Presence Of Portal Vein Thrombosis Research Articles

The potential diagnostic value of serum pentraxin-3 in hepatocellular carcinoma in Egyptian patients

Background and aimHepatocellular carcinoma (HCC) is considered one of the most common cancers in the world and one of the principal causes of cancer-linked deaths. Therefore, identification of new biomarkers for diagnosis, especially early diagnosis of HCC, is very important. Pentraxin 3 (PTX3) is possibly involved in cancer development, and as regard to liver diseases, plasma PTX3 was implicated to be associated with HCC occurrence. Therefore, this study will determine the serum PTX3 levels in patients with cirrhosis and HCC and to assess the potential diagnostic value in HCC in Egyptian patients.ResultsPentraxin 3 was significantly higher in HCC patients than in cirrhotic patients (p < 0.001); also, serum PTX3 was significantly correlated with number, size of focal lesions, the presence of portal vein thrombosis, and BCLC staging (p < 0.001).ConclusionThe significant increased levels of serum pentraxin 3 in HCC may support its use as an early marker for HCC, either alone or in combination with serum alpha-fetoprotein (AFP), allowing early diagnosis and prompt intervention.

Evaluation of 4D Flow MRI-Derived Relative Residence Time as a Marker for Cirrhosis Associated Portal Vein Thrombosis.

Portal vein thrombosis (PVT) is thought to arise from stagnant blood flow, yet conclusive evidence is lacking. Relative residence time (RRT) assessed using 4D Flow MRI may offer insight into portal flow stagnation. To explore the relationship between RRT values and the presence of PVT in cirrhotic participants. Prospective. Forty-eight participants with liver cirrhosis (27 males, median age 67 years [IQR: 57-73]) and 20 healthy control participants (12 males, median age 45 years [IQR: 40-54]). 3 T/4D Flow MRI. Laboratory (liver and kidney function test results and platelet count) and clinical data (presence of tumors and other imaging findings), and portal hemodynamics derived from 4D Flow MRI (spatiotemporally averaged RRT [RRT-mean], flow velocity, and flow rate) were analyzed. We used multivariable logistic regression, adjusted by selected covariates through the Lasso method, to explore whether RRT-mean is an independent risk factor for PVT. The area under the ROC curve (AUC) was also calculated to assess the model's discriminative ability. P < 0.05 indicated statistical significance. The liver cirrhosis group consisted of 16 participants with PVT and 32 without PVT. Higher RRT-mean values (odds ratio [OR] 11.4 [95% CI: 2.19, 118]) and lower platelet count (OR 0.98 per 1000 μL [95% CI: 0.96, 0.99]) were independent risk factors for PVT. The incorporation of RRT-mean (AUC, 0.77) alongside platelet count (AUC, 0.75) resulted in an AUC of 0.84. When including healthy control participants, RRT-mean had an adjusted OR of 12.4 and the AUC of the combined model (RRT-mean and platelet count) was 0.90. Prolonged RRT values and low platelet count were significantly associated with the presence of PVT in cirrhotic participants. RRT values derived from 4D Flow MRI may have potential clinical relevance in the management of PVT. 2 TECHNICAL EFFICACY: Stage 2.

Portal vein thrombosis in patients with liver cirrhosis

Background/Aim. Portal vein thrombosis (PVT) in patients with liver cirrhosis (LC) has a prevalence of 0.6- 26%. It is most commonly discovered incidentally as part of the evaluation of LC or in the context of acute decompensation of LC due to portal hypertension. The aim of the study was to determine the prevalence of PVT in patients with LC in relation to the severity of the disease and individual elements of portal hypertension. Methods. A total of 326 patients treated for LC decompensation were included in a retrospective study. Standard laboratory analyses, abdominal ultrasonography and/or computed tomography, and esophagogastroduodenoscopy were performed. Results. The diameter of the portal vein (PV) differed between patients without esophageal varices (12.2 mm) and those with large varices (13.6 mm), p = 0.026. PVT was identified in 6.1% of patients with LC. The patients were classified according to the Child-Pugh scoring system, which has the A, B, and C categories used to assess the severity of liver disease. PVT was present in 3.0% of patients in class C and 12.0% in class B, while none of the patients in class A had PVT (p = 0.005). PVT was present in 4.4% of patients with small varices and 16.7% with large varices (p &lt; 0.001). There was no difference in the presence of PVT between the groups of patients with and without variceal bleeding nor between groups with different degrees of ascites. A fatal outcome occurred in 29.4% of patients, but there was no difference between patients with and without PVT. Conclusion. PVT is present in more advanced stages of LC and predominantly in patients with large esophageal varices. There was no higher prevalence of PVT observed with the occurrence of variceal bleeding or with the death outcome in patients with LC.

Cardiovascular adverse events in patients with hepatocellular carcinoma receiving vascular endothelial growth factor inhibitors.

Vascular endothelial growth factor inhibitors, including tyrosine kinase inhibitors (TKIs) and anti-angiogenics, are first-line therapies for advanced and metastatic hepatocellular carcinoma. Although TKIs have a greater potential for off-target adverse effects compared with bevacizumab (anti-angiogenics), a direct comparison of the risk of cardiovascular adverse events between these two types of therapies has not been performed. To compare the incidence of and characterize cardiovascular adverse events in patients with hepatocellular carcinoma receiving TKIs versus bevacizumab. This cohort study included adult patients with hepatocellular carcinoma who received first-line TKIs (sorafenib or lenvatinib) or bevacizumab at two academic medical centers and one community cancer center from September 2018 to August 2021. The primary outcome was risk of cardiovascular adverse events. Major secondary outcomes included the incidence of individual types of cardiovascular adverse events and risk factors associated with major adverse cardiovascular events (MACE). The study included 221 patients (159 TKI patients; 62 bevacizumab patients). At a median follow-up of 5 months, the probability of cardiovascular adverse events was not significantly different between the two groups (hazard ratio [HR]: 0.85; 95% confidence interval [95% CI]: 0.58-1.24; p = 0.390). The cumulative incidence of cardiovascular events was highest in patients receiving lenvatinib (sub-distribution hazard ratio [SHR]: 1.53; 95% CI: 1.02-2.30) compared with those receiving sorafenib (reference) or bevacizumab (SHR: 1.05; 95% CI: 0.68-1.64) after adjustment for comorbidities, liver transplant status, and presence of portal vein thrombosis at baseline. Cardiovascular adverse events were observed in 151 (68%) patients, and MACE were observed in 27 (12%) patients. Risk factors associated with MACE were hypertension (SHR: 3.5; 95% CI: 0.9087-15.83; p = 0.086), prior history of MACE (SHR: 2.01; 95% CI: 0.83-4.87; p = 0.124), and tobacco use (SHR: 2.85; 95% CI: 0.90-8.97; p = 0.074). Cardiovascular risk was not significantly different between TKIs and bevacizumab. Lenvatinib appears to have the highest risk of cardiovascular adverse events among these first-line VEGF inhibitors.

Role of Splenic Irradiation Prior to Transplant for Myelofibrosis: A Global Collaboration

JAK inhibitors and novel agents have shown promising reduction of spleen size in newly diagnosed myelofibrosis. However, not all patients will respond or they eventually progress at some point. Despite hematopoietic cell transplantation (HCT) being the only curative treatment option to date, splenomegaly prior to HCT remains a particular challenge. On the other hand, numbers of patients eligible for HCT continue to increase worldwide, and thus management of splenomegaly becomes more and more relevant. One approach to reduce spleen size prior to HCT could be splenic irradiation. However, evidence on its role remains scarce. We took advantage of a global collaboration between European, US, and Latin American centers to investigate the role of splenic irradiation as part of the HCT platform for patients with myelofibrosis. Radiation therapy had to be given within 3 months prior to or be part of conditioning therapy for HSCT. Detailed information on irradiation as well as post-HCT safety profiles was collected in addition to usual patient-, disease-, and transplant-related variables. This global collaborative study included 52 patients, of whom 71% had primary myelofibrosis, 17% post polycythemia vera and 12% post essential thrombocythemia myelofibrosis. Median age at HCT was 60 years (range, 32-76). Risk category according to DIPSS prior to irradiation was intermediate-1 in 20%, intermediate-2 in 52%, and high in 28%. Driver mutation status was JAK2 in 44%, CALR in 40%, MPL in 4%, and triple negative in 12%. Four patients had portal vein thrombosis before irradiation. Ruxolitinib before irradiation was received by 76% and 4% received fedratinib. Reduced intensity conditioning HCT was received by 73% and 85% were matched related or matched unrelated donor transplants. Median time from irradiation to HCT was 2 weeks (range, 0.9-12 weeks) and median spleen size prior to irradiation was 23 cm (range, 14-35). Spleen size was measured by ultrasound in 70%, CT scan in 20%, and physical examination in 10%. Median total irradiation dose was 7 Gy (range, 3-12), fractionated in a median of 5 administrations (range, 2-12). Splenic irradiation resulted in a significant spleen reduction prior to HCT but was also associated with significant reduction in platelet and leukocyte counts ( Table). Spleen size did not correlate with blood counts prior or after irradiation. Higher platelet count prior to irradiation correlated with higher counts after irradiation (r=0.83; P&amp;lt;0.001). There was no correlation between irradiation dose and post-irradiation hematological toxicities. Only 1 patient had non-hematological adverse events (tumor lysis syndrome). Neutrophil engraftment was achieved by 90% within a median of 18 days after HCT and platelet engraftment was achieved by 81% within a median of 38 days. Median follow-up of the total cohort was 2.7 years and 3-year overall survival was 66% (95% CI, 52-80%; Figure). Non-relapse mortality was 27% (95% CI, 15-39%) and cumulative incidence of relapse was 11% (95% CI, 2-20%; Figure). Incidence of acute GVHD grade II-IV and chronic GVHD was 25% and 38%, respectively. Increased spleen size (as continuous variable) prior to irradiation was associated with worse outcome (P=0.05), showing 3-year survival of 73% for spleen ≤25cm vs 42% for &amp;gt;25cm, and non-relapse mortality of 58% vs 14%, respectively (P=0.02). No effect of spleen size after irradiation on outcomes was observed. All 4 patients with portal vein thrombosis died (2-year survival 25%). A multivariable model showed that larger spleen size before irradiation, lower hemoglobin levels, CALR/MPL-unmuated driver mutation genotype, and presence of portal vein thrombosis were significantly associated with worse survival ( Table). This first international and largest study to date on splenic irradiation as part of the HCT algorithm for patients with myelofibrosis and splenomegaly showed a significant impact of spleen size on overall survival and non-relapse mortality, while relapse rates were low. In addition, lower hemoglobin levels and presence of portal vein thrombosis at time of irradiation predicted worse outcomes.

Objective Tumor Response of Hepatocellular Carcinoma Obtained by Transarterial Radioembolization with Iodine-131-Lipiodol Versus Transarterial Chemoembolization for Patients with and without Portal Venous Thrombosis: A Controlled Interventional Trial

Hepatocellular carcinoma (HCC) treatment often requires transarterial chemoembolization (TACE). However, TACE efficacy is controversial in the presence of portal vein thrombosis (PVT). Although transarterial radioembolization (TARE) benefit was previously documented in PVT, neither the objective tumor response (OTR) after TARE with Iodine-131-lipiodol (131I-lipiodol) nor the PVT effect on the results of locoregional therapies was accurately measured in prospective clinical trials. The aim of this study was to compare OTR and survival obtained by TARE with 131I-lipiodol versus TACE in patients with cirrhosis and HCC, as well as between those with and without PVT. 33 patients were included, from whom 38 tumors were assessed. OTR was quantified by a special algorithm to measure hypervascular HCC tissue. 19 tumors received each therapy. Nine subjects (27%) had PVT, most of them in the TARE group (p=0.026). Mean OTR according to the tumor volumes was 24.2%±56% after TARE and 32.8%±48.9% after TACE, with no difference between the treatments (p=0.616). Similar values were also observed between those with and without PVT (p=0.704). Mean survival was 340 days and did not differ between the two treatments (p=0.596), but was 194 days in PVT cases (p=0.007). This is the first study in which OTR obtained by TARE with 131I-lipiodol is accurately measured. Additionally, PVT impact on survival after TARE and TACE was precisely documented. Although the TARE group had more PVT subjects (who had shorter survival), TARE and TACE achieved similar OTR and OS rates.

Abstract No. 580 Correlation of Spleen Volume and Portal Pressure in Patients Undergoing TIPS

Spleen volume has been used as a predictor of adverse events in a variety of settings including assessing risk of liver failure following hepatectomy and predicting hepatocellular carcinoma (HCC) recurrence after treatment. The purpose of this study was to determine the relationship between spleen volume and portal pressure in cirrhotic patients undergoing TIPS. A review of all patients who had undergone TIPS between January 2020 and April 2022 was performed. A total of 59 patients were identified. 19 patients were excluded due to presence of portal vein thrombosis and 40 patients remained for this study. Patients were stratified based on whether they presented for emergent TIPS due to active variceal bleeding or elective TIPS for nonemergent indications. Spleen volumes were determined by semi-automated segmentation on the most recent periprocedural imaging and was divided by body surface area (BSA). Patient characteristics, MELD scores, portal pressure were evaluated. Paired t-tests were used to compare the two groups. Amongst 40 patients who underwent TIPS, 20 presented emergently and 20 presented non-emergently. MELD scores and portal pressures were significantly higher in patients presenting for emergent TIPS (P< .05), with an average MELD of 24 in the emergent TIPS group compared with 11 in the elective TIPS group and an average portal pressure of 24 in the emergent TIPS group compared with 17 in the elective TIPS group. Assessment of spleen volumes demonstrated no difference between the two groups (P = 0.25). A weak correlation of 0.38 was noted between spleen size and portal pressure (95% CI –0.08-0.70). There was no statistical difference in splenic volume between patients presenting for emergent TIPS compared with patients undergoing elective TIPS and a weak correlation between splenic volume and portal pressure. Given these findings, splenic volume may have limited prognostic value in this population. This needs to be validated in a larger population.

Malignant Portal Vein Thrombosis with No Obvious Liver Parenchymal Mass on Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography.

The presence of portal vein thrombosis (PVTT) in hepatocellular carcinoma (HCC) is associated with adverse prognosis with dismal survival. Malignant portal vein thrombosis usually develops as a contiguous extension of the liver tumour into portal vein or its branches. Here we present an interesting FDG PET-CT image of a patient with chronic hepatitis B infection having isolated malignant portal vein thrombosis without any obvious liver mass.

Clinical outcomes with atezolizumab plus bevacizumab or lenvatinib in patients with hepatocellular carcinoma: a multicenter real-world study.

The purpose of this study is to compare response rates of lenvatinib and atezolizumab plus bevacizumab, in first-line real-world setting. Overall cohort included Western and Eastern hepatocellular carcinoma (HCC) patient populations from 46 centres in 4 countries (Italy, Germany, Japan, and Republic of Korea). 1312 patients were treated with lenvatinib, and 823 patients were treated with atezolizumab plus bevacizumab. Objective response rate (ORR) was 38.6% for patients receiving lenvatinib, and 27.3% for patients receiving atezolizumab plus bevacizumab (p < 0.01; odds ratio 0.60). For patients who achieved complete response (CR), overall survival (OS) was not reached in both arms, but the result from univariate Cox regression model showed 62% reduction of death risk for patients treated with atezolizumab plus bevacizumab (p = 0.05). In all multivariate analyses, treatment arm was not found to be an independent factor conditioning OS. Comparing ORR achieved in the two arms, there was a statistically significant difference in favor of lenvatinib compared to atezolizumab plus bevacizumab in all subgroups except for Eastern patients, Child-Pugh B patients, presence of portal vein thrombosis, α-feto-protein ≥ 400ng/mL, presence of extrahepatic disease, albumin-bilirubin (ALBI) grade 2, and no previous locoregional procedures. Lenvatinib achieves higher ORR in all patient subgroups. Patients who achieve CR with atezolizumab plus bevacizumab can achieve OS so far never recorded in HCC patients. This study did not highlight any factors that could identify patient subgroups capable of obtaining CR.

Factors impacting survival after transarterial radioembolization in patients with hepatocellular carcinoma: Results from the prospective CIRT study

Transarterial radioembolization (TARE) with Yttrium-90 resin microspheres is an established treatment option for patients with hepatocellular carcinoma (HCC). However, optimising treatment application and patient selection remains challenging. We report here on the effectiveness, safety and prognostic factors, including dosing methods, associated with TARE for HCC in the prospective observational CIRT study. We analysed 422 patients with HCC enrolled between Jan 2015 and Dec 2017, with follow-up visits every 3 months for up to 24 months after first TARE. Patient characteristics and treatment-related data were collected at baseline; adverse events and time-to-event data (overall survival [OS], progression-free survival [PFS] and hepatic PFS) were collected at every 3-month follow-up visit. We used the multivariable Cox proportional hazard model and propensity score matching to identify independent prognostic factors for effectiveness outcomes. The median OS was 16.5 months, the median PFS was 6.1 months, and the median hepatic PFS was 6.7 months. Partition model dosimetry resulted in improved OS compared to body surface area calculations on multivariable analysis (hazard ratio 0.65; 95% CI 0.46-0.92; p= 0.0144), which was confirmed in the exact matching propensity score analysis (hazard ratio 0.56; 95% CI 0.35-0.89; p= 0.0136). Other independent prognostic factors for OS were ECOG-performance status >0 (p= 0.0018), presence of ascites (p= 0.0152), right-sided tumours (p= 0.0002), the presence of portal vein thrombosis (p= 0.0378) and main portal vein thrombosis (p= 0.0028), ALBI grade 2 (p= 0.0043) and 3 (p= 0.0014). Adverse events were recorded in 36.7% of patients, with 9.7% of patients experiencing grade 3 or higher adverse events. This large prospective observational dataset shows that TARE is an effective and safe treatment in patients with HCC. Using partition model dosimetry was associated with a significant improvement in survival outcomes. Transarterial radioembolization (TARE) is a form of localised radiation therapy and is a potential treatment option for primary liver cancer. We observed how TARE was used in real-life clinical practice in various European countries and if any factors predict how well the treatment performs. We found that when a more complex but personalised method to calculate the applied radiation activity was used, the patient responded better than when a more generic method was used. Furthermore, we identified that general patient health, ascites and liver function can predict outcomes after TARE. NCT02305459.

DCD Liver Grafts Can Safely Be Used for Recipients With Grade I-II Portal Vein Thrombosis: A Multicenter Analysis.

Background.With donation after circulatory death (DCD) liver transplantation (LT), the goal of the recipient implantation procedure is to minimize surgical complexity to avoid a tenuous environment for an already marginal graft. The presence of portal vein thrombosis (PVT) at the time of LT adds surgical complexity, yet‚ to date, no studies have investigated the utilization of DCD liver grafts for patients with PVT.Methods.All DCD LT performed at Mayo Clinic-Florida, Mayo Clinic-Arizona, and Mayo Clinic-Rochester from 2006 to 2020 were reviewed (N = 771). Patients with PVT at the time of transplant were graded using Yerdel classification. A 1:3 propensity match between patients with PVT and those without PVT was performed.Results.A total of 91 (11.8%) patients with PVT undergoing DCD LT were identified. Grade I PVT was present in 62.6% of patients, grade II PVT in 27.5%, grade III in 8.8%, and grade 4 in 1.1%. At the time of LT, thromboendovenectomy was performed in 89 cases (97.8%). There was no difference in the rates of early allograft dysfunction (43.2% versus 52.4%; P = 0.13) or primary nonfunction (1.1% versus 1.1%; P = 0.41) between the DCD PVT and DCD without PVT groups, respectively. The rate of ischemic cholangiopathy was not significantly different between the DCD PVT (11.0%) and DCD without PVT groups (10.6%; P = 0.92). Graft (P = 0.58) and patient survival (P = 0.08) were similar between the 2 groups. Graft survival at 1-, 3-, and 5-y was 89.9%, 84.5%, and 79.3% in the DCD PVT group.Conclusions.In appropriately selected recipients with grades I–II PVT, DCD liver grafts can be utilized safely with excellent outcomes.

Porto-sinusoidal vascular disorder.

It is well established that portal hypertension can occur in the absence of cirrhosis, as reported in patients with immune disorders, infections and thrombophilia. However, similar histological abnormalities primarily affecting the hepatic sinusoidal and (peri)portal vasculature have also been observed in patients without portal hypertension. Thus, the term porto-sinusoidal vascular disorder (PSVD) has recently been introduced to describe a group of vascular diseases of the liver featuring lesions encompassing the portal venules and sinusoids, irrespective of the presence/absence of portal hypertension. Liver biopsy is fundamental for PSVD diagnosis. Specific histology findings include nodular regenerative hyperplasia, obliterative portal venopathy/portal vein stenosis and incomplete septal fibrosis/cirrhosis. Since other conditions including alcohol-related and non-alcoholic fatty liver disease, or viral hepatitis, or the presence of portal vein thrombosis may occur in patients with PSVD, their relative contribution to liver damage should be carefully assessed. In addition to histology and clinical diagnostic criteria, imaging and non-invasive tests such as liver and spleen stiffness measurements could aid in the diagnostic workup. The introduction of PSVD as a novel clinical entity will facilitate collaborative studies and investigations into the underlying molecular pathomechanisms encompassed by this term.

Trends and outcomes of liver transplantation among older recipients in the United States.

BACKGROUNDThe average age of recipients and donors of liver transplantation (LT) is increasing. Although there has been a change in the indications for LT over the years, data regarding the trends and outcomes of LT in the older population is limited.AIMTo assess the clinical characteristics, age-related trends, and outcomes of LT among the older population in the United States.METHODSWe analyzed data from the United Network for Organ Sharing database between 1987-2019. The sample was split into younger group (18-64 years old) and older group (≥ 65 years old).RESULTSBetween 1987-2019, 155758 LT were performed in the United States. During this period there was a rise in median age of the recipients and percentage of LT recipients who were older than 65 years increased (P < 0.05) with the highest incidence of LT among older population seen in 2019 (1920, 23%). Common primary etiologies of liver disease leading to LT in older patients when compared to the younger group, were non-alcoholic steatohepatitis (16.4% vs 5.9%), hepatocellular carcinoma (14.9% vs 6.9%), acute liver failure (2.5% vs 5.2%), hepatitis C cirrhosis (HCV) (19.2 % vs 25.6%) and acute alcoholic hepatitis (0.13% vs 0.35%). In older recipient group female sex and Asian race were higher, while model for end-stage liver disease (MELD) score and rates of preoperative mechanical ventilation were lower (P < 0.01). Median age of donor, female sex, body mass index (BMI), donor HCV positive status, and donor risk index (DRI) were significantly higher in older group (P < 0.01). In univariable analysis, there was no difference in post-transplant length of hospitalization, one-year, three-year and five-year graft survivals between the two groups. In multivariable Cox-Hazard regression analysis, older group had an increased risk of graft failure during the five-year post-transplant period (hazard ratio: 1.27, P < 0.001). Other risk factors for graft failure among recipients were male sex, African American race, re-transplantation, presence of diabetes, mechanical ventilation at the time of LT, higher MELD score, presence of portal vein thrombosis, HCV positive status, and higher DRI.CONCLUSIONWhile there is a higher risk of graft failure in older recipient population, age alone should not be a contraindication for LT. Careful selection of donors and recipients along with optimal management of risk factors during the postoperative period are necessary to maximize the transplant outcomes in this population.

Long-term outcomes and trends in liver transplantation for hereditary hemochromatosis in the United States.

There have been conflicting data regarding liver transplantation (LT) outcomes for hereditary hemochromatosis (HH), with no recent data on LT outcomes in patients with HH in the past decade. Using the United Network for Organ Sharing registry, we evaluated waitlist and post-LT survival in all adult patients listed for HH without concomitant liver disease from 2003 to 2019. Post-LT survival for HH was compared with a propensity-matched (recipient and donor factors) cohort of recipients with chronic liver disease (CLD). From 2003 to 2019, 862 patients with HH were listed for LT, of which 55.6% ( n = 479) patients underwent LT. The 1- and 5-year post-LT survival rates in patients with HH were 88.7% (95% confidence interval [CI], 85.4%-91.4%) and 77.5% (95% CI, 72.8%-81.4%), respectively, and were comparable with those in the propensity-matched CLD cohort ( p value = 0.96). Post-LT survival for HH was lower than for Wilson's disease, another hereditary metabolic liver disease with similar LT volume ( n = 365). Predictors for long-term (5-year) post-LT mortality included presence of portal vein thrombosis (hazard ratio [HR], 1.96; 95% CI, 1.07-3.58), obesity measurements greater than Class II (HR, 1.98; 95% CI, 1.16-3.39), and Karnofsky performance status (HR, 0.98; 95% CI, 0.97-0.99) at the time of LT. The leading cause of post-LT death ( n = 145) was malignancy (25.5%), whereas cardiac disease was the cause in less than 10% of recipients. In conclusion, short- and long-term survival rates for HH are excellent and comparable with those of other LT recipients. Improving extrahepatic metabolic factors and functional status in patients with HH prior to LT may improve outcomes.

Risk factors for emergency endoscopic variceal ligation treatment failure of acute variceal bleeding

Objective To determine the risk factors for emergency endoscopic variceal ligation (EVL) failure in acute variceal bleeding (AVB). Methods Data from 161 cirrhosis patients with oesophageal variceal bleeding who underwent emergency EVL treatment at the Second Hospital of Hebei Medical University from January 2018 to May 2021 were retrospectively analysed. Enrolled patients were divided into a successful treatment group and a failed treatment group. The variables studied were demographic, clinical, imaging, laboratory, and endoscopic data from the enrolled patients. Results Of the enrolled patients, 19 patients experienced emergency EVL failure. Of these patients, nine underwent emergency endoscopic treatment again, six patients were treated with a Sengstaken–Blakemore tube for haemostasis and endoscopic treatment, four patients received drug therapy. The presence of portal vein thrombosis (PVT) in the failure group was higher than that in the success group (p < .05). Active bleeding on endoscopy was associated with emergency EVL failure for patients with Child–Pugh class C (p < .05). Conclusions Child–Pugh class C with active bleeding on endoscopy or the presence of PVT could increase the risk of emergency EVL failure. The patient’s condition should be fully evaluated before emergency endoscopic treatment to reduce the risk of failure.

Clinical Characteristics of Patients with Hepatocellular Carcinoma: A Single-Center 3-Year Experience from Somalia.

Background To evaluate the relationship between prognosticators representing tumor aggressiveness and socio-demographic, laboratory, and imaging findings in patients with hepatocellular carcinoma (HCC). Methods We retrospectively searched patients with HCC between January 2017 and December 2019 in our tertiary referral hospital. The tumor-related factors and liver damage indicators and their relationship to indicate the value of prognosis were analyzed. Results A total of 268 HCC patients, with a male-to-female ratio of 2.8 : 1. The mean age was 52.6 years. The patient with portal vein thrombosis (PVT) was older, had higher liver laboratory parameters (AST, ALT, total bilirubin, and direct bilirubin), and had larger tumor size. Patients with the larger tumor size had a higher AFP level, had more tumor multifocality. The majority of patients were in Child's A (73.6%) and B (17.2%) classes. The laboratory parameters of HCC patients were increased in Child's C compared to other groups of Child-Pugh classification. Conclusions The presence of PVT and large-sized tumor in patients with HCC indicated a poorer prognosis than non-PVT group and small tumor sizes.

Risk Factors for Posttransplantation Mortality in Recipients With Grade 3 Acute-on-Chronic Liver Failure: Analysis of a North American Consortium.

Although liver transplantation (LT) yields survival benefit for patients with acute-on-chronic liver failure grade 3 (ACLF-3), knowledge gaps remain regarding risk factors for post-LT mortality. We retrospectively reviewed data from 10 centers in the United States and Canada for patients transplanted between 2018 and 2019 and who required care in the intensive care unit prior to LT. ACLF was identified using the European Association for the Study of the Liver-Chronic Liver Failure (EASL-CLIF) criteria. A total of 318 patients were studied, of whom 106 (33.3%) had no ACLF, 61 (19.1%) had ACLF-1, 74 (23.2%) had ACLF-2, and 77 (24.2%) had ACLF-3 at transplantation. Survival probability 1 year after LT was significantly higher in patients without ACLF (94.3%) compared with patients with ACLF (87.3%; P=0.02), but similar between ACLF-1 (88.5%), ACLF-2 (87.8%), and ACLF-3 (85.7%; P=0.26). Recipients with ACLF-3 and circulatory failure (n=29) had similar 1-year post-LT survival (82.3%) compared with patients with ACLF-3 without circulatory failure (89.6%; P=0.32), including those requiring multiple vasopressors. For patients transplanted with ACLF-3 including respiratory failure (n=20), there was a trend toward significantly lower post-LT survival (P=0.07) among those with respiratory failure (74.1%) compared with those without (91.0%). The presence of portal vein thrombosis (PVT) at LT for patients with ACLF-3 (n=15), however, yielded significantly lower survival (91.9% versus 57.1%; P<0.001). Multivariable logistic regression analysis revealed that PVT was significantly associated with post-LT mortality within 1year (odds ratio,7.3; 95% confidence interval, 1.9-28.3). No correlation was found between survival after LT and the location or extent of PVT, presence of transjugular intrahepatic portosystemic shunt, or anticoagulation. LT in patients with ACLF-3 requiring vasopressors yields excellent 1-year survival. LT should be approached cautiously among candidates with ACLF-3 and PVT.

Association of early alpha-fetoprotein response with survival in patients with HBV-related hepatocellular carcinoma receiving lenvatinib.

448 Background: Lenvatinib is a standard first-line treatment for unresectable hepatocellular carcinoma (uHCC). We assessed the value of early alpha-fetoprotein (AFP) response for predicting clinical outcomes to lenvatinib treatment in patients with HBV-related uHCC and elevated AFP levels. Methods: This was a retrospective analysis of the medical records of consecutive patients with HBV-related uHCC and baseline AFP levels ≥20 ng/ml who received lenvatinib for &gt; 1 month at The First Hospital of Jilin University between November 2018 and May 2021. Early AFP response was defined as a &gt; 20% decrease in AFP serum level from baseline after 4 weeks of lenvatinib treatment. We evaluated radiological response using Response Evaluation Criteria in Solid Tumors (RECIST) v1.1, as well as progression-free survival (PFS), and overall survival (OS) in AFP responders and non-responders. Potential prognostic factors for PFS and OS were assessed using univariate and multivariate Cox proportional hazards models. Intergroup differences were compared using a Mann–Whitney U test for continuous variables, a Fisher’s exact test for categorical variables and a log–rank test for survival data. Results: Medical records from 79 patients were screened and a total of 46 patients were included in the analysis; 84.4% had received lenvatinib in first-line, 63% were Child-Pugh class A, 56.4% had extrahepatic metastases, 35.6% had portal vein thrombosis and 10.3% and 87.2% had BCLC stage B and C disease, respectively. Of the 46 patients, 65.2% (n = 30) were early AFP responders and 34.8% (n = 16) were AFP non-responders. Baseline characteristics were balanced between early AFP responders and non-responders, except for age (≥60 years: 43.3% vs. 12.5%; p = 0.0366) and presence of portal vein thrombosis (46.7% vs. 13.3%; p = 0.0277). The median follow-up time was 18.0 (IQR, 3-29) months. Early AFP responders versus non-responders had a significantly higher objective response rate (34.5% vs 6.3%, p = 0.0349), disease control rate (82.8% vs 50.0%; p = 0.0203) and a longer median PFS (13.0 vs 7.0 months; HR, 0.464; 95% CI, 0.222-0.967; p = 0.028). Multivariate analysis confirmed that early AFP response (HR, 0.366; 95% CI, 0.169-0.795; p = 0.0110), ECOG PS of 0 (HR, 0.497; 95% CI, 0.323-0.877; p = 0.0326) and ALBI grade 1 (HR, 0.411; 95% CI, 0.277-0.863; p = 0.0283) were independent prognostic factors for longer PFS. Conclusions: AFP is an important prognostic factor and a predictive biomarker of survival benefit for patients with HBV-related uHCC receiving treatment with lenvatinib.

Risk factors associated with non-malignant portal vein thrombosis in patients with decompensated cirrhosis : a case-control study

Backgrounds and Aim: Portal vein thrombosis (PVT) is defined as thrombosis of the portal vein and branches of spleno-portal axis. Incidence of PVT in compensated liver disease is between 0.6-5% and up to 25% in advanced disease. Presence of PVT in decompensated chronic liver disease (DCLD) is associated with significant morbidity and mortality. We evaluated the proportion and risk factors associated with non-malignant PVT in DCLD patients. Methods: 502 patients with DCLD were enrolled over a period of 1.5 years. Patients underwent detailed clinical history and evaluation, baseline investigation and ultrasonography. CECT Abdomen was performed in patients with USG evidence of PVT or alteration in portal flow dynamics. Results: 39 patients were excluded. 51 of the 463 patients included had PVT (11.0%). Duration of cirrhosis >4years(p<0.01), NASH related etiology (p<0.01), prior history of obesity(p<0.01), dyslipidaemia with high serum cholesterol and LDL(p<0.01), clinically evident sarcopenia (p<0.01), first initial decompensation of cirrhosis as upper gastro-intestinal bleed (UGIB), prior UGIB (p=0.002), poorly controlled ascites (p<0.01), 2 history of episodes of SBP(p<0.01), platelet count <66.5x109/L(p=0.002), leucocyte count <5350/cu mm(p<0.01) were significantly associated with PVT group. There was no difference between CHILD B and C status, among the 2 groups. On multiple logistic regression analysis, prior endoscopic variceal ligation, SAAG >1.95 were found as independent risk factors for development of PVT in DCLD patients. Conclusions: Proportion of non-malignant PVT in decompensated cirrhosis was 11%. Presence of poorly controlled ascites, prior history of UGIB, high SAAG, low Platelet count as markers of severity of portal hypertension in cirrhosis are significantly associated with non-malignant PVT in DCLD. Patients with prior history of obesity and dyslipdemia, with NASH related cirrhosis are at high risk for PVT development.

Bridge-to-Transplant External-Beam Radiation Therapy in Patients With Hepatocellular Carcinoma: A Utilization Analysis of the United Network for Organ Sharing (UNOS) Database

<h3>Purpose/Objective(s)</h3> External-beam radiation therapy (EBRT), and more explicitly stereotactic body radiation therapy (SBRT), is a safe and effective bridging therapy to liver transplantation for patients with hepatocellular carcinoma (HCC). However, the national prevalence and clinicopathologic parameters of patients receiving EBRT as a bridging modality in the United States are unknown. The United Network for Organ Sharing (UNOS) is a non-profit organization that manages the national liver transplant waiting list in the United States. Our aim was to determine the national prevalence of EBRT in patients with HCC waitlisted for liver transplantation in the United States. <h3>Materials/Methods</h3> We retrospectively analyzed the UNOS dataset from 10/2013 – 6/2020 and identified adults waitlisted for HCC who had applied for Model of End-Stage Liver Disease (MELD) exceptions to receive waiting list prioritization. The primary outcome was the period prevalence of EBRT (coded as EBRT by UNOS, inclusive of all dose and fractionation schedules). Clinicopathologic parameters, defined as the earliest available recorded value starting from waiting list registration, were compared in patients receiving or not receiving EBRT using Kruskal-Wallis or chi-square tests, as applicable. <h3>Results</h3> We identified 18,447 HCC patients who submitted MELD exception applications during the study period. Ultimately, 11,171 patients received a liver transplant (60.6%) at a median of 7 months (IQR: 4-11) from exception application. 15,759 (85.4%) patients received any liver-directed therapy (LDT). A total of 658 patients received EBRT either alone or in combination with other LDTs (3.6% of the overall cohort). EBRT utilization among all patients increased over time, with an average annual percent increase of 14%. Use of EBRT significantly differed by region, with region 10 (MI, OH, IN) having the largest proportion of patients receiving EBRT (8.7%) compared to region 3 (FL, GA, MS, AL, LA, AR) having the lowest (1.7%, <i>P</i> < 0.001). No statistical difference was detected in EBRT vs. no EBRT groups in regards to tumor size, total bilirubin, presence of portal vein thrombosis, or alpha-fetoprotein level (<i>P</i> > 0.05). <h3>Conclusion</h3> In this first study evaluating national data for the use of EBRT as a bridging therapy for HCC patients awaiting liver transplantation, EBRT was used rarely compared to other LDTs. Although it is becoming more prevalent over the last decade, EBRT continues to be under-utilized relative to other LDTs. As an established safe and effective bridging therapy for HCC, low national utilization of EBRT (and in turn, SBRT) highlights a real-world gap in the treatment armamentarium for HCC and an opportunity to improve the care of patients with advanced liver disease needing liver transplantation.