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Background & Aims: Retrospective studies have reported good results with liver transplantation (LTx) for acute-on-chronic liver failure (ACLF) in selected patients. The aim of this study was to evaluate the selection process for LTx in patients with ACLF admitted to the intensive care unit (ICU) and to assess outcomes. Methods: This prospective, non-interventional, single high-volume center study collected data on patients with ACLF admitted to the ICU between 2017-2020. Results: Among 200 patients (mean age: 55.0 ± 11.2 years and 74% male), 96 patients (48%) were considered potential candidates for LTx. Unfavourable addictology criteria (n = 76) was the main reason for LTx ineligibility. Overall, 69 patients were listed for LTx (34.5%) and 50 were transplanted (25% of the whole population). The 1-year survival in the LTx group was significantly higher than in the non-transplanted group (94% vs. 15%, p 85.4% in those experiencing an increase of 2 organ failures since admission or >91% if experiencing an increase >2 organ failures, at which point futility could be considered. Conclusion: This prospective analysis of outcomes of patients with ACLF admitted to the ICU highlights the drastic nature of selection in this setting. Unfavourable addictology criteria, mechanical ventilation and increasing number of organ failures since admission were predictive of absence of LTx, futility and death. Impact and implications: Liver transplantation (LT) is the best therapeutic option in selected cirrhotic patients admitted to the ICU with acute on chronic liver failure. However, the selection criteria are poorly described and based on retrospective studies. This is the first prospective study that aimed to describe the selection process for LT in a transplant center. Patients with ACLF should be admitted to the ICU and evaluated within a short period of time for LT. In the context of organ shortage, eligibility for LT and either absence of LT, futility of care or death are better clarified in our study. These are mainly determined by prolonged respiratory failure and worsening of organ failures since ICU admission. Considering worldwide variations in the etiology and definition of ACLF, transplant availability and a narrow therapeutic window for transplant further prospective studies are awaited.

In this article, we describe the case of a 34-year-old woman presenting a multifocal and metastatic epithelioid hemangioendothelioma (HEHE) of the liver. Under classical chemotherapy using cyclophosphamide, there was a fast tumor progression in liver and extra-hepatic metastatic sites (lungs and mediastinal lymph node). Taking into account the patient’s age and the natural history of the HEHE, our goal was to try to bring her to liver transplantation (LT) and lenvatinib was an acceptable candidate for this reason. Shortly after the initiation of lenvatinib before LT and surgery, we observed the enlargement of large devascularized necrotic areas in most of the liver HEHE masses, suggesting a good response. The patient was finally transplanted 6 months after initiation of lenvatinib treatment. Eight months after LT, progression occurred (ascites, peritoneal recurrence, and mediastinal lymph node). After restarting lenvatinib, ascites disappeared and the lymph node decreased in size, suggesting a good response, more than 1 year after her transplantation. This is the first case report to our knowledge that illustrates the benefit of lenvatinib as a neoadjuvant bridge until LT for a multifocal and metastatic HEHE. In addition, this drug has also shown a benefit in term of disease control after a late recurrence of the tumor. We suggest that lenvatinib should be proposed as a bridge to the LT for nonresectable HEHE. Moreover, this drug was also beneficial in the treatment of late recurrence after LT. The absence of pharmacologic interactions between classical immunosuppressive drugs and lenvatinib may allow its use as an early adjuvant approach when the risk of recurrence is high. The strength of our case consists in the long follow-up and the innovative message allowing changing palliative strategies into curative ones in case of advanced HEHE.

Background. No data are available on liver transplantation (LT) outcome and donor liver steatosis, classified as large droplet macrovesicular (Ld-MaS), small-droplet macrovesicular (Sd-MaS), and true microvesicular (MiS), taking into account the recipient Hepatitis C virus (HCV) status. Aim. We investigate the impact of allograft steatosis reclassified according to the Brunt classification on early graft function and survival after LT. Methods. We retrospectively reviewed 204 consecutive preischemia biopsies of grafts transplanted in our center during the period 2001-2011 according to recipient HCV status. Results. The median follow-up after LT was 7.5 years (range: 0.0-16.7). In negative recipients (n=122), graft loss was independently associated with graft Sd-MaS, in multivariable Cox regression models comprehending only pre-/intraoperative variables (HR=1.03, 95%CI=1.01-1.05; P=0.003) and when including indexes of early postoperative graft function (HR=1.04, 95%CI=1.02-1.06; P=0.001). Graft Sd-MaS>15% showed a risk for graft loss > 2.5-folds in both the models. Graft Sd-MaS>15% was associated with reduced graft ATP content and, only in HCV- recipients, with higher early post-LT serum AST peaks. Conclusions. In HCV-negative recipients, allografts with >15% Sd-MaS have significantly reduced graft survival and show low ATP and higher AST peaks in the immediate posttransplant period. Donors with >15% Sd-MaS have significantly higher BMI, longer ICU stays, and lower PaO2.

Background. Renal dysfunction in end-stage liver disease (ESLD) results from systemic conditions that affect both liver and kidney with activation of vasoconstrictor systems. In this setting, estimated glomerular filtration rate (eGFR) may undergo variations often outside Kidney Disease Improving Global Outcomes criteria for acute kidney injury (AKI) diagnosis, whose meaning is not clear. The aim of this study was to evaluate eGFR variations in ESLD outpatients listed for liver transplant (liver Tx) and the association with post-Tx outcome. Methods. Fifty-one patients with ESLD were retrospectively evaluated from listing to transplant (L-Tx time), intraoperatively (Tx time), and up to 5 years post-Tx time. Variations between the highest and the lowest eGFR occurring in more than 48 hours, not satisfying Kidney Disease Improving Global Outcomes guideline, were considered as fluctuations (eGFR-F). Fluctuations of eGFR greater than 50% were defined as eGFR drops (DeGFR). Early graft dysfunction, AKI within 7 days, chronic kidney disease, and short- and long-term patient survivals were considered as outcomes. Results. All patients presented eGFR-F, whereas DeGFR were observed in 18 (35.3%) of 51 (DeGFR+ group). These patients presented higher levels of Model for End-stage Liver Disease score, pre-Tx bilirubin and significantly greater incidence of post-Tx AKI stages 2 to 3 compared with patients without drops (DeGFR−). DeGFR was the only independent predictive factor of the occurrence of post-Tx AKI. The occurrence of AKI post-Tx was associated with the development of chronic kidney disease at 3 months and 5 years post-Tx. Conclusions. Drops of eGFR are more frequently observed in patients with a worse degree of ESLD and are associated with a worse post-Tx kidney outcome.

A series of 59 transect surveys was conducted in selected wet forest habitats, along the coast of West Africa, to estimate the density distribution of African Hinge-back tortoises (Kinixys homeana and K. erosa). Line transect data were fed into a simple model to derive a detection function. The parameters estimated by the model produced an elaborate characterisation of tortoise distribution, which proved to be useful in the formulation of hypotheses about tortoise densities. Line transect data were analysed by DISTANCE, with a series of key and the series adjustment: the uniform function, the 1-parameter half-normal function, and the 2-parameter hazard-rate function were considered as key functions; the cosine series, simple polynomials, and Hermite polynomials were considered as series expansions. The detection function was estimated separately for Kinixys homeana and K. erosa, and for transects grouped for each study area by considering all the combinations of the above key functions and series expansions. The Akaike Information Criterion (AIC) was computed for each candidate model and used for model selection. The best model of the detection function, for both the tortoise species was the uniform function with no series expansion. Model results indicated that the density of the two species was inversely related at the local scale, and complementary across the region; such that the density of one species increases from West to East while the other one declines. Overall, the comparison of density estimates between the two tortoises is consistent with a former hypothesis suggesting inter-specific competition and consequent resource partitioning. Other causes may contribute to explain the observed patterns, including the low productivity of rainforest habitats and long-term human perturbation.

Nel contesto del Progetto di riqualificazione ambientale del territorio di Capo Feto, area SIC della Provincia di Trapani si è proceduto allo studio della comunità di mammiferi dell?area. Sono state in tal modo scelte, in base alle loro caratteristiche ambientali, tre aree campione omogenee. L?attività di censimento e trappolamento si è protratta per tre diversi periodi stagionali (dal 22 al 27/10/2001, dal 19 al 24/03/2002 e dal 21 al 26/08/2002) per un totale, per ogni periodo, di 6 giorni e 5 notti trappola. Gli animali catturati sono stati registrati in apposite schede e pesati. Sono stati riportati il sesso e le condizioni riproduttive (giovane, adulto, adulto riproduttore etc.) e gli individui sono stati marcati attraverso un piccolo taglio alle orecchie, attraverso un codice di riconoscimento determinato a priori. Riguardo i micromammiferi si è effettuato un rilevamento quantitativo, attraverso la tecnica del trappolamento MCR (Cattura-marcaggio-ricattura). Sono state utilizzate 100 trappole incruente cosiddette di ?cattura e ricattura? (Ugglan modell 1, di dimensioni 250x78x65 mm). Per i mammiferi di media taglia, si è proceduto (nelle varie tipologie ambientali) con censimenti condotti di giorno e di notte (in cui tali specie mostrano maggiore attività) con l?ausilio di fari e di appositi visori per l?impiego notturno, ed attraverso rilevamenti diretti (OD: osservazione individui, esemplari rinvenuti morti) ed indiretti (OI: tracce, tane, resti ossei in borre, escrementi). Tenendo conto del basso numero di ricatture (in qualche caso uguali a zero), è stato usato l?indice di Chapman, adatto a piccoli campioni. Inoltre i dati ottenuti sono stati elaborati mediante l?indice DAT, che esprime una frequenza relativa per ogni ambiente analizzato. Per la comparazione tra i risultati (a livello di specie catturate) dei tre periodi si è utilizzato il valore medio dell?Indice di somiglianza (S) di Sorensen. I risultati dell?intero periodo di campionamento sono stati analizzati attraverso l?Indice di concentrazione di Dominanza. Complessivamente, nei tre periodi, sono stati catturati e marcati un totale di 70 micromammiferi, di cui 29 Rattus norvegicus, 17 Mus musculus, 10 R. rattus e 14 Crocidura sicula. Scorporando i risultati delle catture nei diversi periodi e per i diversi transetti, si possono evincere alcune variazioni nei popolamenti dell?area in funzione delle stagioni. Durante i diversi periodi in cui sono stati effettuati i campionamenti, infatti, l?area di Capo Feto ha mostrato differenze importanti inerenti l?umidità del suolo, che avrebbe avuto conseguenze nella composizione vegetazionale e quindi nei popolamenti dei mammiferi studiati. Sono state rilevate variazioni nei popolamenti dell?intera area, più evidenti nei riguardi di R. norvegicus e R. rattus, di minore entità riguardo il M. musculus, mentre la C. sicula si mantiene entro valori quasi costanti. I risultati totali dei trappolamenti, in cui si ha la preponderanza di R. norvegicus e M. musculus, confermerebbero il degrado dell?area in questione. Inoltre, l?area di Capo Feto sembrerebbe caratterizzata da una bassa produttività, conseguenza dell?alterazione dell?habitat, e necessita, pertanto, di immediati e profondi interventi di ripristino ambientale.

È stato studiato l'intero popolamento mammaliano, attraverso le catene trofiche, lungo un mega transetto che percorre oltre 1.500 Km lineari attraverso il mosaico foresta-piantagione con locale introgressione di foresta costiera di mangrovie e savana di Guinea, tra la Nigeria e il Camerun, due hot-spots per la biodiversità mammaliana come esempio di un popolamento afro-tropicale-occidentale. Sulla base delle nostre decennali investigazioni, risulta che esiste una sola specie di superpredatore di I grado (Python sebae), una di II grado (Panthera pardus), e, in particolare tra i mammiferi, una serie di predatori intermedi, come, ad es. Genetta spp., etc. Il rapporto numerico tra superpredatori e predatori tende a decrescere da est verso ovest, dai rilievi verso le pianure, e dagli ecosistemi frammentati fino a quelli omofitici, e, in sostanza, dalla foresta temporaneamente allagata alla mangrovia secondaria. Non ultima, grossa influenza viene attribuita alla distribuzione delle ingressioni salmastre che modellano la canopia e le sue "keystone species". Di particolare rilevanza ecologica risulta la debole correlazione che lega la presenza di superpredatori e predatori generalisti con specifiche prede "target", cioè a dire che la predicibilità della presenza-assenza di un determinato taxon predatore è scarsamente rilevata dalla comunità delle prede. Tutto ciò sembrerebbe logicamente derivare dall'azione delle popolazioni cacciatrici native che quindi equivarrebbero funzionalmente a dei superpredatori e predatori generalisti, che per loro stessa natura, non potrebbero essere tollerati dal carico corrente dell'ambiente residuo.