Preoperative Neutrophil-to-Lymphocyte Ratio as an Independent Predictor of 1-Year Graft Loss and Mortality After Orthotopic Liver Transplantation

The pretransplant neutrophil-lymphocyte ratio is associated with postreperfusion syndrome and short-term outcomes after paediatric living-donor liver transplantation

OBJECTIVE

The aim of this study was to evaluate whether the pretransplant neutrophil-lymphocyte ratio (NLR) is associated with postreperfusion syndrome (PRS) after paediatric living-donor liver transplantation (LDLT) and the impact of different pretransplant NLR values on short-term outcomes.

METHODS

Clinical data from paediatric patients who underwent LDLT for biliary atresia were retrospectively analysed. Receiver operating characteristic (ROC) curve analysis was used to evaluate the predictive value of the pretransplant NLR for PRS. The paediatric patients were stratified into two cohorts according to the optimal cut-off value, and their perioperative clinical indices were subsequently compared.

RESULTS

This retrospective study included 313 paediatric patients who had been diagnosed with biliary atresia. Based on ROC analysis, the area under the curve (AUC) of the NLR was 0.738, with a sensitivity of 73.1% and a specificity of 68.2% when predicting PRS. Paediatric patients were split into two groups according to the optimal NLR cut-off: NLR-Low (n = 158) and NLR-High (n = 155). Compared with the NLR-Low group, the NLR-High group had significantly more postoperative intensive care unit and hospitalisation days (p < 0.05). Furthermore, patients in the NLR-High group demonstrated a notably lower 1-year survival rate than their counterparts in the NLR-Low group did. An elevated NLR, a prolonged graft cold ischaemic time, and the occurrence of hypothermia before reperfusion are independent risk factors for PRS.

CONCLUSION

The pretransplant NLR is associated with postreperfusion syndrome in paediatric LDLT patients, and an elevated NLR is correlated with unfavourable short-term postoperative outcomes in paediatric patients after LDLT.

Nomogram for predicting myocardial injury in pediatric patients undergoing living donor liver transplantation for biliary atresia

BACKGROUND

Myocardial injury is common during liver transplantation and is associated with poor outcomes. The development of a reliable prediction system for this type of injury is crucial for reducing the incidence of cardiac complications in children receiving living donor liver transplantation (LDLT). However, establishing a practical myocardial injury prediction system for children with biliary atresia remains a considerable challenge.

AIM

To create and validate a nomogram model for predicting myocardial injury in children with biliary atresia who received LDLT.

METHODS

Clinical data from pediatric patients who received LDLT for biliary atresia between November, 2019 and January, 2022 were retrospectively analyzed. The complete dataset was randomly partitioned into a training set and a validation set at a ratio of 7:3. Least absolute shrinkage and selection operator regression was used to preliminarily screen out the predictors of myocardial injury. The prediction model was established via multivariable logistic regression and presented in the form of a nomogram.

RESULTS

This study included 321 patients, 150 (46.7%) of whom had myocardial injury. The participants were randomly allocated into two groups: A training group consisting of 225 patients and a validation group comprising 96 patients. The predictors in this nomogram included the preoperative neutrophil-to-lymphocyte ratio, high sensitivity C-reactive protein level, pediatric end-stage liver disease score and postreperfusion syndrome. The area under the curve for predicting myocardial injury was 0.865 in the training set and 0.856 in the validation set. The calibration curve revealed that the predicted values were very close to the actual values in the two sets. Decision curve analysis revealed that the prediction model offered a favorable net benefit.

CONCLUSION

The nomogram developed in this study effectively predicts myocardial injury in pediatric LDLT patients, showing good accuracy and potential for clinical application.

Importance of the neutrophil-to-lymphocyte ratio as a marker for microbiological specimens in critically ill patients after liver or lung transplantation

PURPOSE

The correct and early diagnosis of an infection is pivotal for patients, especially if the patients are immunocompromised. Various infection markers are used in clinics with different advantages and disadvantages. The neutrophil-to-lymphocyte ratio (NLR) is a cost effective parameter easily obtained without further investments. The aim of this study is to elucidate the value of the NLR in comparison to other established inflammation markers in patients in the intensive care unit who underwent liver or lung transplantation for the detection of bacterial and fungal specimens.

METHODS

In this retrospective single centre study infection marker and microbiology data of 543 intensive care cases of liver or lung transplanted patients in the intensive care unit after transplantation were analysed.

RESULTS

In total 5,072 lab work results and 1,104 positive microbiology results were analysed. Results of an area under curve analysis were better for the NLR (0.631; p < 0.001) than for CRP (0.522; p = 0.152) or IL-6 (0.579; p < 0.001). The NLR was independent of type of organ which was transplanted and gender of patients, whereas IL-6 values differed significantly between liver and lung transplanted patients and between male and female.

CONCLUSION

All analysed inflammation markers are far from being perfect. The NLR is a sensitive marker with reasonable threshold for the detection of microbiological specimens independent of gender or type of organ transplanted. The use allows a more differentiated approach to face the challenge of bacteria and fungus in patients who underwent liver or lung transplantation.

Does prior radiotherapy impact the acute cellular liver graft rejection?

PURPOSE

Radiotherapy can be used as a bridge therapy prior to liver transplantation. Radiotherapy generates immune reactions involving T cells, which are the main effectors of acute cellular rejection after transplantation. Here, we investigated the impact of radiotherapy on acute cellular rejection.

MATERIALS AND METHODS

We retrospectively reviewed the data of oncological patients who benefited from liver transplantation. Patients who received radiotherapy prior to liver transplantation ("RT cohort", n=17) were compared to a matched cohort ("NoRTmatched cohort", n=17) obtained through propensity score-matching analysis of the total non-irradiated cohort ("NoRTall" cohort, n=136). The acute cellular rejection was evaluated using the Banff score for rejection (mild:<5, moderate: 5-6, and severe: 7-9) obtained on an early post-transplantation biopsy. Overall and disease-free survival were reported for patients with hepatocellular carcinoma.

RESULTS

Median Banff scores was significantly lower for the RT cohort compared to the NoRTall cohort (2.5 versus 5, respectively, P=0.043) but this statistical difference was eliminated after comparison with the NoRTmatched cohort (median: 4, P=0.62). The 5-year overall and disease-free survival rates were 62 % and 69 %, respectively, for hepatocellular carcinoma patients of the RT cohort (n=14) and did not differ from the 5-year overall (83 %, P=0.15) and disease-free survival rates (90 %, P=0.05) of those of the NoRTmatched cohort (n=16).

CONCLUSION

Radiotherapy given prior to liver transplantation did not impact the rate or severity of acute cellular rejection. Furthermore, overall and disease-free survival rates were not impacted by radiotherapy.

Sevoflurane preconditioning in living liver donation is associated with better initial graft function after pediatric transplantation: a retrospective study

INTRODUCTION

Initial allograft function determines the patient's immediate prognosis in pediatric liver transplantation. Ischemia-reperfusion injuries play a role in initial poor graft function (IPGF). In animal studies, preconditioning with inhaled anesthetic agents has demonstrated a protective effect on the liver. In humans, the few available studies are conflicting. This study assesses the association between the hypnotic agent used to maintain anesthesia during hepatectomy in living donors and the occurrence of IPGF after pediatric transplantation.

METHODS

We conducted a single-center retrospective analysis of children who received a living donor liver transplant (LDLT) between 2010 and 2019. We analyzed the incidence of EAD according to the hypnotic agent used to maintain general anesthesia during donor hepatectomy.

RESULTS

We included 183 pairs of patients (living donors-recipients). The anesthetics used in the donor were propofol (n = 85), sevoflurane (n = 69), or propofol with sevoflurane started 30 min before clamping (n = 29). Forty-two children (23%) developed IPGF. After multivariate logistic regression analysis, factors significantly associated with the occurrence of IPGF were the anesthesia maintenance agent used in the donor (p = 0.004), age of the donor (p = 0.03), duration of transplant surgery (p = 0.009), preoperative receiver neutrophil to lymphocyte ratio (p = 0.02), and albumin (p = 0.05).

CONCLUSION

Significantly fewer children who received a graft from a donor in whom only sevoflurane was used to maintain anesthesia developed IPGF. Although additional research is needed, this preconditioning strategy may provide an option to prevent IPGF after living liver donation.

High visceral adipose tissue area is independently associated with early allograft dysfunction in liver transplantation recipients: a propensity score analysis

OBJECTIVES

To evaluate the association between adipose tissue distribution and early allograft dysfunction (EAD) in liver transplantation (LT) recipients.

METHODS

A total of 175 patients who received LT from April 2015 to September 2020 were enrolled in this retrospective study. The areas of abdominal adipose tissue and skeletal muscle of all patients were measured based on the preoperative CT images. The appropriate statistical methods including the propensity score-matched (PSM) analysis were performed to identify the association between adipose tissue distribution and EAD.

RESULTS

Of 175 LT recipients, 55 patients (31.4%) finally developed EAD. The multivariate logistic analysis revealed that preoperative serum albumin (odds ratio (OR) 0.34, 95% confidence interval (CI) 0.17-0.70), platelet-lymphocyte ratio (OR 2.35, 95% CI 1.18-4.79), and visceral adipose tissue (VAT) area (OR 3.17, 95% CI 1.56-6.43) were independent associated with EAD. After PSM analysis, VAT area was still significantly associated with EAD (OR 3.95, 95% CI 1.16-13.51). In survival analysis, no significant difference was identified in one-year graft failure (log-rank: p = 0.487), and conversely result was identified in overall survival (OS) (log-rank: p = 0.012; hazard ratio (HR) 4.10, 95% CI 1.27-13.16).

CONCLUSIONS

LT recipients with high VAT area have higher risk for the occurrence of EAD, and high VAT area might have certain clinical value for predicting the poor OS of patients. For LT candidates with large amount of VAT, the clinicians can take clinical interventions by suggesting physical and nutritional treatments to improve outcomes after LT.

The Provocative Roles of Platelets in Liver Disease and Cancer

Both platelets and the liver play important roles in the processes of coagulation and innate immunity. Platelet responses at the site of an injury are rapid; their immediate activation and structural changes minimize the loss of blood. The majority of coagulation proteins are produced by the liver—a multifunctional organ that also plays a critical role in many processes: removal of toxins and metabolism of fats, proteins, carbohydrates, and drugs. Chronic inflammation, trauma, or other causes of irreversible damage to the liver can dysregulate these pathways leading to organ and systemic abnormalities. In some cases, platelet-to-lymphocyte ratios can also be a predictor of disease outcome. An example is cirrhosis, which increases the risk of bleeding and prothrombotic events followed by activation of platelets. Along with a triggered coagulation cascade, the platelets increase the risk of pro-thrombotic events and contribute to cancer progression and metastasis. This progression and the resulting tissue destruction is physiologically comparable to a persistent, chronic wound. Various cancers, including colorectal cancer, have been associated with increased thrombocytosis, platelet activation, platelet-storage granule release, and thrombosis; anti-platelet agents can reduce cancer risk and progression. However, in cancer patients with pre-existing liver disease who are undergoing chemotherapy, the risk of thrombotic events becomes challenging to manage due to their inherent risk for bleeding. Chemotherapy, also known to induce damage to the liver, further increases the frequency of thrombotic events. Depending on individual patient risks, these factors acting together can disrupt the fragile balance between pro- and anti-coagulant processes, heightening liver thrombogenesis, and possibly providing a niche for circulating tumor cells to adhere to—thus promoting both liver metastasis and cancer-cell survival following treatment (that is, with minimal residual disease in the liver).