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Item Clinical features of ileal pouch-anal anastomosis in African American patients with underlying ulcerative colitis(Blackwell Publishing Ltd, 2009-07-20) Moore, L; Tang, L; Lopez, R; Shen, BBackground: The prevalence of inflammatory bowel disease in African Americans appears to be increasing. The data on differences in disease behavior and severity between the races have been conflicting. Aim: To evaluate the effect of race on outcome and natural history of patients with ileal pouch-anal anastomosis. Methods: All African American patients with underlying ulcerative colitis and ileal pouch-anal anastomosis who were seen in our subspecialty Pouchitis Clinic from 2002 to 2008 were included. The control group consisted of Caucasian patients with ulcerative colitis and ileal pouch-anal anastomosis who were randomly selected from the same Pouch Registry at a ratio of 4:1. We compared pouch failure, Crohn’s disease of the pouch, and chronic pouchitis rates, as well as other 23 demographic and clinical variables between African American and Caucasian patients. Results: A total of 12 African American patients and 48 Caucasian patients were evaluated in this case-control study. There were no significant differences in the frequency of pouch failure, Crohn’s disease of the pouch, or chronic pouchitis between the African American and Caucasian groups. However, African American patients were found to have a significantly shorter duration of inflammatory bowel disease (11.5 years vs. 17.0 years, P = 0.024) as well as significantly shorter duration of pouch (1.5 years vs. 4 years, P = 0.02). African Americans were also less likely to have pancolitis at the time of colectomy (83% vs. 100%, P = 0.037). Conclusions: While there were no significant differences in pouch outcomes between the races, African American patients appeared to have more left-sided colitis at the time of colectomy, with a shorter duration of inflammatory bowel and ileal pouch. This finding suggests that the natural history of ulcerative colitis and disease course before and after restorative proctocolectomy may be different between these racial groups.Item Impact of EGF, IL28B, and PNPLA3 polymorphisms on the outcome of allograft hepatitis C: A multicenter study(Wiley Online Library, 2016-04) Mueller, Jessica L.; King, Linsday Y.; Johnson, Kara B.; Gao, Tian; Nephew, Lauren D.; Kothari, Darshan; Simpson, Mary Ann; Zheng, Hui; Wei, Lan; Corey, Kathleen E.; Misdraji, Joseph; Lee, Joon Hyoek; Lin, M. Valerie; Gogela, Neliswa A.; Fuchs, Bryan C.; Tanabe, Kenneth K.; Gordon, Fredric D.; Curry, Michael P.; Chung, Raymond T.Hepatitis C virus (HCV) infection is accelerated following liver transplantation (LT). Single nucleotide polymorphisms (SNPs) near the epidermal growth factor (EGF) (rs4444903), IL28B (rs12979860), and PNPLA3 (rs738409) loci are associated with treatment response, fibrosis, and hepatocellular carcinoma in non-transplant hepatitis C, but allograft population data are limited. We sought to determine the role of these SNPs in 264 patients with HCV who underwent LT between 1990 and 2008. Genotypes were determined from donor wedge/allograft biopsies and recipient explants. Cox proportional hazards model was used to assess time to cirrhosis, liver-related death, and retransplantation, adjusting for donor age and sustained virological response (SVR). Over a median follow-up of 6.3 yr, a trend toward increased progression to graft cirrhosis was observed among recipients of an EGF non-AA vs. AA donor liver (adjusted HR 2.01; 95% CI 0.93–4.34; p = 0.08). No other genotypes predicted cirrhosis development or graft survival. The CC IL28B variant in both recipients and donors was associated with increased rate of SVR (R-CC/D-CC 8/12[67%], R-non-CC/D-CC or R-CC/D-non-CC 23/52[44%], R-non-CC/D-non-CC 12/45[27%], p linear trend = 0.009). Recipient EGF, IL28B, and PNPLA3, and donor IL28B and PNPLA3 genotypes do not predict adverse outcomes in HCV LT recipients. A potential association exists between donor EGF genotype and cirrhosis.Item Exception points and body size contribute to gender disparity in liver transplantation(2017-08) Nephew, Lauren D.; Goldberg, David; Lewis, James D.; Abt, Peter; Bryan, Mathew; Forde, Kimberly A.Background & Aims—Women are significantly less likely than men to receive a liver transplant and more likely to die on the waitlist. We investigated potential reasons for these disparities, including match run positions and declined organs due to small stature of female recipients. Methods—We analyzed data from the United Network of Organ Sharing registry of candidates placed on the waitlist from May 10, 2007 through June 17, 2013. Primary outcomes included: ranked in first position on a match run, having an organ declined while in first position, declining an organ while in first position because of size mismatch between donor and recipient (body surface area discordance), and death or becoming too sick for liver transplantation. Results—Among 64,995 patients on the waitlist for liver transplantation, 23.1% of men and 15.6% of women received exception points (P<.001). Women listed without exception points were less likely than men to be ranked first (odds ratio [OR], 0.93; 95% CI, 0.88–0.99). Women who achieved a first position were more likely to decline an organ than men (OR, 1.15; 95% CI, 1.06–1.26); this difference was reduced after we accounted for recipient body surface area (OR, 1.08; 95% CI, 0.98–1.19). Women with a single liver decline were more likely than men with a single liver decline to die or become too sick for transplantation (OR, 1.26; 95% CI, 1.12–1.41). The difference was reduced after we accounted for exception points (OR, 1.16; 95% CI, 1.12–1.21) and recipient body surface area (OR, 1.01; 95% CI, 0.96–1.06). Conclusion—In an analysis of data from the United Network of Organ Sharing registry, we found that women when compared to men on the waitlist for liver transplantation. are disadvantaged by an imbalance in exception point allocation and organ decline because of small stature.Item Thirty-Day Readmissions Are Largely Not Preventable in Patients With Cirrhosis(Wolters Kluwer, 2024) Orman, Eric S.; Desai, Archita P.; Ghabril, Marwan S.; Nephew, Lauren D.; Patidar, Kavish R.; Holden, John; Samala, Niharika R.; Gawrieh, Samer; Vuppalanchi, Raj; Sozio, Margaret; Lacerda, Marco; Vilar-Gomez, Eduardo; Lammert, Craig; Liangpunsakul, Suthat; Crabb, David; Masuoka, Howard; Dakhoul, Lara; Pan, Minmin; Gao, Sujuan; Chalasani, Naga; Medicine, School of MedicineIntroduction: Hospital readmissions are common in patients with cirrhosis, but there are few studies describing readmission preventability. We aimed to describe the incidence, causes, and risk factors for preventable readmission in this population. Methods: We performed a prospective cohort study of patients with cirrhosis hospitalized at a single center between June 2014 and March 2020 and followed up for 30 days postdischarge. Demographic, clinical, and socioeconomic data, functional status, and quality of life were collected. Readmission preventability was independently and systematically adjudicated by 3 reviewers. Multinomial logistic regression was used to compare those with (i) preventable readmission, (ii) nonpreventable readmission/death, and (iii) no readmission. Results: Of 654 patients, 246 (38%) were readmitted, and 29 (12%) were preventable readmissions. Reviewers agreed on preventability for 70% of readmissions. Twenty-two (including 2 with preventable readmission) died. The most common reasons for readmission were hepatic encephalopathy (22%), gastrointestinal bleeding (13%), acute kidney injury (13%), and ascites (6%), and these reasons were similar between preventable and nonpreventable readmissions. Preventable readmission was often related to paracentesis timeliness, diuretic adjustment monitoring, and hepatic encephalopathy treatment. Compared with nonreadmitted patients, preventable readmission was independently associated with racial and ethnic minoritized individuals (odds ratio [OR] 5.80; 95% CI, 1.96-17.13), nonmarried marital status (OR 2.88; 95% CI, 1.18-7.05), and admission in the prior 30 days (OR 3.45; 95% CI, 1.48-8.04). Discussion: For patients with cirrhosis, readmission is common, but most are not preventable. Preventable readmissions are often related to ascites and hepatic encephalopathy and are associated with racial and ethnic minorities, nonmarried status, and prior admissions.Item Information overload, financial constraints, and psychological burdens are among the barriers faced by marginalized groups seeking curative treatments for HCC(Wolters Kluwer, 2025-02-26) Nephew, Lauren D.; Moore, Courtney; Garcia, Nicole; Parks, Lisa; McKay, Allison; Strauss, Alexandra T.; Wiehe, Sara; Chalasani, Naga; Hughes-Wegner, Alexandra T.; Rawl, Susan M.; Medicine, School of MedicineBackground: Patients with HCC face numerous barriers to curative therapies, particularly Black patients and those impacted by adverse social determinants of health (SDOH). This study aimed to identify patient-reported barriers and facilitators to curative therapies, to inform interventions that improve equitable access to care. Methods: We conducted 2 qualitative sessions with Black participants and participants experiencing adverse SDOH with HCC referred for liver transplant (LT) or resection. We also conducted one-on-one interviews with participants from sessions that underwent LT (n=2). Human-centered design methods, including journey mapping and group ideation, were used to identify challenges and solutions at various stages in the care pathway. Data were analyzed to identify key themes and to compare the experiences of Black patients with those experiencing adverse SDOH. Results: Both groups faced significant barriers, particularly related to information overload, communication gaps with health care providers, and the complexity of navigating the LT pathway. However, Black patients reported additional challenges related to the psychological burden of the diagnosis and distrust in the health care system, while those with adverse SDOH frequently cited financial instability, lack of social support, and challenges in coordinating care between multiple health systems. Despite these differences, common facilitators included compassionate health care teams and strong personal support networks. Both groups suggested solutions such as improvements in education timing and delivery, better communication pathways, and peer support groups to improve preparedness for treatment and recovery. Conclusions: While Black patients and those with adverse SDOH experience unique barriers, common threads-such as information gaps and desire for peer support suggest shared opportunities for interventions.Item The rate of muscle wasting in liver transplant recipients on waiting list: post-transplant outcomes and associated serum metabolite patterns(AME, 2024) Rokop, Zachary P.; O’Connell, Thomas M.; Munsch, Taylor; Nephew, Lauren; Orman, Eric; Mihaylov, Plamen; Mangus, Richard S.; Kubal, Chandrashekhar; Surgery, School of MedicineBackground: Sarcopenia at the time of liver transplantation (LT) is an established risk factor for mortality following LT. However, most studies in this context have defined sarcopenia by one-time, static measurements. The aims of this study were (I) to determine the impact of the rate of muscle loss in waitlisted LT recipients on post-LT outcomes and (II) to identify patterns of serum metabolites associated with patients with more progressive sarcopenia. Methods: Patients undergoing liver transplant from 2008 to 2018 who received more than one computed tomography (CT) scans within 12 months prior to liver transplant were included (n=61). The psoas muscle index (PMI) was calculated using Slice-O-Matic software and corrected for patient height (m2). Patients were classified into two groups based the rate of reduction in PMI-high wasting [HW; change in PMI (ΔPMI) ≤-1%/month] and low wasting (LW; ΔPMI >-1%/month). Pre-transplant serum metabolic profiles were collected using nuclear magnetic resonance (NMR) spectroscopy. Living kidney donor sera was used as healthy controls. Results: Median ΔPMI was -2.0%/month in HW and -0.15%/month in LW patients (P<0.001). Post-transplant 1-year mortality was significantly higher in HW patients. There were no significant differences in metabolite concentrations between HW and LW patients. However, perturbations in taurine, sarcosine, betaine and the aromatic amino acids (AAAs), were observed in patients with liver disease as compared to healthy controls. Liver disease was also associated with a decrease in lipoprotein profiles, especially high-density lipoprotein (HDL) particles. Conclusions: In patients undergoing LT, the rate of progression of sarcopenia is a strong prognostic indicator of post-LT death. Serum metabolite profiles were not characteristically unique to HW patients, and most closely resemble derangements associated with chronic liver disease.Item Let's take 2 steps forward(Wolters Kluwer, 2023) Nephew, Lauren D.; Medicine, School of MedicineItem Health literacy and cumulative social disadvantage are associated with survival and transplant in patients with hepatocellular carcinoma: a prospective study(BMJ, 2024-10-02) Nephew, Lauren D.; Rawl, Susan M.; Carter, Allie; Garcia, Nicole; Monahan, Patrick O.; Holden, John; Ghabril, Marwan; Montalvan-Sanchez, Eleazar; Patidar, Kavish; Desai, Archita P.; Orman, Eric; Chalasani, Naga; Medicine, School of MedicineObjective: To investigate how individual social determinants of health (SDOH) and cumulative social disadvantage (CSD) affect survival and receipt of liver transplant (LT) in patients with hepatocellular carcinoma (HCC). Methods: We enrolled 139 adult patients from two Indianapolis hospital systems between June 2019 and April 2022. Structured questionnaires collected SDOH and social risk factor data. We compared SDOH and CSD by race, gender and disease aetiology, assigning one point per adverse SDOH. Multivariable competing risk survival analysis assessed associations between SDOH, CSD, survival and LT receipt. Results: Black patients experienced higher CSD than white patients in the cohort (5.4±2.5 vs 3.2±2.1, p<0.001). Black patients were significantly more likely to have household incomesItem Measuring Medication Use, Obstacles and Knowledge in Individuals with Cirrhosis(Elsevier, 2023) Desai, Archita P.; Duzdar, Shahd; Stump, Timothy; Orman, Eric S.; Nephew, Lauren; Patidar, Kavish R.; Ghabril, Marwan S.; Block, Geoffrey; Fallon, Michael; Chalasani, Naga; Monahan, Patrick O.; Medicine, School of MedicineBackground & aims: Although patient knowledge is modifiable, there are no widely accepted tools to measure patient understanding during cirrhosis care. We aimed to develop and validate "My Cirrhosis Coach" (MCC), a personalized, self-administered questionnaire to evaluate cirrhosis-related medication use, obstacles, and understanding. Methods: Adults with cirrhosis were prospectively enrolled at 3 tertiary centers from July 2016 through July 2020. Psychometrics including confirmatory factor analysis was used to develop and validate a final questionnaire. Content validity was measured via the content validity index and expert performance. Discriminant validity was assessed by comparing scores between groups hypothesized to have varying performance. Results: The MCC was tested in a diverse cohort (n = 713) with cirrhosis and its complications including ascites (45%) and hepatic encephalopathy (33%) with median Model for End-Stage Liver Disease-Sodium 10 (interquartile range, 9-15). A 6-factor model of the MCC fit the data well (root mean square error of approximation, 0.22; comparative fit index, 0.96; standardized root mean squared residual, 0.104; final domains: Medication Use & Accessibility, Medication Obstacles, Lactulose Use, Diuretic Use, Beta Blocker Use, and Dietary Sodium Use). The MCC had excellent content validity (content validity index, 81%-94%) and accuracy (91%-100%) ratings by experts. Mean domain scores ranged from 1.1 to 2.6 (range, 0-3; 3 indicating better performance). Those with a cirrhosis complication scored higher in the relevant medication domain (ie, diuretic use score in ascites). Compared with outpatients, inpatients scored higher in all knowledge domains except salt use and reported more medication obstacles. Scores differed by income, education level, and having an adult at home. Conclusions: In a large, diverse cohort, we validated the MCC, which can serve to standardize medication use and knowledge measurement in clinical practice and education-based studies in cirrhosis.Item Medication burden and anticholinergic use are associated with overt HE in individuals with cirrhosis(Wolters Kluwer, 2024-07-22) Montrose, Jonathan A.; Desai, Archita; Nephew, Lauren; Patidar, Kavish R.; Ghabril, Marwan S.; Campbell, Noll L.; Chalasani, Naga; Qiu, Yingjie; Hays, Matthew E.; Orman, Eric S.; Medicine, School of MedicineBackground: Polypharmacy and anticholinergic medications are associated with cognitive decline in elderly populations. Although several medications have been associated with HE, associations between medication burden, anticholinergics, and HE have not been explored. We examined medication burden and anticholinergics in patients with cirrhosis and their associations with HE-related hospitalization. Methods: We conducted a retrospective cohort study of patients aged 18-80 with cirrhosis seen in hepatology clinics during 2019. The number of chronic medications (medication burden) and anticholinergic use were recorded. The primary outcome was HE-related hospitalization. Results: A total of 1039 patients were followed for a median of 840 days. Thirty-seven percent had a history of HE, and 9.8% had an HE-related hospitalization during follow-up. The mean number of chronic medications was 6.1 ± 4.3. Increasing medication burden was associated with HE-related hospitalizations in univariable (HR: 1.09, 95% CI: 1.05-1.12) and multivariable (HR: 1.07, 95% CI: 1.03-1.11) models. This relationship was maintained in those with baseline HE but not in those without baseline HE. Twenty-one percent were taking an anticholinergic medication. Anticholinergic exposure was associated with increased HE-related hospitalizations in both univariable (HR: 1.68, 95% CI: 1.09-2.57) and multivariable (HR: 1.71, 95% CI: 1.11-2.63) models. This relationship was maintained in those with baseline HE but not in those without baseline HE. Conclusions: Anticholinergic use and medication burden are both associated with HE-related hospitalizations, particularly in those with a history of HE. Special considerations to limit anticholinergics and minimize overall medication burden should be tested for potential benefit in this population.