Patients Undergoing Liver Transplantation Research Articles

Intraoperative Normal Saline Administration and Acute Kidney Injury in Patients Undergoing Liver Transplantation

Normal saline is still used in patients undergoing living donor liver transplantation (LDLT) with normonatremia. We investigated whether the normal saline administered during LDLT is associated with the increased risk of acute kidney injury (AKI) compared with the balanced crystalloids. We reviewed 1011 cases undergoing LDLT. The primary exposure variable was normal saline administered intraoperatively compared with the balanced crystalloid. To compare the risk of AKI after adjusting for potential confounders of baseline characteristics and surgical parameters, a propensity score matching analysis was performed. As a sensitivity analysis, ordinal logistic regression analysis was performed for AKI using inverse probability of treatment weighting (IPTW). The incidence of AKI was significantly higher in the saline group (n = 88/174, 50.6%) than in the balanced group (n = 67/174, 38.5%) after matching (P = .010). The incidence of stage 2 or 3 AKI was also significantly higher in the saline group (n = 26/174, 14.9%) than in the balanced group (n = 43/174, 24.7%) after matching (P = .022). The length of hospital stay was significantly longer in the saline group than in the balanced group after matching. Ordinal logistic regression analysis using IPTW showed that the saline group showed a significant association of saline administration with the risk of AKI (odds ratio 1.23, 95% CI 1.05-1.28, P = .013). Our propensity score analysis using propensity score matching and IPTW showed that normal saline administration during LDLT is associated with a high risk of postoperative AKI and longer hospital stays. However, our results should be interpreted carefully due to the relatively long period of data collection.

Gastrointestinal Tonometry in the Perioperative Period of Liver Transplantation: An Integrative Review

Introduction: Gastric tonometry is a useful tool for examining regional splanchnic perfusion as it provides an indirect assessment of the state of the liver graft. This is because splanchnic hypoperfusion is a critical parameter in the context of liver transplantation, being associated with the development of problems such as acute liver failure and multiple organ failure. Objective: To analyze the effects of gastrointestinal tonometry in the perioperative period of patients undergoing liver transplantation. Methodology: This is an Integrative Review using the PubMed and VHL databases. The following descriptors were used: “Tonometry”, “Splanchnic circulation” and “Liver transplantation” with the Boolean operator “AND”, and articles of relevance to the topic were selected. Initially, 24 articles were selected, all published in the last 20 years, in Portuguese and/or English. After analysis, 6 articles matched the proposed objective. Results:It was observed that the difference between PraCO2 at the end of surgery and in the anepathic phase was greater in patients without liver graft dysfunction. A positive correlation was found between ǻpraCO2 and peak ALT after liver transplantation. In another study, it was found that the relationship between poor graft function was the presence of elevated liver enzymes, worsening synthetic liver function, coagulopathy and encephalopathy. It has also been shown that intramucosal gastric pH can predict early graft function. In a group with liver dysfunction, patients had an intramucosal gastric pH of less than 7.3 in the perioperative period, which remained low until the 24th hour postoperatively, while the group without dysfunction had an intramucosal gastric pH of more than 7.3, except in the anepathic phase when it was below this value. Conclusion: The usefulness of gastrointestinal tonometry to monitor splanchnic circulation and liver graft function during liver transplantation has been described and although support for this statement was found in some studies, this review had limitations due to the small number of articles available, which prevents it from covering a wide range of scientific evidence

Perioperative Analysis of Patients Undergoing Liver Transplantation at the Hospital de Clínicas da Unicamp in the Context of SARS-Cov-2 Pandemic

Introduction: SARS-CoV-2 began in 2020 and caused important changes in the number of transplants performed in hospitals and in the protocols for admitting candidates to perform the procedure. The Brazilian Association of Organ Transplantation (ABTO) recommends not performing transplants from donors with active COVID-19 infection, positive test results or with Severe Acute Respiratory Syndrome. The hepatic repercussions related to COVID-19 are presented in some reports in the medical literature. Liver changes resulting from other corona viruses such as SARS-CoV and MERS-CoV are well documented. The Hospital de Clínicas of the State University of Campinas is a tertiary center that performs solid organ transplants. Objectives: To carry out a perioperative, retrospective, descriptive analysis of liver transplants in the context of the SARS-CoV-2 pandemic carried out at the Hospital das Clínicas of the State University of Campinas from March 2020 to July 2021. Materials and Methods: Retrospective, descriptive, longitudinal cohort study based on the review of medical records of patients undergoing liver transplantation in the context of the SARS-CoV-2 pandemic from March 2020 to July 2021 at the clinical hospital of the State University of Campinas. Results:Retrospective analysis was performed on 57 patients in the period. Only 1 patient needed to be excluded because he was under 18 years old. Of the 56 patients, 52 underwent RT-PCR laboratory testing and chest tomography (CT). Of these 52 patients, only 2 tested positive, one pre-transplant (TX) and one post-operatively (post-op). Regarding chest CT scans, none of them showed typical changes for COVID pre-TX, in the post-op 4 patients presented typical chest CT scans. The average age was 55.86 years. The mortality rate was 38% and no deaths were attributed to COVID 19. The average MELD-Na scale was 20.94. Conclusion: The present study carried out at the Hospital de Clínicas da Unicamp analyzed the clinical, laboratory and radiological association to better elucidate the variables determined by COVID-19 in its diagnosis and in-hospital management. It is concluded that the SARS-CoV-2 pandemic had an impact on the routine of liver transplantation worldwide and on the service in which the study was carried out.

A288 ALCOHOL RELAPSE AND ADVERSE OUTCOMES IN EARLY VERSUS ROUTINE LIVER TRANSPLANT FOR ALCOHOL-ASSOCIATED LIVER DISEASE IN THE PROVINCE OF BRITISH COLUMBIA

Abstract Background Liver transplant is a life-saving treatment for patients with alcohol-associated liver disease (ALD) resulting in decompensated cirrhosis or severe alcoholic hepatitis, significantly reducing mortality compared to supportive treatment. Despite its previous wide acceptance, there is a lack of strong evidence to justify a 6-month abstinence period. In 2019, BC Transplant policies were updated to allow liver transplant within 6-months of alcohol use in carefully selected patients with limited life expectancy and favorable multidisciplinary psychosocial assessment. Aims This study aims to assess alcohol relapse rates and adverse outcomes in patients who received an early liver transplant for ALD. Methods A retrospective chart review was performed on all adult patients who underwent liver transplant in the province of British Columbia between January 1, 2020, and December 31, 2022. Follow up data was extracted until May 31, 2023. Patients were included if they had alcohol documented as a contributing factor to their liver disease prior to transplant. Early transplant was defined as alcohol abstinence of 179-days or less and routine transplant as 180-days or more. Alcohol use and time to alcohol use were determined by patient history, random biochemical testing, and health-care utilization for an alcohol-associated complication. Graft dysfunction or rejection resulting in a change in therapeutic management, noncompliance determined by clinician documentation, rehospitalization, and death were recorded as adverse events. Results 278 patients underwent liver transplant during the study period. 81 patients were classified as alcohol-related, and 15 received early transplant. The mean follow-up period was 20.5 months. Early transplant recipients were more likely to be younger (median 45 vs. 58 years, p = 0.003) and have a higher MELD score at the time of transplant (median 37 vs. 17, p ampersand:003C 0.001). There was no significant difference in post-transplant alcohol relapse (13 vs. 15%, hazard ratio = 0.78, 95% CI [0.17, 3.55], p = 0.74). Graft dysfunction was increased in patients who received early transplant (53 vs. 25%, relative risk = 2.17, 95% CI [1.15, 4.10]). There was no significant difference between rates of noncompliance (0 vs. 9%), rehospitalization (53 vs. 56%), or death (0 vs. 2%). Conclusions Alcohol relapse is similar between early and routine liver transplant. Graft dysfunction is increased in early transplant, although other adverse events including medication noncompliance, rehospitalization, and death are not significant different. These results are favorable for the continued use of early liver transplant for ALD, providing an effective treatment for ALD and significantly reducing mortality in patients with a limited life expectancy. Funding Agencies None

Post-transplant hepatitis B virus reactivation impacts the prognosis of patients with hepatitis B-related hepatocellular carcinoma: a dual-centre retrospective cohort study in China.

Highly active hepatitis B virus (HBV) is known to be associated with poor outcomes in patients with hepatocellular carcinoma (HCC). This study aims to investigate the relationship between HBV status and HCC recurrence after liver transplantation. The study retrospectively analyzed HCC patients undergoing liver transplantation in two centres between January 2015 and December 2020. The authors reviewed post-transplant HBV status and its association with outcomes. The prognosis of recipients with hepatitis B surface antigen (HBsAg) reappearance ( n =58) was poorer than those with HBsAg persistent negative ( n =351) and positive ( n =53). In HBsAg persistent positive group, recipients with HBV DNA reappearance or greater than 10-fold increase above baseline had worse outcomes than those without ( P <0.01). HBV reactivation was defined as (a) HBsAg reappearance or (b) HBV DNA reappearance or greater than 10-fold increase above baseline. After propensity score matching, the 5-year overall survival rate and recurrence-free survival rate after liver transplantation in recipients with HBV reactivation were significantly lower than those without (32.0% vs. 62.3%; P <0.01, and 16.4% vs. 63.1%; P <0.01, respectively). Moreover, HBV reactivation was significantly related to post-transplant HCC recurrence, especially lung metastasis. Cox regression analysis revealed that beyond Milan criteria, microvascular invasion and HBsAg-positive graft were independent risk factors for post-transplant HBV reactivation, and a novel nomogram was established accordingly with a good predictive efficacy (area under the time-dependent receiver operating characteristic curve=0.78, C-index =0.73). Recipients with HBV reactivation had worse outcomes and higher tumour recurrence rates than those without. The nomogram could be used to evaluate the risk of post-transplant HBV reactivation effectively.

Pulmonary Complications of Everolimus in Liver Transplant Patients: A 10-Year Experience.

This retrospective study aims to evaluate the safety of everolimus when used as part of the immunosuppression regimen in patients who underwent liver transplant from 2009 to 2019 at a tertiary liver transplant center. Patients were divided into two groups: those who received everolimus as part of the post-transplant regimen and those who did not. The primary safety outcome measured was the development of new pulmonary complications that had been associated with everolimus use in prior studies. Lung function was determined by pulmonary function tests if available or CT scans of the chest. Secondary outcomes measured included everolimus discontinuation rates and survival rates. During the study period, 450 patients underwent liver transplant; 35% of patients received everolimus (n=156) and 65% of patients did not receive everolimus (n=292). Primary safety outcome of pulmonary complications was seen in 3.9% of patients who received everolimus (n=6) and 6.3% of the control group patients who did not receive everolimus (n=19). The association between everolimus use and new pulmonary complications was not significant with a chi-square statistic of 1.33 (p=0.249). Overall, 51.3% of patients who received everolimus during their post-transplant course discontinued the medication (n=80). Everolimus is safe from a pulmonary toxicity standpoint in liver transplant immunosuppression regimens as there was no significant difference found in pulmonary complications between patients who received the medication and those who did not.

Prediction of Biliary Complications After Human Liver Transplantation Using Hyperspectral Imaging and Convolutional Neural Networks: A Proof-of-concept Study.

Biliary complications (BCs) negatively impact the outcome after liver transplantation. We herein tested whether hyperspectral imaging (HSI) generated data from bile ducts (BD) on reperfusion and machine learning techniques for data readout may serve as a novel approach for predicting BC. Tissue-specific data from 136 HSI liver images were integrated into a convolutional neural network (CNN). Fourteen patients undergoing liver transplantation after normothermic machine preservation served as a validation cohort. Assessment of oxygen saturation, organ hemoglobin, and tissue water levels through HSI was performed after completing the biliary anastomosis. Resected BD segments were analyzed by immunohistochemistry and real-time confocal microscopy. Immunohistochemistry and real-time confocal microscopy revealed mild (grade I: 1%-40%) BD damage in 8 patients and moderate (grade II: 40%-80%) injury in 1 patient. Donor and recipient data alone had no predictive capacity toward BC. Deep learning-based analysis of HSI data resulted in >90% accuracy of automated detection of BD. The CNN-based analysis yielded a correct classification in 72% and 69% for BC/no BC. The combination of HSI with donor and recipient factors showed 94% accuracy in predicting BC. Deep learning-based modeling using CNN of HSI-based tissue property data represents a noninvasive technique for predicting postoperative BC.

Mismatched Postsurgical Opioid Prescription to Liver Transplant Patients: A Retrospective Cohort Study From a Single High-volume Transplant Center.

Improper opioid prescription after surgery is a well-documented iatrogenic contributor to the current opioid epidemic in North America. In fact, opioids are known to be overprescribed to liver transplant patients, and liver transplant patients with high doses or prolonged postsurgical opioid use have higher risks of graft failure and death. This is a retrospective cohort study of 552 opioid-naive patients undergoing liver transplant at an academic center between 2012 and 2019. The primary outcome was the discrepancy between the prescribed discharge opioid daily dose and each patient's own inpatient opioid consumption 24 h before discharge. Variables were analyzed with Wilcoxon and chi-square tests and logistic regression. Opioids were overprescribed in 65.9% of patients, and 54.3% of patients who required no opioids the day before discharge were discharged with opioid prescriptions. In contrast, opioids were underprescribed in 13.4% of patients, among whom 27.0% consumed inpatient opioids but received no discharge opioid prescription. The median prescribed opioid daily dose was 333.3% and 56.3% of the median inpatient opioid daily dose in opioid overprescribed and underprescribed patients, respectively. Importantly, opioid underprescribed patients had higher rates of opioid refill 1 to 30 and 31 to 90 d after discharge, and the rate of opioid underprescription more than doubled from 2016 to 2019. Opioids are both over- and underprescribed to liver transplant patients, and opioid underprescribed patients had higher rates of opioid refill. Therefore, we proposed to prescribe discharge opioid prescriptions based on liver transplant patients' inpatient opioid consumption to provide patient-centered opioid prescriptions.

MOBILE GAME: TECNOLOGIA EDUCACIONAL PARA CUIDADOS DOMICILIARES DO PACIENTE SUBMETIDO AO TRANSPLANTE HEPÁTICO

ABSTRACT Objective: to develop and validate an educational game capable of supporting health education actions for patients undergoing liver transplantation. Method: this is a study of a technological product, based on the User-Centered Design framework, carried out in a reference hospital for liver transplantation. Participants were patients undergoing liver transplantation, nurses and information technology professionals. Data collection took place through semi-structured interviews and a questionnaire, using Brazilian standards for usability assessment. Data analysis occurred through content analysis, based on the calculation model for the System Usability Scale. Results: seventeen patients participated, including seven nurses and four information technology professionals. The game is made up of five paths with the main care to be carried out at home. Each path presents steps to be followed with its rules. As for validation, the overall mean was 1.38. Usability assessment by patients had a mean of 80 points, while by professionals it was above 75%. Conclusion: it is considered that the aforementioned tool is capable of being used in practice by users. Furthermore, this was adjusted to meet the needs of patients undergoing liver transplantation to support and manage home care.

Evaluation of knowledge, attitude, and awareness of liver transplant patients toward xenotransplantation.

Xenotransplantation (XTx) is an alternative treatment for organ scarcity. Investigating the acceptance of XTx among patients from diverse cultural and religious backgrounds is essential. This study aimed to evaluate the knowledge, attitudes, and awareness of XTx among patients undergoing liver transplant (LT). This descriptive study was conducted between November 2022 and August 2023. The study population comprised LT patients aged ≥18 years who were admitted to the hepatology clinic of a university hospital in Turkey. Of the 360 patients (n = 360) interviewed, 351 were deemed eligible for inclusion. A questionnaire was used to collect data. The Kolmogorov-Smirnov test, median, standard deviation, minimum-maximum, number, percentage, and Pearson's chi-square test were used for statistical analysis. Of the patients, 78.3% were religious and adhered to religious requirements, and 87.2% considered their religious beliefs when making important decisions. In all, 41.3% of the participants believed that organ or tissue transplantation from animals to humans is ethical, while 70.1% of the participants believed that organ and tissue transplantation from non-halal animals to humans was impossible. Specifically, 56.7% would not allow organ or tissue transplantation from a non-halal animal to themselves or a relative. Knowledge and attitude towards XTx were not affected by transplantation type (p > .05), but were affected by sex and educational level (p < .05). This study found that LT patients generally oppose XTx. To enhance knowledge and awareness, religious leaders and healthcare professionals should organize comprehensive and effective seminars on this topic.

Risk of Cerebral Aneurysm Rupture After Liver Transplantation: Development and Validation of a Hemorrhagic Stroke Scoring Model.

Liver transplantation (LT) patients appear to be more prone to neurological events compared to individuals undergoing other types of solid-organ transplantation. The aims of the present study were to analyze the prevalence of unruptured intracranial aneurysms (UIAs) in patients undergoing liver transplantation (LT) and to examine the perioperative occurrence of subarachnoid hemorrhage (SAH). Also, it intended to systematically identify the risk factors of SAH and hemorrhagic stroke (HS) within a year after LT and to develop a scoring system which involves distinct clinical features of LT patients. Patients who underwent LT from January 2012 to March 2022 were analyzed. All included patients underwent neurovascular imaging within 6 months before LT. We conducted an analysis of prevalence and radiological features of UIA and SAH. The clinical factors that may have an impact on HS within one year of LT were also reviewed. Total of 3,487 patients were enrolled in our study after applying inclusion and exclusion criteria. The prevalence of UIA was 5.4%. The incidence of SAH and HS within one year following LT was 0.5% and 1.6%, respectively. We developed a scoring system based on multivariable analysis to predict the HS within 1-year after LT. The variables were a poor admission mental status, the diagnosis of UIA, serum ammonia levels, and Model for End-stage Liver Disease (MELD) scores. Our model showed good discrimination among the development (C index, 0.727; 95% confidence interval [CI], 0.635-0.820) and validation (C index, 0.719; 95% CI, 0.598-0.801) cohorts. The incidence of UIA and SAH was very low in LT patients. A poor admission mental status, diagnosis of UIA, serum ammonia levels, and MELD scores were significantly associated with the risk of HS within one year after LT. Our scoring system showed a good discrimination to predict the HS in LT patients.

Preoperative predictors of platelet transfusion in adult patients undergoing liver transplant

Preoperative predictors of platelet transfusion in adult patients undergoing liver transplant

Predictors for postoperative dysphagia in liver transplant recipients.

Liver transplant recipients are at a heightened risk for oropharyngeal dysphagia; identification of those who are at high risk for postoperative dysphagia could reduce hospital costs and length of stay. We sought to identify predictors of dysphagia, in a large cohort of patients who underwent liver transplantation. Electronic medical records were queried for patients undergoing liver transplantation, who underwent instrumental swallowing evaluations. Demographics, functional outcomes, and interventions were collected. Logistic regression analyses were performed to identify predictors of dysphagia. Seven hundred and ninety-five patients met inclusionary criteria. Multivariate analyses found ethnic group (p = .0191), MELD Score (p < 0001), cold ischemia time (p = .0123), and length of intubation (p < .0001) to be predictors of post-operative development of dysphagia. Pre-transplant dialysis (p < .0001), dysphagia related to end stage liver disease (p < .0001), Karnofsky Performance Status Scale (p < .0001), wait time to transplant (p = 0.0173), surgery time (p = 0.0095), tracheostomy (p < 0.0001), and transfusion of intraoperative RBC (p < .0001), intraoperative platelets (p = 0.0018), intraoperative FFP (p = 0.0495), perioperative FFP (p = 0.0002), perioperative platelets (p = 0.0151) and perioperative RBC (p = 0.0002) were variables of significance associated with the development of postoperative dysphagia from univariate analysis. Our results propose a set of predictors that should be considered when identifying post-operative critically ill patients at risk for dysphagia.

The role of HBIG in real life for patients undergoing liver transplantation due to HDV-related cirrhosis.

Recommended post-liver transplant (LT) prophylaxis in patients with hepatitis delta includes a nucleos(t)ide analogue (NA) and anti-hepatitis B immunoglobulin (HBIG) indefinitely. We analysed the use of HBIG in real-life clinical practice and its impact on HBV/HDV recurrence in 174 HDV-related LT patients from 10 Spanish liver transplant centres (1988-2018). Median post-LT follow-up was 7.8 (2.3-15.1) years and patient survival at 5 years was 90%. Most patients (97%) received HBIG in the immediate post-LT, but only 42% were on HBIG at the last control. Among those discontinuing HBIG, the median time on treatment was 18 (7-52) months. Post-LT HBsAg+ was detected in 16 (9%) patients and HBV-DNA in 12 (7%). Despite HBsAg positivity, HDV recurrence was reported only in three patients (1.7%), all of whom were not receiving NA and had discontinued HBIG. Our data suggest that a finite HBIG prophylaxis in HDV-LT is feasible, especially if high-barrier NAs are used.

Fecal metabolite profiling identifies liver transplant recipients at risk for postoperative infection

Metabolites produced by the intestinal microbiome modulate mucosal immune defenses and optimize epithelial barrier function. Intestinal dysbiosis, including loss of intestinal microbiome diversity and expansion of antibiotic-resistant pathobionts, is accompanied by changes in fecal metabolite concentrations and increased incidence of systemic infection. Laboratory tests that quantify intestinal dysbiosis, however, have yet to be incorporated into clinical practice. We quantified fecal metabolites in 107 patients undergoing liver transplantation (LT) and correlated these with fecal microbiome compositions, pathobiont expansion, and postoperative infections. Consistent with experimental studies implicating microbiome-derived metabolites with host-mediated antimicrobial defenses, reduced fecal concentrations of short- and branched-chain fatty acids, secondary bile acids, and tryptophan metabolites correlate with compositional microbiome dysbiosis in LT patients and the relative risk of postoperative infection. Our findings demonstrate that fecal metabolite profiling can identify LT patients at increased risk of postoperative infection and may provide guideposts for microbiome-targeted therapies.

Blood salvage and autotransfusion during orthotopic liver transplantation for hepatocellular carcinoma: A systematic review and meta-analysis.

Hepatocellular carcinoma (HCC) is a significant cause of oncologic mortality worldwide. Liver transplantation represents a curative option for patients with significant liver dysfunction and absence of metastases. However, this therapeutic option is associated with significant blood loss and frequently requires various transfusions and intraoperative blood salvage for autotransfusion (IBS-AT) with or without a leukocyte reduction filter. This study aimed to analyze available evidence on long-term oncologic outcomes of patients undergoing liver transplantation for HCC with and without IBS-AT. Per PRISMA guidelines, a systematic review of keywords "Blood Salvage," "Auto-transfusion," "Hepatocellular carcinoma," and "Liver-transplant" was conducted in PubMed, EMBASE, and SCOPUS. Studies comparing operative and postoperative outcomes were screened and analyzed for review. Twelve studies totaling 1704 participants were included for analysis. Length of stay, recurrence rates, and overall survival were not different between IBS-AT group and non IBS-AT group. IBS-AT use is not associated with increased risk of recurrence in liver transplant for HCC even without leukocyte filtration. Both operative and postoperative outcomes are similar between groups. Comparison of analyzed studies suggest that IBS-AT is safe for use during liver transplant for HCC.

Defining characteristics and long-term prognosis of drug-induced autoimmune-like hepatitis: A retrospective cohort study.

Drug-induced autoimmune-like hepatitis (DI-AILH) is poorly defined and more data are required to better characterise and manage this disease entity. The aim of this study was to evaluate the clinical characteristics, histology and long-term outcomes of DI-AILH compared with idiopathic autoimmune hepatitis (AIH). This retrospective cohort study reviewed 28 DI-AILH and 39 AIH patients in a single centre. The new (2022) and simplified (2008) AIH histology criteria were used to assess DI-AILH. DI-AILH were more likely to present with jaundice (p=0.004) and higher bilirubin levels (p=0.04) than AIH. AIH patients had higher rate of immunosuppression (IS) use including second- and third-line agents, though the time to reach biochemical remission were comparable. AIH patients had more advanced fibrosis than DI-AILH (Ishak fibrosis score 3.5 vs. 1.9, p<0.0001). DI-AILH more commonly had eosinophilic aggregates (18% vs. 3%, p=0.031) and less commonly showed plasma cell aggregates (61% vs. 97%, p<0.001) than AIH. The simplified AIH histology criteria identified 1 atypical histology within the DI-AILH cohort, although this patient required long-term IS. The new AIH histology criteria classified 23 (82%) as likely AIH and 5 (18%) as possible AIH. Two of the possible DI-AILH did not require IS and one patient had successful IS withdrawal. Four DI-AILH patients with fibrosis stage ≤3 had successful IS withdrawal compared with none in the AIH group. Four patients underwent liver transplantation (LT) in both cohorts with significantly shorter time to LT in DI-AILH as the indication was for (sub)acute liver failure. Two DI-AILH patients died within 60days of LT. The new AIH histology criteria may be better at identifying DI-AILH. Immunosuppression withdrawal in those without significant fibrosis may be considered. DI-AILH is at risk of (sub)acute liver failure and early discussions with a transplant centre would be desirable.

Multidrug-Resistant Infections After Liver Transplantation, Etiology and Risk Factors: A Single-Center Experience.

Patients undergoing liver transplant are at an increased risk of morbidity and mortality due to the development of infections. We aimed to evaluate the risk factors affecting the incidence of infectious diseases after liver transplant and to present the epidemiological data. We investigated patients aged ≥18 years who underwent liver transplant between 2012 and 2020 at our center. We collected infections, causative microorganisms, and antibacterial resistance patterns seen during the first 6 months posttransplant. Risk factors affecting the development of infectious diseases were also analyzed and evaluated. Of 112 patients included in our study, 76 (67.9%) were men, and the median age was 50 years (range, 20-66 years). Within month 1 and month 6 after transplant, at least 1 episode of infection occurred in 67 (59.8%) and 80 (71.4%) patients, respectively. Bacterial infections were the most common type (n = 78, 95.1%), followed by fungal (n = 2, 2.4%) and viral (n = 2, 2.4%) infections. The rate of multidrug resistance in bacterial infections was high (n = 38, 52.7%) and was also a risk factor for mortality in the first 6 months after transplant (P < .001). Pretransplant values of international normalized ratio, creatinine, bilirubin, and posttransplant intensive care unit stay, as well as the presence of encephalopathy, were shown to increase the risk of infection after transplant. Multidrug-resistant bacterial infections are a significant risk factor for mortality in liver transplant patients. Many risk factors that contribute to the development of infections aftertransplant have been included in prognostic scoring systems of liver failure. Consequently, the severity of end-stage liver failure is directly related to the risk of posttransplant infections.

Hyperbaric Therapy in Patients Undergoing Liver Transplantation: An Integrative Review

Introduction: Patients with liver disease generally have a serious clinical condition that can rapidly worsen, making the wait until liver transplantation or post-surgery a poor prognosis. Hyperbaric oxygen therapy has therefore been described in some studies as an alternative in these cases, as it mitigates the effects of the diseases and liver transplantation. Objective: To describe the effects of hyperbaric oxygen therapy in the pre- and post-operative periods of patients undergoing liver transplantation. Methods: This is an Integrative Review using the PubMed and Web Of Science databases. The following descriptors were used: “Hyperbaric oxygenation”, “Liver transplantation” and “Hyperbaric oxygen therapy” with the Boolean operator “AND”, and articles of relevance to the topic were selected. Initially, 49 articles were selected, all published in the last 20 years, in Portuguese and/or English. After analysis, 6 articles matched the proposed objective. Results: It can be seen that intraoperative systemic O2 content affects postoperative recovery in patients undergoing liver transplantation. Early hyperbaric oxygen therapy acts as a protector in reducing the severity of hepatocyte ischemia/reperfusion injury. Hyperbaric oxygen therapy also influences the immune response of patients undergoing liver transplantation, reducing incompatibility. Still on the subject of the immunomodulatory effects of hyperbaric oxygen therapy, this therapy has been shown to be effective in helping to prevent post-operative infections by improving the antibacterial activity of immune cells and increasing the bactericidal effect of antibiotics. In the case of patients on the waiting list for liver transplants, a reduction in the number and intensity of encephalopathy episodes, an improvement in pruritus and a feeling of well-being were observed after treatment with oxygen therapy. In terms of early allograft dysfunction, it was shown that patients with dysfunction had lower O2 values in the anepathic and neo-hepatic phases when compared to patients without dysfunction in the post-operative period. In addition, during the anepathic phase, the content of the SatO2 level was also lower in the group with dysfunction than in those without. Conclusion: Hyperbaric oxygen therapy is beneficial in liver preservation, as it helps to maintain liver function, prolong liver preservation time and improve the outcome of liver transplantation.

Serial circulating tumor DNA profiling predicts tumor recurrence after liver transplantation for liver cancer.

Minimal residual disease (MRD) is proposed to be responsible for tumor recurrence. The role of circulating tumor DNA (ctDNA) to detect MRD, monitor recurrence, and predict prognosis in liver cancer patients undergoing liver transplantation (LT) remains unrevealed. Serial blood samples were collected to profile ctDNA mutational changes. Baseline ctDNA mutational profiles were compared with those of matched tumor tissues. Correlations between ctDNA status and recurrence rate (RR) and recurrence-free survival (RFS) were analyzed, respectively. Dynamic change of ctDNA was monitored to predict tumor recurrence. Baseline mutational profiles of ctDNA were highly concordant with those of tumor tissues (median, 89.85%; range 46.2-100%) in the 74 patients. Before LT, positive ctDNA status was associated with higher RR (31.7% vs 11.5%; p = 0.001) and shorter RFS than negative ctDNA status (17.8 vs 19.4months; p = 0.019). After LT, the percentage of ctDNA positivity decreased (17.6% vs 47.0%; p < 0.001) and patients with positive ctDNA status had higher RR (46.2% vs 21.3%; p < 0.001) and shorter RFS (17.2 vs 19.2months; p = 0.010). Serial ctDNA profiling demonstrated patients with decreased or constant negative ctDNA status had lower RR (33.3% vs 50.0%; p = 0.015) and favorable RFS (18.2 vs 15.0months, p = 0.003) than those with increased or constant positive ctDNA status. Serial ctDNA profiling predicted recurrence months ahead of imaging evidence and serum tumor biomarkers. ctDNA could effectively detect MRD and predict tumor recurrence in liver cancer patients undergone LT.