In addition to surgical technology, successful liver transplantation (LT) depends on perioperative management, which needs an effective prognostic index. Therefore, a simplified and sensitive postoperative index for adult LT should be developed.

In total, 906 patients who underwent LT were included in this cross-sectional study. Univariate analysis was used to identify the independent risk factors for recipient survival. Multivariate logistic and stepwise regression analyses were used to construct and simplify the model design. Area under the curve (AUC) and Kaplan-Meier's (K-M) analysis demonstrated superiority of the new index. The postoperative survival score (POSS) index was further simplified via restricted cubic spline (RCS) analysis. Finally, the interpretation of the long-term mortality and subgroup analyses extended the application of the POSS index.

Finally, a total of five factors (donor sex, recipient body mass index (BMI), total bilirubin (Tbil), international normalized ratio (INR) and total operative time) were identified as independent risk parameters and included in our POSS index. The AUCs of the original and simplified POSS indices were 0.764 and 0.723, respectively. Patients with high scores had poor short-term survival. Our index also functioned well in predicting long-term mortality, and it was more effective for patients with hepatitis B cirrhosis or hepatocellular carcinoma (HCC).

We constructed a simplified and effective postoperative survival scoring index to predict short-term complications and survival in adult LT patients.

Early prediction of the prognosis of viral-related cirrhosis patients after transjugular intrahepatic portosystemic shunt (TIPS) is beneficial for clinical decision-making. The aim of this study is to explore a comprehensive prognostic assessment model for evaluating the survival outcomes of patients post-TIPS.

A total of 155 patients treated with TIPS were included in the study. The data were collected from electronic records. The nutritional status of the patient is evaluated using imaging examinations measuring by the axial CT images from the L3 vertebral level. The primary endpoint was set as death within 1 year after TIPS. Multivariate Cox regression was performed to determine the factors associated with mortality.

The Cox regression analysis revealed that the lower PMFI was associated with a lower risk of all-cause mortality after TIPS (hazard ratio [HR] 1.159, 95% confidence interval [CI] 1.063-1.263, p = 0.001). Furthermore, subgroup analyses according to gender revealed the PMFI was associated with postoperative death both in male (HR 2.125, 95% CI, 1.147-3.936, p = 0.017) and female patients (HR 1.070, 95% CI, 1.001-1.144, p = 0.047). The area under the curve (AUC) for predicting death within 1 year was 0.807. The clinical impact curve analysis showed that PMFI had higher levels of risk threshold probability and a smaller gap between actual and predicted curves.

In viral-related cirrhosis patients with portal hypertension, increased muscle fat content might be a potential prognostic marker and associated with postoperative death after TIPS.

Acute-on-chronic liver failure (ACLF) represents the terminal and most lethal phase of acute decompensated cirrhosis. Systemic inflammation plays a critical role in the pathogenesis of ACLF. Systemic inflammation reaction syndrome (SIRS) is a marker of ongoing inflammation. Therefore, we aim to evaluate the relationship of sterile SIRS with hepatitis B virus (HBV)-related ACLF (HBV-ACLF).

HBV-ACLF patients with sterile SIRS who were hospitalized between December 2016 and December 2018 were retrospectively analyzed. All patients were followed up until 90 days. Risk factors associated with 90-day mortality and sterile SIRS development were assessed.

Among 151 HBV-ACLF patients without infection, 37 patients (24.5%) presented with or developed sterile SIRS. During the 90-day follow-up, 23 of the 37 patients with sterile SIRS died (62.2%), compared to 40 patients without sterile SIRS (35.1%, P  = 0.004). Univariate analysis showed that age, total bilirubin (TBIL), international normalized ratio, ammonia, presence of sterile SIRS, model for end-stage liver disease score, presence of complications, and organ failures were associated with 90-day mortality. In multivariate analyses, the presence of sterile SIRS was an independent risk factor for 90-day mortality. Among SIRS components, heart rate (HR) was the most frequently met criterion (56 patients, 37.09%). Patients who met the HR or temperature criterion had lower 90-day survival rate than those who did not (46.4 vs 65.3%, P  = 0.020; 16.7 vs 60.0%, P  = 0.020).

The presence of sterile SIRS in HBV-ACLF patients was closely associated with prognosis.

Accurate prediction of disease severity and prognosis are challenging in patients with cirrhosis. We evaluated whether the deep learning-based AI-Cirrhosis-ECG (ACE) score could detect hepatic decompensation and predict clinical outcomes in cirrhosis.

We analyzed 2,166 ECGs from 472 patients in a retrospective Mayo Clinic cohort, 420 patients in a prospective Mayo transplant cohort, and 341 patients in an external validation cohort from Hospital Clínic de Barcelona. The ACE score's performance was assessed using receiver-operating characteristic analysis for decompensation detection and competing risks Cox regression for outcome prediction.

The ACE score showed high accuracy in detecting hepatic decompensation (area under the curve 0.933, 95% CI: 0.923-0.942) with 88.0% sensitivity and 84.3% specificity at an optimal threshold of 0.25. In multivariable analysis, each 0.1-point increase in ACE score was independently associated with increased risk of liver-related death (hazard ratio [HR] 1.44, 95% CI 1.32-1.58, p <0.001). Adding ACE to model for end-stage liver disease-sodium significantly improved prediction of adverse outcomes across all cohorts (c-statistics: retrospective cohort 0.903 vs. 0.844; prospective cohort 0.779 vs. 0.735; external validation 0.744 vs. 0.732; all p <0.001).

The ACE score accurately identifies hepatic decompensation and independently predicts liver-related outcomes in cirrhosis. This non-invasive tool enhances current prognostic models and may improve risk stratification in cirrhosis management.

This study demonstrates the potential of artificial intelligence to enhance prognostication in liver disease, addressing the critical need for improved risk stratification in cirrhosis management. The AI-Cirrhosis-ECG (ACE) score, derived from widely available ECGs, shows promise as a non-invasive tool for detecting hepatic decompensation and predicting liver-related outcomes, which could significantly impact clinical decision-making and resource allocation in hepatology. These findings are particularly important for hepatologists, transplant surgeons, and patients with cirrhosis, as they offer a novel approach to complement existing prognostic models such as model for end-stage liver disease-sodium. In practical terms, the ACE score could be integrated into routine clinical assessments to provide more accurate risk predictions, potentially improving the timing of interventions, optimizing transplant listing decisions, and ultimately enhancing patient outcomes. However, further validation in diverse populations and integration with other established predictors is necessary before widespread clinical implementation.

Robotic-assisted hepatectomy has gained traction in hepatobiliary surgery, but its cost-effectiveness compared to traditional surgical approaches remains unclear. This study investigates clinical outcomes and financial implications of robotic-assisted liver surgery in a high-volume center, comparing it with open and laparoscopic methods. A retrospective cohort study was conducted on patients undergoing hepatectomy at Lille University Hospital in 2018 and 2021, performed by the institution's first experienced robotic hepatobiliary surgeon. Data on patient demographics, intraoperative details, postoperative outcomes, and costs were analyzed. Costs included hospital stays, surgical materials, and complications, derived from national cost studies. A total of 111 patients were included, with a rise in minimally invasive procedures from 47.5% in 2018 to 75% in 2021. Robotic-assisted hepatectomy was associated with reduced hospital stays, lower complication rates, and fewer severe morbidities compared to laparotomy. The average cost per procedure (all surgical approaches combined) decreased from €12,169 in 2018 to €8,513 in 2021, with robotic surgery offering a significant financial advantage. The total savings for the 71 patients in the 2021 cohort was €259,576, driven primarily by reduced hospitalization times and fewer complications. Robotic-assisted hepatectomy is clinically safe and cost-effective, offering substantial financial savings over traditional surgery. The reduction in postoperative complications and hospital stay durations, particularly for complex cases, highlights the advantages of robotic surgery in hepatobiliary procedures. As surgical expertise increases, robotic surgery represents a sustainable and efficient alternative in liver resection.

Phosphatidylethanol (PEth) is an ethanol metabolite used as a specific biomarker for recent alcohol consumption. We aimed to determine the proportion of patients with or at risk for metabolic dysfunction-associated steatotic liver disease (MASLD) who had PEth levels indicative of harmful alcohol consumption, and to assess associations between PEth levels and the risk of major adverse liver outcomes (MALOs).

We conducted a cohort study involving persons tested for PEth in Stockholm, Sweden between 2012 and 2020 (N=46,406), including patients with various steatotic liver disease (SLD) subtypes and individuals without SLD. Cumulative incidences of MALOs were calculated for the different groups while accounting for competing risk. Cox regression was used to evaluate the association between baseline PEth levels and the incidence of MALOs.

Among 6,377 patients with presumed MASLD, 1,294 (20%) had baseline PEth levels between 0.05 and 0.30 μmol/L (35-210 ng/ml), indicating excessive alcohol intake (MetALD), while 854 patients (13%) had values >0.30 μmol/L, indicating alcohol-related liver disease (ALD). Patients with MASLD and PEth levels between 0.05-0.30 μmol/L had similar median FIB-4 scores and cirrhosis prevalence as those with MASLD and PEth levels <0.05 μmol/L. However, patients with PEth levels between 0.05-0.30 μmol/L had higher cumulative incidences of MALOs compared to those with PEth levels <0.05 μmol/L. Elevated PEth levels were significantly linked to higher rates of MALOs in patients without cirrhosis, even after adjustments for age, sex, SLD subtype, and FIB-4 score. Patients with ALD had the highest PEth levels and worst prognosis.

PEth is a valuable alcohol biomarker for distinguishing between SLD subtypes, especially ALD, and predicts adverse outcomes in people with and without SLD.

There is controversy regarding the various proposed steatotic liver disease (SLD) subtypes, the most recent definition suggesting that patients with an elevated alcohol consumption and MASLD should be classified as having MetALD. Here, we address this challenge by classifying patients with SLD by utilizing the biomarker phosphatidylethanol (PEth), a direct and reliable biomarker for recent alcohol consumption. Our analysis of this large cohort-comprising 46,406 patients-revealed that using the objective PEth biomarker may be a valuable tool for distinguishing between MASLD and MetALD, and that PEth is strongly associated with the risk of liver outcomes in individuals with and without known SLD. Integrating PEth testing into routine diagnostic evaluations could enhance knowledge on the underlying pathophysiology in SLD, reduce the potential for misclassification, and ultimately improve patient outcomes by enabling clinicians to offer appropriate therapies. Further research is needed to validate these findings in other populations and to explore the potential integration of PEth into broader clinical guidelines for managing SLD.

This review highlights recent advancements in liver organ allocation, specifically the transition to MELD 3.0 and the potential introduction of continuous distribution. These developments are timely, as they address the increasing need for a more efficient, equitable, and personalized system for prioritizing liver transplant candidates.

The review covers two key innovations: MELD 3.0: A refined version of the original MELD score, designed to improve the prioritization process by incorporating additional factors that offer a more accurate and urgent measure of transplant need. This approach aims to better assess the severity of liver disease and the need for transplantation. Continuous distribution: A dynamic approach that shifts away from the static allocation model. It integrates multiple donor and recipient variables - such as geographic location, organ quality, and recipient condition - into a continuous, flexible allocation process. This framework seeks to make more nuanced decisions based on a broader set of factors that reflect transplant suitability.

These innovations aim to enhance fairness and patient outcomes by refining candidate prioritization and reducing disparities in access to transplants. However, implementing these systems presents challenges, such as technical complexities and regional differences in access. Ongoing evaluation is necessary to ensure their effectiveness and equitable implementation across diverse patient populations.

Given our desire to reduce kidney transplant waiting times by utilizing more difficult-to-place ("higher-risk") DD kidneys, we wanted to better understand post-transplant renal function among 1119 adult DD recipients consecutively transplanted during 2016-2019. Stepwise linear regression of eGFR (CKD-EPI formula) at 3-, 6-, and 12-months post-transplant (considered as biomarkers for longer-term outcomes), respectively, was performed to determine the significant multivariable baseline predictors, using a type I error ≤ 0.01 to avoid spurious/weak associations. Three unfavorable characteristics were selected as highly significant in all three models: Older DonorAge (yr) (p < 0.000001), Longer StaticColdStorage Time (hr) (p < 0.000001), and Higher RecipientBMI (p ≤ 0.00003). Other significantly unfavorable characteristics included: Shorter DonorHeight (cm) (p ≤ 0.00001), Higher Natural Logarithm {Initial DonorCreatinine} (p ≤ 0.001), Longer MachinePerfusion Time (p ≤ 0.003), Greater DR Mismatches (p = 0.01), DonorHypertension (p ≤ 0.004), Recipient HIV+ (p ≤ 0.006), DCD Kidney (p = 0.002), Cerebrovascular DonorDeath (p = 0.01), and DonorDiabetes (p = 0.01). Variables not selected into any model included DonorAKI Stage (p ≥ 0.24), Any DonorAKI (p ≥ 0.04), and five KDRI components: two DonorAge splines at 18 years (p ≥ 0.52) and 50 years (p ≥ 0.28), BlackDonor (p ≥ 0.08), DonorHCV+ (p ≥ 0.06), and DonorWeight spline at 80 kg (p ≥ 0.03), indicating that DonorAKI and the weaker KDRI components have little, if any, prognostic impact on renal function during the first 12 months post-transplant. Additionally, biochemical determinations with skewed distributions such as DonorCreatinine are more accurately represented by natural logarithmic transformed values. In conclusion, one practical takeaway is that donor AKI may be ignored when evaluating DD risk.

Hepatocellular carcinoma arises in the setting of cirrhosis in most cases, requiring multidisciplinary input to define resectability. In this regard, more precise surgical management considers patient factors and anatomical states, including resection margins, tumour biology, and perioperative therapy. Together with advances in surgical techniques, this integrated approach has resulted in considerable improvements in patient morbidity and oncological outcomes. Despite this, recurrence rates in hepatocellular carcinoma remain high. As the systemic treatment landscape in hepatocellular carcinoma continues to evolve and locoregional options are increasingly used, we review current and future opportunities to individualise the surgical management of patients with hepatocellular carcinoma.

Objective: The prevalence and mortality of chronic liver disease has risen significantly. In end-stage liver disease (ESLD), the survival of patients is approximately 2 years. Despite the poor prognosis and high symptom burden, integration of palliative care in ESLD is reduced, and the majority of patients continue to die in inpatient care. We aim to assess predictors and outcomes of home palliative care, as well as factors associated with death at home in patients with ESLD. Methods: Retrospective cohort study of patients with ESLD, followed by a palliative care team between 2017 and 2022. Information regarding patient demographics, ESLD etiology, decompensations, and interventions was collected. Two-sided tests were used to identify factors associated with home palliative care. Results: We analyzed 75 patients: 44% had home palliative care and 33% died at home. ESLD patients with home palliative care were older (72.52 vs 64.45; p = 0.002), had a longer palliative care intervention time (149.97 ± 196.23 vs 43.69 ± 100.60 days; p = 0.007), higher rates of ascites or hepatic encephalopathy (χ2 = 11.024; p = 0.029), and hepatocarcinoma (90.9% vs 64.3%; p = 0.007). Patients with home palliative care had a reduction in-hospital admissions (2.61 vs 1.06; p = 0.000) and a greater probability of death at home (66.7% vs 33.3%; p = 0.000). Patients who died at home (33.3%) were older (72.20 vs 64.40; p = 0.000) and had longer palliative care intervention time (178.80 ± 211.78 vs 46.28 ± 99.67 days; p = 0.006). Conclusion: Home palliative care in ESLD differs based on demographics and disease complications, with a positive impact of homecare translated into a reduction in hospital admissions and an increased probability of death at home.

Emerging evidence suggests that rotational thromboelastometry (ROTEM) is superior to conventional haemostatic tests in the assessment and management of bleeding risk in patients with cirrhosis. Whether ROTEM may also be useful for assessing the prognosis of these patients is unknown. We aimed to explore the role of ROTEM in predicting the transplant-free survival of patients with cirrhosis.

We conducted a prospective cohort study of patients with cirrhosis at two hospitals. All patients underwent ROTEM analysis at baseline and were followed up until death, liver transplantation or the end of follow-up (28 February 2023). Univariate and multivariate Cox regression analyses were performed to explore the association between transplant-free survivals.

Between April 2018 and October 2021, 162 patients with cirrhosis were recruited and followed-up for a median of 42 months. During follow-up, 36 patients died and 7 underwent liver transplantation. On univariate analysis, maximum clot firmness (MCF) using both EXTEM and INTEM tests was significantly reduced in the death/liver transplant group compared to the survivor group (52 vs. 57, P  = 0.02; and 51 vs. 55, P  = 0.01, respectively). After adjusting for age, sex, presence of clinically significant portal hypertension, hepatocellular carcinoma, care setting, bilirubin, sodium and creatinine, only albumin (hazard ratio: 0.92, 95% CI: 0.85-0.99, P  = 0.018) and MCF EXT (hazard ratio: 0.96, 95% CI: 0.92-0.99, P  = 0.032) remained significant predictors of transplant-free survival.

ROTEM may be useful in assessing the survival of patients with cirrhosis. Further research is needed to determine the clinical utility of ROTEM parameters as prognostic markers in cirrhosis.

Biliary strictures are among the most common complications following liver transplantation (LT). If endoscopic retrograde cholangiography fails, percutaneous transhepatic biliary drainage (PTBD) may serve as an alternative approach. Description of clinical important short- and long-term outcomes as well as outcome prediction following PTBD after LT are scarce.

We analyzed outcomes of 56 liver-transplanted adults with biliary complications receiving a PTBD. We described the safety and longitudinal laboratory changes. We analyzed as endpoints, incidence of biliary complications, need for surgical biliary revision/re-LT and overall-survival at 12- and 60-months. We used simple comparison tests accordingly and performed competing risk analysis and multivariate competing risk regression as well as log-rank test and cox proportional hazard regression for further analysis.

PTBD procedures had a high technical success rate (98%) and tolerable safety profile. Multiple laboratory indicators improved during follow-up (37 patients with complete biochemical follow-up). Incidence of subsequent biliary complications was highly dependent on the nature of present biliary strictures (Anastomotic stricture (AS): adjusted SHR: 0.26, 95% CI: 0.09-0.78, p = 0.016). Need for surgical biliary revision/re-LT remained below 15%. 12-month survival was significantly better, if drainage into the small intestine was achieved at first attempt compared to completely external drainage (internal: 92.9 vs. external: 67.9%, p = 0.018). Patients with AS had a numerically higher long-term-survival and higher C-reactive-protein (CRP) and lower body-mass-index (BMI) at baseline were significantly associated with inferior short- and long-term-survival.

PTBD for biliary complications following LT had a high technical success and a tolerable safety profile. Incidence of subsequent biliary complications was highly dependent on the nature of biliary strictures and increased mortality was found in patients with higher CRP, lower BMI and failure of initial PTBD internalization.

Increasingly, acute care surgeons have taken over the management of general surgery consult patients in the hospital, many of whom present with sepsis and/or in septic shock. In this article, we will discuss the intricacies of sepsis management for acute care surgery. The underlying tenants of sepsis management will be outlined with specific attention to the nuances associated with surgical patients. Ultimately, when a surgical problem is identified, this management will culminate with the need for specific source control - the unique aspect when a surgical as opposed to a medical disease process is the cause of sepsis. However, surgeons must also be competent in the other components of sepsis management including antimicrobial therapy and hemodynamic support. This article is designed for the surgeon or for any provider caring for patients with a potential acute care surgical problem, recognizing that different practice settings will vary with regard to resource availability for laboratory tests, invasive monitoring, diagnostics, and surgeon availability.

Hepatocellular carcinoma (HCC) is the sixth common malignancy worldwide. In Egypt, the main cause of HCC is hepatitis C virus (HCV)-related cirrhosis. After the successful mass treatment program of HCV in 2018 with direct-acting antivirals (DAAs) therapy, a large percentage of patients have been treated and effectively achieved sustained virological response (SVR). Recently, some studies claimed that HCCs that developed after treatment with DAAs have more aggressive behavior. Purpose of the study is to detect the possible change of HCC pattern before and after DAAs era and its effect on overall survival (OS).

428 naïve HCC patients were divided into 2 groups: Group I HCC patients not treated with DAAs and Group II HCC patients treated with DAAs. Then we compared demographic, clinical, radiological, and laboratory characteristics between both groups.

Group II had improved liver function tests, including serum bilirubin, albumin, and international normalized ratio, than Group I (p < 0.001, p < 0.001, p < 0.001, respectively). They had a lower level of liver aminotransferases. Group II showed a larger infiltrative pattern of HCC, with a high incidence of portal vein thrombosis (p = 0.003, p < 0.001, p = 0.048, respectively). Group II received more curative or palliative treatment options, while 55 % of Group I received the best supportive care. There was no significant difference in 1-year and 2-years OS between both group, except that group II patients had better 2-year OS in subgroup BCLC stage C.

The tumor pattern has changed into a more aggressive phenotype after DAAs. DAAs have succeeded in preserving the liver condition. However, they did not demonstrate any protective effect on the OS of the patients. There is a strong need for strict screening program for early detection of HCC in the early stages, that are eligible for curative options, after HCV treatment of DAAs.

Triggering receptor expressed on myeloid cells 2 (TREM2)-expressing macrophages and systemic levels of soluble TREM2 (sTREM2) appear critical in the development of chronic liver disease (CLD) and seem relevant in its detection. The aim of this study was to examine sTREM2 as a marker for early CLD and its potential to predict posthepatectomy liver failure (PHLF) in patients undergoing partial hepatectomy.

sTREM2 was assessed in the plasma of 108 patients undergoing liver resection. Blood was drawn prior to surgery (preop) and on the first and fifth postoperative day.

Preop sTREM2 levels were similar across different indications for resection (p = 0.091). Higher preop sTREM2 levels were associated with advanced hepatic fibrosis (p = 0.030) and PHLF (p = 0.007). Fibrosis-4 index (FIB-4) (p = 0.619) and model for end-stage liver disease (MELD) (p = 0.590) did not show a difference between patients grouped by their CLD. Comparing the AUC from receiver-operating characteristic analysis, sTREM2 (AUC = 0.708) outperformed FIB-4 (AUC = 0.529), MELD (AUC = 0.587), Child-Pugh grading (AUC = 0.570) and LiMAx (liver maximum capacity test) (AUC = 0.516) in predicting PHLF. Similarly, in uni- and multivariate analysis, only sTREM2 proved predictive for PHLF (p = 0.023). High-risk (p = 0.003) and low-risk (p = 0.011) cut-offs for systemic sTREM2 levels could identify patients at risk for adverse outcomes after surgery. Finally, high sTREM2 was associated with decreased overall survival after liver surgery (p <0.001).

Circulating sTREM2 shows sensitivity for early-stage, asymptomatic liver disease, irrespective of the underlying indication for liver surgery. Assessment of CLD via sTREM2 monitoring could improve early detection of CLD and improve outcomes after liver surgery.

Soluble TREM2 (sTREM2) has previously been shown to correlate with the degree of chronic liver disease. We found that even in patients undergoing liver resection, who generally do not suffer from end-stage liver disease, sTREM2 reflects liver fibrosis status and predicts postoperative development of liver dysfunction. This is especially relevant for liver surgeons and patients, as postoperative liver dysfunction is the main reason for postoperative mortality. Our findings are also important for hepatologists, as early detection of liver fibrosis and cirrhosis is paramount for overall patient survival and we can show that even in a cohort with a median model for end-stage liver disease score of 6, sTREM2 is able to distinguish patients based on their liver fibrosis status.

Laparoscopic liver surgery following previous resections poses significant challenges due to adhesions and altered anatomy. Hand-assisted laparoscopic liver resection (HALR) combines the tactile advantages of open surgery with minimally invasive techniques, potentially benefitting patients undergoing repeat hepatectomy. This study aims to assess the safety and efficacy of HALR for repeat hepatectomy and compare these outcomes with those of an open liver resection (OR).

A retrospective study included patients who underwent repeat hepatectomy via HALR or OR from January 2013 to December 2022. Patient characteristics and outcomes were compared before and after propensity score matching. The primary outcome was 90-day morbidity. Surgical difficulty was stratified using the Institut Mutualiste Montsouris (IMM) classification into grade I (low), grade II (intermediate), and grade III (high).

The study included 248 patients: 112 in the HALR group and 136 in the OR group. Conversion to open occurred in 2 cases (1.8%). After matching, 76 HALR patients were compared with 76 OR patients. HALR patients had a longer operative time (median: 402 vs. 277 min and p < 0.001), shorter postoperative hospital stay (median: 8.0 vs. 9.0 days and p < 0.001), and higher hospital cost (median: $10,607 vs. $6260 and p < 0.001). No significant differences in 90-day morbidity or readmission rates. Risk factors for 90-day morbidity included the ASA score ≥ 2, diabetes, IMM grade 3, and portal hypertension.

HALR for repeat hepatectomy is feasible and safe, with perioperative outcomes comparable to OR. HALR may be a viable alternative for selected patients.

Transjugular intrahepatic portosystemic shunt (TIPS) placement leads to a reduction in portal pressure and an improvement in survival in patients with recurrent and refractory ascites and variceal haemorrhage. Prediction of post-TIPS survival is primarily determined by factors identified before the TIPS procedure, as data collected during or after TIPS implantation are limited. The aim of the study was to evaluate the influence of early hemodynamic changes after TIPS placement on survival, in order to refine post TIPS management.

In this prospective bicentric study, consecutive patients (n = 105) undergoing TIPS placement for ascites or variceal haemorrhage underwent measurement of portal pressure gradient (PPG) immediately at TIPS insertion (PPG0) and 24 h later (PPG24h) and the ΔPPG was calculated from PPG24h and PPG0 (ΔPPG = PPG24h-PPG0). Kaplan-Meier survival analysis and uni- and multivariable regression analyses were conducted to identify survival predictors.

Patients with lack of increased ΔPPG exhibited poorer 90-day and 1-year survival compared to patients with increased ΔPPG. This worse survival was independent of The Model for End-Stage Liver Disease (MELD) score, Child-Pugh score, bilirubin levels, creatinine and the Freiburg index of post-TIPS survival (FIPS) > 0.92. Among these patients with poorer outcome, elevated bilirubin (> 25 μmol/L) further distinguished survivors from non-survivors.

Lack of increased ΔPPG post-TIPS insertion identifies a high-risk patient group with worse survival. We propose incorporating this second PPG measurement and determining ΔPPG into clinical practice to identify these patients early and tailor post-TIPS patient care.

Acute-on-chronic liver failure (ACLF) is a complicated syndrome associated with high short-term mortality and reversibility. Whether the prior decompensation should be included in the definition of ACLF is controversial.

A total of 532 patients with decompensation (prior or first) of chronic liver disease were retrospectively enrolled and analyzed from January 2018 to June 2023. Clinical data were used to identify the characteristics and determine prognosis.

Of the 532 patients, 99 patients did not meet APASL-ACLF criteria due to the existence of prior decompensation and 433 patients met the Asian Pacific Association for the Study of the Liver (APASL)-ACLF criteria. The two groups had similar characteristics including prognosis scores (Chinese Group on the Study of Severe Hepatitis B (COSSH)-ACLF II score: 7.59 vs. 7.67, p = 0.934; Chronic Liver Failure (CLIF) Consortium ACLF score: 42.90 vs. 44.81, p = 0.273), the distribution of patients with APASL ACLF research consortium score (AARC score) (5-7: 19.2%/12.0%; 8-10: 56.6%/55.0%; 11-15: 24.2%/33.0%, p > 0.05) and the 28-/90-day mortality rates (30.5%/43.2% vs. 36.3%/43.1%, p = 0.267/0.978). In all integrated ACLF patients, Receiver Operating Characteristic (ROC) curve analysis and decision curve analysis (DCA) showed that COSSH-ACLF IIs had higher prognostic efficiency and clinical net benefit than AARC score and CLIF-C ACLFs for 28-/90-day mortality.

Prior decompensated patients exhibited clinical characteristics and high short-term mortality similar to those of first decompensated patients. The COSSH-ACLF IIs demonstrated the highest prognostic efficiency for all integrated ACLF patients. Including prior decompensation in the ACLF definition can help to simplify and improve clinical management.

Biliary tract cancers (BTC) comprise a heterogeneous group of malignancies, including gallbladder cancer, intrahepatic cholangiocarcinoma, and extrahepatic cholangiocarcinoma. The main determinants of prognosis in BTC are the stage of the disease and the eligibility for curative treatment. Additionally, liver functional capacity is also one of the factors influencing survival in biliary tract cancers. The age-bilirubin-INR-creatinine (ABIC) score has been previously shown to predict prognosis in hepatic diseases. The aim of our study is to demonstrate the relationship between the ABIC score and prognosis in BTC.

In this study, a retrospective analysis was performed on 41 patients with non-metastatic BTC and 73 patients with metastatic BTC who were followed up in our clinic between 2003 and 2025. All patients were ≥18 years old at the time of diagnosis, and BTC was pathologically confirmed. The ABIC score was calculated separately for each group. A threshold value for the ABIC score was determined using Receiver Operating Characteristic (ROC) analysis, and based on this threshold, patients were divided into low and high ABIC score groups. Both the relationship between the ABIC score and prognosis and the other factors affecting prognosis were investigated.

In the non-metastatic BTC group, the cutoff value for the ABIC score was 6.89. The median survival time of patients with a high ABIC score was significantly shorter. In the metastatic BTC group, the cutoff value for the ABIC score was 7.41. Similarly, in this group, patients with a high ABIC score had a significantly shorter median survival time. Additionally, in the non-metastatic BTC group, tumor localization and stage were prognostic factors affecting survival, while in the metastatic BTC group, CEA and first-line chemotherapy were the prognostic factors influencing overall survival. Conclusions: We demonstrate that the ABIC score is a prognostic factor determining median survival in both non-metastatic and metastatic BTC patients.

Liver cirrhosis represents the final stage of liver diseases. The transition from the compensated to the decompensated form is a critical phase, as it is associated with a negative impact on patient prognosis. Therefore, having a tool to identify patients at higher risk of complications and mortality is an ideal goal. Currently, the validated scores for this purpose are the model for end-stage liver disease score and the Child-Pugh score. However, these scores have limitations, as they do not account for other factors associated with liver cirrhosis that are equally relevant from a prognostic perspective. Among these, alterations in body composition, particularly sarcopenia, increase the risk of mortality and should therefore be considered in the comprehensive assessment of patients with liver cirrhosis.

Over the past six decades, liver transplantation (LT) has evolved from an experimental procedure into a standardized and life-saving intervention, reshaping the landscape of organ transplantation. Driven by pioneering breakthroughs, technological advancements, and a deepened understanding of immunology, LT has seen remarkable progress. Some of the most notable breakthroughs in the field include advances in immunosuppression, a revised model for end-stage liver disease, and artificial intelligence (AI)-integrated imaging modalities serving diagnostic and therapeutic roles in LT, paired with ever-evolving technological advances. Additionally, the refinement of transplantation procedures, resulting in the introduction of alternative transplantation methods, such as living donor LT, split LT, and the use of marginal grafts, has addressed the challenge of organ shortage. Moreover, precision medicine, guiding personalized immunosuppressive strategies, has significantly improved patient and graft survival rates while addressing emergent issues, such as short-term complications and early allograft dysfunction, leading to a more refined strategy and enhanced post-operative recovery. Looking ahead, ongoing research explores regenerative medicine, diagnostic tools, and AI to optimize organ allocation and post-transplantation car. In summary, the past six decades have marked a transformative journey in LT with a commitment to advancing science, medicine, and patient-centered care, offering hope and extending life to individuals worldwide.

The associations between gray matter (GM) change and neurotransmitter systems in hepatitis B virus-related cirrhosis (HBV-RC) are still poorly understood.

We recruited 60 HBV-RC patients and 60 healthy controls (HCs). Difference of GM volume between HBV-RC and HC groups was evaluated at global and voxel levels. The potential relationship between GM morphology and prognostic models of liver function was evaluated at voxel level in HBV-RC patients. The spatial correspondence between regional GM alteration and the distribution of multiple neurotransmitter systems in HBV-RC compared to healthy controls was assessed by the JuSpace toolbox covering various neurotransmitter maps.

Total GM volume in HBV-RC group was smaller than in HC group (p < 0.05), and the pattern of GM volume alterations showed significantly increased volume in bilateral thalamus and ventral diencephalon and decreased volume in bilateral basal ganglia and cerebellum (p < 0.05, FWE corrected). In HBV-RC group, the volume of left superior frontal gyrus medial segment and right middle frontal gyrus was positively correlated with serum albumin level and negatively correlated with ALBI score, and serum bilirubin level was negatively correlated with right hippocampus and caudate (p < 0.05, FWE corrected). GM alterations in HBV-RC patients relative to HCs were significantly associated with the intrinsic distribution of various neurotransmitter pathways, including GABAergic, cholinergic, serotonergic, and dopaminergic (p < 0.05).

The pattern of GM alteration correlated with liver function and specific neurotransmitter deficits in HBV-RC patients. These findings provide new insight into the complex neuropathogenesis of HBV-RC and the possible therapeutic targets based on neurotransmitter modulation.

Liver cirrhosis is a common cause of morbidity and mortality worldwide. Excessive alcohol consumption and metabolic associated steatotic liver disease are the most common etiological factors of cirrhosis in our region. Cirrhosis occurs in two well-differentiated phases, compensated and decompensated, depending on the absence or presence of complications, respectively. Current therapeutic strategies are aimed at controlling these complications (such as ascites, hepatic encephalopathy, bacterial infections, or digestive hemorrhage, among others) or performing a liver transplant if there are no contraindications. However, it is important to eliminate the etiological factor responsible for the disease, as this can lead to the disappearance of complications, a state known as recompensation. This article proposes an updated review of the epidemiology of cirrhosis and its main causes, and offers an overview of the clinical features and treatment of the disease's complications, in addition to outlining future lines of research in this field.

Background and Objectives: The Model for End-Stage Liver Disease (MELD) score has widely been used for mortality prediction in liver cirrhosis (LC) patients and transplantation allocation. There have been recent modifications of MELD scores, such as MELD-Lactate (MELD-La) and MELD-3.0. The goal of this study was to compare MELD, MELD-La, and MELD-3.0 in predicting mortality among LC patients in Korea. Materials and Methods: This is a retrospective, single-centered study in which LC patients admitted to Konkuk University Hospital between January 2011 and December 2022 were enrolled and reviewed. Predictive values for 1- and 3-month mortality for MELD, MELD-La, and MELD-3.0 were calculated using the area under the receiver operating characteristic (AUROC) curve. Differences between AUROCs were statistically analyzed using DeLong's test. Results: A total of 1152 patients were initially included in this study. Among them, 165 (14.3%) patients died within one month, and 211 (19.7%) died within three months. The AUROCs for 1-month mortality of MELD, MELD-La, and MELD-3.0 were 0.808, 0.79, and 0.807, respectively. For the 3-month mortality of MELD, MELD-La, and MELD-3.0, the AUROCs were 0.805, 0.753, and 0.817, respectively. Multiple comparisons of ROC curves demonstrated that MELD and MELD-3.0 reflected the 3-month mortality prediction of LC patients better than MELD-La (p = 0.0018, p = 0.0003, respectively). Conclusions: This study demonstrated that MELD and MELD-3.0 outperformed MELD-La in predicting the 3-month mortality for LC patients. However, there was no significant difference between MELD and MELD-3.0 in predicting LC patient mortality.

There are no useful treatments to prevent the development of severe complications of liver cirrhosis. Simvastatin and rifaximin have shown beneficial effects in liver cirrhosis.

To assess whether simvastatin combined with rifaximin improves outcomes in patients with decompensated cirrhosis.

Double-blind, placebo-controlled, phase 3 trial conducted among patients with decompensated cirrhosis in 14 European hospitals between January 2019 and December 2022. The last date of follow-up was December 2022.

Patients were randomly assigned to receive simvastatin, 20 mg/d, plus rifaximin, 1200 mg/d (n = 117), or identical-appearing placebo (n = 120) for 12 months in addition to standard therapy, stratified according to Child-Pugh class B or C.

The primary end point was incidence of severe complications of liver cirrhosis associated with organ failure meeting criteria for acute-on-chronic liver failure. Secondary outcomes included transplant or death and a composite end point of complications of cirrhosis (ascites, hepatic encephalopathy, variceal bleeding, acute kidney injury, and infection).

Among the 237 participants randomized (Child-Pugh class B: n = 194; Child-Pugh class C: n = 43), 72% were male and the mean age was 57 years. There were no differences between the 2 groups in terms of development of acute-on-chronic liver failure (21 [17.9%] vs 17 [14.2%] patients in the treatment and placebo groups, respectively; hazard ratio, 1.23; 95% CI, 0.65-2.34; P = .52); transplant or death (22 [18.8%] vs 29 [24.2%] patients in the treatment and placebo groups, respectively; hazard ratio, 0.75; 95% CI, 0.43-1.32; P = .32); or development of complications of cirrhosis (50 [42.7%] vs 55 [45.8%] patients in the treatment and placebo groups, respectively; hazard ratio, 0.93; 95% CI, 0.63-1.36; P = .70). Incidence of adverse events was similar in both groups (426 vs 419; P = .59), but 3 patients in the treatment group (2.6%) developed rhabdomyolysis.

The addition of simvastatin plus rifaximin to standard therapy does not improve outcomes in patients with decompensated liver cirrhosis.

ClinicalTrials.gov Identifier: NCT03780673.

Enhanced recovery after surgery (ERAS) protocols facilitate patient recovery without increasing complication rates. An ERAS protocol designed for our liver transplant (LT) patients obtained a median hospital length of stay (LOS) of 4 days. However, a proportion of patients do not achieve early discharge. This study aimed to identify factors that predict an LOS≤ 4 days.

Identifying factors associated with LOS <4 days in our LT patients.

We performed 293 LTs (2012-2021), LOS≤4 days in 171 (58.4 %). The following factors emerged as statistically predictors of LOS≤4 days in the univariate analysis: male sex, HCC or HCV patients, lower MELD score, lower BAR score, no DCD patients, shorter operative time, no intraoperative transfusion, shorter ICU stay, no Clavien-Dindo complications grade ≥ III, no primary graft dysfunction, no acute rejection, no readmission at 30 days and no retransplantation were associated to LOS≤4 days. However, in the multivariate analysis, the only independent risk factor that predicted LOS≤4 days was the presence of hepatocarcinoma. DCD donors and higher MELD score were negative factors.

Applying ERAS programs in LT patients is beneficial, safe and extensible to all patients, but those with hepatocarcinoma obtain higher rates of LOS≤4 days.

Split liver transplantation (SLT) from deceased donors is a potential solution to the global organ shortage. While effective in patients with mild disease, outcomes in high MELD score recipients remain uncertain and conflicting. This study compares survival in high vs. low MELD score recipients.

This retrospective single-centre study included all consecutive patients transplanted with a split liver graft between 2010 and 2022. Two groups of recipients with MELD<25 and ≥ 25 at LT were compared.

The study population included 119 patients (n = 98 with MELD<25, n = 21 with MELD≥25) with an average follow-up of 55 months. Both groups were comparable in terms of indication for transplantation and donor characteristics. The high MELD group required more blood transfusions (7 vs. 3 units; p < 0.001) during LT and had a longer stay in intensive care unit (7 vs. 5 days; p = 0.011). Biliary, arterial, and venous complications were similar between groups, as well as graft survival (5 years: 75 % vs. 61 %, p = 0.35) and long-term overall survival (5 years: 83 % vs. 75 %, p = 0.17).

Our results indicate that SLT for patients with MELD≥25 improves access to grafts, is feasible and safe, without significant increased risk of severe complications or decreased long-term overall patient or graft survivals.

Disparities in organ supply and demand led to geographic inequities in the score-based liver transplant (LT) allocation system, prompting a change to allocation based on acuity circles (AC) defined by fixed distances. However, fixed distances do not ensure equivalent population size, potentially creating new sources of disparity.

To estimate the association between population size around LT centers and waiting list outcomes for critically ill patients with chronic end-stage liver disease and high Model for End-stage Liver Disease (MELD) scores or acute liver failure (ALF).

This US nationwide retrospective cohort study included adult (aged ≥18 years) candidates for deceased donor LT wait-listed between June 18, 2013, and May 31, 2023. Follow-up was completed June 30, 2023. Participants were divided into pre-AC and post-AC groups.

Population size within defined radii around each LT center (150 nautical miles [nm] for participants with high MELD scores and 500 nm for those with ALF) based on AC allocation policy.

LT candidate waiting list mortality and dropout rate were analyzed using generalized linear mixed-effect models with random intercepts for center and listing date before and after AC implementation. Fine-Gray competing risk regression, accounting for clustering, was used as a secondary model.

The study analyzed 6142 LT candidates (1581 with ALF and 4561 with high MELD scores) during the pre-AC era and 4344 candidates (749 with ALF and 3595 with high- MELD scores) in the post-AC era, for a total of 10 486 participants (6331 male [60.5%]; mean [SD] age, 48.5 [7.1] years). In the high-MELD cohort, being listed at a center in the lowest tertile of population size was associated with increased waiting list mortality in the AC era (adjusted odds ratio [AOR], 1.68; 95% CI, 1.14-2.46). Doubling of the population size was associated with a 34% reduction in the odds of mortality or dropout (AOR, 0.66; 95% CI, 0.49-0.90). These results were consistent with those of the extended Fine-Gray models and were also corroborated by multiple sensitivity analyses. However, there were no significant population density-associated disparities in the ALF cohort.

In this retrospective nationwide cohort study, being wait-listed in less populated regions was associated with greater mortality among critically ill LT candidates with high MELD scores, underscoring the limitations of allocation systems based purely on fixed distances.

Interest in prediction models, including machine learning (ML) models, based on laboratory data has increased tremendously. Uncertainty in laboratory measurements and predictions based on such data are inherently intertwined. This study developed a framework for assessing the impact of biological and analytical variation on the prediction uncertainty of categorical prediction models.

Practical application was demonstrated for the prediction of renal function loss (Chronic Kidney Disease Epidemiology Collaboration [CKD-EPI] equation) and 31-day mortality (advanced ML model) in 6360 emergency department patients. Model outcome was calculated in 100 000 simulations of variation in laboratory parameters. Subsequently, the percentage of discordant predictions was calculated with the original prediction as reference. Simulations were repeated assuming increasing levels of analytical variation.

For the ML model, area under the receiver operating characteristic curve (AUROC), sensitivity, and specificity were 0.90, 0.44, and 0.96, respectively. At base analytical variation, the median [2.5th-97.5th percentiles] percentage of discordant predictions was 0% [0%-28.8%]. In addition, 7.2% of patients had >5% discordant predictions. At 6× base analytical variation, the median [2.5th-97.5th percentiles] percentage of discordant predictions was 0% [0%-38.8%]. In addition, 11.7% of patients had >5% discordant predictions. However, the impact of analytical variation was limited compared with biological variation. AUROC, sensitivity, and specificity were not affected by variation in laboratory parameters.

The impact of biological and analytical variation on the prediction uncertainty of categorical prediction models, including ML models, can be estimated by the occurrence of discordant predictions in a simulation model. Nevertheless, discordant predictions at the individual level do not necessarily affect model performance at the population level.

A consensus has not yet been reached regarding the optimal timing for the combination of transjugular intrahepatic portosystemic shunt (TIPS) and partial splenic embolization (PSE) in patients with cirrhosis-related variceal bleeding and hypersplenism. This study aimed to compare the clinical outcomes of patients who underwent either an early or late combination of TIPS and PSE.

A total of 84 consecutive patients with cirrhosis-related variceal bleeding and hypersplenism who underwent TIPS and PSE between September 2016 and April 2023 were included in this retrospective multicenter study. These patients were subsequently divided into early combination (n = 36) and late combination (n = 48) groups based on the timing of the combination therapy.

Kaplan-Meier curves revealed a significant increase in cumulative survival in the late combination group, compared with that in the early combination group (log-rank P = 0.018). Additionally, the late combination group exhibited a lower cumulative incidence of overt hepatic encephalopathy (OHE), compared with the early combination group (log-rank P = 0.002). In Cox regression models, noninfarcted splenic volume (hazard ratio [HR] = 0.995, 95% confidence interval [CI] = 0.991-0.999, P = 0.044) and grouping (HR = 0.101, 95% CI = 0.011-0.921, P = 0.034) were identified as independent risk factors for mortality. Furthermore, the independent risk factors for OHE were serum albumin (ALB) level (P = 0.032) and grouping (P = 0.028).

The early combination of TIPS and PSE was associated with higher risks of death and OHE than the late combination.

No clear guidelines exist for perioperative anticoagulation management after durable left ventricular assist device insertion. In this study, we sought to compare outcomes between anti-factor Xa (FXa) and activated partial thromboplastin time (aPTT) in monitoring unfractionated heparin (UFH) dosing after HeartMate 3 (HM3) insertion.

This is a single-center retrospective review of patients who received UFH after HM3 insertion between 01/2020-12/2022. Post-operative UFH dose was titrated by aPTT goal 45-60 sec (n = 53) or FXa goal 0.1-0.2 U/mL (n = 59). Baseline differences between cohorts were balanced by inverse probability treatment weighting.

At baseline, unadjusted FXa patients were more likely to be white (47.5% vs. 35.8%, p < 0.001), INTERMACS 1-2 (69.5% vs. 47.2%, p = 0.013), have history of coronary artery disease (66.1% vs. 43.4%, p = 0.026), and lower eGFR (54.1 vs. 63.7 mL/min/1.73 m2, p = 0.029) compared to the aPTT group. After adjusting for several bleeding/thrombosis risk factors, 97.5% of FXa and 91.0% of aPTT patients reached therapeutic levels with comparable UFH duration and maximum dose. Moreover, in-hospital mortality (2.5% vs. 3.1%, p = 0.842), major bleeding events (4.2% vs. 9.2%, p = 0.360), and thromboembolic events (21.8% vs. 10.1%, p = 0.151) remained without significant differences between FXa and aPTT cohorts. There was a high degree of variability in FXa (r2 = 0.20) and aPTT (r2 = 0.22) values for any given UFH dose.

No differences in frequency of bleeding or thromboembolic events were observed in this study between FXa versus aPTT cohorts after HM3 implantation. More longitudinal studies are warranted to determine whether or not one assay is superior to the other.

Hepatorenal dysfunction is prevalent among individuals with heart failure (HF).

This study investigated prognostic value of the modified Model for End-Stage Liver Disease (Model for End-Stage Liver Disease excluding international normalized ratio [MELD-XI] scores and Model for End-Stage Liver Disease with albumin replacing international normalized ratio [MELD-Albumin]) score in patients undergoing cardiac resynchronization therapy (CRT).

We retrospectively evaluated 365 patients (mean age 58.7 ± 11.1 years; 64.9% men) undergoing CRT implantation between 2007 and 2019. Patients were divided into 4 groups based on the modified MELD score quartiles before CRT. The primary endpoint was the combination of all-cause mortality and HF hospitalization, whereas the secondary endpoint was CRT response at 6 months.

During mean follow-up of 3.3 years (interquartile range 1.9-5.2 years), 168 patients reached the primary endpoint. Logistic regression revealed the MELD-Albumin score was independently associated with CRT response, even after adjusting for covariates (odds ratio 1.10; 95% confidence interval [CI] 1.02-1.19; P = .013). Kaplan-Meier analysis revealed that patients with a higher MELD-XI and MELD-Albumin score had a greater risk of adverse outcomes (log-rank test: P < .001). A Cox proportional hazards analysis showed that the modified MELD score remained significantly associated with adverse outcomes after adjusting for clinical and echocardiographic factors (MELD-XI: hazard ratio 1.06, 95% CI 1.02-1.11, P = .006; MELD-Albumin: hazard ratio 1.10, 95% CI 1.05-1.16, P < .001). Furthermore, receiver-operating characteristic analysis indicated that the MELD-Albumin score provided a stronger prognostic value for long-term adverse outcomes in patients undergoing CRT than the MELD-XI score (MELD-Albumin: area under the curve 0.692, 95% CI 0.644-0.742; MELD-XI: area under the curve 0.659, 95% CI 0.608-0.715; P = .008).

The MELD-Albumin score may be useful for stratifying patients at risk for CRT response and adverse outcomes in those undergoing CRT for HF.

Cholestatic complications remain a primary cause of post-liver transplantation (LTX) morbidity in pediatric patients. Standard biliary access by endoscopic retrograde cholangioscopy may not be feasible due to modified biliary drainage. Percutaneous transhepatic biliary drainage (PTCD) may be performed alternatively. However, systematic data concerning safety and efficacy of PTCD in these patients are scarce.

In this retrospective study, procedural and safety characteristics of PTCD in pediatric patients following LTX were analyzed. We compared laboratory indicators of inflammation, cholestasis, and graft function before and at 6 and 12 months after the first PTCD insertion. Efficacy was analyzed by percentage of patients without cholangitis, need for surgical biliary re-intervention and re-transplantation during a follow-up period of 60 months.

Over a decade, PTCD was attempted in a total of 15 patients, with technical success (93.3%) in 14 patients. Periprocedural complications, including bleeding (7.1%) and cholangitis (21.4%) were observed in patients. During follow-up, both MELD-score (baseline: 13 [8-15] vs. 12 months: 8 [7-8], p<0.001) and parameters of cholestasis (GGT: baseline: 286 [47-458] U/L vs. 12 months: 105 [26-147] U/L, p=0.024) decreased. Prior to PTCD, cholangitis (64.3%) and cholangiosepsis (21.4%) were common complications. In contrast, following PTCD, cholangitis occurred in only one patient (7.1%). Five patients (35.7%) needed surgical biliary re-intervention and two (14.3%) required re-transplantation.

PTCD in pediatric patients following LTX had an acceptable safety profile, demonstrating a biochemical improvement of both cholestasis and graft function and may prevent cholestatic complications, thus reducing the need for surgical re-intervention and re-transplantation.