Nathan J. Shores

Kidney transplantation alone in ESRD patients with hepatitis C cirrhosis.

Background Kidney transplantation (KTx) alone in patients with cirrhosis and renal failure (end-stage renal disease [ESRD]) infected with hepatitis C virus (HCV) is controversial. The aim of this study was to compare outcomes of HCV+ patients with ESRD and cirrhosis (C group) versus HCV+ patients with ESRD but with no cirrhosis (NC group) listed for KTx. Methods Ninety HCV+ patients with ESRD were evaluated for KTx between 2003 and 2010. Listed patients underwent transjugular liver biopsy with hepatic portal venous gradient (HPVG) measurements. Only patients with HPVG less than 10 mm Hg were considered for KTx alone. We analyzed patient demographics, waitlist/liver disease characteristics, and posttransplant outcomes between groups. Results Sixty-four patients listed for KTx alone were studied. Twelve patients (18.75%) showed biopsy-proven cirrhosis. Thirty-seven patients underwent KTx alone (9 from C and 28 from NC). No patients developed decompensation of their liver disease, although one patient for NC group developed metastatic hepatocellular carcinoma 16 months after transplantation. One- and three-year graft survival rates were 75% and 75% versus 92.1% and 75.1% for groups C and NC, respectively (P=0.72). One- and three-year patient survival rates were 88.9% and 88.9% versus 96.3% and 77.9% for groups C and NC, respectively (P=0.76). Only increasing recipient age and decreasing albumin levels were significantly associated with worse graft and patient survival. Conclusions Our study suggests that KTx alone may be safe in patients with compensated HCV, cirrhosis, and ESRD with HPVG less than 10 mm Hg. A simultaneous liver-kidney transplantation may be an unnecessary use of a liver allograft in these patients.

Is Oral l-Acyl-Carnitine an Effective Therapy for Hepatic Encephalopathy? Review of the Literature

Hepatic encephalopathy (HE) is a significant cause of morbidity and mortality in patients with advanced chronic liver disease. Current therapies are associated with inconvenient side-effects, high cost, and incomplete efficacy. The quanternary ammonium compound l-acyl-carnitine has been suggested as a potent, low-cost, and safe alternative therapy for patients with cirrhosis and HE. A systematic review of the literature assessing the use of carnitine in the treatment of HE identified three high-quality human trials for review. Analysis of the selected carnitine trials compared to currently accepted therapies suggests that l-acyl-carnitine is promising as a safe and effective treatment for HE, and further trials of this drug are warranted.

Thyroid Storm Complicated by Fulminant Hepatic Failure: Case Report and Literature Review

Objectives: Thyroid storm is a presentation of severe thyrotoxicosis that has a mortality rate of up to 20% to 30%. Fulminant hepatic failure (FHF) entails encephalopathy with severe coagulopathy in the setting of liver disease. It carries a high mortality rate, with an approximately 60% rate of overall survival for patients who undergo orthotopic liver transplantation (OLT). Fulminant hepatic failure is a rare but serious complication of thyroid storm. There have been only 6 previously reported cases of FHF with thyroid storm. Methods: We present a patient from our institution with thyroid storm and FHF. A literature review was performed to analyze the outcomes of the 6 additional cases of concomitant thyroid storm and FHF. Results: Our patient underwent thyroidectomy followed by OLT. Her serum levels of thyroid-stimulating hormone, triiodothyronine, thyroxine, and transaminase normalized, and she was ready for discharge within 10 days of surgery. She has survived without complication. There is a 40% mortality rate for the reported patients treated medically with these conditions. Of the 7 total cases of reported FHF and thyroid storm, 2 patients died. Only 2 of the 7 patients underwent thyroidectomy and OLT — Both at our institution. Both patients survived without complications. Conclusions: Thyroid storm and FHF each independently carry high mortality rates, and managing patients with both conditions simultaneously is an extraordinary challenge. These cases should compel clinicians to investigate liver function in hyperthyroid patients and to be wary of its rapid decline in patients who present in thyroid storm with symptoms of liver dysfunction. Patients with rapidly progressing thyroid storm and FHF should be considered for total thyroidectomy and OLT.

Uvular Necrosis after Endoscopy

A 28-year-old man presented with a sore throat 72 hours after undergoing upper endoscopy with dilation of a Schatzki ring. He noted a sore throat, starting 24 hours after the procedure.

Portal vein thrombosis in liver transplantation: radiologic evaluation, risk factors, and occult diagnosis

Aim: Portal vein thrombosis (PVT) in the liver transplant recipient poses many challenges. Unfortunately, the risk factors and effects on outcomes of PVT are not well-defined. Methods: This study analyzed the experience with PVT in liver transplant program from 2007 to 2013. This included the effectiveness of PVT diagnostics and its risk factors using logistical regression. The primary endpoints were Kaplan-Meir patient and graft survival. The secondary endpoints were the length of stay (LOS), transfusion rate, and overall morbidity. Independent predictors of survival were identified using a Cox’s proportional hazards model. Results: Two hundred and sixteen consecutive liver transplant recipients were examined, and 30 (13.8%) had either a total or partial PVT. Two hundred and five patients had imaging within 1 year of liver transplantation with only 7 (23.3%) of the 30 PVTs identified pre-operatively. Calculated sensitivity (4.8-50%) and negative predictive values (10.5-22.2%) were poor. Only, age significantly predicted PVT [P = 0.037/hazard ratio (HR) =0.95]. Ninety-day-patient and graft survival for PVT was similar at 6 months, although 1-year survival was significantly lower. “Occult” PVT was not associated with inferior survival. Model for end-stage liver disease score > 25 (P = 0.001, HR = 0.49/P = 0.004, HR = 0.52) and age > 60 years (P = 0.017, HR = 0.64/P = 0.013, HR = 0.67) were significant predictors of patient and graft survival. Although the transfusion rate was significantly greater with PVT, LOS, and morbidity were not. Conclusion: Older recipients had a greater likelihood of PVT. Diagnostic studies were not effective at excluding PVT, and occult diagnosis did not affect the outcome. PVT was not an independent predictor of mortality or graft loss, but was associated with greater blood loss but not increased LOS or morbidity.

ERCP Cannulation Using Precut Techniques

With the emergence of endoscopic ultrasound and magnetic resonance retrograde cholangiopancreatography for the non-invasive diagnosis of hepatobiliary and pancreatic (HBP) disease, ERCP has evolved into a predominantly therapeutic technique. Failed bile duct or pancreatic duct cannulation may result in persistent patient morbidity and the need for more invasive procedures (e.g. biliary surgery and/or percutaneous biliary drainage). So-called needle knife pre-cut (NKP) biliary and pancreatic sphincterotomy has emerged as a useful technique when standard cannulation proves difficult. Multiple small retrospective studies – and handful of prospective reports – suggest that in expert hands, NKP is a safe and effective means of achieving therapeutic cannulation. NKP should only be performed by skilled endoscopists with supervised training in the procedure, a detailed knowledge of HBP anatomy, a thorough understanding of the physics of electrosurgery and the ability to place protective (prophylactic) pancreatic duct stents. Various techniques of ‘free-hand’ NKP are described, as well as transsphincteric papillotomy (the Goff technique). Pre-NKP preparation requires careful attention to coagulation issues, and post-NKP patients need to be monitored for complications including pancreatitis, bleeding, perforation and sepsis. After failed NKP in the setting of biliary obstruction, the patient must remain on broad-spectrum antibiotic coverage and a decision made regarding the urgency of biliary drainage. If this cannot wait at least 2–3 days for the NKP site to mature, the patient should be referred for urgent percutaneous biliary drainage or surgery.