Changing trends in the etiology of liver transplantation in Turkiye: A multicenter study

Background and Aim

This study aimed to identify the indications for liver transplantation (LT) based on underlying etiology and to characterize the patients who underwent LT.

Materials and Methods

We conducted a multicenter cross-sectional observational study across 11 tertiary centers in Turkiye from 2010 to 2020. The study included 5,080 adult patients.

Results

The mean age of patients was 50.3±15.2 years, with a predominance of female patients (70%). Chronic viral hepatitis (46%) was the leading etiological factor, with Hepatitis B virus infection at 35%, followed by cryptogenic cirrhosis (24%), Hepatitis C virus infection (8%), and alcohol-related liver disease (ALD) (6%). Post-2015, there was a significant increase in both the number of liver transplants and the proportion of living donor liver transplants (p<0.001). A comparative analysis of patient characteristics before and after 2015 showed a significant decline in viral hepatitis-related LT (p<0.001), whereas fatty liver disease-related LT significantly increased (p<0.001).

Conclusion

Chronic viral hepatitis continues to be the primary indication for LT in Turkiye. However, the proportions of non-alcoholic fatty liver disease (NAFLD) and ALD-related LT have seen an upward trend over the years.

The efficacy and tolerability of glecaprevir/pibrentasvir treatment in a real-world chronic hepatitis C patients cohort

Background and Aim

The aims of the present study were to evaluate the real-life efficacy and tolerability of glecaprevir (GLE)/pibrentasvir (PIB) in the treatment of patients with chronic hepatitis C (CHC).

Materials and Methods

Between May 2019 and May 2022, 686 patients with CHC, treated with GLE/PIB combination from 21 participating centers in Turkiye, were enrolled in the study.

Results

All patients were Caucasian, and their median age was 56 years. At the start of GLE/PIB treatment, the median serum Hepatitis C virus RNA and serum alanine amino transaminase (ALT) levels were 6.74 log10 IU/mL and 47 U/L, respectively. Fifty-three percent of the patients were infected with genotype 1b, followed by genotype 3 (17%). Diabetes was the more common concomitant disease. The sustained virological response (SVR12) was 91.4% with intent-to-treat analysis and 98.5% with per protocol analysis. The SVR12 rates were statistically significant differences between the patients who were i.v. drug users and non-user (88.0% vs. 98.8%, p=0.025). From the baseline to SVR12, the serum ALT levels and Model for End-Stage Liver Disease score were significantly improved (p<0.001 and p=0.014, respectively). No severe adverse effect was observed.

Conclusion

GLE/PIB is an effective and tolerable treatment in patients with CHC.

TASL Practice Guidance on the Clinical Assessment and Management of Patients with Nonalcoholic Fatty Liver Disease

Nonalcoholic fatty liver disease (NAFLD) is a multisystem disease and is significantly associated with obesity, insulin resistance, type 2 diabetes mellitus, metabolic syndrome, and cardiovascular disease. NAFLD has become the most prevalent chronic liver disease in Western countries, and the proportion of NAFLD-related cirrhosis among patients on liver transplantation waiting lists has increased. In light of the accumulated data about NAFLD, and to provide a common approach with multi-disciplines dealing with the subject, it has become necessary to create new guidance for diagnosing and treating NAFLD. This guidance was prepared following an interdisciplinary study under the leadership of the Turkish Association for the Study of the Liver (TASL), Fatty Liver Special Interest Group. This new TASL Guidance is a practical application guide on NAFLD and was prepared to standardize the clinical approach to diagnosing and treating NAFLD patients. This guidance reflects many advances in the field of NAFLD. The proposals in this guidance are meant to aid decision-making in clinical practice. The guidance is primarily intended for gastroenterology, endocrinology, metabolism diseases, cardiology, internal medicine, pediatric specialists, and family medicine specialists.

Characteristics of Newly Diagnosed Hepatocellular Carcinoma Patients Across Turkey: Prospective Multicenter Observational 3K Registry Study

AIMS

To evaluate patient profile for epidemiological and clinicopathological characteristics and potential risk/prognostic factors in newly diagnosed hepatocellular carcinoma (HCC) patients across Turkey.

METHODS

A total of 547 patients (mean (SD) age 62.6 (10.3) years, 81.9% were males) were included in this registry study. Data on patient characteristics, etiologies of HCC, laboratory values, and tumor characteristics and stages were recorded at study enrollment.

RESULTS

HBV infection (68.2%) was the leading etiology, followed by HCV infection (17.2%), HDV infection (5.5%), alcohol (6.4%), and NAFLD (3.5%), as the major etiologies. Considering that 51.6% of the patients had >5 cm HCC, 44% were Child-Pugh B/C and 57% were BCLC B-D, it appears that a significant group of HCC patients were diagnosed at advanced stages. Of 540 patients, 271 (50.2%) were referred or applied with the diagnosis of HCC. Patients with HCC at presentation had larger tumor size (median (min-max) 6.6 (0-30) vs. 4.8 (0-90) cm, P < .001) and more advanced BCLC stage (Stage C-D in 40.8% vs. 26.4%, respectively, P = .005), compared to patients who were diagnosed during follow-up.

CONCLUSIONS

Our findings revealed that HBV infection was the leading etiology and a moderate-to-advanced disease was evident in more than half of patients at the time of diagnosis. HCC patients diagnosed at follow-up had smaller tumor size and earlier BCLC stage.

A cutoff value for the Systemic Immune-Inflammation Index in determining activity of Behçet disease

BACKGROUND

Behçet disease (BD) is an immune-mediated vasculitis-like syndrome characterized by recurrent aphthous lesions and various systemic manifestations. Inflammatory markers may be useful to assess disease severity. The Systemic Immune-Inflammation Index (SII) (neutrophils × platelets/lymphocytes) has been widely used in oncology since 2014, with promising results.

AIM

To assess the efficiency of the SII in determining activity of BD.

METHODS

This retrospective cohort study was conducted on patients with BD who were admitted to the outpatient clinic of the Department of Dermatology and Venereology, Ufuk University Hospital, between 1 January 2010 and 31 December 2019. Patients were divided into two groups based on their disease status upon admission: (i) active BD (n = 103), and (ii) inactive BD (n = 63). Clinical characteristics, demographic features, type of medications, full blood count parameters, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), ferritin and SII were compared between the groups. Furthermore, receiver operating characteristic curve analysis was performed to assess the performance of the SII in determining disease severity upon admission to hospital.

RESULTS

Higher numbers of white blood cells, platelets and neutrophils, greater red cell distribution width, higher levels of ESR, CRP and ferritin, and higher SII were observed in the active disease group (P < 0.001). The cutoff value of 552 × 10³ /mm³ was found to have 81% sensitivity and 82% specificity.

CONCLUSION

The SII may be used as an additional indicator for the assessment of BD status and physicians should be cautious in patients with SII levels of > 552 × 10³ /mm³ ) at the initial evaluation of the patients.

Effectiveness and safety of sofosbuvir/ledipasvir ± ribavirin treatment in liver and/or renal transplant patients with chronic hepatitis C: A single-center experience

Objective:

Successful treatment is possible with novel direct-acting oral antiviral agents in solid organ transplant patients with hepatitis C. In this study, the effectiveness and safety of sofosbuvir/ledipasvir ± ribavirin treatment in liver and/or renal transplant patients with chronic hepatitis C were evaluated.

Materials and methods:

A total of 23 liver and/or renal transplant patients who received sofosbuvir/ledipasvir ± ribavirin for chronic hepatitis C over 12 or 24 weeks were enrolled in the study. The treatment response, clinical and laboratory adverse effects, and effect on immunosuppressive drug levels were assessed.

Results:

A total of 12 patients had undergone renal transplantation and 11 had undergone liver transplantation. All of the renal transplant patients and 91% of liver transplant patients had genotype 1. In total, 10 renal transplant patients and 4 liver transplant patients had treatment experience. Two renal transplant patients and one liver transplant patient had compensated cirrhosis. Nine renal transplant patients were on tacrolimus, and two were on cyclosporine; all of the liver transplant patients were on tacrolimus-based immunosuppressive therapy. While hepatitis C RNA was negative in 75% of renal transplant patients and 91% of liver transplant patients at week 4, it was negative in all of the patients at the end of treatment and 12 weeks after treatment. Significantly reduced hemoglobin levels were observed in patients administered ribavirin during treatment (p = 0.01). There were no significant differences between the baseline and treatment period values of mean creatinine, estimated glomerular filtration rate, bilirubin, and tacrolimus levels. There were no adverse effects leading to treatment discontinuation.

Conclusion:

Sofosbuvir/ledipasvir ± ribavirin is quite safe and effective in hepatitis C treatment after liver and/or renal transplantation.

Significant Association between Serum Levels of Von Willebrand Factor (vWF) Antigen with Stages of Cirrhosis

OBJECTIVE

Von Willebrand factor (vWF) is a mediator that increases endotoxemic medium like in cirrhosis. In this study we evaluated the association of serum VWF antigen (Ag) level with the stage of cirrhosis (according to Child-Pugh classification).

MATERIALS AND METHODS

We included 82 cirrhotic patients (Female/Male (F/M): 26/56) and 86 healthy subjects (F/M: 44/42) in the study. Ages of the both groups of patients were not different (P= 0.095). We excluded possible other reasons that may cause VWF level increase. Diagnosis of cirrhosis was made on the basis of biopsy in 7 patients and with clinical and laboratory parameters in 75 patients. VWF Ag level was determined by immunoturbidimetric test. The stage of cirrhosis was defined with Child-Pugh classification. Data were analysed by using Statistical Package for the Social Sciences (SPSS) 10.0 software program.

RESULTS

VWF Ag level was significantly higher in cirrhotic patients compared to control group (220±90 and 87±38, P<0.001, respectively). We observed significant increase of VWF Ag level with the increasing stages of cirrhosis according to Child-Pugh score (VWF Ag level for Child A-B-C 156.4±54/215±45/284.8±93, respectively; P values for Child A-B/A-C/B-C; <0.001/<0.001/0.006, respectively).

CONCLUSION

Serum VWF Ag level increases in cirrhotic patients and this is more pronounced with higher stages of cirrhosis.

Analysis of risk factors predicting (affecting) mortality and morbidity of peptic ulcer perforations

The goal of this study is to identify invariable risk factors predicting the morbidity and mortality of a serious complication of peptic ulcer perforation (PUP). One hundred fifty-four patients were operated for PUP. We selected 147 patients who underwent primary repair and omentoplasty for PUP. The Boey score used to determine the high mortality risk after open surgery for PUP. The mortality rates were 0%, 12%, 32%, and 63% in the patients who had zero, one, two, and three factors, respectively (P < 0.001). Total postoperative mortality was 13.6% (20/147). Complications occurred in 48 (32.7%) of a total of 147 patients. Age, pulse rate at admission, and creatinine levels can be independent factors associated with prognosis in PUP.

NSAID-related upper gastrointestinal bleeding: are risk factors considered during prophylaxis?

The purposes of this study were to evaluate the effect of nonsteroidal anti-inflammatory drugs (NSAIDs) on acute nonvaricose upper gastrointestinal bleeding (ANUGIB) and establish whether the NSAID-prescribing physicians take precautions to prevent or reduce GI ulcerations. Clinical characteristics, causes of bleeding and clinical outcomes of patients hospitalised in our gastroenterology clinic with ANUGIB were recorded prospectively over a 1.5-year period. NSAIDs, including aspirin, were used by 127 of 168 patients (73%). Among the NSAID users, 100 patients (78%) had at least one risk factor for serious adverse GI events related to NSAIDs. Only two patients were using proton pump inhibitors and one patient was using H2 receptor blocker of the high-risk group for GI side effects of NSAIDs. NSAIDs have an important effect on GI bleeding, and it seems that risk factors are underestimated by physicians.

Relationships between hemodynamic alterations and Child-Pugh Score in patients with cirrhosis

BACKGROUND/AIMS

In this study, central and nonsplanchnic hemodynamic alterations in liver cirrhosis and correlation between Child-Pugh Score and these hemodynamic alterations were evaluated.

METHODOLOGY

With this aim, angiotensin-I, aldosterone, femoral blood flow, cardiac index, free water clearance and renal blood flow index were evaluated in 30 cirrhotic patients and 10 healthy control subjects.

RESULTS

Child-Pugh score was found to be directly related with serum levels of angiotensin-I and aldosterone, cardiac and renal blood flow index (r = 0.60 - p < 0.001, r = 0.57 - p < 0.01, r = 0.55 - p < 0.01 and r = 0.65 - p < 0.001 respectively), and indirectly related with free water clearance and femoral blood flow (r = 0 .72 -p < 0 .001, r = 0.71 -p < 0 .001 respectively).

CONCLUSIONS

We concluded that, in patients with cirrhosis, as the Child-Pugh score becomes greater angiotensin-I and aldosterone, cardiac output and non-splanchnic vasoconstriction progressively increase, on the other hand free water clearance and renal perfusion progressively decrease. Alterations in cardiac index and femoral artery blood flow begin before ascites formation. And the hyperdynamic circulation is a primary event independent of the central blood volume.

Remifentanil/midazolam versus tramadol/midazolam use for colonoscopy

One of the most commonly performed outpatient procedure is colonoscopy. The pain and anxiety is frequently associated with colonoscopy. The aim of this study was to compare the effectiveness of remifentanil/midazolam, and tramadol/midazolam for iv sedation and analgesia during colonoscopy. Twentysix patients (age range 18-65 years) scheduled for ambulatory colonoscopy were included to study. All patients received midazolam 1 mg intravenous. After two minutes in Group R (remifentanil/midazolam, n=18) remifentanil bolus (10 microg) and infusion 0.03 microg kg(-1) min(-1) were administered until adequate sedation level was achieved. In Group T (tramadol/midazolam, n=18) iv tramadol 50 mg was given concurrently. During procedure 2 L/min oxygen was supplemented via face mask to all patients. Haemodynamic variables, respiratory depression, level of sedation, postoperative recovery, patient and gastroenterologist satisfaction were surveyed. Patients were asked to verbally rate their level of pain, on an 10-point numerical rating scale (1=no pain, 10=severe pain). Chi-square, student t test, and mann whitney U test were used for statistical analysis. Colonoscopy was carried out successfully in all patients. There were no episodes of desaturation or airway compromise. Haemodynamic parameters were similar in both groups. Sistolic arterial and diastolic arterial pressures were increased at 10 and 15 minutes in all patients (P<0.05). There were no significant changes in heart rate in both groups. The level of sedation in group R was higher than group T during colonoscopy. The patients in group T had higher pain scores. Gastroenterologist satisfaction and patient satisfaction were similar in both groups. Our results suggests that, sedoanalgesia with midazolam/remifentanil may be an alternative to sedoanalgesia with midazolam/tramadol for colonoscopy.

Hepatopulmonary syndrome in noncirrhotic portal hypertensive patients

Hepatopulmonary syndrome has yet not been sufficiently assessed in noncirrhotic portal hypertension. The prevalence of hepatopulmonary syndrome was determined in 31 consecutive patients with noncirrhotic portal hypertension (19 idiopathic portal hypertension, 7 portal vein thrombosis, 5 congenital hepatic fibrosis) and 46 patients with liver cirrhosis. Contrast echocardiography was carried out in all patients. Macroaggregated albumin lung perfusion scans were performed in patients with positive contrast echocardiogram. Hepatopulmonary syndrome was detected in 5 (10.8%) cirrhotic and 3 (9.7%) noncirrhotic portal hypertensive patients (2 idiopathic portal hypertension, 1 portal vein thrombosis). All patients with hepatopulmonary syndrome had an increased shunt fraction (13-62%) and a decreased diffusion capacity of carbon monoxide (40-79%), and 7 of them were hypoxemic (PaO2, 31.6-69.8 mm Hg). These findings show that hepatopulmonary syndrome may occur in both liver cirrhosis and noncirrhotic portal hypertension and that portal hypertension is the predominant etiopathogenic factor related to hepatopulmonary syndrome.

Tuberculous peritonitis--reports of 26 cases, detailing diagnostic and therapeutic problems

OBJECTIVE

To evaluate the clinical presentation, biochemical (ascites and serum) and laparoscopic findings, and to assess the efficacy of triple antituberculous therapy without rifampicin for 6 months in patients with tuberculous peritonitis.

METHODS

Twenty-six tuberculous peritonitis patients (11 male, 15 female) with a mean age of 34.8 +/- 3.4 years (range 14-77) were assessed with regard to diagnostic and therapeutic features.

RESULTS

The most common symptoms and signs were abdominal pain (92.3%) and ascites (96.2%), respectively. Tuberculin skin test (TST) was positive in all patients. An abnormal chest radiography suggestive of previous tuberculosis was present in five patients (19.2%), and two patients (7.7%) had extra-peritoneal (cerebral, pericardial) active tuberculous involvement. In 24 of the 25 patients who underwent laparoscopy with directed biopsy, whitish nodules suggested tuberculous peritonitis; 76% of the biopsy specimens revealed caseating, 20% non-caseating granulomatous inflammation, and 4% non-specific findings. The ascitic fluid of one patient (3.8%) was positive for acid-resistant bacilli, and culture was positive in two patients (7.7%). Twenty-four of the patients were treated for 6 months with isoniazid, streptomycin (total dose 40 g) and pyrazinamide (for the first 2 months and then substituted with ethambutol). Eighteen patients also received methyl prednisolone, initially 20 mg/day, for 1 month. The follow-up period was 19 +/- 1.7 months after the end of therapy (range 6-36). Ascites and abdominal pain abated earlier in patients on steroid therapy. All but two of the 24 patients responded to treatment.

CONCLUSION

Non-invasive tests such as acid-fast stain and culture of the ascitic fluid are usually insufficient, hence invasive laparoscopy and peritoneal biopsy are necessary for the diagnosis of tuberculous peritonitis if non-invasive tests such as ascites adenosine deaminase activity measurement are not easily available. Triple therapy without rifampicin for 6 months is sufficient to treat tuberculous peritonitis.

Serial measurements of serum transaminases in renal transplant recipients with chronic hepatitis C: do they reflect disease severity?

Chronic hepatitis C infection is a common problem in renal allograft recipients, this study was designed to investigate the association of serum aminotransferase levels with liver histology, in renal transplant patients with chronic hepatitis C virus (HCV) infection, in the long term.

METHODS

In this study, 82 HCV-infected renal allograft recipients, who were followed up with functioning grafts for at least 6 months, were analyzed. Patients were classified according to their transaminase values as persistently normal, intermittently abnormal, or continuously abnormal liver function tests. Serum transaminase levels exceeding at least 1.5 times the upper limit of normal (40 IU) for periods longer than 1 month were taken as abnormal. Patients with abnormal liver function tests owing to HCV unrelated causes (drugs, alcohol, or other toxic substances, other viruses, etc.) were excluded from the study. Forty-eight of these patients underwent at least one liver biopsy.

RESULTS

Of the 82 patients, 34 (41.5%) had persistently normal (liver biopsy revealed normal or minimal changes in 77.0%, chronic persistent hepatitis in 15.3%, chronic active hepatitis in 7.7%; no patient had cirrhosis), 29 (35.3%) intermittently abnormal (liver histology was consistent with minimal changes in 50%, chronic persistent hepatitis in 27.8%, chronic active hepatitis in 16.7%, cirrhosis in 5.5%), 19 (23.2%) persistently abnormal (liver biopsy showed minimal changes in 41.1%, chronic persistent hepatitis in 17.6%, chronic active hepatitis in 35.3%, cirrhosis in 5.9%) transaminase values.

CONCLUSION

Although continuously or intermittently elevated transaminases do not always indicate morphologically advanced disease, the normal course of serum transaminases is mostly accompanied by normal, or near-normal, liver histology, in HCV-infected renal transplant patients. Liver biopsy is not indicated in deciding disease severity in these patients unless clinical findings dictate otherwise.