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Biomedical subjects

Scott W Biggins

Publications and source records attributed to Scott W Biggins.

10 recordsLinked to original sources
PubMed2006

Management of recurrent hepatitis C in liver transplant recipients.

Recurrent HCV infection is universal in liver transplant recipients who are viremic pretransplant. The rate of histologic disease progression after transplantation is more rapid, and the risk of cirrhosis by 5 to 10 years is about 30%. Several donor, recipient, and viral factors have been associated with worse post-transplant outcomes in recipients with recurrent hepatitis C. Whether or not HCV-infected recipients of live donor grafts have worse out-comes compared with deceased donor graft recipients is controversial. To maximize the long-term survival of recipients with HCV infection, eradication of infection is the ultimate goal. Treatment of recurrent HCV after liver transplantation can be undertaken at several different time points: (1) prophylactically, at the time of transplantation; (2) pre-emptively, in the early post-transplant period; and (3) after established recurrent histologic disease is present. Prophylactic therapy for HCV infection has no established role at present, but studies are ongoing. Preemptive therapy using IFN and RBV has resulted in variable SVR rates (9%-43%) and is generally poorly tolerated, especially if the patient has advanced liver disease pretransplantation. Treatment of established recurrent HCV disease with combination PEGIFN and RBV is associated with a SVR in about 30% to 35% of patients overall but is limited by high rates of dose reduction or drug discontinuation. In conclusion, successful HCV eradication in the post-transplant setting is difficult with current treatment options, but it is possible. Determination of the optimal doses of antiviral drugs in transplant patients and improvements in drug tolerability may be important first steps in achieving enhanced response rates. There is a need for new drugs in this population that have greater efficacy and a better safety profile.

Journal Article↗
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

MELD-based liver allocation: who is underserved?

Deceased-donor livers are a scarce, lifesaving resource. For patients whose lives depend upon liver transplantation, policies for prioritizing allograft allocation are of ultimate importance. In the current paradigm, donor livers are allocated on the basis of medical urgency. Thus, the onus is on the transplant community to refine the allocation system continuously so that livers are targeted to patients who need them most. The current model for end-stage liver disease (MELD)-based allocation system works well, accurately predicting short-term mortality for the majority (83 to 87%) of waitlisted candidates. However, there are patients with liver diseases whose survival is dependent upon factors other than the severity of the liver disease and who may not manifest derangements in their MELD parameters. Such patients may be underserved by current MELD policies. This article reviews the development of MELD and the MELD-based liver allocation system and addresses issues relevant to whether this system may be improved.

Humans↗
PubMed2005

Serum sodium predicts mortality in patients listed for liver transplantation.

With the implementation of the model for end-stage liver disease (MELD), refractory ascites, a known predictor of mortality in cirrhosis, was removed as a criterion for liver allocation. Because ascites is associated with low serum sodium, we evaluated serum sodium as an independent predictor of mortality in patients with cirrhosis who were listed for liver transplantation and whether the addition of serum sodium to MELD was superior to MELD alone. This is a single-center retrospective cohort of all adult patients with cirrhosis listed for transplantation from February 27, 2002, to December 26, 2003. Listing laboratories were those nearest the listing date +/-2 months. Of the 513 patients meeting inclusion criteria, 341 were still listed, while 172 were removed from the list (105 for transplantation, 56 for death, 11 for other reasons). The median serum sodium and MELD scores were 137 mEq/L (range, 110-155) and 15 (range, 6-51), respectively, at listing. Median follow-up was 201 (range, 1-662) days. The risk of death with serum sodium <126 mEq/L at listing or while listed was increased, with hazard ratios of 7.8 (P < .001) and 6.3 (P < .001), respectively, and the association was independent of MELD. The c-statistics of receiver operating characteristic curves for predicting mortality at 3 months based upon listing MELD with and without listing serum sodium were 0.883 and 0.897, respectively, and at 6 months were 0.871 and 0.905, respectively. In conclusion, serum sodium <126 mEq/L at listing or while listed for transplantation is a strong independent predictor of mortality. Addition of serum sodium to MELD increases the ability to predict 3- and 6-month mortality in patients with cirrhosis.

Adult↗
PubMed2005

Treatment of recurrent hepatitis C after liver transplantation.

Chronic hepatitis C virus (HCV) infection is the most common indication for liver transplantation in the United States and Europe, and more than 20,000 patients worldwide have undergone transplantation for complications of chronic hepatitis C. In North America, HCV accounts for 15% to 50% of the liver transplants performed in United States transplant programs. To maximize the long-term survival of liver transplant recipients who have HCV infection, eradication of infection is the ultimate goal. Pretransplant antiviral therapy with the goal of achieving viral eradication before transplantation is a consideration in some patients, especially those who have mildly decompensated liver disease. This article focuses on the management of liver transplant recipients who have HCV infection at the time of transplantation. Prophylactic and preemptive therapies, as well as treatment of established recurrent disease, are the strategies reviewed.

Antiviral Agents↗
PubMed2002

Retransplantation for hepatic allograft failure: prognostic modeling and ethical considerations.

Retransplantation already accounts for 10% of all liver transplants performed, and this percentage is likely to increase as patients live long enough to develop graft failure from recurrent disease. Overall, retransplantation is associated with significantly diminished survival and increased costs. This review summarizes the current causes of graft failure after primary liver transplant, prognostic models that can identify the subset of patients for retransplantation with outcomes comparable to primary transplantation, and ethical considerations in this setting, i.e., outcomes-based versus urgency-based approaches.

Ethics, Medical↗