BACKGROUND Transplant teams often hesitate to use the right kidney(RK)in living donor(LD)transplants due to the complexities of anastomosing the short,thin-walled right renal veins,which can potentially lead to graft ...BACKGROUND Transplant teams often hesitate to use the right kidney(RK)in living donor(LD)transplants due to the complexities of anastomosing the short,thin-walled right renal veins,which can potentially lead to graft loss or graft dysfunction.Nevertheless,circumstances may arise where selecting the RK over the left kidney(LK)is unavoidable.Consequently,it is crucial to thoroughly examine the implications of such a choice on the overall transplant outcome.AIM To compare transplant outcomes between recipients of RK and LK while examining the factors that influence these outcomes.METHODS We retrospectively analyzed data from adult patients who received LD kidney transplants involving meticulous patient selection and surgical techniques at our center from January 2020 to December 2023.We included all kidney donors who were over 18,fit to donate,and had undergone diethylenetriamine pentaacetic acid split function and/or computed tomography based volumetry.The variables examined comprised donor and recipient demographics,and outcome measures included technical graft loss(TGL),delayed or slow graft function(SGF),and post-transplant serum creatinine(SC)trends.We used a logistic regression model to assess the likelihood of adverse outcomes considering the donor kidney side.RESULTS Of the 250 transplants performed during the period,56(22%)were RKs.The recipient demographics and transplant factors were comparable for the right and LKs,except that the donor warm and cold ischemia time were shorter for RKs.TGL and SGF each occurred in 2%(n=1)of RKs and 0.5%(n=1)of LKs,the difference being insignificant.These complications,however,were not related to the venous anastomosis.One RK(2%)developed delayed graft function after 48 hours,which was attributable to postoperative hypoxia rather than the surgical technique.The post-transplant SC trend and mean SC at the last follow-up were similar across both kidney sides.CONCLUSION The donor kidney side has little impact on post-transplant adverse events and graft function in LD transplants,provided that careful patient selection and precise surgical techniques are employed.展开更多
BACKGROUND The use of biomarkers,such as the neutrophil-to-lymphocyte ratio(NLR)and the neutrophil-to-platelet ratio(NPR),has shown promise in evaluating early outcomes after medical,interventional,and surgical treatm...BACKGROUND The use of biomarkers,such as the neutrophil-to-lymphocyte ratio(NLR)and the neutrophil-to-platelet ratio(NPR),has shown promise in evaluating early outcomes after medical,interventional,and surgical treatments.NLR has emer-ged as an indicator of systemic inflammation and physiological stress.NPR has emerged as a potential indicator of inflammation and thrombotic risk in the context of surgical and radiological procedures.AIM To analyze the correlation of NLR and NPR with the development of post-liver transplantation(LT)early complications after stratification for hepatocellular carcinoma diagnosis.METHODS Consecutive patients undergone LT between January 2019 and December 2023 were enrolled.Data regarding the concentration of hemoglobin and the differ-ential leukocyte count on postoperative days(POD)0,1,3,and 5 were collected.RESULTS The dataset included 161 consecutive patients undergone LT.Clavien-Dindo IV-V complications had a good correlation with NLR POD 1(P=0.05),NLR POD 3(P<0.001),NLR POD 7(P<0.001),NPR POD 3(P<0.001).In addition,the NPR ratio on POD 3 correlated with the onset of 30-day hemorrhage(P=0.009).Finally,30-day mortality had a significant association with the NLR POD 1(P=0.03)and with NLR POD 7(P=0.004),while NPR had a significant correlation with 30-day mortality in NPR POD 7(P=0.004).CONCLUSION The analysis of NLR and NPR are strictly correlated with Clavien-Dindo IV-V complications and 30-day post-LT death.展开更多
BACKGROUND Family caregivers of cirrhosis patients(CPs)often experience burden,stress,and depression.Investigating whether these conditions improve following the patient undergoing liver transplantation(LT)is crucial,...BACKGROUND Family caregivers of cirrhosis patients(CPs)often experience burden,stress,and depression.Investigating whether these conditions improve following the patient undergoing liver transplantation(LT)is crucial,as it would elucidate the compre-hensive benefits of the procedure and demonstrate the positive impacts not only on the patients but also on their caregivers and society.AIM To compare the levels of burden,stress and depression among family caregivers of cirrhotic and liver transplant patients.METHODS This cross-sectional observational study evaluated caregivers of CPs and LT recipients at a quaternary Brazilian hospital.Instruments included identification cards,interview scripts,the caregiver burden scale Inventory,Lipp’s Stress Symptom Inventory,and the Beck Depression Inventory-Second Edition.Psychometric analyses involved confirmatory factor analysis and calculation of McDonald’s omega and composite reliability.Factor scores were compared with the Mann-Whitney U test,with effect size as the rank-biserial correlation coefficient(r).Statistical analysis was performed with R software(P<0.05).RESULTS Seventy-seven CP caregivers and 65 LT recipient caregivers were included.Most were female(CP:85.7%vs LT:84.6%)and the patients’spouses(76.6%vs 63.1%).The median age and caregiving duration were 55.4(23.3-76.3)vs 54.6(25.7-82.1)and 3.9(1-20)vs 8(1.5-24)years,respectively(P=0.001).LT caregivers were less likely to be at risk of overload(21.5%vs 49.4%),to be under stress(33.8%vs 36.4%)and to show symptoms of depression(15.4%vs 35.1%).Compared with LT caregivers,CP caregivers had greater median factor scores for burden(general tension,P=0.012;isolation,P=0.014;disappointment,P=0.004),depression(P=0.008),and stress(P=0.047),with small to moderate effect sizes.The disappointment(r=0.240)and depression(r=0.225)dimensions had the largest effect sizes.CONCLUSION Family caregivers of LT recipients are less likely to exhibit symptoms of burden,stress,and depression,suggesting that the benefits of LT extend to the patients’family members.展开更多
BACKGROUND The CAR-OLT score predicts major adverse cardiovascular events 1 year after liver transplant(LT).AIM To test the hypothesis that the CAR-OLT score may help avoid cardiac stress tests in LT candidates.METHOD...BACKGROUND The CAR-OLT score predicts major adverse cardiovascular events 1 year after liver transplant(LT).AIM To test the hypothesis that the CAR-OLT score may help avoid cardiac stress tests in LT candidates.METHODS This retrospective single-center cohort study included all adult patients undergoing elective evaluation for first cadaveric donor orthotopic LT for liver cirrhosis with or without hepatocellular carcinoma at Fondazione Policlinico Universitario Agostino Gemelli Istituto di Ricerca e Cura a Carattere Scientifico in Rome,Italy.Cardiac contraindications for LT listing were defined after a center-specific cardiac workup,which included cardiac stress tests for most patients.The diagnostic accuracy of the CAR-OLT score was evaluated using the area under the receiver operating characteristic(AUROC)method.RESULTS A total of 342 LT candidates were evaluated between 2015 and 2019,with a moderate cardiovascular risk profile(37%diabetes,34%hypertension,22%obesity).Of these,80(23%)candidates underwent coronary angiography.Twenty-one(6%)candidates were given cardiac contraindications to LT listing,48%of which were due to coronary artery disease.The CAR-OLT score predicted cardiac contraindications to LT listing with an AUROC of 0.81.The optimal cut-off for sensitivity was a CAR-OLT score≤23,which showed a 99%negative predictive value for cardiac contraindications to LT listing.A total of 84(25%)LT candidates with a CAR-OLT score≤23 underwent 87 non-invasive cardiac tests and 13 coronary angiographies pre-listing,with estimated costs of approximately 48000€.The estimated savings per patient was€574.70 for the Italian National Health System.CONCLUSION A CAR-OLT score≤23 can identify LT candidates who can be safely listed without the need for cardiac stress tests,providing time and cost savings.These findings require external validation.展开更多
The selection of patients with colorectal cancer liver metastases(CRLM)for liver transplantation(LT)represents a significant challenge,requiring a balance between oncological outcomes and organ scarcity.Recent advance...The selection of patients with colorectal cancer liver metastases(CRLM)for liver transplantation(LT)represents a significant challenge,requiring a balance between oncological outcomes and organ scarcity.Recent advancements in transplantation outcomes for CRLM have prompted the establishment of rigorous selection criteria to optimize patient survival and graft utilization.This review examines the key criteria used to select candidates for LT in this setting,with a focus on oncological factors,patient characteristics,and response to therapy.Eligible candidates are typically those with non-resectable liver-only CRLM,demonstrating controlled primary tumor disease.Tumor biology is a critical determinant,excluding patients exhibiting high-risk molecular features such as BRAF or RAS mutations.Furthermore,candidates must show a favorable response to systemic chemotherapy,with either tumor stability or reduction in size and no extrahepatic progression during a defined treatment period.Specific tumor burden scores,such as the Oslo score or criteria based on the number and size of lesions,aid in stratifying candidates with acceptable recurrence risks.Other factors,including age,performance status,and absence of significant comorbidities,are also pivotal.Long-term follow-up data highlight the importance of stringent patient selection,showing superior 5-year survival in patients meeting these criteria compared to those who do not.In conclusion,strict selection criteria based on tumor biology,systemic disease control,and patient-specific factors ensure optimized outcomes for LT in CRLM patients,marking a pivotal step toward broader clinical acceptance of this novel approach.展开更多
BACKGROUND Incisional hernia is one of the known complications of renal transplant surgery,with a reported incidence between 1.1%to 3.8%.Depending on the site and extent of incisional hernia,it may require surgery par...BACKGROUND Incisional hernia is one of the known complications of renal transplant surgery,with a reported incidence between 1.1%to 3.8%.Depending on the site and extent of incisional hernia,it may require surgery particularly if it contains the trans-planted kidney either partially or completely.The current common clinical prac-tice is to repair incisional hernias using polypropylene meshes,which have their own risks and benefits.Biological meshes,which are made from human or animal-derived connective tissue,are also in use and have a less inflammatory response.Recently,hybrid meshes have been developed.These are composed of both biological and synthetic products.One such example is OviTex 1S perma-nent,which is a sterile reinforced tissue matrix composed of ovine(sheep)derived extracellular matrix and monofilament polypropylene.In this case report,we are sharing our experience with the use of OviTex 1S in the repair of post-renal transplant incisional hernias.CASE SUMMARY We report four cases of post-renal transplant incisional hernia with a median time of 27 months post-surgery.The median size of the defect was 15 cm long.There was no post-operative complication.One patient required renal transplant biopsy after mesh repair,which was easily performed compared with polypropylene meshes repaired hernias in the past.CONCLUSION The OviTex 1S mesh provides benefits in hernial repairs pKTx,but cost is an issue,and their long-term viability is unclear.Continued use and reporting will help build a more informed picture.展开更多
Metabolic dysfunction-associated steatotic liver disease(MASLD)is now the predominant global cause of chronic liver disease and represents a major indication for liver transplantation.Post-transplant MASLD manifests a...Metabolic dysfunction-associated steatotic liver disease(MASLD)is now the predominant global cause of chronic liver disease and represents a major indication for liver transplantation.Post-transplant MASLD manifests as recurrent disease in nearly all recipients by five years post-transplantation,while de novo MASLD shows variable incidence(18%-78%).Although histologically similar,recurrent MASLD follows a more aggressive trajectory,with accelerated fibrosis and cirrhosis.Metabolic disturbances,immunosuppression regimens,donorrelated factors,and chronic inflammation synergistically contribute to disease pathogenesis.The disorder not only compromises graft function but is also associated with elevated cardiovascular and overall morbidity,and malignancy risk.Despite advancements in noninvasive diagnostics,histopathology remains essential for definitive diagnosis and prognostic stratification.Management should prioritize metabolic optimization,lifestyle intervention,and tailored immunosuppressive regimens.Glucagon-like peptide-1 receptor agonists represent a promising therapeutic avenue.However,the absence of standardized,transplant-specific guidelines is a significant limitation.Further research is necessary to define diagnostic criteria,risk stratification,and targeted therapy to improve graft survival and patient outcomes.展开更多
BACKGROUND Liver transplantation(LT)is the only curative,life-saving option for children and adults with end-stage liver disease.Due to the well-known shortage and heterogeneity of grafts,split LT(SLT)is an attractive...BACKGROUND Liver transplantation(LT)is the only curative,life-saving option for children and adults with end-stage liver disease.Due to the well-known shortage and heterogeneity of grafts,split LT(SLT)is an attractive strategy to expand the donor pool and reduce waitlist times.Given increased risk of cold ischemia time with SLT,machine perfusion represents a promising option to reduce it and optimize transplant logistics and outcomes.The present communication describes various possible combinations of procurement steps to perform SLT facilitated by placing one or both grafts on a normothermic machine perfusion(NMP)closed circuit device.CASE SUMMARY A 19-month-old female with biliary atresia after failed Kasai portoenterostomy and a 42-year-old woman with unresectable intrahepatic cholangiocarcinoma were selected as recipients for a SLT from a 17-year-old male donor.The SLT generated a left lateral segment and a right trisectional graft of appropriate volume for both recipients.After a mixed in-situ and ex-situ split,in order to improve logistics,the right trisectional graft was placed on a closed circuit NMP device,following an appropriate vascular reconstruction.Both grafts were implanted with excellent short-term outcomes.CONCLUSION Use of NMP with SLT for preservation prior to implantation allows not only for graft optimization but also for significant improvement of transplant logistics.We propose various models and standardization of logistic options for combining SLT with NMP to optimize graft availability and outcomes.展开更多
BACKGROUND Kidney and liver transplantation are two sub-specialized medical disciplines,with transplant professionals spending decades in training.While artificial intelligencebased(AI-based)tools could potentially as...BACKGROUND Kidney and liver transplantation are two sub-specialized medical disciplines,with transplant professionals spending decades in training.While artificial intelligencebased(AI-based)tools could potentially assist in everyday clinical practice,comparative assessment of their effectiveness in clinical decision-making remains limited.AIM To compare the use of ChatGPT and GPT-4 as potential tools in AI-assisted clinical practice in these challenging disciplines.METHODS In total,400 different questions tested ChatGPT’s/GPT-4 knowledge and decision-making capacity in various renal and liver transplantation concepts.Specifically,294 multiple-choice questions were derived from open-access sources,63 questions were derived from published open-access case reports,and 43 from unpublished cases of patients treated at our department.The evaluation covered a plethora of topics,including clinical predictors,treatment options,and diagnostic criteria,among others.RESULTS ChatGPT correctly answered 50.3%of the 294 multiple-choice questions,while GPT-4 demonstrated a higher performance,answering 70.7%of questions(P<0.001).Regarding the 63 questions from published cases,ChatGPT achieved an agreement rate of 50.79%and partial agreement of 17.46%,while GPT-4 demonstrated an agreement rate of 80.95%and partial agreement of 9.52%(P=0.01).Regarding the 43 questions from unpublished cases,ChatGPT demonstrated an agreement rate of 53.49%and partial agreement of 23.26%,while GPT-4 demonstrated an agreement rate of 72.09%and partial agreement of 6.98%(P=0.004).When factoring by the nature of the task for all cases,notably,GPT-4 demonstrated outstanding performance,providing a differential diagnosis that included the final diagnosis in 90%of the cases(P=0.008),and successfully predicting the prognosis of the patient in 100%of related questions(P<0.001).CONCLUSION GPT-4 consistently provided more accurate and reliable clinical recommendations with higher percentages of full agreements both in renal and liver transplantation compared with ChatGPT.Our findings support the potential utility of AI models like ChatGPT and GPT-4 in AI-assisted clinical practice as sources of accurate,individualized medical information and facilitating decision-making.The progression and refinement of such AI-based tools could reshape the future of clinical practice,making their early adoption and adaptation by physicians a necessity.展开更多
BACKGROUND Chylous ascites(CA),which is characterized by lymphatic leakage into the peritoneal cavity,is a rare but significant complication of liver transplantation.Although dietary and pharmacological strategies hav...BACKGROUND Chylous ascites(CA),which is characterized by lymphatic leakage into the peritoneal cavity,is a rare but significant complication of liver transplantation.Although dietary and pharmacological strategies have shown effectiveness in managing CA,standardized treatment protocols have yet to be established.AIMTo evaluate the comparative effectiveness of low-fat diet (LFD) enriched with medium-chain triglycerides (MCTs)vs octreotide therapy in managing post-liver transplantation CA.METHODSA comprehensive literature review was conducted to analyze the outcomes of dietary interventions and octreotidetherapy. The key parameters examined included resolution rates, treatment duration, and recurrence.RESULTSA comprehensive literature search yielded 13 studies that met the inclusion criteria, comprising 4 retrospectivecohort studies and 8 case studies. The incidence of CA following liver transplantation ranges from 0.6% to 4.7%.The onset varied, with a median time to diagnosis of 10 days after transplantation. A LFD with MCT supplementationwas used as the first-line therapy in 83.3% of the studies, with resolution rates ranging from 62.5% to100%. Octreotide therapy was utilized in 66.7% of the studies, primarily as a second-line therapy, with resolutionrates of 83.3% to 100%. Combination therapy showed a significantly higher resolution rate than did dietarymanagement alone (97.8% vs 78.9%, P = 0.02). The time to resolution was significantly shorter with octreotidecontainingregimens than with dietary management alone (median, 7 days vs 14 days;P = 0.03).CONCLUSIONA stepwise approach to CA management is recommended, initiating dietary interventions and escalating tooctreotide when necessary. Further research through well-designed randomized controlled trials is essential toestablish standardized treatment protocols for optimizing patient outcomes.展开更多
Although the perioperative bleeding complications and the major side effects of blood transfusion have always been the primary concern in liver transplantation(OLT),the possible cohesion of an underestimated intrinsic...Although the perioperative bleeding complications and the major side effects of blood transfusion have always been the primary concern in liver transplantation(OLT),the possible cohesion of an underestimated intrinsic hypercoagulative state during and after the transplant procedure may pose a major threat to both patient and graft survival.Thromboembolism during OLT is characterized not only by a complex aetiology,but also by unpredictable onset and evolution of the disease.The initiation of a procoagulant process may be triggered by various factors,such as inflammation,venous stasis,ischemia-reperfusion injury,vascular clamping,anatomical and technical abnormalities,genetic factors,deficiency of profibrinolytic activity,and platelet activation.The involvement of the arterial system,intracardiac thrombosis,pulmonary emboli,portal vein thrombosis,and deep vein thrombosis,are among the most serious thrombotic events in the perioperative period.The rapid detection of occlusive vascular events is of paramount importance as it heavily influences the prognosis,particularly when these events occur intraoperatively or early after OLT.Regardless of the lack of studies and guidelines on anticoagulant prophylaxis in this setting,many institutions recommend such an approach especially in the subset of patients at high risk.However,the decision of when,how and in what doses to use the various chemical anticoagulants is still a difficult task,since there is no common consensus,even for highrisk cases.The risk of postoperative thromboembolism causing severe hemodynamic events,or even loss of graft function,must be weighed and compared with the risk of an important bleeding.In this article we briefly review the risk factors and the possible predictors of major thrombotic complications occurringin the perioperative period,as well as their incidence and clinical features.Moreover,the indications to pharmacological prophylaxis and the current treatment strategies are also summarized.展开更多
AIM To perform a systematic review and meta-analysis on platelet-to-lymphocyte ratio(PLR) as a risk factor for post-transplant hepatocellular cancer(HCC) recurrence. METHODS A systematic literature search was performe...AIM To perform a systematic review and meta-analysis on platelet-to-lymphocyte ratio(PLR) as a risk factor for post-transplant hepatocellular cancer(HCC) recurrence. METHODS A systematic literature search was performed using PubM ed. Participants of any age and sex, who underwent liver transplantation for HCC were considered following these criteria:(1) studies comparing pre-transplant low vs high PLR values;(2) studies reporting post-transplant recurrence rates; and(3) if more than one study was reported by the same institute, only the most recent was included. The primary outcome measure was set for HCC recurrence after transplantation. RESULTS A total of 5 articles, published between 2014 and 2017, fulfilled the selection criteria. As for the quality of the reported studies, all the investigated articles presented an overall high quality. A total of 899 cases were investigated: 718 cases(80.0%) were males. Three studies coming from European countries and one from Japan presented HCV as the main cause of cirrhosis. On the opposite, one Chinese study presented a greater incidence of HBV-related cirrhotic cases. In all the studies apart one, the PLR cut-off value of 150 was reported. At meta-analysis, high PLR value was associated with a significant increase in recurrence after transplantation(OR = 3.33; 95%CI: 1.78-6.25; P < 0.001). A moderate heterogeneity was observed among the identified studies according to the Higgins I^2 statistic value.CONCLUSION Pre-transplant high PLR values are connected with an increased risk of post-operative recurrence of hepatocellular cancer. More studies are needed for better clarify the biological mechanisms of this results.展开更多
Background: Early allograft dysfunction (EAD) is a severe complication after liver transplantation. The associated risk factors and complications have re-gained recent interest. This study investigated risk factors, s...Background: Early allograft dysfunction (EAD) is a severe complication after liver transplantation. The associated risk factors and complications have re-gained recent interest. This study investigated risk factors, survival and complications associated with EAD in a large liver transplant center in Latin America. Methods: Retrospective, unicenter, cohort, based on data from adult patients undergoing first deceaseddonor liver transplant from January 2009 to December 2013. EAD was defined by one or more of the following:(i) bilirubin ≥10 mg/dL on postoperative day 7;(ii) international normalized ratio ≥1.6 on postoperative day 7, and (iii) alanine aminotransferase or aspartate aminotransferase > 2000 IU/L within the first seven days after transplant. Results: A total of 602 patients were included;of these 34.2% developed EAD. Donor risk factors were male ( P = 0.007), age between 50 and 59 years ( P = 0.034), overweight ( P = 0.028) or grade I obesity ( P = 0.012), sodium > 157 mmol/L ( P = 0.002) and grade IV ischemia/reperfusion injury ( P = 0.002). Cold ischemia time ≥10 h ( P = 0.008) and warm ischemia time ≥40 min ( P = 0.013) were the surgical factors. Male ( P < 0.001) was the only recipient protective factor. Compared with the non-EAD group, patients with EAD were submitted to more reoperations (24.3% vs. 13.4%, P = 0.001) and had higher graft loss rates (37.9% vs. 21.2%, P < 0.001), with similar patient survival rates ( P = 0.238). Conclusions: EAD risk factors are related to donor, surgical procedure and recipient. Donor risk factors for EAD were male, age between 50 and 59 years, donor overweight or grade Ⅰ obesity, sodium > 157 mmol/L and grade Ⅳ ischemia/reperfusion injury. Cold ischemia time ≥10 h and warm ischemia time ≥40 min were the surgical risk factors. Male was the only recipient protective factor. Patients with EAD had higher reoperations and graft loss rates.展开更多
De novo neoplasms account for almost 30% of deaths 10 years after liver transplantation and are the most common cause of mortality in patients surviving at least 1 year after transplant. The risk of malignancy is two ...De novo neoplasms account for almost 30% of deaths 10 years after liver transplantation and are the most common cause of mortality in patients surviving at least 1 year after transplant. The risk of malignancy is two to four times higher in transplant recipients than in an age- and sex-matched population, and cancer is expected to surpass cardiovascular complications as the primary cause of death in transplanted patients within the next 2 decades. Since exposure to immunosuppression is associated with an increased frequency of developing neoplasm, long-term immunosuppression should be therefore minimized. Promising results in the prevention of hepatocellular carcinoma(HCC) recurrence have been reported with the use of m TOR inhibitors including everolimus and sirolimus and the ongoing open-label prospective randomized controlled SILVER. Study will provide more information on whether sirolimus-containing vs m TOR-inhibitorfree immunosuppression is more efficacious in reducing HCC recurrence.展开更多
Acute liver failure is a critical medical condition defined as rapid development of hepatic dysfunction associated with encephalopathy. The prognosis in these patients is highly variable and depends on the etiology, i...Acute liver failure is a critical medical condition defined as rapid development of hepatic dysfunction associated with encephalopathy. The prognosis in these patients is highly variable and depends on the etiology, intervalbetween jaundice and encephalopathy, age, and the degree of coagulopathy. Determining the prognosis for this population is vital. Unfortunately, prognostic models with both high sensitivity and specificity for prediction of death have not been developed. Liver transplantation has dramatically improved survival in patients with acute liver failure. Still, 25% to 45% of patients will survive with medical treatment. The identification of patients who will eventually require liver transplantation should be carefully addressed through the combination of current prognostic models and continuous medical assessment. The concerns of inaccurate selection for transplantation are significant, exposing the recipient to a complex surgery and lifelong immunosuppression. In this challenging scenario, where organ shortage remains one of the main problems, alternatives to conventional orthotopic liver transplantation, such as living-donor liver transplantation, auxiliary liver transplant, and ABO-incompatible grafts, should be explored. Although overall outcomes after liver transplantation for acute liver failure are improving, they are not yet comparable to elective transplantation.展开更多
Criteria for liver transplantation(LT)for hepatocellular carcinoma(HCC)and post-LT indicators of prognosis are historically based on the measurement of the tumor mass.Recently,high throughput technologies have increas...Criteria for liver transplantation(LT)for hepatocellular carcinoma(HCC)and post-LT indicators of prognosis are historically based on the measurement of the tumor mass.Recently,high throughput technologies have increased the prediction of recurrence,but these tools are not yet routinely available.The interaction between HCC and the immune system has revealed an imbalance of lymphocyte phenotypes in the peritumoral tissue,and the increase of regulatory T cells with respect to cytotoxic lymphocytes has been linked to a higher rate of post-LT HCC recurrence.Moreover,some inflammatory markers have shown good reliability in predicting cancer reappearance after surgery,as a result of either a systemic inflammatory response or a decreased capacity of the organism to control the tumor growth.Among these markers,the neutrophil-tolymphocyte ratio appears to be the most promising and easily available serum parameter able to predict HCC recurrence after LT and following other types of treatment,although the exact mechanisms determining its elevation have not been clarified.Post-LT immunosuppression may impact on cancer control,and the exposure to high levels of calcineurin inhibitors or other immunusuppressants has recently emerged as a negative prognostic factor for HCC recurrence and patient survival.Despite the absence of prospective randomized trials,inhibitors of the mammalian target of rapamycin have been shown to be associated with lower rates of tumor recurrence compared to other immunosuppressors,suggesting their use especially in patients with HCC exceeding the conventional indication criteria for LT.展开更多
Liver transplantation(LT) is a life-saving treatment forpatients with end-stage liver disease and for patients with liver cell cancer related to liver disease. Acute and chronic liver diseases related to hepatitis vir...Liver transplantation(LT) is a life-saving treatment forpatients with end-stage liver disease and for patients with liver cell cancer related to liver disease. Acute and chronic liver diseases related to hepatitis viruses are between the main indications for liver transplantation. The risk of viral reinfection after transplantation is the main limiting factor in these indications. Before the availability of antiviral prophylaxis, hepatitis B virus(HBV) recurrence was universal in patients who were HBV DNA-positive before transplantation. The natural history of recurrent HBV was accelerated by immunosuppression, and it progressed rapidly to graft failure and death. Introduction of post-transplant prophylaxis with immunoglobulin alone first, and associated to antiviral drugs later, drastically reduced HBV recurrence, resulting in excellent long-term outcomes. On the contrary, recurrence of hepatitis C is the main cause of graft loss in most transplant programs. Overall, patient and graft survival after LT for hepatitis C virus(HCV)-associated cirrhosis is inferior compared with other indications. However, successful pretransplant or post transplant antiviral therapy has been associated with increased graft and overall survival. Until recently, the combination of pegylated interferon and ribavirin was the standard of care for the treatment of patients with chronic hepatitis C. Highly active antiviral compounds have been developed over the past decade, thanks to new in vitro systems to study HCV entry, replication, assembly, and release.展开更多
The age of liver donors has been increasing in the past several years because of a donor shortage. In the United States, 33% of donors are age 50 years or older, as are more than 50% in some European countries. The im...The age of liver donors has been increasing in the past several years because of a donor shortage. In the United States, 33% of donors are age 50 years or older, as are more than 50% in some European countries. The impact of donor age on liver transplantation(LT) has been analyzed in several studies with contradictory conclusions. Nevertheless, recent analyses of the largest databases demonstrate that having an older donor is a risk factor for graft failure. Donor age is included as a risk factor in the more relevant graft survival scores, such as the Donor Risk Index, donor age and Model for End-stage Liver Disease, Survival Outcomes Following Liver Transplantation, and the Balance of Risk. The use of old donors is related to an increased rate of biliary complications and hepatitis C virus-related graft failure. Although liver function does not seem to be significantly affected by age, the incidence of several liver diseases increases with age, and the capacity of the liver to manage or overcome liver diseases or external injuries decreases. In this paper, the importance of age in LT outcomes, the role of donor age as a risk factor, and the influence of aging on liver regeneration are reviewed.展开更多
Liver transplantation is the treatment of choice for end stage liver disease, but availability of liver grafts is still the main limitation to its wider use. Extended criteria donors(ECD) are considered not ideal for ...Liver transplantation is the treatment of choice for end stage liver disease, but availability of liver grafts is still the main limitation to its wider use. Extended criteria donors(ECD) are considered not ideal for several reasons but their use has dramatically grown in the last decades in order to augment the donor liver pool. Due to improvement in surgical and medical strategies, results using grafts from these donors have become acceptable in terms of survival and complications; nevertheless a big debate still exists regarding their selection, discharge criteria and allocation policies. Many studies analyzed the use of these grafts from many points of view producing different or contradictory results so that accepted guidelines do not exist and the use of these grafts is still related to non-standardized policies changing from center to center. The aim of this review is to analyze every step of the donationtransplantation process emphasizing all those strategies, both clinical and experimental, that can optimize results using ECD.展开更多
文摘BACKGROUND Transplant teams often hesitate to use the right kidney(RK)in living donor(LD)transplants due to the complexities of anastomosing the short,thin-walled right renal veins,which can potentially lead to graft loss or graft dysfunction.Nevertheless,circumstances may arise where selecting the RK over the left kidney(LK)is unavoidable.Consequently,it is crucial to thoroughly examine the implications of such a choice on the overall transplant outcome.AIM To compare transplant outcomes between recipients of RK and LK while examining the factors that influence these outcomes.METHODS We retrospectively analyzed data from adult patients who received LD kidney transplants involving meticulous patient selection and surgical techniques at our center from January 2020 to December 2023.We included all kidney donors who were over 18,fit to donate,and had undergone diethylenetriamine pentaacetic acid split function and/or computed tomography based volumetry.The variables examined comprised donor and recipient demographics,and outcome measures included technical graft loss(TGL),delayed or slow graft function(SGF),and post-transplant serum creatinine(SC)trends.We used a logistic regression model to assess the likelihood of adverse outcomes considering the donor kidney side.RESULTS Of the 250 transplants performed during the period,56(22%)were RKs.The recipient demographics and transplant factors were comparable for the right and LKs,except that the donor warm and cold ischemia time were shorter for RKs.TGL and SGF each occurred in 2%(n=1)of RKs and 0.5%(n=1)of LKs,the difference being insignificant.These complications,however,were not related to the venous anastomosis.One RK(2%)developed delayed graft function after 48 hours,which was attributable to postoperative hypoxia rather than the surgical technique.The post-transplant SC trend and mean SC at the last follow-up were similar across both kidney sides.CONCLUSION The donor kidney side has little impact on post-transplant adverse events and graft function in LD transplants,provided that careful patient selection and precise surgical techniques are employed.
文摘BACKGROUND The use of biomarkers,such as the neutrophil-to-lymphocyte ratio(NLR)and the neutrophil-to-platelet ratio(NPR),has shown promise in evaluating early outcomes after medical,interventional,and surgical treatments.NLR has emer-ged as an indicator of systemic inflammation and physiological stress.NPR has emerged as a potential indicator of inflammation and thrombotic risk in the context of surgical and radiological procedures.AIM To analyze the correlation of NLR and NPR with the development of post-liver transplantation(LT)early complications after stratification for hepatocellular carcinoma diagnosis.METHODS Consecutive patients undergone LT between January 2019 and December 2023 were enrolled.Data regarding the concentration of hemoglobin and the differ-ential leukocyte count on postoperative days(POD)0,1,3,and 5 were collected.RESULTS The dataset included 161 consecutive patients undergone LT.Clavien-Dindo IV-V complications had a good correlation with NLR POD 1(P=0.05),NLR POD 3(P<0.001),NLR POD 7(P<0.001),NPR POD 3(P<0.001).In addition,the NPR ratio on POD 3 correlated with the onset of 30-day hemorrhage(P=0.009).Finally,30-day mortality had a significant association with the NLR POD 1(P=0.03)and with NLR POD 7(P=0.004),while NPR had a significant correlation with 30-day mortality in NPR POD 7(P=0.004).CONCLUSION The analysis of NLR and NPR are strictly correlated with Clavien-Dindo IV-V complications and 30-day post-LT death.
文摘BACKGROUND Family caregivers of cirrhosis patients(CPs)often experience burden,stress,and depression.Investigating whether these conditions improve following the patient undergoing liver transplantation(LT)is crucial,as it would elucidate the compre-hensive benefits of the procedure and demonstrate the positive impacts not only on the patients but also on their caregivers and society.AIM To compare the levels of burden,stress and depression among family caregivers of cirrhotic and liver transplant patients.METHODS This cross-sectional observational study evaluated caregivers of CPs and LT recipients at a quaternary Brazilian hospital.Instruments included identification cards,interview scripts,the caregiver burden scale Inventory,Lipp’s Stress Symptom Inventory,and the Beck Depression Inventory-Second Edition.Psychometric analyses involved confirmatory factor analysis and calculation of McDonald’s omega and composite reliability.Factor scores were compared with the Mann-Whitney U test,with effect size as the rank-biserial correlation coefficient(r).Statistical analysis was performed with R software(P<0.05).RESULTS Seventy-seven CP caregivers and 65 LT recipient caregivers were included.Most were female(CP:85.7%vs LT:84.6%)and the patients’spouses(76.6%vs 63.1%).The median age and caregiving duration were 55.4(23.3-76.3)vs 54.6(25.7-82.1)and 3.9(1-20)vs 8(1.5-24)years,respectively(P=0.001).LT caregivers were less likely to be at risk of overload(21.5%vs 49.4%),to be under stress(33.8%vs 36.4%)and to show symptoms of depression(15.4%vs 35.1%).Compared with LT caregivers,CP caregivers had greater median factor scores for burden(general tension,P=0.012;isolation,P=0.014;disappointment,P=0.004),depression(P=0.008),and stress(P=0.047),with small to moderate effect sizes.The disappointment(r=0.240)and depression(r=0.225)dimensions had the largest effect sizes.CONCLUSION Family caregivers of LT recipients are less likely to exhibit symptoms of burden,stress,and depression,suggesting that the benefits of LT extend to the patients’family members.
文摘BACKGROUND The CAR-OLT score predicts major adverse cardiovascular events 1 year after liver transplant(LT).AIM To test the hypothesis that the CAR-OLT score may help avoid cardiac stress tests in LT candidates.METHODS This retrospective single-center cohort study included all adult patients undergoing elective evaluation for first cadaveric donor orthotopic LT for liver cirrhosis with or without hepatocellular carcinoma at Fondazione Policlinico Universitario Agostino Gemelli Istituto di Ricerca e Cura a Carattere Scientifico in Rome,Italy.Cardiac contraindications for LT listing were defined after a center-specific cardiac workup,which included cardiac stress tests for most patients.The diagnostic accuracy of the CAR-OLT score was evaluated using the area under the receiver operating characteristic(AUROC)method.RESULTS A total of 342 LT candidates were evaluated between 2015 and 2019,with a moderate cardiovascular risk profile(37%diabetes,34%hypertension,22%obesity).Of these,80(23%)candidates underwent coronary angiography.Twenty-one(6%)candidates were given cardiac contraindications to LT listing,48%of which were due to coronary artery disease.The CAR-OLT score predicted cardiac contraindications to LT listing with an AUROC of 0.81.The optimal cut-off for sensitivity was a CAR-OLT score≤23,which showed a 99%negative predictive value for cardiac contraindications to LT listing.A total of 84(25%)LT candidates with a CAR-OLT score≤23 underwent 87 non-invasive cardiac tests and 13 coronary angiographies pre-listing,with estimated costs of approximately 48000€.The estimated savings per patient was€574.70 for the Italian National Health System.CONCLUSION A CAR-OLT score≤23 can identify LT candidates who can be safely listed without the need for cardiac stress tests,providing time and cost savings.These findings require external validation.
文摘The selection of patients with colorectal cancer liver metastases(CRLM)for liver transplantation(LT)represents a significant challenge,requiring a balance between oncological outcomes and organ scarcity.Recent advancements in transplantation outcomes for CRLM have prompted the establishment of rigorous selection criteria to optimize patient survival and graft utilization.This review examines the key criteria used to select candidates for LT in this setting,with a focus on oncological factors,patient characteristics,and response to therapy.Eligible candidates are typically those with non-resectable liver-only CRLM,demonstrating controlled primary tumor disease.Tumor biology is a critical determinant,excluding patients exhibiting high-risk molecular features such as BRAF or RAS mutations.Furthermore,candidates must show a favorable response to systemic chemotherapy,with either tumor stability or reduction in size and no extrahepatic progression during a defined treatment period.Specific tumor burden scores,such as the Oslo score or criteria based on the number and size of lesions,aid in stratifying candidates with acceptable recurrence risks.Other factors,including age,performance status,and absence of significant comorbidities,are also pivotal.Long-term follow-up data highlight the importance of stringent patient selection,showing superior 5-year survival in patients meeting these criteria compared to those who do not.In conclusion,strict selection criteria based on tumor biology,systemic disease control,and patient-specific factors ensure optimized outcomes for LT in CRLM patients,marking a pivotal step toward broader clinical acceptance of this novel approach.
文摘BACKGROUND Incisional hernia is one of the known complications of renal transplant surgery,with a reported incidence between 1.1%to 3.8%.Depending on the site and extent of incisional hernia,it may require surgery particularly if it contains the trans-planted kidney either partially or completely.The current common clinical prac-tice is to repair incisional hernias using polypropylene meshes,which have their own risks and benefits.Biological meshes,which are made from human or animal-derived connective tissue,are also in use and have a less inflammatory response.Recently,hybrid meshes have been developed.These are composed of both biological and synthetic products.One such example is OviTex 1S perma-nent,which is a sterile reinforced tissue matrix composed of ovine(sheep)derived extracellular matrix and monofilament polypropylene.In this case report,we are sharing our experience with the use of OviTex 1S in the repair of post-renal transplant incisional hernias.CASE SUMMARY We report four cases of post-renal transplant incisional hernia with a median time of 27 months post-surgery.The median size of the defect was 15 cm long.There was no post-operative complication.One patient required renal transplant biopsy after mesh repair,which was easily performed compared with polypropylene meshes repaired hernias in the past.CONCLUSION The OviTex 1S mesh provides benefits in hernial repairs pKTx,but cost is an issue,and their long-term viability is unclear.Continued use and reporting will help build a more informed picture.
基金Supported by The LTx Unit at Hospital Israelita Albert Einstein is financed by the Programa de Apoio ao Desenvolvimento Insitucional do SUS(PROADI-SUS)a partnership with the Brazilian Ministry of Health,No.25000.171086/2023-80.
文摘Metabolic dysfunction-associated steatotic liver disease(MASLD)is now the predominant global cause of chronic liver disease and represents a major indication for liver transplantation.Post-transplant MASLD manifests as recurrent disease in nearly all recipients by five years post-transplantation,while de novo MASLD shows variable incidence(18%-78%).Although histologically similar,recurrent MASLD follows a more aggressive trajectory,with accelerated fibrosis and cirrhosis.Metabolic disturbances,immunosuppression regimens,donorrelated factors,and chronic inflammation synergistically contribute to disease pathogenesis.The disorder not only compromises graft function but is also associated with elevated cardiovascular and overall morbidity,and malignancy risk.Despite advancements in noninvasive diagnostics,histopathology remains essential for definitive diagnosis and prognostic stratification.Management should prioritize metabolic optimization,lifestyle intervention,and tailored immunosuppressive regimens.Glucagon-like peptide-1 receptor agonists represent a promising therapeutic avenue.However,the absence of standardized,transplant-specific guidelines is a significant limitation.Further research is necessary to define diagnostic criteria,risk stratification,and targeted therapy to improve graft survival and patient outcomes.
文摘BACKGROUND Liver transplantation(LT)is the only curative,life-saving option for children and adults with end-stage liver disease.Due to the well-known shortage and heterogeneity of grafts,split LT(SLT)is an attractive strategy to expand the donor pool and reduce waitlist times.Given increased risk of cold ischemia time with SLT,machine perfusion represents a promising option to reduce it and optimize transplant logistics and outcomes.The present communication describes various possible combinations of procurement steps to perform SLT facilitated by placing one or both grafts on a normothermic machine perfusion(NMP)closed circuit device.CASE SUMMARY A 19-month-old female with biliary atresia after failed Kasai portoenterostomy and a 42-year-old woman with unresectable intrahepatic cholangiocarcinoma were selected as recipients for a SLT from a 17-year-old male donor.The SLT generated a left lateral segment and a right trisectional graft of appropriate volume for both recipients.After a mixed in-situ and ex-situ split,in order to improve logistics,the right trisectional graft was placed on a closed circuit NMP device,following an appropriate vascular reconstruction.Both grafts were implanted with excellent short-term outcomes.CONCLUSION Use of NMP with SLT for preservation prior to implantation allows not only for graft optimization but also for significant improvement of transplant logistics.We propose various models and standardization of logistic options for combining SLT with NMP to optimize graft availability and outcomes.
文摘BACKGROUND Kidney and liver transplantation are two sub-specialized medical disciplines,with transplant professionals spending decades in training.While artificial intelligencebased(AI-based)tools could potentially assist in everyday clinical practice,comparative assessment of their effectiveness in clinical decision-making remains limited.AIM To compare the use of ChatGPT and GPT-4 as potential tools in AI-assisted clinical practice in these challenging disciplines.METHODS In total,400 different questions tested ChatGPT’s/GPT-4 knowledge and decision-making capacity in various renal and liver transplantation concepts.Specifically,294 multiple-choice questions were derived from open-access sources,63 questions were derived from published open-access case reports,and 43 from unpublished cases of patients treated at our department.The evaluation covered a plethora of topics,including clinical predictors,treatment options,and diagnostic criteria,among others.RESULTS ChatGPT correctly answered 50.3%of the 294 multiple-choice questions,while GPT-4 demonstrated a higher performance,answering 70.7%of questions(P<0.001).Regarding the 63 questions from published cases,ChatGPT achieved an agreement rate of 50.79%and partial agreement of 17.46%,while GPT-4 demonstrated an agreement rate of 80.95%and partial agreement of 9.52%(P=0.01).Regarding the 43 questions from unpublished cases,ChatGPT demonstrated an agreement rate of 53.49%and partial agreement of 23.26%,while GPT-4 demonstrated an agreement rate of 72.09%and partial agreement of 6.98%(P=0.004).When factoring by the nature of the task for all cases,notably,GPT-4 demonstrated outstanding performance,providing a differential diagnosis that included the final diagnosis in 90%of the cases(P=0.008),and successfully predicting the prognosis of the patient in 100%of related questions(P<0.001).CONCLUSION GPT-4 consistently provided more accurate and reliable clinical recommendations with higher percentages of full agreements both in renal and liver transplantation compared with ChatGPT.Our findings support the potential utility of AI models like ChatGPT and GPT-4 in AI-assisted clinical practice as sources of accurate,individualized medical information and facilitating decision-making.The progression and refinement of such AI-based tools could reshape the future of clinical practice,making their early adoption and adaptation by physicians a necessity.
文摘BACKGROUND Chylous ascites(CA),which is characterized by lymphatic leakage into the peritoneal cavity,is a rare but significant complication of liver transplantation.Although dietary and pharmacological strategies have shown effectiveness in managing CA,standardized treatment protocols have yet to be established.AIMTo evaluate the comparative effectiveness of low-fat diet (LFD) enriched with medium-chain triglycerides (MCTs)vs octreotide therapy in managing post-liver transplantation CA.METHODSA comprehensive literature review was conducted to analyze the outcomes of dietary interventions and octreotidetherapy. The key parameters examined included resolution rates, treatment duration, and recurrence.RESULTSA comprehensive literature search yielded 13 studies that met the inclusion criteria, comprising 4 retrospectivecohort studies and 8 case studies. The incidence of CA following liver transplantation ranges from 0.6% to 4.7%.The onset varied, with a median time to diagnosis of 10 days after transplantation. A LFD with MCT supplementationwas used as the first-line therapy in 83.3% of the studies, with resolution rates ranging from 62.5% to100%. Octreotide therapy was utilized in 66.7% of the studies, primarily as a second-line therapy, with resolutionrates of 83.3% to 100%. Combination therapy showed a significantly higher resolution rate than did dietarymanagement alone (97.8% vs 78.9%, P = 0.02). The time to resolution was significantly shorter with octreotidecontainingregimens than with dietary management alone (median, 7 days vs 14 days;P = 0.03).CONCLUSIONA stepwise approach to CA management is recommended, initiating dietary interventions and escalating tooctreotide when necessary. Further research through well-designed randomized controlled trials is essential toestablish standardized treatment protocols for optimizing patient outcomes.
文摘Although the perioperative bleeding complications and the major side effects of blood transfusion have always been the primary concern in liver transplantation(OLT),the possible cohesion of an underestimated intrinsic hypercoagulative state during and after the transplant procedure may pose a major threat to both patient and graft survival.Thromboembolism during OLT is characterized not only by a complex aetiology,but also by unpredictable onset and evolution of the disease.The initiation of a procoagulant process may be triggered by various factors,such as inflammation,venous stasis,ischemia-reperfusion injury,vascular clamping,anatomical and technical abnormalities,genetic factors,deficiency of profibrinolytic activity,and platelet activation.The involvement of the arterial system,intracardiac thrombosis,pulmonary emboli,portal vein thrombosis,and deep vein thrombosis,are among the most serious thrombotic events in the perioperative period.The rapid detection of occlusive vascular events is of paramount importance as it heavily influences the prognosis,particularly when these events occur intraoperatively or early after OLT.Regardless of the lack of studies and guidelines on anticoagulant prophylaxis in this setting,many institutions recommend such an approach especially in the subset of patients at high risk.However,the decision of when,how and in what doses to use the various chemical anticoagulants is still a difficult task,since there is no common consensus,even for highrisk cases.The risk of postoperative thromboembolism causing severe hemodynamic events,or even loss of graft function,must be weighed and compared with the risk of an important bleeding.In this article we briefly review the risk factors and the possible predictors of major thrombotic complications occurringin the perioperative period,as well as their incidence and clinical features.Moreover,the indications to pharmacological prophylaxis and the current treatment strategies are also summarized.
文摘AIM To perform a systematic review and meta-analysis on platelet-to-lymphocyte ratio(PLR) as a risk factor for post-transplant hepatocellular cancer(HCC) recurrence. METHODS A systematic literature search was performed using PubM ed. Participants of any age and sex, who underwent liver transplantation for HCC were considered following these criteria:(1) studies comparing pre-transplant low vs high PLR values;(2) studies reporting post-transplant recurrence rates; and(3) if more than one study was reported by the same institute, only the most recent was included. The primary outcome measure was set for HCC recurrence after transplantation. RESULTS A total of 5 articles, published between 2014 and 2017, fulfilled the selection criteria. As for the quality of the reported studies, all the investigated articles presented an overall high quality. A total of 899 cases were investigated: 718 cases(80.0%) were males. Three studies coming from European countries and one from Japan presented HCV as the main cause of cirrhosis. On the opposite, one Chinese study presented a greater incidence of HBV-related cirrhotic cases. In all the studies apart one, the PLR cut-off value of 150 was reported. At meta-analysis, high PLR value was associated with a significant increase in recurrence after transplantation(OR = 3.33; 95%CI: 1.78-6.25; P < 0.001). A moderate heterogeneity was observed among the identified studies according to the Higgins I^2 statistic value.CONCLUSION Pre-transplant high PLR values are connected with an increased risk of post-operative recurrence of hepatocellular cancer. More studies are needed for better clarify the biological mechanisms of this results.
文摘Background: Early allograft dysfunction (EAD) is a severe complication after liver transplantation. The associated risk factors and complications have re-gained recent interest. This study investigated risk factors, survival and complications associated with EAD in a large liver transplant center in Latin America. Methods: Retrospective, unicenter, cohort, based on data from adult patients undergoing first deceaseddonor liver transplant from January 2009 to December 2013. EAD was defined by one or more of the following:(i) bilirubin ≥10 mg/dL on postoperative day 7;(ii) international normalized ratio ≥1.6 on postoperative day 7, and (iii) alanine aminotransferase or aspartate aminotransferase > 2000 IU/L within the first seven days after transplant. Results: A total of 602 patients were included;of these 34.2% developed EAD. Donor risk factors were male ( P = 0.007), age between 50 and 59 years ( P = 0.034), overweight ( P = 0.028) or grade I obesity ( P = 0.012), sodium > 157 mmol/L ( P = 0.002) and grade IV ischemia/reperfusion injury ( P = 0.002). Cold ischemia time ≥10 h ( P = 0.008) and warm ischemia time ≥40 min ( P = 0.013) were the surgical factors. Male ( P < 0.001) was the only recipient protective factor. Compared with the non-EAD group, patients with EAD were submitted to more reoperations (24.3% vs. 13.4%, P = 0.001) and had higher graft loss rates (37.9% vs. 21.2%, P < 0.001), with similar patient survival rates ( P = 0.238). Conclusions: EAD risk factors are related to donor, surgical procedure and recipient. Donor risk factors for EAD were male, age between 50 and 59 years, donor overweight or grade Ⅰ obesity, sodium > 157 mmol/L and grade Ⅳ ischemia/reperfusion injury. Cold ischemia time ≥10 h and warm ischemia time ≥40 min were the surgical risk factors. Male was the only recipient protective factor. Patients with EAD had higher reoperations and graft loss rates.
文摘De novo neoplasms account for almost 30% of deaths 10 years after liver transplantation and are the most common cause of mortality in patients surviving at least 1 year after transplant. The risk of malignancy is two to four times higher in transplant recipients than in an age- and sex-matched population, and cancer is expected to surpass cardiovascular complications as the primary cause of death in transplanted patients within the next 2 decades. Since exposure to immunosuppression is associated with an increased frequency of developing neoplasm, long-term immunosuppression should be therefore minimized. Promising results in the prevention of hepatocellular carcinoma(HCC) recurrence have been reported with the use of m TOR inhibitors including everolimus and sirolimus and the ongoing open-label prospective randomized controlled SILVER. Study will provide more information on whether sirolimus-containing vs m TOR-inhibitorfree immunosuppression is more efficacious in reducing HCC recurrence.
文摘Acute liver failure is a critical medical condition defined as rapid development of hepatic dysfunction associated with encephalopathy. The prognosis in these patients is highly variable and depends on the etiology, intervalbetween jaundice and encephalopathy, age, and the degree of coagulopathy. Determining the prognosis for this population is vital. Unfortunately, prognostic models with both high sensitivity and specificity for prediction of death have not been developed. Liver transplantation has dramatically improved survival in patients with acute liver failure. Still, 25% to 45% of patients will survive with medical treatment. The identification of patients who will eventually require liver transplantation should be carefully addressed through the combination of current prognostic models and continuous medical assessment. The concerns of inaccurate selection for transplantation are significant, exposing the recipient to a complex surgery and lifelong immunosuppression. In this challenging scenario, where organ shortage remains one of the main problems, alternatives to conventional orthotopic liver transplantation, such as living-donor liver transplantation, auxiliary liver transplant, and ABO-incompatible grafts, should be explored. Although overall outcomes after liver transplantation for acute liver failure are improving, they are not yet comparable to elective transplantation.
文摘Criteria for liver transplantation(LT)for hepatocellular carcinoma(HCC)and post-LT indicators of prognosis are historically based on the measurement of the tumor mass.Recently,high throughput technologies have increased the prediction of recurrence,but these tools are not yet routinely available.The interaction between HCC and the immune system has revealed an imbalance of lymphocyte phenotypes in the peritumoral tissue,and the increase of regulatory T cells with respect to cytotoxic lymphocytes has been linked to a higher rate of post-LT HCC recurrence.Moreover,some inflammatory markers have shown good reliability in predicting cancer reappearance after surgery,as a result of either a systemic inflammatory response or a decreased capacity of the organism to control the tumor growth.Among these markers,the neutrophil-tolymphocyte ratio appears to be the most promising and easily available serum parameter able to predict HCC recurrence after LT and following other types of treatment,although the exact mechanisms determining its elevation have not been clarified.Post-LT immunosuppression may impact on cancer control,and the exposure to high levels of calcineurin inhibitors or other immunusuppressants has recently emerged as a negative prognostic factor for HCC recurrence and patient survival.Despite the absence of prospective randomized trials,inhibitors of the mammalian target of rapamycin have been shown to be associated with lower rates of tumor recurrence compared to other immunosuppressors,suggesting their use especially in patients with HCC exceeding the conventional indication criteria for LT.
文摘Liver transplantation(LT) is a life-saving treatment forpatients with end-stage liver disease and for patients with liver cell cancer related to liver disease. Acute and chronic liver diseases related to hepatitis viruses are between the main indications for liver transplantation. The risk of viral reinfection after transplantation is the main limiting factor in these indications. Before the availability of antiviral prophylaxis, hepatitis B virus(HBV) recurrence was universal in patients who were HBV DNA-positive before transplantation. The natural history of recurrent HBV was accelerated by immunosuppression, and it progressed rapidly to graft failure and death. Introduction of post-transplant prophylaxis with immunoglobulin alone first, and associated to antiviral drugs later, drastically reduced HBV recurrence, resulting in excellent long-term outcomes. On the contrary, recurrence of hepatitis C is the main cause of graft loss in most transplant programs. Overall, patient and graft survival after LT for hepatitis C virus(HCV)-associated cirrhosis is inferior compared with other indications. However, successful pretransplant or post transplant antiviral therapy has been associated with increased graft and overall survival. Until recently, the combination of pegylated interferon and ribavirin was the standard of care for the treatment of patients with chronic hepatitis C. Highly active antiviral compounds have been developed over the past decade, thanks to new in vitro systems to study HCV entry, replication, assembly, and release.
文摘The age of liver donors has been increasing in the past several years because of a donor shortage. In the United States, 33% of donors are age 50 years or older, as are more than 50% in some European countries. The impact of donor age on liver transplantation(LT) has been analyzed in several studies with contradictory conclusions. Nevertheless, recent analyses of the largest databases demonstrate that having an older donor is a risk factor for graft failure. Donor age is included as a risk factor in the more relevant graft survival scores, such as the Donor Risk Index, donor age and Model for End-stage Liver Disease, Survival Outcomes Following Liver Transplantation, and the Balance of Risk. The use of old donors is related to an increased rate of biliary complications and hepatitis C virus-related graft failure. Although liver function does not seem to be significantly affected by age, the incidence of several liver diseases increases with age, and the capacity of the liver to manage or overcome liver diseases or external injuries decreases. In this paper, the importance of age in LT outcomes, the role of donor age as a risk factor, and the influence of aging on liver regeneration are reviewed.
文摘Liver transplantation is the treatment of choice for end stage liver disease, but availability of liver grafts is still the main limitation to its wider use. Extended criteria donors(ECD) are considered not ideal for several reasons but their use has dramatically grown in the last decades in order to augment the donor liver pool. Due to improvement in surgical and medical strategies, results using grafts from these donors have become acceptable in terms of survival and complications; nevertheless a big debate still exists regarding their selection, discharge criteria and allocation policies. Many studies analyzed the use of these grafts from many points of view producing different or contradictory results so that accepted guidelines do not exist and the use of these grafts is still related to non-standardized policies changing from center to center. The aim of this review is to analyze every step of the donationtransplantation process emphasizing all those strategies, both clinical and experimental, that can optimize results using ECD.
