Identification of a postoperative survival scoring index for adult liver transplantation

BACKGROUND

In addition to surgical technology, successful liver transplantation (LT) depends on perioperative management, which needs an effective prognostic index. Therefore, a simplified and sensitive postoperative index for adult LT should be developed.

METHODS

In total, 906 patients who underwent LT were included in this cross-sectional study. Univariate analysis was used to identify the independent risk factors for recipient survival. Multivariate logistic and stepwise regression analyses were used to construct and simplify the model design. Area under the curve (AUC) and Kaplan-Meier's (K-M) analysis demonstrated superiority of the new index. The postoperative survival score (POSS) index was further simplified via restricted cubic spline (RCS) analysis. Finally, the interpretation of the long-term mortality and subgroup analyses extended the application of the POSS index.

RESULTS

Finally, a total of five factors (donor sex, recipient body mass index (BMI), total bilirubin (Tbil), international normalized ratio (INR) and total operative time) were identified as independent risk parameters and included in our POSS index. The AUCs of the original and simplified POSS indices were 0.764 and 0.723, respectively. Patients with high scores had poor short-term survival. Our index also functioned well in predicting long-term mortality, and it was more effective for patients with hepatitis B cirrhosis or hepatocellular carcinoma (HCC).

CONCLUSIONS

We constructed a simplified and effective postoperative survival scoring index to predict short-term complications and survival in adult LT patients.

Risk factors for hepatocellular carcinoma: an umbrella review of systematic review and meta-analysis

BACKGROUND

Numerous meta-analyses have identified various risk factors for hepatocellular carcinoma (HCC), prompting a comprehensive study to synthesize evidence quality and strength.

METHODS

This umbrella review of meta-analyses was conducted throughout PubMed, EMBASE, Web of Science, and Cochrane Database of Systematic Reviews. Evidence strength was evaluated according to the evidence categories criteria.

RESULTS

We identified 101 risk factors throughout 175 meta-analyses. 31 risk factors were classified as evidence levels of class I, II, or III. HBV and HCV infections increase HCC risk by 12.5-fold and 11.2-fold, respectively. These risks are moderated by antiviral treatments and virological responses but are exacerbated by higher HBsAg levels, anti-HBc positivity, and co-infection. Smoking, obesity, non-alcoholic fatty liver disease, diabetes, low platelet, elevated liver enzymes and liver fluke infection increase HCC risk, while coffee consumption, a healthy diet, and bariatric surgery lower it. Medications like metformin, glucagon-like peptide-1 receptor agonists (GLP-1 RAs), aspirin, statins, and selective serotonin reuptake inhibitors reduce HCC risk, while acid suppressive agents, particularly proton pump inhibitors, elevate it. Blood type O reduces the risk of HCC, while male gender and older age increase the risk.

CONCLUSIONS

HBV and HCV are major HCC risk factors, with risk mitigation through antiviral treatments. Lifestyle habits such as smoking and alcohol use significantly increase HCC risk, highlighting the importance of cessation. Certain drugs like aspirin, statins, GLP-1 RAs, and metformin may reduce HCC occurrence, but further research is needed to confirm these effects.

Urinary Basigin/CD147 is a useful marker of acute T cell-mediated rejection in kidney transplant recipients

BACKGROUND

Acute T cell-mediated rejection (ATCMR) is a severe negative outcome of kidney transplantation; however, it currently has no reliable marker in Japan.

METHODS

This cross-sectional study was conducted at the Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital from 2016 to 2018 to determine whether plasma or urinary Basigin/CD147 is an effective marker of ATCMR. Plasma and urinary samples were obtained when episode graft biopsies were performed.

RESULTS

Forty-six kidney transplant recipients received graft biopsies. Three of them missed plasma and urinary samples and three in ATCMR were on postrejection treatment. Graft biopsy results revealed ATCMR in 12 of them, calcineurin inhibitor nephrotoxicity (CIN) in nine, chronic active antibody-mediated rejection (CAAMR) in nine, BK nephropathy, recurrence IgA nephropathy, necrotic glomerulonephritis, and infection-related glomerulonephritis in one each, and other complications in six. The urinary Basigin/CD147 levels of patients in the ATCMR group [759.4 (490.0, 843.0)] pg/gCre were significantly higher than the levels of patients in the CAAMR [247.0 (157.1, 288.8)] and CIN groups [379.1 (264.7, 456.7)] pg/gCre (p < 0.001). No statistical difference in plasma Basigin/CD147 levels was observed between those groups. At a urinary Basigin/CD147 of 631.5 µg/gCre, 75% sensitivity and 84% specificity with an area under the curve of 0.80 were attained for the diagnosis of graft rejection.

CONCLUSION

Urinary Basigin/CD147 may be a potential marker for ATCMR in kidney transplant recipients. Further studies will be needed to clarify the effectiveness of Basigin/CD147.

Prognostic Value of Inflammatory Markers in HBV-Related HCC After Hepatectomy Based on a Clinical Database

OBJECTIVE

Hepatitis B virus (HBV) remains an important risk factor for hepatocellular carcinoma (HCC), and inflammation plays an essential role in tumor development. This study aimed to investigate the impact of inflammatory markers in the postoperative outcomes of patients with HBV-related HCC, providing valuable prognostic indicators after hepatectomy.

METHODS

We retrospectively analyzed 222 patients with HBV-related HCC after surgical resection. The ROC curve was used to calculate biomarker cutoff values. The Kaplan-Meier method was used to estimate overall survival (OS) and recurrence-free survival (RFS), and univariate and multivariate analyses were used to identify the prognostic factors.

RESULTS

The Kaplan-Meier analysis revealed that patients with high albumin-bilirubin (ALBI) score, aspartate aminotransferase to platelet ratio index (APRI), and monocyte to lymphocyte ratio (MLR) had worse OS, while those with high ALBI score and MLR had shorter RFS. Multivariate Cox regression analysis identified alpha-fetoprotein >400 ng/mL (hazard ratio [HR]: 2.447, 95% confidence interval [CI]: 1.273-4.706, p = 0.007), alanine aminotransferase (HR: 0.377, 95% CI: 0.171-0.834, p = 0.016), platelet to lymphocyte ratio (HR: 0.385, 95% CI: 0.196-0.755, p = 0.006), systemic inflammatory response index (HR: 1.844, 95% CI: 1.049-3.239, p = 0.033), ALBI score (HR: 1.808, 95% CI: 1.020-3.203, p = 0.043), APRI score (HR: 3.193, 95% CI: 1.662-6.137, p < 0.001), tumor diameter (HR: 1.083, 95% CI: 1.012-1.160, p = 0.022), and portal vein tumor thrombosis (PVTT) (HR: 6.083, 95% CI: 2.774-13.338, p < 0.0001) as independent predictors for OS. MLR (HR: 2.285, 95% CI: 1.290-4.048, p = 0.005) and PVTT (HR: 2.672, 95% CI: 1.280-5.579, p = 0.009) were confirmed as significant prognostic markers of RFS in patients with HBV-related HCC.

CONCLUSIONS

ALBI score, APRI, and MLR are effective prognostic predictors in patients with HBV-related HCC after curative resection. Close monitoring and adjuvant therapies should be considered for high-risk patients.

Incidence, screening, and management of de novo malignancies in liver transplant patients: A review

Liver transplantation (LT) is the definitive treatment for end-stage liver disease, acute liver failure, and liver cancer. Although advancements in surgical techniques, postoperative care, and immunosuppressive therapies have significantly improved outcomes, the long-term use of immunosuppression has increased the risk of complications, including infections, cardiovascular disease, and cancer. Among these, de novo malignancies (DNMs) are a major concern, accounting for 20%-25% of deaths in LT recipients surviving beyond the early post-transplant period. Non-melanoma skin cancers, particularly squamous cell carcinoma are the most prevalent DNMs. Other significant malignancies include Kaposi's sarcoma, post-transplant lymphoproliferative disorders, and various solid organ cancers, including head and neck cancers. Compared to the general population, LT patients face a twofold increase in solid organ malignancies and a 30-fold increase in lymphoproliferative disorders. Risk factors for DNM include chronic immunosuppression, alcohol or tobacco use, viral infections, and underlying liver disease. Emerging evidence emphasizes the importance of tailored cancer screening and prevention strategies, including regular dermatological examinations, targeted screenings for high-risk cancers, and patient education on lifestyle modifications. Early detection through enhanced surveillance protocols has been shown to improve outcomes. Management of DNMs involves a combination of standard oncological therapies and adjustments to immunosuppressive regimens, with promising results from the use of mTOR inhibitors in select patients. The review highlights the critical need for ongoing research to refine risk stratification, optimize screening protocols, and improve treatment approaches to mitigate the burden of DNMs in LT recipients. By implementing personalized preventive and therapeutic strategies, we can enhance long-term outcomes and quality of life for this vulnerable population.

Infantile Onset Budd Chiari Syndrome: Challenges and Outcome of Liver Transplantation After Radiological Interventions

Introduction

Budd-Chiari syndrome (BCS) in infants is rare, and there is limited published literature on liver transplantation (LT).

Methods

Eight children who underwent LT for BCS from 2017 to 2023 were analyzed.

Results

Seven out of the eight children had radiological intervention (RI) prior to LT (3 had transjugular intrahepatic portosystemic shunt [TIPSS], and 4 had hepatic vein venoplasty). Hepatopulmonary syndrome (HPS) was seen post-TIPSS in 3 and postvenoplasty in 2 children, respectively. The indication for LT was refractory ascites or recurrent upper gastrointestinal bleed in 3 patients, HPS in 5 patients, respectively. The median age and weight of children at transplant was 51 months (IQR 26-82 months) and 11.35 kg (IQR 10.05-18 kg), respectively. The median duration from onset of symptoms to LT was 42 months (IQR 18.5-75 months). HPS resolved in the 4 patients alive, after a median period of 25 days (IQR 15.5-60 days). The median duration of post-transplant follow-up is 4 years 9 months (IQR 3 year 5 months-4 years 11 months). Vascular complications were seen in 37.5% patients which were amenable to RI. Biliary complications were seen in 25% of children. The 1-year and 3-year survival rates both were 75%.

Conclusion

BCS in infants can be managed effectively with RI followed by LT. LT has shown good long-term outcomes in children with BCS. HPS seems to be common after TIPSS in pediatric BCS. Recurrent BCS post-LT can be salvaged using RI. High biliary and vascular complications are likely related to HPS and previous TIPSS/RI.

Sorafenib resistance and therapeutic strategies in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) remains one of the most prevalent and lethal cancers globally. While surgical resection and liver transplantation offer potential cures for early-stage HCC, the majority of patients are diagnosed at advanced stages where such interventions are not viable. Sorafenib, a multi-target kinase inhibitor, has been a cornerstone in the treatment of advanced HCC since its approval in 2007. Despite its significant clinical impact, less than half of the treated patients derive long-term benefits due to the emergence of resistance and associated side effects. This review focuses on the role of sorafenib, an FDA-approved multi-target kinase inhibitor, in treating advanced HCC, discusses the mechanisms underlying its therapeutic effects and associated resistance, and explores additional therapeutic strategies being investigated to improve patient outcomes.

Predictors of Non-response to Atezolizumab Plus Bevacizumab in Patients With Unresectable Hepatocellular Carcinoma: A Multicentre Real World Study (HCC-AB Study)

Background

The approved immunotherapies for patients with advanced HCC are Atezolizumab and Bevacizumab. However, patients in India present late and healthcare is often available through self-financing. To rationalise the therapy, we conducted a large multicentre study to identify the baseline predictors of non-response to atezolizumab and bevacizumab in advanced unresectable HCC.

Methods

A dose of atezolizumab 1200 mg and bevacizumab 15 mg/kg was used every 3 weeks from 6 centres across India. A total of 278 patients were screened, and 160 were included in the study. The study included patients with locally advanced metastatic or inoperable hepatocellular carcinoma who were at least 18 years of age and those who received <3 injections were excluded. Fifty-four percent of the included patients were BCLC-B and 46% were BCLC-C. The primary objective was to study overall survival and progression-free survival. While identifying radiological response, objective response rate and adverse effects were secondary objectives.

Results

The mean age was 61.9 ± 11.7 years, 88% were male, 55% had NASH, 16.3% had hepatitis C, 18.8% had hepatitis B and the rest were alcohol. The mean Model for End-Stage Liver Disease (MELD) is 12.05 ± 4.46, Albumin-Bilirubin Score (ALBI) is -2.04 ± 0.57. Fifty-five percent received first-line and 45% as second/other line therapy. The median overall survival was 10 (95% confidence interval [CI]: 6.1-15.6) months. Progression-free survival was found to be 8 (95%CI: 5.1-14.7) months overall. Eleven (6.9%) achieved complete response, 28 (17.5%) partial response, 33 (20.6%) had stable disease and 88 (55%) had progressive disease. On multivariate analysis, CRP>1 mg/dl (P-0.007), PIVKA-II>400 mAU/mL (P-0.019), AFP>100 ng/ml (P-0.009), presence of diabetes (P-0.042) were associated with non-response to atezolizumab and bevacizumab injection. Fifty-three percent of patients developed any grade of adverse effect, and 20% developed grade 3/4 adverse events amounting to the stoppage of therapy.

Conclusion

Non-response to atezolizumab and bevacizumab immunotherapy was predicted by CRP>1 mg/dl, PIVKA-II>400mAU/ml, AFP>100 ng/ml and the presence of diabetes.

Magnesium Deficiency: The Insidious Executor of the Liver Disease

Magnesium (Mg), which is predominantly present in cells as a micronutrient, is involved in numerous vital physiological processes, such as DNA repair and energy metabolism. Mg deficiency has been reported to contribute toward the advent and progression of a variety of liver diseases; in particular, these two pathological entities may synergistically act. Given the significant impact and increasing burden of liver diseases on global healthcare resources and economic expenditure, it is tempting to manage Mg insufficiency as novel promising therapeutic strategies. In this review, we comprehensively elaborate on the complicated relationship between Mg deficiency and several contextual liver diseases, with concentrating on the underlying molecular mechanisms.

Model of End-Stage Liver Disease-alpha-fetoprotein-tumor burden (MELD-AFP-TBS) score to stratify prognosis after liver resection for hepatocellular carcinoma

INTRODUCTION

Morphologic criteria, such as the Barcelona Clinic Liver Cancer staging system often fail to accurately predict long-term survival among patients undergoing liver resection for hepatocellular carcinoma. We sought to develop a continuous risk score that incorporates established markers of tumor biology and liver function to improve the prediction of overall survival.

METHODS

Data from a multi-institutional database were used to identify patients who underwent curative-intent hepatectomy for hepatocellular carcinoma. A predictive score for overall survival was developed using weighted beta-coefficients from a multivariable Cox regression model.

RESULTS

Among 850 patients, 595 (70.0%) were assigned to the training cohort, and 255 (30.0%) to the test cohort. In the training cohort, multivariable analysis identified the Model of End-Stage Liver Disease (hazard ratio, 1.04; 95% confidence interval, 1.01-1.07), log-transformed alpha-fetoprotein (hazard ratio, 1.07; 95% confidence interval, 1.02-1.13), and tumor burden score (hazard ratio, 1.07; 95% confidence interval, 1.03-1.11) as independent predictors of worse overall survival. The Model of End-Stage Liver Disease-alpha-fetoprotein-tumor burden score, based on the Cox model, stratified patients into low-risk (n = 466, 78.3%) with a 5-year OS of 70.5% and high-risk (n = 129, 21.7%) with a 5-year OS of 47.0% (P < .001). In the test cohort, the Model of End-Stage Liver Disease-alpha-fetoprotein-tumor burden score demonstrated superior discriminative accuracy (C-index: 0.72, time-dependent area under the curve 1-year: 0.80, 3-year 0.76, 5-year 0.70) compared with the Barcelona Clinic Liver Cancer staging system (C-index: 0.53, time-dependent area under the curve 1-year: 0.61, 3-year 0.55, 5-year 0.56). An online tool was made accessible at https://jk-osu.shinyapps.io/MELD_AFP_TBS/.

CONCLUSION

The Model of End-Stage Liver Disease-alpha-fetoprotein-tumor burden score provides a novel, accurate tool for prognostic stratification of patients with hepatocellular carcinoma, identifying high-risk patients who may benefit from alternative treatments to improve outcomes.

Haemoadsorption cartridge connected to the machine perfusion for donation after circulatory death porcine liver marginal grafts

BACKGROUND

Marginal donation after circulatory death (DCD) liver grafts are carefully used to combat the constant shortage of donors. Clinically, the worst outcomes are mainly related to severe ischemia-reperfusion-injury and the dangerous effect of various inflammatory cytokines (CK). The machine perfusion (MP) is a promising device to rescue these grafts.

AIM

To analyze the role of MP connected to a sorbent cartridge (PerSorb^®) and used for very damaged DCD pig livers.

METHODS

Seven grafts were procured from pigs from a slaughterhouse. Grafts were made very marginal with at least 60 minutes of donor warm ischemia time and 24 hours of static-cold ischemia time: (1) 3 grafts were perfused in hypothermic MP with PerSorb (Sorb); (2) 2 other grafts in hypothermic MP (HMP) without the cartridge (NoSorb); and (3) The other 2 livers stored in the ice box (NoTreat). The CK were measured at HMP start (T0) and at the end (Tend). Biopsies were taken at T0 and Tend.

RESULTS

All 5 grafts treated with HMP had a negative lactate trend after 3 hours of treatment (8.83 at T0 vs 6.4 at Tend of Sorb; 15 at T0 vs 5.45 at Tend for NoSorb, P value > 0.05). At Tend, both Sorb and NoSorb groups had better hemodynamic parameters, comparable between the two groups. Enzyme-linked immunosorbent assay analysis showed a reduction of monocyte chemotactic protein-1, tumor necrosis factor-alpha and interleukin-1β for NoSorb group at Tend and a complete downregulation to physiological levels of the same CK in Sorb livers after 3 hours of treatment. Biopsies showed a reduction of the perisinusoidal edema for the Sorb grafts compared with the NoSorb livers.

CONCLUSION

These data suggest a potential protective role of treatment of grafts with MP and sorbent cartridge in reducing the inflammatory response after a severe ischemic injury.

Artificial intelligence in gastrointestinal surgery: A minireview of predictive models and clinical applications

BACKGROUND

Artificial intelligence (AI) is playing an increasingly significant role in predicting outcomes of gastrointestinal (GI) surgeries, improving preoperative risk assessment and post-surgical decision-making. AI models, particularly those based on machine learning, have demonstrated potential in predicting surgical complications and recovery trajectories.

AIM

To evaluate the role of AI in predicting outcomes for GI surgeries, focusing on its efficacy in enhancing surgical planning, predicting complications, and optimizing post-operative care.

METHODS

A systematic review of studies published up to March 2025 was conducted across databases such as PubMed, Scopus, and Web of Science. Studies were included if they utilized AI models for predicting surgical outcomes, including morbidity, mortality, and recovery. Data were extracted on the AI techniques, performance metrics, and clinical applicability.

RESULTS

Machine learning models demonstrated significantly better performance than logistic regression models, with an area under the curve difference of 0.07 (95%CI: 0.04–0.09; P < 0.001). Models focusing on variables such as patient demographics, nutritional status, and surgical specifics have shown improved accuracy. AI’s ability to integrate multifaceted data sources, such as imaging and genomics, contributes to its superior predictive power. AI has improved the early detection of gastric cancer, achieving 95% sensitivity in real-world settings.

CONCLUSION

AI has the potential to transform GI surgical practices by offering more accurate and personalized predictions of surgical outcomes. However, challenges related to data quality, model transparency, and clinical integration remain.

Safety and efficacy of simultaneous liver transplantation and sleeve gastrectomy in morbid obese patients with end-stage liver disease: The LT-SG study

In obese patients, metabolic dysfunction-associated steatotic liver disease is becoming a leading etiology of end-stage liver disease and HCC. Simultaneous liver transplantation and sleeve gastrectomy (LT-SG) have been proposed in the United States, but the safety and efficacy of the procedure have not been widely explored in Europe. Between January 2016 and December 2022, morbidly obese patients listed for liver transplantation at Tor Vergata University were enrolled in the LT-SG study. Primary outcomes were (1) safety expressed as 30- and 90-day overall survival and (2) major postoperative complications (Clavien-Dindo >IIIa). The secondary outcome was efficacy expressed as a 3-year %excess body mass index (BMI) loss. Eleven patients were enrolled in the study. The median BMI at transplantation was 42 (IQR 38-48). Indications of LT-SG were HCC (63.6%) and cirrhosis (36.4%). In 54% of cases, donors had high-risk characteristics (eurotransplant donor risk index >1.6). The 30- and 90-day overall survival were 63.6% and 54.5%, respectively. All deaths occurred in patients with P-SOFT >15 or in patients who had at least 3 of the following characteristics: >60 years, BMI >45, metabolic syndrome, MELD >25 or eurotransplant donor risk index >1.6. The 6 months, 1, 2, and 3 years %excess BMI loss was 73%, 60%, 50%, and 43%, respectively. LT-SG is a complex procedure that may carry excess risk in an unselected population. It should be considered only in highly selected patients. Standard donors are recommended, and prioritization of severely obese patients on the waiting list should be considered.

Development and validation of a new prognostic tool for hepatocellular carcinoma undergoing resection: The Weighted Alpha-Fetoprotein Tumor Burden Score (WATS)

PURPOSE

This study aimed to develop and validate a novel prognostic index, the Weighted Alpha-Fetoprotein Tumor Burden Score (WATS), for predicting outcomes in hepatocellular carcinoma (HCC) patients undergoing resection.

MATERIALS AND METHODS

A total of 772 resected HCC patients were included. WATS was developed and validated using an 8:2 cohort split. The score was derived from multivariate Cox regression, resulting in the formula: WATS = 0.73 × tumor number +0.17 × tumor size +0.1 × ln AFP. The time-dependent ROC curve assessed the score's predictive ability, while restricted cubic splines evaluated the dose-response relationship between WATS and prognostic outcomes. Kaplan-Meier curves and multivariate Cox regression further validated the prognostic accuracy.

RESULTS

In the training cohort, AUCs for progression-free survival (PFS) at 1, 2, 3, 4, and 5 years were 0.683, 0.664, 0.661, 0.633, and 0.620, respectively; for overall survival (OS), they were 0.757, 0.732, 0.703, 0.672, and 0.670, respectively. In the validation cohort, AUCs for PFS were 0.711, 0.654, 0.671, 0.662, and 0.684, respectively; for OS, they were 0.724, 0.688, 0.642, 0.698, and 0.721, respectively. WATS outperformed other complex indicators and staging systems. RCS analysis showed a linear relationship between WATS and outcomes. The nomogram based on WATS demonstrated excellent discrimination, calibration, and clinical benefit.

CONCLUSION

WATS is a novel, reliable prognostic tool for HCC post-resection, offering enhanced patient stratification and risk assessment, thereby improving clinical management.

A novel nomogram based on machine learning predicting overall survival for hepatocellular carcinoma patients with dynamic α‑fetoprotein level changes after local resection

The principal aim of the present study was to develop and validate a nomogram predicting overall survival (OS) in patients with α-fetoprotein (AFP)-negative hepatocellular carcinoma (AFP-NHCC) who experience dynamic changes in AFP level after hepatectomy. A cohort of 870 patients were enrolled and randomly assigned into a training cohort (n=600) and a validation cohort (n=270) at a 7:3 ratio. The key variables contributing to the nomogram were determined through random survival forest analysis and multivariate Cox regression. The discriminative ability of the nomogram was evaluated using time-dependent receiver operating characteristic curves and the area under the curves. Furthermore, the nomogram was comprehensively assessed using the concordance index (C-index), calibration curves and clinical decision curve analysis (DCA). Kaplan-Meier (KM) curves analysis was employed to discern survival rates across diverse risk strata of patients. Ultimately, the nomogram incorporated critical factors including sex, tumor size, globulin levels, gamma-glutamyl transferase and fibrinogen levels. In the training and validation cohorts, the C-indexes were 0.72 [95% confidence interval (CI): 0.685-0.755) and 0.664 (95% CI: 0.611-0.717], respectively, attesting to its predictive validity. The nomogram demonstrated excellent calibration and DCA further confirmed its clinical usefulness. Additionally, KM curve analysis unveiled statistically significant differences in OS among three distinct risk groups. In conclusion, the present study successfully formulated a nomogram predicting 3-, 5- and 8-year OS in patients with AFP-NHCC with dynamic changes in AFP level post-local resection. This model serves as a valuable tool for clinicians to promptly identify high-risk patients, thereby facilitating timely interventions and potentially enhancing patient survival outcomes.

Low Incidence of Rejection and De Novo Donor-Specific Antibody Formation Following COVID-19 Vaccination or Infection Among Pediatric Kidney Transplant Recipients

BACKGROUND

Studies in adults have demonstrated a risk for allograft rejection or development of donor-specific antibodies (DSA) following SARS-CoV-2 vaccination. We examined the incidence of acute rejection and de novo DSA following COVID-19 vaccination or infection among pediatric kidney transplant patients.

METHOD

Retrospective analysis of 23 pediatric kidney transplant recipients without prior history of rejection, DSA, or COVID-19 infection who received the SARS-CoV-2 mRNA vaccine. Risk for rejection was evaluated via monitoring of serum creatinine, DSA, and donor-derived cell-free DNA per center protocol. Results concerning for rejection prompted allograft biopsy, graded by the Banff classification system.

RESULTS

Eight of 23 (34.8%) received two doses of SARS-CoV-2 mRNA vaccine, 15 (65.3%) received three doses. Two (8.7%) had rejection; one with de novo DSA, another without. There was no difference in the number of doses of COVID-19 vaccine received in those with rejection vs. no rejection (p = 0.53). 13 (56.5%) developed SARS-CoV-2 infection, with no difference in the number of vaccines received between those infected with COVID-19 vs. those who were not (p = 0.69). No adjustments were made to the maintenance immunosuppression during SARS-CoV-2 infection, and there was no evidence of rejection or DSA formation after infection. Median follow-up time was 29.9 months (IQR 25.0-33.4 months) after the first vaccine dose.

CONCLUSION

In our small single-center cohort, SARS-CoV-2 vaccination or infection is unlikely to increase the risk for rejection or de novo DSA in pediatric kidney transplant recipients. Larger prospective studies with a control group are needed to further understand the immune effects of the COVID-19 vaccine and disease in this population.

The liver allocation landscape: MELD 3.0 and continuous distribution

PURPOSE OF REVIEW

This review highlights recent advancements in liver organ allocation, specifically the transition to MELD 3.0 and the potential introduction of continuous distribution. These developments are timely, as they address the increasing need for a more efficient, equitable, and personalized system for prioritizing liver transplant candidates.

RECENT FINDINGS

The review covers two key innovations: MELD 3.0: A refined version of the original MELD score, designed to improve the prioritization process by incorporating additional factors that offer a more accurate and urgent measure of transplant need. This approach aims to better assess the severity of liver disease and the need for transplantation. Continuous distribution: A dynamic approach that shifts away from the static allocation model. It integrates multiple donor and recipient variables - such as geographic location, organ quality, and recipient condition - into a continuous, flexible allocation process. This framework seeks to make more nuanced decisions based on a broader set of factors that reflect transplant suitability.

SUMMARY

These innovations aim to enhance fairness and patient outcomes by refining candidate prioritization and reducing disparities in access to transplants. However, implementing these systems presents challenges, such as technical complexities and regional differences in access. Ongoing evaluation is necessary to ensure their effectiveness and equitable implementation across diverse patient populations.

Abdominal Organ Transplantation: Noteworthy Literature in 2024

This review highlights noteworthy literature published in 2024 pertinent to anesthesiologists and critical care physicians caring for patients undergoing abdominal organ transplantation. We feature 13 studies from over 5555 peer-reviewed publications on kidney transplantation, 4 studies from 1963 publications on pancreas transplantation, and 3 studies from 1879 publications on intestinal transplantation. The liver transplantation section includes a special focus on 22 studies from 4571 clinical trials published in 2024. We identified the new findings with our specialty interest, including cardiovascular risk assessment, machine perfusion, hemodynamic management, mode of anesthesia and regional techniques, donor management, fluid management, intraoperative monitoring, blood salvage, frailty, and rehabilitation and prehabilitation.

Prognostic role of postoperative persistence of ctDNA molecular signature after liver resection for colorectal liver metastases: Preliminary results from a prospective study

INTRODUCTION

Liver resection represents the cornerstone treatment for Colo-Rectal Liver Metastases (CRLM), but it is still followed by a high recurrence rate. The identification of a valid and reproducible predictor of recurrence can play a key role in correct and timely management of the disease. In this scenario, liquid biopsy may represent an integrative, less invasive, and easily manageable tool to clinically stratify colorectal cancer patients.We aimed to investigate the prognostic role of persistent circulating tumor DNA (ctDNA) signature on CRLM recurrence after liver resection.

METHODS

A series of 51 consecutive patients undergoing liver resection for CRLM were prospectively enrolled between January 2020 and March 2023. Patients underwent liquid biopsy from peripheral blood samples before and after surgery. Other risk factors for disease recurrence were also investigated.

RESULTS

Twenty-nine patients were found to be positive for one of the clinically relevant molecular alterations detected by NGS, at preoperative (T0) ctDNA analysis. At univariate analysis, total tumor size bigger than 60 mm (p = 0.046, HR 2.486) and postoperative persistence of ctDNA molecular signature (p = 0.024, HR 2.831) were significantly associated with recurrence. Multivariable Cox Regression analysis showed that only postoperative persistence of ctDNA molecular signature was associated with recurrence (p = 0.027, HR 2.766). Similarly, 1-3 yr DFS was significantly lower in the subgroup with persistence of molecular signature at liquid biopsy (100-49.5 % vs 57.1-21.4 %, p = 0.018).

CONCLUSION

Postoperative persistence of ctDNA molecular signature could represent a useful tool to predict recurrence after liver resection for CRLM patients.

Large language model-generated clinical practice guideline for appendicitis

BACKGROUND

Clinical practice guidelines provide important evidence-based recommendations to optimize patient care, but their development is labor-intensive and time-consuming. Large language models have shown promise in supporting academic writing and the development of systematic reviews, but their ability to assist with guideline development has not been explored. In this study, we tested the capacity of LLMs to support each stage of guideline development, using the latest SAGES guideline on the surgical management of appendicitis as a comparison.

METHODS

Prompts were engineered to trigger LLMs to perform each task of guideline development, using key questions and PICOs derived from the SAGES guideline. ChatGPT-4, Google Gemini, Consensus, and Perplexity were queried on February 21, 2024. LLM performance was evaluated qualitatively, with narrative descriptions of each task's output. The Appraisal of Guidelines for Research and Evaluation in Surgery (AGREE-S) instrument was used to quantitatively assess the quality of the LLM-derived guideline compared to the existing SAGES guideline.

RESULTS

Popular LLMs were able to generate a search syntax, perform data analysis, and follow the GRADE approach and Evidence-to-Decision framework to produce guideline recommendations. These LLMs were unable to independently perform a systematic literature search or reliably perform screening, data extraction, or risk of bias assessment at the time of testing. AGREE-S appraisal produced a total score of 119 for the LLM-derived guideline and 156 for the SAGES guideline. In 19 of the 24 domains, the two guidelines scored within two points of each other.

CONCLUSIONS

LLMs demonstrate potential to assist with certain steps of guideline development, which may reduce time and resource burden associated with these tasks. As new models are developed, the role for LLMs in guideline development will continue to evolve. Ongoing research and multidisciplinary collaboration are needed to support the safe and effective integration of LLMs in each step of guideline development.

Liver transplantation for primary and secondary liver tumors: Patient-level meta-analyses compared to UNOS conventional indications

BACKGROUND AND AIMS

Liver transplant (LT) for transplant oncology (TO) indications is being slowly adopted worldwide and has been recommended to be incorporated cautiously due to concerns about mid-long-term survival and its impact on the waiting list.

APPROACH AND RESULTS

We conducted 4 systematic reviews of all series on TO indications (intrahepatic cholangiocarcinoma and perihilar cholangiocarcinoma [phCC]) and liver metastases from neuroendocrine tumors (NETs) and colorectal cancer (CRLM) and compared them using patient-level meta-analyses to data obtained from the United Network for Organ Sharing (UNOS) database considering conventional daily-practice indications. Secondary analyses were done for specific selection criteria (Mayo-like protocols for phCC, SECA-2 for CRLM, and Milan criteria for NET). A total of 112,014 LT were analyzed from 2005 to 2020 from the UNOS databases and compared with 345, 721, 494, and 103 patients obtained from meta-analyses on intrahepatic cholangiocarcinoma and phCC, and liver metastases from NET and CRLM, respectively. Five-year overall survival was 53.3%, 56.4%, 68.6%, and 53.8%, respectively. In Mantel-Cox one-to-one comparisons, survival of TO indications was superior to combined LT, second, and third LT and not statistically significantly different from LT in recipients >70 years and high BMI.

CONCLUSIONS

Liver transplantation for TO indications has adequate 5-year survival rates, mostly when performed under the selection criteria available in the literature (Mayo-like protocols for phCC, SECA-2 for CRLM, and Milan for NET). Despite concerns about its impact on the waiting list, some other LT indications are being performed with lower survival rates. These oncological patients should be given the opportunity to have a definitive curative therapy within validated criteria.

Nomogram for prediction of hepatocellular carcinoma recurrence after liver resection

BACKGROUND

Hepatocellular carcinoma (HCC) is a common malignancy with high mortality. Liver resection (LR) is a curative treatment for early-stage HCC, but the prognosis of HCC patients after LR is unsatisfactory because of tumor recurrence. Prognostic prediction models with great performance are urgently needed. The present study aimed to establish a novel prognostic nomogram to predict tumor recurrence in HCC patients after LR.

METHODS

We retrospectively analyzed 726 HCC patients who underwent LR between October 2011 and December 2016. Patients were randomly divided into the training cohort (n = 508) and the testing cohort (n = 218). The protein expression of 14 biomarkers in tumor tissues was assessed by immunohistochemistry. The nomogram predicting recurrence-free survival (RFS) was established by a multivariate Cox regression analysis model and was evaluated by calibration curves, Kaplan-Meier survival curves, time-dependent areas under the receiver operating characteristic (ROC) curves (AUCs), and decision curve analyses in both the training and testing cohorts.

RESULTS

Alpha-fetoprotein [hazard ratio (HR) = 1.013, P = 0.002], portal vein tumor thrombosis (HR = 1.833, P < 0.001), ascites (HR = 2.024, P = 0.014), tumor diameter (HR = 1.075, P < 0.001), E-cadherin (HR = 0.859, P = 0.011), EMA (HR = 1.196, P = 0.022), and PCNA (HR = 1.174, P = 0.031) immunohistochemistry scores were found to be independent factors for RFS. The 1-year and 3-year AUCs of the nomogram for RFS were 0.813 and 0.739, respectively. The patients were divided into the high-risk group and the low-risk group by median value which was generated from the nomogram, and Kaplan-Meier analysis revealed that the high-risk group had a shorter RFS than the low-risk group in both the training (P < 0.001) and testing cohorts (P < 0.001).

CONCLUSIONS

Our newly developed nomogram integrated clinicopathological data and key gene expression data, and was verified to have high accuracy in predicting the RFS of HCC patients after LR. This model could be used for early identification of patients at high-risk of postoperative recurrence.

Enhancing the prognostic accuracy of the RETREAT score with AFP-L3 and DCP tumor markers

The RETREAT (Risk Estimation of Tumor Recurrence After Transplant) Score is a validated tool to predict post-transplant HCC recurrence risk. Alpha-fetoprotein (AFP) bound to Lens culinaris agglutinin (AFP-L3) and des-gamma-carboxyprothrombin (DCP) measured at transplant predict worse post-LT survival and may improve the RETREAT score. Our cohort comprised 284 patients transplanted for HCC who were within or downstaged to Milan, with 23 (8.1%) experiencing HCC recurrence. The modified RETREAT (mRETREAT) score assigns AFP-L3 ≥15% 2 points and DCP ≥7.5 ng/mL 3 points. Patients with a modified RETREAT score ≥4 showed a 3-year recurrence-free survival of 73.2% versus 97.8% recurrence-free survival if <4. In comparison, the original RETREAT score had a 3-year recurrence-free survival of 80.0% if ≥2 versus 98.0% if <2. mRETREAT demonstrated a superior AUC of 0.86, compared to the original RETREAT's 0.82, and enhanced calibration and accuracy with a lower Brier score (0.04). The integration of AFP-L3 and DCP into the RETREAT score appears to enhance the prediction of post-LT HCC recurrence. Given these promising results, further study in a larger multicenter cohort is warranted for empiric derivation and validation of a modified RETREAT score, including AFP-L3 and DCP.

Deceased donor liver utilisation and assessment: Consensus guidelines from the European Liver and Intestine Transplant Association

Over the past two decades, the application of machine perfusion (MP) in human liver transplantation has moved from the realm of clinical exploration to routine clinical practice. Both in situ and ex situ perfusion strategies are feasible, safe, and may offer improvements in relevant post-transplant outcomes. An important utility of these strategies is the ability to transplant grafts traditionally considered too risky to transplant using conventional cold storage alone. While dynamic assessment and ultimately transplantation of such livers is an important goal for the international liver transplant community, its clinical application is inconsistent. To this end, ELITA (the European Liver and Intestine Transplant Association) gathered a panel of experts to create consensus guidelines regarding selection, approach, and criteria for deceased donor liver assessment in the MP era. An eight-member steering committee (SC) convened a panel of 44 professionals working in 14 countries in Europe and North America. The SC identified topics related to liver utilisation and assessment for transplantation. For each topic, subtopics were created to answer specific clinical questions. A systematic literature review was performed, and the panel graded relevant evidence. The SC drafted initial statements addressing each clinical question. Statements were presented at the in-person Consensus Meeting on Liver Discard and Viability Assessment during the ELITA Summit held from April 19-20, 2024, in Madrid, Spain. Online voting was held to approve statements according to a modified Delphi method; statements reaching ≥85% agreement were approved. Statements addressing liver utilisation, the definition of high-risk livers, and strategies and criteria for dynamic liver assessment are presented.

Appropriate use of tissue sampling and somatostatin receptor PET imaging in the diagnosis of pancreatic neuroendocrine tumors: results of an International Delphi Consensus

BACKGROUND

Current guidelines lack clarity regarding the appropriate use of preoperative ultrasound-guided (EUS) biopsy and receptor positron emission tomography (SSTR PET) imaging for pancreatic neuroendocrine tumors (PNETs). This study aims to reach expert consensus on the optimal sequencing of SSTR PET and EUS biopsy in the diagnostic workup and management of patients with suspected PNETs.

METHODS

A three-round modified Delphi process was used. A multidisciplinary panel of experts was recruited via snowball sampling. A set of 22 baseline statements pertaining to diagnostic workup, imaging, and biopsy was developed based on literature review and feedback obtained through a focus group. Survey rounds were conducted electronically and anonymously. A panel of international experts was asked to indicate whether they agreed, disagreed, or lacked the appropriate background to answer each statement. Of the 55 experts invited, 38 (69%) accepted to participate. Consensus was achieved with > 80% agreement.

RESULTS

Response rates were 97%, 100%, and 100% in rounds 1, 2, and 3, respectively. Following rounds 1 and 2, 29 final statements achieved consensus in the following three domains: diagnostic workup (15 statements), imaging (nine statements), and tissue sampling (five statements). Cronbach's alpha value, a measure of internal consistency, was 0.91 and 0.85 for rounds 1 and 2, respectively. The final set of statements achieved a 95% approval rate in round 3.

CONCLUSION

This international Delphi study provides expert consensus-based guidance on the appropriate use of EUS biopsy in the diagnostic workup of PNETs in the era of SSTR PET imaging.

EAES rapid guideline: complete mesocolic excision for right-sided colon cancer-with SAGES and ESCP participation

BACKGROUND

Complete mesocolic excision (CME) is a surgical technique that aims to improve oncological outcomes of right-sided colon cancer resections. However, CME's technical complexity, surgical risks, and need for specialized training, present challenges. Also, variations in technical aspects and implementation lead to inconsistent outcomes.

OBJECTIVE

To develop evidence-informed clinical practice recommendations on complete mesocolic excision for right-sided colon cancer, aiming to address whether laparoscopic CME should be preferred over standard laparoscopic right hemicolectomy for right-sided colon cancer.

METHODS

The present guideline adheres to GRADE, AGREE-S, and Cochrane standards, using MAGICapp for development. The steering group included colorectal and general surgeons, supported by a Guidelines International Network-certified lead guideline developer, trainee methodologists, systematic reviewers and statisticians. The guideline panel included surgeons, oncologists, a pathologist, and a patient partner. It provides recommendations based on a linked systematic review, appraisal of benefits and harms, the certainty of the evidence, patient values and preferences, acceptability, feasibility, use of resources, and equity.

RESULTS

A conditional recommendation is issued in favor of CME for patients undergoing right hemicolectomy for right-sided colon cancer where expertise is available, based on low-to-moderate certainty evidence. The panel suggests CME is acceptable to stakeholders and feasible, despite potential equity issues due to variable expertise availability. There is insufficient evidence to recommend CME based on tumor location or cancer stage. A conditional recommendation means that the majority of well-informed patients, surgeons and other stakeholders, would opt for the recommended course of action, but discussion of relevant benefits and harms is advised prior to decisions. The full guideline with user-friendly decision aids is available in https://app.magicapp.org/#/guideline/EaG1dL .

CONCLUSIONS

This guideline provides evidence-informed recommendations on the management of right-sided colon cancer, developed in line with the highest quality methodological and reporting standards, and informed by an interdisciplinary panel of stakeholders.

The 2024 ILTS-ILCA consensus recommendations for liver transplantation for HCC and intrahepatic cholangiocarcinoma

Liver transplantation (LT) provides the best long-term survival outcomes for patients with liver cancer. As a result, the field of transplant oncology has grown greatly over the past few decades, and many centers have expanded their criteria to allow increased access to LT for liver malignancies. Center-level guidelines and practices in transplant oncology significantly vary across the world, leading to debate regarding the best course of treatment for this patient population. An international consensus conference was convened by the International Liver Transplantation Society and the International Liver Cancer Association on February 1-2, 2024, in Valencia, Spain to establish a more universal consensus regarding LT for oncologic indications. The conference followed the Delphi process, followed by an external expert review. Consensus statements were accepted regarding patient assessment and waitlisting criteria, pretransplant treatment (including immunotherapy) and downstaging, living donor LT, post-LT patient management, and patient- and caregiver-related outcomes. The multidisciplinary participants in the consensus conference provided up-to-date recommendations regarding the selection and management of patients with liver cancer being considered for LT. Although participants deferred to center protocols in many cases, there was great interest in safely expanding access to LT for patients with larger tumor burden and biologically amenable lesions.

A Survey of Clinical Practices for Hepatocellular Carcinoma Among Experts at Tertiary Hospitals in China From 2020 to 2021

Background

Hepatocellular carcinoma (HCC) is the second leading cause of cancer-related death in China. The rapid progress in systemic therapies has led to the approval of many therapeutic methods that have quickly changed clinical guidelines and practices. Because of the high heterogeneity of HCC, there are still some gaps between the guidelines and real-world clinical practice. The present study surveyed experts in China to investigate the current treatment concepts and clinical practice regarding HCC.

Methods

A questionnaire survey on the treatment concepts and clinical practice of HCC was administered to 310 experts with senior professional titles in 2020 and 312 experts in 2021. The results were analyzed and compared.

Results

For treating patients with resectable HCC, 28% of hepatobiliary surgeons indicated neoadjuvant therapy, and 7% chose systemic therapy ± locoregional therapy as 1 L therapy in 2021 compared with 20% and 1% in 2020. More experts chose adjuvant treatment within 1 month in 2021 compared with 2020, and 6 months and 12 months were the leading choices for the duration of adjuvant treatment. In 2021, 79% of surgeons and 19% of interventionalists were willing to conduct downstaging/conversion therapy for patients with potentially resectable HCC, and 78% chose tyrosine kinase inhibitors (TKI) + immunotherapy (IO) + locoregional therapy for cases in which R0 resection could not be achieved. For completely unresectable HCC, more experts preferred TKI + IO-based therapy as 1 L therapy in 2021 compared with 2020 (78% vs. 55%). The proportion of experts who indicated TKI + IO-based therapy as 2 L therapy increased from 32% in 2020 to 40% in 2021.

Conclusion

The survey results indicated that in 2021, compared with 2020, more experts opted to administer IO + TKI for the treatment of liver cancer, and more experts and patients were willing to participate in clinical research.

Tumor biology characteristics score based on alpha-fetoprotein and protein induced by vitamin K absence or antagonist II as a predictor for recurrence and survival after curative resection for hepatocellular carcinoma: a multicenter cohort study

BACKGROUND

Current hepatocellular carcinoma (HCC) staging systems lack comprehensive assessment of tumor biologic characteristics. This study aimed to develop and validate a tumor biology characteristics score (TBCS) based on alpha-fetoprotein (AFP) and protein induced by vitamin K absence or antagonist II (PIVKA-II) to predict long-term oncologic outcomes after HCC resection.

METHODS

In this multicenter retrospective cohort study, patients who underwent curative resection for HCC between June 2018 and December 2022 were included. TBCS (range, 2-6 points) was calculated by combining preoperative AFP (<20, 20-199, and ≥200 ng/mL) and PIVKA-II levels (<40, 40-399, and ≥400 mAU/mL). Patients were stratified into low (2 points), medium (3-4 points), and high TBCS groups (5-6 points). The primary outcomes were recurrence-free survival (RFS) and overall survival (OS).

RESULTS

A total of 695 patients were analyzed; the low, medium, and high TBCS groups comprised 132 (19.0%), 233 (33.5%), and 330 patients (47.5%), respectively. Notably, 5-year RFS was 30.4%, 14.7%, and 9.7%, whereas 5-year OS was 42.1%, 35.5%, and 23.5% for low, medium, and high TBCS groups, respectively (both P <.001). Multivariate analysis identified TBCS as an independent predictor of both RFS (medium TBCS: hazard ratio [HR], 1.583; 95% CI, 1.219-2.057; P =.001; high TBCS: HR, 1.895; 95% CI, 1.473-2.438; P <.001) and OS (high TBCS: HR, 1.781; 95% CI, 1.353-2.343; P <.001).

CONCLUSION

The novel TBCS combining AFP and PIVKA-II effectively stratified patients with HCC into distinct prognostic groups after curative-intent resection, independently predicting both RFS and OS. This score may help identify high-risk patients for more intense postoperative recurrence surveillance and receipt of adjuvant therapies.

Vascular endothelial growth factor/platelet ratio as a potential biomarker for preeclampsia: A study of angiogenic markers in Pakistani patients

Objectives

To determine the levels of angiogenic biomarkers: vascular endothelial growth factor (VEGF), soluble vascular endothelial growth factor receptor 1 (sVEGFR1 or sFlt-1), platelet count, and the VEGF/platelet ratio in preeclampsia.

Methods

Forty-four cases of preeclampsia and 44 controls were recruited.

Results

The serum VEGF, sVEGFR1, and VEGF/platelet ratio were significantly higher and platelet counts lower in preeclampsia in comparison to controls (VEGF: median = 178 vs. 97 pg/mL, p < 0.0001, sVEGFR1: 1634 vs. 627 pg/mL, p < 0.0001, VEGF/platelet ratio: 1.148 vs. 0.417, and platelet count: 178 × 103/µL vs. 232 × 103/µL, p = 0.0006). The VEGF and VEGF/platelet ratio showed better diagnostic accuracy for differentiating preeclampsia, with an area under the curve of 97.47% (95% CI: 0.95-1.00) and 89.46% (95% CI: 0.82-0.96), respectively. VEGFA: c.-2055A>C (rs699947) AA genotype exhibited higher serum VEGF levels associated with preeclampsia.

Conclusion

The higher levels of angiogenic biomarkers in preeclampsia, suggest a role in the pathogenesis and potential diagnosis.

The present and the future of immunotherapy in hepatocellular carcinoma and biliary tract cancers

Hepatobiliary malignancies encompass a spectrum of invasive carcinomas arising in the liver [hepatocellular carcinoma (HCC), bile ducts [intrahepatic cholangiocarcinoma (ICC), and extrahepatic cholangiocarcinoma (EHC)] and the gallbladder. These malignancies represent a growing global health burden, with rising incidence and mortality rates and their overall prognosis remains poor because many patients present with advanced unresectable disease at diagnosis. In recent years, significant advancements in understanding HCC immunogenicity have reshaped the therapeutic scenario of advanced HCC with the immunotherapy revolutionizing the current HCC treatment landscape and patients' prognosis. Moreover, the addition of immunotherapy to chemotherapy has recently established a new standard of care first-line treatment for patients with biliary tract cancers (BTCs) who had historically few therapeutic options. Currently, immunotherapy and immune checkpoint inhibitor (ICI)-based regimens stand as a valuable and practice-changing options in both HCC and BTC management. The mounting recent evidence supporting immunotherapy's survival benefit demands clinicians to stay updated with a rapidly evolving treatment landscape as well as gain knowledge about patient selection, response rate compared with other systemic treatments and immune-mediated adverse events (imAEs) management. A panel of international Experts, comprising hepatologists and oncologists, gathered to explore the challenges in effectively integrating immunotherapy in routine clinical practice. The aim of this review is to present the Experts' insights to inform treatment choice in HCC and BTC with a special emphasis on the role of currently available ICI-based therapies in shifting treatment paradigms and potentially reversing the natural course of these two deadly malignancies.

A novel nomogram to predict the recurrence of hepatocellular carcinoma after liver transplantation using extended selection criteria

BACKGROUND

Liver transplantations (LTs) with extended criteria have produced surgical results comparable to those obtained with traditional standards. However, it is not sufficient to predict hepatocellular carcinoma (HCC) recurrence after LT according to morphological criteria alone. The present study aimed to construct a nomogram for predicting HCC recurrence after LT using extended selection criteria.

METHODS

Retrospective data on patients with HCC, including pathology, serological markers and follow-up data, were collected from January 2015 to April 2020 at Huashan Hospital, Fudan University, Shanghai, China. Logistic least absolute shrinkage and selection operator (LASSO) regression and multivariate Cox regression analyses were performed to identify and construct the prognostic nomogram. Receiver operating characteristic (ROC) curves, Kaplan-Meier curves, decision curve analyses (DCAs), calibration diagrams, net reclassification indices (NRIs) and integrated discrimination improvement (IDI) values were used to assess the prognostic capacity of the nomogram.

RESULTS

A total of 301 patients with HCC who underwent LT were enrolled in the study. The nomogram was constructed, and the ROC curve showed good performance in predicting survival in both the development set (2/3) and the validation set (1/3) (the area under the curve reached 0.748 and 0.716, respectively). According to the median value of the risk score, the patients were categorized into the high- and low-risk groups, which had significantly different recurrence-free survival (RFS) rates (P < 0.01). Compared with the Milan criteria and University of California San Francisco (UCSF) criteria, DCA revealed that the new nomogram model had the best net benefit in predicting 1-, 3- and 5-year RFS. The nomogram performed well for calibration, NRI and IDI improvement.

CONCLUSIONS

The nomogram, based on the Milan criteria and serological markers, showed good accuracy in predicting the recurrence of HCC after LT using extended selection criteria.

The Italian Score for Organ Allocation: A Ten-Year Monocentric Retrospective Analysis in Liver Transplantation for Hepatocellular Carcinoma

BACKGROUND

The Italian Score for Organ Allocation (ISO), a transplant benefit oriented allocation system, was introduced in Italy in 2016. The main objective of this study is to identify risk factors for Drop-Out in hepatocellular (HCC) patients enlisted for LT before (Pre-ISO Era) and after ISO (ISO Era) introduction, while the secondary objective is to evaluate the survival results.

METHODS

CIFs for liver transplantation and Drop-Out were estimated and compared between eras. Factors associated with Drop-Out were identified through multivariable competing risks regression. Survival results were compared using the log-rank test.

RESULTS

Between 2011 and 2020, 410 patients with HCC were listed for LT. We observed 103 vs. 217 LT and 49 vs. 41 Drop-Outs (p < 0.001) during the Pre-ISO and ISO Era, respectively. In the multivariable analysis, ISO ([sHR] 0.43; 95%CI 0.28-0.66, p < 0.001) and Alcoholic Cirrhosis ([sHR] 0.27, 95%CI 0.11-0.70; p = 0.007) were revealed to be protective factors for Drop-Out. One year after listing, the CI for Drop-Out decreased from 13.2% to 6.2% (p = 0.02). Despite no differences observed in post-LT survival, a significant difference in the intention-to-treat survival from enlisting was found (p = 0.0019).

CONCLUSIONS

Among other factors, ISO results were protective for the Drop-Out risk in HCC patients awaiting LT, with a benefit in ITT-OS survival.

Banff 2022 pancreas pathology update: how to make the right diagnosis and decrease inconclusive pathology results

PURPOSE OF REVIEW

The Banff 2022 pancreas transplant pathology update is the most comprehensive to date. It has improved the criteria for T-cell and antibody mediated rejection, recognized other clinicopathological differential diagnoses, and addressed the critically important islet failures. Nevertheless, multidisciplinary discussions during and after the meeting showed a need to enhance the real and perceived value of pancreas transplant biopsies. In particular, the occurrence of clinicopathological discrepancies and/or inconclusive biopsy findings, result in considerable uncertainty in clinical and pathology decision making.

RECENT FINDINGS

The current review expands on the 2022 report by presenting the most common situations leading to an inconclusive diagnosis (Banff "indeterminate" category), a major issue of discussion. The entities discussed herein are: nonspecific infiltrates versus active rejection; residual inflammation after treatment of active rejection; ischemic pancreatitis and peripancreatic reactions in the early posttransplant period; biopsy findings associated with exocrine drainage impairment, and other unusual or nonspecific findings. An algorithm for the evaluation of pancreas allograft biopsies is also presented, that should facilitate the interpretation of morphological findings.

SUMMARY

Systematic integration of essential clinical information with the pathology findings can improve the diagnostic yield of pancreas allograft biopsies and reduce the cases with and "indeterminate" diagnoses.

Occult multifocal and incidental hepatocellular carcinoma: An analysis of long-term survival and risk factors at a single liver transplant center

The clinical significance of occult HCC identified on explant pathology in liver transplantation (LT) remains unclear. Among recipients of LT, discordance between pre-LT radiographic assessment of HCC and explant tumor burden is common. Data regarding the association of incidental HCC (no pre-LT radiographic diagnosis) and occult multifocal hepatocellular carcinoma (omHCC, pre-LT radiology underestimates a number of explant tumors) with outcomes are scarce. Post-LT recurrence and survival were compared among recipients of LT (n=919, 2002-2019) with incidental HCC (n=129), omHCC (n=349), and non-omHCC (n=437). Multivariable analysis identified independent predictors of omHCC in the subset of patients with kHCC. Compared to kHCC, incidental HCC had similar 5-year overall (OS) and recurrence-free survival (RFS), lower post-LT recurrence (6.9% vs. 16.2%, p =0.0019), but higher non-HCC-related mortality (38.4% vs. 23.7%, p =0.0042). Of 790 kHCC, 349 (44.1%) had omHCC, who demonstrated greater radiographic number of lesions ( p =0.049) and locoregional treatments ( p <0.001) but similar maximum and pre-LT alphafetoprotein compared to non-omHCC. Compared to kHCC without omHCC, patients with omHCC had inferior 5-year OS (60.4% vs. 70.9%, p =0.010) and RFS (56.8% vs. 69.7%, p <0.001), higher recurrence (23.8% vs. 9.2%, p <0.001), and similar non-HCC-related mortality. These observations remained true within patients who remained within Milan throughout preoperative imaging (5-y OS: 62.1% vs. 72.6%, p =0.027; RFS: 58.6% vs. 71.7%, p =0.010; recurrence: 21.7% vs. 7.6%, p <0.001). Multivariable predictors of omHCC tumor included a number of pre-LT locoregional therapies (OR 1.62 for 2 treatments, 95% CI 1.15-2.28, p =0.005; OR 1.98 for 3+ treatments, 1.36-2.88, p <0.001). In patients with kHCC prior to LT, the presence of omHCC is common and associated with inferior post-LT survival and higher recurrence rates. The development of improved radiographic and serum biomarkers that more accurately reflect explant tumor burden may improve patient selection and post-LT outcomes.

Liver resection versus interventional treatments for hepatocellular carcinoma patients with hypohepatia: a multicenter study

BACKGROUND

Hypohepatia limits the feasibility of therapeutic options for hepatocellular carcinoma (HCC), negatively affecting patient prognosis. Established guidelines for the treatment strategies of HCC patients with hypohepatia are lacking. This study was performed to evaluate therapeutic benefits between liver resection (LR) and interventional treatments using ablation or transarterial chemoembolization (TACE) in such population.

METHODS

Survival analyses were performed using the Kaplan-Meier method and log-rank test. The Cox proportional hazards regression models were used to analyze potential risk factors associated with prognosis. Multivariate regression and propensity score regression adjustment analyses were applied to adjust for baseline confounding variables. Restricted cubic spline curves were used to assess the association between prognostic index and risk of death or progression on a continuous scale.

RESULTS

Of the enrolled 5774 HCC patients with hypohepatia, 506 (8.8%), 2326 (40.3%) and 2942 (51.0%) underwent ablation, LR and TACE, respectively. A tentative analysis of the overall cohort demonstrated that a high degree of heterogeneity existed in this population, while LR rendered a possible tendency to survival benefit over ablation and TACE through adjustment for baseline confounding variables. After categorizing the patients according to the indication of ablation treatment, the indisputable superiority of LR over ablation and TACE in terms of OS and DFS before and after adjustments were evident and the survival advantages of LR were consistent across all pre-specified subgroups. Individualized treatment decision analyses based on restricted cubic spline curves demonstrated that LR group presented the lowest risk of death and disease progression.

CONCLUSIONS

HCC patients with hypohepatia could obtain survival benefits through surgical and non-surgical treatment approaches. LR appears to confer a significant survival benefit compared with interventional treatments using ablation or TACE, even for selected intermediate and advanced populations.

Evidence Summary of Personalized Management of Peritoneal Dialysis Volume in Adults

Purpose

The overload capacity poses great challenges to the management and prognosis of peritoneal dialysis patients. There have been many studies, but they are relatively fragmented and inconsistent. It is urgent to summarize high-quality evidence. The objective of this study is to thoroughly investigate, extract, assess, and synthesize the most relevant evidence about the individualized management of peritoneal volume in patients undergoing peritoneal dialysis. It can be utilized in clinical practice to improve patient outcomes.

Methods

The study used the "6S" pyramid model to identify all available evidence related to the personalized management of peritoneal volume among patients receiving peritoneal dialysis. This comprehensive search encompassed various types of evidence, including guidelines, recommended practices, systematic reviews, evidence summaries, expert consensus documents, and original research studies. These were sourced from both domestic and international guideline websites, professional association platforms, as well as relevant databases. The time limit was set from the date of database creation until April 2024, with the search commencing in December 2023.

Results

The systematic search yielded 17 pieces of literature that were ultimately included in the analysis. This collection comprised seven guidelines, four best practices, two documents reflecting expert consensus, two systematic reviews, and two randomized controlled trials. The overall quality of the literature analyzed was found to be high. Through this thorough review, a total of 37 pieces of the best evidence were identified and categorized into three critical aspects: risk factors, comprehensive assessment methodologies, and various intervention strategies.

Conclusion

This study serves as a consolidation of the available evidence regarding the personalized management of peritoneal volume for patients undergoing peritoneal dialysis. It underscores the importance of clinical staff's ability to implement tailored volume management programs that address the unique circumstances of each patient.

Unraveling the Metabolic Pathways Between Metabolic-Associated Fatty Liver Disease (MAFLD) and Sarcopenia

Metabolic-Associated Fatty Liver Disease (MAFLD) is a public health concern that is constantly expanding, with a fast-growing prevalence, and it affects about a quarter of the world's population. This condition is a significant risk factor for cardiovascular, hepatic, and oncologic diseases, such as hypertension, hepatoma, and atherosclerosis. Sarcopenia was long considered to be an aging-related syndrome, but today, it is acknowledged to be secondarily related to chronic diseases such as metabolic syndrome, cardiovascular conditions, and liver diseases, among other comorbidities associated with insulin resistance and chronic inflammation, besides inactivity and poor nutrition. The physiopathology involving MAFLD and sarcopenia has still not been solved. Inflammation, oxidative stress, mitochondrial dysfunction, and insulin resistance seem to be some of the keys to this relationship since this hormone target is mainly the skeletal muscle. This review aimed to comprehensively discuss the main metabolic and physiological pathways involved in these conditions. MAFLD and sarcopenia are interconnected by a complex network of pathophysiological mechanisms, such as insulin resistance, skeletal muscle tissue production capacity, chronic inflammatory state, oxidative stress, and mitochondrial dysfunction, which are the main contributors to this relationship. In addition, in a clinical analysis, patients with sarcopenia and MAFLD manifest more severe hepatitis fibrosis when compared to patients with only MAFLD. These patients, with both disorders, also present clinical improvement in their MAFLD when treated for sarcopenia, reinforcing the association between them. Lifestyle changes accompanied by non-pharmacological interventions, such as dietary therapy and increased physical activity, undoubtedly improve this scenario.

Importance of understanding a diagnostic-treatment algorithm for primary hyperparathyroidism-induced acute pancreatitis during pregnancy

In this article, we have commented on the article by Augustin et al. The authors presented a systematic review of the diagnosis, treatment, and outcomes of primary hyperparathyroidism-induced acute pancreatitis in pregnant women. Since acute pancreatitis during pregnancy could cause maternal as well as fetal adverse outcomes, understanding this pathology is essential. Although there are various etiologies of acute pancreatitis during pregnancy, primary hyperparathyroidism is one of the causes that complicate hypercalcemia. Along with conventional treatment for acute pancreatitis, parathyroidectomy can effectively normalize calcium levels and improve acute pancreatitis. Augustin et al have provided vital information that can enable physicians to understand and treat hyperparathyroidism-induced acute pancreatitis in pregnant women, which could contribute to better maternal and fetal outcomes. In addition, since primary hyperparathyroidism is associated with multiple endocrine neoplasia, further consideration regarding screening for multiple endocrine neoplasia might lead to better prognoses.

Qilian Jiechang Ning Alleviates TNBS-Induced Ulcerative Colitis in Mice and Segatella copri Outer Membrane Vesicle-Triggered Inflammation in Colon Epithelial Cells via the Caspase-1/11-GSDMD Pathways

INTRODUCTION

Qilian Jiechang Ning (QJN), a traditional Chinese herbal formula, has demonstrated potential therapeutic effects in the treatment of ulcerative colitis (UC). This study aims to investigate the mechanism of QJN in the outer membrane vesicles (OMVs) of Segatella copri (S. copri)-induced colon epithelial cells and UC mice.

METHODS

Transmission electron microscopy (TEM) and nanoparticle tracking analysis (NTA) were utilized to assess the morphology and size of OMVs. Inflammation markers and tight junction protein levels in HCoEpiCs induced by OMVs were monitored using ELISA and western blot. QJN was administered to intervene in HCoEpiCs treated with S. copri OMVs. Additionally, trinitrobenzene sulfonic acid (TNBS)-induced mouse models were conducted to evaluate the therapeutic effects of QJN on UC.

RESULTS

S. copri OMVs treated with QJN demonstrated a significant reduction in particle size, protein concentration, and LPS content. In HCoEpiCs, QJN effectively decreased the expression of inflammation-inducing cytokines (IL-1β, IL-18, IL-6, TNF-α) and proinflammatory proteins (GSDMD-N, NLRP3, ASC, cleaved Caspase-1, cleaved Caspase-4) triggered by S. copri OMVs, while enhancing the expression of tight junction proteins (ZO-1 and Occludin). In the UC mouse models, QJN significantly reduced the Disease Activity Index (DAI), improved colon length, lowered LPS levels, ameliorated colonic tissue damage, and inhibited Caspase-1- and Caspase-11-dependent inflammatory responses.

CONCLUSION

QJN can alleviate S. copri-OMV-induced inflammatory response in colonic epithelial cells and reduce symptoms of UC in mouse models by modulating the Caspase-1 and Caspase-11 pathways.

Laparoscopic associating liver partition and portal vein ligation for staged hepatectomy for colorectal liver metastases: A single-center experience

BACKGROUND

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a procedure used for patients with initially unresectable colorectal liver metastases (CRLM). However, the procedure has been reported to be associated with high morbidity and mortality. Laparoscopic ALPPS has recently been reported as a minimally invasive technique that reduces perioperative risks.

AIM

To assess the safety and feasibility of full laparoscopic ALPPS in patients with CRLM.

METHODS

A retrospective analysis was conducted on all consecutive patients with CRLM who underwent full laparoscopic ALPPS at the Sixth Affiliated Hospital of Sun Yat-sen University between March 2021 and July 2024.

RESULTS

Fifteen patients were included, 13 with synchronous liver metastases. Nine patients had more than five liver tumors, with the highest count being 22. The median diameter of the largest lesion was 2.8 cm on preoperative imaging. No extrahepatic metastases were observed. RAS mutations were detected in nine patients, and 14 underwent preoperative chemotherapy. The median increase in future liver remnant volume during the interstage interval was 47.0%. All patients underwent R0 resection. Overall complication rates were 13.3% (stage 1) and 53.3% (stage 2), while major complication rates (Clavien-Dindo ≥ IIIa) were 13.3% (stage 1) and 33.3% (stage 2). No mortality occurred in either stage. The median hospital stay after stage 2 was 10 days.

CONCLUSION

Full laparoscopic ALPPS for CRLM is safe and feasible, with the potential for reduced morbidity and mortality, offering radical resection opportunities for patients with initially unresectable CRLM.

Recent Strategies to Attenuate Hepatocellular Carcinoma Recurrence After Liver Transplantation: A Narrative Review

Hepatocellular carcinoma (HCC) is one of the leading causes of liver transplant worldwide. While liver transplantation offers a survival advantage for early-stage HCC patients, post-transplant recurrence remains a significant concern, affecting up to 15% of recipients. We sought to conduct a comprehensive review related to HCC recurrence after liver transplant. Tumor-related factors such as poor differentiation, vascular invasion, and elevated tumor biomarkers like alpha-fetoprotein are key predictors of recurrence. Donor-related factors, including graft type and surgical procedures, can also influence outcomes, though their effects are less conclusive. Advancements in patient selection criteria and scoring systems, such as the Milan Criteria and RETREAT score, have improved risk stratification by incorporating tumor size, biomarkers, and response to pre-transplant treatment. Despite these measures, recurrent HCC after transplantation poses treatment challenges. Curative approaches such as resection are feasible for localized or oligometastatic recurrence and offer the best outcomes when applicable. Locoregional treatments, including ablation and transarterial chemoembolization, provide options for unresectable cases but have limited long-term efficacy. Systemic therapies, including targeted agents like sorafenib, regorafenib, and lenvatinib, have shown modest benefits in managing advanced recurrent HCC. Emerging immunotherapy approaches hold promise but face unique challenges due to the required immunosuppression in transplant recipients. Multidisciplinary evaluation remains essential for tailoring treatment plans. Future efforts should focus on refining predictive tools and exploring novel therapies to improve survival outcomes for patients with recurrent HCC after liver transplantation.

Negative serum alpha-fetoprotein at recurrence predicts good prognosis in recurrent hepatocellular carcinoma patients receiving repeated hepatectomy:a single-center retrospective cohort study

BACKGROUND

The serum alpha-fetoprotein (AFP) serves as a crucial prognostic indicator in patients diagnosed with hepatocellular carcinoma (HCC). Examining the impact of baseline-AFP (b-AFP), recurrence -AFP (r-AFP), and changes in AFP levels on the prognosis of individuals with recurrent hepatocellular carcinoma (RHCC) who undergo repeated hepatectomy holds substantial clinical significance.

METHOD

A total of 400 RHCC patients who had undergone repeated hepatectomy in the Center of Hepato-Pancreato-Biliary Surgery at the First Affiliated Hospital of Sun Yat-Sen University between January 1, 2006, and December 31, 2019 were included in this study. The analysis focused on evaluating the impact of b-AFP, r-AFP, and changes in AFP levels on the prognosis of RHCC patients.

RESULTS

The recurrence rate among HCC patients who underwent hepatectomy was approximately 40.03 %. Among the 400 HCC patients who underwent twice hepatectomy, the 5-year mortality rate was 34.25 %, with an overall mortality rate of 38.75 %. Survival analysis indicated statistically significant disparities in overall survival (OS) and recurrence-free survival (RFS) between the b-AFP (-) group and the b-AFP (+) group, with the latter exhibiting shorter OS and RFS. The 3-year mortality rates for the two groups were 31.7 % and 42.5 %, respectively. The median overall survival (mOS) for the two groups were 107.4 months and 89.5 months, respectively. A statistically significant discrepancy in recurrence-death survival (RDS) was observed between the r-AFP (-) and r-AFP (+) groups (P < 0.0001), with patients in the r-AFP (+) category experiencing a shorter RDS. The median RDS for these two groups were 88.1 months and 31.7 months, respectively. Significant differences in both overall survival (OS) and RDS were observed among the AFP (+/+), AFP (±), AFP (-/+), and AFP (-/-) groups. The order of OS and RDS from lowest to highest was as follows: AFP (+/+) group < AFP (-/+) group < AFP (-/-) group < AFP (±) group. Irrespective of the b-AFP status, patients with positive r-AFP exhibited notably shorter OS and RFS compared to their r-AFP negative counterparts. The 3-year mortality rates for the four groups were 50.9 %, 26.1 %, 39.3 %, and 29.7 %, respectively. Median OS values were 42.4 months, not reached (NA), 77.1 months, and 107.4 months, respectively. Furthermore, an analysis of the cumulative 1-year, 3-year, and 5-year OS, RDS, and RFS rates for each group was conducted.

CONCLUSION

The b-AFP, r-AFP and AFP fluctuations serve as valuable prognostic indicators in individuals who have undergone hepatectomy for HCC on two occasions. These indicators can offer valuable insights for guiding the diagnosis and treatment strategies for HCC recurrence in such patients.

Prediction of surgical resectability after FOLFIRINOX chemotherapy for borderline resectable and locally advanced pancreatic cancer (PeRFormanCe): a multicenter prospective trial - trial protocol

BACKGROUND

Neoadjuvant chemotherapy is used in borderline resectable (BR) and locally advanced (LA) pancreatic ductal adenocarcinoma (PDAC) to increase resection rate and improve cancer outcome. However, there is a need for better prediction of resectability. The aim of this prospective, single arm study is to improve prediction of surgical resection by using radiomics and liquid biopsy.

METHODS

In this multicentric trial, 45 patients with BR or LA PADC will undergo neoadjuvant chemotherapy with FOLFIRINOX. An intention to treat analysis will be performed. The primary endpoint is the accuracy of the prediction of surgical resection. Secondary endpoints are overall survival and disease-free survival from the date of diagnosis, R0 and R1 resection rates, histopathological response, postoperative complications, patient reported outcomes with quality of life and health economic analysis. Translational research with multi-omics and radiomics based on computed tomography and magnetic resonance imaging aims to identify factors predictive of surgical resectability and survival. The primary hypothesis is that these strategies can increase the accuracy of predicting surgical resection.

DISCUSSION

Improved prediction of resectability is necessary in BR and LA PDAC. We aim to investigate whether a combination of clinical, radiological, and multi-omics profiling in liquid biopsies can successfully predict resectability and thus optimize the therapeutic decision tree.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05298722. Date of registration: March 28, 2022.

Portal vein recanalization-transjugular intrahepatic portosystemic shunt (PVR-TIPS) in liver transplant candidates with cirrhosis and complex portal anastomosis

BACKGROUND & AIMS

Portal vein (PV) thrombosis may represent a relative contraindication to liver transplantation (LT). Transjugular intrahepatic portosystemic shunt (TIPS) used in portal hypertension complications, may allow portal vein recanalization (PVR).

METHODS

We reported PVR-TIPS in patients who were candidates for LT for clinical conditions but deemed contraindicated because of PV anatomy. We included consecutive patients undergoing PVR-TIPS at our center from February 2014 to May 2024.

RESULTS

We identified 25 patients (19 males [76 %], mean age 56 years [IQR 51-62]) in which PVR-TIPS was offered because foreseen high complex PV anastomosis. Twelve (48 %) patients showed main PV thrombosis, 8 (32 %) had cavernoma and 5 (20 %) had PV with very small diameter. PVR-TIPS was successfully achieved in all but one patient. All patients were listed after PVR-TIPS, with a listing MELD-Na score higher than pre-PVR-TIPS values (19 [IQR 15-23] vs. 16 [IQR 13-18], p < 0.018). Overall, 3 patients (13 %) were delisted for clinical improvement, 2 (8 %) died on the waiting-list and 16 (66 %) underwent LT. LT was technically feasible in all patients, without immediate major vascular complication.

CONCLUSIONS

PVR-TIPS may be a strategy to enable LT in patients otherwise excluded due to PV anatomy. This needs high technical expertise and often at the expense of a worsening in liver function.

EASL Clinical Practice Guidelines on extrahepatic abdominal surgery in patients with cirrhosis and advanced chronic liver disease

Extrahepatic surgery in patients with cirrhosis of the liver represents a growing clinical challenge due to the increasing prevalence of chronic liver disease and improved long-term survival of these patients. The presence of cirrhosis significantly increases the risk of perioperative morbidity and mortality following abdominal surgery. Advances in preoperative risk stratification, surgical techniques, and perioperative care have led to better outcomes, yet integration of these improvements into routine clinical practice is needed. These clinical practice guidelines provide comprehensive recommendations for the assessment and perioperative management of patients with cirrhosis undergoing extrahepatic surgery. An individualised patient-centred risk assessment by a multidisciplinary team including hepatologists, surgeons, anaesthesiologists, and other support teams is essential.