Recurrence of hepatitis C after liver transplantation (LT) is the main cause of graft loss and retransplantation. Frequent liver biopsies are essential to follow-up hepatitis C virus (HCV)-induced liver damage. However, liver biopsy is an invasive and expensive procedure. We evaluated prospectively the diagnostic accuracy of noninvasive measurement of liver stiffness (by transient elastography) to assess the severity of hepatitis C recurrence after LT. For this purpose, we included 124 HCV-infected liver transplant recipients who underwent 169 liver biopsies and 129 hepatic hemodynamic studies with determination of hepatic venous pressure gradient (HVPG). Simultaneously, patients underwent measurement of liver stiffness. Liver fibrosis was mild (F0-F1) in 96 cases (57%) and significant (F2-F4) in 73 (43%). HVPG was normal (Ͻ6 mm Hg) in 69 cases (54%) and elevated (Ն6 mm Hg) in 60 (46%). Using a liver stiffness cutoff value of 8.5 kilopascals, the sensitivity, specificity, negative predictive value, and positive predictive value for diagnosis of fibrosis ՆF2 were 90%, 81%, 79%, and 92%, respectively. The area under the curve (AUC) for diagnosis of fibrosis ՆF2, ՆF3 and F4 were 0.90, 0.93, and 0.98, respectively. There was a close direct correlation between liver stiffness and HVPG (Pearson coefficient, 0.84; P Ͻ 0.001) and the AUC for diagnosis of portal hypertension (HVPG Ն6 mm Hg) was 0.93. Importantly, none of the individuals with liver stiffness below the cutoff value had either bridging fibrosis (F3) or cirrhosis (F4) or significant portal hypertension (HVPG Ն10 mm Hg). In conclusion, determination of liver stiffness is an extremely valuable tool to assess the severity of HCV recurrence after LT and in reducing the need of follow-up liver biopsies.

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Helical CT and EUS are the most useful individual imaging techniques in the staging of pancreatic cancer. In those cases with potentially resectable tumors a sequential approach consisting of helical CT as an initial test and EUS as a confirmatory technique seems to be the most reliable and cost minimization strategy.

Liver biopsy is essential in the follow-up of HCV-infected liver transplant recipients. The aim of this study was to prospectively compare percutaneous (PLB) versus transjugular liver biopsy (TLB) in the assessment of liver damage. We also explored the diagnostic value of hepatic venous pressure gradient (HVPG) to identify patients at risk of severe HCV disease recurrence after liver transplantation (LT). One hundred sixteen paired PLB and TLB (with HVPG measurement) were performed 3 or 12 months after LT in 80 patients. Concordance for necroinflammation and fibrosis was fair or good, particularly 1 year after LT (kappa > 0.6). At this point, a significant positive association was seen between the median HVPG and the fibrosis stage C hronic hepatitis C virus (HCV) infection leading to liver cirrhosis and hepatocellular carcinoma is the main indication for liver transplantation (LT) in Western countries and Japan. 1 Regretfully, recurrence of HCV infection is universal after LT, 2 and disease progression is significantly faster in immunosuppressed than in immunocompetent individuals. In liver transplant recipients, chronic HCV infection may lead to cirrhosis in as much as 30% of individuals only 5 years after LT. [3][4][5] Once liver cirrhosis is established, the cumulative probability of developing clinical decompensation is close to 50% 1 year after diagnosis and, more importantly, survival after decompensation is extremely short. 6 As a result of this accelerated course of HCV infection, longterm graft and patient survival are significantly reduced in patients undergoing LT for HCV-related cirrhosis compared with other groups. 7 Frequent liver biopsies are essential to monitor HCV-induced liver damage and are part of the routine follow-up of HCV-infected liver transplant recipients. Early histological damage after transplantation correlates with long-term outcome; in fact, the presence of significant liver fibrosis in 1-year liver biopsies identifies patients at high risk of graft loss. 3,8 In addition, assessment of liver damage is relevant to adopt therapeutic decisions, particularly because of the low efficacy and high incidence of adverse events of current antiviral therapy in this group of patients. 3,9,10

Little information exists on the effects of transjugular intrahepatic portosystemic shunts (TIPS) in the management of cirrhotic patients with hepatorenal syndrome (HRS). The current study was aimed to prospectively evaluate the effects of TIPS on renal function and vasoactive systems in patients with type I HRS. Glomerular filtration rate (GFR) (inulin clearance), renal plasma flow (RPF) (para-aminohippurate clearance), plasma renin activity (PRA), aldosterone (ALDO), norepinephrine (NE), and endothelin (ET) were determined in baseline conditions and at different time intervals after TIPS in 7 patients with type I HRS. TIPS induced a marked reduction of portal pressure gradient (PPG) (20 ؎ 1 to 10 ؎ 1 mm Hg; P F .05). Renal function improved in 6 of the 7 patients. Serum creatinine and blood urea nitrogen (BUN) decreased from 5 ؎ 0.8 and 109 ؎ 7 to 1.8 ؎ 0.4 mg/dL and 56 ؎ 11 mg/dL, respectively (P F .05 for both), and GFR and RPF increased from 9 ؎ 4 and 103 ؎ 33 to 27 ؎ 7 mL/min and 233 ؎ 40 mL/min, respectively (P F .05 for both), 30 days after TIPS. These beneficial effects on renal function were associated with a significant (P F .05) reduction of PRA (18 ؎ 5 to 3 ؎ 1 ng/mL · h), ALDO (279 ؎ 58 to 99 ؎ 56 ng/dL), and NE (1,257 ؎ 187 to 612 ؎ 197 pg/mL). ET did not change significantly (28 ؎ 8 to 27 ؎ 11 pg/mL). Mean survival was 4.7 ؎ 2 months (0.3-17 months). Three patients remained alive more than 3 months after TIPS insertion. In conclusion, TIPS improves renal function and reduces the activity of the renin-angiotensin and sympathetic nervous systems in cirrhotic patients with type I HRS. Nevertheless, the efficacy of TIPS in the management of these patients should be confirmed in controlled investigations. (HEPATOLOGY 1998;28:416-422.)Hepatorenal syndrome (HRS) is a common and severe complication of patients with advanced cirrhosis and is characterized by renal failure, marked portal hypertension, abnormalities in the arterial circulation, and overactivity of endogenous vasoactive systems. [1][2][3][4][5] Up to now, the only treatment that has been shown to improve survival in patients with HRS is liver transplantation. 3-7 However, because of the short survival of patients with HRS and the limited availability of organs, only a small percentage of patients with HRS can actually reach transplantation. Therefore, it would be of great value to have a therapeutic method that could improve renal function and increase survival, especially in patients with type I HRS, which is characterized by a rapid progression of renal failure and a very short survival expectancy. 3 The transjugular intrahepatic portosystemic shunt (TIPS) has been introduced recently in clinical practice for the management of cirrhotic patients with variceal bleeding. 8,9 As with surgical portosystemic shunts, the use of TIPS is associated with a marked reduction in portal pressure but with the advantage of a very low operative morbidity and mortality. It has been shown that TIPS is useful in the management of acute variceal hemorrhage th...

Adding walnuts to a high-fat meal acutely improves FMD independently of changes in oxidation, inflammation, or ADMA. Both walnuts and olive oil preserve the protective phenotype of endothelial cells.

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