Francesco Vizzutti. Azienda Ospedaliero Universitaria Careggi, Firenze

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Francesco Vizzutti. Azienda Ospedaliero Universitaria Careggi, Firenze"

Transcription

1 Francesco Vizzutti Azienda Ospedaliero Universitaria Careggi, Firenze Il sottoscritto dichiara di non aver avuto negli ultimi dodici mesi conflitto d interesse in relazione a questa presentazione e che la presentazione non contiene discussione di farmaci in studio o ad uso off-label

2 HEPATIC VENOUS PRESSURE GRADIENT

3 PORTAL HYPERTENSION Complicanza ineluttabile della cirrosi epatica caratterizzata dall aumento patologico del gradiente di pressione portale o HVPG (>5 mmhg) Complicanze: Sanguinamento da rottura di varici Ascite, HRS e SBP PHG e colopatia dell ipertensione portale HPS, PPH Spillover porto-sistemico & HE

4 SBP HE Ascites PHG Bleeding Varices HRS HPS PPH HVPG (mmhg) SUBclinical Portal Hypertension 5 0

5 DIRECT METHODS USED TO MEASURE PORTAL PRESSURE Umbilical vein catheterization Transhepatic portal vein catheterization Splenic pulp pressure measurement Pre-Sinusoidal Portal Hypertension Intra-operative mesenteric vein catheterization

6 HVC IS PERFORMED UNDER STRICTLY STERILE CONDITION.. avoid spitting

7 VENOUS ACCESS SITES FOR HEPATIC VEIN CATHETERIZATION

8 HEPATIC VEIN CATHETERIZATION Balloon catheter FHVP WHVP Portal P HVPG=WHVP-FHVP PCG=portal P- cava P

9 HVPG MEASUREMENT

10 NORMAL Hepatic vein Portal vein

11 CIRRHOTIC Hepatic vein x Portal vein x x x

12 RATIONALE FOR HVC Portal Pressure (mmhg) WHVP (mmhg) Agreement RI Overall series 0.99 HCV 0.94 Alcool 0.93 HCV + Alcool 0.97 RI - interclass correlation coefficient Perelló, Hepatology 1999

13

14 HVPG MEASUREMENTS AT HEPATIC VEIN CATHETERIZATION Complications: puncture site, supraventricular arrhythmias Contraindications: plt<20x10 9 /PT<30% (call repl.) allergic reaction

15 THREE IN ONE 1 1. HVPG 2. TJLB 3. CO 2 Portography 3 2

16 THE NATURAL HISTORY AND PROGNOSIS OF CHIRROSIS Compensated Stage 1 Stage 2 No varices No ascites 7% Varices No ascites 4.4% 1% Decompensated Stage 3 Stage 4 6.6% Ascites ± Varices 7.6% Bleeding ± Ascites 4% 3.4% 20% 57% 50% within 6 w. from BOV DEATH J Hep 2006, D Amico et al

17 Baveno V BACKGROUND: PRE-PRIMARY PROPHYLAXIS 20th ANNIVERSARY INTERNATIONAL CONSENSUS WORKSHOP AND POSTGRADUATE COURSE: current consensus and future directions in the diagnosis and treatment of portal hypertension PROPOSED STATEMENTS: Baveno III: Portal Pressure is predicting of varices formation. More data are needed. Baveno IV: De novo formation of varices: 4-6% per year HVPG is predictive of varices formation Stratify: HVPG: 6-10 and no varices HVPG>10 and no varices Small Varices NSBB are ineffective in preventing EV formation. (Groszmann RJ et al. NEJM 2005) Pts with small varices respond to BB because haemodynamic changes have developed yet. Prevention of the development of complications of portal hypertension is an important area of research. (5;D) Pre-primary prophylaxis should only include patients without gastro-esophageal varices.(5;d) Hepatic venous pressure gradient (HVPG) 10 mmhg is predictive of varices formation and decompensation.(1b;a) Treatment of underlying liver disease may reduce portal hypertension and prevent its clinical complications.(1b;a) There is no indication, at this time, to use beta-blockers to prevent the formation of varices.(1b;a) HVPG measurement in pre-primary prophylaxis may be recommended only in the context of clinical trials.(5; D)

18 THE NATURAL HISTORY AND PROGNOSIS OF CHIRROSIS Compensated Stage 1 Stage 2 No varices No ascites 7% Varices No ascites 4.4% 1% Decompensated Stage 3 Stage 4 6.6% Ascites ± Varices 7.6% Bleeding ± Ascites 4% 3.4% 20% 57% 50% within 6 w. from BOV DEATH J Hep 2006, D Amico et al

19 Baveno V PROPOSED STATEMENTS PRIMARY PROPHYLAXIS 20th ANNIVERSARY INTERNATIONAL CONSENSUS WORKSHOP AND POSTGRADUATE COURSE: current consensus and future directions in the diagnosis and treatment of portal hypertension HVPG BAVENO IV: A la carte treatment using HVPG-response in primary prophylaxis needs to be evaluated, especially in high-risk patients. Until then, routine use of HVPG cannot be recommended (5;D) - In centers where adequate resources and expertise are available, HVPG measurement should be routinely used for prognostic and therapeutic indications(5;d) -Controlled trials using pharmacological therapy in primary prophylaxis should include HVPG measurements(5;d) -A decrease in HVPG of at least 20% from baseline or to 12 mmhg after chronic treatment with NSBB is clinically relevant in the setting of primary prophylaxis(1a;a) - Acute HVPG response to intravenous propranolol may be used to identify responders to betablockers, specifically a decrease in HVPG of 10% or to 12 mmhg may be relevant in this setting (1b;A)

20 THE NATURAL HISTORY AND PROGNOSIS OF CHIRROSIS Compensated Stage 1 Stage 2 No varices No ascites 7% Varices No ascites 4.4% 1% Decompensated Stage 3 Stage 4 6.6% Ascites ± Varices 7.6% Bleeding ± Ascites 4% 3.4% 20% 57% 50% within 6 w. from BOV DEATH J Hep 2006, D Amico et al

21 Baveno V SECONDARY PROPHYLAXIS 20th ANNIVERSARY INTERNATIONAL CONSENSUS WORKSHOP AND POSTGRADUATE COURSE: current consensus and future directions in the diagnosis and treatment of portal hypertension Time to start secondary prophylaxis Secondary prophylaxis should start as soon as possible from day 6 of the index variceal episode (5, D) The start time of secondary prohylaxis should be documented (Baveno IV) (Baveno V: No Changes) BACKGROUND: Baveno IV: Patients with cirrhosis who have not received primary prophylaxis: NSBB (1a;A), EVL (1a;A) or both (1b;A) should be used for prevention of recurrent bleeding Combination of NSBB and EVL is probably the best treatment(1a;a) but more trial are needed Assessment of haemodynamic response to drug therapy provides prognostic information about rebleeding risk(2b B) Patients with cirrhosis who are on NSBB for PP and bleed: EVL should be added(5d) PROPOSED STATEMENTS: Patients with Cirrhosis Combination of beta-blockers and band ligation is the preferred therapy as it results in lower rebleeding compared to either therapy alone.(1a;a) Hemodynamic response to drug therapy provides information about rebleeding risk and survival(1a;a) The addition of ISMN to beta-blockers may improve the efficacy of treatment in hemodynamic non-responders (2;A Check) Cirrhotics unable/unwilling to VBL NSBB + ISMN is the preferred option(1a;a) Cirrhotics and contraindication/intolerance to NSBB EVL is the preferred treatment(5d)

22 Baveno V BACKGROUND: TREATMENT OF ACUTE BLEEDING 20th ANNIVERSARY INTERNATIONAL CONSENSUS WORKSHOP AND POSTGRADUATE COURSE: current consensus and future directions in the diagnosis and treatment of portal hypertension PROPOSED STATEMENTS: Baveno IV: No adequate prognostic model has been developed to predict outcomes(2b;b) No individual characteristics sufficiently predict prognosis(2b;b) Child-Pugh class, active bleeding at endoscopy, hepatic venous pressure gradient (HVPG), infection, renal failure, severity of initial bleeding, presence of portal vein thrombosis or of hepatocellular carcinoma and ALT have been identified as indicators of poor prognosis (2b;B) POST BAVENO IV: HVPG 20 independent predictor of 5-day failure in AVB (Abrdaldes JG et al 2008) Role for early TIPS in HVPG>20? (Thabut 2007) HVPG >20 mmhg, Child-Pugh Class C, and active bleeding at endoscopy are the variables most consistently found to predict 5-day treatment failure.(2b;b) Child-Pugh class C, MELD score > 18, and failure to control bleeding or early rebleeding are the variables most consistently found to predict 6-week mortality.(2b;b) Patients with GI bleeding and features suggesting cirrhosis should have upper endoscopy as soon as possible after admission(within 12 hours)(5d) In suspected variceal bleeding, vasoactive drugs should be started as soon as possible, before diagnostic endoscopy. (1B) Endoscopic therapy is recommended in any patient who presents with documented upper GI bleeding and in whom esophageal varices are the cause of bleeding(1a;a)

23 APPLICATIONS OF HVPG MEASUREMENT Diagnosis of portal hypertension Classification of portal hypertension Presinusoidal: normal WHVP and FHVP Assessment of disease severity Sinusoidal: increased WHVP and normal FHVP Response Postsinusoidal: to therapy both for WHVP portal and hypertension FHVP increased

24 reduction to <12 mmhg reduction of 20% 12 mmhg variceal rupture reduction of 10-12% at acute propranolol 20 mmhg treatment failure and mortality in VB reduction of 10% 10 mmhg clinicaly significant PH CHRONIC LIVER DISEASE COMPENSATED CIRRHOSIS DECOMPENSATED CIRRHOSIS DEATH 6 mmhg risk of disease progression post OLT HCV SINGLE HVPG MEASUREMENT CHANGES IN HVPG 16 mmhg increased risk of mortality 22 mmhg risk of mortality in AAH reduction of 20%

25 APPLICATIONS OF HVPG MEASUREMENT Diagnosis of portal hypertension Classification of portal hypertension Assessment of disease severity Response to therapy for portal hypertension Assessment of new therapeutic agents Changes in HVPG and guidance of therapy Identification of high-risck populations

LA VALUTAZIONE DEL RISCHIO CHIRURGICO. Paolo Caraceni

LA VALUTAZIONE DEL RISCHIO CHIRURGICO. Paolo Caraceni MONOTEMATICA AISF 2014 Cirrosi epatica: Napoli 10 anni dopo. Napoli, 8-10 Ottobre 2014 LA VALUTAZIONE DEL RISCHIO CHIRURGICO Paolo Caraceni Dipartimento di Scienze Mediche e Chirurgiche Centro di Ricerca

More information

Evaluation and Prognosis of Patients with Cirrhosis

Evaluation and Prognosis of Patients with Cirrhosis Evaluation and Prognosis of Patients with Cirrhosis Marion G. Peters, MD John V. Carbone, MD, Endowed Chair Professor of Medicine Chief of Hepatology Research University of California San Francisco Recorded

More information

Cirrhosis and HCV. Jonathan Israel M.D.

Cirrhosis and HCV. Jonathan Israel M.D. Cirrhosis and HCV Jonathan Israel M.D. Outline Relationship of fibrosis and cirrhosisprevalence and epidemiology. Sequelae of cirrhosis Diagnosis of cirrhosis Effect of cirrhosis on efficacy of treatment

More information

Coinfezione HIV-HCV. Raffaele Bruno, MD. Department of Infectious Diseases, University of Pavia Fondazione IRCCS Policlinico San Matteo, Pavia, Italy

Coinfezione HIV-HCV. Raffaele Bruno, MD. Department of Infectious Diseases, University of Pavia Fondazione IRCCS Policlinico San Matteo, Pavia, Italy Coinfezione HIV-HCV Raffaele Bruno, MD This program is supported by educational grants from Department of Infectious Diseases, University of Pavia Fondazione IRCCS Policlinico San Matteo, Pavia, Italy

More information

Pathophysiology of Portal Hypertension

Pathophysiology of Portal Hypertension Pathophysiology of Portal Hypertension Jaime Bosch, M.D. Professor of Medicine, University of Barcelona Liver Unit, Hospital Clínic-IDIBAPS, Centro de Investigación Biomédica de Enfermedades Hepáticas

More information

che la presentazione non contiene discussione di farmaci in studio o ad uso off-label

che la presentazione non contiene discussione di farmaci in studio o ad uso off-label Giovanna Fattovich Professore Associato di Medicina USO Epatologia, UOC di Gastroenterologia do, Dipartimento di Medicina, Azienda Ospedaliera Universitaria Verona La sottoscritta dichiara di non aver

More information

AASLD PRACTICE GUIDELINES Prevention and Management of Gastroesophageal Varices and Variceal Hemorrhage in Cirrhosis

AASLD PRACTICE GUIDELINES Prevention and Management of Gastroesophageal Varices and Variceal Hemorrhage in Cirrhosis AASLD PRACTICE GUIDELINES Prevention and Management of Gastroesophageal Varices and Variceal Hemorrhage in Cirrhosis Guadalupe Garcia-Tsao, 1 Arun J. Sanyal, 2 Norman D. Grace, 3 William Carey, 4 and the

More information

After the Cure: Long-Term Management of HCV Liver Disease Norah A. Terrault, MD, MPH

After the Cure: Long-Term Management of HCV Liver Disease Norah A. Terrault, MD, MPH After the Cure: Long-Term Management of HCV Liver Disease Norah A. Terrault, MD, MPH Professor of Medicine Department of Gastroenterology Director, Viral Hepatitis Center University of California San Francisco

More information

TROMBOSI PORTAL EN LA CIRROSI: SIGNIFICAT I TRACTAMENT

TROMBOSI PORTAL EN LA CIRROSI: SIGNIFICAT I TRACTAMENT TROMBOSI PORTAL EN LA CIRROSI: SIGNIFICAT I TRACTAMENT Virginia Hernández Gea Barcelona Hepatic Hemodynamic Unit Liver Unit. Hospital Clinic. Barcelona. Octubre 2013 Balance of anti & prohemostatic drivers

More information

Screening for Varices and Prevention of Bleeding

Screening for Varices and Prevention of Bleeding Hepatitis C Online PDF created August 24, 2016, 3:30 am Screening for Varices and Prevention of Bleeding Module 3: Lesson 3: Contents: Management of Cirrhosis-Related Complications Screening for Varices

More information

End Stage Liver Disease: What is New? Marion Peters MD UCSF Berlin 2012

End Stage Liver Disease: What is New? Marion Peters MD UCSF Berlin 2012 End Stage Liver Disease: What is New? Marion Peters MD UCSF Berlin 2012 Natural History of ESLD Increasing liver fibrosis Development of HCC Chronic liver disease Compensated cirrhosis Decompensated cirrhosis

More information

How can we best use MELD and Child-Pugh scores to assess the liver at baseline and during treatment of CHC and NASH?

How can we best use MELD and Child-Pugh scores to assess the liver at baseline and during treatment of CHC and NASH? How can we best use MELD and Child-Pugh scores to assess the liver at baseline and during treatment of CHC and NASH? Patrick S. Kamath, MD Division of Gastroenterology and Hepatology Mayo Clinic, College

More information

Optimal Management of Splenic/Portal Vein Thrombosis. David Mauchley University of Colorado

Optimal Management of Splenic/Portal Vein Thrombosis. David Mauchley University of Colorado Optimal Management of Splenic/Portal Vein Thrombosis David Mauchley University of Colorado Overview Portal Vein Thrombosis (PVT) Etiology Presentation/Clinical Aspects Diagnosis Management Cirrhotic vs.

More information

CLINICAL CONSEQUENCES OF PORTAL HYPERTENSION

CLINICAL CONSEQUENCES OF PORTAL HYPERTENSION Página 1 de 10 CLINICAL CONSEQUENCES OF PORTAL HYPERTENSION Part of "11 - PORTAL HYPERTENSION" The portal hypertensive syndrome is responsible for many of the manifestations of advanced, decompensated

More information

Disclosures. Endoscopic Management of Variceal Bleeding

Disclosures. Endoscopic Management of Variceal Bleeding Endoscopic Management of Variceal Bleeding Disclosures I have no relevant financial disclosures with respect to the content of this talk I will discuss the off-label use of cyanoacrylate glue Janak N.

More information

Objectives of Session

Objectives of Session Objectives of Session Project Background Why the need Decision Support Tool summary of key evidence Promotion Key Messages Project Background Grasp AF Audit Initial Grasp AF project undertaken in NHS Buckinghamshire

More information

Role of Ultrasound Findings and Platelet Spleen Ratio in Assessing the Severity of Esophagogastric Varices in Patients with Cirrhosis of Liver

Role of Ultrasound Findings and Platelet Spleen Ratio in Assessing the Severity of Esophagogastric Varices in Patients with Cirrhosis of Liver Original Article Print ISSN: 2321-6379 Online ISSN: 2321-595X DOI: 10.17354/ijss/2016/457 Role of Ultrasound Findings and Platelet Spleen Ratio in Assessing the Severity of Esophagogastric Bikshapathi

More information

1802 CLINICAL REVIEWS

1802 CLINICAL REVIEWS 1802 CLINICAL S nature publishing group Management and Treatment of Patients With Cirrhosis and Portal Hypertension: Recommendations From the Department of Veterans Affairs Hepatitis C Resource Center

More information

Lamivudine for Patients with hronic Hepatitis B and Advanced Liver Disease. From : New England Journal of Medicine

Lamivudine for Patients with hronic Hepatitis B and Advanced Liver Disease. From : New England Journal of Medicine Lamivudine for Patients with hronic Hepatitis B and Advanced Liver Disease From : New England Journal of Medicine Volume 351:1521-1531, Number 15, Oct 7, 2004 馬 偕 紀 念 醫 院 一 般 內 科, 肝 膽 腸 胃 科 新 竹 分 院 陳 重

More information

EVALUATION OF PROGNOSTIC FACTORS IN DECOMPENSATED LIVER CIRRHOSIS WITH ASCITES AND SPONTANEOUS BACTERIAL PERITONITIS

EVALUATION OF PROGNOSTIC FACTORS IN DECOMPENSATED LIVER CIRRHOSIS WITH ASCITES AND SPONTANEOUS BACTERIAL PERITONITIS Rev. Med. Chir. Soc. Med. Nat., Iaşi 2015 vol. 119, no. 4 INTERNAL MEDICINE - PEDIATRICS ORIGINAL PAPERS EVALUATION OF PROGNOSTIC FACTORS IN DECOMPENSATED LIVER CIRRHOSIS WITH ASCITES AND SPONTANEOUS BACTERIAL

More information

Hepatitis C Treatment Criteria Commercial & Minnesota Health Care Programs

Hepatitis C Treatment Criteria Commercial & Minnesota Health Care Programs Last update: February 23, 2015 Hepatitis C Treatment Criteria Commercial & Minnesota Health Care Programs Please see healthpartners.com for Medicare coverage criteria. Table of Contents 1. Harvoni 2. Sovaldi

More information

HBV & HCV induced. Liver Cirrhosis Iradj Maleki MD Gut & Liver Research Center Mazandaran University of Medical Sciences

HBV & HCV induced. Liver Cirrhosis Iradj Maleki MD Gut & Liver Research Center Mazandaran University of Medical Sciences HBV & HCV induced Liver Cirrhosis Iradj Maleki MD Gut & Liver Research Center Mazandaran University of Medical Sciences Definition of Cirrhosis Final pathway for a wide variety of chronic liver diseases

More information

COMPLICATIONS OF CIRRHOSIS COMPLICATIONS OF CIRRHOSIS OBSERVATIONS OF AN AGING HEPATOLOGIST. Philip C. Delich, M.D.

COMPLICATIONS OF CIRRHOSIS COMPLICATIONS OF CIRRHOSIS OBSERVATIONS OF AN AGING HEPATOLOGIST. Philip C. Delich, M.D. 1 COMPLICATIONS OF CIRRHOSIS OBSERVATIONS OF AN AGING HEPATOLOGIST COMPLICATIONS OF CIRRHOSIS Philip C. Delich, M.D. Faculty Disclosure Dr. Delich has indicated that he does not have any relevant financial

More information

Caption: Portal vein, coloured ultrasound scan. The portal vein (red) transports nutrient-rich blood from the digestive organs to the liver.

Caption: Portal vein, coloured ultrasound scan. The portal vein (red) transports nutrient-rich blood from the digestive organs to the liver. Caption: Portal vein, coloured ultrasound scan. The portal vein (red) transports nutrient-rich blood from the digestive organs to the liver. This scan shows the point at which the portal vein enters the

More information

HOW TO MANAGE A PATIENT ON SYSTEMIC CHEMOTHERAPY

HOW TO MANAGE A PATIENT ON SYSTEMIC CHEMOTHERAPY 15th AISF PRE-MEETING COURSE Treatment of hepatocellular carcinoma Rome, February 20th HOW TO MANAGE A PATIENT ON SYSTEMIC CHEMOTHERAPY Dott. Massimo Iavarone 1 Division of Gastroenterology Fondazione

More information

Measurement of the hepatic venous pressure gradient

Measurement of the hepatic venous pressure gradient Liver Stiffness Measurement Predicts Severe Portal Hypertension in Patients with HCV-Related Cirrhosis Francesco Vizzutti, 1 Umberto Arena, 1 Roberto G. Romanelli, 1 Luigi Rega, 2 Marco Foschi, 1 Stefano

More information

The following should be current within the past 6 months:

The following should be current within the past 6 months: EVALUATION Baseline Labs Obtain at time or prior to initial evaluation CBC with diff PT/INR CMP HCV Genotype (obtained PRIOR TO consult visit) HCV RNA (obtained PRIOR TO consult visit) Hep A IgG Hep BsAg,

More information

Portal Hypertension and Gastrointestinal Bleeding

Portal Hypertension and Gastrointestinal Bleeding Portal Hypertension and Gastrointestinal Bleeding Jaime Bosch, M.D., Ph.D., 1,2 Juan G. Abraldes, M.D., 1,2 Annalisa Berzigotti, M.D., 3,4 and Juan Carlos Garcia-Pagan, M.D. 1,2 ABSTRACT Variceal bleeding

More information

June 11, 2015 Tim Halterman

June 11, 2015 Tim Halterman June 11, 2015 Tim Halterman Defini&on Histologic change + loss of liver function Derives from Greek word kirrhos meaning yellow, tawny First named by Rene Laennec in 1819 Laennec s cirrhosis=alcoholic

More information

Endpoints and Populations and Trial Designs for Clinical Trials in NASH Indications

Endpoints and Populations and Trial Designs for Clinical Trials in NASH Indications Endpoints and Populations and Trial Designs for Clinical Trials in NASH Indications Lara Dimick-Santos, MD Food and Drug Administration The Liver Forum November 12, 2015 1 Disclaimer The views presented

More information

Acute on Chronic Liver Failure: Current Concepts. Disclosures

Acute on Chronic Liver Failure: Current Concepts. Disclosures Acute on Chronic Liver Failure: Current Concepts Vandana Khungar, MD MSc Assistant Professor of Medicine University of Pennsylvania, Perelman School of Medicine September 20, 2015 None to declare Disclosures

More information

TIPS: A Discussion of Portal Hypertension and the

TIPS: A Discussion of Portal Hypertension and the TIPS: A Discussion of Portal Hypertension and the Transjugular Intrahepatic Portocaval Shunt Lakshmi Ananthakrishnan University of Louisville MS IV Dr. Department of Radiology Beth Israel Deaconess Medical

More information

REVIEW CLINICAL REVIEWS

REVIEW CLINICAL REVIEWS 1802 CLINICAL S nature publishing group Management and Treatment of Patients With Cirrhosis and Portal Hypertension: Recommendations From the Department of Veterans Affairs Hepatitis C Resource Center

More information

COMPLICATIONS OF CIRRHOSIS: CASES. Anil Seetharam, MD Anil.Seetharam@bannerhealth.com

COMPLICATIONS OF CIRRHOSIS: CASES. Anil Seetharam, MD Anil.Seetharam@bannerhealth.com COMPLICATIONS OF CIRRHOSIS: CASES Anil Seetharam, MD Anil.Seetharam@bannerhealth.com Defining Cirrhosis Histological diagnosis Nodules of regenerating hepatocytes surrounded by fibrous tissue Common final

More information

Cholecystectomy and Cirrhosis. Dr. Vincent Lam

Cholecystectomy and Cirrhosis. Dr. Vincent Lam Conjoint Australia and New Zealand Upper GI and HPB Meeting Queenstown, 28 th September 2010 Cholecystectomy and Cirrhosis Dr. Vincent Lam Senior Lecturer in Surgery, Sydney Medical School Hepatobiliary,

More information

Therapy of decompensated cirrhosis Pre-transplant for HBV and HCV

Therapy of decompensated cirrhosis Pre-transplant for HBV and HCV Therapy of decompensated cirrhosis Pre-transplant for HBV and HCV Universitätsklinikum Leipzig Thomas Berg Sektion Hepatologie Klinik und Poliklinik für Gastroenterologie und Rheumatologie Leber- und Studienzentrum

More information

NP/PA Clinical Hepatology Fellowship Summary of Year-Long Curriculum

NP/PA Clinical Hepatology Fellowship Summary of Year-Long Curriculum OVERVIEW OF THE FELLOWSHIP The goal of the AASLD NP/PA Fellowship is to provide a 1-year postgraduate hepatology training program for nurse practitioners and physician assistants in a clinical outpatient

More information

Adult Living Donor Liver Transplantation Juan Guerrero, MD Clinical Assistant Professor Medicine Division of Gastroenterology

Adult Living Donor Liver Transplantation Juan Guerrero, MD Clinical Assistant Professor Medicine Division of Gastroenterology Adult Living Donor Liver Transplantation Juan Guerrero, MD Clinical Assistant Professor Medicine Division of Gastroenterology Overview Liver Transplantation Indications and contraindications Listing Process

More information

Evaluation and Treatment of Esophageal Varices in the Cirrhotic Patient

Evaluation and Treatment of Esophageal Varices in the Cirrhotic Patient in Evaluation and Treatment of Esophageal Varices in the Cirrhotic Patient Eyal Ashkenazi MD 1, Yulia Kovalev MD 1 and Eli Zuckerman MD 2 1 Liver Unit, Carmel Medical Center, Haifa 2 Liver Unit, Carmel

More information

Case Study in the Management of Patients with Hepatocellular Carcinoma

Case Study in the Management of Patients with Hepatocellular Carcinoma Management of Patients with Viral Hepatitis, Paris, 2004 Case Study in the Management of Patients with Hepatocellular Carcinoma Eugene R. Schiff This 50-year-old married man with three children has a history

More information

PREVENTION OF HCC BY HEPATITIS C TREATMENT. Morris Sherman University of Toronto

PREVENTION OF HCC BY HEPATITIS C TREATMENT. Morris Sherman University of Toronto PREVENTION OF HCC BY HEPATITIS C TREATMENT Morris Sherman University of Toronto Pathogenesis of HCC in chronic hepatitis C Injury cirrhosis HCC Injury cirrhosis HCC Time The Ideal Study Prospective randomized

More information

Prior Authorization Conditions for Approval of Hepatitis C Agents

Prior Authorization Conditions for Approval of Hepatitis C Agents Prior Authorization Conditions for Approval of Hepatitis C Agents All requests for Hepatitis C Agents require a prior authorization and will be screened for medical necessity and appropriateness using

More information

HIV and Hepatitis Co-infection. Martin Fisher Brighton and Sussex University Hospitals, UK

HIV and Hepatitis Co-infection. Martin Fisher Brighton and Sussex University Hospitals, UK HIV and Hepatitis Co-infection Martin Fisher Brighton and Sussex University Hospitals, UK Useful References British HIV Association 2010 http://www.bhiva.org/documents/guidelines/hepbc/2010/ hiv_781.pdf

More information

Recommendations for the Identification of Chronic Hepatitis C virus infection Among Persons Born During 1945-1965

Recommendations for the Identification of Chronic Hepatitis C virus infection Among Persons Born During 1945-1965 Recommendations for the Identification of Chronic Hepatitis C virus infection Among Persons Born During 1945-1965 MMWR August 17, 2012 Prepared by : The National Viral Hepatitis Technical Assistance Center

More information

Hepatitis C Treatment Expansion Initiative Multi-Site Conference Call. March 16, 2011

Hepatitis C Treatment Expansion Initiative Multi-Site Conference Call. March 16, 2011 Hepatitis C Treatment Expansion Initiative Multi-Site Conference Call March 16, 2011 Case Presentations Kansas City Free Health Clinic Carilion Clinic Didactic Session Challenges in Determining HCV Treatment

More information

MANAGEMENT OF LIVER CIRRHOSIS

MANAGEMENT OF LIVER CIRRHOSIS MANAGEMENT OF LIVER CIRRHOSIS Information Leaflet Your Health. Our Priority. Page 2 of 6 What is cirrhosis? Cirrhosis is a result of long-term, continuous damage to the liver and may be due to many different

More information

Prognosis: diagnosing the future. The temporal dimension of diagnosis. Predictive models

Prognosis: diagnosing the future. The temporal dimension of diagnosis. Predictive models Prognosis: diagnosing the future. The temporal dimension of diagnosis. Predictive models Gennaro D Amico Gastroenterology Unit V Cervello Hospital Palermo gedamico@libero.it Diagnosing the future The link

More information

Transjugular Intrahepatic Portosystemic Shunt. Professor A Watkinson The Royal Devon and Exeter Hospital

Transjugular Intrahepatic Portosystemic Shunt. Professor A Watkinson The Royal Devon and Exeter Hospital Transjugular Intrahepatic Portosystemic Shunt Professor A Watkinson The Royal Devon and Exeter Hospital TIPS When would this be required Patients with liver cirrhosis Blood flow from Portal system (Gut)

More information

Appropriate Use Criteria (By Rating) Table 1. Venous Duplex of the Upper Extremities for Patency and Thrombosis

Appropriate Use Criteria (By Rating) Table 1. Venous Duplex of the Upper Extremities for Patency and Thrombosis ACCF 2013 Use Criteria for Peripheral Vascular Ultrasound and Physiological Testing Part II: Testing for Venous Disease and Evaluation of Hemodialysis Access Section 1: Upper Extremity Venous Evaluation

More information

VASCULAR SURGERY. 4. Assess the vascular system by appropriate skills in history-taking and in clinical examination.

VASCULAR SURGERY. 4. Assess the vascular system by appropriate skills in history-taking and in clinical examination. VASCULAR SURGERY PGY-1 Medical Knowledge 1. Describe human arterial and venous anatomy. 2. Describe basic arterial and venous hemodynamics. 3. Review the basic clinical manifestations of vascular disorders.

More information

What to Do with the Patient With Abnormal Liver Enzymes? Nizar N. Zein, M.D. The Cleveland Clinic

What to Do with the Patient With Abnormal Liver Enzymes? Nizar N. Zein, M.D. The Cleveland Clinic What to Do with the Patient With Abnormal Liver Enzymes? Nizar N. Zein, M.D. The Cleveland Clinic Introduction Elevated liver enzymes is often not a clinical problem by itself. However it is a warning

More information

a series of fact sheets written by experts in the field of liver disease HCV DISEASE PROGRESSION

a series of fact sheets written by experts in the field of liver disease HCV DISEASE PROGRESSION www.hcvadvocate.org HCSP FACT SHEET Symptoms & Complications of Cirrhosis Foreword After many years of infection with hepatitis C the liver can become severely scarred. The process starts with inflammation

More information

HEPATITIS C THERAPY PRIOR AUTHORIZATION FORM: Page 1 of 3 Patient Information. Diagnosis Acute Hep C Chronic Hep C Hepatocellular Carcinoma

HEPATITIS C THERAPY PRIOR AUTHORIZATION FORM: Page 1 of 3 Patient Information. Diagnosis Acute Hep C Chronic Hep C Hepatocellular Carcinoma HEPATITIS C THERAPY PRIOR AUTHORIZATION FORM: Page 1 of 3 Patient Information Recipient: MA#: Date of Birth: Phone #: Body Weight: Treatment Plan Sovaldi (sofosbuvir) 400mg: Take once daily for weeks Olysio

More information

Liver Transplantation for Hepatocellular Carcinoma. John P. Roberts, MD Chief, Division of Transplant Service University of California, San Francisco

Liver Transplantation for Hepatocellular Carcinoma. John P. Roberts, MD Chief, Division of Transplant Service University of California, San Francisco Liver Transplantation for Hepatocellular Carcinoma John P. Roberts, MD Chief, Division of Transplant Service University of California, San Francisco Hepatocellular Carcinoma HCC is the 5th most common

More information

PRIOR AUTHORIZATION PROTOCOL FOR HEPATITIS C TREATMENT

PRIOR AUTHORIZATION PROTOCOL FOR HEPATITIS C TREATMENT PRIOR AUTHORIZATION PROTOCOL FOR HEPATITIS C TREATMENT HARVONI (90mg ledipasvir/400mg sofosbuvir): tablet (PREFERRED AGENT) SOVALDI (sofosbuvir ): 400mg tablets (PREFERRED AGENT ) OLYSIO (simeprivir) PEG-INTRON

More information

Management of hepatitis C: pre- and post-liver transplantation. Piyawat Komolmit Bangkok

Management of hepatitis C: pre- and post-liver transplantation. Piyawat Komolmit Bangkok Management of hepatitis C: pre- and post-liver transplantation Piyawat Komolmit Bangkok Liver transplantation and CHC Cirrhosis secondary to HCV is the leading cause of liver transplantation in the US

More information

Current Antiviral Treatment of HCV cirrhosis

Current Antiviral Treatment of HCV cirrhosis Current Antiviral Treatment of HCV cirrhosis Hugo R. Rosen, M.D. Waterman Endowed Chair in Liver Research Division Head, Gastroenterology & Hepatology Professor of Medicine and Immunology University of

More information

Oral Zinc Supplementation as an Adjunct Therapy in the Management of Hepatic Encephalopathy: A Randomized Controlled Trial

Oral Zinc Supplementation as an Adjunct Therapy in the Management of Hepatic Encephalopathy: A Randomized Controlled Trial Oral Zinc Supplementation as an Adjunct Therapy in the Management of Hepatic Encephalopathy: A Randomized Controlled Trial Marcus R. Pereira A. Study Purpose Hepatic encephalopathy is a common complication

More information

Many randomized controlled trials (RCTs) have

Many randomized controlled trials (RCTs) have Portal Hypertension and Variceal Bleeding Unresolved Issues. Summary of an American Association for the Study of Liver Diseases and European Association for the Study of the Liver Single-Topic Conference

More information

LIVER FUNCTION TESTS AND STATINS

LIVER FUNCTION TESTS AND STATINS LIVER FUNCTION TESTS AND STATINS Philippe J. Zamor and Mark W. Russo Current Opinion in Cardiology 2011,26:338 341 SUMMARY Purpose of review: To discuss recent data on statins in patients with elevated

More information

LIVER TRANSPLANTATION Update on Allocation Living Donor Liver Tx.

LIVER TRANSPLANTATION Update on Allocation Living Donor Liver Tx. LIVER TRANSPLANTATION Update on Allocation Living Donor Liver Tx. Steven L. Flamm MD Associate Professor of Medicine Medical Director, Liver Transplantation Northwestern University Medical School 1958

More information

Surveillance for Hepatocellular Carcinoma

Surveillance for Hepatocellular Carcinoma Surveillance for Hepatocellular Carcinoma Marion G. Peters, MD John V. Carbone, MD, Endowed Chair Professor of Medicine Chief of Hepatology Research University of California San Francisco Recorded on April

More information

Patterns of abnormal LFTs and their differential diagnosis

Patterns of abnormal LFTs and their differential diagnosis Patterns of abnormal LFTs and their differential diagnosis Professor Matthew Cramp South West Liver Unit and Peninsula Schools of Medicine and Dentistry, Plymouth Summary liver function / liver function

More information

Hepatocellular Carcinoma: What the hepatologist wants to know

Hepatocellular Carcinoma: What the hepatologist wants to know Hepatocellular Carcinoma: What the hepatologist wants to know Hélène Castel, MD Liver Unit Hôpital St-Luc CHUM? CAR Annual Scientific Meeting Saturday, April 27 th 2013 Disclosure statement I do not have

More information

MELD System: Past and Present. Patrick S. Kamath, MD Mayo Clinic College of Medicine Division of Gastroenterology and Hepatology

MELD System: Past and Present. Patrick S. Kamath, MD Mayo Clinic College of Medicine Division of Gastroenterology and Hepatology MELD System: Past and Present Patrick S. Kamath, MD Mayo Clinic College of Medicine Division of Gastroenterology and Hepatology MELD for Liver Transplantation: Outline What is the MELD Score? Why was liver

More information

LIVER TRANSPLANTATION IN ALAGILLE SYNDROME

LIVER TRANSPLANTATION IN ALAGILLE SYNDROME LIVER TRANSPLANTATION IN ALAGILLE SYNDROME Ronald J. Sokol, MD Children s Hospital Colorado University of Colorado School of Medicine Treatment of Liver Disease in Improve bile flow ALGS Ursodeoxycholic

More information

脂肪肝的西醫藥治療 Western medicine treatment on fatty liver. Vincent Wong 黃煒燊 Institute of Digestive Disease 消化疾病研究所

脂肪肝的西醫藥治療 Western medicine treatment on fatty liver. Vincent Wong 黃煒燊 Institute of Digestive Disease 消化疾病研究所 脂肪肝的西醫藥治療 Western medicine treatment on fatty liver Vincent Wong 黃煒燊 Institute of Digestive Disease 消化疾病研究所 Disclosures Advisory board member: AbbVie, Gilead, Janssen, Otsuka, Roche Consultancy: Merck,

More information

Presented by: Jean Yoo-Campbell, Matthew Konerman, Monica Konerman, Jean Yoo Campbell, Christian Gocke, Eunpi Cho Donald Lynch

Presented by: Jean Yoo-Campbell, Matthew Konerman, Monica Konerman, Jean Yoo Campbell, Christian Gocke, Eunpi Cho Donald Lynch Bass N.M., et. al. N Engl J Med 2010; 362:1071-1081 Presented by: Jean Yoo-Campbell, Matthew Konerman, Monica Konerman, Jean Yoo Campbell, Christian Gocke, Eunpi Cho Donald Lynch Faculty Advisor: Dr. Fred

More information

Recommendations 8/14/2014. Hepatitis C Clinical Approach Primary Care. Purpose of Presentation. HCV Prevalence Year of Birth

Recommendations 8/14/2014. Hepatitis C Clinical Approach Primary Care. Purpose of Presentation. HCV Prevalence Year of Birth Hepatitis C Clinical Approach Primary Care Dr. Vicki L. MIt McIntyre, FNP Tucson Gastroenterology Specialists Tucson, Arizona University of Phoenix Lead Faculty, Department of Nursing Tucson, Arizona Purpose

More information

Autologous CD34+ and CD133+ stem cells transplantation in patients with end stage liver disease

Autologous CD34+ and CD133+ stem cells transplantation in patients with end stage liver disease Autologous CD34+ and CD133+ stem cells transplantation in patients with end stage liver disease Overview Yasser A. Abdelghani, 2012 Tropical Medicine Department, Minia University, EGYPT http://www.endogastrohep.net

More information

Information for patients (and their families) waiting for liver transplantation

Information for patients (and their families) waiting for liver transplantation Information for patients (and their families) waiting for liver transplantation Waiting list? What is liver transplant? Postoperative conditions? Ver.: 4/2016 1 What is a liver transplant? Liver transplantation

More information

Liver cirrhosis Epidemiological and Clinical Aspects

Liver cirrhosis Epidemiological and Clinical Aspects Section of Gastroenterology and Hepatology Department of Internal Medicine Sahlgrenska University Hospital Göteborg University Göteborg, Sweden Liver cirrhosis Epidemiological and Clinical Aspects Steingerður

More information

Approach to Abnormal Liver Tests

Approach to Abnormal Liver Tests Approach to Abnormal Liver Tests Naga P. Chalasani, MD, FACG Professor of Medicine and Cellular & Integrative Physiology Director, Division of Gastroenterology and Hepatology Indiana University School

More information

Guidelines for diagnosis and management of acute pulmonary embolism

Guidelines for diagnosis and management of acute pulmonary embolism Guidelines for diagnosis and management of acute pulmonary embolism By Dr. Ahmed Zaghloul M.D. Anesthesia & Critical Care 2014 Predisposing factors for VTE Predisposing factor Strong predisposing factors

More information

New Anticoagulants and GI bleeding

New Anticoagulants and GI bleeding New Anticoagulants and GI bleeding DR DANNY MYERS MD FRCP(C) CLINICAL ASSISTANT PROFESSOR OF MEDICINE, UBC Conflicts of Interest None I am unbiased in the use of NOAC s vs Warfarin based on risk benefit

More information

OHTAC Recommendation

OHTAC Recommendation OHTAC Recommendation Radiofrequency Ablation for hepatocellular carcinoma or primary June 17, 2004 1 The Ontario Health Technology Advisory Committee (OHTAC) met on June 17, 2003 and reviewed a recommendation

More information

New IDSA/AASLD Guidelines for Hepatitis C

New IDSA/AASLD Guidelines for Hepatitis C NORTHWEST AIDS EDUCATION AND TRAINING CENTER New IDSA/AASLD Guidelines for Hepatitis C John Scott, MD, MSc Associate Professor, UW SoM Asst Director, Liver Clinic, Harborview Medical Center Presentation

More information

Prior Authorization Guideline

Prior Authorization Guideline Prior Authorization Guideline Guideline Name Olysio (simeprevir) Formulary UnitedHealthcare Community & State Formulary Note Approval Date 2/19/2015 Revision Date 4/15/2015 Technician Note : CPS Approval

More information

Successful Treatment for Hepatic Encephalopathy Aggravated by Portal Vein Thrombosis with Balloon-Occluded Retrograde Transvenous Obliteration

Successful Treatment for Hepatic Encephalopathy Aggravated by Portal Vein Thrombosis with Balloon-Occluded Retrograde Transvenous Obliteration 366 This is an Open Access article licensed under the terms of the Creative Commons Attribution- NonCommercial-NoDerivs 3.0 License (www.karger.com/oa-license), applicable to the online version of the

More information

The safety and clinical outcome of chemoembolisation in Child-Pugh Class C patients with hepatocellular carcinoma

The safety and clinical outcome of chemoembolisation in Child-Pugh Class C patients with hepatocellular carcinoma The safety and clinical outcome of chemoembolisation in Child-Pugh Class C patients with hepatocellular carcinoma Poster No.: C-1714 Congress: ECR 2015 Type: Authors: Keywords: DOI: Scientific Exhibit

More information

Section 8: Clinical Exercise Testing. a maximal GXT?

Section 8: Clinical Exercise Testing. a maximal GXT? Section 8: Clinical Exercise Testing Maximal GXT ACSM Guidelines: Chapter 5 ACSM Manual: Chapter 8 HPHE 4450 Dr. Cheatham Outline What is the purpose of a maximal GXT? Who should have a maximal GXT (and

More information

The State of the Liver in the Adult Patient after Fontan Palliation

The State of the Liver in the Adult Patient after Fontan Palliation The State of the Liver in the Adult Patient after Fontan Palliation Fred Wu, M.D. Boston Adult Congenital Heart Service Boston Children s Hospital/Brigham & Women s Hospital 7 th National Adult Congenital

More information

Liver Failure. Nora Aziz. www.3bv.org. Bones, Brains & Blood Vessels

Liver Failure. Nora Aziz. www.3bv.org. Bones, Brains & Blood Vessels Liver Failure Nora Aziz www.3bv.org Bones, Brains & Blood Vessels Severe deterioration in liver function Looses ability to regenerate/repair decompensated Liver extensively damaged before it fails Equal

More information

Three triggers that suggest that patients could benefit from a hospice palliative care approach

Three triggers that suggest that patients could benefit from a hospice palliative care approach Why is it important to identify people nearing the end of life? About 1% of the population dies each year. Although some deaths are unexpected, many more in fact can be predicted. This is inherently difficult,

More information

Atrial Fibrillation An update on diagnosis and management

Atrial Fibrillation An update on diagnosis and management Dr Arvind Vasudeva Consultant Cardiologist Atrial Fibrillation An update on diagnosis and management Atrial fibrillation (AF) remains the commonest disturbance of cardiac rhythm seen in clinical practice.

More information

Lenox Hill Hospital Department of Surgery General Surgery Goals and Objectives

Lenox Hill Hospital Department of Surgery General Surgery Goals and Objectives Lenox Hill Hospital Department of Surgery General Surgery Goals and Objectives Medical Knowledge and Patient Care: Residents must demonstrate knowledge and application of the pathophysiology and epidemiology

More information

Management by the intensivist of gastrointestinal bleeding in adults and children

Management by the intensivist of gastrointestinal bleeding in adults and children Osman et al. Annals of Intensive Care 2012, 2:46 REVIEW Open Access Management by the intensivist of gastrointestinal bleeding in adults and children David Osman 1*, Michel Djibré 2, Daniel Da Silva 3,

More information

Prior Authorization Policy

Prior Authorization Policy Prior Authorization Policy http://www.paramounthealthcare.com/providers Ribavirin Rebetol (ribavirin capsule or oral solution) Copegus (ribavirin tablet), Moderiba (ribavirin tablet), Ribasphere (ribavirin

More information

World Gastroenterology Organisation Global Guidelines. Esophageal varices JANUARY 2014

World Gastroenterology Organisation Global Guidelines. Esophageal varices JANUARY 2014 World Gastroenterology Organisation Global Guidelines Esophageal varices JANUARY 2014 Revision authors Prof. D. LaBrecque (USA) Prof. A.G. Khan (Pakistan) Prof. S.K. Sarin (India) Drs. A.W. Le Mair (Netherlands)

More information

A 55 year old man with cirrhosis due to chronic hepatitis C (CHC) genotype 3a is referred for liver transplantation.

A 55 year old man with cirrhosis due to chronic hepatitis C (CHC) genotype 3a is referred for liver transplantation. A 55 year old man with cirrhosis due to chronic hepatitis C (CHC) genotype 3a is referred for liver transplantation. Three years ago he was treated with 24 weeks of peginterferon alfa-2a (180 µg/wk, PEGIFN)

More information

Vascular Surgery Rotation Goals & Objectives (Junior General Surgery Residents)

Vascular Surgery Rotation Goals & Objectives (Junior General Surgery Residents) Vascular Surgery Rotation Goals & Objectives (Junior General Surgery Residents) Overall Objectives Junior vascular surgery rotations are designed to provide vascular surgery residents with the cognitive,

More information

HCC: Risk factors, surveillance and the importance of a multidisciplinary team

HCC: Risk factors, surveillance and the importance of a multidisciplinary team HCC: Risk factors, surveillance and the importance of a multidisciplinary team Anjana Pillai MD Assistant Professor of Medicine Director, Emory University Hospital Liver Tumor Clinic Division of Digestive

More information

GASTROENTEROLOGY FELLOWSHIP HEPATOLOGY ROTATION GOALS AND OBJECTIVES University of Toledo

GASTROENTEROLOGY FELLOWSHIP HEPATOLOGY ROTATION GOALS AND OBJECTIVES University of Toledo GASTROENTEROLOGY FELLOWSHIP HEPATOLOGY ROTATION GOALS AND OBJECTIVES University of Toledo Educational Purpose: The Hepatology Rotation introduces the fellow to the management of outpatients and inpatients

More information

Recanalized Umbilical Vein in the Presence of Cirrhosis-Induced Portal Hypertension

Recanalized Umbilical Vein in the Presence of Cirrhosis-Induced Portal Hypertension Recanalized Umbilical Vein in the Presence of Cirrhosis-Induced Portal Hypertension Audrey Galey RDMS, RVT, Mary Grace Renfro RDSM, RVT, Lindsey Simon, RVT March 22, 2013 2 Abstract A recanalized umbilical

More information

Abdominal Doppler US. Vascular Ultrasound in Liver Disease Objectives: Portal Vein (PV)

Abdominal Doppler US. Vascular Ultrasound in Liver Disease Objectives: Portal Vein (PV) Doppler Ultrasound Evaluation of the Hepatic Vasculature and Liver Disease Ulrike M. Hamper, M.D.; M.B.A. Russell H. Morgan Department of Radiology and Radiological Sciences Johns Hopkins University School

More information

NICE guideline Published: 6 July 2016 nice.org.uk/guidance/ng49

NICE guideline Published: 6 July 2016 nice.org.uk/guidance/ng49 Non-alcoholic fatty liver disease (NAFLD): assessment and management NICE guideline Published: 6 July 2016 nice.org.uk/guidance/ng49 NICE 2016. All rights reserved. Your responsibility The recommendations

More information

RENAL FAILURE IN CIRRHOSIS Mónica Guevara

RENAL FAILURE IN CIRRHOSIS Mónica Guevara RENAL FAILURE IN CIRRHOSIS Mónica Guevara Síndrome Hepatorrenal Tipo 1: Rápidamente progresivo. Mortalidad mediana de 15 días. Tratamiento con vasoconstrictores y albúmina. Tipo 2: Estable. Mediana de

More information

1. Utility of transradial approach in endovascular management of chronic mesenteric ischemia

1. Utility of transradial approach in endovascular management of chronic mesenteric ischemia PUBLICATIONS, ABSTRACTS AND PRESENTATIONS : 1. Utility of transradial approach in endovascular management of chronic mesenteric ischemia 2. Endovascular management of the suprarenal IVC agenesis 3. The

More information

Nurse Practitioner Outcomes: The Integration & Future Directions of The Liver Transplant NP. Amanda Tinning MN NP October 13, 2011

Nurse Practitioner Outcomes: The Integration & Future Directions of The Liver Transplant NP. Amanda Tinning MN NP October 13, 2011 Nurse Practitioner Outcomes: The Integration & Future Directions of The Liver Transplant NP Amanda Tinning MN NP October 13, 2011 Overview Define clinical outcomes Discuss the contributions of the NP role

More information