Long-term patient outcome and quality of life after liver transplantation: analysis of 20-year survivors. Ann Surg. 2010;252:652-661. [PMID: 20881772 DOI: 10.1097/sla.0b013e3181f5f23a]

Quercetin, a natural flavonoid, protects against hepatic ischemia-reperfusion injury via inhibiting Caspase-8/ASC dependent macrophage pyroptosis

INTRODUCTION

Hepatic ischemia-reperfusion injury (IRI) is an inevitable adverse event following liver surgery, leading to liver damage and potential organ failure. Despite advancements, effective interventions for hepatic IRI remain elusive, posing a significant clinical challenge. The innate immune response significantly contributes to the pathogenesis of hepatic IRI by promoting an inflammatory cytotoxic cycle. We have reported that blocking GSDMD-induced pyroptosis in innate immunity cells protected hepatic IRI from inflammatory injury. However, the search for effective pyroptosis inhibitors continues.

OBJECTIVES

This study aims to evaluate whether quercetin, a natural flavonoid, can inhibit GSDMD-induced pyroptosis and mitigate hepatic IRI.

METHODS

We established the hepatic IRI murine model and cellular pyroptosis model to evaluate the efficacy of quercetin.

RESULTS

Quercetin effectively alleviated hepatic IRI-induced tissue necrosis and inflammation. We found that during hepatic IRI, the cleavage of GSDMD occurred in hepatic macrophages, but not in other non-parenchymal cells. Quercetin inhibited the cleavage of GSDMD in macrophages. Moreover, we found that quercetin blocked the ASC assembly to inhibit the formation of NLRP3 inflammasomes and AIM2 inflammasomes, suppressing macrophage pyroptosis. Co-immunoprecipitation experiments confirmed that quercetin inhibited the interaction between ASC and Caspase-8, which is the mechanism of ASC complex and inflammasome formation. Overexpression of Caspase-8 abolished the anti-pyroptosis effect of quercetin in NLRP3 and AIM2 inflammasome signaling. Furthermore, we found that the hepatoprotective activity of quercetin was reduced in myelocytic GSDMD-deficient mice.

CONCLUSION

Our findings suggest that quercetin has beneficial effects on hepatic IRI. Quercetin could attenuate hepatic IRI and target inhibition of macrophage pyroptosis via blocking Caspase-8/ASC interaction. We recommend that quercetin might serve as a targeted approach for the prevention and personalized treatment of hepatic IRI in perioperative patients.

Pediatric Liver Transplantation: Selection Criteria and Post-transplant Medical Management

Pediatric liver transplantation remains the gold standard for life-threatening acute and chronic liver diseases and multiple liver-based inherited metabolic defects. Advances in surgical techniques, better perioperative care and immunosuppression regimes have resulted in excellent long-term graft and patient survival. The success of pediatric liver transplantation does however bring the additional challenge of long-term patient outcomes including graft hepatitis-related fibrosis and suboptimal biopsychosocial outcomes. In this review, authors will explore the current landscape of pediatric liver transplantation including indications, timing of referral for liver transplantation, surgical techniques and long-term outcomes such as recurrence of pre-transplant liver disease, idiopathic graft hepatitis and biopsychosocial outcomes. Ultimately, early identification and management of potential issues long-term helps ensure our recipients achieve a "meaningful survival".

Effect of pretransplant sarcopenia on patient and graft outcomes in solid organ transplant recipients: A systematic review and meta-analysis

The relationship between sarcopenia and prognosis in solid organ transplantation recipients (SOTr) remains unverified. We aimed to quantify the prevalence of pretransplant sarcopenia and its effect on patient and graft survival in SOTr. We used PubMed, EMBASE, Cochrane Library and Web of Science to search relevant studies published in English (from inception to December 31, 2021). Prospective and retrospective cohort studies that reported the prevalence of sarcopenia before transplant or the association between sarcopenia and clinical outcomes in SOTr were included. Primary outcomes were the prevalence of sarcopenia and its impact on patient and graft survival. Secondary outcomes included perioperative complications, acute rejection, length of hospital stay, length of intensive care unit stay (ICU LOS) and early readmission. Thirty-nine studies involving 5792 patients were included. Pooled prevalence of sarcopenia amongst SOTr candidates was 40 % (95 % confidence interval [CI]: 34%-47 % and I2 = 97 %). Sarcopenia was associated with increased risk of death (hazard ratio [HR] = 1.87, 95 % CI: 1.46-2.41 and I2 = 60 %), poor graft survival (HR = 1.71, 95 % CI: 1.16-2.54 and I2 = 57 %) and increased liver graft loss (HR = 1.43, 95 % CI: 1.03-1.99 and I2 = 38 %). Patients with sarcopenia demonstrated increased incidence of perioperative complications (risk ratio [RR] = 1.34, 95 % CI: 1.17-1.53 and I2 = 40 %), long ICU LOS (mean difference = 2.31 days, 95 % CI: 0.58-4.04 and I2 = 97 %) and decreased risk of acute rejection (RR = 0.61, 95 % CI: 0.42-0.89 and I2 = 0 %). In Conclusion, sarcopenia is prevalent in SOTr candidates and associated with death and graft loss. Identifying sarcopenia before transplantation and intervening may improve long-term outcomes.

The Promise of Complement Therapeutics in Solid Organ Transplantation

Transplantation is the ideal therapy for end-stage organ failure, but outcomes for all transplant organs are suboptimal, underscoring the need to develop novel approaches to improve graft survival and function. The complement system, traditionally considered a component of innate immunity, is now known to broadly control inflammation and crucially contribute to induction and function of adaptive T-cell and B-cell immune responses, including those induced by alloantigens. Interest of pharmaceutical industries in complement therapeutics for nontransplant indications and the understanding that the complement system contributes to solid organ transplantation injury through multiple mechanisms raise the possibility that targeting specific complement components could improve transplant outcomes and patient health. Here, we provide an overview of complement biology and review the roles and mechanisms through which the complement system is pathogenically linked to solid organ transplant injury. We then discuss how this knowledge has been translated into novel therapeutic strategies to improve organ transplant outcomes and identify areas for future investigation. Although the clinical application of complement-targeted therapies in transplantation remains in its infancy, the increasing availability of new agents in this arena provides a rich environment for potentially transformative translational transplant research.

Aging with a Liver Graft: Analysis of Very Long-Term Survivors after Liver Transplantation

BACKGROUND

In Italy, data on long-term survivors after liver transplantation are lacking.

MATERIALS AND METHODS

We conducted a hybrid design study on a cohort of 359 adult recipients who received transplants between 1996 and 2002 to identify predictors of survival and the prevalence of co-morbidities among long-term survivors.

RESULTS

The actuarial (95% CI) patient survival was 96% (94.6-98.3%), 69% (64.2-73.6%), 55% (49.8-59.9%), 42.8% (37.6-47.8%), and 34% (29.2-38.9%) at 1, 5, 10, 15, and 20 years, respectively. The leading causes of death were hepatitis C virus recurrence (24.6%), extrahepatic malignancies (16.9%), infection (14.4%), and hepatocellular carcinoma recurrence (14.4%). The factors associated with the survival probability were younger donor and recipient ages (p = 0.001 and 0.004, respectively), female recipient sex (p < 0.001), absence of HCV (p < 0.01), absence of HCC (p = 0.001), and absence of diabetes mellitus at one year (p < 0.01). At the latest follow-up, the leading comorbidities were hypertension (53.6%), obesity (18.7%), diabetes mellitus (17.1%), hyperlipidemia (14.7%), chronic kidney dysfunction (14.7%), and extrahepatic malignancies (13.8%), with 73.9% of patients having more than one complication.

CONCLUSIONS

Aging with a liver graft is associated with an increased risk of complications and requires ongoing care to reduce the long-term attrition rate resulting from chronic immunosuppression.

Prevalence of post-liver transplant complications and NASH-related cirrhosis in postmenopausal women

INTRODUCTION AND OBJECTIVES

Compared to premenopausal women, postmenopausal women are at greater risk of developing NAFLD and NASH, two common indications for liver transplantation (LT). We aim to determine the prevalence of NASH-related cirrhosis in postmenopausal women from a cohort of LT patients and investigate their post-LT complications.

MATERIALS AND METHODS

Chart review of 1200 LT patients from 2002-2020 was performed. Postmenopausal women were defined as women over 51 and compared to a control group of men over 51. Prevalence of LT indications was determined. Subgroup analysis assessed cardiovascular disease risk. BMI and ASCVD risk scores were calculated at the time of LT and after 1 year.

RESULTS

510 patients met the inclusion criteria: 189 (37.1%) women and 321 (62.9%) men. The most common indication was NASH for women (26.5%, p<0.001) and alcohol-related cirrhosis for men (23.1%). 53 men and 46 women underwent subgroup analysis. There was no significant difference in BMI or ASCVD 10-year risk post-LT between sexes. MI occurred more in men (n=9.17%) than women (n=1, 2%, p=0.015), with no significant differences in CAD, CHF, or stroke. LT complications occurred less in men (n=5.9%) than women (n=20, 43%, p=0.0001).

CONCLUSIONS

Postmenopausal women were significantly more likely to have NASH as an indication for LT than men. Postmenopausal women had greater weight gain and more noncardiac complications than men. Women did not have increased cardiovascular outcomes, ASCVD risk, or mortality. Diet education and weight control in postmenopausal women with existing risk factors for NASH should be encouraged to modulate health outcomes.

Vitamin D status as a predictor for liver transplant outcomes

It is well known that vitamin D plays a pivotal role in immune system modulation; however, its role in liver transplantation (LT) has not yet been well elucidated. This study aimed to assess the association between vitamin D status and LT outcomes. This retrospective cohort study was conducted on 335 registered cirrhotic patients with end-stage liver disease (ESLD) who underwent LT during 2019-2021 and had measurement of serum vitamin D before LT. The association of vitamin D levels before LT with the odds of acute cellular rejection (ACR) and risk mortality was assessed by applying logistic and cox regression, respectively. The mean MELD-Na and serum level of vitamin D were 20.39 ± 9.36 and 21.52 ± 15.28 ng/ml, respectively. In the final adjusted model, there was a significant association between vitamin D deficiency in the pre-transplant period and odds of ACR (odds ratio [OR] 2.69; 95% confidence interval [CI] 1.50-4.68). Although in the crude model, vitamin D deficiency in the pre-transplant period was significantly associated with an increased risk of mortality after two years of follow-up (Hazard ratio (HR) = 2.64, 95% CI 1.42-4.33), after adjustment for potential confounders, the association of vitamin D status and mortality became non-significant (HR = 1.46, 95% CI 0.71-3.00). The present study provides evidence that pre-transplant serum vitamin D levels may be a predictor for ACR in patients with cirrhosis undergoing LT.

Adult 10-year survivors after liver transplantation: a single-institution experience over 40 years

Liver transplantation (LT) represents the best cure for several acute and chronic liver diseases. Several studies reported excellent mid-term survivals after LT. However, lesser evidence has been reported on very long (10- and 20-year) follow-up results. This study aims to analyze the monocentric LT experience of the Sapienza University of Rome to identify the pre-operatively available parameters limiting a 10-year post-transplant survival. A total of 491 patients transplanted between 1982 and 2012 were enrolled. The cohort was split into two groups, namely the Short Surviving Group (< 10 years; n = 228, 46.4%) and the Long Surviving Group (≥ 10 years; n = 263, 53.6%). Several differences were reported between the two groups regarding initial liver function, surgical techniques adopted, and immunosuppression. Four variables emerged as statistically relevant as independent risk factors for not reaching at least 10 years of follow-up: recipient age (OR = 1.02; P = 0.01), donor age (OR = 1.01; P = 0.03), being transplanted during the eighties (OR = 6.46; P < 0.0001) and nineties (OR = 2.63; P < 0.0001), and the UNOS status 1-2A (OR = 2.62; P < 0.0001). LT confirms to be an extraordinary therapy for several severe liver diseases, consenting to reach in half of the transplanted cases even more than 20 years of follow-up. The initial liver function and the donor and recipient ages are relevant in impacting long-term survival after transplantation. A broad commitment from many professional groups, including surgeons, hepatologists, and anesthesiologists, is necessary. The achievement of excellent results in terms of long-term survival is proof of the effectiveness of this multidisciplinary collaboration.

Is socioeconomic deprivation associated with worse quality of life, anxiety and depression in liver transplant recipients? A cross-sectional study in a national transplantation programme

OBJECTIVE

To identify whether socioeconomic deprivation is associated with worse health-related quality of life (HR-QoL), anxiety and depression following liver transplantation.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

Liver transplant recipients within a national transplantation programme.

METHODS

Participants completed the condition-specific 'Short Form of Liver Disease Quality of Life' Questionnaire, the Generalised Anxiety Disorder-7 (GAD-7) Questionnaire and the Patient Health Questionnaire-9 (PHQ-9). The aggregate HR-QoL Score (range 0-100) was derived, and multivariable linear regression was performed based on sociodemographic and clinical variables to estimate its independent association with Scottish Index of Multiple Deprivation (SIMD) quintiles. The GAD-7 Questionnaire and PHQ-9 were used to screen respondents for anxiety and depression, and multivariable logistic regression was performed to estimate their independent association with SIMD quintiles.

RESULTS

Some 331 patients completed the questionnaires. Quintiles were equally distributed in the cohort, with no significant differences observed in underlying patient characteristics. Following multivariable adjustment, greater socioeconomic deprivation was associated with lower post-transplantation HR-QoL scores, with a difference of 9.7 points (95% CI: 4.6 to 14.9, p<0.001) between the most and least deprived quintiles. Recipients living in areas of least deprivation were less likely to suffer from anxiety (OR 0.05, 95% CI: 0.00 to 0.28, p=0.003) or depression (OR 0.13, 95% CI: 0.02 to 0.56, p=0.009).

CONCLUSION

Despite the highly selected nature of liver transplant recipients, those living in the most deprived areas have a significantly lower HR-QoL and are more likely to suffer from anxiety and depression.

Newly developed sarcopenia after liver transplantation, determined by a fully automated 3D muscle volume estimation on abdominal CT, can predict post-transplant diabetes mellitus and poor survival outcomes

BACKGROUND

Loss of muscle mass is the most common complication of end-stage liver disease and negatively affects outcomes for liver transplantation (LT) recipients. We aimed to determine the prognostic value of a fully automated three-dimensional (3D) muscle volume estimation using deep learning algorithms on abdominal CT in patients who underwent liver transplantation (LT).

METHODS

This retrospective study included 107 patients who underwent LT from 2014 to 2015. Serial CT scans, including pre-LT and 1- and 2-year follow-ups were performed. From the CT scans, deep learning-based automated body composition segmentation software was used to calculate muscle volumes in 3D. Sarcopenia was calculated by dividing average skeletal muscle area by height squared. Newly developed-(ND) sarcopenia was defined as the onset of sarcopenia 1 or 2 years after LT in patients without a history of sarcopenia before LT. Patients' clinical characteristics, including post-transplant diabetes mellitus (PTDM) and Model for end-stage liver disease score, were compared according to the presence or absence of sarcopenia after LT. A subgroup analysis was performed in the post-LT sarcopenic group. The Kaplan-Meier method was used for overall survival (OS).

RESULTS

Patients with ND-sarcopenia had poorer OS than those who did not (P = 0.04, hazard ratio [HR], 3.34; 95% confidence interval [CI] 1.05 - 10.7). In the subgroup analysis for post-LT sarcopenia (n = 94), 34 patients (36.2%) had ND-sarcopenia. Patients with ND-sarcopenia had significantly worse OS (P = 0.002, HR 7.12; 95% CI 2.00 - 25.32) and higher PTDM occurrence rates (P = 0.02, HR 4.93; 95% CI 1.18 - 20.54) than those with sarcopenia prior to LT.

CONCLUSION

ND-sarcopenia determined by muscle volume on abdominal CT can predict poor survival outcomes and the occurrence of PTDM for LT recipients.

Liver disease in adolescents

In this article, we discuss common liver diseases in the adolescent population. We describe the initial evaluation of an adolescent presenting with new-onset liver enzyme abnormalities, based on the clinical history and physical examination. The management approach to the adolescent with liver disease is exemplified, including monitoring for adherence, risk-taking behaviours and focusing on psychosocial aspects of their care. Finally, we highlight the challenges of caring for the adolescent patient and the importance of addressing not only the liver disease but, more importantly, the holistic approach towards their management.

Post-liver transplantation patient experience

Given improvements in post-transplant patient and graft survival, there is a growing need to focus on patient experience and health-related quality of life (HRQOL). Though liver transplantation can be life-saving, it can also be associated with significant morbidity and complications. Patient HRQOL improves after transplantation, but it may not improve to that of age-matched cohorts. Understanding patient experience and the factors that contribute to it, including physical and psychological health, immunosuppression and medication adherence, return to employment or school, financial burden, and expectations, helps when thinking creatively about potential interventions to improve HRQOL.

Exercise interventions for adults after liver transplantation

BACKGROUND

The finding that exercise is inversely related to metabolic syndrome after transplantation is novel and suggests that exercise interventions might provide a means for reducing metabolic syndrome complications in liver transplantation recipients. The use of exercise for increasing the physical activity daily levels by more frequent, higher intensity, and longer duration of training sessions, or the sum of these components may be necessary to counteract the effects of the pretransplant reduced activity, metabolic disturbances, and post-transplant immunosuppression, as well as improve physical function and aerobic capacity following liver transplantation. Regular physical activity has a long-term positive impact on recovery following various surgical procedures including transplantation, giving people the opportunity to return to an active life with their families, in society, and in their professional life. Likewise, specific muscle strength training may attenuate the loss of strength after liver transplantation.

OBJECTIVES

To evaluate the benefits and harms of exercise-based interventions in adults after liver transplantation compared to no exercise, sham interventions, or another type of exercise.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 2 September 2022.

SELECTION CRITERIA

We included randomised clinical trials in liver transplantation recipients comparing any type of exercise with no exercise, sham interventions, or another type of exercise.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. all-cause mortality; 2. serious adverse events; and 3. health-related quality of life. Our secondary outcomes were 4. a composite of cardiovascular mortality and cardiac disease; 5. aerobic capacity; 6. muscle strength; 7. morbidity; 8. non-serious adverse events; and 9. cardiovascular disease post-transplantation. We assessed risk of bias of the individual trials using RoB 1, described the interventions using the TIDieR checklist, and used GRADE to assess certainty of evidence.

MAIN RESULTS

We included three randomised clinical trials. The trials randomised 241 adults with liver transplantation, of which 199 participants completed the trials. The trials were conducted in the USA, Spain, and Turkey. They compared exercise versus usual care. The duration of the interventions ranged from two to 10 months. One trial reported that 69% of participants who received the exercise intervention were adherent to the exercise prescription. A second trial reported a 94% adherence to the exercise programme, with participants attending 45/48 sessions. The remaining trial reported a 96.8% adherence to the exercise intervention during the hospitalisation period. Two trials received funding; one from the National Center for Research Resources (US) and the other from Instituto de Salud Carlos III (Spain). The remaining trial did not receive funding. All trials were at an overall high risk of bias, derived from high risk of selective reporting bias and attrition bias in two trials. The results on all-cause mortality showed a higher risk of death in the exercise group versus the control group, but these results are very uncertain (risk ratio (RR) 3.14, 95% confidence interval (CI) 0.74 to 13.37; 2 trials, 165 participants; I² = 0%; very low-certainty evidence). The trials did not report data on serious adverse events excluding mortality or non-serious adverse events. However, all trials reported that there were no adverse effects associated with exercise. We are very uncertain on whether exercise compared with usual care has a beneficial or harmful effect on health-related quality of life assessed using the 36-item Short Form Physical Functioning subscale at the end of the intervention (mean difference (MD) 10.56, 95% CI -0.12 to 21.24; 2 trials, 169 participants; I² = 71%; very low-certainty evidence). None of the trials reported data on composite of cardiovascular mortality and cardiovascular disease, and cardiovascular disease post-transplantation. We are very uncertain if there are differences in aerobic capacity in terms of VO2peak at the end of the intervention between groups (MD 0.80, 95% CI -0.80 to 2.39; 3 trials, 199 participants; I² = 0%; very low-certainty evidence). We are very uncertain if there are differences in muscle strength at end of the intervention between groups (MD 9.91, 95% CI -3.68 to 23.50; 3 trials, 199 participants; I² = 44%; very low-certainty evidence). One trial measured perceived fatigue using the Checklist Individual Strength (CIST). Participants in the exercise group showed a clinically important lower degree of fatigue perception than participants in the control group, with a mean reduction of 40 points in the CIST (95% CI 15.62 to 64.38; 1 trial, 30 participants).  We identified three ongoing studies.

AUTHORS' CONCLUSIONS

Based on very low-certainty evidence in our systematic review, we are very uncertain of the role of exercise training (aerobic, resistance-based exercises, or both) in affecting mortality, health-related quality of life, and physical function (i.e. aerobic capacity and muscle strength) in liver transplant recipients. There were few data on the composite of cardiovascular mortality and cardiovascular disease, cardiovascular disease post-transplantation, and adverse event outcomes. We lack larger trials with blinded outcome assessment, designed according to the SPIRIT statement and reported according to the CONSORT statement.

[Endoscopic management of complications in the hepatobiliary and pancreatic system and the tracheobronchial tree]

Endoscopic methods are nowadays a priceless tool for the treatment of postoperative complications after hepatobiliary, pancreatic and thoracic surgery. Endoscopic decompression of the biliary tract is the treatment of choice for biliary duct leakage after cholecystectomy, hepatic resection or liver transplantation. Postoperative biliary duct stenosis can also be successfully treated by endoscopic balloon dilatation and implantation of various endoprostheses in most of the patients. In the case of pancreatic fistulas, especially those occurring after central or distal pancreatic resections, endoscopic decompression of the pancreatic duct can significantly contribute to rapid healing. Additionally, interventional endosonography provides a valuable treatment option for transgastric drainage of postoperative fluid collections, which often accompany a pancreatic fistula. Various treatment alternatives have been described for the bronchoscopic treatment of bronchopleural and tracheoesophageal fistulas, which often lead to the rapid alleviation of symptoms and often to the definitive closure of the fistula.

The effect of sex inequality on solid organ transplantation: A systematic review and meta-analysis

BACKGROUND

Sex disparities are related to biological differences, which may have significant impact on patient and allograft outcomes. The aim was to investigate the impact of sex on clinical and safety outcomes after solid organ transplantation (SOT).

METHODS

A systematic review and meta-analysis was performed. Observational studies comparing females vs. males after SOT were considered for inclusion after a systematic search of the Pubmed, Cochrane Library, and Web of Science databases conducted from 2016 to 2021. Primary outcome was mortality. PROSPERO register number: CRD42021282615.

RESULTS

After retrieving 1103 studies, 22 observational studies (1,045,380 subjects) were finally deemed eligible for inclusion. Females accounted 36.3% of SOT recipients, but presented significantly lower mortality (odds ratio (OR): 0.87, 95% confidence interval (CI): 0.83-0.92, I2=78%). In subgroup analyses, mortality was significantly lower in females undergoing liver (OR: 0.89 95%CI: 0.86-0.92, I2=0%) or kidney transplantation (OR: 0.82 95%CI: 0.76-0.89, I2=72%). Male sex was consistently reported as a protective factor against hospital readmission. Among the outcomes, allograft dysfunction was influenced by a combination of donor-recipient sex and age. Data on overall infections were inconclusive. Several reports suggest a higher risk of malignancy among males.

CONCLUSIONS

Females represent one-third of SOT recipients but have higher survival rates than males after liver and kidney transplantation. The impact on graft dysfunction was heterogeneous. While further research is warranted, our findings should encourage clinicians and researchers to consider sex as a factor when taking decisions regarding SOT management.

Liver Transplantation for Hepatic Metastases from Colorectal Cancer: Current Knowledge and Open Issues

More than 40% of patients with colorectal cancer present liver metastases (CRLM) during the course of their disease and up to 50% present with unresectable disease. Without surgical interventions, survival for patients treated with systemic therapies alone is dismal. In the past, liver transplantation (LT) for patients with unresectable CRLM failed to show any survival benefit due to poor selection, ineffective chemotherapeutic regimens, unbalanced immunosuppression and high perioperative mortality. Since then and for many years LT for CRLM was abandoned. The turning point occurred in 2013, when the results from the Secondary Cancer (SECA I) pilot study performed at Oslo University were published reporting a 60% 5-year overall survival after LT in patients with unresectable CRLM. These results effectively reignited the interest in LT as a potential therapy for CRLM, and several trials are undergoing. The aims of this article are to give a comprehensive overview of the available evidence on LT for CRLM, discuss the open issues in this rapidly evolving field, and highlight possible ways to address the future of this fascinating therapeutic alternative for selected patients with CRLM.

Balancing the Risks and Benefits of Pet Ownership in Pediatric Transplant Recipients

In recent decades, the number of pediatric transplantations and their survival rates have increased. Psychological problems and poorer quality of life are notable among children undergoing transplantation and can have long-lasting consequences and affect immunosuppressive therapy adherence. Pet ownership and animal contact have been associated with physical, mental, and social health benefits. Despite these potential benefits, however, companion animals are known to be a source of infection, which is one of the main concerns for clinicians. Because of immunosuppression, these children are particularly vulnerable to infections. Zoonoses comprise a long list of infectious diseases and represent a major public health problem. Nevertheless, many families and most healthcare providers are unaware of these potential risks, and there is a worrisome lack of recommendations to manage the risk-benefit balance, which could pose a risk for acquiring a zoonosis. Furthermore, no data are available on the number of transplanted patients with pets, and this risk-benefit balance is difficult to adequately evaluate. In this document, we review the currently available evidence regarding the epidemiology of zoonotic infections in patients undergoing transplantation, focusing on pediatric patients from a risk-benefit perspective, to help inform decision-making for clinicians. Families and healthcare professionals should be aware of the risks, and clinicians should actively screen for pets and offer comprehensive information as part of routine clinical practice. A multidisciplinary approach will ensure proper care of patients and pets and will establish preventive measures to ensure patients are safe living with their pets.

Quality of life and psychosocial outcomes of adults who were pediatric solid organ transplant recipients: A systematic review

BACKGROUND

The number of pediatric SOT recipients surviving into adulthood is increasing. Thus, understanding their psychosocial and QoL outcomes is important. We conducted a systematic review to collate existing literature examining QoL outcomes (physical functioning, psychological functioning, social functioning), as well as risk and protective factors associated with QoL, among adults who underwent SOT during childhood.

METHODS

A systematic search of five databases, from inception to January 6, 2021, was conducted to identify articles that reported on QoL outcomes for adults (≥18-year of age) who received a SOT during childhood (<19-year of age).

RESULTS

Twenty-five articles met inclusion criteria. Studies examined QoL across a range of SOT populations (liver, kidney, heart). QoL and psychosocial outcomes were variable; however, the majority of studies indicated QoL in this population to be similar to the general population, or at least similar to other chronic illness groups, with the exception of physical and social functioning. Factors related to a more optimal medical course, younger age at transplant and follow-up, and positive psychosocial functioning, were found to be predictive of better QoL outcomes.

CONCLUSIONS

While several studies indicated QoL to be similar to the general population, the literature is limited in both quantity and quality. No study employed prospective, longitudinal methodologies to systematically evaluate QoL over time and few studies utilized normative-based measures of QoL. Furthermore, several SOT groups were under-represented in the literature (e.g., lung, intestine, multi-visceral). Nonetheless, findings have implications for intervention and clinical decision-making.

Role of the Hippo pathway in liver regeneration and repair: recent advances

Although the signaling pathways involved in normal liver regeneration have been well characterized, less has been done for livers affected by chronic tissue damage. These "abnormal livers" have an impaired regenerative response that leads to liver repair and fibrosis. The tumor suppressor Hippo pathway plays a key role in liver regeneration and repair. On this basis, this review discusses recent studies focusing on the involvement of the Hippo signaling pathway during "normal healthy liver regeneration" (i.e., in a normal liver after 2/3 partial hepatectomy) and "abnormal liver regeneration" (i.e., in a liver damaged by chronic disease). This could be an important question to address with respect to new therapies aimed at improving impaired liver regenerative responses. The studies reported here have shown that activation of the Hippo coactivators YAP/TAZ during normal liver regeneration promotes the formation of a new bile duct network through direct BEC proliferation or/and hepatocyte dedifferentiation to HPCs which can trans-differentiate to BECs. Moreover, YAP/TAZ signaling interaction with other signaling pathways mediates the recruitment and activation of Kupffer cells, which release mitogenic cytokines for parenchymal and/or non-parenchymal cells and engage in phagocytosis of cellular debris. In addition, YAP-mediated activation of stellate cells (HSCs) promotes liver regeneration through the synthesis of extracellular matrix. However, in chronically diseased livers, where the predetermined threshold for proper liver regeneration is exceeded, YAP/TAZ activation results in a reparative process characterized by liver fibrosis. In this condition, YAP/TAZ activation in parenchymal and non-parenchymal cells results in (i) differentiation of quiescent HSCs into myofibroblastic HSCs; (ii) recruitment of macrophages releasing inflammatory cytokines; (iii) polarization of macrophages toward the M2 phenotype. Since accumulation of damaged hepatocytes in chronic liver injury represent a significant risk factor for the development of hepatocarcinoma, this review also discussed the involvement of the Hippo pathway in the clearance of damaged cells.

Innate Immune Cells during Machine Perfusion of Liver Grafts-The Janus Face of Hepatic Macrophages

Machine perfusion is an emerging technology in the field of liver transplantation. While machine perfusion has now been implemented in clinical routine throughout transplant centers around the world, a debate has arisen regarding its concurrent effect on the complex hepatic immune system during perfusion. Currently, our understanding of the perfusion-elicited processes involving innate immune cells remains incomplete. Hepatic macrophages (Kupffer cells) represent a special subset of hepatic immune cells with a dual pro-inflammatory, as well as a pro-resolving and anti-inflammatory, role in the sequence of ischemia-reperfusion injury. The purpose of this review is to provide an overview of the current data regarding the immunomodulatory role of machine perfusion and to emphasize the importance of macrophages for hepatic ischemia-reperfusion injury.

Standardizing the histological assessment of late posttransplantation biopsies from pediatric liver allograft recipients

Excellent short-term survival after pediatric liver transplantation (LT) has shifted attention toward the optimization of long-term outcomes. Despite considerable progress in imaging and other noninvasive modalities, liver biopsies continue to be required to monitor allograft health and to titrate immunosuppression. However, a standardized approach to the detailed assessment of long-term graft histology is currently lacking. The aim of this study was to formulate a list of histopathological features relevant for the assessment of long-surviving liver allograft health and to develop an approach for assessing the presence and severity of these features in a standardized manner. Whole-slide digital images from 31 biopsies obtained ≥4 years after transplantation to determine eligibility for an immunosuppression withdrawal trial were selected to illustrate a range of typical histopathological findings seen in children with clinically stable grafts, including those associated with alloantibodies. Fifty histological features were independently assessed and, where appropriate, scored semiquantitatively by six pathologists to determine inter- and intraobserver reproducibility of the histopathological features using unweighted and weighted kappa statistics; the latter metric enabled distinction between minor and major disagreements in parameter severity scoring. Weighted interobserver kappa statistics showed a high level of agreement for various parameters of inflammation, interface activity, fibrosis, and microvascular injury. Intraobserver agreement for these features was even more substantial. The results of this study will help to standardize the assessment of biopsies from long-surviving liver allografts, aid the recognition of important histological features, and facilitate international comparisons and clinical trials aiming to improve outcomes for children undergoing LT.

The survival rate of liver transplantation in children: a systematic review and meta-analysis

Liver transplantation is a life-saving treatment for children who are in liver failure. The survival rate index is used to assess the success rate of liver transplantation. The study aimed to assess the survival rate of liver transplantation in children. We searched 5 international databases in this study, including Medline/PubMed, ProQuest, Scopus, Web of Knowledge, and Google Scholar, for published articles by the end of 2020. Also, meta-regression analysis was performed based on the year of the study, and subgroup analysis was performed according to continents. A total of 425 titles were reviewed. Based on the results, 96 articles were entered in the meta-analysis. Established on the random-effect model, the survival rates of 1, 3, 5, and 10 years of transplantation were 86.62%, 77.74%, 73.95%, and 68.60%, respectively. Also, based on the meta-regression results, there was a relationship between the year of the study and the survival rate, as the study year gets more recent, the survival rate is increased. This study can provide documented and comprehensive evidence which can be the basis of many policies and decisions in various sectors of health development, including evaluating treatment options and health interventions in transplantation.

Accuracy of noninvasive fibrosis scores in predicting advanced fibrosis in pediatric patients after liver transplantation

BACKGROUND

Liver biopsy is the gold standard to stage fibrosis in liver disease. Several scoring systems have been studied to predict advanced fibrosis in liver disease. Those scores have not been validated in pediatric liver transplant patients.

AIM

Evaluate the performance of three fibrosis scores (FSc) in assessing the presence of advanced fibrosis (AF) in children after orthotopic liver transplantation (OLT).

METHODS

Patients < 20 years of age who underwent liver biopsy post-OLT with laboratory values within 1 month of the biopsy were included. Fibrosis was determined by an experienced pathologist (F0-4). We defined AF as F3-4. The following FSc were calculated: AST/ALT ratio, APRI, and FIB-4 index. Receiver operating characteristic curve analysis was done to assess the FSc performance in predicting AF.

RESULTS

A total of 232 biopsies were analyzed, of those 42 (18.1%) showed AF (F3-4). FIB-4 was significantly higher in patients with AF compared to those without AF [median value of 1.1 [0.7, 3.0] and 0.6 [0.2, 1.4], respectively (p = .02)]; however, FIB-4 had satisfactory accuracy to diagnose AF with significant overlap and AUC of 0.68 (CI 0.56-0.81). Cutoff points of 0.2 and 3.03 were used to rule in and rule out AF, respectively. AST/ALT and APRI were not significantly different between patients with and without AF.

CONCLUSION

Even though FIB-4 had satisfactory accuracy in detecting AF in pediatric transplant patients, noninvasive hepatic FSc developed in adults still performed poorly. Our results highlight the need to develop a reliable pediatric FSc.

Pediatric Liver Transplantation

Liver transplantation (LT) for children results in excellent short- and long-term patient and graft survival. LT is a lifesaving procedure in children with acute or chronic liver disease, hepatic tumors, and select genetic metabolic diseases in which it can significantly improve quality of life. In this article, the authors discuss the unique aspects of pediatric LT, including the indications, appropriate patient selection and evaluation, allocation of organs, transplant surgery including the use of variant grafts, posttransplant care including immunosuppression management, prognosis, and transition of care.

Liver Transplant Recipients Who Survive for More Than 10 Years: A Long-Term Survey

OBJECTIVES

Liver transplant is the gold standard treatment for end-stage liver failure. Short-term and midterm surveys have been published, but there are few long-term surveys. Here, we report the outcomes of our long-term liver transplant survivors.

MATERIALS AND METHODS

Since 1988, we have performed 694 liver transplants (366 adult, 328 pediatric), including the first deceased donor transplant in Turkey (December 8, 1988); the first pediatric segmental living related transplant in Turkey, the Middle and Near East, and Europe; the world's first adult segmental living related transplant (April 24, 1990); and the world's first living related donor combined liver-kidney transplant (May 16, 1992). We retrospectively evaluated data from recipients who survived >10 years with normal graft function.

RESULTS

Of 215 recipients, survival ranges were ≥20 years (n = 13), 15 to 19 years (n = 86), and 10 to 14 years (n = 116); 211 remain alive today with normal liver function. There were 5 retransplants to treat chronic graft rejection, of which 4 recipients are alive with normal graft function after a second liver transplant (15, 20, 22, and 31 years after first transplant). One patient died soon after the second liver transplant (15 years after first transplant). Acute rejection episodes were seen in 72 (34%), and 7 were steroid resistant. There were 48 (22.7%) drug-induced complications. Ten patients had de novo malignancy: 5 lymphoma, 2 squamous cell carcinoma, 1 gastrointestinal stromal tumor, 1 thyroid papillary carcinoma, and 1 multiple myeloma. There were also 31 patients with hepatocellular carcinoma before liver transplant: 13 were beyond Milan criteria, 6 had incidental HCC, and 12 were within Milan.

CONCLUSIONS

Long-term survival after liver transplant is possible with expert care. Few reports have mentioned long-term surveys; our long-term liver transplant survey is among the largest series in the literature.

Not only a small liver - The pathologist's perspective in the pediatric liver transplant setting

Pediatric liver transplantation represents a safe and long-lasting treatment option for various disease types, requiring the pathologist’s input. Indeed, an accurate and timely diagnosis is crucial in reporting and grading native liver diseases, evaluating donor liver eligibility and identifying signs of organ injury in the post-transplant follow-up. However, as the procedure is more frequently and widely performed, deceptive and unexplored histopathologic features have emerged with relevant consequences on patient management, particularly when dealing with long-term treatment and weaning of immunosuppression.

In this complex and challenging scenario, this review aims to depict the most relevant histopathologic conditions which could be encountered in pediatric liver transplantation. We will tackle the conditions representing the main indications for transplantation in childhood as well as the complications burdening the post-transplant phases, either immunologically (i.e., rejection) or non-immunologically mediated. Lastly, we hope to provide concise, yet significant, suggestions related to innovative pathology techniques in pediatric liver transplantation.

ERCP in critically ill patients is safe and does not increase mortality

ABSTRACT

Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard for minimally-invasive treatment of biliary or pancreatic tract disease. When treating patients on intensive care units (ICU) with ERCP, interventionalists are faced with considerably higher morbidity compared to patients in ambulatory settings. However, data on complications and outcome of critical ill patients undergoing emergency ERCP are limited.A retrospective analysis of 102 patients treated on ICUs undergoing 121 ERCP procedures at the University Hospital of Essen, Germany between 2002 and 2016 was performed. Indications, interventional success, outcome including survival and procedure-related complications were analyzed. Patients' condition pre-ERCP was categorized by using the "Simplified Acute Physiology Score" (SAPS 3).66/102 patients (64.7%) were referred to ERCP from surgical ICU, 36/102 (35.3%) from nonsurgical ICU. The majority of patients were male (63.7%), the mean age was 54.1 ± 14.9 [21-88] years. Indications for ERCP were biliary complications after liver transplantation (n = 34, 33.3%), biliary leakage after hepatobiliary surgery (n = 32, 31.4%), and cholangitis/biliary sepsis (n = 36; 35.3%), respectively. 117/121 (96.7%) ERCPs were successful, 1 patient (1.0%) died during ERCP. Post-ERCP pancreatitis occurred in 11.8% of interventions. The median simplified acute physiology score 3 was 65 points, predicting a risk-adjusted estimated mortality of 48.8%, corresponding to an observed mortality of 52.2% (P = n.s.).ERCP is safe in critically ill patients on ICU, it does not increase overall mortality rate and has a relatively low rate of procedure-associated complications.

The gut microbial metabolite, 3,4-dihydroxyphenylpropionic acid, alleviates hepatic ischemia/reperfusion injury via mitigation of macrophage pro-inflammatory activity in mice

Hepatic ischemia/reperfusion injury (HIRI) is a serious complication that occurs following shock and/or liver surgery. Gut microbiota and their metabolites are key upstream modulators of development of liver injury. Herein, we investigated the potential contribution of gut microbes to HIRI. Ischemia/reperfusion surgery was performed to establish a murine model of HIRI. 16S rRNA gene sequencing and metabolomics were used for microbial analysis. Transcriptomics and proteomics analysis were employed to study the host cell responses. Our results establish HIRI was significantly increased when surgery occurred in the evening (ZT12, 20:00) when compared with the morning (ZT0, 08:00); however, antibiotic pretreatment reduced this diurnal variation. The abundance of a microbial metabolite 3,4-dihydroxyphenylpropionic acid was significantly higher in ZT0 when compared with ZT12 in the gut and this compound significantly protected mice against HIRI. Furthermore, 3,4-dihydroxyphenylpropionic acid suppressed the macrophage pro-inflammatory response in vivo and in vitro. This metabolite inhibits histone deacetylase activity by reducing its phosphorylation. Histone deacetylase inhibition suppressed macrophage pro-inflammatory activation and diminished the diurnal variation of HIRI. Our findings revealed a novel protective microbial metabolite against HIRI in mice. The potential underlying mechanism was at least in part, via 3,4-dihydroxyphenylpropionic acid-dependent immune regulation and histone deacetylase (HDAC) inhibition in macrophages.

Life Expectancy After Liver Transplantation for Alcoholic Cirrhosis

BACKGROUND

Alcohol-associated liver disease is the leading cause of liver transplantation in the western world. For these patients we calculated life expectancies both at time of transplant and several years later, stratified by key risk factors, and determined if survival has improved in recent years.

METHODS

Data on 14 962 patients with alcohol-associated liver disease who underwent liver transplantation in the MELD era (2002-2018) from the United States Organ Procurement and Transplantation Network database were analyzed using the Cox proportional hazards regression model and life table methods.

RESULTS

Demographic and past medical history factors related to survival were patient age, presence of diabetes or severe hepatic encephalopathy, and length of hospital stay. Survival improved over the study period, at roughly 3% per calendar year during the first 5 years posttransplant and 1% per year thereafter.

CONCLUSIONS

Life expectancy in transplanted patients with alcohol-associated liver disease was much reduced from normal, and varied according to age, medical risk factors, and functional status. Survival improved modestly over the study period. Information on patient longevity can be helpful in making treatment decisions.

Factors affecting anxiety, depression, and self-care ability in patients who have undergone liver transplantation

BACKGROUND

Depression, anxiety, and altered self-care ability are among the most important factors affecting the quality of life of liver transplant recipients. Depending on the severity of the underlying liver disease, signs and symptoms of anxiety and depression may become more pronounced.

AIM

To evaluate the factors affecting depression, anxiety and self-care abilities of liver transplant recipients.

METHODS

Recipients who are ≥ 18 years and who underwent liver transplantation at Inonu University Liver Transplantation Institute were included in this descriptive and cross-sectional study. Sample size analysis showed that the minimum number of recipients should be 301 (confidence level = 95%, confidence interval = 2.5, population = 1382). Three hundred and twenty recipients were interviewed and 316 recipients that have answered the questionnaires accurately were analyzed. The dependent variables were the Beck Depression Scale, State-Trait Anxiety Scale (Form I and II), and Self-Care Agency Scale. The independent variables of the study were sociodemographic characteristics, biliary complications, hepatocellular carcinoma, recommending liver transplantation to other patients, and the interval of out-patient clinic visits.

RESULTS

Self-care ability scores were lower (P = 0.002) and anxiety scores were higher (P = 0.004) in recipients with biliary complications. On the other hand, in recipients with hepatocellular carcinoma, self-care scores were lower (P = 0.006) while depression (P = 0.003) and anxiety scores (P = 0.009) were higher. Liver transplantation recipients with a monthly income < 3000 Turkish liras had higher depression (P < 0.001) and anxiety (P = 0.003) scores. The recipients who stated that they would not recommend liver transplantation to others had lower self-care scores (P = 0.002), higher depression (P < 0.001), higher state anxiety (P = 0.02), and trait anxiety (P < 0.001) scores.

CONCLUSION

Presence of biliary complications and hepatocellular carcinoma, low income level, and an obligation for monthly visits to the outpatient clinic are factors that are found to affect self-care capability, depression, and anxiety.

Liver transplantation for pediatric inherited metabolic liver diseases

Liver transplantation (LT) remains the gold standard treatment for end stage liver disease in the pediatric population. For liver based metabolic disorders (LBMDs), the decision for LT is predicated on a different set of paradigms. With improved outcomes post-transplantation, LT is no longer merely life saving, but has the potential to also significantly improve quality of life. This review summarizes the clinical presentation, medical treatment and indications for LT for some of the common LBMDs. We also provide a practical update on the dilemmas and controversies surrounding the indications for transplantation, surgical considerations and prognosis and long terms outcomes for pediatric LT in LBMDs. Important progress has been made in understanding these diseases in recent years and with that we outline some of the new therapies that have emerged.

Endoscopic management of high-grade biliary strictures complicating living donor liver transplantation using soehendra stent retrievers

BACKGROUND

Biliary strictures following living donor liver transplantation (LDLT) are usually managed by endoscopic retrograde cholangiography (ERC) with stricture dilation and stent placement. While current endoscopic techniques are successful in most cases, high-grade biliary strictures (HGBS) pose a challenge using currently employed techniques which have a low rate of technical success.

AIMS

In this study, we have explored the safety and efficacy of Soehendra stent retrievers (SSR) for the dilation of HGBS complicating LDLT.

METHODS

This was a prospective cohort study where all patients with anastomotic biliary strictures following LDLT from January 2016 till February 2018 were included. Patients with HGBS defined as the exclusive passage of 0.018-inch guidewire, were included in Group 1. In these patients, 5 Fr Soehendra stent retrievers were used to dilate HGBS over guidewire, using torsional movements. Technical success, safety and clinical response was compared with patients who required Per-cutaneous transhepatic cholangiography (PTC) with rendezvous procedure due to a failed ERC, before the commencement of the study (Group 2).

RESULTS

Ten patients with HGBS were included into Group 1. Technical success defined as successful placement of a biliary stent across the stricture was achieved in all the patients in group 1. Favorable response to endotherapy was higher in group 1(8/10 patients (80%)) as compared to group 2(6/14 patients (42.8%)). There were no post procedure complications in patients of group 1, while 3 patients developed cholangitis in group 2.

CONCLUSIONS

HGBS can be successfully treated with SSR for stricture dilation. It is safe with no significant complications and requires fewer procedures.

Biliary and duodenal complications after « en bloc» liver-small bowel transplantation in children. A single center cohort study

BACKGROUND

The technique of « en bloc» liver and small bowel transplantation (L-BT) spares a biliary anastomosis, but does not protect against biliary complications. We analyze biliary and duodenal complications (BDC) in our pediatric series.

METHODS

Between 1994 and 2020, 54 L-BT were performed in 53 children. The procurement technique included in situ vascular dissection and pancreatic reduction to the head until 2009 (group A). Thereafter, the whole pancreas was recovered (group B).

RESULTS

Nine BDCs occurred in 8/53 (15%) patients (7 in group A and 1 in group B): leak of the donor's duodenal stump (2), stenosis of the extra-pancreatic bile duct (5), and intra-pancreatic bile duct stenosis (2). Median delay for diagnosis of stricture was 8 months (4-168). Interventional radiology was successful in one child only, the others required reoperations. Two patients died, of biliary cirrhosis or cholangitis, 15-month and 12-year post-L-BT. One was listed and liver re-transplanted 13 years post-L-BT. At last follow-up, two patients only had normal liver tests and ultrasound.

CONCLUSION

BDC after L-BT can cause severe morbidities. Pancreatic reduction might increase this risk. Early surgical complications or chronic pancreatic rejection might be co-factors. Early diagnosis and treatment are key to the long-term prognosis.

Outcomes of adults who received liver transplant as young children

BACKGROUND

Patient and graft survival 20-years after pediatric liver transplantation (pLT) are excellent. In children, attainment of normal growth, education and social adaptation to be an independent adult are equally important. This is particularly relevant for children who receive liver transplant at a young age, where infantile-onset liver disease, surgery and immunosuppression can adversely affect growth and neurodevelopment. The aim of this study was to evaluate the long-term physical and psychosocial outcomes of pLT recipients with normal graft function. We coin the term 'meaningful survival'.

METHODS

We performed a cross-sectional study of pLT recipients who received transplants between 1985 and 2004. A 20-year evaluation of physical health (growth, renal function), mental wellbeing and social outcomes (substance abuse, adherence, education, employment) was performed. All patients included were considered to have normal graft function.

FINDINGS

Eighty-four patients met study criteria. Median age at transplantation was 1.3 years (IQR 0·7-3·3 years), with median duration of follow-up of 20.2 years (18·0-23·5). At median of 20-years, 19 patients (23%) had chronic renal dysfunction and 3 patients (4%) had a BMI of >30 (mean 20·4). Evaluation of long-term psychosocial outcomes demonstrated 22 patients (26%) with mental health disorders. Substance abuse was lower than national average. 62 patients (74%) were in education, employment or training. Overall, only 26% of our cohort achieved a composite outcome of 'meaningful survival'.

INTERPRETATION

This is the largest reported long-term study of biopsychosocial outcomes of pLT recipients with normal liver biochemistry, with follow-up upon completion of physical growth and senior school education. Importantly, despite normal liver function, many patients did not demonstrate 'meaningful survival'. We must refocus our efforts towards better understanding the long-term outcomes of children. A 'meaningful survival' rather than mere survival should be our goal.

FUNDING

None.

Recipient-Specific Risk Factors Impairing Patient and Graft Outcome after Pediatric Liver Transplantation-Analysis of 858 Transplantations in 38 Years

(1) Background and Aim: Despite excellent long-term results in pediatric liver transplantation (pLTx), mortality and graft loss still are to be diminished. We aim to describe time-dependent changes and long-term outcome of a large single-center pLTx cohort and to identify independent recipient-related risk factors impairing patient and graft survival. (2) Methods: This is a retrospective single-center study analyzing all pediatric liver transplants from 1983–2020. Risk factors for mortality and graft loss were identified by univariable and multi-linear regression analysis. (3) Results: We analyzed 858 liver transplantations in 705 pediatric patients. Five-year patient/graft survival increased from 60.9%/48.0% (1983–1992) to 97.5%/86.5% (OR = 12.5; p < 0.0001/OR = 6.5; p < 0.0001) (2014–2020). Indications changed significantly over time, with a higher proportion of patients being transplanted for malignancies and metabolic disease and indications of PFIC and α1AT-deficiency declining. The era of transplantation (log7.378/9.657; p < 0.0001) and indication of acute liver failure (log = 1.944/2.667; HR = 2.015/1.772; p = 0.0114/0.002) impairs patient/graft survival significantly in the multivariate analysis. Furthermore, patient survival is worsened by re-transplantation (log = 1.755; HR = 1.744; p = 0.0176) and prolonged waiting times in high-urgency status (log = 2.588; HR = 1.073; p = 0.0026), whereas the indication of biliary atresia improved outcome (log = 1.502; HR = 0.575; p = 0.0315). Graft survival was additionally impaired by pre-existing portal vein thrombosis (log = 1.482; HR = 2.016; p = 0.0330). (4) Conclusions: Despite more complex indications, patient and graft survival after pLTx continue to improve.. Acute liver failure remains the indication with poorest outcome, and listing for high urgency liver transplantation should be considered carefully and early to keep waiting time on HU list short. Furthermore, pre-transplant portal vein thrombosis should be prevented whenever possible to improve graft survival.

YAP-Dependent Induction of CD47-Enriched Extracellular Vesicles Inhibits Dendritic Cell Activation and Ameliorates Hepatic Ischemia-Reperfusion Injury

Hepatic ischemia-reperfusion injury (IRI) is the most common cause of liver damage leading to surgical failures in hepatectomy and liver transplantation. Extensive inflammatory reactions and oxidative responses are reported to be the major processes exacerbating IRI. The involvement of Yes-associated protein (YAP) in either process has been suggested, but the role and mechanism of YAP in IRI remain unclear. In this study, we constructed hepatocyte-specific YAP knockout (YAP-HKO) mice and induced a hepatic IRI model. Surprisingly, the amount of serum EVs decreased in YAP-HKO compared to WT mice during hepatic IRI. Then, we found that the activation of YAP increased EV secretion through F-actin by increasing membrane formation, while inhibiting the fusion of multivesicular body (MVB) and lysosomes in hepatocytes. Further, to explore the essential elements of YAP-induced EVs, we applied mass spectrometry and noticed CD47 was among the top targets highly expressed on hepatocyte-derived EVs. Thus, we enriched CD47⁺ EVs by microbeads and applied the isolated CD47⁺ EVs on IRI mice. We found ameliorated IRI symptoms after CD47⁺ EV treatment in these mice, and CD47⁺ EVs bound to CD172α on the surface of dendritic cells (DCs), which inhibited DC activation and the cascade of inflammatory responses. Our data showed that CD47-enriched EVs were released in a YAP-dependent manner by hepatocytes, which could inhibit DC activation and contribute to the amelioration of hepatic IRI. CD47⁺ EVs could be a potential strategy for treating hepatic IRI.

Short- and long-term results of liver transplantation according to age at transplant: a single-center experience of 351 children

Pediatric liver transplantation (PLT) has very good results at experienced transplant centers. However, there is still an ongoing discussion about inferior outcomes, especially in young infants. The aim of this retrospective study was to evaluate outcomes of infants compared to older recipients in a single center over 20 years. We conducted a retrospective study of children who received liver transplants at our center between 1991 and 2011. Only patients without other limiting organ involvement were included and compared according to age. The inclusion criteria were fulfilled by 351 patients (173 vs. 178). The most common indication in both groups was biliary atresia (82.1% vs. 49.4%). The 1-, 5-, and 10-year patient survivals were 93.8%/91.8%/91.1% and 93%/90.8%/90.1%, and the graft survivals were 90.4%/83.5%/79.6% and 89.4%/81.8%/77.5%, respectively. Complications such as postoperative bleeding, biliary complications, or perfusion impairment occurred more often in infants. Leading indications for retransplantation (vascular complications/primary nonfunction) and leading causes of death (sepsis/multiorgan failure) were the same in both groups. Significant predictors for patient loss were decade of transplantation, retransplantation, postoperative bleeding, and infections for infants. Predictors for graft loss were bowel perforation, arterial thrombosis, and age >12 months. Children can have excellent results, independent of age at PLT.

Expression of fibrosis-related genes in liver allografts: Association with histology and long-term outcome after pediatric liver transplantation

BACKGROUND

Unexplained graft fibrosis and inflammation are common after pediatric liver transplantation (LT).

OBJECTIVE

We investigated the graft expression of fibrogenic genes and correlated the findings with transplant histopathology and outcome.

METHODS

Liver biopsies from 29 recipients were obtained at a median of 13.1 (IQR: 5.0-18.4) years after pediatric LT. Control samples were from six liver-healthy subjects. Hepatic expression of 40 fibrosis-related genes was correlated to histological findings: normal histology, fibrosis with no inflammation, and fibrosis with inflammation. Liver function was evaluated after a subsequent follow-up of 9.0 years (IQR: 8.0-9.4).

RESULTS

Patients with fibrosis and no inflammation had significantly increased gene expression of profibrotic TGF-β3 (1.17 vs. 1.02 p = .005), CTGF (1.64 vs. 0.66 p = .014), PDGF-α (1.79 vs. 0.98 p = .049), PDGF -β (0.99 vs. 0.76 p = .006), integrin-subunit-β1 (1.19 vs. 1.02 p = .045), α-SMA (1.12 vs. 0.58 p = .013), type I collagen (0.82 vs. 0.53 p = .005) and antifibrotic decorin (1.15 vs. 0.99 p = .045) compared to patients with normal histology. mRNA expression of VEGF A (0.84 vs. 1.06 p = .049) was lower. Only a few of the studied genes were upregulated in patients with both fibrosis and inflammation. The gene expression levels showed no association with later graft outcome.

CONCLUSIONS

Altered hepatic expression of fibrosis-related genes is associated with graft fibrosis without concurrent inflammation.

Cardiovascular mortality in liver and kidney transplant recipients: A retrospective analysis from a single institution

Previous studies have demonstrated cardiovascular causes to be among the leading causes of death after liver (LT) and kidney transplantation (KT). Although both recipient populations have unique pre-transplant cardiovascular burdens, they share similarities in post-transplant exposure to cardiovascular risk factors. The aim of this study was to compare cardiovascular mortality after LT and KT.We analyzed causes of death in 370 consecutive LT and 207 KT recipients from in-hospital records at a single tertiary transplant center. Cardiovascular causes of death were defined as cardiac arrest, heart failure, pulmonary embolism, or myocardial infarction.After a median follow-up of 36.5 months, infection was the most common cause of death in both cohorts, followed by cardiovascular causes in KT recipients and graft-related causes in LT recipients in whom cardiovascular causes were the third most common. Cumulative incidence curves for cardiovascular mortality computed with death from other causes as the competing risk were not significantly different (P = .36). While 1-year cumulative cardiovascular mortality was similar (1.6% after LT and 1.5% after KT), the estimated 4-year probability was higher post-KT (3.8% vs. 1.6%). Significant pre-transplant risk factors for overall mortality after KT in multivariable analysis were age at transplantation, left ventricular ejection fraction <50%, and diastolic dysfunction grade 2 or greater, while significant risk factors for cardiovascular mortality were peripheral artery disease and left ventricular ejection fraction <50%. In the LT group no variables remained significant in a multivariable model for either overall or cardiovascular mortality.The present study found no significant overall difference in cardiovascular mortality after LT and KT. While LT and KT recipients may have similar early cardiovascular mortality, long-term risk is potentially lower after LT. Differing characteristics of cardiovascular death between these two patient populations should be further investigated.

Bittencourt P, Cavalcanti A, Paraná R, Lins-Kusterer L. Poor Oral Health-Related Quality of Life in Pre- and Post-Liver Transplantation Patients

Background:

Oral health is associated with Chronic Liver Disease (CLD) and may play a relevant role in oral (OHRQoL) and general health-related quality of life (HRQoL) among people with chronic liver disease (CLD).

Objective:

To explore the correlations between OHRQoL and HRQoL in pre- and post-liver transplantation (LT) patients.

Methods:

A cross-sectional study with 189 patients: 63 per group (pre-LT, post-LT, and without liver disease). The Oral Health Impact Profile-14 (OHIP-14), the 36-Item Short-Form Health Survey, and the Work Ability Index (WAI) were used to measure oral health-related quality of life, health-related quality of life, and work ability, respectively. Oral health was evaluated according to the World Health Organization criteria. The relationship between the OHIP-14 and independent variables was analysed by multiple linear regression.

Results:

Pre-LT group presented the highest OHIP-14 total mean score, followed by the post-LT group, compared to the group without liver disease (p=0.001). All HRQoL and WAI mean scores were lower in the pre-LT group than in the other groups (p≤0.013). In the pre-LT group, the OHIP-14 total mean score was negatively correlated with the Mental Health, Physical Functioning, and General Health mean scores (p=0.01) and negatively and significantly (p<0.05) associated with decayed teeth and with poor workability. In the post-TL group, OHRQOL of life was associated with decayed and missing teeth, lower educational level, and poor workability.

Conclusion:

Patients in the pre- and post-LT groups presented poorer OHRQoL compared to patients without liver disease. OHRQoL was strongly correlated with HRQoL in the pre-LT group.

GOOD QUALITY OF LIFE AFTER MORE THAN A DECADE OF LIVING DONOR LIVER TRANSPLANTATION

BACKGROUND

Receptors of living donor liver transplantation (LDLT) have higher rate of postoperative biliary and vascular complications that may reduce posttransplant quality of life (QOL) due to the need of invasive and repetitive treatments.

OBJECTIVE

The purpose of our study is to assess the various aspects of QOL of receptors undergoing LDLT after 10 years of transplantation and to identify potential factors that might be associated with impaired QOL.

METHODS

Data of all patients with more than 10 years of LDLT were retrospectively evaluated. Patients were interviewed through a quality of life questionnaire (SF-36).

RESULTS

From a total of 440 LT performed in 17 years (from September 1991 through December 2008), 78 patients underwent LDLT, of which 27 were alive and 25 answered completely the questionnaire. There were 17 (68%) men and 8 (32%) women, with a mean age of 38.6±18.5 years at the time of transplantation and mean follow up time of 15.1±1.9 years. The average MELD was 16.4±4.9 and the main indication for LT was hepatic cirrhosis caused by hepatitis B virus (32%). When compared to the general po-pulation, LDLT patients had lower mental health score (66.4 vs 74.5, P=0.0093) and higher vitality score (87.8 vs 71.9, P<0.001), functional aspects (94.6 vs 75.5, P=0.002), social aspects (93 vs 83.9, P=0.005), physical aspects (92 vs 77.5, P=0.006), and emotional aspects (97.33 vs 81.7, P<0.001). General health status (73.28 vs 70.2, P=0.074) and pain (78.72 vs 76.7, P=0.672) scores were similar in both groups.

CONCLUSION

It is concluded that the various aspects LDLT recipients' QOF are similar to those of the general population more than a decade after the transplant, except for the mental health domain which is lower.

Untangling Local Pro-Inflammatory, Reparative, and Regulatory Damage-Associated Molecular-Patterns (DAMPs) Pathways to Improve Transplant Outcomes

Detrimental inflammatory responses after solid organ transplantation are initiated when immune cells sense pathogen-associated molecular patterns (PAMPs) and certain damage-associated molecular patterns (DAMPs) released or exposed during transplant-associated processes, such as ischemia/reperfusion injury (IRI), surgical trauma, and recipient conditioning. These inflammatory responses initiate and propagate anti-alloantigen (AlloAg) responses and targeting DAMPs and PAMPs, or the signaling cascades they activate, reduce alloimmunity, and contribute to improved outcomes after allogeneic solid organ transplantation in experimental studies. However, DAMPs have also been implicated in initiating essential anti-inflammatory and reparative functions of specific immune cells, particularly Treg and macrophages. Interestingly, DAMP signaling is also involved in local and systemic homeostasis. Herein, we describe the emerging literature defining how poor outcomes after transplantation may result, not from just an over-abundance of DAMP-driven inflammation, but instead an inadequate presence of a subset of DAMPs or related molecules needed to repair tissue successfully or re-establish tissue homeostasis. Adverse outcomes may also arise when these homeostatic or reparative signals become dysregulated or hijacked by alloreactive immune cells in transplant niches. A complete understanding of the critical pathways controlling tissue repair and homeostasis, and how alloimmune responses or transplant-related processes disrupt these will lead to new immunotherapeutics that can prevent or reverse the tissue pathology leading to lost grafts due to chronic rejection.

TRANSITION of Pediatric Liver Transplant Patients to Adult Care: a Review

PURPOSE OF REVIEW

Many pediatric liver transplant patients are surviving to adulthood, and providers have come to recognize the importance of effectively transitioning these patients to an adult hepatologist. The review aims to analyze the most recent literature regarding patient outcomes after transition, barriers to successful transition, recommendations from clinicians and medical societies regarding transition programs, and to provide personal insights from our experience in transitioning liver transplant recipients.

RECENT FINDINGS

While results were variable between studies, many recent reports show significant morbidity and mortality in patients following transition to adult care. Medical non-adherence is frequently seen in adolescents and young adults both prior to and after transition, and is consistently associated with higher rates of rejection, graft loss, and death. In general, transplant programs with a formal transition process had better patient outcomes though recent findings are mostly-single center and direct comparison between programs is difficult. Societal recommendations for how to create a transition program contain a number of common themes that we have categorized for easier understanding. Successful transition is vital to the continued health of pediatric liver transplant patients. While an effective transition program includes a number of key components, it should be individualized to best function within a given transplant center. Here, we have reviewed a number of recent single-center retrospective studies on transition, but multi-site retrospective or prospective data is lacking, and is a fertile area for future research.

500 Consecutive Liver Transplants: The Outcomes of a New Transplantation Program in the Middle West of Brazil

INTRODUCTION

Liver transplantation is the standard treatment for end-stage liver disease. Brazil holds the third highest number of liver transplants performed per year, but center maldistribution results in high discrepancies in accessing this treatment. In 2012, an interstate partnership successfully implemented a new liver transplantation program in the middle west of Brazil. Here, we report the results of the first 500 liver transplants performed in this new program and discuss the impacts of a new transplant center in regional transplantation dynamics.

METHODS

We reviewed data from the first 500 consecutive deceased donor liver transplants performed in the new program during an 8-year period. We analyzed data on patients' clinical and demographic profiles, postoperative outcomes, and graft and recipient survival rates. Univariate survival analysis was conducted using log-rank tests to compare the groups.

RESULTS

Almost half (48%) of the procured organs and 40% of the recipients transplanted in our center were from outside our state. Recipient 30-day mortality was 9%. Overall recipient survival at 1 year and 5 years was 85% and 80%, respectively. Mortality was significantly associated with higher Model for End-Stage Liver Disease (P < .001) but not with the presence of hepatocellular carcinoma (P = .795).

DISCUSSION

The new transplantation program treated patients from different regions of Brazil and became the reference center in liver transplantation for the middle west region. Despite the recent implementation, our outcomes are comparable to experienced centers around the world. This model can inspire the creation of new transplantation programs aiming to democratize access to liver transplantation nationwide.

Safety and efficacy of pharmacologic weight loss in patients with cirrhosis

Background

Obesity poses unique risks in patients with advanced liver fibrosis; however, given surgical risks of bariatric surgery in cirrhosis treatment recommendations are currently limited to lifestyle interventions. This study seeks to inform a potential treatment gap by describing the safety and efficacy of pharmacologic weight loss in patients with advanced liver disease.

Methods

A retrospective chart review of the electronic medical record was conducted for all patients in the Scripps Health system from 2005 to 2017 with established advanced liver fibrosis that were prescribed medications associated with weight loss. The primary outcome was safety as defined by the model for end-stage liver disease (MELD) score. Secondary outcomes included total body weight loss, reasons for medication discontinuation, medication adverse events, and hospitalization before and after medication initiation.

Results

Thirty-eight patients and 63 prescriptions were included in the final analysis. The most frequently prescribed medication associated with weight loss was metformin (63%, n = 24) followed by a GLP-1 agonist (39%, n = 15). There was no significant effect of weight-loss medication on MELD score (p > 0.18) or number of hospitalizations when adjusting for subject (p > 0.26). There was a significant adjusted mean weight loss of 2.2 kg (p < 0.02) following prescription of a medication associated with weight loss. The Federal Drug Administration-approved anti-obesity medications as a group resulted in a significant adjusted weight loss of 7.22 kg (p < 0.013). In a linear mixed-effects model accounting for subjects, weight loss was not independently associated with a change in MELD (t[51] = -1.972, p > 0.05).

Conclusion

Pharmacologic weight loss in patients with advanced liver fibrosis appears feasible based on preliminary safety and efficacy outcomes in this study. Future prospective studies are warranted to evaluate a potential significant treatment gap in the management of obesity in this vulnerable population.

Expression of 6 Biomarkers in Liver Grafts After Pediatric Liver Transplantation: Correlations with Histology, Biochemistry, and Outcome

Background

Subclinical graft inflammation and fibrosis after pediatric liver transplantation (LT) are common. Biomarkers are needed that precede and are associated with these changes and graft outcome.

Material/Methods

We evaluated immunohistochemical expression of 6 biomarkers [α-smooth muscle actin (α-SMA), collagen I, decorin, vimentin, P-selectin glycoprotein ligand-1 (PSGL-1), and CD34] in biopsies taken intraoperatively at LT (baseline) (n=29) and at 11.3 years after LT (first follow-up) (n=51). Liver biochemistry and graft histology were assessed at the first follow-up and at final assessment (19.6 years after LT) (n=48). Second follow-up biopsies for histology were available from 24 patients. The immunostainings were correlated with liver histology, biochemistry, and outcome at these time-points.

Results

Baseline levels of the biomarkers were unrelated to presence of fibrosis at follow-up. Increased α-SMA, collagen I levels, decorin, and vimentin were associated with simultaneous fibrosis at the first follow-up (p=0.001–0.027). Increased SMA, collagen I, decorin, vimentin, PSGL-1, and CD34 expression at first follow-up were associated with simultaneous portal inflammation (p=0.001–0.025). α-SMA, decorin, and vimentin expression were increased in patients without fibrosis at the first follow-up but who developed fibrosis in second follow-up (p=0.014 p=0.024 and p=0.024). Significant fibrosis (F2) and markedly increased α-SMA, collagen I, decorin, and vimentin levels at first follow-up were associated with suboptimal liver status at the final assessment (p=0.002–0.042).

Conclusions

The expression of the biomarkers at LT was unrelated to later development of graft fibrosis. α-SMA, decorin, and vimentin were associated with later graft fibrosis and suboptimal liver status.