As survival after orthotopic liver transplantation (OLT) improves, cardiovascular (CV) disease has emerged as the leading cause of non-graft-related deaths. The aims of our study were to determine the cumulative risk of CV events after OLT and to analyze predictive risk factors for those experiencing a CV event after OLT. We identified all adult patients who underwent OLT at our institution for end-stage liver disease between October 1996 and July 2008. The cumulative risk of CV events after OLT was analyzed with the Kaplan-Meier method. Multivariate logistic regression analysis was used to identify factors independently associated with CV events after OLT. In all, 775 patients were included in our study cohort (mean age of 53.3 years, female proportion ¼ 44%, Caucasian proportion ¼ 84%, median follow-up ¼ 40 months). The most common indications for OLT were hepatitis C virus (33.2%), alcohol (14.5%), and cryptogenic cirrhosis (12.7%). Eighty-three patients suffered 1 or more CV events after OLT. Posttransplant metabolic syndrome was more prevalent in patients with CV events versus patients with no CV events (61.4% versus 34.1%, P < 0.001). According to a multivariate analysis, independent predictors of CV events were an older age at transplantation [odds ratio (OR) ¼ 1. Posttransplant cardiovascular (CV) complications are the leading cause of non-graft-related death for orthotopic liver transplantation (OLT) patients.1 Although the high incidence of posttransplant CV events is regarded as multifactorial, the increased prevalence of metabolic syndrome, which is attributed to immunosuppressant therapy and end-stage liver disease, likely plays a role. End-stage liver disease leads to metabolic disturbances that alter lipid, glucose, and blood pressure levels considerably; for instance, hepatitis C virus (HCV) has been associated with an elevated risk of diabetes.2 With a national shortage of donors, the selection of candidates who are likely to benefit the most and live the longest after receiving a

Nonalcoholic fatty liver disease (NAFLD) is becoming rapidly one of the most common indications for orthotopic liver transplantation in the world. Development of graft steatosis is a significant problem during the post-transplant course, which may happen as a recurrence of pre-existing disease or de novo NAFLD. There are different risk factors that might play a role in development of graft steatosis including post-transplant metabolic syndrome, immune-suppressive medications, genetics and others. There are few studies that assessed the effects of NAFLD on graft and patient survival; most of them were limited by the duration of follow up or by the number of patients. With this review article we will try to shed light on post-liver transplantation NAFLD, significance of the disease, how it develops, risk factors, clinical course and treatment options.

Capnographic monitoring in routine EGD or colonoscopy for ASAPS I and II patients does not reduce the incidence of hypoxemia (ClinicalTrials.gov number, NCT01994785).

Background. The role of urgent colonoscopy in lower gastro-intestinal bleeding (LGIB) remains controversial. Over the last two decades, a number of studies have indicated that urgent colonoscopy may facilitate the identification and treatment of bleeding lesions; however, studies comparing this approach to elective colonoscopy for LGIB are limited.Aims. To determine the utility and assess the outcome of urgent colonoscopy as the initial test for patients admitted to the intensive care unit (ICU) with acute LGIB.Methods. Consecutive patients who underwent colonoscopy at our institution for the initial evaluation of acute LGIB between January 2011 and January 2012 were analysed retrospectively. Patients were grouped into urgent vs. elective colonoscopy, depending on the timing of colonoscopy after admission to the ICU. Urgent colonoscopy was defined as being performed within 24 hours of admission and those performed later than 24 hours were considered elective. Outcomes included length of hospital stay, early re-bleeding rates, and the need for additional diagnostic or therapeutic interventions. Multivariable logistic regression analysis was performed to identify factors associated with increased transfusion requirements.Results. Fifty-seven patients underwent colonoscopy for the evaluation of suspected LGIB, 24 of which were urgent. There was no significant difference in patient demographics, co-morbidities, or medications between the two groups. Patients who underwent urgent colonoscopy were more likely to present with hemodynamic instability (P = 0.019) and require blood transfusions (P = 0.003). No significant differences in length of hospital stay, re-bleeding rates, or the need for additional diagnostic or therapeutic interventions were found. Patients requiring blood transfusions (n = 27) were more likely to be female (P = 0.016) and diabetics (P = 0.015). Fourteen patients re-bled at a median of 2 days after index colonoscopy. Those with hemodynamic instability were more likely to re-bleed [HR 3.8 (CI 1.06–13.7)], undergo angiography [HR 9.8 (CI 1.8–54.1)], require surgery [HR 13.5 (CI 3.2–56.5)], and had an increased length of hospital stay [HR 1.1 (1.05–1.2)].Conclusion: The use of urgent colonoscopy, as an initial approach to investigate acute LGIB, did not result in significant differences in length of ICU stay, re-bleeding rates, the need for additional diagnostic or therapeutic interventions, or 30-day mortality compared with elective colonoscopy. In a pre-specified subgroup analysis, patients with hemodynamic instability were more likely to re-bleed after index colonoscopy, to require additional interventions (angiography or surgery) and had increased length of hospital stay.

With the increasing age of recipients undergoing orthotopic liver transplant (OLT), there is need for better risk stratification among them. Our study aims to identify predictors of poor outcome among OLT recipients ≥ 60 yr of age. All patients who underwent OLT at Cleveland Clinic from January 2004 to April 2010 were included. Baseline patient characteristics and post-OLT outcomes (mortality, graft failure, length of stay, and major post-OLT cardiovascular events) were obtained from prospectively collected institutional registry. Among patients ≥ 60 yr of age, multivariate regression modeling was performed to identify independent predictors of poor outcome. Of the 738 patients included, 223 (30.2%) were ≥ 60 yr. Hepatic encephalopathy, platelet counts < 45,000/μL, total serum bilirubin > 3.5 mg/dL, and serum albumin < 2.65 mg/dL independently predicted poor short-term outcomes. The presence of pre-OLT coronary artery disease and arrhythmia were independent predictors of poor long-term outcomes. Cardiac causes represented the second most common cause of mortality among the elderly cohort. Despite that, this carefully selected cohort of older OLT recipients had outcomes that were comparable with the younger recipients. Thus, our results show the need for better pre-OLT evaluation and optimization, and for closer post-OLT surveillance, of cardiovascular disease among the elderly.