Strategies for ABO Incompatible Liver Transplantation.

Liver transplantation (LT) is a definitive treatment for the decompensated liver cirrhosis and fulminant liver failure. With limited availability of cadaveric liver allograft, ABO incompatible (ABOi) living donor liver transplantation (LDLT) plays an important part in further expansion of donor pool. Over the years, with the introduction of Rituximab and improving desensitisation protocol, outcomes of ABOi LDLT are on par with ABO compatible LT. However, ABOi LDLT protocol varies markedly from centre to centre. Intravenous Rituximab followed by plasmapheresis or immunoadsorption effectively reduce ABO isoagglutinins titre before transplant, thereby reducing the risk of antibody mediated rejection in the post-transplant period. Local infusion therapy and splenectomy are not used routinely at most of the centres in Rituximab era. Post-transplant immunosuppression usually consists of standard triple drug regime, and tacrolimus trough levels are targeted at higher level compared to ABO compatible LT. Introduction of newer therapies like Belatacept and Obinutuzumab hold promise to further improve outcomes and reduce the risk of antibody mediated rejection related complications. ABOi LT in emergency situations like acute liver failure and deceased donor LT is challenging due to limited time period for desensitisation protocol before transplant, and available evidence are still limited but encouraging.

Surgical Risk Assessment in Patients with Chronic Liver Diseases.

Chronic liver diseases (CLD) is one of the leading causes of morbidity and mortality. The overall life span of patients with CLD has increased and so is the number of surgical procedures these patients undergo. Pathophysiological and hemodynamic changes in cirrhosis make these patients more susceptible to hypotension and hypoxia during surgery. They also have a high risk of drug induced liver injury, renal dysfunction and post-operative liver decompensation. Patients with CLD planned for elective or semi-elective surgery should undergo detailed preoperative risk assessment. Patients should be evaluated for the presence of clinically significant portal hypertension and cirrhosis. In the absence of both cirrhosis and clinically significant portal hypertension, patients with CLD can undergo surgery with minimal or low risk. Various risk assessment tools available for patients with advanced CLD are-CTP score, MELD Score, Mayo risk score, VOCAL-Penn score. A Child class C and/or Mayo risk score >15 in general is associated with high risk of post-operative mortality and elective surgery should be deferred in these patients. In patients with Child class, A and MELD 10-15 surgery is permissible with caution (except liver resection and cardiac surgery) while in Child A and MELD <10 surgery is well tolerated. VOCAL-Penn score is a new promising tool and can be the better alternative of CTP, MELD, and Mayo risk score models but more prospective studies with large patients' population are warranted. Certain surgeries like Hepatic resection, intraabdominal, and cardiothoracic have higher risk than abdominal wall hernia repair and orthopedic surgery. Laparoscopic approaches have better outcomes and less risk of liver failure than open surgery. Minimally invasive alternatives like colonic stent placement in case of obstruction can be considered in high-risk cases. Perioperative optimization and management of ascites, HE, bleeding, liver decompensation, and nutrition should be done with multidisciplinary approach. Patients with cirrhosis undergoing high risk elective surgery can develop liver failure in post-operative period and should be evaluated and counseled for liver transplantation if not contraindicated.

Spectrum of Neuroimaging Abnormalities in Brain in Patients of Acute-on-Chronic Liver Failure.

Background and aims: Acute-on-chronic liver failure (ACLF) is associated with high short-term mortality. There is a paucity of data about the spectrum of neuroimaging abnormalities in the brain in ACLF patients. The present study was aimed to study the prevalence of cerebral edema and other parenchymal changes in MR imaging of the brain in patients with ACLF. Methods: In this prospective observational study, MR imaging was done in patients with ACLF (n = 41), and findings were compared with age and sex-matched patients with acute decompensation (AD) (n = 13) and those with cirrhosis but without any decompensation at recruitment (n = 21). Results: Forty-one patients with ACLF (24.4% Grade 1 and Grade 2, 51.2% Grade 3) with 14 (34.1%) having cerebral failure were included in the study. T2-weighted (T2W) diffuse white matter hyperintensities (WMHs) and focal WMHs were seen in 17 (41.4%) and 7 (17%) patients, respectively. T1W basal ganglia hyperintensities in 20 (48.7%), cerebral microbleeds (CMBs) in 6 (14.6%), and 2 (4.8%) patients had cerebral edema. In patients with AD, T2W diffuse WMHs were seen in 3 (23%), T2W focal WMHs in 3 (23%) patients. None of the patients with AD had cerebral edema or CMBs. In compensated cirrhosis patients, T2W diffuse WMHs were present in 7 (33.3%), T2W focal WMHs in 5 (23.8%), while 3 (14.2%) patients had CMBs. T1 weighted hyperintensities in basal ganglia were more common in AD [9 (69.2%)] and compensated cirrhosis [15 (71.4%)] as compared to ACLF patients [20 (48.7%)], P = 0.174. The survival time of 30 and 90 days for patients with diffuse T2W WMHs was significantly lesser than patients without T2W WMHs (P = 0.007). Conclusion: Cerebral edema is uncommon in ACLF patients, and T2-weighted diffuse white matter hyperintensities may be associated with worse outcomes. However, due to the limited scope of the present study, the same needs to be explored further in larger cohorts.

"SARS-CoV-2 Infection in Liver Transplant Recipients - Immunosuppression is the Silver Lining?"

BACKGROUND: COVID-19 is associated with higher mortality among patients who have comorbidities. However, evidences related to COVID-19 among post liver transplant recipients are scarce and evolving. METHODS: Adult Indian patients who had undergone liver transplantation at our centre since 2006 and were under regular follow-up, were contacted either telephonically or on email. Data were recorded related to symptoms and diagnosis of COVID-19, need for hospitalization, and need for ICU stay and mortality. RESULTS: Eighty one (3.71%) of the 2182 adult Liver transplant (LT) recipients on regular follow-up reported SARS-CoV-2 infection between 1st April 2020 and 31st May 2021. Mean age was 51.3(±9.8) years, and 74(91.4%) were males. Thirty five (43.2%) patients had one or more comorbidities. Twenty one (25.9%) patients were transplanted less than 1 year ago. Forty four (54.3% ) patients had mild disease only while 23(28.4%) patients had severe COVID-19 disease. Of the 81 patients 14 patients died and overall mortality was 17.3. CONCLUSION: Uncomplicated liver transplant recipients without comorbidities who acquire SARS-CoV-2 do not have poor outcome.

Prevalence, predictors and impact of bacterial infection in acute on chronic liver failure patients.

BACKGROUND: Acute on chronic liver failure (ACLF) is associated with high short term mortality. We aimed to evaluate the prevalence, predictors and impact of bacterial infection in ACLF. METHODS: Consecutive hospitalized patients with cirrhosis and acute decompensation (AD), from January 2011-March 2017, were included. Predictors of survival and infection were assessed. RESULTS: 572 patients with cirrhosis and AD were classified into 3 groups - no infection (group 1, n = 190, 33.2%), infection at admission/within 48 h (group 2, n = 298, 52.1%) and infection after 48 h (group 3, n = 84, 14.7%). Higher frequency of organ failures - kidney, brain, circulation and respiratory failure - were seen in groups 2 and 3 as compared with group 1 (P < 0.001 for all). Most common site of infection was lungs, followed by spontaneous bacterial peritonitis and urinary tract infection. The frequency of infection increased with higher ACLF grades. Among ACLF patients, on Cox-proportional multivariate analysis, presence of infection was associated with significantly higher mortality [group 2 (HR 2.93; 95%CI, 1.97-4.38, P < 0.001) and group 3 (HR 1.84; 95%CI, 1.16-2.91, P = 0.009)], as compared with group 1. On multivariate logistic regression analysis, advanced hepatic encephalopathy and elevated total leucocyte count were independently associated with development of infection. CONCLUSIONS: Infections are common in ACLF, and associated with poor outcome.