Clinical Liver Disease

High demand and low supply remains a constant challenge in liver transplantation, but in some cases extended criteria donor liver allografts provide an effective alternative.

Acute liver failure (ALF) manifests in patients without preexisting liver disease or cirrhosis, and the results can be devastating. Most patients quickly become critically ill, and approximately one third of ALF patients won't survive without liver transplantation. Read expert commentary from Dr. Oren Fix on the etiology, risks, and prognosis, to better manage patients with ALF.

Liver transplant recipients generally need lifelong immunosuppression - approximately 7 to 17 per cent of patients experience an episode of acute cellular rejection with 3 to 12 months of LT, respectively.

ince the first liver transplant operation in 1963, the field has experienced huge medical and surgical advances. Drs. Miller and Diago Uso review the complex interplay of donor and recipient factors which now contribute to 5-year survival rates approaching 75 per cent.

The rising use of expanded criteria donors in an aging patient population makes careful selection of donors and recipients increasingly important. Understand the complex interplay between factors such as donor age, risk index, sex, race, and genetics, as well as the etiology of the liver disease in the recipient, to improve patient outcomes.

Pioneered in pediatric patients in the late 1980s due to insufficient appropriately sized liver donors and high mortality among children on the organ waiting list, living donor liver transplantation is now also employed in the adult patient population.

Successful treatment of HCV improves survival after liver transplantation, but antiviral therapy for patients awaiting transplantation or on immunosuppression after LT continues to be clinically challenging. In this era of rapidly changing HCV therapy, Dr. Elizabeth Verna explains strategies for eliminating hepatitis C in pre- and post-LT settings.

HBV was once regarded as a contraindication for liver transplantation. In the last 20 years advances such as HBIG and LAM have made HBV infection one of the best indications for LT, although cost and availability of prophylactic therapies can be challenges. .

The Model for End-Stage Liver Disease (MELD) score uses the international normalized ratio, creatinine, and total bilirubin to predict 3-month mortality risk, making it a relatively easy and objective measurement for organ allocation, however concerns about equitable distribution remain.

Drs. Xanthakos and Kohli discuss the challenges in managing the pediatric patient with NAFLD, a growing patient population in both developed and developing countries. NAFLD in youth is often clinically silent and is discovered only upon screening or the incidental testing of serum aminotransferase levels.

NASH-related cirrhosis is the third most common indication for transplantation in the current era and accounts for 10% to 13% of transplants performed. The need for liver transplantation in patients with NAFLD is growing. Dr. Watt explains the impact of disease recurrence on short- and medium-term survival and addresses management approaches necessary to improve long-term survival.

Current guidelines do not recommend the use of hepatic pharmacological therapy in patients with steatosis alone. Instead, patients with NASH and significant liver disease (bridging fibrosis) are good candidates for therapy. Dr. Ratzui outlines the current guidelines, best available evidence, and potential pharmacologic management of the patient with NASH.

In this introduction to CLD’s special issue on NAFLD, Drs. Puri and Sanyal define nonalcoholic fatty liver disease (NAFLD) and its progressive form, non-alcoholic steatohepatitis (NASH), addressing histology, risk factors, and work up.

The treatment of NAFLD is a patient-centered process that requires a patient to accept responsibility for lifestyle modifications. Evidence is emerging that allows physicians to guide patients better with diet and exercise counseling. Drs. Paredes, Torres, and Harrison explain..

Liver biopsy is the gold standard to confirm NASH, a progressive form of NAFLD. Biomarkers and clinical prediction rules for refining the management paradigm of NAFLD are emerging. Drs. Noureddin and Loomba discuss the noninvasive biomarkers that may be useful and indications for performing liver biopsy in patients with NAFLD.

In the context of limited data and controversial approaches to screening, management of pediatric NAFLD presents many challenges for healthcare providers. Dr. Molleston outlines the reviews the best available evidence, recommends management approaches, identifies limitations in the current evidence base, and highlights other important aspects in the care of children with chronic liver disease, such as immunization against hepatitis A and B and counseling to avoid potential hepatotoxins such as alcohol.

NAFLD is associated with an increased risk of cardiovascular disease (CVD) and is frequently associated with metabolic syndrome. This creates a pressing need for the diagnosis and management of the comorbidities of NAFLD, including CVD. Drs. Corey and Vuppalanci guide clinicians in the assessment and management of metabolic disease and CVD in patients with NAFLD.

Transhepatic intrahepatic portosystemic shunt (TIPS) stent placement is a minimally invasive procedure that, given the risk associated with surgical decompression, is preferred for the management of portal decompression. Drs. Bhogal and Sanyal discuss the procedure. .

For portal hypertension, drug therapy with nonselective beta-blockers (NSBBs) is considered by many to be first line for primary and secondary prevention of variceal hemorrhage. In this brief and practical review, Dr. Tripathi outlines the benefits and drawbacks of the range of potential drug therapies.

Gastric varices (GV) are present in approximately 20% of patients with portal hypertension. While GVs bleed less frequently than esophageal varices (EV), bleeding is more severe and mortality is higher. Dr. Wong Kee Song reviews the latest recommendations for endoscopic, radiologic, and surgical interventions and comments on potential approaches for prevention.