List For Liver Transplantation Research Articles

Stand and Wait

Casey had a gift for raising the roof. I did not realize that the first time I met him on a hot and sticky Friday afternoon in a busy urban hospital, but I would soon find out. Casey (names and places have been altered to protect the privacy of the patient) was a 14-year-old boy who had black, curly hair, pale skin, and a broad smile. Previously healthy, he had started to feel lethargic two days earlier, and by the time he had arrived at the hospital, he was experiencing acute liver failure. As part of his liver failure, he was experiencing hepatic encephalopathy, which rendered him psychotic. Casey’s parents were lovely, hardworking people who were scared to death. Their son was mumbling unintelligible things, and they were in a bustling children’s hospital with a lot of doctors and nurses with serious expressions on their faces scurrying in and out of their son’s room. As a newly graduated psychologist, my job that afternoon was unclear other than to introduce myself to Casey’s parents, offer a sympathetic ear to their fears, and hope that Casey would get a new liver soon. Casey was placed on the liver transplant list, and miraculously, he received an organ that night. His surgery went well, and by Monday morning, he had been transferred out of the intensive care unit (ICU) to a surgical bed on the floor. I had received a called at 11:00 AM from his nurses, who were distressed because Casey was swearing and had threatened to throw a telephone at them. They wanted a psychologist to calm him down. I was not sure that I could, but I went anyway. Before entering Casey’s room, I read his chart and noticed that an order to decrease his morphine by a considerable amount had been written early that morning. Thinking little about that, I went in and introduced myself to Casey. He grunted and went back to watching TV. After a few minutes of trying to make small talk, I finally asked Casey whether he was in pain. He glared at me, lifted up his hospital gown to reveal an impressive horseshoeshaped incision, pointed to his wound, and screamed, “Yes!” I told him I would try to help. Then I left his room and called the surgical resident. The resident explained that Casey had reported little pain that morning, so they had decided to decrease his morphine. The resident arrived in his room a short while later and increased his analgesic. Soon, Casey was comfortable. I was starting to feel like I could actually help the kid. The rest of his hospitalization was essentially uneventful. Although he no longer screamed at his nurses, he did annoy them with sexually provocative comments and acerbic observations (ie, “You didn’t actually pay for that haircut, did you?”). He would also frequently leave the floor and not tell anyone where he was going. Although he drove his caregivers a bit crazy, he was endearing in an adolescent sort of way. After several months of doing well with his new liver, Casey arrived in the clinic one day with a large golf ball–sized lump in his neck. There was a collective gasp throughout the clinic as staff realized what the lump likely meant. After a series of exams and tests, Casey was diagnosed with posttransplant lymphoproliferative disease. With a grim prognosis, he started chemotherapy. During that period, I spent more time with Casey and his family as they tried to absorb yet another unforeseen and penetrating blow. Yet despite the seriousness of the new setback, Casey and his family approached the situation as optimistically as they could, hoping for a miracle. That hope was short-lived. One Saturday morning as he was being wheeled down the hall for magnetic resonance imaging, Casey experienced cardiac arrest. He was revived, but there was significant damage to his brain. By Monday morning, it was clear that he would not survive. When his parents were told that his brain was too injured to recover, his parents were given the option of removing life-sustaining interventions. They were gracious in their grief and decided to withdraw support, but they asked whether they could have some time to gather family and friends to say good-bye to Casey. I waited with them, spending most of that day either by Casey’s bedside or out on the street where his parents would go for a smoke. Through idle chitchat about the weather, the Yankees, and traffic, we moved from initial awkwardness to being relaxed and connected. As we relaxed, we laughed about JOURNAL OF CLINICAL ONCOLOGY T H E A R T O F O N C O L O G Y

Comparison of Anxious and Depressive Symptomatology Among Pretransplant Hepatic Patients and Their Relatives

Objective We sought to compare the anxiety and depressive symptoms of patients undergoing pretransplant evaluation with those of their closest relatives. Materials and Methods We assessed 51 patients with hepatic cirrhosis and 51 relatives who were the main care giver for each patient. All subjects were assessed during the interval when the patients were hospitalized to undergo the medical assessment to determine their inclusion on the waiting list for liver transplantation. In both groups, we used a “Psychosocial Survey” and the “Hospital Anxiety and Depression Scale.” Results Significant differences were observed in anxiety ( P = .001), but not in depression ( P = .820). Specifically, relatives presented higher levels of anxiety compared with the hepatic patients. Conclusion The relatives were worse off psychologically than the patients.

The impact of nutrition on cirrhotic patients awaiting liver transplantation

To review the most recent aspects of nutrition therapy of cirrhotic patients on the waiting list for liver transplantation. Undernutrition has been widely reported among these patients, despite the lack of consensus on the best nutritional assessment tools in this population. Nutrition therapy has been marked by controversy. Nonetheless, recent findings have pointed out to the important role of the nutrition status and of some specific nutrients on the outcome of these patients. We report the latest findings on nutrition care of patients with end-stage liver disease on the waiting list for liver transplantation such as the impact of the nutritional status on outcome, probiotic and branched-chain amino acid supplementation, as well as the use of immunomodulating formula. Another important strategy that has been shown to improve these patients' nutritional care is the offering of nocturnal meals and micronutrient supplementation.

Patients on the waiting list for liver transplantation: Caregiver burden and stress

Over the last few decades, informal caregivers of patients with chronic diseases have received more attention, and there is a growing volume of studies demonstrating high rates of burden, stress, and mental disorders in this group of individuals. The objective of this study was to evaluate the burden, stress, and psychosocial characteristics of informal caregivers of liver transplantation candidates. Participants were assessed by individual evaluations with the following instruments: a semistructured interview, the Caregiver Burden Scale, the Inventário de Sintomas de Stress para Adultos de Lipp, and the Beck Depression Inventory. The Mann-Whitney test was used for statistical analysis with a significance level of 0.05. The characteristics of the study group (n = 61) were similar to those of groups in other studies with respect to gender (82% were women), kinship (64% were spouses), and age (the mean age was 47.6 years). The main stressors identified by the participants were as follows: doubts about ways to react in a crisis or in emergency situations (42.6%), mood swings of the patient (29.5%), and care involving food and medications (27.9%). Approximately 25% of the caregivers reported that they felt unprepared to adequately perform their roles. Data analysis indicated a greater burden overall on caregivers when the patient's Model for End-Stage Liver Disease score was greater than or equal to 15 points (P = 0.041). Furthermore, caregivers of patients with alcoholic liver disease showed higher depression (P = 0.034) and overall burden scores (P = 0.031) versus caregivers of patients with liver disease due to other etiologies. In conclusion, the participants showed significantly high levels of burden, stress, and depression. Support measures and caregiver preparation should be implemented by health care providers.

Endoscopic Management of a Spontaneous Gallbladder Perforation and Bile Leak

A 53-year-old man with a past medical history of alcoholic liver disease complicated by esophageal varices, ascites, hepatic hydrothorax, and hepatic encephalopathy presented to a local community hospital with 10-day history of abdominal pain. His pain was 10/10 in intensity, constant, worse in the supine position, increasing on the dependant side of the abdomen (when lying on the left side, the pain worse on left and vice versa), and improved in the upright position. The pain was not worsened by food and was not associated with fevers, chills, nausea or chest pain. He also reported shortness of breath and diarrhea, but denied rectal bleeding. When he was admitted to the local hospital, his white blood cell (WBC) count was 15,000/mm, predominantly bands and neutrophils. Because of concern for spontaneous bacterial peritonitis, empiric antibiotics were started and a nasogastric tube was placed. An abdominal ultrasound revealed a cirrhotic liver and a contracted gallbladder with mild gallbladder wall thickening. There was insufficient ascites to perform a diagnostic paracentesis. An abdominal radiograph series was negative for free air. Over the next 24 h, his pain continued to worsen and there was intermittent abdominal distention. A computed tomography (CT) of the abdomen and pelvis revealed a nodular liver capsule consistent with cirrhosis and large volume ascites (Fig. 1a). The gallbladder was contracted around dependent radio-opaque calculi (arrow, Fig. 1a). Two radio-opaque calcified structures in pelvis (arrow, Fig. 1b) consistent with gallstones with associated free fluid in pelvis were also seen. He was transferred to our institution. The patient’s past medical history was significant for alcoholic cirrhosis, and he had been on the liver transplant list. He also had a history of an incarcerated umbilical hernia that was repaired in 2008, as well as cholelithiasis. Upon transfer he was receiving piperacillin and tazobactam, vancomycin, ondansetron, pantoprazole, lactulose and hydromorphone as needed. He had no known drug allergies. He was single and did not smoke tobacco. The patient had discontinued alcohol use in 2008, and had no history of illicit drug use. Family history was negative. On physical examination, his vital signs were stable. The patient appeared to be in no acute distress with icteric conjunctiva and a nasogastric tube in place. There were decreased breath sounds bilaterally with a diffusely distended abdomen with tenderness to palpation in all quadrants. There was shifting dullness and a fluid wave consistent with ascites, but no guarding or rebound. The patient had scrotal and lower extremity edema but no asterixis. The patient had a WBC count of 10,300/mm, hematocrit 27.2%, mean corpuscular volume 84.7, platelet count 86,000/ mm, sodium 136 mmol/L, carbon dioxide 19 mmol/L, blood urea nitrogen 42 mg/dL, creatinine 1.5 mg/dL, albumin 3.1 g/dL, total bilirubin 8.3 mg/dL, alkaline phosphatase 130 U/L, aspartate aminotransferase 37 U/L, alanine aminotransferase 29 U/L, and international normalized ratio for C. Munroe (&) G. Triadafilopoulos J. Van Dam G. Lutchman Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford University Medical Center, 300 Pasteur Drive, Always Building, Rm M211, Stanford, CA 94305-5187, USA e-mail: camunroe@stanford.edu

Surgical treatment of hepatocellular cancer: expert consensus conference

Surgical treatment of hepatocellular cancer: expert consensus conference

Downstaging of Hepatocellular Carcinoma Prior to Liver Transplant: Is There a Role for Adjuvant Sorafenib in Locoregional Therapy?

Hepatocellular carcinoma (HCC) remains a common cause of mortality worldwide. Liver transplantation has emerged as the optimal treatment for cirrhotic patients with HCC; however, the shortage of donor organs leaves waitlisted patients at risk for disease progression beyond transplant criteria. Prevention of waitlist dropout has fueled investigation into a wide array of locoregional therapies for the management of HCC in candidates awaiting liver transplantation. We present a patient with HCC who underwent treatment with sorafenib, which resulted in a remarkable reduction in tumor burden to allow for liver transplant listing.

Predictive Parameters After Molecular Absorbent Recirculating System Treatment Integrated With Model for End Stage Liver Disease Model in Patients With Acute-on-Chronic Liver Failure

Aim The aim of study was to highlight parameters that in association with Model for End-stage Liver Disease (MELD) provide predictive criteria for long-term survival after treatment with the Molecular Adsorbent Recirculating System (MARS). Two homogenous groups were studied: one treated with standard medical therapy (SMT) and the other, with MARS. Materials and methods Twenty acute-on-chronic liver failure patients on the waiting list for liver transplantation and affected by alcoholic cirrhosis with similar MELD scores (20–29) were evaluated for 7 days from inclusion and for 6-month survival. Ten patients (seven males and three females) were treated with MARS. Their mean age was 48.5 years (range = 35–61). The number of MARS applications was six for 6 consecutive days, and the length of the applications was 8 hours. Ten other patients (seven males and three females) were treated with SMT, including prophylaxis against bacterial infections and judicious use of diuretics. The precipitating factors were also treated appropriately. The mean age of the patients was 51 years (range = 37–64). All the variables that were significant upon univariate analysis were enrolled in a receiver operating characteristic analysis, with the intention to detect predictive parameters for patient death at 6 months. We considered a significant area under curve (AUC) value to be greater than 0.5. Results Among 11 patients who died within 6 months there were in the MARS group and eight in the SMT group: the 3- and 6-month patient survival rates were 90% and 70% versus 30% and 20% in the two groups, respectively. Nine measures resulted in an AUC > 0.5: DeltaMELD; interleukin (IL)-8; IL-6; tumor necrosis factor- alpha, MELD score; creatinine, bilirubin international normalized ratio (INR) and cardiac index. DeltaMELD and postoperative IL-8 concentrations showed better results (AUC = 0.899), followed by postoperative creatinine (AUC = 0.879), postoperative cardiac index (AUC = 0.833), and postoperative INR (AUC = 0.818). Postoperative creatinine showed the best sensitivity (100%), while IL-8, the best specificity (88.9%). Conclusion A combination of biochemical and clinical variables probably represent the best way to predict the survival of patients, allowing physicians to select the best therapies for each patient.

Survival Tree and Meld to Predict Long Term Survival in Liver Transplantation Waiting List

MELD score is a formula based on laboratory variables used as a predictor of short-term mortality index in cirrhotic patients. It is applied to allocate patients in liver transplantation waiting list in many countries. However, MELD score cutoff point accuracy to predict long term mortality has not been statistically evaluated. The aim of this study was to analyze the MELD score and other variables related to long-term mortality using a new model: the Survival Tree analysis. The variables considered in this study were obtained at the time of liver transplantation list enrollment. The graphical representation of the survival trees showed that MELD 16 was the most statistically significant mortality cutoff point. The results were compatible with the MELD cutoff point reported in the clinical literature. This methodology can be extended to identify significant cutoff points related to other diseases whose severity is not necessarily expressed by MELD.

Exclusions and Deaths on the Liver Transplant Waiting List

Objective To analyze the characteristiscs, evolution and survival of patients included on the waiting list (WL) for liver transplantation (OLT). Patients and Methods Between February 2002 and April 2009, 254 patients were included on WL to receive a first graft. Two hundred twenty-two patients (87.4%) were transplanted (group T); 7 (2.8%) died on the WL and 25 (9.8%) were excluded, namely, 13 (52%) due to improvement (group IE) and 12, for other reasons (group OE). Data collected prospectively were analyzed retrospectively. Results Indications for transplant were cirrhosis (58%), hepatocellular carcinoma (HCC; 29%) and other etiologies (13%.) Average time on the WL was 60.3 ± 62.9 days. Significant differences were not observed among the groups with respect to age, gender, or indication for OLT. The probability for exclusion due to progression and/or death was not significantly greater among patients included for HCC than for other reasons ( P = .6). Survivals at 1, 3, and 5 years after WL inclusion were 81.2%, 73.3%, and 68.6%, respectively, in the whole series; and 85,4%, 76,9%, and 71.7% in group T. All group OE patients died before the first year, while group IE showed a survival of 100%, 91.7% and 91.7% at 1, 3, and 5 years, respectively. Survival was not different between groups T and IE ( P = .03), but was lower in group OE than in groups T or IE ( P < .001). Conclusion The list mortality rate in our series was low, probably in relation to the short waiting time. The rate of exclusion from WL was 10%. Patient with hepatocellular carcinoma were not at an increased risk of WL exclusion. Patients excluded due to improvement displayed excellent survivals during the 5 years following exclusion.

Survival on Waiting List for Liver Transplantation Before and After Introduction of the Model for End-stage Liver Disease Score

Background Since July 2006, the Model for End-stage Liver Disease (MELD) score has served as the national basis for allocation of donor livers for transplantation in Brazil. Patients with higher MELD scores receive greater priority for allocation regardless of the time on the waiting list. Purpose To investigate the impact of MELD score implementation on the survival of waiting list patients. Methods A retrospective study of patients registered at the national Organ Procurement Organization (OPO) for the liver transplantation waiting list between January 2004 and June 2006 (pre-MELD) and between July 2006 and December 2008 (post-MELD). Results We included listed patients awaiting liver transplantation in the pre-MELD era ( n = 250, 48.4%) and in the post-MELD era ( n = 266, 51.6%). The times awaiting transplant prior to and after the MELD system were 487.2 ± 384.8 days and 183.9 ± 157.2 days, respectively. Prior to the MELD score, waiting list survivals were greater when compared to rates in the current system. Early posttransplant patient survival rates were significantly reduced in the post-MELD era (83.4%) compared to the period before MELD implementation (93.2%). Conclusions MELD score provides a transparent, objective system to drive allocation policy; however, it presents several important limitations. Constant need of changes and reevaluation are needed as an evolutionary process. Future changes in the present system may be addressed by adjusting the MELD system.

Survival Before and After Model for End-stage Liver Disease Score Introduction on the Brazilian Liver Transplant Waiting List

Introduction To examine whether the official adoption of Model for End-Stage Liver Disease (MELD) as a criterion for organ allocation was effective, we studied risk factors for patient deaths and the accuracy of the MELD score to predict mortality. Methods Patients on the waiting list for liver transplantation were divided into two periods depending on whether they were on the waiting list before (period 1) or after (period 2) the MELD introduction in Brazil. The Kaplan-Meier method with log-rank tests were used to study patient survivals. Predictive factors were identified using the Cox regression method. A receiver operating characteristic (ROC) curve was used to analyze Child-Turcotte-Pugh (CTP) and MELD accuracy. Results We analyzed 295 patients in period 1 and 240 in period 2. The survivals after 3, 6, 9, and 12 months in periods 1 and 2, were 95.6%, 90.5%, 84.9%, and 69.6% vs 95.7%, 92.1%, 85.3%, and 83.3%, respectively ( P = NS). Multivariate analysis showed CTP, MELD-Na, and albumin levels, besides spontaneous bacterial peritonitis (SBP), to be independent factors related to survival in period 1. In period 2, CTP, creatinine levels, international normalized ratio, besides spontaneous bacterial peritonitis, were the independent factors. The ROC curve for CTP was 0.676 and for MELD, 0.644 ( P = .4) in period 1. In period 2, the ROC curve for CTP was 0.680 and for MELD, 0.718 ( P = .4). Conclusion Patient survival on the waiting list for liver transplantation did not change at 1 year after the introduction of the MELD.

Prevalence of diabetes mellitus and impaired glucose tolerance in patients with decompensated cirrhosis being evaluated for liver transplantation: the utility of oral glucose tolerance test

Cirrhosis, diabetes mellitus, impaired glucose tolerance, insulin resistance, and protein calorie malnutrition are important issues in cirrhotic patients because they can increase the progression of liver disease and worsen its prognosis. To determine the prevalence of diabetes mellitus, impaired glucose tolerance and insulin resistance in cirrhotic patients being evaluated for liver transplantation and their impacts on a 3-month follow-up, and to compare fasting glycemia and oral glucose tolerance test. A cross-sectional study was performed in consecutively included adult patients. Diabetes mellitus was established through fasting glycemia and oral glucose tolerance test in diagnosing diabetes mellitus in this population. HOMA-IR and HOMA-beta indexes were calculated, and nutritional assessment was performed by subjective global assessment, anthropometry and handgrip strength through dynamometry. Diabetes mellitus was found in 40 patients (64.5%), 9 (22.5%) of them by fasting glycemia and 31 (77.5%) of them by oral glucose tolerance test. Insulin resistance was found in 40 (69%) of the patients. There was no relationship between diabetes mellitus and the etiology of cirrhosis. Protein calorie malnutrition was diagnosed in a range from 3.22% to 45.2% by anthropometry, 58.1% by subjective global assessment and 88.7% by handgrip strength. Diabetes mellitus identified by oral glucose tolerance test was related significantly to a higher prevalence of infectious complications and deaths in a 3-month period (P = 0.017). The prevalence of diabetes mellitus, impaired glucose tolerance, insulin resistance and protein calorie malnutrition is high in cirrhotic patients on the waiting list for liver transplantation. There were more infectious complications and/or deaths in a 3-month follow-up period in patients with diabetes mellitus diagnosed by oral glucose tolerance test. Oral glucose tolerance test seems to be indicated as a routine practice in this population.

Do smaller adults wait longer for liver transplantation? A comparison of the UK and the USA data

The number of patients on the UK and the USA liver transplant list is increasing. As size match is an important factor in the UK organ allocation, we studied the effect of recipient size on liver transplantation in the UK and the USA. The UK Transplant and United Network for Organ Sharing databases were used to assess difference in access to transplantation between smaller adult patients and their larger counterparts over three time periods. Subsequently, proportions of split, NHBD and living-donor transplants were analyzed. There were 1576 UK and 29,150 USA patients in our analysis. The UK small patients have been significantly disadvantaged in access to transplantation particularly in early years and in adult only transplant units. This contrasts to the USA where smaller patients have never been disadvantaged and transplantation rates are steadily increasing. Split-liver transplants are being carried out in increasing numbers in the UK but not the USA. Small adults are still less likely to be transplanted at six months in adult only units in the UK. The lack of size matched organs for smaller adults and the overall decrease in rates of transplantation in the UK may be remedied by careful consideration of allocation policy and increased use of innovative techniques.

T.N.14 COLLAGEN PROPORTIONATE AREA IN ASSESSING THE AMOUNT OF FIBROSIS IN CHRONIC LIVER DISEASE: DOES HIGH RESOLUTION COMPARED TO CONVENTIONAL IMAGE CAPTURING AND ANALYSIS ALTERS ITS RESULTS?

s A.I.S.F. Annual Meeting (Rome, February 25th−26th, 2010) / Digestive and Liver Disease 42 Suppl. 1 (2010) S1–S51 S19 with normal spleen diameter (p 20 ppm or a rise by 12 ppm above baseline following glucose administration was considered as positive. IP was evaluated by the (51)Cr-EDTA permeability test. SIBO prevalence in LC was compared with healthy controls and correlated with LC severity and IP. Results: Twenty-nine out of 56 LC patients had SIBO vs 2 of the 48 healthy controls (51.8% vs 4%, p< 0.0001). SIBO prevalence correlated with the severity of LC (68.2% of Child C pts vs. 56.2% of Child B and 31.2% of Child A pts), with the presence of ascites (66% in ascitic pts vs. 27% in non-ascitic pts), and with a history of SBP (92% of patients with SBP vs. 48% of those without SBP). A significant correlation was found between presence of SIBO and altered IP: it was weak for Child A but significant for Child B and C pts (R = 0.07, NS; R = 0.35, p = 0.005; R = 0.29, p = 0.03, respectively). Conclusions: SIBO seems to have a higher prevalence in LC, correlates with LC severity and altered IP. This association suggests that SIBO may affect intestinal permeability of splancnic vessels and/or peritoneal membranes leading to SBP outbreak in LC. Future interventional studies are needed to confirm these preliminary data. T.N.13 PREDICTORS OF OUTCOME IN CIRRHOTICS ADMITTED TO INTENSIVE CARE UNIT (ICU); SURVIVORS EXHIBITED SIGNIFICANT RISE OF SERUM SODIUM LEVELS AND A FALL IN LACTATE LEVELS AT 48 HOURS M. Garcovich1,2, V. Vemala1, A. Davenport1, E. Dionigi1, S. Shaw1, B. Agarwal1, A.K. Burroughs1. Sheila Sherlock Liver Centre, Royal Free Hospital, London, UK; Dipartimento di Medicina Interna, Universita Cattolica del Sacro Cuor, Rome, Italy Background: Critically ill cirrhotics admitted to ICU have poor prognosis. Factors known to portend worse outcome include mechanical ventilation, development of shock, renal failure and increasing number of organ failure. While a negative impact on mortality of low serum sodium level is observed in stable cirrhotics active on the waiting list for liver transplant, the impact of admission serum sodium and its changes during the course of an acute illness in these patients is not well known. Methods: We retrospective studied a cohort of cirrhotics admitted to ICU between 2005−08 at the Royal Free Hospital. Data were collected on demographic variables, aetiology of liver disease, liver-specific prognostic scores; Child–Turcotte–Pugh (CTP), Model for end-stage liver disease (MELD), United Kingdom model for end-stage liver disease (UKELD), acute physiological score and chronic health points (APACHE II) and sequential organ failure assessment score (SOFA). In addition, data were also collected for serum Na+ and Lactate levels at 0 (on admission) and at 48 hrs. Results: Currently 67 of 125 patients have been enrolled. 51/67 (76.1%) survived ICU. The non-survivors (16/67) had similar demographics as the survivors, had significantly higher mean MELD, UKELD, SOFA and APACHE II scores, and higher admission lactate. Total CTP score was not different between the groups but serum bilirubin level and prothrombin time were significantly higher in the non-survivors. Although the admission Na+ levels in survivors and non survivors were similar, a significant elevation was observed at 48 hrs in the survivors. The trend for serum lactate levels showed a similar pattern i.e., the survivors showed significant reductions at 48 hrs. Conclusions: The reasons for this observed rise in serum Na+ at 48 hrs in the survivors are not obvious. It may signify a better preserved water balance in patients with less severe underlying liver disease. T.N.14 COLLAGEN PROPORTIONATE AREA IN ASSESSING THE AMOUNT OF FIBROSIS IN CHRONIC LIVER DISEASE: DOES HIGH RESOLUTION COMPARED TO CONVENTIONAL IMAGE CAPTURING AND ANALYSIS ALTERS ITS RESULTS? L. Andreana1, G. Isgro1, M. Garcovich1, A. Hall2, F. Grillo2, A.P. Dhillon2, A.K. Burroughs1, T.V. Luong2. The Sheila Sherlock Liver Centre and University Dept. of Surgery, Royal Free Hospital, London, UK; Dept. of Histopathology, Royal Free Hospital,

Cognitive performance and mood in patients on the waiting list for liver transplantation and their relation to the model for end-stage liver disease

To investigate the links between depression and cognitive functioning in patients with Hepatitis C and other chronic liver diseases with and without the use of alcohol on the waiting list for liver transplantation and their associations with the MELD classification. 40 patients were evaluated on a waiting list for liver transplant by a battery of neuropsychological tests, depression scales and interview at the Liver Transplant Service, of the Hospital das Clínicas University of São Paulo Medical School. After splitting the sample according to the education, the results showed statistical significance in the comparisons between groups of MELD > 15 and <15 in the following functions: estimated IQ, visual-spatial delayed recall and recognition as part of episodic memory and short term memory. These findings, usually found in hepatic encephalopathy, corroborated with the literature and emphasized the need to investigate in more detail the cognitive functions of these patients in order to facilitate the adoption of different conducts.

T.N.13 PREDICTORS OF OUTCOME IN CIRRHOTICS ADMITTED TO INTENSIVE CARE UNIT (ICU); SURVIVORS EXHIBITED SIGNIFICANT RISE OF SERUM SODIUM LEVELS AND A FALL IN LACTATE LEVELS AT 48 HOURS

s A.I.S.F. Annual Meeting (Rome, February 25th−26th, 2010) / Digestive and Liver Disease 42 Suppl. 1 (2010) S1–S51 S19 with normal spleen diameter (p 20 ppm or a rise by 12 ppm above baseline following glucose administration was considered as positive. IP was evaluated by the (51)Cr-EDTA permeability test. SIBO prevalence in LC was compared with healthy controls and correlated with LC severity and IP. Results: Twenty-nine out of 56 LC patients had SIBO vs 2 of the 48 healthy controls (51.8% vs 4%, p< 0.0001). SIBO prevalence correlated with the severity of LC (68.2% of Child C pts vs. 56.2% of Child B and 31.2% of Child A pts), with the presence of ascites (66% in ascitic pts vs. 27% in non-ascitic pts), and with a history of SBP (92% of patients with SBP vs. 48% of those without SBP). A significant correlation was found between presence of SIBO and altered IP: it was weak for Child A but significant for Child B and C pts (R = 0.07, NS; R = 0.35, p = 0.005; R = 0.29, p = 0.03, respectively). Conclusions: SIBO seems to have a higher prevalence in LC, correlates with LC severity and altered IP. This association suggests that SIBO may affect intestinal permeability of splancnic vessels and/or peritoneal membranes leading to SBP outbreak in LC. Future interventional studies are needed to confirm these preliminary data. T.N.13 PREDICTORS OF OUTCOME IN CIRRHOTICS ADMITTED TO INTENSIVE CARE UNIT (ICU); SURVIVORS EXHIBITED SIGNIFICANT RISE OF SERUM SODIUM LEVELS AND A FALL IN LACTATE LEVELS AT 48 HOURS M. Garcovich1,2, V. Vemala1, A. Davenport1, E. Dionigi1, S. Shaw1, B. Agarwal1, A.K. Burroughs1. Sheila Sherlock Liver Centre, Royal Free Hospital, London, UK; Dipartimento di Medicina Interna, Universita Cattolica del Sacro Cuor, Rome, Italy Background: Critically ill cirrhotics admitted to ICU have poor prognosis. Factors known to portend worse outcome include mechanical ventilation, development of shock, renal failure and increasing number of organ failure. While a negative impact on mortality of low serum sodium level is observed in stable cirrhotics active on the waiting list for liver transplant, the impact of admission serum sodium and its changes during the course of an acute illness in these patients is not well known. Methods: We retrospective studied a cohort of cirrhotics admitted to ICU between 2005−08 at the Royal Free Hospital. Data were collected on demographic variables, aetiology of liver disease, liver-specific prognostic scores; Child–Turcotte–Pugh (CTP), Model for end-stage liver disease (MELD), United Kingdom model for end-stage liver disease (UKELD), acute physiological score and chronic health points (APACHE II) and sequential organ failure assessment score (SOFA). In addition, data were also collected for serum Na+ and Lactate levels at 0 (on admission) and at 48 hrs. Results: Currently 67 of 125 patients have been enrolled. 51/67 (76.1%) survived ICU. The non-survivors (16/67) had similar demographics as the survivors, had significantly higher mean MELD, UKELD, SOFA and APACHE II scores, and higher admission lactate. Total CTP score was not different between the groups but serum bilirubin level and prothrombin time were significantly higher in the non-survivors. Although the admission Na+ levels in survivors and non survivors were similar, a significant elevation was observed at 48 hrs in the survivors. The trend for serum lactate levels showed a similar pattern i.e., the survivors showed significant reductions at 48 hrs. Conclusions: The reasons for this observed rise in serum Na+ at 48 hrs in the survivors are not obvious. It may signify a better preserved water balance in patients with less severe underlying liver disease. T.N.14 COLLAGEN PROPORTIONATE AREA IN ASSESSING THE AMOUNT OF FIBROSIS IN CHRONIC LIVER DISEASE: DOES HIGH RESOLUTION COMPARED TO CONVENTIONAL IMAGE CAPTURING AND ANALYSIS ALTERS ITS RESULTS? L. Andreana1, G. Isgro1, M. Garcovich1, A. Hall2, F. Grillo2, A.P. Dhillon2, A.K. Burroughs1, T.V. Luong2. The Sheila Sherlock Liver Centre and University Dept. of Surgery, Royal Free Hospital, London, UK; Dept. of Histopathology, Royal Free Hospital,

Benefit of downsizing hepatocellular carcinoma in a liver transplant population

Long-term results after downstaging hepatocellular carcinoma (HCC) prior to liver transplantation (LT) remain unknown. To investigate dropouts and post-transplant outcome among patients with downstaged HCC by transarterial chemo-lipiodolization (TACL). Between 2000 and 2007, 386 patients with HCC initially exceeding Milan criteria underwent TACL for tumour downstaging and were consecutively enrolled. Overall, 160 (41.5%) patients achieved successful downstaging of HCC to within Milan criteria. During the follow-up, 82 eventually dropped off the waiting list for LT, with estimated dropout rates at 1, 2 and 5 years of 46.7%, 70.2%, and 87.2%, respectively. The overall post-transplant survival rates at 1, 2 and 5 years were 89.2%, 70.3% and 54.6% and the corresponding rates for recurrence-free survival were 74.7%, 71.8% and 66.3% respectively. Multivariate analysis indentified alpha-fetoprotein (AFP) levels > or = 100 ng/mL at LT (P = 0.003), maximum tumour size > or = 7 cm (P = 0.002) and the lack of complete necrosis by TACL (P = 0.048) as independent predictors of HCC recurrence after LT. Patients with none of these risk factors had an excellent post-transplant outcome, with an 87.5% probability of recurrence-free survival up to 6 years. These long-term results may contribute to the database for optimizing management of LT candidates with downstaged HCC. Based on our data, patients with a maximum tumour size <7 cm who achieve complete necrosis together with AFP levels <100 ng/mL at LT may be the best candidates for LT following downstaging using TACL.

Antiviral therapy in HCV-infected decompensated cirrhotics.

Decompensated cirrhosis has traditionally been considered a contraindication to interferon and ribavirin therapy. Whereas, the same may be true for advanced cirrhosis, which is only successfully amenable to liver transplantation (LT), there are reports in the literature in which antiviral therapy was given successfully in selected cases of early hepatic decompensation with an aim to attain sustained viral clearance, halt disease progression, and expect potential (though, often, partial) recovery of hepatic metabolic activity. Antiviral therapy may also be instituted to prevent hepatitis C recurrence after LT (it has even caused removal of some patients from the waiting list for LT). Thus, decompensation per se is no more an absolute contraindication to antiviral therapy. Nonetheless, considering that a large proportion of such patients have pre-existing hematological cytopenias, modifications in antiviral dose regimens and close monitoring is required in order to prevent worsening of the same. Although the final sustained virological response rates attained in these patients are relatively low, successful antiviral therapy is potentially lifesaving which explains the need to go for it. In this article, the pros and cons of antiviral therapy in decompensated liver cirrhosis are reviewed with special emphasis on how to avoid antiviral dose reductions/withdrawals secondary to the development of hematologic side effects by using hematopoietic growth factors.

Importance of Introduction of a Psychological Care Unit in a Liver Transplantation Unit

Background Psychological changes in terminally ill patients with liver disease are underestimated. Therefore, a psychological care unit was introduced in the liver transplantation unit in a transplantation hospital in Spain. Objectives To describe the establishment of the psychological care unit in a liver transplantation unit and to review its operation, and to evaluate and diagnose psychological changes in patients on the waiting list for liver transplantation. Materials and Methods Variables evaluated included consultations, interviews, level of care provided, appointments postponed, difficulties, and cost-effectiveness. Psychopathologic symptoms were evaluated using the Symptom Assessment-45 questionnaire (Derogatis, 1975), examining 9 psychopathologic dimensions. Results Thirty-eight patients were given an appointment, and 28 were interviewed. Twelve postponed the appointment. The level of support provided to patients on the waiting list was 70%. The hospital structure was used to develop the care unit, which is why it was only necessary to employ 1 professional psychologist. Of patients assessed, 54% exhibited relevant clinical symptoms of depression, and 47 demonstrated anxiety. Patients with symptoms of depression reported “loss of interest”; those with anxiety reported feeling “worried and tense.” Of these patients, an increased presence of symptoms was associated with various emotional problems such as hostility (33%), somatization (60%), obsession/compulsion (73%), interpersonal sensitivity (40%), phobic anxiety (20%), paranoid ideation (20%), and psychosis (6%). Conclusions Patients on the waiting list for liver transplantation demonstrate increased clinical symptoms of depression and anxiety. Therefore, it is of great importance to introduce a psychological care unit to detect and treat these conditions. Introduction of the liver transplant unit program has improved multidisciplinary care and is cost-effective.