Waiting times between examinations with intravascularly administered contrast media: a review of contrast media pharmacokinetics and updated ESUR Contrast Media Safety Committee guidelines

The pharmacokinetics of contrast media (CM) will determine how long safe waiting intervals between successive CT or MRI examinations should be. The Contrast Media Safety Committee has reviewed the data on pharmacokinetics of contrast media to suggest safe waiting intervals between successive contrast-enhanced imaging studies in relation to the renal function of the patient. CLINICAL RELEVANCE STATEMENT: Consider a waiting time between elective contrast-enhanced CT and (coronary) angiography with successive iodine-based contrast media administrations in patients with normal renal function (eGFR > 60 mL/min/1.73 m2) of optimally 12 h (near complete clearance of the previously administered iodine-based contrast media) and minimally 4 h (if clinical indication requires rapid follow-up). KEY POINTS: • Pharmacokinetics of contrast media will guide safe waiting times between successive administrations. • Safe waiting times increase with increasing renal insufficiency. • Iodine-based contrast media influence MRI signal intensities and gadolinium-based contrast agents influence CT attenuation.

Construction and validation of a prediction model for the risk of citrate accumulation in patients with hepatic insufficiency receiving continuous renal replacement therapy with citrate anticoagulation

BACKGROUND

To construct and validate a prediction model of the risk of citrate accumulation in patients with hepatic dysfunction receiving continuous renal replacement therapy with regional citrate anticoagulation (RCA-CRRT), which reduces the risk of citrate accumulation.

METHODS

All patients who received RCA-CRRT from 2021 to 2022 and were hospitalized in the First Affiliated Hospital of Zhejiang University were considered for study participation. Logistic regression analysis was used to identify the risk factors for citrate accumulation, based on which a nomogram model was constructed and validated in the validation group.

RESULTS

Six factors were finally identified, from which a nomogram was created to predict the risk of citrate accumulation. The area under the curve of the prediction model was 0.814 in the training group and 0.819 in the validation group, and the model showed acceptable agreement between the actual and predicted probabilities. Decision curve analysis also demonstrated that the model was clinically useful.

CONCLUSIONS

The model constructed from six factors reliably predicted the risk of citrate accumulation in patients with hepatic insufficiency who received RCA-CRRT.

Efficacy and safety of caspofungin for patients with hepatic insufficiency

Background

To observe the changes of hepatic function and efficacy of conventional dosage of caspofungin in the treatment of patients with different Child–Pugh scores.

Methods

In total, 200 patients (Child–Pugh A group: 66 patients, Child–Pugh B group: 83 patients, Child–Pugh C group: 51 patients) treated with caspofungin from May 2018 to March 2021 in the Second Affiliated Hospital of Chongqing Medical University were enrolled. Main investigation items were as follows: sex, age, weight, duration of treatment, dosage, department, underlying diseases, risk factors for fungal infection, albumin, liver enzyme, total bilirubin, serum creatinine, estimated glomerular filtration rate. To investigate the changes of liver, kidney function tests and efficacy during the treatments of caspofungin. Patients were divided into three groups according to the duration of treatment of caspofungin:1-week group, 2-week group and 3-week group, respectively.

Results

In the three groups, albumin, liver enzyme levels, total bilirubin and serum creatinine, estimated glomerular filtration rate had no significant difference (P > 0.05). The efficacy of different Child–Pugh scores and different duration of treatment was also significantly different (P > 0.05).

Conclusions

Caspofungin is well tolerated and highly effective. And it will not exacerbate the hepatic and renal function when administered with the not-reducing dose, which indicate the clinical application value of caspofungin. Besides, extending the treatment duration has little effect on improving the efficacy of caspofungin. The drug should be withdrawn timely according to the patients’ clinical condition in order to reduce the adverse reactions and economic burden.

Iron Overload and the Risk of Diabetes in the General Population: Results of the Chinese Health and Nutrition Survey Cohort Study

BACKGROUND

Recent studies have found that there are significant associations between body iron status and the development of diabetes. In the present study, we aimed to analyze the association among iron overload (IO), insulin resistance (IR), and diabetes in Chinese adults, and to explore the sex difference.

METHODS

Men and women (age >19 years) who participated in the Chinese Health and Nutrition Survey and did not have diabetes at baseline were followed between 2009 and 2015 (n=5,779). Over a mean of 6 years, 75 participants were diagnosed with incident diabetes. Logistic regression was used to assess the risk factors associated with IO. Cox proportional hazard regression was used to estimate the risk of incident diabetes and to determine whether the risk differed among subgroups. Causal mediation analysis (CMA) was used to explore the mechanism linking IO and diabetes.

RESULTS

According to sex-stratified multivariable-adjusted Cox proportional hazards regression, IO increased the risk of incident diabetes. Women with IO had a higher risk of diabetes than men. Subgroup analysis with respect to age showed that the association between IO and diabetes was stronger in older women and younger men (P<0.001). CMA showed that liver injury (alanine transaminase) and lipid metabolism abnormalities (triglyceride, apolipoprotein B) contributed to the association between IO and diabetes.

CONCLUSION

IO is associated with diabetes and this association is sex-specific. IO may indirectly induce IR via liver injury and lipid metabolism abnormalities, resulting in diabetes.

Clinical outcomes of patients with hepatic insufficiency undergoing transcatheter aortic valve implantation: a systematic review and meta-analysis

Background

Transcatheter aortic valve implantation (TAVI) is currently a common treatment in high-risk aortic stenosis patients, but the impact of hepatic insufficiency on prognosis after TAVI is debatable and whether TAVI is superior to surgical aortic valve replacement (SAVR) in patients with hepatic insufficiency is uncertain.

Objective

To investigate the effect of abnormal liver function on the outcome and safety after TAVI and whether TAVI is superior to SAVR in patients with hepatic insufficiency.

Methods

PubMed, Embase, the Cochrane Library and Web of Science were systematically searched from inception up to 26 November 2021. Studies were eligible if mortality and complications after TAVI in patients with and without hepatic insufficiency, or mortality and complications for TAVI versus SAVR in patients with hepatic insufficiency were reported. The Newcastle–Ottawa scale (NOS) was used to evaluate the quality of each study. This meta-analysis was registered with PROSPERO (CRD42021253423) and was carried out by using RevMan 5.3 and Stata 14.0.

Results

This meta-analysis of 21 studies assessed a total of 222,694 patients. Hepatic insufficiency was associated with higher short-term (in-hospital or 30-day) mortality [OR = 1.62, 95% CI (1.18 to 2.21), P = 0.003] and 1–2 years mortality [HR = 1.64, 95% CI (1.42 to 1.89), P < 0.00001] after TAVI. Between TAVI and SAVR in patients with hepatic insufficiency, there was a statistically significant difference in in-hospital mortality [OR = 0.46, 95% CI (0.27 to 0.81), P = 0.007], the occurrence rate of blood transfusions [OR = 0.29, 95% CI (0.22 to 0.38), P < 0.00001] and the occurrence rate of acute kidney injury [OR = 0.55, 95% CI (0.33 to 0.91), P = 0.02].

Conclusions

TAVI patients with hepatic insufficiency may have negative impact both on short-term (in-hospital or 30-day) and 1–2-years mortality. For patients with hepatic insufficiency, TAVI could be a better option than SAVR.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-022-02510-2.

Liver failure-future challenges and remaining questions

This review compiles the current state of controversial aspects of liver failure and outlines future challenges. The definition of acute liver failure (ALF) is widely accepted and implies no previous liver injury whereas the term "acute-on-chronic liver failure" remains contested. We will promote a concept, in which we differentiate three types of liver failure: ALF, acute-on-chronic liver failure (AOCLF) and acute-on-liver-cirrhosis (AOCi). The mechanistical insights into the coagulation system in patients with hepatic insufficiency have increased fundamentally in the past 10 years. Therefore, we follow now the concept of the so-called rebalanced hemostasis. This lower-level equilibrium arises from the fact that most coagulation factors and inhibitors are synthesized within the liver. We will demonstrate the advantage of viscoelastic test methods, which can assess the coagulation situation in patients with liver insufficiency much more precisely than conventional global coagulation tests. The therapeutic option of emergency liver transplantation (ELT) has significantly improved the prognosis of patients with ALF. However, limiting factors such as shortage of organs increase more and more the need for reliable prognostic markers. Due to a better understanding of the regenerative process during ALF new survival markers and prognostic tools have been emerging on the horizon in the last decade. Therefore, we will describe the current state of research in this field.

Clinical features and risk factors of COVID-19-associated liver injury and function: A retrospective analysis of 830 cases

INTRODUCTION AND OBJECTIVES

The incidence of liver injury (LI) in hospitalized COVID-19 patients ranged from 14% to 53% based on sole or multiple elevated indexes for LI. The aims of our study were to investigate the changes of parameters (ALT, AST) in LI and determine the risk factors for LI in a cohort of 830 COVID-19 patients.

METHODS

Demographic information, clinical features, and laboratory testing outcomes on admission were compared between patients with and without liver biochemistry abnormality (LBA). The same comparisons were performed between the LBA and LI groups. The updated RUCAM was used to determine the causality between drugs application and LI. Univariable and multivariable logistic regression analyses were used to explore the potential risk factors associated with LBA and LI.

RESULTS

A total of 227 (27.3%) patients exhibited LBA and 32 (3.9%) patients were categorized as having LI based on the diagnostic criteria. 32.6% (74/227) of the LBA patients had RUCAM score >3, whereas the non-LBA patients had a slight lower at rate of 24.2% (146/603) (P?=?0.047). Multivariable regression showed that a higher incidence of LBA was associated with hepatic hypoattenuation on computed tomography (CT) (odds ratio: 2.243, 95% confidence interval: 1.410-3.592, p?=?0.001), lymphocyte proportion <20% (2.088, 1.476-2.954, p?1?mg/dL (2.650, 1.845-3.806, p?1 (2.558, 1.820-3.596, p?

CONCLUSIONS

CRP levels >1.0?mg/dL, lymphocyte proportion <20%, AST/ALT ratio <1, and triglyceride levels >1.7?mol/L are potential risk factors for LI.

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Key Words

• Betacoronavirus
• Drug induced liver injury
• Hepatic insufficiency
• Pneumonia
• Tomography
• X-ray

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MESH Headings

• Adult
• Aged
• Alanine Transaminase/blood
• Aspartate Aminotransferases/blood
• Biomarkers/blood
• C-Reactive Protein/metabolism
• COVID-19/complications
• COVID-19/epidemiology
• Female
• Humans
• Liver/metabolism
• Liver Diseases/diagnosis
• Liver Diseases/etiology
• Liver Function Tests
• Male
• Middle Aged
• Pandemics
• Retrospective Studies
• SARS-CoV-2
• Tomography, X-Ray Computed

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Affiliation(s)

Faxiang Chen Department of Radiology, Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430014, China.
Wei Chen Department of Otolaryngology, Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430014, China.
Jianpu Chen Department of Radiology, Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430014, China.
Dan Xu Department of Gastroenterology, Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430014, China.
Wei Xie Department of Radiology, Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430014, China.
Xiang Wang Department of Radiology, Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430014, China.
Yuanliang Xie Department of Radiology, Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430014, China.

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Screening for impaired liver function as a risk factor for drug safety at hospital admission of surgical patients

Background Hepatic insufficiency can affect patient safety and should therefore be considered during drug therapy. Hospital admission offers an ideal point to screen for patients at risk and to adjust drug therapy accordingly. Objective To assess the number of patients admitted to hospital with clinically elevated liver parameters. To identify high-risk patients in need of potential drug therapy adjustment to liver function by calculation of liver scores. Finally, to investigate whether pre-hospital medication needed adjustment to liver function. Setting Patients admitted to surgical wards of a tertiary teaching hospital. Method Surgical patients were included in a 3-month retrospective study. A pharmacist-led screening process, including recording of elevated liver parameters and calculation of liver scores (Child-Pugh-score, Model of End-stage Liver Disase [MELD], MELDNa), was used to assess frequency of hepatic insufficiency and patients potentially needing medication adjustment. Additionally, pre-hospital medication was checked for contraindications and correct dosage with regard to liver function. Main outcome measure Percentage of surgical patients with clinically elevated liver parameters at admission, percentage of patients with hepatic insufficiency potentially needing drug therapy adjustment, and percentage of pre-hospital drug intakes not adjusted to liver function. Results Of 1200 patients, 130 (11%) had at least one clinically relevant elevated liver parameter at hospital admission. Of these, need for drug adjustment to liver function was found for 16-36%, depending on the liver score used (equivalent to 2-4% of all patients), with the highest number of patients detected by the MELD- and MELDNa-score. Pre-hospital medication concerned 719 drug intakes and was contraindicated in 2%, dosage not adjusted in 3%, and evaluation not possible in 44% of all drug intakes due to lack of information on the drug. Conclusion A significant proportion of patients admitted for surgery have clinically elevated liver parameters and potentially need medication adjustment. A pharmacist-led screening already at hospital admission can support the identification of patients with clinically relevant elevated liver parameters and patients at risk by calculating liver scores under routine conditions. Evaluation of drug adjustment to liver function is challenging, since no data are available in routine resources for a considerable number of drugs.

Fulminant liver failure following a marathon: Five case reports and review of literature

BACKGROUND

The growing popularity of marathon and half-marathon runs has led to an increased number of patients presenting with exertion-induced heat stroke. Mild hepatic involvement is often observed in these patients; however, fulminant liver failure may occur in approximately 5% of all cases. Liver transplantation is a potentially curative approach for exertion-induced liver failure, although there is a lack of consensus regarding the criteria and optimal timing of this intervention.

CASE SUMMARY

This paper describes 5 patients (4 men and 1 woman) who were referred to the department where this study was performed with the diagnosis of exertion-induced acute liver failure. Three patients underwent liver transplantation, 1 recovered spontaneously, and 1 patient died on day 11 following the exertion.

CONCLUSION

Exertion-induced heat stroke may present as fulminant liver failure. These patients may recover with conservative treatment, may require liver transplantation, or may die. No definitive criteria are available to determine patient suitability for a conservative vs surgical approach.

Risk factors for hepatic insufficiency after major hepatectomy in non-cirrhotic patients

BACKGROUND

Although recent advances in surgical techniques and perioperative management have reduced the morbidity and mortality after hepatectomy, hepatic insufficiency after major hepatectomy remains an important concern. This study aimed to clarify the risk factors for post-hepatectomy liver insufficiency.

METHODS

We enrolled 103 consecutive patients who underwent major hepatectomy which was defined as resection of four or more segments. Hepatic insufficiency is defined as an increase in serum total bilirubin after hepatectomy of 7 mg/dL or more, or death from multiple organ failure. We compared the patient disposition, demographics, perioperative factors such as surgical method, combined procedure, morbidity and so on between the patients with or without hepatic insufficiency.

RESULTS

Hepatic insufficiency occurred in 14 patients (14%) and six of them died during the hospital stay (6%). Risk factors by univariate analysis were the percentage of hepatic parenchyma to be resected (P = .025), combined procedure (P = .008) and postoperative morbidity excluding hepatic insufficiency (P < .001). A combined procedure (P = .036) and postoperative morbidity excluding hepatic insufficiency (P = .002) were a significant risk factor by multivariate analysis.

CONCLUSION

Unless remaining liver after hepatectomy has enough volume, combined procedure may account for hepatic insufficiency, which can follow the development of postoperative morbidity.

Prognostic Role of Liver Stiffness Measurements Using Magnetic Resonance Elastography in Patients with Compensated Chronic Liver Disease

PURPOSE

To retrospectively evaluate the prognostic role of liver stiffness (LS) measurement using magnetic resonance elastography (MRE) in patients with compensated chronic liver disease (cCLD).

METHODS

We enrolled 217 patients with cCLD who underwent MRE. After mean follow-up of 45.0 ± 17.6 months, cumulative incidence (CI) of hepatocellular carcinoma (HCC) occurrence, development of decompensation and overall survival (OS) were estimated using the Kaplan-Meier method. Prognostic factors were evaluated using the Cox proportional hazard regression model.

RESULTS

During the follow-up period, HCC occurred in 33 patients, and 1-, 3- and 5-year CIs of HCC occurrence were 3.8%, 14.8% and 18.9%, respectively. The LS value was a significant predictive factor for HCC occurrence [p < 0.001, hazard ratio (HR) = 1.59 per unit (1.25-2.03)]. Eighteen patients experienced hepatic decompensation, and 1-, 3- and 5-year CIs of decompensation were 2.8%, 7.3% and 11.3%, respectively. The LS value was also significantly associated with decompensation development [p < 0.001, HR = 2.02 per unit (1.37-2.98)]. Fourteen patients died, and 1-, 3- and 5-year OSs were 99.1%, 98.0% and 89.8%, respectively. The LS value was demonstrated to be a significant affecting factor for OS [p = 0.008, HR = 1.39 per unit (1.10-1.78)].

CONCLUSIONS

LS obtained from MRE was a significant predictive factor for the development of decompensation, HCC occurrence and OS in cCLD patients.

KEY POINTS

• Liver stiffness (LS) values obtained from MRE can provide prognostic information. • The LS value was a significant predictive factor for occurrence of hepatocellular carcinoma. • The LS value was significantly associated with development of hepatic decompensation. • Survival of compensated chronic liver disease patients was affected by the LS value.

Portal vein embolization with n-butyl-cyanoacrylate through an ipsilateral approach before major hepatectomy: single center analysis of 50 consecutive patients

Purpose

To evaluate the efficacy of portal vein embolization (PVE) with n-Butyl-cyanoacrylate (NBCA) through an ipsilateral approach before major hepatectomy. Secondary end-points were PVE safety, liver resection and patient outcome.

Methods

Over a 5-year period 50 non-cirrhotic consecutive patients were included with primary or secondary liver cancer treatable by hepatectomy with a liver remnant (FLR) volume less than 25% or less than 40% in diseased livers.

Results

There were 37 men and 13 women with a mean age of 57 years. Colorectal liver metastases were the most frequent tumor and patients were previously exposed to chemotherapy. FLR increased from 422 ml to 629 ml (P < 0.001) after PVE, corresponding to anincrease of 52%. The FLR ratio increased from 29.6% to 42.3% (P < 0.001). Kinetic growth rate was 2.98%/week. A negative association was observed between increase in the FLR and FLR ratio and FLR volume before PVE (P = 0.002). In 31 patients hepatectomy was accomplished and only one patient presented with liver insufficiency within 30 days after surgery.

Conclusions

PVE with NBCA through an ipsilateral puncture is effective before major hepatectomy. Meticulous attention is needed especially near the end of the embolization procedure to avoid complications.

Trial registration

Clinical Study ISRCTN registration number: ISRCTN39855523. Registered March 13th 2017.

Biopsy-proven progressive fatty liver disease nine months post mini-gastric bypass surgery: A case study

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Performance of MGB with a 200 cm bypassed limb in a morbidly obese female.

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Presentation of anemia, low albumin, elevated LFT at 8th month despite good intake.

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NAFLD activity score progressed from 2/8 to 7/8, leading to revisional surgery.

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Rapid course of weight loss after BS and/or long bypassed limb could be responsible.

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Bowel length measurement is recommended to avoid a short common intestinal channel.

Introduction

Mini-gastric bypass (MGB) is a popular bariatric procedure. Its effect on non-alcoholic fatty liver disease (NAFLD), however, has not yet been comprehensively studied.

Presentation of case

A 57 year-old non-alcoholic female with a body mass index of 42.8 kg/m² underwent MGB without any incident. A concurrent liver biopsy showed an NAFLD activity score (NAS) of 2/8 without fibrosis. She presented at postoperative month eight with edema, vague abdominal pain, nausea, and vomiting and was hospitalized. Her BMI had dropped to 25.7 kg/m². Her blood workup revealed mild anemia, mildly elevated liver enzymes, and hypoalbuminemia (2.5 g/dL). Liver ultrasound revealed grade-2 fatty liver. She received parenteral nutrition and intensive nutrient supplementation. Nevertheless, with regard to unsuccessful supportive measures and rising liver enzymes, revisional surgery −gastrogastrostomy- was performed. Her liver biopsy demonstrated a NAS of 7/8 at the time of revisional surgery. Her postoperative course was uneventful and she was discharged after one week.

Discussion

Bariatric surgery has shown favorable results regarding improvement of NAFLD in morbid obesity. This beneficial effect has been linked to the amount of weight loss. However, case reports have shown deteriorating liver function and NAFLD even after significant weight loss. They all have in common significant weight loss in a relatively short period of time. There may also be a connection between specific bariatric surgery procedures and this phenomenon.

Conclusion

Future studies comparing the effect of various bariatric procedures, including MGB, are necessary to help clinicians decide the optimal procedure for patients with this liver condition.

Infusion of mesenchymal stromal cells after deceased liver transplantation: A phase I-II, open-label, clinical study

BACKGROUND & AIMS

Mesenchymal stromal cell (MSC) infusion could be a means to establish tolerance in solid organ recipients. The aim of this prospective, controlled, phase I study was to evaluate the feasibility, safety and tolerability of a single infusion of MSCs in liver transplant recipients.

METHODS

Ten liver transplant recipients under standard immunosuppression received 1.5-3×10⁶/kg third-party unrelated MSCs on postoperative day 3±2, and were prospectively compared to a control group of ten liver transplant recipients. As primary endpoints, MSC infusion toxicity was evaluated, and infectious and cancerous complications were prospectively recorded until month 12 in both groups. As secondary endpoints, rejection rate, month-6 graft biopsies, and peripheral blood lymphocyte phenotyping were compared. Progressive immunosuppression weaning was attempted from month 6 to 12 in MSC recipients.

RESULTS

No variation in vital parameters or cytokine release syndrome could be detected during and after MSC infusion. No patient developed impairment of organ functions (including liver graft function) following MSC infusion. No increased rate of opportunistic infection or de novo cancer was detected. As secondary endpoints, there was no difference in overall rates of rejection or graft survival. Month-6 biopsies did not demonstrate a difference between groups in the evaluation of rejection according to the Banff criteria, in the fibrosis score or in immunohistochemistry (including Tregs). No difference in peripheral blood lymphocyte typing could be detected. The immunosuppression weaning in MSC recipients was not successful.

CONCLUSIONS

No side effect of MSC infusion at day 3 after liver transplant could be detected, but this infusion did not promote tolerance. This study opens the way for further MSC or Treg-based trials in liver transplant recipients.

LAY SUMMARY

Therapy with mesenchymal stromal cells (MSCs) has been proposed as a means to improve results of solid organ transplantation. One of the potential MSC role could be to induce tolerance after liver transplantation, i.e. allowing the cessation of several medications with severe side effects. This study is the first-in-man use of MSC therapy in ten liver transplant recipients. This study did not show toxicity after a single MSC infusion but it was not sufficient to allow withdrawal of immunosuppression.

CLINICAL TRIAL REGISTRATION NUMBER

Eudract: # 2011-001822-81, ClinicalTrials.gov: # NCT 01429038.

Cirrhotic Cardiomyopathy: Another Case of a Successful Approach to Treatment of Hepatorenal Syndrome

Hepatorenal syndrome (HRS) is defined as a failure of renal function, potentially reversible, in patients with liver cirrhosis and ascites. Recently, a component of cardiomyopathy associated with HRS was described, but the use of positive inotropic medicine as part of the treatment of the acute phase has not been extensively evaluated. We report a second case in our hospital of a patient with HRS type I without previous heart disease, with secondary hemodynamic decompensation due to liver disease, in which the abnormalities in systolic function by speckle-tracking echocardiography were observed and could be reversed by the use of inotropes. After partial response to current therapies, the patient presented a clinical and laboratorial response with improvement of renal function after infusion of dobutamine. Clinical studies are needed for the therapy approach to HRS taking into account myocardial dysfunction as a major contributing factor for renal dysfunction.

Monosegment ALPPS: A new variant of the techniques for rapid hepatic regeneration. Critical review of the initial results of our series

Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) is a novel surgical technique that provides fast and effective growth of liver remnant volume, allowing surgical resection of hepatic lesions initially considered unresectable. Short and long-term results and the convenience of carrying out this technique are issues that still remain under debate while waiting for the final outcomes of the multicenter registries with larger number of cases. The aim of this paper is to describe, from a critical point of view, the outcomes of the cases performed at our center (n=8). On the other hand, it is possible to leave only one hepatic segment as a liver remnant and we illustrate this new surgical procedure (ALPPS monosegment) performed in one patient.

Low immediate postoperative platelet count is associated with hepatic insufficiency after hepatectomy

AIM: To investigate the relationship between low immediate postoperative platelet count and perioperative outcome after liver resection in patients with hepatocellular carcinoma (HCC).

METHODS: In a cohort of 565 consecutive hepatitis B-related HCC patients who underwent major liver resection, the characteristics and clinical outcomes after liver resection were compared between patients with immediate postoperative platelet count < 100 × 10⁹/L and patients with platelet count ≥ 100 × 10⁹/L. Risk factors for postoperative hepatic insufficiency were evaluated by multivariate analysis.

RESULTS: Patients with a low immediate postoperative platelet count (< 100 × 10⁹/L) had more grade III-V complications (20.5% vs 12.4%, P = 0.016), and higher rates of postoperative liver failure (6.8% vs 2.6%, P = 0.02), hepatic insufficiency (31.5% vs 21.2%, P < 0.001) and mortality (6.8% vs 0.5%, P < 0.001), compared to patients with a platelet count ≥ 100 × 10⁹/L. The alanine aminotransferase levels on postoperative days 3 and 5, and bilirubin on postoperative days 1, 3 and 5 were higher in patients with immediate postoperative low platelet count. Multivariate analysis revealed that immediate postoperative low platelet count, rather than preoperative low platelet count, was a significant independent risk factor for hepatic insufficiency.

CONCLUSION: A low immediate postoperative platelet count is an independent risk factor for hepatic insufficiency. Platelets can mediate liver regeneration in the cirrhotic liver.

Preparative regimen dosing for hematopoietic stem cell transplantation in patients with chronic hepatic impairment: analysis of the literature and recommendations

Hematopoietic stem cell transplantation (HSCT) is a potentially life-saving therapy for patients with malignant and nonmalignant disease states. Transplant has been associated with high treatment-related morbidity and mortality, therefore limiting its usefulness in patients with baseline liver dysfunction. In the event that a patient with hepatic insufficiency is selected for HSCT, dosage adjustments may be considered; however, no reliable endogenous biomarkers can serve as a guide for adjustments. There is no clear standard or guideline for how to approach these patients, and most adjustments are made empirically on the basis of expert opinion. This article offers practical advice and outlines our personal approaches to provide dosing recommendations for commonly-used preparative agents in the setting of hepatic impairment with the aim to optimize dosing for this patient population.

Schistosomiasis: a case of severe infection with fatal outcome

Schistosomiasis is one of the most common parasitic diseases, still considered of public health significance. Acute schistosomiasis is of difficult diagnosis and therefore has been overlooked, misdiagnosed, underestimated and underreported in endemic areas. The delay between the exposure to contaminated water and the initial symptoms may explain this challenging diagnosis. Acute schistosomiasis is frequently reported in non-immune individuals while reinfection cases occurring in endemic areas is scarcely documented. The later usually shows a benign course but fatal cases do exist. The authors report a case of a young female patient, in the late puerperium, with a three-month history of weight loss, intermittent fever, cough, thoracic and abdominal pain and increased abdominal girth. Physical examination showed a tachycardia, tachypnea and hypotension. Laboratory tests showed a mild anemia, eosinophilia, and a slightly elevation of liver enzymes. Thorax and abdominal multidetector computed tomography evidenced a diffuse and bilateral pulmonary micronodules and peritoneal and intestinal wall thickening. The patient progressed rapidly to hepatic insufficiency, and death after respiratory insufficiency. An autopsy was performed and the findings were compatible with acute Schistosomiasis in a patient previously exposed to Schistosoma mansoni.