Alvaro Koch

Bone Disease in Patients With Primary Sclerosing Cholangitis

BACKGROUND & AIMS Osteopenic bone disease occurs frequently among patients with chronic liver disease but has not been well studied in those with primary sclerosing cholangitis (PSC). We investigated the prevalence, rate of progression, and independent predictors of bone disease in a large number of patients with all stages of PSC. METHODS Bone mineral density of the lumbar spine, hip, and total body was measured yearly for 10 years in 237 patients with PSC. RESULTS Osteoporosis (T-score less than -2.5) was found in 15% of patients and occurred 23.8-fold (95% confidence interval [CI], 4.6-122.8) more frequently in those with PSC than expected from a matched population. By multivariate analysis, age 54 years or older (odds ratio [OR], 7.8; 95% CI, 3.3-18.3), body mass index ≤ 24 kg/m(2) (OR, 4.9; 95% CI, 1.9-12.6), and inflammatory bowel disease for ≥ 19 years (OR, 3.6; 95% CI, 1.5-8.4) correlated with the presence of osteoporosis. Osteoporosis was present in 75% of patients with all 3 risk factors but in only 3.1% of those without all of them. Patients with PSC lost 1% of bone mass per year; this rate of bone loss was significantly associated with duration of inflammatory bowel disease. CONCLUSIONS Osteoporosis occurs frequently among patients with PSC. Old age, low body mass index, and long duration of inflammatory bowel disease can be used to identify patients with PSC who might derive the most benefit from measurements of bone density and treatments for bone diseases.

Predictors of relapse to alcohol and illicit drugs after liver transplantation for alcoholic liver disease.

Background. Alcoholic liver disease (ALD) is a common indication for transplantation worldwide. This study identifies factors predicting posttransplant recidivism. Methods. Clinical and laboratory data were reviewed. Uni- and multivariate analyses for survival and relapse to alcohol and illicit drugs were performed. Result. Between July 1995 and November 2007, 387 patients underwent liver transplantation at our institution. Of these, 147 patients (38%) were found to have ALD. Five patients (3.4%) were excluded because of perioperative mortality. Overall survival was 96.2%, 89.6%, and 84.4% at 1, 3, and 5 years, respectively, with a median follow-up of 41.2 months. Twenty-seven patients (19%) returned to alcohol after transplantation. By univariate analysis, depression was the only significant factor affecting survival (P=0.01), whereas posttransplant relapse to alcohol trended toward significance (P=0.059). Multivariate analysis showed both factors to be independently associated with poor survival (P=0.008 and 0.017, respectively). Factors associated with relapse included less than 12 months of abstinence before transplant (P=0.019) and participation in rehabilitation (P=0.026). Multivariate analysis showed pretransplant abstinence less than 12 months as the only independent factor (P=0.037) associated with alcohol relapse after transplantation. Twenty-five patients (17.2%) had documented drug use after transplantation. Drug abuse before transplantation was the only independent predictor of drug abuse after transplantation (P=0.017). Conclusions. Excellent results can be obtained in patients undergoing liver transplantation for ALD, though depression and recidivism adversely impact survival. In our series, abstinence less than 12 months was associated with relapse to alcohol. Similarly, those with prior drug abuse are more likely to continue drug use after transplantation.

Alpha-fetoprotein and tumour size are associated with microvascular invasion in explanted livers of patients undergoing transplantation with hepatocellular carcinoma

BACKGROUND To determine factors associated with outcomes and microvascular invasion (MVI) in patients undergoing liver transplantation (LT) for hepatocellular carcinoma (HCC). METHODS Between July 1996 and August 2008 at the Universities of Kentucky or Tennessee, LT recipients were retrospectively analysed. RESULTS One hundred and one patients had HCC in the explanted liver; one patient was excluded because of fibrolamellar histology. Seventy-nine (79%) were male and 81 (81%) were older than 50. HCC was incidental in 32 patients (32%). Median follow-up was 31 months. Ten patients (10%) developed recurrence, which was associated with poor survival (P= 0.006). Overall 1-, 3-, and 5-year survival rates were 87%, 69% and 62%, respectively. Excluding patients with lymph node metastasis (LNM) or MVI yielded 91%, 81% and 75% survival at the same time points. MVI was independently associated with recurrence (OR 28.40, 95% CI 1.77-456.48, P= 0.018) and decreased survival (OR 4.70, 95% CI 1.24-17.80, P= 0.023), and LNM with decreased survival (OR 6.05, 95% CI 1.23-29.71, P= 0.027). Tumour size (OR 4.1, 95% CI 1.2-13.5, P= 0.013) and alpha-fetoprotein (AFP) > 100 (OR 5.0, 95% CI 1.4-18.1, P= 0.006) were associated with MVI. CONCLUSIONS MVI greatly increases the risk of recurrence and death after LT for HCC, and is strongly associated with tumour size and AFP > 100.

Diffuse malignant infiltration of the liver manifesting as a case of acute liver failure.

Background A 54-year-old male with a history of coronary artery disease, diabetes mellitus and 120 pack years of tobacco abuse presented to the emergency room with right upper quadrant abdominal pain, decreased appetite and dark urine.Investigations Laboratory investigations, chest radiograph, portal duplex, CT of the abdomen and pelvis, liver serologies and autopsy.Diagnosis Fulminant hepatic failure secondary to metastatic small-cell lung carcinoma.Management Supportive care.

Abnormal Liver Tests as an Initial Presentation of Celiac Disease

A 19-year-old woman presented to her primary care physician complaining of right flank pain and dark urine for 2 days. Because of a history of complicated urinary tract infection (UTI) and no improvement for 2 days with medical treatment, she underwent noncontrasted computed tomography (CT) scan of the abdomen. The CT scan (Fig. 1) revealed no evidence of nephrolithiasis; however, note was made of diffuse low attenuation of the liver consistent with fatty infiltration. Liver tests were then ordered showing elevated transaminases. Her abdominal discomfort resolved after completing a course of antibiotics. The patient was then referred to us because of elevated transaminases and CT scan findings. Upon interview, the patient had no complaints. She denied any history of jaundice, persistent abdominal pain, nausea, emesis, weight loss, diarrhea, rash, or fever. Additionally, no risk factors for viral hepatitis could be identified. Her medical history was notable for arthroscopic knee surgery 4 years prior and complicated UTI requiring hospitalization