Angel E. Alsina

Nonalcoholic fatty liver disease epidemic and its implications for liver transplantation.

Nonalcoholic steatohepatitis (NASH) is increasingly recognized as the most common chronic liver disease worldwide. The aim of this study is to investigate the transplantation trends of liver transplant (LT) recipients with NASH. Using the United Network for Organ Sharing database, we found a steady increase in LT rate especially in those more than 65 years old. We identified differences across ethnic groups and United Network for Organ Sharing regions. This study highlights the impact of the rising prevalence of NASH on the demand for LT and provides invaluable information to healthcare policymakers and the transplant community about the target groups and geographic location for focused and early intervention.

Update on the management of cirrhosis - focus on cost-effective preventative strategies

Cirrhosis is a chronic liver disease stage that encompasses a variety of etiologies resulting in liver damage. This damage may induce secondary complications such as portal hypertension, esophageal variceal bleeding, spontaneous bacterial peritonitis, and hepatic encephalopathy. Screening for and management of these complications incurs substantial health care costs; thus, determining the most economical and beneficial treatment strategies is essential. This article reviews the economic impact of a variety of prophylactic and treatment regimens employed for cirrhosis-related complications. Prophylactic use of β-adrenergic blockers for portal hypertension and variceal bleeding appears to be cost-effective, but the most economical regimen for treatment of initial bleeding is unclear given that cost comparisons of pharmacologic and surgical regimens are lacking. In contrast, prophylaxis for spontaneous bacterial peritonitis cannot be recommended. Standard therapy for spontaneous bacterial peritonitis includes antibiotics, and the overall economic impact of these medications depends largely on their direct cost. However, the potential development of bacterial antibiotic resistance and resulting clinical failure should also be considered. Nonabsorbable disaccharides are standard therapies for hepatic encephalopathy; however, given their questionable efficacy, the nonsystemic antibiotic rifaximin may be a more cost-effective, long-term treatment for hepatic encephalopathy, despite its increased direct cost, because of its demonstrated efficacy and prevention of hospitalization. Further studies evaluating the cost burden of cirrhosis and cirrhosis-related complications, including screening costs, the cost of treatment and maintenance therapy, conveyance to liver transplantation, liver transplantation success, and health-related quality of life after transplantation, are essential for evaluation of the economic burden of hepatic encephalopathy and all cirrhosis-related complications.

Uncovering the truth about covered stents: is there a difference between covered versus uncovered stents with transjugular intrahepatic portosystemic shunts?

INTRODUCTION Polytetrafluoroethylene (PTFE)-covered transjugular intrahepatic portosystemic shunt (TIPS) stents purportedly provide superior patency. This study was undertaken to determine whether covered stents provide better long-term patency and outcomes after TIPSs. METHODS Patients with portal hypertension undergoing TIPS at a large teaching hospital from 2001 to 2010 were studied. Median data are presented. RESULTS Two hundred forty-six patients underwent TIPS; 70 received uncovered stents, and 176 received covered stents. Patients who received uncovered stents had more severely impaired liver function (41% were Child class C cirrhotics). The follow-up was longer with uncovered stents (48 vs 24 months, P < .01). Reinterventions for stenosis were undertaken in 33% with uncovered stents versus 19% with covered stents (P = .01). Shunt dysfunction occurred in 57% with uncovered stents versus 21% covered (P = .05). A deterioration of hepatic function occurred in 31% with uncovered stents versus 30% with covered (P = .32). Survival with uncovered stents was 31 months versus 33 months with covered stents (P = .55, Kaplan-Meier). CONCLUSIONS Covered stents may improve patency but do not mitigate postshunt hepatic dysfunction and do not improve survival.

Early use of renal‐sparing agents in liver transplantation: A closer look

Renal dysfunction is a critical issue for liver transplant candidates and recipients. Acute nephrotoxicity and chronic nephrotoxicity, however, are the compromises for the potent immunosuppression provided by calcineurin inhibitors (CNIs). To maintain the graft and patient survival afforded by CNIs while minimizing renal dysfunction in liver transplant patients, the reduction, delay, or elimination of CNIs in immunosuppression regimens is being implemented more frequently by clinicians. The void left by standard‐dose CNIs is being filled by nonnephrotoxic immunosuppressants such as mycophenolates and mammalian target of rapamycin inhibitors. The results of studies of renal‐sparing regimens in liver transplant recipients have been inconsistent, and this may be explained upon a closer examination of several study‐related factors, including the study design and the duration of follow‐up. Liver Transpl 19:826‐842, 2013.

Outcomes of abdominal surgeries in cirrhotic patients performed by liver transplant surgeons: Are these safe?

BACKGROUND Elective abdominal surgeries in patients with cirrhosis have been discouraged due to the high risk of complications. This study investigates the outcomes and safety of surgeries for hernias, and laparoscopic cholecystectomies in cirrhotic patients. METHODS A retrospective cohort study that compared 91 cirrhotic patients to a control group of non-cirrhotic patients operated by liver transplant surgeons was conducted between 2009 and 2015. RESULTS No statistical significance found in re-admission rates or complication rates (p = 0.21). Hernia recurrent rates were similar (p = 0.27). Survival rates among cirrhotic versus non cirrhotic group was 93.4% and 98.9% respectively (p = 0.0539). Amongst the 91 cirrhotic patients, there was a 100% survival rate for both ventral herniorrhaphies and laparoscopic cholecystectomy. Survival in umbilical and inguinal herniorrhaphies was 88.2% and 89.5% respectively. Mortality rate for umbilical and inguinal hernias was 11.7% and10.5% respectively. Mortality by Child-Pugh (CP) class were; 8.8% for CP B and 10.7% for CP class C. All CP class A patients survived. CONCLUSIONS Our study indicates that elective operations could be performed safely with acceptable mortality in cirrhotic patients.

Successful Liver Transplantation for Hyperammonemic Fibrolamellar Hepatocellular Carcinoma

Fibrolamellar hepatocellular carcinoma is a rare hepatocellular tumor usually arising in noninfected and noncirrhotic livers. Only 2 cases accompanied by hyperammonemia due to intrahepatic shunting have been reported. A 23-year-old white woman presented with a 2-week history of nausea, vomiting, generalized weakness, and intermittent right upper quadrant pain. Abdominal computerized tomography revealed a 13 x 9-cm hepatic mass. Core-needle biopsy revealed fibrolamellar hepatocellular carcinoma. She presented with coma due to hyperammonemia levels (peak at 437 mcg/dL) but without metastatic disease. She was urgently transplanted, started on daily sorafenib 8 weeks after transplantation, and was free of disease at 1 year after transplantation.

621 Treatment of HCV Recurrence After Liver Transplant: A Review of Early Virologic Responses Using Telaprevir, A Single Center Experience of 24 Patients

two groups were compared using independent-samples t-test. Survival analysis and the distributions were calculated using Kaplan-Meier method and Mantel-Cox log-rank test. Results: Out of total 43 combined liver-kidney transplants, 30 SLK cases (24 post-MELD and 6 pre-MELD) were included. Proportions of age, gender, ethnicity, pre-transplant MELD score; pre-transplant renal replacement therapy requirement, hypertension, diabetes mellitus and follow-up period were similar in two groups. Median follow up period was 30 months. Both overall and kidney-graft survival in pre-MELD era were 50%, but improved to 91.7% in post-MELD era (p=0.02). When compared according to HCV diagnosis, there was no statistical significance in overall and kidney-graft survival between 9 HCV and 15 non-HCV groups in post-MELD era (p=0.67 and p=0.4, respectively). Conclusion: Literature suggests lower risk of liver graft loss in SLK compared to LTA, but not much information is available regarding the specific diagnosis of the underlying liver disease, HCV vs non-HCV.Our study demonstrated that overall and kidney graft survival has significantly improved post-MELD as compared to pre-MELD era. Additionally, our study showed that there was no statistical difference in overall and kidney-graft survival between HCV and non-HCV groups. This observation needs to be further studied and verified in larger cohort to fully identify the impact of Hepatitis C infection on liver and kidney grafts, post transplantation.