Acoustic Radiation Force Impulse Elastography in Post-transplant Recurrent Hepatitis C in Living Donor Liver Transplantation.

OBJECTIVE: The aim of the study was to evaluate the efficacy of liver fibrosis (LF) with acoustic radiation force impulse (ARFI) elastography for post-transplant (post-LT) HCV recurrence. PATIENTS AND METHODS: We enrolled 89 adult recipients of living donor liver transplantation (LDLT) who had HCV, with or without post-LT HCV recurrence and treated or not treated. The post-LT HCV recurrence was diagnosed on the basis of RNA viral load present. ARFI examination was performed every 3 months for all patients, with shear wave velocity (SWV) obtained quantitatively in m/s and correlated with histopathologic fibrosis scoring of liver biopsy (LB). RESULTS: There were 50 (50 of 89) patients without HCV recurrence and 39 (39 of 89) with post-LT recurrence in the 89 patients studied. The recurrent group had significantly higher median SWVs (1.87 ± 0.52 vs 1.37 ± 0.52 m/s, P < .0001), in which 18 (18 of 39) patients had antiviral drug treatment and obtained significant improvement with SWVs from 1.83 ± 0.49 to 1.68 ± 0.56 m/s, P = .043. The correlations of LF staging between ARFI elastography and Ishak histopathologic LF scores showed great significance, P = .045. The HCV RNA titer after antiviral treatment decreased from 3,831,750 to 0, P < .0001, but the RNA titer of nontreated patients remained high and the median SWV increased. The Ishak LF staging in the nontreated group progressed from stage 1 to 2, P = .012 and SWV increased from 1.69 ± 0.54 to 1.91 ± 0.66 m/s, P = .085 at 1-year follow-up. CONCLUSION: ARFI elastography has efficient quantitative LF monitoring correlated with histopathologic staging for post-LT HCV recurrence. It could be an alternative, noninvasive method for frequent LB in the disease follow-up.

Efficiency of Transluminal Angioplasty of Hepatic Venous Outflow Obstruction in Pediatric Liver Transplantation.

BACKGROUND: Our aim in this study was to evaluate long-term efficiency of hepatic venous balloon angioplasty (BA) and stent placement (SP) for hepatic venous outflow obstruction (HVOO) in pediatric liver transplantation (LT). METHODS: From January 1999 to September 2016, 262 pediatric patients underwent LT at our hospital. Ten were diagnosed with HVOO, which included 8 living donor grafts and 2 split liver grafts. BA and SP were used in management of these 10 patients with HVOO. After intervention, Doppler ultrasound (DUS) was the major follow-up modality for comparing efficiency of BA and SP. RESULTS: The incidence of HVOO was 3.8% (10 of 262) in our pediatric LTs. Of the 10 HVOO cases, 5 had SP, 3 had BA once, 1 had BA twice, and 1 had BA twice along with SP. The patent hepatic vein was maintained after a mean follow-up of 7.4 (range, 0.04-17) years. Recurrent rate of HVOO after BA was 42%. Neither recurrent HVOO nor stent migration occurred after SP and throughout long-term follow-up. CONCLUSION: Hepatic venous SP was found to be more effective and safe than BA for treatment of HVOO in pediatric LT for long-term follow-up.

The acoustic radiation force impulse elastography evaluation of liver fibrosis in posttransplantation dysfunction of living donor liver transplantation.

BACKGROUND: The acoustic radiation force impulse elastography (ARFI) is a new technology of elastography integrated into B-mode ultrasonography. It has been a reliable method to evaluate liver fibrosis of chronic liver disease in recent years, but less applied in the posttransplantation liver. The aim of the study was to evaluate liver fibrosis by the ARFI with correlation of pathological stages in living donor liver transplantation (LDLT). MATERIALS AND METHODS: From August 2010 to August 2012, there were 57 LDLT patients with liver biopsy (LB) due to posttransplantation dysfunction; all patients also received posttransplantation ARFI liver stiffness measurement (LSM) after transplantation for liver fibrosis staging. The ARFI elastography was performed using a Siemens Acuson S2000 ultrasound system with 4V1 transducers (Acusion, Siemens Medical Systems Co. Ltd. Erlangen, Germany). The ARFI LSM value was presented by shear wave velocity (SWV, m/s). The fibrosis staging as F0 to F4 was in accordance with the Metavir scoring system. RESULTS: A total of 57 patients had both posttransplantation LB and effective ARFI fibrosis staging for correlation. The ARFI LSM value increased with severity of liver fibrosis and had significant linear correlation with the results of histological fibrosis staging. The ARFI LSM sensitivities (Se), specificities (Sp), and cutoff values based on receiver-operator characteristic curve were F0: 0.75 m/s (Se: 93.8%, Sp: 4%), F1: 1.06 m/s (Se: 95.5%, Sp: 25.7%), F2: 1.81 m/s (Se: 50%, Sp: 83.6%) and F3: 2.33 m/s (Se: 100%, Sp: 92.9%). Predictive value of ARFI LSM reported a significant difference between early fibrosis stage (F0-F1) and advanced fibrosis stage (F ≧ 2) (P < .05). CONCLUSION: In this study, ARFI demonstrated a strong linear correlation and severity of liver fibrosis with LB pathologic staging. ARFI can be an alternative and compensatory method for frequent LB in the posttransplantation liver.

Significance of portosystemic shunt on graft survival in liver transplantation: a rat model.

AIMS: Distal splenorenal shunt effectively controls bleeding from esophageal and gastric varices but has a different effect on liver transplantation. This study sought to develop an animal model in rats to mimic the recipient with a portosystemic shunt and to investigate its hemodynamic consequences on liver transplantation. METHODS: We prepared 5 groups of allogeneic or syngeneic rat liver transplantation models with versus without portosystemic shunt, to investigate its effects on graft survival and portal flow. To explore the effects of excessive portal flow on graft survival in small-for-size liver transplantation, we transplanted partial liver grafts into syngeneic recipients. RESULTS: In allogeneic combinations, graft survival among the shunt group was shortened compared with their control counterparts. The graft survival of the large shunt group was significantly lower than that of a small shunt or without shunt group in a syngeneic liver transplantation model. Portal blood pressure of the large shunt group was significantly lower than that of the small shunt group. In contrast, excessive portal flow resulted in dysfunction of liver graft in small-for-size liver transplantation. CONCLUSIONS: These results suggested that reduction in portal flow by portosystemic shunt lead to an acceleration of acute rejection and subsequent liver graft dysfunction, but it may be applicable to regulate the excessive portal flow in small-for-size transplantations. This study showed a valuable model mimicking the recipient with a portosystemic shunt.

Epidemiological study of diabetic retinopathy in a primary care setting in Hong Kong.

OBJECTIVES: To estimate the prevalence and risk factors of diabetic retinopathy in type 2 diabetic patients, and to investigate the difference in retinopathy progression in patients with normal fundi or established retinopathy at baseline and the risk factors implicated in the progression. DESIGN: Retrospective community-based study. SETTING: Ten primary care clinics in Hong Kong. PATIENTS: Type 2 diabetic patients; subsidiary analysis included subjects with more than one screening event. MAIN OUTCOME MEASURES: Patient demographics, baseline prevalence, and risk factors of diabetic retinopathy; progression of retinopathy in patients with normal fundi and established retinopathy at baseline, and the associated risk factors. RESULTS: A total of 6165 patients were recruited from January 1998 to May 2004. Primary analysis included 4423 patients with good-quality retinal photographs. The mean age of the patients was 60.36 years (standard deviation, 10.80 years; range, 28-94 years), the mean duration of diabetes was 4.71 years (standard deviation, 4.67 years; range, 0.1-40.6 years), and the mean level of glycated haemoglobin was 7.47% (standard deviation, 1.44%). The prevalence of retinopathy at baseline was 28.4%. Subsidiary analysis showed progression to sight-threatening retinopathy was more common in the group with baseline retinopathy than that without (7.9% vs 0.7%), and occurred at a faster rate (mean, 1.5 [range, 0.5-3.0] vs 2.0 [1.0-4.2] years). Logistic regression revealed that the level of glycated haemoglobin was positively associated with both the onset (P<0.001) and progression of retinopathy (P=0.03). CONCLUSION: Optimal glycaemic control is important for reducing sight-threatening retinopathy. Close observation is required for patients with established retinopathy as progression occurs more rapidly.

The significance of transarterial embolization for advanced hepatocellular carcinoma in liver transplantation.

INTRODUCTION: Transarterial embolization (TAE) is the treatment of choice for advanced HCC to control or even induce tumor shrinkage. The aim of this study was to evaluate the effect of pretransplantation TAE for treatment of advanced HCC. MATERIAL AND METHODS: From 1996 to 2002, we studied 12 cirrhotic patients with HCC, including six who met and six who exceeded the Milan criteria. All patients had sufficient hepatic function to undergo TAE. Liver transplantations were performed subsequently and they were followed prospectively for a median of 22 months (range = 12 to 53 months). RESULTS: The explanted livers from the 12 patients who had undergone TAE were noted to have extensive tumor necrosis. The pathological specimens at LT showed downstaging of the HCC, which allowed those six patients to meet the Milan criteria. The overall 1- and 2-year survival rates were 92% and 73%, respectively. The overall 1- and 2-year disease-free survival rates were 92% and 73%, respectively. One death unrelated to liver disease at 2 years after LT was noted in the downgraded group. One patient of the initially eligible group developed lung metastasis at 6 months and died at 12 months after LT. CONCLUSION: TAE is effective to downstage advanced HCC and reduce the dropout rate on the LT waiting list. Pre-LT TAE may be considered as a better therapeutic strategy for patients with advanced HCC.

The prevalence of microalbuminuria among patients with type II diabetes mellitus in a primary care setting: cross-sectional study.

OBJECTIVES: To determine the prevalence of microalbuminuria among patients with type II diabetes mellitus in a primary care setting, and to study the association between various risk factors and the presence of microalbuminuria. DESIGN: Cross-sectional community-based study. SETTING: Four primary care clinics, Hong Kong. PATIENTS: All patients with type II diabetes mellitus who regularly attended the clinics between May 2002 and March 2003. MAIN OUTCOME MEASURES: Patients' demographic data, the proportion with microalbuminuria (measured using a spot urine test), and the association between this condition and risk factors for diabetic nephropathy (via correlation and multivariable logistic regression analysis). RESULTS: The mean age of the 1161 patients in the sample population was 58.0 years. The mean duration of diabetes mellitus was 5.7 years, and the mean level of glycated haemoglobin was 7.4%. A total of 13.4% of the patients had microalbuminuria. Having the condition was significantly associated with advanced age, female sex, poor glycaemic control, and coexisting hypertension in both correlation and regression analyses. No significant association with ever smoking was found. CONCLUSION: Early screening for incipient diabetic nephropathy and aggressive management of modifiable risk factors in a primary care setting may be important in optimising the renal outcome of patients with type II diabetes mellitus.