End-stage Chronic Liver Disease Research Articles

Chapter 6.0. History of Paediatric Hepatology in ESPGHAN

ABSTRACTHepatology played an important role in ESPGAN from the beginning. In 1989, the Hepatology Committee was started. In the early 1990s H for hepatology was included in ESPGHAN. Hepatology Summer schools were held from 1995 and later monothematic conferences met the needs of many young ESPGHAN members. The role of ESPGHAN members in the progress of diagnostic and therapeutic measures in hepatitis B and C will be elucidated (Chapter 6.1) as well as the role of other ESPGHAN members in the understanding of immunological hepatic disorders of childhood (Chapter 6.2). During childhood, many metabolic hepatic disorders threaten the life and health of children making orchestrated measures in diagnostic and therapeutic efforts necessary (Chapter 6.3). The pathophysiology of cholestasis was cleared by the detection of bile salt transporters, which were identified by ESPGHAN members in the Netherlands, France, United Kingdom and Germany (Chapter 6.4). Finally liver transplantation for acute fulminant and chronic end stage liver disease was established as a meanwhile standard treatment option (Chapter 6.5). Immunosupression in liver transplantation was improved and standardized through the cooperation of many ESPGHAN member driven studies (Chapter 6.6).

Update on Immunosuppression in Liver Transplantation.

ABSTRACTThe standard therapy for decompensated end-stage chronic liver disease of any etiology and acute fulminant hepatic failure is liver transplantation (LT). Advances in immunosuppressive therapy decreased the rates of acute and chronic rejections. Thus, graft and patient survivals have significantly improved. However, long-term adverse effects of prolonged use of immunosuppressive agents such as malignancies, opportunistic infections, metabolic disorders, and other organ toxicities have now become a major concern. Consequently, alternative approaches are needed to deescalate the customary drugs and their side effects. Therapy must be individualized and additional preventive measures should be taken by patients with particular risk factors or predisposed to certain adverse effects. Current opinion favors a combination of agents with different mechanism of actions and toxicity profiles. Corticosteroids are employed in immediate and early postoperative period. Although they have a pronounced side effect profile, calcineurin inhibitors (CNIs) are still the backbone of early and late phase immunosuppressive regimens because of their proved efficacy. Antimetabolites are frequent choices for steroid and/or CNI-sparing strategies. Studies also have established a role for mammalian target of rapamycin (mTOR) inhibitors in specific groups of recipients. Biologic agents are a hot topic of interest and made their way into current strategies for induction. Agents extrapolated from other transplantation or immunologic experience are being evaluated.How to cite this articleTasdogan BE, Ma M, Simsek C, et al. Update on Immunosuppression in Liver Transplantation. Euroasian J Hepato-Gastroenterol 2019;9(2):96–101.

Low PCSK9 levels are correlated with mortality in patients with end-stage liver disease.

IntroductionProprotein convertase subtilisin/kexin type 9 (PCSK9) plays a key role in the cholesterol metabolism and is synthesized by the liver. It interacts with the LDL-receptor to promote its degradation. The model of end-stage liver disease (MELD) score is a well-established tool to estimate the risk of mortality in patients with end-stage chronic liver disease. The study aims to assess the associations between PCSK9, hypocholesterinemia, liver synthesis, cholestasis, MELD score and mortality in patients with end-stage liver disease.MethodsSerum samples were obtained from 74 patients with severe liver disease. The study participants were aged between 23 and 70 y (mean: 55.8 y; 47 males [63.5%], 27 females [36.5%]). Samples were selected from those with a wide range of MELD scores (7 to 40).Patients that underwent liver transplantation (17 / 74) were censored at the time of transplantation for mortality analysis.ResultsPCSK9 values ranged from 31.47 ng/mL to 261.64 ng/mL. The median value was 106.39 ng/ml. PCSK9 was negatively correlated with markers of liver function and cholestasis (INR, bilirubin). Over a 90-d follow-up, 15 of 57 (26,3%) patients died within the 90-d follow-up without receiving liver transplantation. Thirteen of 31 (42%) patients with PCSK9 levels below the median died compared to 2/26 (8%) patients with higher PCSK9 levels (p = 0.006). In this cohort, there were no significant correlations between PCSK9, cholesterol, its precursors and several phytosterols.ConclusionsLow PCSK9 serum concentrations were associated with higher mortality in patients with end-stage liver disease. The mean PCSK9 levels in the study population were much lower than those found in normal or healthy populations. Further studies are required to acquire a more detailed understanding of the role of PCSK9 in liver-related mortality.

Increased risk of portal vein thrombosis in patients with autoimmune hepatitis on the liver transplantation waiting list.

Liver transplantation (LT) is indicated in autoimmune hepatitis (AIH) for both acute presentation with liver failure and end-stage chronic liver disease. Few studies have suggested an association between AIH and coagulation disorders and a higher incidence of portal vein thrombosis (PVT) in patients with AIH listed for LT. The aim of this study was to determine the incidence of thrombotic complications, particularly PVT, in a cohort of 37 patients undergoing LT because of AIH. PVT was present before transplantation in 30% (n=11) of these patients compared to 11% in the whole population transplanted in our center (P=.002). On comparing only patients with cirrhosis, PVT was present in 55% of the AIH group, being 12% in the whole cohort (P<.001). Among patients with PVT before LT, no patient receiving anticoagulation therapy early after LT developed recurrence of PVT, whereas two patients (33%) without anticoagulation therapy did. The increased incidence of PVT in the pretransplant period and the possibility of thrombosis recurrence after LT suggest that patients with AIH and PVT could benefit from anticoagulation therapy after transplantation. However, further studies are needed to recommend anticoagulation in these patients in clinical practice.

Imaging of liver transplantation

Liver transplantation (LT) is the treatment of choice for end-stage chronic liver disease, fulminant liver failure and early stage hepatocellular carcinoma. As discussed in this review, state-of-the-art imaging modalities including ultrasonography (US), computed tomography (CT) and magnetic resonance imaging (MRI) play a pivotal role in the selection of patients and donors, as well as in early detection of those complications at risk of impairing graft function and/or survival. We also illustrate main imaging findings related to the wide spectrum of clinical problems raised by LT.

Evaluation of the perioperative period of orthotopic liver transplantation with veno-venous bypass and without it

Orthotopic liver transplantation (OLT) is the only treatment for many patients with end-stage chronic liver diseases. In patients with complete vena cava inferior (VCI) cross-clamping veno-venous bypass (VVB) is either used or not depending on the indications. The case management of the patient with complete VCI cross-clamping depends on the initial state of the recipient and the transplant team’s opinion.Aim. To compare the perioperative period of OLT depending on the method to conduct the main stage of the surgery: with the use of veno-venous bypass and without it with complete VCI cross-clamping.Materials and methods. In Group 1 (n = 20), OLT was performed without VVB with complete VCI cross-clamping; in Group 2 (n = 26), the surgery was conducted with veno-venous bypass. Patients in both groups were similar in age (46.15 ± 10.22 and 47.3 ± 9.29, respectively), in severity of the disease: Child-Pugh (10.15 ± 1.42 and 10.19 ± 2.45), MELD 16.47 ± 4.41 and 15.8 ± 4.95).Results. We determined and evaluated hemodynamic parameters, oxygen transport, the quantitative and qualitative infusion composition, urine output, characteristics of the postoperative period.Conclusion. Our data show that changes in hemodynamic and oxygen transport are associated with reperfusion syndrome and do not depend on the method of transplantation. At the same time, it reduces the blood loss, time of surgery, and the duration of postoperative mechanical ventilation and stay in the ICU after liver transplantation in patients without veno-venous bypass.

Local application of tranexamic acid to reduce upper gastrointestinal bleeding in patients with liver cirrhosis

Background There has been a growing interest in the topical use of tranexamic acid (TXA) for the prevention of bleeding during different surgeries. Patients with liver cirrhosis may develop upper gastrointestinal (UGI) bleeding, which arises because of portal hypertension, which includes gastroesophageal varices and portal hypertensive gastropathy. The aim of this study was to evaluate the efficacy of the local application of TXA in reducing blood loss, transfusion requirements, and shortening the time for emergency endoscopy in cirrhotic patients presenting with UGI bleeding. Patients and methods A total of 100 patients with end-stage chronic liver disease presenting with UGI bleeding were randomly assigned to two groups to receive a standard protocol for UGI bleeding management, in addition to nasogastric lavage with either normal saline only (group S) or normal saline with TXA (group S+TXA). The lavage was repeated till its measured hematocrit (Hct) was less than 1%. The duration to reach this Hct was recorded. The volume of washes and transfusion requirements for each group were also recorded. Results Hemodynamic stability was observed in group S+TXA with less bleeding. The volumes of washes were significantly lower in group S+TXA. Time to reach Hct less than 1% in washed fluid was significantly shorter in group S+TXA (81.5±20.7 min) compared with group S (230.1±29.9 min). Transfusion requirements were significantly low in group S+TXA (765±184 ml) compared with group S (1345±278 ml). Duration to perform emergency upper endoscopy was shorter in group S+TXA (667±198 min) compared with group S (1094±163 min). Conclusion Local application of TXA during nasogastric lavage was efficient in reducing blood loss and transfusion requirements and in shortening the time for emergency endoscopy in cirrhotic patients presenting with UGI bleeding.

Imaging follow-up after liver transplantation.

Liver transplantation (LT) represents the best treatment for end-stage chronic liver disease, acute liver failure and early stages of hepatocellular carcinoma. Radiologists should be aware of surgical techniques to distinguish a normal appearance from pathological findings. Imaging modalities, such as ultrasound, CT and MR, provide for rapid and reliable detection of vascular and biliary complications after LT. The role of imaging in the evaluation of rejection and primary graft dysfunction is less defined. This article illustrates the main surgical anastomoses during LT, the normal appearance and complications of the liver parenchyma and vascular and biliary structures.

PWE-040 Natural History of Cirrhosis in A Cohort of Patients Undergoing Structured Surveillance for Hepatocellular Carcinoma: Results from The Aberdeen Surveillance Cohort

Introduction Cirrhosis is the end-stage of chronic liver disease due to a variety of different aetiologies with the natural history of this condition characterised by a variable asymptomatic phase of compensation followed by a rapid ‘decompensated’ phase marked by ascites, jaundice, variceal bleeding, encephalopathy and development of hepatocellular carcinoma (HCC). The cornerstone of management for cirrhotic subjects includes 6 monthly surveillance to detect development of HCC. Aberdeen Royal Infirmary is one of the few centres in the UK to have a structured HCC screening program where patients are followed up in a nurse led clinic. The aim of this study was to determine rates of decompensation and development of HCC in a cohort of cirrhotic patients undergoing structured surveillance. Methods The electronic records of 231 patients who were initiated on surveillance between the years 2010–2015 were reviewed. Only patients who attended the clinic on at least 2 occasions were included. Those with a prior history of HCC or had an HCC discovered at their first ultrasound were excluded. Primary end-points studied were the time to develop ascites, variceal haemorrhage, hepatic encephalopathy, jaundice, HCC and mortality. Data analyses were conducted using SPSS version 23. Statistical methods used include Cox regression and Kaplan Meier survival analyses. Results The 231 patients included in the study were mostly male (61.5%) with alcohol being the predominant aetiological factor (33.3%). The mean age at entry into the cohort was 58.1± 11.2 years, with a mean MELD of 8.6±2.9 and UKELD of 48.2± 3.1. The median follow-up duration was 26 months (range 6–60) giving a total cohort follow up of 522 patient years. Most patients had compensated and Childs-Pugh A cirrhosis at the time of entry (62.8% and 60.2% respectively). Of the 145 patients with compensated cirrhosis at entry, 26 (19.9%) developed jaundice or other signs of decompensation during follow up. Mean time to first decompensation episode was 49 (95% CI; 45–52) months, giving a rate of 8.7 /100 patient years. During follow-up, 7 patients developed HCC giving a detection rate of 1.36/100 patient-years. Mean age at detection of HCC was 71.6 ± 7.3 years. Mortality rate in the entire cohort was 3.6/100 patient years. Conclusion The results from our surveillance cohort outline the natural history of a large group of cirrhotic patients systematically followed up in a structured nurse-led clinic. The rates of decompensation and HCC highlight the importance of pursuing the strategy of active surveillance. Disclosure of Interest None Declared

Divergent Inflammatory, Fibrogenic, and Liver Progenitor Cell Dynamics in Two Common Mouse Models of Chronic Liver Injury

Complications of end-stage chronic liver disease signify a major cause of mortality worldwide. Irrespective of the underlying cause, most chronic liver diseases are characterized by hepatocellular necrosis, inflammation, fibrosis, and proliferation of liver progenitor cells or ductular reactions. Vast differences exist between experimental models that mimic these processes, and their identification is fundamental for translational research. We compared two common murine models of chronic liver disease: the choline-deficient, ethionine-supplemented (CDE) diet versus thioacetamide (TAA) supplementation. Markers of liver injury, including serum alanine transaminase levels, apoptosis, hepatic fat loading, and oxidative stress, as well as inflammatory, fibrogenic and liver progenitor cell responses, were assessed at days 3, 7, 14, 21, and 42. This study revealed remarkable differences between the models. It identified periportal injury and fibrosis with an early peak and slow normalization of all parameters in the CDE regimen, whereas TAA-treated mice had pericentral patterns of progressive injury and fibrosis, resulting in a more severe hepatic injury phenotype. This study is the first to resolve two different patterns of injury and fibrosis in the CDE and TAA model and to indisputably identify the fibrosis pattern in the TAA model as driven from the pericentral vein region. Our data provide a valuable foundation for future work using the CDE and TAA regimens to model a variety of human chronic liverdiseases.

Liver cirrhosis: New concepts

The term `cirrhosis` is used for two centuries to define the end-stage of chronic liver diseases with different etiologies. Clinical manifestations of cirrhosis are related to portal hypertension, hepatic dysfunction progressing to liver failure and development of hepatocellular carcinoma, conditions with unfavorable prognosis. However, recent advances in the diagnosis and treatment of chronic liver diseases have changed the natural history of cirrhosis significantly. According to current concept, liver cirrhosis is heterogeneous, multi-stage condition with variable prognosis. Cirrhosis is considered as a dynamic, biphasic process, based on numerous clinical reports indicating the reversal of advanced fibrosis and cirrhosis after cessation of perpetual injury. This review was focused on current pathology and clinical staging of cirrhosis. The potential mechanism and proves of concept for reversibility of cirrhosis were also discussed.

Imaging in pediatric liver transplantation.

Liver transplantation has become an established curative treatment in adult patients with acute or chronic end-stage liver diseases. In pediatric cases the number of cadaveric donor livers is not sufficient and to overcome the shortage of appropriate-sized whole liver grafts, technical variants of liver transplantation have been practiced. Reduced-size cadaveric and split cadaveric allografts have become an important therapeutic option, expanding the availability of size-appropriate organs for pediatric recipients with terminal liver disease. The number of pediatric deaths awaiting liver transplantation has been reduced by the introduction of living-related liver transplantation, developed to overcome the shortage of suitable grafts for children. It is important for radiologists to know that children have distinct imaging of liver transplantation that distinguish them from adults. A multidisciplinary pediatric liver transplantation team should be skilled in pediatric conditions and in associated processes, risks and complications. Radiologists should know the common pediatric liver diseases that lead to liver transplantation, the anastomotic techniques and the expected postoperative imaging findings. The aim of this study is to illustrate the role of non-invasive imaging such us ultrasonography, color Doppler ultrasonography, multidetector computed tomography and magnetic resonance imaging in the evaluation of pediatric liver transplantation and in potential liver donors.

Noninvasive models for assessment of liver fibrosis in patients with chronic hepatitis B virus infection.

There are approximately 240 million patients with chronic hepatitis B virus (HBV) infection worldwide. Up to 40% of HBV-infected patients can progress to liver cirrhosis, hepatocellular carcinoma or chronic end-stage liver disease during their lifetime. This, in turn, is responsible for around 650000 deaths annually worldwide. Repeated hepatitis flares may increase the progression of liver fibrosis, making the accurate diagnosis of the stage of liver fibrosis critical in order to make antiviral therapeutic decisions for HBV-infected patients. Liver biopsy remains the "gold standard" for diagnosing liver fibrosis. However, this technique has recently been challenged by the development of several novel noninvasive tests to evaluate liver fibrosis, including serum markers, combined models and imaging techniques. In addition, the cost and accessibility of imaging techniques have been suggested as additional limitations for invasive assessment of liver fibrosis in developing countries. Therefore, a noninvasive assessment model has been suggested to evaluate liver fibrosis, specifically in HBV-infected patients, owing to its high applicability, inter-laboratory reproducibility, wide availability for repeated assays and reasonable cost. The current review aims to present the status of knowledge in this new and exciting field, and to highlight the key points in HBV-infected patients for clinicians.

Interferon-γ, interleukin-10 and interferon-inducible protein 10 (CXCL10) as serum biomarkers for the early allograft dysfunction after liver transplantation

Orthotopic liver transplantation (LTP) is nowadays a standard procedure, and provides the chance of survival of patients with end-stage non-treatable chronic liver disease or acute liver failure. Despite long-term survival with a good quality of life in the majority of patients, about 20% develop early allograft dysfunction (EAD), which leads to death or the need for re-transplantation. Therefore, the early diagnosis of EAD and evaluation of its risk factors are very important. Many primary pathological processes leading to EAD are accompanied by the release of different mediators and by a change of biochemical parameters detectable in the peripheral blood. The aim of this study was to investigate cytokines as well as soluble mediators in the serum of patients with and without EAD from our LTP bank, and to evaluate their predictive and prognostic values for EAD. We demonstrated for the first time that the level of IFNγ during the nearest preoperative period may serve as a predictive parameter for EAD. We additionally found that IL-10 and CXCL10 (IP-10) levels in the early postoperative period can be prognostic for EAD. We believe our data expand the spectrum of predictive and prognostic parameters for EAD in LTP.

Cross-Talk Between TGF-β and NADPH Oxidases During Liver Fibrosis and Hepatocarcinogenesis.

Liver fibrosis is a pathological consequence of chronic liver diseases and results from the progressive accumulation of altered extracellular matrix, highly enriched in type I and III fibrillar collagens. In advanced stages, fibrosis leads to cirrhosis, defined by abnormal liver architecture and altered vascularization. Clinical consequences of cirrhosis are failure in the synthetic function of the liver, portal hypertension, high susceptibility to infection and high risk to develop hepatocellular carcinoma (HCC). The TGF-β family of cytokines plays essential roles in many cellular processes, including growth inhibition, cell migration and invasion, extracellular matrix remodelling and immune suppression, being involved in the maintenance of tissue homeostasis. However, TGF-βs are often continuously overexpressed in disease states, such as fibrosis, inflammation and cancer, and they play pivotal roles in the sequence of events leading to end-stage of chronic liver diseases. Reactive oxygen species (ROS) are critical intermediates in liver physiology and pathology. When the equilibrium between ROS generation and the antioxidant defence of the cell is disrupted, it results in an oxidative stress process. The NADPH oxidase (NOX) family has emerged in the last years as important source of ROS in liver pathologies. Interestingly, NOXes mediate TGF-β actions in liver cells, such as regulation of hepatocyte growth and death, as well as activation of hepatic stellate cells to myofibroblasts, key executers of the fibrotic process. In this review we will update the relevant and differential roles of NOX isoforms during liver fibrosis and hepatocarcinogenesis, their cross-talk with the TGF-β pathway and their potential as therapeutic targets for these diseases.

Liver Transplant Experience in Syzganov's National Scientific Center of Surgery.

Patients with chronic end-stage liver disease present a significant problem in the Republic of Kazakhstan. The liver transplant program was started in December 2011 and for May 2015, more than 80 liver transplant operations have been performed in 7 different hospitals of the country. The main problem that hinders the wide implementation of liver transplant in our country is poor development of regularity of deceased-organ donation system. This is because of the specific mentality of the population and imperfect legislation. From 26 operated recipients, 19 lead a normal life (73.1%), receiving a minimal immunosuppressive therapy. In patients with cirrhosis of viral cause, there are no cases of viral hepatitis reinfection. Preliminary findings based on a small experience showed a good perceptiveness of developing of Liver Transplant program in Kazakhstan.

Vanishing Bile Duct Syndrome Leading to Biliary Cirrhosis in a Patient With Remote History of Non-Hodgkin Lymphoma

We present a case of a 60-year-old man with a remote history of non-Hodgkin Lymphoma (NHL) who developed cirrhosis during the course of his lymphoma. Investigation into the underlying cause of cirrhosis was negative including viral and autoimmune serologic markers and imaging studies of biliary tree. He had no history of alcohol abuse. While his NHL was eventually successfully treated with chemotherapy, he developed multiple sequelae of end stage liver disease including variceal bandings, spontaneous bacterial peritonitis, and acute coagulopathic episodes before successful liver transplantation nearly two decades after his diagnosis of NHL. Histologic exam of the explanted liver showed a biliary pattern of cirrhosis with near total loss of interlobular bile ducts. Chronic biliary injury and cholestasis was confirmed by the presence of excess copper deposition and copper binding protein by copper and Victoria blue stains, respectively. There were no features of primary sclerosing cholangitis or primary biliary cirrhosis. There was no steatosis, no evidence of alpha-1-antitrypsin disease, hemochromatosis, or veno-occlusive disease. There was no evidence of lymphomatous involvement. It was determined that the patient had likely developed VBDS and biliary cirrhosis in association with his NHL. Vanishing bile duct syndrome (VBDS) refers to a clinicopathologic group of conditions resulting from progressive destruction and disappearance of intrahepatic bile ducts. It can be seen in a variety of conditions including primary liver disorders or manifestations of systemic illnesses. VBDS has also been reported in association with many drugs. VBDS is an uncommon but potentially fatal complication of Hodgkin lymphoma, and in exceptionally rare cases, NHL. The exact mechanism is unknown but is thought to be a paraneoplastic phenomenon, or possible sequelae of drug induced/chemotherapy injury. There are only 3 prior published cases of VBDS in association with NHL. In 2 of the cases the patients died, one of acute liver failure and the other of multiple organ failure secondary to his underlying lymphoma. The third case demonstrated reversibility of the VBDS with near normalization of total bilirubin levels 6 weeks after onset of chemotherapy. To our knowledge, our case is the first to demonstrate a prolonged course of VBDS in association with NHL, eventually leading to chronic end stage liver disease and biliary cirrhosis, despite complete remission of NHL.

Phases I-II Matched Case-Control Study of Human Fetal Liver Cell Transplantation for Treatment of Chronic Liver Disease.

Fetal hepatocytes have a high regenerative capacity. The aim of the study was to assess treatment safety and clinical efficacy of human fetal liver cell transplantation through splenic artery infusion. Patients with end-stage chronic liver disease on the waiting list for liver transplantation were enrolled. A retrospectively selected contemporary matched-pair group served as control. Nonsorted raw fetal liver cell preparations were isolated from therapeutically aborted fetuses. The end points of the study were safety and improvement of the Model for End-Stage Liver Disease (MELD) and Child-Pugh scores. Nine patients received a total of 13 intrasplenic infusions and were compared with 16 patients on standard therapy. There were no side effects related to the infusion procedure. At the end of follow-up, the MELD score (mean ± SD) in the treatment group remained stable from baseline (16.0 ± 2.9) to the last observation (15.7 ± 3.8), while it increased in the control group from 15.3 ± 2.5 to 19 ± 5.7 (p = 0.0437). The Child-Pugh score (mean ± SD) dropped from 10.1 ± 1.5 to 9.1 ± 1.4 in the treatment group and increased from 10.0 ± 1.2 to 11.1 ± 1.6 in the control group (p = 0.0076). All treated patients with history of recurrent portosystemic encephalopathy (PSE) had no further episodes during 1-year follow-up. No improvement was observed in the control group patients with PSE at study inclusion. Treatment was considered a failure in six of the nine patients (three deaths not liver related, one liver transplant, two MELD score increases) compared with 14 of the 16 patients in the control group (six deaths, five of which were caused by liver failure, four liver transplants, and four MELD score increases). Intrasplenic fetal liver cell infusion is a safe and well-tolerated procedure in patients with end-stage chronic liver disease. A positive effect on clinical scores and on encephalopathy emerged from this preliminary study.

Management of Bleeding and Thrombosis in Critically Ill Patients with Liver Disease.

Bleeding frequently complicates end-stage chronic liver disease, and may follow procedures which are required for effective care of patients with liver failure. Thrombosis is increasingly recognized as common, important, and potentially preventable. Standard laboratory tests may not be useful in predicting bleeding or thrombotic risk or guiding therapy, and functional testing serves a more useful role. A state of rebalanced hemostasis exists in many patients, with hypocoagulability present only in a minority. Approaches to management are poorly supported by high-quality evidence; in this review, a practical pragmatic approach to care and minimization of procedure-related risk is discussed. General measures include the correction of systemic factors that may affect coagulation status, prevention and treatment of infection, and individualized coagulation support therapies for specific clinical situations and procedures.

Self-management and self-efficacy status in liver recipients

Liver transplantation (LT) is a viable treatment for patients with end-stage chronic liver diseases. The main aim of LT is to prolong life and improve life quality. However, although survival after LT continues to improve, some aspects of recipient's health-related quality of life such as self-management and self-efficacy have been largely ignored. A total of 124 LT recipients were included in this study. Questionnaires for general health status information and a "Self-Management Questionnaire for Liver Transplantation Recipients" modified from the Chinese version of "Chronic Disease Self-Management Program Questionnaire Code Book" were used in the survey. Data were collected by self-administered questionnaires. The overall status of self-management in LT recipients was not optimistic. The major variables affecting the self-management of LT recipients were marital status, educational level and employment. The overall status of self-efficacy in LT recipients was around the medium-level. Postoperative time and self-assessment of overall health status were found as the factors impacting on self-efficacy. The self-management behavior of LT recipients needs to be improved. The health care professionals need to offer targeted health education to individual patients, help them to establish healthy lifestyle, enhance physical activity and improve self-efficacy. The development of the multilevel and multifaceted social support system will greatly facilitate the self-management in LT patients.