The burden of nonalcoholic fatty liver disease (NAFLD) is increasing worldwide. We performed a meta-analysis to determine the effectiveness of exercise-based lifestyle interventions on liver-specific ...end points in populations with NAFLD and underlying metabolic disorders such as obesity, type 2 diabetes, or metabolic syndrome.
We searched PubMed-MEDLINE, Embase, and the Cochrane Central register through October 21, 2015 for randomized trials of exercise-based lifestyle interventions on end points such as intrahepatic lipid content and blood levels of alanine and aspartate aminotransferases. Effect sizes are reported as standardized mean difference and weighted mean difference values. To investigate heterogeneity, we performed sensitivity and meta-regression analyses. Results were reported according to the PRISMA statement.
We analyzed data from 28 trials. Physical activity, independently from diet change, was associated with a significant reduction in intrahepatic lipid content (standardized mean difference, -0.69; 95% confidence interval CI, -0.90 to -0.48) and with reductions in alanine aminotransferase (weighted mean difference, -3.30 IU/L; 95% CI, 5.57 to -1.04) and aspartate aminotransferase (weighted mean difference, -4.85 IU/L; 95% CI, -8.68 to -1.02). By meta-regression, we found individuals with increasing body mass index to be increasingly more likely to benefit from the intervention (beta coefficient = -0.10; P = .037). We recorded no effect modification by variables related to the intensity of the intervention.
In a meta-analysis of randomized trials, we found strong evidence that physical activity reduces intrahepatic lipid content and markers of hepatocellular injury in patients with NAFLD. This effect correlated with baseline body mass index.
Liver transplantation (LT) offers excellent long-term outcome for certain patients with hepatocellular carcinoma (HCC), with a push to not simply rely on tumor size and number. Selection criteria ...should also consider tumor biology (including alpha-fetoprotein), probability of waitlist and post-LT survival (ie, transplant benefit), organ availability, and waitlist composition. These criteria may be expanded for live donor LT (LDLT) compared to deceased donor LT though this should not adversely affect the double equipoise in LDLT, namely ensuring both acceptable recipient outcomes and donor safety. HCC patients with compensated liver disease and minimal tumor burden have low urgency for LT, especially after local-regional therapy with complete response, and do not appear to derive the same benefit from LT as other waitlist candidates. These guidelines were developed to assist in selecting appropriate HCC patients for both deceased donor LT and LDLT.
Summary
The portal vein remains the preferred site for pancreatic islet transplantation due to its easy access and low morbidity. However, despite great progress in isolation and transplantation ...protocols over the past few years, it is still associated with the early loss of some 50–70% of transplanted islets. The complex liver microenvironment itself presumably plays an important role in this loss. The present review focuses on the specifics of the liver microenvironment, notably the localized hepatic ischemia/reperfusion injury following transplantation, the low oxygenation of the portal vein, the instant blood‐mediated inflammatory reaction, the endogenous liver immune system, and the gut–liver axis, and how they can each have an impact on the transplanted islets. It identifies the potential, or already applied, clinical interventions for improving intraportal islet survival, and pinpoints those promising areas still lacking preclinical research. Future interventions on clinical intraportal islet transplantation need to take into account the global context of the liver microenvironment, with multi‐point interventions being most likely to improve early islet survival and engraftment.
Prevention of surgical site infection (SSI) is a public health challenge. Our objective was to determine if prophylactic negative-pressure wound therapy (pNPWT) allows preventing SSI after ...laparotomy.
Medline, Embase, and Web of Science were searched on 6 October 2019 for original studies reporting the incidences of SSI in patients undergoing open abdominal surgery with and without pNPWT. Risk differences (RDs) between control and pNPWT patients and risk ratios (RRs) for SSI were obtained using random-effects models.
Twenty-one studies (2930 patients, 5 randomized controlled trials RCTs, 16 observational studies) were retained for the analysis. Pooled RD between patients with and without pNPWT was -12% (95% confidence interval CI, -17% to -8%; I2 = 57%; P < .00001) in favor of pNPWT. That risk difference was -12% (95% CI, -22% to -1%; I2 = 69%; P = .03) when pooling only RCTs (792 patients). pNPWT was protective against the incidence of SSI with a RR of 0.53 (95% CI, .40-.71; I2 = 56%; P < .0001). The effect on pNPWT was more pronounced in studies with an incidence of SSI ≥20% in the control arm. The preventive effect of pNPWT on SSI remained after correction for potential publication bias. However, when pooling only high-quality observational studies (642 patients) or RCTs (527 patients), significance was lost.
Existing studies suggest that pNPWT on closed wounds is protective against the occurrence of SSI in abdominal surgery, but these findings need to be confirmed by more high-quality evidence, preferentially in subgroups of patients with an incidence of SSI ≥20% in the control arm.
The current model of liver graft allocation in place in the United States favors transplantation of patients with small hepatocellular carcinomas (HCCs) within the Milan criteria (a single tumor up ...to 5 cm in diameter or up to three lesions, none larger than 3 cm). Although several reports have suggested that these criteria could be extended, there is currently no agreement on new selection tools. In this study, we performed an overview of 6478 adult recipients of an isolated first liver transplant registered in the Scientific Registry of Transplant Recipients (SRTR) database. From March 2002 to January 2008, increasing numbers of patients outside Milan criteria (P ≤ 0.001) have been registered for a transplant, but they still represent less than 5% of the transplants performed for HCC. Of all the tested variables (tumor number, largest tumor size, and Milan and University of California San Francisco criteria), only total tumor volume (TTV; P ≤ 0.05) and alpha fetoprotein (AFP; P ≤ 0.001) could predict patient survival. While these two parameters demonstrated independent behaviors (no patient demonstrated an increase in both values), a composite score was defined, with patients with a TTV > 115 cm3 or an AFP > 400 ng/mL being outside criteria. The combined TTV/AFP score efficiently predicted posttransplant survival (hazard ratio = 2, 95% confidence interval = 1.7‐2.4, P ≤ 0.001); patients not meeting these criteria had a survival below 50% at 3 years. Conclusion: According to the present SRTR data, Milan criteria are too restrictive, and patients with larger TTV can enjoy satisfactory posttransplant survivals. A composite patient selection score combining TTV and AFP was the most effective of all tested staging criteria for the prediction of posttransplant patient survival for candidates with HCC. (HEPATOLOGY 2009.)
Background & Aims Liver transplantation is a recognized treatment for selected patients with hepatocellular carcinoma (HCC), but transplant criteria still need to be refined, especially in the case ...of more advanced or downstaged tumors. Methods The present study investigated alpha-fetoprotein (AFP) as a predictor of outcome in 6817 patients listed with a diagnosis of HCC in the Scientific Registry of Transplant Recipients. Results Local pre-transplant HCC treatment was used in 41% of patients on the waiting list. Patients with AFP levels >400 ng/ml at the time of listing who were downstaged to AFP ⩽400 ng/ml had better intent-to-treat survival than patients failing to reduce AFP to ⩽400 (81% vs. 48% at 3 years, p ⩽ 0.001) and comparable survival to patients with stable AFP ⩽400 ng/ml (74%, p = 0.14). Patients with AFP levels decreased ⩽400 ng/ml and patients with levels persistently ⩽400 ng/ml also had similar drop-out rates from the list (10% in both groups) and post-transplant survival rates (89% vs . 78% at 3 years, p = 0.11). Such an AFP downstaging was associated with good survivals whatever the level of the original AFP (even if originally >1000 ng/ml). Only the last pre-transplant AFP independently predicted survival ( p ⩽0.001), unlike AFP at listing or AFP changes. Conclusions Overall, downstaging HCC patients with high AFP is feasible and leads to similar intent-to-treat and post-transplant survivals to those of patients with AFP persistently low. Only last AFP appears relevant for patient selection before transplantation and should be used in combination with morphological variables.
Summary
There are scarce data on the impact of COVID‐19 pandemic on liver transplantation (LT) in Europe. The aim of this study was to obtain a preliminary data on incidence, management, and outcome ...of COVID‐19 in liver transplant recipients and candidates in Europe. An Internet‐based survey was sent to the centers affiliated with European Liver Transplant Registry (ELTR). One hundred nine out of 149 (73%) of ELTR centers located in 28 European countries (93%) responded. Ninety‐four (86%) of the centers tested all donors, and 75 (69%) centers tested all LT recipients for SARS‐CoV‐2. Seventy‐three (67%) centers selected recipients for LT in the COVID‐19 pandemic, whereas 33% did not. Eighty‐eight centers reported COVID‐19 infection in 57 LT candidates and in 272 LT recipients. Overall crude incidence of COVID‐19 among LT candidates and recipients was estimated 1.05% (range 0.5–20%) and 0.34% (range 0.1–4.8%), respectively, and it was significantly higher among candidates (P < 0.001). Crude rate of death was 18% (10/57) among candidates and 15% (36/244) among recipients. This first large‐scale European snapshot study clearly shows that both LT candidates and recipients are at a high risk for COVID‐19. These results plead for an early and pro‐active screening of COVID‐19 symptoms in these populations.
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