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

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

Management of hepatocellular carcinoma.

Hepatocellular Carcinoma: Epidemiology and Molecular Carcinogenesis

Hydroxychloroquine and azithromycin as a treatment of COVID-19: results of an open-label non-randomized clinical trial.

The paper describes an algorithm that, given an initial design F n of size n and a linear model with p parameters, provides a sequence F n ⊃ . . . ⊃ F n − k ⊃ . . . ⊃ F p of nested robust designs. The sequence is obtained by the removal, one by one, of the runs of F n till a p -run saturated design F p is obtained. The potential impact of the algorithm on real applications is high. The initial fraction F n can be of any type and the output sequence can be used to organize the experimental activity. The experiments can start with the runs corresponding to F p and continue adding one run after the other (from F n − k to F n − k +1 ) till the initial design F n is obtained. In this way, if for some unexpected reasons the experimental activity must be stopped before the end when only n − k runs are completed, the corresponding F n − k has a high value of robustness for k ∈ { 1 , . . . , n − p } . The algorithm uses the circuit basis, a special representation of the kernel of a matrix with integer entries. The eﬀectiveness of the algorithm is demonstrated through the use of simulations.

Robustness against data loss with Algebraic Statistics

Alcoholic liver disease (ALD) can present with a spectrum of clinical findings ranging from asymptomatic hepatic steatosis to life-threatening alcoholic hepatitis with jaundice or decompensated cirrhosis with ascites and protein-calorie malnutrition. Patients with alcoholic hepatitis (AH) have jaundice, coagulopathy, and a 30–60% 6-month mortality despite abstinence and supportive care. Recent data from a large multicenter study demonstrated that corticosteroids and pentoxyfilline have minimal survival benefit in AH. Therefore, many experts recommend a short course of corticosteroids only in selected AH patients whose total bilirubin levels improve within 1 week of starting treatment. ICU care for patients with ALD requires initial management of alcohol withdrawal syndromes (AWS) as well as addressing infections, bleeding, and renal failure. Management of AWS includes protocolized administration of benzodiazepines based on clinical status in a monitored setting along with correction of metabolic disturbances and supplementation of micronutrient deficiencies. Patients with severe AWS may require anti-psychotics or even propofol with intubation for severe withdrawal symptoms and cardiopulmonary instability. Treatment of upper GI bleeding in patients with ALD includes establishment of large bore IV access and early administration of IV antibiotics, proton pump inhibitors, and octreotide to further reduce bleeding. Targets for blood product replacement include a hemoglobin of 8 g/dL, an INR 50 K to minimize the risk of ongoing bleeding. Following adequate gastric lavage, urgent therapeutic endoscopy is recommended to identify and treat the source of bleeding. Patients with refractory variceal bleeding may require balloon tamponade to achieve hemostasis and emergent TIPS for portal decompression. Many ICU patients with complications of ALD may develop acute kidney injury due to volume depletion, ATN, or hepatorenal syndrome. Initiation of hemodialysis in patients with ALD is frought with complications, and patients with HRS have particularly poor survival. In conclusion, management of the ICU patient with ALD requires coordinated care delivered by the intensivist in conjunction with the GI specialist and mental health provider to achieve optimal short- and long-term outcomes.

The ICU Management of Alcoholic Liver Disease

Advances in the management of idiosyncratic drug-induced liver injury

https://doi.org/10.1016/j.rpth.2023.100082

Hematohepatology: The potential for direct oral anticoagulant “Inflation” in liver transplant candidates

The low incidence of drug-induced liver injury (DILI), along with the difficulty in establishing a diagnosis, has hampered our ability to study the molecular pathogenesis of drug and herbal hepatotoxicity. Multicenter research networks have recently been developed in the United States and other countries to facilitate further research into this uncommon but important adverse drug reaction. Currently, several prospective registries including the Drug-Induced Liver Injury Network utilize standardized definitions, phenotyping, and causality assessment methods in ongoing studies of host immunological, genetic, and environmental factors in DILI pathogenesis and outcome. The increasing use of electronic medical records coupled with the application of natural language processing algorithms may further help identify DILI patients for future studies. Finally, continuing advances in genomic methods may allow us to better identify risk factors for DILI susceptibility and diagnosis, which should help to mitigate the risk for individual patients in the years to come.

Robert J. Fontana

Papers

Robustness against data loss with Algebraic Statistics

The ICU Management of Alcoholic Liver Disease

Advances in the management of idiosyncratic drug-induced liver injury

Hematohepatology: The potential for direct oral anticoagulant “Inflation” in liver transplant candidates

Drug-Induced Liver Injury Research Networks