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Hepatocellular carcinoma (HCC) mostly develops in a cirrhotic liver and represents a serious public health problem. Liver transplantation (LT) is a therapeutic option for HCC that offers to patients a long-term survival. The aim is to investigate depression and anxiety in HCC patients evaluated for LT. Retrospective study (N=179) at liver disease clinic on patients with a diagnosis of cirrhosis evaluated for LT. Inclusion criteria: completion of the psychological evaluation for eligibility to transplantation. The sample was divided in two groups: HCC (89/179; 49.7%) and no-HCC. Patients underwent a psychological evaluation with clinical interviews and psychological assessment with self-report questionnaires for depression (BDI-II), anxiety (BAI) and general psychological problems (SCL-90). Descriptive analyses and linear regression analyses were performed. Among the 179 patients, 84.9% were men, the mean age was 58 years. HCC group has lower depression (p <.01), anxiety (p <.05), SCL-Somatization, SCL-Depression, and SCL-Anxiety (p <.05) than no-HCC group. They also have a lower severty of liver disfunction (MELDNa) (p <.001). Univariate linear regression analysis highlighted a correlation between depression (BDI-II) and respectively: age, gender, HCC, MELDNa class and psychopathological anamnesis. Multivariate linear regression analysis [covariate: male gender OR -3.6 (95% CI -7.11– -0.21); psychopathological anamnesis OR 6.3 (95% CI 3.87 – 8.77), HCC OR -4.3 (95% CI -6.88 – -1.80); p < 0.05] highlighted that depression is positively associated with psychopathological history and inversely with HCC and male gender. Counterintuitively, patients with HCC show less depression/anxiety than patients without HCC, probably because of multiple loco-regional or systemic oncologic therapies. HCC and male gender have a significant effect on depression. HCC patients may not perceive the severity of their liver disease and lack of insights on it, therefore it could be important to enhance their compliance to the transplant programs. [ABSTRACT FROM AUTHOR]

Accurate pre-Liver Transplant(LT) cardiac risk estimation is paramount to guide graft allocation and to improve post-LT outcome. CAR-OLT-score predicts major 1-year post-LT cardiovascular complications(CVD-Com), but external validation is lacking. We aimed to test the performance of the score in identifying cardiac contraindication(Ca-Con) to LT-listing and to validate CAR-OLT-score to predict major 1-year CVD-Com post-LT. We consecutive enrolled all adult cirrhotics who underwent first pre-LT evaluation in Rome-Gemelli-Center(RO-cohort, N=342, from 2015 to 2019) and Turin-Center(TU-cohort, N=302, from 2015 to 2017). The main outcome measures were Ca-Con to listing(after center-specific cardiology work-up) and major 1-year CVD-Com post-transplant(death/hospitalization for CVD event). Discriminative performance of CAR-OLT-score was evaluated by area-under-the-ROC-curve(AUROC) method. Among 644 pre-LT cirrhotics, 23(3.6%) received a Ca-Con to listing (52.2% because of coronary artery disease, CAD). CAD, heart failure and atrial fibrillation were independent predictors of Ca-Con to listing. Among 431 first-LT recipients, 38(8.8%) patients experienced 1-year major CVD-Com (39.5% atrial-fibrillation, 23.7% heart-failure, 21% myocardial infarction). Diabetes, pulmonary hypertension, non-active workers were independent predictors of 1-year major CVD-Com. RO-cohort had higher prevalence of hypertensive, obese, diabetic, alcoholic patients and higher burden of CAD, atrial-fibrillation, heart-failure, peripheral vasculopathy compared with TU-cohort. CAR-OLT-score predicts Ca-Con to listing in RO-cohort (AUROC 0.806) and TU-cohort (AUROC 0.978) and 1-year major CVD-Com in RO-cohort (AUROC 0.746) and TU-cohort (AUROC 0.640). 193(29.9%) candidates had CAR-OLT-score ≤23. This cut-off had 99% NPV for Ca-Con to listing and 95% NPV for 1-year major CVD-Com post-LT. Candidates with CAR-OLT-score ≤23 underwent 18 cardiac-exercise-stress-test, 89 myocardial-perfusion-imaging, 24 dobutamine-stress-echocardiography, 10 coronary-computed-tomography, 17 coronary-angiography pre-listing, with estimated costs of 68.090€. CAR-OLT-score ≤23 identified candidates who can be safely listed without provocative cardiac tests, allowing time and cost savings and we validated CAR-OLT-score as predictor of major 1-year CVD-Com in an Italian cohort of LT recipients. [ABSTRACT FROM AUTHOR]

Abstract: Only patients with Model for End-stage Liver Disease (MELD) scores ≥18 or ≥17 experience a survival benefit (SB) at 12 and 36 months after liver transplantation (OLT). The SB calculation estimates the difference after stratification for risk categories between the survival rate of transplanted versus waiting list patients. The aim of this study was to perform a short- and long-term (60 months) SB analyses of a Italian OLT program. One-hundred seventy-one patients were stratified into four MELD classes (6–14, 15–18, 19–25, 26–40), and two groups: namely, waiting list (WL) and transplanted groups (TX). The median waiting time for transplanted patients was 4.4 months (range, 0–35). SB was expressed as mortality hazard ratio (MHR) as obtained through a Cox regression analysis using as a covariate the status of each patient in the waiting list (WL = 0, reference group) or the TX group (TX = 1). Values over 1 indicated the MHR in favor of the WL with the values below 1 indicating MHR in favor of Tx. In the MELD class 6 to 14, the MHR was above 1 at 3 and 6 months, indicating an SB in favor of WL; subsequently, the MHR dropped below 1, indicating an SB in favor of TX (P < .05). In the MELD class 15 to 18 the MHR was above 1 at 3 months, but below 1 subsequently (P < .05). For MELD classes 19 to 25 and 26 to 40, the MHR was always below 1 (P < .01). According to the SB approach, patients in the MELD class 6 to 14 could safely wait for at least 36 months; patients in the MELD class 15 to 18 should likely remain no longer than 12 months on the waiting list, and all the remaining patients with MELD > 18 should be transplanted as soon as possible. OLT should not be precluded but only postponed for MELD < 19 patients. [Copyright &y& Elsevier]

Abstract: MELD and PELD scores of 255 consecutive grafts were calculated (236 adult cases and 19 pediatric cases). No correction for the etiology of liver disease was performed. Retransplants were excluded. Three categories of patients were identified: low MELD (scores <12, n = 61); intermediate MELD (scores between 12–24, n = 159); high MELD (scores ≥25, n = 35). Grafts were categorized according to donor quality: standard livers (n = 199), vs nonstandard livers (n = 56). Nonstandard livers were identified by age ≥60, or at least by two of the following conditions: severe hemodynamic instability, ultrasound evidence of steatosis, natriemia ≥155 mEq/L, ICU stay >7 days, liver trauma, protracted anoxia as cause of brain death, transaminases levels × 4. In standard livers, the 12-month graft survival (GS) for low, intermediate, and high MELD classes were 88%, 74%, and 77%, respectively. In nonstandard livers, the 12-month GS for the low, intermediate, and high MELD classes were 84%, 55%, and 44%, respectively; differences between low MELD class and both intermediate and high MELD classes were significant (P < .05). Cox regression analysis of all cases identified the following parameters as independent predictors of GS: donor status; donor age; and recipient creatinine. The highest correlation with GS was found using donor age and recipient creatinine as covariates. In standard livers no variable was able to predict GS. In nonstandard livers the MELD-PELD score was the unique variable able to predict GS. We suggest avoiding the use of nonstandard livers for patients with high MELD scores. [Copyright &y& Elsevier]

Abstract: We assessed the safety and clinical efficacy of the Molecular Adsorbent Recirculating System (MARS) in liver failure patients admitted to our intensive care unit (ICU) from May 2000 to February 2006. Of 28 adult patients with bilirubin >15 mg/dL and hepatic encephalopathy (HE) grade ≥2 or hepato-renal syndrome, 22 patients were included in the study, because 6 patients were older than 65 years of age or showed recent alcohol abuse or extrahepatic malignancy. Patients were assigned to 2 groups according to whether MARS therapy was associated with a transplantation procedure: 11 patients received MARS therapy and liver transplantation (OLT group) and 11 patients received MARS therapy alone (non-OLT group). Five of 11 patients in the OLT group were listed for transplantation and 6 patients with graft failure for retransplantation. The patients in the OLT and non-OLT groups were similar in MELD, SOFA, and SAPS scores. All patients were stable and free from complications. MARS significantly reduced bilirubin, bile acids, and blood urea nitrogen (BUN) levels in both groups (P < .05), whereas a significant decrease in ammonia level was observed in the OLT group. Patient survival rates at 3 and 6 months in the OLT group were 91% and 73%, respectively, and in the non-OLT group, 9% and 9%, respectively (P < .001). MARS was safe and well tolerated, improving biochemical parameters, neurological function, and pruritus. In terms of survival, the use of MARS alone was not effective due to the high rate of multiple organ failure. Nevertheless, the association of MARS with a transplant/retransplantation procedure was highly effective. [Copyright &y& Elsevier]

Abstract: Among biliary complications, ischemic-type biliary lesions (ITBLs) remain a major cause of morbidity in liver transplant recipients, significantly affecting the chance of survival of both patients and grafts. We retrospectively reviewed 10 years of prospectively collected donor and recipient data from April 2001 to April 2011. We evaluated the incidence of ITBL occurrence, exploring the possible predisposing factors, including donor and recipient data. Two hundred fifty-one grafts were harvested: 222 of them were transplanted at our institution, the remaining 29 (11.6%) discarded by our donor team as showing >40% macrovesicular steatosis. Mild-moderate (20%–40%) macrovesicular steatosis (P < .001) and cold ischemia time (P = .048) significantly increased the risk of ITBL, also as an independent risk factor after multivariate analysis. [Copyright &y& Elsevier]

Background We assessed the usefulness of color Doppler imaging in diagnosis and monitoring hepatic artery complications after liver transplantation. Methods Subjects were 421 liver transplant recipients who underwent serial ultrasound (US) color Doppler evaluations of the hepatic arteries after surgery. Results We saw 4 hepatic arterial complications after liver transplantation (13 thrombosis, 29 stenosis, 2 kinking, 2 pseudo-aneurysm, and 2 pseudo-aneurysm rupture). All subjects underwent US color Doppler examination periodically after surgery. In 6 cases of early thrombosis, hepatic arterial obstruction was diagnosed with absence of Doppler signals; in the other 7 cases (late hepatic artery thrombosis), thrombosis was suspected for the presence of intra-parenchymal “tardus-parvus” waveforms. In all of the cases, computed tomography angiography showed obstruction of the main arterial trunk and the development of compensatory collateral circles (late hepatic artery thrombosis). In 10 of the 29 cases of stenosis, Doppler ultrasonography examination revealed stenotic tract and intra-hepatic tardus-parvus waveforms; in 17 stenosis cases, the site of stenosis could not be identified, but intra-parenchymal tardus-parvus waveforms were recorded. In 2 patients, hepatic artery stenosis occurred with ischemic complications. Conclusions The use of US color Doppler examination allows the early diagnosis of hepatic arterial complications after liver transplantation. Tardus-parvus waveforms indicated severe impairment of hepatic arterial perfusion from either thrombosis or severe stenosis. The presence of these indirect signs enhanced the accuracy of color Doppler diagnosis, and detection should prompt therapy. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: Hepatic artery stenosis (HAS) is an important complication after liver transplantation. However, studies are not conclusive in terms of definition, incidence, best treatment, and timing of intervention. The aim of this study was to evaluate the incidence of SSHA that occurred in a single center over the past 12 years, pointing out diagnostic and therapeutic strategies. Methods: The incidence of HAS was reviewed in 258 liver transplant recipients between January 1999 and December 2011. All patients underwent Doppler ultrasound (DUS) at fixed times. Multidetector computed tomographic angiography (MDCTA) was performed to confirm the DUS findings. Results: HAS occurred in 23 cases (9.3%). In all cases diagnosis was performed by DUS resulting in a sensitivity of 100% and a specificity of 99.6%. Based on DUS and MDCTA data integration, in 10 cases we adopted the “wait and see” strategy, whereas 13 patients underwent interventional radiology techniques. Conclusion: DUS monitoring is efficacious in the diagnosis of HAS after liver transplantation. Interventional radiology procedures are safe and efficacious. [Copyright &y& Elsevier]