• ERAS
• Hepatocellular carcinoma
• Liver transplantation
• Outcomes

• Artificial intelligence
• Hepatectomy
• Length of stay
• Machine learning
• Quality improvement

• blood transfusion
• lung transplantation
• primary graft dysfunction

• Humans
• Cohort Studies
• Retrospective Studies
• Lung
• Blood Transfusion
• Lung Transplantation/adverse effects
• Lung Transplantation/methods

• liver cancer
• liver failure
• living-donor liver transplantation
• posttransplant outcomes
• predictive factors

Immunotherapy has become a new therapy for advanced hepatocellular carcinoma (HCC); however, its treatment results are considerably different. CD4+ T cells (CD4+) are the key to immunotherapy, but patients with HCC that have low CD4+ are rarely observed for clinical evidence. Hepatitis B virus-related HCC is often accompanied by cirrhosis and portal hypertension; therefore, CD4+ tend to be relatively low in number. TACE is the standard treatment for Barcelona Clinic Liver Cancer (BCLC)-B HCC, which may further reduce the number of CD4 + .

This retrospective cohort study further reduced CD4+ by including patients with human immunodeficiency virus (HIV) to observe the relationship between CD4+ and Chronic hepatitis B virus (CHB) induced HCC. A total of 170 BCLC-B HCC patients (42 HIV+) were included. Univariate and multivariate analyses, and artificial neural networks (ANNs) were used to evaluate the independent risk factors for the two-year survival.

The statistical analysis of the two-year survival rate showed that the main factors influencing survival were liver function and immune indices, including CD4+, platelet, alanine aminotransferase, aspartate aminotransferase, aspartate aminotransferase-to-platelet ratio index, and fibrosis-4 (FIB-4) (P < 0.05). Compared with that in other indices, in logistic and ANN multivariate analysis, CD4 + -to-FIB-4 ratio (CD4+/FIB-4) had the highest importance with 0.716 C-statistic and 145.93 cut-off value. In terms of overall survival rate, HIV infection was not a risk factor (P = 0.589); however, CD4+/FIB-4 ≤ 145.93 significantly affected patient prognosis (P = 0.002).

HIV infection does not affect the prognosis of BCLC-B HCC, but CD4+ have a significant predictive value. CD4+ played a vital role in HCC and this deserves the attention from physicians. Further, the CD4+/FIB-4 is a clinically valuable effective prognostic indicator for these patients.

• Aspartate aminotransferase (AST)
• Aspartate aminotransferase-to-platelet ratio index (APRI)
• Barcelona Clinic Liver Cancer (BCLC)
• Fibrosis-4 (FIB-4)
• Hepatitis B virus (HBV); Platelet (PLT), Alanine aminotransferase (ALT)
• Hepatocellular carcinoma (HCC)
• Human immunodeficiency virus (HIV)

The allocation policy for deceased donor livers in Korea was changed in June 2016 from Child-Turcotte-Pugh (CTP) scoring system-based to Model for End-stage Liver Disease (MELD) scoring system-based. Thus, it is necessary to review the effect of allocation policy changes on anesthetic management.

Medical records of deceased donor liver transplantation (DDLT) from December 2014 to May 2017 were reviewed. We compared the perioperative parameters before and after the change in allocation policy.

Thirty-seven patients underwent DDLT from December 2014 to May 2016 (CTP group), and 42 patients underwent DDLT from June 2016 to May 2017 (MELD group). The MELD score was significantly higher in the MELD group than in the CTP group (36.5 ± 4.6 vs. 26.5 ± 9.4, P < 0.001). The incidence of hepatorenal syndrome was higher in the MELD group than in the CTP group (26 vs. 7, P < 0.001). Packed red blood cell transfusion occurred more frequently in the MELD group than in the CTP group (5.0 ± 3.6 units vs. 3.4 ± 2.2 units, P = 0.025). However, intraoperative bleeding, vasopressor support, and postoperative outcomes were not different between the two groups.

Even though the patient’s objective condition deteriorated, perioperative parameters did not change significantly.

• Allocation
• Liver transplant
• Perioperative care
• Unrelated donors

• RBC transfusion
• blood management
• transfusion practices (surgical)

Adult hemiliver transplantation (AHLT) is an important approach given the current shortage of donor livers. However, the suitability of AHLT versus adult whole liver transplantation (AWLT) for recipients with high Model for End-Stage Liver Disease (MELD) scores remains controversial.

We divided patients undergoing AHLT and AWLT into subgroups according to their MELD scores (≥ 30: AHLT, n = 35; AWLT, n = 88; and < 30: AHLT, n = 323; AWLT, n = 323). Patients were matched by demographic data and perioperative conditions according to propensity scores. A cut-off value of 30 for MELD scores was determined by comparing the overall survival data of 735 cases of nontumor liver transplantation.

Among patients with an MELD score ≥ 30 and < 30, AHLT was found to be associated with increased warm ischemia time, operative time, hospitalization time, and intraoperative blood loss compared with AWLT (P < 0.05). In the MELD ≥ 30 group, although the 5-year survival rate was significantly higher for AWLT than for AHLT (P = 0.037), there was no significant difference between AWLT and AHLT in the MELD < 30 group (P = 0.832); however, we did not observe a significant increase in specific complications following AHLT among patients with a high MELD score (≥ 30). Among these patients, the incidence of complications classified as Clavien-Dindo grade III or above was significantly higher in patients undergoing AHLT than in those undergoing AWLT (25.7% vs. 11.4%, P = 0.047). For the MELD < 30 group, there was no significant difference in the incidence of complications classified as Clavien-Dindo grade III or above for patients undergoing AHLT or AWLT.

In patients with an MELD score < 30, AHLT can achieve rates of mortality and overall survival comparable to AWLT. In those with an MELD score ≥ 30, the prognosis and incidence of complications classified as Clavien-Dindo III or above are significantly worse for AHLT than for AWLT; therefore, we may need to be more cautious regarding the conclusion that patients with a high MELD score can safely undergo AHLT.

• Liver transplantation (LT)
• Living donor liver transplantation (LDLT)
• Model for End-Stage Liver Disease Scores (MELD)
• Split liver transplantation (SLT)

• Hepatocellular carcinoma
• Insulin-like growth factor 1
• Liver transplantation
• MELD-IGF-1
• Model for End-Stage Liver Disease

• Carcinoma, Hepatocellular/blood
• Carcinoma, Hepatocellular/pathology
• Cohort Studies
• Female
• Humans
• Insulin-Like Growth Factor I/genetics
• Liver/metabolism
• Liver/pathology
• Liver Neoplasms/blood
• Liver Neoplasms/pathology
• Male
• Middle Aged
• Patient Selection
• Proportional Hazards Models
• Risk Factors
• Severity of Illness Index

• P30 CA016672 NCI NIH HHS
• R21 CA190945 NCI NIH HHS
• K07 CA106458 NCI NIH HHS
• R01 CA151533 NCI NIH HHS
• R21 CA170035 NCI NIH HHS

Acute respiratory failure requiring mechanical ventilation is a major indicator of intensive care unit (ICU) admissions in cirrhotic patients and is an independent risk factor for ICU mortality. This retrospective study aimed to investigate the outcome and mortality risk factors in patients with liver cirrhosis (LC) who required prolonged mechanical ventilation (PMV) between 2006 and 2013 from two databases: Taiwan’s National Health Insurance Research Database (NHIRD) and a hospital database. The hospital database yielded 58 LC patients (mean age: 65.3 years; men: 65.5%). The in-hospital mortality was significantly higher than in patients without LC. Based on the NHIRD database of PMV cases, patients were age-gender matched in a ratio of 1:2 for patients with and without LC. Model for End-Stage Liver Disease (MELD) score was calculated. The mortality was higher in patients with LC (19.5%) than those without LC (18.12%), though not statistically significant (p = 0.0622). Based on the hospital database, risk factor analysis revealed that patients who died had significant higher MELD score than the survivors (18.9 vs 13.7, p = 0.036) and patients with MELD score of >23 had higher risk of mortality than patients with MELD score of ≤23 (adjusted OR:9.26, 95% CI: 1.96–43.8). In conclusion, the in-hospital mortality of patients with high MELD scores who required PMV was high. MELD scores may be useful predictors of mortality in these patients.

• ADT screening tool
• Additional ICU days
• ICU length of stay
• Liver transplant recovery
• Progressive care unit

• early reoperation
• graft survival
• liver transplantation

• clinical decision support system
• length of hospital stay
• model for end-stage liver disease
• morbidity
• mortality

• Adolescent
• Adult
• Aged
• Aged, 80 and over
• Comorbidity
• Cost of Illness
• End Stage Liver Disease/diagnosis
• End Stage Liver Disease/mortality
• End Stage Liver Disease/therapy
• Female
• Humans
• Inpatients
• Length of Stay
• Male
• Middle Aged
• Multivariate Analysis
• Patient Admission
• Prognosis
• Proportional Hazards Models
• Retrospective Studies
• Severity of Illness Index
• Tertiary Care Centers
• Young Adult

• Area Under Curve
• End Stage Liver Disease/diagnosis
• End Stage Liver Disease/mortality
• End Stage Liver Disease/therapy
• Female
• Graft Survival
• Humans
• Incidence
• Intensive Care Units
• Kaplan-Meier Estimate
• Length of Stay
• Liver Transplantation/mortality
• Logistic Models
• Male
• Middle Aged
• Operative Time
• Prognosis
• ROC Curve
• Retrospective Studies
• Risk Factors
• Severity of Illness Index
• Treatment Outcome

There is a need to reassess the application of MELD and the impact of renal insufficiency with consideration for developing an algorithm with exception points that would lead to timely allocation of livers to patients with hepatorenal syndrome prior to occurrence of permanent renal damage without jeopardizing post-transplant survival.

• MELD
• Hepatorenal syndrome
• Cirrhosis
• Graft survival
• Liver allocation

• cirrhosis
• end-stage liver disease
• liver transplant
• meld

Hepatosplanchnic circulation receives almost half of cardiac output and is essential to physiologic homeostasis. Liver cirrhosis is estimated to affect up to 1% of populations worldwide, including 1.5% to 3.3% of intensive care unit patients. Cirrhosis leads to hepatosplanchnic circulatory abnormalities and end-organ damage. Sepsis and cirrhosis result in similar circulatory changes and resultant multi-organ dysfunction. This review provides an overview of the hepatosplanchnic circulation in the healthy state and in cirrhosis, examines the signaling pathways that may play a role in the physiology of cirrhosis, discusses the physiology common to cirrhosis and sepsis, and reviews important issues in management.

• Liver cirrhosis
• Sepsis
• Splanchnic circulation
• Hepatic circulation
• Hepatic artery buffer response

• Animals
• Hemodynamics
• Hepatic Artery/physiopathology
• Humans
• Liver Circulation
• Liver Cirrhosis/epidemiology
• Liver Cirrhosis/physiopathology
• Liver Cirrhosis/therapy
• Portal Vein/physiopathology
• Prognosis
• Risk Factors
• Sepsis/epidemiology
• Sepsis/physiopathology
• Sepsis/therapy
• Splanchnic Circulation

• Hospital mortality
• Indocyanine green liver testing
• Length of stay in the ICU
• MELD score

• lung transplantation
• mortality
• transfusion
• icu complications

• Allocation
• End-Stage Liver Disease
• Liver Cirrhosis
• Liver Transplantation

• Detoxification
• Hepatocyte growth factor
• Liver failure
• Molecular adsorbent recirculating system
• Sequential Organ Failure Assessment
• Survival

• AH, alcoholic hepatitis
• BAR, balance risk
• CTP, Child–Pugh–Turcotte
• Cirrhosis
• DFI, discriminate function index
• EDC, extended donor criteria
• ESLD, end-stage liver disease
• FHF, fulminant hepatic failure
• GFR, glomerular filtration rate
• HVPG, hepatic venous pressure gradient
• LT, liver transplantation
• Liver transplantation
• MDRD, modification of diet in renal disease
• MELD
• MELD, model for end-stage liver disease
• MLP, multi-layer perceptron
• QALY, quality adjusted life years
• SLK, simultaneous liver kidney transplantation
• SOFA, sequential organ failure assessment
• SOFT, survival outcomes following transplantation
• TIPS, transjugular intrahepatic portosystemic
• UKELD, UK end stage liver disease score
• UNOS, United Network for Organ Sharing
• VH, variceal hemorrhage
• deMELD, drop-out equivalent MELD

Renal failure with following continuous renal replacement therapy is a major clinical problem in liver transplant recipients, with reported incidences of 3% to 20%. Little is known about the significance of postoperative acute renal failure or acute-on-chronic renal failure to postoperative outcome in liver transplant recipients.

In this post hoc analysis we compared the mortality rates of 135 consecutive liver transplant recipients over 6 years in our center subject to their renal baseline conditions and postoperative RRT. We classified the patients into 4 groups, according to their preoperative calculated Cockcroft formula and the incidence of postoperative renal replacement therapy. Data then were analyzed in regard to mortality rates and in addition to pre- and peritransplant risk factors.

There was a significant difference in ICU mortality (p=.008), hospital mortality (p=.002) and cumulative survival (p<.0001) between the groups. The highest mortality rate occurred in the group with RRT and normal baseline kidney function (20% ICU mortality, 26.6% hospital mortality and 50% cumulative 1-year mortality, respectively). The hazard ratio in this group was 9.6 (CI 3.2-28.6, p=.0001).

This study shows that in liver transplant recipient’s acute renal failure with postoperative RRT is associated with mortality and the mortality rate is higher than in patients with acute-on-chronic renal failure and postoperative renal replacement therapy.

Critically ill cirrhosis patients awaiting liver transplantation (LT) often receive prioritization for organ allocation. Identification of patients most likely to benefit is essential. The purpose of this study was to examine whether the Sequential Organ Failure Assessment (SOFA) score can predict 90-day mortality in critically ill recipients of LT and whether it can predict receipt of LT among critically ill cirrhosis listed awaiting LT.

We performed a multicenter retrospective cohort study consisting of two datasets: (a) all critically-ill cirrhosis patients requiring intensive care unit (ICU) admission before LT at five transplant centers in Canada from 2000 through 2009 (one site, 1990 through 2009), and (b) critically ill cirrhosis patients receiving LT from ICU (n = 115) and those listed but not receiving LT before death (n = 106) from two centers where complete data were available.

In the first dataset, 198 critically ill cirrhosis patients receiving LT (mean (SD) age 53 (10) years, 66% male, median (IQR) model for end-stage liver disease (MELD) 34 (26-39)) were included. Mean (SD) SOFA scores at ICU admission, at 48 hours, and at LT were 12.5 (4), 13.0 (5), and 14.0 (4). Survival at 90 days was 84% (n = 166). In multivariable analysis, only older age was independently associated with reduced 90-day survival (odds ratio (OR), 1.07; 95% CI, 1.01 to 1.14; P = 0.013). SOFA score did not predict 90-day mortality at any time. In the second dataset, 47.9% (n = 106) of cirrhosis patients listed for LT died in the ICU waiting for LT. In multivariable analysis, higher SOFA at 48 hours after admission was independently associated with lower probability of receiving LT (OR, 0.89; 95% CI, 0.82 to 0.97; P = 0.006). When including serum lactate and SOFA at 48 hours in the final model, elevated lactate (at 48 hours) was also significantly associated with lower likelihood of receiving LT (0.32; 0.17 to 0.61; P = 0.001).

SOFA appears poor at predicting 90-day survival in critically ill cirrhosis patients after LT, but higher SOFA score and elevated lactate 48 hours after ICU admission are associated with a lower probability receiving LT. Older critically ill cirrhosis patients (older than 60) receiving LT have worse 90-day survival and should be considered for LT with caution.

Liver transplantation is indicated in patients with acute liver failure, decompensated cirrhosis, hepatocellular carcinoma and rare liver-based genetic defects that trigger damage of other organs. Early referral to a transplant center is crucial in acute liver failure due to the high mortality with medical therapy and its unpredictable evolution. Referral to a transplant center should be considered when at least one complication of cirrhosis occurs during its natural history. However, because of the shortage of organ donors and the short-term mortality after liver transplantation on one hand and the possibility of managing the complications of cirrhosis with other treatments on the other, patients are carefully selected by the transplant center to ensure that transplantation is indicated and that there are no medical, surgical and psychological contraindications. Patients approved for transplantation are placed on the transplant waiting list and prioritized according to disease severity. Thus, the appropriate timing of transplantation depends on recipient disease severity and, although this is still a matter of debate, also on donor quality. These two variables are known to determine the “transplant benefit” (i.e., when the expected patient survival is better with, than without, transplantation) and should guide donor allocation.

• Liver transplantation
• Referral
• Waiting list
• Prioritization
• Allocation
• Timing
• Cirrhosis
• Hepatocellular carcinoma
• Indications
• Contraindications