Sumeet K. Asrani M.D.

Winder, G. S. and S. K. Asrani (2020). “Payer coverage and liver transplantation for alcohol associated hepatitis.” Liver Transpl Mar 21. [Epub ahead of print].

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We duly note the insurance challenges discussed by Eswaran and Chan. Many insurance payers continue to require fixed pre-transplant sobriety periods (i.e. “6-month rules”) despite the lack of evidence to support them(1-3). While payers reserve the right to skepticism about any center’s evolving policies regarding liver transplantation (LT) for alcohol-associated hepatitis (AH), we anticipate that payers’ approach to these patients will progress. As 1) transplant centers update their institutional criteria regarding LT/AH, 2) acceptable outcomes are demonstrated in a transparent manner and 3) professional societies offer guidance, we anticipate that insurance payers’ policies will follow suit.

Cullaro, G. and S. K. Asrani (2020). “Not All Episodes of Acute Kidney Injury Are Equal in Patients With Cirrhosis, Based on Patterns of Renal Dysfunction.” Clin Gastroenterol Hepatol Mar 14. pii: S1542-3565(20)30332-3. [Epub ahead of print].

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Renal dysfunction is a major driver of mortality in patients with cirrhosis—2 in every 3 patients will have significant kidney dysfunction at the time of their death.1 Although surrogates of kidney dysfunction—serum creatinine, serum sodium—are included in the
Model for End Stage Liver Disease (MELD) and MELDSodium scores, they do little to account for the patterns or pathology of injury that drive kidney dysfunction among patients with cirrhosis. This is a major limitation, as kidney dysfunction phenotypes have varying impact on mortality. Therefore, there is an ever increasing clinical need to better understand the intricacies and implications of kidney function patterns among patients
with cirrhosis. [Excerpt from Editorial]

Serper, M. and S. K. Asrani (2020). “Liver transplantation and chronic disease management: Moving beyond patient and graft survival.” Am J Transplant 20(3): 629-630.

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With advances in surgical techniques, multidisciplinary care, and immunosuppression, patient and graft survival continue to improve in liver transplantation (LT). Excellent patient and graft survival have translated into an aging liver transplant recipient (LTRs) cohort that resembles a general chronic disease population. LTRs are becoming more medically complex related to LT indication (e.g., nonalcoholic fatty liver disease) and with increased prevalence of relevant chronic conditions such as chronic kidney disease (CKD). Hence a paradigm shift is needed, whereby care provided by LT centers needs to focus not only on survival but also optimizing long‐term management and overall health of the LTR. In the current issue of the American Journal of Transplantation, Dr. VanWagner and colleagues examine an important and understudied aspect of posttransplant care, namely, blood pressure (BP) control. In a single‐center, retrospective cohort of 602 LTRs transplanted from 2010 to 2016 that survived more than 6 months after LT, 54% of patients had preexisting hypertension (HTN) and 84% had uncontrolled BP of 140/90 mm Hg or greater. Patients with uncontrolled BP had the expected risk factors: higher body mass index, higher prevalence of nonalcoholic fatty liver disease, pretransplant HTN, and atherosclerotic cardiovascular disease, and higher corticosteroid and mycophenolate use. Only 16% of LTRs achieved at least one BP of <140/<90 mm Hg within the first posttransplant year and only 29% achieved this goal at 5‐year posttransplant. Adherence to guideline‐recommended BP targets of <130/<80 for groups at higher risk for cardiovascular events (CVEs) such those with CKD and diabetes were dismal; less than 5% in the first year post‐LT and less than 10% at year 5. Rates of discussing initiation of antihypertensives during clinical visits were all below 50% whereas utilization of guideline‐recommended calcium channel blockers was only 14%. (Excerpt from text, p. 629; no abstract available.)

Sarmast, N., G. O. Ogola, M. Kouznetsova, M. Leise, R. Bahirwani, R. Maiwall, E. Tapper, J. Trotter, J. Bajaj, L. R. Thacker, P. Tandon, F. Wong, R. Reddy, J. G. O’Leary, A. Masica, A. M. Modrykamien, P. S. Kamath and S. K. Asrani (2020). “Model for End-stage Liver Disease-Lactate and Prediction of Inpatient Mortality in Patients with Chronic Liver Disease.” Hepatology Feb 21. [Epub ahead of print].

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BACKGROUND & AIMS: As compared to other chronic diseases, patients with chronic liver disease (CLD) have significantly higher inpatient mortality; accurate models to predict inpatient mortality are lacking. Serum lactate (LA) may be elevated in patients with CLD due to both tissue hypoperfusion as well as decreased lactate clearance. We hypothesized that a parsimonious model consisting of Model for End-stage Liver Disease (MELD) and LA at admission may predict inpatient mortality in patients with CLD. APPROACH & RESULTS: We examined all CLD patients in two large and diverse healthcare systems in Texas (North Texas, NTX and Central Texas, CTX) between 2010-2015. We developed (n=3,588) and validated (n=1,804) a model containing MELD and LA measured at time of hospitalization. We further validated the model in a second cohort of 14 tertiary care hepatology centers that prospectively enrolled non-elective hospitalized patients with cirrhosis (n=726). MELD-LA was an excellent predictor of inpatient mortality in development (c-statistic =0.81, 95% CI 0.79-0.82) and both validation cohorts (CTX cohort, c=0.85, 95% CI 0.78-0.87; multicenter cohort c=0.82, 95% CI 0.74-0.88). MELD-LA performed especially well in patients with specific cirrhosis diagnoses (c=0.84, 95% CI 0.81-0.86) or sepsis (c=0.80, 95% CI 0.78-0.82). For MELD score 25, inpatient mortality was 11.2% (LA=1 mmol/L), 19.4% (LA=3 mmol/L), 34.3% (LA=5 mmol/L) and >50% (LA >8 mmol/L). A linear increase (p<0.01) was seen in MELD-LA and increasing number of organ failures. Overall, use of MELD-LA improved the risk prediction in 23.5% of the patients as compared to MELD model alone. CONCLUSION: MELD-LA is an early and objective predictor of inpatient mortality and may serve as a novel model for risk assessment and guide therapeutic options.

Wong, F., E. Bendel, K. Sniderman, T. Frederick, Z. J. Haskal, A. Sanyal, S. K. Asrani, J. Capel and P. S. Kamath (2020). “Improvement in Quality of Life and Decrease in Large Volume Paracentesis Requirements With the Automated Low Flow Ascites Pump.” Liver Transpl Jan 30. [Epub ahead of print].

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BACKGROUND & AIMS: The alfapump is an implantable device that drains ascites directly into the urinary bladder. We studied in North American patients with cirrhosis and refractory ascites ineligible for TIPS, the safety and efficacy of the alfapump in the management of ascites. The former was assessed by absence of serious complications; and the latter by its impact on ascites control as assessed by decreased large volume paracentesis (LVP) requirement and on improvement in quality of life (QOL) as measured by chronic liver disease (CLDQ) and ascites questionnaires (Ascites Q). METHODS: Following alfapump implantation, patients were monitored for ascites control, laboratory abnormalities, QOL, adverse events and survival at 12 months (M). RESULTS: 30 patients (60.0+/-9.9 years, 57% male, MELD 11.4+/-2.7) received an alfapump mostly by an interventional radiology approach (97%), followed by long-term prophylactic antibiotics. The alfapump removed a mean ascites volume of 230.6+/-148.9L/patient at 12M, dramatically reducing the mean LVP frequency from 2.4+/-1.4 pre- to 0.22+/-0.39/patient/M post-pump implantation. 14 patients required 18 re-interventions related to pump or catheter dysfunction. All surviving patients had improved QOL (CLDQ: 3.88+/-1.21 vs. 4.98+/-1.00; Ascites Q: 51.7+/-21.9 vs. 26.7+/-18.6, baseline vs 3M, p<0.001 for both) and better biochemical index of nutritional status (prealbumin 87.8+/-37.5mg/L vs. 102.9+/-45.3mg/L at 3M, p=0.041). Bacterial infections (15 events in 13/30 patients), electrolyte abnormalities (11 events in 6/30 patients), and renal complications (11 events in 9/30 patients) were the most common severe adverse events. Four patients died by 12M of cirrhosis complications. CONCLUSION: Alfapump insertion may be a definitive treatment for refractory ascites in cirrhosis, especially in patients who are not TIPS candidates. www.clinicaltrials.gov, #NCT02400164.