AIM:to assess the effectiveness and safety of Risankizumab (RZB) in a large, nationwide real-world cohort of Crohn's disease (CD) patients. METHODS:We conducted a multicentre, retrospective observational cohort of adults initiating RZB with assessments at weeks 12, 26, and 52. Co-primary endpoints were (i) week-12 steroid-free clinical remission (SFCR) (HBI <5 in the absence of systemic corticosteroids or budesonide) and (ii) week-52 endoscopic remission (SES-CD 0-2 or Rutgeerts i0-i1 post-operatively). The main effectiveness analysis was as-observed; a preplanned sensitivity analysis included patients expected to reach week-52 before database lock and applied non-responder imputation. RESULTS:We included 520 patients, 45.0% failed ≥3 and 54.8% were ustekinumab-exposed. At week 12, clinical response was 76.5% and 60.8% achieved SFCR. By week 52, SFCR was 65.6%; endoscopic remission occurred in 37.5%, while radiologic remission and transmural healing were 24.6% and 9.8%, respectively. Ustekinumab-naïve patients showed significantly superior early clinical outcomes (week-12 SFCR: 69.8% vs 53.3%) and a higher rate of endoscopic remission at week 52 (56.5% vs 28.6%) compared with ustekinumab-exposed patients. Notably, week-52 effectiveness was comparable between patients with 2 and those with ≥3 prior failures. Extra-intestinal manifestations decreased over time, while perianal disease improved modestly. In the sensitivity cohort (N = 213), SFCR was 47% at week-52. Risankizumab was well-tolerated with no new safety signals identified. CONCLUSIONS:In a large, refractory, real-world CD population, RZB induced rapid and sustained favorable clinical, endoscopic, and radiologic outcomes. Importantly, one-year effectiveness was similar in patients with 2, and ≥3 prior failures, supporting RZB as a valuable option for a refractory population.

Crohn’s disease (CD) is a chronic, relapsing inflammatory disorder often resistant to therapies. While upadacitinib (UPA) has shown promise in registration trials, real-world data are scarce. UPGRADE-CD study, promoted by IG-IBD, was designed to assess UPA effectiveness and safety in refractory CD. This is a preliminary analysis of a prospective, multicenter, observational study enrolling consecutive adults patients with refractory CD from Italian referral centers. Patients were treated with UPA and evaluated with standardized clinical (Harvey-Bradshaw Index, HBI), endoscopic (Simple Endoscopic Score for Crohn’s Disease, SES-CD), and biochemical [C-Reactive Protein (CRP), fecal calprotectin] parameters at baseline, 3, and 6 months; 12-month follow-up data collection is still ongoing. Primary endpoints: clinical response (HBI decrease ≥3), clinical remission (HBI < 5), and their steroid-free equivalents. Secondary endpoints were endoscopic improvement (≥50% SES-CD reduction or ≥ 2-point drop if baseline SES-CD = 4) and endoscopic remission (SES-CD ≤ ssss2). Dropouts were counted as non-responders from discontinuation onward, and missing data excluded. Analyses were performed using R software. Overall, 309 patients were included. Demographics characteristics are reported in Table 1. Clinical response rates remained high at 3 and 6 months (58.3% and 62.1%, p < 0.001). Clinical remission showed similar proportions (54.7%, 57.5% p < 0.001). Steroid-free clinical response was achieved in 52.5% at 3 months and 51.1% at 6 months, whereas steroid-free clinical remission rates were 47.9% and 46.6% at 3 and 6 months, respectively. Endoscopic improvement increased over time from 20.0% at 3 months to 43.5% at 6 months (p < 0.001), with endoscopic remission occurring in 40.1% of patients at 6 months (p < 0.01). Mean fecal calprotectin remained above normal but trended lower (from 986.7± 1619.9 at baseline to 362.0 ± 743.3 at 6 months, p < 0.001). Mean CRP levels declined significantly over time (from 62.3±197.4 mg/L at baseline to 17.1±37.2 mg/L at 6 months, p < 0.001). UPA was discontinued in 18 patients by month 3 and 21 patients by 6 months due to inefficacy or adverse events (6/18 and 7/21 at 3 and 6 months, respectively). In this preliminary real-world analysis, UPA induced high clinical and steroid-free remission rates and improved endoscopic outcomes over 6 months in refractory CD, with a favorable safety profile and low discontinuation rates. Extended follow-up will clarify long-term effectiveness and safety. Conflict of interest: Barberio, Brigida: Brigida Barberio: has served as speaker for Abbvie, Agave, Alfasigma, AGpharma, Johnson & Johnson, Eli Lilly, MSD, Pfizer, Procise, Sofar, Takeda, Unifarco. BB has served as consultant for Abbvie, Eli Lilly, ohnson & Johnson. Scaldaferri, Franco: Consultancy fee/board for Janseen, Takeda, Pfizer, MSD, Sandoz, Galapagos, Celltrion, Ferring, Abbvie, Lilly, Alfasigma, Abivax Bezzio, Cristina: Personal Fees: I received consulting/advisory board/lecture fees from Alfa Sigma, AbbVie, Celltrion, Eli Lilly, Ferring, Gilead, Johnson & Johnson MSD, Pfizer and Takeda Dragoni, Gabriele: Grant: ECCO Grant 2020 ECCO/AOCC Travel Grant 2021 ECCO IIS Registry Grant 2023 ECCO/IBUS Research Grant 2023 Personal Fees: - Speaker’s fees from: 2020: Novartis 2022: Janssen 2023: Alfasigma, Janssen, Pfizer, and Takeda 2024: Ferring, Johnson & Johnson, Eli Lilly, Pfizer, and Takeda 2025: Abbvie, Alfasigma, Ferring, Eli Lilly, LionHealth, Pfizer, Takeda - Advisory board fees from: 2023: Celltrion Healthcare and Pfizer 2024: AbbVie 2025: AbbVie, Johnson & Johnson Viola, Anna: No conflict of interest Todeschini, Alessia: The author has served as a consultant and/or received lecture fees from Abbvie, Alfasigma, Celltrion, Johnson & Johnson, Ely Lilly, Ferring, Lion Health,Takeda. Principi, Maria Beatrice: No conflict of interest Onali, Sara: Consultant/lecture fees to: Abbvie, Alfasigma, MSD, Takeda, J & J, Galapagos, Pfizer, Eli Lilly D’Amico, Ferdinando: Grant: ECCO fellowship grant 2020 ECCO grant 2021 Personal Fees: F D’Amico has served as a speaker for Abbvie, Alfasigma, Ferring, Lilly, Sandoz, Janssen, Fresenius Kabi, Galapagos, Giuliani, MSD, Pfizer, Takeda, Tillotts, and Omega Pharma he also served as an advisory board member for Abbvie, AnaptysBio, Ferring, Fresenius Kabi, Galapagos, Janssen, Lilly, MSD, Takeda, and Nestlè. Viganò, Chiara: Consultancy and lecture fees from: AbbVie, Galapagos, Janssen-Cilag, Johnson & Johnson, Pfizer, Takeda, Celltrion, Alfasigma, Eli Lilly and research grant from Celltrion and Pfizer. Cappello, Maria: None Mocci, Giammarco: No conflict of interest Viscido, Angelo: none Bodini, Giorgia: No conflict of interest Ribaldone, Davide Giuseppe: Davide Giuseppe Ribaldone declares the following paid consultancies, lecture fees for the past two years: Johnson & Johnson, Takeda, Celltrion, Alfasigma, Pfizer, Eli Lilly, Abbvie, Sandoz Marafini, Irene: Irene Marafini served as advisory board member for Abbvie, Eli Lilly, Galapagos and received speaker honoraria from Abbvie and Eli Lilly Pugliese, Daniela: Consultant/Lectures fees from: AbbVie, Takeda, Johnson, Pfizer, Alfasigma, MSD, Lilly, Celltrion. Massari, Alessandro: No conflict of interest Saibeni, Simone: Consultancy, lecture fees, and advisory board for AbbVie, Alfasigma, Arena, Eli Lilly, Ferring, Galapagos, Gilead, Janssen, Johnson & Johnson, MSD, Pfizer, and Takeda. Pastorelli, Luca: Luca Pastorelli served as consultant for Giuliani, received lecture fees and/or advisory board fees from Abbvie, Takeda, Ferring, Pfizer, Sandoz, Janssen, Johnson & Johnson, Galapagos, Arena, Eli-Lilly Rizzello, Fernando: No conflict of interest Bergna, Irene Maria Bambina: None Gravina, Antonietta Gerarda: Gravina AG has conducted training activities [e.g. educational continuing medical activities (ECM), preceptorship] for Pfizer, Galapagos Biopharma, and AbbVie. Desideri, Federico: No conflict of interest Merli, Manuela: No conflict of interest Bertani, Lorenzo: No conflict of interest Spagnuolo, Rocco: no Imperatore, Nicola: None to declare Ferracane, Concetta: nothing to declare Quadarella, Alessandro: I have no conflict of interest. Di Luna, Imma: No conflict of interest Tortorella, Vincenza: Nessuno Mazzuoli, Silvia: No conflict of interest Felice, Carla: Advisory board for AbbVie, MSD, J & J. Balestrieri, Paola: Advisory board for Alfasigma- Janssen- Abbvie- Takeda- Eli Lilly Balducci, Daniele: none Aratari, Annalisa: Consultant or Advisory board member (in the last two years) for Takeda,Abbvie,Pfizer,Galapagos De Barba, Caterina: No conflict of interest Zingone, Fabiana: No conflict of interest Savarino, Edoardo Vincenzo: Personal Fees: Takeda, Abbvie, MSD, Janssen, Sofar

Background and aims The purpose of this study was to present data on the safety of anti- severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination in a cohort of inflammatory bowel disease (IBD) patients of an ongoing multicenter study (ESCAPE-IBD) sponsored by the Italian Group for the study of Inflammatory Bowel Disease (ClinicalTrials.gov Identifier: NCT04769258). Methods Anti-SARS-CoV-2 vaccination was administrated to 809 IBD patients. Interviews were conducted to report adverse events related to vaccination. Of these 809, 346 patients were surveyed on the pandemic burden and the main reason for hesitancy in coronavirus disease 2019 vaccination. The chi-square test was used to compare categorical variables. Logistic regression was used to assess the relationship between disease-related characteristics and the onset of adverse events. Results About 45% of patients had at least one side effect, following the first dose (10%), the second (15%), and both doses (19%). All the adverse events were mild and lasted only a few days. Logistic regression analysis revealed that female sex (P < 0.001), younger age (P = 0.001), seroconversion (P = 0.002), and comorbidity (P < 0.001) were significantly associated with adverse events. The survey showed that the main concerns were the possibility of adverse event (33%). Almost all patients (99%) felt safer having been vaccinated at their IBD reference center. Conclusion The vaccine reactions experienced in IBD patients were mostly self-limited. We found high acceptance and good safety of SARS-CoV-2 vaccination in our cohort.

BACKGROUND:Patients on immunosuppressive drugs have been excluded from COVID-19 vaccines trials, creating concerns regarding their efficacy. AIMS:To explore the humoral response to COVID-19 vaccines in patients with inflammatory bowel disease (IBD) METHODS: Effectiveness and Safety of COVID-19 Vaccine in Patients with Inflammatory Bowel Disease (IBD) Treated with Immunomodulatory or Biological Drugs (ESCAPE-IBD) is a prospective, multicentre study promoted by the Italian Group for the study of Inflammatory Bowel Disease. We present data on serological response eight weeks after the second dose of COVID-19 vaccination in IBD patients and healthy controls (HCs). RESULTS:1076 patients with IBD and 1126 HCs were analyzed. Seropositivity for anti-SARS-CoV-2 IgG was reported for most IBD patients, even if with a lesser rate compared with HCs (92.1% vs. 97.9%; p<0.001). HCs had higher antibody concentrations (median OD 8.72 [IQR 5.2-14-2]) compared to the whole cohort of IBD patients (median OD 1.54 [IQR 0.8-3.6]; p<0.001) and the subgroup of IBD patients (n=280) without any treatment or on aminosalicylates only (median OD 1.72 [IQR 1.0-4.1]; p<0.001). CONCLUSIONS:Although most IBD patients showed seropositivity after COVID-19 vaccines, the magnitude of the humoral response was significantly lower than in HCs. Differently from other studies, these findings seem to be mostly unrelated to the use of immune-modifying treatments (ClinicalTrials.govID:NCT04769258).

BACKGROUND & AIMS: Nonpedunculated colorectal polyps are normally endoscopically removed to prevent neoplastic progression. Delayed bleeding is the most common major adverse event. Clipping the resection defect has been suggested to reduce delayed bleedings. Our aim was to determine if prophylactic clipping reduces delayed bleedings and to analyze the contribution of polyp characteristics, extent of defect closure, and antithrombotic use. METHODS: An individual patient data meta-analysis was performed. Studies on prophylactic clipping in nonpedunculated colorectal polyps were selected from PubMed, Embase, Web of Science, and Cochrane database (last selection, April 2020). Authors were invited to share original study data. The primary outcome was delayed bleeding <= 30 days. Multivariable mixed models were used to determine the efficacy of prophylactic clipping in various subgroups adjusted for confounders. RESULTS: Data of 5380 patients with 8948 resected polyps were included from 3 randomized controlled trials, 2 prospective, and 8 retrospective studies. Prophylactic clipping reduced delayed bleeding in proximal polyps >= 20 mm (odds ratio [OR], 0.62; 95% confidence interval [CI], 0.44-0.88; number needed to treat = 32), especially with antithrombotics (OR, 0.59; 95% CI, 0.35-0.99; number needed to treat = 23; subgroup of anticoagulants/double platelet inhibitors: n = 226; OR, 0.40; 95% CI, 0.16-1.01; number needed to treat = 12). Prophylactic clipping did not benefit distal polyps >= 20 mm with antithrombotics (OR, 1.41; 95% CI, 0.79-2.52). CONCLUSIONS: Prophylactic clipping reduces delayed bleeding after resection of nonpedunculated, proximal colorectal polyps >= 20 mm, especially in patients using antithrombotics. No benefit was found for distal polyps. Based on this study, patients can be identified who may benefit from prophylactic clipping.

The search of biochemical markers useful for the management of inflammatory bowel disease (IBD) patients in clinical practice is an important issue [1]. Hypergammaglobulinemia (HGG) is commonly described in patients with autoimmune, infective or inflammatory disorders, where an increment of antibodies production is observed. No data are available for the prevalence and clinical significance of HGG in IBD patients. We conducted a retrospective cross-sectional study including IBD patients referred to the S. Andrea Hospital in Rome, Italy, in an outpatient visit, between January 2013 and December 2014. Inclusion criteria were: firm diagnosis of IBD [ulcerative colitis (UC) or Crohn’s disease (CD)], and complete records of clinical [age, sex, localization, comorbidities, extraintestinal manifestations (articular, dermatologic or ocular IBD-related diseases diagnosed by specialist), disease activity] and biochemical [hemoglobin, C reactive protein, presence of HGG (defined as polyclonal increment of the gammaglobulins level above the normal lab-reported value)] parameters. From a total of 388 IBD patients, 81 patients were excluded (uncertain diagnosis 12, lack of data 64, monoclonal HGG 3, multiple myeloma 1, autoimmune thrombocytopenia 1) and 307 patients were finally considered (UC 212, CD 95). First, the prevalence of HGG was calculated, and clinical and biochemical features in patients with and without HGG were compared by t-test and chi-squared test for parametric and non parametric data, respectively. Hypergammaglobulinemia was found in 46/307 (15%) of IBD patients [CD: 11/95 (12%), UC: 35/212 (17%)]. IBD patients with HGG had higher prevalence of extraintestinal manifestations [13/46 (28%) vs. 33/261 (12%), p<0.05)]. Therefore, we focused on all IBD patients with extraintestinal manifestations, representing a total of 27/95 (28%) with CD, and 19/212 (9%) with UC. In details, LETTERS TO THE EDITOR

L’innovazione tecnologica degli ultimi anni ha permesso di raggiungere due importanti obiettivi: 1) realizzare una diagnostica avanzata, in grado di predire, con buona accuratezza e con la semplice osservazione endoscopica, la natura di una lesione; 2) migliorare l’approccio terapeutico delle lesioni, estendendo le indicazioni al trattamento endoscopico, mini-invasivo, anche a lesioni in passato inviate al trattamento chirurgico. La diagnostica avanzata è stata realizzata con l’introduzione di endoscopi ad alta definizione e della cosiddetta “cromoendoscopia virtuale”. L’innovazione terapeutica è, invece, rappresentata dalla dissezione sottomucosa (ESD), che permette l’asportazione in blocco delle lesioni, in modo da garantire una più accurata valutazione istologica del livello d’infiltrazione della lesione e della radicalità della resezione. Queste metodiche diagnostiche e terapeutiche hanno trovato applicazione nell’esofago di Barrett, nell’early gastric cancer e nelle lesioni neoplastiche del colon-retto. Nell’ambito della prevenzione del cancro colo-rettale, inoltre, la letteratura degli ultimi anni ha posto grande attenzione alla definizione dei requisiti necessari per realizzare una colonscopia efficace e sicura, la cosiddetta “colonscopia di qualità”, per la quale si sono definiti indicatori e standard di riferimento.

In Inflammatory Bowel Disease (IBD), the pro-inflammatory cytokine TNFα plays a pivotal pathogenetic role, and the use of antiTNFα biologic agents is an effective therapeutical option in such patients [1]. Despite the overall good safety profile, these drugs may produce unfavorable adverse events in particular, since TNFα in HBV patients may suppress viral replication, and then its inactivation might theoretically lead to viral reactivation and/or enhanced viral replication, with potential worsening of liver disease [2]. However, the effects of anti-TNFα on liver function in cirrhosis are largely unknown. Anti-TNFα drugs have been reported to cause acute drug induced liver injury or fulminant hepatitis per se, as described in a few cases [3]. The mechanism by which the anti-TNFα can produce such severe side effects is unknown, but dose dependent toxicity is unlikely, since the injury can occur even after the first administration [4]. Very few data are available on the utilization of TNFα agents in chronic hepatitis and to date, no trials are available on IBD patients treated with these drugs in cirrhosis set. In rheumatology, treatment with anti TNF alfa in a cirrhotic has been only described in one case report, a patient with alfa1antitripsin deficiency-related disease successfully treated with adalimumab for severe psoriasis, after infliximab discontinuation due to thrombocytopenia [5]. In patients with serological signs of current or past HBV infection, reports of viral reactivation and development of liver-related morbidity and mortality have been described because of anti TNF treatment [6]. Overt or occult HBV infection does affect the management of patients undergoing immunosuppression for therapeutic purposes [7]. These patients, including those receiving anti TNF treatment or even prolonged, high dose glucocorticoids, should undergo HBV screening, since it is possible to plan effective management when this condition is detected [8]. Several studies evaluated HBV reactivation rate during anti TNFα treatment and lack of antiviral prophylaxis/treatment was one of the factors associated with this event [9,10]. The American College of Rheumatology guidelines state [11] that TNFα blocking agents are contraindicated in the presence of significant liver injury (Child B/C stage), without clear indication for compensated cirrhosis (Child A) and coexistence of chronic HBV infection, and the European League Against Rheumatism (EULAR) indicates that these drugs should be generally avoided in patients with HBV. However, the European Crohn’s and Colitis Organization (ECCO) guidelines state that immunomodulators are not contraindicated in HBV-infected patients. The guidelines recommend that HBsAg-positive patients should be treated with specific anti-viral agent before, during, and for at least 12 months after immunomodulation treatment has ceased [12]. In IBD patients, the available literature provided only a case [13] of a patient with compensated, HBV-related cirrhosis that underwent safely two lines of anti-TNFα (infliximab and adalimumab) for ulcerative colitis, without any liver or drug related side-effects suggesting that infliximab and adalimumab could represent a safe option in patients with compensated, HBV-related cirrhosis when adequate anti-viral management is applied. Thus, even if to date there are no randomized controlled trials evaluating the effectiveness of prophylaxis/treatment of HBV reactivation in anti-TNFα treated patients, the available literature [8,14] supports the notion that the appropriate management of chronic active HBV infection (antiviral treatment) might allow the patient to receive the best treatment of his underlying disease, improving its quality of life and minimizing the risks potentially severe effects due to viral reactivation.

The importance of the endoscopic evaluation in inflammatory bowel disease (IBD) management has been recognized for many years. However, the modalities for reporting endoscopic activity represent an ongoing challenge. To address this, several endoscopic scores have been proposed. Very few have been properly validated, and the use of such tools remains sub-optimal and is mainly restricted to clinical trials. In recent years, a growing emphasis of the concept of 'mucosal healing' as a prognostic marker and therapeutic goal has increased the need for a more accurate definition of endoscopic activity in both ulcerative colitis (UC) and Crohn's Disease (CD). In the present review, the evolution of the challenges related to endoscopic scores in IBD has been analyzed, with particular attention paid to the renewed relevance of endoscopic activity in recent years. Currently, despite the growing relevance of endoscopic activity, evaluating this activity in IBD is still a challenge. The implementation of efficacious endoscopic scores and a better definition of the absence of activity (mucosal healing) are needed.

Recent-years technological innovation has achieved two important objectives: 1) to develop advanced diagnostic tools able to determine with a fair degree of accuracy the nature of a lesion by means of the simple endoscopic observation; 2) to improve the therapeutic approach to lesions, by extending the least-invasive endoscopic treatment also to lesions that in the past were referred to surgery. Advanced diagnostic methodologies have been achieved thanks to the introduction of high definition endoscopes and virtual chromo-endoscopy. Therapeutic innovation is represented by endoscopic sub-mucosal dissection (ESD) that enables the "en bloc" resection of the lesions, thus ensuring a more accurate histological evaluation of their level of infiltration and of the radicality of the resection. These diagnostic and therapeutic methodologies have been applied intensively in Barrett's esophagus, in the early gastric cancer and in the neoplastic lesions of colon-rectum. Concerning the screening of colon-rectum cancer, recent-years literature concentrated on defining the minimal necessary requirements to perform an effective and safe colonoscopy, the so-called "quality endoscopy", for which reference indicators and standards have been set.

The occurrence of pneumoperitoneum after a percutaneous transhepatic intervention is an exceptionally rare event. Generally it resolves spontaneously or with minimally invasive management even in symptomatic conditions (pneumoperitonitis); resorting to surgical approach is exceptional. What is still unclear is the question as to whether the airflow has an intestinal or atmospheric source. Our report lends support to the former hypothesis, as argued hereafter. A 60-year-old woman with inoperable adenocarcinoma of the pancreatic head was referred to our surgical evaluation for the development of abdominal distension and right hypochondrial pain. Two days before, as jaundice treatment, a percutaneous transhepatic puncture of the right biliary tree was performed and a self-expandable metallic Wallstent was placed across the biliary stricture. The procedure resulted successful and uneventful and the external drain was removed the coming day. Two days after, however, the aforementioned clinical scenario manifested and dedicated imaging studies were commenced. A plain abdominal X-ray documented an important pneumoperitoneum (Fig. 1). CT scan showed abundant ascites and, of interest, an intrahepatic gaseous content, presumably corresponding to the previous puncture site, was identified along with pneumobilia and pneumogallbladder (Fig. 2). Due to hemodynamic stability of the patient and after excluding biliary injury by a control endoscopic retrograde cholangiopancreatography, a nonoperative management with analgesic therapy and radiological surveillance was undertaken. On imaging, the pneumoperitoneum totally disappeared after 10 days. The complications most frequently described after placement of percutaneous transhepatic catheter with or without the insertion of metallic biliary stent include abdominal pain, bile leak with choleperitoneum, hemobilia, biloma, and stent migration.1 Pulmonary and bowel puncture are rarer events.1 The occurrence of postpercutaneous transhepatic catheter pneumoperitoneum is exceptional as only three instances have been reported so far.1, 2 Presently, there are two main speculations: the former recognizes the delayed closure of the transhepatic tract as the cause of the gaseous passing from the duodenum into the biliary tree and then into the peritoneum. Conversely, the latter prompts that the atmospheric air is sucked into the peritoneal cavity through a percutaneous track kept patent by the negative intra-abdominal pressure exerted during respiration.1 Previous to our report, the gaseous content inside a transhepatic tract has been demonstrated only in one case: such a radiological finding

Dear Editor, The safety of anti-TNFα drugs in hepatitis B (HBV)-positive patients is debated, and virtually no data are available for cirrhotic patients. Here we report the first case of an ulcerative colitis (UC) patient with compensated, chronic, active HBV-related-cirrhosis, who safely underwent two different anti-TNFα drugs (infliximab and adalimumab) with no drug-induced liver side effects. A 55-year-old male was referred to our gastrointestinal department in 2011 for glucocorticoid-dependent, long-standing UC and HBV infection. The patient’s hepatological history began in 2006 with a diagnosis of chronic HBV infection (positive for hepatitis B surface antigen [HBsAg], antibody to hepatitis B envelope antigen [anti-HBe] and antibody …

In Wilson's disease, liver transplantation can constitute the only option for patients presenting with fulminant hepatic failure or decompensated liver disease unresponsive to drug therapy. We report the case of a 29-year-old woman receiving a liver transplant for end-stage Wilson's disease who developed neurological complications after transplantation. After an accurate evaluation of possible differential causes of neurological complications developing as the result of liver transplantation, moyamoya disease was diagnosed. Moyamoya disease is a rare cerebrovascular disease of unknown etiology. However, data exist supporting a possible role for some immunosuppressive regimens in determining the peculiar vascular alterations observed in moyamoya disease. To the best of our knowledge, the association with post-transplantation state for Wilson's disease has not been previously described.

New-onset diabetes after transplantation (NODAT) is a frequent complication after liver transplantation and has a negative impact on both patient and graft survival. In analogy with the previous finding of an association between posttransplant hypomagnesemia and NODAT in renal transplant recipients, the relation between both pretransplant and posttransplant hypomagnesemia and NODAT was studied in liver transplant recipients (LTRs). One hundred sixty-nine adult LTRs (>18 years old) without diabetes who underwent transplantation between 2004 and 2009 were studied (mean age = 52.11 ± 12.6 years, proportion of LTRs who were male = 67.5%, body mass index = 25.5 ± 4.4 kg/m², proportion receiving tacrolimus = 90.0%). NODAT was defined according to the American Diabetes Association criteria. The association of NODAT with both pretransplant and posttransplant serum magnesium (Mg) was examined. Overall, 52 of 169 patients (30.8%) developed NODAT, and 57.7% of these (30 patients) were treated with antidiabetic drugs. Both pretransplant Mg levels and Mg levels in the first month after transplantation were lower in patients developing NODAT (P = 0.008 and P = 0.001, respectively). A multivariate regression model (adjusted for weight, pretransplant glucose levels, hyperglycemia in the first week after transplantation, gender, hepatitis C, and corticosteroid dosing) demonstrated both pretransplant Mg levels (hazard ratio = 0.844 per 0.1 mg/dL increase, 95% confidence interval = 0.764-0.932, P = 0.001) and posttransplant Mg levels (hazard ratio = 0.659, 95% confidence interval = 0.518-0.838, P = 0.001) to be independent predictors of NODAT together with age, biopsy-proven acute rejection, and cytomegalovirus (CMV) infection in the first year after transplantation. In conclusion, pretransplant hypomagnesemia and early posttransplant hypomagnesemia are independent predictors of new-onset diabetes after liver transplantation. Other risk factors are age, biopsy-proven acute rejection, and CMV infection.