Criteria For Liver Transplantation Research Articles

Radioembolization of HCC and secondary hepatic tumors: a comprehensive review.

Transarterial radioembolization (TARE), also called Selective Internal Radiation Therapy (SIRT), has emerged as an effective locoregional therapy for primary and secondary hepatic tumors, utilizing yttrium-90 (Y90) microspheres and other agents such as holmium-166 and rhenium-188. TARE has various applications in the management of HCC across different BCLC stages. Radiation segmentectomy, which involves administering high doses of Y90 (>190 Gy), can be both curative and ablative, achieving complete necrosis of the tumor. In contrast, radiation lobectomy involves administering a lower dose of Y90 (80-120 Gy) as a neoadjuvant treatment modality to improve local control and induce future liver remnant (FLR) hypertrophy in patients who are planned to undergo surgery but have insufficient FLR. Modified radiation lobectomy combines both techniques and offers several advantages over portal vein embolization (PVE). Y90 is also used in downstaging HCC patients outside liver transplantation criteria, as well as bridging those awaiting liver transplantation (LT). Multiple studies and combined analyses were described to highlight the outcomes of TARE and compare it with other treatment modalities, including TACE and sorafenib. Additionally, the review delves into the efficacy and safety of radioembolization in managing metastatic colorectal cancer and other metastatic tumors to the liver. Recent studies have emphasized the role of personalized dosimetry for improved outcomes, and thus we described the different methods used for this purpose. Pretherapy imaging, estimating lung shunt, selection of therapeutic radionuclides, adverse effects, and cost-effectiveness were all discussed as well.

Japanese living donor liver transplantation criteria for hepatocellular carcinoma: nationwide cohort study.

Validating the expanded criteria for living donor liver transplantation for hepatocellular carcinoma using national data is highly significant. The aim of this study was to evaluate the validity of the new Japanese criteria for living donor liver transplantation for hepatocellular carcinoma patients and identify factors associated with a poor prognosis using the Japanese national data set. The study population comprised patients who underwent living donor liver transplantation for hepatocellular carcinoma at 37 centres in Japan between 2010 and 2018. In a nationwide survey, the overall survival and recurrence-free survival rates were evaluated based on the new Japanese criteria for applying the 5-5-500 rule when extending the indication beyond the Milan criteria. Prognostic factors within the Japanese criteria were determined using the Cox proportional hazards model. Patients within (485 patients) and beyond (31 patients) the Japanese criteria exhibited 5-year overall survival rates of 81% and 58% and 5-year recurrence-free survival rates of 77% and 48% respectively. Patients who met the Milan criteria, but not the 5-5-500 rule, had poorer outcomes. Multivariate analysis for 474 patients identified a neutrophil-to-lymphocyte ratio greater than or equal to 5 and a history of hepatectomy as independent risk factors. This nationwide survey confirms the validity of the Japanese criteria. The poor prognostic factors within the Japanese criteria include a neutrophil-to-lymphocyte ratio greater than or equal to 5 and previous hepatectomy.

Role of high-volume plasmapheresis in the management of paediatric acute liver failure.

Paediatric acute liver failure (PALF) is a life-threatening disease. Management aims to support hepatic regeneration or to bridge to liver transplantation. High-volume plasmapheresis (HVP) removes protein-bound substances, alleviates inflammation, and improves survival in adult acute liver failure. However, experience with HVP in PALF is limited. Aim of this study is to report on feasibility, safety, efficacy and outcomes of HVP in PALF. Retrospective observational study in children with PALF. HVP was performed upon identification of negative prognostic indicators, in toxic aetiology or multiorgan failure (MOF). Exchanged volume with fresh-frozen plasma corresponded to 1.5-2.0 times the patient's estimated plasma volume. One daily cycle was performed until the patient met criteria for discontinuation, that is, liver regeneration, liver transplantation, or death. Twenty-two children with PALF (body weight 2.5-106 kg) received 1-7 HVP cycles. No bleeding or procedure-related mortality occurred. Alkalosis, hypothermia and reduction in platelets were observed. Haemolysis led to HVP termination in one infant. Seven children (32%) survived with their native livers, 13 patients (59%) underwent liver transplantation. Two infants died due to MOF. Overall survival was 86%. International normalization ratio (INR), alanine aminotransaminases (ALT), bilirubin and inotropic support were reduced significantly (p < 0.05) after the first HVP-cycle (median): INR 2.85 versus 1.5; ALT 1280 versus 434 U/L; bilirubin 12.7 versus 6.7 mg/dL; norepinephrine dosage 0.083 versus 0.009 µg/kg/min. Median soluble-interleukin-2-receptor dropped significantly following HVP (n = 7): 2407 versus 950 U/mL (p < 0.02). HVP in PALF is feasible, safe, improves markers of liver failure and inflammation and is associated with lowering inotropic support. Prospective and controlled studies are required to confirm efficacy of HVP in PALF.

Review article: Current indications and selection criteria for early liver transplantation in severe alcohol-associated hepatitis.

Alcohol-associated hepatitis (AH) is a severe inflammatory form of alcohol-associated liver disease (ALD) that carries a high mortality rate. Early liver transplantation for severe AH is increasingly available. However, specific criteria for referral and selection remain a subject of debate. To provide a narrative review of the natural history, diagnostic criteria and indications for referral for early liver transplantation for severe AH. We searched PubMed for articles published through August 2023. Key search terms were 'alcoholic hepatitis,' 'alcohol-associated hepatitis,' 'abstinence,' 'alcohol relapse,' and 'liver transplantation.' Previously, a six-month period of alcohol abstinence was required before patients with ALD were considered for liver transplantation. However, studies in recent years have demonstrated that, among carefully selected patients, patients who received early transplants have much higher survival rates than patients with similarly severe disease who did not undergo transplants (77% vs. 23%). Despite these successes, early liver transplantation remains controversial, as these patients have typically not undergone treatment for alcohol use disorder, with the ensuing risk of returning to alcohol use. While early liver transplantation for AH has survival benefits, many patients would not have received treatment for alcohol use disorder. An integrated approach to evaluating candidacy for early liver transplantation is needed.

Validation of Japanese indication criteria for deceased donor liver transplantation for hepatocellular carcinoma: Analysis of US national registry data.

The Japanese indication criteria for liver transplantation (LT) for hepatocellular carcinoma (HCC) have been updated based on living donor LT data to include either the Milan criteria (MC) or the 5-5-500 rule, which requires a nodule size of ≤5cm, ≤5 nodules, and an alpha-fetoprotein (AFP) level ≤500ng/mL. We aimed to validate the 5-5-500 rule and the MC for deceased donor LT (DDLT). Using national registry data from the United States from 2010 to 2014, we separated DDLT patients into four groups based on the MC and the 5-5-500 rule. The AFP values were stratified into categories: ≤100, 101-300, 301-500, and >500ng/mL. The 5-year survival rate was significantly lower for patients in the groups within MC/beyond 5-5-500 (56.3%) or beyond MC/5-5-500 (60.7%) than for patients in the groups within MC/5-5-500 (76.2%) and beyond MC/within 5-5-500 (72.3%) (p<0.01). Hepatocellular carcinoma recurrence at 5years was highest for the within MC/beyond 5-5-500 (25.4%) group, followed by the beyond MC/within 5-5-500 (13.1%), beyond MC/5-5-500 (9.6%), and within MC/5-5-500 (7.4%) groups. The stratified 5-year survival rates after DDLT were 76.5%, 72.4%, 58.4%, and 55.6% in the AFP ≤100, 101-300, 301-500, and >500 categories, respectively (p<0.01). The 5-5-500 rule guides the appropriate selection of patients with HCC for DDLT. Patients with AFP levels from 300 to 500ng/mL had inferior outcomes even when they met the 5-5-500 rule, so further investigation is needed to guide their treatment.

P358 Impact of end-ileostomy versus ileal pouch-anal anastomosis on graft-survival following liver transplantation for primary sclerosing cholangitis

Abstract Background IBD-PSC patients may require both liver transplantation and ileoanal pouch (IPAA) construction. Recently, concerns have been raised regarding an increased rates of hepatic artery thrombosis, biliary strictures, and graft loss in individuals who underwent IPAA after liver transplantation compared to those who underwent end-ileostomy (EI). We hypothesized that graft survival was not negatively affected by IPAA compared with EI. Methods A prospectively maintained database from a large tertiary center was searched for patients meeting the inclusion criteria for liver transplantation, primary sclerosing cholangitis, ulcerative colitis, and total colectomy with IPAA or EI. Univariate analysis and Kaplan-Meier survival curves were calculated. Results Between January 1990 and December 2023, 55 patients met inclusion criteria. Of these, 46 (83.6%) underwent IPAA, and 9 (16.4%) underwent EI. The average age at colectomy (41.7 vs. 45.7 years; p=0.44), sex distribution (female: 26.1% vs. 22.2%, p=1), and MELD score before transplantation (20.3 vs. 14; p=0.06) were comparable between patients with IPAA and EI patients. The rates of re-transplantation (21.7% vs. 22.2%; p=1), hepatic artery thrombosis (8.7% vs. 0; p=1), episodes of acute rejection (32.6% vs. 44.4%; p=0.7), chronic rejection (4.3% vs. 11.1%; p=0.42), recurrence of primary sclerosing cholangitis (23.9% vs. 22.2%; p=1), and biliary complications (21.7% vs. 33.3%; p=0.43) were similar between the IPAA and EI groups, respectively. None of the EI patients developed parastomal varices. Survival analyses for time to re-transplantation (p=0.97), overall survival (p=0.3), and time to graft loss or mortality (p=0.73) were similar. Conclusion In contrast to a previous study, we observed similar rates of liver transplant graft loss, biliary complications, and recurrent PSC after IPAA compared to those after end-ileostomy. IPAA may be associated with an increased rate of hepatic artery thrombosis.

Fulminant Hepatic Failure as the Initial Presentation of Hodgkin's Disease and Liver Transplantation: A Case Report.

BACKGROUND: Hodgkin's lymphoma (HL) or Hodgkin's disease is a B-cell neoplasm, characterized by affecting the lymph nodes or extranodal lymphoid tissue. Includes two distinct entities: classical HL (95%) and lymphocyte-predominant nodular HL. This disease presents as cervical and intrathoracic lymph node growth in 60-90%, however, presentation due to liver infiltration is extremely rare. Around 30% of patients manifest the disease with a picture of general malaise based on fever, night sweats, weight loss and chronic pruritus. THE CASE: We present the case of a 13-year-old female, who started with an insidious condition that evolved to fulminant hepatic failure of unknown etiology (Table 1), it was decided to perform an orthothopic liver transplant, the histopathological analysis of the explant and a lymph node reported mixed cellularity Hodgkin's disease. Subsequently, the hematology service requested a lumbar puncture, with no evidence of infiltration. It was decided to initiate six cycles of chemotherapy with BEACOPP scheme, evolving without complications and achieving a complete response eleven months later; currently, she has been free of disease for three years. CONCLUSION: The cause remains unknown for this disease, so an early diagnosis and having different treatment options are the key points to combat this disease. Even though having a diagnosed neoplasm is a contraindication for receiving a liver transplant at present, the diagnosis was not available at that time, and because of her clinical situation, she met the criteria for liver transplantation. In the future, it could be essential to individualize each case to weigh the risks and benefits of carrying out the transplant or not.

Summary of a consensus conference on heart-liver transplantation

Patients with severe heart disease may have coexisting liver disease from various causes. The incidence of combined heart-liver transplant (CHLT) is increasing as more patients with congenital heart disease survive to adulthood and develop advanced heart failure with associated liver disease from chronic right-sided heart or Fontan failure. However, the criteria for CHLT have not been established. To address this unmet need, a virtual consensus conference was organized on June 10, 2022, endorsed by the American Society of Transplantation. The conference represented a collaborative effort by experts in cardiothoracic and liver transplantation from across the United States to assess interdisciplinary criteria for liver transplantation in the CHLT candidate, surgical considerations of CHLT, current allocation system that generally results in the liver following the heart for CHLT, and optimal post-CHLT management. The conference served as a forum to unify criteria between the different specialties and to forge a pathway for patients who may need dual organ transplantation. Due to the continuing shortage of available donor organs, ethical issues related to multiorgan transplantation were also debated. The findings and consensus statements are presented.

Current Trends in Surgical Management of Hepatocellular Carcinoma.

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related deaths worldwide. Surgical management, including hepatic resection, liver transplantation, and ablation, offers the greatest potential for a curative approach. This review aims to discuss recent advancements in HCC surgery and identify unresolved issues in the field. Treatment selection relies on the BCLC staging system, with surgical therapies primarily recommended for early-stage disease. Recent studies have shown that patients previously considered unresectable, such as those with portal vein tumor thrombus and uncomplicated portal hypertension, may benefit from hepatic resection. Minimally invasive surgery and improved visualization techniques are also explored, alongside new techniques for optimizing future liver remnant, ex vivo resection, and advancements in hemorrhage control. Liver transplantation criteria, particularly the long-standing Milan criteria, are critically examined. Alternative criteria proposed and tested in specific regions are presented. In the context of organ shortage, bridging therapy plays a critical role in preventing tumor progression and maintaining patients eligible for transplantation. Lastly, we explore emerging ablation modalities, comparing them with the current standard, radiofrequency ablation. In conclusion, this comprehensive review provides insights into recent trends and future prospects in the surgical management of HCC, highlighting areas that require further investigation.

Single-Centre Experience With Low-Volume Plasma Exchange and Low-Dose Steroid to Treat Patients With Idiosyncratic Drug-Induced Acute Liver Failure

BackgroundIdiosyncratic drug induced liver injury (iDILI) causing acute liver failure (ALF) carries high short-term mortality and patients who meet King’s College hospital criteria for liver transplantation have 1-month survival of 34% without liver transplantation (PMID: 20949552). We present our experience with low volume plasma exchange (PLEX-LV, 50% of estimated plasma volume exchanged per session) and low dose steroid to treat iDILI ALF. MethodsWe retrospectively analyzed data of patients with iDILI (diagnosed as per RUCAM score), treated with PLEX-LV and low dose steroid (Prednisolone: 10 mg OD, with rapid taper) in our department from 2016 to 2022. Baseline and dynamic parameters (post-PLEX) were assessed as predictors of 1-month liver transplantation free survival. ResultsTwenty-two iDILI patients [probable: possible iDILI: 20:2, males: 9, age: 30 (14-84) years, median (range); MELD score: 30.5 (19-43)] underwent PLEX-LV for ALF during the study period.Causative agents were complementary and alternative medications (36%), antiepileptics (18%) antimicrobials (14%), antitubercular drugs (14%), antifungal drugs(9%)and others (9%). All patients had jaundice and encephalopathy; 9 patients also had ascites. None of the patients underwent liver transplantation. Study patients underwent 3 (1-7) PLEX sessions and 1.4 (0.6-1.6) litres of plasma was exchanged per session.One-month transplant free survival was 59% (13/22) in the study population and 63% (12/19) among patients who fulfilled Kings College Hospital Criteria for liver transplantation. Reduction of ≥25% in plasma Von Willebrand factor (VWF) levels after PLEX-LV predicted improved survival (HR: 0.09, 95%CI: 0.01-0.65; AUROC: 0.81; 95% CI: 0.6-1.0). ConclusionLow volume PLEX and low dose steroid appears a promising treatment option in patients with iDILI induced ALF not opting for liver transplantation. Dynamic changes in VWF level after PLEX predict 1 month survival in these patients.

Hepatocellular Carcinoma: The Role of Immunotherapy and Transplantation in the Era of Transplant Oncology.

Hepatocellular carcinoma (HCC) is one of the most common causes of cancer deaths worldwide. As most patients present with advanced disease, curative therapy such as surgical resection and radiofrequency ablation are rarely utilized. With the advent of immunotherapy, historical treatment approaches such as liver transplantation are being challenged. In particular, the use of immune checkpoint inhibitors (ICIs) has emerged as a safe and useful option in the treatment of HCC. However, there is concern over adverse effects, such as graft rejection and graft loss. This updated review discusses the role of immunotherapy in the pre- and post-transplantation setting and provides insights into the potential of immunotherapy as an adjunct to liver transplantation. We deliberate on the use of ICI in the setting of the Milan criteria as well as the University of California San Francisco's expanded criteria for liver transplantation. Current data suggest that ICI has utility, especially in the pretransplantation setting. Nevertheless, larger, purposefully designed clinical trials are needed to clearly identify patients who will benefit most from ICI treatment in the transplant setting and determine parameters that will minimize the risk of graft rejection and maximize the benefits of this adjunct treatment.

Controversies and prospects for surgical treatment of pancreatic neuroendocrine neoplasms with liver metastases

The incidence of pancreatic neuroendocrine neoplasm(pNEN) increased over the past two decades. Liver metastasis, the most common type of distal metastasis, is also one of the most important prognostic factors. Although several medical treatments, including biotherapy, chemotherapy, targeted therapy, peptide receptor radionuclide therapy and locoregional therapy, are available for pNEN with liver metastases, surgery is still the only possible treatment for cure. Currently, there are several controversies as regards surgical treatment for pNEN with liver metastases. These controversies include, but are not limited to, whether surgical resection is appropriate for pancreatic neuroendocrine tumor G3 with liver metastases, how to classify primary lesion and hepatic metastases comprehensively and accurately, what is the optimal surgical strategy for type Ⅱ liver metastases, who can benefit greatly from cytoreduction, and how to refine the Milan criteria for liver transplantation. This article aims to discuss those main controversies and provide prospects for future clinical trials.

Hepatorenal syndrome: Updates.

Hepatorenal syndrome: Updates.

Developing a mathematical model for early detection of viral hepatitis induced liver dysfunction

Acute liver failure (ALF) is characterized by a sudden loss of hepatic function within a few weeks without pre-existing cirrhosis or prior history of liver disease. ALF can be difficult to identify using non-invasive methods such as coagulation abnormality and encephalopathy alone as alternative causes may confound the ALF diagnostic. This often results in delayed treatment at the onset of the disease, and a liver transplant might be the only option for ALF patients with a limited success rate. Due to these variables, ALF treatment is highly subjective to the clinicians' expertise, with a very high morbidity and mortality rate. Therefore, a prognostic model can help identify patients who can be managed with medical treatments and those who need liver transplants, along with an optimum intervention time window. Currently, only statistical models are available to identify ALF, such as King's College Hospital criteria, Clichy criteria, and End-Stage Liver Disease score. While these models provide much-needed critical support to clinicians, these models have limited specificity and sensitivity toward the cause of ALF and liver disease progression. For example, among all the common causes, the viral hepatitis-induced liver disease remains a major cause of ALF in developing countries such as in India and Bangladesh. Therefore, a dynamic patient-specific model is needed to improve patient care by correlating liver dysfunction with various healthcare variables and interventions. In this work, a new physiological linked data-driven model is formulated that can track the progression of liver disease and failure due to viral hepatitis. The approach relies on integrating the dynamics of healthy hepatocytes with immune system response, which is a vital component in tracking the time-sensitive infectious disease progression. The model uses the patient-specific measured values of alanine transaminase and aspartate transaminase enzymes and the clinically calculated international normalized ratio value to estimate the sensitive model parameter. This patient-specific model is then used to determine the disease progression by predicting the number of damaged hepatocytes and correlating it with the indication criteria for liver transplantation. The model can reproduce the essential dynamics seen in the ALF patient data and can be adapted to incorporate the effect of different therapeutic interventions. Thus, providing a vital bridge between understanding and treating viral hepatitis-induced liver dysfunction. No conflicts of interest, financial or otherwise, are declared by the author. This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Socio-economic issues in the diagnostic approach and decision to treat of a child with familial cholestasis

Objectives. The diagnostic approach in familial cholestasis cases involves using expensive investigations. The need for complex therapeutic resources is predictable. Material and methods. We present the case of a 3 years 5 months old boy diagnosed with cholestasis and liver cirrhosis, admitted in the Pediatrics Department of “Grigore Alexandrescu” Children’s Hospital for evaluation in order to check the criteria for liver transplantation. Outcomes. The patient is known to our clinic since he was 1 year 3 months; he was admitted at that time for green jaundice. He comes from a family with nine children, low socio-economic status and low education. The first four children have a different father, two of them were stillborn. The next five come from a consanguineous union (the father is maternal uncle of the mother): three (the patient included) presented with the same symptoms, two of them died before 3 years of age with liver cirrhosis. In time, infectious causes, autoimmune, neoplastic and metabolic disease were excluded. The liver biopsy describes cholestasis and fibrosis. Alagille syndrome and progressive familial intrahepatic cholestasis are still debated, but the genetic testing necessary for a positive diagnosis are not financially available to the family. The patient presents with failure to thrive, developmental delay, intense jaundice and pruritus, hippocratic fingers, dyspnea, enlarged abdomen with visible collateral circulation, significant hepatosplenomegaly. The lab tests show anemia, thrombocytopenia, liver cytolysis, normal gamma-glutamyl transferase, low prothrombin activity, normal renal function, no inflammatory syndrome, increased ammonia level, very high bile acids level. The upper endoscopy describes first degree esophageal varices and portal hypertensive gastropathy. A PELD (Pediatric End-Stage Liver Disease) score is calculated – 13.6 (76.3% one year survival rate on the transplant list, 90.9% one year survival rate after liver transplantation). The patient is enrolled on the transplant waiting list provided we would expect suboptimal results considering the developmental delay and difficult post-transplant monitoring. Conclusions. The low education level of the family correlated with a postponed positive diagnosis due to financial reasons and the lack of genetic advice already lead to the demise of four brothers. In this setting, the prognosis of the patient is very likely to be poor.

WITHDRAWN: Evidence Synthesis to Advance Clinical Practice and Scientific Research: A CGH Pillar

WITHDRAWN: Evidence Synthesis to Advance Clinical Practice and Scientific Research: A CGH Pillar

United Kingdom criteria for liver transplantation in the setting of isolated unresectable colorectal liver metastases.

Studies have demonstrated that liver transplantation may be an effective treatment for isolated unresectable colorectal cancer liver metastases (CRCLM). Published data suggest that 5-year survival may be as high as 80%; however, recurrent disease is commonplace. Consequently, the Liver Transplantation for Unresectable Colorectal Liver Metastases Fixed Term Working Unit recommended to the NHS Blood and Transplant Liver Advisory Group that while CRCLM is an appropriate indication for transplantation, selection criteria should be conservative and that it should be undertaken within a clinical service evaluation programme. The aim of this work is to outline the proposed UK selection criteria and follow-up process for CRCLM transplantation. Consensus statement by colorectal cancer/liver transplantation patient representatives, experts in colorectal cancer surgery/oncology, liver transplantation surgery, hepatology, hepatobiliary radiology, hepatobiliary pathology and nuclear medicine. This study provides a comprehensive outline of the inclusion/exclusion criteria for referral in the UK. Furthermore, the referral framework is also explained. Pretransplant assessment criteria for listing/delisting are outlined. Finally, the oncology-specific outcome measures posttransplant are described. It is anticipated this service will begin in December 2022. A series of educational events for the referrers and transplant units will be arranged throughout 2023 to highlight CRCLM as a newly accepted UK indication for transplantation. A national audit will be undertaken to identify patients currently on treatment who meet the criteria for transplant. Data will be collected in a national registry and reviewed on an ongoing basis to confirm the safety of this treatment and to determine if the inclusion criteria require revision.

Role of immunotherapy in downsizing hepatocellular carcinoma prior to liver transplantation.

Hepatocellular carcinoma (HCC) is an aggressive primary liver neoplasm that, according to tumor stage, can be treated with resection, transplantation, locoregional treatment options, or systemic therapy. Although interventions only in early-stage disease can offer complete tumor regression, systemic therapy in advanced disease can significantly prolong overall survival, according to pub lished clinical trials. The emergence of immunotherapy in the field of cancer therapy has had a positive impact on patients with HCC, resulting in atezolizumab-bevacizumab currently being the first-line option for treatment of advanced HCC. In light of this, application of immunotherapy in the preoperative process could increase the number of patients fulfilling the criteria for liver transplantation (LT). Implementation of this approach is faced with challenges regarding the safety of immunotherapy and the possibly increased risk of re jection in the perioperative period. Case reports and clinical trials assessing the safety profile and effectiveness of neoadjuvant immunotherapy, highlight important aspects regarding this newly evolving approach to HCC management. More studies need to be conducted in order to reach a consensus regarding the optimal way to administer immunotherapy prior to LT. In this review, we sum marize the role, safety profile and future considerations regarding the use of neoadjuvant immunotherapy prior to LT in patients with HCC.

Improving Transplant-free Survival With Low-volume Plasma Exchange to Treat Children With Rodenticide Induced Hepatotoxicity

In a prior report, no patient with rodenticidal hepatotoxicity who met Kochi criteria (MELD score ≥36 or baseline INR ≥6 with hepatic encephalopathy) (PMID: 26310868) for urgent liver transplantation survived with medical management alone. Plasma exchange (PLEX) may improve survival in these patients. We describe our experience with low-volume PLEX (PLEX-LV) in treating rodenticide ingestion induced hepatotoxicity in children. From prospectively collected database of rodenticidal hepatotoxicity patients managed as in-patient with department of Hepatology from December 2017 to August 2021, we retrospectively studied outcomes in children (≤18 years). Hepatotoxicity was categorized as acute liver injury (ALI, coagulopathy alone) or acute liver failure (ALF, coagulopathy and encephalopathy). Kochi criteria was used to assess need for urgent liver transplantation. The primary study outcome was one-month survival. Of the 110 rodenticidal hepatotoxicity patients, 32 children (females: 56%; age: 16 [4.7-18] years; median, range) constituted the study patients. The study patients presented 4 (1-8) days after poison consumption (impulsive suicidal intent:31, accidental:1). Twenty children (62%) had ALI [MELD: 18 (8-36)] and 12 (38%) had ALF [MELD: 37 (24-45)].All children received standard medical care, including N-acetyl cysteine; ALF patients also received anti-cerebral edema measures. None of the patient families opted for liver transplantation. Seventeen children (ALI: 6, ALF: 11) were treated with PLEX-LV (3 [1-5] sessions, volume of plasma exchanged per session: 26 [13-38] ml/kg body weight) and peri-procedure low dose prednisolone.At 1 month, 28 of the 32 children (87.5%) were alive (4 ALF patients died). Of 10 children who met Kochi listing criteria for urgent liver transplantation, two children were ineligible for PLEX-LV (due to hemodynamic instability) and of the remaining 8 children treated by PLEX-LV, 6 (75%) survived. PLEX-LV shows promise as an effective non-liver transplant treatment in children with rodenticidal hepatotoxicity.

Local-Regional Treatment of Hepatocellular Carcinoma: A Primer for Radiologists.

The treatment planning for patients with hepatocellular carcinoma (HCC) relies predominantly on tumor burden, clinical performance, and liver function test results. Curative treatments such as resection, liver transplantation, and ablative therapies of small lesions should be considered for all patients with HCC. However, many patients are ineligible for these treatments owing to advanced disease stage and comorbidities. Despite efforts to increase screening, early-stage HCC remains difficult to diagnose, which decreases the possibility of curative therapies. In this context, local-regional treatment of HCC is accepted as a form of curative therapy in selected patients with early-stage disease, as a therapeutic option in patients who are not eligible to undergo curative therapies, as a downstaging approach to decrease tumor size toward meeting the criteria for liver transplantation, and as a bridging therapy to avoid tumor growth while the patient is on the waiting list for liver transplantation. The authors review the indications, types, mechanism of action, and possible complications of local-regional treatment, as well as the expected postprocedural imaging features of HCC. Furthermore, they discuss the role of imaging in pre- and postprocedural settings, provide guidance on how to assess treatment response, and review the current limitations of imaging assessment. Finally, the authors summarize the potential future directions with imaging tools that may add value to contemporary practice at response assessment and imaging biomarkers for patient selection, treatment response, and prognosis. ©RSNA, 2022.