Utility of a score-based approach to liver assessment in heart transplant candidates
Joshua A. Rushakoff, MD, MPP,
Louie Cao, MD,
Joe Ebinger, MD,
Alexander Kuo, MD,
Patrick Botting, MSPH,
Dominic Emerson, MD,
Guillame Countance, MD, PhD,
Pascal Lebray, MD,
Rose Tompkins, MD,
Jon A. Kobashigawa, MD,
Jignesh K. Patel, MD, PhD,
Maha Guindi, MD, FRCPC,
Evan P. Kransdorf, MD, PhD
Affiliations
Joshua A. Rushakoff, MD, MPP
Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California; Duke University Medical Center, Durham, North Carolina; Corresponding author: Joshua A. Rushakoff MD, MPP, Duke University Hospital, Box 3182, Durham, NC 27710.
Louie Cao, MD
Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
Joe Ebinger, MD
Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
Alexander Kuo, MD
Karsh Division of Gastroenterology and Hepatology and Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
Patrick Botting, MSPH
Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
Dominic Emerson, MD
Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
Guillame Countance, MD, PhD
Department of cardiac surgery, Institute of Cardiology, La Pitié-Salpêtrière Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne Université - Medical School, Paris, France
Pascal Lebray, MD
Department of cardiac surgery, Institute of Cardiology, La Pitié-Salpêtrière Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne Université - Medical School, Paris, France
Rose Tompkins, MD
Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
Jon A. Kobashigawa, MD
Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
Jignesh K. Patel, MD, PhD
Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
Maha Guindi, MD, FRCPC
Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California
Evan P. Kransdorf, MD, PhD
Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
Background: While abnormalities of liver function and imaging are common in patients with end-stage heart failure, advanced fibrosis is uncommon. Liver biopsy (LB) is used to identify advanced fibrosis in heart transplant (HT) candidates but can delay or limit access to definitive therapies and cause complications. We sought to develop and determine the utility of a clinical risk score for advanced fibrosis in HT candidates. Methods: We conducted a retrospective, single-center review of patients evaluated for HT between 2012 and 2019 (n = 1,651) and identified those who underwent LB (n = 137) as well as a matched control cohort (n = 160). Patients with congenital heart disease were excluded. All biopsies were reviewed by a liver pathologist. Univariate logistic modeling was used to identify factors predictive of advanced liver fibrosis. Simulation using synthetic data bootstraps was performed to determine the utility of using a score-based approach to trigger LB. Kaplan-Meier curves were used to assess survival. Results: We identified 32 (23%) patients with stage 0, 79 (58%) with stage 1 to 2, and 26 (19%) with stage 3 to 4/advanced fibrosis. The factor most associated with pursuit of LB was abnormal liver parenchyma on ultrasound. We found that a score combining severe tricuspid regurgitation, alcohol use, and low-density lipoprotein improved specificity and reduced the number of LBs required. We found no difference in survival at 3 years post-HT based on pre-HT fibrosis stage. Conclusions: A score composed of noninvasive factors may help reduce the number of patients who require LB for diagnosis of advanced fibrosis. Additional multicenter studies are needed to validate this score.
