Post-Covid-19 Cholangiopathy-A New Indication for Liver Transplantation: A Case Report.

Liver injury is one of the nonpulmonary manifestations described in coronavirus disease 2019 (COVID-19). Post-COVID-19 cholangiopathy is a special entity of liver injury that has been suggested as a variant of secondary sclerosing cholangitis in critically ill patients (SSC-CIP). In the general population, the outcome of SSC-CIP has been reported to be poor without orthotopic liver transplantation (OLT). However, the role of OLT for post-COVID-19 cholangiopathy is unknown. We present a case report of a 47-year-old man who recovered from acute respiratory distress syndrome from COVID-19 and subsequently developed end-stage liver disease from post-COVID-19 cholangiopathy. The patient underwent OLT and is doing well with normal liver tests for 7 months. To our knowledge, this is the first case report of a patient who underwent successful liver transplantation for post-COVID-19 cholangiopathy.

Changes in Alcohol Use Patterns in the United States During COVID-19 Pandemic.

INTRODUCTION: The novel coronavirus SARS-CoV-2 (COVID-19) has rapidly emerged as a public health emergency. In the United States, "stay-at-home" orders have led to loss of social routines and the closing of restaurants and bars; as a result, sales of alcohol have increased. The aim of this study was to assess changes in alcohol use patterns as a result of social distancing measures. METHODS: A single online survey was sent to a convenience sample of adults through social media. Self-reported demographics and alcohol use patterns before and during social distancing were obtained. RESULTS: Four hundred seventeen subjects completed the survey; 83% were women, 77% were married, 44% were between ages 35 and 44 years. Alcohol Use Disorders Identification Test (AUDIT-C) scores increased from median value of 3 to 4 (P < 0.0001); the increase was statistically significant only in women (P < 0.0001). Fewer people use alcohol during social distancing; however, in those who use alcohol, the frequency and quantity ingested increased, as well as the frequency of alcohol use prior to 5 pm. Despite these increases, there was an overall reduction in binge drinking pattern. Multivariate analysis identified women, having children at home, and a history of substance abuse to be associated with increase in alcohol use. CONCLUSION: Among those who continue to drink alcohol, social distancing has led to a significant increase in the amount of alcohol ingested, frequency of alcohol use, and an increase in AUDIT-C scores in women suggesting hazardous alcohol use behaviors. Clinicians should continue to assess patient alcohol use during the pandemic. Further studies will be needed to assess long-term outcomes after the COVID-19 pandemic resolves.

Disparity in Transplant Referral Patterns for Alcohol-Related Liver Disease Based on Physician-Dependent Variables.

INTRODUCTION: Distance from a liver transplant (LT) center does not affect post-transplant outcomes. Rural areas have lower rates of listing and receiving solid organ transplants. The aim of this study was to investigate trends in referral for LT based on physician-dependent variables. METHODS: An online survey was distributed to a cohort of physicians. Questions pertained to physician demographics, including age, specialty, practice location, and training at an LT center. Distances to the nearest transplant center was calculated based on zip code. Variables studied included length of sobriety, patient age, and body mass index required for transplant evaluation. Responses were analyzed using univariate ordinal logistic regression models and multivariable analyses. RESULTS: In the study, 299 physician respondents were analyzed. Physicians without LT center training were 2.05 (confidence interval [CI] 1.33-3.17) times more likely to require longer duration of sobriety. As distance increased from a transplant center, the odds of requiring longer sobriety increased by 1.43 (CI 1.11-1.83) times. Gastroenterologists (GIs) and transplant hepatologists (THs) showed significant differences in referral candidacy for patients with alcohol-related liver disease (P < .0001). When compared to GIs/THs, primary care physicians were 2.11 times (CI 0.97-4.58) more likely to require a longer duration of sobriety. No significant physician-dependent variables were found in respect to patient age or body mass index. DISCUSSION: Our study demonstrates that physician-dependent variables exist in referral for transplant evaluation. GIs and THs were more likely to refer higher-risk patients, which suggests a disparity in referral of patients with alcohol-related liver disease to transplantation depending on access to subspecialty care.

Gender disparities in liver transplant candidates with nonalcoholic steatohepatitis.

BACKGROUND: Nonalcoholic steatohepatitis (NASH) is the fastest growing indication for liver transplantation (LT). Data from the UNOS database were used to compare rates of listing and LT between men and women with NASH. METHODS: The study population consisted of 76 149 patients listed for LT between 2005 and 2012, 5 492 (7.2%) of who were listed for NASH. Patient characteristics and outcomes were compared by gender. RESULTS: Nonalcoholic steatohepatitis was a more frequent indication for transplant listing in women than men throughout the study period. Women had lower serum creatinine levels at listing (1.18 ± 0.76 mg/dL vs 1.28 ± 0.79 mg/dL, P < .001) and were less likely to be listed with exception points (17.7% vs 24.9%, P < .001). Transplantation was less common among women than men with NASH (52.4% vs 64.3%), and women were more likely to experience death on the waiting list (17.1% vs 11.4%) In multivariable analysis adjusting for covariates, the rate of LT remained lower for women with NASH (aHR 0.81 95% CI: 0.75-0.88). CONCLUSIONS: Women with NASH cirrhosis had a higher risk of death on the LT waiting list and were less likely to receive LT compared to men.

Adverse Effect of Post-Discharge Care Fragmentation on Outcomes after Readmissions after Liver Transplantation.

BACKGROUND: Post-discharge surgical care fragmentation is defined as readmission to any hospital other than the hospital at which surgery was performed. The objective of this study was to assess the impact of fragmented readmissions within the first year after orthotopic liver transplantation (OLT). STUDY DESIGN: The Healthcare Cost and Utilization Project State Inpatient Databases for Florida and California from 2006 to 2011 were used to identify OLT patients. Post-discharge fragmentation was defined as any readmission to a non-index hospital, including readmitted patients transferred to the index hospital after 24 hours. Outcomes included adverse events, defined as 30-day mortality and 30-day readmission after a fragmented readmission. All statistical analyses considered a hierarchical data structure and were performed with multilevel, mixed-effects models. RESULTS: We analyzed 2,996 patients with 7,485 readmission encounters at 299 hospitals; 1,236 (16.5%) readmissions were fragmented. After adjustment for age, sex, readmission reason, index liver transplantation cost, readmission length of stay, number of previous readmissions, and time from transplantation, post-discharge fragmentation increased the odds of both 30-day mortality (odds ratio [OR] = 1.75; 95% CI 1.16 to 2.65) and 30-day readmission (OR = 2.14; 95% CI 1.83 to 2.49). Predictors of adverse events after a fragmented readmission included increased number of previous readmissions (OR = 1.07; 95% CI 1.01 to 1.14) and readmission within 90 days of OLT (OR = 2.19; 95% CI 1.61 to 2.98). CONCLUSIONS: Post-discharge fragmentation significantly increases the risk of both 30-day mortality and subsequent readmission after a readmission in the first year after OLT. More inpatient visits before a readmission and less time elapsed from index surgery increase the odds of an adverse event after discharge from a fragmented readmission. These parameters could guide transfer decisions for patients with post-discharge fragmentation.

The time and cost investment required to obtain and initiate direct-acting antiviral therapy.

BACKGROUND: Obtaining direct-acting antiviral (DAA) medications for treatment of HCV is labour-intensive for providers. The purpose of this study was to assess the amount of unbillable time and to estimate the financial burden of obtaining DAAs for HCV. METHODS: Patients prescribed DAA therapy from 30 September 2014 to 19 March 2015 at an academic hepatology practice were enrolled prospectively. Providers recorded the amount of time required to obtain HCV therapy for each patient. RESULTS: A total of 79 patients consented, 27 of whom were excluded due to incomplete data or deferment of therapy. In our patient population 56% of patients had private insurance, 27% Medicare and 15% Medicaid. The median time spent per patient was 92.5 min (IQR 80.00-108.80). The median cost spent per patient was $78.85 (IQR 66.75-94.30). CONCLUSIONS: Development of a streamlined process to reduce the time and cost for physicians to obtain DAAs is needed. Removing this barrier will encourage physicians to adopt HCV treatment to address the large number of patients in need.

Management of Difficult Cases of Autoimmune Hepatitis.

Autoimmune hepatitis (AIH) is a complex autoimmune disease characterized by immune-mediated destruction of hepatic parenchyma which can result in cirrhosis, liver failure, and death. Current American Association for the Study of Liver Diseases (AASLD) and European Association for the Study of Liver (EASL) guidelines recommend corticosteroids alone or in combination with azathioprine as first-line treatment strategies. However, a significant proportion of patients may not be able to tolerate or achieve complete biochemical response with these options. In this article, we discuss approaches to these patients and other challenging AIH patient groups such as the asymptomatic, pregnant, elderly, and liver transplant recipients.

Performance Feedback Improves Compliance With Quality Measures.

Cirrhotic complications portend high morbidity and mortality and burden the health care system. Established quality measures in management of cirrhotics include screening for esophageal varices (EV), screening for hepatocellular carcinoma (HCC), and hepatitis A and B immunization. A retrospective review was conducted to identify adherence to cirrhosis. Baseline rates were shared with providers. Compliance with quality measures was measured prospectively at 1-month, 2-month, 1-year, and 3-year follow-up after provision of performance feedback. Baseline HCC rate was 60%, EV was 68%, and hepatitis A and B immunization was 51% and 47%, respectively. After performance feedback, HCC, EV, and hepatitis A and B vaccination rates improved to rates ranging from 92% to 100% and remained statistically significant after 3 years. Provider feedback, a simple intervention, achieved significant improvement in compliance with quality measures for management of cirrhotics. This improvement in adherence to quality measures was sustainable over a 3-year time period.

Physical activity and metabolic syndrome in liver transplant recipients.

There is a high prevalence of metabolic syndrome in liver transplant recipients, a population that tends to be physically inactive. The aim of this study was to characterize physical activity and evaluate the relationship between physical activity and metabolic syndrome after liver transplantation. A cross-sectional analysis was performed in patients more than 3 months after transplantation. Metabolic syndrome was classified according to National Cholesterol Education Panel Adult Treatment Panel III guidelines. Physical activity, including duration, frequency, and metabolic equivalents of task (METs), was assessed. The study population consisted of 204 subjects, with 156 more than 1 year after transplantation. The median time after transplantation was 53.5 months (range = 3-299 months). The mean duration of exercise was 90 ± 142 minutes, and the mean MET score was 3.6 ± 1.5. Metabolic syndrome was observed in 58.8% of all subjects and in 63.5% of the subjects more than 1 year after transplantation. In a multivariate analysis involving all subjects, metabolic syndrome was associated with a time after transplantation greater than 1 year [odds ratio (OR) = 2.909, 95% confidence interval (CI) = 1.389-6.092] and older age (OR = 1.036, 95% CI = 1.001-1.072). A second analysis was performed for only patients more than 1 year after transplantation. In a multivariate analysis, metabolic syndrome was associated with lower exercise intensity (OR = 0.690, 95% CI = 0.536-0.887), older age (OR = 1.056, 95% CI = 1.014-1.101), and pretransplant diabetes (OR = 4.246, 95% CI = 1.300-13.864). In conclusion, metabolic syndrome is common after liver transplantation, and the rate is significantly higher in patients more than 1 year after transplantation. The observation that exercise intensity is inversely related to metabolic syndrome after transplantation is novel and suggests that physical activity might provide a means for reducing metabolic syndrome complications in liver transplant recipients.