De Novo Autoimmune Hepatitis after COVID-19 Infection in an Unvaccinated Patient.

Liver test abnormalities have been described during severe acute respiratory syndrome coronavirus (SARS-CoV)-2 infection causing coronavirus disease 2019. Most of them consist of elevation of the aminotransferases that resolve once the infection subsides. There are several reports of autoimmune hepatitis developing after vaccination against COVID-19 and one case of autoimmune hepatitis following COVID-19 infection. We present a patient that was not vaccinated against COVID-19 and developed resistant de novo autoimmune hepatitis following COVID-19 infection requiring aggressive immunosuppression.

Prevalence and Susceptibility to Hepatitis B virus and the Need for Community Health Education in Milwaukee's Hmong Community.

BACKGROUND: Chronic Hepatitis B virus infection, the leading cause of hepatocellular carcinoma worldwide, disproportionately affects Asian Pacific Islanders (APIs) within the USA. Among APIs, the Hmong have one of the highest rates of chronic HBV infection-up to 18% compared to 0.1% for non-Hispanic Caucasians. This study sought to estimate the prevalence of HBV infection and assess the need for community HBV education within Milwaukee County's Hmong. METHODS: Between 3/2013 and 12/2019, 287 Hmong participants were screened for HBV and 271 were provided targeted HBV education to evaluate its impact on HBV knowledge. RESULTS: Among participants screened, 178 (62%) were immune; 77 (27%) susceptible; 27 (9%) positive; and 5 (2%) in a "gray zone." Targeted health education showed statistically significant improvement in HBV knowledge. DISCUSSION: With 38% lacking immunity to HBV and 9% with active infection, there remains a significant need for HBV screening, vaccination, and education in Milwaukee's Hmong community.

Ecological Study of Variability in the Relationship between Liver Cancer Mortality and Racial Residential Segregation.

Racial segregation has been identified as a predictor for the burden of cancer in several different metropolitan areas across the United States. This ecological study tested relationships between racial segregation and liver cancer mortality across several different metropolitan statistical areas in Wisconsin. Tract-level liver cancer mortality rates were calculated using cases from 2003-2012. Hotspot analysis was conducted and segregation scores in high, low, and baseline mortality tracts were compared using ANOVA. Spatial regression analysis was done, controlling for socioeconomic advantage and rurality. Black isolation scores were significantly higher in high-mortality tracts compared to baseline and low-mortality tracts, but stratification by metropolitan areas found this relationship was driven by two of the five metropolitan areas. Hispanic isolation was predictive for higher mortality in regression analysis, but this effect was not found across all metropolitan areas. This study showed associations between liver cancer mortality and racial segregation but also found that this relationship was not generalizable to all metropolitan areas in the study area.

Hepatitis B Screening and Awareness in the Milwaukee Hmong Community.

INTRODUCTION: Hepatitis B virus (HBV) infection disproportionately affects the Hmong ethnic group, with reported US prevalence rates up to 20%, but data for Wisconsin's large Hmong community is lacking. We assessed the prevalence of HBV at Hmong screening events and whether small-group counseling affects HBV knowledge. METHODS: Free HBV screening events were held in Milwaukee, Wisconsin at a Hmong market, a local church, and annual Hmong New Year festival. Eligible Hmong subjects age 18 years and older also were invited to complete a 15-point survey on HBV knowledge at baseline and after education sessions. Hmong interpreters were available, and free HBV screening was offered. RESULTS: A total of 187 participants were tested for HBV, and 161 completed surveys. After education sessions, the mean knowledge score rose to 10.6 (71%) vs the pre-education score of 6.7 (45%) (P <0.0001). Active HBV [HBsAg(+) HBsAb(-)] was diagnosed in 18 participants (9.6%), 53 (28.3%) were susceptible [HBsAg(-) and HBsAb(-)], 5 (3.4%) were in the gray zone [HBsAg(-) with low/inadequate HBsAb(+) titer], and the remaining 110 (58.8%) were immune [HBsAg(-)/HBsAb(+)]. Of the 18 individuals with active HBV, 13 were male and 5 were female [age range 24-66]. CONCLUSION: Despite evidence that small-group education with visual aids is effective in enhancing HBV knowledge in the Hmong population, a significant knowledge gap remained on post-education scores, suggesting that better tools or repeated interventions may be warranted. While we acknowledge that this convenience sampling may have introduced biases, the rate of active HBV infection in Wisconsin is much higher than general US population reports, and a quarter of those tested were found to be susceptible to HBV.

Real-world experiences with direct-acting antiviral agents for chronic hepatitis C treatment.

As direct-acting antiviral (DAA) agents become more readily available for the treatment of chronic hepatitis C, it is important to understand real-world treatment experiences. In order to assess the effectiveness of DAA regimens and factors that influence sustained virologic response (SVR) rates in the Veterans Affairs healthcare system, we retrospectively identified veterans with chronic hepatitis C who were treated with DAAs from January 2014 to June 2015. We determined SVR rates and collected data on demographics, genotype (GT), previous interferon-based treatment, antiviral regimens, and co-morbidities (HIV, prior solid organ transplant, haemodialysis) for analysis. Of 15 720 veterans, the majority were infected with genotype 1a (GT1a, 60.5%). Excluding the special populations, the overall cohort SVR rate was 92%. Compared to treatment-experienced patients, treatment-naïve patients had significantly higher SVR rates (90% vs 92%, P = .006). Subgroups associated with lower likelihood of achieving SVR-included African Americans (OR 0.79, 95% CI 0.69-0.91), GT3 (OR 0.65, CI 0.50-0.86), and cirrhosis (OR 0.91, CI 0.84-0.99) or decompensated cirrhosis (ascites: OR 0.78, CI 0.67-0.91, variceal bleed: OR 0.75, CI 0.57-0.99). The only treatment regimen independently associated with lower SVR rates was SOF+RBV+IFN (OR 0.65, CI 0.50-0.84). Special populations achieved high SVR rates: HIV 92%, haemodialysis 93%, liver transplant 96% and renal transplant 94%. In conclusion, overall SVR rates were comparable to those reported in clinical trials and carried over to historically more difficult-to-treat patients. Several patient- and treatment-related factors were identified as independent predictors of treatment failure and suggest subgroups to target for efforts to improve therapeutic strategies.

Racial disparities of liver cancer mortality in Wisconsin.

PURPOSE: To calculate tract-level estimates of liver cancer mortality in Wisconsin and identify relationships with racial and socioeconomic variables. METHODS: County-level standardized mortality ratios (SMRs) of liver cancer in Wisconsin were calculated using traditional indirect adjustment methods for cases from 2003 to 2012. Tract-level SMRs were calculated using adaptive spatial filtering (ASF). The tract-level SMRs were checked for correlations to a socioeconomic advantage index (SEA) and percent racial composition. Non-spatial and spatial regression analyses with tract-level SMR as the outcome were conducted. RESULTS: County-level SMR estimates were shown to mask much of the variance within counties across their tracts. Liver cancer mortality was strongly correlated with the percent of Black residents in a census tract and moderately associated with SEA. In the multivariate spatially-adjusted regression analysis, only Percent Black composition remained significantly associated with an increased liver cancer SMR. CONCLUSIONS: Using ASF, we developed a high-resolution map of liver cancer mortality in Wisconsin. This map provided details on the distribution of liver cancer that were inaccessible in the county-level map. These tract-level estimates were associated with several racial and socioeconomic variables.

Attitudes of Liver and Palliative Care Clinicians toward Specialist Palliative Care Consultation for Patients with End-Stage Liver Disease.

Objective: Delays in specialized palliative care (PC) consultation in end-stage liver disease (ESLD) patients may be explained by clinician attitudes toward PC. Our aim is to assess the attitudes of hepatology and liver transplant (HLT) and PC clinicians toward PC consultation and consultant roles in ESLD patient care. Methods: Clinician members of HLT and PC professional societies were surveyed. Using a five-point Likert scale, they rated their comfort level toward various PC consultant roles and their agreement with triggers for and reasons to defer PC consultation. Change in attitudes toward PC consultation resulting from liver transplant (LT) eligibility was evaluated. Results: A total of 311 HLT (6.2%) and 379 PC (8.1%) clinicians completed the survey. The vast majority of HLT clinicians (>80%) were comfortable if PC consultants palliate symptoms, provide support, or facilitate advance care planning in LT-ineligible patients. LT eligibility reduced HLT clinician comfort toward all PC consultant roles, except supportive care. A vast majority of PC clinicians (>90%) were comfortable assuming all PC roles, except pain management without opioids (43-51%). About 80% of HLT clinicians agree with PC consultation in LT-ineligible patients with decompensated cirrhosis or hepatocellular carcinoma (HCC), compared to 20-30% if LT ineligible. Common justifications for deferring PC consultation included mild disease, LT eligibility, unavailability of PC specialists, and lack of addressable palliative issues. Conclusions: Barriers to specialized PC consultation in ESLD include HLT clinician discomfort with PC consultant roles, patients' LT eligibility, perception that PC is end-of-life care, unclear triggers for PC consultation, and concern about opioid-based pain palliation.

Effect of Donor Race-Matching on Overall Survival for African-American Patients Undergoing Liver Transplantation for Hepatocellular Carcinoma.

BACKGROUND: Liver transplantation (LT) is the preferred treatment for early hepatocellular carcinoma (HCC) in select patients. Differences in outcomes after LT have been previously described between recipient races, but the role of donor race is not well defined. This study sought to examine the effect of donor-recipient race-matching on overall survival after liver transplantation for HCC in African-American patients (AA). STUDY DESIGN: Adult AA patients with HCC undergoing liver transplantation were identified using the Organ Procurement and Transplantation Network database (1994 to 2015). Recipient and donor demographic and clinical characteristics were collected. Patients were separated into unadjusted cohorts based on whether the liver donor was AA (matched) or another race (unmatched). The primary outcome was overall survival, which was analyzed by log-rank test and graphed using the Kaplan-Meier method. Multivariate regression modeling was used to determine adjusted hazard ratios (HR) for overall survival. RESULTS: Of 1,384 AA patients identified, 325 (23.5%) were race-matched. Matched patients experienced significantly better median overall survival when compared with the unmatched cohort (135 vs 78 months, p = 0.007). Multivariate analysis revealed an adjusted hazard ratio of 0.66 for race-matched transplantation (95% CI 0.49 to 0.88; p = 0.004). Matched patients also experienced an improved 5-year survival (64.2% vs 56.9%; p = 0.019). CONCLUSIONS: African-American HCC patients undergoing liver transplantation experienced significantly improved overall survival when the donor race matched the recipient race. Donor-recipient race-matching remained an independent predictor of improved survival after adjusting for comorbidities and disease characteristics. Race-matching should be considered in the process of organ allocation because it may affect long-term survival in African-American HCC patients.

Persistence of Schistosoma japonicum DNA in a Kidney-Liver Transplant Recipient.

Mitochondrial genome analysis of Schistosoma japonicum suggests that diversity of intermediate host snails drove intra-species divergence during its expansion in Asia. We applied the knowledge of this genomic variation to study an unusual patient we recently diagnosed with schistosomiasis. The patient had not visited any schistosomiasis-endemic countries for more than 35 years and had no idea where she became infected. Unusual clinical features of this patient included the absence of egg granulomas in tissue and persistent noncalcified eggs despite multiple praziquantel (PZQ) treatments over 7 years. A digital droplet polymerase chair reaction (PCR) assay that specifically targets the schistosome 1,4 dihydronicotinamide adenine dinucleotide-1 (NADH1) dehydrogenase-1 mitochondrial gene successfully amplified parasite DNA extracted from colon biopsies. DNA sequence analysis of parasite DNA revealed that it was a Philippine strain of S. japonicum. Future molecular studies using stored DNA from patients such as this may provide new insight into why some persons do not respond well to PZQ treatment.

Hepatitis C virus direct-acting antiviral nonadherence: Relationship to sustained virologic response and identification of at-risk patients.

OBJECTIVES: There is a dearth of literature on effects of nonadherence to hepatitis C virus (HCV) direct-acting antiviral (DAA) regimens; thus, the objective of our study was to assess the impact of adherence on sustained virologic response (SVR) and evaluate factors associated with nonadherence, such as race, psychiatric comorbidities, and therapy length. METHODS: We conducted a retrospective cohort study of patients completing DAA treatment between January 2014 and May 2016 within an interdisciplinary hepatology clinic. Adherence was defined a priori as 95% or greater of DAA doses taken within the prescribed treatment period. Post hoc analyses were done with adherence thresholds ≥ 90%, ≥ 85%, and ≥ 80% and adherence as a continuous percentage. Patients lost to follow-up before completing therapy or that discontinued therapy early were excluded from analyses. The association between adherence and SVR rates was assessed using Fisher exact test (for adherence thresholds) and the Wilcoxon rank-sum test (for continuous adherence). Factors associated with adherence were assessed similarly using Fisher exact and Wilcoxon rank-sum tests and multivariable logistic regression. RESULTS: Overall adherence was high, with an average of 97.8% of DAA doses taken within the prescribed treatment period. Achievement of SVR was not significantly different in adherent and nonadherent patients, at an adherence threshold of 95% or greater (93.4% vs. 88.5%; P = 0.246) or any of the post hoc adherence thresholds (≥ 90% [93.3% vs. 84.0%; P = 0.098], ≥ 85% [92.8% vs. 91.7%; P = 0.601], ≥ 80% [92.9% vs. 80.0%; P = 0.315], or as a continuous percentage [P = 0.328]). Black patients were significantly more likely to be nonadherent to DAAs than non-black patients at each adherence threshold (P < 0.05). No other factors evaluated were associated with nonadherence. CONCLUSION: A numerically higher but not statistically significant SVR failure rate was noted in nonadherent patients, although the gold standard definition for adherence remains to be established. Black patients may require additional adherence support.

Risk, Outcomes, and Predictors of Clostridium difficile Infection in Lymphoma: A Nationwide Study.

OBJECTIVE: The risk of Clostridium difficile infection (CDI) has not been well studied in patients with lymphoma. We thus sought to determine the risk of CDI in hospitalizations with lymphoma along with its trend, outcomes, and predictors using a large database. METHODS: Hospital discharge data from the Nationwide Inpatient Sample (NIS) from 2007 to 2011 were used for the study. Using the International Classification of Diseases, Ninth Revision, Clinical Modification codes, all adult patients aged 18 years or older having a primary diagnosis of lymphoma were queried for the presence of CDI as any of the secondary diagnoses. The risk of CDI in lymphoma and its yearly trend were assessed. We performed multivariate logistic regression to determine the independent risk factors of CDI in lymphoma. Furthermore, we studied mortality and other adverse outcomes of CDI in patients with lymphoma. RESULTS: There were 236,312 discharges (weighted) with the primary diagnosis of lymphoma. CDI was present in 2.13% of patients with lymphoma versus 0.8% in the nonlymphoma group (P < 0.001). On multivariate analysis, the significant predictors of CDI in lymphoma were presence of infection (odds ratio [OR] 3.1, 95% confidence interval [CI] 2.7-3.6), stem cell transplant (OR 2.7, 95% CI 2.3-3.4), graft-versus-host disease (OR 1.9, 95% CI 1.4-2.8), race (Asian vs white, OR 1.6, 95% CI 1.1-2.4), chemotherapy (OR 1.6, 95% CI 1.4-1.8), gastrointestinal surgery (OR 1.4, 95% CI 1.2-1.7), and Charlson Comorbidity Index (CCI) (CCI of 2 vs 0-1: OR 1.2, 95% CI 1.1-1.4; CCI of 3 vs 0-1: OR 1.3, 95% CI 1.03-1.6). CDI in lymphoma was associated with worse hospital outcomes such as increased mortality (17% vs 8%), increased length of stay (23.6 vs 9.9 days), mean total hospital charges ($197,015 vs $79,392), rate of intubation (13% vs 4% vs 13%), and rate of total parenteral nutrition (11% vs 3%). CONCLUSIONS: Hospitalization with lymphoma was associated with an increased risk of CDI. The significant predictors for CDI in lymphoma were infection, stem cell transplant, graft-versus-host disease, race, chemotherapy, gastrointestinal surgery, and Charlson Comorbidity Index. CDI in lymphoma was associated with increased mortality and other adverse outcomes warranting a need of more vigilance for CDI in patients with lymphoma.

Advanced Age Does Not Negatively Impact Health-Related Quality of Life in Inflammatory Bowel Disease.

BACKGROUND: Health-related quality of life (HRQoL) is significantly impacted in patients with inflammatory bowel disease (IBD). Many studies have assessed HRQoL in patients of all ages, and few focus on the elderly. AIM: To determine the influence of advanced age (> 65 years) and age at diagnosis on patients with IBD. METHODS: This is a retrospective study of prospectively collected data from a single IBD tertiary referral center. Patients had disease activity indices [Harvey-Bradshaw index (HBI), Ulcerative Colitis Disease Activity Index (UCDAI), and Short Inflammatory Bowel Disease Questionnaire (SIBDQ)] recorded during every clinic visit. Three groups of patients: > 65 years, 41-64 years, and < 40 years with > 5 SIBDQ entries were included. Influence of disease type, disease duration, extent of involvement, and comorbidities such as cardiovascular (CV) disease, pulmonary disease, diabetes mellitus (DM), and psychological disorders were noted as confounders. Statistical analysis was performed using ANOVA, Pearson correlation, and logistic regression model. RESULTS: Disease severity indices significantly affected SIBDQ score in both Crohn's disease (CD) and ulcerative colitis (UC) (p < 0.001 for HBI in CD, p < 0.001 UCDAI in UC). Disease extent (p = 0.011) and psychological disorders (p < 0.001) significantly affected SIBDQ score in CD. Chronological age, age at diagnosis, disease duration, number of clinic visits, CV disease, pulmonary disease, and DM were not significant predictors of SIBDQ score (p > 0.05). CONCLUSIONS: HRQoL was negatively influenced by disease extent and psychological disorders in CD but not in UC patients. Advanced age was not a predictor of poor HRQoL in both CD and UC.

Assessment of Adherence to Baseline Quality Measures for Cirrhosis and the Impact of Performance Feedback in a Regional VA Medical Center.

Baseline adherence to cirrhotic quality improvement measures was assessed and a system to improve adherence with provider performance feedback was developed, with impact of feedback measured over time. A 6-year retrospective database was created of cirrhotic patients seen between 2006 and 2012, and reviewed for hepatitis A and B serologies, hepatocellular carcinoma (HCC) screening, variceal screening, and vaccinations. Cumulative performance feedback was distributed to providers. In all, 265 charts were reviewed retrospectively. Charts were reviewed prospectively at 30 days, 60 days, 6 months, and 12 months. Variceal screening, alpha-fetoprotein, HCC imaging, Pneumovax, lifetime influenza vaccination, hepatitis B vaccination, and hepatitis A serology compliance improved from baseline until 6 months. Hepatitis A vaccination declined at 60 days, but improved from baseline at 6 months. Hepatitis B serology improved from baseline over 12 months. Results were compared graphically. Periodic "cumulative provider performance feedback" is a simple and effective method to improve and maintain adherence to quality measures for cirrhosis.

Increased Rate of Venous Thromboembolism in Hospitalized Inflammatory Bowel Disease Patients with Clostridium Difficile Infection.

BACKGROUND: Risk of venous thromboembolism (VTE) in patients with inflammatory bowel disease (IBD) is well established; however, there is paucity of data on the potential added risk of VTE in patients with IBD with Clostridium difficile infection (CDI). We sought to study the difference in VTE rates in hospitalized patients with IBD with CDI compared to those without CDI. METHODS: We queried Nationwide Inpatient Sample from year 2011 to identify patients ≥18 years of age with a discharge diagnosis of IBD (i.e., Crohn's disease and ulcerative colitis) based on ICD-9-CM codes 555.xx and 556.xx, respectively. Patients were further divided into 2 groups: those with and without CDI. To adjust and control for potential baseline differences between groups, 1:1 propensity matching was performed. Multivariate regression analysis was used to evaluate the difference in VTE rates in 2 groups. RESULTS: Of 312,147 patients with the discharge diagnosis of IBD, 12,560 (4%) had CDI. VTE was present 6% in group with CDI versus 3% in group without CDI (P < 0.001). On performing multivariate analysis after propensity-score matching, CDI was significantly associated with VTE (adjusted odds ratio 1.7, 95% confidence interval 1.4-2.2, P < 0.001). On subgroup analysis, Crohn's disease with CDI had a higher association with VTE compared with Crohn's disease only. Similarly, ulcerative colitis with CDI had a higher association with VTE compared with ulcerative colitis only. CONCLUSIONS: Rate of VTE was higher in hospitalized patients with IBD with CDI compared with those without CDI, necessitating extra vigilance in this patient population.

A Fatal Case of Erdheim-Chester Disease with Hepatic Involvement.

Erdheim-Chester disease (ECD) is a rare form of systemic histiocytosis, typically presenting with striking osseous involvement characterized by bilateral osteosclerosis and involvement of organs such as the lung, pituitary gland, heart, and brain. Liver involvement with ECD is extremely uncommon. We report a 56-year-old woman presenting with newly diagnosed cirrhosis and signs concerning for intra-abdominal malignancy, including omental caking and peritoneal thickening. Liver biopsy demonstrated xanthogranulomatous infiltration from ECD. The patient showed initial improvement with interferon therapy, but she developed severe depression, which led to the discontinuation of the treatment. Shortly afterward, she died from progressive liver dysfunction resulting in hepatorenal syndrome.

A Novel Protocol Obviates Endoscope Sampling for Carbapenem-Resistant Enterobacteriaceae: Experience of a Center with a Prior Outbreak.

BACKGROUND: Numerous published outbreaks, including one from our institution, have described endoscope-associated transmission of multidrug-resistant organisms (MDROs). Individual centers have adopted their own protocols to address this issue, including endoscope culture and sequestration. Endoscope culturing has drawbacks and may allow residual bacteria, including MDROs, to go undetected after high-level disinfection. AIM: To report the outcome of our novel protocol, which does not utilize endoscope culturing, to address our outbreak. METHODS: All patients undergoing procedures with elevator-containing endoscopes were asked to permit performance of a rectal swab. All endoscopes underwent high-level disinfection according to updated manufacturer's guidance. Additionally, ethylene oxide (EtO) sterilization was done in the high-risk settings of (1) positive response to a pre-procedure risk stratification questionnaire, (2) positive or indeterminate CRE polymerase chain reaction (PCR) from rectal swab, (3) refusal to consent for PCR or questionnaire, (4) purulent cholangitis or infected pancreatic fluid collections. Two endoscopes per weekend were sterilized on a rotational basis. RESULTS: From September 1, 2015 to April 30, 2016, 556 endoscopy sessions were performed using elevator-containing endoscopes. Prompted EtO sterilization was done on 46 (8.3%) instances, 3 from positive/indeterminate PCR tests out of 530 samples (0.6%). No CRE transmission was observed during the study period. Damage or altered performance of endoscopes related to EtO was not observed. CONCLUSION: In this pilot study, prompted EtO sterilization in high-risk patients has thus far eliminated endoscope-associated MDRO transmission, although no CRE infections were noted throughout the institution during the study period. Further studies and a larger patient sample will be required to validate these findings.

Changes in the Prevalence of Hepatitis C Virus Infection, Nonalcoholic Steatohepatitis, and Alcoholic Liver Disease Among Patients With Cirrhosis or Liver Failure on the Waitlist for Liver Transplantation.

BACKGROUND & AIMS: Concurrent to development of more effective drugs for treatment of hepatitis C virus (HCV) infection, there has been an increase in the incidence of nonalcoholic fatty liver disease. Data indicate that liver transplantation prolongs survival times of patient with acute hepatitis associated with alcoholic liver disease (ALD). We compared data on disease prevalence in the population with data from liver transplantation waitlists to evaluate changes in the burden of liver disease in the United States. METHODS: We collected data on the prevalence of HCV from the 2010 and 2013-2014 cycles of the National Health and Nutrition Examination Survey. We also collected data from the HealthCore Integrated Research Database on patients with cirrhosis and chronic liver failure (CLF) from 2006 through 2014, and data on patients who received transplants from the United Network for Organ Sharing from 2003 through 2015. We determined percentages of new waitlist members and transplant recipients with HCV infection, stratified by indication for transplantation, modeling each calendar year as a continuous variable using the Spearman rank correlation, nonparametric test of trends, and linear regression models. RESULTS: In an analysis of data from the National Health and Nutrition Examination Survey (2013-2014), we found that the proportion of patients with a positive HCV antibody who had a positive HCV RNA was 0.5 (95% confidence interval, 0.42-0.55); this value was significantly lower than in 2010 (0.64; 95% confidence interval, 0.59-0.73) (P = .03). Data from the HealthCore database revealed significant changes (P < .05 for all) over time in percentages of patients with compensated cirrhosis (decreases in percentages of patients with cirrhosis from HCV or ALD, but increase in percentages of patients with cirrhosis from nonalcoholic steatohepatitis [NASH]), CLF (decreases in percentages of patients with CLF from HCV or ALD, with an almost 3-fold increase in percentage of patients with CLF from NASH), and hepatocellular carcinoma (HCC) (decreases in percentages of patients with HCC from HCV or ALD and a small increase in HCC among persons with NASH). Data from the United Network for Organ Sharing revealed that among patients new to the liver transplant waitlist, or undergoing liver transplantation, for CLF, there was a significant decrease in the percentage with HCV infection and increases in percentages of patients with nonalcoholic fatty liver disease or ALD. Among patients new to the liver transplant waitlist or undergoing liver transplantation for HCC, proportions of those with HCV infection, nonalcoholic fatty liver disease, or ALD did not change between 2003 and 2015. CONCLUSIONS: In an analysis of 3 different databases (National Health and Nutrition Examination Survey, HealthCore, and United Network for Organ Sharing), we found the proportion of patients on the liver transplant waitlist or undergoing liver transplantation for chronic HCV infection to be decreasing and fewer patients to have cirrhosis or CLF. However, the percentages of patients on the waitlist or receiving liver transplants for NASH or ALD are increasing, despite different relative burdens of disease among the entire population of patients with cirrhosis.

Outcome analysis of continuous intraoperative renal replacement therapy in the highest acuity liver transplant recipients: A single-center experience.

BACKGROUND: Orthotopic liver transplantation is the definitive treatment modality for patients with end-stage liver disease. Pre-orthotopic liver transplantation renal dysfunction has a significant negative influence on outcomes post-orthotopic liver transplantation. Intraoperative renal replacement therapy is an adjunctive therapy to address the metabolic challenges during orthotopic liver transplantation in patients with a high acuity of illness. The impact of intraoperative renal replacement therapy on post-orthotopic liver transplantation outcomes, however, is unclear. METHODS: From October of 2012 to April of 2016, 96 adult patients underwent orthotopic liver transplantation for end-stage liver disease. Three groups were identified: (1) Group I: patients with pre-orthotopic liver transplantation renal dysfunction who underwent intraoperative renal replacement therapy, (2) Group II: patients with pre-orthotopic liver transplantation renal dysfunction who did not receive intraoperative renal replacement therapy, and (3) Group III: patients with orthotopic liver transplantation without evidence of pretransplant renal dysfunction. RESULTS: At 17.7 months follow-up, there was no difference in survival among the study groups. Physiologic model for end-stage liver disease at the time of orthotopic liver transplantation was significantly higher in both groups with renal dysfunction (I = 43, II = 39) than in Group III (18). Post-orthotopic liver transplantation, 12-month patient survival in Group II was 100%. While the model for end-stage liver disease score at orthotopic liver transplantation was significantly different between Group I and Group III, the 12-month, post-orthotopic liver transplantation patient survival was comparable at 78% vs 88%, respectively. CONCLUSION: Intraoperative renal replacement therapy is a safe adjunctive therapy during liver transplantation of critically ill patients with renal dysfunction. Identifying patients who require intraoperative renal replacement therapy would improve intraoperative and post-liver transplant survival and may facilitate recovery of native kidney function after transplant.

Gastrointestinal Issues in Liver Disease.

Gastrointestinal (GI) complications of cirrhosis are frequent in patients who require intensive care support and are often the primary indication for intensive care unit (ICU) admission. Perhaps the most worrisome GI complication for the intensivist is variceal hemorrhage. Bleeding from esophageal or gastric varices represents a life-threatening event for cirrhotic patients and provides management challenges for the ICU team. Nonvariceal GI bleeding, impaired GI motility, and malnutrition also provide significant challenges for the intensivist. This article reviews GI issues that present in critically ill cirrhotic patients and their management in the acute setting.