Chun-Tao Wai

Acute-on-chronic liver failure: consensus recommendations of the Asian Pacific Association for the study of the liver (APASL)

The Asian Pacific Association for the Study of the Liver (APASL) set up a working party on acute-on-chronic liver failure (ACLF) in 2004, with a mandate to develop consensus guidelines on various aspects of ACLF relevant to disease patterns and clinical practice in the Asia-Pacific region. Experts predominantly from the Asia–Pacific region constituted this working party and were requested to identify different issues of ACLF and develop the consensus guidelines. A 2-day meeting of the working party was held on January 22–23, 2008, at New Delhi, India, to discuss and finalize the consensus statements. Only those statements that were unanimously approved by the experts were accepted. These statements were circulated to all the experts and subsequently presented at the Annual Conference of the APASL at Seoul, Korea, in March 2008. The consensus statements along with relevant background information are presented in this review.

Non‐invasive models for predicting histology in patients with chronic hepatitis B

Abstract: Background and aim: In contrast to chronic hepatitis C (CHC), few studies had been performed in assessing non‐invasive models for predicting significant fibrosis or cirrhosis in chronic hepatitis B (CHB) patients. We aimed to evaluate non‐invasive markers for diagnosing significant fibrosis/cirrhosis in patients with CHB, and to evaluate accuracy of models from CHC in CHB patients.

Long term outcome and prognostic factors for large hepatocellular carcinoma (10 cm or more) after surgical resection.

BackgroundSurgical resection is the standard treatment for hepatocellular carcinoma (HCC). However, the role of surgery in treatment of large tumors (10 cm or more) is controversial. We have analyzed, in a single centre, the long-term outcome associated with surgical resection in patients with such large tumors.MethodsWe retrospectively investigated 166 patients who had undergone surgical resection between July 1995 and December 2006 because of large (10 cm or more) HCC. Survival analysis was done using the Kaplan-Meier method. Prognostic factors were evaluated using univariate and multivariate analyses.ResultsOf the 166 patients evaluated, 80% were associated with viral hepatitis and 48.2% had cirrhosis. The majority of patients underwent a major hepatectomy (48.2% had four or more segments resected and 9% had additional organ resection). The postoperative mortality was 3%. The median survival in our study was 20 months, with an actuarial 5-year and 10-year overall survival of 28.6% and 25.6%, respectively. Of these patients, 60% had additional treatment in the form of transarterial chemoembolization, radiofrequency ablation or both. On multivariate analysis, vascular invasion (P < 0.001), cirrhosis (P = 0.028), and satellite lesions/multicentricity (P = 0.006) were significant prognostic factors influencing survival. The patients who had none of these three risk factors had 5-year and 10-year overall survivals of 57.7% each, compared with 22.5% and 19.3%, respectively, for those with at least one risk factor (P < 0.001).ConclusionsSurgical resection for those with large HCC can be safely performed with a reasonable long-term survival. For tumors with poor prognostic factors, there is a pressing need for effective adjuvant therapy.

Drug-induced liver injury at an Asian center: a prospective study.

Background/Aims: The aetiology of drug‐induced liver injuries (DILI) in Asia is different from that in the West, as anecdotal studies have shown that traditional complementary and alternative medicines (CAM) accounted for a major proportion of offending drugs in DILI in Asia. We aimed to study DILI in Asia prospectively, and to test whether DILI caused by traditional CAM was related to adulterants.

Liver fibrosis: consensus recommendations of the Asian Pacific Association for the Study of the Liver (APASL).

Liver fibrosis is a common pathway leading to cirrhosis, which is the final result of injury to the liver. Accurate assessment of the degree of fibrosis is important clinically, especially when treatments aimed at reversing fibrosis are being evolved. Liver biopsy has been considered to be the “gold standard” to assess fibrosis. However, liver biopsy being invasive and, in many instances, not favored by patients or physicians, alternative approaches to assess liver fibrosis have assumed great importance. Moreover, therapies aimed at reversing the liver fibrosis have also been tried lately with variable results. Till now, there has been no consensus on various clinical, pathological, and radiological aspects of liver fibrosis. The Asian Pacific Association for the Study of the Liver set up a working party on liver fibrosis in 2007, with a mandate to develop consensus guidelines on various aspects of liver fibrosis relevant to disease patterns and clinical practice in the Asia-Pacific region. The process for the development of these consensus guidelines involved the following: review of all available published literature by a core group of experts; proposal of consensus statements by the experts; discussion of the contentious issues; and unanimous approval of the consensus statements after discussion. The Oxford System of evidence-based approach was adopted for developing the consensus statements using the level of evidence from 1 (highest) to 5 (lowest) and grade of recommendation from A (strongest) to D (weakest). The consensus statements are presented in this review.

MARS®: a futile tool in centres without active liver transplant support

Background and aim: Studies on Molecular Adsorbent Recycling Systems (MARS®) showed inconclusive survival benefits.

Primary biliary cirrhosis in Singapore: evaluation of demography, prognostic factors and natural course in a multi-ethnic population.

Background and Aim:  Primary biliary cirrhosis (PBC) is infrequent in Asians. Among Asian patients with PBC, information on natural course is scarce. The aim of this study was to study the clinical course and prognosticators among Asians with PBC.

Should non-expert clinician examiners be used in objective structured assessment of communication skills among final year medical undergraduates?

Background: Adoption of the objective structured clinical examination may be hindered by shortages of clinicians within a specialty. Clinicians from other specialties should be considered as alternative, non-expert examiners. Aims: We assessed the inter-rater agreement between expert and non-expert clinician examiners in an integrated objective structured clinical examination for final year medical undergraduates. Methods: Pairs of expert and non-expert clinician examiners used a rating checklist to assess students in 8 oral communication stations, representing commonly encountered scenarios from medicine, paediatrics, and surgery. These included breaking bad news, managing an angry relative, taking consent for lumbar puncture; and advising a mother on asthma and febrile fits, and an adult on medication use, lifestyle changes and post-suture care of a wound. 439 students participated in the OSCE (206 in 2005, 233 in 2006). Results: There was good to very good agreement (intraclass coefficient: 0.57–0.79) between expert and non-expert clinician examiners, with 5 out of 8 stations having intraclass coefficients ≥0.70. Variation between paired examiners within stations contributed the lowest variance to student scores. Conclusion: These findings support the use of clinicians from other specialties, as ‘non-expert’ examiners, to assess communication skills, using a standardized checklist, thereby reducing the demand on clinicians’ time.

Younger Age and Presence of Macrovascular Invasion Were Independent Significant Factors Associated With Poor Disease-Free Survival in Hepatocellular Carcinoma Patients Undergoing Living Donor Liver Transplantation

OBJECTIVE Patients with hepatocellular carcinoma (HCC) exceeding the University of California, San Francisco (UCSF) criteria are normally rejected for cadaveric liver transplants. However, whether they should be allowed to undergo living donor liver transplantation (LDLT) has been controversial. We reviewed the outcome of patients with advanced HCC who underwent LDLT at our center. METHODS From April 2002 to May 2011, 176 patients underwent LDLT at our center; of these, 77 (44%) had HCC at the explant liver. Patient overall survival and recurrence-free survival (RFS) was analyzed using Kaplan-Meier method. Multivariate analysis was performed by Cox analysis. RESULTS Age was 56±1 (56, 29-71) years; 62 (80.5%) were male; Model for End-stage Liver Disease Score was 11±1 (9, 6-36), alpha fetoprotein (AFP) was 3683±2019 (69, 3-139,591) ng/L; maximum tumor size was 4.5 (0.5-15) cm. Number or tumor nodules was 5 (1-10), and 32 (42%) had macrovascular invasion diagnosed pretransplant. Eleven (14%) were within UCSF criteria. After follow-up of 953±90 (744, 2-2989) days, 53 (69%) were alive and 48 (62%) were recurrence-free. One-, 3- and 5-year overall survival (OS) and recurrence-free survival (RFS) were 80%, 70%, and 57% and 80%, 65%, and 48%, respectively. Five-year OS and RFS for those within UCSF criteria were both 78% versus 55% and 46% outside UCSF criteria (P=not significant). At multivariate analysis, high AFP, younger age, and macrovascular invasion were associated with both poor RFS. CONCLUSION In HCC patients exceeding UCSF criteria, a reasonable 5-year overall survival of 55% post-LDLT can be obtained. Patients with HCC exceeding the UCSF criteria, especially in the older age group with no portal vein invasion and lower AFP level, should be actively considered for LDLT.

Pretransplant Model for End-stage Liver Disease Score Has No Impact on Posttransplant Survival in Living Donor Liver Transplantation

BACKGROUND A high Model For End-stage Liver Disease (MELD) score≥25 has been reported to be associated with increased posttransplant mortality and morbidity among patients undergoing living donor liver transplantation (LDLT). We reviewed the results of patients undergoing LDLT at our transplant center for decompensated cirrhosis to determine whether a high MELD impacted posttransplant survival. METHODS From April 2002 to May 2011, 86-176 patients (49%) who underwent LDLT at our center had the indication of decompensated cirrhosis without hepatocellular carcinoma. Data were expressed in mean values±standard error of the means (range). Patients survival rates were analyzed using Kaplan-Meier method. RESULTS Among the 86 patients with decompensated cirrhosis: Age was 49±2 (1-68) years and 60 (70%) were of male gender. The causes in 25 (29%) were hepatitis B and 25 (29%) hepatitis C as well as one each for hepatitis B/C and B/D coinfections: 9 (10%), alcoholic cirrhosis. MELD score was 18±1 (range=6-40). In hospital mortality was 6/86 (7%). At 1152±95 (range=7-3317) days posttransplant follow-up 64 (74%) were alive with 1-, 3-, and 5-year survival rates of 84%, 70%, and 70%, respectively. MELD scores did not differ between those who survived and those who died (17.5±8.0 versus 17.8±8.4). No difference was noted in those with MELD<25 or ≥25. In fact, the recipient with the highest MELD score (40) survived. CONCLUSION A high MELD score had no impact on posttransplant survival among cirrhotic patients undergoing LDLT. It should be considered to be an urgent indication rather than a contraindication to LDLT.