Acute Liver Failure With Liver Enzymes >5,000 in Sickle Cell Disease.

Sickle cell disease is a hemoglobinopathy often complicated by painful vaso-occlusive episodes, acute chest syndrome, stroke, and myocardial infarction. Sickle cell intrahepatic cholestasis (SCIC) is a rare and potentially fatal complication of sickle cell disease. SCIC is thought to involve progressive hepatic injury due to sickling within sinusoids. We present the case of a young patient with SCIC and acute liver failure, requiring prompt treatment with exchange transfusion. Our case describes features that should raise suspicion for hepatic failure in SCIC and highlights exchange transfusion as a successful management approach in similar patients with an otherwise high risk of mortality.

EUS imaging for the diagnosis of nonalcoholic fatty liver disease.

BACKGROUND AND AIMS: EUS is increasingly used to evaluate patients with liver disease, but its role in assessing hepatic steatosis has not been reported. The goal of our study was to assess the accuracy of EUS for diagnosing hepatic steatosis. METHODS: We identified all patients who underwent EUS-guided liver biopsy sampling at our institution. All digitally stored EUS liver images were reviewed by a single radiologist, who rated the severity of liver echogenicity using a 4-point US scale. Liver biopsy specimens for all study patients were reviewed by a single liver pathologist, who rated them for steatosis and fibrosis using Nonalcoholic Steatohepatitis Clinical Research Network criteria. Receiver operator characteristic curves were used to assess the diagnostic accuracy of EUS for hepatic steatosis for all patients and in a subgroup analysis for obese and nonobese patients. RESULTS: During the study period, 76 patients underwent EUS-guided liver biopsy sampling. The average age of study patients was 56.5 years, 50% were women, and 43.2% were obese. The accuracy for EUS for the diagnosis of hepatic steatosis was .8 (95% confidence interval [CI], .7-.89). The accuracy of EUS for the diagnosis of hepatic steatosis in obese patients was .93 (95% CI, .8-.99) and in nonobese patients was .69 (95% CI, .54-.83). For obese patients, EUS had a positive predictive value of 89.7% and a negative predictive value of 75%. The finding of course echotexture on EUS had an accuracy of 79% for the diagnosis of grade 3 fibrosis or cirrhosis. CONCLUSIONS: EUS is a useful tool for the diagnosis of hepatic steatosis, particularly in obese patients in whom abdominal US has modest accuracy.

Race/Ethnicity Is Not Independently Associated with Risk of Adverse Waitlist Removal among Patients with HCC Exception Points.

(1) Background: Since 2015, exception points have been awarded to appropriate candidates after six months of waitlist time to allow more equitable access to liver transplants regardless of hepatocellular carcinoma status. However, it remains unknown whether racial disparities in outcomes among waitlisted patients remain after the introduction of a 6-month waiting period for exception points. (2) Methods: Using the United Network for Organ Sharing database, we identified 2311 patients diagnosed with hepatocellular carcinoma listed for liver transplant who received exception points from 2015 to 2019. The outcome of interest was waitlist survival defined as the composite outcome of death or removal for clinical deterioration. Competing risk analysis was used to identify factors associated with death or removal for clinical deterioration. The final model adjusted for age, sex, race/ethnicity, blood type, diabetes, obesity, laboratory MELD score, tumor size, AFP, locoregional therapies, UNOS region, and college education. (3) Results: No difference was found in the risk of adverse waitlist removal among ethnic/racial groups.

Waitlist Mortality and Posttransplant Outcomes in African Americans with Autoimmune Liver Diseases.

BACKGROUND: Liver transplantation is indicated in end-stage liver disease due to autoimmune diseases. The liver allocation system can be affected by disparities such as decreased liver transplant referrals for racial minorities, especially African Americans that negatively impact the pre- and posttransplant outcomes. AIM: To determine differences in waitlist survival and posttransplant graft survival rates between African American and Caucasian patients with autoimmune liver diseases. Study. The United Network for Organ Sharing database was used to identify all patients with autoimmune hepatitis, primary biliary cholangitis, and primary sclerosing cholangitis who underwent liver transplant from 1988 to 2019. We compared waitlist survival and posttransplant graft survival between Caucasians and African Americans using Kaplan-Meier curves and Cox regression models. We also evaluated the cumulative incidence of death or delisting for deterioration and posttransplant incidence of death and retransplantation using competing risk analysis. RESULTS: African Americans were more likely to be removed from the waitlist for death or clinical deterioration (subdistribution hazard ratio (SHR) 1.26, 95% CI 1-1.58, P=0.046) using competing risk analysis. On multivariate Cox regression analysis, there was no difference in posttransplant graft survival among the two groups (hazard ratio (HR) 1.10, 95% CI 0.98-1.23, P=0.081). CONCLUSIONS: Despite the current efforts to reduce racial disparities, we found that African Americans are more likely to die on the waitlist for liver transplant and are less likely to be transplanted, with no differences in graft survival rates. The persistence of healthcare disparities continues to negatively impact African Americans.

Waitlist mortality and transplant free survival in Hispanic patients listed for liver transplant using the UNOS database.

INTRODUCTION AND OBJECTIVES: After the implementation of "Share 35", several concerns arose such as the potential to increase travel distance, costs, and decreased liver availability. These elements could have a negative impact on waitlist outcomes among ethnic minorities. We aimed to determine waitlist survival after the implementation of the Share 35 policy in non-Hispanic white and Hispanic patients. MATERIALS AND METHODS: We identified non-Hispanic whites and Hispanics who were listed for liver transplantation from June 18th, 2013 to June 18, 2018. We excluded pediatric patients, patients with acute hepatic necrosis, re-transplants, multiorgan transplant, living donor, and exception cases. The primary outcome was death or removal from the waitlist due to clinical deterioration. We used competing risk analysis to compare waitlist survival between the two groups. RESULTS: There were 23,340 non-Hispanic whites and 4938 Hispanics listed for transplant. On competing risk analysis, Hispanic patients had a higher risk of being removed from the waitlist for death or clinical deterioration compared to their counterpart (SHR 1.23, 95% CI 1.13-1.34; P < 0.001). CONCLUSION: After the implementation of Share 35, disparities are still present and continue to negatively impact outcomes in minority populations especially Hispanic patients.

New OPTN Simultaneous Liver-Kidney Transplant (SLKT) Policy Improves Racial and Ethnic Disparities.

(1) Background: On 10 August 2017, the Organ Procurement and Transplantation Network (OPTN) adopted standardized eligibility criteria to properly determine which transplant candidates should undergo Simultaneous Liver-Kidney Transplant (SLKT). Racial and ethnic disparities have not been examined after 2017. Therefore, using the United Network for Organ Sharing (UNOS), we aim to evaluate post-graft survival outcomes among Caucasians, African Americans, and Hispanics. (2) Methods: Kaplan-Meier curves and Cox regression models are used to compare post-transplant graft survival for Caucasians, African Americans (AAs), and Hispanics. Competing risk analysis is used to evaluate the cumulative incidence of death or re-transplantation with re-transplantation and death as competing risks. (3) Results: On multivariate Cox regression analysis, no differences in graft survival are found in AA (hazard ratio (HR): 1.30; 95% CI: 0.74-2.29 p = 0.354) or Hispanics (HR: 1.18; 95% CI: 0.70-2 p = 0.520) compared to Caucasians after 2017. On competing risk analysis of the risk of death with re-transplantation as a competing risk, no difference is found between ethnic minorities after 2017. There is a similar finding from competing risk analysis of the risk of re-transplantation with death as a competing risk. (4) Conclusion: After introducing standardized eligibility criteria for SLKT allocation, the post-graft survival outcomes remain similar between the different racial and ethnic groups, displaying the benefits of adopting such policy in 2017.