Prevalence of fat-soluble vitamin (A, D, and E) and zinc deficiency in patients with cirrhosis being assessed for liver transplantation.

PURPOSE: To evaluate the prevalence of fat-soluble vitamin (A, D, and E) and zinc deficiency in patients with cirrhosis being assessed for liver transplantation and the correlations between vitamin deficiencies, nutritional markers, and severity of liver disease. METHODS: This is a single centre retrospective study. Serum vitamin A, D, E, and zinc levels were collected in adult patients being assessed for liver transplantation between January and July 2012. Patient and liver disease demographics, nutritional markers, Child-Pugh score, and MELD-Na score were collected. Fisher's exact test and multiple variable logistic regression was used for statistical analysis. RESULTS: A total of 109 adult patients were assessed for liver transplantation during the 6-month period. The mean patient age was 54 ± 10 years and 66% were males. Mean BMI was 27 ± 6 kg/m2, pre-albumin was 0.10 ± 0.07 g/L, albumin was 33 ± 6 g/L, total bilirubin was 48 ± 61 mmol/L, MELD-Na score was 16 ± 5 (range 6-33), and 15% had hepatocellular carcinoma. The Child-Pugh score was A in 29%, B in 54%, and C in 17%. The causes of liver disease were hepatitis C in 36%, alcohol in 20%, non-alcoholic fatty liver disease in 17%, and other in 27%. The mean vitamin A level was 0.88 ± 0.86 umol/L, D was 69 ± 52 nmol/L, E was 24 ± 17 umol/L, and zinc was 477 ± 145 ug/L. Vitamin A deficiency was prevalent in 77%, D in 63%, E in 37%, and zinc in 84%. On multiple variable analysis, low albumin (OR = 0.78, 95% CI = 0.65-0.94, p = 0.0069) was a predictor of vitamin A deficiency ; cholestatic liver enzyme elevation (OR = 3.53, 95%CI = 1.40-8.89, p = 0.0073) and low albumin (OR = 0.83, 95%CI = 0.73-0.94, p = 0.0032) were predictors of vitamin D deficiency ; low albumin (OR = 0.85, 95% CI = 0.74-0.97, p = 0.015) was a predictor of vitamin E deficiency ; and age (OR = 0.83, 95% CI = 0.72-0.96, p = 0.012), low albumin (OR = 0.59, 95% CI = 0.42-0.84, p = 0.0036), and high MELD-Na (1.43, 95% CI = 1.05-1.94, p = 0.021) were predictors of zinc deficiency. Vitamin A (p = 0.0034), D (p = 0.020), E (p = 0.012), and zinc (p<0.001) deficiency correlated with a higher Child-Pugh. CONCLUSION: Low albumin was a recurrent predictor of fat-soluble vitamin (A, D, and E) and zinc deficiency while other predictors varied depending on the vitamin or mineral. Further studies need to be conducted on fat-soluble vitamin and zinc supplementation in deficient patients with cirrhosis to assess clinical outcomes.

Roux-en-Y choledochojejunostomy versus duct-to-duct biliary anastomosis in liver transplantation for primary sclerosing cholangitis: a meta-analysis.

BACKGROUND: Roux-en-Y choledochojejunostomy and duct-to-duct anastomosis are potential methods for biliary reconstruction in liver transplantation (LT) for recipients with primary sclerosing cholangitis (PSC). However, there is controversy over which method yields superior outcomes. The purpose of this study was to evaluate the outcomes of duct-to-duct versus Roux-en-Y biliary anastomosis in patients undergoing LT for PSC. METHODS: Studies comparing Roux-en-Y versus duct-to-duct anastomosis during LT for PSC were identified based on systematic searches of 9 electronic databases and multiple sources of gray literature. RESULTS: The search identified 496 citations, including 7 retrospective series, and 692 patients met eligibility criteria. The use of duct-to-duct anastomosis was not associated with a significant difference in clinical outcomes, including 1-year recipient survival rates (odds ratio [OR], 1.02; 95% confidence interval [CI], 0.65-1.60; P = .95), 1-year graft survival rates (OR, 1.11; 95% CI, 0.72-1.71; P = .64), risk of biliary leaks (OR, 1.23; 95% CI, 0.59-2.59; P = .33), risk of biliary strictures (OR, 1.99; 95% CI, 0.98-4.06; P = .06), or rate of recurrence of PSC (OR, 0.94; 95% CI, 0.19-4.78; P = .94). CONCLUSIONS: There were no significant differences in 1-year recipient survival, 1-year graft survival, risk of biliary complications, and PSC recurrence between Roux-en-Y and duct-to-duct biliary anastomosis in LT for PSC.

Early allograft dysfunction is associated with excess resource utilization after liver transplantation.

BACKGROUND: There are limited data on length of stay (LOS) following liver transplantation (LT), yet this is an important health services metric that directly correlates with early post-LT health care costs. The primary objective of this study was to examine the relationship between early allograft dysfunction (EAD) and LOS after LT. The secondary objective was to identify additional recipient, donor, and operative factors associated with LOS. METHODS: Adult patients undergoing primary LT over a 32-month period were prospectively examined at a single center. Subjects fulfilling standard criteria for EAD were compared with those not meeting the definition. Variables associated with increased LOS on ordinal logistic regression were identified. RESULTS: Subjects with EAD had longer mean hospital LOS than those without (42.5 ± 38.9 days vs 27.4 ± 31 days; P = .003). Subjects with EAD also had longer mean intensive care LOS (8.61 ± 10.28 days vs 5.45 ± 11.6 days; P = .048). Additional factors significantly associated with LOS included Model for End-Stage Liver Disease (MELD) score, recipient location before LT, and postoperative surgical complications. CONCLUSIONS: EAD is associated with longer hospitalization after LT. MELD score, preoperative recipient location, and postoperative complications were significantly associated with LOS. From a cost-containment perspective, these findings have implications on resource allocation.

Should a lower quality organ go to the least sick patient? Model for end-stage liver disease score and donor risk index as predictors of early allograft dysfunction.

BACKGROUND: There is a global tendency to justify transplanting extended criteria organs (ECD; Donor Risk Index [DRI] ≥ 1.7) into recipients with a lower Model for End-Stage Liver Disease (MELD) score and to transplant standard criteria organs (DRI < 1.7) into recipients with a higher MELD scores. There is a lack of evidence in the current literature to justify this assumption. METHODS: A review of our prospectively entered database for donation after brain death (DBD) liver transplantation (n = 310) between January 1, 2006, and September 30, 2010, was performed. DRI was dichotomized as <1.7 and ≥ 1.7. Recipients were divided into 3 strata, those with high (≥ 27), moderate (15-26), and low MELD (<15) scores. The recently validated definition of early allograft dysfunction (EAD) was used. We analyzed EAD and its relation with donor DRI and recipient MELD scores. RESULTS: The overall incidence of EAD was 24.5%. Mortality in the first 6 months in recipients with EAD was 20% compared with 3.4% for those without EAD (relative risk [RR], 5.56, 95% confidence interval [CI], 1.96-15.73; P < .001). Graft failure rate in the first 6 months in those with EAD was 27% compared with 5.8% for those without EAD (RR, 4.63; 95% CI, 2.02-10.6; P < .001). In patients with low MELD scores, a significantly increased rate of EAD (25%) was seen in patients transplanted with a high DRI liver compared with those transplanted with a low DRI liver (6.25%; P = .012). In moderate and high MELD recipients, there was no significant difference in the rate of EAD in patients transplanted with a high DRI liver (62%) compared with those transplanted with a low DRI liver (59%). CONCLUSION: These results suggest that contrary to common belief it is not justified to preferentially allocate organs with higher DRI to recipients with lower MELD scores.

Randomised clinical trial: the safety and efficacy of long-acting octreotide in patients with portal hypertension.

BACKGROUND: It remains unclear whether a long-acting preparation of octreotide (Sandostatin LAR) can be safely used for portal hypertension in patients with compensated cirrhosis. AIM: To determine the safety and efficacy of LAR among patients with Child Pugh Class A or B cirrhosis and small oesophageal varices. METHODS: A randomised, double-blind, placebo-controlled study was conducted in 39 patients with cirrhosis and small oesophageal varices. Safety was based on frequency and severity of adverse events. Efficacy was determined by hepatic vein pressure gradient (HVPG) measured at baseline and day 84 following administration of LAR 10 mg (n = 15), 30 mg (n = 10) or saline (n = 14). Fasting and postprandial portal blood flow (PBF), superior mesenteric artery pulsatility index (SMA-PI), glucagon and octreotide levels were measured. An intention-to-treat analysis was performed. RESULTS: Four patients in the LAR 30 group (40%) withdrew from the study due to serious adverse events. No patient in the LAR 10 or control group had serious adverse events. There was no statistically significant decrease between HVPG at day 84 and baseline with LAR 30 mg (11.8 ± 2.3 mmHg vs. 14.1 ± 3.2), LAR 10 mg (15.3 ± 4.8 mmHg vs. 15.1 ± 3.8), or saline (13.3 ± 3.8 mmHg vs. 15.1 ± 4.3) (P = 0.26). Neither PBF, SMA-PI nor plasma glucagon levels were significantly decreased from baseline (P = 0.56). CONCLUSIONS: The absence of significant haemodynamic benefit, as well as the high frequency of severe adverse events associated with use of LAR, do not support the use of this agent in the treatment of portal hypertension.