Publications by authors named "Nigel Girgrah"

15 Publications

  • Page 1 of 1

Liver Transplantation Using Hepatitis C Virus-Viremic Donors Into Hepatitis C Virus-Aviremic Recipients as Standard of Care.

Liver Transpl 2021 04;27(4):548-557

Ochsner Health, Ochsner Multi-Organ Transplant Institute, New Orleans, LA.

Liver transplantation (LT) using allografts from hepatitis C virus (HCV)-viremic/nucleic acid testing-positive donors' (DNAT+) organs into HCV-aviremic recipients (rHCV-) has been limited owing to nearly universal HCV transmission and concerns regarding availability, safety, and efficacy post-LT with direct-acting antiviral (DAA) therapy. We report our experience of LT using DNAT+ organs into rHCV- as a routine standard of care. Following verification of DAA access, absence of critical drug-drug interactions (DDIs) with DAAs, and informed consent, allocated DNAT+ organs were offered to patients on the waiting list for LT irrespective of recipient HCV status. Between June 2018 and December 2019, 292/339 rHCV- received an LT. Forty-seven patients were excluded from analysis because of recipient HCV viremia, refusal to receive DNAT+ organs, or inability to receive DAA therapy post-LT. Of these 292 patients, 61 rHCV- received DNAT+ livers (study group), and 231 rHCV- received DNAT- (aviremic donors [nuclear acid test-negative donors]) livers (control group). Recipient and donor characteristics as well as 1-year post-LT patient and graft survival were similar between groups. In the study group, 4 patients died, and 1 patient required retransplantation within the first year post-LT (all unrelated to HCV); 56 patients received DAA therapy, with a median time from LT to the start of DAA treatment of 66.9 days (interquartile range [IQR], 36-68.5), and 51 patients completed DAA treatment, all achieving sustained virologic response for 12 or more weeks (SVR-12) (1 patient required retreatment owing to relapse following initial DAA therapy). No patients had evidence of fibrosing cholestatic hepatitis or extrahepatic manifestations of HCV. This report indicates that transplantation of DNAT+ livers into rHCV- and subsequent DAA therapy is associated with clinical outcomes comparable to those achieved with DNAT- allografts.
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http://dx.doi.org/10.1002/lt.25925DOI Listing
April 2021

Budd-Chiari syndrome after liver transplantation resulting from inferior vena cava occlusion at the suture line.

J Cardiol Cases 2015 Mar 6;11(3):73-77. Epub 2015 Jan 6.

Ochsner Medical Center, John Ochsner Heart and Vascular Institute, New Orleans, LA, USA.

A 64-year-old male with Budd-Chiari syndrome (BCS) due to inferior vena cava (IVC) occlusion after liver transplant presented with massive ascites and lower extremity edema. He was found to have chronic total occlusion of the supra-hepatic IVC with thrombosis in the infra-hepatic IVC, hepatic, renal, and iliac veins. Attempts to recanalize the occlusion by multiple operators failed. He was not a surgical candidate. The patient underwent venography of the IVC, and placement of a McNamara catheter for catheter-directed thrombolysis on the first day. The second day, he underwent right internal jugular access with contrast injections to mark the superior aspect of the occlusion via a Multipurpose catheter. An adult transseptal needle (Bard Electrophysiology Division C. R. Bard, Inc., Lowell, MA, USA) was used to create a tract through a 6 French Raabe Sheath and traverse the occlusion. A 10-mm Snare (Cook, Bloomington, IN, USA) cranially retracted the guidewire. Intravascular ultrasound was performed to further delineate the diameter of the IVC at the lesion before dilation with a 6.0 mm × 40 mm PTA balloon and a 10 mm × 29 mm Palmaz Stent (Cordis Corporation, Bridgewater, NJ, USA) deployment. The patient lost 24.6 kg in 2 weeks with resolution of ascites and pedal edema. < This case provides a unique approach to percutaneous intervention of inferior vena cava chronic total occlusion in the setting of Budd-Chiari syndrome post-liver transplant. There was use of an inferior and superior marker followed by use of transseptal needle to transverse the occlusion followed by balloon dilation and stent placement. While the disease and intervention have been described, the use of dual cranial/caudal markers and use of transseptal needle is unique to this particular case.>.
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http://dx.doi.org/10.1016/j.jccase.2014.08.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6279999PMC
March 2015

Adverse cardiac events after orthotopic liver transplantation: a cross-sectional study in 389 consecutive patients.

Liver Transpl 2015 Jan;21(1):13-21

Departments of Anesthesiology, Ochsner Clinic Foundation, New Orleans, LA.

Current American College of Cardiology/American Heart Association guidelines caution that preoperative noninvasive cardiac tests may have poor predictive value for detecting coronary artery disease in liver transplant candidates. The purpose of our study was to evaluate the role of clinical predictor variables for early and late cardiac morbidity and mortality and the predictive values of noninvasive cardiac tests for perioperative cardiac events in a high-risk liver transplant population. In all, 389 adult recipients were retrospectively analyzed for a median follow-up time of 3.4 years (range = 2.3-4.4 years). Overall survival was 83%. During the first year after transplantation, cardiovascular morbidity and mortality rates were 15.2% and 2.8%. In patients who survived the first year, cardiovascular morbidity and mortality rates were 3.9% and 2%, with cardiovascular etiology as the third leading cause of death. Dobutamine stress echocardiography (DSE) and single-photon emission computed tomography had respective sensitivities of 9% and 57%, specificities of 98% and 75%, positive predictive values of 33% and 28%, and negative predictive values of 89% and 91% for predicting early cardiac events. A rate blood pressure product less than 12,000 with DSE was associated with an increased risk for postoperative atrial fibrillation. Correspondence analysis identified a statistical association between nonalcoholic steatohepatitis/cryptogenic cirrhosis and postoperative myocardial ischemia. Logistic regression identified 3 risk factors for postoperative acute coronary syndrome: age, history of coronary artery disease, and pretransplant requirement for vasopressors. Multivariable analysis showed statistical associations of the Model for End-Stage Liver Disease score and the development of acute kidney injury as risk factors for overall cardiac-related mortality. These findings may help in identifying high-risk patients and may lead to the development of better cardiac tests.
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http://dx.doi.org/10.1002/lt.23997DOI Listing
January 2015

Liver transplantation at the ochsner clinic: quality and outcomes improvement.

Ochsner J 2013 ;13(3):413-8

Multi-Organ Transplant Institute, Ochsner Clinic Foundation, Ochsner Clinical School, New Orleans, LA.

Background: In 2005, the results published by the Scientific Registry of Transplant Recipients showed that Ochsner Clinic Foundation's patient and graft survival rates were statistically lower than expected, and the United Network for Organ Sharing Membership and Professional Standards Committee placed our center under peer review.

Methods: In response, patient outcomes prior to August 2005 were carefully reviewed in a transparent fashion and protocols were written to standardize treatments. We renewed the focus on patient-related outcomes and regulatory adherence and empowered frontline staff to express their views, allowing for real teamwork to develop. Multiple changes were implemented in the everyday running of the program. A quality assurance and performance improvement plan (QAPI) was initiated to improve outcomes.

Results: In 2012, the Ochsner liver transplant program became the largest liver transplant program in the United States by volume and in 2013 was awarded the prestigious CareChex award, acknowledging it as the number one program in terms of quality of care and outcomes for liver transplantation.

Conclusion: The methodical application of this QAPI program achieved a remarkable transformation of the Ochsner liver transplant program and exemplifies what is possible with strong teamwork from dedicated and talented staff.
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June 2014

Liver transplantation in hepatitis B core-negative recipients using livers from hepatitis B core-positive donors: a 13-year experience.

Liver Transpl 2013 Jun;19(6):611-8

Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA 70121, USA.

The use of livers from hepatitis B surface antigen-negative (HBsAg- )/hepatitis B core antibody-positive (HBcAb+ ) donors in liver transplantation (LT) for HBsAg(-) /HBcAb- recipients is still controversial because of a lack of standard antiviral prophylaxis and long-term follow-up. We present our 13-year experience with the use of HBcAb+ donor livers in HBcAb- recipients. Patients received prophylaxis with hepatitis B immunoglobulin at the time of LT and then lamivudine daily. De novo hepatitis B virus (HBV) was defined as positive HBV DNA detection. Between January 1999 and December 2010, 1013 adult LT procedures were performed at our center. Sixty-four HBsAg- /HBcAb- patients (6.3%) received an HBsAg- /HBcAb+ liver. All donor sera were negative for HBcAb immunoglobulin M and HBV DNA. The mean follow-up was 48.8 ± 40.1 months (range = 1.2-148.8). Both the patient survival rates and the graft survival rates were 92.2% and 69.2% at 1 and 5 years, respectively. No graft losses or deaths were related to de novo HBV. Nine of the 64 patients (14.1%) developed de novo HBV. The mean time from LT to de novo HBV was 21.4 ± 26.1 months (range = 10.8-92.8 months). De novo HBV was successfully treated with adefovir or tenofovir. In conclusion, HBcAb+ allografts can be safely used in HBcAb- recipients without increased mortality or graft loss. Lifelong prophylaxis, continuous surveillance, and compliance are imperative for success. Should a de novo infection occur, our experience suggests that a variety of treatments can be employed to salvage the graft and obtain serum HBV DNA clearance.
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http://dx.doi.org/10.1002/lt.23644DOI Listing
June 2013

Liver transplantation at the Ochsner Clinic: programmatic expansion and outcomes improvement.

Clin Transpl 2012 :111-20

Multi-organ Transplant Institute, Ochsner Medical Center, New Orleans, Louisiana, USA.

Liver transplantation has become the best and most durable treatment for both acute and chronic liver disease. Over 1400 liver transplants have been performed at the Ochsner Clinic since the first successful transplant in 1987. Since its inception, the program has gone through several changes and advancements and has become one of the largest liver transplant programs in the United States. We have helped evolve steroid sparing immunosuppression and the use of extended criteria, donor organs. Establishment of criteria for the selection of recipients for re-transplantation has resulted in better than expected short and long-term results. Our center has faced the challenge of Hurricane Katrina and overcome it. We have improved steadily in both outcomes and transplants performed. The Ochnser Clinic Liver Transplant program will continue to improve access and outcomes for all patients with liver disease.
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June 2013

Antiviral treatment of recurrent hepatitis C after liver transplantation: predictors of response and long-term outcome.

Transplantation 2009 Nov;88(10):1214-21

Multi-organ Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada.

Background: Efficacy and long-term outcome of antiviral therapy for recurrent hepatitis C after liver transplantation is poorly defined.

Aim: This study aimed at assessing the efficacy of antiviral therapy regarding sustained hepatitis C virus (HCV) clearance, liver histology, and patient survival.

Methods: We retrospectively reviewed all 446 patients who received a liver allograft at our institution for HCV-related cirrhosis between January 1992 and December 2006. Two hundred thirty-two patients (52%) were eligible for antiviral therapy based on predefined criteria (Metavir stage > or =1 and/or grade > or =2; protocol biopsies). One hundred seventy-two patients (39%) had no contraindication for treatment, received more than or equal to 1 dose of interferon-alpha-based combination therapy, and form the basis of this analysis. Therapy was aimed for 48 weeks; median posttreatment follow-up was 68 months.

Results: The overall sustained virological response (SVR) rate was 50% (genotype 1/4: 40%; genotype 2/3: 76%). SVR was higher on cyclosporine A (CsA) (56%) than on tacrolimus (44%, P=0.05), largely because of a lower relapse rate (6% vs. 19%, P=0.01). In multivariate analysis, genotype 2/3, CsA use, donor age, and pretreatment necroinflammatory activity were independently associated with SVR. SVR significantly improved histology and long-term survival (actuarial 5-year survival 96% vs. 69% in nonresponders, P<0.0001).

Conclusion: Antiviral therapy of recurrent hepatitis C after liver transplantation is able to clear HCV in half the patients, more likely on CsA than on tacrolimus, and markedly improves outcome.
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http://dx.doi.org/10.1097/TP.0b013e3181bd783cDOI Listing
November 2009

The difference in the fibrosis progression of recurrent hepatitis C after live donor liver transplantation versus deceased donor liver transplantation is attributable to the difference in donor age.

Liver Transpl 2008 Dec;14(12):1778-86

Multi-Organ Transplant Program, University Health Network, University of Toronto, Toronto, Canada.

Hepatitis C recurs universally after liver transplantation (LT). Whether its progression differs after live donor liver transplantation (LDLT) and deceased donor liver transplantation (DDLT) is still debated. We retrospectively analyzed 201 consecutive LTs performed at our institution for hepatitis C-related end-stage liver disease between April 2000 and December 2005 (46 LDLTs and 155 DDLTs). Patients were followed with protocol biopsies for medians of 29 (LDLT) and 39 months (DDLT; P = 0.7). Although overall graft and patient survival did not differ, the mean fibrosis stage (Metavir) was significantly higher at 12 to 48 months post-LT (all P < 0.05), and the rate of fibrosis progression tended to be faster after DDLT than LDLT (0.19 versus 0.11 stage/year, P = 0.05). In univariate analysis, donor age, cold ischemic time, and DDLT were significantly associated with a fibrosis stage > or = 1 at 1 year and a fibrosis stage of 3 or 4 at 2 years post-LT. In multivariate analysis, however, donor age was the sole variable independently associated with both surrogate outcomes. Thus, donor age > 45 years carried a relative risk of 8.17 (confidence interval = 2.6-25.5, P = 0.001) for reaching fibrosis stage 3 or 4 at 2 years post-LT. In conclusion, donor age, rather than the transplant approach, determines the progression of recurrent hepatitis C after LT. LDLT, allowing for the selection of younger donors, may particularly benefit hepatitis C patients.
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http://dx.doi.org/10.1002/lt.21598DOI Listing
December 2008

Management of chronic hepatitis C: consensus guidelines.

Can J Gastroenterol 2007 Jun;21 Suppl C:25C-34C

Department of Medicine, University of Toronto, Toronto General Hospital, Toronto, Ontario, Canada.

Since the last consensus conference on the management of chronic viral hepatitis, a number of studies looking at modifications of the standard course of treatment have been published. These changes have been sufficiently substantive to warrant review to determine whether any changes in the recommended treatment algorithms are needed. A consensus development conference was held in January 2007, and the present document highlights the results of the presentations and discussion about these issues. It reviews the epidemiology of hepatitis C in Canada, treatment of acute hepatitis C and new algorithms in chronic hepatitis C, including retreatment of previous treatment failures. In addition, sections on management of hepatitis C in special populations have been updated. There is also a section on the use of hematopoietic growth factors to help manage patients on therapy. The document should be read in conjunction with the previous document to identify changes. Some recommendations made in the previous document remain and are not discussed here.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2794457PMC
June 2007

Management of chronic hepatitis B: consensus guidelines.

Can J Gastroenterol 2007 Jun;21 Suppl C:5C-24C

Department of Medicine, University of Toronto, Toronto General Hospital, Toronto, Canada.

The present document presents the proceedings of the consensus development conference on the management of viral hepatitis held in January 2007 under the auspices of the Canadian Association for the Study of the Liver and the Association of Medical Microbiology and Infectious Disease Canada. Several new agents have become available since the last such document was published in 2004, and new information has become available to help assess risk of adverse outcomes and who should be treated. In addition, the participants at the meeting identified a number of structural barriers that exist uniquely in Canada and that prevent physicians from properly managing their patients. The conference discussed the selection of patients for treatment and the drugs that can be used to treat these patients, as well as the treatment of hepatitis B in special populations. The present document should be read in conjunction with the companion document on the management of chronic hepatitis C.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2794455PMC
June 2007

Clinical recommendations for the use of recombinant human erythropoietin in patients with hepatitis C virus being treated with ribavirin.

Can J Gastroenterol 2006 Jul;20(7):479-85

Toronto General Hospital, University of Toronto, Toronto, Canada.

Today, combination antiviral therapy with pegylated interferon-alpha and ribavirin (RBV) allows many patients infected with hepatitis C virus (HCV) to achieve a sustained virological response, which is equivalent to cure. Data also support the clinical benefit of combination antiviral therapy in patients coinfected with HCV and HIV, and in patients who have received a liver transplant. Antiviral therapy with pegylated interferon-alpha and RBV is, however, associated with a high incidence and significant magnitude of anemia. This anemia may have several mechanisms, including bone marrow suppression and hemolysis. In addition, patients coinfected with HIV may have both pre-existing and RBV-associated anemia. Management of anemia in patients with HCV through RBV dose reduction or treatment discontinuation may compromise the effectiveness of treatment, because studies have demonstrated that treatment adherence or maintenance of antiviral therapy dose is an important predictor of sustained virological response. Anemia associated with combination antiviral therapy in patients with HCV is frequently associated with an inadequate or blunted endogenous erythropoietin response. Accumulating evidence now supports the use of recombinant human erythropoietin (rHuEpo) to manage anemia in these patients, with the objective of maintaining the RBV dose, but clinical standards are lacking. The present article reviews the data relevant to the use of rHuEpo in this patient population and proposes a set of clinical practice standards to assist clinicians in selecting patients for rHuEpo and in implementing rHuEpo therapy effectively.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2659916PMC
http://dx.doi.org/10.1155/2006/497059DOI Listing
July 2006

Analysis and outcomes of right lobe hepatectomy in 101 consecutive living donors.

Am J Transplant 2005 Nov;5(11):2764-9

Department of Surgery, Multiorgan Transplantation Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.

The shortage of deceased organ donors has created a need for right lobe living donor liver transplantation (RLDLT) in adults. Concerns regarding donor safety, however, necessitate continuous assessment of donor acceptance criteria and documentation of donor morbidity. We report the outcomes of our first 101 donors who underwent right lobectomy between April 2000 and November 2004. The cohort comprised 58 men and 43 women with a median age of 37.8 years (range: 18.6-55 years); median follow-up is 24 months. The middle hepatic vein (MHV) was taken with the graft in 55 donors. All complications were recorded prospectively and stratified by grade according to Clavien's classification. Overall morbidity rate was 37%; all complications were either grade 1 or 2, and the majority occurred during the first 30 days after surgery. Removal of the MHV did not affect morbidity rate. There were significantly fewer complications in the later half of our experience. All donors are well and have returned to full activities. With careful donor selection and specialized patient care, low morbidity rates can be achieved after right hepatectomy for living donor liver transplantation.
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http://dx.doi.org/10.1111/j.1600-6143.2005.01094.xDOI Listing
November 2005

Living-donor right hepatectomy with or without inclusion of middle hepatic vein: comparison of morbidity and outcome in 56 patients.

Am J Transplant 2004 May;4(5):751-7

Department of Surgery, Multiorgan Transplantation program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada.

Venous congestion of segments V and VIII is observed frequently in living-donor right lobe liver transplants without middle hepatic vein (MHV) drainage, and can be a cause of graft dysfunction and failure. Inclusion of the MHV with the graft is controversial, however, because of the perceived potential for increased donor morbidity. We compared the outcome of living liver donors in whom the MHV was either left intact in the donor (group 1; n = 28) or was removed with the graft (group 2; n = 28). All prospective donors completed an extensive multidisciplinary evaluation to determine suitability for surgery and to ensure that the MHV could be removed safely without compromising venous outflow from the remaining liver. Patient demographics including age, weight, body-mass index, and liver volumetry as determined by computerized tomography were similar in both groups. Operative time in group 2 was significantly shorter than in group 1. There was no difference in estimated blood loss, transfusion requirements, peak serum liver tests, time interval from surgery to complete normalization of liver tests, complications, and length of hospitalization. We conclude that including the MHV with living-donor right lobe grafts can be performed safely in most donors.
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http://dx.doi.org/10.1111/j.1600-6143.2004.00405.xDOI Listing
May 2004

Cirrhotic cardiomyopathy: does it contribute to chronic fatigue and decreased health-related quality of life in cirrhosis?

Can J Gastroenterol 2003 Sep;17(9):545-51

Department of Medicine, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada.

Unlabelled: Diminished health-related quality of life (HRQoL) and fatigue have been reported in patients with cirrhosis. The presence of cirrhotic cardiomyopathy and the attendant poor cardiac response to physical stress may affect HRQoL and contribute to fatigue in these patients.

Aims: To evaluate the contribution of cirrhotic cardiomyopathy to HRQoL and fatigue in ambulatory cirrhotic patients.

Methods: Thirty ambulatory cirrhotic patients (14 preascitic, Child-Pugh score 5.6 +/- 0.3; 16 ascitic, Child-Pugh score 9.1 +/- 0.5) underwent cardiopulmonary exercise testing and assessment of HRQoL, fatigue and depressive symptomatology. HRQoL and fatigue scores were correlated with liver disease severity, depressive symptomatology and parameters of cardiac function and exercise physiology.

Results: Subscales of all HRQoL measuring the effect of disease on the ability to perform physical, social and emotional roles were significantly impaired when compared with controls (P<0.001). The impact of fatigue, as assessed by the Fatigue Assessment Inventory, was greater in cirrhotics (4.46 versus 2.53 in healthy age-matched controls, P<0.01). Diminished HRQoL, impact of fatigue and vitality were related to depressive symptoms rather than to cardiac structural and functional abnormalities, which were present in cirrhotic patients. Poorer physical quality of life scores correlated with diminished mental health.

Conclusions: Depression, rather than the presence of cirrhotic cardiomyopathy, may have contributed to the diminished HRQoL and vitality in patients with cirrhosis with or without ascites.
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http://dx.doi.org/10.1155/2003/213213DOI Listing
September 2003
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