Waitlist and post-transplant outcomes of pregnancy-related acute liver failure in the United States

BACKGROUND AND AIM

Data on the liver transplant (LT) outcomes of women with acute liver failure (ALF) due to liver diseases unique to pregnancy (P-ALF) are limited.

METHODS

Using United Network of Organ Sharing (UNOS) data (1987-2021), we analyzed waitlist and post-LT outcomes of ALF in women of childbearing age comparing P-ALF vs. ALF due to liver diseases not unique to pregnancy (NP-ALF). Baseline characteristics were compared between groups at the time of listing for LT.

RESULTS

Of 3,542 females aged 16-43 yrs. and listed for LT for ALF, 84 (2%) listed for P-ALF were less likely to be Black (11 vs. 21%, p=0.033), have lower INR (2.74 vs. 4.53 p<0.002), but more likely to have respiratory failure (56% vs. 41%, p<0.005), be on pressors (58% vs. 43%, p<0.005) and require dialysis (23% vs. 10%, p<0.001). The cumulative 90-day waitlist mortality (WLM) was lower in P-ALF vs. NP-ALF (7.4 vs. 16.6%, p<0.001). Post-transplant survival rates at 5-yr were similar (82% vs. 79%, p=0.89). In a Fine and Gray regression model controlled for listing year and MELD score, 90-day WLM was lower in P-ALF with a sub-HR of 0.42 (95% CI 1.06-5.39, p=0.035). Of 84 women with P-ALF and listed for LT, 45 listed for HELLP vs. 39 for acute fatty liver of pregnancy (AFLP) had higher 90-day WLM (19.3% vs. 5.7% p<0.005). The 90-day WLM was about 10-fold higher in HELLP vs. AFLP) with a sub-HR of 9.97 (95% CI: 1.64-60.55, p=0.013).

CONCLUSION

In this UNOS database analysis of ALF among women of childbearing age, the waitlist outcome is better in women with P-ALF compared to NP-ALF. Among women with P-ALF, the 90-day WLM is worse for HELLP vs. AFLP. Further studies are needed to improve the management of HELLP and prevent the development of ALF in this subgroup population.

Pharmacotherapies for Portal Hypertension: Current Status and Expanding Indications

Purpose

Non-selective beta blockers remain pharmacotherapy of choice for prevention of first episode of variceal bleeding (primary prevention) and for prevention of its recurrence after initial hemostasis (secondary prophylaxis). This review will update the current and emerging pharmacological therapies for portal hypertension.

Recent findings

Data have emerged on carvedilol in preventing hepatic decompensation and improving patient survival among patients with clinically significant portal hypertension. Because measurement of WHVP is invasive and not feasible in routine practice, non-invasive tests with liver stiffness measurement in combination with platelet count may be accurate in identifying clinically significant portal hypertension.

Summary

Carvedilol is more effective in reducing portal pressure compared to nadolol or propranolol. Its use has expanded to reduce risk of hepatic decompensation among patients with CSPH, which can be identified non-invasively using liver stiffness and platelet count. Studies are needed on non-invasive biomarkers to guide and optimize pharmacological treatment of portal hypertension.

Role of endoscopic ultrasound and cyst fluid tumor markers in diagnosis of pancreatic cystic lesions

BACKGROUND

Pancreatic cystic lesions (PCLs) are common in clinical practice. The accurate classification and diagnosis of these lesions are crucial to avoid unnecessary treatment of benign lesions and missed opportunities for early treatment of potentially malignant lesions.

AIM

To evaluate the role of cyst fluid analysis of different tumor markers such as cancer antigens [e.g., cancer antigen (CA)19-9, CA72-4], carcinoembryonic antigen (CEA), serine protease inhibitor Kazal-type 1 (SPINK1), interleukin 1 beta (IL1-β), vascular endothelial growth factor A (VEGF-A), and prostaglandin E2 (PGE2)], amylase, and mucin stain in diagnosing pancreatic cysts and differentiating malignant from benign lesions.

METHODS

This study included 76 patients diagnosed with PCLs using different imaging modalities. All patients underwent endoscopic ultrasound (EUS) and EUS-fine needle aspiration (EUS-FNA) for characterization and sampling of different PCLs.

RESULTS

The mean age of studied patients was 47.4 ± 11.4 years, with a slight female predominance (59.2%). Mucin stain showed high statistical significance in predicting malignancy with a sensitivity of 87.1% and specificity of 95.56%. It also showed a positive predictive value and negative predictive value of 93.1% and 91.49%, respectively (P < 0.001). We found that positive mucin stain, cyst fluid glucose, SPINK1, amylase, and CEA levels had high statistical significance (P < 0.0001). In contrast, IL-1β, CA 72-4, VEGF-A, VEGFR2, and PGE2 did not show any statistical significance. Univariate regression analysis for prediction of malignancy in PCLs showed a statistically significant positive correlation with mural nodules, lymph nodes, cyst diameter, mucin stain, and cyst fluid CEA. Meanwhile, logistic multivariable regression analysis proved that mural nodules, mucin stain, and SPINK1 were independent predictors of malignancy in cystic pancreatic lesions.

CONCLUSION

EUS examination of cyst morphology with cytopathological analysis and cyst fluid analysis could improve the differentiation between malignant and benign pancreatic cysts. Also, CEA, glucose, and SPINK1 could be used as promising markers to predict malignant pancreatic cysts.

Impact of Fibrosis-4 Index Prior to COVID-19 on Outcomes in Patients at Risk of Non-alcoholic Fatty Liver Disease

BACKGROUND

Severity of disease and outcomes in patient with COVID-19 has been associated with several risk factors tied to the metabolic syndrome.

AIMS

We conducted a study with the objective of describing the association between the baseline Fibrosis-4 (FIB-4) index prior to SARS-CoV-2 infection and the severity of COVID-19 among patients at risk of non-alcoholic fatty liver disease (NAFLD).

METHODS

This was a retrospective cohort study of patients with at least two risk factors for metabolic syndrome diagnosed with COVID-19. The main exposure of interest was FIB-4 index prior to infection, categorized into three previously validated age-specific levels. The main outcomes of interest were disease requiring hospitalization and in-hospital mortality.

RESULTS

We included 373 patients [median age, 62 years; 194 male (52%); median number of metabolic syndrome risk factors, 3]. The median FIB-4 index was 1.10 (interquartile range 0.78-1.61). In models adjusting for diabetes mellitus and chronic kidney disease, patients with intermediate FIB-4 index had 67% higher odds of hospitalization compared to those in the low category {odds ratio (OR) 1.67 [(95% CI 1.06-2.64); p = 0.03]} and patients with high FIB-4 index had higher odds of mortality compared to intermediate and low category with an OR 2.22 (95% CI 1.20-4.12; p = 0.01). However, when we evaluated components of FIB-4 (age and AST/ALT ratio), we found that age alone was the best predictor of hospitalization and mortality.

CONCLUSIONS

Among patients at risk of NAFLD with COVID-19 infection, elevated pre-infection FIB-4 index was associated with worsened clinical outcomes, but age was the strongest predictor.

Cap-Assisted Technique versus Conventional Methods for Esophageal Food Bolus Extraction: A Comparative Study

BACKGROUND/AIMS

Food bolus impaction is the most common form of esophageal foreign body impaction observed in adults. Clinical guidelines recommend using the push technique or retrieval methods in such cases. The push technique can cause injuries in certain clinical situations. Notably, conventional retrieval methods are time and effort consuming. Cap-assisted endoscopic extraction of an impacted food bolus is an easy and effective technique; however, more data are needed for its validation. This study compared the capassisted extraction technique with conventional methods.

METHODS

This prospective observational multicenter study compared the success and en bloc removal rates, total procedure time, and adverse events in both techniques..

RESULTS

The study included 303 patients who underwent food bolus extraction. The push technique was used in 87 patients (28.7%) and a retrieval procedure in 216 patients (71.3%). Cap-assisted extraction was performed in 106 patients and retrieval using conventional methods in 110 patients. The cap-assisted technique was associated with a higher rate of en bloc removal (80.2% vs. 15%, p<0.01), shorter procedure time (6.9±3.5 min vs. 15.7±4.1 min, p<0.001), and fewer adverse events (0/106 vs. 9/110, p<0.001).

CONCLUSION

Cap-assisted extraction showed no adverse events, higher efficacy, and a shorter procedure time compared with conventional retrieval procedures.

Abatacept use in graft-versus-host disease after orthotopic liver transplantation: a case report

BACKGROUND

Graft-versus-host disease (GVHD) is a rare, serious, fatal disease that occurs after orthotopic liver transplantation (OLT).

CASE REPORT

We treated a 60-year-old man who underwent OLT owing to familial amyloidosis. The patient developed fever on postoperative day 16. The fever was persistent and did not respond to antibiotic therapy. Cultures and radiologic studies were done and excluded infection as a potential cause. On postoperative day 26, a skin rash appeared on his chest, accompanied by diarrhea and persistent fever. The rash spread all over the trunk, neck, and arms, but spared the palms of his hands and soles of his feet. In the meantime, his blood cell count revealed pancytopenia. Skin biopsy was done and showed interface lymphocytic infiltrate that are largely centered on the dermal-epidermal junction, is consistent with GVHD (this pattern of rash distribution is unique and different from the rash of GVHD after hematopoietic stem cell transplant, which is confined to palms of the hands and soles of the feet; Fig 1). The diagnosis was confirmed by colonoscopy and multiple forceps biopsies, which revealed extensive crypt loss. After hematology consultation, the patient was treated by withdrawal of all immunosuppressive therapy coupled with abatacept infusion. Abatacept is a chimeric protein that inhibits T-lymphocytes and is approved by the US Food and Drug Administration for the treatment of rheumatoid arthritis. Interestingly, after second dose of abatacept the patient showed marked clinical and laboratory improvement. The patient was discharged after 47 days in a stable condition.

CONCLUSION

Because of the lack of a consensus for treatment of these patients, we report our experience with a male patient who had post-OLT GVHD and showed a marked improvement in response to abatacept.

Graft-versus-host disease after orthotopic liver transplantation: multivariate analysis of risk factors

Graft-versus-host disease (GVHD) is a rare, fatal complication following orthotopic liver transplantation (OLT). To date, several risk factors have been proposed, but reports on these factors have been inconclusive. This is a retrospective, case-control study of prospectively collected data from 2775 OLTs performed at our institution. Eight cases of GVHD after OLT were diagnosed on the basis of the patient's clinical characteristics, and the findings were confirmed with skin and colonic biopsies. Each case was matched to three controls based on the diagnosis of liver disease, recipient's age, and blood group. Univariate and multivariate analyses were performed to identify risk factors associated with the development of GVHD after OLT. The univariate and multivariate analyses identified two main risk factors associated with development of GVHD in OLT recipients, a difference between recipient and donor age of >20 yr, and any human leukocyte antigen class I matches. Taking these two risk factors into consideration while matching prospective donors and recipients may reduce further incidence of GVHD in OLT patients. However, further studies are recommended to validate these findings.