Early Allograft Dysfunction After Live Donor Liver Transplantation: It's Time to Redefine?

BACKGROUND: An ideal definition of early allograft dysfunction (EAD) after live donor liver transplantation (LDLT) remains elusive. The aim of the present study was to compare the diagnostic accuracies of existing EAD definitions, identify the predictors of early graft loss due to EAD, and formulate a new definition, estimating EAD-related mortality in LDLT recipients. METHODS: Consecutive adult patients undergoing elective LDLT were analyzed. Patients with technical (vascular, biliary) complications and biopsy-proven rejections were excluded. RESULTS: There were 19 deaths due to EAD of a total of 304 patients. On applying the existing definitions of EAD, we revealed their limitations of being either too broad with low specificity or too restrictive with low sensitivity in patients with LDLT. A new definition of EAD-LDLT (total bilirubin >10 mg/dL, international normalized ratio [INR] > 1.6 and serum urea >100 mg/dL, for five consecutive days after day 7) was derived after doing a multivariate analysis. In receiver operator characteristics analysis, an AUC for EAD-LDLT was 0.86. The calibration and internal cross-validation of the new model confirmed its predictability. CONCLUSION: The new model of EAD-LDLT, based on total bilirubin >10 mg/dL, INR >1.6 and serum urea >100 mg/dL, for five consecutive days after day 7, has a better predictive value for mortality due to EAD in LDLT recipients.

Living donor liver transplantation for hepatocellular carcinoma in Indian patients- Is the scenario different?

BACKGROUND: Living donor liver transplant (LDLT) for hepatocellular carcinoma (HCC) has been controversial in terms of selection and outcome. We share our experience of LDLT for HCC in Indian patients. METHODS: Retrospective analysis of patients undergoing LDLT for HCC discovered either preoperatively or incidentally on explant pathology was done. Preoperative characteristics and explant histopathology findings were recorded. Overall, recurrence-free survival and factors predicting recurrence were analyzed. RESULTS: Six hundred and eleven LDLT were performed between June 2011 and October 2019. HCC constituted 6.5% (n = 53) of transplant activity. Forty had preoperative diagnosis, while 13 were detected incidentally. The median model for end-stage liver disease (MELD) score was 18 for patients with HCC. Only in 10 patients (19%), HCC was the primary indication for liver transplant (LT), and the rest had undergone transplant for progressive decompensation. Thirty-two patients were within up-to-7, while 21 were outside up-to-7 criteria. Overall 5-year survival was 85.4% and recurrence-free survival was 83.3% after a median follow-up of 35 months (13-59). This was similar to LDLT for other indications (81.2% at 5 years). Risk Estimation of Tumor Recurrence After Transplant (RETREAT) score was best able to predict recurrence (p = 0.03) with odds ratio of 6.8. CONCLUSION: Patients with HCC in India present late for liver transplant. Most patients have some form of decompensation before they undergo LT. In selected patients, overall survival was comparable with other indications for LDLT with acceptable recurrence rates. RETREAT score was best to predict recurrence.

Large adrenal tumours mimicking hepatic malignancy: the role of concurrent adrenalectomy and anterior approach hepatectomy.

BACKGROUND: Large right adrenal tumours may invade the liver and mimic primary hepatic malignancy, presenting diagnostic and management challenges. The 'anterior approach hepatectomy' (AAH) using hanging manoeuvre may be safe for resection of such tumours. METHODS: Prospectively maintained database was analysed to identify the large tumours of adreno-hepatic region subjected to hepatectomy. Clinico-biochemical, radiological and surgical details were reviewed. AAH and hanging manoeuvre was adopted for the patients requiring right hepatectomy. RESULTS: Out of the eight patients with adreno-hepatic tumour, four had indeterminate origin of the mass, two had complex cysts, and two were diagnosed as hepatocellular carcinoma on the pre-operative imaging. The median age was 38 years (23-66); male:female ratio was 5:3. AAH was performed in four patients, while others underwent non-anatomical resection of involved segment(s). This accounted for 1.01% of 789 hepatectomies performed during the study period. The median intra-operative blood loss was 525 mL (150-2200 mL) and the median tumour size was 9 cm (6-17 cm). All patients underwent R0 resection. The final histopathological diagnoses were: three phaeochromocytomas (two malignant and one benign), two adrenocortical carcinomas, one malignant paraganglionomas and two adrenal cysts. Major complication (grade IVa) was experienced in one patient. On median follow-up of 67.5 months (7-84), all were alive and one patient had tumour recurrence. CONCLUSION: Adrenal tumours mimicking primary hepatic malignancy are rare but pose diagnostic challenges. The AAH is a safe approach with acceptable R0 resection, blood loss, surgical complications and overall outcome for the patients requiring right hepatectomy.

In Situ Splitting of the Cadaver Liver for Two Adult Recipients by LDLT Technique.

BACKGROUND: To expand the donor pool, split liver transplantation is conventionally performed for one adult and one pediatric recipient. Application of this technique for two adult recipients can produce remarkable impact on the waiting list. Proper donor and recipient selection is crucial for the favorable outcome following full-right and full-left liver split. Right lobe adult to adult living donor liver transplantation (LDLT) is essentially a full right and full left split. However, LDLT techniques have not been used for full right and left split. METHODS: We performed in situ splitting of the whole liver using LDLT techniques from a hemodynamically stable young deceased donor and transplanted into two adult recipients, both with model for end-stage liver disease score of 17. The transection was carried out through the midplane of liver, generating a right lobe and a left lobe graft. RESULTS: Both the recipients had uneventful postoperative recovery. At ten months of follow up, both the recipients are doing well with good liver function. CONCLUSION: Based on the concept of living related liver transplantation, our case explores the technical feasibility of full-right and full-left in situ liver split.

The Nonradiographic Axial Spondyloarthritis, the Radiographic Axial Spondyloarthritis, and Ankylosing Spondylitis: The Tangled Skein of Rheumatology.

Since 1984 the diagnosis of ankylosing spondylitis (AS) has been based upon the modified New York (mNY) criteria with mandatory presence of radiographic sacroiliitis, without which the diagnosis is not tenable. However, it may take years or decades for radiographic sacroiliitis to develop delaying the diagnosis for long periods. It did not matter in the past because no effective treatment was available. However, with the availability of a highly effective treatment, namely, tumour necrosis factor-α inhibitors (TNFi), the issue of early diagnosis of AS acquired an urgency. The Assessment of SpondyloArthritis International Society (ASAS) classification criteria published in 2009 was a significant step towards this goal. These criteria described an early stage of the disease where sacroiliitis was demonstrable only on MRI but not on standard radiograph. Therefore, this stage of the disease was labelled "nonradiographic axial SpA" (nr-axSpA). But questions have been raised if, in search of early diagnosis, specificity was compromised. The Federal Drug Administration (FDA, USA) withheld approval for the use of TNFi in patients with nr-axSpA because of issues related to the specificity of these criteria. This review attempts to clarify some of these aspects of the nr-axSpA-AS relationship and also tries to answer the question whether ASAS classifiable radiographic axial spondyloarthritis (r-axSpA) term can be interchangeably used with the term AS.

Synthesis and biological evaluation of novel N-aryl maleimide derivatives clubbed with α-hydroxyphosphonates.

A series of novel molecules 5a-g containing N-aryl maleimide and α-hydroxyphosphonate moieties were synthesized. A distinct approach for high-yielding synthesis of α-hydroxyphosphonates has been discovered using various catalyst and solvents. The structures of the synthesized compounds were elucidated by IR, NMR, MS and CHN analysis. All the synthesized compounds were tested for qualitative (Zone of inhibition) and quantitative (MIC) antimicrobial activities against two pathogenic bacteria such as Bacillus subtilis (NCIM 2250) and Escherichia coli (ATCC 25922) and four pathogenic fungi such as Candida albicans (MTCC 277), Candida tropicalis (MTCC184), Aspergillus niger (MCIM 545) and Aspergillus clavatus (MTCC 132). The investigation of antimicrobial screening data revealed that most of the tested compounds are moderate to good microbial inhibitors.

Calcium oxide supported gold nanoparticles as catalysts for the selective epoxidation of styrene by t-butyl hydroperoxide.

Gold nanoparticles are deposited on basic CaO supports as catalysts for the selective conversion of styrene into styrene oxide. Synthetic methods, gold loading and calcination temperatures are varied to permit an understanding of their influence on gold nanoparticle size, the presence of cationic gold species and the nature of interaction between the gold nanoparticles and the CaO support. Based on these studies, optimal conditions are designed to make the Au/CaO catalyst efficient for the selective epoxidation of styrene.