Introduction

Post liver transplantation portal hypertension (post LT-PH) is an emerging
late complication after LT and a challenging disorder.

Aims & Methods

The aim of this study is to describe the prevalence, risk factors, clinical consequences (oesophageal varices, ascites, portal vein
thrombosis, hydrothorax, hepatic encephalopathy) and the mortality rate of post LT-PH. We retrospectively enrolled 358 patients receiving a liver transplant at the University Hospital Policlinico Umberto I, between 2000 and 2018 to ensure a follow-up period of at least 5 years. For the statistical analysis Chi squared test, Fisher Test and T test were used.

Results

In our cohort 54 (15%) patients developed post LT-PH. The average time between LT and the occurrence of clinical evidence of PH was 6 ± 3.7 years: specifically 5.4 ± 3.4 years in patients with cirrhosis recurrence, and 3.4 ± 4.5 years for all non-cirrhotic portal hypertension causes. Patients with post LT-PH showed significant differences from the other LT patients regarding the immunosuppression regimen, with a more frequent use of cyclosporine (27.7 vs 1.3% p> 0.0001). Etiology of portal hypertension was cirrhotic in 41 (76%) patients and non-cirrhotic in 12 (24%) patients. The most frequent etiologies of cirrhosis recurrence were HCV or HBV, biliary complications, chronic rejection, de novo autoimmune hepatitis. Among the non-cirrhotic portal hypertension, we identified 3 cases of Porto Sinusoidal Vascular Disorder (PSVD), 1 case of Budd-Chiari Syndrome de novo and several cases of pre or post-hepatic anastomotic stenosis. The most frequent complications of post LT-PH were gastroesophageal varices, ascites, and portal vein thrombosis. Four patients underwent TIPS placement for the management of gastrointestinal bleeding. Moreover, as expected, more patients with cirrhotic post LT-PH died for liver failure (61%) while in the non cirrhotic group only in 3 (25%) cases death was liver related (p value 0.0471).

Conclusion

PH may develop during the follow up of liver transplant patients. This event has been mainly reported due to cirrhosis recurrence, especially for viral etiology, and numbers will decrease following the introduction of efficacious antiviral therapies. Despite this, it is important to consider other causes of post LT-PH. In our cohort 3 cases of PSVD have been highlighted, which is a rare and sparsely described event in the literature among transplant patients. Gastroesophageal varices and ascites were the most frequent complications of portal hypertension. Close clinical and instrumental follow-up is suggested for early diagnosis and management.

Introduction

Portal hypertension is a major complication of advanced chronic liver disease (ACLD) and is associated with gastro-oesophageal varices, a leading cause of morbidity and mortality. The British Society of Gastroenterology (BSG) recommends oesophagogastroduodenoscopy (OGD) for variceal screening in all patients with cirrhosis, which could result in a high volume of unnecessary procedures. Given increasing demands on NHS services and the need for cost-effective resource allocation, strategies to reduce unnecessary endoscopy are critical.
The Baveno VI and VII consensus workshops propose non-invasive criteria to optimise variceal screening. Baveno VI suggests that patients with a liver stiffness measurement (LSM) less than 20 kPa and a platelet count greater than 150×10⁹/L can safely avoid OGD. Baveno VII further refines this by recommending non-selective beta-blocker (NSBB) therapy in patients with clinically significant portal hypertension (CSPH), defined as LSM greater than 25 kPa, thereby eliminating the need for screening endoscopy in this group. For patients not clearly stratified by Baveno VI or VII criteria, splenic stiffness measurement (SSM) offers an additional non-invasive tool to refine risk assessment. Incorporating SSM in this intermediate-risk group may further reduce the need for OGD, with recent data showing a high negative predictive value for ​ruling out high-risk varices.

Aims & Methods

We aim to quantify the reduction in endoscopy burden achieved by applying Baveno VI and VII criteria in ACLD patients.
A retrospective analysis was conducted on 1,703 patients who underwent 1,802 FibroScans between January 1, 2024, and December 31, 2024. Patients were stratified based on LSM and platelet counts into the following categories:
1. BSG Criteria: All patients with LSM ≥10 kPa requiring OGD.
2. Baveno VI Criteria: Patients with LSM <20 kPa and platelet count ≥150×10⁹/L, for whom OGD could be safely avoided.
3. Baveno VII Criteria: Patients with CSPH (LSM ≥25 kPa) recommended for NSBB therapy without the need for screening OGD.
4. Patients requiring OGD: Those not meeting Baveno VI criteria and without CSPH.

Results

Liver stiffness distribution:
• <10 kPa: 1,534 patients
• 10–14.9 kPa: 136 patients
• 15–19.9 kPa: 44 patients
• 20–24.9 kPa: 31 patients
• ≥25 kPa: 57 patients
Impact of Adopting Baveno VI and VII:
• BSG Guidelines: 274 patients (LSM ≥10 kPa) would require OGD.
• Baveno VI: 149 patients (LSM <20 kPa, platelets ≥150) could avoid OGD.
• Baveno VII: 57 patients (LSM ≥25 kPa) would be managed with NSBB, avoiding OGD.
• Total Reduction: 206 out of 274 patients (~75%) could avoid OGD.

Conclusion

Adopting Baveno VI and VII criteria would significantly reduce the need for variceal screening endoscopy in ACLD patients. By applying these thresholds, up to 75% of OGDs could be avoided, optimising NHS resources and reducing patient burden. These findings support the routine use of non-invasive risk stratification in ACLD management.

References

1. Tripathi D, Stanley AJ, Hayes PC, et al. UK guidelines on the management of variceal haemorrhage in cirrhotic patients. Gut. 2015;64(11):1680–1704. doi:10.1136/gutjnl-2015-309262
2. de Franchis R, Bosch J, Garcia-Tsao G, et al. Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension. J Hepatol. 2015;63(3):743–752. doi:10.1016/j.jhep.2015.05.022
3. de Franchis R, Bosch J, Garcia-Tsao G, et al. Baveno VII – Renewing consensus in portal hypertension. J Hepatol. 2022;76(4):959–974. doi:10.1016/j.jhep.2021.12.022

Introduction

According to Baveno VII, non-invasive-based criteria is useful to rule in or out for clinically significant portal hypertension (CSPH) in advanced chronic liver disease (ACLD). Liver stiffness measurement (LSM) and platelet count (PLT) are the two parameters considered in this field, particularly LSM≥25 kPa is highly predictive for CPSH, while LSM ≤15 kPa plus PLT ≥150 G/L exclude CSPH. Spleen Stiffness Measurement (SSM) can be used in ACLD patients, identifying patients with a low probability (SSM<40 kPa) of having high-risk varices.

Aims & Methods

The aim of our study is to explore the utility of SSM in predicting endoscopic signs of portal hypertension and its added value compared to LSM and platelet count. This retrospective study was conducted at the University of Naples “Federico II”. All patients with ACLD (for any etiologies) with at least LSM≥10 who underwent esophagogastroduodenoscopy (EGD) for portal hypertension assessment within one year before Spleen Stiffness measurement were enrolled. Exclusion criteria were patients < 18 yrs, PLT>150*10³/cc, liver transplantation, HCC patients, portal vein thrombosis and incomplete data. The study population was divided in three groups: the first includes patients with LSM≥25, the second patients with LSM≥15 and <25 and the third patients with LSM≥10 and <15.

Results

Sixty-nine patients (41 male, mean age 62.7±14.8 years old) were recruited. The main etiology was virus-related (30 patients, 43.4%) followed by metabolic (13 patients, 18.8%), alcohol (12 patients, 17.4%), autoimmune (7 patients, 10.1%) and other (7 patients, 10.1%). Fifty-five patients were Child A and 14 patients were Child B. Overall, mean LSM was 24.7±12.9 kPa, mean SSM was 59.8±23.5 kPa and mean PLT count was 102±50*10³/cc. The groups were composed by 25, 27 and 17 patients, respectively. Eighteen out of 25 patients (69.2%) belonging to the first group had endoscopic sign of PH and almost all of them (17/18, 94.4%) had SSM≥40kPa. In the second group a lower rate of endoscopic sign of PH was found (14/27, 51.8%), although SSM had a high diagnostic performance (100%). Finally, in the third group, in which according to Baveno VII the pre-test probability of CSPH is low, 5 out of 17 (29.4%) had endoscopic sign of PH and, among them, 60% of patients (3/5) had SSM>40kPa. Indeed, SSM demonstrated a better positive correlation with the presence of endoscopic sign of PH (Pearson coefficient r=0.4) then LSM (r=0.3).

Conclusion

SSM enhances the diagnostic performance of LSM and PLT assessment proposed by Baveno VII in predicting portal hypertension in patients with ACLD.

Introduction

​Liver transplantation (LT) is a potentially life-saving treatment for patients with end-stage liver disease, particularly acute-on-chronic liver failure (ACLF) patients due to high mortality rates.

Aims & Methods

Aims: This study aimed to characterize the population and outcomes of patients with ACLF undergoing LT, as well as to identify factors associated with worse prognostic. Methods: Retrospective cohort study including 155 consecutive LTs performed in a Tertiary Center, between January 2020 and December 2022. ACLF was defined according to the EASL-CLIF consortium definitions. The statistical analysis was performed with the SPSS software v28.

Results

A total of 155 patients received a LT, including 25 with ACLF (16.1%). Of these, 16 (64%) had ACLF-1, 3 (12%) ACLF-2, and 6 (24%) ACLF-3, with renal dysfunction being the most common organ failure (27%). Mean age 55 years (80% male). The most frequent etiology of cirrhosis was alcohol (80%). In 68% of patients, at least 1 precipitating event was identified, with infections being the most frequent one (56%). The 1-year mortality rate after LT was 22%. No statistically significant factors associated with mortality were identified, however, spontaneous bacterial peritonitis as a precipitating event of ACLF showed a strong association with death (p=0.08).

Conclusion

ACLF is a growing indication for LT, comprising 1 in every 6 patients transplanted in this cohort. Our results suggest that renal failure and infections should be carefully managed in cirrhotic patients to avoid progression to ACFL. No predictors of post-LT mortality were identified.

Introduction

Hepatocellular carcinoma (HCC) is one of the main indication for liver transplantation (LT) worldwide, however, despite various proposed selection criteria, HCC recurrence rate after LT remains up to 20%. An earlier diagnosis allows for more effective treatments and survival benefit. Recently, the RETREAT score has been proposed showing high accuracy.

Aims & Methods

Our aim was to validate the RETREAT score in a single center cohort.
This is a retrospective study including patients who underwent LT for HCC at Padua University-Hospital between January 2016 and December 2018. Clinical and radiological data before and after LT (aFP, liver function according to MELD and CHILD score, tumor morphology, downstaging and/or bridging treatments) and explant pathology features were collected. RETREAT and TTV/aFP scores, based on explant pathology, were calculated. Cox regression and LogRank models have been used for the association between HCC scores and tumor recurrence.

Results

During the study period, 123 patients underwent LT for HCC (HCV 35%, median MELD 11). After HCC diagnosis, 115 patients (93%) underwent downstaging (47% ≥2 treatments), and 64 of them (56%) received bridging therapies. The median aFP at LT was 4.8 ng/mL. On explant pathology, microvascular invasion was found in 27%, G3 nodules in 30%. On explant pathology, 65 patients (53%) were Milan-out, 44 patients (36%) were TTV/aFP-out, 77 patients (62%) had a RETREAT score ≥2. During the follow-up of 50 months (IQR 39-60), 16 patients (13%) showed post-transplant HCC recurrence, at median time of 14 months (IQR 8-36); 75% of them had extrahepatic recurrence. RETREAT score was associated with the risk of HCC recurrence (p<0.001, HR 1.703, 95%CI 1.30-2.22). Patients with RETREAT score 0-1, 2-4 and 5-8 had a 1 year-HCC recurrence of 2%, 4% and 21%, respectively (log-rank<0.001). TTV/AFP has not been associated with HCC recurrence (p=0.680).

Conclusion

RETREAT score is a reliable tool to improve the selection of patients at higher risk of HCC recurrence and to guide the post-LT management, defining shorten tumor surveillance post-LT. Thus, an earlier diagnosis of tumor recurrence might allow more efficacious treatments and patient survival benefit.

Introduction

Biliary complications following liver transplantation are the leading source of morbidity, graft failure and are associated with 10% mortality rate. Internal biliary stents were reported to decrease the risk of biliary complications when used in high-risk liver transplant recipients with small bile duct diameter.

Aims & Methods

The aim of the study was to assess the prophylactic effect of internal biliary stents (BS) on the incidence of biliary complications, graft loss, overall mortality and to study risk factors for biliary complications. Furthermore, we aimed to examine the prophylactic effect of internal biliary stent in the subgroup of patients with primary sclerosing cholangitis. We performed a large-volume single-center study including all adult patients who underwent deceased-donor liver transplantation either with end-to-end choledococholedocostomy or hepaticojejunostomy between 2005-2021.

Results

Out of 1447 liver transplant recipients (1555 liver transplantations), 456 (29%) were eligible for biliary stenting (size of the recipient or/and donor duct smaller < 6mm). The incidence of biliary complications between the patients with internal biliary stents and the control group was comparable (24% vs. 23%, p= 0,7). Five, ten and fifteen-year graft survival rates were significantly lower among patients with biliary complications regardless of the presence of biliary stents (p<0.01), whereas patient long- term survival did not differ between the groups. In multivariate analysis, thrombosis of the hepatic artery was the only risk factor for all types of biliary complications (p < 0,001). In total 171 patients with primary sclerosing cholangitis as an indication for liver transplantation were included, from which 61 of them (35,7%) received internal biliary stent. The incidence of biliary complications between these patients and the control group was similar (16% vs. 21%, p= 0,5), overall mortality and graft survival did not differ between the groups. Biliary reconstruction was performed as end-to-end choledococholedocostomy in 76 patients and hepaticojejunostomy in 95 patients, anastomotic stricture occurred in a majority of patients with end-to-end choledococholedocostomy (21% v.s. 3 %, p = 0.001), other types of biliary complications were comparable.

Conclusion

Biliary stenting in liver transplant recipients with a narrow bile duct resulted in a similar incidence of biliary complications when compared to recipients with a normal duct and no stents, suggesting its protective role. During a long-term follow-up, graft loss was significantly higher among patients with biliary complications regardless of the presence of internal biliary stents, mortality was comparable.

References

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2) Elkomos, B.E., Abdelaal, A. Do We Need to Use a Stent in Biliary Reconstruction to Decrease the Incidence of Biliary Complications in Liver Transplantation? A Systematic Review and Meta-Analysis. J Gastrointest Surg 27, 180–196 (2023).
3) Girard E, Risse O, Abba J, Medici M, Leroy V, Chirica M, Letoublon C. Internal biliary stenting in liver transplantation. Langenbecks Arch Surg. 2018 Jun;403(4):487-494.
4) Nemes B, Gámán G, Doros A. Biliary complications after liver transplantation. Expert Rev Gastroenterol Hepatol. 2015 Apr;9(4):447-66.
5) Spicák J, Ryska M, Trunecka P, Skála I, Stirand P, Bĕlina F, Sperl J, Hrncárková H, Taimr P, Vítko S, Filip K. The role of ERCP in management of biliary complications after liver transplantation. Ann Transplant. 2001;6(2):29-32.
6) Esfeh JM, Eghtesad B, Hodgkinson P, Diago T, Fujiki M, Hashimoto K, Quintini C, Aucejo F, Kelly D, Winans C, Vogt D, Miller C, Zein N, Fung J. Duct-to-duct biliary reconstruction in patients with primary sclerosing cholangitis undergoing liver transplantation. HPB (Oxford). 2011 Sep;13(9):651-5.