Optimizing liver utilization for transplantation with partial grafts undergoing normothermic machine perfusion: Two case reports

BACKGROUND

Liver transplantation (LT) is the only curative, life-saving option for children and adults with end-stage liver disease. Due to the well-known shortage and heterogeneity of grafts, split LT (SLT) is an attractive strategy to expand the donor pool and reduce waitlist times. Given increased risk of cold ischemia time with SLT, machine perfusion represents a promising option to reduce it and optimize transplant logistics and outcomes. The present communication describes various possible combinations of procurement steps to perform SLT facilitated by placing one or both grafts on a normothermic machine perfusion (NMP) closed circuit device.

CASE SUMMARY

A 19-month-old female with biliary atresia after failed Kasai portoenterostomy and a 42-year-old woman with unresectable intrahepatic cholangiocarcinoma were selected as recipients for a SLT from a 17-year-old male donor. The SLT generated a left lateral segment and a right trisectional graft of appropriate volume for both recipients. After a mixed in-situ and ex-situ split, in order to improve logistics, the right trisectional graft was placed on a closed circuit NMP device, following an appropriate vascular reconstruction. Both grafts were implanted with excellent short-term outcomes.

CONCLUSION

Use of NMP with SLT for preservation prior to implantation allows not only for graft optimization but also for significant improvement of transplant logistics. We propose various models and standardization of logistic options for combining SLT with NMP to optimize graft availability and outcomes.

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.

Hepatic glycogen storage disease: Deciphering the genotype-phenotype conundrum

Glycogen storage diseases (GSDs) are a group of inherited disorders caused by genetic defects in various enzymes involved in glycogen production or breakdown. Hepatic GSDs often have overlapping clinical features, making subtyping or prognostication difficult. With the availability and advancement of next-generation sequencing, definitive molecular diagnosis is now available for most patients, with newer variants being increasingly identified. Molecular diagnosis could help in systematic follow-up, anticipating complications and prognostications. However, the mutations reported in the published literature display wide variations across racial and geographical groups. Hence, natural history, long-term outcome, and genotype-phenotypic correlation studies in patients with various hepatic GSDs are needed for a deeper understanding. Considering the emerging evidence of genetic profiling of patients with hepatic GSDs, including the recent study by Vanduangden et al, this editorial aims to review the various clinical subtypes, the spectrum of genetic mutations, and genotype-phenotype correlations for various hepatic GSDs.

Construction of vascularized liver microtissues recapitulates angiocrine-mediated hepatocytes maturation and enhances therapeutic efficacy for acute liver failure

Liver failure poses a significant challenge for millions of patients. The use of primary human hepatocytes and the engineering of liver organoids or liver tissue provide promising solutions to mitigate the shortage of donor organs. However, insufficient vascularization and functional immaturity remain major barriers impeding optimal functional recovery after transplantation. In this study, adult stem cells derived from human liver tissues were induced to form liver organoids, which were subsequently co-cultured with vascular organoids generated from human induced pluripotent stem cells in a defined ratio to create vascularized liver microtissues. This approach successfully established a complex vascular network analogous to that found in the liver, effectively recapitulating a more physiologically relevant liver architecture. Mechanistically, this configuration promoted the structural and secretory maturation of liver organoids through paracrine signaling from the vasculature. Following transplantation into the mesentery of mice, the vascularized liver microtissues rapidly established connections with the host vasculature and enhanced secretion of albumin into the bloodstream. Moreover, the transplantation of vascularized liver microtissues could effectively ameliorate liver injury and inflammatory responses, reduce apoptosis while promoting cell proliferation in CCl4-induced acute liver failure mice. These findings provide a robust platform for investigating the interactions between vessels and liver, and have important implications for liver failure treatment in the field of regenerative medicine.

Application of combi-elastography for follow-up after pediatric liver transplantation: A prospective study

OBJECTIVE

To investigate the use of combi-elastography in children after liver transplantation.

METHODS

Thirty-five children who underwent liver transplantation at our hospital were prospectively selected. Donor livers were divided into fatty liver and nonfatty liver groups according to the degree of fatty liver. Recipients were categorized into groups with (10 patients) and without complications (25 patients) according to the presence or absence of complications within 6 months after surgery. Combi-elastography was performed on each donor liver, and each patient underwent combi-elastography at the time of surgery and at 1 day, 7 days, 1 month, 3 months, and 6 months after surgery; the results of liver function tests were recorded at the same time points.

RESULTS

Despite the rapid recovery of liver function in the group without complications, the combi-elastography indices were still high in the early stage and gradually stabilized after 3 months but were still higher than those of the donor liver at 6 months. In the fatty liver group, the postoperative 1-day combi-elastography values were significantly higher than those in the nonfatty liver group, and in the group with complications, the postoperative 1-day combi-elastography values were significantly higher than those in the group without complications. The receiver operating characteristic (ROC) curve analysis revealed that the areas under the curves (AUCs) of the combi-elastography values for predicting complications in children at 6 months after liver transplantation were 8.41 kPa for Young's modulus (E) (with a sensitivity of 90 % (9/10 and a specificity of 76 % (19/25)) 1.26 for the F-index (FI) value (sensitivity 80 %(8/10), specificity 80 % (20/25)), and 1.05 kPa for the A-index (AI) value (sensitivity 80 %(8/10), specificity 72 % (18/25)).

CONCLUSIONS

Combi-elastography is useful for assessing changes in liver stiffness in the early period after liver transplantation and should therefore be considered for the follow-up of children who undergo liver transplantation.

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.

Neutrophil gelatinase-associated lipocalin for predicting acute kidney injury in orthotopic liver transplantation: a systematic review and meta-analysis

Acute kidney injury (AKI) is associated with poor prognosis. New biomarkers, like neutrophil gelatinase-associated lipocalin (NGAL), are helpful for early warning of AKI. This study aims to investigate the accuracy of NGAL in evaluating the perioperative AKI of liver transplantation. The four databases, PubMed, Web of Science, Embase, and Cochrane Library, were searched for relevant studies published from database inception to August 2023. Results were pooled using random-effects models, and heterogeneity was examined. A total of 16 case-control studies with 1271 patients were included. The results showed that both preoperative [standardized mean difference (SMD) = 0.53; 95% confidence interval (CI): 0.15, 0.91; P  < 0.001] and postoperative NGAL levels (SMD = 0.63; 95% CI: 0.24, 1.03; P  < 0.001) were higher in the AKI group compared with the non-AKI group. Subgroup analysis by continents showed higher preoperative NGAL levels in AKI patients in the European population (SMD = 1.63; 95% CI: 0.55, 0.27; P  = 0.003), but no differences in Asian, African, North American, and South American. Subgroup analysis by continents revealed higher postoperative NGAL levels in the European (SMD = 1.63; 95% CI: 0.55, 0.27; P  = 0.002) and Asian populations (SMD = 0.42; 95% CI: 0.04, 0.81; P  = 0.039). Higher postoperative NGAL levels in plasma and urine were observed in AKI patients compared with non-AKI patients [plasma (SMD = 1.29; 95% CI: 0.21, 2.38; P  = 0.011), urine (SMD = 0.88; 95% CI: 0.18, 1.59; P  = 0.035)], while there was no difference in African, North American, South American, and serum NGAL. NGAL level may be an important biomarker for early detection of AKI in the perioperative period of liver transplantation.

Improving outcomes of patients with pancreatic cancer

Research studies aimed at improving the outcomes of patients with pancreatic ductal adenocarcinoma (PDAC) have brought about limited progress, and in clinical practice, the optimized use of surgery, chemotherapy and supportive care have led to modest improvements in survival that have probably reached a plateau. As a result, PDAC is expected to be the second leading cause of cancer-related death in Western societies within a decade. The development of therapeutic advances in PDAC has been challenging owing to a lack of actionable molecular targets, a typically immunosuppressive microenvironment, and a disease course characterized by rapid progression and clinical deterioration. Yet, the progress in our understanding of PDAC and identification of novel therapeutic opportunities over the past few years is leading to a strong sense of optimism in the field. In this Perspective, we address the aforementioned challenges, including biological aspects of PDAC that make this malignancy particularly difficult to treat. We explore specific areas with potential for therapeutic advances, including targeting mutant KRAS, novel strategies to harness the antitumour immune response and approaches to early detection, and propose mechanisms to improve clinical trial design and to overcome various community and institutional barriers to progress.

Transforming Transplant Oversight: Enhancing Combined Cardiothoracic Surgery and Liver Transplantation With Normothermic Machine Perfusion

Background

Simultaneous cardiothoracic surgery and liver transplantation (LT) is a high-risk procedure associated with high mortality and morbidity rates. The use of normothermic machine perfusion (NMP) allows graft quality enhancement, assessment of liver viability, and logistics optimization, expanding the donor pool and reducing organ discard rate. We share our institution's experience with simultaneous cardiothoracic surgery and LT, using NMP for liver graft preservation and viability assessment.

Methods

Data was retrospectively collected from 14 patients who underwent simultaneous cardiothoracic surgery and LT with NMP for liver graft preservation from October 2022 to August 2023. Data was divided into 3 groups: combined heart transplant and LT, lungs transplant and LT, and nontransplant cardiothoracic surgery and LT.

Results

All liver grafts were from brain-dead donors. Median machine perfusion times were 211 min (range, 186-242 min), 222 min (range, 211-246 min), and 627 min (range, 180-1003 min) across the 3 groups, respectively. Postreperfusion syndrome occurred in 3 patients (21%), with 5 (36%) readmitted within 30 d because of complications. Biliary complications developed in 5 patients (36%), and 2 (14%) experienced acute liver rejection within 90 d postsurgery. No mortality was recorded during the median 18-mo follow-up.

Conclusions

NMP serves as a safe and valuable tool for patients in need of simultaneous cardiothoracic surgery and LT, potentially broadening the scope of eligibility for these complex procedures.

Normothermic regional and ex situ perfusion reduces postreperfusion syndrome in donation after circulatory death liver transplantation: A retrospective comparative study

In controlled donation after circulatory death (DCD) liver transplantation, ischemia-reperfusion injury is linked to postreperfusion syndrome (PRS), acute kidney injury (AKI), and early allograft dysfunction. Normothermic regional perfusion (NRP) and normothermic machine perfusion (NMP) are techniques that mitigate ischemic injury and associated complications. In this single-center retrospective study, we compared early transplant outcomes of DCD livers undergoing direct procurement (DP) and static cold storage (SCS) (DCD-DP-SCS), NRP procurement with SCS (DCD-NRP-SCS), or DP with NMP (DCD-DP-NMP). Two hundred thirty-eight DCD liver recipients were evaluated, comprising 59 DCD-DP-SCS, 101 DCD-NRP-SCS, and 78 DCD-DP-NMP. Overall, the PRS incidence was 19%. DCD-DP-SCS had a higher incidence of PRS (37%; P < .001), AKI stage ≥2 (47%; P = .033), and an increased model for early allograft function score (P < .001). In adjusted multivariate analysis, recipient age (odds ratio [OR] 1.10, 95% CI 1.05-1.17; P < 0.001), and normothermic perfusion (DCD-NRP-SCS: OR 0.16, 95% CI 0.06-0.39; P < .001; DCD-DP-NMP: OR 0.38, 95% CI 0.15-0.91; P = .032) were significant predictors of PRS, which itself was associated with worse 5-year transplant survival (graft survival non-censored-to-death; Hazard ratio (HR) 2.9, 95% CI 1.3-6.7; P = .012). Compared to SCS alone, the use of either NRP or NMP significantly reduced the incidence of PRS and AKI with better early graft function.

PErioperative respiratory care aNd outcomes for patients underGoing hIgh risk abdomiNal surgery (PENGUIN): a randomised international internal pilot trial

Background

Infections are a common complication of abdominal surgery in low- and middle-income countries (LMICs). The role of a high fraction of inspired oxygen (FiO2) and chlorhexidine mouthwash in preventing post-operative infections is unconfirmed.

Methods

Internal pilot phase of an international outcome assessor-blinded, 2x2 factorial randomised trial of patients aged ≥10-years undergoing midline laparotomy in LMIC hospitals. The main trial objectives are to compare the clinical effectiveness of preoperative 0.2% chlorhexidine mouthwash in preventing pneumonia versus no mouthwash, and 80-100% perioperative FiO2 to prevent surgical site infection (SSI) versus 21-35% FiO2. This 12-month internal pilot assessed feasibility of hospital site opening, patient recruitment, intervention adherence, patient follow-up and safety. Patients were randomised in a 1:1:1:1 ratio to the four intervention group combinations and followed up for 30 days.

Results

We recruited 927 patients from seven hospitals in India and South Africa over 12 months from November 2020. There were 907 adults (97.8%) and 20 children aged ten or over (2.2%): 89/927 (9.6%) patients died. Site opening reached 70% of our target (7/10) hospitals, and patient recruitment 107% (927/870). 917/927 (99%) patients in the mouthwash arm, and 840/927 (91%) patients in the oxygen arm received the allocated intervention. Lower adherence to the oxygen intervention related mainly to clinically necessary FiO2 increases in the 21-35% FiO2 arm. 30-day follow-up was completed appropriately for 924/927 (99%) patients. and was performed by a masked assessor for all patients. There were no reported safety events.

Conclusion

This pilot showed the feasibility and safety of a major phase III trial in post-operative infection prevention in LMICs.

Trial registration

ClinicalTrials.gov NCT04256798.

Normothermic Machine Perfusion vs. Static Cold Storage in Liver Transplantation: A Systematic Review and Meta-Analysis

BACKGROUND

Normothermic machine perfusion (NMP) represents an alternative to prolong liver preservation and reduce organ discard rates. We performed an updated systematic review and meta-analysis to compare NMP with static cold storage (SCS) in liver transplantation.

METHODS

MEDLINE, Embase, and Cochrane were searched for randomized controlled trials (RCTs) or observational studies. Risk ratios (RR) and mean differences were calculated. p < 0.05 was considered significant. A random-effects model was applied for all outcomes.

PROSPERO ID

CRD42023486184.

RESULTS

We included 1295 patients from 5 RCTs and 6 observational studies from 2016 to 2023. 592 (45.7%) underwent NMP. A subgroup RCT analysis favored NMP for non-anastomotic strictures (RR 0.4; 95% CI 0.2, 0.9), postreperfusion syndrome (RR 0.4; 95% CI 0.27, 0.56), and early allograft dysfunction (RR 0.6; 95% CI 0.4, 0.9). NMP favored higher organ utilization rates (RR 1.1; 95% CI 1.02, 1.18). No significant differences between NMP and SCS were observed in graft survival or patient survival at 12 months, primary non-function, serious adverse events, overall biliary complications, AST, or bilirubin levels peak within the first 7 days, ICU or hospital length of stay.

CONCLUSION

Our findings suggest that NMP is associated with lower non-anastomotic biliary stricture rates, postreperfusion syndrome, early allograft dysfunction, and higher organ utilization in the RCT subgroup analysis, without increasing adverse events.

Diagnostic and predictive biomarkers of acute rejection after liver transplantation

Liver transplantation serves as a vital therapeutic intervention for individuals suffering from end-stage liver disease globally. A significant complication encountered by liver transplant recipients during the postoperative period is acute rejection, which has traditionally been identified through invasive graft biopsy procedures. Furthermore, assessing the immune status of liver transplant patients is essential for effective posttransplant management and represents a significant advancement toward the personalization of immunosuppressive therapy. Nevertheless, current immunological monitoring after the transplantation predominantly depends on clinical judgment and the measurement of immunosuppressive drug levels, lacking a comprehensive evaluation of actual immune system suppression. In contrast, biomarkers offer a comparatively novel and safer approach for the detection and prediction of transplant rejection, though their clinical application remains constrained due to the absence of prospective validation studies. This review examines the existing literature on potential biomarkers for acute rejection following liver transplantation, and their implications for clinical decision-making.

Ex situ right posterior sectionectomy (H6,7) as liver graft reduction to overcome mismatch for small-body size adult

Small body size has been associated with an increased hazard ratio for mortality and dropout on the liver transplantation (LT) waitlist especially in female candidates. These findings could be explained by differences in anthropometric between genders, mainly due to smaller right anteroposterior diameter (RAP) of the right abdominal cavity in female. Reduction of graft volume by partial hepatectomy namely ex situ right posterior liver sectionectomy (H6,7) has been recently described to reduce liver grafts in adults. At our center, 4 female recipients, median RAP of 14 cm underwent LT with liver undergoing H6,7 graft reduction. Upon reduction, the graft weight passed from a median of 1654 g (range, 1640-1800) to 1365 g (range, 1230-1450) while the ratio graft weight/RAP passed from 114 g/cm (mean 111, range 102-120) to 93.3 g/cm (mean 92, range 82-98.5). The median cold ischemia time was 411 min (range, 343-478 min) and at a median follow-up of 268 days, all patients were alive with no vascular nor biliary complications and no retransplantation. Ex situ right posterior liver sectionectomy (H6, 7) represents a valid technical option to overcome mismatch for small-body size adult during liver transplantation. The need for this procedure remains exceptional and limited to small-body size adult recipient in urgent need for LT (i.e., fulminant liver failure, impairment of general conditions, ACLF, cancers, etc.) in which split liver transplantation could not be realized and/or is not available.

From Cells to Exosomes: a Review of Non-Surgical Biotherapeutic-Based Strategies for Liver Regeneration in the Face of End-Stage Diseases

Liver diseases, such as hepatitis, cirrhosis, and liver cancer, pose significant public health challenges, ranking as the twelfth leading cause of death globally. Given the liver's critical functions in metabolism, detoxification, and biosynthesis, its impairment can lead to severe consequences, often resulting in end-stage liver failure. Although liver transplantation is regarded as the definitive intervention for advanced liver disease, factors such as a shortage of donors and potential surgical complications necessitate the investigation of non-surgical regenerative medicine alternatives. This manuscript provides a comprehensive review of innovative non-surgical therapies aimed at liver regeneration, with an emphasis on both cell-based and cell-free approaches. It examines the contributions of various stem cell populations, including mesenchymal stem cells, hematopoietic stem cells, and induced pluripotent stem cells, in facilitating liver repair through mechanisms of differentiation and paracrine signaling. Furthermore, it explores the therapeutic potential of exosomes and conditioned media derived from stem cells as biotherapeutic agents in the context of regenerative medicine. By elucidating the mechanisms that underpin liver regeneration, this study aspires to inform the development of effective therapeutic strategies to address liver diseases and slow their progression. By elucidating the underlying mechanisms of liver regeneration, this study aims to contribute to the development of effective therapeutic strategies to address liver diseases and slow their progression.

Postoperative outcomes in older patients living with frailty and multimorbidity in the UK: SNAP-3, a snapshot observational study

BACKGROUND

Older surgical patients experience longer hospital stays and a higher risk of morbidity and mortality than their younger counterparts. Frailty (19.6% of cohort) and multimorbidity (63.1% of cohort) increase these risks. The 3rd Sprint National Anaesthesia Project (SNAP-3) describes the impact of frailty and multimorbidity on postoperative outcomes.

METHODS

We conducted a prospective observational cohort study over 5 days in 2022 aiming to recruit all UK patients aged ≥60 yr undergoing surgery (excluding minor procedures). Data included patient characteristics, clinical variables, Clinical Frailty Scale (CFS), multimorbidity (two or more comorbidities), length of stay (LOS), postoperative delirium, morbidity, and mortality. Quantile regression and mixed effects logistic regression were used to analyse relationships.

RESULTS

We recruited 7129 patients from 214 hospitals. Increasing frailty was associated with longer LOS, higher odds of delirium, morbidity, and mortality ≥1 yr, with a clear increase noted from CFS of 4 (19.0% of cohort). Amongst those without multimorbidity, individuals with CFS score of 4 had longer admissions than non-frail individuals (median LOS 0.75 days longer, 95% confidence interval [CI] 0.34-1.16), increasing to 2.69 days longer for CFS 5 (95% CI 0.76-4.62). Multimorbidity increased the odds of postoperative morbidity by 46% (adjusted odds ratio 1.46, 95% CI 1.24-1.73), but there was no evidence for multimorbidity impacting LOS, delirium, or mortality.

CONCLUSIONS

SNAP-3 highlights the impact of frailty on postoperative outcomes. Multimorbidity had less impact, with an effect on postoperative morbidity the only one to have strong statistical evidence. The impact of these conditions must be discussed with older patients considering surgical intervention.

Feasibility of laparoscopic sleeve gastrectomy in patients with severe obesity and complex abdominal wall hernias with loss of domain

PURPOSE

The literature recommends that patients with complex abdominal wall hernias (CAWH) and severe obesity should be managed with staged treatment, undergoing metabolic and bariatric surgery (MBS) before hernia repair. However, CAWH with loss of domain (LOD) presents a more challenging situation. This study presents the feasibility of Laparoscopic Sleeve Gastrectomy (LSG) in patients with CAWH and LOD.

METHODS

This is a retrospective cohort of unselected consecutive patients with CAWH and LOD defined based on Tanaka and Sabbagh's criteria who underwent LSG from 2016 to 2023. We documented a 90-day complication rate according to the Clavien-Dindo classification.

RESULTS

Sixteen patients, aged 55 ± 10.6 years with a mean BMI of 41.75 ± 4.75 kg/m2, met the inclusion criteria. The median hernia sac volume (HSV) was 3331.0 ml (IQR 2647.25-3616.25), achieving a median volume ratio of 44.69% (IQR 33.58-55.69) and 30.88% (IQR 25.14-34.70) according to Tanaka's and Sabbagh's criteria, respectively. There were no intraoperative complications or conversions. Three patients experienced major 90-day complications, with two requiring reoperations. There was no 90-day mortality.

CONCLUSION

LSG in patients with severe obesity and CAWH with loss of domain is safe and feasible but has a higher-than-expected rate of serious morbidity due to the complexity of this patient population.

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.

Impact of Coronavirus Disease (COVID)-19 on the Indigenous Population of Brazil: A Systematic Review

BACKGROUND

Indigenous peoples in Brazil were severely impacted by coronavirus disease (COVID)-19 pandemic, experiencing high rates of infection and mortality. Geographic isolation, limited access to healthcare, socio-economic disparities, and cultural factors, such as communal living and mistrust of state-led initiatives, heightened their vulnerability. Territorial invasions and oxygen shortages further exacerbated the crisis. Therefore, this systematic review aimed to explore the progression of COVID-19 in this population.

METHODS

A systematic review was conducted in PubMed-MEDLINE, SciELO (Scientific Electronic Library Online), and LILACS (Latin America and the Caribbean Health Sciences Literature) from the beginning of the pandemic in Brazil (2020) to March 2025. Studies addressing COVID-19 vaccination and epidemiological, social, and economic aspects among Indigenous populations in Brazil were included. Reviews and irrelevant studies were excluded. The quality of eligible studies was assessed using the Newcastle-Ottawa Scale.

RESULTS

A total of 50 relevant studies were included, grouped into thematic blocks: mortality/infection, symptoms, vaccination/testing, social impacts, and birth outcomes. Several studies highlighted that being male, of Indigenous or other racial minority background, and having comorbidities increased mortality risk. In contrast, asthma was associated with reduced mortality. Pregnant Indigenous women in rural areas had 33 times higher odds of dying than their urban counterparts. Furthermore, there is a higher likelihood of very low birth weight and inadequate prenatal care among Indigenous mothers. Vaccination reduced the risk of death, particularly after full immunization, though it did not prevent hospitalization. A cohort study of 389,753 Indigenous people showed a lower full vaccination rate (48.7%) compared to the general population (74.8%). Complete vaccination reduced the risk of death by 96% among hospitalized patients. Regarding seroprevalence, Indigenous people had a 5.4% positivity rate, much higher than other racial groups, and were 4.71 times more likely to test positive than White, Black, or Mixed Individuals. Socioeconomic disparities also correlated with increased infection risk.

CONCLUSIONS

The COVID-19 pandemic worsened health disparities among Indigenous peoples in Brazil, revealing systemic inequalities, weak public policies, and limited healthcare access. This review urges culturally sensitive, community-led responses and highlights the need for disaggregated data and equitable, inclusive health strategies.

Bulk and single-cell RNA sequencing identify prognostic signatures related to FGFBP2+ NK cell in hepatocellular carcinoma

Background

Hepatocellular carcinoma (HCC) is a highly aggressive malignancy. As a specific immune cell subpopulation, FGFBP2+ NK cells play a crucial part in immune surveillance of HCC progression. This study set out to identify prognostic signature related to FGFBP2+ NK cell in HCC.

Methods

Bulk and scRNA-seq data were derived from the public databases. The single cell atlas of HCC and heterogeneity of natural killer (NK) cells were delineated by "Seurat" package. Pseudo-time trajectory of FGFBP2+ NK cell was constructed by "Monocle2" package. Cell-cell interactions were analyzed by "CellChat" package. Prognostic signature was screened to develop a RiskScore model, and the prediction robustness was verified. Immune cell infiltration and immunotherapy response were assessed between different risk groups. Drug sensitivity was predicted by "oncoPredict" package. The expressions of the prognosis gene signature were detected by in vitro test utilizing HCC cells. The effects of key genes on the proliferative, migratory and invasive capacity of HCC cells were assessed by EdU assay, wound healing and Transwell assay.

Results

The proportion of NK cell in HCC samples was markedly decreased than that in healthy samples. NK cell was further divided into three cell subpopulations, and FGFBP2+ NK cell was associated with the prognosis of HCC patients. Pseudo-time trajectory analysis of FGFBP2+ NK cell revealed two differential expression gene clusters. FGFBP2+ NK cell exhibited extensive intercellular communication in HCC. Further, eight prognostic signatures were identified, including six "risk" genes (UBE2F, AHSA1, PTP4A2, CDKN2D, FTL, RGS2) and two "protective" genes (KLF2, GZMH). RiskScore model was established with good prognostic prediction performance. In comparison to low-risk group, high-risk group had poorer prognosis, lower immune cell infiltration, and higher TIDE score. Moreover, 16 drugs showed significant correlation with RiskScore. Additionally, the expressions of GZMH was downregulated while FTL, PTP4A2, UBE2F, CDKN2D, RGS2, and AHSA1 were up-regulated in HCC cells. FTL and PTP4A2 silencing could suppress the proliferation, migration and invasion abilities of HCC cells.

Conclusion

This study identified eight prognostic gene signatures related to FGFBP2+ NK cell in HCC, which may serve as potential therapeutic targets for HCC.

Perioperative SARS-CoV-2 infection and postoperative complications: a single-centre retrospective cohort study in China

OBJECTIVE

To explore the association between perioperative SARS-CoV-2 infection and the postoperative complications during the breakout of the Omicron epidemic wave.

DESIGN

Observational retrospective cohort study. Multivariable logistic regression was performed to explore the association between the duration from surgery to COVID-19 diagnosis and the likelihood of postoperative complications.

SETTING

A general hospital in China.

PARTICIPANTS

7927 patients aged 18 years and older who underwent surgical treatment between 1 December 2022 and 28 February 2023.

PRIMARY OUTCOME MEASURES

The outcome was a composite of postoperative adverse events that occurred within the initial 30 postoperative days.

RESULTS

Of all patients, 420 (11.76%) experienced postoperative complications. Compared with No COVID-19, preoperative COVID-19 within 1 week (pre-1w) exhibited a high risk of postoperative complications (adjusted OR (aOR), 2.67; 95% CI 1.50 to 4.78), followed by patients with pre-2w (aOR, 2.14; 95% CI 1.20 to 3.80). For patients with postoperative COVID-19 within 1 week (post-1w), the aOR was 2.48 (95% CI 1.48 to 4.13), followed by patients with post-2w (aOR 1.95; 95% CI 1.10 to 3.45), and those with post-3w (aOR 2.25; 95% CI 1.27 to 3.98). The risks of postoperative complications decreased roughly with the increase of the time interval between the surgery date and SARS-CoV-2 infection. Stratification analyses suggested that perioperative COVID-19 increased the risk of postoperative complications in older patients, smokers, those with comorbidities or experiencing moderate or severe COVID-19 symptoms.

CONCLUSIONS

Our findings reveal a significant time-dependent relationship between perioperative COVID-19 and postoperative complications, highlighting the importance of tailored preoperative risk evaluations, enhanced postoperative surveillance, and the implementation of effective postoperative COVID-19 prevention measures.

TRIAL REGISTRATION NUMBER

ChiCTR2300072473.

Waitlist outcomes after acuity circle-based distribution in pediatric liver transplantation

Pediatric liver transplant (LT) waitlist mortality remains unacceptably high. In 2020, the Organ Procurement and Transplantation Network (OPTN) implemented acuity circle (AC)-based liver distribution and national pediatric prioritization for pediatric donor livers. Using OPTN data, waitlist outcomes for pediatric LT candidates listed between February 4, 2016 and February 3, 2024, were studied by age group and era relative to AC implementation. There were 5,605 waitlist registrations and 3,778 liver transplants. At 1 year, cumulative incidence of transplant was 77.8% pre-AC vs 79.9% post-AC; cumulative incidence of mortality was 5.4% pre-AC vs 5.9% post-AC. Median allocation Model for End-Stage Liver Disease/Pediatric Model for End-Stage Liver Disease score at LT significantly decreased across all age groups post-AC (p<0.001). Candidates age 12-17 years experienced higher cumulative incidence of transplant (65.6% pre-AC vs 79.5% post-AC at 1 year), decreased median time to transplant (66 days pre-AC vs 37 days post-AC, p<0.001), and increased proportion of pediatric donor livers (37.9% pre-AC vs 66.2% post-AC, p<0.001). AC group was associated with increased likelihood of transplant for those age 12-17 years and increased likelihood of waitlist mortality for those age 1-5 years. LT candidates age 12-17 years derived the most benefit from AC-based liver distribution.

Immunosuppressive tumor microenvironment in pancreatic cancer: mechanisms and therapeutic targets

Pancreatic cancer is projected to become the second leading cause of cancer-related death by 2030. Conventional interventions including surgery, radiotherapy, and chemotherapy provide only modest survival benefits, underscoring an urgent need for more effective therapies. Although immunotherapy has revolutionized the management of several solid tumors, its clinical benefit in pancreatic cancer has so far been disappointing. Mounting evidence indicates that a highly immunosuppressive tumor microenvironment (TME), dominated by tumor-associated macrophages (TAMs), myeloid-derived suppressor cells (MDSCs), and regulatory T cells (Tregs), drives immune evasion, tumor progression, metastasis, and chemoresistance through complex cytokine and chemokine networks. This review summarizes current knowledge of these immunosuppressive mechanisms and provides emerging strategies aimed at re-educating or depleting these cellular constituents to enhance the efficacy of immunotherapy in pancreatic cancer.

Unraveling the immunosuppressive microenvironment of glioblastoma and advancements in treatment

Glioblastoma, the most common and aggressive primary brain tumor, remains a significant challenge in oncology due to its immunosuppressive tumor microenvironment (TME). This review summarizes the complex interplay of immune cells and cytokines within the TME, which contribute to immune evasion and tumor progression. We further emphasize the synergistic crosstalk among these components and how it shapes therapeutic vulnerability. Besides, we highlight recent advancements in immunotherapy, including immune checkpoint inhibitors, CAR-T cell therapy, NK cell therapy, oncolytic viruses, and vaccine-based strategies. Despite promising preclinical and clinical results, overcoming the immunosuppressive TME remains a critical hurdle. This review underscores the potential of targeting the TME to enhance therapeutic outcomes in glioblastoma.

Update on pediatric liver transplantation in Europe 2022: An ELITA-ESPGHAN report

OBJECTIVES

The European Liver Transplant Registry (ELTR) has been collecting data on liver transplantation (LT) in Europe since 1968. The aim of this report is to outline the number, techniques utilized, indications for, and outcomes of pediatric LT (pLT) in Europe, focusing on the Year 2022 in comparison to the preceding 5 years.

METHODS

Data were obtained from ELTR and Eurotransplant (ET). Summary statistics were performed.

RESULTS

In 2022, 585 pLTs were performed in Europe. The annual number of pLT decreased for the third consecutive year. Living donor LT represented 34% (n = 201) of pLT. The proportion of living donation (LD) remained stable over time. The major indication for pLT in Europe is biliary atresia. Donor age is increasing overall and is associated with worse graft survival. Graft and patient survival were impacted by both types of donors and types of grafts, and were significantly worse after re-transplantation. Most graft failures (77%) and deaths (82%) occurred within the first 6 months after pLT.

CONCLUSION

Annual numbers of pLT in Europe are decreasing over time. Given that the proportion of LD has remained stable, the shortage of deceased donor organs may not be the major reason for this trend, and other factors play a role. A focus on improving perioperative care is needed because the risk of graft loss and mortality is highest in the first 6 months after transplantation. New techniques like ex-situ machine perfusion may help mitigate risks with declining quality of deceased donor liver grafts.

European strategies in the screening of biliary atresia: a scoping review

Background

Biliary atresia (BA) is a rare condition that meets the criteria for neonatal screening. Taiwan province of China led the way in BA screening during the 1990s by introducing a neonatal stool color card (SCC), which proved effective in facilitating early BA diagnosis and improving outcomes. Another commonly studied BA screening approach is serum bilirubin measurement. Several European countries have also begun implementing BA screening initiatives, although slowly. In this study, we evaluate BA screening strategies across Europe.

Methods

Published data, after having performed a scoping review, as well as internet searches were analyzed. Screening approaches proposed in Europe are described, including SCC, serum bilirubin measurements, and other biochemical markers such as bile acids or amino acid profiles.

Results

In Europe, national BA screening programs have been established solely in Switzerland, France, and Germany, all using the SCC. Other European countries, such as the Netherlands, Portugal, and Italy, have made efforts, but have yet to achieve broad implementation beyond localized initiatives. Skepticism among healthcare professionals and logistical challenges seem to hinder broader adoption. Emerging technologies, such as artificial intelligence-enhanced SCC applications, may show promise in overcoming these barriers. Serum bilirubin measurement is another widely deliberated method, particularly in the UK, where it has been shown to be sensitive and specific for BA detection. However, logistical and financial limitations remain key obstacles to its widespread use. Other biochemical methods, such as bile acid and amino acid profiling, have shown potential in research settings, but lack clinical translation in Europe.

Conclusions

This review highlights Europe's limited role in global BA screening efforts and emphasizes the need for advocacy, collaboration, and integration of screening strategies tailored to regional healthcare systems. Combining the SCC with bilirubin measurements could optimize cost-effectiveness and efficiency. Expanding BA screening programs requires strengthening advocacy efforts to improve outcomes for affected infants.

Metabolic reprogramming in cancer therapy-related cardiovascular toxicity: Mechanisms and intervention strategies

Cancer therapy-related cardiovascular toxicity (CTR-CVT) poses a major challenge in managing cancer patients, contributing significantly to morbidity and mortality among survivors. CTR-CVT includes various cardiovascular issues, such as cardiomyopathy, myocardial ischemia, arrhythmias, and vascular dysfunction, which significantly impact patient prognosis and quality of life. Metabolic reprogramming, characterized by disruptions in glucose, lipid, and amino acid metabolism, represents a shared pathophysiological feature of cancer and cardiovascular diseases; however, the precise mechanisms underlying CTR-CVT remain inadequately understood. In recent years, strategies targeting metabolic pathways have shown promise in reducing cardiovascular risks while optimizing cancer treatment efficacy. This review systematically summarizes metabolic reprogramming characteristics in both cancer and cardiovascular diseases, analyzes how anticancer therapies induce cardiovascular toxicity through metabolic alterations, and explores emerging therapeutic strategies targeting metabolic dysregulation. By integrating current research advancements, this review aims to enhance the understanding of CTR-CVT and provide groundwork for the development of safer and more effective cancer approaches.

A polysaccharide from Agelas aff. Nemoechinata sponge: Structure and potential anti-liver cancer activity evaluation

This study utilized GC-MS and NMR to characterize the detailed chain structure information of polysaccharide (HM0-1) from the Agelas aff. Nemoechinata sponge, and then explored its anti-liver cancer in vitro. Results showed that the HM0-1 was a homogeneous amino-polysaccharide with a molecular weight of 929 kDa, composed of mannose (Man), N-Acetyl-glucosamine (GlcNAc), N-Acetyl-galactosamine (GalNAc), galactose (Gal) and fucose (Fuc). The main chain of HM0-1 was composed of α-(1 → 2)-linked Man and α-(1 → 6)-linked GlcNAc, and the side chains were α-Galp (1→, α-Fucp-(1 → 3)-α-Galp-(1→, α-Manp-(1→) and a branch composed of GalNAc and Gal, which was connected to the main chain through the 3-O position of →2)-β-Manp-(1→and→6)-β-Manp-(1→. Additionally, HM0-1 exhibited anti-liver cancer effects by inhibiting cell proliferation, migration and invasion, and inducing cell apoptosis. We further investigated the potential mechanism of HM0-1-induced apoptosis by RNA-seq, which revealed 3679 significantly altered DEGs. GO enrichment analysis of the DEGs revealed significant enrichment of 2444 GO terms throughout the differentiation process (P < 0.05). KEGG analysis showed that the DEGs were successfully annotated as members of 347 pathways, with 42 significantly enriched KEGG pathways. In conclusion, these studies can provide valuable insights into the potential development and utilization of sponge polysaccharides as marine natural bio-active compounds.

The Critical Role of Regulatory T Cells in Immune Tolerance and Rejection Following Liver Transplantation: Interactions With the Gut Microbiome

Liver transplantation (LT) is the ultimate treatment for patients with end-stage liver disease or early hepatocellular carcinoma. In the context of LT, because of the unique immunological characteristics of human liver allograft, 5%-20% of selected LT recipients can achieve operational tolerance. Nonetheless, there remains a risk of rejection in LT patients. Maintaining immune homeostasis is thus crucial for improving clinical outcomes in these patients. In mechanism, several immune cells, including dendritic cells, Kupffer cells, myeloid-derived suppressor cells, hepatic stellate cells, regulatory B cells, and CD4 + regulatory T cells (Treg), contribute to achieving tolerance following LT. In terms of Treg, it plays a role in successfully minimizing immunosuppression or achieving tolerance post-LT while also reducing the risk of rejection. Furthermore, the gut microbiome modulates systemic immune functions along the gut-liver axis. Recent studies have explored changes in the microbiome and its metabolites under various conditions, including post-LT, acute rejection, and tolerance. Certain functional microbiomes and metabolites exhibit immunomodulatory functions, such as the augmentation of Treg, influencing immune homeostasis. Therefore, understanding the mechanisms of tolerance in LT, the role of Treg in tolerance and rejection, as well as their interactions with gut microbiome, is vital for the management of LT patients.

Randomized trial investigating the utility of a liver tissue transcriptional biomarker in identifying adult liver transplant recipients not requiring maintenance immunosuppression

The maintenance of stable allograft status in the absence of immunosuppression (IS), known as operational tolerance, can be achieved in a small proportion of liver transplant recipients, but we lack reliable tools to predict its spontaneous development. We conducted a prospective, multicenter, biomarker-strategy design, IS withdrawal clinical trial to determine the utility of a predictive biomarker of operational tolerance. The biomarker test, originally identified in a patient cohort with high operational tolerance prevalence, consisted of a 5-gene transcriptional signature measured in liver tissue collected before initiating IS weaning. One hundred sixteen adult stable liver transplant recipients were randomized 1:1 to either arm A (IS withdrawal regardless of biomarker status) or arm B (IS withdrawal in biomarker-positive recipients). Immunosuppression withdrawal was initiated in 82 participants, rejection occurred in 54 (67.5%), and successful discontinuation of IS was achieved in 22 (27.5%), but only 13 (16.3%) met operational tolerance histologic criteria (10 in arm A; 3 in arm B). The biomarker test did not yield useful information in selecting patients able to successfully discontinue IS. Operational tolerance was associated with time posttransplant, recipient age, presence of circulating exhausted CD8+ T cells, and a reduced number of immune synapses within the graft.

Donor-specific immune senescence as a candidate biomarker of operational tolerance following liver transplantation in adults: Results of a prospective, multicenter cohort study

Immunosuppression can be withdrawn from selected liver transplant recipients, although robust clinical predictors of tolerance remain elusive. The Immune Tolerance Network ITN056ST study (OPTIMAL; NCT02533180) assessed clinical outcomes and mechanistic correlates of phased immunosuppression withdrawal (ISW) in nonautoimmune, nonviral adult liver transplant recipients. Enrolled subjects were ≥3 years posttransplant with minimal/absent inflammation or fibrosis on a screening liver biopsy. The primary end point was operational tolerance at 52 weeks following complete ISW. Of 61 subjects who initiated ISW, 34 failed during ISW and 10 restarted immunosuppression after completing ISW due to clinically manifest acute rejection. Only 10 of 17 clinically stable subjects remaining off immunosuppression at 1 year were ultimately deemed tolerant by biopsy. There were no cases of chronic rejection or graft loss; 28.3% developed de novo donor-specific antibody during ISW, which persisted in 11.3%. The majority of subjects (78.6%), including those who experienced rejection, ended the study on same or less calcineurin inhibitor than at baseline. A minority (16.4%) of histologically and clinically stable long-term adult liver transplant recipients can successfully discontinue and remain off immunosuppression. Increased frequency of donor-specific T cell senescence, C4d deposition, and higher density of immune synapses on the screening liver biopsy emerged as potential candidate biomarkers for operational tolerance.

β-Sitosterol protects against lithocholic acid-induced hepatotoxicity and cholestasis via farnesoid X receptor-mediated regulation of transporters and enzymes in vitro and in vivo

Cholestasis arises as a clinical syndrome triggered by the accumulation and aggregation of bile acids. Currently, there are only a few treatment options available for cholestasis. Therefore, it is necessary to explore novel therapeutic strategies. β-sitosterol (SIT), the phytosterol most abundantly found in plants, exhibits diverse pharmacological activities. This study examined SIT's protective role against hepatotoxicity and cholestasis induced by lithocholic acid (LCA). LCA was administered twice a day to male C57BL/6 mice for four days to cause hepatotoxicity and cholestasis. Assessment of the improvement in cholestasis following SIT treatment used H&E staining and serum biomarkers. Mice hepatocyte culture, real-time PCR, immunofluorescence staining, and Western blot were utilized to clarify the mechanisms of SIT hepatoprotection. Furthermore, molecular docking and dual-luciferase reporter gene analysis were utilized to show that SIT would activate the farnesoid X receptor (FXR). In vivo, SIT reduced bile acid accumulation by inducing the bile salt export pump (Bsep), multidrug resistance-related protein 2 (Mrp2), and reduced hepatic uptake of bile acids by inhibiting Na+/taurocholate co-transporting polypeptide (Ntcp), and cholesterol 7α-hydroxylase (Cyp7a1) and oxysterol 12α-hydroxylase (Cyp8b1) while in vitro, it restored FXR expression and transcriptional activity. Besides, SIT decreased hepatic inflammation by suppressing the inflammatory genes NF-κB p65 and p-NF-κB p65, TNF-α, IL-6, and IL-1β. However, the hepatoprotective effects of SIT were abolished by the FXR antagonist guggulsterone in vivo and FXR siRNA in vitro, confirming FXR-dependent mechanisms. In conclusion, SIT protects against LCA-induced hepatotoxicity and cholestasis via FXR activation. These findings highlight SIT as a promising therapeutic candidate for cholestasis.

Monoclonal antibodies as adjuvant therapies for resected melanoma

INTRODUCTION

Systemic adjuvant therapy is indicated in patients with high-risk, resected melanoma to reduce recurrence risk and potentially improve survival rates. Monoclonal antibodies (mAbs) target immune checkpoints and have made significant advances as systemic adjuvant therapies.

AREAS COVERED

This review discusses the main clinical trials that tested adjuvant mAbs in resected high-risk melanoma, including anti-cytotoxic T-lymphocyte antigen-4 (CTLA-4) and anti-programmed cell death-1 (PD-1); in addition to newer immunotherapies being tested in the adjuvant setting, including anti-lymphocyte activation gene 3 (LAG-3). We also briefly discuss targeted therapies as an alternative choice. Moreover, we highlight the pros and cons of using mAbs in the adjuvant setting, the reported adverse events (AEs), and the quality of life impact. Finally, we report data related to biomarker studies tested in the context of these clinical trials.

EXPERT OPINION

Immune checkpoint inhibitors (ICIs) have been shown to significantly improve relapse-free survival (RFS) as adjuvant therapy for high-risk melanoma. The long-term impact on overall survival (OS) was demonstrated in two trials that tested ipilimumab as compared to placebo (EORTC18071) and interferon-α (ECOG-ACRIN E1609). Furthermore, emerging data with neoadjuvant therapy followed by surgery and adjuvant therapy utilizing ICIs have demonstrated improved outcomes in the management of locoregionally advanced disease when compared to upfront surgery followed by adjuvant therapy alone.

Innovations to Expand the Liver Donor Pool: Machine Perfusion and Xenotransplantation

The number of patients awaiting liver transplant exceeds the number of liver grafts available. However, emerging technologies offer hope. Machine perfusion enhances the preservation, graft quality, and utilization of marginal livers, thereby reducing unnecessary graft discards. Xenotransplantation provides an alternative organ source, augmenting the donor supply or serving as a bridge for critically ill patients. These innovations are described in this review, as the recent clinical applications of these technologies promise to alleviate organ scarcity, improve transplant outcomes, and save lives.

Immunosuppression Post-Liver Transplant: End of the Calcineurin Era?

The introduction of calcineurin inhibitors (CNIs) as the primary form of immunosuppression (IS) for liver transplantation (LT) in the late 1970s was a key in increasingly successful outcomes for transplantation over the past 3 decades. Despite the side effects of CNI which directly contribute to the long-term morbidity and mortality post-LT, they will remain the cornerstone of IS in the near future. Efforts to minimize exposure to CNI will require the application of blood and tissue biomarkers that accurately identify the extent of IS and risk of rejection for individual patients.

Mega-authorship implications: How many scientists can fit into one cell?

The past 20 years has seen a significant increase in articles with 500 or more authors. This increase has presented problems in terms of determining true authorship versus other types of contribution, issues with database metadata and data output, and publication length. Using items with 500+ authors deemed as mega-author titles, a total of 5,533 mega-author items were identified using InCites. Metadata about the items was then gathered from Web of Science and Scopus. Close examination of these items found that the vast majority of these covered physics topics, with medicine a far distant second place and only minor representation from other science fields. This mega-authorship saw significant events that appear to correspond to similar events in the Large Hadron Collider's timeline, indicating that the projects for the collider are driving this heavy output. Some solutions are offered for the problems resulting from this phenomenon, partially driven by recommendations from the International Committee of Medical Journal Editors.

An exploration on the involvement of the methyltransferase like 3-m6A‑zinc finger MYM-type containing 1 axis in the progression of liver hepatocellular carcinoma

An existing study has underlined the involvement of Methyltransferase Like 3 (METTL3) and its mediated N6-methyladenosine (m6A) modification on zinc finger MYM-type containing 1 (ZMYM1) in cancers, and we aimed to explore their implication in liver hepatocellular carcinoma (LIHC). The levels of METTL3 and ZMYM1 in LIHC cells were gauged via qPCR. The involvement of METTL3 in LIHC progression was explored via assays in vitro and in vivo, and the mechanisms underlying the effects of METTL3 on LIHC were explored via m6A methylated RNA immunoprecipitation-qPCR (MeRIP-qPCR) and confocal immunofluorescence assays. METTL3, the m6A methyltransferase of interest, expressed relatively higher in LIHC. The promoting effects of METTL3 on LIHC progression were confirmed both in vitro and in vivo, and the relevant mechanisms maybe related to ZMYM1, a target of METTL3. Such effects of METTL3-m6A-ZMYM1 axis on the progression of LIHC were confirmed to be related to the inactivation of RAS/ERK/c-FOS pathway and the reduction in E-cadherin expression yet the elevation in N-cadherin and Vimentin expressions, therefore accelerating the metastasis in LIHC. Our study highlighted the possible involvement of METTL3-mediated m6A modification in LIHC and explored METTL3-m6A-ZMYM1 axis as a possible therapeutic target for the anti-metastatic strategy against LIHC.

Cell therapy for liver disorders: past, present and future

The liver fulfils a plethora of vital functions and, due to their importance, liver dysfunction has life-threatening consequences. Liver disorders currently account for more than two million deaths annually worldwide and can be classified broadly into three groups, considering their onset and aetiology, as acute liver diseases, inherited metabolic disorders and chronic liver diseases. In the most advanced and severe forms leading to liver failure, liver transplantation is the only treatment available, which has many associated drawbacks, including a shortage of organ donors. Cell therapy via fully mature cell transplantation is an advantageous alternative that may be able to restore a damaged organ's functionality or serve as a bridge until regeneration can occur. Pioneering work has shown that transplanting adult hepatocytes can support liver recovery. However, primary hepatocytes cannot be grown extensively in vitro as they rapidly lose their metabolic activity. Therefore, different cell sources are currently being tested as alternatives to primary cells. Human pluripotent stem cell-derived cells, chemically induced liver progenitors, or 'liver' organoids, hold great promise for developing new cell therapies for acute and chronic liver diseases. This Review focuses on the advantages and drawbacks of distinct cell sources and the relative strategies to address different therapeutic needs in distinct liver diseases.

Facilitators and barriers in managing older chronic heart failure patients in community health care centers: a qualitative study of medical personnel's perspectives using the socio-ecological model

Background

Community health care centers (CHCs) plays a crucial role in ensuring timely diagnosis and effective management of congestive chronic heart failure (CHF) in older patients. Understanding the current status of CHF management in CHCs can therefore be effective in reducing the disease burden of CHF.

Objectives

This study evaluates the current state of CHF services in community healthcare facilities and identifies key facilitators and obstacles faced by medical personnel in China.

Methods

This interpretive study applied the social ecological model (SEM) and used a semi-structured interview guide for data collection. Each interview lasted 45-60 min. Thematic analysis was used to analyze the data.

Results

This study involved 30 participants. Facilitators and barriers were identified within the five domains of the SEM. (1) Individual level: medical staff lack knowledge and experience in CHF management while patients' need for greater health education. (2) Interpersonal level: insufficient support from the patients' family and lack of trust in CHCs and staff. (3) Organizational level: inadequate medical knowledge and training programs for medical staff, shortage of medical staff and limited teamwork and few health promotion channels. (4) Community level: Lack of regular screening and follow-up, medical equipment and an information technology-assisted monitoring system. (5) Public policy level: lack of policy support, funding subsidies, national guidelines adapted to the local context and low medical insurance reimbursement rate.

Conclusion

There are many impediments to chronic disease management in the community, so it is vital to improve public understanding of CHF, as well as to improve the quality of community health equipment and services, to improve reciprocal referral mechanisms between hospitals and the community, and to develop policies on chronic disease management for CHF.

Trends in Clinical Outcomes After Major Emergency Abdominal Surgery in Denmark, Data From 2002-2022

Importance

Major emergency abdominal surgery is associated with high morbidity and mortality. Understanding trends in outcomes over time can reveal critical practice-changing improvements, identify gaps in postoperative care, and establish a large-scale benchmark for future research.

Objective

To investigate trends in morbidity and mortality after major emergency abdominal surgery in Denmark.

Design, Setting, and Participants

This was a nationwide, population-based cohort study. Analyses were performed based on data from Danish nationwide administrative registries. Within the public health care system in Denmark, all adult patients undergoing major emergency abdominal surgery from 2002 to 2022 were included. Major emergency abdominal surgeries included laparotomy or laparoscopy due to intra-abdominal pathologies, including intestinal perforation, ischemia, bowel obstruction, abscess, or bleeding.

Exposure

Major emergency abdominal surgery.

Main Outcomes and Measures

The primary outcome was the trend in 30- and 90-day mortality after major emergency abdominal surgery over time.

Results

A total of 61 476 patients (mean [SD] age, 66.2 [16.3] years; 34 827 female [56.7%]) were included. The annual number of surgeries remained constant, with a mean (SD) of 3044 (165) surgeries per year. The 30- and 90-day mortality was reduced from 25% and 33%, respectively, to 13% and 18%, respectively (P < .001). Median (IQR) hospital length of stay was decreased from 10 (5-17) days to 6 (4-13) days (P < .001). The rate of 30-day postoperative complications (classified Clavien-Dindo ≥3a) was reduced from 49% to 44% (P <.001) and the 90-day rate was reduced from 53% to 48% (P <.001), however, with a tendency toward more patients undergoing earlier intervention. The 30- and 90-day readmission rate increased drastically from 9% and 13%, respectively, to 25% and 33%, respectively (P < .001).

Conclusions and Relevance

Results of this cohort study suggest notable reductions in mortality and hospital length of stay after major emergency abdominal surgery. A marked increased readmission rate and a persistently high rate of postoperative complications were found. These shifts underscore the need for enhanced postoperative monitoring and postdischarge follow-up.

Expanding the Use of Ex Situ Organ Machine Perfusion Beyond Transplantation

Machine perfusion preservation of grafts has become the gold standard organ preservation method. It has been developed to improve the quality of grafts due to the increasing gap between demand and supply of organs for transplantation. Following successful long-term machine perfusion preservation with automated commercial devices developed for preservation of organs for transplantation, there is increasing interest in utilizing perfused discarded human organs and xenografts for a variety of purposes beyond transplantation including gene therapy and modulation, drug testing, chemotherapy, ex vivo surgery, organ supporting systems, bioengineering, and surgical training and education. Here, we review all current and potential applications of machine perfusion preservation.

Living-donor availability improves pediatric patient survival in a large North American center: An intention-to-treat analysis

Although living-donor liver transplantation (LDLT) is increasingly adopted for pediatric liver transplantation, there is limited data on whether live donation extends benefits to patients from the time of listing. This study investigated the benefits of pediatric LDLT through an intention-to-treat analysis. Pediatric candidates listed between 2001 and 2023 at a single Canadian center were categorized as pLDLT (with a potential live donor) or pDDLT (without a live donor). The primary endpoint was overall survival from the time of listing. The secondary endpoint involved the waitlist outcomes described by the probabilities of receiving liver transplantation or waitlist dropout. Among 474 candidates, 219 (46.2%) had potential live donors. The pLDLT group had a higher likelihood of receiving a liver transplantation (adjusted HR: 1.38, 95% CI: 1.16-1.64) and a lower risk of dying without a transplant (adjusted HR: 0.11, 95% CI: 0.01-0.82) compared to the pDDLT group. Survival rates from the time of listing were significantly better in the pLDLT group at 1-(98.6% vs. 87.6%), 5-(96.6% vs. 84.4%), and 10-(96.6% vs. 83.1%) years. Having a potential live donor was linked to a 72% reduction in mortality risk (adjusted HR: 0.28, 95% CI: 0.12-0.64). Although the number of patients listed annually increased over the study period, the waiting time for deceased donation shortened. This correlated with increased LDLT utilization, suggesting LDLT not only improved outcomes but also shortened wait times even for pDDLT patients. Having a potential live donor is associated with substantial survival benefit. Pediatric programs offering LDLT can expand the donor pool and decrease the waiting time for DDLT, supporting the argument for making LDLT a standard for pediatric candidates.

Ex vivo machine perfusion as a platform for lentiviral gene delivery in rat livers

Developing new strategies for local monitoring and delivery of immunosuppression is critical to making allografts safer and more accessible. Ex vivo genetic modification of grafts using machine perfusion presents a promising approach to improve graft function and modulate immune responses while minimizing risks of off-target effects and systemic immunogenicity in vivo. This proof-of-concept study demonstrates the feasibility of using normothermic machine perfusion (NMP) to mimic in vitro conditions for effective gene delivery. In this study, lentiviral vectors encoding the secreted biomarker Gaussia Luciferase (GLuc) and red fluorescent protein (RFP) were introduced ex vivo to rodent livers during a 72-h machine perfusion protocol. After an initial 24-h exposure to viral vectors, the organs were maintained in perfusion for an additional 48 h to monitor gene expression, aligning with in vitro benchmarks. Control livers were perfused in similar fashion, but without viral injections. Virally perfused livers exhibited nearly a 10-fold increase in luminescence compared to controls (p < 0.0001), indicating successful genetic modification of the organs. These findings validate the use of machine perfusion systems and viral vectors to genetically engineer whole organs ex vivo, laying the groundwork for a broad range of applications in transplantation through genetic manipulation of organ systems. Future studies will focus on refining this technology to enhance precision in gene expression and explore its implications for clinical translation.

Challenges in studying neuroanatomy in sub-Saharan Africa: The case of Cameroon

Introduction

Quality education is key in addressing the skilled neurological workforce gap in Africa. However, many medics are scared of the neurological sciences because of the challenges faced in medical schools in studying the neurosciences. Understanding its state and educational challenges is crucial for fostering interest in neurosurgery and related specialities on the continent.

Research question

What are the current state, challenges, and solutions to improve neuroanatomy education in Cameroon, Africa in miniature?

Materials and methods

A cross-sectional study using an 11-item electronic survey was conducted among medical students from all nine medical schools in Cameroon. Data were analysed using descriptive statistics and independent t-tests, with significance set at p < 0.05.

Results

Among 220 respondents, 40.1 % and 35.0 % respectively, reported cranial nerves/brainstem and neurovascular anatomy to be the most challenging, with a mean comprehension score of 5.83/10. Faculty predominantly relied on PowerPoint lectures (83.2 %), while most students supplemented learning with YouTube videos (77.7 %). 63.9 % of the respondents perceived classroom teaching alone to limit their understanding of neuroanatomy, and 85.8 % of students reported the time allocated for neuroanatomy teaching to be inadequate. The usage of cadaver dissection (69.5 %), and neurosimulation practicals (66.4 %) were the most recommended tools by students to improve neuroanatomy teaching.

Discussion and conclusion

Challenges in neuroanatomy education in Cameroon are perceived to arise from insufficient hands-on learning, time constraints, and limited access to specialised faculty. These suggest interactive teaching, increased curriculum time, and diverse resources as potential improvements, though further research is needed to assess their effectiveness and ultimately improve understanding, fostering a stronger neurological workforce.

Treatments and cancer: implications for radiologists

This review highlights the critical role of radiologists in personalized cancer treatment, focusing on the evaluation of treatment outcomes using imaging tools like Computed Tomography (CT), Magnetic Resonance Imaging (MRI), and Ultrasound. Radiologists assess the effectiveness and complications of therapies such as chemotherapy, immunotherapy, and ablative treatments. Understanding treatment mechanisms and consistent imaging protocols are essential for accurate evaluation, especially in managing complex cases like liver cancer. Collaboration between radiologists and oncologists is key to optimizing patient outcomes through precise imaging assessments.

Pancreatic neuroendocrine neoplasms coexisting with biliary intraductal papillary mucinous neoplasm: A case report and review of literature

BACKGROUND

Pancreatic neuroendocrine neoplasms (pNENs) are rare, heterogeneous tumors accounting for 1%-2% of pancreatic tumors, with significant malignant potential. Intraductal papillary mucinous neoplasm of the bile duct (IPMN-B) is a rare precancerous lesion in the bile duct system, with potential for malignancy. The combination of pNENs and IPMN-B is exceptionally rare and often leads to misdiagnosis. This study aims to report a rare case of pNENs combined with IPMN-B treated at Yanbian University Hospital to improve understanding and management of this unusual tumor combination.

CASE SUMMARY

We retrospectively analyzed a case from Yanbian University Hospital. We reviewed clinical records, imaging findings, endoscopic retrograde cholangiopancreatography, surgical exploration, and histopathological examination. The patient was diagnosed with pNENs and IPMN-B. Surgical treatment was performed, with follow-up showing effective management and no significant recurrence.

CONCLUSION

This case represents the first report of pNENs combined with IPMN-B. It highlights the need for thorough diagnostic evaluation to prevent misdiagnosis and improve treatment strategies.

Cost-effectiveness and clinical impact of robotic-assisted hepatectomy

Robotic-assisted hepatectomy has gained traction in hepatobiliary surgery, but its cost-effectiveness compared to traditional surgical approaches remains unclear. This study investigates clinical outcomes and financial implications of robotic-assisted liver surgery in a high-volume center, comparing it with open and laparoscopic methods. A retrospective cohort study was conducted on patients undergoing hepatectomy at Lille University Hospital in 2018 and 2021, performed by the institution's first experienced robotic hepatobiliary surgeon. Data on patient demographics, intraoperative details, postoperative outcomes, and costs were analyzed. Costs included hospital stays, surgical materials, and complications, derived from national cost studies. A total of 111 patients were included, with a rise in minimally invasive procedures from 47.5% in 2018 to 75% in 2021. Robotic-assisted hepatectomy was associated with reduced hospital stays, lower complication rates, and fewer severe morbidities compared to laparotomy. The average cost per procedure (all surgical approaches combined) decreased from €12,169 in 2018 to €8,513 in 2021, with robotic surgery offering a significant financial advantage. The total savings for the 71 patients in the 2021 cohort was €259,576, driven primarily by reduced hospitalization times and fewer complications. Robotic-assisted hepatectomy is clinically safe and cost-effective, offering substantial financial savings over traditional surgery. The reduction in postoperative complications and hospital stay durations, particularly for complex cases, highlights the advantages of robotic surgery in hepatobiliary procedures. As surgical expertise increases, robotic surgery represents a sustainable and efficient alternative in liver resection.

A scoping review of work patterns of junior medical officer tasks in hospital out of hours

BACKGROUND

The role of Junior Medical Officers (JMOs) is pivotal in ensuring the delivery of patient care in hospitals. The challenges of providing medical care for patients out of hours (OOH) fall disproportionately to the JMO group, with implications for supervision and well-being.

AIM

The aim was to identify and map the available evidence on the work patterns of hospital JMOs OOH, including tools for measuring tasks and workload; barriers to JMO well-being; factors which impact on the safety of care and strategies to reduce JMO workload OOH.

METHODS

A scoping review following Arksey and O'Malley and the Joanna Briggs Institute framework was performed. A total of 2446 articles were identified, and 49 individual articles were included.

RESULTS

Work performed during non-standard working hours (evenings, nights and weekends) has impacts on both patient safety (morbidity, mortality, intensive care unit readmission, procedural complications). The OOH period is associated with reduced training quality and diminished JMO well-being.

CONCLUSIONS

Strategies to reduce workload and maximise supervision are key to improving OOH care and JMO experience. A more detailed account of JMO work OOH is needed. Tools for studying workload should include direct observation.

Analysis of the incidence of post-cholecystectomy diarrhea and its influencing factors in Hainan Province

BACKGROUND AND AIMS

Cholecystectomy is one of the most common surgical procedures for the treatment of diseases associated with gallstones, and the incidence of post-cholecystectomy diarrhea (PCD) has attracted attention in recent years. The aim of this study was to assess the prevalence of PCD in patients with gallstones and to analyze the factors influencing it.

METHODS

Between August 2022 and December 2024, there were 3385 cases of gallstones diagnosed by abdominal ultrasound or CT examination and laparoscopic cholecystectomy in tertiary hospitals in Hainan Province. All participants in this study were followed up by telephone within 1 year postoperatively and by telephone survey using a standardized questionnaire. The incidence of PCD was calculated, and the relevant components of the follow-up were analyzed by one-way and multifactorial logistic regression using SPSS 26.0 statistical software.

RESULTS

Four hundred seventy-nine patients (14.2%) developed PCD after undergoing laparoscopic cholecystectomy. Univariate analysis showed that age, BMI, dietary patterns, history of diabetes, alcohol consumption, gallstones and fatty liver disease were associated with the development of PCD ( P < 0.05). Binary logistic regression analysis showed that age (OR = 0.532, P = 0.010), BMI (OR = 40.615, P < 0.001), dietary patterns (OR = 0.635, P = 0.013), and history of diabetes (OR = 0.263, P < 0.001) were independent risk factors.

CONCLUSION

The incidence of PCD in Hainan Province is 14.2%. Over 50 years old, BMI, dietary pattern and history of diabetes were independent risk factors for the occurrence of PCD.