- Transplant Hepatology
Clinical Assistant Professor, Medicine - Gastroenterology & Hepatology
Board Certification, American Board of Internal Medicine, Transplant Hepatology (2018)
Fellowship, Northwestern University, Transplant Hepatology (2018)
Board Certification, American Board of Internal Medicine, Gastroenterology (2017)
Fellowship, Saint Louis University, Gastroenterology and Hepatology (2017)
Fellowship, Loyola University, Hepatology (2014)
Board Certification, American Board of Internal Medicine, Internal Medicine (2013)
Residency, University of Illinois at Chicago, Internal Medicine (2013)
Medical School, University of South Carolina, M.D. (2010)
Predictors of Outcomes of Patients Referred to a Transplant Center for Urgent Liver Transplantation Evaluation.
2021; 5 (3): 516–25
Liver transplantation (LT) is definitive treatment for end-stage liver disease. This study evaluated factors predicting successful evaluation in patients transferred for urgent inpatient LT evaluation. Eighty-two patients with cirrhosis were transferred for urgent LT evaluation from January 2016 to December 2018. Alcohol-associated liver disease was the common etiology of liver disease (42/82). Of these 82 patients, 35 (43%) were declined for LT, 27 (33%) were wait-listed for LT, 5 (6%) improved, and 15 (18%) died. Psychosocial factors were the most common reasons for being declined for LT (49%). Predictors for listing and receiving LT on multivariate analysis included Hispanic race (odds ratio [OR], 1.89; P = 0.003), Asian race (OR, 1.52; P = 0.02), non-Hispanic ethnicity (OR, 1.49; P = 0.04), hyponatremia (OR, 1.38; P = 0.04), serum albumin (OR, 1.13; P = 0.01), and Model for End-Stage Liver Disease (MELD)-Na (OR, 1.02; P = 0.003). Public insurance (i.e., Medicaid) was a predictor of not being listed for LT on multivariate analysis (OR, 0.77; P = 0.02). Excluding patients declined for psychosocial reasons, predictors of being declined for LT on multivariate analysis included Chronic Liver Failure Consortium (CLIF-C) score >51.5 (OR, 1.26; P = 0.03), acute-on-chronic liver failure (ACLF) grade 3 (OR, 1.41; P = 0.01), hepatorenal syndrome (HRS) (OR, 1.38; P = 0.01), and respiratory failure (OR, 1.51; P = 0.01). Predictors of 3-month mortality included CLIF-C score >51.5 (hazard ratio [HR], 2.52; P = 0.04) and intensive care unit (HR, 8.25; P < 0.001). Conclusion: MELD-Na, albumin, hyponatremia, ACLF grade 3, HRS, respiratory failure, public insurance, Hispanic race, Asian race, and non-Hispanic ethnicity predicted liver transplant outcome. Lack of psychosocial support was a major reason for being declined for LT. The CLIF-C score predicted being declined for LT and mortality.
View details for DOI 10.1002/hep4.1644
View details for PubMedID 33681683
View details for PubMedCentralID PMC7917272
Viral Hepatitis Other than A, B, and C: Evaluation and Management.
Clinics in liver disease
2020; 24 (3): 405–19
Viral hepatitis can cause a wide spectrum of clinical presentations from a benign form with minimal or no symptoms to acute liver failure or death. Hepatitis D coinfection and superinfection have distinct clinical courses, with the latter more likely leading to chronic infection. Management of chronic hepatitis D virus is individualized because of the paucity of treatment options and significant side effect profile of currently available treatments. Sporadic cases of hepatitis E caused by contaminated meats are becoming increasingly prevalent in immunocompromised hosts. Human herpesviruses are an important cause of disease also in immunocompromised individuals.
View details for DOI 10.1016/j.cld.2020.04.008
View details for PubMedID 32620280
Physical Activity, Measured Objectively, is Associated With Lower Mortality in Patients With Nonalcoholic Fatty Liver Disease.
Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association
The association between physical activity (PA) and all-cause and cause-specific mortality from nonalcoholic fatty liver disease (NAFLD) requires investigation. We studied whether PA, measured by accelerometer, is associated with all-cause and cardiovascular mortality among individuals with NAFLD.We performed a longitudinal analysis using the 2003-2006 US National Health and Nutrition Examination Survey data of adults (20 years or older) and collecting mortality data through December 2015. NAFLD was defined based on hepatic steatosis index or US fatty liver index scores, in the absence of other causes of chronic liver disease. PA was measured from participants who wore accelerometers 10 hrs/day for a minimum of 4 days over a 7-day period and classified as total PA, moderate to vigorous PA (MVPA), and sedentary behavior.Over an average follow-up period of 10.6 years, increasing duration of total PA was associated with reduced risk of death, from any cause, in an age- and sex-adjusted model (hazard ratio [HR], 0.52; 95% CI, 0.32-0.86 for highest quartile vs lowest quartile; P for trend=.001) and multivariable model (HR, 0.46, 95% CI 0.28-0.75; P for trend<.001) among individuals with NAFLD. Increasing duration of MVPA was associated with a lower risk of death from any cause in individuals with NAFLD. Furthermore, longer total PA was associated with a lower risk for cardiovascular disease-related death in individuals with NAFLD (HR, 0.28; 95% CI, 0.08-0.98 for highest quartile vs lowest quartile; P for trend=.007). We did not find this association for cancer-related mortality in individuals with NAFLD. Increasing duration of sedentary behavior did not affect all-cause or cause-specific mortality in individuals with NAFLD.Longer total PA and MVPA, measured by accelerometers over a 7-day period, are associated with lower all-cause and cardiovascular mortality in individuals with NAFLD.
View details for DOI 10.1016/j.cgh.2020.07.023
View details for PubMedID 32683103
Spotlight on Impactful Research: Long-Term Calcineurin Inhibitor Therapy and Brain Function in Patients After Liver Transplantation.
Clinical liver disease
2020; 15 (4): 141–43
http://aasldpubs.onlinelibrary.wiley.com/hub/journal/10.1002/(ISSN)2046-2484/video/15-4-reading-cheung a video presentation of this article - http://aasldpubs.onlinelibrary.wiley.com/hub/journal/10.1002/(ISSN)2046-2484/video/15-4-interview-cheung an interview with the author https://www.wileyhealthlearning.com/Activity/7088571/disclaimerspopup.aspx questions and earn CME.
View details for DOI 10.1002/cld.910
View details for PubMedID 32395239
View details for PubMedCentralID PMC7206322
- Defining Improvement in Nonalcoholic Steatohepatitis for Treatment Trial Endpoints: Recommendations From the Liver Forum HEPATOLOGY 2019; 70 (5): 1841–55
- iLFT: A big assist in the recognition of liver disease in general practice. Journal of hepatology 2019
Hepatobiliary Complications in Critically Ill Patients.
Clinics in liver disease
2019; 23 (2): 221–32
Critically ill patients frequently present with the systemic inflammatory response syndrome, which is largely a reflection of the liver's response to injury. Underlying hepatic congestion is a major risk factor for hypoxic liver injury, the most common cause for hepatocellular injury. Cholestatic liver injury often occurs in critically ill patients due to inhibition of farnesoid X receptor (FXR), the main regulator of bile acid handling, particularly in the liver and intestines. Additional injury to the liver occurs due to alterations in the bile acid pool with increased cytotoxic forms and disturbance in the typical processing of xenobiotics in the liver.
View details for PubMedID 30947873
Nonalcoholic Fatty Liver Disease: Identification and Management of High-Risk Patients.
The American journal of gastroenterology
Nonalcoholic fatty liver disease (NAFLD) is an increasingly dominant cause of liver disease worldwide. The progressive subtype, nonalcoholic steatohepatitis, is a leading indication for liver transplantation and a noteworthy cause of hepatocellular carcinoma. The overall prevalence of NAFLD is on the rise, and even more concerning data modeling predicts that an increasing percentage of those with NAFLD will develop advanced disease. This increased volume of patients with advanced liver disease will impose a significant health care burden in terms of resources and cost. Thus, the identification of patients with established fibrosis or at high risk of developing advanced liver disease is critical to effectively intervene and prevent overall and liver-related morbidity and mortality. Herein, we provide a framework to consider for the identification of patients with NAFLD at high risk of nonalcoholic steatohepatitis with advanced fibrosis and provide a critical assessment of currently accessible diagnostic and treatment modalities.
View details for PubMedID 30839326
Infectious Complications in Critically Ill Liver Failure Patients.
Seminars in respiratory and critical care medicine
2018; 39 (5): 578–87
Infections remain a leading cause of morbidity and mortality among patients with liver failure. A number of factors, including relative immune dysfunction and systemic inflammation, bacterial translocation, gut dysbiosis, small intestine bacterial overgrowth, altered bile acid pools, and changes in pH due to acid suppression, contribute to the high rates of infection in this population. Though a range of infections can complicate the course of cirrhotic patients, spontaneous bacterial peritonitis (SBP), cholangitis, and cholecystitis in addition to other infections (i.e. pneumonia, urinary tract infection, bacteremia, and Clostridioides difficile colitis) are more common in this population and will be reviewed in this article. Preventative strategies are directed at minimizing the risk of SBP through the use of targeted antimicrobial prophylaxis. Lastly, the critically ill cirrhotic patient may present with an acute need for liver transplantation. Thus, careful assessment for ongoing infection should be performed and treated to optimize outcomes of transplant, if needed.
View details for DOI 10.1055/s-0038-1673657
View details for PubMedID 30485888
Follow-up of the Post-Liver Transplantation Patient: A Primer for the Practicing Gastroenterologist.
Clinics in liver disease
2017; 21 (4): 793–813
The focus in liver transplantation in the next 10 years will likely change from preventing viral disease recurrence to minimizing the toll of rejection and fatty liver disease, minimizing the complications from immunosuppression with withdrawal strategies, and more optimal management of long-term risks, such as malignancy, cardiovascular disease, and renal failure. In addition, now that short-term results (<1 year) have improved significantly, there will be a shift toward improving long-term patient and graft survival, as well as a focus on primary care preventive strategies.
View details for DOI 10.1016/j.cld.2017.06.006
View details for PubMedID 28987263
Diarrhea Concealing a Duodenal-Cecal Fistula Secondary to Appendiceal Mucinous Neoplasm.
ACG case reports journal
Primary mucinous adenocarcinoma of the appendix is a rare gastrointestinal malignancy. Fistulous tract formation is a complication that is cited in literature. An 85-year-old man with multiple comorbidities presented with several weeks of persistent non-bloody diarrhea. Laboratory work-up was non-diagnostic. Abdominal imaging with barium contrast showed an enterocolonic fistulous tract extending from the duodenum to the cecum involving an enlarged appendiceal mass. Subsequent biopsy confirmed mucinous appendiceal neoplasm with peritoneal spread to the liver and mesentery. This is the first report describing an enterocolonic fistula formation resulting from this malignancy.
View details for DOI 10.14309/crj.2017.3
View details for PubMedID 28138447
View details for PubMedCentralID PMC5244891
Idiopathic hypereosinophilic syndrome presenting with hepatitis and achalasia.
Clinical journal of gastroenterology
2016; 9 (4): 238-242
Idiopathic hypereosinophilic syndrome (HES) is a rare diagnosis defined by the World Health Organization as a persistent eosinophilia for 6 months and resulting in end-organ dysfunction. While many patients present with nonspecific symptoms, others will present with symptoms of the affected organs, most commonly those involving the heart, skin, or nervous system. Gastrointestinal or liver involvement is estimated to affect up to one-third of patients with HES, although patients with clinically significant disease are limited to case reports. This is the first report of a patient presenting with hepatitis and achalasia related to idiopathic HES.
View details for DOI 10.1007/s12328-016-0661-8
View details for PubMedID 27294613
Presurgical Transarterial Chemoembolization Does Not Increase Binary Stricture Incidence in Orthotopic Liver Transplant Patients
2014; 46 (5): 1413-1419
The goal of this study was to compare the incidence of biliary strictures in orthotopic liver transplant (OLT) patients treated with previous transarterial chemoembolization (TACE) versus those with no TACE history.A single-center retrospective review was performed on 248 patients who underwent OLT from 2006 to 2012. Patient demographic characteristics, history of TACE for treatment of hepatocellular carcinoma, OLT data, and biliary stricture data were obtained. TACE was generally performed in a segmental manner using chemotherapy to ethiodized oil mixture (1:1). Clinically significant biliary strictures resulting in cholestasis or obstructive jaundice were diagnosed by using endoscopic retrograde cholangiopancreatography. Group characteristics were compared by using the Wilcoxon rank sum test, χ(2) analysis, and Kaplan-Meier statistics with log-rank comparison.Forty-six patients (35 men, 11 women; median age, 58 years) with a history of pre-OLT TACE were compared with 185 patients (111 men, 74 women; median age, 54 years) with no history of TACE. TACE and non-TACE patients had 30% and 31% cumulative incidence of biliary stricture, respectively. The median time to stricture was not reached in either group. There was no statistically significant difference in biliary stricture incidence (P = .928) or time to biliary stricture development (P = .803). Biliary strictures were primarily anastomotic in location in both groups: 79% in TACE patients and 84% in non-TACE patients (P = .233).Selective TACE treatment of hepatocellular carcinoma in pretransplant patients does not increase the rate of posttransplant biliary strictures. These findings corroborate the safety of TACE in the treatment of hepatocellular carcinoma in potential OLT patients as a bridge to transplantation.
View details for DOI 10.1016/j.transproceed.2014.03.012
View details for Web of Science ID 000338090600026
View details for PubMedID 24935306