Research Spotlight

Driver, S., C. Swank, K. Froehlich-Grobe, E. McShan, S. Calhoun and M. Bennett (2019). “Weight Loss After Stroke Through an Intensive Lifestyle Intervention (Group Lifestyle Balance-Cerebrovascular Accident): Protocol for a Randomized Controlled Trial.” JMIR Res Protoc 8(10): e14338. [Epub October 18]

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BACKGROUND: Weight gain can be a consequence of stroke, or cerebrovascular accident (CVA), because of impaired mobility, behavioral and emotional disorders, and sensory losses. Weight gain increases the patient’s risk of recurrent stroke and chronic diseases, such as diabetes, metabolic syndrome, and pulmonary and heart disease. Approaches to weight loss in this population are lacking, although necessary because of the unique physiological and cognitive needs of persons after a stroke. Evidence shows that intensive behavioral therapy interventions that address both physical activity and diet offer the greatest potential for weight loss. The Group Lifestyle Balance (GLB) intervention is a 12-month, evidence-based weight loss program that has been used extensively with the general population; this program was modified to meet the needs of people who have had a stroke (GLB-CVA). OBJECTIVE: This randomized controlled trial (RCT) aims to examine the efficacy of the GLB-CVA on weight and secondary outcomes, compared with that of a waitlist control group. METHODS: This RCT will enroll and randomize 64 patients over an 18-month period. RESULTS: Currently, 51 people are waitlisted, with 23 out of 51 screened and 16 out of 23 eligible. CONCLUSIONS: It is anticipated that the findings from this RCT will contribute to the evidence base regarding weight loss strategies for people living with stroke. CLINICAL TRIAL: ClinicalTrials.gov NCT03873467.

Cedars, A., L. Burchill, S. L. Roche, J. Menachem, K. Axsom and K. Tecson (2019). “Impact of durable ventricular assist devices on post-transplant outcomes in adults with congenital heart disease.” Congenit Heart Dis Oct 18. [Epub ahead of print].

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BACKGROUND: There are no published data on post-transplant outcomes in durable ventricular assist device (VAD)-supported adult congenital heart disease (ACHD) patients. METHODS: We compared post-transplant outcomes in VAD-supported vs non-VAD-supported ACHD patients using the Scientific Registry of Transplant Recipients. RESULTS: At 1 year, there was no difference in post-transplant mortality between VAD-supported (12 patients) and non-VAD-supported (671 patients) ACHD patients. CONCLUSIONS: In appropriate ACHD patients, VAD use as a bridge to transplant is a reasonable strategy.

Brahmania, M., M. Lombardero, B. E. Hansen, N. A. Terrault, A. S. Lok, R. P. Perrillo, S. H. Belle, A. M. Di Bisceglie, J. J. Feld, W. M. Lee, M. W. Fried and H. L. A. Janssen (2019). “Association Between Severe Serum Alanine Aminotransferase Flares and Hepatitis B e Antigen Seroconversion and HBV DNA Decrease in Untreated Patients With Chronic HBV Infection.” Clin Gastroenterol Hepatol 17(12): 2541-2551.

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BACKGROUND & AIMS: The incidence and outcomes of alanine aminotransferase (ALT) flares during the natural history of chronic HBV infection has not been determined in a large, racially heterogeneous group of patients in North America. METHODS: We collected data from the Hepatitis B Research Network-an observational cohort study of untreated adults with chronic HBV infection enrolled at 21 sites in the United States and Canada. Clinical and laboratory data were collected from 1587 participants (49.9% male, 73.7% Asian, 35.2% genotype B infection, mean age of 42.6 years) at enrollment, at weeks 12 and 24, and every 24 weeks thereafter for a planned 5 years of follow up (from January 2011 through May 2016). Participants were excluded if they had a history of hepatic decompensation, hepatocellular carcinoma, solid organ or bone marrow transplantation, chronic immune suppression, or antiviral therapy within 6 months before enrollment. Levels of ALT were measured in serum samples and flares were defined as at least 10 times the upper limit of normal (300 U/L in males and 200 U/L in females). RESULTS: ALT flares occurred in 102 participants (6%), with 31 flares (30%) occurring at baseline. The 4-year cumulative incidence of ALT flares was 5.7%. The median peak level of ALT was 450 U/L (25th-75th percentile, 330 U/L to 747 U/L) with a maximum of 2578 U/L. In multivariable analysis, factors associated with the occurrence of an ALT flares were: male sex (odds ratio [OR], 3.02; P=.0007), higher baseline HBV DNA values (OR per log10, 1.41; P<.0001), at risk alcohol use (OR, 2.27 vs none or moderate; P=.02), and higher FIB-4 values (OR, 1.85 per log2; P<.0001). Older age was associated with lower odds of an ALT flare (OR, 0.63 per 10 years; P=.004). Rate of decrease in level of HBV DNA by 1 log10 or more (59 vs 23 per 100 person-years for HB e antigen (HBeAg)-positive vs HBeAg-negative patients; P=.003) and HBeAg loss (47 vs 15 per 100 person-years; P=.002) were higher in patients with an ALT flare than in patients without, but the rate of HBsAg loss was similar (4 vs 2 per 100 person-years; P=.26). No hepatic decompensation, liver transplants, or deaths were observed in participants with ALT flares. CONCLUSION: In a large racially heterogeneous cohort of adults with chronic HBV infection, the cumulative incidence of severe ALT flares was low and associated with greater decreases in HBV DNA and loss of HBeAg, but not with loss of HBsAg.

Black, M., D. Arnold, D. Mason, J. Eidt and S. Hohmann (2019). “Diaphragmatic fenestrations seen after peritoneal dialysis catheter placement: A rare cause of hydrothorax.” J Vasc Access Oct 17. [Epub ahead of print].

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This case report summarizes the clinical course of a patient who developed diaphragmatic fenestrations leading to hydrothorax after the initiation of peritoneal dialysis. We will discuss the interesting disease process in the setting of patient presentation, diagnosis, treatment, and outcome. Learning points: 1) Hydrothorax is an uncommon but serious complication that can occur spontaneously after PD catheter placement. 2) Assessment of respiratory symptoms should always be included in post-operative screening for PD catheter patients, and appropriate imaging should be obtained if screening is positive. 3) This case reaffirms the viability of diaphragm plication and imbrication with 2-0 prolene followed by mechanical and chemical pleurodesis via video thoracoscopy.

Asrani, S. K. (2019). “Accurate assessment of renal function in cirrhosis.” Hepatology Oct 25. [Epub ahead of print].

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First, serum creatinine, sodium and estimated glomerular filtration rate (GFR) are all imperfect surrogates of renal function in patients with cirrhosis. This is especially true in patients with decompensated liver disease, whereby the influence of extrahepatic factors may impede accurate estimation. Often, renal function is dependent on where the patient lies on the acute kidney injury/chronic kidney disease continuum, the degree of liver dysfunction and other relevant patient characteristics. Developing an estimating equation for each and every subset of cirrhotic is untenable.