Portal vein thrombosis as a potential burden for liver transplant candidates in next future
Editorial

Portal vein thrombosis as a potential burden for liver transplant candidates in next future

Giovanni Battista Levi Sandri

Division of General Surgery and Liver Transplantation, San Camillo Hospital, Rome, Italy

Correspondence to: Giovanni Battista Levi Sandri, MD. Division of General Surgery and Liver Transplantation, San Camillo Hospital, Rome, Italy. Email: gblevisandri@gmail.com.

Provenance: This is a Guest Editorial commissioned by Editor-in-Chief Xingshun Qi (Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China).

Comment on: Montenovo M, Rahnemai-Azar A, Reyes J, et al. Clinical Impact and Risk Factors of Portal Vein Thrombosis for Patients on Wait List for Liver Transplant. Exp Clin Transplant 2017. [Epub ahead of print].


Received: 12 January 2018; Accepted: 25 January 2018; Published: 28 March 2018.

doi: 10.21037/amj.2018.03.06


Liver transplantation (LT) is the most impressive and complicated surgical procedure. One of the big challenge for transplant surgeon is the presence of portal vein thrombosis (PVT). Since the first successful LT in patient with PVT in most of centers PVT was a contraindication to transplantation. The manuscript written from Montenovo and colleagues entitled: “Clinical Impact and Risk Factors of Portal Vein Thrombosis for Patients on Wait List for Liver Transplant” is a study analysis of a US national cohort of 134,109 adult patients listed for primary orthotopic liver transplant (OLT) between January 2002 and June 2014 (1). The first important result reported is the increasing rate of PVT at listing from 2% to 6%. No difference of LT rates for patients listed with or without PVT was observed. After multivariable logistic regression analyses, authors found that number of days on a wait list, age, prior abdominal surgery, hepatocellular carcinoma, ascites, history of variceal bleed, NASH, higher body mass index (BMI) at listing, and diabetes mellitus were all independent predictors of PVT development while on a wait list.

Degree and extent of PVT according to the Yerdel grade (2) were not analyzed in this study. This classification may change study conclusions. In previous studies, patients with grades I and II were described to have similar survival post LT of patient without PVT (3,4). The identification of risk factors for the development of PVT described in the study is an important way to identify a high-risk patient category. HCC is well known to be a risk for PVT, but in case of tumoral PVT a treatment with yttrium-90 radioembolization allows to obtain optimal survival after

LT (5-7). Nevertheless, NASH, increased BMI, and presence of diabetes mellitus were high independent risk factors for the development of PVT during the waiting list. This opens the actual discussion of the performance status LT candidates (7,8). Interventions to improve activity and ameliorate frailty in patients with NASH and increased BMI need to be proposed in order to decrease BMI patients. Furthermore, as authors underline in the discussion, NASH-related cirrhosis is growing as an important LT indication. Accordingly, the rate of PVT in LT candidates may increase too. Liver surgeons have to focus this potential risk in the future. At least, authors described the protective effect of TIPS on the development of PVT. I agree with authors and I’ll add that TIPS does not increase the operative morbidity as described in previous study (9).

In summary, PVT rate in at listing and/or at the time of LT is growing. Some factors may increase the risk of PVT after listing and we have to develop optimal therapeutic and preventive strategies in order to avoid worth survival rates after transplantation.


Acknowledgements

None.


Footnote

Conflicts of Interest: The author has no conflicts of interest to declare.


References

  1. Montenovo M, Rahnemai-Azar A, Reyes J, et al. Clinical Impact and Risk Factors of Portal Vein Thrombosis for Patients on Wait List for Liver Transplant. Exp Clin Transplant 2017. [Epub ahead of print]. [PubMed]
  2. Yerdel MA, Gunson B, Mirza D, et al. Portal vein thrombosis in adults undergoing liver transplantation: risk factors, screening, management, and outcome. Transplantation 2000;69:1873-81. [Crossref] [PubMed]
  3. Levi Sandri GB, Lai Q, Berloco PB, et al. Portal vein thrombosis before liver transplant does not alter postoperative patient or graft survival. Exp Clin Transplant 2014;12:238-40. [PubMed]
  4. Qi X, Dai J, Jia J, et al. Association between portal vein thrombosis and survival of liver transplant recipients: a systematic review and meta-analysis of observational studies. J Gastrointestin Liver Dis 2015;24:51-9. [PubMed]
  5. Ettorre GM, Levi Sandri GB, Laurenzi A, et al. Yttrium-90 Radioembolization for Hepatocellular Carcinoma Prior to Liver Transplantation. World J Surg 2017;41:241-9. [Crossref] [PubMed]
  6. Levi Sandri GB, Ettorre GM, Giannelli V, et al. Trans-arterial radio-embolization: a new chance for patients with hepatocellular cancer to access liver transplantation, a world review. Transl Gastroenterol Hepatol 2017;2:98. [Crossref] [PubMed]
  7. Lai JC, Feng S, Terrault NA, et al. Frailty predicts waitlist mortality in liver transplant candidates. Am J Transplant 2014;14:1870-9. [Crossref] [PubMed]
  8. Dunn MA, Josbeno DA, Schmotzer AR, et al. The gap between clinically assessed physical performance and objective physical activity in liver transplant candidates. Liver Transpl 2016;22:1324-32. [Crossref] [PubMed]
  9. Levi Sandri GB, Lai Q, Lucatelli P, et al. Transjugular intrahepatic portosystemic shunt for a wait list patient is not a contraindication for orthotopic liver transplant outcomes. Exp Clin Transplant 2013;11:426-8. [Crossref] [PubMed]
doi: 10.21037/amj.2018.03.06
Cite this article as: Levi Sandri GB. Portal vein thrombosis as a potential burden for liver transplant candidates in next future. AME Med J 2018;3:47.