Survival Outcomes After Liver Transplantation in Elderly Patients: A Single-Center Retrospective Analysis.

AIM: This study aims to evaluate survival rates in elderly patients after liver transplantation (LT) and to analyze the factors associated with mortality. PATIENTS AND METHODS: Our study includes 535 patients over the age of 18 who had undergone LT in our clinic between June 2004 and January 2018. Data were collected prospectively and scanned retrospectively. Data concerning the patients' age, sex, LT indication, Child-Turcotte-Pugh score, Model for End-Stage Liver Disease score, presence of hepatocellular cancer (HCC), coexisting disease, LT types, and post-transplant survival were investigated. The patients were grouped under 2 categories (18-59 years of age and 60 years of age and over) and were compared in terms of their characteristics. In patients aged 60 and over, the causes of mortality and related factors were investigated. RESULTS: The study included 535 patients, 458 (85.6%) of whom were between 18 and 59 years of age and 77 (14.4%) were over 60 years of age. The median follow-up period was 86.7 (1 to 247) months. The elderly group's survival rate was significantly lower than that of the younger group (P = .002). In elderly patients, survival rates of 1, 3, 5, and 10 years were 67.4%, 56.4%, 53.8%, and 46.1%, respectively. CONCLUSION: In elderly patients, factors that increase post-LT mortality require thorough consideration. Equally important is the physiological status of the candidates for transplantation. Correct patient selection in the preoperative stage and good postoperative care can provide successful survival results in elderly patients.

The Analysis of Posthepatectomy Liver Failure Incidence and Risk Factors Among Right Liver Living Donors According to International Study Group of Liver Surgery Definition.

AIM: There is a well-known risk of the emergence of hepatic failure in living donor transplant cases on whom are performed a right donor hepatectomy (RDH). There are different prevalence ratios in literature on this phenomenon. In our study, we aim to depict the prevalence of hepatic failure and risk factors in our cases regarding the most recent description criteria related to hepatic failure. PATIENTS AND METHODS: We included right liver donor hepatectomy cases who fit the donor evaluation algorithm at the Dokuz Eylul University Liver Transplantation Unit between the period of June 2000 and September 2017. The patients were evaluated regarding preoperative data. Liver failure was defined according to the International Study Group of Liver Surgery (ISGLS) criteria. We also included statistical analysis of risk factors that are potentially related to liver failure. RESULTS: We included a total of 276 patients. In 27 (9.7%) patients, we observed posthepatectomy liver failure (PHLF). In 26 (9.4%) patients, we observed Grade A liver failure; in 1 (0.3%) patient, we observed Grade B liver failure. We did not observe any Grade C hepatic failure. In patients with hepatic failure, we observed a significantly longer period of hospitalization (P = .007). Old age (odds ratio = 1.065, 95% confidence interval, 1.135-29.108, P = .035) and preoperatory red blood cell (RBC) transfusion (odds ratio = 5.749, 95% confidence interval, 1.019-1.113, P = .005) were shown as independent risk factors for PHLF. CONCLUSION: Posthepatectomy liver failure is a vital complication of RDH. The risk can be decreased by careful selection of donor candidates. Elderly donor candidates and intraoperative RBC are independent risk factors for PHLF.

Type I cardiorenal syndrome in patients with acutely decompensated heart failure: the importance of new renal biomarkers.

OBJECTIVE: Type 1 cardiorenal syndrome (CRS) is an acute renal failure in patients with acute decompensated heart failure with an incidence of 24% to 45%. The aim of our study was to investigate the significance of new renal biomarkers to predict type 1 CRS. PATIENTS AND METHODS: The study included 111 patients with acute decompensated heart failure diagnosed at the Istanbul Medical Faculty Emergency Department between 2014 and 2016, and 24 healthy volunteers. All urine samples were stored at -80°C after centrifugation. Samples were run according to the instructions of TIMP-2, ILGF-7, KIM-1, and IGFBP-7 ELISA kits. Diuretic treatments were then administered with intravenous administration of at least 80 mg furosemide per day. Follow-up biochemical and spot urine specimens were taken after 72 hours. For statistical analysis, SPSS version 21.0 statistical software was used. Significance was evaluated at p<0.05. RESULTS: The baseline creatinine level was measured as 1.33 ± 0.39 mg/dL in the heart failure group. It was seen that 67% (75) of the patients had increased creatinine levels and developed type 1 CRS. ILGF-7, TIMP-2, and (ILGF-7 * TIMP-2) values were significantly higher in patients with cardiorenal syndrome when we separated the two groups as patients with and without cardiorenal syndrome (0.40 (0.25-0.71), p1: 0.049/2.40 (1.42-3.70), p2: 0.003/1.15 (0.29-2.43), p3: 0.001). CONCLUSIONS: Renal tubular markers reveal promising developments in the pathophysiology of cardiorenal syndrome in light of recently obtained data. Renal tubular biomarkers may have the potential to be a predictor of heart failure and cardiorenal syndrome.

Endocan is markedly overexpressed in severe erectile dysfunction.

This study aimed to measure the serum endocan level of patients with erectile dysfunction (ED) and to investigate the possible association between this and vasculogenic severe ED. We performed a prospective analysis of 86 consecutive patients affected by ED. Patients were divided into severe ED (IIEF-5 score < 7) and mild or moderate ED (IIEF-5 score > 7). A strong negative correlation was found between serum endocan levels and peak systolic velocity (p < .001 and r = -.665) in men with severe ED. Univariate logistic regression analysis demonstrated that tobacco consumption (p < .05), serum total 25-hydroxyvitamin D (p < .01), serum endocan levels (p < .01), peak systolic velocity (p < .01), hypertension (p < .001), dyslipidaemia (p < .001), metabolic syndrome (p = .026) and a history of a cardiovascular event (p < .001) significantly increase the risk of severe ED. In the multivariate logistic regression model, we also found that age, hypertension, metabolic syndrome, cardiovascular events and higher serum endocan levels were independently associated with severe ED. Circulating endocan may be used in daily practice as a new marker that correlates with cardiovascular risks and the severity of ED disease.

Evaluation of Pregnancy Outcomes After Liver Transplantation.

Liver transplantation is increasing worldwide. Pregnancy after liver transplantation is considered to be well tolerated with favorable neonatal outcomes in cases of stable and sufficient graft function. In this study, our aim was to determine pregnancy and neonatal outcomes of patients after liver transplantation. Data for patients who had been followed-up by the liver transplantation clinic at the Dokuz Eylül University Medical Faculty Hospital, Turkey, between 2002 and 2016, and who had pregnancy after the transplantation were evaluated retrospectively. The earliest post-transplantation conception occurred after 22 months and the latest conception occurred after 108 months (mean, 55.4 months). Twenty-one pregnancies concluded with live births (100%). The mean birth week was 37.09. The earliest birth occurred at 27 weeks and the latest at 40 weeks. Mean birth weight was 2993 g (10th to 25th percentiles). No pregnancy-induced hypertension, pre-eclampsia, or gestational diabetes were observed in any patient. Five pregnancies concluded with premature birth. In conclusion, several complications may occur during pregnancy (such as hypertension or pre-eclampsia, etc) in patients with liver transplantation, but it seems that pregnancy has good effects on graft functions and the neonatal outcomes are favorable.

Cost analysis of liver transplantation in Turkey.

The study sought to determine the costs of liver transplantation in Turkey. All costs except physician charges were retrospectively investigated in the period from hospitalization to discharge. Liver transplantation was performed in 326 patients between 1999 and 2009. After exclusion of patients whose records could not be accessed (n=5), who underwent second transplantations in the same hospitalization (n=3) or who died before discharge (n=39), 279 patients were eligible for the study. The mean cost of liver transplantation was 30.823 dollars. The mean cost in 2008 was significantly higher than for all other years; thereafter it decreased. Costs were shown to be higher among patients with model for end-stage liver disease (MELD) scores>15. Although there was no significant cost difference among United Network for Organ Sharing (UNOS) groups, the mean costs of subjects of the B group were significantly lower than those of the Child C subjects C (P=.01). When we evaluated the relationship between etiological groups and costs the highest expenses were noted among hepatitis B virus (HBV) and hepato cellular carcinoma (HCC) patients with 75% HBV-positivity together. There was no significant difference between age, gender, and body mass index (BMI) of recipients. The costs did not significantly change with the presence of diabetes mellitus (DM) or portal vein thrombosis before transplantation or antibiotic use after transplantation. Although there was no difference between donor age and costs, living donor transplantation showed significantly higher costs than cadaveric donor cases (P=.01). In conclusion, liver transplantation is an effective treatment in end-stage liver diseases with high cost, albeit in Turkey it is relatively lower than other countries.

Plasminogen activator inhibitor-1 and thrombin activatable fibrinolysis inhibitor levels in non-alcoholic steatohepatitis.

AIM: This study was conducted to demonstrate the plasminogen activator inhibitor- 1 (PAI-1) and thrombin activatable fibrinolysis inhibitor antigen (TAFI-Ag) levels in non-alcoholic steatohepatitis (NASH). MATERIALS AND METHODS: Twenty-seven patients with biopsy-proven NASH and 18 healthy controls (HC) were recruited for the study. Anthropometric data, liver histology (no.=20) and laboratory parameters including PAI-1 and TAFI-Ag assessments were recorded. RESULTS: When compared with HC, patients with NASH had higher body weight, higher waist circumference, elevated blood pressure, higher fasting plasma glucose (FPG) levels and higher homeostasis model assessment (HOMA) scores. The mean plasma PAI-1 levels of patients was found to be higher than HC (87.60 ng/ml vs 30.84 ng/ml p=0.000) and mean plasma TAFI-Ag levels of patients was found to be significantly lower (8.69 microg/ml vs 12.19 microg/ml p=0.000). PAI-1 levels were correlated with systolic blood pressure, age, body weight, transaminases, waist circumference, FPG, body mass index, and HOMA score. TAFI-Ag levels were found to be negatively correlated with transaminases, waist circumference, and body weight. In multiple regression analysis, BMI was the independent variable effecting PAI-1 levels. We did not show any association between PAI-1, TAFI-Ag, disease activity score and fibrosis score. HOMA was the independent variable effecting liver fibrosis in our patients. CONCLUSION: In this study we demonstrated that patients with biopsy-proven NASH had higher PAI-1 and lower TAFI-Ag expression than HC. Elevated levels of PAI-1 in NASH is the consequence of insulin resistance state. Lower TAFI-Ag levels may be related to the overactivation of TAFI pathway resulting in TAFI-Ag depletion. Furthermore, liver function disturbances may impair TAFI production in NASH. We also showed that NASH patients even with slight elevations of transaminases feature marked insulin resistance and components of metabolic syndrome.

Efficacy of right anterior sector drainage reconstruction in right-lobe live-donor transplantation.

BACKGROUND: Without including the middle hepatic vein (MHV) into right-lobe grafts, venous drainage of the anterior segment (AS) has always been a concern. The efficacy and the necessity of additional venous reconstruction in the AS for graft viability and function are still controversial. METHODS: Since February 2002, 57 right-lobe grafts were implanted into adult recipients. The mean graft to ideal recipient weight ratio (GRWR) was 1.3% (minimum: 0.8%, maximum 2.1%). All minor venous tributaries to the MHV less than 5 mm in diameter were ligated. The management of MHV tributaries was categorized into three groups: (A) no major tributaries (n = 33); (B) major tributaries ligated (n = 11); and (C) major tributaries reconstructed (n = 13). Reconstructions were established using vascular grafts (PTF, n = 8; cadaveric, n = 2) or joining with right hepatic vein orifice (n = 6). The groups were homogenous in age, gender, MELD (17 +/- 6, 16 +/- 4, 18 +/- 7), graft weight (817 +/- 181, 838 +/- 152, and 855 +/- 159 g), and graft/ideal liver weight ratio (0.54 +/- 0.12, 0.57 +/- 0.13, and 0.57 +/- 0.1, respectively). We investigated the volume of ascites, serum bilirubin, albumin, and liver enzyme levels and INR on postoperative day 4 (POD4) and POD21. RESULTS: Two patients died of MRSA sepsis on POD18 and POD23 (MELD: 24 and 28) after initial graft function. Their graft weights were 800 g and 980 g, and their volumes were 47% (group B) and 62% (group A) of the ideal liver mass of the recipients, respectively. One PTF and another cadaveric vascular graft were found occluded 4 and 7 days after implantation without any negative consequence. At 6-month follow-up, the remaining 55 patients were alive with primary liver grafts. Vascular reconstructions were patent except for 2 early occlusions. Among the 3 groups, no significant difference was found on POD4. Three weeks after transplantation, the mean AST level in the major ligation group (46.7 +/- 8.14) was significantly higher than in the minor ligatation group (29.6 +/- 8.6) but not in the major reconstruction group (33.7 +/- 3.7; P = .03 and P = .29). The mean albumin level was highest after minor ligation (3.2 +/- 0.18), which was significantly better than the major reconstruction (2.7 +/- 0.1) but not the major ligation (3.1 +/- 0.14) cohorts (P = .02 and P = .13). CONCLUSIONS: In this study of a limited number of cases, right-lobe liver grafts with GRWR of > or =1.1% displayed optimal graft function without additional venous reconstruction to the AS.

Prophylactic use of low-dose, on-demand, intramuscular hepatitis B immunoglobulin and lamivudine after liver transplantation.

The combination of hepatitis B immunoglobulin (HBIG) and antivirals (nucleos[t]ide analogs) has extended the applicability of orthotopic liver transplantation (OLT) for patients with hepatitis B virus (HBV)-related liver disease. However, HBIG administrations have an extremely high cost. Herein, we evaluated our results with low-dose, on-demand, intramuscular HBIG plus lamivudine (LAM) prophylaxis after OLT. The HBV DNA status in 40 patients at the time of OLT determined the treatment: group A (n = 22), HBV DNA (-), no antiviral pretreatment; group B (n = 11), HBV DNA (-), after LAM; group C (n = 3), HBV DNA (+) after LAM (LAM resistance/Adefovir [ADV] unavailable); group D (n = 2), HBV DNA (+), no antiviral pretreatment; and group E (n = 2), HBV DNA (-) after LAM + ADV (LAM resistance/ADV available). Five patients died within 12 months after OLT unrelated to HBV infection. The remaining 35 patients were followed for a median duration of 16 months (range, 6-93 months). Only two recipients from group C, who were transplanted despite LAM resistance + no ADV pretreatment, revealed recurrent HBV infections at 14 and 16 months posttransplantation; they were then treated successfully with ADV as it became available. The third group C recipient had undetectable HBV DNA at 18 months after OLT. The mean cumulative doses of HBIG administered within the first, second, and third years were 34,014, 5258, and 5090 IU, respectively. In conclusion, low-dose, on-demand, intramuscular HBIG plus (LAM +/- ADV) prophylaxis is a safe, efficient, and cost-effective regimen to prevent recurrent HBV infection following OLT. OLT despite untreated LAM resistance may require sustained higher serum HBsAb levels after surgery.

Assessment of sexual functions in patients with chronic liver disease.

We aimed to determine the sexual problems and the prevalence of erectile dysfunction (ED) in patients with chronic liver disease by means of International Index of Erectile Function (IIEF). A total of 81 patients with stable chronic liver disease were included in the study. Patients were grouped as mild to moderate (Child Pugh A and B) (n=10), chronic hepatitis (hepatitis B, C and D) (n=28) and carriers (n=43) according to the type of their chronic liver disease. All patients were asked to complete a questionnaire including IIEF and demographics. The IIEF domain scores were calculated and ED grading was determined on erectile function domain. IIEF domain scores were compared between these groups. The mean age was 54.8 +/- 10.8 y. Using the IIEF, the prevalence of any ED was 50.6% for all patients, and 50, 50, and 51.1% for cirrhosis, chronic hepatitis and carriers, respectively. The IIEF domain scores were not significantly different among the patient groups. Sexual functions did not appear to be affected by the stable chronic liver disease.

Surface modification of pyrophyllite with amino silane coupling agent for the removal of 4-nitrophenol from aqueous solutions.

The surface of naturally hydrophobic mineral pyrophyllite was modified to hydrophilic by treatment with prehydrolyzed N-(2-aminoethyl)-3-aminopropyltrimethoxysilane (APEO) coupling agent to prepare a novel and effective adsorbent for the removal of 4-nitrophenol (4-NP) from aqueous solutions. XRD, FTIR, and SEM analyses were used to characterize the surface modification. It was found that after the grafting procedure, heat treatment at 110 degrees C results in condensation reaction between the OH groups of the APEO molecule and the hydroxyl groups and/or oxygen atoms on the pyrophyllite surface and the adsorption of 4-NP by APEO-modified pyrophyllite involves interactions between dissociated 4-NP molecules and protonated amine groups of APEO molecules attached to the mineral surface. Adsorption equilibrium data for 4-NP adsorption on APEO-treated and untreated pyrophyllite were most satisfactorily fitted using the Freundlich adsorption isotherm and adsorption capacity was found to be 0.268 mg/g for modified pyrophyllite whereas it was only 0.105 mg/g for untreated pyrophyllite.

Increased levels of tissue factor pathway inhibitor may reflect disease activity and play a role in thrombotic tendency in Behçet's disease.

Tissue factor pathway inhibitor (TFPI) is a Kunitz-type proteinase inhibitor that has a crucial role in haemostasis and is primarily synthesized in the vascular endothelium. We investigated plasma total TFPI, antiphospholipid antibodies, and some other coagulation and fibrinolytic system parameters in 30 patients with Behçet's disease and 15 controls by the enzyme-linked immunosorbent assay method. TFPI levels were significantly higher in the Behçet's group (119 +/- 57.5 ng/ml) compared with the control group (74.8 +/- 31.5) (P < 0.009). We also noted a statistical significance in TFPI levels between patients with active disease (n:16) (139 +/- 55) and patients without activation (n:14) (96 +/- 53) (P < 0.03), whereas inactive patients lacked any significance when compared with the control group (P < 0.29). Other parameters disclosed no statistical significance between patients and control group except for elevated fibrinogen and plasminogen activator inhibitor-1 levels in the patient group (P < 0.003). Increased levels of TFPI may reflect a defensive mechanism like in other diseases characterized by thrombotic tendency and represent a parameter of disease activity.