, and the United Kingdom. In future issues, authors from more countries around the globe will be invited to also share their experiences.

Trotter, J. F. (2016). “Editorial for neuroendocrine tumor for liver transplant.” Am J Transplant: 2016 June [Epub ahead of print].

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Neuroendocrine tumor (NET) of the gastrointestinal tract and pancreas is a very rare indication for liver transplantation. The most definitive treatment of gastrointestinal NET is resection of the primary tumor and isolated hepatic metastasis, if possible. Other therapeutic options include local ablation and medical therapies (mTOR inhibitors and somatostatin analogues which significantly improve progression-free survival, but provide no survival benefit).

Schussler, J. M., S. K. Asrani, M. A. Ramsay and J. F. Trotter (2016). “Use of a pressure wire to evaluate right heart pressures in a pre-liver transplant recipient through a peripheral iv.” Liver Transpl 22(5): 695-697.

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TO THE EDITOR: The pre–liver transplant cardiovascular evaluation of recipients routinely includes echocardiography to evaluate for the presence of pulmonary hypertension (pHTN), as patients with moderate or severe pHTN have significantly increased perioperative morbidity and mortality. A recent article by Khaderi et al.(1) suggested that portopulmonary hypertension carries even longer-term risks in post–liver transplant patients. It has become standard for patients in whom screening echocardiography suggests systolic pulmonary artery (PA) pressures >45 mm Hg to undergo confirmatory invasive testing with right heart catheterization (RHC). This allows for both confirmation of these findings, as well as initiation of treatment (where appropriate) for pHTN, and subsequent successful transplantation.(2,3) The direct assessment of a patient’s pulmonary pressures requires invasive instrumentation. In a large series of patients with pHTN, the overall risk of complication is approximately 1.1%, mostly due to the access site and bleeding risk.(4) In the general population, the presence of elevated international normalized ratio (INR) or thrombocytopenia increases the risk of invasive cardiac procedures and is a relative contraindication to heart catheterization. In end-stage liver disease patients, there are few data looking at the magnitude of the increased risk. Although there is a general assumption that this risk may be mitigated by administration of blood products (such as fresh frozen plasma or platelets), vitamin K, or recombinant factor VIIa, there are no data to support these maneuvers.(5) RHC has traditionally been performed using catheters up to 8 Fr in size, placed percutaneously through the internal jugular or common femoral vein. Smaller catheters, compatible with sheaths down to 5 Fr in size, make the potential for bleeding less, but there is always the possibility that bleeding complications (sometimes due to inadvertent arterial punctures) can occur when making a venous puncture. We describe the use of a novel pressure wire to easily and safely evaluate a patient’s pulmonary pressures without the need for additional venous punctures or blood products.

Ramsay, M. A. and J. F. Trotter (2016). “The INR is only one side of the coagulation cascade: time to watch the clot.” Anaesthesia. Mar 31. [Epub ahead of print]

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The prothrombin time (PT)-derived international normalized ratio (INR) is frequently used to assess the risk of bleeding for patients receiving warfarin, or who have had liver surgery, liver dysfunction or transplantation. Anaesthetists will rely on it when assessing the potential for neuraxial hematoma formation when placing or removing an epidural catheter. It is also a key component of the Model for End-stage Liver Disease (MELD) score, which is an objective means of predicting 90-day patient survival in patients on the liver transplant waiting list, and is used to prioritize donor organs to the most needy patients. The accuracy of PT measurement has been questioned as there is marked variability in the sensitivity of the thromboplastin reagents used in its determination . . . It has now been well demonstrated that in liver disease, particularly liver cirrhosis, there is a reduction in the production of both pro- and anticoagulants by the liver. Therefore, the PT-derived INR only measures the procoagulant side of the cascade and not the anticoagulant side. (Excerpt from editorial; no abstract.)