Satellite liver transplant centres significantly improve transplant assessment outcomes for patients with chronic liver disease but not hepatocellular carcinoma: a retrospective cohort study.

Introduction: Liver transplantation (LT) remains integral to the management of end-stage chronic liver disease (CLD). However, referral thresholds and assessment pathways remain poorly defined. Distance from LT centre has been demonstrated to impact negatively on patient outcomes resulting in the development of satellite LT centres (SLTCs). We aimed to evaluate the impact of SLTCs on LT assessment in patients with CLD and hepatocellular carcinoma (HCC). Methods: A retrospective cohort study was undertaken including all patients with CLD or HCC assessed for LT at King's College Hospital (KCH) between October 2014 and October 2019. Referral location, social, demographic, clinical and laboratory data were collected. Univariable and multivariable analyses (MVA) were performed to assess the impact of SLTCs on patients being accepted as LT candidates and contraindications being identified. Results: 1102 and 240 LT assessments were included for patients with CLD and HCC, respectively. MVA demonstrated significant associations with; patients living greater than 60 min from KCH/SLTCs and LT candidacy acceptance in CLD, and less deprived patients and LT candidacy acceptance in HCC. However, neither variable was associated with identification of LT contraindications. MVA demonstrated that referrals from SLTCs were more likely to result in acceptance of LT candidacy and less likely to result in a contraindication being identified in CLD. However, such associations were not demonstrated in HCC. Conclusion: SLTCs improve LT assessment outcomes in CLD but not HCC reflecting the standardised HCC referral pathway. Developing a formal regional LT assessment pathway across the UK would improve equity of access to transplantation.

The use of tacrolimus in the management of checkpoint inhibitor immunotherapy-induced hepatitis.

Immune-mediated hepatitis is recognised as a frequently occurring complication with the use of checkpoint inhibitor immunotherapy drugs. The mainstay of treatment involves the use of immunosuppressive agents, such as corticosteroids. Mycophenolate mofetil is added when steroid resistant. However, there are limited data to guide further management when the hepatitis remains refractory to these therapies. We present two patients who developed severe immunotherapy-induced hepatitis and required prolonged immunosuppressive therapy with three agents in combination before resolution was achieved. We demonstrate that the addition of tacrolimus can be successful when other drugs fail. We also illustrate how a subsequent wean off immunosuppression can be safely performed and highlight the use of concordant antimicrobial prophylaxis to mitigate against opportunistic infections.

Helping doctors in training to STEP-UP: A leadership and quality improvement programme in the Belfast Health and Social Care Trust.

INTRODUCTION: Medical engagement in healthcare organisations can improve service development and patient experience. Doctors in training have limited opportunities to engage in service improvement work and develop leadership skills. METHOD: We describe the Specialist Trainees Engaged in Leadership Programme (STEP), a programme developed to introduce concepts of medical leadership and quality improvement skills in the Belfast Trust. STEP started in 2013 and over 140 trainees have now participated in the programme. RESULTS: Over 42 quality improvement projects have been completed with the support of the programme. Evaluation of STEP has demonstrated an improvement across all domains explored throughout the duration of the programme, with benefits for the individual trainee and the wider organisation. DISCUSSION: We describe the programme in detail. The STEP curriculum can easily be adapted to meet the needs of NHS trainees, allowing them to understand the objectives and strategy of their employers and improve their ability to plan and deliver safe, effective, patient-centred care.

What is the real function of the liver 'function' tests?

Liver enzymes are commonly used in the evaluation of patients with a range of diseases. Classically they are used to give information on whether a patient's primary disorder is hepatitic or cholestatic in origin. However, knowledge of enzyme ratios and pattern recognition allow much more information to be derived from these simple tests. This paper offers an insight to generalists on how to extractgreater information from these tests in order to improve theinvestigation and management of liver disease.