Acceptable outcomes of liver transplantation in uninsured patients under the coverage of a state assistance program.

The lack of health insurance is a major barrier in the access to healthcare even in case of life-saving procedures such as liver transplantation (LT). Concerns about worse outcomes in uninsured patients have also discouraged the evaluation and transplantation of patients without adequate health insurance coverage. The aim of this study is to evaluate outcomes from the largest cohort of uninsured patients who underwent LT with the support of a state payment assistance program (also called charity care). This study included all consecutive patients who underwent LT at a single center from 2002 to 2020. Demographic, clinical, social variables and outcome metrics were collected and compared between insured and uninsured patients. Among a total of 978 LT recipients, 594 had private insurance, 324 government insurance (Medicare/Medicaid), 60 were uninsured and covered under a state charity care program. In the charity care group, there was a higher proportion of Hispanic subjects, single marital status, younger age, and high-MELD score patients. The 1- and 3-year patient survival rates were 89.0% and 81.8% in private insurance patients, 88.8% and 80.1% in government insurance recipients, and 93.3% and 79.6% in those with charity care (p=0.49). There was no difference in graft survival between insured and uninsured patients (p=0.62). The three insurance groups presented similar hospital length-of-stay and 30-day readmission rates. In both univariate and multivariate analysis, uninsured status (charity care) was not associated with worse patient survival (HR:1.23, 95%CI: 0.84-1.80, p=0.29) or graft survival (HR:1.22, 95%CI:0.84-1.78, p=0.29). In conclusion, there was no difference in outcomes after LT between insured and uninsured patients. A charity care program may be an effective tool to mitigate socio-economic disparities in both outcomes and access to LT.

Trends in hospitalization for alcoholic hepatitis from 2011 to 2017: A USA nationwide study.

BACKGROUND: Severe alcoholic hepatitis (AH) is one of the most lethal manifestations of alcohol-associated liver disease. In light of the increase in alcohol consumption worldwide, the incidence of AH is on the rise, and data examining the trends of AH admission is needed. AIM: To examine inpatient admission trends secondary to AH, along with their clinical outcomes and epidemiological characteristics. METHODS: The National Inpatient Sample (NIS) database was utilized, and data from 2011 to 2017 were reviewed. We included individuals aged ≥ 21 years who were admitted with a primary or secondary diagnosis of AH using the International Classification of Diseases (ICD)-9 and its correspondent ICD-10 codes. Hepatitis not related to alcohol was excluded. The national estimates of inpatient admissions were obtained using sample weights provided by the NIS. RESULTS: AH-related hospitalization demonstrated a significant increase in the USA from 281506 (0.7% of the total admission in 2011) to 324050 (0.9% of the total admission in 2017). The median age was 54 years. The most common age group was 45-65 years (range 57.8%-60.7%). The most common race was white (63.2%-66.4%), and patients were predominantly male (69.7%-71.2%). The primary healthcare payers were Medicare (29.4%-30.7%) and Medicaid (21.5%-32.5%). The most common geographical location was the Southern USA (33.6%-34.4%). Most patients were admitted to a tertiary care center (50.2%-62.3%) located in urban areas. Mortality of AH in this inpatient sample was 5.3% in 2011 and 5.5% in 2017. The most common mortality-associated risk factors were acute renal failure (59.6%-72.1%) and gastrointestinal hemorrhage (17.2%-20.3%). The total charges were noted to range between $25242.62 and $34874.50. CONCLUSION: The number of AH inpatient hospitalizations significantly increased from 2011 to 2017. This could have a substantial financial impact with increasing healthcare costs and utilization. AH-mortality remained the same.

De novo and recurrence of metabolic dysfunction-associated fatty liver disease after liver transplantation.

Metabolic dysfunction-associated fatty liver disease (MAFLD) is a new acronym adopted from the consensus of international experts. Given the increasing prevalence of MAFLD in pre-transplant settings, de novo and recurrent graft steatosis/MAFLD are common in post-transplant settings. The impact of graft steatosis on long-term outcomes is unclear. The current knowledge of incidence rate, risk factors, diagnosis, long-term outcomes, and management of graft steatosis (both de novo and recurrent) is discussed in this review.

Liver Transplantation Beyond Milan Criteria.

Hepatocellular carcinoma (HCC) is one of the leading causes of cancer-related death worldwide, being the fifth most common cancer and the third most common cause of cancer-related mortality. The incidence of HCC has been rising in the USA over the last 20 years. Liver transplantation is an optimal treatment option, as it eliminates HCC as well as the underlying liver disease. The Milan criteria (1 lesion greater than or equal to 2 cm and less than or equal to 5 cm, or up to 3 lesions, each greater than or equal to 1 cm and less than or equal to 3 cm) have been adopted by many transplant societies worldwide as the criteria to determine whether patients with HCC can move forward with liver transplantation. However, many believe that the Milan criteria may be too strict in regard to its size requirements for lesions. This has led to a number of expanded criteria for liver transplantation, concerning both overall size and number of lesions, as well as incorporation of other markers of tumor biology. Tumor markers, such as alpha-fetoprotein, can also be used to follow treatment of HCC and possibly exclude patients from transplant. HCC presenting beyond Milan criteria can also be down-staged with locoregional therapy. Monitoring response to locoregional therapy and longer wait times after locoregional therapy prior to transplant can serve as surrogate markers of tumor biology as well.

A Case Report of Alloimmune Hepatitis after Direct-acting Antiviral Treatment in a Liver Transplant Patient.

Direct-acting antiviral (DAA) therapy is often well-tolerated, and adverse events from DAA therapy are uncommon. We report a case of a woman who underwent orthotopic liver transplant for chronic hepatitis C infection and later developed alloimmune hepatitis shortly after starting DAA therapy for recurrent hepatitis C infection. The patient developed acute alloimmune hepatitis approximately 2 weeks after starting treatment with sofosbuvir, velpatasvir, and voxilaprevir. This case report proposes a dysregulation of immune surveillance due to the DAA stimulation of host immunity and rapid elimination of hepatitis C viral load as a precipitating factor for the alloimmune process, leading to alloimmune hepatitis in a post-transplant patient who starts on DAA.

Liver Transplantation for Acute Liver Failure.

With the advent of liver transplant for acute liver failure (ALF), survival rate has improved drastically. Liver transplant for ALF accounts for 8% of all transplant cases. The 1-year survival rates are 79% in Europe and 84% in the United States. Some patients with ALF may recover spontaneously, and approximately half will undergo liver transplant. It is imperative to identify patients with ALF as soon as possible to transfer them to a liver transplant center for a thorough evaluation. Emergent liver transplant in a patient with ALF may place the patient at risk for severe complications in the postoperative period.

Iron Pill Gastritis: An Under Diagnosed Condition With Potentially Serious Outcomes.

Given the ubiquitous use of oral iron therapy, their side effects are often encountered and well recognized in clinical practice. However, iron pill gastritis remains an often under-reported and elusive diagnosis. An astute clinician should be aware of this condition in order to promptly discontinue oral iron and institute timely treatment. Here in, we present a case of a 46-year-old woman who presented to the gastroenterology clinic with vague epigastric pain and microcytic anemia. Esophagogastroduodenoscopy revealed multiple gastric erosions and non-bleeding gastric antral ulcer with biopsies showing excessive iron deposition suggestive of iron pill gastritis. We reviewed the clinical features, pathology, and treatment of iron pill gastritis along with the review of the literature.