Biliary complications following liver transplantation in the model for end-stage liver disease era: Effect of donor, recipient, and technical factors

Biliary complications remain a significant problem following liver transplantation in the Model for End-Stage Liver Disease (MELD) era. We hypothesized that donor, recipient, and technical variables may differentially affect anastomotic biliary complications in MELD era liver transplants. We reviewed 256 deceased donor liver transplants after the institution of MELD at our center and evaluated these variables' association with anastomotic biliary complications. The bile leak rate was 18%, and the stricture rate was 23%. Univariate analysis revealed that recipient age, MELD, donor age, and warm ischemia were risk factors for leak, whereas a Roux limb or stent was protective. A bile leak was a risk factor for anastomotic stricture, whereas use of histidine tryptophan ketoglutarate (HTK) versus University of Wisconsin (UW) solution was protective. Additionally, use of a transcystic tube/stent was also protective. Multivariate analysis showed that warm ischemia was the only independent risk factor for a leak, whereas development of a leak was the only independent risk factor for a stricture. HTK versus UW use and transcystic tube/stent use were the only independent protective factors against stricture. Use of an internal stent trended in the multivariate analysis toward being protective against leaks and strictures, but this was not quite statistically significant. This represents one of the first MELD era studies of deceased donor liver transplants evaluating factors affecting the incidence of anastomotic bile leaks and strictures. Donor, recipient, and technical factors appear to differentially affect the incidence of anastomotic biliary complications, with warm ischemia, use of HTK, and use of a stent emerging as the most important variables. Liver Transpl 14:73–80, 2008. © 2007 AASLD.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/57538/1/21354_ftp.pd

The accuracy of the report of hepatic steatosis on ultrasonography in patients infected with hepatitis C in a clinical setting: A retrospective observational study

BACKGROUND: Steatosis is occasionally reported during screening ultrasonography in patients with hepatitis C virus (HCV). We conducted a retrospective observational study to assess the factors associated with steatosis on ultrasonography and the relationship between steatosis on ultrasound versus biopsy in patients infected with HCV in a clinical setting. Our hypothesis was ultrasonography would perform poorly for the detection of steatosis outside of the context of a controlled study, primarily due to false-positive results caused by hepatic fibrosis and inflammation. METHODS: A retrospective review of ultrasound reports was conducted on patients infected with HCV in a tertiary care gastroenterology clinic. Reports were reviewed for the specific documentation of the presence of steatosis. Baseline clinical and histologic parameters were recorded, and compared for patients with vs. without steatosis. Multiple logistic regression analysis was performed on these baseline variables. Liver biopsies were reviewed by two pathologists, and graded for steatosis. Steatosis on biopsy was compared to steatosis on ultrasound report, and the performance characteristics of ultrasonography were calculated, using biopsy as the gold standard. RESULTS: Ultrasound reports were available on 164 patients. Patients with steatosis on ultrasound had a higher incidence of the following parameters compared to patients without steatosis: diabetes (12/49 [24%] vs. 7/115 [6%], p < 0.001), fibrosis stage >2 (15/48 [31%] vs. 16/110 [15%], p = 0.02), histologic grade >2 (19/48 [40%] vs. 17/103 [17%], p = 0.002), and ALT (129.5 ± 89.0 IU/L vs. 94.3 ± 87.0 IU/L, p = 0.01). Histologic grade was the only factor independently associated with steatosis with multivariate analysis. When compared to the histologic diagnosis of steatosis (n = 122), ultrasonography had a substantial number of false-positive and false-negative results. In patients with a normal ultrasound, 8/82 (10%) had >30% steatosis on biopsy. Among patients with steatosis reported on ultrasound, only 12/40 (30%) had >30% steatosis on biopsy review. CONCLUSION: Steatosis on ultrasound is associated with markers of inflammation and fibrosis in HCV-infected patients, but does not consistently correlate with steatosis on biopsy outside of the context of a controlled study. Clinicians should be skeptical of the definitive diagnosis of steatosis on hepatic ultrasonography

Pain treatment: A risk factor for delirium in older adults with hip fracture

Delirium and pain are common following hip fracture. Undertreatment of pain has been shown to increase the risk of delirium in older adults experiencing hip fracture in only a very few earlier studies. This study was conducted to describe the clinical trajectory of delirium following hip fracture, and examine relationships between pain, pain treatment and delirium in older adults with hip fracture. The consecutive sample included 204 patients ≥65 years of age with no delirium at baseline at two hospitals in Oslo, Norway. The Confusion Assessment Method was used to identify delirium through patient and nurse interview and patient record review. Multiple logistic regression was used to identify risk factors. Cognitively intact patients reported highest pain intensity at rest and with movement before surgery with gradual decrease over the trajectory. Cognitively impaired patients showed a similar pain pattern based on observed pain behaviors. Despite high pain levels, patients received low doses of opioids and acetaminophen, especially those with cognitive impairment. Of 204 patients, 70 (34.3%) developed postoperative delirium. Patients who received inadequate multimodal pain treatment (<9.9 mg opioids and ≤3500 mg acetaminophen) had a significantly increased risk of delirium compared to patients who received more analgesics (RR 1.7; 95% CI 1.1–2.3). Additional significant, independent risk factors for delirium were cognitive impairment (RR 2.5; 95% CI 1.7–3.1), low body mass index (RR 1.8; 95% CI 1.2–2.4), complete or hemiarthroplasty performed (RR 1.7; 95% CI 1.1–2.3), prolonged preoperative fasting (RR 1.7; 95% CI 1.1–2.3), and postoperative anemia (RR 1.6; 95% CI 1.0–2.2). Of 135 cognitively intact patients, 31 (23%) developed delirium. Severity of illness was the only risk factor significant in multivariate analysis in this subgroup. Of 69 cognitively impaired patients, 39 (56.5%) developed delirium. Risk factors were low body mass index, normal white blood cell count, perioperative benzodiazepines, and acetaminophen. However, there was interaction between benzodiazepines and acetaminophen. Older adults with hip fracture received inadequate pain treatment for their level of pain. Avoiding both opioids and acetaminophen increased the risk of delirium. Undertreated pain appears to be a risk factor for delirium in both cognitively intact and impaired patients