Predictive Factors for Symptomatic Dislodgement of Percutaneous Transhepatic Biliary Drainage Catheter in Patients with Malignant Biliary Obstruction.

Purpose: To evaluate the factors that predict symptomatic dislodgement of a percutaneous transhepatic biliary drainage (PTBD) catheter in patients with malignant biliary obstruction. Materials and Methods: This retrospective study included 572 patients with malignant biliary obstruction who underwent 733 PTBD catheter insertions between January 2010 and February 2015. The duration of catheter placement, approach site, location of the catheter tip, insertion angle, presence of a closed-loop pigtail, and tube diameter were evaluated. Results: During the follow-up period, 224 PTBD catheter dislodgements (30.56%) were observed in 157 patients. Among them, 146 (19.92%) were symptomatic. The mean duration from catheter insertion until dislodgement was 32 days (range: 1-233 days). Male (odds ratio [OR]: 1.636, 95% confidence interval [CI]: 1.131-2.367, p = 0.009), right-sided approach (OR: 1.567, 95% CI: 1.080-2.274, p = 0.018), increased insertion angle (OR: 1.015, 95% CI: 1.005-1.026, p = 0.005), and incomplete closed-loop pigtail formation (OR: 1.672, 95% CI: 1.098-2.545, p = 0.016) were independent factors predictive of symptomatic dislodgement of a PTBD catheter. Conclusion: Factors predictive of symptomatic catheter dislodgement included male sex, a right-sided approach, increased insertion angle, and incomplete closed-loop pigtail formation.

[Sarcopenia in Chronic Liver Disease].

Sarcopenia is a crucial factor in assessing the nutritional status of chronic liver disease patients and predicting their prognosis and survival. The serum ammonia level is closely associated with sarcopenia regarding ammonia, a key regulator in the liver-muscle axis. In addition, various changes in energy metabolism and hormones are also involved in sarcopenia. The psoas muscle area can represent the overall skeletal muscle mass in liver disease patients. Therefore, measuring the psoas muscle area with computed tomography or magnetic resonance imaging is considered an objective and reliable method for assessing muscle mass. Providing sufficient calorie and protein intake is crucial for preventing and treating sarcopenia. In addition, engaging in appropriate exercise and addressing concurrent hormonal and metabolic changes can be helpful.

Improvement of Severe Colon Stricture after Rituximab Therapy for Concomitant Mucosa-associated Lymphoid Tissue Lymphoma in a Patient with Ulcerative Colitis.

Colorectal strictures are uncommon in patients with ulcerative colitis (UC). An extranodal marginal zone B-cell lymphoma of mucosa- associated lymphoid tissue (MALT) lymphoma is rarely involved in the colon but may be associated with inflammatory bowel diseases. A 41-year-old female with a six-year history of UC presented with a severe stricture of the sigmoid colon that prevented the passage of a colonoscope. A histological examination revealed non-specific inflammation and fibrosis without dysplasia or cancer. Despite conventional treatment, including mesalazine and azathioprine for one year after that visit, the stricture persisted. In addition, diffuse, edematous exudative inflammation and multiple shallow ulcers were observed in the distal rectum, revealing a MALT lymphoma testing positive for CD20, CD43, CD5, and Bcl-2, but negative for CD3, CD10, CD23, and cyclin-D1. Four weekly doses of rituximab were administered. Follow-up colonoscopy performed one month after treatment revealed slight improvement in the rectal lesion without remnant histological evidence of a MALT lymphoma. In addition, the stricture showed marked improvement, and the colonoscope could pass easily through the stricture site. This is the first case report on an improvement of a severe sigmoid colon stricture in a patient with UC after rituximab treatment for a concomitant rectal MALT lymphoma.

Clinical usefulness of Mac-2 binding protein glycosylation isomer for diagnosing liver cirrhosis and significant fibrosis in patients with chronic liver disease: A retrospective single-center study.

Accurate diagnosis of liver cirrhosis (LC) and significant fibrosis in patients with chronic liver disease (CLD) is important. The Mac-2 binding protein glycosylation isomer (M2BPGi) has emerged as a novel serum biomarker for liver fibrosis; however, insufficient clinical data of M2BPGi are available in patients with CLD. Therefore, we performed a retrospective cohort study to investigate the clinical usefulness of serum M2BPGi for assessing LC and significant fibrosis in CLD patients. We retrospectively reviewed the CLD patients with measured serum M2BPGi at Kosin University Gospel Hospital between January 2016 and December 2019. Multivariate logistic regression analyses were conducted to identify the independent factors associated with LC. The diagnostic power of serum M2BPGi for LC and significant fibrosis (≥F2) was evaluated and compared to that of other serum biomarkers using receiver operating characteristic curve and area under the curve (AUC). A total of 454 patients enrolled in this study. M2BPGi (adjusted odds ratio [aOR], 1.77; 95% confidence interval [CI], 1.52-2.07) and fibrosis index based on four factors (aOR, 1.23; 95% CI, 1.11-1.37) were identified as significant independent factors for LC. The AUC of M2BPGi for LC (0.866) and significant fibrosis (0.816) were comparable to those of fibrosis index based on four factors (0.860, 0.773), aspartate aminotransferase-to-platelet ratio index (0.806, 0.752), and gamma-glutamyl transpeptidase-to-platelet ratio (0.759, 0.710). The optimal cut-off values for M2BPGi for LC and significant fibrosis were 1.37 and 0.89, respectively. Serum M2BPGi levels were significantly correlated with liver stiffness measurements (ρ = 0.778). Serum M2BPGi is a reliable noninvasive method for the assessment of LC and significant fibrosis in patients with CLD.

Chronic Hepatitis B Viral Activity Enough to Take Antiviral Drug Could Predict the Survival Rate in Malignant Lymphoma.

Hepatitis B virus (HBV) infection carries a risk of liver cancer and extrahepatic malignancy. However, the incidence trend and clinical course of malignant lymphoma (ML) in HBV patients are not well known. Data about ML newly diagnosed in chronic hepatitis B (CHB) patients from 2003 to 2016 were collected from National Health Insurance Service claims. A total of 13,942 CHB patients were newly diagnosed with ML from 2003 to 2016. The number of patients increased 3.8 times, from 442 in 2003 to 1711 in 2016. The 2-year survival rate of all patients was 76.8%, and the 5-year survival rate was 69.8%. The survival rate of patients taking antivirals due to high viral activity before their diagnosis with ML was significantly lower than that of patients with lower viral activity without antivirals (1 yr-77.3%, 3 yr-64.5%, and 5 yr-58.3% vs. 1 yr-84.0%, 3 yr-73.4%, and 5 yr-68.0%, respectively). The survival rate of patients with liver cirrhosis (LC) at baseline was significantly lower than that of those without LC. Cirrhotic patients taking antivirals before ML diagnosis had a worse prognosis than who did not. High viral activity in CHB patients with ML seems to be useful in predicting the prognosis for survival.

Short-term outcome of bariatric surgery on nonalcoholic fatty liver disease: a Korean perspective.

Purpose: Obesity is associated with nonalcoholic fatty liver disease, one of the most common causes of chronic liver disease. We aimed to demonstrate the effectiveness of bariatric surgery for hepatic steatosis and fibrosis in Korean patients. Methods: A total of 32 consecutive patients were enrolled in this study. Hepatic steatosis and liver fibrosis were assessed before surgery and 6 months after surgery using transient elastography and serologic panels. Results: Thirteen patients (40.6%) were male and 19 (59.4%) were female, with a mean age of 39.3 ± 11.3 years. The body mass index was significant at the 6th month: 39.1 ± 6.7 and 30.3 ± 4.7 kg/m2 (P < 0.001), respectively. The mean preoperative controlled attenuation parameter and liver stiffness measurement values were 325.4 ± 55.9 dB/m and 7.4 ± 4.8 kPa, respectively, before surgery, and they decreased to 267.1 ± 45.1 dB/m and 5.3 ± 2.3 kPa, respectively, 6 months postoperatively (P < 0.001, respectively). Conclusion: These results suggest that bariatric surgery is associated with a significant improvement in liver steatosis and fibrosis. Bariatric surgery has a beneficial effect on nonalcoholic fatty liver disease in patients with morbid obesity in Korea.

Machine learning-based survival rate prediction of Korean hepatocellular carcinoma patients using multi-center data.

AIM: To predict survival time of Korean hepatocellular carcinoma (HCC) patients using multi-center data as a foundation for the development of a predictive artificial intelligence model according to treatment methods based on machine learning. METHODS: Data of patients who underwent treatment for HCC from 2008 to 2015 was provided by Korean Liver Cancer Study Group and Korea Central Cancer Registry. A total of 10,742 patients with HCC were divided into two groups, with Group I (2920 patients) confirmed on biopsy and Group II (5562 patients) diagnosed as HCC according to HCC diagnostic criteria as outlined in Korean Liver Cancer Association guidelines. The data were modeled according to features of patient clinical characteristics. Features effective in predicting survival rate were analyzed retrospectively. Various machine learning methods were used. RESULTS: Target was overall survival time, which divided into approximately 60 months (= /< 60 m, > 60 m). Target distribution in Group I (total 514 samples) was 28.8%: (148 samples) less than 60 months, 71.2% (366 samples) greater than 60 months, and in Group II (total 757 samples) was 66.6% (504 samples) less than 60 months, 33.4% (253 samples) greater than 60 months. Using NG Boost method, its accuracy was 83%, precision 84%, sensitivity 95%, and F1 score 89% for more than 60 months survival time in Group I with surgical resection. Moreover, its accuracy was 79%, precision 82%, sensitivity 87%, and F1 score 84% for less than 60 months survival time in Group II with TACE. The feature importance with gain criterion indicated that pathology, portal vein invasion, surgery, metastasis, and needle biopsy features could be explained as important factors for prediction in case of biopsy (Group I). CONCLUSION: By developing a predictive model using machine learning algorithms to predict prognosis of HCC patients, it is possible to project optimized treatment by case according to liver function and tumor status.

Prevalence of Non-Alcoholic Fatty Liver Disease (NAFLD) in Korean Patients Undergoing Bariatric Surgery.

Purpose: The number of Korean patients undergoing metabolic surgery for obesity is on the increase. Patients undergoing obesity and metabolic surgery have a body mass index (BMI) ≥30 kg/m2. In this study, we investigated the prevalence of nonalcoholic fatty liver disease in Korean patients who had undergone bariatric surgery. Materials and Methods: Between January 2019 and December 2021, 147 patients who underwent bariatric surgery were studied. Of these, 133 patients underwent transient elastography, and the prevalence was analyzed after being classified using the World Health Organization (WHO) obesity classification system. The participants were divided into three groups as Class 1, BMI 30 to <35 kg/m2; Class 2, BMI 35 to <40 kg/m2; and Class 3, BMI ≥40 kg/m2). Results: The average ages of three classes of patients according to the WHO obesity classification system were 42.4, 38.8, and 36.0 years with intergroup differences. Controlled attenuation parameter (CAP) and liver stiffness also showed differences in each group (307.6±59.3, 325.8±53.0, and 346.5±52.2, respectively, P=0.007; CAP, 5.5±2.1, 7.1±3.8, and 11.7±9.1, P<0.001; liver stiffness). The prevalence of type 2 diabetes mellitus also differed among the groups (61.3%, 42.2%, and 36.8%, respectively, P=0.036). The proportion of patients with liver fibrosis also showed differences in each group (16.1%, 42.2%, and 59.6%, respectively; P<0.001). Conclusion: Our study shows that most Korean patients undergoing bariatric surgery were also diagnosed with hepatic steatosis. Furthermore, the rate of liver fibrosis was higher among patients with more severe obesity.

Real-world Effectiveness and Safety of Direct-acting Antiviral Agents in Patients with Chronic Hepatitis C Genotype 2 Infection: Korean Multicenter Study.

BACKGROUND: The advancement of treatment with direct-acting antiviral (DAA) agents has improved the cure rate of hepatitis C virus (HCV) infection close to 100%. The aim of our study was to assess the real-world effectiveness and safety of DAA regimens for the treatment of patients with chronic HCV genotype 2. METHODS: We retrospectively analyzed the clinical data of patients treated with sofosbuvir plus ribavirin (SOF + RBV) or glecaprevir/pibrentasvir (G/P) for chronic HCV genotype 2 infection at seven university hospitals in the Korean southeast region. RESULTS: SOF + RBV therapy produced an 89% and 98.3% sustained virologic response 12 week (SVR12) after treatment completion in the full analysis set and per-protocol set, respectively, and the corresponding values for G/P therapy were 89.5% and 99.2%, respectively. The difference between the treatments was probably because 6.2% (59/953) of patients in the SOF + RBV group did not complete the treatment and 9.8% (14/143) in the G/P group did not test HCV RNA after treatment completion. Adverse events (A/Es) were reported in 59.7% (569/953) and 25.9% (37/143) of the SOF + RBV and G/P groups, respectively. In the SOF + RBV group, 12 (1.26%) patients discontinued treatment owing to A/Es, whereas no patients discontinued treatment because of A/Es in the G/P group. CONCLUSION: In both treatment groups, SVR was high when treatment was completed. However, there was a high dropout rate in the SOF + RBV group, and the dropout analysis showed that these were patients with liver cirrhosis (LC; 43/285, 15.1%), especially those with decompensated LC (12/32, 37.5%). Therefore, an early initiation of antiviral therapy is recommended for a successful outcome before liver function declines. Furthermore, patients with decompensated LC who are considered candidates for SOF + RBV treatment should be carefully monitored to ensure that their treatment is completed, especially those with low hemoglobin and high alanine transaminase.

Effectiveness of Albumin-bilirubin Score as a Predictor of Post-hepatectomy Liver Failure in Patients with Hepatocellular Carcinoma.

Backgrounds/Aims: Post-hepatectomy liver failure (PHLF) is a major concern for patients with hepatocellular carcinoma (HCC) who have undergone liver resection. The albumin-bilirubin (ALBI) score is a novel model for assessing liver function. We aimed to investigate the effectiveness of the ALBI score as a predictor of PHLF in HCC patients who have undergone hepatectomy in South Korea. Methods: Between January 2014 and November 2018, HCC patients who underwent hepatectomy and indocyanine retention rate at 15 min (ICG-R15) test were enrolled in this study. Results: A total of 101 patients diagnosed with HCC underwent hepatectomy. Thirty-two patients (31.7%) experienced PHLF. The ALBI score (OR 2.83; 95% CI 1.22-6.55; p=0.015), ICG-R15 (OR 1.07; 95% CI 1.02-1.12; p=0.007) and ALBI grade (OR 2,86; 95% CI 1.08-7.58; p=0.035) were identified as independent predictors of PHLF by multivariable analysis. The area under the receiver operating characteristic curve of the ALBI score and ICG-R15 were 0.676 (95% CI 0.566-0.785) and 0.632 (95% CI 0.513-0.752), respectively. The optimal cutoff value of the ALBI score in predicting PHLF was -2.62, with a sensitivity of 75.0% and a specificity of 56.5%. Conclusions: The ALBI score is an effective predictor of PHLF in patients with HCC, and its predictive ability is comparable to that of ICG-R15.

Difficulty in distinguishing malignant gastric lymphoma from advanced gastric cancer: Focusing on endoscopic findings of the Borrmann type.

ABSTRACT: Malignant gastric lymphoma (MGL) accounts for a small proportion (upto 5%) of gastric malignancies. However, unlike for advanced gastric cancer (AGC) that requires surgical treatment, the standard treatments for MGL are chemotherapy and radiotherapy. Hence, the initial impression of the endoscopist is critical for the differential diagnosis and for planning future treatment. The purpose of this study was to assess the endoscopic diagnostic accuracy and the possibility of distinguishing between AGC and MGL depending on the endoscopist's experience.A total of 48 patients who had MGL, and 48 age and sex-matched patients who had AGC were assessed by endoscopic review at a tertiary referral hospital between June 2008 and February 2017. Two endoscopic specialists reviewed the endoscopic findings and divided these diagnoses into 5 groups: Borrmann type (1, 2, 3, and 4) and early gastric cancer-like type. After this, 7 experts and 8 trainees were asked to complete a quiz that was comprised of 6 images for each of the 96 cases and to provide an endoscopic diagnosis for each case. The test results were analyzed to assess the diagnostic accuracy according to the pathologic results, endoscopic subgroups, and endoscopists' experience. For inter-observer agreement was calculated with Fleiss kappa values.The overall diagnostic accuracy of endoscopic findings by the experts was 0.604 and that by the trainees was 0.493 (P = .050). There was no significant difference in the diagnosis according to the final pathology (lymphoma cases, 0.518 vs 0.440, P = .378; AGC cases, 0.690 vs 0.547, P = .089, respectively). In the subgroup analysis, the experts showed significantly higher diagnostic accuracy for the endoscopic Borrmann type 4 subgroup, including lymphoma or AGC cases, than the trainees (P = .001). Inter-observer agreement of final diagnosis (Fleiss kappa, 0.174) and endoscopic classification groups (Fleiss kappa, 0.123-0.271) was slightly and fair agreement.The experts tended to have a higher endoscopic diagnostic accuracy. Distinguishing MGL from AGC based on endoscopic findings is difficult, especially for the beginners. Even if the endoscopic impression is AGC, it is important to consider MGL in the differential diagnosis.

Therapeutic Potential of Escherichia coli Nissle 1917 in Clinically Remission-attained Ulcerative Colitis Patients: A Hospital-based Cohort Study.

Background/Aims: Escherichia coli Nissle 1917 (EcN) alone therapy is as effective as mesalamine in inducing and maintaining remission in ulcerative colitis (UC). The efficacy and safety of EcN in combination with standard therapies have not been studied. This study examined the changes in the inflammation markers and symptoms following the additional administration of EcN to patients showing the clinical remission of UC. Methods: UC patients who received EcN after being in clinical remission for more than 3 months at Kosin University Gospel Hospital between 2013 and 2018 were evaluated through the retrospective medical-record-based review. The partial Mayo score, fecal calprotectin (FC), BMI, hemoglobin, serum cholesterol, serum albumin levels, and the safety profiles were examined at 3rd and 6th months after initiating EcN. Results: Ninety-four patients were included. After 3 months of treatment, there was no significant change in FC (156.3 µg/g to 141.1 µg/g) (p=0.653). On the other hand, partial Mayo score decreased significantly from 0.085 to 0.014 (p=0.025), and the bodyweight (p=0.001), BMI (p<0.001), hemoglobin (p=0.009), and cholesterol level increased (p=0.148). One patient (1.1%) experienced a serious adverse event with UC flare-up, and 14 patients (14.9%) discontinued EcN due to adverse events; all developed within 3 months. Conclusions: Additional administration of EcN to clinically remission-attained UC patients may improve the UC symptoms without changing the FC levels. EcN-associated adverse events develop within the early few weeks.

Changes in the Crohn's Disease Activity Index and Safety of Administering Saccharomyces Boulardii in Patients with Crohn's Disease in Clinical Remission: A Single Hospital-based Retrospective Cohort Study.

Background/Aims: Crohn's disease (CD) is characterized by uncontrolled inflammation of the intestine. Saccharomyces boulardii (S. boulardii), a probiotic, stabilizes the intestinal wall. This study examined the changes in the CD activity index (CDAI) after taking S. boulardii in patients with CD in clinical remission. Methods: In this single hospital-based retrospective cohort study, the medical records of CD patients in clinical remission, who had received S. boulardii for more than 6 months, were reviewed. The CDAI, BMI, and serum levels of hemoglobin (Hb), ferritin, iron, vitamin B12, folate, total protein, albumin, total cholesterol, CRP, and fecal calprotectin (FC) between the initiation and the 6th month were compared. The timing and reasons for the discontinuation were also investigated. Results: One hundred and fifty-four patients were included, and 92 patients, who received for more than 6 months, were analyzed. The changes in CDAI, BMI, Hb, and total cholesterol were significant as follows: CDAI from 38.52 to 30.53 (p<0.01), BMI (kg/m2 ) from 23.38 to 23.97 (p<0.01), Hb (g/dL) from 13.73 to 14.03 (p<0.01), and total cholesterol (mg/dL) from 154.9 to 161.5 (p<0.01). On the other hand, the changes in FC, CRP, ferritin, vitamin B12, folate, total protein, and albumin were not statistically significant. Only one patient stopped due to a flare-up, but this was not believed to be related to the drug. Conclusions: In patients with CD in remission, S. boulardii appears to improve the CDAI, BMI, serum Hb, and total cholesterol level without safety issues. Further randomized controlled studies will be needed.

[Gallbladder Perforation after Transarterial Chemoembolization in a Patient with a Huge Hepatocellular Carcinoma].

Transarterial chemoembolization (TACE) is a common treatment for unresectable hepatocellular carcinoma (HCC). The most common complications after TACE are non-specific symptoms called post-embolization syndrome, such as abdominal pain or fever. Rare complications, such as liver failure, liver abscess, sepsis, pulmonary embolism, cholecystitis, can also occur. On the other hand, gallbladder perforation is quite rare. This paper reports a case of gallbladder perforation following TACE. A 76-year-old male with a single 9-cm-sized HCC underwent TACE. Five days after TACE, he developed persistent right upper quadrant pain and ileus. An abdomen CT scan confirmed gallbladder perforation with bile in the right paracolic gutter and pelvic cavity. Percutaneous transhepatic gallbladder drainage was performed with the intravenous administration of antibiotics. After 1 month, the patient underwent right hemihepatectomy and cholecystectomy. Physicians should consider the possibility of gallbladder perforation, which is a rare complication after TACE, when unexplained abdominal pain persists.

Propofol alone prevents worsening hepatic encephalopathy rather than midazolam alone or combined sedation after esophagogastroduodenoscopy in compensated or decompensated cirrhotic patients.

BACKGROUND: This study was conducted to determine which type and dose of sedative drugs should be given to cirrhotic patients with compensation or decompensation during esophagogastroduodenoscopy (EGD) to prevent hepatic encephalopathy (HE) after sedation. METHODS: We reviewed the medical records of cirrhotic patients consecutively admitted to the hospital and conducted a number connection test (NCT) before and 2 h after EGD with moderate sedation. Sedation was performed using either propofol alone, midazolam alone, or combined propofol + midazolam. RESULTS: Sixty-seven patients were admitted for a screening EGD. The NCT before and after sedation were not significantly different in the propofol alone (pre-NCT = 47.3 ± 19.71 seconds vs. post-NCT = 49.4 ± 21.79 seconds, P = 0.6389). In the midazolam alone (pre-NCT = 50.3 ± 20.56 vs. post-NCT = 63.7 ± 33.17, P = 0.0021) and in the combined propofol + midazolam (pre-NCT = 47.4 ± 20.99 vs. post-NCT = 60.0 ± 30.79, P = 0.0002), NCT were significantly delayed. The propofol alone group received 52.3 ± 16.31 mg (0.82 ± 0.29 mg/kg). In 45 (67.2%) decompensated patients, only the propofol alone was not significantly different between pre-NCT (49.2 ± 22.92) and post-NCT (52.3 ± 24.90) (P = 0.4548). Serum sodium level was significantly correlated with delta-NCT (r = 0.3594, P = 0.0028). CONCLUSION: Propofol alone could be the best sedation strategy for cirrhotic patients with compensation or decompensation without aggravation of covert or overt HE. Hyponatremia could be a risk factor for developing or worsening HE after EGD with sedation.

Sex differences between Helicobacter pylori infection and cholesterol levels in an adult health checkup program.

BACKGROUND: Helicobacter pylori (H pylori) infection is suggested to be a risk factor of metabolic syndrome (MS) and lipid abnormalities. The aim of this study was to investigate the influence of H pylori infection on MS and lipid abnormalities according to sex differences. MATERIALS AND METHODS: We analyzed a total of 4551 adults who received health checkups from January 2016 to May 2017. We enrolled participants who did not have a history of hypertension, diabetes, hyperlipidemia, or cancer among those who underwent endoscopy with a rapid urease test. RESULTS: We included a total of 1065 participants, and 663 patients (62.3%) were H pylori-positive. The H pylori infection rate was 59.3% (426/719) in males and 68.5% (237/346) in females. The mean level of total cholesterol (P = .003), low-density lipoprotein (LDL) cholesterol (P = .046), and triglycerides (P = .029) were statistically higher in H pylori-infected males. The mean level of high-density lipoprotein (HDL) cholesterol was statistically lower in H pylori-infected females (P = .032). Multivariate analysis showed that total cholesterol in males (odds ratio [OR], 1.007; 95% confidence interval [CI], 1.002-1.011) and HDL cholesterol in females (OR, 0.983; 95% CI, 0.968-0.998) were associated with active H pylori infection. The prevalence of MS was higher in both male and female H pylori-infected groups; however, there was no statistical significance. CONCLUSIONS: H pylori infection is significantly related to increased total cholesterol in males and to decreased HDL cholesterol in females, which suggests that H pylori could affect lipid profiles and may be different by sex.

Liver transplantation for azithromycin-induced severe liver injury.

Drug-induced liver injury is the most common cause of acute liver failure in Western countries by prescription drugs and herbal medications. Liver injury due to azithromycin has rarely been reported. This is a brief report of a patient administered azithromycin and who developed acute liver failure leading to liver transplantation. We report the case of a 68-year-old woman who developed jaundice 1 week after she started taking a azithromycin. On the 3rd day of hospitalization, her hepatic function rapidly deteriorated and level of consciousness decreased to drowsiness. The model for end-stage liver disease score was confirmed to be 33, and liver transplantation was considered. On the 8th day of hospitalization, she underwent emergency living donor liver transplantation, receiving a right lobe liver graft from a 35-year-old male donor, the patient's son. Currently, she is alive with good liver function after 25 months of transplant. This case suggests that azithromycin may cause rare hepatitis with liver failure. Therefore, at the beginning of the azithromycin treatment, patients should visit the hospital immediately if symptoms such as jaundice and abdominal pain are experienced.

Poor preoperative enteral nutrition would be a risk factor for readmission due to infection after liver transplantation.

Background: Most patients who undergo liver transplantation (LT) have advanced cirrhosis and poor nutritional status. The aim of this study was to investigate the effect of enteral nutrition (EN) on the clinical outcomes after LT. Methods: From 2015 to 2019, the medical records of recipient of LT at Kosin University Gospel Hospital were retrospectively reviewed. Results: Thirty-seven patients underwent LT. Nineteen patients underwent living donor liver transplantation (LDLT) and 18 patients underwent deceased donor liver transplantation (DDLT). One LDLT patient was excluded because transplantation was done within 1 month. Five DDLT patients were excluded either because they died within 1 month (n=4) or received transplantation within 1 month. (n=1). Therefore, 31 patients were analyzed. Psoas-muscle index (P=0.715) and serum albumin (P=0.111) were not statistically different between the LDLT and DDLT groups. Four patients (4/31) were readmitted because of infection. One LDLT patient was diagnosed with genitourinary infection. The three DDLT patients were diagnosed with pulmonary tuberculosis (n=1), diverticulitis (n=1), and sepsis (n=1). Readmission caused by infection was not statistically different between LDLD and DDLT patients (P=0.284). Preoperative EN <25% of the recommended amount (P=0.016) was significantly associated with readmission related to infection. In multivariate analyses, preoperative EN <25% was an independent risk factor for readmission due to infection after LT regardless of psoas-muscle index, baseline Model for End-Stage Liver Disease score, or LT type. Conclusions: Preoperative poor EN is significantly associated with readmission risk due to infection within 3 months of LT.

Risk factors associated with hypophosphatemia in chronic Hepatitis B patients treated with tenofovir disoproxil fumarate.

Tenofovir disoproxil fumarate (TDF) is thought to cause varying degrees of hypophosphatemia in patients with chronic hepatitis B (CHB). Therefore, we investigated factors that cause hypophosphatemia in patients treated with TDF and methods to increase serum phosphorus concentrations in clinical practice.We completed a retrospective review of patients with CHB treated with TDF initially at Kosin University Gospel Hospital, Busan, Korea from January 2012 to January 2017. Subclinical hypophosphatemia and hypophosphatemia were defined as serum phosphorus below 3.0 mg/dL and 2.5 mg/dL, respectively.We screened 206 patients with CHB treated with TDF, among which 135 were excluded for the following reasons: baseline malignancy (59), limited data (50), co-administered other antivirals (14), hypophosphatemia at baseline (7), and other reasons (5). The final study population comprised 71 patients. Subclinical hypophosphatemia developed in 43 (60.5%) patients. Hypophosphatemia occurred in 18 patients (25.3%). Liver cirrhosis was the most significant predictor of hypophosphatemia (P = .038, OR = 3.440, CI = 1.082-10.937) Patients diagnosed with subclinical hypophosphatemia were encouraged to increase their intake of nuts and dairy products (25 patients) or reduce their alcohol intake (2), dose reduction of TDF (4) or placed under observation (4). Among patients with subclinical hypophosphatemia, serum phosphorus concentrations were elevated (>3.0 mg/dL) in 23 of 36 patients (63.8%). Increased nut and dairy intake increased phosphorus concentrations to more than 3.0 mg/dl in 16 of 25 patients (64.0%).Entecavir or tenofovir alafenamide fumarate (TAF) should be considered rather than TDF in patients with liver cirrhosis because of the risk of hypophosphatemia. Instead of stopping TDF treatment, encouraging increased intake of phosphorus-rich foods could increase serum phosphorus concentrations in clinical practice.

Clinical Course of Renal Disease in Recipients of Liver Transplant Who Required Peritransplant Dialysis.

PURPOSE: Renal dysfunction is a common complication and one of the factors that affects the outcomes of liver transplantation (LT). The aim of this study was to review the clinical course of recipients of LT who needed peritransplant dialysis at our center. METHODS: We compared the clinical demographics, morbidity, and mortality between patients who required and those who did not require peritransplant dialysis among 26 recipients of LT from May 2015 to February 2018 at our center. RESULTS: Among the recipients, 9 had pretransplant or posttransplant dialysis and 17 did not. The patients who underwent dialysis had a higher pretransplant Model for End-Stage Liver Disease score (42 vs 13; P < .001), older donor age (41 vs 24 years; P < .001), and longer post-LT hospital stay (37 vs 20 days; P < .001). However, there was no significant difference in the serum creatinine level between the 2 groups (1.36 vs 0.93 mg/dL; P = .187) at 2 weeks (1.10 vs 0.96 mg/dL; P = .341), 1 month (1.06 vs 0.86 mg/dL; P = .105), and 3 months after LT (0.92 vs 0.94 vs 0.89 mg/dL; P = .825). Mortality was higher in the peritransplant dialysis group (P = .043). The pre-LT dialysis duration was significantly related to post-LT dialysis (P = .028) and mortality (P = .011). CONCLUSIONS: The pre-LT dialysis duration is considered an important factor in the survival and recovery of kidney function after LT. Therefore, if the patient has started dialysis, it may be beneficial to proceed to LT as soon as possible.