Hepatocellular carcinoma (HCC) is a leading cause of cancer death, with liver transplantation (LT) offering a curative option for early-stage patients who cannot undergo resection. Although LT provides good long-term outcomes within standard criteria, recurrence occurs in approximately 8–20% of recipients and often leads to poor survival. Traditionally, LT eligibility relied on strict criteria like the Milan criteria, which are effective in selecting patients with low recurrence but may exclude patients who could benefit from transplantation. In response, new expanded criteria and models using tumor biology have been developed for better risk stratification, allowing more personalized selection and management. Despite these advances, recurrence remains a major clinical challenge, with no consensus on optimal imaging timing or frequency post-LT. Treatment depends on the recurrence’s extent and location, including surgical resection and locoregional therapies. Systemic treatments are promising, especially for unresectable or extrahepatic recurrence, though most evidence comes from small retrospective studies, limiting the development of standardized protocols. Future research should focus on addressing these gaps and guiding evidence-based post-transplant care. This is a narrative review summarizing recent advances in HCC recurrence.

BACKGROUND Bile cast nephropathy (BCN) is suspected in the setting of liver disease and hyperbilirubinemia and is characterized by the formation of tubular bile casts and acute tubular injury. While postmortem studies reveal a high prevalence of BCN, little is known about this orphan acute kidney injury syndrome. AIM To address this knowledge gap, we performed a systematic review of case reports and case series of BCN, focusing on risk factors, diagnostic criteria, clinical presentation, kidney biopsy findings, severity, treatment approaches, and outcomes. METHODS Electronic databases were searched to identify eligible studies of patients with possible, probable, or definite BCN, using pre-established criteria. Relevant variables were extracted and analyzed. We explored the impact of serum total bilirubin levels and alcoholic liver disease on BCN severity and outcomes by stratifying cases into total bilirubin tertiles and alcoholic vs . non-alcoholic liver disease. Univariate and multivariable logistic regression analyses were used to examine factors associated with the composite outcome of dialysis requirement or death. RESULTS Sixty-seven case reports and six case series (involving 2 patients each) met the inclusion criteria, totaling 79 cases of BCN. The mean age was 48.3 years, and 83.5% were men. The most common cause of liver disease was drug-induced injury (30.4%), followed by infection (18.9%) and alcoholism (12.7%). BCN diagnosis was deemed definite, probable, and possible in 65.8%, 32.9%, and 1.3% of cases, respectively. Levels of serum creatinine, dialysis requirement, and renal recovery did not differ among the total bilirubin tertile groups. However, both initial and peak serum creatinine were significantly higher in the alcoholic liver disease group compared to the non-alcoholic group (P = 0.011 and P = 0.012, respectively). There was also a non-significant trend toward a higher incidence of dialysis requirement or death in the alcoholic liver disease group (80% vs 52%, P = 0.098). Finally, higher initial serum creatinine (per 1 mg/dL increase) was independently associated with dialysis requirement or death (adjusted odds ratio 1.291, 95% confidence interval: 1.032-1.615, P = 0.025). CONCLUSION BCN is a common and potentially serious cause of acute kidney injury in patients with liver disease. The degree of hyperbilirubinemia does not appear to correlate with BCN severity or outcomes. However, in alcoholic liver disease, BCN is associated with a greater rise in serum creatinine and a trend toward worse outcomes compared to non-alcoholic liver disease. Serum creatinine may be a valuable predictor of BCN prognosis. Further studies are needed to develop non-invasive diagnostic tools and establish effective treatments for BCN.

Background: Propofol, a commonly used agent for short- and long-term sedation, is associated with acute pancreatitis. The main indirect mechanism of propofol-associated acute pancreatitis is by inducing hypertriglyceridemia. Patients with severe coronavirus disease 2019 (COVID-19) pneumonia often require prolonged mechanical ventilation and sedation. We examined the incidence rate of acute pancreatitis among critically ill adults with COVID-19 pneumonia on mechanical ventilation receiving propofol. In addition, we attempted to determine cutoff levels of serum triglycerides and doses of propofol that are predictive of propofol-associated acute pancreatitis. Methods: This was a multicenter retrospective cohort study using a large dataset of hospitalized patients with COVID-19. The collected data included the number of days on propofol, cumulative doses of propofol, peak levels of serum triglycerides, serum lipase levels, and abdominal imaging findings. We used receiver-operating characteristic analysis in conjunction with Youden's index to identify the optimal thresholds for propofol administration parameters and levels of triglycerides that would provide maximal sensitivity and specificity for predicting acute pancreatitis. Results: Out of 499 critically ill patients with COVID-19 pneumonia, 154 met the inclusion criteria. Six (4%) patients had suspected acute pancreatitis based on elevated serum lipase levels. Cutoff values greater than 688 mg/dL for peak level of triglycerides, 4.5 days on propofol, 3007 mg/day for average daily propofol dose, and 24 113 mg for cumulative propofol dose were associated with high risk of suspected acute pancreatitis. The negative predictive values for suspected acute pancreatitis using these cutoffs ranged from 98% to 100%. Conclusions: Propofol use in critically ill COVID-19 patients is associated with a low incidence rate of acute pancreatitis. We identified cutoff values for serum triglycerides and cumulative propofol dose that are linked to higher risk of propofol-associated pancreatitis. More research is needed to examine the true incidence of propofol-associated pancreatitis and help develop optimal cutoff values for certain parameters to help guide safe propofol administration.

Gastroenterologists are often the first to encounter patients with metabolic dysfunction-associated steatotic liver disease (MASLD), the most common chronic liver disease worldwide. While MASLD can lead to cirrhosis and hepatocellular carcinoma, cardiovascular disease (CVD) remains the leading cause of mortality in this population. This heightened risk is largely driven by the strong association between MASLD and CVD risk factors, including type 2 diabetes, obesity, and hypertension. Therefore, addressing metabolic health is a fundamental component of MASLD management. Gastroenterologists play a key role in identifying metabolic risk factors, recommending lifestyle, and pharmacologic interventions, in consultation with specialists or multidisciplinary care teams when appropriate. This review provides a practical framework for integrating metabolic health optimization into routine MASLD care, equipping gastroenterologists with the necessary tools to improve both liver-related and overall patient outcomes.