Browsing by Author "Saab, Sammy"

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Hyponatremia: Clinical Associations, Prognosis, and Treatment in Cirrhosis
(Başkent Üniversitesi, 2013-02) Yu, Christine; Saab, Sammy; Sharma, Nikhil
Hyponatremia has long been associated with worsened clinical outcomes in patients with cirrhosis and those awaiting liver transplant. However, in the last several years, new modalities of therapy, particularly aquaretics known as “vaptans,” and comprehensive prognostic models have been increasingly studied in the hopes of bolstering serum sodium levels and altering liver transplant candidate status. To examine the most recent, comprehensive, and pertinent data, a systematic review of both prospective and retrospective studies available on MEDLINE was completed, which provided information detailing clinical associations, treatment, and prognoses seen in those with hyponatremia in cirrhosis. Clinical associations with hyponatremia in cirrhosis including hepatorenal syndrome and hepatic encephalopathy were identified. For hyponatremia in those awaiting liver transplant, tolvaptan is an effective agent in temporarily normalizing serum sodium levels with minimal risk of osmotic demyelination. Prognostic models incorporating serum sodium levels were better able to predict urgency and need for transplant; yet the benefits and posttransplant effects of redefining a liver allocation score have yet to be established.
Liver Transplant: A Primer
(Başkent Üniversitesi, 2010-06) Movahedi, Zohreh; Saab, Sammy; Holt, Curtis D.
Liver transplant has been accepted as a successful therapeutic option for patients with end-stage liver disease. Patient and graft survival has incrementally increased over the past 2 decades, mainly because of immunosuppressive regimens. However, the nonspecific nature of immunosuppressive agents is associated with an increased risk of development of opportunistic infections, renal impairment, metabolic derangements, neurotoxicity, de novo malignancies, and recurrence of the primary disease. Immunosuppressive regimen pharmacologic classes include calcineurin inhibitors, anti-metabolites, mTOR inhibitors, steroids, and antibody-based therapies. These agents affect T-cell–dependent B-cell activation, and target different sites in the T-cell activation cascade by inhibiting T-cell activation or causing T-cell depletion. The goals of immunosuppression in solid-organ transplant are to prevent allograft rejection as well as optimize allograft function, prolong patient survival, and improve patient quality of life. Therefore, it is essential to carefully select the immunosuppressive regimen that will result in significant improvements in long-term liver transplant patients’ survival and quality of life.
Lymphedema Tarda After Liver Transplantation: A Case Report and Review of the Literature
(Başkent Üniversitesi, 2006-12) Saab, Sammy; Nguyen, Stephen; Collins, James; Kunder, Gregg; Busuttil, Ronald W.
We present a patient with lymphedema that developed after orthotopic liver transplantation. The cause of the posttransplant lymphedema was likely related to a developmental abnormality of the lymphatic system that was exaggerated by refractory chylous ascites. A peritoneal fluid with a milky appearance, chylous ascites is rich in triglyceride and is caused by the obstruction or disruption of abdominal lymphatic channels. It is a rare complication that may develop after trauma or abdominal surgery or as a result of a malignant disease [1], and it is even more uncommon after liver transplantation [2]. Therapy for chylous ascites involves treating its underlying cause. In the patient we describe, lymphedema tarda, which was diagnosed 6 months after liver transplantation, was likely caused by chylous ascites and a developmental abnormality of the lymphatic system.
Management of Recurrent Hepatocellular Carcinoma in Liver Transplant Recipients: A Systematic Review
(Başkent Üniversitesi, 2012-12) Rubin, Joshua; Saab, Sammy; Kaldas, Fady; Ayoub, Noel
Hepatocellular carcinoma is the most common form of liver cancer, representing 70% to 85% of primary hepatic malignancies in adults. Liver transplant is an optimal treatment for patients with hepatocellular carcinoma because it eliminates the malignancy as well as the often-underlying liver cirrhosis and restores normal liver function. Since the development of strict selection criteria in hepatocellular carcinoma patients undergoing liver transplant with the implementation of the Milan criteria, patient survival and recurrence rates after liver transplant have dramatically improved. However, several research groups are now seeking to expand this criteria to include more patients with larger tumors who may achieve similar postliver transplant survival rates as those patients meeting current eligibility requirements. Currently, in approximately 20% of patients, hepatocellular carcinoma recurrence is still the rate-limiting event that clearly affects patient survival. Given the limited number of grafts available for transplant, the poor prognosis of untreated hepatocellular carcinoma, and the recent notion of expanding selection criteria, strategies for reducing the rate of, monitoring and treating hepatocellular carcinoma recurrence, in both pretransplants and posttransplants, are explored in this review. We review the available literature to better understand current strategies available to optimize long-term clinical outcomes.
Sorafenib As Adjuvant Therapy For High-Risk Hepatocellular Carcinoma in Liver Transplant Recipients: Feasibility and Efficacy
(Başkent Üniversitesi, 2010-12) Saab, Sammy; Busuttil, Ronald W.; Finn, Richard S.; McTigue, Michael
Objectives: Liver transplant can be a definitive treatment for hepatocellular carcinoma. However, recurrence limits long-term survival. Sorafenib is the first agent to improve survival for patients with advanced hepatocellular carcinoma. Materials and Methods: A retrospective, case- control match analysis was performed, along with assessment of safety and tolerability. The endpoints of the study were recurrence incidence, episodes of rejection, and disease-free overall survival. Eight patients who underwent liver transplant for hepatocellular carcinoma between May 2007 and April 2009, and tolerated adjuvant therapy with sorafenib were matched with patients who did not receive sorafenib according to age, sex, year of transplant, tumor burden, and presence of vascular invasion. Results: During follow-up, there were no episodes of rejection in either group. Eight patients were able to tolerate a predetermined duration of therapy. During a mean (± standard deviation [SD]) follow-up of 17.75 ± 6.26 months, 1 of 8 patients (12.5%) treated with sorafenib developed hepatocellular carcinoma recurrence. During a mean (± SD) follow-up of 31.63 months (± 22.30 months), 4 of 8 matched controls (50.0%) developed hepatocellular carcinoma recurrence. Disease-free 1-year survival for sorafenib and control group was 85.7% and 57.1%. Overall, 1-year survival for sorafenib and control group was 87.5% and 62.5%. Conclusions: Our study demonstrates the safety and potential benefit of sorafenib in reducing the incidence of hepatocellular carcinoma recurrence and in extending disease-free and overall survival for high-risk liver transplant recipients. A prospective trial is needed to fully assess the role sorafenib as prophylaxis against hepatocellular carcinoma recurrence.
The MELD Score in Advanced Liver Disease: Association with Clinical Portal Hypertension and Mortality
(Başkent Üniversitesi, 2006-06) Saab, Sammy; Landaverde, Carmen; Ibrahim, Ayman B.; Durazo, Francisco; Han, Steven; Yersiz, Hasan; Farmer, Douglas G; Ghobrial, R Mark; Goldstein, Leonard I.; Tong, Myron J.; Busuttil, Ronald W.
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.