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Biomedical subjects

Sammy Saab

Publications and source records attributed to Sammy Saab.

At least 19 recordsLinked to original sources
PubMed2007

Postresection hepatic failure: successful treatment with liver transplantation.

Postoperative liver failure (PLF) is a rare but often fatal complication of major hepatic resection. Use of orthotopic liver transplantation (OLT) for PLF remains undefined. We conducted a retrospective review of 435 patients who underwent hepatic resection between 1990 and 2004; 9 of them (2.0%) developed PLF. Indications for resection included primary hepatic malignancies (8), colonic metastases (2), and echinococcic cyst (1); all resections were multisegmental, 6 were extended, and 2 were lobectomies. A total of 7 patients underwent OLT at a mean of 25 days after resection. Patients developing PLF had significantly lower preoperative platelet counts and significant elevations of total bilirubin, direct bilirubin, prothrombin time, and international normalized ratio (INR) by postoperative day 2. Pathological cirrhosis and extended right lobectomy were associated with significantly increased risk of PLF. Following OLT, there were no in-hospital deaths, but 1 patient required retransplantation for primary nonfunction. Mean survival with and without OLT was 42.2 and 1.4 months, respectively (P = 0.03). Following OLT, 1- and 5-yr patient survivals were 88% and 40%, respectively; 1- and 5-yr graft survivals were 75% and 34%, respectively. In conclusion, patients with low platelets, biopsy-proven cirrhosis, or those undergoing extended resection are at increased risk for PLF. OLT for PLF has significant morbidity but allows salvage of an otherwise fatal condition.

Adult↗
PubMed2007

Outcomes in hepatitis C virus-infected recipients of living donor vs. deceased donor liver transplantation.

In this retrospective study of hepatitis C virus (HCV)-infected transplant recipients in the 9-center Adult to Adult Living Donor Liver Transplantation Cohort Study, graft and patient survival and the development of advanced fibrosis were compared among 181 living donor liver transplant (LDLT) recipients and 94 deceased donor liver transplant (DDLT) recipients. Overall 3-year graft and patient survival were 68% and 74% in LDLT, and 80% and 82% in DDLT, respectively. Graft survival, but not patient survival, was significantly lower for LDLT compared to DDLT (P = 0.04 and P = 0.20, respectively). Further analyses demonstrated lower graft and patient survival among the first 20 LDLT cases at each center (LDLT 20; P = 0.002 and P = 0.002, respectively) and DDLT recipients (P < 0.001 and P = 0.008, respectively). Graft and patient survival in LDLT >20 and DDLT were not significantly different (P = 0.66 and P = 0.74, respectively). Overall, 3-year graft survival for DDLT, LDLT >20, and LDLT 20 were not significantly different. Important predictors of graft loss in HCV-infected patients were limited LDLT experience, pretransplant HCC, and higher MELD at transplantation.

Adult↗
PubMed2006

Evidence-based incorporation of serum sodium concentration into MELD.

BACKGROUND & AIMS: Serum sodium (Na) concentrations have been suggested as a useful predictor of mortality in patients with end-stage liver disease awaiting liver transplantation. METHODS: We evaluated methods to incorporate Na into model for end-stage liver disease (MELD), using a prospective, multicenter database specifically created for validation and refinement of MELD. Adult, primary liver transplant candidates with end-stage liver disease were enrolled. RESULTS: Complete data were available in 753 patients, in whom the median MELD score was 10.8 and sodium was 137 mEq/L. Low Na (<130 mEq/L) was present in 8% of patients, of whom 90% had ascites. During the study period, 67 patients (9%) died, 243 (32%) underwent transplantation, 73 (10%) were withdrawn, and 370 were still waiting. MELD score and Na, at listing, were significant (both, P < .01) predictors of death within 6 months. After adjustment for MELD score and center, there was a linear increase in the risk of death as Na decreased between 135 and 120 mEq/L. A new score to incorporate Na into MELD was developed: "MELD-Na" = MELD + 1.59 (135 - Na) with maximum and minimum Na of 135 and 120 mEq/L, respectively. In this cohort, "MELD-Na" scores of 20, 30, and 40 were associated with 6%, 16%, and 37% of risk of death within 6 months of listing, respectively. If this new score were used to allocate grafts, it would affect 27% of the transplant recipients. CONCLUSIONS: We demonstrate an evidence-based method to incorporate Na into MELD, which provides more accurate survival prediction than MELD alone.

Analysis of Variance↗
PubMed2006

Management of patients with cirrhosis in Southern California: results of a practitioner survey.

INTRODUCTION: Cirrhosis is an important medical and public health concern. A paucity of data exists on how patients with cirrhosis are managed. Our aims were to determine how cirrhosis is managed and whether current management practices follow established recommendations. METHODS: A questionnaire was mailed to Southern California Society of Gastroenterology members. Most had practiced for more than 15 years (67%) in a private practice setting (69%). Proportions of physicians who followed established guidelines versus those who had not were compared using chi test. RESULTS: Hepatitis A, hepatitis B, influenza, and pneumococcus vaccinations were recommended by most respondents. Ninety-one percent of respondents routinely screened patients for hepatocellular carcinoma. A significantly greater proportion of respondents screened for hepatocellular carcinoma using either alpha-fetoprotein or ultrasound every 6 months (P < 0.05). Seventy-six percent recommended antibiotic prophylaxis in patients with prior spontaneous bacterial peritonitis, whereas less than half recommended prophylaxis in patients with ascitic protein fluid <1 g/dL, current variceal bleed, and those on the liver transplant list. Sixty-seven percent of respondents performed screening esophagogastroduodenoscopy upon diagnosis of cirrhosis. Most respondents did not recommend repeating endoscopy in 1 to 2 years if a patient was found to have small varices (P < 0.05), and would repeat an endoscopy if large varices were found (P < 0.05). CONCLUSION: The management of patients with cirrhosis in the community varied and did not always conform to established guidelines. These results should be confirmed in a larger group of physicians, and the rationales for physicians accepting or rejecting established guidelines should be further assessed.

California↗
PubMed2006

Effect of nonviral factors on hepatitis C recurrence after liver transplantation.

OBJECTIVE: Hepatitis C (HCV) is now the most common indication for orthotopic liver transplantation (OLT). While graft reinfection remains universal, progression to graft cirrhosis is highly variable. This study examined donor, recipient, and operative variables to identify factors that affect recurrence of HCV post-OLT to facilitate graft-recipient matching. METHODS: Retrospective review of 307 patients who underwent OLT for HCV over a 10-year period at our center. Recurrence of HCV was identified by the presence of biochemical graft dysfunction and concurrent liver biopsy showing diagnostic pathologic features. Time to recurrence was the endpoint for statistical analysis. Five donor, 6 recipient, and 2 operative variables that may affect recurrence were analyzed by univariate comparison and Cox proportional hazard regression models. RESULTS: Recurrence-free survival in the 307 study patients was 69% and 34% at 1 and 5 years, respectively. Four predictive variables related to either donor or recipient characteristics were identified. Advanced donor age, prolonged donor hospitalization, increasing recipient age, and elevated recipient MELD scores were found to increase the relative risk of HCV recurrence. Examination of HLA disparity between donors and recipients demonstrated no correlation between class I or class II mismatches and recurrence-free survival. CONCLUSIONS: We have identified donor and recipient characteristics that significantly predict hepatitis C recurrence following liver transplantation. These factors are identifiable before transplant and, if considered when matching donors to HCV recipients, may decrease the incidence of HCV recurrence after OLT. A change in the current national liver allocation system would be needed to realize the full value of this benefit.

Adult↗
PubMed2006

The MELD score in advanced liver disease: association with clinical portal hypertension and mortality.

BACKGROUND: The Model for End-Stage Liver Disease (MELD) score is a measure of chronic liver disease severity. Patients awaiting transplantation are assessed using this score. However, it has recently been suggested that changes in MELD score may be as important as the absolute MELD score in predicting short-term survival. However, clinical factors that affect the MELD score are unknown. We sought to identify predictors of mortality for potential transplant patients and examine factors that might predict changes in MELD score. MATERIALS AND METHODS: Between January 1, 2002, and July 30, 2004, we retrospectively examined risk factors of 429 adult patients awaiting liver transplantation at the University of California at Los Angeles (UCLA). Analysis of the data was performed using demographics, manifestations of portal hypertension, time between last MELD recorded and event, and laboratory values. Significant factors in univariate analysis were further studied using Cox proportional hazards regression multivariate analysis. RESULTS: At mean follow-up of 2.15 years (+/-1.49 years), 71 patients (16.5%) had MELD scores that increased 5-10 points, 22 had changes of 10-15 points, and 14 had changes of 15-20 points. Manifestations of portal hypertension, laboratory values, and etiology of liver disease did not predict changes in MELD score. However, development of hepatic encephalopathy (HR, 3.95; P=.002; 95% CI, 1.70 to 9.42) and MELD score (HR, 1.04; P=.001; 95% CI, 1.004 to 1.08) were associated with variceal bleeding. Also, MELD score (HR, 1.07; P<.001; 95% CI, 1.05 to 1.09), refractory ascites (HR, 2.15; P=.002; 95% CI, 1.31 to 3.53), and alcoholic cirrhosis (HR, 0.40; P=.04; 95% CI, 0.18 to 0.94) were independent predictors of mortality. CONCLUSIONS: Encephalopathy and MELD score were associated with variceal bleeding. Patients with an elevated MELD score, refractory ascites, and alcoholic cirrhosis had increased mortality while on the liver transplant list. No factors predicting changes in the MELD score were identified.

Adult↗
PubMed2005

Percutaneous radiofrequency ablation of hepatocellular carcinoma as a bridge to liver transplantation.

Orthotopic liver transplantation (OLT) can be a definitive treatment for patients with hepatocellular carcinoma (HCC). Prolonged waiting times for cadaveric livers, however, may lead to dropout from the waiting list or worsened post-OLT prognosis as a result of interval tumor progression. Percutaneous radiofrequency ablation (RFA) is widely used for local control of small unresectable HCC, but its pretransplant role remains unclear. We studied the outcome of 52 consecutive patients accepted for OLT bearing 87 HCC nodules and treated with percutaneous RFA. On initial staging, the tumor burden exceeded the Milan criteria in 10 patients. Complete tumor coagulation was observed in 74 of 87 (85.1%) nodules based on postablation imaging. After a mean of 12.7 months (range: 0.3-43.5) on the waiting list, 3 of 52 patients (5.8%) had dropped out due to tumor progression. Forty-one patients had undergone transplantation, with 1- and 3-year post-OLT survival rates of 85% and 76%, respectively. No patient developed HCC recurrence. There were three major complications in 76 RFA procedures (hepatic arterial hemorrhage, small bowel perforation, and liver decompensation salvaged by OLT), without resultant death or dropout. In conclusion, percutaneous RFA is an effective bridge to OLT for patients with compensated liver function and safely accessible tumors. Tumor-related dropout rate and post-OLT outcome compared favorably with published controls of patients with early-stage disease. This can be attributed to the efficacy of RFA in producing local cure or curbing tumor progression during the waiting period.

Adult↗
PubMed2005

MELD fails to measure quality of life in liver transplant candidates.

Previous studies have demonstrated an association between Child Turcotte-Pugh (CTP) class and impaired quality of life. However, the relationship between the model for end-stage liver disease (MELD) score and quality of life (QOL) has not been well studied. In this study, quality of life questionnaires (Medical Outcomes Short Form 36 [SF-36] and the Chronic Liver Disease Questionnaire [CLDQ]) were administered to 150 adult patients awaiting liver transplantation. We also collected demographic data and laboratory results and recorded manifestations of hepatic decompensation. The study found that all domains of the SF-36 and CLDQ were significantly lower in our patient cohort than in normal controls (P < .001). There was a moderate negative correlation between CPT class and physical components of the SF-36 (r = -.30), while there was a weak negative correlation (r = -.10) between CPT class and the mental component. There was a negative moderate correlation between CPT class and overall CLDQ (r = -.39, P < .001) and a weak correlation (r = -.20) between MELD score and overall CLDQ score. Both encephalopathy (correlation coefficient = -.713, P = .004) and ascites (correlation coefficient = -.68, P = .006) were predictive of the QOL using CLDQ (adjusted R(2) = .1494 and f = 0.000). In conclusion, in liver transplant candidates, the severity of liver disease assessed by the MELD score was not predictive of QOL. The presence of ascites and/or encephalopathy was significantly associated with poor quality of life. CTP correlates better to QOL, probably because it contains ascites and encephalopathy.

Female↗
PubMed2005

Immunization needs of chronic liver disease patients seen in primary care versus specialist settings.

Chronic liver disease patients may benefit from certain vaccines, but their immunization coverage levels have not been widely studied. We examined the serologic and vaccination status of 693 chronic liver disease patients from 37 primary care and specialist centers. Patients in primary care had more often received influenza (47 versus 32%; P < .001) and pneumococcal (39 versus 19%; P < .001) vaccines. Among patients without documented prior exposure, those seeing specialists had more often completed hepatitis A (28 versus 5%; P < .001) and hepatitis B (29 versus 14%; P < .001) vaccination. Coverage was higher in centers with a policy of vaccinating on-site, among non-Hispanic whites, and among patients with hepatitis C and cirrhosis. In summary, most patients were unprotected against one or more vaccine preventable diseases. The higher coverage rates evident in centers vaccinating on-site suggests a breakdown may occur when patients are referred to alternative vaccination venues.

Adult↗
PubMed2005

Treatment of hepatitis C.

Hepatitis C virus is a leading cause of chronic liver disease, with over 170 million people infected worldwide. It is also the leading indication for liver transplantation. Complications from chronic hepatitis C infection include cirrhosis, hepatic decompensation, and hepatocellular carcinoma. As a result, treatment strategies to prevent such complications have been widely researched, although many questions remain unanswered. To date, the standard therapy for chronic hepatitis C infection is the combination of peginterferon and ribavirin. Treatment strategies differ based on factors such as genotype and liver biopsy results. Other strategies must be considered for special groups, such as patients with acute hepatitis C infection, hepatitis C/human immunodeficiency virus (HIV) coinfection, and prior nonresponse to interferon or relapse after its use. The goal of therapy is to achieve a sustained virologic response (ie, no detectable hepatitis C ribonucleic acid 6 months after completion of therapy). The substantial adverse effects associated with both interferon alfa and ribavirin often make it difficult for patients to continue with their therapies.

Algorithms↗
PubMed2005

Analysis of long-term outcomes of 3200 liver transplantations over two decades: a single-center experience.

OBJECTIVE: Few studies have evaluated long-term outcomes after orthotopic liver transplantation (OLT). This work analyzes the experience of nearly 2 decades by the same team in a single center. Outcomes of OLT and factors affecting survival were analyzed. METHODS: Retrospective analysis of 3200 consecutive OLTs that were performed at our institution, between February 1984 and December 31, 2001. RESULTS: Of 2662 recipients, 578 (21.7%) and 659 (24.7%) were pediatric and urgent patients, respectively. Overall 1-, 5-, 10-, and 15-year patient and graft survival estimates were 81%, 72%, 68%, 64% and 73%, 64%, 59%, 55%, respectively. Patient survival significantly improved in the second (1992-2001) versus the era I (1984-1991) of transplantation (P < 0.001). Similarly, graft survival was better in the era II of transplantation (P < 0.02). However, biliary and infectious complications increased in era II. When OLT indications were considered, best recipient survival was obtained in children with biliary atresia (82%, 79%, and 78% at 1, 5, and 10 years, respectively), while malignant disease in adult patients resulted in the worst outcomes of 68% and 43% at 1 and 5 years, post-OLT. Further, patients <18 years and nonurgent recipients exhibited superior survival when compared with recipients >18 years (P < 0.001) or urgent patients (P < 0.001). Of 13 donor and recipient variables, era of OLT, recipient age, urgent status, donor age, donor length of hospital stay, etiology of liver disease, retransplantation, warm and cold ischemia, but not graft type (whole, split, living-donor), significantly impacted patient survival. CONCLUSIONS: Long-term benefits of OLT are greatest in pediatric and nonurgent patients. Multiple factors involving the recipient, etiology of liver disease, donor characteristics, operative variables, and surgical experience influence long-term survival outcomes. By balancing and matching these factors with a given recipient, optimum results can be achieved.

Adolescent↗
PubMed2005

Mortality predictors in liver transplant recipients with recurrent hepatitis C cirrhosis.

BACKGROUND/AIM: Recipients of orthotopic liver transplant for hepatitis C (HCV) invariably develop recurrent disease. The risk factors for death and retransplantation following the development of cirrhosis from HCV are unclear. The aim of this study was to identify predictors of survival in liver transplant recipients who develop cirrhosis from recurrent HCV. METHODS: We reviewed records of patients who underwent liver transplantation for cirrhosis due to HCV between January 1990 and December 2001. Prognostic factors of patient survival following the development of recurrent cirrhosis were identified through multivariate analysis. RESULTS: During the study period, 511 patients underwent transplantation for HCV cirrhosis. Of these, 65 patients (13%) developed biopsy proven recurrent cirrhosis from HCV; 43 (8%) were relisted for transplantation, and 24 (5%) underwent retransplantation. The overall Kaplan-Meier patient survival rates after the histologic diagnosis of cirrhosis at 1 and 5 years were 66% and 30%, respectively. A multivariate Cox proportional hazards model showed patients with higher last (i.e. at follow-up or prior to retransplantation) International normalized ratio (INR) values (hazard ratios (HR)=2.02, 95% confidence interval 1.26, 3.24, P<0.01) to have an increased risk of death. CONCLUSION: Our results suggested survival was decreased after the diagnosis of cirrhosis from recurrent HCV. Higher INR was associated with an increased risk of death following the development of cirrhosis.

Adult↗
PubMed2004

Prediction of survival after liver retransplantation for late graft failure based on preoperative prognostic scores.

The current policy for determining priority for organ allocation is based on the model for end stage liver disease (MELD). We hypothesize that severity of graft dysfunction assessed by either the MELD score or the Child-Turcotte-Pugh (CTP) score correlates with mortality after liver retransplantation (re-OLT). To test this hypothesis, we analyzed the outcome of 40 consecutive patients who received re-OLT more than 90 days after primary orthotopic liver transplantation (OLT). The Kaplan-Meier 1-year and 5-year survival rates after re-OLT were 69% and 62%, respectively. The area under the curve (AUC) values generated by the receiver operating characteristics (ROC) curves were 0.82 (CI 0.70-0.94) and 0.68 (CI 0.49-0.86), respectively (P =.11), for the CTP and MELD models in predicting 1-year mortality after re-OLT. The 1-year and 5-year survival rates for patients with CTP scores less than 10 were 100% versus 50% and 40%, respectively, for CTP scores of at least 10 (P =.0006). Patients with MELD scores less than or equal to 25 had 1-year and 5-year survival rates of 89% and 79%, respectively, versus 53% and 47%, respectively, for MELD scores greater than 25 (P =.038). Other mortality predictors include hepatic encephalopathy, intensive care unit (ICU) stay, recurrent hepatitis C virus (HCV) infection, and creatinine level of 2 mg/dL or higher. Analysis of an independent cohort of 49 patients showed a trend for a correlation between CTP and MELD scores with 1-year mortality, with AUC of 0.59 and 0.57, in respective ROC curves. In conclusion, our results suggest that severity of graft failure based on CTP and MELD scores may be associated with worse outcome after re-OLT and provide a cautionary note for the "sickest first" policy of organ allocation.

Adult↗
PubMed2004

Outcomes of acute rejection after interferon therapy in liver transplant recipients.

Interferon alfa has been increasingly used against recurrent hepatitis C (HCV) disease in post-liver transplant (LT) recipients. A serious potential adverse effect is acute rejection. We reviewed our experience using interferon-based therapy (interferon or pegylated interferon with or without ribavirin) for treating recurrent HCV in LT recipients. Forty-four LT recipients were treated with interferon for recurrent HCV. Five of the 44 patients developed acute rejection during interferon-based therapy. These 5 patients started treatment of 42.4 +/- 33.89 months (mean +/- SD) after LT. Mean (+/- SD) histological activity index and fibrosis scores before initiating antiviral therapy were 8.8 (+/- 1.92) and 2.6 (+/- 0.55), respectively. Patients were treated for 3.3 +/- 2.28 months (mean +/- SD) prior to rejection. At the time of rejection, HCV load was not detectable in 4 of the 5 recipients. All 5 patients had tolerated interferon therapy, and none had stopped therapy because of adverse effects. The rejection was successfully treated in 3 patients. In 2 of those 3 patients, cirrhosis eventually developed. In the 2 patients who did not respond to rejection treatment, immediate graft failure occurred, leading to re-LT in 1 patient and death from sepsis in the other. In conclusion, the results indicate that further studies are needed to assess the safety of interferon in LT recipients. Interferon-based therapy may lead to acute rejection and subsequent graft loss and should therefore be used with caution. Treated recipients may also develop progressive cirrhosis despite achieving a sustained virological response.

Adult↗
PubMed2004

Predictors of survival after liver transplantation for hepatocellular carcinoma associated with Hepatitis C.

The efficacy of orthotopic liver transplantation (OLT) for hepatocellular carcinoma (HCC) associated with hepatitis C virus (HCV) is not well defined. This study examines the variables that may determine the outcome of OLT for HCC in HCV patients. From 1990 to 1999, 463 OLTs were performed for HCV cirrhosis. Of these patients, 67 with concurrent HCC were included in the study. Univariate and multivariate analyses considered the following variables: gender, pTNM stage, tumor size, number of nodules, vascular invasion, incidental tumors, adjuvant chemotherapy, preoperative chemoembolization, alpha-fetoprotein (AFP) tumor marker, lobar distribution, and histological grade. Overall OLT survival of HCV patients diagnosed with concomitant HCC was significantly lower when compared to patients who underwent OLT for HCV alone at 1, 3, and 5 years (75%, 71%, and 55% versus 84%, 76%, and 75%, respectively; P < 0.01). Overall survival of patients with stage I HCC was significantly better than patients with stage II, III, or IV (P < .05). Eleven of 67 patients developed tumor recurrence. Sites of recurrence included transplanted liver (5), lung (5), and bone (1). Twenty-four of 67 patients (36%) died during the follow-up time. Causes of deaths included recurrent HCC in 8 of 24 patients (12%) and recurrent HCV in 3 of 24 patients (4.5%), whereas 13 (19.5%) patients died from causes that were unrelated to HCV or HCC. Both univariate and multivariate analysis demonstrated that pTNM status (I versus II, III, and IV; P < .05) was a reliable prognostic indicator for patient survival. Presence of vascular invasion (P = .0001) and advanced pTNM staging (P = .038) increased risk of recurrence. Multivariate analysis showed that pretransplant chemoembolization and adjuvant chemotherapy reduced risk of death after OLT in HCC recipients. In conclusion, this study demonstrates the effectiveness of OLT for patients with HCC in a large cohort of chronic HCV patients. Advanced tumor stage, and particularly vascular invasion, are poor prognostic indicators for tumor recurrence. Early pTNM stage, adjuvant chemotherapy, and preoperative chemoembolization were associated with positive outcomes for patients who underwent OLT for concomitant HCV and HCC.

Adult↗
PubMed2004

Liver transplantation in the era of model for end-stage liver disease.

Liver transplantation is challenged by organ shortage and prolonged waiting list time. The goal of the ideal organ allocation system is to transplant individuals least likely to survive without a liver transplantation, and maintain appropriate rates of postoperative survival. Currently, liver allocation in the United States is based on the model for end-stage liver disease (MELD). Studies have shown MELD to be objective and accurate in predicting short-term survival in patients with cirrhosis.

Health Care Rationing↗
PubMed2004

Fulminant liver failure due to usnic acid for weight loss.

The use of complementary and alternative medicine (CAM) in developed countries has increased significantly over the years. Among the most popular are the weight loss supplements or "fat burners." Liver failure due to these popular remedies has been widely recognized. Usnic acid has been an ingredient of dietary supplements that cause liver failure. Its hepatotoxicity has not been recognized because it is usually mixed with other ingredients that are presumably hepatotoxic. We describe a case of a 28-yr-old woman who presented with fulminant liver failure requiring orthotopic liver transplantation, after taking pure usnic acid for weight loss. This is the first report on fulminant liver failure associated with the ingestion of pure usnic acid. A discussion about hepatotoxicity of the different compounds of dietary supplements is presented. This is a reminder for the clinicians about the potential side effects of CAM.

Adult↗