Current recommendations for early anticoagulation in acute portal vein thrombosis unrelated to cirrhosis or malignancy are based on limited evidence. The aim of this study was to prospectively assess the risk factors, outcome, and prognosis in patients managed according to these recommendations. We enrolled 102 patients with acute thrombosis of the portal vein, or its left or right branch. Laboratory investigations for prothrombotic factors were centralized. Thrombus extension and recanalization were assessed by expert radiologists. A local risk factor was identified in 21% of patients, and one or several general prothrombotic conditions in 52%. Anticoagulation was given to 95 patients. After a median of 234 days, the portal vein and its left or right branch were patent in 39% of anticoagulated patients (versus 13% initially), the splenic vein in 80% (versus 57% initially), and the superior mesenteric vein in 73% (versus 42% initially). Failure to recanalize the portal vein was independently related to the presence of ascites (hazard ratio 3.8, 95% confidence interval 1.3-11.1) and an occluded splenic vein (hazard ratio 3.5, 95% confidence interval 1.4-8.9). Gastrointestinal bleeding and intestinal infarction occurred in nine and two patients, respectively. Two patients died from causes unrelated to thrombosis or anticoagulation therapy. Conclusion: Recanalization occurs in one-third of patients receiving early anticoagulation for acute portal vein thrombosis, whereas thrombus extension, intestinal infarction, severe bleeding, and death are rare. Alternative therapy should be considered when ascites and splenic vein obstruction are present. (HEPATOLOGY 2010;51:210-218.) A cute portal vein thrombosis (PVT) is characterized by the recent development of a thrombus in the portal vein or its left or right branches. 1,2 Extension to mesenteric venous arches causes intestinal infarction, with a reported mortality of up to 50%. 3,4 Without recanalization, a cavernoma develops, associated with a permanent risk of potentially fatal gastrointestinal bleeding, recurrent thrombosis, or biliary obstruction. 1,5,7 Recanalization is therefore a major goal for the treatment of acute PVT and is often a pressing challenge, because most PVT cases are recognized at the acute stage. 8 Expert panels have recommended early anticoagulation therapy for acute PVT. 2 However, these recommendations are based on small retrospective cohort studies performed over several decades. [9][10][11] The aim of this study was to prospectively assess (1) patient characteristics of those presenting with acute PVT unrelated to cirrhosis or malignancy; (2) the incidence and predictive factors of recanalization in patients managed according to recent recommendations; and (3) the incidence of disease-and treatment-related complications.

Fifth Framework Programme of the European Commission.

Budd-Chiari syndrome (BCS) is a rare, life-threatening disease caused by obstruction of hepatic venous outflow. The aim of the study was to assess long-term outcome and identify prognostic factors in BCS patients managed by a step-wise approach using anticoagulation, angioplasty/thrombolysis, transjugular intrahepatic portosystemic shunting (TIPS), and orthotopic liver transplantation (OLT). We reviewed long-term data on 157 patients previously included by the European Network for Vascular Disorders of the Liver, a multicenter prospective study of newly diagnosed BCS patients in nine European countries. Patients were followed for a median of 50 months (range, 0.1-74.0). During the study, 88 patients (56%) received at least one invasive intervention (22 patients angioplasty/thrombolysis, 62 TIPS, and 20 OLT) and 36 (22.9%) died. Most interventions and/or deaths occurred in the first 2 years after diagnosis. The Rotterdam score was excellent in predicting intervention-free survival, and no other variable could significantly improve its prognostic ability. Moreover, BCS-TIPS prognostic index (PI) score (based on international normalized ratio, bilirubin, and age) was strongly associated with survival and had a discriminative capacity, which was superior to the Rotterdam score. Conclusions: The current study confirms, in a large cohort of patients with BCS recruited over a short period, that a step-wise treatment approach provides good long-term survival. In addition, the study validates the Rotterdam score for predicting intervention-free survival and the BCS-TIPS PI score for predicting survival. (HEPATOLOGY 2013;57:1962-1968

Background: Alcohol relapse can negatively influence the outcome after liver transplantation (LT). The aim of our study was to identify factors that could be associated with the recurrence of harmful alcohol consumption after LT. Methods: A total of 387 consecutive patients (23.8% women) who underwent LT for alcoholic cirrhosis in Geneva, Switzerland, and Lyon, France, between 1989 and 2005 were evaluated. Mean ± SD age was 51.3±7.5 years. Follow-up time was 61.2 ± 47.5 months. Alcohol consumption relapse and potential factors associated with it were studied. Results: The relapse rate of harmful alcohol consumption after LT was 11.9%. In univariate analysis, alcohol relapse was significantly associated with age greater than 50 years (P=.04), year of LT 1995 or earlier (PϽ.05), duration of abstinence less than 6 months (P= .02), presence of psychiatric comorbidities (PϽ.001), presence of a life partner (PϽ.05), and a high score on the High-Risk Alcoholism Relapse (HRAR) scale (PϽ.001). Mul-tivariate logistic regression disclosed the following independent factors of relapse: duration of abstinence of less than 6 months (odds ratio [OR], 3.3; 95% confidence interval [CI], 1.2-9.3) (P =.02); presence of psychiatric comorbidities (OR, 7.8; 95% CI, 3.1-20.0) (PϽ.001); and HRAR score higher than 3 (OR, 10.7; 95% CI, 3.8-30.0) (P=.001). In patients with none of these factors, alcohol relapse was 5%, while the presence of 1, 2, or 3 factors was associated with relapse rates of 18%, 64%, and 100% of the patients, respectively. Conclusions: In a large cohort of patients undergoing LT for alcoholic cirrhosis, a duration of abstinence of less than 6 months before wait-listing for LT, the presence of psychiatric comorbidities, or an HRAR score higher than 3 was associated with relapse into harmful drinking. The presence of more than 1 factor dramatically increased this risk over 50%. In the pre-LT evaluation in this setting, these factors should be accurately determined.

Posttransplant immunosuppression with calcineurin inhibitors (CNIs) is associated with impaired renal function, while mTor inhibitors such as everolimus may provide a renal-sparing alternative. In this randomized 1-year study in patients with liver transplantation (LTx), we sought to assess the effects of everolimus on glomerular filtration rate (GFR) after conversion from CNIs compared to continued CNI treatment. Eligible study patients received basiliximab induction, CNI with/without corticosteroids for 4 weeks post-LTx, and were then randomized (if GFR > 50 mL/min) to contin-