Transplant Surgeon Burnout and Marital Distress in the Sandwich Generation: The Call for Organizational Support in Family Life.

Burnout (emotional exhaustion, depersonalization, and low personal accomplishment) is the enervation an individual experiences from a chronically taxing work environment. Little research has examined the demands of the sandwich generation (both children and older adults in the home) on burnout and marital satisfaction. METHODS: This is a cross-sectional survey of American and European transplant surgeons on the effects of sandwich generation-related demands on burnout and marital satisfaction, covarying for transplant surgeon age. RESULTS: A total of 286 married or partnered transplant surgeons were included. Presence (vs absence) of children in the home did not impact burnout, but those with children who reported difficulties with flexible childcare reported greater emotional exhaustion (P = .03) and depersonalization (P = .02) than those without difficulties. A total of 38.5% of married transplant surgeons reported marital distress. European transplant surgeons reported lower marital satisfaction than those from the United States (P < .01). Having an older adult in the home may also negatively impact transplant surgeons' marital satisfaction (P = .048). DISCUSSION: As health care organizations move forward with programs aimed at creating a sustainable workforce, providing professional environments supportive of important family-related demands is imperative.

Portal Vein Inflow From Enlarged Coronary Vein in Liver Transplantation: Surgical Approach and Technical Tips: A Case Report.

Portal vein thrombosis is common in patients with end-stage liver disease, with an incidence as high as 26% in liver transplant candidates. It is known to be associated with a high risk of morbidity and mortality posttransplantation, and its management can be challenging. The management options range from a simple thrombendvenectomy to multivisceral transplantation in cases with diffuse portomesenteric thrombosis. We report a case of liver transplantation in which we performed a rare reconstruction of the portal vein. Briefly, the patient had diffuse portomesenteric thrombosis, calcified aneurysmosis, and a large collateral coronary vein, to which we directly anastomosed the donor portal vein in an end-to-side fashion. This report describes a unique surgical approach for similar cases of severe portal vein thrombosis in liver transplant candidates.

Compensating the transplant professional: time for a model change.

Compensation models for physicians are currently based primarily on the work relative value unit (wRVU) that rewards productivity by work volume. The value-based payment structure soon to be ushered in by the Centers for Medicare and Medicaid Services rewards clinical quality and outcomes. This has prompted changes in wRVU value for certain services that will result in reduced payment for specialty procedures such as transplantation. To maintain a stable and competent workforce and achieve alignment between clinical activity, growth imperatives, and cost effectiveness, compensation of transplant physicians must evolve toward a matrix of measures beyond the procedure-based activity. This personal viewpoint proposes a redesign of transplant physician compensation plans to include the "virtual RVU" to recognize and reward meaningful clinical integration defined as hospital-physician commitment to specified and measurable metrics for current non-RVU-producing activities. Transplantation has been a leader in public outcomes reporting and is well suited to meet the challenges ahead that can only be overcome with a tight collaboration and alignment between surgeons, other physicians, support staff, and their respective institution and leadership.

Determinants of burnout among transplant surgeons: a national survey in the United States.

Burnout is a response to chronic strain within the workplace characterized by feelings of inefficacy (reduced personal accomplishment), cynicism (depersonalization) and emotional exhaustion. The purpose of this study was to report prevalence and explore organizational and interpersonal contributors of burnout in transplant surgeons. We performed a national cross-sectional survey of 218 transplant surgeons on sociodemographics, professional characteristics, frequency of difficult patient interactions and comfort in dealing with difficult patient interactions, decisional authority, psychological job demands, supervisor and coworker support, with burnout as the outcome. 40.1% reported high levels of emotional exhaustion, 17.1% reported high levels of depersonalization and 46.5% reported low personal accomplishment. Greater emotional exhaustion was predicted by lower decisional authority, higher psychological work demands, and lower coworker support. Greater discomfort with difficult patient interactions and lower coworker support predicted depersonalization. Lastly, lower decisional authority, lower coworker support, less frequent difficult patient interactions but greater discomfort with difficult patient interactions predicted lower personal accomplishment. The findings of this study show that unsupportive environments with little decisional control and high work-related demands contribute to the development of burnout in transplant surgeons. Implications for interventions aimed at prevention of burnout in transplant surgeons are discussed.

Clostridium difficile infection in liver transplant recipients: a retrospective study of rates, risk factors and outcomes.

Clostridium difficile infection (CDI) occurs in 3-7% of liver transplant recipients (LTR). However, few data exist on the recent epidemiology, predictors and outcomes of CDI in LTR. A cohort study was performed including LTR from 2000 to 2010 at a tertiary care hospital in Detroit. CDI was defined as diarrhea with a stool C. difficile positive test. Data analyzed included demographics, comorbidities, length of stay (LOS), severity of CDI, rates of recurrence (<12 weeks), relapse (<4 weeks) and overall mortality. Predictors of CDI were calculated using Cox proportional hazard model; 970 LTR were followed for years. Overall prevalence of CDI was 18.9%. Incidence of CDI within 1 year of transplant was 12.4%. Severe CDI occurred in 29.1%. CDI recurrence and relapse rates were 16.9% and 9.7%, respectively. Independent predictors of CDI were year of transplant (hazard ratio [HR] 1.137, 95% confidence interval [CI] 1.06-1.22; p < 0.001), white race (105/162 whites, HR 1.47, 95% CI 1.03-2.1; p = 0.035), Model for End-Stage Liver Disease score (HR 1.03, 95% CI 1.01-1.045, p = 0.003) and LOS (HR 1.01, 95% CI 1.005-1.02, p < 0.001). Significant mortality was observed among LTR with CDI compared to those without CDI (p = 0.003). We concluded that CDI is common among LTR and is associated with higher mortality.

Renal allograft outcome in recipients of positive-crossmatch combined liver-kidney transplantation.

BACKGROUND: Successful kidney transplantation despite positive crossmatch (+CXM) before transplantation is well recognized in combined liver-kidney transplant (CLKT) recipients. This is probably due to immunologic protection of the renal allograft (RA) conferred by the liver allograft. However, occurrences of antibody-mediated rejection and poor long-term RA outcome is also documented with +CXM CLKT recipients, suggesting that such immunologic protection may not be universal. METHODS: A total of 1,401 CLKT recipients with known status of pre-transplantation CXM were identified from the United Network for Organ Sharing registry from January 1, 1986, to December 31, 2006. Univariate analysis for significant differences in clinical variables and Kaplan-Meier estimate for patient and graft survivals were performed. The results were compared between positive and negative CXM groups. RESULTS: Pre-transplantation +CXM was seen in 17.3% (242/1401) of CLKT recipients studied. The demographic and clinical characteristics were similar between the groups, except for higher panel reactive antibody level and CXM positivity in female recipients. Outcome analysis showed higher RA rejection (19.3% vs 10.8%; P = .026) and increased hospital length of stay (37.3 ± 46.0 vs 28.8 ± 33.2 days; P = .028) in the +CXM group. RA survivals at 1, 3, and 5 years were 8%, 7%, and 6% lower in the +CXM group. The patient and liver allograft survivals were not different between the groups. CONCLUSIONS: In CLKT recipients with pre-transplantation +CXM, the immunologic protection of RA conferred by the liver allograft is less robust than previously perceived and may lead to higher rejection rate and poor RA outcome. This can be mitigated with routine pre-transplantation CXM.

Frequency and predictors of venous thromboembolism in orthotopic liver transplant recipients: a single-center retrospective review.

BACKGROUND: Venous thromboembolism (VTE) is a potentially fatal complication of major abdominal operations. Liver transplantation is carried out as a treatment for end-stage liver disease (ESLD). It is not well studied whether this population is at increased or decreased risk of a VTE event after a liver transplantation. This study was to determine the frequency of VTE in this population and identify possible predictors. METHODS: Retrospective review of 917 patients over 15 years at a single tertiary center was conducted. Liver transplant recipients with symptomatic VTE occurring up to 1 year after liver transplantation were included. Upper and lower extremities deep vein thrombosis (DVT) was identified. The diagnosis of DVT and pulmonary embolism (PE) was made by appropriate diagnostic imaging. Data regarding known risk factors of VTE such as thrombophilia, recent hospitalization, malignancy, and other comorbid conditions were collected. RESULTS: Among 917 patients, a total of 45 events occurred in 42 (4.58%) patients. Twelve had PE and 33 had DVT events. On Cox regression analysis the absence of an alcoholism diagnosis (Hazard Ratio [HR], -0.33; 95% confidence interval [CI], 0.13-0.83), the presence of diabetes (HR, -3.36; 95% CI, 1.76-6.42), a history of VTE (HR, -8.06; 95% CI, 3.37-19.3), and the presence of end-stage renal disease (ESRD; HR, 3.68; 95% CI, 1.34-10.01) were significant predictors of a VTE outcome. No particular diagnosis, history of malignancy, or presence of thrombophilia were associated with increased risk of VTE. CONCLUSION: The 4.58 % incidence of VTE is comparable with the reported incidence after major abdominal procedures (5%-10%). This data also shows that there is increased risk of VTE in transplant recipients with comorbid conditions of diabetes, previous VTE, and ESRD. This study suggests that a more aggressive strategy for prophylaxis of VTE should be used in liver transplant recipients as with other major abdominal procedures.

Efficacy and safety of maribavir dosed at 100 mg orally twice daily for the prevention of cytomegalovirus disease in liver transplant recipients: a randomized, double-blind, multicenter controlled trial.

Maribavir is an oral benzimidazole riboside with potent in vitro activity against cytomegalovirus (CMV), including some CMV strains resistant to ganciclovir. In a randomized, double-blind, multicenter trial, the efficacy and safety of prophylactic oral maribavir (100 mg twice daily) for prevention of CMV disease were compared with oral ganciclovir (1000 mg three times daily) in 303 CMV-seronegative liver transplant recipients with CMV-seropositive donors (147 maribavir; 156 ganciclovir). Patients received study drug for up to 14 weeks and were monitored for CMV infection by blood surveillance tests and also for the development of CMV disease. The primary endpoint was Endpoint Committee (EC)-confirmed CMV disease within 6 months of transplantation. In a modified intent-to-treat analysis, the noninferiority of maribavir compared to oral ganciclovir for prevention of CMV disease was not established (12% with maribavir vs. 8% with ganciclovir: event rate difference of 0.041; 95% CI: -0.038, 0.119). Furthermore, significantly fewer ganciclovir patients had EC-confirmed CMV disease or CMV infection by pp65 antigenemia or CMV DNA PCR compared to maribavir patients at both 100 days (20% vs. 60%; p < 0.0001) and at 6 months (53% vs. 72%; p = 0.0053) after transplantation. Graft rejection, patient survival, and non-CMV infections were similar for maribavir and ganciclovir patients. Maribavir was well-tolerated and associated with fewer hematological adverse events than oral ganciclovir. At a dose of 100 mg twice daily, maribavir is safe but not adequate for prevention of CMV disease in liver transplant recipients at high risk for CMV disease.

Transplant organizational structures: viewpoints from established centers.

This personal viewpoint report summarizes the responses of a survey targeting established transplant programs with a structured framework, such as center, institute, or department, and stability of leadership to assure valuable experiential observations. The 18-item survey was sent to 20 US institutions that met inclusion criteria. The response rate was 100%. Seventeen institutions had a distinct transplant governance structure. A majority of respondents perceived that their type of transplant structure was associated with enhanced recognition within their institution (85%), improved regulatory compliance (85%), transplant volume growth (75%), improved quality outcomes (75%) and increased funding for transplant-related research (75%). The prevailing themes in respondents' remarks were the perceived need for autonomy of the transplant entity, alignment among services and finances and alignment of authority with responsibility. Many respondents suggested that a dialogue be opened about effective transplant infrastructure that overcomes the boundaries of traditional academic department silos.

Left renal vein ligation: a technique to mitigate low portal flow from splenic vein siphon during liver transplantation.

Low portal vein flows in liver transplant have been associated with poor allograft survival. Identifying and ameliorating causes of inadequate portal flow is paramount. We describe successful reversal of significant splenic vein siphon from a spontaneous splenorenal shunt during liver transplant. The patient is a 43-year-old male with cirrhosis from hepatitis C and Budd-Chiari syndrome, who had a variceal hemorrhage necessitating an emergent splenorenal shunt with 8 mm PTFE graft. Imaging in 2006 revealed thrombosis of the splenorenal shunt and evidence of a new spontaneous splenorenal shunt. The patient developed hepatocellular carcinoma and underwent transplant in 2009. After reperfusion, portal flows were low (150-200 mL/min). A mesenteric varix was ligated without improvement. Due to adhesions, direct collateral ligation was not attempted. In order to redirect the splenic siphon, the left renal vein was stapled at its confluence with the inferior vena cava. Portal flows subsequently increased to 1.28 L/min. Postoperatively, the patient had stable renal and liver function. We conclude that spontaneous splenorenal shunts can cause low portal flows. A diligent search for shunts with understanding of flow patterns is critical; ligation or rerouting of splanchnic flow may be necessary to improve portal flows and allograft outcomes.

The influence of alcohol abuse history on the differential, longitudinal patterns of mental and physical quality of life following liver transplantation.

This prospective, longitudinal study investigated change in physical and mental health quality of life (QoL) in a sample of 65 end-stage liver disease patients before and after liver transplantation. Physical and mental health QoL were assessed using the SF-36 Physical Health Summary and Mental Health Summary, respectively. Baseline data were collected prior to transplant and follow-up data were collected at 1 and 6 months after transplantation. Repeated-measures analysis of variance results indicate that physical QoL did not improve significantly between baseline and 1-month follow-up (F = .031, P = .860) but did between 1- and 6-month follow-up (F = 20.873, P < .001). Significant between-subject effects suggested attenuated improvement for patients with alcohol abuse histories (F = 6.213, P = .017). Physical QoL did not improve between 1- and 6-month follow-up for patients with alcohol abuse history (t((13)) = -1.074, P = .112). By contrast, mental health QoL improved significantly between baseline and 1-month follow-up (F = 13.840, P < .001), but not between 1- and 6-month follow-up (F = .750, P = .391). No significant differences were found on the Mental Health Summary index based on alcohol abuse history for either time period. Post hoc multivariate analysis of variance results suggested worse functioning (F = 2.674, P = .013) for individuals with alcohol abuse history on SF-36 Physical Functioning (F = 5.55, P = .021), Body Pain (F = 13.578, P < .001), Vitality (F = 4.337, P = .040), and Social Functioning (F = 10.50, P = .002) subscales. For liver transplant patients, improvements in psychosocial functioning and QoL precede improvements in physical QoL. Attenuated physical QoL improvements for patients with alcohol abuse histories are related to greater pain and physical deficits.

Survival after liver transplantation in patients who develop renal insufficiency.

BACKGROUND: Renal insufficiency (RI) after liver transplantation (OLT) is associated with worse outcomes but the actual survival after RI ensues is not well described. We examined the survival of OLT recipients who developed moderate or severe RI or end-stage renal disease (ESRD), seeking to identify variables associated with these outcomes. METHODS: Between 1993 and 2007, 731 patients underwent OLT. After excluding patients undergoing retransplantation, combined kidney-liver grafts, and those who died within 1 year, we had a cohort of 527 subjects whose basic demographic data were obtained. Glomerular filtration rate (GFR) calculated (by MDRD4-Modification of Diet in Renal Disease 4-formula) at 3-month intervals in the first year and then at 6-month intervals. Moderate RI was defined as a GFR < 60 mL/min/1.73 m(2); severe RI, GFR < 30; and ESRD by need for dialysis or renal transplantation. We determined survival from the point of developing RI. An analysis determined factors associated with survival. RESULTS: Among 527 patients, 251 developed moderate (47.6%) and 40 (7.6%) severe RI as well as 40 (7.6%) with ESRD. Once RI ensued, the 5-year survivals for patients with moderate RI, severe RI or ESRD were 84.0%, 67.7%, and 48.5%, respectively. Five-year survival, for patients receiving a renal transplant was 100%. On multivariate Cox regression analysis, the only variables associated with time to death for patients with any RI were higher age at transplant (hazard ratio [HR] = 1.04, P = .02), higher creatinine at transplant (HR = 1.25, P = .01), pretransplant diabetes (HR = 2.34, P = .008), and transplantation in the Model for End-stage Liver Disease (MELD) era (HR = 0.15, P = .002). CONCLUSION: Development of severe RI or ESRD correlated with diminished survival. For patients with RI, age and creatinine at transplant, pretransplant diabetes, and transplantation in the pre-MELD era were associated with lower survival rates. Five-year survival for dialysis patients was somewhat higher than that previously reported but worse than that of subjects treated by renal transplantation.

Biliary complications after orthotopic liver transplantation from donors after cardiac death: broad spectrum of disease.

BACKGROUND: Donation-after-death liver transplantation (DCD-LT) carries higher complication rates compared with donation-after-brain death liver transplantation (DBD-LT). In this report we describe our experience with biliary complications in DCD-LT with emphasis on anatomical patterns and outcomes. MATERIALS AND METHODS: We performed retrospective review of patients' medical records from August 2004 to December 2008, during which time total of 26 DCD-LTs were performed. Mean follow-up was 29 months (range 3 to 51 months). RESULTS: Biliary complications occurred in 12 patients (46%), of whom 9 were related to DCD (35%). Four patients had more than 1 biliary complication, and 4 had concomitant arterial problems (stricture/thrombosis). Treatment of complications included: ERCP (n = 5, 3 resolved), conversion to roux (n = 5, 2 resolved), revision of roux (n = 1), percutaneous transhepatic cholangiography (n = 1), artery revision (n = 3). Three patients with casts had operative extraction of casts depicting a mummified biliary tree; histology showed casts and fibrosis and anastomotic suture material. Six patients underwent retransplantation (23%). Among retransplanted patients, 2 deaths occurred (7.7%). CONCLUSION: Our experience with DCD-LT reveals a high prevalence of biliary complications with a new and wide spectrum of clinicopathologic findings. Better strategies for prevention of these unique biliary complications are needed to better justify the added risks and costs for performance of DCD-LT.

The role of microscopic hematuria in the evaluation of urologic malignancy in renal transplant recipients.

Urologic malignancy is a relatively uncommon but serious complication following kidney transplantation. The reported prevalence of renal cell carcinoma (RCC) of the native kidneys is 4.4% and of bladder malignancy is 2.6%. However, presently there are no universal guidelines for prospective screening of urologic malignancies after kidney transplantation. We routinely monitored all renal transplant recipients for microscopic hematuria and persistent hematuria (>3 separate occasions) results in imaging studies (ultrasound or computed tomography scan) of both native kidneys and the allograft. Cystoscopy is performed if imaging studies are negative. This retrospective study identified a total of 18 urologic malignancies among the study cohort, which consisted of 539 patients with an incidence of 3.3% (12 cases of RCC of native kidneys [10/12 had hematuria], and six cases of bladder and ureteral malignancies [6/6 had hematuria]). There were no significant differences between cyclosporine- and tacrolimus-based immunosuppression (IS). Among RCC recipients, two lost the allograft from chronic allograft nephropathy and one patient died unrelated to malignancy. Among patients with bladder and ureteral malignancies, two lost the graft possibly from IS reduction and one had BK virus nephropathy prior to diagnosis of bladder carcinoma. In conclusion, screening transplant recipients routinely for persistent microscopic hematuria may identify urologic malignancies in renal transplant recipients.

Incidental hepatocellular carcinoma after liver transplantation: population characteristics and outcomes.

We combined data from two liver transplant centers to determine the tumor characteristics and outcomes of 51 patients transplanted with incidental hepatocellular carcinoma (iHCC) compared with 143 patients transplanted for previously known HCC (pkHCC). There were no differences in age, gender, or frequency of hepatitis C infection. Patients with iHCC were more likely to be African-American (22% vs 10%; P = .016), more likely to be screened by ultrasound (38% vs 9%; P < .001), had a lower alpha-fetoprotein (83.9 +/- 258.1 vs 572.4 +/- 2376.4 ng/mL; P = .005), and had a higher model for end-stage liver disease (MELD) score (14.3 +/- 4.1 vs 11.8 +/- 4.7; P < .001). The liver explants of patients with iHCC had smaller total tumor burden than patients with pkHCC (3.1 +/- 3.5 vs 4.1 +/- 2.6 cm; P < .001), but a similar percentage of single lesions (66% vs 65%) and tumors that met Milan criteria (76% vs 65%). Patients with iHCC had 1-, 3-, and 5-year survivals of 78%, 67%, and 58%, and 1-, 3-, and 5-year recurrence-free survivals of 90%, 87%, and 87% compared with the 1-, 3-, and 5-year survivals of 90%, 82%, and 70%, and the 1-, 3-, and 5-year tumor-free survivals of 91%, 84%, and 78% in patients with pkHCC. We concluded that patients with iHCC were more likely to be African-American, to be screened by ultrasound, to have a lower alpha-fetoprotein, and a higher MELD score. Ultrasound is not a sensitive modality for screening patients for HCC. Patients with iHCC do not have an advantage in survival over those with pkHCC.

Impact of model for end-stage liver disease on patient survival and disease-free survival in patients receiving liver transplantation for hepatocellular carcinoma.

We combined data from two transplant centers to determine the impact of the model for end-stage liver disease (MELD) allocation system on outcomes in patients undergoing liver transplantation for hepatocellular carcinoma (HCC). We compared 55 patients listed before MELD to 117 patients in the MELD era. Patients before MELD were less likely to receive a transplant (67% vs 91%) and waited a median of 127 days vs 20 days (P < .001). On an intention to treat (ITT) basis, the 1-, 3-, and 5-year survivals for patients before MELD were 79%, 60%, and 48%, and in the MELD era were 84%, 73%, and 73% (P = .055). On an ITT basis, the 1-, 3-, and 5-year tumor-free survivals before MELD were 58%, 58%, and 55% vs 83%, 74%, and 70% in the MELD era (P = .018). In patients who received a transplant, however, there were no differences in overall or tumor-free survival. In these patients, the 1-, 3-, and 5-year patient survivals were 92%, 84%, and 67% before MELD, and 90%, 81%, and 81% in the MELD era (P = .57). In transplanted patients, the 1-, 3-, and 5-year tumor-free survivals before MELD were 88%, 88%, and 83% vs 92%, 83%, and 78% in the MELD era (P = .403). On explant, patients listed before MELD had lower grade tumors (P = .046). We concluded that patients with HCC listed in the MELD era had higher and more rapid rates of transplantation with improvements in survival. However, the more efficacious rates of transplantation did not result in lower rates of tumor recurrence.

New application of the bipolar vapor plasma coagulation system for laparoscopic major liver resections.

BACKGROUND: In recent years, laparascopic techniques have become a more widely used and accepted means for performing various types of liver resections. In this report, the authors describe the use and initial applications of a new approach to laparoscopic liver resection using vapor pulse coagulation. METHODS: Liver resections using vapor plasma coagulation technology were performed for 11 patients at the authors' center. Candidates were initially selected because they had benign disease and lesions amenable to standard resections along anatomic planes. Four resections were performed with a hand-assist technique and seven without it. RESULTS: All the patients faired well. The length of the hospital stay was 3.4 +/- 0.7 days. There were no major surgical complications, bile leaks, or reoperations. None of the patients required blood transfusions. One patient was readmitted for fever and urinary tract infection, and one patient had 1 week of right leg swelling attributable to the use of stirrups. CONCLUSIONS: Vapor plasma coagulation using a laparoscopic approach for hepatic resection is a promising new technology that deserves further exploration.

One-year results with extended-release tacrolimus/MMF, tacrolimus/MMF and cyclosporine/MMF in de novo kidney transplant recipients.

Once-daily tacrolimus extended-release formulation (Prograf XL, formerly referred to as MR or MR4) was compared with the twice-a-day tacrolimus formulation (TAC) and cyclosporine microemulsion (CsA), all administered in combination with mycophenolate mofetil (MMF), corticosteroids and basiliximab induction, in a phase 3, randomized (1:1:1), open-label trial in 638 de novo kidney transplant recipients. In combination with MMF and corticosteroids, XL had an efficacy profile comparable to TAC and CsA. XL/MMF and TAC/MMF were statistically noninferior at 1-year posttransplantation to CsA/MMF for the primary efficacy endpoint, efficacy failure (death, graft loss, biopsy-confirmed acute rejection (BCAR) or lost to follow-up). One-year patient and graft survival were 98.6% and 96.7% in the XL/MMF group, 95.7% and 92.9% in TAC/MMF group and 97.6% and 95.7% in CsA/MMF group. The safety profile of XL in comparison with CsA was similar to that observed with TAC in this study and consistent with previously published reports of TAC in comparison with CsA. The results support the safety and efficacy of tacrolimus in combination with MMF, corticosteroids and basiliximab induction, as well as XL as a safe and effective once-daily dosing alternative.

Neuropsychological changes in a large sample of liver transplant candidates.

One-hundred forty-eight pre-liver transplant candidates completed a psychological interview and brief neuropsychological testing. Assessment measures included the Repeatable Battery of Neuropsychological Status, Shipley Institute of Living Scale, Trail Making Test Parts A and B (TMT-A and TMT-B), and the Folstein Mini Mental State Exam. Participants in our sample scored in the Below Average range of functioning (mean score = 100; SD = 10) on measures of memory (mean = 89.51, SD = 17.43), attention (mean = 87.62, SD = 17.23), and spatial perception (mean = 88.69, SD = 20.39). Scores reflected moderate to severe impairment in organization and processing speed (TMT-B completion time in seconds: mean = 137.22, SD = 88.64). Controlling for the effects of prior education, MELD scores were strongly correlated with poorer performance on immediate and delayed memory subtests (both P < .01), as well as with diminished attentional capacity (P = .03). MELD scores also were significantly related to slower completion times on the TMT-A and TMT-B (both P < .05). Furthermore, independent sample t tests indicated that patients with higher MELD scores (>10) experienced significantly greater difficulty with executive functioning (P < .05) and delayed memory (P < .05) than those with lower MELD scores. Thorough evaluations of cognitive functioning are needed pretransplant to identify and treat cases of subclinical hepatic encephalopathy before daily functioning becomes significantly impaired.