Sumeet K. Asrani M.D.

Agbim, U. and S. K. Asrani (2019). “Non-invasive assessment of liver fibrosis and prognosis: an update on serum and elastography markers.” Expert Rev Gastroenterol Hepatol Feb 6: p. 1-14. [Epub ahead of print].

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INTRODUCTION: Non-invasive assessment of fibrosis is increasingly utilized in clinical practice to diagnose hepatic fibrosis. Non-invasive assessment of liver fibrosis relies on biologic and/or physical properties to assess tissue fibrosis. Serum markers estimate fibrosis by incorporating markers reflecting hepatic function (indirect markers) and/or markers measuring extracellular matrix degradation/fibrogenesis (direct markers). Radiology based techniques relay the mechanical properties and stiffness of a tissue, with increased stiffness associated with more advanced fibrosis. Areas covered: In this comprehensive review, the recent literature discussing serum markers and elastography-based techniques will be covered. These modalities are also explored in the setting of various liver diseases. Expert opinion: The etiology of liver disease and clinical context should be taken into consideration when non-invasive markers are incorporated in clinical practice. Non-invasive assessment of fibrosis has been most extensively utilized in hepatitis C, followed by hepatitis B and nonalcoholic fatty liver disease, but its role remains less developed in other etiologies of liver disease such as alcohol-associated liver disease and autoimmune liver disease. The role of non-invasive markers in predicting progression or regression of fibrosis, development of liver-related events and survival needs to be further explored.

Idriss, R., J. Hasse, T. Wu, F. Khan, G. Saracino, G. McKenna, G. Testa, J. Trotter, G. Klintmalm and S. K. Asrani (2019). “Impact of Prior Bariatric Surgery on Perioperative Liver Transplant Outcomes.” Liver Transpl 25(2): 217-227.

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Bariatric surgery (BS) is effective in treating morbid obesity, but the impact of prior BS on candidacy for liver transplantation (LT) is unclear. We examined 78 patients with cirrhosis with prior BS compared with a concurrent cohort of 156 patients matched by age, Model for End-Stage Liver Disease score, and underlying liver disease. We compared rates of transplant denial after evaluation, delisting on the waiting list, and survival after LT. The median time from BS to LT evaluation was 7 years. Roux-en-Y gastric bypass was the most common BS procedure performed (63% of cohort). Nonalcoholic fatty liver disease was the leading etiology for liver cirrhosis (47%). Delisting/death on the waiting list was higher among patients with BS (33.3% versus 10.1%; P = 0.002), and the transplantation rate was lower (48.9% versus 65.2%; P = 0.03). Intention-to-treat (ITT) survival from listing to 1 year after LT was lower in the BS cohort versus concurrent cohort (1-year survival, 84% versus 90%; P = 0.05). On adjusted analysis, a history of BS was associated with an increased risk of death on the waiting list (hazard ratio [HR], 5.7; 95% confidence interval [CI], 2.2-15.1), but this impact was attenuated (HR, 4.9; 95% CI, 1.8-13.4) by the presence of malnutrition. When limited to matched controls by sex, mortality attributed to BS was no longer significant for females (P = 0.37) but was significant for males (P = 0.046). Sarcopenia, as captured by skeletal muscle index, was calculated in a subset of patients (n = 49). The total skeletal surface area was lower in the BS group (127 [105-141] cm(2) versus 153 [131-191] cm(2) ; P = 0.005). Rates of sarcopenia were higher among patients delisted after listing (71.4% versus 16.7%; P = 0.04). In conclusion, a history of BS was associated with higher rates of delisting on the waiting list as well as lower survival from the time of listing on ITT analysis. Presence of malnutrition and sarcopenia among patients with BS may contribute to worse outcomes.

Sundaram, V., R. Jalan, T. Wu, M. L. Volk, S. K. Asrani, A. S. Klein and R. J. Wong (2018). “Factors Associated with Survival of Patients With Severe Acute on Chronic Liver Failure Before and After Liver Transplantation.” Gastroenterology 2018 Dec 18. [Epub ahead of print].

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BACKGROUND & AIMS: Liver transplantation for patients with acute on chronic liver failure with 3 or more failing organs (ACLF-3) is controversial. We compared liver waitlist mortality or removal according to model for end-stage liver disease (MELD) score vs ACLF category. We also studied factors associated with reduced odds of survival for 1 year after liver transplantation in patients with ACLF-3. METHODS: We analyzed data from the United Network for Organ Sharing from 2005 through 2016. We identified patients who were on the waitlist (100,594) and those who received liver transplants (50,552). Patients with ACLF were identified based on the EASL-CLIF criteria. Outcomes were evaluated with competing risks regression, Kaplan-Meier analysis, and Cox proportional hazards regression. RESULTS: Patients with ACLF-3 were more likely to die or be removed from the waitlist, regardless of MELD-Na score, compared to the other ACLF groups; the proportion was greatest for patients with an ACLF-3 score and MELD-Na score below 25 (43.8% at 28 days). Mechanical ventilation at liver transplantation (hazard ratio [HR], 1.49; 95% CI, 1.22-1.84), donor risk index above 1.7 (HR, 1.22; 95% CI, 1.09-1.35), and liver transplantation within 30 days of listing (HR, 0.89; 95% CI, 0.81-0.98) were independently associated with survival for 1 year after liver transplantation CONCLUSIONS: In an analysis of data from the United Network for Organ Sharing registry, we found high mortality among patients with ACLF-3 on the liver transplant waitlist-even among those with lower MELD-Na scores. So, certain patients with ACLF-3 have poor outcomes regardless of MELD-Na score. Liver transplantation increases odds of survival for these patients, particularly if performed within 30 days of placement on the waitlist. Mechanical ventilation at liver transplantation and use of marginal organs were associated with increased risk of death.

Kanwal, F., E. B. Tapper, C. Ho, S. K. Asrani, N. Ovchinsky, J. Poterucha, A. Flores, V. Ankoma-Sey, B. Luxon and M. Volk (2018). “Development of Quality Measures in Cirrhosis by the Practice Metrics Committee of the American Association for the Study of Liver Diseases.” Hepatology Dec 26. [Epub ahead of print].

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Health care delivery is increasingly evaluated according to quality measures, yet such measures are underdeveloped for cirrhosis. The Practice Metrics Committee of the American Association for the Study of Liver Diseases was charged with developing explicit process- and outcome-based measures for adults with cirrhosis. We identified candidate measures from comprehensive reviews of the literature and input from expert clinicians and patient focus groups. We conducted an 11-member expert clinician panel and used a modified Delphi method to systematically identify a set of quality measures in cirrhosis. Among 119 candidate measures, 46 were identified as important measures to define quality of cirrhosis care, including 26 process measures, 7 clinical outcome measures, and 13 patient-reported outcome measures. The final process measures captured care processes across the entire spectrum from diagnosis, treatment, and prevention for ascites (5 measures), varices/bleeding (7 measures), hepatic encephalopathy (4 measures), hepatocellular cancer (HCC) screening (1 measure), liver transplantation evaluation (2 measures), and other care (7 measures). Clinical outcome measures included survival, variceal bleeding and re-bleeding, early-stage HCC, liver-related hospitalization, and rehospitalization within 7 and 30 days. Patient-reported outcome measures covered physical symptoms, physical function, mental health, general function, cognition, social life, and satisfaction with care. The final list of patient-reported outcomes was validated in 79 cirrhosis patients from 9 institutions in the United States.Conclusion We developed an explicit set of evidence-based quality measures for adult patients with cirrhosis. These measures are a tool for providers and institutions to evaluate their care quality, drive quality improvement, and deliver high-value cirrhosis care. The quality measures are intended to be applicable in any clinical care setting in which care for patients with cirrhosis is provided.

Asrani, S. K. and J. Hasse (2018). “Bariatric surgery and long-term outcomes.” Liver Transpl Dec 24. [Epub ahead of print].

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We appreciate the interest in our work by Professor Yildiz looking at the association between bariatric surgery and outcomes among patients evaluated for liver transplantation.(1) We share the sentiment that some of the outcomes noted in the study may be related to malabsorptive rather than restrictive weight reduction surgery. As reflected in the results, rates of delisting or death were high for gastric bypass versus non-gastric bypass patients (44% vs. 16.7%, p<0.01). However, rates of moderate or severe malnutrition were similar between the groups (68% vs. 57%, p=0.5). Hence, in this analysis of historical data it is hard to assess whether it is the surgery itself of consequence of malnutrition regardless of surgery type that are driving the effect.