The Outcomes of Liver Transplantation in Severe Metabolic Dysfunction-Associated Steatotic Liver Disease Patients

The increasing prevalence of diabetes mellitus, obesity, and metabolic syndrome in the population can lead to metabolic dysfunction-associated steatohepatitis (MASH) and metabolic dysfunction-associated steatotic liver disease (MASLD). In Western industrialized countries, this has become a major problem with significant socioeconomic impacts. MASH is now a leading cause of liver transplantation (LT), especially in developed countries. However, the post-transplant outcomes of such patients are a major concern, and published data are limited and extremely variable. In this article, we discuss graft and patient survival after LT, complications, the recurrence of MASH, and MASH appearing de novo after transplantation. Recent studies suggest that patients with MASH have slightly worse short-term survival, potentially due to increased cardiovascular mortality. However, most studies found that longer-term outcomes for patients undergoing LT for MASH are similar or even better than those for other indications. Hepatocellular carcinoma due to MASH cirrhosis also has similar or even better outcomes after LT than other etiologies. In conclusion, we suggest questions and topics that require further research to enhance healthcare for this growing patient population.

Fetuin-A Deficiency but Not Pentraxin 3, FGF-21, or Irisin, Predisposes to More Serious COVID-19 Course

Analysis of liver biopsy specimens showed that SARS-CoV-2 might have led to liver damage. This study aimed to evaluate the role of selected hepatokines and myokines in the development and progression of COVID-19. Seventy patients with laboratory-confirmed COVID-19 and 20 healthy volunteers were enrolled in the study. Irisin, pentraxin 3, fetuin-A, and FGF-21 serum concentrations and biochemical parameters were assessed using an immunoenzymatic method with commercially available enzyme immunoassay (EIA) or enzyme-linked immunosorbent assay (ELISA) kits. Serum fetuin-A concentrations were significantly decreased in COVID-19 patients compared to healthy volunteers. The serum concentration of FGF-21 was significantly increased in obese COVID-19 patients compared to overweight ones. Moreover, the FGF-21 level was higher in COVID-19 patients diagnosed with metabolic syndrome than in patients without metabolic syndrome. PTX3 concentration was higher in COVID-19 patients with higher HOMA-IR values than those with lower HOMA-IR values. COVID-19 patients with HOMA-IR ≤ 3 and >3 had significantly lower fetuin-A levels than the control group. Irisin concentration was significantly decreased in the HOMA-IR ≤ 3 COVID-19 subgroup when comparing with the control group. Lower levels of fetuin-A observed in COVID-19 patients despite higher HOMA-IR, CRP, and ferritin levels, pneumonia, patients requiring ICU care suggests that fetuin-A deficiency predisposes to more severe COVID-19 course. Upregulated pentraxin 3 may be used as a potential predictor of COVID-19 severity.

Liver Disease During Pregnancy: A Challenging Clinical Issue

One of the least studied topics in the field of obstetrics is liver disease during pregnancy, which creates a challenge for both gynecologists and hepatologists. Approximately 3% of pregnant women are affected by some form of liver disease during pregnancy. Some of these conditions can be fatal for both the mother and child. In addition, 3 types of liver disease need to be differentiated during pregnancy. One type is liver disease directly related to pregnancy, which can occur at a specific time during pregnancy. Another type is liver disease not related to pregnancy, which can occur at any time, such as viral- or drug-induced hepatitis. Furthermore, pregnancy can occur in women with pre-existing liver disease. It is essential that the clinicians are familiar with this disorder so they can respond promptly and appropriately in all of these situations, especially when emergency delivery is needed and must not be postponed.

Liver elastography malignancy prediction score for noninvasive characterization of focal liver lesions

BACKGROUND & AIMS

To analyse elastographic characteristics of focal liver lesions (FLL)s and diagnostic performance of real-time two-dimensional shear-wave elastography (RT-2D-SWE) in order to differentiate benign and malignant FLLs.

METHODS

Consecutive patients diagnosed with FLL by abdominal ultrasound (US) underwent RT-2D-SWE of FLL and non-infiltrated liver by intercostal approach over the right liver lobe. The nature of FLL was determined by diagnostic work-up, including at least one contrast-enhanced imaging modality (MDCT/MRI), check-up of target organs when metastatic disease was suspected and FLL biopsy in inconclusive cases.

RESULTS

We analysed 196 patients (median age 60 [range 50-68], 50.5% males) with 259 FLLs (57 hepatocellular carcinomas, 17 cholangiocarcinomas, 94 metastases, 71 haemangiomas, 20 focal nodular hyperplasia) of which 70 (27%) were in cirrhotic liver. Malignant lesions were stiffer (P < .001) with higher variability in intralesional stiffness (P = .001). The best performing cut-off of lesion stiffness was 22.3 kPa (sensitivity 83%; specificity 86%; positive predictive value [PPV] 91.5%; negative predictive value [NPV] 73%) for malignancy. Lesion stiffness <14 kPa had NPV of 96%, while values >32.5 kPa had PPV of 96% for malignancy. Lesion stiffness, lesion/liver stiffness ratio and lesion stiffness variability significantly predicted malignancy in stepwise logistic regression (P < .05), and were used to construct a new Liver Elastography Malignancy Prediction (LEMP) score with accuracy of 96.1% in validation cohort (online calculator available at http://bit.do/lemps).

CONCLUSION

The comprehensive approach demonstrated in this study enables correct differentiation of benign and malignant FLL in 96% of patients by using RT-2D-SWE.

Nonalcoholic fatty liver disease and liver transplantation - Where do we stand?

Nonalcoholic fatty liver disease/nonalcoholic steatohepatitis (NAFLD/NASH) is a challenging and multisystem disease that has a high socioeconomic impact. NAFLD/NASH is a main cause of macrovesicular steatosis and has multiple impacts on liver transplantation (LT), on patients on the waiting list for transplant, on post-transplant setting as well as on organ donors. Current data indicate new trends in the area of chronic liver disease. Due to the increased incidence of metabolic syndrome (MetS) and its components, NASH cirrhosis and hepatocellular carcinoma caused by NASH will soon become a major indication for LT. Furthermore, due to an increasing incidence of MetS and, consequently, NAFLD, there will be more steatotic donor livers and less high quality organs available for LT, in addition to a lack of available liver allografts. Patients who have NASH and are candidates for LT have multiple comorbidities and are unique LT candidates. Finally, we discuss long-term grafts and patient survival after LT, the recurrence of NASH and NASH appearing de novo after transplantation. In addition, we suggest topics and areas that require more research for improving the health care of this increasing patient population.

Simultaneous Orthotopic Liver Transplantation With Abdominal Aortic Aneurysm Repair: A Case Report

The simultaneous occurrence of an abdominal aortic aneurysm and liver cirrhosis needing surgical treatment is extremely rare. There is still controversy regarding the timing of abdominal aortic aneurysm repair and liver transplantation and regarding optimal treatment of the aneurysm. Here, we describe a 70-year-old white male patient who presented with end-stage liver disease secondary to chronic hepatitis C with a solitary hepatocellular carcinoma measuring 5.5 cm in diameter in the right liver lobe. A pretransplant work-up resulted in discovery of a 6.7-cm abdominal aortic aneurysm. The decision was made to perform orthotopic liver transplantation with simultaneous aneurysm repair. The patient was initially explored through a median laparotomy. The liver transplant was performed first with the graft prepared on the back table using a standard procedure. The liver graft was transplanted using a "piggy-back" technique with end-to-side caval and end-to-end portal vein anastomosis. The arterial anastomosis was performed with an end-to-end anastomosis between the donor's proper hepatic artery and the recipient's common hepatic artery. The bile duct anastomosis was performed with an end-to-end anastomosis. A midline incision was extended to the pubis. After proximal and distal vascular control of the infrarenal aorta, resection of the abdominal aortic aneurysm was performed followed by reconstruction with an InterVascular 22-mm prosthesis using 3.0 Prolene in a running fashion. Eight days after surgery, the patient was discharged and remained well during the 2-year follow-up. Although rare, in a patient with end-stage liver disease and abdominal aortic aneurysm, a simultaneous liver transplantation and aneurysm repair procedure represents the safest treatment solution.

[Multifocal epithelioid hemangioendothelioma treated by liver transplantation--case report]

Multifocal epithelioid hemangioendothelioma of the liver is a rare primary tumor with a variable course of disease. A case is presented of a 27-year-old female patient with multiple hepatic lesions on ultrasonography, suspect of metastatic tumor of the liver. Serum tumor markers were not elevated, while clinical examination of the lungs, gastrointestinal and gynecologic systems did not confirm the presence of a primary tumor process. Metastatic tumor and primary hepatocellular tumor were ruled out by fine needle aspiration cytology. Along with a characteristic immunophenotype of the vascular cell endothelium (positive for CD31 and CD34), high proliferation demonstrated by the analysis of argyrophilic nucleolar organization regions (AgNOR) and DNA aneuploidy, cytomorphological pattern suggested the diagnosis of angiosarcoma. Histopathologic finding corresponded to epithelioid hemangioendothelioma. Ten years after orthotopic liver transplantation, the patient is free from disease relapse, with regular follow up testing. Hemangioendothelioma of the liver is characterized by multifocality, which excludes resection; thus, liver transplantation is the method of choice. Therefore, preoperative diagnostic workup is of utmost importance to differentiate it from other primary and metastatic tumors of the liver.

[Post-transplant lymphoproliferative disease in liver transplant recipients--Merkur University Hospital single center experience]

Post-transplant lymphoproliferative disorder (PTLD) is an increasingly recognized condition as the number of solid organ and bone marrow transplant recipients increases. It can be a life threatening fulminant disorder and affects approximately 8% of solid organ transplant recipients. Epstein-Barr virus (EBV) is closely involved in the pathogenesis of PTLD and the majority of PTLD cases arise in response to primary infection with EBV or to re-activation of previously acquired EBV. The principal risk factors underlying the development of PTLD are the degree of overall immunosuppression and EBV serostatus of the recipient. The most commonly used pathologic classification of PTLD is the World Health Organization classification, which divides PTLD into three categories: early lesions, polymorphic PTLD, and monomorphic PTLD. Early lesions are characterized by reactive plasmacytic hyperplasia. Polymorphic PTLD may be either polyclonal or monoclonal and is characterized by destruction of the underlying lymphoid architecture, necrosis, and nuclear atypia. In monomorphic PTLD, the majority of cases (>80%) arise from B cells, similar to non-Hodgkin's lymphoma in immunocompetent hosts. The most common subtype is diffuse large B-cell lymphoma, but Burkitt's/Burkitt's-like lymphoma and plasma cell myeloma are also seen. Rarely T-cell variants occur, which include peripheral T-cell lymphomas and, rarely, other uncommon types, including gamma/delta T-cell lymphoma and T-natural killer (NK) cell varieties. Hodgkin's disease-like lymphoma is very unusual. An accurate diagnosis of PTLD requires a high index of suspicion, since the disorder may present subtly and/or extranodally. Radiologic evidence of a mass or the presence of elevated serum markers (such as increased LDH levels) are suggestive of PTLD, with positive finding on ultrasonography, computed tomography, magnetic resonance and/or positron emission tomography scanning (possibly indicating metabolically active areas) also favoring the diagnosis. The management of PTLD poses a major therapeutic challenge and although there is reasonable agreement about the overall principles of treatment, there is still considerable controversy about the optimal treatment of individual patients. EBV-related PTLDs are a significant cause of mortality in patients undergoing orthotopic liver transplantation with the observed mortality rate of up to 50%. This paper presents the experience acquired at Merkur University Hospital in the diagnosis and treatment of patients with liver transplantation and PTLD.

[Hepatocellular carcinoma initially diagnosed by fine needle aspiration cytology of the pelvic bone metastasis]

Hepatocellular carcinoma mostly develops in patients with liver cirrhosis due to chronic hepatitis C virus (HCV) infection. A case is presented of a patient with hepatorenal syndrome as a sequel of liver cirrhosis due to HCV infection. Primary tumor of the liver was not diagnosed by routine procedures, but by fine needle aspiration cytology of the extensive osteolytic lesion of the pelvic bone, performed as part of the pre-transplantation workup. Transplantation procedure was abandoned because of inappropriate donor liver (hepatic artery thrombosis), and palliative pain-relieving irradiation was recommended. However, hepatic coma developed very rapidly and the patient died within a month of the diagnosis of metastatic hepatocellular carcinoma. Although hepatocellular carcinoma metastases are not rare, massive bone infiltration from a primary tumor undetectable by routine methods is not frequently encountered.

[Acute plastic bronchitis--case report]

Plastic bronchitis is a rare disorder characterized by formation and sometimes dramatic expectoration of bronchial casts. It may occur at any age, but most published cases refer to pediatric population. We report a case of an 81-year-old man hospitalized at intensive care unit, who presented with the appearance of plastic bronchitis type I. He had profuse expectoration of several pieces, a few cm long and up to 1 cm wide, of wormlike reddish-brownish "tissue". Histologically, it was a slimy purulent secretion with abundant fibrin and blood and with cytopathic effect of herpes virus. The pathogenesis of plastic bronchitis is not clear.

[Extramedullary multiple myeloma of the colon--case presentation and literature review]

Multiple myeloma with gastrointestinal infiltration is rare, and it has been usually described in some case reports or case series. Stomach and small intestine are mostly involved, while large bowell involvement is very rare. Multiple myeloma should be considered in the differential diagnosis of some other diseases of the large bowel associated with weight loss, diarrhoea, malabsorption, frequent lumbar pain, effort intolerance. Colonoscopic biopsy followed by histopathological examination is essential for the diagnosis of multiple myeloma. Multiple myeloma with extramedullary infiltration of the colon has no well defined treatment guideline. Localised infiltration of gastrointestinal tract could be treated by surgical resection, but as these tumors are radiosensitive, radiotherapy has also been used. Chemotherapy with pulsed dexamethasone and afterwards a combination of cyclophosphamide, vincristine, melphalan and prednisone has been described in some case studies. Some patients were treated with other therapies incuding thalidomide, bortezomib, autologous or allogeneic stem cell transplantation. The clinical presentation, diagnosis and therapy may be challenging, so we present a 66-year old patient with extramedullary multiple myeloma of the colon who was treated at our Department.

Role of fine needle aspiration cytology in management of hepatocellular carcinoma: a single centre experience

Hepatocellular carcinoma (HCC) mostly occurs in chronic liver disease and cirrhosis. Liver resection and liver transplantation (LT) represent potentially curative treatments of choice and if not feasible, palliative strategies such as percutaneous interventional techniques (PITs) and chemotherapy (ChT) are considered. Elevated alfa-fetoprotein, typical imaging pattern, needle core biopsy (NCB) and fine needle aspiration cytology (FNAC) complement diagnostic assessment of HCC. We have retrospectively analyzed all patients with contraindications for NCB in which HCC was diagnosed by FNAC during consecutive 5 years in our hospital. Ultrasound guided FNAC provided a safe method of approach and, except for mild transitory discomfort at the site of puncture, no complications were documented. The diagnosis was established on May-Grünwald-Giemsa (MGG) stained aspirates and additional immunocytochemistry. Of our 62 patients, HCC developed in 61.3% cirrhotic and 38.7% non-cirrhotic livers. In the setting of cirrhosis 18.4% of patients underwent LT, 15.8% PITs, 26.3% ChT and 39.5% symptomatic therapy. In non-cirrhotic setting 46% of patients underwent liver resection, and PIT, ChT and symptomatic therapy were applied in 4%, 25%, 25% of cases, respectively. Pathohistology of resected and explanted livers (18 cases) confirmed the initial diagnosis made on FNAC. Since only early stage of HCC has a better prognosis, every effort should be made to establish prompt and accurate diagnosis. Our observations demonstrate that FNAC offers minimally invasive, rapid and uncomplicated diagnostic approach, with sensitivity from 67% to 93% and specificity from 96% to 100%. FNAC, is of utmost importance in the setting of abnormal coagulation tests and ascites commonly seen in advanced liver disease, facilitating diagnostic workup and treatment decisions.

Classic Kaposi's sarcoma: a case report

A 60-year-old male from the Mediterranean area presented with edematous right leg and livid nodules and macules on the skin of upper and lower extremities. Biopsy specimen obtained from the right upper leg showed a pathohistologic finding indicative of Kaposi's sarcoma. Polymerase chain reaction testing revealed HHV-8 in the skin lesion. Serology for HIV was negative. Additional examinations did not reveal dissemination of the disease. Negative HIV serology, normal laboratory findings and absence of immunosuppressant therapy in the patient's history confirmed the diagnosis of the classic form of Kaposi's sarcoma.