The clinical implications of trial endpoints in immunotherapy for hepatocellular carcinoma

INTRODUCTION

Investigative work in the treatment of hepatocellular carcinoma is rapidly growing with the advent of immunotherapy. Nonetheless, trial endpoints and, more importantly, clinically meaningful endpoints need to be accurately chosen depending on the phase of trial and the patient population studied. We provide a scoping review focusing on trial endpoints on the use of immunotherapy in hepatocellular carcinoma.

AREAS COVERED

We searched PubMed and Google Scholar for prospective phase II and III trials using immunotherapy, whether in the neoadjuvant, adjuvant, bridging, downstaging, or palliative settings, while discussing the clinical implications of trial endpoints.

EXPERT OPINION

The field of immune oncology is rapidly progressing and has become the standard of care in advanced hepatocellular carcinoma. However, the role of immunotherapy in the treatment of early and intermediate stage hepatocellular carcinoma is yet to be defined. Prospective trials for all stages of disease must strive for endpoints that are not only statistically significant but also clinically consequential. Whereas overall response rate may be a reasonable trial endpoint in phase II trials, phase III trials should rather aim for the improvement of overall survival or quality of life to have clinically meaningful impacts.

Multi-omic analysis reveals a CAF-stemness-governed classification in HCC liver transplant recipients beyond the Milan criteria

In patients with hepatocellular carcinoma (HCC) meeting the Milan criteria, liver transplantation (LT) is an effective therapy. This study aims to define the survival-related molecular biological features helping precisely identifying the patients with HCC beyond the Milan criteria who have acceptable outcomes. In the derivation cohort, integrated analyses of tumor tissues are conducted using RNA sequencing (RNA-seq), proteomic landscape, and transposase-accessible chromatin sequencing (ATAC-seq). Based on transcriptomics, three subgroups that significantly differ in overall survival were identified in the derivation cohort, and these findings are validated in an independent cohort. In-depth bioinformatics analysis using RNA-seq and proteomics reveals that the promotion of cancer stemness by cancer-associated fibroblasts (CAFs) can be responsible for the negative biological characteristics observed in high-risk HCC patients. The ATAC-seq identifies key factors regulating transcription, which may bridge CAF infiltration and stemness. Finally, we demonstrate that the CAF-derived CXCL12 sustains the stemness of HCC cells by promoting XRCC5 through CXCR4.

lncSLERT Promotes Liver Metastasis in Colorectal Cancer by Down-Regulating HUNK Expression via RBM15-Mediated m6A Modification

Background

Metastasis is a hallmark of cancer and the leading cause of cancer-related mortality. However, the mechanism underlying liver metastasis in colorectal cancer (CRC) remains incompletely understood. This study explores the role of long non-coding RNA (lncRNA) SLERT in promoting CRC liver metastasis by downregulating HUNK expression.

Methods

SLERT expression levels in CRC tissues were analyzed and correlated with patient survival outcomes. Functional assays, including migration and invasion assays, were performed to assess the impact of SLERT knockdown and overexpression on metastatic behavior. Mechanistic studies examined SLERT's interaction with the RNA-binding protein RBM15 and its effect on HUNK mRNA stability. The subcellular localization of SLERT was also determined.

Results

SLERT was significantly upregulated in CRC tissues and associated with poor survival outcomes. Silencing SLERT inhibited CRC cell migration and invasion, whereas its overexpression enhanced these metastatic properties. Mechanistically, SLERT interacted with RBM15, impairing its ability to stabilize HUNK mRNA, leading to decreased HUNK expression and increased metastatic potential. SLERT was primarily localized in the cytoplasm, indicating its active role in gene regulation within the tumor microenvironment.

Conclusion

LERT promotes liver metastasis in CRC by downregulating HUNK expression through RBM15-mediated mRNA destabilization. These findings suggest that SLERT could serve as a diagnostic biomarker and therapeutic target. Targeting SLERT or restoring HUNK expression may provide novel strategies to combat CRC liver metastasis and improve patient prognosis.

Long-Term Outcomes of Liver Transplant Recipients. What Do Patients Die From?

BACKGROUND

Several advances in liver transplantation (LT) have provided an increased rate in 1-year patient survival, currently reported between 84.5% and 91.4%. However, this significant improvement is not widely maintained after the 1-year of follow-up. In this study, we analyze short-term and long-term results in LT recipients.

METHODS

A retrospective observational cohort study, including patients who underwent LT between 1990 and 2009 and were followed for a minimum 15-year period, analyzing the causes and risk factors of mortality and patient and graft survival from LT up to the last outpatient visit.

RESULTS

A total of 594 patients with LT were included (median age, 53-year and 69.7% male). The most common indications for LT were HCV-cirrhosis (267 patients), alcoholic cirrhosis (250 patients), and hepatocellular carcinoma (HCC) (144 patients). Post-LT complications were acute rejection in 44.1%, cardiovascular in 40.6%, chronic kidney disease in 40.1%, hypertension in 22.6%, and de novo tumors in 25.6%. Retransplantation was performed in 40 (6.7%) patients. A total of 388 (65.3%) patients died during a follow-up over 20 years: 106 (17.8%) in the first year post-LT; 76 (12.8%) between 2 and 5 years; 75 (12.6%) between 6 and 10 years; 73 (812.3%) between 11 and 15 years; 30 (5%) between 16 and 20 years; and 28 (4.7%) after 20 years. The overall causes of death were infection in 69 (11.6%) patients, cardiovascular complications in 58 (9.8%) patients, pulmonary complications in 8 (1.3%) patients, liver graft failure in 126 (21.2%) patients, HCC recurrence in 15 (2.6%) patients, de novo tumors in 72 (12.1%) patients, and miscellaneous in 40 (6.7%) patients. Rates of actuarial patient survival at 1-, 3-, 5-, 10-, 15-, and 20-year after LT were 82.7%, 75.6%, 70%, 58.6%, 45.2%, and 37.6%, respectively, and actuarial graft survival were 80%, 72.5%, 67.1%, 54.8%, 42.6%, and 34.6%, respectively. Advanced recipient age, blood transfusion, and infection were the main risk factors for patient mortality.

CONCLUSIONS

The highest mortality rate was within the first year of LT, and the most common causes of death were hepatic failure, de novo tumors, infection, cardiovascular disease, and HCC recurrence.

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.

EASL Clinical Practice Guidelines on the management of autoimmune hepatitis

Autoimmune hepatitis (AIH) is a chronic liver disease of unknown aetiology which may affect any patient irrespective of age, sex, and ethnicity. At baseline, the clinical spectrum of the disease varies largely from asymptomatic cases to acute liver failure with massive hepatocyte necrosis. The aim of these EASL guidelines is to provide updated guidance on the diagnosis and management of AIH both in adults and children. Updated guidance on the management of patients with variants and specific forms of AIH is also provided, as is detailed guidance on the management of AIH-associated cirrhosis, including surveillance for portal hypertension and hepatocellular carcinoma, as well as liver transplantation in decompensated cirrhosis.

Liver transplantation as a treatment for cancer: comprehensive review

BACKGROUND

Liver transplantation for cancer indications has gained momentum in recent years. This review is intended to optimize the care setting of liver transplant candidates by highlighting current indications, technical aspects and barriers with available solutions to facilitate the guidance of available strategies for healthcare professionals in specialized centres.

METHODS

A review of the most recent relevant literature was conducted for all the cancer indications of liver transplantation including colorectal cancer liver metastases, hilar cholangiocarcinoma, intrahepatic cholangiocarcinoma, neuroendocrine tumours, hepatocellular carcinoma and hepatic epitheloid haemangioendothelioma.

RESULTS

Transplant benefit from the best available evidence, including SECA I, SECA II, TRANSMET studies for colorectal liver metastases, various preoperative protocols for cholangiocarcinoma patients, standard, extended selection criteria for hepatocellular carcinoma and neuroendocrine tumours, are discussed. Innovative approaches to deal with organ shortages, including machine-perfused deceased grafts, living donor liver transplantation and RAPID procedures, are also explored.

CONCLUSION

Cancer indications for liver transplantation are here to stay, and the selection criteria among all cancer groups are likely to evolve further with improved prognostication of tumour biology using adjuncts such as radiomics, cancer genomics, and circulating DNA and RNA status. International prospective registry-based studies could overcome the limitations of smaller patient cohorts and lack of level 1 evidence.

Gastroenterology/Hepatology: What You May Have Missed in 2024

This article highlights selected major advances in gastroenterology and hepatology from 2024 that are relevant for internal medicine specialists. In colorectal cancer (CRC) screening, new developments include a head-to-head comparison of different fecal immunochemical tests and a new blood-based DNA screening test, benefits and harms of artificial intelligence-assisted colonoscopy, and adenoma detection rate improvement and risk for cancer. Treatment options for metabolic dysfunction-associated steatotic liver disease now include resmetirom, a recently approved drug for treatment of patients with moderate-to-severe fibrosis, and liver transplantation may now be an option in patients with unresectable colorectal liver metastases. Also featured are new data on the efficacy of indomethacin and pancreatic stent placement for prevention of pancreatitis after endoscopic retrograde cholangiopancreatography and news on the efficacy and safety of zastaprazan, a new potassium-competitive acid blocker for reflux esophagitis. Finally, a recent randomized trial is highlighted that has dispelled concerns about potential harms of proton-pump inhibitors for stress ulcer prophylaxis in patients receiving invasive mechanical ventilation.

Role of Locoregional Therapy on Survival After Living Donor Liver Transplantation for Hepatocellular Carcinoma--Experience from a High-volume Center

Background

Locoregional therapy (LRT) in patients with hepatocellular carcinoma (HCC) before liver transplantation (LT) has a role in improving the tumor biology and post-LT survival outcome apart from downstaging and bridging. We retrospectively analyzed our database of adult living donor liver transplants (LDLT) for HCC, to compare the survival outcomes in Group-1 (upfront-LT, HCC within Milan/UCSF/AFP<1000 ng/ml) and Group-2 (LT post-LRT, HCC beyond UCSF/irrespective of tumor burden with AFP>1000 ng/ml). We also explored the risk factors for recurrence on follow-up.

Methods

A study group (n = 506, Group-1-348, Group-2 = 158) of patients with HCC who underwent LDLT between July 2006 and December 2022, excluding incidental HCC (n = 42), patients with other histology (n = 13) and in-hospital mortality (n = 43), were analyzed. Study cohort (n = 341), after propensity score matching, was analyzed for survival outcomes (overall survival, OS and disease-free survival, DFS) and risk factors for recurrence between Group-1 (n = 156) and Group-2 (n = 158).

Results

Group-2 exhibited a trend towards better mean OS and DFS compared to Group-1 (OS-133 vs. 107-months, P = NS, DFS-118 vs. 102-months, P = NS). Long-term OS (10-year) for those within Milan and UCSF criteria was superior in Group-2, P = NS. Complete pathological response (cPR) after LRT (46.8%), significantly improved OS and DFS compared to those with partial response and stable disease; 152 vs. 94 vs. 49 months, P = 0.001, and 147 vs. 75 vs. 41 months, P = 0.006, respectively. Recipient age, size of tumor, and pre-LT serum alpha-fetoprotein (AFP) were independent predictors of cPR. Independent risk factors for recurrence included pre-LT AFP, tumors beyond UCSF, perineural invasion, and high-grade tumors.

Conclusion

Locoregional therapy in HCC offers significantly better OS and DFS in those who had a complete pathological response. Risk factors for recurrence post-LT were AFP level, beyond UCSF tumors, and high-grade HCC with PNI on histology.

[Frozen sections in hepatobiliary surgery]

Complete removal of the tumor (R0 resection) is one of the most important prognostic factors for overall and recurrence-free survival in patients with hepatobiliary malignancies. Accordingly, the intraoperative confirmation of tumor-free resection margins is of central importance. At the same time, despite extensive preoperative diagnostics intraoperative findings can arise that require immediate histological clarification. For example, the discovery of peritoneal carcinomatosis or previously unknown intrahepatic metastases often leads to the termination of the operation and thus to a change in the oncological concept. In addition, the estimation of the local tumor spread, particularly in the case of biliary tumors related to the liver hilum, is sometimes difficult based on preoperative imaging, so that a timely intraoperative assessment of tissue samples is necessary to confirm the resectability. The possibility of intraoperative frozen section diagnostics is, therefore, of particular importance, especially in complex surgical interventions in the hepatobiliary area.

Sclerosing Encapsulating Peritonitis: A Surgical Challenge in Liver Transplantation

Sclerosing Encapsulating Peritonitis (SEP) is a rare condition characterized by chronic inflammation of the peritoneum, of either idiopathic origin or sometimes due to local or systemic factors. The symptoms are often non-specific, and in many cases, the diagnosis is only made during laparotomy or laparoscopy. In severe cases, SEP can be a contraindication for liver transplantation because of the associated risk of surgical complications.

METHOD

To report on the incidence and management of SEP identified during liver transplantation at our center, and to document the associated Serious Adverse Events (SAEs).

RESULTS

We present a series of 3 cases from 2022 to 2023, where SEP was diagnosed intraoperatively. These cases were marked by significant technical challenges, including extensive adhesions, dense fibrous encapsulations, and severe intraoperative hemorrhage necessitating blood transfusions. Despite these complexities, all transplants were successfully completed. One patient experienced a peak serum AST of 2000 U/L, and another had a bilirubin of 10 mg/dL, indicative of early graft dysfunction, both of which resolved within the first week. One patient required an emergency laparotomy due to hemorrhage. No additional severe complications were observed postoperatively. All patients are currently alive with functioning grafts and have been followed for at least 18 months.

CONCLUSIONS

A multidisciplinary approach and advanced surgical planning are crucial for successfully performing complex liver transplants in patients with SEP. Intraoperative recognition of SEP requires meticulous strategies to minimize blood loss and optimize hemostasis, while avoiding organ injuries, as these factors are critical for improving the survival outcomes in these patients.

Assessment of anaesthesia trainees using performance metrics derived from electronic health records: a longitudinal cohort analysis

BACKGROUND

The development of competencies in anaesthesia residents is assessed by direct observation of their performance and written and oral examinations. Little is known about how residents' competencies are reflected by objective data in anaesthetic records. We investigated whether performance metrics derived from electronic anaesthesia records are associated with anaesthesia residents' progress of training and European written examination timing and results.

METHODS

We recruited 46 anaesthesia providers who trained at the Vienna University Hospital between September 2013 and June 2021, and we reviewed the anaesthesia records of all cases they managed during the study period. We derived six performance measures based on perioperative data routinely collected: intraoperative hypotension and hypothermia, glycaemic control, postoperative nausea and vomiting prevention, lung-protective ventilation, and postoperative kidney injury. We evaluated the association between these quality metrics with training level and written exam completion status in anaesthesia residents after adjusting for patient and surgical factors.

RESULTS

We found a statistically significant association between the level of training and most performance measures. The probability of preventing intraoperative hypotension increased (OR 1.16, 95% CI 1.12 - 1.20) with the level of training, as did the probability of preventing hypothermia (OR 1.08, 95% CI 1.05 - 1.11) and administering appropriate postoperative nausea and vomiting prophylaxis (OR 1.21, 95% CI 1.15 - 1.27). However, the odds of preventing acute kidney injury decreased (OR 0.91, 95% CI 0.83 - 0.99), as did the use of lung-protective ventilation (OR 0.94, 95% 0.92 - 0.97). All participating residents who took the written exam passed it, precluding a direct pass versus fail comparison, but the exam completion status was associated with increased odds of lung-protective ventilation (OR 1.42, 95% CI 1.03 - 1.95) and decreased odds of preventing intraoperative hypotension (OR 0.7, 95% CI 0.49 - 0.99). Glycaemic control was not associated with either of the training milestones.

CONCLUSIONS

The training level of anaesthesia residents had a significant association with several performance metrics. Passing the written exam only had a modest effect. Performance measures based on patient outcomes and intraoperative care may serve as assessment methods for anaesthesia residents' progress tracking.

EORTC consensus recommendations on the optimal management of colorectal cancer liver metastases

Patients with colorectal cancer liver metastases have long represented a unique and thoroughly investigated population. Nevertheless, the optimal management of these is still controversial with a number of open questions which are only partially addressed by available studies and existing guidelines. The European Organisation for Research and Treatment of Cancer (EORTC) Gastrointestinal Tract Cancer Group (GITCG) sought to fill this knowledge gap and promoted the development of a European consensus on this subject. By using the Delphi methodology and leveraging a multidisciplinary team of 43 international experts, including gastrointestinal oncologists, hepatobiliary surgeons, interventional radiologists, radiation oncologists, radiologists, nuclear medicine physicians and pathologists from 12 European countries, 34 practical recommendations and two consensus statements were proposed. These cover varying aspects of the optimal management of colorectal cancer liver metastases such as baseline imaging, selection criteria for liver-directed therapies, treatment strategies, assessment of treatment response, follow-up, care delivery, clinical research and future perspectives. This roadmap document is intended to complement national and international guidelines, and to provide practical guidance for clinicians and multidisciplinary teams, ultimately promoting practice standardisation, optimal management and better patient outcomes across Europe. Also, it provides a unique opportunity to highlight grey areas and unmet needs, and to give a strategic direction to future research in the field by identifying topics where there is no consensus among experts.

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.

Serum pro-inflammatory cytokine interleukin-6 level is predictive of further decompensation and mortality in liver cirrhosis

AIM

Systemic inflammation drives the progression of portal hypertension in patients with liver cirrhosis. Interleukin-6 is a key mediator of the cytokine network in acute inflammation that stimulates the production of many acute phase reactants. In this study, we investigated the association between serum interleukin-6 and acute phase reactant levels and the disease stage and prognosis of patients with liver cirrhosis.

METHODS

A single-center retrospective cohort of 359 patients with liver cirrhosis was staged according to the symptomatic decompensation. Baseline serum C-reactive protein , interleukin-6, procalcitonin, and serum amyloid A protein levels were measured. The outcomes of further decompensation, hepatocellular carcinoma development, and mortality were identified during a 3.3-year median follow-up period.

RESULTS

Serum C-reactive protein , interleukin-6, and procalcitonin levels were significantly different across the stages. The multivariate Cox proportional hazards model identified serum interleukin-6 as an independent predictor of further decompensation in patients with compensated and the first single decompensated cirrhosis. Kaplan-Meier analyses showed that the probability of further decompensation was stratified by serum interleukin-6 level in a dose-dependent manner. In the entire cohort, serum interleukin-6 level also showed a significant association with liver-related and all-cause mortalities, but not with hepatocellular carcinoma development, independent of stage and liver disease severity indices.

CONCLUSIONS

Elevated levels of serum markers of systemic inflammation were associated with symptomatic decompensation, and serum interleukin-6 level is a predictor of further decompensation and mortality in patients with liver cirrhosis.

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.

Role of Liver Transplant in Primary and Secondary Liver Malignancies

Hepatocellular carcinoma (HCC) and cholangiocarcinoma are the primary hepatic malignancies with established pathways to transplantation and model for end-stage liver disease (MELD) exception points. Other tumors managed with liver transplantation (LT) include hepatic epithelioid hemangioendothelioma and fibrolamellar HCC. LT for metastatic neuroendocrine tumor has been established with patient selection criteria and a path to MELD exception points. Additionally, recent data on LT for patients with unresectable hepatic colorectal metastases demonstrate increasingly encouraging initial results.

Incidence and risk factors for chronic rejection in pediatric liver transplantation

Chronic rejection (CR) is a progressive immunological injury that frequently leads to long-term liver allograft dysfunction and loss. Although CR remains an important indication for retransplantation, as transplant immunosuppression has evolved, its prevalence in adults undergoing liver transplantation (LT) has declined. However, the incidence and factors that lead to CR in pediatric LT are poorly defined. Therefore, we sought to systematically measure CR's incidence and assess both the risk factors for developing CR and outcomes in a large cohort of pediatric recipients of LT. In this single-center study, we retrospectively analyzed and compared relevant recipient characteristics, surgical details, immunosuppression, graft, and patient survival in the CR and control groups over a 17-year period. After a median time of 1.9 years after LT, 19/356 recipients of LT (5.3%) developed CR in our cohort. Posttransplant lymphoproliferative disorder ( p = 0.01), infections ( p = 0.02), autoimmune liver diseases (HR = 7.3, p = <0.01), Black race (HR = 11.5, p = 0.01), and 2 or more episodes of T cell mediated rejection (HR = 5.1, p = <0.01) were associated with CR development. The retransplantation rate among CR cases was 15.8% at a median follow-up time of 4.1 years. Overall, patient survival was lower in the CR group (78.9%) versus controls (91.1%). While CR incidence in our pediatric cohort was lower than previously reported rates of >12%, the CR group had a higher graft failure rate that required retransplantation and lower overall patient survival. Thus, identifying risk factors may warrant specialized immunosuppression protocols and closer posttransplantation monitoring to reduce the risk of morbidity and mortality from CR.

Recurrent and De Novo Liver Disease After Liver Transplantation

Disease recurrence after liver transplantation (LT) is common. Certain liver diseases such as autoimmune hepatitis and steatotic liver disease may appear de novo after LT. This review discusses post LT alcohol-associated liver disease, metabolic dysfunction-associated liver disease, autoimmune hepatitis, primary biliary cholangitis, and primary sclerosing cholangitis. Both recurrent and de novo diseases are important causes of allograft failure.

A novel ypN-TRG staging system for gastric cancer patients after neoadjuvant therapy based on the metro-ticket paradigm: a multicenter and large sample retrospective analysis

BACKGROUND

Conventional ypT category evaluates the depth of invasion after neoadjuvant therapy (NAT) for gastric cancer (GC) and has limited prognostic value. Tumor regression grade (TRG) measures the extent of tumor response to treatment, and when combined with the ypN category, it may enhance the prediction of patient outcomes. This study aims to develop a new staging system by integrating TRG and ypN category to better evaluate the prognosis of GC patients receiving NAT.

METHODS

This retrospective analysis included 962 patients who underwent radical gastrectomy after NAT, with 513 in the development cohort (from one center) and 449 in the external validation cohort (from five centers). The ypN-TRG staging system was established by calculating the distance from the origin on a cartesian plane incorporating the ypN (x-axis) stage and TRG (y-axis) grade, and five sub-stages were delineated.

RESULTS

In the development cohort, 3-year overall survival rates according to ypN-TRG stage I, IIA, IIB, IIIA, IIB were 87.6%, 80.2%, 70.7%, 47.3%, 21.5%, p < 0.01. Compared with ypTNM, the ypN-TRG staging system performed better in terms of the prognostic discrimination power (C-index), goodness-of-fit (AIC, BIC), model improvement (NRI, IDI), and model stability (time-AUC). Multivariate Cox regression analysis confirmed the superiority of ypN-TRG over ypTNM staging. In the external validation cohort, ypN-TRG staging was a better predictor of OS and DFS in patients with GC.

CONCLUSIONS

The ypN-TRG staging system is superior to the AJCC eighth edition ypTNM staging system in accurately assessing the prognosis of patients with GC after NAT.

Monosegmental Reduction as Strategy to Simplify Venous Reconstruction During Pediatric Liver Transplantation

BACKGROUND

Pediatric liver transplantation in small children is a technical challenge; the use of liver grafts from living donors improves access but faces further technical difficulties due to size mismatch and anatomical variants. Avoiding outflow complications is a major concern in pediatric liver transplantations.

CASE REPORT

A 14-month-old girl weighing 6.2 kg with extrahepatic biliary atresia without ascites was referred to our hospital. Her father volunteered to donate, and the calculated volume of the left lateral section was 315 mL, with an estimated ratio of 4.5. Segment-3 vein drained into the middle hepatic vein. Given the high graft ratio, variant venous anatomy, and absence of ascites, a segment-2 monosegment graft was planned with a final ratio of 2.8, with no need for venous reconstruction and primary abdominal closure. No technical complications were observed after 6 years of follow-up.

CONCLUSION

This is the first case of monosegmental liver transplantation in Mexico. The use of this strategy, in the setting of aberrant hepatic vein anatomy, showed that the procedure can avoid unnecessary venous reconstruction and reduce the need for abdominal wall reconstruction or reintervention for closure.

The gut microbiome and cancer: from tumorigenesis to therapy

The gut microbiome has a crucial role in cancer development and therapy through its interactions with the immune system and tumour microenvironment. Although evidence links gut microbiota composition to cancer progression, its precise role in modulating treatment responses remains unclear. In this Review, we summarize current knowledge on the gut microbiome's involvement in cancer, covering its role in tumour initiation and progression, interactions with chemotherapy, radiotherapy and targeted therapies, and its influence on cancer immunotherapy. We discuss the impact of microbial metabolites on immune responses, the relationship between specific bacterial species and treatment outcomes, and potential microbiota-based therapeutic strategies, including dietary interventions, probiotics and faecal microbiota transplantation. Understanding these complex microbiota-immune interactions is critical for optimizing cancer therapies. Future research should focus on defining microbial signatures associated with treatment success and developing targeted microbiome modulation strategies to enhance patient outcomes.

Preoperative iron supplementation in non-anemic patients undergoing major surgery: a systematic review and meta-analysis

BACKGROUND

Blood transfusions are associated with increased morbidity and mortality, and maintaining global blood supplies can be a challenge. This systematic review investigates the impact of preoperative iron supplementation on the risk of blood transfusion among non-anemic patients undergoing major surgeries.

METHODS

We conducted a systematic search of PubMed, Embase, and Cochrane Central for randomized controlled trials published up to May 2024. Studies involving the use of erythropoietin, or patients already using iron supplementation when trial randomization was conducted were excluded. Outcomes assessed included the number of individuals who received blood transfusions, and mean hemoglobin levels at the first day and by the first postoperative week.

RESULTS

A total of 1,162 non-anemic patients from 9 studies were included. Of these, 54% received preoperative iron supplementation. The average age was 71 years, and 44% were women. Preoperative iron supplementation was associated with a significantly lower risk of receiving a blood transfusion (OR = 0.54; 95% CI 0.40 to 0.75; p < 0.001). At the first postoperative day, the iron supplementation group had significantly higher mean hemoglobin levels compared to the no-treatment group (MD = 0.22 g.dL-1; 95% CI 0.02 to 0.42; p = 0.03). However, the pooled results could not rule out the null hypothesis for the difference in mean hemoglobin levels throughout the first week (MD = 0.12 g.dL-1; 95% CI -0.12 to 0.35; p = 0.34).

CONCLUSION

Preoperative intravenous iron supplementation in non-anemic patients undergoing major surgeries, particularly cardiac procedures, significantly reduces transfusion requirements. However, the benefits of oral iron remain uncertain, and further research is warranted to establish standardized perioperative supplementation protocols.

PROSPERO IDENTIFIER

CRD42024552559.

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.

Recurrent Portal Hypertension after Liver Transplant: Impact on Survival and the Role of Transjugular Intrahepatic Portosystemic Shunt Creation in Management

PURPOSE

To evaluate the impact of transjugular intrahepatic portosystemic shunt (TIPS) on outcomes of recurrent portal hypertension (PH) after liver transplant (LT).

MATERIALS AND METHODS

From a cohort of 1,846 LT recipients, 36 patients who underwent TIPS creation after LT were identified. To streamline comparison with the remaining LT patients without TIPS, a representative subset comprising more than 20% of the entire population (381/1,810) was randomly selected as controls. Diuretic refractory ascites and endoscopic findings were reviewed to detect recurrent PH in patients without TIPS. Repeat transplantation and graft and overall survival were compared between patients with recurrent PH with and without TIPS. Survival analysis with multivariable Cox regression analysis was used for risk factors of survival.

RESULTS

Of 1,846 patients, 36 (2%) underwent TIPS creation after LT. Among the control group, 24 (of 381, 6.3%) patients had recurrent PH. TIPS creation resulted in ascites resolution in 25 (of 36, 74%). Repeat transplant was more frequent in recurrent PH without TIPS than in recurrent PH with TIPS (33% vs 11%; P = .035). Median overall survival after TIPS creation was 2.4 years (95% CI, 0.6-3.2). Transplant-free survival after initial LT was not different between patients with and without TIPS (8.6 years vs 7.6 years; P = .360). Multivariable Cox regression showed that repeat transplant was associated with reduced mortality in recurrent PH (hazard ratio, 0.15; P = .016).

CONCLUSIONS

Recurrent PH after LT is rare but adversely affects patient outcomes. However, TIPS in recurrent PH improves ascites without worsening survival.

The effects of interleukin-21 in the biology of transplant rejection

Interleukin-21 (IL-21) is a cytokine that plays a crucial role in regulating immune responses, affecting various immune cell types, including T cells, B cells, natural killer (NK) cells, and dendritic cells. IL-21 is primarily produced by CD4+ T cells, particularly follicular helper T (Tfh) cells and Th17 cells, and has been shown to be extensively involved in regulating both innate and adaptive immunity. IL-21 is particularly significant in the differentiation, proliferation, and effector functions of T cells and B cells. In the context of organ transplantation, IL-21 contributes to the promotion of acute transplant rejection and the development of chronic rejection, which is primarily antibody-mediated. This review summarizes relevant studies on IL-21 and discusses its multifaceted roles in transplant immune rejection, providing insights into therapeutic strategies for either inhibiting graft rejection or promoting tolerance. It also explores the feasibility of blocking the IL-21 signaling pathway within current immunosuppressive regimens, aiming to provide further clinical references.

A 13-Year Nationwide Analysis of Nocardia and Actinomyces Infection Outcomes in Liver Transplant Recipients

Liver transplant (LT) recipients have a profound susceptibility to infections. Although Nocardia and Actinomyces (NAs) are well-known bacteria that typically affect immunosuppressed patients, a scarcity of research exists on the effects of LT with NA infections. Our study aims to evaluate the outcomes associated with NA infections in patients with LT. Patients were selected from the National Inpatient Sample (NIS) from 2008 through 2020. International Classification of Disease revision 9 (ICD-9) and ICD revision 10 (ICD-10) codes. Patients admitted with a history of LT were subdivided into those who were and were not diagnosed with an NA infection. Records were weighted using the NIS algorithm. Primary outcomes were all-cause hospital mortality, acute kidney injury (AKI), acute myocardial infarction (AMI), shock, and a composite of these. Secondary outcomes were length of stay, total charges, cytomegalovirus (CMV), and transplant rejection. Demographics and comorbidities were compared between the groups with a weighted chi-square test. Outcomes were compared between the two groups, and adjusted odds ratios (ORs) and regression coefficients were calculated using weighted logistic or linear regression as appropriate. ORs were adjusted for age, gender, race, hospital characteristics, Charlson Comorbidity Index (CCI), median income based on zip code, weekend admission, and insurance. There were 469,141 patients with LT who were included in this study, 310 of them had NA infection (0.07%). Patients in each group were of similar age, race, and overall medical complexity (P > .05). Patients with NA infection were less likely to have a history of coronary artery disease (CAD; 4.84% vs 16.20%, P < .05), hypertension (14.53% vs 25.82%, P < .05), and obesity (1.61% vs 9.0%, P < .05) than the healthy controls. Patients with LT with NA infection were found to have higher odds of mortality (OR = 5.50, P < .001), AKI (OR = 1.9, P < .05), composite outcome (OR = 2.19, P < 0.01), and more likely to have CMV infection (OR = 6.38, P < .01). Patients with LT with NA infection stayed 13.11 days longer in the hospital (P < .01) with charges of $60,399 more (P < .01) than the healthy controls. Patients with LT who acquired an NA infection were at nearly six-fold higher odds of death and other negative outcomes. Based on previous research that has demonstrated organ transplant patients to be at high risk of infections, more vigilant care should be taken to protect patients with LT from such opportunistic infections.

Intraoperative Blood Loss Predicts Local Recurrence After Curative Resection for Stage I-III Colorectal Cancer

BACKGROUND

To identify the predictors of local recurrence and distant metastasis after radical surgery for stage I-III colorectal cancer.

MATERIALS AND METHODS

Patient and tumor characteristics, clinicopathological stages, perioperative factors, and postoperative outcomes, including local and distant recurrence, of patients who underwent primary colorectal resection were evaluated in this multicenter retrospective analysis. Univariate and multivariate regression analyses were performed to identify the risk factors for local and distant recurrences, with a focus on the intraoperative blood loss (IBL) ratio [IBL (mL)/total blood volume (mL)] and postoperative complications.

RESULTS

The risk factors for local and distant recurrence pattern differed. The predictors for local recurrence included perioperative factors, such as the IBL ratio and anastomotic leakage, as well as tumor factors, including pT4, rectal cancer, and poorly differentiated histology, in the multivariate analysis. On the other hand, the predictors for distant recurrence included perioperative factors, such as Clavien-Dindo score ≥ 3, and absence of adjuvant chemotherapy as well as tumor factors including pT stage, pN stage, and rectal cancer. The area under the receiver operating characteristic curve (AUC) for local recurrence in the IBL ratio was 0.745, which was higher than the AUCs for other recurrence patterns in the IBL ratio. Patients with a higher IBL ratio had a higher rate of early local recurrence within 2 years postoperatively (Wilcoxon test and p = 0.028).

CONCLUSION

Reducing IBL and formulating perioperative strategies to prevent anastomotic leakage may help decrease the local recurrence rate and improve prognosis.

The impact of donor-specific antibody and non-HLA antibodies on acute cellular rejection in pediatric liver transplantation

Antibodies to HLA or non-HLA antigens are associated with detrimental outcomes in organ transplants. Here, we aim to examine whether donor-specific antibodies (DSA) and non-HLA antibodies are associated with rejection in a single-center cohort of 101 pediatric liver transplant (PLTx) recipients. Rejection was found in 50/101 biopsies (49.5 %). DSA was positive in 32 paired sera and associated with rejection (HR = 2.63[1.10-6.30]). Antibodies to 3 non-HLA antigens, SNRPB (small nuclear ribonucleoprotein polypeptides B), GSTT1 (Glutathione S-transferase theta-1), and Actin were associated with rejection. Rejection was found in 22/35 cases positive for any of the three non-HLA antibodies. The presence of DSA and non-HLA antibodies was associated with an augmented risk of rejection (HR = 6.32[1.57-25.30], p < 0.01]. In conclusion, DSA or non-HLA antibodies were associated with a higher risk for rejection in PLTx recipients. When they were detected concomitantly, the risk for rejection increased significantly, indicating the synergistic effect of actions.

Utility of 18F-FDG PET/CT metabolic parameters on post-transplant lymphoproliferative disorder diagnosis

OBJECTIVE

Using 18F-FDG PET/CT metabolic parameters to differentiate post-transplant lymphoproliferative disorder (PTLD) and reactive lymphoid hyperplasia (RLH), and PTLD subtypes.

METHODS

18F-FDG PET/CT and clinical data from 63 PTLD cases and 19 RLH cases were retrospectively collected. According to the 2017 WHO classification, PTLD was categorized into four subtypes: nondestructive (ND-PTLD), polymorphic (P-PTLD), monomorphic (M-PTLD), and classic Hodgkin. Metabolic parameters included maximum standardized uptake value (SUVmax), mean standardized uptake value (SUVmean), metabolic tumor volume (MTV), total lesion glycolysis (TLG) and at different thresholds of SUVmax (2.5 and 41%), as well as gross tumor volume (GTV) was also collected. Nonparametric test and receiver operating characteristic (ROC) curves were used for statistics.

RESULTS

There were 42 ND-PTLD patients, 7 P-PTLD patients, and 14 M-PTLD patients. Ki-67 was significantly correlated with all metabolic parameters (P all < 0.01). SUVmean, SUVmax, MTV, TLG and GTV were all highest in M-PTLD, followed by P-PTLD, ND-PTLD, and RLH. ROC curves showed 18F-FDG PET/CT metabolic parameters all had moderate diagnostic efficacy in differentiating between PTLD and RLH, the area under the curves (AUC) range from 0.682 to 0.747. Diagnostic efficacy for P-PTLD + M-PTLD showed excellent performance (AUC for RLH + ND-PTLD vs P-PTLD + M-PTLD was 0.848 for SUVmax, 0.846 for SUVmean41%, 0.834 for SUVmean2.5, and 0.819 for GTV). For MTV41%, TLG 41%, MTV2.5, TLG2.5, the AUC was 0.676, 0.761, 0.761, 0.787, respectively.

CONCLUSION

18F-FDG PET/CT metabolic parameters at different thresholds of SUVmax (2.5 and 41%) exhibited comparable diagnostic efficacy for PTLD and its subtypes. All metabolic parameters demonstrated moderate diagnostic efficacy in distinguishing PTLD and RLH. SUVmax, SUVmean41%, SUVmean2.5 and GTV showed excellent performance in diagnosing P-PTLD + M-PTLD.

Recurrence of Primary Sclerosing Cholangitis After Pediatric Liver Transplantation: A Single-Center, Retrospective Study in Japan

AIM

Liver transplantation (LT) is a well-accepted treatment for primary sclerosing cholangitis (PSC) with generally good outcomes, although recurrent PSC (rPSC) poses significant challenges. This study aimed to describe patient characteristics and identify potential risk factors of rPSC in pediatric LT recipients.

METHODS

This retrospective study analyzed 13 pediatric patients who underwent LT for PSC at a single center. Patient characteristics, risk factors, and outcomes were compared between those with and without rPSC.

RESULTS

The median age at PSC diagnosis was 5.2 years and at LT, 15.4 years. Inflammatory bowel disease (IBD) was present in 12 patients (92.3%), and four (30.7%) had overlapping autoimmune hepatitis (AIH) before LT. Two patients received grafts from living-related donors, and 11 from deceased donors. During a median follow-up of 53 months, 4 of the 13 patients (30.7%) developed rPSC at a median of 48.9 months post-LT. Patients with rPSC tend to be younger at PSC diagnosis. All rPSC cases were associated with IBD, and half had AIH overlap, though the frequency difference was not significant. Acute cellular rejection (ACR) was universal in rPSC patients (100%) compared to nonrecurrent cases (33.3%, p = 0.07). One case of rPSC developed pulmonary hypertension following rPSC and succumbed to PH crisis, resulting in a 5-year patient survival rate of 82%.

CONCLUSIONS

The recurrence rate was high in pediatric patients with PSC. The observed association with immune-activating conditions raises the possibility of utilizing immunologic interventions to prevent rPSC, although further prospective studies are warranted to clarify the underlying mechanisms.

Predicting futile outcomes following deceased donor liver transplantation in non-HCC patients with MELD-Na score above 30: a retrospective international multicenter cohort study

INTRODUCTION

In the current "sickest first" allocation policy for limited deceased liver grafts, identifying patients "too sick to transplant" before transplantation is crucial to optimize outcomes. This study aimed to predict futile outcomes following deceased donor liver transplantation (DDLT) in patients with model for end-stage liver disease-sodium (MELD-Na) scores ≥30.

METHODS

This international multicenter study was conducted as part of the International Society of Liver Surgeons. We collected data from patients with a MELD-Na score of ≥30 who underwent DDLT. A total of 994 patients were enrolled between 2010 and 2021, including 654 from the Republic of Korea, 224 from the USA, and 116 from other regions. Futility was defined as death within 3 months or during the hospital stay following a DDLT. After exclusion, 160 (16.6%) patients were classified into a futile group and 803 (83.4%) into a non-futile group.

RESULTS

The MELD-Na scores collected at three time points (listing, matching, and transplantation) were comparable between the groups ( P = 0.442, P = 0.180, and P = 0.554, respectively). Regarding concomitant organ failure factors, the futile group showed a higher incidence of organ dysfunction across all measured parameters, including the use of mechanical ventilators, continuous renal replacement therapy (CRRT), pneumonia, bacteremia, and vasopressor use (all P < 0.01). Independent risk factors for futile outcome were recipient age (≥65 years), body mass index (<18.5 kg/m 2 ), mechanical ventilator use, CRRT (≥1 week), and prolonged intensive care unit stay before transplantation (≥2 weeks). The futility rate was 53.3% in patients with ≥3 risk factors ( P < 0.001). We developed a nomogram to predict futility after DDLT based on multivariate regression analysis, which showed a better predictive power than previous models.

CONCLUSION

The risk factors and new nomogram, which adequately reflect concomitant organ failure before liver transplantation, could effectively predict the risk of futile outcomes after DDLT and contribute to decision-making regarding transplantation eligibility in clinical practice.

Pre-transplant myosteatosis worsens the survival after liver transplantation: A systematic review and meta-analysis

OBJECTIVE

Sarcopenia worsens survival after liver transplantation (LT). However, it remains unclear whether myosteatosis, a pathological phenomenon involving excess fat deposition, also causes adverse effects. We performed a meta-analysis to evaluate the effect of myosteatosis on survival in this patient population.

METHODS

We searched PubMed, EMBASE, Web of Science, and Cochrane databases through March 30, 2025 for articles that focused on the association between myosteatosis and post-LT mortality. The Newcastle-Ottawa Scale was used to assess the quality of the studies. The primary outcome was mortality rate. Meta-analyses were performed using Review Manager software. Study quality, publication bias, and subgroup analyses were performed.

RESULT

28 studies involving 7068 patients were included. The studies were of moderate-to-high quality. The pooled results suggested that myosteatosis as a categorical variable was an independent predictor of mortality, both in univariate analyses (hazard ratio[HR] = 1.80, 95%CI 1.59-2.05) and multifactorial analyses (HR = 1.69, 95%CI 1.51-1.89). Similar results were found when myosteatosis was treated as a continuous variable. Further pooling of data comparing patients with and without myosteatosis within 6-month, one, three, and five years of follow-up (odds ratio[OR] = 5.49, 95%CI 3.69-8.17, OR = 1.93, 95%CI: 1.55-2.41, OR = 1.62, 95%CI 1.30-2.00, and OR = 1.68, 95%CI 1.28-2.19, respectively) also suggested a high mortality risk in myosteatosis patients. Finally, sensitivity analyses based on the different definitions of myosteatosis confirmed these results. In addition, patients with myosteatosis had significantly increased ICU stay (mean difference[MD] = 7.86 days; 95 % CI, 2.41-13.30), hospital stay (MD = 2.04 days, 95 % CI, 0.56-3.53), and more post-LT complications (OR = 2.35, 95 % CI 1.93-2.87) than those without myosteatosis.

CONCLUSIONS

Our results revealed that myosteatosis is associated with an increased risk of mortality in patients undergoing LT. These findings indicate that myosteatosis can be a tool to identify high-risk patients and make informed clinical decisions during perioperative management.

Long-Term Exposure to Microplastics Promotes Early-Stage Hepatocarcinogenesis Induced by Diethylnitrosamine in Rats by Modulation of Their Gut Microbiota

Hepatocarcinogenesis is linked to environmental factors, with microplastics (MPs) emerging as a global environmental concern that may contribute to liver injury. However, the impact of MPs on the early stages of hepatocarcinogenesis has been largely ignored. Here we investigated the impact of long-term MP exposure on the formation of preneoplastic lesions during hepatocarcinogenesis induced by diethylnitrosamine (DEN) in rats. Rats were injected with DEN to induce preneoplastic lesions, and then they were orally administered with 1 µm MPs 0.5 mg/kg body weight per day for 20 weeks. The results revealed that long-term exposure to MPs did not induce the formation of glutathione S-transferase placental form (GST-P)-positive foci as preneoplastic lesions during hepatocarcinogenesis in these animals, thereby indicating non-carcinogenicity. However, MP exposure resulted in a 1-fold increase in both the number and size of GST-P-positive foci in rats initiated with DEN compared to those treated with DEN alone. Accordingly, MP exposure led to a 0.61-fold increase in the index of proliferating cell nuclear antigen (PCNA)-positive cells in DEN-initiated rats when compared to DEN treatment alone. In addition, the composition of the gut microbiota was significantly altered, accompanied by various levels of short-chain fatty acids. Our results suggest that long-term MP exposure can promote pre-neoplastic lesion formation in DEN-induced rats by increased cell proliferation as well as alterations in the gut microbiota and short-chain fatty acid levels. This highlights the potential health risks associated with hepatocarcinogenesis linked to long-term exposure to MPs.

First results from the international registry on liver venous deprivation (EuroLVD)

BACKGROUND

An international registry on liver venous deprivation (LVD, simultaneous portal and hepatic vein embolization) was created in 2020. This study assessed the outcomes after LVD in patients included in the registry.

METHODS

Eight international centers participated. Future liver remnant (FLR) and standardized FLR ratios were defined as FLR/total functional liver volume and FLR/total estimated liver volume.

RESULTS

216 patients were included (80 women, median age 63). Main surgical indication was colorectal metastases (n=124). Median and standardized FLR ratios before LVD were 33% (IQR27-47) and 32% (IQR24-39). In one patient, right hepatic vein embolization failed. Complications after LVD occurred in 14 patients (6.5%). After LVD, median and standardized FLR ratios significantly increased to 46% (IQR38-60, p<0.001) and 44% (IQR35-51, p<0.001), corresponding to a median kinetic growth rate of 3.4%/week (IQR1.5-6.0). Hepatectomy was performed in 160 patients (72 extended hepatectomies), while 56 dropped out (4% insufficient hypertrophy, 13% tumor progression). Seventy-seven patients had postoperative complications (48%; 5 postoperative liver failures, 3%). Median Comprehensive Complication Index was 20.9 (IQR0-30.8).

CONCLUSION

Preliminary data of this international registry showed that LVD had a high technical success rate with few post-procedural complications and significant kinetic growth. Major hepatectomy after LVD appeared to be safe.

Machine learning algorithms reveal gut microbiota signatures associated with chronic hepatitis B-related hepatic fibrosis

BACKGROUND

Hepatic fibrosis (HF) represents a pivotal stage in the progression and potential reversal of cirrhosis, underscoring the importance of early identification and therapeutic intervention to modulate disease trajectory.

AIM

To explore the complex relationship between chronic hepatitis B (CHB)-related HF and gut microbiota to identify microbiota signatures significantly associated with HF progression in CHB patients using advanced machine learning algorithms.

METHODS

This study included patients diagnosed with CHB and classified them into HF and non-HF groups based on liver stiffness measurements. The HF group was further subdivided into four subgroups: F1, F2, F3, and F4. Data on clinical indicators were collected. Stool samples were collected for 16S rRNA sequencing to assess the gut microbiome. Microbiota diversity, relative abundance, and linear discriminant analysis effect size (LEfSe) were analyzed in different groups. Correlation analysis between clinical indicators and the relative abundance of gut microbiota was performed. The random forest and eXtreme gradient boosting algorithms were used to identify key differential gut microbiota. The Shapley additive explanations were used to evaluate microbiota importance.

RESULTS

Integrating the results from univariate analysis, LEfSe, and machine learning, we identified that the presence of Dorea in gut microbiota may be a key feature associated with CHB-related HF. Dorea possibly serves as a core differential feature of the gut microbiota that distinguishes HF from non-HF patients, and the presence of Dorea shows significant variations across different stages of HF (P < 0.05). The relative abundance of Dorea significantly decreases with increasing HF severity (P = 0.041). Moreover, the gut microbiota composition in patients with different stages of HF was found to correlate with several liver function indicators, such as γ-glutamyl transferase, alkaline phosphatase, total bilirubin, and the aspartate aminotransferase/alanine transaminase ratio (P < 0.05). The associated pathways were predominantly enriched in biosynthesis, degradation/utilization/assimilation, generation of precursors, metabolites, and energy, among other categories.

CONCLUSION

HF affects the composition of the gut microbiota, indicating that the gut microbiota plays a crucial role in its pathophysiological processes. The abundance of Dorea varies significantly across various stages of HF, making it a potential microbial marker for identifying HF onset and progression.

Living Donor Liver Transplantation Versus Deceased Donor Liver Transplantation for Hepatocellular Carcinoma and HCV Patients: An Initial Umbrella Review

Background: Living donor liver transplantation (LDLT) has become a widely accepted alternative to deceased donor liver transplantation (DDLT). Nevertheless, the available meta-analyses shed light on a perplexing issue regarding which transplant is better. Therefore, we performed an umbrella review to summarize and evaluate the evidence from current meta-analyses. Methods: Two independent reviewers conducted a search of PubMed, Embase, Web of Science, and the Cochrane Database of Systematic Reviews from inception to 1 June 2024. The methodological quality of each included meta-analysis was evaluated using AMSTAR2 (A Measurement Tool to Assess Systematic Reviews). Results: The search identified 10 meta-analyses from 486 individual articles, including cohort studies and observational studies. Regrettably, the quality of these meta-analyses ranged from critically low to moderate. Receipt of LDLT offers a survival advantage to the patients with HCC compared with DDLT but with a higher complication rate. However, high-quality studies are required in the future to validate our assertions owing to the low certainty of the evidence. Conclusions: Despite the complication risks, LDLT remains a cost-effective option without compromising patient and graft survival, especially for HCC patients. Extensive, well-designed studies are essential to validate these conclusions.

Hepatocellular Carcinoma and the Role of Liver Transplantation: An Update and Review

Hepatocellular carcinoma (HCC) is the fourth leading cause of cancer-related death worldwide. Multiple treatment modalities are available for the management of HCC, depending on its stage as determined by the Barcelona Clinic Liver Cancer staging system. Because liver transplantation (LT) theoretically removes the cancer and replaces the organ at risk for future malignancy, LT is often considered the most definitive and one of the most efficacious treatment options for HCC. Nevertheless, the success and efficacy of liver transplantation depend on various tumor characteristics. As a result, multiple criteria have been developed to assess the appropriateness of a case of HCC for LT, with the pioneering Milan Criteria established in 1996. Over the past 20 to 30 years, these criteria have been critically evaluated, expanded, and often liberalized to make LT for patients with HCC a more universally applicable option. Furthermore, the development of other treatment modalities has enabled downstaging and bridging strategies for HCC prior to LT. In this narrative and comprehensive review, we provided an update on recent trends in the epidemiology of HCC, selection criteria for LT, implementation of LT across different regions, treatment modalities available as bridges, downstaging strategies, alternatives to LT, and, finally, post-LT surveillance.

Positive crossmatch with persistent donor specific antibodies increases risk of rejection in liver transplantation: A retrospective single-center analysis

Evidence is mixed regarding the effect of positive crossmatch (XM) and preformed donor-specific antibodies (DSA) on rejection in liver transplant recipients. We categorized liver transplant recipients by XM and DSA status (XM negative, XM positive with resolved DSA, and XM positive with persistent DSA or any de novo DSA) and examined biopsy-proven rejection incidence within 6 months post-transplant, DSA trends, and immunosuppression management. Of 273 liver transplant recipients, 237 (86.8 %) were XM negative and 36 (13.2 %) were XM-positive, of whom 13 (36.1 %) had persistent or de novo DSA and 23 (63.8 %) had resolved DSA. Recipients in the persistent DSA group experienced earlier rejection at a higher rate (69.2 % at median of 25 days post-transplant) compared to the other two groups (21.7 % at median of 31 days in the resolved DSA group and 19.4 % at median of 46 days in the XM negative group; p < 0.001). Recipients in the persistent DSA group were also more likely to experience multiple rejection events (p < 0.001). XM positive recipients with persistent DSA or de novo DSA are at higher risk for early allograft rejection, while those who can clear their DSA early have a rejection risk profile similar to recipients with a negative crossmatch.

Development and Validation of a Pre-Transplant Risk Score (LT-MVI Score) to Predict Microvascular Invasion in Hepatocellular Carcinoma Candidates for Liver Transplantation

Background/Objectives: MVI is a relevant prognostic factor among patients with hepatocellular carcinoma (HCC) receiving liver transplantation (LT). The preoperative assessment of the risk for MVI is relevant to pre-LT patient management and selection. The objective of this study was to create and validate a model to predict microvascular invasion (MVI) based on preoperative variables in the LT setting. Methods: A total of 2170 patients from 11 collaborative centers in Europe, Asia, and the US, who received transplants between 1 January 2000 and 31 December 2017, were enrolled in the study. The entire cohort was split into a training and a validation set (70/30% of the initial cohort, respectively) using random selection. Results: MVI was reported in 586 (27.0%) explanted specimens. Using the training set data, multivariable logistic regression identified three preoperative parameters associated with MVI: α-fetoprotein (lnAFP; odds ratio [OR] = 1.19; 95% confidence interval [CI] = 1.13-1.27), imaging tumor burden score (lnTBS; OR = 1.66; 95%CI = 1.39-1.99), and a fast-track approach before LT due to the availability of a live donation (OR = 1.99; 95%CI = 1.56-2.53). In the validation set, the LT-MVI c-index was 0.74, versus 0.69 for the MVI score proposed by Endo et al. (Brier Skill Score +75%). The new score had a relevant net reclassification index (overall value = 0.61). Stratifying the validation set into three risk categories (0-50th, 51st-75th, and >75th score percentiles), a very good stratification was observed in terms of disease-free (5-year: 89.3, 75.5, and 50.7%, respectively) and overall survival (5-year: 79.5, 72.6, and 53.7%, respectively). Conclusions: The preoperative assessment of MVI using the proposed score demonstrated very good accuracy in predicting MVI after LT.

Pilot Case Series of Robotic-Assisted Hernia Repair in Patients With Cirrhosis

Umbilical and ventral hernias in patients with cirrhosis cause significant morbidity including flood syndrome, bowel obstruction, and pain and limit quality of life. Ascites and portal hypertension increase the risk of complications, resulting in apprehension with intervention and costly cycles of readmission. No studies have explored the safety or efficacy of robotic-assisted repair of primary umbilical hernias in this population. We performed a retrospective review of patients with cirrhosis at a single institution who underwent elective or emergent robotic hernia repair between June 2023 and May 2024. A total of 7 patients were included with a median MELD-Na of 17 (IQR 14-22) and the majority of whom (6 of 7, 85.7%) had ascites at the time of surgery. Three patients required emergent or urgent operations. No drains were required at the time of surgery. There were no Clavien-Dindo grade 3 or higher complications, no patients had leakage of ascites from their incisions, and no patients developed hernia recurrence (median follow-up 173 days). There were 2 Clavien-Dindo grade 1 or 2 complications: one superficial skin infection treated with antibiotics and one case of urinary retention. This limited series suggests that robotic hernia repair is technically feasible and safe in a select group of patients with cirrhosis including those with ascites. We propose an approach to robotic-assisted hernia repair in these complex patients.

Understanding the role of Hedgehog signaling pathway and gut dysbiosis in fueling liver cancer

Liver cancer is one of the most prevalent types of cancer worldwide with less than 20% of patients surviving in the past half a decade. Several molecular pathways have been uncovered that may lead to the development of liver cancer but more recently the Hedgehog pathway (HH) and its interactions with the gut microbiota has emerged as an underlying cause of the development of liver cancer. Gut-liver axis is vital to maintaining homeostasis. The HH pathway controls cellular differentiation, proliferation, and apoptosis evasions, its abnormal activation can lead to uncontrolled proliferation of liver cancer stem cells. Additionally, the intricate interplay between HH signaling and the gut microbiota introduces a novel dimension. Recent investigations suggest that potential modulation of HH activity by gut microbiota influence HCC progression. This review explores a crosstalk between HH signaling and the gut microbiota, uncovering intricate mechanisms by which it fuels liver cancer development. This interplay provides insights into gut dysbiosis, HCC etiology and potential therapeutic avenues, highlighting the cooperative role of HH signaling and gut microbiota in shaping the overall HCC landscape.