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TRANSPLANTATION DIRECT ; 8(8), 2022.
Article in English | Web of Science | ID: covidwho-1968022

ABSTRACT

Background. The COVID-19 pandemic has limited liver transplant (LT) candidates access to clinics. Telehealth methods to assess frailty are needed. We developed a method to estimate the step length of LT candidates, which would permit remotely obtaining the 6-min walk test (6MWT) distance with a personal activity tracker (PAT). Methods. 6MWT was performed while candidates wore a PAT. On first 21 subjects (stride cohort), the step length was measured and compared with calculated one (6MWT-distance/6MWT steps). On a second cohort (PAT-6MWT;n=116), we collected the 6MWT step count and used multivariable models to generate formulas estimating step length. We multiplied the estimated step length times 6MWT steps to estimate the distance and compared it to the measured distance. The liver frailty index (LFI) and 6MWT were used as frailty metrics. Results. Measured/calculated step length were highly correlated (rho =0.85;P<0.001) in the stride cohort. In the PAT-6MWT cohort, LFI was the strongest variable associated with step length, along with height, albumin, and large-volume paracentesis (R-2 =0.58). On a second model without LFI, age, height, albumin, hemoglobin, and large-volume paracentesis were strongly associated with step length (R-2 =0 .45). There was a robust correlation between observed 6MWT and PAT-6MWT utilizing step length equations with (rho = 0.80;P<0.001) or without LFI (rho =0.75;P<0.001). Frailty by 6MWT <250 m did not change significantly using the observed (16%) or the with/without LFI-estimated (14%/12%) methods. Conclusions. We created a method to obtain 6MWT distance remotely with the use of a PAT. This novel approach opens the possibility of performing telemedicine PAT-6MWT to monitor LT candidates' frailty status.

2.
Gastroenterology ; 162(7):S-1252, 2022.
Article in English | EMBASE | ID: covidwho-1967441

ABSTRACT

Introduction We sought to evaluate the longitudinal serological response from the second to third dose of SARS-CoV-2 vaccine in liver transplant recipients at our institution. This study is ongoing and the total N will increase. Methods We prospectively enrolled 54 LT patients who received Pfizer-BioNTech or Moderna vaccine in two doses 3-4 weeks apart at our institution and an additional third dose after CDC approval in August 2021. 6 patients were excluded because of a positive nucleocapsid Ab after the third dose that indicated prior COVID infection. Recipients had semi-quantitative spike IgG and nucleocapsid IgG titers tested between 30 and 75 days after receiving a second vaccine dose. Serological responses to both spike and nucleocapsid antigens indicated COVID-19 infection. All recipients had spike and nucleocapsid Ab titers checked at least 14 days after receiving the third dose. Recipients who had a positive spike Ab titer and negative nucleocapsid titer after a second vaccine dose had repeat spike and nucleocapsid Ab testing within 1 week prior to receiving their third vaccine dose. Results Among 48 LT recipients that met inclusion criteria, seropositivity for spike Ab increased from 47.9% after the second dose to 81.3% after the third dose. 9 patients who were seronegative after a third dose had failed to develop detectable spike Ab after their second dose. The median interval between the second and third doses was 5.9 months. After the third dose, 69% of seropositive recipients had a high spike Ab titer. In 25 recipients who were seronegative after a second dose, 64% produced spike Abs after their third dose. Recipients who remained seronegative after 3 vaccine doses had significantly higher mean tacrolimus trough concentrations. To assess whether spike Ab titers waned after the second vaccine dose, we retested spike Ab titers within one week prior to the third dose in 14 out of 23 recipients who were seropositive after their second dose. All 14 patients had a decline in their spike Ab titers after their second dose. Previously detectable spike Ab titers became undetectable in 5 recipients. However, all five of these patients regained detectable spike Ab after the third vaccine. Discussion We demonstrate that a third dose of mRNA SARS-CoV-2 vaccine in LT recipients was effective. Minimizing immunosuppression by lowering tacrolimus trough thresholds is one potential strategy to improve immune responses. Our results also provide useful information about the optimal interval between the second and third vaccine doses in SOT recipients. Our cohort received the third vaccine dose after a longer delay of 6 months. With this delay, we demonstrated higher seropositivity and seroconversion rates than those reported after shorter interval dosing. A shorter delay between doses is a practical approach to help mitigate the immediate risk in this population. (Table Presented)

3.
Gastroenterology ; 162(7):S-1143, 2022.
Article in English | EMBASE | ID: covidwho-1967415

ABSTRACT

Background and aim Telehealth (TH) interventions may improve access to care, diseasespecific and general quality outcomes in chronic liver diseases (CLD). Given the current COVID-19 pandemic, TH interest has grown exponentially. We aimed to systematically evaluate outcomes of TH interventions in a variety of CLD. Methods We used key terms and searched PubMed/EMBASE from inception to 12/5/2020 for observational studies or clinical trials. Two authors independently screened s. We included any type of CLD, including post-transplant patients. Disagreements were solved by a third reviewer. We excluded s, case-reports, and reviews. We extracted the outcomes defined by the authors for each CLD (chronic hepatitis C or B, decompensated cirrhosis, hepatocellular carcinoma-HCC-, liver transplant referral and readmission/rejection after transplantation or weight loss in nonalcoholic fatty liver disease-NAFLD). No meta-analysis was planned due to the heterogeneity of the data. Results Of a total of 3567 studies screened, 29 met inclusion criteria (Table 1). Of these, 17 reported on HCV treatment outcomes [14 video telemedicine, 2 remote specialist consultation, and one texting based intervention]. All studies showed no statistically significant differences between sustained virological response (SVR) rates in telehealth intervention groups compared to control groups or historic general population. 4 retrospective studies examined decompensated cirrhosis/liver transplant referral, followup after transplant, and showed a reduction in time to transplant (138.8 days vs 249 day, P<0.01), mortality or readmission following transplant (28% vs 58%, P=0.004), and improved referral timing (0% immediate rejections of transplant referral vs 41%, P<0.001). Other important outcomes measured also demonstrated benefit in favor of telemedicine incorporation including autoimmune hepatitis remission (100% vs 77.3%, P=0.035). One study assessed chronic hepatitis B outcomes and had no difference in development of hepatocellular carcinoma, ALT fluctuation or cirrhosis over 2 years of follow-up. Finally, two studies assessed weight loss in nonalcoholic fatty liver disease: the prospective study showed no change in weight loss while the randomized clinical trial did. Conclusion TH interventions in patients with CLD shows consistent equivalent or improved clinical outcomes compared to traditional encounter. Similar SVR, decreased time to liver transplant referral and mortality outcomes were observed in the TH groups. In CHB, development of HCC, cirrhosis or biochemical remission was similar as well. In the NAFLD clinical trial, the TH group had 5%+ weight loss over 3 months compared to the control group. In the light of the ongoing COVID19 pandemic, TH in CLD should be the bridge to improve clinical outcomes when face-to-face encounters are not possible. (Table Presented) Abbreviations: DOC: Department of Corrections, TH: Telehealth, SVR: sustained virological response, SVR12: sustained virological response for 12 weeks, SVR24: sustained virological response for 24 weeks, GP: general practitioner, RCT: randomized controlled trial *Sterling et al, 2018 compared patients with private insurance in clinic vs indigent patients in clinic vs patients in the department of corrections using telemedicine. †Lepage et al, 2020 compared patients in outpatient clinic vs mixed delivery including clinic and telemedicine vs telemedicine only. ††These studies reported rates of SVR in their cohort and compared to historical rates of SVR in similar cohorts.

4.
Hepatology ; 74(SUPPL 1):1215A, 2021.
Article in English | EMBASE | ID: covidwho-1508704

ABSTRACT

Background: The COVID pandemic has limited LT candidates access to clinics disrupting frailty assessment. Telehealth methods to assess frailty are needed. The liver frailty index (LFI) and 6MWT can objectively assess frailty. We aimed to develop a method to estimate the stride length of LT candidates, which would permit remote 6MWT calculation via a PAT. Methods: A physical therapist obtained LFI and 6MWT;patients wore a PAT (Fitbit) linked to EL-FIT (Exercise & Liver FITness app). Stride length was obtained by dividing the distance strolled by the steps during the 6MWT. In the first 10 patients we measured the stride length while performing the 6MWT and compared it to the PAT-calculated stride. Using multivariable linear regression models, we identified the clinical parameters better explaining stride length variability and developed formulas to estimate the stride length. We then multiplied the estimated stride length by steps taken during the test (from PAT) to obtain PAT-calculated 6MWT strolled distance and compared it to the observed distance. Investigators were masked to measured stride length and 6MWT distance. Results: We included 116 consecutive patients (age 57±12, male 53%, MELDNa 14±7). There was excellent agreement between measured and PAT-calculated stride (54±15 vs. 56±11 cm, p=0.5). LFI, height, albumin, and recurrent paracentesis were the best parameters predicting stride length (R2=0.58). An alternative model excluding LFI identified age, height, albumin, hemoglobin, and recurrent paracentesis (R2=0.45). There was a very strong correlation between observed and PAT-calculated 6MWT distance, as shown in Figure. Using 6MWT<250 m to define frailty, 16%, 14% and 12% of patients were frail according to measured distance, with and without LFI PAT-calculated methods, respectively. There was 91% agreement between each PATcalculated method and measured 6MWT distance (p=0.5 and p=0.2). Conclusion: We were able to accurately estimate the stride length of LT candidates using routine clinical parameters. This is the limiting factor precluding implementation of telemedicine frailty testing via PAT-calculated 6MWT. To fully assess patients remotely, excluding the in-office parameter LFI, we provided an alternate estimate with similar reliability. Future research should focus on validating telemedicineobtained PAT-calculated 6MWT against clinical outcomes and incorporating this novel method to existing telerehabilitation apps (i.e., EL-FIT).

6.
Hepatology ; 72(1 SUPPL):406A, 2020.
Article in English | EMBASE | ID: covidwho-986104

ABSTRACT

Background: The Houston Veterans Affairs (VA) Medical Center is one of six VA liver transplant centers and has typically brought patients to Houston for evaluation and follow-up During the coronavirus 2019 (COVID-19) pandemic, VA Video Connect (VVC) - a VA-specific HIPAAcompliant video telehealth portal - was pilot-tested to provide remote and socially-distanced care for transplant patients We assessed VVC implementation by measuring patient and provider satisfaction Methods: Pilot implementation of VVC between March 13 & May 27, 2020 was based on model for improvement and Plan-Do-Study-Act (PDSA) frameworks Patients opted into VVC visits Providers were surveyed on overall satisfaction, technical difficulties, and missed crucial physical exam findings. Patients were surveyed on overall satisfaction, quality of interface, and self-report of time- and money-savings All satisfaction scores were assessed using a 5-point Likert scale (1= least satisfied, 5=most satisfied or 1=very easy, 5=very difficult). Demographic information was obtained via chart review Summary statistics were performed Results: There were 63 VVC liver transplant encounters with 2 providers. Technical difficulties occurred in 33 (53 2%) encounters, with 46 (74 2%) completed using VVC alone (8 1% switched to telephone;6 4% to other video modality) Average (standard deviation) provider satisfaction was 4 0 (1 2) No providers reported management would have changed if in-person physical exam were available Of 20 (32 3%) patients who responded to the telephone survey (95% male;average age 59 years), average patient satisfaction was 4 8 (0 7), quality of interface was 4 1 (1 3), and ease of technical set up was 1 6 (1 4] All patients would do a VVC visit again Overall, respondents lived a median of 219 miles away from the study site and reported a median time saving of 1 75 hours and median money saving of $50 Conclusion: Our pilot implementation demonstrated VVC encounters are feasible and acceptable to liver transplant patients and their providers We found substantial time and money savings for our patients Although this pilot occurred during restrictions of the COVID-19 pandemic, our findings hold promise to continue video visits beyond the pandemic and thus improve access to care for liver transplant patients who live far from transplant centers Notably, technical issues were common Further resources should be directed towards studying and improving video telehealth, especially among older populations.

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