Objective Population: Pediatric liver transplant recipients (≤18 years old), Intervention/Exposure: ABO-incompatible liver transplantation (ABO-i LT), Comparator: ABO-compatible liver transplantation (ABO-c LT), Outcomes: Patient survival rate, graft survival rate, rejection, infection, biliary complications, and vascular complications. Secondary objectives: Subgroup analysis by donor type, era and rejection. Methods In PubMed, Embase, and Cochrane databases, eligible articles were searched from inception to February 21, 2026. Outcome indicators, including patient survival rate, graft survival rate, rejection, biliary complications, infection complications, and vascular complications, were analyzed to compare the clinical effects of ABO-i LT and ABO-c LT. Quality assessment were conducted by the Newcastle-Ottawa scale (NOS). Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated by MedCalc 22.009. Results A total of 24 studies with 8940 pediatric patients were included in the meta-analysis. Compared with ABO-c LT, the 1-year, 5-year and 10-year patient survival rates of ABO-i LT were significantly lower (1-year: OR = 0.62, 95%CI: 0.49-0.77, P < 0.001; 5-year: OR = 0.64, 95%CI: 0.51- 0.81, P < 0.001; 10-year: OR = 0.62, 95%CI: 0.43- 0.90, P= 0.01). Pooled results showed that the risk of infection in ABO-i LT were significantly higher compared with this in ABO-c LT (infection: OR = 1.81, 95%CI: 1.19-2.76, P =0.006). The pooled results between the two groups showed no significant differences in the 3-year patient survival rate, graft survival rates, as well as the incidence of biliary and vascular complications. The subgroup analysis showed that 1-year, 5-year and 10-year patient survival rates of ABO-i LT were also significantly lower than those of ABO-c LT in the late-era and living donor subgroups. However, in the living donor subgroup, there were significantly lower 1-year and 5-year graft survival rates and significantly higher risk of rejection in ABO-i LT. Conclusion In spite of evidence of non-inferior graft survival, findings of poorer patient survival and increased infectious complications should concern the surgeon before opting for an ABO-i donor and this option should be reserved only for unavailable group matched donors in pediatric patients.
Background Hepatic venous outflow obstruction (HVOO) remains a persistent complication of deceased donor liver transplantation (DDLT). Established anastomotic approaches modify orifice calibre or clamping strategy but do not address the lateral orientation of the outflow reconstruction relative to the graft's natural position within the right subphrenic space. Methods We describe the right-lateralized side-to-side cavo-caval anastomosis with right hepatic vein-extended cavotomy (STSCCA-RHV). A partial side-biting clamp is applied at the right hepatic vein orifice and a 4 cm cavotomy extended inferiorly along the right lateral inferior vena cava wall, aligning the anastomosis with the graft's natural lie and eliminating the anterior hinge point implicated in midline reconstructions. We report a retrospective cohort of 121 consecutive adults undergoing primary DDLT with STSCCA-RHV, performed by a single unified surgical team across five high-volume centres in India (August 2023–August 2025). The primary outcome was clinically significant, intervention-requiring HVOO within 90 days. Results Clinically significant HVOO occurred in 2 of 121 recipients (1.6%; 95% CI 0.2–5.8%). Both cases were salvaged by single-stent endovascular intervention with no graft loss attributable to outflow failure. Veno-venous bypass was not required in any case. Median operative time was 380 min (IQR 320–440) and cold ischaemia time 185 min (IQR 160–210). Early allograft dysfunction occurred in 5.8%, primary non-function in 1.7%, and acute kidney injury (any KDIGO stage) in 33.9%, with only 3.3% reaching Stage 3. None of the 18 unplanned reoperations (14.9%) involved outflow-related indications. Ninety-day patient and graft survival were 90.1% and 89.4%, respectively. Conclusion The STSCCA-RHV achieved a low HVOO incidence, complete avoidance of veno-venous bypass, and 90-day survival outcomes consistent with contemporary DDLT benchmarks, without additional operative complexity. This anatomy-guided modification to caval reconstruction is technically simple, reproducible and warrants prospective comparative evaluation against standard piggyback and side-to-side techniques.
Background Postoperative pulmonary complications (PPCs) remain highly prevalent after liver transplantation (LT), driven by impaired preoperative respiratory reserve and early postoperative physiological instability. Incentive spirometry (IS) is widely used to promote lung expansion; however, evidence of its efficacy in LT recipients remains limited. This study evaluated the effect of adjunctive IS on arterial blood gas (ABGs) levels and early postoperative recovery in LT recipients. Methods In this prospective, randomized controlled study, 40 adults undergoing living-donor LT were assigned to standard post-transplant mobilization and breathing exercises alone (n=20) or standard exercises plus structured IS training (n=20). ABG parameters (pH, PO2, PCO2, HCO3-, and SpO2) were measured at baseline and on postoperative days 1–3. Linear mixed-effects models were used to assess group differences in ABG trajectories, and slope analyses quantified the decline and recovery phases. Secondary outcomes included ICU and hospital length of stay (LOS) and the incidence of PPCs. Results Both groups had similar baseline characteristics and comparable immediate postoperative declines in ABG values. IS significantly accelerated recovery across all ABG parameters (group×time p < 0.003), with faster improvement in pH, PO2, HCO3-, and SpO2 and higher PCO2, consistent with the enhanced ventilation. IS use was associated with earlier ICU discharge. The incidence of PPCs remained high in both groups, with no significant differences. Conclusion Adjunctive IS markedly improved early ABG normalization and shortened ICU stay in LT recipients, suggesting enhanced ventilatory efficiency and oxygenation recovery. However, this did not significantly reduce PPCs. Incorporating structured and supervised IS into early postoperative rehabilitation may provide clinically meaningful physiological benefits. Larger randomized trials are required to confirm these findings. Clinical Trial Number The Clinicaltrials.gov registration number is NCT07318766, retrospectively registered on January 5, 2026.
Introduction In the general population, vWF antigen levels are 20-30% lower in blood-group O. However, the effect of blood-group O on vWF antigen in compensated advanced chronic liver disease (cACLD) is unknown. Further, there is limited data comparing vWF with elastography for assessment of clinically significant portal hypertension (CSPH). We assessed the effect of blood-group O on vWF antigen levels, and the discriminative ability of vWF-platelet ratio (VITRO) for assessment of CSPH in comparison to liver stiffness measurement (LSM) on elastography in cACLD. Methods One-hundred patients with cACLD were prospectively included. Hemogram, blood-biochemistry, plasma vWF antigen levels, CT abdomen, LSM with vibration-controlled transient elastography, and endoscopic screening for varices were performed. CSPH was defined by the presence of collaterals on imaging, varices on endoscopy, or portosystemic pressure gradient >10 mmHg. Results vWF antigen levels were comparable between blood group O and non-O (282.9±44.6% vs 289.9±86.3%, p=0.60). vWF: antigen had significant correlation with LSM [rho:0.65 (95% CI:0.48-0.75, p<0.001)] and portosystemic pressure gradient [rho=0.60 (95% CI: 0.27-0.81, p<0.001)].AUROCs of LSM (0.878, 95% CI:0.747-0.980) and VITRO (0.881, 95% CI: 0.745-0.982, p=0.95) for detecting CSPH were comparable. Optimal VITRO rule-out and rule-in cutoffs for CSPH were <1.14 (sensitivity 95%, NPV 74.83%) and >1.93 (specificity 90%, PPV 95.85%). Proportion of patients in the indeterminate-zone using BAVENO-VII criteria (48%) was significantly higher than that with VITRO (22%, p<0.001). 81.3% patients lying in the intermediate zone using BAVENO VII criteria could be recategorized as ruled-out or ruled-in using VITRO. Conclusion Blood-group O did not affect vWF levels in our cohort of cACLD patients. VITRO holds promise as potential blood-based adjunct to elastography for assessment of CSPH and varices in cACLD. Clinical trial registration Not applicable
Background and Aims The impact of plant-based dietary patterns on liver-related outcomes, including metabolic dysfunction-associated steatotic liver disease (MASLD) and liver cancer, remains uncertain and has not been systematically assessed. We aimed to evaluate the association between plant-based diet (PBD) indices and the risk of MASLD and liver cancer in adult individuals through a systematic review and meta-analysis. Methods We searched PubMed and Embase databases from 2016 until October 31, 2025, for observational studies examining the associations of the plant-based diet index (PDI), healthy PDI (hPDI), or unhealthy PDI (uPDI) with MASLD and/or liver cancer. Study-level data were extracted using a standardized form. Adjusted odds ratios (aORs) or hazard ratios (aHRs) were pooled using random-effects meta-analysis. Results Thirteen studies (∼1.2 million adults) were included. In non-longitudinal studies, higher adherence to PDI and hPDI was associated with lower odds of prevalent MASLD (PDI: aOR=0.85, 95%CI: 0.74 to 0.96; hPDI: aOR=0.76, 95%CI: 0.71 to 0.80), whereas higher uPDI was associated with greater odds (aOR=1.32, 95%CI: 1.21 to 1.43). In longitudinal studies, higher adherence to PDI and hPDI was associated with a reduced risk of incident MASLD (PDI: aHR=0.82, 95%CI: 0.70 to 0.95; hPDI: aHR=0.70, 95%CI: 0.62 to 0.79), while higher uPDI increased risk (aHR=1.24, 95%CI: 1.10 to 1.40). Higher adherence to PDI and hPDI was associated with a lower risk of liver cancer (PDI: aHR=0.78, 95%CI: 0.67 to 0.92; hPDI: aHR=0.71, 95%CI: 0.60 to 0.84), whereas higher uPDI increased risk (aHR=1.34, 95%CI: 1.04 to 1.73). Heterogeneity was low to moderate. Conclusions Higher adherence to healthy PBDs is associated with lower risks of MASLD and liver cancer, while unhealthy PBDs have the opposite pattern of association. Although the evidence base is observational and causality cannot be inferred, these findings support further investigation of nutrient-rich, minimally processed plant foods in hepatology and public health.
Background Quality of life (QoL) is significantly impaired by chronic liver disease (CLD) due to socioeconomic, psychological, and physical reasons. In a cohort of Egyptian cirrhosis patients, this study evaluated QoL determinants and their association with mental health. Methods In this cross-sectional study at the National Liver Institute (from January to May 2024), 197 cirrhotic patients completed the Chronic Liver Disease Questionnaire (CLDQ) and Depression Anxiety Stress Scales–21 (DASS-21). Child-Pugh and Model for End-Stage Liver Disease (MELD) scores were used to assess disease severity. Spearman correlation, Mann-Whitney U, and Kruskal-Wallis tests evaluated nonparametric data, and ridge and gamma regressions determined QoL predictors. Results The median age was 62.0 [11.0] years; most had compensated cirrhosis and mild disease severity. Substantial psychological distress was observed, with (mild to very severe) depression, anxiety, and stress reported in 31.0%, 40.6%, and 21.8%, respectively. Significant negative correlation was found between CLDQ scores and all DASS-21 domains (ρ (rho)= -0.625 to -0.697). Poorer QoL was independently associated with higher DASS subscale scores (all p < 0.001), ascites (ridge -0.627; unit-gamma EXP(B) 0.37, p < 0.001), and moderate-severe Child-Pugh class (ridge -0.300, p = 0.020; EXP(B) 0.50, p < 0.001). Better QoL was associated with health insurance (ridge 0.280, p = 0.027; EXP(B) 1.40, p = 0.040) and more rooms (ridge 0.179, p = 0.053; EXP(B) 1.53, p < 0.001). Conclusion QoL in Egyptian cirrhotic patients is significantly affected by psychological distress, disease severity, and socioeconomic factors, highlighting the need for integrated biopsychosocial management approaches.
Introduction Endoscopic ultrasound-guided liver biopsy (EUS-LB) is an emerging alternative to percutaneous liver biopsy (PC-LB), offering simultaneous assessment of varices and portal pressure and reduced patient discomfort. Prospective data comparing the two are limited. Methodology In this prospective cohort study at a tertiary centre, consecutive patients undergoing EUS-LB with 19G fine-needle biopsy (FNB) needle or PC-LB for parenchymal liver disease were enrolled. Exclusions: grade 2/3 ascites, INR >1.5, platelets <50,000/mm3, inability to stop anticoagulation, and pregnancy. Technique was decided after discussion with patient. Primary outcome was sample adequacy defined as aggregate sample length (ASL) ≥20 mm and ≥11 complete portal triads (CPT). Secondary outcomes: ASL, longest core (LC), CPT count and adverse events. Results Of the sixty patients included (EUS-LB n=30; PC-LB n=30), platelet counts were higher in those who underwent EUS-LB, rest of the blood parameters being similar . Deranged liver enzymes were the predominant indication (EUS-LB 63%, PC-LB 83%). Adequate samples were obtained in 100% of EUS-LB versus 57% of PC-LB cases (p<0.001). EUS-LB yielded greater ASL (5.4 ± 1.6 cm vs 4.0 ± 1.9 cm; p=0.002), LC (2.1 ± 0.8 cm vs 1.4 ± 0.6 cm; p=0.001), and more CPT [median 15 (IQR 12.5–18) vs 12 (IQR 8.2–16); p=0.01]. Immediate post-procedure pain scores were lower with EUS-LB [median 1 (0–2) vs 4 (4–6); p<0.001]. No major complications occurred; puncture-site bleed occurred in 2 (6.6%) EUS-LB patients and was controlled endoscopically. Conclusion EUS-LB is a feasible alternative to PC-LB with a comparable diagnostic yield, lesser immediate post procedure discomfort and comparable safety profile.
Background and aim Peripheral neuropathy (PN) and restless leg syndrome (RLS) are common in patients with cirrhosis. We report the PN profile in cirrhosis, both with and without RLS. Methods This cross-sectional study included non-diabetic adults (aged >18 years) with cirrhosis, who were screened for RLS. Participants with recent (<4 weeks) deterioration of liver disease, hemodynamic instability, overt neuropathy, any neurological illness, pregnancy, chronic kidney disease, use of psychotropic drugs, or uncontrolled systemic illness were excluded. RLS was diagnosed using standard criteria. Nerve conduction studies (NCS) were performed and evaluated using Keypoint EMG/NCS/EP workstation (Dantec, Skovlunde, Denmark) with a standard protocol for all participants. Motor NCS were recorded in the median, ulnar, and common peroneal nerves (CPN). Sensory NCS were performed using the antidromic technique on the median, ulnar, and sural nerves. PNs were grouped as demyelinating /axonal/combined and motor/sensory/combined. Numerical and categorical variables were summarized as median (interquartile range) and proportions (percentage). Results Among 97 patients (69.1% male; age 52 [44-60] years; CTP-A/B/C 46.4%/47.4%/6.2%), 27.8% had RLS. PN was present in 53.6% (65.4% motor, 13.5% sensory, 21.1% combined). The incidence of PN in CTP-A/B/C was 57.8%/50%/50% (p=0.746). PN was present in 48.2% of patients with RLS and 55.7% of those without RLS (p=0.503). The distribution of demyelinating/axonal/combined neuropathies, as well as motor /sensory/combined neuropathy, was comparable between those with and without RLS. Conclusions PN is frequently detected in patients with cirrhosis, with motor involvement more common than sensory neuropathy. In this cohort, the presence or type of PN was not associated with RLS.
Background and Aims Altered mental status (AMS) is common in cirrhosis patients. While hepatic encephalopathy (HE) is the most frequent cause, non-hepatic causes like sepsis, metabolic disturbances, brain lesions, and toxins may coexist and affect outcomes. This study evaluated the causes and role of non-contrast computed tomography (NCCT) head in cirrhosis patients with AMS and mortality. Methods In this prospective study, 116 cirrhotic patients with index AMS were enrolled over 18 months. The etiologies were categorised as hepatic, infectious, metabolic, structural lesions of the brain, toxic, or multifactorial based on clinical evaluation, laboratory investigations, and NCCT of the head. The diagnostic yield of NCCT of the head was evaluated in all patients with AMS. Mortality was assessed during hospitalisation, at 30 and 90 days. Results Hepatic encephalopathy accounted for 54.3% of AMS, while non-hepatic causes accounted for 45.7%; sepsis (20.7%) and metabolic abnormalities (14.7%) were the predominant non-hepatic causes, followed by structural brain lesions (5.2%), toxins (1.7%), and multifactorial etiologies (3.5%). Six patients had focal neurological deficits with structural brain lesions on NCCT head scans; NCCT did not show any acute clinically relevant intracranial pathologies in all patients without focal deficits or structural lesions. Overall mortality in the study population was 29.31%, 33.33% with HE, and 24.53% among those with other causes of AMS. Conclusions Among patients with liver cirrhosis presenting with index AMS, hepatic encephalopathy was the most common etiology, and non-HE causes of AMS were present in nearly half of the presentations. Sepsis and metabolic abnormalities predominate among patients with non-HE causes. Mortality was numerically higher in HE patients and was highest in those with brain structural lesions. Routine NCCT head imaging has low diagnostic yield in patients with AMS without focal neurological deficits. Clinical Trial Registry of India CTRI/2025/05/087896
Objectives Liver Transplant (LT) is lifesaving for patients with biliary atresia (BA), either primary or post-Kasai Portoenterostomy (KPE), but comparative data are limited. Aim was to compare the clinical profile, peri-transplant course, and survival at 3 months after transplant among children of BA with LT primarily or after KPE Method Single-center retrospective study with electronic medical records of all the BA children with liver transplant between January 2016 and December 2021 were included. Demographic, clinical, laboratory parameters, peri-transplant course, and 3-month survival were compared between primary and post-KPE groups Results One hundred children of BA (53% male), median age at LT- 12(range 11-17) months, and 29% post KPE with living donor liver transplant (LDLT) were analyzed. Post-KPE group of children were older at LT [14 (range 12-14.5) versus 12 (range 11-16) months], p= 0.004, had frequent cholangitis (17.2% versus 1.4%, p=0.008) before LT. Those with primary LT (PLT) were older at their first presentation at the time of diagnosis [60(15-150) vs 45(21-60) days of life, p<0.001], and had ascites (78.9% versus 51.7%, p=0.008) before LT. PELD score was high (26.9±8.2 versus 27.6±9.9, p=0.78) in both groups at LT. Duration of surgery, post-transplant complications like bile leaks, bleeding, hemorrhagic/chylous ascites, vascular complications, and sepsis were comparable in both the groups. The surgical re-exploration rate was higher with post-KPE (34.5% versus 18.3%, p=0.08), but with a comparable 3-month post-transplant mortality (6.89% versus 14.1%, p=0.54). Conclusion LT for biliary atresia has a comparable peri-transplant course and survival, irrespective of whether it is primary LT or post-Kasai portoenterostomy.
Introduction and Objectives: Hepatitis C virus (HCV) infection is a major risk factor for hepatocellular carcinoma (HCC). Substitutions at residue 70 of the HCV core protein (R70Q/H) have been associated with advanced liver disease and increased HCC risk, particularly in genotype 1b. This study aimed to determine the prevalence of the 70Q/H mutation and its association with clinical and biochemical markers of liver injury. Methods Eighty-seven HCV-infected patients were evaluated prior to antiviral treatment. Clinical data, imaging studies, liver enzymes (ALP, GGT, ALT, AST), serological markers (AFP, PIVKA-II), and fibrosis indices (APRI, FIB-4, Child-Pugh) were collected. Viral RNA was sequenced and analyzed to determine its genotype (G) and presence of R70Q/H substitutions. Results Genotype distribution was 56.3% (49) G1a, 34.5% (30) G1b, and 9.2% (8) G2. The overall prevalence of the 70Q/H mutation was 27.6% (24/87; 95% CI, 18.5-38.2%), detected exclusively in G1a (30.6%) and G1b (30.0%). Patients carrying the mutation showed significantly (p≤0.05) higher APRI, FIB-4, ALP, GGT, AFP and PIVKA-II levels compared with wild-type carriers. In univariate analysis, elevated ALP, GGT, FIB-4, and AFP were associated with the presence of the 70Q/H mutation; however, none remained significant in multivariate analysis. Conclusions The 70Q/H substitution was frequent in HCV genotypes 1a and 1b in the group of patients studied and was associated with surrogate markers of advanced liver disease and increased HCC risk.
Background Non-alcoholic fatty liver disease (NAFLD) frequently coexists with obesity and type 2 diabetes (T2D), and the presence of these metabolic conditions contributes to substantial heterogeneity in disease progression and metabolic dysfunction. Gut microbiota and their derived metabolites are increasingly recognized as important mediators linking NAFLD with systemic metabolic disorders; however, how overweight and T2D differentially shape gut microbiota–metabolite alterations in NAFLD under complex clinical conditions remains unclear. Methods In this study, 66 patients with NAFLD (including 27 with T2D) and 26 healthy controls were enrolled. All participants underwent liver ultrasound–based assessment, biochemical testing, and fecal sample collection on the same day. Gut microbiota composition was analyzed using 16S rRNA gene sequencing, and fecal metabolites, including short-chain fatty acids and bile acids, were quantified using LC–MS/MS. Participants were stratified according to overweight and diabetes status to compare microbiota and metabolite profiles across metabolic subgroups. Results Distinct alterations in gut microbiota and metabolites were observed among NAFLD patients with different metabolic conditions. Patients with T2D showed a butyrate-related pattern in exploratory analysis, including nominally lower butyrate and isobutyrate levels and lower abundance of several butyrate-producing genera, particularly Lachnospira, Roseburia, and Anaerostipes, compared with non-diabetic NAFLD patients. Faecalibacterium was lower in NAFLD patients than in healthy controls but did not show a clear diabetes-specific decrease. Bile acid–related metabolites and associated bacterial taxa also showed exploratory patterns in diabetic NAFLD patients. Overall, diabetes was associated with more evident gut microbiota differences and exploratory metabolite patterns than overweight alone within the NAFLD population. Conclusion Under complex clinical conditions, overweight and T2D were associated with different gut microbiota profiles and exploratory metabolite patterns in patients with NAFLD, with diabetes showing a stronger association than overweight alone. These exploratory findings highlight the importance of considering metabolic comorbidities when interpreting gut microbiota–metabolite changes in imaging-defined NAFLD and provide preliminary insight into microbial–metabolic patterns underlying disease heterogeneity.
Polycystic liver disease (PLD) comprises hereditary disorders characterized by the progressive cystic replacement of liver parenchyma, leading to variable degrees of hepatomegaly and potential liver dysfunction. Depending on the affected gene, it may appear as isolated autosomal dominant polycystic liver disease (ADPLD) or in association with renal cysts as autosomal dominant or recessive polycystic kidney disease (ADPKD/ARPKD). This scoping review analyzed the genetic, pathophysiological, and therapeutic aspects of PLD in PKD1 and PKD2 mutation carriers, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and including 29 relevant studies published between 2014 and 2024. Several included studies suggested an association between PKD1 and PKD2 mutations and differences in disease severity and hepatic cyst burden, confirming their central role in the molecular pathogenesis of PLD. Current therapeutic strategies primarily rely on somatostatin analogs, which have demonstrated benefits in reducing liver volume and symptom burden in selected patients, whereas mechanistic target of rapamycin (mTOR) inhibitors have shown variable and modest results and remain under continued investigation. Surgical interventions, such as cyst fenestration, hepatic resection, or transplantation, are reserved for advanced cases. Emerging therapies targeting molecular pathways and personalized approaches show promise for future clinical application. Advances in genetics and molecular biology have enhanced the understanding of hepatic cystogenesis and provide the basis for the development of precision treatments and standardized clinical management protocols for patients with PLD.
