Transplantation for Peri-Hilar and Intrahepatic Cholangiocarcinoma With mTOR Immunosuppression

BACKGROUND

Cholangiocarcinoma (CCA) has rising incidence and mortality rates. Outcomes from combination systemic, loco-regional therapy (LRT) and liver transplantation (LT) are improving, but more granular data are needed to inform evidence-based management, including patient selection and immunosuppression.

METHODS

Patients with peri-hilar (PH) and intrahepatic (IH) CCA who underwent LT at a single center between January 2008 and February 2023 were reviewed retrospectively. Primary outcomes were overall survival (OS) and recurrence-free survival (RFS) with significance determined by Cox proportional hazards model.

RESULTS

During the study period, 53 patients underwent LT for either PH (n = 27), or IH (26). Cohort had mean age 58.5 years old (IQR, 47.0-63.0), body mass index (BMI) 25.9 (IQR, 22.9-30.0) kg/m2, and mean biologic MELD 9 (IQR, 7-17). Most frequent etiology was PSC (n = 12, 22.6%). Forty-nine patients (92.5%) received neoadjuvant therapy, including systemic (n = 48, 90.6%) and locoregional therapy (LRT) (n = 22, 41.5%), to which PH tumors were both most and least responsive (P = .03). On explant pathology, tumor were a median size of 3.5 cm and lympho-vascular invasion (LVI) was present in 13 (24.5%) cases. Median follow-up post-transplant was 910 days (IQR, 407-1509). Probabilities of OS and RFS at 3-years post-LT were 69.2% (95% CI, 56.9%-84.2%) and 57.4% (95% CI, 43.7%-75.4%). In multivariable analysis, OS was associated with tumor type and LVI, and RFS with age, BMI, PSC and LRT. After a median post-LT period of 38 days (IQR, 27-79.5), 39 (71.7%) patients started mTOR inhibition with lowered tacrolimus goal. Cox proportional hazard model showed significant association of OS with mTOR inhibition, though this was not validated by a time-dependent co-variate approach.

CONCLUSIONS

In this single center cohort of CCA, post-LT outcomes were significantly greater for patients with IH tumors and no LVI. Immunosuppression with mTOR inhibition was not consistently associated with outcomes.

Quality management, ethical considerations, and emerging challenges in genomics and biobanking: A comprehensive review

The integration of genomics into personalized medicine has the potential to transform healthcare by customizing treatments according to individual genetic profiles. This paper examines the diverse applications of genomics, including the identification of disease susceptibility, improvement of diagnostic methods, optimization of drug therapies, and monitoring of treatment responses. It also explores the expanding global market for genetic testing and the increasing implementation of whole-genome sequencing in clinical practice, with a focus on pilot programs that are advancing comprehensive genomic analysis. Despite challenges such as high costs, data interpretation complexities, and ethical concerns, significant efforts are being made to address these issues. Additionally, the creation of biobanks as vital resources for preserving high-quality biosamples and supporting research highlights the critical need for infrastructure development in genomics. By fostering interdisciplinary collaboration and establishing robust ethical and regulatory frameworks, personalized medicine can ensure equitable access to tailored therapies and enhance health outcomes for everyone. This abstract provides an overview of the transformative potential of genomics and personalized medicine in ushering in a new era of precision healthcare.

Core outcome sets and benchmarking complications: Defining best practices for standardized outcome reporting in liver transplantation

The comparison of outcomes in liver transplantation (LT) is hampered by using clinically nonrelevant surrogate endpoints and considerable variability in reported relevant posttransplant outcomes. Such variability stems from nonstandard outcome measures across studies, variable definitions of the same complication, and different timing of reporting. The Clavien-Dindo classification was established to improve the rigor of outcome reporting but is nonspecific to an intervention, and there are unsolved dilemmas specifically related to LT. Core outcome sets (COSs) have been used in other specialties to standardize outcomes research, but have not been defined for LT. Thus, we use the 5 major benchmarking studies published to date to define a 10-measure COS for LT using previously validated metrics. We further provide standard definitions for each of the 10 measures that may be used in international research on the topic. These definitions also include standard time points for recording to facilitate between-study comparisons and future meta-analysis. These 10 outcomes are paired with 3 validated, procedure-independent metrics, including the Clavien-Dindo Classification and the Comprehensive Complications Index. The Clavien scale and Comprehensive Complications Index are specifically reviewed to enhance their utility in LT, and their use, along with the COS, is explored. We encourage future studies to employ this COS along with the Clavien-Dindo grading system and Comprehensive Complications Index to improve the reproducibility and generalizability of research concerning LT.

Population pharmacokinetics of tacrolimus whole blood and peripheral blood mononuclear cell concentrations in stable kidney-transplanted patients

AIM

Therapeutic drug monitoring of tacrolimus based on whole blood drug concentrations is routinely performed. The concentration of tacrolimus in peripheral blood mononuclear cells (PMBCs) is likely to better reflect drug exposure at the treatment target site. We aimed to describe the relationship between tacrolimus whole blood and PBMC concentrations, and the influence of patient characteristics on this relationship by developing a population pharmacokinetic model.

METHODS

We prospectively enrolled 63 stable adult kidney-transplanted patients and collected dense (12-h, n = 18) or sparse (4-h, n = 45) pharmacokinetic profiles of tacrolimus. PBMCs were isolated from whole blood (Ficoll density gradient centrifugation), and drug concentrations in whole blood and PBMCs were analysed using liquid chromatography-mass spectrometry. Patient genotype (CYP3A4/5, ABCB1, NR1I2) was assessed with PCR. Population pharmacokinetic modelling and statistical evaluation was performed using NONMEM.

RESULTS

Tacrolimus whole blood concentrations were well described using a two-compartment pharmacokinetic model with a lag-time and first-order absorption and elimination. Tacrolimus PBMC concentrations were best estimated from whole blood concentrations with the use of a scaling factor, the ratio of whole blood to PBMC concentrations (RC:PBMC), which was the extent of tacrolimus distribution into PBMC. CYP3A5*1 non-expressors and NR1I2-25 385T allele expressors demonstrated higher RC:PBMC ratios of 42.4% and 60.7%, respectively.

CONCLUSION

Tacrolimus PBMC concentration could not be accurately predicted from whole blood concentrations and covariates because of significant residual unexplained variability in the distribution of tacrolimus into PBMCs and may need to be measured directly if required for future studies.

Outcomes of peritoneal dialysis in cirrhosis: A systematic review and meta-analysis

BACKGROUND

Cirrhosis and end-stage kidney disease (ESKD) are significant global health concerns, contributing to high mortality and morbidity. Haemodialysis (HD) is frequently used to treat ESKD in patients with cirrhosis. However, it often presents challenges such as haemodynamic instability during dialysis sessions, leading to less than optimal outcomes. Peritoneal dialysis (PD), while less commonly used in cirrhotic patients, raises concerns about the risks of peritonitis and mortality. Our systematic review and meta-analysis aimed to assess outcomes in PD patients with cirrhosis.

METHODS

We executed a comprehensive search in Ovid MEDLINE, EMBASE and Cochrane databases up to 25 September 2023. The search focused on identifying studies examining mortality and other clinical outcomes in ESKD patients with cirrhosis receiving PD or HD. In addition, we sought studies comparing PD outcomes in cirrhosis patients to those without cirrhosis. Data from each study were aggregated using a random-effects model and the inverse-variance method.

RESULTS

Our meta-analysis included a total of 13 studies with 15,089 patients. Seven studies compared ESKD patients on PD with liver cirrhosis (2753 patients) against non-cirrhosis patients (9579 patients). The other six studies provided data on PD (824 patients) versus HD (1943 patients) in patients with cirrhosis and ESKD. The analysis revealed no significant difference in mortality between PD and HD in ESKD patients with cirrhosis (pooled odds ratio (OR) of 0.77; 95% confidence interval (CI), 0.53-1.14). In PD patients with cirrhosis, the pooled OR for peritonitis compared to non-cirrhosis patients was 1.10 (95% CI: 1.03-1.18). The pooled ORs for hernia and chronic hypotension in cirrhosis patients compared to non-cirrhosis controls were 2.48 (95% CI: 0.08-73.04) and 17.50 (95% CI: 1.90-161.11), respectively. The pooled OR for transitioning from PD to HD among cirrhotic patients was 1.71 (95% CI: 0.76-3.85). Mortality in cirrhosis patients on PD was comparable to non-cirrhosis controls, with a pooled OR of 1.05 (95% CI: 0.53-2.10).

CONCLUSIONS

Our meta-analysis demonstrates that PD provides comparable mortality outcomes to HD in ESKD patients with cirrhosis. In addition, the presence of cirrhosis does not significantly elevate the risk of mortality among patients undergoing PD. While there is a higher incidence of chronic hypotension and a slightly increased risk of peritonitis in cirrhosis patients on PD compared to those without cirrhosis, the risks of hernia and the need to transition from PD to HD are comparable between both groups. These findings suggest PD as a viable and effective treatment option for ESKD patients with cirrhosis.

Global Epidemiology of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the most common type of primary liver cancer and a significant global health challenge due to its high mortality rate. The epidemiology of HCC is closely linked to the prevalence of chronic liver diseases, the predominant etiology being hepatitis B virus (HBV) and hepatitis C virus (HCV) infections, alcohol consumption, and metabolic disorders such as metabolic dysfunction-associated steatotic liver disease (MASLD). HCC incidence varies widely globally, with the highest rates observed in East Asia and sub-Saharan Africa. This geographic disparity is largely attributed to the endemicity of HBV and HCV in these regions. In Western countries, the incidence of HCC has been rising, driven by increasing rates of alcohol abuse and the presence of steatosis liver disease. MASLD-associated HCC has a higher body mass index, a higher rate of type 2 diabetes mellitus, hyperlipidemia, hypertension, and association with cardiovascular diseases. Steatosis-associated HCC is also known to develop in the absence of cirrhosis, unlike alcohol-related liver disease and viral hepatitis. Prevention strategies vary by region, focusing on vaccination against HBV, antiviral treatments for HBV and HCV, alcohol moderation, and lifestyle interventions along with weight reduction to reduce obesity and incidence of MASLD-related HCC incidence.

Comparison of cyclosporine and tacrolimus after liver transplantation for primary biliary cholangitis: A propensity score-matched intention-to-treat registry study

The optimal calcineurin inhibitor after liver transplantation (LT) for primary biliary cholangitis (PBC) remains debated. We compared tacrolimus with cyclosporine in a propensity score-matched intention-to-treat analysis from the Scientific Registry of Transplant Recipients. We included adults with PBC who underwent primary LT from 1995 to 2022. Patients with initial cyclosporine treatment were 1:3 matched with those with initial tacrolimus treatment, ensuring exact calendar-period match. Primary outcomes were patient and graft survival. After matching, 579 patients with PBC and initial cyclosporine and 1348 with tacrolimus were well balanced for baseline characteristics. During a median follow-up of 11.1 years, 1044 (54%) deaths and 124 (6%) re-LTs occurred. In the overall matched sample, no significant survival difference emerged between cyclosporine and tacrolimus. However, tacrolimus conferred a survival advantage in some secondary analysis, such as LT after year 2000 and women, and in a 6-month landmark analysis excluding early postoperative events and calcineurin inhibitor switches. Cyclosporine did not reduce graft loss from PBC recurrence or affect laboratory markers of recurrence. In conclusion, we found no benefit of starting immunosuppression with cyclosporine after LT for PBC.

Caroli Syndrome: Challenges in Early Diagnosis for Infants

Caroli syndrome is an uncommon disorder characterized by congenital, segmental dilation of the intrahepatic bile ducts, often widespread and accompanied by liver fibrosis, progressing to juvenile portal hypertension. Although present at birth, this congenital anomaly is often undetected until adulthood. The diagnosis is usually delayed due to its clinical latency. In this case, a one-year-and-eight-month-old infant with abdominal distension and hepatosplenomegaly underwent imaging, which revealed segmental dilation of the intrahepatic bile ducts. Early detection allowed for timely management, reducing the risk of severe complications. Early diagnosis of Caroli syndrome in infants is rare but crucial to preventing severe complications such as recurrent cholangitis, liver fibrosis, and portal hypertension. Physicians should maintain a high index of suspicion for Caroli syndrome in cases of persistent abdominal distension, as early recognition can facilitate appropriate imaging, timely intervention, and improved patient outcomes.

Too Big to Fail: Volumetric Analyses and Incidence of Posthepatectomy Liver Failure in 125 Major Hepatectomies in Children

OBJECTIVE

To assess the incidence of posthepatectomy liver failure (PHLF) and the role of the future liver remnant (FLR) in children undergoing major hepatectomy.

BACKGROUND

Incidence and risk factors of PHLF in children are unclear, with no validated definition for this age group. Consequently, the role of the FLR in pediatric hepatectomy and evidence-based preoperative guidelines remains undefined.

METHODS

All pediatric patients undergoing major hepatectomy at a tertiary care center over a 10-year study period were analyzed. Preoperative imaging was used for volumetry. The incidence of PHLF was assessed by applying predefined definitions, and the prognostic impact of the FLR on PHLF and complications was evaluated.

RESULTS

A total of 125 children underwent major hepatectomy, including 35 trisectionectomies. There was a strong correlation between imaging-based measured total liver volume (TLV) and calculated standard liver volume ( r = 0.728, P < 0.001). The median TLV-to-body weight (BW) ratio was 3.4%, and the median FLR/BW ratio was 1.5%. The median FLR-to-TLV ratio was 44% (range: 18%-97%). No clinically relevant PHLF occurred. FLR/TLV and FLR/BW ratios had low predictive value for postoperative liver dysfunction and morbidity.

CONCLUSIONS

This is the largest reported single-center series of pediatric major hepatectomies. PHLF is exceedingly rare in children. The liver volume-to-BW ratio is higher in children compared with adults, and the FLR is sufficient even in extreme resections with <20% of the liver remnant. These findings strongly question the use of asociating liver partition and portal vein ligation for staged hepatectomy, portal vein embolization, or transplantation based on suspected insufficient liver remnants in children.

Intention-to-treat outcomes of patients with hepatocellular carcinoma receiving immunotherapy before liver transplant: The multicenter VITALITY study

BACKGROUND & AIMS

The use of immune checkpoint inhibitors (ICIs) in patients with advanced hepatocellular carcinoma (HCC) has become widespread with encouraging outcomes in the neoadjuvant setting. Safety and intention-to-treat (ITT) outcomes in the peri-transplant setting are currently based on small and heterogenous single-center reports.

METHODS

This first multiregional US study (2016-2023) included 117 consecutive patients with HCC assessed for liver transplantation (LT) and treated preoperatively with ICIs. ITT and survival analyses were conducted with evaluation of post-LT rejection rates.

RESULTS

In total, 86 (73.5%) patients exceeded Milan criteria (MC) and 65 (75.6%) were successfully downstaged within a median of 5.6 months; 43 (36.7%) underwent transplantation, including 18 (15.4%) within MC and 23 (19.7%) who were initially beyond but were downstaged. Overall, 94% of the cohort received concurrent ICIs and locoregional therapies. No grade 4-5 adverse events occurred on the waiting list. The 3-year cumulative probability of dropout was 28% for those within MC and 48% for those beyond. Independent predictors of dropout included being beyond MC (p <0.001), alpha-fetoprotein doubling from baseline (p = 0.014) and radiographic responses (p <0.001). The 3-year ITT survival rate was 71.1% (73.5% within MC vs. 69.7% beyond MC, p = 0.329), with a 3-year post-LT survival rate of 85%. Post-LT rejection occurred in seven patients, six received their last dose of ICI less than 3 months prior to LT, resulting in one graft loss.

CONCLUSIONS

The first multicenter evaluation of patients with HCC receiving ICIs pre-LT demonstrates favorable survival and safety outcomes, justifying continued utilization and further evaluation of this strategy in clinical practice. High tumor burden, doubling of alpha-fetoprotein levels, and radiographic response were identified as predictors of unfavorable oncologic outcomes.

IMPACT AND IMPLICATIONS

Herein, we report results from the first multicenter evaluation of pretransplant immune checkpoint inhibitors in hepatocellular carcinoma to show promising intention-to-treat survival, safety and rejection rates. Immune checkpoint inhibitors, either alone or combined with locoregional therapy, demonstrate reliable efficacy. This preoperative strategy could be particularly beneficial for high-risk patients, including those requiring downstaging or with elevated alpha-fetoprotein levels despite locoregional treatment. These findings fill current knowledge gaps and offer reassuring evidence for the feasibility of pretransplant use of immune checkpoint inhibitors, pending results from ongoing trials.

Donation After Circulatory Death Liver Transplantation: Impact of Normothermic Machine Perfusion on Key Variables

BACKGROUND

During orthotopic liver transplantation, allograft reperfusion is a dynamic point in the operation and often requires vasoactive medications and blood transfusions. Normothermic machine perfusion (NMP) of liver allografts has emerged to increase the number of transplantable organs and may have utility during donation after circulatory death (DCD) liver transplantation in reducing transfusion burden and vasoactive medication requirements.

METHODS

This is a single-center retrospective study involving 226 DCD liver transplant recipients who received an allograft transported with NMP (DCD-NMP group) or with static cold storage (DCD-SCS group). Veno-venous bypass was not used in any patients. Infusion doses of norepinephrine, epinephrine, and vasopressin as well as bolus doses of vasoactive medications during reperfusion were recorded. Blood component therapy was recorded according to phase of liver transplantation and during the first 24 hours postprocedure.

RESULTS

A total of 103 recipients in the DCD-NMP group and 123 patients in the DCD-SCS group were included. Post-reperfusion syndrome (PRS) incidence was reduced in the DCD-NMP group compared to the DCD-SCS group (10.7% [95% confidence interval, CI, 5.5%-18.3%] vs 42.3% [95% CI, 33.4%-51.5%]; P < .001). During the reperfusion period, patients in the DCD-SCS group required increased bolus doses of epinephrine and vasopressin compared to the DCD-NMP group (24.6 vs 7.5 µg; P < .001) and (5.4 vs 2.4 units; P < .001), respectively. The DCD-SCS group received a higher infusion dose of epinephrine during anhepatic phase, at reperfusion, and up to 90 minutes after reperfusion. In the postreperfusion period, there were significant increases in the transfusion of red blood cells (RBCs; 5.3 vs 3.7 units; P = .006), fresh frozen plasma (FFP; 3.4 vs 1.9 units; P < .001), cryoprecipitate (2.7 vs 1.8 pooled units; P = .015) and platelets (0.9 vs 0.4 units; P = .008) in the DCD-SCS group compared to the DCD-NMP group. During the first 24 hours postprocedure, transfusion of RBCs, FFP, and cryoprecipitate in the DCD-SCS group was increased compared to the DCD-NMP group ([2.6 vs 1.7 units; P = .028], [1.6 vs 0.8 units; P < .001], [1.5 vs 0.9 pooled units; P = .031]) respectively. Administration of tranexamic acid was more frequent in the DCD-SCS group during the post-reperfusion period compared to the DCD-NMP group (13% [95% CI, 5.7%-17.4%] vs 3.9% [95% CI, 1.1%-9.6% 95%]; P = .018).

CONCLUSIONS

In DCD liver transplantation, use of NMP was associated with reduced incidence of PRS and decreased vasopressor and inotrope requirements at the time of allograft reperfusion compared to using SCS. Additionally, NMP was associated with reduced transfusion of all blood product components as well as antifibrinolytic agent administration in the post-reperfusion period. Reduced transfusion burden in the DCD-NMP group also occurred during the first 24 hours posttransplant.

A scoping review of nonmedical barriers to living donor liver transplant

This study aims to identify and categorize nonmedical barriers encountered by recipients, donors, and health care providers in the context of living donor liver transplantation (LDLT). Liver transplantation is vital for individuals with liver failure, yet high mortality rates on the transplant waitlist persist. LDLT was introduced to address deceased donor organ shortages; however, its adoption varies widely across regions, prompting the need to explore barriers hindering its implementation. The scoping review employed inclusion and exclusion criteria to identify studies focusing on nonmedical barriers to LDLT in both adult and pediatric populations. Qualitative, quantitative, and mixed-method studies were considered, covering the period from January 2005 to February 2023. The review's search strategy was conducted in the Ovid MEDLINE and Ovid EMBASE databases. Studies meeting the criteria were assessed for their characteristics and findings, which were synthesized into recipient, donor, and provider-level barriers. Among 2394 initially screened articles, 17 studies were eligible for inclusion. Recipient-level barriers encompassed systemic disparities in access, limited social support, immigration status, and inadequate awareness of LDLT. Donor-level barriers involved surgery-related risks, recovery time concerns, financial burdens, and religious beliefs. Provider-level barriers highlighted institutional support inadequacies and specialized surgeon shortages. The scoping review underscores nonmedical barriers to LDLT across recipient, donor, and provider levels. These barriers include socioeconomic disparities, information gaps, and inadequate institutional support. The findings underscore the need for comprehensive national efforts to raise awareness about LDLT and provide essential financial support.

Nonlinear Relationship Between Body Mass Index and Liver Transplant Outcomes: A Dose-Response Meta-Analysis

BACKGROUND

Weight management was recommended to have more access to transplantation and improve transplant outcomes after liver transplantation (LT). However, the dose-response relationship between body mass index (BMI) and transplant outcomes has not been clearly defined.

METHODS

PubMed, Embase, Web of Science, and Cochrane Library databases were searched up to October 20th, 2019. Dose-response meta-analyses was conducted to establish the dose-response relationship pattern.

RESULTS

Twenty-three observational studies were eligible. In the pair-wise analysis, compared with normal BMI, HRs in underweight, overweight, obesity-I, obesity-II, and obesity-III were 2.13, 0.96, 1.06, 1.36, and 1.97 for patient death, and 3.08, 1.02, 1.25, 1.58, and 2.90, for graft loss. In the dose-response analysis, U-shaped relationships were observed between BMI and both patient and graft survival (P < .001, P < .001). Referring to 17.5kg/m2, the patient death risk decreased to 0.72 (95% CI: 0.62-0.84) in 27kg/m2 and then increased to 1.44 (95% CI:1.09-1.90) in 28.7-42kg/m2. Comparing to 17.5kg/m2, individuals in 26.7-28.0kg/m2 had the least risk of graft loss with HR of 0.62 (95% CI:0.48-0.80) and increased to 1.64 (95% CI:1.03-2.61) in 42kg/m2. Subgroup analyses by age, sex, sample size, duration of follow-up, location, publication year, and study type presented similar results.

CONCLUSION

Underweight and severe obesity are associated with a significantly increased risk of graft loss and patient death after liver transplantation. Overweight, especially BMI of 26-28 kg/m2, may have extra survival benefit. Weight management before liver transplantation may be necessary.

Pancreatic necrosis: a scoping review

Acute pancreatitis (AP) is a commonly encountered GI diagnosis, accounting for 275,000 hospital admissions annually in the United States alone. Pancreatic necrosis (PN) is the most common complication of AP, and the development of PN is associated with significant morbidity and increased mortality. This expert review evaluates the evidence-based management of symptomatic PN from the era of maximal open pancreatic necrosectomy in the late 1990s though the modern paradigm of minimally invasive and endoscopic interventions. The authors present the retrospective and controlled data behind the "step-up approach" to PN treatment and discuss the application of current society guidance. Evidence based management of PN is characterized by early supportive care, and treatment by minimally invasive intervention when a patient is critically ill or persistently symptomatic. Appropriate choices when intervention is required include percutaneous drainage, minimally invasive surgery, and/or endoscopic treatment. The transition from open maximal necrosectomy to minimally invasive intervention has resulted in improved outcomes for patients, including gains in mortality, significant morbidity, and cost. The ideal precision management strategy for an individual patient remains an area of increasing understanding.

Diagnostic Efficiency of Tongue-Coating Microbiome in Patients With SARS-CoV-2 Omicron Variant Infection and Recovery

SARS-CoV-2 variants still pose threats to human public health. However, there has been little research regarding alterations in the tongue-coating microbiome in patients infected with the Omicron variant (PIOVs). Herein, we collected 963 tongue-coating samples prospectively, including 349 samples from PIOVs, 242 samples from recovered PIOVs, 300 samples from healthy controls (HCs) and 72 samples from patients infected with the original strain (PIOSs). We randomly selected tongue-coating samples from PIOVs and HCs as the discovery cohort and validation cohort. Tongue-coating microbiota was analyzed using Miseq sequencing. Our results showed that the tongue-coating microbial diversity of PIOVs was increased. We found that in PIOVs, the abundance was increased in 20 genera, including Prevonella and Atopobium, while the abundance was decreased in 23 genera, including Neisseria and Haemophilus. The classifier based on six optimal microbial markers had high diagnostic efficiency in the discovery cohort (area under the curve of 97.73%) and the validation cohort (area under the curve of 93.06%) between the PIOV and HC groups. Importantly, compared with PIOSs, PIOVs showed an increase in Fusobacterium. Recovery of patients was associated with the restoration of the tongue-coating microbiota. In conclusion, this study is the first to characterize the tongue-coating microbiota in PIOVs and to construct noninvasive diagnostic models, providing new strategies for the prevention and control of coronavirus variants.

Optimization of surgical evaluation algorithms for living donor liver transplantation

BACKGROUND

Living donor liver transplantation (LDLT) is an established and endorsed alternative for deceased donor liver transplantation with better recipient outcomes. Nevertheless, while extensive evaluation of potential donors is crucial, evaluation algorithms differ between transplant centres and guidelines.

METHODS

We included 317 individuals evaluated for LDLT between 07/2007-07/2022 in a retrospective analysis. The evaluation process was analysed to identify the key reasons for declining 77 potential donors. Additionally, 146 donors that underwent LDLT were analysed regarding risk factors for complications.

RESULTS

The main reasons for donor refusal were liver volumetry (40.3 %) and metabolic factors including obesity or steatotic liver disease (20.8 %). Contrast-enhanced computed tomography (CECT) identified 63.6 % of all declined donors; CECT combined with assessment of medical history, physical examination, blood testing and ultrasonography, identified 87.0 % of declined potential donors. Associated with this selection, complication rates in donors were low (≥II in 17.1 %; none with ≥IVb). Notably, higher age was a risk factor for developing a complication ≥II after hemi-hepatectomy (p = 0.0373).

CONCLUSIONS

We propose a progressive 4-step evaluation algorithm that begins with a very basic assessment combined with up-front CECT. This early phase of testing is expected to identify nearly 90 % of ineligible donors, thereby conserving critical resources, time and money, as well as minimising burden for potential donors.

FUNDING

J.M.W. received funding by grant We-4675/6-1 from the Deutsche Forschungsgemeinschaft (DFG) in Bonn, Germany.

Examining the Relationship Between Healthy Life Awareness and Psychological Well-Being in Liver Transplantation Patients: A Structural Equation Model

This study aimed to evaluate the mediating role of healthy life awareness in the relationship between the sociodemographic characteristics and psychological well-being of liver transplant patients. The sample of the study consisted of 202 patients aged between 18 and 69 years who underwent liver transplantation surgery at a hospital in Turkey. The data were collected using a sociodemographic information form, the "Healthy Life Awareness Scale" and the "Psychological Well-Being Scale." Healthy life awareness directly predicted psychological well-being (β: 0.68, p < 0.01). Education positively predicted psychological well-being both directly (β: 0.14, p < 0.05) and indirectly through healthy life awareness (β: 0.76, p < 0.05). Age indirectly predicted healthy life awareness and psychological well-being through employment status and education. The income level positively predicted healthy life awareness (β: 0.14, p < 0.05), whereas gender (male) negatively predicted healthy life awareness (β: -0.22, p < 0.01). Healthy life awareness was a significant predictor of psychological well-being. The results of this study may offer valuable information for healthcare providers to tailor interventions that also support mental and emotional health, which is critical to the long-term success of transplant outcomes.

Development and External Validation of a Combined Clinical-Radiomic Model for Predicting Insufficient Hypertrophy of the Future Liver Remnant following Portal Vein Embolization

OBJECTIVES

This study aimed to develop and externally validate a model for predicting insufficient future liver remnant (FLR) hypertrophy after portal vein embolization (PVE) based on clinical factors and radiomics of pretreatment computed tomography (CT) PATIENTS AND METHODS: Clinical information and CT scans of 241 consecutive patients from three Swedish centers were retrospectively collected. One center (120 patients) was applied for model development, and the other two (59 and 62 patients) as test cohorts. Logistic regression analysis was adopted for clinical model development. A FLR radiomics signature was constructed from the CT images using the support vector machine. A model combining clinical factors and FLR radiomics signature was developed. Area under the curve (AUC) was adopted for predictive performance evaluation RESULTS: Three independent clinical factors were identified for model construction: pretreatment standardized FLR (odds ratio (OR): 1.12, 95% confidence interval (CI): 1.04-1.20), alanine transaminase (ALT) level (OR: 0.98, 95% CI: 0.97-0.99), and PVE material (OR: 0.27, 95% CI: 0.08-0.87). This clinical model showed an AUC of 0.75, 0.71, and 0.68 in the three cohorts, respectively. A total of 833 radiomics features were extracted, and after feature dimension reduction, 16 features were selected for FLR radiomics signature construction. When adding it to the clinical model, the AUC of the combined model increased to 0.80, 0.76, and 0.72, respectively. However, the increase was not significant.

CONCLUSIONS

Pretreatment CT radiomics showed added value to the clinical model for predicting FLR hypertrophy following PVE. Although not reaching statistically significant, the evolving radiomics holds a potential to supplement traditional predictors of FLR hypertrophy.

Management of the acute on chronic liver failure in the intensive care unit

Acute on chronic liver failure (ACLF) reflects the development of organ failure(s) in a patient with cirrhosis and is associated with high short-term mortality. Given that ACLF has many different 'phenotypes', medical management needs to take into account the relationship between precipitating insult, organ systems involved and underlying physiology of chronic liver disease/cirrhosis. The goals of intensive care management of patients suffering ACLF are to rapidly recognize and treat inciting events (e.g. infection, severe alcoholic hepatitis and bleeding) and to aggressively support failing organ systems to ensure that patients may successfully undergo liver transplantation or recovery. Management of these patients is complex since they are prone to develop new organ failures and infectious or bleeding complications. ICU therapy parallels that applied in the general ICU population in some complications but differs in others. Given that liver transplantation in ACLF is an emerging and evolving field, multidisciplinary teams with expertise in critical care and transplant medicine best accomplish management of the critically ill ACLF patient. The focus of this review is to identify the common complications of ACLF and to describe the proper management in critically ill patients awaiting liver transplantation in our centres, including organ support, prognostic assessment and how to assess when recovery is unlikely.

Surgical treatment for hepatocellular carcinoma in era of multidisciplinary strategies

Hepatocellular carcinoma (HCC) remains a significant global health challenge, with over 800,000 new cases diagnosed annually. This comprehensive review examines current surgical approaches and emerging multidisciplinary strategies in HCC treatment. While traditional surgical criteria, such as the Barcelona Clinic Liver Cancer (BCLC) staging system, have been relatively conservative, recent evidence from high-volume Asian centers supports more aggressive surgical approaches in carefully selected patients. The review discusses the evolution of selection criteria, including the new "Borderline Resectable HCC" classification system, which provides more explicit guidance for surgical decision-making. Technical innovations have significantly enhanced surgical precision, including three-dimensional simulation, intraoperative navigation systems, and the advancement of minimally invasive approaches. The review evaluates the ongoing debate between anatomical versus non-anatomical resection and examines the emerging role of robotic surgery. In liver transplantation, expanded criteria beyond the Milan criteria show promising outcomes, while the integration of novel biomarkers and imaging techniques improves patient selection. The role of preoperative and adjuvant therapies is increasingly important, with recent trials demonstrating the potential of immune checkpoint inhibitors combined with anti-VEGF agents in both settings. Despite these advances, postoperative recurrence remains a significant challenge. The review concludes that successful HCC treatment requires a personalized approach, integrating surgical expertise with emerging technologies and systemic therapies while considering individual patient factors and regional variations in practice patterns.

Comparison of textbook outcomes between laparoscopic and open liver resection for patients with hepatocellular carcinoma: a multicenter study

OBJECTIVE

We aimed to clarify whether laparoscopic liver resection (LLR) is better than open liver resection (OLR) concerning textbook outcome (TO) achievement for patients with hepatocellular carcinoma (HCC).

METHODS

Data from HCC patients who underwent liver resection from a multicenter database were retrospectively reviewed (n = 2617). Propensity score matching (PSM) was used to balance the baseline characteristics of the two groups. Logistic regression analysis was performed to identify the risk factors that are independently associated with TO.

RESULTS

Before PSM, more aggressive biological characteristics were observed in patients who underwent OLR. After PSM, 771 patients in each group were matched. The overall rate of TO achievement in patients with LLR (78.2%) was higher than that in patients with OLR (71.7%; P < 0.001) after PSM. Subgroup analysis further revealed that LLR was associated with a greater incidence of TO achievement than OLR was in patients who underwent minor liver resection (after PSM; LLR: 83.8% vs. OLR: 73.0%, respectively; P < 0.001) but was similar in those who underwent major liver resection (after PSM; LLR: 68.8% vs. OLR: 65.7%; P = 0.468). Multivariate logistic regression analysis suggested that the LLR (OR = 0.471, 95% CI 95% CI = 0.361-0.614, P < 0.001) was an independent protective factor against non-TO in patients who underwent minor liver resection but not in those who underwent major liver resection. After PSM, the 5-year overall survival (OS) rates of patients who underwent OLR (74.6%) and LLR (73.9%) were similar (P = 0.485). Patients with TO had significantly better OS than those without TO, regardless of whether they underwent LLR (TO: 76.5% vs. non-TO: 65.7%, P = 0.005) or OLR (TO: 76.8% vs. non-TO: 69.1%, P = 0.042).

CONCLUSION

LLR favored TO achievement in HCC patients who received minor liver resection but not in those who underwent major liver resection. Patients who achieved TO had better OS regardless of LLR or OLR.

Hypothermic oxygenated machine perfusion influences the immunogenicity of donor livers in humans

Hypothermic oxygenated machine perfusion (HOPE) is an organ preservation strategy shown to reduce ischemia-reperfusion injury (IRI)-related complications following liver transplantation. In animal models, HOPE can also decrease alloimmune responses after transplantation, but this remains to be evaluated in humans. Our study, involving 27 patients undergoing liver transplantation enrolled in 2 randomized controlled trials comparing static cold storage with HOPE (14 HOPE-treated and 13 static cold storage-treated), delves into the impact of HOPE on the molecular profile of liver allografts and on the immune responses elicited after transplantation. Following HOPE treatment, fewer intrahepatic immune cells were observed in liver perfusates compared to static cold storage. Analysis of liver tissue transcriptome at reperfusion revealed an effect of HOPE on the reactive oxygen species pathway. Two weeks after transplantation, HOPE recipients exhibited increased circulating CD4+FOXP3+CD127lo regulatory T cells ( p < 0.01), which corresponded to a higher frequency of donor-specific regulatory T cells ( p < 0.01) and was followed by reduced alloreactivity index of CD8+ T cells 3 months after transplant. Our study provides novel mechanistic insight into the capacity of HOPE to influence liver ischemia-reperfusion injury and to modulate effector and regulatory donor-specific T-cell responses after transplantation. These findings, which confirm observations made in animal models, help explain the decreased rejection rates reported in patients receiving HOPE-treated allografts.

Comparative Validation of Prediction Models for HCC Outcomes in Living Donor Liver Transplantation: Superiority of Tumor Markers to Imaging Study

BACKGROUND

Living donor liver transplantation (LDLT) offers timely curative treatment for unresectable hepatocellular carcinoma (HCC). This study aims to validate and compare previous prediction models for HCC outcomes in 488 LDLT recipients.

METHODS

For 488 patients who underwent LDLT for HCC, pretransplant imaging studies assessed by modified RECSIT criteria, tumor markers such as alpha feto-protein (AFP) and protein induced by vitamin K absence or antagonist-II (PIVKA II), and explant pathology were recruited. C-index of models for the HCC outcomes was compared, followed by further investigation for the predictive performances of the best model.

RESULTS

We found MoRAL (11√PIVKA-II + 2√AFP) demonstrated a higher C-index for HCC recurrence than other models that included radiologically viable tumor number and/or size (MoRAL: 0.709, Milan: 0.537, UCSF: 0.575, Up-to-7: 0.572, French AFP: 0.634, Pre-MORAL: 0.637, HALT-HCC: 0.626, Metroticket2.0: 0.629) and also had the highest C-index for HCC-specific deaths (0.706). Five-year HCC recurrence was well stratified upon dividing the patients into three groups by MoRAL cutoffs (11.9% for MoRAL < 100, 29.6% for MoRAL 100-200, and 48.6% for MoRAL > 200, p < 0.001). However, patients with major vessel invasion or portal vein tumor thrombus showed similarly high HCC recurrence regardless of this grouping (p = 0.612).

CONCLUSION

The MoRAL, based on tumor markers, showed the best predictive performance for HCC recurrence and HCC-specific death among the validated models, except in cases with major vessel invasion or portal vein tumor thrombus.

Artificial Intelligence-Driven Patient Selection for Preoperative Portal Vein Embolization for Patients with Colorectal Cancer Liver Metastases

PURPOSE

To develop a machine learning algorithm to improve hepatic resection selection for patients with metastatic colorectal cancer (CRC) by predicting post-portal vein embolization (PVE) outcomes.

MATERIALS AND METHODS

This multicenter retrospective study (2000-2020) included 200 consecutive patients with CRC liver metastases planned for PVE before surgery. Data on radiomic features and laboratory values were collected. Patient-specific eigenvalues for each liver shape were calculated using a statistical shape model approach. After semiautomatic segmentation and review by a board-certified radiologist, the data were split 70%/30% for training and testing. Three machine learning algorithms predicting the total liver volume (TLV) after PVE, sufficient future liver remnant (FLR%), and kinetic growth rate (KGR%) were trained, with performance assessed using accuracy, sensitivity, specificity, area under the curve (AUC), or root mean squared error. Significance between the internal and external test sets was assessed by the Student t-test. One institution was kept separate as an external testing set.

RESULTS

A total of 114 (76 men; mean age, 56 years [SD± 12]) and 37 (19 men; mean age, 50 years ± [SD± 11]) patients met the inclusion criteria for the internal validation and external validation, respectively. Prediction accuracy and AUC for sufficient FLR% or liver growth potential (KGR%> 0%) were high in the internal testing set-85.81% (SD ± 1.01) and 0.91 (SD ± 0.01) or 87.44% (SD ± 0.10) and 0.66 (SD ± 0.03), respectively. Similar results occurred in the external testing set-79.66% (SD ± 0.60) and 0.88 (SD ± 0.00) or 72.06% (SD ± 0.30) and 0.69 (SD ± 0.01), respectively. TLV prediction showed discrepancy rates of 12.56% (SD ±4.20%; P = .86) internally and 13.57% (SD ± 3.76%; P = .91) externally.

CONCLUSIONS

Machine learning-based models incorporating radiomics and laboratory test results may help predict the FLR%, KGR%, and TLV as metrics for successful PVE.

Anesthesia management for total robotic liver transplantation: Inaugural case series in Europe

Robotic liver transplantation represents a cutting-edge technique that may surpass traditional open surgery. Nonetheless, it introduces unique anesthetic challenges, including extended pneumoperitoneum, restricted patient access, and a risk of undetected blood loss. This article describes an anesthetic approach and patient outcomes for the first four total robotic liver transplants performed at a tertiary university hospital in Portugal, along with inaugural procedures of their kind in Europe. We retrospectively analyzed surgical and anesthetic data from four patients who underwent total robotic liver transplantation from February to April 2024. Data encompassed clinical profile, preoperative assessment, surgical and anesthesia details, postoperative course, and outcomes. Patients' age ranged from 51 to 69 years. Their cirrhosis was primarily due to alcohol use, hepatitis C virus infection, hepatocellular carcinoma, or nonalcoholic steatohepatitis. General anesthesia was administered. Hemodynamic monitoring and goal-directed fluid therapy were conducted using a PiCCO system. Blood loss varied from 1,000 to 5,000 mL. Blood products were transfused as needed. All donor livers underwent hypothermic oxygenated machine perfusion before transplantation. After surgery, two patients were immediately extubated, while two required extended ventilation. Hospital stays ranged from 10 to 40 days. The 30-day survival rate was 100%. This initial case series affirmed the feasibility and safety of total robotic liver transplantation for carefully selected patients, yielding favorable short-term results. Anesthetic management can rely on proactive strategies, acute situational awareness, and effective multidisciplinary collaboration.

Systemic treatment for recurrence of hepatocellular carcinoma after liver transplantation: a case report

BACKGROUND

Liver transplantation (LT) is considered the optimal treatment approach for patients with cirrhosis progressing to hepatocellular carcinoma (HCC). LT not only allows for complete removal of tumors from the liver but also potentially eliminates cirrhosis. However, recurrence of HCC after LT remains a significant issue, with recurrence rates ranging from 8% to 20%. The median time to recurrence is 14 months, and the median survival after recurrence is 12.2 months. We present the first case of long-term remission following hepatic arterial infusion chemotherapy (HAIC) combined with targeted therapy in a patient with multifocal recurrence and distant metastasis of HCC after LT.

CASE DESCRIPTION

A 62-year-old male experienced recurrence of HCC after LT, with metastases to the sigmoid colon. Following multidisciplinary discussions, he received HAIC combined with small molecule targeted therapy. The liver tumor lesions and hemorrhagic foci remained stable, even tending to shrink, while tumor marker levels steadily declined. The patient did not experience any serious adverse events during treatment. Unfortunately, the patient developed acute enteritis with dysbiosis following a meal in March 2024, which led to rapid onset of septic shock, ultimately resulting in death.

CONCLUSIONS

This case suggests that the combination of HAIC and targeted therapy may offer a promising approach for treating recurrent HCC after LT. These findings provide valuable insights for further exploration of treatment strategies for recurrent HCC post-LT and may contribute to advancing clinical research and practice for the benefit of patients.

Feasibility of indocyanine green fluorescence imaging to predict biliary complications in living donor liver transplantation: A pilot study

Backgrounds/Aims

Liver transplantation (LT) is now a critical, life-saving treatment for patients with liver cirrhosis or hepatocellular carcinoma. Despite its significant benefits, biliary complications (BCs) continue to be a major cause of postoperative morbidity. This study evaluates the fluorescence intensity (FI) of the common bile duct (CBD) utilizing near-infrared indocyanine green (ICG) imaging, and examines its association with the incidence of BCs within three months post-LT.

Methods

This investigation analyzed data from nine living donor LT (LDLT) recipients who were administered 0.05 mg/kg of ICG prior to bile duct anastomosis. Real-time perfusion of the CBD was recorded for three minutes using an ICG camera, and FI was quantified using Image J (National Institutes of Health). Key parameters assessed included F max, F1/2 max, T1/2 max, and the slope (F max/T max) to evaluate the fluorescence response.

Results

BCs occurred in two out of nine patients. These two patients exhibited the longest T1/2 max values, which were linked with lower slope values, implicating a potential relationship between extended T1/2 max, reduced slope, and the occurrence of postoperative BCs.

Conclusions

The study indicates that ICG fluorescence imaging may serve as an effective tool for assessing bile duct perfusion in LDLT patients. While the data suggest that an extended T1/2 max and lower slope may correlate with an increased risk of BCs, further validation through larger studies is required to confirm the predictive value of ICG fluorescence imaging in this setting.

Side Effects of Immunosuppressant Drugs After Liver Transplant

Liver transplantation (LT) is the standard of care for both end-stage liver failure and hepatocellular carcinoma (HCC). Side effects of the main used immunosuppressive drugs have a noteworthy impact on the long-term outcome of LT recipients. Consequently, to achieve a balance between optimal immunosuppression and minimal side effects is a cornerstone of the post-LT period. Today, there are no validated markers for overimmunosuppression and underimmunosuppression, only a few drugs have therapeutic drug monitoring, and immunosuppression regimens vary from center to center and from country to country. Currently, there are many drugs with different efficacy and safety profiles. Using different agents permits a decrease in the dosage and minimizes the toxicities. A small subset of recipients achieves immunotolerance with the chance to stop immunosuppressive therapy. This article focuses on the side effects of immunosuppressive drugs, which significantly impact long-term outcomes for LT recipients. The primary aim is to highlight the balance between achieving effective immunosuppression and minimizing adverse effects, emphasizing the role of personalized therapeutic strategies. Moreover, this review evaluates the mechanisms of action and specific complications associated with immunosuppressive agents. Finally, special attention is given to strategies for reducing immunosuppressive burdens, improving patient quality of life, and identifying immunotolerant individuals.

'Back-to-base' combined hypothermic and normothermic machine perfusion of human donor livers

The shortage of suitable donor organs has resulted in the use of suboptimal, high-risk, extended-criteria donor (ECD) livers, which are at an increased risk of failure after transplantation. Compared with traditional static cold storage, dynamic preservation by ex situ machine perfusion reduces the risks associated with the transplantation of ECD organs. Ex situ machine perfusion strategies differ in timing (that is, speed of procurement and transport), perfusion duration and perfusion temperature. For 'back-to-base' protocols, the donor liver is statically cold stored during transportation to the recipient hospital (the 'base') and then perfused, instead of transporting the liver using a portable perfusion system. While dual hypothermic (8-12 °C) oxygenated machine perfusion (DHOPE) allows safe prolongation of preservation duration and reduces ischemia-reperfusion injury-related complications, including post-transplant cholangiopathy, normothermic machine perfusion (NMP) at 35-37 °C facilitates ex situ viability testing of both liver parenchyma and bile ducts. Here, we describe a clinical protocol for 'back-to-base' combined DHOPE and NMP, linked by a period of controlled oxygenated rewarming (COR), which we call the DHOPE-COR-NMP protocol. This protocol enables restoration of mitochondrial function after static ischemic preservation and minimizes both ischemia-reperfusion and temperature-shift-induced injury during the start of NMP. The NMP phase allows viability assessment before final donor liver acceptance for transplantation. Sequential DHOPE and COR-NMP may reduce the risks associated with transplantation of ECD livers and facilitate enhanced utilization, thereby helping to alleviate the organ shortage.

Effectiveness and Tolerability of Dual Antiviral Therapy in Immunosuppressed Patients with Protracted SARS-CoV-2 Infection

BACKGROUND

Immunosuppressed patients still exhibit a high mortality rate due to SARS-CoV-2 infection, up to 21%. Persistent viral load replication and protracted viral symptoms result in a high risk of developing pneumonia, a potential risk of antiviral resistance, and a subsequent delay of onco-hematological treatments.

METHODS

Hematological patients and kidney transplant patients with SARS-CoV-2 infection, treated at GOM Niguarda Hospital (Milan) with combined antiviral therapy (remdesivir plus nirmatrelvir/ritonavir at standard doses) between November 2022 and March 2024, were retrospectively reviewed.

RESULTS

Thirty-four patients were analyzed. Twenty-four (71%) patients had pneumonia. The median duration of SARS-CoV-2 positivity before antiviral treatment was 40 (10-34) days. The median treatment duration was 11 (10-10) days. All patients went through clinical resolution. Thirteen patients were exposed to a new immune-chemotherapy cycle early after antiviral treatment (median 13, IQR 6-12 days), while five resumed a standard immunosuppressive regimen immediately after viral clearance. No relapse or recurrence of symptoms was reported for up to 226 (106-318) days of follow-up. Antiviral therapy was well tolerated, and no adverse events were observed. The 30-day overall survival was 94%, while the 90-day survival was 88%. No patient died of SARS-CoV-2 infection.

CONCLUSIONS

The administration of nirmatrelvir/ritonavir and remdesivir lead to the complete resolution of SARS-CoV-2 pneumonia with no side effects in this cohort. The combination of these two antivirals may be a safe option in immunosuppressed population at risk of severe complications and prolonged SARS-CoV-2 infection in order to treat severe clinical presentation and to avoid viral recurrence after chemotherapy.

CYP3A5 and POR gene polymorphisms as predictors of infection and graft rejection in post-liver transplant patients treated with tacrolimus - a cohort study

Liver transplantation is the only curative option for patients with advanced stages of liver disease, with tacrolimus used as the immunosuppressive drug of choice. Genetic variability can interfere with drug response, potentially leading to overexposure or underexposure. This study aims to investigate the association of CYP3A4 (rs2740574, rs2242480, rs35599367), CYP3A5 (rs776746, rs10264272), POR (rs1057868) and ABCB1 (rs1128503, rs2229109, rs9282564) gene polymorphisms with infection, acute rejection, and renal failure. The logistic regression model found an influence of CYP3A5 (rs776746) and POR28 (rs1057868) on the development of acute rejection after liver transplantation (p = 0.028). It also found an association between carriers of the variant allele of the POR*28 gene and infection.

Expanding Indications in Transplant Oncology

Liver transplantation is aptly described as the only curative treatment for cirrhosis and cirrhosis with co-morbid hepatocellular carcinoma (HCC). Its utility in the management of various other primary and secondary liver cancers is gaining traction rapidly, with more thorough assessments on broader populations continuing to emerge. Most prominently, this includes colorectal cancer liver metastasis (CRLM), cholangiocarcinoma (CCA), neuroendocrine tumors (NETs), and more. Furthermore, despite being a well described treatment for HCC for many years, growing evidence supports a change in oncological strategy for HCC, with broadened selection criteria and more advanced systemic and locoregional therapies available. Our review aims to describe the evidence supporting the expansion of indications and selection criteria for liver transplantation in various oncologic indications of primary and secondary liver tumors.

Microvascular Inflammation of Kidney Allografts and Clinical Outcomes

BACKGROUND

The heterogeneous clinical presentation of graft microvascular inflammation poses a major challenge to successful kidney transplantation. The effect of microvascular inflammation on allograft outcomes is unclear.

METHODS

We conducted a cohort study that included kidney-transplant recipients from more than 30 transplantation centers in Europe and North America who had undergone allograft biopsy between 2004 and 2023. We integrated clinical and pathological data to classify biopsy specimens according to the 2022 Banff Classification of Renal Allograft Pathology, which includes two new diagnostic categories: probable antibody-mediated rejection and microvascular inflammation without evidence of an antibody-mediated response. We then assessed the association between the newly recognized microvascular inflammation phenotypes and allograft survival and disease progression.

RESULTS

A total of 16,293 kidney-transplant biopsy specimens from 6798 patients were assessed. We identified the newly recognized microvascular inflammation phenotypes in 788 specimens, of which 641 were previously categorized as specimens with no evidence of rejection. As compared with patients without rejection, the hazard ratio for graft loss was 2.1 (95% confidence interval [CI], 1.5 to 3.1) among patients with microvascular inflammation without evidence of an antibody-mediated response and 2.7 (95% CI, 2.2 to 3.3) among patients with antibody-mediated rejection. Patients with a diagnosis of probable antibody-mediated rejection had a higher risk of graft failure beyond year 5 after biopsy than those without rejection (hazard ratio, 1.7; 95% CI, 0.8 to 3.5). Patients with a diagnosis of either newly recognized microvascular inflammation phenotype had a higher risk of progression of transplant glomerulopathy during follow-up than patients without microvascular inflammation.

CONCLUSIONS

Microvascular inflammation in kidney allografts includes distinct phenotypes, with various disease progression and allograft outcomes. Our findings support the clinical use of additional rejection phenotypes to standardize diagnostics for kidney allografts. (Funded by OrganX. ClinicalTrials.gov number, NCT06496269.).

Microbiota and Radiotherapy: Unlocking the Potential for Improved Gastrointestinal Cancer Treatment

Radiotherapy (RT) is one of the major cornerstones in managing gastrointestinal (GI) cancers. However, several side effects, such as intestinal inflammation, mucosal injury, and dysbiosis, often compromise this. The gut microbiota increasingly attracts much interest as an essential modulator of RT effects influencing immune responses and tissue repair. Through short-chain fatty acids such as butyrate, representatives of certain bacterial species play a crucial role under normal conditions, keeping the mucosal integrity intact and reducing oxidative stress-mediated damage. Dysbiosis, a state where diminished microbial diversity and increased pathogenic species in the microbiota are seen, amplifies RT-induced toxicity in patients. Clinical investigations highlight that microbiota-targeted interventions, including probiotics, prebiotics, and fecal microbiota transplantation, hold the means to augment RT efficacy and lessen toxicity. Increased microflora diversity and specific microbial profiles have yielded serious patient improvements. Advanced RT methods use stereotactic body radiotherapy combined with microbiota modulation as a promising technique to shield healthy tissue and maximize immune-mediated antitumor effects. Additionally, there is an implication in tumor behavior regulated by the intratumoral microbiota regarding the response to radiotherapy. Notably, the modulation of gut and tumor microbiota provides an avenue to optimize RT benefits in GI cancers, underscoring the importance of personalized therapy.

High relevance of invasive fungal disease in chronic liver transplant failure: a comprehensive cross-sectional study

Invasive fungal infection (IFI) is a severe complication in organ transplant patients and a major diagnostic and therapeutic challenge. The aim of this comprehensive retrospective study was the characterization of IFI in context of chronic liver transplant failure regarding prevalence, morphological changes, and inducing fungal species. All explanted liver transplants due to chronic transplant failure from Heidelberg University Hospital were extensively reexamined for the presence of mycotic infection. Special stains were performed to uncover severity and associated conditions of IFI and fungal species were identified on the molecular level. Light-microscopic examination revealed fungal infection in 41 (27.5%) of 149 explanted livers with chronic transplant failure, with 68% representing newly specified cases compared to primary reports. We could show an increase of the proportion of mycotic infections during the investigated time period (1991-2021) as well as a shorter transplant survival when compared to the non-affected organs. Typically, large bile ducts were affected, accompanied by acute inflammation with frequent abscess and bile concrement formation. In 35 of 41 cases, the identification of the fungal species was achieved, revealing Candida albicans as prominent species (74.3%). In three autopsy livers of patients that died after liver transplantation of septic multiorgan failure, Candida spp. could be identified. Our data show the underestimated prevalence and high diagnostic and clinical relevance of mycotic infection in chronic liver transplant failure. Adapting diagnostic procedures, molecular pathological analyses, and therapeutic strategies is relevant to identify and prevent chronic transplant organ failure caused by IFIs.

Perspectives and Tools in Liver Graft Assessment: A Transformative Era in Liver Transplantation

Liver transplantation is a critical and evolving field in modern medicine, offering life-saving treatment for patients with end-stage liver disease and other hepatic conditions. Despite its transformative potential, transplantation faces persistent challenges, including a global organ shortage, increasing liver disease prevalence, and significant waitlist mortality rates. Current donor evaluation practices often discard potentially viable livers, underscoring the need for refined graft assessment tools. This review explores advancements in graft evaluation and utilization aimed at expanding the donor pool and optimizing outcomes. Emerging technologies, such as imaging techniques, dynamic functional tests, and biomarkers, are increasingly critical for donor assessment, especially for marginal grafts. Machine learning and artificial intelligence, exemplified by tools like LiverColor, promise to revolutionize donor-recipient matching and liver viability predictions, while bioengineered liver grafts offer a future solution to the organ shortage. Advances in perfusion techniques are improving graft preservation and function, particularly for donation after circulatory death (DCD) grafts. While challenges remain-such as graft rejection, ischemia-reperfusion injury, and recurrence of liver disease-technological and procedural advancements are driving significant improvements in graft allocation, preservation, and post-transplant outcomes. This review highlights the transformative potential of integrating modern technologies and multidisciplinary approaches to expand the donor pool and improve equity and survival rates in liver transplantation.

Pharmacokinetics of ethambutol and weight banded dosing in South African adults newly diagnosed with tuberculosis and HIV

Ethambutol is used to treat tuberculosis (TB) in individuals living with HIV. Low concentrations of ethambutol have been reported in patients dosed with the World Health Organization (WHO)-recommended first-line regimen. We analyzed the pharmacokinetics of ethambutol in 61 HIV-positive individuals diagnosed with drug-sensitive TB enrolled in the tuberculosis and highly active antiretroviral therapy (TB-HAART) study. Participants started on TB treatment and were randomized to early or later introduction of efavirenz-based antiretroviral treatment. We explored potential covariate effects and evaluated the current WHO dosing recommendations for ethambutol in drug-susceptible and multidrug-resistant (MDR)-TB. A two-compartment model with first-order elimination allometrically scaled by fat-free mass and transit compartment absorption best described the pharmacokinetics of ethambutol. Clearance was estimated to be 40.3 L/h for a typical individual with a fat-free mass (FFM) of 42 kg. The Antib-4 formulation had 26% higher bioavailability and slower mean transit time by 37% compared with Rifafour. Simulations showed that individuals in the lower weight bands (<55 kg) who were administered ethambutol at WHO-recommended doses had relatively low drug exposures. These individuals would need doses of 825 mg if their body weight is <37.9 kg and 1,100 mg if it is between 38 and 54.9 kg to achieve the reference maximum concentrations of 2-6 mg/L and an area under the concentration-time curve (0-24) of 16-29 mg·h/L. To achieve these targets in MDR-TB treatment, a dose increment of 400 mg (extra tablet) would be required for individuals in the lower weight band (<46 kg). Our dose adjustments are consistent with the literature and can be recommended for consideration by the WHO for first-line drug-susceptible and MDR-TB treatment.

Microbial dynamics of acute pancreatitis: integrating culture, sequencing, and bile impact on bacterial populations and gaseous metabolites

Background

Our study examined the composition of the intestinal microflora in a hospitalized patient with AP symptoms treated several months earlier for diverticulitis. The therapeutic intervention necessitated Hartmann's procedure, culminating in colostomy creation.

Aims

Employing a thorough microbiological analysis we attempted to demonstrate whether the microflora isolated from the peripancreatic fluid exhibited a stronger correlation with the contents of the stoma or with the rectal swab. Additionally, we sought to determine the association between later onset of AP and diverticulitis.

Methods

Following clinical materials from the patient in the initial phase of AP were collected: rectal swab, colostomy bag contents (in the publication referred to as stoma content/stool) and peripancreatic fluid. Microbiological analysis was performed, including classic culture methodology, NGS techniques, and genotyping methodologies. Furthermore, the effect of bile on the shift in the population of selected bacterial species was examined.

Results

The NGS technique confirmed greater consistency in bacteria percentage (phyla/family) between stoma content and peripancreatic fluid. In both samples, a clear dominance of the Proteobacteria phyla (over 75%) and the Enterobacteriaceae family was demonstrated. Moreover, NGS verified the presence of the Fusobacteriota phylum and Fusobacteriaceae family only in rectal swabs, which may indicate a link between this type of bacteria and the etiology of diverticulitis. We observed that Escherichia coli 33 isolated from stool exhibited active gaseous metabolite production (mainly hydrogen).

Conclusions

The abundant production of hydrogen may substantially impact enzymatic processes, inducing specific alterations in disulfide bonds and trypsin inactivation. Our investigation alludes to the conceivable active involvement of bile in effecting qualitative and quantitative modifications in the peripancreatic microbiota composition, establishing a correlation between released bile and bacterial generation of gaseous metabolites.

Validity, Accuracy, and Safety Assessment of an Aerobic Interval Training Using an App-Based Prehabilitation Program (PROTEGO MAXIMA Trial) Before Major Surgery: Prospective, Interventional Pilot Study

BACKGROUND

Major surgery is associated with significant morbidity and a reduced quality of life, particularly among older adults and individuals with frailty and impaired functional capacity. Multimodal prehabilitation can enhance functional recovery after surgery and reduce postoperative complications. Digital prehabilitation has the potential to be a resource-sparing and patient-empowering tool that improves patients' preoperative status; however, little remains known regarding their safety and accuracy as medical devices.

OBJECTIVE

This study aims to test the accuracy and validity of a new software in comparison to the gold-standard electrocardiogram (ECG)-based heart rate measurement.

METHODS

The PROTEGO MAXIMA trial was a prospective interventional pilot trial assessing the validity, accuracy, and safety of an app-based exercise program. The Prehab App calculates a personalized, risk-stratified aerobic interval training plan based on individual risk factors and utilizes wearables to monitor heart rate. Healthy students and patients undergoing major surgery were enrolled. A structured risk assessment was conducted, followed by a 6-minute walking test and a 37-minute supervised interval session. During the exercise, patients wore app-linked wearables for heart rate and distance measurements, which were compared with standard ECG and treadmill measurements. Safety, accuracy, and usability assessments included testing alarm signals, while the occurrence of adverse events served as the primary and secondary outcome measures.

RESULTS

A total of 75 participants were included. The mean heart rate differences between wearables and standard ECG were ≤5 bpm (beats per minute) with a mean absolute percentage error of ≤5%. Regression analysis revealed a significant impact of the BMI (odds ratio 0.90, 95% CI 0.82-0.98, P=.02) and Timed Up and Go Test score (odds ratio 0.12, 95% CI 0.03-0.55, P=.006) on the accuracy of heart rate measurement; 29 (39%) patients experienced adverse events: pain (5/12, 42%), ECG electrode-related skin irritations (2/42, 17%), dizziness (2/42, 17%), shortness of breath (2/42, 17%), and fatigue (1/42, 8%). No cardiovascular or serious adverse events were reported, and no serious device deficiency was detected. There were no indications of clinically meaningful overexertion based on laboratory values measured before and after the 6-minute walking test and exercise. The differences in means and ranges were as follows: lactate (mmol/l), mean 0.04 (range -3 to 6; P=.47); creatinine kinase (U/l), mean 12 (range -7 to 43; P<.001); and sodium (mmol/l), mean -2 (range -11 to 12; P<.001).

CONCLUSIONS

The interventional trial demonstrated the high safety of the exercise program and the accuracy of heart rate measurements using commercial wearables in patients before major surgery, paving the way for potential remote implementation in the future.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00026985; https://drks.de/search/en/trial/DRKS00026985 and European Database on Medical Devices (EUDAMED) CIV-21-07-0307311.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1136/bmjopen-2022-069394.

Liver Transplantation for Hepatocellular Carcinoma: An Expanding Cornerstone of Care in the Era of Immunotherapy

Liver transplantation (LT) has been accepted as a cornerstone of care in hepatocellular carcinoma (HCC) for almost three decades. In recent years, its role has been evolving to include patients with disease burden beyond the widely used Milan criteria. The integration of dynamic biomarkers such as alpha-fetoprotein together with downstaging approaches and tumor evolution after enlistment has allowed the selection of patients most likely to benefit, resulting in 5-year survival rates greater that 70%. With the increasing use of immune checkpoint inhibitors (ICIs) across all stages of disease, alone or in combination with locoregional therapies, there is now the potential to further expand the patient population with HCC who may benefit from LT. This brings challenges, given the global shortage of organs and the need to better understand the optimal use of ICIs before transplantation. Furthermore, the field of transplant oncology awaits additional biomarkers that can predict those likely to benefit from ICIs. More than ever, a multidisciplinary approach for liver cancer management is critical to ensure all patients are considered for LT where appropriate, and do not miss the opportunity for long-term survival.

The role of the comprehensive complication index in the prediction of tumor-related death in transplanted patients with hepatocellular carcinoma

Liver transplantation (LT) is the primary treatment for selected patients with hepatocellular carcinoma (HCC). However, HCC-related mortality post-LT remains a significant concern, with up to 10% of cases reported in international series. Identifying risk factors for adverse clinical outcomes is essential. We hypothesized that post-LT HCC-related mortality rates are higher in patients with a high (≥ 42) Comprehensive Complication Index (CCI) calculated at discharge. This study aims to compare post-LT HCC-related mortality rates between two groups of patients with high versus low CCI following LT for HCC. This study included data from seven collaborative European centers. A cohort of 1121 HCC patients transplanted between 2005 and 2019, surviving more than six months post-LT, was analyzed retrospectively. Patients were divided into two groups based on the CCI at discharge: Low-CCI Group (n = 942, 84.0%) and High-CCI Group (n = 179, 16.0%). An inverse probability of treatment weighting (IPTW) approach was applied for analysis. In the post-IPTW cohort, four multivariable logistic regression models with mixed effects identified independent risk factors for HCC-related death, overall death, recurrence, and early recurrence. A CCI score of ≥ 42 emerged as an independent risk factor across all models. Specifically, CCI ≥ 42 was associated with increased odds of HCC-related death (OR = 3.35; P < 0.0001), overall death (OR = 2.63; P < 0.0001), overall recurrence (OR = 2.09; P = 0.001), and early recurrence (OR = 1.88; P = 0.02). A CCI score at discharge should be considered a critical factor for recurrence and HCC-related mortality risk. Incorporating CCI into standard post-LT predictive models may enhance prognostic accuracy for adverse HCC outcomes.

Update on the Complications and Management of Liver Cirrhosis

Liver cirrhosis represents the advanced pathological stage of chronic liver disease, characterized by the progressive destruction and regeneration of the hepatic parenchyma over years, culminating in fibrosis and disruption of the vascular architecture. As a leading global cause of morbidity and mortality, it continues to affect millions worldwide, imposing a substantial burden on healthcare systems. Alcoholic/nonalcoholic fatty liver disease and chronic viral hepatitis infection, hepatitis C (HCV) in particular, remain leading causes of cirrhosis. Despite significant advances in understanding the pathogenesis of cirrhosis, its management is still complex due to the multifaceted complications, including ascites, hepatic encephalopathy, variceal bleeding, and hepatocellular carcinoma, all of which severely compromise the patient outcomes and quality of life. This review aims at filling a critical gap by providing a comprehensive summary of the latest evidence on the complications and management of liver cirrhosis. Evidence-based therapies targeting both the etiologies and complications of cirrhosis are essential for improving outcomes. While liver transplantation is considered a definitive cure, advancements in pharmacological therapies offer promising avenues for halting and potentially reversing disease progression. This review summarizes the latest management strategies for cirrhosis and its associated complications, emphasizing the importance of early intervention and novel therapeutic options for improving outcomes and quality of life in affected individuals.

Mono-HOPE Versus Dual-HOPE in Liver Transplantation: A Propensity Score-Matched Evaluation of Early Graft Outcome

Hypothermic oxygenated machine perfusion (HOPE) has become an integral technique to enhance donor graft function in liver transplantation (LiTx). This study compares early posttransplant outcomes of mono-HOPE (portal vein perfusion only) versus dual- HOPE (both portal vein and hepatic artery perfusion). A retrospective analysis was conducted on 183 LiTx recipients, with 90 receiving mono-HOPE and 93 receiving dual-HOPE grafts. Propensity Score Matching (PSM) was applied, resulting in a matched cohort of 146 patients. Primary outcomes included one-year patient and graft survival, and non-anastomotic biliary strictures (NAS). Secondary outcomes included hospital length of stay (HLS). One-year patient survival was 81.7% in the mono-HOPE and 81.7% in the dual-HOPE group, and overall survival did not differ (p = 0.990). One-year death-censored graft survival was similarly comparable (91.2% vs. 93.3%, p = 0.893). NAS were observed in 10.96% in the mono-HOPE and 8.22% in the dual-HOPE group (p = 0.574). The median HLS was 29 days for both groups. Results suggest that dual-HOPE did not significantly improve patient or graft survival, nor did it reduce NAS or HLS compared to mono-HOPE. Assuming that larger cohorts and long-term follow-up data confirm this, additional cannulation of the hepatic artery during machine perfusion in hypothermic conditions may not be beneficial.

Inflammation and Immunity in Liver Neoplasms: Implications for Future Therapeutic Strategies

Over the past two decades, the "hallmarks of cancer" have revolutionized cancer research and highlighted the crucial roles of inflammation and immunity. Protumorigenic inflammation promotes cancer development along with inhibition of antitumor immunity, shaping the tumor microenvironment (TME) toward a tumor-permissive state and further enhancing the malignant potential of cancer cells. This immunosuppressive TME allows tumors to evade immunosurveillance. Thus, understanding the complex interplay between tumors and the immune system within the TME has become pivotal, especially with the advent of immunotherapy. Although immunotherapy has achieved notable success in many malignancies, primary liver cancer, particularly hepatocellular carcinoma, presents unique challenges. The hepatic immunosuppressive environment poses obstacles to the effectiveness of immunotherapy, along with high mortality rates and limited treatment options for patients with liver cancer. In this review, we discuss current understanding of the complex immune-mediated mechanisms underlying liver neoplasms, focusing on hepatocellular carcinoma and liver metastases. We describe the molecular and cellular heterogeneity within the TME, highlighting how this presents unique challenges and opportunities for immunotherapy in liver cancers. By unraveling the immune landscape of liver neoplasms, this review aims to contribute to the development of more effective therapeutic interventions, ultimately improving clinical outcomes for patients with liver cancer.

The Impact of Human Liver Transplantation on the Concentration of Fibroblast Growth Factors: FGF19 and FGF21

The multitude of processes in which the liver participates makes it vulnerable to many serious diseases, which can lead to chronic organ failure. Modern medicine bases the treatment of end-stage liver failure on liver transplantation. To ensure the proper functioning of the transplanted liver, a balance of cellular and immunological processes and appropriate concentrations of many different factors are necessary, including, among others, fibroblast growth factors (FGFs). Over the last several years, studies have focused on some FGF growth factors, i.e., FGF19 and FGF21. These two growth factors belong to the FGF19 subfamily, and we concentrate on these two factors in our work. These factors diffuse away from the site of secretion into the blood, acting as hormones. FGF19 is a growth factor with a high therapeutic potential, involved in the homeostasis of bile acids necessary to maintain the proper function of the transplanted liver. FGF21, in turn, plays an important role in regulating lipid and glucose homeostasis. This study aimed to evaluate changes in the concentration of growth factors FGF19 and FGF21 in the plasma of 84 patients before, 24 h, and 2 weeks after liver transplantation (ELISA test was used). Additionally, the correlations of the basic laboratory parameters-alanine aminotransferase (ALT), aspartate aminotransferase (AST), gamma-glutamyl transpeptidase (GGTP), alkaline phosphatase (ALP), total bilirubin, C-reactive protein (CRP), albumin and hemoglobin (Hb)-with FGF19 and FGF21 were determined. Our studies noted statistically significant changes in FGF19 and FGF21 concentrations before, 24 h, and 2 weeks after liver transplantation. The highest values for FGF19 before liver transplantation and the lowest values 24 h after this surgery were observed for FGF21; the highest concentrations were observed the day after liver transplantation, and the lowest were observed immediately before surgery. Observations of increases and decreases in the concentration of the examined factors at individual time points (before and after transplantation) allow us to suspect that FGF19 has an adaptive and protective function toward the transplanted liver. At the same time, FGF21 may affect the regenerative mechanisms of the damaged organ.

Caring Readiness Among Parents of Children Who Have Undergone Liver Transplantation and Are Transitioning From the Intensive Care Unit: A Cross-Sectional Study

OBJECTIVE

To investigate the status and influencing factors of caring readiness among parents of children undergoing liver transplantation transitioning from the intensive care unit, and to explore the associations between caring readiness and other variables.

DESIGN

A cross-sectional study.

METHODS

A total of 126 parents of children who underwent liver transplantation at a tertiary hospital in China took a questionnaire survey via convenience sampling. Independent t-test, ANOVA and correlation analysis were conducted to analyse the data. Multivariable stepwise linear regression was used to analyse the influencing factors of caring readiness. The PROCESS macro (Model 4) was used to verify the mediating effect of caregiver burden between social support and caring readiness.

REPORTING METHOD

The STROBE checklist was used as a guideline in this study.

RESULTS

The mean score of caring readiness among parents of children who had undergone liver transplantation and were transitioning from the intensive care unit was 23.62 ± 5.34. Multivariable stepwise linear regression analysis indicated that experience with caregiving, intensive care unit length of stay, social support and caregiver burden were the factors associated with caring readiness, explaining 18.6% of the variance in caring readiness among parents. Caregiver burden partially moderated the relationship between social support and caring readiness (20.93%).

CONCLUSION

The study shows caring readiness was moderate among parents of children who have undergone liver transplantation and are transitioning from the intensive care unit. It reveals that lack of caregiving experience and children's short intensive care unit length of stay should be emphasised, preventing inadequate readiness of parents. Furthermore, enhancing social support interventions and burden-reduction strategies are important for improving parents' caring readiness.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

The findings demonstrate that health care professionals should provide timely and appropriate intervention strategies to enhance parents' caring readiness, which could potentially be achieved by increasing social support and reducing caregiver burden.

PATIENT OR PUBLIC CONTRIBUTION

Parents of children who underwent liver transplantation participated in this study via a questionnaire survey.