Setting Of End-stage Liver Disease Research Articles

S1173 Terlipressin Treatment of Patients With Hepatorenal Syndrome Type 1 Decreased the Need for Renal Replacement Therapy in Transplant Recipients: A 12-Month Follow-Up of the CONFIRM Study

Introduction: Hepatorenal syndrome type 1 (HRS) is a rapid-onset renal failure in the setting of end-stage liver disease. While liver transplant (LT) is the definitive treatment, posttransplant renal failure requiring renal replacement therapy (RRT) is common and contributes to low patient survival rates. A randomized, placebo (PBO)-controlled study (CONFIRM; NCT02770716) demonstrated that terlipressin (TERLI) reversed HRS and reduced the need for RRT. This subgroup analysis of LT recipients from CONFIRM assessed whether TERLI treatment reduced the incidence of RRT and improved overall survival (OS) through 12-months posttransplant. Methods: Patients with HRS were treated with TERLI plus albumin (n=199) or PBO plus albumin (n=101) for up to 14 days. RRT was defined as any procedure that replaced nonendocrine kidney function including continuous hemofiltration and hemodialysis, intermittent hemodialysis, peritoneal dialysis, ultrafiltration, or other dialysis and filtration techniques. The incidence of verified HRS reversal (primary endpoint in CONFIRM), HRS reversal, the need for RRT (pretransplant; at Day 180 and Day 365 posttransplant), and OS at 12-months were compared between groups. Verified HRS reversal was defined as the percentage of patients with 2 consecutive qualified serum creatinine (SCr) values of ≤1.5 mg/dL at least 2 hours apart. HRS reversal was defined as the percentage of patients with a SCr value of ≤1.5 mg/dL while receiving treatment by Day 14 or day of discharge. Results: In total, 46 (23%) patients in the TERLI group and 29 (28%) patients in the PBO group received an LT (P=.290). Five of these patients (TERLI n=3; PBO n=2) received a simultaneous liver–kidney transplant. Verified HRS reversal was comparable between the TERLI group (30%, n=14) and the PBO group (17%, n=5; P=.168). HRS reversal was significantly higher in the TERLI group (37%, n=17) vs the PBO group (14%, n=4; P=.021). The pretransplant need for RRT was significantly lower in the TERLI group compared with PBO (P=.007; Figure). The posttransplant need for RRT was significantly lower in the TERLI vs PBO group at Day 180 (P=.017; Figure) and Day 365 (P=.009; Figure). Posttransplant 12-month OS in the TERLI group was 94% (n=43) compared with 83% (n=24) in the PBO group (P=.093). Conclusion: Patients with HRS who received TERLI treatment and an LT had a decreased need for RRT for up to 12-months posttransplant. These findings have implications for morbidity and mortality in patients with advanced cirrhosis.Figure 1.: Incidence of RRT by Treatment Group in Transplant Recipients in the CONFIRM Study, ITT population. Values at the bottom of each bar represent n/N. ITT, intent-to-treat; n, number of patients requiring RRT; N, number of patients who were alive at each timepoint; RRT, renal replacement therapy.

S3292 A Rare Complication of End-Stage Liver Disease: Flood Syndrome

Introduction: Flood syndrome describes a condition seen in the setting of end-stage liver disease in which an umbilical hernia ruptures leading to a rush of fluid through the defect. It is a rare complication of cirrhosis and has a high mortality rate. Herein, we present two cases of flood syndrome in patients with advanced liver disease. Case Description/Methods: Case 1: A 37-year-old female with a history of factor Leiden deficiency, MTHFR deficiency, and decompensates alcoholic cirrhosis presented with 1 day of continued fluid leakage from an umbilical wound. She was afebrile, normotensive yet tachycardic to 114 bpm. Abdominal exam showed a positive fluid wave shift and small umbilical hernia with ascitic fluid in the stoma bag. Labs showed a total bilirubin of 11.6 mg/dl, AST of 61 U/L, ALT of 36 U/L, and ALP of 79 U/L. She was treated with antibiotics and underwent hernia repair. She later required large volume paracentesis before the fluid leakage stopped and she was discharged home. Case 2: A 48-year-old female with alcoholic cirrhosis and a history of incisional abdominal hernia secondary to laparotomy presented with abdominal distension, pain and leakage of fluid through the hernia site. Exam showed a midline abdominal protuberance with an ulcerated hernia. CT confirmed the abdominal wall hernia with sigmoid colon in the hernia sac and ascitic fluid and air (Figure 1). She was treated with antibiotics and the defect was closed by general surgery prior to discharge. Discussion: Flood syndrome is a rare complication seen in cirrhotic patients with ascites defined as a rush of fluid through rupture of an umbilical hernia. It is associated with serious complications and a high mortality rate of up to 30%. As such, the most important step in management of ascites is prevention. Sodium and fluid restrictions and diuretics may be used to reduce hypervolemia in these patients. Paracentesis is often necessary to aid in fluid removal in those with recurrent ascites; however, the procedure can also increase the risk of developing flood syndrome. Ultimately, patients may require surgery to repair the defect.Figure 1.: CT demonstrating an abdominal wall hernia with sigmoid colon in the hernia sac and ascitic fluid and air.

Role of Portal Hemodynamics in Mortality and Adverse Out-come Prediction of Hyponatremic Cirrhotic Patients

Background: Cirrhotic patients have variable degrees of hepatic dysfunction. Impaired portal hemodynamics and hyponatremia occurs in the setting of end-stage liver disease. Aim: to uncover the role of portal hemodynamics in mortality and adverse outcome prediction of hyponatremic cirrhotic patients. Subjects and Methods:Eighty cirrhotic patients with hyponatremia (serum Na<130mmol/L) were included. ]iagnosis of hepatic encephalopathy using West Haven criteria, laboratory investigations, modified Child-Pugh and MELD scores were calculated, abdominal ultrasonography with Doppler study of portal circulation and upper GIT endoscopy were performed and the patients were followed up during their stay in hospital. Results:Serum sodium level has high statistically significant negative correlation with modified Child-Pugh score (P <0.001) and with MELD score (P <0.001). Most of the patients developed hepatic encephalopathy, spontaneous bacterial peritonitis, hepato-renal syndrome, and bleeding recorded in some patients; meanwhile mortality in 10% of the patients. In addition, apart from Hepatic Artery resistive Index, the difference in MELD score, MELD-Na score and Portal vein congestive Index between non-survived and survived patients was statistically insignificant, although all these indices were highly significant with hepatic encephalopathy, Portal vein congestive Index is highly significant in hepatorenal syndrome and bleeding esophageal varices, and Hepatic Artery resistive Index is highly significant in hepatorenal syndrome. Analysis of the receiver operating characteristic curve revealed that Portal vein CI was the most sensitive indicator (sensitivity 78.5%) and hepatic A resistive Index was the most specific indicator for prediction of mortality in hyponatremia cirrhotic patients. Conclusion:portal vein CI and hepatic A. RI can be used in the prediction of mortality in hyponatremia cirrhotic patients.

Peripheral Angioinvasive Aspergillosis in the Setting of End-Stage Liver Disease

Invasive aspergillosis of the peripheral arteries is a rare complication in vascular surgery. Angioinvasion can compromise vascular wall integrity, leading to local and systemic complications. We report the case of peripheral angioinvasive aspergillosis of the common femoral artery (CFA) and superficial femoral artery in a patient with decompensated alcoholic liver cirrhosis. We reviewed the electronic medical records for the patient's medical history, diagnostic imaging, operative reports, and in-hospital course. All information was de-identified. A 58-year-old man with advanced alcoholic liver cirrhosis had presented to our tertiary care center for orthotopic liver transplant evaluation. A part of the workup included coronary angiography, which was performed through a 6F femoral sheath access. Subsequently, the patient developed right groin hematoma with a CFA pseudoaneurysm and evidence of femoral nerve compression. He underwent hematoma evacuation and CFA repair that required endarterectomy. His postoperative course was complicated by a recurring surgical site hematoma requiring transfusions, several groin reexplorations, and creation of a sartorius flap to provide coverage of the femoral vascular bundle. A vacuum-assisted closure device was used for wound dressing. During the ensuing days, sartorius flap necrosis developed, and the patient experienced acute arterial bleeding. On reexploration, the CFA was noted to have sieve-like bleeding with complete disintegration of the arterial wall. Ligation of the CFA, profunda femoris, and superficial femoral artery as lifesaving measures was required. The patient's condition continued to worsen, with liver failure and right leg ischemia. After the goals of care were discussed with the family, they decided for terminal extubation, after which the patient died. Evaluation of samples of the femoral vessels obtained during surgery returned positive for the presence of Aspergillus species on fungal stains within the arterial wall, with large fungal bodies protruding into the vessel segment lumen (Fig). Distorted vessel wall anatomy was also observed with dense infiltration and hyphae and evidence of vessel microperforation. The presence of invasive aspergillosis was most likely responsible for the arterial wall disintegration. Peripheral angioinvasive aspergillosis is a rare infectious complication in vascular surgery and can occur in patients with end-stage liver disease. Angioinvasion is difficult to treat and can result in vascular wall compromise, presenting as life-threatening hemorrhage.

S2642 A Novel Use of Transcatheter Aortic Valve Replacement for Aortic Regurgitation in End-Stage Liver Disease

INTRODUCTION: The combination of severe aortic regurgitation (AR), end-stage liver disease (ESLD), and end-stage renal disease (ESRD) carries significant morbidity and mortality. ESLD induces a hyperdynamic circulation characterized by peripheral vasodilation, low intravascular volume, and impaired contractility, resulting in poor cardiac reserve. As such, treatment options for valvular abnormalities such as AR in the setting of ESLD and ESRD remain challenging. While transcatheter aortic valve replacement (TAVR) for treatment of severe aortic stenosis (AS) is well established, minimally-invasive treatment options for AR are limited. We present a case of severe AR in a patient with ESLD and ESRD treated via expanded-access TAVR, hence allowing the patient to maintain transplant candidacy. CASE DESCRIPTION/METHODS: A 48 y/o male with history of alcohol-related ESLD and ESRD was referred for evaluation of simultaneous liver and kidney transplant. Initial evaluation revealed him to be Child Turcotte Pugh class C with a MELD-Na of 33. During pre-transplant evaluation, a transthoracic echocardiogram revealed a mobile hypoechoic mass near the non-coronary leaflet, with resultant severe eccentric AR. Transesophageal echocardiogram confirmed a 10 × 4.5mm mobile vegetation on the left coronary cusp (AR PISA radius: 0.81cm and AR PISA volume: 52.29ml). Upon further workup, blood cultures were found to be positive for Streptococcus, likely disseminated from his tunneled internal jugular dialysis catheter. The patient was initiated on 6 weeks of IV Cefazolin with subsequent replacement of the hemodialysis catheter. The presence of severe AR was deemed prohibitive for transplantation, and he was assessed to be too high-risk for open cardiac valve repair. However, after presentation at a multi-disciplinary structural heart disease case conference, the treating team recommended an expanded access, compassionate use TAVR, usually performed for AS. FDA and Henry Ford IRB approval was obtained with completion of TAVR via transfemoral approach and resulting reduction of his severe AR to trivial AR. This novel technique has allowed the patient to potentially be re-listed for liver and kidney transplant. DISCUSSION: Our case displays the use of a multidisciplinary approach to determining a novel and minimally-invasive approach for repair of AR in a high-risk patient. Furthermore, correction of the patient’s AR has allowed for preservation of his transplant candidacy.

Prothrombin Complex Concentrate in Liver Transplant Surgery: Correction of Therapeutic Anticoagulation and the Coagulopathy of End-Stage Liver Disease: Case Series

Suggested treatment for active bleeding or invasive procedure prophylaxis has been described in the setting of end-stage liver disease (ESLD) in patients not receiving anticoagulation, and has included fresh frozen plasma (FFP), prothrombin complex concentrates (PCC), platelets, and cryoprecipitate. Today, the therapy for pharmacologically anticoagulated patients with ESLD presenting for liver transplant surgery remains controversial, poorly studied, and physician-dependent. We observed a variety of treatments administered at initiation of liver transplantation to correct acquired coagulopathy at our leading transplant center and present these cases. Three patients receiving preoperative therapeutic anticoagulation with warfarin for acute deep venous thrombosis and/or atrial fibrillation were transfused PCC, FFP, and/or cryoprecipitate for liver or liver-kidney transplant surgery. No thrombotic complications occurred, and one patient required reoperation for hemorrhage. We report data from these cases including estimated blood loss, presence of complications, duration of ICU stay, and length of hospitalization. Perioperative orthotopic liver transplant hematologic management and a review of relevant literature is presented.

Trends in Hospitalizations for Clostridioides difficile Infection in End-Stage Liver Disease, 2005–2014

Data on the current estimates of the disease burden of Clostridioides difficile (C. difficile) infection in the setting of end-stage liver disease (ESLD) are emerging. We examined the recent trends and predictors of hospitalizations and in-hospital mortality from C. difficile infection among hospitalizations with ESLD in the USA. We performed a retrospective analysis using the National Inpatient Sample, 2005-2014. We defined ESLD and C. difficile infection using the International Classification of Diseases, Ninth Revision, Clinical Modification. Multivariable logistic regression was used to determine the risk factors that impacted hospitalization and mortality. The prevalence of coding for C. difficile infection in decompensated cirrhosis increased from 1.3% in 2005 to 2.7% in 2014, with an annual rate of 7.8%. In hospitalizations with hepatocellular carcinoma, C. difficile infection increased steadily from 1.0 to 1.7% with an annual incremental rate of 6.4%. Among hospitalizations with ESLD, each passing 2-year period, increasing age, female, higher Charlson index, accompanying infection, hepatorenal syndrome, and ascites were associated with C. difficile infection. Although C. difficile infection was an independent predictor of in-hospital mortality during hospitalization with decompensated cirrhosis (odds ratio 1.53, 95% confidence interval 1.44-1.63), the proportion of in-hospital mortality during hospitalization with C. difficile infection and decompensated cirrhosis decreased from 15.4% in 2005 to 11.1% in 2014, with an annual rate of - 3.1% (95% CI - 5.7% to - 0.3%). While the prevalence of C. difficile infection in hospitalized patients with ESLD increased approximately twofold, the in-hospital mortality decreased significantly during the past decade.

3235 Black Stomach: A Rare Clinical Entity in a Patient With Recurrent Primary Sclerosing Cholangitis With Cirrhosis

INTRODUCTION: Acute gastric necrosis is rarely encountered given the stomach's rich vascular distribution and collateral circulation. Reported causes of gastric necrosis include gastric outlet obstruction, intrathoracic herniation, ingestion of caustic substances, anorexia nervosa and bulimia, and systemic hypotension. We present a case of “black stomach” secondary to persistent shock in the setting of end-stage liver disease. CASE DESCRIPTION/METHODS: A 33-year-old female with a history of primary sclerosing cholangitis status post orthotopic liver transplant in 2017 was initially hospitalized for pneumonia complicated by worsening graft function (MELD 38). Liver biopsy confirmed recurrent PSC with cirrhosis. Her course deteriorated after developing multiple episodes of coffee-ground emesis and melena requiring pressors. Initial EGD showed mild portal hypertensive gastropathy and two, 5 mm clean-based ulcers in the gastric antrum. No esophageal varices were visualized. Despite medical therapy, her melena and hypotension continued, leading to acute renal failure requiring CVVH. Repeat EGD two days later showed an adherent clot in the gastric fundus and severe portal hypertensive gastropathy with spontaneous oozing. Despite supportive measures, she continued to have melena. A third EGD showed a large blood clot in the fundus that was unable to be removed. Friable mucosa was noted throughout, as well as a non-healing, clean-based antral ulcer. Two days later, a fourth EGD revealed mucosa in the fundus and proximal body that appeared black and diffusely necrotic with sloughing of mucosa, with normal mucosa distally. The patient was not a candidate for IR embolization, TIPS procedure or surgery. One week later, she decompensated and died of septic shock from VRE bacteremia. DISCUSSION: Our case demonstrates that persistent gastric ischemia in the setting of shock and underlying end-stage liver disease results in gastric necrosis noted endoscopically over the course of a week. It is possible that the patient's underlying decompensated graft cirrhosis predisposed her to developing segmental gastric necrosis and “black stomach” in the area supplied and drained by the left gastric vessels, which can be affected by shock and portal congestion. Despite aggressive measures and supportive care, gastric necrosis carries a high morbidity and mortality. Therefore, a high index of clinical suspicion is required to make an early diagnosis in order to guide potential therapeutic interventions in such critically ill patients.

Kidney Injury and Electrolyte Abnormalities in Liver Failure.

The liver and kidney are key organs of metabolic homeostasis in the body and display complex interactions. Liver diseases often have direct and immediate effects on renal physiology and function. Conversely, acute kidney injury (AKI) is a common problem in patients with both acute and chronic liver diseases. AKI in patients with acute liver failure is usually multifactorial and involves insults similar to those seen in the general AKI population. Liver cirrhosis affects and is directly affected by aberrations in systemic and renal hemodynamics, inflammatory response, renal handling of sodium and free water excretion, and additional nonvasomotor mechanisms. Subsequent problems, for example, worsening ascites, hyponatremia, and AKI, often complicate management of patients with chronic progressive liver disease and add to their morbidity and mortality. Thus, AKI must be carefully defined and diagnosed in patients with liver disease. The kidney also plays a pivotal role in balancing acid-base disturbances resulting from advanced liver disease, making AKI in the setting of end-stage liver disease very difficult to manage clinically. While renal dysfunction in these patients often resolves following orthotopic liver transplant, dialysis may be required as a bridge to transplantation to mitigate the metabolic disarray found in these critically ill patients.

Timing of Hepatitis C Virus Treatment in Liver Transplant Candidates in the Era of Direct-acting Antiviral Agents.

Chronic hepatitis C virus (HCV) infection remains the leading indication for liver transplantation (LT) in the United States. While most patients with chronic HCV infection remain asymptomatic, up to one-third develop progressive liver disease resulting in cirrhosis. LT is often the only curative treatment once significant hepatic decompensation develops. However, antiviral therapy for HCV infection has advanced markedly in the past 5 years with the discovery and approval of direct-acting antiviral agents. These new regimens are well tolerated, of short duration and highly effective, unlike the traditional treatment with pegylated-interferon and ribavirin. As achieving sustained virological response becomes increasingly attainable for a majority of HCV-infected patients, concerns have been raised regarding the optimal timing of treatment for HCV infection in the setting of end-stage liver disease and during the peri-transplant period. On one hand, HCV treatment may improve hepatic function and negate the need for LT in some, which is crucial given the scarcity of donor organs and mortality on the waiting list in certain regions. On the other hand, HCV treatment may result in lowering the priority for LT without improving quality of life, thereby delaying potentially curative LT surgery. This review evaluates the evidence supporting the use of direct-acting antiviral agents in the period before and following LT.

Prevalence, Severity, and Prognostic Effect of Hepatopulmonary Syndrome in Liver Transplant Candidates.

Hepatopulmonary syndrome (HPS) is commonly encountered in the setting of end-stage liver disease (ESLD). Past studies have reported conflicting results in terms of demonstrating an association between HPS and mortality. The aim of this study was to determine the prevalence of HPS in patients with ESLD referred for assessment of transplantation suitability. In addition, we investigated survival rates in the setting of HPS, with and without liver transplantation. The medical records of 524 consecutive patients with ESLD evaluated for potential liver transplantation were retrospectively reviewed. HPS was defined by a reduced partial pressure of oxygen or an elevated alveolar-arterial oxygen gradient and the presence of intrapulmonary vascular dilatation on contrast-enhanced echocardiography. In total, 57 subjects (12%) fulfilled the diagnostic criteria of HPS; 88% of these had mild to moderate HPS. For patients with HPS, the overall survival rates at 1 and 3 years were 95% and 92%, respectively. Liver transplants were received by 245 patients (53%), 26 of whom had HPS. For transplant recipients with HPS, the overall survival rates at 1 and 3 years were 96% and 91%, respectively, compared to 85% and 80% in subjects without HPS. Post-transplantation survival in patients with and without HPS did not differ significantly (HR=0.489, 95% CI: 0.153-1.564; p=0.228). This study demonstrated a high prevalence of IPVD and HPS among patients who were potential candidates for liver transplantation. HPS was mild to moderate in the majority of those affected and had no significant effect on overall survival.

End-Stage Liver Disease Is a Strong Predictor of Early Mortality in Cryptococcosis.

Background. Cryptococcosis in the setting of end-stage liver disease (ESLD) has been associated with high mortality. We sought to compare the outcome of cryptococcal disease in patients with ESLD to that of human immunodeficiency virus (HIV)-positive patients and to those patients without HIV or ESLD. Methods. We assembled a retrospective cohort of 232 consecutive cases of cryptococcosis in our institution, from 2002 to 2014, inclusively. We analyzed the cases for comorbidities, type of infection, and survival. Data were analyzed with t tests, Fishers Exact test, and Kaplan-Meyer analysis. Results. Twenty-five (10.8%) patients with cryptococcal infection had concomitant ESLD; of these, 5 (20%) presented with peritonitis. Most (17 of 25, 68%) did not have any other cause of immunocompromise that has been more classically associated with cryptococcosis. Patients with ESLD had a significantly higher mortality than HIV-positive patients and HIV-negative patients without ESLD (HIVNE) (80% vs 13.6% and 22.7%, respectively; P < .001). In addition, fatal outcome in ESLD patients occurred more rapidly than in HIVNE patients, with a median survival of 6 days (vs 17), despite a comparable time to diagnosis (6.2 vs 6.6 days). Conclusions. Cryptococcosis is an important morbidity in patients with ESLD. Patients with ESLD who are infected with Cryptococcus have a high and rapid mortality. This suggests that a high level of vigilance for cryptococcal infection should be kept in patients with ESLD.

Vitamin D deficiency, parathyroid hormone levels, and bone disease among patients with end‐stage liver disease and normal serum creatinine awaiting liver transplantation

Vitamin D deficiency is common among patients with end-stage liver disease (ESLD). The primary aim of our study was to assess the prevalence of vitamin D deficiency, secondary hyperparathyroidism, and bone disease in patients with ESLD awaiting LT. We retrospectively studied 190 patients at our center. Serum total 25-hydroxyvitamin D (25-OH D), parathyroid hormone (PTH), calcium, and bone mineral analysis (BMA) were recorded. Standard World Health Organization (WHO) criteria were used to diagnose osteopenia/osteoporosis. Only patients with normal serum creatinine were analyzed. Thirty-two of 190 patients were excluded from the final analysis (missing serum total 25-OH D levels in three patients and elevated serum creatinine, 29 patients). 105 of 158 (66.4%) evaluable patients had 25-OH D levels <25 ng/mL. Patients included in the analysis (n = 158) were divided according to serum total 25-OH D levels: 0-10 ng/mL (n = 23), 11-20 ng/mL (n = 64), and >20 ng/mL (n = 71). There were no significant differences in mean serum PTH and corrected calcium levels among the three subgroups. Only three patients had elevated serum PTH. Patients with total 25-OH D ≤ 10 ng/mL had higher model for end-stage liver disease (MELD) scores vs. those with 25-OH D > 20 ng/mL (13.3 ± 3, range 8-21, vs. 11.9 ± 3.4, range 6-29, p = 0.004). Irrespective of vitamin D status, bone disease was present in 64.6% of patients. Low vitamin D levels and bone disease are common among patients with ESLD awaiting LT. Despite a high prevalence of low serum total 25-OH D, our cohort maintained normal corrected calcium levels and did not develop secondary hyperparathyroidism. We propose that free serum 25-OH D and vitamin D-binding protein may be necessary to accurately establish the diagnosis of vitamin D deficiency in the setting of ESLD. Additional studies are needed to further define mechanisms of bone disease in patients with ESLD.

Prevalence of portopulmonary hypertension among liver transplant candidates in a region highly endemic for viral hepatitis

Portopulmonary hypertension (POPH) is rarely encountered in the setting of end-stage liver disease (ESLD) and, if severe, may preclude patients from undergoing liver transplantation. The aim of the present study was to determine the prevalence of POPH in the setting of ESLD for patients who were referred to King Abdulaziz Medical City-Riyadh (Riyadh, Saudi Arabia) for assessment for liver transplantation. The medical records of all patients evaluated for liver transplantation between 1993 and 2009 were retrospectively reviewed. Pulmonary hypertension (PH) was defined as an echocardiographically estimated right ventricular systolic pressure ≥40 mmHg and a mean pulmonary arterial pressure >25 mmHg measured using right heart catheterization. A total of 542 consecutive subjects with ESLD who underwent assessment for liver transplantation were identified; however, medical records for 18 were missing. The final cohort, therefore, consisted of 524 subjects with a mean (±SD) age of 49±13.9 years, 60% were male, and 70% had viral hepatitis. PH was detected by echocardiography in 64 (12%) of the 524 subjects. Hemodynamic data obtained from intraoperative right heart catheterization or as part of the pre-transplantation evaluation were available for 248 subjects, including 57 of the 64 who had echocardiographically defined PH. PH was confirmed in 30 subjects and ruled out in 27, and only 4 (0.76%) subjects fulfilled the criteria for POPH. The prevalence of POPH determined in the present study was lower than previously reported. Further prospective research is needed to confirm this finding and to explore possible clinical, genetic, and environmental factors that contribute to the low prevalence of POPH in regions highly endemic for viral hepatitis.

Efficiency of the LigaSure Vessel Sealing System for Recipient Hepatectomy in Liver Transplantation

BackgroundAlthough the LigaSure device is widely used, its use in liver transplantation, where compounding factors of portal hypertension, coagulopathy, and thrombocytopenia exist, is poorly described. MethodsFrom October 1, 2011, to December 31, 2011, 6 patients underwent liver transplantation with recipient hepatectomy utilizing the LigaSure device. Outcomes using the device were compared with 6 contemporaneous patients in whom the device was not used. ResultsPatient demographics, preoperative laboratory values, and Model for End-Stage Liver Disease scores were not different. Recipient hepatectomy was performed, on average, 43 minutes faster using the LigaSure device (P = .02). Although total operative time and intraoperative blood product usage were lower when the LigaSure was used, these differences did not attain statistical significance. Duration of stay and recipient readmission rates were similar. ConclusionsLigaSure vessel sealing is an efficient method for recipient hepatectomy in liver transplantation. Vessel sealing of caval, portal, and other structures can be safely performed in the setting of end-stage liver disease.

High prevalence of normal serum albumin in NASH patients with ascites: A retrospective analysis

Ascites usually occurs in the setting of end-stage liver disease and low serum albumin and is associated with increased mortality. However, some patients develop ascites despite normal serum albumin (NSA), when a higher portal pressure and/or enhanced renal sodium retention would be expected. This study investigated the relationship between the hepatic venous pressure gradient (HVPG) and serum albumin in ascitic patients with different etiologies of cirrhosis and mortality. Records of all patients with non-malignant ascites who underwent HVPG measurement from 2005 to 2009 were reviewed. One hundred and thirty-eight 138 patients met inclusion criteria; 18.8% had NSA. No difference in sodium excretion or diuretic use was noted in patients with and without NSA. NASH patients were more likely to have a NSA (34.2% vs 12.4%; P=0.001) as well as lower HVPG (15 vs 17.9 mmHg; P=0.009) compared to other etiologies. MELD and HVPG predicted overall survival. However, mortality did not differ by disease etiology, though NASH patients had lower CTP (7.6 vs 8.5; P<0.001) and MELD (15.6 vs 18.1; P=0.09) scores, particularly among patients who died. In patients with ascites and NSA, there were no increase in HVPG or urinary sodium retention. NASH patients with ascites had lower HVPG and a higher prevalence of NSA. They also had a higher mortality relative to MELD and CTP scores in other patients. In these patients, mechanisms other than portal and oncotic pressures and sodium retention play a role in ascites development, and increase mortality rate when complicated by low albumin.

Renal dysfunction in liver transplant recipients: Evaluation of the critical issues

Major progress has been made in the field of liver transplantation since the first procedure was performed nearly 50 years ago. Despite these improvements, renal dysfunction before and after liver transplantation remains a major complicating factor associated with increased health care costs, morbidity, and mortality. Creatinine-based estimates of renal function are inaccurate in the setting of end-stage liver disease and often lead to underdiagnosis and late intervention. This issue is critical in that it is important to understand both the etiology and chronicity of renal dysfunction before liver transplantation because the treatment clearly varies, especially with respect to simultaneous liver-kidney (SLK) transplantation. Because of the scarcity of available grafts, identifying appropriate candidates for SLK transplantation is crucial. Hepatorenal syndrome is common in liver transplant candidates; however, other etiologies of renal dysfunction need to be considered. Renal dysfunction after liver transplantation is common and may have an acute or chronic presentation. Although calcineurin inhibitors (CNIs) have been associated with post-liver transplant nephrotoxicity, their role may be overestimated, and other contributing etiologies should remain in a clinician's differential diagnosis. Alternatives to CNIs have been evaluated; however, a safe immunosuppressive regimen that achieves the preservation of renal function in liver transplant recipients remains to be established. In this review of the literature, renal dysfunction in the setting of liver transplantation is evaluated, and the critical issues that are barriers to improved outcomes are highlighted.

Intraoperative Management of Liver Transplantation in Patients with Hypertrophic Cardiomyopathy: A Review

Hypertrophic cardiomyopathy (HCM) is a genetic disorder defined by the presence of a hypertrophied nondilated left ventricle in the absence of other known causes. Anatomic variants exist, and dynamic features of this disease process may include left ventricular outflow tract obstruction during systole, systolic anterior motion of the mitral valve, and mitral regurgitation. Patients with HCM are at higher risk for sudden cardiac death, stroke, atrial fibrillation, atrial reentrant tachycardia, syncope, and congestive heart failure (CHF). Few studies have evaluated the perioperative risk of noncardiac surgery in this patient population. However, there appears to be a relatively high incidence of perioperative adverse cardiac events, such as CHF, myocardial ischemia, stable and life-threatening arrhythmias, and transient hypotension. Interoperative challenges of patients with HCM are exacerbated in the setting of end-stage liver disease (ESLD) and liver transplantation. ESLD physiology includes relative hypovolemia, decreased systemic vascular resistance and arterial pressure, and hyperdynamic circulation characterized by increased cardiac output. General anesthesia, release of ascites, temporary occlusion of the inferior vena cava, and reperfusion of the donor liver can result in cardiovascular instability. Liver transplantation is associated with blood loss, hypovolemia, vasodilation, tachycardia, and hypotension. Anesthetic goals to limit the dynamic features of HCM include avoiding tachycardia and increased contractility, as well as maintaining preload and afterload. Transesophageal echocardiography (TEE) is an ideal monitoring technique for patients with HCM undergoing liver transplantation. Benefits of TEE include real-time visualization of cardiac function and structure, better indication of intravascular volume, and immediate evaluation of pharmacologic interventions.

M2005 Nitric Oxide Disturbance and Chronic Liver Disease

In the setting of end-stage liver disease (ESLD), In-Vivo balance between proand anticoagulants has not been completely clear. Guidelines on prevention of Venous thromboembolism (VTE) fail to address patients with coagulopathy from ESLD. Risk of VTE still exists in hospitalized patients with ESLD despite elevated INR. We investigated the perceived risk of VTE in patients with ESLD among house-staff and weather this was reflected in clinical practice. Methods: We first distributed a questionnaire in 2006 among medicine housestaff in our tertiary medical center to evaluate their practices of VTE prophylaxis in ESRD and then distributed the same questionnaire in 2009. No housestaff was involved in both surveys. Housestaff with <3 months in medicine wards were excluded. Investigators were blinded to the data until all responses were obtained. Results: Among 244 housestaff, 223(91%) returned the questionnaire. Only 11/223(7%) housestaff believed that risk of VTE among hospitalized patients with ESLD and elevated INR is lower than those with normal liver function. Hundred and ninety of 223(85%) followed guidelines for VTE prophylaxis, and 155(70%) applied them to patients with ESLD. Subcutaneous heparin was the most commonly used agent(190;85%) for patients with normal INR. But as INR increased due to ESLD, the use of heparin decreased correspondingly (Figure). This pattern of practice persisted in both 2006 and 2009. Majority of the participants (198/223;89%), felt that patient compliance to intermittent compression devices (ICD) was inadequate. Conclusions: Although compliance with ICD's is perceived as inadequate and subcutaneous heparin is the cost-effective and preferred mode for VTE prophylaxis, ICD use increased with the rise in INR values. This phenomenon may be due to fear of a perceived increase in risk of bleeding in ESLD. Despite awareness of risk of VTE in patients with ESLD and elevated INR, no strides have been made in translating this into clinical practice due to lack of clear guidelines and fear of bleeding risk. Prospective studies to determine the risk of VTE in hospitalized patients with ESLD are warranted to enhance current guidelines for VTE prophylaxis

Current indications for combined liver and kidney transplantation in adults

A significant number of patients awaiting liver transplantation have associated renal failure. Combined Liver and Kidney Transplantation (CLKT) is increasingly offered especially since the introduction of Model for End-Stage Liver Disease (MELD). Decision to perform CLKT is straightforward when both organs suffer end-stage failure. However, the indications for CLKT are not well defined and there is controversy concerning some. We reviewed available data on PUBMED, United Network for Organ Sharing (UNOS), Organ Procurement Transplantation Network (OPTN), European Society for Organ Transplantation (ESOT) and discuss all current indications for CLKT. Overall long-term outcome following CLKT is acceptable. There is an urgent need to further refine our ability to identify the cases with reversible renal injury in the setting of end-stage liver disease to avoid unnecessary CLKT. Liver protects the kidney from disease recurrence and allograft loss in metabolic diseases. However, the use of liver allograft for immunological protection of kidneys in highly sensitised patients with positive cross-match and previously failed renal transplants is still experimental.