Research Spotlight

Durand, F., C. Francoz, S. K. Asrani, S. Khemichian, T. A. Pham, R. S. Sung, Y. S. Genyk and M. K. Nadim (2018). “Acute Kidney Injury After Liver Transplantation.” Transplantation 102(10): 1636-1649.

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Since the implementation of the Model of End-stage Liver Disease score-based allocation system, the number of transplant candidates with impaired renal function has increased. The aims of this review are to present new insights in the definitions and predisposing factors that result in acute kidney injury (AKI), and to propose guidelines for the prevention and treatment of postliver transplantation (LT) AKI. This review is based on both systematic review of relevant literature and expert opinion. Pretransplant AKI is associated with posttransplant morbidity, including prolonged post-LT AKI which then predisposes to posttransplant chronic kidney disease. Prevention of posttransplant AKI is essential in the improvement of long-term outcomes. Accurate assessment of baseline kidney function at evaluation is necessary, taking into account that serum creatinine overestimates glomerular filtration rate. New diagnostic criteria for AKI have been integrated with traditional approaches in patients with cirrhosis to potentially identify AKI earlier and improve outcomes. Delayed introduction or complete elimination of calcineurin inhibitors during the first weeks post-LT in patients with early posttransplant AKI may improve glomerular filtration rate in high risk patients but with higher rates of rejection and more adverse events. Biomarkers may in the future provide diagnostic information such as etiology of AKI, and prognostic information on renal recovery post-LT, and potentially impact the decision for simultaneous liver-kidney transplantation. Overall, more attention should be paid to pretransplant and early posttransplant AKI to reduce the burden of late chronic kidney disease.

Asrani, S. K., H. Devarbhavi, J. Eaton and P. S. Kamath (2018). “Burden of Liver Diseases in the World.” J Hepatol. Sep 25. [Epub ahead of print].

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Liver disease accounts for approximately 2 million deaths per year worldwide, one million due to complications of cirrhosis and one million due to viral hepatitis and hepatocellular carcinoma. Cirrhosis is currently the 11(th) most common cause of death globally and liver cancer is the 16th leading cause of death; combined, they account for 3.5% of all deaths worldwide. Cirrhosis is within the top 20 causes of disability-adjusted life years and years of life lost and account for 1.6% and 2.1% of worldwide burden. About 2 billion people consume alcohol worldwide and upwards of 75 million are diagnosed with alcohol use disorders and are at risk for alcohol associated liver disease. Approximately 2 billion adults are obese or overweight and over 400 million have diabetes; both serve as risk factors for the increase in non-alcoholic fatty liver disease as well as hepatocellular carcinoma. The global prevalence of hepatitis B (3.5%) and hepatitis C (1%) is high. Drug induced liver injury continues to increase as a major cause of acute hepatitis. Liver transplantation is the second most common solid organ transplantation after kidney transplantation worldwide. However, less than 10% of global needs of organ transplantation are met at current rates of transplantation. Though these numbers are sobering, they offer an important opportunity to improve public health given that most causes of liver diseases are preventable.

Annamalai, S. K., M. L. Esposito, L. Jorde, T. Schreiber, S. Hall, W. W. O’Neill and N. K. Kapur (2018). “The Impella Micro-Axial Flow Catheter is Safe and Effective for Treatment of Myocarditis Complicated by Cardiogenic Shock: An Analysis from the Global cVAD Registry.” J Card Fail Sep 20. [Epub ahead of print].

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BACKGROUND: Myocarditis complicated by cardiogenic shock remains a complex problem. The use of acute mechanical circulatory support devices for cardiogenic shock is growing. We explored the utility of Impella trans-valvular micro-axial flow catheters in the setting of myocarditis with cardiogenic shock. METHODS AND RESULTS: We retrospectively analyzed data from 21 sites within the cVAD registry, an ongoing multicenter voluntary registry at sites in North America and Europe that have used Impella in patients with myocarditis. Myocarditis was defined by endomyocardial biopsy in 34% (n=11) or by clinical history without angiographic evidence of coronary disease (n=23). A total of 34 patients received Impella 2.5, CP, 5.0, or RP device for cardiogenic shock complicating myocarditis. Baseline characteristics included age 42+/-17 years, left ventricular ejection fraction (LVEF) 18+/-10%, cardiac index 1.82+/-0.46 L/min/m2, pulmonary capillary wedge pressure 25+/-7 mmHg, and lactate 27+/-31 mg/dL. Prior to Impella placement, 32% (n=11) of patients required intra-aortic balloon pump. Mean duration of Impella support was 91+/-74 hours. 21 of 34 (62%) patients survived the index hospitalization and were discharged with an improved mean LVEF of 37.32 +/- 20.31% (p=0.001). 15 patients recovered with successful support, 5 patients were transferred to another hospital on initial Impella support, 1 patient underwent orthotopic heart transplant. Ten patients required transition to another mechanical circulatory support device, Conclusions: This is the largest analysis of Impella-supported myocarditis cases to date. The use of the Impella appears to be safe and effective in the settings of myocarditis complicated by cardiogenic shock.

Ambrosy, A. P., H. Mulder, A. Coles, W. E. Krauss, C. S. P. Lam, P. A. McCullough, I. Pina, J. Tromp, D. J. Whellan, C. M. O’Connor and R. J. Mentz (2018). “Renal Function and Exercise Training in AmbulatoryHeart Failure Patients With a Reduced Ejection Fraction.” Am J Cardiol 122(6): 999-1007.

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Patients with chronic kidney disease (CKD) and/or end-stage renal disease are less active and experience significant functional limitations. The impact of a structured aerobic exercise intervention on outcomes in ambulatory heart failure (HF) patients with comorbid CKD is unknown. HF-ACTION enrolled 2,331 outpatients with HF and a reduced ejection fraction (i.e., =35% or less) from April 2003 to February 2007 and randomized them to aerobic exercise training versus usual care. Patients were grouped according to the presence of CKD, defined as an estimated glomerular filtration rate <60 ml/min/1.73 m(2). A total of 2,091 patients (90%) had serum creatinine measured and were included in the final analytical cohort. The prevalence of CKD was 41% at baseline. In patients with and without CKD, respectively, the incidence of all-cause death and hospitalization was 75% and 63% over a median follow-up of 30 months. After adjusting for potential confounders, CKD was associated with increased risk of the composite of all-cause mortality and hospitalization (hazard ratio 1.18, 95% confidence interval 1.04 to 1.33; p value =0.01 or less). With the exception of a marginally greater improvement in exercise duration in response to aerobic exercise training (estimate +/- standard error: 0.9 +/- 0.2 minutes vs 1.4 +/- 0.1 minutes; p value=0.01), there was no interaction between treatment arm and CKD on functional status, health-related quality of life, or clinical outcomes (p value =0.05 or greater for all interactions). In conclusion, the prevalence of CKD was high in ambulatory reduced ejection fraction patients and was associated with a poorer overall prognosis but not a differential response to aerobic exercise training.

Allen, C. G., J. N. Brownstein, M. Cole, G. Hirsch, S. Williamson and E. L. Rosenthal (2018). “Building a Framework for Community Health Worker Skills Proficiency Assessment to Support Ongoing Professional Development.” J Ambul Care Manage 41(4): 298-307.

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Although community health workers (CHWs) continue to gain credibility and recognition in the health care and public health sectors, there is still a need to expand workforce identity and development efforts, including identifying best practices for assessing CHW skill proficiencies. During this qualitative study, we interviewed 32 CHWs, trainers, and supervisors to understand current practice, perspectives, and perceived importance in assessing CHW skills and guiding principles for CHW skill assessment. Results from these interviews can be used to inform CHW workforce development to enhance efforts among those who are actively building CHW programs or who are considering improvements in strategies to assess CHW skill proficiencies.