Sumeet K. Asrani M.D.

Posted December 21st 2021

Liver stiffness and prediction of cardiac outcomes in patients with acute decompensated heart failure.

Sumeet K. Asrani M.D.

Sumeet K. Asrani M.D.

Panchani, N., Schulz, P., Van Zyl, J., Felius, J., Baxter, R., Yoon, E.T., Baldawi, H., Bindra, A. and Asrani, S.K. (2021). “Liver stiffness and prediction of cardiac outcomes in patients with acute decompensated heart failure.” Clin Transplant Nov 24;e14545. [Epub ahead of print]. e14545.

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BACKGROUND: In acute decompensated heart failure (ADHF), noninvasive markers that predict morbidity and mortality are limited. Liver stiffness measurement (LSM) increases with hepatic fibrosis; however, it may be falsely elevated in patients with ADHF in the absence of liver disease. We investigated whether elevated LSM predicts cardiac outcomes in ADHF. METHODS: In a prospective study, we examined 52 ADHF patients without liver disease between 2016 and 2017. Patients underwent liver 2D shear wave elastography (SWE) and were followed for 12 months to assess the outcomes of left ventricular assist device (LVAD), heart transplant (HT) or death. RESULTS: The median LSM was elevated in patients who received an LVAD or HT within 30-days compared to those who did not (median [IQR]: 55.6 [22.5 – 63.4] vs 13.8 [9.5 – 40.3] kPa, p = .049). Moreover, the risk of composite outcome was highest in the 3rd tertile (> 39.8 kPa compared to 1(st) and 2(nd) combined, HR 2.83, 95% CI 1.20- 6.67, p = .02). Each 1-kPa increase in LSM was associated with a 1%-increase in the incidence rate of readmissions (IRR 1.01, 95% CI 1.00-1.02, p = .01). CONCLUSIONS: LSM may serve as a novel noninvasive tool to determine LVAD, HT, or death in patients with ADHF.


Posted December 21st 2021

Quality measures in HCC care by the Practice Metrics Committee of the American Association for the Study of Liver Diseases

Sumeet K. Asrani M.D.

Sumeet K. Asrani M.D.

Asrani, S.K., Ghabril, M.S., Kuo, A., Merriman, R.B., Morgan, T., Parikh, N.D., Ovchinsky, N., Kanwal, F., Volk, M.L., Ho, C., Serper, M., Mehta, S., Agopian, V., Cabrera, R., Chernyak, V., El-Serag, H.B., Heimbach, J., Ioannou, G.N., Kaplan, D., Marrero, J., Mehta, N., Singal, A., Salem, R., Taddei, T., Walling, A. and Tapper, E.B. (2021). “Quality measures in HCC care by the Practice Metrics Committee of the American Association for the Study of Liver Diseases.” Hepatology Nov 15. [Epub ahead of print].

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BACKGROUND AND AIMS: The burden of hepatocellular carcinoma (HCC) is substantial. To address gaps in HCC care, the American Association for the Study of Liver Diseases (AASLD) Practice Metrics Committee (PMC) aimed to develop a standard set of process-based measures and patient-reported outcomes along the HCC care continuum. APPROACH AND RESULTS: We identified candidate process and outcomes measures for HCC care based on structured literature review. A 13-member panel with content expertise across the HCC care continuum evaluated candidate measures on importance and performance gap using a modified Delphi approach (two rounds of rating) to define the final set of measures. Candidate patient-reported outcomes (PRO) based on a structured scoping review were ranked by 74 patients with HCC across 7 diverse institutions. Out of 135 measures, 29 measures made the final set. These covered surveillance (6 measures), diagnosis (6 measures), staging (2 measures), treatment (10 measures), and outcomes (5 measures). Examples included the use of ultrasound (± alpha-fetoprotein [AFP]) every 6 months, need for surveillance in high-risk populations, diagnostic testing for patients with a new AFP elevation, multidisciplinary liver tumor board (MLTB) review of Liver Imaging-Reporting and Data System 4 lesions, standard evaluation at diagnosis, treatment recommendations based on Barcelona Clinic Liver Cancer staging, MLTB discussion of treatment options, appropriate referral for evaluation of liver transplantation candidacy, and role of palliative therapy. PROs include those related to pain, anxiety, fear of treatment, and uncertainty about the best individual treatment and the future. CONCLUSIONS: The AASLD PMC has developed a set of explicit quality measures in HCC care to help bridge the gap between guideline recommendations and measurable processes and outcomes. Measurement and subsequent implementation of these metrics could be a central step in the improvement of patient care and outcomes in this high-risk population.


Posted November 15th 2021

Extrahepatic causes of death in cirrhosis compared to other chronic conditions in the United States, 1999-2017.

Sumeet K. Asrani M.D.

Sumeet K. Asrani M.D.

Shankar, N., A. Ramani, C. Griffin, U. Agbim, D. Kim, A. Ahmed and S. K. Asrani (2021). “Extrahepatic causes of death in cirrhosis compared to other chronic conditions in the United States, 1999-2017.” Ann Hepatol: 100565.

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INTRODUCTION AND OBJECTIVES: Cirrhosis- related mortality is underestimated and is increasing; extrahepatic factors may contribute. We examined trends in cirrhosis mortality from 1999-2017 in the United States attributed to liver-related (varices, peritonitis, hepatorenal syndrome, hepatic encephalopathy, hepatocellular carcinoma sepsis) or extrahepatic (cardiovascular disease, influenza and pneumonia, diabetes, malignancy) causes, and compared mortality trends with congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) populations. MATERIALS AND METHODS: A national mortality database was used. Changes in age-standardized mortality over time were determined by joinpoint analysis. Average annual percentage change (AAPC) was estimated. RESULTS: Cirrhosis cohort: From 1999-2017, both liver-related (AAPC 1.3%; 95% confidence interval [CI] 0.7-1.9) and extrahepatic mortality (AAPC 1.0%; 95% CI 0.7-1.2) increased. Cirrhosis vs other chronic disease cohorts: changes in all-cause mortality were higher in cirrhosis (AAPC 1.0%; 95% CI 0.7-1.4) than CHF (AAPC 0.1%; 95% CI -0.5- 0.8) or COPD (AAPC -0.4%; 95% CI -0.6- -0.2). Sepsis mortality was highest in cirrhosis (AAPC 3.6%, 95% 3.2- 4.1) compared to CHF (AAPC 0.6%, 95% CI -0.5- 1.7) or COPD (AAPC 0.8%, 95% CI 0.5- 1.2). Cardiovascular mortality increased in cirrhosis (AAPC 1.3%, 95% CI 1.1- 1.5), declined in CHF (AAPC -2.0%, 95% CI -5.3- 1.3) and remained unchanged in COPD (AAPC 0.1%, 95% CI -0.2- 0.4). Extrahepatic mortality was higher among women, rural populations, and individuals >65 years with cirrhosis. CONCLUSIONS: Extrahepatic causes of death are important drivers of mortality and differentially impact cirrhosis compared to other chronic diseases.


Posted November 15th 2021

Underestimation of cirrhosis related mortality in the Medicare eligible population, 1999-2018.

Sumeet K. Asrani M.D.

Sumeet K. Asrani M.D.

Griffin, C., U. Agbim, A. Ramani, N. Shankar, F. Kanwal and S. K. Asrani (2021). “Underestimation of cirrhosis related mortality in the Medicare eligible population, 1999-2018.” Clin Gastroenterol Hepatol Oct 30;S1542-3565(21)01149-6. [Epub ahead of print].

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The burden of cirrhosis may be increasing, especially among the elderly. A recent updated definition of cirrhosis has a >90% positive predictive value (PPV) for identifying cirrhosis and cirrhosis related complications. We hypothesized that cirrhosis-related mortality is underestimated, and that the elderly are disproportionally impacted. In this study, we aimed to 1) examine trends in liver related mortality using this updated definition among the elderly and 2) identify changes by relevant subsets of gender, race and rurality. [No abstract; excerpt from article].


Posted November 15th 2021

Role of novel kidney biomarkers in patients with cirrhosis and after liver transplantation.

Sumeet K. Asrani M.D.

Sumeet K. Asrani M.D.

Asrani, S. K., N. Shankar, B. da Graca, M. K. Nadim and A. Cardenas (2021). “Role of novel kidney biomarkers in patients with cirrhosis and after liver transplantation.” Liver Transpl Oct 29. [Epub ahead of print].

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Acute kidney injury (AKI) and chronic kidney disease (CKD) are important drivers of morbidity and mortality in patients with cirrhosis before and after liver transplantation (LT). In this review, we examine the role of novel kidney biomarkers for early recognition of kidney injury. Studies are limited by lack of reference standards, heterogeneous definitions of outcomes and biomarker cutoffs, and inconsistent diagnostic performance. Overall, a change in biomarker is more relevant than an absolute cutoff. CIRRHOSIS: Cystatin C and urinary neutrophil gelatinase-associated lipocalin (NGAL) are the most studied candidate biomarkers and identify AKI or progression of AKI earlier than serum creatinine (sCr). Kidney injury molecule 1 and liver-type fatty acid binding protein (L-FABP) also show potential. NGAL and IL-18 may play a role in differentiating acute tubular necrosis from other forms of AKI. Combining novel biomarkers with the Model for End-Stage Liver Disease (MELD) score may assist prognosis. Persistent elevations in select markers (e.g., NGAL) can portend irreversible injury. TRANSPLANT: Several pretransplant markers (including sCr) predict posttransplant kidney dysfunction. Pretransplant assessment of clinical factors (e.g., age, diabetes) and novel markers (osteopontin and TIMP1) may predict renal kidney recovery after LT. Intraoperative changes in biomarkers predict early post-LT AKI. Prediction of CKD remains difficult, although a combination of biomarkers (e.g., beta 2 microglobulin, CD40) are promising. Novel biomarkers have yet to replace sCr in guideline-based evaluation and management of kidney dysfunction in patients with cirrhosis. We propose a theoretical framework for practical incorporation of these biomarkers that considers patient characteristics (risk for irreversible injury), markers of functional and structural change, and assessment of the AKI-CKD continuum to identify patients at highest risk for progressive kidney disease before and after LT.