EASL-EORTC clinical practice guidelines : management of hepatocellular carcinoma

Since the publication of the American Association for the Study of Liver Diseases (AASLD) practice guidelines on the management of hepatocellular carcinoma (HCC) in 2005, new information has emerged that requires that the guidelines be updated. The full version of the new guidelines is available on the AASLD Web site at http://www.aasld.org/practiceguidelines/ Documents/Bookmarked%20Practice%20Guidelines/ HCCUpdate2010.pdf. Here, we briefly describe only new or changed recommendations.

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AASLD PRACTICE GUIDELINE Management of Hepatocellular Carcinoma: An Update

There is no consensus definition of acute renal failure (ARF) in critically ill patients. More than 30 different definitions have been used in the literature, creating much confusion and making comparisons difficult. Similarly, strong debate exists on the validity and clinical relevance of animal models of ARF; on choices of fluid management and of end-points for trials of new interventions in this field; and on how information technology can be used to assist this process. Accordingly, we sought to review the available evidence, make recommendations and delineate key questions for future studies. We undertook a systematic review of the literature using Medline and PubMed searches. We determined a list of key questions and convened a 2-day consensus conference to develop summary statements via a series of alternating breakout and plenary sessions. In these sessions, we identified supporting evidence and generated recommendations and/or directions for future research. We found sufficient consensus on 47 questions to allow the development of recommendations. Importantly, we were able to develop a consensus definition for ARF. In some cases it was also possible to issue useful consensus recommendations for future investigations. We present a summary of the findings. (Full versions of the six workgroups' findings are available on the internet at http://www.ADQI.net
 ) Despite limited data, broad areas of consensus exist for the physiological and clinical principles needed to guide the development of consensus recommendations for defining ARF, selection of animal models, methods of monitoring fluid therapy, choice of physiological and clinical end-points for trials, and the possible role of information technology.

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Acute renal failure - definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group.

https://aasldpubs.onlinelibrary.wiley.com/doi/pdf/10.1002/hep.20933

Management of hepatocellular carcinoma.

Acute kidney injury (AKI) is a complex disorder for which currently there is no accepted definition. Having a uniform standard for diagnosing and classifying AKI would enhance our ability to manage these patients. Future clinical and translational research in AKI will require collaborative networks of investigators drawn from various disciplines, dissemination of information via multidisciplinary joint conferences and publications, and improved translation of knowledge from pre-clinical research. We describe an initiative to develop uniform standards for defining and classifying AKI and to establish a forum for multidisciplinary interaction to improve care for patients with or at risk for AKI. Members representing key societies in critical care and nephrology along with additional experts in adult and pediatric AKI participated in a two day conference in Amsterdam, The Netherlands, in September 2005 and were assigned to one of three workgroups. Each group's discussions formed the basis for draft recommendations that were later refined and improved during discussion with the larger group. Dissenting opinions were also noted. The final draft recommendations were circulated to all participants and subsequently agreed upon as the consensus recommendations for this report. Participating societies endorsed the recommendations and agreed to help disseminate the results. The term AKI is proposed to represent the entire spectrum of acute renal failure. Diagnostic criteria for AKI are proposed based on acute alterations in serum creatinine or urine output. A staging system for AKI which reflects quantitative changes in serum creatinine and urine output has been developed. We describe the formation of a multidisciplinary collaborative network focused on AKI. We have proposed uniform standards for diagnosing and classifying AKI which will need to be validated in future studies. The Acute Kidney Injury Network offers a mechanism for proceeding with efforts to improve patient outcomes.

Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury

HCV infection is commonly found in patients with chronic liver disease undergoing liver transplantation. However, the presence of antibody to HCV does not appear to be associated with the development of hepatitis posttransplant. No other risk factors were identified that appear to predispose patients to development of hepatitis in the posttransplant period, including amount of blood product exposure. The role of immunosuppression in the acquisition and expression of liver disease caused by HCV remains to be determined.

Hepatitis C in liver transplant recipients.

Outcome of other organs recovered during in situ split-liver procurements

https://aasldpubs.onlinelibrary.wiley.com/doi/pdf/10.1002/hep.1840120309

Mechanisms of transport of nontransferrin-bound iron in basolateral and canalicular rat liver plasma membrane vesicles.

This review focuses on mechanisms of bile acid transport across the basolateral and canalicular hepatocyte plasma membranes and on ursodeoxycholic acid (UDCA) hypercholeresis and biotransformation. Conjugated trihydroxy bile acids enter hepatocytes via a sodium-coupled mechanism localized to the basolateral membrane, which is saturable, concentrative, inhibited by other bile acids as well as by furosemide and bumetanide, and exhibits developmental changes in rats and probably also in humans. The stoichiometry of sodium-coupled bile acid uptake has been controversial. Hydrophobic, unconjugated dihydroxy and monohydroxy bile acids, including UDCA, enter hepatocytes more rapidly than does taurocholate, and their uptake is largely nonsaturable and sodium independent. A hydroxyl-exchange mechanism that mediates the uptake of cholic acid has also been reported, but its existence is controversial. Current evidence suggests that a 49-kDa protein mediates Na+-dependent taurocholate uptake and that a 54-kDa protein is involved in Na+-independent bile acid uptake. Studies with canalicular membrane vesicles have demonstrated saturable, sodium-independent taurocholate transport, which is sensitive to electrical potential, exhibits trans-stimulation, and appears to be mediated by a 100-kDa canalicular membrane glycoprotein. Studies in mutant rats with conjugated hyperbilirubinemia suggest the presence of a separate canalicular transport mechanism utilized by sulfated bile acids and organic anions such as bilirubin and sulfobromophthalein. UDCA produces in some species a dramatic hypercholeresis that is greater than expected based on the osmotic effect of the secreted bile acid. The hypercholeresis appears attributable to stimulation of biliary bicarbonate output and is decreased or abolished in the perfused rat liver by amiloride or perfusate Na+ substitution. These same maneuvers dramatically alter UDCA biotransformation (unconjugated UDCA disappears from bile, and UDCA glucuronide becomes a major metabolite) and lower hepatocyte intracellular pH. These and other findings indicate that UDCA hypercholeresis is tightly linked to biliary excretion of the unconjugated species and suggest that UDCA biotransformation may be influenced by intracellular pH.

John R. Lake

Papers

Hepatitis C in liver transplant recipients.

Outcome of other organs recovered during in situ split-liver procurements

Mechanisms of transport of nontransferrin-bound iron in basolateral and canalicular rat liver plasma membrane vesicles.

Hepatocellular bile acid transport and ursodeoxycholic acid hypercholeresis.

Benefits of cyclosporine microemulsion (Neoral) C2 monitoring are sustained at 1 year in de novo liver transplant recipients