AIM:To evaluate the clinical outcomes of patients undergoing hepatectomy with hemihepatic vascular occlusion(HHO) compared with total hepatic inflow occlusion(THO).METHODS:Randomized controlled trials(RCTs) comparing ...AIM:To evaluate the clinical outcomes of patients undergoing hepatectomy with hemihepatic vascular occlusion(HHO) compared with total hepatic inflow occlusion(THO).METHODS:Randomized controlled trials(RCTs) comparing hemihepatic vascular occlusion and total hepatic inflow occlusion were included by a systematic literature search.Two authors independently assessed the trials for inclusion and extracted the data.A metaanalysis was conducted to estimate blood loss,transfusion requirement,and liver injury based on the levels of aspartate aminotransferase(AST) and alanine aminotransferase(ALT).Either the fixed effects model or random effects model was used.RESULTS:Four RCTs including 338 patients met the predefined inclusion criteria.A total of 167 patients were treated with THO and 171 with HHO.Meta-analysis of AST levels on postoperative day 1 indicated higher levels in the THO group with weighted mean difference(WMD) 342.27;95% confidence intervals(CI) 217.28-467.26;P = 0.00 001;I2 = 16%.Meta-analysis showed no significant difference between THO group and HHO group on blood loss,transfusion requirement,mortality,morbidity,operating time,ischemic duration,hospital stay,ALT levels on postoperative day 1,3 and 7 and AST levels on postoperative day 3 and 7.CONCLUSION:Hemihepatic vascular occlusion does not offer satisfying benefit to the patients undergoing hepatic resection.However,they have less liver injury after liver resections.展开更多
AIM:To explore the relationship between α-fetoprotein(AFP) and various clinicopathological variables and different staging system of hepatocellular carcinoma(HCC) thoroughly.METHODS:A retrospective cohort study of co...AIM:To explore the relationship between α-fetoprotein(AFP) and various clinicopathological variables and different staging system of hepatocellular carcinoma(HCC) thoroughly.METHODS:A retrospective cohort study of consecutive patients diagnosed with HCC between January 2008 and December 2009 in West China Hospital was enrolled in our study.The association of serum AFP values with the HCC clinicopathological features was analysed by univariate and multivariate analysis,such as status of hepatitis B virus(HBV) infection,tumor size,tumor number,vascular invasion and degree of tumor differentiation.Also,patients were divided into four groups at the time of enrollment according to different cutoff values for serum value of AFP(≤ 20 μg/L,21-400 μg/L,401-800 μg/L,and ≥ 801 μg/L),to compare the positive rate of patient among four groups stratified by various clinicopathological variables.And the correlation of different kinds of tumor staging systems,such as TNM,Barcelona Clinic Liver Cancer(BCLC) staging classification and China staging,were compared with the serum concentration of AFP.RESULTS:A total of 2304 HCC patients were enrolled in this study totally;the mean serum level of AFP was 555.3 ± 546.6 μg/L.AFP levels were within the normal range(< 20 μg/L) in 27.4%(n = 631) of all the cases.81.4%(n = 1875) patients were infected with HBV,and those patients had much higher serum AFP level compared with non-HBV infection ones(573.9 ± 547.7 μg/L vs 398.4 ± 522.3 μg/L,P < 0.001).The AFP level in tumors ≥ 10 cm(808.4 ± 529.2 μg/L) was significantly higher(P < 0.001) than those with tumor size 5-10 cm(499.5 ± 536.4 μg/L) and with tumor size ≤ 5 cm(444.9 ± 514.2 μg/L).AFP levels increased significantly in patients with vascular invasion(694.1 ± 546.9 μg/L vs 502.1 ± 543.1 μg/L,P < 0.001).Patients with low tumor cell differentiation(559.2 ± 545.7 μg/L) had the significantly(P = 0.007) highest AFP level compared with high differentiation(207.3 ± 420.8 μg/L) and intermediate differentiation(527.9 ± 538.4 μg/L).In the multiple variables analysis,low tumor cell differentiation [OR 6.362,95%CI:2.891-15.382,P = 0.006] and tumor size(≥ 10 cm)(OR 5.215,95%CI:1.426-13.151,P = 0.012) were independent predictors of elevated AFP concentrations(AFP > 400 μg/L).Serum AFP levels differed significantly(P < 0.001) in the D stage of BCLC(625.7 ± 529.8 μg/L) compared with stage A(506.2 ± 537.4 μg/L) and B(590.1 ± 551.1 μg/L).CONCLUSION:HCC differentiation,size and vascular invasion have strong relationships with AFP,poor differentiation and HCC size ≥ 10 cm are independent predictors of elevated AFP.BCLC shows better relationship with展开更多
AIM:To assess systematically the safety and efficacy of bile leakage test in liver resection.METHODS:Randomized controlled trials and controlled clinical trials involving the bile leakage test were included in a syste...AIM:To assess systematically the safety and efficacy of bile leakage test in liver resection.METHODS:Randomized controlled trials and controlled clinical trials involving the bile leakage test were included in a systematic literature search.Two authors independently assessed the studies for inclusion and extracted the data.A meta-analysis was conducted to estimate postoperative bile leakage,intraoperative positive bile leakage,and complications.We used either the fixed-effects or random-effects model.RESULTS:Eight studies involving a total of 1253 patients were included and they all involved the bile leakage test in liver resection.The bile leakage test group was associated with a significant reduction in bile leakage compared with the non-bile leakage test group(RR=0.39,95%CI:0.23-0.67;I2=3%).The white test had superiority for detection of intraoperative bile leakage compared with the saline solution test(RR=2.38,95%CI:1.24-4.56,P=0.009).No significant intergroup differences were observed in total number of complications,ileus,liver failure,intraperitoneal hemorrhage,pulmonary disorder,abdominal infection,and wound infection.CONCLUSION:The bile leakage test reduced postoperative bile leakage and did not increase incidence of complications.Fat emulsion is the best choice of solution for the test.展开更多
AIM:To determine whether an elevated neutrophillymphocyte ratio(NLR)is negatively associated with tumor recurrence in patients with hepatitis B virus(HBV)-related hepatocellular carcinoma(HCC)after liver transplantati...AIM:To determine whether an elevated neutrophillymphocyte ratio(NLR)is negatively associated with tumor recurrence in patients with hepatitis B virus(HBV)-related hepatocellular carcinoma(HCC)after liver transplantation(LT),and to determine the optimal predictive NLR cut-off value.METHODS:The data of HCC patients who had undergone LT came from the China Liver Transplant Registry database.We collected data from 326 liver cancer patients who had undergone LT at our medical center.We divided the patients into groups based on their NLRs(3,4 or 5).We then compared the clinicopathological data and long-time survival between these groups.Meanwhile,we used receiver operating characteristic analysis to determine the optimal NLR cut-off.RESULTS:Of 280 HCC patients included in this study,263 were HBV positive.Patients with an NLR<3 and patients with an NLR≥3 but<4 showed no significant differences in overall survival(OS)(P=0.212)or disease-free survival(DFS)(P=0.601).Patients with an NLR≥4 but<5 and patients with an NLR≥5also showed no significant differences in OS(P=0.208)or DFS(P=0.618).The 1-,3-and 5-year OS rates of patients with an NLR<4 vs an NLR≥4 were 87.8%,63.8%and 61.5%vs 73.9%,36.7%and 30.3%,respectively(P<0.001).The 1-,3-and 5-year DFS rates of patients with an NLR<4 vs NLR≥4 were 83.9%,62.9%and 60.7%vs 64.9%,30.1%and 30.1%,respectively(P<0.001).Univariate and multivariate analyses demonstrated that three factors,including NLR≥4(P=0.002),were significant predictors of tumor recurrence in HCC patients after LT.CONCLUSION:A preoperative elevated NLR significantly increased the risk for tumor recurrence in HCC patients after LT.展开更多
AbstractAIM： To investigate the impact of minimum tacrolimus（TAC） on new-onset diabetes mellitus （NODM） afterliver transplantation （LT）.METHODS： We retrospectively analyzed the data of973 liver transplant reci...AbstractAIM： To investigate the impact of minimum tacrolimus（TAC） on new-onset diabetes mellitus （NODM） afterliver transplantation （LT）.METHODS： We retrospectively analyzed the data of973 liver transplant recipients between March 1999and September 2014 in West China Hospital LiverTransplantation Center. Following the exclusion ofineligible recipients, 528 recipients with a TAC-dominantregimen were included in our study. We calculatedand determined the mean trough concentration ofTAC （cTAC） in the year of diabetes diagnosis in NODMrecipients or in the last year of the follow-up in non-NODM recipients. A cutoff of mean cTAC value forpredicting NODM 6 mo after LT was identified usinga receptor operating characteristic curve. TAC-relatedcomplications after LT was evaluated by χ^2 test, andthe overall and allograft survival was evaluated usingthe Kaplan-Meier method. Risk factors for NODM afterLT were examined by univariate and multivariate Cox regression.RESULTS： Of the 528 transplant recipients, 131（24.8%） developed NODM after 6 mo after LT, andthe cumulative incidence of NODM progressivelyincreased. The mean cTAC of NODM group recipientswas significantly higher than that of recipients in thenon-NODM group （7.66 ± 3.41 ng/mL vs 4.47 ± 2.22ng/mL, P 〈 0.05）. Furthermore, NODM group recipientshad lower 1-, 5-, 10-year overall survival rates （86.7%,71.3%, and 61.1% vs 94.7%, 86.1%, and 83.7%, P 〈0.05） and allograft survival rates （92.8%, 84.6%, and75.7% vs 96.1%, 91%, and 86.1%, P 〈 0.05） thanthe others. The best cutoff of mean cTAC for predictingNODM was 5.89 ng/mL after 6 mo after LT. Multivariateanalysis showed that old age at the time of LT （〉 50years）, hypertension pre-LT, and high mean cTAC （≥5.89 ng/mL） after 6 mo after LT were independent riskfactors for developing NODM. Concurrently, recipientswith a low cTAC （〈 5.89 ng/mL） were less likely tobecome obese （21.3% vs 30.2%, P 〈 0.05） or todevelop dyslipidemia （27.5% vs 44.8%, P 〈0.05）,chronic kidney dysfunction （14.6% vs 22.7%, P 〈 0.05）,and moderate to severe infection （24.7% vs 33.1%, P〈 0.05） after LT than recipients in the high mean cTACgroup. However, the two groups showed no significantdifference in the incidence of acute and chronicrejection, hypertension, cardiovascular events and newonsetmalignancy.CONCLUSION： A minimal TAC regimen can decreasethe risk of long-term NODM after LT. Maintaining a cTACvalue below 5.89 ng/mL after LT is safe and beneficial.展开更多
BACKGROUND: Combined hepatectomy and radiofrequency ablation(RFA) provides an additional treatment for patients with Barcelona Clinic Liver Cancer(BCLC) stage B hepatocellular carcinoma(HCC) who are conventionally dee...BACKGROUND: Combined hepatectomy and radiofrequency ablation(RFA) provides an additional treatment for patients with Barcelona Clinic Liver Cancer(BCLC) stage B hepatocellular carcinoma(HCC) who are conventionally deemed unresectable. This study aimed to analyze the outcome of this combination therapy by comparing it with transarterial chemoembolization(TACE). METHODS: We retrospectively reviewed 51 patients with unresectable BCLC stage B HCC who had received the combination therapy. We compared the survival of these patients with that of 102 patients in the TACE group(control). Prognostic factors associated with worse survival in the combination group were analyzed.RESULTS: No differences in tumor status and liver function were observed between the TACE group and combination group. The median survival time for the combination group and TACE group was 38(6-54) and 17(3-48) months, respectively(P<0.001). The combination group required longer hospitalization than the TACE group [8(5-14) days vs 4(2-9) days,P<0.001]. More than two ablations decreased the survival rate in the combination group. CONCLUSIONS: Combined hepatectomy and RFA yielded a better long-term outcome than TACE in patients with unresectable BCLC stage B HCC. Patients with a limited ablated size(≤2 cm), a limited number of ablations(≤2), and adequate surgical margin should be considered candidates for combination therapy.展开更多
AIM:To identify risk factors that might contribute to hepatic artery thrombosis(HAT)after liver transplantation(LT).METHODS:The perioperative and follow-up data of a total of 744 liver transplants,performed from Febru...AIM:To identify risk factors that might contribute to hepatic artery thrombosis(HAT)after liver transplantation(LT).METHODS:The perioperative and follow-up data of a total of 744 liver transplants,performed from February1999 to July 2010,were retrospectively reviewed.HAT developed in 20 patients(2.7%).HAT was classified as early(occurring in fewer than 30 d post LT)or late(occurring more than 30 d post LT).Early HAT developed in 14 patients(1.9%).Late HAT developed in 6patients(0.8%).Risk factors associated with HAT were analysed using theχ2 test for univariate analysis and logistic regression for multivariate analysis.RESULTS:Lack of ABO compatibility,recipient/donor weight ratio≥1.15,complex arterial reconstruction,duration time of hepatic artery anastomosis>80 min,duration time of operation>10 h,dual grafts,number of units of blood received intraoperatively≥7,number of units of fresh frozen plasma(FFP)received intraoperatively≥6,postoperative blood transfusion and postoperative FFP use were significantly associated with early HAT in the univariate analysis(P<0.1).After logistic regression,independent risk factors associated with early HAT were recipient/donor weight ratio≥1.15(OR=4.499),duration of hepatic artery anastomosis>80 min(OR=5.429),number of units of blood received intraoperatively≥7(OR=4.059)and postoperative blood transfusion(OR=6.898).Graft type(whole/living-donor/split),duration of operation>10 h,retransplantation,rejection reaction,recipients with diabetes preoperatively and recipients with a high level of blood glucose or diabetes postoperatively were significantly associated with late HAT in the univariate analysis(P<0.1).After logistic regression,the independent risk factors associated with early HAT were duration of operation>10 h(OR=6.394),retransplantation(OR=21.793)and rejection reactions(OR=16.936).CONCLUSION:Early detection of these risk factors,strict surveillance protocols by Doppler ultrasound and prophylactic anticoagulation for recipients at risk might be determined prospectively.展开更多
BACKGROUND: The elevation of neutrophil-lymphocyte ratio(NLR) has adverse effects on the prognosis of patients with hepatocellular carcinoma(HCC) who have received liver transplantation(LT). The Hangzhou criteria are ...BACKGROUND: The elevation of neutrophil-lymphocyte ratio(NLR) has adverse effects on the prognosis of patients with hepatocellular carcinoma(HCC) who have received liver transplantation(LT). The Hangzhou criteria are set for selecting HCC patients for LT. The present study aimed to establish a set of new criteria combining the NLR and Hangzhou criteria for selecting HCC patients for LT.METHODS: Receiver operating characteristic(ROC) analysis was done to determine the optimal NLR threshold. Univariate and multivariate analyses were made to evaluate the factors affecting the outcomes of HCC patients after LT. We also proposed new criteria consisting of the elevated NLR and Hangzhou criteria. ROC analysis was carried out to validate the feasibility of the new criteria.RESULTS: Three hundred and five HCC patients were included in this study. The mean follow-up time of these patients was 5.4 years. Of the 305 patients,197(64.6%) showed elevated NLRs(NLR >4). The recurrence-free survival rates of the patients with elevated NLRs at 1,3 and 5 years were lower than those of the patients with normal NLRs(NLR ≤4)(50.1%,21.7% and 20.2% vs 80.5%,58.7% and 56.4%,respectively; P<0.001). The overall survival rate was lower in the patients with elevated NLR than in those with normal NLR at 1,3 and 5 years(60.8%,27.0% and 22.5% vs 78.4%,51.1% and 47.8%,respectively; P<0.001). Multivariate analysis demonstrated that an NLR >4(P=0.034),total tumor size >8 cm(P=0.005),alpha-fetoprotein level >400 μg/L(P=0.007) and the presence of vascular invasion(P=0.003) were independent predictors of HCC recurrence in post-transplant patients. We proposed a set of new criteria based on the elevated NLR and Hangzhou criteria. A ROC analysis demonstrated that the patients with scores ≥1 had an area under the curve of 0.764.CONCLUSION: The criteria combining the elevated NLR and Hangzhou criteria can be used to select patients with HCC for LT.展开更多
AIM:To investigate whether the use of synchronoushepatectomy and splenectomy(HS)is more effective than hepatectomy alone(HA)for patients with hepatocellular carcinoma(HCC)and hypersplenism.METHODS:From January 2007 to...AIM:To investigate whether the use of synchronoushepatectomy and splenectomy(HS)is more effective than hepatectomy alone(HA)for patients with hepatocellular carcinoma(HCC)and hypersplenism.METHODS:From January 2007 to March 2013,84consecutive patients with HCC and hypersplenism who underwent synchronous hepatectomy and splenectomy in our center were compared with 84 well-matched patients from a pool of 268 patients who underwent hepatectomy alone.The short-term and longterm outcomes of the two groups were analyzed and compared.RESULTS:The mean time to recurrence was 21.11±12.04 mo in the HS group and 11.23±8.73 mo in the HA group,and these values were significantly different(P=0.001).The 1-,3-,5-,and 7-year disease-free survival rates for the patients in the HS group and the HA group were 86.7%,70.9%,52.7%,and 45.9%and 88.1%,59.4%,43.3%,and 39.5%,respectively(P=0.008).Platelet and white blood cell counts in the HS group were significantly increased compared with the HA group one day,one week,one month and one year postoperatively(P<0.001).Splenectomy and micro-vascular invasion were significant independent prognostic factors for disease-free survival.Gender,tumor number,and recurrence were independent prognostic factors for overall survival.CONCLUSION:Synchronous hepatectomy and hepatectomy potentially improves disease-free survival rates and alleviates hypersplenism without increasing the surgical risks for patients with HCC and hypersplenism.展开更多
AIM:To compare the morbidity and mortality in young and elderly hepatocellular carcinoma(HCC)patients undergoing liver resection.METHODS:We retrospectively enrolled 1543 consecutive hepatitis B(HBV)-related HCC patien...AIM:To compare the morbidity and mortality in young and elderly hepatocellular carcinoma(HCC)patients undergoing liver resection.METHODS:We retrospectively enrolled 1543 consecutive hepatitis B(HBV)-related HCC patients undergoing elective hepatic resection in our cohort,including 207elderly patients(≥65 years)and 1336 younger patients(<65 years).Patient characteristics and clinical outcomes after liver resection were compared between the two groups.RESULTS:Elderly patients had more preoperative comorbidities and lower alanine aminotransferase and aspartate aminotransferase levels.Positive rates for hepatitis B surface antigen(P<0.001),hepatitis B e antigen(P<0.001)and HBV DNA(P=0.017)were more common in younger patients.Overall complications and their severity classified using the Clavien system were similarin the two groups(33.3%vs 29.6%,P=0.271).Elderly patients had a higher rate of postoperative cardiovascular complications(3.9%vs 0.6%,P=0.001),neurological complications(2.9%vs 0.4%,P<0.001)and mortality(3.4%vs 1.2%,P=0.035),and had more hospital stay requirement(13 d vs 12 d,P<0.001)and more intensive care unit stay(36.7%vs 27.8%,P=0.008)compared with younger patients.However,postoperative hepatic insufficiency was more common in the younger group(7.7%vs 3.4%,P=0.024).CONCLUSION:Hepatectomy can be safely performed in elderly patients.Age should not be regarded as a contraindication to liver resection with expected higher complication and mortality rates.展开更多
AIM: To compare the recurrence-free survival(RFS) and overall survival(OS) of hepatitis B virus(HBV)-positive hepatocellular carcinoma(HCC) after living donor liver transplantation(lDlT) and deceased donor liver trans...AIM: To compare the recurrence-free survival(RFS) and overall survival(OS) of hepatitis B virus(HBV)-positive hepatocellular carcinoma(HCC) after living donor liver transplantation(lDlT) and deceased donor liver transplantation(DDlT).METHODS: We retrospectively collected clinical data from 408 liver cancer patients from February 1999 to September 2012. We used the chi-squared test or Fisher's exact test to analyze the characteristics of lDlT and DDlT. Kaplan-Meier analysis was used to compare the RFS and OS in HCC.RESULTS: Three hundred sixty HBV-positive patients(276 DDlT and 84 lDlT) were included in this study.The mean follow-up time was 27.1 mo(range 1.1-130.8 mo). One hundred eighty-five(51.2%) patients died during follow-up. The 1-, 3-, and 5-year RFS rates for lDlT were 85.2%, 55.7%, and 52.9%, respectively; for DDlT, the RFS rates were 73.2%, 49.1%, and 45.3%(P = 0.115). The OS rates were similar between the lDlT and DDlT recipients, with 1-, 3-, and 5-year survival rates of 81.8%, 49.5%, and 43.0% vs 69.5%, 43.0%, and 38.3%, respectively(P = 0.30). The outcomes of HCC according to the Milan criteria after lDlT and DDlT were not significantly different(for lDlT: 1-, 3-, and 5-year RFS: 94.7%, 78.7%, and 78.7% vs 89.2%, 77.5%, and 74.5%, P = 0.50; for DDlT: 86.1%, 68.8%, and 68.8% vs 80.5%, 62.2%, and 59.8% P = 0.53).CONCLUSION: The outcomes of lDlT for HCC are not worse compared to the outcomes of DDlT. lDlT does not increase tumor recurrence of HCC compared to DDlT.展开更多
Metabolic disease,including diabetes mellitus,hypertension,dyslipidemia,obesity,and hyperuricemia,is a common complication after liver transplantation and a risk factor for cardiovascular disease and death.The develop...Metabolic disease,including diabetes mellitus,hypertension,dyslipidemia,obesity,and hyperuricemia,is a common complication after liver transplantation and a risk factor for cardiovascular disease and death.The development of metabolic disease is closely related to the side effects of immunosuppressants.Therefore,optimization of the immunosuppressive regimen is very important for the prevention and treatment of metabolic disease.The Chinese Society of Organ Transplantation has developed an expert consensus on the management of metabolic diseases in Chinese liver transplant recipients based on recent studies.Emphasis is placed on the risk factors of metabolic diseases,the effect of immunosuppressants on metabolic disease,and the prevention and treatment of metabolic diseases.展开更多
AIM: To investigate the relationship between low immediate postoperative platelet count and perioperative outcome after liver resection in patients with hepatocellular carcinoma(HCC).METHODS: In a cohort of 565 consec...AIM: To investigate the relationship between low immediate postoperative platelet count and perioperative outcome after liver resection in patients with hepatocellular carcinoma(HCC).METHODS: In a cohort of 565 consecutive hepatitis B-related HCC patients who underwent major liver resection, the characteristics and clinical outcomes after liver resection were compared between patients with immediate postoperative platelet count < 100 × 109/L and patients with platelet count ≥ 100 × 109/L. Risk factors for postoperative hepatic insufficiency were evaluated by multivariate analysis.RESULTS: Patients with a low immediate postoperative platelet count(< 100 × 109/L) had more grade Ⅲ-Ⅴ complications(20.5% vs 12.4%, P = 0.016), and higher rates of postoperative liver failure(6.8% vs 2.6%,P = 0.02), hepatic insufficiency(31.5% vs 21.2%, P < 0.001) and mortality(6.8% vs 0.5%, P < 0.001), compared to patients with a platelet count ≥ 100 × 109/L. The alanine aminotransferase levels on postoperative days 3 and 5, and bilirubin on postoperative days 1, 3 and 5 were higher in patients with immediate postoperative low platelet count. Multivariate analysis revealed that immediate postoperative low platelet count, rather than preoperative low platelet count, was a significant independent risk factor for hepatic insufficiency.CONCLUSION: A low immediate postoperative platelet count is an independent risk factor for hepatic insufficiency. Platelets can mediate liver regeneration in the cirrhotic liver.展开更多
Recent studies have shown that radiofrequency(RF) ablation therapy is a safe, feasible, and effective procedure for hepatic hemangiomas, even huge hepatic hemangiomas. RF ablation has the following advantages in the t...Recent studies have shown that radiofrequency(RF) ablation therapy is a safe, feasible, and effective procedure for hepatic hemangiomas, even huge hepatic hemangiomas. RF ablation has the following advantages in the treatment of hepatic hemangiomas: minimal invasiveness, definite efficacy, high safety, fast recovery, relatively simple operation, and wide applicability. It is necessary to formulate a widely accepted consensus among the experts in China who have extensive expertise and experience in the treatment of hepatic hemangiomas using RF ablation, which is important to standardize the application of RF ablation for the management of hepatic hemangiomas, regarding the selection of patients with suitable indications to receive RF ablation treatment, the technical details of the techniques, therapeutic effect evaluations, management of complications, etc. A final consensus by a Chinese panel of experts who have the expertise of using RF ablation to treat hepatic hemangiomas was reached by means of literature review, comprehensive discussion, and draft approval.展开更多
AIM: To determine whether low-dose tacrolimus(TAC) combined with mycophenolate mofetil(MMF) is a safe approach to decrease the incidence of chronic kidney disease(CKD) in liver transplantation(LT) recipients.METHODS: ...AIM: To determine whether low-dose tacrolimus(TAC) combined with mycophenolate mofetil(MMF) is a safe approach to decrease the incidence of chronic kidney disease(CKD) in liver transplantation(LT) recipients.METHODS: We analyzed the medical records of 689 patients who underwent LT between March 1999 and December 2012 in a single Chinese center. Immunosuppression was initiated with a calcineurin inhibitor(TAC or CSA) and prednisone with or without MMF. CKD is defined by the glomerular filtration rate(GFR), estimated by an abbreviated Modification of Diet in Renal Disease formula, < 60 mL/min per 1.73 m2 for at least 3 consecutive months after LT. Individuals with TAC trough concentrations ≤ 8 ng/mL at 3 mo after LT were defined as the low-dose group. The incidence of CKD within 5 years was compared between the TAC group and the CSA group, as well as between four subgroups(low-dose and high-dose TAC groups with orwithout MMF). RESULTS: No difference regarding the occurrence of pre-LT renal dysfunction or that of post-LT rejection was found between the TAC and CSA groups or between the four subgroups. With a definition of GFR < 60 mL/min per 1.73 m2, the overall incidence of CKD was significantly higher in the CSA group than in the TAC group. The incidence of CKD in the low-dose TAC + MMF group(7.7%) was significantly lower than that observed in the low-dose TAC group(15.9%), high-dose TAC group(24.6%) and high-dose TAC + MMF group(18.5%). The cumulative 1-, 3- and 5-year incidence rates of CKD were 12.7%, 14.5% and 16.7%, respectively. The cumulative 5-year survival rates were 61.7% and 82.2% in patients with or without CKD, respectively.CONCLUSION: In LT patients, the choice of immunosuppressive therapy appears to affect renal function and patient survival.展开更多
AIM: To evaluate the prophylactic efficacy of hepatitis B immunoglobulin(HBIG) in combination with different nucleos(t)ide analogues.METHODS: A total of 5333 hepatitis B surface antigenpositive patients from the China...AIM: To evaluate the prophylactic efficacy of hepatitis B immunoglobulin(HBIG) in combination with different nucleos(t)ide analogues.METHODS: A total of 5333 hepatitis B surface antigenpositive patients from the China Liver Transplant Registry database were enrolled between January 2000 and December 2009. Low-dose intramuscular(im) HBIG combined with one nucleos(t)ide analogue has been shown to be very cost-effective in recent reports. Hepatitis B virus(HBV) prophylactic outcomes were compared based on their posttransplant prophylactic protocols [group A(n = 4684): im HBIG plus lamivudine; group B(n = 491): im HBIG plus entecavir; group C(n = 158): im HBIG plus adefovir dipivoxil]. We compared the related baseline characteristics among the three groups, including the age, male sex, Meld score at the time of transplantation, Child-Pugh score at the time of transplantation, HCC, pre-transplantation hepatitis B e antigen positivity, pre-transplantation HBV deoxyribonucleic acid(HBV DNA) positivity, HBV DNA at the time of transplantation, pre-transplantation antiviral therapy, and the duration of antiviral therapy before transplantation of the patients. We also calculated the 1-, 3- and 5-year survival rates and HBV recurrence rates according to the different groups. All potential risk factors were analyzed using univariate and multivariate analyses.RESULTS: The mean follow-up duration was 42.1 ± 30.3 mo. The 1-, 3- and 5-year survival rates were lower in group A than in groups B(86.2% vs 94.4%, 76.9% vs 86.6%, 73.7% vs 82.4%, respectively, P < 0.001) and C(86.2% vs 92.5%, 76.9% vs 73.7%, 87.0% vs 81.6%, respectively, P < 0.001). The 1-, 3-and 5-year posttransplant HBV recurrence rates were significantly higher in group A than in group B(1.7% vs 0.5%, 3.5% vs 1.5%, 4.7% vs 1.5%, respectively, P = 0.023). No significant difference existed between groups A and C and between groups B and C with respect to the 1-, 3- and 5-year HBV recurrence rates. Pretransplant hepatocellular carcinoma, high viral load and posttransplant prophylactic protocol(lamivudine and HBIG vs entecavir and HBIG) were associated with HBV recurrence.CONCLUSION: Low-dose intramuscular HBIG in combination with a nucleos(t)ide analogue provides effective prophylaxis against posttransplant HBV recurrence, especially for HBIG plus entecavir.展开更多
BACKGROUND Given the shortage of suitable liver grafts for liver transplantation, proper use of hepatitis B core antibody-positive livers might be a possible way to enlarge the donor pool and to save patients with end...BACKGROUND Given the shortage of suitable liver grafts for liver transplantation, proper use of hepatitis B core antibody-positive livers might be a possible way to enlarge the donor pool and to save patients with end-stage liver diseases. However, the safety of hepatitis B virus core antibody positive(HBcAb+) donors has been controversial. Initial studies were mainly conducted overseas with relatively small numbers of HBcAb+ liver recipients, and there are few relevant reports in the population of China's Mainland. We hypothesized that the safety of HBcAb+ liver grafts is not suboptimal.AIM To evaluate the safety of using hepatitis B virus(HBV) core antibody-positive donors for liver transplantation in Chinese patients.METHODS We conducted a retrospective study enrolling 1071 patients who underwent liver transplantation consecutively from 2005 to 2016 at West China Hospital Liver Transplantation Center. Given the imbalance in several baseline variables, propensity score matching was used, and the outcomes of all recipients were reviewed in this study.RESULTS In the whole population, 230 patients received HBcAb+ and 841 patients received HBcAb negative(HBcAb-) liver grafts. The 1-, 3-and 5-year survival rates in patients and grafts between the two groups were similar(patient survival: 85.8% vs 87.2%, 77.4% vs 81.1%, 72.4% vs 76.7%, log-rank test, P = 0.16; graft survival: 83.2% vs 83.6%, 73.8% vs 75.9%, 70.8% vs 74.4%, log-rank test, P = 0.19). After propensity score matching, 210 pairs of patients were generated. The corresponding 1-, 3-and 5-year patient and graft survival rates showed no significant differences. Further studies illustrated that the post-transplant major complication rates and liver function recovery after surgery were also similar. In addition, multivariate regression analysis in the original cohort and propensity score-matched Cox analysis demonstrated that receiving HBcA b+ liver grafts was not a significant risk factor for long-term survival. These findings were consistent in both HBV surface antigen-positive(HBsAg+) and HBsA g negative(HBsAg-) patients.Newly diagnosed HBV infection had a relatively higher incidence in HBsAg-patients with HBcAb+ liver grafts(13.23%), in which HBV naive recipients suffered most(31.82%), although this difference did not affect patient and graft survival(P = 0.50 and P = 0.49, respectively). Recipients with a high HBV surface antibody(anti-HBs) titer(more than 100 IU/L) before transplantation and antiviral prophylaxis with nucleos(t)ide antiviral agents post-operation, such as nucleos(t)ide antiviral agents, had lower de novo HBV infection risks. CONCLUSION HBcA b+ liver grafts do not affect the long-term outcome of the recipients. Combined with proper postoperative antiviral prophylaxis, utilization of HBcAb+ grafts is rational and feasible.展开更多
AIM:To investigate the tacrolimus dosage requirements and blood concentrations in adult-to-adult right lobe living donor liver transplantation (AALDLT) recipients with small-for-size (SFS) grafts.METHODS: During Janua...AIM:To investigate the tacrolimus dosage requirements and blood concentrations in adult-to-adult right lobe living donor liver transplantation (AALDLT) recipients with small-for-size (SFS) grafts.METHODS: During January 2007 and October 2008, a total of 54 cases of AALDLT with an observation period of 6 mo were enrolled in this study. The 54 patients were divided into two groups according to graft-recipient body weight ratio (GRBW): SFS grafts group (Group S, GRBW<0.8%, n=8) and non-SFS grafts group (Group N, GRBW ≥0.8%, n=46). Tacrolimus 12-hour blood levels and doses were recorded during weeks 1,2,3 and 4 and months 2,3,4,5 and 6 in group S and group N. Meanwhile, acute rejection rates, liver and renal function test results, and the number of potentially interacting medications were determined at each interval in the two groups. A comparison of tacrolimus dosage requirements and blood levels were made weekly in the first month post-surgery, and monthly from months 2 to 6.RESULTS: There were no differences in the demo-graphic characteristics, acute rejection rates, liver and renal function test results, or the number of potentially interacting medications administered between the two groups. The tacrolimus dosage requirements in group S were significantly lower than group N at 2 wk (2.8±0.4 mg/d vs 3.6±0.7 mg/d, P=0.006), 3 wk (2.9±0.7 mg/d vs 3.9±0.8 mg/d, P=0.008), 4 wk (2.9±0.8 mg/d vs 3.9±1.0 mg/d, P=0.023) and 2 mo (2.8±0.7 mg/d vs 3.8 ±1.1 mg/d, P=0.033). Tacrolimus 12-h trough concentrations were similar between the two groups at all times except for 2 wk post-transplantation, when the concentrations were signifi cantly greater in group S recipients than in group N recipients (11.3±4.8 ng/mL vs 7.0±3.8 ng/mL, P=0.026).CONCLUSION: SFS grafts recipients have signifi cantly decreased tacrolimus dosage requirements compared with non-SFS grafts recipients in AALDLT during the first 2 mo post-surgery.展开更多
AIM:To evaluate the clinical outcomes and safety of anterior-and conventional-approach hepatectomy for patients with large liver tumors.METHODS:Pub Med,EMBASE,Google Scholar and the Cochrane Library databases were sea...AIM:To evaluate the clinical outcomes and safety of anterior-and conventional-approach hepatectomy for patients with large liver tumors.METHODS:Pub Med,EMBASE,Google Scholar and the Cochrane Library databases were searched for randomized controlled trials(RCTs)and controlled clinical trials comparing anterior-approach hepatectomy(AAH)and conventional-approach hepatectomy(CAH).Two observers independently extracted the data using a spreadsheet and assessed the studies for inclusion.Studies that fulfilled the inclusion criteria and addressed the clinical questions of this analysis were further assessed using either fixed effects or random effects models.RESULTS:Two RCTs and six controlled clinical trials involving 807 patients met the predefined inclusion criteria.A total of 363 patients underwent AAH and 444underwent CAH.Meta-analysis indicated that the AAH group had fewer requirements for transfusion(OR=0.37,95%CI:0.21-0.63),less recurrence(OR=0.57,95%CI:0.37-0.87),and lower mortality(OR=0.29,95%CI:0.13-0.63).There were no significant differences between AAH and CAH with regard to perioperative complications(OR=0.94,95%CI:0.58-1.51),intraoperative tumor rupture(OR=0.98,95%CI:0.40-2.40),or length of hospital stay(weighted mean difference=-0.17,95%CI:-2.36-2.02).CONCLUSION:AAH has advantages of decreased transfusion,mortality and recurrence compared to CAH.It is a safe and effective method for large cancers requiring right hepatectomy.展开更多
BACKGROUND: Liver resection is a major surgery requiring perioperative blood transfusion. Predicting the need for blood transfusion for patients undergoing liver resection is of great importance. The present study aim...BACKGROUND: Liver resection is a major surgery requiring perioperative blood transfusion. Predicting the need for blood transfusion for patients undergoing liver resection is of great importance. The present study aimed to develop and validate a model for predicting transfusion requirement in HBV-related hepatocellular carcinoma patients undergoing liver resection.METHODS: A total of 1543 consecutive liver resections were included in the study. Randomly selected sample set of 1080 cases(70% of the study cohort) were used to develop a predictive score for transfusion requirement and the remaining 30%(n=463) was used to validate the score. Based on the preoperative and predictable intraoperative parameters, logistic regression was used to identify risk factors and to create an integer score for the prediction of transfusion requirement.RESULTS: Extrahepatic procedure, major liver resection,hemoglobin level and platelets count were identified as independent predictors for transfusion requirement by logistic regression analysis. A score system integrating these 4 factors was stratified into three groups which could predict the risk of transfusion, with a rate of 11.4%, 24.7% and 57.4% for low,moderate and high risk, respectively. The prediction model appeared accurate with good discriminatory abilities, generating an area under the receiver operating characteristic curve of 0.736 in the development set and 0.709 in the validation set.CONCLUSIONS: We have developed and validated an integerbased risk score to predict perioperative transfusion for patients undergoing liver resection in a high-volume surgicalcenter. This score allows identifying patients at a high risk and may alter transfusion practices.展开更多
文摘AIM:To evaluate the clinical outcomes of patients undergoing hepatectomy with hemihepatic vascular occlusion(HHO) compared with total hepatic inflow occlusion(THO).METHODS:Randomized controlled trials(RCTs) comparing hemihepatic vascular occlusion and total hepatic inflow occlusion were included by a systematic literature search.Two authors independently assessed the trials for inclusion and extracted the data.A metaanalysis was conducted to estimate blood loss,transfusion requirement,and liver injury based on the levels of aspartate aminotransferase(AST) and alanine aminotransferase(ALT).Either the fixed effects model or random effects model was used.RESULTS:Four RCTs including 338 patients met the predefined inclusion criteria.A total of 167 patients were treated with THO and 171 with HHO.Meta-analysis of AST levels on postoperative day 1 indicated higher levels in the THO group with weighted mean difference(WMD) 342.27;95% confidence intervals(CI) 217.28-467.26;P = 0.00 001;I2 = 16%.Meta-analysis showed no significant difference between THO group and HHO group on blood loss,transfusion requirement,mortality,morbidity,operating time,ischemic duration,hospital stay,ALT levels on postoperative day 1,3 and 7 and AST levels on postoperative day 3 and 7.CONCLUSION:Hemihepatic vascular occlusion does not offer satisfying benefit to the patients undergoing hepatic resection.However,they have less liver injury after liver resections.
基金Supported by The 12th Five-year Major Projects of National Science and Technology,No. 2012ZX10002-016
文摘AIM:To explore the relationship between α-fetoprotein(AFP) and various clinicopathological variables and different staging system of hepatocellular carcinoma(HCC) thoroughly.METHODS:A retrospective cohort study of consecutive patients diagnosed with HCC between January 2008 and December 2009 in West China Hospital was enrolled in our study.The association of serum AFP values with the HCC clinicopathological features was analysed by univariate and multivariate analysis,such as status of hepatitis B virus(HBV) infection,tumor size,tumor number,vascular invasion and degree of tumor differentiation.Also,patients were divided into four groups at the time of enrollment according to different cutoff values for serum value of AFP(≤ 20 μg/L,21-400 μg/L,401-800 μg/L,and ≥ 801 μg/L),to compare the positive rate of patient among four groups stratified by various clinicopathological variables.And the correlation of different kinds of tumor staging systems,such as TNM,Barcelona Clinic Liver Cancer(BCLC) staging classification and China staging,were compared with the serum concentration of AFP.RESULTS:A total of 2304 HCC patients were enrolled in this study totally;the mean serum level of AFP was 555.3 ± 546.6 μg/L.AFP levels were within the normal range(< 20 μg/L) in 27.4%(n = 631) of all the cases.81.4%(n = 1875) patients were infected with HBV,and those patients had much higher serum AFP level compared with non-HBV infection ones(573.9 ± 547.7 μg/L vs 398.4 ± 522.3 μg/L,P < 0.001).The AFP level in tumors ≥ 10 cm(808.4 ± 529.2 μg/L) was significantly higher(P < 0.001) than those with tumor size 5-10 cm(499.5 ± 536.4 μg/L) and with tumor size ≤ 5 cm(444.9 ± 514.2 μg/L).AFP levels increased significantly in patients with vascular invasion(694.1 ± 546.9 μg/L vs 502.1 ± 543.1 μg/L,P < 0.001).Patients with low tumor cell differentiation(559.2 ± 545.7 μg/L) had the significantly(P = 0.007) highest AFP level compared with high differentiation(207.3 ± 420.8 μg/L) and intermediate differentiation(527.9 ± 538.4 μg/L).In the multiple variables analysis,low tumor cell differentiation [OR 6.362,95%CI:2.891-15.382,P = 0.006] and tumor size(≥ 10 cm)(OR 5.215,95%CI:1.426-13.151,P = 0.012) were independent predictors of elevated AFP concentrations(AFP > 400 μg/L).Serum AFP levels differed significantly(P < 0.001) in the D stage of BCLC(625.7 ± 529.8 μg/L) compared with stage A(506.2 ± 537.4 μg/L) and B(590.1 ± 551.1 μg/L).CONCLUSION:HCC differentiation,size and vascular invasion have strong relationships with AFP,poor differentiation and HCC size ≥ 10 cm are independent predictors of elevated AFP.BCLC shows better relationship with
基金Supported by National Science and Technology Major Project of ChinaNo.2012ZX10002-016 and No.2012ZX10002-017
文摘AIM:To assess systematically the safety and efficacy of bile leakage test in liver resection.METHODS:Randomized controlled trials and controlled clinical trials involving the bile leakage test were included in a systematic literature search.Two authors independently assessed the studies for inclusion and extracted the data.A meta-analysis was conducted to estimate postoperative bile leakage,intraoperative positive bile leakage,and complications.We used either the fixed-effects or random-effects model.RESULTS:Eight studies involving a total of 1253 patients were included and they all involved the bile leakage test in liver resection.The bile leakage test group was associated with a significant reduction in bile leakage compared with the non-bile leakage test group(RR=0.39,95%CI:0.23-0.67;I2=3%).The white test had superiority for detection of intraoperative bile leakage compared with the saline solution test(RR=2.38,95%CI:1.24-4.56,P=0.009).No significant intergroup differences were observed in total number of complications,ileus,liver failure,intraperitoneal hemorrhage,pulmonary disorder,abdominal infection,and wound infection.CONCLUSION:The bile leakage test reduced postoperative bile leakage and did not increase incidence of complications.Fat emulsion is the best choice of solution for the test.
基金Supported by The National Science and Technology Major Project of ChinaNo.2012ZX10002-016 and No.2012ZX10002017-017
文摘AIM:To determine whether an elevated neutrophillymphocyte ratio(NLR)is negatively associated with tumor recurrence in patients with hepatitis B virus(HBV)-related hepatocellular carcinoma(HCC)after liver transplantation(LT),and to determine the optimal predictive NLR cut-off value.METHODS:The data of HCC patients who had undergone LT came from the China Liver Transplant Registry database.We collected data from 326 liver cancer patients who had undergone LT at our medical center.We divided the patients into groups based on their NLRs(3,4 or 5).We then compared the clinicopathological data and long-time survival between these groups.Meanwhile,we used receiver operating characteristic analysis to determine the optimal NLR cut-off.RESULTS:Of 280 HCC patients included in this study,263 were HBV positive.Patients with an NLR<3 and patients with an NLR≥3 but<4 showed no significant differences in overall survival(OS)(P=0.212)or disease-free survival(DFS)(P=0.601).Patients with an NLR≥4 but<5 and patients with an NLR≥5also showed no significant differences in OS(P=0.208)or DFS(P=0.618).The 1-,3-and 5-year OS rates of patients with an NLR<4 vs an NLR≥4 were 87.8%,63.8%and 61.5%vs 73.9%,36.7%and 30.3%,respectively(P<0.001).The 1-,3-and 5-year DFS rates of patients with an NLR<4 vs NLR≥4 were 83.9%,62.9%and 60.7%vs 64.9%,30.1%and 30.1%,respectively(P<0.001).Univariate and multivariate analyses demonstrated that three factors,including NLR≥4(P=0.002),were significant predictors of tumor recurrence in HCC patients after LT.CONCLUSION:A preoperative elevated NLR significantly increased the risk for tumor recurrence in HCC patients after LT.
基金Supported by Key Technology Support Program of Sichuan ProvinceNo.2013SZ0023
文摘AbstractAIM： To investigate the impact of minimum tacrolimus（TAC） on new-onset diabetes mellitus （NODM） afterliver transplantation （LT）.METHODS： We retrospectively analyzed the data of973 liver transplant recipients between March 1999and September 2014 in West China Hospital LiverTransplantation Center. Following the exclusion ofineligible recipients, 528 recipients with a TAC-dominantregimen were included in our study. We calculatedand determined the mean trough concentration ofTAC （cTAC） in the year of diabetes diagnosis in NODMrecipients or in the last year of the follow-up in non-NODM recipients. A cutoff of mean cTAC value forpredicting NODM 6 mo after LT was identified usinga receptor operating characteristic curve. TAC-relatedcomplications after LT was evaluated by χ^2 test, andthe overall and allograft survival was evaluated usingthe Kaplan-Meier method. Risk factors for NODM afterLT were examined by univariate and multivariate Cox regression.RESULTS： Of the 528 transplant recipients, 131（24.8%） developed NODM after 6 mo after LT, andthe cumulative incidence of NODM progressivelyincreased. The mean cTAC of NODM group recipientswas significantly higher than that of recipients in thenon-NODM group （7.66 ± 3.41 ng/mL vs 4.47 ± 2.22ng/mL, P 〈 0.05）. Furthermore, NODM group recipientshad lower 1-, 5-, 10-year overall survival rates （86.7%,71.3%, and 61.1% vs 94.7%, 86.1%, and 83.7%, P 〈0.05） and allograft survival rates （92.8%, 84.6%, and75.7% vs 96.1%, 91%, and 86.1%, P 〈 0.05） thanthe others. The best cutoff of mean cTAC for predictingNODM was 5.89 ng/mL after 6 mo after LT. Multivariateanalysis showed that old age at the time of LT （〉 50years）, hypertension pre-LT, and high mean cTAC （≥5.89 ng/mL） after 6 mo after LT were independent riskfactors for developing NODM. Concurrently, recipientswith a low cTAC （〈 5.89 ng/mL） were less likely tobecome obese （21.3% vs 30.2%, P 〈 0.05） or todevelop dyslipidemia （27.5% vs 44.8%, P 〈0.05）,chronic kidney dysfunction （14.6% vs 22.7%, P 〈 0.05）,and moderate to severe infection （24.7% vs 33.1%, P〈 0.05） after LT than recipients in the high mean cTACgroup. However, the two groups showed no significantdifference in the incidence of acute and chronicrejection, hypertension, cardiovascular events and newonsetmalignancy.CONCLUSION： A minimal TAC regimen can decreasethe risk of long-term NODM after LT. Maintaining a cTACvalue below 5.89 ng/mL after LT is safe and beneficial.
文摘BACKGROUND: Combined hepatectomy and radiofrequency ablation(RFA) provides an additional treatment for patients with Barcelona Clinic Liver Cancer(BCLC) stage B hepatocellular carcinoma(HCC) who are conventionally deemed unresectable. This study aimed to analyze the outcome of this combination therapy by comparing it with transarterial chemoembolization(TACE). METHODS: We retrospectively reviewed 51 patients with unresectable BCLC stage B HCC who had received the combination therapy. We compared the survival of these patients with that of 102 patients in the TACE group(control). Prognostic factors associated with worse survival in the combination group were analyzed.RESULTS: No differences in tumor status and liver function were observed between the TACE group and combination group. The median survival time for the combination group and TACE group was 38(6-54) and 17(3-48) months, respectively(P<0.001). The combination group required longer hospitalization than the TACE group [8(5-14) days vs 4(2-9) days,P<0.001]. More than two ablations decreased the survival rate in the combination group. CONCLUSIONS: Combined hepatectomy and RFA yielded a better long-term outcome than TACE in patients with unresectable BCLC stage B HCC. Patients with a limited ablated size(≤2 cm), a limited number of ablations(≤2), and adequate surgical margin should be considered candidates for combination therapy.
基金Supported by Grants from the National Science and Technology Major Project of China,No.2008ZX10002-026the National Science Foundation for Young Scientists of China,No.81200226
文摘AIM:To identify risk factors that might contribute to hepatic artery thrombosis(HAT)after liver transplantation(LT).METHODS:The perioperative and follow-up data of a total of 744 liver transplants,performed from February1999 to July 2010,were retrospectively reviewed.HAT developed in 20 patients(2.7%).HAT was classified as early(occurring in fewer than 30 d post LT)or late(occurring more than 30 d post LT).Early HAT developed in 14 patients(1.9%).Late HAT developed in 6patients(0.8%).Risk factors associated with HAT were analysed using theχ2 test for univariate analysis and logistic regression for multivariate analysis.RESULTS:Lack of ABO compatibility,recipient/donor weight ratio≥1.15,complex arterial reconstruction,duration time of hepatic artery anastomosis>80 min,duration time of operation>10 h,dual grafts,number of units of blood received intraoperatively≥7,number of units of fresh frozen plasma(FFP)received intraoperatively≥6,postoperative blood transfusion and postoperative FFP use were significantly associated with early HAT in the univariate analysis(P<0.1).After logistic regression,independent risk factors associated with early HAT were recipient/donor weight ratio≥1.15(OR=4.499),duration of hepatic artery anastomosis>80 min(OR=5.429),number of units of blood received intraoperatively≥7(OR=4.059)and postoperative blood transfusion(OR=6.898).Graft type(whole/living-donor/split),duration of operation>10 h,retransplantation,rejection reaction,recipients with diabetes preoperatively and recipients with a high level of blood glucose or diabetes postoperatively were significantly associated with late HAT in the univariate analysis(P<0.1).After logistic regression,the independent risk factors associated with early HAT were duration of operation>10 h(OR=6.394),retransplantation(OR=21.793)and rejection reactions(OR=16.936).CONCLUSION:Early detection of these risk factors,strict surveillance protocols by Doppler ultrasound and prophylactic anticoagulation for recipients at risk might be determined prospectively.
基金supported by grants from the National Science and Technology Major Project of China(2012ZX10002-016 and 2012ZX10002-017)
文摘BACKGROUND: The elevation of neutrophil-lymphocyte ratio(NLR) has adverse effects on the prognosis of patients with hepatocellular carcinoma(HCC) who have received liver transplantation(LT). The Hangzhou criteria are set for selecting HCC patients for LT. The present study aimed to establish a set of new criteria combining the NLR and Hangzhou criteria for selecting HCC patients for LT.METHODS: Receiver operating characteristic(ROC) analysis was done to determine the optimal NLR threshold. Univariate and multivariate analyses were made to evaluate the factors affecting the outcomes of HCC patients after LT. We also proposed new criteria consisting of the elevated NLR and Hangzhou criteria. ROC analysis was carried out to validate the feasibility of the new criteria.RESULTS: Three hundred and five HCC patients were included in this study. The mean follow-up time of these patients was 5.4 years. Of the 305 patients,197(64.6%) showed elevated NLRs(NLR >4). The recurrence-free survival rates of the patients with elevated NLRs at 1,3 and 5 years were lower than those of the patients with normal NLRs(NLR ≤4)(50.1%,21.7% and 20.2% vs 80.5%,58.7% and 56.4%,respectively; P<0.001). The overall survival rate was lower in the patients with elevated NLR than in those with normal NLR at 1,3 and 5 years(60.8%,27.0% and 22.5% vs 78.4%,51.1% and 47.8%,respectively; P<0.001). Multivariate analysis demonstrated that an NLR >4(P=0.034),total tumor size >8 cm(P=0.005),alpha-fetoprotein level >400 μg/L(P=0.007) and the presence of vascular invasion(P=0.003) were independent predictors of HCC recurrence in post-transplant patients. We proposed a set of new criteria based on the elevated NLR and Hangzhou criteria. A ROC analysis demonstrated that the patients with scores ≥1 had an area under the curve of 0.764.CONCLUSION: The criteria combining the elevated NLR and Hangzhou criteria can be used to select patients with HCC for LT.
基金Supported by Grants from National Science and Technology Major Project of China,No.2012ZX10002-016 and No.2012ZX10002-017
文摘AIM:To investigate whether the use of synchronoushepatectomy and splenectomy(HS)is more effective than hepatectomy alone(HA)for patients with hepatocellular carcinoma(HCC)and hypersplenism.METHODS:From January 2007 to March 2013,84consecutive patients with HCC and hypersplenism who underwent synchronous hepatectomy and splenectomy in our center were compared with 84 well-matched patients from a pool of 268 patients who underwent hepatectomy alone.The short-term and longterm outcomes of the two groups were analyzed and compared.RESULTS:The mean time to recurrence was 21.11±12.04 mo in the HS group and 11.23±8.73 mo in the HA group,and these values were significantly different(P=0.001).The 1-,3-,5-,and 7-year disease-free survival rates for the patients in the HS group and the HA group were 86.7%,70.9%,52.7%,and 45.9%and 88.1%,59.4%,43.3%,and 39.5%,respectively(P=0.008).Platelet and white blood cell counts in the HS group were significantly increased compared with the HA group one day,one week,one month and one year postoperatively(P<0.001).Splenectomy and micro-vascular invasion were significant independent prognostic factors for disease-free survival.Gender,tumor number,and recurrence were independent prognostic factors for overall survival.CONCLUSION:Synchronous hepatectomy and hepatectomy potentially improves disease-free survival rates and alleviates hypersplenism without increasing the surgical risks for patients with HCC and hypersplenism.
基金Supported by Grants from the National Science and Technol-ogy Major Project of China,No.2012ZX10002-016 and No.2012ZX10002-017
文摘AIM:To compare the morbidity and mortality in young and elderly hepatocellular carcinoma(HCC)patients undergoing liver resection.METHODS:We retrospectively enrolled 1543 consecutive hepatitis B(HBV)-related HCC patients undergoing elective hepatic resection in our cohort,including 207elderly patients(≥65 years)and 1336 younger patients(<65 years).Patient characteristics and clinical outcomes after liver resection were compared between the two groups.RESULTS:Elderly patients had more preoperative comorbidities and lower alanine aminotransferase and aspartate aminotransferase levels.Positive rates for hepatitis B surface antigen(P<0.001),hepatitis B e antigen(P<0.001)and HBV DNA(P=0.017)were more common in younger patients.Overall complications and their severity classified using the Clavien system were similarin the two groups(33.3%vs 29.6%,P=0.271).Elderly patients had a higher rate of postoperative cardiovascular complications(3.9%vs 0.6%,P=0.001),neurological complications(2.9%vs 0.4%,P<0.001)and mortality(3.4%vs 1.2%,P=0.035),and had more hospital stay requirement(13 d vs 12 d,P<0.001)and more intensive care unit stay(36.7%vs 27.8%,P=0.008)compared with younger patients.However,postoperative hepatic insufficiency was more common in the younger group(7.7%vs 3.4%,P=0.024).CONCLUSION:Hepatectomy can be safely performed in elderly patients.Age should not be regarded as a contraindication to liver resection with expected higher complication and mortality rates.
基金Supported by National Science and Technology Major Project of China,No.2012ZX10002-016 and No.2012ZX10002017-017
文摘AIM: To compare the recurrence-free survival(RFS) and overall survival(OS) of hepatitis B virus(HBV)-positive hepatocellular carcinoma(HCC) after living donor liver transplantation(lDlT) and deceased donor liver transplantation(DDlT).METHODS: We retrospectively collected clinical data from 408 liver cancer patients from February 1999 to September 2012. We used the chi-squared test or Fisher's exact test to analyze the characteristics of lDlT and DDlT. Kaplan-Meier analysis was used to compare the RFS and OS in HCC.RESULTS: Three hundred sixty HBV-positive patients(276 DDlT and 84 lDlT) were included in this study.The mean follow-up time was 27.1 mo(range 1.1-130.8 mo). One hundred eighty-five(51.2%) patients died during follow-up. The 1-, 3-, and 5-year RFS rates for lDlT were 85.2%, 55.7%, and 52.9%, respectively; for DDlT, the RFS rates were 73.2%, 49.1%, and 45.3%(P = 0.115). The OS rates were similar between the lDlT and DDlT recipients, with 1-, 3-, and 5-year survival rates of 81.8%, 49.5%, and 43.0% vs 69.5%, 43.0%, and 38.3%, respectively(P = 0.30). The outcomes of HCC according to the Milan criteria after lDlT and DDlT were not significantly different(for lDlT: 1-, 3-, and 5-year RFS: 94.7%, 78.7%, and 78.7% vs 89.2%, 77.5%, and 74.5%, P = 0.50; for DDlT: 86.1%, 68.8%, and 68.8% vs 80.5%, 62.2%, and 59.8% P = 0.53).CONCLUSION: The outcomes of lDlT for HCC are not worse compared to the outcomes of DDlT. lDlT does not increase tumor recurrence of HCC compared to DDlT.
基金National Science and Technology Major Project of China,No.2017ZX10203205National Natural Science Funds for Distinguished Young Scholar of China,No.81625003National Natural Science Foundation of China,No.81930016.
文摘Metabolic disease,including diabetes mellitus,hypertension,dyslipidemia,obesity,and hyperuricemia,is a common complication after liver transplantation and a risk factor for cardiovascular disease and death.The development of metabolic disease is closely related to the side effects of immunosuppressants.Therefore,optimization of the immunosuppressive regimen is very important for the prevention and treatment of metabolic disease.The Chinese Society of Organ Transplantation has developed an expert consensus on the management of metabolic diseases in Chinese liver transplant recipients based on recent studies.Emphasis is placed on the risk factors of metabolic diseases,the effect of immunosuppressants on metabolic disease,and the prevention and treatment of metabolic diseases.
基金Supported by Grants from the National Science and Technology Major Project of China,No.2012ZX10002-016 and No.2012ZX10002-017
文摘AIM: To investigate the relationship between low immediate postoperative platelet count and perioperative outcome after liver resection in patients with hepatocellular carcinoma(HCC).METHODS: In a cohort of 565 consecutive hepatitis B-related HCC patients who underwent major liver resection, the characteristics and clinical outcomes after liver resection were compared between patients with immediate postoperative platelet count < 100 × 109/L and patients with platelet count ≥ 100 × 109/L. Risk factors for postoperative hepatic insufficiency were evaluated by multivariate analysis.RESULTS: Patients with a low immediate postoperative platelet count(< 100 × 109/L) had more grade Ⅲ-Ⅴ complications(20.5% vs 12.4%, P = 0.016), and higher rates of postoperative liver failure(6.8% vs 2.6%,P = 0.02), hepatic insufficiency(31.5% vs 21.2%, P < 0.001) and mortality(6.8% vs 0.5%, P < 0.001), compared to patients with a platelet count ≥ 100 × 109/L. The alanine aminotransferase levels on postoperative days 3 and 5, and bilirubin on postoperative days 1, 3 and 5 were higher in patients with immediate postoperative low platelet count. Multivariate analysis revealed that immediate postoperative low platelet count, rather than preoperative low platelet count, was a significant independent risk factor for hepatic insufficiency.CONCLUSION: A low immediate postoperative platelet count is an independent risk factor for hepatic insufficiency. Platelets can mediate liver regeneration in the cirrhotic liver.
文摘Recent studies have shown that radiofrequency(RF) ablation therapy is a safe, feasible, and effective procedure for hepatic hemangiomas, even huge hepatic hemangiomas. RF ablation has the following advantages in the treatment of hepatic hemangiomas: minimal invasiveness, definite efficacy, high safety, fast recovery, relatively simple operation, and wide applicability. It is necessary to formulate a widely accepted consensus among the experts in China who have extensive expertise and experience in the treatment of hepatic hemangiomas using RF ablation, which is important to standardize the application of RF ablation for the management of hepatic hemangiomas, regarding the selection of patients with suitable indications to receive RF ablation treatment, the technical details of the techniques, therapeutic effect evaluations, management of complications, etc. A final consensus by a Chinese panel of experts who have the expertise of using RF ablation to treat hepatic hemangiomas was reached by means of literature review, comprehensive discussion, and draft approval.
基金Supported by Grants from The National Sciences and Technology Major Project of China,No.2012ZX10002-016 and 2012ZX10002-017
文摘AIM: To determine whether low-dose tacrolimus(TAC) combined with mycophenolate mofetil(MMF) is a safe approach to decrease the incidence of chronic kidney disease(CKD) in liver transplantation(LT) recipients.METHODS: We analyzed the medical records of 689 patients who underwent LT between March 1999 and December 2012 in a single Chinese center. Immunosuppression was initiated with a calcineurin inhibitor(TAC or CSA) and prednisone with or without MMF. CKD is defined by the glomerular filtration rate(GFR), estimated by an abbreviated Modification of Diet in Renal Disease formula, < 60 mL/min per 1.73 m2 for at least 3 consecutive months after LT. Individuals with TAC trough concentrations ≤ 8 ng/mL at 3 mo after LT were defined as the low-dose group. The incidence of CKD within 5 years was compared between the TAC group and the CSA group, as well as between four subgroups(low-dose and high-dose TAC groups with orwithout MMF). RESULTS: No difference regarding the occurrence of pre-LT renal dysfunction or that of post-LT rejection was found between the TAC and CSA groups or between the four subgroups. With a definition of GFR < 60 mL/min per 1.73 m2, the overall incidence of CKD was significantly higher in the CSA group than in the TAC group. The incidence of CKD in the low-dose TAC + MMF group(7.7%) was significantly lower than that observed in the low-dose TAC group(15.9%), high-dose TAC group(24.6%) and high-dose TAC + MMF group(18.5%). The cumulative 1-, 3- and 5-year incidence rates of CKD were 12.7%, 14.5% and 16.7%, respectively. The cumulative 5-year survival rates were 61.7% and 82.2% in patients with or without CKD, respectively.CONCLUSION: In LT patients, the choice of immunosuppressive therapy appears to affect renal function and patient survival.
文摘AIM: To evaluate the prophylactic efficacy of hepatitis B immunoglobulin(HBIG) in combination with different nucleos(t)ide analogues.METHODS: A total of 5333 hepatitis B surface antigenpositive patients from the China Liver Transplant Registry database were enrolled between January 2000 and December 2009. Low-dose intramuscular(im) HBIG combined with one nucleos(t)ide analogue has been shown to be very cost-effective in recent reports. Hepatitis B virus(HBV) prophylactic outcomes were compared based on their posttransplant prophylactic protocols [group A(n = 4684): im HBIG plus lamivudine; group B(n = 491): im HBIG plus entecavir; group C(n = 158): im HBIG plus adefovir dipivoxil]. We compared the related baseline characteristics among the three groups, including the age, male sex, Meld score at the time of transplantation, Child-Pugh score at the time of transplantation, HCC, pre-transplantation hepatitis B e antigen positivity, pre-transplantation HBV deoxyribonucleic acid(HBV DNA) positivity, HBV DNA at the time of transplantation, pre-transplantation antiviral therapy, and the duration of antiviral therapy before transplantation of the patients. We also calculated the 1-, 3- and 5-year survival rates and HBV recurrence rates according to the different groups. All potential risk factors were analyzed using univariate and multivariate analyses.RESULTS: The mean follow-up duration was 42.1 ± 30.3 mo. The 1-, 3- and 5-year survival rates were lower in group A than in groups B(86.2% vs 94.4%, 76.9% vs 86.6%, 73.7% vs 82.4%, respectively, P < 0.001) and C(86.2% vs 92.5%, 76.9% vs 73.7%, 87.0% vs 81.6%, respectively, P < 0.001). The 1-, 3-and 5-year posttransplant HBV recurrence rates were significantly higher in group A than in group B(1.7% vs 0.5%, 3.5% vs 1.5%, 4.7% vs 1.5%, respectively, P = 0.023). No significant difference existed between groups A and C and between groups B and C with respect to the 1-, 3- and 5-year HBV recurrence rates. Pretransplant hepatocellular carcinoma, high viral load and posttransplant prophylactic protocol(lamivudine and HBIG vs entecavir and HBIG) were associated with HBV recurrence.CONCLUSION: Low-dose intramuscular HBIG in combination with a nucleos(t)ide analogue provides effective prophylaxis against posttransplant HBV recurrence, especially for HBIG plus entecavir.
文摘BACKGROUND Given the shortage of suitable liver grafts for liver transplantation, proper use of hepatitis B core antibody-positive livers might be a possible way to enlarge the donor pool and to save patients with end-stage liver diseases. However, the safety of hepatitis B virus core antibody positive(HBcAb+) donors has been controversial. Initial studies were mainly conducted overseas with relatively small numbers of HBcAb+ liver recipients, and there are few relevant reports in the population of China's Mainland. We hypothesized that the safety of HBcAb+ liver grafts is not suboptimal.AIM To evaluate the safety of using hepatitis B virus(HBV) core antibody-positive donors for liver transplantation in Chinese patients.METHODS We conducted a retrospective study enrolling 1071 patients who underwent liver transplantation consecutively from 2005 to 2016 at West China Hospital Liver Transplantation Center. Given the imbalance in several baseline variables, propensity score matching was used, and the outcomes of all recipients were reviewed in this study.RESULTS In the whole population, 230 patients received HBcAb+ and 841 patients received HBcAb negative(HBcAb-) liver grafts. The 1-, 3-and 5-year survival rates in patients and grafts between the two groups were similar(patient survival: 85.8% vs 87.2%, 77.4% vs 81.1%, 72.4% vs 76.7%, log-rank test, P = 0.16; graft survival: 83.2% vs 83.6%, 73.8% vs 75.9%, 70.8% vs 74.4%, log-rank test, P = 0.19). After propensity score matching, 210 pairs of patients were generated. The corresponding 1-, 3-and 5-year patient and graft survival rates showed no significant differences. Further studies illustrated that the post-transplant major complication rates and liver function recovery after surgery were also similar. In addition, multivariate regression analysis in the original cohort and propensity score-matched Cox analysis demonstrated that receiving HBcA b+ liver grafts was not a significant risk factor for long-term survival. These findings were consistent in both HBV surface antigen-positive(HBsAg+) and HBsA g negative(HBsAg-) patients.Newly diagnosed HBV infection had a relatively higher incidence in HBsAg-patients with HBcAb+ liver grafts(13.23%), in which HBV naive recipients suffered most(31.82%), although this difference did not affect patient and graft survival(P = 0.50 and P = 0.49, respectively). Recipients with a high HBV surface antibody(anti-HBs) titer(more than 100 IU/L) before transplantation and antiviral prophylaxis with nucleos(t)ide antiviral agents post-operation, such as nucleos(t)ide antiviral agents, had lower de novo HBV infection risks. CONCLUSION HBcA b+ liver grafts do not affect the long-term outcome of the recipients. Combined with proper postoperative antiviral prophylaxis, utilization of HBcAb+ grafts is rational and feasible.
文摘AIM:To investigate the tacrolimus dosage requirements and blood concentrations in adult-to-adult right lobe living donor liver transplantation (AALDLT) recipients with small-for-size (SFS) grafts.METHODS: During January 2007 and October 2008, a total of 54 cases of AALDLT with an observation period of 6 mo were enrolled in this study. The 54 patients were divided into two groups according to graft-recipient body weight ratio (GRBW): SFS grafts group (Group S, GRBW<0.8%, n=8) and non-SFS grafts group (Group N, GRBW ≥0.8%, n=46). Tacrolimus 12-hour blood levels and doses were recorded during weeks 1,2,3 and 4 and months 2,3,4,5 and 6 in group S and group N. Meanwhile, acute rejection rates, liver and renal function test results, and the number of potentially interacting medications were determined at each interval in the two groups. A comparison of tacrolimus dosage requirements and blood levels were made weekly in the first month post-surgery, and monthly from months 2 to 6.RESULTS: There were no differences in the demo-graphic characteristics, acute rejection rates, liver and renal function test results, or the number of potentially interacting medications administered between the two groups. The tacrolimus dosage requirements in group S were significantly lower than group N at 2 wk (2.8±0.4 mg/d vs 3.6±0.7 mg/d, P=0.006), 3 wk (2.9±0.7 mg/d vs 3.9±0.8 mg/d, P=0.008), 4 wk (2.9±0.8 mg/d vs 3.9±1.0 mg/d, P=0.023) and 2 mo (2.8±0.7 mg/d vs 3.8 ±1.1 mg/d, P=0.033). Tacrolimus 12-h trough concentrations were similar between the two groups at all times except for 2 wk post-transplantation, when the concentrations were signifi cantly greater in group S recipients than in group N recipients (11.3±4.8 ng/mL vs 7.0±3.8 ng/mL, P=0.026).CONCLUSION: SFS grafts recipients have signifi cantly decreased tacrolimus dosage requirements compared with non-SFS grafts recipients in AALDLT during the first 2 mo post-surgery.
基金Supported by Grants from the National Science and Technol-ogy Major Project of China,No.2012ZX10002-016 and No.2012ZX10002-017
文摘AIM:To evaluate the clinical outcomes and safety of anterior-and conventional-approach hepatectomy for patients with large liver tumors.METHODS:Pub Med,EMBASE,Google Scholar and the Cochrane Library databases were searched for randomized controlled trials(RCTs)and controlled clinical trials comparing anterior-approach hepatectomy(AAH)and conventional-approach hepatectomy(CAH).Two observers independently extracted the data using a spreadsheet and assessed the studies for inclusion.Studies that fulfilled the inclusion criteria and addressed the clinical questions of this analysis were further assessed using either fixed effects or random effects models.RESULTS:Two RCTs and six controlled clinical trials involving 807 patients met the predefined inclusion criteria.A total of 363 patients underwent AAH and 444underwent CAH.Meta-analysis indicated that the AAH group had fewer requirements for transfusion(OR=0.37,95%CI:0.21-0.63),less recurrence(OR=0.57,95%CI:0.37-0.87),and lower mortality(OR=0.29,95%CI:0.13-0.63).There were no significant differences between AAH and CAH with regard to perioperative complications(OR=0.94,95%CI:0.58-1.51),intraoperative tumor rupture(OR=0.98,95%CI:0.40-2.40),or length of hospital stay(weighted mean difference=-0.17,95%CI:-2.36-2.02).CONCLUSION:AAH has advantages of decreased transfusion,mortality and recurrence compared to CAH.It is a safe and effective method for large cancers requiring right hepatectomy.
基金supported by grants from the National Science and Technology Major Project of China(2012ZX10002-016 and 2012ZX10002-017)
文摘BACKGROUND: Liver resection is a major surgery requiring perioperative blood transfusion. Predicting the need for blood transfusion for patients undergoing liver resection is of great importance. The present study aimed to develop and validate a model for predicting transfusion requirement in HBV-related hepatocellular carcinoma patients undergoing liver resection.METHODS: A total of 1543 consecutive liver resections were included in the study. Randomly selected sample set of 1080 cases(70% of the study cohort) were used to develop a predictive score for transfusion requirement and the remaining 30%(n=463) was used to validate the score. Based on the preoperative and predictable intraoperative parameters, logistic regression was used to identify risk factors and to create an integer score for the prediction of transfusion requirement.RESULTS: Extrahepatic procedure, major liver resection,hemoglobin level and platelets count were identified as independent predictors for transfusion requirement by logistic regression analysis. A score system integrating these 4 factors was stratified into three groups which could predict the risk of transfusion, with a rate of 11.4%, 24.7% and 57.4% for low,moderate and high risk, respectively. The prediction model appeared accurate with good discriminatory abilities, generating an area under the receiver operating characteristic curve of 0.736 in the development set and 0.709 in the validation set.CONCLUSIONS: We have developed and validated an integerbased risk score to predict perioperative transfusion for patients undergoing liver resection in a high-volume surgicalcenter. This score allows identifying patients at a high risk and may alter transfusion practices.
