Predictors of Long-Term Outcomes After Liver Transplantation for Unresectable Metastatic Neuroendocrine Tumors

BACKGROUND Malignant and benign neuroendocrine tumors (NET) share many histopathological features. Liver transplantation (LT) is one of the liver-directed therapies for neuroendocrine liver metastases (NELM). The aim of this study was to determine the outcomes of patients undergoing LT for NELM. MATERIAL AND METHODS This was a retrospective study that included 19 patients who underwent LT for unresectable NELM between December 1989 and December 2022 in the Department of General, Transplant, and Liver Surgery of the Medical University of Warsaw. Kaplan-Meier estimator and Cox proportional hazards regression were used for statistical analyses. RESULTS The primary tumor was located most frequently in the pancreas. The median follow-up was 72.5 months. The overall survival (OS) was 94.7%, 88.0%, 88.0%, 70.4%, and 49.3% after 1, 3, 5, 10, and 15 years, respectively. Accordingly, the recurrence-free survival (RFS) rates were 93.8%, 72.9%, 64.8%, 27.8%, and 27.8% after 1, 3, 5, 10, and 15 years, respectively. Ki-67 index ≥5% was found as a risk factor for both worse OS (hazard ratio (HR) 7.13, 95% confidence intervals (95% CI) 1.32-38.63, P=0.023) and RFS (HR 13.68, 95% CI 1.54-121.52, P=0.019). Recipient age ≥55 years was a risk factor for worse RFS (P=0.046, HR 5.47, 95% CI 1.03-29.08). Multivariable analysis revealed Ki-67 ≥5% as the sole independent factor for worse OS (HR 13.78, 95% CI 1.48-128.56, P=0.021). CONCLUSIONS Patients with unresectable NELM achieve great OS and satisfying RFS after LT. The risk factors associated with worse outcomes are attributed to primary tumor aggressiveness.

Routine End-ischemic Hypothermic Oxygenated Machine Perfusion in Liver Transplantation From Donors After Brain Death: A Randomized Controlled Trial

OBJECTIVE

To assess whether end-ischemic hypothermic oxygenated machine perfusion (HOPE) is superior to static cold storage (SCS) in preserving livers procured from donors after brain death (DBD).

BACKGROUND

There is increasing evidence of the benefits of HOPE in liver transplantation, but predominantly in the setting of high-risk donors.

METHODS

In this randomized clinical trial, livers procured from DBDs were randomly assigned to either end-ischemic dual HOPE for at least 2 hours or SCS (1:3 allocation ratio). The Model for Early Allograft Function (MEAF) was the primary outcome measure. The secondary outcome measure was 90-day morbidity (ClinicalTrials. gov, NCT04812054).

RESULTS

Of the 104 liver transplantations included in the study, 26 were assigned to HOPE and 78 to SCS. Mean MEAF was 4.94 and 5.49 in the HOPE and SCS groups ( P =0.24), respectively, with the corresponding rates of MEAF >8 of 3.8% (1/26) and 15.4% (12/78; P =0.18). Median Comprehensive Complication Index was 20.9 after transplantations with HOPE and 21.8 after transplantations with SCS ( P =0.19). Transaminase activity, bilirubin concentration, and international normalized ratio were similar in both groups. In the case of donor risk index >1.70, HOPE was associated with significantly lower mean MEAF (4.92 vs 6.31; P =0.037) and lower median Comprehensive Complication Index (4.35 vs 22.6; P =0.050). No significant differences between HOPE and SCS were observed for lower donor risk index values.

CONCLUSION

Routine use of HOPE in DBD liver transplantations does not seem justified as the clinical benefits are limited to high-risk donors.

Alpha-Fetoprotein Response after First Transarterial Chemoembolization (TACE) and Complete Pathologic Response in Patients with Hepatocellular Cancer

Transarterial chemoembolization (TACE) is used as a bridging treatment in liver transplant candidates with hepatocellular carcinoma (HCC). Alpha-fetoprotein (AFP) is the main tumor marker used for HCC surveillance. The aim of this study was to assess the potential of using the AFP change after the first TACE in the prediction of complete tumor necrosis. The study comprised 101 patients with HCC who underwent liver transplantation (LT) after TACE in the period between January 2011 and December 2020. The ΔAFP was defined as the difference between the AFP value before the first TACE and AFP either before the second TACE or the LT. The receiver operator characteristics (ROC) curves were used to identify an optimal cut-off value. Complete tumor necrosis was found in 26.1% (18 of 69) and 6.3% (2 of 32) of patients with an initial AFP level under and over 100 ng/mL, respectively (p = 0.020). The optimal cut-off value of ΔAFP for the prediction of complete necrosis was a decline of ≥10.2 ng/mL and ≥340.5 ng/mL in the corresponding subgroups. Complete tumor necrosis rates were: 62.5% (5 of 8) in patients with an initial AFP < 100 ng/mL and decline of ≥10.2 ng/mL; 21.3% (13 of 61) in patients with an initial AFP < 100 ng/mL and decline of <10.2 ng/mL; 16.7% (2 of 12) in patients with an initial AFP > 100 ng/mL and decline of ≥340.5 ng/mL; and null in 20 patients with an initial AFP > 100 ng/mL and decline of <340.5 ng/mL, respectively (p = 0.003). The simple scoring system, based on the initial AFP and AFP decline after the first treatment, distinguished between a high, intermediate and low probability of complete necrosis, with an area under the ROC curve of 0.699 (95% confidence intervals 0.577 to 0.821, p = 0.001). Combining the initial AFP with its change after the first treatment enables early identification of the efficacy of TACE.

Postoperative Supplemental Oxygen in Liver Transplantation (PSOLT) does not reduce the rate of infections: results of a randomized controlled trial

BACKGROUND

Despite inconsistent evidence, international guidelines underline the importance of perioperative hyperoxygenation in prevention of postoperative infections. Further, data on safety and efficacy of this method in liver transplant setting are lacking. The aim was to evaluate efficacy and safety of postoperative hyperoxygenation in prophylaxis of infections after liver transplantation.

METHODS

In this randomized controlled trial, patients undergoing liver transplantation were randomly assigned to either 28% or 80% fraction of inspired oxygen (FiO₂) for 6 postoperative hours. Infections occurring during 30-day post-transplant period were the primary outcome measure. Secondary outcome measures included 90-day mortality, 90-day severe morbidity, 30-day pulmonary complications, durations of hospital and intensive care unit stay, and 5-day postoperative bilirubin concentration, alanine and aspartate transaminase activity, and international normalized ratio (INR) (clinicatrials.gov NCT02857855).

RESULTS

A total of 193 patients were included and randomized to 28% (n = 99) and 80% (n = 94) FiO₂. With similar patient, operative, and donor characteristics in both groups, infections occurred in 34.0% (32/94) of patients assigned to 80% FiO₂ as compared to 23.2% (23/99) of patients assigned to 28% FiO₂ (p = 0.112). Patients randomized to 80% FiO₂ more frequently developed severe complications (p = 0.035), stayed longer in the intensive care unit (p = 0.033), and had higher bilirubin concentration over first 5 post-transplant days (p = 0.043). No significant differences were found regarding mortality, duration of hospital stay, pulmonary complications, and 5-day aspartate and alanine transaminase activity and INR.

CONCLUSIONS

Postoperative hyperoxygenation should not be used for prophylaxis of infections after liver transplantation due to the lack of efficacy.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02857855. Registered 7 July 2016.

Skin Autofluorescence Measurement as Initial Assessment of Hepatic Parenchyma Quality in Patients Undergoing Liver Resection

Skin autofluorescence (SAF) can detect advanced glycation end products (AGEs) that accumulate in tissues over time. AGEs reflect patients’ general health, and their pathological accumulation has been associated with various diseases. This study aimed to determine whether its measurements can correlate with the liver parenchyma quality. This prospective study included 186 patients who underwent liver resections. Liver fibrosis and/or steatosis > 10% were found in almost 30% of the patients. ROC analysis for SAF revealed the optimal cutoff point of 2.4 AU as an independent predictor for macrovesicular steatosis ≥ 10% with an AUC of 0.629 (95% CI 0.538−0.721, p = 0.006), 59.9% sensitivity, 62.4% specificity, and positive (PPV) and negative (NPV) predictive values of 45.7% and 74.1%, respectively. The optimal cutoff point for liver fibrosis was 2.3 AU with an AUC of 0.613 (95% CI 0.519−0.708, p = 0.018), 67.3% sensitivity, 55.2% specificity, and PPV and NPV of 37.1% and 81.2%, respectively. In the multivariable logistic regression model, SAF ≥ 2.4 AU (OR 2.16; 95% CI 1.05−4.43; p = 0.036) and BMI (OR 1.21; 95% CI 1.10−1.33, p < 0.001) were independent predictors of macrovesicular steatosis ≥ 10%. SAF may enhance the available non-invasive methods of detecting hepatic steatosis and fibrosis in patients prior to liver resection.

The Effect of Early Retransplantation on Early and Late Survival After Liver Transplantation

BACKGROUND

Early liver retransplantation after liver transplantation (LT) is the ultimate salvage procedure for irreversible graft failure. The aim of this study was to assess the impact of early retransplantation on 90-day and 5-year patient survival.

METHODS

This retrospective cohort study included 2185 patients after LT in the period between 1997 and 2019. First, the patients undergoing first retransplantation within 6 months after initial LT were compared with naïve LT patients for early mortality (within 90 days). Second, to assess late survival, the patients who had retransplantation and survived at least 90 days post LT were compared with naïve LT patients for 5-year overall survival. The patients undergoing late retransplantation (>6 months) were excluded from analyses. Fisher's exact test was used to compare groups for early survival and log-rank test for late survival.

RESULTS

The cumulative 1-, 3-, and 5-year overall survival was 87.0%, 79.9%, 75.0%, respectively, and did not differ significantly between the groups. The patients undergoing early retransplantation had lower 90-day survival rate of 89.2% as compared to 95.7% for naïve LT patients (P < .001).

CONCLUSIONS

The early liver retransplantation has profound impact on post-LT 90-day survival; however, patients who survive that period can achieve long overall survival comparable with naïve LT patients.

Early results of the implementation of laparoscopic major liver resection program

Background

Laparoscopic liver resections offer potential benefits but may require advanced laparoscopic skills and are volume dependent.

Methods

This retrospective study included 12 patients who underwent major laparoscopic resection and 24 patients after open major liver resection for liver malignancy in the time period between September 2020 and May 2021. The primary outcomes were complications according to Clavien-Dindo classification and duration of hospital stay.

Results

Median duration of hospital stay in laparoscopic resection group (6 days) was significantly shorter than in open resection group (8 days) (p = 0.046). Complications classified as grade II or higher were significantly less frequent in the laparoscopic resection group (2 patients) versus open resection group (13 patients) (p = 0.031).

Conclusions

Although laparoscopic major liver resections should be limited to expert hepatobiliary centers and are characterized by long learning curve, this approach may offer favorable short-term outcomes even during launching a new program.

The molecular phenotypes of injury, steatohepatitis, and fibrosis in liver transplant biopsies in the INTERLIVER study

To extend previous molecular analyses of rejection in liver transplant biopsies in the INTERLIVER study (ClinicalTrials.gov #NCT03193151), the present study aimed to define the gene expression selective for parenchymal injury, fibrosis, and steatohepatitis. We analyzed genome-wide microarray measurements from 337 liver transplant biopsies from 13 centers. We examined expression of genes previously annotated as increased in injury and fibrosis using principal component analysis (PCA). PC1 reflected parenchymal injury and related inflammation in the early posttransplant period, slowly regressing over many months. PC2 separated early injury from late fibrosis. Positive PC3 identified a distinct mildly inflamed state correlating with histologic steatohepatitis. Injury PCs correlated with liver function and histologic abnormalities. A classifier trained on histologic steatohepatitis predicted histologic steatohepatitis with cross-validated AUC = 0.83, and was associated with pathways reflecting metabolic abnormalities distinct from fibrosis. PC2 predicted histologic fibrosis (AUC = 0.80), as did a molecular fibrosis classifier (AUC = 0.74). The fibrosis classifier correlated with matrix remodeling pathways with minimal overlap with those selective for steatohepatitis, although some biopsies had both. Genome-wide assessment of liver transplant biopsies can not only detect molecular changes induced by rejection but also those correlating with parenchymal injury, steatohepatitis, and fibrosis, offering potential insights into disease mechanisms for primary diseases.

Incisional Surgical Site Infections After Mass and Layered Closure of Upper Abdominal Transverse Incisions: First Results of a Randomized Controlled Trial

OBJECTIVE

To compare the early results of mass and layered closure of upper abdominal transverse incisions.

SUMMARY OF BACKGROUND DATA

Contrary to midline incisions, data on closure of transverse abdominal incisions are lacking.

METHODS

This is the first analysis of a randomized controlled trial primarily designed to compare mass with layered closure of transverse incisions with respect to incisional hernias. Patients undergoing laparotomy through upper abdominal transverse incisions were randomized to either mass or layered closure with continuous sutures. Incisional surgical site infection (incisional-SSI) was the primary end-point. Secondary end-points comprised suture-to-wound length ratio (SWLR), closure duration, and fascial dehiscence (clinicatrials.gov NCT03561727).

RESULTS

A total of 268 patients were randomized to either mass (n=134) or layered (n=134) closure. Incisional-SSIs occurred in 24 (17.9%) and 8 (6.0%) patients after mass and layered closure, respectively (P =0.004), with crude odds ratio (OR) of 0.29 [95% confidence interval (95% CI) 0.13-0.67; P =0.004]. Layered technique was independently associated with fewer incisional-SSIs (OR: 0.29; 95% CI 0.12-0.69; P =0.005). The number needed to treat, absolute, and relative risk reduction for layered technique in reducing incisional-SSIs were 8.4 patients, 11.9%, and 66.5%, respectively. Dehiscence occurred in one (0.8%) patient after layered closure and in two (1.5%) patients after mass closure (P >0.999). Median SWLR were 8.1 and 5.6 (P <0.001) with median closure times of 27.5 and 25.0 minutes (P =0.044) for layered and mass closures, respectively.

CONCLUSIONS

Layered closure of upper abdominal transverse incisions should be preferred due to lower risk of incisional-SSIs and higher SWLR, despite clinically irrelevant longer duration.

Skin autofluorescence as a novel predictor of acute kidney injury after liver resection

Abstract

Background

Skin autofluorescence (SAF) reflects accumulation of advanced glycation end-products (AGEs). The aim of this study was to evaluate predictive usefulness of SAF measurement in prediction of acute kidney injury (AKI) after liver resection.

Methods

This prospective observational study included 130 patients undergoing liver resection. The primary outcome measure was AKI. SAF was measured preoperatively and expressed in arbitrary units (AU).

Results

AKI was observed in 32 of 130 patients (24.6%). SAF independently predicted AKI (p = 0.047), along with extent of resection (p = 0.019) and operative time (p = 0.046). Optimal cut-off for SAF in prediction of AKI was 2.7 AU (area under the curve [AUC] 0.611), with AKI rates of 38.7% and 20.2% in patients with high and low SAF, respectively (p = 0.037). Score based on 3 independent predictors (SAF, extent of resection, and operative time) well stratified the risk of AKI (AUC 0.756), with positive and negative predictive values of 59.3% and 84.0%, respectively. In particular, SAF predicted AKI in patients undergoing major and prolonged resections (p = 0.010, AUC 0.733) with positive and negative predictive values of 81.8%, and 62.5%, respectively.

Conclusions

AGEs accumulation negatively affects renal function in patients undergoing liver resection. SAF measurement may be used to predict AKI after liver resection, particularly in high-risk patients.

Post-hoc analysis of a randomized controlled trial on the impact of pre-transplant use of probiotics on outcomes after liver transplantation

Perioperative use of probiotics serves as efficient prophylaxis against postoperative infections after liver transplantation, yet data on long-term effects of pre-transplant probiotic intake is lacking. The aim of this study was to assess the effects of pre-transplant probiotic administration on long-term results of liver transplantation. This was secondary analysis of a randomized trial. Patients were randomized to receive either 4-strain probiotic or placebo before liver transplantation. Five year graft survival was set as the primary end-point. Secondary end-points comprised serum bilirubin and C-reactive protein (CRP) concentration, international normalized ratio (INR), serum transaminases and gamma-glutamyl transferase (GGT) activity. Study group comprised 44 patients, of whom 21 received probiotics and 23 received placebo with 5-year graft survival of 81.0% and 87.0%, respectively (p = 0.591). Patients in the probiotic arm exhibited lower INR (p = 0.001) and CRP (p = 0.030) over the first 6 post-transplant months. In the absence of hepatitis B or C virus infection, pre-transplant administration of probiotics also reduced aspartate transaminase activity (p = 0.032). In the intervention arm, patients receiving probiotics for under and over 30 days had 5-year graft survival rates of 100% and 66.7%, respectively (p = 0.061). Duration of probiotic intake > 30 days was additionally associated with increased INR (p = 0.031), GGT (p = 0.032) and a tendency towards increased bilirubin (p = 0.074) over first 6 post-transplant months. Pre-transplant administration of probiotics has mild positive influence on 6-month allograft function, yet should not exceed 30 days due to potential negative effects on long-term outcomes. (ClinicalTrials.gov Identifier: NCT01735591).

Importance of Intraoperative Transfusions of Packed Red Blood Cells and Fresh Frozen Plasma in Liver Transplantation for Hepatocellular Cancer

BACKGROUND The impact of packed red blood cells (PRBCs) and fresh frozen plasma (FFP) transfusions in patients with hepatocellular cancer (HCC) undergoing liver transplantation has rarely been evaluated. The aim of the current study was to assess the impact of intraoperative transfusions on posttransplant outcomes. MATERIAL AND METHODS This retrospective cohort study was based on 229 HCC transplant recipients. The primary outcome measure was 5-year recurrence-free survival. Secondary outcome measures comprised overall and long-term survival at 5 years and 90-day mortality. Cox proportional hazard models and logistic regression were used to assess risk factors. RESULTS After adjustment for potential confounders, no association was found with respect to tumor recurrence for PRBCs (P=0.368) or FFP (P=0.081) transfusions. Similarly, PRBC transfusion (P=0.623) and FFP transfusion (P=0.460) had no impact on survival between 90 days and 5 years. PRBC transfusion increased the risk of 90-day mortality (P=0.005), while FFP transfusion was associated with a lower risk (P=0.036). CONCLUSIONS Intraoperative transfusions of blood products does not impair recurrence-free and long-term survival of patients with HCC undergoing liver transplantation. Intraoperative PRBC transfusion increases the risk of early mortality, whereas adequate supplementation of FFP plays a protective role.

The molecular diagnosis of rejection in liver transplant biopsies: First results of the INTERLIVER study

Molecular diagnosis of rejection is emerging in kidney, heart, and lung transplant biopsies and could offer insights for liver transplant biopsies. We measured gene expression by microarrays in 235 liver transplant biopsies from 10 centers. Unsupervised archetypal analysis based on expression of previously annotated rejection-related transcripts identified 4 groups: normal "R1_normal " (N = 129), T cell-mediated rejection (TCMR) "R2_TCMR " (N = 37), early injury "R3_injury " (N = 61), and fibrosis "R4_late " (N = 8). Groups differed in median time posttransplant, for example, R3_injury 99 days vs R4_late 3117 days. R2_TCMR biopsies expressed typical TCMR-related transcripts, for example, intense IFNG-induced effects. R3_injury displayed increased expression of parenchymal injury transcripts (eg, hypoxia-inducible factor EGLN1). R4_late biopsies showed immunoglobulin transcripts and injury-related transcripts. R2_TCMR correlated with histologic rejection although with many discrepancies, and R4_late with fibrosis. R2_TCMR , R3_injury , and R4_late correlated with liver function abnormalities. Supervised classifiers trained on histologic rejection showed less agreement with histology than unsupervised R2_TCMR scores. No confirmed cases of clinical antibody-mediated rejection (ABMR) were present in the population, and strategies that previously revealed ABMR in kidney and heart transplants failed to reveal a liver ABMR phenotype. In conclusion, molecular analysis of liver transplant biopsies detects rejection, has the potential to resolve ambiguities, and could assist with immunosuppressive management.

Unsatisfactory Long-term Results of Liver Transplant in Patients With Intrahepatic Cholangiocarcinoma

BACKGROUND

Cholangiocarcinoma is the primary liver tumor forming from the biliary epithelium. Two major subtypes of this disease are distinguished because of the initial location: the extra- and intrahepatic form. The latter disease is currently a controversial indication for liver transplant (LT). The aim of this study was to evaluate the outcomes of LT of patients with intrahepatic cholangiocarcinoma.

METHODS

Based on postoperative histopathologic examination of the explanted liver, 8 patients with intrahepatic cholangiocarcinoma were identified from all LT recipients in the period between 1994 and 2019 and included in this retrospective cohort study. Four of the patients received transplants with a preoperative diagnosis of hepatocellular carcinoma; the remaining tumors were incidental findings. Patient survival was the primary outcome measure.

RESULTS

Six recipients had solitary lesion with a maximum tumor diameter of 6 cm. The median carbohydrate antigen 19-9 concentration prior to LT was 52.3 U/mL. The overall survival was 75.0%, 37.5%, and 25% after the first, third, and fifth year, respectively, with a median survival of 18 months. Age (P = .758), carbohydrate antigen 19-9 (P = .282), largest tumor size (P = .862), and the sum of the number of lesions and diameter of the largest tumor (P = .530) were not significantly associated with overall survival. Recurrence-free survival was 71.4% after 1 year and 28.6% after 3 and 5 years. Correspondingly, no significant predictors of worse recurrence-free survival were found.

CONCLUSIONS

Intrahepatic cholangiocarcinoma remains associated with a very high risk of recurrence and dismal survival after LT irrespective of macroscopic disease burden.

Analysis of Patients With Incidental Perihilar Cholangiocarcinoma: An Old and a Persistent Burden for Liver Transplantation

BACKGROUND

Selected patients with unresectable perihilar cholangiocarcinoma (p-CCA) are now considered as candidates for liver transplant, provided they fulfill a strict perioperative treatment and staging protocol. The aim of this study was to examine the outcomes of patients after liver transplant with incidental p-CCA found in the liver explants.

METHODS

A cohort of 10 patients with incidental p-CCA after liver transplant in the period between 1994 and 2019 was included in this retrospective analysis. All patients with this diagnosis were scheduled for transplant because of primary sclerosing cholangitis. The primary and secondary endpoints comprised patient's death and tumor recurrence, respectively, assessed over a 5-year postoperative period.

RESULTS

Patient median age was 35 years (range, 32-42 years). Median size of the tumor was 3.0 cm (range, 2.5-4.0 cm). Five patients (50%) had metastases to local lymph nodes. Overall survival was 100%, 37.5%, and 18.8% after the first, third, and fifth postoperative year, respectively, with median survival of 21 months. Patient age (P = .827), R1 resection status (P = .144), tumor diameter (P = .432), and presence of lymph node metastases (P = .663) were not significantly associated with overall survival. Recurrence-free survival was 60.0% after the first postoperative year and 22.5% after the third and fifth postoperative years, with median recurrence-free survival of 13.6 months. No significant predictors of tumor recurrence were found.

CONCLUSIONS

Incidental p-CCA in patients with primary sclerosing cholangitis undergoing liver transplant is associated with universally very high risk of postoperative tumor recurrence and short expected survival.

Hepatic Epithelioid Hemangioendothelioma: A Rare Disease With Favorable Outcomes After Liver Transplantation

BACKGROUND

Hepatic epithelioid hemangioendothelioma (HEHE) is a rare vascular tumor with indolent behavior in terms of malignancy. The treatment of choice is either resection in the case of resectable lesions or liver transplantation (LT) for the disseminated intrahepatic form. The aim of this study was to investigate the outcomes of patients with HEHE treated by LT.

MATERIAL AND METHODS

There were 18 patients with HEHE who underwent LT between 2002 and 2018 included in this retrospective study. The study group was comprised of young recipients (median age of 39 years) and mainly women (15 of 18; 83.3%). Two recipients had concomitant tumors of epithelioid hemangioendothelioma in the liver and lungs prior to LT. The survival probability was calculated using the Kaplan-Meier estimator.

RESULTS

According to histopathological data, none of the patients had a macrovascular invasion. In 4 patients (22.2%), the disease had spread to the hilar lymph nodes. The maximum diameter of the tumor in the studied group was 18 cm. The survival probability after 1, 5, and 15 years was 94.0%, 82.6%, and 41.3%, respectively. No disease recurrence was observed during a median follow-up of 65.9 months.

CONCLUSION

Liver transplantation provides favorable outcomes for selected patients with a hepatic form of epithelioid hemangioendothelioma.

Prognostic Relevance of a Complete Pathologic Response in Liver Transplantation for Hepatocellular Carcinoma

BACKGROUND

A complete pathologic response (CPR) after neoadjuvant treatment is reported to be associated with an exceptionally low risk of recurrence after liver transplantation for hepatocellular carcinoma (HCC). This study aimed to evaluate the prognostic role of CPR in liver transplantation for HCC.

METHODS

This retrospective cohort study was based on 222 HCC transplant recipients. Incidence of recurrence and survival at 5 years were the primary and secondary outcome measures, respectively. Competing risk analyses were applied to evaluate recurrence incidence and its predictors. Propensity score matching was performed to compare the outcomes for patients after neoadjuvant treatment with and without CPR.

RESULTS

Neoadjuvant treatment was performed for 127 patients, 32 of whom achieved CPR (25.2%). Comparison of baseline characteristics showed that the patients with CPR were at lowest baseline recurrence risk, followed by treatment-naïve patients and patients without CPR. Adjusted for potential confounders, CPR did not have any significant effects on tumor recurrence. No significant net reclassification improvement was noted after addition of CPR to existing criteria. Neoadjuvant treatment without CPR was associated with increased risk of recurrence in subgroups within the Milan criteria (p = 0.016), with alpha-fetoprotein concentration (AFP) model not exceeding 2 points (p = 0.021) and within the Warsaw criteria (p = 0.007) compared with treatment-naïve patients who were at risk similar to those with CPR. The 5-year incidences of recurrence in propensity score-matched patients with and without CPR were respectively 14.0% and 15.9% (p = 0.661), with corresponding survival rates of 73.2% and 67.4%, respectively (p = 0.329).

CONCLUSIONS

The findings showed that CPR is not independently associated with long-term outcomes after liver transplantation for HCC.

Fulminant liver failure following a marathon: Five case reports and review of literature

BACKGROUND

The growing popularity of marathon and half-marathon runs has led to an increased number of patients presenting with exertion-induced heat stroke. Mild hepatic involvement is often observed in these patients; however, fulminant liver failure may occur in approximately 5% of all cases. Liver transplantation is a potentially curative approach for exertion-induced liver failure, although there is a lack of consensus regarding the criteria and optimal timing of this intervention.

CASE SUMMARY

This paper describes 5 patients (4 men and 1 woman) who were referred to the department where this study was performed with the diagnosis of exertion-induced acute liver failure. Three patients underwent liver transplantation, 1 recovered spontaneously, and 1 patient died on day 11 following the exertion.

CONCLUSION

Exertion-induced heat stroke may present as fulminant liver failure. These patients may recover with conservative treatment, may require liver transplantation, or may die. No definitive criteria are available to determine patient suitability for a conservative vs surgical approach.

Impact of Donor Risk Index on Risk of Hepatic Artery Thrombosis in Patients After Orthotopic Liver Transplantation

BACKGROUND

Hepatic artery thrombosis (HAT) is one of the most severe complications after liver transplantation (LT). HAT can lead to early graft loss and retransplantation or death of the recipient.

METHODS

This retrospective cohort study was conducted using data from patients treated between January 2008 and December 2013 in the Department of General, Transplant and Liver Surgery at the Medical University of Warsaw. A total of 750 patients underwent LT over this period.

RESULTS

HAT occurred in 27 patients (2.1%). The median DRI was 1.414 (IQR 1.103-1.578) points and median donor age was 47 (IQR 33-56) years. The optimal cut-off value of DRI in predicting HAT was ≥1.328 points. The cutoff point was characterized by sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 88.0%, 41.3%, 5.5% and 98.9%, respectively (AUC = 0.605, 95% CI 0.477-0.733). A DRI ≥1.328 was a significant risk factor for HAT (OR = 5.16, 95% confidence interval [CI] 1.529-17.48, P = .008). The optimal cutoff point for donor age was 50 years and was characterized by sensitivity, specificity, PPV, and NPV of 66.7%, 55.8%, 5.3%, and 97.8%, respectively. Donor age ≥50 years (OR = 2.53, 95% CI 1.123-5.714, P = .025) was a significant risk factor for HAT.

CONCLUSION

DRI is a clinically relevant factor that allows estimating the risk of HAT after liver transplantation from a deceased donor. To reduce the incidence of this complication, the allocation of organs taken from donors at DRI exceeding 1.328 for recipients without other HAT risk factors should be considered.

Individual Surgeon Experience Yields Bimodal Effects on Patient Outcomes After Deceased-Donor Liver Transplant: Results of a Quantile Regression for Survival Data

OBJECTIVES

Data on the relevance of surgeon experience in liver transplant procedures are scarce. In this study, we evaluated the effects of individual surgeon experience on survival outcomes after deceased-donor liver transplant.

MATERIALS AND METHODS

In this retrospective analysis of 1193 liver transplant procedures, quantile regression for survival data was performed to assess the effects of surgeon experience. Conditional quantiles of mortality and graft loss were set as primary and secondary outcome measures, respectively, which were categorized as early, midterm, and late.

RESULTS

Greater experience of a surgeon performing hepatectomy increased the risk of early mortality (P = .005) and graft loss (P = .025) when the recipient Model for End-Stage Liver Disease was ≤ 25 and the donor Model for End-Stage Liver Disease was ≤ 1600. In conventional transplant procedures, greater experience of surgeon performing hepatectomy additionally increased the risk of midterm mortality (P = .027) and graft loss (P = .046). Conversely, a graft implant procedure performed by a more experienced surgeon was associated with better early, midterm, and late outcomes after conventional transplants (all P < .037) and reduced the risk of early graft loss when the donor Model for End-Stage Liver Disease score was > 1600 (P = .027).

CONCLUSIONS

Unexpectedly, individual surgeon experience yields bimodal effects on posttransplant outcomes, dependent on the stage of operation, operative technique, severity of recipient status, and transplant risk profile.

Cancer-associated circulating large extracellular vesicles in cholangiocarcinoma and hepatocellular carcinoma

BACKGROUND & AIMS

Large extracellular vesicles, specifically AnnexinV⁺ EpCAM⁺ CD147⁺ tumour-associated microparticles (taMPs), facilitate the detection of colorectal carcinoma (CRC), non-small cell lung carcinoma (NSCLC) as well as pancreas carcinoma (PaCa). Here we assess the diagnostic value of taMPs for detection and monitoring of hepatocellular carcinoma (HCC) and cholangiocarcinoma (CCA). Specifically, the aim of this study was to differentiate liver taMPs from other cancer taMPs, such as CRC and NSCLC.

METHODS

Fluorescence-activated cell scanning (FACS) was applied to detect various taMP populations in patients' sera that were associated with the presence of a tumour (AnnexinV⁺ EpCAM⁺ CD147⁺ taMPs) or could discriminate between cirrhosis (due to HCV or HBV) and liver cancers (AnnexinV⁺ EpCAM⁺ ASGPR1⁺ taMPs). In total 172 patients with liver cancer (HCC or CCA), 54 with cirrhosis and no liver neoplasia, and 202 control subjects were enrolled.

RESULTS

The results indicate that AnnexinV⁺ EpCAM⁺ CD147⁺ taMPs were elevated in HCC and CCA. Furthermore, AnnexinV⁺ EpCAM⁺ ASGPR1⁺ CD133⁺ taMPs allowed the distinction of liver malignancies (HCC or CCA) and cirrhosis from tumour-free individuals and, more importantly, from patients carrying other non-liver cancers. In addition, AnnexinV⁺ EpCAM⁺ ASGPR1⁺ taMPs were increased in liver cancer-bearing patients compared to patients with cirrhosis that lacked any detectable liver malignancy. The smallest sizes of successfully detected cancers were ranging between 11-15mm. AnnexinV⁺ EpCAM⁺ ASGPR1⁺ taMPs decreased at 7days after curative R0 tumour resection suggesting close correlations with tumour presence. ROC values, sensitivity/specificity scores and positive/negative predictive values (>78%) indicated a potent diagnostic accuracy of AnnexinV⁺ EpCAM⁺ ASGPR1⁺ taMPs.

CONCLUSION

These data provide strong evidence that AnnexinV⁺ EpCAM⁺ ASGPR1⁺ taMPs are a novel biomarker of HCC and CCA liquid biopsy that permit a non-invasive assessment of the presence and possible extent of these cancers in patients with advanced liver diseases.

LAY SUMMARY

Microparticles (MPs) are small vesicles that bleb from the membrane of every cell, including cancer cells, and are released to circulate in the bloodstream. Since their surface composition is similar to the surface of their underlying parental cell, MPs from the bloodstream can be isolated and by screening their surface components, the presence of their parental cells can be identified. This way, it was possible to detect and discriminate between patients bearing liver cancer and chronic liver cirrhosis.

Challenging the principle of utility as a barrier for wider use of liver transplantation for hepatocellular cancer

Background

Although transplant benefit appears superior for patients with advanced hepatocellular cancer (HCC), liver transplantation remains limited to selected low-risk HCC patients to keep their outcomes similar to heterogeneous group of non-HCC patients. The purpose of this study was to assess the rationale for current policy of restricting access to liver transplantation to minority of HCC patients based on utility principle.

Methods

This retrospective cohort study comprised 1246 liver transplant recipients, including 206 HCC and 1040 non-HCC patients. Patient survival was the primary outcome measure. Patients with HCC and benign diseases were divided into low-, moderate-, and high-risk subgroups basing on independent risk factors for disease-free survival and model for end-stage liver disease (MELD) score (<30, 30–40, >40), respectively.

Results

MELD (p < 0.001) and presence of HCC (p = 0.008) were independent risk factors for early and late mortality, respectively. Total tumor volume (p = 0.008) and alpha-fetoprotein (p = 0.013) were independent predictors of recurrence and mortality used for division of HCC patients into low-, moderate-, and high-risk subgroups, with disease-free survival rates of 74.9% (5 years), 51.7% (5 years), and 8.0% (3 years), respectively (p < 0.001). There were no differences in 5-year overall survival between low-risk HCC (74.9%) and non-HCC (81.9%) patients (p = 0.210), moderate-risk HCC (63.3%) and non-HCC (68.0%) patients (p = 0.372), and high-risk HCC (55.0%) and non-HCC (56.0%) patients (p = 0.559).

Conclusions

The principle of utility is unequally applied for restriction of access to liver transplantation for HCC patients. The results provide rationale for discussion on reinitiation of liver transplantation for advanced HCCs.

Electronic supplementary material

The online version of this article (doi:10.1245/s10434-017-5989-x) contains supplementary material, which is available to authorized users.

Prognostic Factors and Outcomes of Patients After Liver Retransplantation

BACKGROUND

Despite great progress and improvement in results of orthotopic liver transplantation (OLTx), 10%-20% of patients still require retransplantation (re-OLTx). The aim of the study was to present long-term results of liver retransplantation and to determine the factors influencing outcomes.

PATIENTS AND METHODS

From December 1994 to July 2014, a total of 1461 liver transplantations were performed in the Department of General, Transplant and Liver Surgery of Medical University of Warsaw. There were 92 retransplantations (6.3%), including 40 early re-OLTx (up to 30 days). The most common indication for re-OLTx were vascular complications (41/92, 44.6%). Influence of clinical variables on short- and long-term outcomes was analyzed.

RESULTS

Postoperative mortality was 30.4% (28/92). One-year, 3-year and 5-year survival for all patients was 59.8%, 56.5% and 54.1%, respectively. The best results were achieved in patients undergoing retransplantation due to chronic rejection and biliary complications, whose 5-year survival rates were 75.0% and 72.9% respectively. There was no difference in long-term survival after early and late retransplantations (60.9% and 49.3%, respectively; P = .158). Multivariable analysis revealed factors associated with longer survival of patients, namely, higher preoperative hemoglobin concentration (P = .001), increased blood transfusions (P = .048), and decreased fresh frozen plasma transfusions (P = .004).

CONCLUSIONS

Liver retransplantation is a method providing satisfactory outcomes in selected patients. The perioperative period has a major impact on patient outcome.

Profile of Gut Microbiota Associated With the Presence of Hepatocellular Cancer in Patients With Liver Cirrhosis

BACKGROUND

Changes within the gut microbiota contribute to the progression of chronic liver diseases. According to the results of several studies performed in animal models, gut dysbiosis plays an important role in hepatocarcinogenesis. The aim of this study was to explore the characteristics of gut microbiota associated with the presence of hepatocellular cancer (HCC) in patients with cirrhosis of the liver undergoing liver transplantation.

METHODS

A total of 15 patients with HCC and 15 non-HCC patients matched according to etiology of cirrhosis and Model for End-Stage Liver Disease (MELD) scores who underwent liver transplantations between 2012 and 2014 were included. Analysis of their gut microbial profile was based on prospectively collected stool samples from the pretransplant period.

RESULTS

Patients with and without HCC were similar with respect to age (P = .506), sex (P = .700), hepatitis C virus (P > .999) and hepatitis B virus (P = .715) infection status, alcoholic liver disease (P > .999), and MELD score (P = .337). Notably, the presence of HCC was associated with significantly increased fecal counts of Escherichia coli (P = .025). Prediction of HCC presence based on E coli counts was associated with the area under the receiver-operating curve of 0.742 (95% confidence interval, 0.564-0.920), with the optimal cutoff on the level of 17.728 (natural logarithm of colony-forming units per 1 g of feces). Sensitivity and specificity rates for the established cutoff were 66.7% and 73.3%, respectively.

CONCLUSIONS

The profile of gut microbiota associated with the presence of HCC in cirrhotic patients is characterized by increased fecal counts of E coli. Therefore, intestinal overgrowth of E coli may contribute to the process of hepatocarcinogenesis.

Liver Transplantation Outcomes in Recipients with High Model for End-Stage Liver Disease (MELD) Scores: The Relevance of MELD Scores

BACKGROUND The aim of this study was to assess risk factors for postoperative mortality after liver transplantation among patients with Model for End-Stage Liver Disease (MELD) scores ≥35, with special focus on the MELD scores. MATERIAL AND METHODS Data from 68 primary liver transplantations in patients with MELD scores ≥35 among 1376 liver transplantations performed in the Department of General, Transplant, and Liver Surgery (Medical University of Warsaw) between January 2002 and October 2014 were analyzed retrospectively. Postoperative (90-day) mortality was set as the primary outcome measure. RESULTS Postoperative mortality was 29.4% (20 of 68). The overall survival rates after 1, 5, and 10 years were 61.9%, 59.7%, and 59.7%, respectively. According to univariate analyses, MELD (p=0.014), conventional technique of liver transplantation (p=0.049), intraoperative fresh frozen plasma (p=0.040), and red blood cells (p=0.026) transfusions were risk factors for postoperative mortality. MELD score was the only independent risk factor for postoperative mortality (p=0.023) in multivariate analysis. According to receiver operating characteristics analysis, the optimal cut-off for MELD score in prediction of postoperative mortality was ≥43 (Area Under Curve=0.703, 95% Confidence Interval 0.575-0.831). Postoperative mortality was 21.4% and 42.3% among patients with MELD score <43 and ≥43, respectively (p=0.066). CONCLUSIONS MELD score is an important predictor of early mortality after liver transplantation, even among recipients with high MELD scores. In particular, patients with MELD score ≥43 should be considered as very high-risk candidates for liver transplantation.

Surgical treatment of gall-bladder cancer

Despite the aggressive nature and poor prognosis of gall-bladder cancer there is a group of patients who can achieve significant benefits from a radical surgical treatment. The possibility of obtaining long-term survival, even in case of patients with locally advanced cancer and metastases to regional lymph nodes, prompts to verify nihilistic approach to the treatment of this disease. Obviously such therapy can and should be performed only in centers specializing in hepatobiliary surgery. Due to the high recurrence rate, most of which are systemic, the hope of improving treatment outcomes should be sought in the use of combination therapy, based on a new chemotherapy and chemoradiotherapy regimens with the addition of targeted therapy. Unfortunately, the current application of these methods did not bring the expected benefits.

Limitations of predicting microvascular invasion in patients with hepatocellular cancer prior to liver transplantation

Microvascular invasion (MVI) is well known to negatively influence outcomes following surgical treatment of hepatocellular cancer (HCC) patients. The aim of this study was to evaluate the rationale for prediction of MVI before liver transplantation (LT). Data of 200 HCC patients after LT were subject to retrospective analysis. MVI was present in 57 patients (28.5%). Tumor number (p = 0.001) and size (p = 0.009), and alpha-fetoprotein (p = 0.049) were independent predictors of MVI used to create a prediction model, defined as: 0.293x(tumor number) + 0.283x(tumor size in cm) + 0.164xlog_e(alpha-fetoprotein in ng/ml) (c statistic  =  0.743). The established cut-off (≥2.24) was associated with sensitivity and specificity of 72%. MVI was not an independent risk factor for recurrence (p = 0.307), in contrast to tumor number (p = 0.047) and size (p < 0.001), alpha-fetoprotein (p < 0.001) and poor differentiation (p = 0.039). Recurrence-free survival at 5 years for patients without MVI was 85.9% as compared to 83.3% (p = 0.546) and 55.3% (p = 0.001) for patients with false negative and true positive prediction of MVI, respectively. The use of both morphological and biological tumor features enables effective pre-transplant prediction of high-risk MVI. Provided that these parameters are combined in selection of HCC patients for LT, pre-transplant identification of all patients with MVI does not appear necessary.

Reoperations for Intraabdominal Bleeding Following Deceased Donor Liver Transplantation

Intraabdominal hemorrhage remains one of the most frequent surgical complications after liver transplantation. The aim of the study was to evaluate risk factors for intraabdominal bleeding requiring reoperation and to assess the relevance of the reoperations with respect to short- and long-term outcomes following liver transplantation.

MATERIAL AND METHODS

Data of 603 liver transplantations performed in the Department of General, Transplant and Liver Surgery in the period between January 2011 and September 2014 were analyzed retrospectively. Study end-points comprised: reoperation due to bleeding and death during the first 90 postoperative days and between 90 postoperative day and third post-transplant year.

RESULTS

Reoperations for intraabdominal bleeding were performed after 45 out of 603 (7.5%) transplantations. Low pre-transplant hemoglobin was the only independent predictor of reoperation (p=0.002) with the cut-off of 11.3 g/dl. Postoperative 90-day mortality was significantly higher in patients undergoing reoperation as compared to the remaining patients (15.6% vs 5.6%, p=0.008). Post-transplant survival from 90 days to 3 years was non-significantly lower in patients after reoperation for bleeding (83.3%) as compared to the remaining patients (92.2%, p=0.096). Nevertheless, multivariable analyses did not reveal any significant negative impact of reoperations for bleeding on short-term mortality (p=0.589) and 3-year survival (p=0.079).

CONCLUSIONS

Surgical interventions due to postoperative intraabdominal hemorrhage do not appear to affect short- and long-term outcomes following liver transplantation. Preoperative hemoglobin concentration over 11.3 g/dl is associated with decreased risk of this complication, yet the clinical relevance of this phenomenon is doubtful.

The Warsaw Proposal for the Use of Extended Selection Criteria in Liver Transplantation for Hepatocellular Cancer

BACKGROUND

Combination of the University of California, San Francisco (UCSF) and the up-to-7 criteria with alpha-fetoprotein (AFP) cutoff of 100 ng/ml was proposed as the Warsaw expansion of the Milan criteria in selection of hepatocellular cancer (HCC) patients for liver transplantation. The purpose of this retrospective study was to validate this proposal.

METHODS

A total of 240 HCC patients after liver transplantation were included. Recurrence-free survival and overall survival at 5 years were set as the primary and secondary outcome measures, respectively.

RESULTS

The Warsaw expansion increased transplant eligibility rate by 20.3 %. AFP >100 ng/ml significantly increased the recurrence risk in patients within the Milan criteria (p = 0.025) and in those beyond, yet within either the UCSF or the up-to-7 criteria (p < 0.001). Recurrence-free survival at 5 years was 90.8 % for patients within the Milan criteria, 100.0 % in patients within the Warsaw expansion, 54.9 % in patients beyond the Warsaw expansion but within either the UCSF or the up-to-7 criteria, and 45.1 % in patients beyond both the UCSF and the up-to-7 criteria (p < 0.001). The corresponding overall survival rates were 71.6, 82.4, 64.3, and 55.3 %, respectively (p = 0.027).

CONCLUSIONS

The Warsaw expansion of the Milan criteria substantially increases the recipient pool without compromising outcomes.

Outcomes of Patients With Poorly Differentiated Hepatocellular Carcinoma After Liver Transplantation

BACKGROUND

Liver transplantation (LT) outcomes for patients with poorly differentiated (G3) hepatocellular carcinoma (HCC) are unsatisfactory. The aim of this study was to evaluate outcomes in patients with poorly differentiated HCC undergoing LT.

PATIENTS AND METHODS

There were 192 HCC patients after LT in the Department of General, Transplant and Liver Surgery, Medical University of Warsaw, between January 2001 and April 2014. The study group comprised 24 patients with poorly differentiated tumors.

RESULTS

Disease-free survival (DFS) for all patients was 49.5% at 5 years. The 5-year DFS for patients who met the Milan criteria (n = 9, 88.9%) was significantly better compared to those who did not (n = 15, 28.0%, P = .025). Multivariable analysis revealed that only the largest tumor diameter (P = .014) and α-fetoprotein (AFP) concentration (P = .001) were independent risk factors for DFS. The optimal cut-off AFP and tumor size that could distinguish patients with the highest risk were ≥500 ng/mL and ≥3.5 cm, respectively. DFS for patients with AFP <500 ng/mL and tumor size <3.5 cm was 100% after 2.8 years, and for those with ≥500 ng/mL or tumor size ≥3.5 cm was 46.9% after 5 years. However, the DFS for patients with AFP ≥500 ng/mL and tumor size ≥3.5 cm was only 12.5% after 4.7 years (P = .002).

CONCLUSIONS

Outcomes of patients with poorly differentiated HCC treated with LT can be characterized with acceptable survival when applying criteria based on tumor size <3.5 cm and AFP <500 ng/mL.

Liver Transplantation in Patients with Cryptogenic Cirrhosis Provides Excellent Long-Term Outcome

BACKGROUND

Cryptogenic cirrhosis (CC) is an indication for liver transplantation in 5-9% of recipients. Diagnosis is made when other diagnostic possibilities have been ruled out. The aim of this study was to present long-term outcomes of liver transplantation for CC.

MATERIAL AND METHODS

There have been 1367 liver transplantations performed during the years 1994-2013 in the Department of General, Transplant and Liver Surgery at the Medical University of Warsaw. This retrospective study comprised 55 patients after liver transplantation for CC (4.0%). Perioperative mortality (30 days) and patient and graft 1-, 5-, and 10-year survival rates were set as outcome measures.

RESULTS

Peri-operative mortality reached 10.9% (6 of 55). The 1-, 5- and 10-year patient and graft survival rates were 85.2%, 78.8%, and 73.9%, respectively, and 83.3%, 74.5%, and 74.5%, respectively. In univariate analyses, the following parameters significantly influenced patient survival: pre-operative aspartate (AST; p=0.013) and alanine (ALT; p=0.043) aminotransferases activity, INR (p=0.040), bilirubin concentration (p=0.045), and donor age (p=0.033). Similarly, graft survival was significantly associated with AST (p=0.013), ALT (p=0.043), bilirubin concentration (p=0.044), INR (p=0.038), and recipient sex (p=0.049). In multivariable analyses, a tendency towards worse patient and graft survival was observed in patients with higher pre-operative AST (p=0.078 for patient survival and p=0.063 for graft survival). Analyses of the pathological reports indicated that underlying immunological processes were the most probable cause of liver damage in 16 of 51 patients (31.4%).

CONCLUSIONS

Long-term outcomes of liver transplantation in patients with cryptogenic liver cirrhosis are encouraging. Analysis of the clinical course, biochemical parameters, and factors influencing outcomes suggest an underlying autoimmunological etiology of cirrhosis in this population of patients.

Relevance of Pre-Transplant α-fetoprotein Dynamics in Liver Transplantation for Hepatocellular Cancer

BACKGROUND

The magnitude of pre-transplant a-fetoprotein (AFP) changes has been advocated to be a superior predictor of hepatocellular cancer (HCC) recurrence following liver transplantation. The aim of this study was to compare AFP dynamics and last pre-transplant AFP as risk factors for post-transplant HCC recurrence.

MATERIAL AND METHODS

Data of 146 patients after liver transplantation for HCC were analyzed retrospectively.

RESULTS

While last pre-transplant AFP was a significant predictor of microvascular invasion (p=0.006) and poor tumor differentiation (p=0.020), AFP slope was associated only with microvascular invasion (p=0.029). Notably, last pre-transplant AFP (p<0.001), but not AFP slope (p=0.279), was an independent risk factor for recurrence. No significant effects of AFP slope were also found following division of patients into those with pre-transplant AFP <100 (p=0.260) and those with AFP >100 (p=0.178) ng/mL. Moreover, prediction of recurrence based on last pre-transplant AFP was superior (p=0.018) to those based on AFP slope. Recurrence-free survival at 5 years was superior in patients with pre-transplant AFP persistently at (97.3%) or dropping to <100 ng/mL (100.0%) as compared to patients with AFP rising to (75.0%) or persistently at >100 ng/mL (38.4%; p<0.001).

CONCLUSIONS

The risk of post-transplant HCC recurrence is dependent on the last pre-transplant AFP regardless of its previous dynamics.

Effects of Donor Age and Cold Ischemia on Liver Transplantation Outcomes According to the Severity of Recipient Status

BackgroundProlonged cold ischemic time (CIT) and increased donor age are well-known factors negatively influencing outcomes after liver transplantation (LT).

AIMS

The aim of this study was to evaluate whether the magnitude of their negative effects is related to recipient model for end-stage liver disease (MELD) score.

METHODS

This retrospective study was based on a cohort of 1402 LTs, divided into those performed in low-MELD (<10), moderate-MELD (10–20), and high-MELD (>20) recipients.

RESULTS

While neither donor age (p = 0.775) nor CIT (p = 0.561) was a significant risk factor for worse 5-year graft survival in low-MELD recipients, both were found to yield independent effects (p = 0.003 and p = 0.012, respectively) in moderate-MELD recipients, and only CIT (p = 0.004) in high-MELD recipients. However, increased donor age only triggered the negative effect of CIT in moderate-MELD recipients, which was limited to grafts recovered from donors aged ≥46 years (p = 0.019). Notably, utilization of grafts from donors aged ≥46 years with CIT ≥9 h in moderate-MELD recipients (p = 0.003) and those with CIT ≥9 h irrespective of donor age in high-MELD recipients (p = 0.031) was associated with particularly compromised outcomes.

CONCLUSIONS

In conclusion, the negative effects of prolonged CIT seem to be limited to patients with moderate MELD receiving organs procured from older donors and to high-MELD recipients, irrespective of donor age. Varying effects of donor age and CIT according to recipient MELD score should be considered during the allocation process in order to avoid high-risk matches.

Evolution Of The Results Of 1500 Liver Transplantations Performed In The Department Of General, Transplant And Liver Surgery Medical University Of Warsaw

Liver transplantation is a well-established treatment of patients with end-stage liver disease and selected liver tumors. Remarkable progress has been made over the last years concerning nearly all of its aspects. The aim of this study was to evaluate the evolution of long-term outcomes after liver transplantations performed in the Department of General, Transplant and Liver Surgery (Medical University of Warsaw).

MATERIAL AND METHODS

Data of 1500 liver transplantations performed between 1989 and 2014 were retrospectively analyzed. Transplantations were divided into 3 groups: group 1 including first 500 operations, group 2 including subsequent 500, and group 3 comprising the most recent 500. Five year overall and graft survival were set as outcome measures.

RESULTS

Increased number of transplantations performed at the site was associated with increased age of the recipients (p<0.001) and donors (p<0.001), increased rate of male recipients (p<0.001), and increased rate of piggyback operations (p<0.001), and decreased MELD (p<0.001), as well as decreased blood (p=0.006) and plasma (p<0.001) transfusions. Overall survival was 71.6% at 5 years in group 1, 74.5% at 5 years in group 2, and 85% at 2.9 years in group 3 (p=0.008). Improvement of overall survival was particularly observed for primary transplantations (p=0.004). Increased graft survival rates did not reach the level of significance (p=0.136).

CONCLUSIONS

Long-term outcomes after liver transplantations performed in the Department of General, Transplant and Liver Surgery are comparable to those achieved in the largest transplant centers worldwide and are continuously improving despite increasing recipient age and wider utilization of organs procured from older donors.

Relevance of male-to-female sex mismatch in liver transplantation for primary biliary cirrhosis

BACKGROUND

Because male-to-female transplantations are related to exposure to H-Y antigen, sex matching may influence the outcomes after liver transplantation for autoimmune diseases. The purpose of this retrospective study was to evaluate the relevance of male-to-female mismatch in liver transplantation for primary biliary cirrhosis (PBC).

MATERIAL AND METHODS

This retrospective study was based on the data of 82 female liver transplant recipients with PBC from a single institution. The primary outcome measure was graft survival at 10 years. The negative effects of well-known risk factors for poor outcomes were evaluated separately and compared between the female-to-female and male-to-female transplantations.

RESULTS

Graft survival was similar after female-to-female and male-to-female transplantations (74.7% versus 73.1% at 10 years, respectively, p=0.676). Regarding the differential impact of other risk factors, prolonged cold ischemia and increased amount of blood transfusions adversely influenced outcomes after male-to-female transplantation (p=0.039 and p=0.039, respectively) but not after female-to-female transplantation (p=0.843 and p=0.110, respectively). Sex mismatched transplantations were associated with lower 10-year graft survival in subgroups of patients with blood transfusions >4 units (61.4% versus 100.0%, p=0.063) and >8 hours of cold ischemia (54.7% versus 75.8%, p=0.418).

CONCLUSIONS

Although male-to-female sex mismatch does not seem to yield a direct negative impact on outcomes following liver transplantation for PBC, it can aggravate the negative effects of prolonged cold ischemia and blood transfusions.

The relevance of intestinal dysbiosis in liver transplant candidates

BACKGROUND

The gut microbial ecosystem plays an important role in the pathogenesis of liver diseases. However, the association of microbial community structure with the severity of liver dysfunction is not completely understood.

METHODS

Fecal microflora was assessed in 40 patients with liver cirrhosis listed for primary liver transplantation (LT). Independent associations between fecal microbial counts and serum bilirubin, serum creatinine, international normalized ratio (INR), and the Model for End-stage Liver Disease (MELD) score were established in multiple linear regression models.

RESULTS

Bifidobacterium (standardized regression coefficient [sβ] = -0.549; P < 0.001), Enterococcus (sβ = 0.369; P = 0.004), and yeast (sβ = 0.315; P = 0.018) numbers were independently associated with serum bilirubin, while Escherichia coli counts (sβ = 0.318; P = 0.046) correlated with INR, and Bifidobacterium counts (sβ = 0.410; P = 0.009) with serum creatinine. Only Bifidobacterium (sβ = -0.468; P = 0.003) and Enterococcus (sβ = 0.331; P = 0.029) counts were independent predictors of the MELD score. Bifidobacterium/Enterococcus ratio, proposed as a measure of pre-LT gut dysbiosis, was significantly related to the MELD score following the adjustment for the absolute Bifidobacterium (sβ = -0.333; P = 0.029) and Enterococcus (sβ = -0.966; P = 0.003) numbers. This pre-transplant dysbiosis ratio (PTDR) was significantly correlated with Enterococcus (R = -0.897; P < 0.001) but not with Bifidobacterium (R = 0.098; P = 0.546) counts. Among the other components of gut microflora, only hydrogen peroxide (H2 O2 )-producing Lactobacillus strains significantly influenced Enterococcus counts (sβ = 0.349; P = 0.028) and PTDR (sβ = -0.318; P = 0.046).

CONCLUSION

While the abundance of both Bifidobacterium and Enterococcus is related to liver dysfunction, the size of the Enterococcus population seems to be the most important determinant of pre-LT gut dysbiosis in cirrhotic patients. The H2 O2 -producing Lactobacillus strains potentially ameliorate this dysbiotic state.

Differential impact of risk factors for tumor recurrence in hepatitis B and hepatitis C virus-infected patients undergoing liver transplantation for hepatocellular carcinoma

BACKGROUND

Hepatitis B (HBV) and C (HCV) virus infection are the 2 most important risk factors for the development of the hepatocellular carcinoma (HCC). The aim of this study was to assess the importance of the type of viral infection in evaluation of HCC recurrence risk after liver transplantation (LT).

MATERIAL AND METHODS

This retrospective study was based on 130 HCC patients undergoing LT. Patients were subdivided by HBV or HCV infection only or HBV and HCV co-infection (HBV-HCV). The primary outcome measure was recurrence-free survival (RFS) 5 years after transplantation.

RESULTS

The 5-year RFS did not differ significantly according to HBV infection, HCV infection, or HBV-HCV co-infection in the entire study cohort (p=0.902) or among patients who fulfilled (p=0.454) or did not fulfill (p=0.999) the Milan criteria. Neither HCV (p=0.869) nor HBV (p=0.968) infection significantly affected 5-year RFS following adjustment for covariates. Higher lesion number (p=0.004), increased alpha-fetoprotein (p=0.017), microvascular invasion (p=0.004), and female donor sex (p=0.025) were significant risk factors for poor RFS in HBV patients; older recipient age (p=0.010) and increased total tumor volume (p=0.028) were significant risk factors in HCV patients.

CONCLUSIONS

Although the viral infection type does not affect post-LT outcomes in HCC patients, the influence of other risk factors is markedly different in HBV- and HCV-related HCC.

Negative outcomes after liver transplantation in patients with alcoholic liver disease beyond the fifth post-transplant year

Although up to 50% of patients with alcoholic liver disease (ALD) resume alcohol consumption after liver transplantation (LT), numerous studies indicate that long-term results are not compromised. This study focused on evaluating the impact of ALD on outcomes up to and beyond the fifth year after LT. Among the 432 primary LT recipients included in this study, 97 underwent transplantation for ALD. Alcohol relapse rate at 10 yr was 33.5%, with younger recipient age being the only independent predictor (p = 0.019). Survival of patients with ALD (77.0%) was similar to those without (79.0%) up to the fifth post-transplant year (p = 0.655) but worse during the five subsequent years among the five-yr survivors (70.6% vs. 92.9%; p = 0.002). ALD was an independent risk factor for poorer survival beyond the fifth post-transplant year (p = 0.049), but not earlier (p = 0.717). Conversely, alcohol relapse increased the risk of death only during the first five post-transplant years (p = 0.039). There were no significant differences regarding graft failure incidence between ALD and non-ALD recipients up to the fifth post-transplant year (7.3% vs. 11.6%; p = 0.255) and beyond (12.9% vs. 5.0%; p = 0.126). In conclusion, pre-transplant diagnosis of ALD yields negative effects on post-transplant outcomes beyond the fifth post-transplant year, not attributable to recidivism.