Su2059: SAFETY OF GLP-1 AGONISTS IN PATIENTS UNDERGOING ELECTIVE PROCEDURES REQUIRING ANESTHESIA OR SEDATION.

Gastroenterology · 2025-05-01

S4324 Gallbladder, Liver, or Infection? A Case of an Atypical Autoimmune Hepatitis Presentation

The American Journal of Gastroenterology · 2024-10-01

Difference in Prevalence of Obstructive and Restrictive Ventilatory Defects Using Race-neutral and Race-based Spirometry in Candidates for Liver Transplantation: PVCLD2

2024-04-30

S4495 Not DRESSed for Success: A Case of DRESS Syndrome With Progressively Elevated Aminotransferases Even After Stopping Offending Agent

The American Journal of Gastroenterology · 2024-10-01 · 1 citations

Introduction: Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a condition that leads to eosinophilia and systemic symptoms about 2-8 weeks after initiating a drug. It often resolves after stopping the offending agent and initiating steroid treatment. However, our case demonstrates an atypical presentation of increasing aminotransferases despite drug cessation. Case Description/Methods: A 31-year-old woman with a history of intellectual disability, mood disorder, hypertension, and eczema presented to the hospital for a nonspecific diffuse whole-body rash. Her initial aminotransferase levels were elevated (ALT 97 U/L, AST 75 U/L) and CBC showed leukocytosis with eosinophilia. Acute viral hepatitis panel was negative. For her mood disorder, she was initiated on lamotrigine 3 weeks prior to admission. She was suspected to have DRESS syndrome secondary to lamotrigine. Dermatology recommended holding her lamotrigine and starting high-dose steroids. However, despite holding her lamotrigine for a week and initiation of steroids, her aminotransferases continued to rise (ALT 627 U/L, AST 267 U/L) (Figure 1). During the admission, the patient became febrile and tachycardic. Given the patient’s worsening clinical status and aminotransferase levels, an infectious work-up and liver biopsy were pursued. EBV, CMV, HSV, hepatitis B, and C viral loads were negative. She was started on N-acetylcysteine due to worsening liver synthetic function. Abdominal ultrasound Doppler was negative for thrombus. Biopsy showed preserved liver architecture with lobular inflammation and numerous eosinophils with negative HSV stains, pointing towards DRESS syndrome. Steroids were continued and lamotrigine was discontinued. Her laboratory results began to improve one month after discontinuation of lamotrigine and initiation of steroid treatment. Discussion: This case highlights an unusual presentation of DRESS syndrome where the patient’s liver injury worsened after discontinuation of the offending agent and despite appropriate steroid treatment, persisted for weeks. It was further complicated by positive SIRS criteria, which pointed to a possible infectious etiology. There are few cases of severe liver injury due to DRESS syndrome; however, improvement is usually seen after a few days of steroid treatment. Our case shows that DRESS syndrome may not always result in an expected improvement in the aminotransferases after stopping the offending agent and further workup may be needed to confirm the diagnosis.Figure 1.: Trend of the patient’s aminotransferase levels from admission to discharge.

Smoking and outcomes in candidates for liver transplantation: Analysis of the Pulmonary Vascular Complications of Liver Disease 2 (PVCLD2)

Liver Transplantation · 2024-11-19 · 2 citations

Patients with chronic liver disease commonly have abnormal lung function; however, the impact of smoking on outcomes in these patients is unknown. We hypothesized current or past smoking would be associated with worse survival in patients with advanced liver disease. The Pulmonary Vascular Complications in Liver Disease Study 2 (PVCLD2) was a prospective cohort of patients with advanced liver disease undergoing evaluation for liver transplantation (LT). Patients were classified by self-report as a "non-smoker," "past smoker," or "current smoker." We used Cox proportional hazards models and Fine-Gray models with LT as a competing risk. Models were adjusted for age, sex, body mass index, race, family income, liver disease etiology, and Model for End-Stage Liver Disease-Sodium score. Of the 410 patients included, most (65%) were male and the mean age at enrollment was 56.5 years. One hundred sixty (39%) patients were nonsmokers, 183 (45%) were past smokers, and 67 (16%) were current smokers. In total, 151 (37%) patients received an LT, and 88 (20%) patients died. When compared to nonsmokers, current smokers had a 2.17-fold increase in risk of death overall (95% CI: 1.12-4.18, p = 0.02). There was a 7% increase in overall risk of death for every 5 pack-years increase (95% CI: 1.01-1.13, p = 0.02). With LT as a competing risk, the subdistributional HR of current smokers versus nonsmokers for death was 2.45 (95% CI: 1.31-4.60, p = 0.005). In this model, past smokers displayed a nonsignificant increase in the risk of death compared to nonsmokers (subdistributional HR: 1.58, 95% CI: 0.91-2.72, p = 0.10). Patients with advanced liver disease undergoing evaluation for LT who smoke have an increased risk of death. Smoking cessation could lead to improved overall survival with or without LT.

Six-Minute walk distance predicts outcomes in liver transplant candidates

Liver Transplantation · 2023-01-24 · 17 citations

A 6-minute walk test is a simple tool for assessing submaximal exercise capacity. We sought to determine whether a 6-minute walk distance (6MWD) predicts outcomes in patients with cirrhosis. The Pulmonary Vascular Complications of Liver Disease 2 study is a multicenter, prospective cohort study that enrolled adults with portal hypertension during liver transplantation evaluation. We excluded subjects with an incident or prevalent portopulmonary hypertension. The 6-minute walk test was performed using standardized methods. Cox proportional hazards modeling and multivariable linear regression analysis were performed to determine the relationship between baseline 6MWD and outcomes. The study sample included 352 subjects. The mean 6MWD was 391±101 m. For each 50-meter decrease in 6MWD, there was a 25% increase in the risk of death (HR 1.25, 95% CI [1.11, 1.41], p < 0.001) after adjustment for age, gender, body mass index, MELD-Na, and liver transplant as a time-varying covariate. In a multistate model, each 50-meter decrease in 6MWD was associated with an increased risk of death before the liver transplant ( p < 0.001) but not after the transplant. 6MWD was similar to MELD-Na in discriminating mortality. Each 50-meter decrease in 6MWD was associated with an increase in all-cause ( p < 0.001) and transplant-free hospitalizations ( p < 0.001) in multivariable models for time-to-recurrent events. Shorter 6MWD was associated with worse Short Form-36 physical ( p < 0.001) and mental component scores ( p = 0.05). In conclusion, shorter 6MWD is associated with an increased risk of death, hospitalizations, and worse quality of life in patients evaluated for liver transplantation. The 6-minute walk distance may be a useful adjunct for risk assessment in patients undergoing liver transplant evaluation.

Smoking and Outcomes in Candidates for Liver Transplantation: PVCLD2

2023-05-01

Use of the European Organisation for Research and Treatment of Cancer multiple myeloma module (EORTC QLQ-MY20): a review of the literature 25 years after development

Blood Cancer Journal · 2023-05-16 · 9 citations

The European Organisation for Research and Treatment of Cancer Quality of Life Multiple Myeloma Questionnaire (EORTC QLQ-MY20) was developed in 1996 to assess health-related quality of life (HRQoL) in patients with multiple myeloma. Since its development new therapies have prolonged survival in patients with myeloma and new combination agents are likely to impact HRQoL outcomes and its measurement.The aim of this review was to explore the use of the QLQ-MY20 and reported methodological issues.An electronic database search was conducted (1996-June 2020) to identify clinical studies/research that used the QLQ-MY20 or assessed its psychometric properties. Data were extracted from full-text publications/conference abstracts and checked by a second rater.The search returned 65 clinical and 9 psychometric validation studies. The QLQ-MY20 was used in interventional (n = 21, 32%) and observational (n = 44, 68%) studies and the publication of QLQ-MY20 data in clinical trials increased over time. Clinical studies commonly included relapsed patients with myeloma patients (n = 15, 68%) and assessed a range of combinations therapies.QLQ-MY20 subscales (disease symptoms [DS], side effects of treatment [SE], future perspectives [FP], body image [BI]) were defined as secondary (n = 12, 55%) or exploratory (n = 7, 32%) trial endpoints, particularly DS (n = 16, 72%) and SE (n = 16, 72%). Validation articles demonstrated that all domains performed well regarding internal consistency reliability (>0.7), test-reset reliability (intraclass correlation coefficient > =0.85), internal and external convergent and discriminant validity. Four articles reported a high percentage of ceiling effects in the BI subscale; all other subscales performed well regarding floor and ceiling effects.The EORTC QLQ-MY20 remains a widely used and psychometrically robust instrument. While no specific problems were identified from the published literature, qualitative interviews are ongoing to ensure new concepts and side effects are included that may arise from patients receiving novel treatments or from longer survival with multiple lines of treatment.

S3768 Case Report: An Urban Case of Multi-Organ Failure Due to Weil Disease

The American Journal of Gastroenterology · 2023-10-01

Introduction: Leptospirosis is a zoonotic disease caused by the spirochete bacteria Leptospira interrogans. Though typically described as a tropical disease, due to negligence, rapid urbanization, poor sanitation, as well as climate change and human migration, it can less commonly be identified in urban settings in the developed world. This case report describes a patient with Weil disease, a severe form of leptospirosis, contracted in Philadelphia, USA. Case Description/Methods: A 56-year-old woman with prior history of HCV status post SVR (2011) presented to the ED in early December with several weeks of malaise and generalized weakness. History revealed she was in her normal state of health until 2 weeks prior when she was outside walking when a rat ran up her pant leg. She notably presented to the ED 2 days prior with similar symptoms that were thought to be secondary to a viral prodrome. Laboratory studies on admission revealed Hgb 11.3 g/dL, platelets 99 K/mm3, total bilirubin 12.8 mg/dL, direct bilirubin 10 mg/dL, ALP 190 U/L, AST 111 U/L, ALT 48 U/L, and creatinine 2.47 mg/dL. The patient became altered and developed progressively worsening renal function and liver function (Graph 1) requiring pressor support and CRRT. Liver function continued to decline, with a peak total bilirubin of 34.8 mg/dL. She did not have obvious obstructive signs or symptoms and biliary obstruction was ruled out with imaging. She was supportively started on ursodiol. A broad workup was initiated; an acute hepatitis panel and ADAMTS13 were negative, as well as various other infectious workups. Given concern for zoonotic etiology, she was empirically placed on ceftriaxone and doxycycline as per the Infectious Disease consult service. Leptospira DNA PCR of the urine returned positive, confirming the diagnosis of icteric leptospirosis (Weil's disease) and antimicrobial therapy was narrowed to parenteral high-dose penicillin G. The patient made a full recovery and was discharged to a subacute nursing facility. Discussion: Leptospirosis is commonly associated with rural settings and occupational exposure to contaminated water. However, cases of leptospirosis are increasingly being reported in urban areas. This case highlights the severity of fulminant leptospirosis and the need for rapid, reliable diagnostic testing. Hepatocellular liver injury is typically a consequence of prior ischemic hepatopathy, with improvement of hepatocellular injury with treatment of underlying shock. Early recognition and treatment can improve outcomes (Figure 1).Figure 1.: Graph 1: This graph shows the trend of this patient's renal failure with concomitant liver dysfunction, and the gradual improvement in kidney and liver function following supportive continuous renal replacement therapy.

Cardiac index and hepatopulmonary syndrome in liver transplantation candidates: The pulmonary vascular complications of liver disease study

Liver Transplantation · 2023-03-02 · 7 citations

BACKGROUND AND AIMS: Hepatopulmonary syndrome (HPS) and a hyperdynamic circulation are common complications of advanced liver disease, but the relationship between HPS and cardiac index (CI) is poorly understood. We sought to compare CI in patients with and without HPS and to assess the relationship between CI and symptoms, quality of life, gas exchange, and exercise capacity among liver transplantation (LT) candidates. We performed a cross-sectional analysis within the Pulmonary Vascular Complications of Liver Disease 2 study, a multicenter prospective cohort study of patients being evaluated for LT. We excluded patients with obstructive or restrictive lung disease, intracardiac shunting, and portopulmonary hypertension. We included 214 patients (81 with HPS and 133 controls without HPS). Compared with controls, patients with HPS had a higher CI (least square mean 3.2 L/min/m 2 , 95% CI 3.1-3.4 vs. 2.8 L/min/m 2 , 95% CI 2.7-3.0, p < 0.001) after adjustment for age, sex, Model for End-stage Liver Disease-Sodium (MELD-Na) score and beta-blocker use, and a lower systemic vascular resistance. Among all LT candidates, CI was correlated with oxygenation (Alveolar-arterial oxygen gradient r =0.27, p < 0.001), intrapulmonary vasodilatation severity ( p < 0.001), and biomarkers of angiogenesis. Higher CI was independently associated with dyspnea and worse functional class and physical quality of life after adjusting for age, sex, MELD-Na, beta-blocker use, and HPS status. HPS was associated with a higher CI among LT candidates. Independent of HPS, higher CI was associated with increased dyspnea and worse functional class, quality of life, and arterial oxygenation.