Research Spotlight

Fallahzadeh, M. A. and R. S. Rahimi (2020). “Hepatic Encephalopathy and Nutrition Influences: A Narrative Review.” Nutr Clin Pract 35(1): 36-48.

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Hepatic encephalopathy (HE) is a potentially reversible neurocognitive condition seen in patients with advanced liver disease. The overt form of HE has been reported in up to 45% of patients with cirrhosis. This debilitating condition is associated with increased morbidity and mortality and imposes a significant burden on the caregivers and healthcare system. After providing an overview of HE epidemiology and pathophysiology, this review focuses on the interaction of HE and frailty, nutrition requirements and recommendations in cirrhotic patients with HE, and current dietary and pharmacologic options for HE treatment.

Diwan, T. S., T. C. Lee, S. Nagai, E. Benedetti, A. Posselt, G. Bumgardner, S. Noria, B. A. Whitson, L. Ratner, D. Mason, J. Friedman, K. J. Woodside and J. Heimbach (2020). “Obesity, Transplantation, and Bariatric Surgery: An Evolving Solution for a Growing Epidemic.” Am J Transplant Jan 21. [Epub ahead of print].

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The increasing obesity epidemic has major implications in the realm of transplantation. Patients with obesity face barriers in access to transplantation as well as unique challenges in perioperative and postoperative outcomes. Due to comorbidities associated with obesity along with the underlying end-stage organ disease leading to transplantation candidacy, these patients may not even be referred for transplant evaluation, much less be waitlisted or actually undergo transplantation. However, the utilization of bariatric surgery in this population can help optimize the transplant candidacy of patients with obesity and end-stage organ disease as well as improve perioperative and postoperative outcomes. In this paper, we will review the impact of obesity on kidney, liver, and cardiothoracic transplant candidates and recipients, as well as explore potential interventions to address obesity in these populations.

Cork, D. P., P. A. McCullough, H. S. Mehta, C. M. Barker, J. Van Houten, C. Gunnarsson, M. Ryan, E. Baker, S. Mollenkopf and P. Verta (2020). “The economic impact of clinically significant tricuspid regurgitation in a large, administrative claims database.” J Med Econ Jan 17:1. [Epub ahead of print].

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Aim: This study aims to quantify the healthcare burden of clinically significant tricuspid regurgitation (TR) in patients with and without heart failure (HF).Materials and Methods: Data were from the IBM(R) MarketScan((R)) Research Databases from October 2011 to September 2016. Eligible patients met the following inclusion criteria: age >/=18 with a TR diagnosis, 12 months pre (baseline) and 6 months post (landmark) medical enrollment. The landmark period was used to categorize TR severity, defined as a record of pulmonary hypertension with ascites, lower extremity edema or hepatic insufficiency, or tricuspid valve surgery. Cohorts were defined based on TR etiology and severity: (1) no HF and no clinically significant TR; (2) HF with no clinically significant TR; (3) no HF with clinically significant TR; and (4) HF with clinically significant TR. Outcomes of interest were all-cause hospitalizations, hospital days, and expenditures. Multivariable models were fit for each of the annualized outcomes and adjusted for patient demographics, comorbidities, and other concomitant valve diseases.Results: There were 92,994 patients eligible for analysis. Patients with no HF and no clinically significant TR had the annualized healthcare burden of 0.20 all-cause hospitalizations (approximately 1 inpatient hospitalization every 5 years), 1.07 hospital days, and $17,478 in expenditures. The presence of clinically significant TR, alone or with HF, significantly increased healthcare utilization and expenditures. For patients with no HF with clinically significant TR, the annualized economic burden increased to 0.41 all-cause hospitalizations, 3.13 hospital days, and $29,985 in expenditures. For patients with HF and clinically significant TR, the annualized economic burden was even greater with 0.59 all-cause hospitalizations, 4.31 hospital days, and $42,255 in expenditures.Conclusion: The presence of clinically significant TR is associated with an increase in healthcare utilization and expenditures, irrespective of the presence of HF.

Cheng, X. S., J. Goldhaber-Fiebert, J. C. Tan, G. M. Chertow, W. R. Kim and A. E. Wall (2020). “Defining a Willingness-to-transplant Threshold in an Era of Organ Scarcity: Simultaneous Liver-kidney Transplant as a Case Example.” Transplantation 104(2): 387-394.

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BACKGROUND: Organ scarcity continues in solid organ transplantation, such that the availability of organs limits the number of people able to benefit from transplantation. Medical advancements in managing end-stage organ disease have led to an increasing demand for multiorgan transplant, wherein a patient with multiorgan disease receives >1 organ from the same donor. Current allocation schemes give priority to multiorgan recipients compared with single-organ transplant recipients, which raise ethical questions regarding equity and utility. METHODS: We use simultaneous liver and kidney (SLK) transplant, a type of multiorgan transplant, as a case study to examine the tension between equity and utility in multiorgan allocation. We adapt the health economics willingness-to-pay threshold to a solid organ transplant setting by coining a new metric: the willingness-to-transplant (WTT) threshold. RESULTS: We demonstrate how the WTT threshold can be used to evaluate different SLK allocation strategies by synthesizing utility and equity perspectives. CONCLUSIONS: We submit that this new framework enables us to distill the question of SLK allocation down to: what is the minimum amount of benefit we require from a deceased donor kidney to allocate it for a particular indication? Addressing the above question will prove helpful to devising a rational system of SLK allocation and is applicable to other transplant settings.

Arnold, S. V., P. Manandhar, S. Vemulapalli, A. Kosinski, N. D. Desai, J. E. Bavaria, J. D. Carroll, M. J. Mack, V. H. Thourani and D. J. Cohen (2020). “Impact of Short-Term Complications of TAVR on Longer-Term Outcomes: Results from the STS/ACC Transcatheter Valve Therapy Registry.” Eur Heart J Qual Care Clin Outcomes Jan 11. [Epub ahead of print].

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BACKGROUND: While complications of TAVR have decreased, they still occur commonly and may negatively impact both short- and long-term outcomes. We sought to examine the association of complications after TAVR with survival and health status in a real world cohort. METHODS AND RESULTS: Among 45,884 TAVR patients from 513 US sites who survived 30 days, 21.4% had at least one major complication (stroke, bleed, vascular complication, new pacemaker, acute kidney injury [AKI], moderate/severe paravalvular leak [PVL]). In multivariable models, stage 3 AKI (HR 3.43, 95% CI 2.64-4.45), stroke (HR 2.62, 95% CI 2.06-3.32), and bleeding (HR 1.83, 95% CI 1.55-2.16) were independently associated with significantly increased risk of early death (<3 months) with slight attenuation in these hazards between 3 and 12 months. Moderate/severe PVL (HR 1.37, 95% CI 1.21-1.55) and new pacemaker (HR 1.15, 95% CI 1.05-1.25) were associated with more modest risk of excess mortality that was consistent through 12 months. Among surviving patients, stroke (-6.1 points, 95% CI -8.4 to -3.7), moderate/severe PVL (-3.2 points, 95% CI -4.9 to -1.6), and new pacemaker (-2.3, 95% CI -3.2 to -1.5) were associated with less improvement in 1-year health status, as assessed by the Kansas City Cardiomyopathy Questionnaire. CONCLUSIONS: In this study of contemporary TAVR, we found that complications remain common within the first 30 days after TAVR and are associated with worse one-year survival and health status among survivors. These findings support continued efforts to reduce major complications of TAVR and may also help define quality of care.