Complications In Liver Transplant Recipients Research Articles

Association of Preoperative Red Cell Distribution Width with Postoperative Outcomes in Liver Transplantation Recipients

Background: The 1-year mortality rate after liver transplantation is approximately 8%-20%. It is important to explore risk factors associated with postoperative outcomes in liver transplantation recipients (LTRs). Red cell distribution width (RDW) is an indicator that assesses the variability in the volume of red blood cells in circulation. RDW is not only related to inflammatory levels and nutritional status but also associated with postoperative outcomes in surgical patients. However, the relationship between preoperative RDW and postoperative outcomes in LTRs remains unclear. Therefore, we designed a retrospective observational study to investigate the impact of preoperative RDW levels on postoperative outcomes in LTRs. Methods: We retrospectively collected clinical data of patients who underwent allogeneic liver transplantation at West China Hospital, Sichuan University, from January 2016 to December 2020. The primary outcome was 1-year mortality. Secondary outcomes included 30-day mortality, long-term survival, early postoperative graft dysfunction, acute kidney injury, renal replacement therapy, pulmonary complications, duration of postoperative mechanical ventilation, length of ICU stay, and length of hospital stay. Patients were divided into two groups: RDW ≤ 14.5% and RDW > 14.5%. We selected 14 covariates and used propensity score matching (PSM) to adjust for baseline characteristics. Postoperative outcomes and long-term survival were analyzed after PSM. Receiver operating characteristics (ROC) curves and subgroup analyses were also performed. Results: A total of 661 patients who underwent liver transplantation surgery were screened for this study. Finally, 438 patients were included in the statistical analysis. After PSM, there were no statistically significant differences in postoperative mortality and complications between the RDW ≤ 14.5% group and the RDW > 14.5% group (P > 0.05). The comparison of long-term survival between the two groups also showed no statistical difference (hazard ratio = 0.67, 95% confidence interval: 0.28-1.61, P = 0.358). Subgroup analyses showed consistent results. The ROC curve indicated that the predictive ability of preoperative RDW levels for 1-year mortality is moderate (area under the ROC curve 0.661). Conclusion: Preoperative RDW levels do not affect postoperative mortality and the incidence of complications in LTRs. However, these results still need further research for verification.

Association of iron overload with infectious complications in liver transplant recipients: a systematic review and meta-analysis.

This study was performed to examine the possible association of iron overload with infectious complications and survival among liver transplant recipients. We conducted a systematic review and meta-analysis of studies published in the PubMed, Embase, Web of Science, and Cochrane Library databases up to September 2022. Hazard ratios (HRs) and 95% confidence intervals (CIs) were extracted to estimate the association of iron overload with infectious outcomes and overall survival after liver transplantation. Eight studies involving 2817 recipients met the inclusion criteria. Iron overload was strongly associated with an increased risk of infection after liver transplantation (HR, 1.66; 95% CI, 1.03-2.68). An increase in the serum ferritin level was associated with an increased risk of infection after liver transplantation (HR, 1.44; 95% CI, 1.09-1.91). Iron overload was a significant predictor of worse overall survival (HR, 1.35; 95% CI, 1.11-1.64). In addition, a high serum ferritin level was significantly associated with an increased risk of death (HR, 1.34; 95% CI, 1.10-1.64). Iron overload may be associated with a higher risk of infectious complications and a worse prognosis among liver transplant recipients.

Frequency of Chest Complications after Liver Transplantation

Background: Liver transplantation is a critical intervention for patients with advanced liver disease. However, postoperative complications, particularly pulmonary complications, significantly impact patient outcomes. Understanding these complications is essential for improving post-transplant care. Objective: To investigate the prevalence and nature of pulmonary complications in liver transplant recipients and to identify potential risk factors associated with these complications. Methods: This study was conducted at the Hepatobiliary and Liver Transplant Centre, Shaikh Zayed Hospital, Lahore, Pakistan, over a six-month period. A case series design with non-probability purposive sampling was employed. The sample size, determined using the WHO Sample Size Tool, was set at 100 participants, given logistical constraints. Data collection involved detailed postoperative assessments to identify pulmonary complications. The study included participants of all sexes and ages awaiting liver transplantation, excluding those undergoing a second transplant. Data analysis was performed using SPSS version 25. Results: Out of 100 liver transplant recipients, 98.5% (n=128) presented with stable vital signs at the time of data collection, while 1.5% (n=2) were unstable. Discharge planning indicated 68.5% (n=89) under observation and 23.1% (n=30) with routine planning. In terms of education, 59.2% (n=77) had 10 years of education, and 16.9% (n=22) were illiterate. Donor health status was excellent in 98.5% (n=128) of cases. Pulmonary complications included respiratory infections (23.8%, n=31), pleural effusion (36.2%, n=47), atelectasis (15.4%, n=20), bronchospasm (7.7%, n=10), and pneumonia (9.2%, n=12). Conclusion: The study highlights a significant incidence of pulmonary complications post-liver transplantation, with pleural effusion, respiratory infections, and atelectasis being the most common. These findings underscore the need for enhanced monitoring and proactive management of pulmonary complications in liver transplant recipients.

The Revolutionary Role of GLP-1 Agonists and SGLT-2 Inhibitors in Managing Diabetes and Chronic Kidney Disease in Liver Transplant Recipients

Successful liver transplant is the only life-saving intervention for patients with end-stage liver disease, but post-transplant complications, particularly diabetes mellitus and chronic kidney disease, significantly compromise both patient and graft survival. These complications not only heighten clinical and economic burdens but also worsen long-term outcomes due to the rising prevalence of metabolic syndrome, which predisposes many liver transplant recipients to metabolic dysfunctions like diabetes and chronic kidney disease. Additionally, metabolic syndrome is a key driver of Metabolic Associated Steatotic Liver Disease, a leading cause of liver failure and a growing indication for liver transplantation worldwide. While liver transplantation resolves end stage liver disease, it fails to address the underlying metabolic challenges, such as pre-existing or post-transplant diabetes and chronic kidney disease. The use of calcineurin inhibitors ,a cornerstone of immunosuppression, exacerbates these issues by disrupting glucose metabolism, increasing insulin resistance, and causing pancreatic beta-cell dysfunction, which further contributes to post-transplant diabetes mellitus. Post-transplant diabetes mellitus is associated with increased morbidity, mortality, and graft rejection, underscoring the need for improved management strategies. Emerging therapies, such as GLP-1 receptor agonists and SGLT-2 inhibitors, have shown promise in mitigating the effects of diabetes and chronic kidney disease in non-transplant populations. These agents offer potential benefits for liver transplant recipients by improving glycemic control, promoting weight loss, and offering renal protection. However, their application in liver transplantation remains underexplored, with limited clinical data available. This review explores the pathogenesis of diabetes and chronic kidney disease in liver transplant recipients, the challenges posed by current immunosuppressive regimens, and the potential role of GLP-1 agonists and SGLT-2 inhibitors in improving patient and graft outcomes. Future research is essential to optimize post-transplant care and reduce the burden of metabolic complications in liver transplant recipients.

Yüksek vücut kitle indeksi, sağ lob canlı donörden karaciğer nakli alıcılarında postoperatif kanama ve safra komplikasyon oranlarını artıran bir faktör mü?

Purpose: High Body Mass Index emerges as an important perioperative and postoperative risk factor for liver transplantation We aimed to examine the effect of increased BMI on perioperative follow-up parameters and per-postoperative complications in liver transplant recipients.
 Materials and methods: One hundred and seventy-two patients who underwent living-donor liver transplantation for end stage liver cirrhosis were included in the study. Whether there was a difference between cold ischemia time, operation time, blood product transfusion rates, hospital, biliary complications, hepatic vein thrombosis, portal vein thrombosis, NASH etiology, postoperative hemorrhage, sepsis, and primary graft dysfunction were analyzed statistically in terms of those with a BMI of 25 and above and those below 25.
 Results: Anhepatic phase duration (p=0.047) and cold ischemia duration (p=0.009) were statistically longer in patients with BMI >25.
 Conclusion: Prolonged anhepatic phase and cold ischemia times may be important in terms of the effect of increased BMI on postoperative graft survival.

Angiotensin receptor blockers might be protective against hepatic steatosis after liver transplantation

BackgroundHepatic steatosis is an increasing complication in liver transplant recipients. Currently, there is no pharmacologic therapy for treatment of hepatic steatosis after liver transplantation. The aim of this study was to determine the association between use of angiotensin receptor blockers (ARB) and hepatic steatosis in liver transplant recipients.MethodsWe conducted a case-control analysis on data from Shiraz Liver Transplant Registry. Liver transplant recipients with and without hepatic steatosis were compared for risk factors including use of ARB.ResultsA total of 103 liver transplant recipients were included in the study. Thirty five patients treated with ARB and 68 patients (66%) did not receive these medications. In univariate analysis, ARB use (P = 0.002), serum triglyceride (P = 0.006), weight after liver transplantation (P = 0.011) and etiology of liver disease (P = 0.008) were associated with hepatic steatosis after liver transplantation. In multivariate regression analysis, ARB use was associated with lower likelihood of hepatic steatosis in liver transplant recipients (OR = 0.303, 95% CI: 0.117–0.784; P = 0.014). Mean duration of ARB use (P = 0.024) and mean cumulative daily dose of ARB (P = 0.015) were significantly lower in patients with hepatic steatosis.ConclusionOur study showed that ARB use was associated with reduced incidence of hepatic steatosis in liver transplant recipients.

Management of biliary complications in liver transplant recipients using a fully covered self-expandable metal stent with antimigration features.

Following liver transplant (LT) with duct-to-duct anastomosis, biliary strictures and leaks are typically managed with endoscopic retrograde cholangiopancreatography (ERCP) and stenting. While multiple side-by-side plastic stents are typically used for management of anastomotic strictures, fully covered self-expandable metal stents (FCSEMS) can be used to decrease the number of ERCPs with longer periods of stent patency. The risk of migration can limit their use. FCSEMS with antimigration fins to manage benign biliary complications following LT may provide stricture resolution with limited adverse events (AEs). Single center retrospective study of LT patients who required FCSEMS from 1/2014 to 4/2022. Primary outcomes included stricture resolution and recurrence. Secondary outcomes were stent migration, occlusion, removability, and number of ERCPs. Forty-three patients (mean age 55.5 years) with anastomotic strictures (N.=37), bile leaks (N.=4) or both (N.=2) were included. The median time from LT to FCSEMS placement was 125 days. Within one year of LT, 31 patients required intervention; early intervention at less than 30 and 90 days was needed in 7 and 19 patients, respectively. The median length of follow-up was 816.5 days. Stricture resolution was seen in 35 patients (81%) after a median stent dwell time of 130.5 days; recurrence occurred in 8 patients. There were three instances of partial stent migration that did not require reintervention or interfere with removability. The mean number of ERCPs required was 2.5. The use of a FCSEMS with antimigration features yields effective stricture resolution with longer stent dwell times and fewer ERCPs.

Management of Biliary Complications in Liver Transplant Recipients with Duct-To-Duct Anastomosis: A Single-Center Experience.

The aims of this study were to investigate biliary complications in liver transplant recipients with choledochocholedocho stomy anastomosis, to identify the risk factors for the development of such complications, and to evaluate the success of endoscopic approaches in liver transplant recipients. Between January 2013 and May 2021, a total of 238 patients with liver diseases underwent liver transplantation: 174 recipients undergoing choledochocholedochostomy anastomosis were included in the analysis. Their median age was 54.0 years. The median posttransplant follow-up period was 29 months. Hepatitis B virus infection (33%) was the most common indication for liver transplantation. Most patients (87%) received living donor liver transplantation. The overall prevalence of posttransplant biliary complications was 31%. Anastomotic biliary strictures were the most common biliary complications (72%), followed by biliary leakage (13%). The median time between endoscopic retrograde cholangiography and liver transplantation was 4 months, with a mean of 3 ± 1.6 sessions. Endoscopic retrograde cholangiography-guided drainage and balloon dilation with or without stent placement was the most common treatment modalities for recipients with biliary strictures. The overall success rate of endoscopic treatment modalities was 83.3%, with 65% of the recipients exhibiting complete biochemical and endoscopic responses. The response did not differ significantly between living donor liver transplantation and cadaveric donor liver transplant recipients (P > .05). Three recipients required revision surgery for biliary complication repair. Six patients died due to biliary sepsis. Biliary stricture and leakages were the most common biliary complications after liver transplantation. Endoscopic treatment was successful in most recipients.

Safety and indications for endoscopic retrograde cholangiopancreatography in liver transplant patients: an analysis of the United States' National Inpatient Sample database.

Endoscopic retrograde cholangiopancreatography (ERCP) is performed to treat biliary complications after a liver transplantation; however, the previously available literature on the safety of ERCP in liver transplant patients is limited. We aimed to study the safety of ERCP in liver transplant patients. We used a National Inpatient Sample database from 2016-2019 to identify patients who underwent ERCP and had a history of a liver transplantation, using the international classification of diseases, 10th revision. Multivariate logistic regression analysis was conducted to determine the odds of post-ERCP complications in liver transplant recipients. Liver transplant patients who underwent ERCP had a higher rate of post-ERCP pancreatitis and bleeding compared to the general adult population (11.39% vs. 9.19%, 0.83% vs. 0.53%, respectively). However, the adjusted odds of post-ERCP pancreatitis (adjusted odds ratio [aOR] 1.13, 95% confidence interval [CI] 0.86-1.49; P=0.36) and bleeding (aOR 1.41, 95%CI 0.58-3.46; P=0.45) were similar in both the liver transplant and no-transplant groups. There was no difference in the odds of post-ERCP cholangitis (aOR 1.26, 95%CI 0.80-2.01; P=0.32), and sepsis (aOR 0.94, 95%CI 0.66-1.34; P=0.76) between liver transplant and no transplant groups. Biliary stricture was the most common indication for ERCP in the liver transplant group, whereas choledocholithiasis was the main reason for ERCP in the general adult population. ERCP is a safe procedure for treating biliary complications in liver transplant patients. The odds of post-ERCP complications (pancreatitis, bleeding, sepsis, cholangitis) in liver transplant patients are comparable to those in patients with no transplantation.

Metabolic syndrome after liver transplant in patients at the specialized Center San Vicente Fundación, Rionegro, Antioquia, Colombia, 2013-2017.

Motivation for the study: there is a lack of studies in Latin America on the frequency of metabolic syndrome in patients who receive liver transplants. Main findings: two-thirds (66%) of patients who received liver transplantation between 2013 and 2017 at the Specialized Center San Vicente Fundación de Rionegro, Antioquia, Colombia, subsequently presented metabolic syndrome. Implications: this study confirms that liver transplant recipients very frequently develop metabolic syndrome; however, the frequency found by this study (66%) was almost double that reported in other regions of the world, suggesting that patients from the Specialized Center San Vicente Fundación de Rionegro, Antioquia, Colombia, may present some additional condition. The medical records of all liver transplant patients attended at the Centro Especializado San Vicente Fundación between January 2013 and June 2017 were reviewed in order to determine the frequency of post-transplant metabolic syndrome (MS). We collected sociodemographic data, pathological history, toxicological history, complications, and ATP III criteria in a validated instrument. The statistical analysis was carried out with OpenEpi 3.01; p<0.05 was considered as statistically significant. Of the 102 reviewed medical records, 73 met the inclusion criteria (no MS diagnosis prior to transplant and complete information for the instru-ment) and were analyzed. Most patients were male (59%), older adults (64%) and married (62%). The frequency of MS after liver transplant was 66%. The association between MS and history of hypertension and diabetes was significant. We confirmed that MS is a frequent complication in liver transplant recipients and that history of hypertension and diabetes are the most frequent associated factors.

Clinical outcomes of transjugular intrahepatic portosystemic shunt with PTFE-covered stents after liver transplantation and technical results in split and whole liver graft recipients.

To assess the outcomes of transjugular intrahepatic portosystemic shunt (TIPS) creation using PTFE-covered stents in liver transplant (LT) recipients and to analyze the technical result of TIPS creation in split grafts (SG) compared with whole liver grafts (WG). Single-center, retrospective study, analyzing LT patients who underwent TIPS using PTFE-covered stents. Clinical and technical variables were analyzed. Between 2005 and 2021, TIPS was created using PTFE-covered stents in 48 LT patients at a median of 43 months (range, 0.5-192) after LT. TIPS indications were refractory ascites (RA) in 33 patients (69%), variceal bleeding (VB) in 9 patients (19%), others in 6 (12%). Ten patients (21%) received a SG. Technical success rate was 100% in both groups: in two WG recipients, (5%) a second attempt was required. An unconventional approach (combined transhepatic or transplenic access) was needed in 2 WG (5%) and 2 SG recipients (20%). Two procedure-related death occurred in the WG group. After a median follow-up of 22 months (range, 0,1-144), 16 patients (48%) in the RA group did not require post-TIPS paracentesis, in the VB group rebleeding occurred in 3 patients (33%). Fifteen patients (31%) underwent TIPS revision. Overt hepatic encephalopathy occurred in 14 patients (29%). Patient survival at 6 months, 1 year, and 3 years was 77%, 66%, and 43%, respectively. The feasibility and safety of TIPS creation in SG are comparable to that of WG. TIPS creation using PTFE-covered stents represents a viable option to treat portal hypertensive complications in LT recipients. • TIPS creation using PTFE-covered stents represents a viable option to treat complications of PH in LT recipients. • TIPS creation in LT SG recipients appears to be safe and feasible as in WG. • Results from this study may help to refine the management of LT patients with recurrent portal hypertensive complications encouraging physicians to consider TIPS creation as a treatment option in both SG and WG recipients.

PSUN228 Incidence and Predictors of New Onset Diabetes After Transplant (NODAT) in Liver Transplant recipients.

Abstract Background NODAT (New onset Diabetes after Transplant) is associated with multiple complications in liver transplant recipients which has to be diagnosed and treated early to prevent graft failure, cardiovascular morbidity and mortality. With improvement in the care of liver transplant recipients, post-transplant survival has significantly increased. With improved survival, incidence of chronic rejection, Diabetes, Hypertension, Dyslipidemia, etc. complications incidence also increasing. Aims and Objectives To know the incidence and predictors of NODAT. Methodology This was a prospective study of non-Diabetic recipients who underwent Liver Transplantation at Yashoda Hospital, Secunderabad from January 2020 to May 2021. The follow-up duration was 6 months. Total 65 patients were enrolled after excluding recipients who were &amp;lt;18 years of age, were already having diabetes, whose survival was less than 6 months of transplantation and who were not of an Indian origin. All the relevant clinical and biochemical data were collected. Appropriate statistical tests were applied to compare NODAT and Non-diabetes groups (recipients who did not develop diabetes after liver transplantation) to know the predictors of NODAT. Diagnosis of NODAT was be established by the standard ADA guidelines using Fasting blood sugar (FBS), Post prandial blood sugar(PPBS) or HbA1C. Diagnosis of NODAT required the presence of one of the four parameters: (i) fasting blood glucose levels ≥ 126 mg/dL on two occasions OR (ii) Insulin therapy requirement for &amp;gt;= 30 days OR (iii) oral hypoglycemic agent use for ≥ 30 consecutive days OR (iv) HbA1c ≥ 6.5. Transient NODAT was defined as the resolution of hyperglycemia within 6 months of transplantation. Results Total incidence of NODAT in our study was 29.2%. Among them 47.36% were transient NODAT and 52.67% were persistent NODAT. Factors significantly associated with occurrence of NODAT were: Type of Transplant (Living donor liver transplant v/s Deceased donor liver transplant), Presence of Impaired fasting glucose (IFG), presence of post-operative hyperglycemia, lower pre-transplant Magnesium &amp; Immediate post-operative Magnesium level, lower post-operative Albumin, higher trough Tacrolimus level at 3 Months, higher Tacrolimus and steroid dose at 3 months. Factors for which association with NODAT could not be found were: Age, Hepatitis C cirrhosis, alcoholic cirrhosis, pre-transplant BMI, baseline MELD score, pre-transplant FBS, donor age, donor gender, donor BMI, donor FBS &amp; Hba1c, donor CT LAI (Liver Attenuation Index, L-S) value, Steroid dose at discharge, immediate post-op trough Tacrolimus level and use of Everolimus. CONCLUSION: NODAT is the significant entity to be addressed. A robust strategy should be in place for the screening of NODAT. Lower Magnesium levels, presence of pre-transplant IFG and post-operative hyperglycemia give an early opportunity for detection of NODAT. Minimizing Tacrolimus level and steroid dose could be an effective strategy for the prevention of NODAT. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Utility of Digital Single-operator Video Cholangioscopy for the Endoscopic Management of Biliary Complications After Liver Transplantation-A Single-center Experience.

Liver transplant recipients (LTRs) frequently develop biliary complications, and endoscopy is crucial for their subsequent management. Recently, single-operator video cholangioscopy (SOVC) with digital imaging quality was introduced. This study evaluated the utility of digital SOVC for the management of biliary complications in LTRs. This observational study retrospectively analyzed all LTRs undergoing digital SOVC between 2015 and 2019 at a tertiary referral center. Endpoints included the assessment of biliary strictures, performance of selective guidewire passage across biliary strictures, and diagnosis and treatment of biliary stone disease. In total, 79 digital SOVCs performed in 50 LTRs were identified. Fifty-eight percent of the procedures were performed for biliary stricture assessment, and using visual signs or guided biopsies, SOVC excluded malignancy in all cases (100%). Of all the examinations, 29.1% (23/79) were performed solely because of a previous failure of conventional endoscopic methods to pass a guidewire across a biliary stricture. Using SOVC, guidewire passage was successfully performed in 73.9% of these examinations, enabling subsequent endoscopic therapy. Furthermore, biliary stones were found in 16.5% (13/79) of the examinations. In 38.5% of these cases, standard fluoroscopy failed to detect stones, which were only visualized using digital SOVC. Biliary stone treatment was successful in 92% (12/13) of the examinations. Complications occurred in 11.4% of all SOVCs. No procedure-associated mortalities were observed. Digital SOVC is effective and safe for the endoscopic management of biliary complications in LTRs and offers unique diagnostic and therapeutic opportunities that strongly impact the clinical course in selected cases.

S91 Management of Biliary Complications in Liver Transplant Recipients Using a Fully Covered Self-expandable Metal Stent With Antimigration Features

Introduction: Following liver transplant (LT) with duct-to-duct anastomosis, biliary strictures and leaks are typically managed with endoscopic retrograde cholangiopancreatography (ERCP) and stenting. While multiple plastic stents are typically used for strictures, self-expandable metal stents (SEMS) can be used to decrease the number of ERCPS with longer periods of stent patency. However, their use is limited by stent migration. The use of fully covered SEMS (FCSEMS), with antimigration fins to manage benign biliary complications following LT may provide stricture resolution with limited adverse events. As such we aimed to describe clinical outcomes of FCSEMS in LT recipients using one type of FCSEMS. Methods: This was a single center retrospective study of consecutive adult LT patients undergoing FCSEMS from January 2014 to April 2022. Primary outcomes were stricture resolution and recurrence. Secondary outcomes included rates of stent migration, stent occlusion, and number of ERCPs required. Results: 46 LT patients with anastomotic strictures (n=40), bile leaks (n=4) or both (n=2) (average age 55.8 years, 33% women) were treated with a FCSEMS with antimigration features (Viabil, W.L. Gore, Flagstaff, AZ) approved for malignant strictures. The median time from LT to FCSEMS placement was 132.5 days. Within one year of LT, 32 patients (69.5%) required intervention; early intervention at less than 30 and 90 days was needed in 7 and 20 patients, respectively. At the time of study conclusion there were 3 patients with stents in situ. Stricture resolution was seen in 34 patients (74%) after an average stent dwell time of 134.5 ± 71 days; recurrence was observed in 8 patients (17%). There were three instances of partial proximal stent migration that did not require reintervention or interfere with removability. Procedural details are listed in Table: The total mean number of ERCPS required was 2.48 (range 1-5). Conclusion: The use of a FCSEMS with antimigration features offers an opportunity to enhance stricture resolution with longer stent dwell times and fewer ERCPs. In our cohort there were no instances of clinically significant stent migration, dysfunction, or procedure related adverse events. Furthermore, these stents provide an opportunity reduce procedure related costs. Additional studies are needed to identify suitable patients for FCSEMS placement. Table 1. - Procedure related details and stent outcomes Stent Dwell Time +/- Standard Deviation (days) 134.5 +/- 71.8 Stent Placement transpapillary vs intraductally, n (%) 36 (78.3%) vs 10 (21.7%) Prior Sphincterotomy, n (%) 17 (40%) Stricture Recurrence, n (%) 8 (17%) Average Number ERCPs, n (range) 2.48 (1-5) Stent Migration, n (%) 3 (6.5 %) Stent Occlusion, n (%) 8 (17%)

Risk factors and management of biliary stones after living donor liver transplant and its effect on graft outcome.

BackgroundBile stones are associated with numerous complications in liver transplant recipients. Endoscopic retrograde cholangiopancreatography (ERCP) has been proven to be safe and highly effective in dealing with most post-transplant biliary complications.ObjectiveThe objective of this study was to identify the possible risk factors for bile stone formation on top of biliary stricture, the effects of stones on graft outcomes, and their management.MethodsThis case–control study included 83 patients who underwent living donor liver transplant (LDLT) and suffered from postoperative biliary stricture with or without stones. Patients were divided into two groups. Group 1 (n = 55) included patients with biliary strictures with no stones and group 2 (n = 28) included patients who developed stones on top of biliary strictures. Data about the recipient and donor characteristics, surgical technique, blood lipid profile, immunosuppressive drugs, post-transplant complications, and interventions were collected from the medical records.ResultsThe frequency of hepatitis C virus (HCV) was significantly higher in group 2 compared to group 1 (71.4% vs. 47.3%, p = 0.036). The body mass index (BMI) of the donors was significantly higher in group 2 than in group 1 (25.17 ± 2.53 vs. 23.68 ± 2.63, p = 0.015). Episodes of acute rejection were significantly higher in group 2 than in group 1 (21.4% vs. 5.5%, p = 0.027). The ERCP was sufficient in most of the cases (89.2%) to ensure biliary drainage. The identified independent risk factors for biliary stones included HCV, biliary drain, donor's BMI, and serum cholesterol level.ConclusionPositive HCV, biliary drain insertion, donor's BMI, and serum cholesterol level were independent risk factors for developing bile stones on top of biliary strictures. Biliary stones were associated with high episodes of acute graft rejection, and they could be successfully managed by the ERCP modality.

Perioperative Delta Sodium and Post-Liver Transplant Neurological Complications in Liver Transplant Recipients.

Hyponatremia before liver transplant (LT) increases risk of post-LT neurological complications in patients with decompensated cirrhosis, but it is unknown to what extent change in sodium from pre- to post-LT influences risk of central nervous system (CNS) sequelae. We assessed the relationship between pre- to post-LT delta sodium and prevalence of CNS complications during LT hospitalization. We performed retrospective single-center chart review of 1265 adults with cirrhosis who underwent LT (2011-2020). Delta sodium is defined as the difference between maximum sodium within 48 h post-LT and lowest sodium within 7 d pre-LT. Primary outcomes are post-LT CNS events during same hospitalization-encephalopathy, delirium, seizure, coma, osmotic demyelination syndrome, or other altered mental status, determined by International Classification of Diseases codes. Secondary outcome is length of hospital stay post-LT (LOS). Logistic regression modeled association between delta sodium and post-LT CNS outcomes; negative binomial regression modeled LOS. Median age was 59 y, 36% were female, and median Model for End-Stage Liver Disease score was 20. Median delta sodium was 8 mmol/L (interquartile range, 5-11). One hundred ninety-four (15%) experienced post-LT CNS complications. In multivariable analysis, controlling for confounders including pre-LT hyponatremia, every 5 mmol/L increase in delta sodium associated with 47% greater odds of CNS complication (95% confidence interval, 22%-77%). Delta sodium also associated with 7% increased LOS in adjusted regression (95% confidence interval, 3%-12%). Adult LT recipients with higher perioperative delta sodium shifts displayed a higher risk of post-LT CNS complications, even after adjusting for pre-LT sodium. LT recipients, even those with pre-LT hyponatremia, may benefit from maintenance of stable serum sodium levels to minimize post-LT CNS complications.

Branched chain amino acids are associated with metabolic complications in liver transplant recipients

BackgroundObesity, dyslipidemia and type 2 diabetes (T2D) contribute substantially to increased cardiovascular morbidity and mortality in patients after orthotopic liver transplantation (OLTx). Elevated plasma branched chain amino acids (BCAA) are linked to metabolic disturbances and cardiovascular disease (CVD) risk profiles in several non-OLTx populations. MethodsCross-sectional analysis of liver transplant recipients from TransplantLines, a single-center biobank and cohort study. BCAA plasma levels were measured by means of nuclear-magnetic resonance spectroscopy. CVD and cardiometabolic factors were collected by using data from electronic patient records. Associations were determined between BCAA plasma levels and T2D, Metabolic Syndrome (MetS), CVD as well as mTOR inhibition in liver transplant recipients. Results336 Patients were divided into sex-stratified tertiles of total BCAA. MetS (P < 0.001) and T2D (P = 0.002) were significantly more frequent in subjects in the highest BCAA tertile. In logistic regression analyses, the multivariable adjusted odds ratio (OR) per 1 standard deviation increase in BCAA was 1.68 (95%CI: 1.18–2.20, P = 0.003) for MetS and 1.60 (95%CI: 1.14–2.23, P = 0.006) for T2D. Use of Sirolimus (mTOR inhibitor) was significantly associated with higher BCAA plasma levels, independent of age, sex, time after OLTx, MetS and other immunosuppressive medication (adjusted P = 0.002). ConclusionElevated BCAA plasma levels are associated with T2D, MetS and use of Sirolimus in liver transplant recipients. BCAA plasma levels may represent a valuable biomarker for cardiometabolic complications after OLTx.

A bibliometric analysis of infectious diseases in patients with liver transplantation in the last decade.

BackgroundA bibliometric analysis was performed to reveal the current status of investigations in infectious diseases in patients with liver transplantation (LT) and to prioritize future research needs.MethodsThe present study comprehensively retrieved publications relevant to infectious diseases in LT recipients published between 2010 and 2020. The search was conducted on the Web of Science (WoS) database. A bibliometric analysis was conducted through machine learning and visualization tools, including VOSviewer, Bibliographic Item Co-Occurrence Matrix Builder, and Graphical Clustering Toolkit. Research hotspots and trends in the field were assessed, while the contributions and collaborations of countries, institutions, and authors were documented.ResultsA total of 691 publications were analyzed. Research output sharply increased in 2015, with a fast drop afterward. “Liver transplantation” was the most frequent keyword, with strong links to “hepatitis C virus” and “infection”. Study areas included risk factors of infectious diseases in LT recipients, pathogens causing post-transplantation infections, antibacterial therapy and prophylaxis for peritransplant infection complications, living donor LT, and pediatric LT. The efficacy and safety of direct-acting antivirals (DAAs) for hepatitis C virus (HCV) infection among liver transplant recipients has attracted recent research interest. Didier Samuel was the most productive author, while Xavier Forns was the top-cited author. Shanghai Jiao Tong University was the most productive contributor, and Gilead Sciences was the most cited organization. Moreover, the USA was the greatest contributor. Gastroenterology was the most cited journal, while Liver Transplantation was the most prolific journal.ConclusionsThis bibliometric analysis will better understand the research status of infectious complications in LT recipients and forecast future research trends. Priority should be given to identifying risk factors for peritransplantation infections and effective treatments against infectious complications in the coming years.

Comanagement With Nephrologist Care Is Associated With Fewer Cardiovascular Events Among Liver Transplant Recipients With Chronic Kidney Disease.

LTRs with CKD plus those at risk were identified in an inception cohort at a single tertiary care network between 2010 and 2016, using electronic health record data and manual chart review. CKD was defined as estimated glomerular filtration rate <60 mL/min/1.73 m2 or International Classification of Diseases 9th or 10th revision code for CKD and at-risk CKD as estimated glomerular filtration rate 60-89 mL/min/1.73 m2. Cox proportional hazard models assessed the association between nephrology comanagement and CV events among LTRs with or at risk for CKD. Among 602 LTRs followed for up to 6 y posttransplant, prevalence of CKD plus those at risk increased yearly (71% in year 1, 86% in year 6) (P < 0.0001). Rates of nephrology comanagement decreased yearly posttransplant (35% in year 1, 28% in year 6). In multivariable models, nephrology comanagement was associated with lower CV events (adjusted hazard ratio, 0.57; 95% confidence interval, 0.33-0.99). Among LTRs with CKD, nephrology comanagement may be associated with lower CV events. A prospective study is needed to identify the reasons for improved outcomes and barriers to nephrology referral.

Metabolic Complications in Liver Transplantation Recipients: How We Can Optimize Long-Term Survival.

Liver transplantation (LT) recipients have experienced a significant improvement in short-term survival during the past 3 decades attributed to advancements in surgical techniques, perioperative management, and effective immunosuppressive regimens. However, long-term survival is affected by a high incidence of metabolic disorders and their consequences, including cardiovascular disease (CVD) and malignancies. Pretransplant metabolic impairments especially in those with nonalcoholic steatohepatitis cirrhosis are aggravated by the addition of posttransplant weight gain, physical inactivity, and reversal from catabolic to anabolic state. Moreover, although immunosuppressants are vital to avoid graft rejection, long-term exposure to these medications is implicated in metabolic impairments after LT. In this review, we summarize the molecular pathogenesis of different metabolic disorders after LT, including diabetes mellitus, dyslipidemia, and nonalcoholic fatty liver disease. Furthermore, CVD, malignancies, and graft rejections were provided as significant complications of post-LT metabolic conditions threatening both the patient and graft survival. Ultimately, emerging preventive and treatment strategies for posttransplant diabetes mellitus are summarized. This review highlights the significant need for more clinical trials of antihyperglycemic agents in LT recipients. Also, translational studies will help us to better understand the molecular and genetic factors underlying these metabolic complications and could lead to more personalized management in this high-risk population.