About

Jenn Batisti, MD, is an assistant professor of medicine (digestive diseases) at Yale School of Medicine. She is a gastroenterologist and transplant hepatologist with specific interests in the care of liver transplant patients, organ allocation, nutrition in transplant, and non-alcoholic fatty liver disease. Dr. Batisti focuses on treating patients with advanced liver diseases, including those who have undergone liver transplants and individuals interested in organ donation. Her research includes studying hepatic steatosis, arsenic toxicity related to liver health, and management of cirrhosis and fatty liver disease. She has contributed to peer-reviewed publications on these topics and is involved in clinical trials such as the HOPE in Action trial for HIV+ liver transplant recipients. Dr. Batisti is actively engaged in community involvement and professional organizations, including serving on advisory boards and the National Liver Review Board.

Research topics

• Medicine
• Internal medicine
• Intensive care medicine
• Gastroenterology
• Pathology
• General surgery
• Environmental health

Selected publications

• Management of the hospitalized patient with cirrhosis

  Clinical Liver Disease · 2024

  1st authorCorresponding
  • Medicine
  • Intensive care medicine
  • General surgery

  In the United States, the rate of chronic liver disease (CLD)-related hospitalization has been steadily increasing.1 Among patients with cirrhosis, hospitalization may occur due to a complication of cirrhosis itself, or cirrhosis may be a secondary problem that nevertheless requires close attention and sometimes specialized management. Although the overall mortality rates related to CLD have remained stable, high mortality rates have been observed among hospitalized patients with alcoholic cirrhosis as well as HCC.1 Across all etiologies of CLD, cirrhosis and its complications have increased the clinical needs and overall health care resource utilization of patients with CLD.1,2 Patients with cirrhosis are at particular risk of hypervolemia, infections, renal dysfunction, hepatic encephalopathy, bleeding complications, malnutrition, and frailty.3–5 The widespread nature of these problems means that they will be encountered by both specialized and general providers alike, across all strata of the hospital. Clinical manifestations of cirrhosis are primarily driven by progressive portal hypertension and systemic inflammation,6 and clinical management centers on treatment of the underlying etiology, anticipation/prevention of decompensation, and referral for liver transplantation when appropriate. Patients may present to the hospital with their initial decompensation event or complications, such as acute kidney injury or spontaneous bacterial peritonitis. Alternatively, events that occur during hospitalization may trigger cirrhosis decompensation—for example, sedating medications, or infection, or bleeding associated with a surgery unrelated to liver disease. Fortunately, there are steps that can be taken to mitigate these risks. In doing so, we can improve outcomes, shorten hospital stays, and in appropriate cases refer patients for liver transplantation in a timely manner. In this series, we will introduce and facilitate the use of key concepts and standards of care through a series of articles presenting practical and evidence-based approaches to the management of cirrhosis that can be applied by multiple providers caring for the hospitalized patient with cirrhosis. All providers can improve the outcomes of these patients, irrespective of specialty.

  PublisherOA PDFDOI

• Arsenic and young liver: a case report of hepatic steatosis due to arsenic toxicity

  Clinical Journal of Gastroenterology · 2024-10-08

  articleSenior author
  PublisherDOI

• Hospitalized patients with cirrhosis: Addressing gaps in care

  Clinical Liver Disease · 2024-01-01

  articleOpen access1st author

  In the last 3 years, all major hepatology and gastroenterology societies (American Association for the Study of Liver Diseases—AASLD, American Gastroenterological Association—AGA, American College of Gastroenterology—ACG, European Association for the Study of the Liver—EASL) have published detailed guidance regarding the management of patients with cirrhosis. Those recommendations include evidence-based practices relevant for hospitalized patients, from treating several complications of cirrhosis such as ascites/spontaneous bacterial peritonitis,1 acute kidney injury/hepatorenal syndrome,2,3 variceal bleeding,4,5 HE,6 acute-on-chronic liver failure,7,8 to integration of palliative care9,10 and optimal management of malnutrition.11 This shows the highly complex care required to appropriately take care of patients with cirrhosis. While therapeutic advances are certainly benefiting our patients, consistent guideline-driven clinical practice remains challenging. In addition, transitions of care and appropriate transfer/referral for liver transplantation are critical for providing patient-centered quality hospital care. We hope that the following considerations will help hospital-based practitioners with variable experience in hepatology to address these gaps in the management of hospitalized patients with cirrhosis and deliver high-value inpatient care. ALIGNING CLINICAL PRACTICE WITH GUIDELINE RECOMMENDATIONS Successful implementation of practice guidelines is variable across hospital systems.12,13 To promote value improvement in cirrhosis care by reliably measuring and tracking the health care provided, AASLD has developed a standardized set of quality measures, including process measures, clinical, and patient-reported outcomes.14Table 1 summarizes the AASLD quality measures applicable for the inpatient management of cirrhosis and relevant major society guidelines. Higher adherence to certain quality measures was associated with lower overall mortality and lower inpatient health care use,15 but further research is needed to evaluate the full impact of process measures on clinical outcomes. TABLE 1 - AASLD quality measures and relevant major society guidelines, as applicable for inpatient management of cirrhosis Selected AASLD quality measures Ascites/acute kidney injury Variceal bleeding HE Nutrition Process measures Patients with ascites who are admitted to the hospital for evaluation and management of symptoms related to ascites or encephalopathy should receive a diagnostic paracentesis during the index hospitalization Patients who are admitted with or develop GI bleeding should receive antibiotics within 24 h of presentation. Antibiotics should be continued for at least 5 d Patients with previous overt HE should be counseled regarding the risks associated with driving Patients with cirrhosis should be assessed for frailty using a systematic screening method Hospitalized patients with ascites, with an ascitic fluid PMN≥250 cells/mm3, should receive empiric antibiotics and albumin within 12 h (1.5 g/kg D1, 1.0 g/kg D3) Patients with cirrhosis who present with upper GI bleeding should receive upper endoscopy within 12 h of presentation Patients with HE should have a search for evidence of precipitating factors documented in the chart Patients undergoing large-volume paracentesis (>5 L removed) should receive i.v. albumin (6–8 g/L removed) Patients with cirrhosis who are found to have bleeding esophageal varices should receive EVL or sclerotherapy at the time of index endoscopy Patients who are hospitalized and have an acute episode of overt HE should receive lactulose Patients who undergo paracentesis should not receive fresh frozen plasma or platelets Patients with cirrhosis who survive an episode of acute variceal hemorrhage should receive a combination of EVL and beta-blockers Patients who are discharged after an acute episode of HE should receive secondary prophylaxis with lactulose and/or rifaximin Patients with ascites and/or hepatic hydrothorax should be managed with both sodium restriction and diuretics — — — Clinical outcomes — First variceal bleedingVariceal rebleeding — — Overall: liver-related hospitalization, rehospitalization within 7 or 30 d Patient-reported outcomes Fluid in the legs/belly — Confusion, concentration/memory General: medication side effects/muscle cramps, falls Relevant guidelines 2021 AASLD ascites/SBP/HRS2022 AGA AKI, 2024 AGA vasoactive drugs/HRS 2024 AASLD portal hypertension /varices2023 AASLD TIPS/RTO variceal bleed EASL HE 2021 AASLD malnutrition/frailty General: ACLF (ACG, 2022, EASL 2023), Palliative care (AGA 2021, AASLD 2022) Abbreviations: AASLD, American Association for the Study of Liver Diseases; ACG, American College of Gastroenterology; ACLF, acute-on-chronic liver failure; AGA, American Gastroenterological Association; AKI, acute kidney injury; EASL, European Association for the Study of the Liver; EVL, endoscopic variceal ligation; GI, gastrointestinal; HRS, hepatorenal syndrome; PMN, polymorphonuclear cells; RTO, retrograde transvenous obliteration; SBP, spontaneous bacterial peritonitis. Given increased interest and publications on quality improvement (QI) in cirrhosis, there is now substantial data assessing the efficacy of several initiatives to align real-world practice with guidelines-based management. Various QI interventions in cirrhosis targeted higher compliance to recommended process measures with the goal of achieving superior clinical outcomes (survival, decreased rate of complications) and avoiding unwarranted hospital service utilization (preventable admissions/readmissions, unjustified length of hospital stay). To overcome the knowledge gap due to time restrains and difficulty for hospital practitioners to keep up to date with the latest guidelines, many QI trials have used easy-to-access and time-efficient tools to reduce variation in clinical practice: handheld checklists,16 templated notes,17 best practice alerts/decision support,16 and clinical pathways/order sets.18,19 More resource-intensive solutions have addressed institutional logistics and culture changes but require high commitment across all shareholders: “best practice” in emergency room focusing on timely interventions,20 dedicated teams to perform emergency room or inpatient paracentesis,21 bundled interventions to ensure timely performance of diagnostic paracentesis (education + workflow support/ultrasound/premade kits + alert + orderset)22 or postdischarge care management programs.23,24 Despite the increase in compliance with practice guidelines, the results of QI initiatives have varied in terms of sustainability and impact on clinical outcomes (survival, length of stay, and readmissions), sometimes leading to undesired effects (increased length of stay due to electrolyte disturbances secondary to excessive lactulose use).19 Nevertheless, they provide useful ideas that should be tailored to the local institutional needs and practices. Optimal QI in cirrhosis should integrate clinical practice with an iterative QI process, ideally based on a learning health system paradigm, continuously assessing the efficacy of interventions and responding to clinical challenges.25 NUTRITION MANAGEMENT FOR THE HOSPITALIZED PATIENTS WITH CIRRHOSIS There is a high prevalence of malnutrition among patients with cirrhosis, exceeding 90% in some study populations.26 Both macronutrients and micronutrients/trace elements may be deficient,27–30 with important implications for the hospitalized patient. For patients with alcohol use disorders and cholestatic disorders, malnutrition may be present to a significant degree prior to the onset of cirrhosis and can worsen as the liver disease progresses.29,31 Imposed fasting states, such as preprocedure or pretesting “nil per os” periods, exacerbate this caloric deficit, which may be particularly relevant in the inpatient setting. Malnutrition in cirrhosis is associated with sarcopenia, infection, and frailty and thus contributes to an increased risk of mortality.32–35 This risk extends to patients who receive a liver transplant (LT); malnutrition is a risk factor for poor transplant outcomes.36 Despite the consequences of malnutrition, it tends to be under-assessed and under-diagnosed, even by subspecialty providers.26,37 However, addressing and treating malnutrition in patients with cirrhosis can both improve quality of life and extend survival.38,39 Therefore, in the hospitalized patient with cirrhosis, nutritional status should be assessed at admission and may need repeated assessment if a hospital stay is prolonged.11,26,35 Ideally, this assessment should involve a multispecialty team with a gastroenterologist/hepatologist and a dietician.11,26,35 Choosing the correct screening tools can be challenging, as the majority of validated nutritional screening and assessment instruments are not specific for liver disease. Furthermore, their use in the inpatient setting can be limited by expense, the need for specialized equipment, and patient factors such as hypervolemia.35,40 For example, the presence of ascites can mask abnormally low body mass index.41 True obesity, far from reassuring the clinician that malnutrition is not present, can also obfuscate the presence of sarcopenia as well as other nutrient deficiencies.34,42 The Royal Free Hospital-Nutritional Prioritizing Tool can be used at the bedside by nonspecialist staff as a screening tool,43 though further, more specific testing may later be needed. Several general nutritional principles can be applied in the inpatient setting. In situations where patients with cirrhosis present with significant ascites and/or edema, a low salt diet, defined as ≤2000 mg/24 hours of dietary sodium, is recommended.43 This should be differentiated from a “no salt added” diet, which for US adults is typically 3400 mg/24 h of dietary sodium, most of which comes from processed foods.44 Patients with cirrhosis typically have elevated protein needs, requiring 1.2–1.5 g/kg/d of protein.45 There is no role for protein restriction to prevent HE,46 and there is insufficient evidence to recommend animal-based or plant-based protein sources specifically for the prevention of HE.47 Oral nutritional supplementation may be beneficial in the hospital setting; although a recent meta-analysis has not supported an overall mortality benefit from supplementation use, subgroup analyses support its use in hospitalized patients.11,48 Given the prevalence of micronutrient deficiencies within this population, some societies have suggested the use of an empiric multivitamin.11 In addition to minimizing times of nil per os, small frequent meals and the implementation of evening snacks are additional strategies40,49,50 that can be employed to maximize nutrition in the inpatient with cirrhosis. Patient education regarding nutrition and dietary strategies remains crucial. Many patients with cirrhosis have a limited understanding of their disease state, including nutrition goals,51 and an inpatient hospital stay provides a potential opportunity for patient and family education. TRANSITIONS OF CARE FOR THE HOSPITALIZED PATIENTS WITH CIRRHOSIS There is limited data on best practices for transitions of care for hospitalized patients with cirrhosis. This represents a significant information deficit, as patients with cirrhosis have a high rate of hospitalization, which has been increasing within the United States.52 A timely transfer to a LT center is an important part of an optimal transition of care for patients who are critically ill and need to undergo their LT evaluation in an “expedited” fashion. Delayed referrals were associated with worse outcomes.53,54 While discussions about LT are typically deferred to gastroenterology/hepatology team, hospital providers responsible for the inpatient care of patients with cirrhosis should have a basic understanding of indications for LT and be comfortable to initiate the transfer to a transplant center for an expedited evaluation especially if their local access to inpatient specialty care is limited. Barring a specific contraindication to LT, patients hospitalized for complications of cirrhosis, such as portal hypertensive bleeding, HE, ascites, spontaneous bacterial peritonitis, or hepatorenal syndrome should be considered for transplant evaluation.55–57 Model for End-Stage Liver Disease–Sodium score ≥15 has also been used as a threshold for LT referral56; however, it is important to note that patients with cirrhosis may have a low Model for End-Stage Liver Disease–Sodium score and still demonstrate elements of decompensation; transplant referral should not be withheld based on a low Model for End-Stage Liver Disease–Sodium score. Multiple barriers to initiation of LT referral and evaluation have been identified. These include incorrect provider understanding of transplant contraindications,53 patient socioeconomic status,58 perceived complexity of referral process,59 and geography.60 Parameters for defining contraindications to LT, especially psychosocial contraindications, have changed since the inception of transplant care. Severe acute alcoholic hepatitis, previously considered a contraindication to LT, is now accepted as an indication for LT at an increasing number of centers within the United States61 and should not preclude referral. While transplant centers within the United States are encouraged to develop program-specific criteria for patient evaluation, a recent Organ Procurement and Transplantation Network white paper62 has recommended that neither patient chronologic age nor immigration status should serve as the sole criteria for determining eligibility for transplant. Finally, patient education and facilitation of post-hospital discharge follow-up remain critical points in the transitional care of patients with cirrhosis from hospital to home or from local hospital to transplant center. Patients and their caregivers have reported significant educational deficiencies regarding the process of LT.63 Lack of patient education from the multidisciplinary team has been identified as a risk factor for medication-related problems in patients with cirrhosis64 and for poor medication adherence post-LT.65 Multimodal education presentations (eg, both written and verbal) have been identified as helpful.63 Provision of educational tools regarding cirrhosis in general has demonstrated utility,66 though further studies on the type and timing of educational interventions are needed. The increased use of telehealth platforms has also shown promise in decreasing hospital readmission for patients with cirrhosis and improving outcomes.67,68 PALLIATIVE CARE CONSIDERATIONS FOR THE HOSPITALIZED PATIENTS WITH CIRRHOSIS The lack of including palliative care in the 2019 AASLD quality measures in cirrhosis is rather proof of a rapidly growing field, as both AASLD and AGA published recent guidance9,10 regarding the importance of primary and specialty palliative care in the management of patients with advanced liver disease. Both documents highlight the unmet demand for palliative care and include great resources that hospital providers can use in their practice, from introducing the benefits of palliative care to their patients to improving their palliative care skills specifically to address the needs of patients with cirrhosis. There is reluctance to start palliative care discussions in the inpatient setting as likely there is no longitudinal relationship between patient and providers, but hospitalizations and transitions of care, especially escalation of care to medical intensive care unit, are sentinel events that should prompt goals of care conversations.10 Hospitalized patients with cirrhosis must cope with unexpected deteriorations in their disease course, new or worsening cirrhosis complications, frequent readmissions, invasive procedures, medication side effects, and they should be given the opportunity to reassess if the medical care they receive remains concordant with their wishes. All providers caring for patients with cirrhosis should feel comfortable applying primary palliative care principles within their practice (assess/treat symptoms, foster communication around goals of care, and advance care planning) and collaborate with gastroenterology/hepatology specialists regarding prognosis and LT candidacy.10 As specialty palliative care is more available inpatient rather than outpatient in most health care systems, patients with complex needs (eg, difficult goals of care discussions and family dynamics, management of refractory symptoms) could access palliative care consultation during hospitalization, but this requires active involvement of the hospital team to explore the need to involve palliative care consultants. In summary, the management of hospitalized patients with cirrhosis is increasingly complex. High-value inpatient care requires adherence to best practices, and integration of QI processes with clinical care keeps us accountable to achieve and maintain a higher standard of health care delivery.

  PublisherOA PDFDOI

• Mo1571 OVERCOMING METABOLIC BARRIERS TO LIVING LIVER DONATION

  Gastroenterology · 2023-05-01

  article
  PublisherDOI

• S2926 Hepatic Steatosis and Acute Liver Injury in Chronic Arsenic Exposure

  The American Journal of Gastroenterology · 2022 · 1 citations

  Senior authorCorresponding
  • Medicine
  • Gastroenterology
  • Internal medicine

  Introduction: Arsenic toxicity may not be apparent on initial presentation given its myriad of effects across many body systems and its rarity in developed countries. Case Description/Methods: A 29-year-old woman with history of gastroesophageal reflux disease, irritable bowel syndrome, gastroparesis, post-traumatic stress disorder, obsessive-compulsive disorder, and generalized anxiety disorder presented with abdominal pain, nausea, and vomiting. Her recent medical history included 7 months of progressive sensorimotor polyneuropathy, bowel and bladder incontinence, vision decline, skin rash and flaking, poor oral intake with 25% weight loss, and recent hospitalization for stress-induced cardiomyopathy and ventricular tachycardia. She was found to have coagulopathy, hemolytic anemia, and elevated transaminases, alkaline phosphatase, direct and indirect bilirubin, and serum ammonia. She developed encephalopathy with rising ammonia requiring scavenger therapy. She underwent diagnostic evaluation for alcohol-related, metabolic, inflammatory, and vascular causes of liver disease. Liver biopsy revealed non-cirrhotic portal fibrosis, severe and mostly macrovesicular steatosis, ductular proliferation, and canalicular cholestasis. Initial labs showed high urine orotic acid and low serum citrulline, so empiric treatment for ornithine transcarbamylase deficiency was initially given. Whole exome sequencing was negative. Urine and serum heavy metal testing was negative. However, arsenic was highly elevated in hair and nail samples, most consistent with chronic arsenic exposure. Discussion: We present a case of hepatic steatosis and acute liver injury in chronic arsenic exposure. Recent work has associated arsenic toxicity with non-cirrhotic portal fibrosis and elevated risk of non-alcoholic fatty liver disease in humans, previously seen in mice.1 In this patient, arsenic exposure may explain the hepatic steatosis, either directly or indirectly via rapid weight loss. Arsenic toxicity also explains the hepatic injury and portal fibrosis, encephalopathy, polyneuropathy, hair loss, and skin changes. Recognizing metal toxicity as a cause of liver injury was crucial, as arsenic testing dramatically altered our course of management and patient care.

  PublisherDOI

• Nonalcoholic Fatty Liver Disease in the Post Liver Transplant Patient

  Current Transplantation Reports · 2020 · 1 citations

  1st authorCorresponding
  • Medicine
  • Intensive care medicine
  • Internal medicine
  PublisherDOI

• Clinical utility of genomic analysis in adults with idiopathic liver disease

  Journal of Hepatology · 2019-04-15 · 75 citations

  articleOpen access
  PublisherOA PDFDOI

• PRO: Older Adults Should Be Offered Liver Transplantation

  Clinical Liver Disease · 2019-08-01 · 2 citations

  reviewOpen accessSenior authorCorresponding

  Watch a video presentation of this article Watch the interview with the author LT is the only definitive therapy for end-stage liver disease.1 Successful LT improves life expectancy and quality of life in patients with decompensated cirrhosis, including older adults without additional significant comorbidities.1 There are currently more than 49 million adults older than 65 years in the United States, and this number will continue to increase so much so that older adults are expected to outnumber children by the year 2035.2 The burden of liver disease in the elderly is also expanding, and with it the number of patients older than 65 years who are listed for LT.3 With these changing demographics, considering LT for older candidates is an inevitable reality. For those with no contraindications and otherwise unremarkable LT evaluations including a normal cardiopulmonary assessment, good social support, and robust functional status, LT is a reasonable option. The median survival for patients with decompensated cirrhosis is approximately 2 years.4 As the number of decompensating events increases, the prognosis worsens.4 For instance, the estimated 1-year mortality rate for a patient with decompensated cirrhosis complicated by ascites is 20%.4 If the patient has a Model for End-Stage Liver Disease (MELD) score of 20, the predicted 3-month mortality rate is as high as 19.6%.5 In contrast, the average adult between the ages of 70 and 75 years in the United States has a predicted life expectancy between 12.3 and 15.7 years.6 Even taking into account common comorbidities such as uncomplicated diabetes and well-controlled hypertension, individuals in their early seventies may live an additional 8 to 13 years.7 Therefore, it is clear that in a patient with decompensated cirrhosis and well-controlled comorbidities, LT would provide a significant survival benefit. LT among older adults is already occurring.8 In 2016, more than 20% of all deceased donor LTs in the United States occurred in recipients aged 65 and older.3 Furthermore, post-LT outcomes in this age group are also improving. Analyses using data from the Scientific Registry of Transplant Recipients have shown that compared with previous periods, LT performed between 2013 and 2016 in recipients at least 65 years of age was associated with lower rates of acute rejection, graft loss, and mortality.3 Survival rates among recipients aged 65 years and older during this period were 91%, 86%, and 72% at 1, 3, and 5 years, respectively.3 These data compare favorably with average survival rate after deceased donor LT, which is situated at 90%, 82%, and 76%, respectively, for those time points.8 Several studies have specifically addressed outcomes of LT in recipients older than 70 years. A single-center review comparing post-LT outcomes of patients aged 70 years and older with those aged 50 to 59 years reported no significant difference in patient survival between the groups at 1, 3, 5, and 10 years.9 A second study comparing outcomes in recipients older than 70 years with matched controls younger than 60 years found similar rates of graft loss and 5-year mortality.10 A small, retrospective analysis of outcomes in recipients older than 75 years showed a mean survival of 65 months after LT.11 Finally, a recent meta-analysis of pooled data from LTs done in 23,660 older adults between 2000 and 2018 concluded that there is no significant difference in patient and graft survival between older and younger recipients.12 Taken together, the evidence suggests that patient and graft survival in carefully selected older adults are comparable with younger counterparts. As we prepare to care for greater numbers of older adults, it is important to acknowledge that not all are alike. Adults older than 65 years comprise an increasing percentage of the workforce,13 and almost 20% of caregivers in the United States are older than 65 years.14 Although some individuals remain independent in their seventies and beyond, younger adults may be debilitated by comorbidities. Chronological age does not always reflect physiological age. The concept of physiological age is so important that the American Association for the Study of Liver Diseases guidelines on LT explicitly state that age older than 70 years in isolation is not a contraindication to LT, and that physiological age must be prioritized.1 A key dimension of determining physiological reserve, especially in older adults and in patients with cirrhosis, involves assessing for frailty.15 Various tools including the recently developed Liver Frailty Index define frailty in terms of physical strength, equilibrium, and cardiopulmonary endurance.16 Frailty is associated with dependence in instrumental activities of daily living and poorer performance in the 6-minute walk distance (6MWD) test,17 conferring a higher wait-list mortality.15 Patients who are independent in their instrumental activities of daily living and have a 6MWD of more than 250 m are less likely to be frail.17, 18 Although functional measures of frailty are associated with wait-list mortality, sarcopenia predicts post-LT outcomes.19 For instance, total psoas muscle area correlates with post-LT survival, even after controlling for recipient chronological age.19 Older LT candidates who are functionally robust are less likely to have sarcopenia and are, therefore, more likely to have a favorable post-LT outcome. Given the variability in functional status among older adults, chronological age must be considered within the context of physiological age, which can be assessed objectively with these measures. Living donor LT can be effective in older adults as well. A retrospective study comparing outcomes in recipients of living donor liver grafts aged 60 to 65 years with those older than 65 years showed similar graft and patient disease-free survival among the two groups.20 Data for recipients older than 70 years are limited; however, a recent retrospective study describing outcomes in recipients aged 70 to 78 years who received living donor grafts showed that patient survival rate was 84% and 69.8% at 1 and 5 years, respectively.21 In our current era of organ shortage, living donor LT may be safely offered to carefully selected older recipients without affecting access to organs for other registrants on the wait list. The current MELD-based allocation system stratifies registrants according to the predicted wait-list mortality and urgency of LT.22 Projected post-LT survival has no bearing on this model. Efforts to illustrate a more utilitarian perspective in a recent study using data from the United Network for Organ Sharing showed similar survival benefits among younger and older age groups with the same MELD score at 5 years post-LT.23 Although post-LT mortality in this study was slightly higher in patients aged 50 years and older compared with those aged 18 to 49 years, older registrants also had a higher likelihood of pre-LT death or dropout, thereby balancing the difference between predicted survival with and without LT.22, 23 Furthermore, it is important to acknowledge that post-LT outcomes in appropriately selected older adults may exceed that of younger individuals in whom LT may be futile. For example, a younger patient with a MELD score greater than 40 may be considered for LT with the highest priority despite a diminished predicted post-LT survival rate estimated at 60%.24 Chronological age is just one variable to consider in the context of a myriad of other factors that inform a thorough pre-LT assessment, and must not cloud the ability to perform an objective, individualized evaluation. We are asked to consider LT in older adults with well-controlled comorbidities, normal cardiovascular assessments, and robust functional status. Current evidence clearly supports prioritizing physiological over chronological age in assessing LT candidacy. LT may be a highly appropriate and lifesaving intervention in carefully selected older adults.

  PublisherOA PDFDOI

• Geographic Areas of Liver Distribution in the United States Should Not Be Redesigned According to the 2016 Eight‐District Organ Procurement and Transplantation Network Proposal

  Clinical Liver Disease · 2018-08-01

  reviewOpen access1st author

  Watch a video presentation of this article The U.S. Department of Health and Human Services implemented the Final Rule in March 2000, which establishes a regulatory framework for the structure and operations of the Organ Procurement and Transplantation Network (OPTN). This document stated that fair allocation of organs should not be based on the “candidate's place of residence or place of listing.”1 However, disparities in organ allocation exist. At the same time, differences in waiting-list mortality, organ donation rates, and use of exception points mar attempts to analyze or correct those disparities. In 2016, the OPTN “redistricting” proposal aimed to make liver distribution more equitable in the United States by creating eight regions.2 However, changing the geographic areas of liver distribution without addressing other elements of disparity will not solve the problem. The use of Model for End-Stage Liver Disease (MELD) exception points, not geography, is a major factor contributing to disparities in organ allocation, and the prior OPTN proposal failed to adequately address this. It also did not discuss overall access to transplant care, organ usage, and donation rates. The redistricting proposal is based on the premise that MELD score at time of transplant is an accurate surrogate for waiting-list mortality. However, with the current widely variable and often excessive usage of MELD exception points, this is not the case. Exception points were designed to reflect disease severity and transplant need for patients who are underserved by laboratory MELD scores. Unfortunately, there is wide variation in the use of exception points between regions (Fig. 1).3 For example, in 2015, 21% of patients listed for transplant in region 6 had nonstandard MELD exception points compared with only 5.7% of patients in region 3.4 Currently, death on the wait list occurs approximately five times more often for patients without exception points than for those with exception points.5 Transplant candidates without MELD exception points wait longer for a transplant and are less likely to be transplanted. Between 2005 and 2012, 79% of patients with exception points underwent liver transplant compared with only 40% of patients without exception points.5 Most exception points are allotted to patients with hepatocellular carcinoma (HCC). Within this population, advanced locoregional therapies have established a large and stable cohort of patients who are actually less likely to die while on the wait list than their non-HCC counterparts.6 A recent proposal to form a National Liver Review Board will hopefully decrease exception point variability and should be implemented prior to redistricting.4 Access to health care, from availability of physicians to presence of hospital beds, also varies nationwide, and this is mirrored in access to transplant centers.7, 8 Physical distance to a transplant center matters. In all United Network for Organ Sharing regions, rural residents are less likely to be wait-listed than urban dwellers. Even when they do have a position on the wait list, they are still less likely to receive a transplant.9 Redistricting changes how organs are distributed to a transplant center, but it does not improve an individual's access to the transplant center. An additional concern is the optimal utilization of organs. Regional availability of organs differs based on multiple factors, including eligible deaths, organ procurement organization performance, and variable organ donation rates.10 Decisions about the use of an organ are made by the individual transplant center, without national or regional consensus.7 Consequently, more than 20% of donations after cardiac death status organs and more than 10% of hepatitis C virus–positive organs are recovered but not transplanted.7 These organs represent a pool of resources that could be tapped with improved organization. Finally, the liver-simulated allocation model predicts that, with implementation of the new redistricting proposal, there will be approximately 2% fewer transplants overall and an increase in organ transport costs.2, 11 The cost of each transplant would increase by US $4,980.11 Although total Medicare spending may decline, this prediction was based on past health care reimbursements and cannot predict future spending behaviors. The crux of the problem is that attempts to merely alter the geographic areas of liver distribution to equalize MELD scores may not have a meaningful impact on organ access disparities where they matter most—among patients at risk for dying while on the wait list. A more efficacious proposal would address the standardization of exception points, improve access to transplant centers, optimize use of available organs, and then consider larger expansion of distribution. The current OPTN proposal, which includes the implementation of a national review board for exception points and more modest geographic changes, represents a step in the right direction.12, 4

  PublisherOA PDFDOI

• Single‐Center Experience with the Use of Teduglutide in Adult Patients with Short Bowel Syndrome

  Journal of Parenteral and Enteral Nutrition · 2017-12-13 · 44 citations

  article

  BACKGROUND: Teduglutide is a glucagon-like peptide 2 (GLP-2) analog that has been approved for the treatment of adult short bowel syndrome (SBS)-associated intestinal failure (IF; SBS-IF). Teduglutide increases villus height and crypt depth in the small bowel mucosa, promoting nutrition absorption and enteral independence from parenteral nutrition (PN). We aim to report our single-center experience with teduglutide in adult patients with SBS to provide real-world context to its use. METHOD: We conducted a retrospective analysis on patients managed within our tertiary-level intestinal rehabilitation program to identify patients with SBS-IF treated with teduglutide from 2009-2015. The current report includes all patients at our center who had any exposure to teduglutide, including those who received commercial drug after approval by the Food and Drug Administration (FDA) and outside the scope of clinical trials. RESULTS: A total of 18 patients were treated with teduglutide. Eleven patients (61%) achieved complete enteral independence from PN and/or intravenous fluids (IV) at a median time of 10 months (range: 3-36 months). PN/IV volume requirement was reduced in all patients except two. Ten of the 11 patients (91%) who achieved enteral autonomy had colon. All patients off PN/IV required additional oral vitamins and electrolyte supplementations. CONCLUSION: Our preliminary experience is consistent with prior reports of successful partial or complete weaning from PN/IV with teduglutide treatment in adult patients with SBS. The presence of colon appears to be favorable in obtaining enteral independence from PN/IV, regardless of residual small bowel length. Patients on teduglutide may remain at high risk of micronutrient deficiencies.

  PublisherDOI

Frequent coauthors

• Emily A. Schonfeld

  Weill Cornell Medicine

  11 shared

• Zaid H. Tafesh

  9 shared

• Simona Jakab

  8 shared

• Farbod Raiszadeh

  Harlem Hospital Center

  4 shared

• Jessica Dekhtyar

  4 shared

• William Lee

  4 shared

• Robert S. Brown

  Weill Cornell Medicine

  4 shared

• Mario J. García

  Albert Einstein College of Medicine

  4 shared

Awards & honors

• Member of the National Liver Review Board
• Donate Life Connecticut Advisory Board (2023 - Present)
• Ethical Considerations in Living Donor Liver Transplant Lect…