Ángeles García-Criado

Background and Aims: Assessing liver congestion and portal hypertension (PHT) in Budd–Chiari syndrome (BCS) remains challenging. We evaluated liver and spleen stiffness measurements (LSM, SSM) obtained by transient elastography as non‐invasive tools for identifying clinically meaningful liver congestion in BCS. Methods: This retrospective study included consecutive patients with BCS followed at our unit. At each visit, patients were classified as having a controlled or uncontrolled clinical status based on clinical, biochemical, imaging and/or hemodynamic data, by absence or presence of clinically significant PHT. LSM and SSM were independently obtained at all visits and diagnostic performance for classifying clinical status was assessed using receiver operating characteristic (ROC) analysis. Results: Sixty‐six patients were included with a median follow‐up of 65.5 months (range:2–182): 34 had persistently controlled status, 11 persistently uncontrolled, 14 initially uncontrolled improved to sustained controlled status and 7 showed fluctuating status. Two‐hundred eighty‐nine LSM were obtained during periods of controlled clinical status (median:15. 1 kPa , IQR :10.9–19.9) and 203 during uncontrolled status (median: 41. 1 kPa , IQR : 34.8–64.5). LSM discriminated controlled from uncontrolled status ( AUC 0.985). LSM cut‐off of 25 kPa yielded 97.5% sensitivity, 92.5% specificity, 97.6% negative predictive value and 90% positive predictive value. SSM showed good discrimination ( AUC 0.854), with values ≤ 30 kPa ruling out and > 40 kPa ruling in uncontrolled status, but accuracy was inferior to LSM . LSM values rapidly decreased following liver congestion resolution after interventional procedures. Conclusions: In BCS, LSM shows excellent concordance with clinical status and periodic assessment may facilitate clinical management. SSM provides complementary information but does not outperform LSM.

Background/Objectives: Ischemia–reperfusion injury (IRI) contributes to graft dysfunction in solid organ transplantation, with the pancreas vulnerable due to its fragile vasculature. Endothelial glycocalyx (eGCX) disruption is central to this process. This study prospectively examined perioperative endothelial injury in pancreas transplantation. Methods: Fifty-two recipients were included, of whom 47 underwent simultaneous pancreas-kidney (SPK) transplantation and 5 pancreas retransplantation. Biomarkers of eGCX degradation (syndecan-1, heparan sulfate (HS) and hyaluronan) and endothelial injury (soluble thrombomodulin, VEGF and soluble VEGFR1) were measured in plasma preoperatively, 10 min after pancreas reperfusion, 24 h later, and at discharge. Associations with donor type and early post-transplant outcomes were explored. Results: A marker endothelial injury was evident within 10 min of pancreas reperfusion, before kidney implantation, characterized by increased syndecan-1, HS, and sVEGFR1, together with decreased VEGF. Hyaluronan peaked at 24 h, consistent with a broader systemic endothelial response. Controlled donation after circulatory death donors showed higher syndecan-1 levels at 10 min PR and higher VEGF at 24 h. Seven recipients developed pancreas graft loss, which was linked to lower VEGF at 10 min post-reperfusion and lower hyaluronan levels both before surgery and at discharge. Kidney acute tubular necrosis was related with higher preoperative HS and elevated 24 h sVEGFR1. Among recipients with functioning grafts, preoperative endothelial biomarkers were linked to postoperative complications. Conclusions: Pancreas transplantation triggers early endothelial injury and glycocalyx shedding, particularly in a predominant SPK setting. Perioperative endothelial biomarkers may have a value for early risk stratification after transplantation.

Objectives Rejection is the leading cause of graft failure, and its diagnosis remains a challenge. Elastography and dynamic contrast-enhanced ultrasound (DCE-US) are novel non-invasive techniques for quantifying tissue elasticity and perfusion. Their role in pancreas graft rejection has not yet been defined. Materials and methods From October 16 to January 20, all pancreas transplantations performed at our institution were prospectively studied with elastography and DCE-US at 1 week, 3 weeks, and 12 months post-transplantation. Surveillance biopsies were performed at 3 weeks and 12 months. Elastography and DCE-US were also conducted in all requested biopsies during this period (regardless of the date of transplantation). Patients were categorized according to the biopsy result: normal/rejection. Grafts with other complications were excluded. Cut-off values were established. Results One hundred twenty-one elastography and 127 DCE-US in 56 patients were included. All parameters showed a high dispersion during the first 90 days post-transplantation. After this period, the rejection group presented higher stiffness (0.97 vs 1.46 m/s, p < 0.001) and lower perfusion. The optimal cut-off value for elastography was 1.27 m/s (AUC 0.80), and for DCE-US were: peak enhancement 601 a.u. (AUC 0.67), wash-in AUC 2748 a.u. (AUC 0.70), wash-in rate 118 a.u. (AUC 0.65), wash-in perfusion index 369 a.u. (AUC 0.67), wash-out AUC 5181 a.u. (AUC 0.69) and total AUC 6388 a.u. (AUC 0.68). A combined predictive score showed that alteration of elastography and DCE-US was associated with a 23.2-fold probability of rejection. Conclusion After the first 90 days post-transplantation, pancreas graft rejection is associated with higher stiffness and lower graft perfusion. Key Points Question Pancreas graft rejection remains a clinical challenge, as there are currently no reliable non-invasive tests for its diagnosis. Findings After the first 90 days post-transplantation, elastography and DCE-US show higher stiffness and lower pancreas graft perfusion in the presence of rejection. Clinical relevance These non-invasive tools, which can be easily integrated into daily routine practice, may be useful in identifying grafts at higher risk of rejection, allowing closer follow-up or early biopsy to establish early rejection treatment, improving graft and patient survival. Graphical Abstract

Liver transplantation (LT) remains one of the most effective treatments for hepatocellular carcinoma (HCC) and significantly enhances patient survival. However, the application of LT for HCC faces challenges owing to advancements in cancer-specific treatment modalities and the increased burden of patients’ comorbidities. This narrative review explores current controversies and advancements in LT for HCC. Key areas of focus include the management of comorbidities and patient education by advanced practice nurses, impacts of frailty on waitlists and post-LT outcomes, selection criteria for LT in the era of new downstaging tools, role of radiology in patient selection, and implications of potential immunotherapy use both before and after LT. Additionally, the importance of immunosuppression management with strategies aimed at minimizing rejection while considering the risk of HCC recurrence and the role of surveillance for HCC recurrence is highlighted. This review also underscores the importance of a multidisciplinary approach for optimizing outcomes in patients with HCC undergoing LT.

Duodeno-duodenostomy (DD) has been proposed as a more physiological alternative to conventional duodeno-jejunostomy (DJ) for pancreas transplantation. Accessibility of percutaneous biopsies in these grafts has not yet been assessed. We conducted a retrospective study including all pancreatic percutaneous graft biopsies requested between November 2009 and July 2021. Whenever possible, biopsies were performed under ultrasound (US) guidance or computed tomography (CT) guidance when the US approach failed. Patients were classified into two groups according to surgical technique (DJ and DD). Accessibility, success for histological diagnosis and complications were compared. Biopsy was performed in 93/136 (68.4%) patients in the DJ group and 116/132 (87.9%) of the DD group (p = 0.0001). The graft was not accessible for biopsy mainly due to intestinal loop interposition (n = 29 DJ, n = 10 DD). Adequate sample for histological diagnosis was obtained in 86/93 (92.5%) of the DJ group and 102/116 (87.9%) of the DD group (p = 0.2777). One minor complication was noted in the DD group. The retrocolic position of the DD pancreatic graft does not limit access to percutaneous biopsy. This is a safe technique with a high histological diagnostic success rate.

Introduction: The incidence of hepatocellular carcinoma (HCC) in Budd-Chiari syndrome (BCS) is unknown and there is no validated diagnostic work-up to define the liver nodules with arterial phase hyperenhancement (APHE), suggesting malignancy. This prospective study evaluates HCC incidence in a Western cohort of patients with BCS and assesses the performance of MRI with hepatobiliary contrast (HB-MRI) for nodule characterization. Methods: Patients with BCS followed in our hospital were prospectively evaluated by MRI with extracellular contrast (EC-MRI). Nodules with APHE categorized as non-conclusively benign by 2 radiologists were studied by HB-MRI and reviewed by 2 radiologists blinded to the EC-MRI results. A new EC-MRI 1 year later and clinical, analytical, and sonographic follow-up every 6 months for a median of 10 years was performed. Results: A total of 55 non-conclusively benign nodules with APHE were detected at EC-MRI in 41 patients. While 32 of them were suggestive of HCC by EC-MRI, all the 55 nodules showed increased uptake of hepatobiliary contrast. An unequivocal central scar was seen in 12/55 nodules at HB-MRI regardless of it was not detected on the EC-MRI. None of the nodules was hypointense in the hepatobiliary phase (HBP). HCC was not detected during a median of 10 years of follow-up. Conclusions: Detection of nodules with APHE is frequent in patients with BCS, but HCC is rare in Western patients with BCS. While EC-MRI may detect nodules suggesting malignancy, the identification of contrast uptake in the HBP at HB-MRI may help categorize them as benign.