Nathalie A. Pena Polanco's research while affiliated with Mercy Medical Center, Iowa and other places

Renal dysfunction frequently develops in patients with advanced liver disease. Renal dysfunction in this setting is associated with adverse outcomes and an unfavorable prognosis. Hepatorenal syndrome (HRS), defined as worsening renal function in patients with advanced cirrhosis that can present either acutely (<3 months) or more indolently in the absence of other etiologies, remains a common cause of acute kidney injury. If reversal is not promptly achieved, rapid decline to mortality is common. Volume expansion and vasoconstrictors are the mainstays of therapy. Terlipressin, a vasopressin analogue licensed in several countries but not in the United States, is currently used for the treatment of HRS. Timely liver transplantation remains the only effective therapeutic option for a large group of patients with persistent renal dysfunction despite pharmacotherapy. In patients with underlying chronic renal dysfunction, simultaneous liver-kidney transplantation should be considered. The aim of this article is to present an overview of renal dysfunction in patients with cirrhosis, including diagnosis and management.

Increased life expectancy and advances in the care of chronic liver disease has increased the number of elderly patients needing liver transplant. Organ donation policies prioritize transplant to the sickest. There is an ongoing debate with regard to balancing the principles of equity and utility. Several hospitals have adopted center-specific policies and there has been an increased trend of transplant in elderly patients since 2002. Appropriate patient selection and long-term outcomes in the setting of limited organ availability pose several challenges. This article reviews the data and discusses the pros and cons of transplants in the elderly.

Background and Aims: Hispanic patients with primary biliary cholangitis (PBC) have reduced rates of biochemical response to ursodeoxycholic acid (UDCA) and increased risk of disease progression compared to non-Hispanic patients. In this study, we sought to identify differences in demographics, comorbidities, environmental risk factors and socioeconomic status between Hispanic and non-Hispanic patients with PBC. Methods: In a case control study, we analyzed data from Hispanic (n=37 females and 1 male) and non-Hispanic (n=54 females and 4 males) patients with PBC seen at the University of Miami/Jackson Memorial Hospital from January 1998 through January 2013. Data were obtained by filling out a questionnaire either via phone call, mail, or e-mail. Odds ratios were calculated to measure the association between exposure and outcomes. Results: Baseline demographics, environmental risk factors and comorbidities were similar between Hispanic and non-Hispanic patients with PBC. Hispanic patients were less likely to be married and fewer Hispanics had education beyond high school level compared to non-Hispanics. Sixty four percent of Hispanic patients had a household income of less than $50000, compared to 19.5% of non-Hispanics. Fewer Hispanic patients with PBC had health insurance coverage compared to non-Hispanics (86.5% vs. 98.1%; odds ratio: 0.1, 95% confidence interval: 0-0.9). Conclusions: Differences in disease severity and response to therapy observed in prior studies could not be explained by environmental exposures. In addition to genetic variation, socioeconomic discrepancies (access to care) may further explain these differences.

Background: Studies suggest that gender differences in academic medicine exist. Men frequently have better measures of performance such as number of publications, number of citations, remuneration, and funding. Aims: To evaluate whether a gender disparity in authorship exists. Methods: We recorded the gender of first and senior authors of original papers, editorials/reviews from liver-related manuscripts in Gastroenterology, Hepatology, Transplantation, American Journal of Gastroenterology, and Liver Transplantation from January 2014 to 2016. Results: Of 2424 articles reviewed, we excluded 232 (10%) due to inability to determine gender. Among papers analyzed, 72.0% were original and 28.1% reviews/editorials with 65.1% of first authors being male and 34.9% female. Only 20.3% of papers with multiple authors had a female senior author. The proportion of male first and senior authorship between original papers and reviews/editorials was comparable. 72% of original papers had a male as first or senior author, but only 28% females. 71% of review/editorial papers had a male as first or senior author, but only 29% females. When the senior author of an original paper was female, 47.1% of first authors were male and 52.9% female. When the senior author was male, 67.1% of first authors were male and 32.9% female (p < 0.00001). Conclusions: A significant gender difference exists in Hepatology publications. Female authorship mirrors the percentage of female AASLD membership; however, female senior authorship remains disproportionate. In general, funding for male authors is greater. Fewer women are first authors when the senior author is male, highlighting the importance of female mentorship in Hepatology.

Purpose of Review Overlap syndromes show concomitant or sequential findings of two or more autoimmune liver diseases. Primary sclerosing cholangitis (PSC) is rare and PSC-overlap syndromes are much rarer. There is limited data in PSC-overlap syndromes which pose significant diagnostic and therapeutic challenges for this condition. We summarized the published data in this review to update the management strategies in PSC-overlap syndrome. Recent Findings PSC incidence is 0.77–1 per 100,000 person/years, of which 2–10% are reported to have PSC-autoimmune hepatitis (AIH) overlap syndrome. The incidence of PSC-primary biliary cholangitis (PBC) is extremely rare. Inflammatory bowel disease (IBD) is more common in classic PSC than in PSC-AIH patients (80% vs. 63%) and unusual in PSC-PBC. PSC can present with a more hepatocellular form of injury in children, also called autoimmune sclerosing cholangitis (ASC) rather than the typical classic cholestatic presentation in the adults. The presence of overlap syndrome can be diagnosed concomitantly or sequentially during the disease course in an individual. Liver fibrosis progression in PSC-AIH overlap syndrome is similar to classic PSC but hepatobiliary malignancy is reportedly infrequent. Diagnostic scoring criteria are not recommended and clinical diagnosis relies primarily on liver biochemistry, cholangiography and liver biopsy. Ursodeoxycolic acid and immunosuppressive therapy is beneficial in some patients with PSC-overlap syndrome. The biochemical response to pharmacotherapy is higher in PSC-overlap syndrome when compared to classic PSC but lower than that observed in classic AIH. Summary PSC overlap syndromes are poorly understood. Current evidence is based on data compiled from case reports and series. This review provides an updated summary that could assist in the clinical management of patients with this complex disorder.

Over the past several years, single- and multi-center case series have reported on the successful use of livers from hepatitis C virus (HCV)-antibody positive and HCV-viremic donors to HCV-negative recipients. Several authors have studied not only the efficacy of this practice but also its cost-effectiveness of transplanting HCV-infected organs to HCV-negative donors. However, previous studies had limited follow-up and had not examined transplants beyond the beginning of 2018. Using national data from 2014-2018, Thuluvath et al. demonstrated that post-transplant outcomes of recipients from either HCV-antibody and/or HCV-viremic donors were not different than those using livers from HCV-negative donors.

INTRODUCTION Pancreatic transplant represents the ultimate treatment for certain patients with diabetes mellitus & end-stage renal disease. Despite good outcomes, it carries a high rate of vascular complications, & with increased numbers of enterically-drained grafts, obscure gastrointestinal bleeding (GIB) can be the initial presentation. Delayed diagnosis & treatment of life-threatening hemorrhage can ensue if clinicians are not aware of this association. Therefore, we aimed to perform a systematic review of the literature, evaluating the presentation, diagnosis & treatment of patients with GIB caused by complications from enterically-drained pancreatic transplants. METHODS We performed a systematic search of published data, regarding GIB due to complications from pancreatic transplant. Specific keywords including pancreatic transplant & gastrointestinal bleeding, with all possible permutations & associated MeSH terms were used, from inception of PubMed database to 04/30/2019. 107 results matched initial search criteria. After assessment to determine appropriateness, 26 publications with complications resulting in GIB at presentation were included. A recursive search was performed from bibliographies, yielding the remaining results. RESULTS 36 publications met final inclusion criteria (25 case reports & 11 case series) dating from 1989 to 2019, for a total of 69 patients, (47.8% men, mean age 41.4 years). Of these, 67 (97%) presented with overt bleeding, with lower GIB as the most common presentation (59.4%), followed by cases of both upper & lower GIB (8.7%), & occult GIB the least common (2.9%). Sentinel GIB was reported in 49.3% of cases. GIB etiologies included formation of fistulas (52.2%), anastomotic ulcer & donor duodenal bleed (11.6% each) & pseudoaneurysms (8.7%), with other rare causes (mucosal rejection, cytomegalovirus-related ulcers) also identified. Diagnosis was made by angiography in 31.9% & by surgery in 21.7% of cases, respectively. Endoscopic diagnosis was only successful in 7 patients. Surgery (n = 42) & interventional radiology procedures (n = 19) were the mainstays for treatment. Overall, 50.7% of patients had pancreatic graft loss prior to GIB. CONCLUSION GIB after pancreatic transplant can be devastating. In our review, failed grafts were found in half the cases, with lower GIB due to arterial-enteric fistulas being the most common presentation. Angiography & surgery were the most common diagnostic & therapeutic modalities.

INTRODUCTION Small bowel bleeding (SBB) accounts for 5–10% of gastrointestinal bleeding cases. Common causes of SBB are inflammatory bowel disease, angioectasias, ulcers, & primary & metastatic neoplasms. The aim of this case report & literature review is to present ovarian clear cell carcinoma (CCC) as a rare cause of SBB. CASE DESCRIPTION/METHODS A 51 year old woman with dual primary stage IIB CCC of bilateral ovaries & uterus, & stage IA, grade 1 endometrioid adenocarcinoma underwent total laparoscopic hysterectomy, bilateral salphingo-oophorectomy, bilateral pelvic lymph node dissection, & omentectomy. Pathology from the right pelvic side wall peritoneum was positive for CCC involving fibroadipose tissue. She completed 6 cycles of chemotherapy with paclitaxel & carboplatin. Following treatment, she achieved clinical remission for 14 months until computed tomography (CT) scan performed for new abdominal pain & constipation showed a 6.3 × 4.6 cm heterogeneously enhancing lobular mass lesion within the pelvis in close contact with the sigmoid colon without definite invasion. A month later, she was admitted with lower abdominal pain & bloody stools. Colonoscopy showed blood in the entire colon & terminal ileum (TI), without active source of bleeding identified. CT Angiography showed no evidence of active bleeding, but revealed increasing pelvic mass size (6.5 × 6.4 cm). No lymphadenopathy was noted on CT scan. Upper endoscopy was unrevealing. Video capsule endoscopy (VCE) showed an actively bleeding mass likely in the distal small bowel, without VCE passage beyond the mass or cecal intubation. Exploratory laparotomy revealed an 8cm mass arising from the distal TI adherent to the epiploica of the rectosigmoid, not involving the vaginal cuff or prior resection sites. A portion of distal TI was resected with a side-to-side ileo-ascending colon anastomosis. TI pathology was positive for CCC, with negative omental & lymph node pathology. Chemotherapy with carboplatin & doxorubicin was initiated without further bleeding. DISCUSSION Ovarian cancer is thought to metastasize via direct invasion, lymphatic or hematogenous infiltration, or peritoneal dissemination. Solitary metastasis of ovarian CCC to the small bowel without peritoneal carcinomatosis or lymphatic involvement is a rare phenomenon. Our literature review revealed only one other published case report describing this entity. Solitary CCC metastases should be added to the list of potential neoplastic causes of SBB.