Sheila Eswaran

Racial differences in fibrosis progression after HCV-related liver transplantation

Background Black recipients undergoing liver transplantation (LT) for hepatitis C virus (HCV) have decreased patient and graft survival compared with white recipients, a finding that is primarily limited to black recipients of livers from white donors. The cause(s) for these discrepant outcomes are unclear but may be related to HCV disease recurrence. The rates of HCV-related disease recurrence and liver fibrosis progression among black and white liver transplant recipients have not been investigated. Methods In this study, we compared liver fibrosis progression between 105 black and 364 white recipients after HCV-related LT in a multisite cohort study and assessed the impact of donor race. Results At 6, 12, and 24 months after LT, there was a significantly higher percentage in the black recipient/white donor (B/W) group with severe fibrosis, defined as stage 3 or 4 (F3/F4), compared with all other recipient/donor race combinations. The adjusted odds ratio of developing F3/F4 for the B/W group was 2.54 (1.49–4.69; reference group, white recipient/white donor). Black recipients with black donors demonstrated a similar rate of progression to F3/F4 as white recipients. Patient survival was also decreased in the B/W group compared with other recipient/donor race combinations. Conclusion African American recipients with white donors have more severe fibrosis progression after HCV-related LT. The mechanisms responsible for accelerating fibrosis progression in this high-risk race-mismatched group need to be investigated.

Niacin, the Internet, and Urine Drug Testing: A Cause of Acute Liver Failure

Niacin (Vitamin B3) is a naturally occurring human nutrient found in abundance in meat, yeast, vegetables, and seeds. Deficiencies of this vitamin lead to pellagra and it has also been found to be useful in the treatment of hypercholesterolemia. As the use of niacin has increased, several cases of hepatotoxicity have been reported resulting in the recommendation to initiate treatment with a lower dose and to monitor liver function test. We report two cases of hepatotoxicty in young adults who attempted to pass a drug screening test based on faulty internet advice to use niacin.

Transarterial chemoembolization for HCC in patients with extensive liver transplantation waiting times.

The treatment of hepatocellular cancer (HCC) with transarterial chemoembolization (TACE) prior to orthotopic liver transplant (OLT) is of increasing importance due to the rise in HCC incidence and donor shortage. This single-center study examines 28 patients treated with TACE and 7 patients not treated with TACE, with HCC prior to OLT between 1999 and 2008. The overall 1- and 5-year survival of all transplanted patients with HCC was 94% (33 of 35) and 80% (28 of 35). There was no difference in survival (P = .99) between patients who underwent transplantation immediately (median 95 days) and patients who had significantly longer wait times (median 308 days) when treated with TACE. During extensive wait times for OLT, TACE can be used to keep patients with HCC on the waiting list by preventing tumor progression, with similar outcomes compared with those who underwent transplantation immediately.

Limited Hepatitis B Immunoglobulin With Potent Nucleos(t)ide Analogue Is a Cost-Effective Prophylaxis Against Hepatitis B Virus After Liver Transplantation

BACKGROUND Prophylaxis against hepatitis B virus (HBV) recurrence after orthotopic liver transplantation (OLT) includes lifelong hepatitis B immunoglobulin (HBIG) and oral antiviral agent(s). In the presence of high-genetic-barrier nucleos(t)ide analogues, the need for lifelong HBIG is questioned. We evaluated the safety and cost-effectiveness of a limited HBIG course. METHODS OLT from 2006 to 2013 were reviewed. Patients with pre-OLT hepatitis B virus surface antigen who received HBV prophylaxis with 2 HBIG doses (anhepatic and first post-operative day; 10,000 units/dose) and potent nucleos(t)ide analogues were included. The primary end point was HBV recurrence (HBV-DNA detection). RESULTS Thirteen patients (primary transplants) were included, median Model for End-Stage Liver Disease score was 18, and there was no fulminant failure; HBV-DNA was detected in 4 patients at OLT. After OLT, 10 patients received entecavir and/or tenofovir. Median follow-up was 23 months. One recurrence occurred (7.7%) at month 13 (HBV-DNA: 14 IU/mL); the graft maintained excellent function. This minimal viremic expression is related to hepatocellular carcinoma recurrence with neoplastic replication carrying integrated HBV-DNA; thus, there is no defined HBV viral recurrence. No graft loss or patient death was related to HBV recurrence. The 1-year patient and graft survival rate was 84.6%. Cost-savings in the first year was

Outcomes after combined liver-kidney transplant vs. kidney transplant followed by liver transplant

178,100 per patient when compared with Food and Drug Administration-approved HBIG dosing. CONCLUSIONS In the era of potent oral nucleos(t)ide analogues, a limited HBIG course appears to be cost-effective in preventing HBV recurrence.

Intra-abdominal desmoid tumor after liver transplantation: A case report.

The decision for isolated kidney transplant (KT) vs. combined liver–kidney transplant (CLKT) in patients with end‐stage renal disease (ESRD) with compensated cirrhosis remains controversial. We sought to determine outcomes of patients requiring listing for a liver transplant (LT) following either a cadaveric or living donor KT and compare these outcomes to similar patients receiving a CLKT.

Outcomes Using Pediatric Small for Size Grafts in Adult Liver Transplant Recipients.: Abstract# B1095

We are reporting the first documented case of an abdominal desmoid tumor presenting primarily after liver transplantation. This tumor, well described in the literature as occurring both in conjunction with familial adenomatous polyposis as well as in the post-surgical patient, has never been noted after solid organ transplantation and was therefore not included in our differential upon presentation. Definitive diagnosis required the patient to undergo surgical excision and immunochemical staining of the mass for confirmation. A review of the literature showed no primary tumors after transplantation. In a population of patients who received a small bowel transplant after they developed short gut post radical resection of aggressive fibromatosis, only rare recurrences were seen. No connection of tumor development with immunosuppression or need to decrease immunosuppressant treatment has been demonstrated in these patients. Our case and the literature show the risk of this tumor presenting in the post-transplantation patient and the need for a high index of suspicion in patients who present with a complex mass after transplantation to prevent progression of the disease beyond a resectable lesion. Results of a thorough search of the literature are detailed and the medical and surgical management of both resectable and unresectable lesions is reviewed.

Outcomes of Early Liver Transplantation for Patients With Severe Alcoholic Hepatitis

B1095 Outcomes Using Pediatric Small for Size Grafts in Adult Liver Transplant Recipients. E. Chan, S. Fayek, R. Lieber, S. Eswaran, E. Cohen, N. Shah, M. Hertl. Rush University Medical Center, Chicago. Introduction: There is persistent shortage of cadaveric liver grafts for patients with end-stage liver disease. However, it is not unusual for pediatric grafts (age 1-17) to be offered to adult recipients which may be declined secondary to patient and recipient size miss-match. We looked at the outcomes of using small for size grafts for liver transplantation in a single institution. Methods: A retrospective review was performed in all liver transplant recipients at our medical center between 2002 -2012. Patients were included if they received a pediatric full-size graft. Patients who were listed as Status 1A were excluded. We correlated outcomes to recipient-weight-to-donor-weight ratio (RWDWR), recipient age, sex, donation after cardiac death (DCD), and recipient’s calculated Model for End Stage Liver Disease (MELD) score at time of transplant. Results: 68 patients were included in the analysis. Donor age ranged between 4-17 years. The RWDWR ranged from 4.54 to 0.5. There was no signifi cant difference regarding recipient MELD score or age. Using DCD grafts resulted in lower 1 year survival rates. Most strikingly, 1 month and 1 year survivals were inferior if the RWGWR was >3. RWDWR PATIENTS (N) GRAFT FAILURE (%) 1MONTH/1YEAR SURVIVAL 0.5-1 12 3/12 (25%) 83%/75% >1-2 27 10/27 (37%) 81%/63% >2-3 20 2/20 (10%) 95%/90% >3-4.5 9 5/9 (56%) 67%/44% ALL DCD 21 9/21 (57%) 86%/57% ALL PATIENTS 68 20/68 (41%) 84%/71% Conclusions: We caution against the use of small for size grafts if the RWDWR is >3. Pediatric grafts can have excellent outcomes if the recipient weight does not exceed the donor weight more than 3-fold. Our fi ndings will need to be confi rmed looking at national data. Abstract# B1096 The Charlson Comorbidity Index as a Predictor of Long-Term Outcome in Liver Transplantation: Single Centre Experience From the UK. S. Pathak,1 J. Dixon,1 J. Hutchinson,2 R. Jones,2 E. Hidalgo,1 K. Prasad.1 1Department of Hepatobiliary and Transplant Surgery, St James’s University Hospital, Leeds, United Kingdom; 2Department of Hepatology, St James’s University Hospital, Leeds, United Kingdom. Aims B1096 The Charlson Comorbidity Index as a Predictor of Long-Term Outcome in Liver Transplantation: Single Centre Experience From the UK. S. Pathak,1 J. Dixon,1 J. Hutchinson,2 R. Jones,2 E. Hidalgo,1 K. Prasad.1 1Department of Hepatobiliary and Transplant Surgery, St James’s University Hospital, Leeds, United Kingdom; 2Department of Hepatology, St James’s University Hospital, Leeds, United Kingdom. Aims Severity of liver disease and likelihood of post transplantation survival are used to prioritise liver graft allocation in potential recipients. Whilst there are several scoring systems used to predict patient survival pre-transplantation, such as the Model for End Stage Liver Disease (MELD), and the UKELD, there is a need to accurately predict post transplantation survival. Several co-morbidity indices exist for this purpose, although only the Charlson Co-morbidity IndexOrthoptic Liver Transplantation (CCI-OLT) score has been shown to accurately predict post-transplant survival. The purpose of this study was to validate the CCI-OLT score as an assessment tool for predicting survival in patients post OLT in a UK population. Methods A retrospective study of 313 patients was undertaken between November 2007 and December 2011. Data on pre-transplant comorbidities was collected and CCI-OLT scores calculated, along with baseline demographics, patient survival data, and number of days spent on the Intensive Care Unit (ICU). Statistical analysis examining for an association of CCI-OLT with patient survival and number of days on the ICU was performed using the Kaplan-Meier method and an unpaired t-test. Results Three hundred and thirteen patients were included with a median age of 54 years (range 20-73 years). Male to female ratio was 109:204, respectively. Ninety day mortality was 92.8%, 97.4%, 92.9% and 83.3% for patients with CCI-OLT scores of either zero, one, two, or equal and greater than three, respectively. The mean ICU stay was seven days (range 0-126 day). CCI-OLT predicted ICU stay; patients with scores equal or less than one had a signifi cantly shorter ICU stay than patients with scores of equal or greater than two (6 days vs 14 days, p<0.005). Conclusions CCI-OLT is a useful tool for predicting 90 day patient survival post OLT, with CCI scores equal or greater than three having a poorer prognosis than those scoring equal or less than two. Furthermore the CCI-OLT was shown to predict patient ICU stay. CCI-OLT should be used routinely as part of the OLT listing criteria. Abstract# B1097 Liver Transplantation for MELD-Score 40 Patients: Preliminary Results and Single Center Experience. S. Vernadakis,1,2 A. Paul,1 G. Gercken,3 G. Sotiropoulos.1 1Dept. of General, Visceral and Transplantation Surgery, University Hospital, Essen, Germany; 2Transplantation Unit, LAIKO University Hospital, Athens, Greece; 3Dept. of Gastroenterology and Hepatology, University Hospital, Essen, Germany. Objective: To identify factors infl uencing the survival of liver transplanted patients with Model-for-End-Stage-Liver-Disease (MELD)-Score of 40. Summary Background Data:Organ shortage and the related waiting-list mortality have led to changes in the allocation criteria and introduction of the MELD-Score in the Eurotransplant Era. The highest medical urgency represents the current allocation principle for liver transplantation (LT). Patients with MELD-Score 40 have a 3-month survival probability of almost 0% without LT. Patients and Methods: Data of all adult patients transplanted in a 3.5-year period with a labMELD-score 40 were reviewed. Recipients with acute liver failure, high urgency listed patients for re-transplantation or patients receiving live donor LT were excluded. All operations were performed using standard surgical techniques. Donor and recipient perioperative characteristics, operative details, treatmentrelated complications and pathological fi ndings were analyzed. Statistical analysis encompassed Kaplan-Meier analysis/log-rank test as well as univariate and multivariable Cox proportional hazard regression analyses. Results: Thirty patients were considered. The survival rate regarding the fi rst 3, 6 and 9 months was 53% respectively and 50% after one year. 3-year patient survival was 50%. A re-transplantation has been performed in 4 cases. Graft survival was 57% at 3, 6, and 9 months, and 53% at one year, respectively. Forty-three variables were evaluated for prognostic signifi cance. Multivariable analysis revealed preoperative dialysis (p=0.0246) and portal vein thrombosis (PVT) (p=0.0231) to be independent prognostic factors for patient survival. A point scoring system was determined as follows: patients without PVT: patients with PVT=0:1 points; patients without preLT dialysis: patients with pre-LT dialysis=0:1 points. The model reached statistical signifi cance (p=0.0007). 3-, and 12-months survival for scores 0, 1 and 2 were 72% and 72%, 51% and 42%, and 0%, respectively. Conclusions: According to our study coexistence of preoperative dialysis and PVT represents a clear contraindication for LT regarding MELD-score 40 patients. B1097 Liver Transplantation for MELD-Score 40 Patients: Preliminary Results and Single Center Experience. S. Vernadakis,1,2 A. Paul,1 G. Gercken,3 G. Sotiropoulos.1 1Dept. of General, Visceral and Transplantation Surgery, University Hospital, Essen, Germany; 2Transplantation Unit, LAIKO University Hospital, Athens, Greece; 3Dept. of Gastroenterology and Hepatology, University Hospital, Essen, Germany. Objective: To identify factors infl uencing the survival of liver transplanted patients with Model-for-End-Stage-Liver-Disease (MELD)-Score of 40. Summary Background Data:Organ shortage and the related waiting-list mortality have led to changes in the allocation criteria and introduction of the MELD-Score in the Eurotransplant Era. The highest medical urgency represents the current allocation principle for liver transplantation (LT). Patients with MELD-Score 40 have a 3-month survival probability of almost 0% without LT. Patients and Methods: Data of all adult patients transplanted in a 3.5-year period with a labMELD-score 40 were reviewed. Recipients with acute liver failure, high urgency listed patients for re-transplantation or patients receiving live donor LT were excluded. All operations were performed using standard surgical techniques. Donor and recipient perioperative characteristics, operative details, treatmentrelated complications and pathological fi ndings were analyzed. Statistical analysis encompassed Kaplan-Meier analysis/log-rank test as well as univariate and multivariable Cox proportional hazard regression analyses. Results: Thirty patients were considered. The survival rate regarding the fi rst 3, 6 and 9 months was 53% respectively and 50% after one year. 3-year patient survival was 50%. A re-transplantation has been performed in 4 cases. Graft survival was 57% at 3, 6, and 9 months, and 53% at one year, respectively. Forty-three variables were evaluated for prognostic signifi cance. Multivariable analysis revealed preoperative dialysis (p=0.0246) and portal vein thrombosis (PVT) (p=0.0231) to be independent prognostic factors for patient survival. A point scoring system was determined as follows: patients without PVT: patients with PVT=0:1 points; patients without preLT dialysis: patients with pre-LT dialysis=0:1 points. The model reached statistical signifi cance (p=0.0007). 3-, and 12-months survival for scores 0, 1 and 2 were 72% and 72%, 51% and 42%, and 0%, respectively. Conclusions: According to our study coexistence of preoperative dialysis and PVT represents a clear contraindicati