Etiologies Associated With Elevated Liver Enzymes After Renal Transplant.

OBJECTIVES: One of the most important causes of morbidity and mortality in renal transplant recipients is liver disease. Liver dysfunction is shown in 7% to 67% of kidney transplant recipients. Liver insufficiency accounts for death in up to 28% of kidney transplant recipients. We stratified various etiological factors responsible for elevated liver enzymes in kidney transplant recipients. MATERIALS AND METHODS: We enrolled all patients who fulfilled inclusion criteria. The principal investigator obtained and recorded demographic and clinical information via a standardized form. We reviewed clinical records of kidney recipients with hepatotoxicity during the course of illness, and we analyzed data with SPSS statistical software (version 22). Descriptive statistics were used for continuous and categorical variables. RESULTS: All recipients of living related renal transplants from January 2015 to December 2016 were included in the study (n = 496). We excluded 64 patients with positive serology for hepatitis B or hepatitis C before transplant. Of the remaining 432 patients, 74 (17.1%) had deranged liver enzymes. Forty-one patients (55.4%) had deranged liver enzymes 3 to 4 years after transplant, whereas 23 patients (31.1%) had deranged liver enzymes 4 years after transplant. Liver parenchymal biopsy was performed in 17 patients (23%) to evaluate the etiology. The most common cause of deranged liver enzymes was sepsis, which was seen in 21 patients (28.4%), followed by viral hepatitis, ie, cytomegalovirus hepatitis in 7 (9.5%) and hepatitis C in 6 (8.1%) patients. Other causes included antituberculosis treatment-induced liver injury, autoimmune hepatitis, sinusoidal obstruction syndrome, and nonalcoholic steatohepatitis, observed in 4 patients each (5.4%). CONCLUSION: The most common cause of deranged liver enzymes in patients who received living related renal transplants in our population was sepsis, which can have a substantial effect on graft survival.

Role of Endoscopic Ultrasound in Predicting Solid Pancreatic Lesions Using Strain Ratio and Elastography.

Background: Despite advancement in imaging techniques, the diagnosis of solid pancreatic lesions (SPLs) remains challenging. The latest advancement in elastography permits the quantitative measurements of the average elasticity of a lesion. Therefore, our main aim of this study was to determine the utility of endoscopic ultrasound-guided elastography (EUS-EG) and strain ratio (EUS-SR) in predicting SPLs. Materials and methods: This cross-sectional study was performed at the Department of Hepatogastroenterology, Sindh Institute of Urology and Transplantation. All patients with radiological diagnosis of SPLs underwent EUS-EG, followed by strain ratio (SR) measurement and targeted pancreatic fine needle lesion biopsy (FNB). Area under the receiver operating curve (AUROC) was obtained for SR and combined elastography and SR and at an optimal cutoff, diagnostic accuracy was obtained in predicting the nature of SPLs. Results: A total of 52 patients were included in this study. Out of them, 32 (61.5%) patients were males while 20 (38.5%) were females. The mean age was 50.8 ± 12.5 years. Twenty-four (46.2%) patients had malignant pancreatic lesions. Among malignant lesions, the most common etiology was pancreatic adenocarcinoma seen in 18 (34.6%) patients. Out of 28 (53.8%) patients with benign lesions, 14 (26.9%) patients had inflammatory disease. Area under the receiver operating curve was obtained for both SR alone and SR combined with elastography score in differentiating benign from malignant SPLs which was 0.832 (p-value < 0.001) for SR alone and a slightly higher for combined SR with elastography (AUROC-0.839)(p-value < 0.001). At an optimal cutoff of SR of >17, the sensitivity was 94.8% and the diagnostic accuracy was 74% in predicting SPLs. While, when SR and elastography were combined together, the sensitivity increased to 96% with a diagnostic accuracy of 75%. Conclusion: Combined EUS-EG and SR were accurate in diagnosing malignant pancreatic lesions with a diagnostic accuracy of 75% providing additional diagnostics information before biopsy. However, multicentric studies with larger sample sizes are required for the validation of our results to determine the utility and diagnostic accuracy of EUS-SR in defining the characteristic of pancreatic lesions. How to cite this article: Bajaj K, Yaseen T, Tasneem AA, et al. Role of Endoscopic Ultrasound in Predicting Solid Pancreatic Lesions Using Strain Ratio and Elastography. Euroasian J Hepato-Gastroenterol 2023;13(1):1-4.

Role of "HinCh Score" as a Non-invasive Predictor of Post-endoscopic Retrograde Cholangiopancreatography Cholangitis.

Introduction: Post-endoscopic retrograde cholangiopancreatography (ERCP) cholangitis (PEC) is associated with increased morbidity and mortality in patients ERCP. The aim of the present study was to analyze the predictors of PEC and to formulate a predictive model for early diagnosis and management. Materials and methods: It was a cross-sectional study that was carried out at the Sindh Institute of Urology and Transplantation from September 2019 to June 2021. All patients aged between 18 and 75 years and undergoing ERCP due to obstructive jaundice were included. Patients with altered biliary anatomy, history of hepatobiliary surgery, and concurrent sepsis were excluded. Endoscopic retrograde cholangiopancreatography intervention was performed by an expert gastroenterologist. Laboratory parameters (total leukocyte count, total bilirubin, alanine transaminase) and patient temperature were checked on admission, at 12 hours, 24 hours, and 36 hours after ERCP to document PEC. Results: A total of 349 patients were included in the study. Among them, 176 (50.4%) patients were males. Common bile duct (CBD) stricture was the most common indication of ERCP seen in 148 (42.4%) patients followed by CBD stone and cholangiocarcinoma in 108 (30.9%) and 48 (13.8%) patients, respectively. The most common presenting complaint was jaundice noted in 300 (86%) patients followed by right hypochondrial pain in 280 (80.2%) and weight loss in 194 (55.6%) patients, respectively. Post-ERCP cholangitis developed in 251 (71.9%) patients. On univariate analysis, age >50 years, female gender, right hypochondrial pain, fever, bilirubin >5 mg/dL on admission, CBD stricture on ERCP, TLC of >10,000 cells/L at 12 hours, 24 hours, and 36 hours post-ERCP and rise in ALT >50 IU 24 and 48 hours post-ERCP were significantly associated with PEC. While on multivariate analysis, female gender, bilirubin >5 mg/dL on admission, CBD stricture on ERCP, post-ERCP fever, and rise in TLC of >10000 cells/L at 24 hours post-ERCP were independently associated with PEC. HinCh score was formulated and was found to be significantly associated with the presence of cholangitis. Area under the receiver operating characteristics (AUROC) of HinCh score was 0.74 and at cutoff of ≥4, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of HinCh were 81.67%, 59.18%, 83.67%, and 55.71%, respectively with a diagnostic accuracy of 75.36%. Conclusion: The performance of HinCh score in predicting PEC was accurate in 86% of the patients. However, further studies are needed to validate the score. How to cite this article: Ismail H, Yaseen RT, Danish M, et al. Role of "HinCh Score" as a Non-invasive Predictor of Post-endoscopic Retrograde Cholangiopancreatography Cholangitis. Euroasian J Hepato-Gastroenterol 2022;12(1):19-23.

Clinical Characteristics and Comparison of Different Prognostic Scores in Wilson's Disease.

Aim: Wilson's disease (WD) is a rare autosomal recessive disease, that can involve any organ of the body, the main ones being the liver and the brain. These patients can have varied presentations, ranging from having no symptoms to having neurological manifestations to features of chronic liver disease (CLD). Those patients that end up having CLD are prognosticated via the Child-Turcotte-Pugh (CTP) score and the Model for End-stage Liver Disease (MELD) score. However, two specific scores exist for prognostication in patients having WD, namely, the Nazar score and the Dhawan score. However, these are yet to be validated nor has their use been implemented in clinical practice. Materials and methods: Our study involved 65 patients with WD, comprising both the pediatric and the adult population. We aimed at evaluating the clinical manifestations the lab parameters and the management of these patients. Furthermore, we tried validating the Nazar and the Dhawan score and later compared them with the CTP and the MELD score, which are well-known prognostic tools in CLD. Results: Our patients were subdivided into the pediatric (more than 50%) and the adult group. The most common presenting complaint noted in both groups was abdominal distension. Values of the urine copper and serum ceruloplasmin did not defer between the pediatric and adult patients. Hepatic involvement is frequently seen in the pediatric age-group. Also, CTP class C was chiefly seen in pediatrics 17/33 (51.5%), while CTP class B was in adults 13/32 (40.6%). The mean Nazar score was 3 ± 3, while the mean Dhawan score was 5 ± 4. The main treatment offered for both groups was zinc along with penicillamine. Conclusion: Our study showed the Dhawan score was comparable to the CTP and the MELD score in terms of predicting the disease severity of WD in our patient population. How to cite this article: Majid Z, Abrar G, Laeeq SM, et al. Clinical Characteristics and Comparison of Different Prognostic Scores in Wilson's Disease. Euroasian J Hepato-Gastroenterol 2022;12(2):69-72.

Refractory coeliac disease a reality: views from Pakistan.

Refractory coeliac disease (RCD) is described as persistence or recurrence of signs and symptoms of malabsorption with small-intestinal villous atrophy despite being on a strict gluten-free diet (GFD) for more than 12 months. RCD is a diagnosis of exclusion. There are two types of RCD, based upon the immunohistochemical features (presence of intraepithelial lymphocytes), response to treatment and prognosis. The treatment of RCD includes GFD and immunosuppressive agents. We hereby present a case of refractory celiac disease type II in a young man who later went on to develop Addisonian crisis and did not survive.

Prognostic factors of survival in patients with non-resectable hepatocellular carcinoma: hepatitis C versus miscellaneous etiology.

OBJECTIVE: To identify prognostic determinants of survival in patients with non-resectable hepatocellular carcinoma (HCC), determine the effect of transarterial chemoembolization (TACE) on prognosis, compare hepatitis C related HCC with mixed etiologies and evaluate the prognostic value of different staging systems. METHODS: This cohort study included 129 patients (male = 97, 75%) with non-resectable HCC. Data was collected from 2002 until August 2006. A series of demographic, clinical and biochemical and radiological data were collected. Cases were staged according to the Child's, Okuda, Cancer Liver Italian program (CLIP), Barcelona Clinic Liver Cancer (BCLC) and Chinese University Prognostic Index (CUPI) systems. Survival analysis was performed. Any effect of TACE on prognosis was recorded. RESULTS: Median age of patients was 52 years (range 18-82). Median follow-up 11 months (range 2-36). At the time of analysis, 102 patients had died (79%). Etiology of HCC was hepatitis C virus (HCV) in 66 (51.2%), hepatitis B virus (HBV) 31 (24%), HBV + HCV 10 (7.8%), HBV + delta hepatitis 02 (1.6), and non-B non-C 20 (15.4%). Forty-one patients (31%) were offered TACE. Univariate analysis for HCV related HCC showed that age > 52 years (p<0.05), bilirubin >1.17 mg/dl (p<0.01), INR > 1.3 (p<0.01), alpha fetoprotein > 400 ng/ml (p<0.05), splenomegaly (p<0.01), ascites (p<0.001), portal vein thrombosis (p<0.01), splenic varices (p<0.01), and TACE not offered (p<0.01) were the prognostic factors while in miscellaneous etiology female sex (p<0.05), haemoglobin < 11.0 gm/dl (p<0.01), alkaline Phosphatase > 169 lU/L (p<0.05), ascites (p<0.05) and multifocality (p<0.05) were adversely effecting prognosis. Overall independent determinants were Hepatitis C etiology, female sex and multifocality of tumour (Hazard ratios 3.0, 3.0 and 1.9 respectively). Mean survival was 17.2 vs. 12.8 months for patients offered vs. not offered TACE respectively (p value = 0.015). Okuda, CLIP, BCLC, CUPI and Child's staging systems retained their performance as judged by chi square values in regression analysis. Discriminatory ability for death evaluated by receiver operating characteristic curve was better for Okuda system in the first year. CONCLUSION: Hepatitis C as the etiology of HCC, female sex and multi-focality are associated with poor prognosis. HCV related HCC may differ in prognostic factors from non-HCV HCC. Simple staging system by Okuda predicts prognosis effectively in non-resectable.