Transplantation – Liver
AGA Clinical Practice Update on Managing Portal Vein Thrombosis in Cirrhotic Patients: Expert Review
3 Jan, 2025 | 10:00h | UTCIntroduction: This summary highlights key recommendations from an AGA expert review on portal vein thrombosis (PVT) in cirrhotic patients. PVT is common in cirrhosis, with an estimated five-year incidence of around 11%, and may worsen portal hypertension and elevate mortality. Management is challenging because of limited evidence, the potential complications of both PVT and anticoagulation, and significant heterogeneity regarding clot characteristics, host factors, and cirrhosis severity. This review presents the latest guidance on identifying clinically relevant PVT, selecting anticoagulation, and considering endovascular interventions, including TIPS (transjugular intrahepatic portosystemic shunt).
Key Recommendations:
- No Routine Screening: Asymptomatic patients with compensated cirrhosis do not require regular screening for PVT in the absence of suggestive clinical changes.
- Imaging Confirmation: When Doppler ultrasound reveals suspected PVT, contrast-enhanced CT or MRI is recommended to confirm the diagnosis, exclude malignancy, and characterize clot extent and occlusion.
- Hypercoagulability Testing: Extensive thrombophilia workup is not indicated unless there is family or personal history of thrombotic events, or associated laboratory abnormalities.
- Intestinal Ischemia Management: Patients who develop PVT with evidence of intestinal ischemia should receive prompt anticoagulation and, ideally, multidisciplinary team care involving gastroenterology, hepatology, interventional radiology, hematology, and surgery.
- Observation of Minor or Recent Thrombi: In cirrhotic patients without ischemia, with recent (<6 months) thrombi that are <50% occlusive, close imaging follow-up every three months is a reasonable option to track potential spontaneous clot regression.
- Anticoagulation for Significant PVT: Consider anticoagulation for more extensive or obstructive (>50%) recent PVT, especially if the main portal vein or mesenteric vessels are involved. Candidates for liver transplantation and those with inherited thrombophilia may derive additional benefit.
- Chronic Cavernous PVT: Anticoagulation is generally not advised in patients with long-standing (>6 months) complete occlusion and well-formed collateral channels.
- Variceal Screening: Perform endoscopic screening or ensure prophylaxis for varices. Avoid delays in initiating anticoagulation, as timeliness is essential for better recanalization outcomes.
- Choice of Anticoagulant: Vitamin K antagonists, low-molecular-weight heparin, and direct oral anticoagulants (DOACs) are all viable options in cirrhosis. DOACs may be appropriate in well-compensated (Child-Turcotte-Pugh class A or certain class B) cirrhosis but should be avoided in class C. Treatment selection should consider patient preferences, monitoring feasibility, and risk of bleeding.
- Duration of Therapy: Reassess clot status with cross-sectional imaging every three months. Continue anticoagulation for transplant-eligible individuals who show partial or complete recanalization, and consider discontinuation in nonresponders after six months if futility is evident.
- TIPS Revascularization: Portal vein revascularization using TIPS may be pursued in patients who have other TIPS indications (like refractory ascites or variceal bleeding) or to improve transplant feasibility by recanalizing portal flow.
Conclusion: PVT in cirrhosis remains a complex clinical issue requiring careful evaluation of clot extent, timing, and the potential need for transplantation. The recommendations presented here underscore prompt imaging, timely anticoagulation for high-risk thrombi, and individualized therapy based on Child-Turcotte-Pugh classification and bleeding risk. When necessary, multidisciplinary collaboration is key to achieving optimal patient outcomes. Prospective randomized trials and standardized classifications of PVT will be instrumental in refining future guidelines.
Reference:
Davis JPE, Lim JK, Francis FF, Ahn J. AGA Clinical Practice Update on Management of Portal Vein Thrombosis in Patients With Cirrhosis: Expert Review. Gastroenterology. 2024. DOI: http://doi.org/10.1053/j.gastro.2024.10.038
Management of Ascites in Cirrhosis: Key Recommendations from the British Society of Gastroenterology Guidelines
12 Oct, 2024 | 18:23h | UTCIntroduction: Ascites, the pathological accumulation of fluid within the peritoneal cavity, is a common and serious complication of cirrhosis, indicating advanced liver disease and portending increased morbidity and mortality. Recognizing the need for updated clinical guidance, the British Society of Gastroenterology (BSG), in collaboration with the British Association for the Study of the Liver (BASL), has issued comprehensive guidelines. These aim to standardize the diagnosis and management of ascites in cirrhotic patients, incorporating recent advances to optimize patient outcomes.
Key Recommendations:
- Diagnostic Paracentesis: It is strongly recommended that all patients with new-onset ascites undergo diagnostic paracentesis to measure total protein concentration and calculate the serum-ascites albumin gradient (SAAG). (Quality of evidence: moderate; Recommendation: strong)
- Spontaneous Bacterial Peritonitis (SBP): Prompt diagnostic paracentesis should be performed in hospitalized patients with ascites, especially those with gastrointestinal bleeding or signs of infection, to rule out SBP. An ascitic neutrophil count >250/mm³ confirms SBP, necessitating immediate empirical antibiotic therapy tailored to local resistance patterns. (Quality of evidence: moderate; Recommendation: strong)
- Dietary Salt Restriction: Patients should restrict dietary sodium intake to no more than 5–6.5 grams per day (87–113 mmol), equivalent to a no-added-salt diet, to manage fluid accumulation effectively. (Quality of evidence: moderate; Recommendation: strong)
- Diuretic Therapy: For initial moderate ascites, spironolactone monotherapy is recommended. In cases of recurrent severe ascites, combination therapy with spironolactone and furosemide is advised. Regular monitoring for adverse events such as electrolyte imbalances and renal impairment is essential. (Quality of evidence: moderate; Recommendation: strong)
- Large Volume Paracentesis (LVP): LVP is a safe and effective treatment for refractory ascites. Informed consent is required, and routine coagulation studies or prophylactic blood product infusions before the procedure are not recommended. (Quality of evidence: moderate; Recommendation: strong)
- Use of Human Albumin Solution (HAS): After LVP exceeding 5 liters, infusion of HAS at 8 grams per liter of ascites removed is strongly recommended to prevent circulatory dysfunction. (Quality of evidence: high; Recommendation: strong)
- Transjugular Intrahepatic Portosystemic Shunt (TIPSS): TIPSS should be considered for patients with refractory ascites not responding to medical therapy, with caution exercised in patients over 70 years or those with significant comorbidities. (Quality of evidence: high; Recommendation: strong)
- Non-Selective Beta-Blockers (NSBBs): The presence of refractory ascites is not a contraindication for NSBB therapy. Patients should be closely monitored, and dose adjustments made in cases of hypotension or renal dysfunction. (Quality of evidence: moderate; Recommendation: strong)
- Palliative Care: Patients unsuitable for liver transplantation should be offered palliative care referral to focus on symptom management and quality of life improvement. Alternative interventions for refractory ascites may also be considered. (Quality of evidence: weak; Recommendation: strong)
Conclusion: Implementation of these evidence-based guidelines is expected to enhance patient care by promoting early diagnosis, preventing complications, and standardizing management strategies for ascites in cirrhosis. Adherence to these recommendations can improve clinical outcomes, reduce hospitalizations, and enhance the quality of life for affected patients.
Nonrandomized Controlled Trial | Long-term survival of 80% in selected colorectal cancer patients post liver transplant
1 Aug, 2023 | 14:20h | UTCLong-Term Survival, Prognostic Factors, and Selection of Patients With Colorectal Cancer for Liver Transplant: A Nonrandomized Controlled Trial – JAMA Surgery (link to abstract – $ for full-text)
Commentary on Twitter
Selected patients with liver-only CRLM and favorable pre-transplant prognostic scoring have long-term OS comparable to conventional indications for LT, providing a potential curative treatment option in patients otherwise offered only palliative treatments https://t.co/Xso5R7IDsX pic.twitter.com/uwEWijcrBp
— JAMA Surgery (@JAMASurgery) July 26, 2023
AHA Statement | Indications, evaluation, and outcomes for dual heart-kidney and heart-liver transplantation
14 Jul, 2023 | 12:51h | UTC
Guideline | Acute liver failure
10 Jul, 2023 | 13:59h | UTCAcute Liver Failure Guidelines – The American Journal of Gastroenterology
Related:
EASL Clinical Practice Guidelines on acute-on-chronic liver failure – Journal of Hepatology
Guidelines for the management of adult acute and acute-on-chronic liver failure in the ICU
Acute-on-chronic liver failure: far to go—a review – Critical Care
Liver Transplantation 2023 | Status report, current and future challenges
29 Jun, 2023 | 13:50h | UTC
Extracorporeal CPR dissemination and integration with organ preservation in the USA: ethical and logistical considerations
28 Apr, 2023 | 12:47h | UTC
Perspective | Liver transplantation for patients with severe acute on chronic liver failure: it is time to change paradigms
25 Apr, 2023 | 14:37h | UTC
Commentary on Twitter
Liver #Tx in severe acute on chronic failure
➡️ #ICU care crucial in ACLF-3
➡️ improve referrals to LT centers & pre-LT workup
➡️ to decide to put pt on waitlist consider donor shortage/collective utility of LT
➡️ identifying transplantability window
🖇️ https://t.co/VZxDyZ1k74 pic.twitter.com/6YOcd5rzMu— Intensive Care Medicine (@yourICM) April 19, 2023
Guidelines for the management of adult acute and acute-on-chronic liver failure in the ICU
17 Apr, 2023 | 13:19h | UTCGuidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU: Neurology, Peri-Transplant Medicine, Infectious Disease, and Gastroenterology Considerations – Critical Care Medicine (free for a limited period)
Executive Summary: Guidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU: Neurology, Peri-Transplant Medicine, Infectious Disease, and Gastroenterology Considerations – Critical Care Medicine (free for a limited period)
Overcoming size disparity in liver transplant access: prioritizing smaller donors for smaller candidates
3 Apr, 2023 | 13:41h | UTCAssociation of Body Surface Area With Access to Deceased Donor Liver Transplant and Novel Allocation Policies – JAMA Surgery (free for a limited period)
Invited Commentary: Addressing Size-Based Disparities in Liver Transplant – JAMA Surgery (free for a limited period)
Commentary on Twitter
In this study, liver waitlist candidates with the smallest body surface areas had a disadvantage due to size. Prioritizing allocation of smaller liver donors to smaller candidates may help overcome this disparity. https://t.co/p5F76Hgzm0
— JAMA Surgery (@JAMASurgery) March 30, 2023
Expanding Organ Usage: UK study finds organs from patients with a primary brain tumor are a viable option
27 Mar, 2023 | 13:27h | UTCSummary: A national cohort study in the UK investigated the risk of cancer transmission from deceased donors with primary brain tumors to organ recipients. The study found no cases of brain tumor transmission among 778 transplants from 282 donors with primary brain tumors, including 262 from donors with high-grade tumors. Organ transplant survival was equivalent to that in matched controls, and some organs from donors with high-grade tumors were less likely to be transplanted.
The results suggest that the risk of cancer transmission in transplants from deceased donors with primary brain tumors is lower than previously thought. Furthermore, the study indicated that donors with brain tumors provided good-quality organs with favorable risk markers and excellent transplant outcomes. Some organs from donors with high-grade tumors were underutilized, indicating a possible aversion by transplant clinicians or patients to use these organs.
These findings imply that it may be possible to safely expand organ usage from donors with primary brain tumors without negatively impacting outcomes, potentially benefiting many patients waiting for a transplant. Although this might lead to a slight rise in transplant numbers in the UK, the findings may hold particular significance for nations with stricter guidelines, such as the United States. The study’s findings can help transplant clinicians discuss the risks and benefits of accepting organ offers from such donors.
Current status of liver transplantation for non-B non-C liver cirrhosis and hepatocellular carcinoma
17 Feb, 2023 | 12:36h | UTC
Post-transplant biliary complications: advances in pathophysiology, diagnosis, and treatment
3 Feb, 2023 | 14:01h | UTC
Guidance on developing and/or expanding pediatric solid organ transplantation programs in low- and middle-income countries.
6 Dec, 2022 | 13:47h | UTC
Expert consensus on liver transplantation perioperative evaluation and rehabilitation for acute-on-chronic liver failure.
21 Nov, 2022 | 14:21h | UTC
Review | Determining prognosis of alcoholic liver disease and alcoholic hepatitis.
4 Nov, 2022 | 13:17h | UTC
ERAS Guidelines for perioperative care for liver surgery.
1 Nov, 2022 | 12:16h | UTCRelated:
Complete List of Enhanced Recovery After Surgery (ERAS) Society Guidelines
AHA Scientific Statement | Emerging evidence on coronary heart disease screening in kidney and liver transplantation candidates.
24 Oct, 2022 | 14:11h | UTCTop Things to Know: Emerging Evidence on Coronary Heart Disease (CHD) Screening in Kidney and Liver Transplantation Candidates – American Heart Association
Meta-analysis of observational studies | In patients with hepatocellular carcinoma, intraoperative blood salvage during liver transplantation appears safe.
30 Aug, 2022 | 12:03h | UTC
Supplement | The role of liver transplantation in acute-on-chronic liver failure.
25 Aug, 2022 | 11:57h | UTCHomepage: The Role of Liver Transplantation in Acute-on-Chronic Liver Failure – Clinical Liver Disease
Introduction: The Role of Liver Transplantation in Acute-on-Chronic Liver Failure
Identifying the patient with acute-on-chronic liver failure: navigating through multiple definitions
Pretransplant management of the patient with severe acute-on-chronic liver failure
Transplantation in Acute-on-Chronic Liver Failure: Feasibility and Futility
Palliative Care in the Patient With Acute-on-Chronic Liver Failure
Con: Patients With Acute-on-Chronic Liver Failure Should Not Receive Priority on the Waiting List
Review | Acute liver failure management and liver transplantation.
15 Aug, 2022 | 11:41h | UTCCAQ Corner: Acute liver failure management and liver transplantation – Liver Transplantation
Case-Control Study | Survival benefit of living-donor liver transplant.
4 Aug, 2022 | 13:59h | UTCSurvival Benefit of Living-Donor Liver Transplant – JAMA Surgery
Commentaries:
Just How Low a Model for End-stage Liver Disease Score Benefits From Living-Donor Liver Transplant? – JAMA Surgery (free for a limited period)
Low MELD Score No Barrier to Long Survival After Living-Donor Transplant — End-stage liver disease patients with scores as low as 11 achieved survival of 13 years or beyond – MedPage Today (free registration required)
Review | Liver transplantation in alcohol-related liver disease and alcohol-related hepatitis.
6 Jul, 2022 | 11:22h | UTCThe role of T-tubes and abdominal drains on short-term outcomes in liver transplantation – A systematic review of the literature and expert panel recommendations.
26 May, 2022 | 10:04h | UTC
Bring it on: Top five antimicrobial stewardship challenges in transplant infectious diseases and practical strategies to address them.
29 Apr, 2022 | 10:51h | UTC
Commentary on Twitter
🆕💥Review Article @ASHE_Journal
Bring it on: Top five antimicrobial stewardship challenges in transplant infectious diseases and practical strategies to address them #IDTwitter #medtwitter #TwitteRx #MedEd https://t.co/ToPLQXtC4r pic.twitter.com/pZQWWb3ZSx— Antibiotic Steward Bassam Ghanem 🅱️C🆔🅿️🌟 (@ABsteward) April 28, 2022
Under a http://creativecommons.org/licenses/by/4.0/ license