Characteristics and Outcomes of Liver Transplantation for Primary Biliary Cholangitis in Young Patients: Analysis of the United Network for Organ Sharing Database

The association of perioperative serum albumin concentrations with outcome after deceased donor liver transplantation

BACKGROUND

Perioperative hypoalbuminemia has been associated with worse outcome after major surgery. Although hypoalbuminemia is common in patients with chronic liver disease and frequently occurs following liver transplantation (LT), data are sparse regarding perioperative hypoalbuminemia and outcome after LT.

METHODS

In this single-center retrospective study performed at the Medical University of Vienna, we evaluated adult patients undergoing orthotopic liver transplantation (OLT) between 2004 and 2019. The association between perioperative serum albumin concentrations and survival, acute kidney injury (AKI), and postoperative surgical complications was analyzed using cox and logistic regression models.

RESULTS

In total, 724 patients were analyzed. Serum albumin concentrations decreased from 32.0 ± 6.8 to 22.8 ± 4.8 g/l (nadir within 48 h following OLT). Overall survival was not associated with serum albumin concentrations on day 1, day 2, or at nadir within 48 h after OLT (Day1: HR:0.988, 95%CI:0.966-1.011, P = 0.306; Day2: HR:1.021, 95%CI:0.991-1.052, P = 0.167; Nadir: HR:0.998, 95%CI:0.971-1.025, P = 0.863). Serum albumin concentrations on day 1, day 2, or at nadir within 48 h after OLT were not associated with AKI (Day1: OR:0.975, 95%CI:0.949-1.002, P = 0.070; Day2: OR:1.011, 95%CI:0.971-1.053, P = 0.601; Nadir: HR:0.976, 95%CI:0.940-1.013, P = 0.20) or with postoperative complications (Day1: OR:0.997, 95%CI:0.976-1.059, P = 0.80; Day2: OR:1.002, 95%CI:0.973-1.032, P = 0.890; Nadir: HR:0.993, 95%CI:0.966-1.021, P = 0.610). However, we observed an increased risk for initiation of renal replacement therapy with lower serum albumin concentrations on the day preceding initiation (HR = 0.946; 95%CI:0.896-1.000; P = 0.049).

CONCLUSION

Hypoalbuminemia was not associated with reduced survival, the development of AKI, or postoperative surgical complications after OLT. However, postoperative hypoalbuminemia was associated with the timing of initiating renal replacement therapy after OLT.

Primary biliary cholangitis: Epidemiology, prognosis, and treatment

Primary biliary cholangitis (PBC) is a chronic cholestatic autoimmune liver disease characterized by a destructive, small duct, and lymphocytic cholangitis, and marked by the presence of antimitochondrial antibodies. The incidence and prevalence of PBC vary widely in different regions and time periods, and although disproportionally more common among White non-Hispanic females, contemporary data show a higher prevalence in males and racial minorities than previously described. Outcomes largely depend on early recognition of the disease and prompt institution of treatment, which, in turn, are directly influenced by provider bias and socioeconomic factors. Ursodeoxycholic acid remains the initial treatment of choice for PBC, with obeticholic acid and fibrates (off-label therapy) reserved as add-on therapy for the management of inadequate responders or those with ursodeoxycholic acid intolerance. Novel and repurposed drugs are currently at different stages of clinical development not only for the treatment of PBC but also for its symptomatic management. Here, we summarize the most up-to-date data regarding the epidemiology, prognosis, and treatment of PBC, providing clinically useful information for its holistic management.

Prediction of Transplant-Free Survival through Albumin-Bilirubin Score in Primary Biliary Cholangitis

Albumin–bilirubin (ALBI) grade is defined using the ALBI score, which is calculated based on total serum bilirubin and albumin. This study aimed to evaluate the diagnostic ability of the ALBI score for determining hepatic fibrosis stage and transplant-free survival in primary biliary cholangitis (PBC) patients. A total of 181 Japanese patients with biopsy-proven or serologically diagnosed PBC were enrolled. The pathological stage was assessed using the Scheuer classification. The ALBI score differentiated fibrosis in stage 4 from that of 3 in the biopsy-proven cohort (p < 0.05). With an ALBI score cut-off value of −1.679, the sensitivity and specificity were 100% and 91.1%, respectively, with a likelihood ratio of 12.3 to differentiate stage 4 from stages 1–3. The ALBI score at the beginning of ursodeoxycholic acid (UDCA) prescription correlated with the two prognostic scores calculated after 1-year UDCA treatment. Kaplan–Meier analysis showed that the baseline ALBI score differentiated liver transplant-free survival (p < 0.05). The ALBI score presented a greater hazard ratio for transplant-free survival than aspartate aminotransferase-to-platelet ratio index (APRI) in Cox proportional hazard model. In conclusion, ALBI score indicates pathological stage in Japanese PBC patients and scores before UDCA prescription predict better liver transplant-free survival, which correlated well with the two major prognostic scores. The prognosis-predicting ability of the ALBI score might surpass that of APRI.

Safety of vedolizumab in liver transplant recipients: A systematic review

BACKGROUND

The management of inflammatory bowel disease in patients who have previously undergone liver transplantation can be a clinical challenge. There are serious concerns among physicians regarding the use of biologics for treating such immuno-compromised patients.

OBJECTIVE

We performed a systematic review on vedolizumab therapy in transplant recipients to assess its safety.

METHODS

PubMed/Embase/Scopus were searched up to November 2018 to identify papers regarding liver transplant recipients and therapy with vedolizumab. Primary outcomes were adverse events. Secondary outcomes were liver transplant and inflammatory bowel disease outcomes.

RESULTS

Eight studies (31 patients) were included. Nine out of 31 patients experienced an infection within a mean follow-up time ranging from 5-20 months. No malignancies were reported. Inflammatory bowel disease clinical response was experienced by 20/26 patients. Abnormalities in liver tests were recorded in 2/22 patients.

CONCLUSION

Vedolizumab may be considered safe for treating inflammatory bowel disease in liver transplant recipients. Caution is recommended for patients with an unstable liver graft function.