Post Living Donor Liver Transplant Research Articles

Gastroduodenal Ulcers in Liver Transplant Recipients under Immunosuppressive Therapy

Introduction: The proportion of gastroduodenal ulcers caused by drugs is increasing. However, the risk of gastroduodenal ulcer from drugs other than nonsteroidal anti-inflammatory drugs (NSAIDs) and low-dose aspirin is unclear. An association between immunosuppressive drugs and gastroduodenal ulcers has been suggested. We aimed to identify the immunosuppressive drugs and clinical characteristics associated with gastroduodenal ulcers in post-liver transplant patients. Methods: The study investigated 119 patients who underwent esophagogastroduodenoscopy after liver transplantation, and 2 patients were excluded. Clinical characteristics, medications, and endoscopic images were retrospectively reviewed. Results: Among 117 post-living donor liver transplant recipients, gastroduodenal ulcers were found in 10 (9.2%) patients. The ulcer group had endoscopic gastritis more frequently (40%) compared with the non-ulcer group (10%). Logistic regression analysis revealed gastritis, NSAID use, and mycophenolate mofetil were risk factors in the post-liver transplant patients. Among 103 patients not on NSAIDs, 8 (7.8%) had peptic ulcer. The most common ulcer site and ulcer shape were the gastric antrum and a circular shape, respectively. All patients in the ulcer group were taking mycophenolate mofetil, which was the only immunosuppressive drug that showed a significant difference between the two groups. Five out of 8 ulcer patients (63%) were taking gastric acid suppressants, and gastroduodenal ulcers in post-liver transplant recipients were suggested to be refractory. Conclusion: Patients treated with immunosuppressive drugs after liver transplantation can develop gastroduodenal ulcers, even with gastric acid suppressant medication. Mycophenolate mofetil may increase the risk of gastroduodenal ulcers compared with other immunosuppressive drugs.

Biomarkers for Living Donor Liver Transplants in Hepatocellular Carcinoma

Liver transplantation is one of the more definitive treatments for hepatocellular carcinoma (HCC). In the United States, liver transplantation has historically been focused on deceased donor organs, and tumor burden is used for risk-stratifying patients on the transplant waitlist. Living donor liver transplantation (LDLT) is gaining popularity in the United States and has long been practiced in Asian countries. To improve outcomes of overall survival and disease-free survival post-living donor liver transplantation, surrogates of tumor biology are now being regarded to be as important as tumor burden. This article reviews the different surrogates of tumor biology and discusses their role in the application of LDLT for advanced HCC.

Assessing anxiety pre- and post-living donor liver transplantation in the First Central Hospital

Assessing anxiety pre- and post-living donor liver transplantation in the First Central Hospital

Cholangioscopic classification of post-living donor liver transplantation biliary strictures can predict their natural history and response to therapy.

The study aimed to assess the morphology of post-living donor liver transplant (LDLT) anastomotic biliary strictures using cholangioscopy and assess the impact of morphology on its prognosis. A single centre, prospective, observational study was conducted at a tertiary care teaching hospital from August 2014 to July 2016. Single operator cholangioscopy (SOC) was used to assess post-LDLT anastomotic biliary strictures at presentation in 24 patients. Analysis included demographic and biochemical characteristics, time to stricture development, endoscopic procedural details, time to remodelling and development of recurrence on follow-up. Two distinct patterns of strictures were identified, type I with minimal inflammatory changes and type II with severe inflammatory changes. Guidewire cannulation was successful in 23 out of 24 (95.8%) patients. There was no significant difference between the two types of strictures based on aetiology of liver disease, CTP and MELD scores, time taken for the development or laboratory parameters at presentation. However, type II strictures required more sessions of dilatation (4 vs. 2; P=0.002), longer duration for resolution (282.5 vs. 201.5 days, P=0.095) and more number of stents. Addition of cholangioscopy tends to improve stricture cannulation rates at ERCP. It offers a useful classification of post-LDLT strictures with prognostic and therapeutic significance. Type II strictures tend to require more sessions of endotherapy than type I strictures over a longer duration for remodelling.

Surgical Site Infections in Post-Living Donor Liver Transplantation: Surveillance and Evaluation of Care Bundle Approach

Background and Aim: Although implantation of a care bundle approach is well established in intensive care units (ICUs), yet its impact on reducing surgical site infections (SSI) among post living-donor-liver transplantation (LDLT) patients has not been established. Our aim is to evaluate the impact of a care bundle in reducing SSI and to detect the pattern of antibiotic resistance in LDLT. Materials and Methods: This before and after comparative study was conducted at Elmanial specialized tertiary hospital, Cairo University over a period of 3 years (January 2016 - December 2018) including 57 LDLT patients. We introduced a care bundle comprised of a group of evidence-based practices implemented together. The study was divided into three phases. All bacterial identification and antibiotic sensitivity testing were done by a Vitek 2 compact system. Results: SSIs rates were reduced significantly by 30.4% from the pre-implementation to the post implementation phase (from 13/24, 54.2% to 5/21, 23.8%, OR 0.21, CI 95%: 1.137- 0.039). This reduction went hand in hand with increase in the hand hygiene compliance from 57.3 % to 78 %, then remained sustained with a median rate of 78% in the last 6 months. Klebsiella pneumoniae 11\25 (44% of SSIs), Acinetobacter baumannii 8\25 (32% of SSIs), Escherichia coli 5\25 (20%), Pseudomonas aeruginosa 5\25 (20%) and MRSA 4\25 (16%). With predominance of XDR phenotype 14/25 (56%), followed by ESBL of gram-negative bacteria 6/25 (24%), then MRSA 4/25 (16%). Conclusion: SSIs in LDLT mandates strict implementation of comprehensive evidence-based care bundles for better patent outcome.

Ascites post-living donor liver transplantation: Risk factors and outcome

Background and aimPersistent ascites post-liver transplantation is reported to be a rare event. This study aimed to determine the prevalence, risk factors, etiology and outcome of ascites post-living donor liver transplantation (LDLT). MethodsThis is a retrospective observational study on 347 recipients who underwent LDLT at our center from 2008 to 2018. We classify the ascites post-LDLT into either persistent (PA): present > four weeks post LT, or refractory (RA): new-onset ascites after the first-month post LT. ResultsThe prevalence of ascites post LDLT was 8.4% (n = 29), including PA, 4.9%, and RA, 3.45%. Idiopathic ascites (no specific cause) was the most common in the PA group, while vascular complications and graft failure were more common in the RA group. On regression analysis model, the presence of pre-LT PVT, small for size syndrome (SFSS) and vascular complications were the independent risk factors of PA (p value=0.017, 0.026, 0.011, respectively and Odds ratio (95% CI) = 4.25(1.290–13.97), 4.01(1.177–13.63) and 7.4(1.596–34.46), respectively. Pre-LT-HCV-related chronic liver disease, significant portal hypertension, donor overweight and vascular complications were the risk factors for the development of RA (p value= 0.04, 0.001, 0.031, <0.001, respectively and Odds ratio (95% CI) = 18.99 (1.1–315.14), 46.67 (4.51–483.08), 4.72 (1.15–19.31) & 67.23(6.38–708.72) respectively. Three- and five-year survival are not significantly reduced in patients who developed ascites post LDLT. ConclusionsAscites post-LDLT does not affect the 3- and 5-year survival rates. Idiopathic ascites pos-LDLT is common and has a good prognosis.

Nutritional intervention could improve long term outcome post LDLT in limited resources university hospital in Egypt

Introduction: liver transplantation (LT) is considered as salvage therapy for those with irreversible liver failure. Malnutrition is prevalent in transplanted patient’s pre and post transplantation. Objective: to analyze the nutritional status of patients post living donor liver transplantation (LDLT) by using different nutritional assessment tools with nutritional modification in order to improve the outcomes post liver transplantation. Materials and methods: Our prospective cohort study was conducted on 30 who underwent liver transplantation before the study, they were nutritionally assessed through different nutritional scores and anthropometric parameters with application of nutritional modification. Results: ALT and AST decreased significantly and normalized at 6 months with p-value .025, .036; respectively. HbA1c, fasting blood sugar and post prandial blood sugar levels decreased after 6 months. There was statistically significant improvement in lipid profile after 3 and 6 months with nutritional modification. There was significant improvement (p= 0.017) in metabolic syndrome. There is correlation between numbers of years from transplantation and appearance of metabolic syndrome Regarding dyslipidemia, there was significant improvement after 6 months (p&lt; 0.001).CAP study showed improvement (p= 0.014).

Treatments and outcomes of intra-operative portal vein thrombosis in living-donor liver transplantation due to biliary atresia

Pediatric living-donor liver transplantation (LDLT) has become one of the most effective therapies for pediatric end-stage liver diseases. We aim to investigate the risk factors for intra-operative portal vein thrombosis (PVT) and the short- and long-term outcomes in children post LDLT. This was a retrospective analysis from 584 cases of biliary atresia (BA) patients who had undergone LDLT from January 2014 to December 2019 at our hospital. Patients were divided into PVT and non-PVT groups according to the occurrence of PVT during LDLT. The median age of recipients at transplantation was 7.22 (quartiles, 6.03, 9.50) months, the incidence of intra-operative PVT was 5.31% (31/584). The independent risk factors for intra-operative PVT were the diameter of the recipient's PV not greater than 4mm and a higher ratio of graft-to-recipient PV diameter. The cumulative survival rates of grafts and recipients were 93.5% and 93.5% in the PVT group, and 94.9% and 95.3% in the non-PVT group, respectively, without significant difference. The recovery of graft function was similar in recipients with or without interposed graft vessel (IGV). However, the incidence of PV stenosis was higher in recipients with IGV after LDLT. Intra-operative PVT is a common complication in pediatric LDLT, but an excellent prognosis can be achieved by appropriate and individualized surgical treatment. We noted that intra-operative PVT did not affect the survival rates of grafts and recipients, but there was a higher incidence of PV complications after LDLT. Ⅲ.

Resuming post living donor liver transplantation in the COVID-19 pandemic: real-life experience, single-center experience

BackgroundSolid organ transplantation (SOT) service has been disrupted during the current coronavirus disease 2019 (COVID-19) pandemic, which deferred the service in most centers worldwide. As the pandemic persists, there will be an urgency to identify the best and safest practices for resuming activities as areas re-open. Resuming activity is a difficult issue, in particular, the decision of reopening after a period of slowing down or complete cessation of activities.ObjectivesTo share our experience in resuming living donor liver transplantation (LDLT) in the context of the COVID-19 pandemic in the Liver Transplantation Unit of El-Manial Specialized Hospital, Cairo University, Egypt, and to review the obstacles that we have faced.Material and methodsThis study is a single-center study. We resumed LDLT by the 26th of August 2020 after a period of closure from the 1st of March 2020. We have taken a lot of steps in order to prevent COVID-19 transmission among transplant patients and healthcare workers (HCWs).ResultsIn our study, we reported three LDLT recipients, once resuming the transplantation till now. All our recipients and donors tested negative for SARS-CoV-2 by nasopharyngeal RT-PCR a day before the transplantation. Unfortunately, one of them developed COVID-19 infection. We managed rapidly to isolate him in a single room, restricting one team of HCWs to deal with him with strict personal protective measures. Finally, the patient improved and was discharged in a good condition. The second patient ran a smooth course apart from FK neurotoxicity which improved with proper management. The third patient experienced a sharp rise in bilirubin and transaminases on day 14 that was attributed to drug toxicity vs. rejection and managed by discontinuing the offending drugs and pulse steroids. In addition, one of our head nurses tested positive for SARS-CoV-2 that was manageable with self-isolation.ConclusionCareful patient, donor, personnel screening is mandatory. Adequate supply of personal protective equipments, effective infection control policies, and appropriate administrative modifications are needed for a safe return of LDLT practice.

Optimal drainage of anastomosis stricture after living donor liver transplantation.

Endoscopic biliary stenting (EBS) with a fully covered, self-expandable metallic stent (FC-SEMS) and plastic stent (PS) is safe and efficient for biliary anastomotic strictures (ASs) after a deceased donor liver transplantation. Limited studies have investigated the use of FC-SEMSs for biliary strictures post-living donor liver transplantation (LDLT). We compared the resolution rate of biliary ASs post-LDLT and the 12-month recurrence rates post-stent removal between EBS with an FC-SEMS, PS, and percutaneous transhepatic biliary drainage (PTBD). Patients with biliary ASs after an LDLT (mean age: 57.3years, 76.1% men) hospitalized between 2014 and 2017 were enrolled. Endoscopic retrograde cholangiopancreatography (ERCP) was repeated every 3-4months. Patients were followed-up for at least 1-year post-stent removal. Of the 75 patients enrolled, 16, 20, and 39 underwent EBS with an FC-SEMS, PS, and PTBD, respectively. Median follow-up period was 39.2months. Fewer ERCP procedures were needed in the FC-SEMS group than in the PS group (median, 2 vs. 3; P = 0.20). Median stent indwelling periods were 4.7, 9.3, and 5.4months in the FC-SEMS, PS, and PTBD groups, respectively (P = 0.006). The functional resolution rate was lower in the PS group (16/20) than in the FC-SEMS (16/16) or PTBD (39/39) group (P = 0.005). The radiologic resolution rate was higher in the FC-SEMS group (16/16) than in the PS group (14/20) (P = 0.07). The 12-month recurrence rates showed no significant differences (FC-SEMS, 4/16; PS, 3/16; PTBD, 6/39; P = 0.66). The rates of complications during treatment differed significantly between the groups (P = 0.04). Stent migration occurred in 1 (6.3%) and 5 (25.0%) patients in the FC-SEMS and PS groups, respectively (P = 0.59). EBS with an FC-SEMS is comparable with EBS with a PS or PTBD in terms of biliary stricture resolution and 12-month recurrence rates. The use of FC-SEMSs is potentially effective and safe for biliary AS resolution after LDLT.

Study of Early Postoperative Doppler Changes Post Living Donor Liver Transplantation and Their Impact on Early Mortality and Small-for-Size Syndrome: A Retrospective Study.

BackgroundAdult-to-adult living donor liver transplantation (LDLT) has been a common practice because of the deficiency of deceased donor liver transplants. Liver hemodynamics differ substantially between cases with end-stage liver disease undergoing LT because of various degrees of hepatic affection, nature of implicated causative factors, and pathogenesis of the hepatic disorder. The present retrospective study primarily aimed to study the early postoperative doppler changes after adult to adult LDLT. The secondary aim was to assess these hemodynamics’ impact on early in-hospital deaths and small for size syndrome (SFSS) development.MethodsThis retrospective work was done on 123 adult cases with end-stage liver disease for whom adult LDLT was performed after exclusion of pediatric patients and those with vascular complications.ResultsPostoperative (PO) mean portal vein velocity (PVV), hepatic artery (HA) peak systolic velocity (PSV), and HA resistivity index (RI) declined gradually but significantly post adult LDLT. Phasicity of hepatic veins changes towards the triphasic waveform gradually in the early PO period. There is a notable negative relationship between PO mean PVV with PO mean HA PSV. Higher PO HA RI affected PO mortality, while higher PO PVV and lower HA PSV increased the incidence of SFSS.ConclusionEarly postoperative Doppler changes post-LDLT (PO PVV, HA RI, and HA PSV) can affect both mortality and SFSS development.

De novo hepatocellular carcinoma in living donor liver grafts: A Japanese multicenter experience.

Direct-acting antivirals for hepatitis C virus have reduced the decompensation risk. Immunosuppressants for transplantation raise the risk of occurrence of de novo malignancies. We assessed the probabilities of and risk factors for de novo hepatocellular carcinoma (HCC) development post-living donor liver transplantation (LDLT). We retrospectively evaluated the data of developed HCC in a graft including metastatic HCC post-LDLT from 2779 adult cases collected from nine major liver transplantation centers in Japan. Of 2779 LDLT adult recipients, 34 (1.2%) developed HCCs in their grafts. Of 34, five HCCs appeared to be de novo because of a longer period to tumor detection (9.7 [6.4-15.4] years) and no HCC within the native liver of the two recipients. The donor origin of three of five de novo HCCs was confirmed using microsatellite analysis in resected tissue. Primary disease of all five was hepatitis C virus-related cirrhosis, of which two were treated with direct-acting antivirals. Four of five developed HCC de novo in the hepatitis B core antibody-positive grafts. De novo HCCs had favorable prognosis; four of five were cured with complete remission. However, recurrent HCC (n = 29) in the graft had a poorer outcome, especially in patients with neutrophil to lymphocyte ratio scores above 4 (median survival time, 262 [19-463] days). Analysis of the database from major liver transplantation institutes in Japan revealed that de novo HCCs determined by microsatellite analysis were rarely detected, but the majority were successfully treated. LDLT recipients with higher risks of de novo HCC, including those with hepatitis B core antibody-positive grafts, should be carefully followed by surveillance of the liver graft.

Post-transplant indolent T cell lymphoproliferative disorder in living donor liver transplantation: a case report

BackgroundPost-transplant lymphoproliferative disorder (PTLD) of T cell type has been rarely reported. Accurate diagnosis of this life-threatening rare form of PTLD is important for the treatment strategy.Case presentationA 7-year-old boy had severe diarrhea and weight loss progressively at 7 years post-living donor liver transplantation (LDLT) for biliary atresia. Endoscopy in the gastrointestinal (GI) tract revealed multiple erosions and ulcer lesions with prominent intraepithelial lymphocytosis in the duodenum and terminal ileum. Immunohistochemical examination demonstrated that these accumulated lymphocytes mainly comprised small- to medium-sized T cells expressing CD3, CD4, CD5, CD7, and CD103, but lacking CD8, CD56, and Epstein-Barr virus-encoded small RNAs. In addition, T cell receptor β gene rearrangement was detected by polymerase chain reaction analysis. Comprehensively, the lesions were best interpreted as post-transplant indolent T cell lymphoproliferative disorder (LPD) of the intestine. Clinical remission was achieved by reducing the immunosuppressant.ConclusionA rarely reported indolent type of T cell LPD in post-LDLT was diagnosed by direct inspection and histological investigation. Although the histological classification and therapeutic strategy for post-transplant indolent T cell LPD have not been established, reducing immunosuppression allowed complete remission in our case. To prevent the incidence of PTLD and de novo malignancy, developing a methodology to set a proper dose of immunosuppressant is required.

Unilateral Versus Bilateral Biliary Drainage for Post-Transplant Anastomotic Stricture

Living donor liver transplantation is the most common type of liver transplantation in Asia. Post-transplant biliary stricture is frequent in living donor liver transplantation, and endoscopic management is considered to be the treatment of choice. However, endoscopic management is still challenging in patients who undergo right lobe living donor liver transplantation because of the anatomical alteration. In this article, we reviewed the recently updated results for proper endoscopic biliary drainage in post-living donor liver transplantation anatomical biliary stricture and compared unilateral and bilateral drainage.

Endoscopic stent placement above the sphincter of Oddi for biliary strictures after living donor liver transplantation

BackgroundEndoscopic balloon dilation and/or plastic stent placement has been a standard method for treating biliary strictures complicated post living donor liver transplantation (LDLT). The strictures may be refractory to endoscopic treatment and require long-term stent placement. However, consensus on the optimal period of the stent indwelling and usefulness of the inside stent does not exist.MethodsWe evaluated the long-term efficacy of stent treatment in patients with biliary stricture post LDLT. In addition, we compared the stent patency between inside stent and conventional outside stent.ResultsA total of 98 ERC sessions (median 6: range 1–14) performed on 16 patients receiving endoscopic treatment for biliary strictures post LDLT with duct-to-duct biliary reconstruction were analyzed. Biliary strictures successfully treated in 14 patients (88%) included 7 patients (44%) showing improvement of biliary strictures with repeated endoscopic stent placement. Stent replacement was carried out every 6 to 12 months for the remainder 7 patients (44%). Biliary stents were placed in 87 sessions (77 inside sessions and 10 outside sessions). Stent migration occurred 13 times (16%) and none of the inside stent sessions and the outside stent sessions, respectively. Median patency of inside stent and outside stent were 222 days (range; 8–1736) and 99 days (range; 7–356), respectively. The stent occlusion was significantly less in inside stent than in outside stent (p < 0.001). Stone formation was observed in 14 (18%) of the inside stent and 3 (30%) of the outside stent. Biliary stones were small and successfully removed endoscopically.ConclusionsThe endoscopic treatment using inside stent was useful in the management of biliary strictures after LDLT.

Salvage PTBD in post living donor liver transplant patients with biliary complications-a single centre retrospective study.

To study the outcome of salvage percutaneous transhepatic biliary drainage (PTBD) in complex and technically challenging post-liver transplant (LT) biliary complications and analyse the reason for failure of endoscopic retrograde cholangiopancreatography (ERCP). Hospital data were searched for all LT patients with biliary complications requiring salvage PTBD (upon failure of ERCP) from January 2010 to May 2017. Patients who underwent primary PTBD were excluded. Patients clinical and biochemical parameters were analysed for clinical, biochemical and imaging response, stent-free survival and the reason for ERCP failure. Salvage PTBD was performed in 32 patients with post-LT biliary stricture/bile leak presenting with deranged liver function in 12 (37.5%), cholangitis in 12 (37.5%) and cholangitis with cholangitic abscess in remaining 8 (25%) patients. Of 32 patients, 20 (62.5%) already had plastic biliary stent placed by ERCP, while in remaining (n = 12, 37.5%) a wire could not be negotiated across stricture by ERCP. These patients were found to have long/tortuous stricture (n = 18, 56.3%) and multiple duct disconnection at anastomosis (n = 14, 43.7%). Immediate as well as sustained (persisting for a year or more) clinical and biochemical improvement was seen in 26 (81.3%) patients, while failure of resolution of sepsis and death occurred in remaining 6 (18.8%). Salvage PTBD is an effective treatment in difficult-to-treat post-LT biliary strictures with deranged liver functions with or without cholangitis/cholangitic abscess. It can reduce graft loss with improved clinical outcome. Post-LT ductal anatomy at anastomosis is important to decide the appropriate approach (ERCP/PTBD). (1). PTBD as a salvage procedure in difficult anatomy or upon failure of ERCP-based intervention is effective and a good alternative strategy. (2). Postoperative surgical anatomy (type & length of stricture, number of ductanastomosis, location and graft-recipient duct alignment) is the key factor indeciding the appropriate therapeutic procedure.

Ascariasis, the uncommon cause of bile leak, postliving donor liver transplant - A case report

Ascaris lumbricoides is one of the most common parasitic infections in developing countries. History of previous biliary tract surgery risks migration of these worms to the biliary tree. Usually, 10% of patients with living donor liver transplants have biliary complications including bile leak and strictures. Here, we present an unusual case of ascariasis being a cause of biliary obstruction and bile leak in the immediate postoperative period of liver transplant.

Impact of MRCP findings on the management of biliary strictures in post-living donor liver transplant

BackgroundBiliary strictures are a well-recognized complication of liver transplant. Magnetic resonance cholangiopancreatography (MRCP) is the imaging modality of choice for the diagnosis of post-liver transplant biliary strictures because of its high rate of diagnostic accuracy and limited risk of complications. The purpose of this study was to assess the potential role of MRCP in the diagnosis and management of biliary strictures following living donor liver transplantation (LDLT). Data were retrospectively collected from recipients who had developed biliary stricture following living donor liver transplantation. Informed consent was signed by the patients. All patients were subjected to a proper assessment of history and clinical examination as well as routine laboratory investigations. MRCP was performed to diagnose biliary strictures and to follow cases after management.ResultsAnalysis involved 32 liver transplant recipients as 28 had anastomotic biliary stricture, 2 had intrahepatic biliary stricture, and 2 had both types (mixed biliary stricture). Management was done in 20 patients by endoscopic therapy and 4 patients by surgical therapy, while 8 patients were exposed only for long-term follow-up. Satisfactory improvement of the biliary stricture was noted in about 16 with endoscopic therapy and 2 with surgical therapy.ConclusionMRCP is a reliable non-invasive imaging modality for evaluating the biliary stricture following LDLT providing important information on its management.

Non-Invasive Assessment of Graft Fibrosis After Living Donor Liver Transplantation: Is There Still a Role for Liver Biopsy?

Non-invasive methods have evolved as a surrogate for liver biopsy such as indirect markers (aspartate transaminase to platelet ratio index, fibro-α score), transient elastography (TE), and magnetic resonance elastography (MRE).The aim of this study is to prospectively compare the value of MRE, TE, and indirect markers in detecting and staging allograft fibrosis compared to liver biopsies in patients who have undergone living donor liver transplantation for complications related to hepatitis C virus.A total of 31 living donor liver transplantation recipients with hepatitis C virus recurrence underwent a liver biopsy, TE, and MRE within 3 months of a liver biopsy. Fibrosis was assessed according to the biopsy and staged according to Metavir criteria.There was a significant correlation between both MRE and fibro-α scores, as well as histologic classification by liver biopsy (P = .02, .002). The diagnostic accuracy of MRE and fibro-α scores in diagnosing significant fibrosis (F ≥ 3) was measured as the area under the curve (.708 and .833, respectively). Both methods showed good diagnostic performance. TE and aspartate transaminase to platelet ratio index were insignificantly correlated with the degree of fibrosis in liver biopsy (P value of .134, .535). At a cutoff value of 5.5 kPa, MRE predicted graft fibrosis (Metavir stage ≥ 3) with 71.43% sensitivity, 75% specificity, 45.5% positive predictive value, and 90% negative predictive value; at a cutoff value > 1.47, fibro-α scores predicted significant graft fibrosis (Metavir stage ≥ 3) with 85.7% sensitivity and 70.83% specificity, with a positive predictive value of 46.2% and a negative predictive value of 94.4%. These data suggest that non-invasive methods could be considered a reliable tool in assessing significant graft fibrosis post-living donor liver transplantation.

P4.56: Muscle and adipose measurement of pre and post-surgical intestinal transplant patients using computed tomography to compare malnutrition diagnosis using nutrition focused physical exam

Introduction: Sarcopenia has been defined as a low appendicular skeletal muscle mass (kg/m2) two standard deviations below the mean of a young healthy reference group (Baumgartner 1998) coupled with a concomitant loss of muscle function, or severe muscle depletion. Studies have shown that sarcopenic patients undergoing surgical resection diagnosed by computed tomography (CT) prior to surgery were at increased risk for perioperative infections, increased length of stay (LOS) and higher mortality (Moissy et al 2013, Weijs 2014). Sarcopenic obesity measured by CT imaging has been correlated with poorer outcomes in post living donor liver transplantation (Itoh S, 2016). In our institution, highly trained and experienced registered dietitians (RDs) assess muscle loss as part of the nutrition focused physical exam (NFPE) using the new guidelines to diagnose malnutrition set by the Academy of Nutrition and Dietetics and the American Society of Parenteral and Enteral Nutrition (White 2012). This practice, however, has yet to be validated. CT scans are an objective measurement of assessing skeletal muscle mass, and abdominal wall and visceral adipose (Gomez-Perez 2016), and may be useful in determining skeletal muscle loss. Methods: Our team studied the correlation between malnutrition diagnosis via NFPE and muscle and fat mass on CT scans before and after intestinal transplantation. We also looked at the correlation of CT measurements with predicting post-operative morbidity and mortality. Results: A total of 42 subjects were included in the study consisting of 31% male and 69% female patients. Sixty percent of subjects did not have any degree of malnutrition during the pre-transplant NFPE, while 40% had moderate to severe protein calorie malnutrition. We found a significant correlation between patients diagnosed with malnutrition and those without malnutrition in subcutaneous fat CT measurements during pre-transplant evaluation (p=0.037). We also found a significant correlation with LOS (p=0.005) and mortality (p=0.006) with patients who received multivisceral transplants versus all other types of transplant (isolated intestine, modified multivisceral, intestine and pancreas). Conclusion: This study is the first of its kind to analyze malnutrition in the intestinal transplant population. Based on these results, it may be feasible to analyze CT measurements to assess recent patient nutriture to help identify patients with malnutrition prior to transplantation.