Expanded criteria for liver transplantation in patients with hepatocellular carcinoma

Liver transplantation (LT) is one of the few effective treatment options for hepatocellular carcinoma (HCC). Our aim in this study was to evaluate the risk factors for HCC recurrence and propose new criteria for LT based on pretransplantation findings. One hundred eighty patients who underwent LT for HCC between 2002 and 2008 were reviewed retrospectively. Outcome measures included maximal tumor size and number of tumors revealed by radiological studies before transplantation, demographics, and tumor recurrence. Maximal tumor size >6 cm, >7 tumors, and alpha-fetoprotein (AFP) levels >1000 ng/mL were identified as independent prognostic factors of HCC recurrence in univariate and multivariate analysis. Disease-free survival rate in patients with a maximal tumor size ≤6 cm, ≤7 tumors, and/or AFP levels ≤1000 ng/mL at 1, 3, and 5 years was 97.9%, 91.5%, and 90.0%, respectively, but the 1-, 3-, and 5-year disease-free survival rate of patients who had a maximal tumor size >6 cm, >7 tumors, and/or AFP levels >1000 ng/mL was 61.9%, 47.6%, and 47.6%, respectively (P < .001). In conclusion, LT can improve the survival of patients with advanced HCC if they have a maximal tumor size ≤6 cm, tumor number ≤7, and/or AFP levels ≤1000 ng/mL.

Analysis of predictors for lactate elimination after reperfusion in recipients of living-donor liver transplantation

BACKGROUND

Graft-recipient weight ratio (GRWR) is the only documented predictor that influences the lactate elimination after reperfusion in living-donor liver transplantation (LDLT). This study was performed to investigate the predictors of lactate elimination after reperfusion in recipients of adult LDLT.

METHODS

The medical records of 159 patients who underwent LDLT were analyzed. Lactate level (mmol/L) was measured from just before the initiation of surgery (P0) and 5, 60, and 120 minutes after reperfusion of graft (R0, R1, and R2, respectively). The change of lactate level after reperfusion was defined as difference between lactate level measured at R0 and R2. Patients were divided into accumulation and elimination groups. Donor and recipient factors were compared between the 2 groups.

RESULTS

Lactate accumulation occurred in 80 of 159 recipients (50.3%), and elimination occurred in 79 (49.7%). GRWR and Model for End-Stage Liver Disease (MELD) score were higher in the elimination group. Lactate at R0 was lower in the elimination group.

CONCLUSIONS

Higher GRWR and MELD score and lower lactate level immediate after reperfusion of graft were predictors of lactate elimination after reperfusion during adult LDLT.

Factors associated with consciousness recovery time after liver transplantation in recipients with hepatic encephalopathy

BACKGROUND

Hepatic encephalopathy (HE) occurs as a result of liver failure and is often considered to be a clinical indication for liver transplantation (LT). An assessment of post-transplantation consciousness level in recipients with HE is crucial, because recovery of consciousness implies reestablishment of transplant liver function and lack of perioperative brain damage. The purpose of this study is to evaluate factors associated with consciousness recovery time after LT in recipients with HE.

METHODS

Out of 633 adult recipients who underwent LT, recipients who exhibited HE at the time of LT were analyzed retrospectively. The time between graft reperfusion and postoperative consciousness recovery was determined, and recipients were divided into 2 groups: group E with recovery of consciousness early (≤48 hours), and group L with recovery of consciousness late (>48 hours). Analyzed variables included recipient sex, age, graft type, Model for End-Stage Liver Disease score, HE history/duration/type/grade, and preoperative laboratory values, including blood ammonia concentration.

RESULTS

HE was present at the time of LT in 69 (10.9%) of 633 recipients. Among the 69 recipients, 11 recipients who died or underwent reoperation before consciousness recovery were excluded, and 58 recipients (group E: n = 32; group L: n = 26) were enrolled into analysis. Multivariate analysis showed that HE duration >5 days (odds ratio [OR], 15.58; 95% confidence interval [CI], 1.35-179.56; P = .028) and HE type C (OR, 30.90; 95% CI, 1.67-573.48; P = .021) were the independent factors associated with late recovery from HE after LT.

CONCLUSIONS

We suggest that recipients with long-duration or type C HE should be carefully managed during the post-transplantation period to prevent deterioration of HE.

Higher serum uric acid as a protective factor against incident osteoporotic fractures in Korean men: a longitudinal study using the National Claim Registry

In this large longitudinal study of 16,078 Korean men aged 50 years or older, we observed that baseline elevation of serum uric acid level significantly associated with a lower risk of incident fractures at osteoporosis-related sites during an average follow-up period of 3 years.

INTRODUCTION

Male osteoporosis and related fractures are becoming recognized as important public health concerns. Oxidative stress has detrimental effects on bone metabolism, and serum uric acid (UA) is known to be a strong endogenous antioxidant. In the present study, we performed a large longitudinal study with an average follow-up period of 3 years to clarify the role of UA on the risk of incident osteoporotic fractures (OFs).

METHODS

A total of 16,078 Korean men aged 50 years or older who had undergone comprehensive routine health examinations were enrolled. Incident fractures at osteoporosis-related sites (e.g., hip, spine, distal radius, and proximal humerus) that occurred after the baseline examinations were identified from the nationwide claims database of the Health Insurance Review and Assessment Service of Korea by using selected International Classification of Diseases, 10th revision codes.

RESULTS

In total, 158 (1.0 %) men developed incident OFs. The event rate was 33.1 per 10,000 person-years. Subjects without incident OFs had 6.0 % higher serum UA levels than subjects with OFs (P = 0.001). Multivariable-adjusted Cox proportional hazard analyses adjusted for age, body mass index, glomerular filtration rate, lifestyle factors, medical and drug histories, and the presence of baseline radiological vertebral fractures revealed that the hazard ratio per standard deviation increase of baseline UA levels for the development of incident OFs was 0.829 (95 % CI = 0.695-0.989, P = 0.038).

CONCLUSIONS

These data provide the epidemiological evidence that serum UA may act as a protective factor against the development of incident OFs in Korean men.

The comparisons of hepatitis C virus RNA level between intraoperative blood salvage (cell saver) and systemic hepatitis C virus RNA kinetics during liver transplantation

BACKGROUND

Cell Saver (CS; Haemonemic Corp, Braintree, Mass, United States) is frequently used to decrease transfusion requirements of homologous blood during liver transplantation (OLT). However, the use of CS in hepatitis C virus (HCV)-infected recipients is still debated owing to the potential elevation of HCV RNA level. In this study, we compared HCV RNA levels of CS blood with a series of blood samples obtained from HCV-infected OLT recipients.

METHODS

Twelve HCV-infected patients with >50,000 copies/mL of HCV RNA were enrolled. HCV RNA was measured immediately after induction (I), at the end of anhepatic period (II), at the end of operation (III), and from the first returned blood in CS (CSb). HCV RNA level at each time period was compared.

RESULTS

HCV RNA levels ranged from 77,931 to 9,072,000 copies/mL at I. When compared to I, HCV RNA levels were reduced to 11.1% ± 13.0% and 0.7% ± 1.0% at II and III, respectively. Also, the RNA level reduced to 3.0% ± 2.0% of I after CS processing. The HCV RNA level at I was significantly higher than the levels at II, III, and CSb (P = .012, each), and the level at II was significantly higher than the level at III (P = .012). The HCV RNA level at CSb showed no statistical difference with the levels at II, but it was significantly higher than the level at III (P = .042).

CONCLUSIONS

The use of CS in HCV-infected OLT recipients seems to carry no additional risk with respect to intraoperative HCV RNA kinetics.

The comparison of femoral and radial arterial blood pressures during pediatric liver transplantation

BACKGROUND

Orthotopic liver transplantation (OLT) is frequently associated with dramatic hemodynamic changes; thus, it is critical to accurately monitor blood pressure. Although comparisons between femoral arterial blood pressure (FABP) and radial arterial blood pressure (RABP) have been reported in adult liver recipients, we compared FABP with RABP in pediatric recipients.

METHODS

Thirty-five pediatric liver recipients younger than 13 years of age were included in this prospective, observational study. We measured simultaneous FABP and RABP in the femoral and radial arteries at nine time points during the procedure, including: baseline (after anesthetic induction); 1 hour thereafter; 30 minutes after the beginning of the anhepatic period as well as 0, 1, 3, 5, 15, and 60 minutes after graft reperfusion.

RESULTS

Of the 35 pediatric liver recipients, 2 infants and 1 13-month-old child were excluded from the analysis because of radial arterial catheter malfunction. The remaining 32 patients including 16 infants and 16 children all showed significantly higher systolic and mean FABP than RABP during most stages of pediatric OLT. Overall diastolic FABP measurements were similar to diastolic RABP throughout the study.

CONCLUSIONS

Systolic and mean FABP were significantly higher than RABP during most stages of pediatric OLT. Radial arterial catheter malfunctions were not uncommon during pediatric OLT. Our results indicated that it is useful to cannulate the femoral artery to accurately and reliably measure arterial blood pressure to detect hemodynamic instability during pediatric OLT.

Comparison of mixed venous oxygen saturation after in vitro calibration of pulmonary artery catheter with that of pulmonary arterial blood in patients undergoing living donor liver transplantation

INTRODUCTION

Mixed venous saturation (SvO2) reflects the balance between oxygen delivery and consumption throughout the body. A multifunction pulmonary artery catheter (PAC) can monitor continuous SvO2 after in vitro calibration (CSvO2), obviating the need for in vivo calibration with pulmonary arterial blood. In critically ill patients CSvO2 has shown a good correlation with measured SvO2 of pulmonary arterial blood using co-oximetry (MSvO2). The aim of this study was to compare CSvO2 and MSvO2 in liver transplantation (OLT) recipients.

METHODS

We enrolled 44 OLT recipients for comparison with 24 coronary artery bypass graft (CABG) controls free of end-stage liver disease. After anesthetic induction, the PAC was inserted after in vitro calibration and CSvO2 and MSvO2 simultaneously measured. In OLT recipients, additional measurements of CSvO2 and MSvO2 were performed at anhepatic and postreperfusion phases. Pearson's correlation analysis was used to evaluate the correlation between the 2 measurements. A Bland-Altman analysis was used to determine precision of and bias between the 2 measurements. With ±3% regarded to be interchangeable.

RESULTS

Cardiac output and intrapulmonary shunt in CABG patients were lower than among OLT recipients. OLT recipients, showed a significant correlation between CSvO2 and MSvO2, but the coefficients were different during the three phases of OLT (r = 0.597, 0.753, and 0.756). In addition, bias values between the two measurements were 6.0%, 6.4%, and 2.9% for the preanhepatic, anhepatic, and postreperfusion phases, respectively, with 29.5%, 31.8%, and 50% of them being interchangeable. In contrast CABG patients showed bias in -0.17% with 75% of measurements interchangeable.

CONCLUSION

While in vitro calibration of the PAC can be used in CABG patients, MSvO2 is higher than CSvO2 in OLT recipients. Therefore, in vivo calibration with pulmonary arterial blood is necessary for accurate monitoring of SvO2 in OLT recipients.

Vecuronium requirements according to the operative phase during living donor liver transplantation under desflurane anesthesia

INTRODUCTION

The requirements of nondepolarizing neuromuscular blocking agent during liver transplantation show conflicting results. We sought to evaluate the requirements according to the operative phase and find extrahepatic factors that influence neuromuscular blocking agent requirements.

METHODS

We enrolled 35 patients undergoing living donor liver transplantation. Continuous infusion of vecuronium was adjusted every 15 minutes for consistent neuromuscular blockade aimed at T1/Tc of 0.10 monitored with a neuromuscular transmission module. We compared the mean infusion dose in each phase, and investigated whether it is correlated with preoperative Model for End-Stage Liver Disease (MELD) score, Child-Turcotte-Pugh (CTP) score, graft-recipient weight ratio (GRWR), or time to recovery of first twitch response to train-of-four (TOF) stimulation.

RESULTS

There was a significant difference between vecuronium doses during each phase (P < .001): 0.48 ± 0.16 μg/kg/min, preanhepatic; 0.38 ± 0.14 μg/kg/min, anhepatic and 0.26 ± 0.07 μg/kg/min, neohepatic phase. There was a significant positive correlation between vecuronium infusion dose in the preanhepatic phase and CTP scores (P = .006, correlation coefficient = 0.465). There was also a significant negative correlation between the time to recovery of first twitch response of TOF stimulation and vecuronium infusion dose in the preanhepatic phase (P = .001, correlation coefficient = -0.546). The infusion dose during the preanhepatic phase was not associated with the MELD score, and that of neohapatic phase not with GRWR.

CONCLUSIONS

The vecuronium infusion dose requirement during the anhepatic decreased compared with that in the preanhepatic phase. It further decreased during the neohepatic phase compared with the previous phases. Vecuronium infusion dose reduction is suggested especially during the neohepatic phase for early extubation. The dose during the preanhepatic phase is suggested to be determined considering the CTP score and the time to recovery of the TOF response.

Higher serum uric acid is associated with higher bone mass, lower bone turnover, and lower prevalence of vertebral fracture in healthy postmenopausal women

Higher serum uric acid (UA) was associated with higher bone mass, lower bone turnover, and lower prevalence of vertebral fracture in postmenopausal women. Furthermore, UA suppressed osteoclastogenesis and decreased production of reactive oxygen species in osteoclast precursors, indicating UA may have beneficial effects on bone metabolism as an antioxidant.

INTRODUCTION

UA is known to play a physiological role as an antioxidant, and oxidative stress has detrimental effects on bone metabolism. In the present study, we investigated the association of serum UA level with the osteoporosis-related phenotypes and its direct effect on bone-resorbing osteoclasts using in vitro systems.

METHODS

This is a large cross-sectional study, including 7,502 healthy postmenopausal women. Bone mineral density (BMD) and serum UA concentrations were obtained from all subjects. Data on bone turnover markers and lateral thoracolumbar radiographs were available for 1,023 and 6,918 subjects, respectively. An in vitro study investigated osteoclastogenesis and reactive oxygen species (ROS) levels according to UA treatment.

RESULTS

After adjusting for multiple confounders, serum UA levels were positively associated with BMD at all sites (all p < 0.001). Compared with the participants in the highest UA quartile, the odds for osteoporosis were 40 % higher in those in the lowest quartile. The serum UA levels were inversely related to both serum C-terminal telopeptide of type I collagen and osteocalcin levels (p < 0.001 and p = 0.004, respectively). Consistently, subjects with vertebral fracture had lower serum UA levels, compared with those without it (p = 0.009). An in vitro study showed that UA decreased osteoclastogenesis in a dose-dependent manner and reduced the production of ROS in osteoclast precursors.

CONCLUSION

These results provide epidemiological and experimental evidence that serum UA may have a beneficial effect on bone metabolism as an antioxidant in postmenopausal women.

Afamin stimulates osteoclastogenesis and bone resorption via Gi-coupled receptor and Ca2+/calmodulin-dependent protein kinase (CaMK) pathways

BACKGROUND

Afamin was recently identified as a novel osteoclast-derived coupling factor that can stimulate the in vitro and in vivo migration of preosteoblasts.

AIM

In order to understand in more detail the biological roles of afamin in bone metabolism, we investigated its effects on osteoclastic differentiation and bone resorption.

METHODS

Osteoclasts were differentiated from mouse bone marrow cells. Tartrate-resistant acid phosphatase (TRAP)-positive multinucleated cells were considered as osteoclasts, and the resorption area was determined by incubating the cells on dentine discs. The intracellular cAMP level was determined using a direct enzyme immunoassay. Signaling pathways were investigated using western blot and RT-PCR. Recombinant afamin was administered exogenously to bone cell cultures.

RESULTS

Afamin stimulated both osteoclastogenesis and in vitro bone resorption. Consistently, the expressions of osteoclast differentiation markers were significantly increased by afamin. Although afamin mainly affected the late-differentiation stages of osteoclastogenesis, the expression levels of receptor activator of nuclear factor-κB ligand (RANKL)-dependent signals were not changed. Afamin markedly decreased the levels of intracellular cAMP with reversal by pretreatment with pertussis toxin (PTX), a specific inhibitor of Gi-coupled receptor signaling. In addition, PTX almost completely blocked afamin-stimulated osteoclastogenesis. Furthermore, pretreatment with KN93 and STO609 - Ca2+/cal - mo dulin-dependent protein kinase (CaMK) and CaMK kinase inhibitors, respectively - significantly prevented decreases in the intracellular cAMP level by afamin while attenuating afamin-stimulated osteoclastogenesis.

CONCLUSION

Afamin enhances osteoclastogenesis by decreasing intracellular cAMP levels via Gi-coupled receptor and CaMK pathways.

Liver transplantation in lymphoma patients with hepatitis B virus reactivation

BACKGROUND

Acute-on-chronic liver failure (AoCLF) occurs in lymphoma patients because of hepatitis B virus (HBV) reactivation. We aimed to identify characteristics of patients who underwent liver transplantation (OLT) because of AoCLF that occurred due to HBV reactivation in the setting of lymphoma and to compare these patients with AoCLF patients who did not have lymphoma.

METHODS

Twenty patients underwent OLT due to AoCLF between February 2009 and June 2011. Among these patients, five were diagnosed with lymphoma before OLT and assigned to group 1. The remaining patients (n = 15) were assigned to group 2.

RESULTS

Hospitalization after transplantation in group 2 was longer than in group 1 (P = .014). However, there were no differences in other variables between the two groups. The overall survival rate of group 1 was lower than that of group 2, but there was no difference between the two groups (P = .134). With the exception of one patient, the median time from complete remission to liver transplantation in group 1 was 4.5 months (range, 1-15) in group 1. Lymphoma recurrence occurred in one patient 8 months after transplantation.

CONCLUSION

Our study revealed that OLT is a feasible and effective approach in AoCLF due to HBV reactivation in select lymphoma patients.

The association between higher serum ferritin level and lower bone mineral density is prominent in women ≥45 years of age (KNHANES 2008-2010)

SUMMARY

Data gathered from a nationally representative cohort demonstrate that higher serum ferritin levels are significantly associated with lower bone mass at various skeletal sites and the increased prevalence of osteoporosis and fractures, especially in women ≥45 years of age.

INTRODUCTION

Despite extensive in vitro and in vivo studies showing the detrimental effects of iron on bone metabolism, the clinical studies relating to osteoporosis-related phenotypes have not been evaluated extensively. In the present study, we investigated and compared the association between serum ferritin and bone mineral density (BMD), depending on the stratified age groups in both genders.

METHODS

This is a population-based, cross-sectional study from the Korea National Health and Nutrition Examination Surveys, including 14,017 Koreans (6,817 men and 7,200 women) aged 10-80 years. BMD was measured using dual X-ray absorptiometry, and osteoporosis was diagnosed by the World Health Organization definition.

RESULTS

Initially, we divided the subjects into three age groups, based on the patterns of age-related BMD changes in this national cohort (i.e., ≤24, 25-44, and ≥45 years old). Serum ferritin concentrations were inversely associated with BMD values at all measured sites after adjustment for confounders, only in women ≥45 years of age (P = 0.041 to <0.001). Furthermore, when we divided these women into serum ferritin quartiles, the odds for prevalent osteoporosis and fractures were 1.55-fold (95 % CI = 1.09-2.23) and 1.52-fold (95 % CI = 1.02-2.27) higher, respectively, in subjects in the highest quartile compared with those in the lowest quartile.

CONCLUSIONS

These results provide the first clinical evidence that the associations between serum ferritin level and bone parameters could be the most prominent in women ≥45 years of age.

Association between metabolic syndrome and bone loss at various skeletal sites in postmenopausal women: a 3-year retrospective longitudinal study

Although the presence of metabolic syndrome (MetS) and increasing numbers of MetS components were associated with attenuated bone loss at various skeletal sites in postmenopausal women, this beneficial effect of MetS on bone mass can be mainly explained by higher mechanical loading in the affected subjects.

INTRODUCTION

Previous cross-sectional epidemiological studies reported the inconsistent results regarding the combined effects of MetS on bone mass. In our present report, we performed a large, longitudinal study to evaluate MetS in relation to annualized bone mineral density (BMD) changes in postmenopausal Korean women.

METHODS

The study cohort consisted of 1,218 postmenopausal women who had undergone comprehensive routine health examinations with an average follow-up interval of 3 years. The BMD at the lumbar spine and proximal femur sites was measured with dual-energy X-ray absorptiometry using the same equipment at baseline and at follow-up.

RESULTS

Following adjustment for age, baseline BMD, and lifestyle factors, the women with MetS had 21.7, 17.0, 26.7, and 31.1 % less bone loss at the total femur, femur neck, trochanter, and lumbar spine, respectively, compared with MetS-free women (P = 0.004 to 0.041). Consistently, the rates of bone loss at all skeletal sites were linearly attenuated with increasing numbers of MetS components (P = 0.004 to <0.001). Importantly, when weight and height were added as confounding factors, the differences and trends of annualized BMD changes according to the MetS status disappeared.

CONCLUSION

Our current results indicate that the beneficial effects of MetS on bone mass can be mainly explained by higher mechanical loading in the affected subjects. Consequently, MetS per se may not be a meaningful concept for predicting future bone loss and for explaining associations between osteoporosis and cardiovascular diseases.

Arthroscopic shoulder surgery under general anesthesia with brachial plexus block: postoperative respiratory dysfunction of combined obstructive and restrictive pathology

OBJECTIVE

Changes in respiratory parameters and pulmonary function tests were evaluated after shoulder arthroscopic surgery with brachial plexus block (BPB). The purpose of this study was to identify the mechanism of respiratory dysfunction after this type of surgery.

METHODS

Patients undergoing arthroscopic rotator cuff repair under general anesthesia (GA) with BPB were enrolled in the arthroscopy group (n = 30) while those undergoing open reduction of a clavicle or humerus fracture under GA were enrolled in the control group (n = 30). Forced vital capacity (FVC) and forced expiratory volume 1 s (FEV(1)) were measured at the outpatient clinic stage (#1) before (#2) and 20 min after BPB (#3) and 1 h after extubation (#4). Respiratory variable measurements along with the cuff leak test were performed 5 min after surgical positioning (T1) and at the start of skin closure (T2). Respiratory discomfort was evaluated after extubation. The upper airway diameters and soft tissue depth of chest wall were also measured by ultrasonography at stages #3 and #4.

RESULTS

Static compliance decreased significantly at T2 in the arthroscopy group (50 ± 11 at T1 vs. 44 ± 9 ml/cm H(2)O at T2, p =0.035) but not in the control group. The incidence of positive cuff leak tests at T2 was significantly higher in the arthroscopy group than in the control group (47% in the arthroscopy group vs. 17% in controls, p =0.010). While FEV(1) and FVC remained stable at stages #1 and #2, FVC and FEV(1) decreased at stages #3 and #4 only in the arthroscopy group (FVC in arthroscopy group, #2: 3.26 ± 0.77 l; #3: 2.55 ± 0.63 l, p =0.015 vs. #2; #4: 2.66 ± 0.41 l, p =0.040 vs. #2). The subglottic diameter decreased at #4 in the arthroscopy group, while no changes occurred in the control group (0.70 ± 0.21 cm vs. 0.85 ± 0.23 cm in the arthroscopy and control groups, respectively, p =0.011). Depth of skin to pleura increased at both intercostal spaces 1-2 and 3-4 in the arthroscopy group. There were three cases of hypoxia (S(p)O(2) < 95%) with room air in the arthroscopy group while none occurred in the controls.

CONCLUSION

Shoulder arthroscopic surgery under GA with BPB induced both restrictive and obstructive pathologies. It is important to maintain a high level of awareness for the potential negative respiratory effects of this surgery especially for subjects with pre-existing cardiopulmonary disease. The measurements in this study would be useful to monitor the risk of respiratory dysfunction in these patients.

Effectiveness of locoregional therapy before living donor liver transplantation in patients with hepatocellular carcinoma who meet the Milan criteria

BACKGROUND

Many patients are diagnosed with hepatocellular carcinoma (HCC) within the Milan criteria. In Korea, these patients are preferentially treated with locoregional therapy (LRT) instead of living donor liver transplantation. We investigated the effectiveness of LRT in liver transplant recipients who met the Milan criteria at the time of HCC diagnosis and investigated risk factors for HCC recurrence.

METHODS

We retrospectively reviewed the medical records of patients diagnosed with HCC who met the Milan criteria between 2002 and 2008.

RESULTS

We performed 101 liver transplants for HCC during the study period. Seventy-one patients (70%) underwent pretransplant LRT. The disease-free survival rates at 1, 3, and 5 years in patients who received LRT were 96.6%, 93.1%, and 93.1%, and in those who did not receive LRT, 94.2%, 83.4%, and 83.4%, respectively. There were no differences between the 2 groups. Multivariate analysis showed that a low Model for End-Stage Liver Disease (MELD) score and microvascular invasion were independent predictors of HCC recurrence after transplantation. The MELD scores and rate of microvascular invasion were not statistically different in patients with or without previous LRT.

CONCLUSION

Pretransplant LRT for patients with HCC who met the Milan criteria at the time of diagnosis did not provide a clear benefit with respect to HCC recurrence after transplantation. If patients have suitable living donors, those who meet the Milan criteria should undergo a liver transplantation as soon as possible.

The relationship between postoperative intravenous patient-controlled fentanyl analgesic requirements and severity of liver disease

PURPOSE

Decreased inhalational anesthetic requirements during orthotopic liver transplantation (OLT) have been reported according to the severity of the pre-existent disease as well as decreased opioid requirements thereafter. The aim of the present study was to determine the relationship between postoperative opioid requirements and severity of liver disease among OLT patients.

METHODS

We retrospectively reviewed 44 recipients who used intravenous fentanyl-based patient-controlled analgesia (PCA) after OLT from November 2009 to May 2010. The severity of liver disease was assessed using the model for end-stage liver disease (MELD) score. Recipients were divided into a low-MELD group (<20; n=30) and a high-MELD group (≥20; n=14). The amounts of PCA infusion and rescue opioid up to 3 postoperative days (POD) were compared between the 2 groups. The intensity of pain at rest and when coughing was assessed using visual analog scale (VAS) scores.

RESULTS

The cumulative opioid requirements via PCA on POD 1, 2, and 3 were significantly lower in the high-MELD than the low-MELD group. The amounts of rescue opioid were similar between the 2 groups. However, the intensity of pain at both rest and when coughing on POD 1, 2, and 3 were significantly less severe in the high-MELD than the low-MELD group.

CONCLUSIONS

OLT patients with high MELD scores required less postoperative opioids and experienced less pain than those with low scores. Therefore, postoperative pain control after OLT should be carefully titrated according to the severity of the liver disease.

Which score system can best predict recipient outcomes after living donor liver transplantation?

INTRODUCTION

Many scoring systems have been suggested to predict the outcomes of deceased donor liver transplantations. The aims of this study were to compare the Model for End-Stage Liver Disease (MELD) score with respect to other scores among patients who underwent living donor liver transplantation (LDLT) seeking to evaluate the best system to correlate with postoperative outcomes after LDLT.

METHODS

We analyzed retrospectively data from 202 adult patients who underwent LDLT from January 2008 to July 2010. We calculated preoperative MELD, MELD-sodium, MELD to serum sodium ratio (MESO), integrated MELD, United Kingdom MELD, Child-Turcotte-Pugh, Acute Physiology and Chronic Health evaluation II (APACHE II), and Sequential Organ Failure Assessment (SOFA) scores in all patients. We analyzed the correlation of each score with postoperative laboratory results, as well as survival at 1, 3, 6 and 12 months after LDLT.

RESULTS

There was significant positive correlation between all scores and peak total bilirubin during the first 7 days after LDLT. The MELD score showed the greatest correlation with peak total bilirubin (r=0.745). APACHE II and SOFA scores at 6 months and 1 year after LDLT and MESO score at 1 year after LDLT showed acceptable discrimination performance {area under the receiver operating characteristic curves (AUC)>0.7, while other scoring systems showed poor discrimination. However, the AUCs of each score were not significantly different from the MELD score AUC.

CONCLUSION

The MELD score most correlated with total bilirubin after LDLT, while the APACHE II and SOFA scores seemed to correlate with mortality after LDLT.

Hormonal differences between female kidney transplant recipients and healthy women with the same gynecologic conditions

BACKGROUND

End-stage renal disease is associated with severe abnormalities in reproductive function. However, the abnormalities are reversed by successful kidney transplantation. The aim of the present study was to compare hormonal levels between recipients with successful kidney transplantations and healthy women with the same gynecologic conditions.

METHODS

The study group consisted of 31 women of reproductive age with end-stage renal disease who underwent successful kidney transplantation. The ratio of the control group, composed of healthy woman, to the study group was 3:1 matched for age and symptoms.

RESULTS

Abnormal bleeding (n = 14) and infertility were the most common gynecologic conditions in kidney transplant recipients. The levels of estrogen (E2) and follicle-stimulating hormone (FSH) in the study group were higher than in the control group, but the levels of progesterone (P4) and luteinizing hormone (LH) were lower in the study group than in the control group. There were no significant differences in prolactin and thyroid-stimulating hormone between the two groups. The incidence of infertility in patients who receive steroid was higher than those with no steroid use (P = .007).

CONCLUSIONS

Compared with healthy age- and symptom-matched women, female kidney transplant recipients have increased levels of E2 and FSH and decreased levels of P4 and LH. These differences in hormone profiles may predispose kidney transplant recipients to increased risk of gynecologic pathologies.

Comparison between thymoglobulin and ATGAM as an induction agent in adult kidney transplantation: a single-center experience

OBJECTIVE

The best antithymocyte globulin (ATG) preparation for induction suppression in kidney transplant recipients is still not clear. The aim of this study was to identify short- and long-term outcomes in kidney transplant recipients who received thymoglobulin or ATGAM as an induction agent.

METHODS

We retrospectively reviewed patients who underwent kidney transplantation from 1996 to 2010. Recipients were classified according to the ATG preparation.

RESULTS

One hundred fifty-two patients (64.4%) received thymoglobulin and 84 (35.6%) received ATGAM. The occurrence of delayed graft function in patients receiving thymoglobulin was higher than in patients receiving ATGAM (P = .005), but serum creatinine levels and acute rejection after kidney transplantation were not different between the two groups. The death-censored graft survival curve in thymoglobulin recipients was higher than in ATGAM recipients (P = .027). Bacterial infection was a predisposing factor for graft survival (P = .008).

CONCLUSION

The efficacy of thymoglobulin induction is generally better than that of ATGAM induction, and prevention of bacterial infections was just as important as the use of ATG because bacterial infection was an important risk factor for graft failure.

Long-term treatment with raloxifene, but not bisphosphonates, reduces circulating sclerostin levels in postmenopausal women

We determined whether suppression of sclerostin levels by estrogen treatment was mediated by anti-resorptive effect. Raloxifene, but not bisphosphonates, suppressed circulating sclerostin concentration, suggesting that sclerostin may mediate the action of estrogen on bone metabolism, independently of their anti-resorptive effects.

INTRODUCTION

Circulating sclerostin concentrations are higher in postmenopausal than in premenopausal women, and estrogen treatment suppresses sclerostin levels in both men and women. We determined whether anti-resorptives may suppress the circulating sclerostin levels.

METHODS

We conducted a retrospective observational study. Eighty postmenopausal women were treated with raloxifene for 19.4 ± 7.7 months (n = 16), bisphosphonates for 19.2 ± 6.7 months (n = 32), or were untreated (n = 32) for 17.1 ± 4.6 months. Plasma sclerostin concentrations were measured before and after treatment.

RESULTS

Plasma sclerostin levels after treatment were significantly lower in the raloxifene than in the control group (55.8 ± 23.4 pmol/l vs. 92.1 ± 50.4 pmol/l, p = 0.046), but were similar between the bisphosphonate and control groups. Relative to baseline, raloxifene treatment markedly reduced plasma sclerostin concentration (-40.7 ± 22.8%, p < 0.001), with respect to both control (-7.5 ± 29.1%) and bisphosphonate (-3.1 ± 35.2%) groups. Changes in bone-specific alkaline phosphatase and osteocalcin levels showed reverse associations with sclerostin concentration changes in the raloxifene (γ = -0.505, p = 0.017) and control (γ = -0.410, p = 0.020) groups.

CONCLUSIONS

Raloxifene, but not bisphosphonates, significantly suppressed circulating sclerostin concentration, suggesting that sclerostin may mediate the action of estrogen on bone metabolism, independently of their anti-resorptive effects.

The association between serum osteocalcin levels and metabolic syndrome in Koreans

The association between serum osteocalcin levels and metabolic syndrome (MS) in Korean individuals was investigated. Serum osteocalcin levels are significantly lower in subjects with MS than in those without the disease, regardless of glucose metabolism.

INTRODUCTION

Osteocalcin was recently shown to affect energy metabolism. In the present study, we investigated the possible association between serum osteocalcin concentrations and MS.

METHODS

A cross-sectional community-based survey was conducted. Serum osteocalcin, type 1 collagen C-telopeptide (CTX) and total alkaline phosphatase (ALP) concentrations were determined in 567 subjects. MS was defined according to NCEP-ATP III criteria.

RESULTS

Serum osteocalcin concentrations were significantly lower in subjects with MS than those without MS in postmenopausal women (18.923 ± 7.685 vs 22.513 ± 7.344 ng/ml, P<0.001) and marginally lower in subjects with MS than those without MS in men (14.550 ± 5.090 vs 16.125 ± 4.749 ng/ml, P=0.086) after adjustment for age and BMI. Further controlling with CTX or ALP did not affect this association in postmenopausal women; however, controlling with osteocalcin abolished the association between CTX and MS. Significant differences in serum osteocalcin levels by MS status were noted in subjects with normal glucose tolerance as well as those with abnormal glucose tolerance (P=0.032 and P<0.001, respectively). Compared with subjects with the highest quartile of osteocalcin, those in the lower quartile groups (Q1-Q3) had significantly increased risks of MS (ORs=5.18, CIs=1.15-23.42) in men. In postmenopausal women, the ORs for MS were significantly higher in the lowest quartile than in the highest quartile (ORs=5.25, CIs=2.42-11.36).

CONCLUSIONS

These findings suggest that osteocalcin is associated with MS, independently of glucose metabolism.

Association of SMAD2 polymorphisms with bone mineral density in postmenopausal Korean women

In a candidate gene association study, we found that SMAD2 promoter alleles and haplotypes were significantly associated with bone mineral density (BMD) at the lumbar spine and various proximal femur sites. Our results suggest that SMAD2 polymorphisms may be one of genetic determinants of BMD in postmenopausal women.

INTRODUCTION

SMAD2, which is the specific intracellular transducer of TGF-ß, is thought to participate in bone metabolism by playing a critical role in the development and function of osteoclasts and osteoblasts. We performed association analyses of the genetic variation in SMAD2 to ascertain the contribution of this gene to BMD and risk of osteoporotic fracture.

METHODS

We selected three SMAD2 promoter single-nucleotide polymorphisms (SNPs) based on heterozygosity and validation status. Postmenopausal Korean women (n = 1,329) were genotyped for these SNPs, and their BMD and risk of fractures were assessed. BMD at the lumbar spine and proximal femur was measured using dual-energy X-ray absorptiometry. P values were corrected for multiple testing by the effective number of independent marker loci (P (cor)).

RESULTS

We found that SMAD2 -35302C>T, -34952A>G, and ht2 were significantly associated with BMD at both the lumbar spine and femur neck (P (cor) = 0.020-0.046), whereas SMAD2 -36201A>G and ht1 affected the femur neck BMD (P (cor) = 0.018-0.031). The genetic effects of these three polymorphisms on BMD at the lumbar spine and femur neck were risk-allele dependent in additive model. The three polymorphisms and two hts were also significantly associated with BMD at other proximal femur sites, such as the total femur, trochanter, and femur shaft (P (cor) = 0.001-0.046). However, none of the polymorphisms or hts was associated with an increased risk of fracture.

CONCLUSIONS

Our results suggest that SMAD2 polymorphisms may be one of genetic determinants of BMD in postmenopausal women.

Predictors of high intraoperative blood loss derived by simple and objective method in adult living donor liver transplantation

We conducted a risk factor analysis for high intraoperative blood loss (IBL) in 555 living donor liver transplantation (LDLT) cases with a simple and objective method of IBL estimation based on the concept of red cell mass (RCM): Lost RCM (mL) = patient's estimated blood volume (mL) × (preoperative hematocrit in % - postoperative hematocrit in %) + (transfused leukocyte-depleted red blood cell in units × 213 × 70%) + (transfused Cell Saver blood in mL × 55%). Analysis of 33 preoperative variables revealed that Model for End-stage Liver Disease (MELD) score, albumin, the presence of ascites, and previous abdominal surgery were correlated with high IBL (lost RCM > 1000 mL) in multivariate logistical regression analysis. In conclusion, we found that MELD score, albumin, the presence of ascites, and previous abdominal surgery were significantly correlated with high IBL during adult LDLT.

Efficacy and safety of bazedoxifene in postmenopausal Asian women

This 6-month study examined the efficacy and safety of bazedoxifene 20 mg in postmenopausal Asian women. Bazedoxifene showed statistically significant improvements over placebo in bone mineral density at all skeletal sites evaluated. Bazedoxifene significantly reduced bone turnover and had favorable effects on lipid parameters. Bazedoxifene was safe and well tolerated.

INTRODUCTION

This 6-month, randomized, double-blind, placebo-controlled phase 3 study conducted in China, Korea, and Taiwan evaluated the efficacy and safety of bazedoxifene in postmenopausal Asian women.

METHODS

Generally, healthy postmenopausal Asian women (N=487; mean age, 57.2 years; mean lumbar spine bone mineral density [BMD], -1.1) were randomized to daily therapy with bazedoxifene 20 mg or placebo; all subjects received daily supplemental calcium carbonate 600 mg. The changes from baseline in BMD at the lumbar spine (primary end point) and at other skeletal sites, bone turnover markers, and lipid parameters were evaluated at 6 months. Safety assessments included adverse event (AE) reporting and physical/gynecologic examination.

RESULTS

At 6 months, women who received bazedoxifene 20 mg had significantly greater BMD compared with those receiving placebo at the lumbar spine (0.41% vs -0.32%, P<0.01), femoral neck (-0.08% vs -0.69%, P=0.014), trochanter (0.50% vs -0.23%, P=0.010), and total hip (-0.03% vs -0.77%, P<0.001), respectively. Bazedoxifene 20 mg was also associated with significant differences from placebo in median percent reductions from baseline in serum C-telopeptide (-21.8%, P<0.001) and osteocalcin (-12.9%, P<0.001) levels and total (-5.0%, P<0.001) and low-density lipoprotein cholesterol (-9.5%, P<0.001) levels. The incidence of AEs was not different between subjects treated with bazedoxifene and those who received placebo.

CONCLUSION

Bazedoxifene was generally safe and effective in preventing bone loss in this short-term study of postmenopausal Asian women.