Pre-and intraoperative predictors of acute kidney injury after liver transplantation

BACKGROUND Acute kidney injury(AKI)after liver transplantation(LT)is a frequent and multifactorial event related to increased morbidity and mortality.Risk factors for AKI after LT still need to be clarified.AIM To identify the predictors of acute kidney injury after liver transplantation.METHODS The frequency and pre-and intraoperative predictors of AKI within the first 7 d after LT were evaluated in adult liver transplant candidates in a single LT center in Croatia.AKI was defined according to the Kidney Disease:Improving Global Outcomes criteria.RESULTS Out of 205 patients(mean age 57±10 years;73.7%males,52.7%with alcoholrelated liver disease)93(45.36%)developed AKI,and the majority of them(58.06%)had stage 1.Only 5.38%of patients required renal replacement therapy after LT.The majority of patients(82.8%)developed AKI within the first two days after the procedure.Multivariate logistic regression identified pre-LT body mass index(OR=1.1,95%CI:1.05-1.24)and red blood cell transfusion(OR=1.66,95%CI:1.09-2.53)as independent predictors of early post-LT AKI occurrence.30-d survival after LT was significantly better for patients without AKI(P=0.01).CONCLUSION Early AKI after LT is a frequent event that negatively impacts short-term survival.The pathogenesis of AKI is multifactorial,but pre-LT BMI and intraoperative volume shifts are major contributors.

Liver transplantation and aging

An increase in the average life expectancy,paralleled by a demographic shift in the population with end-stage liver disease lies behind the rising demand for liver transplantation(LT)among the elderly.Some of the most common indications for LT including hepatocellular carcinoma,alcohol-related liver disease,chronic hepatitis C and non-alcoholic fatty liver disease tend to affect older patients.Transplant professionals are faced with an increasing demand for LT among elderly patients in an age of organ shortage and it is important that risk and benefits are carefully weighed in order to achieve the optimum use of precious liver grafts.

Liver transplantation for benign liver tumors

Benign liver tumors are common lesions that are usually asymptomatic and are often found incidentally due to recent advances in imaging techniques and their widespread use.Although most of these tumors can be managed conservatively or treated by surgical resection,liver transplantation(LT)is the only treatment option in selected patients.LT is usually indicated in patients that present with life-threatening complications,when the lesions are diffuse in the hepatic parenchyma or when malignant transformation cannot be ruled out.However,due to the significant postoperative morbidity of the procedure,scarcity of available donor liver grafts,and the benign course of the disease,the indications for LT are still not standardized.Hepatic adenoma and adenomatosis,hepatic hemangioma,and hepatic epithelioid hemangioendothelioma are among the most common benign liver tumors treated by LT.This article reviews the role of LT in patients with benign liver tumors.The indications for LT and long-term outcomes of LT are presented.

How far along are we in revealing the connection between metformin and colorectal cancer?

Colorectal cancer(CRC)is among the most prevalent cancers worldwide,and its prevention and reduction of incidence is imperative.The presence of diabetes has been associated with a 30%increased risk of CRC,likely through the mechanism of hyperinsulinemia,which promotes tumorigenesis via the insulin receptor in the epithelium or by insulin-like growth factor pathways,inflammation,or adipokines,inducing cancer cell proliferation and cancer spread.Metformin,the first-line agent in treating type 2 diabetes,has a chemopreventive role in CRC development.Additionally,preclinical studies suggest synergistic effects of metformin with oxaliplatin in inhibiting in vitro models of colon cancer.Although preclinical studies on the post diagnostic use of metformin were promising and suggested its synergistic effects with chemotherapy,the data on the possible effects of metformin after surgery and other CRC treatment in the clinical setting are less conclusive,and randomized controlled trials are still lacking.

Emerging and neglected zoonoses in transplant population

Zoonoses represent a problem of rising importance in the transplant population.A close relationship and changes between human,animal and environmental health(“One Health”concept)significantly influence the transmission and distribution of zoonotic diseases.The aim of this manuscript is to perform a narrative review of the published literature on emerging and neglected zoonoses in the transplant population.Many reports on donor-derived or naturally acquired(re-)emerging arboviral infections such as dengue,chikungunya,West Nile,tick-borne encephalitis and Zika virus infection have demonstrated atypical or more complicated clinical course in immunocompromised hosts.Hepatitis E virus has emerged as a serious problem after solid organ transplantation(SOT),leading to diverse extrahepatic manifestations and chronic hepatitis with unfavorable outcomes.Some neglected pathogens such as lymphocytic choriomeningitis virus can cause severe infection with multi-organ failure and high mortality.In addition,ehrlichiosis may be more severe with higher casefatality rates in SOT recipients.Some unusual or severe presentations of borreliosis,anaplasmosis and rickettsioses were also reported among transplant patients.Moreover,toxoplasmosis as infectious complication is a well-recognized zoonosis in this population.Although rabies transmission through SOT transplantation has rarely been reported,it has become a notable problem in some countries.Since the spreading trends of zoonoses are likely to continue,the awareness,recognition and treatment of zoonotic infections among transplant professionals should be imperative.

Role of total pancreatectomy in the treatment of paraduodenal pancreatitis:A case report

BACKGROUND Paraduodenal pancreatitis(PP)is a rare form of chronic pancreatitis presenting with symptoms of duodenal obstruction.Conservative treatment is often unsuccessful and pancreaticoduodenectomy is the preferred surgical approach.A mini review of the outcomes of surgical therapy for PP shows that the results of pancreaticoduodenectomy are predominantly favorable.CASE SUMMARY In our case report of PP,we describe an unusual course first presenting with the symptoms of chronic pancreatitis and a pseudocyst of the pancreatic tail.A pseudocystojejunostomy was performed and the late postoperative course was complicated with the symptoms of duodenal obstruction.At laparotomy,PP was found and the patient was treated with a total pancreatectomy.The postoperative course was uneventful and good weight gain with resolution of pain was demonstrated at follow up visits.CONCLUSION Surgery is currently the optimal treatment option for PP.It is also the best diagnostic tool in distinguishing between pancreatitis and pancreatic adenocarcinoma.

Borderline resectable pancreatic cancer and vascular resections in the era of neoadjuvant therapy

While pancreatic cancer is still characterized by early systemic spread and poor outcomes,the treatment of this disease has changed significantly in recent years due to major advancements in systemic therapy and advanced surgical techniques.Broader use of effective neoadjuvant approaches combined with aggressive surgical operations within a multidisciplinary setting has improved outcomes.Borderline resectable pancreatic cancer is characterized by tumor vascular invasion,and is a setting where the combination of potent neoadjuvant chemotherapy and aggressive surgical methods,including vascular resections and reconstructions,shows its full potential.Hopefully,this will lead to improved local control and curative treatment in a number of patients with this aggressive malignancy.

Liver re-transplantation for donor-derived neuroendocrine tumor: A case report

BACKGROUND Donor-origin cancer is a well-recognized but rare complication after liver transplantation (LT). The rise in the use of extended criteria donors due to the current shortage of organs increases the risk. Data on donor-origin neuroendocrine neoplasms (NENs) and the most appropriate treatment are scarce. Here, we report a case of a patient who developed a NEN confined to the liver after LT and was treated with liver re-transplantation (re-LT). CASE SUMMARY A 49-year-old man with no other medical co-morbidities underwent LT in 2013 for alcoholic liver cirrhosis. The donor was a 73-year-old female with no known malignancies. Early after LT, a hypoechogenic (15 mm) lesion was detected in the left hepatic lobe on abdominal ultrasound. The lesion was stable for next 11 mo, when abdominal magnetic resonance identified two hypovascular lesions (20 and 11 mm) with atypical enhancement pattern. Follow-up abdominal ultrasound revealed no new lesions for the next 2.5 years, when magnetic resonance showed a progression in size and number of lesions, also confirmed by abdominal computed tomography. Liver biopsy proved a well-differentiated NEN. Genetic analysis of the NEN confirmed donor origin of the neoplasm. As NEN was confined to liver graft only, in 2018, the patient underwent his second LT. At 12 mo after re-LT the patient is well with no signs of NEN dissemination. CONCLUSION The benefits of graft explantation should be weighed against the risks of re-LT and the likelihood of NEN dissemination beyond the graft.

Constrictive pericarditis as a cause of refractory ascites after liver transplantation:A case report

BACKGROUND Refractory ascites is a rare complication following orthotopic liver transplantation(OLT).The broad spectrum of differential diagnosis often leads to delay in diagnosis.Therapy depends on recognition and treatment of the underlying cause.Constrictive pericarditis is a condition characterized by clinical signs of right-sided heart failure.In the advanced stages of the disease,hepatic congestion leads to formation of ascites.In patients after OLT,cardiac etiology of ascites is easily overlooked and it requires a high degree of clinical suspicion.CASE SUMMARY We report a case of a 55-year-old man who presented with a refractory ascites three months after liver transplantation for alcoholic cirrhosis.Prior to transplantation the patient had a minimal amount of ascites.The transplant procedure and the early postoperative course were uneventful.Standard posttransplant work up failed to reveal any typical cause of refractory post-transplant ascites.The function of the graft was good.Apart from atrial fibrillation,cardiac status was normal.Eighteen months post transplantation the patient developed dyspnea and severe fatigue with peripheral edema.Ascites was still prominent.The presenting signs of right-sided heart failure were highly suggestive of cardiac etiology.Diagnostic paracentesis was suggestive of cardiac ascites,and further cardiac evaluation showed typical signs of constrictive pericarditis.Pericardiectomy was performed followed by complete resolution of ascites.On the follow-up the patient remained symptom-free with no signs of recurrent ascites and with normal function of the liver graft.CONCLUSION Refractory ascites following liver transplantation is a rare complication with many possible causes.Broad differential diagnosis needs to be considered.