Miriam Maschmeier

Association Between Grade of Acute on Chronic Liver Failure and Response to Terlipressin and Albumin in Patients With Hepatorenal Syndrome

BACKGROUND & AIMS: Type 1 hepatorenal syndrome (HRS) is the most high‐risk type of renal failure in patients with cirrhosis. Terlipressin and albumin are effective treatments for type 1 HRS. However, the effects of acute on chronic liver failure (ACLF) grade on response to treatment are not clear. We aimed to identify factors associated with response to treatment with terlipressin and albumin in patients with type 1 HRS (reduction in serum level of creatinine to below 1.5 mg/dL at the end of treatment) and factors associated with death within 90 days of HRS diagnosis (90‐day mortality). METHODS: We performed a retrospective analysis of 4 different cohorts of consecutive patients with HRS treated with terlipressin and albumin from February 2007 through January 2016 at medical centers in Europe (total, 298 patients). We analyzed demographic, clinical, and laboratory data collected before and during treatment; patients were followed until death, liver transplantation, or 90 days after HRS diagnosis. RESULTS: Response to treatment was observed in 53% of patients. Of patients with grade 1 ACLF, 60% responded to treatment; among those with grade 2 ACLF, 48% responded, and among those with grade 3 ACLF, 29% responded (P < .001 for comparison between grades). In multivariate analysis, baseline serum level of creatinine (odds ratio, 0.23; P = .001) and ACLF grade (odds ratio, 0.63; P = .01) were independently associated with response to treatment. Patient age (hazard ratio [HR], 1.05; P < .001), white blood cell count (HR, 1.51; P = .006), ACLF grade (HR, 2.06; P < .001), and no response to treatment (HR, 0.41; P < .001) associated with 90‐day mortality. CONCLUSION: In a retrospective analysis of data from 4 cohorts of patients treated for type 1 HRS, we found ACLF grade to be the largest determinant of response to terlipressin and albumin. ACLF grade affects survival independently of response to treatment. New therapeutic strategies should be developed for patients with type 1 HRS and extrarenal organ failure.

Complications after endoscopic sphincterotomy in liver transplant recipients: A retrospective single-centre study

BACKGROUND AND STUDY AIMS Biliary tract complications after liver transplantation are usually treated by endoscopic retrograde cholangiopancreatography. When biliary tract intervention is indicated, endoscopic sphincterotomy is often required. However, data regarding complication rates after endoscopic sphincterotomy in liver transplant recipients are limited. This study therefore investigated complication rates during the first 15 days after endoscopic sphincterotomy in liver transplant recipients. PATIENTS AND METHODS This study retrospectively reviewed 157 consecutive liver transplant recipients who underwent endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy between January 1998 and August 2013 at the University Hospital of Münster, Germany. Complications that occurred within the first 15 days after the procedure were recorded, and complication rates were compared between patients who underwent conventional and precut endoscopic sphincterotomy. RESULTS A total of 24 complications (15.2%) were recorded, including 9 cases (5.7%) of pancreatitis, 6 cases (3.8%) of bleeding, and 1 case (0.6%) of perforation. There were no procedure-related deaths. There were no significant differences in complication rates between the two sphincterotomy techniques. The rate of post-procedural pancreatitis decreased over time. CONCLUSION Endoscopic sphincterotomy is a safe procedure in liver transplant recipients. The procedure-related complication rate is reasonable and most complications can be managed conservatively.

C4d Deposition – An Independent Predictor of Graft Failure Following Liver Transplantation

Introduction Patient and graft survival after liver transplantation (LT) has strongly improved in the last decades. However, new data are emerging regarding causes of graft failure. Studies indicate that humoral response to both HLA and non-HLA antigens have a detrimental effect on allograft survival. Aim To investigate clinical and immunological risk factors for graft failure at 5 years following LT. Methods A total of 174 LT recipients were enrolled in the study. Patients underwent biopsy for histologic and C4d examinations. Assessment of sMICA, sMICB and sULBP2 was realized by enzyme linked immunosorbent assay. Screening for anti-HLA class I, class II or MICA antibodies was performed using Luminex technology. Graft failure was defined as histologically proven liver cirrhosis or allograft dysfunction requiring relisting for LT or leading to death. Cox proportional hazards regression model was used to identify predictors of graft failure after LT. Results In the univariate analysis, the following factors were identified as risk factors for graft failure at 5 years: increasing donor age (p=0.0002), as well as the increasing recipient age (p=0.04), presence of disease recurrence after LT (p=0.03), presence of donor specific anti-HLA II antibodies >5000MFI (p=0.001), high serum levels of sMICA (p=0.01) and ULPB2 (p<0.0001), positive complement-dependent cytotoxic crossmatches at LT (p=0.0003), presence of positive C4d staining liver biopsies (p<0.0001). In multivariate analysis, C4d deposition (p<0.0001) and increased donor age (p=0.001) were independent predictors for graft failure at 5 years after LT. Conclusion C4d deposition and advanced age of the donor (>66 years) correlated with allograft injury among LT patients.

Portal Hypertensive Polyposis in Advanced Liver Cirrhosis: The Unknown Entity?

Background Portal hypertension is a serious complication of liver cirrhosis. Objective To identify relevant endoscopic findings in patients with advanced cirrhosis and consecutive portal hypertension. Methods This was a retrospective study of liver transplant candidates who underwent upper gastrointestinal endoscopy between April 2011 and November 2015. Results A total of 1,045 upper endoscopies were analyzed. Portal hypertensive gastric and duodenal polyps were frequently observed and were associated with thrombocytopenia (p = 0.040; OR: 2.4, 95% CI 1.04–5.50), Child-Pugh score > 6 (p = 0.033; OR: 2.3, 95% CI 1.07–4.92), Model for End Stage Liver Disease score > 16 (p = 0.030; OR: 4.1, 95% CI 1.14–15.00), and previous rubber band ligation (p < 0.001; OR = 5.2, 95% CI 2.5–10.7). These polyps often recurred after polypectomy; however, no malignant transformation occurred during the observational time until October 2017. The most common endoscopic finding was esophageal varices, observed in more than 90% of patients. Conclusion Portal hypertensive polyposis is common in patients with advanced cirrhosis. Our data suggest that these polyps have benign characteristics.

Sonografie der transplantierten Leber

The overall long-term survival rate of liver transplant patients is 70-75 %. During the early stages, the complications are vascular in nature, and in the later stages, biliary complications are major causes of morbidity. With the help of sonography, in particular with the addition of contrast enhanced ultrasound, a reliable diagnosis is possible. Despite this, in individual cases, other additional imaging methods should still be employed. The therapy should be used exclusively by interventional gastroentologists, radiologists or surgeons.Das Langzeituberleben von Lebertransplantierten liegt bei 70–75 %. Im fruhen Verlauf sind vaskulare und im spateren Verlauf biliare Komplikationen wichtige Ursachen der Morbiditat. Mithilfe der Sonografie, insbesondere mit Hinzunahme der Kontrastmittelsonografie, ist eine zuverlassige Diagnose moglich. Auf weitere bildgebende Verfahren sollte im Einzelfall nicht verzichtet werden. Die Therapie bleibt dem interventionellen Gastroenterologen bzw. Radiologen oder Chirurgen vorbehalten.

Langzeitbetreuung nach Organtransplantation

Due to advances in immunosuppressive therapy and surgical techniques, survival rates after solid organ transplantation have constantly improved over the last decades. In long-term care after transplantation, physicians need to focus as much on diagnosis and treatment of allograft-related complications as they should consider comorbidities and evaluate risk-factors and adverse events of immunosuppressive agents to prevent secondary diseases. In particular, cardiovascular and metabolic diseases, malignancy and infection play a major role in long-term survival. Therefore, screening of organ transplant recipients in regard to these complications and adverse events is a crucial part of follow up in these patients.