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P69 Table 1Demographic and transplant data for all 14 prioritised patientsPatient/Sex Centre Age at registration (yrs) Primary liver disease Registered prior to Prioritisation Indication of Prioritization LT Waiting time on prioritised tier/Time on list prior to prioritisation 1/M 1 0 CDG Yes Acute decompensation with presence of encephalopathy Yes/LLS 5/27 2/M 2 1 Cryptogenic Cirrhosis Yes CLD with nodular lesions s/o HCC Yes/LLS 16/48 3/F 1 15 AILD Yes Chronic rejection Yes/whole liver 3/4 4/M 2 0 Biliary Atresia Yes PTLD/HAT/Sepsis Yes/LLS 14/71 5/F 2 4 IFALD No Coagulopathy with active bleeding/Renal impairment Yes/LLS 15/820 6/F 2 0 Biliary Atresia Yes Acute decompensation due to portal hypertension Yes/LLS 37/405 7/M 2 10 NSC Yes Decompensated chronic liver disease/Renal impairment Yes/reduced R lobe 4/7 8/M 3 8 PFIC3 Yes Acute decompensation of Chronic liver disease Yes/LLS 6/51 9/F 1 0 Other (Hepatoblastoma) Intestinal Tx prioritized Acute decompensation of Chronic liver disease Yes/LLS 11/ 10/F 2 0 Biliary atresia Yes Decompensated Chronic Liver Disease with Severe Coagulopathy Yes/LLS 10/120 11/M 1 0 Biliary atresia (Hepatoblastoma) Yes Acute decompensation of Chronic liver disease Yes/LLS 9/4 12/F 3 0 Biliary atresia Yes Acute decompensation of Chronic liver disease Yes/LLS 12/323 13/F 1 17 Hepatic Artery thrombosis Yes Hepatic Artery thrombosis Yes/whole liver 2/ 14/F 2 0 Biliary atresia Yes Acute decompensation of Chronic liver disease Suspended 12/65 PFIC3;Progressive Familial Intrahepatic Cholestasis type 3, LT;Liver transplantation, HCC;Hepatocellular Carcinoma NSC;Neonatal Sclerosing Cholangitis, CDG;Congenital Disorder of Glycosylation, AILD;Autoimmune Liver Disease, IFALD;Intestinal Failure Associated Liver Disease,PTLD;Center 1-Kings;Center2-Birmingham;Center3-Leeds.ConclusionThe national paediatric prioritization tier, introduced during the COVID19 pandemic, has been a pivotal initiative for the UK paediatric LT program, showcasing national collaboration. All patients underwent a LT successfully within a short time from prioritization with 100% patient and graft survival. The intention is to maintain this prioritized paediatric tier beyond the pandemic.
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IntroductionThe pandemic Covid-19 normalised remote working and we addressed what this meant for our living donors. Within the liver donor liver transplant (LDLT) team one of the major challenges was gaining access to getting donors blood groups which is required as the initial stage of assessment to see if they are a compatible blood group to proceed with their intended recipient. To enable our service evaluated the ‘Eldon Home Blood Typing Kit’ for ABO and Rh blood grouping.The aim of this study was to evaluate the accuracy and reliability of the Eldon Home blood typing kit 1n comparison with the standard laboratory method.MethodThe Eldon Home Kit 2511 is a rapid user friendly self-test kit to determine the blood group inside the ABO and RhD blood group systems. The blood kits were evaluated by 30 living donors to determine their accuracy. Blood grouping was conducted as per the instructions in the company manual.ResultsThe Eldon Home blood typing kit correctly identified the blood group of all 30 potential donors in comparison with the gold-standard hospital laboratory slide and tube method. No disparity was observed. The living donors described that the cards were easy to use and gave reliable results within one minute thus providing a convenient and reliable way of remotely obtaining the donor’s blood group required to assess their suitability as a living donor for their intended recipient within the pandemic.ConclusionThe Eldon Home Blood Typing Kit provides a rapid method for potential living donors that is both accurate and acceptable to prospective donors. Whilst this service development was initiated during the Covid-19 pandemic it will continue to be used in increase efficiency in living donor assessment process and to reduce unnecessary travel.
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OP27 Figure 1The authors propose a model, summarised in Figure 1, to integrate palliative and supportive care alongside and within standard hepatology care for patients with end stage liver disease who are ineligible for transplant, in an era where remote and distant review requires innovation to provide care in the right place and at the right time, to safeguard the previous progress made.
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Transjugular intrahepatic portosystemic shunt (TIPSS) is an effective treatment for decompression of portal hypertension and is most commonly indicated in patients with chronic liver disease (CLD) or portal vein thrombosis (PVT). It is a technically challenging intervention. CLD patients are often frail with comorbidities conferring increased procedural risk. We tell the story of one year of procedures at the Royal Free Hospital (RFH), one of the major centres for TIPSS in Europe.A retrospective electronic casenote review was carried out for all patients who underwent TIPSS procedure at the RFH between April 2021 and April 2022. The outcomes of interest were success rate, complications and survival including those who went on to transplantation. A successful procedure was defined as a correctly placed stent with no procedural complications and symptom resolution. Eighty-four (84) patients underwent TIPSS during the 12-month period. Of these, 3 were abandoned: 2 because portal hypertension was absent on direct measurement and 1 due to anatomical infeasibility. Of the 81 completed, the most common indication was diuretic-intolerant ascites (n=32), followed by variceal bleeding (n=27), PVT (n=14), and other indications (n=8). The clinical success rates post-TIPSS for each indication are as follows. For diuretic intolerant ascites, 53.1% (17/32) of patients no longer require large volume paracentesis (LVP), 28.1% (9/21) require LVP at a reduced frequency, 6.3% (2/32) have been transplanted and 1 patient continues to have LVP at the same rate. For variceal bleeding, 85.2% (23/27) of patients have had no further episodes of bleeding. For PVT, 85.7% (12/14) of TIPSS remain patent with no patient requiring surgical intervention. No procedural complications were reported. Overall survival post-TIPSS is 87.7% (71/81) with procedure-related mortality accounting for no deaths. 8 patients who received TIPSS went on to be listed for liver transplant, of those 3 successfully received a graft, 4 remain listed and 1 has died while listed.A high number of TIPSS procedures were performed. The majority were successful with favourable clinical outcomes. Major challenges faced by the service during this time included staff shortages, bed capacity, transfer logistics and the wider impacts of the COVID-19 pandemic. This service depends on the collective expertise and close working of multiple specialties including hepatology, interventional radiology, intensive care and anaesthetics along with logistical and operational support. In an environment where all of these healthcare professionals work together to support the provision of TIPSS, patients can benefit from positive outcomes.
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The 2013 NCEPOD report ‘Measuring the Units’ reviewed the care of patients who died with alcohol-related liver disease (ArLD) in 2011. It highlighted that the care of patients who died of ArLD was less than good in more than 50% of cases reviewed. Given the ongoing concerns about the variation in outcomes of patients with ArLD, a Survey of the care of patients admitted to hospital with ArLD was commissioned by NCEPOD.All Acute Trusts in England, Wales and Northern Ireland were sent the Survey, which required completion based on Trust data and Lead Gastroenterologist/Hepatologist input. The questions covered numbers of admissions and mortality, alcohol screening and withdrawal management, the presence and constitution of an Alcohol Care Team (ACT), triage of decompensated ArLD patients to Gastroenterology/Hepatology and use of the BSG/BASL chronic liver disease care bundle, as well as escalation of care. In view of the impact of COVID-19, the Survey was sent round to Acute Trusts in January 2021 interrogating information from 2019.ResultsNCEPOD received responses from 145 Acute Trusts including District General Hospitals, regional Liver Units as well as Liver Transplant Units. This included 20,876 ArLD admissions and 2481 deaths in hospital, constituting 11.9% of admissions), with a wide variation in the numbers of reported admissions and deaths between Trusts. The use of symptom-triggered alcohol withdrawal scale (CIWA-Ar) was only 9.9% in the original report, but was employed on specific wards in 88.2% of Trusts in this Survey. The presence of a multidisciplinary ACT increased from 23.2% of Trusts in 2011 to 51.9%, although only 20% of Trusts responding had a Consultant Lead with dedicated sessions. 78% of Trusts stated that they triage patients with decompensated cirrhosis to a Gastroenterologist/Hepatologist and 70% of responding Trusts stated that they used BSG/BASL decompensated chronic liver disease care bundle. The responding clinician reported that it was subjectively more difficult to get patients with decompensated ArLD rather than other forms of cirrhosis into Critical Care in 28.3% of Trusts. Only 23% of ArLD patients who died had coded evidence of palliative care input.ConclusionsThis Survey compares specific aspects of care in patients with ArLD between 2011 and 2019 and indicates that there have been noteworthy improvements in certain areas of care provision, but also points to where attention is required in order to achieve consistent, high-quality care for this patient group, who have a high in-patient mortality.
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IDDF2022-ABS-0185 Table 1Clinical characteristics of patients with Giloy-induced liver injuryCharacteristics Number of patients (Total-16 patients) Gender Male 7 (43.75%) Female 9 (56.25%) Age (mean ± SD) 48.3±14 years Presentation type Acute hepatitis 6 (37.5%) ACLF 10 (62.5%) Mean duration for symptom onset after consumption of giloy 84.3±35 days Mean BMI 23.23±3 kg/m2 Comorbidities Type 2 diabetes 9 (56.25%) Interstitial lung disease (on inhalational steroids) 2 (12.5%) Hypertension 1 (6.25%) None 5 (31.25%) NAFLD 2 (6.25%) Symptoms Jaundice 16 (100%) Ascites 8 (50%) Fatigue 12 (75%) Pruritus 4 (25%) Liver function tests Peak total bilirubin (Mean ± SD) 17 ± 9.4 mg/dl Peak ALT (mean ± SD) 365± 219 U/L Peak AST (mean ± SD) 558 ± 475 U/L Peak ALP (mean ± SD) 186 ± 114 U/L Peak serum IgG (mean ± SD) 2400 ± 1213 mg/dl Peak INR (mean ± SD) 2.63 ± 1.05 AIH serology ANA 1(6.25%) ASMA - Anti LKM1 - AMA - Seronegative (biopsy proven) - Liver biopsy 10 (62.5) Drug induced liver injury 5 (31.25%) Features of AIH 5 (31.25%) Treatment N-Acetyl Cysteine infusion+Ademetionine 3 (18.75%) Steroids 10 (62.5%) Plasma Exchange 3 (18.75%) Outcome Alive 16 (100%) One listed for liver transplant Mean duration for recovery 37 ± 16 days IDDF2022-ABS-0185 Figure 1ConclusionsGiloy, a commonly used immunity booster, can produce drug-induced liver injury, which often mimics autoimmune hepatitis and responds to steroids.
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Background: Since response to COVID-vaccine among transplant recipients remains diminished comparing to general population, we decided to assess effect of COVID-specifically among islet transplant patients. Methods: Response to COVID-infection and vaccine was assessed in a cohort of 20 islet transplant recipients: N=13 after islet transplant alone (ITx) , N=7 with islet after kidney (IAK) or pancreas after islet transplantation (PAI) . The median age was 48 years (25-62) . Maintenance immunosuppression included tacrolimus and an antimetabolite in addition to 5mg of Prednisone in IAK and PAI recipients. Nine patients received booster. Results: Seven patients (38%) chose not to be vaccinated and 4 (57%) of them remained COVID-free with no SARS-CV-2 Spike total antibody (Spike ab) present in their blood. The other three patients (43%) developed only mild symptoms of infection with a high level of Spike ab (>2,500 U/ml) afterwards. In contrast, all remaining 13 patients (62%) , who were vaccinated while on immunosuppression for a median of 7 years (0.5-16) , remained COVID-free (p=0.11, Fischer) . The level of Spike ab in response to vaccine varied: undetected- (N=4) , in range 1-100U/ml (N=6) , around 400U/ml (N=2) , and above 2,500U/ml (N=1) . Presence of 5mg of Prednisone did not affect the outcomes. Booster was administered in patients and increased the level of Spike ab above 100U/ml in all of them, in 7 (78%) to over 2,500 U/ml. One patient responded neither to vaccine nor to booster. There were no SAEs related to the vaccination or booster. Islet graft function remained stable in all but one patient after initial vaccination or COVID-19. Conclusion: Nearly half of unvaccinated islet transplant recipients developed Covid-19, however, all of them presented only with mild symptoms. In contrast, none of vaccinated transplant patients developed COVID-infection with 69% rate of seroconversion. Booster increased level of the Spike ab in those patients who responded to the original vaccination.
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In a phase 3 trial, the antibody–drug conjugate trastuzumab deruxtecan resulted in longer progression-free and overall survival than the physician’s choice of chemotherapy among patients with HER2-low breast cancer. see Original Article, N Engl J Med 2022;387:9-20 Previous Infection and Vaccination in Covid-19 A study in Qatar assessed the effectiveness of previous infection, vaccination, and both against symptomatic SARS-CoV-2 caused by omicron BA.1 and BA.2 and against severe, critical, or fatal Covid-19. see Original Article, N Engl J Med 2022;387:21-34 Brief Report: Porcine-to-Human Cardiac Transplantation In this report, a porcine-to-human heart transplantation is described. Most patients with low-risk pulmonary embolism can be treated with oral anticoagulants. see Clinical Practice Audio, N Engl J Med 2022;387:45-57 The Vaccine-Hesitant Moment The proliferation of vaccine misinformation and its use for political purposes are placing a large number of people at risk in the Covid-19 pandemic and allowing the pandemic to continue. see Review Article, N Engl J Med 2022;387:58-65 Monkeypox Genital Lesions A 31-year-old man presented with a painless genital rash. The midscapular pain was worse at night and lessened with exercise. see Clinical Problem-Solving, N Engl J Med 2022;387:67-73 Genetic Modification in Xenotransplantation In a recent case of xenotransplantation, now described in the Journal, a porcine heart was transplanted into a human patient, an advance made possible through genetic alterations in the animal donor. see Editorial, N Engl J Med 2022;387:79-82 Tympanostomy Tubes for Recurrent Otitis Media This interactive feature about recurrent acute otitis media in a young child offers a case vignette accompanied by two essays, one supporting insertion of tympanostomy tubes and the other supporting conservative medical management. see Clinical Decisions, N Engl J Med 2022;387:83-85 Physicians Spreading Misinformation on Social Media In light of widespread falsehoods about Covid-19 and its treatment and prevention, the American Board of Internal Medicine has informed doctors that disseminating misinformation is grounds for disciplinary sanctions. see Perspective, N Engl J Med 2022;387:1-3 Institutionalizing Misinformation A new bill, the Dietary Supplement Listing Act of 2022, would create the impression of reform in the supplement industry while leaving the current lax regulatory framework largely untouched. see Perspective, N Engl J Med 2022;387:3-5 The Portal What does it mean for a physician who has long maintained her privileged back channels to finally acquiesce to entering her own electronic medical record — and interacting with her doctors — through the patient portal? see Perspective, N Engl J Med 2022;387:5-7 A Call for Antiracist Action The neo-Nazi march on Brigham and Women’s Hospital and attacks on health equity interventions are stark reminders of the obligation of physicians to denounce White supremacism and reaffirm race-conscious antiracism efforts. see Perspective, N Engl J Med 2022;387:e1 Decreased Neutralization of Omicron Subvariants In a small study involving 54 participants, omicron subvariants BA.2.12.1, BA.4, and BA.5 of SARS-CoV-2 were more likely to escape neutralizing antibodies induced by both vaccination and previous infection than were the prior omicron subvariants BA.1 and BA.2. see Correspondence, N Engl J Med 2022;387:86-88 VITT Recurrence after Covid-19 or Vaccine In 69 patients with vaccine-induced immune thrombotic thrombocytopenia caused by anti–PF4 antibodies, subsequent Covid-19 infection or receipt of an mRNA-based vaccine did not induce VITT recurrence. see Correspondence, N Engl J Med 2022;387:88-90
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This presentation discusses how the realignment of resources at Great Ormond Street Hospital during the pandemic permitted the development of a new virtual form of service delivery for families, prior to a child’s bone marrow transplant. The new format both facilitated interprofessional working and reduced the need for families to attend multiple meetings.Prior to the pandemic, different allied health professionals (AHPs) (occupational therapist, physiotherapist, social worker and clinical psychologist) each met families separately during their out-patient appointment, prior to the child’s bone marrow transplant. Despite the different specific concerns of the various AHPs, the separate assessments were often repetitive and inefficient, with families feeding back that meeting the AHPs separately was ‘too much’. There had long been a wish within the Bone Marrow Transplant Department to run a joint AHPs clinic, but this was thwarted by limitations of time and office space.During the COVID-19 pandemic, the expansion of virtual means of service delivery provided the opportunity to establish a virtual clinic (O’Reilly et al 2021), which all AHPs could attend simultaneously. It was anticipated that this would be cost-effective for AHPs, reduce the need for families to repeat information to different professionals, and lessen the extent to which families felt overwhelmed by the experience.The presentation will summarise the issues involved, and the benefits and disadvantages of this new arrangement for both AHPs and families. It will consider whether families will continue to opt for virtual clinics post-pandemic or whether a desire for face-to-face clinics will return.