The obesity epidemic has resulted in an increased prevalence of obesity in liver transplant (LT) candidates and in non-alcoholic fatty liver disease (NAFLD) becoming the fastest growing indication for LT. LT teams will be dealing with obesity in the coming years, and it is necessary for them to recognize some key aspects surrounding the LT in obese patients. Obesity by itself should not be considered a contraindication for LT, but it should make LT teams pay special attention to cardiovascular risk assessment, in order to properly select candidates for LT. Obese patients may be at increased risk of perioperative respiratory and infectious complications, and it is necessary to establish preventive strategies. Data on patient and graft survival after LT are controversial and scarce, especially for long-term outcomes, but morbid obesity may adversely affect these outcomes, particularly in NAFLD. The backbone of obesity treatment should be diet and exercise, whilst being careful not to precipitate or worsen frailty and sarcopenia. Bariatric surgery is an alternative for treatment of obesity, and the ideal timing regarding LT is still unknown. Sleeve gastrectomy is probably the procedure that has the best evidence in LT because it offers a good balance between safety and efficacy.

Background: Fibrolamellar Carcinoma (FLC), a subtype of hepatocellular carcinoma (HCC), is a rare primary hepatic malignancy. Several aspects of the clinic features and epidemiology of FLC remain unclear because most of the literature on FLC consists of case reports and small cases series with limited information on factors that affect survival. Methods: We did a retrospective analysis of the clinical and histological characteristics of FLC. We also determined the rate of cellular proliferation in biopsies of these tumors. We assessed whether these variables were associated with survival. Results: We found 15 patients with FLC out of 174 patients with HCC (8.6%). Between patients with these neoplasms, we found statistically significant survival, age at onset, level of alpha fetoprotein, and an earlier stage of the disease. The 1, 3 and 5 year survival in patients with FLC was of 66, 40 and 26% respectively. The factors associated with a higher survival in patients with FLC were age more than 23 years, feasibility of surgical resection, free surgical borders, absence of thrombosis or invasion to hepatic vessels and the absence of alterations in liver enzymes. The size of the tumor, gender, cellular proliferation and atypia did not affect the prognosis. Conclusion: We concluded that FLC patients diagnosed before 23 years of age have worse prognosis than those diagnosed after age 23. Other factors associated with worse prognosis in this study are: lack of surgical treatment, presence of positive surgical margins, vascular invasion, and altered hepatic enzymes.

Background: Pirfenidone has demonstrated significant anti‐inflammatory and antifibrotic effects in both animal models and some clinical trials. Its potential for antifibrotic activity positions it as a promising candidate for the treatment of various fibrotic diseases. Pirfenidone exerts several pleiotropic and anti‐inflammatory effects through different molecular pathways, attenuating multiple inflammatory processes, including the secretion of pro‐inflammatory cytokines, apoptosis, and fibroblast activation.Objective: To present the current evidence of pirfenidone's effects on several fibrotic diseases, with a focus on its potential as a therapeutic option for managing chronic fibrotic conditions.Findings: Pirfenidone has been extensively studied for idiopathic pulmonary fibrosis, showing a favorable impact and forming part of the current treatment regimen for this disease. Additionally, pirfenidone appears to have beneficial effects on similar fibrotic diseases such as interstitial lung disease, myocardial fibrosis, glomerulopathies, aberrant skin scarring, chronic liver disease, and other fibrotic disorders.Conclusion: Given the increasing incidence of chronic fibrotic conditions, pirfenidone emerges as a potential therapeutic option for these patients. However, further clinical trials are necessary to confirm its therapeutic efficacy in various fibrotic diseases. This review aims to highlight the current evidence of pirfenidone's effects in multiple fibrotic conditions.

Introduction and objectives The potential benefits of branched-chain amino acids (BCAAs) in cirrhosis extend beyond just the improvement of nutritional status. Their effects include improvement of glucose tolerance, oxidative stress, and inflammatory markers, as has been shown in several studies. A dual nutritional approach of a high-protein, high-fiber diet plus BCAAs in cirrhosis could have additional benefits, compared with BCAAs alone. Such an approach has not been explored and therefore the aim of the present study was to evaluate the effect of a combination of a high-protein, high-fiber diet plus BCAA supplementation over a 6-month period of time on the nutritional status of patients with cirrhosis, as well as its safety and tolerability for those same patients. Methods: An open, randomized clinical trial was conducted. Patients were randomized to one of two groups: the BCAAs + HPHF diet intervention group: a high-protein, high-fiber diet with 1.2 g/kg protein and 30 g of fiber plus supplementation with oral branched-chain amino acids 110 g daily and the HPHF diet control group: a high-protein, high-fiber diet with 1.2 g/kg protein and 30 g of fiber. The differences between the treatment groups were compared using the unpaired T test and the differences at the end of treatment were compared using the paired T test. Results: A total of 72 patients were included, 37 in the intervention group and 35 in the control group. At the end of the study period, ammonia and glucose levels showed no significant increase in either group, reflecting the safety of the BCAA supplement. Furthermore, muscle and fat mass were evaluated through triceps skinfold thickness and mid-arm muscle circumference measurements. There was an increase in muscle mass and a decrease in fat mass in the BCAA group, but not in the control group. After the intervention, there were no significant changes in the Psychometric Hepatic Encephalopathy Score or the Critical Flicker Frequency score results in either group, and no episodes of hepatic encephalopathy were observed during the treatment period. Conclusion: Supplementation with branched-chain amino acids plus a high-fiber, high-protein diet is a safe intervention in patients with cirrhosis. It helps increase muscle mass and does not raise the levels of ammonia or glucose, nor is it associated with the development of hepatic encephalopathy. Introducción y objetivos Los beneficios potenciales de los aminoácidos de cadena ramificada (AACR) en la cirrosis se extienden más allá de solo la mejora del estado nutricional. Sus efectos incluyen la mejora de la tolerancia a la glucosa, estrés oxidativo y los marcadores inflamatorios, como se ha mostrado en varios estudios. Un abordaje nutricional dual de una dieta alta en proteína y fibra más AACR en la cirrosis podría tener beneficios adicionales, comparado con los AACR por sí solos. Tal abordaje no se ha explorado, y por lo tanto el objetivo del presente estudio fue evaluar el efecto de la combinación de una dieta alta en proteína y fibra con la suplementación de AACR durante un periodo de 6 meses sobre el estado nutricional de los pacientes con cirrosis, así como su seguridad y tolerabilidad en dichos pacientes. Métodos: Se realizó un ensayo clínico aleatorizado abierto. Los pacientes se aleatorizaron en uno de 2 grupos: el grupo de intervención con dieta de AACR + APAF: una dieta alta en proteína y fibra con 1.2 g/kg de proteína y 30 g de fibra más la suplementación con aminoácidos de cadena ramificada orales 110 g diarios y el grupo de control con dieta APAF: una dieta alta en proteína y fibra con 1.2 g/kg de proteína y 30 g de fibra. Las diferencias entre los grupos de tratamiento se compararon utilizando la prueba «t» no pareada, y las diferencias al final del tratamiento se compararon utilizando la prueba «t» pareada. Resultados: Se incluyó un total de 72 pacientes, 37 en el grupo de intervención y 35 en el grupo de control. Al final del periodo de estudio no se mostró un incremento significativo en los niveles de amonio y glucosa en ambos grupos, reflejando la seguridad del suplemento con AACR. Aún más, se evaluó la masa muscular y la grasa por medio de la medición del espesor del pliegue cutáneo del tríceps y de la circunferencia muscular en la parte media del brazo. En el grupo con AACR hubo un incremento en masa muscular y una disminución en masa grasa, pero no en el grupo de control. Después de la intervención, no hubo cambios significativos en los resultados de puntajes en el puntaje psicométrico de encefalopatía hepática o en la frecuencia crítica de fusión en cualquiera de los grupos, y no se observaron episodios de encefalopatía hepática durante el periodo de tratamiento. Conclusión: La suplementación con AACR más una dieta alta en proteína y fibra es una intervención segura en los pacientes con cirrosis. Ayuda al incremento de la masa muscular y no eleva los niveles de amonio o de glucosa, y tampoco se asocia con el desarrollo de encefalopatía hepática.