E. Poli

Hepatic encephalopathy expands the predictivity of model for end‐stage liver disease in liver transplant setting: Evidence by means of 2 independent cohorts

Despite its documented prognostic relevance, hepatic encephalopathy (HE) is not considered in liver transplantation (LT) due to its possible poor objectivity. To override this problem, we aimed to analyze if an objective diagnosis of HE may confer additional mortality risk beyond MELD. Study and validation cohorts of patients with cirrhosis were considered in Italy and Canada, respectively. Patients were considered to be HE+ if an episode of overt HE was documented in a hospitalization. Of the 486 patients enrolled in Italy, 184 (38%) were HE+. During the 6‐month follow‐up, 77 patients died and 50 underwent transplantation. The 6‐month mortality of HE+ versus HE– patients was significantly higher (P < 0.001). Model for End‐Stage Liver Disease (MELD; subdistribution hazard ratio [sHR], 1.2; 95% confidence interval [CI], 1.1‐1.2; P < 0.001), HE+ (sHR, 3.6; 95% CI, 1.8‐7.1; P < 0.001), and sodium (sHR, 0.9; 95% CI, 0.8‐0.9; P < 0.001) were independent predictors of 6‐month mortality. In HE+ patients, short‐term mortality increased across the entire MELD spectrum (range, 6‐40). The results were unchanged by including or excluding patients with hepatocellular carcinoma or stratifying patients according to HE characteristics. The higher 6‐month mortality of HE+ versus HE– patients was confirmed also in the Canadian cohort (P < 0.001; n = 300, 33% HE+; 33 died, 104 transplanted). A similar and statistically significant C‐index increase derived by the incorporation of HE in MELD was observed both in the Italian (from 0.67 to 0.75) and Canadian (from 0.69 to 0.74) cohorts. A score based on MELD plus 7 points (95% CI, 4‐10) for HE+ patients optimally predicted 6‐month mortality in the 2 cohorts. According to the net reclassification index, by not considering HE, 29% of overall patients were misclassified by MELD score. In conclusion, the incorporation of HE in MELD score might improve the listing and allocation policy in LT. Liver Transplantation 22 1333–1342 2016 AASLD.

Plasma fatty acid lipidome is associated with cirrhosis prognosis and graft damage in liver transplantation

BACKGROUND Knowledge regarding the plasma fatty acid (FA) pattern in patients with liver cirrhosis is fragmentary. OBJECTIVE We evaluated plasma FA lipidome and its association with the prognosis of cirrhosis and severity of liver graft damage after transplantation. DESIGN In this observational study, plasma FA lipidome was investigated in 51 cirrhotic patients before liver transplantation and in 90 age- and sex-matched healthy control subjects. In addition, we studied ischemia-reperfusion damage in the liver of 38 patients for whom a graft biopsy was available at transplantation. With the use of logistic regression, we modeled the presence of cirrhosis, the dichotomized model for end-stage liver disease score below and above the median, and the presence of severe liver graft ischemia-reperfusion damage. RESULTS The FA pattern was markedly altered in cirrhotic patients, who showed, compared with healthy controls, higher monounsaturated FAs, lower n-6 and n-3 polyunsaturated FAs, and undetectable cerotic acid. Plasma di-homo-γ-linolenic acid was independently associated with the presence of cirrhosis (OR: 0.026; 95% CI: 0.004, 0.196; P < 0.0001), severity of its prognosis (OR: 0.041; 95% CI:0.005, 0.376; P = 0.006), postreperfusion graft hepatocellular necrosis (OR: 0.921; 95% CI: 0.851, 0.997; P = 0.043), and sinusoidal congestion (OR: 0.954; 95% CI: 0.912, 0.998; P = 0.039). Associations of di-homo-γ-linolenic acid with the presence of cirrhosis and severity of its prognosis were confirmed also after false discovery rate correction. CONCLUSIONS Cerotic and di-homo-γ-linolenic acids may serve as markers of disease and prognosis in liver cirrhosis. Dietary supplementation with di-homo-γ-linolenic acid could be a reasonable interventional strategy to delay disease progression in liver cirrhosis.

Recipient perioperative cholesterolaemia and graft cholesterol metabolism gene expression predict liver transplant outcome

We analysed for the first time whether recipient perioperative serum total cholesterol (sTC) concentration is associated with liver transplantation outcome.

The multidisciplinary support in preventing alcohol relapse after liver transplantation: A single-center experience

Alcoholic liver disease (ALD) represents a frequent indication for liver transplantation (LT). Since 2004, we have adopted a program of multidisciplinary support(MS) to assist patients undergoing LT for ALD. We aimed at analyzing the relapse rate and the risk factors for relapse. The relapse rate was also compared with that of a historical group of patients who underwent transplantation. Their survival rate was also analyzed.

Beneficial effect of sulphate-bicarbonate-calcium water on gallstone risk and weight control

AIM To investigate the effect of drinking sulphate-bicarbonate-calcium thermal water (TW) on risk factors for atherosclerosis and cholesterol gallstone disease. METHODS Postmenopausal women with functional dyspepsia and/or constipation underwent a 12 d cycle of thermal (n = 20) or tap (n = 20) water controlled drinking. Gallbladder fasting volume at ultrasound, blood vitamin E, oxysterols (7-β-hydroxycholesterol and 7-ketocholesterol), bile acid (BA), triglycerides, total/low density lipoprotein and high density lipoprotein cholesterol were measured at baseline and at the end of the study. Food consumption, stool frequency and body weight were recorded daily. RESULTS Blood lipids, oxysterols and vitamin E were not affected by either thermal or tap water consumption. Fasting gallbladder volume was significantly (P < 0.005) smaller at the end of the study than at baseline in the TW (15.7 ± 1.1 mL vs 20.1 ± 1.7 mL) but not in the tap water group (19.0 ± 1.4 mL vs 19.4 ± 1.5 mL). Total serum BA concentration was significantly (P < 0.05) higher at the end of the study than at baseline in the TW (5.83 ± 1.24 μmol vs 4.25 ± 1.00 μmol) but not in the tap water group (3.41 ± 0.46 μmol vs 2.91 ± 0.56 μmol). The increased BA concentration after TW consumption was mainly accounted for by glycochenodeoxycholic acid. The number of pasta (P < 0.001), meat (P < 0.001) and vegetable (P < 0.005) portions consumed during the study and of bowel movements per day (P < 0.05) were significantly higher in the TW than in the tap water group. Body weight did not change at the end of the study as compared to baseline in both groups. CONCLUSION Sulphate-bicarbonate-calcium water consumption has a positive effect on lithogenic risk and intestinal transit and allows maintenance of a stable body weight despite a high food intake.

Fluctuations of Estimated Glomerular Filtration Rate Outside Kidney Disease Improving Global Outcomes Diagnostic Criteria for Acute Kidney Injury in End-Stage Liver Disease Outpatients and Outcome Postliver Transplantation

Background Renal dysfunction in end-stage liver disease (ESLD) results from systemic conditions that affect both liver and kidney with activation of vasoconstrictor systems. In this setting, estimated glomerular filtration rate (eGFR) may undergo variations often outside Kidney Disease Improving Global Outcomes criteria for acute kidney injury (AKI) diagnosis, whose meaning is not clear. The aim of this study was to evaluate eGFR variations in ESLD outpatients listed for liver transplant (liver Tx) and the association with post-Tx outcome. Methods Fifty-one patients with ESLD were retrospectively evaluated from listing to transplant (L-Tx time), intraoperatively (Tx time), and up to 5 years post-Tx time. Variations between the highest and the lowest eGFR occurring in more than 48 hours, not satisfying Kidney Disease Improving Global Outcomes guideline, were considered as fluctuations (eGFR-F). Fluctuations of eGFR greater than 50% were defined as eGFR drops (DeGFR). Early graft dysfunction, AKI within 7 days, chronic kidney disease, and short- and long-term patient survivals were considered as outcomes. Results All patients presented eGFR-F, whereas DeGFR were observed in 18 (35.3%) of 51 (DeGFR+ group). These patients presented higher levels of Model for End-stage Liver Disease score, pre-Tx bilirubin and significantly greater incidence of post-Tx AKI stages 2 to 3 compared with patients without drops (DeGFR−). DeGFR was the only independent predictive factor of the occurrence of post-Tx AKI. The occurrence of AKI post-Tx was associated with the development of chronic kidney disease at 3 months and 5 years post-Tx. Conclusions Drops of eGFR are more frequently observed in patients with a worse degree of ESLD and are associated with a worse post-Tx kidney outcome.

P921 NEGATIVE PROGNOSTIC IMPACT OF HEPATIC ENCEPHALOPATHY IN CIRRHOSIS: IS IT TIME TO IMPLEMENT THE MELD SCORE TO IMPROVE THE TRANSPLANT BENEFIT?

levels 30–60 minutes after ACTH stimulation; delta cortisol (Dc = Pc −Bc]. AI was defined as at least two of the following: Bc < 148nmol/L, Pc < 550nmol/L, Dc < 250nmol/L. All patients had Methylprednisolone intraand post-operatively. Parameters of graft and renal function were recorded 48 hours post-LT. Results: 18 patients (22.5%) had AI. Patients with AI had higher MELD score (19 vs. 15; p = 0.003), higher pre-LT INR, bilirubin and potassium, and lower sodium and haemoglobin levels. 48 hours post-LT patients with AI had higher creatinine (152 vs. 91umol/L; p = 0.038) compared to those with normal adrenal function. There was no difference in mechanical ventilation, vasopressor support, renal replacement therapy, length of ICU and hospital stay between the two groups. Parameters that correlated with 48-hour creatinine were age, Bc, Pc and pre-LT creatinine. In multivariate analysis only Pc and pre-LT creatinine were significant predictors of 48-hour creatinine. Conclusions: Pre-LT AI was associated with immediate post-LT renal dysfunction in our study. The full extent of AI implications may have been masked by the intaand post-operative use of steroids. These results should be confirmed in further studies.

P.03.5 RECIPIENT SERUM TOTAL AND LDL CHOLESTEROL CONCENTRATION AT TRANSPLANT PREDICTS GRAFT SURVIVAL AFTER LIVER TRANSPLANTATION INDEPENDENTLY FROM MELD SCORE

TRANSIENT ELASTOGRAPHY IN CELIAC PATIENTS: A NON INVASIVE METHOD TO DETECT LIVER INVOLVEMENT ASSOCIATED TO CELIAC DISEASE R.E. Rossi∗ ,5, S. Massironi 2, M. Fraquelli 2 , M.T. Bardella 3 , L. Elli 3, M. Maggioni4, C. Terrani 1, M. Colombo6, D. Conte5 1Postgraduate School of Gastroenterology, Universita degli Studi di Milano, Milan, Italy; 2Gastroenterology Unit II, Fondazione Irccs Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy; 3Center For Prevention and Diagnosis of Celiac Disease, Fondazione Irccs Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy; 4U.O.C. Anatomia Patologica, A.O. San Paolo and Fondazione Irccs Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy; 5Postgraduate School of Gastroenterology, Universita degli Studi di Milano; Gastroenterology Unit II, Fondazione Irccs Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy; 6Postgraduate School of Gastroenterology, Universita degli Studi di Milano; Gastroenterology Unit I, Fondazione Irccs Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy