Two sides to every story: Reappraising the early history of liver transplantation at Addenbrooke's Hospital, Cambridge

Over the course of the past six decades, liver transplantation has evolved to become the treatment of choice for chronic end-stage liver disease and some cases of acute hepatic failure. Currently, more than 34,000 liver transplants are conducted worldwide per annum, and overall one year survival rates exceed 90%. However, the early years of human liver transplantation were beset by failure. Eyewitness reports from this period make for tragic, yet compelling reading. Volume 12 of The History of Anaesthesia Society Proceedings contains one such account, written by Dr Elizabeth Gibbs. This outlined the experience of single-handedly anaesthetising the recipient of the first liver transplant to be undertaken at Addenbrooke's Hospital, Cambridge, UK, in June 1967. Despite the best efforts of the team, the patient died from uncontrollable haemorrhage 19 hours after the start of the procedure. While this tragic outcome might have been expected in the early days of liver transplantation, Gibbs included an unsettling postscript in her paper. This stated that all of the patient's records had apparently been 'lost', and the date of the first Cambridge liver transplant was publicly reported as 2 May 1968, some 11 months after the events described. This article outlines the results of research aimed at critically appraising this postscript. In doing so a number of unexpected discoveries were made. These highlight some important lessons for medical historians and demonstrate that if you look hard enough, there really are two sides to every story.

Prevalence and impact on the outcome of myosteatosis in patients with cirrhosis: a systematic review and meta-analysis

BACKGROUND

Myosteatosis in cirrhotic patients has been evaluated in limited studies with conflicting results and no systematic review or meta-analysis have been performed in this setting.

METHODS

We searched for all articles published until June 2023 to evaluate the prevalence of myosteatosis in cirrhosis and chronic liver disease.

RESULTS

Seventeen studies focused on cirrhosis and five studies in patients with chronic liver disease were included: the overall pooled prevalence of myosteatosis was 46% [95% Confidence Interval (CI) 36-57%] and 33% (95% CI 15-59%), respectively (p = 0.35). Among the studies with cirrhosis, the prevalence of myosteatosis was higher in those using the body mass index-based definition of myosteatosis (56%), than gender-based (36%) or other criteria (21%) (p < 0.01); was higher in women than in men (61% vs 45%), in Child-Pugh class C than A or B (57% vs 49% vs 50%), in non-alcoholic fatty liver disease (NAFLD)- than viral-associated cirrhosis (57% vs 43%), but these differences were not statistically significant (p > 0.05). Cirrhotic patients with myosteatosis, compared to those without myosteatosis, had more frequently a previous history of hepatic encephalopathy (32% vs 15%, p = 0.04), less frequently a previous history of variceal bleeding (46% vs 65%, p < 0.01), were more likely to suffer from diabetes mellitus (27% vs 18%, p < 0.01), while they had higher mortality rates (40% vs 14%, p = 0.02).

CONCLUSION

Myosteatosis is highly prevalent in patients with cirrhosis, particularly in those with NAFLD-associated cirrhosis. Myosteatosis is associated with hepatic encephalopathy, while it seems to have a negative impact on the outcome.

Model for end-stage liver disease-3.0 vs. model for end-stage liver disease-sodium: mortality prediction in Korea

BACKGROUND/AIMS

The model for end-stage liver disease (MELD) serves as an indicator for short-term mortality among patients diagnosed with liver cirrhosis (LC) and is used to prioritize patients for liver transplantation. In 2021, the updated version of MELD, MELD-3.0, was introduced to improve the accuracy of the mortality prediction of MELD. Therefore, this study aimed to compare the efficacy of MELD 3.0 and MELD-Na in predicting mortality among Korean patients with LC.

METHODS

A retrospective review was conducted using the medical records of patients diagnosed with LC who were admitted to Konkuk University Hospital From 2011 to 2021. The study calculated the predictive values of MELD-Na and MELD-3.0 for 3- and 6-months mortality using the area under the receiver operating curve (AUROC) and compared the results using the DeLong test.

RESULTS

Of the 3,034 patients enrolled in the study, 339 (11.2%) died within 3 months and 421 (14.4%) died within 6 months. The AUROCs values for predicting 3 months mortality were 0.846 for MELD-Na and 0.851 for MELD-3.0. The corresponding AUROC values for predicting 6 months mortality were 0.843 for MELD-Na and 0.848 for MELD-3.0. MELD-3.0 exhibited better discrimination ability than MELD-Na for both 3 (p = 0.03) and 6 months mortality (p = 0.01).

CONCLUSION

Our study found a significant difference between the performance of MELD-3.0 and MELD-Na in Korean patients with LC.

Modified Charlson comorbidity index as a survival prediction tool for older patients after liver transplantation

Purpose

An increasing number of older patients now undergo liver transplantation (LT). Although the overall outcomes in older patients are not different from those of younger patients, there is no tool to predict LT prognosis in older patients. We hypothesized that a modified Charlson comorbidity index (mCCI) and 5-factor modified frailty index (mFI-5) can predict outcomes in older patients after LT.

Methods

This retrospective study included 155 patients (aged >65 years) who underwent LT at Seoul National University Hospital. The recipients were subcategorized into 2 groups based on the mCCI score and mFI-5: the low (0-1) and high (2-5) mCCI groups, and low (≤0.4) and high (>0.4) mFI-5 groups. The independent effect of each variable on post-LT survival was determined using the mCCI subgroup, age at transplantation, sex, Child-Turcotte-Pugh score, model for end-stage liver disease (MELD) score, and mFI-5 subgroup.

Results

The high-mCCI group (41 patients) showed significantly lower 1- and 3-month and 1-, 3-, and 5-year survival than the low-mCCI group. Using the Cox regression model, the mCCI, sex, and MELD score remained significant. The mFI-5 was not a significant factor to predict patients' survival.

Conclusion

The mCCI and MELD scores could be used to predict post-LT survival in older patients.

Utility of an Artificial Intelligence Enabled Electrocardiogram for Risk Assessment in Liver Transplant Candidates

BACKGROUND

Post-operative cardiac complications occur infrequently but contribute to mortality after liver transplantation (LT). Artificial intelligence-based algorithms based on electrocardiogram (AI-ECG) are attractive for use during pre-operative evaluation to screen for risk of post-operative cardiac complications, but their use for this purpose is unknown.

AIMS

The aim of this study was to evaluate the performance of an AI-ECG algorithm in predicting cardiac factors such as asymptomatic left ventricular systolic dysfunction or potential for developing post-operative atrial fibrillation (AF) in cohorts of patients with end-stage liver disease either undergoing evaluation for transplant or receiving a liver transplant.

METHODS

A retrospective study was performed in two consecutive adult cohorts of patients who were either evaluated for LT or underwent LT at a single center between 2017 and 2019. ECG were analyzed using an AI-ECG trained to recognize patterns from a standard 12-lead ECG which could identify the presence of left ventricular systolic dysfunction (LVEF < 50%) or subsequent atrial fibrillation.

RESULTS

The performance of AI-ECG in patients undergoing LT evaluation is similar to that in a general population but was lower in the presence of prolonged QTc. AI-ECG analysis on ECG in sinus rhythm had an AUROC of 0.69 for prediction of de novo post-transplant AF. Although post-transplant cardiac dysfunction occurred in only 2.3% of patients in the study cohorts, AI-ECG had an AUROC of 0.69 for prediction of subsequent low left ventricular ejection fraction.

CONCLUSIONS

A positive screen for low EF or AF on AI-ECG can alert to risk of post-operative cardiac dysfunction or predict new onset atrial fibrillation after LT. The use of an AI-ECG can be a useful adjunct in persons undergoing transplant evaluation that can be readily implemented in clinical practice.

Hepatic encephalopathy on magnetic resonance imaging and its uncertain differential diagnoses: a narrative review

Hepatic encephalopathy (HE) is a severe neuropsychiatric abnormality in patients with either acute or chronic liver failure. Typical brain magnetic resonance imaging findings of HE are bilateral basal ganglia high signal intensities due to manganese deposition in chronic liver disease and hyperintensity in T2, fluid-attenuated inversion recovery, or diffusion-weighted imaging (DWI) with hemispheric white matter changes including the corticospinal tract. Low values on apparent diffusion coefficient mapping of the affected area on DWI, indicating cytotoxic edema, can be observed in acute HE. However, neuropsychological impairment in HE ranges from mild deficits in psychomotor abilities affecting quality of life to stupor or coma with higher grades of hepatic dysfunction. In particular, the long-lasting compensatory mechanisms for the altered metabolism in chronic liver disease make HE imaging results variable. Therefore, the clinical relevance of imaging findings is uncertain and differentiating HE from other metabolic diseases can be difficult. The recent introduction of concepts such as "acute-on-chronic liver failure (ACLF)," a new clinical entity, has led to a change in the clinical view of HE. Accordingly, there is a need to establish a corresponding concept in the field of neuroimaging diagnosis. Herein, we review HE from a historical and etiological perspective to increase understanding of brain imaging and help establish an imaging approach for advanced new concepts such as ACLF. The purpose of this manuscript is to provide an understanding of HE by reviewing neuroimaging findings based on pathological and clinical concepts of HE, thereby assisting in neuroimaging interpretation.

Mortality scoring systems for liver transplant recipients: before and after model for end-stage liver disease score

The mortality scoring systems for patients with end-stage liver disease have evolved from the Child-Turcotte-Pugh score to the model for end-stage liver disease (MELD) score, affecting the wait list for liver allocation. There are inherent weaknesses in the MELD score, with the gradual decline in its accuracy owing to changes in patient demographics or treatment options. Continuous refinement of the MELD score is in progress; however, both advantages and disadvantages exist. Recently, attempts have been made to introduce artificial intelligence into mortality prediction; however, many challenges must still be overcome. More research is needed to improve the accuracy of mortality prediction in liver transplant recipients.

Acute-on-chronic liver failure: Controversies and consensus

Acute-on-chronic liver failure (ACLF) is a poorly defined syndrome characterised by rapid clinical deterioration in patients with chronic liver disease. Consequences include high short-term morbidity, mortality, and healthcare resource utilisation. ACLF encompasses a dysregulated, systemic inflammatory response, which can precipitate extra hepatic organ failures. Common precipitants include infection, alcoholic hepatitis, and reactivation of viral hepatitis although frequently no cause is identified. Heterogenous definitions, diagnostic criteria, and treatment guidelines, have been proposed by international hepatology societies. This can result in delayed or missed diagnoses of ACLF, significant variability in clinical management, and under-estimation of disease burden. Liver transplantation may be considered but the mainstay of treatment is organ support, often in the intensive care unit. This review will provide clarity around where are the controversies and consensus in ACLF including: Epidemiology and resource utilisation, key clinical and diagnostic features, strategies for management, and research gaps.

A retrospective study on use of palliative care for patients with alcohol related end stage liver disease in United States

BACKGROUND

Palliative care (PC) has been shown to be beneficial in end stage liver disease (ESLD), yet the hospitalization data for PC utilization is unknown.

AIM

To identify the trend of PC utilization for the special population of alcohol-associated ESLD patients, factors affecting its use and ascertain its impact on healthcare utilization.

METHODS

We analyzed around 78 million discharges from the 2007-2014 national inpatient sample and 2010-2014 national readmission database including adult patients admitted for decompensated alcohol-associated cirrhosis. We identified patients with PC consultation as a secondary diagnosis. Odds ratios (OR) and means were adjusted for confounders using multivariate regression analysis models.

RESULTS

Out of the total 1421849 hospitalizations for decompensated liver cirrhosis, 62782 (4.4%) hospitalizations had a PC consult, which increased from 0.8% (1258) of all alcohol-associated ESLD hospitalizations in 2007 to 6.6% in 2014 (P < 0.01). Patient and hospital characteristics associated with increased odds of PC utilization were advanced age, lower income, Medicaid coverage, teaching institution, urban location, length of stay > 3 d, prolonged ventilation, and administration of total parenteral nutrition (all P < 0.01). Palliative encounters in alcohol-associated ESLD and acute-on-chronic liver failure (ACLF) score were associated with increased odds of discharge to a rehabilitation facility, but significantly lower odds of 30-d readmissions (aOR: 0.35, 95%CI: 0.31-0.41), lower total hospitalization charges and lower mean hospitalization days (all P < 0.01).

CONCLUSION

Inpatient PC is sparingly used for patients with decompensated alcohol related liver disease, however it has increased over the past decade. PC consultation is associated with lower 30-d readmission rates on multivariate analysis, and lower hospitalization cost and length of stay in patients with ACLF score ≥ 2.

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.

Cardiac risk stratification of the liver transplant candidate: A comprehensive review

Cardiovascular diseases (CVD) form a principal consideration in patients with end-stage liver disease (ESLD) undergoing evaluation for liver transplant (LT) with prognostic implications in the peri- and post-transplant periods. As the predominant etiology of ESLD continues to evolve, addressing CVD in these patients has become increasingly relevant. Likewise, as the number of LTs increase by the year, the proportion of older adults on the waiting list with competing comorbidities increase, and the demographics of LT candidates evolve with parallel increases in their CVD risk profiles. The primary goal of cardiac risk assessment is to preemptively reduce the risk of cardiovascular morbidity and mortality that may arise from hemodynamic stress in the peri- and post-transplant periods. The complex hemodynamics shared by ESLD patients in the pre-transplant period with adverse cardiovascular events occurring in only some of these recipients continue to challenge currently available guidelines and their uniform applicability. This review focusses on cardiac assessment of LT candidates in a stepwise manner with special emphasis on preoperative patient optimization. We hope that this will reinforce the importance of cardiovascular optimization prior to LT, prevent futile LT in those with advanced CVD beyond the stage of optimization, and thereby use the finite resources prudently.

Ability of dynamic preload indices to predict fluid responsiveness in a high femoral-to-radial arterial pressure gradient: a retrospective study

Background

Dynamic preload indices may predict fluid responsiveness in end-stage liver disease. However, their usefulness in patients with altered vascular compliance is uncertain. This study is the first to evaluate whether dynamic indices can reliably predict fluid responsiveness in patients undergoing liver transplantation with a high femoral-to-radial arterial pressure gradient (PG).

Methods

Eighty liver transplant recipients were retrospectively categorized as having a normal (n = 56) or high (n = 24, difference in systolic pressure ≥ 10 mmHg and/or mean pressure ≥ 5 mmHg) femoral-to-radial arterial PG, measured immediately after radial and femoral arterial cannulation. The ability of dynamic preload indices (stroke volume variation, pulse pressure variation [PPV], pleth variability index) to predict fluid responsiveness was assessed before the surgery. Fluid replacement of 500 ml of crystalloid solution was performed over 15 min. Fluid responsiveness was defined as ≥ 15% increase in the stroke volume index. The area under the receiver-operating characteristic curve (AUC) indicated the prediction of fluid responsiveness.

Results

Fourteen patients in the normal, and eight in the high PG group were fluid responders. The AUCs for PPV in the normal, high PG groups and total patients were 0.702 (95% confidence interval [CI] 0.553–0.851, P = 0.008), 0.633 (95% CI 0.384–0.881, P = 0.295) and 0.667 (95% CI 0.537–0.798, P = 0.012), respectively. No other index predicted fluid responsiveness.

Conclusion

PPV can be used as a dynamic index of fluid responsiveness in patients with end-stage liver disease but not in patients with altered vascular compliance.

Local recurrence following complete radiologic response in patients treated with transarterial chemoembolization for hepatocellular carcinoma

PURPOSE

The purpose of this study was to determine the local progression rate and identify factors that may predict local progression, in patients who achieve a complete response (CR) radiologically after undergoing transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

One-hundred-forty-seven patients, who achieved CR of 224 HCCs after TACE, were retrospectively reviewed. There were 109 men and 38 women with a mean age of 61.6 ± 6.8 (SD) years (range: 45.4-86.9 years). Logistic mixed-effects and Cox regression models were used to evaluate associations between clinical factors and local progression.

RESULTS

A total of 75 patients (75/147; 51%) and 99 (99/224,44.2%) lesions showed local progression at a median of 289.5 days (Q1: 125, Q3: 452; range: 51-2245 days). Pre-treatment, international normalization ratio (INR) (1.17 ± 0.15 [SD] vs. 1.25 ± 0.16 [SD]; P <0.001), model for end-stage liver disease (9.4 ± 2.6 [SD] vs. 10.6 ± 3.2 [SD]; P = 0.010) and Child-Pugh score (6 ± 1 [SD] vs. 6.4 ± 1.3 [SD]; P = 0.012) were significantly lower while albumin serum level (3.4 ± 0.62 [SD] vs. 3.22 ± 0.52 [SD]; P = 0.033) was significantly greater in those who showed local progression as compared to those who did not. In terms of local-recurrence free survival, the number of TACE treatments (hazard ratio [HR]: 2.05 [95% CI: 1.57-2.67]; P<0.001), INR (HR: 0.13 [95% CI: 0.03-0.61]; P = 0.010) and type of TACE (P = 0.003) were significant. Patients with local progression on any tumor did not differ from those who did in terms of overall survival (P = 0.072), however, were less likely to be transplanted (20/75, 26.7%) than those who did not (33/72; 36.1%) (P = 0.016).

CONCLUSION

A significant number of patients who achieve CR of HCC after TACE have local progression. This emphasizes the importance of long-term follow up.

The impact of pretransplant hepatic encephalopathy, model for end-stage liver disease (MELD) scale on long-term survival following deceased donor liver transplantation: a retrospective study

BACKGROUND

Liver transplantation (LT) has the incidence of 30-day mortality about 5-10%, Jo et al. reported that 30-day mortality and 1-year mortality for DDLT were 30%, and 39% respectively. It is not easy to create a model for predicting post-transplantation outcomes based on pretransplant variables. MELD does not take into account individual complications such as hepatic encephalopathy (HE), and research has shown that the greater the severity of pretransplant HE, the lower the survival rate after LT; the importance of monitoring for HE is therefore emphasized.

METHODS

The medical records of adult patients who underwent deceased donor LT (DDLT) were retrospectively reviewed for analysis of the effect of HE on the long-term survival rate of post-transplant for more than 1 year.

RESULTS

Presence of HE is not statistically associated to patient survival (P=0.062), but the hazard ratio is 1.954 (95% CI, 0.968, 3.943). In addition, the severe HE group significantly decreased survival compared to the non-HE group, and the cumulative 1- and 3-year overall survival rates were 80.9% and 78.7%, respectively, in non HE group, and 65.7% and 56.1%, respectively, in severe HE group (P=0.031).

CONCLUSIONS

Severe HE is a factor influencing the long-term survival over 3 years in the patients who underwent DDLT. Although prospective validation should be conducted to determine the prognostic value of HE severity, efforts could be made to reduce the severity of HE before DDLT, and consider severity of HE rather than MELD score in DDLT allocation.

Clinical implications of inducible left ventricular outflow tract obstruction among patients undergoing liver transplant evaluation

Introduction

Patients with end stage liver disease (ESLD) have a hyperdynamic state due to decreased systemic vascular resistance and increased cardiac output. Preoperative evaluation with dobutamine stress echocardiography (DSE) is used to risk-stratify patients prior to liver transplant. We sought to identify the impact of inducible left ventricular outflow tract obstruction (LVOTO) on DSE on post-operative liver transplant outcomes.

Methods

Patients with ESLD who underwent liver transplant at Cleveland Clinic between January 2007 and August 2016 were identified. Pre-operative DSE data, and post-operative intensive care unit (ICU) data were extracted. Patients with inducible LVOTO were compared to those without LVOTO.

Results

Of the 515 patients identified who underwent DSE prior to liver transplant, 165 (30%) were female, and 95 (18%) had LVOTO. There were no major differences in baseline characteristics between the two groups. In the LVOTO group, rest gradients were 10.8 ± 3 mm Hg while peak gradients were 90 ± 48.2 mm Hg. No significant differences in ICU length of stay or duration of mechanical ventilation between both groups were noted. There were 21 deaths at 30 days. There were 2 (2.1%) deaths in the LVOTO group, versus 19 (4.5%) deaths in the non LVOTO group (p = 0.28). Higher Model for End Stage Liver Disease (MELD) scores predicted longer duration of mechanical ventilation and ICU length of stay.

Conclusion

Inducible LVOTO on DSE does not adversely affect the short-term outcomes post liver transplant. Presence of inducible LVOTO should not be the mere reason to deny liver transplant among patients with ESLD.

Evidence-based protocol for diagnosis and treatment of hepatorenal syndrome is independently associated with lower mortality

BACKGROUND

Hepatorenal syndrome (HRS) is the deadliest complication of cirrhosis. The purpose of this study is to analyze if the use of a protocol for HRS is associated with higher survival in these patients.

METHODS

An evidence-based protocol for the diagnosis and treatment of HRS was instituted in 2013. Data from medical records from 2010 to 2016 were obtained by searching the hospital database for patients who received terlipressin, in the three years before and after the institution of the protocol. Data were reviewed to confirm the diagnosis of HRS and multiple variables were collected. Liver-specific scores were calculated and a stepwise Cox regression approach was used for univariate and multivariate analysis.

RESULTS

The study included 46 patients, 20 from the pre-protocol period and 26 from the post-protocol period. Respectively, mortality at 30 days, 90 days and 365 days was 75%, 75% and 90% for the pre-protocol period, and 61%, 69% and 80% for the post-protocol period. In the multivariate analysis, an aspartate aminotransferase (AST) of <40U/L, the pre-protocol period and higher Child-Turcotte-Pugh scores were associated with higher 30-day and 90-day mortality. The total mean dose of terlipressin and human albumin used per patient was reduced from 27mg to 22mg and from 236g to 144g, respectively, after the institution of the protocol. This was not associated with higher mortality.

CONCLUSION

The use of an evidence-based protocol for the treatment of HRS translated into a higher survival. The authors suggest that the use of evidence-based protocols for the diagnosis and treatment of HRS could reduce cost and mortality in tertiary hospitals.

[Progress in basic and clinical and clinical research of a cell therapy for end-stage liver disease]

Clinically, the incidence of end-stage liver disease including decompensated cirrhosis and liver failure is high, which seriously threatens people's health. The existing comprehensive internal medicine treatment is ineffective, and liver transplantation is still the most effective treatment method. However, the shortage of matching liver donors and other reasons constrain the development of liver transplantation, thus limiting the treatment of patients with end-stage liver disease. In recent years, domestic and foreign scholars have conducted many pre-clinical and clinical trials using a variety of cells, and have achieved certain results, providing a new method for the treatment of end-stage liver disease. This article reviews and discusses the existing problems, research status and application progress of varieties of cell therapy for end-stage liver diseases.

[Current Status of Deceased Donor Liver Transplantation for Alcoholic Liver Disease in Korea in MELD Era]

The organ allocation system should be fair and efficient to predict the prognosis of patients with end-stage organ failure. The liver allocation system in Korea was changed to the model for end-stage liver disease (MELD) score system from Child-Turcotte-Pugh score-based status system in 2016. Since then, there have been some changes in matching liver graft to recipients in deceased liver transplantation. The severity of sickness of the end-stage liver failure patients has been increased in the MELD era than before. Since 2013, liver transplantation for alcoholic liver disease has been gradually increasing in Korea. We should take proper evaluation into consideration when we decide early liver transplantation particularly for patients with severe alcoholic hepatitis, who have a high MELD score. Above all, overcoming organ shortage, it is necessary for us to try to increase the number of deceased donors to meet the need for liver transplantation for end-stage liver disease patients.

Clinical utility of viscoelastic testing in chronic liver disease: A systematic review

BACKGROUND

Conventional coagulation tests are widely used in chronic liver disease to assess haemostasis and to guide blood product transfusion. This is despite the fact that conventional tests do not reliably separate those with a clinically significant coagulopathy from those who do not. Viscoelastic testing such as thromboelastography (TEG) correlate with bleeding risk and are more accurate in identifying those who will benefit from blood product transfusion. Despite this, viscoelastic tests have not been widely used in patients with chronic liver disease outside the transplant setting.

AIM

To assess the utility of Viscoelastic Testing guided transfusion in chronic liver disease patients presenting with bleeding or who require an invasive procedure.

METHODS

PubMed and Google Scholar searches were performed using the key words “thromboelastography”, “TEG” or “viscoelastic” and “liver transplantation”, “cirrhosis” or “liver disease” and “transfusion”, “haemostasis”, “blood management” or “haemorrhage”. A full text review was undertaken and data was extracted from randomised control trials that evaluated the outcomes of viscoelastic test guided transfusion in those with liver disease. The study subjects, inclusion and exclusion criteria, methods, outcomes and length of follow up were examined. Data was extracted by two independent individuals using a standardized collection form. The risk of bias was assessed in the included studies.

RESULTS

A total of five randomised control trials included in the analysis examined the use of TEG guided blood product transfusion in cirrhosis prior to invasive procedures (n = 118), non-variceal haemorrhage (n = 96), variceal haemorrhage (n = 60) and liver transplantation (n = 28). TEG guided transfusion was effective in all five studies with a statistically significant reduction in overall blood product transfusion compared to standard of care. Four of the five studies reported a significant reduction in transfusion of fresh frozen plasma and platelets. Two studies showed a significant reduction in cryoprecipitate transfusion. No increased risk of bleeding was reported in the three trials where TEG was used perioperatively or prior to an invasive procedure. Two trials in the setting of cirrhotic variceal and non-variceal bleeding showed no difference in control of initial bleeding. In those with variceal bleeding, there was a statistically significant reduction in rate of re-bleeding at 42 d in the TEG arm 10% (vs 26.7% in the standard of care arm P = 0.012). Mortality data reported at various time points for all five trials from 6 wk up to 3 years was not statistically different between each arm. One trial in the setting of non-variceal bleeding demonstrated a significant reduction in adverse transfusion events in the TEG arm 30.6% (vs 74.5% in the control arm P < 0.01). In this study there was no significant difference in total hospital stay although length of stay in intensive care unit was reduced by an average of 2 d in the TEG arm (P = 0.012).

CONCLUSION

Viscoelastic testing has been shown to reduce blood product usage in chronic liver disease without compromising safety and may enable guidelines to be developed to ensure patients with liver disease are optimally managed.

Clinical implications, diagnosis, and management of diabetes in patients with chronic liver diseases

Diabetes mellitus (DM) negatively affects the development and progression of chronic liver diseases (CLD) of various etiologies. Concurrent DM and CLD are also associated with worse clinical outcomes with respect to mortality, the occurrence of hepatic decompensation, and the development of hepatocellular carcinoma (HCC). Unfortunately, early diagnosis and optimal treatment of DM can be challenging, due to the lack of established clinical guidelines as well as the medical complexity of this patient population. We conducted an exploratory review of relevant literature to provide an up-to-date review for internists and hepatologists caring for this patient population. We reviewed the epidemiological and pathophysiological associations between DM and CLD, the impact of insulin resistance on the progression and manifestations of CLD, the pathogenesis of hepatogenic diabetes, as well as the practical challenges in diagnosis and monitoring of DM in this patient population. We also reviewed the latest clinical evidence on various pharmacological antihyperglycemic therapies with an emphasis on liver disease-related clinical outcomes. Finally, we proposed an algorithm for managing DM in patients with CLD and discussed the clinical and research questions that remain to be addressed.

Treatment Outcomes and Prognostic Factors of Acute Variceal Bleeding in Patients with Hepatocellular Carcinoma

Background/Aims

The treatment outcomes and prognostic markers of acute variceal bleeding (AVB) in hepatocellular carcinoma (HCC) patients remain unclear. Therefore, we evaluated the clinical outcomes and prognostic factors of AVB in HCC patients.

Methods

Cirrhotic patients with endoscopically confirmed AVB between 2007 and 2013 were enrolled in this prospective study. Prognostic factors were identified by multivariate Cox proportional hazards regression analysis.

Results

Among the 329 enrolled patients, 125 patients (38.0%) were diagnosed with HCC. The 6-week mortality rates of all enrolled AVB patients and the HCC subgroup were 14.9% and 26.4%. The 5-day treatment failure, 6-week mortality, cirrhosis-related complications, and duration of hospitalization were greater in HCC patients than in non-HCC patients (all p<0.05). In the HCC subgroup, the Model for End-Stage Liver Disease (MELD) score (hazard ratio [HR], 1.145; p=0.001) and Barcelona Clinic Liver Cancer (BCLC) stage (C-D vs 0-B) (HR, 3.096; p=0.019) were independent predictors of 6-week mortality. Our study revealed that 85% of HCC patients with both a MELD score ≥15.5 and BCLC stage C-D died within 6 weeks, and the 6-week mortality risk was 21-fold higher in this group than in the group with a lower MELD score and earlier HCC stage (p<0.001).

Conclusions

The 5-day treatment failure and 6-week mortality rates were significantly higher among AVB patients with HCC than those without HCC. The MELD score and the presence and stage of HCC are strong predictors of 6-week mortality in patients with AVB.

Life-Sustaining Treatment in End-Stage Liver Disease Patients: Patients' Decisions and Results

Purpose

In 2018, the Act on Decisions on Life-Sustaining Treatment for Patients in Hospice and Palliative Care or at the End of Life was implemented and the scope of official recognition for terminally ill patients was expanded. The purpose of this study was to investigate the decisions made by patients with end-stage liver disease about their life-sustaining treatment in a clinical setting.

Methods

The subjects of this study were patients with endstage liver disease hospitalized at a tertiary hospital in Seoul, Korea who wrote physician orders for life-sustaining treatment (POLST). Data collection was done using patients' electronic medical records, and a retrospective analysis of POLST was conducted.

Results

Among 101 patients, 18.8% were female and 81.2% were male, and their mean age was 61.8 (±10.61) years. Sixty-three patients (62.4%) wrote their POLST by themselves. Three patients withdrew the POLST, of whom two did so for liver transplantation, and one did so for chemotherapy.

Conclusion

This study shows that sufficient consideration of liver transplantation is needed for end-stage liver disease patients before making decisions on life-sustaining treatment. The self-determination of patients must be respected and effective guidelines are urgently needed.

Resistance training combined with blood flow restriction in cirrhosis: study protocol for a randomized controlled trial

BACKGROUND

Patients affected by hepatic cirrhosis show reductions in muscle mass and function, with poor quality of life and functional performance. As such, resistance training with blood flow restriction (BFR-RT) could be a useful therapeutic tool for health promotion. Thus, we aim to verify the effects of this intervention on muscle strength, muscle mass, fiber Pennation angle, fascicle length, functional performance, quality of life, and fall risk scores in this population.

METHODS

Thirty participants will be randomly distributed between 1) BFR-RT and 2) control (CTRL). Assessments will occur at three time points: before the training intervention (0 W), after 12 weeks (12 W), and at follow-up (24 W). The following variables will be assessed: Child-Pugh classification; MELD score; SF-36 questionnaire; fatigue severity index; 6-min walk test; timed-up and go; 30-s sitting and rising test; dietary record; one-repetition maximum (1-RM) strength test (knee extension exercise); and vastus lateralis' cross-sectional area, Pennation angle, and fascicle length. The BFR-RT group will undergo 12 weeks of knee extension exercise (1 × 30 repetitions and 3 × 15 repetitions at 20% 1-RM and 50% of total blood flow occlusion pressure), with two sessions per week. Data normality will be assessed using the Shapiro-Wilk test. In case of normal distribution, a one-way repeated measures analysis of variance will be implemented to test for differences in baseline values. A mixed model then will be applied for each dependent variable. In case of non-normal data distribution, a Kruskal-Wallis test will be implemented to test for differences in baseline values. Next, the Friedman test will be used to analyze repeated measures. Within- and between-group effect sizes will be calculated using Cohen's d for each outcome. Finally, the minimal clinically important difference will be analyzed with distribution-based methods.

DISCUSSION

To our knowledge, this will be the first trial to investigate BFR-RT in patients with cirrhosis and evaluate the effects on neuromuscular parameters, functional performance, disease severity, and quality of life outcomes.

TRIAL REGISTRATION

Brazilian Clinical Trials Registry (ReBec): RBR-395mfw. Registered on 25 August 2018.

Epidemiological trend of hepatitis C-related liver events in Spain (2000-2015): A nationwide population-based study

OBJECTIVE

Analysis the epidemiological trends of hospital admissions, intra-hospital deaths, and costs related to chronic hepatitis C (CHC) taking into account four major clinical stages [compensated cirrhosis (CC), end-stage liver disease (ESLD), hepatocellular carcinoma (HCC), and liver transplantation (LT)] in Spain.

METHODS

Retrospective study in patients with chronic hepatitis C and a hospital admission in the Spanish Minimum Basic Data Set from 2000 to 2015. Outcome variables were admission, death, length of hospital stay and costs.

RESULTS

A total of 868,523 hospital admissions with CHC (25.5% CC, 25.3% ESLD, 8.6% HCC, and 2.5% LT) were identified. Overall rates of admission and mortality increased from 2000-2003 to 2004-2007, but after 2008, these rates stabilized and/or decreased. An upward trend was found for hospitalization percentage in CC (from 22.3% to 30%; p < 0.001), ESLD (from 23.9% to 27.1%; p < 0.001), HCC (from 7.4% to 11%; p < 0.001), and LT (from 0.07% to 0.10%; p = 0.003). An upward trend was also found for case fatality rate, except in ESLD (p = 0.944). Gender and age influenced the evolution of hospitalization rates and mortality differently. The length of hospital stay showed a significant downward trend in all strata analyzed (p < 0.001). Cost per patient had a significant upward trend (p < 0.001), except in LT, and a decrease from 2008-2011 to 2012-2015 in CC (p = 0.025), HCC (p < 0.001), and LT (p = 0.050) was found.

CONCLUSION

The initial upward trend of the disease burden in CHC has changed from 2000 to 2015 in Spain, improving in many parameters after 2004-2007, particularly in the 2012-2015 calendar period.

Magnesium Therapy Improves Rotational Thromboelastometry Findings Prior to Liver Transplantation: A Randomized Clinical Trial

An important challenge during orthotopic liver transplantation (OLT) is optimal coagulation management. There are diverse studies regarding effect of Mg sulfate on coagulation system. This study evaluates the impact of Mg sulfate on the coagulation parameters of the rotational thromboelastometry (ROTEM) in patients about to undergo OLT. In this randomized clinical trial, 60 patients who were going to undergo OLT were randomly allocated into two groups. In the Mg group, the patients received a 1.5 g infusion of Mg 5 min before the surgical incision. In the control group, patients received a physiological saline instead of Mg. Plasma Mg levels before and after the infusions were measured in both groups. Also, three ROTEM tests: EXTEM, INTEM and FIBTEM were performed before and after the infusions. Baseline mean plasma magnesium levels were within normal range in the control and Mg groups: 2.06 and 2.18 mg/dl, respectively. After magnesium therapy, the mean plasma Mg level in the Mg group increased to 2.78 mg/dl in compared to the control group that was 2.01 mg/dl (P < 0.000). Mean value of the clotting time (CT) in the magnesium group were significantly decreased from 129.50 ± 7.76, 381.86 ± 8.51 and 114.26 ± 6.80 to 86.13 ± 3.4, 209.33 ± 6.68 and 81.56 ± 5.01 in the EXTEM, INTEM, and FIBTEM respectively after intervention in the Mg group (P = 0.001). Among patients with end-stage liver diseases who have ROTEM evidence of hypocoagulability, magnesium could correct CT parameter of the ROTEM tests.

Curcumin ameliorates health-related quality of life in patients with liver cirrhosis: A randomized, double-blind placebo-controlled trial

OBJECTIVES

Current study aimed to find the effects of curcumin on quality of life (QoL) in liver cirrhotic patients.

DESIGN

In this randomized double-masked placebo-controlled trial, 70 cases with liver cirrhosis aged 20-70 years were randomly divided into two groups to receive 1000 mg/day curcumin (n = 35) or placebo (n = 35) for 12 weeks. The health-related QoL (HRQoL) was assessed by CLDQ, LDSI 2.0, and SF-36.

RESULTS

Fifty-eight patients (28 in curcumin and 30 in placebo groups) finished the research. Compared with baseline, overall scores as well as most of CLDQ domains (e.g. Fatigue, Emotional Function, Worry, Abdominal Symptoms, and Systemic Symptoms) and the Physical and Mental health (Total) scores and most of SF-36 domains (e.g. Physical Functioning, Bodily Pain, Vitality, Social Functioning, and Mental Health) increased considerably (P < 0.05) after curcumin administration. Furthermore, curcumin reduced most of LDSI 2.0 domains (e.g. Itch, Joint pain, Pain in the right upper abdomen, Sleeping during the day, Decreased appetite, Depression, Fear of complication, Jaundice, Hindrance in Financial Affairs, Change in use of time, Decreased sexual interest, and Decreased sexual activity) significantly (P < 0.05). Significant differences were noticed between two groups in CLDQ domains and overall scores, LDSI 2.0 domains and overall scores, SF-36 Physical and Mental health (total) scores and all its domains scores (P < 0.05), adjusting for baseline values and disease duration.

CONCLUSIONS

Curcumin improved QoL in liver cirrhotic patients according to CLDQ, LDSI 2.0, and SF-36 domains. Additional studies are warranted to consider curcumin as a safe, accessible, and low-cost complementary therapeutic option in cirrhosis.

Dual graft living donor liver transplantation - a case report

Background

Living donor liver transplantation (LDLT) has emerged as an equally viable option to deceased donor liver transplant for treating end stage liver disease patients. Optimising the recipient outcome without compromising donor safety is the primary goal of LDLT. Achieving the adequate graft to recipient weight ratio (GRWR) is important to prevent small for size syndrome which is an uncommon but potentially lethal complication of LDLT.

Case presentation

Here we describe a case of successful dual lobe liver transplant for a 32 years old patient with ethanol related end stage liver disease. A right lobe graft without middle hepatic vein and another left lateral sector graft were transplanted successfully. Recipient and both donors recovered uneventfully.

Conclusion

Dual lobe liver transplant is a feasible strategy to achieve adequate GRWR without compromising donor safety.

Hepatitis C virus cure with direct acting antivirals: Clinical, economic, societal and patient value for China

About 10 million people in China are infected with hepatitis C virus (HCV), with the seroprevalence of anti-HCV in the general population estimated at 0.6%. Delaying effective treatment of chronic hepatitis C (CHC) is associated with liver disease progression, cirrhosis, hepatocellular carcinoma, and liver-related mortality. The extrahepatic manifestations of CHC further add to the disease burden of patients. Managing CHC-related advanced liver diseases and systemic manifestations are costly for both the healthcare system and society. Loss of work productivity due to reduced well-being and quality of life in CHC patients further compounds the economic burden of the disease. Traditionally, pegylated-interferon plus ribavirin (PR) was the standard of care. However, a substantial number of patients are ineligible for PR treatment, and only 40%-75% achieved sustained virologic response. Furthermore, PR is associated with impairment of patient-reported outcomes (PROs), high rates of adverse events, and poor adherence. With the advent of direct acting antivirals (DAAs), the treatment of CHC patients has been revolutionized. DAAs have broader eligible patient populations, higher efficacy, better PRO profiles, fewer adverse events, and better adherence rates, thereby making it possible to cure a large proportion of all CHC patients. This article aims to provide a comprehensive evaluation on the value of effective, curative hepatitis C treatment from the clinical, economic, societal, and patient experience perspectives, with a focus on recent data from China, supplemented with other Asian and international experiences where China data are not available.

[Anesthesiological aspects of liver transplantation]

Liver transplantation (LTPL) is the only curative option for patients with end stage liver disease (ESLD) or with hepatocellular carcinoma (HCC). Eurotransplant in Leiden, the Netherlands, is responsible for organ allocation. The model of end stage liver disease (MELD) score, which describes the severity of the liver disease, is decisive for organ allocation. The heterogeneous patient collective and hepatic-related comorbidities and their dynamics represent challenges. The anesthesiologist is responsible for evaluating the overall prognosis, whereby cardiac, pulmonary, renal and neurological comorbidities must be taken into consideration. During LTPL surgery is divided into several stages. Besides volume management, heat preservation and coagulation management, major challenges for the anesthesiologist are hemodynamic stabilization and regulation of the acid-base balance.

Nonalcoholic fatty liver disease prevalence in an Italian cohort of patients with hidradenitis suppurativa: A multi-center retrospective analysis

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) includes two distinct conditions, with different histologic features and prognosis: non-alcoholic fatty liver (NAFL) and non-alcoholic steatohepatitis (NASH). Furthermore, NASH is the more aggressive necro-inflammatory form, which may accumulate fibrosis and result in End stage liver disease (ESLD). NAFLD is also linked to systemic inflammatory conditions such as psoriasis. NAFLD is currently the most common cause of ESLD in Western countries, becoming a serious public health concern. Hidradenitis suppurativa (HS) is a systemic inflammatory/autoinflammatory disease of the terminal follicular epithelium of the apocrine gland with a prevalence of 0.05% to 4.10%. Due to its systemic inflammatory behavior several comorbidities were recently associated, however liver ones were scarcely assessed.

AIM

To evaluate the prevalence and characteristics of NASH/NAFL in HS patients.

METHODS

This retrospective study is a sub-analysis of a larger study carried out in 4 Italian dermatological centers. In this cohort, there were 83 patients: 51 patients with HS only, 20 patients with HS/NAFL and 12 with HS/NASH.

RESULTS

Inflammatory comorbidities were present in 3.9% of HS only patients, 25% of HS/NAFL patients and 58.3% of HS/NASH patients (P < 0.001). Similarly, mean Autoinflammatory Disease Damage Index (ADDI) was significantly higher among patients with HS/NASH (5.3 ± 2.2, P < 0.001) compared to patients with HS/NAFL or HS only (2.8 ± 1.6 and 2.6 ± 1.4 respectively). Furthermore, ADDI correlates with IHS4 in HS, HS/NAFL and HS/NASH. Diabetic patients have higher Hurley score than not diabetic ones. Ultrasound examination was significantly different in the three groups.

CONCLUSION

HS patients displayed a high prevalence of NASH/NAFLD and ultrasound examination should be particularly addressed to patients that display high ADDI scores.

Patterns of palliative care utilization among patients with end stage liver disease during end-of-life hospitalizations: A population-level analysis

PURPOSE

To investigate the patterns and predictors of palliative care (PC) utilization across ICU- and non ICU-managed patients with end-stage liver disease (ESLD) during end-of-life hospitalization.

MATERIALS AND METHODS

The Texas Inpatient Public Use Data File was used to perform a retrospective, population-based cohort study of patients with ESLD and end-of-life hospitalization during 2005-2014. PC use among ICU- and non ICU-managed patients was examined. Logistic regression modeling was used to identify predictors of PC.

RESULTS

We studied 30,301 patients, of which 5484 (18.1%) had reported PC and 24,174 (79.8%) were admitted to ICU. Between 2005 and 2014 PC use among ICU- and non ICU-managed patients increased from 0.5% to 32.9% and 7.1% to 47.0%, respectively, while ICU admission rate rose from 76.5% to 82.9%. PC use was reduced with rising APR-DRG illness severity (adjusted odds ratio, "extreme" vs. "minor" 0.36 [95% confidence interval, 0.24-0.54]), ICU admission (0.60 [0.55-0.65]), and use of mechanical ventilation (0.75 [0.70-0.81]).

CONCLUSIONS

There was persistent gap in use of PC among ICU-managed patients with ESLD during end-of-life hospitalization. ICU utilization rose, unexpectedly, despite the increasing use of PC in this cohort, and PC utilization was, paradoxically, lower among patients with the highest need.

Frequency of gallstones and mean BMI in decompensated cirrhosis

Introduction

The aim of the study was to determine the frequency of gallstones in patients with decompensated cirrhosis and to know about mean Body mass index (BMI) in patients of decompensated cirrhosis i.e End stage liver disease (ESLD) with and without gallstones.

Methods

it is a cross sectional descriptive study, conducted at the department of Hepato-gastroenterology, Sindh Institute of Urology and Transplantation (SIUT), Karachi from 1^st August 2014 to 28 February 2015. Two hundred patients were enrolled from outpatient clinics of Hepato-gastroenterology that fulfilled the defined selection criteria. Questionnaire was filled for data collection. SPSS version 20.0 was used to analyze data. Mean value of age and BMI was calculated by mean ± S.D. values. Mean ± SD was also calculated for BMI in patients with and without gallstones. Stratification of the age, gender, and liver disease severity were done and chi-Square test was applied. p-values less than 0.05 considered statistically significant.

Results

Two hundred consecutive patients were enrolled among them 112(56%) were male. Mean age was 46.89 ± 11.9, BMI 23.59 ± 4.7 and CTP score was 9.7 ± 1.9. Most of the patient had Child class 'B' cirrhosis 102(51%), most common etiology was found to be Hepatitis C 133 (66.5%), cholelithiasis was found in 59(29.5%), sludge in 36 (18%) and both stone and sludge in 24(12%) of the cases. Advanced liver disease that is, more CTP score and child class 'C' was associated with increased frequency of gall stone formation (p-value = 0.012), and advancing age on age stratification (p-value = 0.024) however no relation was observed with increase BMI, gender, ethnicity, cause or duration of disease in this population.

Conclusion

Gallstone formation is associated with advanced stage of cirrhosis and hepatitis C Virus related CLD, contrary to the established risk factors, no relation of gender or BMI was found in decompensated liver disease.

Physical exercise in cirrhotic patients: Towards prehabilitation on waiting list for liver transplantation. A systematic review and meta-analysis

BACKGROUND

Early survival after Liver Transplantation (LT) is reduced among sarcopenic patients. Despite, Adapted Physical Activity (APA) before LT is rarely proposed for the risk to impair portal hypertension and its resulting complications.

OBJECTIVES

To assess the effects of APA program in adults affected by End Stage Liver Disease (ESLD) on hospital stay, 1-year mortality and morbidity after LT, adverse events (Primary outcomes). Secondary outcomes were changes in VO2 peak, muscle morphology, 6minutes walking distance test (6MWD), Body Mass Index (BMI), MELD, CHILD score and Hepatic Venous Pressure Gradient (HVPG).

SEARCH METHODS

MEDLINE, EMBASE, Google Scholar and the Cochrane Library database were explored for randomized clinical trials (RCT).

DATA COLLECTION AND ANALYSIS

Data were collected by one review author on the type of study, participants, treatments used for primary and secondary outcomes. Review Manager 5.2 was used for the analysis.

MAIN RESULTS

Four RCT with 81 patients were included. Primary outcomes: no severe adverse event was observed, but no published data were available on hospital stay or mortality after LT.

SECONDARY OUTCOMES

CHILD, MELD and BMI were not worsened by physical activity. No significant muscle diameter, 6MWD and VO2 peak changes were observed after exercise. Significant reduction in HVPG in the treatment group was observed in a single study (MD-2.5mmHg; 95%CI [-04.76, -0.24]; P=0.03).

AUTHORS' CONCLUSIONS

Knowledge in this field is still at an early stage. Evidence derived from small trials of medium quality on ESLD patients suggests that APA is safe, without increasing portal hypertension. Further research is very likely to have an important impact on our confidence in the intervention effect.

Treatment of Elderly Patients with Chronic Hepatitis C: A Retrospective Cohort Study

SUMMARY – The prevalence of chronic hepatitis C increases in elderly patients. The aims of this study were to identify the factors associated with hepatocellular carcinoma (HCC) and end-stage liver disease development and to evaluate the efficacy and safety of pegylated interferon (PEG-IFNα) plus ribavirin (RBV) therapy in elderly patients. A retrospective cohort study included all consecutive patients with hepatitis C virus (HCV) infection treated with PEG-IFNα+RBV between 2003 and 2013. Elderly patients had a higher frequency of poor prognostic factors including genotype 1 infection, high fibrosis, and high fibrosis index based on four factors (FIB-4) score. The sustained virologic response (SVR) rate for genotype 1 was significantly lower (35.8% vs. 57.1%), while the frequency of PEG-IFNα (27.2% vs. 7.8%), RBV dose reduction (19.6% vs. 9.7%) and treatment discontinuation (13.0% vs. 4.1%) was significantly higher in elderly patients. However, age was not associated with SVR in multivariate analysis, and comparable SVR rates were achieved when adjusted for fibrosis score (Ishak ≤3: 66.7% vs. 69.8%). During the follow-up, HCC was diagnosed in 18 elderly patients (3 SVR+, 4 SVR- and 9 untreated patients). In conclusion, selected elderly patients can achieve comparable SVR rates as younger patients, but with a higher rate of side effects. Since complications of HCV infection occur more frequently in elderly patients, they should be given priority for antiviral therapy.

Anesthesia for Liver Transplantation

The provision of anesthesia for a liver transplant program requires a dedicated team of anesthesiologists. Liver transplant anesthesiologists must have an understanding of liver physiology and anatomy; the spectrum of clinical disease associated with liver dysfunction; the impact of warm and cold ischemia times, surgical techniques in liver transplantation, and the impact of ischemia-reperfusion syndrome; and optimal practices to protect the liver. The team must provide a 24-hour service, be actively involved in the selection committee process, and stay current with advances in the subspecialty.

Performance of Disease-Specific Scoring Models in Intensive Care Patients with Severe Liver Diseases

INTRODUCTION

Egypt has the highest prevalence of Hepatitis C Virus (HCV) in the world, estimated nationally at 14.7%. HCV treatment consumes 20% ($80 million) of Egypt's annual health budget. Outcomes of cirrhotic patients admitted to the ICU may, in fact, largely depend on differences in the state of the disease, criteria and indications for admission, resource utilization, and intensity of treatment.

AIM

The aim of the present study was to evaluate the efficacy of liver specific scoring models in predicting the outcome of critically ill cirrhotic patients in the ICU as it may help in prioritization of high risk patients and preservation of ICU resources.

MATERIALS AND METHODS

Over one year, a total of 777 patients with End Stage Liver Disease (ESLD) due to HCV infection were included in this retrospective non-randomized human study. All statistical analyses were performed by the statistical software SPSS version 22.0 (SPSS, Chicago, IL, USA). Child Turcotte Pugh (CTP) score, MELD score, MELD-Na, MESO, iMELD, Refit MELD and Refit MELD-Na were calculated on ICU admission.

RESULTS

ICU admission was mainly due to Gastrointestinal (GI) bleeding and Hepatic Encephalopathy (HE). Overall mortality was 27%. Age and sex showed no statistical difference between survivors and non survivors. Significantly higher mean values were observed for all models among individuals who died compared to survivors. MELD-Na was the most specific compared to the other scores. MELD-Na was highly predictive of mortality at an optimized cut-off value of 20.4 (AURC=0.789±0.03-CI 95%=0.711-0.865) while original MELD was highly predictive of mortality at an optimized cut-off value of 17.4 (AURC=0.678±0.01-CI 95%=0.613-0.682) denoting the importance of adding serum sodium to the original MELD. INR, serum creatinine, bilirubin, white blood cells count and hyponatremia were significantly higher in non survivors compared to survivors, while hypoalbuminemia showed no statistical difference. The advent of Hepatorenal Syndrome (HRS) and Spontaneous Bacterial Peritonitis (SBP) carried worse prognosis. Hyponatremia and number of transfused blood bags were additional independent predictors of mortality.

CONCLUSION

In cirrhosis of liver, due to HCV infection, patients who died during their ICU stay displayed significantly higher values on all prognostic scores at admission. The addition of sodium to MELD score greatly improves the predictive accuracy of mortality. MELD-Na showed the highest predictive value of all scores.

Life-sustaining treatment and palliative care in patients with liver cirrhosis - legal, ethical, and practical issues

With the enactment of the ‘Act on Decisions on Life-Sustaining Treatment for Patients in Hospice and Palliative Care or at the End of Life’ (Act No. 14013) in Korea, there is growing concern about the practicality of this law. In this review, we discuss definitions, ethics, and practical issues related to this law.

Markers of bacterial translocation in end-stage liver disease

Bacterial translocation (BT) refers to the passage of viable bacteria or bacterial products from the intestinal lumen, through the intestinal epithelium, into the systemic circulation and extraintestinal locations. The three principal mechanisms that are thought to be involved in BT include bacterial overgrowth, disruption of the gut mucosal barrier and an impaired host defence. BT is commonly observed in liver cirrhosis and has been shown to play an important role in the pathogenesis of the complications of end stage liver disease, including infections as well as hepatic encephalopathy and hepatorenal syndrome. Due to the importance of BT in the natural history of cirrhosis, there is intense interest for the discovery of biomarkers of BT. To date, several such candidates have been proposed, which include bacterial DNA, soluble CD14, lipopolysaccharides endotoxin, lipopolysaccharide-binding protein, calprotectin and procalcitonin. Studies on the association of these markers with BT have demonstrated not only promising data but, oftentimes, contradictory results. As a consequence, currently, there is no optimal marker that may be used in clinical practice as a surrogate for the presence of BT.

“Weighing the risk”: Obesity and outcomes following liver transplantation

Obesity is on the rise worldwide. As a result, unprecedented rates of patients are presenting with end stage liver disease in the setting of non-alcoholic fatty liver disease (NAFLD) and are requiring liver transplantation. There are significant concerns that the risk factors associated with obesity and the metabolic syndrome might have a detrimental effect on the long term outcomes following liver transplantation. In general, short term patient and graft outcomes for both obese and morbidly obese patients are comparable with that of non-obese patients, however, several studies report an increase in peri-operative morbidity and increased length of stay. Continued studies documenting the long-term outcomes from liver transplantation are needed to further examine the risk of recurrent disease (NAFLD) and also further define the role risk factors such cardiovascular disease might play long term. Effective weight reduction in the post liver transplant setting may mitigate the risks associated with the metabolic syndrome long-term.

Use of non-selective beta blockers in cirrhosis: The evidence we need before closing (or not) the window

Non selective beta blockers (NSBBs) are used in primary and secondary prophylaxis of portal hypertension-related bleeding in patients with cirrhosis. The efficacy of NSBBs treatment is predicted by hemodynamic response in term of reduction of the hepatic venous pressure gradient (HVPG) below 12 mmHg or at least 20% of the basal value. Nevertheless a relevant number of patients who do not achieve this HVPG reduction during NSBBs therapy do not bleed during follow up; this evidence suggests an additional non-hemodynamic advantage of NSBBs treatment to modify the natural history of cirrhosis. Recent studies have questioned the efficacy and safety of NSBBs in patients with advanced stage of liver disease characterized by refractory ascites and/or spontaneous bacterial peritonitis. These studies have suggested the existence of a defined and limited period to modify the natural history of cirrhosis by NSBBs: the “window hypothesis”. According with this hypothesis, patients with cirrhosis benefit from the use of NSBBs from the appearance of varices up to the development of an advanced stage of cirrhosis. Indeed, in patients with refractory ascites and/or spontaneous bacterial peritonitis the hemodynamic effects of NSBBs may expose to a high risk of further complications such as renal insufficiency and/or death. Methodological concerns and contrasting results counterbalance the evidence produced up to now on this issue and are the main topic of this editorial.

Retrospective cohort study of liver transplantation in the United Kingdom between 1994 and 2010: the impact of hepatitis C infection

BACKGROUND

Liver transplantation is an important and established treatment option for chronic hepatitis C virus (HCV) related end-stage liver disease (HCV-related ESLD). This study describes trends in elective liver transplantation among persons with HCV-related ESLD.

STUDY DESIGN

Retrospective cohort.

METHODS

Analyses of United Kingdom (UK) Transplant Registry data for the period 1994 to 2010, with follow-up information extending to 2011.

RESULTS

Annual registrations for liver transplantation increased linearly and alcoholic liver cirrhosis (2075, 24%) and HCV-related ESLD (1213, 14%) were the most common indications. HCV-related ESLD patients were mainly aged 40-49 years (32%) and 50-59 years (43%); males (76%); and of white ethnicity (74%). Overall, 75% (956/1213) received a liver transplant with a linear increase over the period (OR 1.11, 95% CI 1.08, 1.13). Pre transplant mortality was unchanged (adjusted OR 1.0, 95% CI 0.96, 1.05) and post-transplant mortality decreased in both HCV-related (adjusted OR 0.77, 95% CI 0.68, 0.88) and non-HCV-related ESLD (adjusted OR 0.82, 95% CI 0.75, 0.89) patients.

CONCLUSION

The increase in demand for and receipt of liver transplants among persons with HCV-related ESLD requires coordinated efforts to increase not only organ donation, but investment in HCV prevention programmes and improved access to hepatitis C treatment services.

Epistaxis in end stage liver disease masquerading as severe upper gastrointestinal hemorrhage

AIM: To describe the prevalence, diagnosis, treatment, and outcomes of end stage liver disease (ESLD) patients with severe epistaxis thought to be severe upper gastrointestinal hemorrhage (UGIH).

METHODS: This observational single center study included all consecutive patients with ESLD and epistaxis identified from consecutive subjects hospitalized with suspected UGIH and prospectively enrolled in our databases of severe UGIH between 1998 and 2011.

RESULTS: A total of 1249 patients were registered for severe UGIH in the data basis, 461 (36.9%) were cirrhotics. Epistaxis rather than UGIH was the bleeding source in 20 patients. All patients had severe coagulopathy. Epistaxis was initially controlled in all cases. Fifteen (75%) subjects required posterior nasal packing and 2 (10%) embolization in addition to correction of coagulopathy. Five (25%) patients died in the hospital, 12 (60%) received orthotopic liver transplantation (OLT), and 3 (15%) were discharged without OLT. The mortality rate was 63% in patients without OLT.

CONCLUSION: Severe epistaxis in patients with ESLD is (1) a diagnosis of exclusion that requires upper endoscopy to exclude severe UGIH; and (2) associated with a high mortality rate in patients not receiving OLT.

Bone marrow derived stem cells for the treatment of end-stage liver disease

End-stage disease due to liver cirrhosis is an important cause of death worldwide. Cirrhosis results from progressive, extensive fibrosis and impaired hepatocyte regeneration. The only curative treatment is liver transplantation, but due to the several limitations of this procedure, the interest in alternative therapeutic strategies is increasing. In particular, the potential of bone marrow stem cell (BMSC) therapy in cirrhosis has been explored in different trials. In this article, we evaluate the results of 18 prospective clinical trials, and we provide a descriptive overview of recent advances in the research on hepatic regenerative medicine. The main message from the currently available data in the literature is that BMSC therapy is extremely promising in the context of liver cirrhosis. However, its application should be further explored in randomized, controlled trials with large cohorts and long follow-ups.

Portopulmonary hypertension and hepatopulmonary syndrome

Portopulmonary hypertension (POPH) and hepatopulmonary syndrome (HPS) are two frequent complications of liver disease, with prevalence among liver transplant candidates of 6% and 10%, respectively. Both conditions result from a lack of hepatic clearance of vasoactive substances produced in the splanchnic territory. Subsequently, these substances cause mainly pulmonary vascular remodeling and some degree of vasoconstriction in POPH with resulting elevated pulmonary pressure and right ventricular dysfunction. In HPS the vasoactive mediators cause intrapulmonary shunts with hypoxemia. Medical treatment is disappointing overall. Whereas liver transplantation (LT) results in the disappearance of HPS within six to twelve months, its effect on POPH is highly unpredictable. Modern strategies in managing HPS and POPH rely on a thorough screening and grading of the disease’s severity, in order to tailor the appropriate therapy and select only the patients who will benefit from LT. The anesthesiologist plays a central role in managing these high-risk patients. Indeed, the important hemodynamic and respiratory modifications of the perioperative period must be avoided through continuation of the preoperatively initiated drugs, appropriate intraoperative monitoring and proper hemodynamic and respiratory therapies.

Non-cirrhotic portal fibrosis related end stage liver disease in adults: evaluation from a study on living donor liver transplant recipients

BACKGROUND

That non-cirrhotic portal fibrosis (NCPF) can lead to end stage chronic liver disease (CLD) has been convincingly demonstrated only recently after the study of explant livers from clinically cirrhosis cases.

AIMS

This study attempted to determine the frequency of NCPF among adults transplanted for end stage CLD and to identify parameters for a pre-transplant diagnosis of NCPF.

METHODS

Several parameters were analyzed in three categories of cases: pure NCPF (n = 10), overlap NCPF (n = 10), and NAFLD cirrhosis controls (n = 44). Morphologic features of NCPF were looked for in explant livers of all these.

RESULTS

Explant livers in the pure NCPF group were non-cirrhotic and showed histologic features of NCPF. These features were also present in all cases of overlap NCPF in the background of established cirrhosis of other etiologies but absent in the NAFLD cirrhosis controls. Values of seven objective and two subjective parameters showed significant differences between pure NCPF and NAFLD control groups. Compared to NAFLD controls, the model for end stage liver disease (MELD) score, body mass index (BMI), bilirubin, albumin, aspartate amino transferase (AST), and international normalized ratio (INR) were significantly less, whereas variceal grade was higher in the pure NCPF group.

CONCLUSIONS

The study concludes that in our population, NCPF constitutes about 5% of the subset of end stage CLD considered eligible for liver transplantation (LT), presenting mostly as cryptogenic cirrhosis (CC). A diagnosis of NCPF should be considered when patients presumed to have cryptogenic or other cirrhosis become eligible for LT even in the presence of relatively well-preserved liver function and low MELD scores. End stage CLD manifests at earlier age, when cirrhosis of another etiology supervenes on pre-existent NCPF.

Prevalence of myocardial perfusion abnormalities in end-stage liver disease

BACKGROUND

The prevalence of coronary artery disease (CAD) in end-stage liver disease (ESLD) being evaluated for orthotopic liver transplantation (OLT) is unclear based on variable definition used for CAD.

OBJECTIVE

The aim of this study to investigate the prevalence of abnormal stress myocardial perfusion single-photon emission computed tomography (MPS) imaging, as a marker for CAD, among patients with ESLD who were referred for stress MPS imaging as a routine work up before OLT.

MATERIALS AND METHODS

This was a single-center, retrospective study. We reviewed data on 167 patients who were referred for MPS as a routine work up before OLT over the last 2 years. All patients underwent evaluation for CAD risk factors [age, hypercholesterolemia, diabetes mellitus (DM), hypertension (HTN), and smoking], and stress MPS as per standard protocol.

RESULTS

The total number of patients referred for stress MPS was 167. Seven patients (4% of total study population) were excluded from the study due to poor and/or nondiagnostic studies. 147 patients (92%) had normal, but only 13 patients (8%) had abnormal MPS scans. DM and male gender were the most independent risk factors for abnormal MPS with P value of 0.046, and 0.26, respectively. There was no significant association between the abnormal MPS result and HTN, hypercholesterolemia, smoking, age or etiology of the liver disease.

CONCLUSION

Based on our data, the prevalence of abnormal MPS and left ventricular ejection fraction in patients with ESLD was found to be 8%. DM and male gender were the most independent predictor factors for abnormal MPS. True prevalence of CAD and usefulness of MPS in patients with ESLD can only be studied using a very large and randomized prospective study.

Utility of Serum YKL-40 as a Tumor-Specific Marker of Hepatobiliary Malignancies

BACKGROUND/AIMS

Serum YKL-40 has been linked to several human cancers. We investigated the potential role of serum YKL-40 as a marker of hepatobiliary malignancies.

METHODS

Archived serum samples of patients undergoing liver transplantation evaluation at the Mayo Clinic Rochester were used to measure YKL-40 levels. Patients were divided into three groups: hepatocellular carcinoma (HCC), cholangiocarcinoma (CCA), and end-stage liver disease (ESLD) without malignancies. The Model for ESLD (MELD) score was used to quantify the severity of liver disease.

RESULTS

The median serum YKL-40 level was highest in the ESLD group at 296 ng/mL, compared to 259 ng/mL in the HCC group and 80 ng/mL in the CCA group (p<0.01). There was a significant correlation between the MELD score and serum YKL-40 level (r=0.50, p<0.01). In a multivariate analysis, there was no significant difference in serum YKL-40 level between ESLD and HCC. CCA was associated with lower YKL-40 levels, a finding that was attributable to a lower prevalence of cirrhosis.

CONCLUSIONS

The serum YKL-40 level has little utility as a cross-sectional screening tool for hepatobiliary malignancies, namely HCC and CCA. The role of YKL-40 as a surveillance marker in the follow-up of individual patients remains to be determined.

Stem cells for end stage liver disease: How far have we got?

End stage liver disease (ESLD) is a health problem worldwide. Liver transplantation is currently the only effective therapy, but its many drawbacks include a shortage of donors, operative damage, risk of rejection and in some cases recidivism of the pre-transplant disease. These factors account for the recent growing interest in regenerative medicine. Experiments have sought to identify an optimal source of stem cells, sufficient to generate large amounts of hepatocytes to be used in bioartificial livers or injected in vivo to repair the diseased organ. This update aims to give non-stem cell specialists an overview of the results obtained to date in this fascinating field of biomedical research.