Aparna Goel

All Publications

• Liver Simulated Allocation Modeling: Were the Predictions Accurate for Share 35? Transplantation Goel, A., Kim, W. R., Pyke, J., Schladt, D. P., Kasiske, B. L., Snyder, J. J., Lake, J. R., Israni, A. K. 2018

  Abstract

  The liver simulated allocation model (LSAM) can be used to study likely effects of liver transplant allocation policy changes on organ offers, acceptance, waitlist survival, and posttransplant survival. Implementation of Share 35 in June 2013 allowed for testing how well LSAM predicted actual changes.LSAM projections for 1 year of liver transplants before and after the Share 35 policy change were compared with observed data during the same period. Numbers of organs recovered, organ sharing, transplant rates, and waitlist mortality rates (per 100 waitlist years) were evaluated by LSAM and compared with observed data.Candidate, recipient, and donor characteristics in the LSAM cohorts were similar to those in the observed population before and after Share 35. LSAM correctly predicted more accepted organs and fewer discarded organs with Share 35. LSAM also predicted increased regional and national sharing, consistent with observed data, although the magnitude was overestimated. Transplant rates were correctly projected to increase and waitlist death rates to decrease.Although the absolute number of transplants was underestimated and waitlist deaths overestimated, the direction of change was consistent with observed data. LSAM correctly predicted change in discarded organs, regional and national sharing, waitlist mortality, and transplants after Share 35 implementation.

  View details for PubMedID 29309379

• Natural History of Primary Biliary Cholangitis in the Ursodeoxycholic Acid Era: Role of Scoring Systems. Clinics in liver disease Goel, A., Kim, W. R. 2018; 22 (3): 563–78

  Abstract

  Primary biliary cholangitis (PBC) is a chronic disease that progresses to end-stage liver disease. Ursodeoxycholic acid (UDCA), the standard treatment for PBC for several decades, is associated with improved survival without liver transplantation. Approximately 40% of patients do not respond to UDCA. Because of disease variability, several prognostic models exist that incorporate various factors including biochemical response to UDCA. Useful for patient care and counseling as well as risk stratification for research and clinical trials, the role of these models in the pre-UDCA and UDCA eras is discussed.

  View details for PubMedID 30259853

• Systematic review with meta-analysis: rifaximin for the prophylaxis of spontaneous bacterial peritonitis. Alimentary pharmacology & therapeutics Goel, A., Rahim, U., Nguyen, L. H., Stave, C., Nguyen, M. H. 2017

  Abstract

  The primary and secondary prevention of spontaneous bacterial peritonitis (SBP) is recommended in high-risk patients with cirrhosis. Several studies evaluating the efficacy of rifaximin for SBP prophylaxis have yielded conflicting results. Rifaximin has the potential advantage of preventing bacterial overgrowth and translocation without the systemic side effects of broad-spectrum antibiotics.To evaluate the efficacy of rifaximin in the primary and secondary prevention of SBP.A literature search using five databases was performed to identify studies on the association between rifaximin and SBP. We performed two meta-analyses: (1) rifaximin compared to systemic antibiotics and (2) rifaximin compared to no antibiotics. Random-effect modelling was conducted to determine overall pooled estimates and 95% confidence intervals (CIs).Five studies with 555 patients (295 rifaximin, 260 systemic antibiotics) compared rifaximin with systemic antibiotics. The pooled odds ratio (OR) for SBP was 0.45 (95% CI 0.16-1.27; P = .13) in patients receiving rifaximin and strengthened on sensitivity analysis (OR 0.38, 95% CI 0.19-0.76, P = .01). In the analysis comparing rifaximin with no antibiotics, there were five studies with 784 patients (186 rifaximin, 598 no antibiotics). The OR for SBP was 0.34 (95% CI 0.11-0.99; P < .05) in patients receiving rifaximin. In subgroup analysis, rifaximin reduced the risk of SBP by 47% compared to no antibiotics for primary prophylaxis and by 74% compared to systemic antibiotics for secondary prophylaxis.Rifaximin may be effective in preventing SBP in patients with cirrhosis and ascites compared to systemically absorbed antibiotics and compared to placebo.

  View details for PubMedID 28994123

• Timing of Hepatitis C Virus Treatment in Liver Transplant Candidates in the Era of Direct-acting Antiviral Agents. Journal of clinical and translational hepatology Cholankeril, G., Joseph-Talreja, M., Perumpail, B. J., Liu, A., Yoo, E. R., Ahmed, A., Goel, A. 2017; 5 (4): 363–67

  Abstract

  Chronic hepatitis C virus (HCV) infection remains the leading indication for liver transplantation (LT) in the United States. While most patients with chronic HCV infection remain asymptomatic, up to one-third develop progressive liver disease resulting in cirrhosis. LT is often the only curative treatment once significant hepatic decompensation develops. However, antiviral therapy for HCV infection has advanced markedly in the past 5 years with the discovery and approval of direct-acting antiviral agents. These new regimens are well tolerated, of short duration and highly effective, unlike the traditional treatment with pegylated-interferon and ribavirin. As achieving sustained virological response becomes increasingly attainable for a majority of HCV-infected patients, concerns have been raised regarding the optimal timing of treatment for HCV infection in the setting of end-stage liver disease and during the peri-transplant period. On one hand, HCV treatment may improve hepatic function and negate the need for LT in some, which is crucial given the scarcity of donor organs and mortality on the waiting list in certain regions. On the other hand, HCV treatment may result in lowering the priority for LT without improving quality of life, thereby delaying potentially curative LT surgery. This review evaluates the evidence supporting the use of direct-acting antiviral agents in the period before and following LT.

  View details for PubMedID 29226102

• A Real-World Evaluation of Repeat Paracentesis-guided Management of Spontaneous Bacterial Peritonitis. Journal of clinical gastroenterology Goel, A., Biewald, M., Huprikar, S., Schiano, T., Im, G. Y. 2016

  Abstract

  Spontaneous bacterial peritonitis (SBP) is a common infection in cirrhosis associated with high mortality. More than 20% of patients with SBP do not respond to initial antibiotics. Guidelines differ in recommendations to repeat paracentesis (retap) to confirm antibiotic efficacy. We aim to evaluate the effect of retap-guided management of SBP on antibiotic escalation and 30-day transplant-free survival.Retrospective cohort study of cirrhotic patients with SBP admitted to a single transplant center from 2010 to 2014. Patients were divided into 2 groups: retap-guided management versus no retap. Prevalence of initial antibiotic treatment failure, defined as <25% decrease in ascitic polymorphonuclear cells, and factors associated with treatment failure, antibiotic escalation and 30-day transplant-free survival were evaluated.Out of 210 patients, 146 (age 58, 74% male, mean model for end-stage liver disease score, 25) had retap and treatment failure was noted in 28 (22%). Gram-positive bacteria accounted for 44% of all positive cultures and third-generation cepahalosporin resistance was noted in 23%. Thirty-day transplant-free survival was 72% and 62% in retap and control groups, respectively (P=0.07). Treatment failure independently doubled the 30-day mortality rate (hazard ratio: 2.15, 1.03 to 4.50, P=0.04). After adjusting for age, model for end-stage liver disease and nosocomial infection, retap-guided management was not associated with improved survival (P=0.34).The prevalence of initial treatment failure is high (22%) in patients with SBP and doubles the 30-day mortality risk, supporting recommendations to retap all patients with SBP.

  View details for DOI 10.1097/MCG.0000000000000704

  View details for PubMedID 27661968

• A systematic model improves hepatitis C virus birth cohort screening in hospital-based primary care. Journal of viral hepatitis Goel, A., Sanchez, J., Paulino, L., Feuille, C., Arend, J., Shah, B., Dieterich, D., Perumalswami, P. V. 2016

  Abstract

  Despite national and local governing board recommendations in the United States of America to perform an HCV screening test in baby boomers, screening rates remain low. Our goal was to study the impact of an HCV screening and link to care program with patient navigation in two New York City primary care practices. This was a two-year prospective study of patients born between 1945-1965 ("baby boomers") with encounters at two primary care practices at the Mount Sinai Hospital between November 1, 2013 and November 30, 2015. Baseline HCV screening rates were collected for four months. A multifaceted intervention was sequentially implemented involving electronic alerts, housestaff education, data feedback and patient navigation. HCV screening rates and link to care, defined as attending an appointment with a viral hepatitis specialist, were compared before and after these interventions. There were 14,642 primary care baby boomer patients of which 4,419 (30.2%) were newly screened during the study. There was a significant increase in HCV screening rates from 55% to 75% (p<0.01) and the HCV seropositive rate was 3.3%. Factors associated with being HCV seropositive included older age (p<0.01), male sex (p<0.01), African American race (p<0.01) and receiving care in the housestaff practice (p<0.01). With patient navigation, 78 of 84 (93%) newly diagnosed HCV infected persons were referred to a specialist and 60 (77%) attended their first appointment. A structured, multifaceted HCV screening program using well-studied principles identifies a large number of undiagnosed baby boomers within hospital-based primary care and improves access to specialty providers in a timely manner. This article is protected by copyright. All rights reserved.

  View details for DOI 10.1111/jvh.12669

  View details for PubMedID 28039935

• Hepatic Artery and Biliary Complications in Liver Transplant Recipients Undergoing Pretransplant Transarterial Chemoembolization LIVER TRANSPLANTATION Goel, A., Mehta, N., Guy, J., Fidelman, N., Yao, F., Roberts, J., Terrault, N. 2014; 20 (10): 1221-1228

  Abstract

  Liver transplantation (LT) is the treatment of choice for patients with cirrhosis and hepatocellular carcinoma (HCC) not amenable to resection. Locoregional therapies for HCC are often used to reduce tumor burden, bridge patients to LT, and down-stage HCC so that patients are eligible for LT. We hypothesized that prior endovascular antitumor therapy may increase the risk of hepatic artery (HA) and biliary complications after LT. The aim of this study was to compare HA and biliary complications in LT recipients with HCC who received transarterial chemoembolization (TACE) before LT with complications in LT recipients with HCC who did not receive TACE before LT. This was a retrospective cohort study of HCC patients at two transplant centers. The prevalence of HA complications (HA thrombosis, stenosis, or pseudoaneurysm) and biliary complications (nonanastomotic stricture, bile leak, and diffuse injury) were compared between patients treated with or without TACE. There were 456 HCC patients with a median age of 61 years (77% were male, and 63% had hepatitis C virus), and 328 (72%) received TACE before LT. The overall prevalence of HA complications was 4.7% in the no-TACE group and 7.9% in the TACE group (P = 0.22). All HA stenosis complications (n = 14) occurred in the TACE group (P = 0.018 versus the no-TACE group). An older donor age and a lower albumin level significantly increased the odds of HA complications. There was a nonstatistically significant increased odds of HA complications in the TACE group versus the no-TACE group according to an adjusted analysis (odds ratio = 2.02, 95% confidence interval = 0.79-5.16, P = 0.14). The overall prevalence of biliary complications was 16.4% in the no-TACE group and 19.8% in the TACE group (P = 0.40). In conclusion, a lower pre-LT albumin level and an older donor age were significantly associated with higher odds of HA complications after LT. TACE was not associated with higher odds of overall HA complications but was associated with a higher prevalence of HA stenosis. Further studies are warranted to confirm the HA stenosis findings and elucidate the pathogenesis.

  View details for DOI 10.1002/lt.23945

  View details for Web of Science ID 000343012000010

  View details for PubMedID 25045002

• Practical strategies for pruritus management in the obeticholic acid-treated patient with PBC: proceedings from the 2018 expert panel. BMJ open gastroenterology Pate, J., Gutierrez, J. A., Frenette, C. T., Goel, A., Kumar, S., Manch, R. A., Mena, E. A., Pockros, P. J., Satapathy, S. K., Yimam, K. K., Gish, R. G. 2019; 6 (1): e000256

  Abstract

  Background and aims: This article provides expert guidance on the management of pruritus symptoms in patients receiving obeticholic acid (OCA) as treatment for primary biliary cholangitis (PBC). PBC is a chronic, autoimmune cholestatic liver disease that affects intrahepatic bile ducts. If not adequately treated, PBC can lead to cholestasis and end-stage liver disease, which may require transplant. Timely treatment is therefore vital to patient health. Pruritus is a common symptom in patients with PBC. Additionally, the use of OCA to treat PBC can contribute to increased pruritus severity in some patients, adding to patient discomfort, decreasing patient quality of life (QoL), and potentially affecting patient adherence to OCA treatment.Methods: In May 2018, a group of physician experts from the fields of gastroenterology, hepatology, and psychiatry met to discuss the management of pruritus in OCA-treated patients with PBC. Recognizing the importance of optimizing treatment for PBC, these experts developed recommendations for managing pruritus symptoms in the OCA-treated PBC patient based on their experience in clinical practice.Results: These recommendations include a comprehensive list of management strategies (including over-the-counter, prescription, and alternative therapies), guidance on titration of OCA to minimize pruritus severity, and an algorithm that outlines a practical approach to follow up with patients receiving OCA, to better assess and manage pruritus symptoms.Conclusions: Pruritus associated with OCA therapy is dose dependent and often manageable, and with the proper education and tools, most pruritus cases can be effectively managed to minimize treatment discontinuation.

  View details for PubMedID 30815273

• Early Liver Transplantation is a Viable Treatment Option in Severe Acute Alcoholic Hepatitis ALCOHOL AND ALCOHOLISM Puri, P., Cholankeril, G., Myint, T. Y., Goel, A., Sarin, S., Harper, A. M., Ahmed, A. 2018; 53 (6): 716–18

  Abstract

  Liver transplantation is lifesaving for patients with severe acute alcoholic hepatitis (SAH) with preliminary data demonstrating favorable early post-transplant outcomes. Using the United Network for Organ Sharing database, we demonstrate that liver transplantation for SAH in the USA has steadily increased and is associated with similar 1- and 3-year post-transplant survival as well as comparable 30-day waitlist mortality to acute liver failure due to drug-induced liver injury.

  View details for PubMedID 30099535

  View details for PubMedCentralID PMC6203122

• Clinical utility of ledipasvir/sofosbuvir in the treatment of adolescents and children with hepatitis C Adolescent Health, Medicine and Therapeutics Yang, C. H., Goel, A., Ahmed, A. 2018; 9: 103—110

  Abstract

  Chronic infection with hepatitis C virus (HCV) affects an estimated 0.1%-2% of the pediatric population in the United States. While the clinical course in young children is indolent, adolescents who contract HCV have a disease course similar to adults, with a 26-fold increased risk of chronic liver disease-associated mortality, hepatocellular carcinoma, and need for curative liver transplantation. Furthermore, adolescent patients are entering childbearing age and carry a risk of passing HCV to their offspring via vertical transmission. Pegylated-interferon (PEG-IFN) with ribavirin was previously the only treatment option for pediatric patients with chronic hepatitis C (CHC), but the high likelihood of adverse reactions and subcutaneous route of administration limited its use and efficacy. Recently, the direct-acting antivirals (DAAs) ledipasvir (LDV) and sofosbuvir (SOF) were approved for adolescents with CHC. This review discusses the natural history of CHC in pediatric patients, data supporting LDV/SOF in adolescents, and ongoing studies evaluating DAAs in pediatric patients.

  View details for DOI 10.2147/AHMT.S147896

  View details for PubMedCentralID PMC6071628

• Improved Post-Transplant Mortality After Share 35 for Liver Transplantation. Hepatology (Baltimore, Md.) Kwong, A. J., Goel, A., Mannalithara, A., Kim, W. R. 2017

  Abstract

  The Share 35 policy was implemented in June 2013 to improve equity in access to liver transplantation (LT) between patients with fulminant liver failure and those with cirrhosis and severe hepatic decompensation. The aim of this study was to assess post-LT outcomes after Share 35.Relevant donor, procurement, and recipient data were extracted from the OPTN/UNOS database. All adult deceased donor LT from January 1, 2010 to March 31, 2016 were included in the analysis. One-year patient survival before and after Share 35 was assessed by multivariable Cox proportional hazards analysis, with adjustment for variables known to affect graft survival.Of 34,975 adult LT recipients, 16,472 (47.1%) were transplanted after the implementation of Share 35, of whom 4,599 (27.9%) had a Model for End-Stage Liver Disease (MELD) ≥35. One-year patient survival improved from 83.9% to 88.4% after Share 35 (p<0.01) for patients with MELD ≥35. There was no significant impact on survival of patients with MELD <35 (p=0.69). Quality of donor organs, as measured by Donor Risk Index without the regional share component, improved for patients with MELD ≥35 (p<0.01) and worsened for patients with lower MELD (p<0.01). In multivariable Cox regression analysis, Share 35 was associated with improved one-year patient survival (hazard ratio 0.69, 95% confidence interval 0.60-0.80) in recipients with MELD ≥35.Share 35 has had a positive impact on survival after transplantation in patients with MELD ≥35, without a reciprocal detriment in patients with lower acuity. This was in part a result of a more favorable donor-recipient matching. This article is protected by copyright. All rights reserved.

  View details for DOI 10.1002/hep.29301

  View details for PubMedID 28586179

• The features of mucosa-associated microbiota in primary sclerosing cholangitis ALIMENTARY PHARMACOLOGY & THERAPEUTICS Torres, J., Bao, X., Goel, A., Colombel, J., Pekow, J., Jabri, B., Williams, K. M., Castillo, A., Odin, J. A., Meckel, K., Fasihuddin, F., Peter, I., Itzkowitz, S., Hu, J. 2016; 43 (7): 790-801

  Abstract

  Little is known about the role of the microbiome in primary sclerosing cholangitis.To explore the mucosa-associated microbiota in primary sclerosing cholangitis (PSC) patients across different locations in the gut, and to compare it with inflammatory bowel disease (IBD)-only patients and healthy controls.Biopsies from the terminal ileum, right colon, and left colon were collected from patients and healthy controls undergoing colonoscopy. Microbiota profiling using bacterial 16S rRNA sequencing was performed on all biopsies.Forty-four patients were recruited: 20 with PSC (19 with PSC-IBD and one with PSC-only), 15 with IBD-only and nine healthy controls. The overall microbiome profile was similar throughout different locations in the gut. No differences in the global microbiome profile were found. However, we observed significant PSC-associated enrichment in Barnesiellaceae at the family level, and in Blautia and an unidentified Barnesiellaceae at the genus level. At the operational taxa unit level, most shifts in PSC were observed in Clostridiales and Bacteroidales orders, with approximately 86% of shifts occurring within the former order.The overall microbiota profile was similar across multiple locations in the gut from the same individual regardless of disease status. In this study, the mucosa associated-microbiota of patients with primary sclerosing cholangitis was characterised by enrichment of Blautia and Barnesiellaceae and by major shifts in operational taxa units within Clostridiales order.

  View details for DOI 10.1111/apt.13552

  View details for Web of Science ID 000371742300004

  View details for PubMedID 26857969

• Early Liver Transplantation for Severe Alcoholic Hepatitis in the United StatesA Single-Center Experience AMERICAN JOURNAL OF TRANSPLANTATION Im, G. Y., Kim-Schluger, L., Shenoy, A., Schubert, E., Goel, A., Friedman, S. L., Florman, S., Schiano, T. D. 2016; 16 (3): 841-849

  Abstract

  Early liver transplantation (LT) in European centers reportedly improved survival in patients with severe alcoholic hepatitis (AH) not responding to medical therapy. Our aim was to determine if a strategy of early LT for severe AH could be applied successfully in the United States. We reviewed 111 patients with severe AH at our center from January 2012 to January 2015. The primary end point was mortality at 6 months or early LT, with a secondary end point of alcohol relapse after LT. Survival was compared between those receiving early LT and matched patients who did not. Using a process similar to the European trial, 94 patients with severe AH not responding to medical therapy were evaluated for early LT. Overall, 9 (9.6%) candidates with favorable psychosocial profiles underwent early LT, comprising 3% of all adult LT during the study period. The 6-month survival rate was higher among those receiving early LT compared with matched controls (89% vs 11%, p<0.001). Eight recipients are alive at a median of 735 days with 1 alcohol relapse. Early LT for severe AH can achieve excellent clinical outcomes with low impact on the donor pool and low rates of alcohol relapse in highly selected patients in the United States.

  View details for DOI 10.1111/ajt.13586

  View details for Web of Science ID 000371240500016

  View details for PubMedID 26710309

• An Atypical Cause of a Typical Symptom. Gastroenterology Menezes, A., Goel, A., Sam, G. 2016

  View details for DOI 10.1053/j.gastro.2016.06.019

  View details for PubMedID 27591422

• Reply: To PMID 25045002. Liver transplantation Goel, A., Terrault, N. 2015; 21 (3): 416-?

  View details for DOI 10.1002/lt.24066

  View details for PubMedID 25530165

• Identification of Liver Transplant Candidates With Hepatocellular Carcinoma and a Very Low Dropout Risk: Implications for the Current Organ Allocation Policy LIVER TRANSPLANTATION Mehta, N., Dodge, J. L., Goel, A., Roberts, J. P., Hirose, R., Yao, F. Y. 2013; 19 (12): 1343-1353

  Abstract

  It has been shown that patients with hepatocellular carcinoma (HCC) meeting the United Network for Organ Sharing T2 (Milan) criteria have an advantage in comparison with patients without HCC under the current organ allocation system for liver transplantation (LT). We hypothesized that within the T2 HCC group, there is a subgroup with a low risk of wait-list dropout that should not receive the same listing priority. This study evaluated 398 consecutive patients with T2 HCC listed for LT with a Model for End-Stage Liver Disease exception from March 2005 to January 2011 at our center. Competing risk (CR) regression was used to determine predictors of dropout. The probabilities of dropout due to tumor progression or death without LT according to the CR analysis were 9.4% at 6 months and 19.6% at 12 months. The median time from listing to LT was 8.8 months, and the median time from listing to dropout or death without LT was 7.2 months. Significant predictors of dropout or death without LT according to a multivariate CR regression included 1 tumor of 3.1 to 5 cm (versus 1 tumor of 3 cm or less), 2 or 3 tumors, a lack of a complete response to the first locoregional therapy (LRT), and a high alpha-fetoprotein (AFP) level after the first LRT. A subgroup (19.9%) that met certain criteria (1 tumor of 2 to 3 cm, a complete response after the first LRT, and an AFP level ≤ 20 ng/mL after the first LRT) had 1- and 2-year probabilities of dropout of 1.3% and 1.6%, respectively, whereas the probabilities were 21.6% and 26.5% for all other patients (P = 0.004). In conclusion, a combination of tumor characteristics and a complete response to the first LRT define a subgroup of patients with a very low risk of wait-list dropout who do not require the same listing priority. Our results may have important implications for the organ allocation policy for HCC.

  View details for DOI 10.1002/lt.23753

  View details for Web of Science ID 000327431600009

  View details for PubMedID 24285611

• The Housestaff Incentive Program improving the timeliness and quality of discharge summaries by engaging residents in quality improvement BMJ QUALITY & SAFETY Bischoff, K., Goel, A., Hollander, H., Ranji, S. R., Mourad, M. 2013; 22 (9): 768-774

  Abstract

  Quality improvement has become increasingly important in the practice of medicine; however, engaging residents in meaningful projects within the demanding training environment remains challenging.We conducted a year-long quality improvement project involving internal medicine residents at an academic medical centre. Resident champions designed and implemented a discharge summary improvement bundle, which employed an educational curriculum, an electronic discharge summary template, regular data feedback and a financial incentive. The timeliness and quality of discharge summaries were measured before and after the intervention. Residents and faculty were surveyed about their perceptions of the project; primary care providers were surveyed about their satisfaction with hospital provider communication.With implementation of the bundle, the average time from patient discharge to completion of the discharge summary fell from 3.5 to 0.61 days (p<0.001). The percentage of summaries completed on the day of discharge rose from 38% to 83% (p<0.001) and this improvement was sustained for 6 months following the end of the project. The percentage of summaries that included all recommended elements increased from 5% to 88% (p<0.001). Primary care providers reported a lower likelihood of discharge summaries being unavailable at the time of outpatient follow-up (38% to 4%, p<0.001). Residents reported that the systems changes, more than the financial incentive, accounted for their behaviour change.Our discharge summary improvement project provides an instructive example of how residents can lead clinically meaningful quality improvement projects.

  View details for DOI 10.1136/bmjqs-2012-001671

  View details for Web of Science ID 000329777400009

  View details for PubMedID 23704085