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The demand for liver transplantation in the Kingdom of Saudi Arabia (KSA) is associated with the country's high burden of liver disease. Trends in the epidemiology of liver transplantation indications among recipients in KSA have changed over 20 years. Non-alcoholic steatohepatitis has eclipsed the hepatitis C virus in the country due to the effective treatment strategies for HCV. Risk factors for NASH, like type 2 diabetes mellitus, obesity, and hyperlipidemia, are becoming a major concern and a leading indication for liver transplantation in the KSA. There is also a significantly increased prevalence and incidence of genetic adult familial liver diseases in KSA. New immunosuppressive agents and preservation solutions, improved surgical capabilities, and early disease recognition and management have increased the success rate of liver transplant outcome but concerns about the side effects of immunosuppressive therapy can jeopardise long-term survival outcomes. Despite this, indications for liver transplantation continue to increase, resulting in ongoing challenges to maximize the number of potential donors and reduce patient mortality rate while expecting to get transplanted. The Saudi Center of Organ Transplant is the recognized National Organ

Objectives:To describe a novel animal model for ex-vivo liver perfusion.Methods:This study was carried out at King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia, between September 2016 and January 2019. We assembled a perfusion circuit operated by a continuous pressure-driven arterial pump with continuous portal and arterial pressure and volume measurements. We used normothermic oxygenated perfusate. The livers used were retrieved from the sheep.Results:Ex-vivo continuous perfusion of the liver was achieved for up to 9 hours with stable pressure and volume in both hepatic artery and portal vein. In 4 experiments the arterial pressure was kept in a range of 48-52 mmHg with a mean of 51.75±4.31 resulting in arterial volume at steady state of 223.5±48.25 ml/minute (95% confidence level). At steady state the mean portal pressure was 16.25±1.45 mmHg with a mean volume of 854±313.75 ml/minute (95% confidence level). Bile production was observed during the perfusion period. Hemodynamic parameters were similar to the physiological parameters observed in normothermic perfusion model of the porcine liver.Conclusion:A normothermic oxygenated ex-vivo perfusion circuit was successfully constructed using the sheep liver. A sustainable functional circuit with physiological hemodynamic parameters was achieved. Further study on sheep model seems to be feasible.

Background and Aim Management of genotype 4 hepatitis C virus (HCV) has shifted to interferon‐free regimens with a high sustained virological response (SVR‐12), especially with NS5B/NS5A inhibitor combinations such as sofosbuvir and ledipasvir (Sof‐Led). The guidelines have recommended the combination of sofosbuvir and another NS5A inhibitor, daclatasvir, to manage HCV genotypes 1–3. However, its use was extended to genotype 4 HCV based on extrapolating evidence. Our aim is to assess the efficacy of generic sofosbuvir + branded daclatasvir (Sof‐Dac) compared to the Sof‐Led combination in treating genotype 4 HCV. Methods This study is an open‐label, 2‐period, noninferiority study that compared patients receiving a combination of generic sofosbuvir 400 mg and daclatasvir 60 mg orally daily (Group 2) prospectively to a historical control (Group 1) that included patients who received a combination of sofosbuvir/ledipasvir 400/90 mg orally daily. The primary endpoint is the proportion of patients who achieved SVR‐12. Results The study included 111 patients in the (Sof‐Led) Group 1 and 109 patients (Sof‐Dac) Group 2. For the primary outcome, SVR‐12 was achieved in 106 (95.5%) of the patients in Group 1 versus 108 (99.1%) in Group 2 (p = 0.2). In addition, all patients who achieved SVR‐12 also achieved SVR‐24. Conclusion Generic sofosbuvir combined with branded daclatasvir was safe and effective for treating genotype 4 HCV compared to Sof‐Led. This combination may significantly reduce the cost burden, enabling a larger pool of treated patients. Office of research affairs at KFSHRC RAC# 2171 036.

[1],[2] In response to this mandate, in 2002, the United Network for Organ Sharing (UNOS), a federally appointed organization which organizes and overlooks transplant activities in the US, made the first change in organ allocation by adopting the Model for End Stage Liver Disease (MELD) score as an objective model for prioritizing patients based on its ability to predict waiting list mortality within the 58 geographical areas called Donation Service Areas (DSAs) which are further grouped into 11 regions (the Kingdom may be equivalent to 5 DSAs or one region). Despite having two changes in the organ allocation system in USA with a possible third change in the near future addressing the regional allocation, the liver transplant community in Saudi Arabia has not made a single change and the current allocation system has been in effect since the early 1990s when the liver transplantation programs were launched in the Kingdom, leading to unjust distribution of organs between patients in the same country based on the transplant center they are listed at.

Objectives: To describe a novel animal model for ex-vivo liver perfusion. Methods: This study was carried out at King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia, between September 2016 and January 2019. We assembled a perfusion circuit operated by a continuous pressure-driven arterial pump with continuous portal and arterial pressure and volume measurements. We used normothermic oxygenated perfusate. The livers used were retrieved from the sheep. Results: Ex-vivo continuous perfusion of the liver was achieved for up to 9 hours with stable pressure and volume in both hepatic artery and portal vein. In 4 experiments the arterial pressure was kept in a range of 48-52 mmHg with a mean of 51.75[+ or -]4.31 resulting in arterial volume at steady state of 223.5[+ or -]48.25 ml/minute (95% confidence level). At steady state the mean portal pressure was 16.25[+ or -]1.45 mmHg with a mean volume of 854[+ or -]313.75 ml/minute (95% confidence level). Bile production was observed during the perfusion period. Hemodynamic parameters were similar to the physiological parameters observed in normothermic perfusion model of the porcine liver. Conclusion: A normothermic oxygenated ex-vivo perfusion circuit was successfully constructed using the sheep liver. A sustainable functional circuit with physiological hemodynamic parameters was achieved. Further study on sheep model seems to be feasible. Keywords: porcine liver, machine perfusion, organ preservation, hepatic flow, animal handling [phrase omitted]

HEHE is a rare neoplasm of vascular origin that occurs in the liver; UNOS reported a favorable outcome after liver transplantation in 110 patients with 1-year and 5-year survival of 80% and 64%. Case Report. A 40-year-old lady presented with a three-month history of right upper abdominal pain with nausea, vomiting, and significant loss of weight associated with scleral icterus and progressive abdominal distension. Examination revealed jaundice, hepatomegaly, and ascites. Serum bilirubin was 26.5 mg/dL and ALP was 552 CT. Abdomen and pelvis showed diffuse infiltrative neoplastic process of the liver with a mass effect and stretching of the hepatic and portal veins, in addition to bile duct dilatation. Viral hepatitis markers were negative and serum alpha fetoprotein was within reference range. Liver biopsy was consistent with HEHE, with positive endothelial markers (CD31, CD34, and factor VIII-related antigen). She underwent living related liver transplantation on June 2013 and was discharged after 20 days with normal liver enzymes. Four months later, she presented with diffuse disease recurrence. Liver biopsy confirmed disease recurrence; she received supportive treatment and unfortunately she died 2 weeks later. Conclusion. HEHE can have rapid and aggressive recurrence after liver transplantation.

The liver transplantation program at KFSHRC has been active since 2001. More than 450 liver transplants have been performed so far. The program evolved from adult cadaveric transplant to living donor and recently to pediatric and split techniques. The 1-year survival of patients for both pediatric and adult exceeded 90% and the 5-year survival of patients is more than 80%. Associated with this success are challenges that include: organ shortage, quality of organ harvested, inability to meet the growing national need, increased demand of resource to meet the need of the program, and lack of a collaborative national strategy in organ donation and transplantation.

There are few reports on hepatitis C virus genotype 4 (HCV-4) recurrences after orthotopic liver transplantation (OLT). Therefore, we undertook a study to determine the epidemiological, clinical and virological characteristics of patients with biopsy-proven recurrent HCV infection and analyzed the factors that influence recurrent disease severity. We also compared disease recurrence and outcomes between HCV-4 and other genotypes. All patients who underwent OLT (locally or abroad) for HCV related hepatic cirrrhosis from 1991 to 2006 and had recurrent HCV infection were identified. Clinical, laboratory and pathological data before and after OLT were collected and analyzed. Of 116 patients who underwent OLT for hepatitis C, 46 (39.7%) patients satisfied the criteria of recurrrent hepatitis C. Twenty-nine (63%) patients were infected with HCV genotype 4. Mean (SD) for age was 54.9 (10.9) years. Nineteen of the HCV genotype 4 patients (65.5%) were males, 21 (72.4%) received deceased donor grafts, and 7 (24.1%) developed > or =1 acute rejection episodes. Pathologically, 7 (24.1%) and 4 (13.8%) patients had inflammation grade 3-4 and fibrosis stage 3-4, respectively. Follow-up biopsy in 9 (31%) HCV genotype 4 patients showed stable, worse and improved fibrosis stage in 5, 2 and 2 patients, respectively. Of the 7 patients in the recurrent HCV group who died, 6 were infected with genotype 4 and 4 of them died of HCV-related disease. This analysis suggests that HCV recurrence following OLT in HCV-4 patients is not significantly different from its recurrence for other genotypes.

BACKGROUND AND OBJECTIVES: The recipients of liver transplantation (LT) are subjected to lifelong immunosuppression with its many drawbacks. De novo and recurrent malignancy in transplant recipients are attributed to attenuation of immunosurveillance. In the present study, we present our experience with de novo malignancies encountered after both deceased and living donor liver transplantations. DESIGN AND SETTING: Retrospective study of patients referred to LT center between April 2001 and January 201 0 PATIENTS AND METHODS: Various data were collected including type of malignancy and histopathologic features, immunosuppression regimen, and patient survival. RESULTS: Of 248 LT procedures performed in 238 patients (10 retransplants), 8 patients (3.4%) developed de novo post-LT malignancies. De novo malignancies included post-LT lymphoproliferative disorders (PTLD) in 5 patients who were all Epstein-Barr virus (EBV) positive, and who were treated successfully with anti-CD20 monoclonal antibody therapy, reduction of immunosuppression, and control of EBV activity; urinary bladder cancer in 1 patient who was treated with radical surgical resection and chemotherapy but died of bone and lung metastasis within 1 year of diagnosis; endometrial carcinoma in 1 patient who was treated with radical surgical resection; and Kaposi sarcoma in 1 patient who was successfully treated with surgical excision and reduction of immunosuppression. CONCLUSION: EBV-associated PTLD is the most frequently encountered de novo malignancy after LT and is easily treatable by chemotherapy and reduction of immunosuppression.