One-Year Outcomes of the Multi-Center StudY to Transplant Hepatitis C-InfeCted kidneys (MYTHIC) Trial.

INTRODUCTION: Transplanting kidneys from hepatitis C virus (HCV) viremic donors into HCV-negative patients (HCV D-RNA-positive/R-negative) has evolved from experimental to "standard-of-care" at many centers. Nevertheless, most data derive from single centers and provide only short-term follow-up. METHODS: The Multicenter Study to Transplant Hepatitis C-Infected Kidneys (MYTHIC) study was a multicenter (7 sites) trial of HCV D-RNA-positive/R-negative kidney transplantation (KT) followed by 8 weeks of glecaprevir/pibrentasvir (G/P) initiated 2 to 5 days post-KT. Prespecified outcomes included probability of KT (vs. matched waitlist comparators) and 1-year safety outcomes, allograft function, and survival. RESULTS: Among 63 enrolled patients, 1-year cumulative incidence of KT was approximately 3.5-fold greater for the MYTHIC cohort versus 2055 matched United Network for Organ Sharing (UNOS) comparators who did not opt-in to receive a kidney from an HCV-viremic donor (68% vs. 19%, P < 0.0001). Of 30 HCV D-RNA-positive/R-negative KT recipients, all achieved HCV cure. None developed clinically significant liver disease or HCV-related kidney injury. Furthermore, 1-year survival was 93% and 1-year graft function was excellent (median creatinine 1.17; interquartile range [IQR]: 1.02-1.38 mg/dl). There were 4 cases of cytomegalovirus (CMV) disease among 10 CMV-negative patients transplanted with a kidney from an HCV-viremic/CMV-positive donor. CONCLUSION: The 1-year findings from this multicenter trial suggest that opting-in for HCV-viremic KT offers can increase probability of KT with excellent 1-year outcomes. Trial Registration: NCT03781726.

Changes in County-Level Economic Prosperity Are Associated With Liver Disease-Related Mortality Among Working-Age Adults.

BACKGROUND & AIMS: There is significant variability in county-level rates of liver disease-related mortality. Although this variability is explained partly by demographics, risk factors for liver disease, and access to specialty liver care, little is known about temporal changes in mortality, and its association with economic prosperity. Therefore, we sought to explore the association between changes in county-level economic prosperity and liver disease-related mortality. METHODS: We performed a retrospective cohort study using county-level mortality data from the Centers for Disease Control and Prevention, economic prosperity measures from the Distressed Communities Index, and county-level markers of demographics, risk factors for liver disease, and access to health care. Primary analyses focused on adults aged 20 to 64 years of age. We used generalized linear mixed models (outcome = annual percentage change in age-adjusted liver disease-related mortality), with the primary exposure being an interaction between year and change in economic prosperity. RESULTS: There was an inverse relationship between county-level changes in economic prosperity and changes in county-level age-adjusted liver disease-related mortality rates (eg, counties with the smallest increase in economic prosperity had the biggest annual increase in liver disease-related mortality). In generalized linear mixed models accounting for county-level covariates, there was a significant association between economic prosperity and liver disease-related mortality, that is, for every 10-point higher mean rank for change in economic prosperity, there was an additional 0.65% decrease (95% CI, 0.19%-1.10%; P = .006) in mortality per year. CONCLUSIONS: County-level changes in economic prosperity, independent of other county-level clinical, demographic, and access-to-care variables, may play a role in population-level trends in liver disease-related deaths among the working age population.

Waitlisted Candidates With Polycystic Liver Disease Are More Likely to be Transplanted Than Those With Chronic Liver Failure.

BACKGROUND: Polycystic liver disease (PCLD) is characterized by cystic replacement of the hepatic parenchyma, leading to hepatic dysfunction, portal hypertension, and hepatomegaly. Patients with liver dysfunction and/or symptomatic disease are eligible for liver transplantation. However, little is known about these patients' waitlist outcomes relative to others with chronic liver disease. METHODS: We used Organ Procurement and Transplantation Network/United Network for Organ Sharing data from February 27, 2002 to December 31, 2015 to compare waitlist outcomes of adult patients with PCLD to those with chronic liver failure (CLF) and hepatocellular carcinoma. RESULTS: The study cohort included 620 patients with PCLD, 18 240 patients with hepatocellular carcinoma, and 98 567 patients with CLF. Compared with CLF patients, PCLD patients had significantly lower bilirubin and international normalized ratio at waitlisting, and less ascites and encephalopathy. However, they were significantly more likely to have severe chronic kidney disease. Moreover, patients with PCLD were more than 70% more likely to be transplanted compared with patients with CLF (odds ratio, 1.72; 95% confidence interval, 1.46-2.02) and had significantly longer posttransplant survival (P < 0.001). PCLD patients with exceptions were 5.7 times more likely to be transplanted than those without (odds ratio, 5.67; 95% confidence interval, 3.95-8.15) and measures of hepatic/renal dysfunction were inversely associated with the receipt of exceptions. CONCLUSIONS: Despite having more preserved liver synthetic function than patients with CLF on the waitlist, patients with PCLD are preferentially transplanted because they frequently receive exception points in an unstandardized fashion.

Outcomes and disparities in liver transplantation will be improved by redistricting-cons.

PURPOSE OF REVIEW: Over the last 2 years, the liver transplant community has been debating a proposal to redraw the maps of organ distribution. The basis for these proposed changes is reported disparities in severity of illness at transplantation across the USA - however, this is based on the allocation model for end-stage liver disease score. In this review, we provide a critical overview of the redistribution proposal, its flaws and how it may worsen outcomes and exacerbate disparities in liver transplantation. RECENT FINDINGS: The main findings we highlight are data questioning the disparity metric used to justify the redistribution. We also review data published in recent articles and presented at public forums questioning whether there truly are disparities in access to transplant care among the broader population with liver disease, and whether disparities even getting to the waitlist are important and not to be ignored. SUMMARY: This review article highlights major methodological and policy flaws with the current redistribution proposal. We demonstrate how the waitlist disparities that the proposal is intended to fix are not as they seem. Furthermore, if this proposal is passed, outcomes of liver transplantation nationally may worsen, and disparities for those with limited access to healthcare will worsen.

Liver Transplantation for Cholestatic Liver Diseases in Adults.

Liver transplantation (LT) is an established lifesaving therapy for patients with cholestatic liver diseases, including primary cholestatic diseases, namely primary sclerosing cholangitis and primary biliary cirrhosis, as well as secondary forms of cholestatic liver disease, including those with cholestatic complications of LT needing a retransplant. Patients with cholestatic liver diseases can be transplanted for complications of end-stage liver disease or for disease-specific symptoms before the onset of end-stage liver disease. These patients should be regularly assessed. Patient survival after LT for cholestatic liver diseases is generally better than for other indications.

Current trends in living donor liver transplantation for primary sclerosing cholangitis.

BACKGROUND: Use of the Model for End-Stage Liver Disease (MELD) score has improved the efficiency of allocating deceased donor organs for liver transplant. However, its use may reduce access to deceased donor livers for patients with primary sclerosing cholangitis (PSC) due to the weighting of the MELD score variables. To overcome such barriers in the post-MELD era, clinicians might refer patients with PSC, relative to patients without PSC, for living donor transplants more frequently. METHODS: To test this hypothesis, we examined patients in the United Network for Organ Sharing database from December 1, 1994, to May 31, 2009. RESULTS: In multivariable models conditioned on transplant center, patients with PSC were significantly more likely to receive a living donor transplant in both the pre-MELD (odds ratio [OR]=2.75; 95% confidence interval [CI], 2.20-3.44) and post-MELD eras (OR=4.08; 95% CI, 3.45-4.82). There was a significant interaction between PSC and post-MELD era of transplantation (OR=1.48; 95% CI, 1.11-1.97), indicating that patients with PSC were more likely to receive living donor transplants at baseline relative to patients without PSC, and that this effect was magnified following the introduction of the MELD score. CONCLUSIONS: These findings raise the possibility that allocating livers on the basis of MELD score may have yielded the unintended consequence of increasing rates for living donor transplants for patients with PSC relative to patients with other forms of end-stage liver disease. Future research is needed to determine whether the practice of selectively transplanting patients with PSC with living donor transplants is associated with differences in clinical outcomes.