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PurposeAcute liver failure (ALF) and acute on chronic liver failure (ACLF) are associated with significant mortality and morbidity. Extracorporeal liver support (ECLS) devices have been used as a bridge to liver transplant; however, the efficacy and safety of ECLS are unclear. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to examine the efficacy and safety of ECLS in liver failure.MethodsWe searched MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials from inception through March 13, 2019. RCTs comparing ECLS to usual care in ALF or ACLF were included. We used the Grading of Recommendations Assessment, Development and Evaluation approach to assess the certainty of the evidence.ResultsWe identified 25 RCTs (1796 patients). ECLS use was associated with reduction in mortality (RR 0.84; 95% CI 0.74, 0.96, moderate certainty) and improvement in hepatic encephalopathy (HE) (RR 0.71; 95% CI 0.60, 0.84, low certainty) in patients with ALF or ACLF. The effect of ECLS on hypotension (RR 1.46; 95% CI 0.98, 2.2, low certainty), bleeding (RR 1.21; 95% CI 0.88, 1.66, moderate certainty), thrombocytopenia (RR 1.62; 95% CI 1.0, 2.64, very low certainty) and line infection (RR 1.92; 95% CI 0.11, 33.44, low certainty) was uncertain.ConclusionsECLS may reduce mortality and improve HE in patients with ALF and ACLF. The effect on other outcomes is uncertain. However, the evidence is limited by risk of bias and imprecision, and larger trials are needed to better determine the effect of ECLS on patient-important outcomes.

The field of hepatology has evolved significantly over the last two decades. Hepatology practice in Saudi Arabia (SA) was dominated by hepatitis B and C viruses but is now being overtaken by patients with non-alcoholic fatty liver disease. These patients require greater medical attention as their care is more complex compared to patients with viral hepatitis. In addition, liver transplantation (LT) has expanded significantly in SA over the last three decades. There is a necessity to increase the hepatology workforce to meet the demand in SA. The time has come to reinforce the transplant hepatology fellowship program, that was launched recently, and to develop a nurse practitioner practice model to meet these demands. In addition, SA is going through a health care reform to enhance health care delivery which may affect the financial compensation polices of various specialties including gastroenterology and hepatology. Therefore, the Saudi Association for the Study of Liver diseases and Transplantation (SASLT) established a task force to discuss the current and future demands in the hepatology workforce in SA, as well as to discuss different avenues of financial compensation for transplant hepatologists in LT centers.

The World Health Organization (WHO), on March 11th 2020, upgraded the status of the novel coronavirus disease (COVID-19) from epidemic to pandemic. Over two million individuals have been infected with SARS-CoV-2, the virus causing COVID-19, and as of April, 14th 2020, there were over 5000 confirmed cases in Saudi Arabia (SA). Many countries, including SA, have imposed major restrictions on travel, and everyday life, and the implications of these necessary changes are being felt in liver transplant (LT) centers in SA. Concerns remain that there is an increased risk for individuals over 65 years of age, with underlying medical conditions, or for those who are immunocompromised. Therefore, the Saudi Association for the Study of Liver Diseases and Transplantation (SASLT) established an urgent task force to launch a statement that can be utilized by LT centers as a guidance in the management of patients with advanced liver disease from the time of LT listing to the post-operative care of transplanted patients.

The field of hepatology has evolved significantly over the last two decades. Hepatology practice in Saudi Arabia (SA) was dominated by hepatitis B and C viruses but is now being overtaken by patients with non-alcoholic fatty liver disease. These patients require greater medical attention as their care is more complex compared to patients with viral hepatitis. In addition, liver transplantation (LT) has expanded significantly in SA over the last three decades. There is a necessity to increase the hepatology workforce to meet the demand in SA. The time has come to reinforce the transplant hepatology fellowship program, that was launched recently, and to develop a nurse practitioner practice model to meet these demands. In addition, SA is going through a health care reform to enhance health care delivery which may affect the financial compensation polices of various specialties including gastroenterology and hepatology. Therefore, the Saudi Association for the Study of Liver diseases and Transplantation (SASLT) established a task force to discuss the current and future demands in the hepatology workforce in SA, as well as to discuss different avenues of financial compensation for transplant hepatologists in LT centers.

Purpose Biliary complications following liver transplantation are a significant source of morbidity, potentially leading to graft failure necessitating retransplantation. We sought to evaluate smoking as an independent risk factor for post-transplant biliary complications. Methods The clinical course of all adult primary deceased donor liver transplants at our center from 1992 to 2012 was reviewed. Eligible patients were assigned to cohorts based on their lifetime tobacco exposure: never smokers indicating 0 pack-year exposure and all others were ever smokers. Biliary complications were defined as strictures, leaks, or bilomas requiring intervention. Complication rates were analyzed using univariate regression models correlated with donor and recipient characteristics. Associations found during univariate analysis were included in the final multivariate Cox model. Results Eight hundred sixty-five subjects were followed for a median of 65 months; 482 (55.7%) of patients had a positive smoking history at the time of transplant. In univariate analysis, positive tobacco smoking history (HR = 1.36; p  = 0.037) and increased time from quit date to transplantation (HR = 0.998; p  = 0.011) were positive and negative predictors of biliary complication, respectively. Lifetime tobacco exposure remained a significant predictor of biliary complication on multivariate analysis (HR = 1.408; p  = 0.023). Conclusions Smoking status is an independent predictor of post-transplant biliary complications, and the data presented reinforces the importance of early smoking cessation in the pre-transplantation period.

[1],[2] Several published guidelines on the management of HCC have indicated that liver transplantation, surgical resection (SR), and local regional therapy such as radiofrequency ablation (RFA) are the treatment options for early stage HCC. [5] SR has the advantage over RFA by tumor removal with clean resection margin. [...]it would be expected that HCC recurrence would be lower in the SR group compared to the RFA group. Despite the study limitations which include study design, missing data such as the Child-Pugh score, performance status, patients' comorbidities, tumor characteristics, and location, it has a reasonable sample size and is consistent with what has been published in the literature regarding the safety and efficacy of RFA and SR group in elderly HCC patients.

Background: The outcome of primary sclerosing cholangitis (PSC) after liver transplantation can be affected by recurrent PSC (rPSC) and subsequent graft failure. IgG4-related sclerosing disease is a recently described entity that has a similar morphological appearance to PSC, making the distinction difficult. However, IgG4-related sclerosing cholangitis has an excellent prognosis since it is steroid sensitive, but the impact of IgG4 on rPSC after liver transplant is still unknown. Objectives: To determine the association between IgG4 positive immunochemical staining in liver explants and recurrence of primary sclerosing cholangitis post-liver transplantation. Methods: Clinical information on all adult patients who underwent liver transplantation for PSC from 1990 to 2014 at our institution was obtained. IgG4 immunochemical staining was performed on the porta-hepatis region of these patient’s explanted livers. Immunochemical staining was considered to be positive if the score was > 5 cells/high power field (HPF). Results: Eighty patients met inclusion criteria. IgG4 staining was positive in 21 subjects. Median time for follow-up in the IgG4 positive group was 99.6 months compared to 152.6 months in the IgG4 negative. There were more instances of rPSC in the IgG4 negative group compared to the IgG4 positive group (26% vs. 5%, P < 0.009), and rPSC occurred earlier in the IgG4 negative group (P = 0.016). The frequency of graft failure, however was not significantly different among the two groups. Conclusions: The presence of IgG4 positive cells in liver explants of patient’s transplanted for PSC is associated with fewer episodes of and longer time to recurrent PSC. In addition, IgG4 status of the liver explants does not affect graft survival. Presence of IgG4 positive cells may suggest protective effect against recurrence of PSC.