ABSTRACT
COVID-19 is characterized by predominant respiratory and gastrointestinal symptoms. Liver enzymes derangement is seen in 15-55% of the patients. Cirrhosis is characterized by immune dysregulation, leading to concerns that these patients may be at increased risk of complications following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Patients with metabolic dysfunction-associated fatty liver (MAFLD) had shown a 4-sixfold increase in severity of COVID-19, and its severity and mortality increased in patients with higher fibrosis scores. Patients with chronic liver disease had shown that cirrhosis is an independent predictor of severity of COVID-19 with increased hospitalization and mortality. An international European registry study included 756 patients with chronic liver disease from 29 countries reports high mortality in patients with cirrhosis (32%). Data of 228 patients collected from 13 Asian countries on patients with CLD, known or newly diagnosed, with confirmed COVID-19 (APCOLIS study) showed that SARSCoV- 2 infection produces acute liver injury in 43% of CLD patients without cirrhosis. Additionally, 20% of compensated cirrhosis patients develop either ACLF or acute decompensation. In decompensated cirrhotics, the liver injury was progressive in 57% of patients, with 43% mortality. Patients with CLD and associated diabetes and obesity had a worse outcome. Liver related complications were seen in nearly half of the decompensated cirrhotics, which were of greater severity and with higher mortality. Increase in Child Turcotte Pugh (CTP) score and model for end-stage liver disease (MELD) score increases the mortality in these patients. In a subsequent study of 532 patients from 17 Asian countries was obtained with 121 cases of cirrhosis. An APCOLIS risk score was developed, which included presence of comorbidity, low platelet count, AKI, HE and respiratory failure predicts poor outcome and an APCOLIS score of 34 gave a sensitivity and specificity of 79.3%, PPV of 54.8% and NPV of 92.4% and predicted higher mortality (54.8% vs 7.6%, OR = 14.3 [95 CI 5.3-41.2], p<0.001) in cirrhosis patients with Covid-19. The APCOLIS score is helpful in triaging and prognostication of cirrhotics with Coivd-19. The impact of COVID-19 on patients with cirrhosis due to non-alcoholic fatty liver disease (NASH-CLD) was separately studied in 177 NASH-CLD patients. Obese patients with diabetes and hypertension had a higher prevalence of symptomatic COVID. Presence of diabetes [HR 2.27], fraility [HR 2.68], leucocyte counts [HR 1.69] and COVID-19 were independent predictors of worsening liver functions in patients with NASH-CLD. Severity of Covid in Cirrhosis could also be assessed by measuring ICAM1 the Intercellular Adhesion Molecule, an indicator of Endothelial Injury Marker. in Cirrhosis with Covid 19 Immunosuppression should be reduced prophylactically in patients with autoimmune liver disease and post-transplantation with no COVID-19. Hydroxychloroquine and remdesivir are found to be safe in limited studies in a patient with cirrhosis and COVID-19. And is safe in cirrhosis patients. However, flare of AIH has been reported in AIH patients. For hepatologists, cirrhosis with COVID-19 is a pertinent issue as the present pandemic cause severe disease in patients with chronic liver disease leading to more hospitalization and decompensation.
ABSTRACT
Primary sclerosing cholangitis (PSC), secondary sclerosing cholangitis (SSC), and primary biliary cholangitis (PBC) are impor-tant indications for liver transplantation. An emerging indication for liver transplantation in selected cases is SSC after severe COVID-19 infection. The clinical presenta-tion of these cholestatic diseases is highly heterogeneous - from asymptomatic and mild elevations of liver enzymes to severe disease-specific complications like recurrent cholangitis or severe bone disorder to de-compensated liver cirrhosis. Such disease-specific clinical complications, disease-spe-cific scores, as well as the MELD score, need to be considered when selecting patients for liver transplantation.Copyright © 2023 Dustri-Verlag Dr. K. Feistle.
ABSTRACT
Introduction and Objectives: Cirrhosis and acute liver failure have a high mortality rate and liver transplantation is the only treatment that has shown improvement in the survival of these patients, being 90% in the first year after transplantation and 80% in five years. Currently, in our center there are 95 patients on the liver transplant waiting list, being the largest in the country. The availability of an organ is of key importance and is directly related to the morbidity and mortality of our patients. This study aimed to determine direct and indirect variables that affect mortality on the waiting list in our transplant center. Material(s) and Method(s): We did a retrospective observational study in which we reviewed the clinical charts of the 116 patients who died in the liver transplant list between 2015 and 2021. We described the stage of cirrhosis, its complications and the cause of death. For the analysis of the results, we performed a statistical description. Result(s): Between 2015 and 2021, 116 patients died on the liver transplant waiting list. The cause of cirrhosis was autoimmune disease in 42%of the patients, 75% were CHILD C and 39.7% had MELD >25. The main cause of death was an infection, and the main complications of cirrhosis were ascites (84.5%), encephalopathy (59.5%) and variceal hemorrhage (39.7%). Between 2020 and 2021, COVID-19 infection was documented in 16.7% of deceased patients. Conclusion(s): Infection in patients on the waiting list is the main cause of death before transplantation. It has been documented in the literature that one-year mortality, according to the Meld score, is 30% and 50% for scores of 20-29 and 30-39, respectively. Because of this reason, liver transplantation is the only alternative to impact the survival of these patients. The pandemic contingency affected the care of patients with terminal liver disease, reducing the number of transplants performed because of the lower donation rate. Being pioneers in Colombia of living donor transplantation, it was possible to mitigate the low availability of organs during the Covid-19 pandemic, and in 2020 -2021, 38% of the transplants performed in our center were from a living donor.Copyright © 2023
ABSTRACT
Purpose: COVID-19 pandemic has had a significant impact on access to routine healthcare in both hospitalized and out-patient settings. This impact was also noted in various aspects of pre and post-transplant care of liver transplant (LT) recipients. The aim of our study was to analyze the direct and indirect impact of COVID-19 on mortality in patients with recent LT. Method(s): We retrospectively analyzed 30-day, 6-month and 1-year mortality data from the UNOS database in adult LT recipients from 3 distinct groups;Pre-COVID (March 11- September 10, 2019: LT and immediate follow-up care before pandemic), Para-COVID (September 11- March10, 2020: LT before pandemic and follow-up care during pandemic), and COVID (March 11- September 10, 2020: LT and follow-up care during pandemic). Result(s): 12,598 LTs were performed during the study period. During COVID period, there was increase in LT for alcoholic liver disease, average MELD score was higher, LT for hepatitis C decreased, use of thymoglobulin induction decreased and waiting time was shorter. During the 30-day period, overall mortality between 3 groups remained same. In the COVID group, mortality from graft failure was higher (7.4 vs 17.9%, p=0.07), rate of infection was lower (14% vs 4.2%, p=0.039), and incidence of graft rejection prior to discharge was higher. During the 6-month follow-up, overall mortality, mortality from malignancy and COVID, and graft failure increased significantly in the COVID group. During the 1-year follow-up period, mortality was highest in COVID group over para-COVID group and lowest in the pre-COVID group. In the COVID group, increased mortality was from graft failure and COVID. Overall mortality in the study cohort directly from COVID was 7.8%, which was highest in the COVID group. Multivariable cox regression for one year mortality showed that risk factors for mortality were COVID period [Hazard Ratio (95%CI) 1.22 (1.02-1.46), p=0.027], older age of recipient, diabetes, portal vein thrombosis, ventilation at the time of transplant, hemodialysis at the time of transplant, re-transplant, and prolonged cold ischemic time. Conclusion(s): COVID-19 significantly impacted LT short term outcomes with increased mortality seen from COVID directly as well as indirectly. During COVID, cautious and lower use of immuno-suppression was likely associated with higher rates of rejection and lower rates of infection. Disruptions in routine post-transplant follow-up likely contributed to increased death from graft failure, malignancy, and poor control of chronic medical conditions like diabetes. (Figure Presented).
ABSTRACT
Purpose: Acuity circles (AC) allocation was implemented on 2/4/2020 with a goal of removing DSA and region from liver allocation and broadening the distribution of livers, particularly for highly medically urgent candidates. Method(s): OPTN waitlist and transplant data was analyzed 18 months pre- (8/6/2018- 2/3/2020) and post- (2/4/2020-8/3/2021) AC implementation. Result(s): Post-policy, there were 448 more adult (age 18+ at listing) and 83 less pediatric (<18 at listing) waitlist additions, 570 more adult (age 18+ at transplant) and 4 less pediatric (<18 at transplant) deceased donor liver-alone transplants, and 121 less adult and 12 less pediatric removals for death or too sick. Transplant rates significantly increased overall post-policy, notably in the most medically urgent groups (Figure 1). The national median transplant score for adults remained unchanged at 28 and decreased from 35 to 30 for pediatric transplant recipients, likely due to the increased number of adolescents (age 12-17) transplanted at MELD scores under 29. There was a noticeable shift in the distribution of distance between donor hospital and transplant program, particularly for the most medically urgent groups where larger proportions of livers are coming from 250-500 NMs (Figure 2). Despite this change, median cold ischemia time increased only 11 minutes for adult recipients and 33 minutes for pediatric recipients post-policy. One year post transplant patient survival decreased from 94% pre-policy to 93% post-policy (p=0.02). Conclusion(s): Broader allocation increased transplant rates and livers are traveling longer distances for candidates with greater medical urgency with little effect on cold ischemia time and post-transplant survival. Unfortunately, AC implementation was followed shortly by COVID-19 making it difficult to parse out COVID-19 from potential policy effects. Metrics will continue to be monitored as more data become available. (Figure Presented).
ABSTRACT
Background: Traditionally, patients were kept intubated for 48 hours in the postoperative period. Living donor liver transplantation poses a different set of challenges. Most of the predictors mentioned in the literature were, low MELD, low BMI, and with stable comorbidities etc. for early extubation following living donor liver transplantation. We assessed the feasibility of fast tracking and early extubation in our patients, who were not fitting in those mentioned predictors in the literature. Methods: We present a case series of 6 patients who were fast tracked and extubated early, following living donor liver transplantation, out of 22 patients over the last 6 months. Results: All these patients were aged more than 45 yrs, with an average age of 55.8 yrs, average MELD score of 20.8, Child status C, some of our patients had cardio pulmonary comorbidities. patient 2, was COPD, post asymptomatic COVID, with CoRad score3 on HRCT, patient 5, was class 3 obese with no OSA, patient 6, had Hypertension, CAD- triple vessel disease, post CABG 7 yrs back, The intraoperative metabolic parameters like base excess and Lactates were showing good correction and all of them had very minimal inotropic support at the time of extubation, with Norepinephrine < 0.05mcg/kg/minutes. There was no post reperfusion hemodynamic instability or PRS in our patients, the average GRWR in our patients was 0.94, the mean anhepatic period, warm ischemia and cold ischemia times were pretty low. None of them had any significant postoperative complications. Conclusions: We propose, we can safely fast track and extubate early, following living donor liver transplantation with high MELD scores, and stable comorbidities. Further, large studies are needed to look for the feasibility of expanding the criteria for early extubation.
ABSTRACT
Background and aims: Sarcopenia is a promising tool for prognostication of cirrhosis.EWGSOP2 guidelines define sarcopenia based on muscle strength, muscle quantity or quality and physical performance. Many previous studies didn’t use a standardized definition of sarcopenia and was based on skeletal muscle measurement by CT or MRI.Ultrasound guided thigh muscle thickness (TMT) measurement is a validated, cost effective and easy method for assessment of muscle quantity.There is paucity of Indian studies analysing prognostic role of sarcopenia in cirrhosis. To study the predictive role of sarcopenia on mortality and complications in cirrhosis patients. Method: This was a prospective cohort study with 120 consecutive patients each in sarcopenia and no sarcopenia groups. Sarcopeniawas diagnosed based on EWGSOP2 guidelines using ultrasound guided measurement of TMT.They were followed up for 6 months.Kaplan- Meier analysis with LogRank test was used to compare survival and Cox proportional hazards modelwas used for multivariate analysis to determine risk factors of mortality. Results: Cirrhosis patients with sarcopenia[N1 = 120, M:F = 80:40, Median age-58yrs (51–64)] and without sarcopenia[N2 = 120, M:F = 93:27, Median age-54yrs (46.25–60)] were enrolled.Six month cumulative survival was 56.7% and 76.7% in sarcopenia and no sarcopenia groups respectively (p = 0.001).Six month cumulative survival in severe and non-severe sarcopenia was 23.9% and 70% respectively (p = 0.001).Age, sex, nutritional status, sarcopenia status, CTP score, MELD score, Bilirubin, Albumin, INR and Sodium were significantly associated with survival.A multivariate analysis showed sarcopenia (HR = 1.283, 95%CI 1.092–2.130, p = 0.031), female sex (HR = 1.851, 95%CI 1.106–3.097, p = 0.019), CTP class C (HR = 1.447, 95%CI 1.252–1.794, p = 0.002) and MELD score>15 (HR = 1.116, 95%CI 1.056– 2.203, p = 0.05) as independent predictors of mortality. Development of complications like ascites, HE, Covid infection and UGI bleed were significantly higher in sarcopenia group, while SBP, AKI, cellulitis, UTI, HCC and ACLF were not statistically significant between two groups.(Figure Presented) Figure 1. Survival curves in both groups (Log rank p = 0.001) Conclusion: Sarcopenia is an independent prognostic marker of mortality in cirrhosis and is associated with increased risk of complications like ascites, HE, Covid infection and UGI bleed. Severe sarcopenia has even poorer outcome. It appears that addition of sarcopenia to existing scoring systems of cirrhosis will improve prognostication of patients
ABSTRACT
Background and Aim: Hepatic encephalopathy (HE) in acute-on-chronic liver failure (ACLF) is associated with significant morbidity and mortality. There is limited evidence regarding HE management in patients with ACLF. We conducted a prospective, randomized controlled clinical trial to study the efficacy of intravenous branched chain amino acids (IV-BCAA) with lactulose versus lactulose alone for improvement in HE at 24h, day 3 & day 7. Duration of ICU stay and survival at days 7 and 28 was compared. Methods: CANONIC ACLF patients with HE grades>=2 were randomized into two groups - experimental arm (IV-BCAA - 500mL/day for 3 days + Lactulose;n=39) and comparator arm (Lactulose alone;n=37). Six patients developed COVID-19 after randomization & were excluded (4-experimental arm & 2-comparator arm). HE Grade was assessed by West Haven Classification and Hepatic Encephalopathy Scoring Algorithm (HESA). ACLF severity was determined by CLIF-C ACLF and MELD scores. All patients received standard of care. Results: Both groups were similar in baseline characteristics including grade of HE (2.85 ± 0.75 vs 2.82 ± 0.66;P = 0.864) and CLIF-C ACLF score (54.19 ± 5.55 vs 54.79 ± 5.74;P = 0.655). Overall survival was 40% at 28 days (48.5% vs 31.4%;P=0.143). Significant improvement in HESA score by 1 grade at 24h was seen in 14 patients (40%) in BCAA arm and 6 patients (17.14%) in control group (P=0.034) which translated to shorter ICU stay in the BCAA arm. Median change in HESA score at 24h was significantly more in BCAA arm than control arm (P=0.006), however, this was not sustained at day 3 or 7. Ammonia levels did not correlate with HE grade (Spearman correlation coefficient (-0.0843;P=0.295). Conclusion: Intravenous BCAA leads to early but ill-sustained improvement in grade of HE and reduced ICU stay in ACLF.
ABSTRACT
Objectives: Liver injury precipitated by drugs and herbal medicines( DHMs) can have variable presentations and outcomes. In Indian subcontinent, drug induced liver injury due to Anti-tubercular drugs( ATDs) and inadvertent herbs induced liver injury (HILI) are common. Comparative natural history and outcome of acute-onchronic liver failure(ACLF) due to common DHMs is largely unknown. Materials and Methods: Consecutive in-patients with ACLF precipitated by herbs or ATDs(year 2010-2021) were compared for baseline clinical profile, disease severity, histological features and organ failures. Treatment outcomes and predictors of in-hospital mortality were also analyzed. Results: 529 patients presented with ACLF related to HILI(ACLF-H, n = 430) and ATDs(ACLF-D, n = 99) [Mean Age-47.6 - 14 years, mean MELD score and HVPG were 29.1 - 5.4 and 15.5 - 3.4 mmHg respectively]. 61.4% patients had underlying histological cirrhosis. 21.2% patients had additional superadded acute insult [severe alcoholic hepatitis(n = 66), acute hepatitis E or A(n = 24/15)]. Twelve percent ACLF-H patients presented with clinical cholestasis, autoimmune hepatitis(n = 18) and hypersensitivity reactions(n = 4). Most common recognizable agent associated with ACLF-H was Tinospora cordifolia (n = 35,8.1%), inadvertently used in Indian households during the COVID-19 pandemics. Patients with ACLF-H as compared to ACLF-D had higher male preponderance (70.9% vs. 54.5%;p-0.002) and peripheral eosinophilia (6.4% vs. 1%;p-0.03), clinical cholestasis (19.6% vs 10.8%;p-0.05) and acute kidney injury (44.4% vs. 28.3%;p-0.003) at presentation. Use of plasma exchange(18.5%) had no impact on outcomes. None of the patients underwent liver transplantation. In-hospital mortality(19.2%) was higher in ACLF-D compared to HILI ACLF-H (31.3% vs. 17.2%;p-0.002). Presence of AKI [HR:5.5 (95%CI:2.78 to 11.1)], hepatic encephalopathy[HR:4.4(95%CI:1.76 to 11)] and pneumonia[ HR:7.2(95%CI: 3.59 to 14.65)] were independent predictors of mortality. Conclusion: Herbs and anti-tubercular drugs are common precipitants of ACLF in India and have high in-hospital mortality resulting from sepsis and organ(s) failure. In the absence of specific treatment options, prevention and early and careful monitoring of liver functions is of utmost importance.
ABSTRACT
Objectives: To study the predictive role of sarcopenia on mortality and complications in cirrhosis patients. Sarcopenia is a promising tool for prognostication of cirrhosis.EWGSOP2 guidelines define sarcopenia based on muscle strength,muscle quantity or quality and physical performance.Many previous studies didn't use a standardized definition of sarcopenia and was based on skeletal muscle measurement by CT or MRI.Ultrasound guided thigh muscle thickness (TMT) measurement is a validated,cost effective and easy method for assessment of muscle quantity.There is paucity of Indian studies analysing prognostic role of sarcopenia in cirrhosis.This study was aimed at the same. Materials and Methods: This was a prospective cohort study with 120 consecutive patients each in 'sarcopenia' and 'no sarcopenia groups'.Sarcopenia was diagnosed based on EWGSOP2 guidelines using ultrasound guided measurement of TMT.They were followed up for 6 months.Kaplan-Meier analysis with LogRank test was used to compare survival and Cox proportional-hazards model was used for multivariate analysis to determine risk factors of mortality. Results: Cirrhosis patients with sarcopenia[N1 = 120,M:F = 80:40,Median age-58yrs (51-64)] and without sarcopenia[N2 = 120,M:F = 93:27,Median age-54yrs (46.25-60)] were enrolled.Six month cumulative survival was 56.7% and 76.7% in sarcopenia and no sarcopenia groups respectively (p = 0.001).Six month cumulative survival in severe and non severe sarcopenia was 23.9% and 70% respectively (p = 0.001).Age,sex,nutritional status, sarcopenia status, CTP score, MELD score, Bilirubin, Albumin, INR and Sodium were significantly associated with survival.A multivariate analysis showed sarcopenia (HR = 1.283,95%CI 1.092-2.130,p = 0.031),female sex (HR = 1.851,95%CI 1.106-3.097,p = 0.019), CTP class C (HR = 1.447,95%CI 1.252-1.794,p = 0.002) and MELD score>15 (HR = 1.116,95%CI 1.056-2.203,p = 0.05) as independent predictors of mortality. Development of complications like ascites,HE,Covid infection and UGI bleed were significantly higher in sarcopenia group, while SBP,AKI,cellulitis,UTI,HCC and ACLF were not statistically significant between two groups. Conclusion: Sarcopenia is an independent prognostic marker of mortality in cirrhosis and is associated with increased risk of complications like ascites, HE, Covid infection and UGI bleed. Severe sarcopenia has even poorer outcome. It appears that addition of sarcopenia to existing scoring systems of cirrhosis will improve prognostication of patients. (Figure Presented).
ABSTRACT
Background and Aims: ACLF is a condition in which 2 insults to liver operate simultaneously, 1 being chronic, and other acute. Complementary & alternative medicine (CAM) are important causes for ACLF. India is the birth place of Ayurveda & CAM is considered safe by the common population with around 80% of the population relying on it. CAM consumption has increased in recent years. Due to the pandemic and the focus on improved immunity, the consumption of CAM has gone up. India has reported 4.8 lakh COVID 19 related deaths till December 2021. However, WHO has estimated 4.7 million deaths directly or indirectly related to COVID-19. We documented a case series of CAM related DILI-ACLF, with CAM being consumed for COVID prevention Methods: ACLF established with APASL defining criteria. USG was done to assess for features of CLD. Liver biopsy was done where feasible. Results: Case 1-39-year-old diabetic taking Giloy Kwath for 2 months for COVID prevention. Presenting with jaundice & ascites having MELD score 18 and CTP class B, he had NASH related cirrhosis on biopsy and is still on follow up. Case 2- f/u/c of CTP A alcoholic cirrhosis who consumed a crushed herb for protection against COVID given by a quack for 3 months, with no alcohol intake in 2 years. He presented with jaundice and encephelopathy, had MELD score 38 & CTP C & succumbed to illness. Case 3 49-year-old lady consuming Giloy Kwath for 4 months for COVID prevention. She was diagnosed with AIH type 1 with MELD score 39. She succumbed to illness with post-mortem liver biopsy showed features of AIH cirrhosis Conclusion: CAM is the most common cause of drug induced ACLF. CAM consumption increased during the pandemic and may have lead to increase in indirect COVID related deaths
ABSTRACT
Introduction: The aim of this study was to assess the impact of Covid-19 infection on patients with decompensated liver cirrhosis (DLC) in terms of acute-on-chronic liver failure (ACLF), hospitalization and mortality. Material adn method: In this retrospective study we analyzed patients known with DLC and admitted in the Gastroenterology Department with COVID-19 virus. Clinical and biochemical data were obtained to compare the development of ACLF, chronic liver failure- acute decompensation (CLIF-AD), hospitalization and the presence of independent factors of mortality in comparison with a non COVID-19 DLC group. All the patients enrolled were not vaccinated for COVID-19. Variables used in statistical analyses were obtained at the time of hospital admission. Results: Of 145 subjects (mean age 61 years;74.48% males), 31% were confirmed with COVID-19 infection. There were no significant differences in terms of ACLF [35.5% vs. 23%, (p=0.1712)] in COVID- 19 vs. non COVID-19 group, nor between MELD score values (20.62±8.46 vs.18.28±7.59, p=0.0997). After excluding subjects with ACLF, the CLIF-C AD score was calculated and significantly higher values were obtained in COVID-19 subjects (60.52 ±11.74 vs. 9.57 ±6.36, p<0.0001). 53.3% (24/45) of the subject from the COVID-19 group had CLIF-C AD > 60, and 66.7% of them died during admission. The length of hospital stay (days) was significantly longer in patients with COVID-19 infection (11.2±7.85 vs. 5.91±4.74, p<0.0001) and 46.7% (21/45) of the subjects with COVID-19 infection died during admission, while only 15% non COVID-19 died (p=0.0001). In univariate regression analysis CLIF-C AD (p=0.012), Child-Pugh (p=0.012), MELD values (p=0.004), and the presence of infections (p<0.001) were independent predictors of mortality. In multivariate regression analysis, the model including CLIF-C AD values (p=0.0036) and the presence of infections (p=0.0009) was associated with death during admission. Conclusions: COVID- 19 significantly influenced disease progression in patients with DLC in terms of CLIF- C AD, hospitalization and mortality and did not in terms of MELD and ACLF.
ABSTRACT
Background Frailty is defined as a clinical state of increased vulnerability to health and age associated stressors. The liver frailty index (LFI), composed of grip strength, chair stand and balance testing, is an accepted predictor of morbidity and mortality in cirrhosis. With the need for COVID-19 related social distancing, many appointments are being carried out virtually. The chair stand subcomponent of the LFI has the potential to be evaluated virtually, with a high reliability as compared to in-person testing noted in other disease populations. Objective To determine if the chair stand test is an independent predictor of morbidity and mortality in patients with cirrhosis. Methods 822 adult patients with cirrhosis were prospectively enrolled from five centers (3 in Canada, 1 in the United States, and 1 in India). Inclusion criteria included adult patients with cirrhosis. 787 of these patients completed a chair stand test at baseline, measured as the time (seconds) a patient takes to rise from sitting with their arms folded across their chest five times (measured in-person). The times were divided into 3 categories: >15 seconds, between 10 and 15 seconds, and <10 seconds. Patients who could not complete 5 chair stands were classified in the >15 seconds category. Primary outcome was all-cause mortality. Secondary outcome was unplanned all-cause hospital admission. Fine-Gray proportional hazard regression models were used to evaluate the association between the chair stand time and the outcomes. We adjusted for baseline age, sex, and MELD score and accounted for liver transplantation as a competing risk. Cumulative incidence functions were used to create a graphical representation of the survival analysis. Results Patients were divided into three groups: group 1, <10 seconds (n = 276);group 2, 10-15 seconds (n = 290);and group 3, >15 seconds (n = 221). Mortality was increased in group 3 in comparison to group 1 (HR 3.21, 95% CI: 2.16-4.78, p<0.001). Similarly, the hazard of non-elective hospitalizations was higher in group 3 in comparison to group 1 (HR 2.24, 95% CI: 1.73-2.91, p<0.001). Overall, patients with chair stand times greater than 15 seconds had increased all-cause mortality (HR 2.78, 95% CI 2.01-3.83, p<0.001) and non-elective hospitalizations (HR 1.84, 95% CI 1.48-2.29, p<0.001) when compared to patients with times less than 15 seconds. Conclusion A time to complete 5 chair stands of >15 seconds predicts morbidity and mortality in patients with cirrhosis. This test shows promise as a frailty measure that could be evaluated over a virtual platform. (Figure Presented)
ABSTRACT
Background: Rates of alcohol use disorder amongst women have increased markedly since the start of the Covid-19 Pandemic with some studies showing as much as a 41% increase in heavy drinking days (1). Among women with alcohol use disorder, there is a high degree of comorbidity with eating disorders (ED) with studies suggesting rates of co-occurring disease as high as 23-50%(2). However, there is little data on the assessment of transplant recipients presenting with co-occuring ED and AUD. Case: A 34-year-old woman with no known past psychiatric or substance use history presented to our hospital in acute hepatic failure (MELD Score 34) in the context of escalating alcohol use over the course of the COVID-19 Pandemic. As the patient did not respond to multiple medical therapies, evaluation for liver transplantation was initiated. The patient was assessed using the Stanford Integrated Psychosocial Assessment for Transplant (SIPAT), and found to be a high risk candidate. During the course of our evaluation, the patient demonstrated a lack of interest in eating food, refusing to eat food that required chewing, and expressed multiple consequences about the aversive consequences of eating. She described extremely restrictive eating patterns with her lowest weight being 95 lbs (BMI < 16), leading to nutritional deficiencies, peripheral neuropathy and anemia. Given the absence of excessive concern regarding appearance or body weight, a diagnosis of avoidant restrictive food intake disorder (ARFID) was made. Despite efforts to engage the patient, she demonstrated little understanding of her ED. The patient was declined for listing and medically stabilized. She was declined by all inpatient substance use programs given the extent of her ED and rejected recommendations for targeted ED treatment. She was ultimately discharged to an intensive outpatient program for AUD. Discussion: There is a paucity of information regarding liver transplantation in patients with co-occurring AUD and EDs. However, there are many unique considerations in the management of this patient population in both the pre- and post- transplant period. Existing screening methods such as the SIPAT do little to evaluate transplant risk in patients with EDs relative to other psychiatric illnesses. And while predictive risk factors for recurrence of alcohol use after transplant have been identified, little is known about the risk factors for ED relapse. It appears that the emphasis on abstinence from alcohol in the post-transplant period can be a potent trigger for ED relapse(3). Post-transplant, patients with ED have an increased risk of relapse to alcohol and poorer retention in residential treatment(4). Conclusion: Patients with co-occurring ED and AUD requiring liver transplantation are a challenging patient population with complex pre- and post-transplant considerations. References: 1. Pollard M, et al. "Changes in Adult Alcohol Use and Consequences During COVID-19 Pandemic in the US." JAMA Netw Open. 2020;3(9). 2. Bulik, Cynthia, et al. “Alcohol Use Disorder Comorbidity in Eating Disorders: A Multi-center Study.” Journal of Clinical Psychiatry. 65:7, July 2004. 3. Coffman K L, et al. Treatment of the Postoperative Alcoholic Liver Transplant Recipient With Other Addictions." Liver Transpl Surg. 1997;3:322–327. 4. Elmquist, J. et al., "Eating Disorder Symptoms and Length of Stay in Residential Treatment for Substance Use: A Brief Report." Journal of Dual Diagnosis, 11(3-4), 233–237. https://doi.org/10.1080/15504263.2015.1104480.2015.
ABSTRACT
Primary sclerosing cholangitis (PSC) is a cholestatic disorder wherein liver transplant is the definitive treatment for advance stages. However, recurrence of PSC after liver transplant is of concern which can leads to graft failure and may require retransplant. There is limited data on outcomes of living donor liver transplant (LDLT) in PSC. Also, in LDLT as donors are related there is possibility of disease recurrence. So, we conducted this retrospective study to analyse the outcomes of LDLT in PSC at a tertiary liver transplant centre in north India. Methods: We conducted a retrospective analysis of 3213 transplant recipients who underwent LDLT from January 2006 to May 2021. Of these 26 (0.80%) patients has PSC as indication for liver transplantation (PSC=24, PSC/AIH overlaP=2). Data analysis was done to look for baseline demographics, clinical details, transplant outcomes, PSC recurrence and survival. Results: Mean age of study group was 42(±13.8) years and 19 (73.1%) were males. All patients had decompensated cirrhosis at time of transplant. Mean CTP score and MELD score were 9.5(±1.8) and 18.9(±7.1) respectively. 16 patients received modified right lobe graft, 7 extended right lobe graft and 5 patients received left lateral graft. Average graft weight and GRWR were 633.5(IQR 473.5-633.5) grams and 1.23(SD±0.42) respectively. Most common biliary anastomosis was hepaticojejunostomy, done in 19(73.1%) while duct to duct anastomosis was performed in 7(26.9%) patients. Median follow- up was 96(36-123) months. One patient had ulcerative colitis and none had cholangiocarcinoma. Two (7.7%) patients had bile leak during early post-transplant period. Three (11.1%) patients developed graft rejection and managed successfully with steroid pulses. Three patients died during early post-transplant period while 7 deaths occurred during long term follow-up including one death due to COVID-19. Five (19.2%) patients had recurrence of PSC of which 2 patients lost their grafts including one after retransplantation. The overall 1 year and 5-year survival rates were 88.5% and 75% respectively. Conclusion: LDLT can be performed in PSC with good long-term outcomes with a risk of PSC recurrence in about 1/5th patients.
ABSTRACT
Background: Budd-Chiari Syndrome (BCS) is a complex thrombotic disorder caused due to obstruction of hepatic venous outflow involving anywhere from small hepatic venules to the entrance of inferior vena cava into the right atrium. This leads to venous stasis and ischemic injury of hepatic parenchyma and sinusoids, with the risk of liver failure. The prognosis of patients with BCS had improved significantly with long-term anticoagulation and measures like Trans-Jugular-Intrahepatic-Porto-Systemic shunt (TIPS) and liver transplantation. We report the outcomes of patients who follow in our hematology practice and describe the factors predicting the need for TIPS/Liver Transplant. Methods: After appropriate Investigational Review Board permission, we identified patients with a history of BCS following in our thrombosis clinical practice from the year 2010 onwards. We evaluated their laboratory, demographic, anticoagulation data, Model of End-stage Liver Disease (MELD) score, Child-Pugh (CP) score at diagnosis or when earliest available, and other relevant clinical information as outlined. Descriptive statistics with medians, quartiles, frequencies, and percentages are reported. Further, we compared the two categories of patients who needed TIPS/Liver transplants versus those who did not. SAS version 9.4 was used for analysis. For continuous variables, a univariate nonparametric Mann-Whitney test was used. The Fisher's Exact Test was used to associate each variable with the need for TIPS/Liver Transplant. Results: Our study included 23 patients with baseline characteristics, including median age of 36 years (11-59 years), 91% whites, 61% females, 44% smokers, 61% obese(median BMI 29.9 kg/m 2), 6 of 14 women on oral contraceptive pills, 22% with thrombosis history, 17% with stroke history, median hemoglobin 13.4 gm/dL(8.9-20 gm/dL), white blood cell count 9,400/L (3,050-31,500/L), platelet count 294,000/L(14,000-767,000/L), serum creatinine 0.87 mg/L (0.55-2.52 mg/dL), total protein 6.3 gm/dL (5.2-8.8 gm/dL), Bilirubin 2.1 mg/dL(0.1-20.2 mg/dL), Aspartate Aminotransferase (AST) 61 U/L(16-1037 U/L), Alanine Aminotransferase (ALT) 43U/L(18-1694 U/L), MELD score 15 (range 7-38), CP score 9 (5-14), 74% with cirrhosis, 82% with ascites at one point, 57% with myeloproliferative neoplasm (MPN), 4.3% with Paroxysmal Nocturnal Hemoglobinuria (PNH), 17% with Antiphospholipid antibodies positive (APS), 13% had positive antinuclear antibodies, 35% needed TIPS and 44% required liver transplantation. 57% with Janus Kinase (JAK2) V617F mutation (1 patient with a low variant allele frequency of 1%), 1 patient (4.3%) had Calreticulin (CALR) mutation positive MPN, 91% remained on long-term anticoagulation with 40% using warfarin, 35% apixaban, 9% Enoxaparin or Rivaroxaban for long-term anticoagulation, 13% developed heparin-induced thrombocytopenia (HIT). 8.7% had developed BCS after Ad26.COV2.S vaccine to prevent SARS-CoV-2 infection. Excluding the patients with missing variables, 5 of 12 had Protein C deficiency, 3 or 10 had Protein S deficiency, 8 of 20 with Antithrombin (AT) deficiency, 4 of 14 with heterozygous factor V Leiden mutation, 0 of 10 with prothrombin gene mutation, 1 of 13 with hyper-homocysteinemia. 35% had gastrointestinal bleeding though 65% of patients had evidence of varices by endoscopy. When the group needing TIPS/Liver transplant/died is compared to those who did not, they had higher bilirubin, MELD, PC score, AT deficiency, cirrhosis, ascites, and JAK2 mutation (p-value significant: Table 1). With a median follow-up of 90 months, overall survival was not statistically significant between the two groups (Figure 1). Two patients (8.7%) died out of a total of 23. Conclusions: Our data indicate that in patients with BCS, neoplasms (61%), particularly MPN (57%), are very commonly diagnosed. Compared to the historical data in patients with BCS with dismal prognosis (60-80% six-month mortality rate), the overall survival had significantly improved, likely due to supportive measures like TIPS/Liver transplant and long-ter anticoagulation. Outside the established variables like CP and MELD, lower antithrombin activity and positive JAK2 mutation status also predicted a higher TIPS/Liver transplant need. [Formula presented] Disclosures: Bhatt: Partnership for health analytic research, LLC: Consultancy;Abbvie: Consultancy, Research Funding;Jazz: Research Funding;Incyte: Consultancy, Research Funding;Pfizer: Research Funding;Tolero Pharmaceuticals, Inc: Research Funding;National Marrow Donor Program: Research Funding;Abbvie: Consultancy, Research Funding;Genentech: Consultancy;Servier Pharmaceuticals LLC: Consultancy;Rigel: Consultancy. Gundabolu: BioMarin Pharmaceuticals: Consultancy;Blueprint Medicines: Consultancy;Bristol-Myers Squibb Company: Consultancy;Pfizer: Research Funding;Samus Therapeutics: Research Funding.
ABSTRACT
Background and aim: Infections in cirrhotic patients are associated with an increased risk of liver-related complications (LRC) and mortality. Limited data regarding the prevalence of Coronavirus disease (COVID-19) in cirrhotic patients’ awaiting liver transplantation (LT) are available. The aim of this study was to evaluate the prevalence of SARS-CoV2 in a cohort of cirrhotic patients and its impact on LRC rate and on LT.Materials and methods: We retrospectively included 187 waitlist patients for LT from 24-January-2020 (2020-cohort) and 123 patients from 24-January-2019 (2019-cohort). All 2020-cohort patients were screened for COVID-19 symptoms with a survey. COVID-19 infection was defined by a positive PCR assay for SARS-CoV-2 on nasopharyngeal swab or the positivity for specific antibodies or typical lung lesions on CT scan. We also assessed the indirect impact of SARSCoV2 infection on LRC and LT rate, estimated by competitive risk survival analyses in 2020-cohort vs. 2019-cohort (Fine and Gray method).Results: In 2020-cohort, 72.7% (n=136) of patients were male with mean age of 55.5±12, 47.2% (n=85) patients have alcohol and/or NASH related cirrhosis, with a median MELD score of 14.1±7.4. 45.5% (n=71), 38.5% (n=60) and 14.8% (n=23) of patients were A, B and C for Child-Pugh-score, respectively. 172 patients responded to survey and 22% (n= 38) had symptoms. 20/38 patients were tested for SARS-CoV2 and 4 patients were positive. 3/4 patients with COVID-19 disease needed hospitalization and 1 intensive care support. No death was reported and 1 patient was LT. The 2020-cohort and 2019-cohort were comparable for sex (p=0,6), age (p=0.7), comorbidities (p=0.2) and Child-Pugh-score (p=0.2). The cumulative incidence of LRC was not significantly higher in the 2020-cohort vs. 2019-cohort (SHR 0.65, 95% CI 0.36-1.15, p=0.138). The cumulative incidence of LT was significantly lower in the 2020-cohort than in the 2019-cohort (SHR0.21, 95% CI 0.13-0.33, p<0.001). Conclusions: Our study reported a low prevalence rate of SARSCoV2 infection in a cohort of cirrhotic patients waiting for LT. No SARS-CoV2 infection direct or indirect impact on mortality and LRC rate was reported. However, a significant shortage of LT was found in 2020 cohort.
ABSTRACT
Background and aim: Access to liver transplantation (LT) can beaffected by several barriers resulting in delayed referral and increased risk of mortality. Therefore, hub-and-spoke networks have been implemented in order to manage patients with liver disease. COVID-19 pandemic may have significantly changed this scenario, as most of medical resources have been allocated for the care of patients with SARS-CoV-2 infection. This study aimed to assess the influence of COVID-19 pandemic on referrals of patients with liver disease to a LT Center.Materials and methods: An integrated referral program was developed since 10.2017 at Multivisceral Transplant Unit, PadovaUniversity. All consecutive adult patients with liver disease referred for the first time using this program from 10.2017 to 12.2020 were prospectively collected. Clinical characteristics were analyzedoverall and according to era of referral (pre-COVID-19 era:10.2017-02.2020;COVID-19 era:03.2020-12.2020).Results: 231 patients with liver disease were referred over the study period (men 61%, mean ± SD age: 54±10 years). End-stage liver disease was the most common underlying condition (78.3%), followed by acute liver injury/acute liver failure (17.3%). During COVID-19 pandemic, the rate of referred patients showed a stable trend, if compared with the previous period (5.1 patients/monthvs. 6.1 patients/month), also when only in-patient referrals wereconsidered (pre-COVID-19 era vs.COVID-19 era: 2.9 vs. 3.2 patients/month). Considering 181 patients with cirrhosis, underlying etiology (p=0.22), severity of liver disease (MELD score: 21±7 vs. 20±8;p=0.44), and inpatient referrals (42% vs. 51%;p=0.34) did not differ between pre-COVID-19 and COVID-19 eras. There was a decreasing rate of ICU admission for cirrhosis-related complicationsduring COVID-19 pandemic (22% vs. 34%;p=0.3), with an increased in-hospital transplant-free mortality (41% vs. 30%;p=0.3).Conclusions: Conclusion: Our results did not show a significant decrease in the number of referrals and type of indications during the COVID-19 pandemic;however, the in-hospital transplant free mortality showed an increasing trend, which could be the consequence of a decreasing rate of ICU admissions. Taken together, thesefactors confirmed the importance of a referral network for the care of patients with liver disease, but also how the COVID-19 pandemic may influence the short-term outcome of patients with liver disease.